By Celez Suratos, MS, RD, ACCN15 Blogger

It’s no surprise that obesity was one of the many topics covered at the recent Advances and Controversies in Clinical Nutrition (ACCN) conference. At his presentation during ACCN, Dr. Scott I. Kahan, MD, MPH, delved into the many obesity guidelines and algorithms that exist today.

According to Dr. Kahan and the National Guidelines Clearinghouse, there are over 400 guidelines on the topic of obesity (this excludes the number of other various topics that may include obesity as secondary information). With an ongoing and growing list of information on obesity, how does a clinician sift through it all to find a best strategy to put into practice? Luckily Dr. Kahan summarized four recently published guidelines that can help anyone interested in knowing more about how obesity should be approached from a treatment standpoint. These guidelines were derived from the (1) National Heart, Lung, and Blood Institute (NHLBI); (2) Endocrine Society; (3) American Association of Clinical Endocrinologists (AACE); and (4) American Society of Bariatric Physicians (ASBP).

The information shared in this post will be from Dr. Kahan’s summary of the guidelines from the NHLBI. The recommendations derived from this organization attempt to answer questions regarding the benefits of weight loss, risk of being overweight, the ideal diet an obese individual should follow, what lifestyle interventions are relevant to assist obese patients achieve and maintain weight loss, and the any benefits or risks of bariatric surgery, if such an intervention is necessary. The five recommendations a practitioner should follow when treating the obese patient include:

– Use body mass index (BMI) as the primary screening tool to identify patients who are obese (currently defined as BMI greater than 30). One should also consider waist circumference as a secondary screening tool to identify patients who may be at increased risk for cardiovascular disease
– Advise on moderate weight loss, as defined by a three to five percent reduction in weight, rather than a goal weight. Three to five percent may sound like such a small amount, but it can still have a great impact on various health outcomes in an obese individual. And it may be a less daunting goal for the patient
– Just like a magic pill to make a person instantly lose weight overnight does not exist, there is no such thing as the perfect diet prescription to guarantee sustained weight loss. The focus should be on an individualized meal plan that is lower in calories, incorporates the patient’s food preferences (to encourage compliance), and is used in conjunction with modified lifestyle behaviors
– A successful intervention requires a multidisciplinary approach inclusive of professionals from the fields of nutrition, physical activity, and behavior modification that proceeds for at least six months. According to the data included in Dr. Kahan’s presentation, during this comprehensive intervention period, patients with frequent on-site counseling exhibited more weight loss than patients who relied on other forms of counseling (i.e. electronic counseling, counseling through more commercial weight loss programs)
– The last recommendation from the NHLBI guidelines involves bariatric surgery when appropriate. At present time, patients with BMI greater or equal to 40 kilograms (kg)/meter (m)2 or greater or equal to 35 kg/m2 with co-morbidities, bariatric surgery may be a more viable option than the other previously mentioned recommendations.

Weight loss is not a “one size fits all” scenario; it is always best practice to individualize, individualize, individualize! Obesity is a complex issue that involves more than just number of calories, or those seen on a weighing scale. It is a disease state that constantly relies on a collaborative approach from experts in multiple health-related disciples in order to ensure the best results.

By Celez Suratos, MS, RD, ACCN15 Blogger

An individual only needs two things to easily access a myriad of information: a device that has the ability to connect to the internet, and an internet connection. Such information may be as simple as finding nearby show times for a movie, or something more complex, such as trying to self-diagnosis when exhibiting symptoms of a particular disease. This concept is the same when it comes to how the general public may be finding nutrition information. Along with the ease of access of internet searches however, is a high potential of inaccurate or incomplete nutrition information that’s widely distributed.

This can be further exhibited when it comes to myths surrounding carbohydrate (CHO) intake in people with diabetes mellitus (DM). DM is a complex disease in and of itself.Add the ever-evolving nutrition recommendations, such as the diabetic exchange list, glycemic index, and CHO counting into the mix, and one may be more sympathetic as to why a patient may struggle with compliance and management of his or her diabetes.

Alison Evert, MS, RD, CDE from the University of Washington Medical Center approached some of the frequent concerns that arise from patients and healthcare providers when it comes to DM and CHO intake at the 2015 Advances and Controversies in Clinical Nutrition conference. From the presentation and based on a 2005 Dietary Reference Intake report, individuals need to consume at least approximately 139 gram (g) of CHO per day (this does not include creating glucose through pathophysiological processes, such as gluconeogenesis) in order to meet minimum obligatory glucose needs. Ms. Evert reports recent data of median intake of CHO as 220-330 g/day by men and 180-230 g/day by women. Moreover, data from a 2014 National Health and Nutrition Examination Survey (NHANES) reports that adults (20 years and older) without diabetes consume 48 to 50 percent of their daily calories from CHOs. This information tells consumers that intake of CHOs is a necessity, whether or not he or she has DM. It also communicates to nutrition educators that there may not be an ideal percentage of calories that should be consumed from a single macronutrient.

This begs the question, is current and best practice to make percentage recommendations of macronutrient intake based off of total calories, or is this an archaic and irrelevant practice? During her session, Ms. Evert reflected on her time as a dietetic intern in which she made specific calculations on g of CHO a diabetic should consume per day, and passed on a meal plan to patients based on this information. Imagine trying to explain a generic serving recommendation, such as “eat 13 to 17 servings of CHO per day” to an ill and perhaps non-compliant, underserved, or even under-educated patient.

The take-away message Ms. Evert’s presentation is that patients with DM need individualized nutrition recommendations/meals plans, particularly as there are major differences in type 1 versus type 2 DM, the spectrum of type 2 DM progression among patients, and medications that affect glycemic control. Her suggestion – make it a point to discuss what our food sources of CHO are and focus on lifestyle behavior change.

By Celez Suratos, MS, RD, ACCN15 Blogger

Motivational interviewing (MI) is a technique used to incite positive behavior change. It is directive and client/patient-centered. Healthcare providers (including registered nurses and dietitians) use MI to direct self-motivational statements from the patient. Hence, allowing patients to be in charge of setting and meeting their own goals. Dr. Kathryn I. Pollack from the Duke University School of Medicine facilitated an interactive workshop on MI at this year’s Advances and Controversies in Clinical Nutrition Conference (ACCN). The main focus was to inform healthcare providers of the “spirit” of MI, as well as putting MI techniques into practice through role-playing.

Most of us are familiar with the phrase, “it’s not what you say, it’s how you say it.” But did you know that communication is approximately 90 percent body language? MI is more than a methodological counseling approach. It also causes a healthcare provider be more present and aware of how he/she is communicating to the patient. According to Dr. Pollack, the “spirit” of MI embodies four key principles to elaborate on such a concept; Partnership, Acceptance, Evocation, and Compassion.

A healthcare provider may have the tendency to dominate the conversation by supplying the patient with numerous facts about the status of his/her health, likely telling the patient what he/she “must” do in order to prevent the “worst-case scenario” from happening to them. However, in MI, a provider should focus on building a partnership-like relationship rather than one that is hierarchical. One can do this by initially asking permission before sharing information and giving advice. This allows patients a choice to discuss their health based on their own readiness to handle the information you want to give them. Alternatively, a provider can ask the patient what concerns he/she may have in order to allow the patient to set the agenda, giving the patient the power to discuss what he/she may already be thinking about improving.

Acceptance goes beyond the concept of non-judgment. This means the healthcare provider accepts the patient’s motivation, commitment, and choices in totality. This relates back to non-verbal communication. If you are feeling judgment, you are also likely exhibiting judgment, which then means your patient can see your judgment. Think about it – do you ever cross your arms or furrow your brow when you disagree with a statement? Letting go of judgment will not only improve your skills as a practitioner, but can be freeing as well.

A healthcare provider may be able to provide a patient with beneficial reasons to improve his/her health status. However, evocation is the idea that people are motivated by their own reasons. In MI, the provider facilitates a conversation that allows the patient to find his or her own motivation for adopting positive change. One way to help patients find their motivation is to prompt them with questions to discuss their readiness to change. Such questions may include asking patients to rank their readiness to change (i.e., on a scale of 1 to 7 –with 1 being least ready to change and 7 being most ready for change, for example), then asking why they chose that particular number on the scale, what it would take for them to rank their readiness for change even higher (if not already ranked as a priority), and when will they be ready to implement their plan. Evocation extracts information from the patient, such as reasons to change, identifies barriers to change, and eventually a self-actualized plan to get patients to reach their goal(s).

Dr. Pollack also mentioned ‘compassion’ as a novel principle to the spirit of MI, particularly in the provider-patient relationship. It comes from the idea that providers should use open-ended questions, reflective statements, and summarize the conversation when they interact with their patients. This demonstrates active listening, versus a series of agreeable head-nods or dismissive “uh huh” verbal responses. Compassion also calls on providers to give patients affirmation with each step they take to reach their goal(s), even during times of perceived setbacks.

Dr. Pollack summarized that only the patient can make change happen for him or herself. The patient is the one who needs to put in the work to see results. Motivational interviewing is not only a tool healthcare providers can use as a catalyst for positive change, but is also a specific skill that takes practice and time to perfect.

By Chris Radlicz

According to NHANES (National Health and Nutrition Examination Survey) 2005-2010 the average American consumes about 20 teaspoons of sugar per day, with sugar consumption being the highest in teens and men (1). Interestingly, 33% of calories from added sugars come from beverages, and the majority of those beverages are sweetened with high fructose corn syrup (HFCS) (1).

But what is the novelty of HFCS? Aren’t the grams of sugar on the package all that matters? Although calorically equivalent, not all sugars are metabolized the same way.

Previous papers have established epidemiological links between fructose consumption, obesity, and metabolic disease. To take this further, recent literature has indicated that fructose, particularly in high concentrations, as present in high fructose corn syrup and sucrose, are proving to be toxic. HFCS is composed of about 60% fructose and 40% glucose (2). Prior to the processing of sugars, it was nearly impossible to find such high concentrations of sugar in the diet, but it now seems to be commonplace.

Dr. Kimber Stanhope out of University of California Davis published a recent review paper that touched on the metabolic dysregulation that occurs with high consumption of fructose.

Dr. Stanhope’s group has previously shown that subjects consuming fructose-sweetened beverages for 10 weeks, in addition to their normal diet, had increased de novo lipogenesis, dyslipidemia, circulating uric acid levels, visceral adiposity, reduced fatty acid oxidation, and insulin resistance. In contrast, subjects who consumed glucose-sweetened beverages, had comparable weight gain to the fructose group, but did not exhibit the aforementioned metabolic changes (3). These adverse effects seen in the fructose group all increase the likelihood of chronic diseases such as obesity, fatty liver, type-2 diabetes, and cardiovascular disease.

When consuming glucose, the liver is initially bypassed and the glucose reaches systemic circulation to be used by tissues such as the brain and muscles. If excess glucose is consumed in the diet, it will first be stored as glycogen, and secondarily as fat. Fructose on the other hand, takes a different path. When fructose is consumed, it is exclusively metabolized in the liver, where a particular enzyme, fructokinase, will allow for the uptake of fructose (3). Fructose metabolism as a whole lacks many of the cellular controls that are present in the glucose metabolism, which allows for unrestrained lipid synthesis (2).

Significant metabolic issues arise when a high concentration of fructose is consumed, such as in HFCS. An overload of fructose in the liver will lead to de novo lipogenesis and subsequent lipid droplet accumulation in the liver. With these high levels of fructose, the increase in lipid accumulation consequently decreases the breakdown of fat in the liver (3).

This intra-hepatic lipid will promote the production and secretion of very low-density lipoprotein 1 (VLDL1) leading to an increase in post-prandial triglycerides. A vicious cycle occurs effecting insulin resistance as well. The lipid in the liver will increase insulin resistance resulting in increases in circulating diacylglycerol. Additionally, the insulin resistance will lead to further lipid deposit in the liver with sugar having a greater propensity to turn to fat (3). A downstream effect of increased apoCIII and apoB will lead to muscle lipid accumulation, and end in whole body insulin resistance. All of this metabolic dysregulation results from the direct route fructose initially takes to the liver.

Although there is this well-defined and unique pathway for fructose metabolism, many industry-funded studies, haven’t shown the negative metabolic outcomes of consuming HFCS or sucrose (3). More research is certainly needed, but it is best to remember that added sugar in such high concentrations, no matter the culprit monosaccharide, is not favorable for overall health.

It is interesting to note a possible evolutionary perspective, which proposes the advantage of enhanced fructose to fat conversion. At the end of a growing season, ripened fruit will tend to have high levels of fructose. Therefore the fruit consumed at the end of the season may allow for increased fat storage, which would have been beneficial because of the low food availability in the ensuing months (2).

1.U.S. adults, 2005– 2010. NCHS data brief, no 122. Hyattsville, MD: National Center for Health Statistics. 2013.

2.Lyssiotis CA, Cantley LC. F stands for fructose and fat. Nature. 2013; 508:181-182.

3.Stanhope KL. Sugar consumption, metabolic disease and obesity: The state of the controversy. Crit Rev Clin Lab Sci. 2015;1-16.

By Caitlin Dow, PhD

If you’ve spent any time on the internet in the last couple of months, you’ve likely heard about the recent statement on red and processed meat from the World Health Organization (WHO).The statement was produced by a Working Group of 22 scientists who gathered together at the International Agency for Research on Cancer (IARC), with the goal of considering all data from over 800 epidemiological studies on red and processed meat in order to determine their potential carcinogenicity. The group defines red meat as “mammalian muscle meat – such as beef, veal, pork, lamb, mutton, horse, or goat” and processed meat as “meat that has been transformed through salting, curing, fermentation, smoking, or other processes to enhance flavour or improve preservation” (1). Based on the available data, the Working Group concluded that “that there is sufficient evidence in human beings for the carcinogenicity of the consumption of processed meat.” And then the internet exploded. But what exactly does this mean?

The IARC is responsible for categorizing chemical compounds based on the strength of evidence that said chemical may be carcinogenic. In this statement, they categorized processed meat as a Group 1 carcinogen and red meat as a Group 2B carcinogen.These categorizations are used to describe the strength of evidence that these compounds may be carcinogens; thus, Group 1 is used to distinguish “established carcinogens” [e.g. acetaldehyde (a metabolite of alcohol), oral contraceptives, formaldehyde, and sawdust], whereas Group 2B includes compounds that are considered “possible carcinogens” [e.g. benzofuran (a compound in coal tar), butylated hydroxyanisole (an additive found in foods, cosmetics, rubber, etc.)] (2).And while these classifications are important, they are easily misconstrued, as was the case in this statement by the IARC. These classifications simply tell us that a compound could be hazardous to human health. What they don’t tell us is degree of risk.That’s important because lots of things can be hazardous without posing a significant risk.For example, UV radiation is a hazard, but it is only a risk if one is exposed to excessive amounts of UV radiation.That is, risk is the product of hazard multiplied by exposure. Reduce your exposure, reduce your risk. That’s where most people got confused with this IARC statement.

The media jumped on the statement and let out a warcry against red and processed meats.But what most of them failed to mention is the all-important question: how much red and processed meat need be consumed to increase risk for developing cancer? One meta-analysis found that risk of colorectal cancer increased with increasing intake of red and processed meats up to 140 g/day (~5 oz/day) (3). Further, risk of developing colon cancer in response to consuming red/processed meat increases by ~25% for every additional 100g consumed/day. Thus, this study was evaluating risk in consumers who eat A LOT of red and processed meats.Importantly, these effects were strongest in European (29% elevated risk/100 g/day increase in intake) compared to North American (11% elevated risk/100 g/day increase in intake) and especially to Asia-Pacific studies that observed a non-significantly reduced risk (6% reduced risk/100 g/day increase in intake). These results indicate that not all populations are equally affected, which is likely due to differences in genetics and/or lifestyle. And what about people who don’t even eat red/processed meat everyday? Are they at risk just by eating these foods once in awhile? A meta-analysis by Norat, et al. (4) estimated that reducing red meat consumption to 70 g/week (~one 3 oz. serving/week) would reduce colorectal cancer rates by 7-24% in regions with high intake.That is, eating red or processed meat once a week likely does not increase risk for colorectal cancer.

At the end of the day, the IARC added processed and red meat to their list of carcinogens.But in terms of translating that into a public health message, they didn’t do a great job.Yes, red and processed meats are hazards to health. If you choose to eat them, keep your exposure low and your risk will likely also be low. As always, eat a varied diet, high in fruits and vegetables, whole grains, legumes, nuts and seeds to ensure high antioxidant and anti-inflammatory compound intake to protect against potential damage that red and processed meats may pose.

References

1.Bouvard, et al. on behalf of the International Agency for Research on Cancer Monograph Working Group.Carcinogenicity of consumption of red and processed meat. Lancet: Oncology. 2015 Dec;16(16):1599-1600.

2.American Cancer Society. Known and Probably Human Carginogens. http://www.cancer.org/cancer/cancercauses/othercarcinogens/generalinformationaboutcarcinogens/known-and-probable-human-carcinogens. 2015 Oct.

3.Chan DS, et al. Red and Processed Meat and Colorectal Cancer Incidence: Meta-Analysis of Prospective Studies. PLoS One. 2011;6(6):e20456.

4.Norat T, et al. Meat consumption and colorectal cancer risk: dose-response meta-analysis of epidemiological studies. Int J Cancer. 2002 Mar;98(2):241-56.