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Nutrition and Heart Failure: what we know and don’t know

By Audrey Shively, MCHES
Official ACCN16 Blogger
Dr. Scott Hummel’s presentation on heart failure (HF) and nutrition provided great insights in to what research has told us to date and what we still need to learn.
One in five people have congestive heart failure which equates to six million people and one in nine deaths in the United States. It is a large and growing problem defined as the heart not being able to meet the physiologic demands of the body.
The presentation focused on dietary guidelines, malnutrition and frailty, micronutrient deficiencies, and energy interventions. It was full of lots of great data and I strongly encourage you to view this recorded session to see the complete picture. I am only going to be able to address the highlights here.
Nutrition intervention in heart failure encompasses a variety of issues such as diet adherence, neurohormonal affects, metabolic aspects, and the physical effects of malnutrition. We often ask why our HF patients cannot eat a more healthy diet but such things as a decreased sense of smell, early satiety, and medications all affect how patients eat.
There are several comorbidities associated with HF such as cognitive dysfunction, disability, and polypharmacy with studies showing HF patients can easily have five or more comorbidities to be addressed.
Dr. Hummel focused a great deal of his talk on the Academy of Nutrition and Dietetics (AND) guidelines for heart failure. I will share in overview of his remarks here.
Sodium and fluid intake: should be adapted to the patient and should allow for adequate protein in the diet.The dietary sodium debate has not been answered based on both observational and random control studies.
Malnutrition: if a patient is deemed malnourished there are more adverse outcomes; this is true of fragility as well. If one is malnourished most often they are also frail.
Micronutrients: HF patients are encouraged to take folate, vitamin B6, vitamin B12, thiamine, and magnesium; it is felt these prove to be more beneficial when coming from foods rather than supplements.
Energy metabolism: HF patients have impaired energy production and nutrient deficiency can affect this.
Dr. Hummel spent time addressing new mechanisms that may be promising for HF treatment. These include dietary nitrates, metabolic improvements, microbiomes, and vascular salt sensitivity.
There are also many studies still underway that will have an impact on HF treatments including those looking at the effect of calorie restrictions, sodium intake and quality of life, and the correlation between sodium intake and energy.
His overall takeaway messages were:
  1. Heart failure is a large and growing problem
  2. Nutrition is important but is incompletely understood
  3. Sodium intake must be adapted to each patient
  4. New mechanisms may improve our knowledge base
His final message gives us all sound advice about our nutrition and health and that is we should adopt a whole food dietary approach to eating healthy.
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Audrey Shively

Simply Living Healthy Reduces Cancer Risk

Colleen Doyle, MS, RD, from the American Cancer Society shared both the myths and realities relating to cancer risk. Her overall message? Live healthier lives!
We know there are 160 million people overweight in the United States, we also know 120 million don’t meet the physical activities guidelines and 95 million don’t eat enough fruits and vegetables. How this relates to cancer risk lies in the data that tells us obesity, poor nutrition, inactivity, and smoking are the leading causes of cancer and that eating well, maintain a healthy weight, and exercise is the best way to avoid it.
The 2012 American Cancer Society guidelines recommend:
Maintain a  healthy weight: up to 20% of all deaths in the United States are related to obesity
Adapt a physically active lifestyle: Adults should get at least 150 minutes of moderate exercise a week and adolescents should have one hour per day. People are encouraged to limit sedentary behavior such as sitting and watching television.
Consume a healthy diet with focus on plant sources: We should eat two and a half cups of fruits and vegetables a day as well as limit processed and red meat while choosing whole grains over refined produce. The only known cancer risk is associated with eating processed meats and colon cancer.
Drink alcohol in moderation: Limit consumption to one or two glasses per day.
As nutrition professionals, how do we support cancer survivors? Studies have shown that patients who adhere to the ACS guidelines do have lower rates of cancer and cardiovascular disease. Unfortunately, too many people are not aware of these guidelines.
The presentation also addressed several myths surrounding the risk of cancer, including sugar feeds cancer, soy is dangerous, superfoods have special health powers, alkaline diets are best,  organic foods add protective value, and GMOs, artificial sweeteners, or supplements reduce cancer risk. There is no research that shows any of these myths to be true.
Ms. Doyle concluded her presentation with an insightful look at how environmental factors conspire against us and affect our ability to make healthy food choices.
She emphasized we all have a role to play in reducing the barriers to a healthy diet and exercise. We can influence changes in policies and systems to make healthier communities.
The bottom line is that we all need to look at the big picture in creating healthy communities, living healthier lives,  and improving our quality of life.
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Audrey Shively

Eat More Berries!

The session held Thursday afternoon on Aging and Cognition presented by Barbara Shukitt-Hale, PhD focused on the increase in inflammation and oxidative stress in brain aging.
Thirty percent of the United States population is over the age of 65. If these individuals suffer from decreased motor and cognitive function there could be a healthcare crisis in this country.
Dr. Shukitt-Hale and her staff have conducted several research studies looking at impaired motor performance and cognitive function in aging rats. Their results showed a  decrease in motor behavior, learning,  and spatial memory.
Their research question was whether this impaired function could be stopped or improved by altering the diet of the rats.  They specifically looked at polyphenols found in dark fruit and vegetables, wine, chocolate, and walnuts.
Polyphenols show many neuroprotective features such as anti-inflammation, antioxidants, and reduced risk of cardiovascular disease and cancer as well as improved vision.
The overall findings of their research show that nutrition intervention can forestall age related deficits in learning and memory and reverses deficits in learning and memory and declines in motor behavior performance.
But, can this translate to humans now becomes the question. The research group expanded their studies to assess exactly that.
Initial studies looked at the effects of aging on balance, gait, and cognition. Both cognition and mobility decrease with age and these declines are measurable at younger ages than expected.
The introduction of blueberries and strawberries into the diet of their human subjects improved both the measures of executive function and spatial recognition.
Their results showed:
  • Berries can reduce proinflammatory signals in cells
  • Functional declines in mobility and cognition are key features of aging
  • Berry fruit can improve cognition
  • Different berry fruits affect different aspects of cognition
In summary, polyphenols have direct effects on the brain and they can reverse age related declines.
And most importantly, eat more berries!
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Audrey Shively

Culinary Medicine Workshops at Advances and Controversies in Clinical Nutrition 2016

Culinary medicine combines two of my favorite things…food and health. The first in a series of Culinary Medicine Workshops being offered to ACCN attendees focused on disease implications of diet. The faculty from the Goldring Center for Culinary Medicine, a physician, dietitian, and chef, spent three hours discussing the benefits of both the Mediterranean and DASH diets. The workshop participants included physicians, dietitians, food scientists, and a nurse practitioner. This diversity provided a lively discussion with all sharing their different perspectives. Using a flipped classroom approach, the participants were asked to view an online webinar, read reference material, and pass a post test. This was a helpful way to introduce the concepts of both these diet interventions. In a very interactive format, the participants were given a patient case study and asked to reflect on the weight loss, nutrition, and exercise treatment options for the patient. The most fun was a cooking session where six different recipes for spaghetti and meat sauce were prepared. With each successive recipe healthy alternatives were introduced to increase the health benefits of this traditional dish. These alternatives included whole wheat pasta, lentils, and plenty of fresh vegetables. These modifications lowered the calorie and fat content as well as raised fiber and protein intake. The food tasting that followed made for a very healthy lunch. The key takeaway message was to move people as far as they can toward making healthier food choices. Tim Harlan, MD, Executive Director of the Goldring Center, gave great advice on how to discuss nutrition and diet with patients. He emphasized “It is important to meet the patients where they live”, suggesting healthy food alternatives that are both affordable and accessible in their daily lives. As Dr. Harlan reminded us, our focus should be less on weight loss and more on healthy food choices to improve our overall health and well being. Sound advice for us all to follow.

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The Risks and Benefits of Weight Loss in Overweight Seniors: ACCN Day Three

By Sheela Sinharoy, Student Blogger

Is weight loss always recommended for obese persons, or are there some individuals for whom weight loss may not be necessary or may even be harmful? In a session on Saturday, Dr. Julie Locher looked at this question in relation to seniors. Given that 14% of Americans – or one in seven – are over age 65, and that this proportion is expected to increase to 20% by 2030, it is important to understand the needs and special requirements of this group.

As the proportion of Americans who are over age 65 increases, so too does the prevalence of overweight and obesity. According to Dr. Locher, approximately 35% of older persons are obese. Many of these individuals experience co-morbidities and functional limitations, which are often associated with or impacted by obesity. However, the effects of weight loss treatment in older adults have not been extensively studied.

The benefits of weight loss in older adults are similar to those found in the general population, including reduced markers of inflammation and improved cardiovascular health. As co-morbid conditions increase with age, weight loss may address some of these conditions. Especially when weight loss occurs through a combination of diet and exercise, research has shown that muscle quality and physical function also improve, as does global cognition.

At the same time, some studies have found being overweight to be potentially beneficial. For older adults in particular, a number of studies indicate that being overweight yields no extra risk of mortality, and in fact, may be associated with a lower risk of mortality than being normal weight. Obesity is also associated with increased bone mineral density and decreased osteoporosis as well as with decreased risk of hip fracture.

In addition, weight loss in overweight seniors carries certain risks. First, intentional weight loss is associated with a loss of bone mineral density. Also, weight cycling – when individuals lose and then regain weight – may be a more serious concern with older adults because of their different body composition. When seniors regain weight, it is disproportionately fat, especially abdominal fat, compared to lean muscle. This is associated with higher cardiometabolic risk and an increased risk of disability and mortality.

Even among older adults, needs may differ between sub-populations. For example, as the proportion of older adults continues to rise, the fastest-growing segment is those ages 85 and over. These individuals may require a different therapeutic approach than younger seniors, and improving physical function and quality of life may be more important than obesity treatment.

As some providers move increasingly toward personalized medicine, this may be one more way in which recommendations and a therapeutic approach may need to be tailored to the individual patient. Depending on their bone health, metabolic health, and a range of other factors, doctors may decide that weight loss is not always the best approach for obese older adults. For some seniors, the risks of weight loss may in fact not outweigh the benefits.

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The Sugar Debate: ACCN Day Two

By Sheela Sinharoy, Student Blogger

Do you consider sugar to be controversial? From reading the mainstream media, where it is not uncommon to see “sugar” and “toxic” in the same sentence, one might assume that any debates about sugar have been resolved. However, Friday’s session on sugars and health made it clear that questions remain about sugar’s role in body weight, cardiovascular disease, insulin resistance, and dental caries.

In many people’s mind, a clear relationship exists between sugar and body weight. However, as Dr. John Sievenpiper explained, a 2013 systematic review and meta-analyses of dietary sugars and body weight (https://www.bmj.com/content/346/bmj.e7492) found no relationship between sugar and weight in isoenergetic comparisons (i.e., in trials where researchers substituted sugar with other carbohydrates, but held total calories equal). The study did find that an increased sugar intake was associated with increased weight, but Sievenpiper argued that this was simply due to increased calories, not to any unique properties of sugar. As he stated, when addressing weight gain, it is important to focus on overconsumption of all caloric food, including those high in added sugars.

Focusing next on cardiovascular disease, Dr. James Rippe shared evidence from a series of trials investigating the relationship of sugars with LDL, HDL, total cholesterol, triglycerides, blood pressure, total body fat, and abdominal fat. The trials found no relationship between sugars and any of the outcomes except for HDL and triglycerides. For these latter two outcomes, Dr. Rippe, like Dr. Sievenpiper, argued that these findings were due more to the excess calories than to any unique contribution of sugars.

The story with sugar and insulin resistance was, again, similar. Dr. Ian Macdonald explained that in animal models, evidence exists of large doses of fructose and sucrose leading to insulin resistance. However, this does not necessarily translate to human nutrition, and randomized controlled trials in humans have been inconclusive. Some studies have shown an effect of high doses of fructose on insulin resistance and liver fat, while others show no relationship.

The most conclusive evidence of an effect of sugar exists in relation to dental caries, which Dr. Paula Moynihan pointed out is the most prevalent chronic disease worldwide. As part of the World Health Organization (WHO) guideline development process, Dr. Moynihan led a systematic review on the relationship between sugar intake and dental caries. Based on the results, WHO has issued strong recommendations for reduced intake of free sugars throughout the life course and for intake of free sugars to be no more than 10% of total energy.

Throughout the conference, a number of speakers have referenced Americans’ changing dietary patterns and increases in consumption. This session was no different, as the overall message seemed to be that sugars alone cannot explain increases in overweight and obesity, cardiovascular disease, insulin resistance and diabetes. Rather, sugars are part of a larger constellation of factors that include dietary patterns and lifestyle patterns as a whole, which should be researched and addressed together in order to reduce the prevalence of chronic disease.

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ACCN14: A Day of Micronutrients

By Sheela Sinharoy, Student Blogger

Living up to its name, the Advances & Controversies in Clinical Nutrition conference began with sessions exploring the many controversies and uncertainties around micronutrients. Some of the issues explored by speakers included potential cancer-preventive and cancer-promoting effects of micronutrients, as well as the challenges of micronutrient research. Ultimately, it seems, questions remain about all of these areas and more.

The evidence on micronutrients is often contradictory and confusing. For example, Dr. Joel Mason spoke about micronutrients such as folate, selenium, and vitamin E, each of which has been shown to be cancer-preventive in some trials and cancer-promoting in others. He explained that the effects of these and other micronutrients may follow a curve in which they are protective in amounts up to a maximal optimal dose, after which the effect plateaus and may even become detrimental. However, even if this is the case, the optimal dose of each micronutrient remains unclear.

Similarly, other speakers discussed dietary supplements and their relationship to all-cause mortality, cardiovascular disease, cancer, and neurological diseases. Dr. Eliseo Guallar discussed meta-analyses of dietary supplements and concluded that most supplements have no effect or, in the worst cases, actually cause harm. He explained that there is very little evidence on multivitamins, because most studies focus on individual supplements rather than on multivitamins.

A further complicating factor is that different populations have different nutrient needs. Addressing this issue, Dr. Johanna Dwyer exhorted the audience to “mind the gaps” in micronutrient intakes in the US population. For example, she shared data indicating that women ages 20-29 years old in the US have borderline insufficient intakes of iodine. This has serious implications given the importance of iodine during pregnancy for neurological development of the fetus. Thus, special recommendations on iodine may be needed for women in this age group. Other sub-populations at risk, according to Dr. Dwyer, may include exclusively breastfed infants and some elder populations, especially those with heart failure.

Of course, more research is needed to better understand the role of micronutrients and dietary supplements, especially in the prevention of age-related chronic disease. However, as pointed out by multiple speakers, both observational studies and randomized controlled trials (RCTs) are fraught with challenges. Observational studies have a large potential for bias, and the observable effects will be small. At the same time, RCTs are problematic because, unlike pharmaceutical trials, there is never a true placebo group when studying micronutrients. As Dr. Balz Frei pointed out, everyone has some level of the essential micronutrients; at best, researchers can plan to measure the baseline levels and use those as inclusion or exclusion criteria for the study.

The goal of nutrition research, at least for many of us, is to generate evidence that can be used to guide others – whether clinicians, policy makers, or other program implementers – in making informed decisions. However, the current evidence base on micronutrients does not lend itself to clear guidance. One suspects that this will remain an area of advances and controversies for quite some time.

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