Dr. Cardel is an obesity and nutrition scientist, registered dietitian, the Director of Global Clinical Research & Nutrition at WW International, Inc. (formerly Weight Watchers) and a faculty member at the University of Florida (UF) College of Medicine, where she is also an Associate Director for the Center for Integrative Cardiovascular and Metabolic Diseases. Her research is focused on three areas, assessing the effects of psychosocial factors, including low social status and food insecurity, on eating behavior and obesity-related disease, the development and implementation of effective healthy lifestyle interventions with a focus on underserved populations, and improving gender equity within academia.
Episode Description
An entire industry has grown up around nutrition and health. People pushing everything from shakes, to meal kits, to special diets. While some of the claims surrounding such products can be questionable at best, the field of nutrition science is growing. Filled with researchers who are working to truly understand the science of food that is a focus of this episode of Stats and Stories with guest Michelle Cardel.
+Timestamps
What is Nutrition science? (1:45), What is the difference between a nutritionist and registered dietitian?(2:10), How did you become interested in this study to begin with? (7:02), Misguided influencer advice to stay away from. (10:15), Wading through all the noise about obesity out there. (13:58), Obesity intervention (16:10), Nutrition science quantitative studies (19:20), Motivational interviewing (23:03)
+Full Transcript
Rosemary Pennington
An entire industry has grown up around nutrition and health, with people pushing everything from shakes to meal kits to special diets. While some of the claims surrounding such products can be questionable at best, the field of nutrition science is growing, filled with researchers who are working to truly understand the science of food and health. That is a focus of this episode of stats and stories where we explore the statistics behind the stories and the stories behind the statistics. I'm Rosemary Pennington. Stats and Stories is a production of Miami University's Department of Statistics and Media Journalism and Film, as well as the American Statistical Association. Joining me as regular panelist John Bailer, Chair of Miami Statistics Department. Our guest today is Dr. Michelle Cardel. Cardel is an obesity and nutrition scientist, registered dietitian, the director of global clinical research and nutrition at WW International Inc, and a faculty member at the University of Florida College of Medicine, where she's also an Associate Director for the Center for Integrative cardiovascular and metabolic diseases. Her research is focused on three areas, assessing the effects of psychosocial factors on eating behavior, and obesity related disease, the development and implementation of effective healthy lifestyle interventions with a focus on underserved populations, and improving gender equity within academia. Michelle, thank you so much for joining us again. We're so glad to have you back.
Michelle Cardel
It's wonderful to be back. I appreciate the invite.
Rosemary Pennington
I think just to begin our conversation, I wondered if you could talk about what is nutrition science?
Michelle Cardel
Yeah, so nutrition science is basically a study of how the body responds to different foods and how that ultimately influences various aspects of our health.
John Bailer
So Michelle, thank you again for joining us. It's such a pleasure to have you on the podcast with us once again. I'm curious about the difference between a nutritionist and a registered dietician.
Michelle Cardel
Yeah, it's a great question, John. So basically, anyone can call themselves a nutritionist, there is no licensing board. There's no credentials required for somebody to say they're a nutritionist, a lot of the people that you see, you know, on Instagram who are talking about, like eating a certain way, or certain diets are trying to sell you supplements. And you know, in their profile, it says they're a nutritionist that doesn't really have any sort of quantifiable meaning. Whereas conversely, to be a registered dietician, somebody has to get a four year undergraduate degree in nutrition or related based science degree. And then on top of that, they have to qualify and be accepted into an internship. So these internships are highly competitive, it's very difficult to get into them. And through those dietetic internships, you gain 1200 hours of supervised learning and training, where you're taught how to counsel patients, you learn about the ins and outs of nutrition and managing nutrition from a counseling perspective. And then on top of that, then you have to take an exam to become a registered dietician that is, like overseen by the Academy of Nutrition and Dietetics. So there's many, many steps to becoming a registered dietician. And in a clinical setting, when you go and see somebody for food related factors, you're going to get referred to a registered dietician or registered dietitian, nutritionist, again, very different than somebody who just identifies as a nutritionist.
Rosemary Pennington
How did you get interested in this field of study?
Michelle Cardel
Yeah, so when I was an undergrad, I took this really interesting class called Death dying in the individual. Rosemary space right now was great. I was like, it sounds great. I wouldn't. Yeah, it was, it was a fascinating class. You know, in our society, we don't tend to talk about death a lot. And while in that class, this group came in, and they came from a hospice group. And they talked to us and said, you know, we're always in need of hospice volunteers. It's an area where we really struggled to get volunteers because we don't talk about death a lot in our culture, and people almost see it as like morbid in a way. So they said, if anybody's interested, you know, please let us know. We'd love to have more volunteers and I thought, you know, I think I could do this like this is something that I think would provide respite care for the families or, you know, during somebody's end of life care. And so I volunteered with them, I underwent, like the pretty extensive training to become a hospice volunteer. And I did that for about 10 years. And during that time, as a volunteer, I heard a lot of different stories from people end of life is like this really privileged time to get to be around folks, people are, have lost a lot of their inhibitions and are, are open to being vulnerable, and really sharing with you, their, what they're thinking, what they're feeling, how they're processing this end of life piece. And a lot of people, you know, shared things with me, for example, I had a patient say, you know, I'm worried I killed myself with a fork, basically. And I was, I was 19 years old, when I started as a hospice volunteer, like, I in no way shape or form was thinking about how my choices today would impact me 20, 30, 50 years down the road, or how that could potentially impact my quality of life. And so that was the first time that I really was getting interested in nutrition. At that point, I was a biology major, and I was minoring in chemistry, so a really heavy science background. And then it wasn't until like, working with these hospice patients that I was like, this is fascinating to me that, that from their perspective, this had a role in not just their life, but also in the end of their life. It's something that was coming up for them. And so I applied to do a master's in nutrition, and then a PhD in nutrition. And I had no idea what I was doing. When I started, I had never taken a nutrition course before my master's program. Once I started, I just fell in love with the profession.
John Bailer
Well, that's a great story. That's a great foundation. I mean, when I've been visiting family and nursing homes, it was very clear how critical nutrition was, as part of the story. And it seemed like a lot of the therapies for some individuals involved just ways of trying to make sure that they were getting, you know, sufficient sustenance and turn, you know, in their diets. And so I find that to be a, it's an interesting path into nutrition for you.
Michelle Cardel
Yeah, absolutely. And during my dietetic internship, it was so eye opening to see the foundation of care for certain patients is so based in nutrition. So for example, in the burn unit, where you're working with a patient who has burns over 70% of their body, their metabolic rate has increased, you know, significantly to help in order for the body to heal itself. But oftentimes, you know, if they have a burn over their face, they can't eat. So then as a registered dietician, you're coming in, you're calculating their body's energy needs, you're working with the physician to help identify what is the best route to feed this patient if they can't do it orally. So you know, people tend to think about a registered dietician working in, you know, the weight management space, which is the area that I work in, but there's all these other incredibly important areas that registered dietitians are working in HIV in cancer and burn unit in trauma, you know, in the NICU. It is such a rewarding career to do, and a real privilege to get to be a part of it.
Rosemary Pennington
You mentioned sort of your focus, Michelle, and I wonder if you could talk a bit about how you became interested in sort of eating behavior and obesity in particular.
Michelle Cardel
Yeah, so, you know, once I started grad school, you know, and I have to say this, like, I had never done research before I started grad school. For all those grad students out there listening, you know, I hope that this makes you feel better. But the first two years of grad school I basically walked around feeling like the dumbest person in the room at all times. I didn't know what the National Institute of Health was. I didn't know anything about research. It was all so new to me. And I was really fortunate that I have an amazing PhD mentor, Dr. Jose Fernandez, who really encouraged me to explore what are the areas that I was passionate about, and to not just follow in his footsteps. So he is a statistical geneticist. So I started doing some work in the same area that he was doing, looking at genetic predictors of body composition, but ultimately through exercise flooring the literature, I really found my passion to be more focused on eating behavior, particularly in underserved populations, and how that affected the development of obesity.
John Bailer
You know, when you were talking a bit about these distinctions between kind of the, you know, anybody can hang out a nutritionist shingle, and, and express opinions. you've commented a bit about the idea of these, the influencer advice and some of the misguided nutrition advice. And I really appreciated the one piece that you wrote, where you were talking about some of the signals the red flags of concern, could you talk a little bit about, you know, what people should be aware of, and say, Well, wait a minute, you may not want to follow these nuggets of so called wisdom.
Michelle Cardel
So the first thing that you want to look out for is somebody making like these huge claims, or like blanket statements, so something like carbs are bad for you, or no one should eat sugar, you know, there's no one right way to eat. And ultimately, you know, the dietary pattern that you choose should be decided by, you know, what you like, what you dislike, what's, what's available to you in terms of your resources, and then also, what's your medical history, and ultimately, a one size fits all doesn't work, the data shows that it's a lot less about the macronutrient composition of your diet, whether it's high fat or high carb, in terms of effectiveness for weight loss over the long term, then it is of how well that you can, you know, adhere to that diet. Adherence reigns, you know, so whatever works for you over the long term, is what's going to work for you. And it needs to be a solution that's livable, needs to be something that actually works within your life. And at the end of the day, you know, with these influencers, often, their body is their business card in many ways. And that's what they use to have influence. But just because somebody is fit or young or attractive, doesn't mean that if you do what they do, you're going to look like them, we could all move our bodies in the exact same way and eat the same things. And our body shapes and size would look very different across the board. So that's the first thing that I would watch out. The second red flag would be that an influencer is selling something like a supplement or a detox or a tea that is a huge red flag. And people are struggling with their weight, they're in a super vulnerable place. And I get really frustrated when I see that. People are basically targeting their marketing to people who are in a really vulnerable place and then offering them a quick fix that is not based on evidence whatsoever. And then the third flag is that they're missing credentials. You know, we talked about already, what's the difference between a registered dietician or registered dietician nutritionist versus just somebody who says that they're a nutritionist, anyone who just says that they're a nutritionist that in no way shape or form says that they have the that they've studied the area of nutrition that it comes from an accredited university, you know, the dietitians are going to have completed at least 1200 hours of supervised practice, and passed a board certifying exam. So you want to make sure that who you're turning to, for nutrition or weight related advice is somebody who has the credentials to back that up.
Rosemary Pennington
You're listening to Stats and Stories and today we're talking about nutrition and statistics with Michelle Cardel. Michelle, I wonder if you could talk a bit about the obesity research you do and in particular, I'm thinking about you know, the things that you think listeners need to understand about obesity with their it's such a fraught conversation and it seems like, every few months, it's back in the news. So you know, some studies showing one thing, you know, there's been a lot of discussion around obesity and COVID. And so I want and it feels like, it can be confusing to figure out like, what do we know about obesity? So I wonder again, if you could just share sort of what you think listeners need to understand.
Michelle Cardel
Absolutely. So first off, I think a really important distinction is to understand what obesity is. So obesity is one somebody has an excess amount of adipose tissue that is causing health problems. Okay, this is very different than somebody wants To lose weight to reach like a westernized, thin ideal. Okay, these are two separate things. Obesity is defined by the influence on health. So having simply an elevated BMI, BMI is a screening tool, it is not a diagnostic tool. So there needs to be clear differentiation between what obesity is and obesity is a very complex and multifactorial disease that can be developed in a variety of different ways. So you can develop obesity as a combination of endocrine factors, other physiological factors, medications that you're on socio cultural factors, it can be due to the environment, that you're in behaviors that you engage it, but it's very complex.
John Bailer
You know, as you're talking about this, I find that a lot of the ways that as I said, I've read some of your work that really resonates for me is even the language of like nutrition plan versus dieting and weight loss language. There's a lot of what I've found when reading your stuff that I think about framing as being a really important part of this, this message and understanding what an intervention is. So can you just just comment a little bit about, you know, sort of thinking about obesity in a way in particular for intervention? I mean, you talked about all this, the fact that it's multifactorial doesn't make it easier for an intervention, I think it makes it much harder. So maybe talk a little about the kind of interventions that you think about?
Michelle Cardel
Absolutely. So when we think about interventions for obesity, we tend to three, think about three different buckets. One is intensive lifestyle interventions, two is pharmacotherapy, and three is devices or bariatric surgery. And so across treatment modalities, the lifestyle intervention piece is going to be the foundation of that. So whether you're taking a prescription for an anti obesity medication for, you know, planning to undergo bariatric surgery, or a combination of the above, across the board, lifestyle intervention is going to be the foundation of that treatment. So what does intensive lifestyle intervention actually mean? It does not mean dieting. Okay. Dieting, to me, is defined by a self-directed engagement in certain behaviors or following a certain diet and usually coincides with something along the lines of like a fad diet. Okay, so the cabbage soup diet is considered dieting, which if your mom ever did that, like my mom did, horrible. Soup Diet, you know, I have seen patients who have tried, you know, some really interesting diets, like the great food diet, the cookie diet, there's so many different diets out there. So that is dieting, and that is a very different then, then what you do an intensive lifestyle intervention, intensive lifestyle interventions are evidence based, they include not just changes in terms of your food and your activity, but also utilizes behavior change strategies, you want to engage in something that has an evidence base behind it that has done research, you know, looking at this program, or this intervention.
Rosemary Pennington
You mentioned this, this issue of the psycho social factors that are at play. And I wonder if you could one, explain what a psychosocial factor is, and then talk about how you measure them in relation to something like, you know, lifestyle interventions or obesity interventions?
Michelle Cardel
Yeah, so in my research, when I'm talking about psychosocial factors, I'm talking about the combination of psychological and social factors that interact, and then ultimately how they influence eating behavior and risk for obesity. So in my research, some examples of psychosocial factors that we've studied our stress, how to stress influence are eating behavior and risk for obesity, experiences with food insecurity, with poverty, with racism and discrimination. Those are the types of psychosocial factors that I have looked at in my research.
John Bailer
So you've mentioned the evidence base a couple of times in our conversation here and you're talking about your research. Could you just give a quick sketch of an example of the kind of study that might be conducted to evaluate, you know, one of the things like you just mentioned stress as a and its impact on on weight and another change? So can you describe that study and what you did and how it was conducted?
Michelle Cardel
Yeah. So I can talk a little bit about a study that we did that Actually experimentally manipulated social status and looked at the effect of the experimental manipulation on eating behavior, which would thereby influence, you know, the development of obesity. So what we did in a laboratory setting was we randomized people to experimentally high and experimentally low social status conditions. And then, in the lab, we measured how that influenced what they ate, and how much they ate, as well as their levels of physical activity. And we were able to look at a 24 hour energy balance. And what we learned from that study is that when we place people in experimentally low social status conditions, even when it's for an acute amount of time, that it directly influence their eating behavior, such that they ate more calories, and ended up in more positive energy balance than when individuals were randomized to a high social status condition. So to quantify that for you, in the first study that we did on this topic, it was a randomized crossover design. So participants experienced both the low and the high social status conditions. So we were able to look at within person variation. And when placed in the low social status condition, it was only a 40 minute manipulation. But in the lunchtime meal that they ate, after that manipulation, they ate 130 more calories at lunch than they did when they were placed in the high social status condition. So for me, the big takeaway from that body of studies is that people are experiencing this low social status in a lab for a very acute period of time. And that alone was enough to influence their eating behavior in a way that could be adverse if it was done in excess over time. But if you think about people who are in low social status positions in life, and we step back from this, people don't experience poverty or food insecurity for 40 minutes, people don't experience racism and discrimination for a short period of time. These are cycles, their cycles of poverty, their cycles of privilege in our society. And when people are experiencing these things, it's oftentimes in a chronic manner over the long term. So when I think about this, and the implications on health, experiencing food insecurity, experiencing poverty, and experiencing the social inequities that we have in our society, those things in and of themselves, set up an obesogenic environment, or an environment that predisposes individuals to develop obesity.
John Bailer
So just as one last quick question, you know, I was intrigued to read that some of the specialized training that you had, that you have had included things that I had absolutely no clue what it meant, and that that happens pretty regularly on the show. But but but, you know, the idea of motivational interviewing and Acceptance and Commitment Therapy, I just was really curious, what does that do if you give a quick, quick definition of those?
Michelle Cardel
Sure. So motivational interviewing is when we work with a patient and really motivate them to identify what is the best path forward for them. And so you're there basically to facilitate that conversation being essentially with themselves for Acceptance and Commitment Therapy. This is a therapy and I'll talk about it in the weight related space, because that's where I'm most familiar with the literature, Dr. Evan Forman, and Dr. Megan veteran from Drexel University basically took Acceptance and Commitment Therapy and modified it and changed it to what's called acceptance based therapy for weight loss. And they took evidence based components of standard behavioral therapy that we utilize in weight loss or healthy lifestyle interventions. And to that they added these components from Acceptance and Commitment Therapy, really focused on mindfulness and self regulation skills and value driven living. What that means is assessing your values and making sure that the actions that you engage in align with that value system. And in standard behavioral therapy interventions, we're pretty happy as adults if we see about five to 8% body weight loss over a one year period, but what Dr. Foreman and veterans saw was actually 13.3% body weight loss over that one year period. So you reach almost like pharmacotherapy levels of weight. Last, utilizing this therapy.
Rosemary Pennington
Well, thank you. That's all the time we have for this episode of Stats and Stories. Michelle, thank you so much for joining us again.
Michelle Cardel
Thank you. I really appreciate the opportunity to be here and to talk with you all.
Rosemary Pennington
Stats and Stories is a partnership between Miami University's Department of Statistics and media journalism and film and the American Statistical Association. You can follow us on Twitter at stats and stories Apple podcasts are other places where you can find podcasts. If you'd like to share your thoughts on the program. Send your email to StatsandStories@Miami.oh.edu Or check us out at StatsandStories.net and be sure to listen for future editions of Stats and Stories where we discuss the statistics behind the stories and the stories behind the statistics.