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Breakfast Consumption and Weight Loss

Student Blogger
By Caitlin Dow, PhD

 

Breakfast is often considered the “most important meal of the day,” and if you are looking to lose weight, you mustn't skip breakfast… or so the story goes. This idea is widely believed in popular culture as well as by many nutrition scientists and government bodies and is repeated so often that many in the field consider it health dogma. Indeed, the Dietary Guidelines for Americans even recommend breakfast consumption as an important tool for weight loss.  But what does the science say?

            Observational studies indicate that breakfast consumption is linked to lower weight.  Data from the National Weight Control Registry demonstrated that 78% of the nearly 3,000 subjects included in the analysis (adults who had lost at least 13 kg and kept the weight off for a year or more) reported eating breakfast everyday and only 4% reported never eating breakfast [1]. Further, a recent meta-analysis of observational studies that have evaluated the relation between weight and breakfast consumption found that skipping breakfast was associated with a 55% increased odds of having overweight or obesity [2]. These findings are likely the reason many tout breakfast consumption as an important weight loss modality, despite these studies not actually testing that outcome.

Observational studies can only describe associations, but are not appropriate to determine causation.  Thus, randomized controlled trials (RCTs) have sought to test whether breakfast consumption directly impacts weight.  In one of the first RCTs to evaluate the role of breakfast in weight loss, Schlundt et al. [3]studied women with obesity who were self-reported breakfast eaters or skippers.Within each group, women were randomized to eat or skip breakfast in addition to following a 1200 kcal/day diet for 12 weeks. All groups lost at least 6 kg, but interestingly, those who were randomized to switch their breakfast condition (e.g. ate breakfast at baseline, then started skipping) lost more weight than those who maintained their breakfast habit. These results suggest that changing an eating behavior in addition to following a reduced calorie diet may accelerate weight loss. However, the results from a study by Dhurandhar et al. did not corroborate those findings. Adults with overweight and obesity were randomized to one of three conditions in which all groups received a USDA pamphlet on healthy eating practices: the control group received no other information, one group received additional instructions to consume breakfast, and the third group was instructed to not eat breakfast [4]. After 16 weeks, there was no observed effect of treatment assignment on weight loss.Contrary to the results from the Schlundt study, baseline breakfast eating habit was not related to weight change, though this study didn't evaluate breakfast consumption in conjunction with a reduced calorie diet.Finally, in a recently published 4-week study, adults with overweight and obesity were randomized to three different breakfast conditions: water (control), frosted flakes, or oatmeal [5].Interestingly, skipping breakfast resulted in an average weight loss of 1.2 kg, while those randomized to either breakfast condition demonstrated no significant weight change.However, total cholesterol also increased in the control group, suggesting that skipping breakfast may result in slight weight loss, but have detrimental effects on cardiometabolic health.

Thus, the results from the few RCTs completed in adults with overweight and obesity, to date, do not support the notion that breakfast consumption should be part of a weight loss regimen. Importantly, though, the results are also not compelling to suggest that eating breakfast hinders weight loss.  This field is still young and many questions remain unanswered. I look forward to more RCTs evaluating breakfast consumption (and potentially, breakfast quality) on various facets of weight and metabolic health.

References

1.Wyatt, H.R., et al., Long-term weight loss and breakfast in subjects in the National Weight Control Registry. Obes Res, 2002. 10(2): p. 78-82.

2.Brown, A.W., M.M. Bohan Brown, and D.B. Allison, Belief beyond the evidence: using the proposed effect of breakfast on obesity to show 2 practices that distort scientific evidence. Am J Clin Nutr, 2013. 98(5): p. 1298-308.

3.Schlundt, D.G., et al., The role of breakfast in the treatment of obesity: a randomized clinical trial. Am J Clin Nutr, 1992. 55(3): p. 645-51.

4.Dhurandhar, E.J., et al., The effectiveness of breakfast recommendations on weight loss: a randomized controlled trial. Am J Clin Nutr, 2014. 100(2): p. 507-13.

5.Geliebter, A., et al., Skipping breakfast leads to weight loss but also elevated cholesterol compared with consuming daily breakfasts of oat porridge or frosted cornflakes in overweight individuals: a randomised controlled trial. J Nutr Sci, 2014. 3: p. e56.



Green Tea: Who Does it Help, and How?

Student Blogger
By: Emma Partridge, MS Candidate

Green tea contains a high concentration of polyphenols, most of which are flavanols. Flavanols are commonly known as catechins, the most active catechin being epigallocatechin-3-gallate (EGCG).1 Within the world of nutrition, green tea is consistently touted as a beverage with a plethora of health benefits. These benefits are far-reaching and specific roles of green tea have been identified to improve symptoms or reverse disease damage amongst people with autoimmune disease, heart disease, cancer, liver disorders, smoking complications, chronic inflammation, and more. The roles of green tea often overlap and while green tea consumption is important for those with various diseases, the consumption of green tea by healthy individuals may be integral in the prevention of many of the following diseases.

Chronic Inflammatory Disease 
EGCG may be most important flavanol when it comes to inflammation control.2 EGCG has been shown to suppress the production of cytokines, pro-inflammatory mediators. Suppressing cytokines decreases long-term inflammation and has been shown to improve inflammation-related symptoms in arthritis models.3,4 

Autoimmune Disease
In addition to helping to control the chronic inflammation associated with most autoimmune diseases, EGCG has been shown to suppress auto-reactive T cell proliferation. Auto-reactive T cells act against the body, resulting in various forms of autoimmune diseases. EGCG may also help to regulate T-helper cell balance, which may decrease the pathogenesis of arthritic diseases, especially rheumatoid arthritis.3 

Type 2 Diabetes Risk
Type 2 Diabetes is sweeping America, and food production practices, availability, and affordability are making it harder for people to access healthy options. The ease of accessing and affording unhealthy foods is increasing the risk of diabetes among populations. Green tea, as well as coffee, has been associated with lowering the risk of type 2 diabetes, though the mechanism is unknown and the data inconsistent. However, in a study of 40,000+ people followed for 10 years, researchers found that daily consumption of at least three cups of coffee or tea may lower type 2 diabetes risk.5

Heart Disease & Stroke Risk
In an article published by the American Heart Association, researchers found that people who drank two to three cups of green tea per day had a 14% lower risk of stoke.6 The research on green tea and stroke risk comes on the wake of multiple studies finding links between green tea and heart health. Multiple studies found green tea consumption to lower risk of death from heart attacks by 26% and lower risk of coronary artery disease by 28%.7 

Cancer & Tumor Growth
Cancer is a leading cause of death in the United States, behind heart disease. Green tea has already been shown to be beneficial in preventing the leading cause of death; now studies have now shown that the EGCG may affect transformed cells by inhibiting the growth of certain cell lines, inducing apoptosis, and altering gene expression to prevent transformed cells from becoming cancerous.8

Smoking 
The polyphenols in green tea have shown to work against carcinogens, while the antioxidant effects may reverse endothelial dysfunction in healthy smokers.8 The reversal of endothelial dysfunction in smokers is important because it plays a role in the pathogenesis of atherosclerosis and cardiovascular disease.9

Liver Disease
Green tea's aforementioned anti-carcinogenic affect may play a role in preventing liver disease. Active polyphenols detoxify reactive oxygen species, preventing oxygen free radicals from destroying hepatocytes and causing oxidative DNA damage. Multiple studies have shown that, most likely via this method, green tea intake can attenuate liver disease or liver cancer.10

Weight Loss & Weight Maintenance
Green tea's affect on weight loss may be attributed to two components: EGCG and caffeine. Caffeine alone does play some role in increasing energy expenditure, but when combined with EGCG, the mixture stimulates energy expenditure and fat oxidation to a greater degree. This may trigger weight loss, and additional evidence reveals that continual green tea consumption can further help to maintain weight.11

In determining whether or not green tea is for you, the answer is likely yes. While there are risks by way of overconsumption, a few glasses a day has been shown to be beneficial for the all-around healthy person in preventing disease and for the person suffering from various diseases or ailments.

1.Ehrlich SD. Green Tea. 2011; http://umm.edu/health/medical/altmed/herb/green-tea.
2.Hamer M. The beneficial effects of tea on immune function and inflammation: a review of evidence from in vitro, animal, and human research. Nutrition Research. 2007;27(7):373-379.
3.Wu DY, Wang JP, Pae M, Meydani SN. Green tea EGCG, T cells, and T cell-mediated autoimmune diseases. Molecular Aspects of Medicine. 2012;33(1):107-118.
4.Kim HR, Rajaiah R, Wu QL, et al. Green Tea Protects Rats against Autoimmune Arthritis by Modulating Disease-Related Immune Events. Journal of Nutrition. 2008;138(11):2111-2116.
5.van Dieren S, Uiterwaal C, van der Schouw YT, et al. Coffee and tea consumption and risk of type 2 diabetes. Diabetologia. 2009;52(12):2561-2569.
6.Green tea, coffee may help lower stroke risk. 2013; http://newsroom.heart.org/news/green-tea-coffee-may-help-lower-stroke-risk.
7.Green tea may lower heart disease risk. Harvard Heart Letter 2012; http://www.health.harvard.edu/heart-health/green-tea-may-lower-heart-disease-risk.
8.Chen ZP, Schell JB, Ho CT, Chen KY. Green tea epigallocatechin gallate shows a pronounced growth inhibitory effect on cancerous cells but not on their normal counterparts. Cancer Letters. 1998;129(2):173-179.
9.Nagaya N, Yamamoto H, Uematsu M, et al. Green tea reverses endothelial dysfunction in healthy smokers. Heart. 2004;90(12):1485-1486.
10.Jin X, Zheng R-h, Li Y-m. Green tea consumption and liver disease: a systematic review. Liver International. 2008;28(7):990-996.
11.Hursel R, Viechtbauer W, Westerterp-Plantenga MS. The effects of green tea on weight loss and weight maintenance: a meta-analysis. International Journal of Obesity. 2009;33(9):956-961.


Uganda and Food Security: Thoughts from a Personal Experience

Student Blogger
By Amber Furrer, MS

The term “food security” at a basic level was defined by the World Food Summit of 1996 as “when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life” (FAO 1996).  This is obviously a key element in success and well-being of any people, though its realization will look a little bit different in America, where we do still have food insecure, compared to other parts of the world. 

There are many facets to the problem: poor infrastructure and organization, poverty, limited education, social injustice and gender inequality, conflict, and lack of natural resources.  Solutions also cannot generally be broadly applied because each country experiences these issues differently.  Despite the successes of the Green Revolution in agriculture and food research implementation and nutrition interventions since the 1960's, around 850 million people (or about 15% of the world's population) remain malnourished.  For children specifically, this jumps to 20%. The enormity of the problem can leave a person wondering what possible difference one person or one organization could make.   
 
On May 8, I traveled to Uganda on 3-week assignment with a United States-based NGO whose mission is to serve the vulnerable in developing countries with development and relief efforts.  Uganda, like the surrounding countries, is given a “low human development” score in the 2014 Human Development Report by the United Nations.  In 2006, 38% of Ugandan children experienced chronic malnutrition, or stunting.  Vitamin A and iron deficiency remain critical problems in population health, especially for mother and children (FAO 2010).
uganda.jpg

The broad focus of my assignment was nutrition education and recipe development for a small-holder farmer cooperative.  In general, farmers are an important target for nutrition education because they are able to impact the local food supply and most farmers are women of reproductive age.
Preparing for my trip, I wasn't sure what kind of impact I would have.  A semi-tropical climate allows Ugandans to grow and consume a variety of foods, and on paper I thought their diet seemed pretty adequate.  But of course things on paper are always a bit different than what you find in reality. 

I spent two days with each group of farmers, the first day communicating (through a translator) the basic, important concepts of nutrition and the second explaining and demonstrating foods and preparation methods that could improve the diet quality of people in their district.  I shared the kind of information that we take for granted: the role of carbohydrates, protein, fat, vitamins, and minerals in our bodies and the importance of consuming a balanced diet including a variety of foods in addition to other simple but important tidbits like “don't feed tea and coffee to your children.”  When it came to recipe demonstrations, I explained things that most people in the US could look up on a computer whenever they wanted, but for these women and men was not accessible.

Along the way, I began to recognize that consumption patterns, while related to economic factors, often have more to do with cultural practices and preferences and societal barriers.  A visitor to Uganda immediately notices the huge amount of carbohydrate sources consumed at every meal.  There are several, including Irish potatoes, (white) sweet potatoes, cassava, green banana, rice, corn and millet-based pastes, and wheat-based chapatti.  Ugandans also grow a variety of beans, ground and tree nuts, vegetables, and fruits, so it is not that nutritious foods are totally absent, but are consumed in skewed proportions. 

Fruit is considered child's food, and vegetables (including beans) are consumed in very small amounts.  Meat, dairy, and eggs are not widely affordable, and insects and fish have an undesirable “poor food” stigma attached.  Influences and perceptions of a Western diet have made white bread and other packaged foods sought-after commodities, rather than the native whole grain millet, avocadoes, mangos, and other naturally nutritious foods that Americans are ironically trending towards. 

In lacking a strong education system and broad computer access, Ugandan people live in an information desert.  Despite the agricultural potential for variety, many dishes are made and consumed the same way day after day with the same ingredients because knowledge on nutrition and food preparation is lacking. There are countries with enough conflict and natural resource struggles that educating on the benefits of vegetable and dairy/animal protein consumption might be a moot point, but in Uganda these things are more achievable.  Timing seems critical: these farmers were at a point where they requested this training, and that makes the potential impact far greater. 

Easily-modified agricultural factors can have broad influence on the diet.  For example, simple introduction of orange-fleshed, rather than white-fleshed, sweet potatoes can vastly improve vitamin A intake.  Increasing use of fertilizers or crop rotation practices can ensure that minerals which foods like peanuts should theoretically contain are actually present.         
Gender-related issues can also impact diet quality. Women are responsible for feeding themselves and their children, but the money, even money they earned, is not always in their hands. Men may have a nice meal at a restaurant while women eat cassava and potatoes at home.  In addition, the common practice of multiple wives and the perception of children as a status symbol often make families quite large. 

Overall, while economic, agricultural, and societal factors do play a role in food security, in countries such as Uganda I think nutrition education has strong potential to directly provide needed knowledge and indirectly change practices and prejudices that impede diet quality.  My personal experience fully supports UNICEF recommendations for future nutrition education programs, including starting young, investing in women and girls, and collaborating across ministries to support integrated approaches to improving the diet (Unicef 2014).  These integrated approaches address other strong nutrition influencers such as food safety and hygiene and health and disease, in addition to agricultural production.     

FAO. 1996. “Declaration on World Food Security.” World Food Summit, Rome: FAO.
FAO. 2010. “Uganda.” United Nations. http://www.fao.org/ag/AGN/nutrition/uga_en.stm
Unicef. 2014. “Multi-Sectoral Approaches to Nutrition: The Case for Investment by Educational Programmes.” http://www.unicef.org/eapro/Brief_Education_Nutrition.pdf


FDA’s Proposal to Update Nutrition Facts label

Student Blogger
By Emily Roberts

For nutrition professionals, deciphering the Nutrition Facts labels on food packages may be second nature. However, for the general public it is often difficult to understand and interpret this information. The FDA took this into consideration when proposing new requirements for Nutrition Facts labels in 2014 (1). Two main changes were proposed: new information on labels as well as design changes and new serving and package size requirements (2). The appearance of the label will be quite different if they are accepted.

This is of course to be the biggest change since 1993. The only alteration in the past 20 years has been the requirement of the amount of trans fat to the label in 2006 (1). This month the FDA proposed two more changes to the label. The one getting the most attention is the percent daily value of added sugars. 

The most notable changes issued in March 2014 were (1):
•    increased font size of calories
•    changing of serving size requirements
•    placement and update of percent daily value
•    including added sugars
•    removing calories from fat
•    including the gram amount of micronutrients
•    including vitamin d and potassium
•    making vitamin C and vitamin A voluntary

As of this July 2015, two new changes were proposed (1):
•    require the percent daily value of added sugars
•    change the footnote to help consumers understand daily values

What are considered added sugars?
Simply stated added sugars are not naturally occurring and are added to the product. ChooseMyPlate says they are sugars that are added when processed or prepared. USDA lists some common sources of added sugars seen on ingredient lists including corn syrup, honey, fructose and lactose.  However, for many manufactures this can be quite difficult to quantify because fructose and lactose are naturally occurring in fruits and milk. Yet, when they are added during processing they are now considered an “added sugar”. The current requirements from the FDA states in The Code of Federal Regulations Title 21 (101.60 c) that manufactures can use the claim “No added sugars” if “no sugar or sugar-containing ingredient is added during processing” (3).

Why does the FDA want percent daily value of added sugars?
Currently, there is no percent daily value of sugars because the FDA recommends that consumers limit their sugar intake to as low as possible. Things changed this month when the FDA argued that the percent daily value helps consumers understand how much is too much added sugars. Added sugars provide no nutrient value, increase caloric intake and replace nutrient dense foods. Susan Mayne, director of the FDA's Center for Food Safety and Applied Nutrition, argued this change will help consumers reduce their intake of added sugars (4).

How much is too much of added sugars?
FDA recommends that daily intake of added sugars should not exceed 10% of total calories (1). If you are eating a 2,000 calorie diet you can easily exceed this 10% mark by consuming one 20 fl oz Minute Maid Lemonade.

How are food manufacturers reacting?
Food companies argue that including added sugars and a percent daily value could be misleading because the body utilizes added sugars the same as natural sugars and question the amount and quality of scientific evidence the FDA used to support their new proposal. Manufacturers claim that nutrition information seldom alters consumer's food intake, so these changes would be more costly than they would be beneficial (5).

When can the public see these new changes?
The two new proposed changes will go through a comment period before they are accepted.

References
1.    http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm385663.htm#supplemental
2.    http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm387533.htm
3.    http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm064911.htm
4.    http://www.npr.org/sections/thesalt/2015/07/24/425908798/no-more-hidden-sugar-fda-proposes-new-label-rule
5.    http://www.wsj.com/articles/fda-proposes-listing-added-sugar-on-food-labels-1437774370
6.    http://www.natlawreview.com/article/calorie-count-delay-fda-extends-compliance-date-menu-labeling-rules
7.    http://www.choosemyplate.gov/weight-management-calories/calories/added-sugars.html
8.    http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm
9.    http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=101.9
10.    http://www.minutemaid.com/content/minutemaid/en/home/products/lemonade/lemonade/

The Path to Policy: ODS Interview

Student Blogger
Interview with NIH Office of Dietary Supplements Director Dr. Paul Coates
By: R. Alex Coots

Academia is changing.

Today's universities increasingly rely on adjunct faculty to teach courses and reserve the coveted full-time academic position for the science superstars.  This phenomenon, coupled with decreasing paylines from funding agencies, makes a science career especially challenging to pursue. And that's not even considering the project difficulties!

The problem has become so pressing that even the NIH has realized it. New initiatives, such as the BEST Innovation Award, aim to ensure that graduate students and post-docs have increased opportunities to expand their skill sets for a future outside of academia.  

Policy is one of the many areas that nutrition experts can serve. The current Director of the Office of Dietary Supplements (ODS), Dr. Paul Coates, successfully made the transition from bench research as a geneticist to a career in science policy. He spoke with me about his career and transition to ODS.

What motivated your interest into policy?
I was curious. For all these years, I had been funded to do research by the NIH and other organizations, but what I concentrated most on was my own research. I was pretty naïve when I came to the NIH, not knowing what life was like for people who worked on the government side. There were plenty of them like me, PhD's in one setting or another, who had come to the NIH to work as extramural program directors.

What are the important skills or knowledge that someone should have when moving into policy?
One of the things I understood was the importance of making connections. My first job at the NIH was focusing on diabetes research efforts. I learned how to work with other people within an institute, and then gradually in other institutes and beyond to achieve common goals. I think the art of science policy is knowing who else works in this field that you can benefit from, and flip it around and ask “How can I help other people benefit from working together with them?” Recognize the talent that's out there in other organizations.

What advice would you give to students?
You need to pay your dues as a scientist first. You need to understand the scientific method. You don't have to spend an eternity in science, but you must have spent some time doing it. Author publications and write grants. My observation is that the people best prepared for this kind of experience “get it” about what a scientist does. They must be prepared to critically analyze data and know what to look for in the literature to inform policy.

What types of projects do the AAAS and Milner fellows work on?
The AAAS Science and Technology Policy Fellowship is beautifully designed to encourage people at different levels of experience in science to work closely with federal agencies to learn about the science-to-policy transition. In ODS, we're recent partners in that program. Fellows are engaged in projects that my office works on. We have a very active role in translating science into policy, but also in identifying research needs.

The Milner fellowship has a different side to it. Jointly funded by ODS and the Beltsville Human Nutrition Research Center, the Milner fellowship brings in one or two people per year for a two-year stint that will allow them to conduct research in one of the labs at Beltsville. At the same time, they participate at ODS in work on science policy.

How do you see ODS changing in the future?
ODS is getting a little older. A fairly urgent challenge is identifying people who can come up behind us and continue to identify opportunities for research—particularly those that have public health implications— and be committed to help tackle them.


ASN Focused on Collaboration to Solve Nutrition’s Complex Problems

John Courtney
By John E. Courtney, PhD

As a society, ASN highlights the very best scientific research that promotes healthy people and communities; we recognize that nutrition research is conducted within and across the public, private and government sectors of our society. ASN members understand that the nutrition challenges facing the world are multi-faceted and require research-based solutions. The Society also understands that public confidence in scientific research and integrity is essential to translate scientific evidence into improved dietary practices by consumers.

ASN's professional activities allow members to come together and share information and research findings that accelerates discoveries that allow us to better understand the connections among diets and health. As a broad member-based organization, we are transparent about the fact that industry, government, trade groups and other scientific organizations contribute funding to help our society support the research enterprise for all of our members.  ASN is committed to openness, objective science, and disclosure of potential conflicts. The Society's Conflict of Interest attestation and “guiding principles for working with external groups and addressing COI” can be found on our website. All of the Editors for ASN's three journals have publicly-available conflict of interest statements, which is not a required process and is an example of our commitment to transparency.
 
ASN promotes rigorous research that highlights the very best dietary practices, policies and guidance. Because issues of nutrition impact virtually every aspect of the food supply chain, involvement of all informed stakeholders in the scientific enterprise is essential. Furthermore, in today's extremely competitive research environment, industry support helps progress research that might otherwise be impossible due to limited federal funding.  ASN, like all scientific societies, remains vigilant in safeguarding the integrity of the scientific process from the biases and influences that can be associated with research funding from all sources. Without scientific integrity, there can be no public trust. 

ASN does not have small goals, and therefore we cannot work in a vacuum. We believe that scientists in academia, government, and industry can partner to solve the world's nutrition challenges. Our members work with moms and dads, children, the elderly, the sick, the under- and over- nourished, foundations, companies, governments, and media. We look forward to continuing to work with all stakeholders who are passionate about nutrition and committed to the highest ethical standards for research that advances the public health to achieve a healthier world.

ASN welcomes all to the table to learn from one other and to make progress on continuing to solve today's complex nutrition challenges. These challenges include improving mechanisms and processes to fund, conduct and review nutrition research that improves global health.

Dietary Guidelines Committee Focuses on the Diet-Health-Environment Trilemma

Student Blogger
By Banaz Al-khalidi

First released in 1980, the Dietary Guidelines for Americans are updated and jointly published by the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (HHS) every 5 years. These guidelines provide recommendations on nutrition and physical activity for Americans aged 2 and older, and are the driving force behind Federal nutrition policies, nutrition education and food procurement programs. As such, these guidelines are used by both the public and industry, and by a wide variety of audiences including educators, health professionals and government agencies.

Earlier the 2015 Dietary Guidelines Advisory Committee (DGAC) released a Scientific Report based on the latest evidence, which will shape the finalized guidelines later this year. The committee's work was influenced by two fundamental connections between nutrition and lifestyle-related health issues facing the U.S population:

1) Chronic diseases, overweight and obesity: about half of all American adults (~117 million) have one or more preventable chronic diseases such as type 2 diabetes, cardiovascular diseases, hypertension, and diet related cancers, and about two-thirds of adults and one-third of children are overweight or obese due to poor dietary habits and physical inactivity.  
2) Food environment and settings: diet and lifestyle behaviors are strongly influenced by personal, social, organizational, and environmental context and systems. As such, the DGAC developed their recommendations based on a conceptual model of socio-ecological framework to provide recommendations at the individual, social, organizational, and environmental level.

What does the DGAC's report say about the latest research on diet and lifestyle-related health outcomes?

The DGAC found that the current average American diet is low in vegetables, fruits, and whole grains and too high in refined grains, added sugars, saturated fat, and sodium. Furthermore, inadequate consumption of vitamin D, calcium, fiber, and potassium were categorized as nutrients of public health concern for the majority of the U.S population. Lifestyle-related health problems in the U.S. have persisted for more than 2 decades and the DGAC's report calls for urgent preventative actions at the national, state, and local community levels. The DGAC recommended a shift in focus to a more environmentally friendly, sustainable plant-based diet that focuses on whole foods rather than specific nutrients. The overall body of evidence examined by the committee is summarized below:

“A diet higher in plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts, and seeds, and lower in calories and animal based foods is more health promoting and is associated with less environmental impact than is the current U.S. diet.”

This is not to say that any food groups need to be eliminated completely to improve health and sustainability outcomes. In fact, the DGAC recommended three dietary patterns to provide options that can be adopted by the U.S. population and are also aligned with lower environmental impacts. These dietary patterns include the Healthy U.S. style Pattern, the Healthy Mediterranean style Pattern, and the Healthy Vegetarian Pattern.  Furthermore, the 2015 DGAC left out cholesterol restrictions where previously, the 2010 DGAs recommended that cholesterol intake be limited to no more than 300 mg/day. The up-to-date evidence on cholesterol showed no substantial relationship between dietary consumption of cholesterol and blood cholesterol. Thus, the 2015 DGAC concluded, “Cholesterol is not a nutrient of concern for overconsumption.”

The message is clear—the 2015 DGAC recommends the U.S population consume dietary patterns that are rich in vegetables, fruits, whole grains, seafood, legumes, and nuts; moderate in low- and non-fat dairy products and alcohol; lower in red and processed meat; and low in saturated fat (less than 10% of total calories consumed per day), added sugars (maximum of 10% of total calories consumed per day), and sodium (2,300 mg per day or age-appropriate Dietary Reference Intake amount). Whether the USDA and the HHS will choose to adopt or ignore these recommendations put forth by the 2015 DGAC remains uncertain at this point. Meanwhile, dozens of health and environmental groups support the committee's recommendations regarding sustainability, as viewed in the open letter found at My Plate My Planet, Food for a Sustainable Nation.  

The advisory recommendations put forth by the 2015 DGAC are also closely aligned with recent research highlighting the urgency of shifting global diets, where healthy dietary patterns (i.e. Vegetarian, Pescetarian, and Mediterranean diets) are found to be associated with more favorable health as well as environmental outcomes. Thus, the available data strongly suggest that diets that are higher in plant-based foods will not only improve personal and public health, but also boost our planet's health via “weight” reduction in greenhouse gases mainly due to reduction in livestock production.


Food for Health

Suzanne Price
By Sarah Ohlhorst, MS, RD and John Courtney, PhD

While nutrition scientists in academia and industry seek to increase research and inquiry with respect to the potential value and role of foods and nutrition-based products in improving health, the current regulatory framework appears to limit research on the health benefits of foods. Is it not time for a renewed discussion of the role of food in health? It appears to be necessary, especially related to risk reduction for noncommunicable diseases, given research that consistently shows the role of food in reducing risk of or managing a range of acute and chronic conditions.  Read the full guest blog posted at the Altarum Health Policy Forum.

Rethinking the problem of long-term weight management

Student Blogger
By Banaz Al-khalidi

Losing weight is hard enough. Keeping it off is even harder. Despite decades of scientific advancement in our understanding of energy intake and energy expenditure, weight regain after weight loss remains a major issue in obesity treatment. What could we be missing in this energy balance equation? Rethinking this problem, I think it is worth asking ourselves whether we live to eat or eat to live. There is a huge difference. Given the abundance of food in our environment, the majority of us will live to eat. But what drives this motivation or simply put, what are the determinants of healthy versus unhealthy behaviors?  

Generally, healthy lifestyle interventions including diet, exercise, and behavioral strategies, such as keeping a food log, have proven to be effective for weight loss in the short term. However, participants' lack of adherence to the intervention coupled with subsistence of unhealthy behaviors result in weight regain in the long term. According to a research on cardiovascular health behaviors and health factor changes in the US population from 1988 to 2008, healthy diet scores changed minimally (from 0.3% to 1.4% between 1999 and 2008), and physical inactivity levels decreased by only 7-10% from 1999 to 2006. Furthermore, by 2020, it is estimated that 43% of American men and 42% of American women will have a BMI of ≥ 30 kg/m2 (i.e., obese category). Despite the established risks and benefits associated with diet and physical activity, it seems that health behaviors tend to be incredibly resistant to change.
 
A recent report from a panel of obesity experts convened at the National Institutes of Health discussed the issue of weight regain after weight loss. The authors highlighted the problem of behavioral fatigue, in which patients grow weary of strict lifestyle regimens, especially when weight loss declines after the first 6 months. Specifically, the authors mentioned that “Initially, the positive consequences of weight loss (e.g., sense of accomplishment, better fit of clothes) outweigh the cognitive and the physical effort needed to lose the weight. Later, when the goal is to maintain lost weight, the positive feedback is less compared to the effort required to keep adhering to the same regimen. Thus, the benefits no longer seem to justify the costs”. In other words, the costs of adherence to these interventions exceed the benefits as time progresses, and patients seem to justify their behavior by re-thinking about the cost/benefit ratio in the long run. How can we then increase the long-term benefits while decrease the costs associated with weight maintenance?

There is a need to understand what factors allow people to successfully maintain a behavior over a long period of time. In recent years, obesity and behavioral scientists have started to explore strategies that involve incorporating ‘mindfulness' to promote the sustainability of healthy behaviors. Mindfulness is defined as: awareness of the present moment, and paying attention to one's moment-to-moment experiences non-judgmentally. This attention leads to a clear awareness of one's own thoughts as well as one's environment in that one observes what is happening, but instead of reacting, the mind views these thoughts as inconsequential. This does not mean disconnection from life; rather, the mind is actively engaged and flexible. Mindfulness is not a technique but it is a way of being.

You might ask, what does this have to do with obesity and health behaviors? They're all related. Mindfulness-based interventions (MBIs) have recently become a focus for the treatment of obesity-related eating behaviors. A recent review paper examined the effectiveness of MBIs for changing obesity-related eating behaviors. Of the 21 studies included in the review, 18 studies reported positive results for obesity related eating behavior outcomes. Specifically, mindfulness enhanced self-awareness and self-regulation (i.e. long lasting self-motivation) by improving awareness of emotional and sensory cues, which may be effective for sustaining a behavior in the long term. It's about acceptance of the moment we're in and feeling whatever we feel (accepting both positive and negative emotions) without trying to resist, change or control it. Under emotional stress, most of us will try to comfort ourselves by putting something into our mouths, but being aware of the negative emotions, and having greater self-control skills may help us resist the urge to eat large quantities of food or unhealthy food. Thus, greater awareness and self-control skills may help an individual to better monitor and regulate their dietary intake as well as their engagement in physical activity.

When we live to eat, we tend to engage in the act of mindless eating because we tend to see food as a source of reward or entertainment, and we shovel food into our mouths without paying attention to what we're eating and whether we feel full. However, when we're more mindful or self-aware (i.e. eating to live), we become more conscious of what goes into our bodies by focusing fully on the act of eating and eating related decisions. The bottom line is mindfulness may help patients identify internal and external eating cues, manage food cravings, and enhance self-regulation and resilience- all factors important to counteract the behavioral fatigue that tends to occur in lifestyle interventions over time. Perhaps, when we're more mindful, we'll tune into our bodies instead of our thoughts (i.e., thinking about the costs/benefits), and will start to look at food as nourishment rather than as emotional comfort blanket. It is important to note that research in this area is still preliminary but exploring and understanding the relationship between mindfulness and health behaviors may hold promise for long-term weight management.


New Focus on Reducing Anemia in Adolescent Girls

Student Blogger
By Marion Roche, PhD

The target set out by the World Health Assembly is to reduce the anemia in all women of reproductive age by 50% by 2025. Women make up about 3.5 billion in population on our planet. In order to reach this World Health Assembly target, it will be essential to address anemia in the 600 million adolescent girls in the world and recently their nutrition has been getting more attention.

The global birth rate has declined over the past decade, except when analyzing the rate for adolescent girls, with 17-20 million adolescent pregnancies per year. Eleven percent of all pregnancies are to adolescents and 95% of these adolescent pregnancies are occurring in developing countries. 

Complications from pregnancy and child birth are the second greatest contributor to mortality for girls 15-19 years of age. Young maternal age increases the risk for anemia during pregnancy, yet adolescent women are less likely to be covered by health services, including micronutrient supplementation, than older women. Compared with older mothers, pregnancy during adolescence is associated with a 50% increased risk of stillbirths and neonatal deaths, and greater risk of preterm birth, low birth weight and small for gestational age (SGA) (Bhutta et al, 2013; Kozuki et al, 2013; Gibbs et al, 2012).

Reducing anemia in adolescents is often motivated by efforts to improve maternal and newborn health outcomes for pregnant adolescents; however, benefits for improving adolescent school performance and productivity at work and in their personal lives should also be valued.

Globally, iron deficiency anaemia is the third most important cause of lost disability adjusted life years (DALYs) in adolescents worldwide at 3%, behind alcohol and unsafe sex (Sawyer et al, 2012).

Adolescents have among the highest energy needs in their diets, yet in developing countries many of them struggle to meet their micronutrient needs. The World Health Organization recommends intermittent or weekly Iron Folic Acid Supplements for non-pregnant women of reproductive age, including adolescent girls. IFA supplementation programs have often been designed to be delivered through the existing health systems, without specific strategies for reaching adolescent girls.

I have heard adolescence referred to as “the awkward years” when individuals explore self-expression and autonomy, but it is also definitely an awkward period for public health services in terms of delivering nutrition, as we often fail to reach this age group. 

There have been examples of programs going beyond the health system to reach adolescent girls, such as through schools, peer outreach, factory settings where adolescents work in some countries and even sales in private pharmacies to target middle and upper income adolescent girls.
The Micronutrient Initiative implemented a pilot project with promising results in Chhattisgarh, India where teachers distributed the IFA supplements to 66,709 female students once per week during the school year over a 2 year pilot. 

It was new for the schools to become involved in distribution of health commodities, but engaged teachers proved to be effective advocates. There were also efforts to reach the even more vulnerable out of school girls through the integrated child development centers, yet this proved to be a more challenging group of adolescents to reach. Peer to peer outreach by the school girls offered a potential strategy. The current project is being scaled up to reach over 3.5 million school girls.

Adolescent girls have much to offer to their friends, families and communities beyond being potential future mothers. It is time to get them the nutrients they need to thrive in school, work and life.