American Society For Nutrition

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Excellence in Nutrition Research and Practice

Dr. Patrick Stover Reflects on Career Successes and Challenges

Danielle Jordan

Student Blogger

By Allison Dostal, PhD, RD

Dept. of Medicine, University of Minnesota Medical Center, Division of Gastroenterology, Hepatology, and Nutrition


ASN's immediate Past President Patrick J. Stover, PhD, has been elected as a new member of the National Academy of Sciences (NAS) in recognition of his achievements for original science and research in nutrition. In addition to his important work with ASN and the NAS, he directs Cornell University's Division of Nutritional Sciences and maintains an active research program. Through all of these accomplishments, Dr. Stover hasn't lost sight of the many pitfalls, challenges, and chance happenings that have led him to the successful career he has today. In this interview, Dr. Stover discusses his trajectory from graduate student to ASN's 2015-2016 president and NAS member and offers valuable insights that both young and established scientists can take to heart.


“Relationships are so important in science. They're absolutely critical.”


Planning a career after completion of a PhD takes considerable, thought, effort, and not a small amount of stress. And yet, there's no denying the power of chance and serendipity. For Dr. Stover, attendance of a summer conference in Vermont just one week before defending his dissertation forever changed his career focus. “They had messed up room assignments – I was supposed to room with my PhD advisor, and instead I ended up rooming with chair of nutrition at Berkeley, Barry Shane. My intention was to do a postdoc in crystallography and catalytic antibodies, because my PhD is in biochemistry. But I got that room assignment, and Barry and I just got along so well that week. I kept trying to find my thesis to do my thesis corrections, but he kept taking it with him because he wanted to read it. I changed my postdoc plans and went to Berkeley in nutrition. That's really how I got introduced to nutrition - through that gratuitous error in roommate assignments.”

When asked what he believed his greatest career accomplishment to be, Dr. Stover immediately responded, “Oh, that's easy. The greatest accomplishment is finding and working with some absolutely wonderful collaborators and mentors. This also includes students. The successes have always been finding the right people to work with that enable you to address the important questions, of both scientific importance but also public health importance.”


Stover was trained as a metabolic biochemist when he first started his faculty position, with an interest in folate metabolism. He soon realized that the most important questions that matched his interests were related to fundamental mechanisms of the role of folate in birth defect prevention. “We knew it worked; we didn't know why it worked. And going out and finding people who were experts in embryonic development or an expert in cancer, and being able to work with…people who were experts in these other areas who didn't know about or weren't familiar with the science that I knew, [we were able to] put those two together and solve interesting problems and learn new techniques.”


“All good research starts with an interesting, important question.”


This concept is “absolutely paramount” for young scientists to understand as they enter a research career, Stover says. Along with this, “You really have to love what you do. You have to love asking these questions and love doing research.” After having this foundation and investment in the work of discovery, the next step is ensuring that one has the proper training, tools, and collaborators to be able to address the important question at hand.


“You have to collaborate. You don't have to know everything, but you have to know what you don't know and who you need to work with to be successful.”


Dr. Stover acknowledged that today, a lot of the important questions that many of us are interested in require multidisciplinary approaches and collaborative work, because these problems require different perspectives, tools, and techniques.

He also mentioned that throughout the years, ASN's Graduate Nutrition Education Committee had written pieces about the importance of being an expert in something, but also having a broad knowledge base. “You have to be deep in what your expertise is - your disciplinary expertise and your technical expertise. But that's not enough to address many of the important public health problems and the important scientific questions we have.”

Dr. Stover also recognized the increasing importance of communicating our science to other researchers and the general public. “A lot of us increasingly have to be well aware that what we're interested in, and what excites us, has to be effectively communicated to external audiences so that they're excited to support our work, [and to] the federal government so they're excited to fund our work”.

Many of the issues Stover has had to navigate as a scientist are not unlike those that concern young investigators today. When discussing the biggest challenge that he's had to face in his career, he emphasized the difficult transition from focused researcher to faculty member. “As academic faculty…we get our positions because we've been good at research. And then we get these faculty positions and we get put in offices, and we get asked to teach, and we get asked to manage personnel, and get asked to manage budgets and do some administration, for which we are utterly unqualified and untrained for, for the most part. I think being an assistant professor is really, really tough.” He noted vast improvements in career training tools since he first became an assistant professor in 1994, highlighting ASN's workshops on effective teaching, mentoring, and skill sets needed for professional development.

As he continues to amass accolades and respect for his scientific career, Dr. Stover shows no sign of slowing down. When asked about the nutrition science-related goals he would like to achieve, he offered insight for both his own research program and for ASN. “In my own work, we continue to be really interested in the molecular basis of pathology related to folate metabolism, because we're very interested in how folate requirements differ among individuals and how those affect important endpoints like genome stability and gene expression.” He also spoke about improving nutritional approaches to address diseases such as neuropathy, cancers, and neural tube defects, all of which are tied into folate's role in human health. “We want to provide an engineering approach to understand how these things work and how nutrition throughout the life cycle can be used to improve the quality of life and wellness of life.”


He also intends on having a broader impact. Stover acknowledged that the number of ASN members elected into the National Academy of Sciences is very small, despite the excellent work produced by nutrition researchers that belong to ASN. “We need to get more outstanding nutrition scientists into greater visibility. I want to really work for that as well.


This interview has been condensed and edited.


Meat Preparation and Carcinogens– Practical Recommendations

Student Blogger

By Chris Radlicz

This past October, the International Agency for Research on Cancer (IARC), the cancer agency of the World Health Organization (WHO), made headlines when they classified processed meat as a Group 1 carcinogen. This classification was based on “sufficient evidence in humans that the consumption of processed meats causes colorectal cancer”. Additionally, red meat has been classified as a Group 2A carcinogen due to “limited evidence that consumption of red meat causes cancer in humans and strong mechanistic evidence supporting a carcinogenic effect” [1]. These IARC statements advocating a limited intake of processed and red meats tend to be misconstrued by the public and many may take it to mean that all meat should be avoided. Besides the inherent benefits of protein and various micronutrients in meat, red meat is primarily trumpeted as the best source of heme-iron in the diet. With iron deficiency as the most common nutritional disorder in the world [2], limiting red meat may not be prudent advice. What, therefore, is unique to red meat and processed meats which explains their carcinogenic potential?

What gives meat a bad rap is not inherent in the animal muscle itself, but rather the preservatives added to meats and the cooking processes which meats undergo. So what can be done to mitigate and avoid the proposed cancerous effects of some meats? Below are some practical tips to be conscious of and implement when meat shopping and preparing meats so that consumers can take full advantage of the nourishment from meats while limiting any risk

  • 1. Cook with Moist Heat: The Journal of the American Dietetic Association in a 2010 article, showed that cooking with dry heat promoted a 10 to 100-fold increase in advanced glycation end products (AGEs). AGEs increase oxidative stress and inflammation, and have shown to be a player in the pathogenesis of many chronic diseases. Cooking with moist heat, at low temperatures, and shorter cooking times have all been shown to reduce AGE formation [3]. Cooking meat in stews and sauces at low temperatures for longer periods of time, typical of crock-pot style cooking, is an effective way to reduce formation of these questionable AGEs.
  • 2. Avoid Charring Meats: Cooking meat at high temperatures, typically on a grill or skillet, can lead to browning or charring. This browning is known to occur as a result of the Maillard reaction which has been shown to produce heterocyclic amines (HCAs), and polycyclic aromatic hydrocarbons (PAHs). PAHs form when fat from grilled meat is ignited, causing flames containing these PAHs, which can then adhere to the meat's surface. HCAs are formed from amino acids, sugars, and creatine reacting at high temperatures. These chemicals have been shown to be mutagenic to DNA after consumption and digestion, leading to genetic instability and increased risk of cancer [4]. Cooking meats at higher temperatures and for long periods of time will lead to increased HCAs, while smoking and charring will result in more PAH formation. No Federal guidelines exist addressing PAH and HCA consumption, but these chemicals provide a mechanism as to meats carcinogenic capacity. With this in mind, the National Cancer Institute suggests that concerned individuals should turn meat over frequently when cooking, use a microwave first to shorten high temperature cooking time, remove charred portions of meat, and refrain from using gravy made from meat drippings as ways to reduce PAH and HCA exposure [5].
  • 3. Purchase Nitrate-Free and Uncured Meats: Nitrates and nitrites added as preservatives to meat have been shown to convert to activated N-nitroso compounds (nitrosamines and nitrosamides) in the gut, and are proposed to be carcinogenic due to their ability to cause DNA damage [6]. N-nitroso compound formation can also be increased with the intake of red meat, principally due to interactions with the heme-iron [7].
  • 4. Purchase Meat that isn't Smoked: Smoked meats fall under the category of processed meats. Epidemiological studies, have shown a correlation between cancer of the intestinal tract and the frequency of dietary intake of smoked foods [8]. More convincingly, the smoking process forms N-nitroso compounds and inevitably contain high levels of PHAs.
  • 5. Purchase Antibiotic-Free Meat- Some antibiotics and pesticides in meats can react with nitrite to form nitrosamines in high quantities [9]. Additionally, there is much worry that the antibiotic use in agriculture is contributing to the growing prevalence of antibiotic resistance, and in a more minor capacity, to the obesity epidemic [10,11]

Bibliography

[1]       WHO | Q&A on the carcinogenicity of the consumption of red meat and processed meat

[2]       Liu K, Kaffes AJ. Iron deficiency anaemia: a review of diagnosis, investigation and management. Eur J Gastroenterol Hepatol 2012;24:109–16. doi:10.1097/MEG.0b013e32834f3140.

[3]       Uribarri J, Woodruff S, Goodman S, Cai W, Chen X, Pyzik R, et al. Advanced glycation end products in foods and a practical guide to their reduction in the diet. J Am Diet Assoc 2010;110:911–6.e12. doi:10.1016/j.jada.2010.03.018.

[4]       Cross AJ, Sinha R. Meat-related mutagens/carcinogens in the etiology of colorectal cancer. Environ Mol Mutagen 2004;44:44–55. doi:10.1002/em.20030.

[5]       Knize MG, Felton JS. Formation and human risk of carcinogenic heterocyclic amines formed from natural precursors in meat. Nutr Rev 2005;63:158–65.

[6]       You C, Wang J, Dai X, Wang Y. Transcriptional inhibition and mutagenesis induced by N-nitroso compound-derived carboxymethylated thymidine adducts in DNA. Nucleic Acids Res 2015;43:1012–8. doi:10.1093/nar/gku1391.

[7]       Rohrmann S, Linseisen J. Processed meat: the real villain? Proc Nutr Soc 2015:1–9. doi:10.1017/S0029665115004255.

[8]       Fritz W, Soós K. Smoked food and cancer. Bibl Nutr Dieta 1980:57–64.

[9]       Elespuru RK, Lijinsky W. The formation of carcinogenic nitroso compounds from nitrite and some types of agricultural chemicals. Food Cosmet Toxicol 1973;11:807–17.

[10]     Cox LM, Blaser MJ. Antibiotics in early life and obesity. Nat Rev Endocrinol 2015;11:182–90. doi:10.1038/nrendo.2014.210.

[11]     Chang Q, Wang W, Regev-Yochay G, Lipsitch M, Hanage WP. Antibiotics in agriculture and the risk to human health: how worried should we be? Evol Appl 2015;8:240–7. doi:10.1111/eva.12185.



Advocacy for Health Research

Student Blogger
By: R. Alex Coots

For scientists, the benefits of nutrition and health research are immediately apparent. It's easy for us to see how the general public and policymakers alike can benefit from a better understanding of health and nutrition. Few of us would argue that we need less health research or fewer grants, but this is exactly what's been happening since the NIH budget doubling ended over a decade ago. Decreasing budgets means fewer studies, and fewer studies means less progress on today's pressing health problems. To help address this problem, I spent a day on Capitol Hill with professors, patients, and other stakeholders to advocate for a more sustainable and predictable funding schedule for health research.

Given the abundance of high quality research institutions in New York, I thought it would be easy to get legislators to support science. How wrong I would be. At best, congressional staff received us with apathy and at worst, hostility. During one particular meeting, an elected representative went so far as to say "All you people want is more and more and more rather than try to make what you have go farther." And this was said by someone who co-sponsored the 21st Century Cures Act!

What became clear to me during the meetings was that the science profession was not viewed as one that provides answers to today's most pressing questions; rather, it was viewed as just another (expensive) special interest group. While many scientists do advocate for use of scientific information in the formation of policy, not many of us advocate for the resources we need to carry out our work. Professor Lawrence Goldstein at UCSD has previously advocated for a phone call with each grant written and each grant reviewed. I'd extend this model to include a call with each paper published so that policymakers can hear the scientific progress being made in their district or state. Ensuring that scientific information is used in policy formation is only part of the advocacy battle. We scientists must ensure that our discoveries are limited by our imaginations, not by a lack of grants.


Pursuing a RD/RDN after a PhD: Motives, Experiences and Challenges from Nutrition Experts

Student Blogger
By Hassan S. Dashti, PhD

I spent a lot of time contemplating whether I should pursue an RD after completing my PhD. I was told by one of my professors that back in his days, he had to choose between dietetics and research. He told me that it was assumed that students with ‘social' and ‘people' skills went into dietetics, whereas the rest went into research. The mutual exclusivity of nutrition clinical practice (dietitian nutritionists, RDNs; but more commonly referred to as RDs) and research is no longer the case. A recent 2016 survey from the Academy of Nutrition and Dietetics (The Academy) revealed that 4% of RDs hold a doctoral degree (PhD, RD) in the US. For the vast majority of those 4%, their curriculum vitae(CVs) will likely indicate that they have completed a dietetic training program (RD) followed by a doctoral degree in nutrition (PhD), and rarely a PhD first then RD. So having completed vigorous doctoral programs, what makes some researchers go back to school to get their RDs?

Perhaps the most common reason is to obtain training for effective translation of nutrition research. Being able to communicate nutrition knowledge to patients and other people was also particularly the reason why Stephanie Harshman, a doctoral student at Tufts University studying vitamin K, applied to RD programs while in her last year of her graduate training. She shared, “The RD training provides a different perspective when examining clinical research, community based interventions, and allows someone to better translate basic science research into terms and ideas that will positively impact human health.” Similarly, the PhD, RD combined training program at Cornell University's Division of Nutritional Science recognizes the growing need for translational research expertise in order to enhance the “effectiveness and impact of clinical and public health nutrition,” which is made possible through this combined training. 

As nutrition is a young and evolving science, a PhD, RD is particularly crucial when leading the translation of novel and cutting-edge science, like nutrigenomics or nutritional chronotherapy, where the translation is not as simple as a dietary prescription like a low-fat diet. Previous president of the American Society for Nutrition (2014-2015) and current director of the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Simin Nikbin Meydani, DVM, PhD, shared with me the story of one of her former doctoral students who wanted to bridge the gap between what is studied and what makes the news headlines and thus went on to getting her RD. Dr. Meydani said, “[The PhD and RD training together] could be applied to meaningful approaches that promote the health of an individual through proper nutrition.” 

But it's not only about how to apply and translate the science, a combined PhD, RD training may facilitate generating pertinent research questions with important implications. Having that human and patient interaction experience, which is often very limited in doctoral training, may help in study design development, particularly in human intervention studies. President-elect of the American Society for Parenteral and Enteral Nutrition (ASPEN) and Professor of Nutrition Science at the University of Pennsylvania School of Nursing, Charlene W Compher, PhD, RD, CNSC, LDN, FADA, said, “The best translational research comes from clinicians who understand what a nutritional problem really means for patients.”

While more than half of RDs (~58%) do work in clinical nutrition (acute care, ambulatory care, or long-term care), contrary to common belief —particularly among non-RDs— not all RDs end up working as full-time clinical dietitians. Practice areas for RDs keep expanding and now include community, food management, communications, consultation and business, and as indicated earlier in this article, in education and research. Thus it's not uncommon that the realization of the need of a dietetics training may occur later in a PhD's career. 

Stella Uzogara, PhD, MS, RDN, LDN CFS works in public health and decided to pursue an RD in order to get both clinical and non-clinical training to effectively discuss the challenges in public health nutrition and to positively impact health of consumers and patients. Dr. Uzogara who got her PhD in food science is also a certified food scientist (CFS). She now works as a nutritional epidemiologist in the Bureau of Family Health and Nutrition at the Massachusetts Department of Public Health and a state liaison for pediatric nutrition and pregnancy nutrition surveillance systems between Massachusetts and the CDC. She also works in several community health programs. Dr Uzogara said: “Personally, nutrition has served me well in my job and it gives me more flexibility, enabling me to practice both food science and health science, two disciplines which interest me a lot.” On the other hand, incoming Brigham and Women's Hospital dietetic intern and current doctoral student at the University of Connecticut in biomedical engineering, Anna Roto, MS, MPH, is learning about clinical instruments, mobile health devices, as well as how to design new equipment for medical use in her doctorate program. When asked about her intentions for pursuing an RD, she said, “I am not getting the clinical experience that I believe is necessary for a career in the rehabilitation science field, as I plan to work with individuals experiencing trauma or debilitating illnesses to improve their physical abilities and overall quality of life.” 

An RD may also be used as an opportunity to steer towards a new career. Dominica Nichols, PhD, RD, LDN, competed her doctoral training at Northeastern University in microbiology where her work in microbial ecology informed the technology used by several biotech startups. However, after years of culturing microorganisms, Dr. Nichols was looking for other opportunities that would enable her to mentor students and have more interactions with people. Having completed her dietetic internship at Simmons College, she now serves as a pediatric outpatient dietitian at a community center affiliated with Boston Children Hospital. Her research training allows her to work closely with other physicians on various research projects. She said, “Dietetics is an interdisciplinary field. Having training in another field, microbiology in my case, benefits my dietetics practice.”

While less demanding than a doctoral program, completing an RD does come with its own challenges. Interns should be ready to work very closely with a preceptor and shadow current practicing dietitians for an extended period of the internship. As most dietetic internships are fulltime programs, it is often challenging to work on other ongoing projects and jobs, but possible. When asked about the difficulties she experienced as a doctoral student who decided to pursue an RD, Stephanie Harshman shared, “I think the most challenging part of this experience has been trying to find support and guidance from faculty as I pursue the credential.” Dr. Dominica also claimed, “I constantly had to explain to other people why I was doing what I was doing.” 

Despite these challenges, most of which are only temporary, whether your interests lie in public health policy, community, or teaching (yes, numerous teaching opportunities are now seeking PhD, RDs), an RD is nonetheless an opportunity for growth and expansion. Dr. Compher said, “I continue to treasure my clinical practice because it keeps me in touch with issues of importance to patients.”


Moving Beyond BMI - An Evaluation of an Alternative Adiposity Index and Mortality Risk

Student Blogger
By Caitlin Dow

Body Mass Index. BMI, for short. Those three words tend to conjure up some intense feelings in scientists and the general public, alike. In 1832, a Belgian statistician named Adolphe Quetelet created his namesake index, the Quetelet Index, to describe the normal variation seen in weight relative to height across populations. That index got its new name “Body Mass Index” in 1972 from Ancel Keys (1) and was  by the World Health Organization as a clinical tool to be used easily and effectively to determine levels of obesity. 

As Cyndi Thomson, PhD, RD, a professor in the College of Public Health at the University of Arizona points out, “BMI was meant for population evaluation and we keep applying it to individuals.” BMI is useful when we study populations. It predicts risk for development of a number of chronic diseases (2). However, applying BMI to individuals, which is likely not what Quetelet had in mind when he created it, creates a number of issues. While BMI correlates well with fat mass on a population (but not necessarily on an individual level), it certainly does not consider distribution of fat. This is important because plenty of data indicate that abdominal fat predisposes people to a number of health risks more so than fat distributed evenly throughout the body (2). Furthermore, associations between BMI and various outcomes like risk for disease or mortality are assumed to be linear. That is, as BMI increases, risk for disease also increases. However, some cross-sectional, epidemiological studies have shown a “U-shaped” relation between BMI and mortality (3,4), meaning that people with very low or very high BMIs are at elevated risk of dying within a given period of time than those in the middle (generally overweight) range. The increased mortality risk with normal BMIs later in life is actually probably due to smoking or weight loss due to disease (like cancer), but this hasn't stopped the media from concluding that “being overweight is good for you!” Due to these shortcomings of BMI, it is high time to consider/develop some type of index that (a) has a linear relation with mortality for ease of interpretation; (b) considers fat mass and/or distribution; and (c) can be used easily in both research and clinical settings.

To address this need, new adiposity indices are being studied that may provide more clinical and scientific utility than BMI. A body shape index (ABSI) considers waist circumference (a surrogate measure of abdominal adiposity), adjusted for height and weight and was first developed by Krakauer, et al (5). Cyndi Thomson and colleagues recently published a paper in Obesity evaluating the relation between ABSI and mortality risk in a very large cohort study (6). The analysis included over 77,500 postmenopausal women enrolled in the Women's Health Initiative Observational Study. Anthropometrics were measured at baseline and the women were followed for an average of 13.5 years. Similar to previous findings, a U-shaped association between BMI and mortality was demonstrated. However, ABSI was strongly and positively associated with mortality, such that those in the highest quintile of ABSI had a 37% increased risk of death compared with those in the lowest quintile.

I discussed the implications of these findings with Dr. Thomson over the phone. The results from this study that indicate that ABSI is associated with mortality in postmenopausal women support similar findings from a smaller cohort from the British Health and Lifestyle Survey (7). However, while ABSI may be a more robust index describing the effect of adiposity on mortality risk, it's not ready for clinical implementation. First, because it is so new, there are no standard reference values or categorical values that correspond with normal or excessive adiposity. As Dr. Thomson says, “ABSI may provide some additional information that informs on risk, but I think we still have the issue of people not measuring waist circumference [clinically].” Because waist circumference requires more than standing on a scale, it has been difficult to implement. Clinicians have to be trained on how to properly measure waist circumference, and while it is inexpensive and not overly complicated to learn, accuracy and inter-individual measurement techniques are an issue. Despite these current setbacks, she remains optimistic: “The measurements haven't gotten there, but they will.”

Another important aspect of using ABSI (or any index of body composition) will be validating it across a range of races and ethnicities. Thomson notes that in a preliminary analysis that has yet to be published, the ABSI and mortality risk does indeed differ between races and ethnicities. Because of that, “one clinician may use one [adiposity index] while another may use something else, depending on their patient population.” 

Although still in the preliminary stages of research, ABSI may pan out as a useful measure of adiposity that could replace or complement BMI. It will need to be rigorously tested across age groups, race/ethnicities, genders and in its associations with a variety of chronic diseases. Stay tuned as this very young area of research unfolds!

References
1. Keys A,  Fidanza F, Karvonen M, Kimura N, Taylor H. Indices of relative weight and obesity. Journal of Chronic Diseases 1972; 25 (6–7): 329–43. 
2.Harvard T. Chan School of Public Health. Why Use BMI? http://www.hsph.harvard.edu/obesity-prevention-source/obesity-definition/obesity-definition-full-story/
3.Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 2013; 309:71-82.
4.Winter JE, Macinnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause mortality in older adults: a meta-analysis. Am J Clin Nutr 2014;99:875-890.
5.Krakauer NY, Krakauer JC. A new body shape index predicts mortality hazard independently of body mass index. PloS One 2012;7:e39504
6.Thomson CA, Garcia DO, Wertheim BC, Hingle MD, Bea JW, Zaslavsky O, Caire-Juvera G, Rohan T, Vitolins MZ, Thompson PA, Lewis CE. Body shape, adiposity index, and mortality in postmenopausal women: Findings from the Women's Health Initiative. Obesity; 2016; 1061-9.
7.Krakauer NY, Krakauer JC. Dynamic association of mortality hazard with body shape. PloS One 2014;9:e8879.


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

Student Blogger
By: R. Alex Coots

The below interview is a continuation of an interview with Angela Tagtow, Executive Director of the Center for Nutrition Policy and Promotion at the USDA. Part 1 of this interview can be found here.

Tell me about the challenges of nutrition policy.

I imagine health policy falling into one of two categories, little-p policy (LPP) or big-p policy (BPP). LPP is a socioecological approach to policy, using individuals and organizations to make decisions to improve public health that don't require an elected official. BPP requires elected officials to create broader, more top-down initiatives to improve public health. Both types of policy working in concert can create greater collective impact.

Many people see BPP as the primary driver of policy, but LPP can be very effective to improve community health. The Northeast Iowa Food and Fitness Initiative exemplifies the power of LPP. Through the initiative they recruited hundreds of community stakeholders to make commitments to improve public health whether that is at home, school, workplace or throughout the community. Starting the initiative was a slow process built on networking and strengthening relationships, but proved to make an impact in the lives of community members.

BPP also creates change, but has its own challenges. It can take several years for State or Federal programs to be fully implemented. For example, the Healthy Hunger-Free Kids Act was signed into law back in 2010, and we're still seeing elements roll out. At the Federal level, Congress is another aspect that makes BPP challenging. Each Congressperson has a different perspective and set of values with respect to healthy food access, nutrition, public health. The ability to recognize their priorities and influencers is an important part of building support behind an initiative. 

Given the number of different opinions and interests regarding public health, do you think there's a way to make everyone happy?

There's always going to be struggle. Every organization out there has a set of goals that are different from the next organization. Industry has an interest to protect its products and public health has an interest to keep people healthy. These goals are not always aligned, so there are challenges.

The media often reports on about industry trying to make changes to their offerings in the name of public health. Do you think these efforts are genuine?

Not all industry should be discounted. Some companies do consider how their products and services contribute to public health and are trying to make a difference. But for others, they need to evaluate whether they are doing all that they could be doing.

What are some of the future goals for the USDA and the CNPP?

The CNPP does much more than just produce the Dietary Guidelines for Americans (DGA) and the iconic MyPlate. The Nutrition Evidence Library, a very rigorous review of the literature that directly informs the DGA. The CNPP also makes many tools and online resources available to assist individuals with eating and physical activity goals. ChooseMyPlate.gov and Supertracker.usda.gov are dynamic online resources for individual, families and professionals that put the Dietary Guidelines for Americans into action.

In the near term, the launch of the 2015 Dietary Guidelines for Americans and the Healthy Hunger-Free Kids Act are the top priorities. Some policymakers are challenging the validity of improving child health, and the House and Senate have inserted language in appropriation bills that will restrict USDA and HHS's  abilities to create the Dietary Guidelines. It's a very interesting political time regarding advancing the nutritional health of Americans.

Do you have any final advice for students?

Yes, be engaged. Having a good grasp of the content knowledge and political processes are good, but having contacts and networks is just as important. Knowing key people who create change and understanding how to work with them will allow you to be more effective in your endeavors. We need more people to get engaged with nutrition and public health efforts.


Health Professionals Need More Nutrition Education. How Can We Deliver?

Student Blogger
By Allison Dostal, PhD

It's not a revelation that most Americans would benefit from increased nutrition education and guidance. Newly released data from the Centers for Disease Control and Prevention1 show that 64% of Americans are overweight or obese - a number that's held steady over the past few decades - and that nearly 40% of us consume less than 1 serving of fruits or vegetables daily. $210 billion is spent annually on obesity-related disease2. 

It is known, perhaps intuitively, that physicians trained in nutrition achieve improved health outcomes in patients with obesity-related conditions3. Numerous clinical guidelines recommend that physicians counsel their overweight and obese patients on diet, and yet, fewer than 25% feel that they received adequate training in doing so. As a result, only 1 in 8 medical visits includes a discussion of nutrition4,5. This disconnect in recommendations versus practice is a significant issue in medical education today, and the perennial discussion of how to improve the current state of nutrition education in the medical curriculum continues to increase in relevance in our nation's obesity crisis. 

The Problem
It is recommended that physicians-in-training receive 25 contact hours of nutrition education, including basic nutrition knowledge, assessment, nutrition intervention, and dietary treatment of disease. However, nutrition education in medical schools has continued to fall below this target – and it's getting worse. A 2012 survey4 found that most medical schools fail to require the recommended amount of nutrition education, with less than 15% of schools providing the 25-hour minimum. The number of hours devoted to nutrition education has dropped substantially since 2004, while the number of schools with no required nutrition education has risen4.

Compounding this issue, many medical training programs provide only basic nutrition background, often buried within a biochemistry or physiology course. While it is undeniably important to highlight the specific actions of vitamins and minerals, this model fails to highlight real-world clinical application of nutrition. Even less time is devoted to developing patient counseling skills. Lastly, the U.S.'s health professional training systems do not provide expertise or incentives to deliver effective counseling on how to achieve and maintain a healthy weight, diet, and physical activity level. This leads to a divide in thinking - a “should” or “want to do” versus “need to” or “have time to do”, and a reduced sense of urgency about implementing changes. 

Working Toward a Solution
In addition to a lack of monetary or standard-of-care incentive to increase knowledge dissemination, another primary reason for suboptimal nutrition education is lack of time. This exists both in the amount of time devoted to actual coursework within medical training and for development of a nutrition curriculum within a program. Fortunately, several groups have worked diligently to provide resources that alleviate these barriers. In contrast to many programs that are specific to a particular institution, Nutrition in Medicine6, is a web-based series for students and healthcare professionals, administered through the University of North Carolina at Chapel Hill's Department of Nutrition. There are over 40 modules ranging from 15 to 60 minutes in length that offer basic nutrition knowledge as well as evidence-based instruction of clinical skills. In addition to providing biochemical, clinical, and epidemiological components and virtual case studies, NIM also offers nutrition tools like pocket notes, nutrient recommendations, quizzes, and YouTube video vignettes. Nearly 75% of U.S. medical schools take advantage of at least one NIM module, and the program has proven to be successful in providing 33% more nutrition education in schools that use NIM versus those that do not. 

And the best part? It's completely free.

Future Directions
Despite the advances made by NIM in improving the dissemination of nutrition knowledge in the medical curriculum, challenges remain. Martin Kohlmeier, NIM's principal investigator, has acknowledged that building good nutrition education tools is expensive and time consuming, since materials need to be reviewed continuously and updated every 4-5 years. Supporting a web-based tool takes a significant amount of resources, and funding sources are difficult to consistently maintain. 

Recently, this cause has been taken up by several prominent health and medicine-focused organizations. A new effort has been launched to teach medical students, physicians, and other allied health professionals how to discuss obesity treatment and prevention options with patients. This initiative is a collaboration between the Bipartisan Policy Center, the Health and Medicine Division of the National Academies of Sciences, the American College of Sports Medicine, and the Alliance for a Healthier Generation. The multi-year project, supported by the Robert Wood Johnson Foundation, will develop “core competencies for obesity prevention, management, and treatment for the health professional training pipeline and identify payment policies that will incentivize the delivery of this care”, as stated in their April 11th press release7. Their goals are for these competencies to be implemented in training programs across the full spectrum of health professionals, and to determine a strategy to reimburse effective counseling for maintaining a healthy weight, diet, and physical activity level. “Training health professionals without a concurrent strategy to reimburse this type of care will not lead to meaningful change. And offering payment without having trained professionals to provide the care also will not result in improve[d] patient care,” the group stated. 

This working group, like those involved in the Nutrition in Medicine curriculum, acknowledges that systemic changes to improve nutrition education in medical training will require continuous commitment from a wide range of stakeholders. Details of this initiative have not yet been announced, but those of us involved in education and clinical care certainly look forward to seeing the first steps begin. 

Are you a health care professional, student, or educator? What is your experience in teaching or learning nutrition and nutrition counseling skills? I welcome your comments and insight on this issue.

References
1.Nutrition, Physical Activity and Obesity Data, Trends and Maps web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity, Atlanta, GA, 2015. Available at http://www.cdc.gov/nccdphp/DNPAO/index.html.

2.Cawley J and Meyerhoefer C. The Medical Care Costs of Obesity: An Instrumental Variables Approach. Journal of Health Economics, 31(1): 219-230, 2012.

3.Rosen BS, Maddox PJ, Ray N. A position paper on how cost and quality reforms are changing healthcare in America: focus on nutrition. Journal of Parenteral and Enteral Nutrition 2013;37(6):796–801.

4.Adams, K.M., Kohlmeier, M., & Zeisel, S.H. Nutrition Education in U.S. Medical Schools: Latest Update of a National Survey. Academic Medicine. 2010;85(9): 1537-1542.

5.Early KB, Adams KM, Kohlmeier M. Analysis of Nutrition Education in Osteopathic Medical Schools. Journal of Biomedical Education, vol. 2015, Article ID 376041, 6 pages, 2015. doi:10.1155/2015/376041

6.K. M.Adams, M.Kohlmeier, M. Powell, and S. H. Zeisel, “Nutrition in medicine: nutrition education for medical students and residents. Nutrition in Clinical Practice. 2010;25(5), 471–480. Available at: http://nutritioninmedicine.org/

7.Bipartisan Policy Center. New Effort Launch to Train Health Professionals in Nutrition and Physical Activity. http://bipartisanpolicy.org. 21 Mar. 2016.


My Clinical Nutrition Internship Experience

Danielle Jordan

By Seth Morrison

My name is Seth Morrison, a final year medical student at the Medical School for International Health in Israel. I would like to share with you a taste of my experiences in the ASN's unique Clinical Nutrition Internship.

Clinical nutrition was never really on my radar as something I might become interested in until halfway through medical school. It was then that I attended the International Congress of Nutrition held in Granada, Spain, where I met some members of the ASN. Like most medical students, the nutrition content in my courses was only enough to whet my appetite. I never had a chance to really delve into nutrition in-depth so that I would feel comfortable counselling patients or speaking intelligently about it with colleagues. The ICN conference opened my eyes to the many different research branches of the nutrition sciences as well as public health nutrition. The global trends in the “double burden” of malnutrition (undernutrition and overnutrition) in developing countries began to worry me, and I started learning about the many efforts that are underway to intervene. All of this made me want to find an opportunity to supplement my nascent interest in nutrition, and see which career avenues exist. I would like to incorporate nutrition into my medical practice and possibly conduct public health nutrition interventions in resource-limited settings worldwide. That is when I discovered this clinical nutrition internship.

I think my internship was an unparalleled opportunity for a medical student to get an insider's look into the fascinating world of clinical nutrition and nutrition science. The variety of opportunities I had at the University of Colorado and Children's Hospital Colorado working with Dr. Nancy Krebs as my mentor gave me the ability to look at the role of nutrition in health from many different angles. I saw how important clinical nutrition is in the weekly outpatient clinics at Children's Hospital. There were two separate clinics for kids with either growth faltering or obesity. These clinics are where I spent a great deal of my time. Throughout that time, I gradually gleaned the beauty in which skilled nutrition practitioners were able to make a real difference in outcomes as a team. Other physicians in these clinics, along with the amazing nutritionists, nurses, and a clinical psychologist, each contributed to my education in unique ways. They taught me the decision-making process of how to decipher clues to the causes of very different clinical nutrition problems (i.e. overweight vs. underweight), whether they be organic, lifestyle-related, or sometimes, in the case of young children, family food-related behaviors. This created the immensely enjoyable opportunity to decipher solutions to these myriad problems with clinical judgement and a creativity that respects the patient's/family's abilities and interests. I like to say today that in order to provide effective dietary counselling to patients, each doctor should have a little bit of a nutritionist inside them. This skill is one of the greatest gifts that the internship provided me for my own toolbox of clinical skills.

A sampling of the other components of my internship that made it very well-rounded were a research project, visits to WIC clinics, family eating well classes, several journal clubs and special nutrition lectures every week, and even a few nutrition-related Grand Rounds on Friday afternoons. I also completed a research project, which was a small metabolomics study on the relative serum levels of acylcarnitines and branched-chain amino acids in lean vs. obese groups of pregnant Guatemalan women.

This research component of the internship added an essential ingredient to the overall experience. Not only did I get to work with a fantastic and knowledgeable basic science researcher on a project in a burgeoning field of nutrition science (metabolomics), I also gained new skills and refined others that are needed in any research project I may become involved with in the future. This academic component reinforced the ever-present need for an army of researchers to inform the nutritional counsel given to patients in clinical medicine.

Inpatient care in the University of Colorado Hospital especially gave me the chance to see how crucial proper nutrition is for pre- and post-operative patients, burn unit patients, and of course in critical care. The nutrition support physician and the knowledgeable dietitians there broadened my knowledge of TPN and other topics in critical care nutrition research. In doing so, the truth was ingrained in me that nutrition is dynamic and can, in different circumstances, be prevention, treatment, or even both. Whether a patient is acutely ill or on a path of long term lifestyle change to reach a healthy weight, nutrition is likely to play an important role in their success!

The ASN Clinical Nutrition Internship satiated a special hunger for this nutrition niche in my medical education. I could not be more grateful and proud to have been awarded this unique opportunity, and the memories from it will linger with me for the rest of my career. As a soon-to-be physician, I've now learned that nutrition is a bit like music. It's nice to listen to, but to really appreciate it, you must also learn to play some of your own notes.


Designing interventions to achieve impact

Danielle Jordan

Student Blogger for Global Nutrition Council at ASN's Scientific Sessions and Annual Meeting at EB 2016

By: Sheela Sinharoy, MPH

A symposium titled Program Effectiveness for Addressing Undernutrition during the First 1,000 Days provided attendees with examples of programs in Bangladesh, Guatemala, and Burundi.

In Bangladesh, the Rang-Din Nutrition Study tested lipid-based nutrient supplements (LNS) in a community-based program. According to presenter Kay Dewey, the study found that giving LNS to mothers prenatally reduced the prevalence of stunting and increased the birth weight, head circumference, and body mass index (BMI) in infants at birth. LNS and multiple micronutrient powders (MNP) for children were also associated with better developmental and cognitive outcomes. Dr. Dewey noted that the impact on child anthropometry was much larger in food insecure households, so future programs may want to target based on this and other criteria.

Moving from Asia to Africa, Marie Ruel presented results from an impact evaluation of a food-assisted integrated health and nutrition program in Burundi. The program gave food rations to mothers and children and also provided behavior change communication. Interestingly, the nutrition situation in Burundi deteriorated sharply during the program period, but decreases were less severe in the treatment groups. For example, while the prevalence of stunting increased dramatically in the control group, the prevalence in the treatment group remained essentially flat. Thus, although the treatment group did not improve, the results suggest that the intervention protected families who otherwise would have been vulnerable to economic shocks.

Guatemala is another country with a very high prevalence of chronic undernutrition, and Deanna Olney presented results from a study of a similar food assistance program. The impact of the program was greatest among those who received a full family food ration plus an individual ration of corn-soy blend. In these households, mothers had significantly higher mean BMIs, children had a lower prevalence of stunting, and both mothers and children had a lower prevalence of anemia. However, there were no significant impacts on child underweight, wasting, or language or motor development.

The differing impacts of various programs was the impetus for a talk by Per Ashorn, who discussed pathways of impact for fetal growth, linear growth, and cognitive function. He explained that the pathways for linear, ponderal, and head growth are partially different, and there are possibly partially different pathways to childhood length gain and brain function. This suggests a need for multipronged interventions targeting pathways including infection, nutrition, and inflammation, as well as a variety of outcome measures to assess the interventions' impact.

Of course, cost is an important – and often challenging – issue when planning interventions. The final talk of the symposium was given by Steve Vosti, who explained that programs must balance need, acceptability, use, and both short-term and persistent demand in order to achieve impact. These and many other factors, such as the costs of manufacturing supplements in country and the proportion of locally available ingredients being used, can affect the cost of an intervention. In addition to deciding on the most appropriate intervention to meet a need, practitioners must take these factors into account when planning their programs.


The complexity and mystery of linear growth

Danielle Jordan
Student Blogger for Global Nutrition Council at ASN's Scientific Sessions and Annual Meeting at EB 2016
By: Sheela Sinharoy, MPH

A symposium called Biology of Linear Growth on Tuesday examined linear growth from the molecular to the population level, bringing perspectives from biology, physical anthropology, nutrition, and epidemiology. 

Are you familiar with the process of endochondral ossification? Julian Lui, MD PhD explained that this is the process that results in linear growth. It takes place in the growth plates, at the end of long bones such as the femur, and is subject to systemic regulation by endocrine, nutritional, and inflammatory cytokine factors as well as local regulation by paracrine factors and other cellular mechanisms. Malnourished children have lower levels of hormones like insulin-like growth factor 1 (IGF-1) and estrogen, as well as increased levels of glucocorticoids, leading to decreased linear growth. Dr. Liu explained that this allows the body to conserve resources and that, in situations of food insecurity, “Growth is something of a luxury that can be postponed until better times.”

Rather than growing continuously, children grow in saltations, meaning that – as many a parent has observed – a child may grow substantially overnight and then not at all for a number of days afterwards. Michelle Lampl, MD PhD stated that as children age, these saltations become less and less frequent, with older children growing much less often than infants. The amount and frequency of these growth saltations can be affected by environmental factors, which can interact with cellular effects. Maternal smoking, for example, has a well-documented inhibitory effect on growth, as does maternal alcohol consumption and stress.

Since linear growth happens most rapidly in early life, the first 1,000 days from conception to two years of age are considered a critical period. Parul Christian, DrPH presented results from a meta-analysis analyzing various maternal and child nutrition interventions targeting this 1,000-day window. Starting during pregnancy, balanced protein-energy, iron-folic acid, and multiple micronutrient supplementation were all found to increase birth weight. However, maternal supplementation during pregnancy was not associated with any long-term linear growth in children under five years old. For infants and young children, nutrition promotion and food supplementation showed promise as interventions with positive impacts on child height.

In the final talk of the symposium, Aryeh Stein, PhD addressed the question of linear catch-up growth: for those children whose growth has been suppressed by malnutrition, is it possible to catch up on missed growth, even after the first 1,000 days? A number of studies have provided different nutrients and foods to children ages two and older. Dr. Stein presented results from studies of protein, zinc, iron, iodine, calcium, multiple micronutrients, and food. Protein and some of the micronutrients may have promise, but several of the calcium studies reported negative effects, while food had no association with growth. 

The symposium made it clear that nutrition has an important role to play in stimulating or inhibiting linear growth. However, a great deal remains to be learned about these complex biological processes and the most effective interventions to promote children's optimal growth.