Andrea K. Garber

Contribution of pollinator-mediated crops to nutrients in the human food supply

The contribution of nutrients from animal pollinated world crops has not previously been evaluated as a biophysical measure for the value of pollination services. This study evaluates the nutritional composition of animal-pollinated world crops. We calculated pollinator dependent and independent proportions of different nutrients of world crops, employing FAO data for crop production, USDA data for nutritional composition, and pollinator dependency data according to Klein et al. (2007). Crop plants that depend fully or partially on animal pollinators contain more than 90% of vitamin C, the whole quantity of Lycopene and almost the full quantity of the antioxidants β-cryptoxanthin and β-tocopherol, the majority of the lipid, vitamin A and related carotenoids, calcium and fluoride, and a large portion of folic acid. Ongoing pollinator decline may thus exacerbate current difficulties of providing a nutritionally adequate diet for the global human population.

A Prospective Examination of Weight Gain in Hospitalized Adolescents With Anorexia Nervosa on a Recommended Refeeding Protocol

PURPOSE Current refeeding recommendations for adolescents hospitalized with anorexia nervosa (AN) are conservative, starting with low calories and advancing slowly to avoid refeeding syndrome. The purpose of this study was to examine weight change and clinical outcomes in hospitalized adolescents with AN on a recommended refeeding protocol. METHODS Adolescents aged 13.1-20.5 years were followed during hospitalization for AN. Weight, vital signs, electrolytes, and 24-hour fluid balance were measured daily. Percent median body mass index (%MBMI) was calculated as 50th percentile BMI for age and gender. Calories were prescribed on admission and were increased every other day. RESULTS Thirty-five subjects with a mean (SD) age of 16.2 (1.9) years participated over 16.7 (6.4) days. Calories increased from 1,205 (289) to 2,668 (387). No subjects had refeeding syndrome; 20% had low serum phosphorus. Percent MBMI increased from 80.1 (11.5) to 84.5 (9.6); overall gain was 2.10 (1.98) kg. However, 83% of subjects initially lost weight. Mean %MBMI did not increase significantly until day 8. Higher calories prescribed at baseline were significantly associated with faster weight gain (p = .003) and shorter hospital stay (p = .030) in multivariate regression models adjusted for %MBMI and lowest heart rate on admission. CONCLUSIONS Hospitalized adolescents with AN demonstrated initial weight loss and slow weight gain on a recommended refeeding protocol. Higher calorie diets instituted at admission predicted faster weight gain and shorter hospital stay. These findings support the development of more aggressive feeding strategies in adolescents hospitalized with AN. Further research is needed to identify caloric and supplementation regimens to maximize weight gain safely while avoiding refeeding syndrome.

Position Paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults.

The medical provider plays an important role in the management of adolescents and young adults with restrictive eating disorders including anorexia nervosa. This position paper clarifies the role of the medical provider in diagnosing and treating eating disorders, proposes an evidence-based method for determining degree of malnutrition, and advocates for standardization of terminology and consistency in the use of terms referring to ideal, expected, or median body weight. The need for medical monitoring at each level of care is underscored. Scientific evidence supports more aggressive approaches to refeeding and the use of family-based therapy as a first-line psychological treatment for adolescents with anorexia nervosa.

Predictors of Outcome at 1 Year in Adolescents With DSM-5 Restrictive Eating Disorders: Report of the National Eating Disorders Quality Improvement Collaborative

PURPOSE The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year. METHODS Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed. RESULTS At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration. CONCLUSIONS The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

Does Delivering Preventive Services in Primary Care Reduce Adolescent Risky Behavior

PURPOSE To determine whether the delivery of preventive services changes adolescent behavior. This exploratory study examined the trajectory of risk behavior among adolescents receiving care in three pediatric clinics, in which a preventive services intervention was delivered during well visits. METHODS The intervention consisted of screening and brief counseling from a provider, followed by a health educator visit. At age 14 (year 1), 904 adolescents had a risk assessment and intervention, followed by a risk assessment 1 year later at age 15 (year 2). Outcomes were changes in adolescent behavior related to seat belt and helmet use; tobacco, alcohol, and drug use; and sexual behavior. Analysis involved age-related comparisons between the intervention and several cross-sectional comparison samples from the age of 14-15 years. RESULTS The change in helmet use in the intervention sample was 100% higher (p < .05), and the change in seat belt use among males was 50% higher (p = .14); the change in smoking among males was 54% lower (p < .10), in alcohol use was no different, and in drug use was 10% higher (not significant [NS]); and the change in rate of sexual intercourse was 18% and 22% lower than cohort comparison samples (NS). CONCLUSIONS The intervention had the strongest effect in the area of helmet use, shows promise for increasing seat belt use and reducing smoking among male adolescents, and indicates a nonsignificant trend toward delaying the onset of sexual activity. Participation in the intervention seemed to have no effect on the rates of experimentation with alcohol and drugs between the ages of 14 and 15 years.

Update on the Medical Management of Eating Disorders in Adolescents

The medical practitioner has an important role to play in the management of adolescents with eating disorders, usually as part of a multidisciplinary team. This article reviews the role of the medical practitioner in the diagnosis and treatment of eating disorders, updating the reader on the changing epidemiology of eating disorders, revised diagnostic criteria, newer methods of assessing degree of malnutrition, more aggressive approaches to refeeding, and current approaches to managing low bone mass.

A systematic review of approaches to refeeding in patients with anorexia nervosa.

OBJECTIVE Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings. METHODS Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic. RESULTS Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown; DISCUSSION Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.

A Clinic-Based Lifestyle Intervention for Pediatric Obesity: Efficacy and Behavioral and Biochemical Predictors of Response

AIM To examine efficacy and predictors of response to a lifestyle intervention for obese youth. METHODS Retrospective chart review of 214 children and adolescents aged 8-19 years. Linear regression identified baseline predictors of response (delta BMI z-score) at first and ultimate follow-up visits. RESULTS Mean delta BMI z-score from baseline was -0.04 (p < 0.001) at first follow-up and -0.09 (p < 0.001) at ultimate follow-up (median time 10 mo) among 156 children and adolescents. Higher baseline BMI z-score predicted poor response at first and ultimate follow-up, explaining 10% of variance in response. Fasting insulin explained 6% of response variance at first follow-up. delta BMI z-score at the first visit along with baseline BMI z-score explained up to 50% of variance in response at ultimate visit. CONCLUSION Clinic-based interventions improve weight status. Baseline variables predict only a small proportion of response; response at the first visit is a more meaningful tool to guide clinical decisions.

Pollination and plant resources change the nutritional quality of almonds for human health.

Insect-pollinated crops provide important nutrients for human health. Pollination, water and nutrients available to crops can influence yield, but it is not known if the nutritional value of the crop is also influenced. Almonds are an important source of critical nutrients for human health such as unsaturated fat and vitamin E. We manipulated the pollination of almond trees and the resources available to the trees, to investigate the impact on the nutritional composition of the crop. The pollination treatments were: (a) exclusion of pollinators to initiate self-pollination and (b) hand cross-pollination; the plant resource treatments were: (c) reduced water and (d) no fertilizer. In an orchard in northern California, trees were exposed to a single treatment or a combination of two (one pollination and one resource). Both the fat and vitamin E composition of the nuts were highly influenced by pollination. Lower proportions of oleic to linoleic acid, which are less desirable from both a health and commercial perspective, were produced by the self-pollinated trees. However, higher levels of vitamin E were found in the self-pollinated nuts. In some cases, combined changes in pollination and plant resources sharpened the pollination effects, even when plant resources were not influencing the nutrients as an individual treatment. This study highlights the importance of insects as providers of cross-pollination for fruit quality that can affect human health, and, for the first time, shows that other environmental factors can sharpen the effect of pollination. This contributes to an emerging field of research investigating the complexity of interactions of ecosystem services affecting the nutritional value and commercial quality of crops.

Disordered eating behaviors and cardiometabolic risk among young adults with overweight or obesity

OBJECTIVE To determine if unhealthy weight control behaviors or binge-eating behaviors among young adults with overweight/obesity are associated with body mass index (BMI) change and cardiometabolic risk at 7-year follow-up. METHODS We used longitudinal cohort data from 5,552 young adults with overweight/obesity at baseline (18-24 years) with 7-year follow-up (24-32 years) from the National Longitudinal Study of Adolescent to Adult Health. Baseline predictors were: (a) unhealthy weight control behaviors such as vomiting, fasting, skipping meals, or laxative/diuretic use to lose weight; or (b) binge-eating behaviors. Participants reporting either unhealthy weight control behaviors or binge-eating behaviors were considered to engage in any disordered eating behavior (DEB). Outcomes at 7-year follow-up were BMI change, incident diabetes, incident hypertension, and incident hyperlipidemia. RESULTS Young adults with overweight/obesity reporting unhealthy weight control behaviors at baseline had higher BMI and weight at 7-year follow-up than those without unhealthy weight control behaviors. In regression models adjusting for baseline BMI, race/ethnicity, age, and education, unhealthy weight control behaviors were associated with greater change in BMI in both sexes and binge-eating behavior at baseline was associated with greater odds of incident hyperlipidemia (odds ratio 1.90, 95% CI 1.29-2.79) at 7-year follow-up in males. CONCLUSIONS The higher risk for increased BMI (in both males and females) and incident hyperlipidemia (in males) over time in young adults with overweight/obesity who engage in DEBs underscores the need to screen for DEBs in this population and provide referrals and tailored interventions as appropriate.