Should Clinicians Ever Recommend Supplements to Patients Trying to Lose Weight?

Helping patients lose weight can mitigate their risk of chronic disease and improve their quality of life. Over-the-counter dietary supplements for weight loss, however, are not reviewed or approved for safety or efficacy, nor does evidence support their clinical use. This commentary on a case suggests 3 reasons why clinicians cannot ethically recommend these supplements to patients: these products' safety and efficacy are unknown, ingredient lists might not be complete, and advertising could be misleading. This article reviews facts clinicians should know regarding over-the-counter weight loss products and explains how they can support, educate, and promote culturally and individually sensitive weight-management strategies.

Effectiveness of Education Interventions Designed to Improve Nutrition Knowledge in Athletes: A Systematic Review.

BACKGROUND: A range of nutrition education strategies are used to assist athletes to improve nutrition knowledge. Evaluation of nutrition education interventions guides the delivery of efficacious nutrition education for athletes. AIM: Our aim was to systematically review sport/general nutrition education interventions delivered to athletes, and to evaluate their effectiveness. METHODS: A search was conducted using terms related to nutrition knowledge, athletes, education, and intervention. Included studies had to be conducted in athletes (all calibres), use a scored nutrition knowledge assessment tool, and measure knowledge before and after a nutrition education intervention. Peer-reviewed and unpublished theses were included. RESULTS: Thirty-two manuscripts (randomised controlled trial, n = 13; single-arm pre/post design, n = 19) met the inclusion criteria. Participants (n = 2180; mean age 17.4 ± 1.7 years) were mostly female (66.1%), university-level (56.3%) athletes based in the US (75%). Comparison of different education methods was limited since the majority of interventions (n = 28/36, 77.8%) used face-to-face education. Most intervention conditions (n = 19) had a total contact time of < 300 min (5 h). The majority of interventions (n = 30, 85.7%) reported significant knowledge improvement, with a mean increase of 16.1 ± 0.7% (mean effect size 1.72; range 0.4-17.1). Only 15.6% of studies used well-validated knowledge assessment tools (more than three types of validity or reliability testing). CONCLUSIONS: Most interventions reported a significant improvement in nutrition knowledge. Unfortunately, the wide range of knowledge assessment tools with limited validation, and the predominant use of face-to-face interventions, prohibits identification of the most effective modality and dose for nutrition education in athletes.

How Low-Income Mothers Select and Adapt Recipes and Implications for Promoting Healthy Recipes Online.

We describe a 5-year (2011⁻2015) qualitative evaluation to refine the content/delivery of the Food Hero social marketing campaign recipes to low-income mothers. Objectives were to: (1) identify characteristics looked for in recipes; (2) determine recipe sources; (3) understand motivation for seeking new recipes and recipe adaptations; and (4) identify recipe website characteristics users valued. Nine focus groups (n = 55) were conducted in Portland, Oregon. Participants (35⁻52 years) were primary caregivers for ≥ one child, the primary household food shoppers/preparers, enrolled in the Supplemental Nutrition Assistance Program (SNAP) and able to speak/read English. Participants reported having "go-to" family recipes and regularly searching online for new recipes, especially those using ingredients available/preferred by family members. Recipe websites with highest appeal were polished and engaging to mothers/children, offered user-ratings/comments and were reachable from search engines. Results identified key recommendations: (1) understand the target audience; (2) aim to add healthy/customizable recipes to family "go-to' recipe rotations and understand the impact of generational influences (e.g. how mothers/grandmothers cooked) on family meals; and (3) create websites that meet target audience criteria. Seeking the target audience's input about the content/delivery of recipes is an important formative step for obesity-prevention projects that include healthy recipes.

Changes in Sport Nutrition Knowledge, Attitudes/Beliefs and Behaviors Following a Two-Year Sport Nutrition Education and Life-Skills Intervention among High School Soccer Players.

The purpose of this study was to examine the impact of a sport nutrition education and life-skills intervention on sport nutrition knowledge (SNK), attitudes/beliefs and dietary behaviors relevant to sport nutrition among high school (HS) soccer players. Three assessments were done over the 2-year intervention (baseline = time 1, end year 1 = time 2, end year 2 = time 3). Participants (n = 217; females = 64%; Latino = 47.5%; 14.9 ± 0.9-year; 46.5% National School Breakfast/Lunch Program) were assigned to an intervention group (IG, n = 153; 9 schools) or comparison group (CG, n = 64; 4 schools) based on geographical location. Differences over time were examined based on group, sex, socioeconomic status (SES) and race/ethnicity. The IG increased SNK scores by ~10% (time 1 = 51.6%; time 3 = 60.9%; p ≤ 0.001), with the greatest change in the female IG vs. CG and no differences in male IG vs. CG. Daily breakfast consumption was 53.7% in both groups. IG players were 3 times more likely (95%CI = 2.59, 7.77) to report trying to eat for performance (IG = 48.7% vs. CG = 30.2%). By time 3, IG players were less likely to report that 'diet met nutritional requirements' (31.6%) compared to CG (47.6%). For IG, the consumption of lunch (≥5-days/week) did not change (92.2⁻93.4%), but declined in the CG (90.6%) (p = 0.04). No other differences by sub-population (race/ethnicity, SES) were observed. Our findings indicate that HS athletes are motivated to learn and improve diet behaviors, and benefit from team-based nutrition interventions. Future interventions should consider delivery of curriculum/experiential learning during a defined training period, with messages reinforced with supports at home, school and athletic settings.

Promoting Healthy Diet, Physical Activity, and Life-Skills in High School Athletes: Results from the WAVE Ripples for Change Childhood Obesity Prevention Two-Year Intervention.

The purpose of this study was to compare changes in diet and daily physical activity (PA) in high school (HS) soccer players who participated in either a two-year obesity prevention intervention or comparison group, while controlling for sex, race/ethnicity, and socioeconomic status. Participants (n = 388; females = 58%; Latino = 38%; 15.3 ± 1.1 years, 38% National School Breakfast/Lunch Program) were assigned to either an intervention (n = 278; 9 schools) or comparison group (n = 110; 4 schools) based on geographical location. Pre/post intervention assessment of diet was done using Block Fat/Sugar/Fruit/Vegetable Screener, and daily steps was done using the Fitbit-Zip. Groups were compared over-time for mean changes (post-pre) in fruit/vegetables (FV), saturated fat (SF), added sugar, and PA (daily steps, moderate-to-vigorous PA) using analysis of covariance. The two-year intervention decreased mean added sugar intake (-12.1 g/day, CI (7.4, 16.8), p = 0.02); there were no differences in groups for FV or SF intake (p = 0.89). For both groups, PA was significantly higher in-soccer (9937 steps/day) vs. out-of-soccer season (8117 steps/day), emphasizing the contribution of organized sports to youth daily PA. At baseline, Latino youth had significantly higher added sugar intake (+14 g/day, p < 0.01) than non-Latinos. Targeting active youth in a diet/PA intervention improves diet, but out of soccer season youth need engagement to maintain PA (200).

WAVE~Ripples for Change Obesity Two-Year Intervention in High School Soccer Players: Process Evaluation, Best Practices, and Youth Engagement.

This paper reports the process data on program fidelity, best practices for intervention implementation, youth and coach engagement, and youth application of knowledge and skills for the two-year WAVE~Ripples for Change (WAVE) obesity prevention intervention program focused on healthy eating, physical activity, and life skills with high school (HS) soccer players aged 14⁻19 years. Internal (staff: n = 7; volunteers: n = 27) and external (youth: n = 100; coaches: n = 9) stakeholders were interviewed/ surveyed. Staff rated program fidelity as high (94%), as did volunteers (85%). Best practices included coach encouragement for athlete participation, use of on-line consent for enrollment, building relationships with HS staff to complete assessments, sending text reminders, and providing incentives. Study results showed an enrollment rate of 72%, completion of baseline assessments of 89⁻98%, attendance of sports nutrition lessons in Year 1 and Year 2 of 90% and 39%, respectively, and team-building workshop (TBW) attendance of 25⁻31%. Activities exceeding youth expectations (>90%) included, (1) activities with their soccer team; (2) the TBW-cooking; and (3) sports nutrition lessons. The obesity prevention skills most applied by youth were obtained from the TBW-gardening and harvesting (49%), the TBW-cooking (43%), and sports nutrition lessons (44%). Coaches also rated the sports nutrition lessons highly and reported increased awareness for hydration/fueling during sport by the athletes. Using sport teams/clubs to engage youth in obesity prevention is a feasible model for future study.

Dynamic Energy Balance: An Integrated Framework for Discussing Diet and Physical Activity in Obesity Prevention-Is it More than Eating Less and Exercising More?

Understanding the dynamic nature of energy balance, and the interrelated and synergistic roles of diet and physical activity (PA) on body weight, will enable nutrition educators to be more effective in implementing obesity prevention education. Although most educators recognize that diet and PA are important for weight management, they may not fully understand their impact on energy flux and how diet alters energy expenditure and energy expenditure alters diet. Many nutrition educators have little training in exercise science; thus, they may not have the knowledge essential to understanding the benefits of PA for health or weight management beyond burning calories. This paper highlights the importance of advancing nutrition educators' understanding about PA, and its synergistic role with diet, and the value of incorporating a dynamic energy balance approach into obesity-prevention programs. Five key points are highlighted: (1) the concept of dynamic vs. static energy balance; (2) the role of PA in weight management; (3) the role of PA in appetite regulation; (4) the concept of energy flux; and (5) the integration of dynamic energy balance into obesity prevention programs. The rationale for the importance of understanding the physiological relationship between PA and diet for effective obesity prevention programming is also reviewed.

Sport Nutrition Knowledge, Behaviors and Beliefs of High School Soccer Players.

For adolescent athletes (14-18 years), data on sport nutrition knowledge, behaviors and beliefs are limited, especially based on sex, race/ethnicity and socioeconomic status. High school soccer players (n = 535; 55% female; 51% White, 41% Latino; 41% National School Lunch Program (NSLP) participants (80% Latino)) completed two questionnaires (demographic/health history and sport nutrition). The sport nutrition knowledge score was 45.6% with higher scores in NSLP-Whites vs. NSLP-Latinos (p < 0.01). Supplement knowledge differed by sex (16% lower in females; p = 0.047) and race/ethnicity (33% lower in Latinos; p < 0.001). Breakfast consumption was 57%; females ate breakfast less (50%) than males (60%; p < 0.001); NSLP-participants ate breakfast less (47%) than non-NSLP (62%; p < 0.001). Supplement use was 46%, with Latinos using more supplements than Whites do (p = 0.016). Overall, 30% used protein shakes, with females using less than males (p = 0.02), while use was twice as likely in Latino vs. White (p = 0.03). Overall, 45% reported their nutrient requirements were different from non-athlete peers. Latinos were less likely (p = 0.03) to report that their diet met nutritional requirements, but more than twice as likely to report that nutritional supplements were necessary for training (p < 0.001). Adolescent athletes, especially females and Latinos, would benefit from sport nutrition education that enhances food selection skills for health and sport performance.

The Family Home Environment, Food Insecurity, and Body Mass Index in Rural Children.

BACKGROUND: Family homes are a key setting for developing lifelong eating and physical activity habits, yet little is known about how family home nutrition and physical activity (FNPA) environments influence food insecurity (FI) and childhood obesity, particularly in rural settings. AIMS: This study examined associations among FNPA, FI, and body mass index (BMI) in rural children. METHOD: Parents of 186 elementary school-age children completed FNPA and FI surveys. Child anthropometrics were directly measured. Logistic and linear regressions were used to examine associations. RESULTS: Approximately 37% of children were overweight/obese; 43% of families were at risk for FI. Children whose families limited watching TV while eating were less likely to be obese (odds ratio [OR] = 0.56, p = .03) as were children whose families monitored intake of chips, cookies, and candy (OR = 0.54, p = .01). FI was higher in obese than normal weight children (OR = 11.00, p = .003) but only among families not eligible to receive free/reduced-cost school meals. Among eligible families, lower odds of FI were found for those who ate meals together often (OR = 0.31, p = .04) and for those with children frequently enrolled in organized sports/activities (OR = 0.65, p = .04). Findings were not significant after adjusting for multiple comparisons. DISCUSSION: Results suggest that favorable FNPA factors were associated with healthier BMI and lower odds of FI. CONCLUSION: Opportunities for healthy eating at home may support rural children's weight health. Additional resources may be necessary to promote food security among low-income families. Future research is warranted to better understand FNPA in relationship to the disproportionate rates of obesity and FI in rural populations.

Reaching Low-Income Mothers to Improve Family Fruit and Vegetable Intake: Food Hero Social Marketing Campaign-Research Steps, Development and Testing.

The objective of this study was to create/test a social marketing campaign to increase fruit/vegetable (FV) intake within Oregon Supplemental Nutrition Assistance Program (SNAP) eligible families. Focus groups (n = 2) and pre/post campaign phone surveys (n = 2082) were conducted in intervention counties (IC) and one control county. Participants were female (86%-100%) with 1-2 children at home. Mean FV intake/without juice was 3.1 servings/day; >50% preferred the Internet for delivery of healthy eating information. Participants reported time/financial burdens, low household FV variety and desirability of frozen/canned FV, and acceptance of positive messages. A Food Hero (FH) campaign was created/delivered daily August-October 2009 to mothers through multiple channels (e.g., grocery stores, online, educators). Results showed that the IC had better FH name recall (12%) and interpretation of intended messages (60%) vs. control (3%, 23%, respectively). Compared to controls, the IC were less likely to report healthy food preparation as time consuming or a FV rich diet expensive, and it was easier to get their family to eat fruit. Results did not vary based on county/household characteristics. The FH campaign increased FH awareness and positive FV beliefs. A longer campaign with FV assessments will increase understanding of the target audience, and allow for campaign refinement.

No Effect of Exercise Intensity on Appetite in Highly-Trained Endurance Women.

In endurance-trained men, an acute bout of exercise is shown to suppress post-exercise appetite, yet limited research has examined this response in women. The purpose of this study was to investigate the effect of exercise intensity on appetite and gut hormone responses in endurance-trained women. Highly-trained women (n = 15, 18-40 years, 58.4 ± 6.4 kg, VO2MAX = 55.2 ± 4.3 mL/kg/min) completed isocaloric bouts (500 kcals or 2093 kJ) of moderate-intensity (MIE, 60% VO2MAX) and high-intensity (HIE, 85% VO2MAX) treadmill running at the same time of day, following a similar 48-h diet/exercise period, and at least 1-week apart. Blood was drawn pre-exercise (baseline), immediately post-exercise and every 20-min for the next 60-min. Plasma concentrations of acylated ghrelin, PYY3-36, GLP-1 and subjective appetite ratings via visual analog scale (VAS) were assessed at each time point. Acylated ghrelin decreased (p = 0.014) and PYY3-36 and GLP-1 increased (p = 0.036, p < 0.0001) immediately post-exercise, indicating appetite suppression. VAS ratings of hunger and desire to eat decreased immediately post-exercise (p = 0.0012, p = 0.0031, respectively), also indicating appetite suppression. There were no differences between exercise intensities for appetite hormones or VAS. Similar to males, post-exercise appetite regulatory hormones were altered toward suppression in highly-trained women and independent of energy cost of exercise. Results are important for female athletes striving to optimize nutrition for endurance performance.

Vegetarian, Gluten-Free, and Energy Restricted Diets in Female Athletes.

Female athletes who follow a diet that fails to meet energy and nutrient needs are at risk for musculoskeletal injuries, menstrual disturbances, and poor sports performance. Common nutritional concerns for the female athlete include low energy availability (EA) (i.e., energy intake from food remaining for metabolic processes after accounting for energy expended during exercise) and inadequate dietary intakes (i.e., not meeting sports nutrition guidelines) of carbohydrates, protein, essential fatty acids (EFAs), B-vitamins, calcium, iron, and vitamin D. Low EA and the associated nutrient deficiencies are more common in athletes who compete in weight-sensitive sports (i.e., aesthetic, gravitational, and weight category sports) because low body fat and mass confer a competitive advantage. Other athletes at risk for energy and nutrient deficits include athletes following a vegetarian or gluten-free diet (GFD). Careful dietary planning can help an athlete meet energy and nutrient needs. This review covers the nutrition issues associated with low EA and special diets (i.e., vegetarian and GFD) and describes strategies to help female athletes meet their energy and nutrient needs.

Weight Management for Athletes and Active Individuals: A Brief Review.

Weight management for athletes and active individuals is unique because of their high daily energy expenditure; thus, the emphasis is usually placed on changing the diet side of the energy balance equation. When dieting for weight loss, active individuals also want to preserve lean tissue, which means that energy restriction cannot be too severe or lean tissue is lost. First, this brief review addresses the issues of weight management in athletes and active individuals and factors to consider when determining a weight-loss goal. Second, the concept of dynamic energy balance is reviewed, including two mathematical models developed to improve weight-loss predictions based on changes in diet and exercise. These models are now available on the Internet. Finally, dietary strategies for weight loss/maintenance that can be successfully used with active individuals are given. Emphasis is placed on teaching the benefits of consuming a low-ED diet (e.g., high-fiber, high-water, low-fat foods), which allows for the consumption of a greater volume of food to increase satiety while reducing energy intake. Health professionals and sport dietitians need to understand dynamic energy balance and be prepared with effective and evidence-based dietary approaches to help athletes and active individuals achieve their body-weight goals.

The Family-Home Nutrition Environment and Dietary Intake in Rural Children.

Obesity and food insecurity rates are higher among rural compared to non-rural populations. Little is known, however, about how family-home environments influence childhood obesity-related behaviors, particularly in rural settings. This study examined associations between the family-home nutrition (FN) environment, food insecurity, and dietary intake (fruits, vegetables, whole grains, dairy, protein foods, and added sugars) in rural elementary school-age children (grades K-5/6; n = 102). Parents/caregivers completed surveys on FN, food insecurity, and the Block Kids Food Screener (BKFS). Body mass index (BMI, kg/m2) was calculated from measured height and weight. Approximately 33% of children were classified as overweight/obese and 28% of families were at-risk for food insecurity. Multivariable linear regression analyses examined associations between dietary intakes with FN and food insecurity. More favorable FN scores were associated with lower added sugar intake (B = -1.38, p = 0.04) and higher vegetable (B = 0.15, p < 0.001), fruit (B = 0.71, p = 0.01), and dairy (B = 0.31, p < 0.001) intakes. No significant associations were found between food insecurity and dietary intake. Given the association between higher FN scores and more favorable dietary intake, promoting healthy FN environments among rural children is warranted.

Exercise-trained men and women: role of exercise and diet on appetite and energy intake.

The regulation of appetite and energy intake is influenced by numerous hormonal and neural signals, including feedback from changes in diet and exercise. Exercise can suppress subjective appetite ratings, subsequent energy intake, and alter appetite-regulating hormones, including ghrelin, peptide YY, and glucagon-like peptide 1(GLP-1) for a period of time post-exercise. Discrepancies in the degree of appetite suppression with exercise may be dependent on subject characteristics (e.g., body fatness, fitness level, age or sex) and exercise duration, intensity, type and mode. Following an acute bout of exercise, exercise-trained males experience appetite suppression, while data in exercise-trained women are limited and equivocal. Diet can also impact appetite, with low-energy dense diets eliciting a greater sense of fullness at a lower energy intake. To date, little research has examined the combined interaction of exercise and diet on appetite and energy intake. This review focuses on exercise-trained men and women and examines the impact of exercise on hormonal regulation of appetite, post-exercise energy intake, and subjective and objective measurements of appetite. The impact that low-energy dense diets have on appetite and energy intake are also addressed. Finally, the combined effects of high-intensity exercise and low-energy dense diets are examined. This research is in exercise-trained women who are often concerned with weight and body image issues and consume low-energy dense foods to keep energy intakes low. Unfortunately, these low-energy intakes can have negative health consequences when combined with high-levels of exercise. More research is needed examining the combined effect of diet and exercise on appetite regulation in fit, exercise-trained individuals.

Dietary intervention restored menses in female athletes with exercise-associated menstrual dysfunction with limited impact on bone and muscle health.

Exercise-related menstrual dysfunction (ExMD) is associated with low energy availability (EA), decreased bone mineral density (BMD), and increased risk of musculoskeletal injury. We investigated whether a 6-month carbohydrate-protein (CHO-PRO) supplement (360 kcal/day, 54 g CHO/day, 20 g PRO/day) intervention would improve energy status and musculoskeletal health and restore menses in female athletes (n = 8) with ExMD. At pre/post-intervention, reproductive and thyroid hormones, bone health (BMD, bone mineral content, bone markers), muscle strength/power and protein metabolism markers, profile of mood state (POMS), and energy intake (EI)/energy expenditure (7 day food/activity records) were measured. Eumenorrheic athlete controls with normal menses (Eumen); n = 10) were measured at baseline. Multiple linear regressions were used to evaluate differences between groups and pre/post-intervention blocking on participants. Improvements in EI (+382 kcal/day; p = 0.12), EA (+417 kcal/day; p = 0.17) and energy balance (EB; +466 kcal/day; p = 0.14) were observed with the intervention but were not statistically significant. ExMD resumed menses (2.6 ± 2.2-months to first menses; 3.5 ± 1.9 cycles); one remaining anovulatory with menses. Female athletes with ExMD for >8 months took longer to resume menses/ovulation and had lower BMD (low spine (ExMD = 3; Eumen = 1); low hip (ExMD = 2)) than those with ExMD for <8 months; for 2 ExMD the intervention improved spinal BMD. POMS fatigue scores were 15% lower in ExMD vs. Eumen (p = 0.17); POMS depression scores improved by 8% in ExMD (p = 0.12). EI, EA, and EB were similar between groups, but the intervention (+360 kcal/day) improved energy status enough to reverse ExMD despite no statistically significant changes in EI. Similar baseline EA and EB between groups suggests that some ExMD athletes are more sensitive to EA and EB fluctuations.

Energy balance at a crossroads: translating the science into action.

UNLABELLED: One of the major challenges facing the United States is the high number of overweight and obese adults and the growing number of overweight and unfit children and youth. To improve the nation's health, young people must move into adulthood without the burden of obesity and its associated chronic diseases. PURPOSE: To address these issues, the American College of Sports Medicine, the Academy of Nutrition and Dietetics, and the US Department of Agriculture/Agriculture Research Service convened an expert panel meeting in October 2012 titled "Energy Balance at a Crossroads: Translating the Science into Action." Experts in the fields of nutrition and exercise science came together to identify the biological, lifestyle, and environmental changes that will most successfully help children and families attain and manage energy balance and tip the scale toward healthier weights. METHODS: Two goals were addressed: 1) professional training and 2) consumer/community education. The training goal focused on developing a comprehensive strategy to facilitate the integration of nutrition and physical activity (PA) using a dynamic energy balance approach for regulating weight into the training of undergraduate and graduate students in dietetics/nutrition science, exercise science/PA, and pre-K-12 teacher preparation programs and in training existing cooperative extension faculty. The education goal focused on developing strategies for integrating dynamic energy balance into nutrition and PA educational programs for the public, especially programs funded by federal/state agencies. RESULTS: The meeting expert presenters and participants addressed three key areas: 1) biological and lifestyle factors that affect energy balance, 2) undergraduate/graduate educational and training issues, and 3) best practices associated with educating the public about dynamic energy balance. CONCLUSIONS: Specific consensus recommendations were developed for each goal.