May/June 2016 The Nutrition Issue

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Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

t r u i N t ion e Th Issue Nutrition Facts Serving Size 1 Day Amount Per Serving Calories 2000

As Served Calories from Fat 0 % Daily Value

Trans Fat 0g Saturated Fat 20g Cholesterol 30 00mg Sodium 2400mg Total Carbohydrate 300g Dietary Fiber 25g Sugars male-37g female-25g Protein 40g Vitamin A 0 % Calcium 0%

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0% 100% 100% 100% 100% 100%

Vitamin C 0% Iron 0%

Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs: Female Male Total Fat Sat Fat Cholesterol Sodium Total Carbohydrate Dietary Fiber

Calories

2,000

2,500

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65g 20g 300mg 2,400mg 300g 25g

70g 25g 300mg 2,400mg 375g 30g

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Stephanie Misono, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Emily Larsen MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

May/June Index to Advertisers TCMS Officers

President: Carolyn A. McClain, M.D. President-elect: Matthew A. Hunt, M.D. Secretary: Thomas E. Kottke, M.D. Treasurer: Nicholas J. Meyer, M.D. Past President: Kenneth N. Kephart, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799; sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Karen Peterson, BSN Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Annie Krapek, Assistant Project Coordinator Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com Emily Larsen, Marketing & Communications Coord.

(612) 623-2885; elarsen@metrodoctors.com Helen Nelson, Administrative Assistant, Honoring Choices Minnesota (612) 362-3705; hnelson@metrodoctors.com Ellie Parker, Project Coordinator Physician Advocacy Network (612) 362-3706; eparker@metrodoctors.com

Allina Health System........................................30 Audiology Concepts .........................................14 Coldwell Banker Burnet..................................16 Crutchfield Dermatology.....................................

Inside Front Cover Entira Family Clinics .......................................31 Fairview Health Services .................................29 Genevive...............................................................29 Healthcare Billing Resources, Inc. ................. 2 HealthPartners Medical Group .....................31 Kathy Madore....................................................... 4 Lakeview Clinic .................................................30 M Health ................................................. 12 & 13 Medifast Weight Control Centers .................. 1 Melrose Center ..................................................... 9 MMIC ................................ Outside Back Cover PrairieCare PAL .................................................22 Red Pine Realty..................................................20 Saint Therese.......................................................24 Senior LinkAge Line.........................................14 St. Cloud VA Medical Center ............................

Inside Back Cover St. David’s Center .............................................26 Uptown Dermatology & SkinSpa................24

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.

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May/June 2016

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The Journal of the Twin Cities Medical Society

CONTENTS V O L U M E 1 8 , N O . 3 M AY / J U N E 2 0 1 6

5

IN THIS ISSUE

Nutrition Bits

By Robert R. Neal, Jr., M.D.

6

PRESIDENT’S MESSAGE

Carrots Aren’t Just for Rabbits

By Carolyn A. McClain, M.D.

7

TCMS IN ACTION

By Sue Schettle, CEO

Page 27

THE NUTRITION ISSUE

8

V

Gut Health as the Foundation for All Health

By Gregory A. Plotnikoff, M.D., MTS, FACP

11

V

SPONSORED CONTENT:

Behavior-Change Strategies Key to Achieving Healthful Diet and Activity Lifestyle

By Michelle Draxten, MPH

15

V

Colleague Interview: A Conversation with Joshua O. Zimmerman, M.D.

19

V

Vitamins: Yay or Nay?

By Courtney Jordan Baechler, M.D., Carolyn Denton, RD, and Debra G. Bell, M.D.

21

V

Pediatric Nutritional Pitfalls and Practical Solutions: 5-2-1-0 and Beyond

By M. Jennifer Abuzzahab, M.D.

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V

The MATTERbox: An Innovative Approach to Hunger Relief

By Gates Lindquist

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V

The Sheridan Story—Fighting Child Hunger and its Affects on Children in Our Community

By Rob Williams

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V

From Bratwust to Broccoli New Ulm Project Transforms Nutrition Culture

By Rebecca Lindberg, MPH, RD, and Thomas Knickelbine, M.D., FACC, FSCAI, FSCCT

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In Memoriam

Page 32

Career Opportunities Page 23

32

LUMINARY OF TWIN CITIES MEDICINE

David Abelson, M.D.

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The Journal of the Twin Cities Medical Society

Achieving and maintaining good health are dependent on good nutrition. Authors describe key strategies for balancing food and lifestyles for success. Articles begin on page 8.

May/June 2016

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IN THIS ISSUE...

Nutrition Bits THIS ISSUE OF METRODOCTORS IS A TIMELY followup to our last issue on obesity as they are closely related. Our nutritional habits were formed initially by our parents and other relatives. The advice we got, “drink your milk,” “eat your vegetables,” “snack on an apple,” is still pertinent today but too often neglected. It seems to me that we had more outdoor play and exercise time. Despite advancements in the nutrition sphere like frozen food, allergy knowledge, better distribution and variety of fresh food, and food safety, the nutrition of our population has deteriorated significantly. This decline is significantly due to societal factors that put pressure on the time available for food shopping and preparation. Enter the fast food restaurants and the processed food industry. Now we are largely exposed to excessive serving sizes and food that is high in fat, sugar, salt, and additives.

Research has shown that when we have a choice of what to eat, we lean toward foods higher in fat and sugar because they please the reward center in our brains. So we are confronted, as physicians, with a population that is 70% overweight and 35% obese. Fortunately, research is helping us to understand the underlying causes of poor nutrition and their relation to disease.

A very insightful article by Greg Plotnikoff, M.D. discusses the microbiome, an exciting “new” area for research to explore.

He outlines the newly discovered links between the microbiome and various organ systems from depression to IBS. He states that the health of our gut bacteria may be our most important health factor.

We form eating habits, exercise patterns and fat cells early in life. We have two articles that directly address pediatric nutrition.

First, Dr. Jennifer Abuzzahab gives us some practical ideas on how to manage pediatric nutrition from the viewpoint of a specialist and a mother. Second we have the Sheridan Story, a local hunger project that provides bags of quality food to needy kids on Fridays to support their weekend nutrition when they are without school food programs.

The MATTERbox article depicts another local program that provides a box of nutritional food to needy people but also includes nutrition basics, recipes and helpful lifestyle hints. These boxes are handed to patients by practitioners at local clinics where verbal exchange can take place about them.

By Robert R. Neal, Jr., M.D. Member, MetroDoctors Editorial Board

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Drs. Courtney Jordan Baechler, Debra G. Bell, and Carolyn Denton, RD from the Penny George Institute for Health and Healing have provided an article discussing vitamins and other supplements and how they relate to nutrition.

Michelle Draxten, MPH from M Health discusses the components of a healthy lifestyle, diet and exercise, and specific behavior modifications to increase the likelihood of achieving them. She also provides several mobile apps for patients to try.

A success story on a large scale is that of The Heart of New Ulm Project, launched in 2009 by the Mpls. Heart Institute, Allina and the New Ulm Medical Center. The initiative is a 10 year public health project to reduce cardiac events and CVD. The program shows what can be done by rallying a community.

Our colleague interview is with Josh Zimmerman, M.D., Medical Director of the Melrose Institute for eating disorders. He provides valuable insight into eating disorder detection, ‘diets,’ and weight loss. He notes that 80% of their care is out-patient and includes family based therapy, cognitive behavioral therapy and sub specialized care for chemical dependency and type 1 diabetic patients.

As usual Marv Segal has a great luminary article that features David Abelson, M.D. It seems like the more we discover in medicine to help conquer disease, the more complex the picture becomes. We discovered the immune system, antibiotics, the genetic code, epigenetics and now the microbiome. We have a lot to learn. Until we have specific biotic regimens with detailed research to support them, we will need to rely on what seems well proven: stress management and mental health support, adequate exercise, a good basic diet that follows the RDA guidelines for fat, sugar, protein, salt, and calories, and contains recommended amounts of fruits and vegetables. On the horizon are proposals to use the microbiome for crime detection and the possibility to take advantage of the unregulated microbiome to market unproven treatments.

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President’s Message

Carrots Aren’t Just for Rabbits CAROLYN A. McCLAIN, M.D.

A

few years ago, one of my friends on the TCMS Board, Dr. Tom Kottke, told me about an article he wrote in the American Journal of Preventative Medicine.

He had conducted research on the effects of lifestyle changes versus medical treatments for cardiac patients. Turns out his study showed if everyone would walk 150 minutes per week, and eat two servings of fruits and three servings of vegetables every day, we would have nearly four times the impact on total mortality than we saw in patients being treated medically. As an Emergency Physician, this was a little discouraging. After all, I am measured by all sorts of quality metrics like use of Aspirin for chest pain, Metropolol for acute coronary syndromes, and Lasix for CHF. And now Dr. Kottke tells me that all of this hard work makes significantly less difference to the patient’s long-term outcome than a bell pepper and a carrot. Seriously?

Speaking of diets...I recently read a case report about hand pain related to the paleo diet.

Paleo-induced mineral periostitis is a recently recognized disease that involves the metacarpals and phalanges which produce periostial projections or spines, creating a cactus-like appearance. In severe cases, these spines actually tent the skin. Apparently going back to our paleolithic roots has some serious complications. The impact of diet on good health has been the subject of substantial medical research but it seems that the most pertinent information from these studies appears to be filtering through to the general public in the form of infomercial ads for diet programs, vitamin regimens and home exercise equipment. Most of the public googles their information and as physicians we have an opportunity to help guide the discussion. But are we ready to do this?

In medical school, I had a one week nutrition course. It was 40 hours and it focused heavily on the transgenic OB/OB mouse, leptin, vagal stimulators and metabolism. We did have an interesting homework project — we were asked to calculate, using our current weight, how long we could live without eating — I could go three months (I should remember that as I open my snack cabinet).

I also learned that the LD50 for ingesting giant pickles is about 20. So yes, I did learn something but I don’t think that knowledge has saved any lives. Turns out, at 40 hours, I had twice as much exposure to nutritional education as most medical schools. A 2011 survey of U.S. medical schools found that on average medical school curriculums include only 20 hours of class time on nutrition.

Given the impact of nutrition on health this seems like an area of training that needs significantly more focus.

With chronic illnesses like diabetes and heart disease being profoundly affected by diet and accounting for a large portion of the nation’s health care expenditure, it is critical that as physicians we start widely disseminating information on nutrition, regardless of specialty. As research advances in the gut microbiota, we are also learning the importance of diet in the health of our bacterial partners and their impact on human disease. In the future, quality metrics may include conversations regarding specific dietary changes depending on the individual patient’s health profile. Focusing on the effect of diet on a patient’s health would be a much more affordable way to provide health care. In short, bell peppers and carrots are medicine. In fact, they are more powerful than many of the medications we use today and, as physicians, we should prescribe them.

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May/June 2016

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

Physician Advocacy Network Work Expands

Thanks to the support of a grant received from the Association for Non Smokers Rights, TCMS will strengthen its “Physician Advocacy Network” this spring to offer education to Health Science students at the University of Minnesota on the impact of flavored and menthol tobacco on minority populations. Curriculums in some Colleges under the umbrella of Health Science address tobacco but do not include the depth or breadth of specific products nor tactics the tobacco companies use to addict youth and minority populations.

Beyond education, this project will sponsor workshops to develop student’s advocacy skills to equip them for involvement in future ordinance adoption.

The Physician Advocacy Network model will also be on display at the July 2016 American Association of Medical Society Executives annual conference in Baltimore. Many county medical societies from across the country are looking for innovative physician leadership programs. We were pleased to be accepted at the AAMSE annual conference to highlight our model and demostrate ways that it can be adapted to support local public health programs. TCMS has used this model of engaging, educating and empowering physicians for over a decade.

TCMS Supports St. Paul Paid Sick Leave Policy

The St. Paul City Council’s Earned Sick and Safe Time Task Force is debating the specifics of requiring employers to

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offer earned sick and safe time benefits to their employees. TCMS member Stefan Pomrenke, M.D. serves on this task force and presented the opportunity for TCMS to lend its voice to the discussion. After thorough discussion at a recent Board of Directors meeting, TCMS supported the findings noted in the MN Department of Health’s White Paper on Paid Leave and Health (March 2015) and is now on record encouraging all employers to provide paid sick leave to enhance the health of the public.

Legislative and Policy Committee to Change Focus and Title

The TCMS Board of Directors recently made a slight, but noteworthy, change to the charge and name of its Legislative and Policy Committee. The new name, “Public Policy Committee,” and the new charge will require the committee to focus on city and county and much less on statewide issues. The Board overwhelmingly supported the notion that TCMS physicians could become more actively involved in city and county issues that are not being addressed by the MMA, for example, or other specialty societies.

Work Group Forming to Address Environmental Health Issues

A new work group is taking shape in 2016 that will be charged with drafting a position or policy statement that will be presented to the Board of Directors for consideration. The position statement will include information highlighting the health consequences of

The Journal of the Twin Cities Medical Society

environmental issues (pollution, etc.).

The next phase of the work will include an assessment of efforts, initiatives or causes that are happening within the seven-county metro area that are related to environmental health and that might require a physician’s perspective. If you are interested in joining the workgroup please email TCMS@metrodoctors.com.

7th Annual Advance Care Planning Conference

Honoring Choices is preparing for its annual Sharing the Experience Conference on Thursday July 21 in Minneapolis. This event grows each year, and the 2016 gathering is expected to be the largest ever. Plan to join colleagues and friends for a day of learning about what is happening with advance care planning (ACP) in our state. Highlights of the day will include keynote speaker Rahul Koranne, M.D., Chief Medical Officer, Minnesota Hospital Association, sharing his experiences with ACP throughout the state, medical students giving updates on how learning about ACP is impacting their educational journeys, information on legal considerations, the soon-to-be-released updated POLST form, state and federal regulations, CMS reimbursement codes and much, much more.

Ken Kephart, M.D., Medical Director of Honoring Choices will chair the event at the Minneapolis Ramada Plaza Conference Center. Save the date now and watch for upcoming information on registration.

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The Nutrition Issue

Gut Health as the Foundation for All Health

F

rancis S. Collins, M.D., Ph.D., Director of the NIH, may be best known for his leadership of the Human Genome Project. However, five years ago at the Society for Integrative Oncology meeting, he stated that as excited as he is by the world of genetics, he is even more excited by the promise of the Human Microbiome Project. I was intrigued and then hooked.

Dr. Collins gave at least three reasons for his excitement. First, the total number of human cells in our body are just 1/10th that of the total microbial cells. We are definitely outnumbered. Who is really in charge? Second, the total number of genes associated with the human microbiome may exceed our 23,000 human genes by 100-500x or more. Our microbes appear to have much greater capacities to respond to ecologic challenges and opportunities.

And, third, using new genetic probes rather than traditional culture methods, scientists have described by location on or in the body the microorganisms that are found in association with human health and disease. Causality is now being tested in many corners of the world.

Scientists have since made strong links between the intestinal microbiome and numerous intestinal and extra-intestinal disease states. The range of links include mental health and neurologic issues such as depression, anxiety, and autism to asthma, obesity, both type I and type II diabetes, both alcoholic and non-alcoholic fatty liver disease, atherosclerosis, kidney stones and

By Gregory A. Plotnikoff, M.D., MTS, FACP

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May/June 2016

multiple cancers, among others. Indeed, our bacteria may be our greatest risk factor.

Or our bacteria may be our greatest health factor. As stated in the February 26, 2016 issue of Nature, the microbiome may yield a new class of bacteria, termed psychobiotics, for the treatment of anxiety, depression and other mood disorders. The future will also likely see greater use of fecal microbial transplantation (FMT).

The FDA has already approved a clinical trial of FMT for autism at the University of Arizona.

Most importantly for now, however, we already have the power to rebalance the microbiota through diet, exercise, mind-body self-care skills, as well as the judicious use of antibiotics, probiotics and prebiotics.

A key message for the public is that “gut health may be the foundation for all health.” The mechanism behind the strong links noted above is that gut microbiota are

biologically very active. Their metabolic products influence the bidirectional communication between the enteric nervous system and the central nervous system.

This is relevant for central nervous system and other extra-intestinal functions as well as key intestinal functions including motility, sensitivity, secretion and immunity.

Furthermore, each of the five forms of stress can adversely affect gut ecology and gut wall permeability. Lipopolysaccharide (LPS) translocation follows resulting in local and systemic inflammatory processes.

This combination of functions means that patients with gastrointestinal symptoms, that cannot be explained by traditional studies of structure and anatomy, can find great relief through a combination of ecological rebalancing and neurohormonal retraining.

Ecological rebalancing includes both the inner ecology of the intestines as well as one’s external ecology. Not surprisingly, the five forms of stress we humans can experience, (environmental, physical, emotional, pharmaceutical and dietary), can all adversely affect gut ecology and function. Addressing the external issues can affect the internal issues. Neurohormonal retraining reverses the Pavlovian-like conditioned stress hormone responses and anxiety in response to intestinal sensations.

Both approaches encourage patient awareness and engagement in a time-effective manner.

These two types of interventions are well described in the book, Trust Your Gut: Get Lasting Healing from IBS and Other Chronic Digestive Problems without Drugs,

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(Continued on page 10)

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MELROSE

HEALS

EATING DISORDERS Do you know how to help your patient take the ďŹ rst steps to recovery?

Call our dedicated provider referral line with your questions or for urgent appointments.

952-993-5864 | Monday – Friday, 8:30 a.m. to 5 p.m.

Your patient can have an initial assessment appointment immediately.

Visit melroseheals.com/refer for tools and resources, including our How to Talk to Your Patient About Eating Disorders guide.

The Nutrition Issue Gut Health (Continued from page 8)

that I co-authored with local health psychologist Mark Weisberg, Ph.D. Many physicians report that they use this book with their IBS patients in order to save time and emotional energy while strengthening their relationship with their patient and empowering their patient to act on their own behalf. The book incorporates many self-assessment tools including the five forms of stress, including dietary stress. Assessing and managing dietary stressors, including food intolerance, is a new area of competence for physicians.

Yes, there are eating disorders that must always be considered. And, yes, there are nutritional risks associated with certain diets that require a mindful vigilance to avoid. The expanded differential diagnosis for food intolerance includes IgE reactivity, IgE-related food cross-reactivity, IgG–mediated food reactivity, gluten reactivity or sensitivity, FODMAPS intolerance, nickel reactivity, histamine intolerance and salicylate intolerance, among others. Assessment tools include monitored elimination diets as well as stool testing for eosinophil protein X, calprotectin and/or secretory IgA. Serum testing can include total IgA and total IgE, as well as IgE and IgG panels.

For counseling patients, the following may be helpful: Your gut is much more of a garden than a gutter. Your mission is to be a good gardener. And this requires good soil, good seeds and good support.

The good soil includes attention to the five forms of stress. The good seeds include the use of appropriate probiotics. And the good support includes a diet rich in prebiotics, foods that support the growth and flourishing of beneficial bacteria. And, when appropriate by symptoms, good support can include the use of digestive enzymes with meals.

In general, the best probiotics should include a mix of lactobacilli and bifidobacterial species plus the beneficial yeast Saccharamyces boulardii. Usual dosing guidelines are 20 billion colony –forming units (CFU), taken with cool, unchlorinated water, away from warm food or drinks by 30 minutes. Many good 10

May/June 2016

Microbial Interaction with Hosts V V

We have co-evolved and share a symbiotic relationship.

Microbial signaling affects host metabolic, neurological, inflammatory, immunologic and host-defense functions.

V The nature of host responses also shapes microbiome populations and metabolism.

Muegge et al., 2011; Vijay-Kumar et al., 2010.

products do not require refrigeration and can be kept next to one’s toothbrush for taking at bedtime.

Saccharamyces boulardii has been shown in multiple randomized controlled trials to prevent antibiotic-associated diarrhea. This is the product to use with concurrent antibiotics. Note that some lactobacilli species produce histamine which can be troublesome for persons with histamine intolerance issues.

Multiple foods are good prebiotics.

These include fermented foods, such as sauerkraut, kimchi or kefir, cultured foods such as yogurt, cottage cheese or lassi, several cruciferous vegetables, onion, leeks and garlic, dandelion greens, asparagus and bananas. Supplements that are prebiotics include inulin, fructooligosaccharides (FOS), and arabinogalactan. These can adversely affect people with FODMAP sensitivities. And, multiple foods are good support for other reasons related to the metabolic functions of the intestinal bacteria. These are described in my review article on enteric biotransformations available for free on www.pubmed.gov at https://www. ncbi.nlm.nih.gov/pubmed/24891992.

The medical literature is rich now with resources. Below are some selected recent articles that are downloadable for free via pubmed.

In the future, as we learn more about the microbiome’s power over us, we should keep in mind our power over our microbiome. As noted in 1908 by Nobel Prize winning scientist Elie Metchnikoff, “The dependence of the intestinal microbes on our food intake

makes it possible to adapt measures to modify the flora in our bodies and to replace harmful microbes by useful microbes.”

These adaptable measures appear to be exactly what contemporary author Michael Pollan has promulgated: “Eat real food, mostly plants, not too much.” Bon appetit!

References: Distrutti E, et al. Gut microbiota role in irritable bowel syndrome: New therapeutic strategies. World J Gastronenterol. 2016; 21(27): 2219-41.

Luczynski P, et al. Growing up in a bubble: Using germ-free animals to assess the influence of the gut microbiota on brain and behavior. Int J Neuropsychopharmacol. 2016; pii: pyw020.

Lau CS, Chamberlain RS. Probiotics are effective at preventing Clostridium difficile-associated diarrhea: a systemic review and meta-analysis. Int J Gen Med. 2016; Feb 22;9:27-37.

Agnacio A, et al. Innate sensing of the gut microbiota: Modulation of inflammatory and autoimmune diseases. Front Immunol. 2016; 7:54.

Salvidge TC. Epigenetic regulation of enteric neurotransmission by gut bacteria. Front Cell Neurosci.

2016; 9:503.

Moraaes-Fiho JP, Quigley EM. The intestinal microbiota and the role of probiotics in irritable bowel syndrome: a review. Arq Gastroenterol. 2015 Dec; 52(4):331-8.

Kelly JR, et al. Breaking down the barriers: the gut microbiome, intestinal permeability and stressrelated psychiatric disorders. Front Cell Neurosci.

2015; 9:392.

Gregory A. Plotnikoff, M.D., MTS, FACP, is a consultative internist and resource for colleagues with patients challenged by mystery, complexity and severity. He practices at Minnesota Personalized Medicine (Minneapolis) and Minnesota Natural Medicine (St. Paul) and can be reached at (612) 354-2768; gregory.plotnikoff@gmail.com.

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Sponsored Content

Behavior-Change Strategies Key to Achieving Healthful Diet and Activity Lifestyle Contributed by Michelle Draxten, MPH A well-balanced diet and regular physical activity promotes overall health, reduces the risk of chronic disease and aids in reaching and maintaining a healthy body weight. Many of our patients understand this but struggle to meet these health goals.

To achieve a healthy diet and exercise routine, focus should turn to modifying habits into new behaviors so that they can become part of one’s lifestyle. Healthcare providers can help in this process. Although the thought of change may feel daunting for some of our patients, it’s never too late to start, and health goals may be easier to reach than many clients originally thought.

In our weight management clinic, each counseling session is unique and individualized to the patient. However, two topics consistently come up: (1) the components of a healthy lifestyle and (2) thoughtful strategies on how to incorporate healthful behaviors so that they become part of one’s lifestyle.

Components of a Healthy Lifestyle

All foods can fit into a healthy nutrition plan, but how often certain foods are eaten (frequency) and the amount of specific foods eaten (portion sizes) should be considered. Additionally, variety is important.

A healthy, well-balanced diet includes a variety of fruits and vegetables, whole grains, lean protein, low-fat/fat-free dairy, healthy fats and adequate amounts of water.1 Sodium, added sugars, and saturated fats should be limited.

Physical activity is the other half of the healthy lifestyle equation. Regular physical activity makes individuals feel better physically, mentally, and emotionally. With increased physical activity, individuals

will want to eat healthful and nourishing foods. Patients should aim for 2.5 hours of moderate-intensity aerobic activity (i.e., brisk walking) every week and at least 2 days every week of muscle-strengthening activities.2 Examples of muscle-strengthening activities include weight lifting, yoga, push-ups, sit-ups, planks, squats, and lunges.

While these guidelines seem straightforward, they are not often understood or followed. Current dietary patterns for the majority of the population do not meet recommended servings of fruit, vegetables and dairy, and exceed recommended amounts of sodium, added sugars, and saturated fats.3 Educating individuals on healthful foods and physical activity guidelines is important. More important, working with individuals to identify strategies to shift health behaviors in a way that is conducive to their lifestyle may be the most promising approach in helping patients achieve sustainable, healthful behaviors.

Making Healthful Behaviors a Lifestyle

Several strategies exist around behavior change. Sustainable behavior change is slow and gradual and looks different for everyone. Self-efficacy, the belief in one’s ability to execute and achieve an outcome, is a key component.4 However, the strategies below focus on changing habits and environments to achieve healthy behaviors.

Setting goals also make behavior change feasible. Consider having individuals set SMART goals: those that are Specific, Measurable, Achievable, Relevant, and Time-bound. This strategy can be applied to many behavior change tactics.

Nutrition

Plan ahead. Planning ahead helps with making healthful choices and could mean planning tomorrow’s lunch or planning meals for the upcoming week. Planning ahead helps many eat healthier overall, save time and money, have a variety of meals, stress less, and eliminate having to rely on eating out and eating highly processed foods. A few planning strategies to share with patients include: prepare a food that can be used in two different recipes (e.g., grilled chicken for fajitas one night and adding to a mixed green salad another night); designate a grocery shopping day, make a grocery list and stick to the list; prep and chop fruits and vegetables immediately after returning from the grocery store; and get family members involved (Continued on page 12)

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May/June 2016

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Behavior-Change Strategies (Continued from page 11)

with menu planning, grocery shopping, and food prepping.

Make healthful foods available and accessible. Research has shown that individuals are more likely to eat foods that are available and accessible.5 Having ready-to-eat healthy foods can increase the likelihood they are eaten. Preparing vegetables after getting home from grocery shopping or designating a food prep day saves time later and ensures there will be a serving (or more) of vegetables at the next meal. Storing chopped vegetables in a salad spinner in the fridge not only makes them accessible but keeps them fresh and crisp.

Rearranging cupboards, counter space, and refrigerators to make healthy foods more visible can make the consumption of healthful foods easier. The same principle holds true for less-healthful foods: removing chips and cookies from visible counter space and shelves can help patients resist any urges.

Encourage patients to try new foods.

Our tastes change over time, and a food we did not like years ago might become a new favorite. Some foods take on different flavors depending on the preparation method. Cauliflower eaten raw, for example, will taste very different from cauliflower that is steamed or roasted.

Encourage patients to try a new fruit or vegetable every season. Produce that is inseason will have better flavor and cost less.

Be mindful of portion sizes, hunger and satiety cues. As a society, our portion sizes have steadily become larger, and individuals often have difficulty identifying appropriate serving sizes. Research has shown that serving on larger dishes results in greater portions and increased caloric intake.6,7 Eating meals on smaller plates, such as salad plates, can reduce overall portion sizes and calories. Eating past the point of satiety and in the absence of hunger has also become more common. To allow time to assess satiety, recommend that patients slow down when eating by using their non-dominant hand to feed

themselves. Or to create a visual guide to control portions, have them use measuring cups to measure appropriate serving sizes.

It is also important to educate patients in recognizing hunger cues and eating with intention of nourishment and enjoyment.

Diverting attention to a non-food activity (e.g., taking a walk) can be a strategy to recommend if patients experience urges to eat in the absence of hunger.

Have a source of accountability. Individuals tend to be more successful if they have a support system and/or a source of accountability. Consider having patients work with someone who has similar goals and is working on achieving them. Or suggest that they work with a registered dietitian who has experience in goal-setting and behavior change. Tracking behaviors (e.g., logging food intake) is also a beneficial accountability strategy, and there are several, free apps that individuals can utilize. Popular and user-friendly apps include MyFitnessPal, LoseIt and SparkPeople. These apps are also great for tracking physical activity levels.

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Physical Activity

Make time for physical activity. Have patients designate certain days of the week and/or times of day to exercise and pack a gym bag that stays in the vehicle so they can exercise after work without having to go home first. Recommend patients set a reminder on their phones to get up and move every hour. Spreading out activity through the day (three 10-minute exercises) can be just as beneficial as exercising one time per day (one 30-minute exercise).

Recommend creative or non-traditional ways to increase activity. Some individuals may be more inclined to be active if they have enjoyable activities that do not necessarily feel like exercise. Walking poles engage a large group of upper-body muscles and can add intensity to a walking workout. Sit-stand workstations have been shown to reduce fatigue, sedentary time at work and appetite, as well as increase energy and sense of well-being.8 Gardening, playing with kids, dancing, having “walking” meetings, biking to work and taking the stairs are just a few creative activities for recommendation.

Rally a support system. Have patients work with someone who will hold them accountable or track their physical activity levels. A step counter is an easy, inexpensive way to set minimum daily step goals. Recommend patients register for an upcoming walk/run event to give them something to work towards.

Pathways to behavior and lifestyle changes are unique and different for everyone. Setting goals, starting with small behavior changes and focusing on the best combinations of strategies for each patient will lead to success.

References 1.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http:// health.gov/dietaryguidelines/2015/guidelines/.

2.

Centers for Disease Control and Prevention.

Division of Nutrition, Physical Activity, and Obesity: How much physical activity do adults need? Accessed January 18, 2016. http://www. cdc.gov/physicalactivity/basics/adults.

3.

What We Eat in America, NHANES 2007-2010 for average intakes by age-sex group. Healthy U.S.-Style Food Patterns, which vary based on age, sex, and activity level, for recommended intakes and limits.

4.

5.

6.

7.

8.

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215.

Nicklas TA, Jahns L, Bogle ML, et al. Barriers and facilitators for consumer adherence to the dietary guidelines for Americans: the HEALTH study. Journal of the Academy of Nutrition and Dietetics. 2013;113(10):1317-1331.

Wansink B, van Ittersum K, Painter JE. Ice cream illusions bowls, spoons, and self-served portion sizes. American journal of preventive medicine. 2006;31(3):240-243.

Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. The American journal of clinical nutrition. 2002;76(6):12071213.

Dutta N, Koepp GA, Stovitz SD, Levine JA, Pereira MA. Using sit-stand workstations to decrease sedentary time in office workers: a randomized crossover trial. International Journal of Environmental Research and Public Health. 2014; 11(7):6653-6665.

Michelle Draxten, MPH, is the registered dietitian at the Lifestyle Medicine Program for Weight Management clinic, as well as a research associate at the University of Minnesota, Department of Family Medicine and Community Health, coordinating a study to identify how familial factors act as risk or protective factors for predicting childhood obesity.

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Colleague Interview: A Conversation with Joshua O. Zimmerman, M.D.

J

oshua O. Zimmerman, M.D. is the Chief of Behavioral Health, Park Nicollet Health System, responsible for all mental health care delivered in the Park Nicollet Health Systems. He also provides treatment to patients in residential, outpatient and partial hospitalization through the Melrose Center. Dr. Zimmerman received his medical degree from Case Western Reserve University; completed a Medical/Psychiatric Internship at Carney Hospital, Beth Israel Deaconess Medical Center, Children’s Hospital and residency at Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center, where he also served as a Chief Resident. In addition, Dr. Zimmerman completed an Adams House Fellowship in Advanced Psychotherapy.

Tell us about the Melrose Center for Eating Disorders.

What is the scope of services offered — inpatient and outpatient?

Melrose Center is a large multispecialty treatment program for eating disorders. We take a team approach to treating all aspects of eating disorders: medical, psychological, nutrition, social, etc. The team includes primary care physicians, psychiatrists, psychologists, registered dietitians, physical therapists and occupational therapists.

About 80% of our patients are managed exclusively in outpatient programs. However, we do offer a range of services including: V Standard outpatient appointments.

V Intensive outpatient programming and a partial hospital program.

V Intensive short-term inpatient treatment.

V Long-term residential treatment.

Melrose Center is one of the only facilities in the world that offers sub-specialized care for patients who have type I diabetes and an eating disorder or chemical dependency and an eating disorder.

Our psychotherapeutic focus for the pediatric population is family-based therapy (FBT), a strong evidence-based treatment for eating disorders. In adults, we prioritize cognitive behavioral therapy for eating disorders (CBT-E) but use other therapy modalities as indicated to treat comorbidities.

Only 20% of our patients require a higher level of care. We MetroDoctors

The Journal of the Twin Cities Medical Society

offer two levels of residential treatment, one for individuals who are medically unstable and need intensive short-term treatment and another for individuals who need long-term residential treatment. Our units are unlocked and integrated into a beautiful and welcoming setting. Although we can provide tube feeding and intravenous fluids, we prioritize behavioral therapy and oral feeding, and very few of our patients require those interventions.

We offer three day a week intensive outpatient programming and a daily partial hospital program for individuals who are medically stable but still need intensive treatment.

We are strong partners with the International Diabetes Center at Park Nicollet.

We provide Suboxone services for individuals who require residential eating disorder treatment and also need opiate detoxification. We ensure appropriate aftercare by working closely with local halfway houses and residential substance abuse centers.

What determines whether a patient should be treated as an inpatient or outpatient?

Residential treatment is indicated when a patient is medically unstable. We usually define this as a BMI below 17, syncope, severe orthostasis, hypokalemia, starvation hepatitis, or rapid weight loss.

We often aggressively treat younger patients who are early

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The Nutrition Issue Colleague Interview (Continued from page 15)

in their illness with residential care because it can significantly reduce the chance of remission.

The majority of our patients can be stabilized with outpatient care from our psychotherapists, primary care physicians, and registered dieticians, and do not become medically unstable.

Family Based Therapy (FBT) particularly emphasizes keeping the family unit as intact as possible and using the family unit to refeed the ill child in their home setting.

Does health insurance typically cover treatment for eating disorders?

Eating disorders have the highest fatality rate of any mental illness. Residential treatment is sometimes necessary, but like many intensive treatments, it is quite expensive. Medicare does not cover residential eating disorder treatment, and as a result patients who are very ill with their eating disorder and have Medicare may need to seek services in a general medical hospital setting. Medicare does cover outpatient care with the exception of registered dietician visits, though they do cover registered dietician visits for individuals with diabetes or significant kidney disease. Outpatient coverage with Medicaid through the exchange system is generally quite good.

Over the last few years, with our focus on using various levels of evidence-based outpatient treatment for patients, our average

residential length of stay has dropped about 50%. As a result, Melrose Center tends to have very good relationship with major local health insurers and we prioritize collaborating around coverage for our inpatient services. Private insurance almost always covers outpatient care with a primary care physician, psychotherapist, psychiatrist, and registered dietician.

What is the screening process to get someone into the program? Is there a checklist that primary care providers can use to determine if a patient might benefit from a referral to Melrose Center?

Early detection and treatment of eating disorders improve the prognosis. Because eating disorders often present as physical symptoms in primary care, it is important to support primary care physicians in making the correct diagnosis. One simple tool that is available is the SCOFF questionnaire which can help determine whether a more rigorous clinical assessment is needed. This five question survey is evidence-based and is publicly available online.

The SCOFF questions are: V Do you make yourself Sick because you feel uncomfortably full?

V Do you worry that you have lost Control over how much you eat?

V Have you recently lost more than One stone (14 lb.) in a 3-month period?

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V

Do you believe yourself to be Fat when others say you are too thin?

V Would you say that Food dominates your life?

A referring physician can call our provider hotline at (952) 993-5864. The hotline is supported by care managers who can answer questions, help navigate immediate hand-overs of patients as well as schedule patients. Depending on the physician’s preference, we can reach out to the patient or the patient can contact us. We can also consult with a physician regarding the best way to help patients get care.

At their first appointment, a patient visits with a primary care physician and a psychologist for a full assessment. We then recommend services that are clinically indicated and send a summary to the referring clinician.

Are there similarities between conditions characterized by over-consumption of food (obesity), underconsumption of food (anorexia) and bulimia — and can these similarities be addressed as treatment programs are utilized?

Obesity is not an eating disorder. Obesity is a complex sociocultural condition caused by many factors. The way we eat, live, and work as a society influences our body weights.

Binge eating disorder (BED) very commonly occurs with obesity. But it is not the same as just overeating. Individuals with binge eating disorder are unable to stop themselves from eating large amounts of food very rapidly, to the point where they feel physically uncomfortable and are wracked with guilt and shame.

BED became a formal psychiatric diagnosis in 2013 and today more than one in four new patients at Melrose have Binge Eating Disorder (BED).

Individuals with bulimia engage in similar binge eating activity but compensate by purging. This can be by vomiting, excessive exercise, laxative abuse, diuretic abuse, or any other method that results in sudden and rapid calorie loss. Individuals with bulimia are most often normal weight but can struggle with being overweight as well.

Focusing on weight loss is contraindicated when first treating a patient with an eating disorder. It sets up unreasonable expectations and weight loss may not be a reasonable goal given the degree of metabolic derangement someone may be experiencing from repeated binges and starvation diets.

The first steps are to: V Focus on building healthy coping skills.

V Gain perspective on their behavior and develop an internal language to argue against the logic of their eating disordered mind.

V Identify specific eating disordered behaviors to target and reduce.

V Assess willingness to change.

V Outline the pros and cons of reducing eating disordered behaviors.

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V V

Assess for psychiatric comorbidities and treat them aggressively.

Provide regular medical assessment looking for any signs of medical instability.

V Begin to put plans into action.

If someone’s eating disorder is in relative remission for 6-12 months, a shift to focusing on weight loss can be considered.

However, this is risky and controversial because this approach could trigger a resumption of eating disorder behaviors.

How does nutrition relate to mental illness?

I am often asked whether or not poor nutrition can be a cause of mental illness. I am not aware of any study that shows a causative link between diets high in calories, sugar, or saturated fats and mental health problems.

There is no evidence that sugar consumption in children leads to attention deficit hyperactivity disorder. Some parents say that it appears that their children become hyperactive after eating sugar and in fact it can result in short-term hyperactivity and euphoria due to a spike in dopamine levels.

Many of the medications used to treat mental illnesses such as bipolar disorder and schizophrenia are associated with slowed metabolism, increased appetite, glucose intolerance, and high cholesterol. Individuals with these mental health conditions are also more likely to have lower-incomes, live a sedentary lifestyle, and have diets high in calories. As a result, heart attack is the #1 cause of death in individuals with serious and persistent mental illness. Their life spans are markedly shortened as a result of early onset cardiovascular disease.

A very small subset of patients are “primed” to experience an eating disorder as a result of food deprivation or starvation in childhood, although these circumstances in the U.S. are relatively rare.

Please discuss the good and bad psychological approaches to good nutrition and weight control.

There are no inherently good or bad foods. The key to balanced nutrition is for people to learn at an early age to listen to what their body needs in terms of calories, to be attuned to their natural sense of satiety, and to do their best to prioritize a regular moderate degree of aerobic activity throughout the week. The earlier these skills can be developed in family units, the better.

Dieting can be very damaging to women. There is a clear association between repeated dieting and developing eating disorders. Most diets involve a combination of fairly severe calorie restriction combined with increased exercise. Restricting calories can slow metabolism. Over time this can lead to a starvation state, trigger spikes of ravenous hunger, and resultant binge eating.

Excessive focus on numbers should be avoided, and instead attention should be given to healthy lifestyle, establishing a regular (Continued on page 18)

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The Nutrition Issue Colleague Interview (Continued from page 17)

routine of exercise, setting manageable meal goals, and building positive self-esteem.

Please summarize the current research areas that may contribute to our understanding of nutrition and health.

Eating disorder research is in its infancy compared to other areas of medicine. We know that individuals with anorexia, bulimia, and binge eating disorder have different brain chemistry than people without these conditions. We also know that there are both genetic and environmental factors that trigger eating disorders.

Perhaps most fascinating has been research which demonstrates that anorexia and bulimia are almost exclusively culture bound syndromes that only exist in “westernized” or European society. For example, in America, the prevalence of anorexia is rising and may be approaching as high as 3% in some populations.

In Southeast Asia, however, the prevalence is well below 0.01%.

Multiple studies show a clear and direct link between obesity and heart attack, stroke, cancer, and hypertension. And yet there is no consensus from research about the “cure” for obesity. This is because obesity is a complex cultural condition with a wide variety of factors contributing to the endpoint.

I do think recent research on the Mediterranean Diet is quite exciting. The Mediterranean diet has whole grains, vegetables, nuts, seeds, and olive oil as its foundation. Fish is consumed regularly, dairy eaten moderately, and red meat and sugars eaten very sparingly.

Fairly high quality and replicable research has suggested that this diet has positive impacts on cardiovascular health and blood sugar. Less well established are potential preventative impacts on Alzheimer’s, but the data so far is quite encouraging.

Take note that the Mediterranean Diet is not a “diet” by American standards. It is not calorie reduced. It has an abundance of fat, predominately vegetable based and monounsaturated. It does not forbid any foods, and focuses on moderation. After all, this is the same culture that brought us gelato! It also links to larger cultural and lifestyle changes. It is not something that is done briefly and intensely to lose weight, and as such I do not think carries the risks of traditional American dieting.

improves your ability to absorb nutrients. In reality, juices are extremely high in sugar. Juices remove all of the fiber from fruits and vegetables which research suggests is crucial to maintaining stable blood sugar levels, satiety, and healthy gut function.

In the 1950s a juice glass held about 3-4 ounces of juice.

Now a 16 ounce bottle of juice is marketed as being healthy, yet contains more sugar than a soft drink.

On the more dangerous end of the spectrum are over-thecounter and herbal weight loss supplements. It is worth noting that these products are heavily marketed in women’s magazines.

I have seen panic attacks, atrial fibrillation, nausea, and paranoia in patients who have taken these medications in combination with a starvation diet. These products are not regulated by the U.S. Food and Drug Administration, but they are dangerous and I believe they should be removed from the market.

“Gluten sensitivity” is another great example of a syndrome with no valid scientific basis but results in significant food restriction and can also result in eating disordered behavior. Celiac disease is quite real, and devastating. But there is absolutely no scientific evidence to suggest that restricting all gluten from the diet of an individual without celiac has any health benefits beyond placebo.

Are there any “fast foods” that pass the muster of good nutrition?

There are no inherently good or bad foods. With moderation and balance any food can be incorporated into a diet which provides good nutrition. Eating chocolate chip cookies, corndogs, and a pork chop on a stick at the State Fair is not going to hurt you as long as you do not eat like that regularly.

What is dangerous about “fast food” and processed food in general is that it has been specifically constructed in a laboratory to offer the greatest degree of dopamine surge possible and to chemically overwhelm your brain and taste buds. Therefore, there is a greater tendency to overeat these foods and your brain becomes attuned to needing more intense sensory experiences in order to remain satisfied.

The parallel with alcohol is an easy one. Alcohol is bad for you. But if you drink in a moderate and limited way, the risks are minimal. However, because it is an addictive substance, it is easy to switch from moderate drinking to more dangerous drinking. Similarly, fast food and processed food is addictive, but not inherently evil.

What role do food fads play in healthy nutrition, e.g. smoothies, etc.?

Who are your competitors and how do they differ from Melrose Center?

At best, food fads are expensive and have no proven health benefits.

At worst, they can be potentially dangerous.

Juicing is a fad that has come and gone over the years. Proponents argue that juicing is a great way to eat more fruits and vegetables and that breaking down cellular walls prior to consumption

We are fortunate to have a lot of great treatment options for eating disorders in the Twin Cities. Features that distinguish Melrose Center are the facts that it is non-profit, has a strong medical focus, has subspecialty programming in diabetes and chemical dependency, and treats severely ill patients.

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Vitamins: Yay or Nay?

R

esearch and practice in nutrition has generally related to the effects of food and its components in terms of single nutrients or supplements. The discovery of fundamental activity of nutrients, such as vitamin C and their role in deficiency diseases was lifesaving. In food, however, the biological ingredients are coordinated.

Mother Nature has “packaged” foods to provide a wide array of nutrients. Ideally when a balanced, varied diet is consumed all necessary nutrients are included.

A healthy diet consists of a variety of foods that nourish the body. Each food is made up of an assortment of nutrients: proteins, fats, carbohydrates, fiber, vitamins, minerals and phytonutrients. Each nutrient has information for the body concerning function and act as cofactors and coenzymes.

They are used to trigger metabolic processes such as detoxification, immune support or the sleep cycle. Without the information from nutrients metabolic processes slow down or even stop.

Vitamins and minerals are required in small amounts by the body for normal metabolic functions. Most cannot be manufactured by the body and are, therefore, deemed essential to include in the diet. Phytonutrients are organic compounds in a plant that serve as the plant’s defense system. A plant is stationary. It cannot flee or fight but must be able to defend itself against disease, blight, radiation from the sun and anything else that may be threatening. When the plant containing these compounds is consumed, phytonutrients play the same role in the human body. Phytonutrients have been shown

By Courtney Jordan Baechler, M.D., Carolyn Denton, RD, and Debra G. Bell, M.D.

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Courtney Jordan Baechler, M.D.

Carolyn Denton, RD

to be helpful in prevention of diseases such as cancer.

Rather than using single nutrients in nutrition research, Professor David Jacobs, University of Minnesota, published an article in the American Journal of Clinical Nutrition purposing that “thinking food first” results in more effective nutrition research and policy. Food synergy is a perspective stating that more information can be obtained by looking at whole food rather than single nutrients. For example, an orange not only contains vitamin C, but also fiber, oils and phytonutrients found in the pitch and juice.

The evidence for health benefit appears to be even stronger when put together in a synergistic dietary pattern than for individual foods or nutrients.

However, the unfortunate truth is, many Americans may not be consuming all vital nutrients in a synergistic dietary pattern. The Standard American Diet (SAD) is woefully lacking in nutrients, comprised of processed foods low in fat but high in sugar, full of artificial colorings and flavorings.

For example when whole grain is processed: V 60% of calcium is lost V 85% of magnesium is lost

The Journal of the Twin Cities Medical Society

Debra G. Bell, M.D.

V V V V

77% of potassium is lost 78% of zinc is lost 75% of vitamins are lost 95% of fiber is lost Conditionally then, when the diet is inadequate and not providing optimal nutrient combinations, targeted supplementation may be needed.

First developed in 1941 and revised in 1989, the Recommended Daily Allowance (RDA) was created to prevent deficiency diseases and were intended for healthy people who may have inadequate or poor nutrition.

The allowances were flawed in that they were not adequate for many people, including the elderly, immune compromised, recovering from surgery or who are taking medication.

The RDA was not intended necessarily for the general prevention of disease.

Scientific studies have examined the value of multivitamins in the prevention of chronic disease and cancer. Most are inconclusive and some show no positive impact.

There are many aspects of these studies that allow for critique and dialogue. However, deficiency is different from insufficiency. It is most important to recognize the distinction between a multivitamin for support in poor (Continued on page 20)

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The Nutrition Issue Vitamins: Yay or Nay? (Continued from page 19)

or deficient nutrition and the use of vitamins and herbs as supplementation. The notion of supplementation is the utilization of additional vitamins, minerals, and herbs for their health effects. They are used to supplement healthy nutrition, for treatment alone and in conjunction with pharmaceuticals.

Dietary supplement formulas are created based on scientific research in biochemistry, physiology, and genetics as well as wisdom from ancient healing practices. Integrative medicine, a specialty in which the practitioner has knowledge and skill regarding this science, plays a key role in helping patients to safely and effectively navigate through these nutraceuticals.

Fish oil and vitamin D are frequently used as dietary supplements. There are reproducible evidenced-based clinical and scientific studies demonstrating the potential health benefits of purified fish oil/omega-3 fatty acids, and vitamin D. Fish oil can reduce triglyceride levels by 20% to 50%. The evidence for purified fish oil in lowering elevated triglycerides is sound and is exemplified

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How to Choose a Supplement V V V V V V V

Check dissolvability. A capsule or tablet should dissolve in vinegar in one hour.

Check content. Many supplements contain additives and fillers, binders and colorings.

Choose a multivitamin without herbs added. Amounts are insignificant and added cost is high.

Look for a supplement that can deliver the stated nutrients in two or less tablets or capsules.

Look for GMP (good manufacturing practices) from an outside certifying body.

The United States Pharmacopeia (USP) has a voluntary testing program called the Dietary Supplement Verification Program.

The USP Dietary Supplement Verification mark shows that the supplement has passed USP tests to ensure that it contains the ingredients listed on the label, contains the amount of each ingredient listed on the label, dissolves effectively, does not contain harmful contaminants, and was manufactured using safe and sanitary procedures.

by development of a pharmaceutical grade product. Fish oil, particularly the omega-3 fatty acid eicosapantaenoic acid (EPA), also has data that supports its use in the treatment of depression. The evidence regarding fish oil is variable due to inconsistent formulations and dosages of omega-3s, sample size, duration of trials, co-morbidities, and use as augmentation/adjunct vs. monotherapy.

The 2010 American Psychiatric Association Task Force on Complementary and Alternative Medicine report concluded that “the established general health benefits of omega-3 fatty acids, epidemiologic evidence, at most modest efficacy data, and low safety risks make omega-3 fatty acids a reasonable augmentation strategy in MDD.” There are newer studies suggesting benefits in anxiety disorder as well as in ADHD in children.

In addition, supplementation with omega-3 fatty acids may have anti-inflammatory effects with studies showing reduction in serum inflammatory markers.

Vitamin D, a fat soluble vitamin, is primarily obtained from exposure to the sun.

Low levels of vitamin D as well as significant vitamin D deficiency are frequently seen in residents of the upper Midwest. In addition to its important role in bone growth and remodeling, research studies as well as epidemiologic evidence suggest that vitamin D may also play a role in cancer risk, specifically in prostate, breast and colon cancer prevention. Supplementation may prevent other autoimmune diseases such as multiple sclerosis and type 1 diabetes. Research also points to its role in immune support with evidence of risk reduction of flu, upper respiratory infection and asthma exacerbation

in children. It may also play a role in the prevention of hypertension, glucose intolerance and type 2 diabetes.

Utilization of dietary supplements not only provides for additional tools in the treatment and disease prevention, they often have minimal adverse effects and can be used safely. One area to have increased awareness is the fat-soluble vitamins (Vitamins A, D, E and K). Since these vitamins are absorbed in the fat, it is more difficult for the body to excrete excess levels and thus it is possible to become toxic if levels get too high. While this is rare, when patients are supplementing at higher doses it is appropriate to check levels. Since there can be some interactions between herbal supplements and medications, patients interested in using herbs as a part of their health plan can be referred to an integrative medicine specialist to make sure that they are being used in a safe manner.

The use of dietary supplements continues to increase. We know that about 70% of the American consumers report using dietary supplements. Supplement users are more likely to be women, it is more common with advancing age, and the numbers continue to rise. It is important as clinicians that we ask our patients routinely about the use of supplements and that we continue to grow our knowledge base in the area of nutrition and supplementation. If patients do not feel trusted or feel belittled when sharing about their use of supplements, the information is often withheld. This leads to an inaccurate assessment of the patient’s overall health history as well as an inability

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The Journal of the Twin Cities Medical Society

Pediatric Nutritional Pitfalls and Practical Solutions: 5-2-1-0 and Beyond

A

s a pediatric endocrinologist, I generally see kids who are heavy enough that they require a referral either for a known endocrine complication, or to screen for endocrine complications. I find that many of these kids have had some diet counseling from their primary care doctor. Interestingly, most of the kids I see for other reasons generally have not had the same discussions regarding healthy eating. This has made me reassess my own interactions with patients and how I address healthy eating with all my patients, my own family, and occasionally a colleague. I feel that I will never be an expert at motivational interviewing, and that I am always on the edge of judging.

I am always learning.

In my current level of expertise, motivational interviewing goes well for a certain amount time, or visits, with me asking open questions in a non-judgmental manner. At some point, however, I break.

This is generally when a parent tells me that their 8-year-old needs to “have the willpower” to stop eating the chips in the house since they couldn’t possibly stop buying them. My calm melts away, and I start making goals for people; I try to get them to meet my goals rather than help them meet their own goals. This is not the way to create change. I know that I need to be better at nudging kids and their families towards their goals and realistic lifestyle changes.

When I look back at the patients who have made lifestyle changes, this is what I have learned to date. Planting the seed of change is great. It is truly frustrating to wait (and wait, and wait) for that seed to grow; however, with enough time, it

does grow. The adolescents in my clinic who have gotten to a healthier weight have all done so because they made goals for themselves. Good ideas and sound advice are also more likely to grow when tended by the trusted primary care physician than the specialist whom they have just met.

My favorite fast diet assessment is using the “MyPlate” (choosemyplate.gov).

I use it as a tool to reinforce healthy eating goals. I start by showing the MyPlate diagram to the kids. We then talk about how “no one” eats every meal and snack according to this, even though that is the ultimate goal. I ask kids to give their meals a grade based on the MyPlate document; with the explicit understanding that every meal isn’t an “A.” I then ask them which meal gets the best grade, and why. They are often very insightful.

Next comes the tough part. I ask them which meal gets the worst grade, and why.

By M. Jennifer Abuzzahab, M.D.

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This is the more interesting part. I would give a breakfast bar and juice box a much lower grade for a meal than most of my kids. This, however, is not important to anyone but me. And it is never about me. Kids will frequently, with the wishful thinking fervor of youth, give this a solid “B.” Without blinking, I ask them what they can do to get a higher grade for the meal. They will almost always say “trade the juice for a piece of fruit.” We then talk about how hard this would be to do, and how many days a week they could make this change. It is, again, not often as much of a change as I would like. This is, again, OK. It is about the steps they can take every day to nudge each meal closer to the goal.

The American Academy of Pediatrics (AAP) 5-2-1-0 guidelines are a great foundation — 5 servings of vegetables and fruits, 2 hours of screen time, 1 hour of exercise, and zero sugar-sweetened beverages each day are ideal goals. These should be, and are, discussed with all kids, not just the kids who are overweight. It is a good message and I find almost universally, both kids and parents can recite the guidelines and avow that they follow them. However, at least once a day, families will say that they are following 5-2-1-0, and yet each family member in the exam room is drinking from a plastic bottle filled with a (Continued on page 22)

Tips:

) ) ) ) )

Prohibition doesn’t work.

Eat a fruit or vegetable at every meal.

Processed food and fast food are equally poor choices.

Food should not be used as a reward.

Teach your kids to prepare meals.

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The Nutrition Issue Pediatric Nutritional Pitfalls (Continued from page 21)

sugar-laden often neon colored beverage.

Digging into how to use or live a reasonable life with the 5-2-1-0 guidelines takes more time, often several visits to get the families to be ready for and then implement the necessary changes.

Remember that prohibition doesn’t work. Although I completely agree with the AAP regarding sugar sweetened beverages, it is virtually impossible in our Western society to make this happen. Instead, it seems best to focus on how to navigate the world of sugar sweetened beverages. A recent CDC study shows “In 2012, about one in four adults reported consuming regular soda, fruit drinks, or both *1 times daily in the 18 states surveyed.” (MMWR weekly August 15, 2014 / 63(32);686690). Despite a significant push from the CDC, AAP and other national organizations, this has increased to “approximately one in three adults reported consuming sugar sweetened beverages at least once daily in DC and the 23 states surveyed.”

(MMWR weekly February 26, 2016 /

65(7);169–174 ). In addition, there is compelling evidence that drinking sugar is worse than eating sugar, in terms of increases in triglycerides and fatty liver changes. We also need to stop pretending that only juice and kool-aid are “bad” and look at all sugar sweetened beverages, including coffee drinks and vegetable smoothies. Instead of removing all sugar sweetened beverages from hospitals and schools, let’s take a page from the alcohol industry and work on teaching people how to drink responsibly. This can be as simple as not drinking chocolate milk every day, or limiting juice to 4 ounces; but it needs to be a change the kids and families are ready for.

I love asking kids what they ate the day before they came to clinic. Admittedly, this is more time consuming and is not the best route for chatty kids. It is fascinating to hear what their parents say when they recite the meals from the day before; and also amazing to the kids when they count only 1 or 2 servings of vegetables and fruit for the whole day. This is one of those times when I make a suggestion: eat a

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May/June 2016

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fruit or vegetable at every meal. Ideally, eat both a fruit and vegetable at every meal.

This includes snacks (IMHO fruit snacks are neither a fruit nor a snack, they are candy and should be treated as such). It is easy to vilify school lunch or fast food, but it is really about how to make the best of the choices available. Often the options are better in the cafeteria than what is sent from home in a packed lunch.

The corollary of this is that you can choose a healthy meal at your favorite fast food chain, restaurant, or the school cafeteria. It is often healthier to get a small sandwich or burger from a fast food establishment than a salad at a sit down restaurant. It is also often healthier to eat a small burger than a bag of chips. This is because processed food and fast food are equally poor choices. It’s fascinating to hear how many kids eat more processed foods on days when they have an organized sport activity. This can open the door to discussions about what foods are better fuel for exercise. It also opens the door to a frank discussion about what the family could use as rewards, and suggesting that food should not be used as a reward.

Kids should be allowed to help choose foods at the store or farmer’s market. They should be involved in meal planning, and guided to planning a healthy meal. As convenience, we tend to allow kids to open their own snack foods, but not wash grapes or slice an apple. Teach your kids to prepare meals. Kids should learn from an early age how to prepare a healthy meal and what foods “go together.” If children have an active role in planning the meal, they are less reluctant participants at meal time.

The bottom line is that calories, portions, and food choices matter more than we all think. We should help all of our patients eat healthier meals and learn about proper nutrition. And, as my family likes to remind me, it is really hard to exercise your way out of a bag of cheesy puffs.

M. Jennifer Abuzzahab, M.D. is a Pediatric Endocrinologist at the McNeely Pediatric Diabetes Center and Endocrine Clinic at Children’s Hospitals and Clinics of Minnesota. She can be reached at (651) 220-6624; Jennifer.Abuzzahab@childrensmn.org.

MetroDoctors

The Journal of the Twin Cities Medical Society

The MATTERbox: An Innovative Approach to Hunger Relief

M

interacting daily with those facing food atter is a nonprofit on a misinsecurity. These organizations did not sion to expand access to have the capacity to host a food program. health — next door and around Driven to break down the barriers between the world. Internationally, Matter sends health and hunger, Matter partnered with 40-foot containers of life-saving medical Hennepin County Medical Clinic dietiequipment to outfit hospitals and clinics cians to identify the obstacles. Lack of in developing countries. Locally, this is access to healthy food and the ability to done through the MATTERbox program, reach people in nontraditional avenues was which is an innovative program utilizing identified. Together, the MATTERbox was nutrition, education, and shelf-stable created, a healthy food box that provides food items. In the short term, the MATimmediate alleviation to hunger and also TERbox alleviates hunger and long-term serves as an educational health tool, which provides educational tools on nutrition serves as the real impact within the MATto the community. By the end of 2018, TERbox. Each MATTERbox contains Matter — along with its community partners — has a goal to impact four million people who are The MATTERbox is a shelf stable, experiencing food insecurity educational tool that is easily used within the Twin Cities metbetween a doctor and his/her paropolitan area with healthy meals. tient to begin the conversation In recent years, it has beabout nutrition. come increasingly clear that traditional means of providing food resources to our neighbors living healthy eating education, recipes and with food insecurity are falling short: only easy-to-prepare meals that can be used as 5% of a Minnesota food insecure person’s a preventative tool to long-term health ismeals comes from a food shelf. With the sues such as obesity, diabetes, pre-diabetes traditional food shelf relying solely on and heart disease. donations, there is a lack of nutrient rich Within the past decade, hospitals and and healthy options. Additionally, due to clinics have seen a rise in patient readfood deserts — urban or rural areas where mission rates for chronic illnesses easily access to healthy food or supermarkets is preventable and managed by a healthy limited — fast food restaurants are typidiet and exercise. Many physicians accally prevalent. Diabetes, pre-diabetes, knowledge that only 20% of a patient’s heart disease and obesity are a direct conheath is influenced within the walls of sequence of these circumstances. a hospital and clinic, and the remaining Matter saw many organizations, pro80% is affected by outside influences such grams, and businesses that were already as lifestyle, diet, and exercise. The question for many health providers has now become

By Gates Lindquist

MetroDoctors

The Journal of the Twin Cities Medical Society

how to reach this 80% to improve patient outcomes and reduce readmission rates.

Clinics and hospitals are investing more into patient outreach programs, nutritional programs, home visits etc. Medical and community programs such as fire and law enforcement utilize the MATTERbox as an essential tool to alleviate immediate hunger. Medical home visits are using the box as a tangible teaching tool about nutrition. Minnesota is ranked one of the highest in the nation for children whose only meal is eaten at school. Many schools within the Twin Cities are now using the MATTERbox to provide nutritious meals outside of school hours.

Countless diseases are preventable by maintaining a healthy lifestyle. Through proper nutrition and health, many physicians are moving towards the idea of “Food as Pharmacy.” The MATTERbox is a shelf stable, educational tool that is easily used between a doctor and his/her patient to begin the conversation about nutrition.

This versatile tool is used in many ways (Continued on page 24)

May/June 2016

23

The Nutrition Issue The MATTERbox (Continued from page 23)

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May/June 2016

by the different organizations with whom Matter partners. For example, Hennepin County Medical Center’s Diabetes Education Program is using the MATTERbox as a teaching tool for multi-generational education on healthy eating and nutrition, as well as a way to ensure its patients are connected with the right type of food.

Native American Community Clinic in Minneapolis utilizes the MATTERbox as an educational tool, to help demystify the concept of maintaining a healthy diet and lifestyle. Through educational information found in the MATTERbox, patients are taught what a complete and healthy meal looks like, correct portion sizes, how to read nutrition labels, and how to grocery shop on a budget.

When asked about the MATTERbox program, Joe Newhouse Matter’s Vice President of Strategy and Innovation stated, “What I feel is so unique about the MATTERbox is that it is truly a collaborative effort within the Twin Cities Community. Starting with Super Value Corporation, where we source the shelf stable food items, to the local companies and businesses who engage their employees in packing the MATTERboxes, to the hospitals, clinics, law enforcement and schools who distribute the MATTERbox to those who can beneďŹ t locally. This is Minnesota rallying together to create a healthier community.â€?

Matter is committed to ďŹ nding nontraditional ways to reach its goal of impacting four million food insecure people by the end of 2018. If you are interested in learning more about how your hospital or clinic could use the MATTERbox program, please contact Matter’s Vice President of Strategy and Innovation, Joe Newhouse at Joe@MatterMore.org for more details.

Gates Lindquist, Communications Coordinator at MatterMore.org.

MetroDoctors

The Journal of the Twin Cities Medical Society

The Sheridan Story— Fighting Child Hunger and its Affects on Children in Our Community

I

n 2012, the Sheridan Elementary School principal reached out to the staff of Mill City Church in Minneapolis. “I’ve noticed kids in my school hoarding food at lunch on Friday,” she shared. “I asked the kids why they were doing that, and they told me they don’t have food at home on the weekends. We’ve also noticed that the lack of food causes behavioral problems on Fridays and attention issues on Monday. Is there anything you can do to help?”

Over 100,000 children in the Twin Cities live in food insecurity, meaning they don’t always have enough food for their next meal. This is especially problematic on the weekends, when the children aren’t able to receive free and reduced meal programs at school.

Here at The Sheridan Story we call this the “weekend food gap.”

I’m not a doctor, but I am sure you are all aware of the dire repercussions that result when your patients, especially kids in their crucial developmental years, do not receive adequate nutrition. In fact, some doctors are even writing prescriptions for healthy food.

Behavior, attentiveness, relational competence, self-esteem, obesity (from eating snack foods instead of nutritious foods), school attendance, and more are all negatively affected when children have limited access to nutrition.

The Sheridan Story exists to fight against the devastating reality of child hunger. The organization was created as a response to the principal’s question, “…

By Rob Williams

MetroDoctors

Is there anything you can do to help?” The Sheridan Story first operated as a project of Mill City Church and went on to establish itself as a 501c3 non-profit organization.

Our response to the weekend food gap was, and still is, very simple: let’s give children who live in food insecurity a bag of food every weekend. Let’s provide a consistent, stable source of nutrition to sustain them over the weekend while not in school.

The Sheridan Story first began in 2010 by serving 27 kids in kindergarten at Sheridan Elementary School. Now, we have broadened our impact in the Twin Cities and currently work in 15 school districts and 86 schools serving nearly 4,000 children weekly. Since we started, we have provided over half a million meals to children in our community and are now providing a rate of approximately 14,000 meals weekly.

Many of the children we serve live in areas with poor access to food, commonly called “food deserts.” I prefer to call these areas “food swamps,” since there actually is access to food, but it is very unhealthy food, such as the kind one might find at a typical gas station.

I don’t think kids can grow in a healthy way if they only have gas station food at home.

My background in logistics has helped me form a perspective on the issue of child hunger that is perhaps different than most. I view child hunger as a logistical breakdown. We have plenty of food available, but it’s not where it needs to be: in the homes of the children. In other words, child hunger is not a supply problem; it’s a distribution problem and

The Journal of the Twin Cities Medical Society

The Sheridan Story offers a distribution solution.

The Sheridan Story’s growth and impact is possible through our networkapproach to fighting child hunger. Our method is to involve the community in the solution by developing and supporting successful partnerships between sponsoring community organizations and schools. Community organizations provide funding and volunteers and manage their relationship with the school. Meanwhile, The Sheridan Story manages the operational aspects of the weekend food program such as healthy food sourcing, inventory management, packing events, and storage and delivery of the food. Our role allows community groups to fight child hunger through a program that would otherwise be difficult for them to manage.

We have certainly experienced significant growth and can see the statistical (Continued on page 26)

May/June 2016

25

The Nutrition Issue The Sheridan Story (Continued from page 25)

evidence of our impact, which I’m proud of. However, none of the numbers matter unless our program operates in a way that truly supports the children and families. There are many ways we accomplish this goal. One is by the type of food we provide, which is a key differentiator between The Sheridan Story and many other weekend food programs (commonly called backpack programs). We believe, and have confirmed, that the type of food that provides the greatest level of support to our children and families is healthy, nutritious, and substantive food, not snack food items. We reached this decision many years ago through feedback from schools and families, analysis with nutritionists from Allina Health and Saint Paul Public Schools, and by following the guidance of the USDA MyPlate.

In addition to providing healthy food, we also provide food that is safe, high-quality, and that preserves dignity for our participating families and children.

YOU

Therefore, we do not provide food considered near-expiring, back-of-the-truck, leftover items that no one wants. We buy our food from several different suppliers throughout the country to ensure it is healthy, safe, and high-quality. (Less than 1% of our food items are from food drives. All food drive donations are sorted to keep only items that fit our criteria.)

Food we put in our bags are only items that we would use in our own homes, not simply whatever food items we can find for as little cost as possible.

The Sheridan Story’s commitment to high-quality food results in increased costs for our organization. For instance, we can source the following snack items inexpensively: granola bars ($0.12), snack mix ($0.08), and ramen noodles ($0.19).

While items we provide cost significantly more: pears ($0.73), chunk chicken ($0.69), and green beans ($0.52). If we provided two of each snack item in place of the nutritious items we currently provide, our food cost would decrease nearly 60%.

However, we are confident that the

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May/June 2016

benefits to our children of the nutritious food we provide (versus the alternative snacks) drastically outweigh the costs we incur. We aim to not simply mitigate hunger pains, but rather to make a positive impact on all those areas affected by food insecurity: behavior, attentiveness, relational competence, self-esteem, obesity (from eating snack foods instead of nutritious foods), school attendance, and more.

Although our growth has been significant and swift, we have just scratched the surface. I previously mentioned that over 100,000 kids in the Twin Cities live in food insecurity. The Sheridan Story serves 4,000 children with our program, yet we’re only reaching 4% of the children who need it. I am sure that many of you, especially primary care providers, still have kids come into your clinics who are unable to access nutritious food.

The Sheridan Story, working with the community in which we serve, will continue to increase our impact on child hunger by serving more districts, more schools, and more kids. I am not OK with where we are at, and I have seen that our community isn’t OK with it either. We hope to make this problem of child hunger less and less prevalent so that our kids can have the nutrition they need to learn and grow.

To learn more about The Sheridan Story, the work we are doing, the ways you can get involved, and/or to donate visit www.thesheridanstory.com.

Rob Williams is the Executive Director and Founder of The Sheridan Story, a Minneapolis-based organization with the mission to fight child hunger here in our local community. Leaving a corporate career in international logistics to launch The Sheridan Story in 2013, he has led the organization’s significant growth to become the largest weekend food program in the state. You can reach Rob at (612) 568-4003 or rob@thesheridanstory.com; http://www.thesheridanstory.com/; http://well.blogs.nytimes.com/2014/12/01/ prescribing-vegetables-not-pills/?_r=0; or http://millcitychurch.com/.

MetroDoctors

The Journal of the Twin Cities Medical Society

From Bratwurst to Broccoli New Ulm Project Transforms Nutrition Culture

I

n 2009, at one of the oldest German restaurants in rural New Ulm, Minn., the only vegetables on the menu were sauerkraut and iceberg lettuce — with lots and lots of cheese. Among adults in the community who attended a heart-health screening, only 17 percent were eating the recommended five or more servings of fruits and vegetables a day. In addition, 35 percent were overweight, 38 percent were obese, and 35 percent had metabolic syndrome. In a nutshell, New Ulm’s risk profile for nutrition and cardiovascular disease (CVD) was less than desirable.

Fast forward to 2016 — and that profile looks markedly different. Adjusted for age and gender differences, data from 2014-15 now show that 30% of adults who participate in heart health screenings are eating the recommended servings of fruits and vegetables. The Rotary Club’s luncheon at that same German restaurant now includes an ample serving of vegetables, and throughout the entire community, it’s clear the culture has transformed to help people embrace healthier nutrition choices.

The transformation can be credited in large part to the efforts of Hearts Beat Back: The Heart of New Ulm Project (HONU), a collaborative partnership of Minneapolis Heart Institute Foundation® (MHIF) and Allina Health and its New Ulm Medical Center (NUMC). Launched in 2009, the project is a 10-year population health research project designed to reduce the number of heart attacks in the

By Rebecca Lindberg, MPH, RD, and Thomas Knickelbine, M.D., FACC, FSCAI, FSCCT

MetroDoctors

community and improve modifiable risk factors for CVD. The project has achieved success by employing evidence-based health improvement practices in health care, worksites and the community.

While the project has worked to address major modifiable CVD risk factors, efforts to improve nutrition measures have been foundational. Educational interventions have heavily focused on increasing intake of fruits and vegetables, but also increased intake of whole grains, portion control, reduced sugar intake, and healthier food choices overall. It’s also been a priority to improve the food environment by increasing the availability, identification and promotion of healthier choices in stores, restaurants, cafeterias and concessions.

Tracking Nutrition Outcomes at a Population Level

Thomas Knickelbine, M.D., a preventive cardiologist who serves as HONU’s medical director in his role as a researcher at MHIF, says, “Even modest improvements in population-level risk hold the potential to significantly reduce CVD rates. With the HONU project, we set out to rigorously track health outcomes, as well as create a population health improvement model with elements that can be replicated in other rural accountable care communities across the country.”

Fruit and vegetable consumption has been tracked through heart-health

The Journal of the Twin Cities Medical Society

screenings in the community that are also offered during a patient’s annual preventive visit. Data on fruit and vegetable consumption has then been entered into patients’ electronic medical records.

Knickelbine says, “We chose New Ulm as the site for our research project in part because 90% of people in the community get their care from NUMC, providing the opportunity for surveillance of health outcomes using a single electronic health record system. In the still somewhat fledgling arena of population health, being able to demonstrate outcomes has been critical.”

Community Support all Around

Daniel Holmberg, M.D., Director of Medical Affairs at NUMC and a member of the project’s community leadership team, says, “One of the significant advantages of a community-based program like the Heart of New Ulm is that the nutrition and other lifestyle messages our patients hear in their provider’s office are repeated in the community. When they leave their (Continued on page 28)

May/June 2016

27

The Nutrition Issue From Bratwurst to Broccoli (Continued from page 27)

provider’s office, they head out into a community where it’s easier to make healthful eating choices and there is support and plenty of resources.”

That was exactly the case for Tom H., an 83-year-old who went to see his doctor in May 2013. He already had CVD, and at 230 pounds, his doctor told him he needed to lose 20 pounds. A month later, Tom was reading the local newspaper when he and his wife noticed an article about LOSE IT to WIN IT, a free community challenge from HONU designed to help people lose weight.

The couple signed up, and as just one aspect of the program, they received emails with weekly and daily food menus and ingredient lists. Tom says they were also introduced to many new fruits and vegetables that they didn’t know they would enjoy so much. At his checkup in early 2014, he weighed 198 pounds, a healthy weight that he planned to maintain.

Other nutrition educational efforts have been plentiful and varied. For example, a SWAP IT to DROP IT® campaign used billboards, point-of-purchase messaging, social media and traditional media to encourage people to make small 100-calorie food or beverage SWAPs each day to lose 10 pounds over the course of a year. The project has offered free grocery store tours with a registered dietitian; local cooking contests, demonstrations and classes; a Mediterranean dining experience; and even a weekly cable TV cooking show featuring a registered dietitian alongside a local resident guest preparing their favorite heart-healthy recipe. Various campaigns have promoted local foods, the farmers market and Community-Supported Agriculture programs.

The project also received a grant from Delta Dental to help oral health providers in the area facilitate better conversations with their patients about reducing their intake of sugar-sweetened beverages and quitting tobacco use. This spring, MHIF’s population health team is implementing a similar program in South Minneapolis.

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May/June 2016

Modifying the Food Environment

To improve the food environment, staff cultivated partnerships with restaurants, grocery stores, convenience stores and agricultural commodities producers.

Slowly, the demand and offering of healthier foods has increased in tandem, due to the project’s resources as well as the community’s interest.

Virginia Suker-Moldan, general manager at Turner Hall restaurant, was initially skeptical about whether changes would be successful in a town renowned for the second oldest family-owned brewery, the largest butter packing plant in North America, and the largest processed cheese factory in the world. Suker-Moldan is now one of the project’s most passionate champions and serves on the project’s community leadership team.

She says, “We’ve seen an increased demand from our customers for healthier food choices such as salads and so we’ve been working with our menu to accommodate that. To my surprise, the demand has continued to grow.”

Data show that among all restaurants in the community that were exposed to some education on how to improve their offerings, healthful practices improved over two years. Non-fried vegetable availability in those restaurants increased from 63% to 84%, fruit availability increased from 41% to 53%, and whole grain bread availability increased from 25% to 38%.

Looking Ahead

The project’s five-year data outcomes were presented at The American Heart Association Scientific Sessions in November 2014 and a journal article will be published in The American Heart Journal later this year.

Electronic health record data show that among New Ulm residents age 40-79, the percentage of people at goal for blood pressure (< 140/90) increased from 79% to 86%. Those at goal for total cholesterol (< 200) increased from 59% to 64%.

While their direct correlation with

improved eating habits has not been studied explicitly, Knickebline says, “These improvements over a five-year period are particularly notable because they represent larger improvements than trends being seen in the rest of the country.”

In 2014, HONU and its partner New Ulm Medical Center were honored with the NOVA award from the American Hospital Association and also the Community Benefit Award from the Minnesota Hospital Association. HONU’s current work in New Ulm is focused on ensuring the sustainability of the project once the 10-year research component has ended.

MHIF’s population health team is working to disseminate best practices to other communities in Minnesota and nationwide. For more information, visit www. heartsbeatback.org.

Rebecca Lindberg, MPH, RD serves as the director of population health at the Minneapolis Heart Institute Foundation and is accountable for population health strategic direction and operational leadership, including for Hearts Beat Back: The Heart of New Ulm Project and other community programs.

She can be reached at: (612) 863-4087; rlindberg@mhif.org.

Thomas Knickelbine, M.D., FACC, FSCAI, FSCCT has been with the Minneapolis Heart Institute since 1996 as a researcher and cardiologist. He serves as the Director, Preventive Cardiology at the Minneapolis Heart Institute® at Abbott Northwestern Hospital and Medical Director, Hearts Beat Back®: Heart of New Ulm. He can be reached at: Thomas.Knickelbine@allina.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

CAREER OPPORTUNITIES

Vitamins: Yay or Nay? (Continued from page 20)

to adequately advise on how to safely supplement. One such example is eating green, leafy vegetables while taking Coumadin. We should all try to encourage our patients to eat as many green, leafy vegetables as possible.

However, the correct message when patients require Coumadin should be to encourage consistency in green, leafy vegetable intake and avoiding vitamin K1.

One true reality is that there is wide variation in the quality of supplements. This can be one area that draws significant angst for providers to safely recommend supplements to their patients. When it comes to safety and quality of supplements, there are a few key areas to keep close to mind. Since dietary supplements are not considered medications, they are not required to be regulated by the FDA. However, there are a growing number of supplement companies that are choosing to become FDA certified.

This requires that the company pass a variety of random audits to ensure the highest standards as well as testing to verify consistent purity, strength, identity and composition of the various products. Additionally, when choosing a product, it is important that the composition of the product match the clinical trial in both dosage and formulation.

For example, Q-SYMBIO was a trial that showed an improvement in both morbidity and mortality in moderate and severe congestive heart failure and the appropriate dosage of coenzyme Q 10 was 100 mg by mouth three times a day. Another example is magnesium supplementation. It is recommended that magnesium be bound with citrate, chelate, or glycinate. Magnesium oxide often irritates the digestive tract and was not routinely used in the studies where magnesium was found to be effective.

In the end, we come full circle and remind the reader that our best recommendation is for our nutritional information to come from our food rather than supplementation. However, as we have illustrated there are both safe and effective ways to help advise our patients on the clinical role of supplements to aid in health and healing.

Editor’s Note: MetroDoctors acknowledges that the benefits of many dietary supplements are

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The Journal of the Twin Cities Medical Society

May/June 2016

29

The Nutrition Issue Vitamins: Yay or Nay? (Continued from page 29)

CAREER OPPORTUNITIES

See Additional Career Opportunities on page 31.

uncertain, and does not endorse any specific supplement regimen.

Authors: Courtney Jordan Baechler, M.D. is a preventive cardiologist and the executive sponsor of population health. She is currently Vice President of the Penny George Institute for Health and Healing and the chair of the prevention and wellness clinical service line at Allina Health.

Dr. Baechler can be reached at Courtney. baechler@allina.com.

Carolyn Denton, RD is a member of the Integrative Medicine Team at Abbott Northwestern’s Penny George Institute for Health and Healing. She also teaches Functional Nutrition at the University of Minnesota. She can be reached at Carolyn.Denton@allina.com.

Debra G. Bell, M.D.sees patients at the Penny George Institute for Health and Healing at Allina Health in Minneapolis. She offers integrative medicine consultations and has a holistic approach to care. She can be reached at Debra.

Bell@allina.com.

In Memoriam ROBERT B. COOPER, M.D., ophthalmologist, passed away on January 1, 2016.

JAMES B. GAVISER, M.D., plastic surgeon, passed away on February 9, 2016.

ELIZABETH (BETTY) JEROME, M.D., pediatrician, passed away on February 2, 2016. She was a founder of Teen Age Medical Services (TAMS).

RICHARD P. LYNCH, M.D., pathologist, passed away on February 21, 2016.

JOHN (JACK) POPOWICH, M.D., pathologist, passed away on February 17, 2016. He was a founder of Three Rivers Pathology.

WARREN WARRICK, M.D., internist, passed away on February 15, 2016.

He was a pioneer in the treatment of cystic fibrosis.

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May/June 2016

You focus on taking care of patients.

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MetroDoctors

The Journal of the Twin Cities Medical Society

CAREER OPPORTUNITIES

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LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

DAVID ABELSON, M.D. THE MEDICAL PROFESSION IN RECENT YEARS has

undergone remarkable change in both a clinical and administrative sense — most of it of a positive nature. These changes didn’t just occur out of the blue. Countless individuals contributed to effect those advancements, but few of them stand out in bold relief — like our Luminary — as true leaders in this multifaceted endeavor. Let’s see how this came about.

David Abelson was born and raised in Minneapolis and moved directly from 11th grade to the U of M where he obtained his B.A. and M.D. degrees — being honored respectively with summa cum laude distinction and AOA membership.

After completing his U of M residency, Dave joined Internal Medicine Physicians (IMP) as a bright and newly minted private physician. While there his ready smile, calm demeanor, amazing fund of clinical knowledge and ability to practically apply that wisdom led to striking popularity among his growing patient base and respectful collegiality with his peers. That pattern would repeat itself with each ascending step in his thriving career.

Dr. Abelson continued his medicine practice at the much larger Park Nicollet (PN) after five years with IMP, and there became fascinated with medical informatics and data analysis as a key to effect positive change in care delivery. Lead positions in information management and care improvement led to meaningful strides in the early development of clinical guidelines of care. He became PN’s Vice President (V.P.) for Strategic Improvement and directed an Electronic Medical Record (EMR) initiative, which was integrated into their Methodist Hospital, clinic and home care divisions. Other promotions and associated responsibilities came about — including appointments as the Senior V.P. for PN Health Services, Chief Information Officer, President of the $21 million PN Institute dedicated to research and education and the Chief Clinical Officer leading clinic activities of over 1,000 physicians and clinical professionals.

In 2010, David assumed the role of President and CEO of PN — which was soon to become a $1.2 billion annual revenue organization, and then led its direction to shared savings and population health enhancement through a successful merger with HealthPartners (HP).

Accomplishments such as clinical guideline development, EMR institution, directing a medical mega-merger while championing the movement from a volume-based to a 32

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value-based system of caring for people don’t just happen.

Effective and efficient change agent leadership is required, and the attributes required of such a leader include: knowledge of and experience in the current health care environment; a firm grasp of the causal elements that came together to create the current positioning; recognition of opportunities for movement; willingness to challenge the status quo and make tough decisions; clear expression of ideas to inspire and motivate others while building alignment; and finally — the gumption to “pull the trigger.” David Abelson has all of those competencies!

He modestly states that these accomplishments came about mainly via “on-the-job training.” However, it’s clear for others to see that they wouldn’t have occurred without utilizing a stunning variety of personal characteristics including perseverance, brilliance, amiability, humility, forthrightness and a passion to really make a difference.

Dr. Abelson recently retired from his executive position in the HP-PN entity, thus giving him more time to provide counsel to that organization and as a Board member for intriguing smaller companies. He also vigorously pursues a healthy lifestyle with exercise and meditation which has successfully kept health issues stable and at bay. He literally sparkles while describing the quality time and activities devoted to his wife, Susan, his five children and young grandchildren as priceless.

We are proud to have this industrious visionary as our Luminary.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

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