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Path to Policy: Interview with Angela Tagtow, Executive Director of the Center for Nutrition Policy

Student Blogger
By: R. Alex Coots

The below interview is a continuation of an interview with Angela Tagtow, Executive Director of the Center for Nutrition Policy and Promotion at the USDA. Part 1 of this interview can be found here.

Tell me about the challenges of nutrition policy.

I imagine health policy falling into one of two categories, little-p policy (LPP) or big-p policy (BPP). LPP is a socioecological approach to policy, using individuals and organizations to make decisions to improve public health that don't require an elected official. BPP requires elected officials to create broader, more top-down initiatives to improve public health. Both types of policy working in concert can create greater collective impact.

Many people see BPP as the primary driver of policy, but LPP can be very effective to improve community health. The Northeast Iowa Food and Fitness Initiative exemplifies the power of LPP. Through the initiative they recruited hundreds of community stakeholders to make commitments to improve public health whether that is at home, school, workplace or throughout the community. Starting the initiative was a slow process built on networking and strengthening relationships, but proved to make an impact in the lives of community members.

BPP also creates change, but has its own challenges. It can take several years for State or Federal programs to be fully implemented. For example, the Healthy Hunger-Free Kids Act was signed into law back in 2010, and we're still seeing elements roll out. At the Federal level, Congress is another aspect that makes BPP challenging. Each Congressperson has a different perspective and set of values with respect to healthy food access, nutrition, public health. The ability to recognize their priorities and influencers is an important part of building support behind an initiative. 

Given the number of different opinions and interests regarding public health, do you think there's a way to make everyone happy?

There's always going to be struggle. Every organization out there has a set of goals that are different from the next organization. Industry has an interest to protect its products and public health has an interest to keep people healthy. These goals are not always aligned, so there are challenges.

The media often reports on about industry trying to make changes to their offerings in the name of public health. Do you think these efforts are genuine?

Not all industry should be discounted. Some companies do consider how their products and services contribute to public health and are trying to make a difference. But for others, they need to evaluate whether they are doing all that they could be doing.

What are some of the future goals for the USDA and the CNPP?

The CNPP does much more than just produce the Dietary Guidelines for Americans (DGA) and the iconic MyPlate. The Nutrition Evidence Library, a very rigorous review of the literature that directly informs the DGA. The CNPP also makes many tools and online resources available to assist individuals with eating and physical activity goals. ChooseMyPlate.gov and Supertracker.usda.gov are dynamic online resources for individual, families and professionals that put the Dietary Guidelines for Americans into action.

In the near term, the launch of the 2015 Dietary Guidelines for Americans and the Healthy Hunger-Free Kids Act are the top priorities. Some policymakers are challenging the validity of improving child health, and the House and Senate have inserted language in appropriation bills that will restrict USDA and HHS's  abilities to create the Dietary Guidelines. It's a very interesting political time regarding advancing the nutritional health of Americans.

Do you have any final advice for students?

Yes, be engaged. Having a good grasp of the content knowledge and political processes are good, but having contacts and networks is just as important. Knowing key people who create change and understanding how to work with them will allow you to be more effective in your endeavors. We need more people to get engaged with nutrition and public health efforts.


Health Professionals Need More Nutrition Education. How Can We Deliver?

Student Blogger
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.


My Clinical Nutrition Internship Experience

Danielle Jordan

By Seth Morrison

My name is Seth Morrison, a final year medical student at the Medical School for International Health in Israel. I would like to share with you a taste of my experiences in the ASN's unique Clinical Nutrition Internship.

Clinical nutrition was never really on my radar as something I might become interested in until halfway through medical school. It was then that I attended the International Congress of Nutrition held in Granada, Spain, where I met some members of the ASN. Like most medical students, the nutrition content in my courses was only enough to whet my appetite. I never had a chance to really delve into nutrition in-depth so that I would feel comfortable counselling patients or speaking intelligently about it with colleagues. The ICN conference opened my eyes to the many different research branches of the nutrition sciences as well as public health nutrition. The global trends in the “double burden” of malnutrition (undernutrition and overnutrition) in developing countries began to worry me, and I started learning about the many efforts that are underway to intervene. All of this made me want to find an opportunity to supplement my nascent interest in nutrition, and see which career avenues exist. I would like to incorporate nutrition into my medical practice and possibly conduct public health nutrition interventions in resource-limited settings worldwide. That is when I discovered this clinical nutrition internship.

I think my internship was an unparalleled opportunity for a medical student to get an insider's look into the fascinating world of clinical nutrition and nutrition science. The variety of opportunities I had at the University of Colorado and Children's Hospital Colorado working with Dr. Nancy Krebs as my mentor gave me the ability to look at the role of nutrition in health from many different angles. I saw how important clinical nutrition is in the weekly outpatient clinics at Children's Hospital. There were two separate clinics for kids with either growth faltering or obesity. These clinics are where I spent a great deal of my time. Throughout that time, I gradually gleaned the beauty in which skilled nutrition practitioners were able to make a real difference in outcomes as a team. Other physicians in these clinics, along with the amazing nutritionists, nurses, and a clinical psychologist, each contributed to my education in unique ways. They taught me the decision-making process of how to decipher clues to the causes of very different clinical nutrition problems (i.e. overweight vs. underweight), whether they be organic, lifestyle-related, or sometimes, in the case of young children, family food-related behaviors. This created the immensely enjoyable opportunity to decipher solutions to these myriad problems with clinical judgement and a creativity that respects the patient's/family's abilities and interests. I like to say today that in order to provide effective dietary counselling to patients, each doctor should have a little bit of a nutritionist inside them. This skill is one of the greatest gifts that the internship provided me for my own toolbox of clinical skills.

A sampling of the other components of my internship that made it very well-rounded were a research project, visits to WIC clinics, family eating well classes, several journal clubs and special nutrition lectures every week, and even a few nutrition-related Grand Rounds on Friday afternoons. I also completed a research project, which was a small metabolomics study on the relative serum levels of acylcarnitines and branched-chain amino acids in lean vs. obese groups of pregnant Guatemalan women.

This research component of the internship added an essential ingredient to the overall experience. Not only did I get to work with a fantastic and knowledgeable basic science researcher on a project in a burgeoning field of nutrition science (metabolomics), I also gained new skills and refined others that are needed in any research project I may become involved with in the future. This academic component reinforced the ever-present need for an army of researchers to inform the nutritional counsel given to patients in clinical medicine.

Inpatient care in the University of Colorado Hospital especially gave me the chance to see how crucial proper nutrition is for pre- and post-operative patients, burn unit patients, and of course in critical care. The nutrition support physician and the knowledgeable dietitians there broadened my knowledge of TPN and other topics in critical care nutrition research. In doing so, the truth was ingrained in me that nutrition is dynamic and can, in different circumstances, be prevention, treatment, or even both. Whether a patient is acutely ill or on a path of long term lifestyle change to reach a healthy weight, nutrition is likely to play an important role in their success!

The ASN Clinical Nutrition Internship satiated a special hunger for this nutrition niche in my medical education. I could not be more grateful and proud to have been awarded this unique opportunity, and the memories from it will linger with me for the rest of my career. As a soon-to-be physician, I've now learned that nutrition is a bit like music. It's nice to listen to, but to really appreciate it, you must also learn to play some of your own notes.


Designing interventions to achieve impact

Danielle Jordan

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.


The complexity and mystery of linear growth

Danielle Jordan
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. 


The French Brown Bag

Student Blogger

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.

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

http://asn-cdn-remembers.s3.amazonaws.com/a8fe1a700c976459593309fc73e983d2.jpg

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.


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

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

3. Guide de la Restauration Scolaire, Ville de Montpellier

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

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

6. http://www.nejm.org/doi/full/10.1056/NEJMp1409353

7. Full March and April Menu

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


Influences on nutrition at the individual, household, and national level

Moira Holt
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.


Moving toward a holistic model of woman-centered antenatal care

Moira Holt

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

By: Sheela Sinharoy, MPH


Sunday began with a symposium titled, Delivering Nutrition Interventions to Women during Pregnancy: Beyond Individual Interventions to Comprehensive Antenatal Guidelines and Care. A series of speakers made clear that as antenatal care (ANC) models continue to evolve, there is plenty of room for improvement to provide a positive pregnancy experience for women and their families.

ANC is not meeting its potential. This was the conclusion of the first speaker, Erica Phillips. She discussed the model of focused ANC (FANC) recommended by the World Health Organization (WHO), which involves 75-80 tasks for an intake visit and 60-65 tasks for each follow-up. She explained that following these recommendations would require an estimated 30-40 minutes for a first visit and 20 minutes for a follow-up. Even when recommended tasks are completed, quality of care may still be low. Ms. Phillips stated that “where FANC has been adopted, success has been limited.”

Still, ANC can be an effective platform for breastfeeding promotion, according to the next speaker, Mduduzi Mbuya. He presented a case study from the Sanitation, Hygiene, Infant Nutrition Efficacy (SHINE) trial in Zimbabwe. The country faces a critical shortage of health workers, with only 9.8 skilled health workers per 10,000 people (as compared to a ratio of 117:10,000 in the USA). SHINE therefore engaged community-based village health workers and found that the prevalence of exclusive breastfeeding at six months of age increased from 23% to 68%. Dr. Mbuya attributed this result primarily to strong fidelity of implementation by village health workers.

Micronutrient supplementation is another important component of ANC, and Kate Dickin spoke about a trial of calcium supplementation in Kenya and Ethiopia. There, researchers found that women were motivated and willing to take calcium supplements as recommended and that most women sustained their adherence to the supplements through the six-week study period and said they would continue through the end of their pregnancies. Dr. Dickin attributed this largely to the intervention's behavior change communication strategy, which was based on extensive formative research and addressed context-specific motivators and barriers.

Next, Catharine Taylor spoke about the way forward and the need for integrated, women-centered models of care. She said that ANC models should take the local context into account; have all goods and personnel in same physical space; provide clear and consistent guidelines, training and supervision to health workers; provide demonstrations and encourage active engagement and discussion; provide incentives and support; and implement women-held records and integrated health registers. As examples, she described the Centering Pregnancy model and women's support groups, which have shown promise in a number of developing country settings.

Finally, Rebecca Stoltzfus closed the session, emphasizing the need for more community-based evidence, especially looking at “packages of ANC that are contextually adapted to be delivered in the most effective ways.” Thus, symposium attendees walked away with a substantial research agenda for the strengthening of antenatal guidelines and care.


The Folate Fortification Story – How we fixed one problem…but may have created another

Student Blogger
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.



Is January 1 the best date to kick-start a weight loss diet?

Student Blogger
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:

1.https://blog.compete.com/2010/10/06/seasonal-traffic-trends-to-weightloss-websites/
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.