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CONFERENCE ISSUE Vol. 19 No. 9

September 2017

The Magazine for Nutrition Professionals

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Diet vs Statins

Determine the best approach to lowering CVD risk.

Food Fears

Are they a deterrent to healthful eating?

Aquafaba’s Versatility Discover its many culinary uses.

www.TodaysDietitian.com

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EDITOR’S SPOT

STROKE RISING IN YOUNGER CLIENTS September marks the end of summer, the beginning of fall, and National Cholesterol Education Month—a great time for dietitians to amp up efforts to educate clients and patients about cholesterol, including its perils when levels are high, strategies to maintain normal levels, and the importance of regular screenings. According to the Centers for Disease Control and Prevention, more than 102 million American adults aged 20 and older have high cholesterol (≥200 mg/dL), of whom 35 million have levels of 240 mg/dL or higher, putting themselves at risk of heart disease and stroke.

Recently, I learned some shocking news that more young people are having strokes than ever before. A 2016 study of New Jersey hospitalizations published in the Journal of the American Heart Association found that strokes more than doubled in people aged 35 to 39 between 1995 and 2014 and increased in groups up to age 55. In a 2017 study published in JAMA Neurology, researchers saw increases in stroke in people aged 35 to 44 from 2003 to 2012, and there was a 42% rise in men and 30% boost in women.

The reason for the increased stroke rates? More people between the ages of 18 and 64 develop three or more of the five common stroke risk factors: high blood pressure, obesity, diabetes, tobacco use, and high cholesterol. Other less common risk factors include congenital blood vessel abnormalities, blood vessel injury, and pregnancy-related hormones.

To help reduce the stroke rate in young clients and patients, RDs can encourage them to begin adopting lifestyle changes to help them maintain acceptable cholesterol levels. They also can remind clients to check their cholesterol every five years. You can discuss the types of foods known to lower stroke risk, which include oatmeal, legumes, fruits, vegetables, whole grains, fatty fish (eg, salmon, mackerel, albacore tuna, sardines), nuts, avocados, and dark chocolate. You can offer recipes, provide information about smoking cessation programs, and discuss ways to incorporate physical activity into busy lifestyles. Your guidance and expertise can save many lives.

Next month, many of you are heading to the Windy City to attend FNCE®. But before you leave, check out our annual dining guide to plan your culinary journey. Home to award-winning celebrity chefs, ethnic eateries, and gastropubs, Chicago is also known for its ketchup-free, veggie-laden hot dogs; spicy beef sandwiches; and deep-dish pizza.

The staff of Today’s Dietitian looks forward to seeing all of you there. Stop by booth #1336 to say hello, and please enjoy the issue!

Judy

Judith Riddle Editor TDeditor@gvpub.com

4 today’s dietitian september 2017

President & CEO Kathleen Czermanski Vice President & COO Mara E. Honicker EDITORIAL Editor Judith Riddle Nutrition Editor Sharon Palmer, RDN Editorial Director Lee DeOrio Production Editor Kevin O’Brien Editorial Assistants Heather Hogstrom, Hadley Turner Editorial Advisory Board Dina Aronson, RD; Jenna A. Bell, PhD, RD; Janet Bond Brill, PhD, RD, CSSD, LDN; Marlisa Brown, MS, RD, CDE, CDN; Constance Brown-Riggs, MSEd, RD, CDE, CDN; Carol Meerschaert, MBA, RD; Christin L. Seher, MS, RD, LD ART Art Director Charles Slack Junior Graphic Designers Laura Brubaker, Emily Fisher ADMINISTRATION Administrative Manager Helen Bommarito Administrative Assistants Pat Plumley, Allison Shanks, Susan Yanulevich Executive Assistant Matt Czermanski Systems Manager Jeff Czermanski Systems Consultant Mike Davey FINANCE Director of Finance Jeff Czermanski CONTINUING EDUCATION Director of Continuing Education Jack Graham Continuing Education Editor Kate Jackson Continuing Education Coordinator Susan Graver CIRCULATION Circulation Manager Nicole Hunchar MARKETING AND ADVERTISING Publisher Mara E. Honicker Director of Marketing and Digital Media Jason Frenchman Web Designer/Marketing Assistant Jessica McGurk Sales Manager Brian Ohl Associate Sales Manager Peter J. Burke Senior Account Executives Gigi Grillot, Diana Kempster, Beth VanOstenbridge Account Executives Victor Ciervo, Bill Eichler, Chandra Pietsch

© 2017 Great Valley Publishing Company, Inc. Phone: 610-948-9500 Fax: 610-948-7202 Editorial e-mail: TDeditor@gvpub.com Sales e-mail: sales@gvpub.com Website: www.TodaysDietitian.com Subscription e-mail: subscriptions@gvpub.com Ad fax: 610-948-4202 Ad artwork e-mail: TDads@gvpub.com All articles contained in Today’s Dietitian, including letters to the editor, reviews, and editorials, represent the opinions of the authors, not those of Great Valley Publishing Company, Inc. or any organizations with which the authors may be affiliated. Great Valley Publishing Company, Inc., its editors, and its editorial advisors do not assume responsibility for opinions expressed by the authors or individuals quoted in the magazine, for the accuracy of material submitted by the authors, or for any injury to persons or property resulting from reference to ideas or products discussed in the editorial copy or the advertisements.

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ADVANCED R EG IST RA TH T OC ROU TO GH ION B

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THE EVENT EVERYONE’S TALKING ABOUT! Join the conversation and register for our advanced rate by October 31

Earn 15+ CEUs at the fifth annual Today’s Dietitian Spring Symposium on May 20–23, 2018 at the Hyatt Regency Austin! Our diverse program features continuing education sessions and workshops, an all-star line-up of presenters, networking with fellow RDs, and engagement with sponsors.

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Sessions that engage and inspire!

Chat with your RD friends and make plans to join us in Austin!

Our Advanced Rate ends October 31. Register now at www.TodaysDietitian.com/SS18

Thank you to our 2018 Symposium Sponsors!

CONTENTS

40

SEPTEMBER 2017

18

FEATURES

DEPARTMENTS

20

4

Editor’s Spot

8

Reader Feedback

The Best of Chicago Dining If you’re going to the Academy of Nutrition and Dietetics’ Food & Nutrition Conference & Expo™ next month, prepare to enjoy a wide variety of award-winning, world-class cuisine in this historic melting pot of different cultures.

26

Diet vs Statins Is one better than the other for the prevention of CVD?

32

Food Fears Packaging claims such as “free from,” “clean,” “natural,” and “organic” may be deterrents to healthful eating.

36

Aquafaba’s Versatility Instead of pouring it down the drain, clients can put this ingredient to good use in many of the foods they enjoy.

40

46

50

Hair Growth Supplements A plethora of supplemental nutrients and botanicals boast claims to regrow hair and restore hair health, but are they evidence based?

Alkaline and Plant Waters Research suggests that while functional waters may contain some nutrients, they may not be better than bottled or tap water for rehydration.

12 Ask the Expert 14 Breakfast 16 Organics 18 The Retail RD 56 Focus on Fitness 58 Bookshelf 60 Get to Know …

62 News Bite 63 Conference Showcase 64 Personal Computing 65 Datebook 66 Culinary Corner

CPE Monthly: Assessing and Monitoring Body Composition This continuing education course compares and contrasts BMI with a variety of strategies for measuring body composition as it relates to weight management throughout the life cycle. It also provides recommendations and strategies for RDs to apply this information in various patient care settings.

Page 50

Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published monthly by Great Valley Publishing Company, Inc., 3801 Schuylkill Road, Spring City, PA 19475. Periodicals postage paid at Spring City, PA, Post Office and other mailing offices. Permission to reprint may be obtained from the publisher. Reprints: Wright’s Media: 877-652-5295 Note: For subscription changes of address, please write to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on last label. Postmaster: Send address changes to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Subscription Rates — Domestic: $14.99 per year; Canada: $48 per year; Foreign: $95 per year; Single issue: $5. Today’s Dietitian Volume 19, Number 9.

6 today’s dietitian september 2017

READER FEEDBACK From Our Facebook Page

From Our Twitter Feed Popular Tweets, Retweets

Webinar Baby-Led Weaning: A Step-By-Step Guide to Starting Solids Using a Safe, Practical, and Natural Alternative to Spoon-Feeding Purees @YourFamilyRD: Such great info. Can’t wait to try with my own baby! Thanks!

RD Lounge 6 Networking Mistakes and Ways to Fix Them

“This Hospital Grows Its Own Food, Then Serves It to Patients” miamiherald.com

Tylane Garrett: Farm to hospital—what a beautiful solution!

@simpleeatsRD: Thank you Mandy Enright, MS, RDN, RYT, for sharing that ‘A little karmic deposit can go a long way.’ @MichaelYarmo: I struggle [with] going to networking events when I don’t know anyone. Hardest part is approaching people cold and overcoming internal anxiety.

“Nutrition’s Impact on Mental Health” wbkb11.com

Annette Parsons Adams: Why is it so hard for people to believe that food affects our mind? Our brain is in the same body as the rest of us, isn’t it?

“How Much Food Do Older Adults Need?”

RDLounge.com

The Domestic Dietitian: I love this article! I worked in an aging care/retirement home for more than 10 years, and we were constantly trying to advocate for smaller portion sizes so we didn’t overwhelm our residents with too much food.

It was hard to balance between the residents’ smaller portion requests and the state guidelines for serving sizes. A very good read.

“Dietitian Served as a Sniper in Iraq War”

July Issue

CONF EREN CE ISSUE Vol. 19 No. 7

Fruit Forward Desserts

July 2017

The Magazine for Nutrition Profession als

@TheSpicyRD: Fun article! Now I’m really hungry. @kristynhall: Yesterday I made a rhubarb cobbler … no crisp. Whatever you call it, it was a delicious dessert and breakfast this morning.

INSIDE

Today’s Dietitian Spring Symposium Highlights page 26

Diabetes Management & Nutrition Guide ia, counsel patients on developing more.

Learn to better manage hypoglycem for disease prevention, and the best dietary patterns

Delicious Fruit Forward Desserts Prebiotics’ Role in Treating Lactose Intolerance www.TodaysDietitian.com

June Issue Stevia’s Splendor @MaryroseRD: My customers always ask if stevia is good for them. Great info.

timesrepublican.com

Jennifer Mitchell Morris: I too am a veteran dietitian working at a VA. I wonder how many more of us there are. I’m sure not just James and me!

David Orozco: Awesome! Congrats, James, and tons of thanks for your service and for being one of the few and strong guyatitians!

Nancy Norton Foresteire: Thanks for your service, James, and for still serving our vets!

Rebecca Shrago: Rock on, James!

8 today’s dietitian september 2017

CORRECTION In July’s issue, the third sentence in the fifth paragraph of “The Latest Physical Activity Recommendations” should have read as follows: “A goal of moderate to vigorous aerobic activity for 150 minutes per week for adults and 60 minutes per day for children and adolescents are the goals set for structured exercise.”

Celebrating 100 Years of Delicious Nutrition Since its beginnings in 1917, Sunsweet® has been dedicated to innovating new and delicious ways for consumers to feel their best. As we celebrate our 100th Anniversary and the Academy of Nutrition & Dietetics’ Centennial, we remain passionate about helping people eat right and enjoy healthy lifestyles.

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U.S.– Grown Soybean Oil Achieves FDA’s Heart Health Claim Health professionals have long regarded soybean oil, commonly labeled as vegetable oil, as a healthy cooking oil for patients. Now, thanks to the Food and Drug Administration’s July 2017 authorization of a qualified health claim confirming soybean oil’s ability to reduce the risk of coronary heart disease, consumers will begin to see heart-healthy labeling on bottles.

Reduced Risk of CHD The new health claim that will appear on labels of qualified soybean oil and soybean oil-containing products*states: “Supportive but not conclusive scientific evidence suggests that eating about 1½ tablespoons (20.5 grams) daily of soybean oil, which contains unsaturated fat, may reduce the risk of coronary heart disease.

To achieve this possible benefit, soybean oil is to replace saturated fat and not increase the total number of calories you eat in a day. One serving of this product contains [x] grams** of soybean oil." ¹

“Lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, like those found in soybean oil, will lower the incidence of cardiovascular disease.”

- Dietary Fats and Cardiovascular Disease, A Presidential Advisory from the American Heart Association, June 2017.

Favorable Fatty Acid Profile Most soybean oil is made with U.S.-grown soybeans and has a favorable fatty acid composition, containing 0 grams of trans fat and just 2 grams of saturated fat per 1 tablespoon serving. It is one of the few non-fish sources of omega-3 polyunsaturated fatty acids.²,³ The alpha-linolenic acid (ALA) found in soybean oil is the principal source of omega-3s in the U.S. diet.⁴ Omega-3s affect cardiovascular health and may reduce blood pressure.⁵ 8

<1

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COTTONSEED

61

PALM

13

CANOLA

28

CORN

SUNFLOWER

SOYBEAN

65

80 19 26

% Saturated Fatty Acids % Oleic Acids

54

30

54

9

6

22

38

<15

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OLIVE

26

23

<1

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% Linoleic Acid % Linolenic Acid

13

% Trace Amounts

This research-based health article is provided by the United Soybean Board. For the latest nutrition information on soybean oil, visit SoyConnection.com. *Qualified products have a minimum of 5 grams of soybean oil per reference amount customarily consumed.1 **Gram amount varies by product.

1. U.S. Food and Drug Administration. "Soybean Oil and Reduced Risk of Coronary Heart Disease."

July 31, 2017. https://www.fda.gov/downloads/Food/IngredientsPackagingLabeling/ LabelingNutrition/UCM568508.pdf 2. USDA National Nutrient Database for Standard Reference.

3. Blasbalg TL, Hibbeln JR, Ramsden CE, Majchrzak SF, Rawlings RR. “Changes in consumption of omega-3 and omega-6 fatty acids in the United States during the 20th century.” Am J Clin Nutr. 2011; 93:950-62.

4. PM Kris-Etherton, Denise Shaffer Taylor, et al. “Polyunsaturated fatty acids in the food chain in the United States.” Am J Clin Nutr. 2000 Jan; 71 (1) 1: 179S-188S. 5. “Omega-3 fatty acids.” http://umm.edu/health/medical/altmed/supplement/omega3fatty-acids#ixzz2dygJvVyU. University of Maryland Medical Center. 2013.

ADVERTISEMENT

Roasted Vegetable & Couscous Salad

Client Meal Planning:

For this and more recipes, visit

SoyConnection.com/Recipes

Nutrition Per Serving

Instructions for Roasted Vegetable & Couscous Salad

Calories

Protein

Carbohydrates

Fiber

270

5g

31 g

3g

Fat

Saturated/Trans

Cholesterol

Sodium

14 g

2g / 0g

0 mg

210 mg

Ingredients 3 cups of broccoli florets, cut into ½ inch pieces 1 red bell pepper, cut into 1 inch squares 1 ½ cups of red onion, peeled and cut into ¼ inch slices 6 tablespoons soybean oil, divided ½ tablespoon ground black pepper, divided ½ tablespoon salt, divided 1 ½ cups dry, giant Israeli couscous 2 tablespoons balsamic vinegar

Preheat oven to 425° F. Toss broccoli, peppers and onions with 2 tablespoons soybean oil and ¼ teaspoon each salt and pepper. Place on foil-lined baking sheet.

Bake for 15 minutes until vegetables are tender and lightly browned.

PREP TIME:

15 min

COOK TIME:

15 min

Meanwhile, cook couscous according to package directions.

Place cooked couscous and roasted vegetables in large bowl. Pour vinegar and remaining soybean oil over salad and sprinkle with remaining salt and pepper; toss lightly until combined.

You may substitute 3 cups cooked regular couscous, brown rice or quinoa.

FNCE ® 2017 Stop by Soy Connection Booth 1711 for the

latest soy research, plus samples and giveaways!

TOTAL TIME:

30 min

MAKES:

6 servings

ASK THE EXPERT levels of nitrogen excretion during protein metabolism can cause an increase in glomerular pressure and hyperfiltration.1 Furthermore, bone metabolism is a possible consequence of long-term adherence to a ketogenic diet; in children with intractable epilepsy, the diet may lead to reduction in bone mineral content.2 Conversely, Kristen Mancinelli, MS, RD, author of The Ketogenic Diet: The Scientifically Proven Approach to Fast, Healthy Weight Loss, is an advocate of ketosis for weight loss. “The unique benefit of ketosis is that it promotes significant weight loss because the body is constantly breaking down stored fat to meet its energy needs,” says Mancinelli, who recommends exercising regularly and limiting calorie overconsumption while following this diet. “Ketosis dramatically diminishes hunger—another boon to weight loss that’s unique to ketosis, so overconsumption tends not to be a problem.”

Counseling Recommendations

KETOSIS FOR WEIGHT LOSS

By Toby Amidor, MS, RD, CDN

Q: A:

I’ve been hearing a lot of buzz about people going on a ketogenic diet so they can lose weight. Is there science to support this?

There’s science for and against following a ketogenic diet for weight loss, and the long-term effects on the body and weight maintenance are questionable. I spoke with two RDs who explained their stance on this debate.

Ketosis is a metabolic adaptation that has allowed humans to survive during periods of famine. When the body’s glycogen stores are depleted, the body breaks down fat and produces ketones, which provide energy for the brain when glucose is scarce. Ketosis can be achieved either by fasting or by strictly limiting carbohydrate intake to less than 20 to 30 g per day. Fat is increased to about 70% to 80% of total calories, and protein intake is moderate.

The ketogenic diet has been used in children with epilepsy but recently has become trendy as a weight loss diet and parallels the popularity of the Atkins diet in the 1990s. Some followers of a ketogenic diet are seeking approval to eat hefty amounts of bacon and mayonnaise, while others seek to eat fewer processed and sugary foods. However, for years RDs have known the dangers of being in a state of ketoacidosis, says Felicia D. Stoler, DCN, MS, RDN, FACSM, FAND, who advises against following a ketogenic diet for weight loss. “In the clinical setting, health care professionals work very hard to control lab values,” Stoler says, “and blood sugar, insulin, and ketoacidosis are some parameters closely monitored.”

A 2014 review discusses the science behind the safety concerns of following a ketogenic diet. There’s a lack of research on the long-term effects of a ketogenic diet in humans. As such, there’s concern of the effects on renal function, as high

12 today’s dietitian september 2017

Consumers already are confused about nutrition information, and conflicting RD recommendations make it even more confusing for them. Until long-term effects have been studied, RDs should be wary about recommending ketosis as a means for weight loss. Ultimately, it’s a restrictive diet plan limiting fruits, vegetables, and fiber-filled foods, all of which provide health benefits.

There are clients, however, who will insist on following a ketogenic diet. Stoler suggests assessing the clients’ knowledge base and motivation for doing so. “My style of diet planning is about lifestyle and feeling that food choices are not restricted,” says Stoler, who’s a firm believer that all foods can fit into a diet plan in moderation.

RDs must keep in mind that if a client is set on following a strict ketogenic diet to go into a state of ketosis for weight loss, nutrient insufficiencies can result. For this reason, Mancinelli recommends a multivitamin and mineral supplement that contains electrolytes, such as sodium and magnesium, and some B vitamins, all of which may be deficient in the diet.

— Toby Amidor, MS, RD, CDN, is the founder of Toby Amidor Nutrition (http:// tobyamidornutrition.com) and the author of the cookbook The Greek Yogurt Kitchen: More Than 130 Delicious, Healthy Recipes for Every Meal of the Day and her newly released The Healthy Meal Prep Cookbook.

She’s a nutrition expert for FoodNetwork. com and a contributor to US News Eat + Run and MensFitness.com.

For references, view this article on our website at www.TodaysDietitian.com.

Send your questions to Ask the Expert at TDeditor@gvpub.com or send a tweet to @tobyamidor.

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BREAKFAST

THE BREAKFAST CONTROVERSY

Contrasting Definitions and Counseling Clients

By Lauren Harris-Pincus, MS, RDN We’ve all heard the cliché that breakfast is the most important meal of the day. But what does that mean? There’s been a large body of research regarding the potential health benefits of consuming breakfast, but, upon reviewing the literature, a glaring fact stands out that may change what we’ve always thought to be understood: There’s no standard definition of breakfast. In 2016, a study published in the British Journal of Nutrition screened 1,023 articles in PubMed, identifying 50 different definitions of breakfast and narrowing them down to 12 for the purposes of their article.

So, if there’s no standardized definition of breakfast in the scientific community, and the body of research we look to for clinical recommendations is based on as many as 50 varying definitions, what does that say about the accuracy or inaccuracy of the conclusions? That’s certainly something to think about.

What Is Breakfast, Really?

Merriam-Webster defines breakfast as breaking the fast—essentially, the first meal of the day—with no qualifying information. Not taken into account are timing, macronutrient distribution, number of calories, number of food groups included, micronutrient values, and more.

This led me to reach out to fellow RDs to ask about their definition of breakfast, including their perceptions regarding timing and meal composition. Of the 64 RDs surveyed, at

14 today’s dietitian september 2017

least 10 different definitions of breakfast were shared—and some included multiple definitions. Slightly more than one-half felt that breakfast was defined as eating within two hours of waking. Based on that parameter alone, if a mom wakes at 6:30 am, gets the kids off to school, exercises, and first eats breakfast around 9 am, that’s 21⁄2 hours after waking. Does that count as breakfast, or did she “skip” it because it’s not within two hours?

When asked, “What does a morning meal need to consist of in order to be considered breakfast?,” 8% of those surveyed said a beverage counted; 82% felt there needs to be at least some solid food involved; and 28% believed a breakfast should contain a minimum number of calories to qualify with the suggested range between 200 and 500 kcal. This small sample of RDs confirmed what the literature revealed: The definition of breakfast is inconsistent among researchers and dietitians.

In 2014, O’Neil and colleagues published a commentary, “The Role of Breakfast in Health: Definition and Criteria for a Quality Breakfast,” in the Journal of the Academy of Nutrition and Dietetics. The purpose was to propose a definition of breakfast and further define what constitutes a quality breakfast. The researchers settled on the following definition: “Breakfast is the first meal of the day that breaks the fast after the longest period of sleep and is consumed within two to three hours of waking; it is comprised of food or beverage from at least one food group, and may be consumed at any location.”

O’Neil and colleagues’ proposed criteria for a quality breakfast included the following: • Calories should constitute 15% to 25% of total energy

needs, allowing for customization based on snacking habits.

• The meal should contain at least one food group but ideally

three or more to help close nutrient gaps and improve overall eating patterns.

• Protein-rich foods should be paired with nutrientdense, carbohydrate-rich foods such as grains, fruits, or vegetables, which should be considered essential for providing carbs needed for energy and replenishment of glycogen stores after a period of fasting.

• Foods should meet a minimum of 10% DV for as many nutrients as possible, with a goal of 20% or more for nutrients of concern (calcium, vitamin D, potassium, and fiber).

• Portion sizes should be consistent with MyPlate guidelines.

• Individuals should pay attention to foods to reduce, including saturated fat and sodium.

• Nutrient-dense foods should be included relative to the calories provided.

Why Is It Important?

Clearly, creating a breakfast meal based on these proposed criteria requires thought and planning. According to a 2011– 2012 National Center on Health Statistics survey, 15% of Americans skip breakfast entirely, with up to 32% of young adult males missing their morning meal. Why is it so important to consume breakfast within two to three hours of waking as proposed in the definition by O’Neil and colleagues? The American Heart Association weighed in, releasing a scientific statement in the February 2017 edition of Circulation, called “Meal Timing and Frequency: Implications for Cardiovascular Disease Prevention,” by St-Onge and colleagues. They reviewed the literature on breakfast skipping in relation to diet quality and other cardiovascular risk factors. According to this paper, “Epidemiological studies provide strong evidence of a relation between breakfast skipping and cardiometabolic risk including greater risk of overweight, obesity, metabolic risk profile, diabetes mellitus, CVD, and hypertension. These risks seem to be independent of differences in diet quality between breakfast eaters and nonconsumers.”

Several studies question the effect of eating breakfast on weight loss, and outcomes are mixed. Some show that those who skip breakfast consume fewer total calories throughout the day, and, though they may be hungrier by lunchtime than breakfast eaters, breakfast skippers tend not to overcompensate with calories at later meals.

However, it isn’t only about weight. According to the same American Heart Association Scientific Statement, “Skipping breakfast has been associated with markers of impaired glucose metabolism including elevated hemoglobin A1c, higher fasting plasma glucose, and all-day postprandial hyperglycemia.” Therefore, while we often make the case that breakfast is important to jump start metabolism or to assist with weight management, the more intriguing impact of consuming breakfast on a regular basis is the importance of managing cardiometabolic risk. Moreover, when individuals skip breakfast, they’re less likely to make up nutrients of concern at subsequent meals such as calcium, potassium, vitamin D, and fiber.

Putting Recommendations Into Practice When I asked RDs what was the biggest barrier to their clients consuming a healthful breakfast, the overwhelming response was time, which was shared by about 90% of those surveyed. With the proposed criteria to define breakfast, is it realistic to expect the average person to possess the skill, time, and motivation to include each of these points when planning their morning meal?

What are practical, actionable steps RDs can take to help clients create and consume a high-quality breakfast and not just something resembling a dessert such as a donut or pastry, a candy bar masquerading as a protein bar, or a “coffee” that’s actually a 500-kcal latte with 80 g sugar? Notably missing in breakfast choices is adequate protein. Higher levels of protein at breakfast have been

shown to help prevent sarcopenia as well as increase satiety and thermogenesis, which may be helpful when trying to lose weight.

Dietitians need to address barriers such as time constraints, and lack of creativity and resources while encouraging meal prep, getting portable and nonperishable items ready, and creating a daily routine.

RDs can help clients set the stage for success with the following suggestions: • Set the table with dishes, utensils, and ready-to-serve foods

such as whole wheat bread or ready-to-eat cereal the night before. If measuring is required, set out measuring cups and spoons to make portion control easy.

• Place refrigerated items such as milk, yogurt, and fresh fruit in the front of the refrigerator for easy access. Wash and cut fruit for fruit cups and have it ready to go.

• Blend low-fat or fat-free Greek yogurt, frozen fruit, and 100% juice for a quick smoothie. Clients can make smoothie bowls in advance and cover them overnight in the refrigerator. They will thicken, particularly with the addition of chia seeds or ground flaxseeds.

• Prepare hard-cooked eggs in advance.

• Batch-cook oatmeal or other whole grains on the stove or in a slow cooker to have it prepared for the week.

• Make muffin tin omelets or breakfast sandwiches/burritos in advance and refrigerate or freeze them to reheat on demand.

• Prepare overnight oats in Mason jars for several mornings at a time.

• Make cereal parfaits with whole grain cereal, Greek yogurt, and fresh or frozen (defrosted) fruit with nuts and/or seeds.

Have each ingredient in a bowl, ready to assemble in the morning.

Takeaways for Dietitians Several studies support the importance of consuming breakfast for weight maintenance, improved insulin sensitivity, cardiovascular health, and adequate nutrient consumption, but not necessarily specifically for weight loss.

Higher levels of protein have been shown to increase satiety and thermogenesis, which may be helpful for weight loss. At least 20 g protein is recommended for breakfast to help prevent sarcopenia with aging.

Clients require actionable steps to overcome obstacles to consuming a balanced, nourishing breakfast. Meal prep is a key intervention to create nutrient-rich meal options for the entire family.

— Lauren Harris-Pincus, MS, RDN, is the author of The Protein-Packed Breakfast Club and owner of Nutrition Starring YOU, LLC, based in New Jersey, where she specializes in weight management and prediabetes.

Follow her on social media @LaurenPincusRD.

september 2017 www.todaysdietitian.com 15

ORGANICS

ORGANIC DAIRY MYTHS AND FACTS

By Carrie Dennett, MPH, RDN, CD

Help patients make an educated choice for better health and the environment.

Organic milk has been in the news frequently this year, with reports of farmers dumping excess organic milk and investigations questioning whether some organic milk really is organic.

Overall, more consumers are choosing organic foods at least occasionally, and more mass-market retailers are selling them.

As a result, organic milk is no longer a niche product. Consumer demand for organic milk has been expanding, especially in the United States.1 According to IRI scanned retail sales volume data provided by the National Dairy Council (NDC), organic milk and dairy now represent an estimated 15% of organic food sales and 4.6% of total dairy sales. But what’s driving this growth—and has the bubble burst?

Growing Trend While fluid milk always has been the biggest driver of the organic dairy market, currently accounting for 92% of all organic dairy sales, NDC data show that organic yogurt represents 7% of organic dairy sales and 4% of total yogurt sales. And while organic cheese has carved out only 1% of organic dairy sales and 0.5% of all dairy sales, its sales more than doubled between 2012 and 2016.

In April, the media began reporting on an oversupply of organic milk on the market, with headlines such as “Even the hipster organic milk craze isn’t enough to end glut.”2 Although these media reports cite overproduction as the cause, USDA data for monthly

16 today’s dietitian september 2017

total organic fluid milk sales show that demand, while still increasing over time, has been slowing since 2014,3 but sales of nonorganic fluid milk are down, too.

Organic dairy saw growth in 2012–2014, but nearly flattened the following year. After a smaller rate of growth in 2015–2016, the market was down slightly this year as of the end of June. “Once farms convert to organic production, it will take some time for enough to convert back to conventional production in order to scale production growth to slower-growing demand,” says Erin Coffield, RDN, LDN, of the National Dairy Council.

While reasons for not purchasing organic foods vary, concerns about antibiotics, growth hormones, and pesticides often top the list of reasons to purchase them, as do broader concerns about animal welfare and the environment.4 Many consumers believe organic foods are more healthful and nutritious than conventional foods,5 and research shows this drives many organic food purchases.6,7 Coffield cites the Hartman Group Organic & Natural 2016 report, which says consumers purchase organic food and beverages based on the following desires and perceptions, in order of importance: • avoidance of farm-level pesticides and chemicals; • organic foods are “safer for me”; • avoidance of products that rely on growth hormones; • avoidance of products that rely on antibiotics; and • avoidance of genetically modified products.

Defining Organic Dairy The three aspects of USDA organic regulations for dairy that most consumers are interested in are related to pesticides, antibiotics, and growth hormones,4 although beliefs about the differences between organic and conventional dairy are based on both myths and facts.

It’s true that all feed provided to organic dairy cows—including fresh pasture, hay, grain, and other agricultural products— must be free from GMOs and grown without the use of synthetic fertilizers, pesticides, and herbicides. In fact, part of the organic certification process includes documenting that no prohibited substances were applied to grazing land for the previous three years.8 It’s also true that the use of recombinant bovine growth hormone (rBGH) isn’t allowed in organic dairy production. However, more stores are refusing to carry milk from rBGH-treated cows, so its use in conventional herds in the United States, while allowed, has been declining for years.9 Where mythology starts to emerge is with antibiotic use.

While the use of subtherapeutic doses of antibiotics isn’t allowed in organic livestock, the practice isn’t common in

conventional dairy herds compared with beef herds. Antibiotics are allowed for treating bacterial infections in both organic and conventional dairy herds.8 Consumers may think that by opting for organic milk, they’re avoiding ingesting antibiotic residues, but the truth is that antibiotic residues aren’t permitted in any milk. If a conventional cow is treated with antibiotics, her milk can’t be sold until the number of days has passed on the drug label, as mandated by the FDA. If any milk tests positive for antibiotics, no milk from that tank can be sold. Of the nearly 38,000 dairy samples the FDA tested in 2014, none tested positive for traces of antibiotics.10 The slight difference between organic and conventional dairy farms is that if an organic cow needs antibiotics, she’s permanently removed from the milking herd.8 Another myth about organic dairy is that organic cows are 100% grass-fed. Under USDA Certified Organic regulations, dairy cows must have free access to certified organic pasture for the entire grazing season. This typically runs from spring through the first frost—at least 120 days per year—but will vary based on geography and climate. During the grazing season, at least 30% of the cow’s forage (grass, legumes, and silage) needs must come from grazing on certified organic pasture. Organic grain, corn, and soybeans also are allowed. During the nongrazing season, dairy cows must have free access to the outdoors, weather permitting.8

Health and Environmental Effects Consumers are willing to pay more for milk with higher levels of omega-3 polyunsaturated fatty acids,7 but this is difficult to achieve in ruminant animals such as cattle. Most of the polyunsaturated fatty acids in the cow’s feed, whether that be grain or grass, are converted to saturated fatty acids in the rumen, the first chamber in the cow’s alimentary canal.11,12 About 70% of the fats in milk are saturated, 25% are monounsaturated, and 2.3% are polyunsaturated.13 However, the fatty acid composition of milk depends on several factors, including genetics, how and where the cow was raised, where she is in her lactation cycle (the period between one calving and the next), diet, and season (spring vs summer or grazing vs nongrazing).14 When dairy cows—whether organic or conventional—eat a grass diet, they produce milk that’s higher in omega-3s.15 Alphalinolenic acid (ALA) is the predominant omega-3 fatty acid in milk.

Although ALA levels are consistently higher in grass-fed milk and organic milk, the amounts of the long-chain omega-3s EPA and DHA are present in much smaller amounts, even in grassfed milk. These forms are most important to human health and chronic disease prevention; human conversion of ALA to EPA or DHA is limited.14,16,17 In 2016, a meta-analysis of 170 published studies compared the fatty acid compositions of organic and conventional milk.18 The results revealed no significant differences in total saturated fatty acid and monounsaturated fatty acid concentrations, but found that organic milk contained 7% more total polyunsaturated fatty acids and 56% more omega-3s than conventional.

Concentrations of ALA were 69% higher, levels of EPA and

DHA were 57% higher, and levels of conjugated linoleic acid were 41% higher.18 However, levels of ALA are still far lower than what’s found in walnuts or flaxseeds, and levels of EPA and DHA are far lower than what’s present in fish and seafood. Limited research suggests that conjugated linoleic acid has anticarcinogenic and antiatherogenic effects, but, even if this is true, the amounts needed would be significantly higher than what’s present in milk fat.14,16 Despite the difficulty of shifting the fatty acid composition of milk, research does show there’s a difference in fatty acid composition between organic and conventional milk. The differences are great enough that fatty acid analysis is used to authenticate the origins of bulk milk.19,20 In fact, a large organic dairy producer, Aurora Organic Dairy, came under fire in May after an investigative report by The Washington Post claimed that only a small percentage of the cows was on pasture and that an independent lab analysis found that the fatty acid profile of Aurora milk was similar to conventional milk. Aurora supplies the “private label” (or store-brand) milk to Costco, Walmart, and other major retailers.21 According to the Organic Center, a nonprofit organization based in Washington, D.C., organic dairy farms have less of a negative impact on land, air, and water quality than conventional dairy farms, giving them a reduced “environmental footprint.”

This is partly because organic dairies don’t use synthetic pesticides and fertilizers that can leach into water and soil, but also because they use significantly less “prime” land. When organic dairies use Jersey cows instead of Holsteins, for example, they produce significantly less manure, which leads to less methane—a gas that may contribute to global warming—and less nutrient runoff of nitrogen, phosphorous, and potassium, for example, which helps protect water quality.22

Bottom Line Even if there are nutritional differences between organic and conventional dairy, there’s no evidence that the differences are clinically meaningful. Both organic and conventional dairy farmers care for their animals, and both types of farms may be small family farms or large mega-farms. Use of sustainable farming practices has benefits for the environment and the future of farmland health, but the avoidance of pesticide use in organic dairy production is just one part of that. Dietitians can help patients separate myth from fact so they can make the best, most educated decisions for themselves and their families.

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times and speaks frequently on nutrition-related topics. She also provides nutrition counseling via the Menu for Change program in Seattle.

For references, view this article on our website at www.TodaysDietitian.com.

september 2017 www.todaysdietitian.com 17

THE RETAIL RD kits that don’t require a subscription commitment and are making them available via online delivery or in stores where shoppers can purchase them any time.

Online Grocers Offer Meal Kit Delivery

MEAL KITS TAKE ROOT IN GROCERY STORES

By Barbara Ruhs, MS, RDN

To remain competitive, supermarkets are getting in on the burgeoning market.

Subscription-based meal kit delivery programs such as Blue Apron, Hello Fresh, Purple Carrot, and Sun Basket captured $2.2 billion in sales in the past year, and supermarkets are responding with innovative meal kit ideas of their own to retain customers and profits.1 Facing increased competition from restaurants over the past decade, the supermarket foodservice segment is the highest-performing, fastest-growing segment in the food industry, proving that retailers can retain and attract customers with high-quality prepared foods and dining experiences.2 With stores full of fresh ingredients, including a variety of precut, premeasured, and prewashed items, supermarkets are well positioned to grab a share of the growing meal kit segment.

Convenience and lack of culinary skills combined with rising restaurant prices are fueling the growth of meal kit programs.3 According to a 2016 survey that ReportLinker conducted, 31% of Americans cited lower costs, while 22% said more healthful eating motivates the drive to cook at home vs eating out at a restaurant.4 A 2016 Harris Poll reported that 84% of Americans are cooking at home at least once per week, and 31% report cooking every day.5 Supermarkets are using in-house chefs and dietitians to create easy-to-prepare, healthful, and lower-cost meal

18 today’s dietitian september 2017

Peapod is the leading internet grocer and a subsidiary of AholdDelhaize, one of the largest supermarket retailers on the eastern seaboard.6 Peapod delivers groceries in 13 states in 24 markets for retail banners including Stop & Shop, Giant Food Stores, Food Lion, and Hannaford.

Peapod partnered with ORC International to host a year-end national survey that discovered that 72% of Americans reported cooking at home four nights or more per week, and 51% of Americans said they would prepare dinner at home more often if they had new ideas, resulting in Peapod proclaiming 2017 as “the year of the home cook.”

Through the creation of mutually beneficial partnerships with leading trusted food brands sold in its stores, including Barilla, Conagra, and Campbell’s, Peapod has capitalized on knowledge, culinary expertise, and marketing power to capture a share of the growing meal kit market.7,8 To further expand its marketing reach, Peapod formed a partnership with well-known food blogger Gina Homolka of Skinnytaste to feature recipes from her latest no. 1 New York Times bestseller Skinnytaste Fast and Slow: Knockout Quick-Fix and Slow Cooker Recipes. Customers had the unique opportunity to preview recipes online and select ingredients for their online shopping carts for home delivery.

Priced lower than subscription-based kits at $5 to $8 per serving, Peapod reported a 250% increase in sales of their meal kits in the last year.9 In addition to e-grocers like Peapod, Amazon Fresh, New York-based Fresh Direct, and San Francisco-based Good Eggs, traditional brick and mortar supermarkets also are offering meal kits using online grocery delivery platforms. Coborn’s, based in St. Cloud, Minnesota, rolled out “To the Table Kits,” created by its in-house dietitians and chefs. The kits don’t require an ongoing subscription, are delivered on the same day they’re ordered, and feature locally sourced ingredients from the Midwest at lower prices ($16.99 to $28.99 for two servings) compared with national competitors.

In-Store Meal Kit Options According to a 2017 Harris Poll, one-third of subscribers to meal kit delivery programs said they’d purchase the meal kits in a local supermarket if they were available.10 To retain in-store sales and grow a new source of revenue, national supermarket chains, including Whole Foods and Kroger, are customizing meal kits to their unique customer bases and offering the convenience and flexibility to choose meal kits in stores while shopping.

Appealing to vegetarians and vegans, Whole Foods Market partnered with Purple Carrot, the leading plant-based meal kit delivery program, to offer customers meal kits in select stores.

Customers can choose a single Purple Carrot meal, customized specifically for Whole Foods Market, for two people for $19.99.11 As more than one-half of meal kit subscribers cancel their subscriptions within the first six months,12 it’s a smart move for retailers to offer flexibility to customers to choose meal kits on demand in stores in contrast to subscription-based kits that send a minimum of three meals for two people each week.

Kroger introduced Prep + Pared meal kits featuring chefinspired, dietitian-approved, restaurant-quality meals that can be prepared in 20 minutes or less to attract customers who want to prepare meals in their own kitchen. The kits, which don’t require a subscription, include fresh ingredients that are washed, premeasured, and prepared (eg, chopped, diced, grated), making it quick and easy for customers to prepare a healthful meal at home with limited food waste. Each kit feeds two adults and ranges in price from $14 to $18.13

Similar to Kroger’s meal kit program, regional retailers such as Lakeland, Florida-based Publix supermarkets and Des Moines, Iowa-based Hy-Vee supermarkets are working with their retail dietitians to offer customers healthful, fresh, and local ingredients at reduced prices compared with subscription meal kits.

Growing Opportunities For nearly a century, supermarkets have countered competition with innovation. When it comes to offering subscription-based meal kit delivery programs, supermarkets are finding ways to provide customers what they want while taking advantage of many of the challenges and obstacles their competition faces.

By testing meal kits in stores or through online delivery services, supermarkets are exhibiting their eagerness to meet the growing needs of customers seeking healthful, affordable, convenient options. With continued innovation and competition, home cooking may just become the new “normal.”

— Barbara Ruhs, MS, RDN, is a retail health expert to super­ markets and food companies and founder of the Oldways Supermarket Dietitian Symposium. Follow her @BarbRuhsRD.

For references, view this article on our website at www.TodaysDietitian.com.

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The

Best of

Chicago Dining

By CARRIE DENNETT, MPH, RDN, CD

M

any people associate comfort food such as deep dish pizza, hot dogs, and Italian beef with the Windy City, but Chicago also is home to world-class fine dining, gastropubs, and scrumptious Mexican food.

From the celebrity chefs of West Loop to the taquerias of the Pilsen neighborhood, Chicago proves it’s not a one-note wonder—it’s a culinary symphony. Just in time for the Food & Nutrition Conference & Expo™ (FNCE®), Today’s Dietitian asks a team of local food experts and dietitians to offer their views on the best of Chicago dining.

“Chicago’s food scene is constantly changing and elevating itself,” says Chicago native Roger Waysok, executive chef at South Water Kitchen (www.southwaterkitchen.com, 225 N. Wabash Avenue, Chicago, 312-236-9300). “Not only do we offer almost every type of cuisine but we also have a variety of dining experiences. In one weekend, you could eat at an elevated fast food restaurant, try an eight-course tasting menu, or head to your local hole-in-the-wall bar for comfort food. As long as you’re open to trying new places, you can find exactly what you’re craving, whether it be Mexican, Indian, or American, in just about every type of atmosphere and price range.”

Kendra Peterson, a private chef and owner of Drizzle Kitchen (http://drizzlekitchen.com) and friend of Dawn Jackson Blatner,

20 today’s dietitian september 2017

RDN, LDN, the Chicago dietitian behind the winner of the ABC reality TV show My Diet Is Better Than Yours, says Chicago’s status as the “Second City” means it’s had to prove that it has just as much talent as Los Angeles and New York. “Because of that I think our chefs rock in the kitchen; they have to work harder to prove their worth and it’s finally starting to pick up steam,” she says. “We have some amazing restaurants that are constantly recognized for James Beard Awards.”

Chicago’s status as a true food city received a unique stamp of approval with the announcement that the James Beard Award ceremony—which was held in Chicago in 2016 and 2017—will remain in town an additional four years. That’s with good reason, says Chicago-area dietitian and nutrition expert Christine Palumbo, MBA, RDN, FAND: “Chicago is a food town!”

Three Neighborhoods to Know River North This neighborhood is north of the Chicago River and the location of many of the FNCE® hotels. Restaurants include an ode to Mexican cuisine, such as Frontera Grill (www.rickbayless.com/ restaurants/frontera-grill, 445 N. Clark Street, Chicago, 312-6611434), and the Clark Street location of all-day American eatery RIGHT: PHOTO BY ELIZABETH PRINZ

If you’re going to the Academy of Nutrition and Dietetics’ Food & Nutrition Conference & Expo™ next month, prepare to enjoy a wide variety of awardwinning, world-class cuisine in this historic melting pot of different cultures.

Charred cauliflower with curry butter and burnt orange, asparagus salad with green goddess dressing, whitefish tartine, and chicken liver mousse with red wine syrup from The Bristol

The Best of Chicago Dining

Beatrix (http://beatrixchicago.com, 519 N. Clark Street, Chicago, 312-284-1377; 671 N. St. Clair, Chicago, 312-642-0001; 834 W. Fulton Market, Chicago, 312-733-0370), as well as food destinations such as Eataly Chicago (www.eataly.com/us_en/stores/ chicago, 43 E. Ohio Street, Chicago, 312-521-8700), which Palumbo calls “a must-see for FNCE® attendees.” This sprawling outpost of all things Italian includes a range of eateries and food markets.

An option for those staying in hotels south of the river is Revival Food Hall (www.revivalfoodhall.com, 125 S. Clark Street, Chicago, 773-999-9411), which offers 15 fast-casual food stalls.

This 24,000-square foot marketplace gives patrons a chance to sample fare from many of Chicago’s best neighborhood restaurants, including the award-winning Smoque BBQ (www. smoquebbq.com, also located at 3800 N. Pulaski Road, Chicago, 773-545-7427), a favorite of food blogger Starr Nordgren, MS, MA (www.chicagofoodiegirl.com), for its house-smoked meats and housemade rubs and sauces.

West Loop Restaurant Row in West Loop is home to some of the city’s finest restaurants, including Chef Stephanie Izard’s Girl & the Goat (www.girlandthegoat.com, 809 W. Randolph Street, Chicago, 312-492-6262), open-hearth cooking at the Argentinean Steakhouse El Che (www.elchebarchicago.com, 845 W. Washington Boulevard, Chicago, 312-265-1130), and Elske (https:// elskerestaurant.com, 1350 W. Randolph Street, Chicago, 312733-1314), an à la carte and tasting menu comprising Danishinfluenced dishes.

Just steps north of Restaurant Row is Fulton Market (http:// fultonmarketchicago.com). Nestled within Chicago’s Fulton River District in West Loop, the market is home to some of the city’s best spots, such as Paul Kahan’s The Publican (www.thepub licanrestaurant.com, 837 W. Fulton Market, Chicago, 312-7339555) and Publican Quality Meats (www.publicanqualitymeats. com, 825 W. Fulton Market, Chicago, 312-445-8977) for beer and meat, and Grant Achatz’s Next (http://nextrestaurant.com, 953 W.

Fulton Market, Chicago, 312-226-0858) and Aviary (https://theaviary.com/site, 955 W. Fulton Market, Chicago, 312-226-0868) for a world-renowned tasting menu and cocktails.

Nordgren also mentions BLVD (www.blvdchicago.com, 817 W. Lake Street, Chicago, 312-526-3116), a modern American eatery that draws inspiration from Hollywood’s Sunset Blvd circa 1950; Roister (www.roisterrestaurant.com, 951 W. Fulton Market, Chicago), superstar Achatz’s new hip, casual American eatery; and the award-winning Japanese restaurant Momotaro (www.momotarochicago.com, 820 W. Lake Street, Chicago, 312-733-4818). “The neighborhood has something for everyone—you can spend an entire week simply eating your way down one block,” Nordgren says. The West Loop also features Au Cheval (www.auchevalchicago.com, 800 W. Randolph Street, Chicago, 312-929-4580), as well as Greektown.

The area also is home to one of Chicago’s Green City Markets (www.greencitymarket.org, 115 S. Sangamon Street, Chicago, 773-880-1266), open on Saturdays in Mary Bartelme Park. It’s the city’s first and largest year-round sustainable farmers’ market supporting small family farms.

Logan Square “Logan Square is a little off the beaten path for those staying in the Loop, but it’s a neighborhood chock full of amazing restaurants and cocktail bars,” Waysok says.

Ginger Hultin, MS, RDN, CSO, a Seattle-based dietitian and writer who once called Chicago home, also is a fan, offering that the neighborhood is easily accessible on the Blue Line (www. transitchicago.com/blueline). “Grab a drink at cocktail gin bar Scofflaw (www.scofflawchicago.com, 3201 W. Armitage Avenue, Chicago, 773-252-9700) or enjoy the outdoor patio next door at Parson’s (www.parsonschickenandfish.com, 2952 W. Armitage Avenue, Chicago, 773-384-3333) for a Negroni slushy,” she suggests. “Try to get in to the well-known and ever-popular Longman & Eagle (www.longmanandeagle.com, 2657 N. Kedzie Avenue, Chicago, 773-276-7110) for New American, innovative fare, or Table, Donkey and Stick (www.tabledonkeystick.com, 2728 W. Armitage Avenue, Chicago, 773-486-8525) for creative, seasonally driven dishes inspired by the cuisine of the Alps.”

Must-Taste in the Windy City Deep-dish pizza from Lou Malnati’s Pizzeria

22 today’s dietitian september 2017

“Any visitor to the Windy City is required to try the deep dish pizza—although most locals prefer thin crust, a ketchup-free Chicago-style hot dog, an Italian beef sandwich with spicy giardiniera (an Italian condiment made of pickled peppers, celery, carrots, cauliflower, and other vegetables packed in oil), and Garrett’s (www.garrettpopcorn.com) Garrett Mix popcorn (caramel and cheddar),” says Chicago dietitian and blogger Amari Thomsen, MS, RD, LDN. “First-timers always want to try deep dish,” Waysok says. “If you’re going to go for it, head to Pequod’s Pizza (http://pequods pizza.com/chicago, 2207 N. Clybourn Avenue, Chicago, 773-3271512) because you won’t find anywhere else a caramelized cheese crust cooked to perfection.” Hultin agrees, and recommends LEFT: PHOTO BY ADAM ALEXANDER PHOTOGRAPHY/CHOOSE CHICAGO

North Pond offers seasonal farm-totable favorites like this green salad with squash and pear.

loading up on toppings such as fresh basil, spinach, pineapple, or spicy giardiniera. If you want to see—and taste—where the deep dish craze began, Palumbo recommends Pizzeria Uno (www. unos.com, 29 E. Ohio, Chicago, 312-321-1000), opened by Rudy Malnati, Sr, in 1943, and Pizzeria Due (www.unos.com, 619 Wabash Avenue, Chicago, 312-943-2400), each of which are close to the hotels. Rudy Malnati, Jr, carries on the legacy with Pizano’s Pizza & Pasta (www.pizanoschicago.com, 61 E. Madison Street, Chicago, 312-236-1777; 864 N. State Street, Chicago, 312-751-1766; 800 N. Dearborn Street, Chicago, 312-335-8833; 2056 W. Division Street, Chicago, 773-252-1777; 2106 S. Indiana, Chicago, 312-842-0777).

At Lou Malnati’s Pizzeria (www.loumalnatis.com, multiple Chicago locations, including 439 N. Wells Street, Chicago, 312-8289800), Hultin recommends the “Lou”: spinach, mushrooms, and sliced tomatoes on the classic garlic buttercrust.

From Italian pizza, it’s a short culinary hop to Italian beef sandwiches. “While there are a few excellent chain restaurants that serve a good beef sandwich—Portillo’s (www.portillos.com, 520 W. Taylor Street, Chicago, 312-667-4560; 100 W. Ontario Street, Chicago, 312-587-8910) comes to mind—there are dozens, if not hundreds, of beef joints throughout the city and its suburbs,” Palumbo says. “Near the hotels are Al’s (www.alsbeef.com, 1079 W. Taylor Street, Chicago, 312-226-4017) and Mr. Beef (666 N. Orleans Street, Chicago, 312-337-8500). Ask for the sweet peppers.” While Portillo’s wins raves for its Italian beef, its true Chicago-style hot dogs top the menu. “A Chicago-style hot dog goes like this,” Palumbo instructs. “Steamed poppy seed bun, kosher-style dog—Vienna Beef is the favored brand, but there are others—topped with a ‘garden’ consisting of chopped raw onion, a couple of tomato wedges, dill pickle spear, yellow mustard, bright green pickle relish, a sprinkle of celery salt, and optional hot sport peppers. And never ketchup!”

Jim’s Original (www.jimsoriginal.com, 16 E. 95th Street, Chicago, 773-785-9865) serves up the Original Maxwell Street Polish Sausage on a hot bun with a mountain of grilled sweet onions, yellow mustard, and spicy hot sport peppers. “If you want to try classic Chicago pizza and hot dogs while exercising, there’s a four-hour bike tour you can take to hit a few great spots,” Blatner says. In addition to the Bikes, Bites & Brews tour, Bobby’s Bike Hike (www.bobbysbikehike.com, 540 N. Lake Shore Drive, Chicago, 312-245-9300) offers an assortment of biking, walking,

Comfort food with a twist at Stephanie Izard’s Little Goat Diner in the West Loop’s Restaurant Row

and food tours. Prefer burgers to dogs? Head to Au Cheval (see page 22), which features a cheeseburger that Nordgren dubs “quintessentially Chicago” and Eater Chicago, an online Chicago dining guide, says may be the best on the planet.

Celebrity Chefs and Michelin Stars For those who prefer stargazing, enjoy counting the Michelin stars awarded to Chicago’s celebrity chefs. Achatz is one of the most celebrated chefs in the world, and Alinea (http://alineares taurant.com, 1723 N. Halstead, Chicago, 312-867-0110), with its modernist tasting menus, is routinely named one of the world’s best restaurants, one of only 13 Michelin three-star restaurants in the United States. Sixteen (http://sixteenchicago.com, 401 N. Wabash Avenue, Chicago, 312-588-8030) is a Michelin two-star restaurant with seasonal, contemporary American menus that draw inspiration from local farmers, ranchers, and fishmongers.

At Grace (www.grace-restaurant.com, 652 W. Randolph Street, Chicago, 312-234-9494), Chef Curtis Duffy has earned numerous Michelin stars for his Instagram-worthy tasting menus, one vegetarian (flora), the other not (fauna). At Monteverde Restaurant & Pastificio (http://monteverdechicago.com, 1020 W. Madison Street, Chicago, 312-888-3041), Chef Sarah Gruenberg blends Italian culinary tradition with influences from her global travels and Texan roots. Nordgren says Gruenberg’s Cacio Whey Pepe is another quintessentially Chicago dish. This year, Gruenberg won a James Beard award for Best Chef: Great Lakes and was a competitor on Iron Chef Gauntlet. In 2016, Monteverde made Food & Wine’s list of America’s Best Restaurants.

Girl & the Goat (see page 22) was nominated for best new restaurant by the James Beard Foundation in 2011. Izard— winner of both Top Chef and Iron Chef—was one of Food & Wine’s “Best New Chefs” in 2010. Izard serves up a family-style menu with global influences. Her empire reaches across the street to Little Goat Diner (www.littlegoatchicago.com, 820 W. Randolph Street, Chicago, 312-888-3455), which offers comfortfood favorites with a twist, including gluten-free options, and around the corner to Duck Duck Goat (www.duckduckgoatchi cago.com, 857 W. Fulton Market, Chicago, 312-902-DUCK) with “reasonably authentic Chinese food,” plus dim sum on weekends.

GreenRiver (www.greenriverchi.com, 259 E. Erie, 18th Floor, Chicago, 312-337-0101) made virtually every best new restaurant

LEFT: PHOTO COURTESY OF NORTH POND; RIGHT: PHOTO BY CLAYTON HAUCK/CHOOSE CHICAGO

september 2017 www.todaysdietitian.com 23

French toast from South Water Kitchen

list in 2015, the year it opened. It boasts Michelin stars as well as seasonal American fare and a beautiful outdoor terrace. Executive Chef Aaron Lirette is a Chicago native, as is Chef Jimmy Bannos, Jr, of The Purple Pig (https://thepurplepigchicago.com, 500 N. Michigan Avenue, Chicago, 312-464-1744). Called “The Prince of Pork” by Food & Wine editor Dana Cowin, Bannos was 2014’s James Beard Rising Star Chef, and Purple Pig was named one of Bon Appétit’s “10 Best New Restaurants in America.” Expect sharable plates focusing on “cheese, swine, and wine,” showcasing Mediterranean flavors. No reservations? No problem— the restaurant is walk-in only.

Global Melting Pot “Chicago is a historic melting pot of different cultures. Traditional cuisines from various countries shine through across each and every neighborhood of the city,” Thomsen says.

Palumbo enthusiastically agrees. “You can find just about any ethnic food that exists! In addition to a myriad of options for popular ethnic food (Italian, Greek, Chinese, German, Polish), you can find Ethiopian, Egyptian, etc, restaurants,” she says. “We have long-established ‘food towns’ such as Greektown, Little Italy, [and] Chinatown. All three of these are close to the FNCE® hotels.”

Mexican food is huge in Chicago, thanks largely to Chef Rick Bayless, who opened Frontera Grill (see page 20) in 1987. This James Beard Award-winning restaurant is ever popular (read: busy), so for a Rick Bayless restaurant without the wait, Thomsen recommends Xoco, pronounced SHO-ko (www.rickbayless. com/restaurants/xoco, 449 N. Clark St, Chicago, 312-661-1434).

While Xoco has a following for its unique bean-to-cup Mexican chocolate, Thomsen emphasizes that the restaurant’s sustainability and farm-to-table cred continues with “counter-served Mexican street food including incredible tortas (Mexican sandwiches) and caldos (meal-in-a-bowl soups) made with fresh ingredients straight from Bayless’s urban Chicago garden.”

It’s also a short Uber or Lyft ride from McCormick Place to the Pilsen neighborhood, the cultural center of Chicago’s Mexican population, with lots of tasty, inexpensive eats on W. 18th Street.

When Waysok’s off duty, he likes to eat at Dos Urban Cantina (www.dosurbancantina.com, 2829 W. Armitage Avenue, Chicago, 773-661-6452), which he calls a neighborhood gem. “Frontera alumni serve some of my favorite Mexican food and delicious Mezcal cocktails,” he says. Many of the items on the menu are

24 today’s dietitian september 2017

Nellcôte offers seasonal menus in a Euro-chic setting

gluten-free. Peterson and Hultin both love Antique Taco (www. antiquetaco.com, 1360 N. Milwaukee, Chicago, 773-687-8697; 1000 W. 35th Street, Chicago, 773-823-9410; 125 S. Clark Street, Chicago, 773-770-6195), a Wicker Park hot spot that offers a seasonal menu of “farmers’ market style” Midwest-Mexican gourmet tacos and appetizers. Want to stick closer to your hotel?

Antique Taco also has a spot in Revival Food Hall (see page 22).

Also in the Wicker Park neighborhood are two of Nordgren’s picks: Irazú (www.irazuchicago.com, 1865 N. Milwaukee Ave, Chicago, 773-252-5687), a cash-only, vegetarian-friendly BYOB restaurant serving Costa Rican cuisine, and 90 Miles Cuban Café (www.90milescubancafe.com, 2540 W. Armitage Avenue, Chicago, 773-227-2822).

Nordgren also gives a nod to Fat Rice (http://eatfatrice.com, 2957 W. Diversey Avenue, Chicago, 773-661-9170), where Chef Abraham Conlon epitomizes global fusion. One of Peterson’s picks is Parachute (www.parachuterestaurant.com, 3500 N. Elston Avenue, Chicago, 773-654-1460), a funky-chic place serving sharable, modern, creative Korean-American fare—Bon Appetit called it “a Korean mom-and-pop shop gone delectably rogue.” Chinatown is less than a mile from McCormick place, and Argyle Street in the Uptown neighborhood is home to lots of Vietnamese and Chinese dim sum restaurants. For a taste of the Mediterranean, Palumbo recommends Greek Islands (www.greekislands.net, 200 S. Halsted Street, Chicago, 312-782-9855) and Santorini (www.santorinichi cago.com, 800 W. Adams Street, Chicago, 312-829-8820) in Greektown for their freshly prepared foods, authentic menu, and seafood.

Farm-to-Table “Lula Café (http://lulacafe.com, 2537 N. Kedzie Boulevard, Chicago, 773-489-9554) started it all back in 1999 with its farmto-table philosophy and is still one of the best places in the neighborhood,” Waysok says.

Hultin agrees, adding that Lula’s “never disappoints for a classic breezy brunch, lunch, or farm dinner.”

At his own South Water Kitchen (see page 20), Waysok says his culinary philosophy is “Let the food be the star. Fresh ingredients are great on their own and don’t need to be overworked to taste delicious in a dish. I always make sure that you can taste

LEFT: PHOTO BY COLIN BECKETT; RIGHT: PHOTO BY ADAM ALEXANDER PHOTOGRAPHY/CHOOSE CHICAGO

the fresh ingredients in my dishes and they don’t get lost in the other flavors.” He offers his shaved zucchini “pasta” dish as an example. “The zucchini is shaved and treated like pasta—tossed in a white wine garlic wine sauce with cherry tomatoes, black olives, and torn basil, then topped with Parmesan cheese. It’s light and fresh, while the basil accents each of the flavors so they can all be identified. This dish also is gluten-free and vegan, so it speaks to a variety of guests.”

Sixteen (see page 23) is a stellar farm-to-table example, as is Uncommon Ground (www.uncommonground.com/home, 1401 W. Devon Avenue, Chicago, 773-465-9801), which serves contemporary comfort fare and has the country’s first certified organic rooftop farm. Peterson and Palumbo both count the creative American fare at North Pond (http://northpondrestaurant.com, 2610 N. Cannon Drive, Chicago, 773-477-5845) inside Lincoln Park as a farm-to-table favorite. Other standouts include American heirloom foods at Blue Door Kitchen (http://bluedoorkitchenchicago. com, 52 W. Elm Street, Chicago, 312-573-4000), small plates in a Euro-chic setting at Nellcôte (www.nellcoterestaurant.com, 833 W. Randolph Street, Chicago, 312-432-0500), and one of Nordgren’s favorites, new-American gastropub The Bristol (www.thebris tolchicago.com, 2152 N. Damen Avenue, Chicago, 773-862-5555).

Plant-Forward Stay energized for all of the educational and networking opportunities FNCE® offers with a delicious, nutritious meal from True Food Kitchen (www.truefoodkitchen.com, 1 W. Erie Street, Chicago, 312-204-6981), which merges seasonal, nutrient-rich ingredients with a flavor-forward menu that includes vegan, vegetarian, gluten-free, and omnivorous options. Thomsen and Nordgren are both fans of modern hot spot Beatrix (see page 22). Thomsen calls it “the perfect place for breakfast or lunch with the girls,” adding that it has “fresh juice cocktails, plenty of quinoa and kale, and decadent gluten-free desserts you won’t be able to pass up.”

The vegetarian tasting menu at Grace (see page 23) is only one facet of vegetable-forward eating in Chicago. Peterson likes Bad Hunter (https://badhunter.com, 802 W. Randolph Street,

Dining Resources To learn more about the best of Chicago dining, visit the following websites: • Choose Chicago (www.choosechicago.com/restaurants/ best-of-chicago) • Chicago Magazine (www.chicagomag.com/dining-drinking) • Chicago Tribune (www.chicagotribune.com/dining/ best-restaurants) • Eater Chicago (https://chicago.eater.com/2016/9/ 19/12523944/chicago-city-guide-where-to-eat-drink) • Bon Appétit (www.bonappetit.com/city-guides/package/ chicago) • Food & Wine (www.foodandwine.com/articles/ chicago-restaurants) • Thrillist Chicago (www.thrillist.com/chicago)

The Best of Chicago Dining

Chicago, 312-265-1745), which The New York Times called “a shrine to vegetables” and Chicago magazine pegged as one of the best new restaurants of 2017. Nordgren recommends Green Zebra (www.greenzebrachicago.com, 1460 W. Chicago Avenue, Chicago, 312-243-7100), which features innovative menus built on vegetarian and vegan dishes that focus on seasonal fruits and vegetables from local farmers and foragers. This approach and execution has won Chef Shawn McClain praise from The New York Times, Bon Appetit, Food & Wine, and several other publications.

Fine Dining Looking for a gorgeous meal in impeccable surroundings?

Palumbo gives a shout-out to Spiaggia (www.spiaggiarestaurant. com, 980 N. Michigan Avenue, Chicago, 312-280-2750). “The menu items are incredible with a beautiful, relaxed presentation and a view outside onto Michigan Avenue that is to die for,” she says.

The New York Times called Topolobampo (www.rickbayless.com/ restaurants/topolobampo, 445 N. Clark Street, Chicago, 312-6611434) “possibly the most elegant and serious Mexican restaurant in the country.” Topolobampo won the James Beard award for Outstanding Restaurant in 2017 and has a Michelin star to boot.

One of Food & Wine’s best new chefs of 2017 is Noah Sandoval of Oriole (www.oriolechicago.com, 661 W. Walnut Street, Chicago, 312-877-5339). The magazine calls him a “chef with gob-smacking vision,” and Peterson offers no argument. “Simply stunning presentation, incredible location,” she says. “My date had the classic tasting menu. I did as well, but they accommodated my gluten issue better than any restaurant I’ve ever been to. It makes sense that they were awarded two Michelin stars and are getting insane recognition in the city after being open for barely a year.”

Chicago native Carrie Nahabedian’s NAHA (http://naha-chicago. com, 500 N. Clark Street, Chicago, 312-321-6242) has earned seven consecutive Michelin stars and a James Beard award.

NAHA’s menu, which draws from American influences as well as Nahabedian’s Armenian and Greek roots, favors fresh, seasonal produce, meats, and cheeses from local farmers and growers. Just up the street is Brindille (http://brindille-chicago.com, 534 N. Clark Street, Chicago, 312-595-1616), which Nahabedian opened in 2013 to celebrate her favorite spots in Paris. Chicago magazine called it “a destination for French cuisine in style and comfort” when it named it one of 2014’s restaurants of the year.

Make your restaurant reservations, pack your bags, and get ready to taste and savor your way through the Windy City!

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times and speaks frequently on nutritionrelated topics. She also provides nutrition counseling via the Menu for Change program in Seattle. This is her first year writing Today’s Dietitian’s dining guide.

september 2017 www.todaysdietitian.com 25

DIET STATINS vs

By Densie Webb, PhD, RD

A

therosclerotic CVD (ASCVD) is a leading cause of premature death and disability in the United States.1 Advice on ways to reduce CVD risk abounds. So what’s the best method for preventing atherosclerosis and ultimately CVD? Dietary changes can reduce cholesterol levels in the blood, sometimes significantly. Drugs, such as statins, also have been proven effective. But which is best?

Should diet be altered before turning to drugs? Should statins be prescribed more liberally? Should diets and drugs be used together for optimal results?

Today’s Dietitian examines the research and speaks with experts to learn more about the diet vs statins debate.

Statins for ASCVD Prevention Elevated blood cholesterol is well established as a factor in the development of atherosclerosis and eventual CVD.2 Prolonged exposure to elevated cholesterol levels increases risk, so the sooner patients take preventive measures the better.3 Statins are medications that commonly are prescribed to lower LDL cholesterol in an effort to prevent CVD development. In fact, they’re the only cholesterol-lowering drugs that have been directly associated with decreasing the risk of heart attack or stroke.4 So not only do statins effectively lower LDL cholesterol, but there’s also clear evidence they reduce the risk of having a heart attack and prevent both nonfatal and fatal major vascular events. The degree of benefit, however, depends on the person’s risk profile, the magnitude of LDL reduction and length of treatment, and whether low-intensity, moderate-intensity, or high-intensity statin therapy is given.

26 today’s dietitian september 2017

Intensity is based on dosage of the statin used; the higher the risk, the higher the dose recommended.3,5 Despite some reports that statins may offer other health benefits, such as reduced risk of cancer, infections, respiratory disease, and arrhythmias, there’s no conclusive evidence demonstrating that these other benefits occur.5 Statin drugs such as Lipitor, Mevacor, Crestor, and Zocor lower LDL cholesterol between 20% and 50% by slowing down the liver’s production of cholesterol.6 They also increase the liver’s ability to remove LDL cholesterol that’s already in the blood.7 Cost varies widely from a few dollars per month to a few hundred dollars depending on whether the statin is available as a generic (most, but not all, have generic formularies) and whether health insurance policies, including Medicare, will reimburse patients (some do, some don’t).

The 2016 guidelines from the American College of Cardiology (ACC) recommend statin therapy for four at-risk population groups: 1) adults aged 21 and older with ASCVD; 2) adults aged 21 and older with LDL cholesterol ≥190 mg/dL; and 3) adults aged 40 to 75 without ASCVD but who have diabetes and LDL cholesterol 70 to 189 mg/dL and an estimated 10-year risk of ASCVD of 7.5% or greater.8 A large portion of the adult population meets these criteria.

A patient’s or a client’s 10-year risk of heart attack or stroke can be calculated online using the American Heart Association (AHA)/ACC risk calculator at www.cvriskcalculator.com.

It’s also available as an app in iTunes. The calculator assumes there’s no existing heart disease and no history of stroke. It doesn’t take weight or physical activity into account. According to Jo Ann Carson, PhD, RDN, a professor of clinical nutrition at the University of Texas Southwestern Medical School in Dallas,

Is one better than the other for the prevention of CVD?

when people use the risk factors in the calculator, adding in body weight doesn’t make a significant difference in the calculated risk.

The calculation is based on total cholesterol and HDL cholesterol, blood pressure, whether a person has received treatment for high blood pressure, and smoking and diabetes status. Because of a lack of evidence, the calculator can’t predict CVD risk for people younger than 40 or older than 79 or for those with total cholesterol greater than 320 mg/dL. Nonetheless, according to a recent Cochrane systematic review, statin treatment can be an effective lipid-lowering therapy in children with familial hypercholesterolemia.9 The review found statin treatment to be safe for children in the short term, but long-term safety hasn’t been studied. Children treated with statins should be carefully monitored.

Detecting CVD before a cardiac event can be difficult.

The risk calculator is an indirect method for detecting the possibility of developing or having CVD. However, a method for more directly assessing risk in people without symptoms of CVD is the Calcium Scoring screening technique, a noninvasive imaging system that detects coronary artery calcium, which indicates the presence of disease with essentially no false-positive findings.10 While statins work virtual miracles for many, they can cause uncomfortable side effects. About 10% to 20% of people taking statins report experiencing muscle aches and muscle weakness.3 In fact, this side effect is a major reason cited for stopping the medication. Rarely, it can progress to rhabdomyolysis, severe muscle weakness from damaged muscles, which can, in turn, damage the kidneys as they try to rid the body of muscle breakdown products.11

Diet for ASCVD Prevention “Lifestyle modification, including a heart-healthy diet, should be adopted irrespective of level of cardiovascular risk,” says Gregg C. Fonarow, MD, a professor of medicine at UCLA and director of the Ahmanson–UCLA Cardiomyopathy Center.

Recent studies show that dietary changes can make a big difference in ASCVD risk, even among people who are genetically predisposed to the condition.

28 today’s dietitian september 2017

An analysis published in the December 15, 2016, issue of The New England Journal of Medicine found that the relative risk of having a coronary event was 91% higher among people at high genetic risk than among those at low genetic risk.

However, a “favorable” lifestyle (defined as having at least three of four healthful lifestyle factors— healthful diet, physical activity, nonsmoking, not overweight—was associated with a substantially lower risk of coronary events than an unfavorable lifestyle (defined as having no or only one healthful lifestyle factor), regardless of genetic makeup.

Among study participants at high genetic risk, a favorable lifestyle was associated with a 46% lower relative risk of coronary events.12 That’s not the result of diet alone, but a heart-healthy diet was a major factor.

Mediterranean-style diets have been found to reduce LDL cholesterol anywhere from 10% to 29%.13,14 Another study published in the April 4, 2013, issue of The New England Journal of Medicine found that the Mediterranean diet was associated with primary CVD prevention in people at high risk.15 As part of the PREDIMED study (Prevención con Dieta Mediterranea), a Mediterranean diet supplemented with extra-virgin olive oil or nuts substantially reduced the incidence of major cardiovascular events in a Spanish population. But the problem with broadly applying the findings, according to the AHA, is that while the Mediterranean diet is widely recommended, it’s inconsistently defined.16 For all patients, the current recommendations from the AHA and the ACC for ASCVD prevention emphasize that lifestyle modification (a heart-healthy diet, regular exercise, avoidance of tobacco products, and maintenance of a healthy weight) remains a critical component of any prevention plan, both before and together with the use of any cholesterol-lowering drug therapies. The ACC also states that “referral to a registered dietitian nutritionist may be considered to improve understanding of heart-healthy dietary principles and individualize nutrition recommendations.” The recommendations also state that adherence to lifestyle modifications should be regularly assessed both before and during statin therapy monitoring.

Achieving adherence to the AHA-recommended dietary pattern for risk reduction can be accomplished by helping clients and patients choose preferred foods they enjoy, with consideration of cultural, economic, and social factors. The AHA statement says that by considering nutrient-dense choices that meet but don’t exceed calorie needs, individuals can achieve further weight-control goals. Emphasizing patient/ client-tailored intervention that encourages self-monitoring of diet and physical activity levels is an effective strategy for promoting greater acceptance and sustained adherence to the recommended heart-healthy AHA dietary pattern.16 Angel Planells, MS, RDN, CD, a spokesperson for the Academy of Nutrition and Dietetics and lead dietitian in the home-based primary care program at the VA in Puget Sound, Washington, says,

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“Encouraging citizens to get their annual health checkups and see a dietitian can be a great way to get folks to make a change before adding statins to a regimen to reduce risk.”

The 2016 joint recommendations of the AHA and the ACC for lowering blood cholesterol and reducing ASCVD risk include the following for a 2,000-kcal diet*: • Fruits: 2 cups/day • Vegetables: 21⁄2 cups/day • Beans and peas: 11⁄2 cups/week • Whole grains: 3 servings/day • Nuts, seeds, legumes: 5 oz/week • Fat-free or low-fat dairy: 3 cups/day • Fiber: 31 g/day • Sodium: 1,787 mg/day • Oils, unsaturated: 3 T/day • Added sugars: 61⁄2 tsp/day • Fish: 8 oz/week • Meat, poultry, eggs: 26 oz eq/week**

* For other calorie levels, visit http://circ.ahajournals.org/ content/134/22/e505.long. ** 1 oz equivalent is 1 oz lean meat, poultry, or seafood; 2 egg whites or 1 egg; 1⁄4 cup cooked beans; 1 T peanut butter; 0.5 oz unsalted nuts/seeds.

So, Diet or Statins?

The answer to this question isn’t so simple. That’s because there’s no single answer. Whether diet or statins is best depends on individual patients, their risk profile, and which approach they’re likely to adhere to over the long term. Carson says that while some populations may be motivated to follow a riskreducing Mediterranean-style diet, others have no desire to even attempt such a change from their usual dietary patterns.

“For individuals with 5% or more risk over 10 years (using the risk calculator), statin therapy is recommended and statins should be applied together with lifestyle modifications,” Fonarow says. But how much an individual’s lifestyle will be changed is impossible to predict.

Statin therapy and dietary modifications can be thought of as two legs of a three-legged stool—the third being other lifestyle factors, such as physical activity and not smoking.

“There’s a whole stack of studies showing statins are effective at reducing risk, but most incorporated a heart-healthy diet as part of the treatment,” Carson says.

And while statins generally reduce blood cholesterol, regardless of diet, Carson says that fact can present a perception problem, noting that attitudes sometimes shift in patients taking statins. “They might say, ‘I can eat hot dogs now. I don’t have to worry, because I’m taking a statin,’” she says.

Another issue that can affect adherence to statins is that patients feel the same whether they take them or not. A similar situation exists with blood pressure medications: The patient doesn’t feel any improvement, so there’s no tangible reward, no incentive for continuing.

30 today’s dietitian september 2017

Patients may be much more aware of the side effects than of the benefits. The potential side effect of muscle pain can be a deterrent to sticking with statin therapy. However, “The side effect of not taking statins is a 25% to 45% higher risk of heart attack, stroke, and premature cardiovascular death,” Fonarow says, adding that “it’s generally difficult to get individuals to adhere to things that help lower their risk safely and effectively. This is true whether it involves dietary changes or taking a prescription medication.”

In addition, there’s considerable hype and misinformation on the internet from fad diet groups pushing the idea that cholesterol is good, ie, it’s OK to have high cholesterol. Add to that consumer mistrust of large pharmaceutical companies and people often are willing to avoid statins and rely on diet and exercise alone to lower cholesterol no matter the health consequences.

The current health care climate of high health insurance deductibles, increased out-of-pocket expenses, and changing availability and unaffordability of many insurance policies can present even greater obstacles to continued adherence to statins and obtaining diet counseling.

Bottom Line It’s a given that everyone, regardless of risk profile, should make lifestyle modifications, including a heart-healthy diet, to reduce the likelihood of ASCVD developing or worsening.

Whether statins should be added to the mix is something a client’s health care provider must determine. But it’s important for individuals to understand that while statins are effective at lowering cholesterol and reducing the risk of a cardiac event, a statin prescription doesn’t mean that a hearthealthy diet is no longer needed to reduce risk.

— Densie Webb, PhD, RD, is a freelance writer, editor, and consultant based in Austin, Texas.

For references, view this article on our website at www.TodaysDietitian.com.

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CODE: 090117

FOOD

FEARS C

lean. Free-from. Natural. Organic.

Non-GMO. These marketing buzzwords featured on product packaging communicate to consumers that the products are healthful and better for the environment. Today’s shoppers often rely on these claims more than nutrient content.

However, buzzwords can backfire when they foster fear and scare consumers away from healthful, accessible, and affordable food choices. For example, the fear of ingesting pesticides often prevents people from eating produce if they can’t afford organic varieties. Fear of GMOs may steer them away from healthful foods that aren’t marked non-GMO. Unfamiliar names for vitamins in fortified cereal can lead to choosing a less nutritious, unfortified brand.

“The food and nutrition environment has changed in recent years from proactive to reactive,” says Leah McGrath, RD, LDN, a retail dietitian at Ingles Markets in Asheville, North Carolina. “Questions I receive during talks, via e-mail, or on social media are almost all fearbased, and the level of food fears is overwhelming.”

Factors Fostering Food Fears The health halo surrounding organics has led to fear of conventional foods. In one study, in-depth interviews revealed that some study participants attributed health issues such as cancer, weight gain, and allergies to eating foods that weren’t organic.1 Fruit and vegetable consumption—consistently below recommended levels—is

32 today’s dietitian september 2017

particularly vulnerable to the effects of fear. Huang and colleagues surveyed low-income shoppers to learn about their attitudes concerning organic and conventional fruits and vegetables. Those who had heard messages about pesticide residues on produce were less likely to purchase any type of fruits and vegetables, conventional or organic.2 However, according to the Organic Trade Association Organic Market Analysis, more than 82% of US households buy organic foods, and organic food sales have nearly doubled over the past 10 years.3 Although “organic” is a production term that doesn’t address quality, safety, or nutrition, the public thinks otherwise. A 2016 Pew Research Center study found that a majority of people say organic produce is more healthful than conventional.4 Research, however, supports a different conclusion: Conventionally grown produce doesn’t differ nutritionally from organic crops. Furthermore, farmers of both organic and conventionally grown crops typically rely on pesticide use.

Organic farmers can use products with approved natural and synthetic substances, and conventional farmers can do the same, with a couple of important caveats.

First, due to their low toxicity, many natural pesticides are exempt from US Environmental Protection Agency (EPA) requirements for a tolerance limit for residues on food. Second, in contrast with conventional pesticides, data on pesticide use in organic farming are limited.

Organic and conventional produce each offer benefits, and consumers who choose not to purchase organic produce because of cost, availability, or other factors need not fear that conventional produce is unsafe.

Are packaging claims such as “free from,” “clean,” “natural,” and “organic” deterrents to healthful eating?

By Mindy Hermann, MBA, RDN; Michael P. Holsapple, PhD, ATS; and Heather E. Dover, RDN

Fear-based messaging also can pressure the food industry to steer clear of food additives that have beneficial uses. Bedale and colleagues assert that today’s antiadditive sentiment leads to consumer fears of preservatives such as nitrate and nitrite in meat, even though changes in processing methods have reduced health risks and the benefits of nitrate consumption are better understood.5

Hazard or Risk?

Misperceptions of risk as it relates to the presence of a hazard, and a general lack of understanding of the benefitrisk relationship, both contribute to food fears. The EPA has developed a four-step human health risk assessment model to estimate the nature and probability of adverse health effects in humans who may be exposed to chemicals in the environment6: Step 1. Hazard Identification: Can a substance cause harm to humans and under what conditions?

Step 2. Dose Response Assessment: What’s the relationship between exposure and effect?

september 2017 www.todaysdietitian.com 33

Step 3. Exposure Assessment: What’s the frequency, timing, and level of contact with the hazard?

Step 4. Risk Characterization: What’s the risk to health based on the hazard and exposure?

Here, it’s important to understand the difference between hazard, which is something that could cause harm, and risk, which represents the probability that harm will occur at a given exposure. A shark can be used as a metaphor for the difference between a hazard and a risk. Sharks have sharp teeth and powerful jaws that certainly could cause harm; the shark is therefore unquestionably a hazard. However, viewing the hazardous shark at an aquarium poses a much diminished risk compared with swimming in shark-infested waters, because of a lower probability for exposure.

The health community uses both hazard- and risk-based approaches to food safety, and each offers advantages and disadvantages.7 A hazard-based approach is easier to regulate and explain because all potentially harmful compounds are included. However, it can lead to overuse of precautionary statements such as “may contain,” and therefore may be impractical.

A risk-based approach quantifies and prioritizes risk while considering potential benefits. However, it requires more time and data to evaluate each hazard. Various terms describe the dose-response approach to risk assessment that establishes the highest doses at which no toxic effects are identified (No Observed Adverse Effect Level) and the lowest doses at which toxic effects are observed (Lowest Observed Adverse Effect Level).

Evaluation of the herbicide glyphosate provides an example of the different conclusions drawn by hazard-based and risk-based approaches. Using a hazard-based approach of cancer causation under any possible situation, the World Health Organization (WHO) International Agency for Research on Cancer states that glyphosate is “probably carcinogenic to humans.” The Food and Agriculture Organization (FAO)/WHO Joint Meeting on Pesticide Residues considered whether the chemical causes cancer in real-life situations and concluded that “glyphosate is unlikely to pose a carcinogenic risk to humans from exposure through the diet.” It can be argued that the conclusion from a risk-based approach, with its focus on the importance of exposure is, by design, much more relevant to our lives.

The highly publicized pesticide scoring system of the Environmental Working Group (EWG), which each year names the “Dirty Dozen” fruits and vegetables, errs by conflating hazard with risk. It considers that all pesticides are equally toxic and that any exposure to a pesticide is toxic. Effectively, the EWG equates the presence of any pesticide residue as a risk, rather than relating detected pesticide residues to known safety standards. The EWG publicizes these results annually even though the actual levels are almost always below established tolerances, that is, their presence represents a hazard but not a risk.

34 today’s dietitian september 2017

Interestingly, in addition to publishing their annual “Dirty Dozen” list, the EWG also presents a series of frequently asked questions on its website. In its response to the question, “Should we eat more fruits and vegetables?” the EWG says, “The health benefits of a diet rich in fruits and vegetables outweigh the risks of pesticide exposure. Eating conventionally grown products is far better than skipping fruits and vegetables.” Unfortunately, there’s no direct link from the “Dirty Dozen” warnings to this more balanced and appropriate response from a diet and health perspective.

The USDA’s Pesticide Data Program (PDP) produces the most comprehensive annual pesticide residue database in the United States. Data from the PDP enable the EPA to assess dietary exposure, particularly among commodities highly consumed by infants and children, and provide guidance for the FDA and other governmental agencies to make informed decisions. Importantly, over the 20 years that the PDP has been testing residues, ~99% of the crops and commodities have tested below and, most often, significantly below tolerance levels set by the EPA. The USDA has consistently emphasized that “based on the PDP data, consumers can feel confident about eating a diet that is rich in fresh fruits and vegetables.” Notably, the EWG develops its annual “Dirty Dozen” list based on the results of the analyses conducted by the PDP the previous year.

Fundamentals for Communicating Risk Dietitians can do their part to avoid escalating food fears by learning and educating clients about risk. The FAO/WHO Risk Communication Applied to Food Safety handbook lists openness, transparency, timeliness, and responsiveness as key principles of good risk communication.8 The handbook also notes the importance of building trust (people rely on personal trust when deciding between conflicting messages) through providing or citing credible and independent scientific information and being honest.

To put food safety risk communication into action, FAO/WHO recommends comprehending the nature of risks, benefits, and hazards; assessing available data; understanding what can be done; and dealing with unintended consequences. Dietitians also should consider cultural and socioeconomic background, history of the risk, and any related political and media issues when working to understand client perspectives.

Researchers at Cornell University examined how experts could correct misperceptions among individuals who were most likely to have food fears. They found that providing participants with historical and contextual information about an ingredient led to higher ratings of healthfulness. The authors noted that information regarding an ingredient’s history, functions, uses, and benefits may help alleviate fears.9

Helping Clients Overcome Food Fears As RDs fight fears with facts and speculation with science, face-to-face conversations may be more effective than social media. According to the International Food Information Council

RESOURCES • Alliance for Food and Farming, www.foodandfarming. info; www.safefruitsandveggies.com • American Chemistry Council, www.chemical safetyfacts.org • Center for Research on Ingredient Safety, http://cris. msu.edu • Environmental Protection Agency, www.epa.gov/ safepestcontrol/food-and-pesticides • International Food Information Council Foundation, www.foodinsight.org • Sense About Science, http://senseaboutscience.org • USDA Pesticide Data Program, www.ams.usda.gov/ datasets/pdp • US Farmers and Ranchers Alliance, www.food dialogues.com • Food and Agriculture Organization/World Health Organization Risk Communication Applied to Food Safety Handbook, www.who.int/foodsafety/ Risk-Communication/en

Foundation 2017 Food & Health Survey,10 a higher percentage of respondents said they trust advice from a conversation with an RD compared with an RD’s advice on social media or on a health, food, or nutrition blog. “I use multiple outlets, including talks, in-store radio, podcasts, articles I write for magazines, social media, and the Ingles website (www.inglesinfoaisle.com) to help shoppers sort out good information from bad,” McGrath says.

Empathy is the most important starting point when working with clients who have fears of foods or ingredients. Whether counseling patients, working with supermarket shoppers, communicating through social media, or interacting in other ways, dietitians first should try to understand where clients are coming from. “They may be afraid of developing cancer or putting something toxic into their body, or just trying to do the best job possible raising a healthy child,” says Melinda Johnson, MS, RDN, a clinical associate professor in the school of nutrition and health promotion at Arizona State University. “Once you see fear through their eyes, you will be better equipped to guide them toward credible information that is relevant to them.”

“I help clients take apart their beliefs and fears, many of which turn out to be irrational,” says Karin Kratina, PhD, RD, LDN, a nutrition therapist, author, and speaker in Gainesville, Florida. “Food choices that are mediated by fear are stressful and unhealthy, and people really want to be healthy. I share reliable articles with my clients during appointments and on my website.”

Evelyn Tribole, MS, RDN, coauthor of Intuitive Eating: A Revolutionary Program that Works and owner of a nutrition counseling practice in Newport Beach, California, works with a growing number of clients who have orthorexia, an eating disorder characterized by an extreme focus on healthful

eating. She notes that many clients become so rigid and fearful of foods perceived as unhealthful that they won’t eat at other people’s homes. “Social media is a main culprit because it fosters all-or-none attitudes, food guilt trips, and fear mongering,” Tribole says. “I discuss with my clients whether social media is helping or harming their recovery.”

When necessary, Kratina will put clients on a social media “diet” that calls for ignoring or deleting any messages about food and fear of food. She finds that periodically turning away from less credible sources and reading only science-based information strengthens her own ability not to be influenced by fear.

Johnson often relies on health professionals and organizations that offer resources on chemical literacy. “Observing or reading about how they explain the complicated topic of biotechnology and handle emotionally charged conversations adds to my own communication toolbox,” Johnson says.

She also seeks out farmers through social media sites for answers to questions about farming practices.

“People shut off when they get overwhelmed by too much information, so keep messaging simple,” says Chris Vogliano, MS, RDN, who consults on wellness, sustainability, and the environment in Seattle. “Eat a diverse diet with more whole and plant-based foods. Live a healthful lifestyle. Don’t smoke.

Use sunscreen. Don’t sit all day. And don’t obsess over avoiding toxins because it’s impossible.”

Joan Salge Blake, EdD, RDN, LDN, FAND, a clinical associate professor at Boston University, says that because a diet rich in fruits and vegetables is associated with numerous health benefits and few risks, “we have to continue educating people that all fruits and vegetables are good for you. The best path to health through produce is to buy what’s on sale—those items are more likely to be in season, local, abundant, affordable, and tasty.”

— Mindy Hermann, MBA, RDN, is president of Hermann Communications in Somers, New York, and a contributing writer for Produce Business and Organic Produce Network.

— Michael P. Holsapple, PhD, ATS, is director and endowed chair at the Center for Research on Ingredient Safety (CRIS), and a professor of food science and human nutrition at Michigan State University in East Lansing, Michigan. CRIS is a partnership between academia, industry, government, and nongovernmental organizations focused on chemical-based ingredient safety.

CRIS conducts research and provides insight on the safety of ingredients in food and consumer products to support evidenceinformed decisions by consumers, industry, and policy makers.

— Heather E. Dover, RDN, is a research assistant at CRIS at Michigan State University.

For references, view this article on our website at www.TodaysDietitian.com.

september 2017 www.todaysdietitian.com 35

Instead of pouring aquafaba down the drain, clients can put it to good use in many of the foods they enjoy.

Aquafaba’s Versatility

By Jessica Levinson, MS, RDN, CDN

C

anned beans are a staple of most pantries, but if dietitians ask clients what aquafaba is, there’s a good chance they won’t know. That’s because for years RDs have advised people to drain and rinse their canned beans. But recently that recommendation has changed as the popularity of bean juice, otherwise known as aquafaba, has skyrocketed.

History of Aquafaba The ability to cook and bake with the liquid from canned beans was discovered only two years ago by Goose Wohlt, a vegan American software engineer who was attempting to create eggless meringues for his mother’s Passover seder. Wohlt found that the liquid from garbanzo beans, or chickpeas, could be whipped and used as an egg replacer. He called the bean liquid aquafaba, a combination of the Latin words aqua (water) and faba (beans). Out of nowhere, a trend to use the liquid from cooked beans of all kinds was born.

In short time, the humble chickpea liquid has grown in fame among vegan bakers, home cooks, and chefs alike. Cookbooks devoted to this “miracle ingredient,” as some have called it, are hitting bookshelves; food bloggers are developing new aquafababased recipes; and well-known chefs such as Dan Barber are starting to incorporate aquafaba into their restaurant dishes.

Even bartenders are using this vegan ingredient in place of egg whites to add a foamy top to cocktails.

While there aren’t many commercial products made with aquafaba just yet, it’s only a matter of time before more of them will take up space on grocery store shelves. Leading the charge in that domain is Fabanaise, a vegan mayonnaise made with aquafaba produced by Sir Kensington, a condiment manufacturer.

Nutrition and Culinary Uses The balance of starch and protein in aquafaba is responsible for its ability to be used in several ways. However, it isn’t a powerhouse nutritionally. Each tablespoon of aquafaba has roughly 3 to 5 kcal and trace amounts of carbs, protein, fat, vitamins, and minerals.

Despite its minimal nutrition profile, RDs enjoy cooking and baking with aquafaba for many reasons. Gretchen F. Brown, RD, a culinary nutritionist in Oakton, Virginia, likes using aquafaba “because eggs are a common allergy, so it’s nice to have a delicious and easy way to make traditionally egg-based desserts safe for everyone.”

Emily Kyle, MS, RDN, owner of Emily Kyle Nutrition, uses aquafaba “to reduce food waste and because of the unique plantbased cooking and baking properties [it] offers.” A popular topic on food blogs, decreasing food waste is a huge issue for restaurants, supermarkets, and farms. Using aquafaba helps reduce food waste because “you’re utilizing a part of the food that traditionally gets discarded,” Kyle says.

Making use of an ingredient that would otherwise be poured down the drain is wonderful, but keep in mind that for some people beans can cause intestinal distress and gas. These side effects are due to the presence of oligosaccharides, complex sugars that are difficult to digest because humans don’t produce the enzyme required to properly break down these sugars. Studies have shown that soaking and cooking beans reduces the oligosaccharides that leach into the soaking and cooking water—which is what we now call aquafaba. As a result, aquafaba is the gaseous part of beans, which can be problematic for some clients.

This raises the question “should clients who are sensitive to bean sugars use aquafaba?” The simple answer is no. However, Serena Ball, MS, RD, a food writer and owner of Teaspoon Communications, a food-focused nutrition communications organization

37

in St. Louis, who blogs about Healthy Kitchen Hacks at TeaspoonOfSpice.com, says that “if the total amount of aquafaba used in a whole recipe is three tablespoons, the amount in an individual serving is very small” and may not cause a gaseous response.

Since aquafaba acts much like eggs and egg whites, it’s used as a binder, thickener, and emulsifier in a variety of recipes. Unlike other ingredients that have been used as egg replacements, such as applesauce, mashed bananas, and prunes, aquafaba can be whipped into soft or stiff peaks, thereby making it a vegan substitute for meringues, mousse, custards, and whipped cream. It can even be added to pancake and waffle batter for a lighter, fluffier end result.

Brown, who loves making baked meringues with aquafaba, plans to try her hand at a quick chocolate mousse, which she says “requires no baking and no worries about foodborne illness from uncooked eggs. That’s a win-win.”

When using aquafaba as an egg replacement, roughly three tablespoons is equivalent to one whole egg, and two tablespoons is equivalent to one egg white. If using aquafaba as a binder or to replace whole eggs, as in a quiche or most baked goods, it should be slightly whipped with a fork just until it’s foamy. “Baked goods using aquafaba don’t always brown as deeply as those using an egg, but the texture is often very similar,” Ball says.

When using aquafaba to replace egg whites in recipes such as meringues, macaroons, and mousses, it should be whipped with a small amount of cream of tartar, lemon juice, or vinegar for five to 10 minutes until stiff peaks form.

The addition of cream of tartar or other acids helps stabilize the whipped aquafaba, Ball says.

Putting Aquafaba to the Test Aquafaba is an ingredient all clients can use, but it’s especially useful for those who follow a vegan diet or have an egg allergy or intolerance. Clients can look on Pinterest or do a Google search for a multitude of recipes to try. While many aquafaba recipes are for desserts and on the sweeter side, there are savory applications, too. For example, clients can add aquafaba to homemade hummus in place of some oil, or use it to make vegan mayonnaise, various sauces, crepes (which can have savory fillings), and even pasta dough.

When discussing the use of aquafaba with clients, recommend no-salt-added or low-sodium canned beans. If reduced-sodium beans aren’t available, Ball recommends using only one-half the amount of salt specified in the recipe to keep sodium levels down. As with other baked goods, it’s also important to reduce the total amount of added sugars—usually the sugar can be reduced by one-fourth, sometimes by one-half. And don’t forget to remind clients of all the ways they can put beans to use.

— Jessica Levinson, MS, RDN, CDN, is a New York-based culinary nutrition expert and recipe developer. You can read more of her articles and find her recipes at JessicaLevinson.com.

38 today’s dietitian september 2017

RECIPES Beet & Apple Salad in an Edible Walnut Salad Bowl Serves 2

Ingredients Edible Walnut Bowl 11⁄2 cups walnuts 1 ⁄4 cup ground flaxseeds 6 pitted dates 2 T aquafaba Pinch of salt 1 ⁄2 tsp coconut oil

Salad 3 cups spring mix greens 1 apple, diced 1 beet, diced or spiralized 1 ⁄4 cup dried cranberries 1 ⁄4 cup walnuts 1 ⁄2 cup balsamic vinaigrette 1 tsp whole flaxseeds

Directions 1. Preheat oven to 400˚ F.

2. In a food processor, add the walnuts, ground flaxseeds, pitted dates, and salt. Pulse until the ingredients begin to come together to a fine consistency.

3. While the food processor is still running, very slowly pour in the aquafaba. Pulse for another 60 seconds before removing mixture from the processor.

4. Divide the mixture in half and place each half on a separate sheet of parchment paper. Roll each half into balls.

5. Lightly coat a nonstick rolling pin with a dab of coconut oil. With the rolling pin, quickly flatten out the ball. (Note: You don’t want to overwork this. Use the rolling pin to get the basic flat shape, but then use hands to get the crust flat.)

6. Working from the inside out, gently flatten the crust to approximately 1 ⁄4-inch thickness. You don’t want the crust to be too thin, but you do want it to have a uniform thickness so it cooks evenly. Smooth any cracks with your fingers.

7. When ready, drape the parchment paper over a small, upside down, oven-safe bowl to create your “bowl.” Use your fingers to mend any cracks. Place the bowl on a cookie sheet and cover the crust with a sheet of foil.

8. Bake in the oven for 30 minutes. Remove the foil and bake for another 3 minutes. Watch carefully to be sure the crust doesn’t get too dark.

9. Remove from the oven and let cool completely, while still molded over the bowl. When the crust is completely cool, gently remove the parchment paper and set right side up.

10. Fill each salad bowl with spring mix, apples, beets, dried cranberries, and walnuts. Drizzle with balsamic vinaigrette, and sprinkle with flaxseeds.

Nutrient Analysis per serving Calories: 470; Total fat: 32 g; Sat fat: 3.5 g; Sodium: 75 mg; Total carbohydrate: 45 g; Sugars: 32 g; Dietary fiber: 9 g; Protein: 10 g — RECIPE AND PHOTO COURTESY OF EMILY KYLE, MS, RDN, OWNER OF EMILY KYLE NUTRITION

Aquafaba Very Berry Pavlova Serves 6

Ingredients Aquafaba liquid from one 15-oz can chickpeas, chilled (chickpeas strained out and used for another purpose) 1 ⁄2 tsp apple cider vinegar 3 ⁄4 cup sugar 2 tsp vanilla paste 1 T arrowroot starch (or cornstarch) Sweetened whipped cream Berries (strawberries, blueberries, red raspberries, yellow raspberries) Strawberry jam, melted Mint leaves (optional) Rose petals (optional)

Vegan Chocolate Cherry Mousse

Directions 1. Preheat oven to 275˚ F.

2. Combine aquafaba and apple cider vinegar in the bowl of a stand mixer or large bowl. Beat with whisk attachment until soft peaks form.

3. Add sugar, one tablespoon at a time, beating with whisk attachment, until mixture reaches stiff peaks. Stir in vanilla and arrowroot starch.

4. Spread meringue into a large circle on a parchment lined baking sheet (leaving room for circle to spread slightly while baking).

5. Place baking sheet in oven and reduce temperature to 250˚ F. Bake for 2 hours or until meringue is set and hollow. Allow to cool.

6. Spread whipped cream evenly over cooked meringue. Top cream with berries. Drizzle melted jam over berries and sprinkle with mint leaves and rose petals, if desired.

Nutrient Analysis per serving Calories: 159; Total fat: 3 g; Sodium: 10 mg; Total carbohydrate: 31 g; Sugars: 30 g; Dietary fiber: 1 g; Protein: 0 g — RECIPE AND PHOTO COURTESY OF GRETCHEN F. BROWN, RD

Serves 4 to 6

Ingredients 3 cups frozen cherries, thawed 3 ⁄4 cup aquafaba (drained from one 15-oz can) 1 ⁄4 tsp cream of tartar 1 ⁄3 cup confectioners sugar 1 ⁄3 cup almond milk 14 oz chopped chocolate (can use mix of dark and regular; use dairy-free for vegan)

Directions 1. Place the thawed and drained fruit in a medium saucepan over medium heat. Cook the fruit, stirring and mashing often for 10 to 12 minutes, until reduced and thick. There should be enough liquid in the frozen fruit to prevent the fruit from sticking, but if it becomes too thick, add in a tablespoon or two of orange juice or cherry juice. Set aside and let cool.

2. In the bowl of a stand mixer, place the aquafaba, cream of tartar, and sugar. Beat on medium-high speed for 13 to 15 minutes until liquid has tripled in volume and has formed stiff peaks.

3. While the aquafaba is being whipped, melt the chocolate. Heat almond milk in a double boiler along with the chocolate over medium-low heat. Stir to combine until chocolate is smooth and completely melted. Alternatively, melt the milk and chocolate in a microwave-safe bowl in 30-second intervals.

4. Place the cooled chocolate in a large bowl. Then fold in the aquafaba, being as delicate as possible.

5. Divide half the cherry mixture from step 1 in the bottom of 4 to 6 small bowls, then dollop the chocolate mousse on top. Place in the refrigerator to set for at least one hour.

6. Before serving, dollop the remaining cherry mixture and more shaved chocolate, if desired.

Nutrient Analysis per serving (1⁄6 recipe) Calories: 147; Total fat: 5 g; Sat fat: 3 g; Sodium: 27 mg; Total carbohydrate: 25 g; Sugars: 22 g; Dietary fiber: 2 g; Protein: 2 g — RECIPE AND PHOTO COURTESY OF ALEXANDRA CASPERO, MA, RD, AUTHOR OF FRESH ITALIAN COOKING FOR THE NEW GENERATION, RECIPE DEVELOPER AT DELISH KNOWLEDGE, AND NUTRITION CONSULTANT

* Note: The sodium content of the recipes may vary depending on whether the aquafaba comes from no-salt added, low-sodium, or regular cans of beans.

september 2017 www.todaysdietitian.com 39

Hair Growth Supplements

By JESSICA LEVINGS, MS, RDN

A

lex always took pride in having a full head of thick hair. Her hair grew quickly whenever she trimmed or cut it. She could style it any way she wanted to with the use of a blow dryer, curling iron, or flat iron. She could color and relax her hair, and it remained healthy and strong. However, after many years of doing this, she began losing hair that didn’t grow back. To stop the hair loss and promote healthy hair growth, she stopped getting relaxers and heat styling her hair and began using products to help stimulate hair growth. She also started taking hair growth supplements in hopes of restoring what was lost. After several months, some, but not all, of her hair grew back. But the overall health of her hair began to improve.

Hair loss is a common condition, affecting about 80% of men and 50% of women.1 Manufacturers have responded to growing concerns over hair loss, and, as a result, hair care has become the largest segment of the $56.2 billion beauty industry, with 24% of market share by revenue.

Many oral supplements and topical solutions marketed as hair loss treatments are available online and over the counter and claim to produce benefits such as healthy hair and sustained growth. To someone with thinning hair, this may sound enticing, but these supplements aren’t risk-free. Online and over-the-counter hair growth supplements don’t need FDA approval before reaching shelves and scalps,2 and, according to the FDA, each company is responsible for ensuring that “the products it manufactures or distributes are safe” and that any claims “are not false or misleading.” Furthermore, excessive intake of certain vitamins and minerals, such as selenium and vitamin A, has been linked to hair loss,3-7 and, since the quantity

40 today’s dietitian september 2017

of ingredients contained in supplements isn’t regulated, it’s hard to know how much the consumer is actually getting.

Common causes of hair loss include one or a mixture of the following: • heredity (also known as male or female pattern baldness,

and androgenetic alopecia); • underlying disease state (such as thyroid disease or

anemia); • hormones and stress; • medications (eg, blood thinners; medications for arthritis,

depression, gout, heart problems, and high blood pressure; some birth control pills; anabolic steroids); • diet (eg, excessive vitamin supplementation, insufficient protein or iron, rapid weight loss, eating disorder or fad dieting leading to nutrient deficiencies); • hair hygiene (excessive shampooing, combing, or brushing; heat styling; relaxers; tightly braided hair styles; rubbing wet hair with a towel; and brushing or combing wet hair); and • life stage (pregnancy, breast-feeding, and menopause).

Over-the-counter hair loss products and supplements may seem ubiquitous, but they’re not created equal. The FDA has approved only one topical product (sold over-the-counter and online) proven to treat hair loss in men and women. Minoxidil (sold under brand names such as Rogaine, Theroxidil, Re-Stim, and Re-Stim+) is a topical scalp application that stops hair from thinning while stimulating growth. It’s effective in approximately two out of three men and one out of five women and is most effective for people younger than 40 who’ve recently started experiencing hair loss. However, it

A plethora of supplemental nutrients and botanicals boast claims to regrow hair and restore hair health, but are they evidence based?

doesn’t cure the root cause of hair loss. Users must continue to apply it or they’ll experience hair loss again.

Research Summary Online and over-the-counter hair growth supplements range in price from nominal to expensive. But do these products work, and are they worth the money?

According to a 2017 study, “While such products contain a variety of nutrients, review of the medical literature finds a notable lack of evidence supporting their use.” The study goes on to mention that much of the evidence about the relationship between nutrients and hair loss is based on people with an underlying nutrient deficiency, and few studies have looked at hair growth supplementation in individuals without nutrient deficiency.2 Furthermore, findings from the limited data that exist vary, with some looking at the effect of one nutrient alone and others analyzing a group of nutrients in combination.

For example, a 2013 observational study found that women experiencing hair loss had significantly lower levels of serum vitamin D compared with women not experiencing hair loss.8 A 2015 study evaluated supplementation with omega-3 and omega-6 fats, along with other antioxidants, and found that subjects reported a significant increase in hair regrowth and hair diameter after six months.9 Similarly, while some products target one nutrient, such as biotin, newer supplements and products claim a multifactorial effect and include many active ingredients.

Hair growth products commonly include the following ingredients and claim they promote normal, healthy hair, but limited evidence supports these benefits in the absence of a nutrient deficiency. Listed below are nutrients and botanicals and their related claims made by manufacturers. Only the claims with references are associated with publicly available

42 today’s dietitian september 2017

research findings, none of which provide adequate evidence for RDs to recommend these supplements to clients in the absence of an underlying nondiet-related nutrient deficiency (eg, medication, stage of life, or illness).

Protein and Amino Acids • Methionine is an essential amino acid, and products touting this ingredient say it works by providing adequate amounts of sulfur to hair cells, aiding in growth and appearance including delayed graying.10,11 • Cysteine is a sulfur-based amino acid and an important part of keratin, which contributes to healthy hair structure and growth. Products touting this ingredient claim to support hair strength (and thus prevent loss) by providing sulfur.12,13 • Lysine is an essential amino acid touted as aiding hair growth when combined with other amino acids, specifically arginine. Products with lysine claim to promote healthy hair growth through aiding hormone secretion and immune function.

• Keratin is a protein that serves as a structural component of hair and contributes to healthy hair growth.

Vitamins • Vitamin A helps with hair growth by maintaining healthy follicles. Products high in vitamin A claim to contribute to thicker, longer hair.14,15 • Vitamin C helps produce and maintain healthy collagen levels within hair follicles. It’s also an effective antioxidant helping to reduce free radical and UV damage to follicle cells and collagen.

• Vitamin E helps support cell membranes and also is a powerful antioxidant that reduces the effect of free radicals on hair, especially when consumed with selenium.16,17 • B vitamins are common in hair growth supplements and offer a range of benefits to hair health.18 Niacin (B3) can improve blood flow and increase the delivery of nutrients to hair follicles, supporting hair growth. Pantothenic acid (B5) increases hair flexibility, strength, and shine and helps prevent hair loss and graying. Pyridoxine (B6) aids in the metabolism of amino acids required for hair growth.

Biotin (B7) is needed for protein, fat, and carbohydrate metabolism; a deficiency can lead to poor metabolism of nutrients and undernourished hair follicles over time. While clinical studies suggest that a biotin deficiency, while rare, can lead to severe hair loss, there’s no evidence supporting the role of biotin supplementation in the prevention of hair loss when biotin is consumed in adequate amounts in the diet.19,20 People with adequate protein intake shouldn’t experience a biotin deficiency or hair growth-related side effects of a biotin deficiency.

Folic acid (B9) stimulates growth of new hair, and inadequate amounts can lead to reduced hair follicle cell division and growth. Cobalamin (B12) aids in overall scalp health. Inadequate levels of thiamin (B1), riboflavin (B2), niacin (B3), and pantothenic acid (B5) allegedly can lead to undernourished, dull hair follicles.

Food Sources of Nutrients That Promote Healthy Hair Growth Minerals • Iodine helps maintain healthy thyroid function. A deficiency can lead to thyroid disorders as a cause of hair loss.21,22 • Zinc contributes to stronger hair structure and can improve the rate of hair growth. Zinc deficiencies have been linked to hair loss; products touting zinc claim to help reverse hair loss.23 • Iron levels have been linked to hair loss, with research suggesting that many women who experience hair loss have low levels of blood iron.24,25 • Selenium, a trace mineral that aids in iodine metabolism and thyroid function, protects hair follicles through its role as an antioxidant. Products claim selenium supports hair growth through its role in maintaining the thyroid.26 • Copper helps other enzymes function properly in the body, supports healthy blood flow, and acts as an antioxidant to prevent hair loss. Emerging research suggests copper might stimulate the production of new hair follicles.27,28 • Manganese is a silica-rich mineral aiding in the production of connective tissue and collagen, both of which are important for healthy hair development. Silica occurs in trace amounts in the diet, but many forms aren’t bioavailable. Foods rich in manganese can help provide adequate silica.29,30

Nutrient

Food Source

Omega-3 fatty acids

Fatty cold-water fish (eg, salmon, mackerel, sardines, herring, and tuna) Ground flaxseeds Macadamia nuts Walnuts

Protein

Legumes Meats Dairy products Fish Eggs Ground flaxseeds Walnuts

Vitamin B12

Fatty cold-water fish (eg, salmon, mackerel, sardines, herring, and tuna) Meat Poultry Eggs Milk and milk products Fortified breakfast cereal

Iron

Legumes Fatty cold-water fish (eg, salmon, mackerel, sardines, herring, and tuna) Ground flaxseeds Macadamia nuts Walnuts Dark green leafy vegetables

Zinc

Legumes Walnuts Fish oil Flaxseeds Meat Eggs Seafood (eg, oysters, crab, lobster)

Biotin

Legumes Cereal grain products Liver Egg yolks Soy flour Yeast

Selenium

Nuts, especially Brazil Fish (eg, yellowfin tuna, sardines, halibut, oysters)

Calcium

Dark green leafy vegetables Dairy products Figs Oranges Sardines Canned salmon White beans Tofu Almonds

Vitamin A

Orange vegetables Dark green leafy vegetables Winter squash Lettuce Dried apricots Tropical fruit

Antioxidants • Resveratrol protects the follicles and scalp against inflammation and oxidative stress caused by free radicals. Resveratrol also helps improve blood circulation, providing sufficient oxygen and enhancing the development and growth of hair follicles.

Fatty Acids • Polyunsaturated fatty acids, such as omega-3 and omega-6 fatty acids, help with the appearance of hair and reduce dry, scaly skin.

• Gamma-linoleic acid commonly is consumed in supplement form as borage oil.

Products claim it supports hair growth by reducing inflammation in the skin and scalp and helping to retain moisture.31,32

Botanicals • Saw palmetto is sometimes referred to as “The Natural Rogaine” because its compounds help prevent the shrinking of

— SOURCE: NATIONAL INSTITUTES OF HEALTH OFFICE OF DIETARY SUPPLEMENTS FACT SHEETS FOR HEALTH PROFESSIONALS

september 2017 www.todaysdietitian.com 43

hair follicles, which can lead to hair loss.33,34 • Ginkgo biloba has been shown to increase the growth rate of follicle cells and improve circulation, which increases blood flow to the scalp and enhances nutrient delivery.35,36

Role of Diet and Food

While the exact cause of hair loss usually isn’t clear, many times it’s associated with an underlying nutrient deficiency.2 Products claiming to improve hair growth and prevent hair loss tout specific nutrients to support their use, but RDs understand that an inadequate eating pattern can’t be fixed with supplements.

Furthermore, topical solutions won’t impact a nutrient deficiency, so the application of products containing Minoxidil won’t improve nutrient intake or treat the cause of the hair loss.

If a client presents with concerns about hair loss or questions about hair loss supplements, many times their eating patterns are at the root of the concerns. Clients eating too little fat could be at risk of nutrition-related hair loss due to inadequate intake of essential fatty acids. Furthermore, individuals consuming inadequate amounts of protein could be at risk of nutrition-related hair loss from B vitamin deficiencies.

Similarly, clients eating too few calories may have a zinc deficiency. Fad diets with rapid weight loss can affect the normal hair growth cycle, causing increased shedding within six to 12 weeks upon initiation.

In the absence of an underlying disease state, a healthful, balanced eating pattern can be sufficient to prevent nutrient deficiencies and provide adequate amounts of nutrients to protect hair without the need for supplements specifically marketed for hair growth.

Recommendations for Clients RDs faced with questions about hair growth supplements or concerns about hair loss should suggest clients talk with their doctor or dermatologist, if they haven’t already, to diagnose the root cause of hair loss. Counseling related to consuming a healthful eating pattern with a variety of foods also is important. When presented with concerns about hair loss, it’s important to review client food intake data to ascertain whether the eating pattern and nutrient intake is adequate.

Most nutrient-related causes of hair loss can be prevented with a balanced eating pattern. However, for clients wanting to take a hair growth supplement or begin using a topical solution or product, it’s important to remind them that the supplement should be taken only in the dosage provided. Excess supplementation can, in some cases, exacerbate hair loss, and the exact quantity of ingredients contained in supplements isn’t regulated.

Counseling for lifestyle-related risk factors, such as stress, in addition to diet also is important. Clients concerned that a medication may be contributing to hair loss should be encouraged to continue taking the medication at the dosage provided

44 today’s dietitian september 2017

and make an appointment to talk with the prescribing doctor about their concerns.

A balanced eating plan similar to the Mediterranean diet consisting of lean protein sources, fruits, vegetables, whole grains, legumes, fatty fish, and low-fat dairy products is important for hair and overall health. Remember that clients don’t always readily know food sources of specific nutrients affecting hair health; providing this information can help. (See table on page 43.)

A variety of fatty cold-water fish such as salmon and mackerel, as well as ground flaxseed, macadamia nuts, and walnuts, can provide omega-3 fatty acids, protein, vitamin B12, and iron. Legumes are a plant-based source of protein that also contain iron, zinc, and biotin. Good sources of biotin include cereal grain products, liver, egg yolk, soy flour, and yeast. Nuts contain high amounts of selenium, and some nuts, such as walnuts, also contribute alpha-linoleic acid and zinc.

Zinc also can be found in fish oil, flaxseed, meat, eggs, and seafood such as oysters. Dark green leafy vegetables can provide iron and calcium, and dairy products also are good sources of calcium. Orange vegetables such as carrots are an excellent source of vitamin A. Clients should be encouraged to seek out hair loss supplements and topical products that have ingredient lists readily available. Also, the products should be from manufacturers engaging in Good Manufacturing Practices. For clients who insist on using a hair growth product, RDs should recommend a supplement over a topical solution, since this will help increase nutrient intake.

If a client presents with concerns about hair loss or questions about hair loss supplements, many times their eating patterns are at the root of the concerns.

Bottom Line Data are scant associating hair growth supplements with the benefits they purport to convey. Consuming a balanced diet should prevent deficiencies associated with nutrientrelated hair loss, but, in some disease states and life stages, a supplement may be needed. If clients feel they must consume a supplement to aid in hair growth, a basic one-a-day vitamin most likely will offer the same benefits at a fraction of the cost of over-the-counter and online hair growth supplements.

— Jessica Levings, MS, RDN, is a freelance writer and owner of Balanced Pantry, a consulting business helping companies develop and modify food labels, conduct recipe analysis, and create nutrition communications materials.

Learn more at www.balancedpantry.com, Twitter @balancedpantry, and Facebook.com/balancedpantry1.

For references, view this article on our website at www.TodaysDietitian.com.

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Alkaline and While these waters may contain some nutrients, they may not be any better than bottled or tap water for rehydration.

Plant Waters What’s Behind the Trend?

By Esther Ellis, MS, RD, LDN

T

he Beverage Marketing Corporation recently released data that show bottled water has become the largest beverage category by volume in the United States, surpassing carbonated soft drinks for the first time.1 The rise coincides with overall food and beverage trends—consumers are looking for healthier, more nutrient-dense products. It’s no longer enough to sell plain water. Instead, clients are searching for functional waters with more perceived benefits, which include alkaline waters and plant, or botanical, waters.

“There are a lot of health-conscious people out there who are looking for the next big thing,” says Sarah Ladden, MS, RD, director of nutrition, health, and wellness for Nestlé Waters North America in Stamford, Connecticut. “Plant water is coming on people’s radars, and alkaline has been on the market for a while. You’re always going to see the marketplace respond to consumer demand, and right now they’re looking for their products to be more functional and provide more benefits.”

Alkaline Waters Pure water has a pH of 7, so alkaline water is any water that has a pH higher than 7. The pH scale, which runs from 0 to 14, measures how acidic or basic a substance is. Neutral is pH 7; anything below is acidic, and anything higher is basic or alkaline.2 The average pH range for alkaline waters is around pH 8 and pH 9, though one brand claims to be the highest with pH 10. Each number on the scale represents a tenfold change in the acidity or alkalinity.

The most common minerals found in water include calcium, sodium, potassium, copper, manganese, magnesium, and iron.3 According to the World Health Organization, water contributes anywhere from 1% to 20% of the total dietary intake of some trace minerals, providing up to 20% of the total required daily intake of calcium and magnesium. Location impacts the concentration of minerals

in water; hard water has significantly more calcium and magnesium compared with soft water.4 A higher mineral content in water means it has a higher pH level.

Alkaline waters are higher in alkalizing agents such as calcium, potassium, bicarbonate, silica, and magnesium.

Some waters are naturally alkaline, while others undergo processing to become alkaline. A water ionizer creates alkaline water by running the water over positive and negative electrodes, separating it into acidic and alkaline.5 There also are water filters that add alkalizing minerals and water filters that reverse osmosis. For a simpler fix, adding baking soda to water can make it more alkaline.

Alkaline waters are marketed to a wide range of consumers, including athletes, acid reflux sufferers, and anyone looking to increase antioxidant intake and improve overall health, bone health, and muscle health. It isn’t uncommon to see a celebrity or athlete endorsing major brands of alkaline water and their purported benefits.

One company says its water, “along with healthy life choices, can reduce acid in the body, leading to overall better bone and physical health.” Another says that doctors and nutritionists recommend drinking alkaline beverages to prevent “acid tide,” which can lead to loss of strength and increased tiredness as well as decreased bone, kidney, and muscle health.6 “What you drink is more important than how much you drink,” one company states, describing its product as “supercharged ionized alkaline water” and explaining that it’s better at rehydrating after exercise compared with regular water.

The most shared health claim among alkaline water manufacturers is the promise to detoxify the body and fight against the acidity of the Western diet. Some claims go so far as to say that “bacteria, disease, and viruses thrive in acidic water but struggle to survive in alkaline,” explaining that drinking their water increases the level of pH in the body.7 Others simply display a pH scale depicting a sad face, sickly figure, or the words “sickness” on the acidic side and a happy face or “health” on the alkaline side.

september 2017 www.todaysdietitian.com 47

It’s true that chronic acid retention can lead to bone loss; it promotes the increase of urine calcium excretion, and, without an increase in intestinal calcium absorption, the body takes calcium from the bones.8 The condition is also known as metabolic acidosis, and, though it can have many causes such as kidney disease, lactic acid buildup, ketoacidosis, and even severe diarrhea, it’s an uncommon condition in healthy individuals.9 One study published in Urolithiasis found that patients with osteoporosis and abnormal distal renal tubular acidification showed improvements in bone density after alkali therapy.10 However, the alkali therapy consisted of three 400-mg capsules of ammonium chloride daily, which isn’t obtainable through drinking alkaline water.

Claims to prevent acid tide may be misleading, as acid tide is a condition that occurs after fasting and results in a temporary increase of acidic urine—not a common occurrence as the claim suggests. The research on the benefits of alkaline water for human consumption is limited. A 2012 study published in Annals of Otology, Rhinology & Laryngology found that alkaline water with a pH of 8.8 inactivated human pepsin, which contributes to acid reflux, whereas bottled/tap water with a pH of 7 didn’t.11 The tests were performed in vitro, and further clinical trials need to be conducted to support these findings.

Claiming that viruses, disease, and bacteria thrive in acidic water is misleading. Bacteria typically thrive in more neutral pH conditions, though some can live in either basic or acidic conditions.12 Typical cleaning agents developed to kill bacteria usually are either highly acidic or basic. For instance, cleaners such as vinegar or lemon have a pH near 2, which is acidic and doesn’t promote bacterial growth.

The company that calls its water “supercharged” and “ionized” cites a research study published in the Journal of the International Society of Sports Nutrition that compared its water (pH 8.5) with tap water (pH 7) and tested biomarkers of rehydration after exercise. The randomized, double-blinded study included 100 adults who were mildly dehydrated after aerobic exercise; dehydration was measured as a loss of 2% body weight during aerobic activity. The four biomarkers for rehydration included blood viscosity, plasma osmolality, bioimpedance, and body mass. Results showed a statistically significant increase in blood viscosity after exercise in those who drank alkaline water compared with those who drank tap water.

There were no statistically significant differences in plasma osmolality, bioimpedance, or body mass.13 A statistically significant increase in one of four biomarkers of hydration from one single study shouldn’t be considered substantial evidence to advertise a product as a better hydrator for athletes.

“From an athletic environment when you’re exercising a lot, you’re producing more acid, free radicals, and hydrogen ions; that’s the thought process,” says Amy Goodson, MS, RD, CSSD, LD, owner of a private practice in Dallas. Goodson has 11 years of experience as a sports dietitian at Ben Hogan Sports Medicine and has worked with Texas Christian University Athletics, the Dallas Cowboys, Texas Rangers, FC Dallas, Jim McLean Golf School, and many PGA Tour players. “There’s really not a lot of great research that says that drinking alkaline water is any better than [drinking] regular water.”

48 today’s dietitian september 2017

Leslie Bonci, MPH, RD, CSSD, LDN, owner of Active Eating Advice in Pittsburgh, says she’s gotten questions about alkaline water from her athletes as well. Bonci spent 24 years as the dietitian for the Pittsburgh Steelers. She now runs her own practice and serves clients such as the Pittsburgh Pirates, Carnegie Mellon University athletics, the Toronto Blue Jays, Kansas City Chiefs, Pittsburgh Ballet Theatre, and the Women’s National Basketball Association. Bonci and Goodson agree that alkaline water does provide the benefit of extra minerals when compared with tap water or lower pH waters.

Sonya Angelone, MS, RD, CLT, who runs a private practice in San Francisco, gets questions about alkaline water from her nonathlete clients, often with goals of lowering their pH. “I think there’s misinformation on what pH balance is and how your body maintains your pH,” Angelone says. “If alkaline water goes into your stomach, that stomach acid is going to neutralize the water.

Your blood has an optimal, healthy pH of somewhere around 7.36, and your body does a really good job of maintaining that.

If someone is looking to lessen the acidity in their diet, start by adding more fruits and vegetables and water in general.”

Coconut Water The trend in functional waters has expanded to plant, or botanical, waters, the most notable being coconut water, which is the clear liquid inside of coconuts. According to the USDA nutrition database, an 8-oz serving of unsweetened, ready-to-drink coconut water provides 44 kcal, 64 mg sodium, 11 g carbohydrate, 9 g sugar, and 0 g protein.14 One cup provides 14% DV of potassium. The drink has long been popular in tropical countries, where coconuts are cracked open and sold by street vendors.15 Coconut water comes with its share of athlete and celebrity endorsements. If clients visit the most popular brands’ websites, they’ll more than likely see a model, singer, or athlete holding a bottle. Currently, the product is most widely marketed to athletes, professional and nonprofessional alike, as a “natural sports drink.”15 One Thrillist reviewer wrote, “Coconut water provides electrolytes and replenishes lost fluids at a rate equal to that of a sports drink, making it an all-natural alternative to those bottles filled with processed sugar.”16 Research on coconut water for hydration and exercise is mixed and somewhat scarce. Studies that do exist typically involve a small number of participants. One research study compared the rehydration ability of coconut water with bottled water and sports drinks after exercise and found no significant differences. The study included 12 men who exercised on a treadmill for 60 minutes; researchers measured dehydration as a 2% body mass loss. While the study reported no differences in fluid retention and exercise performance, subjects who drank coconut water reported a higher incidence of upset stomach and bloating.17 Another study compared plain water with coconut water to determine athletic performance and rehydration during exercise. The study involved 10 men who completed 60 minutes of cycling and drank either coconut water or water at will during the activity. There were no significant differences between the two regarding performance or hydration, but participants

drank less coconut water, suggesting it was less palatable than plain water. This contrasts with other studies that reported coconut water as being more palatable during exercise.18 Bonci and Goodson agree that it’s OK for the average person exercising in a gym for 45 minutes to rehydrate with coconut water. But they explain that the research can be misleading, as coconut water isn’t a suitable substitute for a sports drink when considering professional athletes or those engaging in high-level training.

“Sports drinks were designed for what they are; they were designed for people playing sports,” Goodson says. “Coconut water is often marketed as a low-sodium sports drink, which to me is an oxymoron because the point of a sports drink is partly to replace sodium. When we sweat, the average person loses about three times the amount of sodium as they would potassium, so you simply don’t need as much potassium for replacing what’s lost in sweat and helping with cramping.”

For comparison: an 8-oz serving of Gatorade Thirst Quencher, Frost Glacier Freeze flavor, provides 57 kcal, 109 mg sodium, 31 mg potassium, 14 g carbohydrate, and 14 g sugar—almost double the sodium and an additional 3 g carbohydrate and 5 g sugar compared with coconut water.19 An 8-oz serving of Powerade, Lemon-Lime flavor, provides 78 kcal, 102 mg sodium, 44 mg potassium, 19 g carbohydrate, and 15 g sugar—also nearly double the sodium and carbohydrates and an additional 6 g sugar compared with coconut water.20 The sports drinks provide more carbohydrate and sodium that high-level or endurance athletes need to properly replenish what’s lost during exercise.

Bonci also hears and experiences the same with her athletes. “I think that the allure is that it says ‘natural.’ It comes from a coconut, so therefore it must be better than something that comes from a bottle that’s a beautiful shade of teal,” Bonci says. “It’s perception vs reality. The sugar is natural, therefore it’s better for me.”

It may not be best for serious athletes during or after exercise, but Goodson, Bonci, and Angelone agree that coconut water can be good to drink throughout the day since it’s a good source of potassium.

Cactus Water Another growing trend is cactus water, which is a mixture of prickly pear cactus extract, prickly pear cactus purée, and water. An 8-oz serving of the leading brand provides 26 kcal, 7 g carbohydrate, 7 g sugar, 12 mg sodium, and 5 mg potassium.21 A top-selling cactus water brand advertises its water as a good way to detoxify the body and maintain good skin. It also touts

its ability to enhance athletic performance because it contains the amino acid taurine, which helps regulate water and minerals in the blood and assists with neurological development.22 Research on cactus water is limited. There’s no research stating that it specifically contributes to skin health, and there’s little known on the impact of taurine supplementation over the long haul. Some studies have shown cactus water can improve athletic performance short term, although more research is needed. The claim of cactus water’s benefits due to taurine may be unjustified. Some analyses have shown that the prickly pear plant does contain taurine (up to 572.1 mg/L),22 but it’s unclear whether the juice or water contains any taurine after processing.23 One study analyzed commercially available prickly pear juices and didn’t detect any free taurine.24 Bonci explains that all the amino acids must work in conjunction with one another to provide the most benefit. “It’s a stretch to say taurine in and of itself is the reason someone may be able to optimize their performance,” Bonci says.

Aloe Vera Water Aloe vera water, often referred to as aloe vera juice, contains a mixture of aloe vera pulp, aloe vera juice, and water.

An 8-oz serving of the leading brand provides 60 kcal, 15 g carbohydrate, 15 g sugar (including added sugars), and 29 g sodium.25 As with cactus water, it’s advertised as a detoxifying drink with skin health benefits.

There’s research that shows aloe vera improves certain skin conditions when used topically, but studies on the effects of ingesting the water are scarce. Bonci knows many athletes who drink aloe vera juice to help with digestion problems.

There’s some research that suggests aloe vera may have a laxative effect, but the safety of regularly ingesting the gel of the plant is still in question.26

Jury’s Still Out As the bottled water industry continues to expand and grow, it’s unknown what the next trend may be. Functional waters such as alkaline and plant waters are getting more time in the spotlight, but until further research is conducted, there isn’t enough evidence to say alkaline water or plant waters are significantly better than drinking bottled water or tap water.

— Esther Ellis, MS, RD, LDN, is a retail dietitian and freelance writer based in New Orleans.

For references, view this article on our website at www.TodaysDietitian.com.

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CPE MONTHLY Body Composition Basics

ASSESSING AND MONITORING BODY COMPOSITION

By Cassie Vanderwall, MS, RD, CD, CDE, CPT When it comes to overall health, a person’s weight isn’t nearly as important as the composition of the weight.

Body composition evaluation should involve use of the most appropriate, accurate, and accessible strategy available to clinicians to estimate an individual’s adiposity, musculature, and body habitus. The composition of an individual’s weight is important on two fronts. The consequences of overnutrition/obesity, including hypertension, insulin resistance leading to type 2 diabetes mellitus, cardiovascular disease, cerebrovascular disease, and other weight-related comorbidities are well known. There are also, of course, consequences to undernutrition/inadequate body fat, including malnutrition and disruption of the endocrine system, such as that seen in the female athlete triad.1-9 Accurate estimation of lean body mass and fat mass are critical components of the nutrition assessment and key determinants of a client’s overall health and well-being. The RD’s evidencebased practice requires knowledge and skills for determining the most appropriate strategies for nutrition assessment, including estimation of body composition. The body composition variables—lean body mass, bone mass, fat mass, and body fat percentage—will influence energy estimation and the RD’s individualized intervention and, thus, affect the client’s nutritionrelated health outcomes.

This continuing education course compares and contrasts BMI with a variety of strategies for measuring body composition as it relates to weight management throughout the life cycle and provides recommendations and strategies for RDs to apply this information to a variety of patient care settings.

50 today’s dietitian september 2017

The most prevalent body composition estimation strategy is known as the two-compartment model, which views the body as having two parts: fat and fat-free compartments.10,11 The fat compartment is composed of fat mass, whereas the fat-free compartment consists of not only lean body mass but also 2% to 8% lipid, based on gender.12 Body fat percentage can be calculated by dividing fat mass by total body weight.

Excessive body fat, or obesity, is characterized by greater than 25% body fat in males and 32% in females.13 Obesity is associated with a host of short- and long-term morbidities including cardiovascular and cerebrovascular diseases, hypertension, insulin resistance and type 2 diabetes, asthma, obstructive sleep apnea, psychosocial problems, decreased quality of life, and, in children and adolescents, an increased likelihood of becoming obese adults.1-7 Likewise, having inadequate body fat and scant lean body mass also is associated with acute and chronic disease. Essential body fat is present in bone marrow, major organ systems, and cellular membranes; the loss of this fat will result in compromised physiological function of the cardiovascular, endocrine, reproductive, skeletal, gastrointestinal, renal, and nervous systems.8,9 Essential body fat is estimated to be about 2% to 5% for males and 10% to 13% for females, as indicated in Table 1 on page 51.

Stored fat, which is different from essential body fat, accumulates due to excess energy. Both types of body fat are vital to good health; healthful ranges of body fat are 12% to 24% for males and 25% to 31% for females. Women require higher levels of both types

COURSE CREDIT: 2 CPEUs

LEARNING OBJECTIVES After completing this continuing education course, nutrition professionals should be better able to: 1. Distinguish key methods and strategies used to measure body composition.

2. Assess limitations of key methods and strategies used to measure changes in body composition over time.

3. Compare and contrast the use of BMI with other body composition assessment strategies used in weight management.

4. Demonstrate the role of RDs in using appropriate body composition assessment strategies as part of the nutrition care process.

Suggested CDR Learning Codes 3080, 3090, 4060, 5370 Suggested CDR Performance Indicators 8.3.6, 10.1.1, 10.2.1, 10.2.2 CPE Level 2

of fat to maintain reproductive function.8 When total body fat falls below the minimum recommended levels of essential body fat, the body can’t effectively deliver key macro- and micronutrients to organs, resulting in deficiencies and electrolyte imbalances.

This increases the risk of fracture, sarcopenia, damage to the heart muscle, poor growth, and even death.8,9 Accurate body composition assessment is critical considering the impact of having too little or too much body fat. Directly assessing the composition of an individual’s body weight, or his or her body fat, is a key strategy for preventive and therapeutic intervention for the aforementioned disease states.14

BMI BMI, formally known as the Quetelet Index, was first described in 1832 by Adolphe Quetelet, a Belgian statistician who applied mathematical science to his studies related to human physicality. His cross-sectional studies of human growth led him to conclude that weight increases as the square of the height.15 Quetelet’s observation resulted in the commonly known BMI equation: dividing individuals’ weight (in kilograms) by their height (in meters) squared. BMI is highly correlated with adult weight, independent of height.16 Obesity also is described using BMI ranges.17 For children and adolescents aged 2 to 19, BMI is plotted on the gender-specific Centers for Disease Control and Prevention growth chart to identify the BMI-for-age percentile. Normal weight for a child and adolescent is a BMI-for-age range between the 5th and the 85th percentiles, as indicated in Table 2 on page 52.

Childhood obesity is defined as a BMI at or above the 95th percentile on the BMI-for-age growth chart. This definition of obesity is calculated based on a reference population and, therefore, BMI doesn’t directly measure adiposity.18 In adults, BMI is calculated using the aforementioned equation. A normal BMI is 18.5 to 24.9, and obesity is classified by a BMI greater than 30, as seen in Table 2.

There’s evidence that BMI calculations correlate with direct measures of body fat mass, including skinfold thickness, bioelectrical impedance analysis (BIA), densitometry, dual-energy X-ray absorptiometry (DXA), air displacement plethysmography (ADP), and hydrodensitometry (underwater weighing).19-21 The indirect relationship between BMI and adiposity has been established but varies according to gender, age, and race/ethnicity.22,23 These variations are due to differences in hormones between the sexes (estrogen vs testosterone), resulting in greater degrees of fat mass in women vs men, metabolism throughout the life cycle (decrease in the metabolic rate with age), and genetics. Furthermore, BMI levels correlate with risk of weight-related morbidities and mortality.24,25 The vast adoption and use of BMI over several decades are a strength of this simple surrogate measure of body fat and are responsible for the increase in research literature and public health data related to obesity and chronic disease.18 BMI may be a suitable screening tool and may be ideal for many clinical situations due to its ease of use; however, it may

2018

Join us for the 2018 Spring Symposium Advanced Registration just $199 May 20–23 in Austin, Texas www.TodaysDietitian.com/SS18 be an inappropriate diagnostic tool as well as a poor strategy for measuring and monitoring changes in body composition over time.26,27 Therefore, understanding the limitations of BMI and the advantages of using other body composition strategies to measure changes in body fat and lean mass over time extends the RD’s toolkit.

Limitations of BMI The limitations of BMI can be summarized by its lack of sensitivity and specificity. The accuracy of BMI is questionable when comparing weight classifications in a racially diverse population.

There’s increasing evidence that BMI classifications are outdated because they don’t account for the variety of patient populations that differ according to gender, age, and race/ethnicity.28 It’s also necessary to exercise caution when comparing BMI across race-ethnicity groups due to variations in body composition and location of adiposity.29 BMI also maintains a weak relationship with percent body fat and doesn’t distinguish the components of total weight. Direct measurements of total percent body fat provide a better tool for classifying overweight and obesity.29 In fact, BMI is positively associated with body fat mass, but the correlation between BMI and percent body fat is tenuous.30,31 Therefore, BMI is more closely linked with the weight of adiposity vs the percentage. However, total body fat mass isn’t indicative of relative fat or obesity.

Consider an athlete vs a sedentary adult. Both individuals may be the same age and sex and both also may have the same fat mass, but it’s likely that the athlete has greater muscle mass and thus a smaller percentage of body fat. Therefore, BMI may classify people as obese or nonobese incorrectly; this is

TABLE 1

Body Fat Percentage Categories, by Sex CLASSIFICATION

FEMALE

MALE

Essential fat

10% to 13%

2% to 5%

Average

25% to 31%

18% to 24%

Obese

≥32%

≥25%

september 2017 www.todaysdietitian.com 51

CPE MONTHLY especially true of men who generally maintain more muscle mass than women.32 These limitations can be summarized by BMI’s inability to distinguish between fat and fat-free mass in both pediatric and adult populations.32,33 Total fat mass doesn’t identify an individual’s relative fat, or the amount of fat in relation to their bone, muscle, and total body mass.

As stated earlier, BMI is the product of individuals’ weight in kilograms divided by the square of their height in meters.

Therefore, total fat would be expected to highly correlate with BMI because weight is the numerator in the BMI formula. Mathematically, a heavier individual will have a higher fat mass than a lighter individual with the same percent body fat. Specifically, the utility of BMI is limited in older adults, men, highly trained athletes, overweight children (BMI-for-age percentile between the 86th and 95th), and underweight children.18 A client’s percent body fat is an indicator of overall health. As noted previously, individuals with body fat percentages below those that are essential for health can experience morbidities and mortality comparable to those experienced by individuals with high body fat percentages. Despite these limitations, health care professionals continue to use BMI as a screening tool for overweight and obesity based on the assumption that a high BMI equals excessive adiposity. However, the literature doesn’t support the use of BMI as a diagnostic tool for body fatness in the general population.28,29 Therefore, BMI should serve as an initial screening tool for weight and weight-related disease but should be integrated with other components of a thorough health assessment, including a client’s medical, family, biochemical, dietary, and exercise histories, as well as the composition of their weight. Accurate measurement of body composition can be a valuable tool for preventing, managing, and treating both acute and chronic disease states in pediatric and adult populations. Therefore, it’s essential for RDs to know which assessment strategies best fit their practices, and all health care practitioners can benefit from a more valid tool than BMI to screen for excess fat mass relative to total body weight.

Assessment Strategies Following are the most common clinical assessment strategies for directly evaluating body composition with the greatest evidence to validate their use in both pediatric and adult populations.

These include the skinfold method, BIA, hydrodensitometry, ADP, and DXA. The methods are compared below and on the following pages based on their utility in accurately measuring body composition as well as their feasibility in terms of clinician use and cost.

Skinfold Method The skinfold method is quick, inexpensive, and easily performed. It estimates body composition based on skinfold thickness via equations validated by Jackson and Pollock in 1985. These skinfold estimation equations are preferred and highly used in the industry.34 The four-site skinfold equations are unique for

52 today’s dietitian september 2017

TABLE 2

BMI Classifications for Pediatric (2 to 18 years) and Adult (>18 years) Populations BMI-FOR-AGE PERCENTILE

CLASSIFICATION

<5th percentile

Underweight

5 to <85 percentile

Normal weight

85th to <95th percentile

Overweight

≥95th percentile

Obese

th

th

ADULT BMI CLASSIFICATION

CLASSIFICATION

<18.5

Underweight

18.5 to 24.9

Normal weight

25 to 29.9

Overweight

30 to 34.9

Obese, Class I

35 to 39.9

Obese, Class II

≥40

Obese, Class III

males and females but use the same variables: sum of the four skinfolds in millimeters and age in years.

Calipers are used to measure skinfold thickness at three to seven sites on the bodies of males and females to calculate body density or percent body fat. Ideally, skinfolds are measured on the abdomen, triceps, thigh, and suprailiac in millimeters in both males and females. The percentage of total body fat also can be derived from the body’s density.

Hydrodensitometry and ADP, which will be discussed later, both use body density equations to estimate body fat percentages. The gold standard equations—the Jackson and Pollock equations—use a client’s age, gender, race/ethnicity, and physical activity to calculate the most precise value.34 The following predictive equations have been validated in athlete and nonathlete populations to promote precision: 4-Site Skinfold Equation for Males: Body fat (%) = (0.29288 X sum of skinfolds, mm) – (0.0005 X sum of skinfolds, mm squared) + (0.15845 X age, years) – 5.76377 4-Site Skinfold Equation for Females: Body fat (%) = (0.29669 X sum of skinfolds, mm) – (0.00043 X sum of skinfolds, mm squared) + (0.02963 X age, years) + 1.4072 The accuracy of the skinfold method also depends on the technician’s skill, standardized procedures, the type of calipers

used, and the clients’ hydration status.35 The quality of calipers varies; plastic calipers have less pressure, varied pressure throughout the range of measurement, and a smaller measurement scale than do higher quality calipers.3 In addition, hydration affects the compression of the adipose tissue, so it’s important to keep hydration status stable from measurement to measurement. Exercise also influences hydration and can increase accumulation of water in adipose tissue. Therefore, skinfolds shouldn’t be measured immediately following exercise. The skinfold method may not be satisfactory for measuring body composition in the morbidly obese or very muscular clientele. It’s vital, however, that skinfold technicians practice with precision in mind and adhere to standardized measurement procedures. If this isn’t possible, an alternative strategy for assessing body composition is indicated.

BIA BIA is widely used and allows for determination of fat-free mass and total body water. BIA estimates body composition based on the principle that an electrical current travels more quickly through hydrated fat-free body mass and fluids than it does through fat and bone due to the higher concentration of electrolytes in fat-free tissues. BIA predicts body density by measuring the rate of a small electrical current passing between two electrodes. Impedance—resistance to the electrical current or speed of the current—is relative to the amount of water and predicts the fat and fat-free mass.36 A variety of BIA methods differ depending on the frequencies used. The most popular is the single-frequency technique, which transmits a current between two surface electrodes placed on either the hand or foot, allowing current measurement from hand-tohand or foot-to-foot. Newer BIA tools, scales, and estimation equations consider the clients’ age, gender, race/ethnicity, and circumference (girth) measurements.

BIA requires standardized measurement conditions to safeguard precision and accuracy. Clients must maintain consistent hydration status, skin temperature, and length of time since exercise. As with the skinfold method, hydration affects the accuracy of the BIA. Impedance is lower in dehydration and higher in the overhydrated. Therefore, dehydrated individuals display a body fat percentage deceivingly higher than the actual percentage. In addition, skin temperature can alter impedance; a warmer skin temperature decreases impedance and results in a lower predicted body fat percentage. Practitioners can promote ambient measurement conditions by maintaining the same room temperature for all measurements. Time since exercise also is an important variable that’s best kept consistent. Even moderate exercise before BIA measurements can lead to overestimation of lean body mass and thus underestimation of total body fat percentage.

Even under optimal and standardized conditions, BIA measurements aren’t as accurate as other body composition estimation techniques. Conventional BIA is unsuited for predicting body fat because it measures only properties of fat-free mass.

The single-frequency BIA is very precise, but only if electrode placement is consistent across measurements.37 BIA tends to overestimate body fatness in lean and athletic clientele and underestimate body fat in obese clients, often negating its utility. If conditions are standardized, it can be a tool better suited for monitoring change over time than for accuracy.

Hydrodensitometry Densitometry is based on the fact there are specific densities for fat mass and fat-free mass and thus requires measurement of total body density to calculate individual masses. Recall that density is mass divided by volume. The density of fat mass is fairly constant, but the density of fat-free mass depends on its composition (bone vs tissue). Fat-free materials are denser than water, and fat is known to be less dense than water. Therefore, a person with greater fat-free mass likely will have a greater density. The volume of individuals’ bodies is calculated based on their density using generalized equations. The body fat percentage then is calculated from the density using either the Brozek or Siri estimation equations,10,37 listed below; population-specific equations have yet to be validated. The Brozek and Siri equations are comparable and differ only by the values into which density is divided and values that are subtracted from the result, illustrated as follows: • Brozek formula: Body fat (%) = (4.57 / density − 4.142) X 100 • Siri formula: Body fat (%) = (4.95 / density − 4.5) X 100 Body volume originally was measured by hydrodensitometry.

This technique is considered a criterion method, or a method providing a standard with which other procedures are compared.38 Underwater weighing requires weighing individuals on dry land, and then immersing them completely in water and weighing them again underwater. The individuals must be weighed underwater three to five times to calculate a reliable average.

Certain factors can affect hydrodensitometry’s accuracy.

The equipment used varies in sophistication from a stainless steel tub to a cot mounted to an underwater scale. In addition, air remaining in a person’s lungs isn’t completely expelled; this residual air must be estimated or the resulting densities will be inaccurate. Accuracy also depends on the stillness of the water; there can be no movement. Standardization of the testing environment is critical.

Hydrodensitometry was considered the gold standard for measuring volume for many years and remains a viable method for measuring change over time. Recently, however, it has been viewed as a cumbersome strategy compared with other available methods and as too uncomfortable for most clients. The technique may be inappropriate or uncomfortable for specific patient populations, including children and individuals with anxiety, panic, or posttraumatic stress disorders due to the nature of the measurement method. Moreover, hydrodensitometry may be inappropriate for patients with chronic disease states that result in fluid retention; these effects will modify the composition of lean mass.38

september 2017 www.todaysdietitian.com 53

CPE MONTHLY ADP A newer technique that embraces the principles of densitometry and can be appropriate for a variety of patient populations (eg, children, obese persons, older adults, and disabled persons) is ADP. A more comfortable, noninvasive, and automated process for measuring body composition, ADP is more precise than hydrodensitometry. It measures the volume of air clients displace when placed in an enclosed chamber, often referred to as a “bod pod.” The body volume is calculated indirectly by identifying the difference in the volume of air in the chamber when the clients are in the chamber vs when they are not. The calculation also accounts for normal breathing movement with its application of Boyle’s law, a governing physical gas principle that states that at a constant temperature, volume and pressure are inversely related. Therefore, standardized temperatures are critical for accurate measurements with ADP. The same limitations described for underwater weighing also apply to ADP, and thus this technique may be inappropriate for children and individuals with pulmonary disease.

DXA Absorptiometry is the measurement of the amount of radiation absorbed by living tissue to determine the density of the tissue. DXA, previously known as DEXA, calculates mass from the differential absorption of X-rays of two different energies.

The strategy uses ionizing radiation, but the effective dose equivalents are below background levels, or those levels that are naturally occurring in the environment.37 The measurements are collected while the clients are in a supine position on the instrument’s platform and the arm of the instrument passes over them. The body fat percentage estimation equation—often the Brozek equation—for DXA requires measurement of fat and fat-free masses that are acquired from whole body scans. This method also relies on algorithms that are specific to individual instruments or machines.

DXA is validated for use in children as young as age 4 but also can be used with small infants. It has become the gold standard for measuring not only bone mineral density but also body composition due to its ease, accuracy, and precision. As with other methods, the results are affected by age, race/ethnicity, body figure, and adiposity. Moreover, accuracy varies depending on the region of the body scanned. For example, body fat estimation of the trunk region requires substantial prediction as compared with that of the limbs due to the amount of soft tissue present.

Overall, DXA provides the most accurate measures for body composition, with accuracy decreasing with the complexity of the region—from limb (least complex) to trunk (most complex).37

The Nutrition Care Process It’s the role of RDs to understand and use appropriate body composition assessment strategies as part of the nutrition care process (NCP). This standardized, four-step NCP guides RDs’ assessment, diagnosis, intervention, and monitoring/evaluation of patients and clientele in a variety of domains. The estimation of

54 today’s dietitian september 2017

an individual’s body composition is part of the nutrition assessment, and the results will direct the remainder of the NCP. Accurate estimates of an individual’s body composition provide insight into their overall health, disease risk, and consequences of disease. This insight will help to determine the dietitian’s intervention. For example, when dietitians identify that female athletes are maintaining body fat percentages lower than the recommended range, they can provide evidence for the likely health consequences (eg, fracture, amenorrhea, and poor performance) as well as estimate their energy needs for appropriate weight restoration, enhanced athletic ability, and overall health.

Acknowledging the strengths and limitations of the BMI classifications as well as body composition strategies can equip RDs to select the most appropriate strategy. A summary, “Comparison of Common Body Composition Techniques,” available at humankinetics.com, presents all of the aforementioned strategies for assessing body composition and compares them by cost of the instrument, time required to appropriately employ the method, the expertise required for a standard and accurate measure, sensitivity of the instrument or precision, and accuracy.38 It’s evident that BMI and BIA are quick, inexpensive, and require less expertise. Of the two, BMI is less precise and less accurate at measuring body composition compared with BIA.38 The skinfold method also is fairly quick and inexpensive, but requires greater training and experience to produce an accurate measurement and estimate. When a trained practitioner completes the skinfold assessment, accuracy is comparable to that achieved though BIA. Hydrodensitometry was the gold standard, but is now rarely used due to advances in technology and the cost, time, and expertise required. Today, despite its cost, DXA is the gold standard because it provides accurate estimates that vary little from day-to-day and is capable of monitoring changes in body composition over time.

Knowledge is Impactful RDs’ knowledge of BMI and its indications for use and the variety of strategies for accurately measuring body composition will greatly influence their practices and care for a variety of patient and client populations. Overall, it’s vital for dietitians to base their practice on sound evidence and appropriate tools for nutrition assessment and diagnosis because these steps in the NCP will guide their intervention and plan and ultimately dictate the nutrition-related health outcomes for patients and clients.

— Cassie Vanderwall, MS, RD, CD, CDE, CPT, is a Madison, Wisconsin-based freelance food and nutrition writer, manager for the University of Wisconsin (UW) health dietetic internship program, and a clinical nutritionist at UW Health’s Pediatric Fitness Clinic.

For references, view this article on our website at www.TodaysDietitian.com.

Register or log in on CE.TodaysDietitian.com to purchase access to complete the online exam and earn your credit certificate for 2 CPEUs on our CE Learning Library.

CPE Monthly Examination 1. Which of the following is an accurate equation for

calculating BMI in an adult? a. BMI = height (m) / weight (kg)2 b. BMI = height (cm) / weight (lbs)2 c. BMI = weight (kg) / height (m)2 d. BMI = weight (lbs) / height (cm)2 2. What is the primary benefit of using BMI as a screen-

ing tool? a. Its ability to determine abdominal adiposity b. Its simplicity and widespread use c. Its ability to determine total lean body mass d. Its direct association with percent body fat 3. Practitioners can be fairly confident when using BMI

in athletes, pregnant women, and older adults. a. True b. False

6. Which of the following explains why it’s inappropriate to use densitometry in individuals with chronic disease? a. I t may result in overestimation of body fatness due to fluid retention. b. It may result in overestimation of lean body mass due to fluid retention. c. It may result in underestimation of body fatness due to increased density of lean mass. d. It may result in underestimation of lean mass due to excess mineralization.

7. Which of the following strategies more effectively assesses trends over time vs accurate cross-sectional estimates? a. Skinfold method b. BIA c. Hydrodensitometry d. Dual-energy X-ray absorptiometry (DXA)

4. Which of the following statements accurately

describes best the procedures for estimating body composition using the skinfold method? a. C alipers are used to measure skinfold thickness at four sites on the body to calculate body density. b. Plastic calipers are used to measure skinfold thickness at two sites on the body to calculate body density. c. Calipers are used to measure skinfold thickness at three sites on the body to calculate body fatness. d. Plastic calipers are used to measure skinfold thinness at three sites on the body to calculate body density.

8. What is the gold standard method for estimating body composition? a. Skinfold method b. BIA c. Hydrodensitometry d. DXA

5. Bioelectrical impedance analysis (BIA) estimates body composition based on the principle that an electrical current travels more quickly through hydrated fat-free body mass and fluids than fat and bone mass due to which of the following? a. The higher concentration of calcium in bone mass b. The higher concentration of electrolytes in fat mass c. The higher concentration of electrolytes in lean mass d. The lower concentration of electrolytes in lean mass

10. The estimation of an individual’s body composition

9. Which of the body composition estimation strategies may be most appropriate for RDs in private practice? a. Skinfold method b. BIA c. Hydrodensitometry d. DXA

can be incorporated into all steps of the nutrition care process. a. True b. False

For more information, call our continuing education division toll-free at 877-925-CELL (2355) M-F 9 am to 5 pm ET or e-mail CE@gvpub.com.

september 2017 www.todaysdietitian.com 55

FOCUS ON FITNESS • psychosocial behavior; • physical functioning; and • information processing.

EXERCISING WITH TRAUMATIC BRAIN INJURY

By Jennifer Van Pelt, MA September is National Traumatic Brain Injury (TBI) Awareness Month. According to the Centers for Disease Control and Prevention, approximately 3.2 million to 5.3 million Americans are currently living with a TBI and its related disabilities. But the agency notes that TBI prevalence likely is underestimated because its statistics don’t include those who didn’t receive medical care or were cared for in an outpatient setting, active military members, or veterans cared for at VA hospitals.1 The incidence of TBI is increasing in both adults and youth, making TBI a condition of interest for anyone in the wellness field.

TBI is caused by any external force (a sudden and forceful blow to the head or violent shaking), which can occur with sports injuries, car accidents, physical violence, military action, or falls.

A TBI is basically a “bruised brain,” with nerve fiber damage and bleeding within the skull, and generally results in a functional and/or psychosocial disability—the extent of the disability depends on the severity of the TBI and the location of the brain injury. TBIs are classified as mild, moderate, or severe based on level of consciousness, motor and neurologic functioning, and how long consciousness was lost. Individuals with TBI have impairments in one or more of the following2,3: • memory; • attention; • cognition; • motor abilities and gait; • language and speech; • reasoning and problem-solving; • abstract thinking; • judgment; • educational performance; • sensory and perception abilities; • emotions;

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TBI also can cause insomnia, posttraumatic headache and seizures, bowel and bladder issues, agitation, and depression.3 The most common mild TBI is concussion. Generally, individuals recover from a concussion, with minimal short-term side effects that resolve with proper rest and recovery. However, the repetitive brain trauma from multiple concussions—common in sports such as football, boxing, and soccer—is considered a TBI. In addition to developing impairments associated with TBI, those with repetitive brain trauma are at risk of developing chronic traumatic encephalopathy, a progressive degenerative disease.

Chronic traumatic encephalopathy diagnosed in many wellknown professional athletes is one reason TBI has become of greater concern in young athletes. Young veterans of the Iraq/ Afghanistan conflicts who were medically discharged with TBI is another reason. TBI is a leading cause of disability in children and adults younger than age 35 and is now considered a serious public health problem due to its increasing prevalence and related billions of dollars in health care costs.1 Dietitians working with young athletes and veterans are likely to encounter TBI. While there are guidelines for diagnosing and managing TBI (including nutritional needs), currently there’s no established guideline for exercising with TBI. Due to the varied short- and long-term impairments that can result from TBI, a generic exercise recommendation can’t be made; the type and duration of exercise will vary by client, depending on the severity of his or her injury and impairments.

The most challenging client is likely to be the young athlete, who, before the TBI, was competitive and high performing.

Recently, a teenage girl joined my twice-weekly yoga classes.

A former star soccer player, she had continued playing soccer through three concussions. After her third head injury, she began having problems with balance, attention, visual perception, and memory. She tried running cross-country but had difficulty following the running courses. A former spelling bee champion and straight-A student, she now needed special assistance with test taking and some homework assignments. She continues to take yoga to help with balance and sees a TBI specialist for vision and cognitive therapy. For cardiovascular exercise, she uses the gym’s elliptical machines and treadmills with her mother. Adjusting from a former high-functioning athlete to her current TBIaffected lifestyle indeed has been difficult.

The American Physical Therapy Association (APTA), American College of Sports Medicine (ACSM), and National Center on Health, Physical Activity and Disability have released guidance on exercising with TBI.3-5 According to the APTA, appropriate exercise can benefit those with TBI who have issues with weight and stress management, emotions and mood, memory, attention, endurance, and energy. APTA suggests that low-resistance, rhythmic, dynamic aerobic exercise such as walking, stationary cycling, jogging, and the elliptical machine may be appropriate

after TBI; those with physical and cognitive limitations, however, may need to adjust the way in which they exercise. For example, a client with difficulty remembering directions shouldn’t jog or walk outside but should instead opt for home exercise on stationary exercise equipment.4 The ACSM emphasizes the need for those with TBI to choose exercises that suit their motor control and balance abilities and to ensure that protective headgear is worn for activities that involve a risk of falling. The rate of a second head injury is three times greater after an initial head injury. For individuals with balance issues, the National Center on Health, Physical Activity and Disability recommends always choosing aerobic exercises with a low risk of falling, such as water exercise, rowing machine, or recumbent cycle. Furthermore, strength exercises always should be performed from a stable position to reduce fall risk.

Yoga, tai chi, and Pilates are suggested to improve balance and reduce the risk of falls.4,5 In addition, both the ACSM and APTA note that supervised exercise may be necessary. In general, all TBI patients are prescribed therapeutic exercise during recovery. Those with long-term TBI effects who are no longer eligible for prescribed exercise can work with a trained fitness professional or simply have an “exercise buddy” to go along on walks or to the gym to ensure safety.4,5 Regular exercise has the same physical benefits for those with TBI as it does for the general population—improving cardiovascular and respiratory fitness and increasing strength and flexibility. Therefore, clients with TBI should establish a regular

exercise program that suits their physical and cognitive abilities to safely achieve the most physical benefits.

Based on emerging evidence, exercise also has substantial benefits related to mood and quality of life for those with TBI. A small study of aerobic exercise for ambulatory patients with chronic TBI found significant improvements in mood in both the short and long term. Individual exercise sessions improved mood, and overall long-term mood improved as early as four weeks into the 12-week regimen.6 Another small study in adults with TBI found that yoga improved self-perception, negative emotions, and overall quality of life.7 This positive effect on mood isn’t surprising, as exercise, especially yoga, has been found to improve mood and alleviate anxiety and depression for all exercisers, as well as those with medical conditions.

Hopefully, further research and preventive measures will reduce the number of individuals with long-term TBI side effects as well as provide more evidence supporting the benefits of certain types of exercise for TBI-related impairments.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Reading, Pennsylvania, area.

For references, view this article on our website at www.TodaysDietitian.com.

WHERE RDs BLOG FOR RDs Enjoy a blog where the real nutrition experts post opinions and insights from the RD’s point of view. We cover a wide range of topics and our bloggers represent many different facets and philosophies within nutrition and dietetics. We welcome comments from all fellow dietitians and encourage you to share with colleagues.

Visit RDLounge.com often for updates and join the conversation!

september 2017 www.todaysdietitian.com 57

BOOKSHELF Body Kindness: Transform Your Health From the Inside Out — And Never Say Diet Again

By Rebecca Scritchfield, MA, RDN, HFS 2016, Workman Paperback, 296 pages, $14.95

Rebecca Scritchfield has experienced the negative effects of diet culture first-hand. Through her life experiences and training as a “nondiet” dietitian, she aims to help others say “no” to diet culture once and for all through “body kindness.”

Body kindness is based on the following four principles: • What you do: the choices you make about food, exercise, sleep, and more; • How you feel: befriending your emotions and standing up to the unhelpful voice in your head; • Who you are: goal-setting based on your personal values; and • Where you belong: body-loving support from people and communities that help you create a meaningful life.

Scritchfield’s book is a user-friendly manual written in a friendly, conversational tone. It’s nicely organized, with many call-outs and colorful diagrams to further demonstrate the author’s points.

The personal touch in her writing is sure to harness connection with readers as she shares insights from her own life and past struggles with body acceptance and dieting.

Body kindness embraces proper self-care through adequate sleep and sexual, emotional, physical, and nutritional wellness.

Strict diets and punishing exercise aren’t part of body kindness.

Mindful eating, meditation, journaling, enjoyable physical movement, and harnessing deep personal connections are key tenets.

Chapters are filled with self-discovery and reflection activities, aptly named “Spiral Up,” for the reader to do along the way. For example, in the chapter “All Feelings Matter” there’s a Spiral Up to “Make Friends With Your Feelings.” In this exercise, the reader is guided through a process called PACT: Presence, Acceptance, Choice, and Take Action. This Spiral Up instructs readers to complete the feelings sentence: “[Blank] happened and I feel [blank].

I want to [blank] but instead I will [blank].” This Spiral Up activity could be useful practice for an individual who struggles with emotional eating.

As a dietitian already practicing a nondiet approach to wellness with clients, I find Scritchfield’s manual to be a great resource. I definitely will be using some of the Spiral Up activities in future

client sessions and will recommend the book to clients who have been stuck in today’s diet culture. In addition to the book, readers can visit bodykindnessbook.com for podcasts, support, videos, resources, and more. Some also may choose to become Body Kindness Insiders, aka “BKIND Insiders” to obtain even more resources and access to a private Facebook group.

— Janice H. Dada, MPH, RD, CDE, maintains a Newport Beach, California-based private practice and consulting business (SoCal Nutrition & Wellness, www.socalnw.com).

Follow her on Twitter and Instagram @SoCalRD.

The Protein-Packed Breakfast Club: Easy High Protein Recipes With 300 Calories or Less to Help You Lose Weight and Boost Metabolism

By Lauren Harris-Pincus, MS, RDN 2017, Eggplant Press Paperback, 91 pages, $13.95

Lauren Harris-Pincus is a frequent media consultant and speaker, and founder of Nutrition Starring YOU, LLC, a private practice where she specializes in counseling patients on weight management and prediabetes. Harris-Pincus also runs a blog of the same name featuring low-calorie, low-sugar recipes and consumer nutrition advice. This is her first book.

As an impetus for writing, Harris-Pincus cites confusion over what to eat for breakfast as the most common challenge her clients face. In addition, she hints at the fact that popular breakfast choices—such as bagels and cereal—generally don’t contain adequate protein and, thus, aren’t satisfying.

The book is divided into six chapters, each focusing on a specific category of breakfast options such as oats, smoothies, eggs, fruit and grains, savory toasts, and wraps. A brief introduction prefaces each recipe chapter, featuring a list of tips on how to choose ingredients that are used repeatedly throughout the book such as artificial sweeteners, protein powders, cottage cheese, and nut milks. (Harris-Pincus explains that she prefers nut milk to cow’s milk as a way to help limit total carbohydrates and calories.)

— Amelia Sherry, RDN, CDN, is a nutrition counselor in the division of pediatric endocrinology and diabetes at the Icahn School of Medicine at Mount Sinai in New York.

28-Day Plant-Powered Health Reboot: Reset Your Body, Lose Weight, Gain Energy & Feel Great

By Jessica Jones, MS, RD, CDE, and Wendy Lopez, MS, RD 2017, Page Street Paperback, 224 pages, $22.99

RDs Jessica Jones and Wendy Lopez are founders of the Food Heaven Made Easy website, blog, and podcast. The best friends specialize in plant-based eating, providing recipes, meal plans, and vegetarian starter kits on their website. In this book, they mention research supporting the benefits of plant-based eating but

stop short of citing the source of such evidence. Nonetheless, as both authors are RD credentialed, one would anticipate that they’ve done their due diligence.

The crux of the book is the 100 original, plant-based recipes, with just a sprinkling of nutrition information and instruction on how to adopt a plant-based diet.

The book is organized into four parts. Part 1 provides a brief introduction to plant-based eating and basic guidance on how to calculate individual calorie needs. Jones and Lopez provide a chart with calorie levels based on age, sex, and physical activity level.

However, they don’t define levels of physical activity, leaving the reader to estimate whether they’re sedentary, moderately active, or active. Furthermore, there’s no mention of how body weight figures into daily energy needs.

In Part 2 they make a good case for taking the time to plan meals and offer up a comprehensive grocery list and a one-week sample menu to help readers get started. The grocery list could be a little confusing for readers, as the authors list food quantities in household measurements (eg, 1 cup cucumber, 3 T tomato paste) rather than how foods are typically made available (eg, 1 cucumber, 1 can tomato paste) in the grocery store. The oneweek meal plan is simple, listing breakfast, lunch, and dinner recipes from the book without portion guidance.

Part 3 is dedicated to the recipes with beautiful photography that makes each dish look mouthwatering. Most of the recipes don’t require a slew of ingredients, a big plus for beginner cooks or anyone else daunted by long ingredient lists. There’s a great deal of variety among the recipes, so one wouldn’t expect to become bored with such a diverse selection. The recipes are calorie-conscious, falling between 300 to 500 kcal per serving. Readers are instructed to plug their recipes of choice into meal plan worksheets found in Part 4.

This book is more about the recipes and less about how to structure a plant-based eating meal pattern. Readers looking for good plant-based recipes who like to cook their own food and can allocate time for meal planning every week likely will find 28-Day Plant-Powered Health Reboot useful and interesting. However, I would stop short of recommending it for those in need of more meal planning guidance and structure.

— Andrea N. Giancoli, MPH, RD, is a freelance health and nutrition writer and nutrition communications consultant in Hermosa Beach, California.

— (ABOVE) COVER AND BOOK DESIGN IS BY PAGE STREET PUBLISHING CO., AND PHOTOGRAPHY, FOOD STYLING, AND PROPPING IS BY TONI ZERNIK.

Visually, the layout of the recipes is highly appealing. Each includes a vibrant photo, clear instructions, helpful preparation tips, and nutrient information. Here, Harris-Pincus really shines in her ability to provide high-protein, low-calorie versions of the latest food trends, such as mug cakes, overnight oats, smoothie bowls, and avocado toast. She also makes use of ancient grains, chia seeds, and flaxseeds. In contrast, she manages to offer a few delicious, updated, and nutrient-dense versions of traditional favorites, too, such as “Cherry Vanilla French Toast,” which boasts 13 g fiber.

Regarding nutrients, the recipes all hit the low calorie (300 or less) and high protein (20 g or more) per serving mark that Harris-Pincus promises. On the downside, recipes less consistently contain adequate fiber, with a few containing as little as 0 to 4 g per serving. Since fiber is a key nutrient when it comes to maintaining lean body mass and blood sugar control, this shortfall could be a sticking point for some clinicians.

Overall, I’d recommend The Protein-Packed Breakfast Club to clients who are curious about specific trends, as well as those who are struggling to get excited about breakfast. Harris-Pincus solidly provides direction on what to combine to create tasty, protein-dense versions of Pinterest and Instagram superstars such as mug cakes and smoothie bowls. Since lack of time often is cited as a reason for missing a morning meal, I’d emphasize the ease of recipes that can be made ahead of time, such as overnight oats, protein muffins, and egg soufflés. For those considering referring clients to this book, I’d recommend providing additional education on the importance of breakfast and protein overall. While references are provided, the explanation of the impact of breakfast and protein on satiety, metabolism, and blood sugar control is limited.

GET TO KNOW …

MARISA E. SANTIAGO-RIVERA Puerto Rico’s First Retail Dietitian

By Juliann Schaeffer When the family owners of three supermarkets in Puerto Rico decided they wanted to connect their wholesome product offerings with nutrition education that could benefit their island communities, they searched for the perfect person to trailblaze their message of health and wellness.

After placing a national newspaper ad that read “Retail Dietitian Wanted — MUST LOVE FOOD,” Econo Healthy Path Markets received a groundswell of interest. But only one person was perfect for the opportunity: Marisa E. Santiago-Rivera, RD, LDN. “I have been a dietitian for seven years, but I have worked in [nondietetics] retail for almost 14 years,” Santiago-Rivera says.

“I believe I have been preparing for this position my whole life.”

Santiago-Rivera has the distinction of being the first retail dietitian in Puerto Rico, and so far she’s exceeded expectations for what the island’s first supermarket RD could accomplish.

In a sentence, the purpose of her job can be summed up as such: “The Healthy Path Market … [has] the goal of transforming those three stores from big pantries into interactive dietary resources that provide the necessary tools for our customers to make educated choices on which foods best fit their dietary needs.”

Santiago-Rivera’s plate is full with myriad responsibilities that stem from this end goal. In-store cooking demonstrations, supermarket tours, and in-store information booths educate shoppers on smart snacking, diabetes management, food safety, and more. But that hardly scratches the surface.

Also in the store, she provides MNT for individuals and groups, specializing in HIV, diabetes, and weight management, which means Santiago-Rivera oversees the first in-store nutrition counseling clinic in Puerto Rico. And she takes her healthful messaging on the road as well.

For example, for the supermarket’s Kids Eat Right Program, Santiago-Rivera and her team visit local schools to expose children to healthful food habits. (She’s the only RD on the team currently, but Healthy Path is working toward hiring more.) Partnering with Nestlé Nutrition, the dietetics team trains local teachers in basic nutrition for kids.

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“I have also been able to develop educational programs to train other licensed nutritionists about patient-centered interventions,” she says. “And I have been a dietetics internship preceptor [for some] who are now successful dietetics professionals. As a retail dietitian, I have also been able to influence customer service in our stores.”

For her exhaustive efforts, Santiago-Rivera recently was named Retail Dietitian of the Year by the Retail Dietitians Business Alliance. Yet of all her many responsibilities, Santiago-Rivera says what she’s most proud of is being considered a change agent and exposing her community to a new way of living that’s both healthful and in line with local customs.

Keep reading for a peek inside Santiago-Rivera’s experience and the beauty of island life.

Today’s Dietitian (TD): Can you tell us more about the in-store Dietetic Clinic?

Santiago-Rivera: The Dietetic Clinic became a new and necessary department as part of my position at the Healthy Path Markets. It’s located inside one of the stores, becoming the first (and so far only) dietitian’s office inside a supermarket in Puerto Rico.

In it, clients receive individualized MNT through counseling and education. I use techniques exclusive to this intervention, like meal plans, menu planning, and guided goal setting.

TD: If you could offer clients only one piece of advice, what would it be?

Santiago-Rivera: You don’t have to eat “perfectly” just better, most of the time, and mostly plants. (It sounds better in Spanish: En vez de tratar de comer perfecto—come mejor, la mayoría de las veces, enfatizando las plantas.)

TD: In your view, what’s the biggest nutrition challenge facing the community you serve?

Santiago-Rivera: My community is very smart and inquisitive, but I find that they struggle not only with fad diets and food trends but also with conflicting nutrition education, especially when people try to simplify food choices into “good” or “bad” lists.

This is the reason I spend most of my education and counseling time teaching solutions that support my focus on balance.

Making small changes and better-for-you choices have allowed my community to come a long way.

TD: What’s your best advice for those new to the nutrition field?

Santiago-Rivera: Get outside the box. When put to the task of developing nutrition education tools that will directly influence a client, patient, or group, go back to the kitchen, the supermarket, and the restaurant. They will appreciate it.

I would love new professionals to step away (a little) from individual nutrient recommendations and think more of the diet in its totality. To take into consideration your client’s cooking skills (and the skills you can teach them), where they buy food, and the restaurants they visit will help them make wiser and smarter food choices.

TD: What makes your work with dietetics interns so important to you?

Santiago-Rivera: I have been a dietetics internship preceptor for several years. It’s a beautifully rewarding job, a two-way learning street. Interns help me stay up to date (especially on topics related to social media). They also bring to the mix their own style and skills, helping me reach a broader spectrum of clients and offering new solutions.

TD: What do you find to be the most fulfilling task you’ve performed thus far in your career?

Santiago-Rivera: The supermarket tour, right after discussing the meal plan—particularly that instant the client realizes it’s possible to include their favorite foods in a balanced meal plan.

Not to generalize, but many of us love rice and beans and tostones [double-fried plantain slices]. Sometimes learning that you can easily incorporate these choices into a healthful meal plan makes all the difference during my individualized interventions. I may even provide the recipe for baked tostones de pana (which I’m baking right now).

For some, this little piece of knowledge is evidence that a lot of things they thought were impossible (like portion control, declining extra calories at a party because of local customs, or taking home half of a big portion of food from a restaurant) become feasible.

TD: Give us a peek inside your refrigerator/cupboard. What are the mainstays in your kitchen?

Santiago-Rivera: For me, a “flexitarian” approach is the way to go. Every weekend, I try to make sure to have enough fresh vegetables, fruits, and dry pulses to last me the week. In case of emergency, I always stock my freezer with big bags of frozen fruits and vegetables as well as portioned rice, pasta, and starchy vegetables. If I had to make a list, I would say the following items are my must-haves:

clients stay within budget and also reduce food waste (which is literally wasted money).

TD: How do you stay current on both nutrition research and food trends?

Santiago-Rivera: I’m an avid workshop/lecture/webinar taker.

And my long commute has helped me stay current even more.

While driving, I like to listen to recorded lectures and webinars.

I also find that teaching is a great way to stay current.

TD: What foods do you crave?

Santiago-Rivera: I want to say grilled vegetables, but really it’s just onions—anything with onions.

TD: How often do you cook vs eat out?

Santiago-Rivera: I like to cook big batches at least once per week.

Living what I teach has helped me improve my dietetic interventions, turning it from “offering recommendations” to “teaching solutions.” With a two hour-long commute to work, eating out has always been a strong contender in my food choices. But with limited healthful choices around, I feel that eating out (too often) leaves too much to chance.

My solution: one afternoon of meal prepping for the whole week, with the help of portion-controlled containers, one-pot and one-sheet-pan recipes, and an adequate lunch bag that ensures food safety.

TD: Two hours is a long commute. Do you simply love where you live too much to move closer to work?

Santiago-Rivera: All three of my stores, which I share my time between, are located in beautiful towns. Two of them, Isabela and Aguadilla, are near beautiful beaches. Mountains decorated with beautiful waterfalls surround San Sebastián. They’re about two hours away from home, but I love my work and I love where I live too much to move.

• dry lentils; • chickpeas; • ground flaxseeds and chia seeds; • cardamom; • really good Puerto Rican coffee; • quinoa; and • spinach.

TD: Using your retail dietetics expertise, what’s your best tip for helping clients get the most value from a grocery store trip while still making healthful choices?

Santiago-Rivera: Eating less meat (or animal-based proteins) will probably translate into a cheaper way to shop. Also, dietitians can give excellent feedback to help clients shop smarter and more healthfully.

After making a client’s meal plan, translate it into a shopping list so it’s more practical for them. It will always be cheaper and wiser for them to shop for just what they need. For example, knowing how many fruits they expect to eat each day can help

TD: How do you stay active?

Santiago-Rivera: I live in San Juan, a beautiful community that promotes physical activity and outdoor fun. I love to take long walks on its blue cobblestone streets with my dog (a fullof-energy Boston terrier named Galaxia 5) and enjoy riding my bike to the beach. I often go paddleboarding on Laguna del Condado with friends and family.

When the schedule allows it, I love to go on adventures kayaking and hiking in Maricao, Las Marías, Fajardo, Mayagüez, Vieques, and Culebra. There’s nothing better than to plan a three-day healthful menu for camping.

I’m fortunate to live on this beautiful island where one day you can go hiking to the rain forest and sunbathe at beautiful secluded beaches and the next day camp in the mountains.

— Juliann Schaeffer is a freelance food and health writer based outside of Allentown, Pennsylvania, and a frequent contributor to Today’s Dietitian.

september 2017 www.todaysdietitian.com 61

NEWS BITE

POSSIBLE PSYCHOLOGICAL INTERVENTION TO PREVENT OBESITY People who experience unpredictable childhoods due to issues such as divorce, crime, or frequent moves face a higher risk of becoming obese as adults, according to a new study by a Florida State University researcher.

Professor of Psychology Jon Maner, PhD, found that people who had an unpredictable childhood tended to overeat, while those who experienced a stable childhood didn’t. The study was published in the journal Proceedings of the National Academy of Sciences.

“Experiencing an unpredictable environment in childhood sensitizes people to the idea that it’s difficult to plan for the future, because if you don’t know what’s around the next corner, you live for the now,” Maner says. “They end up focusing on short-term rather than long-term goals, and they’re not good at delaying gratification.”

Past research has confirmed a clear link between low socioeconomic status and obesity, but those studies haven’t clearly identified the root causes of the problem. That research has generally concluded too much stress in families can lead to a wide variety of negative outcomes for children when they grow up.

This new research uses Life History Theory, an important, well-established perspective from behavioral science that’s

62 today’s dietitian september 2017

been used to predict a wide range of behaviors, such as a person’s ability to parent and make financial decisions. It marks the first time this approach has been used to study obesity.

Life History Theory is rooted in the idea that people have a limited amount of reproductive energy in their lives, and the way they use that energy is influenced by the amount of structure they experience during childhood.

Unpredictable childhoods can cause a “fast-life-history strategy” for adults, Maner says. They live for the now, often have children at an earlier age, spend money rather than save, and seek immediate gratification.

In contrast, predictable childhoods tend to teach that planning for the future is good, and that mindset results in a “slow-life-history strategy.” As adults, they form long-term goals, often have children at an older age, and are more likely to invest in education and save money for retirement.

“If you don’t know where the next meal is coming from, it would make sense to eat what you can now,” Maner says. “But people with a slow-life-history strategy feel the future is more certain, and they intuitively know where their next meal will come from. They are inclined to listen to their body and eat based on their current needs.”

More than one-third of American adults and 17% of youth aged 2 to 19 are obese, according to data from the US Centers for Disease Control and Prevention. The agency calls obesity a serious, costly problem that causes heart disease, stroke, cancer, liver disease, type 2 diabetes, and other health issues. Maner says those negative effects create urgency for researchers and health professionals to identify the behavioral factors causing obesity.

One of the main goals of Maner’s research is to identify ways to prevent obesity. While past research vaguely encouraged families to reduce stress without suggesting clear tips on how to make that happen, Maner says his research points toward some potentially valuable prevention ideas.

“Our research suggests it’s not just about reducing stress; it’s more about creating structure and predictability for children,” Maner says. “For example, have family meals at the same time each night or bedtime rituals every day. Routines teach children to have expectations that, when met, result in a sense of certainty and structure. Theoretically, that feeling of predictability instills a slower-life-history strategy, which may reduce obesity in adulthood.”

— SOURCE: FLORIDA STATE UNIVERSITY

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Find pulse recipes and resources at: www.pulses.org • www.lentils.org september 2017 www.todaysdietitian.com 63

PERSONAL COMPUTING

STREAMING VIDEO OVER THE INTERNET

By Reid Goldsborough More and more people are “cutting the cord”—getting their television and movies without a traditional pay TV package.

Frustrated by cable and other pay TV companies forcing consumers to subscribe to channels they don’t watch, making channels they do watch part of bundles that can cost more than $100 per month, and providing lousy customer service, customers are opting out.

Cord cutters have two main choices. They can go forward in time, getting their shows and movies through their internet connection. Or they can go backward in time, getting shows and movies over the air through an antenna. They also can do both.

The advantages are price and control. You can get your TV and movies for low cost or for free; as a citizen of the Digital Age, you decide what content you want.

Rabbit-ear TV antennas are on the comeback, a related trend.

The availability today of multiple free digital broadcast channels makes this option even more appealing than in the old days.

As in the old days, however, with over-the-air channels, unlike with many streaming services or premium cable, you need to put up with TV commercials. And your reception may be spotty, preventing you from getting some channels.

Streaming, however, is the video option that’s all the rage these days, requiring just a Wi-Fi connection, a Wi-Fi-enabled device, and a streaming service.

Just about all new TVs have Wi-Fi adapters built in, and, with smaller or older sets that don’t, you can buy a media streaming device to attach to it. You also can stream to your smartphone, tablet, gaming console, or computer.

Some streaming media devices, such as Roku Streaming Stick, Amazon Fire TV Stick, and Google Chromecast, provide only streaming content. Blu-ray players from major consumer electronics companies such as Sony and Samsung provide

64 today’s dietitian september 2017

streaming content in addition to being able to play Blu-ray discs and DVDs from your collection or the local library.

The most notable streaming media services include Netflix, Amazon Prime Video, Hulu, Sling TV, PlayStation Vue, DirecTV Now, and YouTube.

Netflix is the oldest and largest of the popular streaming media subscription services, and it continues to grow. It currently has about 50 million US subscribers, which includes a gain of 2 million in the fourth quarter of 2016.

Lately, Netflix has been reducing the size and expense of its movie library while it focuses more on original TV series. Amazon Prime Video now has about four times more movies. Sling TV has the best sports offerings. YouTube has the best free offerings, along with pay options for movies and other content.

Among the newer big kids on the block is HBO Now, which launched in April 2015. HBO didn’t provide a streaming service sooner because it didn’t want to risk alienating its cable partners, which continue to lucratively sell HBO as a premium TV service. HBO offers movies as well as original TV series.

Prices for these services vary. Netflix charges $10 per month, Amazon Prime Video $9, Hulu $8 with commercials and $12 without, Sling TV $20, PlayStation Vue $40, DirecTV Now $30, and HBO Now $15. Other subscription options often are available.

Niche services also abound. Seeso is a new comedy service from NBC Universal costing $4 per month. Crackle has old TV series and movies and is free.

Many people subscribe to more than one streaming service, sometimes along with a pay TV cable package. But subscribing to many multiple streaming services can increase the price beyond that of a pay TV cable package.

Beware of the lure of piracy. Some people access movies and TV illegally over the internet. Penalties on the books for such piracy in the United States range from a fine between $750 and $30,000 per illegally downloaded work to up to five years in prison.

Often, lawsuits are brought by a motion picture studio or association and are settled out of court. When cases go to court, judges have a lot of discretion, with crooks who make money from pirating content and consumers who filch much material typically getting hit hardest.

Anecdotal evidence suggests that, relatively speaking, consumers of pirated content rarely get caught. But the threat of getting caught is always there, and this deterrent is primarily what television networks and movie studios and their associations rely on. Low-cost and free content is out there, so why take the chance?

— Reid Goldsborough is a syndicated columnist and author of the book Straight Talk About the Information Superhighway. He can be reached at reidgoldsborough@gmail.com or reidgold.com.

DATEBOOK SEPTEMBER 15, 2017

NORTH CAROLINA DIETETIC ASSOCIATION REGIONAL MEETING Wilmington, North Carolina www.eatrightnc.org SEPTEMBER 16-19, 2017

11TH CONGRESS OF THE INTERNATIONAL SOCIETY OF NUTRIGENETICS AND NUTRIGENOMICS Los Angeles, California www.nutritionandgenetics.org SEPTEMBER 24-27, 2017

ASSOCIATION OF CORRECTIONAL FOOD SERVICE AFFILIATES ANNUAL INTERNATIONAL CONFERENCE AND VENDOR SHOWCASE San Diego, California www.acfsa.org SEPTEMBER 25-28, 2017

BIENNIAL NATIONAL WIC ASSOCIATION WIC TECHNOLOGY, PROGRAM INTEGRITY, AND VENDOR MANAGEMENT EDUCATION & NETWORKING CONFERENCE AND EXHIBITS Memphis, Tennessee www.nwica.org

MARCH 2-5, 2018 NOVEMBER 10-12, 2017

REGISTER NOW FOR THE 2017 RENFREW CENTER FOUNDATION EATING DISORDERS CONFERENCE FOR PROFESSIONALS — “FEMINIST RELATIONAL PERSPECTIVES AND BEYOND: INTEGRATING SCIENCE, CREATIVITY AND CLINICAL WISDOM” Featuring Keynote Speakers: Patrick J. Kennedy; Roxane Gay, PhD; Janet Treasure, OBE, PhD, FRCP, FRCPsych; and Adele Lafrance, PhD, CPsych.

Panel: Beth Hartman McGilley, PhD, FAED; Gayle Brooks, PhD; Rachel Calogero, PhD; Melissa-Irene Jackson, BS, BA; and Marcella Raimondo, PhD, MPH. November 10-12, 2017 Philadelphia, PA 18 Continuing Education Credits Available Contact: Kavita Patel Phone: 1-877-367-3383 E-mail: kpatel@renfrewcenter.com www.renfrewconference.com

AMERICAN ACADEMY OF ALLERGY, ASTHMA & IMMUNOLOGY ANNUAL MEETING Orlando, Florida www.aaaai.org MARCH 10-13, 2018

AMERICAN SOCIETY OF PREVENTIVE ONCOLOGY 42ND ANNUAL CONFERENCE New York, New York http://aspo.org APRIL 5-7, 2018

PENNSYLVANIA ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETING AND EXPO Grantville, Pennsylvania www.eatrightpa.org APRIL 10-14, 2018

NATIONAL KIDNEY FOUNDATION SPRING CLINICAL MEETINGS Austin, Texas www.kidney.org APRIL 11-13, 2018

WISCONSIN ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE Wisconsin Dells, Wisconsin www.eatrightwisc.org

OCTOBER 3, 2017

IOWA ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETING Ames, Iowa http://eatrightiowa.org OCTOBER 9-12, 2017

17TH INTERNATIONAL NUTRITION & DIAGNOSTICS CONFERENCE Prague, Czech Republic www.iuns.org DECEMBER 1, 2017

NORTH CAROLINA DIETETIC ASSOCIATION REGIONAL MEETING Durham, North Carolina www.eatrightnc.org

APRIL 12-14, 2018 JANUARY 21-23, 2018

SCHOOL NUTRITION ASSOCIATION SCHOOL NUTRITION INDUSTRY CONFERENCE New Orleans, Louisiana http://schoolnutrition.org JANUARY 22-25, 2018

AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION NUTRITION SCIENCE AND PRACTICE CONFERENCE Las Vegas, Nevada www.nutritioncare.org

TEXAS ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE & EXHIBITION Houston, Texas www.eatrighttexas.org

Datebook listings are offered to all nonprofit organizations and associations for their meetings. Paid listings are guaranteed inclusion. All for-profit organizations are paid listings. Call for rates and availability.

Call 610-948-9500 Fax 610-948-7202 E-mail TDeditor@gvpub.com

FEBRUARY 26 – MARCH 4, 2018

NATIONAL EATING DISORDERS AWARENESS WEEK http://nedawareness.org

Send Write with your listing two months before publication of issue.

september 2017 www.todaysdietitian.com 65

CULINARY CORNER Apples and Celery With Pecans I like using one tart and one sweet apple for this salad, but really any apple variety will taste great. This recipe calls for celery hearts, which are the tender and lighter green center stalks of a head of celery. Remove the outer celery stalks (reserve for eating with peanut butter) and just use the tender center stalks plus the flavorful light green leaves.

Serves 6

Ingredients ⁄2 cup raw pecan halves 2 cups (about 1 large) Granny Smith apple, julienne 2 cups (about 1 large) Golden Delicious apple, julienne 2 T lime juice or lemon juice 2 cups celery hearts and leaves, thinly sliced on a bias 1 ⁄4 cup flat leaf parsley, rough chopped 1 ⁄4 cup mayonnaise 1 ⁄4 cup plain low-fat yogurt 1 T apple cider vinegar 1 T honey 1 ⁄2 tsp celery seed 1 ⁄2 tsp kosher salt 1 ⁄4 tsp ground black pepper 1

SWEET, TART, CRISPY APPLES

By Chef Garrett Berdan, RDN, LD

Experiment with different varieties in this crunchy salad.

I grew up in the middle of a five-acre apple orchard in Wenatchee, Washington, the “Apple Capital of the World.” I was surrounded by hundreds of giant 35-year-old Golden Delicious and Red Delicious apple trees for the latter half of my childhood. My family worked together in the orchard, and as a kid I learned much about growing and cooking with apples.

In late summer and into the fall, depending on the growing region, apples are harvested by hand, transferred to large wooden or plastic bins, and trucked to a packing company. Fall is the ideal time for tasting apples fresh from the tree. Thanks to controlled atmosphere storage conditions, however, high-quality US-grown apples are available fresh all year round. Controlled atmosphere storage is a way to extend the life of fresh apples (and other fruits) through controlling storage temperature, humidity, and oxygen and carbon dioxide concentrations in airtight storage rooms.

Every few years, a new (or old) apple variety seems to emerge, so I often buy one of each and conduct a taste test. There are many differences among apple varieties, qualities that dictate specific culinary applications such as fresh eating, sauce making, and baking. For pies and baking, I like to use Golden Delicious, Granny Smith, and Honeycrisp. One apple I’m particularly excited to see in the coming years is Cosmic Crisp, a cross between Enterprise and Honeycrisp apples. This new variety, developed by the Washington State University tree fruit breeding program, recently was released to apple growers. The first Cosmic Crisps are due to hit the produce section in 2019.

I love apples because they’re simultaneously sweet, tart, crisp, and crunchy, yet they also transform to become soft and silky when cooked or baked. At only about 130 kcal, one large apple is a filling, fiber-rich snack or meal component that works as a sharp cheddar delivery system or a low-calorie dessert when simply baked with spices. My recipe for Apples and Celery With Pecans is an easy, slawlike salad that exploits crisp and crunchy textures.

Conduct your own apple taste test by using any apple variety in this recipe.

— Chef Garrett Berdan, RDN, LD, is a culinary nutrition consultant from the Pacific Northwest. Find him at garrettberdan.com, on Twitter @garrettberdan, and at www.facebook.com/GarrettBerdanChefRDN.

66 today’s dietitian september 2017

Directions 1. Preheat oven to 325˚ F. Place pecans on a

rimmed sheet pan and place in the preheated oven. Toast the pecans for about 10 to 12 minutes.

They will become aromatic and golden brown inside, and will have a crispier texture than raw pecans. Cool at room temperature.

2. Meanwhile, place the julienne apples (4 cups total) in a large mixing bowl. Add the lime or lemon juice and toss to coat the apples to prevent browning.

3. Add the sliced celery hearts and leaves, and the rough-chopped flat leaf parsley. Set aside.

4. In a small mixing bowl, whisk together the mayonnaise, yogurt, cider vinegar, honey, celery seed, salt, and pepper. Pour over the apple and celery mixture and gently toss until the salad is evenly dressed. Transfer the salad to a serving dish.

5. Chop the cooled toasted pecans and sprinkle over the salad. Serve immediately.

Nutrient Analysis per serving Calories: 154; Total fat: 10 g; Sat fat: 1 g; Cholesterol: 3 mg; Sodium: 203 mg; Total carbohydrates: 18 g; Dietary fiber: 3 g; Sugars: 13 g; Protein: 2 g

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