American Society For Nutrition

ASN Blog

ASN Blog

Excellence in Nutrition Research and Practice

Can Vitamin D Help Prevent the Development of Type 2 Diabetes?

Student Blogger
By Banaz Al-khalidi

November is National Diabetes Month and World Diabetes Day takes place every year on November 14 to engage millions of people worldwide in diabetes advocacy and awareness. The International Diabetes Federation estimated that 382 million adults (20-79 years old) suffered from diabetes in 2013, which equates to a prevalence of 8.3%. To provide a better perspective by nation, the 10 countries with the highest prevalence of diabetes in 2013 were as follows: Tokelau (37.5%), Federated States of Micronesia (35%), Marshall Islands (34.9%), Kiribati (28.8%), Cook Islands (25.7%), Vanuatu (24%), Saudi Arabia (24%), Nauru (23.3%), Kuwait (23.1%), and Qatar (22.9%). However, if we were to look at the 3 countries with the greatest number of people with diabetes, China ranks the highest (98.4 million), followed by India (65.1 million) and USA (24.4 million). These figures are quite alarming.

Of those suffering from diabetes, type 2 diabetes comprises almost 90% of people with diabetes around the world. As such, type 2 diabetes is one of the fastest growing health problems in the world. So what could be driving this epidemic?

Evidence from observational studies have consistently shown us that low blood levels of vitamin D are associated with an increased risk of type 2 diabetes. The results of numerous observational studies led to speculation that the development of type 2 diabetes is associated with vitamin D insufficiency. Going back to the figures presented earlier, if vitamin D insufficiency is a risk factor for type 2 diabetes, one might also speculate that countries with higher prevalence of diabetes are facing a coexisting problem of type 2 diabetes and vitamin D insufficiency. For example, Tokelauans (the nationals of Tokelau) who have the highest prevalence of type 2 diabetes may also be at risk for vitamin D insufficiency despite having a tropical and marine climate. The question then becomes, could vitamin D be a causal factor in the development of type 2 diabetes? While this might sound too simplistic, I assure you it's not.

Interpretation of evidence on vitamin D and type 2 diabetes is complicated for a number of reasons. First and foremost, observational studies do not tell us anything about the cause-effect relationship between vitamin D and type 2 diabetes because of possible uncontrolled confounding factors, such as physical activity, that may affect both vitamin D levels and the risk of type 2 diabetes. Second, observational studies cannot inform us about reverse causation. In other words, which comes first, the chicken or the egg? Third, there are a myriad of factors that affect vitamin D levels, including environmental, cultural, genetic and physiological factors.

It remains unclear then whether there is a causal link between vitamin D and type 2 diabetes.

To answer this question, a large genetic study, published in The Lancet Diabetes and Endocrinology journal, looked at the causal association between low blood levels of vitamin D and risk of type 2 diabetes. The study concluded that the association between vitamin D and type 2 diabetes is unlikely to be causal. The research, which was a Mendelian randomization study, examined the link between type 2 diabetes risk and vitamin D, by assessing the genes that control blood levels of vitamin D. Most importantly, the design of this study has a powerful control for confounding factors and reverse causation which are issues of concern in observational studies. This may partly explain the discrepancy between results from earlier observational studies and this study in question. However, we still need to be cautious about interpreting the results from mendelian randomization studies as some of the underlying assumptions in the study might remain untested.

The take home message is that no special recommendations could be made about vitamin D levels or supplementation for people with type 2 diabetes. However, long-term randomized trials of vitamin D supplementation remain important to elucidate vitamin D's role in type 2 diabetes.

As we recognize National Diabetes Awareness this month, it is important to remind patients that diabetes is a progressive chronic lifestyle disease that can be controlled by making healthy lifestyle changes- such as partaking in regular physical activity, eating a balanced diet, maintaining a healthy body weight, taking prescribed medications, joining a smoking cessation program, and improving sleeping patterns.

Reference
Zheng Ye, Stephen J Sharp, Stephen Burgess, Robert A Scott, Fumiaki Imamura, Claudia Langenberg, Nicholas J Wareham, Nita G Forouhi. Association between circulating 25-hydroxyvitamin D and incident type 2 diabetes: a mendelian randomisation study. The Lancet Diabetes & Endocrinology, 2014; DOI: 10.1016/S2213-8587(14)70184-6.

Health Literacy and Implications in Nutrition Care

Student Blogger
By Mayra Sofia Crespo Bellido

“I drink tea of guanábana leaves when I can't make it to my chemotherapy sessions. Did you know Miss, that eating guanábana is just as good as 10 chemotherapy sessions?” I was shocked when a patient shared this piece of information with me during a nutritional assessment interview. Luckily, my preceptor stepped in and educated the patient and his spouse on the risks of completely substituting traditional medicine with alternative treatments that are not evidence-based. He argued with my professor. In that moment it sunk in how dangerous health illiteracy can be.

Health literacy has been defined as  “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” It involves different factors such as: health knowledge, listening, speaking, arithmetical, writing, and reading skills, and cultural competencies of health professionals as well as other systemic factors.

According to the National Center for Education Statistics, nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease. Nearly 14% of adults (30 million people) have ‘below basic' health literacy. These adults were more likely to report their health as poor (42%) and are more likely to lack health insurance (28%) than adults with Proficient health literacy. These patients are more likely not to vocalize their concerns and questions as well as being less active participants in their care because of the stigma associated with being health illiterate. Being health illiterate is a stronger predictor of health than socioeconomic status, education, ethnicity, or race.

Nutrition professionals in all areas face health illiteracy on a day-to-day basis. During my dietetic internship training, I have a difficult time gathering accurate information from patients during the nutritional assessment in the clinical setting, particularly when assigned a high patient load. That initial interaction may be somewhat compromised by the fact that most patients do not know how to express nutritional concerns and time is too constricted to dig deep into the answers provided. Same goes to other areas of practice: nutrition researchers dealing with tailoring informed consent forms to the level of health literacy of their population of interest or foodservice managers explaining to their employees the reasons to follow HACCP procedures to ensure food safety. Even public health nutrition professionals may face it while trying to advocate in favor of measures such as the taxation of sugar-sweetened beverages.

Healthy People 2020 includes the specific objective to increase health literacy under the topic of Health Communication and Health Information Technology. In this era health and nutrition information is produced and distributed by individuals and organizations with various agendas.  It is critical that people have the skills to navigate this sea of information without feeling overwhelmed by nutrition confusion. Guiding people through this process and giving them strategies to find and understand accurate food and nutrition information could allow for a new sense of empowerment that could position dietitians, nutritionists and other nutrition professionals as the go-to source in these matters for people who have put their trust elsewhere to get the information.

The World Health Organization has determined improving health literacy has implications in a greater scope than individual decision-making processes with the following quote:
“[…] Health Literacy goes beyond a narrow concept of health education and individual behavior-oriented communication, and addresses the environmental, political and social factors that determine health. Health education, in this more comprehensive understanding, aims to influence not only individual lifestyle decisions, but also raises awareness of the determinants of health, and encourages individual and collective actions which may lead to a modification of these determinants. Health education is achieved therefore, through methods that go beyond information diffusion and entail interaction, participation and critical analysis. Such health education leads to health literacy, leading to personal and social benefit, such as by enabling effective community action, and by contributing to the development of social capital.”
Such an impact could guide the food and nutrition policy measures that are needed to ensure the population's health by activism that intends to change social determinants of health. Wow!

There is a vast amount of literature in health literacy, yet there is still some room for improvement in the scope of practice. Public health and community nutrition professionals could make use of the health care system's shift from acute care towards preventive care and health promotion to justify projects that improve basic health literacy skills. Helping people understand the purpose of health and nutrition behavior change, increasing self-efficacy and helping individuals make decisions accordingly is vital.

References
Department of Health and Human Services (US), Office of Disease Prevention and Health Promotion. Health literacy online: A guide to writing and designing easy-to-use health web sites.

Health Communication and Health Information Technology- https://www.healthypeople.gov/2020/topics-objectives/topic/health-communication-and-health-information-technology

Health literacy and health behaviour- http://www.who.int/healthpromotion/about/en/

Carbone E., Zoellener, J. (2012) Nutrition and Health Literacy: A Systematic Review to Inform Nutrition Research and Practice. J Acad Nutr Diet. doi: 10.1016/j.jada.2011.08.042

Interview Featuring MNC Chair Dr. Connie Bales

Suzanne Price
Connie Bales, PhD, RD, is the current chair of ASN's Medical Nutrition Council, which leads ASN's clinical nutrition conference series.  In an interview, the clinical researcher and educator from Duke University Medical Center and the Durham VA Medical Center speaks about upcoming pursuits for the council, what she hopes to achieve in her new role, and the information overload problem the field is facing. Read the entire interview here.

Mobile Innovations in Global Nutrition Research

Student Blogger
By Marion Roche, PhD

At the 2014 Clinton Global Initiative in late September, former President Bill Clinton remarked that a Masaai Warrior has better access to mobile communications today using a small cell phone than he had during his presidency 25 years ago. This access to technology is providing a wealth of opportunities, including in nutrition research and programming. Cell phones are ubiquitous across the African continent and are being used increasingly as an essential part of health community plans: in the area of emergency maternal health, such as when labour stops progressing;  for improving supply demands, such as when rural clinics run low on zinc and oral rehydration salts (ORS). The use of cell phones has been at the forefront of the emergence of an entire field of mobile health, known as m-health.  One of the most popular uses is probably communications messaging, such as sending regular SMS reminders to parents for growth monitoring visits.

Mobile technologies also offer innovations in global nutrition research.  As cell phone use across Africa increases, it becomes easier and easier to train field workers in the use of personal data assistants (PDAs), as people are more familiar with the technology from having their own cell phones. One such example from the Micronutrient Initiative (MI) is the use of PDAs for data collection in our field surveys evaluating a mass media intervention to improve zinc and ORS for the treatment of diarrhea in Senegal. Interviewers carried a PDA with questionnaires loaded onto their device. Text-prompts guided them through the questionnaire, eliminating the need for paper surveys and the logistical complications of storage and transportation that paper surveys add. In the case of our Senegal survey, the PDAs connected to the mobile network daily and sent the interviews to a central server, eliminating the step of manual data entry, as PDAs are configured to send the data directly into the digital database. Anyone who has done data entry can appreciate the extreme benefit of being able to skip this time-consuming and high-risk-for-errors step. Further, the study supervisor can check for concerns in data quality from multiple study sites on a daily basis and follow up with interviewers the next day, potentially increasing overall data quality. And just as important, the issue of lost or damaged paper questionnaires is greatly reduced.

Using PDAs for field surveys opens up other new opportunities, such as incorporating visual media into questionnaires. We were able to provide caregivers in our Senegal zinc and ORS study with pictures of the different brands of products available, giving programmers important insights. The use of images can also be helpful in surveys with dietary recalls, although this option would require preparation of uploading photos and knowing the foods and supplements available to the targeted audience in advance. After a media campaign, we could include images from television spots or radio segments to see if parents recall the ads.

Global Positioning System (GPS) is now offered with some PDAs, which can help in monitoring data quality, survey implementation, and new ways for interpreting data. For example, with the Senegal project, we have the GPS coordinates for households and a visual map of clusters, or hot spots, for diarrhea infections, enabling us to prioritize these areas for intervention.  We were also able to ask families about radio stations they listened to and create a map of radio stations reaching the communities in order to develop a national mass media campaign using local radio stations. With traditional surveys it could be months before this type of information would be available.

Despite the advances in using PDAs for data gathering, there are downsides, the biggest being initial purchase costs, related software, as well as having the training and expertise to support surveys in-country. Other challenges are short battery life, theft, connectivity issues, and, in some cases, the need for accompanying paper consent forms.  At MI we are fortunate to work with Canadian partner Health Bridge whose expertise and equipment support our local partners and the MI office in Senegal.  Innovations in enabling access to these new technologies may be the next challenge in m-health for nutrition surveys, as we work towards systems that provide greater access to larger segments of populations in low to middle income countries.

PDA zinc.jpg
Field worker using PDA in our zinc and ORS diarrhea treatment intervention study in Senegal.


Can the Vegetarian Diet Be Healthy?

Student Blogger
By Meghan Anderson Thomas, MS

I constantly hear:

Omnivores: “Vegetarians just don't look healthy.”
Vegetarians: “ Meat just isn't good for you.” Or “I feel so much better when I'm not eating it”

So who has it right?  Can they both be right and wrong at the same time? I think the answer lies in the motivations behind the eater.  The omnivore may have a point because vegetarianism, like all other diets, has the capacity to be unhealthy.

Essentially, vegetarianism, pescetarianism, veganism, etc. are elimination diets.  Like any elimination diet, they have the potential to lack vital nutrients including certain vitamins that are predominately found in animal products.  According to Sabate, vegetarian diets when compared to meat-based diets are more likely to be deficient in vital nutrients(1).  Similarly, when omnivores (typical American diet) obtain the abundance of their calories from meat and dairy they have less room for the fruit and vegetables that provide them with the other nutrients vegetarians so easily acquire.  Moreover, studies show that the increased risk of cancer and heart disease in meat-based diets may be related to a deficiency in the phytochemicals and other compounds found in plant-based foods, not just the intake of saturated fats and excess calories(2).

Again, the problem lies in the motivation. Vegetarians and omnivores alike that eat for health are much more likely to eat properly. The choice of becoming a vegetarian for health reasons alone may lead the vegetarian in question to a more healthful diet in which they are cognizant of variety and balance. That being said, there are plenty of vegetarians that may be doing it for the wrong reasons or are, like most, uneducated in making the proper nutritional decisions.

The observation that vegetarians are unhealthy may actually be evident. Most will argue that they have been deficient in iron, zinc, calcium and B vitamins since they have eliminated animal products, leading to anemia(2).  Not to mention that most vegetarians are women who are prone to anemia due to menstruation. The fatigue that follows leads to the snowball effect of fatigue, decreased exercise and depression. The point is, diet has a strong influence on health and well-being and it is dangerously easy to eat incorrectly, even if one's intentions may be pure. This is seen in all “types” of eaters alike.

It is important to remember that as a vegetarian, the elimination of a steak may reduce your risk for heart disease, hypertension, atherosclerosis, hyperlipidemia, etc., but it is not a free pass to eat all the junk food you can to make up for it.  The elimination of meat alone is not the ticket to health.  Instead, it seems to be a correlation: the vegetarians motivated by health are also more likely to be cognizant enough to eat right all of the time.  Furthermore, Sabate illustrates that the vegetarian diet is viewed as improving health and limiting disease when compared to the meat-based diet(1).

References
1. Sabate, J. (2003). The contribution of vegetarian diets to health and disease: a paradigm shift? The American Journal of Clinical Nutrition, 78 (3), 502S-507S.
2. Nieman, D. C. (1999). Physical fitness and vegetarian diets: is there a relation? The American Journal of Clinical Nutrition, 70 (3), 570S-575S.




Changes on the Horizon: Redefining Malnutrition Diagnoses in Older Adults

Student Blogger
By Jonelle Agurs, ASN Intern

No one wants to get half a diagnosis from their doctor.

Unfortunately, that's what tends to happen when diagnosing malnutrition in hospitalized adult patients in the United States.  The present criteria for some malnutrition assessments, like the Malnutrition Screening Tool (MST), are under scrutiny because they only evaluate patients on symptoms of starvation, such as unintentional weight loss or poor appetite.  However, new studies postulate that malnutrition should not be limited to food behaviors, but should be expanded to include inflammation resulting from chronic disease.  The body's inflammatory response can intensify the symptoms of starvation, and vice versa; poor eating habits may induce inflammation as well.  The human body does an impeccable job of patching itself up using the inflammatory response, but this process often triggers symptoms strongly associated with malnutrition, such as weight loss.  With approximately half of the U.S. adult population (117 million) suffering from at least one chronic condition, such as coronary heart disease and diabetes, it is no surprise that there is an increasing prevalence of malnutrition cases among hospitalized adult patients.

ASN supports the efforts of many of its partner organizations, such as the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics, which want to recognize the role of the inflammatory response when diagnosing malnutrition. They have proposed four standard criteria: insufficient energy intake, unintended weight loss, muscle mass and fat loss, and diminished physical function.  These criteria will support a more etiological-based diagnosis of malnutrition; a diagnosis more closely linked to the chronic diseases that cause it.  Misdiagnoses often result in patients being discharged early from hospital care, causing inpatients to return later for health issues made worse by the symptoms of poor nutrition.

The International Classification of Diseases, 10th Revision, or ICD-10, is a coding system under the Affordable Care Act of 2010, scheduled to be implemented after October 1, 2015.  Designed to improve disease management, this revision will include coding using an updated definition of malnutrition.  Absence of a standard screening system for this condition is like installing the proverbial cork in the leaky faucet; diagnoses without a simple malnutrition assessment may “plug” up the issue, but the pressure continues to build, waiting for a more thorough solution.  The expansion of the ICD-10 coding system will provide a part of that solution by enhancing screening accuracy.  With five times more descriptors than its ICD-9 predecessor, ICD-10 coding will include more conditions that could be linked to a range of malnutrition-related issues.

Hospitals across the nation are preparing for the ICD-10 updates, but it is imperative that hospital personnel fully understand how to recognize and diagnose malnutrition to code it properly.  Despite shortages of nursing staff and other trained individuals, quality of patient care must be maintained in order to indicate their risk of malnutrition.  Clinicians must be able to perform comprehensive assessments of the patient's complete medical background, so that, along with the newly-proposed diagnostic construct, every patient will receive comprehensive care that will, ideally, lower the cost of their medical care expenses in the future.

Malnutrition, among other hospital-based nutrition topics will be discussed on Saturday, December 6 during the fourth annual Advances and Controversies in Clinical Nutrition conference. Dr. Gordon Jensen, ASN's immediate past president, will give an address titled “Malnutrition and the Affordable Care Act.” The conference runs December 4-6 at the Gaylord National Resort & Convention Center in National Harbor, MD, and features a dynamic program with topics ranging from dietary supplements to nutrition and cancer. To learn more about this year's conference, please visit the website.

Reference
Jensen, G, Compher, C, Sullivan, D, Mullin, G. (2013). Recognizing Malnutrition in Adults: Definitions and Characteristics, Screening, Assessment, and Team Approach. Journal of Parenteral and Enteral Nutrition, 802-807.


Nutrition Research: Revisiting our Foci

Student Blogger
By Kevin Klatt

A few weeks ago, I had the pleasure of reading Allyson West and Marie Caudill's Research and Practice Innovations paper in the Journal of the Academy of Nutrition and Dietetics, entitled “Applied Choline-Omics: Lessons from Human Metabolic Studies for the Integration of Genomics Research into Nutrition Practice” (1). The publication elegantly describes how integrating metabolomic, transcriptomic and genetic/epigenetic approaches into traditional controlled feeding studies can help refine the Dietary Reference Intakes, and elucidate the mechanisms by which choline and folate contribute to overall health.

Referencing the Nutrition Research Priorities established by the American Society for Nutrition (ASN) in 2013 (2), we can clearly see that the approaches described by West and Caudill fall in line with ASN's thinking on how to advance the field of nutritional sciences. The Nutrition Research Priorities report specifically highlights furthering our understanding of nutrition and health by pursuing –omics research to understand individual responses to nutrients. For me, it was encouraging to see these kinds of advanced techniques and their clinical applications representing the field of research in a major clinical nutrition journal.

Fast-forwarding to this past week, I found myself staring at headlines inflaming the conversation around the newest low-carbohydrate/low-fat research, published in the reputable Annals of Internal Medicine (3). The publication is a randomized trial that ultimately concludes “the low-carbohydrate diet was more effective for weight loss and cardiovascular risk factor reduction than the low-fat diet”. Being in such a high profile journal and funded by the NIH, one would expect this publication to add some significant perspective to our understanding of energy balance and disease progression, two areas also highlighted in the 2013 Nutrition Research Priorities report. Unfortunately, upon reading the paper, one is quickly underwhelmed by the lackluster weight loss over 12 months, the poor accuracy of the dietary recall data, the lack of any information about diet quality, the use of imprecise measurement techniques, and the authors' failure to discuss alternative conclusion, beyond just the low-carbohydrate component of the diet. I have specifically detailed the limitations of this trial elsewhere.

As I finished reading the study, West and Caudill's ‘Choline-omics' paper came to mind, and I couldn't help but feel frustrated: why are we still funding these overly reductionist paradigms of low-carb vs low-fat, when much more integrative and informative approaches are being taken? To quote the 2013 Nutrition Research Priorities report on the topic of energy balance:
“A systems approach is preferable because the standard experimental approach of varying one factor at a time has accomplished little to address the population-wide problem of energy imbalance.”
Yet here we are, still trying (and failing) to vary only one factor, and publishing it in a premier journal for physicians. Is this how we want to represent nutrition research?

I further sat and thought about this trial: even at the outset, given the design, and the quality of the proposed data to be collected, what could this have added to our knowledge of nutrition? The trial states that its goal was to conduct a randomized trial to compare low-carb versus low-fat diets on body weight and CVD risk factors in a diverse population without comorbidities. Beyond the overly reductionist paradigm of low-carb/fat, the study design is questionable in that “neither diet included a specific calorie or energy goal.” Ultimately, the trial tested whether a macronutrient goal, coupled with education and a meal replacement bar would spontaneously lead individuals to lose weight, in a diverse population without comorbid conditions. Not surprisingly, after being sent into an environment with highly palatable, minimally nutritious high carbohydrate/ high calorie foods, the low-carbohydrate group fared better. Is this substantially improving our understanding of nutrition and energy balance? If there's any theme that holds true with weight loss and disease risk reduction, it's that choosing a well-planned, reduced energy diet which an individual can adhere to is most important (4,5,6,7). Given the failure to reach recommended fiber intakes and minimal weight loss seen in this trial, nothing about the previous statement appears to change.

Even worse than the limited information to be gained from this kind of trial is the media reporting and subsequent public response to this research. The public's perception of nutrition recommendations isn't that great, as acknowledged in what I would argue is the most pertinent point of the Nutrition Research Priorities report:
“Perhaps the greatest barrier to advancing the connections between food and health is the variability in individual responses to diet; it is also the origin of public skepticism to acceptance of dietary advice….”
If individual variability spurs public skepticism, we should seek to explain that variability. One only needs to look to the original 1980's Dietary Guidelines for Americans (4) to see that we've known that there is individual variation in weight gain/loss and in biomarker response to diets high/low in fat. Yet here we are, 3 decades later, and we're conducting trials that do nothing to further isolate and understand the factors that contribute to this variation. However, what we are doing is deepening this public skepticism, as history shows us the controversial topic of low-carb vs. low-fat undoubtedly garners a lot of press.

Don't get me wrong, research that attempts to understand individual variation in response to food and nutrients is being done, but, despite being identified as a major priority, it does not appear to be so. It's truly a shame to be in this field and see examples of researchers employing the most cutting edge techniques to answer pressing questions, only to be overshadowed by overly simplistic paradigms that incite more sentiment than they do advance science. It is essential that scientists, and more importantly funding agencies, are aware of the field's established research priorities, so that we can stop asking the uninformative questions that tantalize a public controversy and start generating truly substantial evidence, which fosters public trust in recommendations. These established Nutrition Research Priorities can be found in full here.

References:
1.    http://www.ncbi.nlm.nih.gov/pubmed/24529976
2.    http://www.ncbi.nlm.nih.gov/pubmed/23784071
3.    http://annals.org/article.aspx?articleid=1900694
4.    http://www.health.gov/dietaryguidelines/1980thin.pdf
5.    http://www.nejm.org/doi/full/10.1056/NEJMoa022207
6.    http://www.nejm.org/doi/full/10.1056/NEJMoa0804748
7.    http://jama.jamanetwork.com/article.aspx?articleid=200094
8.    http://www.health.gov/dietaryguidelines/1980thin.pdf




Food Security in Puerto Rico: Vulnerable Food Supply

Student Blogger
By Mayra S. Crespo Bellido

In 1942, Dr. Lydia J. Roberts was asked by Dr. M. L. Wilson of the US Food and Nutrition Board to visit Puerto Rico under the pretenses that “there was a problem in [the island], which ordinarily imported much of its food.” After all, the island only produced 65% of the food the habitants needed, 35% was being imported at the time. Dr. Roberts was assigned to study the food and nutrition situation in order to report back to Washington, DC. Out of her collaboration with the University of Puerto Rico as a visiting professor, a clear picture of the living situation for the islanders during the 1940s was portrayed in her book Patterns of Living in Puerto Rican Families. This classic one-of-a-kind report depicts explicitly the poor health conditions and severe food insecurity in most households, mostly due to lack of educational and monetary resources. During this period infectious diseases were ranked #1 among the most common causes of mortality for all ages.

In the 21st century, a changing landscape of health problems troubles Puerto Rico. Following nutrition transition patterns of developing countries, the leading causes of death of our time are all from complications of chronic conditions associated with the increasing prevalence of obesity in the island. In 2013, 35% of Puerto Ricans living in the island benefited from the Nutrition Assistance Program, and the majority of the population benefits from other programs such as WIC and Child Nutrition Programs. Nonetheless, Puerto Rico deals with serious food security issues as the island produces only 17.65% of the food it consumes, importing 82% from over 10 different countries.

According to the Food and Agriculture Organization (FAO), food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life. The four dimensions of food security as defined by the FAO are: food availability, food access, proper utilization and stability. A recent study established that food security is not distributed equally as people living in rural areas of the island are disproportionately affected unemployment rate, greater proportion of habitants below the poverty level and lower education levels all of which may create barriers to food access and proper utilization. However for the Puerto Rican population it becomes a little more complicated than that.

Dr. Myrna Comas, Puerto Rico Secretary of Agriculture, has made it her lifework to bring awareness of the vulnerability of the food chain supply in Puerto Rico. As stated by Dr. Comas, the high dependence on imported foodstuff, constant decreases in local agricultural production, the fact that there is only one functioning seaport that receives all merchandise imported, the great distances food has to travel to get to the island, and a lack of policy to ensure food security are some of the many reasons the food chain supply to the island is susceptible to external influences. Some identified risk factors that could interfere with the supply of food are: global climate change, food and water contamination, reduction of terrains devoted to agriculture in the island, accidents, and free trade agreements, among others.

Under the direction of Dr. Comas, the Puerto Rico Department of Agriculture has systematically addressed these issues for the past couple of years. Part of this plan to counterattack the risk of having a food crisis includes an educational campaign to bring awareness to the matter of food security, and initiatives to conserve agricultural lands and to promote local agricultural production of staple foods. There is evidently a long way to go until this matter is resolved. Hopefully with increased knowledge and understanding of the repercussions of letting this problem remain unaddressed will encourage the proper authorities to create local and international food policy that avoids an impending food crisis in the island.

References
Rosario-Mejías, M, Dávila-Román, A. (2012). Distribución geográfica de la seguridad alimentaria en Puerto Rico, 2005-2009. CIDE Digital 3(1-2), 109-118.

http://academic.uprm.edu/mcomas/HTMLobj-159/tesis.pdf

http://www.elnuevodia.com/expuestopuertoricoaunacrisisalimentaria-1717099.html

http://puertorico.media.indypgh.org/uploads/2012/01/bolet_n__13_enero_2012.pdf

http://jp.pr.gov/Portal_JP/Portals/0/Publicaciones/PublicacionesHistoricasOnline/Compendio%20de%20Estadisticas%20Sociales%20-%201988-2.pdf

http://www.fao.org/focus/e/obesity/obes2.htm

https://www.cfda.gov/index?s=program&mode=form&tab=core&id=3050f5bc0ed98a93fcc273237e0dd0cd







My Clinical Nutrition Internship: Enhancing Physician Education

Student Blogger
By Hans Chiang

I used to be very picky with my food as a child. My parents tried multiple ways to keep me on a well-balanced diet. My interest in nutrition sparked when my parents persuaded me to eat carrots by claiming “carrots are good for your eyes.” While I did not have the scientific fundamentals and resources to research the biochemical mechanism that validates their claim at that age, I trusted my parents, labelled carrots as “good food” and tried to incorporate them into my food choices. When taking biochemistry in my undergraduate studies, these mysterious interactions between foods and the human body unfolded as I learned the science behind how nutrients actually work. Realizing how dietary intake plays a huge role in disease prevention and treatment, I wanted to advance my nutrition education in medical school so that I can provide relevant nutritional guidance to my patients as a physician.

For this reason, I applied for a position in the Clinical Nutrition Internship Program during the summer after my first year of medical school at Indiana University School of Medicine. The program provided me with valuable experiences; not only did I learn about nutritional science from registered dietitians, I also shadowed physicians of different specialties, observe procedures, and learn how they incorporate nutrition into their fields of practice. On top of the clinical exposure, I reviewed my physiology and biochemistry by participating in literature research with my mentor and writing a research paper on the assessment and dietary modulations of endothelial functions.

I had the opportunity to learn from dietitians who assist different patient populations. I spent time in a diabetes care center, a hospital pulmonary and cardiac rehabilitation unit, a retirement community, a cancer radiation center, the local WIC clinic, a community health clinic, the Volunteers in Medicine clinic of Monroe County, and the University Student Health Center. I was surprised to learn how diets are formulated so differently for each unique population. In addition, I learned to appreciate the communication techniques dietitians use to encourage their patients to follow an optimized diet. As a future physician, I would also be working with a very diverse population and these are all useful techniques I can use in my practice.

Besides learning about nutrition from dietitians, I participated in nutrition support rounds and shadowed physicians in different specialties. I shadowed a gastroenterologist and observed esophagogastroduodenoscopies (EGD), colonoscopies, colon decompressions, and gastric tube insertions. I shadowed a bariatric surgeon and observed lap band, cholecystectomy, and hernia repair procedures. I also spent time with an oncologist, a pediatrician, and an endocrinologist to learn about how weight control plays an immense role in treating cancer patients, infants, teenagers, and diabetic patients.

The Clinical Nutrition Internship Program was a wonderful enhancement to my education in becoming a physician. Besides learning about the various roles nutrition has in the health care field, I also obtained valuable communication skills through observing the interactions between the health care professionals and their patients. Regardless of the specialty I pursue in the future, I will be able to incorporate what I learned through this internship into my practice to provide my patients with the best care and education. I enjoyed the eight weeks of the internship very much and am very grateful to have had this opportunity.

Meet ASN's 2014-15 Bloggers

Suzanne Price
ASN is pleased to announce the following 9 bloggers who will serve one-year terms. ASN bloggers are selected through a competitive application process, and those selected hail from a variety of settings, including doctoral programs, medical schools, and postdoc fellowships. Their professional goals and photos can be found here. Let us know what topics you'd like to see written about.

•    Banaz Al-Khalidi, MSc, Doctoral Student, York University, Canada
•    Meghan Anderson, MS, Student, Medical University of South Carolina
•    Mayra S. Crespo Bellido, Dietetics Intern, University of Puerto Rico-Medical Sciences
•    Debbie Fetter, Doctoral Student, University of California-Davis
•    Kevin Klatt, Doctoral Student, Cornell University
•    Brett Loman, Dietetic Intern and Graduate Student, University of Illinois-Urbana Champaign
•    Marion Roche, PhD, MPH, Technical Adviser, Micronutrient Initiative
•    Sheela Sinharoy, MPH, Doctoral Student, Emory University
•    Tiffanie Stewart, MSc, Doctoral Student, Florida International University