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 https://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. https://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. https://ajcn.nutrition.org/content/106/3/717.full.pdf
  6. https://ajcn.nutrition.org/content/99/6/1525.full.pdf
  7. https://aaccipublications.aaccnet.org/doi/pdf/10.1094/CFW-62-4-0182
  8. https://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. https://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 https://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).

 

 

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.”

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.

 

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.

 

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.

By Mary Scourboutakos

Living in Canada, I was never worried about recombinant bovine somatotropin hormone, aka rBST. This synthetic hormone, which mimics a natural hormone that causes cows to produce more milk, was banned in Canada in the 1990s. So North of the 49th parallel, most people have never heard of it.

Meanwhile in the United States, the situation is a little different. rBST is legal in the US because technically, there’s no evidence that it causes harm to humans. Meanwhile in Canada, the rationale for its ban is that it may pose risks for the cows that are treated with it.

With that in mind, whenever I visit the US, I always explore the milk on grocery store shelves to see if it contains rBST. To my surprise, on nearly every occasion, I’ve been hard pressed to find a jug of milk that didn’t say “from cows not treated with rBST”.

This was reassuring. But then I noticed something…while every jug of milk said “no rBST” I couldn’t find a single block of cheese, or container of yogurt declaring this.

This got me thinking…are they using the rBST-treated milk in yogurt and cheese? Could it be that consumers are so far removed from the food chain that they would think to look for “no rBST” on their milk, but wouldn’t think to look for it on their cheese?

It didn’t make sense…were the labels missing? Or was the industry using rBST milk in places where people would be less likely to look for it? I wanted to get to the bottom of this, so I started asking people about it. No one really knew the answer until I spoke with a representative from the food industry who told me that it takes so much effort to change labels, the industry won’t label something unless there is extremely consumer demand. She predicted that the yogurts and cheese are probably made with rBST-free milk, they’re just not advertising it.

Lo and behold, after doing some reading I found that in fact, many brands have removed rBST from ALL of their products, they’re just not stating it on their label, or they’re doing so haphazardly on some products but not others.

Perhaps I’m an over informed consumer who is paying attention to details that nearly no one else even knows or cares about, nevertheless, it’s interesting to consider that a product could in fact be potentially healthier—or at least kinder to the animal it’s coming from—than expected. I guess sometimes the food industry doesn’t show off everything it could.

By Celez Suratos, MS, RD, ACCN15 Blogger

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

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

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

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

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

By Celez Suratos, MS, RD, ACCN15 Blogger

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

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

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

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

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

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

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