Nutrition: Beyond the Scale.

Examining our Biases! Introduction

• Conditions related to • Review of guidelines • HAES- a word on eating disorders • FADS • Tools for patients/clinicians • RD top ten “We aren't the food police.” -RD Conditions related to nutrition (what isn’t?)

• The obvious triad: • Acne (microbiome) v HTN v DM • Inflammatory bowel disease v Hyperlipidemia • IBS • • Constipation • allergies/asthma • Gout • GERD • Anemia • celiac disease • Osteoporosis • • Depression • eating disorders • kidney disease • kidney disease • More? BIASES -many sources lead to our belief system

• Media, popular culture • Regional and ethnic factors • Socioeconomic factors (food insecurity- even in a surprising demographic at times) • Personal experience • Misinformation from “experts”. “Diets don't work.” -RD • Body type- body shaming • Cooking/food prep skills “People often like "healthy foods" if given quick easy ways to fix them.” -RD International Food Information Council Foundation’s 12th annual Food and Health Survey- 2017

• Most common source of nutrition information: #1 personal health-care professionals #2 Friends and family about what foods to eat or avoid. • Most trusted source of nutrition information: ranked (health providers rated high) and friends and family as low on the trustworthiness scale. • Myriad of sources including: health coaches, personal trainers, social media, bloggers, television, government agencies and food companies. • Biggest influence on your decision to follow a specific eating pattern or : #1 probably your immediate circle. Health-care providers and registered nutritionists (RDNs) lagging behind. • “RDs job is to make all the nutrition recommendations make sense, even if they all sound contradicting in the press.” -RD International Food Information Council Foundation’s 12th annual Food and Health Survey: MORE FINDINGS

• Weight loss is the most desired health benefit from ages 18 to 49, but preventing becomes more important after age 50. “Weight loss isn't everything.” -RD • Opinions about added sugars and artificial sweeteners have grown more polarized over the past year, with many people choosing one to specifically avoid the other. Friends and family are a big influence on this topic. • Almost 3 in 4 respondents seek non-GMO labels because they believe these foods are more healthful, safer or better for the environment. “Tell patients they don't have to eat the last supper.” -RD 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk

• LDL reduction: vemphasizes intake of vegetables, fruits, and whole grains vincludes low-fat dairy products, poultry, fish, legumes vNon-tropical vegetable oils, and nuts vlimits intake of sweets, sugar-sweetened beverages, and red meats. • TAKE INTO ACCCOUNT: personal and cultural food preferences, and nutrition therapy for other medical conditions (including ). • DASH diet: Still a good place to start! NON tropical vegetable oils

• What about Coconut Oil?? • Coconut oil is extracted from the fruit of mature coconuts. It is a saturated fat, and consumers are cautioned against a diet high in saturated fat. Virgin coconut oil is high in lauric acid, a medium-chain fatty acid that raises both good and bad cholesterol levels. • How should you use it? Coconut oil has a sweet, nutty taste, and is often used as a substitute for shortening or butter in a vegan diet. It also imparts a tropical flavor to vegetables, curry dishes and fish. Because it is a saturated fat, use coconut oil in moderation, and buy the kind labeled "virgin.“ (from eatright.org) • Although eating coconut oil in moderation isn't going to result in great harm to your health, it's not likely to help you lose weight either. For successful, long-term weight loss, stick to the basics — an overall healthy-eating plan and exercise. (from mayoclinic.org) 2015-2020 Dietary Guidelines for Americans (health.gov)

• Follow a healthy eating pattern across the lifespan. All food and beverage choices matter. Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease. • Focus on variety, nutrient density, and amount. To meet nutrient needs within calorie limits, choose a variety of nutrient-dense foods across and within all food groups in recommended amounts. • Limit calories from added sugars and saturated fats and reduce sodium intake. Consume an eating pattern low in added sugars, saturated fats, and sodium. • Shift to healthier food and beverage choices. Choose nutrient-dense foods and beverages across and within all food groups in place of less healthy choices. Consider cultural and personal preferences to make these shifts easier to accomplish and maintain. “Everyone is different and it is not one size fits all. Honor each person's food preferences.” -RD • Everyone has a role in helping to create and support healthy eating patterns in multiple settings nationwide, from home to school to work to communities. Key Recommendations A healthy eating pattern includes:

• A variety of vegetables from all of the subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other. EAT THE RAINBOW… • Fruits, especially whole fruits • Grains, at least half of which are whole grains • Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages • A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products • Oils BIAS in the Nutrition Guidelines?

• The Dietary Guidelines is required under the 1990 National Nutrition Monitoring and Related Research Act, which states that every 5 years, the U.S. Departments of Health and Human Services (HHS) and of Agriculture (USDA) must jointly publish a report containing nutritional and dietary information and guidelines for the general public. (USDA=US Dept. of Agriculture) • The information in the Dietary Guidelines is used in developing Federal food, nutrition, and health policies and programs. It also is the basis for Federal nutrition education materials designed for the public and for the nutrition education components of HHS and USDA food programs. (school lunches, WIC, etc.) “A healthy eating pattern limits: oSaturated fats otrans fats oadded sugars oSodium” -from the 2015-2020 Dietary Guidelines for Americans -“Limits” are quantified in the guidelines. BUT, “All foods fit at some point.” - RD Key Recommendations that are quantitative:

1. Consume less than 10 percent of calories per day from added sugars. (For 2000 cal/d diet = 200 calories/day = 50 grams/day.) *** HOWEVER: The World Health Organization (WHO) recommends added sugar intake for adults be cut in half, from the original 10 percent of total daily calories to 5 percent. For a normal weight adult, that's about 25 grams, or 6 teaspoons, per day. June 18, 2015 2. Consume less than 10 percent of calories per day from saturated fats. 3. Consume less than 2,300 milligrams (mg) per day of sodium. AMERICAN HEART ASSOCIATION recommendation Same as WHO (for women and slightly more for men) Salt/sodium

o FOR EVERYONE: The American Heart Association recommends < 2,300 milligrams (mgs) a day. (One teaspoon of table salt=2300mg of sodium!) o This will likely help patients reduce their . (Most Americans eat >3400mg/day.) o Further reduction of sodium intake to an ideal limit of <1500 mg/d for most adults can result in even greater reduction in BP o Even without achieving these dietary limits (1500-2300mg/d), reducing sodium intake by at least 1000 mg/d lowers BP. Nutrition Guidelines- Pediatrics AAP-PEDIATRICS volume 117 Feb. 2006

• Balance dietary calories with physical activity to maintain normal growth. • 60 min of moderate to vigorous play or physical activity daily. • Eat vegetables and fruits daily, limit juice intake. • Use vegetable oils and soft margarines low in saturated fat and trans fatty acids instead of butter or most other animal fats in the diet. • Eat whole-grain breads and cereals rather than refined-grain products. • Reduce the intake of sugar-sweetened beverages and foods. • Use nonfat (skim) or low-fat milk and dairy products daily. • Eat more fish, especially oily fish, broiled or baked. • Reduce salt intake, including salt from processed foods. FOOD LABELING CHANGES (pending) (original compliance date 7/26/18- but on June 13, 2017, the FDA announced its intention to extend the compliance date.)

On May 20, 2016, the FDA announced the new Nutrition Facts label for packaged foods to reflect new scientific information: o Manufacturers must declare the actual amount, in addition to percent Daily Value of D, calcium, iron and potassium. o They can voluntarily declare the gram amount for other and minerals. o “Added sugars,” in grams and as percent Daily Value, will be included on the label. (Scientific data shows that it is difficult to meet nutrient needs while staying within calorie limits if you consume more than 10 percent of your total daily calories from added sugar) o and potassium will be required on the label. o Calcium and iron will continue to be required. o Vitamins A and C will no longer be required but can be included on a voluntary basis. o While continuing to require “Total Fat,” “Saturated Fat,” and “Trans Fat” on the label, “Calories from Fat” is being removed because research shows the type of fat is more important than the amount. FOOD LABEL CHANGES RE: SERVING SIZE

• Serving sizes must be based on amounts of foods and beverages that people are actually eating, not what they should be eating. (How much people eat and drink has changed since the previous serving size requirements were published in 1993. For example, the reference amount used to set a serving of ice cream was previously 1/2 cup but is changing to 2/3 cup. The reference amount used to set a serving of soda is changing from 8 ounces to 12 ounces.) • For certain products that are larger than a single serving but that could be consumed in one sitting or multiple sittings, manufacturers will have to provide “dual column” labels to indicate the amount of calories and nutrients on both a “per serving” and “per package”/“per unit” basis. Examples would be a 24-ounce bottle of soda or a pint of ice cream. Label Comparison More biases

• HAES “Practice the approach of Health at Every Size.”- RD • BMI vs. WC - the “boomer belly” • Body shaming • Generational differences • Cultural differences Eating disorders- case study

• Don’t ignore this possible diagnosis in thin older women! http://www.consultant360.com/articles/anorexia-nervosa-older-woman-eating- disorders-chronic-conditions

“If you sense a disordered relationship with food or exercise or an eating disorder, ask questions- don't ignore!” -RD CLINICAL CASE

• 68 yo woman, assisted living resident noted to be exercising excessively. • Retired RN, moved to assisted living after husband died. • Pt noted to drink many glasses of water in waiting room. • Thin, well-groomed and able to provide detailed history of her health, using medical terminology. History

• Age 10 was teased at school for developing breast tissue. Began to worry about her weight and restricted herself to one daily. • Age 14 admitted for syncope. • Gives history of water loading prior to medical appointments to increase her weight. • During nursing school, fainted few times. Diagnosed with anemia and hypotension. • Learned to eat enough to maintain her weight at 84#, and exercise enough on days when exceeded her specific calorie count to keep weight at the magic number of 84# at 5’ 1”. Adult years

• Married at 28yo and was able to successfully gain wt. for two pregnancies, though recalls “hating” being pregnant and having obsessive thoughts about how she would lose her weight again after giving birth. (One adult daughter suffers from anorexia nervosa.) • Diagnosed at 52 yo w/ severe osteoporosis and painful compression fractures. Could no longer exercise and weight increased to 92#. • Anxiety about this weight caused patient to go on a liquid “fast” (diluted fruit juice only) during which time she fell down stairs sustaining hip and arm fractures requiring surgery. Post op she required tube feeding. • Was able to maintain a weight of 100# for a few years after this, primarily due to her fears of falling. • After her husband passed away, she moved to assisted living, and resumed her eating and exercise patterns to seek the 84# again. Hallmarks and/or red flags- watch biases • Water loading • Health professional • Elderly female • Behavior starts at age 10 years • Successful pregnancies • Child with AN • Osteoporosis-severe at 52 yo • Exercising • Anemia and fainting • Chronic disease with periods of remission and relapse • “Magic number” “Check your biases at the door”

• “Remember that eating disorders don't look any one way and come in all shapes and sizes. I've worked with seemingly "normal" weight clients who are bingeing and purging daily, clients in larger bodies who barely eat, and the examples go on and on, so please don't assume anything about someone's relationship with food or exercise solely based off of their weight.” -RD • Case of JD- “I don’t care how you lose the weight…” FADS

• Medical foods • “Functional foods” • Detox • Eating “clean” “Be more aware of orthorexia.”- RD • Kombucha • Acai • Coconut oil “All supplements aren't worthless and they are not all powerful either.”-RD What about medical foods?

• Definition: "a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.“ • in 1972 – FDA developed a category of nutrition for specific medical conditions such as: Phenyl- Free® 1,aphenylalanine-free formula for babies with phenylketonuria, and Ketonex®-1, a branched-chain -free formula for babies with maple syrup urine disease ) • Examples: vayacog (), deplin (depression), limbrel (OA) • However, medical foods have not been evaluated for safety or efficacy, and the FDA does not require approval before marketing. "Caution: Federal law prohibits dispensing without prescription" is not required on product labeling. Some manufacturers request not to be dispensed w.o. physician Rx. • Unlike dietary supplements, medical foods can be labeled for medical conditions such as Alzheimer disease. Dietary supplements must be labeled for so-called "structure and function claims" and cannot make claims to treat or prevent disease.[4] For example, ginkgo may be labeled "supports memory function" but not "for treatment of dementia." A drug or medical food could be labeled "for treatment of dementia associated with Alzheimer disease." L ? The basis of “vayacog”

• A non essential amino acid found in and seaweeds (Okinawa Ogimi longevity study) also found in sweet potatoes, pork, eggs • http://www.jayheinrichs.com/blog/2016/9/1/flying-foxes- caribbean-monkeys-a-tiny-laboratory-in-a-wyoming-cabin- and-a-young-mormon-missionary-who-became-a-samoan- chief-before-pursuing-one-of-the-greatest-medical-mysteries L serine

Vayacog = The manufacturers cite this study: Phosphatidylserine Containing Omega–3 Fatty Acids May Improve Memory Abilities in Non-Demented Elderly with Memory Complaints: A Double-Blind Placebo-Controlled Trial

"... 131 participants completed the study...

"... The study was designed as a single-center randomized double blind placebo-controlled study. Duration of treatment was 15 weeks. Participants were randomized according to a computerized randomization process based on 6 and 8 blocks, in a 1: 1 ratio stratified by gender, to receive 3 capsules per day of PS-DHA or a matched identically looking placebo (cellulose). The daily PSDHA dosage provided 300 mg PS and 79 mg DHA+EPA (DHA/EPA ratio of 3: 1). PS-DHA (Vayacog TM ) was supplied by Enzymotec Ltd., Migdal HaEmeq, Israel.

"... To conclude, the current study shows that administration of PS-DHA may ameliorate cognitive deficits in a non-demented elderly population. Post-hoc analysis of subgroups suggests that, within the study sample, those with higher baseline cognitive status were more likely to respond to PS-DHA treatment..." L serine in ALS one small trial

• Journal Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration • Volume 18, 2017 - Issue 1-2 What are functional foods?

• Products such as “Activia” or “Danactive” • Kombucha • Apple cider vinegar • Not defined by the FDA. • There are a myriad of on line websites and apps that patients may find. Examples are: “supertracker”, “calorie counter”, “lose it” • USDA- health.gov • MAYO • culinarymedicine.org (NOLA live CME course) • Website for fitness professionals: Tools and http://www.destructivelyfit.com/ • ED screening tool: Resources (on https://www.nationaleatingdisorders.org/scree ning-tool] line and other) • www/eatright.org • 3 programs to consider: DUFB, Food Pharmacy, “Houston Ask” Houston Ask program- hidden bias

• Starting in fall 2015, clinicians at Houston-based Memorial Hermann Health System began to examine the food struggles among patients at four medical sites, as well as emergency rooms and 10 school-based clinics in areas with high rates of poverty. • They’ve asked patients two questions: 1. Did you run out of food in the prior month, or did you think that you would? (Depending upon the location surveyed, 11 percent to 30 percent said they did.) 2. Do you have access to nutritious food? • There’s been “some surprise at the numbers, “That’s one of the things that the doctors have realized — you can’t tell this just by looking at somebody.” • In the process, preconceptions are being debunked. Even obese patients might be coping with food shortages or loading up on high-calorie foods during the limited stretches when it’s available. Senior citizens barely eking by on a fixed income might wear their nicer clothes for an outing to the doctor’s office, creating the perception they’re doing fine financially. Houston Ask- more surprises and some solutions

• Amid “the hidden pockets of poverty” in suburbia, someone who has been laid off might put every dollar into keeping their house and car, with little left to fill the refrigerator. One suburban practice is located southwest of Houston in Sugar Land, Texas. The median household income for the surrounding ZIP code is $92,000 annually, nearly twice the statewide median of $53,200. • Before asking patients about food insecurity, most of the doctors and nurses would likely have predicted that no more than 2 percent qualified. “Then it ended up being 11 percent, which was, I think, fairly shocking to most of us.” • Some without sufficient food were patients who had jobs with insurance, as well as numerous seniors. • “The "what" of eating is only half of it. Help them figure out how to make the changes they want to make.” - RD • It’s easier for doctors and nurses to ask about food worries if they feel as if they can offer some options: vHire a community health worker to connect patients with food banks and brainstorm how to stretch food budgets. Help eligible patients enroll in food assistance programs. vIt also has planted a vegetable garden, so patients can literally grab some okra or collard greens on the way home. Food insecurity

• Food deserts • And speaking of farmers markets… SNAP (AKA “food stamps”)

DUFB (double up food bucks)• Launched in 2009, DUFB is a food incentive program designed to supplement the federal -MICHIGAN Supplemental Nutrition Assistance Program (SNAP). With DUFB the customer can purchase locally grown produce through a $20 per visit incentive match, using his or her SNAP benefits, from June to October. • The design of Double Up is simple: for every dollar a SNAP customer spends on fresh Michigan- grown produce he or she receives an additional Double Up dollar to spend on more nutritious fruits and vegetables. • From 2007 (prior to start of the program) to 2015 annual SNAP sales increased from a mere $15,000 to more than $1.5 million in combined SNAP and Double UP. • Less , healthier foods=better health, financial support of local agriculture! Increasing awareness of DUFB in a medical office - a study

• SNAP is currently available in over 40 states, while the DUFB program is available at over 200 grocery stores and farmers' markets across Michigan, and continues to expand. • The authors noted that most SNAP participants are unaware of the DUFB program. • Could brief chats in the waiting room increase use of DUFB? • 127 eligible participants were recruited from a waiting room of an academic outpatient family medicine and pediatric practice in Ypsilanti, Mich. The participants were already enrolled in SNAP at the time of recruitment. Background and methodology

• The researchers had brief chats in the outpatient waiting room with the participants, explaining how to use the DUFB program and presented them with a one-time, $10 voucher for use at the farmers' market. • Participants were followed up with via telephone survey three times after recruitment. • At baseline, 57% of participants reported having been to a farmers' market in the last year, but only 18% had used Double Up. "This underscored how many patients were missing out on the opportunity to have their money doubled for fruits and vegetables. • This brief, low-cost waiting room intervention could lead to a nearly four-fold increase in Double Up use -- and even more importantly, clinically significant increases in fruit and vegetable consumption." Results

• Healthy food shopping habits among low-income families improved. • Use of the Double Up Food Bucks (DUFB) food incentive saw an uptick after a 5- minute explanation about the program. (aOR 19.2, 95% CI, 10.3-35.5, P<0.001) • Consumption of fruits and vegetables increased after first use of the program and continued to rise by 0.66 servings/day (0.38-0.93, P<0.001) over the first 3 months of the study. (reported in the American Journal of Preventive Medicine) • Consumption of fruits and vegetables stabilized, but continued to remain high through the remainder of the study (0.63 servings/day higher than baseline, 0.34- 0.92, P≤0.001). • Among participants who used the DUFB program three or more times, consumption of fruits and vegetables was even greater after baseline (P=0.002 for frequency of DUFB use). Even after farmers' market season had ended in October, consumption remained increased for 2 months following. Geisinger Fresh Food Pharmacy

• Launched fall 2016 in Shamokin, PA where one in three residents is considered food insecure. • Program that offers food insecure, diabetic patients in Shamokin, Pa., prescriptions for free foods aimed at keeping their disease under control. • My patient’s story: TVV • The clinic's patients often experience not just temporary hunger, but food insecurity—the enormous physical and psychological impact of not knowing where your next meal comes from • Because clients might not be familiar with some of the foods, recipes, menus and regular phone calls from a health manager are provided. • Free diabetes wellness classes, dietary consultation and workshops are also provided to teach healthy eating habits and incentives are being worked into the program to encourage participation. Referring to dieticians

1.Referring sooner rather than later (not as a “last resort”) 2.Explain to patients why they are being referred. 3.Send medical history and recent labs so RD knows enough background to make the appointment more meaningful. 4.“Interview" . 5.“Feel free to call us and run questions by us.” -RD 6.Help your patients understand what to expect when they see an RD. Top ten things dieticians want us to know.

1.Weight loss isn't everything 2.Everyone is different and it is not one size fits all. Honor each person's food preferences. 3.Diets don't work. 4.Practice the approach of Health at Every Size. 5.We aren't the food police. 6.The "what" of eating is only half of it. Help them figure out how to make the changes they want to make. 7.All foods fit at some point. 8.Tell patients they don't have to eat the last supper. 9.Be more aware of orthorexia. 10. If you sense a disordered relationship with food or exercise or an eating disorder, ask questions- don't ignore! END ?’s?