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Soda Politics: A Discussion with Dr. Marion Nestle

Student Blogger
By Chris Radlicz

Marion Nestle, PhD, MPH is Paulette Goddard Professor in the Department of Nutrition, Food Studies, and Public Health at New York University, which she has chaired from 1988-2003. Additionally, she is Professor of Sociology at NYU and Visiting Professor of Nutritional Sciences at Cornell. Dr. Nestle earned her PhD in molecular biology and MPH from University of California, Berkeley. Her research examines scientific and socioeconomic influences on food choice, obesity, and food safety, with an emphasis on the role of food marketing. She is the author of several prize-winning books, and in her latest, Soda Politics: Taking on Big Soda (and Winning), Dr. Nestle provides insight on the soda industries tactics to gain consumers and addresses what is now working in the fight against ‘Big Soda'. I recently had the opportunity to ask Dr. Nestle some questions relevant to her newest book.

1. How has your background in molecular biology lead you to your career interest in public health, and particularly food politics?

The direct story is that I was teaching undergraduate molecular and cell biology in the Biology Department at Brandeis University and was assigned a nutrition course to teach. Undergraduate biology majors wanted a course in human biology and it was my turn to take one on. From the first day I started preparing that course, it was like falling in love. I've never looked back. Politics was in the course from day one. It's not possible to understand how people eat without understanding the social, economic, and political environment of food marketing and food choice.

2. What lead you to write your newest book, “Soda Politics: Taking on Big Soda (and Winning)”?

I've been writing about soda marketing since the late 1990s when I learned about "pouring rights" contracts--soda company arrangements with educational institutions for exclusive sale of their brand. These started with colleges but had just gotten to elementary schools when I learned about them.  Since then, I've followed Coke and Pepsi marketing with great interest.  I teach food politics and food advocacy at NYU and was well aware of all the advocacy groups working to reduce soda intake as a public health measure.  When my agent suggested that I ought to write a book about sodas, it seemed like a terrific idea to encourage readers to engage in advocacy for healthier food systems.  Sodas are a good example of how to do this.

3. The title is provocative. Why do you say that those taking on 'Big Soda' are in fact ‘winning'?

That's the best part.  Soda sales are way down in the United States. The soda industry thinks public health advocacy is responsible, and who am I to argue?

4. What has influenced the slow but successful decline in soda consumption seen today?
Excellent public health advocacy. Think of New York City's poster campaigns over the last four or five years. These illustrated the amount of sugar in sodas and how far you would have to walk to work off the calories in one vending machine soda.

5. The Coca-Cola funded non-profit, "Global Energy Balance Network", recently shut its doors. Do you think this is evidence of gaining momentum?

Reporters from the New York Times and the Associated Press were shocked to discover that Coca-Cola was funding university research to demonstrate that physical activity is more effective than eating healthfully in preventing weight gain.  This idea is patently false. Investigations revealed that the researchers worked closely with Coca-Cola executives to craft the research, conduct it, interpret it, publish it, and present it at meetings. This too seemed shocking. Now Coca-Cola is scrutinizing who it supports and many organizations know they need to be more careful to avoid such conflicts of interest.

6. In what ways do you see parallels in tactics used by 'Big Soda' and those previously used by cigarette companies in defending their respective products?

Soda is not tobacco but the tactics sure look similar. The soda industry follows the tobacco industry's playbook to the letter. It too attacks inconvenient science, buys loyalty, funds front groups, lobbies behind the scenes to get what it wants, and spends fortunes to oppose public health measure that might reduce soda intake.

7. Where can people follow your current work and get involved in this fight against 'Big Soda'?

I write an (almost) daily blog at www.foodpolitics.com where I cover such issues. Soda Politics has an Appendix that lists the principal advocacy groups working on soda issues and provides links to their websites.  It's easy to get involved in food advocacy and well worth the time.





Obesity is Not a Disease of Sloth and Gluttony

Student Blogger

By Caitlin Dow, PhD

The most recent data from the CDC indicates that approximately 35% of American adults have obesity (1). In order to reduce obesity prevalence, a popular notion is that people with obesity just need to “eat less and move more.” Indeed, many public health programs use this concept as their primary approach for combating obesity. While eating less and moving more may help prevent obesity or result in successful, sustained weight loss in individuals who are simply overweight (but not yet obese), ongoing research indicates that these simple lifestyle changes will do very little in the face of prolonged obesity (2).

If you look at any weight loss study, you will most assuredly find the same results, regardless of study design. The first six months are generally characterized by substantial weight loss, followed by sustained weight regain, resulting in a final weight that is negligibly lower and potentially higher than the starting weight . This “checkmark effect” or weight loss recidivism that has been reported nearly ubiquitously across diet and exercise-based weight loss trials (3) indicates that lifestyle interventions are generally not successful modalities for treating obesity.

Based on a rudimentary understanding of metabolism, the calories in/out approach should work for weight loss and weight loss maintenance. So why doesn't it work for so many people? The answer lies in the complex network linking the environment, genetic predisposition to obesity, as well as metabolic and physiological changes. A large body of literature indicates that the brain's reward systems are significantly dysregulated in individuals with obesity (4). In an environment that supports ease of access to highly palatable foods, the pleasurable effects of consuming said foods can override homeostatic control of intake. While some people are able to regulate intake despite the high palatability of these foods, a number of genetic mutations in the brain's reward systems may result in overeating and obesity in many people. Furthermore, the hypersensitive reward systems that often lead to obesity can become insensitive once a state of obesity is attained. In effect, this leads to overeating to receive the same pleasure from the same foods. These dysregulated reward systems are coupled with preadipocyte expansion into mature adipocytes, allowing for increased fat storage. While this isn't the entire story, this should shed some light on the complex interactions of dysregulated internal systems that foster the metabolic abnormalities that result in obesity. Importantly though, these impairments are typically only demonstrated once obesity has been introduced and sustained (3).

As for weight loss, when caloric restriction is initiated, the body triggers a number of systems to prevent starvation. From an evolutionary perspective, this makes sense as food sources were often unpredictable and the body adapted to conserve energy - the “feast and famine” principle. However, for most of us living in industrialized nations, famine is rare and feast is common, limiting the need for this once very necessary adaptation (though the body has not evolved to recognize the abundance of calories in our modern food supply). When we try to induce weight loss via caloric restriction, the body will reduce its resting metabolic rate to counter these advances (5). This supports the “set point theory” - the idea that the body will defend its highest-sustained weight. In fact, as weight loss increases, the drive to restore the highest bodyweight only increases (6). It's like when you're pulling on your dog's leash to get him into the vet and he plants his feet firmly and resists with all his might. Ultimately his strength pulls him out of his collar and sends him running in the opposite direction. Except here we're talking about the human body and it's not nearly as comical.

All of these biological adaptations that introduce, sustain, and defend obesity explain why weight loss and its maintenance is so exhaustingly difficult for so many people. As Ochner and colleagues suggest, most individuals who had obesity but lost weight simply have “obesity in remission and are biologically very different from individuals of the same age, sex, and body weight who never had obesity.” As a hypothetical scenario, imagine you are comparing two people: they weigh the same, but person A had obesity and has lost weight whereas person B has never lost weight. Person A will have to burn up to 300 calories more (or consume 300 calories fewer) than person B to maintain that weight (2). This underscores the idea that weight regain is not simply an issue of willpower and weakness.

What we need more of are studies evaluating multiple approaches to weight loss (surgeries, medications, likely in combination with lifestyle changes). What we need less of is bias from people without obesity, the media, and even healthcare providers. Indeed, “the mere recommendation to avoid calorically dense foods might be no more effective for the typical patient seeking weight reduction than would be a recommendation to avoid sharp objects for someone bleeding profusely” (2). We also need better obesity prevention approaches because, clearly, it's biologically more feasible to prevent weight gain than to lose weight and keep it off.


References

1.Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adults obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732.

2.Ochner CN, Tsai AG, Kushner RF, Wadden TA. Treating obesity seriously: when recommendations for lifestyle change confront biological adaptations. Lancet Diabetes Endocrinol. 2015:

3.Ochner CN, Barrios DM, Lee CD, Pi-Sunyer FX. Biological mechanisms that promote weight regain following weight loss in obese humans. Physiol Behav. 2013:120:106-13. doi: 10.1016/j.physbeh.2013.07.009.

4.Kenny JP. Reward mechanisms in obesity: new insights and future directions. Neuron. 2011:69(4):664-79. doi:10.1016/j.neuron.2011.02.016

5.Grattan BJ, Connolly-Schoonen J. Addressing Weight Loss Recidivism: A Clinical Focus on Metabolic Rate and the Psychological Aspects of Obesity. ISNR Obesity. 2012. doi:10.5402/2012/567530

6.Rosenbaum M, Leibel RL. Adaptive thermogenesis in humans. Int J Obes. 2010:34:S47-55. doi:10.1038/ijo.2010.184


Inflammatory Bowel Disease - A Condition of our Culture, or Cultures of our Condition?

Student Blogger

By Allison Dostal, PhD

Gastrointestinal problems are one of the most common unpleasant issues that we all experience at some time or another. But what if your upset stomach wasn't just a passing discomfort? What if severe abdominal pain, cramping, fatigue, and diarrhea became more of your norm and less of a passing annoyance? For more than 1.4 million Americans, these symptoms typify their experience with inflammatory bowel disease (IBD), a disorder characterized by chronic inflammation of the gastrointestinal (GI) tract. The specific cause (or causes) of IBD remain unknown, but one leading hypothesis is that the bacteria that inhabit our GI system – termed the gut microbiome – play a central role. In this post, we'll take a closer look at this condition and highlight research aimed at elucidating the impact of the microbiome in IBD development, progression, and treatment.

Characteristics, Diagnosis, and Treatment of IBD 

Inflammatory bowel disease is unique in that its symptoms vary from person to person, and an individual's own experience with their condition can differ markedly from another affected person. Most people are diagnosed with one of the two most common types of IBD, which are ulcerative colitis (UC) and Crohn's disease (CD). The primary distinguishing factor between the subtypes is that in UC, symptoms are limited to the colon. In contrast, any part of the GI tract – from the mouth to the anus - can be affected in CD. In addition, UC only involves the innermost layer of the colon, while CD can extend deeper into the cell layers of the GI tract. Lastly, in CD, the inflammation can “skip”, leaving normal areas between patches of affected GI tract.

Making a clear IBD diagnosis isn't always as easy as meeting – or not meeting – these criteria. There is no gold standard available for a clear-cut diagnosis, and 5-15% of cases do not meet strict criteria for either UC or CD. These patients fall into the “IBD type unclassified” (IBDU) group. And in up to 14% of patients, the diagnosis changes over time. Despite the difficulty in specific diagnosis, all subtypes of IBD have one strong feature in common: an abnormal response by the body's immune system. The immune system is composed of various cells and proteins that usually protect our bodies from infection. However, in people suffering from IBD, the immune system reacts inappropriately, and mistakes benign or beneficial cells and bacteria for harmful foreign substances. When this happens, the immune system produces an inflammatory response within the GI tract and produces the symptoms of IBD. This adverse reaction is termed a “flare”, and can result in symptoms such as abdominal pain and cramping, diarrhea, fever, and blood in the stool. People with IBD often have deficiencies in vitamins, minerals and macronutrients stemming from loss of appetite, reduced food intake, and malabsorption from the GI tract. The lack of nutrients can lead to worsening of symptoms or development of new complications.  

Treatment for IBD is centered around two goals: achievement of remission and prevention of flares. Anti-inflammatory drugs such as aminosalicylates and antibiotics are often the first line of treatment, and can be followed by corticosteroids, immunomodulators, and/or biologic agents. In severe cases, removal of the affected part of the GI tract is needed if a patient is not responsive to other treatments. 

The Role of the Microbiome in IBD

In recent years, it has become clear that the microbes in our gut have a key role in IBD, but the bacteria involved and their associated functions remain largely unknown. An imbalance of the normal gut bactera due to loss or overabundance of certain species is important in the persistence of the inflammatory responses seen in IBD. The role of the gut microbiota in IBD pathogenesis has been demonstrated by studies showing that antibiotic use can reduce or prevent inflammation – antibiotics work by reducing the number and types of bacteria found in the gut, therefore killing microbes that are causing IBD symptoms. Also, results from studies with UC patients who underwent a transfer of stool collected from healthy donors – called a fecal microbiota transplant – had notable disease remission. However, results have not been consistent between studies, due to differences in populations studied, official diagnosis, treatment methods and doses, and methods of assessing study endpoints. Therefore, no consensus on the microbiome's relationship to IBD has been reached. 

Research Endeavors

As you can imagine, the combination of unpleasant, potentially severe symptoms and an uncertain diagnosis or treatment can result in significant stress on IBD sufferers, their caregivers, and health care providers. The scientific efforts dedicated to identifying causes and cures for IBD have rapidly expanded in recent years due to advances in technology that allow researchers to work toward refining a clear diagnosis, map specific gut bacteria associated with disease development and symptoms, and identify defined targets for therapy. One of these initiatives is the Crohn's and Colitis Foundation of America (CCFA) Microbiome Initiative, which is dedicated to understanding the role of the gut microbes in IBD, IBD families, and disease flares. Thus far, there are 7 active projects and 30 published manuscripts stemming from the Initiative, which have determined that different subsets of IBD are characterized by signature bacterial compositions and that people carrying different IBD genes have different microbiome compositions, among other accomplishments. 

Other organizations are also supporting IBD research endeavors, including the Kenneth Rainin Foundation, whose Innovator Awards program provides $100,000 grants for one-year research projects conducted at non-profit research institutions, and the NIH's Human Microbiome Project, which has funded several projects aimed at genetic and metabolomic elucidation of risk for Crohn's disease. Several randomized trials are ongoing at this time, and their results will inform future directions for diagnosis, treatment, and eventual resolution of IBD.

References

Borody TJ, Warren EF, Leis SM, Surace R, Ashman O, Siarakas S. Bacteriotherapy using fecal flora: toying with human motions. J Clin Gastroenterol. 2004;38(6):475–483.

Bull MJ, Plummer NT. Part 1: The Human Gut Microbiome in Health and Disease. Integr Med. 2014 Dec; 13(6):17-22.

Crohn's and Colitis Foundation of America: http://www.ccfa.org/

Swidsinski A, Weber J, Loening-Baucke V, Hale LP, Lochs H. Spatial organization and composition of the mucosal flora in patients with inflammatory bowel disease. J Clin Microbiol. 2005;43(7):3380–3389.

Tontini GE, Vecchi M, Pastorelli L, Neurath MF, Neumann H. Differential diagnosis in inflammatory bowel disease colitis: state of the art and future perspectives. World J Gastroenterol. 2015 Jan 7;21(1):21-46.


How accurate are dietary intake apps and what improvements need to be made?

Student Blogger
By Emma Partridge

Dietary tracking applications (apps) have become quite sophisticated over the years, moving from manual entering of a food and portion to using barcode scanners to identify brand name products and return nutritional content information based on an entered portion. However refined these apps have become, their most poignant issue may not lie in the accuracy of the nutritional content information returned, but in the accuracy of the user's portion estimation. An analysis of misreporting on National Health and Nutrition Examination Surveys (NHANES) between 2003 and 2012 published in the British Journal of Nutrition found that under-reporting of energy intake was most prevalent in US adults 20 years or older. Specifically likely to under-report were women and overweight or obese subjects.1 The reality that under-reporting, conscious or subconscious, can happen in any subjective food recording process leads to questioning whether these types of apps are actually successful in their dietary tracking abilities, especially for overweight or obese people tracking their diets in attempts to lose weight. In a randomized control trial conducted at the Duke University Medical Center and published in Obesity, researchers found that overweight and obese young adults (18-35 years) were no more likely to lose weight using a smartphone app than the control group, who did not undergo any weight loss or health intervention.2 If we can reasonably determine that smartphone apps where one enters their food intake or receives social support don't help the majority of overweight or obese people lose the weight they're aiming to, how can this be improved? The latest technologies coming into play are image-assisted apps that allow users to submit photos of their meals then receive nutritional content based on the food and the portion size. Apps such as MealLogger allow the user to submit a photo of their meal, choose their portion size, and post the photo for others to view. While this form of social photo-sharing may skew users to acceptable portioning by social pressure, the user's ability to choose their portion size still introduces under-reporting bias. Other apps rely on objective, but far broader, methods of extrapolating nutritional content from a food photo. Apps like MealSnap allow users to submit photos of their meal to have the MealSnap system “auto-magically detect the nutritional breakdown” of the meal, according to their Microsoft.com page. While this calorie estimate is likely rougher than one where users choose their portion, it is also objective and prevents under-reporting bias. Apps with more user input may fall victim to inaccuracies from under-reporting, while apps that avoid biased reporting may sacrifice accuracy for objectivity.  To correct this, future technologies must undoubtedly continue to move toward a goal of improved accuracy and usability. Likely, these technologies will move toward advanced imaging, as imaging, finding ways to take in the real food, rather than relying on the user's input.  The future of image-assisted food technology will determine how close inventors and researchers can get to exact measurement of food and portion while maintaining accurate extraction of nutritional content. I, for one, am excited to see where it leads. 

1.Murakami K, Livingstone MBE. Prevalence and characteristics of misreporting of energy intake in US adults: NHANES 2003-2012. British Journal of Nutrition. 2015;114(8):1294-1303.
2.Svetkey LP, Batch BC, Lin PH, et al. Cell phone intervention for you (CITY): A randomized, controlled trial of behavioral weight loss intervention for young adults using mobile technology. Obesity. 2015;23(11):2133-2141.


Living the Mediterranean Lifestyle

Student Blogger
By Emily Roberts

The Mediterranean Diet is based on the eating patterns in the Mediterranean region and focuses on fruits, vegetables, fish, whole grains and healthy fats (1).  A diet not invented, but discovered, is now recognized as one of the healthiest dietary patterns (2). UNESO defines it as “a social practice based on all the “savoir-faire”, knowledge, traditions ranging from the landscape to the table and covering the Mediterranean Basin, cultures, harvesting, fishing, conservation, processing, preparation, cooking and in particular the way we consume” (3). The Mediterranean region is considered the Mediterranean Basin that borders the Mediterranean Sea and includes parts of seven countries: France, Portugal, Italy, Spain, Greece, Malta and Cyprus (4). There have been foreseen health benefits of consuming this diet, classifying it as “heart healthy” due to its likelihood to reduce the risk for heart disease (5,6). Living on the southern coast of France, I not only experience the Mediterranean lifestyle, but I have the opportunity to consume a Mediterranean Diet. 

The Discovery
The Mediterranean Diet was discovered to have particular health benefits by Ancel Keys of the University of Minnesota in the 1950's. He happened upon this discovery while studying the health of poor populations in Southern Italy in comparison to the wealthy in New York. He found the Italian populations had lower levels of cholesterol and a low rate of coronary heart disease (1).

Typical Foods 
The diet is full of fresh foods including fruits, vegetables, herbs, fish, olive oil, breads, nuts and pastas (1). There is a very low consumption of red meats, poultry, butter, refined grains and processed foods. The diet is rich in fiber, monounsaturated fats and polyunsaturated fats, antioxidant compounds, and essential vitamins and minerals; conversely, it is very low in saturated fats. Given the diet's composition of nutrient dense foods, strong adherence to this diet is associated with improved nutritional adequacy (2).

The Benefits 
A strong adherence to the Mediterranean Diet enhances the chances of improving your health status. It has been found to reduce the risk for mortality, especially due to cardiovascular disease (7). There have been many cohort studies conducted in the Mediterranean Basin often showing good adherence to the diet and resulting in reduced incidence for cardiovascular events (6). The benefits of the diet are likely to improve with physical activity as well, such as decreased blood levels of LDL (1). 

My observations
During my time in the south of France I have noticed the influence the agriculture and natural resources of the Mediterranean Basin has on the cuisine. This area is rich in olive groves, offering a plentiful supply of fresh olive products. The sea offers fresh fish, shellfish and other seafood, while local markets sell fresh fruits and vegetables. Cattle farms are not as populous in this area, so the consumption of red meat and butter is not as high as other European regions (such as Northern France). However, considering I am still residing in France, pastries, baguettes, and of course cheese are a typical part of the French dietary meal pattern. This differentiates my diet somewhat from other Mediterranean regions. Thankfully, walking as a means of transport is very common if not necessary, offering an efficient form of daily exercise. Fresh and homemade are the two words that best describe home cooking near the Mediterranean.  While residing with a local French family, I ate many freshly prepared meals. Everything made from scratch from salad dressings to whole grain bread. 

The Mediterranean Diet is not an effort, rather a daily practice for many Europeans. As Americans, we may recommend it as a diet intervention or integrate it into our own eating habits for health reasons. This diet is seen to be successful by offering significant health benefits. This encourages me to try various diets from around the world that could potentially provide various health benefits for Americans, as well as a taste of a new culture.


3.La DiÈte MÉditerranÉenne 2010. Candidature transnationale en vue de l'inscription sur la Liste ReprÉsentative du Patrimoine Culturel ImmatÉriel de l'HumanitÉ. Espagne / GrÈce / Italie/Maroc, Version Informations Additionnelles.


Spotty labeling confused this customer…the lesson I learned about rBST labeling

Student Blogger

By Mary Scourboutakos

Living in Canada, I was never worried about recombinant bovine somatotropin hormone, aka rBST. This synthetic hormone, which mimics a natural hormone that causes cows to produce more milk, was banned in Canada in the 1990s. So North of the 49th parallel, most people have never heard of it.

Meanwhile in the United States, the situation is a little different. rBST is legal in the US because technically, there's no evidence that it causes harm to humans. Meanwhile in Canada, the rationale for its ban is that it may pose risks for the cows that are treated with it.

With that in mind, whenever I visit the US, I always explore the milk on grocery store shelves to see if it contains rBST. To my surprise, on nearly every occasion, I've been hard pressed to find a jug of milk that didn't say “from cows not treated with rBST”.

pic1

This was reassuring. But then I noticed something…while every jug of milk said “no rBST” I couldn't find a single block of cheese, or container of yogurt declaring this.

pic2

This got me thinking…are they using the rBST-treated milk in yogurt and cheese? Could it be that consumers are so far removed from the food chain that they would think to look for “no rBST” on their milk, but wouldn't think to look for it on their cheese?

It didn't make sense...were the labels missing? Or was the industry using rBST milk in places where people would be less likely to look for it? I wanted to get to the bottom of this, so I started asking people about it. No one really knew the answer until I spoke with a representative from the food industry who told me that it takes so much effort to change labels, the industry won't label something unless there is extremely consumer demand. She predicted that the yogurts and cheese are probably made with rBST-free milk, they're just not advertising it.

Lo and behold, after doing some reading I found that in fact, many brands have removed rBST from ALL of their products, they're just not stating it on their label, or they're doing so haphazardly on some products but not others.

Perhaps I'm an over informed consumer who is paying attention to details that nearly no one else even knows or cares about, nevertheless, it's interesting to consider that a product could in fact be potentially healthier—or at least kinder to the animal it's coming from—than expected. I guess sometimes the food industry doesn't show off everything it could. 


ACCN15: Navigating the New Obesity Guidelines and Algorithms

Valerie Bloom
By Celez Suratos, MS, RD, ACCN15 Blogger

It's no surprise that obesity was one of the many topics covered at the recent Advances and Controversies in Clinical Nutrition (ACCN) conference. At his presentation during ACCN, Dr. Scott I. Kahan, MD, MPH, delved into the many obesity guidelines and algorithms that exist today. 

According to Dr. Kahan and the National Guidelines Clearinghouse, there are over 400 guidelines on the topic of obesity (this excludes the number of other various topics that may include obesity as secondary information). With an ongoing and growing list of information on obesity, how does a clinician sift through it all to find a best strategy to put into practice? Luckily Dr. Kahan summarized four recently published guidelines that can help anyone interested in knowing more about how obesity should be approached from a treatment standpoint. These guidelines were derived from the (1) National Heart, Lung, and Blood Institute (NHLBI); (2) Endocrine Society; (3) American Association of Clinical Endocrinologists (AACE); and (4) American Society of Bariatric Physicians (ASBP).

The information shared in this post will be from Dr. Kahan's summary of the guidelines from the NHLBI. The recommendations derived from this organization attempt to answer questions regarding the benefits of weight loss, risk of being overweight, the ideal diet an obese individual should follow, what lifestyle interventions are relevant to assist obese patients achieve and maintain weight loss, and the any benefits or risks of bariatric surgery, if such an intervention is necessary. The five recommendations a practitioner should follow when treating the obese patient include:
  • Use body mass index (BMI) as the primary screening tool to identify patients who are obese (currently defined as BMI greater than 30). One should also consider waist circumference as a secondary screening tool to identify patients who may be at increased risk for cardiovascular disease
  • Advise on moderate weight loss, as defined by a three to five percent reduction in weight, rather than a goal weight. Three to five percent may sound like such a small amount, but it can still have a great impact on various health outcomes in an obese individual. And it may be a less daunting goal for the patient
  • Just like a magic pill to make a person instantly lose weight overnight does not exist, there is no such thing as the perfect diet prescription to guarantee sustained weight loss. The focus should be on an individualized meal plan that is lower in calories, incorporates the patient's food preferences (to encourage compliance), and is used in conjunction with modified lifestyle behaviors
  • A successful intervention requires a multidisciplinary approach inclusive of professionals from the fields of nutrition, physical activity, and behavior modification that proceeds for at least six months. According to the data included in Dr. Kahan's presentation, during this comprehensive intervention period, patients with frequent on-site counseling exhibited more weight loss than patients who relied on other forms of counseling (i.e. electronic counseling, counseling through more commercial weight loss programs)
  • The last recommendation from the NHLBI guidelines involves bariatric surgery when appropriate. At present time, patients with BMI greater or equal to 40 kilograms (kg)/meter (m)2 or greater or equal to 35 kg/m2 with co-morbidities, bariatric surgery may be a more viable option than the other previously mentioned recommendations.
Weight loss is not a “one size fits all” scenario; it is always best practice to individualize, individualize, individualize! Obesity is a complex issue that involves more than just number of calories, or those seen on a weighing scale. It is a disease state that constantly relies on a collaborative approach from experts in multiple health-related disciples in order to ensure the best results.

ACCN15: Carb Recommendations for Diabetes Nutrition Management

Valerie Bloom
By Celez Suratos, MS, RD, ACCN15 Blogger

An individual only needs two things to easily access a myriad of information: a device that has the ability to connect to the internet, and an internet connection. Such information may be as simple as finding nearby show times for a movie, or something more complex, such as trying to self-diagnosis when exhibiting symptoms of a particular disease. This concept is the same when it comes to how the general public may be finding nutrition information. Along with the ease of access of internet searches however, is a high potential of inaccurate or incomplete nutrition information that's widely distributed. 

This can be further exhibited when it comes to myths surrounding carbohydrate (CHO) intake in people with diabetes mellitus (DM). DM is a complex disease in and of itself.Add the ever-evolving nutrition recommendations, such as the diabetic exchange list, glycemic index, and CHO counting into the mix, and one may be more sympathetic as to why a patient may struggle with compliance and management of his or her diabetes.

Alison Evert, MS, RD, CDE from the University of Washington Medical Center approached some of the frequent concerns that arise from patients and healthcare providers when it comes to DM and CHO intake at the 2015 Advances and Controversies in Clinical Nutrition conference. From the presentation and based on a 2005 Dietary Reference Intake report, individuals need to consume at least approximately 139 gram (g) of CHO per day (this does not include creating glucose through pathophysiological processes, such as gluconeogenesis) in order to meet minimum obligatory glucose needs. Ms. Evert reports recent data of median intake of CHO as 220-330 g/day by men and 180-230 g/day by women. Moreover, data from a 2014 National Health and Nutrition Examination Survey (NHANES) reports that adults (20 years and older) without diabetes consume 48 to 50 percent of their daily calories from CHOs. This information tells consumers that intake of CHOs is a necessity, whether or not he or she has DM. It also communicates to nutrition educators that there may not be an ideal percentage of calories that should be consumed from a single macronutrient.

This begs the question, is current and best practice to make percentage recommendations of macronutrient intake based off of total calories, or is this an archaic and irrelevant practice? During her session, Ms. Evert reflected on her time as a dietetic intern in which she made specific calculations on g of CHO a diabetic should consume per day, and passed on a meal plan to patients based on this information. Imagine trying to explain a generic serving recommendation, such as “eat 13 to 17 servings of CHO per day” to an ill and perhaps non-compliant, underserved, or even under-educated patient.

The take-away message Ms. Evert's presentation is that patients with DM need individualized nutrition recommendations/meals plans, particularly as there are major differences in type 1 versus type 2 DM, the spectrum of type 2 DM progression among patients, and medications that affect glycemic control. Her suggestion – make it a point to discuss what our food sources of CHO are and focus on lifestyle behavior change.

ACCN15: Motivational Interviewing Techniques to Encourage Lifestyle Changes/Weight Loss

Valerie Bloom
By Celez Suratos, MS, RD, ACCN15 Blogger

Motivational interviewing (MI) is a technique used to incite positive behavior change. It is directive and client/patient-centered.  Healthcare providers (including registered nurses and dietitians) use MI to direct self-motivational statements from the patient.  Hence, allowing patients to be in charge of setting and meeting their own goals.  Dr. Kathryn I. Pollack from the Duke University School of Medicine facilitated an interactive workshop on MI at this year's Advances and Controversies in Clinical Nutrition Conference (ACCN).  The main focus was to inform healthcare providers of the “spirit” of MI, as well as putting MI techniques into practice through role-playing.  

Most of us are familiar with the phrase, “it's not what you say, it's how you say it.”  But did you know that communication is approximately 90 percent body language?  MI is more than a methodological counseling approach.  It also causes a healthcare provider be more present and aware of how he/she is communicating to the patient.  According to Dr. Pollack, the “spirit” of MI embodies four key principles to elaborate on such a concept; Partnership, Acceptance, Evocation, and Compassion.

A healthcare provider may have the tendency to dominate the conversation by supplying the patient with numerous facts about the status of his/her health, likely telling the patient what he/she “must” do in order to prevent the “worst-case scenario” from happening to them. However, in MI, a provider should focus on building a partnership-like relationship rather than one that is hierarchical.  One can do this by initially asking permission before sharing information and giving advice.  This allows patients a choice to discuss their health based on their own readiness to handle the information you want to give them.  Alternatively, a provider can ask the patient what concerns he/she may have in order to allow the patient to set the agenda, giving the patient the power to discuss what he/she may already be thinking about improving.  

Acceptance goes beyond the concept of non-judgment.  This means the healthcare provider accepts the patient's motivation, commitment, and choices in totality.  This relates back to non-verbal communication.  If you are feeling judgment, you are also likely exhibiting judgment, which then means your patient can see your judgment.  Think about it – do you ever cross your arms or furrow your brow when you disagree with a statement?  Letting go of judgment will not only improve your skills as a practitioner, but can be freeing as well.  

A healthcare provider may be able to provide a patient with beneficial reasons to improve his/her health status.  However, evocation is the idea that people are motivated by their own reasons.  In MI, the provider facilitates a conversation that allows the patient to find his or her own motivation for adopting positive change.  One way to help patients find their motivation is to prompt them with questions to discuss their readiness to change.  Such questions may include asking patients to rank their readiness to change (i.e., on a scale of 1 to 7 –with 1 being least ready to change and 7 being most ready for change, for example), then asking why they chose that particular number on the scale, what it would take for them to rank their readiness for change even higher (if not already ranked as a priority), and when will they be ready to implement their plan.  Evocation extracts information from the patient, such as reasons to change, identifies barriers to change, and eventually a self-actualized plan to get patients to reach their goal(s). 

Dr. Pollack also mentioned ‘compassion' as a novel principle to the spirit of MI, particularly in the provider-patient relationship.  It comes from the idea that providers should use open-ended questions, reflective statements, and summarize the conversation when they interact with their patients. This demonstrates active listening, versus a series of agreeable head-nods or dismissive “uh huh” verbal responses.  Compassion also calls on providers to give patients affirmation with each step they take to reach their goal(s), even during times of perceived setbacks. 

Dr. Pollack summarized that only the patient can make change happen for him or herself.   The patient is the one who needs to put in the work to see results.  Motivational interviewing is not only a tool healthcare providers can use as a catalyst for positive change, but is also a specific skill that takes practice and time to perfect.  

Are All Sugars Created Equal? Let’s Talk Fructose Metabolism

Student Blogger

By Chris Radlicz

According to NHANES (National Health and Nutrition Examination Survey) 2005-2010 the average American consumes about 20 teaspoons of sugar per day, with sugar consumption being the highest in teens and men (1). Interestingly, 33% of calories from added sugars come from beverages, and the majority of those beverages are sweetened with high fructose corn syrup (HFCS) (1).

But what is the novelty of HFCS? Aren't the grams of sugar on the package all that matters? Although calorically equivalent, not all sugars are metabolized the same way.

Previous papers have established epidemiological links between fructose consumption, obesity, and metabolic disease. To take this further, recent literature has indicated that fructose, particularly in high concentrations, as present in high fructose corn syrup and sucrose, are proving to be toxic. HFCS is composed of about 60% fructose and 40% glucose (2). Prior to the processing of sugars, it was nearly impossible to find such high concentrations of sugar in the diet, but it now seems to be commonplace.

Dr. Kimber Stanhope out of University of California Davis published a recent review paper that touched on the metabolic dysregulation that occurs with high consumption of fructose.

Dr. Stanhope's group has previously shown that subjects consuming fructose-sweetened beverages for 10 weeks, in addition to their normal diet, had increased de novo lipogenesis, dyslipidemia, circulating uric acid levels, visceral adiposity, reduced fatty acid oxidation, and insulin resistance. In contrast, subjects who consumed glucose-sweetened beverages, had comparable weight gain to the fructose group, but did not exhibit the aforementioned metabolic changes (3). These adverse effects seen in the fructose group all increase the likelihood of chronic diseases such as obesity, fatty liver, type-2 diabetes, and cardiovascular disease.

When consuming glucose, the liver is initially bypassed and the glucose reaches systemic circulation to be used by tissues such as the brain and muscles. If excess glucose is consumed in the diet, it will first be stored as glycogen, and secondarily as fat. Fructose on the other hand, takes a different path. When fructose is consumed, it is exclusively metabolized in the liver, where a particular enzyme, fructokinase, will allow for the uptake of fructose (3). Fructose metabolism as a whole lacks many of the cellular controls that are present in the glucose metabolism, which allows for unrestrained lipid synthesis (2).

Significant metabolic issues arise when a high concentration of fructose is consumed, such as in HFCS. An overload of fructose in the liver will lead to de novo lipogenesis and subsequent lipid droplet accumulation in the liver. With these high levels of fructose, the increase in lipid accumulation consequently decreases the breakdown of fat in the liver (3).

This intra-hepatic lipid will promote the production and secretion of very low-density lipoprotein 1 (VLDL1) leading to an increase in post-prandial triglycerides. A vicious cycle occurs effecting insulin resistance as well. The lipid in the liver will increase insulin resistance resulting in increases in circulating diacylglycerol. Additionally, the insulin resistance will lead to further lipid deposit in the liver with sugar having a greater propensity to turn to fat (3). A downstream effect of increased apoCIII and apoB will lead to muscle lipid accumulation, and end in whole body insulin resistance. All of this metabolic dysregulation results from the direct route fructose initially takes to the liver.

Although there is this well-defined and unique pathway for fructose metabolism, many industry-funded studies, haven't shown the negative metabolic outcomes of consuming HFCS or sucrose (3). More research is certainly needed, but it is best to remember that added sugar in such high concentrations, no matter the culprit monosaccharide, is not favorable for overall health.

It is interesting to note a possible evolutionary perspective, which proposes the advantage of enhanced fructose to fat conversion. At the end of a growing season, ripened fruit will tend to have high levels of fructose. Therefore the fruit consumed at the end of the season may allow for increased fat storage, which would have been beneficial because of the low food availability in the ensuing months (2).

1.U.S. adults, 2005– 2010. NCHS data brief, no 122. Hyattsville, MD: National Center for Health Statistics. 2013.

2.Lyssiotis CA, Cantley LC. F stands for fructose and fat. Nature. 2013; 508:181-182.

3.Stanhope KL. Sugar consumption, metabolic disease and obesity: The state of the controversy. Crit Rev Clin Lab Sci. 2015;1-16.