Does my BMI really matter? Will I be able to lose the weight I gained during my pregnancy? How do I know if the supplements I’m taking really do what the packaging says they will do?
These types of questions are on consumers’ minds, and at this year’s ADA conference, experts presented the latest research on these very topics. Read on to learn what leading nutrition authorities had to say about these and other subjects, and to find out how to create health messages that clients will heed.
Fat and Fit:
and the Practice
What do numbers—such as weight and body mass index (BMI)—really tell us about a person’s health? With BMIs of 25 or higher, 50 percent of Americans are currently considered overweight or obese. However, these statistics can be misleading. Just as you can’t always tell by looking whether a person is active or fit, you can’t make an immediate assumption about someone’s health from these numbers. In fact, unfit men, whether lean or obese, have a higher risk of early mortality from all causes and cardiovascular disease than men who are fit and obese, according to a study published in the American Journal of Clinical Nutrition (Lee, Blair & Jackson 1999). For a person with a high number of risk factors (such as alcohol use, cigarette smoking and parental history) as well as a high BMI, the risk for premature death increases fivefold.
According to Steven Blair, PED, one of the study’s authors, “It’s important to treat, not based on BMI, but on the individual” because obese, fit individuals have lower early-mortality rates than lean individuals who are unfit. Moderate to high levels of cardiorespiratory fitness appear to improve the mortality risks associated with obesity.
Speaking on a related subject, Cynthia Byfield, PhD, RD, challenged fitness conference attendees to consider “redefining success” when it comes to working with weight loss clients. “Consider the current paradigm: Weight loss equals improved health,” suggests Byfield. “Now consider a new paradigm: Physical activity and nutrition equal improved health, regardless of weight changes. Let the weight settle where it’s naturally going to settle, and focus on nutrition and physical activity. Success equals behavior change.”
Byfield said health and fitness professionals can help clients change their behavior by suggesting ways to do the following:
Improve Cognitive Skills. Help clients change the way they think about physical activity. Suggest they aim for moderate intensity and accumulate activity over the course of the day.
Increase Awareness of Potential Activities. For example, have clients identify where the local bike path is and track how much time they spend sitting; also help them discover which physical activities are available and which ones they like to do.
Identify Barriers and Benefits to Exercise. Is time a factor? Are clients embarrassed to exercise?
Modify Behavior. Encourage clients to enlist support from others, set goals and manage their time (for example, three 10-minute exercise bouts).
Pat Lyons, RN, MS, originator of the “Great Shape Approach,” based on the book Great Shape: The First Fitness Guide for Large Women (Lyons & Burgard, iUniverse, 2000), also noted that the following points contribute to the prevalent belief that you can’t be fit and fat. The federal “war on obesity” focuses on weight and BMI, not healthy lifestyle choices; medical models focus on physical parameters rather than overall health; and cultural weight prejudice puts the emphasis on thinness.
What can health and fitness professionals do to counteract these issues? Be yourself and encourage clients to do the same; speak up and challenge research practices and policies that foster weight prejudice; and support and mentor each other in this new approach.
Women’s Health and Obesity
The significant milestones in a woman’s life—menarche, pregnancy and menopause—are often associated with weight gain and the onset of obesity. Hormonal, psychological and environmental factors all play a role. These challenges, as well as treatment strategies for managing weight during the three critical periods, were the subject of the “Women’s Health and Obesity” session.
Puberty has been identified as a potentially critical period in the development of obesity. The average age of menarche has declined substantially over the past two centuries. It is currently estimated at approximately 12.6 years (U.S. Department of Health and Human Services). A review of more than 200 European reports from 1975 on suggests a decline of approximately two to three months per decade, and several recent reports have indicated that age at menarche is still on the decline. In some countries it appears that improved nutritional status may be part of this phenomenon. Additional reasons may be hormones added to food, environmental estrogens (possible sources include phthalates leached from plastics), critical fat (the fat level that is a “trigger” for menarche) and skeletal maturity. Early obesity gives rise to early menarche, and young girls who are heavy and experience early menarche may experience a higher BMI at age 40.
There are three pregnancy-related risk factors for obesity:
1. Prepregnancy Weight. Women who are overweight at the start of their pregnancy are more likely to gain weight during pregnancy. Retention of weight gained between a first birth and subsequent births puts women at higher risk for obesity.
2. Gestational Weight. Greater weight gain is often seen during the first and second trimesters. Interestingly, weight gain at this time doesn’t contribute as much to fetal health as does weight gain during the third trimester.
3. Race. Black women show higher weight gain overall than white women.
Interventions for Managing Pregnancy Weight Gain. During pregnancy, the first trimester is a prime time to focus on physical activity and nutrition education. After giving birth, new moms anxious to return to their prepregnancy weight and condition are more likely to make behavior changes. However, the early months of motherhood may be difficult for many women as demands on their time increase and stress levels rise. One study looked at whether postpartum weight retention contributed to the development of obesity. Ninety women who had given birth in the past three to 12 months and whose weight exceeded their prepregnancy weight by at least 6.8 kilograms (kg), or 14.96 pounds, were randomly assigned to either a behavioral weight loss intervention program through correspondence or a no-treatment control group. During the six-month treatment, subjects in the correspondence group lost significantly more weight than the control subjects (7.8 kg vs. 4.9 kg, or 17.16 pounds vs. 10.78 pounds) and lost a greater percentage of their excess postpartum weight (79% vs. 44%). Furthermore, a significantly greater percentage of correspondence subjects than control subjects returned to their prepregnancy weight (33% vs. 11.5%) (Leermakers, Anglin & Wing 1998).
In general, postpartum clients trying to lose weight gained during pregnancy should be informed that the most effective way to do so is through diet combined with exercise. Women trying to lose postpartum weight appear to be more successful when they use a behavioral weight loss intervention program than when they attempt weight loss on their own. Such a program could serve to reduce the incidence of obesity resulting from weight gain following consecutive pregnancies. Women should also be assured that exercise will have no negative effect on breast-fed infants. However, many questions remain about achieving and maintaining postpartum weight loss.
After menopause, women’s risk for coronary heart disease increases. Weight gain, obesity and adverse changes in body fat distribution can also occur during the postmenopausal years. Lifestyle intervention is a positive option to help counteract weight gain and other risk factors.
Postmenopausal women experience increased levels of body fat with greater central body fat distribution. They also experience a decrease in resting metabolic rate, which may be due in part to a decrease in bone and muscle (fat-free mass). Postmenopausal weight gain is related to decreased physical activity and aging, while increased weight circumference is due to hormonal and physiological changes. Physical activity is important to counteract these effects.
Activity goals should be set and monitored, individualized to support favorite activities and performed on a consistent basis. Nutritional goals should focus on reducing calories, total fat, saturated fat and cholesterol.
Dietary Supplements: Are You Getting
What You Paid For?
Dietary supplements are a booming industry. Multivitamins lead the pack, followed by single vitamins, sports nutrition supplements, supplements combining herbal and nonherbal ingredients, single minerals, specialty supplements, amino acids, other dietary supplements, herbs and homeopathic remedies. With such a wide variety of supplements available, what regulations are in place to ensure their safety? How can consumers be certain that a supplement contains what the package says it does?
Food items fall into two categories: conventional foods, regulated under the Nutrition Labeling and Education Act (NLEA), and dietary supplements, which fall under the Dietary Supplement and Health Education Act (DSHEA). The U.S. Food and Drug Administration (FDA) is responsible for the manufacturing and labeling aspects of food products and for enforcing the NLEA and DSHEA. The Federal Trade Commission (FTC) enforces laws related to product advertising.
Assessing the quality and safety of supplements is challenging for three reasons:
- Enforcement is poor, since the FDA lacks adequate enforcement tools.
- Before the ingredients used in dietary supplements can be assessed using analytical methods, an officially recognized compendium is needed to support label claims, strengthen the credibility of third-party certification programs and aid the FDA in enforcement activities.
- The industry needs a ruling on and implementation of dietary supplement Good Manufacturing Practices (GMPs), since supplement manufacturers currently follow food GMPs.
Within the industry, several “standardized” assessments or working definitions are used for supplements:
Authenticated Reference Standards are actual plant specimens that have been authenticated, by a botanist or botanical society, based on plant morphology or microscopic characteristics.
Standardized Extracts typically are extracts with a known and agreed-on concentration of a biomarker constituent, such as Valerian extract standardized to 0.8 percent valerenic acids.
Standardized Test Methods are developed and validated according to Good Laboratory Practices or Association of Official Agricultural Chemists criteria.
Product or System Standards are documented agreements containing technical specifications or other precise criteria to be used consistently as rules, guidelines or definitions of characteristics, to ensure that materials, products, processes and services are fit for their purpose. These agreements provide measurable criteria that can be evaluated in a reproducible manner to determine a product or system’s compliance with the standard.
American National Standards are developed in accordance with the requirements set forth by the American National Standards Institute.
Manufacturers can use “self-declaration” to state that their product complies with a standard. Typically, the manufacturing company conducts its own testing to verify compliance. The company may also contract with a lab to perform testing, but it’s still the manufacturer who makes the claim. For example, the manufacturer may use its own “quality seal.”
“Verification” allows for a product to be tested to verify compliance with a given standard at a specific time. However, verification provides information only on the specific product sample tested; there are no requirements for ongoing testing, plant audits or market surveillance.
With “third-party certification,” an independent body determines whether the product complies with a standard. This process includes verifying compliance initially, following up to ensure ongoing compliance, issuing a certificate of compliance to the manufacturer and/or authorizing the use of a certification mark on the product. A variety of third-party certification programs exist. They include the NSF International Dietary Supplement Certification Program, U.S. Pharmacopeia (USP) Quality Demonstration Program, National Nutritional Foods Association (NNFA) Good Manufacturing Practices Program, NNFA TruLabel Program, Schuster Labs Seal of Quality, Good Housekeeping Seal of Approval and ConsumerLab.com. Third-party certification is not mandatory; manufacturers who choose it do so voluntarily.
Despite the variety of standards and tests, the FDA recalled more than 1,050 supplements for safety reasons in 2000. If a supplement is determined to be toxic or unsanitary, the FDA can pull the product from store shelves or stop the sale of the product.
Currently, the supplement industry is self-regulated. Consumers need to be aware that standards vary among manufacturers. Consumers can call supplement companies, ask for the internal standards that support the final products and request citations from journal articles to support the claims the companies make about their products. In addition, consumers can look on the product packaging for independent third-party identifying marks from the companies listed above.
Its Influence on American Consumers
Mediterranean food is simple, fresh, seasonal and rich in fiber, complex carbohydrates and monounsaturated fats. At its core are complex carbohydrates, such as rice, pasta and beans. A typical meal also includes a small amount of protein, mainly from fish, since intake of red meat and cheese is limited; olive oil, onions, garlic and wine step in as additional components. Wine, considered an aid to digestion and an appetite stimulant, is always consumed with food (hence mezze, tapas, etc. as accompaniments). Despite a consistent intake of wine by Mediterranean dwellers, the incidence of alcoholism is low. Fried food is cooked and eaten all over the Mediterranean, yet people are not obese. Long walks after meals and a reduced-stress lifestyle are hallmarks of the Mediterranean lifestyle.
It wasn’t that long ago that here in the United States, spaghetti and pasta were thought of as ethnic foods. But a trip to your local grocery store will reveal a range of Mediterranean-inspired foods that is almost overwhelming in scope!
Just what are some of the Mediterranean influences redefining the American palate?
Retail. Sales of olive oil have tripled in the last eight years. It’s not uncommon for large supermarkets to stock 30 to 40 different varieties. We are also beginning to see a small industry of olive growers here in the United States. The variety of pastas (many shapes, whole wheat and white, flavored and plain) and pasta sauces is also huge.
Restaurants. The number of tapas restaurants is increasing, giving more diners the opportunity to sample deliciously prepared cuisine from the entire Mediterranean region. This trend broadens the frame of reference for ethnic food and creates a demand for more.
Agriculture. Farmers’ markets are ubiquitous throughout the United States. Where the offerings used to be fairly standard fare, it’s now more commonplace to discover items like fava beans, fennel and baby artichokes.
Specialty Foods. Artisanal food products—such as breads, coffee, wine, cheeses and olive oil—are finding a large and appreciative market.
To encourage people to choose more healthy foods, especially those used in Mediterranean cuisine, follow these suggestions:
- Urge clients to eat a variety of healthy foods.
- Copy and distribute the Mediterranean Food Guide Pyramid, shown above.
- Advise keeping meals simple—not fussing too much with numerous ingredients.
- Suggest eating seasonally. It costs less, is more nutritious and tastes better.
A New Conversation With Clients:
Creating Messages That Work
Delivering messages about health and fitness to clients may often feel like traveling a one-way street. You know what you want to say, but your clients may not want to hear it. The mission of the International Food Information Council (IFIC) is to communicate science-based information on food safety and nutrition issues to health professionals, media, educators and government officials. Following are guidelines the IFIC employs when sharing nutrition messages, as well as tips from public relations firms Porter Novelli, Strategy One/Edelman Worldwide and Quagliani Communications.
The old way of conveying messages to consumers was to provide information and hope for change. A new way of thinking is to enable behavior change. But how do you enable people to make healthy changes? Develop initial message concepts by defining the issues. In other words, focus on what you want to achieve with your message. Here’s how:
- Know who the message recipients are and how they think.
- Know what you want them to do with the information you provide for them.
- Once you’ve gathered this information, plan how you will use it. Do you want to counsel clients or create educational aids? Do you want to launch a new marketing or advertising campaign or freshen up an existing one?
- Design research methods specific to your target audience. The methods can be formal or informal; consider personal interviews.
- Execute research. Use what you’ve gathered to define your targeted sample, process information and develop conclusions.
- Develop message concepts by focusing on what you want to say. Share these concepts with your target audience.
- Fine-tune the messages based on feedback.
- Continue to evaluate your messages and assess their effectiveness.
Reaching the Consumer. Consumers don’t want to be told what to do; they want to know how to do it. Diane Quagliani, MBA, RD, of Quagliani Communications in Western Springs, Illinois, shared an example of a message she wanted to convey to consumers regarding high-fat food. “Food with fat can fit; moderate, don’t eliminate.” Then she cited two specific tips to demonstrate how clients can implement positive changes.
1. Donuts for breakfast every day? Instead, try a chewy bagel with light cream cheese three times each week.
2. Order once, enjoy twice. Eat half your steak in the restaurant. Take the rest home to savor tomorrow.
Consumers look for positive messages that are short and simple. They like messages created with specific and manageable goals. They also want to know the payoff, and they’re looking for messages that combine food and fun.
Mary Christ-Erwin of Porter Novelli in Washington, DC, shared suggestions on how to communicate in order to elicit behavior change. Christ-Erwin pointed out that self-interest (“What’s in it for me?”) is a fundamental and powerful motivator. Keeping that in mind, health professionals might ask, Where is the self-interest in nutrition (or fitness for that matter)? Why do people want to be healthy? For personal goals? Family care? Career advancement? The sake of appearance? Specific health goals?
Consider the following realities when delivering health messages:
- Clients want assistance and support.
- They need to be given the tools.
- Preaching is passé.
- Everyone’s life is different.
- Not all clients will do everything we want them to do.
Conference attendees were urged to do as follows:
- Take a hard look at reasonable outcomes.
- Take lives, not just food (or exercise), into consideration.
- Assess how far a client is willing to go.
- Recognize any internal and external barriers to change.
Let Food Be Thy Medicine: Medicinal Properties of Flavonoids
All too often, clients lump foods into two categories: good or bad. Total calories, fat and sugar determine whether a particular food is a healthy choice. However, in terms of health, food is much too complex to be reduced to the sum of a few nutrients. Increased awareness of the broader health benefits of a variety of foods can help fitness professionals promote the “food for health” message.
Heart disease is the leading killer of men and women in the developed world. To reduce and perhaps reverse risk factors, dietary intervention is often a physician’s first recommendation. A variety of physiological pathways lead to heart disease and death. Two risk factors for heart disease—high levels of low-density lipoprotein cholesterol (LDL-C) and total cholesterol—are often associated with diets high in cholesterol and saturated fat. Yet, despite a diet relatively high in fat, French people escape the high incidence of heart disease found in other developed countries. This phenomenon, dubbed “The French Paradox,” has triggered interest. Could the flavonoids present in red wine, another staple at the French table, be responsible?
Flavonoids are phytochemicals commonly found in plant-derived foods, such as some chocolates, cocoas, teas, grape juices and wines. Flavonoids appear to have potent antioxidant effects on proteins, lipids and DNA. They also appear to have anti-inflammatory, antithrombogenic and vasodilator properties, as well as the ability to influence regulatory enzymes within the body. Initial research suggests that flavonoids may enhance cardiovascular health, reduce the risk of heart disease and help protect against LDL-C oxidation, which has been linked to heart disease (Rein et al. 2000a; Rein et al. 2000b; Rein et al. 2000c).
One common recommendation for the prevention and/or treatment of heart disease is aspirin, which was developed from willow bark. Preliminary evidence suggests that certain dietary flavonols may act through mechanisms similar to those of aspirin, but without causing its side effects, such as gastrointestinal bleeding.
Although data on flavonoids are still developing, a significant enough number of flavonoids have been identified to warrant a “USDA Flavonoid Database.” This resource, which will possibly be released as early as fall 2002, will describe the most commonly consumed flavonoids. The database will provide a universal system to measure flavonoids in all plant foods.
Good food sources of flavonoids include:
- fruits and vegetables, with a focus on a variety of colors, such as green, red, purple and orange (Examples include broccoli, tomatoes, red grapes and squash.)
- black and green teas (Brew 3-5 minutes to release 85 percent of the flavonoids. Approximately 50 percent of tea’s flavonoids are destroyed when it is decaffeinated, or when it is processed into powder form for instant iced tea.)
- chocolate (Dark chocolate contains 3 times as many flavonoids as milk chocolate, while white chocolate contains none. But remember that chocolate is a concentrated source of calories and fat, so use it only in small amounts; for example, dip strawberries in chocolate, or add chocolate chips to whole-grain pancakes and waffles.)
Remember, all foods can fit—and there may actually come a day when companies list foods’ flavonoid content on the labels.
Lee, C. D., Blair, S. N., & Jackson, A. S. 1999. Cardiorespiratory fitness, body composition and all-cause and cardiovascular disease mortality in men. American Journal of Clinical Nutrition, 69 (3), 373-80.
Leermakers, E. A., Anglin, K., & Wing, R. R. 1998. Reducing postpartum weight retention through a correspondence intervention. International Journal of Obesity Related Metabolic Disorders, 22 (11), 1103-9.
Rein, D., et al. 2000a. Cocoa inhibits platelet activation and function. American Journal of Clinical Nutrition, 72 (1), 30-5.
Rein, D., et al. 2000b. Cocoa and wine polyphenols modulate platelet activation and function. Journal of Nutrition, 130 (8, Suppl.).
Rein, D., et al. 2000c. Epicatechin in human plasma: In vivo determination and effect of chocolate consumption on plasma oxidation status. Journal of Nutrition, 130 (8, Suppl.).
U.S. Department of Health & Human Services. National Center for Health Statistics. NHANES III (National Health and Nutrition Examination Survey, 1988-1994).
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