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Are consumers benefitting more than they know from recent food and behavior trends?

Student Blogger
By: Emma Partridge

American consumers are undoubtedly moving toward natural foods. An analysis by Datassential of consumer foodservice issue concerns may explain some factors in this overall trend; consumers appeared most concerned with antibiotics and steroids in animal proteins and/or dairy products, local food sources and manufacturers surviving, and GMOs, among other issues.1 Fortune magazine calls it “the war on big food” – but are consumers benefitting from more than just those ‘left out' factors?2 I had the chance to sit down with Dr. Mario Kratz, researcher at the Fred Hutchinson Cancer Research Center, core faculty member of the University of Washington (UW), and Associate Director of the UW Diabetes Research Center, to discuss a few of these food trends and what their intrinsic health benefits might be. 

One trend of note is the move toward full-fat dairy products. Whole milk sales rose 11% in the first half of 2015 alongside a 14% fall in skim milk purchases.3 While many speculate this shift is in line with movement toward wholesome, unprocessed foods, there are unrecognized benefits to full-fat dairy beyond its less-processed nature. Full-fat dairy may increase satiety, or lead a person to feel more full than if (s)he ate a low-fat dairy product. In evaluations of 16 dairy fat studies, Dr. Kratz's team found that, of studies comparing high-fat dairy to low-fat dairy, high-fat dairy intake was actually associated with better weight outcomes, and was not associated with higher weight. Further, 11 of the 16 studies revealed that people who ate more dairy fat or high-fat dairy foods tended to be leaner and/or gain less weight over time than those who ate less dairy fat.4 The results from these analyses make a case for full-fat dairy as a protectant against weight gain, potentially due to increased satiety response. Additionally, there are other fatty acids present in full-fat dairy that can act as hormones, and small amounts of these fatty acids may be beneficial. The scientific reasoning behind the presence of many fatty acids supports full-fat dairy and, on the other side of that coin, there is no data supporting healthful benefits from consuming non-fat, low-fat, or isolated-fat dairy products in which many of the fatty acids have been removed.5 

Another food trend of note over the past few years is that of coconut oil. While part of the trend may be attributable to its non-cooking uses, coconut oil is also highly heat resistant, has a long shelf life, and is rich in medium chain saturated fatty acids (MCFAs). The heat-stability of coconut oil is beneficial to reducing intake of harmful free radicals, but MCFAs may be the most significant of coconut oil's intrinsic health benefits. In a study comparing long chain fatty acids, generally purported to be less-healthy fatty acids, to MCFAs, researchers found MCFA-treated mice exhibited increased energy expenditure, reduced adiposity, and improved insulin sensitivity.6 It is possible, then, that consumers following the coconut oil trend may be reaping such metabolic health benefits.

Perhaps the most significant trend to watch is that of developing healthy, lifestyle-based eating patterns, which is recommended by the 2015 Dietary Guidelines Advisory Committee in the recently-released 2015-2020 Dietary Guidelines for Americans. In a media-driven world of shoulds and should-nots, the Dietary Guidelines Advisory Committee took a different approach with this year's release: develop patterns of healthy eating and physical activity within the environment around you. Dr. Kratz argues something similar, that pattern matters and a varied eating pattern may allow for small amounts of cravings and diet-breakers, thusly providing a method to control them.5 In short, his “number one” advice point is, “in spite of whatever craze you may be following right now…if you find something new, you should find a way to incorporate it into your overall diverse diet.” 

1.Webster M. Changing Consumer Behaviors and Attitudes. Culinary Institute of America; 2015. 
2.Kowitt B. Special report: the war on big food. Fortune 2015.
3.O'Connor A. Consumers Are Embracing Full-Fat Foods. The New York Times 2015.
4.bottomlinehealth.com. Why Whole Milk May Be Better Than Skim. Bottom Line Health 2014.
5.Mario Kratz P, MS. In: Emma Partridge MC, ed2016.
6.Montgomery MK, Osborne B, Brown SHJ, et al. Contrasting metabolic effects of medium- versus long-chain fatty acids in skeletal muscle. Journal of Lipid Research. 2013;54(12):3322-3333.


A new rationale for breastfeeding – the benefits for the Mom!

Student Blogger
By: Mary Scourboutakos

Presently in America breastfeeding rates are sub-par.

While the World Health Organization recommends exclusive breastfeeding for up to six months of age, with continued breastfeeding alongside complementary foods up to two years of age or beyond—in the US 79% of mothers initiate breastfeeding, but only 22% exclusively breastfeed to six months and only 27% are still breastfeeding (non-exclusively) at two years postpartum.1 Meanwhile in countries like Sri Lanka, 83.1% of mothers are still breastfeeding their children two years post-partum.2 

So the question is…how do we get women in America to breastfeed longer?
Traditionally, when trying to promote breastfeeding, people have focused on the benefits for infants, such as improved cognitive development,3 fewer childhood infections,4 and decreased risk for obesity and chronic disease later in life.5

But when you consider current rates of breastfeeding (see above!), clearly this approach isn't working. Nevertheless, there may be a presently unexplored way to promote breastfeeding...  
Emerging research suggests that in fact, the benefits of breastfeeding for the mother may surpass the benefits of breastfeeding for the infant.6-8
In fact, research has shown that long-term breastfeeding is associated with decreased maternal risk for breast cancer,9-11 ovarian cancer,12, 13 endometrial cancer,14 diabetes,15 heart disease,16 as well as greater postpartum weight-loss,17, 18 and mental health benefits.19, 20

But how long is long? And by how much does risk decrease? In terms of breast cancer, research from China has shown that women who breastfeed for more than 24 months per child cut their risk for breast cancer in half, compared to women who breastfed for only one to six months.10 Furthermore, dose-response curves for risk of diabetes show an inverse relationship with lifetime duration of breastfeeding, which suggests that the longer you breastfeed for, the lower your risk is.15

So, my unsolicited piece of advice for public health agencies is…if you're trying to improve rates of breastfeeding, never mind touting the benefits for the baby, maybe try promoting the benefits for the Mom!

REFERENCES
1.National Center for Chronic Disease Prevention and Health Promotion. Breastfeeding - Report Card. 2014; Available at: http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf (Accessed: 7 February 2016).
2.Ministry of Health Care and Nutrition. Sri Lanka - Demographic and Health Survey. 2006; Available at: http://www.statistics.gov.lk/social/DHS%20200607%20FinalReport.pdf (Accessed: 2016 February).
3.Quigley MA, Hockley C, Carson C, Kelly Y, Renfrew MJ, and Sacker A. Breastfeeding is associated with improved child cognitive development: a population-based cohort study. J Pediatr, 2012. 160(1):25-32.
4.Li R, Dee D, Li CM, Hoffman HJ, and Grummer-Strawn LM. Breastfeeding and risk of infections at 6 years. Pediatrics, 2014. 134 Suppl 1:S13-20.
5.Yan J, Liu L, Zhu Y, Huang G, and Wang PP. The association between breastfeeding and childhood obesity: a meta-analysis. BMC Public Health, 2014. 14:1267.
6.Schwarz EB. Infant feeding in America: enough to break a mother's heart? Breastfeed Med, 2013. 8(5):454-7.
7.Bartick MC, Stuebe AM, Schwarz EB, Luongo C, Reinhold AG, and Foster EM. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol, 2013. 122(1):111-9.
8.Bartick M and Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics, 2010. 125(5):e1048-56.
9.Zhou Y, Chen J, Li Q, Huang W, Lan H, and Jiang H. Association between breastfeeding and breast cancer risk: evidence from a meta-analysis. Breastfeed Med, 2015. 10(3):175-82.
10.Zheng T, Duan L, Liu Y, Zhang B, Wang Y, Chen Y, et al. Lactation reduces breast cancer risk in Shandong Province, China. Am J Epidemiol, 2000. 152(12):1129-35.
11.De Silva M, Senarath U, Gunatilake M, and Lokuhetty D. Prolonged breastfeeding reduces risk of breast cancer in Sri Lankan women: a case-control study. Cancer Epidemiol, 2010. 34(3):267-73.
12.Luan NN, Wu QJ, Gong TT, Vogtmann E, Wang YL, and Lin B. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Am J Clin Nutr, 2013. 98(4):1020-31.
13.Li DP, Du C, Zhang ZM, Li GX, Yu ZF, Wang X, et al. Breastfeeding and ovarian cancer risk: a systematic review and meta-analysis of 40 epidemiological studies. Asian Pac J Cancer Prev, 2014. 15(12):4829-37.
14.Jordan SJ, Cushing-Haugen KL, Wicklund KG, Doherty JA, and Rossing MA. Breast-feeding and risk of epithelial ovarian cancer. Cancer Causes Control, 2012. 23(6):919-27.
15.Aune D, Norat T, Romundstad P, and Vatten LJ. Breastfeeding and the maternal risk of type 2 diabetes: a systematic review and dose-response meta-analysis of cohort studies. Nutr Metab Cardiovasc Dis, 2014. 24(2):107-15.
16.Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol, 2009. 113(5):974-82.
17.Jarlenski MP, Bennett WL, Bleich SN, Barry CL, and Stuart EA. Effects of breastfeeding on postpartum weight loss among U.S. women. Prev Med, 2014. 69:146-50.
18.Baker JL, Gamborg M, Heitmann BL, Lissner L, Sorensen TI, and Rasmussen KM. Breastfeeding reduces postpartum weight retention. Am J Clin Nutr, 2008. 88(6):1543-51.
19.Groer MW. Differences between exclusive breastfeeders, formula-feeders, and controls: a study of stress, mood, and endocrine variables. Biol Res Nurs, 2005. 7(2):106-17.
20.Groer MW and Davis MW. Cytokines, infections, stress, and dysphoric moods in breastfeeders and formula feeders. J Obstet Gynecol Neonatal Nurs, 2006. 35(5):599-607.



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”.

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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.

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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.