What do I eat? That is a question most people ask themselves at least once a day. Imagine getting a prescription from your physician and vetted by a nutritionist to cook certain foods at home. The prescription is tailored to your personal needs, and your care team has received training as health coaches to help you successfully implement this new plan. This is culinary medicine.
Doctor David B. Allison is the current dean, distinguished professor, and provost professor at the Indiana University School of Public Health-Bloomington. Prior to Indiana University, Allison was a distinguished professor, Quetelet Endowed Professor, and director of the NIH-funded Nutrition Obesity Research Center (NORC) at the University of Alabama at Birmingham (UAB). Allison was appointed director of the NORC in 2003 and served until 2017. Allison has published more than 500 scientific papers with research interests including obesity and nutrition, quantitative genetics, clinical trials, statistical and research methodology, and research rigor and integrity.
According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NORCs are “intended to integrate, coordinate, and foster interdisciplinary basic, clinical, translational, and public health research by a group of established investigators actively conducting programs of important, high-quality research that is related to research specific to NIDDK’s mission.”
There are currently twelve university-based NORCs across the United States from New York to Washington State. These centers are funded by P30 Center Core Grants from the NIDDK to bring together investigators who are conducting research in nutrition and obesity and improve the quality of research by promoting multidisciplinary work and sharing access to specialized technical resources and expertise. These centers allow for cost-effective collaboration between groups of investigators at the same institution. The NORC at UAB currently has 159 investigators from 58 different academic units – a manifestation of the center’s multidisciplinary approach.
Allison’s 14-year appointment as director of UAB’s NORC makes him an ideal individual to speak with about the successes of the initiative since its inception in 1999. Allison was gracious enough to answer several questions about his tenure as director and about NORCs more broadly.
What role do you see NORCs playing on university campuses?
NORCs are enormously helpful, and it is valuable to consider them in a historical context. The first NORC – before they were even called NORCs – was the New York Obesity Research Center at Columbia University and, at the time, Rockefeller University. It was the first and for many years only federally funded obesity research center in the United States. The NIDDK subsequently decided to call all the clinical nutrition research units and obesity nutrition research centers “NORCs,” and there are now twelve under this designation.
The New York center is where I started my career as an obesity researcher during my second postdoc. It was a lot of fun there. The NY Obesity Research Center was the mecca of obesity research. If you were an obesity researcher, and if you wanted to get trained, you knew where the mecca was. If you wanted to make a pilgrimage, you could see what the great leaders of the field were doing. You could go there and meet esteemed individuals such as Ted VanItallie, Xavier Pi-Sunyer, and Steven Heymsfield.
You sort of knew where the leadership was – where the intelligentsia and cognoscenti were. There were certainly other places in the world that were powerhouses in obesity, but in the United States, the NY Obesity Research Center served as a galvanizing force. It also served as a great training ground at the time – and NORCs still do. It is one of the things that makes NORCs special: they are multidisciplinary, and they are focused on a topic.
What you sometimes see in the field of obesity, which is probably true in other fields as well, is that there are a lot of instances of people making mistakes that I refer to as “errors in interdisciplinarity.” This is an error which one makes because one is completely unaware of something that would be basic and fundamental to someone in another discipline – but you as a member of a different discipline aren’t aware of it.
A simple example would be if you are a social scientist and you know that physical activity matters for obesity, and you make an assessment that some program will have an important effect, but you don’t know anything about body mass or energetics. You then project the amount of weight change that could occur because of the physical activity intervention without understanding the physics, the mechanics, or the energetics. This is an error of interdisciplinarity. We see these things regularly.
When I was “growing up” in the NY Obesity Research Center, these kinds of things would become the fodder of your education as a young person. So if you piped up and raised your hand in a seminar and said, “What about this?” it may reveal that you didn’t understand a basic concept in statistics, psychology, physiology, or anatomy. Then the more senior people around, who were experts in those things, would say to you, “Come on over here, kid, let’s explain to you that’s not how that works.” You got it drilled into your head, an emphasis of interdisciplinarity – the idea of real expertise – and avoiding these simplistic mistakes that you still see so often now in people who are focused on obesity research. That is one very valuable part of it: bringing together an interdisciplinary cadre of experts on the topic who then educate young people to be an expert in a topic, and not just get caught up in their own discipline.
The second thing that is extremely valuable is the idea of the NORC as provocateurs of people’s interests. The total amount of money in the NORCs per se is not much – around $750k/year in direct costs – not much bigger than one or two R01s. What is important is not the total cash value, but the way the value is delivered through a leader on campus, who then uses the funds as a lever, at the right points to provoke activity, and provoke interests.
Years ago, early in the NORC’s history at UAB, it became clear to me that using more invertebrate models for obesity was important, that genomics was upon us, and that we should have people working with Drosophila and C. elegans. I was able to use different pieces of the NORC to provoke that. For example, I would bring in speakers through our seminar series who worked on those topics. We had funding for pilot grants that could be used on that research. There were extra discretionary funds from institutional matching, so I could use those funds to recruit some younger people to work on these topics. All those things came together so that people were writing and getting R01s to do research involving those organisms.
There are other things that are important for the NORC in terms of sense of identity. People are excited to be at an NORC because they feel that they are at one of “the” places. The dollar amount of the NORC isn’t that great, but the prestige value is high. It serves to create an identity to get people excited – to pull them together to work together on things. Those are some of the big values of the NORCs today.
You were director of the NORC at the University of Alabama at Birmingham for nearly 15 years. How have you seen the effect of NORCs change over that time?
I think we have seen a couple of changes. In general, science has changed, and the NORC science has changed with it. Science has become more molecular, more genetic, and the NORCs keep up with the trends of general science. Other things I have seen in NORCs is this idea of leveraging the amount of money. Not only is the amount of money provided by the direct costs of the NORC not large, especially compared to diabetes centers, cancer centers, and other NIH centers that receive much more than NORCs, but it’s been flatlined for over 20 years. If you compared the NORC funds in real dollars to the dollars from 20 years ago, the current funds are much smaller.
NORCs have become these engines – at their best – where creative leaders use the P30 grants as the nucleating site around which to build other stuff. You go to your institution and get a match in funds, and then you get some T32 grants. You say, “Isn’t this great we have an NORC, so we can do great training. Please give us a postdoctoral and predoctoral T32 in obesity, and then why don’t you give us an R5 to do a national short course in obesity?” … You keep adding those things on. We at UAB were very strong on that. Many other institutions are as well, and that is one way you have seen the NORCs change. They have become these multi-infrastructure grant organizations.
When speaking with other NORC directors and center administrators, what are some of the advances and successes that have stood out to you?
I think probably more than anything, the successes and advances that I hear the NORC directors take the greatest pride in is the young people who they help get started, and that is especially true for those NORCs that go on to get T32s, which many have. How I got my own start was on a T32 while in New York. That is also how I learned to write T32s, by being thrown into it by my old boss at the NORC. He said, “Here’s my old folder. I’m going on a trip out of the country. I will be back after this thing is due. Good luck,” and I said “…okay,” and so I learned how to write a T32 grant.
I think when people are successful in getting those T32 grants, as well as in getting young people involved, however they do it, bringing new people into the field, and helping those new people achieve, it is a great success. You can look at many of us and say that we are products of the NORC systems themselves. Myself, Doctors Dympna Gallagher, Tim Nagy, Barbara Gower, Michael Goran, and many others, are all the products of these centers, brought in as postdocs at the beginning of a center. Many who are NORC directors now got their start there.
How do NORCs help cultivate the future generation of nutrition and obesity researchers?
To reiterate, the interdisciplinarity: training people so they are not just a public health person that says, “Yeah I get it, people, they eat too much and exercise too little, what else do I need to know about obesity. Now I just need to talk about the policies that will make people eat less and exercise more.” Well, maybe it would be good to know a little more than that. NORCs bring up people with a more robust knowledge of this. The NORCs also draw people into the field, give them a sense of identity and belonging and an enthusiasm for being in the field.
You have been critical of the rigor at which obesity and nutrition research is performed. Do you think that NORCs have been able to increase the quality of research in the field?
I think that NORCs do increase the quality of research in the field, and they lead by example. I am critical of the rigor and quality of the research everywhere, including in my own research. That is important for us to do as scientists – to be critical of the rigor and the quality of research – and to make it better. I think there are particular concerns raised in the field of obesity, and some of those concerns in my mind came out in the mid-90s when obesity began to be seen as a public health crisis.
Instead of obesity research being driven to a greater extent by people who were fully involved in it for a long time, and involved with others in getting this interdisciplinary background, it became more that anybody felt that they can jump in. Any economist, any public health official, jumped in with zealous passion, which much of the time wasn’t matched with rigorous background knowledge. This has led to some of the more questionable research we have seen. It’s not everything, but just one factor. NORCs are helping by providing training for people, by putting out good research, and by leading by example.
What are some fond memories from your time at UABs NORC
Well, pulling together on things in general. Part of what makes a great center great is people working together as a center. In fact, one of the things that attracted me to come down to UAB was in fact its centeredness. I had other offers before heading to UAB, and some were at institutions that were more attractive in some ways, but what I liked about UAB and the NORC was the feeling that this was a group of people that worked together, and only a slight exaggeration, but it was a sense of a family. I really liked that. To me, a lot of my fondest memories were pulling together with Tim Nagy, Barbara Gower, José Fernández, Tim Garvey, the late Roland Weinsier, Stephen Barnes, Steve Austad, Kevin Fontaine, Julie Locher, Gary Hunter, and I am sure I’ve missed many important people, but the ability to pull together through tough challenges, working hard, overcoming obstacles – doing things together which none of us could have done alone.
This is part two of a two-part interview with Dr. David Allison.
Doctor David B. Allison is the current dean, distinguished professor, and provost professor at the Indiana University School of Public Health-Bloomington. Prior to Indiana University, Allison was a distinguished professor, Quetelet Endowed Professor, and director of the NIH-funded Nutrition Obesity Research Center (NORC) at the University of Alabama at Birmingham (UAB). Allison was appointed director of the NORC in 2003 and served until 2017. Allison has published more than 500 scientific papers with research interests including obesity and nutrition, quantitative genetics, clinical trials, statistical and research methodology, and research rigor and integrity.
In addition to his primary appointments, Allison is a co-director for two NIH-funded “Short Courses” on obesity research held in Birmingham, Ala., during the summer. Dr. Allison’s “Short Course on Mathematical Sciences in Obesity Research” is going on its fifth consecutive year, while the “Short Course on Strengthening Causal Inference in Behavioral Obesity Research” is coming up on its fourth consecutive year. These interdisciplinary courses convene a cadre of expert faculty members who teach on various aspects of obesity research, covering economics, epidemiology, statistics, genetics, and much more. These courses are oriented toward investigators who want to increase the rigor in their approach to obesity research, and they bridge various disciplines in which obesity research is performed. Allison took the time to answer a few questions regarding the ability to better approach obesity and nutrition research.
You have noted that the rigor of obesity research has been lacking. Has there been a shift in recent years?
I don’t have unequivocal data as to whether there has been a shift in recent years in obesity research or research overall. I have a hypothesis though, which is when you look within any one journal, research is getting ever more rigorous, whereas when you look across all journals, it may be getting less rigorous because of the influx of new journals.
If you take a journal like the American Journal of Clinical Nutrition, they keep getting more rigorous. That is in part because the editor-in-chief, Dr. Dennis Bier, has a very strong commitment to that, and he has built an associate editorial board who shares the commitment. Meanwhile, other journals keep springing up that are not as rigorous. So for the overall quality of the literature, I am not sure if it is going up or down, since you have these competing factors.
One of the things my colleagues and I are writing a paper on now is the childhood obesity intervention literature, which seems to be particularly susceptible to distortion. We hypothesize that this has to do with feelings of zealousness – the idea that childhood obesity is such a problem and it must be addressed. To come out after an expensive and effortful intervention and say, “Guess what, I did an intervention and it just didn’t work, so let’s move on.” People just don’t want to say that. They want to instead say, “But it must work, we can’t tell people not to do this, especially if we don’t have something better, so let’s twist and bend and ‘find a pony in there’.” We see a lot of “spin” in these things, and that is an area where things seem to have become worse.
What are your suggestions to researchers in the field to increase conscientiousness in limiting and being transparent about shortcomings in the quality of the research produced?
I think there are different aspects to it. Some aspects to it, and perhaps related to what I was saying about the childhood obesity literature, is that people, often again with good intentions, are bending the truth. I think that we need to continually remind ourselves that we are scientists and reflect on why we all got into science in the first place. To be a scientist means to pursue truth through the scientific method. We have to affirm that speaking the unvarnished truth is an uncompromisable imperative. Commitment to one’s identity as a scientist is something to be held dear.
Then, I think there are some things that are more skill-level. Many errors I see – and partially because this is my expertise, so I see what I understand and know about – are statistical errors. One of the challenges is that the norm for many years was, and still is, that many scientists should be able to conduct their own statistical analyses. Physicians are generally not trained with this mentality, because they get very little training in statistics. They accept that they will need to go to a statistician – most at least. Whereas if you are trained in a field like nutrition, psychology, physiology, or biology, you get a PhD in that, and you get one or two statistics courses as you earn your PhD, often taught by that same department. The person who teaches that course tends to not be a professional statistician, but rather a physiologist, biologist, or nutritionist who knows a little statistics. What you are getting is kind of an intelligent amateur who is running the statistics for professional research.
If you think about that – it’s the equivalent of me saying that I need to get a kidney surgery and I say, “Well, I have an anatomy book. I know approximately where my kidneys are. I have a bottle of hand sanitizer. I can get some rubber gloves and a pocket knife, and I can do it myself.” Well, no. Just because you have an anatomy book and you know where the kidneys are and you understand the idea of surgery doesn’t mean you are a professional surgeon, and we wouldn’t have you do it. Why take a different view about statistics? Part of what we are currently exploring, since statisticians are in limited supply, is how we can get more professional statisticians to be involved with more papers, and how can we create a culture and an economic situation that would permit that.
Is there an overreliance on observational research in nutrition/obesity studies? If so, why is this the case?
I think there is sometimes a reliance on observational studies for situations in which they are not what I would call “probative.” For example, you can think, “Well, maybe Pokémon GO is going to reduce obesity levels.” No-one has ever looked at it, so sure, go ahead and do an observational study. Do people who start using Pokémon GO lose weight or gain less weight? And that is fine, there is nothing wrong with that. You might even want to replicate it once or twice. But if you say, “Well, now we’ve done that, so let’s do 20 more of those,” then you need to wonder why you need the next 20. Maybe you need one more to confirm it, but not 20 more. What you see is people not shifting out of the observational and into the experimental when it is called for. For example, breakfast consumption, fruit and vegetable consumption, things like that – when people continue to grind on the observational literature long after it is really useful.
You have noted that you see many errors in obesity and nutrition related meta-analyses. How would you caution investigators in interpreting these papers?
I would say, interpret with a grain of salt, particularly if there isn’t a professional statistician on there. The issue is that there is software out there, where it is seemingly easy. You plug in a few numbers, and it spits out a meta-analysis for you. The problem is, you need to know what numbers to plug in. That is where the problem, the challenge, and the mistakes often occur. Particularly, these mistakes seem to occur around variances. I would caution anybody who is going to do a meta-analysis who thinks, “Oh, meta-analyses are easy. I can just get a grad student to grab some papers, write the numbers down, and plug them in some public software.” I would caution people not to do that, but to have a professional statistician involved.
You have published articles criticizing the statistics and assumptions of various academic papers, resulting in their retractions. Can you theorize why these papers are being published in the first place? What are some mistakes that you see most often?
Why they get published in part is because we don’t really have a good system for vetting papers. Many people seem to think that peer review is that system, but I don’t think it was ever realistic to expect that peer review can be the true gatekeeper of papers and can eliminate all mistakes – or even most mistakes. I think peer review just checks if a paper belongs, and then you receive advice. But the peer reviewers don’t have the time and the ability to go through everything the author and investigator did to see if it is correct. That must fall on the investigators themselves. I think many investigators let a lot slip through – some intentional and some unintentional. I think we need to work on both of those things.
What would you recommend to young researchers in the field of obesity and nutrition who would like to improve their ability to identify poor methods and conclusions?
I would say to take our short courses. Read very widely, including interdisciplinary work. Read some work on the physiology of obesity, the genetics of obesity, engineering approaches, computational approaches, nutritional, psychology, medical, and economic approaches, so that you have a broad base to compare things to. I would say to talk broadly and question everything. Question yourself. Question your own ideas. Those are all important things to do.
This is part two of a two-part interview with Dr. David Allison.
Suppose you’ve been told to eat an anti-inflammatory diet, or maybe you’re a practitioner whose clients want to know whether this is right for them. Before hopping on this buzzy bandwagon, ask yourself ‘For what purpose?’
Without missing a beat, you say ‘Well, to reduce my inflammation!’
While technically a noble intention, let’s first acknowledge that this term is used loosely in everyday conversation, but it’s more misunderstood than one might initially believe. Let’s talk about this elephant in the room, dive in, and answer a few key questions: What’s inflammation in the first place? What factors (dietary and otherwise) contribute to, or mitigate it? And finally, how might we modify our diets and our behavior to reduce it?
What is inflammation?
In broad terms, inflammation is the body’s immune system’s response to a stimulus.1This can be in response to common injuries such as burning your finger, or falling off of a bicycle, after which you feel the affected area become red, warm, and puffy- this is a localized response to injury, characterized by ‘increased blood flow, capillary dilation, leucocyte infiltration, and production of chemical mediators.’2In short, an inflammatory response means the innate (non-specific) immune system is ‘fighting against something that may turn out to be harmful.’
It turns out that while inflammation is often cast in a negative light, it’s actually essential in small amounts for immune-surveillance and host defense.2 In true ‘Goldilocks’ form, too little and too much inflammation both pose problems; in fact, most chronic diseases are thought to be rooted in low-grade inflammation that persists over time. This inflammation may go unnoticed by the host (you!) until overt pathologies arise, which include, but are not limited to, diabetes, cardiovascular disease, nonalcoholic fatty liver disease, obesity, autoimmune disorders, inflammatory bowel disease, and even clinical depression. This concept is called ‘The inflammation theory of disease,’ in which inflammation is the common underlying factor among the leading causes of death.3
How do we measure inflammation?
Although measuring low-grade chronic inflammation (read: A chronic, low-grade immune response) carries a number of limitations, studies frequently measure cellular biomarkers such as activated monocytes, cytokines, chemokines, various adhesion molecules, adiponectin, non-specific markers such as C-reactive protein, fibrinogen, and serum amyloid alpha. Key inflammatory pathways include sympathetic activity, oxidative stress, nuclear factor kappaB (NF-kB) activation, and proinflammatory cytokine production.4 Now you might wonder, ‘What does this mean for me? What modifiable factors can activate my key inflammatory pathways?’ If we are to address this question appropriately, let us turn our attention to both dietary and behavioral moderators.
What makes up an anti-inflammatory diet?
Prolonged low-grade inflammation is associated with excessive oxidative stress and altered glucose and lipid metabolism in our fat (adipose) cells, muscle, and liver.4 Therefore, research suggests that certain dietary components can modulate these key inflammatory pathways and clinical pathologies. Dr. Barry Sears explains in a review paper that “anti-inflammatory nutrition is the understanding of how individual nutrients affect the same molecular targets affected by pharmacological drugs.” 5
Compelling research from large-scale, longitudinal observational studies including the Women’s Health Initiative Observational Study6 and Multi-Ethnic Study of Atherosclerosis (MESA) study7suggest that a diet with appropriate calories that is low in refined carbohydrates, high in soluble fiber, high in mono-unsaturated fatty acids, a higher omega-3 to omega-6 ratio, and high in polyphenols, all have anti-inflammatory effects on the body. A Mediterranean diet pattern that incorporates olive oil, fish, modest lean meat consumption, and abundant fruits and vegetables, legumes, and whole grains, shows more anti-inflammatory effects when compared to a typical American dietary pattern. Other observational and interventional studies have also suggested that dietary patterns incorporating green and black tea, walnuts, ground flaxseed, and garlic are also associated with reduced inflammation.
Can my stress levels influence inflammation, too?
To conclude our discussion with anti-inflammatory dietary strategies would be a half-told story. In fact, “Communication between the systemic immune system and the central nervous system (CNS) is a critical but often overlooked component of the inflammatory response to tissue injury, disease or infection.”3
Behavioral studies have shown that prolonged psychological stress can activate the same pro-inflammatory pathways we’ve been discussing all along. While chronic psychological stress can promote over-expression of pro-inflammatory mediators, it can also promote overeating unhealthful foods in the absence of hunger. 8 Repetitively stress-eating calorie-dense, nutrient-poor foods not only further exacerbates psychological distress and creates a vicious cycle of stress-eating, but over time promotes adiposity, which we’ve described is itself a pro-inflammatory state.
Integrative strategies and considerations
This ‘cross-talk’ between the brain and body suggests that strictly dietary or strictly behavioral interventions are not enough to reduce inflammation on their own. Instead, we must consider integrative diet and lifestyle preventions/interventions simultaneously. Going forward, we’ll need better biomarkers and more research looking at individual responses to diet (personalized nutrition!), and better understanding of how food components and behavioral factors modulate genetic targets involved in the inflammatory response.
- What is an inflammation? National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072482/. Published January 7, 2015. Accessed March 16, 2018.
- Hunter P. Stress, Food, and Inflammation: Psychoneuroimmunology and Nutrition at the Cutting Edge. EMBO Reports. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492709/. Published November 2012. Accessed March 16, 2018.
- Hunter, Philip. The Inflammatory Theory of Disease. EMBO Reports, Nature Publishing Group, Nov. 2012, ncbi.nlm.nih.gov/pmc/articles/PMC3492709/.
- Galland, Leo. “Diet and Inflammation.” Sage, 7 Dec. 2010, journals.sagepub.com/doi/abs/10.1177/0884533610385703?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed.
- Sears, Barry, and Camillo Ricordi. “Anti-Inflammatory Nutrition as a Pharmacological Approach to Treat Obesity.” Journal of Obesity, Hindawi Publishing Corporation, 2011, ncbi.nlm.nih.gov/pmc/articles/PMC2952901/.
- Thomson, C A, et al. “Association between Dietary Energy Density and Obesity-Associated Cancer: Results from the Women’s Health Initiative.” Journal of the Academy of Nutrition and Dietetics., U.S. National Library of Medicine, ncbi.nlm.nih.gov/pubmed/28826845.
- “Associations of Dietary Long-Chain n-3 Polyunsaturated Fatty Acids and Fish With Biomarkers of Inflammation and Endothelial Activation (from the Multi-Ethnic Study of Atherosclerosis [MESA]).” The American Journal of Cardiology, Excerpta Medica, 4 Mar. 2009, www.sciencedirect.com/science/article/pii/S0002914909001088?via=ihub.
- Tryon, M., Carter, C., DeCant, R. and Laugero, K. (2013). Chronic stress exposure may affect the brain's response to high calorie food cues and predispose to obesogenic eating habits. Physiology & Behavior, 120, pp.233-242.
I spend a lot of time reading social media postings of various dietary tribes, and constantly see success stories of weight loss and a wide range of other health observations. To build on my last post on social media misinformers, the anecdote is a key feature of binding these groups together and reinforcing their dietary supremacy. Anecdotes about any particular diet’s efficacy are often trumpeted by highly motivated individuals in which the diet may align with their personal ideologies. But when thinking about health and nutrition in a scientific way, how should we internalize them? At extreme ends, people will interpret anecdotes in different ways. For example, if a particular diet helped someone lose more weight than compared to other diets in research trials, some will say that the diet can’t be appropriately studied in the research setting. On the other end, someone with a training in science might suggest we disregard anecdotes completely as unreliable. I’ve been pondering a lot lately how much weight we should give to diet anecdotes that we read online. In this post, I’ll try to argue why a mixture of both in the appropriate contexts is probably the best approach, and explore several cognitive biases that make us exaggerate the importance of anecdotes in the interpretation of health and nutrition.
We do scientific trials in nutrition because individual anecdotes cannot give us an accurate sense of how well something works. If I go on a weight loss diet and find success, I am not likely to try a different one while holding all other factors in my life the same to see if it really is the best. This is the beauty of randomized controlled trials: with enough people in the study, these others factors should average out and you can find the effect of the diet per se. However, in reality, in particular in nutrition studies, it is extremely difficult to get people to stay on a diet, especially more than a half year at a time. For this reason, such trials will underestimate the potential of a diet (on whatever outcome) for those that are self-motivated to comply to a diet, more so reflecting an average of a population (with the caveats that inclusion criteria aren’t overly restrictive and accounting for effects of being in a clinical trial) that is likely at least a little self-motivated to start a new diet. (For a recent example of a range of weight loss responses to being in a trial, see Fig. 1 of Supplement 2 in the DIETFITS study.) We can only truly find out how successful a diet is if we control as much as we can about many participants’ lives, and this is prohibitively expensive and inconvenient for more than short periods of time. So with this inherent uncertainty in nutrition science, we have to make some extrapolations on how to live. How reliable are individual observations?
We know anecdotes are not objective reflections of reality, which is why we developed the scientific process. That doesn’t mean they are useless. But there are a number of cognitive biases that cause some to put too much regard in them. To discuss a few: the perception bias causes us to misperceive how much of a particular behavior occurs in the broader population. If you see a number of people on a social media platform talking about a particular diet, you will likely overestimate how successful that diet will be outside of that bubble. These people have self-selected to a particular diet, so this further skews how we perceive the applicability of the diet to the broader population. Because social media relays uncontrolled memories of people who self-select diets, it creates an environment rife for self-selecting what information they share. Inaccurate recollecting of information is a well-known problem in research, even in a situation that is set up to be consistent in data collection methods. In social networks it will be much worse. Confirmation bias also can lead us to surround ourselves only with like-minded individuals that share information that supports our beliefs. Scientific research has defined methods to prevent this bias from influencing results, but Google “research” does not. In addition, people are likely to start a new dietary pattern when they have a health concern than when they are healthy. This not only fuels recall bias, but makes it difficult to tell whether the diet truly helped or if the condition would have resolved with other diets or doing nothing different at all (“regression to the mean”). In public spheres, there is a wax and wane of interest in particular diets that does not reflect the pace of research. For instance, see Google Trends for paleo vs ketogenic diets. There is a potential for bias in new areas of research with scientific inquiry, and this will also extend to internet communities with a much greater impact, exaggerating the perception of how successful the diet is in a variety of different applications.
There is also fairly good evidence that health myths can fuel physical conditions. For instance, see the history of MSG or likely to an extent, gluten. How many anecdotes of a particular fringe recommendation improving a condition are the result of the nocebo effect causing it in the first place? Finally, the use of weak evidence, or using argumentative techniques like strawmen or ad-hominems can manifest as rhetoric bias in online conversations that isn’t observed in scientific discourse. These may change our thinking if there is no serious reflection in how they are being misappropriated as logical argument. If everyone understood these biases, we could have much better public hypothesis-driven discussion about health and nutrition.
Education, however, does not immunize us completely from cognitive biases. In an annual lecture on cognitive biases and nutrition that I give to undergraduate dietetics students, I provide a pre-lecture quiz to demonstrate the power of cognitive biases. One question that I’ve found to be particularly effective is: “What percent of US households received SNAP (food stamp) assistance in 2013?” After this question, they are randomly shown one of two values: “Is it more or less than 5%?” OR “Is it more or less than 60%?”. This is a demonstration of the anchoring heuristic that tells us that giving an initial piece of information will influence our subsequent estimation/judgement. Year after year, those that I ask if it is more or less than 5% guess on average that about 20% of households receive SNAP (~13% is correct). But when I ask if it is more or less than 60%, the average guess is that nearly 50% of households receive SNAP! Simply by changing that starting value, I get drastically different responses. Education may help a little in some instances- there seems to be some protection against dietary recall bias between dietitians and non-dietitians, but still a large underreporting of energy intake in both.
So, when are anecdotes useful? When they are considered in a systematic and rigorous way. For instance, in clinical settings. After all, the plural of anecdote is in fact data, despite the misquotation that it is not. But, to be data of value, the conditions in which it is collected and documented need to be clear and sound. We can collect anecdotes with consistent and controlled methods to make them worth thinking about in pragmatic ways. For instance, the National Weight Loss Control Registry surveys people who report successfully losing weight and keeping it off long-term. Researchers can then do careful analyses on various behavioral and psychological factors that predict success. Biases still may exist in the representations of various diets (but can be mitigated with statistical analysis), but there is no selective promotion of various predictors without hard data. Interpreting the limited scientific evidence of nutrition trials on various diet patterns in the context of an individual patient’s overall habits, preference, lifestyle, etc. is a difficult task. Adherence is key, and in my opinion any diet within reason that someone can learn to adopt long-term shouldn’t be discouraged. We have serious health epidemics, and research and policy is slow and doesn’t quickly adapt to changing times. Recently I attended a talk by a scientist who has worked at several high level posts at various government agencies who argued that since what we are doing policy-wise isn’t really working, we should try community-based experiments first, then build policy based on what practices are successful. This position surprised me at first but it really isn’t in conflict with evidence-based practices assuming these collective anecdotes are well-documented and supervised.
When thinking about anecdotes, it is also important to consider both how much a particular diet deviates from a person’s normal diet, and what type of anecdote it is. When I read about people going on extreme diets like a recently trending “all meat” diet, it is not surprising to me in the least that people will report dramatic weight losses to start. If you restrict yourself to only eating one particular food group, and you are highly motivated to boot, and perhaps it aligns with an anti-authority view of healthcare, it is not a shock that one could lose a lot of weight. Consider the external cultural, behavioral, socio-economic, or other factors that may prevent adherence long-term. The more deviation from normality, the more difficult adherence can become. But anecdote seekers can find refuge in common communities which might increase motivation, in a sense creating their own normality. Is it a good or bad thing that people find success in such communities that also foment a lot of dietary misinformation? Most scientists I know lean toward the latter, though the most successful book promoters seem to have no issue embracing a little pseudoscience if it expands and amplifies the community. Of course, to appropriately put anecdotes in context we have to consider what type of anecdote it is too. For example, it is correct to dismiss someone claiming that a certain diet prevented them from getting cancer, because it is a chronic disease that may be decades in the making. But what do we do with something much more acute, like someone feeling better after they take out an additive from their diet? It is not likely that they meticulously self-tracked their reactions before and after doing so. Nocebo and placebo effects could be playing a role. They may have read a lot of anecdotes online and numerous biases lead them to conclude that it is a real effect. Because of all of these factors it is much more likely that these anecdotes are unreliable than that they could reflect some scientific unknown that has yet to be discovered. Yet, if they feel better and it isn’t harming their health does it matter? This balance between a desire to squash misinformation and help people improve their wellbeing can cause immense cognitive dissonance. What do we make of the “biohacker” culture that self-experiment to try to find what dietary or lifestyle factors work best for them? It is unlikely that they are contributing to scientific understanding in any meaningful way for the host of reasons discussed above, but if that is what keeps them motivated and interested in health, and if they are experimenting within reason, to what extent should their communities be left unchecked if they help others get interested as well? How can we better measure those that may be harmed? Can people eating more fat or more carbs who lose weight produce reliable anecdotes when so many other things about their diet, lives, interests, and motivations may have changed? We know some variation apart from measurement error exists between individuals in highly controlled experiments. Yet in nutrition, variability is compounded with the complexities of teasing apart many simultaneous dietary changes, compliance, faulty memories, and strong ideologies and biases. In other words, when do anecdotes in nutrition reflect true individual physiological responses to a diet, or just the other baggage?
For these reasons I try to value scientific evidence and anecdotes in very different ways, because each reflects very different things. We need to carefully understand what each of them means in terms of accuracy, applicability, and potential harm. The top-down application of research versus a bottom-up personal journey can both fit into the reality that we need many ideas to improve population health. est aproach
The New England Journal of Medicine recently published an article entitled “Simulation of Growth Trajectories of Childhood Obesity into Adulthood.” The models in the study projected that 57.3% of today’s children will be obese by age 35.1 The bleak predictions of future health trends such as these reaffirm the need for health professionals to be knowledgeable about nutrition.
Patients expect physicians to be sources of information related to nutrition. In fact, 61% of respondents to an American Dietetic Association (now the Academy of Nutrition and Dietetics) survey stated that they believe physicians are a “very credible” source of nutrition information.2 At the same time, though, in a study of internal medicine interns, 86% of respondents admitted to being inadequately trained to provide nutritional counseling. This inadequacy starts early in a physician’s career, with 51.1% of medical school graduates in 2005 reporting that they received insufficient nutrition education during medical school.3
Take the field of cardiology, for example, where a recent study found that, among a cohort of 930 cardiologists, 90% believe their role includes providing patients with basic nutrition information. In the same group of physicians, though, 90% stated that they had received little-to-no training in nutrition during their fellowship, 59% stated that they had received no nutrition during internal medicine training, and 31% reported no nutrition education in medical school.4 Simply put, the perceived role of physicians and the training they are given don’t match up.
This is not a matter of self-reported opinion either, because curricula also lack dedicated nutrition training, and this is not a new phenomenon. In 1962, the American Medical Association (AMA)’s Council on Foods and Nutrition held a conference pertaining to the “inadequate recognition, support and attention” given to nutrition education in medical schools. The council acknowledged that nutrition is intimately involved in the pathogenesis of chronic and degenerative diseases and that the medical curriculum was lagging with respect to advances in nutrition science. 5 The interrelatedness of medicine and nutrition was recognized by the council as more than the just the treatment of isolated nutrient deficiencies.
In 1976, the AMA conducted a mail survey to better understand the status of nutrition education in U.S. medical schools. When 102 medical schools responded to the surveys, fewer than 20% of schools reported requiring a nutrition course.6 The schools cited lack of funds, inadequate number of physicians trained in clinical nutrition, and limited amount of time available in the curriculum as limitations for increased nutrition education. This forty-year-old survey also highlighted the increased interest in nutrition from students and faculty at these institutions.7 We can only assume this interest has since grown.
The scientific conferences and congressional hearings in the decades leading up to the 80s drew attention to the need to improve nutrition education in U.S. medical schools. As a result, the National Research Council Committee on Nutrition in Medical Education published recommendations in 1985 stating that a minimum of 25 to 30 classroom hours during preclinical years should be allotted to covering the topics in nutrition that were underscored by the committee.6 For the past two decades, research spearheaded by University of North Carolina at Chapel Hill has tracked the state of nutrition education in U.S. medical schools every four years. Unfortunately, the data show no sign of changes in the average hours required in nutrition education since 2000. The most recent survey during the 2012-2013 academic year included 121 medical schools, with an average of 19 hours (SD =13.7) of nutrition education in their curriculum. The survey showed that 71% of medical schools failed to meet the minimum recommendation of 25 hours, 36% provided 12 or fewer hours, and 9% provided none.8
Current nutrition education is evidently not translating into practice when only 10% of primary care physicians include weight counseling for patients, and fewer than half of obese and overweight patients are advised to lose weight.9 Primary care practitioners overwhelmingly support requiring additional training so that they will be better informed about the care they provide to their patients with obesity.10
The Association of American Medical Colleges has recently declined to incorporate nutrition into its new blueprint for medical competencies.11 The 2013 American Council for Graduate Medical Education (ACGME) program requirements for Graduate Medical Education in Cardiovascular Disease neglects to mention nutrition. 12 This continues to be the case in the most recent iteration of the ACGME requirements along with the ACGME for Internal Medicine.13,14 These examples show that both medical schools and graduate medical education have yet to legitimize the value of incorporating nutrition training through their competencies.
Three programs that have become recognized for their innovative approach to nutrition curriculum at medical schools include:
- The Nutrition in Medicine (NIM) Project – since 1995 this program has aided in the development and distribution of nutrition curriculum for medical students through comprehensive online courses free of charge. The curriculum is a 29-unit curriculum covering basic science content along with clinical applications through cases. About 50% of medical schools actively use the NIM curriculum and the flexibility of the curriculum has allowed for varied implementation at these schools .15 A more recent initiative by the NIM team is the Nutrition Education for Practicing Physicians for residents, fellows, and practicing physicians. These online modules differ from the medical school resources through the greater level of clinical detail and practical applications (http://www.nutritioninmedicine.org/).
- Healthy Kitchens, Healthy Lives – The Culinary Institute of America and the Harvard T.H. Chan School of Public Health have collaborated as a strategy to enhance physician ability and motivation for nutrition counseling through interactive cooking experiences. The program uses teaching kitchens to demonstrates how nutrition science can be translated into nutritious meals. This initiative has shown to be successful in changing physicians’ dietary practices and their inclination to offer nutrition counseling at a 3-month follow-up.16 Currently, over 6,000 health professionals have taken the course. This initiative has expanded to 32 organizations located in 16 different states, plus Italy and Japan. The kitchens are active in universities, hospitals, and corporate buildings. (http://www.healthykitchens.org/)
- Tulane University School of Medicine’s Goldring Center for Culinary Medicine – this is the first teaching kitchen implemented at a medical school. The center trains medical students and professionals through culinary medicine classes in the form of electives and seminars as well as continuing education. The idea is grounded in the idea that the knowledge to cook nutritious meals encourages patients to buy vegetables and fruits that they previously avoided because they didn’t know how to prepare them. Tulane offers an institutional and away rotation at Johnson & Whales University in Providence Rhode Island where students can participate in hands-on culinary and culinary nutrition classes as well as an academic research project related to medical nutrition therapy. Medical students can also opt to take an 8-class culinary medicine elective during their first or second year of school. (https://culinarymedicine.org/)
The physician is the head of the care team and is responsible for directing care and allocating personnel and resources. Physicians see many patients when they are most in need of nutrition guidance. Therefore, physicians should be able to assess and recognize nutrition-related problems, and appropriately coordinate patient care. Let us hope that these programs are increasingly adopted in medical education so that physicians will be better equipped to address the health of their patients.
- Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017;377(22):2145-2153. doi:10.1056/NEJMoa1703860.
- Nutrition and You: Trends 2008.; 2008. http://www.eatrightpro.org/~/media/eatrightpro files/media/trends and reviews/nutrition and you/trends_2008_are_you_already_doing_it.ashx. Accessed November 30, 2017.
- Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. What do resident physicians know about nutrition? An evaluation of attitudes, self-perceived proficiency and knowledge. J Am Coll Nutr. 2008;27(2):287-298. http://www.ncbi.nlm.nih.gov/pubmed/18689561. Accessed November 30, 2017.
- Devries S, Agatston A, Aggarwal M, et al. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130(11):1298-1305. doi:10.1016/j.amjmed.2017.04.043.
- Council on Foods and Nutrition. JAMA. 1963;183(11):955. doi:10.1001/jama.1963.03700110087015.
- National Research Council (US) Committee on Nutrition in Medical Education. Nutrition Education in U.S. Medical Schools. Washington, DC; 1985. doi:10.1007/BF02427708.
- Cyborski CK. Nutrition content in medical curricula. J Nutr Educ. 1977;9(1):17-18. doi:10.1016/S0022-3182(77)80110-6.
- Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. J Biomed Educ. 2015;2015:1-7. doi:10.1155/2015/357627.
- Kraschnewski JL, Sciamanna CN, Pollak KI, Stuckey HL, Sherwood NE. The epidemiology of weight counseling for adults in the United States: a case of positive deviance. Int J Obes. 2013;37(5):751-753. doi:10.1038/ijo.2012.113.
- Bleich SN, Bennett WL, Gudzune KA, Cooper LA. National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care. BMJ Open. 2012;2(6):e001871. doi:10.1136/bmjopen-2012-001871.
- Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Acad Med. 2013;88(8):1088-1094. doi:10.1097/ACM.0b013e31829a3b2b.
- Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med. 2014;127(9):804-806. doi:10.1016/j.amjmed.2014.04.003.
- ACGME Program Requirements for Graduate Medical Education in Cardiovascular Disease (Internal Medicine). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/141_cardiovascular_disease_2017-07-01.pdf. Accessed November 30, 2017.
- ACGME Program Requirements for Graduate Medical Education in Internal Medicine.; 2017. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_internal_medicine_2017-07-01.pdf. Accessed November 30, 2017.
- Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: nutrition education for medical students and residents. Nutr Clin Pract. 2010;25(5):471-480. doi:10.1177/0884533610379606.
- Eisenberg DM, Myrdal Miller A, McManus K, Burgess J, Bernstein AM. Enhancing Medical Education to Address Obesity: “See One. Taste One. Cook One. Teach One.” JAMA Intern Med. 2013;173(6):470. doi:10.1001/jamainternmed.2013.2517.
When you open Instagram*, you’re immediately bombarded with beautiful pictures of iconic nature scenes, happily engaged couples, the most adorable animals, and, of course, drool-worthy plates of food.
This relatively new social network has been growing in users every day and novel ways of using the application have emerged, including tracking weight loss and weight management. Research has shown that social support can be a key feature for many when embarking on a diet to lose weight. Emerging studies have found that online social networks can help motivate and encourage participants to adhere to their health goals. Instagram has captured the attention of people looking to share and find healthy living inspirations through photos and captions.
Recently, researchers from the University of Washington conducted semi-structured interviews with participants that use Instagram to share photos of their daily eats instead of using a traditional food journal or application to record their food intake. They found that one of the benefits of the Instagram method was taking photos of food when dining out or dining with friends is easier than trying to write or record a description of the meal. Also, Instagram provides a visual food diary, which can be useful in identifying volume and quality of food.
Another benefit is that participants reported that the social and emotional support they received from other Instagram users helped keep them accountable towards their goals, honest about their dietary intake, and encouraged them to extend support to other users. Instagram also allows users to create multiple accounts, so participants appreciated how they could create an account specifically geared towards healthy living. This led them to find likeminded communities and followers through the use of healthy eating, tracking, and weight loss-related hashtags. This also allowed participants to keep their personal account separate so they do not overwhelm friends and family with their food photos. Participants that met their weight loss goals and reached the maintenance stage found that staying on Instagram to mentor others motivated them to stick to their health goals, since they have users relying on them for support.
However, Instagram is not a foolproof platform for successful weight loss and weight management. Dr. Charles Spence, University of Oxford, warns in his review that looking at visually appealing pictures of food through advertisements and social media could stimulate hunger signals. When this “digital grazing” is done too often, it could tempt people to eat, even when they are not hungry. Another study administered an online survey to participants about their social media use, dietary habits, and had them complete an orthorexia nervosa assessment tool. The study found that out of all the social media channels, only higher Instagram use was linked to a greater tendency towards orthorexia nervosa.
Instagram has only been in existence since 2010 and research on the platform is still in its early stages. As access to technology continues to evolve, more research in this area will hopefully continue to emerge. For some, utilizing a social media platform to track and meet health goals could be a useful strategy.
*Instagram is a picture-messaging smartphone application where users can upload photos, apply photo editing filters, and share with the Instagram community through strategically-placed hashtags that link photos together into a virtual photo album.
Chung CF, Agapie E, Schroeder J, et al. When Personal Tracking Becomes Social: Examining the Use of Instagram for Healthy Eating. CHI. 2017. doi:10.1145/3025453.3025747
Elfhag K and Rossner S. Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obesity Rev. 2005; 6, 67–85. doi:10.1111/j.1467-789X.2005.00170.x
Harvey-Berino J, Pintauro S, and Buzzell P. Effect of Internet Support on the Long-Term Maintenance of Weight Loss. Obes Res. 2004;12, 320–329. doi:10.1038/oby.2004.40
Hu Y, Manikonda L, Kambhampati S. What We Instagram: A First Analysis of Instagram Photo Content and User Types. Proceedings of the Eighth International AAAI Conference on Weblogs and Social Media. 2014. Retrieved from https://www.aaai.org/ocs/index.php/ICWSM/ICWSM14/paper/viewFile/8118/8087
Hwang KO, Ottenbacher AJ, Green AP, et al. Social support in an Internet weight loss community. Int J Med Inform. 2010; 79(1), 5–13. doi:10.1016/j.ijmedinf.2009.10.003
Spence C, Okajima K, Cheok AD, et al. Eating with our eyes: From visual hunger to digital satiation. Brain Cogn. 2016; 110, 53–63. doi:10.1016/j.bandc.2015.08.006
Turner PG and Lefevre CE. Instagram use is linked to increased symptoms of orthorexia nervosa. Eat Weight Disord. 2017; 22, 277–284. doi:10.1007/s40519-017-0364-2
Walking into the “Developing Healthy Eating and Physical Activity Behaviors through Education, Extension or Technology” session sponsored by the ASN Nutrition Education and Behavioral Sciences RIS, you could feel the energy in the room as everyone waited in anticipation for the oral sessions to begin.
The session began with a presentation by Gabriella McLoughlin, University of Illinois at Urbana Champaign, on “School Lunch and Physical Activity During Recess: Interactive Effects of Health Behaviors in the School Setting.” Her presentation focused on how the timing of lunch affects food intake during lunch and physical activity during recess for 4th– and 5th-grade students. Her study found that students who ate lunch before recess were more physically active during recess and consumed more vegetables. Further, engaging in moderate-to-vigorous physical activity was inversely associated with lower intakes of carbohydrate, fat, sugar, and overall calories. However, students who ate lunch after recess ate more and had greater intakes of carbohydrate and fat.
Laura Adam, University of Alberta, followed with her presentation on “Sense of Weight Control Prior to Pregnancy Could Help Predict Women at Risk for Excessive Gestational Weight Gain.” Her analysis sought to understand if differing amounts of lifestyle support provided by a Registered Dietitian (RD) during pregnancy could help women achieve appropriate gestational weight gain. Participants were randomized into the control or intervention group. The intervention group received two visits from an RD during pregnancy, while the control group did not. No difference was found for total gestational weight gain, rate of weight gain, and adherence to the gestational weight guidelines between the groups. However, she found that more women with BMIs in the obese and overweight category exceeded the recommended gestational weight gain, as compared to women with a normal BMI. Further, women who felt more in control of their weight before pregnancy were more likely to adhere to the gestational weight gain guidelines.
James Roemmich, Grand Forks Human Nutrition Research Center, next shared a unique perspective for how to motivate people to be active during his talk on “Increasing Discomfort Tolerance Predicts Incentive Sensitization of Exercise Reinforcement: Preliminary Results from a Randomized Controlled Intervention to Increase the Reinforcing Value of Exercise in Adults.” His work uses the Incentive Sensitization Theory, which is usually used to describe how people become addicted to drugs. This theory postulates that neuroadaptations in the brain increase craving of a behavior causing the object to become more motivating, so the individual wants to consume the stimulus. Roemmich applies this theory to physical activity to determine if tolerance for exercise discomfort is related to relative reinforcing value of exercise. He conducted a 3-arm, randomized, controlled trial over the course of 6 weeks with two exercise arms (expending 150 or 300 kcals during cardio-type exercise 3 days/wk) and a control group. He found that those who exercised more intensely increased their tolerance to exercise and those with more tolerance had greater relative reinforcing value of exercise. He recommends the focus be on guidelines to increase motivation for exercise, so it becomes a habit.
Jacqueline Vernarelli, Fairfield University, explored the relationship between energy density and enjoyment of physical activity for her presentation on “Early development of healthy habits: Children who enjoy physical activity have healthier diets than children who do not.” She used data from NHANES: 2012 National Youth Fitness Survey (NYFS) with a sample of 1,640 children between 3-15 years old. Children were asked if they liked recess using a 5-point likert scale. She found that children who strongly liked recess had lower energy dense diets. Vernarelli recommends focusing on future strategies to examine ways to increase enjoyment of physical activity to encourage children and adolescents to be active.
Sofia Segura-Pérez, Hispanic Health Council, examined a novel way to reach a Latino audience during her talk on “Development and Validation of a Culturally Appropriate Heart Disease Prevention Fotonovela among Spanish Speaking Low-income Latinos.” She employed Community Based Participatory Research to develop a fotonovela (a form of sequential storytelling that uses photographs in the form of photo comics) about heart disease prevention. Through a series of focus groups, she identified common barriers to eating healthy, exercising, and smoking cessation and was able to create messages to encourage healthier behaviors. After her final focus group, she found participants increased knowledge following reading the fotonovela and wanted to be more active, eat better, and stop smoking. Her research shows that fotonovelas are culturally and literacy appropriate educational instruments to use for Latinos.
Sarah Stotz, University of Georgia, took the podium next to share how she developed an eLearning nutrition program to encourage Supplemental Nutrition Assistance Program Education (SNAP-Ed) eligible participants to make healthier choices during her talk on “Expectations and Recommendations from Low-Income Adults Regarding an eLearning Nutrition Education Program Prior to Program Use.” With increased access to the Internet, online learning can be used to address the barrier to attending nutrition education sessions in-person. Further, online learning is self-directed, which capitalizes on adult learning principles. Stotz developed the Food eTalk eLearning Program, which was adapted from the validated nutrition education program, Food Talk. To gauge how her intended audience would respond to the program, she conducted a focus group series (n = 45) and individual interviews (n = 19) to see what participants wanted in an online education program. She uncovered three common themes: 1) Participants used their phones a lot; 2) Participants had low expectations for an online program; and 3) Even though they were unprompted, participants wanted to share that they know they should eat healthier, but “it’s just hard.” Based on this information, Stotz learned to make the eLearning program mobile-friendly, create short learning modules (~10 minutes), identify specific learning topics, and make the lessons entertaining and video-based.
Sharon Kirkpatrick, University of Waterloo, discussed her findings from using a web-based dietary assessment tool during her presentation on “Evaluation of the Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24) for use with children: An observational feeding study.” ASA24 is an online, self-administered dietary recall tool that follows a format based on the Automated Multiple-Pass Method used in the National Health and Nutrition Examination Survey (NHANES). Dietary assessment, particularly among children, is a challenge since it’s subjected to many biases. Kirkpatrick conducted a study to determine how precise ASA24 was with children in 5th-8th grade. She provided each child with lunch that was weighed before and after consumption. The next day, the children were given time to complete ASA24 during class independently. She found most children reported the main lunch item well, but recall was lower for side dishes and the lowest for condiments, such as dip. Kirkpatrick also found that the younger children had more difficulty completing ASA24. Overall, she found that ASA24 performed relatively well, but younger children need more time and help to complete the recall. She suggests accompanying ASA24 and similar technologies with a training, tailored help, and/or supplementary sources of information, such as including menus.
The session concluded with a presentation by Soghra Jarvandi, University of Tennessee Extension, on “Goal Setting, Past Performance and Behavioral Outcomes in a Worksite Wellness Program.” Jarvandi used the Walk Across Tennessee program, a team-based walking program, as a platform for using goal setting as a strategy for facilitating behavior change. Before the study, participants completed the International Physical Activity Questionnaire – short form (IPAQ-short) to assess their initial physical activity level. Participants also self-selected a walking goal and during the study received weekly feedback through a visual graph depicting how much they walked compared to their initial goal. Jarvandi used the IPAQ-short questionnaire to divide the participants into high activity (compliers) and low activity (non-compliers) to see if they had differences in their activity and goal setting during the study. After the study concluded, she found no difference between compliers and non-compliers in terms of their activity habits and goal setting. However, she suggests participants with low levels of physical activity may benefit from behavioral strategies that improve motivation.
By Hassan S. Dashti, PhD
I spent a lot of time contemplating whether I should pursue an RD after completing my PhD. I was told by one of my professors that back in his days, he had to choose between dietetics and research. He told me that it was assumed that students with ‘social’ and ‘people’ skills went into dietetics, whereas the rest went into research. The mutual exclusivity of nutrition clinical practice (dietitian nutritionists, RDNs; but more commonly referred to as RDs) and research is no longer the case. A recent 2016 survey from the Academy of Nutrition and Dietetics (The Academy) revealed that 4% of RDs hold a doctoral degree (PhD, RD) in the US. For the vast majority of those 4%, their curriculum vitae(CVs) will likely indicate that they have completed a dietetic training program (RD) followed by a doctoral degree in nutrition (PhD), and rarely a PhD first then RD. So having completed vigorous doctoral programs, what makes some researchers go back to school to get their RDs?
Perhaps the most common reason is to obtain training for effective translation of nutrition research. Being able to communicate nutrition knowledge to patients and other people was also particularly the reason why Stephanie Harshman, a doctoral student at Tufts University studying vitamin K, applied to RD programs while in her last year of her graduate training. She shared, “The RD training provides a different perspective when examining clinical research, community based interventions, and allows someone to better translate basic science research into terms and ideas that will positively impact human health.” Similarly, the PhD, RD combined training program at Cornell University’s Division of Nutritional Science recognizes the growing need for translational research expertise in order to enhance the “effectiveness and impact of clinical and public health nutrition,” which is made possible through this combined training.
As nutrition is a young and evolving science, a PhD, RD is particularly crucial when leading the translation of novel and cutting-edge science, like nutrigenomics or nutritional chronotherapy, where the translation is not as simple as a dietary prescription like a low-fat diet. Previous president of the American Society for Nutrition (2014-2015) and current director of the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Simin Nikbin Meydani, DVM, PhD, shared with me the story of one of her former doctoral students who wanted to bridge the gap between what is studied and what makes the news headlines and thus went on to getting her RD. Dr. Meydani said, “[The PhD and RD training together] could be applied to meaningful approaches that promote the health of an individual through proper nutrition.”
But it’s not only about how to apply and translate the science, a combined PhD, RD training may facilitate generating pertinent research questions with important implications. Having that human and patient interaction experience, which is often very limited in doctoral training, may help in study design development, particularly in human intervention studies. President-elect of the American Society for Parenteral and Enteral Nutrition (ASPEN) and Professor of Nutrition Science at the University of Pennsylvania School of Nursing, Charlene W Compher, PhD, RD, CNSC, LDN, FADA, said, “The best translational research comes from clinicians who understand what a nutritional problem really means for patients.”
While more than half of RDs (~58%) do work in clinical nutrition (acute care, ambulatory care, or long-term care), contrary to common belief —particularly among non-RDs— not all RDs end up working as full-time clinical dietitians. Practice areas for RDs keep expanding and now include community, food management, communications, consultation and business, and as indicated earlier in this article, in education and research. Thus it’s not uncommon that the realization of the need of a dietetics training may occur later in a PhD’s career.
Stella Uzogara, PhD, MS, RDN, LDN CFS works in public health and decided to pursue an RD in order to get both clinical and non-clinical training to effectively discuss the challenges in public health nutrition and to positively impact health of consumers and patients. Dr. Uzogara who got her PhD in food science is also a certified food scientist (CFS). She now works as a nutritional epidemiologist in the Bureau of Family Health and Nutrition at the Massachusetts Department of Public Health and a state liaison for pediatric nutrition and pregnancy nutrition surveillance systems between Massachusetts and the CDC. She also works in several community health programs. Dr Uzogara said: “Personally, nutrition has served me well in my job and it gives me more flexibility, enabling me to practice both food science and health science, two disciplines which interest me a lot.” On the other hand, incoming Brigham and Women’s Hospital dietetic intern and current doctoral student at the University of Connecticut in biomedical engineering, Anna Roto, MS, MPH, is learning about clinical instruments, mobile health devices, as well as how to design new equipment for medical use in her doctorate program. When asked about her intentions for pursuing an RD, she said, “I am not getting the clinical experience that I believe is necessary for a career in the rehabilitation science field, as I plan to work with individuals experiencing trauma or debilitating illnesses to improve their physical abilities and overall quality of life.”
An RD may also be used as an opportunity to steer towards a new career. Dominica Nichols, PhD, RD, LDN, competed her doctoral training at Northeastern University in microbiology where her work in microbial ecology informed the technology used by several biotech startups. However, after years of culturing microorganisms, Dr. Nichols was looking for other opportunities that would enable her to mentor students and have more interactions with people. Having completed her dietetic internship at Simmons College, she now serves as a pediatric outpatient dietitian at a community center affiliated with Boston Children Hospital. Her research training allows her to work closely with other physicians on various research projects. She said, “Dietetics is an interdisciplinary field. Having training in another field, microbiology in my case, benefits my dietetics practice.”
While less demanding than a doctoral program, completing an RD does come with its own challenges. Interns should be ready to work very closely with a preceptor and shadow current practicing dietitians for an extended period of the internship. As most dietetic internships are fulltime programs, it is often challenging to work on other ongoing projects and jobs, but possible. When asked about the difficulties she experienced as a doctoral student who decided to pursue an RD, Stephanie Harshman shared, “I think the most challenging part of this experience has been trying to find support and guidance from faculty as I pursue the credential.” Dr. Dominica also claimed, “I constantly had to explain to other people why I was doing what I was doing.”
Despite these challenges, most of which are only temporary, whether your interests lie in public health policy, community, or teaching (yes, numerous teaching opportunities are now seeking PhD, RDs), an RD is nonetheless an opportunity for growth and expansion. Dr. Compher said, “I continue to treasure my clinical practice because it keeps me in touch with issues of importance to patients.”
It’s not a revelation that most Americans would benefit from increased nutrition education and guidance. Newly released data from the Centers for Disease Control and Prevention1 show that 64% of Americans are overweight or obese – a number that’s held steady over the past few decades – and that nearly 40% of us consume less than 1 serving of fruits or vegetables daily. $210 billion is spent annually on obesity-related disease2.
It is known, perhaps intuitively, that physicians trained in nutrition achieve improved health outcomes in patients with obesity-related conditions3. Numerous clinical guidelines recommend that physicians counsel their overweight and obese patients on diet, and yet, fewer than 25% feel that they received adequate training in doing so. As a result, only 1 in 8 medical visits includes a discussion of nutrition4,5. This disconnect in recommendations versus practice is a significant issue in medical education today, and the perennial discussion of how to improve the current state of nutrition education in the medical curriculum continues to increase in relevance in our nation’s obesity crisis.
It is recommended that physicians-in-training receive 25 contact hours of nutrition education, including basic nutrition knowledge, assessment, nutrition intervention, and dietary treatment of disease. However, nutrition education in medical schools has continued to fall below this target – and it’s getting worse. A 2012 survey4 found that most medical schools fail to require the recommended amount of nutrition education, with less than 15% of schools providing the 25-hour minimum. The number of hours devoted to nutrition education has dropped substantially since 2004, while the number of schools with no required nutrition education has risen4.
Compounding this issue, many medical training programs provide only basic nutrition background, often buried within a biochemistry or physiology course. While it is undeniably important to highlight the specific actions of vitamins and minerals, this model fails to highlight real-world clinical application of nutrition. Even less time is devoted to developing patient counseling skills. Lastly, the U.S.’s health professional training systems do not provide expertise or incentives to deliver effective counseling on how to achieve and maintain a healthy weight, diet, and physical activity level. This leads to a divide in thinking – a “should” or “want to do” versus “need to” or “have time to do”, and a reduced sense of urgency about implementing changes.
Working Toward a Solution
In addition to a lack of monetary or standard-of-care incentive to increase knowledge dissemination, another primary reason for suboptimal nutrition education is lack of time. This exists both in the amount of time devoted to actual coursework within medical training and for development of a nutrition curriculum within a program. Fortunately, several groups have worked diligently to provide resources that alleviate these barriers. In contrast to many programs that are specific to a particular institution, Nutrition in Medicine6, is a web-based series for students and healthcare professionals, administered through the University of North Carolina at Chapel Hill’s Department of Nutrition. There are over 40 modules ranging from 15 to 60 minutes in length that offer basic nutrition knowledge as well as evidence-based instruction of clinical skills. In addition to providing biochemical, clinical, and epidemiological components and virtual case studies, NIM also offers nutrition tools like pocket notes, nutrient recommendations, quizzes, and YouTube video vignettes. Nearly 75% of U.S. medical schools take advantage of at least one NIM module, and the program has proven to be successful in providing 33% more nutrition education in schools that use NIM versus those that do not.
And the best part? It’s completely free.
Despite the advances made by NIM in improving the dissemination of nutrition knowledge in the medical curriculum, challenges remain. Martin Kohlmeier, NIM’s principal investigator, has acknowledged that building good nutrition education tools is expensive and time consuming, since materials need to be reviewed continuously and updated every 4-5 years. Supporting a web-based tool takes a significant amount of resources, and funding sources are difficult to consistently maintain.
Recently, this cause has been taken up by several prominent health and medicine-focused organizations. A new effort has been launched to teach medical students, physicians, and other allied health professionals how to discuss obesity treatment and prevention options with patients. This initiative is a collaboration between the Bipartisan Policy Center, the Health and Medicine Division of the National Academies of Sciences, the American College of Sports Medicine, and the Alliance for a Healthier Generation. The multi-year project, supported by the Robert Wood Johnson Foundation, will develop “core competencies for obesity prevention, management, and treatment for the health professional training pipeline and identify payment policies that will incentivize the delivery of this care”, as stated in their April 11th press release7. Their goals are for these competencies to be implemented in training programs across the full spectrum of health professionals, and to determine a strategy to reimburse effective counseling for maintaining a healthy weight, diet, and physical activity level. “Training health professionals without a concurrent strategy to reimburse this type of care will not lead to meaningful change. And offering payment without having trained professionals to provide the care also will not result in improve[d] patient care,” the group stated.
This working group, like those involved in the Nutrition in Medicine curriculum, acknowledges that systemic changes to improve nutrition education in medical training will require continuous commitment from a wide range of stakeholders. Details of this initiative have not yet been announced, but those of us involved in education and clinical care certainly look forward to seeing the first steps begin.
Are you a health care professional, student, or educator? What is your experience in teaching or learning nutrition and nutrition counseling skills? I welcome your comments and insight on this issue.
1.Nutrition, Physical Activity and Obesity Data, Trends and Maps web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, Atlanta, GA, 2015. Available at http://www.cdc.gov/nccdphp/DNPAO/index.html.
2.Cawley J and Meyerhoefer C. The Medical Care Costs of Obesity: An Instrumental Variables Approach. Journal of Health Economics, 31(1): 219-230, 2012.
3.Rosen BS, Maddox PJ, Ray N. A position paper on how cost and quality reforms are changing healthcare in America: focus on nutrition. Journal of Parenteral and Enteral Nutrition 2013;37(6):796–801.
4.Adams, K.M., Kohlmeier, M., & Zeisel, S.H. Nutrition Education in U.S. Medical Schools: Latest Update of a National Survey. Academic Medicine. 2010;85(9): 1537-1542.
5.Early KB, Adams KM, Kohlmeier M. Analysis of Nutrition Education in Osteopathic Medical Schools. Journal of Biomedical Education, vol. 2015, Article ID 376041, 6 pages, 2015. doi:10.1155/2015/376041
6.K. M.Adams, M.Kohlmeier, M. Powell, and S. H. Zeisel, “Nutrition in medicine: nutrition education for medical students and residents. Nutrition in Clinical Practice. 2010;25(5), 471–480. Available at: http://nutritioninmedicine.org/
7.Bipartisan Policy Center. New Effort Launch to Train Health Professionals in Nutrition and Physical Activity. http://bipartisanpolicy.org. 21 Mar. 2016.
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