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HOT TOPICS IN NUTRITION AND HOW TO ADVISE YOUR CLIENT

Perrella, Kristen M.S., RDN, CDN; Cerny, Frank J. M.Div., Ph.D., FACSM

doi: 10.1249/FIT.0000000000000281
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Apply It! By reading this article, the health and fitness professional should understand:

• The dietary basis for some of the most prominent current controversies and myths in the food industry.

• How to help clients sort through these controversies and myths and make sensible food choices based on these understandings.

Kristen Perrella, M.S., RDN, CDN, is a registered dietitian nutritionist with her Master of Science in Nutrition from the University at Buffalo, Buffalo, NY. Her work has focused on breastfeeding promotion and supplemental foods for New York State’s Special Supplemental Nutrition Program for Women, Infants, and Children.

Frank J. Cerny, M.Div., Ph.D., FACSM, is a professor emeritus of the departments of exercise and nutrition sciences and pediatrics at the University at Buffalo, Buffalo, NY. His research has focused on chronic childhood diseases and population health.

Disclosure:The authors declare no conflict of interest and do not have any financial disclosures.

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HIGH-FRUCTOSE CORN SYRUP

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Quick Review of Background

High-fructose corn syrup (HFCS) has had a bad rap in recent years. Often looked at as a marker of foods that are off limits, this sugar source is crafted from cornstarch. HFCS is produced by enzymatically converting corn syrup into a high-fructose substance, thus giving it its high-sweetness value and making it less expensive than table sugar. HFCS is extremely sweet and inexpensive, making it ideal for use by food companies.

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Current Status

The prevalence of added sweeteners was particularly prominent in the 1990s. During the low-fat craze of that time, sugar in various forms of sweeteners began infiltrating packaged food, in which the heavily demonized fat was replaced with sugar and salt to maintain palatability. Research has later revealed, however, that excess sugar is a notable contributor of weight gain, obesity, and ultimately preventable chronic diseases such as diabetes.

What started as a sensible sweetener that aligned with the public’s desire for inexpensive food as well as health professionals’ recommendation of limiting fat ultimately has become a problem in and of itself. Although HFCS is convenient and affordable, its use goes against the grain in America’s present-day quest for increasingly natural products. Consumers are searching for minimally processed foods, and HFCS simply does not fit the bill.

Food companies and restaurants have been responding to consumer preferences by eliminating or pledging to remove HFCS from products. Panera Bread recently removed the sweet syrup from its products, whereas Whole Foods has an “Unacceptable Ingredients for Food List,” and HFCS is on it. Even the 1990s favorite SnackWell’s products have been reformulated to not contain HFCS.

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Challenges for the Health Fitness Practitioner

In spite of the increasingly popular decision to remove HFCS, it remains ubiquitous. When people decide to cut it or other added sugars from their diet, it can prove to be a challenge. Part of the challenge lies simply in identifying sources of sugar. Use Table 1 as a guide to determine whether a product contains added sugars.

TABLE 1

TABLE 1

An additional challenge for the health fitness practitioner (HFP) is that in some cases, people can become overly restrictive in their food choices. Watch clients for red flags that could indicate orthorexia, an unhealthy obsession with eating healthy fueled by a concern over consuming a diet without added sugars. These thoughts can become mentally debilitating and ultimately harmful to one’s health, both physically and mentally. A diet as such can easily lack essential nutrients and adequate energy to sustain daily activities. Symptoms to watch for include spending an excessive amount of time worrying about food, isolation and loneliness because of controlling food and food intake, and guilt caused by deviating from one’s pure diet.

Last, removing added sugars, particularly HFCS, can prove to be difficult for those on a limited income. The products that contain added sugars are likely to be attractive to the vulnerable markets of parents purchasing on behalf of children and older adults on a fixed income. Again, HFCS is less expensive than other forms of sugar. Alternatives that do not contain HFCS (but might contain just as much added sugar) are likely to be more expensive. Keep in mind that it is now a marketing tool to proclaim that a product does not contain HFCS, thus creating a health halo for consumers. When one aspect of a product is perceived to be nutritious or healthy, people often automatically assume that the entire product is healthy overall. A brownie that once contained 20 g of HFCS that now contains 20 g of sugar certainly is not a healthy alternative.

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Suggestions/Advice on How to Discuss or Incorporate Going Forward

With this knowledge, going forward, the HFP should emphasize to clients that added sugars do not have any nutritive value. With the release of the U.S. Department of Agriculture’s (USDA) 2015–2020 Dietary Guidelines for Americans (DGA), there is now a numerical limit on one’s sugar consumption. Previously, the guideline was simply to limit added sugars, whereas now, it is recommended to limit added sugars to no more than 10% of one’s total calories. The average person eating 2,000 cal per day, therefore, could have 200 cal or 50 g of added sugar per day.

Although 50 g might seem like a lot of sugar, be mindful that there often are added sugars in foods that are not commonly thought of as sweet, including breads, crackers, nut butters, salad dressings, and sauces. It can add up quickly, especially when consuming sugar-sweetened beverages such as soda, lemonade, and specialty coffee drinks.

Most important, to increase awareness of the added sugars a person consumes, clients should read labels! Sugar is listed under carbohydrates on the food label; however, it currently does not distinguish between sugar that is naturally from fruit or milk versus added sugars. The Food and Drug Administration’s (FDA) revised food label, to be implemented by 2018 for most manufacturers, will distinguish between the two, making it easier to decide what to eat and what to skip (Figure). For additional help in reading food labels, refer your client to a local registered dietitian nutritionist (RDN).

Figure. Fi

Figure. Fi

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Dispelling Myths

  1. Myth: HFCS is drastically different from table sugar.
    1. Fact: The two sugars are chemically very similar. HFCS is 50% to 55% fructose and remaining glucose, whereas table sugar (sucrose) is equal parts fructose and glucose. Keep in mind, however, that when comparing equal volumes of HFCS and sucrose, the increased free fructose of HFCS can potentially lead to increased triglyceride levels (7,8).
  2. Myth: Because fruit contains fructose, I should avoid it.
    1. Fact: Although fruit does in fact contain fructose, it also contains vitamins, minerals, water, and fiber. It is significantly more nutritious than candy. As per the USDA’s MyPlate (2), it is recommended to have approximately 2 cups of fruit per day for the average adult.
  3. Myth: Honey and agave are better than HFCS because they are natural.
    1. Fact: Although honey and agave are in fact natural, they are still sources of added sugar. In fact, agave has a higher percentage of fructose than HFCS does!
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PROBIOTICS

Quick Review of Background

Probiotics are helpful bacteria that are either the same as or similar to that which are found in the gut. They are found in fermented products — think yogurt with live, active cultures, kefir, buttermilk, fermented vegetables such as kimchi and sauerkraut, and in fermented soy products such as miso and tempeh. Prebiotics, in contrast, are dietary fibers that provide food for the probiotics to thrive. Some sources of prebiotics include whole grains, berries, flax, fruit, legumes, garlic, onions, and leeks. For optimal health, include both prebiotics and probiotics in your diet.

Although it is not definitively known how probiotics function in the maintenance of health and gut health, there are a number of existing hypotheses. One is through increasing a person’s immunity via various modes, for example, increasing phagocytosis, the process by which cells engulf harmful material in the blood. Another is that by increasing good bacteria, there is less room for the pathogenic bacteria to thrive. A third hypothesis is that by creating a more acidic environment in the colon due to the results of fermentation, probiotics create a hostile environment for pathogenic bacteria. Last, probiotics promote fecal bulk, leading to a quicker transit time and therefore less exposure to potential toxins (4).

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Current Status

Although the research is not yet conclusive, probiotics continue to be a focus for researchers looking to discover how a person’s gut flora is associated with specific facets of health. They have been associated with improved digestive health and immunity and also can improve calcium absorption by increasing calcium-binding protein expression.

One of the most popular reasons for incorporating probiotics into the diet is to improve the health of a person’s digestive system. Irritable bowel syndrome, commonly referred to as IBS, is a set of symptoms in which a person has recurrent diarrhea and/or constipation. There is not one specific test for IBS, so it is a diagnosis by exclusion. Today, a walk through your local supermarket will reveal a multitude of products touting probiotics and their generally associated gastrointestinal health benefits. As a result, health and fitness professionals are increasingly being asked about probiotics and their relationship to IBS. Essentially, as described previously, probiotics are good bacteria and because the good bacteria flourish, it leaves less space for harmful bacteria. Increased probiotics also are associated with better management of inflammatory bowel disease (IBD) (Crohn disease and ulcerative colitis) and preventing bloating and/or diarrhea. Although it is not yet established how probiotics accomplish these effects, it is currently an exciting area of research. If a client has or suspects that he or she has IBS or IBD, refer him or her to an RDN for help in determining whether a probiotic is right for him or her in addition to determining which foods cause discomfort and/or flare-ups.

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Challenges for the HFP

Although many may be quick to recommend a probiotic supplement, keep in mind that like other supplements, probiotics are not regulated by the FDA. Consumers may prefer simply taking a pill to eating a Greek yogurt, so try to emphasize that with a product such as Greek yogurt, you are getting not only the live, beneficial bacteria, but other key nutrients such as protein and calcium. There are synergistic effects of various nutrients, and isolating one, such as probiotics, could result in suboptimal function of this element as well as others. In most cases, dietitians advocate for a food-first approach. The best way to get nutrients in a person’s diet is typically through food as a part of a balanced diet (6). Check out Table 2 and see if these probiotic and prebiotic-containing foods could fit into your diet.

TABLE 2

TABLE 2

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Suggestions/Advice on How to Discuss or Incorporate Going Forward

On paper, probiotics promise to be the cure-all for digestive health and immune function. Before a client goes out and purchases a probiotic supplement, encourage him or her to speak with his or her physician, reviewing reasons for supplementing and other medications that could potentially interact. There may be more effective methods to cope with the client’s problem at hand. Incorporating probiotic-containing foods into one’s diet, however, is a safe way to potentially improve a person’s digestive and immune health without the risk of supplement use.

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GLUTEN

Quick Review of Background

Gluten is a protein found in wheat, rye, and barley. It provides elasticity and chewiness to foods such as pizza, pasta, and bread. A gluten-free diet is most commonly associated with celiac disease, an autoimmune disease affecting 1 in 133 Americans (5). When a person with celiac disease ingests food containing gluten, an immune response is elicited, causing damage to the lining or villi of the small intestine where many nutrients are absorbed. The only treatment is a lifelong gluten-free diet that restores the lining of the small intestine and ultimately corrects any deficiencies caused by the previous disruption.

There also are people who may have a wheat allergy, in which case a person has an allergic reaction to wheat. An allergy is present when a person has an immune system response to an offending food, whereas a sensitivity or intolerance will lead to digestive distress. With sensitivity, it is possible that small amounts of the offending food can be consumed before symptoms appear. Finally, there are people who may have gluten intolerance, where they have gastrointestinal issues that resemble IBS due to gluten consumption. Studies, however, have shown that this is commonly due to certain carbohydrates collectively referred to as FODMAPs, which can be difficult for people to digest (1,3). Before a client eliminates gluten from his or her diet, encourage him or her to a see a medical professional who can test for celiac disease and wheat allergy before defaulting to a nonceliac gluten sensitivity, which is a diagnosis of exclusion. If, after testing and diagnosis, a client is prescribed a gluten-free diet, refer him or her to an RDN to help make necessary modifications to his or her diet.

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Current Status

Although there are legitimate reasons for eliminating gluten from the diet, for example, celiac disease and gluten intolerance, there are many people who believe a diet without gluten in and of itself will lead to weight loss and better overall health. By removing gluten without medical need, it is easy to miss out on important B vitamins, which help to convert food to energy, because it is not common for gluten-free breads, baked goods, and cereals to be fortified. In addition, removing wheat may eliminate a source of fiber from the diet. It also is important to note that gluten-free baked goods are not necessarily healthier than their gluten-containing counterparts. Many gluten-free products such as baked goods or crackers contain increased fat and/or sugar compared with traditional products to make up for a difference in texture because of the removal of gluten. Last, substituting gluten-free pasta for pasta or gluten-free bread for bread can prove to be very costly.

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Challenges for the HFP

A client may insist on eating a gluten-free diet for a number of reasons. If a person believes he or she feels better as a result of eliminating gluten, it is important to insist that he or she reintroduces gluten and makes an appointment with his or her doctor to be tested for celiac disease. Because the intestinal villi of a person with celiac disease are restored by a gluten-free diet, a small intestine biopsy, which tests for celiac disease, will turn up negative without the affected person resuming a gluten-containing diet. Doing so will allow for the potential diagnosis to be made. Because celiac disease is an autoimmune disease, it is important that it does not go untreated because it can lead to the susceptibility of other autoimmune diseases.

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Suggestions/Advice on How to Discuss or Incorporate Going Forward

With this information, it is important to emphasize that eliminating gluten does not automatically make a person healthier. One reason that many people feel better by removing gluten from the diet is because they cut down on snacks such as baked goods and crackers as well as foods that people tend to consume in excess such as pasta and breads.

If a person does, in fact, have a medical reason to avoid gluten, it is critical that he or she becomes an avid label reader. Ingredients such as wheat, rye, and barley are found in products that one might not think of right away, such as beer and soy sauce. In addition, the client should be well versed in food safety practices to avoid cross-contamination with gluten-containing products.

See Table 3 for a quick reference of foods that contain gluten and foods that are gluten free.

TABLE 3

TABLE 3

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ORGANIC

Quick Review of Background

People tend to seek out organic foods for health, ethical, or sustainability reasons. In reference to meat, poultry, eggs, and dairy, organic products come from animals that have not been given antibiotics or growth hormones. Organic produce, however, is grown only with USDA-approved pesticides and without fertilizers containing synthetic ingredients or sewage, bioengineering, or ionizing radiation.

The USDA has defined three levels of labeling claims for organic products. Foods that are entirely organic can be labeled as “100-percent organic” and qualify for the USDA Organic Seal; foods labeled as “organic” contain at least 95% organic products and qualify for the USDA Organic Seal as well; and finally, products that are “made with organic ingredients” contain at least 70% certified organic ingredients; however, the USDA Organic Seal may not be used.

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Current Status

A walk through most supermarkets’ natural sections will reveal not only organic grains and soups but also organic chips, crackers, cookies, and cakes. An organic cookie is not automatically healthy, and there is little reason to purchase an item simply because it is labeled as an organically processed food. At the same time, organic products are not inherently more harmful, either.

Deciding to purchase organic for sustainability is becoming more and more common. Organic foods have been shown to require less energy, reduce pesticide residues in food and water, enhance biodiversity, and improve organic matter in the soil.

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Challenges for the HFP

For people on a budget, it can be difficult to justify the cost of organic foods. An easy way to cut costs is to purchase organic produce when it is in season and more likely to be comparable in price with nonorganic foods. It also is important to emphasize that consuming fruits and vegetables is critical in maintaining a healthy diet regardless of whether the produce is organic. Fruits and vegetables in any form, fresh, frozen, or canned, provide vitamins and minerals that are necessary for proper functioning of all processes in the body. Besides the vitamins and minerals, fruits and vegetables are essential for maintaining a healthy weight because they are low in calories and contain fiber and water to keep you feeling fuller, longer.

Just like vegetables, the fact that animal-based products are organic does not mean that they better meet your body’s nutritional needs. Clients might choose to restrict protein if an organic source is unavailable, and that should be discouraged. Animal or plant-based protein should be approximately a quarter of a person’s diet, regardless of whether it is organic, according to the USDA’s MyPlate. The HFP should encourage the client to speak with an RDN to learn more about protein and how to incorporate it into the diet for optimal performance.

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Suggestions/Advice on How to Discuss or Incorporate Going Forward

The Environmental Working Group® (EWG) tests produce for pesticide levels and compiles a list each year of what is known as the “Clean 15” and the “Dirty Dozen” to help guide consumers in their purchases. The Dirty Dozen are conventionally grown foods that have been found to contain higher levels of pesticides, whereas the Clean 15 are conventionally grown foods that are lower in pesticides. Therefore, if you want to purchase some organic produce but not all, select the organic options of the Dirty Dozen for your best value because those contain the most pesticides when conventionally grown. The Clean 15, however, are lower in pesticides to begin with, so purchasing the conventional form is just fine (Table 4).

TABLE 4

TABLE 4

If a person insists on and can afford purchasing all organic produce and animal products, that is great; however, adequate nutrition should be prioritized if it means the difference between 1 serving of organic produce per day and 3 servings of conventional produce per day.

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BRIDGING THE GAP

In an attempt to satisfy consumer demand for cheap food with appealing taste, manufacturers have resorted to manipulations that may not result in healthy foods or healthy eating habits. It is important for the HFP to understand the most prominent current food controversies to help clients make better, healthier food choices. A big step in helping clients sort through these issues is that it is recommended that the HFP teaches clients how to read food labels and identify products that may sound healthy, but which may have made trade-offs that, in fact, result in unhealthy food choices.

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References

1. Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, Gibson PR. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterology. 2013;145(2):320–8.
2. Choose MyPlate Web Site [Internet]. Alexandria, VA: USDA; [cited June 12, 2016]. Available from: http://www.choosemyplate.gov/fruit.
3. De Giorgio R, Volta U, Gibson PR. Sensitivity to wheat, gluten, and FODMAPs in IBS: facts or fiction? Gut. 2016;65(1):169–78.
4. Gropper SS, Smith JL. Advanced Nutrition and Human Metabolism. 6th ed. Belmont (CA): Wadsworth, Cengage Learning; 2013. p. 55–6.
5. Gujral N, Freeman HJ, Thomson AB. Celiac disease: prevalence, diagnosis, pathogenesis and treatment. World J Gastroenterol. 2012;18(42):6036–59.
6. Homayoni Rad A, Vaghef Mehrabany E, Alipoor B, Vaghef Mehrabany L. The comparison of food and supplement as probiotic delivery vehicles. Crit Rev Food Sci Nutr. 2016;56(6):896–909.
7. Silbernagel G, Machann J, Unmuth S, et al. Effects of 4-week very-high fructose/glucose diets on insulin sensitivity visceral fat and intrahepatic lipids: an exploratory trial. Br J Nutr. 2011;106(1):79–86.
8. Stanhope KL, Bremer AA, Medici V, et al. Consumption of fructose and high fructose corn syrup increase postprandial triglycerides, LDL-cholesterol, and apolipoprotein-B in young men and women. J Clin Endocrinol Metab. 2011;96(10):E1596–605.
Keywords:

Sugar; Gluten; Organic; Probiotics; Nutrition

© 2017 American College of Sports Medicine.