By Jonelle Agurs, ASN Intern

According to the National Health and Nutrition Examination Survey (NHANES), national reports indicate a steady increase in childhood obesity levels, in preschoolers up to four years of age. However, state-specific studies of data retrieved from the Pediatric Nutrition Surveillance System (PedNSS) tell a slightly different story: in 2011, nineteen U.S. states/territories reported a drop in obesity prevalence among low-income preschoolers up to 2.6%, with the greatest decline observed in the Virgin Islands. Although national obesity levels among this age group still range from 9.2-17.9%, we must acknowledge the sporadic, yet significant lapse in prevalence rates of this medical condition from state-to-state.

Childhood obesity is associated with a variety of physical complications, such as high blood pressure, diabetes, and asthma, which in turn, contribute to mental health setbacks that affect a child’s self-esteem and motivation to perform daily tasks. Obese preschoolers are five times as likely to become obese adults, as compared to their non-obese peers, and low-income households are particularly vulnerable to chronic obesity – inexpensive fast food options, that boast great taste, but have little nutritional value, are disproportionately marketed in low-income, minority communities. Using cross-promotion marketing tactics, 71% of food products use third-party licensed characters to appeal to adolescent audiences, but less than 20% meet nutritional guidelines set for children. A public health intervention at this impressionable stage of a child’s life is crucial in ensuring better health habits for a lifetime.

So, why do some states show significant improvements in obesity levels? It is most likely because these state and county agencies play a unique role in the success of their communities – a role that involves everyone from the enthusiastic teacher in a child’s preschool class, to the soccer coach in charge of physical education after school, to the local grocer who provides fresh fruits and vegetables for the community. Local and state initiatives, aimed to implement healthier food and recreational options for the communities they serve, have aligned their WIC programs with the Dietary Guidelines for Americans, which gives nutritional recommendations for consumers at every level.

In my home state of Maryland, for example, county health departments have already begun to equip families and healthcare providers with strategies to manage and prevent obesity in pediatric clients. In 2013, the Montgomery County Government initiated Be Active Montgomery! – a series of summer fitness events, in partner with Montgomery County schools, that promote physical fitness and family community building. In 2014, the Howard County Health Department in Columbia, MD issued a Childhood Obesity Prevention Toolkit to educate families on how to encourage healthy dietary/physical habits at home, and they also provided website access to a WIC Vendor Locator that would assist families in finding stores in their communities. I believe that local strategies such as these have contributed to the decrease in low-income pediatric obesity rates in Maryland from 2008-2011, despite the steady population increase.

Childhood obesity in America is one of those issues that is entangled in a web of possible causes. Food deserts in low-income communities promote consumption of quick-and-easy, fatty meal solutions. Highway expansion results in more vehicles per capita and an increase in traffic safety concerns for parents whose children walk and bike around the neighborhood. Public transportation, however useful, proves inconvenient for expectant, single mothers, who are incapable of transporting loads of groceries to their homes. All in all, the solution to the obesity epidemic in America may seem elusive; however health professionals should approach the situation with a modicum of hope that children will be our nation’s saving grace. Regardless of personal opinion, if the movers and shakers of this country made every effort to, literally, think of the children, perhaps we can redesign our environmental and socioeconomic constructs as a nation, to afford every child access to a proper community that promotes healthy living.

Hot Topics in Obesity will be discussed on Friday, December 5 during the fourth annual Advances and Controversies in Clinical Nutrition conference. Dr. William H. Dietz, Director of Redstone Global Center for Prevention and Wellness at GWU in Washington, DC, will give an address “What Explains the Reported Declines in Childhood Obesity?” Dr. Rebecca Puhl will address obesity and weight-related stigma during the same session. Read an interview with her.

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.


By Sheela Sinharoy

When people think of nutrition, they probably do not think immediately of toilets. However, there is growing interest within the global public health community in the relationship between sanitation and nutrition. A group of researchers led by Dr. Tom Clasen of Emory University and the London School of Hygiene and Tropical Medicine has been studying this topic. They recently published findings from a study examining the effectiveness of a rural sanitation program on several outcomes, including child malnutrition, in The Lancet.

The intervention took place in Odisha, India, in the context of the national Total Sanitation Campaign, through which the government of India promotes latrine construction. The campaign focuses on households below the poverty line; it provides them with a latrine but requires that they contribute materials and labor for construction. For this study, the researchers selected 100 rural villages and enrolled households with pregnant women or children under age four. The study took place between May 2010 and December 2013.

Malnutrition was measured in two ways, through height-for-age z-score (HAZ) in children under two and weight-for-age z-score (WAZ) in children under five. The intervention had no effect on mean HAZ. Intention-to-treat analysis also showed no effect on mean WAZ, but per-protocol analysis showed a modest effect size of 0.10 (95% CI: 0.003-0.20). In other words, among the households that were compliant with the intervention, the children had slightly better WAZ scores. The absence of a stronger effect was surprising enough to garner attention from The New York Times, which published an article titled, “Latrines May Not Improve Health of Poor Children.”

I wanted to learn more, so I spoke with Dr. Clasen about the findings. He explained that while latrine coverage increased through the intervention, latrine use remained sub-optimal. While it may seem counter-intuitive, many community members chose not to use their new latrines, preferring instead the culturally accepted practice of open defecation. In particular, the study found that “latrine use was nearly five times higher for women than for men or children.” The reasons behind these gender and age differences are not clear, but Dr. Clasen emphasized the need to increase latrine use, aiming for “everybody, all the time.”

Researchers are examining other potential factors influencing latrine compliance. For example, what role do women play in deciding whether a household invests the resources necessary to build a latrine? If this decision is in the hands of men, and men are less likely to use a latrine, what are the implications for sanitation coverage and compliance? The study team is carrying out analyses on these and many other questions.

Ultimately, Dr. Clasen explained, this was an isolated intervention that could not address the multitude of issues that might affect the study outcomes. Factors such as poor disposal of child feces, the close proximity of livestock, poor water quality, and other forms of contamination likely play an important role in determining child nutrition outcomes. As always, more research is needed to better understand the complicated relationship between sanitation and nutrition.

Clasen T, Boisson S, Routray P, Torondel B, Bell M, Cumming O, et al. Effectiveness of a rural sanitation programme on diarrhea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. Lancet. 2014 [cited 2014 Nov 3].

By Banaz Al-khalidi

November is National Diabetes Month and World Diabetes Day takes place yearly on November 14 to engage millions of people worldwide in diabetes advocacy and awareness. The International Diabetes Federation estimates that 382 million adults (20-79 years old) suffered from diabetes in 2013, which equates to a prevalence of 8.3%. To provide a better perspective by nation, the 10 countries with the highest prevalence of diabetes in 2013 were as follows: Tokelau (37.5%), Federated States of Micronesia (35%), Marshall Islands (34.9%), Kiribati (28.8%), Cook Islands (25.7%), Vanuatu (24%), Saudi Arabia (24%), Nauru (23.3%), Kuwait (23.1%), and Qatar (22.9%). However, if we were to look at the 3 countries with the greatest number of people with diabetes, China ranks the highest (98.4 million), followed by India (65.1 million) and USA (24.4 million). These figures are quite alarming.

Of those suffering from diabetes, type 2 diabetes comprises almost 90% of people with diabetes around the world. As such, type 2 diabetes is one of the fastest growing health problems in the world. So what could be driving this epidemic?

Evidence from observational studies have consistently shown us that low blood levels of vitamin D are associated with an increased risk of type 2 diabetes. The results of numerous observational studies led to speculation that the development of type 2 diabetes is associated with vitamin D insufficiency. Going back to the figures presented earlier, if vitamin D insufficiency is a risk factor for type 2 diabetes, one might also speculate that countries with higher prevalence of diabetes are facing a coexisting problem of type 2 diabetes and vitamin D insufficiency. For example, Tokelauans (the nationals of Tokelau) who have the highest prevalence of type 2 diabetes, may also be at risk for vitamin D insufficiency despite having a tropical and marine climate. The question then becomes, could vitamin D be a causal factor in the development of type 2 diabetes? While this might sound too simplistic, I assure you it’s not.

Interpretation of evidence on vitamin D and type 2 diabetes is complicated for a number of reasons. First and foremost, observational studies do not tell us anything about the cause-effect relationship between vitamin D and type 2 diabetes because of possible uncontrolled confounding factors, such as physical activity, that may affect both vitamin D levels and the risk of type 2 diabetes. Second, observational studies cannot inform us about reverse causation. In other words, which comes first, the chicken or the egg? Third, there are a myriad of factors that affect vitamin D levels, including environmental, cultural, genetic and physiological factors. It remains unclear then whether there is a causal link between vitamin D and type 2 diabetes.

To answer this question, a large genetic study published in The Lancet Diabetes and Endocrinology journal looked at the causal association between low blood levels of vitamin D and risk of type 2 diabetes. The study concluded that the association between vitamin D and type 2 diabetes is unlikely to be causal. The research, which was a Mendelian randomization study, examined the link between type 2 diabetes risk and vitamin D, by assessing the genes that control blood levels of vitamin D. Most importantly, the design of this study has a powerful control for confounding factors and reverse causation which are issues of concern in observational studies. This may partly explain the discrepancy between results from earlier observational studies and this study in question. However, we still need to be cautious about interpreting the results from mendelian randomization studies as some of the underlying assumptions in the study might remain untested.

The take home message is that no special recommendations could be made about vitamin D levels or supplementation for people with type 2 diabetes. However, long-term randomized trials of vitamin D supplementation remain important to elucidate vitamin D’s role in type 2 diabetes.

As we recognize National Diabetes Awareness this month, it is important to remind patients that diabetes is a progressive chronic lifestyle disease that can be controlled by making healthy lifestyle changes- such as partaking in regular physical activity, eating a balanced diet, maintaining a healthy body weight, taking prescribed medications, joining a smoking cessation program, and improving sleeping patterns.

Zheng Ye, Stephen J Sharp, Stephen Burgess, Robert A Scott, Fumiaki Imamura, Claudia Langenberg, Nicholas J Wareham, Nita G Forouhi. Association between circulating 25-hydroxyvitamin D and incident type 2 diabetes: a mendelian randomisation study. The Lancet Diabetes & Endocrinology, 2014; DOI: 10.1016/S2213-8587(14)70184-6.