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
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
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
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.
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
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
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.
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:
4.Kenny JP. Reward
mechanisms in obesity: new insights and future directions.
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.
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.
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
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.
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
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
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.
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.
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 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
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).
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
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.
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
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.
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.
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
- 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
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.
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.
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.
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)
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
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
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
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
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
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
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.
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.