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Experimental Biology 2017: Developing Healthy Eating and Physical Activity Behaviors through Education, Extension or Technology

Walking into the “Developing Healthy Eating and Physical Activity Behaviors through Education, Extension or Technology” session sponsored by the ASN Nutrition Education and Behavioral Sciences RIS, you could feel the energy in the room as everyone waited in anticipation for the oral sessions to begin.

The session began with a presentation by Gabriella McLoughlin, University of Illinois at Urbana Champaign, on “School Lunch and Physical Activity During Recess: Interactive Effects of Health Behaviors in the School Setting.” Her presentation focused on how the timing of lunch affects food intake during lunch and physical activity during recess for 4th– and 5th-grade students. Her study found that students who ate lunch before recess were more physically active during recess and consumed more vegetables. Further, engaging in moderate-to-vigorous physical activity was inversely associated with lower intakes of carbohydrate, fat, sugar, and overall calories. However, students who ate lunch after recess ate more and had greater intakes of carbohydrate and fat.

Laura Adam, University of Alberta, followed with her presentation on “Sense of Weight Control Prior to Pregnancy Could Help Predict Women at Risk for Excessive Gestational Weight Gain.” Her analysis sought to understand if differing amounts of lifestyle support provided by a Registered Dietitian (RD) during pregnancy could help women achieve appropriate gestational weight gain. Participants were randomized into the control or intervention group. The intervention group received two visits from an RD during pregnancy, while the control group did not. No difference was found for total gestational weight gain, rate of weight gain, and adherence to the gestational weight guidelines between the groups. However, she found that more women with BMIs in the obese and overweight category exceeded the recommended gestational weight gain, as compared to women with a normal BMI. Further, women who felt more in control of their weight before pregnancy were more likely to adhere to the gestational weight gain guidelines.

James Roemmich, Grand Forks Human Nutrition Research Center, next shared a unique perspective for how to motivate people to be active during his talk on “Increasing Discomfort Tolerance Predicts Incentive Sensitization of Exercise Reinforcement: Preliminary Results from a Randomized Controlled Intervention to Increase the Reinforcing Value of Exercise in Adults.” His work uses the Incentive Sensitization Theory, which is usually used to describe how people become addicted to drugs. This theory postulates that neuroadaptations in the brain increase craving of a behavior causing the object to become more motivating, so the individual wants to consume the stimulus. Roemmich applies this theory to physical activity to determine if tolerance for exercise discomfort is related to relative reinforcing value of exercise. He conducted a 3-arm, randomized, controlled trial over the course of 6 weeks with two exercise arms (expending 150 or 300 kcals during cardio-type exercise 3 days/wk) and a control group. He found that those who exercised more intensely increased their tolerance to exercise and those with more tolerance had greater relative reinforcing value of exercise. He recommends the focus be on guidelines to increase motivation for exercise, so it becomes a habit.

Jacqueline Vernarelli, Fairfield University, explored the relationship between energy density and enjoyment of physical activity for her presentation on “Early development of healthy habits: Children who enjoy physical activity have healthier diets than children who do not.” She used data from NHANES: 2012 National Youth Fitness Survey (NYFS) with a sample of 1,640 children between 3-15 years old. Children were asked if they liked recess using a 5-point likert scale. She found that children who strongly liked recess had lower energy dense diets. Vernarelli recommends focusing on future strategies to examine ways to increase enjoyment of physical activity to encourage children and adolescents to be active.

Sofia Segura-Pérez, Hispanic Health Council, examined a novel way to reach a Latino audience during her talk on “Development and Validation of a Culturally Appropriate Heart Disease Prevention Fotonovela among Spanish Speaking Low-income Latinos.” She employed Community Based Participatory Research to develop a fotonovela (a form of sequential storytelling that uses photographs in the form of photo comics) about heart disease prevention. Through a series of focus groups, she identified common barriers to eating healthy, exercising, and smoking cessation and was able to create messages to encourage healthier behaviors. After her final focus group, she found participants increased knowledge following reading the fotonovela and wanted to be more active, eat better, and stop smoking. Her research shows that fotonovelas are culturally and literacy appropriate educational instruments to use for Latinos.

Sarah Stotz, University of Georgia, took the podium next to share how she developed an eLearning nutrition program to encourage Supplemental Nutrition Assistance Program Education (SNAP-Ed) eligible participants to make healthier choices during her talk on “Expectations and Recommendations from Low-Income Adults Regarding an eLearning Nutrition Education Program Prior to Program Use.” With increased access to the Internet, online learning can be used to address the barrier to attending nutrition education sessions in-person. Further, online learning is self-directed, which capitalizes on adult learning principles. Stotz developed the Food eTalk eLearning Program, which was adapted from the validated nutrition education program, Food Talk. To gauge how her intended audience would respond to the program, she conducted a focus group series (n = 45) and individual interviews (n = 19) to see what participants wanted in an online education program. She uncovered three common themes: 1) Participants used their phones a lot; 2) Participants had low expectations for an online program; and 3) Even though they were unprompted, participants wanted to share that they know they should eat healthier, but “it’s just hard.” Based on this information, Stotz learned to make the eLearning program mobile-friendly, create short learning modules (~10 minutes), identify specific learning topics, and make the lessons entertaining and video-based.

Sharon Kirkpatrick, University of Waterloo, discussed her findings from using a web-based dietary assessment tool during her presentation on “Evaluation of the Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24) for use with children: An observational feeding study.” ASA24 is an online, self-administered dietary recall tool that follows a format based on the Automated Multiple-Pass Method used in the National Health and Nutrition Examination Survey (NHANES). Dietary assessment, particularly among children, is a challenge since it’s subjected to many biases. Kirkpatrick conducted a study to determine how precise ASA24 was with children in 5th-8th grade. She provided each child with lunch that was weighed before and after consumption. The next day, the children were given time to complete ASA24 during class independently. She found most children reported the main lunch item well, but recall was lower for side dishes and the lowest for condiments, such as dip. Kirkpatrick also found that the younger children had more difficulty completing ASA24. Overall, she found that ASA24 performed relatively well, but younger children need more time and help to complete the recall. She suggests accompanying ASA24 and similar technologies with a training, tailored help, and/or supplementary sources of information, such as including menus.

The session concluded with a presentation by Soghra Jarvandi, University of Tennessee Extension, on “Goal Setting, Past Performance and Behavioral Outcomes in a Worksite Wellness Program.” Jarvandi used the Walk Across Tennessee program, a team-based walking program, as a platform for using goal setting as a strategy for facilitating behavior change. Before the study, participants completed the International Physical Activity Questionnaire – short form (IPAQ-short) to assess their initial physical activity level. Participants also self-selected a walking goal and during the study received weekly feedback through a visual graph depicting how much they walked compared to their initial goal. Jarvandi used the IPAQ-short questionnaire to divide the participants into high activity (compliers) and low activity (non-compliers) to see if they had differences in their activity and goal setting during the study. After the study concluded, she found no difference between compliers and non-compliers in terms of their activity habits and goal setting. However, she suggests participants with low levels of physical activity may benefit from behavioral strategies that improve motivation.

At What Point Do We Enact Obesity-Targeting Policies?

How much evidence should be demonstrated before enacting obesity-targeted health policy? This difficult question was debated between two speakers Sunday at ASN’s Scientific Sessions and Annual Meeting, as part of the Obesity Research Interest Section Forum, chaired by Andrew Brown, PhD.

The first speaker, Laura Schmidt, PhD, defended the need to set such policies early on. According to Schmidt, one reason we cannot afford to wait for perfect evidence is because the National Nutrition Research Roadmap indicated that the average amount of time that it takes for research to go from bench to bedside/community is 17 years. Dr. Schmidt noted that how research is translated to policy needs to be strategic and carefully considered, the evidence must be robust and systematically reviewed, but that science can only inform, not drive policy decisions. Often it is not possible to enact policy at exactly the specifications that research suggests. For example, a 20% tax on sugar sweetened beverages was indicated to show an effect on sales, but San Francisco couldn’t get a bill passed into law until the tax was reduced below 20%. Standards for evidence are often higher in the scientific community, she said: they utilize systematic reviews, expert panel summaries, and formal guidelines by federal and global agencies. When the results of a large number of different types of studies that use different measures and outcomes point in the same direction (i.e. observational, clinical trials, and mechanistic), we can be confident in the strength of the evidence. Schmidt gave an example of some issues she perceives haven’t reached a body of research big enough to act on yet: taxing 100% juice or diet sodas, even though there is emerging concern on each from the literature. Finally, Dr. Schmidt noted that we need to be concerned with industry funded research as some evidence suggests it may bias conclusions on a topic. To summarize: we should acknowledge the need to translate research in ways that can inform policy and that best practices and standards for evidence-to-policy are shaping up, but that challenges remain, including scientific bias due to conflicts of interest.

As a contrasting perspective, Michael Marlow, PhD, outlined his concerns with setting policies without a very high level of confidence that they will succeed. In other words, caution must be exercised because researchers don’t yet know optimal policies. He outlined his concerns as follows: 1) There are good intentioned hunches over scientific exploration. Confirmation bias and common narratives may lead to policies that don’t reflect reality. 2) Many research methods promote type-I errors, such as P-hacking, often a consequence of tenure and grant requirements and journal editor demands. 3) The quality of dietary data is poor. Dr. Marlow pointed to a study that found that for 95% of a study sample, fast food, soft drinks, and candy had no association with BMI. There are a number of possible interpretations to this: the data sources (diet recalls) may be so seriously flawed that it is ok to advocate laws that only affect 5% of the population. Should we enact policy or wait until data collection is improved? And, 4) There is naive modeling of interventions that goes into estimating policy efficacy. Linear relationships are often assumed between availability of nutrition information and behavioral changes, for instance. Because of what is overlooked, Marlow’s simulations of policy success range from 6.25% with optimistic probabilities of effects to 0.01% with less optimistic assumptions. To summarize: policy proposals need solid theoretical and empirical support, data quality needs more attention and acknowledgement, measures for policy success need major rethinking, uncertainty and unintended effects need acknowledgment, and we need to resist ill-advised albeit good-intentioned policies from citizen pressure.

There is no easy answer to how long we should wait before enacting health policies that target obesity. Translating research to policy is difficult and policy as a natural experiment can help us understand if we can impact obesity. A common thread of agreement is the need to ensure that we have high quality research methods and to reduce bias wherever possible. Perhaps then the question would be easier to answer.

Multivitamins and Moving Toward Personalized Nutrition

multivitamins

Are multivitamin/mineral supplements beneficial? How do they relate to personalized nutrition? What even is a multivitamin? These questions were discussed at the “Multivitamin/Mineral Supplements in the Age of Personalized Nutrition” session Sunday during ASN’s Scientific Sessions and Annual Meeting. The chair of the session, Jeffrey Blumberg, PhD, introduced the session by noting that we don’t have a good consensus definition of either multivitamins or personalized nutrition. Multivitamins currently market for health claims such as bone health, vision, achieving nutrient recommendations etc… are these personalization or just marketing segmentation?

Regan Bailey, PhD, MPH, RD, was the first speaker who brought her expertise in epidemiology for an overview of multivitamin research, particularly from the National Health and Nutrition Examination Survey (NHANES) data. She discussed the various ways the definition of a “multi” can be operationalized: multivitamin to multivitamin/multimineral, and that there is no standard or regulatory definition. This has led to different ways of assessing multi use in NHANES research; for instance > 3 vitamins, > 30 vitamins & > 1 mineral, > 10 vitamins, etc. Depending on how you define, it you could change the estimate of how many people use these products in the U.S. by a couple million people. This also makes it difficult to monitor trends over time. Survey data tells us that the #1 reason why people use multis is to improve health, and associations with health behaviors suggests that these are people who are looking to take an active role in their health. In addition, multis are the #1 recommended product by physicians, although the use of multis is usually not disclosed to physicians. Other findings from NHANES tell us that adult users of multi products tend to have higher vitamin and mineral intakes from foods than non-users, that supplements help users meet recommendations for all micronutrients except potassium, but also that supplements increase the potential for intakes above Tolerable Upper Intake Levels for some nutrients. There are concerns with the level of nutrients on labels versus the actual amounts.This can vary by quite a bit in certain products, as well as bioavailability, nutrient and drug interactions, and keeping databases up to date. To solve some of these issues, more funding is needed. Dr. Bailey provided perspective that if annual supplement sales represent a $100 bill, the amount of funding that the entire National Institutes of Health (NIH) receives is only $1.

Cornelia Ulrich, PhD, spoke to the relationship between micronutrients and nutrigenomics/epigenetics, focusing on folate as an example of the bigger picture. An issue, she says, is that adults with cancer or cancer survivors frequently use vitamin and mineral supplements. This may put folic acid intakes well over the requirement, combined with folic acid fortification of foods. Antifolates are used in cancer therapy, and some research suggests an increased risk for certain cancers such as prostate with folate supplementation. In silico modeling of folate metabolism based on known kinetics and biochemical properties also suggests that high folic acid can impact cancer biomarkers, particularly in those with a genetic predisposition (i.e. MTHFR polymorphisms). Biological changes with high folate include a reduction leukocyte global DNA methylation, and a reduction in natural killer cell cytotoxicity, which may explain some of the relationships with cancers. Folate appears to modify associations between DNA methylation and outcomes such as fasting glucose, and its effects may be passed on in uterine development. Dr. Ulrich concluded with a summary that folate may have potential dual roles dependent on dose and context that warrants caution with supplementation or fortification, and that genetic make-up can affect these associations which will no doubt be a consideration going forward toward nutrition personalization.

Lastly, Howard Sesso, SCD, MPH, discussed the evidence from randomized controlled trials of multivitamin interventions. The U.S. Preventive Services Task Force (USPSTF)’s latest recommendations concluded that there is insufficient evidence regarding the long-term chronic disease effects of multivitamins on chronic disease risk. A big issue stemming from the lack of a standardized definition of a multivitamin is that it makes the meta-analyses on the topic more difficult to interpret. In recent years several large randomized trials have explored the effects of multis on primary and secondary disease prevention. With regard to cancer, the SU.VI.MAX study suggested a possible benefit on cancer incidence and mortality in men but not women. A trial in Linxian, China indicated a reduction in total and cancer mortality and stomach cancer, and the Physicians’ Health Study II also found a reduction in total cancer. For cardiovascular outcomes, multis reduced blood pressure and C-reactive protein, TACT showed no effect on cardiovascular events, and the Linxian Dysplasia Nutrition Intervention showed no effect on overall mortality. The Physicians’ Health Study II also indicated a reduction in cataracts. This overview led to their trial currently in progress: the COcoa Supplement and Multivitamin Outcomes Study (COSMOS). It will consist of 18,000 participants who undergo a 4 year treatment and follow-up, due to be completed around 2020. Ancillary studies will look at cognition, eye disease, and other chronic diseases like diabetes, cancer, etc. Sesso concluded by reiterating the need for multivitamin trials given their high prevalence of use and recommendation by clinicians, that more short-term mechanistic trials are needed, but that we need to improve the designs of larger, longer prevention trials as well.

Multivitamins are used by a large percentage of the population, yet despite large trials we are still unclear of their efficacy on many health outcomes. It is important to standardize definitions and databases so further trials can be adequately designed to answer such questions. More short-term trials should explore the plausibility by which multivitamins could be acting to reduce disease risk in various populations, including genetic subgroups to explore those who may benefit most from a move toward personalization.

How Nutrition Science Should Mature

how nutrition science should mature

Dennis Bier, MD, was this year’s W.O. Atwater Memorial Award Winner and Lecturer at ASN’s Scientific Sessions and Annual Meeting on Tuesday, sponsored by USDA-ARS and ASN. His talk, titled “Traveling the Road From Precision to Imprecision- Have I Gone in the Wrong Direction?” was a broad critique on the state of nutrition science, contrasting his long research career using isotopics for precise kinetic measurements in humans to some of the more imprecise techniques being used in nutrition. Human nutrition today remains an immature science, says Dr. Bier, because it is so difficult to accurately measure what people eat.

Among his critique along this line, he noted that individual nutrient intake measurement methods are “validated” against other imprecise methods, and even these correlations are generally weak within the 0.2 to 0.5 range. Further, it generally takes between 5-15 24-hour diet recalls, sometimes many more, to achieve an adequate estimation of nutrient intakes in overweight and obese participants, which is never done in practice. Another problem is the seasonal variability of nutrients in foods, using vitamin C as an example, or variation from changes during processing and cooking. If such variation is considered in epidemiological studies associating foods with disease outcomes, it greatly reduces the power to detect a statistically significant result, or can change a result from a positive association to a neutral one.

Should we think about nutrition as a science in the same manner as other disciplines like physics? Bier thinks we should. The differences are obvious now. It is extremely difficult to do long-term experiments in people for many reasons of practicality and cost. But if we concede to this difficulty, our confidence in certain areas of nutrition science will remain stagnant. There are some examples where observational data seems to have led us astray, for example with vitamin E and a follow-up negative trial, and similarly with homocysteine reduction with folic acid and a follow-up negative trial. Dr. Bier noted that more than 15 randomized controlled trials have failed to support nutrient hypotheses generated from observational studies of food intake. There may be many reasons for this: differences in subjects, inclusion criteria, dose or duration, therapeutic window, etc., but we also must consider that the observational data may lead us astray. There are underappreciated interdependencies in observational variables that cannot all be statistically accounted for. Bier’s cautions on such data should be uncontroversial. Associations uncovered in observational studies are hypothesis, they cannot infer causality, and drawing conclusions from them are fine as long as their uncertainty is acknowledged where they are used. In practice, however, these rules are often not followed.

Bier concluded by talking about the many issues that plague science in general that make the literature less reliable. For instance, 95% of the biomedical literature contains a significant result, suggesting a severe publication bias in favor of positive results. Other issues arise with a large researcher degrees of freedom; that is, the number of choices the researcher makes when designing a study or analyzing the results. Asking a lot of questions, changing the primary endpoints, focusing on positive endpoints and discounting negative ones. In reporting of results, implying causality from associations is often done inappropriately, or inflating the effect of the finding by only reporting relative risk instead of absolute risk.

“Transparent science, like transparent government, means releasing your tax returns.” Dr. Bier wants the field to think more about reporting. Among a long list of ways that scientific integrity can be improved: require a priori registration of all studies and a data analysis plan, report all primary endpoints together, require perspective in reporting of the results (e.g. effect sizes, confidence intervals, absolute risks, NNT, etc.), mandatory use of reporting guidelines, report alternative analyses (e.g. alternative models that fit the data with equivalent statistical confidence), making the original data available for scrutiny, and improving the disclosure of conflicts of interest. Everyone has some form of conflicts, for example, money, grants, fame, etc., and Bier thinks that allegiance biases are at least as common as financial ones, so we need to come up with a universal conflict of interest system to make this standardized and fair.

While Dr. Bier’s views may be too idealistic for some, he promotes a necessary conversation about how we improve nutrition science and reduce our uncertainties. To that end, the field should continuously strive to enforce policies and practices that better our measurement techniques and limit bias.

Predictive Modeling in Nutrition

ASN Scientific Sessions

How does predictive modeling influence nutrition research, clinical interventions, and public health? This question was pondered in a session co-chaired by David Allison, PhD, and Kevin Hall, PhD, on Saturday morning at Experimental Biology. Dr. Allison introduced the session by giving an overview of some uses of predictive modeling related to nutrition research: modeling the social contagion of obesity, obesity propagation over generations, projecting policy implications, and agent-based modeling.

Kevin Hall, PhD, shared his influential work that started with developing predictive models and now uses them within clinical studies. Using previous highly controlled studies in metabolic chambers, he was able to form a mathematical model to predict metabolic adaptations in response to changes in energy intake. Recently, he and colleagues have used these models to design and predict what occurs in response to reducing the level of carbohydrate in the diet. The carbohydrate-insulin hypothesis, which postulates that carbohydrates cause body fat gain through the increase of insulin, has recently gained prominence from those filling in research gaps with their own speculations. To address this gap, he tested the predictions of his mathematical model against this hypothesis in a metabolic ward study by providing isocaloric diets restricted in either carbohydrates or fat. Though the low carbohydrate diet group did exhibit reduced insulin, both groups lost body fat, and in fact, the reduced fat group had a greater fat loss,because energy expenditure was decreased by the reduced carb group. In response to this study, Dr. Hall noted that they were criticized by some low carb advocates that their study wasn’t “true low-carb”, and that they didn’t wait long enough to observe a rebound in energy expenditure on a low-carb diet. However, in 2016 they published a second study on a ketogenic diet. The small, but not clinically significant increase in energy expenditure on the ketogenic diet was predicted by the model. Such successful application of mathematical modeling demonstrates that the models can be used to make testable predictions for experiments, and data can be continuously integrated to evolve the model.

Corby Martin, PhD, talked about the application of predictive modeling into the clinical setting. Combining such modeling into technology can theoretically improve adherence to a weight loss intervention, in part by allowing feedback between the clinician and the patient. Dr. Martin emphasized however that the presence of a device does little itself to change behavior over the long-term; it must be used in combination with a behavior change theory and the goals of the patient. He and his colleagues have been developing mobile health interventions to bring the rigor a clinic-based weight loss intervention to larger scale. For example, their SmartLoss app allows tracking of objective data such as weight that can be be fed into a predictive model to quantify diet adherence, and feedback can be sent to the patient in near real-time. Such data can be useful to individualize recommendations; for instance patterns may arise if patients don’t come often enough for clinic visits, or if certain methods of calorie restriction like portion control work better than others. Further, it can make it easy to visually show the plateau effect of even small intermittent non-adherence. Their initial trial demonstrated a 9.4% weight loss using the app versus 0.6% in those only receiving health tips by smartphone.

Next, Ben van Ommen, PhD, discussed the concept of “personalized nutrition” – that health is defined by “the ability to adapt”, and that we all have variability within certain oxidative, inflammatory, and metabolic processes in response to dietary challenges. In other words, we have a phenotypic flexibility in the ability to adapt to inflammation, or different amounts of nutrients in the diet (e.g. fats vs. carbs). This may be indicated by Blanco-Rojo et al 2015, who found that a low-fat versus Mediterranean diet may result in improved insulin sensitivity depending on whether participants have liver or muscle insulin resistance. Dr. van Ommen also discussed the issue of data ownership, something that they’ve put a lot of thought into in Europe that will become a bigger issue as we move toward personalization of nutrition.

Lastly, Emily Dhurandhar, PhD, talked about the usefulness of predictive modeling for public health obesity policies. Two issues with public health policies is that they often don’t account for energy balance being a dynamic, adaptable system, because the models are built in clinical settings, and they often focus on one food or habit instead of achieving a substantial shift in overall energy balance. For instance, Dr. Hall and colleagues showed that using the simple 3500 kcal per pound fat gain rule greatly overestimates how much weight will be lost over time in response to calorie reductions because it fails to account for metabolic adaptations in energy expenditure. In addition, behavioral compensation is not considered in health policies. Dhurandhar and colleagues showed that such compensation in exercise interventions to increase energy expenditure may be 55-64% less than expected because of such compensation like increased appetite. From this data they built an “E-EBALANCE” calculator that corrects for behavioral compensation. Dr. Hall’s group also revealed the underappreciated role of appetite in slowing weight loss compared to energy expenditure. If models that inform public health policies don’t take both metabolic and behavioral adaptations into account, the effectiveness of public health recommendations will be overestimated.

Diana Thomas summarized the session by concluding that predictive modeling can be used to ask “what if” questions, and these results can form the basis for targeted experimental design, which lends more rigor to the experiment. It can be used to determine deviations from expectation during weight loss interventions, and closely assess patient adherence, while guiding behavior change. We are slowly uncovering evidence of individual metabolic responses to dietary challenges, and predictive modeling will have a role in the future of personalized nutrition. Modeling needs to be incorporated into assessing the potential impacts of public policy, and tracking unintended changes and long-term national trends. It is clear that modeling will play an important role in nutrition research, the clinic, and public policy going forward.

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Multimodal interventions: Combining nutrition with exercise in clinical populations

nutrition and exercise

Nutrition provides the building blocks our body needs, including energy to move for physical activity and metabolic adaptations that occur after exercise. Similarly, those who are physically active are more likely to eat a healthier diet [1]. As an athlete, it’s easy to see this reciprocal relationship; but can we simultaneously administer physical activity and nutrition interventions in populations that are not athletes? More specifically, can we use these modalities together in clinical populations?

The answer is yes. Multimodal interventions constitute two or more modalities aimed at improving outcomes. While these types of interventions do not necessarily have to include nutrition and exercise, this approach is highly effective, especially when the goal outcome is increasing or maintaining muscle. Exercise has anabolic and anti-catabolic effects, but a net protein balance occurs only when sufficient energy and protein is consumed after exercise [2]. The theoretical rationale for using these interventions in clinical populations is that many patients have systemic inflammation, insulin resistance, and muscular disuse – all of which can be ameliorated through physical activity and nutritional strategies (especially those with high calories and protein). Indeed, studies in older individuals, individuals who are obese or have HIV/AIDs or chronic obstructive pulmonary disease, and healthy adults undergoing prolonged bedrest show that while nutrition supplementation might promote muscle anabolism and strength, adding exercise is even more effective [3].

Clearly, clinical populations have diverse nutrition needs, functional limitations, and disease status that might impact the feasibility and efficacy of such integrative interventions. Inclusion criteria must be carefully selected in order to observe any statistical impact. For example, in critically ill patients, there is a possibility that inclusion of “severely ill” individuals might make statistical or clinical impact impossible to detect, since these patients experience such high mortality because of their condition. Conversely, if a patient’s hospital stay is short (i.e. <4 days), then muscle atrophy might not develop, again negating the benefits of an intervention [3]. Like a clinical trial in any population, the primary outcome must be carefully selected, the intervention should be clear and feasible, and statistical tests must be robust.

Interventions like the MENAC trial are implementing nutrition, exercise, and anti-inflammatory interventions in individuals with cancer cachexia, a population that is likely to lose muscle and have significant nutrition impact symptoms. In the pilot phase II study, patients on the intervention arm gained weight while the control group lost weight (p<0.001); there was also a trend indicating the control arm might have lost more muscle [4]. The phase III trial is currently underway in multiple sites across Europe, Canada, and Australia.

Dietitians will play a crucial role in these trials by working with patients and colleagues in other fields to design and implement optimal nutrition throughout the disease trajectory. Future research should highlight the role of the dietitian and elucidate the ideal amount and quality of nutrition to recommend, the mechanisms and outcomes of such interventions, and the patient experience.

References:
1. Loprinzi PD, Smit W, Mahoney S. Physical Activity and Dietary Behavior in US Adults and Their Combined Influence on Health. Mayo Clin Proc. 2014 Feb;89(2):190-8.
2. Poole C, Willborn C, Taylor L, Kerksick C. The role of post-exercise nutrient administration on muscle protein synthesis and glycogen synthesis. J Sports Sci Med. 2010 Sep 1;9(3):354-63
3. Heyland DK, Stapleton RD, Mourtzakis M, Hough CL, Morris P, Deutz NE, Colantuoni E, Day A, Prado CM, Needham DM. Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues. Clin Nutr. 2016 Oct;35(5):1196-206.
4. Kaasa S, Solheim T, Laird BJA, Balstad T, Stene G, Bye A, Fallon MT, Fayers P, Kearon K. A randomised, open-label trial of a multimodal intervention (exercise, nutrition, and anti-inflammatory medication) plus standard of cares versus standard of care alone to prevent/attenuate cachexia in advanced cancer patients undergoing chemotherapy. J Clin Oncol. 2015; 33(suppl; abstr 9628)

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Does Breastfeeding Make You Smarter?

Does Breastfeeding Make You Smarter?

Good nutrition has been shown to help with survival, growth, mental development, health, and well-being across one’s lifespan. Unearthing precisely what to eat to help achieve maximal benefit has been the subject of many research studies and debates, especially regarding childhood nutrition starting at an early age.

Breastfeeding has been recognized for its ability to provide infants with essential nutrients to help with growth and development. Research has shown there are many benefits associated with breastfeeding, such as building a healthy gut microbiota and increasing the bond between mother and child. The child benefits from the nutrients found in breast milk, such as docosahexaenoic acid (DHA) and arachidonic acid, omega-3 and -6 fatty acids essential for cognitive development. Somewhere down the line the notion that breastfeeding can make your baby smarter has been perpetuated. However, this has not yet been proven.

Researchers from the University College Dublin in Ireland conducted a study to investigate the impact of breastfeeding on children’s cognitive development. Around 8,000 families from the Growing Up in Ireland longitudinal infant cohort were randomly selected to participate. Data was collected when the child was 9 months old, 3 years old, and 5 years old. Questionnaires were used to measure children’s cognitive abilities, expressive vocabulary, and problem behaviors, and breastfeeding data was collected as retrospective self-report from the mothers. Propensity score matching, instrument variables, and sibling pair models were used for the analysis. The “breastfed” and “never breastfed” groups were matched based on infant, mother, and family-level factors, such as birth weight and maternal age.

Children who were breastfed scored higher on the problem-solving scale. However, after adjusting for potential confounders, this result was found to be no longer significant. This means other factors, such as socioeconomic status, could better explain the variability here. Breastfed children had lower parent-rated hyperactivity compared with controls after the adjustment, but this effect was only seen at 3 years of age. This may mean that breastfeeding helps reduce hyperactivity in the short term, but this effect was not maintained. Although the researchers found no evidence to support that breastfeeding helps improve cognitive abilities, they did note that their study did not contradict any of the medical benefits of breastfeeding. Research on breastfeeding will continue to be done and hopefully we will see more positive findings emerge in this area. For now, the current World Health Organization recommendation for breastfeeding is to exclusively breastfeed for the first 6 months of a child’s life, if you are able.

 

References:

Girard L, Doyle O, Tremblay RE. Breastfeeding, Cognitive and Noncognitive Development in Early Childhood: A Population Study. Pediatrics. 2017;139(4):e20161848. doi:10.1542/peds.2016-1848

Interview with Robert Bertolo

April 2017 Member Highlight Interview for ASN Nutrition Notes eNewsletter:

Interview with Robert Bertolo, Professor, Department of Biochemistry, Memorial University of Newfoundland, Vice Chair of ASN Publications Management Committee, and Immediate Past President of the Canadian Nutrition Society

Dr. Bertolo has been with the Memorial University of Newfoundland since 2002. He trained at the Universities of Guelph and Alberta studying nutrition and metabolism during development with a focus on amino acid and protein nutrition. As a Professor of Nutrition and Metabolism and Canada Research Chair in Human Nutrition, his current research involves the neonatal use of amino acids for growth and non-growth requirements.

1. How did you first get involved in biochemistry and nutrition? What made you interested in the field?

My undergraduate degree was in liberal arts with a minor in biochemistry and when it came time to choose my honours thesis topic, a course in nutritional biochemistry by Stephanie Atkinson piqued my interest. The work in the lab was exciting and that environment felt like home. So I started my MSc at Guelph in nutrition shortly thereafter and never looked back. What I really enjoyed about studying nutrition and metabolism is the combination of mechanisms with real world applicability. Anyone who eats is a self-declared expert in nutrition so the field is uniquely influenced by the public and is very dynamic. There’s always so much to learn, and even more to teach.

2. When and why did you first join ASN? What convinced you to join the organization?

As with most of us, I first joined ASN as a graduate student to get connected with the network of researchers and to present our data. It’s a testament to ASN’s support of trainees that we all join so early. My first EB was an unforgettable experience of excitement, nerves, intellectual stimulation and fun. Presenting to the names on your reference list is quite the experience, but also realizing they’re all just regular folks made it so rewarding. After that first conference, ASN became the home base for networking with international experts and learning about many other disciplines within nutrition.

3. What aspects of ASN membership have you found most useful, professionally? What other aspects of your membership do you find useful as your career has progressed?

Probably the most important asset to membership is the networking opportunities with nutritionists from around the world. ASN is the gathering place for nutritionists from around the world and it allows you to learn about peripheral topics in nutrition so you don’t get consumed by your own little niche. A key part of this networking is getting involved in ASN activities including RIS events, committees, judging, etc. That’s really where you meet wonderful people of all career levels and from various disciplines. Many collaborations (and friendships) are started in the hallway between sessions or at a poster or at a break during the committee meetings. The world of research today is all about team effort, so these connections are key to research success.

4. How do you see ASN’s role in the nutrition community?

I was president of Canadian Nutrition Society shortly after it too was formed from the merger of nutritional sciences and clinical nutrition societies. ASN was a model we used to build a community of nutritionists with different goals and priorities. We admired ASN’s ability to grow and be strong, while at the same time taking risks and constantly looking for opportunities. It was because of our similar goals that we established a joint membership opportunity and we continue to collaborate. And beyond Canada, ASN has made it a point to link with many nutrition societies internationally which is a testament to their role as global leaders.

5. Can you tell us more about your current position and the research in which you are involved?

I am full professor at Memorial University of Newfoundland, which is on the eastern edge of North America. It is a mid-size university in a beautiful location with a great collaborative atmosphere. For research, I am interested in amino acid metabolism and how it affects requirements in different situations. Currently, I am trying to determine how neonatal nutrition and methyl metabolism affect programming of risk for developing obesity and hypertension. From a nutritional perspective, my question is how much methionine is needed to maintain growth and methylation demands and which pathways take priority when nutrition is inadequate. We have some exciting data on the non-protein pathways of methionine and are able to quantify these fluxes using tracer kinetics. I also have other research on amino acid requirements during intestinal stress, such as in parenteral feeding and short bowel syndrome. Overall, I try to conduct all of my research by building a team of experts to enhance the research questions and outcomes. I feel this is the key to research success.

6. What do you feel are the biggest challenges facing nutrition researchers today? Are there any areas where you would like to see more research?

The funding climate has become very difficult, especially for young researchers. There is a short-sighted emphasis to funnel more money to the top researchers which starves the more modest base. I think the key for young nutrition researchers is collaboration and to lead team approaches to big ideas. Don’t be afraid to have someone take you out of your comfort zone; we’re to learn after all. In terms of areas of future research, I think we need more understanding of nutrition behaviours and food environments. We have known for a long time what we should eat to be healthy, but we can’t seem to convince the public to do it. I am also concerned about food insecurity in North America and more work at the policy level is needed resolve this issue. And all of this relates back to the obesity epidemic, which is a very modern issue that has eluded effective solutions.

7. Is there anything else you’d like to tell ASN members, especially students and postdocs?

I think the key message for trainees is to get involved. There are many opportunities out there that could lead to something great. Almost none of us foresaw our current path as students and so trying to plan a specific outcome is just not realistic. Get involved in ASN and other societies and meet people. Most of us are where we are after a chance meeting with someone at the right time and that happens by getting out there. So get involved!

Editor’s Note: Under Dr. Bertolo’s leadership, ASN and CNS began offering joint memberships in 2015.