Does Breastfeeding Make You Smarter?

Good nutrition has been shown to help with survival, growth, mental development, health, and well-being across one’s lifespan. Unearthing precisely what to eat to help achieve maximal benefit has been the subject of many research studies and debates, especially regarding childhood nutrition starting at an early age.

Breastfeeding has been recognized for its ability to provide infants with essential nutrients to help with growth and development. Research has shown there are many benefits associated with breastfeeding, such as building a healthy gut microbiota and increasing the bond between mother and child. The child benefits from the nutrients found in breast milk, such as docosahexaenoic acid (DHA) and arachidonic acid, omega-3 and -6 fatty acids essential for cognitive development. Somewhere down the line the notion that breastfeeding can make your baby smarter has been perpetuated. However, this has not yet been proven.

Researchers from the University College Dublin in Ireland conducted a study to investigate the impact of breastfeeding on children’s cognitive development. Around 8,000 families from the Growing Up in Ireland longitudinal infant cohort were randomly selected to participate. Data was collected when the child was 9 months old, 3 years old, and 5 years old. Questionnaires were used to measure children’s cognitive abilities, expressive vocabulary, and problem behaviors, and breastfeeding data was collected as retrospective self-report from the mothers. Propensity score matching, instrument variables, and sibling pair models were used for the analysis. The “breastfed” and “never breastfed” groups were matched based on infant, mother, and family-level factors, such as birth weight and maternal age.

Children who were breastfed scored higher on the problem-solving scale. However, after adjusting for potential confounders, this result was found to be no longer significant. This means other factors, such as socioeconomic status, could better explain the variability here. Breastfed children had lower parent-rated hyperactivity compared with controls after the adjustment, but this effect was only seen at 3 years of age. This may mean that breastfeeding helps reduce hyperactivity in the short term, but this effect was not maintained. Although the researchers found no evidence to support that breastfeeding helps improve cognitive abilities, they did note that their study did not contradict any of the medical benefits of breastfeeding. Research on breastfeeding will continue to be done and hopefully we will see more positive findings emerge in this area. For now, the current World Health Organization recommendation for breastfeeding is to exclusively breastfeed for the first 6 months of a child’s life, if you are able.

 

References:

Girard L, Doyle O, Tremblay RE. Breastfeeding, Cognitive and Noncognitive Development in Early Childhood: A Population Study. Pediatrics. 2017;139(4):e20161848. doi:10.1542/peds.2016-1848

By Chris Radlicz

This past October, the International Agency for Research on Cancer (IARC), the cancer agency of the World Health Organization (WHO), made headlines when they classified processed meat as a Group 1 carcinogen. This classification was based on “sufficient evidence in humans that the consumption of processed meats causes colorectal cancer”. Additionally, red meat has been classified as a Group 2A carcinogen due to “limited evidence that consumption of red meat causes cancer in humans and strong mechanistic evidence supporting a carcinogenic effect” [1]. These IARC statements advocating a limited intake of processed and red meats tend to be misconstrued by the public and many may take it to mean that all meat should be avoided. Besides the inherent benefits of protein and various micronutrients in meat, red meat is primarily trumpeted as the best source of heme-iron in the diet. With iron deficiency as the most common nutritional disorder in the world [2], limiting red meat may not be prudent advice. What, therefore, is unique to red meat and processed meats which explains their carcinogenic potential?

What gives meat a bad rap is not inherent in the animal muscle itself, but rather the preservatives added to meats and the cooking processes which meats undergo. So what can be done to mitigate and avoid the proposed cancerous effects of some meats? Below are some practical tips to be conscious of and implement when meat shopping and preparing meats so that consumers can take full advantage of the nourishment from meats while limiting any risk

  • 1. Cook with Moist Heat: The Journal of the American Dietetic Association in a 2010 article, showed that cooking with dry heat promoted a 10 to 100-fold increase in advanced glycation end products (AGEs). AGEs increase oxidative stress and inflammation, and have shown to be a player in the pathogenesis of many chronic diseases. Cooking with moist heat, at low temperatures, and shorter cooking times have all been shown to reduce AGE formation [3]. Cooking meat in stews and sauces at low temperatures for longer periods of time, typical of crock-pot style cooking, is an effective way to reduce formation of these questionable AGEs.
  • 2. Avoid Charring Meats: Cooking meat at high temperatures, typically on a grill or skillet, can lead to browning or charring. This browning is known to occur as a result of the Maillard reaction which has been shown to produce heterocyclic amines (HCAs), and polycyclic aromatic hydrocarbons (PAHs). PAHs form when fat from grilled meat is ignited, causing flames containing these PAHs, which can then adhere to the meat’s surface. HCAs are formed from amino acids, sugars, and creatine reacting at high temperatures. These chemicals have been shown to be mutagenic to DNA after consumption and digestion, leading to genetic instability and increased risk of cancer [4]. Cooking meats at higher temperatures and for long periods of time will lead to increased HCAs, while smoking and charring will result in more PAH formation. No Federal guidelines exist addressing PAH and HCA consumption, but these chemicals provide a mechanism as to meats carcinogenic capacity. With this in mind, the National Cancer Institute suggests that concerned individuals should turn meat over frequently when cooking, use a microwave first to shorten high temperature cooking time, remove charred portions of meat, and refrain from using gravy made from meat drippings as ways to reduce PAH and HCA exposure [5].
  • 3. Purchase Nitrate-Free and Uncured Meats: Nitrates and nitrites added as preservatives to meat have been shown to convert to activated N-nitroso compounds (nitrosamines and nitrosamides) in the gut, and are proposed to be carcinogenic due to their ability to cause DNA damage [6]. N-nitroso compound formation can also be increased with the intake of red meat, principally due to interactions with the heme-iron [7].
  • 4. Purchase Meat that isn’t Smoked: Smoked meats fall under the category of processed meats. Epidemiological studies, have shown a correlation between cancer of the intestinal tract and the frequency of dietary intake of smoked foods [8]. More convincingly, the smoking process forms N-nitroso compounds and inevitably contain high levels of PHAs.
  • 5. Purchase Antibiotic-Free Meat– Some antibiotics and pesticides in meats can react with nitrite to form nitrosamines in high quantities [9]. Additionally, there is much worry that the antibiotic use in agriculture is contributing to the growing prevalence of antibiotic resistance, and in a more minor capacity, to the obesity epidemic [10,11]

Bibliography

[1]       WHO | Q&A on the carcinogenicity of the consumption of red meat and processed meat

[2]       Liu K, Kaffes AJ. Iron deficiency anaemia: a review of diagnosis, investigation and management. Eur J Gastroenterol Hepatol 2012;24:109–16. doi:10.1097/MEG.0b013e32834f3140.

[3]       Uribarri J, Woodruff S, Goodman S, Cai W, Chen X, Pyzik R, et al. Advanced glycation end products in foods and a practical guide to their reduction in the diet. J Am Diet Assoc 2010;110:911–6.e12. doi:10.1016/j.jada.2010.03.018.

[4]       Cross AJ, Sinha R. Meat-related mutagens/carcinogens in the etiology of colorectal cancer. Environ Mol Mutagen 2004;44:44–55. doi:10.1002/em.20030.

[5]       Knize MG, Felton JS. Formation and human risk of carcinogenic heterocyclic amines formed from natural precursors in meat. Nutr Rev 2005;63:158–65.

[6]       You C, Wang J, Dai X, Wang Y. Transcriptional inhibition and mutagenesis induced by N-nitroso compound-derived carboxymethylated thymidine adducts in DNA. Nucleic Acids Res 2015;43:1012–8. doi:10.1093/nar/gku1391.

[7]       Rohrmann S, Linseisen J. Processed meat: the real villain? Proc Nutr Soc 2015:1–9. doi:10.1017/S0029665115004255.

[8]       Fritz W, Soós K. Smoked food and cancer. Bibl Nutr Dieta 1980:57–64.

[9]       Elespuru RK, Lijinsky W. The formation of carcinogenic nitroso compounds from nitrite and some types of agricultural chemicals. Food Cosmet Toxicol 1973;11:807–17.

[10]     Cox LM, Blaser MJ. Antibiotics in early life and obesity. Nat Rev Endocrinol 2015;11:182–90. doi:10.1038/nrendo.2014.210.

[11]     Chang Q, Wang W, Regev-Yochay G, Lipsitch M, Hanage WP. Antibiotics in agriculture and the risk to human health: how worried should we be? Evol Appl 2015;8:240–7. doi:10.1111/eva.12185.

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 https://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: https://nutritioninmedicine.org/

7.Bipartisan Policy Center. New Effort Launch to Train Health Professionals in Nutrition and Physical Activity. https://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

A symposium called Biology of Linear Growth on Tuesday examined linear growth from the molecular to the population level, bringing perspectives from biology, physical anthropology, nutrition, and epidemiology

Are you familiar with the process of endochondral ossification? Julian Lui, MD PhD explained that this is the process that results in linear growth. It takes place in the growth plates, at the end of long bones such as the femur, and is subject to systemic regulation by endocrine, nutritional, and inflammatory cytokine factors as well as local regulation by paracrine factors and other cellular mechanisms. Malnourished children have lower levels of hormones like insulin-like growth factor 1 (IGF-1) and estrogen, as well as increased levels of glucocorticoids, leading to decreased linear growth. Dr. Liu explained that this allows the body to conserve resources and that, in situations of food insecurity, “Growth is something of a luxury that can be postponed until better times.”

Rather than growing continuously, children grow in saltations, meaning that – as many a parent has observed – a child may grow substantially overnight and then not at all for a number of days afterwards. Michelle Lampl, MD PhD stated that as children age, these saltations become less and less frequent, with older children growing much less often than infants. The amount and frequency of these growth saltations can be affected by environmental factors, which can interact with cellular effects. Maternal smoking, for example, has a well-documented inhibitory effect on growth, as does maternal alcohol consumption and stress.

Since linear growth happens most rapidly in early life, the first 1,000 days from conception to two years of age are considered a critical period. Parul Christian, DrPH presented results from a meta-analysis analyzing various maternal and child nutrition interventions targeting this 1,000-day window. Starting during pregnancy, balanced protein-energy, iron-folic acid, and multiple micronutrient supplementation were all found to increase birth weight. However, maternal supplementation during pregnancy was not associated with any long-term linear growth in children under five years old. For infants and young children, nutrition promotion and food supplementation showed promise as interventions with positive impacts on child height.

In the final talk of the symposium, Aryeh Stein, PhD addressed the question of linear catch-up growth: for those children whose growth has been suppressed by malnutrition, is it possible to catch up on missed growth, even after the first 1,000 days? A number of studies have provided different nutrients and foods to children ages two and older. Dr. Stein presented results from studies of protein, zinc, iron, iodine, calcium, multiple micronutrients, and food. Protein and some of the micronutrients may have promise, but several of the calcium studies reported negative effects, while food had no association with growth.

The symposium made it clear that nutrition has an important role to play in stimulating or inhibiting linear growth. However, a great deal remains to be learned about these complex biological processes and the most effective interventions to promote children’s optimal growth.

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

By: Sheela Sinharoy, MPH

A symposium titled Program Effectiveness for Addressing Undernutrition during the First 1,000 Days provided attendees with examples of programs in Bangladesh, Guatemala, and Burundi.

In Bangladesh, the Rang-Din Nutrition Study tested lipid-based nutrient supplements (LNS) in a community-based program. According to presenter Kay Dewey, the study found that giving LNS to mothers prenatally reduced the prevalence of stunting and increased the birth weight, head circumference, and body mass index (BMI) in infants at birth. LNS and multiple micronutrient powders (MNP) for children were also associated with better developmental and cognitive outcomes. Dr. Dewey noted that the impact on child anthropometry was much larger in food insecure households, so future programs may want to target based on this and other criteria.

Moving from Asia to Africa, Marie Ruel presented results from an impact evaluation of a food-assisted integrated health and nutrition program in Burundi. The program gave food rations to mothers and children and also provided behavior change communication. Interestingly, the nutrition situation in Burundi deteriorated sharply during the program period, but decreases were less severe in the treatment groups. For example, while the prevalence of stunting increased dramatically in the control group, the prevalence in the treatment group remained essentially flat. Thus, although the treatment group did not improve, the results suggest that the intervention protected families who otherwise would have been vulnerable to economic shocks.

Guatemala is another country with a very high prevalence of chronic undernutrition, and Deanna Olney presented results from a study of a similar food assistance program. The impact of the program was greatest among those who received a full family food ration plus an individual ration of corn-soy blend. In these households, mothers had significantly higher mean BMIs, children had a lower prevalence of stunting, and both mothers and children had a lower prevalence of anemia. However, there were no significant impacts on child underweight, wasting, or language or motor development.

The differing impacts of various programs was the impetus for a talk by Per Ashorn, who discussed pathways of impact for fetal growth, linear growth, and cognitive function. He explained that the pathways for linear, ponderal, and head growth are partially different, and there are possibly partially different pathways to childhood length gain and brain function. This suggests a need for multipronged interventions targeting pathways including infection, nutrition, and inflammation, as well as a variety of outcome measures to assess the interventions’ impact.

Of course, cost is an important – and often challenging – issue when planning interventions. The final talk of the symposium was given by Steve Vosti, who explained that programs must balance need, acceptability, use, and both short-term and persistent demand in order to achieve impact. These and many other factors, such as the costs of manufacturing supplements in country and the proportion of locally available ingredients being used, can affect the cost of an intervention. In addition to deciding on the most appropriate intervention to meet a need, practitioners must take these factors into account when planning their programs.

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 Emily Roberts

The American Cafeteria

The quality, cost and nutritional adequacy of school lunches have been an ongoing hot bed for debate in our country. The National School Lunch Program has been enact since 1946 and provides lunches to many children of the public school system in the United States (1). The Healthy, Hunger-Free Kids Act of 2010 called for a revision of school meals to meet new nutritional standards that adhere to the 2010 Dietary Guidelines for Americans (2). However these changes have caused some upset including increased cost and waste. As we struggle to perfect the American school lunch, it is helpful to observe how other countries are managing their school lunch programs. My current position as a primary teacher in France gives me the opportunity to witness how the French tackle lunchtime

La Cantine FranÇaise

La cantine, French for the cafeteria, is where children enjoy their lunches if they choose not to return home for the two-hour break. From 11:45am to 1:45pm public schools in France have lunchtime, a time to eat, learn and relax. If the students choose to stay at school for their meal, they often have a wide selection of foods throughout the month from mutton stew, roasted chicken and veal, always paired with a meatless option. Accompanying the main dish is a fruit, vegetable and of course cheese. Throughout the month there are regional recipes capitalizing on local favorites as well as resources.

What’s on the menu?

Montpellier, France Public Elementary Schools

Tuesday March 29th, 2016

A Regional Recipe

Pomelos au sucre grapefruit with sugar

Gardianne de taureau bull meat with onions and carrots

Riz de Camargue long grain rice

Leerdamer cheese

Chocolat de Pâques Easter chocolate

Repas sans viande: flageolets

Meatless recipe: flageolets, a type of legume

Origine de la gardianne de taureau: nÉ, ÉlevÉ et abattu en Franc

Meat Origin: Born, raised and slaughtered in France

—————–

Baltimore County, Maryland Public Elementary Schools

Wednesday March 23rd, 2016

Chicken Nuggets

Grilled Cheese Sandwich

Yogurt Box (including yogurt, string cheese, granola clusters, fruit, vegetables and milk)

Green Beans

Carrot Sticks

Peaches

Meatless option is only offered on Monday


There is no national program in France that helps provide public school lunches assuring that all meals meet certain standards. Rather the menus are developed, reviewed and prepared by each region. Montpellier, France is a general representation of the school lunches in France.

The development and review

A technical team creates the menus that are then reviewed by two certified dietitians (3). The dieticians ensure the meals provide the necessary nutrients for each corresponding age group. They also take into account specific preferences of children. The dieticians will often intervene during lunchtime as well to explain the meals and educate the students on healthy eating.

The preparation

Before preparing the food, there is a careful selection process for products by Quality Assurance. They must be tasted and closely examined to ensure all ingredients meet criteria (such as absence of GMO’s, proper nutritional content and the least additives as possible). They conduct visits to schools to verify proper adherence to the quality guidelines (3,4). Similar to the Unites States, there are strict regulations for the storage, cooking and serving of food to ensure safety.

The price

It ranges from 1€ – 5€ per child depending on the amount of children in each family and the meals consumed (4). This is comparable to the US Average of $2.18 per meal in Elementary Schools (5)

My views

My memories of school bought lunches include pizza, mozzarella sticks, fruit cups and the ice cream cart. Given the limited options I was always a packer. Needless to say I was amazed by the variety, quality and importance of school lunches in France. This local approach to school meal management allows them to utilize local resources and allocate more attention to the nutrition, quality and preference of meals.

USA A school lunch in an elementary school in Maryland with two mini cheeseburgers, applesauce, French fries, broccoli and chocolate milk.

France A school meal I ate at la cantine in a small town outside of Montpellier. A green salad with a light oil dressing, a plain egg omelet, sautÉed carrots, fresh bread, an apple and a piece of almond cake. The omelet was a little boring, but overall a satisfactory lunch.

https://www.fns.usda.gov/nslp/national-school-lunch-program-nslp

tp://www.fns.usda.gov/school-meals/nutrition-standards-school-meals

. Guide de la Restauration Scolaire, Ville de Montpellier

https://www.montpellier.fr/689-cantine-ligne-ecoles-de-montpellier.htm

https://schoolnutrition.org/AboutSchoolMeals/SchoolMealTrendsStats/#4

https://www.nejm.org/doi/full/10.1056/NEJMp1409353

Full March and April Menu

https://www.bcps.org/offices/OFNS/menus/Elementary-Lunch-Menu.pdf

By: Mary Scourboutakos

Neural tube defects are a type of birth defect—affecting the brain, spine or spinal cord—that result from suboptimal folate status.
Folate is a B vitamin that’s naturally found in legumes (like chickpeas, lentils, pinto and kidney beans), seeds, leafy greens (like spinach, collard greens and romaine lettuce) and other vegetables such as asparagus, brussels sprouts and broccoli.

The problem is, people don’t eat enough of these foods. As a result, for many years, pregnant women were at risk for folate deficiency and hence, neural tube defects.

Prenatal supplements were the original solution to this problem as one of their prime ingredients is folic acid, the synthetic form of folate. However, they’re not a fool proof solution because neural tube defects form within four weeks of conception, often before women know they’re pregnant, and thus, before they start taking their supplements.

As a result, in the late 1990s folic acid was mandatorily added to white flour and enriched grain products to ensure that pregnant women would get enough folate, irrespective of whether they take a supplement.

Problem solved? Sort of…

Back in the early 1990s when discussions regarding the addition of folic acid to the food supply were taking place, it was suggested that after fortification was implemented, the dose of folic acid in prenatal supplements should be revised to prevent excessive intakes. The new problem is…the doses were never revised.

Currently, marketed prenatal supplements usually contain 1000 micrograms of folic acid, which is the daily upper limit for folic acid. Meanwhile, it’s recommended that pregnant women should consume about 400 micrograms of folic acid per day for neural tube defect prevention.

With mandatory fortification, three-quarters of a cup of cereal can provide greater than 400 micrograms of folic acid. So if you add a prenatal supplement to a bowl of cereal at breakfast, some bread at lunch, and pasta for dinner, you’re consuming a lot of folic acid!

According to Dr. Deborah O’Connor, a Professor from the University of Toronto who has spent decades studying folate and infant health, this could be a problem. She explained that in animal models, it has been shown that folate can make changes to the genes that are transcribed during development. And while similar data have not been done on humans, she said “if you’re not getting any benefit from those high levels, it would be prudent to cut back given the current status…(because) if there’s no benefit, there’s only a risk.”

From a regulatory point-of-view, she says there’s nothing stopping the industry from changing the amount of folic acid in the supplements. She suggested that the industry’s reluctance to modify the dose in prenatal supplements is probably due to inertia and the fact that “with nutrition you’re always fighting against the more is better philosophy.”

In the meantime, what should women do? In their 2015 clinical practice guidelines, the Society of Obstetrics and Gynecologists recommended a multivitamin containing 400 to 1000 micrograms of folic acid. But currently, there are no prenatal vitamins available with less than 1000. Hence, Dr. O’Connor’s recommendation is “do not use the prenatal, just use a regular multi-vitamin and maybe add a little iron.” Furthermore, she added “care must be taken to ensure vitamin A intakes do not exceed 3,000 mcg retinol activity equivalents (RAE) or 10,000 IU during pregnancy.”

Alas, it’s a classic story, you try to fix one problem, but in doing so, you create another. Hopefully prenatal supplements will be adjusted soon, but in the meantime, prudent folic acid intakes are probably a good idea.

By: Hassan S Dashti, PhD

The most popular New Years resolution by far is weight loss. People kick-start their new year on new ‘detox’ or fad diets with hopes to lose some weight or, less commonly, to adopt a healthy lifestyle, only to quit a few months later. Traffic to websites like caloriecounter.com and weightwaterchers.com hits an all time high in January! (1) People often envision January 1 of every year as an empowering and motivating moment that enables them to consider making these daring lifestyle changes. People might be less inclined to make these commitments on arbitrary dates like March 1 or October 19. With emerging evidence suggesting seasonal changes in the environment and human physiology, driven primarily by seasonal changes in sunlight and temperature, is it possible that certain start dates or seasons are more conducive to successful weight loss?

Seasonal variations have been observed for numerous communicable and non-communicable diseases (2) and both biological and behavioral traits. One of the earliest observations of seasonal variation in a disease was that of rickets, a disease resulting from vitamin D deficiency (3). Clinical observations indicated that rickets was common in spring, but rare in fall. The subsequent finding of seasonal variation in plasma 25(OH)D levels suggested that summer sunlight exposure was indeed an important determinant of vitamin D status. For more complex traits, like obesity, the seasonal etiology, if present, is likely to be multifactorial!

Successful weight loss is largely determined by the ability to reduce overall caloric intake, which depends on food availability and internal hunger cues. Living at a time where food is essentially abundant year-round in the Western world, people are typically not dealing with food shortages. For most processed foods, seasonal price variability is also absent, particularly in metropolitan areas, so people’s intakes are likely to be homogenous year-round (4,5). However, seasonal price variability of nutrient dense fruits and vegetables may limit a person’s likelihood to adhere to diets higher in fruits and vegetables. For example, strawberry prices tend to decrease through the first four months of the year and rise again from September to December. Fresh apples, on the other hand, have a fairly weak seasonal price pattern as a result of new apple varieties with later harvest dates and sophisticated storage technology. But it seems that despite the constant supply of most foods at steady prices, seasonal variation in dietary intake may exist. In the Framingham Heart Study, for example, self-reported total energy intake was 86 kcal/day higher during the fall than in the spring (6). Also, percentage of calories from carbohydrate, fat and saturated fat showed slight seasonal variation, with a peak in the spring for carbohydrate and in the fall for total fat and saturated fat intake. Of course these differences may be due to seasonal differences in self-reporting and recall, but if it’s true, is weight loss in the spring more successful than the fall?

Another important aspect of weight loss to consider is seasonal variability in energy expenditure.

The investigation from the Framingham Heart Study (6) also observed seasonal variation in physical activity, including common activities such as gardening, carpentry, lawn mowing, golf and running for men, and gardening, swimming, health club exercise, dancing and bicycling for women. Not surprisingly, people residing in the Northeast are less inclined to engage in outdoor physical activity. This sedentary lifestyle in the winter may partly explain the reason why people tend to be the heavier in the winter! (7)

Newer studies are investigating more complex physiologic changes that might interfere with energy balance. Recent observations in humans suggest that cold exposure may induce the conversion of white adipose tissue to more metabolically active brown-like adipose tissue (8). This ‘beiging’ effect of cold exposure could potentially have clinical implications for diabetes and obesity. Other studies have observed seasonal variability in metabolism and epigenetics as well (9,10). Whether these physiologic differences can override energy imbalance resulting from seasonal lifestyle differences is currently unknown.

To test whether there are seasonal differences in weight loss success we’d ideally test this in a randomized and controlled weight loss trial whereby people are prescribed hypocaloric diets and assigned random start dates. This can also be investigated analytically in previously conducted weight loss cohorts. Various methodologies are available for the assessment of seasonality and those range from simple comparisons across seasons, to simple models such as fitting monthly counts to a sine curve, or more complex statistical models (2).

Despite the little evidence we have so far relating seasonality and energy balance, healthcare providers, including nutritionists, should account for seasonality in their practice, and tailor their dietary (food and fluids) and physical activity recommendations accordingly – it’d be senseless to recommend berries when they are unavailable at stores or outdoor exercise when it’s uncomfortably warm! But perhaps reaching that point of enthusiasm for weight loss is the most important factor predicting weight loss success, so if January 1 is that date when motivation hits in, then so be it!

References:

2.Christiansen CF, Pedersen L, Sørensen HT, Rothman KJ. Methods to assess seasonal effects in epidemiological studies of infectious diseases–exemplified by application to the occurrence of meningococcal disease. Clin Microbiol Infect. 2012 Oct;18(10):963–9.
3.Stamp TC, Round JM. Seasonal changes in human plasma levels of 25-hydroxyvitamin D. Nature. 1974 Feb 22;247(5442):563–5.
4.Evolving U.S. Fruit Markets and Seasonal Grower Price Patterns, by Kristy Plattner, Agnes Perez, and Suzanne Thornsbury, USDA, Economic Research Service, September 2014
5.Bernstein S, Zambell K, Amar MJ, Arango C, Kelley RC, Miszewski SG, et al. Dietary Intake Patterns Are Consistent Across Seasons in a Cohort of Healthy Adults in a Metropolitan Population. J Acad Nutr Diet. 2016 Jan;116(1):38–45.
6.Ma Y, Olendzki BC, Li W, Hafner AR, Chiriboga D, Hebert JR, et al. Seasonal variation in food intake, physical activity, and body weight in a predominantly overweight population. Eur J Clin Nutr. 2006 Apr;60(4):519–28.
7.Visscher TLS, Seidell JC. Time trends (1993-1997) and seasonal variation in body mass index and waist circumference in the Netherlands. Int J Obes Relat Metab Disord. 2004 Oct;28(10):1309–16.
8.Iyengar P, Scherer PE. Obesity: Slim without the gym – the magic of chilling out. Nat Rev Endocrinol. 2016 Feb 26.
9.van Ooijen AMJ, van Marken Lichtenbelt WD, van Steenhoven AA, Westerterp KR. Seasonal changes in metabolic and temperature responses to cold air in humans. Physiol Behav. 2004 Sep 15;82(2-3):545–53.
10.Aslibekyan S, Dashti HS, Tanaka T, Sha J, Ferrucci L, Zhi D, et al. PRKCZ methylation is associated with sunlight exposure in a North American but not a Mediterranean population. Chronobiol Int. 2014 Jul 30;:1–7.

By: Emma Partridge

American consumers are undoubtedly moving toward natural foods. An analysis by Datassential of consumer foodservice issue concerns may explain some factors in this overall trend; consumers appeared most concerned with antibiotics and steroids in animal proteins and/or dairy products, local food sources and manufacturers surviving, and GMOs, among other issues.1 Fortune magazine calls it “the war on big food” – but are consumers benefitting from more than just those ‘left out’ factors?2 I had the chance to sit down with Dr. Mario Kratz, researcher at the Fred Hutchinson Cancer Research Center, core faculty member of the University of Washington (UW), and Associate Director of the UW Diabetes Research Center, to discuss a few of these food trends and what their intrinsic health benefits might be.

One trend of note is the move toward full-fat dairy products. Whole milk sales rose 11% in the first half of 2015 alongside a 14% fall in skim milk purchases.3 While many speculate this shift is in line with movement toward wholesome, unprocessed foods, there are unrecognized benefits to full-fat dairy beyond its less-processed nature. Full-fat dairy may increase satiety, or lead a person to feel more full than if (s)he ate a low-fat dairy product. In evaluations of 16 dairy fat studies, Dr. Kratz’s team found that, of studies comparing high-fat dairy to low-fat dairy, high-fat dairy intake was actually associated with better weight outcomes, and was not associated with higher weight. Further, 11 of the 16 studies revealed that people who ate more dairy fat or high-fat dairy foods tended to be leaner and/or gain less weight over time than those who ate less dairy fat.4 The results from these analyses make a case for full-fat dairy as a protectant against weight gain, potentially due to increased satiety response. Additionally, there are other fatty acids present in full-fat dairy that can act as hormones, and small amounts of these fatty acids may be beneficial. The scientific reasoning behind the presence of many fatty acids supports full-fat dairy and, on the other side of that coin, there is no data supporting healthful benefits from consuming non-fat, low-fat, or isolated-fat dairy products in which many of the fatty acids have been removed.5

Another food trend of note over the past few years is that of coconut oil. While part of the trend may be attributable to its non-cooking uses, coconut oil is also highly heat resistant, has a long shelf life, and is rich in medium chain saturated fatty acids (MCFAs). The heat-stability of coconut oil is beneficial to reducing intake of harmful free radicals, but MCFAs may be the most significant of coconut oil’s intrinsic health benefits. In a study comparing long chain fatty acids, generally purported to be less-healthy fatty acids, to MCFAs, researchers found MCFA-treated mice exhibited increased energy expenditure, reduced adiposity, and improved insulin sensitivity.6 It is possible, then, that consumers following the coconut oil trend may be reaping such metabolic health benefits.

Perhaps the most significant trend to watch is that of developing healthy, lifestyle-based eating patterns, which is recommended by the 2015 Dietary Guidelines Advisory Committee in the recently-released 2015-2020 Dietary Guidelines for Americans. In a media-driven world of shoulds and should-nots, the Dietary Guidelines Advisory Committee took a different approach with this year’s release: develop patterns of healthy eating and physical activity within the environment around you. Dr. Kratz argues something similar, that pattern matters and a varied eating pattern may allow for small amounts of cravings and diet-breakers, thusly providing a method to control them.5 In short, his “number one” advice point is, “in spite of whatever craze you may be following right now…if you find something new, you should find a way to incorporate it into your overall diverse diet.”

1.Webster M. Changing Consumer Behaviors and Attitudes. Culinary Institute of America; 2015.
2.Kowitt B. Special report: the war on big food. Fortune 2015.
3.O’Connor A. Consumers Are Embracing Full-Fat Foods. The New York Times 2015.
4.bottomlinehealth.com. Why Whole Milk May Be Better Than Skim. Bottom Line Health 2014.
5.Mario Kratz P, MS. In: Emma Partridge MC, ed2016.
6.Montgomery MK, Osborne B, Brown SHJ, et al. Contrasting metabolic effects of medium- versus long-chain fatty acids in skeletal muscle. Journal of Lipid Research. 2013;54(12):3322-3333.