October 2009 Archives

While working my way through some on-line newspaper reading last week, I came upon an article in the Chicago Tribune about the medical home model - an increasingly discussed dimension of health care reform. Simply stated, in this model, the hub of a patient's medical home is his/her primary care physician who oversees a team of nurses and other health care professionals (including registered dietitians) who provide preventive and routine care, support, and education for patients with chronic conditions, thus freeing the doctor to focus on acute medical issues.

In the past, each time I've read or heard about the medical homes, I have had a nagging thought: Kind of sounds like an HMO to me, and we all know how patient unfriendly that so called disease management model can be. But one sentence in the Tribune article allayed that fear: "In a medical home model, doctors are evaluated on what's done for patients and rewarded if patients get recommended care, which discourages the restrictions that have frustrated some HMO patients."

Putting aside, for now, the question of how we will pay for this approach in the short run, I think the medical home model is a great idea and an enormous opportunity for registered dietitians to reach people with chronic conditions in which diet can make a tremendous difference.

The American Dietetic Association (ADA) thinks so, too. In the November issue of the Journal of the American Dietetic Association (ADA members can access at www.eatright.org), Jennifer Teters, manager of

Legislative and Political Affairs in ADA's Washington, DC, office, summarizes the association's position in "The Patient-Centered Medical Home: What Is It and Why It's Important to Dietetics Practitioners." Here are just a few of the facts Jennifer presents:

·         Chronic diseases account for up 75% of US health spending.

·         It is estimated that half of the US population has some form of chronic disease. By 2025 it is expected that one fourth of all Americans will have two or more chronic conditions - many of which are preventable.

·         According to the World Health Organization, 80% of all cardiovascular diseases and cases of diabetes can be prevented through lifestyle changes (improved diet, increased physical activity, and smoking cessation). In addition, nearly 40% of cancers can also be prevented through similar behavioral changes.

The medical home model would address the cost (in money, time, premature death and unnecessary suffering) of chronic conditions by focusing on prevention and education and by coordinating care so people receive it - rather than being denied it. You can read more about ADA's positions on health care reform here.

Earlier this week, the Food and Drug Administration (FDA) said it will crack down on the potentially misleading symbols some food companies are using on their products to flag health benefits. This initiative is the agency's first major effort to control nutrition information on food packaging since it introduced the Nutrition Facts label 15 years ago.

FDA Commissioner Margaret Hamburg, MD, stated that existing front-of-the-package labeling programs may mislead consumers by focusing on the presence or absence of selected nutrients while ignoring others that have an impact on health. For example a label may announce a product contains no trans fat, but omit the fact that the item is high in saturated fat or contains a lot of sugar. Hamburg also noted that front-of-the-packages messages make is less likely that consumers will look at the complete Nutrition Facts label.

Hamburg announced that FDA is currently working on a proposal defining criteria for front label claims made by food manufacturers and retailers. She expects FDA to release the proposed standards - which will probably mandate information on saturated fat, salt, added sugar and calories - in several months.

I think both of Dr. Hamburg's points are well taken. It is time for FDA to step into this issue. I hope FDA also looks at two additional facets of the nutrition labeling conundrum: First, we need safeguards in place to ensure manufacturers cannot add extraneous nutrients to foods in order to qualify to use a label claim. Second, we need FDA's new plan to acknowledge the importance of considering the whole diet. Foods that do not carry a front-of-the-package health claim are not by definition "bad" foods; they simply may require portion control and moderation. Consumers who understand this can manage and enjoy their food intake based on the concept of the whole diet.  Let's hope FDA introduces a powerful consumer education effort when it implements its new labeling rules. Registered dietitians can help make this happen. Make sure your voice is heard.

The symposium titled "Current Perspectives on Sodium and Health: The Salty Evidence," chaired by Chor-San Khoo, PhD, vice president of global nutrition and health at the Campbell Soup Company, featured thought-provoking presentations from Victor L. Fulgoni, III, PhD, senior vice president of Nutrition Impact, LLC, and Debra Krummel, PhD, RD, of the University of Cincinnati.

Americans consume about 3,400 mg of sodium daily - significantly more than the recommended limit of 2,400 mg. In fact, 81% people exceed that recommendation. Although we have alerted people to the danger of consuming excess salt - namely, rising blood pressure - we don't know as much as we should in order to provide comprehensive, realistic dietary guidance.

Dr. Fulgoni pointed out that the largest share of sodium in the diet comes from grains and meat, fish and poultry.  Fruit is the only food group that does not contribute sodium. Two-thirds of the sodium we consume comes from the processed and unprocessed foods we purchase or grow; one-third comes from food eaten out.     

Dr. Krummel talked about the work being done by ADA's Evidence Analysis Library, a synthesis of the best, most relevant nutritional research on important dietetic practice. The strongest evidence centers on lowering sodium chloride. There are no good data on other salts such as sodium bicarbonate, sodium glutamine or sodium citrate, all of which are used in food.

Dr. Krummel explained that sodium intake remains stable despite efforts to lower it. Salt's taste and ability to preserve food are key reasons why it's difficult to replace. Everyone is "salt sensitive" to an extent - some more so than others. But not everyone responds in the same way to reducing salt in the diet. We need to do a better job defining salt sensitivity and customizing diets accordingly. This is where the work of registered dietitians is essential.

If sodium intake is reduced below 2,300 mg/day, blood pressure will decrease. But the question is: Will people do it?  This is something the Dietary Guidelines committee must take into consideration.

Fleishman-Hillard (FH) hosted "What's in Store," a first-of-its kind seminar to help supermarket RDs share their success and learn about new research on key foods. Judy Dodd, MS, RD, who is with Giant Eagle, kicked things off with a discussion of the important role supermarket RDs play as the public face of dietetics.

In the past, it has been difficult for the public to locate a dietitian outside the healthcare system. Now, however, supermarkets are hiring RDs to help promote consumer health and wellness. Judy and I talked about how critical it is for these dietitians to continue to build their food knowledge, collaborate and reach out to the public.

The FH seminar continued with presentations designed to help RDs understand emerging research on gut health and fruits and vegetables - specifically, potato starch (resistant starch) affecting satiety, blood lipids and insulin sensitivity; dried fruits fostering good bacteria in the gut; and decreasing Ph in the large bowel to enhance the growth of good bacteria.

FH did a terrific job presenting this cutting-edge science and suggesting how supermarket RDs can communicate it to store management and customers. Participants left eager to learn "what's in store" for next year's FNCE symposium.

Several years ago, James O. Hill, PhD, director of the Center for Human Nutrition in Colorado (a nutrition center funded by the National Institutes of Health) and co-founder of America on the Move, outlined three strategies for reversing the runaway obesity trend.

1. Increase the level of physical activity in the population with small gradual steps.

2. Improve dieting behaviors to reduce excess energy intake - eat smarter.

3. Help children develop energy balance skills.

I recently asked Dr. Hill if he still believed in the viability of these goals. His response: "Absolutely. We must increase physical activity in the population, and we must forget the concept of food restriction. It doesn't work. Instead, we should be focusing on portion size and energy density. And finally - and this is most critical of all - we must empower our children with skills for achieving energy balance in their own lives."

I also asked Dr. Hill a few more questions about topics in the news. His answers support the work of groups like the Healthy Schools Partnership and the Healthy Weight Commitment Foundation. These are the kind of efforts - the ones that reach into the grass roots with actionable information - that ultimately make the difference,

Where are we in the debate over whether diet or exercise is the chief driver of weight loss and weight management?

Dr. Hill: Frankly, we are wasting a lot of time on this debate - time better spent on finding a unified solution to the obesity problem. We need a strategy that integrates diet and exercise; we cannot do without either one and maintain health. The recent article in Time magazine ("Why Exercise Won't Make You Thin," August 9, 2009) did a real disservice to the people working in the field and to the public. A lot of research suggests that it is not the case that when sedentary people become active, their food intake increases to match their increased activity.

You have said that at our current level of energy expenditure, we simply cannot achieve a low enough energy intake to reach energy balance. Can you elaborate a bit?

Dr. Hill: All our physiological systems drive us to eat. Eating is good thing. An enormous amount of data suggests that food restriction is not an effective strategy for weight management.  It is not possible to get people to follow a restricted diet over time. Every study shows that when focusing only on food, people regain the weight they lose. Physical activity is necessary to keep the weight off.

People may be surprised to learn that energy balance can occur at any weight - even obesity. Of course, the goal is to achieve energy balance at the healthy weight, right?

Hill: Right. But the fact is that not everyone can be skinny. We have to take variables like genetics and physiology into account. People need realistic goals. We've been telling people who need to lose weight to adjust their lifestyle. That approach hasn't worked. It's time to switch it up - consider lifestyle first, then weight. In other words, given my lifestyle, here is what I can do and succeed. 

You were one of the first to talk about the value of making small changes. Is this approach still one you recommend?

Hill: Yes. In fact, the same "making small changes" approach we have been promoting in personal eating and activity behavior can be applied to the food industry as well. For example, what if the Big Mac or the Whopper became 5% smaller a year over about five years? If the fast food companies made those burgers 25% smaller tomorrow, customers would complain about losing value. But making small reductions over time could change consumers' expectations and their value equation. It's a long-term approach, but the Big Gulp didn't happen overnight and it's not going away overnight either.

As health care reform is debated, we are hearing a lot more about prevention. What is your take on role of prevention in weight arena?

It's always going to be harder to lose weight than to prevent weight gain in the first place. After a certain point, an obese person's metabolism is permanently altered. We should continue to help these people with treatment, but as a society, our emphasis needs to be on prevention.

But is anyone paying attention? A study published in the October 6 online Health Affairs looked at whether or not calorie postings in fast food establishments influence diners' food choices. The answer - at least at the time of the study - appears to be no.

Researchers from New York University and Yale tracked customers at four fast food chains in low-income neighborhoods of New York City. About half the customers noticed the calorie counts, which were prominently posted on menu boards. About 28% of those who noticed them said the information had influenced their ordering; 90% of that group said they had made healthier choices as a result.

But when the researchers checked receipts (1,100 of them), they found that customers actually ordered slightly more calories than the typical customer had before New York City's labeling law went into effect, in July 2008.

I think this study strongly supports The American Dietetic Association's labeling policy statement, especially these two principles:

·        The label is only a source of information, and thus sustained support for educational programs and individual counseling by registered dietitians is essential.

·        Furthermore, consumers should be able to understand the information in the context of their total diet and their individual health concerns.

The writing may be on the wall, but if people don't understand what to do with the information, it's just words. The problem is far too complex to solve with labels alone.  Public education - like the Healthy Weight Commitment's multi-platform approach - must go hand in hand with tools like food labeling on products and in restaurants. And it will take time to impart knowledge and to move people to action.

Something unprecedented happened earlier this week. Food and beverage manufacturers, retailers and non-governmental groups joined together in the Healthy Weight Commitment Foundation - a coordinated effort to fight obesity in the marketplace, the workplace, and primary  and middle schools. A public education campaign launching this winter will focus on energy balance - balancing calories consumed as part of a healthy diet with calories expended by physical activity. Retailers and manufacturers will be reinforcing this message.

As president and CEO of the American Council for Fitness and Nutrition (ACFN) and the council's foundation, I am particularly proud that HWC will use the Healthy Schools Partnership - an ACFN Foundation, American Dietetic Association Foundation and PE4Life initiative -as a model for the school-based arm of its strategy. The Healthy Schools Partnership, currently operating in three Kansas City, Mo., school districts, will expand into more communities. External evaluators will measure the program, thus ensuring it has its intended effect.

By addressing key sectors where Americans spend much of their time - school, work and in the marketplace - HWC is creating a "surround-sound" environment where people are empowered to build healthier lifestyles.  Members of the Healthy Weight Commitment Foundation have already committed $20 million in seed money to this joint initiative to raise awareness about the importance of balancing a healthy diet with physical activity, particularly among children ages six to 11 years old and their parents and caregivers. HWC members will continue to raise funds to support the initative.

I think the HWC effort could be a game changer. I say this because we have not seen this level of cooperation among sectors in the past. Changing the environment - the stage on which we act out our 21^st century lives - is the first step toward making the cultural and societal changes we need to reverse runaway obesity.