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

Carbs increase belly fat. Gluten-free diets cure cancer. Artificial sweeteners cause diabetes. It seems like the more we hear about nutrition, the less we actually “know.” Facts and data give way to beliefs and assumptions. In the hands of the media and laypeople even solid research is boiled down to broad sweeping generalizations about marvelous miracles and perilous poisons. Since my last blog post(1) I’ve been contemplating this dilemma and paused on a thought – can we blame them?

There are three key players at work here: scientists, media, and laypeople. As I discussed last time, scientists are sensationalizing their work under the stress of the current scientific machine. As a result, scientists relay eye-catching yet complicated messages to the media. Members of the media generally aren’t scientists. Plus, to receive newly published studies requires a subscription or email request. Just like any other industry, the media’s ultimate goal is to make a profit. To make this profit they need to sell advertising and to sell advertising they need to capture viewers/listeners/web surfers (the laypeople).

This throws a wrench into things. Detailed data turns into 25 seconds of broad reaching conclusions spoken over images of test tubes and lab coats.

Audiences everywhere hear “drinking more coffee could prevent diabetes, a new Harvard study reveals.” Joe Schmo, who has limited scientific interpretation skills, type I diabetes, and no healthy dose of skepticism, runs out for a Frappuccino. We’ve not accomplished the goal.

So who is to blame, and what can we do to fix it? As scientists, we need to take ownership of our work and ensure that we deliver our findings to the public in a way that is both responsible and comprehensible. To take it a step further, scientists need to become a bigger part of the mechanism by interacting with the media. Public service announcements and PBS specials aren’t going to cut it. We need charismatic scientists who are committed to expressing complex scientific information in an interesting and accessible way. However, this isn’t traditionally part of our training. This will take some work to acquire a new skill set, but the payoff will be instrumental to society.

As a population, we need to make sure that scientific reasoning is a skill that is stressed in our schools prior to higher education and that information is made publicly available. Science is not a body of static facts as it is presented to children today, but a fluid system of critical thinking that asks you to sort through good and bad information and decide the facts for yourself. A good discussion and suggestions for accomplishing this feat can be found at Science Direct.

We all share the blame, but there are definite steps that we can make to repair the system. It may take a little ingenuity, but I have the confidence that we can adapt. What do you think?

By Mayra Sofia Crespo Bellido

“I drink tea of guanábana leaves when I can’t make it to my chemotherapy sessions. Did you know Miss, that eating guanábana is just as good as 10 chemotherapy sessions?” I was shocked when a patient shared this piece of information with me during a nutritional assessment interview. Luckily, my preceptor stepped in and educated the patient and his spouse on the risks of completely substituting traditional medicine with alternative treatments that are not evidence-based. He argued with my professor. In that moment it sunk in how dangerous health illiteracy can be.

Health literacy has been defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” It involves different factors such as: health knowledge, listening, speaking, arithmetical, writing, and reading skills, and cultural competencies of health professionals as well as other systemic factors.

According to the National Center for Education Statistics, nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease. Nearly 14% of adults (30 million people) have ‘below basic’ health literacy. These adults were more likely to report their health as poor (42%) and are more likely to lack health insurance (28%) than adults with Proficient health literacy. These patients are more likely not to vocalize their concerns and questions as well as being less active participants in their care because of the stigma associated with being health illiterate. Being health illiterate is a stronger predictor of health than socioeconomic status, education, ethnicity, or race.

Nutrition professionals in all areas face health illiteracy on a day-to-day basis. During my dietetic internship training, I have a difficult time gathering accurate information from patients during the nutritional assessment in the clinical setting, particularly when assigned a high patient load. That initial interaction may be somewhat compromised by the fact that most patients do not know how to express nutritional concerns and time is too constricted to dig deep into the answers provided. Same goes to other areas of practice: nutrition researchers dealing with tailoring informed consent forms to the level of health literacy of their population of interest or foodservice managers explaining to their employees the reasons to follow HACCP procedures to ensure food safety. Even public health nutrition professionals may face it while trying to advocate in favor of measures such as the taxation of sugar-sweetened beverages.

Healthy People 2020 includes the specific objective to increase health literacy under the topic of Health Communication and Health Information Technology. In this era health and nutrition information is produced and distributed by individuals and organizations with various agendas. It is critical that people have the skills to navigate this sea of information without feeling overwhelmed by nutrition confusion. Guiding people through this process and giving them strategies to find and understand accurate food and nutrition information could allow for a new sense of empowerment that could position dietitians, nutritionists and other nutrition professionals as the go-to source in these matters for people who have put their trust elsewhere to get the information.

The World Health Organization has determined improving health literacy has implications in a greater scope than individual decision-making processes with the following quote:
“[…] Health Literacy goes beyond a narrow concept of health education and individual behavior-oriented communication, and addresses the environmental, political and social factors that determine health. Health education, in this more comprehensive understanding, aims to influence not only individual lifestyle decisions, but also raises awareness of the determinants of health, and encourages individual and collective actions which may lead to a modification of these determinants. Health education is achieved therefore, through methods that go beyond information diffusion and entail interaction, participation and critical analysis. Such health education leads to health literacy, leading to personal and social benefit, such as by enabling effective community action, and by contributing to the development of social capital.”
Such an impact could guide the food and nutrition policy measures that are needed to ensure the population’s health by activism that intends to change social determinants of health. Wow!

There is a vast amount of literature in health literacy, yet there is still some room for improvement in the scope of practice. Public health and community nutrition professionals could make use of the health care system’s shift from acute care towards preventive care and health promotion to justify projects that improve basic health literacy skills. Helping people understand the purpose of health and nutrition behavior change, increasing self-efficacy and helping individuals make decisions accordingly is vital.

References
Department of Health and Human Services (US), Office of Disease Prevention and Health Promotion. Health literacy online: A guide to writing and designing easy-to-use health web sites.

Health Communication and Health Information Technology- https://www.healthypeople.gov/2020/topics-objectives/topic/health-communication-and-health-information-technology

Health literacy and health behaviour- https://www.who.int/healthpromotion/about/en/

Carbone E., Zoellener, J. (2012) Nutrition and Health Literacy: A Systematic Review to Inform Nutrition Research and Practice. J Acad Nutr Diet. doi: 10.1016/j.jada.2011.08.042

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 Joyanna Hansen

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

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

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

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

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

References
1.    What is the meaning of ‘natural’ on the label of food? FDA.gov. Retrieved Feb. 7, 2013 from https://www.fda.gov/AboutFDA/Transparency/Basics/ucm214868.htm.
2.    Crowley, L. (2008, July 8). HFCS is natural, says FDA in a letter. Foodnavigator-usa.com. Retrieved Feb. 7, 2013 from https://www.foodnavigator-usa.com/Business/HFCS-is-natural-says-FDA-in-a-letter
3.    Sifferlin, A. (2012, Nov. 7). California Fails to Pass GM Foods Labeling Initiative. TIME.com. Retrieved Feb. 8, 2013
4.    Meat and Poultry Labeling Terms (last modified April 12, 2011). USDA.gov. Retrieved Feb. 8, 2013 from https://www.fsis.usda.gov/FACTSheets/Meat_&_Poultry_Labeling_Terms/index.asp#14.
5.    National Organic Program (last modified Oct. 17, 2012). USA.gov. Retrieved Feb. 8, 2013.

By Sarah Ohlhorst, ASN Director of Government Relations

The White House recently issued a proclamation declaring September as National Childhood Obesity Awareness Month. ASN has served as a national partner of National Childhood Obesity Awareness since 2010, along with other organizations including America on the Move, American College of Sports Medicine, and HealthCorps. In July, the American Society for Nutrition (ASN) endorsed a resolution introduced by Representatives Marcia Fudge (D-OH) and Kay Granger (R-TX) re-designating the month of September as Childhood Obesity Awareness Month. Educational efforts and events are taking place throughout the entire month of September to bring national attention to the issue of childhood obesity. For example, Nickelodeon is planning a September 24 Worldwide Day of Play– a “blackout” day with zero television programming!

Obesity rates worldwide have doubled in the last three decades, according to a number of articles recently published in The Lancet as part of an obesity series. Globally, an estimated 170 million children under the age of 18 are overweight or obese. In some countries, this includes more than 25% of all children. In the U.S., approximately 17% (or 12.5 million) of children and adolescents aged 2—19 years are obese. Being overweight or obese as a child increases the risk of developing additional diseases such as heart disease, hypertension, and type 2 diabetes and increases the likelihood of becoming an overweight or obese adult. The hospital costs associated with childhood obesity alone were estimated at $237.6 million in 2005.

ASN supports research to elucidate the etiology of childhood obesity, which is a multifactorial epidemic affecting the majority of Americans. Through translational research, ASN members are working to understand how obesity develops and negatively impacts the health of individuals. With this basic knowledge, they are developing and evaluating strategies to prevent obesity in individuals, to aid and maintain weight loss, and to identify and advocate for environmental and policy changes that best support a healthy weight in the U.S. population.

“ASN has increased our focus on the issue of obesity as its impact becomes more and more widespread, including establishing an Obesity Working Group with members who are leading obesity researchers to develop an obesity platform” said ASN Executive Officer John Courtney, PhD. “It is vital that NIH and USDA receive the funding they need so our scientists can continue their research into childhood obesity, it causes, and how to lessen its negative impact.”

Do your part to support National Childhood Obesity Month – help encourage healthy behaviors like regular exercise and good nutrition in your own city or state this month and throughout the year!