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National Nutrition Month

March is National Nutrition Month. The campaign promotes healthy eating habits and nutrition education, and it celebrates the people who promote these healthy habits. In 2018, the theme is “Go Further with Food”, highlighting that food decisions make an impact on your overall health.

Members of the American Society for Nutrition (ASN) are diverse. We study nutrition as a science, reporting on the physiological and biological aspects of foods and nutrients. We are also the nutrition educators and practitioners who get the latest nutrition science into the hands of those who need it: policymakers, dietitians, medical doctors, nurses and allied health professionals, and consumers. To celebrate National Nutrition Month and ASN’s impact on enhancing the knowledge of nutrition and quality of life, we will be highlighting some of our programs and activities that ultimately influence public health and how we can “go further with food.”

NUTRITION 2018 – American Society for Nutrition’s Annual Meeting

Nutrition 2018 LogoThis year ASN kicks off a new annual meeting that will focus on the multidisciplinary field of nutrition science. The meeting will bring together basic, translational, clinical, and population scientists and practitioners. The meeting will be held in Boston June 9-12 and registration is open now!

Some hot nutrition topics at the meeting:

  • Role of Anti-inflammatory Nutrition Strategies
  • Pediatric Nutrition
  • Nutrition and the Environment
  • Precision Nutrition
  • Science of Breastfeeding
  • Food Allergies

These are only a few topics that are included in the 4-day nutrition meeting. Our NUTRITION 2018 schedule is now open so please refer to it for the latest sessions.

Stay tuned for more news and a special membership offer for dietitians and nutritionists during National Nutrition Month.

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How can we implement better health behaviors in cancer survivors?

Lifestyle interventions targeted at obtaining/maintaining a healthy body weight and/or incorporating physical activity and healthy eating habits have great potential in improving outcomes in cancer survivors. Cancer diagnosis is a “teachable moment” wherein many patients are highly motivated to make changes (1). Furthermore, a balanced diet and moderate exercise can improve prognosis, quality of life, physical function, and survival across the cancer continuum. As such, groups such as the Amercian Cancer Society, National Comprehensive Cancer Network and the American College of Sports Medicine have released lifestyle guidelines for cancer survivors.

However, implementing changes in individuals and healthcare systems is challenging, to say the least. This is a recent topic covered by Karen Basen-Engquist and a number of colleagues as part of a special Issue of Obesity (Transdisciplinary Research on Energetics and Cancer)(2). Their article provides a 6-point agenda for translating research into clinical and community action, as follows:

  1. Increase the availability of different types of activities for weight management, nutrition counseling, and physical activity. One size will never fit all when it comes to improving health. Individual goals/preference, resources, and logistics all come into play, and cancer-specific programs may be needed.
  2. Improve screening and referral to lifestyle interventions. A system for evaluating and triaging patients for health programs should be developed. Importantly, an individual’s physical status, health needs, and goals should be considered.
  3. Improve the health care provider’s ability to screen, assess, and refer survivors for lifestyle programs. Oncology providers have a powerful role in helping cancer survivors; however, they often do not feel confident in screening, giving advice, or administering recommendations for lifestyle-related constructs. Implementation of processes such as the 5As (Ask, Advise, Assess, Assist, Arrange), which has been successful in tobacco cessation (3) and obesity management (4) might prove beneficial.
  4. Expand the support of oncology-specific professional training and certification. Professional organizations of dietitians, exercise professionals, psychiatrists, and physical therapists have additional certification programs for oncology or are working on developing one for its members. However, professionals with specific expertise in oncology are still greatly needed to address the unique needs of this population.
  5. Expand dissemination and implementation research. Many research programs do not address how a program could be implemented in a real-world setting (external validity). Dissemination of research findings with consideration of the sustainability and generalizability of programs is essential for broader impact.
  6. Advocate for health care policies that support lifestyle services for cancer survivors. Coverage for health programs is highly variable and often has barriers such as large co-payments, no coverage in grandfathered plans, and cost sharing. A potential solution could be incentivizing nutrition and exercise services, although more research is needed to determine the effectiveness of such actions.

As the authors eloquently articulate, the time has come to enable research into action for optimal healthcare in all cancer survivors.

References:

  1. Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol 2005;23:5814–30.
  2. Basen-Engquist K, Alfano CM, Maitin-Shepard M, Thomas CA, Schmitz KH, Pinto BM, et al. Agenda for Translating Physical Activity, Nutrition,and Weight Management Interventions for Cancer Survivors into Clinical and Community Practice. Obesity 2017; 25, S9-S22.
  3. Siu AL, Force USPST. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015;163:622-634.
  4. Rueda-Clausen CF, Benterud E, Bond T, Olszowka R, Vallis MT, Sharma AM. Effect of implementing the 5As of Obesity Management framework on provider-patient interactions in primary care. Clin Obes 2013; 4, 39-44.

 

Telenutrition: Reaching More People with Technology

We have all experienced the tedious process of setting up an appointment to see your doctor, PT, RDN, or other healthcare provider. You call their office to schedule an appointment and often have to wait weeks or even months to see them. You take time off work to drive there, you sit in the waiting room, then you wait in the patient room. You see your provider for roughly eight minutes and then you are done (1). The entire experience can take an average of two hours depending on how long it takes you to drive there or how long you have to wait (2).

 

Health care is traditionally structured as a provider-centric service, meeting the needs of the hospitals and doctors. Yet, there is increasing interest by patients and providers alike to provide health care that is more patient-centric, where patients are treated as customers who are interested in convenient and effective healthcare services (3). Introducing telemedicine! A method for providing healthcare services via technology such as video chat, telephonic, emails, or instant chats. This trend began as a means to provide services to people in rural areas with limited access to hospitals and providers. Today telemedicine has gained popularity as a convenient and prefered way to receive healthcare, solving many of the problems with in-person appointments.

 

Telemedicine is shaking up how service is provided, shifting the focus from treating the sick to being an active integrated part of individuals’ health and wellbeing. In other words, telemedicine is a great opportunity to implement preventative services and encourage patients to be involved in their health! Nutrimedy, a telenutrition startup out of Boston is passionate about the promise telenutrition holds in providing a much needed shift in our healthcare system. Karolina Starczak, the CEO of Nutrimedy says,

 

“Telenutrition along with other forms of telemedicine allow for improved access at a reduced cost to patients. As we embrace technology, we are not only helping reduce some of the barriers that patients have to overcome with in-person appointments, but we are also helping them understand how to fit health and wellness services into their day-to-day life. We have embraced the need for preventive and proactive care for decades, but with the help of telehealth we can actually create a less intimidating environment where patients finally feel like a member of the healthcare team and are encouraged to engage in their health”

Registered Dietitian Nutritionists (RDNs) are qualified nutrition experts to provide telenutrition services (4), yet society tends to not know who RDNs are or even how to get an appointment with one. This leaves people vulnerable to trusting nutrition guidance from unqualified personnel. You wouldn’t trust your carpenter to give you medical advice, right? That’s because people know and trust the credibility of MDs. Unlike MDs, RDNs are less known and less accessible, leaving people at the will of any person who gives information about nutrition, regardless of their qualifications. This has been an apparent limitation for Nutrimedy as they utilized RDNs to engage patients in their diets and health.

 

One of our biggest hurdles has actually not been around the video component, but spreading the word about why we are committed to having RDNs as the nutrition experts on our platform. We have found that many people don’t currently understand the training and education of RDNs, so we dedicate time to helping spread the word. Our goal is to make it as easy and seamless for the average person to access an RDN as it currently is to purchase sessions at a fitness studio. And who knows, maybe in the future with every tenth spin class you get a free session with Nutrimedy,” said Starczak.

 

With telenutrition, RDNs have the potential to reach more individuals, making them a common and well known provider in society. Even if the patient is aware of what RDNs do and is interested in scheduling a counseling session with one, very few know how to go about doing so.

 

What I have always found surprising is that when I ask people I meet how they would go about scheduling a visit with an RDN, most can’t tell me. Navigating the healthcare landscape and coordinating services can be disturbingly complex, but with Nutrimedy patients can connect to nutrition experts right through their phone or other device. It saves time and finally makes consults with an RDN simple, so that anyone can receive personalized video counseling and stay connected in between sessions all in one app.”

 

Currently, Medicare Part B will reimburse for approved services that are provided via telecommunication (5). Since nutrition counseling is covered under Medicare Part B, these nutrition counseling services will be reimbursed even if provided via telenutrition. In addition, more than thirty states have passed laws that require private insurance companies to cover telemedicine services (6). As telemedicine services become increasingly recognized as legitimate healthcare services, the use of and reimbursement for these services will continue to grow. Telemedicine has the potential to revolutionize our healthcare system, save money, and engage patients in their health to create lasting preventative changes.

 

  1. M.D, P. W. C. For New Doctors, 8 Minutes Per Patient. Well (1369886512). Available at: https://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/. (Accessed: 3rd October 2017)
  2. Paying for Health Care with Time | HMS. Available at: https://hms.harvard.edu/news/paying-health-care-time?utm_source=twitter&utm_medium=social&utm_campaign=hms-twitter-general. (Accessed: 3rd October 2017)
  3. The Ultimate Telemedicine Guide | What Is Telemedicine? eVisit® Telemedicine Solution Available at: https://evisit.com/what-is-telemedicine/. (Accessed: 25th September 2017)
  4. Academy of Nutrition and Dietetics. Practice Tips: Telehealth Challenges and Opportunities. February 2017.
  5. Telehealth | Medicare.gov. Available at: https://www.medicare.gov/coverage/telehealth.html. (Accessed: 2nd October 2017)
  6. More than 30 States force Private Insurance to reimburse for telehealth. Available at: http://www.securetelehealth.com/private-insurance.html. (Accessed: 2nd October 2017)

The Debate Over the Health Effects of Food Processing

While debates about the relative healthfulness of carbohydrates/type of fat/salt/sweeteners/etc. never cease, there is one nutritional message that can unite (almost) anyone: eat less processed foods. On the surface, this seems obvious; after all, the top sources of calories for adults in the US include grain-based desserts, burgers, sugar-sweetened beverages and chips (1,2), which are certainly not what dietary recommendations are going for. But when we pose “What are the effects of food processing on health?” as a scientific question, things suddenly become very complex. Is there a consensus on what food processing is? Is all food processing unhealthy? What research has been done on processed food?

What is Processed Food?

First, we should start on the tricky subject of definitions.

Jones and Clemens published a nice summary of how various organizations differ in their definitions of “processed food” (3). The United States Department of Agriculture and other government organizations, for example, tend to use a broad definition that includes any changes from a natural state – such as washing, heating, and cooking, to adding preservatives, flavors, additives, etc. The American Institute for Cancer Research uses the term “minimally processed” to denote vegetables, grains, and beans prepared without much added to them, or minimal refining. Then there is the “NOVA” system, an attempt by Dr. Carlos Monteiro and colleagues to categorize food processing into: “unprocessed or minimally processed foods”, which are essentially unmodified from nature or include light processing such as drying, boiling, freezing, etc., “processed culinary ingredients”, “processed foods”, and “ultra-processed foods” as the extreme, which includes foods made with ingredients with limited “unprocessed foods”, such as concentrated energy sources like sugars, oils, fat, salt, extracts like casein, lactose, and whey, or additives like dyes, flavors, sweeteners, etc. (4). There doesn’t appear to be good published data on what the public considers processed food, although the International Food Information Council (IFIC) has developed definitions with input from consumer focus groups, discussed below.

What the Critics Say

Some critiques of definitions push against a broad classification of food processing because it could put washing an apple and baking a cookie in the same basket. To this end, while the NOVA system is an attempt to standardize food processing classification for study, not everyone agrees with it. For instance, Dr. Mike Gibney and colleagues published a commentary last month in AJCN arguing that the system is not superior to using associations of nutrient intakes with disease (5). In essence, they argue that the NOVA definition of “ultra-processed” foods and beverages is too subjective and simplistic; that classifying solely by processing would not be of use to study disease links to specific micronutrients (i.e., goiter, allergies and intolerances, anemia, etc.); that it does not improve upon using already established dietary pattern analysis in research; that analysis of the NOVA system indicates that it does not predict nutrients that are suggested to be increased by processed foods such as fat and salt; that certain nutritional requirements such as folic acid could not be met with solely unprocessed foods; and that there is little evidence to date that processing relates to measures of satiety or “hyper-palatability”/”food addiction”. Further, changes to modern eating that relate to consuming more energy including increased portion sizes and energy density, may not necessarily be related to food processing. (As such, processing can be used to formulate smaller portion sizes and reduce energy density.)

Similarly, the 2014 American Society for Nutrition scientific statement on the nutritional role of processed foods by Dr. Connie Weaver and colleagues (6) takes issue with using the NOVA classification based on subjectivity, favoring instead IFIC definitions of processed foods as described below:

Type of Food Examples
Foods that require little processing or production (also called “minimally processed”). Washed and packaged fruits and vegetables; bagged salads; roasted and ground nuts and coffee beans
Foods processed to help preserve and enhance nutrients and freshness of foods at their peak. Canned tuna, beans and tomatoes; frozen fruits and vegetables; pureed and jarred baby foods
Foods that combine ingredients such as sweeteners, spices, oils, flavors, colors, and preservatives to improve safety and taste and/or add visual appeal. (Does not include “ready-to-eat” foods listed below.) Some packaged foods, such as instant potato mix, rice, cake mix, jarred tomato sauce, spice mixes, dressings and sauces, and gelatin
“Ready-to-eat” foods needing minimal or no preparation. Breakfast cereal, flavored oatmeal, crackers, jams and jellies, nut butters, ice cream, yogurt, garlic bread, granola bars, cookies, fruit chews, rotisserie chicken, luncheon meats, honey-baked ham, cheese spreads, fruit drinks and carbonated beverages
Foods packaged to stay fresh and save time Prepared deli foods and frozen meals, entrées, pot pies and pizzas

Republished from http://www.foodinsight.org/sites/default/files/IFIC_Handout1_high_res.pdf

The statement addressed how processed foods contribute to the health and nutrition of populations, stakeholders in improving diet, and research still needed. Analysis of foods that provide nutrient enrichment and fortification (added by processing) indicates that much of the population would fall below adequate intakes for several nutrients. On the other hand, on average they contribute to nutrients that are recommended to be limited such as added sugar, sodium, saturated fat, and calories. They critique the term “ultra-processed” because the degree of processing does not necessarily reflect nutrient content of a food. The paper also summarizes what the future of processed food should look like to better address nutritional and food security around the world, including more cross-discipline collaboration to improve upon processed products and better communication between consumers and relevant stakeholders (6). It also remains to be seen whether the NOVA classification system would lead consumers to choose better diets compared to healthy diet patterns developed by nutrient epidemiology such as MyPlate, DASH, or Mediterranean-style diets, which can include foods with various levels of processing (7).

Thus, depending on how you define it, food processing can contribute necessary nutrients but also nutrients that should be reduced, and how different forms of processing may affect health is understudied.

Research on Processed Foods

Most research on “processed foods” as a whole-diet approach has come from epidemiological studies or animal experiments. Many challenges exist that may prohibit effective research from being done, including defining and classifying processed foods, accurate recalling of foods in dietary surveys, utilizing suitable comparisons, getting study subjects to stay on an assigned diet for the necessary period of time, etc.

Instead of looking at processing, per se, as predictive of health effects, much research currently looks at individual aspects of food processing that may contribute to increased (or decreased) health risks. For example, my dissertation research focuses on dietary phosphorus, which is widely utilized as a food additive (8). Growing evidence suggests that excess phosphorus in the diet, particularly in the form that is added for processing purposes, may increase risks for cardiovascular and bone disease, particularly in those who have kidney disease. For example, a human trial directly compared foods with elevated levels of phosphorus additives vs. those that do not have additives and measured surrogate outcomes for bone and mineral metabolism, and observed changes that would predict long-term bone loss (9). For more, see recent reviews from our group (10,11). It is, however, difficult to definitively tease out the effect of individual components like phosphorus additives to long-term health from the whole food packages that they accompany.

An upcoming trial by Dr. Kevin Hall and others will test the effect of “ultra-processed foods” (based on the NOVA definition) in a highly controlled setting to see what effect on insulin sensitivity and other outcomes such foods have that should prove very interesting and continue the discussion on the utility of such classification schemes (12).

Conclusion

Like any nutrition guidance, we must rely on imperfect evidence to communicate dietary recommendations. Which is why telling the public to choose alternatives to “processed foods” when possible is likely an appropriate message despite scientific disagreement on classifications and health implications. Indeed, the 2015-2020 Dietary Guidelines for Americans contain 25 instances and the scientific report 67 instances of the word “processed” (13,14), in context implying that we should limit processed food, mostly focusing on processed meats where more research has been done. This is because processed foods tend to contribute nutrients that Americans already consume high amounts of, such as sodium and saturated fat. At the same time, it will be interesting to see the results of natural experiments such as Brazil’s Dietary Guidelines, which put the focus on food processing instead of nutrient levels (15). It is an area ripe for research and cross-disciplinary collaborations.

 

 

References

  1. https://www.cnpp.usda.gov/sites/default/files/dietary_guidelines_for_americans/PolicyDoc.pdf
  2. https://health.gov/dietaryguidelines/2015-scientific-report/pdfs/scientific-report-of-the-2015-dietary-guidelines-advisory-committee.pdf
  3. http://aaccipublications.aaccnet.org/doi/pdf/10.1094/CFW-62-3-0120
  4. https://www.researchgate.net/profile/Geoffrey_Cannon/publication/315497241_The_UN_Decade_of_Nutrition_the_NOVA_food_classification_and_the_trouble_with_ultra-processing/links/58d2c71aa6fdccd24d43bcbf/The-UN-Decade-of-Nutrition-the-NOVA-food-classification-and-the-trouble-with-ultra-processing.pdf
  5. http://ajcn.nutrition.org/content/106/3/717.full.pdf
  6. http://ajcn.nutrition.org/content/99/6/1525.full.pdf
  7. http://aaccipublications.aaccnet.org/doi/pdf/10.1094/CFW-62-4-0182
  8. http://advances.nutrition.org/content/5/1/104.full
  9. https://academic.oup.com/jcem/article-lookup/doi/10.1210/jc.2015-2279
  10. https://link.springer.com/article/10.1007%2Fs11914-017-0398-4
  11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503680
  12. https://clinicaltrials.gov/ct2/show/NCT03189121
  13. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf
  14. https://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf
  15. http://www.fao.org/nutrition/education/food-dietary-guidelines/regions/brazil/en/

 

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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)

Corporate Wellness Programs: A New Frontier for RDNs

Corporate wellness

Registered dietitian nutritionists (RDNs) are best known for their roles in clinical nutrition, food service management, community nutrition, and public policy. However, there is increasing opportunity for RDNs to expand their job search into the private sector. Employers across the United States are implementing corporate wellness programs to increase employee health and reduce their healthcare costs. A 2010 study found that for every $1 an employer spends on corporate wellness, they save $4 on health care costs and absenteeism (1). This is an obvious incentive for any business, small or large, to implement a corporate wellness program. So much so that the 2016 Employer Health Benefits Survey showed that 46% of small businesses and 83% of large companies provide some sort of corporate wellness program to their employees (2). With growing popularity, these programs are excellent opportunities for RDNs to explore new employment options and reach new clientele.

When searching through corporate wellness providers, I quickly learned that the term “corporate wellness” could take on many different definitions. Platforms varied from one-on-one services, to software packages, to interactive phone apps. Services mostly included diet and exercise initiatives but some also provided physical therapy, massage therapy, mindfulness, and meditation. Overall, these programs are designed to prevent the development of chronic diseases by identifying risk factors and implementing lifestyle changes to reduce those risks.

In addition to lowering employer costs and improving employee health, corporate wellness may also address the 2015-2020 Dietary Guidelines for Americans, which emphasize the need to “support healthy eating patterns for all” (3). Corporations are like communities that allow individuals to interact every day, share comparable work experience, possess similar values, and likely have similar education backgrounds. As such, the corporate environment is a great opportunity to stimulate support and discussion around nutrition and health issues. By creating a culture of health at work, we are more likely to create a culture of health at home, with friends, and eventually in the community.

With the many potential benefits of corporate wellness programs, how are RDNs utilized in these programs? I had the pleasure of interviewing the founder and owner of Family Food LLC, a corporate wellness provider based out of Philadelphia. Krista Yoder Latortue is an advocate for the use of RDNs to design and implement corporate wellness initiatives.

“When people are spending the bulk of their day in a work environment, meeting them at work increases the public’s accessibility to Registered Dietitian Nutritionists (RDNs). Additionally, with the increased demand for corporate wellness, it is essential that RDNs, the nutrition experts, lead corporate wellness initiatives to ensure evidence-based nutrition interventions are being used”

Unfortunately, I don’t think every corporate wellness provider thinks like Latortue. After looking at websites of many corporate wellness programs, I began to question the quality of services being provided. Of the 25 companies I looked at, only 9 of them clearly stated they had RDNs on staff, on the executive team, or working as health coaches. Others provided services from nurses, personal trainers, physiologists, or even“company certified wellness coaches,” with no description of the certification process. Latortue expressed her concern about programs that don’t utilize the skills of RDNs.

“If nutrition education is being provided by unqualified providers, the chances of actually reducing employee health care costs decreases. Not only do they waste money on paying for a program, they continue to lose money to poor employee health. It is important to educate companies and wellness committees about the importance of using qualified health professionals, like RDNs, to provide corporate wellness programs.”

In a study that examined 150 corporate and hospital wellness programs, registered dietitians were more likely to work for hospital-based wellness programs and not corporate wellness programs (4). RDNs have classically been employed in clinical settings, and branching into the corporate world may be challenging. I asked Latortue how RDNs interested in corporate wellness should get involved.

Pay attention to local groups in your area that may be forming around corporate wellness and get involved to be the voice of RDNs, the nutrition experts”

As corporate wellness continues to grow, it is imperative that RDNs are on the forefront of the services being provided. Working in corporate wellness is an opportunity for RDNs that are interested in preventive care and lifestyle modification, enjoy working with individuals, and are passionate about shaping the nutrition and health beliefs of society. RDNs in corporate wellness also have a chance to increase public knowledge of what RDNs do, who we are, and why we are the trusted experts in nutrition.

 

  1. Baicker, K., Cutler, D. & Song, Z. Workplace wellness programs can generate savings. Health Aff. Proj. Hope 29, 304-311 (2010).
  2. 2016 Employer Health Benefits Survey-Summary of Findings. The Henry J. Kaiser Family Foundation (2016).
  3. S. Department of Health and Human Services and U.S. Department of Agriculture.2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/.
  4. Hickerson, M. & Gregoire, M. Characteristics of the Nutrition Provider in Corporate and Hospital Wellness Programs. Am. Diet. Assoc. 92, 339-341 (1992).

 

 

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Pursuing a RD/RDN after a PhD: Motives, Experiences and Challenges from Nutrition Experts

By Hassan S. Dashti, PhD

I spent a lot of time contemplating whether I should pursue an RD after completing my PhD. I was told by one of my professors that back in his days, he had to choose between dietetics and research. He told me that it was assumed that students with ‘social’ and ‘people’ skills went into dietetics, whereas the rest went into research. The mutual exclusivity of nutrition clinical practice (dietitian nutritionists, RDNs; but more commonly referred to as RDs) and research is no longer the case. A recent 2016 survey from the Academy of Nutrition and Dietetics (The Academy) revealed that 4% of RDs hold a doctoral degree (PhD, RD) in the US. For the vast majority of those 4%, their curriculum vitae(CVs) will likely indicate that they have completed a dietetic training program (RD) followed by a doctoral degree in nutrition (PhD), and rarely a PhD first then RD. So having completed vigorous doctoral programs, what makes some researchers go back to school to get their RDs?

Perhaps the most common reason is to obtain training for effective translation of nutrition research. Being able to communicate nutrition knowledge to patients and other people was also particularly the reason why Stephanie Harshman, a doctoral student at Tufts University studying vitamin K, applied to RD programs while in her last year of her graduate training. She shared, “The RD training provides a different perspective when examining clinical research, community based interventions, and allows someone to better translate basic science research into terms and ideas that will positively impact human health.” Similarly, the PhD, RD combined training program at Cornell University’s Division of Nutritional Science recognizes the growing need for translational research expertise in order to enhance the “effectiveness and impact of clinical and public health nutrition,” which is made possible through this combined training.

As nutrition is a young and evolving science, a PhD, RD is particularly crucial when leading the translation of novel and cutting-edge science, like nutrigenomics or nutritional chronotherapy, where the translation is not as simple as a dietary prescription like a low-fat diet. Previous president of the American Society for Nutrition (2014-2015) and current director of the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Simin Nikbin Meydani, DVM, PhD, shared with me the story of one of her former doctoral students who wanted to bridge the gap between what is studied and what makes the news headlines and thus went on to getting her RD. Dr. Meydani said, “[The PhD and RD training together] could be applied to meaningful approaches that promote the health of an individual through proper nutrition.”

But it’s not only about how to apply and translate the science, a combined PhD, RD training may facilitate generating pertinent research questions with important implications. Having that human and patient interaction experience, which is often very limited in doctoral training, may help in study design development, particularly in human intervention studies. President-elect of the American Society for Parenteral and Enteral Nutrition (ASPEN) and Professor of Nutrition Science at the University of Pennsylvania School of Nursing, Charlene W Compher, PhD, RD, CNSC, LDN, FADA, said, “The best translational research comes from clinicians who understand what a nutritional problem really means for patients.”

While more than half of RDs (~58%) do work in clinical nutrition (acute care, ambulatory care, or long-term care), contrary to common belief —particularly among non-RDs— not all RDs end up working as full-time clinical dietitians. Practice areas for RDs keep expanding and now include community, food management, communications, consultation and business, and as indicated earlier in this article, in education and research. Thus it’s not uncommon that the realization of the need of a dietetics training may occur later in a PhD’s career.

Stella Uzogara, PhD, MS, RDN, LDN CFS works in public health and decided to pursue an RD in order to get both clinical and non-clinical training to effectively discuss the challenges in public health nutrition and to positively impact health of consumers and patients. Dr. Uzogara who got her PhD in food science is also a certified food scientist (CFS). She now works as a nutritional epidemiologist in the Bureau of Family Health and Nutrition at the Massachusetts Department of Public Health and a state liaison for pediatric nutrition and pregnancy nutrition surveillance systems between Massachusetts and the CDC. She also works in several community health programs. Dr Uzogara said: “Personally, nutrition has served me well in my job and it gives me more flexibility, enabling me to practice both food science and health science, two disciplines which interest me a lot.” On the other hand, incoming Brigham and Women’s Hospital dietetic intern and current doctoral student at the University of Connecticut in biomedical engineering, Anna Roto, MS, MPH, is learning about clinical instruments, mobile health devices, as well as how to design new equipment for medical use in her doctorate program. When asked about her intentions for pursuing an RD, she said, “I am not getting the clinical experience that I believe is necessary for a career in the rehabilitation science field, as I plan to work with individuals experiencing trauma or debilitating illnesses to improve their physical abilities and overall quality of life.”

An RD may also be used as an opportunity to steer towards a new career. Dominica Nichols, PhD, RD, LDN, competed her doctoral training at Northeastern University in microbiology where her work in microbial ecology informed the technology used by several biotech startups. However, after years of culturing microorganisms, Dr. Nichols was looking for other opportunities that would enable her to mentor students and have more interactions with people. Having completed her dietetic internship at Simmons College, she now serves as a pediatric outpatient dietitian at a community center affiliated with Boston Children Hospital. Her research training allows her to work closely with other physicians on various research projects. She said, “Dietetics is an interdisciplinary field. Having training in another field, microbiology in my case, benefits my dietetics practice.”

While less demanding than a doctoral program, completing an RD does come with its own challenges. Interns should be ready to work very closely with a preceptor and shadow current practicing dietitians for an extended period of the internship. As most dietetic internships are fulltime programs, it is often challenging to work on other ongoing projects and jobs, but possible. When asked about the difficulties she experienced as a doctoral student who decided to pursue an RD, Stephanie Harshman shared, “I think the most challenging part of this experience has been trying to find support and guidance from faculty as I pursue the credential.” Dr. Dominica also claimed, “I constantly had to explain to other people why I was doing what I was doing.”

Despite these challenges, most of which are only temporary, whether your interests lie in public health policy, community, or teaching (yes, numerous teaching opportunities are now seeking PhD, RDs), an RD is nonetheless an opportunity for growth and expansion. Dr. Compher said, “I continue to treasure my clinical practice because it keeps me in touch with issues of importance to patients.”

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My Clinical Nutrition Internship Experience

By Seth Morrison

My name is Seth Morrison, a final year medical student at the Medical School for International Health in Israel. I would like to share with you a taste of my experiences in the ASN’s unique Clinical Nutrition Internship.

Clinical nutrition was never really on my radar as something I might become interested in until halfway through medical school. It was then that I attended the International Congress of Nutrition held in Granada, Spain, where I met some members of the ASN. Like most medical students, the nutrition content in my courses was only enough to whet my appetite. I never had a chance to really delve into nutrition in-depth so that I would feel comfortable counselling patients or speaking intelligently about it with colleagues. The ICN conference opened my eyes to the many different research branches of the nutrition sciences as well as public health nutrition. The global trends in the “double burden” of malnutrition (undernutrition and overnutrition) in developing countries began to worry me, and I started learning about the many efforts that are underway to intervene. All of this made me want to find an opportunity to supplement my nascent interest in nutrition, and see which career avenues exist. I would like to incorporate nutrition into my medical practice and possibly conduct public health nutrition interventions in resource-limited settings worldwide. That is when I discovered this clinical nutrition internship.

I think my internship was an unparalleled opportunity for a medical student to get an insider’s look into the fascinating world of clinical nutrition and nutrition science. The variety of opportunities I had at the University of Colorado and Children’s Hospital Colorado working with Dr. Nancy Krebs as my mentor gave me the ability to look at the role of nutrition in health from many different angles. I saw how important clinical nutrition is in the weekly outpatient clinics at Children’s Hospital. There were two separate clinics for kids with either growth faltering or obesity. These clinics are where I spent a great deal of my time. Throughout that time, I gradually gleaned the beauty in which skilled nutrition practitioners were able to make a real difference in outcomes as a team. Other physicians in these clinics, along with the amazing nutritionists, nurses, and a clinical psychologist, each contributed to my education in unique ways. They taught me the decision-making process of how to decipher clues to the causes of very different clinical nutrition problems (i.e. overweight vs. underweight), whether they be organic, lifestyle-related, or sometimes, in the case of young children, family food-related behaviors. This created the immensely enjoyable opportunity to decipher solutions to these myriad problems with clinical judgement and a creativity that respects the patient’s/family’s abilities and interests. I like to say today that in order to provide effective dietary counselling to patients, each doctor should have a little bit of a nutritionist inside them. This skill is one of the greatest gifts that the internship provided me for my own toolbox of clinical skills.

A sampling of the other components of my internship that made it very well-rounded were a research project, visits to WIC clinics, family eating well classes, several journal clubs and special nutrition lectures every week, and even a few nutrition-related Grand Rounds on Friday afternoons. I also completed a research project, which was a small metabolomics study on the relative serum levels of acylcarnitines and branched-chain amino acids in lean vs. obese groups of pregnant Guatemalan women.

This research component of the internship added an essential ingredient to the overall experience. Not only did I get to work with a fantastic and knowledgeable basic science researcher on a project in a burgeoning field of nutrition science (metabolomics), I also gained new skills and refined others that are needed in any research project I may become involved with in the future. This academic component reinforced the ever-present need for an army of researchers to inform the nutritional counsel given to patients in clinical medicine.

Inpatient care in the University of Colorado Hospital especially gave me the chance to see how crucial proper nutrition is for pre- and post-operative patients, burn unit patients, and of course in critical care. The nutrition support physician and the knowledgeable dietitians there broadened my knowledge of TPN and other topics in critical care nutrition research. In doing so, the truth was ingrained in me that nutrition is dynamic and can, in different circumstances, be prevention, treatment, or even both. Whether a patient is acutely ill or on a path of long term lifestyle change to reach a healthy weight, nutrition is likely to play an important role in their success!

The ASN Clinical Nutrition Internship satiated a special hunger for this nutrition niche in my medical education. I could not be more grateful and proud to have been awarded this unique opportunity, and the memories from it will linger with me for the rest of my career. As a soon-to-be physician, I’ve now learned that nutrition is a bit like music. It’s nice to listen to, but to really appreciate it, you must also learn to play some of your own notes.

 

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Influences on nutrition at the individual, household, and national level

Student Blogger for Global Nutrition Council at ASN’s Scientific Sessions and Annual Meeting at EB 2016

By: Sheela Sinharoy, MPH

Many factors can influence the success of a project, from the individual to the institutional level. Presenters at the minisymposium on Global Nutrition: Nutrition-Sensitive Programs shared results from studies at a variety of levels.

At the individual and household level, gender roles within the household can influence individuals’ ability and willingness to carry out different activities. Marion Min-Barron presented results from qualitative research in Ethiopia, in which men and women were asked about gender roles for nutrition activities. In general, men and women felt that the activities were the responsibility of both the male and the female. However, later in the minisymposium, Gordon Zello shared results from a different study in Ethiopia, where researchers found that women’s work burden (for example, being responsible for fetching water) was a significant factor associated with household food insecurity and hunger. This suggested even if men and women feel that they are equally responsible for nutrition, disproportionate constraints on women’s time could be affecting nutrition in the household.

Women’s self-efficacy in complementary feeding was the focus of a study in Zambia. Djeinam Toure explained that in this study, a home gardening intervention had a positive association with women’s self-efficacy in complementary feeding, and that this relationship was mediated by social support from husbands and also by household food insecurity. In other words, the intervention was positively associated with social support from husbands, which was in turn positively associated with women’s self-efficacy.

Also focusing on household food production, Afua Atuobi-Yeboah and Lilia Bilznashka presented results from Ghana and Burkina Faso, respectively. The study in Ghana found that an intervention to improve egg production at the household level, coupled with nutrition education, significantly improved egg consumption among children. The study in Burkina Faso was a follow-on to an impact evaluation that had previously found positive impacts on women’s dietary diversity and underweight as well as child wasting and anemia. Two years later, significant differences remained between intervention and control groups in women’s underweight and child wasting but not in women’s dietary diversity or child anemia, suggesting that for the latter two indicators, the control group may have improved to the level of the intervention group.

Moving to the institutional level, speakers presented findings from both qualitative and quantitative research. Tuan Nguyen presented results from an impact evaluation of a national mass media campaign in Vietnam, which was found to be positively associated with exclusive breastfeeding. Andrea Warren shared findings from a qualitative study in Ethiopia that found inadequate coordination structures for nutrition-sensitive interventions at the national level, among other challenges. Gita Singh presented findings from a project to collect and analyze individual-level national or subnational data to determine dietary intakes of key nutritional factors across 188 countries from 1980-2015. This effort has thus far assembled 1,226 total survey-years of data on dietary intakes of a variety of foods and nutrients.

The findings of the minisymposium made clear that a variety of approaches, through a variety of sectors, are important for improving nutrition globally.

 

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The Folate Fortification Story – How we fixed one problem…but may have created another

By: Mary Scourboutakos

Neural tube defects are a type of birth defect—affecting the brain, spine or spinal cord—that result from suboptimal folate status.
Folate is a B vitamin that’s naturally found in legumes (like chickpeas, lentils, pinto and kidney beans), seeds, leafy greens (like spinach, collard greens and romaine lettuce) and other vegetables such as asparagus, brussels sprouts and broccoli.

The problem is, people don’t eat enough of these foods. As a result, for many years, pregnant women were at risk for folate deficiency and hence, neural tube defects.

Prenatal supplements were the original solution to this problem as one of their prime ingredients is folic acid, the synthetic form of folate. However, they’re not a fool proof solution because neural tube defects form within four weeks of conception, often before women know they’re pregnant, and thus, before they start taking their supplements.

As a result, in the late 1990s folic acid was mandatorily added to white flour and enriched grain products to ensure that pregnant women would get enough folate, irrespective of whether they take a supplement.

Problem solved? Sort of…

Back in the early 1990s when discussions regarding the addition of folic acid to the food supply were taking place, it was suggested that after fortification was implemented, the dose of folic acid in prenatal supplements should be revised to prevent excessive intakes. The new problem is…the doses were never revised.

Currently, marketed prenatal supplements usually contain 1000 micrograms of folic acid, which is the daily upper limit for folic acid. Meanwhile, it’s recommended that pregnant women should consume about 400 micrograms of folic acid per day for neural tube defect prevention.

With mandatory fortification, three-quarters of a cup of cereal can provide greater than 400 micrograms of folic acid. So if you add a prenatal supplement to a bowl of cereal at breakfast, some bread at lunch, and pasta for dinner, you’re consuming a lot of folic acid!

According to Dr. Deborah O’Connor, a Professor from the University of Toronto who has spent decades studying folate and infant health, this could be a problem. She explained that in animal models, it has been shown that folate can make changes to the genes that are transcribed during development. And while similar data have not been done on humans, she said “if you’re not getting any benefit from those high levels, it would be prudent to cut back given the current status…(because) if there’s no benefit, there’s only a risk.”

From a regulatory point-of-view, she says there’s nothing stopping the industry from changing the amount of folic acid in the supplements. She suggested that the industry’s reluctance to modify the dose in prenatal supplements is probably due to inertia and the fact that “with nutrition you’re always fighting against the more is better philosophy.”

In the meantime, what should women do? In their 2015 clinical practice guidelines, the Society of Obstetrics and Gynecologists recommended a multivitamin containing 400 to 1000 micrograms of folic acid. But currently, there are no prenatal vitamins available with less than 1000. Hence, Dr. O’Connor’s recommendation is “do not use the prenatal, just use a regular multi-vitamin and maybe add a little iron.” Furthermore, she added “care must be taken to ensure vitamin A intakes do not exceed 3,000 mcg retinol activity equivalents (RAE) or 10,000 IU during pregnancy.”

Alas, it’s a classic story, you try to fix one problem, but in doing so, you create another. Hopefully prenatal supplements will be adjusted soon, but in the meantime, prudent folic acid intakes are probably a good idea.