Master of Science in Nutrition and Dietetics Student at King's College
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Biochemistry of nutrition I
The Mayo Clinic Diet Podcast Episode
Welcome to the Monarch Health Bites! My name is Emma Becker and I’m a Graduate student in the M.S. Nutrition Science Program here at King’s College. Today I am going to chat with you about "The Mayo Clinic Diet." Many of us have heard of the esteemed Mayo Clinic. Mayo Clinic Hospitals are known for their cutting-edge research and for being one of the top-ranked hospitals in the country.(1) Because of this, it’s natural to think that a weight-loss diet designed by a doctor from the Mayo Clinic would be one of the best weight-loss diets you can try! Except, it’s not. But we’ll get into that later. First, let’s discuss what "The Mayo Clinic Diet" is. The 12-week "Mayo Clinic Diet" claims to be a different kind of weight-loss program that’s designed more as a life-style approach to help you improve your health and reduce your risk of developing chronic diseases.(2) It is broken into two phases, the "Lose it!" phase and the "Live it!" phase. Let’s dig a little deeper into these two phases. The "Lose it!" phase lasts two weeks and tells diet participants to add 5 habits, to break 5 habits, and to optionally adopt 5 bonus habits.(2) So what are these mandatory habits? The “Add 5” habits consist of eating a healthy breakfast, eating 4 or more servings of vegetables and 3 or more servings of fruits, eating whole grains, eating healthy fats, and exercising for 30 or more minutes every day.(2) The 5 habits to break consist of avoiding TV while eating, avoiding sugar, avoiding snacks, limiting meat and low-fat dairy, and to avoid eating out at restaurants.(2) The next phase, which is the "Live it!" phase lasts a total of 10-weeks and encourages diet participants to continue the 10 mandatory habits created during the previous phase but also claims to teach diet participants how to set goals and determine calorie limits. However, when it’s time to determine calorie limits, we realize that "The Mayo Clinic Diet" is just a fancy name for another low-calorie fad diet. We know this because "The Mayo Clinic Diet" recommends that a woman weighing 250 pounds or less consume only 1200 calories daily and that a man weighing 250 pounds or less should consume only 1400 calories daily.(2) For reference, 1200 calories is the recommended daily nutrition goals for female children between the ages of 4-8 and 1400 calories is recommended for male children between the ages of 4-8.(3) When "The Mayo Clinic Diet" is recommending an adult weighing 250 pounds or less consume the same amount of calories that’s recommended for children between the ages of 4-years old and 8-years old, we know that this is just another fad diet that is not recommended nor sustainable over the long term. So, what can you do instead? Focus on filling half your plate with fruits and vegetables, a quarter of your plate with protein, a quarter of your plate with grains (ensure half of all grains are whole grains) and consume dairy or dairy alternatives. This will ensure you establish a balanced dietary pattern that is sustainable over the long-term! Nutrition isn’t complicated, don’t let these fad diet books try and convince you otherwise, even if they have a fancy name, such as "The Mayo Clinic Diet!" References 1. Mayo Clinic. Quality and Mayo Clinic. Accessed February 18, 2024. https://www.mayoclinic.org/about-mayo-clinic/quality/rankings 2. Hensrud D. The Mayo Clinic Diet. 3rd ed. Rochester, MN: Mayo Clinic Press; 2023. 3. US Department of Health and Human Services. Appendix E-3.1.A4. Nutritional goals for each age/sex group used in assessing adequacy of USDA Food Patterns at various calorie levels. heath.gov Updated January 5, 2022. Accessed February 18, 2024. https://health.gov/our-work/nutrition-physical-activity/dietary-guidelines/previous-dietary-guidelines/2015/advisory-report/appendix-e-3/appendix-e-31a4
Reflection
I enjoyed completing a thorough critique of "The Mayo Clinic Diet." I suspected "The Mayo Clinic Diet" was a fad diet book prior to completing the formal critique as the front cover tagline stated, “Lose up to 6 to 10 lbs. in 2 weeks.” This stood out to me because losing 6- to 10-pounds in 2 weeks is both unhealthy and unsustainable. However, I was able to accurately identify this book as a fad diet book when, on page 86, this book recommends that adult men and women consume the same number of calories as female and male children between the ages of 4-years-old and 8-years-old. This led to me concluding that "The Mayo Clinic Diet" is just a fancy name for another low-calorie, fad diet. Send me a message via the "Contact" tab and let me know what you think of "The Mayo Clinic Diet" podcast episode!
Modulen IBD
1. What are some Pros and Cons of your product, and reasons for these. There are many pros to Modulen® IBD. First, Modulen® IBD is a polymeric formula designed specifically for Crohn’s disease (CD) patients that can be used either as exclusive enteral nutrition (EEN) or oral exclusive nutrition during the active phase of disease (flare-ups) or as nutritional support during remission.(1,2) The fact that this formula is specifically formulated for CD patients is a huge pro, as the scientists who designed this formula considered the unique nutritional needs of CD patients. Another pro of Modulen® IBD is that when used as the sole source of nutrition (either as EEN or orally), complete nutritional uptake of macronutrients may occur as the casein-based powdered formula consists of 44% carbohydrates, 42% lipids, and 14% proteins.(1,3) Additionally, the Dietary Reference Intakes for adults are met for 13 vitamins and 15 minerals.(1) Another pro is that this formula was designed to have a low osmolality level to support good feeding tolerance (340 mOsm/kg per 100 g).(2) This is important because the better a product tastes and the more palatable it is, the better patient compliance may be. Another major pro is that several studies suggest that Modulen® IBD is effective at inducing remission in pediatric IBD patients.(1) This is important because many pediatric IBD patients suffer from debilitating flare-ups that may significantly decrease overall quality of life and may cause long-term side effects that include malnutrition, micronutrient deficiencies (most notably iron, vitamin D, folate, and vitamin B12), growth failure (40% of children with CD), delayed puberty, failure to obtain optimal bone mass, and suffer from anxiety and/or depression.(4) Lastly, when the formula is reconstituted, it can be consumed within 24-hours if refrigerated or within 6-hours at room temperature.(2) This is a pro because the ability to prepare this formula ahead of time is convenient for IBD patients. Additionally, this may help with patient compliance as it does not need to be prepared several times a day but instead can be prepared the evening before, and if refrigerated, will last throughout the following day. Cons of Modulen IBD include lower amounts of the micronutrients sodium, potassium, and fluoride, which may result in CD patients not meeting adequate intake amounts.(1) For example, 500g of Modulen® IBD provides 2,460 kcal and only 850 mg of sodium, which is well below the sodium AI of 1500 mg/day for adults.(3,5) Though CD patients are not the “healthy” population the Recommended Dietary Allowances (RDA) and Adequate Intake (AI) amounts were created for, it is still concerning that this polymeric formula, which may be the sole source of nutrition for many CD patients in active disease states, does not meet the AI for some micronutrients. Another example is that 2,460 kcal of formula contains 3000 mg of potassium, which does not meet the potassium AI for adult males (3400 mg/day), but does meet the AI for adult females (2600 mg/day).(3,5) Additionally, 2,460 kcal of formula only provides 175 mg of the essential nutrient choline, which is well below the AI of 550 mg/day for adult males and 425 mg/day for adult females.(3,5) Lastly, this formula does not meet the AI for linoleic acid and 𝛼-linolenic acid.(1) 2,460 kcal of formula only provides 1 g of 𝛼-linolenic acid, which is below the AI of 1.6 g/day for adult males and 1.1 g/day for adult females.(3,5) Additionally, 2,460 kcal of formula only provides 10.6 g of linoleic acid, which is below the recommended AIs for both adult men and women. In my assessment, a formula that may be used as the sole nutrition source for CD patients must meet all recommended RDA and AI amounts. CD patients in active flare-ups may require higher amounts of these micronutrients due to possible nutritional deficiencies. Additional cons, albeit of much smaller concern, is that Modulen® IBD is not suitable for CD patients with an allergy to cow’s milk protein as this formula is 100% casein based.(2) This excludes IBD patients who are truly allergic to cow’s milk protein. Lastly, this formula, which is highly successful in inducing remission amongst the pediatric population, is not suitable for pediatric patients under 5 years old.(1,2) In my assessment, this is a con because pediatric patients less than 5 years of age do not have the opportunity to try Modulen® IBD and may instead have to rely on corticosteroid medications, which may result in severe side effects for this very young patient population.(1) 2. Have you any personal experience with the product you noted in the Shared Sheet? If so, please explain (sensory characteristics, cost, ease of use, other information from your experience(s), etc.) If you do not have experience with the product, can you find any Sensory Data / other information that you can share (sensory if is designed to be consumed orally)? I do not have any personal experience with Modulen® IBD. Modulen® IBD has a slight vanilla taste and was designed to have a low osmolality level to support good feeding tolerance (340 mOsm/kg per 100 g).(2,3) I looked up “verified purchase” patient reviews and found that Modulen® IBD has a total of 11 reviews and a 4.82 out of 5 star rating.6 Out of the 11 reviews, four individuals specifically commented on “good taste” and “good flavor.”(6) All other reviews highly recommended this product, but did not specifically comment on taste. Additionally, Modulen® IBD is a polymeric formula and may be more palatable than elemental formulas.(7) 3. You are going to choose a study this week: Link and Citation to an original/primary Peer-reviewed research article that features your product. Please include a short synopsis of the study, in your own words, including your QCC rating for this study, reasons for your rating, and why you chose this particular study to discuss. The study I chose can be found at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070662/ Citation: Boumessid K, Barreau F, Mas E. How Can a Polymeric Formula Induce Remission in Crohn's Disease Patients?. Int J Mol Sci. 2021;22(8):4025. Published 2021 Apr 14. doi:10.3390/ijms22084025 Study synopsis: The researchers of this review article searched all articles containing Modulen® IBD from the years 1994-2020 to explore the relationship between enteral nutrition with Modulen® IBD formula and clinical outcomes.(1) Study researchers found 13 studies that fit this criteria, all on pediatric CD patients.(1) After thoroughly reviewing these 13 studies, researchers concluded that EEN with Modulen® IBD results in significant clinical remission, mucosal healing, and overall improved quality of life.(1) A proposed mechanism for this outcome may be due to the fact that Modulen® IBD is different than other enteral formulas because it contains the cytokine transforming growth factor β2 (TGF- β2).(1) TGF- β2 is responsible for suppressive and inflammatory immune responses and may be involved during intestinal mucosal healing.(1,8) Therefore, there may be synergistic effects with many of the Modulen® IBD ingredients, including TGF- β2, casein, and 25% of fats provided by medium-chain triglycerides (MCT).(1) Interestingly, study researchers found that remission rates are particularly high amongst newly diagnosed pediatric CD patients.(1) Additionally, researchers found that nutrition therapy with Modulen® IBD may be more effective than corticosteroid treatment.(1) Amazingly, 73% of pediatric CD patients receiving nutritional therapy with Modulen® IBD experienced endoscopic and histological healing compared to 40% of patients receiving corticosteroid treatment after just 10-weeks.(1) This suggests Modulen® IBD EN may greatly benefit CD pediatric patients as a first-line medical treatment and should be considered over corticosteroid treatment, especially considering the severe side-effects that may occur from corticosteroid medications.(1) Overall, this study highlights the importance of nutritional therapy with Modulen® IBD as an early intervention for pediatric CD patients.(1) However, more large-scale RCTs should be conducted, especially in adult patients. QCC rating for this study: I rate this study as + (Positive). The research question was clearly stated, the selection of studies used for the review was free from bias, all studies used were comparable with similar patient population (IBD pediatric patients) and interventions (nutrition therapy via Modulen® IBD) were clearly stated. All studies compared in this review paper were thoroughly described in a “Summary of the studies investigating Modulen® IBD” table, the outcomes of the review were clearly and thoroughly described, and study conclusions were supported by the results. Lastly, limitations of the different studies used were mentioned, funding was mentioned and is free from bias, and no conflict of interest was declared. The only odd section of this review study was the fact that there was not a dedicated “Statistical Analysis” section. However, a “Search Strategy” on how the 13 papers used for the review were obtained. I assess that the review article researchers critically reviewed each of the 13 selected research papers one by one and did not use any other statistical analysis once the 13 studies were found via the mentioned “Search Strategy.” Why I chose this particular study: I chose this particular study because, for the first time in scientific literature, this review paper explored the association between Modulen® IBD and IBD patient clinical outcomes.(1) I have been very interested in Modulen® IBD and learned about this formula through the Crohn’s Disease Exclusion Diet (CDED). I have read a variety of scientific research papers on the combination of Modulen® IBD with dietary modifications but had never read scientific research on the outcomes of using Modulen® IBD by itself as either EEN or oral enteral nutrition, which is why this study stood out to me! I was very excited to learn more about pediatric CD patient clinical outcomes when only Modulen® IBD is used as nutrition therapy. My ultimate goal is to serve as an IBD-specific dietitian, with an emphasis on pediatric patients, so I felt I could learn a great deal from this review paper. References 1. Boumessid K, Barreau F, Mas E. How Can a Polymeric Formula Induce Remission in Crohn's Disease Patients?. Int J Mol Sci. 2021;22(8):4025. Published 2021 Apr 14. doi:10.3390/ijms22084025 2. Nestle Health Science. Modulen® IBD Powder. Accessed February 6, 2024. https://www.nestlehealthscience.co.uk/brands/modulen/modulen-ibd 3. Nestle Health Science. Modulen® IBD Powder: Nutrition Information. Published July 2019. Accessed February 6, 2024. https://www.nestlehealthscience.co.uk/sites/default/files/2020-07/modulen-datacard-july-2019.pdf 4. Rosen MJ, Dhawan A, Saeed SA. Inflammatory Bowel Disease in Children and Adolescents. JAMA Pediatr. 2015;169(11):1053-1060. doi:10.1001/jamapediatrics.2015.1982 5. Gropper SS, Smith JL, Carr TP. Advanced Nutrition and Human Metabolism. 8th ed. Boston, MA: Cengage; 2022. 6. Every Health. Modulen® IBD Customer Reviews. Updated June 24, 2023. Accessed February 7, 2024. https://www.everyhealth.com/modulen-ibd-complete-nutritional-support-powder/12691819.reviews?pageNumber=2 7. Wall C, Gearry R, Day A. Polymeric formula more palatable than elemental formula to adults with Crohn’s disease. ESPEN J. 2014;9(6):e200-e203. doi.org/10.1016/j.clnme.2014.08.003. 8. Sanjabi S, Oh SA, Li MO. Regulation of the Immune Response by TGF-β: From Conception to Autoimmunity and Infection. Cold Spring Harb Perspect Biol. 2017;9(6):a022236. Published 2017 Jun 1. doi:10.1101/cshperspect.a022236
Reflection
My ultimate goal is to serve Inflammatory Bowel Disease (IBD) patients by working as an IBD-specific registered dietitian. This goal drives me to read as many evidence-based research articles as possible. As an IBD patient myself, I know how devastating malnutrition can be and also know that it may seem impossible to find foods that one can tolerate when in a severe flare. When I was extremely ill with a severe flare in 2008, I bought Unflavored Peptamen through eBay and drank this formula out of desperation as I could not tolerate anything else. I chose the “unflavored” version as I thought the “chemicals” in the vanilla flavor were “bad for me” and were going to exacerbate my disease state. I now know this is not the case, however, at the time I was scared and desperate. I did not realize that Peptamen was an enteral formula that should be consumed under the watchful supervision of a registered dietitian or medical doctor. Instead, out of desperation, I found something (Peptamen) that would hopefully give me relief from my debilitating symptoms and ordered it from an unknown individual over the internet with no knowledge of how this enteral formula was stored. My experiences have caused me to become particularly curious about different enteral formulas that may be recommended to IBD patients in clinical settings. Because of this, I became curious about Modulen® IBD when I learned about it through reading research studies that explore the effects the “Crohn’s Disease Exclusion Diet” has on IBD patients. I decided to further study this enteral formula as I know the lengths IBD patients with debilitating symptoms will go through to find relief. I have made it my mission to read as many studies as possible about nutrition-interventions in IBD patients. This includes studies on Modulen® IBD, which is why I chose this study when completing the clinical prospective (CP) discussion post on protein supplements and medical nutrition products.
Health at Every Size (HAES)
While watching the webinar "Can traditional weight management and a Health At Every Size (HAES) approach coexist,"(1) I quickly realized that everything I had thought about the Health At Every Size (HAES) movement was incorrect. I used to think that HAES was a fad-movement (much life a fad-diet). I used to think that HAES didn’t really help patients/clients make healthy sustainable life choices and thought that this movement would eventually contribute to poorer health outcomes. I now know that HAES is an empowering movement that truly focuses on improving health outcomes and overall quality of life for patient/clients that live in larger bodies. Prior to watching the webinar, I had never heard the terms “larger bodies” and “smaller bodies.” Hearing these terms in context made me realize that words really do matter. Referring to a patient/client as an individual in a “larger body” sounds much more compassionate and humanizing than referring to a patient/client as “obese” or “overweight.” I think it is important for an RD to understand and acknowledge that the patient/client may, by medical definition, be obese or overweight. However, when working one-on-one with the actual patient/client during nutrition counseling or medical nutrition therapy, saying “larger body” is less stigmatizing and more humanizing, which may result in better patient trust and overall health outcomes. After watching this webinar, I reflected on how I would interact with an obese or overweight patient/client as a (future) RD. First and foremost, I learned that compassion and inclusion are key, and that establishing a genuine, meaningful relationship with the patient/client is a must.(1) Prior to watching the webinar, I think I would have referred to the patient/client as “overweight” or “obese” while speaking with them. However, I have learned that telling them that they are “obese” or “overweight” may cause additional unnecessary trauma. Similar to the nutrition counseling and MNT video we watched previously, I was reminded to fully listen to our patient/client in a larger body. I learned to validate their feelings, and understand that they may have suffered from trauma most of their lives due to living in a larger body.(1) I learned to work on understanding why they want to change their weight and/or dietary and lifestyle habits.(1) I learned to focus on their intent, and to work together to establish outcomes the patient/client feels will work best for them and their overall health and wellness goals.(1) Two things stood out to me the most. First, learning that advocating for health promoting behaviors regardless of their effect on weight status is something I had not thought of before.(1) I did not realize that one could have body weight acceptance and still pursue health promoting behaviors.(1) I used to think that being unhappy with weight or the health risks associated with weight was the true motivation behind health promoting behaviors. I now know that one can accept the body they are in, not necessarily want to change what their body looks like, and still work on health promoting behaviors regardless of weight.(1) Learning that health gains are not always related to the number on the scale1 was liberating for me, as I had not thought about this before. I always thought that to achieve health gains, the number on the scale must decrease if one is technically in the “obese” or “overweight” category. It was interesting to learn that behaviors such as better stress management, a more balanced dietary pattern, and more physical activity has more of an impact on positive health outcomes than losing weight, and that one could maintain the same weight and still experience positive health outcomes by implementing behavior change.(1) The second thing that stood out to me the most was the quote “We find it hypocritical to prescribe practices for heavier people that we would diagnose as eating disordered in thin ones.”(1,2) When this powerful quote by fat-positive clinician Debora Burgard was mentioned in the webinar, I immediately looked it up and found a study that suggested that the focus when working with patients/clients in larger bodies should be on modifiable health behaviors, regardless of weight status, so quality of life can be improved.(2) While reading this study, I also learned that many individuals in larger bodies often delay getting medical care due to fear of bias, and that “weight discrimination may be associated with a 60% increased risk of mortality not explained by BMI or other clinical and behavioral risk factors.”(2) Learning this statistic broke my heart because it indicates that individuals living in larger bodies truly suffer, many times silently, and that weight discrimination ultimately may cause premature death. This was also a huge “wow” moment for me, because it completely underscored everything that was said in the webinar. I also appreciate how the study stressed that provider education and competency must be increased,(2) which reminded me that we, as RDs, should always advocate for our patients/clients with the interdisciplinary health care team, which was also mentioned in the webinar.(1) This study, in addition to the webinar, has completely changed my thought process and has changed the way I will approach future nutrition education, nutrition counseling, or MNT as an RD when providing care to a patient/client who lives in a larger body. I also learned we must be advocates for our patient/clients with members of the interdisciplinary healthcare team that may not understand that weight and BMI are not the sole indicators of health.(1) I learned that there may sometimes be conflict with a referring physician, and that it is important to remember that as an RD, we are responsible for the nutrition intervention, not the referring physician.(1) I was also taught that we must communicate and dig deeper with the referring physician who writes “referred for weight loss.”(1) I learned to ask the referring physician “what is the ultimate goal with wanting the patient to lose weight?”(1) “Is it improving cholesterol, lowering blood pressure, blood sugar management?”(1) Once we get to the why, we can focus on behavioral changes that will achieve the goal without having to rely and focus solely on weight outcomes. Overall, I learned that individuals who live in larger bodies may suffer from trauma due to weight stigma, fat-bias, and the cruelty of society. I have learned that patients/clients who live in larger bodies must be met with compassion, must be listened to, and must feel validated.(1) I have learned that we, as (future) RDs, can empower patients/clients in larger bodies by focusing on modifying behaviors and that positive health outcomes are not always related to weight.(1) I feel that watching this webinar (and finding the study due to the quote mentioned in the webinar) has completely changed my way of thinking and how I would approach a patient/client who lives in a larger body. References 1.Bauer J, Bonci L, Rumsey A. Dietitian to Dietitian Episode 1: Can traditional weight management and a Health At Every Size approach coexist? Dietitian Connection webinar. July 29, 2021. Accessed January 24, 2024. https://dietitianconnection.com/product/d2d-weight-management-haes-coexist/ 2. McEntee ML, Philip SR, Phelan SM. Dismantling weight stigma in eating disorder treatment: Next steps for the field. Front Psychiatry. 2023;14:1157594. Published 2023 Apr 11. doi:10.3389/fpsyt.2023.1157594
Reflection
The above write-up accurately depicts my initial misconception about the Health At Every Size (HAES) movement. As stated above, I quickly realized that everything I had thought about HAES was incorrect. I used to think that HAES was a fad-movement that didn’t help patients/clients make healthy sustainable life choices. I thought this movement supported obesity and would contribute to poorer health outcomes. However, I learned that my misconception was incorrect as I now know that HAES is an empowering movement that truly focuses on improving health outcomes and overall quality of life for patient/clients that live in larger bodies. No individual should feel ashamed or be stigmatized because of their weight. I reflect on when my body changed from a smaller to a larger body after having children. I was treated differently in clothing stores and by other individuals. For the first time in my life, I experienced the same discrimination that larger-bodied individuals experience and realized the mental turmoil and harm caused to larger-bodied individuals by those that judge. Visiting a doctor or seeing a registered dietitian is the last place a larger-bodied individual should face criticism or shame. It is up to us, as medical professionals, to empower and support all individuals, regardless of body shape or size.