Nutrition Viewpoint

Shortly before Thanksgiving, I came across Michael Pollan's list of the seven most powerful voices shaping America's food systems. It wasn't surprising that Pollan included First Lady Michelle Obama as well as some vocal journalists with platforms from which their views can be heard. But I was struck by who was missing from the list - the nutrition authorities who have dedicated their professional lives to helping people eat well for health and enjoyment.

While I admit I have a bias, I do wonder about the 70,000 registered dietitians who focuses on helping people - healthy, sick, young, old - make food choices that meet their needs. And what about the Academy of Nutrition and Dietetics spokespersons who interact with the media everyday, providing context and guidance on the day's issue or controversy. What about leading nutrition scientists in government and universities. Are their messages not as dramatic?

We're all aware that confusion over food and health abounds. Not only is nutrition a very complex area of study, effective nutrition-related advice must take individual preferences and behavior into account. While I have no objections to Pollan's choices, I think he stopped short of the mark. Number eight on his list should be the registered dietitian.

Last week, I tweeted on several studies that focus on times in life when people are at risk for obesity. A great deal of obesity-related research today explores the period of time from infancy through the teen years. Children are receptive to behavior change and, frankly, usually present a better return on investment of resources. For example, consider the growing rate of cardiovascular disease and diabetes in young children. Preventing these diseases early makes sense on so many levels.   

As important as research on children and teens is, however, we can't short-change other population segments and here is why: Who provides children with healthy food and who influences children by example? Parents and other adult authority figures.

We are not going to solve this country's obesity problem unless we reach out to all age levels. So let's not spend any more research dollars trying to establish who is most at risk. We're all at risk. Our focus should now shift to action - what works. What can people do to achieve and maintain a healthy weight at any age? What are the common denominators for people of all ages? What are the key messages? That's where our focus should be.

We already have an abundance of studies suggesting "appropriate" messaging. For example, skip one meal; eat smaller meals more frequently. Limit certain foods; eat more fruits and vegetables. How do we use all this information? My opinion is that we need to take a page out of the books of leaders like Ronald Reagan and Bill Clinton. These two great communicators advised that leaders who get things done focus on just a few key issues or messages.      

As nutrition advisors, so should we. The Institute of Medicine (IOM) offers us some help here. In its recently released report, Leveraging Food Technology for Obesity Prevention and Reduction Efforts, the IOM authors make three points concerning strategies that work: Focus on portion size, frequency of snacking (especially among teens) and meals eaten outside the home. The IOM report provides the evidence to support these three strategies. Take a look. As the German writer/poet, biologist and physicist Johann Wolfgang von Goethe famously said, "Knowing is not enough; we must apply. Willing is not enough; we must do."

I have been doing some research for a book that explores why nutrition advice is mired in so much confusion these days. Along the way, I came upon a disturbing statistic: According to a study published in March by researchers at Johns Hopkins University, 30% to 55% of hospital patients are malnourished. There seems to be a shocking lack of awareness regarding this problem and the role proactive nutrition support plays in speeding healing and recovery and in preventing complications such as infections - not to mention decreasing costs.

It's almost 2012! How can this be? Didn't we identify and address this problem in the early 1980s? With so many advances in disease-specific nutrition therapies, how can we be facing this problem again?

And this time around, it's not only about doing the right thing for patients; it's about money. When provisions of the Affordable Health Care Act take effect in July 2012, hospitals will be penalized for unnecessary readmissions that occur within 30 days of discharge for certain conditions. Patients who are discharged in a malnourished state or without access to the nutrition therapy necessary to support continued recovery are extremely vulnerable to unnecessary readmission.
 
I spent the majority of my career as a dietitian/nutritionist with Abbott Nutrition (formerly Ross Laboratories) - for more than two decades, the leading the manufacturer of medical nutrition products. In 1989, Abbott created and funded the Nutrition Screening Initiative, a multifaceted campaign to educate hospital professionals about the need to identify patients at nutritional risk and intervene before complications develop. We promoted the seminal work of scientists like George Blackburn, PhD, MD, and B. R. Bistrian, PhD, MD, that demonstrated the seriousness of iatrogenic malnutrition - that is, protein-calorie malnutrition brought on by treatments, medications and hospitalization.

Abbott was committed to providing solutions to prevent and treat patients at high risk for this condition. As we had done many times in the past, we once again showcased the value of the registered dietitian, this time as an architect of effective prevention and treatment of iatrogenic malnutrition.

That was then. Here's where I think we are today: Nutrition's role in health and wellness garners a lot of attention, with much of the focus centering on obesity. With overweight so prevalent in this country, I fear that we just assume that it's okay for a person to not eat for a few days. Not true - especially among the sick and the elderly. What we need to remember is that malnutrition and obesity are not mutually exclusive.

To advance nutrition science and promote best practices, we must build on what we have learned, not abandon it. Hospitals are under tremendous pressure to develop protocols that help avoid costs. Here's an easy (and familiar) one: Assess nutrition status at admission. Provide necessary nutrition support during hospitalization. Prescribe continuing nutrition therapy at discharge. It's not a new idea. But it is an idea whose time has come.

Here is an article that recently caught my eye: "Long-term habituation to food in obese and non-obese women" by Leonard Epstein, et al., in the August American Journal of Clinical Nutrition. It made me think about the advice we usually give to consumers. "Eat a well-balanced diet, including a variety of foods" is usually part of the message.

Epstein's study gives us reason to ponder this automatic response. The authors found that women, whether in the study's obese or its non-obese group, ate more food when they were given a variety of foods every day. Subjects in both groups who were fed the same macaroni and cheese every day for weeks, however, decreased their intake and consumed fewer calories. This finding brought back memories of the all-banana or all-hot dog or all-ice cream diets that surface from year to year with a promise to cure obesity. Of course, it's not the particular food that's making a difference - but does the lack of variety play a role?

Here is what this study and the accompanying commentary say to me and what I believe nutrition professionals should be thinking about as they try to help consumers adopt healthy eating patterns and/or lose weight:

·         Keep an open mind to all (basically sound) approaches. What works for one person may not work for another. Find out what the consumer wants and build around that foundation. Innovate!

·         Food-related behavior is very complex. It's going to take a long time to unravel the brain chemistry involved. Understanding behavior modification strategies is becoming increasingly important. Get familiar with this research and share your views.

·          Take a leadership position in the profession by developing your expertise in behavior and food intake. Determine how your work on the front lines with consumers can move the field forward.

This observation comes from Karen Lechowich, MBA, RD, ADA's executive administrator for diversity, alliances and international relations. I thought it was important to share her concern here, namely: What about the teens?

When tackling the obesity issue in this country we focus on children and adults. Adolescents are often overlooked, but according to the Centers for Disease Control, the prevalence of obesity among those aged 12 to 19 years has increased from 5.0% to 18.1% over the past 30 years. Type 2 diabetes among teens has increased dramatically as a result.

How about intervening at the start of junior high and again before college with a screening that includes an assessment of healthy weight. When there is an issue with overweight or obesity (or disordered eating), these teens can be referred to private or community resources for help learning to maintain weight successfully and pursue a healthier lifestyle. This strategy takes advantage of natural transitions in a teen's life and, once established, will become a normal part of progressing through school.