Why Dietitians Should Practice Cultural Humility and How to Make a Habit of it

 By Sarah Bostic, SLU Dietetic Intern

In the clinical realm, I have heard the ambiguous term “cultural competency” tossed around (might I say) haphazardly, with little regard for the confusion it causes. As far as we, the health sciences students, know, cultural competency is a standard. The American academic system requires most of us healthcare professionals to complete a workshop, take a class, or ace a test to ensure future practitioners meet a standard for understanding of diversity. But does anyone actually know what it means to achieve cultural competency? Can we actually become fully competent in culture?

Spoiler alert: We can’t.

Disheartening? Perhaps. As dietetics professionals, we aspire to be worldly. We want to soak up every ounce of cultural and culinary knowledge to best relate to patients. But frankly, as humans, we are naturally limited in our knowledge of the world. We will never be fully “competent” in culture, no matter the number of hours we study, years we practice, or multitude of crash courses we take in history or culture. No length of education is sufficient enough to lead healthcare professionals to full understanding of the needs and desires of unique individuals in this diverse world. Therefore, instead of striving for competence, I propose we should encounter the backgrounds of patients and clients with cultural humility. 

Practicing Cultural Humility: Explained

Cultural humility is a relatively new tool in healthcare; it was developed in 1998 to teach US doctors how to treat populations with diverse cultures, races, and ethnicities. It has since taken hold in various settings around the world, one of them being dietetics.

Cultural humility allows healthcare workers to obtain a comprehensive understanding of a client’s personal beliefs and values without relying on preconceived ideas about their culture.

Rather than “achieving” cultural humility, the practice is regarded as a lifestyle. We are asked to continually educate ourselves, engage in conversation, reflect, recognize and overcome biases, and work toward compassion and understanding in every interaction. Practicing cultural humility allows workers to enter relationships with patients openly, seeing that their patients are uniquely wonderful individuals. The interaction is doubly fruitful-- the client can aid in providing the most culturally appropriate (and likely most effective) intervention, AND the client will feel deeply heard, valued, and safe. Who doesn’t love that? 

Practicing Cultural Humility: Clinical Implications

Dietitians, among all healthcare professionals, have a great opportunity and responsibility to be the experts that practice cultural humility and lean in when we encounter unfamiliar cultural practices. Food is intimately tied to an individual’s culture, tradition, and upbringing. Meals are a communal experience, so in using cultural humility, we can capitalize on our curiosity about food to gain a beautiful insight into the client’s practices and values.

Practicing Cultural Humility: Personal Growth and Development

As dietitians and dietetics students, we must use our greatest tool-- the commonality of food-- as a ground for understanding, learning, and offering improved patient-centered care. In little increments, we can use our knowledge to inform future interactions and grow as professionals and people.

 In addition to learning from patients, we can intentionally choose to grow daily in our knowledge of history, culture, and food habits. With greater exposure to new thoughts and ideas through engagement with the world, we can uncover and break free from our ethno-centric American biases and encounter clients and patients from a more compassionate and informed standpoint.

Cultural humility is a tool for facilitating personal growth and development; it is grounded in the understanding that there is always something valuable to learn. 

How to Make Cultural Humility a Regular Habit

Though there are no concrete steps to follow, the following practices that will help you grow in your approach to cultural humility:

●     Develop Awareness-- Recognize diversity and how your unique identity and experiences shape the world around you.

●     Evaluate Perspective-- Welcome discomfort when your personal views are challenged. Work to understand why you feel the way you do. Address bias. Work toward respecting others and the beauty their unique perspective brings.

●     Practice-- Listening, reflecting, analyzing, and empathizing with other perspectives.

●     Gain Exposure-- Inform yourself through conversation, non-fiction reading, films, documentaries, podcasts, trying new restaurants, traveling, and regularly following trusted media outlets.

●     Include and Engage-- Make a habit of inclusion by promoting diversity in every decision you make. Ask if there is more you can do to ensure your actions have equitable and sustainable outcomes.

●     Act-- Utilize your position to actively work against inequity. Encounter individuals with love and openness.

Adapted from Baylor University's “Developing Cultural Humility” https://www.baylor.edu/diversity/index.php?id=948078

For more information on Cultural Humility:

With a limited budget, I, personally, have taken up reading as a hobby to expand my knowledge of the world and create a foundation for patient interaction. Reading books on populations I do not interact with regularly has opened my eyes to the diversity of needs that exist. The following resources may be a great start!

●     Cultural Competence v Cultural Humility, Public Health Culture Podcast

●     “What is Cultural Humility?” https://www.youtube.com/watch?v=c_wOnJJEfxE

●     Recommended reading:

○     Ask Me Why I Hurt by Randy Christensen, MD

○     Tattoos on the Heart by Fr. Gregory Boyle

Final Thoughts:

As a dietetics student, I am lucky that “autopilot” has not yet set in. I am always looking for new things to learn and often feel a strong sense of humility any time I speak with a patient. More often than not, I know, when I walk into my patient’s room with sweaty palms and a handful of questions, that I will be learning much more from the interaction than the patient will be learning from me. That has been my greatest take-away-- I sincerely hope that all Dietitians, no matter their tenure, will encounter patients with this same vulnerability as they carry out their important work. Dietitians should always approach patients with fresh eyes and anticipate there is something to learn from their patients.

Image taken from https://a-thousand-words.tumblr.com/page/3

Avoiding Diet Talk This Holiday Season (and beyond)

 Written by: Haley Jensen, SLU Dietetic Intern

With the Holidays quickly approaching, you may find yourself cornered in unwanted conversations about diet and weight loss. This is one of the busiest seasons of the year, often surrounded by friends, acquaintances and family. For a lot of people talking about diets feels like a “safe topic”. It’s often thought of as a causal conversation, just like discussing the weather. Even though the people you are around are comfortable discussing diets and diet culture doesn’t mean you have to be. This guide is meant to inspire you and give you tools to navigate uncomfortable conversations. Ultimately my hope is that the sample responses and coping techniques provided give you a sense of comfort and confidence this holiday season and beyond.

Helpful reminders

More than likely this holiday season you will find yourself in diet/weight-talk and you many not be sure what to say. Understand that its okay, building comfort around diet talk conversation takes time.

You’re not always going to have the “perfect“ thing to say.

You are allowed to say the “wrong” thing. There might be times where you need to take a break and not say anything at all.

You’re allowed to have boundaries.

You get to decide how much you share about your recovery, your relationship with food, your feeling towards your body and how your past experiences have brought you to where you are now. You do not need to have any conversations that make you uncomfortable.

You don’t always have to be a vocal advocate for anti-diet culture.

Conversations defending diet culture can sometimes be exhausting. It is perfectly acceptable to not educate up to your friends and family on the determinants of diet culture for a day.

Tips for Social Events

This season is filled with cocktail parties and mixers. Your might be meeting a lot of new people and the conversations surrounding diet culture are popular around the hors d’oeuvres table.

Your coworker is talking about their own diet/exercise plan… and they won’t stop.

• “I actually made a New Year’s Resolution to always talk about something new at parties- don’t you feel like we always talk about diets? Have you seen any good movies recently?”

Your friend makes a comment about having to “make up” for the holidays at the gym and asks you to join

• “You know that’s not how bodies work, there‘s really no need to make up for what the food we eat. I prefer to just enjoy delicious food with people I care about”

An acquaintance says “oh we are being so bad aren’t we”

• “The only bad foods are the foods that you stole”
• “My only food rule is that I don’t eat foods that are poisoned”

Tips for Family Events

We love our families but that doesn’t mean they can’t cross the line sometime. Navigating conversations gently can be difficult but that doesn’t mean that you shouldn’t say something if you want to.

Your aunt says “wow, you’ve lost so much weight since last time we saw you!”

• “I know I used to talk about diets and weight with you but I’ve recently realized it makes me feel pretty anxious, but I would love to talk about something else. Tell me how your and your family has been.”

Your cousin comments on your plate “oh, so calories don’t count today, do they?”

• “Actually, I don’t count calories today or any day. I prefer to let my body tell me what it needs, and today it needs my favorite holiday meals.”

A sibling tells you about the new diet their coworker is on

• “I love spending time talking with you but I would prefer if we talked about ourselves. I saw you went to Florida recently how was your trip?”

Overcoming Triggers

Now that we have discussed how to respond to diet talk, its important to understand how to not let those words someone said effect you negatively. You have chosen to take a journey into avoiding diet culture and its important to not let the word of someone else trigger you into diet, or feeling guilt for not participating in diet culture.

Work on your mindset

·         Use mantras and affirmations to help you remember why you’re trying to avoid diet conversations, some examples include:

• I understand that the holidays are about creating memories, and I won’t let food rules ruin that
• I will show my body that it can trust me by not restricting food
• I am more than the food I eat
• I give my body permission to change
• It’s okay to not know what my body needs right now, I am figuring it out

Have coping mechanisms ready

• Breath work- focus on your conscious awareness of your inhales and exhales. Using deep and focused breathing to create a therapeutic and calming effect. There are a variety of apps and techniques available.

• Create a happiness folder of photos on your phone filled with photos that cheer you up.

References

https://colleenchristensennutrition.com/diet-talk-how-to-respond-what-to-say/

https://alissarumsey.com/how-to-respond-to-diet-talk/

https://www.washingtonpost.com/lifestyle/wellness/thanksgiving-weight-diet-talk-advice/2021/11/08/2d4c4a3e-4007-11ec-9ea7-3eb2406a2e24_story.html

https://www.katiehake.com/blog/anti-diet-affirmations

10 Tips for Grocery Shopping on a Budget

By Sarah Katherine Gaston, Dietetic Intern

People often ask me how I keep my grocery budget as low as it is. I stick to a strict grocery budget while still ensuring I get all the food I need and want! Below are some tips and tricks I use to follow an affordable grocery budget: 

1. Make a list 

This is the first and most important step. Before entering the grocery store, write down your list of ingredients and stick to it. Making lists avoids over-purchasing items that you don’t need, and it will also save you time wandering around the store. 

2. Shop once a week 

I’m a huge proponent of shopping once a week. It forces you to make a meal plan, which avoids over-purchasing. It minimizes what I like to call “grab items.” These are ingredients you grab off the shelf when passing by and not ones that you necessarily need or planned to buy. The more times you go to the grocery store throughout the week, the more you tempt yourself with “grab items.” 

3. Check your pantry 

Taking inventory of the pantry can be helpful to remind yourself of non-perishables you might have stocked up on but aren’t utilizing. Pantries are often cluttered, making it easy for items to get pushed to the back and forgotten. Taking stock of what you have on hand can help while meal planning and avoid purchasing extra items you might already have at home. 

4. Coordinate your recipe ingredients 

I believe this is the biggest way I save. When planning my meals for the week, I typically start with one or two meals I’m craving and write down the ingredients needed. Then, I look at my ingredients and base additional meals/snacks around utilizing the same items. This reduces potential food waste and minimizes purchases. 

5. Buy Meat/Protein in Bulk 

Not all food items are cheaper in bulk, but meats/proteins typically are. I buy my meat in bulk and freeze for longer lasting quality. This is especially helpful if you are cooking for only 1-2 people. 

6. Buy in season 

Seasonal produce is always cheaper. An added bonus is that the in-season produce is usually better in taste than when out of season, and it is more environmentally sustainable. 

7. Check out the frozen aisle 

Some people frown on frozen food, but you can find gold in the frozen section. Frozen food does not always equal lower quality, and it usually means reduced prices. One way I save in the frozen aisle is by buying frozen fruit which I use to make smoothies. Smoothies are a great way to ensure you get your daily fruit intake and save on costly fresh fruits. 

8. Get creative with leftovers 

Leftovers when eaten over and over again get boring. To spice things up, make a meal that can be used in multiple ways. Grain-based or lettuce-based bowls are a great way to utilize leftovers to make something new the next day. Getting creative with leftovers reduces potential for food waste. 

9. Set up rewards if possible 

Some grocery stores offer reward cards or point systems that can be a quick and simple method to save a little extra. Check to see if your favorite grocery stores offer rewards programs. 

10. Grant yourself one “fun” purchase 

Sticking to a budget is good, but everyone deserves a little splurge. After I check all the items off my grocery list, I allow myself a treat purchase. Sometimes this is a dessert that hits the spot after a long week or a seasonal specialty item that I’ve been waiting for. While this isn’t a money-saving tip, it’s a nice reminder that budgets are great, but you can’t neglect a little treat every once in a while.

What is MSG and Why are We So Afraid of It?

 Written by: Kate Aragon, Dietetic Intern

Contrary to popular belief, I (as a nutrition student) don’t cook very often. I’ve always had men and women in my life who enjoyed cooking far more than I ever will and because of that, I didn’t grow up spending a lot of time in the kitchen. Regardless, food was always a big part of my culture as a Filipino-American, and just like many parts of Asia, MSG is widely used in the Philippines^[1].

My aunt would have me and my brother over for family dinners every so often, and I remember how she would try to hide the fact that she used MSG in her cooking. I was eight at the time. At 8 years old I was already given a reason to believe that this mystery ingredient, “M-S-G”, was a bad thing.

So what IS MSG?

MSG, or monosodium glutamate, is derived from the amino acid, glutamate (also known as “glutamic acid”)^[2]. Glutamate is produced by our bodies and is also a naturally-occurring compound found in foods like tomatoes, mushrooms, and seaweed.

MSG as we know it today, is a flavor-enhancer first discovered by a Japanese chemist who identified it as the dominant flavor component in kelp. When used, MSG can help to bring out the savory and umami flavor in dishes.

Why is MSG so controversial?

In the 1960s, Robert Ho Man Kwok, MD, published a letter in the New England Journal of Medicine that described a mysterious ill-feeling he would get after eating in Chinese restaurants^[3]. To no surprise, this “ill-feeling” (typically headaches, a rapid heart rate, and nausea) was eventually called “Chinese Restaurant Syndrome”. And since many Chinese-American restaurants at the time were making use of MSG, Robert theorized that his symptoms were tied to that.

Shortly after, other studies tried to show that MSG was the cause of brain lesions, female sterility, and even obesity. The catch? These studies used faulty science^[4].

Many of these studies were animal experiments, and the mice experimented on were injected with such large doses of MSG that it was completely unrealistic to extrapolate their findings into human conditions⁴. But it didn’t matter. By the time the faulty science was discovered, it was too late. The findings caught everyone’s attention and the world villainized MSG. As a result of the changing diet trend, Chinese-American restaurant owners had no choice but to advertise the absence of MSG in their dishes by displaying “No MSG” signs on their restaurants’ doors to keep their businesses afloat. And soon it became common knowledge that MSG should be avoided without even questioning: 1. The faulty science behind the blame, and 2. The xenophobia tied along with it.

How is MSG used?

When asked to think about the sources of MSG, most people would probably first mention Asian-American cuisine. But, a lot of snack foods in grocery store aisles use MSG as well. For example, Doritos®, Pringles®, and Cambell’s® all use MSG and can be found in the ingredient list of several of their products^[5][6][7].

Surprised? Maybe ask yourself if you’ve ever reported a headache after eating a bag of Doritos®. If not, then maybe begin entertaining the idea that MSG (or Asian-American food in general) is NOT the culprit for your mystery headache.

(DORITOS® Nacho Cheese Flavored Tortilla Chips, n.d.)

(Cambell’s®Chicken Noodle Soup, 2021)

 

(Pringles® BBQ CRISPS, n.d.)

What does science say about MSG now?

Here’s a quick list:

●        MSG is formally placed on the Food and Drug Administration (FDA) list of foods that are “generally recognized as safe” (GRAS)^[8]. Additionally, the Federation of American Societies for Experimental Biology (FASEB) examined the safety of MSG in the 1990s and their report concluded that MSG is safe as well^[9].

●        The FASEB report identified some mild, short-term symptoms in some sensitive individuals who consume 3 grams or more of MSG without food. However, a typical serving of a food with added MSG contains less than 0.5 grams of MSG. In other words, consuming more than 3 grams of MSG without food at one time is simply unlikely and should not be an area of concern^[10].

●        Although it is possible for individuals to be “sensitive” to MSG, a 2017 meta-analysis observed that “scientists have not been able to consistently elicit reactions in double-blind studies with ‘sensitive’ individuals using MSG or placebo in food”^[11]. Meaning that, scientists were unable to consistently trigger reactions in individuals who claimed to be sensitive.

●        Several studies that highlight the adverse effects of MSG are conducted on animals, and therefore, are only relevant to those animals tested⁴. If the study in question showed an effect of MSG on rats… MSG has an effect on rats. Conclusions derived from experiments conducted on animals cannot be assumed to be true in humans.

Potential Benefits of MSG and My Final Thoughts

Did you know MSG only has about one-third of the amount of sodium compared to table salt^[12]? MSG can be helpful for those trying to reduce sodium intake, which according to the American Heart Association, should be about 90 percent of us because most Americans consume too much sodium. Perhaps by seasoning dishes with MSG, one may lessen the risk of heart disease!

Here’s a cool trick: By replacing half of the table salt in your salt shaker with MSG, you’d be able to cut the amount of salt you add when cooking without even realizing it!

Bottom line: Rather than fearing MSG as a dietary bogeyman, perhaps it’s time to reevaluate; consider its history, the xenophobia tied to its bad reputation, and its potential benefits. Perhaps it’s time to end the controversy surrounding it, and just see it for what it is -- a flavor enhancer that knows how to pack a punch.

---

^[1] Germain, Thomas. "A Racist Little Hat: The MSG Debate and American Culture." Columbia Undergraduate Research Journal 2.1 (2015).

^[2] Singh, M. (2005). Fact or Fiction? The MSG Controversy.

^[3] International Glutamate Information Service. “Glutamate: The Purest Taste of Umami”.

^[4] Zanfirescu, A., Ungurianu, A., Tsatsakis, A. M., Nițulescu, G. M., Kouretas, D., Veskoukis, A., ... & Margină, D. (2019). A review of the alleged health hazards of monosodium glutamate. Comprehensive reviews in food science and food safety, 18(4), 1111-1134.

^[5] Pringles® BBQ CRISPS. Barbecue Pringles® Crisps | Pringles®. (n.d.). Retrieved September 23, 2021, from https://www.pringles.com/us/products/favorites/bbq.html.

^[6] Chicken Noodle Soup. Campbell Soup Company. (2021, September 21). Retrieved September 23, 2021, from https://www.campbells.com/products/condensed/chicken-noodle-soup/.

^[7] DORITOS® Nacho Cheese Flavored Tortilla Chips. DORITOS®. (n.d.). Retrieved September 23, 2021, from https://www.doritos.com/products/doritos-nacho-cheese-flavored-tortilla-chips.

^[8] Center for Food Safety and Applied Nutrition. (2018). Questions and answers on monosodium glutamate (MSG). U.S. Food and Drug Administration. Retrieved September 23, 2021, from https://www.fda.gov/food/food-additives-petitions/questions-and-answers-monosodium-glutamate-msg.

^[9] Maluly, H. D., Arisseto‐Bragotto, A. P., & Reyes, F. G. (2017). Monosodium glutamate as a tool to reduce sodium in foodstuffs: Technological and safety aspects. Food science & nutrition, 5(6), 1039-1048.

^[10] Raiten, D. J., Talbot, J. M., & Fisher, K. D. (Eds.). (1995). Executive summary from the report: analysis of adverse reactions to monosodium glutamate (MSG). The Journal of Nutrition, 125(11), 2891S-2906S.

^[11] Department of Human Nutrition and Dietetics, College of Applied Food Sciences and Tourism, Michael Okpara University of Agriculture, Umudike, P.M.B 7267 Umuahia, Abia State, Nigeria

^[12] Halim, J., Bouzari, A., Felder, D., & Guinard, J. X. (2020). The Salt Flip: Sensory mitigation of salt (and sodium) reduction with monosodium glutamate (MSG) in “Better‐for‐You” foods. Journal of food science, 85(9), 2902-2914.

Gut Health for Diabetic People During the COVID-19 Pandemic

 Written by: Hamza Alvi, SLU Dietetic Intern

The unwanted effects of COVID

Nowadays, it feels impossible to live our lives without a mention of COVID-19, the contagious disease caused by the virus – SARS-CoV-2. This microscopic virus has crept into every corner of our lives and has infected our bodies, our communities, our relationships, and our lifestyles. But, SARS-CoV-2 does not pose the same threat for everyone equally. The elderly is placed at a disadvantage from COVID-19 outcomes, especially if they present with underlying chronic diseases such as diabetes, lung disease, cardiovascular disease, and cancer. [1]. Majority of the people infected with COVID-19 display mild flu-like symptoms or don’t develop symptoms at all, while others rapidly degenerate with viral pneumonia. The novel coronavirus can result deleterious effects for seniors (65+ years old), including higher rates of hospitalizations, increased ICU admissions, and deaths [2]. On April 21, 2021, AARP reported 32.1% deaths seen in people aged 65 and up. Comparatively, only 0.5% deaths were seen in a person aged below 24 [3].

While the disease has contributed with unwanted consequences in the senior population, it also developed undeniable challenges for the diabetics. Type 2 diabetes acts as a prime comorbid factor of COVID-19. According to The Centers for Disease Prevention and Infections (CDC), preliminary data enabled the scientists and physicians to postulate diabetes to be the most prevailing medical condition existing in COVID-19 patients [4]. Poor glycemic control may be a potential reasoning for this finding which leads to higher mortality rate from COVID-19 [5]. Hence, glycemic management is essential for diabetic patients and a plant-rich diet — high in fermentable fibers (soluble and insoluble), pasture-raised animal proteins, and low in sugars — can help improve glycemic control and help strengthen the immune system among patients with type 2 diabetes [6,7].

Using nutrition to strengthen our immune system

Concentrating on lifestyle factors, such as dietary regimen, can enable an individual to modulate their immune system. The immune system is home to trillions of microbes- bacteria, fungi, and viruses – which inhabit inside the human body called the gut microbiome. Most of these microbes reside in our lower digestive tract and some in the colon. The human body is remarkable at metabolizing proteins, carbohydrates, and fats to its constituents, but can’t digest fiber due to the absence of enzymes that degrade fiber. Fiber travels through the digestive tract unaltered until it arrives to the colon. As alluded earlier, the gut microbiota is home to trillions of symbionts – good or bad bacteria that exists in symbiosis with us. We could generate space for pathogenic bacteria through an inflammatory diet (i.e., SAD – standard American diet) and they direct us to the path of disease. On the contrary, we can choose to consume a diet – full of fermentable fibers (insoluble & soluble) – and beneficial bacteria help us by fermenting it and producing short-chain fatty acids (SCFAs). SCFAs are generated during the fermentation of the fiber, which play as the main source of energy for enterocytes (gut cells) and keep our gut happy and healthy. SCFAs – produced as a by-product of the bacterial feast – can enter the blood circulation and can exert advantageous effects on the immune system [8] and alleviate inflammation in the gut and other organs [9]. 

The effects of fiber on our body

So, what happens to our health in the absence of fiber? typical western diet – high in processed foods, meats, sugar, and low in fermentable fibers (soluble & insoluble) – can decimate the beneficial microbial communities in the gut microbiota. Numerous studies have verified the fiber intake for many average Americans is half of the amount recommended by the American Dietetic Association (25g for women and 38 grams for men) [10]. Contrasted with other countries with high-fiber diets, such as Ghana and Jamaica, the microbiome of many Americans is less diverse in microbial communities and may be posed a higher susceptibility to disproportions in advantageous vs. pathogenic bacteria [11]. This toxic environment triggered in the gut by the consumption of processed foods and lack of fiber — a trademark of the western diet — is a breeding ground for pathogenic microbes, which carry the potential to initiate various forms of inflammatory diseases such as obesity, colorectal cancer, autoimmune disorders, and type 2 diabetes [12]. 

Say yes to plants

The positive news is that it is practical to increase your fiber intake throughout the day. It starts with simple changes, like eating an apple and a cup of oatmeal with almonds for breakfast, or adding legumes (e.g., beans, lentils, etc.) or quinoa to a salad for lunch. Since plants (e.g., vegetables, nuts, and fruits) present with distinct types of fibers resulting in unique health benefits, and some microbes may selectively prefer one type of fiber over another, consuming an assorted diet with various fruits and vegetables is the cornerstone for enhancing the health span of the gut and improving diabetes-related complications. Few of the primary tactics in increasing fiber in your diet include the following: consume a nutritious and diverse diet with a wide range of different plant-based foods, across all six food groups – fruits, vegetables, wholegrains, legumes (beans & lentils), nuts and seeds. Strive to get as many different types as you can. Canned, frozen, fresh, it all counts. Eating the rainbow allows us to flourish heterogeneous microbial communities in our gut. If we eat well, the microbes eat well, therefore, we are more likely to feel well.

References

1.      How Coronavirus Affects Older   Adults. health.usnews.com/conditions/articles/how-  coronavirus-affects-older-adults.

2.      CDC COVID-19 Response Team. “Severe Outcomes Among Patients with      Coronavirus Disease 2019 (COVID-19) – United States, February 12-March 16,      2020.” MMWR. Morbidity and mortality weekly report vol. 69,12 343-346. 27        Mar. 2020, doi:10.15585/mmwr.mm6912e2

3.      Nania, R. (n.d.). 95 percent of Americans killed by Covid were 50+. AARP.    Retrieved September 13, 2021, from https://www.aarp.org/health/conditions-       treatments/info-2020/coronavirus-deaths-older-adults.html.

4.      Preliminary Estimates of the Prevalence of Selected Underlying Health            Conditions Among Patients with Coronavirus Disease 2019 — United States,          February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep 2020;69:382–386.       DOI: http://dx.doi.org/10.15585/mmwr.mm6913e2

5.      Zhu, Lihua, et al. Association of Blood Glucose Control and Outcomes in         Patients with COVID-19 and Pre-Existing Type 2 Diabetes. 1 May       2020, www.sciencedirect.com/science/article/pii/S1550413120302382?ca      sa_token=Z62_Kb0zrqQAAAAA%3AYoK9OnCK2T3rHDULwhCYmLA4uF      8PZGoCFbzYpK4qcYYC7ZQ_JhUvDT-OU_YzFNCjBJVnNT_SihvQ.

6.      Mcintosh, et al. “Diet Containing Food Rich in Soluble and Insoluble Fiber     Improves Glycemic Control and Reduces Hyperlipidemia among Patients with         Type 2 Diabetes Mellitus.” OUP Academic, Oxford University Press, 1 Feb.       2001, academic.oup.com/nutritionreviews/article/59/2/52/1826089.

7.      Yokoyama, Yoko et al. “Vegetarian diets and glycemic control in diabetes: a   systematic review and meta-analysis.” Cardiovascular diagnosis and         therapyvol. 4,5 (2014): 373-82. doi:10.3978/j.issn.2223-3652.2014.10.04

8.      Arnolds, Kathleen L, and Catherine A Lozupone. “Striking a Balance with Help from             our Little Friends – How the Gut Microbiota Contributes to Immune           Homeostasis.” The Yale journal of biology and medicine vol. 89,3 389-395. 30   Sep. 2016

9.      Sivaprakasam S, Prasad PD, Singh N. Benefits of short-chain fatty acids and their       receptors in inflammation and carcinogenesis. Pharmacol Ther. 2016;164:144‐        151. doi:10.1016/j.pharmthera.2016.04.007

10.  UCSF Health. “Increasing Fiber Intake.” Ucsfhealth.org, UCSF Health, 31 Oct.       2019, http://www.ucsfhealth.org/education/increasing-fiber-intake.

11.  Yatsunenko, Tanya et al. “Human gut microbiome viewed across age and       geography.” Nature vol. 486,7402 222-7. 9 May. 2012,        doi:10.1038/nature11053

12.  Graham, Catherine et al. “Obesity and the gastrointestinal microbiota: a review of       associations and mechanisms.” Nutrition reviews vol. 73,6 (2015): 376-85.   doi:10.1093/nutrit/nuv00413.Wen, Li, and Andrew Duffy. “Factors Influencing       the Gut Microbiota, Inflammation, and Type 2 Diabetes.” The Journal of             nutritionvol. 147,7 (2017): 1468S-1475S. doi:10.3945/jn.116.240754

Book Review: Overcoming Binge-Eating by Christopher G. Fairburn

 Written by: Margaret Conte, Dietetic Intern

As a dietetic intern, we learn to calculate patient needs and how to present our findings to the patient. We receive training on counseling, but the focus is on nutrition. When it comes to treating eating disorder patients, in many ways the counseling is far more important than nutrition. “Overcoming Binge-Eating” gives an intimate look into the therapy and counseling side of treating binge eating disorders, and I believe it is a valuable read for all current and future dietitians.

            The book is divided into two parts, the first of which discusses the research and what is known about binge eating disorders. Part II is an evidence-based curriculum that can be followed by an individual alone or in conjunction with a therapist. One asset of the book is its readability. An individual need not be a medical professional to understand the information or follow the curriculum.

What is binge eating?

            Binge eating is more recently being recognized as an eating disorder with a psychological basis, rather than a merely lack of discipline when it comes to eating. Some people can binge, and it has no effect on their lives. This is called an indulgence and is a common phenomenon in men and women. When the repeated practice has a profound impact on a person’s quality of life and health, then it becomes an eating disorder, and we as dietitians can help with this. The two hallmarks of a binge are 1) the amount eaten is excessive in the eyes of the individual and 2) there is a sense of loss of control in the eyes of the individual.

            We are taught as nutrition students that binges are the result of restriction. According to Fairburn, the most common foods eaten in a binge are foods the person is trying to avoid. There is a myth that binges are characterized by high carbohydrate content, but in reality, the proportion of carbohydrates in a binge is no different than in ordinary meals. Binges are characterized by the amount of food rather than the macronutrient composition of the food.

            Binges can cause extreme distress in people. So why would someone subject themselves to feeling “gross” and “disgusted” over and over? This is important to understand in order to help someone overcome binge eating. One study interviewed women with bulimia nervosa who binge and revealed major precipitants of binges: tension, eating something (anything at all), being alone, craving specific foods, thinking of food, going home (after school or work), feeling bored and lonely. Other reasons for binges include undereating and the associated hunger (especially those who eat little outside of binges), breaking a dietary rule, and unpleasant emotions.

            Binge eating can be an eating disorder in itself, “binge eating disorder”, or it can be a component of anorexia nervosa, bulimia nervosa, or eating disorders not otherwise specified (do not meet the diagnostic criteria for anorexia nervosa, bulimia nervosa, or binge eating disorder). Many people who binge also diet. People who binge might think their dieting is in response to the binging, while in reality the binging may have initially resulted from the dieting, and the two cyclically encourage one another. The person may also engage in self-induced vomiting or laxative misuse, which encourages more binging. As we have learned in class, self-induced vomiting and laxative misuse can cause very serious health effects.

           

How can I use this book to help my patients?

Part II is a self-help program for people who binge. There are many concepts throughout Part II that hark back to the motivational interviewing and transtheoretical model of change we learned in counseling classes. It begins with the chapter, “Why Change?” and instructs the reader to “Start by drawing up a list of the potential advantages of change. To help you do so, ask yourself the following questions:

If I stop binge eating . . .

• Will I feel better about myself?

• Will it improve my quality of life?

• Will my physical health be enhanced?

• Will others benefit?”

            The rest of Part II outlines steps of the program. Step 1: Starting Well covers self-monitoring and weekly weighing. Step 2: Regular Eating establishes a pattern of regular eating and stopping vomiting and misuse of laxatives. Step 3: Alternatives to Binge Eating substitutes alternative activities and identifies changes in weight. Step 4: Problem Solving addresses problems that may be coming up. Step 5: Taking Stock reviews progress and decides what else needs to be tackled. Next there is a diet module which tackles strict dieting and a body image module that addresses shape concerns, shape checking, shape avoidance, and feeling fat. The program closes with the section Ending Well, which discusses maintaining progress and addressing setbacks.

 

Why is this important?

            Because eating disorders are so complex, it is especially important for the dietitian to collaborate with other professionals, and understand their own scope of practice and refer appropriately. I hope this blog post will encourage future dietitians to read “Overcoming Binge Eating”, because the information I have written here only scratches the surface of the links between dieting, binge eating, and eating disorders. We will be better dietitians for understanding where binging behavior comes from, and how to make recommendations appropriately for optimal health of body and mind.

Do I Really Have to Cut Out Alcohol?

 

Written by: Hailey Wegner, SLU Dietetic Intern

When the word “dietitian” slips into conversation with any friend or passerby – I often know what is going to come next... a question regarding nutritional intake that this person wants to know about.

Friends: “What’s with this keto diet... Anyway?”

Stranger at the grocery store: “So...should I be eating more super foods?”

But when I am among young adults... there is one question that almost always comes up.

Everyone: “Do I really have to cut out alcohol?”

This question especially comes up when the young adult wishes to see physique changes. This is especially, especially true when the young adult is a competitive athlete... and especially, especially, especially true when the young adult is a competitive collegiate athlete.

_______________________

There is no question that drinking alcohol is written into the culture of almost every college attendee. First year students of traditional college often drink irresponsibly, and believe drinking to be integral to the college experience with over 40% of college students endorse heavy episodic or “binge” drinking (generally defined as 5 + drinks in one sitting for men and 4 + drinks in one sitting for women)^{(1, 2)}.

This is not untrue for athletes. While some may believe that the collegiate athlete is at a lower risk of engaging in binge drinking due to scheduling constraints or the physical demand of peak performance; studies show that students involved in sports have a higher tendency to drink/get drunk/binge on alcohol more often than those students with no involvement in sports⁽³⁾.

So what DO I tell athletes when the question of: “so what about alcohol...” comes up?

_______________________

Me: “I’m glad you asked... because it indicates that you care about your body performing the BEST that it can...”

Depending on the circumstances that apply to the athlete in front of me... I can choose from the LARGE array of evidence that shows the detrimental effects of alcohol on athletic performance.

Me: “Alcohol consumption disrupts our metabolism of nutrients... so your body and performance will suffer.”

And its true! Research has shown that: Alcohol consumption has been shown to inhibit liver glucose output during exercise; which can cause low blood sugar while exercising, and alcohol will decrease muscle glucose uptake – so tissues cannot get the fuel that they need. It also suppresses the breakdown of fatty acids—and is therefore regarded as a risk factor for weight gain ^{(5) .} Alcohol consumption prevents your body from absorbing important nutrients like thiamin, vitamin B12, folic acid and zinc⁽⁴⁾. (These nutrients help in the formation of new cells, boost your immune system, and aid in the metabolism of proteins and fats).

Me: “Most importantly to athletes, though, is that large amounts of alcohol can shut off muscle repair, growth, and even has been shown to produce muscle wasting.” ⁽⁷⁾

Which is ALSO true. AND... Athletes tend to consume the most alcohol in the 1-2 hours after exercise, which is the timeframe that is the most critical for optimal nutrient uptake. ⁽⁶⁾

Me: “Not surprisingly then... Athletes who drink alcohol at least once per week have an elevated risk of injury as compared to athletes who do not drink”

This is for a variety of reasons... Alcohol is shown to increase fatigue during high-intensity exercise, ⁽⁶⁾ which can lead to poor concentration and sloppy performance. Alcohol increases production of anti-inflammatory molecules; and inflammation is a key part of the muscle repair process, and alcohol consumption induces dehydration and loss of blood flow to active tissue. ⁽⁶⁾

Me: “There are even some detriments that most people wouldn’t think about... such as impaired temperature regulation, depressed immune functioning, low testosterone production, and decreased quality and duration of sleep.” ^{(10, 6)}

I am sure we can all imagine how those could negatively impact performance.

Me: “And I know you think you can hang... but even mild hangover symptoms have direct impact on performance; such as: headache, nausea, hypersensitivity to light or sound, diarrhea, fatigue, dehydration, and body aches” ⁽⁴⁾

Athlete: “Okay... so I will avoid alcohol in-season... but it’ll be fine in off season.. right?

Me: “Well... actually, no. Studies have shown “chronic” detrimental effects of alcohol can accumulate in as little as as 6-weeks.”

Some well-researched chronic detriments include increased whole-body protein breakdown and long-term compromises to the immune system... which makes an athlete more susceptible to career-delaying illnesses  ^{(6, 8)}

Me: “But... Don’t worry! Everything in moderation, including moderation... there is evidence that low doses of alcohol can be safely consumed without an impact on performance”

That’s right! As long as the athlete is of legal drinking age, low-to moderate doses of alcohol have been shown to have no effect on certain subsets of athletic performance. 

Studies show that low doses of alcohol are unlikely to be detrimental to repletion of glycogen, rehydration and muscle injury and have little to no effect on muscle protein balance or muscle growth ⁽¹¹⁾

Notably, low doses of alcohol would be less than 1-2 drinks per day for men, and less than ½-1 drink per day for women; and that “stacking” these drinking events to 1-2 days per week is still considered binge drinking. ⁽¹²⁾ These drinks would be measured using a “1 drink” equivalent of 5 oz of wine, 12 oz of beer, or 1 shot (1.5 oz) of liquor ⁽¹³⁾ .

_______________________

All in all, the evidence AGAINST consuming alcohol while participating in athletics is overwhelming. However, much like a human-relationship to food, the human-relationship to alcohol can be seen written into many aspects of collegiate culture. My overarching recommendation for athletes always encompasses these two ideas.

Me: “It is best to avoid any alcohol consumption to ensure top-notch athletic performance. But for athletes who choose to drink, you should become fiercely aware with the AMOUNTS that are shown to cause no affect... drinking to achieve social acceptance should not be a priority over your physical performance in your sport, especially since there IS an amount of alcohol that is considered safe to consume. With this in mind, avoid alcohol 48 hours prior to any athletic event and rehydrate/ consume food BEFORE celebratory drinking to slow alcohol absorption.”

Love,

Your Sports Dietitian

 

References:

1) Crawford, L. A., Novak, K. B., & Jayasekare, R. R. (2019). Volunteerism, Alcohol        Beliefs, and First-Year College Students’ Drinking Behaviors: Implications for       Prevention. The Journal of Primary Prevention, 40(4), 429-448.             doi:10.1007/s10935-019-00558-z

2) D.A. Dawson, B.F. Grant, F.S. Stinson, P.S. Chou, Another look at heavy episodic       drinking and alcohol use disorders among college and noncollege youth,        Journal of Studies on Alcohol, 65 (2004), pp. 477-488

3) Ford JA. Alcohol use among college students: a comparison of athletes and nonathletes. Subst Use Misuse. 2007;42(9):1367–77.

4) Alcohol and Athletic Performance. (n.d.). Retrieved from        https://alcohol.stanford.edu/alcohol-drug-info/staying-safe/alcohol-and-          athletic-performance

5) Suter, P., Schutz, Y. The effect of exercise, alcohol or both combined on health and physical performance. Int J Obes 32, S48–S52 (2008).         https://doi.org/10.1038/ijo.2008.206

6) Barnes MJ. Alcohol: impact on sports performance and recovery in male athletes. Sports Med. 2014 Jul;44(7):909-19. doi: 10.1007/s40279-014-0192-8. PMID:        24748461)

7) Steiner JL, Lang CH. Dysregulation of skeletal muscle protein metabolism by           alcohol. Am J Physiol Endocrinol Metab. 2015 May 1;308(9):E699-712. doi:   10.1152/ajpendo.00006.2015. Epub 2015 Mar 10. PMID: 25759394; PMCID:     PMC4420901.

8) Hong-Brown LQ, Frost RA, Lang CH. Alcohol impairs protein synthesis and degradation in cultured skeletal muscle cells. Alcohol Clin Exp Res.            2001;25(9):1373–82.

9) Cameron C. et al, Sport-related achievement  motivation and alcohol outcomes:     An athlete-specific risk factor among  intercollegiate athletes, Addictive       Behaviors, Volume 38, Issue 12, 2013,  Pages 2930-2936, ISSN 0306-4603,

10) Yoda T, et al,. Effects of alcohol on thermoregulation during mild heat exposure   in humans. Alcohol. 2005 Jul;36(3):195-200. doi:         10.1016/j.alcohol.2005.09.002. PMID: 16377461.

11) Kimball, S. R., & Lang, C. H. (2018). Mechanisms Underlying Muscle Protein          Imbalance Induced by Alcohol. Annual review of nutrition, 38, 197–217.       https://doi.org/10.1146/annurev-nutr-071816-064642)

12) Maraldi, C., et al,. (2009). Moderate Alcohol Intake and Risk of Functional Decline: The Health, Aging, and Body Composition Study. Journal of the           American Geriatrics Society, 57(10), 1767-1775. doi:10.1111/j.1532-   5415.2009.02479.x

13) National Institute on Alcohol Abuse and Alcoholism. (NIH Publication No. 07-      3769).Helping patients who drink too much: a clinician’s guide   (updated) 2007