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Can the Vegetarian Diet Be Healthy?

By Meghan Anderson Thomas, MS

I constantly hear:

Omnivores: “Vegetarians just don’t look healthy.”
Vegetarians: “ Meat just isn’t good for you.” Or “I feel so much better when I’m not eating it”

So who has it right? Can they both be right and wrong at the same time? I think the answer lies in the motivations behind the eater. The omnivore may have a point because vegetarianism, like all other diets, has the capacity to be unhealthy.

Essentially, vegetarianism, pescetarianism, veganism, etc. are elimination diets. Like any elimination diet, they have the potential to lack vital nutrients including certain vitamins that are predominately found in animal products. According to Sabate, vegetarian diets when compared to meat-based diets are more likely to be deficient in vital nutrients(1). Similarly, when omnivores (typical American diet) obtain the abundance of their calories from meat and dairy they have less room for the fruit and vegetables that provide them with the other nutrients vegetarians so easily acquire. Moreover, studies show that the increased risk of cancer and heart disease in meat-based diets may be related to a deficiency in the phytochemicals and other compounds found in plant-based foods, not just the intake of saturated fats and excess calories(2).

Again, the problem lies in the motivation. Vegetarians and omnivores alike that eat for health are much more likely to eat properly. The choice of becoming a vegetarian for health reasons alone may lead the vegetarian in question to a more healthful diet in which they are cognizant of variety and balance. That being said, there are plenty of vegetarians that may be doing it for the wrong reasons or are, like most, uneducated in making the proper nutritional decisions.

The observation that vegetarians are unhealthy may actually be evident. Most will argue that they have been deficient in iron, zinc, calcium and B vitamins since they have eliminated animal products, leading to anemia(2). Not to mention that most vegetarians are women who are prone to anemia due to menstruation. The fatigue that follows leads to the snowball effect of fatigue, decreased exercise and depression. The point is, diet has a strong influence on health and well-being and it is dangerously easy to eat incorrectly, even if one’s intentions may be pure. This is seen in all “types” of eaters alike.

It is important to remember that as a vegetarian, the elimination of a steak may reduce your risk for heart disease, hypertension, atherosclerosis, hyperlipidemia, etc., but it is not a free pass to eat all the junk food you can to make up for it. The elimination of meat alone is not the ticket to health. Instead, it seems to be a correlation: the vegetarians motivated by health are also more likely to be cognizant enough to eat right all of the time. Furthermore, Sabate illustrates that the vegetarian diet is viewed as improving health and limiting disease when compared to the meat-based diet(1).

References
1. Sabate, J. (2003). The contribution of vegetarian diets to health and disease: a paradigm shift? The American Journal of Clinical Nutrition, 78 (3), 502S-507S.
2. Nieman, D. C. (1999). Physical fitness and vegetarian diets: is there a relation? The American Journal of Clinical Nutrition, 70 (3), 570S-575S.

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Changes on the Horizon: Redefining Malnutrition Diagnoses in Older Adults

By Jonelle Agurs, ASN Intern

No one wants to get half a diagnosis from their doctor.

Unfortunately, that’s what tends to happen when diagnosing malnutrition in hospitalized adult patients in the United States. The present criteria for some malnutrition assessments, like the Malnutrition Screening Tool (MST), are under scrutiny because they only evaluate patients on symptoms of starvation, such as unintentional weight loss or poor appetite. However, new studies postulate that malnutrition should not be limited to food behaviors, but should be expanded to include inflammation resulting from chronic disease. The body’s inflammatory response can intensify the symptoms of starvation, and vice versa; poor eating habits may induce inflammation as well. The human body does an impeccable job of patching itself up using the inflammatory response, but this process often triggers symptoms strongly associated with malnutrition, such as weight loss. With approximately half of the U.S. adult population (117 million) suffering from at least one chronic condition, such as coronary heart disease and diabetes, it is no surprise that there is an increasing prevalence of malnutrition cases among hospitalized adult patients.

ASN supports the efforts of many of its partner organizations, such as the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics, which want to recognize the role of the inflammatory response when diagnosing malnutrition. They have proposed four standard criteria: insufficient energy intake, unintended weight loss, muscle mass and fat loss, and diminished physical function. These criteria will support a more etiological-based diagnosis of malnutrition; a diagnosis more closely linked to the chronic diseases that cause it. Misdiagnoses often result in patients being discharged early from hospital care, causing inpatients to return later for health issues made worse by the symptoms of poor nutrition.

The International Classification of Diseases, 10th Revision, or ICD-10, is a coding system under the Affordable Care Act of 2010, scheduled to be implemented after October 1, 2015. Designed to improve disease management, this revision will include coding using an updated definition of malnutrition. Absence of a standard screening system for this condition is like installing the proverbial cork in the leaky faucet; diagnoses without a simple malnutrition assessment may “plug” up the issue, but the pressure continues to build, waiting for a more thorough solution. The expansion of the ICD-10 coding system will provide a part of that solution by enhancing screening accuracy. With five times more descriptors than its ICD-9 predecessor, ICD-10 coding will include more conditions that could be linked to a range of malnutrition-related issues.

Hospitals across the nation are preparing for the ICD-10 updates, but it is imperative that hospital personnel fully understand how to recognize and diagnose malnutrition to code it properly. Despite shortages of nursing staff and other trained individuals, quality of patient care must be maintained in order to indicate their risk of malnutrition. Clinicians must be able to perform comprehensive assessments of the patient’s complete medical background, so that, along with the newly-proposed diagnostic construct, every patient will receive comprehensive care that will, ideally, lower the cost of their medical care expenses in the future.

Malnutrition, among other hospital-based nutrition topics will be discussed on Saturday, December 6 during the fourth annual Advances and Controversies in Clinical Nutrition conference. Dr. Gordon Jensen, ASN’s immediate past president, will give an address titled “Malnutrition and the Affordable Care Act.” The conference runs December 4-6 at the Gaylord National Resort & Convention Center in National Harbor, MD, and features a dynamic program with topics ranging from dietary supplements to nutrition and cancer. To learn more about this year’s conference, please visit the website.

Reference
Jensen, G, Compher, C, Sullivan, D, Mullin, G. (2013). Recognizing Malnutrition in Adults: Definitions and Characteristics, Screening, Assessment, and Team Approach. Journal of Parenteral and Enteral Nutrition, 802-807.

Nutrition Research: Revisiting our Foci

By Kevin Klatt

A few weeks ago, I had the pleasure of reading Allyson West and Marie Caudill’s Research and Practice Innovations paper in the Journal of the Academy of Nutrition and Dietetics, entitled “Applied Choline-Omics: Lessons from Human Metabolic Studies for the Integration of Genomics Research into Nutrition Practice” (1). The publication elegantly describes how integrating metabolomic, transcriptomic and genetic/epigenetic approaches into traditional controlled feeding studies can help refine the Dietary Reference Intakes, and elucidate the mechanisms by which choline and folate contribute to overall health.

Referencing the Nutrition Research Priorities established by the American Society for Nutrition (ASN) in 2013 (2), we can clearly see that the approaches described by West and Caudill fall in line with ASN’s thinking on how to advance the field of nutritional sciences. The Nutrition Research Priorities report specifically highlights furthering our understanding of nutrition and health by pursuing –omics research to understand individual responses to nutrients. For me, it was encouraging to see these kinds of advanced techniques and their clinical applications representing the field of research in a major clinical nutrition journal.

Fast-forwarding to this past week, I found myself staring at headlines inflaming the conversation around the newest low-carbohydrate/low-fat research, published in the reputable Annals of Internal Medicine (3). The publication is a randomized trial that ultimately concludes “the low-carbohydrate diet was more effective for weight loss and cardiovascular risk factor reduction than the low-fat diet”. Being in such a high profile journal and funded by the NIH, one would expect this publication to add some significant perspective to our understanding of energy balance and disease progression, two areas also highlighted in the 2013 Nutrition Research Priorities report. Unfortunately, upon reading the paper, one is quickly underwhelmed by the lackluster weight loss over 12 months, the poor accuracy of the dietary recall data, the lack of any information about diet quality, the use of imprecise measurement techniques, and the authors’ failure to discuss alternative conclusion, beyond just the low-carbohydrate component of the diet. I have specifically detailed the limitations of this trial elsewhere.

As I finished reading the study, West and Caudill’s ‘Choline-omics’ paper came to mind, and I couldn’t help but feel frustrated: why are we still funding these overly reductionist paradigms of low-carb vs low-fat, when much more integrative and informative approaches are being taken? To quote the 2013 Nutrition Research Priorities report on the topic of energy balance:
“A systems approach is preferable because the standard experimental approach of varying one factor at a time has accomplished little to address the population-wide problem of energy imbalance.”
Yet here we are, still trying (and failing) to vary only one factor, and publishing it in a premier journal for physicians. Is this how we want to represent nutrition research?

I further sat and thought about this trial: even at the outset, given the design, and the quality of the proposed data to be collected, what could this have added to our knowledge of nutrition? The trial states that its goal was to conduct a randomized trial to compare low-carb versus low-fat diets on body weight and CVD risk factors in a diverse population without comorbidities. Beyond the overly reductionist paradigm of low-carb/fat, the study design is questionable in that “neither diet included a specific calorie or energy goal.” Ultimately, the trial tested whether a macronutrient goal, coupled with education and a meal replacement bar would spontaneously lead individuals to lose weight, in a diverse population without comorbid conditions. Not surprisingly, after being sent into an environment with highly palatable, minimally nutritious high carbohydrate/ high calorie foods, the low-carbohydrate group fared better. Is this substantially improving our understanding of nutrition and energy balance? If there’s any theme that holds true with weight loss and disease risk reduction, it’s that choosing a well-planned, reduced energy diet which an individual can adhere to is most important (4,5,6,7). Given the failure to reach recommended fiber intakes and minimal weight loss seen in this trial, nothing about the previous statement appears to change.

Even worse than the limited information to be gained from this kind of trial is the media reporting and subsequent public response to this research. The public’s perception of nutrition recommendations isn’t that great, as acknowledged in what I would argue is the most pertinent point of the Nutrition Research Priorities report:
“Perhaps the greatest barrier to advancing the connections between food and health is the variability in individual responses to diet; it is also the origin of public skepticism to acceptance of dietary advice….”
If individual variability spurs public skepticism, we should seek to explain that variability. One only needs to look to the original 1980’s Dietary Guidelines for Americans (4) to see that we’ve known that there is individual variation in weight gain/loss and in biomarker response to diets high/low in fat. Yet here we are, 3 decades later, and we’re conducting trials that do nothing to further isolate and understand the factors that contribute to this variation. However, what we are doing is deepening this public skepticism, as history shows us the controversial topic of low-carb vs. low-fat undoubtedly garners a lot of press.

Don’t get me wrong, research that attempts to understand individual variation in response to food and nutrients is being done, but, despite being identified as a major priority, it does not appear to be so. It’s truly a shame to be in this field and see examples of researchers employing the most cutting edge techniques to answer pressing questions, only to be overshadowed by overly simplistic paradigms that incite more sentiment than they do advance science. It is essential that scientists, and more importantly funding agencies, are aware of the field’s established research priorities, so that we can stop asking the uninformative questions that tantalize a public controversy and start generating truly substantial evidence, which fosters public trust in recommendations. These established Nutrition Research Priorities can be found in full here.

References:
1. http://www.ncbi.nlm.nih.gov/pubmed/24529976
2. http://www.ncbi.nlm.nih.gov/pubmed/23784071
3. http://annals.org/article.aspx?articleid=1900694
4. http://www.health.gov/dietaryguidelines/1980thin.pdf
5. http://www.nejm.org/doi/full/10.1056/NEJMoa022207
6. http://www.nejm.org/doi/full/10.1056/NEJMoa0804748
7. http://jama.jamanetwork.com/article.aspx?articleid=200094
8. http://www.health.gov/dietaryguidelines/1980thin.pdf

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Food Security in Puerto Rico: Vulnerable Food Supply

By Mayra S. Crespo Bellido

In 1942, Dr. Lydia J. Roberts was asked by Dr. M. L. Wilson of the US Food and Nutrition Board to visit Puerto Rico under the pretenses that “there was a problem in [the island], which ordinarily imported much of its food.” After all, the island only produced 65% of the food the habitants needed, 35% was being imported at the time. Dr. Roberts was assigned to study the food and nutrition situation in order to report back to Washington, DC. Out of her collaboration with the University of Puerto Rico as a visiting professor, a clear picture of the living situation for the islanders during the 1940s was portrayed in her book Patterns of Living in Puerto Rican Families. This classic one-of-a-kind report depicts explicitly the poor health conditions and severe food insecurity in most households, mostly due to lack of educational and monetary resources. During this period infectious diseases were ranked #1 among the most common causes of mortality for all ages.

In the 21st century, a changing landscape of health problems troubles Puerto Rico. Following nutrition transition patterns of developing countries, the leading causes of death of our time are all from complications of chronic conditions associated with the increasing prevalence of obesity in the island. In 2013, 35% of Puerto Ricans living in the island benefited from the Nutrition Assistance Program, and the majority of the population benefits from other programs such as WIC and Child Nutrition Programs. Nonetheless, Puerto Rico deals with serious food security issues as the island produces only 17.65% of the food it consumes, importing 82% from over 10 different countries.

According to the Food and Agriculture Organization (FAO), food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life. The four dimensions of food security as defined by the FAO are: food availability, food access, proper utilization and stability. A recent study established that food security is not distributed equally as people living in rural areas of the island are disproportionately affected unemployment rate, greater proportion of habitants below the poverty level and lower education levels all of which may create barriers to food access and proper utilization. However for the Puerto Rican population it becomes a little more complicated than that.

Dr. Myrna Comas, Puerto Rico Secretary of Agriculture, has made it her lifework to bring awareness of the vulnerability of the food chain supply in Puerto Rico. As stated by Dr. Comas, the high dependence on imported foodstuff, constant decreases in local agricultural production, the fact that there is only one functioning seaport that receives all merchandise imported, the great distances food has to travel to get to the island, and a lack of policy to ensure food security are some of the many reasons the food chain supply to the island is susceptible to external influences. Some identified risk factors that could interfere with the supply of food are: global climate change, food and water contamination, reduction of terrains devoted to agriculture in the island, accidents, and free trade agreements, among others.

Under the direction of Dr. Comas, the Puerto Rico Department of Agriculture has systematically addressed these issues for the past couple of years. Part of this plan to counterattack the risk of having a food crisis includes an educational campaign to bring awareness to the matter of food security, and initiatives to conserve agricultural lands and to promote local agricultural production of staple foods. There is evidently a long way to go until this matter is resolved. Hopefully with increased knowledge and understanding of the repercussions of letting this problem remain unaddressed will encourage the proper authorities to create local and international food policy that avoids an impending food crisis in the island.

References
Rosario-Mejías, M, Dávila-Román, A. (2012). Distribución geográfica de la seguridad alimentaria en Puerto Rico, 2005-2009. CIDE Digital 3(1-2), 109-118.

http://academic.uprm.edu/mcomas/HTMLobj-159/tesis.pdf

http://www.elnuevodia.com/expuestopuertoricoaunacrisisalimentaria-1717099.html

http://puertorico.media.indypgh.org/uploads/2012/01/bolet_n__13_enero_2012.pdf

http://jp.pr.gov/Portal_JP/Portals/0/Publicaciones/PublicacionesHistoricasOnline/Compendio%20de%20Estadisticas%20Sociales%20-%201988-2.pdf

http://www.fao.org/focus/e/obesity/obes2.htm

https://www.cfda.gov/index?s=program&mode=form&tab=core&id=3050f5bc0ed98a93fcc273237e0dd0cd

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My Clinical Nutrition Internship: Enhancing Physician Education

By Hans Chiang

I used to be very picky with my food as a child. My parents tried multiple ways to keep me on a well-balanced diet. My interest in nutrition sparked when my parents persuaded me to eat carrots by claiming “carrots are good for your eyes.” While I did not have the scientific fundamentals and resources to research the biochemical mechanism that validates their claim at that age, I trusted my parents, labelled carrots as “good food” and tried to incorporate them into my food choices. When taking biochemistry in my undergraduate studies, these mysterious interactions between foods and the human body unfolded as I learned the science behind how nutrients actually work. Realizing how dietary intake plays a huge role in disease prevention and treatment, I wanted to advance my nutrition education in medical school so that I can provide relevant nutritional guidance to my patients as a physician.

For this reason, I applied for a position in the ASN Clinical Nutrition Internship Program during the summer after my first year of medical school at Indiana University School of Medicine. The program provided me with valuable experiences; not only did I learn about nutritional science from registered dietitians, I also shadowed physicians of different specialties, observe procedures, and learn how they incorporate nutrition into their fields of practice. On top of the clinical exposure, I reviewed my physiology and biochemistry by participating in literature research with my mentor and writing a research paper on the assessment and dietary modulations of endothelial functions.

I had the opportunity to learn from dietitians who assist different patient populations. I spent time in a diabetes care center, a hospital pulmonary and cardiac rehabilitation unit, a retirement community, a cancer radiation center, the local WIC clinic, a community health clinic, the Volunteers in Medicine clinic of Monroe County, and the University Student Health Center. I was surprised to learn how diets are formulated so differently for each unique population. In addition, I learned to appreciate the communication techniques dietitians use to encourage their patients to follow an optimized diet. As a future physician, I would also be working with a very diverse population and these are all useful techniques I can use in my practice.

Besides learning about nutrition from dietitians, I participated in nutrition support rounds and shadowed physicians in different specialties. I shadowed a gastroenterologist and observed esophagogastroduodenoscopies (EGD), colonoscopies, colon decompressions, and gastric tube insertions. I shadowed a bariatric surgeon and observed lap band, cholecystectomy, and hernia repair procedures. I also spent time with an oncologist, a pediatrician, and an endocrinologist to learn about how weight control plays an immense role in treating cancer patients, infants, teenagers, and diabetic patients.

The Clinical Nutrition Internship Program was a wonderful enhancement to my education in becoming a physician. Besides learning about the various roles nutrition has in the health care field, I also obtained valuable communication skills through observing the interactions between the health care professionals and their patients. Regardless of the specialty I pursue in the future, I will be able to incorporate what I learned through this internship into my practice to provide my patients with the best care and education. I enjoyed the eight weeks of the internship very much and am very grateful to have had this opportunity.