By Banaz Al-khalidi

November is National Diabetes Month and World Diabetes Day takes place yearly on November 14 to engage millions of people worldwide in diabetes advocacy and awareness. The International Diabetes Federation estimates that 382 million adults (20-79 years old) suffered from diabetes in 2013, which equates to a prevalence of 8.3%. To provide a better perspective by nation, the 10 countries with the highest prevalence of diabetes in 2013 were as follows: Tokelau (37.5%), Federated States of Micronesia (35%), Marshall Islands (34.9%), Kiribati (28.8%), Cook Islands (25.7%), Vanuatu (24%), Saudi Arabia (24%), Nauru (23.3%), Kuwait (23.1%), and Qatar (22.9%). However, if we were to look at the 3 countries with the greatest number of people with diabetes, China ranks the highest (98.4 million), followed by India (65.1 million) and USA (24.4 million). These figures are quite alarming.

Of those suffering from diabetes, type 2 diabetes comprises almost 90% of people with diabetes around the world. As such, type 2 diabetes is one of the fastest growing health problems in the world. So what could be driving this epidemic?

Evidence from observational studies have consistently shown us that low blood levels of vitamin D are associated with an increased risk of type 2 diabetes. The results of numerous observational studies led to speculation that the development of type 2 diabetes is associated with vitamin D insufficiency. Going back to the figures presented earlier, if vitamin D insufficiency is a risk factor for type 2 diabetes, one might also speculate that countries with higher prevalence of diabetes are facing a coexisting problem of type 2 diabetes and vitamin D insufficiency. For example, Tokelauans (the nationals of Tokelau) who have the highest prevalence of type 2 diabetes, may also be at risk for vitamin D insufficiency despite having a tropical and marine climate. The question then becomes, could vitamin D be a causal factor in the development of type 2 diabetes? While this might sound too simplistic, I assure you it’s not.

Interpretation of evidence on vitamin D and type 2 diabetes is complicated for a number of reasons. First and foremost, observational studies do not tell us anything about the cause-effect relationship between vitamin D and type 2 diabetes because of possible uncontrolled confounding factors, such as physical activity, that may affect both vitamin D levels and the risk of type 2 diabetes. Second, observational studies cannot inform us about reverse causation. In other words, which comes first, the chicken or the egg? Third, there are a myriad of factors that affect vitamin D levels, including environmental, cultural, genetic and physiological factors. It remains unclear then whether there is a causal link between vitamin D and type 2 diabetes.

To answer this question, a large genetic study published in The Lancet Diabetes and Endocrinology journal looked at the causal association between low blood levels of vitamin D and risk of type 2 diabetes. The study concluded that the association between vitamin D and type 2 diabetes is unlikely to be causal. The research, which was a Mendelian randomization study, examined the link between type 2 diabetes risk and vitamin D, by assessing the genes that control blood levels of vitamin D. Most importantly, the design of this study has a powerful control for confounding factors and reverse causation which are issues of concern in observational studies. This may partly explain the discrepancy between results from earlier observational studies and this study in question. However, we still need to be cautious about interpreting the results from mendelian randomization studies as some of the underlying assumptions in the study might remain untested.

The take home message is that no special recommendations could be made about vitamin D levels or supplementation for people with type 2 diabetes. However, long-term randomized trials of vitamin D supplementation remain important to elucidate vitamin D’s role in type 2 diabetes.

As we recognize National Diabetes Awareness this month, it is important to remind patients that diabetes is a progressive chronic lifestyle disease that can be controlled by making healthy lifestyle changes- such as partaking in regular physical activity, eating a balanced diet, maintaining a healthy body weight, taking prescribed medications, joining a smoking cessation program, and improving sleeping patterns.

Zheng Ye, Stephen J Sharp, Stephen Burgess, Robert A Scott, Fumiaki Imamura, Claudia Langenberg, Nicholas J Wareham, Nita G Forouhi. Association between circulating 25-hydroxyvitamin D and incident type 2 diabetes: a mendelian randomisation study. The Lancet Diabetes & Endocrinology, 2014; DOI: 10.1016/S2213-8587(14)70184-6.

By Meghan Anderson Thomas, MS

I constantly hear:

Omnivores: “Vegetarians just don’t look healthy.”
Vegetarians: “ Meat just isn’t good for you.” Or “I feel so much better when I’m not eating it”

So who has it right? Can they both be right and wrong at the same time? I think the answer lies in the motivations behind the eater. The omnivore may have a point because vegetarianism, like all other diets, has the capacity to be unhealthy.

Essentially, vegetarianism, pescetarianism, veganism, etc. are elimination diets. Like any elimination diet, they have the potential to lack vital nutrients including certain vitamins that are predominately found in animal products. According to Sabate, vegetarian diets when compared to meat-based diets are more likely to be deficient in vital nutrients(1). Similarly, when omnivores (typical American diet) obtain the abundance of their calories from meat and dairy they have less room for the fruit and vegetables that provide them with the other nutrients vegetarians so easily acquire. Moreover, studies show that the increased risk of cancer and heart disease in meat-based diets may be related to a deficiency in the phytochemicals and other compounds found in plant-based foods, not just the intake of saturated fats and excess calories(2).

Again, the problem lies in the motivation. Vegetarians and omnivores alike that eat for health are much more likely to eat properly. The choice of becoming a vegetarian for health reasons alone may lead the vegetarian in question to a more healthful diet in which they are cognizant of variety and balance. That being said, there are plenty of vegetarians that may be doing it for the wrong reasons or are, like most, uneducated in making the proper nutritional decisions.

The observation that vegetarians are unhealthy may actually be evident. Most will argue that they have been deficient in iron, zinc, calcium and B vitamins since they have eliminated animal products, leading to anemia(2). Not to mention that most vegetarians are women who are prone to anemia due to menstruation. The fatigue that follows leads to the snowball effect of fatigue, decreased exercise and depression. The point is, diet has a strong influence on health and well-being and it is dangerously easy to eat incorrectly, even if one’s intentions may be pure. This is seen in all “types” of eaters alike.

It is important to remember that as a vegetarian, the elimination of a steak may reduce your risk for heart disease, hypertension, atherosclerosis, hyperlipidemia, etc., but it is not a free pass to eat all the junk food you can to make up for it. The elimination of meat alone is not the ticket to health. Instead, it seems to be a correlation: the vegetarians motivated by health are also more likely to be cognizant enough to eat right all of the time. Furthermore, Sabate illustrates that the vegetarian diet is viewed as improving health and limiting disease when compared to the meat-based diet(1).

1. Sabate, J. (2003). The contribution of vegetarian diets to health and disease: a paradigm shift? The American Journal of Clinical Nutrition, 78 (3), 502S-507S.
2. Nieman, D. C. (1999). Physical fitness and vegetarian diets: is there a relation? The American Journal of Clinical Nutrition, 70 (3), 570S-575S.

By Jonelle Agurs, ASN Intern

No one wants to get half a diagnosis from their doctor.

Unfortunately, that’s what tends to happen when diagnosing malnutrition in hospitalized adult patients in the United States. The present criteria for some malnutrition assessments, like the Malnutrition Screening Tool (MST), are under scrutiny because they only evaluate patients on symptoms of starvation, such as unintentional weight loss or poor appetite. However, new studies postulate that malnutrition should not be limited to food behaviors, but should be expanded to include inflammation resulting from chronic disease. The body’s inflammatory response can intensify the symptoms of starvation, and vice versa; poor eating habits may induce inflammation as well. The human body does an impeccable job of patching itself up using the inflammatory response, but this process often triggers symptoms strongly associated with malnutrition, such as weight loss. With approximately half of the U.S. adult population (117 million) suffering from at least one chronic condition, such as coronary heart disease and diabetes, it is no surprise that there is an increasing prevalence of malnutrition cases among hospitalized adult patients.

ASN supports the efforts of many of its partner organizations, such as the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics, which want to recognize the role of the inflammatory response when diagnosing malnutrition. They have proposed four standard criteria: insufficient energy intake, unintended weight loss, muscle mass and fat loss, and diminished physical function. These criteria will support a more etiological-based diagnosis of malnutrition; a diagnosis more closely linked to the chronic diseases that cause it. Misdiagnoses often result in patients being discharged early from hospital care, causing inpatients to return later for health issues made worse by the symptoms of poor nutrition.

The International Classification of Diseases, 10th Revision, or ICD-10, is a coding system under the Affordable Care Act of 2010, scheduled to be implemented after October 1, 2015. Designed to improve disease management, this revision will include coding using an updated definition of malnutrition. Absence of a standard screening system for this condition is like installing the proverbial cork in the leaky faucet; diagnoses without a simple malnutrition assessment may “plug” up the issue, but the pressure continues to build, waiting for a more thorough solution. The expansion of the ICD-10 coding system will provide a part of that solution by enhancing screening accuracy. With five times more descriptors than its ICD-9 predecessor, ICD-10 coding will include more conditions that could be linked to a range of malnutrition-related issues.

Hospitals across the nation are preparing for the ICD-10 updates, but it is imperative that hospital personnel fully understand how to recognize and diagnose malnutrition to code it properly. Despite shortages of nursing staff and other trained individuals, quality of patient care must be maintained in order to indicate their risk of malnutrition. Clinicians must be able to perform comprehensive assessments of the patient’s complete medical background, so that, along with the newly-proposed diagnostic construct, every patient will receive comprehensive care that will, ideally, lower the cost of their medical care expenses in the future.

Malnutrition, among other hospital-based nutrition topics will be discussed on Saturday, December 6 during the fourth annual Advances and Controversies in Clinical Nutrition conference. Dr. Gordon Jensen, ASN’s immediate past president, will give an address titled “Malnutrition and the Affordable Care Act.” The conference runs December 4-6 at the Gaylord National Resort & Convention Center in National Harbor, MD, and features a dynamic program with topics ranging from dietary supplements to nutrition and cancer. To learn more about this year’s conference, please visit the website.

Jensen, G, Compher, C, Sullivan, D, Mullin, G. (2013). Recognizing Malnutrition in Adults: Definitions and Characteristics, Screening, Assessment, and Team Approach. Journal of Parenteral and Enteral Nutrition, 802-807.

By Mayra S. Crespo Bellido

In 1942, Dr. Lydia J. Roberts was asked by Dr. M. L. Wilson of the US Food and Nutrition Board to visit Puerto Rico under the pretenses that “there was a problem in [the island], which ordinarily imported much of its food.” After all, the island only produced 65% of the food the habitants needed, 35% was being imported at the time. Dr. Roberts was assigned to study the food and nutrition situation in order to report back to Washington, DC. Out of her collaboration with the University of Puerto Rico as a visiting professor, a clear picture of the living situation for the islanders during the 1940s was portrayed in her book Patterns of Living in Puerto Rican Families. This classic one-of-a-kind report depicts explicitly the poor health conditions and severe food insecurity in most households, mostly due to lack of educational and monetary resources. During this period infectious diseases were ranked #1 among the most common causes of mortality for all ages.

In the 21st century, a changing landscape of health problems troubles Puerto Rico. Following nutrition transition patterns of developing countries, the leading causes of death of our time are all from complications of chronic conditions associated with the increasing prevalence of obesity in the island. In 2013, 35% of Puerto Ricans living in the island benefited from the Nutrition Assistance Program, and the majority of the population benefits from other programs such as WIC and Child Nutrition Programs. Nonetheless, Puerto Rico deals with serious food security issues as the island produces only 17.65% of the food it consumes, importing 82% from over 10 different countries.

According to the Food and Agriculture Organization (FAO), food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life. The four dimensions of food security as defined by the FAO are: food availability, food access, proper utilization and stability. A recent study established that food security is not distributed equally as people living in rural areas of the island are disproportionately affected unemployment rate, greater proportion of habitants below the poverty level and lower education levels all of which may create barriers to food access and proper utilization. However for the Puerto Rican population it becomes a little more complicated than that.

Dr. Myrna Comas, Puerto Rico Secretary of Agriculture, has made it her lifework to bring awareness of the vulnerability of the food chain supply in Puerto Rico. As stated by Dr. Comas, the high dependence on imported foodstuff, constant decreases in local agricultural production, the fact that there is only one functioning seaport that receives all merchandise imported, the great distances food has to travel to get to the island, and a lack of policy to ensure food security are some of the many reasons the food chain supply to the island is susceptible to external influences. Some identified risk factors that could interfere with the supply of food are: global climate change, food and water contamination, reduction of terrains devoted to agriculture in the island, accidents, and free trade agreements, among others.

Under the direction of Dr. Comas, the Puerto Rico Department of Agriculture has systematically addressed these issues for the past couple of years. Part of this plan to counterattack the risk of having a food crisis includes an educational campaign to bring awareness to the matter of food security, and initiatives to conserve agricultural lands and to promote local agricultural production of staple foods. There is evidently a long way to go until this matter is resolved. Hopefully with increased knowledge and understanding of the repercussions of letting this problem remain unaddressed will encourage the proper authorities to create local and international food policy that avoids an impending food crisis in the island.

Rosario-Mejías, M, Dávila-Román, A. (2012). Distribución geográfica de la seguridad alimentaria en Puerto Rico, 2005-2009. CIDE Digital 3(1-2), 109-118.

By Hans Chiang

I used to be very picky with my food as a child. My parents tried multiple ways to keep me on a well-balanced diet. My interest in nutrition sparked when my parents persuaded me to eat carrots by claiming “carrots are good for your eyes.” While I did not have the scientific fundamentals and resources to research the biochemical mechanism that validates their claim at that age, I trusted my parents, labelled carrots as “good food” and tried to incorporate them into my food choices. When taking biochemistry in my undergraduate studies, these mysterious interactions between foods and the human body unfolded as I learned the science behind how nutrients actually work. Realizing how dietary intake plays a huge role in disease prevention and treatment, I wanted to advance my nutrition education in medical school so that I can provide relevant nutritional guidance to my patients as a physician.

For this reason, I applied for a position in the ASN Clinical Nutrition Internship Program during the summer after my first year of medical school at Indiana University School of Medicine. The program provided me with valuable experiences; not only did I learn about nutritional science from registered dietitians, I also shadowed physicians of different specialties, observe procedures, and learn how they incorporate nutrition into their fields of practice. On top of the clinical exposure, I reviewed my physiology and biochemistry by participating in literature research with my mentor and writing a research paper on the assessment and dietary modulations of endothelial functions.

I had the opportunity to learn from dietitians who assist different patient populations. I spent time in a diabetes care center, a hospital pulmonary and cardiac rehabilitation unit, a retirement community, a cancer radiation center, the local WIC clinic, a community health clinic, the Volunteers in Medicine clinic of Monroe County, and the University Student Health Center. I was surprised to learn how diets are formulated so differently for each unique population. In addition, I learned to appreciate the communication techniques dietitians use to encourage their patients to follow an optimized diet. As a future physician, I would also be working with a very diverse population and these are all useful techniques I can use in my practice.

Besides learning about nutrition from dietitians, I participated in nutrition support rounds and shadowed physicians in different specialties. I shadowed a gastroenterologist and observed esophagogastroduodenoscopies (EGD), colonoscopies, colon decompressions, and gastric tube insertions. I shadowed a bariatric surgeon and observed lap band, cholecystectomy, and hernia repair procedures. I also spent time with an oncologist, a pediatrician, and an endocrinologist to learn about how weight control plays an immense role in treating cancer patients, infants, teenagers, and diabetic patients.

The Clinical Nutrition Internship Program was a wonderful enhancement to my education in becoming a physician. Besides learning about the various roles nutrition has in the health care field, I also obtained valuable communication skills through observing the interactions between the health care professionals and their patients. Regardless of the specialty I pursue in the future, I will be able to incorporate what I learned through this internship into my practice to provide my patients with the best care and education. I enjoyed the eight weeks of the internship very much and am very grateful to have had this opportunity.

By Colby Vorland

Southwest Airlines is consistently rated as serving good food on their flights, yet they don’t serve food at all. Can we trust diet data if people don’t know if they even ate? This amusing anecdote was offered by Dr. David Allison at the following session during ASN’s Scientific Sessions in San Diego in April: “Not Everything That Counts Can be Counted and Not Everything That Can Be Counted Counts: How Should We Collect Dietary Data for Research?” chaired by Drs. Regan Bailey and Claire Zizza. The session was organized by ASN’s Nutritional Epidemiology, Aging/Chronic Disease, and Community/Public Health RISs. The panel took a critical perspective but also emphasized the value in using self-reported diet intake data.

Dr. Allison was the first presenter, taking a hard position on self-reported energy intake in nutritional research: it just isn’t good enough. Not only that, it often flat-out misleads obesity research. Allison highlighted a recent paper by Archer and colleagues that looked at energy intake of respondents in NHANES from 1971-2012, finding that 67.3% of women and 58.7% of men were not physiologically plausible – i.e. the number of calories is “incompatible with life.” Correlations with the IOM’s gold standard equation for estimating total energy expenditure were 0.163 for women and 0.225 for men, effectively yielding no meaningful relationship. This “doesn’t seem like science anymore,” Allison stated. This problem has been known for a long time: in 1991, Goldberg and others looked at 37 studies across 10 countries and found that over 65% of the mean ratio between reported energy intake and basal metabolic rate measures were implausible. Forrestal also published a review in 2010 of 28 papers looking specifically at children and adolescents, finding that about half misreport energy intake.

It is time to abandon self-reported energy intakes in favor of less misleading paths in obesity research, Allison said. It is not worthy of scientific use because the measurement errors are not random and modest, estimates are often not in the correct direction, and errors will not lead to the detection of false effects under plausible circumstances. He told a story of how originally, self-report intake data suggested that the overweight consumed less energy than they expended, but using more rigorous methods proved exactly the opposite to be true (here is a 1990 review by Schoeller). Allison said that we currently have no economic and social incentive to make a complete transition to incorporating doubly labeled water, as the cost has been flat since the 1980s. It will be painful initially, but clearly we need to make the transition.

Dr. Amy Subar argued that energy intake is not the only important aspect of diet data, and improvements are being made to collection methods, and therefore we shouldn’t throw the baby out with the bathwater. Even if total energy intake isn’t accurate, we still can track food patterns, diet quality, nutrient intakes, and social and physical environments. Subar emphasized the utility of self-reported data- it can yield more comprehensive data with much less of an investigator burden compared to biomarkers or observation, but there is the issue with error. Within-person variation and memory are 2 potential errors, but adjustments are possible. New technologies, such as keeping food records with mobile phones or wearable sensors to reduce reactivity to monitoring and burden, are being developed to improve self-report data. In addition, Subar has been involved in the development of self-administered 24-hour recalls – ASA24 – to be able to gather a lot more data from participants without investigator burden. They have validated the accuracy of this method against interviewer-administered recalls. Dr. Subar noted that food frequency questionnaires have more bias than short-term methods but combining multiple recalls with food frequency questionnaires could reduce this.

Dr. Elizabeth Yetley expanded on how self-reported diet data is currently relied on in national policy. For example, fortification strategies would not be possible without such data. Many considerations go into fortification, and modeling specific foods and evaluating the outcomes of such programs are important. The IOM uses diet data to track added sugars and salt disappearance. Nutrient safety can also be tracked. For example, data from the Total Diet Study in 1981 was able to quickly identify unexpected iodine sources in the food supply that were resulting in extremely high intakes. Diet data is also used for food additive/GRAS reviewing, to examine what has been added vs naturally occurring. Yetley states that there would be a significant adverse effect on policy if intake data wasn’t available. However, intake data can fail to accurately predict nutrient status, as Pfeiffer et al. (2012) have demonstrated. In 1988, Lewis and colleagues showed that cola intake could be underestimated by about 50%, though Yetley notes that surveys have been improved since then. Iron fortified cereals also virtually always underestimate the actual intake when using the amount listed on the label. Self-reported intake using label data is therefore not accurate. Infrequently consumed foods such as alcohol beverages also cause problems in nutritional epidemiology. However, Dr. Yetley reiterated that it is still crucial for many uses and we can work to improve precision while using caution when interpreting.

Finally, Dr. Laurence Freedman discussed some studies that are being done to improve self-reported intake measurement. Freedman began by emphasizing that we can do validation for some nutrients by comparing to recovery of biological products; for example, using doubly-labeled water for energy expenditure, nitrogen for protein, potassium and sodium for themselves. The error is indicative of true intake. However, for many we don’t have accurate recovery products. Freedman described a project he is involved in – the Validation Studies Pooling Project – that aims to better understand measurement errors of food frequency questionnaires and 24-hour recalls using recovery biomarkers. For example, in the AMPM study, energy intake is underreported on 24-hour recalls by about 10%, but underreporting of intake differs by nutrient. Measurement error effects diet-health outcomes by attenuating relative risks and statistical power. This attenuation is expressed as an “attenuation factor” – the ratio of attenuation to the actual value. Preliminary data shows that attenuation factors are more extreme for energy intake compared to protein, and protein density is less so than both. Adjusting datasets from energy intake alleviates attenuation factors somewhat but does not solve it, and increasing samples size does not itself solve it because of unknown confounding. Freedman went into more detail about the ASA24 (multiple 24-hour recalls) – emphasizing that they have a high response and low attrition. With 3 or more recalls, the attenuation factor for protein improves. Relative risks increase with additional recalls compared to 1 food frequency questionnaire, and combining both methods yields even better data according to Carroll and colleagues (2012). Combining biomarkers with self-report data improves statistical power because measurement error is reduced, as Freedman and others (2011) have shown. Dr. Freedman reiterated that self-report data is extremely useful for surveillance, education, dietary guidance apart from the difficulties of using it to measure energy intake.

It is clear that self-reported diet data has many important uses, but caution must be accepted when interpreting it. Hopefully improvements that are currently being validated will be adopted quickly, and for some measures such as energy intake, it seems necessary that current methods be abandoned because we know they are unacceptable.

By Sabrina Sales Martinez, MS, RDN

In the United States, more than 35% of the adult population and 17% of children and adolescents are obese [1-2]. Overconsumption of calories has been contributing to the rise in obesity, and fast food restaurants are often mentioned as a possible culprit. Fast food menu items have been shown to be lower in nutritional quality, higher in saturated fat and misaligned with national dietary guidelines. Often, full-service restaurants are thought to offer higher quality foods and healthier menu options. Data on the nutritional quality of foods sold in full-service restaurants, however, is lacking. According to a recent article in the Journal of Nutrition Education and Behavior, there may be a misconception that full-service restaurants are healthier than fast food restaurants.

A recently published article by Auchincloss and colleagues [3] may provide much needed information on full-service restaurants and the nutritional content of their menu items. The researchers at Drexel University and University of Pennsylvania reviewed menus from 21 full-service chain restaurants in Philadelphia at different price points and over 2,600 menu items. Menu items that were labeled as being healthier options were also compared to the US Dietary Guidelines. Restaurants were included if they provided calorie and sodium information for all menu items and if most of their main dishes were single serving entrees. Their results showed that on average a la carte entrees and appetizers were about 800 kcalories and 50% did not meet the healthier criteria set by the authors based on the US Dietary Guidelines. About one-third of the entrees and appetizers exceeded the dietary reference values (DRV) for a 2,000 kcalorie diet for adults and 1,400 kcalorie diet for children for saturated fat and sodium. In addition, only 20% of the items met minimum fiber recommendations. The most astonishing findings from this study was that, on average, a meal that consisted of an adult entrÉe, side dish and shared appetizer provided about 1,495 kcalories, 28 grams of saturated fat, 3,312 mg of sodium and 11 grams of fiber. If a non-alcoholic beverage and dessert was added to the meal, then it totaled 2,020 kcalories, 39 grams of saturated fat, 3,760 mg sodium and 12 grams of fiber. Yes, one meal exceeded the average adult’s energy needs for the day! Other important findings include that menu items targeted to seniors had surpassed the DRV for saturated fat and sodium, and that those mostly targeted to children exceeded calorie and sodium DRVs.

The results from the study by Auchincloss and colleagues [3] are welcomed, because as previously mentioned, data on the nutritional quality of menu items in full-service restaurants are scarce. Considering that full-service chain restaurants control most of the US restaurant market and that almost half of food expenditures are from restaurants [4], this study provides important information that can be translated into nutrition education for the restaurant customer. Most of the healthy labeled items at these restaurants only considered calories as a criterion for being “healthy” and only half of the restaurants offered a healthier option.

This study only provides the starting point in addressing the nutritional quality of meals in restaurants, and the authors hope that these data can be compared to future studies to see whether changes occur in providing healthier options and whether these options are implemented at the request of consumers or due to regulation. As part of the Affordable Health Care Act of 2010 all restaurants with greater than 20 locations will need to provide menu labeling and the customers will need to have the necessary tools to understand the meaning of these labels and its implications for their health. Findings from present and future studies should be used to propose and implement interventions and/or strategies that can be used to bring about awareness to the restaurant industry and its consumers of the recommended dietary intakes and adoption of healthier menu options. Examining the nutritional quality of restaurant meals may be a worthwhile public health endeavor to reduce obesity, its associated health conditions and their financial burden in medical expenses, especially when there is a strong trend towards consuming increased number of meals outside the home, and there is evidence that these meals may be higher in calories, saturated fat and sodium. In these conditions, establishing criteria for healthier options for restaurants may be warranted.

The authors have made recommendations to restaurants based on their findings.

1. Centers for Disease and Control (CDC). Overweight and Obesity: Adult Obesity Facts.
2. Centers for Disease and Control (CDC). Overweight and Obesity: Childhood Obesity Facts.
3. Auchincloss AH, Leonberg BL, Glanz K, Bellitz S, Ricchezza A, Jervis A. Nutritional Value of Meals at Full-service Restaurant Chains. J Nutr Educ Behav. 2014 Jan;46(1):75-81. doi: 10.1016/j.jneb.2013.10.008.
4. Industry at a glance. National Restaurant Association website.

By Joyanna Hansen

Consumers navigating grocery store aisles have many choices, and food labels are one way in which food manufacturers compete for attention. The label “all natural” or “100% natural” can be found on diverse food products ranging from peanut butter and cereal to “all natural” sodas, and may bring to mind images of wholesome, minimally processed foods. However, the U.S. Food and Drug Administration (FDA), responsible for regulating and supervising food production, does not define or regulate use of the label “natural” on food products. Instead, the FDA official policy is that “the agency has not objected to the use of the term if the food does not contain added color, artificial flavors, or synthetic substances,” (1) an ambiguous policy that leaves interpretation of “natural” largely up to the food industry.

Without a formal definition of what “natural” means, let’s examine what this label does not mean. First of all, foods containing natural flavors, sweeteners, or other plant-derived substances can be labeled natural. In addition, foods containing highly processed high fructose corn syrup (HFCS) can also be labeled “natural”, since the synthetic materials used to generate HFCS are not incorporated into the final product (2). Finally, foods containing genetically engineered or modified ingredients can be labeled “natural,” something California’s recently defeated Proposition 37 tried to prevent (3). Although far from an exhaustive list of what can be labeled a “natural” food, these are a few examples of how “natural” may mean something different than consumers think.

In contrast to the FDA, the United States Department of Agriculture (USDA) does regulate use of the word “natural” when applied to meat, poultry, and eggs, stating that a “natural” food is “a product containing no artificial ingredient or added color and is only minimally processed” (4). Although consumers purchasing “natural” meat, poultry, and eggs can be confident that there are no artificial ingredients or colors added, it’s important to note that “natural” does not necessarily mean hormone-free or antibiotic-free; these are separate labels, also regulated by the USDA.

Unlike “natural,” which has no clear definition, use of the “organic” food label and seal is strictly regulated by the National Organic Program, which is administered through the USDA. Foods with an organic seal are certified organic and contain at least 95% organic content (5). Organic food is produced using approved organic farming methods “that foster cycling of resources, promote ecological balance, and conserve biodiversity. Specifically, “synthetic fertilizers, sewage sludge, irradiation, and genetic engineering may not be used” to produce organic food, meaning that organic food products are not genetically modified and have not been treated with synthetic pesticides or fertilizers (5).

Unless the FDA adopts a stricter definition of “natural,” consumers trying to make informed decisions should be wary of the “natural” food label and pay close attention to ingredient lists, or choose organic foods that have been produced through a closely regulated process.

1.    What is the meaning of ‘natural’ on the label of food? Retrieved Feb. 7, 2013 from
2.    Crowley, L. (2008, July 8). HFCS is natural, says FDA in a letter. Retrieved Feb. 7, 2013 from
3.    Sifferlin, A. (2012, Nov. 7). California Fails to Pass GM Foods Labeling Initiative. Retrieved Feb. 8, 2013
4.    Meat and Poultry Labeling Terms (last modified April 12, 2011). Retrieved Feb. 8, 2013 from
5.    National Organic Program (last modified Oct. 17, 2012). Retrieved Feb. 8, 2013.

By Joyanna Gilmour

Basil, easily recognized by its fragrant, green, oval-shaped leaves, makes an appearance in many foods including pasta, salads, sandwiches, cocktails and more. This delicious herb is best known as the star ingredient in pesto, a thick paste made from basil, pine nuts, oil, and parmesan cheese. First cultivated in India thousands of years ago, basil has since been incorporated into a variety of ethnic cuisines from Italian to Thai.

As well as adding a fresh taste to food, this bright green herb also has beneficial health effects. Basil is a good source of vitamin K: 2 tablespoons of fresh basil contains about 20% of the daily recommended intake of this nutrient.(1) Fresh basil is also a good source of beta-carotene, a powerful antioxidant that is converted to vitamin A in the body. Antioxidants are vital for keeping cells healthy and reducing the number of damaging free radical molecules in the body. Basil is also widely used in Ayurvedic medicine to treat a variety of ailments, including arthritis and other inflammatory diseases. (2)

Basil oil, extracted from the leaves of the plant, is a natural antimicrobial and can kill or inhibit the growth of bacteria.  Scientists have shown that basil oil reduces the growth of a number of food-borne bacteria species including cholera (V. cholera) and E. coli O:157:H7 (3-5).  Given recent outbreaks of food-borne illnesses, cooking with natural ingredients such as basil oil which inhibit bacterial growth is a great way to make food safer as well as tastier.  Although basil shows promise as a natural antibacterial agent, it’s important to note that most scientific studies looking at this question have been done in laboratory settings using high doses of basil extract. The effect on bacterial growth observed by home cooks using smaller amounts of basil or basil oil is not clear.

In addition to its health-promoting qualities, basil is easy to grow in a sunny windowsill or garden.  A handful of basil leaves can add a delicious flavor to a wide variety of dishes – a few ideas are listed below!

Cooking with basil:
–    Use fresh basil as a pizza topping along with tomato sauce and fresh mozzarella
–    Add fresh or dried basil to tomato-based pasta sauces
–    Add chopped fresh basil to fruit salads or green salads for a refreshing flavor twist
–    Mix with ripe tomatoes, garlic, oil, and balsamic vinegar for a quick bruschetta appetizer

Selecting basil:
–    Choose fresh basil over dried basil when possible, as fresh basil contains the basil oils.
–    Look for vibrant, green basil leaves.  Store fresh basil in the refrigerator; fresh basil can also be frozen.

1.    USDA National Nutrient  Database for Standard Reference. Available at:  Accessed June 1, 2012.
2.    Prakash P, Gupta N. Therapeutic uses of Ocimum sanctum Linn (Tulsi) with a note on eugenol and its pharmacological actions: a short review. Indian Journal Physiol. Pharmacol 2005; 49: 125-131
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By Chris Sovey, RN, BSN

Do you know someone who is depressed? You probably do, whether you realize it or not. Major Depression is a crippling mood disorder currently affecting over 26.2% of the adult population in the United States (U.S.) (NIMH, 2005, NIMH 2008). The prevalence of Major Depression in the U.S. has increased by a factor of ten fold in the last two decades (Ilardi, 2009). It is expected to continue to rise. The National Institute of Mental Health estimates that 1 in 4 Americans will meet the diagnostic criteria for major depression during their lifetime (NIMH, 2008). Medicare claims of those suffering with depression tend to incur charges an average of $2,409 greater per medical incident than their non-depressed counterparts (NIMH, 2009).

There is a significant body of literature supporting the use of nutritional interventions in the treatment of depression. Because of the increasing prevalence of this troublesome disorder, my goal is to briefly outline four nutritional supplements that have demonstrated safety and at least some efficacy in research. Keep in mind that research surrounding these particular items is still controversial.

Omega-3’s– Omega-3 supplementation comes highly recommended by a growing number of practitioners as an integral part of depression treatment. Dr. Neil Nedley, MD and Stephen S. Ilardi, PhD claim that diets high in omega-3’s may assist in the treatment of both major depression and bipolar disorder. Because the Western American Diets tend to lack foods containing omega-3’s, it may be beneficial to find a supplemental source, such as fish oil or flaxseed. Some authors claim that the alpha-linolenic acid (ALA) found in flax is not a bio-available source of Omega-3 fatty acids. Fish oil may be another viable option. Walnuts also contain a relatively high level of Omega-3’s. Regardless of source, omega-3 supplementation has consistently demonstrated a reduction in depressive symptoms in the literature (Riediger, et al 2009).

Folate and Vitamin B-12 – Depressed patients tend to demonstrate higher deficiency levels of vitamin B-12. Folate levels typically are lower in depressed patients (Bodner, 2005). It has been suggested that a deficiency in either of these vitamins may impair methylation in the central nervous system that is necessary to produce monoamine neurotansmitters (Penninx, 2000). This may in turn lead to the impaired mood symptoms evident in depression.

Vitamin D – Serum 25-hydoxyvitamin D levels tend to be low among depressed individuals. Some authors argue that there may be a causal link between depression and Vitamin D deficiency (Jorde, et. al 2008), while others maintain that the evidence is not strong enough at this point. Even more confusing is the lack of an established dosage to treat various disorders. This includes depression. Some studies suggest a dose of 2000 IUs / day for general intake (Vieth, 1999). In the treatment of depression, some studies have used dosages as high as 20,000 – 40,000 IUs / day! (Jorde, et. al 2008) Regardless of whether or not there is a direct causal relationship, it appears that some studies are yielding positive results in reducing depressive symptoms.

St. John’s Wort – Hypericum perforatum L. (St. John’s Wort) is currently a hotspot for research. It is widely popular in Europe, and used as a front-line treatment for mild to moderate depression. The United States is a little more hesitant to adopt this herb into the realm of psychotherapy, as it comes with several drug interactions. Many systematic reviews present confusing and contradictory results. A meta-analysis by Linde, et al. found Hypericum to be as effective as standard antidepressants to decrease depressive symptoms in mild to moderately severe depression (Linde, 1996). It is likely that more research will need to be completed before St. John’s Wort becomes an accepted treatment for depression in the U.S.

I want to stress that when applied correctly, an appropriate regimen of nutritional interventions in addition to other therapies for depression may yield profound results in mood and other symptoms. You must work the details out with your healthcare provider.

Lastly, if you’re reading this out of sheer curiosity, pass this information on to someone who is struggling with depression. Maybe it is a family member. Maybe it is you. Sometimes things can seem pretty hopeless in our darkest moments. But there is always hope. Finding the correct information and acting upon it is the first step to recovery.

Disclaimer: These interventions are not meant to serve as medical advice. Please consult with your healthcare provider. Supplements, and even foods, may cause interactions with your current medications.


Bodnar, L., & Wisner, K. (2005). Nutrition and depression: Implications for improving mental health among childbearing-aged women.Biological Psychology, 58, 679-685. Retrieved from

Ilardi, S. (2010). The depression cure. Da Capo Press. 1999. Philadelphia, PA.

Jorde, R., Sneve, M., Figenschau, Y., Svartberg, J., & Waterloo, K. (2008). Effects of vitamin d supplementation on symptoms of depression in overweight and obese subjects: randomized double blind trial. Journal of Internal Medicine,264(6), 599-609. Retrieved from

Linde, K., Ramirez, G., Mulrow, C., Pauls, A., Weidenhammer, W., & Melchart, D. (1996). St john’s wort for depression—an overview and meta-analysis of randomised clinical trials. British Medical Journal, 313(253), Retrieved from

NIMH. (2009, February 13). Health care costs much higher for older adults with depression plus other medical conditions. Retrieved from

NIMH. (2005). Major depressive disorder among adults. Retrieved from

NIMH. (2008, June 26). The numbers count: Mental disorders in america. Retrieved from

Penninx, B., Guralnik, J., Ferrucci, L., Fried, L., Allen, R., & Stabler, S. (2000). Vitamin b12 deficiency and depression in physically disabled older women: Epidemiologic evidence from the women’s health and aging study. American Journal of Psychiatry, 157, 715-721. Retrieved from

Riediger, N., Othman, R., Miyoung, S., & Moghadasian, M. (2009). A systemic review of the roles of n-3 fatty acids in health and disease. American Dietetic Association, 109, 668-679.

Vieth, R. (1999). Vitamin d supplementation, 25-hydroxyvitamin d concentrations, and safety.American Journal of Clinical Nutrition, 69(5), 842-856. Retrieved from