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Small, Frequent Meals

Student Blogger
By: Hassan S. Dashti, PhD

Small, frequent meals, also referred to as grazing, picking, nibbling, and snack-eating, is a dietary pattern characterized by consuming multiple meals throughout the day. This dietary pattern has been on a rise, thanks to aggressive marketing of snacks, decline in home-meal preparation, longer waking hours, among other reasons. But aside from convenience, does consuming 6 to 8 or even 10 meals per day instead of the traditional 3 meals per day confer health benefits?

It was commonly believed that having many small meals per day increases satiety. Supporting this notion are cross-sectional studies suggesting an inverse association between eating frequency and body weight in adults(1). Meanwhile, data from the NHANES suggest a positive association between eating frequency and energy intake in the healthy US population, whereby each additional ‘eating episode' is estimated to contribute an additional ~200 kcal to overall energy intake potentially resulting in weight gain in the long-term (2). These findings, however, are greatly hindered as a result of underreporting of energy intake and meal frequency, particularly among nibblers (3).

The relationship between meal frequency and weight loss in overweight and obese individuals is also limited. A randomized, controlled trial in 2012 identified no differences in energy intake and BMI between participants randomized to either three or five meals per day (4). These findings were similar to other trials as well, which suggest no weight loss benefit from frequent meal intake (5). Meanwhile, in the healthy elderly, grazing may ensure adequate energy and micronutrient intake (6,7). While the contribution of small, frequent meals on energy balance remains equivocal, its influence should further be examined in the context of dietary quality and achieving adequate micronutrients intake.

Clinically, ‘small, frequent meals' is perhaps the most commonly used medical nutrition therapy.  Clinical nutrition guidelines generally recommend six to ten meals per day for patients experiencing early satiety and anorexia as they battle various diseases, such as pancreatitis and gastroparesis, or undergoing appetite suppressive treatment, such as chemotherapy, as recommended by the American Cancer Society(8). This eating pattern promises to decrease bloating, overcome early satiety and other symptoms, to help achieve adequate caloric intake (9). Grazing is also indicated post surgery for many gastrointestinal procedures including bariatric surgery and Whipple, to accommodate calories without abdominal distention and discomfort or dumping syndrome. Despite its short-term benefits, prolonging this dietary pattern post surgery may result in adverse health outcomes, such as less weight loss and eventual weight regain following bariatric surgery (10). These findings support the notion that this eating pattern more likely than not contributes to positive energy balance in the long-term. Yet this remains under examined, and whether the provision of small, frequent meals does indeed result in increased caloric intake in nutritionally at-risk individuals, such as those with pancreatitis, has yet to be elucidated.

An often-overlooked consequence of grazing is curtailed fasting duration. Clinical indications of small, frequent meals also include avoiding prolonged fasting, which is critical for cirrhotic patients, for example, to overcome the onset of endogenous protein breakdown for gluconeogenesis particularly during nocturnal fasting. However in healthy individuals, nocturnal fasting has been shown to provide various health benefits .

Several hurdles remain to be overcome in advancing our understanding of the relationships between grazing pattern and health. Among the most pressing limitations is the consistent use of a single definition for ‘meals' for meaningful comparisons among studies. In addition, appropriate assessment tools, such as multiple food diaries –capturing meal size and time – in addition to nutrient intake, instead of food-frequency questionnaires should be adopted moving forward to accurately assess frequency.

The 2010 Dietary Guidelines of Americans concludes that there seems to be inadequate evidence to accurately evaluate the relationship between meal frequency and nutrient intakes. The current evidence does seem to suggest that unless clinically indicated, perhaps the general population should follow a more structured, 3 nutritious meals at regular times per day because of difficulty related to achieving energy balance without proper portion control. In addition, small, frequent meals often tend to be in the form of convenient snacks, which contribute refined carbohydrates, rather than fats and proteins, to the diet, and therefore add minimal nutrition to the diet for the most part. Thus, if necessary, provision of this dietary pattern should also be supplemented by an education focused on healthy meals/snacks and portion control.


1.Kant AK. Evidence for efficacy and effectiveness of changes in eating frequency for body weight management. Adv Nutr. 2014 Nov;5(6):822–8. 

2.Kant AK, Schatzkin A, Graubard BI, Ballard-Barbash R. Frequency of eating occasions and weight change in the NHANES I Epidemiologic Follow-up Study. Int J Obes Relat Metab Disord. 1995 Jul;19(7):468–74. 

3.McCrory MA, Campbell WW. Effects of eating frequency, snacking, and breakfast skipping on energy regulation: symposium overview. J Nutr. 2011 Jan;141(1):144–7. 

4.Bachman JL, Raynor HA. Effects of manipulating eating frequency during a behavioral weight loss intervention: a pilot randomized controlled trial. Obesity (Silver Spring). 2012 May;20(5):985–92. 

5.Kulovitz MG, Kravitz LR, Mermier C, Gibson AL, Conn CA, Kolkmeyer D, et al. Potential role of meal frequency as a strategy for weight loss and health in overweight or obese adults. Nutrition. 2014 Apr;30(4):386–92. 

6.Zizza CA, Tayie FA, Lino M. Benefits of snacking in older Americans. J Am Diet Assoc. 2007 May;107(5):800–6. 

7.Zizza CA, Arsiwalla DD, Ellison KJ. Contribution of snacking to older adults' vitamin, carotenoid, and mineral intakes. J Am Diet Assoc. 2010 May;110(5):768–72. 



10.ConceiÇão EM, Mitchell JE, Engel SG, Machado PPP, Lancaster K, Wonderlich SA. What is “grazing?” Reviewing its definition, frequency, clinical characteristics, and impact on bariatric surgery outcomes, and proposing a standardized definition. Surg Obes Relat Dis. 2014 Sep;10(5):973–82. 

11.Marinac CR, Natarajan L, Sears DD, Gallo LC, Hartman SJ, Arredondo E, et al. Prolonged Nightly Fasting and Breast Cancer Risk: Findings from NHANES (2009-2010). Cancer Epidemiol Biomarkers Prev. 2015 May;24(5):783–9. 

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

Student Blogger

By: R. Alex Coots

The field of nutrition is diverse. Some nutrition researchers pursue their work to better understand human metabolism, while others seek to help people build healthy eating habits. Despite the different approaches in their research programs, nutrition researchersall aim to improve public health. But simply producing the information isn't enough. The entirety of scientific knowledge must be evaluated and used to create effective policies to fully realize the benefits of nutrition research.

Angela Tagtow, Executive Director of the Center for Nutrition Policy and Promotion at the USDA, continues an illustrious career in health promotion at the USDA. She's worked in nutrition, public health and food systems at levels ranging from local initiatives to international endeavors. She and I had a conversation about her career, her advice for students interested in policy, and her thoughts on the challenges of policy work.

How did you get your start in nutrition and policy?

Growing up, food and meals were very important in my family. We maintained a large garden which provided diverse foods for our day-to-day meals. In college I had an intense interest in health promotion, but clinical dietetics was focused on treatment rather than prevention of illness. Health promotion at the time was nascent but I saw the potential and oriented my life towards it.

After graduation from college I started work at the American Heart Association as a program director. This position helped build out my network and gave me my start in the health promotion world, however I quickly realized I'd need graduate-level training to take my career further. After graduate school I started work as a consultant in the WIC program at the Iowa Department of Public Health. Here I worked more broadly in the public health domain with a variety of groups such as the county boards of health and Title V Maternal and Child Health Services.

After 9 years, I decided to expand my areas of expertise to include food systems as well as public health and nutrition. I founded a consulting company where I provided education, informed policy, and developed communication tools around health, the environment, and food systems. After 9 years of consulting, I moved back to government to work at the CNPP.

What are the key lessons or skills that you took away from these endeavors?

Consulting work affords you a good deal of flexibility in the types of work that you take on. I was able to broaden my skillsets, increase my knowledge base, and diversify my network in ways that I wouldn't have been afforded in government. Consulting does have a bit more uncertainty with respect to job security. A career in government is a much different experience. The scope of the work is more defined and the position is more secure compared to consulting, but it may be difficult to advance upward.

The key skillsets that today's students should focus on are critical thinking, communication, and engagement. As dietitians and nutritionists, we need to feel comfortable being assertive and asking the difficult questions. Of these three skills, engagement and networking are the hardest to teach. Students should continually practice this skill throughout their careers. Networking is something that takes time and is an ongoing learning experience.

When creating nutrition policy, are particular data or data types more useful than others?

All of the different data types must be considered, especially systematic reviews and randomly controlled trials. We need to be looking at the preponderance of data to reach a conclusion, not create policy based on one particular study or study type, as each type of study has strengths and weaknesses. After evaluation of the data, we have to be able to translate the body of research into appropriate policy or interventions. Policy is like a puzzle and data are the pieces.

Do you feel that there's siloing of academic fields, and that crosstalk can improve healthoutcomes?

There's still some siloing of research topics, but there has been improvement. Some land grant institutions with great agricultural research programs focus on food production or food processing issues, but this work is not necessarily connected to the greater picture of human health. Some schools have recognized this issue and have started interdisciplinary programs aimed towards interconnectivity – programs in food systems is a good example. People have recognized the value of an integrated approach, but it's a process that takes time to develop.

Part 2 of this interview will be posted in my next entry.

High Sodium Warning Labels…New York’s Latest Public Health Policy

Student Blogger

By: Mary Scourboutakos

In just a few weeks, New York will be the first city to introduce high sodium warning labels in restaurants. As a result, come December 1st 2015, any menu item that exceeds 2300 mg of sodium will be required to sport the new graphic [pictured here] illustrating a salt shaker inside of a triangle.

The policy, which is an amendment to the New York City Health Code, will affect any chain restaurant with at least fifteen locations, and will affect over 3000 restaurants, or one-third of all restaurant traffic in New York City.

Megan Lent, the Acting Director of Policy at the Bureau of Chronic Disease Prevention and Tobacco Control, who was involved in the background research and development of the policy, said the idea came from research which showed that people are eating more of their meals away from home. Furthermore, she said the rationale also comes from sodium's effect on blood pressure, and ultimately heart disease—which is the leading cause of death in New York City. Hence, she explained that this policy will “put information back into consumers hands” and thus hopefully foster healthier choices.

While some might argue that 1500 mg—the daily Adequate Intake level—would be a more conservative limit, Lent says they went with 2300 mg—the daily Upper Tolerable intake level—because “this clearly lets people know when they've reached that threshold, without making assumptions.”

As for the choice of a pictorial warning label, Lent explained that listing the number of milligrams of sodium is preempted by the federal calorie labeling law that was passed as part of the Patient Protection and Affordable Care Act, back in 2010. Hence, numerical information regarding sodium simply isn't allowed. Nevertheless, as Lent highlighted, one advantage of the graphic is that it provides an “actionable symbol.”

The implementation of policies such as this one, rarely come without backlash from critics. However, while this policy did receive some comments from the food industry during the public comment period, Lent explained that with regards to the media coverage “a lot has been fairly supportive.” And while some experts have criticized the whole notion of menu-labeling, citing a lack of evidence of effectiveness, Lent says polling has shown that “many New Yorkers think calorie labeling is useful and that these interventions are helpful.”

In a recent article posted on Nation's Nutrition News, Anita-Jones Mueller, the founder of Healthy Dining and, told industry to “just say no” by stating “save money and time, and prevent the risk of disappointed guests, by saying NO to the icon and making sure that most — if not all — of your menu items contain under 2,300 mg of sodium. It's possible!”

But is it possible? In my own research, I've found that 56% of meals from chain, sit-down restaurants would qualify for the warning label, if it was implemented in Canada. However, when menu items are listed individually on the menu (ex. side dishes separate from entrÉes) only 9% would carry the label.

The New York Department of Health plans to evaluate the policy by monitoring changes in sodium levels over time using “Menu Stat”, their free online longitudinal nutrition database containing information for thousands of restaurant foods. But will the policy encourage decreases in sodium, as was seen in King County, Washington after the implementation of their sodium labelling policy? One can only hope!

The French Approach to Nutrition

Student Blogger
By Emily Roberts

The United States is able to utilize government assistance to support various programs to help improve the nutritional status of our nation. There is a safety net of several programs to improve public health via nutrition. Prolonged consequences of an unhealthy lifestyle including obesity, heart disease and type II diabetes are being seen in other countries as well. As I am currently residing in the south of France for seven months to teach English, I have the opportunity to discover how another country is tackling the public health problems associated with nutrition.  

Chronic Diseases in France

Worldwide we are seeing an increase rate of health disparities. Cardiovascular disease, obesity and type II diabetes are three main common ailments and are often preventable. Cardiovascular disease is the leading cause of death worldwide (1). Now in the 21st century over 30% of the world's population suffers from heart disease. Interestingly enough in France, heart disease mortality isn't as high as other 1st world countries (2). Despite a diet rich in saturated fats and cholesterol, the incidence of heart disease remains low (3). While heart disease may not been the main concern, circulatory disease remains an issue, being the second leading cause of death in 2012 after cancer (2).  In 2014 25.7% of the French adult population was obese (4). Comparing this to the United States at 35% they aren't too far behind (5). Type II diabetes is drawing attention as well as a health issue. In 2009 7.0%- 7.5% of the French population had type II diabetes in comparison to about 10.41% of the United States Population (6,7). France is addressing currently addressing these problems and taking on tactics similar to the United States by promoting preventative methods.

Le Programme National Nutrition SantÉ (PNNS)

Manger Bouger translates to Eat and Move. It is supported by Programme National Nutrition SantÉ (PNNS) meaning a national nutrition and health program (8). PNNS began in 2001 with the objective to improve public health and reduce the incidence of chronic diseases by improving nutritional practices. The goals of PNNS assess different social, cultural, cognitive and economic disparities when trying to improve the nutritional status and the level of physical activity of France. Under the umbrella of PNNS there are a few specific programs. In 2010, the French government has implemented un plan obÉsitÉ (PO) (an obesity plan) and also un programme national pour l'alimentation (PNA) (a national food program).

Manger Bouger

Similar to the US's ChooseMyPlate, the Manger Bouger site offers a plethora of helpful nutritional information to the public (9,10). It stresses to regularly eat a diet mixed in fruits, vegetables, grains and fish; limit salts, sugars and fats and to participate in regular physical activity (10). It explains to the public how these healthy lifestyle choices can reduce your risk for many chronic ailments. The site also briefly mentions to read nutrition facts labels, but there is little assistance on how to understand this information. Furthermore, the format for Nutrition Facts in France is very different and hard to interpret given the main point that there are often no serving size portions and only 100g portion sizes. While, there is no software on the site similar to SuperTracker or any type of diet assessment tool, there is La Fabrique à Menus, which helps to plan out a daily menu of various healthy dishes. Manger Bouger also includes a blog titled “Le Mag” which includes tips on how to enjoy the many rich flavors of France or eating on a budget, while still eating healthy.

My experience

Living in France, I have witnessed how important cuisine is to the French population. A prime example is how each region has traditional dishes tied closely to their culture. In Nice a popular dish is socca, a chickpea pancake, and in SÈte you cannot walk a block without finding tielle, a savory fish tart. Manger Bouger embraces this by providing general nutritional practices like consuming smaller portions, while keeping the tradition of French cuisine alive. Manger Bouger only offers specific meal advice for lunch and dinner (11). This is most likely because a typical French breakfast or petit dÉjeuner is only a slice of bread or a croissant and a coffee.  Snacking in France is also less common. While in America five small meals a day can be seen as a healthy eating habit, this would not be ideal for the French as they value their meal time as a time to relax and experience their food. Unfortunately, the French do not seem to draw much attention to the specific nutritional content of their food. Consequently the general public does not seem as well educated on their daily caloric intake and the nutritional makeup. This could be due to the fact that they seem to focus more on reducing portion sizes and over eating rather than changing the composition of their diet.














Interview with Andrew Brown, PhD

Student Blogger
By Allison Dostal, PhD, RD

The relationship between nutrition and health is fully entrenched in the mainstream media - everyone from career scientists to our next door neighbor seems to be an expert on the topic. Trained health professionals and researchers do our best to deliver credible information, but it's all too easy for clear messages to get lost in the constant stream of 30-second sound bites. 

Dr. Andrew Brown, a Scientist with the University of Alabama-Birmingham's Nutrition Obesity Research Center (NORC) & Office of Energetics, is focusing his current work on illuminating common misconceptions in the field of nutrition and increasing awareness of media perspectives and biases. I recently had the opportunity to ask him a few questions related to research integrity, science communication, and being a part of the next generation of nutrition researchers and educators working to effectively deliver nutrition information in the Digital Age.

Tell us about your work with NORC and the Office of Energetics.

The majority of my work is in the field of meta-research, which can involve investigating what was studied, why it was studied, and how it was studied. In addition to the more common forms of meta-research, like systematic reviews and meta-analyses, I look at the way that research is conducted, the quality of reporting, analytical choices during statistical analysis, and from where nutritional zeitgeist comes despite little strong empirical evidence.

How did you become interested in calling attention to myths, presumptions, and reporting accuracy of nutrition research?

As a student studying lipid chemistry, I noted that most lipid biochemists (as well as many others) recognized that dietary cholesterol had little impact on blood cholesterol, and yet cholesterol-containing foods were demonized. During my doctoral degree, I attended the Office of Dietary Supplements' Research Practicum, where I anticipated learning what was and was not known about the health impacts of dietary supplements. Instead, and to my benefit, much of the talk was about limitations of current research, regulatory limitations, and differences in philosophies about how diet – and particularly supplements – could be studied. Claims about dietary cholesterol and supplements are just some of the dietary beliefs that are either completely refuted by our best science or at best weakly supported; yet, many people within and beyond the nutrition science community believe them. Thus my interest is at least two fold. The first is trying to determine which beliefs I hold that are not supported by the evidence, such as the relationship between eating/skipping breakfast and obesity. The other is to help communicate the state of science to hopefully decrease confusion. 

With the attention that your research group is calling to this movement, how do you see publication and the media's attention to nutrition changing in the next 5-10 years?

I am optimistic that nutrition science will continue to improve, including more discussions of the nuances of nutrition science rather than speaking in absolutes. If we ‘know' that sugar is bad, or polyunsaturated fats are good, or that breakfast prevents obesity, then there is nothing left to study. Because of human heterogeneity within ever-changing local and global environments, it is unlikely that there is one diet or one set of recommendations that is appropriate for everyone and every situation, even for essential nutrients. Population-level recommendations are great place-holders until we develop more refined recommendations for individuals, subgroups, food-types, food-compositions, and other aspects of diet. 

In a recent ASN blogger interview with Paul Coates, the Director of the NIH Office of Dietary Supplements, he stated with regard to the aging of the nutrition researcher population, “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.” What are your thoughts on strategies for engaging young nutrition researchers in scientific discourse? How can young researchers take part in a dialogue with fellow scientists, the media, and the public to improve communication and perception of nutrition research?

I think we need to keep our eyes open for promising individuals that we can trust to think scientifically and ethically, and help them grow in a tailored way. The increased use of Individual Development Plans seems to be a great step in this direction, as is putting a maximum number of years on post-doctoral training, with the idea that a post-doctoral position is for additional training, not for an indefinite job. I have been extremely fortunate to have had mentors that gave me opportunities to speak, develop ideas, and truly contribute to teams and discussions throughout my formal education, as early as my freshman year. I was encouraged to write grants, publish, and complete other essential activities in the business of science, but my mentors focused very much on teaching me how to ask scientific questions; read the existing literature; develop critical scientific thinking skills; communicate with precision; and conduct good science. 

On the side of mentees and students, I think it is important to be inquisitive while being willing to admit if you don't know something. Stating confidently something that is false is a great way to lose trust and be excluded from the discussion. Instead, ask for clarification; add information to the conversation that might be useful; and, most importantly, don't force yourself into discussions just to be noticed. 

I also think it is important to move away from research focusing so heavily on public health (with the full disclosure that I work in a School of Public Health). Improvements in the public's health is a noble and lofty goal, but to come into a study with the assumption that the outcome will result in an improvement in public health (particularly the entire population's health) encourages overstating of results, misinterpretation of data, and doubling-down on dietary preconceptions. In science, the focus needs to be on determining some form of objective truth or lawful relationship. If we can identify these truths and relationships, then ways to improve public health will become self-evident, with the understanding that policy decisions are based on value structures beyond scientific evidence.

What advice do you have for graduate students and early career investigators? 

Make sure you are doing something you love, that you do it to the best of your ability, and that you do it with the highest integrity. Be sure anything you put your name to is something that you are willing to take credit for, but also understand that this means you will be responsible for shortcomings of the work if problems are discovered later. And always be willing to entertain and evaluate an idea, especially one you disagree with or find unpalatable; these could be the very ideas that lead you to new lines of work, may help you better communicate your ideas to those who disagree with you, or might even overturn your entire view on a subject. As Aristotle said, “It is the mark of an educated mind to be able to entertain a thought without accepting it.”

Fish Consumption during Pregnancy: Weighing the Risk-Benefit

Michelle Hendley

By Christopher Radlicz

Currently, only one-quarter of pregnant women in the United States are eating the amount of fish recommended for optimal maternal and child health (1). On the other end of the spectrum, about 10% of women of childbearing age have higher than recommended blood mercury concentrations (2).

A qualitative study done in 2010 has helped explain why women may be consuming less than the recommended two-servings of fish per week (1). Pregnant women in the Boston area, who under-consumed fish according to these guidelines, were broken into focus groups and discussed what was keeping them from eating more fish. These groups revealed that many women knew that fish might contain mercury, but were naïve of the fact that fish contained beneficial fatty acids, such as docosahexaenoic acid (DHA), which is essential for optimal fetal brain development (3). The women admitted that they hadn't received advice to eat more fish or more specifically to eat fish that contain lower amounts of mercury and higher amounts of beneficial fatty acids. Instead, the women confessed that they were advised to limit fish intake due to possible mercury exposures.

Are these women misguided in keeping their fish consumption below the recommended two-servings per/week during pregnancy?

This past February, The 2015 Dietary Guidelines Advisory Committee reiterated that women who are pregnant, nursing, or are planning to become pregnant should still consume fish because neither the risk of mercury nor other organic pollutants outweigh the benefits (4). In a recent New York Times article on the issue, Dr. Steve Abrams, medical director of the Neonatal Nutrition Program at Baylor College of Medicine and panel member on the advisory committee commented on tuna consumption, explained, “The benefit of having (omega-3 fatty acids) in your diet really exceeds the likely risk of contamination. The point is that you should have a variety of types of seafood and not limit yourself to one type, and variety includes canned tuna.”(5).

The intake of fish during pregnancy is certainly more nuanced than simple elimination from the diet due to potential mercury exposure. Fish contains essential nutrients proven to have beneficial effects on brain neurodevelopment and may prevent cardiovascular disease (6). These benefits have been attributed in part to the long chain polyunsaturated fatty acids (LCPUFAs), DHA and eicosapentaenoic acid (EPA), but in addition seafood is a good source of protein, selenium, iron, iodine, choline, and vitamins E and D (4,7). These LCPUFAs are essential throughout pregnancy but are critical from the beginning of the third trimester until about 18 months after birth when the human brain is growing the fastest. Neglecting to supply LCPUFA among other nutrients during this period may result in deficits in brain development (9).

That being said, mercury exposure is a real possibility. Methylmercury is the organic form of mercury that we are exposed to when consuming fish in our diet. This form of mercury is relatively stable, mobile within the body, and exhibits a high potential to damage the brain (8). Mercury poisoning outbreaks in Japan are a testament to the wide spread damage that can occur from exposure to methylmercury, resulting in infants born with serious neurological damage, even when mothers were seemingly unaffected (10).

Extreme exposure to mercury in the food chain as in the case of Japan is a rather isolated instance though. But what is the balance? Do the beneficial effects of fish counteract the adverse effects of toxicants?

In the literature, detection of methylmercury exposure in infants is typically done by measuring levels in maternal hair, maternal toenails, cord blood, and maternal blood. These methods are variable in measuring biomarkers and on certain occasion, can be imprecise (5,7). Additionally, many observational studies do not statically control for negative confounders. This means that majority of the cohort studies done in this field have focused on either the risk of methylmercury or on nutrient benefits but not both (7).

All of the complications in study design and analysis show the complexity of establishing recommendations from these studies. Even with good study designs, clear-cut recommendations as to how much fish pregnant women should eat may still not be feasible, due to the variability of toxicants in seafood species. Empowering pregnant women by informing them of seafood that is lower in mercury levels and higher in LCPUFAs is a practical solution. A pertinent rule to apply when making seafood choices is that small sea creatures, which live shorter lives and are lower on the food chain, tend to be the lowest in methylmercury levels and exponentially higher in LCPUFAs. Larger seafood, on the other hand, tends to have higher levels of methylmercury due to a longer lifespan and their higher settlement on the food chain allowing for an accumulation of more methylmercury. The Dietary Guidelines Advisory Committee is in consensuses with the FDA and EPA in advising pregnant women to avoid eating these larger fish, such as swordfish, tilefish, shark, and king mackerel due to their high levels of methylmercury (4,7).


1.Bloomingdale A, Guthrie LB, Price S, Wright RO, Platek D, Haines J, Oken E. A qualitative study of fish consumption during pregnancy. Am J Clin Nutr 2010; 92: 1234-40. doi:10.3945/ajcn.2010.30070

2.Mahaffey KR, Clickner RP, Bodurow CC. Blood organic mercury and

 dietary   mercury   intake:   National   Health   and   Nutrition   Examination

 Survey, 1999 and 2000. Environ Health Perspect 2004 ;112:562–70.

3.Koletzko B, Cetin I, Thomas Brenna J. Dietary fat intakes for pregnant

 and lactating women. Br J Nutr 2007;98:873–7.

4.United States Department of Agriculture. Scientific Report of the 2015 Dietary guidelines Advisory Committee. Washington, DC. 2015.

5.Parker-Pope T. (2015, March 2). Should Pregnant Women Eat More Tuna. The New York Times. Retrieved from

6.Anon. The Madison Declaration on Mercury Pollution. Ambio 2007;36:62–65. [PubMed: 17408191]

7.Choi AL, Cordier S, Weihe  P, Grandjean G. Negative Confounding in the Evaluation of Toxicity: The Case of Methylmercury in Fish and Seafood. Crit Rev Roxicol. 2008; 38: 877-893. doi:10.1080/10408440802273164.

8.Clarkson CW, Vyas JB, Ballatori N. Mechanisms of Mercury Disposition in the Body. American Journal of Industrial Medicine 2007;50:757-764.

9.Innis SM. Essential fatty acids in growth and development. Prog Lip Res 1991; 30: 39.

10.Harada M. Minamata Disease: Methylmercury Poisoning in Japan Caused by Environmental Pollution. Crit Rev Toxicol 1995;25:1–24.

11.Hibbeln JR, Davis JM, Steer C, Emmett P, Rogers I, Williams C, Golding J. Maternal seafood consumption in pregnancy and neurodevelopmental outcomes in childhood (ALSPAC study): an observational cohort study. Lancet 2007;369:578–585. 

Why Economists are making the Case for Stunting Reduction

Michelle Hendley

By Marion Roche, PhD

Approximately162 million children are stunted.In the global nutrition community the human costs of stunting are well recognized: stunted children complete less school, have less learning and earning opportunities, and females who become moms in the future are more likely to give birth to stunted children. Intervening early in 1000-day window (from conception to the age of two) and even earlier, pre-pregnancy, is recognized as most cost-effective way to prevent, as in many settings it challenging to reverse the physical and cognitive deficits from chronic malnutrition.  Beyond the human costs, there is also an economic case to be made for investing in stunting reduction.

Every four years, the world's leading economists and experts from diverse development fields come together to rank the best investments for development in what is called the Copenhagen Consensus. Nutrition is one such investment that is consistently ranked as a “best buy”.  Specific interventions such as vitamin A supplementation, salt iodization, zinc & ORS for diarrhea treatment and support for breastfeeding and adequate complementary feeding have all been in the top 10 best investments in previous years.  In addition, nutrition-sensitive approaches, such as keeping girls in school, improvements to agriculture yields and crop quality, enabling gender equity for women, and overall poverty reduction, are all necessary to sustainable long-term stunting reductions for communities and countries.

                This month, world leaders and experts met in Addis Ababa, Ethiopia for the Third International Financing for Development conference. A presentation by Dr. Meera Shekar of the World Bank and Dr. Robert Hetch of Results for Development at an MI co-hosted side-event on nutrition at the conference laid out what it would take to  achieve the World Health Assembly target of reducing stunting by 40% by 2025.  They emphasized that strategic investing in improving the nutrition situation for 68 million children would offer a long-term $45 dollar return on each dollar invested. More specifically, every dollar invested in reducing stunting is estimated to generate an $18 return in the long run.  However, although many nutrition interventions look affordable on an individual scale, a more detailed analysis has been done to show what it would cost to deliver these interventions and reduce stunting at a global scale. 

                The Financing for Development conference was centred on funding the Sustainable Development Goals, the set of targets relating to the of future international development post-2015. Looking at the return on investment (ROI) in nutrition and knowing that nutrition has such a profound effect on other areas of a person's life, I think there is no better investment the world can make to reach the SDGs more quickly and effectively than that in nutrition! 

What do we know about the timing of intake?

Michelle Hendley
By Hassan S Dashti, PhD

When we describe our habitual diets, we often find ourselves talking about its nutritional composition (i.e. what) and quantity (i.e. how much), however novel research suggests that timing of intake might be yet another important component of diet we want to pay attention to. This was the main focus of discussion at the ASN Scientific Sessions at EB 2015 symposium titled, “Is ‘When' We Eat as Important as ‘What' We Eat? – Chronobiological Aspects of Food Intake” (read more here: Biologically, this makes sense as an endogenous clock, commonly termed the circadian clock, regulates a constellation of biologic processes, including metabolism (1). If up to 30 percent of genes in the intestines, liver, and kidney fluctuate throughout the day, yielding varying temporal functional profiles, doesn't it make sense that there ought to be a time when dietary intake is optimal? Well, if the effect of a calorie on health is dependent on timing, what we all would like to know next is at what time should we be eating?

What currently determines our timing of intake is our culture and lifestyle for the most part. For instance, kids' lunchtime is predetermined by school cafeterias, adults' dinnertime is predetermined by rush-hour traffic, but even breakfast also seems to determine when we'll have our next meal, lunch (2). History also played a role in determining meal times. In certain parts of the world, lunchtime was set for noon to enable workers to cope with long working hours in factories during the Industrial revolution. Perhaps it's time to have science determine our meal hours.

Preliminary evidence suggests that earlier meal times tend to be healthier and “better aligned” with our biological clock. In one study, it was found that calories consumed after 8:00pm significantly predicted higher BMI (3). Meanwhile results from a 20-week weight loss intervention among overweight and obese individuals suggested that late eaters (lunch after 3:00pm) were less successful at weight loss compared to early eaters (lunch before 3:00pm), independent of 24-hour energy intake (4). Another trial assessing overweight and obese women further identified that high-calorie breakfasts, as opposed to high calorie dinners, were more beneficial for various cardiometabolic traits (5). Consistent with the findings from these trials is a cross-sectional analysis of a diverse cohort in the Los Angeles area that suggested that participants who consumed over a third of their calories by noon were less likely to be overweight and obese (6).

While these findings generally suggest that earlier hours of intake are generally healthier, they are not without their many limitations. One limitation worth noting is the high interrelatedness between timing of intake and other aspects of diet and life that also impact overall health and particularly sleep timing and duration, frequency of intake, and hours of fasting. Therefore, future studies should account for these strongly related dimensions when elucidating the timing of intake that best aligns with our internal clock.

1.Garaulet M, Gómez-Abellán P. Timing of food intake and obesity: a novel association. Physiol Behav. 2014 Jul;134:44–50. 
2.Kant AK, Graubard BI. Within-person comparison of eating behaviors, time of eating, and dietary intake on days with and without breakfast: NHANES 2005-2010. Am J Clin Nutr. 2015 Sep;102(3):661–70. 
3.Baron KG, Reid KJ, Kern AS, Zee PC. Role of sleep timing in caloric intake and BMI. Obesity (Silver Spring). 2011 Jul;19(7):1374–81. 
4.Garaulet M, Gómez-Abellán P, Alburquerque-BÉjar JJ, Lee Y-C, Ordovás JM, Scheer FAJL. Timing of food intake predicts weight loss effectiveness. Int J Obes (Lond). 2013 Apr;37(4):604–11. 
5.Jakubowicz D, Barnea M, Wainstein J, Froy O. High caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity (Silver Spring). 2013 Dec;21(12):2504–12. 
6.Wang JB, Patterson RE, Ang A, Emond JA, Shetty N, Arab L. Timing of energy intake during the day is associated with the risk of obesity in adults. J Hum Nutr Diet. 2014 Apr;27 Suppl 2:255–62. 

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.


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

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;
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;
7.Green tea may lower heart disease risk. Harvard Heart Letter 2012;
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.