By Allison Dostal, PhD

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.

The Problem

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.

Future Directions

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.

References

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.

Student Blogger for Global Nutrition Council at ASN’s Scientific Sessions and Annual Meeting at EB 2016

By: Sheela Sinharoy, MPH

Many factors can influence the success of a project, from the individual to the institutional level. Presenters at the minisymposium on Global Nutrition: Nutrition-Sensitive Programs shared results from studies at a variety of levels.

At the individual and household level, gender roles within the household can influence individuals’ ability and willingness to carry out different activities. Marion Min-Barron presented results from qualitative research in Ethiopia, in which men and women were asked about gender roles for nutrition activities. In general, men and women felt that the activities were the responsibility of both the male and the female. However, later in the minisymposium, Gordon Zello shared results from a different study in Ethiopia, where researchers found that women’s work burden (for example, being responsible for fetching water) was a significant factor associated with household food insecurity and hunger. This suggested even if men and women feel that they are equally responsible for nutrition, disproportionate constraints on women’s time could be affecting nutrition in the household.

Women’s self-efficacy in complementary feeding was the focus of a study in Zambia. Djeinam Toure explained that in this study, a home gardening intervention had a positive association with women’s self-efficacy in complementary feeding, and that this relationship was mediated by social support from husbands and also by household food insecurity. In other words, the intervention was positively associated with social support from husbands, which was in turn positively associated with women’s self-efficacy.

Also focusing on household food production, Afua Atuobi-Yeboah and Lilia Bilznashka presented results from Ghana and Burkina Faso, respectively. The study in Ghana found that an intervention to improve egg production at the household level, coupled with nutrition education, significantly improved egg consumption among children. The study in Burkina Faso was a follow-on to an impact evaluation that had previously found positive impacts on women’s dietary diversity and underweight as well as child wasting and anemia. Two years later, significant differences remained between intervention and control groups in women’s underweight and child wasting but not in women’s dietary diversity or child anemia, suggesting that for the latter two indicators, the control group may have improved to the level of the intervention group.

Moving to the institutional level, speakers presented findings from both qualitative and quantitative research. Tuan Nguyen presented results from an impact evaluation of a national mass media campaign in Vietnam, which was found to be positively associated with exclusive breastfeeding. Andrea Warren shared findings from a qualitative study in Ethiopia that found inadequate coordination structures for nutrition-sensitive interventions at the national level, among other challenges. Gita Singh presented findings from a project to collect and analyze individual-level national or subnational data to determine dietary intakes of key nutritional factors across 188 countries from 1980-2015. This effort has thus far assembled 1,226 total survey-years of data on dietary intakes of a variety of foods and nutrients.

The findings of the minisymposium made clear that a variety of approaches, through a variety of sectors, are important for improving nutrition globally.

 

By Allison Dostal, PhD

Gastrointestinal problems are one of the most common unpleasant issues that we all experience at some time or another. But what if your upset stomach wasn’t just a passing discomfort? What if severe abdominal pain, cramping, fatigue, and diarrhea became more of your norm and less of a passing annoyance? For more than 1.4 million Americans, these symptoms typify their experience with inflammatory bowel disease (IBD), a disorder characterized by chronic inflammation of the gastrointestinal (GI) tract. The specific cause (or causes) of IBD remain unknown, but one leading hypothesis is that the bacteria that inhabit our GI system – termed the gut microbiome – play a central role. In this post, we’ll take a closer look at this condition and highlight research aimed at elucidating the impact of the microbiome in IBD development, progression, and treatment.

Characteristics, Diagnosis, and Treatment of IBD

Inflammatory bowel disease is unique in that its symptoms vary from person to person, and an individual’s own experience with their condition can differ markedly from another affected person. Most people are diagnosed with one of the two most common types of IBD, which are ulcerative colitis (UC) and Crohn’s disease (CD). The primary distinguishing factor between the subtypes is that in UC, symptoms are limited to the colon. In contrast, any part of the GI tract – from the mouth to the anus – can be affected in CD. In addition, UC only involves the innermost layer of the colon, while CD can extend deeper into the cell layers of the GI tract. Lastly, in CD, the inflammation can “skip”, leaving normal areas between patches of affected GI tract.

Making a clear IBD diagnosis isn’t always as easy as meeting – or not meeting – these criteria. There is no gold standard available for a clear-cut diagnosis, and 5-15% of cases do not meet strict criteria for either UC or CD. These patients fall into the “IBD type unclassified” (IBDU) group. And in up to 14% of patients, the diagnosis changes over time. Despite the difficulty in specific diagnosis, all subtypes of IBD have one strong feature in common: an abnormal response by the body’s immune system. The immune system is composed of various cells and proteins that usually protect our bodies from infection. However, in people suffering from IBD, the immune system reacts inappropriately, and mistakes benign or beneficial cells and bacteria for harmful foreign substances. When this happens, the immune system produces an inflammatory response within the GI tract and produces the symptoms of IBD. This adverse reaction is termed a “flare”, and can result in symptoms such as abdominal pain and cramping, diarrhea, fever, and blood in the stool. People with IBD often have deficiencies in vitamins, minerals and macronutrients stemming from loss of appetite, reduced food intake, and malabsorption from the GI tract. The lack of nutrients can lead to worsening of symptoms or development of new complications.

Treatment for IBD is centered around two goals: achievement of remission and prevention of flares. Anti-inflammatory drugs such as aminosalicylates and antibiotics are often the first line of treatment, and can be followed by corticosteroids, immunomodulators, and/or biologic agents. In severe cases, removal of the affected part of the GI tract is needed if a patient is not responsive to other treatments.

The Role of the Microbiome in IBD

In recent years, it has become clear that the microbes in our gut have a key role in IBD, but the bacteria involved and their associated functions remain largely unknown. An imbalance of the normal gut bactera due to loss or overabundance of certain species is important in the persistence of the inflammatory responses seen in IBD. The role of the gut microbiota in IBD pathogenesis has been demonstrated by studies showing that antibiotic use can reduce or prevent inflammation – antibiotics work by reducing the number and types of bacteria found in the gut, therefore killing microbes that are causing IBD symptoms. Also, results from studies with UC patients who underwent a transfer of stool collected from healthy donors – called a fecal microbiota transplant – had notable disease remission. However, results have not been consistent between studies, due to differences in populations studied, official diagnosis, treatment methods and doses, and methods of assessing study endpoints. Therefore, no consensus on the microbiome’s relationship to IBD has been reached.

Research Endeavors

As you can imagine, the combination of unpleasant, potentially severe symptoms and an uncertain diagnosis or treatment can result in significant stress on IBD sufferers, their caregivers, and health care providers. The scientific efforts dedicated to identifying causes and cures for IBD have rapidly expanded in recent years due to advances in technology that allow researchers to work toward refining a clear diagnosis, map specific gut bacteria associated with disease development and symptoms, and identify defined targets for therapy. One of these initiatives is the Crohn’s and Colitis Foundation of America (CCFA) Microbiome Initiative, which is dedicated to understanding the role of the gut microbes in IBD, IBD families, and disease flares. Thus far, there are 7 active projects and 30 published manuscripts stemming from the Initiative, which have determined that different subsets of IBD are characterized by signature bacterial compositions and that people carrying different IBD genes have different microbiome compositions, among other accomplishments.

Other organizations are also supporting IBD research endeavors, including the Kenneth Rainin Foundation, whose Innovator Awards program provides $100,000 grants for one-year research projects conducted at non-profit research institutions, and the NIH’s Human Microbiome Project, which has funded several projects aimed at genetic and metabolomic elucidation of risk for Crohn’s disease. Several randomized trials are ongoing at this time, and their results will inform future directions for diagnosis, treatment, and eventual resolution of IBD.

References

Borody TJ, Warren EF, Leis SM, Surace R, Ashman O, Siarakas S. Bacteriotherapy using fecal flora: toying with human motions. J Clin Gastroenterol.2004;38(6):475–483.

Bull MJ, Plummer NT. Part 1: The Human Gut Microbiome in Health and Disease. Integr Med. 2014 Dec; 13(6):17-22.

Crohn’s and Colitis Foundation of America:http://www.ccfa.org/

Swidsinski A, Weber J, Loening-Baucke V, Hale LP, Lochs H. Spatial organization and composition of the mucosal flora in patients with inflammatory bowel disease.J Clin Microbiol. 2005;43(7):3380–3389.

Tontini GE, Vecchi M, Pastorelli L, Neurath MF, Neumann H. Differential diagnosis in inflammatory bowel disease colitis: state of the art and future perspectives. World J Gastroenterol. 2015 Jan 7;21(1):21-46.

By Emma Partridge

Dietary tracking applications (apps) have become quite sophisticated over the years, moving from manual entering of a food and portion to using barcode scanners to identify brand name products and return nutritional content information based on an entered portion. However refined these apps have become, their most poignant issue may not lie in the accuracy of the nutritional content information returned, but in the accuracy of the user’s portion estimation. An analysis of misreporting on National Health and Nutrition Examination Surveys (NHANES) between 2003 and 2012 published in the British Journal of Nutrition found that under-reporting of energy intake was most prevalent in US adults 20 years or older. Specifically likely to under-report were women and overweight or obese subjects.1 The reality that under-reporting, conscious or subconscious, can happen in any subjective food recording process leads to questioning whether these types of apps are actually successful in their dietary tracking abilities, especially for overweight or obese people tracking their diets in attempts to lose weight. In a randomized control trial conducted at the Duke University Medical Center and published in Obesity, researchers found that overweight and obese young adults (18-35 years) were no more likely to lose weight using a smartphone app than the control group, who did not undergo any weight loss or health intervention.2 If we can reasonably determine that smartphone apps where one enters their food intake or receives social support don’t help the majority of overweight or obese people lose the weight they’re aiming to, how can this be improved? The latest technologies coming into play are image-assisted apps that allow users to submit photos of their meals then receive nutritional content based on the food and the portion size. Apps such as MealLogger allow the user to submit a photo of their meal, choose their portion size, and post the photo for others to view. While this form of social photo-sharing may skew users to acceptable portioning by social pressure, the user’s ability to choose their portion size still introduces under-reporting bias. Other apps rely on objective, but far broader, methods of extrapolating nutritional content from a food photo. Apps like MealSnap allow users to submit photos of their meal to have the MealSnap system “auto-magically detect the nutritional breakdown” of the meal, according to their Microsoft.com page. While this calorie estimate is likely rougher than one where users choose their portion, it is also objective and prevents under-reporting bias. Apps with more user input may fall victim to inaccuracies from under-reporting, while apps that avoid biased reporting may sacrifice accuracy for objectivity.  To correct this, future technologies must undoubtedly continue to move toward a goal of improved accuracy and usability. Likely, these technologies will move toward advanced imaging, as imaging, finding ways to take in the real food, rather than relying on the user’s input.  The future of image-assisted food technology will determine how close inventors and researchers can get to exact measurement of food and portion while maintaining accurate extraction of nutritional content. I, for one, am excited to see where it leads.

1.Murakami K, Livingstone MBE. Prevalence and characteristics of misreporting of energy intake in US adults: NHANES 2003-2012. British Journal of Nutrition. 2015;114(8):1294-1303.
2.Svetkey LP, Batch BC, Lin PH, et al. Cell phone intervention for you (CITY): A randomized, controlled trial of behavioral weight loss intervention for young adults using mobile technology. Obesity. 2015;23(11):2133-2141.

By Meghan Anderson Thomas

The age of menarche has decreased significantly in the past century, from an average age of 16-17 years old to younger than 13 years of age (Buttke, Sircar, & Martin, 2012). There are several different theories as to why this may be occurring. Some believe that environmental toxins or exposure to estrogen-disrupting compounds (EDC) may play a role. EDCs are found in household plastics, cleaners, deodorizers and personal care products. Other theories include increased body mass index in children and adolescents. Increased hormones found in obese children maybe responsible for the earlier onset of puberty. Finally, nutritional implications such as breast versus bottle-feeding and increased dairy and meat intake in adolescence may also play a role in puberty at younger ages.

EDCs include benzophenones, dichlorophenols, parabens, triclosan, which are compounds that effect estrogen signaling by binding to the receptor and have downstream effects (Buttke, Sircar, & Martin, 2012). These compounds are becoming increasingly common in everyday and household use. This type of exposure may be implicated as one of the causes of decreased age of menarche. In a study by Buttke et al, the level of urinary EDCs was analyzed in females between the ages of 6-11 and 12-19 (2012). Females with urinary EDCs above the 75th percentile have significantly lower age of menarche (Buttke, Sircar, & Martin, 2012). These results are worrisome, because pollutants in our environment are influencing the development of adolescents. This is a larger public health concern than previously believed. Further investigations are underway to better understand which products are the most dangerous culprits.

Obesity has become a major epidemic, whereas two-thirds of the Americans are overweight or obese and one-third of children are overweight or obese. While obesity in adulthood can lead to a plethora of health concerns, it was previously thought that childhood obesity might have reversible effects. However, obesity in young females has been shown to have an influence on early-onset puberty. Obesity causes an increase in certain hormonal levels including leptin, insulin, IGF-1, certain binding proteins, and androgens (Marcovecchio & Chiarelli, 2013). Early signs of puberty are not the only effects seen by the hormonal changes associated with obesity, hyperandrogenism may be present as well (Marcovecchio & Chiarelli, 2013). Hyperandrogenism involves increased body and facial hair, alopecia, acne, and increased libido. Both hyperandrogenism and earlier development in females may have extreme social effects in adolescent females.

Nutrition in newborns is predominately breast-feeding at approximately 75%, however, after just one-week postpartum breast feeding incidence drops to 16.2%. Approximately 20% of formula-fed infants are given soy-based formula (Andres, Moore, Linam, Casey, Cleves, & Badger , 2015). Isoflavones are organic compounds that act as phytoestrogens in mammals and are found in soy-based products and may be feared to cause estrogenic effects such as early-onset puberty (Andres, Moore, Linam, Casey, Cleves, & Badger , 2015). Currently, the most recent study on hormonal additives was done in 1988 by the FAO/WHO Committee on Food Additives Joint with the Federal Drug Administration (FDA) which showed no concern for human consumption of hormonal additives (Larrea & Chirinos, 2007). Later, Larrea and Chirinos show that the study may be concerning due to the inadequate scientific elements that were used (Larrea & Chirinos, 2007). Furthermore, previous studies on the effects of hormonal additives on early onset of puberty are inconclusive and current studies are still underway (Andres, Moore, Linam, Casey, Cleves, & Badger , 2015). The conclusions of the current longitudinal studies will be a vital factor in not only post-partum nutrition but child and adolescent nutrition as well.

The significance of all of the theories behind early menarche is due to the psychosocial effects of early maturity of young girls and the unwanted attention they may receive. Early onset of puberty also causes women to have longer exposure to estrogen, which may be associated with several types of cancers, including breast and endometrial cancer. Estrogen exposure also increases risks for cardiovascular disease and high cholesterol. These health-related side effects were significantly lower when women were experiencing menarche at older ages. Clearly, more research needs to be done in order to investigate the multifactorial causes of early menarche in adolescents; however, current studies seem to implicate both environmental and nutritional exposures.

References
Andres, A., Moore, M., Linam, L., Casey, P., Cleves, M., & Badger , T. (2015, March). Compared with feeding infants breast milk or cow-milk formulas, soy formula feeding does not affect subsequent reproductive organ size at 5 years of age. The Journal of Nutrition , .
Buttke, D., Sircar, K., & Martin, C. (2012). Exposure to endocrine-disrupting chemicals and age of menarche in adolescent girls in NHANES. Environmental Health Prospective , 120 (11), 2003-2008.
Larrea, F., & Chirinos, M. (2007). Impact on human health of hormonal additives used in animal production. Rev Invest Clin , 59 (3), 206-211.
Marcovecchio, M., & Chiarelli, F. (2013). Obesity and growth during childhood and puberty. World Review of Nutrition and Dietetics , 106, 135-141.
NIH. (2009-2010). Overweight and Obesity Statistics. Retrieved 2015, from National Institute of Diabetes and Digestive and Kidney Diseases: niddk.nih.gov

By Teresa L. Johnson, MSPH, RD

W. Allan Walker, MD, and Emeran Mayer, MD chaired a symposium during ASN’s Scientific Sessions and Annual Meeting on March 30 that considered the role the gut microbiome plays in human behavior.

Mark Lyte, PhD, MS, a professor at Texas Tech University, provided insights into aspects of gut-brain communication pathways. He introduced the idea that gut bacteria, as neuroendocrine organisms, are more interactive with their human hosts than previously believed. Lyte then pointed out that the gut is highly innervated, and information flows in a bi-directional but asymmetrical fashion between the gut and the brain, with as much as 90 percent of the information flowing from the gut. He suggested that neuroendocrine chemicals naturally present in foods might influence gut bacteria responses, and mechanisms that were previously considered immunological might be neuroendocrinal instead. The take-home message, Lyte said, was that these food-derived neurochemicals, when absorbed in gut, likely interact with the microbiota. In response, the microbiota produce neurochemicals that affect behavior and cognition in a sort of feedback loop. He cautioned that much of the data are correlational, and causation cannot be assigned.

Sarkis Mazmanian, PhD, California Institute of Technology, focused his remarks on specific molecular communications between the gut and brain. He explained that our bodies are in contact with trillions of microbes. “This microbial fingerprint has effects on many aspects of our biology,” said Mazmanian. He noted that in recent decades, the prevalence of autism spectrum disorder (ASD) has increased dramatically, and he presented data demonstrating that in rodents, maternal immune activation during pregnancy yields offspring with ASD and dysbiosis, suggesting a possible gut-microbiome-brain connection in ASD.

Premysl Bercik, MD, a gastroenterologist and associate professor at McMaster University, noted that while individuals with inflammatory bowel disorders commonly have abnormal gut function and low-grade inflammation, they also experience psychiatric comorbidities such as depression, stress, and anxiety. The trigger for this chain of events has not been identified, Bercik said, but some have hypothesized that infections or abnormal gut flora might be responsible. He then presented data from animal models that demonstrate the bi-directional communication between the gut and brain, and described recent research indicating that both microbial and host factors influence behavior.

Mayer, a professor at the David Geffen School of Medicine at UCLA, began his presentation with a historical perspective on the perceived gut-brain connection, which dates back several millennia. He then described notable limitations to using rodent models to study the gut-brain connection due to structural differences between rodent and human brains, and added that the germ-free mouse, a common model for understanding gut microbiome function, introduces many confounders into the research due to its altered metabolism. Mayer presented data that indicate that pre- and post-natal stress alters the gut microbiome in animals, as evidenced by both behavioral and biological changes, and he raised the idea that the gut microbial organization might influence brain structure. Attempts to modulate behavior with probiotics are promising, Mayer said, because intake blunts the reactivity of several internal organs, including those in the gut. Mayer concluded his presentation by cautioning that although enthusiasm to extrapolate findings from rodent models to human conditions including obesity, autism, and others is high, many questions remain about the role the gut microbiome plays in human health.

By Ann Liu, PhD

Systematic reviews are the basis for nutrition policy and guidance, but gaps in the evidence base can impact recommendations. Presenters at the symposium “Creating the Future of Evidence-Based Nutrition Recommendations, Using Lipid Research Case Studies” sponsored by ILSI North America spoke on various aspects that inform the process of developing dietary guidance and its implementation on Saturday, March 28. Major policy and regulatory groups such as the Dietary Guidelines for Americans Scientific Advisory Committee, American Heart Association, and the Institute of Medicine use systematic reviews as the basis for their decision making, but often the ability to make recommendations can be hampered by a lack of strong evidence.

The process of developing evidence-based reviews, such as the one used by the USDA Nutrition Evidence Library, must be rigorous, transparent, and minimize bias, because these reviews inform federal nutrition policy and programs. At the outset, key systematic review questions are developed which should reflect important decisional dilemmas in public health nutrition guidance.

The next critical step is deciding on inclusion and exclusion criteria, which determines what literature is included in the evidence base. Criteria that may be considered include study design, study duration, size of groups, drop out rates, and the health status of participants. This process is thoroughly documented and transparent so it can easily be determined why a study was included or excluded. The evidence base will go on to be evaluated by expert panels in order to make recommendations and guidances.

How can scientists ensure that their research is included in the evidence base?

– When designing studies, it is important to consider the validity of the study design, the impact of endpoints, and the relevance and feasibility of interventions. Are the outcomes meaningful and are they translatable? If not, what additional information do you need? Researchers can also use the gaps in the literature identified in Nutrition Evidence Library systematic reviews to inform future investigations.
– If studying chronic disease risk, use validated surrogate biomarkers.
– Carefully consider your comparator group. One of the most common reasons studies are discounted from systematic reviews is they did not include appropriate control groups.
– Once you are ready to report your results, follow established reporting standards such as the Consolidated Standards of Reporting Trials (CONSORT) for randomized clinical trials or the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. This can help ensure that key information is included and is available for data abstraction in future systematic reviews and meta-analyses.
– Participate in the process. Once draft reports such as the Dietary Guidelines for Americans Scientific Report are issued, there is the opportunity for public comment. Feedback from scientists with expertise is strongly encouraged.

By Brett Loman

Nutrition may be a relatively young science, but perhaps the intuition of our elders has informed us more than we realize. Food superstitions are as old as culture itself and essentially every civilization has added its share to the ever-growing list of dos and don’ts. In respect to two months in a row with Friday the 13ths this year, I investigated how some long-standing tales about what we eat might actually be grounded in truth.

Spilling salt brings bad luck. This widely recognized superstition originating in ancient Greece may hold some hidden truths. One of the most commonly believed concepts about sodium (salt) today is that eating too much can aggravate conditions such as hypertension, cardiovascular disease, and chronic kidney disease. The American Heart Association and National Kidney Foundation recommend limiting salt consumption to about 1,500 mg/d. So whether you believe the superstition or modern medicine, you will think twice and shake the habit of spilling salt onto your meal.

Eating garlic, onions, and mustard seeds is good luck by granting blessings or warding off evil. This superstition is rooted in many proverbs, and it just so happens that vegetables in the Amaryllis (onions, garlic, etc) and Brassicaceae (mustard, broccoli, etc) families are being investigated as anticarcinogens. Many of the naturally occurring phytochemicals in these plants may serve to halt the formation of cancer causing compounds, enhance repair of damaged DNA, and induce apoptosis of tumor cells. Chowing down on these luckily talismans could ward off disease, but don’t forget that those same beneficial compounds may also scare off your friends with the odors they leave lingering behind.

Bringing bananas on a boat will cause fishermen ill will and a bad catch. Green bananas, coincidentally, may just cause some unwanted symptoms of illness. Un-ripened bananas are a good source of resistant starch. Depending on your personal disposition, fermentation of resistant starch could either provide a healthy dose of short-chain fatty acids to the intestines, or a healthy dose of gas and diarrhea. Any angler would have difficulty landing the big one between frequent trips to the loo, and that’s no fish tale.

Planting parsley will help a woman become pregnant. Of course having good nutrition is important for increasing chances of beginning a pregnancy, but parsley is specifically of interest for the health of the newly developing fetus. This ubiquitous herb is a good source of many vitamins and minerals, including folic acid. In the first few weeks, adequate folate is especially important for preventing neural tube defects in the rapidly growing baby. Consider sowing seeds of parsley before sowing your wild oats.

Every day we find out more and more about how our eating habits affect our bodies, but in some cases we shouldn’t overlook what prior generations have already provided us. Tell the researchers and your grandma thanks for the advice.

References
1. Cobb, L.K., Anderson, C.A.M., Elliott, P., et al. Methodological issues in cohort studies that relate sodium intake to cardiovascular disease outcomes: A science advisory from the American Heart Association (2014) Circulation, 129 (10), pp. 1173-1186. http://www.scopus.com/inward/record.url?eid=2-s2.0-84895928005&partnerID=40&md5=75ecd90a4f86d73a8c200d300b4ca6c8
2. https://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/About-Sodium-Salt_UCM_463416_Article.jsp
3. https://www.kidney.org/atoz/content/sodiumckd
4. http://www.cancer.gov/cancertopics/factsheet/prevention/garlic-and-cancer-prevention#r18
5. http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/dietandnutrition/broccoli
6. http://digestivehealthinstitute.org/2013/05/10/resistant-starch-friend-or-foe/
7. http://ndb.nal.usda.gov/ndb/foods/show/3080?fg=&man=&lfacet=&format=&count=&max=25&offset=&sort=&qlookup=parsley
8. http://www.cdc.gov/features/folicacidbenefits/

By Debbie Fetter

Summer is quickly disappearing and school is right around the corner. Or, as the graduate students are thinking, what is summer anymore? Regardless, the beginning of school brings new responsibilities and puts time management skills to the test. One thing that often seems to fall by the wayside is healthy living. With a little bit of planning, this doesn’t have to be the case.

The Dietary Guidelines Alliance (DGA) recently released a campaign with a mission of taking charge of diet and overall health, rightfully titled, “It’s All About You.” The campaign emphasizes the key to maintaining a healthy lifestyle is to be realistic, active, balanced, adventurous, and sensible. Under each of these components, the DGA offers helpful tidbits designed to assist with goal setting. So, let’s have some fun and relate this resource to the typical graduate student lifestyle. [Keeping in mind, this tool is equally helpful for parents, caregivers, and others seeking to make healthy living easy].

Be realistic: Just like how you’re probably not going to be able to write your dissertation in a week, you can make small changes over time. Set small goals for yourself, such as walking or biking to campus, packing fruit and vegetables to snack on, or choosing whole grain foods.

Be Active: As students, we spend way too much time hunched over a desk or staring at a computer screen until our eyes start tearing. Come up with a physical activity goal each week and track your progress using a tool, such as SuperTracker. Schedule workouts, just as you would schedule meetings. Set a reminder every hour to get up and do a short circuit (i.e. jumping jacks, push ups, a lap around the hallway, etc.). Get some much needed socialization with a walking date. The possibilities are endless!

Be Balanced: Although we rarely feel balanced (hello looming stress levels), we can still find balance with our eating and activity. Figure out how many calories your body needs each day here and use a food and activity tracker, such as MyFitnessPal to effortlessly keep count.

Be Adventurous: Healthy living should never be boring! Pick up a new vegetable and incorporate it into a meal. Find healthy recipe inspiration in cookbooks or online. Choose a day to prepare food for the week, so you’ll have nutritious food on hand. Center meals around vegetables, whole grains, and lean protein sources. Escape from the grind and take a scenic walk or hike. Or, find a brave soul to do acrobatic yoga with you (please don’t pick me).

Be Sensible: Graduate students choose to be in school forever, clearly we’re not sensible people. Okay, okay, but we can make sensible food choices by reading the Nutrition Facts Label, cutting back on added sugars, adding flavor with spices, and choosing to cook with unsaturated oils (i.e. olive oil, yum!). I guess we can limit the trips to taco bell too.

As summer comes to a close, we don’t have to fear losing our healthy eating habits and behaviors. Now, my biggest fear is the undergraduate students…

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.

Sources:

Bodnar, L., & Wisner, K. (2005). Nutrition and depression: Implications for improving mental health among childbearing-aged women.Biological Psychology, 58, 679-685. Retrieved from http://www.spectracell.com/media/022fullpaper2005biolpsychiatrynutritionanddepressionpdf-.pdf

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 http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2008.02008.x/full

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 http://www.bmj.com/content/313/7052/253.short

NIMH. (2009, February 13). Health care costs much higher for older adults with depression plus other medical conditions. Retrieved from http://www.nimh.nih.gov/science-news/2009/health-care-costs-much-higher-for-older-adults-with-depression-plus-other-medical-conditions.shtml

NIMH. (2005). Major depressive disorder among adults. Retrieved from http://www.nimh.nih.gov/statistics/1MDD_ADULT.shtml

NIMH. (2008, June 26). The numbers count: Mental disorders in america. Retrieved from http://wwwapps.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml

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 http://psychiatryonline.org/article.aspx?articleid=174107

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 http://www.ajcn.org/content/69/5/842.short