Rukshan Mehta

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Nutrition and Oral Health – Do our mouths hold the key?

A logical start when we think about nutrition is the mouth. The mouth is the first point of entry for all nutrients, in the form of the food we consume. Oral health and periodontal disease and their connection to nutrition run bi-directionally, where several studies have shown associations between individual micronutrients and periodontitis [1, 2]. Additional associations have been found between cumulative histories of oral problems including untreated caries, poor oral health, dental pain, restorations, extractions, use of prosthetics and food insecurity [3].

Periodontitis is defined as an inflammatory disease of the supportive tissues of the teeth caused by microorganisms which result in progressive destruction of periodontal ligaments and alveolar bone [4]. Periodontitis impacts 40-90% of the world’s population and is one of the most prevalent epidemics globally. Several micronutrients also impact periodontal health and include vitamin A (carotenoids, β-carotene), vitamin C (ascorbic acid), vitamin E (α-tocopherol), glutathione and melatonin [5,6]. These anti-oxidants have been shown to help overcome reactive-oxygen species mediated inflammation present in periodontal tissue which leads to periodontitis.

It is estimated that 15.8 million children under the age of 18 years in the United States live in households that are unable to access nutritious food necessary for healthy growth on a consistent basis [7]. In addition, over-nutrition in the form of childhood obesity and overweight, particularly among lower income children, is compounded by a preponderance to more cariogenic foods. A study conducted in Japan documented association between high body mass index (BMI) and increased risk of periodontal disease among young adults [8]. An abundance of fast food, poor quality, high sugar and simple carbohydrate-based diets in lower income neighborhoods predispose children to the development of plaque, dental decay and caries [9, 10]. Inadequate consumption of fruits and vegetables deprive children of the nutrients they need for healthy growth and development [10]. Proper oral health care started at a young age is essential to ensure good nutrition and oral hygiene into adolescence and adulthood.

Pregnant women are more prone to periodontitis, gingivitis and gingival hyperplasia. Increased secretion of estrogen during pregnancy has also been linked to periodontal disease during pregnancy [11]. Periodontal disease both during preconception and in pregnancy has been linked to adverse outcomes including premature birth, preeclampsia, gestational diabetes, fetal loss, small for gestational age babies [12]. Antioxidant rich foods consumed during pregnancy, in addition to diets high in fiber and low in refined sugar are important to prevent periodontal disease. Improved oral hygiene is also essential.

In America, life spans have increased by upwards of 30 years in the last century. It is estimated that by 2050, people will live to an average age of 100 [13]. The elderly, in addition to children and pregnant women, are also susceptible to the impacts of nutrition on oral health. Among this age group, compromised oral health care, due to age-related factors such as tooth loss, use of oral prosthetics, a lack of appetite and mastication ability, in addition to altered taste and gastrointestinal conditions, are important concerns. An inability to consume certain foods due to difficulties with chewing and swallowing can compound food insecurity [14, 15]. Oral care in the elderly and customized nutrition to account for their complex needs is essential to ensure good quality of life.

The link between good oral health and nutrition is undeniable and complex. It is time for more concerted efforts to be made to link the two interconnected areas of health, across the lifespan. Increased efforts to educate oral health providers on the importance of nutrition education, in addition to ensuring proper nutrition security for at risk groups, will ensure healthy bodies and wide toothy smiles!

 

References:

[1] Dommisch, Kuzmanova, Jonsson, Grant & Chapple. (2018). Effect of micronutrient malnutrition on periodontal disease and periodontal therapy. Periodontology 2000, 78, 129-153.

[2] Najeeb, S., Zafar, M.S., Khurshid, Z., Zohaib, S., & Almas, K. (2016). The role of nutrition in periodontal health: An update. Nutrients, 8, 530.

[3] Santin, G.C., Martins, C.C., Pordeus, I.A., & Ferreira, F.M. (2014). Food insecurity and oral health: A systematic review. Pesquisa Brasileira em Odontopediatria e Clinica Integrada, 144, 335-246.

[4] Newman, G.M., Takei, H.H., Klokkevol, R.P., Carranza, A.F. (2012). Carranza’s clinical periodontology. Classification of diseases and conditions affecting the periodontium. In Carranza’s Clinical Periodontology, 12th ed.; Michael, G.N., Henry, H.T., Perry, R.K., Fermin, A.C., Eds.; Elsevier: Amsterdam, The Netherlands, pp. 45-67.

[5] Garcia, J.J., Reiter, R.J., Guerrero, J.M., Escames, G., Yu, B.P., Oh, C.S., & Munoz-Hoyos, A. (1997). Melatonin prevents changes in microsomal membrane fluidity during induced lipid peroxidation. FEBS Letters, 408, 297-300.

[6] Najeeb, S., Khurshid, Z., Zohaib, S., & Zafar, M.S. (2016). Therapeutic potential of melatonin in oral medicine and periodontology. Kaohsiung Journal of Medical Sciences, 32, 391-396.

[7] Coleman-Jensen A, Gregory C, Singh A. (2014). Household Food Security in the United States in 2013. USDA ERS.

[8] Ekuni., D., Yamamoto, T., Koyama, R., Tsuneishi, M., Naito, K., & Tobe, K. (2008). Relationship between body mass index and periodontitis in young Japanese adults. Journal of Periodontitis Research, 43, 417-421.

[9] Moynihan P, Petersen PE. (2004). Diet, nutrition and the prevention of dental diseases. Public Health Nutrition, 7(1A):201-226.  Accessed 7/7/2015 at https://www.who.int/nutrition/publications/public_health_nut7.pdf.

[10] Edgar, W. (1993). Extrinsic and instinsic sugars: A review of recent UK recommendations on diet and caries. Caries Research, 27, 64-67.

[11] Hemalatha, V., Manigandan, T., Sarumathi, T., Aasthi Nisha, V., & Amudhan, A. (2013). Dental considerations in pregnancy – A critical review on oral care. Journal of Clinical Diagnostics Research, 7, 948.

[12] Ziegler, J., & Mobley, C.C. (2014). Pregnancy, child nutrition and oral health. Chapter 2: In Nutrition and Oral Medicine; Touger-Decker R., Mobley, C., & Epstein, J.B., Eds. Springer Science+Business Media, New York, pp. 19-37.

[13] Ham-Chande, R., (2005). Shapes and limits of longevity in Mexico. In proceedings of the living to 100 and beyond symposium, Orlando, FL, USA, 12-14 January 2005.

[14] Sheiham, A., & Steele, J. (2001). Does the condition of the mouth and teeth affect the ability to eat certain foods, nutrient and dietary intake and nutritional status amongst older people? Public Health Nutrition, 4, 797-803.

[15] Brodeur, J., Laurin, D., Vallee, R.,&  Lachapelle, D. (1993). Nutrient intake and gastrointestinal disorders related to masticatory performance in the edentulous elderly. Journal of Prosthetics and Dentistry, 70, 468-473.

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Sarah Dimitratos

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Food and Mood: What Is Nutritional Psychiatry?

Choose your own adventure: Which scenario do you identify with?

  1. You wake up crabby and groggy each morning, reluctantly rolling out of bed after hitting ‘snooze’ three times at a minimum. You curse the morning as you shock your system with a splash of cold water- a cruel, yet necessary ritual. You grab strong coffee and a slightly stale bear claw pastry as an afterthought on the way out the door. This caffeine/sugar combination gives you life for a few hours until you succumb to intense hunger pangs at 11:30am. Take-out lunch quenches the stomach rumbling and dulls your throbbing temples, and you turbulently sail until the 3 o’clock hour, after which point productivity squeals to a halt. More coffee, a fistful of candy from the office jar (and some nuts and carrots in a half-hearted attempt to be healthy) offer a temporary solution. 5pm rolls around, and you leave work in a ravenous, foggy state of mind. You planned to hit the gym, but a date with microwave dinner and Vino are the way to your heart tonight. Once home, you sigh a great, empty sigh as you kick your gym bag to the corner of your room and fall face-first on the couch in one fell swoop.
  2. You wake up as early morning light streams through the cracks in your blinds, pleasantly surprised your alarm clock is set to ring in two minutes. You lie still for a moment, calmly preparing for the day ahead. You move through your morning routine that leaves ample time for breakfast, coffee, and reading the paper. Your philosophy hasn’t failed you yet: ‘Make it fast, eat it slow’: Today’s breakfast is a chopped apple, Greek yogurt, cinnamon, and steel-cut oatmeal topped with honey and slivered almonds. You grab your lunch from the fridge (a colorful salmon, farro, roasted veggie and garbanzo bean salad prepped the night before) on the way out the door. Around 11:30am, you hear a chorus of yawns around your open-layout office; Although wide awake, your stomach gently requests more fuel. Lunch powers you through a productive afternoon with a walking meeting (your preference) and impressive brainstorm session for an exciting new research study that integrates Nutrition, Psychology, and Neuroscience. At 4pm, you re-fuel body and mind with walnuts and blueberries for your planned strength training workout. Energized once more, you grab dinner out with friends- your favorite way to socialize! Roasted herb chicken, bread with olive oil, kalamata olives, and caramelized seasonal vegetables are the way to your heart tonight. Although it’s been a full day, you feel mentally and physically strong.

 

The above scenarios differ like night and day; Although each is dramatized for effect, be honest- most of us can identify with one situation more strongly than the other. Go ahead and select the category that resonates most with you, and let’s dive deeper with a brief brainstorm. What factors make the above scenarios glaringly different?

  1. Person A failed to plan, and Person B practically has a degree in Life-Skills 101
  2. Person A’s job is a drain, while Person B is energized by his/her work
  3. Person A might suffer from depression, while Person B likely does not

So far, so good: Each observation is a deeper reflection of the individuals’ moods. Person A is lethargic, fatigued, unmotivated, and ‘empty,’ while Person B is energized, mentally sharp, mindfully present, and fulfilled.

Excellent, let’s pursue this lead! Consider this: What deeper, underlying factor might account for these distinct moods? Consider one more glaring difference between scenario A and B, this time considering trends in the foods consumed:

  1. Simple carbohydrates, high sodium, and high saturated fat, with a modest sprinkling of vitamins, minerals, and fiber from primarily packaged-foods
  2. Whole grains, lean protein, ample produce, monounsaturated and polyunsaturated fats, lots of fiber, probiotics, vitamins and minerals, and all primarily from whole-food sources

Credit: Easy Recipe Depot

Person A and B both know that their food choices influence their outward appearances- after all, you are what you eat! Digging deeper, however, we see that Person B still has an advantage: This person also understands that one’s food choices influence mental state and behavior! Whether intuitively or intentionally, this person knows a thing or two about an emerging research area called ‘Nutritional Psychiatry.’

Credit: Mind Brighton & Hove

Let’s briefly turn to the research to get the low-down on Nutritional Psychiatry:

If you begin your knowledge quest with a Google search of the term, you’ll find a variety of media reports and research foundations devoted to the topic. Case in point:

The Harvard Health blog published an article called “Food and Mood-Is there a connection?” This article articulates how certain dietary patterns may protect mental health. More specifically, a Mediterranean diet pattern rich in fruits, vegetables, olive oil, whole grains, and lean protein such as chicken and fish, and low in red meat and unhealthy fats may provide promising benefits. Important to note, however, is that one single dietary factor or lifestyle factor is unlikely to affect mental health independently.

The Conversation explains that although research is in early stages, “it is now known that many mental health conditions are caused by inflammation in the brain. This inflammatory response [may be] associated with a lack of nutrients…Recent research has shown that food supplements such as zinc, magnesium, omega 3, and vitamins B and D3 can help improve people’s mood, relieve anxiety and depression and improve the mental capacity of people with Alzheimer’s.

(Psst…see that hyperlink on ‘recent research?’ That’s a link to an original study! Click it, friends!)

-A research foundation called the International Society of Nutritional Psychiatry Research will direct you towards “high quality evidence for nutritional approaches to the prevention and treatment of mental disorders.”

Both sources are good places to start, but our search has just begun! You can either scour each article for links to official research studies written by the research teams themselves, and read such study (Rule of thumb: Media reports are for entertainment first, and comprehensive education second or third or fourth). Alternatively, you may turn to Pubmed and pull up a review article on ‘Nutritional Psychiatry.’ (What’s a review article? Aside from being my preferred, reader-friendly way to learn about science, here’s a description)

The fourth result in our original Google search is conveniently a link to a 2017 review paper called “Nutritional Psychiatry-Where to Next?” This article explains that “A consistent evidence base from the observational literature confirms that the quality of individuals’ diets is related to their risk for common mental disorders, such as depression.”

While promising so far, comprehensive research is still needed in this area, as articulately stated by the same authors: “Key challenges for the field are to…replicate, refine and scale up promising clinical and population level dietary strategies; identify a clear set of biological pathways and targets that mediate the identified associations; conduct scientifically rigorous nutraceutical and ‘psychobiotic’ interventions that also examine predictors of treatment response; conduct observational and experimental studies in psychosis focused on dietary and related risk factors and treatments; and continue to advocate for policy change to improve the food environment at the population level.”

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Aubree Hawley

Should You Prioritize Sleep?

https://thedigestersdilemma.com/are-you-getting-enough-sleep-for-your-and-your-microbes/Copyright 2016 Lorene Sauro / Site Designed by Hal & Marc
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Sleep in America

Do you prioritize your sleep? If you do, you are among the 10% of American adults who make sleep a priority. However, if sleep is not your priority, you may relate more to the 33% of American adults who currently sleep less than seven hours per night, which may have health consequences.

Potential Consequences of Neglecting Your Sleep 

Poor sleep habits can be detrimental to your overall health.  Short sleepers (<7 hours) and those with low sleep quality (sleep efficiency < 85%) are at risk for weight gain, obesity, hypertension and cardiovascular disease. Lack of sleep and low sleep quality have been associated with an increase in cravings and an increase in appetite. Current research has focused on how sleep duration and quality may influence or be influenced by nutrition and eating behavior.

Behavior Influences Sleep 

In one weight loss study, researchers observed sleep changes in overweight and obese participants over a ten-month period. Participants lost weight and slept longer at the end of the two-month weight loss plan and continued to sleep longer up to their 3-month follow up appointment. The researchers concluded that successful weight loss is accompanied by an increase in sleep time.

Another study focused on the timing of food intake and how it relates to fat mass and circadian rhythm (your 24-hour internal clock) in college-aged participants.  The findings of this study showed that participants with a higher body fat percentage (32.4% body fat) consumed more calories later in the day and closer to their biological sleeping time than the lean group (22.2% body fat).

Sleep has also been shown to influence food choices. Recently, a study found that when adults who were short sleepers (sleeping 5 to less than 7 hours a night) increased their sleep time by 21 minutes per night, they consumed less sugar and less fat when compared to a group that did not extend their sleeping hours.

Nutrition and Sleep

It is not yet clear if sleep is a driver of food intake or if food intake is a driver of sleep. Increases in dietary protein, fish and vegetables have been shown to elicit many health benefits including benefits related to sleep.  For example, in a weight loss study, dietary protein intake above the current dietary recommendations of 0.8g protein per kilogram of body weight daily, improved sleep quality in overweight and obese middle-aged and older adults when compared to a normal protein diet.

Foods such as milk obtained from cows at night, fatty fish (>5% fat), kiwi (2 kiwi fruits/day 1 hour before bed), and cherries (tart cherry juice or whole fruit) have been labeled as “sleep promoting foods”, but further research is needed to justify these claims.

Nighttime milk is obtained by milking cows at nighttime. Nighttime milk is naturally higher in the sleep promoting hormone melatonin and the essential amino acid tryptophan. More research is needed to support the sleep promoting benefits of nighttime milk.

Conclusion

Sleep has been shown to impact various aspects of behavior and well-being. If you are looking to improve your health and nutrition, it may be time to put sleep on your priority list.

References

  1. Al Khatib Haya K, Hall Wendy L, Creedon Alice, Ooi Emily, Masri Tala, McGowan Laura, Harding V Scott, Darzi Julia and Pot Gerda K. Sleep extension is a feasible lifestyle intervention in free-living adults who are habitually short sleepers: a potential strategy for decreasing intake of free sugars? A randomized controlled pilot study. Am J Clin Nutr. 2018.
  2. McHill Andrew W, Phillips Andrew JK, Czeisler Charles A , Keating Leigh ,Yee Karen ,Barger Laura K, Garaulet Marta ,Scheer Frank , and Klerman Elizabeth B. Later circadian timing of food intake is associated with increased body fat. Am J Clin Nutr. 2017.
  3. National Sleep Foundation’s 2018 Sleep in America Poll Shows Americans Failing to Prioritize Sleep. (n.d.) Retrieved from https://sleepfoundation.org/media-center/press-release/2018-sleep-in-america-poll-shows
  4. Patterson Ruth E, Emond Jennifer A, Natarajan Loki, Wesseling-Perry Katherine, Kolonel Lauren N, Jardack  Patrick, Ancoli-Israel Sonia and Arab Lenore. Short sleep duration is associated with higher energy intake and   expenditure among African-American and non-Hispanic white adults. J Nutr. 2014; 144(4):461-466.
  5. St-Onge Marie-Pierre, McReynolds Andrew, Trivedi Zalak B, Roberts Amy L, Sy Melissa and Hirsch Joy. Sleep restriction leads to increased activation of brain regions sensitive to food stimuli. Am J Clin Nutr. 2012; 95(4):818-824.
  6. St-Onge Marie-Pierre, Mikic Anja and Pietrolungo Cara E. Effects of Diet on Sleep Quality. Adv Nutr. 2016; 7(5):938- 949.
  7. Verhoef Scanne PM, Camps Stefan GJA, Gonnissen Hanne K, Westerterp Klass R and Westerterp-Plantenga, Margriet S. Concomitant changes in sleep duration and body weight and body composition during weightloss and 3-mo weight maintenance. Am J Clin Nutr. 2013; 98(1):25-31.
  8. Zhou, Jing & Kim, Jung Eun & Lh Armstrong, Cheryl & Chen, Ningning & W Campbell, Wayne . Higher-protein diets improve indexes of sleep in energy-restricted overweight and obese adults: results from 2 randomized            controlled trials. Am J Clin Nutr. 2016; 103(3):766-774.
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Rukshan Mehta

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Breastfeeding: The Long and the Short of It

Breastfeeding as an issue of significance in the world of public health and nutrition has gained considerable traction in recent months. With globally publicized opposition by the US to the World Health Assembly Resolution on Infant and Young Child Feeding (triggered by severe restrictions on milk products for older infants and young children) and reports of coercion to further corporate interests, the issue is of great pertinence in today’s times. It being World Breastfeeding Week, this blog will delve into the science of breastfeeding, a nutrition-focused behavior that has amassed a tremendous body of evidence in its favor when concerning infant and young child health [1].

The Lancet series published in 2016 describes both the micro and macro level benefits of breastfeeding for infants in countries of all economic strata. One paper [2] from the series estimates that approximately 823,000 annual deaths among children <5 years of age and 20,000 annual deaths of women from breast cancer can be avoided through the promotion of improved breastfeeding practices. Additionally, breastfeeding has long lasting impacts on morbidity and improves the cognitive capacity and educational potential of children, with economic benefits including higher wages in adulthood [2]. Greater benefits are achieved with longer durations of breastfeeding, and this behavior has impact on morbidity with evidence showing protective benefits against diarrhea, respiratory infections, and asthma [3].

Additionally, a growing body of evidence shows overwhelming support for breastfeeding as protective behavior against long-term health outcomes related to non-communicable diseases including obesity [3]. An analysis of 113 studies shows that longer durations of breastfeeding are associated with a 26% reduction (95% CI: 22-30) in the odds of obesity across income groups. Another pooled analysis of 11 studies showed a 35% reduction (95% CI: 14-51) in the incidence of type 2 diabetes [3]. Prior work has shown that breastfeeding confers protection against obesity later in life, with lower prevalence rates after adjusting for confounders such as socioeconomic status, birthweight and sex [4].

Recent papers published in the American Journal of Clinical Nutrition highlight the nuanced impact of breastfeeding on child growth trajectories. A study by Kramer et al. (2018) showed, using various different statistical analyses, a causal effect of randomization to a breastfeeding promotion intervention on growth during the first 2-3 months of life [5]. Additionally, these authors noted that children in a breastfeeding intervention group and those who were breastfed for ≥12 months experienced faster growth when compared to those in the control group or those breastfed for <12 months, particularly during the first 2-3 months. The differences in growth velocity between groups was lower in subsequent months and almost equalized by 12 months of age.

A study by Eny et al. conducted in Canada found that maternal BMI was positively correlated to infant BMI [6]. These authors note that maternal BMI has been shown to modify BMI growth rates among children beginning at birth up to 12 years of age [7]. These authors note that the trajectories for growth differed by breastfeeding duration, maternal BMI and birth weight from 1-3 months of age.

Results from these studies and others highlight the need for more prospective research to assess how, when and whether breastfeeding practices influence infant weight gain, and what factors within breastmilk impact lean and fat mass growth [8]. Overall, the case for early initiation, exclusivity of breastfeeding for the first 6 months and continued breastfeeding up to 2 years remain strong and programs, policies and incentives to encourage and promote adequate breastfeeding behaviors remain the need of the hour. So this World Breastfeeding Week, may mothers’ across the world be motivated, encouraged and supported to continue gifting their young one of the most valuable gifts nature has accorded us!

References:
[1] Jacobs, A. (2018). Opposition to breast-feeding resolution by the US stuns world health officials. Retrieved from: https://www.nytimes.com/2018/07/08/health/world-health-breastfeeding-ecuador-trump.html
[2] Rollins, N.C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C.K., Martines, J.C., Piwoz, E.G., Richter, L.M., Victora, C.G. (2016). Why invest, and what it will take to improve breastfeeding practices? Lancet, 387, 491-504.
[3] Victora, C.G., Bahl, R., Barros, A.J., Franca, G.V.A., Horton, S., Krasevec, J., Murch, S., Sankar, M.J., Walker, N., Rollins, N.C. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet, 287, 475-490.
[4] Armstrong, J., Reilly, J.J., & Child Health Information Team. (2002). Breastfeeding and lowering the risk of childhood obesity. Lancet, 359 (9322), 2003-2004.
[5] Kramer, M.S., Davies, N., Oken, E., Martin, R.M., Dahhou, M., Zhang, X., & Yang, S. (2018). Infant feeding and growth: putting the horse before the cart. American Journal of Clinical Nutrition, 107, 635-639.
[6] Eny, K.M., Anderson, L.N., Chen, Y., Lebovic, G., Pullenayegum, E., Parkin, P.C., Maguire, J.L., Birken, C.S. (2018). Breastfeeding duration, maternal body mass index, and birth weight are associated with differences in body mass index growth trajectories in early childhood. American Journal of Clinical Nutrition, 107, 584-592.
[7] Bornhorst, C., Siani, A., Russo, P., Kourides, Y., Sion, I., Molnar, D., Moreno, L.A., Rodrigues, G., Ben-Shlomo, Y., Howe, L., et al. (2016). Early life factors and inter-country heterogeneity in BMI growth trajectories of European children: the IDEFICS study. PLoS One, 2016:11:e0149268.
[8] Hay, W.W. Jr. (2018). Breastfeeding newborns and infants: some new food for thought about an old practice. American Journal of Clinical Nutrition, 107, 499-500.

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asnutrition

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World Breastfeeding Week – Research from ASN

Breastfeeding: Foundation of Life

World Breastfeeding Week is celebrated every year from August 1 – 7 across the globe to encourage breastfeeding and promote healthy practices from the earliest stages of life. This campaign is led by the World Alliance for Breastfeeding Action (WABA), a global network of organizations and individuals who work to promote and support breastfeeding practices worldwide. The 2018 slogan is “Breastfeeding: Foundation for Life”.

“In a world filled with inequality, crises and poverty, breastfeeding is the foundation of lifelong good health for babies and mothers.”

Latest Research on Breastfeeding

ASN’s four nutrition science journals often publish new research on breastfeeding, and there were many sessions on the topic at ASN’s annual meeting, Nutrition 2018. ASN also ensures the representation and support of breastfeeding research within our membership and scientific programs through a dedicated research interest section, Maternal, Perinatal, and Pediatric Nutrition. Members who belong to this group focus on the biology of nutrition as it impacts human development, and the role of nutrition on both short-and long-term outcomes in the mother, fetus, infant, and child.

New Research on Breastfeeding from American Journal of Clinical Nutrition

Breastfeeding newborns and infants: some new food for thought about an old practice

“Feeding newborns and infants is hardly a new topic, but these 2 articles provide some important new food for thought, and hopefully might stimulate appetite for studying how breastfeeding and human milk confer unique advantages on infant growth and development, as well as prevention of later life diseases such as obesity, which are programmed early in life.”

Breastfeeding duration, maternal body mass index, and birth weight are associated with differences in body mass index growth trajectories in early childhood

Infant feeding and growth: putting the horse before the cart

Current Knowledge on Micronutrients in Human Milk: Adequacy, Analysis, and Need for Research

This free supplement was published with the May 2018 issue of Advances in Nutrition. Articles included are:

Introduction to Current Knowledge on Micronutrients in Human Milk: Adequacy, Analysis, and Need for Research

Overview of Nutrients in Human Milk

Limitations of the Evidence Base Used to Set Recommended Nutrient Intakes for Infants and Lactating Women

Micronutrients in Human Milk: Analytical Methods

Retinol-to-Fat Ratio and Retinol Concentration in Human Milk Show Similar Time Trends and Associations with Maternal Factors at the Population Level: A Systematic Review and Meta-Analysis

Iodine in Human Milk: A Systematic Review

Vitamin B-12 in Human Milk: A Systematic Review

Breastfeeding and the Microbiome

ASN Fellow Dr. David Heber recently published a video Microbiome #3: Getting it Started. This is what he says:

“The Microbiome is established in the gut during breast feeding. While some bacteria enter the body during delivery and from the mother’s skin, the majority are formed from a special group of complex carbohydrates called Human Milk Oligosaccharides (HMO’s). There are about 150 HMO’s and they feed a single bacterial species called Bacteroides Infantilis which has a series of pumps on its surface bringing these sugars called oligosaccharides inside the cell to be digested. This bacteria is called an “inside” eater and does not share the HMO’s with other bacteria so it becomes the dominant bacteria in the gut Microbiome setting up the baby’s immune system. The breast milk has protein, fat, and lactose (the same sugar in cow’s milk) but is unique in having the 150 HMO’s. This is another reason why it is so important for women to breast feed their babies. Breastfeeding also removes 500 Calories per day from the Mom’s body helping with reducing pregnancy weight gain. During breast feeding women need to get extra protein, Calcium, vitamin D and B vitamins to replace what is being put out in breast milk!!”

Video shared with Dr. David Heber’s permission.

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Annabel Biruete

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When calcium is not equal to bone health

Calcium is traditionally considered the bone-health nutrient. This is because 99% of calcium is contained within the bone, in which calcium creates a mineral complex with phosphate (hydroxyapatite), giving bone its characteristic strength and function. However, besides forming part of bone, calcium is also involved in other functions, such as muscle function, nerve transmission, intracellular signaling, and others.

Bone is a very dynamic organ in which the rate of formation and resorption (or destruction) is different throughout the lifespan. During childhood and adolescence, the rate of formation is higher than the rate of resorption, leading to maximum bone gain. In older adults these rates are switched, causing loss of bone. This bone loss may lead to osteopenia, osteoporosis, and an increased risk of bone fractures.

Is an increased intake of calcium associated with reduced risk of fractures?

As a way to prevent bone loss and fractures in middle-aged and older adults, there is usually a push from public health initiatives and healthcare professionals to increase the intake of calcium. However, an increased intake of calcium (dietary + supplements) may not necessarily lead to fewer fractures. Two of the most recent systematic reviews and meta-analyses showed that increasing dietary calcium and the supplementation of calcium (and vitamin D) did not reduce the risk of fractures. However, this remains controversial as a previous meta-analysis showed that the supplementation of calcium and vitamin D was associated with a 15% risk reduction in middle-aged and older adults (community-dwelling and institutionalized).

 The use of calcium supplements may lead to a higher risk of cardiovascular disease

The hypothesis is that an increased intake of calcium may lead to a positive calcium balance (intake lower than output in urine + feces), in the absence of increased bone formation. This positive calcium balance may lead to the calcification of tissues other than the bone, such as the vasculature, increasing the risk of cardiovascular disease. However, this association remains controversial. A sub-analysis of the Multi‐Ethnic Study of Atherosclerosis (MESA), showed that those that had higher dietary calcium intake (without supplements) had a lower risk of coronary artery calcification, while those that were taking supplements had a higher risk. However, the National Osteoporosis Foundation and the American Society for Preventive Cardiology suggested that calcium intake (diet + supplements) that does not exceed the tolerable upper level of intake of 2000 to 2500mg/d is not associated with cardiovascular outcomes, and should be considered safe.

Special caution of high intake of calcium in subjects with reduced kidney function

A high intake of calcium, particularly those that use calcium supplements, may represent a problem for those with reduced kidney function, as they may not be able to excrete the extra calcium. In a study by Hill and collaborators, a calcium intake of 2500mg (1000 mg through diet + 1500mg from calcium carbonate), compared with a dietary calcium intake of 1000mg, led to 500mg of calcium retention in patients with reduced kidney function. Similarly, Spiegel and collaborators compared a diet with 800mg vs. 2000mg of calcium in subjects with normal and reduced kidney function. In those on the 2000mg calcium diet, there was a positive calcium balance, which was more marked in those with reduced kidney function. With these results, a calcium intake higher than 800-1000mg (diet + supplements) should be avoided in those patients with a reduced kidney function to prevent calcifications of tissues other than the bone.

Should health care professionals recommend a high intake of calcium?

The current evidence, in middle-aged and older adults, does not seem to support high calcium intakes (above the tolerable upper level) for the prevention of fractures. Additionally, high calcium intakes achieved with the use of supplements may be associated with increased risk of cardiovascular disease. However, the use of supplements may be useful for patients that have low calcium intake. Finally, special attention should be taken in patients with reduced kidney function, as a high intake (diet + supplements) may lead to an increased risk of cardiovascular disease.

 

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Sarah Dimitratos

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The shopper’s Dilemma: To Shun Or Embrace The Center Aisles?

Which consumer are you?

–The astute academic or health professional: You have a degree (one or more) in nutrition, you have PubMed bookmarked on your internet browser, and you spend your days dispelling nutrition myths and/or researching the next nutrition breakthrough.

–The health foodie. You scour wholesome recipes online, you already know the nutrition trends for 2019, you make detailed grocery lists like it’s your job, you’re a #mealprepsunday veteran, and always know where to find the best deals for natural/organic/raw/fresh eats.

–The bachelor/broke student: Is it cheap? Edible? Delicious? Easy to prepare? If yes, it goes in the cart.

–The athlete with phenomenal sport skills, and (developing) culinary know-how: You know that the foods you eat influence your athletic performance. You are game for eating better, under one condition: you need quick/easy foods that pack a nutritional punch.

–The busy parent: There are lunches to make, picky eaters to feed, and you can’t remember the last time you enjoyed a calm, healthy mealtime at home. Grocery shopping is typically a stressful battle between your healthy intentions, and the little ones’ demands for sugary cereals and flashy marketing.

Photo Credit: Lifehacker

Whether you identify with one or multiple distinct categories listed here, each one is unified by a few common underlying themes:

We all eat.

We crave amazing flavors.

There are never enough hours in the day.

We really do have good intentions; We want to eat well.

Assuming we don’t grow/hunt/gather our own food, we cross paths with one another for a common purpose: Food Shopping! On that note, we’ve been exposed to the same rules of thumb for healthy grocery shopping:

-Shop the perimeter!

-Steer clear of the middle aisles!

The way I see it, there are two types of people in this world: Those who love the center aisles (but could use a little strategy for picking the best options), and those who openly shun those aisles (but are secretly curious to explore the forbidden foods within).

As a health professional, it’s my duty to pass along this tried-and-true advice. But as a real-life RD on a budget, I hear you: Those middle aisles are mighty tempting, so what’s a guy/girl to do?

Take a deep breath, direct that grocery cart towards those center aisles, keep your eye on the prize and walk with intention because you have a fool-proof plan. Healthy shoppers, unite! Today, you’ll conquer those middle aisles like the savvy consumer you are.

Photo Credit: The Sports Nutrition Coach

Your strategy: Divide and conquer by food group like so:

Whole grains, legumes, and pseudograins: Instant oatmeal, frozen brown rice or quinoa (that’s a pseudograin), ready-to-serve plain cooked rice, Grape Nuts (for impressive iron and fiber content), popcorn, Vaccuum packed pre-cooked lentils (that’s a legume), whole grain bread (can you find bread with 0-1g sugar per serving? Can you find fiber above 2g per serving?)

Fruits and vegetables: Frozen is your friend! These items are picked at peak ripeness and flash-frozen immediately afterwards. Canned items are fine as well (in light syrup or water). Can you get all colors of the rainbow?

Protein: Canned beans, canned tuna, canned chicken, canned salmon, frozen chicken strips (no breading), hummus

Dairy: single serve plain Greek yogurt (Ok, you’ll find this in the perishables, but this is too versatile not to include), string cheese

Fats: Olives, frozen Cool Whip, prepared guacamole

Snacks: Dark chocolate (Pro-tip: Pick one with single-digit grams sugar per serving), nuts (try pistachios, almonds, or walnuts), dried fruit, jerky, whole grain chips, hummus

Drinks: Chocolate milk

Spreads/flavorings: Sriracha, olive oil, balsamic vinegar, mustard, pesto

Photo credit: Smile Sandwich

 Once you return home from this über successful grocery trip, you’ll want to assemble some stellar meals using your new bounty. Try this one-day sample plan:

Breakfast: Yogurt cup topped with frozen fruit, Grape Nuts, nut butter (purchase single serve packets in a pinch!) Feeling extra hungry? Prepare a side of instant oatmeal

Lunch: Tuna sandwich (canned tuna mixed w/ mustard, Ezekiel bread). Side of green salad (found in deli section)

Snack: Handful of nuts, handful chips, and hummus

Post Workout: Classic PB&J, or chocolate milk

Dinner: Defrost that frozen rice, quinoa, or lentils, frozen veggies of choice, top w/ beans (and/or thawed ready-to-eat chicken), salsa, pre-made guacamole, and Sriracha

Dessert: 2-3 squares of dark chocolate, alongside frozen blueberries w/ a dollop of cream

Not everyone has a nutrition coach by their side, but you, ASN reader, have an edge. Use this guide to confidently navigate the previously forbidden center aisles. Print it, internalize it, share it. No nonsense, no gimmicks. Blasphemy? Hardly. Creative and backed in science? Absolutely.

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Olivia Rivera

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Maternal diet influences long-term health of children well before pregnancy

Mother and infant

Maternal diet during pregnancy is thought to be one of the most influential factors on child health and development. However, dietary interventions during this period may miss a critical window to improve health during childhood, as well as adult life.

In a recent series of articles in The Lancet, researchers address the significance of nutrition in the preconception period, or the time before a woman becomes pregnant. The series of three articles challenges the current perspective of the preconception period. Currently defined as 3 months before conception, the authors suggest preconception should also include any time a woman is at child bearing age. This revision is based on an understanding of the biological events occurring during the periconceptional period, or the time immediately surrounding conception. In addition, it addresses a lack of nutritional preparedness for pregnancy in women of reproductive age and the failure of dietary interventions during pregnancy in preventing adverse health outcomes.

How does pre-pregnancy nutrition affect child health?

The periconceptional period begins before fertilization occurs, with maturation of sperm and oocytes, and extends until implantation of the fertilized egg. From the time of fertilization, this process occurs relatively quickly (up to 9 days in humans) but is characterized by drastic changes developmentally, genetically, and metabolically. The embryonic genome undergoes epigenetic modifications, or alterations to the DNA that do not change the genetic code but rather affect how a gene is expressed by turning expression on or off. These modifications are responsive to environmental conditions and nutrient availability, and likely adapt to promote optimal survival under existing conditions. However, the established gene expression pattern may be detrimental in environmental conditions outside of the uterus, promoting disease development later in life.

Although epigenetic changes can occur throughout one’s lifetime, the periconceptional period is unique in that a small number of cells are present. Full exposure to the environment allows this founder population of cells to establish the genetic program that persists throughout development.

How does this change current practice?

The influence of maternal nutrition during the periconceptional period on disease and development in offspring is not a new concept. Both maternal overnutrition and obesity, as well as undernutrition have been known to adversely affect metabolic regulation in offspring and increase the risk for metabolic disease development.

More recently, analysis from the UK National Diet and Nutrition Survey suggest that less than 10% of women of reproductive age meet the recommended daily intakes during pregnancy for several key micronutrients including zinc, vitamin A, folate, and calcium. Only 30% of women meet the daily intake recommendations for iron. A lack of success of multiple micronutrient supplementation during pregnancy in improving child health outcomes, including survival, growth, body composition, and blood pressure, indicate the importance of correcting such nutritional deficiencies well before pregnancy.

These findings suggest that preconception intervention strategies should include population targeted interventions for women of reproductive age, in addition to those targeting the 3 months before conception. This will allow adequate time to correct for nutritional deficiencies before pregnancy.

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ASN Blogger

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Submit Your Comments on the 2020-2025 Dietary Guidelines

2020-2025 Dietary Guidelines for Americans

The U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) are seeking public comments on topics and supporting scientific questions to inform the development of the 2020-2025 Dietary Guidelines for Americans. This is a new step in the development process. View the Federal Register Notice here.

Topics and questions proposed by USDA and HHS are based on four criteria: relevance, importance, potential federal impact, and avoiding duplication. The topics for 2020-2025 Dietary Guidelines are within a life stages approach, focusing on priority scientific questions from birth through older adulthood. In addition, the topics reflect a continued focus on patterns of what we eat and drink as a whole, on average and over time.

Learn more on the development of the dietary guidelines here. Submit your comments here.

Listed below are the five life stages with proposed topics and scientific questions. The guidelines will also describe current dietary patterns, including intakes of food groups and nutrients, for each stage of life.

Infants and toddlers from birth to 24 months (healthy, full-term infants)

Topic Question(s)
Recommended duration of exclusive human milk or infant formula feeding What is the relationship between the duration of exclusive human milk or infant formula consumption and 1) growth, size, and body composition; 2) food allergies and other atopic allergic diseases; and 3) long-term health outcomes?
Frequency and volume of human milk and/or infant formula feeding What is the relationship between the frequency and volume of human milk and/or infant formula consumption and 1) micronutrient status; and 2) growth, size, and body composition?
Dietary supplements (e.g., iron, vitamin D, vitamin B12) What is the relationship between specific micronutrient supplements for infants fed human milk and/or infant formula and 1) micronutrient status; and 2) growth, size, and body composition?
Complementary foods and beverages*: Timing of introduction, types, and amounts

*Beverages (cow’s milk, water, 100% fruit juice, sugar-sweetened beverages, milk alternatives)

 What is the relationship between complementary feeding and 1) micronutrient status; 2) growth, size, and body composition; 3) developmental milestones; 4) food allergies and other atopic allergic disease; and 5) bone health?

What is the relationship between complementary feeding, including foods and beverages, and achieving nutrient and food group recommendations of infants and toddlers?

Note: Evidence related to dietary patterns (including beverage patterns) consumed during the complementary feeding period will be considered as part of these questions.

 

Children and adolescents, ages 2-18 years old (with data reviewed by age group)

Topic Question(s)
Dietary patterns to promote health and normal growth and meet nutrient needs What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed during childhood and adolescence and 1) growth, size, and body composition; and 2) bone health?

Are changes to the USDA Food Patterns needed based on the relationships identified? If so, how well do USDA Food Pattern variations meet nutrient recommendations for children and adolescents?
Beverages (cow’s milk, water, 100% fruit juice, sugar-sweetened beverages, milk alternatives, caffeinated beverages) What is the relationship between beverage consumption during childhood and adolescence and achieving nutrient and food group recommendations?
Added sugars What is the relationship between added sugars consumption during childhood and adolescence and achieving nutrient and food group recommendations?

How much added sugars can be accommodated in a healthy diet during childhood and adolescence while still meeting food group and nutrient needs?

 

Adults, ages 19-64 years old (with data reviewed by age group)

Topic Question(s)
Dietary patterns to promote health, prevent disease, and meet nutrient needs What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed during adulthood and 1) body weight or obesity; 2) risk of cardiovascular disease; 3) risk of type 2 diabetes; and 4) risk of certain types of cancer?

Are changes to the USDA Food Patterns needed based on the relationships identified? If so, how well do USDA Food Pattern variations meet nutrient recommendations for adults?
Beverages (cow’s milk, water, 100% fruit juice, sugar-sweetened beverages, milk alternatives, caffeinated beverages) What is the relationship between beverage consumption during adulthood and achieving nutrient and food group recommendations?
Added sugars What is the relationship between added sugars consumption during adulthood and achieving nutrient and food group recommendations?

How much added sugars can be accommodated in a healthy diet during adulthood while still meeting food group and nutrient needs?
Saturated fats What is the relationship between saturated fats consumption (types and amounts) during adulthood and risk of cardiovascular disease?

 

Pregnancy and lactation

Topic Question(s)
How additional calorie needs should be met during pregnancy and lactation What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed among women who are pregnant and 1) risk of gestational diabetes; 2) risk of hypertensive disorders during pregnancy; 3) gestational age at birth; and 4) birth weight standardized for gestational age and sex?

What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed among women who are lactating and human milk composition and quantity?

Are changes to the USDA Food Patterns needed based on the relationships identified? If so, how well do USDA Food Pattern variations meet nutrient recommendations for women who are pregnant or lactating?
Dietary supplements (e.g., iron, folate, vitamin D) What is the relationship between micronutrient supplements consumed during pregnancy and lactation and 1) micronutrient status; 2) birth outcomes; and 3) human milk composition and quantity?
Diet during pregnancy and lactation and risk of food allergy in the infant What is the relationship between maternal diet during pregnancy and lactation and risk of infant allergies and other atopic allergic disease?
Seafood What is the relationship between seafood consumption during pregnancy and lactation and neurocognitive development of the infant?
Beverages (cow’s milk, water, 100% fruit juice, sugar-sweetened beverages, milk alternatives, caffeinated beverages) What is the relationship between beverage consumption during pregnancy and lactation and 1) achieving nutrient and food group recommendations; 2) birth outcomes; and 3) human milk composition and quantity?
Alcoholic beverages What is the relationship between maternal alcohol consumption during lactation and human milk composition and quantity?

 

Older adults, ages 65 years and older (with data reviewed by age group)

Topic Question(s)
Dietary patterns to promote health, prevent disease, and meet nutrient needs What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed across the lifespan and 1) body weight or obesity; 2) risk of cardiovascular disease; 3) risk of type 2 diabetes; 4) risk of certain types of cancer; and 5) risk of osteoporosis?

What modifications to dietary patterns are effective in preventing or reversing declines in muscle mass or bone density in older adults?

Are changes to the USDA Food Patterns needed based on the relationships identified? If so, how well do USDA Food Pattern variations meet nutrient recommendations for older adults, age 65-80 years and those age 81+ years?
Specific nutritional needs related to older adults What modifications to food and beverage choices promote meeting nutrient needs in older adults with impaired dentition, dry mouth, or other aspects of aging that interfere with food and beverage consumption?

Comments are accepted through March 30, 2018. If you have a new topic or question to suggest, provide a brief summary including information pertaining to the four prioritization criteria. After the review of comments and finalization of topics and supporting questions, USDA and HHS will post a public call for the Dietary Guidelines Advisory Committee nominations.

Read more about the Dietary Guidelines here.

If you have any suggestions to inform ASN’s comments please reach out to Sarah Ohlhorst, Senior Director of Advocacy and Science Policy, at sohlhorst@nutrition.org or 240-428-3647.

 

 

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Sarah Purcell

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How can we implement better health behaviors in cancer survivors?

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

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

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

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

References:

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

 

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