In a well-timed article in the New York Times last month, Aaron Carroll discusses the implications SNAP restrictions can have on the obesity levels of its participants. Whether due to the higher costs of nutrient-dense food or other factors, obesity has been linked to food insecurity.² This relates back to SNAP, as much of the concern surrounding restrictions for SNAP participants involves the stigma and embarrassment such a policy could cause. However, a strategy to encourage SNAP participants to eat healthier must be implemented in some way or another. Carroll looks at a recent study in which Harnack et al. evaluated the effects of incentive and restrictions on the obesity levels of SNAP participants. 279 low-income participants, who were not currently enrolled in SNAP, were utilized in this randomized control trial and placed into one of four different study groups. The first group, incentives, provided a 30% financial incentive for participants who purchased fruits and vegetables. The second group, restrictions, did not receive any incentives and were not allowed to purchase SSB’s, baked goods, or candy using their food benefits. The third group, incentives plus restrictions, were given the 30% financial incentive for fruits and vegetables but also had the same purchasing restriction as group two. Finally, group four was the control group, on which no incentives or restrictions were placed.³

With outcome measurements of energy intake, discretionary calories, and overall quality of diet, the researchers found that the third group (incentives plus restrictions) was significantly improved compared to the control group.³ However, although group three had reduced energy, discretionary calorie, and sugared food intake as well as increased fruit intake, the study did not have obesity as an outcome measurement. Carroll concludes that Harnack et al.’s study has found a solution to the link between obesity and SNAP participants; yet the study does not itself conclude that incentives and restrictions for a SNAP program will lead to a reduction in overall obesity.¹ Yes, the participants eating habits became healthier, but this is only one contributing factor to obesity. Carroll does make a valid point however that although this study seems to demonstrate a strategy to improve the healthful diets of SNAP participants, actually instituting these polices is a long ways away.¹ I also agree that Carroll makes a valid point by referencing the restrictions placed on other federal food benefit programs, such as WIC and the national school lunch program. If restrictions for healthy eating can be implemented with these programs, finding an agreeable solution for SNAP hopefully shouldn’t be so far off.

¹Carroll, A. (2016, September 22). How Restricting Food Stamp Choices Can Fight Obesity. Retrieved October 23, 2016 from http://www.nytimes.com/2016/09/23/upshot/restrictions-on-food-stamp-purchases-can-improve-diets.html?_r=0.

²Dinour, L., Bergen, D., & Yeh, M. (2007, November). The Food Insecurity–Obesity Paradox: A Review of the … Retrieved October 23, 2016, from http://www.andjrnl.org/article/S0002-8223(07)01616-1/fulltext.

³Harnack, L., Oakes, JM., Elbel, B., et al. (2016, September 19). Effects of subsidies and prohibitions on nutrition in a food benefit program. JAMA Internal Medicine. Retrieved October 23, 2016 from http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2553293

In a webinar on school gardening, presenter Kyla Van Deusen of the Captain Plant Foundation focuses on bridging the gap between locally grown foods and access to them in schools. Gardens are a hands-on experience that allows students to actively participate in the planting process and provides them with the knowledge of where their food actually comes from. Ms. Deusen mentions many ways to get students involved in gardening such as harvesting, taste testing in the classroom, and placing it in the cafeterias. She also mentioned different ways to connect a garden into school learning such as through after school programs, service learning, or project-based learning in the classroom. One example provided was of a school using spinach instead of green dye for “green eggs and ham” for Dr. Suess day. Big or small steps can make a difference, so a simple start can lead to big changes.

Outdoor and indoor gardens can both be options depending on the location of a school, so it is possible for any school to begin a garden program. Paying attention to seasonality and food safety are important factors to keep in mind no matter what kind of garden a school is implementing. Keeping track of when vegetables and plants are in season helps to ensure the crop is utilized, so Ms. Deusen recommends keeping a seasonal chart as a guide. Food safety includes not only with the food grown in the garden but personal hygiene and post-garden handling as well. Hand washing stations and making sure sick students are not involved in garden activities for a few days are just some of the recommendations for ensuring all food and students are safe. Proper food handling after harvesting is also important for student and food safety, such as making sure the food is cooled down then put in the refrigerator.

Practitioners can benefit from this information by assisting schools with the process of starting a garden. Many partnerships are available for these types of projects, including support from USDA or local grants, so practitioners can be the bridge that connects these partners with the schools. Health practitioners could also provide useful resources on proper food handling and safety to ensure schools understand all factors that play a role in a school garden. Starting a garden program is a team effort, so support from a practitioner in a school’s community is beneficial for success. For more information on gardening in schools, check out growing-gardens.org – manual and captainplanetfoundation.org.

In a webinar presented by a policy and health researcher named Dr. Jamie Chriqui, the focus is on research she has conducted on the role of zoning and its relationship with adult activity. She discusses designing communities to be more active-friendly, especially for pedestrian orientation. This means more biking and walking accessibility in the environment such as more sidewalks and safer conditions for these activities. She also discusses how zoning is related to public health through zoning laws. These laws can include improving communities to increase active living through the implementation of sidewalks, bike lanes and parking, and street connectivity to just name a few. She also mentions The Community Guide’s recommendations for environmental and policy approaches to increase physical activity that focus on design techniques for different strategies such as safe street crossings, reducing car use, and facilitating walking and biking.

In her research examining the prevalence of active-living zoning across the United States, her research team found that it is stronger in urban areas and weaker in non-urban areas, and low-income areas have weaker zoning compared to higher income areas. These results were not that surprising considering there is a higher need for safety on streets and sidewalks in urban areas with more traffic. Overall, her findings show that active living-oriented zoning measures are significantly associated with increased walking, biking, and taking any active transportation to work. It is important to note that these are correlations and not causations, but it shows that these policies do have the potential to be successful.

This information is beneficial for practitioners that are seeking to improve zoning in a community that may not have efficient active-living policies in place. Practitioners can be the bridge connecting the community leaders to the people of the community by working with leaders on the planning and designing of these policies. This is also useful for promoting active living in a community by not only incorporating active-living into zoning policies, but to also encourage individuals to walk or bike to their destination once developments have been made. Sidewalks and safety developments can be successful, but individuals must be aware of them and encouraged to use them. For additional information on active living oriented zoning, check out the National Complete Streets Coalition’s website: https://smartgrowthamerica.org/program/national-complete-streets-coalition/.

Farmer’s Markets are a breeding group for food borne illnesses. Think of how many people touch those peaches or how long that hand milled cream has been sitting in the sun! You should never, ever, frequent these places!

Or so someone would think if they glanced at Dr. Marc. F Bellemare’s initial research and New York Times article published on this research. In a recent presentation at the University of Georgia, Dr. Bellemare went through his results in depth to explain what he actually found.

Over the past 20 years, farmers markets in the United States have been on the rise, with a five-fold increase. The food sold at these markets typically isn’t regulated like the food bought in grocery stores and convenience markets and fresh produce has been a growing cause of food-borne illnesses like Campylobacter.

Dr. Bellemare and his research team set out to research the relationship between farmer’s market and food borne illness rates across the nation. They began by looking at a survey study by Lusk et. al, in which 45% of participants reported that they did not know if the food at farmer’s market was safer or not than grocery store products, 27% thought it was more dangerous, and 27% thought it was safer. In other words, no one really knows. From there, the team set out to give everyone a definite answer.

Using CDC and USDA data on food borne illness cases and outbreaks and the density of farmer’s markets in each state, Bellemare collected the data needed to find a correlation. The research team did control for spillover in other states and regions and utilized state-specific, year-specific, and region-specific linear trends to make sure nothing out of the usual had occurred to skew data. They also recognized that food borne illness rates are typically under-reported to the CDC, as not everyone who gets sick got to a doctor for treatment.

Norovirus

So after evaluating data for year, what did the Bellemare team find? A positive linear relationship exists between the number of outbreaks and individual cases of food borne illnesses, especially Norovirus, and the number of farmer’s market in any given state. They confirmed this as a causation by using weather data and noting that lower average temperatures usually meant lower numbers of markets and in turn outbreaks. But this isn’t inherently the fault of the farmer’s and suppliers of the markets, instead it is most likely due to what happens after the transaction has taken place. Food borne illnesses are typically the result of errors in food preparation, such as cooking at incorrect temperatures or leaving food exposed for too long.

This information can be used to inform consumers on how to properly handle food. Practitioners can make sure that their patrons are not only selecting the best foods from these local suppliers, but also serving them in the safest way possible. Eat local, but be mindful of temperatures!

A City Lab article, “Living Near A Transit Line Might be Good for your Mental Health,” talks about the effect that living near a transit line has for the mental health of senior citizens. According to this article, access to public transit will have beneficial effects towards mental health in older populations.  This was based on a 2015 study published in the International Journal of Environmental Research and Public Health that looks at the effect of the built environment on the mental health of its residents across age groups in Turin, Italy. They measured the mental health outcomes based on the incidence rate ratio of the use of anti-depressants across socio-economic variables and built environment measures.

Both the article and the paper mention that density and access to public transit had a positive effect on mental health especially for older women (Jaffe 2015; Melis et al., 2015). The article also says that the older populations were prescribed fewer anti-depressants when living near public transit or in areas with a higher population density. However, looking at the actual statistics and comparing to the male population, this might be a slight exaggeration.  When looking at close proximity to public transit, the incidence rate ratios for prescription medications for women are all statistically significant, but the protective impact decreases in higher age groups; from the 20 to 34 years age group there was only a 6% reduction in risk in being prescribed anti-depressants and this went down to a 5% reduction risk in the 35 and up age groups. Compared to the women, men in the 50-64 years age group who lived near public transit had a 6-7% reduced risk in being described anti-depressants and a 7% reduced risk when living in a densely populated area.

The article and paper both were transparent in mentioning the limitations of the study. The article actually mentioned a NIH study which showed that living near public transit actually increased the risk for symptoms of depression among youth in Boston (Jaffe, 2015; Duncan et. Al, 2013). In addition, tracking the use of antidepressants does not fully encompass those who suffer from depression (Jaffe, 2015; Melis et al., 2015).

That being said, there still was a reduced risk in the prescribing of anti-depressants across older populations which indicates that proximity to public transit could have a positive effect on one’s mental health. A health practitioner could find this policy useful when getting involved in transportation policy. Health practitioners can inform city planners of the positive effect of public transportation on the mental health of senior citizens and advocate for more transportation services in areas that have a significant elderly population.  In addition, for an area with a more established public transportation network, practitioners could advocate for more paratransit services which will increase accessibility for older people with disabilities. While this study does have some limitations, it is the first of its kind that explored the link between various elements of the built environment and mental health.

SOURCES
Duncan, D. T., Piras, G., Dunn, E. C., Johnson, R. M., Melly, S. J., & Molnar, B. E. (2013). The built environment and depressive symptoms among urban youth: A spatial regression study. Spatial and Spatio-Temporal Epidemiology, 5, 11–25.

Jaffe, E. (1, Dec 2015). Living Near a Transit Line Might Be Good for Your Mental Health.  City Lab.
Retrieved from http://www.citylab.com/commute/2015/12/study-transit-density-mental-health-depression-turin/417969/

Melis, G., Gelormino, E., Marra, G., Ferracin, E., & Costa, G. (2015). The Effects of the Urban Built Environment on Mental Health: A Cohort Study in a Large Northern Italian City. International Journal of Environmental Research and Public Health, 12(12), 14898–14915.

Less Might Be More

More protein, less carbs, no sugar, more carbs, less protein, Mediterranean diet, Atkins diet?! In my thirty-six years I have heard almost every different kind of diet advice imaginable. The one thing that has remained steady is that almost always, what was once “proven” effective is soon replaced by a new magic bullet, sure to make me a size 4 again.

According to a recent article on Time.com, It’s Time to Rethink High-Protein Diets for Weight-loss, new evidence suggests “while the diet (high protein) may help people slim down, it doesn’t necessarily improve other health problems under the hood.” Wait, so should I re-think it or will it help me slim down? Rethink protein for weigh loss – they just said it will help slim down! Like most weight loss articles and advice out there, this one is no exception and may add to the confusion.

So, what is the scientific premise of this article? The author cites a small study out of Washington University School of Medicine in St. Louis. The original study, titled High-Protein Intake during Weight Loss Therapy Eliminates the Weight-Loss-Induced Improvement in Insulin Action in Obese Postmenopausal Women, followed 34 postmenopausal women in three conditions: no diet change, calorie-restricted diet (with DRV of protein), and calorie-restricted with increased protein by 150-250 calories. They found that both intervention groups were able to achieve 10% weight loss. Not to shabby! Refer back to the title of the media article and we can stop reading there (weight loss achieved in both conditions, done and done, size 4 here I come!). But, wait, I’m not post menopausal and – oh yeah – they mentioned insulin action. So, this sample is not exactly representative of larger populations.

The popular media article, like the scientific study, goes on to explain that the women who did not increase protein experienced a 25 – 30% improvement in insulin sensitivity, a key risk factor in developing type-2 diabetes. So, surprisingly, the metabolic benefit came to those who didn’t increase protein in their diets. The scientific article also states that the high-protein condition experienced a 45% reduction in the weight-loss-induced decline in lean muscle mass. So, higher protein diets resulted in more muscle retention. The authors concluded that protein content of a weigh loss diet can have profound effects on metabolic function. These two major findings have positive implications that relate to overall health, but applications by health practitioners may differ depending on concerns around type-2 diabetes.

Despite the fact that this was a small study including a very specific demographic, health practitioners can still find some important take-aways. Based on the results of the study, if obesity complications such as type-2 diabetes are a concern, then adopting a weight-loss diet that includes protein in moderation should be more beneficial for the overall health of an individual. However, if muscle mass retention is a concern – as it might be with postmenopausal women, then a high-protein diet helps retain muscle while also losing fat.

Sifferlon, A. (2016, October 11). It’s Time to Rethink High-Protein Diets for Weight Loss.

Retrieved October 17, 2016, from http://time.com/4526448/high-protein-diet-weight- loss-insulin/

Smith, G.I., & Yoshino, J., et al., (2016). High-Protein Intake during Weight Loss Therapy Eliminates the

Weight-Loss-Induced Improvement in Insulin Action in Obese Postmenopausal Woman. Journal of

 Applied Developmental Psychology, 17(3), 849-861. http://dx.doi.org/10.1016/j.celrep.2016.09.047

Once the clock strikes midnight (or in this case 6pm), all calories go straight to the waist, hips and thighs, right? Everyone has heard the mantra that eating after a certain time at night leads to greater weight gain, but is 6pm really a hard and fast rule? Danna Hunnes, Ronald Reagan UCLA Medical Center, and The New York Post think not. However, there is agreement that eating at night can lead to greater weight gain, particularly when the late night munchies chooses junk foods as its snack of choice. James LeCheminant and others looked at the differences in weight among 29 male participants under two difference circumstances.⁴ The first involved a nighttime eating restriction, where no food was consumed between the hours of 7pm and 6am for two weeks.⁴ The participants lost about one pound each.⁴ However, when this restriction was lifted, the participants gained an average of 1.3 pounds back.⁴ Researchers concluded that this difference was mostly due to the fact that eating at night increased daily energy intake, rather than because the food was specifically consumed at night instead of during the day.³

The New York Post article also references an article in Women’s Health that discusses Eckel et al.’s research concerning the effects of evening eating on insulin levels, in which “ad libitum food intake [during the biological night] resulted in ∼20% reduced oral and intravenous insulin sensitivity.”² Eating in the evenings, when your body is more resistant to insulin’s effects, causes blood sugar to increase as well as excess sugar to be store as fat, both of which are unfavorable health effects.

Dietician Danna Hunnes suggests that adequately fueling oneself throughout the day should help to reduce nighttime hunger and thus lessen the weight gain effects that do result from eating unhealthy snacks late at night. Practitioners can utilize this information to help disseminate information to patients on what composes a healthy meal (i.e. a breakfast with enough protein, proper portions throughout the day, etc.) and thus help decrease individual’s need to snack after dinnertime.

¹Arnold, C. How to Cut Out Late-Night Snacking. (December 31, 2013). Women’s Health. Retrieved on October 16, 2016 from http://www.womenshealthmag.com/weight-loss/night-snacks. 

²Eckel, R. et al. Morning Circadian Misalignment during Short Sleep Duration Impacts Insulin Sensitivity. (November 5, 2015). Current Biology. Retrieved October 16, 2016 from http://www.cell.com/current-biology/fulltext/S0960-9822(15)01239-7.

³Fetters, K. Just how serious is that ‘no eating after 6’ rule? (August 29, 2016). New York Post. Retrieved October 16, 2016 from http://nypost.com/2016/08/29/just-how-serious-is-that-no-eating-after-6-rule/.

⁴LeCheminant, J., Christenson, E., Bailey, B., & Tucker, L. Restricting night-time eating reduces daily energy intake in healthy young men: a short-term cross-over study. (December 2013). British Journal of Nutrition. Retrieved October 16, 2016 from https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/restricting-night-time-eating-reduces-daily-energy-intake-in-healthy-young-men-a-short-term-cross-over-study/3627087601F148E8D16163468FCB3F05.

The familiar phrases “out of sight out of mind” and “why fight an uphill battle” can apply well to whether the layout of one’s fridge and kitchen will affect one’s eating habits. The Times Free Press takes a look at behavioral and nutritional science professor Brian Wansink’s book Slim by Design, in which various studies on the design of kitchens, restaurants and school lunchrooms are compiled to determine their effect on eating habits. We already had a sneak peek at a portion of Wansink’s ideas in the Lunch’d Project. However, this article focused specifically on kitchen design and whether it works for or against healthy eating habits. Wansink’s ideas focus on working with human nature to make healthy eating choices easier and simpler for individuals to actually make.

One such study, “Slim by Design: Kitchen Counter Correlates of Obesity,” documented the state of 210 households in Syracuse, NY and compared BMI with the state of the kitchen counters in each household, i.e. clutter and presence of fruit or various unhealthy foods sitting on the counter.² The Times Free Press slightly exaggerated the results, claiming a difference of 21 pounds between those who had a box of cereal visible on the counter and those who didn’t.¹ Wansink et al. actually found that weights ranged from 20 pounds to 31 pounds when the kitchen had a presence of “candy, cereal, soft drinks, and dried fruits”.² They also found lower BMI was associated with households who had fruits sitting out on the counters.

This returns back to those phrases mentioned earlier. If unhealthy foods are out of sight (not sitting in plain view on the counter), are individuals more likely to avoid them and grab an apple or banana as a snack instead? Wansink thinks yes. The Times Free Press also mentions Wansink’s studies that show individuals are more likely to reach for the first foods they see (a theory he tested out in Lunch’d as well), and thus will take the less cumbersome task of grabbing the healthier foods positioned in the front of the fridge rather than reaching towards the back for the leftover chinese or sodas. Practitioners can use these ideas (whether in lunchrooms, fueling stations for sports teams, snack stands in the workplace, etc.) to their advantage by making access to healthier foods more compatible with human nature, thus increasing the likelihood than individuals will make healthier food selections simply because those selections are within closer reach.

¹Pierce, S. Is your kitchen making you fat? Author says design, setup of kitchen can work for or against you (January 10, 2015). Times Free Press. Retrieved October 16, 2016 from http://www.timesfreepress.com/news/life/entertainment/story/2015/jan/10/your-kitchen-making-you-fat/281726/.

²Wansink, B., Andrew, S., and Kaipainen, K. Slim by Design: Kitchen Counter Correlates of Obesity (August 12, 2015). Health Education & Behavior, Forthcoming. Retrieved October 16, 2016 from https://ssrn.com/abstract=2643023.

While scrolling through your preferred news outlet in the morning while eating a bowl of oatmeal, you may stumble across several food items or activities that can all of the sudden cause cancer. So what’s the latest? Well, according to New York Post, vegetarianism.

What?, you may be saying to yourself. I thought vegetarianism was the way of the future, the optimal diet for humans? How is this possible? Did I give up steak for nothing? Well, according to the New York Post long-term vegetarianism leads to a genetic mutation that leaves individuals vulnerable to heart and colon conditions, cancer included.

Genes? Now I’m confused. Let’s dive a little deeper into the literature. The study in question was looking specifically at a gene variant that causes the body to increase the amount of arachidonic acid that it can make from smaller omega-6 molecules found in plants. So, this mutation creates more omega-6 fatty acid from smaller molecules. What we know about omega-6 fatty acid is that it is pro-inflammatory and that having a large ratio of omega-6s to omega-3s in the body could play a role in lifestyle related diseases like colon cancer, heart disease, and other inflammatory-related diseases (however, even the research for that is unclear).

As the researchers were studying this predominantly vegetarian Indian city, they identified the genetic mutation, or vegetarian gene variant, in 68% of the residents. Therefore, they hypothesized (hypothesized being the key word here) that perhaps these individuals were also at a higher risk for inflammatory-related diseases. However, the New York Post skipped over all of this and made the connection without any research backing this information. The study did not even look at any data linking genes to the disease risk.

This study is one of the first looking at vegetarianism gene mutations, and any potential implications that it has need to be further studied. Research needs to done on possible disease risk outcomes in people with this genetic mutation. Perhaps prospective cohort studies or observational studies can be conducted on prominently vegetarian communities with this mutation to see their mortality risk for omega-6 related inflammatory diseases.

Until then, health practitioners should take these popular media articles with several grains of salt. Reading articles like the New York Post can really discourage someone on the fence of changing diets to not adopt this new behavior, based on one [incorrectly summarized] research study, when several studies have documented the benefits of vegetarianism, especially for lowering disease risk. Health practitioners need to be really well-informed on the current research to educate individuals to may be reading that vegetarianism causes cancer over their morning oatmeal.

1. Kothapalli, Kumar SD, et al. “Positive selection on a regulatory insertion-deletion polymorphism in FADS2 influences apparent endogenous synthesis of arachidonic acid.” Molecular biology and evolution (2016): msw049.
2. Li, David. “Being a vegetarian could kill you, science warns.” The New York Post. March 30, 2016.

Do ‘soda taxes’ curb consumption of sugar-sweetened beverages? According to the LA Times article, “Berkeley sees a big drop in soda consumption after penny-per-ounce ‘soda tax,’ this seems to be the case. The article mentions a recent study published in the American Journal of Public Health (AJPH) concerning the consumption patterns of residents in Berkeley five months after the tax was implemented. According to Falbe et al. (2016), lower-income residents in Berkeley reduced their intake of sugar-sweetened beverages by 21% and increased their water consumption by 63% (Kaplan, 2016). Interestingly enough, the neighboring cities actually experienced an increase in consumption of sugar-sweetened beverages and only a 19% increase in water consumption (Kaplan, 2016). While these are promising results, does this mean that a soda-tax will be just as successful in other places as well?

The LA Times article echoes a lot of what the AJPH article says and makes a lukewarm endorsement of ‘soda taxes’ at the most.  Both the LA Times article and the AJPH article both state that it is unknown that such a tax would work in other cities since the study was only done in one city. It would be erroneous to state that what will work in Berkeley, a city with a population of 120,927 will work in a city like Washington D.C., with a population of around 672,228 (U.S. Census Bureau, 2015). Another thing to take in consideration is the presently held health beliefs before the implementation of the tax. The AJPH article mentioned that the significant decrease in sugar-sweetened beverages could have also been due to Berkeley being a health conscious city. In addition, there was wide community support of these initiatives.  In addition, Berkeley has relatively higher median income compared to it’s neighbors. How would these policy affect cities with much lower median incomes? It could have detrimental effects, especially in places which are food insecure.  The APJH article was quite transparent in realizing the limitations of the study and called for longer-term studies.

While this is a short-term study, health practitioners, especially those who work in health policy and community health, can find some takeaways from these studies. As mentioned previously, it is integral to garner community support on the implementation of a ‘soda tax.’ There could be opposition to this measure by community members for some might see it as an infringement on their freedoms and punishing them for the choices they have. In other words, there would be a mismatch between policy and community concerns.  Secondly, health practitioners in these areas could see that in order to gain support for these measures, one must be already be health conscious. Before even proposing this tax, practitioners should set the groundwork in creating community-wide programs which gets people thinking about their health.

SOURCES
Falbe, J., Thompson, H., Becker, C., Rojas, N., McCulloch, C., & Madsen, K. (2016).  Impact of the Berkley Excise Tax  on Sugar-Sweetened Beverage
Consumption. American Journal of Public Health, 106(10), 1865-1871.

Kaplan, K (23 August 2016). Berkeley sees big drop in soda consumption after penny-per-ounce ‘soda tax.’ LA Times. Retrieved from
http://www.latimes.com/science/sciencenow/la-sci-sn-soda-tax-works-20160823-snap-story.html

U.S. Census Bureau (2015).  Quickfacts. Retrieved from http://www.census.gov/quickfacts/table/PST045215/11,0606000,00.