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DIABETES MANAGEMENT & NUTRITION GUIDE Vol. 20 No. 8

August 2018

The Magazine for Nutrition Professionals

A A DE C ONF E RE NC E ISSUE

Do Genes or the Environment Shape the Gut Microbiota? Campus Farms Boost Student Health, Academics Turn Diet Advice Into Meals and Menu Planning

www.TodaysDietitian.com

Grilled Chicken Breasts with Avocado Chimichurri Sauce

MAKE IT EASY TO EAT

MINDFULLY Avocados, Satiety and Glucose Research published in Nutrition Journal reports that adding fresh avocado to lunch may help healthy overweight people feel more satisfied, and it reduced their desire to eat following a meal.* This research is one of the avocado nutrition studies that can be found at LoveOneToday.com/Research. Help your clients add a food they already love to their eating plans with heart-healthy recipes at LoveOneToday.com/HeartRecipes. *The conclusions drawn from this study cannot be applied to the general public due to the study size and limitations noted by the researchers. More research is needed to investigate avocadosâ&#x20AC;&#x2122; effect on glucose homeostasis. ÂŠ 2018 Hass Avocado Board. All rights reserved.

Creamy Avocado Tomato Soup

Kale Avocado Salad with Roasted Carrots and Avocado Kale Pesto

Slow Cooker Avocado Lime Chicken Soup

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Important Risk Information If regular adjustments or modifications to the basal rate of insulin are required in a 24-hour period, or if the amount of insulin used at meals requires adjustments of less than 2-Unit increments, use of the V-Go Disposable Insulin Delivery Device may result in hypoglycemia. The following conditions may occur during insulin therapy with V-Go: hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose). Other adverse reactions associated with V-Go use include skin irritation from the adhesive pad or infections at the infusion site. V-Go should be removed before any magnetic resonance imaging (MRI) testing. V-Go is a registered trademark of Valeritas, Inc. ART-1388 8/2018 ©2018 Valeritas, Inc.

The State of the Science on Stevia Understanding its Role in the Fight Against Obesity and Diabetes

At the IUNS 23rd International Congress of Nutrition, Dr. Keith Ayoob discussed two of today’s most common health epidemics – obesity and Type 2 diabetes – and reviewed the science confirming the role low calorie sweeteners (LCS) such as stevia can play in reducing added sugar intake. Dr. Ayoob’s presentation on the state of the science on stevia drew from in-vitro, animal and human studies, and discussed stevia’s potential role in helping manage diabetes, blood pressure, weight, and appetite. In addition he cited regulatory body approvals from around the world which confirm LCS and stevia are safe for the whole family.

Keith Ayoob, EdD, RDN, FADN is an Associate Clinical Professor Emeritus at the Albert Einstein College of Medicine. As a pediatric nutritionist and registered dietitian, Dr. Ayoob is also a past national spokesperson for the Academy of Nutrition and Dietetics.

For more on the state of the science, visit steviabenefits.org/science

EDITOR’S SPOT

DIABETES DIAGNOSES RISING Last month, my husband and I spent a week in Nassau, The Bahamas, for our summer vacation. My husband’s affinity for the Caribbean has grown over the last couple of years as we’ve visited the countries of Grenada and Jamaica. My love of the Caribbean stems from my childhood and ancestry. My father was born and bred in Barbados (St. Andrews Parish), so I spent many summers there with him, my mom, and my brother. My mother’s family is from Maroon Town, Jamaica (a locale spanning the St. James, St. Elizabeth, and Trelawny Parishes). That makes me an African/West Indian gal—and a very proud one I might add! While in The Bahamas, I wondered what the prevalence of diabetes is among the people there, what it is in the West Indies as a whole, and how it compares with that of the African American population in the United States and the United States overall. After doing some research, boy were my eyes opened. According to 2017 data from the International Diabetes Federation (IDF) North America and Caribbean (NAC) Region, 425 million people worldwide and more than 46 million people in the NAC region have diabetes, and it’s projected that by 2045 this statistic will skyrocket to 62 million. The IDF Diabetes Atlas, 8th Edition, shows that of the adult population aged 20 to 79, 13.6% in The Bahamas has diabetes, 11.4% in Jamaica has it, 9.5% in Grenada has it, and 17.6% in Barbados has it. These statistics are comparable to those of non-Hispanic blacks in the United States: 12.2% and 13.2% of non-Hispanic black men and women aged 18 and older have diabetes, respectively, according to the National Diabetes Statistics Report, 2017. And all together, 13% of adults in the United States are living with the disease. Sadly, diabetes prevalence is expected to increase dramatically by 2045 in the United States and in every other world country. That said, it’s obvious that the world has its work cut out for it to help prevent diabetes and reduce the enormous health care costs associated with it through better patient education programs and services. This month, Today’s Dietitian (TD) is featuring its second annual Diabetes Management & Nutrition Guide on page 30. In it, you’ll find articles on diabetes nutrition, bariatric surgery’s role in managing type 2, digital health technology in diabetes care, treatments for sexual dysfunction, and more. In addition to reading this special section, turn to features on the gut microbiota and college farming programs. The staff of TD looks forward to seeing you at the American Association of Diabetes Educators annual conference in Baltimore. Stop by booth 850 to say hello, and please enjoy the issue!

Judy

Judith Riddle Editor TDeditor@gvpub.com

4 today’s dietitian august 2018

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 Senior Graphic Designer Erin Faccenda Junior Graphic Designer Sam LeVan ADMINISTRATION Administrative Manager Helen Bommarito Administrative Assistants Allison Czermanski, Pat Plumley, 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 Assistant Director of Continuing Education Susan Graver Continuing Education Assistant Sam LeVan 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 Laura Berman, Bill Eichler, Doug Paugh, Chandra Pietsch

© 2018 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.

Grilled Chicken Breasts with Avocado Chimichurri Sauce

MAKE IT EASY TO EAT

Creamy Avocado Tomato Soup

Kale Avocado Salad with Roasted Carrots and Avocado Kale Pesto

Slow Cooker Avocado Lime Chicken Soup

CONTENTS

AUGUST 2018

FEATURES

DEPARTMENTS

Shaping the Gut Microbiota The centuries-old debate on nature vs nurture applies not only to human behavior but also to the gut. How much of our gut composition can be controlled through lifestyle, and how can RDs develop actionable recommendations from this information?

4 Editor’s Spot

Benefits of College Farms & Gardens On-campus gardening and

12 Culinary Education

farming help students eat better, learn better, and live better.

Turn Diet Advice Into Meals and Menu Planning Many private practice RDs wonder what happens when clients leave their offices and step into the supermarket. Teaming up with in-store retail dietitians can help clients translate nutrition prescriptions into practical shopping experiences. Diabetes Management & Nutrition Guide This section includes guest commentary and articles on diabetes nutrition throughout the lifecycle, digital health technology in diabetes care, bariatric surgery’s role in type 2 diabetes, treatments for sexual dysfunction, strategies for reversing prediabetes, and mind-body exercise for diabetes management.

8 Reader Feedback 10 Ask the Expert

14 Supplements 59 Products + Services 60 Get to Know … 62 Focus on Fitness 63 Product Showcase 65 Datebook 66 Culinary Corner

CPE Monthly: Childhood Obesity Prevention and Treatment This continuing education course discusses the diagnosis of childhood obesity, its complications, evidence-based treatment strategies, and key messages for RDs to communicate to families. The key messages focus on the behavioral contributors to childhood obesity that families can modify by working with RDs. Some suggestions for effectively communicating these key messages also are included.

Page 52

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 20, Number 8.

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READER FEEDBACK From Our Facebook Page

From Our Twitter Feed Popular Tweets, Retweets

RDs React to the Death of Chef Anthony Bourdain Wendy S Chatham: Rest easy, Mr. Bourdain. Ava Donovan: I don’t think I’m the only one who was touched by Anthony Bourdain’s death. He gave us passion and perspective. He refined our idea of what food meant to an individual and a culture. He inspired us to dig deeper, and he made us better and more empathetic dietitians. Here’s to a man who brought passion and life to our profession. Yvostay Reneese Rushing: RIP. “9 Things a Registered Dietitian Wants You to Know About Weight Loss” beta.nbcnews.com

Danielle LeBlanc Landry: So much yes … hard work, realistic goals, and common sense. There are no shortcuts! Samantha Cassetty, MS, RD: Wow! Thanks so much for this!

Applying Nutrigenomics in Clinical Practice: The Nuts and Bolts (Webinar) @NishtisChoice: Oh, I’m excited for this! I’ve recently embarked on the journey of nutrigenomics and aim to offer this service to clients in the future.

June Issue

CO N FER EN CE I SSU E Vol. 20 No. 6

Navigating the Yogurt Aisle @nutritionmentor: Navigating the yogurt aisle—great insights that may help with your next yogurt purchase, from Constance Brown-Riggs, MSEd, RD, CDE, CDN, in Today’s Dietitian.

June 2018

The Magazine for Nutrition Professional s

NAV IGATING THE

YOGURT AISLE Learn about the expanding abundance of varieties and tips for counseling clients.

Omega-3 Supplements and Children’s Health Military RDs on the Front Lines Optimal Nutrition for Liver Health

May Issue Women and Heart Failure @KathyBirkettRDN: Women, heart failure, and new guidelines to intervene for health.

Communicating Nutrition Research @hannahrimes: Takeaway: objectivity is key!

“Toddler Test Kitchen Heats Up Summer Cooking for Kids” 12news.com

Heather Johnson: Love that this is happening. Research supports that kids who participate in cooking new foods are more likely to sample them. Shontel Antonette: I love Toddler Test Kitchen! “3 Tips to Improve Clients’ Relationship With Food” RDLounge.com

Meredith Johnson: You make a ton of spot-on points about how to continue helping clients and meet them where they are! Loved it! “The New Global Plan to Eliminate the Most Harmful Fat in Food, Explained” vox.com

Karen Proctor: Unfortunately, a lot of trans fat is replaced with palm oil in Western “foods,” which is devastating tropical forests.

8 today’s dietitian august 2018

@RDspillthebeans: “Dietitians must be able to accurately evaluate and translate studies when nutrition is trending.” Another great article from Today’s Dietitian. @serenedoc: The best way for RDs to position themselves as experts in interpreting and translating evidence is for them to get a PhD in nutrition. The PhD training and degree is the ultimate preparation for a scientist who is the expert in interpreting and translating research evidence. @ABenderRD: Great article in Today’s Dietitian by Emily A. Callahan, MPH, RDN, and Karen Collins, MS, RDN, CDN, FAND, on critical evaluation of nutrition research. We see spin reporting in media more often than we should, and RDs can help relay accurate information to the public.

www.TodaysDietitian.com

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ASK THE EXPERT

WHAT’S THE DEAL WITH CARRAGEENAN? By Toby Amidor, MS, RD, CDN

Q: A:

Lately, there’s been a great deal of controversy around carrageenan. What is it, why is it a contentious topic, and is it safe to eat? Carrageenan is a food gum that’s been used for decades as a food additive. There’s been much controversy on its use and safety, with some in vitro studies showing harm at certain levels of exposure, and many consumers have called for its removal from food products. That said, long-standing research shows that carrageenan is safe for human consumption.

What Is Carrageenan? Carrageenan is derived from red seaweed and is used as a thickener, emulsifier, and stabilizer in a wide variety of foods including ice cream, chocolate milk, infant formula, and plantbased milk alternatives such as soy, almond, coconut, and hemp. In certain vegan foods, it’s used as an alternative to animal-derived gelatin. It has no nutritive value.

Controversy and Safety Profile Many regulatory agencies have deemed the use of carrageenan as a food additive to be safe, including the FDA, European Commission Health & Consumer Protection,1 and the Joint Food and Agriculture Organization of the United Nations/World Health Organization Expert Committee on Food Additives.2 Since 1970, the expert committee has assessed the safety of carrageenan eight times. In its latest review, the committee reviewed 77 studies and didn’t find evidence of any toxicological concerns. One of the most recent studies on carrageenan, published in Food Toxicology and Chemistry, found that carrageenan doesn’t cross the intestinal epithelium, induce oxidative stress, nor cause intestinal inflammation.3 However, many food companies are choosing to remove carrageenan because of consumer demands based on fear of carrageenan’s lack of safety. These fears are rooted in several

10 today’s dietitian august 2018

studies that challenge its safety, some of which have concluded that it contributes to fasting hyperglycemia,4 inflammation, and cancer.5 However, a 2017 review of carrageenan’s safety published in Nutrition Today states, “It is important to recognize that data obtained from in vitro cell-based models stimulated with an artificially high or unnatural exposure of the compound in question cannot be equated with in vivo human health.”6 The review provides an in-depth look at the several studies claiming carrageenan’s harmful effects and provides a biochemical explanation as to why each doesn’t apply to carrageenan when used as a food additive. The researchers further concluded, “The energy from debate over its possible health risks illustrates how important it is to understand how laboratory and translational research are conducted, linked with public health policy and regulations, and translated to practical nutrition and health messages.” Although carrageenan has been repeatedly deemed safe for use as a food additive, consumers continue to demand its removal from food products. In addition, the National Organic Standards Board has recommended its removal from the organic food supply (though the USDA ignored this recommendation), giving credence to consumers’ fears. Unfortunately, finding a replacement that acts like carrageenan is no easy feat and may lead food manufacturers to use less-researched food additives for which longterm safety and appropriate use levels are unknown.

Recommendation for Clients Today, consumers are questioning every ingredient that goes into a food, and practitioners should expect clients to challenge ingredients’ safety. In the case of carrageenan, there’s a lack of applicable scientific evidence supporting its purported harmful effects. However, not all clients will be convinced of its safety. For those who wish to reduce intake or exclude carrageenan from their diet, recommend they purchase fewer packaged foods, check ingredient lists, and/or consume less food in general (if healthful for the client). In addition, if clients can grow and preserve their own food, they can reduce their intake of carrageenan. — Toby Amidor, MS, RD, CDN, is the founder of Toby Amidor Nutrition (http:// tobyamidornutrition.com) and a Wall Street Journal best-selling author. Her four cookbooks are Smart Meal Prep for Beginners, The Easy 5-Ingredient Healthy Cookbook, The Healthy Meal Prep Cookbook, and The Greek Yogurt Kitchen. She’s a nutrition expert for FoodNetwork. com and a contributor to US News Eat + Run, Muscle&Fitness.com, and MensJournal.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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CULINARY EDUCATION sharpen and expand recipe writing skills,” says Barbara Ruhs, MS, RDN, a retail supermarket health consultant, an expert columnist for Today’s Dietitian, and founding partner at the Oldways Supermarket Symposium. Newgent breaks down her advice into the following actionable steps to help you start creating delicious, healthful recipes.

Recipe Writing Basics 1. Know your audience. This is the first step in deciding what recipe you plan to develop, according to Newgent. The recipe should be targeted for its intended audience and purpose, be that a website, supermarket demonstration, live cooking demonstration on television, or a community cooking class. Your audience will inform the overall style and approach of the recipe. Newgent suggests that if your recipe is for a supermarket event, “try to keep it simple and ‘now-worthy,’” which means the recipe can be prepared in 20 minutes or less with ingredients people can take home on the spot. If the recipe is for a publication, such as a magazine or newsletter, try to stay on track with current food trends and seasons. And if the recipe will be featured on live media, such as television or video, keep it newsy by linking ingredients to the latest research on health, yet easy enough to inspire viewers to visit or click on a recipe site and try it at home.

THE ART OF RECIPE DEVELOPMENT By Sharon Palmer, RDN

Learning these skills can help you encourage clients to cook more healthful meals at home. Whether you’re a supermarket dietitian, blogger, or community nutritionist, the ability to develop a good recipe is a valuable skill to have in your toolbox. A well-written recipe is like a piece of art, offering inspiration for your clients to enjoy a beautiful, delicious meal that promotes a healthful lifestyle. So, how can you acquire this skill? This question was answered by Jackie Newgent, RDN, CDN, an award-winning cookbook author and culinary nutritionist, at the Oldways Supermarket Symposium, held in San Diego on March 18, 2018. Newgent explained how dietitians can develop the basic skills required for recipe development in a key presentation at the conference. “Whether it is creating new recipes or modifying existing recipes to maximize nutrition, dietitians know the many benefits of helping consumers cook and prepare more meals at home. In particular, supermarket dietitians reach millions of customers in the aisles and through their retail publications and social media outlets, so it’s important to continuously

12 today’s dietitian august 2018

2. Focus on food trends. Newgent says that once you know your audience you can start focusing on other factors that can influence your recipe development, such as seasons and popular food trends, including Instagram trends, global fare, and vintage cuisine. “It’s also important to know your brand, style, or shtick,” Newgent says. Some of the strategies Newgent employs when she approaches recipe development include exploring various flavor affinities; covering all meal occasions; considering flavorful global cuisines; aiming for a balance in textures, colors, and tastes; using accessible ingredients; keeping techniques simple; planning for “evergreen” appeal when possible; adding a pop of surprise or a trendy element; pushing the envelope just slightly; keeping deliciousness top of mind; and getting inspired by fellow culinary dietitians’ recipes. 3. Choose freestyle or modification. You can create your recipes in a “freestyle” form, starting with a blank sheet of paper. Or you can take a recipe and modify it, though Newgent warns against plagiarizing others’ recipes. She suggests when you modify an existing recipe you make at least two ingredient changes, at least one significant method change, and a total rewrite of the instructions. “Give credit for the recipe source when necessary,” Newgent adds. When modifying an existing recipe, she suggests, “Try to consider making a few tweaks and swaps that make it seem ‘now’ without overcomplicating it. Just adding ‘more’ to a recipe doesn’t always work.” For example, you could tweak a recipe by swapping out ingredients

to make it more healthful, seasonal, trendy, or global. “Create a signature in your recipes,” encourages Newgent, who tends to add a Lebanese influence to her own recipes. 4. Fine-tune the details. Once you’ve developed your recipe, it’s time to sit down and write it out, using the following elements: • Title: Newgent suggests that your title be descriptive, concise, searchable, and enticing. • Number of Servings: Make sure to include the yield and specific serving size (such as 8 ½-cup servings). • Ingredients List: The ingredients should be listed in the exact order mentioned in the instructions, Newgent stresses. It should also be specific without being overly wordy. You also should use parentheses wisely (eg, when noting package sizes), list divided ingredients, note prepared items, and break up lengthy ingredient lists with headings. • Recipe Instructions: “This is not the time to be a storyteller,” Newgent says. When writing out your instructions, she suggests keeping it simple, providing visual descriptors (eg, appearance when done), listing cooking times, indicating cookware size, being logical, considering multitasking when writing out steps, and using numbers or bullets. • Extras: Consider adding headnotes (an attractive description under the title of the recipe), photos, and nutrient analysis.

and keeping up with the trends are key to opening the door for media opportunities in the realm of recipe development. 8. Stay up on trends. To make your recipes relevant, Newgent suggests that you stay “in the know” with current food trends, such as vegan, paleo, and gluten-free diets, and incorporate them into your recipe writing. At the same time, you want to stay away from some of the fad diet trends and remain true to your identity as a nutrition professional. Some of the diet strategies Newgent uses in her recipe development include minimizing sodium, unhealthful fats, processed carbohydrates, red and processed meats, and added sugars. She keeps in mind the adage “Taste always rules.” “Recipes can inspire people to cook more,” Newgent says. Indeed, dietitians can make a huge impact on public health by creating approachable, healthful, delicious recipes to share with their clients in a variety of settings. After all, encouraging people to cook more of their meals at home can be one of the most important changes people can make to achieve their health goals. And dietitians can be part of the home-cooking movement through the simple art of recipe writing. To learn more about Newgent’s recipes and culinary writing, visit http://jackienewgent.com. — Sharon Palmer, RDN, is a recipe developer, author of Plant-Powered for Life, nutrition editor for Today’s Dietitian, and blogger at The Plant-Powered Dietitian.

5. Try it out. “Test the recipe as often as you can,” Newgent suggests. If it needs adjustment, retest it, taste it, and repeat until you’re satisfied with the results. 6. Follow through. Along with these basic recipe writing skills, Newgent offers a few of her own well-earned insider recipe writing tips, including the following: • Fully write out the recipe before you test it, which can help improve the ease and accuracy of your final recipe. • Use a style guide for writing your recipes, which can provide some structure and consistency to your recipes. • Use your own testing sheet in the form of a chart, which can help you track the changes you make to your recipe. • Make notes and edits on your recipe development as you test it. • Don’t be afraid to tweak your recipe slightly while you’re in the process of testing it. • Think of your end consumer, not you, when you develop your final recipe. • Serve the food attractively, even if it’s just meant for the testing phase. 7. Watch for opportunities. Newgent encourages dietitians to stay open to media opportunities in recipe development, such as with blogs, food companies, and food media. Staying active and relevant on social media, showcasing your expertise, producing recipe videos, adding your own voice and style,

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U B . august 2018 www.todaysdietitian.com 13

SUPPLEMENTS the National Institutes of Health. However, studies testing the efficacy of ginkgo extract haven’t produced consistent evidence of any benefit for any medical condition.1

Efficacy

GINKGO BILOBA EXTRACT By Jessica Levings, MS, RD

Is it effective for improving memory and cognitive function? Long used in the United States as a popular dietary supplement marketed for improving memory and cognitive function, Ginkgo biloba extract is derived from the leaves of the Ginkgo biloba tree; common names include ginkgo, Ginkgo biloba, fossil tree, maidenhair tree, Japanese silver apricot, baiguo, and yinhsing.1 In the United States, ginkgo extract is sold as an oral over-the-counter herbal supplement in forms such as capsules, tablets, teas, and liquid extracts. While there’s currently no recommended dose of supplemental Ginkgo biloba, experts suggest starting at 120 mg daily and increasing gradually to the desired intake level. Total daily doses in clinical trials and prescriptions from health care providers range from 120 to 240 mg for treatment of Alzheimer’s disease and vascular dementia, 240 mg for healthy adults aiming to improve memory function, and between 120 and 600 mg for those aiming for improved cognitive function.2 As with many drugs and supplements, a small percentage of individuals has reported minor side effects when taking ginkgo extract including nervousness, headache, and stomachache. In the United States, the National Toxicology Program (NTP) regulates ginkgo, but current federal law doesn’t require dietary supplements to undergo the same premarket testing for safety or efficacy as pharmaceutical drugs. Ginkgo extract is marketed for improving myriad conditions such as memory and brain function due to its ability to improve circulation and blood flow to the brain, according to

14 today’s dietitian august 2018

According to the NTP, studies haven’t consistently found that ginkgo extract improves brain function; more research is needed. In the largest clinical trial of Ginkgo biloba extract to date, the Ginkgo Evaluation of Memory study, researchers assessed data on 3,069 people aged 75 and older with normal cognition or mild cognitive impairment. One-half of the participants took 120 mg of ginkgo extract twice daily for nearly six years, and the other half didn’t. The results showed that 240 mg of ginkgo extract over six years wasn’t effective in reducing the incidence of dementia or lessening cognitive decline in either people with normal cognition or those with mild cognitive impairment.3 However, a 52-week trial administering 120 mg of ginkgo extract daily to patients with mild to severe dementia or Alzheimer’s disease found that it was effective in stabilizing and in many cases improving cognitive performance and social functioning.4 Furthermore, a 24-week trial administering 240 mg of ginkgo extract or placebo daily to patients with presenile and senile Alzheimer’s- and stroke-related dementia also was found to improve memory.5 A review of 30 clinical trials examining the effect of Ginkgo biloba on people with acquired cognitive impairment including dementia found benefits associated with Ginkgo extract at a dose greater than 200 mg/day (but not for a lower dose) after 24 weeks and found benefits to cognition after taking the ginkgo supplement at any dose at 12 weeks but not at 24 weeks.6 However, the study authors noted that publication bias couldn’t be determined and that many of the trials were small and used unsatisfactory methods. Due to this, study authors concluded, “The evidence that Ginkgo has predictable and clinically significant benefit for people with dementia or cognitive impairment is inconsistent and unconvincing.” Findings also are mixed for adults with normal cognitive functioning. A study of 188 adults aged 45–56 with normal cognitive function randomized to receive 240 mg of ginkgo extract once daily or placebo for six weeks found those receiving the ginkgo supplement had improved memory recall but not recognition. While this one study might suggest the potential for short-term benefits of ginkgo supplementation in middle-aged adults with normal cognitive function, earlier studies in healthy individuals didn’t demonstrate a significant benefit to memory.7

Safety While it appears from human studies that moderate doses of ginkgo extract are safe, the NTP studied the effects of an oral ginkgo extract in rats and mice at a dose several

hundred times more per kg of body weight than what’s taken by humans. It found an increase in liver cancer in male and female mice and an increase in cancer of the thyroid gland in male and female rats and male mice over a two-year period. The NTP deemed more information is needed to determine any potential risks to humans, including identifying components in the extract accounting for the cancer incidence and collecting additional information on human intake of ginkgo extract.8

What’s Really in the Supplements? According to ConsumerLab.com, ginkgo supplements can be expensive to manufacture because it takes about 50 lbs of dried ginkgo leaves to make 1 lb of ginkgo extract. The result is a high rate of adulteration via spiking ginkgo supplements with compounds from other plants to make lower-quality extracts appear higher quality to consumers. Ginkgo extract contains two types of phytochemicals—flavanol glycosides and terpene lactones—contributing to antioxidant and blood vessel dilation benefits, respectively. According to ConsumerLab.com, one way manufacturers adulterate ginkgo is by purposefully using (or unknowingly purchasing raw materials with) more flavanol glycosides and little actual ginkgo.2 To test what’s really in ginkgo supplements, in 2018 ConsumerLab.com performed quality tests on 13 popular brands of Ginkgo biloba supplements sold in the United States.2 Seven supplements contained the labeled amount of real ginkgo extract, and one product contained only 3% of the labeled amount of ginkgo extract. The tests also identified significant differences in cost of the supplement, ranging from nine cents to over $2 for an equivalent amount of ginkgo extract. Among the supplements tested, the following were “approved” by ConsumerLab.com for their quality and label accuracy, and for containing the same quantity of pure ginkgo extract as the labeled dose: • GNC Herbal Plus Ginkgo Biloba 120 mg; • Life Extension Ginkgo Biloba; • Nature Made Ginkgo Biloba; • Nature’s Way Ginkgold; • Nutrilite Memory Builder; • Pure Encapsulations Memory Pro; and • The Vitamin Shoppe Ginkgo Biloba Extract.

Four products weren’t approved, including BulkSupplements.com Ginkgo Biloba (for containing less than 3% of its labeled amount of ginkgo), Doctor’s Best Extra Strength Ginkgo, ProCaps Laboratories Andrew Lessman Ginkgo Biloba 120, and Source Naturals Ginkgo-24 (for adulteration with an unknown botanical ingredient). Two products were labeled “uncertain” for potentially being adulterated: Metagenics GinkgoRose and NOW Double Strength Ginkgo Biloba 120 mg. Based on these findings, ConsumerLab.com identified a Ginkgo biloba supplement “Top Pick” for consumers: Life Extension Ginkgo Biloba. According to ConsumerLab.com,

this supplement contains the dose most commonly used in clinical trials (120 mg) while also containing the correct concentrations of flavanol glycosides and terpene lactones with no sign of adulteration. The cost also was less than the other supplements at just nine cents per capsule.2

Recommendations for Clients Ginkgo has been shown to interact with other drugs including blood-thinning drugs such as warfarin and aspirin as well as reduce the efficacy of antiseizure medication and responses to blood sugar-lowering medications in people with diabetes. Ginkgo extract also can lead to potentially serious complications for people who have had or are at risk of having a stroke and may interfere with fertilization and conception.2 Anyone considering taking a ginkgo supplement should consult his or her health care provider before beginning, and RDs should remind patients not to take supplements in place of, or in combination with, prescription medication without first notifying their health care provider. According to ConsumerLab.com, most research studies have used a standardized ginkgo extract containing 24% flavonol glycosides and 6% terpene lactones, so consumers should look for this on supplement labels that have been tested by independent third parties.2 Clients should be encouraged to compare label information for different brands of supplements using the Dietary Supplement Label Database to search for specific ingredients in a product, a particular supplement manufacturer, label text, and health-related claims. RDs should remind patients and clients that “natural” and “safe” aren’t synonymous, and, in the case of supplements, the terms “standardized,” “verified,” or “certified” on the bottle don’t guarantee product quality or consistency. As it’s difficult to determine the quality of a dietary supplement based on its label, there are a few independent organizations offering seals of approval indicating that the product has passed certain quality tests for factors such as potency and contamination. Importantly, any seal of approval doesn’t mean the product is safe or effective, only that it was properly manufactured and contains the ingredients listed on the label without harmful levels of contaminants. Consumers can look for the ConsumerLab.com Approved Quality Product Seal,9 NSF certification seal,10 or US Pharmacopeial Convention supplement seal.11 — Jessica Levings, MS, RD, realtor, is a freelance writer and food industry consultant. She blogs at Home in on Health to provide consumers with accurate, science-based nutrition information and resources. You can read more of her articles at BalancedPantry.com and follow her on Twitter and Facebook @BalancedPantry.

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

august 2018 www.todaysdietitian.com 15

the Shaping

Gut Microbiota Do genes or the environment matter more in influencing one’s internal ecosystem? By Carrie Dennett, MPH, RDN, CD

he human gut microbiota—which includes about 10 times more cells than are in the entire human body— is an important factor in human health, playing critical roles in metabolism, immunity, development, and even human behavior.1 One reason is that the gut microbiome, the collective DNA of our gut microbes, is in effect our second genome, significantly expanding our physiological potential.2 The composition of the gut microbiota—which includes thousands of species of bacteria, viruses, fungi, and protozoa—varies from person to person and shifts to some degree over time. Diversity and abundance of various species in gut microbial communities can vary widely across populations, with dramatic contrasts observed in people living on different continents.3 Many differences appear to be driven by varying diets, lifestyles, and other environmental exposure, but genetic ancestry also may shape the microbiota.

In theory, the human genome could evolve to promote a microbiome that contributes to host health—it would certainly be in its best interest.2,4 The original hypothesis was that our genes drive our microbiota, in part because the microbiota exhibits some stability over time,4-6 but newer research suggests that diet and environment may play the larger roles in shaping our gut microbiome across the lifespan. So which is ultimately more important, nature or nurture?

The Heritability Question One open question is how much of our gut microbiota is “heritable.” Heritability is the proportion of variance in phenotype—a set of observable traits—explained by host genetics rather than environmental factors. For example, height is highly heritable, so variation in height across a population has a strong genetic basis.2-7 Researchers have identified several bacterial taxa (classifications based on genus, family, class, order, phylum, etc) that appear heritable, as well as some associations of varying strengths between single nucleotide polymorphisms (SNPs)—the most common type of genetic variation—in the human host and individual bacterial taxa. The lingering question was what proportion of our microbiota these heritable taxa make up. As recently as a decade ago, the heritability of a phenotype was assessed by studying families and making assumptions about the genetic similarities. In the wake of the mapping of the human genome, researchers can now measure heritability with genomewide association studies (GWAS), but they’re finding there’s a “heritability gap.” In other words, the genetic variants identified through GWAS don’t completely explain the heritability of complex traits.7 And the gut microbiota is certainly complex. Recent GWAS suggest that environmental factors explain 10% to 20% of microbiome variance, with genetics explaining 10%.8 It’s unclear what factors explain the microbiome variance that can’t be accounted for by genes or environment.7,8 Family members tend to have more similar microbiotas than unrelated individuals. When family members share a household, these similarities are often attributed to shared environmental influences, such as dietary preference.9,10 However, related individuals also share DNA. Genetics aside, we acquire microbes via two types of transmission. Vertical transmission, when microbes pass directly from parents to offspring, tends to happen early in life, and these primary colonizers easily establish themselves. Our microbiota is largely shaped during infancy, starting with birth, and it may be that the microbial species that establish themselves during this pivotal time are the ones that persist.2,11 Horizontal transmission, the spread of microbes via environmental exposure and social interaction, including cohabitation, happens later in life. These microbes have a harder time integrating themselves permanently into the already-stable gut microbial community.12

From Genome to Microbiome A number of twin studies have looked at whether monozygotic (identical) twins have microbiotas that are more similar than those of dizygotic (fraternal) twins. Identical twins share 100% of their DNA, and fraternal twins share 50%, on average, yet they share the same mother and environment.2 Early twin studies did find that identical twin pairs had more similar microbiomes than fraternal twins, strongly suggesting a genetic component, but these studies had some major limitations, including very small population sizes—20 to 30 twin pairs—and less-advanced techniques than are currently available.2 Later studies, from six to 10 years ago, had small sample sizes but better techniques. They also found a genetic effect on the overall gut microbiome, albeit not enough to reach statistical significance, seeing few differences between identical and fraternal twins.2,13 Then, a 2014 twin study looked at samples from 416 twin pairs from the UK Twin Registry, focusing on dominant bacterial families.14 It confirmed previous studies, finding that identical twin microbiomes were more similar overall than those of fraternal twins, but with the increased sample size the difference reached statistical significance and allowed for heritability for many specific taxa to be calculated.2 The same authors followed up with a 2016 study of 1,126 twin pairs.5 This was shaken up a bit when a study published in March in Nature found that host genetics have only a minor role in determining the makeup of our gut microbiota.13 The study looked at more than 1,000 healthy Israeli individuals from several distinct ancestral origins—primarily Ashkenazi but also including North African, Middle Eastern, Shephardi, and Yemenite—but with similar lifestyles. Blood samples provided information on genotypes and phenotypes, while stool samples provided information on the metagenome—the collective genome of microbes from an environmental sample, in this case the stool.13 The researchers found no significant associations between the gut microbiota and genetic ancestry or SNPs. What they did find was significant microbial similarity among genetically unrelated individuals who share a household. As for relatives who have never shared a household? No significant similarities. Whether individuals in the study were genetically related or not, it was past or present household sharing that partly determined composition of the gut microbiota.13 The authors also reanalyzed the most recent UK Twins data, finding that the percentage of the microbiome that’s heritable is between 1.9% and 8.1%, significantly lower than other estimates.8,13 “Previous research has shown that some gut bacterial species are heritable,” says Omer Weissbrod, PhD, one of the Nature study’s lead authors and a postdoctoral fellow at Harvard University. “However, our analysis showed that such species form a small minority of the overall microbiome composition. We believe that research like ours will shift the focus back to the role of diet/lifestyle.” He says the most important take-home message is that we can potentially reshape our gut microbiome by changing our august 2018 www.todaysdietitian.com 17

lifestyle and dietary habits. “In other words, our gut microbiome is not necessarily tied to our biological parents,” he says. “Another important conclusion is that we can likely carry out microbiome transplant (a very effective treatment for C difficile infections) without worrying about genetic compatibility between a donor and a host.” A recent study of 127 participants from the Hutterite community found a genetic effect on specific bacterial taxa, but the environmental influence was much larger. The Hutterites are a religious group that has reduced genetic diversity because they’re descended from a small number of colonizing ancestors. They also live on communal farms and prepare and eat meals together, limiting the dietary and environmental differences that could mask genetic effects on the microbiota.15

Likely Gene-Microbe Pairings No matter what total number, it appears that heritability is lower in the microbiome than in other traits—such as height— and may not be distributed equally among taxa. Specifically, more heritability has been found among bacteria in the phylum Firmicutes than among Bacteroidetes.16 The UK twin study found the highest heritability within the Christensenellaceae family, which has greater abundance in lean twins and is associated with low serum triglyceride levels. It co-occurs with other heritable taxa, including the dominant methane-producing species, Methanobrevibacter smithii, also associated with leanness.2,14 The second most heritable taxon identified was the genus Turicibacter, an active member of the small intestinal microbiome. It appears to be a pathobiont,5 an organism that can activate the immune system and amplify any imbalances in the microbota (dysbiosis), promoting inflammation.7,17 There’s a particularly strong link between the LCT gene and Bifidobacterium. The LCT gene codes for the enzyme lactase, which humans need to metabolize the disaccharide lactose in dairy foods. Genetic variants of LCT are directly related to an individual’s “lactase persistence”—the ability to digest lactose after weaning and into adulthood. However, members of the genus Bifidobacterium also can metabolize lactose, and it’s the preferred food for some strains.18 The abundance of bifidobacteria appears to be dependent on the interaction between genotype and intake of dairy products, which serves as evidence of interaction between diet and host genetics in regulating the composition of the microbiome19: • Lactase persisters digest the lactose directly, so they have

few bifidobacteria; there’s no leftover lactose to feed them. • Nonpersisters who still consume dairy products have more

bifidobacteria because they have an ample food source. • Individuals who don’t consume dairy have low bifidobacteria

levels regardless of whether they still produce lactase.2,5 Explanations of how the genome might shape the microbiome are scarce. The most commonly proposed mechanisms are genetically driven biochemical and physical factors such as levels of immunoglobulin A antibodies, gut pH, metabolism,

18 today’s dietitian august 2018

concentrations of metabolites, and gut motility, all of which could affect the gut microbiota.7,12,20 For example, hormones in the brain influence bacteria in the gut,15 and some SNPs associated with Crohn’s disease—including variants of the NOD2 gene—have been shown to affect both the immune system response and the gut microbiota.8,20 Simply being a carrier of the NOD2 variation is associated with higher abundance of Enterobacteriaceae, a bacterial family that includes a number of pathogens including E coli, Klebsiella, and Shigella.8

Environmental Exposures Should researchers be focusing less on matching diet to genotype and more on matching diet—and other environmental interventions—to microbial-driven phenotype? Weissbrod says yes, for two reasons. “First, we showed that our microbiome can reflect many clinically relevant phenotypes, like waist-hip ratio or fasting glucose, much better than our own genotypes. Second, the microbiome can reflect lifestylerelated factors like fitness, whereas our genome is determined from birth.” The following are some of the most notable environmental factors affecting the gut microbiota.

Vaginal vs C-section Delivery When comparing vaginally delivered infants and infants delivered via C-section, the gut microbiota of C-section infants had significantly less resemblance to their mothers’ gut microbiotas, with a 41% match to species found in the mother’s stool, compared with a 72% match for vaginally born infants. This difference starts to diminish between 4 and 12 months of age,1 although the initial microbiota will influence the microbiota composition later in life.21

Dietary Influence Changes in diet can affect both the composition and function of the gut microbiota community.22 The microbiota of the breast-fed infant is rich in species found in the breast milk, including Bifidobacterium. The infant’s gut microbiota starts to mature into a more complex, adultlike composition once breast-feeding is stopped.1,11 Breast milk is high in microbiota-accessible carbohydrates (MACs)—complex polysaccharides that are resistant to our digestive enzymes but are digestible by enzymes produced by gut microbes—and a postweaning diet that supports a healthy, diverse, gut microbial population will also be high in MACs while being low in saturated fat, which pathobionts thrive on.17,23,24 That said, a one-size-fits-all approach to dietary interventions for the microbiota is unlikely to be beneficial, says Genelle Healey, PhD, who researches the gut microbiota at the University of British Columbia. “Presently, it is very difficult to predict how a dietary intervention may affect an individual’s gut microbiota and subsequent health, as it appears there is profound interindividual variability in dietary responsiveness,” she says, adding that baseline gut microbiota and habitual dietary intake may influence how both microbiota and host respond to dietary changes.25

Antibiotics Antibiotic use in children, especially in early childhood, has become more widespread in the United States. It’s estimated that children in the United States receive an average of three courses of antibiotic treatment before 2 years of age, roughly twice the amount prescribed to children in northern European countries.21 The effect on the gut microbiota depends on the antibiotic class, dose, and length of exposure, as well as the mode of action and the target bacteria.21 A very small 2015 study of three dichorionic triplet sets— one pair of monozygotic twins plus a fraternal sibling—found that host genetics appeared to play a role in the composition of an individual’s gut microbiome at 1 month of age, unless antibiotics were administered, as was the case with two of the triplet sets. By 12 months of age, environmental factors had a larger role in gut microbiome composition for all three sets of infants, and the early antibiotic exposure appeared to no longer have a strong influence.26

Social Contact A study of 48 wild baboons from two different social groups in Kenya found that an individual’s social group and social network predicted the species found in its gut microbiota, even when other factors—such as diet, kinship, and shared environments—were taken into account.27

Interaction With the Environment The hygiene hypothesis—that proper hygiene and cleanliness were associated with a lower risk of immune-mediated conditions and protection from infection—was recently reframed as “the old friends hypothesis,” which emphasizes the benefit of exposure to nonpathogenic microorganisms in order to help develop the microbiome while still practicing basic hygiene. This may reduce the risk of immune-mediated diseases, such as asthma and allergies, while preventing spread of pathogens and the rise of antimicrobial resistance.28 In their book, The Good Gut: Taking Control of Your Weight, Your Mood, and Your Long-Term Health, Stanford researchers Justin and Erica Sonnenburg, PhDs, recommend being vigilant about

handwashing during flu season, but not as much the rest of the year. Other tips? Get your hands dirty in an herbicide- and pesticide-free garden—and get (or at least pet) a dog.24 Pets collect beneficial microbes from outside, increasing our exposure.24,29

Research Challenges One reason that studying the impact of host genes on the gut microbiome is complicated is that the microbiome is strongly influenced by diet, environment, medications, and overall health status, which could mask any effects of the host’s genetics.6,8,20 Discovering clinically relevant associations may be possible only in study populations with specific diseases, such as inflammatory bowel disease or rheumatoid arthritis, which have complex genetic features and are associated with a disrupted gut microbiota.6 That said, association isn’t causation, and the microbiota’s natural fluctuations due to diet and environment mean one individual’s microbiota could look very different depending on when you look at it.30 “There is still a lot of research to be done to understand exactly how and why our lifestyle and diet affects our microbiome, and how our microbiome affects our health,” Weissbrod says. “We are actively working on trying to figure this out.” Healey says these will be key factors in harnessing the gut microbiota as a target for personalized medicine and personalized nutrition, which has great potential in clinical practice. “Additional research that focuses on the factors involved in interindividual variability in gut microbiota and host response is needed before this can become a reality.” In the future, she says, algorithms that can predict successful dietary interventions— which currently are being developed—may better help dietitians provide personalized advice that ultimately improves health.31-33 — 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.

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august 2018 www.todaysdietitian.com 19

Benefits Gardens and farms on campus boost student health and strengthen academic programs.

College

Farms

Gardens By Christen Cupples Cooper, EdD, RDN, and Michael H. Finewood, PhD

s reported in The New York Times in 1910, New York City Mayor William Jay Gaynor visited a school garden in DeWitt Park, located in midtown Manhattan. School children served the mayor a meal entirely composed of produce grown in the garden. Francis Parsons, director of the New York City Parks Department Children’s School Farm Bureau, went on to open 80 school gardens and train city teachers as gardeners. Parsons reported years later that the garden had made such an impact that several students and their families had moved to the countryside to farm.1 While one may assume that interest in school gardens arose from the relatively recent increased concern for environmental sustainability, the practice began more than 150 years ago and the idea is even older. According to a comprehensive article on the history of school gardens by Kate Gardener Burt, PhD, RDN, published in the Journal of Hunger & Environmental Nutrition in June 2016, 17th-century philosophers such as John Amos Comenius and JeanJacques Rousseau asserted that students could learn important lessons about nature through gardening. Progressive education pioneer Friedrich Froebel coined the term “kindergarten,” which translates from German as “children’s garden.” School farming was considered so integral to the educational experience in Europe that in the 1870s Austria, Germany, Sweden, Belgium, France, Russia, and England mandated that every school build a garden.1 Around the same time, John Dewey and Maria Montessori were emphasizing the importance of classroom and practical (hands-on) education, highlighting the value of gardening for stimulating curiosity and enthusiasm, social skills development, problem solving, and critical thinking, as well as a sense of social responsibility.1

During the US depression of 1893, many farmers moved to large cities in search of employment. The Association for Improving the Conditions of the Poor in New York City organized a committee to promote agriculture and believed that teaching agriculture in rural schools would help to rekindle interest and careers in agriculture. The Boys and Girls Agricultural Experiment Club, which eventually became the 4-H Club, was formed based on the rationale that if children and their parents learn about growing food first hand, they will gain important skills to improve their communities.1 By the turn of the century, school gardening was recognized as “valuable for learning geometry (patterns), reading (about caring for plants), and arithmetic (calculating expenses and production value), among other subjects,” Burt wrote. She also explains that some scholars believe gardens were a nod to Jeffersonian ideals, “connecting urban youth to their rural, agricultural ancestors and helping immigrant children to assimilate.” Gardening embodied a departure from discipline and obedience and promoted individualism, interaction, self-expression, and interpersonal skills such as cooperation. By World War I, school gardens became more directly used for food production. The US School Garden Army, a “club” comprised of students and formed within the Federal Bureau of Education, promoted “Victory Gardens” to enhance patriotism and support for the war. President Woodrow Wilson allocated tens of thousands of dollars for school gardens. The motto for these efforts was: “A garden for every child. Every child in a garden.”1 Enthusiasm for school gardens began to wane after World War II, when McCarthyism cast a pall on Progressive education. However, since 1964, school gardening has experienced a slow but steady reemergence.1

College Farms Today

Established Campus Farms

With an emphasis on health, whole foods, local and sustainable agriculture, and hands-on learning, there has been renewed enthusiasm for and investment in gardens and farms.2 The American Community Gardening Association defines a community garden as any piece of land gardened by a group of people in an urban, suburban, or rural setting.2 Land grant universities, such as Cornell University in Ithaca, New York, and other schools have long offered agricultural studies and used college farms to help students learn the trades of farming, conservation, animal science, and other subjects. In recent years, however, college farms have gained traction as learning, research, and recreational resources for students, faculty, and community members at colleges nationwide. The literature and RDs who work with college farms list the following as benefits2:

Interestingly, nutrition and dietetics professionals are relative newcomers to farm involvement at many institutions. Growing expertise among dietitians at the nexus between nutrition science and sustainable agriculture is paving the way for the profession to become a leader and pioneer in these areas. College campus gardens come in many different shapes and sizes, from small greenhouse experiments to multiple acres of cultivated land. Many farms start small and grow with participation, time, and resources. Colleges don’t have to go it alone in developing their own farms. Many operate their farms in partnership with community-based organizations or private organizations. Many also use the help of volunteers and community groups. There are several larger-scale campus farms in the United States that can serve as models for schools that hope to start, grow, or expand their farms. Dietetics faculty and students can learn from these facilities, broaden their programs, and provide hands-on experiences for students.

• improved community nutrition knowledge and consumption

of healthful foods; • a natural form of moderate physical activity; • creation of green spaces conducive to healthful, sustain-

University of Maryland

able lifestyles; • improved mental health for participants; • hands-on experience with growing food; • higher academic achievement; • lower student attrition rates; • a local source of food for dining halls; and • opportunities to connect with the surrounding community.

Phyllis Fatzinger McShane, MS, RDN, LD, director of the dietetic internship program at the University of Maryland (UMD), College Park, speaks about the success of her campus’ farm and her campus dining services’ history of dedication to sustainability. She has worked to integrate the nutrition students’ learning into the farm operations. The UMD dietetic internship program is located within the College of Agriculture and Natural Resources, with the farm being a joint project between UMD dining services and the college. UMD dietetic interns spend a two-week rotation in campus dining, focusing on sustainability. They’re responsible for organizing a farm festival and a term food day for the campus.

Penn State University Carissa Heine, a 2018 honors graduate from Penn State University in State College, Pennsylvania, with a BS in nutritional science and dietetics, was a student farm pioneer on her campus. As a freshman, she joined the Student Farm Initiative with a few graduate students and a newly hired farm design coordinator. To get the ball rolling on creating a student farm, Heine started an undergraduate farm club in her sophomore year. Heine and her recruits worked hard and grew the club, with members cultivating hydroponic lettuce and herbs for the dining halls; holding numerous sustainability, agriculture, and food systems events each year; and advocating for the future of the farm. Today, the Penn State student farm is a one-acre diversified vegetable farm that uses organic practices. Before she graduated, Heine spent her time “prepping the farm, reforming the beds, starting seeds, transplanting and direct seeding, managing pests, and harvesting and storing the produce.” She also worked with a community-supported agriculture program. The farm is currently securing a nine-acre site for expansion.

Cornell University Cornell University’s Agricultural Experiment Station is a large-scale operation with a long list of learning and research projects. Cornell’s 11 campus area farms manage 325 acres of land in and around the university campus. The farms are home to numerous research projects such as the breeding of popular food crops including corn, small grains, potatoes, and pumpkins. A new project focuses on finding different grasses suitable for biofuels. The farm’s “cucurbit” breeding project, which is done in partnership with the Northern Organic Vegetable Improvement Collaborative, produces cucumber, melon, squash, and pepper varieties that demonstrate superior performance in organic growing systems. Other experiments focus on developing new potato varieties adapted to northeastern US weather and ideal for various food products and on breeding fresh market varieties of tomatoes and onions that are disease and pest resistant.

Medical University of South Carolina The Medical University of South Carolina (MUSC) is home to an impressive farm that was born from a desire to create spaces that provide healthful food and educational opportunities in a state with high obesity rates, as well as to help ameliorate health care workers’ disproportionately unhealthful lifestyles. The farm began as one-half acre that had served as a parking lot that had been slated as green space. The project architect proposed building a garden, which would reflect the university’s commitment to health and wellness.2 The growth process was collaborative from the beginning. A consulting firm brought together an advisory board composed of a landscape designer and several other stakeholders, including students, faculty, volunteers, and others in the community. This group developed a mission, vision, and plans for sustainability. Next, a core team was defined and the project was housed in the Office of Health Promotion, also home to the university’s employee wellness program. A leadership team composed of representatives from grounds, nutrition services, sustainability, and marketing crafted a plan for making the farm a living classroom that was open to everyone and highlighted the connection between nutritious food and good health.2 Today, MUSC chefs and RDs host guest lectures and cooking demonstrations with tastings and recipes. The farm also offers “work and learn” sessions in which participants can work on the farm and hear speakers on urban agriculture, land stewardship, planting, and harvesting. Patients from the MUSC Weight Management Center, the MUSC Bariatric Surgery Support Group, children and parents from the Pediatric Endocrinology Support Group, VA Hospital patients, participants in Student Mentors for Minorities in Medicine, and those in the STAR Adolescent Day Treatment Program are among the groups that use the farm for various purposes.2

The farm also takes its show on the road, participating in local health fairs, farmers’ market events, Earth Day celebrations, and more. The farm recently partnered with a Class A baseball affiliate, the Charleston RiverDogs, whose home games now feature information on living a healthful lifestyle, complete with healthful concessions such as tacos made from vegetables grown on the farm. The farm also partners with the MUSC Wellness Center and Lighten Up Charleston, organizations devoted to promoting better health. However, the lion’s share of the harvested food is used for teaching children, patients, students, staff, and the greater community about whole foods. Anyone who works on the farm can take produce home, as food is culled and divided at the end of each harvesting day. The farm also donates produce to local charities and partners with the Charleston Area Children’s Garden Project, contributing produce to its school-based farmers’ markets in lowincome elementary schools.2 MUSC reports that more than 1,700 individuals have participated in over 200 educational sessions at its farm. There are also 300 Friends of the Farm, a group of trained volunteers. The farm is strictly organic. Plants and seeds are selected for the region’s climate. In its first growing season, the farm cultivated foods from bachelor’s buttons (an edible flower) to dill to microgreens.2

Starting Small Kathleen Carozza, MA, RDN, FAND, director of the dietetic internship program at the College of Saint Elizabeth in Morristown, New Jersey, works with a community-based organization, Grow It Green Morristown, to farm in a greenhouse owned by the college. Carozza says that the hope is to expand this partnership. The college’s dietetic interns will begin working with the farming efforts in summer 2019 as part of a new concentration in Community Health and Nutrition. Not far away, Lauren Dinour, DrPH, RD, an assistant professor of nutrition and food studies at Montclair State University in Montclair, New Jersey, says that her campus recently started a community garden where individuals and groups have signed up to care for raised beds. The produce will be donated to the campus food pantry and other pantries in the community. Judith Rodriguez, PhD, RDN, LDN, FADA, a professor at the Brooks College of Health at the University of North Florida in Jacksonville, Florida, reports that her nutrition students do service work in her university’s garden, which provides some food for dining services and some for faculty research and student use in foods classes. Her university will be adding a food systems minor this fall, and dietetics students will be working on projects with the garden director. California Polytechnic State University at San Luis Obispo has a larger farm, which Arlene Grant-Holcomb, EdD, RD, director of the didactic program in dietetics, uses for valuable student learning experiences. Her major involvement with august 2018 www.todaysdietitian.com 23

the campus farm is a springtime service learning activity in which students in quantity food production class plan, prepare, and serve lunch to about 1,500 admitted students and their parents. She says that the garden activities are a major attraction for prospective students: “Students love to share that not only were the strawberries grown on campus, but students made the fruit salad as part of a class.” She posted a YouTube video on this experience, which can be found at https://youtu.be/00FMl-gqJOU. Kristin Wiens, MSc, RDN, LDN, a clinical instructor at the University of Delaware in Newark, teaches a one-credit sustainability and food course that involves hands-on cooking, a tour of the campus farm, and the use of produce grown on the farm. She hopes to expand her program’s connections to the farm with the opening of a new demonstration kitchen in the fall. Clancy Cash Harrison, MS, RDN, FAND, of Misericordia University in Shavertown, Pennsylvania, is working with both Penn State and Marywood University (Scranton, Pennsylvania) dietetics students to run FARMU, the campus farm. She plans to use the produce for nutrition outreach programs, including those for low-income children in her county.

systems and expand the use of its campus farm. Faculty discuss the value of crossing traditional academic boundaries to provide students with deeper learning experiences. The Inter-institutional Network for Food, Agriculture and Sustainability (INFAS) is a national network of university and college educators whose members are researchers and activists from 25 institutions across 20 states. The organization promotes collaboration for analysis, synthesis, and problem-solving among those who wish to increase food system resilience, illuminate trends, and promote common stewardship of biodiversity and ecosystem services, while reducing inequity and vulnerability in the US food system. Resources are available for those wishing to develop campus farms. INFAS recommends that garden starters also use resources provided by the Sustainable Agriculture Education Association, the USDA National Agriculture Library, and the Association for the Study of Food and Society. Heine explained the value of a campus farm experience: “We all eat food, and as dietitians we study the biochemistry of how food interacts with our bodies. I think that in order to fully understand the body and health, knowing food is important. Experiencing agriculture helps us get to know our food differently and appreciate it more. Knowing more about the entire food system also helps us understand our clients, their food choices, and the factors that influence their choices so we can serve them better.” She continues: “Farming opened up a whole new side of food for me that helped me develop my own definition of good food. I have always loved eating food, but farming made me work and sweat and bleed for that food.” — Christen Cupples Cooper, EdD, RDN, is founding director and an assistant professor of nutrition and dietetics at Pace University in Pleasantville, New York.

Future of College Farms The use of gardening and farming in education has a long and rich history. Many nutrition and dietetics programs are joining forces interprofessionally with agriculture, environmental studies, agricultural science, and other professions to promote sustainability and wider knowledge about our food system and the importance of healthful food choices. At Pace University in Pleasantville, New York, collaborations are underway between its nutrition and dietetics and environmental studies faculty to research food

24 today’s dietitian august 2018

— Michael H. Finewood, PhD, is an assistant professor for environmental studies and science at Pace University in Pleasantville, New York.

References 1. Burt KG. A complete history of the social, health and political context of the school gardening movement in the United States: 1840–2014. J Hunger Environ Nutr. 2016;11(3):297-316. 2. Johnson SL. Cultivating integration: urban farming on a medical university campus. Plan Higher Educ. 2013;41(3):11-17.

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Turn Diet Advice Into Meals & Menu Planning 5 Real-Life Case Studies BY MINDY HERMANN, MBA, RDN

lients often present with complex diagnoses that require multiple short-term and long-term dietary changes. These diagnoses may include type 2 diabetes, CVD, lactose intolerance, celiac disease, nonceliac gluten sensitivity, inflammatory bowel disease, and other gastrointestinal (GI) discomfort caused by FODMAPs (fermentable oligo, di-, monosaccharides, and polyols). While an appointment with a clinical or consultant dietitian can yield diet and nutrition advice, clients may require additional assistance with food shopping to translate their diet prescriptions into meals and menu planning. “Things that make sense in the comfort of a private office can suddenly become unclear when a shopper is in the supermarket,” says Allison Stowell, MS, RD, CDN, a dietitian at Hannaford Supermarkets in Pawling, New York. This article discusses five real-life cases, each presented hypothetically to a supermarket dietitian, who offers guidance to the client as if he or she were a shopper seeking the assistance of a supermarket dietitian in store.

CASE 1 Nancy, a 15-year-old ninth-grade student with celiac disease and lactose intolerance, received nutrition counseling from Angela Lemond, RDN, CSP, LD, of Lemond Nutrition in Plano, Texas.

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“Nancy had been following a gluten-free, lactose-free diet and came to me with complaints of gas, bloating, and diarrhea, along with vomiting almost daily,” Lemond recalls. “When I first saw her, she weighed 163 lbs, having recently lost 15 lbs because of her symptoms. “Nancy’s mother, who shops and cooks for the family, described Nancy as a very picky eater who does not like most fruits or vegetables. Her typical daily diet included gluten-free toast, a turkey sandwich and chips for lunch, a clementine or apple, and grilled chicken or beef tacos for dinner. “I placed Nancy on a strict low-FODMAP diet for one week, followed by instructions for adding high-FODMAP foods back into her diet. I also provided written FODMAP materials, suggestions for low-FODMAP and shopping apps, and general IBS diet information. “I would like a supermarket RD to reinforce information on FODMAPs in foods and help Nancy’s mom plan for food reintroduction.” Stowell at Hannaford Supermarkets offers the following guidance to Nancy and her mother. “My goals would be to ensure that Nancy’s mom doesn’t feel overwhelmed, understands the information from Angela, and finds foods that fit Nancy’s diet. First steps are to review Angela’s materials, do a 24-hour recall and food preferences outline,

identify low-FODMAP foods, and create a ‘working’ shopping list of low-FODMAP items that are nutritionally balanced and suitable for the family’s regular ‘meal rotation.’ “While the produce department and center aisles are important, every section of the market has foods that can or shouldn’t be consumed on a low-FODMAP diet. As we visit each aisle, we will add to the shopping list of low-FODMAP foods Nancy likes to eat and tolerates. One of the best parts of shopping with a retail dietitian is that Nancy and her mom can try foods before buying them. For her mom, understanding the label and ingredient list is critical. A probiotic, along with fermented foods, may help restore Nancy’s gut bacteria. “I would advise Nancy’s mom to come back during our store’s weekly nutrition demonstrations to follow up, take another tour, and get additional meal planning ideas as Nancy’s diet is liberalized. Periodic follow-up as Nancy progresses through different diet goals will address her changing needs and any new goals or guidance that Angela offers.”

CASE 2 Peter, a 20-year-old male collegiate football player, was recently diagnosed with Crohn’s disease and was following a high-protein diet. Leslie J. Bonci, MPH, RD, CSSD, LDN, owner of Active Eating

Advice, a nutrition consulting company in Pittsburgh, provided Peter with nutrition counseling. “Peter was referred to me to help manage his symptoms of diarrhea and bloating,” Bonci says. “He has a long history of GI distress, diarrhea, pain, bloating, and some nausea. Before his Crohn’s diagnosis, Peter consumed lots of fried foods, dairy products, carbonated beverages, and sugary snacks. His weight is down 20 lbs after recent flare ups, and he says he feels sapped of strength. “Peter lives in an apartment off campus and does not know how to cook. He eats meals at the training table during the season, tends to skip meals on weekends, does not have a lot of money to spend on food, and buys lower-cost items like fast food and chips. “I instructed him to follow a diet high in protein, low in sugar, lactose-free, low-fat, and low in fiber, with smaller, more frequent, nutrient-dense meals. Foods to restore weight and muscle mass include lower-cost protein foods; higher protein, dairy-free alternatives such as soy, pea, or peanut milk; lowlactose products; nuts, nut butters, and seeds; lower-cost, easily digested carbohydrates; and ingredients to increase calories in beverages. “I would like a supermarket RD to educate Peter on higherprotein, lower-cost choices within his allowed foods, and on the august 2018 www.todaysdietitian.com 27

use of texturized vegetable protein to add protein without the fat and at a low price point.” Matthew Whipple, RDN, LDN, a retail dietitian at ShopRite of Whitman Plaza in Philadelphia, would offer Peter the following guidance: “My goal would be to help Peter expand his diet safely with variety and optimal nutrition while keeping in mind cost and convenience. “A shopping list will help Peter stay organized and get the food he needs for the week. He can use free smartphone apps to keep a running list. The ShopRite app will allow him to access the weekly circular and digital coupons for saving time and money. ShopRite’s premium private-label Wholesome Pantry brand does not cost more and may even be cheaper than brand name items. “Peter should start in the produce section, where foods have the highest nutrient density, and shop for colorful, seasonal items to save money. Fruits and veggies that are suitable for slicing and bagging make great snacks. It’s important for Peter to try one new fruit or vegetable at a time to make sure he tolerates it. A 100% fruit juice can be a good low-fiber option for people with symptoms of Crohn’s disease. “Protein sources can include low-fat, lactose-free milk or unsweetened plant-based milks like soy, almond, or cashew. Greek yogurt is lower in lactose and higher in protein. Nut and seed butters are low-cost and work great on sandwiches and as a quick high-protein snack. Powdered peanut butter works well in smoothies. Textured vegetable protein and soy crumbles can be added to a pasta sauce for extra protein. Eggs are among the most affordable protein foods, and they are easy to cook. “In the grain section, pasta made with added veggies like spinach powder or tomato powder provides a wider array of nutrients. Peter can buy a bag or box of rice and make enough for the week. Bread wraps are a versatile option for breakfast, lunches, quesadillas, and roll-ups.”

CASE 3 Barbara, a single 26-year-old clerical receptionist, actress, and student, presented with bloating, constipation, and food sensitivities. She was previously diagnosed with small intestinal bacterial overgrowth (SIBO) and received nutrition counseling from Alicia Galvin, MEd, RD, LD, CLT, in Dallas. “When I first saw Barbara, she had a history of severe constipation and laxative use and had been diagnosed with irritable bowel syndrome and SIBO (by lactulose breath test). Barbara has been on and off antibiotics for SIBO and urinary tract infections. Colonoscopy, endoscopy, blood tests, food allergy testing, and GI tests all were normal. A recent HLA-DQ8 test for celiac disease was positive. “Barbara avoided gluten, dairy, eggs, onion and garlic, pork, caffeine, nightshades (tomatoes, potatoes, bell peppers), added sugars, plant-based proteins, bananas, peanuts, and legumes. Going gluten-free helped to mitigate her abdominal pain but not her bloating and gas. A different nutritionist placed Barbara on a low-FODMAP diet approximately six months before I saw her. “Barbara lives on her own and does her own grocery shopping and cooking. I reinforced the principles of a low-FODMAP diet,

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to be followed for another month, with additional elimination of nuts, seeds, grains, soy, eggs, and dried fruit. I instructed her to reintroduce one high-FODMAP food at dinner, add back nightshades, and have two daily servings of fresh fruit. “I would like the supermarket RD to help Barbara find minimally processed foods with simple ingredients that meet her current restrictions, including convenience-type items for her busy schedule.” Jennifer Blaser, RD, LD, a supermarket dietitian at Valley West Hy-Vee in West Des Moines, Iowa says, “We would start in HyVee’s FODMAP section and gluten-free food aisles with a quick review of what to look for on the label. From there we would go through the other areas of the store, with emphasis on foods that are quick and easy to prepare and fit into easy meal planning for Barbara’s lifestyle. The perimeter of the store—produce, meat, and seafood—offers minimally processed foods that should be a focus for shoppers following a low-FODMAP diet because they simplify the diet and label reading. The Hy-Vee HealthMarket department offers a wide variety of packaged items, including the FODMAPPED for You and FODY food lines. Both have items that can make life much easier, such as sauces, dry soup bases, and spices. On conventional items, the words “natural flavors” or “spices” should be avoided unless the item specifically states FODMAP friendly, as these can be sources of gluten, onion, and garlic. “Writing out meal options for the week, looking through store ads and coupons, and making a grocery list before getting to the store will help Barbara stay on budget, while still having a little extra money for some of the pricier FODMAP convenience items. The app FastFODMAP includes a search feature for FODMAP foods, knowledge games, and a diary of foods, activities, and moods. Hy-Vee Aisles Online, an online grocery ordering and delivery service accessible through the Hy-Vee website, simplifies shopping and saves time. Hy-Vee’s free store tours with a dietitian are very informal, can answer questions, and can help Barbara locate FODMAP-friendly items in the store. “A follow-up visit will help Barbara reintroduce foods back in to her diet as appropriate and broaden her food and meal options.”

CASE 4 Cassie, a 63-year-old life coach and dietitian with food intolerances, follows a lactose-free diet. She explains her dilemma to me, the author of this article. “I first developed extreme fatigue in early 2017 and suspected I had food allergies. I tried two different elimination diets following the suggestion of a naturopath, with no improvement. I then visited my physician, who diagnosed me with depression (‘like all women your age’) and prescribed an antidepressant. I disagreed with the diagnosis. “A colleague recommended LEAP (Lifestyle Eating and Performance) testing several years earlier, but I had resisted because of the cost. I changed my mind when I became frustrated with the lack of a diagnosis and underwent LEAP and saliva cortisol testing as recommended by my naturopath. I was diagnosed with adrenal fatigue stage 3, reactivity to caffeine, saccharine, cow’s milk, and vanilla, and moderate reactivity to certain fruits,

vegetables, plant and animal proteins, and food additives. I worked with a dietitian, who provided me with a five-phase, four-week food introduction plan. “Currently I eat eggs, meat, salads, vegetables, nuts, and dried fruit. I avoid certain fruits and vegetables and have dairy only sparingly. “I would like a supermarket RD to make sure I am choosing balanced, sensible foods.” Stephanie Chelton, RDN, retail clinical dietitian at Kroger/The Little Clinic in Farragut, Tennessee, says that “Because Cassie has a plan from another dietitian, a 30-minute personal shopping session will help her navigate the aisles efficiently and find products to support her goals. First stops will be the produce and meat and seafood departments. Kroger’s Easy for You Seafood service provides optional free seasonings and ready-to-cook packaging for fresh seafood. “Since Cassie mentioned concern about cost, bulk foods may be a cost-effective option for the grains and nuts and seeds on her plan. Some of the foods on her list can be found in multiple forms throughout the store. These products could help her think outside the box and keep her diet more varied while providing options to simplify meal preparation, for example, whole and preshredded zucchini in produce and zucchini spirals in the frozen section, and fresh, frozen, and freeze-dried mango. The frozen section provides convenient whole food items that can meet her diet needs and limit food waste. “A blank grocery list rather than a set list of foods will enable Cassie to take notes during her session. The Kroger app enables her to make a shopping list in advance, with the aisle numbers noted to make her trip to the grocery store quick and efficient. It can also help her identify sale items and find any available digital coupons for the foods on her list.”

CASE 5 Ronald, a 59-year-old house painter with type 2 diabetes, is following a vegan diet. He received nutrition counseling from Lisa Stollman, MA, RDN, CDE, CDN, owner of Lisa Stollman Nutrition, a food and nutrition consultancy in Huntington, New York. “Ronald has been following a plant-based, mostly vegan, 1,800to 2,000-calorie diet for four months. Previously, he had six to eight eggs daily for breakfast and either chicken or red meat at lunch and dinner, limiting carbohydrates out of concern about his blood glucose. He has started to eat more fruit, beans, and whole grains and takes a vitamin B12 supplement. Ronald has lost 90 lbs since his diagnosis four years ago, and his hemoglobin A1c has been going down. “Ronald does all of his shopping and cooking. Healthful eating is so important to him that he shops at three different stores weekly to get the food that he enjoys at the lowest prices. He cooks his vegan meals for the week on Sundays. “I would like the supermarket RD to help Ronald find healthful, budget-friendly vegan protein sources, as well as additional whole grains that he may not be familiar with, and show him how to incorporate these foods into his diet.”

Andrea M. Barnes, MS, RD, LDN, FAND, an in-store dietitian at Weis Markets, Inc in Allentown, Pennsylvania, says, “A personalized shopping experience with a focus on Weis Market’s new Plant-Powered Eating program will help Ronald manage his diabetes on a vegan diet. Weis Markets now offers the new ‘Simple Guide to Plant-Powered Eating’ brochure, with tips for incorporating plant-based diet staples into meal planning, including simple swaps and grocery guides to highlight nutritious and budget-friendly, plant-based foods throughout the store. We’ve also identified ‘plant-powered’ items through shelf tags on both store and national brands of fresh and frozen vegetarian and vegan products. “The produce section provides a good foundation, with numerous high-fiber fruits and vegetables. Fresh herbs infuse additional flavor into foods without adding salt or sweeteners. Ronald also should consider frozen fruits and vegetables since they’re picked at the peak of freshness, are available without added sugars or salt, and are budget friendly. “To help manage his diabetes, Ronald can expand his food choices with high-fiber grains and a variety of nuts and seeds, which he can find in their own aisles in the store. Beans and legumes are packed with fiber and protein and make excellent meat substitutes.” Other in-store resources include the Weis NutriFacts program of colorful shelf icons that identify foods that are vegan, whole grain, high in fiber, or lower in carbs, Barnes adds. And the Weis website, HealthyBites magazine, and consultations and tours with the store dietitian are all free of charge. Supermarket RDs can be an important resource for clients with various food sensitivities, intolerances, and chronic diseases, and the nutrition professionals who counsel them. Stronger connections between dietitian consultants and supermarket RDs can help turn dietary instructions into practical meal planning, recipes, and shopping experiences to achieve better health. — Mindy Hermann, MBA, RDN, is a New York-based food and nutrition writer and consultant who was inspired to explore the synergies between consultant and supermarket dietitians after shopping inefficiently for a client with multiple food restrictions.

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Diabetes Management & Nutrition Guide Diabetes Nutrition Throughout the Lifecycle page 33

Treatments for Sexual Dysfunction page 37

Digital Health Technology in Diabetes Care page 40

Bariatric Surgeryâ&#x20AC;&#x2122;s Role in Managing Type 2 page 44

GUEST COMMENTARY

Type 2 Diabetes Prevention A Golden Opportunity for RDs to Engage By Hope Warshaw, MMSc, RD, CDE, BC-ADM, FAADE

n April 1, 2018, the United States reached a milestone in its efforts to prevent type 2 diabetes. The Centers for Medicare & Medicaid Services (CMS) added the Medicare Diabetes Prevention Program (MDPP), a yearlong evidence-based service, as a benefit to eligible beneficiaries.1 Reaching this milestone was more than 30 years in the making. What research and Medicare pathway paved the way? What should RDs know about the MDPP and the Centers for Disease Control and Prevention (CDC) National Diabetes Prevention Program (National DPP)? And how can RDs get involved?

Prediabetes Stats The CDC estimates that 84 million Americans have prediabetes. Fifty percent of these individuals are 65 or older, and nearly 90% aren’t aware of this diagnosis.2,3 The American Diabetes Association, in its 2017 economic costs analysis, highlighted the rising prevalence and related costs in the older population and noted that Medicare is bearing this escalating financial burden.4

Prevent or Delay? A Critical Caveat Though we use the term “diabetes prevention,” many individuals at high risk more likely will delay their onset of type 2 diabetes. Research from the DPP identified four predictive factors for prevention: achieving normoglycemia at a point during the DPP, relatively high beta-cell function and insulin sensitivity, prediabetes diagnosis at a younger age, and maximum pounds lost.5 Another study from the DPP details interindividual variation based on clinical variables measured in the baseline evaluation. Participants at highest risk of developing type 2 diabetes who lost ≥5% of their initial body weight at six months or who took ≥80% of their prescribed medication at the six-month follow up had a 39% absolute risk reduction.6 Three factors appear to be critical: early intervention, maintenance of maximal weight loss, and living a healthful lifestyle that includes sufficient physical activity.

20 Years of Research Confirms the Answer Results from long-term global intervention and follow-up studies have confirmed that type 2 diabetes can be prevented or delayed in people at high risk or with prediabetes, which can

lower risk of comorbidities, complications, and decrease premature mortality.7-10 The longest study was conducted in Da Qing, China.7 The Finnish Diabetes Prevention Study began in 1993 and has reported 13-year results,8 and the US National Institutes of Health-funded DPP began in 1998.9 The DPP intervention was three years. The follow-up DPP Outcomes Study began in 2002 and will continue until 2026.10 While these three type 2 diabetes prevention studies researched similar interventions with foci on weight loss using a healthful eating plan (consistent with the 2015–2020 Dietary Guidelines for Americans) and/or physical exercise and intensive individual or group lifestyle support, there were study differences. In sum, these studies demonstrated that the loss of about 5% of body weight, even with some weight regain over time, can prevent or delay type 2 diabetes.7-10

Path to the CDC’s National DPP One of the CDC’s roles is to translate research into programs that improve the public’s health. In 2002, Congress authorized the CDC to establish and manage the National DPP.11 Since 2002, the CDC has been developing the infrastructure to scale the National DPP with both success and challenges.11 To date, more than 220,000 individuals have enrolled in this program. While this is positive, the numbers reflect just 1% of the 84 million US adults with prediabetes, according to a presentation by Ann Albright, PhD, RD, director of the CDC Division of Diabetes Translation, at the American Diabetes Association 2018 Scientific Sessions in Orlando, Florida.

Path to the MDPP A logical next step was to expand the CDC National DPP as a Medicare benefit. This took seven years to accomplish. The Affordable Care Act stipulates that to add a Medicare service it must achieve cost savings. To determine cost savings, a health care innovation award was given to the National Council of YMCAs in 2011 to conduct a study.12 The study enrolled about 7,000 Medicare beneficiaries. After the study’s completion, a cost savings analysis was conducted by the CMS chief actuary and certified because it demonstrated net Medicare savings by $2,650 per beneficiary

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in the first 15 months of the program.12 This certification allowed the addition of this as a Medicare service. It’s the first disease prevention service ever covered by Medicare. It took another two years to initiate the MDPP on April 1, 2018.1 A revised set of CDC Diabetes Prevention Recognition Program Standards were published to coincide with the start of the MDPP and align both services.13

The National DPP and MDPP Eating Plan The eating plan and weight loss goals of the National DPP and MDPP are built on the evidence from the DPP study protocol.9 Over the course of the yearlong program, facilitators slowly introduce concepts of healthful eating based on the dietary guidelines. They cover many food and nutrition-related topics from healthful food preparation to how to choose foods in restaurants. A critical part of the program is selfassessment and goal setting to achieve 5% weight loss and maintain it long term. Participants must keep and submit food records and physical activity minutes weekly, and, in turn, facilitators provide them with feedback.

How Can RDs Engage? I posed this question to Albright. She says all health professionals can do one or more of the following: • raise awareness of prediabetes and the National DPP; • refer people at risk to a CDC-recognized lifestyle change

program; and • offer the National DPP lifestyle change program by encour-

aging your organization to seek CDC recognition. Given their skills in nutrition assessment, counseling, and evaluation, and experience in MNT, weight loss management, and diabetes self-management, RDs are well positioned to serve as program coordinators for CDC-recognized lifestyle change programs. Many RDs are trained to support clients with or at risk of type 2 diabetes, and some are already serving as lifestyle coaches in CDC-recognized lifestyle change programs. RDs serving as lifestyle coaches can continue to build their skills as strong group facilitators who can engage and motivate participants on their journey through the yearlong program. Dietitians can connect with community health workers and other paraprofessionals that have been trained to deliver the National DPP lifestyle change program to find ways to leverage the skills and expertise that each have.

RESOURCES • Centers for Disease Control and Prevention National Diabetes Prevention Program (DPP): www.cdc.gov/diabetes/prevention/index.html • Medicare DPP: https://innovation.cms.gov/ initiatives/medicare-diabetes-prevention-program • American Association of Diabetes Educators: www.diabeteseducator.org/prevention • National Association of Chronic Disease Directors: https://coveragetoolkit.org/about-national-dpp

CDC-Recognized Lifestyle Change program, and use an approved curriculum.14 While evidence demonstrates that MNT for prediabetes provided by RDs can improve outcomes and quality of life and be cost effective, Medicare doesn’t yet cover it.15 Proposed federal legislation, The Preventing Diabetes in Medicare Act, seeks this coverage.16

Final Thoughts With millions of Americans at risk of type 2 diabetes, there are a plethora of opportunities for RDs to engage in this national public health effort. Stemming this tide, even delaying the diagnosis for several years, can decrease comorbidities and premature death. It also can help many Americans experience greater quality of life and productivity while saving health care dollars. I encourage you to engage. — Hope Warshaw, MMSc, RD, CDE, BC-ADM, FAADE, owns Hope Warshaw Associates, LLC, a diabetes and nutrition focused consultancy based in Asheville, North Carolina. She’s the author of numerous books and has served as the 2016 president of AADE. Currently, she serves on the Academy of Nutrition and Dietetics Foundation board.

* Hope Warshaw, MMSc, RD, CDE, BC-ADM, FAADE, reports the following relevant disclosures: She serves as a consultant and spokesperson for the American Diabetes Association, Common Sensing, Johnson & Johnson Diabetes Institute, LLC, and WellDoc. She also serves on the advisory board for Eli Lilly and Company and Meredith Corporation.

About MNT for Prediabetes The National DPP and MDPP are group-based and yearlong services. They must achieve and maintain recognition,13 be delivered by lifestyle coaches who have completed the

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

Diabetes Nutrition Throughout the Lifecycle While there’s no one-size-fits-all dietary pattern to manage type 2 diabetes, children and teens, adults, and seniors have different nutrition needs and management goals. By Kathy W. Warwick, RD, CDE

he diagnosis of type 2 diabetes can be daunting, if not devastating, for many individuals. Wellmeaning family members, friends, and colleagues will offer advice about all the foods and beverages they should avoid. However, the days of the so-called “diabetic diet” are long gone. Diabetes care has shifted to an approach that places patients and their families at the center of the care model, working in collaboration with a team of health care professionals. RDs address nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness and ability to make behavioral changes, and barriers to change, all the while considering their patient’s age and season of life—as nutrition requirements and management goals differ for children and adolescents, younger adults, and older adults. In other words, children and adolescents with type 2 diabetes will have different nutrient needs and management goals than a young adult, and an older adult will have different nutrient needs and management goals than a younger adult or child with type 2 diabetes.1,2 In general, there’s no ideal distribution of calories from carbohydrates, fats, and proteins for people with diabetes,

and therefore dietitians must individualize macronutrient distribution while keeping total calorie and metabolic goals in mind. The good news is there’s a wide variety of eating patterns that are acceptable for the management of type 2 diabetes.3,4 This article will discuss MNT throughout the lifecycle for type 2 diabetes to help dietitians better counsel clients of all ages.

Children and Adolescents The medical community first began to officially identify children with type 2 diabetes about 20 years ago. Researchers involved in the SEARCH for Diabetes in Youth study released data collected from 2000 to 2012 that suggested there are 5,300 new cases of type 2 diabetes annually in US children aged 10 to 19. Cases of type 1 diabetes are more prevalent in children, but the incidence of type 2 has risen along with obesity rates. Because of the increase in obesity among youth, it can be challenging for clinicians to accurately diagnose type 1 vs type 2 diabetes.5 Stephen Ponder, MD, CDE, FAAP, a pediatric endocrinologist with the Baylor Medical System in Temple, Texas, and the 2018 AADE Educator of the Year, says he was practicing in south Texas when he first saw

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cases of type 2 diabetes in Hispanic youth. Type 2 diabetes disproportionately affects youth of ethnic/racial minorities from disadvantaged backgrounds. “Excess weight is the driving factor for type 2 diabetes,” Ponder says. “We have learned that obesity is a family affair, and effective treatment plans must involve the entire family. Many at-risk families are living on the edge with limited time and food budgets so the challenge is to meet them where they are with our nutrition guidance.” Ponder and his colleague Meaghan Anderson, MS, RD, LD, CDE, developed the acronym S.A.F.E. to describe basic changes families can make to decrease the risk of obesity and type 2 diabetes (see sidebar below). RDs can present these options and ask families to choose one or two of these interventions. “For example, a 16-year-old girl seen in our clinic lost 22 lbs in six months by substituting sugar-free beverages for sugary drinks,” Ponder says. “Encouraging families to make small, simple changes that can easily be maintained is much more likely to impact long-term health than an impractical, complicated eating plan.” Adolescents present a greater challenge because they can be particularly resistant to lifestyle modification interventions, Ponder adds, and “because they dislike being singled out or feeling they are different from their peers. Puberty also decreases insulin sensitivity.”2 When it comes to setting goals for weight loss, Ponder discourages giving specific numbers to families. Instead, he counsels parents of younger children that weight maintenance may be an appropriate goal if children are still growing. Older adolescents may become discouraged if health care providers set unrealistic goals of 100 lbs to reach “ideal” body weights. In general, a 7% to 10% weight loss should be the target.1 RDs should always praise positive behavior changes instead of focusing on medical outcomes.

S A F

Sugar-sweetened beverages. Limit portions and/or substitute with calorie-free options. After-meal snacks. Encourage nutrient-rich, lower-calorie snack options.

Fast food. Limit the number of visits per week, choose smaller portions, and limit convenience food items.

Exercise. Limit screen time, decrease sedentary behavior, and encourage 60 minutes per day of activity for the whole family. — SOURCE: PONDER SW, ANDERSON MA. TEACHING FAMILIES TO KEEP THEIR CHILDREN S.A.F.E. FROM OBESITY. DIABETES SPECTR. 2008;21(1):50-53.

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Goals of MNT in children and adolescents include the following: • achieving adequate nutrition for normal growth and

development; • emphasizing a variety of nutrient-rich food choices—fruits,

vegetables, whole grains, and dairy to supply nutrients of concern such as calcium, potassium, dietary fiber, vitamin D, and iron; • reducing sodium and added sugars; • substituting solid fats with liquid oils6; and • assessing food insecurity and providing a referral to community resources as needed.2,7 When describing eating patterns or presenting alternative food choices, RDs should use nonjudgmental language. Avoiding the use of labels such as “bad” or “good” for individual foods is important when dealing with children, who may internalize they’re “bad” if they eat a “bad” food. This idea can set the stage for an unhealthful relationship with food and disordered eating behavior. Screening adolescents for eating disorders and referral to psychological services may be appropriate.2,7

Adults According to the Centers for Disease Control and Prevention, there were 13.7 million adults aged 18–64 with diagnosed type 2 diabetes in 2015. In addition, 5.6 million had diabetes but were unaware of their condition. Prevalence was higher among American Indians/Alaska Natives, non-Hispanic blacks, and people of Hispanic ethnicity than among non-Hispanic whites and Asians. Prevalence varied significantly by education level, which often is an indicator of socioeconomic status. Specifically, 12.6% of adults with less than a high school education had diagnosed diabetes vs 9.5% of those with a high school education, and 7.2% of those with more than a high school education.8 Nearly all adults with a new diagnosis of type 2 diabetes already have at least one comorbid condition such as hypertension, overweight or obesity, hyperlipidemia, and CVD.9 By the time clients arrive for a consultation with a dietitian, they’re confused and their first question is “What can I eat?” Dietitians can play a pivotal role in guiding this population through the maze of eating plans and food choices so they can achieve optimal health. According to the 2018 ADA Standards of Medical Care for Diabetes, lifestyle management is the foundation of diabetes care and includes diabetes self-management education and support (DSMES), MNT, physical activity, smoking cessation counseling, and psychosocial care.1

Goals of MNT for Adults MNT for adults involves meal planning that takes carbohydrates, fats, and protein into consideration.

• Carbohydrates in meal planning. When counseling adults with type 2 diabetes, many may have questions about very lowcarb diets and carb counting to control blood sugar. Although carbohydrate is the macronutrient that most affects blood glucose, the amount of carbohydrate included in the meal plan can vary greatly (39% to 57% of energy) without significant changes in A1c.4,10 The Academy of Nutrition and Dietetics (the Academy) Evidence Analysis Library systematic review of current research identified energy reduction and weight loss as the dominant driver of A1c change. Many healthful eating patterns can be adapted for adults with type 2 diabetes to achieve and maintain a 5% to 7% weight loss.3,4,10 Before recommending carb counting, dietitians should assess client interest and numeracy skills. Carb counting and use of insulin-to-carb ratios is beneficial for those on meal-time insulin or insulin pumps. Patients prescribed fixed insulin doses or secretagogues may find consistent carbohydrate intake is helpful for glycemic control and avoidance of hypoglycemia. The monitoring of carbohydrate intake generally is recommended for those on other medications or lifestyle therapy alone.10 RDs can encourage carbohydrate intake from vegetables, fruits, legumes, whole grains, and dairy products, with an emphasis on foods higher in fiber and lower in added sugars.1 Simplified meal plans (ie, plate method, portion control, food lists with carb choices) all can be effective.4,10 According to Janice MacLeod, MA, RDN, LDN, CDE, director of clinical innovation for WellDoc in Columbia, Maryland, and lead author of the Academy’s nutrition practice guidelines, “A useful strategy is to encourage blood glucose monitoring before and after meals to determine how much carbohydrate an individual can tolerate without causing postprandial hyperglycemia. Blood glucose monitoring should be used strategically to help patients learn if the treatment plan components—including food, medication, and activity—are working in synergy.” Using these data, RDs can help clients problem solve to improve postprandial glucose readings. • Fats in meal planning. In the past, low-fat diets were recommended to help prevent heart disease, a chief comorbidity of type 2 diabetes in adults. But the type of fat included in the eating pattern is more important than the amount. Again, the Evidence Analysis Library guidance shows that 27% to 40% of energy may be derived from fat with no significant change in A1c, independent of weight loss. Consistent with the 2015–2020 Dietary Guidelines for Americans, the recommendations for people with diabetes are to modify the type of fat consumed. Substituting unsaturated fats for saturated and trans fat may reduce total and LDL cholesterol.4,10 The Mediterranean eating pattern has been shown to reduce the risk of hypertension, hyperlipidemia, and CVD.11 Dietitians should offer practical tips for making these fat substitutions in snack choices or cooking

methods. Eating foods rich in omega-3s is associated with cardioprotective benefits, while fish oil supplementation isn’t.1 • Protein in meal planning. The old “diabetic bedtime snack” intended to prevent nocturnal hypoglycemia generally included a carb and a protein related to the idea that added protein would stabilize blood glucose levels. Research shows protein is a potent stimulant for the pancreas to release insulin, but protein doesn’t increase blood glucose levels. It’s no longer advised to use protein to treat hypoglycemia or prevent hypoglycemia. For this reason, milk has been removed from the list of appropriate carbohydrate sources used to treat low blood sugar. Protein intakes ranging from 20% to 30% of energy or 1–1.5 g/kg are acceptable. Some evidence supports increased satiety with higher protein intakes.1

Putting It All Together • As for the general population, encourage fiber intake of 14 g per 1,000 kcal, limits on sodium to 2,300 mg per day, and reduction of added sugars to less than 10% of kcal.1,6 • Sucrose and other sugars may be substituted for isocaloric amounts of starch with similar effects on blood glucose levels.3,4,10 • Several eating plans such as DASH (Dietary Approaches to Stop Hypertension), Mediterranean, and plant-based may be adapted by individuals based on preferences, access, willingness to change, barriers, and metabolic goals. The plate method, estimation of carb intake, and portion control are all effective tools.1,4,10 • Energy reduction for modest weight loss can reduce A1c 0.3% to 2% as well as decrease medication use and boost quality of life.10 • Low- and very low-carbohydrate diets have shown benefits in the short term, but over time these diets are similar in efficacy to moderate-carb diets. Drastic dietary changes are difficult to maintain, and most people with diabetes will return to their usual macronutrient distribution. Research shows most people with diabetes report a moderate intake of carbohydrate ranging from 44% to 46% of kcal.1 • Studies lasting longer than 12 weeks report no significant impact of glycemic index or glycemic load on A1c, independent

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of weight loss. There’s mixed evidence of improvement in fasting glucose and endogenous insulin levels.1 • Moderate alcohol use (no more than one drink per day for women and two drinks per day for men) can be incorporated into eating plans. One drink is defined as 12 oz of beer, a 5-oz glass of wine, or 1.5 oz of distilled spirits. Alcohol can increase the risk of delayed hypoglycemia for those taking insulin or secretagogues.1,4,10 • There’s no evidence to support reductions in protein intake below the Recommended Dietary Allowance of 0.8 g/kg for those with chronic kidney disease. Studies show no difference based on the source of protein (animal or vegetable) on kidney function.1,4,10 • FDA-approved nonnutritive sweeteners may be helpful for weight reduction and are safe to use within the acceptable daily intake range.1,4,10 • There continues to be no clear evidence of benefit for micronutrient or herbal supplements beyond their use to correct deficiencies. Metformin use has been associated with B12 deficiency, and periodic testing is recommended, especially for those with anemia or peripheral neuropathy.1

Older Adults One out of four older adults over age 65 has diabetes, and one-half of older adults has prediabetes. This population presents an interesting challenge due to its wide range of functional and cognitive abilities, economic resources, comorbidities, psychosocial issues, and living situations. You may see an 85-year-old who travels the world and a disabled, home-bound 65-year-old in the same day. Seniors may be living alone and receiving home-delivered meals or residing in assisted living or long term care facilities. Even though DSMES is a Medicare benefit, only 5% to 7% of those eligible take advantage of these services. Diabetes is an independent predictor of admission to long term care facilities, and diabetes alone is the reason for nearly one-half of all hospital admissions in the older adult population. The diagnosis of diabetes significantly increases the risk of dementia and depression. Dementia and depression can lead to poor self care. Goals for glycemic control should be carefully tailored based on these factors. Hypoglycemia risk should be minimized as older adults are at higher risk of hypoglycemia because of the need for insulin therapy, progressive renal insufficiency, cognitive decline resulting in medication errors, living alone, and the potential for food insecurity.12-14 Those with long-standing diabetes may develop gastroparesis and other chronic gastrointestinal issues. Gluten sensitivity is more common in this population and should be investigated if diarrhea, weight loss, unexplained iron deficiency anemia, or other autoimmune disease is present. Moreover, many older adults are at risk of magnesium

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deficiency related to long-term use of proton pump inhibitors to control gastroesophageal reflux disease. A1c goals should be relaxed, and MNT primarily should focus on nutritional adequacy and quality of life issues for those who are frail and have established CVD or limited life expectancy. Healthy, active older adults and RDs can collaboratively work toward treatment goals similar to those of younger adults.1,12-14

Words of Wisdom Type 2 diabetes is a progressive chronic illness. Despite best efforts, people with diabetes likely will see deterioration in glucose control over time related to impaired beta cell function usually requiring treatment with insulin.1 Type 2 in children appears to progress more rapidly than in adults with increased risk of kidney disease and cardiovascular complications.2,7 Diabetes is a complicated and challenging disease. The laundry list of daily diabetes tasks and constant attention to glucose monitoring, food intake, exercise, as well as the financial burden of diabetes can result in diabetes-related distress and burnout.1,15 People with diabetes need uncomplicated, individualized nutrition and activity recommendations based on current eating patterns, preferences, and metabolic goals. MNT delivered by a dietitian is associated with A1c decreases of 0.3% to 2% for people with type 2 diabetes.1 According to the 2015 joint position statement by the Academy, American Diabetes Association, and the American Association of Diabetes Educators, the overall objectives of DSMES are to support informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team to improve clinical outcomes, health status, and quality of life in a cost-effective manner. The need for DSMES in type 2 diabetes should be evaluated by medical care providers and/or multidisciplinary teams, and referrals to RDs made as needed at four critical times: at the time of diagnosis; annually for assessment of education, nutrition, and emotional needs; when new complicating factors (ie, health conditions, physical limitations, emotional issues, or basic living needs) arise that inﬂuence self-management; and when transitions in care occur (from childhood and adolescence to older adulthood).16 — Kathy W. Warwick, RD, CDE, is a diabetes educator, freelance writer, speaker, expert witness, and consultant. Warwick currently serves as the print communications chair of the Diabetes Care and Education Practice Group of the Academy of Nutrition and Dietetics. She’s the owner of Professional Nutrition Consultants, LLC, in Madison, Mississippi.

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

Treatments for Sexual Dysfunction RDs can help clients cope with this underdiscussed and overlooked aspect of diabetes management. By Janis Roszler, LMFT, RD, LD/N, CDE, FAND

t least one-half of all men and women with diabetes develop sexual complications that negatively impact their intimate relationships, self-esteem, and quality of life. RDs can offer support by listening to patients’ concerns, providing information about supplements and aphrodisiacs, and encouraging them to adhere to a healthful, anti-inflammatory eating pattern such as the Mediterranean diet.

intercourse, and difficulty achieving orgasm. Yeast or urinary tract infections, which are more common in women with diabetes, also can limit sexual activity until itching and discomfort are resolved. Because sexual complaints tend to be underreported due to their private nature, the estimated prevalence of FSD is believed to be higher.7-10 Like men, women also can develop elevated A1c and cardiovascular and neurological issues, but these don’t appear to be related to the development of FSD.7,9 Instead, obesity, metabolic syndrome, and microvascular complications are associated with FSD in women with type 2 diabetes, and issues in women with type 1 diabetes are more related to “menopausal status, depression, and marital status,” according to a study by Maiorino and colleagues.9 In the study, married women with type 1 diabetes were 2.5 times more likely to experience FSD.7 Interestingly, women who take multiple insulin injections daily have a higher prevalence of FSD (27%) than do those who use insulin pumps (13%) to manage their diabetes.9

Additional Causes

Inflammation plays a role in the development of some sexual challenges. The inflammation present with visceral adiposity reduces the body’s level of nitric oxide, a compound that helps muscle tissue relax so blood can flow into the pelvic area to create erections and clitoral, labial, and vaginal engorgement.2,11 Sexual complications in both men and women also can be related to unhealthful diets, physical inactivity, smoking, alcohol abuse, medication side effects (eg, antidepressants), and emotional/relationship issues.2,12

Treatments

The Issues

Men

At least 50% of men with diabetes develop erectile dysfunction (ED), with their symptoms appearing 10 to 15 years earlier than in the general population.1,2 Some men also experience decreased sexual desire, performance anxiety, retrograde ejaculation, and reduced testosterone levels.1,3-5 The presence of elevated A1c, neuropathy, or CVD can promote the development of ED.1,6 Obesity, diabetes, and metabolic diseases also are considered risk factors for sexual complications in both men and women, though studies involving women are less conclusive. Approximately 40% to 60% of women with diabetes develop female sexual dysfunction (FSD), with postmenopausal women experiencing the highest number of symptoms, which include reduced desire, arousal/lubrication challenges, painful

Prescription medications such as Viagra, Cialis, and Levitra work in about 60% of men with diabetes.13 Other treatment options include vacuum pumps, constriction rings, alprostadil penile injections/suppositories, penile sleeves that enable flaccid penises to participate in intercourse, and surgical implants. Implants are available as bendable rods or multipiece fluid-filled implantable types. According to the website EDCure.org, the three-piece fluid-based implantable type has a satisfaction rating among patients and partners of 92% to 98%, can’t be detected, and provides a natural orgasm. Lifestyle treatments include individual and couple’s counseling, smoking cessation, reduced alcohol intake, use of depression medication with fewer sexual side effects, and behaviors that improve one’s A1c level, such as a

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well-managed diabetes meal plan, exercise, and weight loss. The Mediterranean diet, which will be discussed shortly, is an effective option for many men with type 2 diabetes.14,15

Women Treatments for women with diabetes include water-based vaginal lubricants, hormone and nonestrogen medications such as Osphena and Intrarosa, switching depression medications to those with fewer sexual side effects, Kegel exercises, and engaging in behaviors that increase emotional and physical wellness, such as avoiding fad diets, getting adequate sleep, limiting obligations, and participating in physical activity. Individual and couple’s therapy is helpful as well.16 Women with type 2 diabetes also may enjoy increased sexual satisfaction by following a dietary pattern similar to the Mediterranean diet.17

Mediterreanean Diet The Mediterranean diet, an anti-inflammatory regimen, can help many individuals with type 2 diabetes prevent, delay, or improve their sexual challenges. With the diet’s emphasis on consuming virgin olive oil, vegetables, fruits, whole grains, nuts, fiber, fish, and moderate amounts of wine, it’s associated with a lower risk and severity of ED. The diet also improves lipid and glucose metabolism and increases antioxidant defenses, and its arginine levels may raise the body’s nitric oxide activity. Lycopene, found in tomatoes, contains anti-inflammatory properties that help prevent vascular dysfunction in ED, improve nitric oxide availability, and normalize aortic vasoconstriction. The diet also encourages individuals to be physically and socially active every day.15,17

Aphrodisiacs The following is a list of popular aphrodisiacs. Their known effectiveness was compiled from selected studies and a review published by researchers at the University of California at Irvine and the Southern California Center for Sexual Health and Survivorship Medicine in Newport Beach, California.18 • Arginine: helps the body synthesize nitric oxide. The Uni-

versity of Hawaii School of Medicine observed that arginine significantly increased a women’s sexual desire, sexual satisfaction, frequency of orgasm, and clitoral sensation19; • Chasteberry: small amounts reduce estrogen and raise progesterone levels. Studies support its use in treating premenstrual syndrome, but there’s no evidence that it helps sexual issues; • Chocolate: increases serotonin, which can elevate mood, but research doesn’t support its ability to improve sexual function; • Damiana: comes from a Mexican shrub, and there’s some evidence it may enhance sexual performance in men and women;

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• Ginkgo biloba: may improve sexual dysfunction in men

and women; • Ginseng: the Korean Red variety enhances synthesis of

nitric oxide, which can improve ED. It also may improve female sexual arousal; • Honey: traditionally was used to enhance romance, but no research supports its efficacy as an aphrodisiac; • Maca: demonstrates increased libido and improved sexual function in animal studies and also has shown promise in those areas in human studies; • Muira puama: may increase male libido and improve ED. One small study confirmed this, but additional research is needed; • Oysters: contain zinc, which enhances testosterone production and spermatogenesis, but don’t offer any researchsupported sexual benefit; • Tribulus terrestris: comes from Asia, Africa, and Europe. An animal study showed this herb’s ability to increase sperm production. A Brazilian study and a randomized, double-blinded, placebo-controlled study demonstrated its ability to improve female sexual desire; • Wine: a small amount can stimulate sexual interest, but too much hinders performance and can prompt a drop in blood glucose; and

SUPPLEMENT SAFETY TIPS Many clients aren’t aware that supplements have limited regulation and can be dangerous if used improperly. Share the following tips with them so they can make educated supplementation decisions: • Be wary of supplements that make unrealistic claims about cures, reversal of symptoms, etc. • Choose products based on information from a reliable source such as an RD or from websites such as WebMD.com, National Institutes of Health Office of Dietary Supplements (https://ods.od.nih.gov), and ConsumerLab.com. If an item isn’t listed, ask the manufacturer for published research that supports its claims of efficacy, and discuss the report with a health care provider. • Select products that have the NSF International, US Pharmacopeia, Underwriters Laboratory, or ConsumerLab.com emblem on their labels. These groups monitor supplements for safety and potency. • Tell a health care provider about the supplements you use or intend to use. • Immediately stop using any supplements that cause negative side effects. — JR

• Yohimbe: may promote increased blood flow to the penis,

but it can cause serious health issues such as hypertension, anxiety, nausea, and flushing, and shouldn’t be used.

The Dietitian’s Role RDs are uniquely positioned to help clients with diabetes meet the challenges of sexual dysfunction in the following ways: • Some patients may choose to speak to you about their

sexual challenges during a session. • RDs can use the strong relationship between A1c and ED

to motivate male patients to manage their diabetes more effectively. • ED often develops five to 10 years before a heart attack or stroke. This information may prompt some patients to adopt more healthful lifestyle behaviors.20 • Dietitians can help men and women with type 2 diabetes prevent or improve their sexual complications by helping them incorporate Mediterranean diet recommendations into their lives. • RDs can act as a resource about treatments for sexual complications and refer patients to mental health professionals when therapy seems appropriate. Dietitians also can direct patients to reliable educational websites such as EDCure.org, WebMD, and Mayo Clinic.

• Nutrition professionals can guide patients regarding the

safe use of aphrodisiacs and supplements. • RDs can communicate patients’ concerns to other members

of the health care team. Discussing sexual topics with patients can be awkward and uncomfortable. If patients don’t bring up the topic, be the one to open it up for discussion. Dietitians can mention sexual concerns in a list of other complications or just ask if patients have any issues in the bedroom. Remember, at least onehalf of patients with diabetes that RDs see are struggling with some form of sexual complication. You can help! — Janis Roszler, LMFT, RD, LD/N, CDE, FAND, was the 2008–2009 AADE Diabetes Educator of the Year and is the author of several books, including Approaches to Behavior, Diabetes on Your OWN Terms, and Sex and Diabetes.

* Janis Roszler, LMFT, RD, LD/N, FAND, reports the following relevant disclosures: She serves as a consultant and spokesperson for Boston Scientific and Ascensia Diabetes Care. 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!

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evidence advocating its use, the promising technologies available, and the rapidly evolving role of dietitians as part of the health care team that cares for people with diabetes.

The Case for Digital Health

Digital Health Technology in Diabetes Care It’s transforming the way people with diabetes communicate with personal health care teams and treat and manage their disease. By Janice MacLeod, MA, RDN, CDE, FAADE

s consumers increasingly use technology in their everyday lives to communicate, perform daily living tasks, and seek information, they’re expecting their health care services to be readily accessible digitally on their phones and tablets wherever and whenever they want. These newly empowered, engaged, and educated “e-patients” who have diabetes also are increasingly using technology to log and share lifestyle data, keep track of their health status, obtain health information, and become more active participants in their own care. Digital health is the convergence of health care and technology. It has reached a tipping point and is rapidly redesigning clinical care. This article provides an overview of what’s driving the trend in digital health supporting diabetes care, the

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Chronic diseases such as diabetes that require regular follow-up and therapy progression can benefit from the integration of technology-based tools. The anytime-anywhere nature of digital technology supports the delivery of automated, individualized coaching, enabling patients to address their health issues by sharing data and connecting with their health care team when needed in between scheduled appointments. The diabetes e-health ecosystem, the use of information and communication technologies for health, as illustrated in Figure 1 on page 41, has expanded well beyond diabetes devices to include personal health devices such as physical activity and sleep trackers, cloud-connected monitoring systems, data management platforms, telehealth services, digital education, mobile apps, digital therapeutics (clinically validated apps), and social media platforms. As outcomes-based accountability becomes the norm among diabetes specialists, there’s increased demand for diabetes care and education services outside of the traditional siloed diabetes selfmanagement education and support (DSMES) services that offer face-to-face individual and group sessions. In addition, diabetes treatment protocols are becoming more complex, and as patients require extensive ongoing self-management support, digital health technology will be able to provide the critical platform to improve the health care experience and the health of populations while reducing the per capita cost of health care.1 Of interest is a quote by Kaufman and Woodley in a commentary published in the Journal of Diabetes Science and Technology in 2011: “The current laborintensive approach to preventing and treating diabetes is no longer feasible, and self-management support interventions that are clinically linked and technology enabled are key to modern diabetes care and represent a solution whose time has long since arrived.”2

Supporting Evidence According to a 2017 systematic review of 25 studies evaluating technology-enabled DSMES, there were improvements in A1c ranging from 0.1% to 0.8% in 18 of the 25 studies. This review identified four key elements that were incorporated into the most effective interventions. They included two-way communication, analyses of patient-generated health data,

FIGURE 1

FIGURE 2

Diabetes e-Health Ecosystem

Technology-Enabled Self-Management Feedback Loop

— SOURCE: AMERICAN ASSOCIATION OF DIABETES EDUCATORS (AADE) 2016 TECHNOLOGY WORKGROUP. BASED ON ARCHITECTURE FOR INTEGRATED MOBILITY FRAMEWORK (AIM). REPRINTED BY PERMISSION OF THE AADE.

— SOURCE: GREENWOOD DA, GEE PM, FATKIN KJ, PEEPLES M. A SYSTEMATIC REVIEW OF REVIEWS EVALUATING TECHNOLOGY-ENABLED DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT. J DIABETES SCI TECHNOL. 2017;11(5):1015-1027. USED WITH PERMISSION OF THE AADE.

tailored education, and individualized feedback. The authors referred to this as a technology-enabled self-management feedback loop (see Figure 2), which connects people with their health care providers.3 Health care team members’ review of patient-generated health data can lead to more immediate adaptions to the care plan by providing insights for shared decision making and

proactive patient-team communication that engages patients in their care with members of the health care team. However, to be of value, digital health tools and the resulting patientgenerated health data must be integrated into clinical practice, becoming a critical part of what’s done vs merely what’s being added. Due to the growing evidence of the efficacy of digital health tools for improving A1c and other diabetes-related outcomes, both the 2017 National Standards for DSMES4 and the 2018 American Diabetes Association Standards of Medical Care5 encourage inclusion of technology-enabled solutions to deliver diabetes care and education.

DIGITAL HEALTH STATISTICS

Technology-Enabled Solutions

• It’s estimated that 77% of Americans now own smartphones. • By 2022, the penetration of smartphone use is estimated to reach 80% of the US population. • Nearly 80% of US adults own desktop, laptop, or tablet computers. • There are 200 new health-related apps introduced each day. • Currently, 314 wearables are available. • Out of the 318,000 apps on the market, 41 account for one-half of all downloads. • Sixteen percent of disease-specific apps target diabetes. — JM

Resources 1. Mobile fact sheet. Pew Research Center website. www.pewinternet.org/ fact-sheet/mobile/. Updated February 5, 2018. Accessed April 24, 2018. 2. The growing value of digital health: evidence and impact on human health and the healthcare system. IQVIA Institute for Data Science website. https:// www.iqvia.com/institute/reports/the-growing-value-of-digital-health. Published November 7, 2017. Accessed April 24, 2018.

Yet, while technology is poised to become a major part of the solution in transforming diabetes care, it remains a rapidly expanding and confusing space. The FDA is focused on digital health with an aim toward fostering innovation, allowing for rapid iterative modifications in digital health products, and streamlining the approval process (see the sidebar “The Evolving Digital Health Regulatory Environment” online for an overview of current regulatory guidance and categories in digital health). Many diabetes technology solutions offer the opportunity to track and visualize data related to daily diabetes care, regarding blood glucose management, food, physical activity, and medications. In some cases, the digital applications provide cloud-based methods of sharing data with others, including health care team members. In most cases, the technology provides minimal data analysis, interpretation, or guidance to patients. At present, Livongo and OneDrop, two digital health solution-based companies, have received American Diabetes

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Association recognition or American Association of Diabetes Educators (AADE) accreditation to have health coaches and diabetes educators deliver a DSMES program virtually.6,7 Livongo enables users to monitor their blood glucose virtually through a connected blood glucose meter while certified diabetes educators provide real-time coaching if users experience hypo- or hyperglycemia. These virtual interactions to resolve blood glucose excursions often include additional diabetes education relevant to the individual. Educators are available on-demand to users by text or e-mail as needed. OneDrop is a mobile app that offers in-app coaching on blood glucose management by a certified diabetes educator. The app facilitates tracking of blood glucose and diabetes selfmanagement data and includes a digital diabetes education program. Two other digital health solution-based companies, WellDoc and OnDuo, have licensed AADE’s DSMES curriculum for integration into their digital health therapeutic and virtual diabetes clinical models.8,9 WellDoc, a digital therapeutic company, has translated the DSMES curriculum and digitized it to be delivered in an in-app diabetes education curriculum designed for people with type 2 diabetes. The digital curriculum is designed to be completed over 12 weeks, though individuals can choose to progress at their own pace. OnDuo is a virtual diabetes clinic that provides either a connected blood glucose meter or a continuous glucose monitor to facilitate remote monitoring. It offers an app for data tracking and visualization, and virtual diabetes coaching by certified diabetes educators. Individuals can connect with their diabetes coach as needed through text or e-mail. WellDoc’s BlueStar, an FDA-cleared, clinically validated digital therapeutic for people with type 2 diabetes, falls within a category of digital health called digital therapeutics. Digital therapeutics are distinguished from health and wellness apps in that they conduct peer-reviewed randomized controlled trials to demonstrate clinical efficacy and safety of the digital therapeutic product, and in many cases they obtain FDA clearance as a mobile medical app. In addition, digital therapeutics enable users to connect with members of their care team, share personal data, and, through two-way communication, partner together to make changes as needed to their care plan. BlueStar provides automated coaching in real time that’s tailored to users’ treatment and self-management plans, their personal routines and preferences, and the types and timing of data they’re sharing either manually or through synced wearables, apps, meters, or trackers. This allows 24/7 support to be provided during the time individuals are navigating the complexities of diabetes on their own. Individuals can share their data with their care teams on a regular schedule or as needed to support collaboration of care.

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AADE/WELLDOC DIABETES DIGITAL HEALTH LEARNING NETWORK A Diabetes Digital Health Learning Network was established in August 2017 as a collaboration between the American Association of Diabetes Educators (AADE) and WellDoc, a digital therapeutic company and the developer of BlueStar, an FDA-cleared, clinically validated digital therapeutic for people with type 2 diabetes. The intent of the network collaboration was to provide opportunities for diabetes educators to collectively develop and share best practices for implementing a clinically validated digital health therapeutic into a variety of practice settings. Educators explored taking on new roles, including population health management, use of patient-generated health data to identify and resolve self-care barriers, and partner with patients and other health care team members to optimize care plans in a timely manner. The group also discussed opportunities to improve care delivery and practice efficiency, including the potential for diabetes educators to leverage technology to position themselves as valued leaders in evolving care and payment models. A key objective of the network was to inform AADE about the skills and practice needs of diabetes educators who are engaged in population health management and the use of digital technologies. A publication with further details about the learning network methodology and lessons learned is in development. Currently, the network is adding new members of the health care team and is considering applying the learning network methodology to other evidencebased technology tools, such as insulin titration apps, to support chronic disease management. Next steps include the following: • continuing with the Learning Network with a small, focused group committed to practice innovation that will go beyond diabetes devices to optimizing the way diabetes education and care is provided; • incorporating lessons learned to define and develop Technology-Enabled Population Health Diabetes Education and Care Services, including patient and health care team engagement strategies and utilization of the patient-generated health data; and • building the case for payment transition from feefor-service to value-based. To learn more about the network and opportunities in which to get involved, contact Janice MacLeod at jmacleod@welldocinc.com. — JM

Transforming Role of RDs and Diabetes Educators Because of ongoing technological advances, digital diabetes education and care has the potential to transform the role of dietitians. They can become leaders in redesigning care, moving from the fee-for-service approach to value-based payment, as demonstrated in integrated delivery systems, patientcentered medical homes, and accountable care organizations. Diabetes-focused dietitians/educators are the subject matter experts in diabetes care and in the use of patient-generated health data, and therefore can work with other members of the care team as mentors and leaders. Dietitians can become the distribution channel for placing evidence-based technology tools (digital therapeutics) into the hands of patients to ensure optimal use. The goal is to connect e-patients with their health care teams through a complete feedback loop to optimize diabetes self-management and treatment. Preparing patients, dietitians, diabetes educators, and other diabetes stakeholders to operate successfully within the continuously evolving health care and technology landscape will be critical. Training is needed to identify evidence-based health technology tools, learn how to integrate these tools into practice, and learn how to use the resulting patient-generated health data to optimize individual care plans. Moreover, it will be necessary to learn how to use the population level data (ie, aggregated patient data to assess overall health status of a population) to support quality improvement and population health initiatives, such as using data to determine the right timing for clinical interventions or improving practice work flow.10 Recognizing the need to keep abreast of the latest technological advances, the AADE is launching a new online diabetes technology training and education website for its members called DANA (Diabetes Advanced Network Access), available at www.danatech.org. DANA is a hub for diabetes educators and other health care providers, as well as the industry, to come together to learn about the latest devices, medications, mobile apps, and technology-focused research so they can serve patients and caregivers more effectively. When DANA is fully released in 2018, it will include resources in four functional areas targeted at a professional health care audience: device training, resource library, education, and evolving and emerging technology. In addition, a Digital Health Learning Network was established as a collaboration between AADE and WellDoc to explore new strategies that will bring innovative tools to the practice of diabetes education and care (see the sidebar “AADE/WellDoc Diabetes Digital Health Learning Network”).

Reimbursement and Payment As the use of digital tools in diabetes care increases, more private payers within fee-for-service or value-based models of payment may cover virtually delivered DSMES services or digital health technologies. Medicare, through its Merit-based

Incentive Payment System (MIPS), incentivizes remote patient care. For example, one of the 93 MIPS Improvement Activities is the use of digital tools to monitor patient-generated health data with clinically endorsed tools that include an active feedback loop that in turn provides actionable information to patients or their health care providers.11 As of 2018, Medicare “unbundled” an existing Part B CPT code, 99091, and has begun to pay separately for remote patient monitoring done by qualified providers (eg, physicians, nurse practitioners, physician assistants, and clinical nurse specialists). Providers can be paid approximately $58 for a cumulative time of 30 minutes per month to review biometric data the patient and/or caregiver digitally transmits and communicate the findings and care plan recommendations to the patient and/or caregiver. The Academy of Nutrition and Dietetics is working on getting RDs designated as qualified providers. Learn more about CPT code 99091 at www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM10393.pdf.

Bright Future Technology is transforming health care, including diabetes management. Opportunities are here for practices, health care systems, dietitians, diabetes educators, and other members of the health care team to expand and leverage these tools to improve diabetes outcomes for patients. Diabetes-focused dietitians, with their extensive experience in the practical use of patient-generated health data, patient-centered diabetes care, and self-management training, are uniquely positioned to lead in integrating evidence-based technology tools into clinical practice. The time is now. — Janice MacLeod, MA, RDN, CDE, FAADE, began her career as a diabetes dietitian for Carilion Health System in Virginia and more recently served at the University of Maryland Center for Diabetes and Endocrinology in Baltimore. MacLeod also worked for many years at Johnson & Johnson Diabetes Care, and has served as both author and editor for multiple publications. She has contributed to book and curriculum manuals on diabetes and has developed numerous education programs and presentations in the areas of diabetes nutrition, glucose monitoring, digital health, and practice transformation.

* The author reports the following relevant disclosure: She serves as director of clinical innovation at WellDoc, a digital health company in Columbia, Maryland. In her role, she works with health care teams, bringing technology to clinical practice. For references and a sidebar, view this article on our website at www.TodaysDietitian.com.

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Bariatric Surgery’s Role in Managing Type 2 Learn about the different procedures available and strategies for counseling patients. By Constance Brown-Riggs, MSEd, RD, CDE, CDN

besity is a significant independent risk factor for developing type 2 diabetes, and more than 90% of people with type 2 diabetes are overweight or obese.1 There’s a robust body of evidence stating that obesity management can delay the progression from prediabetes to type 2 diabetes and may be beneficial in the treatment of type 2 diabetes.2 Moreover, in overweight and obese individuals with type 2 diabetes, modest and sustained weight loss of just 5% of total body weight has been shown to improve glycemic control and reduce the need for glucose-lowering medications.1,2 Various treatment options for obesity management are available, including but not limited to lifestyle modification, a very low-calorie diet, pharmacotherapy, and bariatric surgery.2 Metabolic and bariatric surgery may resolve or improve type 2 diabetes; these results can occur independently of weight loss.1 Improvements in glycemia after weight

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loss are most likely to occur early in the natural history of type 2 diabetes when obesity-associated insulin resistance has caused reversible beta-cell dysfunction, but insulin secretory capacity remains relatively preserved.2 This article will provide an overview of surgical interventions for obesity management as treatments for hyperglycemia in type 2 diabetes and as a mechanism of diabetes improvement and remission. Counseling tips and considerations when advising clients and patients on the most appropriate surgical procedure also will be discussed.

What Is Bariatric Surgery? The term “bariatric surgery” comes from the Greek words baros, which means “weight,” and iatrikos, “the art of healing.”3 Bariatric surgery refers to any surgical procedure on the stomach or intestines to induce weight loss.

The use of bariatric surgery for the treatment of type 2 diabetes started from a report by Pories and colleagues published in the Annals of Surgery in 1995. Pories’ report documents how gastric bypass surgery provides longterm control of obesity and diabetes. Since Pories’ report, a substantial body of evidence shows that bariatric surgery is an effective treatment for severe obesity, indicated by a BMI >35 kg/m2, and results in marked improvement of type 2 diabetes control. Metabolic surgery, therefore, is increasingly associated with the treatment of type 2 diabetes, including for patients with a BMI <35 kg/m2.4 “The term ‘metabolic surgery’ is most commonly used to describe someone who has bariatric surgery with diabetes; however, it also can be used to describe weight loss surgery in a patient who has prediabetes or [is] at risk of diabetes,” says Kristen Smith, RDN, bariatric surgery coordinator for Piedmont Healthcare in Atlanta.

The benefits of weight loss must be balanced against the potential risks of bariatric surgery. It’s also important to consider both immediate and chronic complications following the different types of surgeries. In the longer term, obesity surgery can lead to malabsorption of micronutrients such as vitamins and minerals—which may result in anemia, a loss of lean mass, an increased risk of kidney stones, and a small risk of acute kidney injury.5 The most common bariatric surgery procedures performed in the United States are gastric bypass, gastric sleeve (also called sleeve gastrectomy), and laparoscopic adjustable gastric band. A fourth surgery, biliopancreatic diversion with duodenal switch, is used less often and won’t be discussed within the context of this article.6 Surgical options for weight loss include restrictive procedures and malabsorptive procedures. Each surgery has its advantages and disadvantages.

Studies show long-term (>10 years) weight loss after Rouxen-Y to be around 25% to 30% total weight loss and 55% to 70% excess weight loss. However, up to 20% of Roux-en-Y patients may, amid various complications or weight regain, require revisional surgery.4 A common side effect of Roux-en-Y is dumping syndrome. About 85% of patients experience dumping syndrome at some point after surgery with symptoms ranging from mild to severe.9 In Roux-en-Y, the pyloric sphincter is bypassed, resulting in faster emptying of food into the small intestine. Dumping syndrome can occur with intake of refined sugars, highglycemic carbohydrates, dairy products, fats, and fried foods.9 “When undigested carbohydrates such as sugar reach the small intestine too quickly, extracellular fluid is drawn in to restore isotonicity, and in turn, the patient may experience dumping syndrome. Symptoms include sweating, bloating, cold sweats, tachycardia, emesis, dizziness, hypotension, diarrhea, and/or nausea,” says Melissa Majumdar, MS, RD, CSOWM, LDN, CPT, nutrition coordinator at Brigham and Women’s Hospital’s Center for Metabolic and Bariatric Surgery in Boston. Individuals may experience early dumping, which occurs in about 70% of patients, or late dumping (5% of patients), Majumdar says. Early dumping occurs 30 to 60 minutes after eating and can last up to 60 minutes. Symptoms include sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lie down, upper abdominal fullness, nausea, diarrhea, cramping, and active audible bowels sounds.9 Late dumping occurs one to three hours after eating. Symptoms are related to reactive hypoglycemia (low blood sugar) and include sweating, shakiness, loss of concentration, hunger, and fainting.9 “Patients may experience reactive hypoglycemia if they have gone more than three to four hours without eating or if they have eaten a meal with refined carbohydrates, especially if the meal lacked protein,” Majumdar says.

Gastric Bypass

Gastric Sleeve

Gastric bypass—also called Roux-en-Y gastric bypass— is considered the gold standard for weight-loss surgery by the American Society for Metabolic and Bariatric Surgery and the National Institutes of Health.7 It consists of creating a small gastric pouch 20 to 30 mL in volume—about the size of an egg—that’s surgically connected to the small intestine.8 The Roux-en-Y gastric bypass is a restrictive and malabsorptive procedure. Weight loss is triggered by several mechanisms. First, the newly created pouch facilitates smaller meals, translating into fewer calories consumed.9 The bypass also results in faster emptying of food, which contributes to malabsorption of nutrients and calories. In addition, the bypass produces changes in the gut hormones that promote satiety and suppress hunger.9

Often referred to as sleeve gastrectomy or the sleeve, gastric sleeve surgery involves removing part of the stomach and leaving a thin, banana-shaped portion of the stomach connecting the esophagus to the pylorus. Sizing of the sleeve is based on a 32- to 36-French bougie, resulting in approximately 100 mL volume.8 A bougie is a measuring device used to guide the surgeon when dividing the stomach. Sleeve gastrectomy initially was used as a first-step bariatric procedure for high-risk patients or those with a BMI more than 60 kg/m2 to reduce the risk profile of patients. Once adequate weight loss occurred, a malabsorptive surgery often was performed.10 However, it was discovered that sleeve gastrectomy alone could cause significant weight loss before the second procedure.

Bariatric Surgical Options

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Sleeve gastrectomy not only restricts food intake but also increases both gastric emptying and intestinal transit time. As a result of its efficacy for weight loss, relative simplicity, and fewer long-term nutritional problems, sleeve gastrectomy has rapidly become the most commonly performed bariatric/metabolic surgery worldwide.4 Total weight loss of approximately 25% to 30% and excess weight loss of 60% to 70% for as many as 10 years can be achieved. However, a significant drawback of this procedure is the development of reflux esophagitis. Given this possibility, or amid subsequent weight regain, up to 30% of sleeve gastrectomy patients may require revisional surgery.4

Adjustable Gastric Band In an adjustable gastric band procedure, a silicone band is placed around the stomach at the level of the cardia with an adjustment port placed in the subcutaneous tissue—usually in the epigastric region—connected to the band via silicone tubing.8 Adjustable gastric band is the safest bariatric surgical procedure, but the efficacy is less than that of other bariatric procedures. Once sleeve gastrectomy emerged, it quickly replaced adjustable gastric band in almost every part of the world. Long-term (>10 years) weight loss after adjustable gastric band surgery was approximately 15% of total weight loss and 40% to 45% of excess weight loss. However, up to one-half of adjustable gastric band patients may require revisional surgery in the event of insufficient weight loss.4

Efficacy of Metabolic Surgery in Diabetes Metabolic surgery is associated with improvements in weight, glycemia, hepatic insulin and peripheral insulin resistance, insulin secretion, blood pressure, lipid profile, inflammation, end-organ damage, and diabetes remission. Changes in hepatic insulin resistance, peripheral insulin resistance, and insulin secretion are due to increased serum bile acid levels, which stimulate glucagonlike peptide-1 and peptide YY.8 At two years, pancreatic beta-cell function improves in patients with Roux-en-Y gastric bypass but not in those who have had sleeve gastrectomy. Postoperatively, plasma insulin concentration levels are reduced but the postprandial response is exaggerated. These changes occur within days of Roux-en-Y surgery and are associated with the rise in glucagonlike peptide-1 and peptide YY, reduced fasting insulin levels, and increased insulin sensitivity. The changes also are observed in sleeve gastrectomy but to a lesser extent than in Roux-en-Y. In patients with a gastric band, improvements in glycemia, insulin secretion, and insulin resistance are directly related to weight loss.8 Studies show that more than 70% of patients with type 2 diabetes of two years or less in duration achieved a fasting blood glucose level of less than 126 mg/dL through a gastric band.8

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The mechanisms for improved blood pressure are multifactorial and may be associated with weight loss, reduced systemic inflammation, increased urinary sodium loss, and restoration of metabolic homeostasis. Research shows blood pressure improves in 73.2% of patients who are still losing weight after bariatric surgery. Serum total cholesterol, triglycerides, and LDL cholesterol decrease while HDL cholesterol increases following bariatric surgery.8 Remission of type 2 diabetes after bariatric surgery was first reported in the late 1980s. Since that time, multiple observational studies have demonstrated significant, sustained improvements in type 2 diabetes among patients with severe obesity (BMI ≥35 kg/m2) after weight loss procedures.11 A meta-analysis involving 19 studies (mostly observational) and 4,070 patients reported an overall type 2 diabetes resolution rate of 78% after bariatric surgery. Resolution typically was defined as becoming “nondiabetic” with normal HbA1c without the use of medications. HbA1c usually improved from baseline by a minimum of 1%, up to 3% following surgery.11 One of the largest and longest weight loss studies is the Swedish Obese Subjects study, a prospective study evaluating the long-term effects of bariatric surgery compared with nonsurgical weight management of severely obese (BMI >34 kg/m2) patients. In the study, the remission rate for type 2 diabetes was 72% at two years and 36% at 10 years compared with 21% and 13%, respectively, for the nonsurgical control patients. Bariatric surgery also was markedly more effective than nonsurgical treatment in the prevention of type 2 diabetes, with a relative risk reduction of 78%.11,12

Strategies for Helping Patients The increasing prevalence of bariatric surgery makes it likely that dietetics professionals will encounter patients preand postbariatric surgery. Following is a list providing best practices when counseling patients regarding bariatric surgery. • Understand the different metabolic weight loss procedures and who the ideal candidate is for each. According to the American Diabetes Association’s Standards of Medical Care in Diabetes — 2018, appropriate surgical candidates are those with a BMI ≥40 kg/m2 (BMI ≥37.5 kg/ m2 in Asian Americans), regardless of the level of glycemic control or complexity of glucose-lowering regimens, and in adults with BMI 35 to 39.9 kg/m2 (BMI 32.5 to 37.4 kg/m2 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy. Metabolic surgery should be considered as an option for adults with type 2 diabetes and BMI 30 to 34.9 kg/m2 (BMI 27.5 to 32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical therapy by either oral or injectable medications (including insulin).

Majumdar says, “From a dietitian’s perspective, the ideal candidate is looking for an opportunity to change their life using the tool of metabolic surgery along with the support of their fellow patients and the education and support of the surgery program. An ideal candidate uses surgery as a springboard to adjust diet and lifestyle and possibly change their whole family’s take on food and nutrition. They take control of their hunger through the hormonal and appetite adjustments surgery provides and, in the meantime, increase activity and face nonhunger reasons for eating head on.” • Promote protein-rich foods. Depending on an individual’s medical condition, type of surgery, and activity level, protein intake recommendations range from 60 to 100 g daily.9 “During a nutrition consult, we analyze a typical eating pattern and measure protein intake. After protein goals are met, we look for a variety of food (nonstarchy vegetables, fruits, whole grains, and healthful fats) just like we would assess any patient,” Majumdar says. To improve weight loss, clients should be encouraged to limit foods high in added sugars (eg, cookies, cakes, candy, juice, or other sweets) and refined carbohydrates (eg, white breads, pastas, crackers, refined cereals).9 • Educate clients who choose Roux-en-Y gastric bypass on risk and prevention of dumping syndrome—a common side effect—and hypoglycemia. Majumdar helps her patients understand the “blood sugar roller coaster” that may occur if they go too long without eating or if they eat refined carbohydrates. “The patient should be encouraged to include protein and fiber at all eating events, spacing meals and snacks to every three to four hours,” Majumdar says. “If patients are in the habit of forgetting meals, we may use reminder techniques such as timers or apps; we will also discuss snacks and meals for emergencies (shelf-stable foods, protein shakes/bars), and on-the-go eating.” Dumping can occur from consuming added sugars and drinking fluids with meals; however, Majumdar says it’s less likely to be the result of consumption of natural sugars such as fruit, milk, and yogurt. “We advise patients to look for protein shakes with less than 20 g total sugar (from added and total sugars), limit added sugars, and choose products with more protein and fiber compared to sugar,” says Majumdar, who also encourages patients to wait 30 minutes after eating before drinking to prevent dumping. Clients also should be informed about other common complaints after surgery, such as nausea, vomiting, anorexia, dehydration, halitosis, constipation, diarrhea, flatulence, and lactose intolerance. • Meet clients where they are. “Registered dietitians must avoid being ‘food police’ and establish an approachable environment for lifelong follow-up,” Smith says. She suggests offering a long-term support system using a variety of

techniques, “whether that’s through support groups, check-in telephone calls, or individual counseling sessions.” • Treat both conditions—diabetes and bariatric surgery. Don’t assume the patient understands how to manage diabetes. “I sometimes assume a patient has been educated on diabetes and proper eating but find the patient munching on candy to keep blood sugars from falling or drinking juice daily,” Majumdar says. “Starting with a clean slate and educating on how making changes in preparation for surgery or postop can help both with surgery success and blood sugar control.” • Check for vitamin deficiencies, as people with morbid obesity have a higher risk of developing them. Studies have shown that 55% to 80% of those with morbid obesity possibly have a vitamin D deficiency, and nearly 50% of patients seeking bariatric surgery have iron deficiency. Vitamin B12 and thiamin deficiencies also have been identified in bariatric surgery candidates. Majumdar suggests nutrition professionals “look closer for deficiencies such as B12 or other B vitamins in patients with diabetes who have been on metformin, both preoperatively and postop.” — Constance Brown-Riggs, MSEd, RD, CDE, CDN, is a national speaker and coauthor of the Diabetes Guide to Enjoying Foods of the World, a convenient guide to help people with diabetes enjoy all the flavors of the world while still following a healthful meal plan.

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

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MLDE, a nationally recognized speaker, book author, and past president of the American Association of Diabetes Educators, who provides nutrition counseling and diabetes self-management education and support. Personalizing the diet plan while considering individual goals, health beliefs, culture, religion, economics, and metabolic goals is critical, she says. Below are three dietary patterns that show promise for managing or reversing prediabetes.

Mediterranean-Style Diet

Lifestyle Strategies for Reversing Prediabetes It’s Not All About Weight Loss By Jill Weisenberger, MS, RDN, CDE, CHWC, FAND

shocking 84 million adults in the United States are estimated to have prediabetes. Perhaps even more shocking is that a mere 12% of them have received the diagnosis.1 The other 70 million are unaware they have a disorder that places them at increased risk of developing type 2 diabetes, heart disease, stroke, and even some types of cancer. To increase awareness, the Centers for Disease Control and Prevention and other organizations are running a multimedia campaign. Dietitians can help people with prediabetes by sharing evidence-based recommendations tailored to their specific needs. A well-known and effective type 2 diabetes prevention strategy is weight loss. Both the federally funded Diabetes Prevention Program and the Finnish Diabetes Prevention Program showed that losing weight lowered the risk of developing type 2 diabetes among people at high risk. But not everyone with prediabetes needs to lose weight, and many individuals with extra weight or obesity don’t want to focus on weight loss. Fortunately, there are additional lifestyle strategies to reduce the risk of type 2 diabetes and perhaps even reverse prediabetes.

Eating Patterns When the emphasis is on wholesome foods, an array of eating patterns may improve glycemia among people with prediabetes, explains Tami Ross, RD, LD, CDE,

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A large meta-analysis of more than 100,000 participants from around the world found that those whose diets most resembled a Mediterranean style were 23% less likely to develop diabetes.2 The PREDIMED study found that after four years, those participants assigned to follow a Mediterranean-style eating pattern were 52% less likely to develop type 2 diabetes than those assigned to a low-fat diet. Though the specific foods eaten in countries surrounding the Mediterranean Sea vary by locale, this dietary pattern centers around fruits, vegetables, whole grains, olive oil, nuts, and other plant foods. In addition, clients will benefit from eating fish at least twice weekly. Wine is frequently consumed with a meal, and fruit is a typical dessert.

The DASH Diet Though the Dietary Approaches to Stop Hypertension (DASH) diet was created and studied to lower blood pressure, ongoing research finds it beneficial for those with prediabetes. A meta-analysis of prospective cohort studies found that the DASH diet reduced the risk of developing type 2 diabetes by 20%.3 In the PREMIER study, individuals with high blood pressure who followed a DASH eating plan experienced improved fasting insulin and glucose levels as well as enhanced insulin action.4 Additional research shows that the DASH eating pattern improves dyslipidemia, lowers CVD risk, and is linked to lower risk of obesity.5 Though similar in many ways to a Mediterranean-style diet, the DASH eating plan is lower in fat and richer in animal foods, promoting consumption of fruits, vegetables, poultry, fish, nuts, whole grains, and nonfat and low-fat dairy products.

Vegan and Vegetarian Diets Epidemiologic studies support the use of vegan and vegetarian diets in the prevention of type 2 diabetes. For example, researchers from the Adventist Health Study-2 found that vegan diets protected against type 2 diabetes compared with nonvegan diets even when they accounted for other lifestyle factors and BMI. In this study, all types of vegetarian diets offered some protection compared with nonvegetarian diets.6 Possible mechanisms for this reduced risk include greater fiber and low heme iron intakes and healthier weight status.7

Individual Foods Though the emphasis should be on an overall healthful eating pattern, the American Diabetes Association (ADA) reports there’s evidence that eating specific foods may help lower risk. Higher intakes of coffee, tea, yogurt, berries, and nuts are associated with reduced risk of type 2 diabetes.8 Other foods have been studied for their effects on insulin sensitivity and glycemic control. Several foods with potential benefit include the following: • Oats and barley. These whole grains contain the viscous fiber beta-glucan, which improves insulin action and lowers blood glucose levels. As a bonus, it sweeps cholesterol from the digestive tract, lowering blood cholesterol levels and reducing CVD risk.9 • Legumes. Studies show that diets rich in beans, peas, and lentils have beneficial effects on both short-term and longterm fasting blood glucose levels.10 Possible mechanisms include their magnesium, phytonutrients, dietary fibers, and resistant starches, which resist digestion in the small intestine and are later fermented by bacteria in the colon. • Nuts. Though each type of nut has a unique nutrient profile, nuts are a source of unsaturated fats, magnesium, folate, fiber, and a host of phytonutrients. • Berries. A Finnish study found that middle-aged and older men who consumed the most berries had a 35% lower risk of developing type 2 diabetes.11 • Yogurt. Researchers following participants in the Health Professionals Follow-Up Study, the Nurses’ Health Study, and the Nurses’ Health Study II found that an increase of one serving of yogurt per day was associated with an 18% reduced risk of developing the disease. The mechanism by which yogurt influences diabetes risk is unclear, but it may be related to its probiotics or unique nutritional profile.12 • Coffee and tea. The habitual consumption of either beverage is associated with decreased risks of developing type 2 diabetes. Mechanisms are unclear and may be related to the unique phytonutrients present in coffee and tea.13,14 Dietitians should advise clients to avoid common high-calorie add-ins such as whipped cream, heavy creamers, and syrups. Moreover, the ADA states that red meats and sugarsweetened beverages are associated with a greater risk of the disorder.8 Overall, a balanced eating pattern with an emphasis on wholesome food choices rather than macronutrient distribution appears effective in decreasing the risk of developing type 2 diabetes.

Physical Activity Even without weight loss, moving the body helps prevent type 2 diabetes. 1. Cardiovascular exercise. The ADA recommends people at risk of type 2 diabetes engage in at least 150 minutes of

moderate-intensity physical activity, such as brisk walking, each week.8 Exercise improves insulin resistance for two to 48 hours, so clients should be encouraged to exercise as frequently as possible, even if they don’t make time for the full 150 minutes each week. To help resistant or hesitant clients achieve the exercise goal, Nashville-based Lindsey Joe, RDN, LDN, a DPP Lifestyle Coach, encourages them to break it up into 10-minute sessions. “It’s amazing where you can find pockets of time if you prioritize using them for activity and not scrolling on social media,” she says. 2. Lift weights. “Resistance training is probably the most important exercise of all for anyone wanting to prevent type 2 diabetes,” says Sheri Colberg, PhD, FACSM, a professor emerita at Old Dominion University in Norfolk, Virginia. “We store most of the carbohydrates we eat in our muscles.” Resistance training builds more muscle, giving us more storage capacity for blood glucose, she says. 3. Reduce sedentary time. Even regular exercisers should avoid prolonged periods of sedentary behavior. The ADA recommends breaking up periods of inactivity with at least three minutes of walking, leg lifts, standing, or other light activity every 30 minutes. These activities stimulate the muscles to use blood sugar, Colberg says.

Sleep When time is tight, many people skimp on sleep without knowing that shortened sleep or poor sleep can harm their health. In a meta-analysis of 482,502 participants, researchers observed a U-shaped dose-response relationship between sleep duration and risk of type 2 diabetes. The lowest risk of developing the disease was associated with a sleep duration of seven to eight hours per night.15 Research suggests that chronic and acute sleep deprivation impact glucose metabolism. For example, in a small study of healthy adults, one night of sleep restricted to four hours resulted in decreased insulin sensitivity of 19% to 25%.16 Dietitians can coach clients to set goals around bedtime and look for solutions to common obstacles of getting too little sleep. Though the majority of people with prediabetes will benefit from losing weight, it isn’t the only successful strategy for diabetes prevention or delay. Even in the absence of weight loss, healthful eating, physical activity, and other lifestyle behaviors can improve health and prevent or delay the onset of type 2 diabetes. — Jill Weisenberger, MS, RDN, CDE, CHWC, FAND, is the author of the newly released book Prediabetes: A Complete Guide. She’s a freelance writer and consultant to the food industry, and she has a private practice in Newport News, Virginia.

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

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every aspect of diabetes care requires balancing medical care with one’s personal life—24 hours a day, seven days a week. The intensity of these self-management efforts can overwhelm patients with diabetes very quickly. Diabetes distress is estimated to occur in about one-half of those with type 1 or type 2 diabetes.1 Common emotional stressors that can lead to diabetes distress include the following: • remembering to take medications at the

right time every day; • worrying about hypoglycemia; • affording the recent tremendous increase

in the cost of insulin; • fearing the development of serious

Mind-Body Exercises and Therapies Mindfulness-based activities can help those with diabetes cope with the stress of their chronic condition. By Jennifer Van Pelt, MA

ue to the potential for serious side effects if diabetes isn’t managed properly, most clients with diabetes will understandably focus on their medications, diet, and blood glucose measurements. Depending on the type and severity of their disease, daily management may be quite rigorous and require diligence, especially with busy work and family schedules. Having to manage diabetes all day every day takes a heavy toll; many patients with diabetes experience emotional and mental distress, mental fatigue, and “burnout” from the daily stresses of diabetes management. Diabetes distress is now a recognized diagnosis, defined as “significant emotional reactions to the diagnosis, threat of complications, selfmanagement demands, or unsupportive social structures” associated with living with diabetes; in many cases, diabetes distress causes a substantial emotional and mental burden. Feelings associated with diabetes distress may run the gamut from anger and denial to frustration and loneliness. Almost

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diabetes-related complications, such as blindness, kidney damage, and foot ulcers leading to amputation; • feeling self-conscious about having to test blood glucose around others; • maintaining a healthful diet appropriate for diabetes management, especially when family members don’t follow the same diet and in social situations centered around food; • feeling alone and isolated while living with diabetes; and • feeling guilty when diabetes management doesn’t go well.

Diabetes distress has been linked to poor adherence to treatment regimens, poor glycemic control, higher rates of complications, and decreased quality of life.1,2 Stress associated with diabetes management can adversely impact glycemic control, leading to rapid and possibly substantial increases in blood glucose levels. These increases may be due to physiologic responses to stress, missing medications due to diabetes distress, or a combination of the two. Stress also leads to negative thinking and emotions, impairs decision making, and causes physical and mental wear and tear. Consistently high levels of stress can lead to anxiety and/or depression; clients with diabetes are at higher risk of developing one or both of these conditions than those without diabetes. Anxiety and depression are underdiagnosed and undertreated in patients with diabetes.3,4 Rates of depression among individuals with type 1 diabetes are three times greater than the general population and two times greater for those with type 2 diabetes.1 Research has

shown that depression affects one’s ability to manage diabetes and may lead to behaviors that worsen the disease, such as smoking, eating poorly, sleeping less, and not exercising. The occurrence of depression in those with diabetes is separate and distinct from diabetes distress; approximately 70% of individuals with diabetes distress don’t meet diagnostic criteria for depression. But the conditions can occur together, and diabetes distress frequently can lead to depression and/or anxiety.1-4

How to Help Clients The American Diabetes Association recommends that all patients with diabetes be routinely screened for psychosocial problems, such as diabetes distress, depression, and anxiety. However, such screening often isn’t performed during medical appointments, and mental/behavioral health services aren’t yet well integrated into diabetes clinical care. Clients with diabetes can be encouraged to ask their physicians about mental health screening. To help individuals with diabetes manage stress, mindbody techniques have been recommended for about 15 years; however, uptake has been slow. Given the overall growing interest and participation in mind-body exercise, meditation, and mindfulness-based stress reduction practices, their application for those with diabetes also is increasing and becoming an integral part of diabetes management. Clients already may be practicing yoga, tai chi, or qigong as part of their exercise program, all of which have mind-body and meditative aspects that help with relaxation and stress management. If your clients with diabetes haven’t yet added one of these activities to their weekly exercise regimen, suggest they do, as all three have been shown to provide benefits to those with diabetes. An April 2018 systematic review found that both tai chi and qigong were effective in reducing fasting blood glucose and BMI in those with diabetes. Tai chi also was found to improve quality of life, while qigong also was found to improve glycosylated hemoglobin and reduce depression.5 A 2016 systematic review found that practicing yoga can lower oxidative stress and blood pressure and improve mood, sleep, quality of life, glycemic control, and lipid levels in type 2 diabetes.6 Several other studies have found similar diabetes-related benefits associated with yoga. Clients don’t need to do vigorous yoga—gentle, slow, and restorative yoga all provide benefits. Adding a mind-body component to diabetes management doesn’t have to involve exercise—benefits can be realized with just a few minutes of relaxation breathing or mindful meditation each day or mindfulness-based therapies. A 2017 systematic review found that mindfulness-based interventions (none involving exercise) reduced distress, depression, and anxiety in those with diabetes.7 A small

2018 study found that a mindfulness-based stress reduction program significantly improved diabetes distress, psychological self-efficacy, depression, anxiety, coping, and self-compassion in patients with diabetes.8 Clients can find mindfulness-based stress reduction programs in their local communities in a range of locations, including community centers and yoga studios, and education and medical facilities. Programs also are available as online courses. For busy clients who prefer not to invest much time or money initially, there are many smartphone and computer apps geared toward daily mindful meditation and stress relief, such as The Mindfulness App, Headspace, Calm, Breathe2Relax, and Stop, Breathe & Think. Some are free, while others offer a free trial and subsequent minimal monthly fees. Mood trackers also are available if clients are interested in tracking the frequency of diabetes-related stress and its impact on their mood. For clients who already are using diabetes apps for tracking and reminders for medication and diet, adding an app for stress management and/or meditation should be relatively easy. Most meditation/ relaxation apps have features that enable the user to choose music, time spent, and visual/audio instructions. Just five to 10 minutes of simple relaxation breathing daily, guided by an app, can help reduce stress. Research on the use of mobile apps for management of diseases, including diabetes, has shown benefits in terms of symptom control and adherence to treatment regimens. Research on general stress reduction from mindful meditation and relaxation apps has shown benefits. However, research on the use of apps specifically for reducing stress associated with chronic disease management is limited. One small study published in 2017 evaluated the use of a mobile app for biofeedback-assisted relaxation on weight, blood pressure, and glycemic measures in seven patients with type 2 diabetes. The researchers found that the app improved glycemic control, weight, and blood pressure, indicating that reducing stress can positively influence disease management.9 Technology and research have brought mindfulness practices and their benefits into the mainstream. In the past, patients with diabetes may have been told to just “deal with” the daily stress of diabetes management. Now, several options for alleviating diabetes distress are easily accessible for clients and patients. — Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

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

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CPE MONTHLY in 2012, severe obesity in childhood is defined as BMI greater than 120% of the 95th percentile values, or a BMI greater than 35 (whichever is lower). This corresponds to approximately the 99th percentile. Unlike in previous generations, a large majority of parents don’t recognize when their children are overweight or obese.3 This is likely because there are many more overweight and obese children now than there were decades ago, so heavier children may be perceived as having a healthy weight. Since parents are unlikely to notice that their children are overweight, pediatricians have an important role in screening for high BMI during visits and subsequently providing an appropriate intervention or referring to another obesity intervention program if a child is found to be overweight or obese.4

Contributors to Childhood Obesity

CHILDHOOD OBESITY PREVENTION AND TREATMENT By Karolina Balkenbush, RDN One-third of children in the United States are overweight or obese. The prevalence of pediatric overweight and obesity has increased greatly since 1980, doubling in children aged 2 to 5 and tripling among those aged 6 to 11 and 12 to 19.1 The proportion of children affected by overweight and obesity is greatest among minority and underserved populations.2 As physicians may have limited nutrition expertise and time to counsel patients on obesity prevention and treatment, RDs should be actively involved as essential members of obesity management teams. This continuing education course discusses the diagnosis of childhood obesity, its complications, evidence-based treatment strategies, and key messages for RDs to communicate to families. The key messages focus on the behavioral contributors to childhood obesity that families can modify by working with RDs. Some suggestions for effectively communicating these key messages also are included.

Assessment of Weight Status Childhood overweight and obesity in children aged 2 to 18 are defined by percentiles of BMI. BMI percentile charts are available at the Centers for Disease Control and Prevention website (www.cdc.gov/growthcharts). Overweight in children is defined as having a BMI between the 85th and 94th percentile. Obesity in this group is defined as having a BMI greater than the 95th percentile. According to Gulati and colleagues in Pediatrics

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Childhood obesity is a complex health issue because there are many contributing causes, associated health risks, and treatment approaches. The main causes of overweight and obesity in children are similar to those in adults. These include a combination of genetic predisposition, behavioral patterns, and environmental factors. Behavioral factors include dietary patterns, physical activity, inactivity, and medication use. Additional contributing factors in our society include food marketing and promotion, foods available for children to consume at home and in school,

COURSE CREDIT: 2 CPEUs

LEARNING OBJECTIVES After completing this continuing education course, nutrition professionals should be better able to: 1. Evaluate childhood overweight and obesity based on BMI percentiles. 2. Identify at least three risk factors for childhood obesity. 2. Distinguish at least three complications of childhood obesity. 4. Manage childhood obesity as part of a multidisciplinary team using evidence-based interventions. Suggested CDR Learning Codes 4150, 5070, 5080, 5370 Suggested CDR Performance Indicators 8.1.4, 8.2.1, 8.3.6, 12.2.1 CPE Level 2

opportunities for children to be physically active at school and home, and education level and skills of children and parents.5 The Academy of Nutrition and Dietetics has published the organization’s position on the prevention and treatment of childhood obesity. Combating the problem requires “systemslevel approaches that include the skills of RDs, as well as consistent and integrated messages and environmental support across all sectors of society to achieve sustained dietary and physical-activity behavior change.”6

Advance Registration for our 2019 Spring Symposium is just $199! www.TodaysDietitian.com/SS19

Complications of Childhood Obesity Overweight children aren’t simply heavier than their peers. Their weight status puts them at greater risk of a variety of physical and mental health problems, even before reaching adulthood.5,7-18 Children who are obese are likely to remain obese as adults. In addition, their degree of obesity and severity of disease risk factors are likely to be more pronounced in adulthood.17,18 Childhood obesity adversely affects the endocrine, cardiovascular, orthopedic, gastrointestinal, and pulmonary systems. It’s associated with greater risk of CVD later in life. Two risk factors of CVD more common in obese children than in healthy-weight children are hypertension and elevated cholesterol. In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more.7 Other studies have shown increased risk of impaired glucose tolerance, insulin resistance, and type 2 diabetes.8 Childhood obesity also is associated with breathing problems, such as sleep apnea and asthma.9,10 Moreover, obese children are likely to develop joint problems and musculoskeletal discomfort.11 They’re at greater risk of having fatty liver disease, gallstones, and gastroesophageal reflux (ie, heartburn).9,10 Many of these comorbidities that used to be considered “adult diseases” are now regularly seen in obese children. Mental health consequences of childhood obesity also are reported. These include a variety of eating disorders, ranging from generalized preoccupation with food and distorted body image to restrictive eating and bulimia nervosa, as well as depression.5 Psychological stress leading to behavioral problems and issues in school have been exhibited,12-14 along with low self-esteem and low self-reported quality of life.15,16

Prevention and Treatment Evidence-based prevention of and treatment for childhood obesity is a priority in health care because targeting this problem early in children’s lives may reduce the likelihood of developing various risk factors associated with obesity in adulthood. Prevention and treatment strategies for pediatric overweight and obesity are commonly categorized along a continuum. Population-level prevention approaches are interventions that are offered to the entire population of children in a community, school, or health care setting. This is referred to as primary prevention and is offered to children of all body sizes and weights.19

Secondary prevention strategies and interventions are more structured and directed at overweight and obese youth to help them achieve a healthier weight. Tertiary prevention interventions are the most intensive and comprehensive medical treatment programs for overweight and obese children and adolescents. These programs are conducted under medical supervision and are designed to resolve or decrease the severity of complications related to excess weight. RDs have a role at each level of prevention. There are several components of a comprehensive intervention program that have been shown to be successful at improving weight and health status in the long term. Effective programs should include changes in nutrition and physical activity along with behavioral therapy.20 Treatment for childhood obesity is based on a child’s age and health status, but it usually includes implementing changes in the child’s diet and physical activity level. In certain circumstances, treatment also may include medications or weight loss surgery. The RD’s role in secondary and tertiary prevention interventions is to provide evidencebased recommendations to families of overweight and obese children and use behavioral therapy techniques to help families apply knowledge. The following section summarizes appropriate recommendations based on review of evidence.

Early Prevention Prevention of childhood obesity should begin early in life, during the fetal period and the first two years of life. Observational studies suggest that these early stages may be critical periods for learning behaviors that lead to obesity.21,22 In addition to learned behaviors, long-term taste preferences are developed in utero and during breast-feeding. Children are likely to prefer the foods their mothers exposed them to at these stages.23 For these reasons, RDs working with expectant mothers and parents of young children should be prepared to assess parental weight status and children’s rate of weight gain as risk factors for later obesity as well as be prepared to assist parents with helping the whole family develop healthful eating and physical activity habits from the start to prevent the progression of childhood obesity. Since the frequency of doctor visits is highest for expectant mothers compared with any other time in the lifespan, RDs august 2018 www.todaysdietitian.com 53

CPE MONTHLY working in collaboration with OB/GYN clinicians and WIC have an excellent opportunity to provide dietary counseling to these women. For example, RDs can expect to assist with implementing a plan to gain only the recommended amount of weight during pregnancy. They also have a role in educating mothers about the importance of breast-feeding. For each additional month that a woman breast-feeds, the risk of childhood obesity decreases.24

Key Messages Used in Treatment and Prevention The following key messages are a sampling of the evidencebased guidance currently available to RDs. They’re used in prevention and treatment. In counseling, these messages should be communicated to families in a way that’s culturally appropriate and memorable. Messages should be presented in a manner that’s sensitive to each individual family’s socioeconomic status and psychological characteristics, and to the child’s developmental stage.4 Each section provides examples or information that help RDs translate research data into guidance that’s most likely to yield behavior change.

Curb Calorie Intake Evidence suggests that a calorie-restricted diet may be effective for short- and long-term weight management in children aged 6 to 12 when implemented as part of a multicomponent program.6,7 This reduced-calorie diet should have fewer calories than required to maintain weight but not less than 1,200 kcal per day.25 Low-glycemic load diets show the most promise for management of pediatric obesity.26 Typically, a balanced macronutrient nutrition prescription is appropriate. A balanced macronutrient diet for children is defined by the Institute of Medicine’s Dietary Reference Intakes as 45% to 65% calories from carbohydrates, 10% to 35% calories from protein, and 20% to 35% calories from fat. A “nutrition prescription” should be provided as part of the dietary intervention in a weight-management program for children. The prescribed calorie level and nutrient specifications often form the basis of the recommended eating plan and corresponding nutrition interventions, such as smaller portion sizes or increased intake of fruits and vegetables. Research shows that when an individualized “nutrition prescription” is included, improvements in weight status are more consistently observed among overweight children and teens than when the specific eating guidelines aren’t provided. Therefore, RDs are encouraged to provide specific guidance to families by providing sample meal plans or meal patterns to structure daily eating with a calorie goal in mind. Sample meal plans and eating patterns are available at ChooseMyPlate.gov.

Limit High-Calorie Foods and Sugar-Sweetened Drinks Children are at greater risk of excess body fat when they consume a diet rich in high-energy density foods.27 Highenergy density foods, commonly known as calorie-dense foods, are those that have a large number of calories in a small

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portion size. Examples of these foods are those high in fat and sugar such as pastries, cookies, crackers, chips, and sweets.28 These foods are common calorie sources in children’s diets. Beverages also are major contributors of calories in children’s diets in the United States. In fact, sugar-sweetened beverages are the largest source of added sugars in their diets.29 Large consumption of sugary beverages, such as soda and sports drinks, has been associated with obesity.30 On a typical day, 80% of children drink sugar-sweetened beverages, which typically are devoid of nutrients.31 Reducing intake of sugary beverages may be one of the easiest and most effective ways to reduce excess calories in children’s diets.32 RDs should educate families on identifying sugary beverages. Much like soda, fruit juice is an energy-dense beverage. While 100% fruit juice is nutrient rich, consumption should be limited to avoid excess calorie and sugar intake. Fruit juice should be limited to 6 oz per day for children aged 1 to 6 and 12 oz per day for children aged 7 to 18.33 Families should be reminded that plain water is the most healthful choice. The use of artificially sweetened beverages is controversial because these drinks may reinforce the habit of consuming sweet drinks, but they can provide an alternative to full-calorie sugary drinks as children transition to drinking plain water. The role of low-calorie beverages remains an area of ongoing research and debate, but use of nonnutritive sweeteners hasn’t been associated with weight gain among children in several longitudinal studies.34-36 However, they should be used in limited quantities, as there’s

emerging evidence in humans that calorie-free sweeteners may alter gut bacteria, thereby impairing glucose tolerance.37 The American Heart Association recently released guidance on consumption of added sugars. While adults are instructed to consume no more than 10% of their daily calories from added sugars, children are advised to consume no more than 25 g added sugars per day.38 This amounts to approximately six teaspoons. RDs should be prepared to teach families how to read food labels and provide examples of alternatives to foods and beverages high in added sugars.

Appropriate Portion Sizes Over the past several decades, portion sizes of high-calorie, low-nutrient density foods and drinks sold in restaurants, grocery stores, and vending machines have increased. Evidence suggests that children eat more if they’re served larger portions.39 This can mean they’re consuming many extra calories without realizing it, especially when eating high-calorie foods. RDs should instruct parents to offer healthful foods in age-appropriate portions at meals and snacks and let the child decide how much to eat of what’s offered. The American Academy of Pediatrics has developed a helpful chart suggesting appropriate portion sizes for children based on age.40 RDs can use this chart to educate parents on the appropriate serving sizes for children.

Healthful Food Choices It’s been shown that consuming high-energy density foods is associated with excessive calorie intake and overweight in children.41 Since fiber-rich foods tend to be lower in calories, it’s likely that diets rich in fruits, vegetables, whole grains, beans, and nuts may be effective in preventing and treating obesity in children. High-fiber diets also may have a role in the prevention of CVD and type 2 diabetes, independent of their effect on weight management.42 Increased fruit and vegetable intake is associated with a decreased risk of childhood obesity.43 RDs can help by advising families about food shopping, meal planning, food preparation, and making healthful choices while eating out to maximize intake of fiber and nutritious foods. RDs can lead creative interventions such as grocery shopping tours, group nutrition classes, and cooking classes to show families how to introduce unfamiliar foods. In addition, RDs can advise families about strategies to overcome picky eating when introducing healthful food choices such as fruits and vegetables.

Limit Eating Out Children, particularly adolescents, are at higher risk of obesity if they eat out frequently. This can be true if they eat at fast food restaurants often (more than twice per week). Furthermore, some evidence suggests that a greater degree of obesity results from eating fast food regularly year after year.45,46 RDs can help families devise a personalized plan to decrease fast food consumption and advise them on more healthful fast food and restaurant menu options. For example, if a family eats at a particular fast food chain often, an RD can print out a current list of menu items with less than 500 kcal for the family to reference. Alternatively, an RD can suggest quick and easy meals to prepare at home or identify strategies to add fresh produce to takeout meals to transition to eating meals prepared at home more often.

Regulate Screen Time While there are many potential causes of childhood obesity stemming from physical inactivity and poor dietary habits, some of the strongest evidence of a behavioral risk suggests that excessive television viewing is largely to blame. In fact, limiting screen time is supported as a primary prevention strategy for reducing the risk of overweight and other chronic diseases.47 The American Academy of Pediatrics recommends that children younger than age 2 avoid screen time entirely and children older than age 2 should view no more than one hour per day.48 Because many forms of sedentary entertainment, such as smartphones, tablets, video games, and computers are widely available and less studied, it’s reasonable to assume that use of these electronics also should be limited.4 RDs should encourage parents to be actively involved in setting, monitoring, and enforcing screen time limits. A key recommendation here is to keep televisions out of children’s bedrooms. As smartphone and tablet technology is increasingly available to children, new applications also are being developed to make limiting time on these devices easier for families. RDs should be prepared to discuss suggestions for screen time alternatives to occupy children’s time, such as age-appropriate chores, inexpensive family activities, and fun hobbies. A common misconception is to assume that it’s fine for children to spend more than the recommended amount of time on electronics as long as they’re exercising enough. It’s important to stress to parents that limiting sedentary activities is warranted regardless of increases in exercise; both should be emphasized. In fact, limiting screen time appears to be more effective than increasing physical activity to control weight.49

Don’t Skip Breakfast Lean children are more likely to eat breakfast daily and eat larger breakfasts than are heavier children. Older children and teens appear to be especially at risk of higher body fat if they skip breakfast.44 RDs should encourage children to eat breakfast every day and help families overcome the common reasons for skipping breakfast, such as limited time or poor appetite in the morning.4

Increase Physical Activity In addition to encouraging children to reduce time spent in sedentary activities, RDs should encourage increases in both structured and nonstructured physical activity because time spent this way likely plays a role in preventing weight gain and associated health problems.50 On the other hand, physical inactivity puts school-age children at risk of obesity august 2018 www.todaysdietitian.com 55

CPE MONTHLY and insulin resistance.51 The USDA recommends children and adolescents participate in 60 minutes of moderate-intensity physical activity most days of the week, preferably daily.52 RDs can encourage parents to help children meet this activity goal by serving as role models and exercising together as a family. RDs should be able to provide information to families about community resources such as local parks, recreation centers, walking paths, family gyms, and sports leagues. If outdoor physical activity isn’t a realistic option for families, indoor activities, such as exercising to videos, doing yoga, using hula hoops, dancing, or jumping rope, should be encouraged. Moreover, RDs should be realistic in setting goals for very obese or deconditioned children, who may need to start with lower-intensity exercise for shorter periods of time than the USDA-recommended 60 minutes.

Get Enough Sleep Insufficient sleep may be one of many contributors to childhood obesity.53 Sleep deprivation impairs attention, impulse control, and higher-level problem solving, all of which can contribute to poor dietary choices.54 In their assessment of a child’s obesity risk, RDs should ask parents about the child’s sleep habits. RDs can determine any problematic sleeping patterns suspected and help parents improve their child’s sleep habits. Helpful suggestions include removing electronics from children’s bedrooms and enforcing boundaries around bedtime to achieve appropriate targets for sleep duration.4 The National Sleep Foundation has developed the following recommendations as of February 2015:55 • newborns (0 to 3 months): 14 to 17 hours each day; • infants (4 to 11 months): 12 to 15 hours; • toddlers (1 to 2 years): 11 to 14 hours; • preschoolers (3 to 5): 10 to 13 hours; • school age children (6 to 13): 9 to 11 hours; • teenagers (14 to 17): 8 to 10 hours; and • younger adults (18 to 25): 7 to 9 hours.

Behavior Modification It’s clear from the evidence that the most effective treatment strategies for childhood obesity include changing dietary and physical activity habits; simply providing information about needed interventions, however, is ineffective.56 Lifestyle change resulting in weight loss must be facilitated through behavioral therapy, which commonly focuses on modifying and controlling the foods and opportunities for physical activity available to children. Stimulus control and regular self-monitoring of weight, eating, and physical activity have been shown to be effective behaviors for weight management.57 Stimulus control means restructuring the home to encourage healthful eating and activity behaviors and discourage unhealthful behaviors. Children benefit from family-based interventions, in which parents are actively involved in treatment. Whether parents

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are successful in controlling their own weight predicts the success their children will have in weight management.58 Therefore, parents should be taught to serve as role models for their children by monitoring and modifying their own eating and exercise habits. Behavior change in children often results from a system of consequences and rewards. Rewards appear to be particularly effective in encouraging children to achieve their goals. RDs can instruct parents to have a system for rewarding achievements such as losing weight, cutting back on portion sizes, increasing exercise, or decreasing screen time. Instead of using food rewards, ideal incentives promote healthful behavior.59 Nonfood rewards include new sports equipment, family hikes, bike rides, and swimming. In addition to role modeling and providing consistent reinforcement, parents should be taught how to implement stimulus control strategies. For example, RDs may suggest keeping nutritious foods readily available, perhaps by keeping a bowl of fruit on the counter while keeping sugary snacks out of the house. Ultimately, RDs should emphasize the importance of family involvement in making lifestyle changes and teach them the aforementioned skills to develop healthful behaviors and improve children’s weight. Specific family praise also is effective in reinforcing positive behaviors.60 Within various practice settings, RDs are encouraged to develop creative interventions to address childhood obesity. The behavior-centered design, a relatively novel approach to behavior change, suggests that behavior change messages are more effective when the intervention is creative and surprising.61 Many inexpensive and effective visual demonstrations come to mind, particularly for communicating the excess of sugar in children’s diets. To educate families about the importance of reducing intake of sugar-sweetened beverages, don’t simply state the risks associated with excess sugar. Instead, show a soda can alongside a clear sandwich bag containing 10 teaspoons of sugar to make the message more memorable and shocking. This image can be made even more impactful by creating a similar prop to illustrate the amount of sugar consumed over the course of a week or even a year by someone who drinks just one can of soda per day. In addition to the counseling RDs provide, effective pediatric weight management programs can be structured to last 12 weeks and include behavioral therapy sessions with a psychologist as a complement to diet and exercise education.

Medications Weight loss medications sometimes have a role in pediatric weight management. They’re only prescribed to patients who haven’t been successful in achieving a healthier weight with structured diet and lifestyle modification programs and have significant health risks associated with their weight. These patients must understand the limitations of pharmacotherapy and the need to make lifestyle changes in addition to taking weight loss medications. It’s important for RDs to be aware of weight loss medications approved for use in children

and teens and to appropriately counsel children and their parents stating that weight loss medication should be used only as part of weight loss therapy that includes diet, physical activity, and behavior modification.25 Obese children who may benefit from pharmacotherapy should be referred to a tertiary care center for evaluation and treatment. Currently, Orlistat is the only prescription weight loss medication in the United States that’s approved for obesity treatment in adolescents aged 12 and older.6 It’s not approved for use in children younger than 12. This medication blocks the absorption of fat in the intestine by inhibiting the enzyme lipase. It’s been shown to be moderately effective in adolescents. Short-term weight loss of one year or less has been observed when orlistat was prescribed in conjunction with a weight loss program including diet, exercise, and behavior therapy.62 The use of orlistat is limited by unpleasant gastrointestinal symptoms, and its efficacy long term hasn’t been thoroughly studied. Metformin, a drug approved for treatment of type 2 diabetes in children aged 10 or older, is currently being considered as a weight loss drug as well, though it’s not yet FDA approved for this purpose. Metformin is an antihyperglycemic drug that can reduce insulin resistance and hyperinsulinemia, thereby reducing hunger and decreasing fat storage.63 A recent review of literature has suggested that Metformin provides a statistically significant but modest reduction in BMI when combined with lifestyle interventions over the short term. It wasn’t shown to be superior to other interventions for childhood obesity.64

In most cases, the general goal for all ages is for BMI to trend downward until it’s below the 85th percentile. Some children are healthy with BMI values between the 85th and 95th percentiles. If they have no additional cardiovascular risk factors at this BMI range, weight maintenance may be recommended. In the case of comorbid conditions and complications, resolution of these also is a goal.25 Once weight loss goals are met, it’s imperative for RDs to continue assisting clients with a weight maintenance program.70 An optimal length of time between follow-up visits with RDs hasn’t been established; therefore, RDs should work with families on a case-by-case basis to schedule timely assessments. A 2016 study reported that continuing to follow up with a dietitian was associated with greater improvements in BMI.71 Unfortunately, this study also stated that a majority of families don’t seek continued support from a dietitian. Improving compliance with follow-up and dietary interventions is an important topic for further research.

Surgery

Putting It Into Practice

Bariatric surgery is an increasingly common option for some obese teens, typically those with severe comorbidities who have failed to benefit from a more conservative medically supervised treatment for at least six months.6 While overweight and obesity in teens are defined by BMI percentiles, indication for bariatric surgery is determined by BMI index thresholds. The most recent guidelines by the American Society for Metabolic and Bariatric Surgery recommend the following BMI thresholds for obese adolescents to be eligible: BMI greater than 35 with serious comorbidity or BMI greater than 40 with less severe comorbidity. This recommendation is backed by evidence that bariatric surgery in teens has been shown to consistently confer sustained and clinically significant weight loss as well as resolution of comorbidities.65 Despite positive outcomes, it’s important to note that complications sometimes do arise. At five-year follow up postsurgery, many teens still have BMIs over 35, vitamin D and B12 deficiency, iron-deficiency anemia, and surgical complications that have resulted in reoperation.66 The most common bariatric procedures performed on adolescents are Roux-en-Y gastric bypass, which resections the stomach to a small pouch that limits the amount of food that can be consumed in one sitting, and sleeve gastrectomy.67 Sleeve gastrectomy is less complex than Roux-en-Y and

The most effective way in which RDs can improve outcomes for overweight children and adolescents is by working as part of a multidisciplinary team in a multicomponent pediatric obesity program that teaches healthful eating, exercise, and behavior modification strategies to children and their parents or caregivers. RDs are reminded to provide nutrition education along with a diet prescription and training for parents or caregivers to be the key agents of change in the treatment of their child’s obesity.72 The childhood obesity epidemic is an urgent public health problem; therefore, RDs working in this field are encouraged to develop, implement, and evaluate creative interventions to contribute to the flourishing research on the prevention and treatment of childhood obesity.

has a lower theoretical risk of micronutrient deficiencies, but it may be less effective long term.68 Its popularity has increased rapidly over the past decade, now accounting for 80% of bariatric surgical procedures in adolescents.69 RDs assist with preparing the family for lifestyle changes required with bariatric surgery and, along with a team of specialists, participate in long-term follow-up care of the metabolic and psychosocial needs of the patient and family.

Weight Loss Goals

— Karolina Balkenbush, RDN, is program coordinator of the Healthy Hearts Program, a clinical-based, multicomponent pediatric obesity treatment program at the Children’s Heart Center, a pediatric cardiology practice in Las Vegas.

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

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CPE MONTHLY

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

CPE Monthly Examination 1. Obesity in children is determined by which of the

following? a. BMI greater than 25 b. BMI greater than 30 c. BMI greater than the 85th percentile for gender and age d. BMI greater than the 95th percentile for gender and age 2. Which of the following is a tertiary prevention

intervention for childhood obesity? a. S erving more healthful school lunches b. Enrolling the patient in a medically supervised weight loss program c. Increasing the physical education requirement in schools d. Having the patient make an annual pediatrician visit to screen for obesity 3. What’s the best way for parents to address a child’s

weight problem? a. D iscuss the weight problem directly with the child. b. Restrict second helpings at meals. c. Teach the child to keep a detailed food log. d. Model healthful eating and exercise behaviors. 4. The best evidence exists for which of the following

diet types for treating childhood obesity? a. L ow-glycemic load, reduced-calorie diet b. Ketogenic, reduced-calorie diet c. Low-fat, reduced-calorie diet d. High-protein, reduced-calorie diet 5. How much added sugar does the American Heart Association recommend for children aged 2 to 18? a. Up to 25 g per day b. Up to 10% of daily calories c. Up to 50 g per day d. Up to 20% of daily calories

6. What is the American Academy of Pediatrics’ recommendation for screen time among school-aged children? a. Up to 30 minutes per day b. Up to one hour per day c. Up to two hours per day d. Up to three hours per day 7. What level of activity does the USDA recommend for children and adolescents? a. W ork up to at least 30 minutes of low-intensity physical activity daily. b. Work up to at least one hour of moderate-intensity physical activity most days of the week. c. Work up to at least 20 minutes of high-intensity physical activity daily. d. Work up to at least two hours of moderateintensity physical activity several days per week. 8. At what age should childhood obesity prevention begin? a. Fetal period to age 2 b. Ages 2 to 5 c. As soon as children enter kindergarten d. As soon as children pass through puberty 9. Which weight loss medication is approved for use in adolescents? a. Metformin b. Orlistat c. Ephedra d. Phentermine 10. Which of the following is a key message for RDs to

communicate to families as recommendations for their overweight children? a. Engage in time-restricted eating. b. Avoid skipping breakfast. c. Pack lunch for school. d. Avoid eating dinner after 5 pm.

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.

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PRODUCTS + SERVICES

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Bean Pasta Introduced Explore Cuisine, maker of bean and rice pastas, launches Organic Mung Bean Rotini pasta. Made from only organic mung bean flour, the pasta is an excellent source of protein, fiber, and potassium, and a good source of iron per 180-kcal serving. The pasta is Certified Gluten-Free, Certified Vegan, kosher, and Non-GMO Project Verified. www.explorecuisine.com

New Vegan Sipping Broths Millie’s has unveiled a line of vegetable sipping broths in Tomato Basil, Thai Lemongrass, Curry Spice, Delight Pho, Spicy Tortilla, and Smoky Facon varieties. All varieties consist of vegetables, herbs and spices, and decaf green tea in a broth tea bag, ready to be steeped in hot water; are gluten-free and vegan; and contain less than 300 mg sodium per bag. http://sippingbroth.com

Rose Sparkling Water Petal debuts a line of sparkling botanical blends made with rose water in Original Rose, Mint Rose, and Lychee Rose varieties. It contains 0 kcal and is sweetened with stevia and erythritol. Petal also is certified USDA Organic. www.drinkpetal.com

Frozen Pops Released JonnyPops, maker of fruit and cream frozen pops, unveils its Delights line with five new varieties: Root Beer Float & Cream, Dark Chocolate & Cream, Cherry Chocolate & Cream, Vanilla Mint Chocolate & Cream, and Cold Press Coffee Chocolate & Cream. JonnyPops are made with real cream and no artificial ingredients and contain fewer than 200 kcal per pop, and some varieties are a good source of vitamin A. www.jonnypops.com

Fruit Medley Chips Bare Snacks, maker of a variety of fruit, vegetable, and coconut chips, unveils a new fruit chip medley that includes dried strawberries, bananas, and pineapple. Made with only those ingredients, the baked chips are fat-free, gluten-free, and Non-GMO Project Verified. https://baresnacks.com

Apple ‘Donuts’ Debut Edible, maker of fruit arrangements, introduces Edible Donuts made from donut-shaped slices of Granny Smith apples covered with semisweet chocolate and sprinkles, coconut shavings, or caramelized hazelnuts. They’re available by the dozen or half-dozen, in two- or three-packs, or in one of Edible’s fruit arrangements. www.ediblearrangements.com

Chia Bars Unveiled Health Warrior, maker of protein bars and chia seeds, debuts its Chia Bar line. Each bar is made from a base of chia seeds and nuts and/or nut butter, contains 90 to 100 kcal and 3 g sugar, and is a good to excellent source of fiber. Available varieties include Acai Berry, Apple Cinnamon, Banana Nut, Beauty Begins Within Dragon Fruit, Caramel Sea Salt, Chocolate Peanut Butter, Coconut, Dark Chocolate Cherry, Dark Chocolate, Mango, and Vanilla Almond. All are kosher, vegan, Certified Gluten-Free, and Non-GMO Project Verified, and contain 1,100 mg omega-3s. www.healthwarrior.com august 2018 www.todaysdietitian.com 59

GET TO KNOW …

LISA DRAYER

Nutrition, Media, and Beauty From the Inside Out By Lindsey Getz Though she started out as a premed student, Lisa Drayer, MA, RD, admits she hated the sight of blood and wasn’t sure how she would reconcile that fear as a doctor. She had always loved the analytical aspect of studying science—and she particularly loved the research—but she wasn’t crazy about the “hands-on” aspect of practicing medicine. During the summer after her freshman year, Drayer met with a nutritionist about dropping the “freshman 15” she’d gained. She was intrigued by what she heard and learning that being a nutritionist involved research and a good understanding of the sciences. That’s when Drayer decided she would transfer from University of Michigan to Cornell University to pursue a degree in nutrition. After graduating at the top of her class, Drayer went on to complete the dietetic internship at Brigham and Women’s Hospital. However, she admits she was disillusioned from what she had envisioned her career to be.

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“Suddenly everything I had disliked about medicine was presenting itself in the clinical setting,” Drayer says. “It was a very difficult year for me. I had studied nutrition and been incredibly passionate about it and suddenly I wasn’t sure if I had made the right choice.” But she powered through, earned her credentials, and ultimately took a job counseling patients in a medical office and began seeing private clients on the side. She was happier but still hadn’t found her true calling. Having heard about a master’s in science journalism program, she decided to give it a shot, and that’s where Drayer says her vision for her future finally came together. After obtaining a journalism degree, Drayer took an editorial manager position at an online diet website called DietWatch.com. During this time, she was asked to appear on CNN for several nutrition topics. For several years she did television work on the side—getting into the CNN studio around 5 am before going to her editorial job. From these occasional appearances, Drayer’s future was born. She became a regular contributor at CNN and the go-to dietitian for the network’s primetime programming. She also created and developed CNN’s “Breakfast With Daybreak” segment, producing and delivering health and nutrition reports for CNN’s flagship morning show and concurrently appearing on CNN’s sister network Headline News. During this time, Drayer also penned two books: The Beauty Diet: Looking Great Has Never Been So Delicious and Strong, Slim, and 30!: Eat Right, Stay Young, Feel Great, and Look Fabulous. She has appeared on numerous other television and radio shows, written for a variety of magazines, and earned the Academy of Nutrition and Dietetics’ Media Excellence Award for her dedication to journalism. Today, she works for CNN Health and is focused on its digital content. This includes a lot of writing as well as video work. However, Drayer says her greatest job of all is being a mom to two girls, Brooke, age 8, and Elle, age 5, who keep her quite busy. She lives in Manhattan with her husband and daughters while spending summers on Long Island at the family’s Southampton home. “I can write from anywhere and I love the summer break from the city,” Drayer says. “I get to swim and spend quality time all summer long with the girls while still making sure I file my assignments on time. It’s the best of both worlds for me.” Today’s Dietitian (TD): Is there any such thing as a typical day for you? Drayer: No, not really. My job allows me the flexibility to be the type of mom I want to be—and that comes first for me. Today, for instance, I was able to go to the Central Park Zoo for a field trip with my daughter before coming into my office to work on some writing projects. So, no day is truly typical. But a good chunk of my day is generally spent on writing. I turn in articles on a weekly basis, and that requires structured time in my office or a local library, where a lot of writers go because it’s so quiet you can hear a pin drop.

On a shoot day, it’s much different. I have to arrive by 7:45 am and be in the studio by 9 am with hair and makeup already done. Then I generally have an hour to shoot before the next show has to come in. I don’t use a teleprompter, so it’s quite challenging, as we have to get things done smoothly and quickly! My days ebb and flow in terms of intensity, and that keeps it interesting. But my favorite part of the day is walking one of my daughters to school—my husband walks our other daughter. And I try to be there for pick-up, too. We often like to cook together and then share dinner as a family. A lot of it is working around their schedule, which may mean working again after they go to sleep. As often as I can, I also like to fit in a workout. That might mean taking a yoga class, doing Pilates, going for a walk or jog around the reservoir in Manhattan, or playing tennis. TD: What do you like to cook with the girls? Drayer: They love helping me cook and bake, and we do a lot of it on the weekends. They’re at such a fun age and they wear their little aprons and just have a lot of fun with it. One of their favorite things to make is ricotta gnocchi—rolling the balls is a lot like playing with Play-Doh. That’s their favorite recipe, and I like it too because it’s lighter than potato gnocchi. I also like making healthy mac n’ cheese that has mushrooms and spinach. And we recently made a vegan avocado lime dessert that everyone liked. Cooking with my kids gives me first-hand experience of ways to help children eat healthfully. I write a lot about it and now I get to experience it—and that often gives me a lot of ideas for articles or television segments. They’re good sports about it and enjoy helping me. TD: Do you like to dine out as well? Drayer: Absolutely. I usually like to order a salad and a piece of fish when I dine out, but I won’t deprive myself if there’s something really indulgent on the menu that I want to try. I’ll just ask for a half portion or plan to take some of it home. I love food and I believe strongly in portion control. Eating is one of life’s pleasures, and being able to try new things and delicious dishes is something I enjoy. I always save room for some dessert when I dine out. TD: What’s your favorite dessert? Drayer: I love a scoop of salted caramel ice cream or gelato. I just feel like cake or pie is often too much after a meal. But a tasty scoop of ice cream or even sorbet changes the palate and feels light and refreshing. TD: You mentioned that media work was your true calling. What do you like so much about it? Drayer: I’m an educator at heart. I love the idea of teaching. My goal has always been to translate complex science into language that people can understand and apply to their lives. That was the essence of my journalism training. It also requires some analytical skill, which has always been a

strength. In general, the messaging about being healthy or being “well” is also consistent with what has always resonated with me and my beliefs. If I had to define my platform, or what I’d consider my calling card, it would be beauty from the inside out. I read a lot of studies when I wrote the beauty book and I feel like one piece to inner beauty is nutrition— but that’s just one extension of it. As a wife and a mother, the idea of inner beauty resonates strongly with me and I appreciate the opportunity to convey a healthy message about what beauty means within the media. TD: Is there anything you find especially challenging about working in the media? Drayer: The media is a tough field in that it lacks a degree of continuity or more defined “ladder” you might get from other industries. There are so many changes and paths it can take—even on a daily basis—and there is a lot of unknown. But in a sense, I think that’s a heightened sense of what life is all about. On some level, none of us knows where our lives are truly headed. As a mom, I feel as though I deal with a lot of unknowns. One day, one of my girls might wake up not feeling well and they’re unable to go to school, and I have to drop everything and figure out a solution to make that day work. If you think about it this way, media is a template for life. I feel like it prepared me for being a mom in that way— in the sense that I feel more confident about handling the uncertainty. I never know what each day may hold, but I’m prepared to tackle it. TD: What advice do you have for RDs who would like to pursue a media career like yours? Drayer: I would say it’s important to give some thought as to what role you would like the media to play in your career. It could be writing or blogging in order to promote your own brand or business. It could be doing spokesperson work for companies that align with your brand. Or you could be working in the role of a traditional journalist, where it’s less about your own opinion and more about covering different sides of a story through an objective lens. Each of these roles will have its own set of priorities and allegiances, and it’s important to know that. Also, consider the skills required in each role. Speaking in front of the camera, especially live, is very different from researching or writing at a desk. It’s also important to be focused and persistent. It can take many efforts over time before you end up in the role you wish for, but it will pay off if you continue to be true to yourself and align yourself with opportunities that make sense for your goals. Finally, it’s important to develop a thick skin. Don’t take things too personally, and don’t let rejection get you discouraged—it often has nothing to do with your personal circumstances, so pick yourself up and go where the door is open! — Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.

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FOCUS ON FITNESS

ECO-FRIENDLY EXERCISE By Jennifer Van Pelt, MA It seems that millennials are being blamed for many things— almost every day I see a meme or hear someone over the age of 35 criticizing millennials’ behavior. One positive thing millennials are responsible for, however, is the trend toward environmental sustainability and eco-friendly products and behaviors. Although the term “eco-friendly” made it into dictionaries in 1993, it’s only within the last five years or so that the term has come into widespread use. In the 1990s and early 2000s, few people were committed to consistent eco-friendly living. Today, eco-friendly houses, cars, appliances, and numerous other products are widely available. Many individuals now follow vegetarian and vegan lifestyles specifically for their lower impact on the environment than meat-based diets and animal-based products. A May 2017 international survey conducted by Unilever, the company responsible for popular brands such as Dove and Ben & Jerry’s, as well as hundreds of others, found that one-third of consumers are now making purchase decisions about product brands based on their social and environmental impact. And, a market exceeding $1 trillion exists for brands that are transparent about their sustainability practices.1 It’s no surprise that the fitness industry has jumped on the sustainability bandwagon—eco-friendly fitness-focused vacations, exercise equipment, and workouts are becoming more available and more popular. For instance, athletic and leisure shoes are now being manufactured from products like recycled yoga mats, plastic collected from oceans, reclaimed wood, and recycled fabrics. For environmentally conscious consumers who exercise regularly, there are now many ways to expand their eco-friendly purchasing habits and lifestyle to include fitness activities. Ecofriendly exercise isn’t a new trend but is now in the spotlight due

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to recent American media coverage of a Swedish activity called “plogging.” A combination of the words “jogging” and “plocka upp,” which is Swedish for “pick up,” plogging started in Sweden in 2016 in response to growing concerns with plastic pollution. Since then, plogging groups have formed in Scandinavian countries, Germany, and other European countries, but only reached the United States as an organized fitness activity in early 2018. According to several runners interviewed by various media sources, picking up litter while jogging is fairly common, especially by those who run in more natural areas and dislike seeing trails littered with trash. In Tennessee, an event called “Trashercise” has been going on since before plogging reached the United States as a way to encourage fitness and cleaning up the local community. The plogging sensation from Sweden has just made such activities more visible and given American runners the idea to organize group plogging outings for exercise and socializing. Plogging adds cross-training to a running workout in the form of squatting and bending to pick up trash—movements that runners don’t typically perform. Plogging is for all ages and all fitness levels, since the activity can be done while walking or jogging. Adding a weekly or biweekly plogging outing to one’s walking or running routine is an easy way to help the environment—just don’t forget gloves and trash bags. Rather than doing only occasional outings focused on the environment, exercisers who want their fitness lifestyle to be as eco-friendly as possible can ensure that most of their fitness expenditures go toward companies committed to environmental sustainability. Fitness-focused vacations always have been popular, and many getaways now advertise eco-friendly lodgings, dining choices, and activities. For your clients interested in an eco-friendly, active vacation, share the following tips: • Not all vacations advertised as “wellness” or “holistic” retreats are also eco-friendly, though some are. Fully sustainable getaways may not have air-conditioned lodgings, unless they operate on solar power, and facilities may be more primitive than other vacation areas. If clients prefer to vacation in comfort, they can limit eco-friendly behavior to outings, such as educational nature tours on bikes or kayaks. • Eco-friendly dining options on vacation generally are easy to find and include farm-to-table, healthful cuisine; in many cases, meals will be vegetarian or vegan. Prepackaged foods and beverages generally will be either handpicked and packaged there from local suppliers or purchased from companies committed to environmentally sustainable production practices. • Many eco-friendly vacation packages lack facilities for constant connection to smartphones and the internet, so be prepared to disconnect—possibly for the entire vacation. • Eco-friendly retreats and resorts generally have fitness activities involving “back to nature” walks, yoga, swimming, and other activities that help guests appreciate the environment. • Eco-friendly vacations don’t have to be expensive retreats or resorts. Backpacking, camping, or bicycling tours with stops