As mentioned in my post last week, we have a problem of malnutrition in the clinical setting and a second problem is the gap between prevalence and actual diagnosis of malnutrition. In Argentina and many other countries, there is no consensus on how to diagnose malnutrition and criteria like  ASPEN/Academy or ESPEN are  barely used. The Subjective Global Assessment (SGA) tool is sometimes more popular. Its good to know now that, a few weeks ago, during ESPEN Congress, the Criteria for the Diagnosis of Malnutrition — a Consensus Report from the Global Clinical Nutrition Community were released. The report provides the much needed global consensus scheme for diagnosing malnutrition in adults in clinical settings. It was elaborated by the Global Leadership Initiative on Malnutrition (GLIM) working group with representatives from ASPEN, ESPEN, the Latin American Federation for Parenteral and Enteral Nutrition (FELANPE), and the Parenteral and Enteral Nutrition Society of Asia (PENSA). The consensus document can be found at doi.org/10.1002/jpen.1440 .
The five criteria for malnutrition include unintentional weight loss, low body mass index, and reduced muscle mass as phenotypic criteria, and reduced food intake/assimilation and inflammation/disease burden as etiologic criteria. It is proposed that the diagnosis of malnutrition be based upon the presence of at least one phenotypic criterion and one etiologic criterion. The severity of phenotypic criteria classifies malnutrition into severe or moderate (note that poor oral intake is not used to determine moderate vs severe malnutrition)

In my country Argentina, 48% of people - practically 1 out of 2 - arrive at the hospital with some degree of malnutrition (AANEP 2014 study), similarly to what happens in the rest of the world. We also know that during hospitalization this malnutrition can be exacerbated (by fasting, dietary restrictions, adverse effects of treatments, depression, etc.). And, many times malnutrition is not so obvious because it coexists with obesity (we still have doctors that say: "but he is overweight, why does he needs supplemental nutrition? ..."). 
From September 24thto 28th, ASPEN (American Society of Parenteral and Enteral Nutrition) organizes Malnutrition Awareness Week # MAW2018 to raise awareness (at all levels: professionals, health administrators, patients, general public) of the importance of early detection and treatment of malnutrition. The Academy of Nutrition and Dietetics also joins this initiative with a series of events and webinars for its members.
Malnutrition has a negative impact on patient outcomes: increased rates of infections, poor healing, prolonged hospitalization, higher frequency of readmission, increased costs and deaths. It was also shown that timely nutritional intervention is cost effective. Knowing all this, why does not the diagnosis of malnutrition appear in medical records? Why is there a gap between the prevalence of malnutrition (which can range between 30-50%) and screening and treatment (only 7%)? I invite colleagues to continue to raise awareness among health administrators of the importance of having qualified food and nutrition experts and multidisciplinary teams working to reduce this gap. I believe that our argument should be related to “nutrition for better clinical results and lower health care costs” as well as our research. 
In view of this global problem, the use of quality indicators such as the Malnutrition Quality Improvement Initiative (MQII) is being promoted. MQII uses tools that can be integrated into the electronic medical record (EHR), to improve early diagnosis and effective treatment of malnutrition in hospitals.
More resources and information here:
http://mqii.defeatmalnutrition.today
http://www.nutritioncare.org/maw/
https://www.eatrightpro.org/practice/practice-resources/malnutrition

A while ago the Evidence Analysis Library (EAL) of the Academy of Nutrition and Dietetics, published the systematic review Umami and Healthy Eating and Umami in Foods. I found it very interesting and wanted to share here the most important things about umami and to discuss the safety of monosodium glutamate since there is a lot of controversy in the media.
 
What is umami?
It is called the fifth flavor and is not very easy to describe it. It´s related to a savory meaty  taste. Appreciated for centuries by oriental cultures, the term comes from Japanese, umai = delicious. There are a number of compounds that activates umami taste receptors: glutamic acid, glutamate, glutamate salts (including monosodium glutamate, potassium glutamate, calcium glutamate) and ribonucleotides such as inosinate and guanylate.
 
¿Which foods contains umami?
Glutamate is found naturally in food in either a free form as a non-essential amino acid, glutamic acid, or bound to proteins as glutamate. But, protein hydrolysis to glutamic acid is necesary for the umami taste to be sensed. Certain processes such as dehydration, fermentation, aging of food and cooking by wet methods with broths increases the release of glutamic acid and consequently the response to umami taste. Also, the more mature the fruit and vegetables, the greater the content of glutamic acid. Did you know that human milk is our first encounter with the umami flavor? Mushrooms, tomatoes, broccoli, cheeses, seafood, green tea are all good sources. 

The so-called Chinese salt or ajinomoto is basically monosodic glutamate that is widely used in Asian cuisine and in world gastronomy (not much in Argentina). It is used in small amounts as a condiment (0.3 -0.8%) since it can worsen the flavor of the preparation if used in excess.
 
What´s umami relationship with monosodium glutamate (MSG)? Does MSG have health risks?
The sodium salt of glutamate, monosodium glutamate (MSG) is used in the industry as a flavor enhancer (INS 621). It´s extracted from the sugar cane or beet molasas or from the fermentation of hydrolyzed starches from corn,cassava or rice. MSG is classified as GRAS (generally recognized as safe) by the FDA, approved by JECFA of FAO / WHO and by the Argentine Food Code.
There is a lot of controversy and myths about their safety. It is speculated that MSG could contribute to obesity, cancer, asthma, urticaria, headaches, etc. According to the review of the EAL, there were no adverse reactions to the consumption of MSG (1). It must be taken into account that: 1) the human body does not distinguish between natural glutamate in food from the additive, 2) that it´s completely metabolized by the enterocyte and practically the glutamate ingested does not pass into the bloodstream, 3) it does not cross the placenta or the brain-blood barrier, and 4) randomized double-blind studies in "sensitive" persons to MSG did not find consistent negative effects when consumed in usual quantities (2). In Europe, EFSA has established an aceptable daily intake (ADI) level of MSG of 30mg/kg/day. The usual intake of MSG in the world is estimated at 240-300 mg and twice as many in Asian countries.
 
What are the benefits of umami?
Some scientists postulate the use of glutamate as an alternative to decrease the sodium content of foods (3). Also, some claim that it could increase the power of satiety and reduce energy intake, but evidence is not conclusive on this (4). Finally, it may increase salivation in older people collaborating with the process of chewing and swallowing.
 
After all, I think we're going to see both extreme positions in favor and and against. As everything in the science of nutrition, we must carefully analyze the available evidence.  It seems to me that MSG is safe in usual quantities and that it would not be necessary to avoid foods that contain it as an additive.  As food and nutrition experts we should consider the general nutritional quality of a food product and the total diet of an individual. What do you all think?
 
-Romina
 

For my upcoming baby I´m thinking to explore and try Baby Led Weaning (BLW), an alternative way of complementary feeding that originated in UK, is trendy in the US and has an increasing popularity in Latin America. BLW is a method for introducing solid foods that doesn´t involve spoon feeding and purees. If you are not familiar, here are the basics of BLW that every RD should know:
Why? After 6 months of exclusive on demand breastfeeding where the baby regulates the amount he eats, BLW allows him to continue with this self-regulation in a natural way. The initial goal is more didactic than nutritional: it aims for the baby to develop its autonomy, to learn how to coordinate and to explore textures, tastes and sensations.
When? At 6 months (and not before), when the baby can sit and hold pieces with his hands and shows interest in food. Always recommend moms to discuss BLW with the pediatrician.
How? Adults have to offer (by putting directly on the chair tray) healthy, varied and soft foods that the baby can take with their hands.  The food is not given by parents. It´s recommended to place baby highchair at the family table and to adapt family meals instead of cooking a totally different meal. Some BWL food examples are:
Pumpkin, potato, sweet potatoes and carrot cubes or sticks
Strips of avocado or ripe fruit such as pear, banana
Steamed broccoli pieces
Chicken or shredded meat
Pieces of egg
Soft pasta/noodles
Apple & oat muffins
Puffed cereal
The baby decides whether to grab food and how much is taken to the mouth (goodbye to the spoon and the airplane!). There are not too many food restrictions but to avoid addition of salt and sugar, honey, whole nuts, large fish and seafood, foods with “empty calories” and excess fats.
Pros? The purpose of this practice is to develop a more positive and natural relationship with food. It allows to respect baby´s hunger and interest of food without pressure. Food is not a reward or punishment. Even so, there is no evidence that BLW prevents childhood obesity. More studies are needed to confirm potential benefits.
Cons? Prepare yourself for messy meals and it may demand more time to end a meal. A recent study confirms that babies fed in this way do not have more episodes of choking than those who use traditional feeding methods. Moreover, the UK Department of Health recommends foods in pieces from the beginning of complementary feeding.
No more spoon feeding? Not necessarily. You can easily combine this method with some baby purees with spoon feeding once and then. BLW is not for everyone, some babies (and moms) prefer purees at least at the beginning and later introduce finger foods. It´s essential, whatever the method, not to push or force food when feeding babies, introduce new foods every three or four days and be patient! As professionals, it´s important to support parents in the decisions they made for their child, providing the best information available.

Any experience to share?

Romina

References
Brown, A., Jones, S. W., & Rowan, H. (2017). Baby-Led Weaning: The Evidence to Date. Current Nutrition Reports, 6(2), 148–156. 

​Who could possible be able to memorize more than 10,000 recipes, considering tastes and textures of 2,000 ingredients, within different cuisines and special diets and, based on all this, be able to propose instantly more than 16 billions of different combinations? Chef Watson from IBM can. I discovered it recently and I'm already using it to create recipes.  I have so much fun with Watson, I’m now more open to new ingredient combinations and I can expand (not replace) my creativity.

This technology is very intuitive and easy to use: select the ingredients you want to use, the type of dish or occasion (drink, dessert, main, breakfast, etc) and if you want, special diets (such as vegetarian, paleo, gluten free). Then, the proposed recipe can be personalized and of course it has to be tested. Artificial intelligence (AI) does not replace human thinking because these recipes have to be tested and with our feedback Watson keeps learning from us.
Chef Watson works using algorithms which calculate the level of pairing of flavors and based on the psychology of what pleases or not human taste buds. You may find combinations that a priori sound awful, (like combining champagne with milk). But why don’t we try Chef Watson suggestions? Chef Watson helps culinary professionals when investigating new recipes. For those food and nutrition expert who work developing recipes or designing menus in schools or hospitals, Chef Watson can help to do it more efficiently.

Chef Watson is just a sample of the multiple applications that may have systems of AI (such as IBM Watson). AI aims to help people make more successful decisions, based on the analysis of big data. Health care is the main sector where IBM Watson is having greater interest. Centers like New York Genome Institute or Mayo Clinic, are working with IBM Watson to deliver personalized treatments to their patients. "In an area like cancer — where time is of the essence — the speed and accuracy that Watson offers will allow us to develop an individualized treatment plan more efficiently, so we can deliver exactly the care that the patient needs," says Steven R. Alberts, M.D., chair of Medical Oncology at the Mayo Clinic Cancer Center.

Another example, Food Print™ by Nutrino, an app that uses this type of technology, demonstrated a significant reduction of hypoglycemia episodes in patients with type 1 diabetes (presented at the last meeting of the American Diabetes Association). We will increasingly see more AI in nutrition and health. I was a little reluctant at first, but as food and nutrition experts we have to be prepared to use this technology that will help us to do our work better and to empower people to make healthier food choices.  See the following videos for more info.

In my recent trip to Florida, I stayed a few days on a house hosted by this gracious Cuban guy who cooked great breakfast and one day we prepared malanga fritters. Then I when to some food markets and local produce stores to find produce that was new at least for me. 

​What is Malanga root? It is a potato like vegetable, a staple in Cuba and Puerto Rico, that grows in the Caribbean, part of South America and other tropical parts of the globe (it ‘s also being cultivated in Florida and California). It has an elongated shape and the skin is bumpy and patchy, brown. The flavor is nutty and earthy with a waxy, starchy consistency when it's prepared. A 1/3-cup serving of cooked malanga contains 70 calories; along with 3 grams of fiber and 1 gram of protein (while same amount of boiled potato has 45 calories and 1 gram each of fiber and protein).  How to cook with Malanga? It cannot be eaten raw because it can be toxic (contains calcium oxalate), but cooking eliminates the chemical. Malanga is easily digested and is often used in baby food. It is usually prepared mashed, baked, boiled, sautéed or deep fried. Malanga flour can be used for baking.  

​I also have the chance to taste for the first time the exotic dragon fruit or pitaya. Originally from Central America and north South America and cultivated also in Southeast Asia, Australia and US, it’s hard to find in the Argentinean market.  And I loved its eye catching pink color and its refreshing taste. It’s a fruit of the cactus family with a leader exterior and a juicy flesh that can be white or red with tiny black seeds (similar to kiwi seeds) that contain small amount of monounsaturated and omega 3 fatty acids (similar to kiwi seeds). Dragon fruit and other exotic fruits are gaining popularity in many cuisines worldwide.  Dragon fruit is promoted as a superfood, but like many other fruits full of antioxidants, fiber and vitamin A, C and potassium.  

Finally, I came across of the widest selection of citrus fruit I have ever seen! Florida is a synonymous of citrus. My favorites were the tangerines or mandarines, specially the Pixie variety (though is an hybrid originated in Southern California). Mildly sweet, seedless with a medium-orange flesh and easy-to-peel. Also, I love blood oranges and tangerines with red colored flesh as they add great color to salads. Perfect for our picnics at the beach!

Whenever you have the chance to travel, don’t miss the chance of going to local food markets to become familiar with foreign vegetables and fruits. When I was a child kiwi and mango where exotic (actually didn’t knew they existed) and now are commonly found in most supermarkets around the globe. 

En Español

National Nutrition Month ® 2017 theme “Put your best fork forward” remind us that each bite counts and invites us to cook more at home. Considering that home cooked meals are usually healthier, teaching kids how to cook becomes a life saving skill we can help develop. The benefits of involving kids in the kitchen are short and long term: it helps broaden their palate, cultivates an appreciation for real ingredients, builds math skills and develops confidence. Plus, it’s a lot of fun! I have great memories of my mom and I cooking together and I’m now passing down the tradition to my 4-year old daughter. Parents may be afraid that cooking with kids will just mean more mess and more time. So, here are some tips to help parents get started:
​
1. Plan ahead and start small. You may need more time when cooking with kids, especially at the beginning and with younger kids.  Choose one meal per week for which a child can be kitchen helper. Invite kids to be part of the recipe and ingredient selection. You may want to start with an easy side dish or dessert.

2. Find doable, age-appropriate tasks. It varies from child to child, but the following are some of the tasks they might be able to do at different stages:
​     2-to 3-years old: mixing and pouring ingredients, stirring and mashing, washing and drying produce, picking fresh herb leaves off stems and ripping them into small pieces, tearing up lettuce, peeling fruit with hands (tangerines, bananas), kneading dough, brushing oil with a pastry brush.
         4- to 5-years old: all of the above plus cracking eggs, using a pepper grinder, measuring dry and wet ingredients, decorating cookies.
       6- to 7-years old: all of the above plus whisking, grating, peeling, dicing and mincing fruits and vegetables (with supervision), greasing pans, shape patties and meatballs, plating.
      8- to 9- years old: continue with the above tasks or decide if they are ready to take on more sophisticated tasks to follow an entire recipe and cook on a stove with supervision.
       10- to 12- years old and up: after assessing how careful they are with heat, sharp tools and food safety, they might be able to work independently in the kitchen with an adult in the house.

3. Accept that not all children like to cook.  In this case, they can help grabbing ingredients, washing produce, setting and clearing up the table, tasting dishes for seasoning. Their curiosity and interest in the kitchen may change over time.

4. Safety is a priority. An adult should always supervise cooking until you are certain that your child is old enough to handle the responsibility. Part of cooking with kids is teaching them kitchen and food safety.

5. Consider this experience as an investment! These mini chefs are more likely to eat what they made and become more audacious in trying new foods. Plus, by the age of 12 they can help prepare dinner before you get home.  And by the time they leave home, you’ll feel good knowing they don’t need to rely on delivered or frozen dinners. 

En Español

​Who would imagine a store where you pick your groceries and just leave without going to the cashier? The future is now. Tech companies, supermarket chains, and thought-leading visionaries are working to reinvent your trip to the grocery store. It's been years of people going to one supermarket for all their shopping, but that is changing:
Online, personalized purchases.According to the Nielsen Global Report, “The Future of Grocery”, one-quarter of online respondents say they order grocery products online, and 55% are willing to do so in the future. Growth of online grocery shopping is driven in part by the maturation of the digital natives—Millennials and Generation Z. They are not just calling to order groceries, they better use the seller mobile app. Online retailers can fulfill unique customer needs, such as the desire for better-for-you foods as well as specialty-needs products.  Additionally, in the last couple of years, the market has been flooded with app-based grocery delivery companies like Instacart, AmazonFresh, Google Express App, which basically pick food from a variety of vendors and have it delivered to your door. So, will clicks replace bricks? Not so fast. For many food buyers (including myself), there are powerful sensory experiences we don´t want to lose, like smelling freshly baked bread or checking for freshness of perishable products. At least for now, that is impossible to replicate online.  
Smart carts & shopping apps. To compete with online purchases, some retailers are working on a prototype that is not new, tablet-laden smart carts with kinetic and body recognition sensors, which can provide aisle maps, calculate the best route through the store, tick items off your shopping list, give you recipe recommendations, and even save you for pushing a heavy cart. On the other hand we have lots of available grocery shopping apps in our smart phones like Anylist, Buy Me a Pie!, Grocery iQ and some retailers own apps. These are designed to create grocery shopping list, share lists with others, use coupons, find deals, store recipes and organize your meals. 

​Cashier-less stores.Amazon Go, an innovative concept that’s being piloted in a downtown Seattle grocery store that lets customers walk in, grab food from the shelves and simply walk out again, without ever having to wait in a checkout line, no cash or credit cards, just you need your phone and the company account. Walmart already launched (in two locations) the app Scan & Go where customers scan items with their phone as they shop, pay via the app and show the receipt from their phone on their way out.  
Recreating the supermarket experience. Companies are focusing on how to create an experience, a reason to come to the store (considering that potential customers are doing groceries online). Some supermarkets offer wellness and health services, while others have brew pubs and restaurants inside to attract millennials. 

Last Saturday I was happy to conduct an educational session to a group of mothers and families of the city of Lanus, as a volunteer (and recipient of a mini-grant) for Kids Eat Right. Kids Eat Right is an educational campaign of the Academy of Nutrition and Dietetics Foundation to promote educational projects that address the problems of overweight and obesity in children. Also, there is an international chapter called Kids Eat Right International (KERI) that carries the goals of the campaign to a global level by providing international educational resources for professionals in each country, contributing to better nutrition for children in the world.  
The topic of the session was Tossed Treasures: How Can We All Waste Less Food from the initiative The Future of Food. I have adapted the Spanish version of the toolkit presentation to the Argentinean audience. It was great to help many attendees who didn’t know how to use a thermometer in the kitchen, and was very fun to see how they created healthy recipe ideas with leftovers!
If interested in having the Argentinean adapted presentation, let me know!

Want to learn more about Kids Eat Right? Check out the website for articles, tips, toolkits, recipes and videos! If you would like to be on the Kids Eat Right International (KERI) mailing list, please email Jamie Wise at KER@eatrightoverseas.org.
Become a Kids Eat Right Campaign Volunteer here!