The popularity of the essential polyunsaturated omega-3 fatty acids (O3FA) is on the rise. In 2017, O3FA achieved a spot on the top 20 foods and ingredients list that Americans are adding to their diets (The Hartman Group). In addition, the global fish oil market is expected to reach a whopping 4.08 billion dollars in the next four years!  The proposed health benefits are likely the driving force behind the increasing demand.

Despite their booming popularity, a large percentage of adults are not meeting the O3FA recommended intake. There are three primary O3FAs with distinct characteristics: alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Although commonly grouped under the umbrella term O3FAs, are all O3FAs created equal?

Unique Characteristics of O3FAs

Omega-3 fatty acids cannot be sufficiently produced in the body earning them the title of “essential fatty acids.” The plant-derived omega-3, ALA, is the parent precursor to EPA and DHA. Unfortunately, the conversion rate in our bodies is very low.  It is important to realize that in the process of metabolizing ALA to EPA and DHA, a series of anti-inflammatory markers are produced (leukotrienes, prostaglandins and thromboxane). As these anti-inflammatory metabolites are beneficial, direct EPA and DHA consumption is needed to meet bodily requirements.

Independent and Complementary Health Benefits

The majority of current research focuses on the health benefits of marine fatty acids.  DHA and EPA consumption portray an array of shared and complementary benefits related to the treatment of cardiovascular disease, depression diabetes, sleep disorders and more. DHA is more significantly associated with decreases in resting heart rate, blood pressure and with improvements in cellular membrane health due to its additional double bond and longer carbon chain. Increased cellular levels of EPA have been shown to benefit coronary heart disease, hypertension and to decrease inflammation. EPA and DHA are both associated with reduced gene expression related to fatty acid metabolism, reduced inflammation and oxidative stress.

Specific supplementation of ALA is not consistently associated with cardiovascular health. Although plant-derived ALA can be easily substituted in for excess omega-6 fatty acids (O6FAs). Research has shown that by reducing the O3FA:O6FA ratio, you can decrease bodily inflammation, increase anti-inflammatory markers and more efficiently utilize EPA and DHA.

An ALA, EPA and DHA-Rich Diet

The 2015-2020 Dietary Guidelines for Americans recommends that healthy adults consume at least 8 ounces of a variety of non-fried fatty seafood per week. For EPA and DHA requirements, the American Heart Association recommends fatty marine sources containing 500 mg or more of EPA and DHA per 3oz cooked serving (e.g., salmon and tuna).   ALA is the most commonly consumed O3FA in the Western diet as it is found in plant-based foods (e.g., dark green leafy vegetables, walnuts, canola oil, flax seed). Unlike EPA and DHA, an Adequate Intake (AI) level is established at 1.6 g/day and 1.1 g/day for men and women respectively.

The Final Verdict 

The wide range of benefits stemming from marine O3FAs indicates the importance of regular consumption of fatty seafood and EPA and DHA-containing products.  The incorporation of plant-derived ALA may serve more importantly as a substitute for omega-6 fatty acids to reduce bodily inflammation, decrease the high O3FA:O6FA ratio typically observed in the Western diet, and to help elevate EPA and DHA levels in the body. EPA and DHA may be featured as the health promoting “dynamic duo,” but ALA is still invited to the party!

 

References

1.         Yanni Papanikolaou JB, Carroll Reider and Victor L Fulgoni. U.S. adults are not meeting recommended levels for fish and omega-3 fatty acid intake: results of an analysis using observational data from NHANES 2003–2008. Nutrition Journal 2014.

2.         Harris WS, Mozaffarian D, Lefevre M, Toner CD, Colombo J, Cunnane SC, Holden JM, Klurfeld DM, Morris MC, Whelan J. Towards establishing dietary reference intakes for eicosapentaenoic and docosahexaenoic acids. J Nutr 2009;139(4):804S-19S. doi: 10.3945/jn.108.101329.

3.         Frits A. J. Muskiet MRF, Anne Schaafsma, E. Rudy Boersma and Michael A. Crawford. Is Docosahexaenoic Acid (DHA) Essential? Lessons from DHA Status Regulation, Our Ancient Diet, Epidemiology and Randomized Controlled Trials. Journal of nutrition 2004;134.

4.         Mozaffarian D, Wu JH. (n-3) fatty acids and cardiovascular health: are effects of EPA and DHA shared or complementary? J Nutr 2012;142(3):614S-25S. doi: 10.3945/jn.111.149633.

5.         Bork CS, Veno SK, Lundbye-Christensen S, Jakobsen MU, Tjonneland A, Schmidt EB, Overvad K. Dietary Intake of Alpha-Linolenic Acid Is Not Appreciably Associated with the Risk of Ischemic Stroke among Middle-Aged Danish Men and Women. J Nutr 2018. doi: 10.1093/jn/nxy056.

6.         Evangeline Mantzioris MJJ, Robert A Gibson and Leslie G Cleland Differences exist in the relationships between dietary linoleic and alpha-linolenic acids and their respective long-chain metabolites. Am J Clin Nutr 1995;61:320-4.

7.         Agriculture. USDoHaHSaUSDo. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015.

With more than 20 featured sessions, 2,000 presentations of new, original research, 5 award lectures, numerous workshops and non-stop networking opportunities, we think it’s safe to say that there is something for everyone at Nutrition 2018.

Be sure to check out the Nutrition 2018 Schedule Planner before you go.  This interactive, online platform will help you navigate all of Nutrition 2018’s offerings.  Click here for tips on planning your conference experience to get the most out of Nutrition 2018.

Here’s a preview of just a few of the offerings you will find in Boston:

Scientific and Statistical Principles, A Workshop based on the Best (but Oft-Forgotten) Practices Article Series in the American Journal of Clinical Nutrition
Saturday, 1:00 – 3:00 PM

The American Journal of Clinical Nutrition has published a series of articles to help reinforce important scientific and statistical principles that should be useful for researchers in general and for those in nutrition in particular. The conduct and analysis of scientific endeavors are constantly changing, and much like there is continuing medical education, the AJCN editors intend for this series to serve in a way as “continuing scientific education.”  Join Associate Editor David Allison, PhD and Editor-in-Chief Dennis Bier, MD for a refresher course on topics related to statistical design and analysis.

Nutrition and Natural Disasters, a featured presentation in the Japan Society of Nutrition and Food Science Forum
Saturday, 1:30 – 3:00 PM

From major earthquakes to tsunamis, Japan has endured its share of catastrophic natural disasters.  Nobuyo Kasaoka, PhD, RD, will discuss how Japan addresses nutrition challenges following natural disasters.

Ensuring Trust in Nutrition Science
Saturday, 1:30 – 3:00 PM  AND Monday, 1:00 PM  (ASN Live! in The Hub)

ASN commissioned a Blue Ribbon Panel on “Ensuring Trust in Nutrition Science” to develop best practices regarding how to work collaboratively with various stakeholders across sectors and disciplines while maintaining transparency and scientific rigor in nutrition science to uphold the trust of all stakeholders.  Join panel member, Patrick Stover, PhD, to learn more about the recommendations coming out of this effort.

Is a Calorie a Calorie:  Reframing the Question
Sunday, 8:00 – 10:00 AM

Does obesity result from consuming more calories than you burn or might the body’s hormonal and metabolic regulation systems also play a role?  What are the right research questions we should be asking to advance our understanding of this topic? Esteemed researchers share their views and advance the discussion on this long-debated topic.

NIH CSR Grant Review
Sunday, 12:15 – 12:45 PM at Science Stage in The Hub

Interested in learning more and becoming involved with the NIH grant review process?  Join Fungai Chanetsa, PhD, MPH, Scientific Review Officer for NIH’s Center for Scientific Review for an interactive discussion. Dr. Chanestsa will also highlight the Early Stage Career Reviewer Program.

 How Can Dietary Assessment be Improved?  Budding Entrepreneurs Propose New Ideas in Sight and Life’s Elevator Pitch Contest
Sunday, 3:00 – 5:00 PM

Seven finalists from around the world will pitch their ideas for new technologies and methods to improve the measurement of dietary intake. Paired with mentors from the Harvard School of Business, these young professionals aim to impress an esteemed panel of judges for a cash prize. Sit back and enjoy Nutrition 2018’s version of Shark Tank.

Altmetrics:  Real Time Measurement of Your Scholarly Impact
Sunday, 3:00 – 4:00 PM and Monday, 10:30 – 11:30 AM

Online tools allow researchers to broaden the impact of their published work in an ever increasing way.  What are alternative metrics, when should you use them and why should you care?  Join us for this workshop to learn about the major trends in the development of new metrics to measure the impact of your publications.

Recent Advances in Nutritional Modulation of the Immune System
Monday, 8:00 – 10:00 AM

Recent years have brought a new understanding of the role of the immune system in health and disease.  In this session, researchers will present intriguing new findings suggesting how foods, nutrients and conditions such as obesity interact with the immune system and inflammation.

New Technologies in the Food System:  How Do they Fit and Who Decides?  (Food Evolution Movie Screening and Discussion)
Monday, 10:30 AM – 12:30 PM

What are the decision-making processes that bring changes to the food system? What is the role of government, consumers, producers and scientists in these discussions? How do new technologies such as GMOs fit into the hierarchy of needs for the food system?  Join us for a viewing of the Food Evolution movie followed by a panel discussion moderated by The Washington Post’s Tamar Haspel.

Nutrition and Health in an Accelerating Pace of Life
Tuesday, 8:00 – 10:00 AM

There is no single metric to quantify the pace of life, but many indices indicate that it is fast and accelerating nationally and globally.  Since World War II, there has been an increasing demand for a food supply that is not only safe, palatable, and affordable, but also convenient. This has been driven to a large extent by substantive shifts in where people live, the types of jobs they have, the increasing hours worked, dual-income families, food preparation methods and other behaviors. This has all driven the desire for, indeed the necessity of, options that emphasize convenience. The consequence of this for food availability and choice, nutrient composition and health are still largely unknown, but widely speculated upon.  Consumer expectations and claims by some clinicians and policy makers have far outpaced the science leading to confusion and increased risk of poor food choices.  The magnitude and duration of this shift in ingestive behaviors elevates it beyond a “fad” to a reality that must be better understood. This session will explore the historic, current and future consequences of changing lifestyles on diet quality and health.

Tasting Outside the Oral Cavity
Monday, 10:30 AM – 12:30 PM

Recent evidence documents the presence of taste receptors throughout the GI tract as well as in many other peripheral sites. The nature of these receptors and the ligands they bind are often the same as those in the oral cavity. These discoveries raise new questions with important health implications. To what extent is there a continuity of sensory and nutrient information flowing from the oral cavity through the extent of the GI tract and what are the implications of activating or disrupting this information flow?  Are compounds once thought to be biologically inert in the GI tract actually modulating processes such as digestion, appetite and nutrient absorption? This session will review the evidence for extra oral “taste” sensing and its potential health implications.  Evidence from cell culture, animal models and human trials will be presented.

Prevention of Food Allergies & Atopic Disease: The Atopic March – Can it Be Halted?
Tuesday, 10:30 AM – 12:30 PM

Food allergy occurs in up to 12% of American children and adults, and as many as 5% of infants have eczema. Rates of food allergy have been steadily increasing over the past 2 decades.  Past infant feeding guidelines have emphasized breastfeeding, delaying the introduction of complementary foods, and extended delay in exposure of the most allergenic foods such as peanuts, eggs, fish, soy and wheat.  On the basis of randomized controlled trials, these guidelines have recently been revised to recommend early exposure to allergens. Controversy remains regarding potential protective effects of hydrolyzed formulas (are they as hypoallergenic as breast milk?); optimal timing of introduction, especially in relation to recommendations for exclusive breastfeeding for 6 months; and potential benefit of breastfeeding at time of introduction of peanut, gluten, egg.  Also, who should be targeted for these recommendations?   Those deemed high risk or the general population?

To attend these sessions, please click here to register for Nutrition 2018!

 

By: Nafisa M. Jadavji, PhD

 

A stroke occurs when there is reduced blood flow to the brain. Blood carries oxygen and glucose to cells in the brain. When there are reduced levels of blood, these cells start to die. Since the brain controls behavior, this cell death leads to impairments in function. The impairments are dependent on where the stroke happens in the brain. There are two main types of stroke: hemorrhagic and ischemic. For this blog, I will be focusing on ischemic stroke which is a result of blockage in a blood vessel. Currently, stroke typically affects older individuals and the global population is aging according to the United Nations. Additionally, older individuals also lose their ability to absorb all the vitamins and nutrients they require from their diet as they age.

Nutrition is a modifiable risk factor for diseases of aging. For example, B-vitamin absorption decreases as individuals age. B-vitamins play a major role in reducing levels of homocysteine, a non-protein amino acid. High levels of homocysteine have been associated with increased risk to develop cardiovascular diseases, such as stroke. Supplementation with B-vitamins has been reported to have positive effects on brain health.

A study by researchers in Oxford University and University of Oslo has shown that B-vitamin supplementation in the elderly within the United Kingdom reduced age-related brain atrophy after 2 years of supplementation. Furthermore, another study by the same group reported that B-vitamin supplementation reduced cerebral atrophy in areas vulnerable to Alzheimer’s disease.

More recently, a group from China reported that folic acid supplementation in combination with Enalapril, used to treat heart disease, reduced the risk of stroke by 21% in patients that were hypertensive.

Within the aging population, B-vitamin supplementation has been reported to have positive effects on brain health. The elderly are more prone to ischemic stroke, but the mechanisms through which this benefit is accomplished are not well understood.

A recent study investigating the role of B-vitamin supplementation on ischemic stroke was published in the Neurobiology of Disease. This study tried to examine the mechanisms of how supplementation improved brain function. A group of wildtype males were put on a folic acid deficient diet (0.2 mg/kg) prior to ischemic damage to increase levels of homocysteine and another group of mice were put on a control diet (2mg/kg folic acid). After ischemic damage to the sensorimotor cortex, FADD mice were put on a supplemented diet, where levels of folic acid, riboflavin, vitamin B12, and choline were increased. Animals were maintained on the diets for 4-weeks after which motor function was assessed.  Researchers found that supplemented diet mice performed better on motor tasks compared to CD mice with ischemic damage. In the brain tissue, increased levels of plasticity and antioxidant activity were reported.

Combination therapies for stroke-affected patients are thought to be most effective. A pharmaceutical in combination with a lifestyle change, such as increased exercise may be beneficial for stroke-affected patients. This data suggests that nutrition may also be a viable option to prevent or attenuate ischemic damage.

 

 

The renal diet is commonly recommended for those with late stages of chronic kidney disease and end-stage kidney disease. The renal diet is characterized by the reduction of dietary sodium, potassium, and phosphorus. The rationale behind these restrictions is to prevent the buildup of these micronutrients in the blood and to reduce complications, such as hypertension, fluid overload, arrhythmias, bone disorders, and vascular calcifications. However, this diet is considered restrictive, hard to prescribe and follow.

A consequence of the renal diet is the reduction in the consumption of some food groups, such as fruits, vegetables, whole grains, legumes, and nuts. These food groups, besides being good sources of the aforementioned nutrients, are also good sources of vitamins, other minerals, polyphenols, and dietary fiber. Indeed, when researchers have looked into the nutrient intake of patients with late stages of chronic kidney disease and end-stage kidney disease undergoing renal replacement therapy (i.e., hemodialysis), patient consumption of some vitamins and dietary fiber is below the recommendations.

Moreover, when dietary patterns have been explored, a predominance of a Western-type dietary pattern with a high consumption of red meat, salt, and refined sugars, and a lower consumption of fruits, vegetables, legumes, whole grains, and nuts has been reported. A Western-type diet may seem counterintuitive as patients with chronic kidney disease have a higher prevalence of cardiovascular disease and mortality than the general population, as well as other comorbidities, such as obesity and diabetes.

The renal diet is restrictive and hard to follow 

But why are patients with chronic kidney disease and end-stage kidney disease consuming a Western-type diet? If you are a registered dietitian, you know that the renal diet is one of the hardest to prescribe. Additionally, often times a patient with kidney disease has other comorbidities, such as diabetes and hypertension, which adds a layer of difficulty to the medical nutrition therapy. Some dietitians provide a list of foods that are high in potassium, phosphorus, and sodium. If you look into the lists of foods, you quickly realize that your options are reduced. Also, some of the cooking methods to reduce these nutrients may require extra time and resources, which could be a barrier for patients and a burden for their care givers. This may lead patients to disregard the recommendations altogether and may be reflected in the nutrient intake and dietary patterns reported. 

The traditional approach to the renal diet is evolving 

The traditional approach to the renal diet is beginning to change. Recently, the European Renal Association-European Dialysis and Transplantation Association recommended the Mediterranean diet as the dietary pattern of choice for chronic kidney disease patients. Additionally, modified and “liberalized” dietary recommendations based on easy-to-follow guidelines have been proposed for hemodialysis patients. However, there may be some healthcare and nutrition professionals who may disagree with these recommendations. One reason is that potassium intake may be increased and a risk of high concentrations of potassium in blood, or hyperkalemia, may outweigh the benefits of the diet overall. However, the association of dietary potassium and serum potassium in end-stage kidney disease patients undergoing hemodialysis treatment is very weak. Moreover, with these dietary patterns most of the phosphorus comes from plant-based foods, as the consumption of animal-based products is limited, which confers a benefit as the bioavailability of phosphorus is lower than the animal sources and the consumption of ultra-processed foods is also limited.

The Mediterranean and DASH-style diet have been associated with reduced cardiovascular and all-cause mortality in the general population. In kidney disease, a dietary pattern that resembles these diets has been associated with a 27% reduction in mortality risk. However, recent results from the DIET-HD multinational cohort of over 8,000 hemodialysis patients showed that a high adherence to the Mediterranean or DASH-type diet was not associated with reduced cardiovascular mortality or all-cause mortality. This study, however, was an observational prospective multinational cohort from European countries using a food frequency questionnaire that uses the British Food Composition Table and, therefore, there is a limited generalizability of the results.  

The nutrition guidelines for patients with chronic kidney disease are being updated

An update for the major nutrition guidelines for kidney disease patients (the Kidney Disease Outcomes Quality Initiative [K/DOQI] guidelines by the National Kidney Foundation) is expected later this year. Even though an overall focus of nutrient recommendations is still expected, it is not known if a particular dietary pattern will be recommended following the recommendations of the European Renal Association-European Dialysis Transplantation Association. Despite this, without a doubt there is a need for prospective, randomized-clinical trials  to provide proof of the benefit on outcomes and quality of life with focusing on dietary patterns rather than mere nutrient restrictions. nd

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.

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.

 

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)

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/

 

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

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).