According to the National Health and Nutrition Examination Survey (NHANES), national reports indicate a steady increase in childhood obesity levels, in preschoolers up to four years of age. However, state-specific studies of data retrieved from the Pediatric Nutrition Surveillance System (PedNSS) tell a slightly different story: in 2011, nineteen U.S. states/territories reported a drop in obesity prevalence among low-income preschoolers up to 2.6%, with the greatest decline observed in the Virgin Islands. Although national obesity levels among this age group still range from 9.2-17.9%, we must acknowledge the sporadic, yet significant lapse in prevalence rates of this medical condition from state-to-state.
Childhood obesity is associated with a variety of physical complications, such as high blood pressure, diabetes, and asthma, which in turn, contribute to mental health setbacks that affect a child's self-esteem and motivation to perform daily tasks. Obese preschoolers are five times as likely to become obese adults, as compared to their non-obese peers, and low-income households are particularly vulnerable to chronic obesity – inexpensive fast food options, that boast great taste, but have little nutritional value, are disproportionately marketed in low-income, minority communities. Using cross-promotion marketing tactics, 71% of food products use third-party licensed characters to appeal to adolescent audiences, but less than 20% meet nutritional guidelines set for children. A public health intervention at this impressionable stage of a child's life is crucial in ensuring better health habits for a lifetime.
So, why do some states show significant improvements in obesity levels? It is most likely because these state and county agencies play a unique role in the success of their communities – a role that involves everyone from the enthusiastic teacher in a child's preschool class, to the soccer coach in charge of physical education after school, to the local grocer who provides fresh fruits and vegetables for the community. Local and state initiatives, aimed to implement healthier food and recreational options for the communities they serve, have aligned their WIC programs with the Dietary Guidelines for Americans, which gives nutritional recommendations for consumers at every level.
In my home state of Maryland, for example, county health departments have already begun to equip families and healthcare providers with strategies to manage and prevent obesity in pediatric clients. In 2013, the Montgomery County Government initiated Be Active Montgomery! – a series of summer fitness events, in partner with Montgomery County schools, that promote physical fitness and family community building. In 2014, the Howard County Health Department in Columbia, MD issued a Childhood Obesity Prevention Toolkit to educate families on how to encourage healthy dietary/physical habits at home, and they also provided website access to a WIC Vendor Locator that would assist families in finding stores in their communities. I believe that local strategies such as these have contributed to the decrease in low-income pediatric obesity rates in Maryland from 2008-2011, despite the steady population increase.
Childhood obesity in America is one of those issues that is entangled in a web of possible causes. Food deserts in low-income communities promote consumption of quick-and-easy, fatty meal solutions. Highway expansion results in more vehicles per capita and an increase in traffic safety concerns for parents whose children walk and bike around the neighborhood. Public transportation, however useful, proves inconvenient for expectant, single mothers, who are incapable of transporting loads of groceries to their homes. All in all, the solution to the obesity epidemic in America may seem elusive; however health professionals should approach the situation with a modicum of hope that children will be our nation's saving grace. Regardless of personal opinion, if the movers and shakers of this country made every effort to, literally, think of the children, perhaps we can redesign our environmental and socioeconomic constructs as a nation, to afford every child access to a proper community that promotes healthy living.
Hot Topics in Obesity will be discussed on Friday, December 5 during the fourth annual Advances and Controversies in Clinical Nutrition conference. Dr. William H. Dietz, Director of Redstone Global Center for Prevention and Wellness at GWU in Washington, DC, will give an address “What Explains the Reported Declines in Childhood Obesity?” Dr. Rebecca Puhl will address obesity and weight-related stigma during the same session. Read an interview with her.
The conference runs December 4-6 at the Gaylord National Resort & Convention Center in National Harbor, MD, and features a dynamic program with topics ranging from dietary supplements to nutrition and cancer. To learn more about this year's conference, please visit the website.
When people think of nutrition, they probably do not think immediately of toilets. However, there is growing interest within the global public health community in the relationship between sanitation and nutrition. A group of researchers led by Dr. Tom Clasen of Emory University and the London School of Hygiene and Tropical Medicine has been studying this topic. They recently published findings from a study examining the effectiveness of a rural sanitation program on several outcomes, including child malnutrition, in The Lancet.
The intervention took place in Odisha, India, in the context of the national Total Sanitation Campaign, through which the government of India promotes latrine construction. The campaign focuses on households below the poverty line; it provides them with a latrine but requires that they contribute materials and labor for construction. For this study, the researchers selected 100 rural villages and enrolled households with pregnant women or children under age four. The study took place between May 2010 and December 2013.
Malnutrition was measured in two ways, through height-for-age z-score (HAZ) in children under two and weight-for-age z-score (WAZ) in children under five. The intervention had no effect on mean HAZ. Intention-to-treat analysis also showed no effect on mean WAZ, but per-protocol analysis showed a modest effect size of 0.10 (95% CI: 0.003-0.20). In other words, among the households that were compliant with the intervention, the children had slightly better WAZ scores. The absence of a stronger effect was surprising enough to garner attention from The New York Times, which published an article titled, “Latrines May Not Improve Health of Poor Children.”
I wanted to learn more, so I spoke with Dr. Clasen about the findings. He explained that while latrine coverage increased through the intervention, latrine use remained sub-optimal. While it may seem counter-intuitive, many community members chose not to use their new latrines, preferring instead the culturally accepted practice of open defecation. In particular, the study found that “latrine use was nearly five times higher for women than for men or children.” The reasons behind these gender and age differences are not clear, but Dr. Clasen emphasized the need to increase latrine use, aiming for “everybody, all the time.”
Researchers are examining other potential factors influencing latrine compliance. For example, what role do women play in deciding whether a household invests the resources necessary to build a latrine? If this decision is in the hands of men, and men are less likely to use a latrine, what are the implications for sanitation coverage and compliance? The study team is carrying out analyses on these and many other questions.
Ultimately, Dr. Clasen explained, this was an isolated intervention that could not address the multitude of issues that might affect the study outcomes. Factors such as poor disposal of child feces, the close proximity of livestock, poor water quality, and other forms of contamination likely play an important role in determining child nutrition outcomes. As always, more research is needed to better understand the complicated relationship between sanitation and nutrition.
Clasen T, Boisson S, Routray P, Torondel B, Bell M, Cumming O, et al. Effectiveness of a rural sanitation programme on diarrhea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. Lancet. 2014 [cited 2014 Nov 3]. http://www.thelancet.com/journals/langlo/article/PIIS2214-109X%2814%2970307-9/abstract
November is National Diabetes Month and World Diabetes Day takes place yearly on November 14 to engage millions of people worldwide in diabetes advocacy and awareness. The International Diabetes Federation estimates that 382 million adults (20-79 years old) suffered from diabetes in 2013, which equates to a prevalence of 8.3%. To provide a better perspective by nation, the 10 countries with the highest prevalence of diabetes in 2013 were as follows: Tokelau (37.5%), Federated States of Micronesia (35%), Marshall Islands (34.9%), Kiribati (28.8%), Cook Islands (25.7%), Vanuatu (24%), Saudi Arabia (24%), Nauru (23.3%), Kuwait (23.1%), and Qatar (22.9%). However, if we were to look at the 3 countries with the greatest number of people with diabetes, China ranks the highest (98.4 million), followed by India (65.1 million) and USA (24.4 million). These figures are quite alarming.
Of those suffering from diabetes, type 2 diabetes comprises almost 90% of people with diabetes around the world. As such, type 2 diabetes is one of the fastest growing health problems in the world. So what could be driving this epidemic?
Evidence from observational studies have consistently shown us that low blood levels of vitamin D are associated with an increased risk of type 2 diabetes. The results of numerous observational studies led to speculation that the development of type 2 diabetes is associated with vitamin D insufficiency. Going back to the figures presented earlier, if vitamin D insufficiency is a risk factor for type 2 diabetes, one might also speculate that countries with higher prevalence of diabetes are facing a coexisting problem of type 2 diabetes and vitamin D insufficiency. For example, Tokelauans (the nationals of Tokelau) who have the highest prevalence of type 2 diabetes, may also be at risk for vitamin D insufficiency despite having a tropical and marine climate. The question then becomes, could vitamin D be a causal factor in the development of type 2 diabetes? While this might sound too simplistic, I assure you it's not.
Interpretation of evidence on vitamin D and type 2 diabetes is complicated for a number of reasons. First and foremost, observational studies do not tell us anything about the cause-effect relationship between vitamin D and type 2 diabetes because of possible uncontrolled confounding factors, such as physical activity, that may affect both vitamin D levels and the risk of type 2 diabetes. Second, observational studies cannot inform us about reverse causation. In other words, which comes first, the chicken or the egg? Third, there are a myriad of factors that affect vitamin D levels, including environmental, cultural, genetic and physiological factors. It remains unclear then whether there is a causal link between vitamin D and type 2 diabetes.
To answer this question, a large genetic study published in The Lancet Diabetes and Endocrinology journal looked at the causal association between low blood levels of vitamin D and risk of type 2 diabetes. The study concluded that the association between vitamin D and type 2 diabetes is unlikely to be causal. The research, which was a Mendelian randomization study, examined the link between type 2 diabetes risk and vitamin D, by assessing the genes that control blood levels of vitamin D. Most importantly, the design of this study has a powerful control for confounding factors and reverse causation which are issues of concern in observational studies. This may partly explain the discrepancy between results from earlier observational studies and this study in question. However, we still need to be cautious about interpreting the results from mendelian randomization studies as some of the underlying assumptions in the study might remain untested.
The take home message is that no special recommendations could be made about vitamin D levels or supplementation for people with type 2 diabetes. However, long-term randomized trials of vitamin D supplementation remain important to elucidate vitamin D's role in type 2 diabetes.
As we recognize National Diabetes Awareness this month, it is important to remind patients that diabetes is a progressive chronic lifestyle disease that can be controlled by making healthy lifestyle changes- such as partaking in regular physical activity, eating a balanced diet, maintaining a healthy body weight, taking prescribed medications, joining a smoking cessation program, and improving sleeping patterns.
Zheng Ye, Stephen J Sharp, Stephen Burgess, Robert A Scott, Fumiaki Imamura, Claudia Langenberg, Nicholas J Wareham, Nita G Forouhi. Association between circulating 25-hydroxyvitamin D and incident type 2 diabetes: a mendelian randomisation study. The Lancet Diabetes & Endocrinology, 2014; DOI: 10.1016/S2213-8587(14)70184-6.
Advances & Controversies in Clinical Nutrition on opening day, December 4. Dr. Meyerhardt spoke with ASN in the interview found here, where he highlights the impact lifestyle can have on cancer survivorship, and the benefits of exercise for those living with cancer.
Register for the conference to attend this lecture and all of the presentations during the 3 days.
“I drink tea of guanábana leaves when I can't make it to my chemotherapy sessions. Did you know Miss, that eating guanábana is just as good as 10 chemotherapy sessions?” I was shocked when a patient shared this piece of information with me during a nutritional assessment interview. Luckily, my preceptor stepped in and educated the patient and his spouse on the risks of completely substituting traditional medicine with alternative treatments that are not evidence-based. He argued with my professor. In that moment it sunk in how dangerous health illiteracy can be.
Health literacy has been defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” It involves different factors such as: health knowledge, listening, speaking, arithmetical, writing, and reading skills, and cultural competencies of health professionals as well as other systemic factors.
According to the National Center for Education Statistics, nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease. Nearly 14% of adults (30 million people) have ‘below basic' health literacy. These adults were more likely to report their health as poor (42%) and are more likely to lack health insurance (28%) than adults with Proficient health literacy. These patients are more likely not to vocalize their concerns and questions as well as being less active participants in their care because of the stigma associated with being health illiterate. Being health illiterate is a stronger predictor of health than socioeconomic status, education, ethnicity, or race.
Nutrition professionals in all areas face health illiteracy on a day-to-day basis. During my dietetic internship training, I have a difficult time gathering accurate information from patients during the nutritional assessment in the clinical setting, particularly when assigned a high patient load. That initial interaction may be somewhat compromised by the fact that most patients do not know how to express nutritional concerns and time is too constricted to dig deep into the answers provided. Same goes to other areas of practice: nutrition researchers dealing with tailoring informed consent forms to the level of health literacy of their population of interest or foodservice managers explaining to their employees the reasons to follow HACCP procedures to ensure food safety. Even public health nutrition professionals may face it while trying to advocate in favor of measures such as the taxation of sugar-sweetened beverages.
Healthy People 2020 includes the specific objective to increase health literacy under the topic of Health Communication and Health Information Technology. In this era health and nutrition information is produced and distributed by individuals and organizations with various agendas. It is critical that people have the skills to navigate this sea of information without feeling overwhelmed by nutrition confusion. Guiding people through this process and giving them strategies to find and understand accurate food and nutrition information could allow for a new sense of empowerment that could position dietitians, nutritionists and other nutrition professionals as the go-to source in these matters for people who have put their trust elsewhere to get the information.
The World Health Organization has determined improving health literacy has implications in a greater scope than individual decision-making processes with the following quote:
“[…] Health Literacy goes beyond a narrow concept of health education and individual behavior-oriented communication, and addresses the environmental, political and social factors that determine health. Health education, in this more comprehensive understanding, aims to influence not only individual lifestyle decisions, but also raises awareness of the determinants of health, and encourages individual and collective actions which may lead to a modification of these determinants. Health education is achieved therefore, through methods that go beyond information diffusion and entail interaction, participation and critical analysis. Such health education leads to health literacy, leading to personal and social benefit, such as by enabling effective community action, and by contributing to the development of social capital.”Such an impact could guide the food and nutrition policy measures that are needed to ensure the population's health by activism that intends to change social determinants of health. Wow!
There is a vast amount of literature in health literacy, yet there is still some room for improvement in the scope of practice. Public health and community nutrition professionals could make use of the health care system's shift from acute care towards preventive care and health promotion to justify projects that improve basic health literacy skills. Helping people understand the purpose of health and nutrition behavior change, increasing self-efficacy and helping individuals make decisions accordingly is vital.
Department of Health and Human Services (US), Office of Disease Prevention and Health Promotion. Health literacy online: A guide to writing and designing easy-to-use health web sites.
Health Communication and Health Information Technology- https://www.healthypeople.gov/2020/topics-objectives/topic/health-communication-and-health-information-technology
Health literacy and health behaviour- http://www.who.int/healthpromotion/about/en/
Carbone E., Zoellener, J. (2012) Nutrition and Health Literacy: A Systematic Review to Inform Nutrition Research and Practice. J Acad Nutr Diet. doi: 10.1016/j.jada.2011.08.042
clinical nutrition conference series. In an interview, the clinical researcher and educator from Duke University Medical Center and the Durham VA Medical Center speaks about upcoming pursuits for the council, what she hopes to achieve in her new role, and the information overload problem the field is facing. Read the entire interview here.
At the 2014 Clinton Global Initiative in late September, former President Bill Clinton remarked that a Masaai Warrior has better access to mobile communications today using a small cell phone than he had during his presidency 25 years ago. This access to technology is providing a wealth of opportunities, including in nutrition research and programming. Cell phones are ubiquitous across the African continent and are being used increasingly as an essential part of health community plans: in the area of emergency maternal health, such as when labour stops progressing; for improving supply demands, such as when rural clinics run low on zinc and oral rehydration salts (ORS). The use of cell phones has been at the forefront of the emergence of an entire field of mobile health, known as m-health. One of the most popular uses is probably communications messaging, such as sending regular SMS reminders to parents for growth monitoring visits.
Mobile technologies also offer innovations in global nutrition research. As cell phone use across Africa increases, it becomes easier and easier to train field workers in the use of personal data assistants (PDAs), as people are more familiar with the technology from having their own cell phones. One such example from the Micronutrient Initiative (MI) is the use of PDAs for data collection in our field surveys evaluating a mass media intervention to improve zinc and ORS for the treatment of diarrhea in Senegal. Interviewers carried a PDA with questionnaires loaded onto their device. Text-prompts guided them through the questionnaire, eliminating the need for paper surveys and the logistical complications of storage and transportation that paper surveys add. In the case of our Senegal survey, the PDAs connected to the mobile network daily and sent the interviews to a central server, eliminating the step of manual data entry, as PDAs are configured to send the data directly into the digital database. Anyone who has done data entry can appreciate the extreme benefit of being able to skip this time-consuming and high-risk-for-errors step. Further, the study supervisor can check for concerns in data quality from multiple study sites on a daily basis and follow up with interviewers the next day, potentially increasing overall data quality. And just as important, the issue of lost or damaged paper questionnaires is greatly reduced.
Using PDAs for field surveys opens up other new opportunities, such as incorporating visual media into questionnaires. We were able to provide caregivers in our Senegal zinc and ORS study with pictures of the different brands of products available, giving programmers important insights. The use of images can also be helpful in surveys with dietary recalls, although this option would require preparation of uploading photos and knowing the foods and supplements available to the targeted audience in advance. After a media campaign, we could include images from television spots or radio segments to see if parents recall the ads.
Global Positioning System (GPS) is now offered with some PDAs, which can help in monitoring data quality, survey implementation, and new ways for interpreting data. For example, with the Senegal project, we have the GPS coordinates for households and a visual map of clusters, or hot spots, for diarrhea infections, enabling us to prioritize these areas for intervention. We were also able to ask families about radio stations they listened to and create a map of radio stations reaching the communities in order to develop a national mass media campaign using local radio stations. With traditional surveys it could be months before this type of information would be available.
Despite the advances in using PDAs for data gathering, there are downsides, the biggest being initial purchase costs, related software, as well as having the training and expertise to support surveys in-country. Other challenges are short battery life, theft, connectivity issues, and, in some cases, the need for accompanying paper consent forms. At MI we are fortunate to work with Canadian partner Health Bridge whose expertise and equipment support our local partners and the MI office in Senegal. Innovations in enabling access to these new technologies may be the next challenge in m-health for nutrition surveys, as we work towards systems that provide greater access to larger segments of populations in low to middle income countries.
Field worker using PDA in our zinc and ORS diarrhea treatment intervention study in Senegal.
I constantly hear:
Omnivores: “Vegetarians just don't look healthy.”
Vegetarians: “ Meat just isn't good for you.” Or “I feel so much better when I'm not eating it”
So who has it right? Can they both be right and wrong at the same time? I think the answer lies in the motivations behind the eater. The omnivore may have a point because vegetarianism, like all other diets, has the capacity to be unhealthy.
Essentially, vegetarianism, pescetarianism, veganism, etc. are elimination diets. Like any elimination diet, they have the potential to lack vital nutrients including certain vitamins that are predominately found in animal products. According to Sabate, vegetarian diets when compared to meat-based diets are more likely to be deficient in vital nutrients(1). Similarly, when omnivores (typical American diet) obtain the abundance of their calories from meat and dairy they have less room for the fruit and vegetables that provide them with the other nutrients vegetarians so easily acquire. Moreover, studies show that the increased risk of cancer and heart disease in meat-based diets may be related to a deficiency in the phytochemicals and other compounds found in plant-based foods, not just the intake of saturated fats and excess calories(2).
Again, the problem lies in the motivation. Vegetarians and omnivores alike that eat for health are much more likely to eat properly. The choice of becoming a vegetarian for health reasons alone may lead the vegetarian in question to a more healthful diet in which they are cognizant of variety and balance. That being said, there are plenty of vegetarians that may be doing it for the wrong reasons or are, like most, uneducated in making the proper nutritional decisions.
The observation that vegetarians are unhealthy may actually be evident. Most will argue that they have been deficient in iron, zinc, calcium and B vitamins since they have eliminated animal products, leading to anemia(2). Not to mention that most vegetarians are women who are prone to anemia due to menstruation. The fatigue that follows leads to the snowball effect of fatigue, decreased exercise and depression. The point is, diet has a strong influence on health and well-being and it is dangerously easy to eat incorrectly, even if one's intentions may be pure. This is seen in all “types” of eaters alike.
It is important to remember that as a vegetarian, the elimination of a steak may reduce your risk for heart disease, hypertension, atherosclerosis, hyperlipidemia, etc., but it is not a free pass to eat all the junk food you can to make up for it. The elimination of meat alone is not the ticket to health. Instead, it seems to be a correlation: the vegetarians motivated by health are also more likely to be cognizant enough to eat right all of the time. Furthermore, Sabate illustrates that the vegetarian diet is viewed as improving health and limiting disease when compared to the meat-based diet(1).
1. Sabate, J. (2003). The contribution of vegetarian diets to health and disease: a paradigm shift? The American Journal of Clinical Nutrition, 78 (3), 502S-507S.
2. Nieman, D. C. (1999). Physical fitness and vegetarian diets: is there a relation? The American Journal of Clinical Nutrition, 70 (3), 570S-575S.
No one wants to get half a diagnosis from their doctor.
Unfortunately, that's what tends to happen when diagnosing malnutrition in hospitalized adult patients in the United States. The present criteria for some malnutrition assessments, like the Malnutrition Screening Tool (MST), are under scrutiny because they only evaluate patients on symptoms of starvation, such as unintentional weight loss or poor appetite. However, new studies postulate that malnutrition should not be limited to food behaviors, but should be expanded to include inflammation resulting from chronic disease. The body's inflammatory response can intensify the symptoms of starvation, and vice versa; poor eating habits may induce inflammation as well. The human body does an impeccable job of patching itself up using the inflammatory response, but this process often triggers symptoms strongly associated with malnutrition, such as weight loss. With approximately half of the U.S. adult population (117 million) suffering from at least one chronic condition, such as coronary heart disease and diabetes, it is no surprise that there is an increasing prevalence of malnutrition cases among hospitalized adult patients.
ASN supports the efforts of many of its partner organizations, such as the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics, which want to recognize the role of the inflammatory response when diagnosing malnutrition. They have proposed four standard criteria: insufficient energy intake, unintended weight loss, muscle mass and fat loss, and diminished physical function. These criteria will support a more etiological-based diagnosis of malnutrition; a diagnosis more closely linked to the chronic diseases that cause it. Misdiagnoses often result in patients being discharged early from hospital care, causing inpatients to return later for health issues made worse by the symptoms of poor nutrition.
The International Classification of Diseases, 10th Revision, or ICD-10, is a coding system under the Affordable Care Act of 2010, scheduled to be implemented after October 1, 2015. Designed to improve disease management, this revision will include coding using an updated definition of malnutrition. Absence of a standard screening system for this condition is like installing the proverbial cork in the leaky faucet; diagnoses without a simple malnutrition assessment may “plug” up the issue, but the pressure continues to build, waiting for a more thorough solution. The expansion of the ICD-10 coding system will provide a part of that solution by enhancing screening accuracy. With five times more descriptors than its ICD-9 predecessor, ICD-10 coding will include more conditions that could be linked to a range of malnutrition-related issues.
Hospitals across the nation are preparing for the ICD-10 updates, but it is imperative that hospital personnel fully understand how to recognize and diagnose malnutrition to code it properly. Despite shortages of nursing staff and other trained individuals, quality of patient care must be maintained in order to indicate their risk of malnutrition. Clinicians must be able to perform comprehensive assessments of the patient's complete medical background, so that, along with the newly-proposed diagnostic construct, every patient will receive comprehensive care that will, ideally, lower the cost of their medical care expenses in the future.
Malnutrition, among other hospital-based nutrition topics will be discussed on Saturday, December 6 during the fourth annual Advances and Controversies in Clinical Nutrition conference. Dr. Gordon Jensen, ASN's immediate past president, will give an address titled “Malnutrition and the Affordable Care Act.” The conference runs December 4-6 at the Gaylord National Resort & Convention Center in National Harbor, MD, and features a dynamic program with topics ranging from dietary supplements to nutrition and cancer. To learn more about this year's conference, please visit the website.
Jensen, G, Compher, C, Sullivan, D, Mullin, G. (2013). Recognizing Malnutrition in Adults: Definitions and Characteristics, Screening, Assessment, and Team Approach. Journal of Parenteral and Enteral Nutrition, 802-807.