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Diet and Nutrition Fads

Quickly evolving evidence could change your advice to patients

Diet fads come and go, but when it comes to nutrition there is no place for trends. Yet research does keep healthcare's understanding of human nourishment in a constant state of evolutionary change.

If patients are confused by what they perceive to be adequate nutrition, it is no wonder. "Even nutritionists and endocrinologists do not always have the most recent information," said Katherine Sherif, MD, director of Jefferson Women's Primary Care and vice chair of the Department of Medicine at  Thomas Jefferson University Hospital in Philadelphia. Sherif is also a cofounder of the Global Nutrition & Health Alliance.

Some nurse practitioners also may have fallen prey to a lack of cutting-edge information. For example, how many have advised women to take calcium to keep bones strong and to avoid osteoporosis?

"We now actually understand that calcium drives magnesium out of the body and that we may well get enough calcium through our diets," Sherif said. "But it is very hard to get magnesium, which is vital to over 300 enzymatic reactions in the body." A severe deficiency can cause cardiac arrhythmias, but less severe deficiencies can affect immunity, mood and gastrointestinal function on many different levels, she said.

Sherif said the fact that "magnesium deficiency is probably universal" may be new information for many nurses. She added another important caveat: "About 90% of magnesium supplements sold in drug stores and health food stores are in the form of magnesium oxide, which is not well absorbed. Tell patients to get anything but oxide - magnesium maleate, aspartate, gluconate, glycinate, taurate - anything but oxide."

Vitamin D and Omega 3
Sherif underscored what is now becoming common knowledge about vitamin D: Many patients need to raise their D3 levels, particularly people of dark skin pigmentation who do not quickly convert cholesterol to vitamin D in the skin, or people with celiac disease who do not absorb D easily, and obese people whose D stores are stored in fat.

"But have your patients measure their D level in February, when it is the lowest - not in August when it is at its highest point," she advised. "If patients need D3 supplementation in February, they should continue taking it throughout the summer even though they might test adequate in August. It's very difficult, if not impossible, to reach a toxic level of D3; that's nearly a myth."

Also on Sherif's highly favored supplementation list are omega 3 fatty acids, of which she says people simply cannot get enough through diet alone. "You'd have to eat at least four cans of tuna a day to get enough - which is too many calories and too many heavy metals. Not only would you need to eat a lot of tuna, but if the tuna is in oil, the omega-3s leach out of the tuna and into the oil. Even more complicated, different types of tuna have different amounts of omega-3s. She recommends taking 1,000 mg daily of a combination of EPA and DHA.

"Omega 3s are anti-inflammatory antioxidants that promote health in many organs; some 40% of omega 3s are found in the brain and support mood stabilization and nerve cell membranes," Sherif said. "But be aware that 'fish oil' is not necessarily EPA and DHA. Patients must check the label to make sure the 1,000 milligrams are EPA and DHA - not just oil squeezed from a dead fish. And they should stay away from supplements that include omega 6; it is actually pro-inflammatory."

Slowing the Aging Process
Sherif also suggested that nurses pay attention to mounting evidence that resveratrol supplementation (derived from red wine, and which should be taken in a gelatinous, not dry, form) may help delay the aging process.

"DNA is like a long shoelace - the end of the shoelace has the telomeres. Every time a cell divides, the telomeres get shorter, until there is nothing left and the cell dies," Sherif explained. "If DNA were to have a protective plastic cap on the end of the shoelace, the telomeres would not shorten with each cell division and the cells would not die. Resveratrol acts as the cap that prevents the end of the DNA from fraying; animal studies show that resveratrol significantly increases life expectancy."

Sherif also noted that a challenge to taking resveratrol is the fact that very little is absorbed unless it is in a fat-soluble form. Understandably, drug companies are racing to create a resveratrol analog that will be better absorbed.

Sherif's observations about omega 3 and resveratrol were echoed in a study published in December 2014 (Crous-Bou M, et al. Mediterranean diet and telomere length in Nurses' Health Study: population based cohort study. BMJ. 2014;349:g6674). While the merits of nutrition delivered through a diet rich in resveratrol and omega 3 - largely vegetables, fruit, olive oil, fresh fish and red wine - have long been associated with health benefits, no previous study had examined whether adherence to the Mediterranean diet is associated with longer telomere length, a biomarker of aging. Not only does this nutritional mix appear to keep skin glowing and hair gleaming, the study's research team found that it affects human health on a cellular level by providing a buffer against damage to tissues and cells, safeguarding those protective telomeres on chromosomes.

Sherif is convinced that even with an excellent diet, it is important to supplement to some degree. "Because we now have so many genetically modified foods (GMOs), we can't be sure of what we are getting. If you look at nutrition charts you'll see that a green pepper provides 60 mg of vitamin C. But now, a GMO pepper only provides 15 mg. But no one tells you that. It's hard to know if you are getting enough nutrients."

SEE ALSO: Diet Desperation

Understanding Fats
While excess fat on the human body is cause for concern, fat in the diet is not necessarily the menace it was once believed to be. Christina K. Major, MS, ND, a holistic nutritionist and naturopathic doctor, practices in Trevorton, Pa., where she guides patients toward holistic healing and health. She emphasizes the importance of eating whole, unprocessed, non-GMO organic foods, advising that about two-thirds of the diet should be comprised of fresh, whole fruits and vegetables, with the rest derived from organic whole grains, protein and healthy fats.

"Thinking has swung back and forth on fats, and right now people understand that fats do not have to be avoided. Our body needs over a hundred different types of fat for hormone production and cellular repair," she said. Healthy fats include olive oil, coconut oil, sesame oil and butter, which contains 40 kinds of fats as well as calcium, vitamin A and vitamin D. Even saturated fats, once shunned, are preferred for making insulin, serotonin, estrogen and testosterone, she pointed out.

David L. Katz, MD, PhD, of Yale University Prevention Research Center, has written extensively on the wrongful vilification of saturated fats, as well as the overly enthusiastic charge to return them to the diet.

"We have evidence that not all saturated fat is created equal," Katz said. "Stearic acid, one of the fats found in meat and the predominant saturated fat found in dark chocolate, seems to exert no harmful effects. Lauric acid, the saturated fat found in coconut oil, also appears to be innocuous." However Katz noted that "palmitic and myristic acids, two of the commonly consumed saturated fats, are indeed potentially harmful, contributing to inflammation, elevated lipids, atherogenesis and vascular disease."

Major also suggested that nurses tell patients to stay clear of canola oil, long incorrectly touted as a "healthy" oil. "The healthfulness of any oil has much to do with the ratio of omega 3 to omega 6 fatty acids. The rule of thumb is we want about four times as much omega 3 as omega 6. Canola oil contains 20 times more omega 6 than omega 3. I always recommend avoiding it."

Personalized Nutrition
Just as the value of personalized medicine is recognized, so is the importance of personalized nutrition emerging. Personalized dietary advice based on genetic makeup improves eating habits compared to one-size-fits-all recommendations, said University of Toronto researcher Ahmed El-Sohemy, PhD.

One of his studies, the first randomized, controlled trial to determine the impact of disclosing DNA-based dietary advice on eating, was published in November 2014 (Nielsen DE, El-Sohemy A. Disclosure of genetic information and change in dietary intake: a randomized controlled trial. PLoS One. 2014;9[11]:e112665).

"We showed that giving people their genetic information, about specific genes that affect the way they respond to certain nutrients, motivates them to change their eating habits to a greater extent than just giving them the standard advice," El-Sohemy said. A resulting genetic test kit by Nutrigenomix is now available through healthcare professionals. "We originally developed training materials for dietitians, but we recently modified the training guides to make it available to other qualified healthcare professionals, including nurses," El-Sohemy said.

A Path to Better Outcomes
"Customized" nourishment can also have profound effects on chronically or acutely ill patients - more than clinicians once thought, said Refaat Hegazi, MD, PhD, medical director at Abbott Nutrition.

"This is an area where many clinicians are playing catch-up, but it is also an area of great opportunity," Hegazi said. "If nurses could tune in on nutrition and signs of malnutrition early on, they could help patients much more than they already do. Unfortunately, nutrition does not always come to mind when clinicians are assessing signs and symptoms of disease."

Hegazi said newer nutritional thinking has defined malnutrition as an imbalance between the nutrients we need and the nutrients we get, caused by one of three factors: a decrease in nutritional intake, chronic inflammation or acute inflammation. "The tie to inflammation is great for the healthcare field because it is terminology providers understand. We 'get it,'" Hegazi said.

This is a departure from an earlier definition that tied malnutrition to body weight and body mass index - highly inaccurate because even obese people experience malnutrition.

"Patients with chronic obstructive pulmonary disease (COPD), chronic kidney disease, chronic heart failure, rheumatoid arthritis, inflammatory bowel disease, and on and on, must confront the possibility of malnutrition," Hegazi said, explaining that inflammation itself makes huge energy demands on the body. "Inflammation burns off protein and degrades muscles by using that muscle mass for energy. So a patient with COPD, for example, will benefit from higher protein intake, which will help spare and build muscles and in turn will support the very respiratory process at the heart of the disease."

Indeed, the benefits of early nutritional intervention go beyond the health of a patient. Hegazi said the high prevalence of disease-associated malnutrition results in a healthcare toll of $156.7 billion per year. A study he co-authored in 2014 showed that Medicare patients with COPD fed additional supplements during hospital stays were associated with a 2-day decrease in length of stay, a 12.5% reduction in hospitalization costs and a 13.1% decrease in readmissions (Snider JT, et al. Effect of hospital use of oral nutritional supplementation on length of stay, hospital cost, and 30-day readmissions among Medicare patients with COPD. Chest. 2014;doi: 10.1378).

"If I could give one over-arching message to nurses and all other healthcare providers, it would be this: You are a pivotal member of the nutrition team. The earlier we can help patients to embrace quality nutrition, the more effective we can be at assuring better patient outcomes."

Sherif hopes to help demystify emerging information about nutrition and supplementation with the co-founding of the Global Nutrition & Health Alliance. "Our alliance will sort through all of the research, and come up with the most definitive information for healthcare professionals and their patients," Sherif said. "We're already tackling vitamin D and omega 3. And we'll keep on going from there."

Valerie Neff Newitt is a staff writer. Contact: vnewitt@advanceweb.com.

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