Today s dietitian march 2014 by quangbmw

CONFERENCE ISSUE Vol. 16 No. 3

March 2014

The Magazine for Nutrition Professionals

Anthocyanins THESE POWERFUL COMPOUNDS MAY HELP PREVENT CVD AND CANCER AND BOOST COGNITIVE FUNCTION

TD10

Meet 10 Amazing RDs

Midlife Nutrition for Women Diet and Detoxification www.TodaysDietitian.com

Making Beverage Choices Count The Facts About 100% Orange Juice

Whether fresh, frozen, canned, dried or 100% juice, fruits provide an abundance of nutrients important for overall good health. Unfortunately, fruit consumption in the U.S. is surprisingly low, with most Americans consuming less than half of their recommended daily intake. 1 As a complement to whole fruit, 100% orange juice is a convenient way to help people reach their daily fruit intake goal.

100% Orange Juice Counts as Part of the MyPlate Fruit Group Any fruit or 100% fruit juice counts as part of the Fruit Group. Studies show that children, adolescents and adults who consume 100% orange juice have higher intakes of whole fruit and total fruit compared to nonconsumers.2,3 One 8-ounce glass of 100% orange juice is considered as one cup of fruit.

100% Orange Juice is a Naturally Nutrient-Dense Beverage More nutrient dense than many other commonly consumed 100% fruit juices,4 100% orange juice is a natural source of essential vitamins and minerals needed for good health. One 8-ounce glass is an excellent source of vitamin C and a good source of potassium and folate — three nutrients that are underconsumed in the U.S.5 100% orange juice also includes phytochemicals, such as hesperidin and beta-cryptoxanthin. Emerging research suggests that hesperidin—the most common flavonoid found in 100% orange juice—may help maintain healthy blood pressure and blood vessel function.6

100% Orange Juice has No Added Sugar 100% orange juice contains only the naturally-occurring sugars found in whole, fresh oranges. These natural fruit sugars along with vitamins, minerals and plant compounds make up its total nutrient package as a healthy beverage.

100% Orange Juice can be Part of a Healthy Diet for Children Research shows that consumption of 100% orange juice/100% fruit juice makes a significant contribution to nutrient intake and can help children reach daily fruit consumption goals as a complement to whole fruit.2,7-9 Portion sizes should be age appropriate, and The American Academy of Pediatrics recommends that the intake of 100% fruit juice should be limited to 4 to 6 ounces per day for children ages 1-6 years and 8 to 12 ounces per day for children ages 7-12 years.10

“Fat-free or low-fat milk and 100% fruit juice provide a substantial amount of nutrients along with the calories they contain.” 2010 Dietary Guidelines for Americans

Help your patients and clients feel confident about including 100% orange juice as part of a healthy diet. Visit OJNutrition. com to download the OJ Nutrition: Telling the 100% Story Toolkit and the OJ Nutrition: How 100% Orange Juice Fits into a Healthy Diet for Children Toolkit.

REFERENCES 1. U.S. Department of Agriculture, Agricultural Research Service, Beltsville Human Nutrition Research Center, Food Surveys Research Group (Beltsville, MD) and U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics (Hyattsville, MD). What We Eat in America, National Health and Nutrition Examination Survey (WWEIA, NHANES) 2003-2004 or 2005-2006.

5. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, D.C.: U.S. Government Printing Office, December 2010.

2. O’Neil CE, Nicklas TA, Rampersaud GC, Fulgoni III, VL. One hundred percent orange juice consumption is associated with better diet quality, improved nutrient adequacy, and no increased risk for overweight/obesity in children. Nutrition Research. 2011;31(9):673-682.

7. O’Neil CE, Nicklas TA, Zanovec M, Fulgoni VL 3rd. Diet quality is positively associated with 100% fruit juice consumption in children and adults in the United States: NHANES 2003-2006. Nutr J. 2011;10:17.

3. O’Neil CE, Nicklas TA, Rampersaud GC, Fulgoni III VL. 100% Orange juice consumption is associated with better diet quality, improved nutrient adequacy, decreased risk for obesity, and improved biomarkers of health in adults: National Health and Nutrition Examination Survey, 2003-2006. Nutrition Journal. 2012;11:107. 4. Rampersaud GC. A comparison of nutrient density scores for 100% fruit juices. J Food Sci. 2007;72:S261-S266.

6. Morand C, Dubray C, Milenkovic D, et al. Hesperidin contributes to the vascular protective effects of orange juice: a randomized crossover study in healthy volunteers. Am J Clin Nutr. 2011;93:73-80.

8. O’Neil CE, Nicklas TA, Zanovec M, Kleinman RE, Fulgoni VL. Fruit juice consumption is associated with improved nutrient adequacy in children and adolescents: the National Health and Nutrition Examination Survey (NHANES) 2003-2006. Public Health Nutr. 2012; 15:1871-1878. 9. Nicklas TA, O’Neil CE, Kleinman R. Association between 100% juice consumption and nutrient intake and weight of children aged 2 to 11 years. Arch Pediatr Adolesc Med. 2008;162:557-565. 10. American Academy of Pediatrics. The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107:1210-1213.

New!

FLAKE CEREAL

Sprouted for Life

6 Organic Sprouted Grains, Legumes and Seeds in Every Bite HIGH IN FIBER

GOOD SOURCE IN PROTEIN

foodforlife.com

LOW IN SUGAR

Power the Day with Daisy DISCOVER THE BENEFITS THAT COME WITH NUTR ITION AND TASTE . Maximize Muscle Synthesis

Encourage your patients and clients to make the most of their protein consumption. Studies show that consuming 20 to 30 grams of protein at each meal—instead of one large meal high in protein— can maximize muscle synthesis, which is critical for everyone.1

Stay On Track

Research suggests that when people eat breakfast, they tend to eat a healthier overall diet, one that is more nutritious and lower in fat. 2,3 Part of this means starting the day with a breakfast high in protein. Daisy Low Fat Cottage Cheese has 13 grams of satisfying protein and 4 grams of carbs per 90 calorie ½ cup serving. A meal high in protein and low in calories and carbohydrates will promote satiety and regulate blood sugar levels.

Variety – The Spice of Life

Cottage cheese is so convenient and versatile; you can enjoy it for breakfast, lunch, dinner or a snack. Pair it with fruits, vegetables, nuts or whole grains, or use as an ingredient in favorite recipes, such as lasagna, for a healthier spin. Eating healthy doesn’t need to be complicated or boring.

Better Ingredients: That’s the Daisy Difference

Daisy Low Fat Cottage Cheese is made with 4 high quality ingredients—no additives, thickeners or preservatives. Look for our new packaging with colored lids.

Add Daisy to the healthy foods you already recommend. References: 1. Leidy HJ, Armstrong CL, Tang M, Mattes RD, Campbell WW: The influence of higher protein intake and greater eating frequency on appetite control in overweight and obese men. Obesity (Silver Spring) 2010, 18:1725–1732. 2. Purslow LR, et al. Energy intake at breakfast and weight change: Prospective study of 6,764 middle-aged men and women. American Journal of Epidemiology. 2008;167:188 3. Kant AK, et al. Association of breakfast energy density with diet quality and body mass index in American adults: National Health and Nutrition Examination Surveys, 1999-2004. American Journal of Clinical Nutrition. 2008;88:1396.

EDITOR’S SPOT President & CEO Kathleen Czermanski Vice President & COO Mara E. Honicker EDITORIAL Editor Judith Riddle Editorial Director Jim Knaub Senior Production Editor Tracy Denninger Assistant Editor Brandi Redding Editorial Assistants Heather Hogstrom, Leesha Lentz Contributing Editor Sharon Palmer, RD 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; Sharon Palmer, RD; Christin L. Seher, MS, RD, LD ART Art Director Charles Slack Graphic Designer Erin Prosini ADMINISTRATION Administrative Manager Helen Bommarito Administrative Assistant Pat Plumley Executive Assistant Matt Czermanski Systems Manager Jeff Czermanski Systems Consultant Mike Davey FINANCE Director of Finance Jeff Czermanski CONTINUING EDUCATION Director of Continuing Education Jack Graham Continuing Education Editor Kate Jackson Continuing Education Coordinator Leara Angello 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 Marketing Coordinator Leara Angello Sales Manager Brian Ohl Associate Sales Manager Peter J. Burke Senior Account Executives Sue Aldinger, Seth Bass, Gigi Grillot, Diana Kempster, Beth VanOstenbridge Account Executives Stephanie Fanfera, Dan Healey Sales Coordinator Joe Reilly

© 2014 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.

THE PERILS OF AGEs One important topic in dietetics that has gotten much attention in recent months is advanced glycation end products’ (AGEs) impact on various aspects of our health. When I attended the Food & Nutrition Conference & Expo in Houston last year, I sat in on an interesting session about AGEs in the foods we eat and learned about the implications for nutrition therapy. AGEs are harmful compounds that result from cooking foods at high temperatures. The American diet contains foods that are largely heat processed and include high levels of pro-oxidant AGEs, known to cause inflammation, suppress defense mechanisms, boost appetite, enhance obesity, and increase insulin resistance and diabetes risk. People should beware of overcooked foods, especially red meat that’s charred in the oven, on the stove, or on the grill, as this is a sign that AGEs are present. Does this mean clients will have to give up grilling this summer? Not exactly. But they’ll need to learn how to modify their cooking methods and choose foods that don’t produce large amounts of AGEs when cooked. You can learn how to counsel clients who may be overweight or obese, insulin resistant, or at risk of prediabetes and diabetes in “Advanced Glycation End Products” on page 10. Your discussion about this matter will tie in nicely with National Nutrition Month®, a time for celebrating the hard work you do in the nutrition profession and helping clients focus on making informed food choices and developing regular exercise habits. “Enjoy the Taste of Eating Right” is this year’s theme, which centers on how to combine taste and nutrition to develop healthful meals in line with the 2010 Dietary Guidelines for Americans. In honor of National Nutrition Month® and Registered Dietitian Nutritionist Day, we’re excited to bring you our fifth annual “TD10” feature on page 24, which includes profiles of the top 10 RDs you helped nominate for the phenomenal work they do in dietetics. We invite you to meet these exceptional nutrition professionals and read their incredible stories. And we hope you enjoy the rest of the features in this issue, including articles on midlife nutrition, anthocyanins, and the role nutrition plays in detoxification. Happy National Nutrition Month® from all of us at Today’s Dietitian!

Judy

Judith Riddle Editor TDeditor@gvpub.com

march 2014 www.todaysdietitian.com 5

CONTENTS

MARCH 2014

FEATURES

DEPARTMENTS

Anthocyanins Studies suggest these phytochemicals may

Editor’s Spot

help prevent cardiovascular disease and cancer and also boost cognitive function.

Reader Feedback

Ask the Expert

TD10 Here’s Today’s Dietitian’s fifth annual showcase of 10

10 Dynamics of Diabetes

amazing RDs who are making a difference.

14 The Heart Beat

Midlife Nutrition RDs can help women over the age of 40

16 Living Gluten Free

24 30

overcome nutrition challenges.

Diet and Detoxification Learn how diet plays a role in the detoxification process and how dietitians specializing in integrative and functional medicine are applying the research to clinical practice.

Taking the SNAP Challenge Through the personal pages of their diaries, five RDs describe the experiences that gave them a new appreciation for families who are food insecure.

CPE Monthly: Diverticular Disease This course discusses a

52 Supplement Spotlight 54 Bookshelf 58 News Bites 56 Focus on Fitness 60 Get to Know… 62 Products + Services 64 Personal Computing 65 Datebook 66 Culinary Corner

reexamination of the fiber hypothesis.

Page 46

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: The Reprint Outsource, Inc.: 877-394-7350 or e-mail bwhite@reprintoutsource.com 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 16, Number 3.

Arm Yourself in the Fight Against Free Radicals Though many dietary supplements contain antioxidants, the major antioxidant group â&#x20AC;&#x201D; A C E + Selenium efficiently fights free radicals. Oxidative stress, caused by free radicals, can deeply affect your nervous system, joints, organs and blood vessels. Stop cellular aging by preventing the depletion of your antioxidant resources with ACES. Providing known free radical fighters, vitamins A, C, E, and Selenium, ACES facilitates healthy living for people of all ages. The time to fight back against free radicals is now.

ÂŽ

888-234-5656 | www.carlsonlabs.com *This statement has not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.

READER FEEDBACK

From Our Twitter Page

From Our Facebook Wall

Popular Tweets, Retweets

“FDA to Revise Nutrition Facts on Food Labels” ASPEN CONFERENCE ISSUE

January Issue

Vol. 16 No. 1

The Magazine for Nutrition Professionals

January 2014

“Assessing Weight Status — Is BMI the Best Tool?” @elena9G: It’s just a guide, people! Top 5 Leadership Skills for 2014

@Dietitianbeth: The fact that BMI doesn’t differentiate between fat/ muscle/bone mass can be a limitation.

Solving Hospital Malnutrition Living Gluten Free With Type 1 Diabetes

www.TodaysDietitian.com

“Taking the Lead in 2014” @SarahKoszykRD: Empowering RDs to become leaders! I loved Emma Fogt’s article in Today’s Dietitian. @ANutritionNerd: Where dietetics is going in 2014. Excited about the future!

“Hospital Malnutrition — Standardized Guidelines Take Center Stage” @WittyNutrition: Great article to share. I’m so glad to see Today’s Dietitian covering this with such an emphasis on malnutrition in acute care. @rustnutrition: If your loved one is in the hospital or LTC facility, ask for the dietitian; don’t wait for your doc to send one.

December Issue

SEASON’S GREETINGS Vol. 15 No. 12

“Can GMOs Harm Digestive Health?” (Digestive Health)

December 2013

Plant Foods

&Preschoolers

@kriziaRD: Say no to GMOs.

New strategies to get kids eating more fruit and veggies at every meal

@DesireeRD: Must read!

Dietitians’ Holiday Party Recipes

@FuelinRoadie: Love this article by Today’s Dietitian. Bravo coverage on GMOs and gut inflammation.

The Magazine for Nutrition Professionals

2014

RESO UR GUID CE E

FDA Rules on Gluten-Free Food Labeling Update on Functional Fibers www.TodaysDietitian.com

“Plant Foods and Preschoolers” @KimHobanRD: Good tips on getting kids to enjoy eating plant based. @DAmbrosioRd: Informative article.

8 today’s dietitian march 2014

http://news.msn.com Dina Kimmel: I’m so glad to see this. I e-mailed the FDA a couple of years ago suggesting that they break down the sugar into naturally occurring and added. I love the idea of also including how much whole grain is in the food. I’d be interested in also seeing how much of the dietary fiber is naturally occurring vs. added from other sources. Jodi Burckhart: Added sugar is pretty huge if it actually happens! Nancy Wyrick Teeter: Can’t come soon enough! Neal Kurmas: Heard this before, five years ago? Whoever designed the current nutrition label needs a good butt whipping. The current label is designed to set the public up for failure and to confuse them more than they are already.

“Vitamin Supplements Make Sense for Some, Experts Say” www.usatoday.com Debbi A. Fleming: The Annals article is totally misleading. The masses are utterly dependent on vitamin and mineral supplements for good health. What would be the state of our health without food fortification and enrichment, which can be viewed as a “vitamin pill” sprinkled into our breakfast cereals, bread flours, grain products in general, juices, peanut butter. That list could go on. The only way, which is impossible, to determine the benefits of an oral pill supplement is to account for a dietary history and estimate the contribution of vitamin/mineral supplements in the food supply of the people studied. Lindsay Rogers: Food first, smart and purposeful supplementation second.

ASK THE EXPERT

Willett, MD, showed a link between higher trans fatty acid consumption and a higher risk of heart attacks and death from coronary heart disease.1 By 1994, the Center for Science in the Public Interest (CSPI) petitioned for trans fat to be added to the Nutrition Facts label. In 2003, the FDA mandated that trans fat be listed on food labels, and the law went into effect in January 2006. A review article published in Nutrition in Clinical Practice estimated that every year in the United States, 30,000 to 100,000 deaths from heart disease were caused by trans fat consumption.2 Since 2006, many major restaurant chains have eliminated partially hydrogenated trans fat from their menus. Numerous food manufacturers have reformulated their products, resulting in a concurrent reduction of saturated fat. In addition, some local regulations and state laws banned the use of trans fat in restaurants (eg, New York).

Client Recommendations

BANNING TRANS FAT By Toby Amidor, MS, RD, CDN

Q: A:

How will the proposed trans fat ban impact the foods that contain them? In November 2013, the FDA announced that it would tentatively remove partially hydrogenated oils, the primary source of trans fat, from the generally recognized as safe (GRAS) list. Currently, trans fat can be found in fried foods, microwave popcorn, frozen pies and pizzas, cookie dough, biscuits, frosting, and other baked goods. In addition, some restaurants continue to serve foods containing trans fat. Should the FDA ban trans fat, eliminating it from the food supply will take time. Meanwhile, RDs can advise clients on how to identify products that contain trans fat and update them on when the phase out may occur, according to the FDA’s to-be-released timeline.

History of Trans Fat German chemist Wilhelm Normann discovered artificial trans fat in the early 1900s. He found that when hydrogen gas was added to liquid vegetable or fish oils, it resulted in a solid or semisolid product. For close to 70 years, it was thought that hydrogenated foods were more healthful than their nonhydrogenated counterparts. Trans fat also was found to help improve the shelf life, flavor, and texture of foods. Similar to saturated fat, trans fat has been shown to increase LDL cholesterol, which promotes heart disease. However, unlike saturated fat, trans fat also decreases the HDL cholesterol that’s associated with a lower risk of heart disease. In the 1970s and 1980s, a handful of scientific studies began linking trans fat consumption with heart disease. But it wasn’t until the 1990s that studies provided irrefutable evidence that consumption was a major cause of heart disease. One such landmark study published in 1993 by Harvard’s Walter

With artificial trans fat still part of our food supply for the time being, nutrition practitioners should recommend that clients read the ingredient list on food products and look for the words “partially hydrogenated.” They also should educate clients about food labeling laws regarding trans fat. Any food labeled as having 0 g of trans fat may still have up to 0.49 g. Numerous servings of foods containing this amount can add up and surpass the daily 2-g recommended maximum. Clients also should be advised that some restaurants may receive prepackaged foods containing trans fat or may use trans fat to cut costs or improve flavor, especially in fried foods, frozen foods, and baked goods. — Toby Amidor, MS, RD, CDN, is the founder of Toby Amidor Nutrition (http:// tobyamidornutrition.com) and the author of the forthcoming cookbook The Greek Yogurt Kitchen. She’s also the nutrition expert for FoodNetwork.com and a contributor to US News Eat + Run.

References 1. Willett WC, Stampfer MJ, Manson JE, et al. Intake of trans fatty acids and risk of coronary heart disease among women. Lancet. 1993;341(8845):581-585. 2. Zaloga GP, Harvey KA, Stillwell W, Siddiqui R. Trans fatty acids and coronary heart disease. Nutr Clin Pract. 2006;21(5):505-512. Have questions about nutrition trends, patient care, and other dietetics issues you’d like to ask our expert? Send your questions to Ask the Expert at TDeditor@gvpub.com or send a tweet to @tobyamidor.

march 2014 www.todaysdietitian.com 9

DYNAMICS OF DIABETES Dietary Intervention

ADVANCED GLYCATION END PRODUCTS By Lori Zanteson

Studies show these harmful compounds may lead to insulin resistance and type 2 diabetes. It’s well-known that overeating and obesity can lead to insulin resistance, triggered by chronically elevated oxidative stress and chronic inflammation. Recent evidence has found that excessive consumption of advanced glycation end products (AGEs), harmful compounds that stem from cooking foods at high temperatures and accumulate in the body as people age, are a major cause of this inflammation that can increase the risk of insulin resistance and type 2 diabetes. Dietary interventions that reduce the consumption of foods high in AGEs, which are common in the standard Western diet, can be effective in helping prevent these metabolic disorders.

Understanding AGEs AGEs naturally form inside the body when proteins or fats combine with sugars (glycation). This affects the normal function of cells, making them more susceptible to damage and premature aging. AGEs are particularly high in animalderived foods that are high in fat and protein, such as meats (especially red meats), which are prone to AGE formation through cooking. Sugary foods and highly processed and prepackaged products also are high in AGEs. Cooking methods that use high temperatures to brown or char foods, such as grilling, roasting, and broiling, have the largest impact on the amount of AGEs consumed. The body naturally rids itself of harmful AGE compounds, but it doesn’t eliminate them effectively when too many are ingested through food. All of the body’s cells are affected by the accumulation of AGEs, which not only have been linked to aging but also the development or worsening of many chronic illnesses, such as cardiovascular, liver, and Alzheimer’s diseases.

10 today’s dietitian march 2014

To reduce AGE consumption, eating foods that contain low AGE levels is key to decreasing the risk of insulin resistance and type 2 diabetes. “We believe strongly that dietary restriction of AGEs are of tremendous importance,” says Jaime Uribarri, MD, a professor of medicine and nephrology at Mount Sinai School of Medicine in New York City, who’s conducted extensive research on AGEs and their effects on diabetes patients. According to one study, published in the July 2011 issue of Diabetes Care, in which Uribarri was the lead author, AGE consumption may contribute to insulin resistance in type 2 diabetes, and restricting AGE foods may help preserve the body’s natural defenses against insulin resistance by preventing the development of oxidative stress. In the study, two groups of diabetes patients following the recommended standard of care for diabetes were randomized to either a high- or low-AGE diet. The results of the group who ate a low AGE diet “went far and beyond [those receiving] standard care. The AGE-restricted diet improved insulin resistance in those individuals. This is very impressive to us,” Uribarri says. Another study coauthored by Uribarri, published in the January issue of Current Diabetes Reports, showed that because AGEs are associated with oxidative stress, they’re of particular concern to patients with diabetes and prediabetes. The researchers found that subjects who consumed a meal with a high AGE content had an increased circulation of AGEs in the body, and that lowering dietary AGE intake could improve hyperinsulinemia by about 40% in type 2 diabetes patients. Excessive intake of AGEs as a potential cause of diabetes is “an area of major clinical relevance,” the study concluded. In research that’s under way and due to conclude in June, Uribarri is following a group of prediabetes patients with classic diabetes indicators, or metabolic risk factors, such as large waist circumference and hypertension, who are following a low-AGE diet for one year. He’s confident the results will support his previous findings that a low-AGE diet can play a role in preventing diabetes.

Modifying Cooking Methods The most effective way to reduce intake of foods high in AGEs is to modify cooking methods. In a study published in the June 2010 issue of the Journal of the American Dietetic Association, Uribarri and colleagues developed a guide to AGE dietary reduction. The researchers found a link between heat-processed foods and AGEs. They compared different types of cooking methods and found that dry heat promoted AGE formation by more than 10- to 100-fold above uncooked foods in all food categories. Meats high in protein and fat were likely to form AGEs during cooking, while carbohydrate-rich foods such as fruits, vegetables, and whole grains maintained low AGE levels after cooking. Foods cooked with moist heat, shorter cooking times and lower temperatures, and acidic ingredients such as vinegar or lemon juice produced the least amount of AGEs.

The USDA recommends servings of dairy every day.

Make yogurt one of them!

The American diet is more unbalanced than ever and in a state of crisis. Americans consume only about half of the USDA recommended daily servings of low fat and fat free dairy. Yogurt is a convenient, nutrient-dense food that contributes to the recommended 3 daily servings of dairy. Most yogurts contain nutrients that are lacking in the American diet, including calcium, vitamin D and potassium. Yogurt can be an excellent source of high-quality protein, which helps with satiety, and promotes muscle and bone health. Recent epidemiological studies in healthy populations also show that frequent yogurt consumption, as part of a healthy diet, is associated with less weight gain over time and healthy levels of blood pressure and circulating glucose. Eating one yogurt every day is an important first step toward creating a more balanced diet and a healthier lifestyle, and improving public health. Brought to you by

A Danish study published in the January issue of Diabetes Care showed that overweight women who ate foods cooked at high temperatures had much higher biological markers of insulin resistance compared with those who ate foods prepared by boiling or steaming. Pat Baird, MA, RD, FADA, a member of the advisory board of the AGE Foundation, an organization committed to educating the public about the harmful effects of AGEs, is optimistic about sharing the benefits of a low-AGE diet. “We produce AGEs in our body, and we’re also ingesting them. The good news is we can adjust it,” she says, adding that preparing foods in a slow cooker is another good option.

Insider Tips Despite these recommendations, Baird knows that people will continue to grill their food, so she encourages them to do so less frequently. When they do grill, however, she suggests they use an acid-based marinade that contains lemon or other citrus fruit juices, or vinegar. Not only does the acidity reduce AGE levels, “it enhances the flavor of food and enhances the flavor of the spices,” she says. “The indication is color.” Whether on the grill, in a skillet, or in the oven, browning or charring foods is an indication that AGEs are present. Baird also suggests cooking foods with medium heat for an extra minute or two instead of using high heat. Because it can be a challenge for people to eat fewer convenience foods, such as packaged snacks and ready-to-eat meals, Baird says using slow cookers can help, especially in families that often are short on time. But the benefits go beyond timesaving convenience. According to Baird, less oil is needed in slow cookers, more nutrients are retained compared with many other cooking methods, and recipes tend to include more vegetables. In fact, eating more vegetables and fruits is another way to reduce AGE consumption. Baird stresses the importance of dietary phytonutrients, which are found in the pigments of various colorful fruits and vegetables. One type of phytonutrient in particular, called iridoids, which are found in deeply colored blueberries, cranberries, and noni fruit, can lower AGEs in the body, she says.

Counseling Clients Counseling patients about AGEs is straightforward, Baird says. Dietitians already recommend patients eat less sugar and fewer processed foods, which is what they should suggest to clients who need to lower their AGE intake. In addition, people who are sleep deprived have higher circulating AGEs, Baird says. Sleep is the time when the body does most of its tissue growth and repair, making it better able to defend itself against AGEs. Sleep, daily activity, and stress reduction play important roles, along with diet, to reduce AGEs. While most dietitians understand this, Baird says, the new research may not be so familiar. The AGE Foundation website (http://agefoundation.com) is an ideal source to bring dietitians

12 today’s dietitian march 2014

Tips for Lowering AGE Consumption Foods High in AGEs • Sugary items such as candy, cookies, cakes, soda, and pastries • Processed foods, including packaged meats and cheese • High-fat (especially red) meats • Fats, including butter, margarine, and oil • Fried foods

Foods Low in AGEs • Fruits and vegetables • Seafood • Whole grains • Low-fat breads • Pasta • Vegetarian burgers

Cooking Methods • Use a slow cooker • Cook foods in water through boiling, steaming, or poaching • Marinate foods in acidic or citrus-based sauces

Healthful Lifestyle Changes • Get the recommended seven to nine hours of sleep per night • Exercise 150 minutes per week • Treat preexisting conditions such as obesity and high blood pressure — SOURCE: AGE FOUNDATION

up-to-date on the most current research, complete with background information, resources, and FAQs. There’s even information on AGE scanners that use LED light to penetrate the skin and measure AGE levels. According to Baird, this technology, which currently is being tested in clinical trials, may one day be a useful noninvasive tool for dietitians to use. Uribarri and Baird look forward to dietitians becoming more familiar with the topic of AGEs. “They should be the first to embark on this chain,” Uribarri says. Patients with prediabetes and diabetes may benefit from the healthful lifestyle of a low AGE diet. — Lori Zanteson is a food, nutrition, and health writer based in southern California.

Educating your patients about their digestive system is fundamental…

...because digestive health is important to overall well-being. • Digestive health refers to the ability of the digestive system to function properly and to support a high quality of life. • ACTIVIA® helps optimize the function of the gastrointestinal tract, leading in turn to better daily well-being. • ACTIVIA® is a probiotic yogurt that helps with occasional irregularity.*

• ACTIVIA® contains an exclusive culture, Bifidus Regularis® (scientifically known as Bifidobacterium animalis lactis DN-173 010), which is shown to survive passage through the gastrointestinal tract in sufficient numbers for ACTIVIA® to have its beneficial effects.

RECOMMEND ACTIVIA® Get your coupon referral pad today! Scan here to request your coupon referral pad or go to www.activiareferralpad.com. Offer available to healthcare professionals only.

*Clinical studies show that ACTIVIA,® with Bifidus Regularis® (Bifidobacterium animalis lactis DN-173 010), helps with slow intestinal transit when enjoyed 3 times per day for two weeks as part of a balanced diet and healthy lifestyle. ©2014 The Dannon Company, Inc.

THE HEART BEAT

NEW CHOLESTEROL GUIDELINES RELEASED

Lifestyle Changes and Statin Use Said to Make the Most Impact on Cutting Risk By Judith C. Thalheimer, RD, LDN In the November 2013 issue of Circulation, the American Heart Association (AHA) and the American College of Cardiology (ACC) released new clinical practice guidelines for managing blood cholesterol. The first new recommendations since 2004, the Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk advises significant changes in the way the health care community approaches lowering LDL cholesterol: The focus has moved away from achieving target numbers and toward assessing risk and, when necessary, using statins proven to reduce that risk.1 “Our goal in developing these guidelines was to align recommendations more closely to the latest scientific evidence, and that evidence shows that lifestyle changes plus the proper dose of statins has the maximum impact on risk reduction,” says Neil J. Stone, MD, the Bonow Professor of Medicine at Northwestern University’s Feinberg School of Medicine and chair of the cholesterol guideline panel.

New Recommendations for Statin Use For decades, patients have been told to lower their LDL cholesterol levels to a specific target number. The primary means for reaching this goal was through the use of statins. However, based on a four-year review of scientific evidence, the new guidelines eliminate target numbers and instead establish risk categories for statin use. The highest

14 today’s dietitian march 2014

risk categories include people who already have suffered a heart attack or stroke or suffer from other forms of clinical atherosclerotic cardiovascular disease (ASCVD) such as angina; those with an LDL cholesterol level of 190 or higher due to genetic predisposition; and individuals aged 40 to 75 with diabetes and LDL cholesterol between 70 and 189 without clinical ASCVD. For patients without clinical ASCVD or diabetes with LDL cholesterol of 70 to 189, the AHA and the ACC created an online risk calculator to help determine whether these patients could benefit from statin use (http:// my.americanheart.org/profes sional/StatementsGuidelines/ PreventionGuidelines/Prevention-Guidelines_UCM_457698_ SubHomePage.jsp). Anyone with a 10-year ASCVD risk of 7.5% or above on the risk calculator could benefit from statin use, according to the guidelines. The calculator takes into account well-established risk factors for both heart attack and stroke, including sex, age, blood pressure, total and HDL cholesterol levels, smoking status, diabetes and, for the first time, race.2,3

Heart of the Controversy A good deal of controversy has arisen around the guidelines, primarily with regard to the statin recommendations. Janet Bond Brill, PhD, RDN, FAND, a cardiovascular nutritionist and author, sees an upside to all the fuss. “The media attention is fabulous,” she says. “Anytime the spotlight is on heart health and cholesterol, it’s a good thing. And really, it’s hard to overestimate the risk of cardiovascular disease. We’re all at risk. CVD is the No. 1 killer of men and women in the United States.” Stone agrees: “Sixty percent of Americans will have a heart attack or stroke, and almost one-third of us will die of heart attack or stroke. Statins are inexpensive, well tolerated by most people, safe when taken as directed, and proven effective.” While there’s little argument that people in the three highrisk categories will benefit from statins, there’s concern over using the risk calculator to determine statin use in the rest of the population. “Some people have said the risk calculator will result in an overuse of statins,” Stone notes. “Our numbers show that overall statin use should not change but will shift to have less low-risk people treated and more high risk. We also believe that it will lead to more discussions and chances

to address issues like lifestyle and blood pressure. When someone scores over 7.5% on the online risk calculator, it opens the door for a risk discussion with their provider, a discussion that can lead to primary prevention.” However, not everyone is as confident those risk conversations will take place. “Hopefully, the new guidelines will help, but right now I don’t see physicians having any meaningful discussions about lifestyle,” says Lisa M. Laura, JD, RD, LDN, an assistant professor of nutrition at La Salle University in Philadelphia and a private practice dietitian. “Typically, with the clients I see, their doctor recommended statins and, when the client resisted, they were given three months to change their lifestyle with little or no advice on what to do or how to do it. People come to me very confused.”

What About Lifestyle Changes? For many nutrition professionals, this emphasis in the medical community on statin use over lifestyle changes such as diet and exercise has long been an issue. “I am, of course, a believer in diet and exercise first,” Brill says. “We have this idea as a society that popping a pill will cure the disease. Statins are great, but they’re still only a medication. What I call ‘the statin mentality’ takes away from the fact that diet and exercise are the more powerful foundation of the CVD prevention pyramid, and statins are just an upper layer.” For Stone, the media’s focus on the statin portion of the guidelines is frustrating. “Lifestyle actually figures prominently in these guidelines,” he says. “Because of the controversy, the report’s focus on lifestyle has been lost.” In fact, the cholesterol guideline is just part of a package of guidelines released by the AHA and the ACC to address ASCVD. These include risk assessment, body weight management, and lifestyle management in addition to the cholesterol recommendations. A fifth guideline, addressing hypertension, also is expected.4 In addition, the Guideline on Lifestyle Management to Reduce Cardiovascular Risk was published in the November 2013 issue of Circulation. “Based on a rigorous, systematic review of the latest research, the lifestyle guideline offers information on diet patterns, sodium and potassium intake, and physical activity to reduce risk of cardiovascular disease by controlling blood pressure and lipids,” explains Janet M. de Jesus, MS, RD, a nutritionist and coauthor of the AHA/ACC lifestyle guideline. “The purpose of the lifestyle report was to feed into both the cholesterol and blood pressure reports,” she adds. “Lifestyle changes should be the first line of defense. Doctors should start with recommending lifestyle changes, even when patients are on medication.” This guideline recommends a diet of fruits, vegetables, whole grains, lean protein, and low-fat dairy with a reduced intake of sugar-sweetened beverages and red meat in the style of the DASH, AHA, or USDA food patterns. Calories from saturated and trans fats should be reduced, with calories from

saturated fat optimally making up only 5% to 6% of total calories. Reducing sodium intake by at least 1,000 mg has been shown to lower blood pressure, but fewer than 2,400 mg/day is recommended. A reduction of sodium intake to 1,500 mg/day can result in even lower blood pressure.5

Seizing the Moment RDs and other nutrition professionals can capitalize on the media attention and controversy surrounding the new guidelines to stress the proven impact of lifestyle on cardiovascular health. As physicians acquaint themselves with the new recommendations, RDs have an opportunity to emphasize the lifestyle portion of the cholesterol guideline and make other health care professionals, the media, and the public aware of the companion lifestyle guideline. Moreover, this new set of evidence-based recommendations from the AHA and the ACC provides a chance for nutrition professionals to familiarize themselves with the latest information and prepare themselves for more risk-aware patients seeking nutrition and lifestyle advice. “Lifestyle changes work,” Laura says. “I’ve had success recommending a plant-based diet in my practice. Many people are willing to make changes when they know they’re at risk. They just need to be given the knowledge and support to make those changes.” — Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer and community educator living outside Philadelphia.

References 1. Krumholz HM. 3 things to know about the new cholesterol guidelines. The New York Times website. http://well. blogs.nytimes.com/2013/11/12/3-things-to-know-about-thenew-cholesterol-guidelines/?ref=health&_r=0. November 12, 2013. Accessed December 18, 2013. 2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/ AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;Epub ahead of print. 3. Kolata G. Experts reshape treatment guide for cholesterol. The New York Times website. http://www.nytimes. com/2013/11/13/health/new-guidelines-redefine-use-ofstatins.html?ref=health. November 13, 2013. 4. Harold JG, Jessup M. New ACC/AHA prevention guidelines: building a bridge to even stronger guideline collaborations. Circulation. 2013;128:2852-2853. 5. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;Epub ahead of print.

march 2014 www.todaysdietitian.com 15

LIVING GLUTEN FREE

GLUTEN ATAXIA By David Yeager

Research suggests that gluten may cause this rare but serious medical condition. Dietitians are familiar with the fact that celiac disease is characterized by a permanent intolerance to the protein gluten. But many are less familiar with research that suggests that being gluten intolerant is also associated with a mysterious neurological condition called gluten ataxia. Ataxia, apart from its association with gluten, is a condition that affects the brain, causing problems with balance and coordination. Some patients with sporadic ataxia develop a progressive condition that tends to occur later in life and often is linked to gait abnormalities and problems with coordination. If the ataxia is idiopathic, it’s believed that an immune response to gluten may be the cause. But gluten ataxia is extremely difficult to diagnose because currently there are no tests that can positively identify it. “There are no unique clinical symptoms that would distinguish gluten ataxia from other types of ataxia,” says Armin Alaedini, PhD, an assistant professor in the department of medicine at Columbia University Medical Center who specializes in autoimmune disorders. “Patients usually present with gradual onset of gait ataxia, which is sometimes accompanied by symptoms of peripheral neuropathy. The term ‘gluten ataxia’

16 today’s dietitian march 2014

generally is used to refer to cases of cerebellar ataxia of unknown cause, also known as sporadic ataxia, which is associated with increased levels of gluten antibodies [also known as] antigliadin antibodies.” To further complicate matters, while some studies have suggested that as many as 20% of people with sporadic ataxia may test positive for antigliadin antibodies, up to 15% of people with no ataxia symptoms also may test positive for antigliadin antibodies, suggesting that there are additional mechanisms at work in the development of ataxia, says Brent L. Fogel, MD, PhD, an assistant professor in the neurology department at the UCLA David Geffen School of Medicine. Just as a patient who tests positive for antigliadin antibodies may or may not have celiac disease, testing positive does not necessarily mean the patient has ataxia. In addition, there are many patients with sporadic ataxia who have no gluten sensitivity. Many of the patients Fogel sees at UCLA are older than 50, have gait difficulties, and may have mild neuropathy. “This describes about 70% of the people who walk into my clinic,” he says. “So it’s really hard to say, based on someone’s symptoms, that gluten ataxia is responsible.” Fogel says he routinely screens for antigliadin antibodies but rarely encounters cases of suspected gluten ataxia, which may be just a reflection of the patients seen at the UCLA clinic.

Looking Deeper To further study the association between gluten and ataxia, researchers and neurologists at Columbia University and UCLA have begun a research trial that will assess the prevalence of gluten sensitivity in a population of US patients with sporadic ataxia compared with a control group. Currently, more than 80 patients have signed up, and recruitment will last a few more months, Alaedini says. Once the study begins, it will take about one year to perform the analyses. While it’s difficult to say with certainty how often gluten sensitivity causes ataxia, it may be more common than clinicians realize. “Gluten sensitivity is one of the most common causes of sporadic ataxia with no family history [to explain it] and, unfortunately, remains underdiagnosed,” says Marios Hadjivassiliou, MD, a professor of neurology and the

neuroinflammation research theme lead at Sheffield Teaching Hospitals NHS Foundation Trust at Sheffield University in the United Kingdom. “There’s an urgent need to increase awareness of this type of neurological manifestation of sensitivity to gluten because the damage to the balance center can be irreversible with time.” Hadjivassiliou is the physician who discovered and named gluten ataxia and the lead author of a study that found gluten to be the single biggest cause of sporadic idiopathic ataxia.1 Patients with sporadic idiopathic ataxia were significantly more likely to test positive for antigliadin antibodies than patients whose ataxia could be explained by other causes.1,2 Although the antibodies more often are associated with celiac disease, patients rarely exhibit gastrointestinal symptoms.1,2 Hadjivassiliou recommends that any patient with sporadic idiopathic ataxia be screened for antigliadin antibodies. Unfortunately, if a patient is diagnosed with gluten ataxia, there are few treatment options. Alaedini says immunomodulatory therapy with IV immunoglobulin and a gluten-free diet have been found to be promising in some studies. Typically, it takes six months to one year before physicians can determine the diet’s efficacy, Fogel says. If patients haven’t shown any improvement in symptoms within that time frame, it’s unlikely that gluten ataxia is the cause, he says.

Eating Gluten Free Because adhering to a gluten-free diet can be challenging for patients, it’s important for physicians to work closely with dietitians. Hadjivassiliou says good nutrition advice is the key to treating gluten ataxia. RDs provide crucial support for patients who are transitioning to a gluten-free diet. “It’s unfortunately one of the hardest diets for people to stay on, particularly if they’re used to the typical American diet,” Fogel says. “It’s difficult to get somebody to switch over to gluten free and stay on it without the assistance of a dietitian to help them do it in a palatable way. People aren’t going to be successful on their own. We wouldn’t put somebody on that type of a diet without getting them involved with a professional who can help them stay on it.” To ease the transition, Marlisa Brown, MS, RD, CDE, CDN, a consultant, a chef, and the author of Gluten-Free, Hassle Free and Easy Gluten-Free, begins by asking patients about their dining habits. Cooking at home, although challenging, offers more control over the diet than eating out. Brown helps patients modify favorite recipes and suggests gluten-free foods that are similar to what they already enjoy so that the change isn’t too abrupt. For those who eat out more frequently, the biggest challenge is the possibility of cross-contamination, Brown says. Even something as basic as butter can be problematic depending on how it’s handled. Brown provides her clients

with “safe/not safe” lists and “question foods” lists, and she recommends clients question anything they’re unsure about. She also offers names of eating establishments that have good reputations for serving gluten-free fare. Even with her support, clients still have some difficulty sticking to a gluten-free diet. “I try to focus on things that are going to make them happier. The only thing that sometimes upsets them is when I talk about the fact that they can’t consume any gluten at all,” Brown says. “That’s the hardest part, that they can’t even have a crumb. Somebody can put out a cheese platter but, if there are crackers on that platter, you can’t even have the cheese.” Educating patients about what to avoid also extends to food shopping. Rachel Begun, MS, RDN, a food and nutrition consultant and expert in gluten-related disorders, says clients must become avid label readers to successfully eliminate gluten. Gluten is used in a wide range of products, so it’s important for dietitians to educate clients about how to detect gluten in packaged foods, she says. The three grains that contain gluten are wheat, rye, and barley, but only wheat is required to be highlighted on package labels because it’s also a significant allergen. Begun says the Food Allergen Labeling and Consumer Protection Act requires that significant allergens be highlighted on packaging. Yet, because an allergic reaction is different from an autoimmune reaction, rye, barley, and gluten aren’t required to be highlighted. Gluten-free labeling is voluntary. In addition, clients need to be careful about oats, Begun says. Oats don’t contain gluten, but often they’re contaminated with gluten during harvesting, transportation, and manufacturing. “My recommendation for anybody on a gluten-free diet is to focus the diet on naturally gluten-free foods because those are many of the foods that we promote for a healthful diet anyway, such as fruits and vegetables; low-fat dairy; lean cuts of meat; plant-based proteins such as beans, nuts, and seeds; and, obviously, gluten-free whole grains,” Begun says. “Certified gluten-free products provide an extra layer of protection to insure they’re gluten free and there hasn’t been any cross-contamination.” — David Yeager is a freelance writer and editor based in Royersford, Pennsylvania.

References 1. Hadjivassiliou M, Grünewald RA, Sharrack B, et al. Gluten ataxia in perspective: epidemiology, genetic susceptibility and clinical characteristics. Brain. 2003;126(3):685-691. 2. Hadjivassiliou M, Grünewald RA, Chattopadhyay AK, et al. Clinical, radiological, neurophysiological, and neuropathological characteristics of gluten ataxia. Lancet. 1998;352(9140):1582-1585.

march 2014 www.todaysdietitian.com 17

A LEARNING EXPERIENCE FOR NUTRITION PROFESSIONALS It’s the beginning of a new annual springtime tradition for registered dietitians and nutrition professionals—and we want YOU to be part of it. All registered dietitians are cordially invited to participate in this continuing education and n networking event produced by Today’s Dietitian magazine and our CE Learning Library.

at the

, LD

B eck y

Plo

B arbar

Sharon

S, RD

er ,M

D, ,R

Ro b in

r, R

llin

Kar e n

, AT

ll ,

J i l l We

ise

J enna

S, ,M

N, C DE

, LDN

Toby A

, CDN

N, CDN

A DOUBLETREE BY HILTON

, FA N D

Covering subjects that regularly affect nutrition professionals and their clients, our educational sessions will be led by some of the profession’s most respected experts. Our program’s esteemed faculty includes:

Dana W

hit

THANKS TO OUR SPONSORS FOR THEIR SUPPORT OF CONTINUING EDUCATION IN NUTRITION AND DIETETICS

Calorie Free Specialties

EARN UP TO 14 CPEUs FROM OUR CE LEARNING LIBRARY Registration for the 2014 Spring Symposium is filling quickly. The registration fee is only $299 per person. Your registration includes: • 2 full days of sessions for CDR-accredited continuing education credits

Seats are filling quickly!

• Welcome reception on Sunday night

Don’t miss out on an event you will remember for a lifetime.

• Keynote breakfast • Monday morning yoga session • Opportunities for networking and peer interaction • Lunch plus morning and afternoon breaks on both program days

HOTEL + TRAVEL

DON’T DELAY!

Registration closes April 15th (or sooner if all spots are filled!)

Our suggested travel itinerary for this event would be: • Arrive in Las Vegas in the afternoon/evening on Sunday, May 18. • Enjoy our welcome reception from 7-9 PM on Sunday evening. • Stay at the Tropicana Las Vegas on Sunday and Monday nights. • Attend a full program of sessions on Monday and Tuesday. • Depart on Tuesday evening or Wednesday morning. The discounted Today’s Dietitian group rate is valid from Friday, May 16 through Tuesday, May 20 for those who want to extend their stay.

Our event enjoys a cost-effective discounted group rate for rooms at the Tropicana Las Vegas, starting at just $95 per night. The Tropicana is a Doubletree by Hilton property, so HiltonHonors members can use their points and rewards.

Tropicana Las Vegas 800.GO2.TROP 702.739.2222 www.TodaysDietitian.com/SS14room

REGISTRATION IS ONLY $299! www.TodaysDietitian.com/SS14

Anthocya

nins M

any dietitians are well aware of the benefits fruits and vegetables provide, but few may know the actual names and types of the diseasefighting compounds they contain that are so important for good health. Anthocyanins, a particular group of compounds, are one of the more than 6,000 members of the flavonoid family of polyphenol phytochemicals found in various plant foods.1 In addition to anthocyanins, the flavonoid group includes flavanols, flavones, flavanones, flavan-3-ols, and isoflavones. Anthocyanin pigments have been used in folk medicine for generations, but only recently the specific pharmacological properties of these compounds have been isolated and studied.2 There are many aspects to anthocyanins’ role in the body that remain a mystery, such as bioactivity, uptake, absorption, bioavailability, and distribution in the tissues. But laboratory research as well as studies in animals and humans have suggested that anthocyanins may play important roles in helping reduce the risk of cardiovascular disease (CVD), cognitive decline, and cancer. The role of anthocyanins in the prevention of these diseases has been linked to their antioxidant properties, but research now suggests that anthocyanins’ health benefits likely result from unidentified chemical properties beyond their antioxidant capacity.3

An Overview Anthocyanins are plentiful in plant foods, providing the bright red-orange to blue-violet colors of many fruits and vegetables. These compounds occur naturally in plants in the form of glycosides, in which an anthocyanidin molecule is paired with a sugar. The part of the pigment that exists free of sugar (generically known as aglycone) is called an anthocyanidin.3 These compounds are most abundant in berries (eg, black currants, elderberries, blueberries, strawberries) and their juices, and in red and purple grapes, red wine, sweet cherries, eggplants, black plums, blood oranges, and red cabbage. Plants produce anthocyanins as a protective mechanism against environmental stressors, such as ultraviolet light, cold temperatures, and drought. This production of anthocyanins in roots, stems, and especially leaf tissues is believed to provide resistance against these environmental hazards.

These powerful compounds may help prevent CVD and cancer and boost cognitive function BY DENSIE WEBB, PHD, RD

Moreover, anthocyanins are the most easily recognized and prominent flavonoid in the diet; the intake of these compounds is estimated to be as much as ninefold higher than that of other dietary flavonoids1—estimated to be between 3 and 215 mg/ day.4 The amount of anthocyanins in foods can vary greatly. For example, Red Delicious apples provide more anthocyanins than Fuji apples; black raspberries are a far richer source than red raspberries; and Concord grapes are a much more concentrated source than red grapes.5 While the answers to how and why anthocyanins may help prevent disease remain undiscovered or unexplained, the literature to date is intriguing, and most researchers are calling for more studies to explore the potential health benefits of these naturally occurring compounds. “While one could argue that the evidence is inadequate to define a specific dietary recommendation, it’s clear that consuming anthocyanin-rich foods should be encouraged,” says Jeffrey Blumberg, PhD, director of the antioxidants research laboratory at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University in Boston.

Cardiovascular Disease Several studies have found an association between the consumption of anthocyanin-rich foods and CVD protection. As part of the Iowa Women’s Health Study, 34,489 postmenopausal women without CVD had their diets assessed and were followed for 16 years. The researchers found that consuming anthocyanin-rich strawberries and blueberries once per week was associated with a significant reduction in death from CVD and coronary artery disease.6 In addition, several epidemiologic studies have found an association between the consumption of red wine and decreased risk of death from CVD.6,7 Another study that assessed the effect of anthocyanins on health followed 87,242 women from the Nurses’ Health Study II; 46,672 women from the Nurses’ Health Study I; and 23,043 men from the Health Professionals Follow-Up Study for 14 years.8 Researchers found that those in the highest quintile of anthocyanin intake (mostly from blueberries and strawberries) had a significant 8% decreased risk in developing hypertension compared with those in the lowest quintile of anthocyanin intake. The risk reduction was even greater (12%) for those aged 60 or younger and, for all subjects, the decreased risk remained even after controlling for a large

march 2014 www.todaysdietitian.com 21

number of factors, including family history, physical activity, BMI, and other dietary factors associated with hypertension. A larger group of 93,600 healthy women from the Nurses’ Health Study II was followed for 18 years; a high intake of anthocyanins was associated with a significant reduction in the risk of myocardial infarction.9 Specifically, those consuming more than three servings of blueberries and strawberries per week had a 34% lower risk compared with those who consumed fewer. The decreased risk of CVD may be due, in part, to a reduction in arterial stiffness and blood pressure.10 Arterial stiffness is assessed based on the structure and function of arteries, and central systolic blood pressure is a strong predictor of atherosclerosis and the incidence of CVD. As part of the Twins UK study of 1,898 women aged 18 to 75, researchers found that a higher intake of anthocyanins was associated with significantly lower central systolic blood pressure and arterial pressure. The authors suggested that consuming one to two portions of berries per day might be an important strategy for lowering CVD risk.10 A systematic review of clinical studies and meta-analyses on the effect of alcohol on CVD concluded that the polyphenolic compounds found in red wine, including anthocyanins, provide cardiovascular benefits that can’t be attributed to alcohol alone.11 However, recent studies have found that anthocyaninrich black currant juice and blood orange juice had no effect on cardiovascular risk markers.12,13 A study of rats fed a red cabbage extract rich in anthocyanins recently provided the first piece of evidence that an anthocyanin extract protected against hypercholesterolemia induced by an atherogenic diet and related cardiac oxidative stress.14 Similar findings were obtained in a more recent study with rats that were fed a grape-bilberry juice rich in anthocyanins (15 mg/day or 50 mg/kg body weight—a physiological, not pharmacological dose) compared with those consuming an anthocyanin-depleted juice for 10 weeks.15 The animals consuming the grape-bilberry juice experienced reductions in serum cholesterol and triglyceride concentrations as well as increases in the proportion of polyunsaturated fatty acids and decreased saturated fatty acids.15 Laboratory studies suggest that anthocyanins and their metabolites, which are produced by gut microflora, may decrease inflammatory markers associated with increased CVD risk.4 Anthocyanins also may have antiplatelet activity.3

Cancer Anthocyanins and anthocyanin-rich extracts in cell culture and in animals have anticarcinogenic activities. While laboratory studies have provided some insight into how they may work, the exact mechanism (or mechanisms) for how these dietary compounds prevent cancer is unclear.

22 today’s dietitian march 2014

Laboratory studies that used a variety of cancer cells have indicated that anthocyanins not only act as antioxidants, they also activate detoxifying enzymes; prevent cancer cell proliferation; induce cancer cell death (apoptosis); have antiinflammatory effects; have antiangiogenesis effects (ie, they inhibit the formation of new blood vessels that encourage tumor growth); prevent cancer cell invasion; and induce differentiation (the more differentiated the cancer cell, the less likely it is to grow and spread).16 In animal studies, anthocyanins inhibit cancer development in animals given carcinogens and in those with a hereditary predisposition to cancer.16 Anthocyanins have been tested against esophageal, colon, skin, and lung cancer, and in several cases have been effective against the development and progression of these cancers.16 In one study, freeze-dried black raspberries inhibited cell proliferation, inflammation, and angiogenesis of esophageal cancer cells in rats.17 In cell culture, anthocyanins from an anthocyanin-enriched purple sweet potato stopped the reproduction of colon cancer cells and initiated cancer cell death.18 Human studies have been less promising. Two studies from Italy found no relationship between anthocyanin intake and the risk of oral, pharyngeal, or prostate cancer.19,20 Another study examined the effect of supplementing the diets of young cancer patients receiving chemotherapy with 50 mg of anthocyanins, 40 mg of cysteine, and 200 mg of glutathione, and found no increased inhibition of tumor growth when compared to chemotherapy alone.21 However, in a study of 25 colon cancer patients who received 60 g/day of an anthocyanin-rich black raspberry powder for two to four weeks, the tumors had reduced proliferation rates and increased apoptosis.22 Another study of 25 colorectal cancer patients given 0.5 to 2 g/day of anthocyanins as a bilberry extract for seven days, found an improvement in several changes consistent with colorectal cancer chemoprevention.23 Paradoxically, the smallest dose of 0.5 g/day was most beneficial.

Cognitive Function With regard to cognitive function, research suggests that flavonoids, including anthocyanins, have the ability to enhance memory and help prevent age-related declines in mental functioning.23 Extensive research in animals has shown that the flavonoids found in fruit and fruit juices can improve memory and slow age-related loss of cognitive functioning.

Several other studies have found that berries, most notably blueberries, which are rich in anthocyanins, can effectively reverse age-related deficits in certain aspects of working memory. Anthocyanins and other flavonoids are thought to work by inhibiting neuroinflammation, activating synaptic signaling, and improving blood flow to the brain.3,24 It appears that some dietary anthocyanins can cross the blood-brain barrier, allowing the compounds to have a direct beneficial effect.25 The authors of a recent review on the subject suggested that the consumption of flavonoid-rich fruits such as berries, apples, and citrus throughout life potentially could limit or even reverse age-dependent deteriorations in memory and cognition. As of now, however, there are no human studies to prove a causal relationship between the consumption of anthocyanins, or any flavonoid, and cognitive functioning. Whether the consumption of flavonoid-rich foods can have a beneficial effect on cognition also may depend on when in life exposure occurs.

Anthocyanin Advice The effects of anthocyanins are closely linked to their absorption and metabolism, but more research is needed to better understand how they’re absorbed and used in the body before anthocyanin doses can be prescribed for disease prevention. “Eating enough fruits and veggies is a never-ending challenge,” says Jennifer Neily, MS, RDN, CSSD, LD, owner of Neily

on Nutrition in Dallas. “I always encourage my clients to eat a rainbow of colors—red, orange/yellow, green, blue/purple— because of the disease-fighting benefits they provide.” For anthocyanin-rich berries, she recommends keeping frozen ones on hand. “They’re great for a quick fiber-filled smoothie.” Ximena Jimenez, MS, RDN, LD, a spokesperson for the Academy of Nutrition and Dietetics, says that while anthocyanins haven’t reached star status yet, consumers are starting to hear more about them. “Aim for three or more servings per week,” she recommends telling clients and patients. “Start your day with blueberries or blackberries, grape juice for lunch, and add eggplant, purple cauliflower, or purple onions to your favorite recipes.” While Blumberg admits that the medical community has limited knowledge of the mechanisms of action and health benefits of anthocyanins, he questions the wisdom of waiting for definitive research when clients may benefit from increased consumption of anthocyanin-rich foods now. — Densie Webb, PhD, RD, is a freelance writer, editor, and industry consultant based in Austin, Texas.

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

Morrison Healthcare is a leading national food and nutrition services company exclusively dedicated to serving more than 600 hospitals and healthcare systems across the Nation. We are a division of Compass Group and have more than 1,300 registered dietitians, 450 executive chefs and 19,000 professional food service team members. Our vision for success is a powerful one – Great People! Great Service! Great Results! We are always looking for Registered Dietitians as leaders for our foodservice operations and clinical nutrition management roles. Some of these positions pay up to $15,000 in Sign-On Bonuses and includes additional relocation assistance. If you feel you have the experience and qualities to be part of our Vision then take a closer look at what we have to offer.

Contact us to see where our opportunities can take your Career: www.IamMorrison.com Inquiries welcome MelissaPeterson@IamMorrison.com

Morrison0314.indd 1

2/19/14 9:12 AM march 2014 www.todaysdietitian.com 23

TD10 Today’s Dietitian’s Fifth Annual Showcase of 10 Incredible RDs Who Are Making a Difference BY LINDSEY GETZ

or the past five years, Today’s Dietitian has asked readers to nominate colleagues who they believe have accomplished incredible feats in the dietetics field, who have gone above and beyond what’s expected of them to spread nutrition messages, establish new trends, lead movements, and help the underserved lead healthier lives. Each year, all the wonderful successes you have in the nutrition profession continue to amaze us, making it increasingly difficult to select only 10 winners from such an exceptional pool of high achievers. Dietitians represent nutrition in many different areas and in many different ways. Some work with underprivileged populations, the elderly, and children. Others tirelessly investigate our food sources and sustainable food systems and provide nutritious meals to those who don’t have access to them. And still more are making great strides in the areas of education, policy reform, research, and engaging one another as they advance the profession. In honor of National Nutrition Month® and Registered Dietitian Nutritionist Day, Today’s Dietitian has chosen 10 exemplary dietitians who deserve recognition for their exceptional work in the field. We hope you enjoy their stories and become even more inspired to continue the incredible work you do each day.

24 today’s dietitian march 2014

Melinda Hemmelgarn, MS, RD

Freelance Writer, Speaker, Columnist, and Food Sleuth Radio Host

Melinda Hemmelgarn says she always has been one to ask the why questions, so it makes sense that she now is best known as the award-winning Food Sleuth columnist and radio show host. Over the years, Hemmelgarn has focused much of her investigative work on media literacy, pursuing the big question: Who owns the messages about our food? She’s also a passionate advocate for growing and eating organic and locally produced food and living sustainably, and zealous about educating food consumers to put more thought into their choices. “Whenever I’m giving a talk, I hand out a postcard that says, ‘Thinking beyond our plate,’ because that’s what I want people to do,” she says. “I want to help people think more critically. The food choices they make affect so much more than just us. People need to ask: Where does my food come from? Who

produced it? Under what conditions was my food grown or produced? And were the workers treated fairly?” Hemmelgarn says individuals who have been brave enough to ask the hard questions and pursue the truth always have inspired her. And there’s no doubt she’s become one of those people. As the founder and former director of the University of Missouri’s Nutrition Communications Center, she led the movement for integrating media literacy into nutrition education. “People are getting their nutrition information from the media, and we really need to start questioning what information they’re getting,” she says. “We don’t realize how much we’re influenced by media, and I want to be sure there’s a voice in the media that’s bringing food truths to light.” That passion for pursuing the truth may have been instilled at a young age. Hemmelgarn says she had an excellent role model in her mom. “She was a stay-at-home mom that was active in the PTA and always writing letters to senators or fighting for what she believed in,” Hemmelgarn remembers. “She showed me how to be an advocate for those who might not have a voice.”

Angela Grassi, MS, RD, LDN Founder of the PCOS Nutrition Center

After gaining more than 30 lbs for no distinguishable reason, Angela Grassi saw three different physicians who each told her just to watch her diet more closely. She already was doing intense workouts and, as a dietitian, knew her diet shouldn’t have promoted that kind of weight gain. After much frustration, Grassi finally wound up seeing a polycystic ovary syndrome (PCOS) expert who confirmed she had PCOS, even though she didn’t have some of the telltale signs that might have brought a quicker diagnosis. It was a life-changing moment in many ways. Driving home from that specialist visit, a lightbulb went off, and Grassi decided she would devote her dietetics career to PCOS. Her goal has been to educate other dietitians since they’re often well positioned to be the first to recognize the condition. “My mission is for every dietitian to know what PCOS is,” she says. “When I told other dietitians I was diagnosed with it, many didn’t even know what PCOS was. That astounded me since it’s fairly common.” As many as one in 10 women of childbearing age have PCOS, but for many it goes undiagnosed. Grassi seeks to change that. “I knew that when I wanted to educate other professionals that a key way to do that would be a book,” she says. The second edition of PCOS: The Dietitian’s Guide just came

out, and she’s working on her first cookbook. Now Grassi is involved with getting a study under way that will look at the relationship between gluten and PCOS to determine whether women with PCOS also are gluten sensitive. Grassi says helping women realize they can become pregnant despite PCOS constantly inspires her to keep going. “When I first got diagnosed, it was the change in my diet plus supplements that helped me to get pregnant easily,” she says. “Many women with PCOS have difficulty getting pregnant, but it’s inspiring to help them make changes and have success.”

Jan Patenaude, RD, CLT

Director of Medical Nutrition for Oxford Biomedical Technologies

Having grown up on a farm, Jan Patenaude says she always has “known where food came from— and it wasn’t a box or a package.” Her family grew its own vegetables and raised cattle and chickens, and her father hunted and fished. Her interest in food led her to a restaurant management program that she started as a senior in high school. But during her first full year of college, she had to take a required nutrition course and says she instantly was hooked. She switched to a dietetics degree and never looked back. Patenaude says what she’s loved most about being a dietitian has been the freedom and the variety the profession offers. She has worked in hospitals, long term care, prisons, and home health care, and she has served as a speaker at industry meetings. Now with Oxford Biomedical Technologies, Patenaude works to educate others about the LEAP (Lifestyle Eating and Performance) diet protocol, which is designed to reduce clinical and subclinical inflammation in conditions such as irritable bowel syndrome, migraines, eczema, and chronic rhinitis. As a true LEAP pioneer, she was the first dietitian to take part in this growing field. “It’s been really exciting,” Patenaude says. “I have mentored many RDs who were bored in their former careers and who wanted to make more of a difference in the lives of others. Being a LEAP therapist has allowed them to do that.” In fact, Patenaude says it’s the stories of patients who have been helped by the LEAP diet that drive her own passion. “It’s even saved the lives of suicidal patients,” she says. “We’ve had patients who have tried everything, including medications, but it ultimately ends up being some dietary changes that they really needed. The work we do is very important because we’re giving people their lives back.”

march 2014 www.todaysdietitian.com 25

Fifteen years ago, Patenaude’s sister had a best friend who committed suicide because she gave up hope of ever finding a solution to her relentless migraines. “She left behind a family because she couldn’t spend another day living in pain,” Patenaude says. “I wish I’d known about this work then. Maybe someone could have helped her. I do feel like we’re making a difference for people, and that keeps me going.”

Jo Jo Dantone-DeBarbieris, MS, RDN, LDN, CDE Owner and CEO of Nutrition Education Resources

Jo Jo Dantone-DeBarbieris began her schooling as a religious education major at a Baptist university, with plans of serving the Lord as a counselor. But she found that she struggled with the major. As much as she’d thought religious counseling was meant to be her calling, she says the Lord ultimately led her elsewhere. During a discussion with her mother’s best friend (a dietitian), Dantone-DeBarbieris realized dietetics really was the path meant for her. “Dietitians can go into so many different fields,” she says. “When the guidance counselor asked what I wanted to do, I told her I wanted to serve people in underprivileged countries. But my first job wound up being in the health department in rural Mississippi’s poorest of poor areas. I was still serving people in an underprivileged area; it just turned out to be in my own country.” That’s also where Dantone-DeBarbieris was first exposed to geriatrics. Today, as the president and CEO of Nutrition Education Resources, she provides consulting services to a large number of nursing homes, hospitals, home health agencies, correctional facilities, and even child nutrition programs. She also works in an HIV clinic. In addition to a passion for geriatrics, she has a special interest in diabetes education after her own diagnosis 20 years ago. Dantone-DeBarbieris says it’s the opportunity to inspire others that motivates her. Her consulting firm employs approximately 30 to 40 dietitians, and she always has encouraged them to go above and beyond the call of duty. For 37 years, she has required all dietitians working for her to take a hands-on approach to assessments. “Instead of just looking at charts, I say to lay your hands on the patient and actually touch their skin,” she says. “A physical exam tells you things that a chart does not. It’s a hands-on, eyes-on assessment. About five years ago, they finally put that in the CMS [Centers for Medicare & Medicaid Services] regulations. After preaching it for so many years, I was pleased to see it become official.”

26 today’s dietitian march 2014

Maria Caranfa, RDN, LD

Nutrition Program Manager for Bloomin’ Brands

From a very young age, Maria Caranfa enjoyed being around food and was curious about creating healthful meals. When she was 10 years old, she cocreated an at-home “restaurant” that family members would visit. The menu was filled with flavorful options such as “magic fried chicken” that was baked instead of fried and various pastas filled with garden-fresh vegetables. Caranfa attributes her passion for food to both her mother and grandmother, and says it was no surprise that she wound up in the restaurant industry. As the nutrition program manager for Bloomin’ Brands, a portfolio of five leading restaurant brands, Caranfa helps teach and consult the 80,000-plus team members who comprise the organization. In helping to lead and support the research and development team on the analysis of new menu efforts, Caranfa also has assisted in removing more than 20,000 kcal from the brands’ menus. “We literally trimmed the fat from many of the portfolio’s menu items,” she says. “We took a careful look at each recipe and identified ways to maximize the flavor and minimize the fat. And we did all of this without sacrificing the experience that guests come to expect from each brand.” Caranfa says she always has appreciated the ways she can bring “health and flavor together” and feels the restaurant industry has provided that. But it’s ultimately food that inspires her. “I think there are millions of ways to combine food’s natural flavors to create meals that are both healthful and flavorful,” she says. “I am inspired by the intrinsic goodness and deliciousness of natural healthful foods like nuts, seafood, colorful produce, and grains.”

Shirley Y. Chao, PhD, RD, LD/N

Director of Nutrition for the Massachusetts Executive Office of Elder Affairs

Supporting seniors to live independently has been a major focus for Shirley Y. Chao for the past 20 years—long before aging in place or home health care became a growing trend. As the director of nutrition for a statewide elder nutrition program, Chao has helped raise the quality of nutritious meals served while also keeping it cost-effective. Her efforts have supported the program for 20 years, eliminating the need for a permanent waiting list that can force seniors who

qualify for meals to have to wait for months or even years because of a lack of funding. Chao also helps uphold standards, inspections, and training to ensure food safety and provides nutritious meals to improve the health and lives of approximately 75,000 seniors each year. Her daily responsibilities range from financial contract negotiation to policy recommendations. She also helps set policy that directs the local programs and ensures individuals meet eligibility requirements to receive meals. This year, the organization started several new statewide initiatives, including a breakfast program, weekend frozen meals, therapeutic meals, and nutritional supplementation. Chao has proven to not only be a statewide leader but a national one as well. She has served as chair of the Healthy Aging Dietetic Practice group and is on the board of the National Association of Nutrition and Aging Services Programs. Throughout her career, she has helped influence policy such as the Older Americans Act. “My main goal is to be able to support seniors to live independently in the community as long as possible,” Chao says. “This year, when we got back our satisfaction surveys, I learned that the Older Americans Act ‘noon meal’ represents more than half of the participants’ daily intake. I also learned that more than 75% of the participants are older than 80 years; 25% of them have been with the program for more than five years. All of this keeps me going. We also have 70-plus people who receive home-delivered meals who are older than 100 years old! I believe the best is yet to come.”

Silvia Benincaso, MPH, RD

Captain for the US Public Health Service, Acting Director of Nutrition Services at Phoenix Indian Medical Center, and Director of the Southwestern Dietetic Internship

Silvia Benincaso became interested in nutrition and its role in health and wellness—particularly in the treatment of disease—as an undergraduate at Rutgers University in New Jersey. In 1992, she was commissioned as an officer in the US Public Health Service and has been stationed with the Indian Health Service for her entire career as an officer. While working and learning about the health concerns of Native Americans, it became clear to Benincaso that the rate of nutrition-related diseases

was very high, yet there were few RDs who worked within Native American communities. Even more troubling, she learned that only 0.3% of all RDs were from American Indian or Alaska Native tribes, despite the well-known fact that individuals learn best from people who understand their culture. Benincaso felt compelled to make a change. That change would come through education. At the time, the Indian Health Service didn’t have a dietetic internship program. Benincaso and her supervisor, CAPT (retired) Edith Clark, began investigating what designing such a program would entail. Partnering with Kayenta Service Unit, another Indian Health Service facility, a 33-week (now 40-week) accredited dietetic internship program was formed. The program provides housing during the six-week (now sevenweek) rotation in which interns can immerse themselves in Navajo culture. To date, 13 interns have graduated, and nine are employed in programs serving American Indian people. Another major accomplishment has been providing additional public health messages to the general public and the employees of the Phoenix Indian Medical Center. “To increase public health messages to people receiving services at the Phoenix Indian Medical Center, we purchased three large bulletin boards,” Benincaso explains. “The dietetic technicians I supervise also rotate preparing colorful educational displays on a variety of topics. This year we plan to showcase food-related traditions of different Native American tribes around the nation.” Benincaso says what inspires her on a daily basis is a team that’s dedicated and supportive. “I work in an environment that has embraced interdisciplinary teamwork and values the contributions of registered dietitians.”

Paul Moore, MS, RD, CSSD, LDN, CSCS*D, NSCA-CPT*D

Assistant Director for the Appalachian Regional Healthcare System Wellness Center and an Adjunct Instructor in the College of Health Sciences at Appalachian State University

Although Paul Moore works full-time at a hospital-based wellness center, where he serves as the facility’s assistant director, he finds time to fit in a variety of other roles, including teacher and volunteer. As an adjunct instructor at Appalachian State University, Moore enjoys teaching a general nutrition course and encouraging students to make life-long healthier choices. But the course he enjoys teaching the most is “Nutrition for Children,” which often is inspired by his experiences as a father of two young kids. “Having children of my own is when I really turned the corner in understanding the impact that nutrition has on our lives,”

march 2014 www.todaysdietitian.com 27

Moore says. “Watching them learn to eat and seeing how it affects them has inspired me in all areas of practice and made me more passionate about the field.” Currently, Moore also serves as the 2013-2014 North Carolina Dietetic Association (NCDA) president and volunteers as an editor for the Weight Management Matters newsletter, published quarterly by the Weight Management Dietetic Practice Group. Though he’s busy with his full- and part-time jobs as well as his family, Moore says he believes in the importance of dietitians becoming more involved in professional associations and outside opportunities. That’s why he’s taken an active approach to engaging more NCDA members. One major change has been switching from one annual meeting (two to three days in length at one location) to four, one-day meetings held across the state and throughout the year. “We’re also trying to connect members with a monthly webinar so that regardless of where they live or how busy they are, they can still be engaged,” he says. In addition, Moore is making a difference in his local community of Bonne, North Carolina, with a medically supervised program called THRIVE for patients with chronic disease. “Patients have really loved the program, and we’re getting a lot of success stories,” he says. “People will come in telling us their doctor made them, but two years later, they’ll still be coming every day. It’s inspiring.”

Susanne Trout, RDN, IBCLC, RLC, LD Program Director at LifeStyle Evolve

Susanne Trout’s career shows the true versatility of a dietetics degree. She once served as a site coordinator for a pediatric bariatric group at Texas Children’s Hospital, where she helped build one of the first adolescent gastric bypass programs in the country. Before that, she worked in the hospital’s neonatal ICU (NICU), where she developed an interest in breast-feeding and became a lactation consultant. Recently, however, she moved to Arizona and into the area of health and wellness. Working for a company that provides medical-grade skincare products as well as nutrition and wellness consultation has been new and exciting for Trout. “That’s what I love about this field,” she says. “There are always new things to learn, and that keeps me going. I enjoy thinking outside of the box and looking at fresh perspectives.” Trout also continues to offer lactation consulting services and says she’s passionate about helping people understand why breast-feeding is so important. “I loved my work in the NICU, and that’s where I also developed an understanding of the

28 today’s dietitian march 2014

importance of breast-feeding,” she says. “While [consulting] was meant to be a little side business, I often just offer my lactation consultations as a service to the community. It’s something I really believe in.” Like many other RDs, Trout says one of the biggest challenges she’s faced is convincing others of the “value of the dietitian.” This is the one plus about the company for which she now works: “They’re really promoting the dietitian and the value behind nutrition education, which is a great thing.”

Lisa Eberhart, RD, CSSD, LDN, CDE

Dietitian for University Dining at North Carolina State University

As a full-time dietitian with North Carolina State University, Lisa Eberhart hasn’t only changed the way students eat but the way they perceive food. She has proven that even minor changes can make a dramatic difference in students’ nutrition, as one healthful choice often leads to another. Putting fruit and vegetables in prominent positions, changing milk from 2% to 1%, using turkey in place of beef, and switching from white to wheat bread are just a few healthful changes students on campus readily are accepting. “We’ve tried to make things healthier without making a big deal [about it] to the students because that can turn them off,” Eberhart says. “I’m proud of how far we’ve come. We have a huge fruit and vegetable bar that’s very popular with students as well as a hydration station that looks like something you’d see at a spa and that attracts students to drink more water.” But Eberhart also is especially proud of the food labeling program. She says North Carolina State has one of the best allergy marking systems among universities, and that allows students with allergies to feel comfortable making safe dining decisions. The campus offers iPads that enable students to sort menu items by allergen, she explains. For instance, if students have a peanut allergy, they can select the peanut icon to bring up a list of safe foods they can eat. Eberhart began her work for North Carolina State as a consultant while keeping up with a thriving private practice. Ultimately, it morphed into a full-time job, which she says is a bit like a dream come true. “I have the perfect job because it’s a marriage between food, foodservice, clinical nutrition, and education,” she says. “It’s such a great combination, and I really love it.” — Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.

Midlife

By MARYANN JACOBSEN, MS, RD

Nutrition Helping Women Over 40 Overcome Nutrition Challenges

30 today’s dietitian march 2014

never had a weight problem until I turned 40. The weight just doesn’t come off like it used to.” If you work with women aged 40 and older, this complaint probably sounds all too familiar. The challenges facing female clients in midlife regarding nutrition and overall health can seem insurmountable to them. Whether it’s unwanted weight gain, the loss of lean body mass, bone health concerns, or other issues that occur during the years leading to menopause and beyond, there’s much dietitians can do to help these women remain healthy and stronger than ever.

Culprits Behind the Weight Gain One of the most irksome challenges facing women in midlife is unwanted weight gain. According to 2003-2004 National Health and Nutrition Examination Survey (NHANES) data, the largest jump in the percentage of women who become overweight or obese occurs between the ages of 20 and 39 (51.7%) and 40 and 59 (68.1%).1 Research indicates that hormonal changes are responsible for the increases in body fat, especially in the midsection. The female hormone estrogen begins to decline during perimenopause, the time during which a woman’s body makes its natural transition to menopause, although erratically, and it decreases further along with progesterone when menstruation ends. Perimenopause usually begins in a woman’s 40s but can begin as early as the mid-30s, according to the Mayo Clinic website. Menopause occurs one year after the last period, typically at age 51. These hormonal changes increase the rate at which women store visceral fat, which surrounds the vital organs deep within the abdomen, and precipitate changes in insulin sensitivity and glucose metabolism, putting them at increased risk of cardiovascular disease and diabetes.2 Emerging research has revealed that changes at the cellular level cause menopausal women to store more fat with a diminished ability to burn fat.3 “Due to a loss of estrogen, fat is metabolized differently,” says Colleen Keller, PhD, regents professor and director of Arizona State University’s Center for Healthy Outcomes in Aging. “It’s actually laid down differently in the body as subcutaneous fat.” Keller argues that these changes associated with midlife aren’t to be feared but to be accepted as a normal part of aging. She believes arming women with strategies to decrease weight gain and chronic disease risk is key in helping them anticipate physiologic and metabolic changes. Research shows estrogen therapy helps prevent some of these age-related changes,4 however, it’s no longer recommended for all women because of potential adverse effects such as an increased breast cancer risk.5 It’s important for women to talk with their physician about hormone therapy, as it can be beneficial for some women, including those who experience premature menopause (before age 40).5

Physical Activity The good news is that there’s a not-so-secret weapon that can help women fight the inevitable weight gain: exercise. Physically active women who enter menopause are leaner than

inactive women and have a decreased risk of developing metabolic disease.6 According to a longitudinal study that included the Study of Women’s Health Across the Nation cohort, women whose activity decreased the most packed on the most pounds overall as well as in the midsection. Those who maintained their weight throughout the study participated in an average of 60 minutes of activity per day, the same amount recommended for the average adult by the Institute of Medicine (IOM).7 “Women in midlife begin to start suffering from a new STD: sitting-to-death disease,” says Bonnie Roill, RDN, MBA, CPT, CWC, owner of Aspire2Wellness, who counsels women in midlife. “I recommend a standing desk or standing while on the phone. Setting the alarm on the computer to remind the person to stand up and walk around a bit.”

Lean Body Mass Research has shown that while changes in fat distribution can be attributed to hormonal shifts experienced by women in midlife, overall weight gain that occurs with age (about 1 lb per year) primarily is due to the effects of aging, such as decreased activity and a loss of lean body mass, which is more metabolically active than fat.6 “Loss of lean body mass starts in the 30s and 40s,” says Douglas Paddon-Jones, PhD, a professor in the department of nutrition and metabolism at The University of Texas Medical Branch. “Women need to understand the impact diet has on muscle loss the same way they understand how diet affects osteoporosis risk.” Paddon-Jones explains that after age 40, women lose about 1% of their lean body mass per year if they’re inactive. He says all types of exercise are important to maintain and build muscle, from cardio and strength training to yoga. For example, cardiovascular exercise, such as brisk walking or jogging, strengthens the heart and lungs, helps improve the blood sugar and insulin response, and strengthens large muscle groups, while strength training helps build lean body mass in the arms, legs, and upper and lower back.

Protein Intake In addition to participating in physical activity to maintain and build muscle, women in midlife also should strive to eat protein during meals to promote muscle-protein synthesis, which is essential to the body’s ongoing growth, repair, and maintenance of skeletal muscle, according to Paddon-Jones. In his research, Paddon-Jones has found that as much as 25 to 30 g of protein is needed at each meal to optimally stimulate muscle-protein synthesis.8 For example, in one study, subjects who received 90 g of protein evenly distributed among three meals (30/30/30) experienced a larger anabolic response to the meals after 24 hours compared with those who received a more uneven distribution (10/20/60).9 Another study, published in the Journal of the Academy of Nutrition and Dietetics, found that, in a single meal, 30 g of protein had the same anabolic effect as 90 g, showing that after about 30 g, protein synthesis is maxed out.10

march 2014 www.todaysdietitian.com 31

What’s behind this may be the amino acid leucine, which is needed to “turn on the protein-synthesis machinery” as people age, Paddon-Jones explains. “This is a big change for many people who have toast for breakfast and a salad for lunch followed by a big chicken breast for dinner,” says Nancy Clark, MS, RD, author of Nancy Clark’s Sports Nutrition Guidebook. “They need to redistribute their protein evenly throughout the day.” Paddon-Jones adds that if women skimp on protein after workouts, it’s a missed opportunity to help build muscle mass. He says dietitians can help clients find creative ways to boost their protein intake, especially at breakfast, during which the average American gets only about 10 g.11 In addition to eating sufficient protein and balancing intake across the day, eating the proper amount and type of carbohydrate can help cut calories and control blood sugar. Roill recommends swapping high-glycemic foods such as frappuccinos and cookies for those with a lower glycemic index, such as an apple with cheese or peanut butter, since many of her female clients approaching menopause have been diagnosed with prediabetes. She suggests women eat in reverse: the larger meal at breakfast and the lightest meal at dinner, and reduce calories from beverages such as alcohol, coffee drinks, and smoothies, which tend to be calorically dense. “The reduction in caloric needs as we age coincides with a time in many [women’s] lives when they have the income and time to socialize, vacation, etcetera,” she says. “These activities are closely tied to dining out and the opportunity for consuming excessive calories.”

Bone Health Another concern for women is the depletion of bone density, which often occurs after menopause when the ovaries stop producing estrogen. Women can lose as much as 20% of their bone density five to seven years after menopause.12 The best case scenario, experts say, is for women to enter menopause with sufficient bone density to minimize subsequent losses. “There’s a critical window for bone loss, which occurs one to two years before a woman’s last period and five years after that,” says Diane L. Schneider, MD, author of The Complete Book of Bone Health. “Between waning hormones, weight gain, and changes in physical activity, there’s a synergistic effect on bone in women as they age.” Schneider says calcium, vitamin D, adequate protein, not smoking, and exercise are key components to decreasing the amount of bone loss. In one study, researchers estimated that women aged 80 who don’t smoke, are physically active, and have a BMI of 25 will lose 25% to 38% less bone than women of the same age who smoke, are sedentary, and are thin.13 Low BMI is a known risk factor for osteoporosis and fractures. In a 2005 meta-analysis, those with a BMI of 20 had almost double the risk of hip fracture compared with those with a BMI of 25. After age 50, the Recommended Dietary Allowance (RDA) for calcium climbs to 1,200 mg/day, which makes meeting

32 today’s dietitian march 2014

calcium needs challenging, especially since calcium supplements now are recommended less often because of potential heart disease risks. Schneider suggests a food-first approach to increasing calcium intake and using supplements as a way to fill in the gaps. “One day you may need to supplement, and another day [you may not],” she says. “And women should take no more than 500 to 600 mg at a time, since more than that isn’t utilized by the body.” Schneider says vitamin D supplementation should be based on an individual patient’s blood levels. There’s debate about what the optimal vitamin D blood levels should be for bone health. The IOM’s 2010 report, based solely on vitamin D’s role in bone health, states the baseline target should be 20 ng/ mL,14 while the Endocrine Society recommends a target of 30 ng/mL.15 Schneider says the best recommendation for optimal vitamin D levels to maintain muscle and bone health is no lower than 30 ng/dL. “It takes at least 1,000 to 2,000 IU of vitamin D to maintain levels over 30,” she adds. Just as physical activity is important to maintain lean body mass, it’s also vital for preserving bone health. Weightbearing exercises such as jogging and walking and resistance training are beneficial because they add force to the body, which sustains bone density. “Recommendations for exercise jump from 30 minutes per day of activity to 60 minutes per day when transitioning to menopause,” Schneider says. “Without exercise, stem cells are more likely to become fat cells.” Keeping track of daily activity by wearing a pedometer and tallying the number of steps taken while adding resistance exercise works well for busy women, she adds. Roill, who feels strongly that women in midlife should embrace resistance training, suggests RDs recommend their clients purchase a set of dumbbells and instructional DVDs to get them started, especially if they have no previous experience with exercise. “The goal is for clients to work out with weights a minimum of two times per week,” she says. Other lifestyle factors that can negatively affect bone health include excess alcohol consumption and a family history of osteoporosis. Certain drugs such as proton pump inhibitors for acid reflux disease, selective serotonin reuptake inhibitors for depression, and certain diabetes and breast cancer medications also can deplete bone density. In addition, diabetes can increase osteoporosis risk because the disease decreases the rate of bone turnover, Schneider says. Women who have a family history of diabetes or other risk factors should have their first bone density test during the perimenopausal years, Schneider says. Women at low risk of osteoporosis should discuss the best timing for a bone density scan with their primary care physician.

Hot Flashes and Sleep Disturbances Along with concerns of bone health, women in midlife can experience sleep disturbances as they transition to menopause. According to the National Sleep Foundation, up to 61%

of postmenopausal women report symptoms of insomnia, which include trouble falling or staying asleep for three or more nights per week for one month.16 The decline in estrogen and progesterone, which leads to hot flashes in about 75% to 85% of women, contributes to insomnia.16 Hot flashes can disrupt sleep because body temperature dramatically rises, leading to night sweats that cause sudden waking. Most women experience hot flashes for about one year, but some experience them for up to five years. Anxiety and depression at midlife also may contribute to sleep problems.16 It’s important for dietitians to address sleep quality with clients and patients because sleep loss interrupts appetite regulation by elevating levels of the hunger hormone ghrelin and decreasing the satiety hormone leptin, which can raise the risk of weight gain.17 Recommendations from the Harvard Medical School Division of Sleep Medicine can help dietitians advise their clients to improve sleep quality and include refraining from drinking caffeinated beverages four to six hours before bedtime and alcohol within three hours of bedtime, practicing a regular sleep routine, eating a light evening meal, exercising early in the day or at least three hours before bedtime, and going to bed only when tired.18 There are other options for peri- and postmenopausal women who are having trouble sleeping. “I focus on the importance of sleep, and an effective way to get rid of night sweats and hot flashes is to take a very low (nontherapeutic) dose of the antidepressant Effexor [venlafaxine hydrochloride),” Clark says of the prescription medication. “It works like a charm. Once a woman gets enough sleep, she has the energy to exercise and to eat better.” Sleep disorders such as restless leg syndrome and sleep apnea also can contribute to poor sleep quality, so making sure patients get treated for these conditions is important.

Gastrointestinal Changes Other issues that women in midlife may face include changes in digestion. Fluctuations in ovarian hormones may contribute to belly bloating and sluggish intestines, says Kate Scarlata, RDN, CDN, author of The Complete Idiot’s Guide to Eating Well With IBS. The same gastrointestinal (GI) symptoms that occur during pregnancy, premenses, and menses— bowel discomfort, abdominal pain, bloating, and altered bowel patterns—also occur during perimenopause and menopause. Researchers believe it’s the fluctuations in ovarian hormones that contribute to GI distress.19 Scarlata says that gut microbiota changes with age,20 with a decline in the number and variety of protective microbes, but she says researchers aren’t sure how that specifically impacts GI issues in midlife. Dietitians can counsel women who have endured chronic antibiotic use, and therefore a decrease in beneficial gut bacteria, about probiotics that can help bring their gut flora back into balance. Some women develop lactose intolerance as they age, so incorporating lactose-free milk, cottage cheese, and yogurt into

their diet will enable them to continue to eat dairy products and help them meet their calcium needs. Scarlata recommends clients follow a low-lactose diet if gas and bloating are related to milk consumption. And she advises patients drink six to eight 8-oz glasses of water daily and eat adequate amounts of fiber (approximately 25 g/day) that are less gassy, such as chia seeds, pumpkin seeds, strawberries, and baked potatoes with the skin on vs. choosing inulin or whole wheat fibers, which can cause more GI distress.

Changing Nutrient Needs When it comes to nutrient needs, women who have reached menopause don’t need as much iron as they used to because they no longer menstruate; the RDA drops from 18 to 8 mg/day. Folic acid, which helps protect unborn children against neural tube defects in the womb, no longer is a concern since postmenopausal women can’t get pregnant. Some research suggests that too much folic acid from fortified foods and supplements may increase the risk of certain cancers,21 so discussing folic acid supplements and fortified foods with postmenopausal women is important. Because the risk of cardiovascular disease, diabetes, and weight gain rises after menopause, helping women choose a diet rich in nutrients but lower in caloric density is key, as is choosing healthful fats, lean sources of protein, low-fat dairy or dairy alternatives, and plenty of fruits and vegetables.

Final Thoughts While women in midlife face many challenges, such as hormonal changes that lead to weight gain, loss of bone and muscle mass, and digestive issues, there’s much they can do with the help of dietitians to begin a healthful transition into the postmenopausal years. Counseling clients about the importance of evenly distributing protein among meals, eating nutrient-dense foods, consuming fewer calories because of reduced energy needs, getting adequate amounts of vitamin D and calcium, and engaging in physical activity such as aerobic and strength training exercise will help burn unwanted fat, build muscle and bone, and prevent metabolic disease. Dietitians can help women realize that bodily changes start well before midlife, and that they can benefit from knowing what to expect beforehand and how best to prevent the negative effects of aging. RDs are in the perfect position to empower women before, during, and after menopause so they can live their healthiest lives and let them know that the best is yet to come. — Maryann Jacobsen, MS, RD, is a freelance writer based in San Diego.

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

march 2014 www.todaysdietitian.com 33

Learn how diet plays a role in the detoxification process and how RDs specializing in integrative and functional medicine are applying the research to clinical practice.

Diet

and

Detoxification By Juliann Schaeffer

34 today’s dietitian march 2014

etox: For one small word, it has a whole host of meanings, depending on who’s talking— and possibly what they’re selling. When a client reaches out for nutritional guidance with “detoxing,” he or she may reference a weight-loss cleanse marketed by a celebrity or maybe some simple information on juicing. Or a client may come to an RD complaining of general malaise or illness and wonder whether detoxing can alleviate the symptoms. Whatever images of detoxing clients bring with them to a consult, likely they have questions about how a diet may work or how it may help them, and they’re looking to you for answers. Yet the topic of detoxification is a contentious one, not just among consumers, but among the RD community as well. While debate may linger among dietitians as a whole, there are many RDs within the integrative and functional medicine community who believe today’s highly toxic environment necessitates a form of detox diet as medical nutrition therapy (MNT) that could benefit many individuals based on their exposure level, diet and lifestyle habits, and genetics. Dietitians refer to previous and emerging research that suggests specific nutrients play an integral role in the detoxification process, noting that many tenets of a clinical detox diet contain guidance quite similar to what most dietitians already provide each day.

The Debate Some dietitians, skeptical of what they perceive to be fad diets, steer clients away from over-the-counter detox plans and toward whole-food prescriptions. Other RDs, many specializing in integrative and functional medicine, point out that proper detoxification protocols can help clients conquer any number of ills. Much of the debate surrounding detox centers on whether the body needs help flushing from its system any foreign toxins (also known as xenobiotics, which refers to any chemical substance foreign to the human body), since detoxification is a natural human bodily process. According to Marjorie Nolan Cohn, MS, RD, CDN, ACSMHFS, a spokesperson for the Academy of Nutrition and Dietetics (the Academy) and the author of The Belly Fat Fix, the human body can eliminate any toxins it comes into contact with just fine and says RDs should warn consumers of the risks involved with such fad diets. “Detox diets are illusive and popular, but they aren’t proven to do what they say they’ll do—ie, flush toxins out of your system,” she says. “Organs and the immune system can handle detoxification on their own, no matter what you eat. The best detox is an overall healthful eating plan along with plenty of fluid that promotes regular trips to the bathroom.” Robin Foroutan, MS, RDN, HHC, an integrative medicine nutritionist who’s given presentations on the subject of detoxing, is a big proponent of assisting the detoxification process with diet and supplements, though she may agree with Cohn’s second

point. According to Foroutan, while RDs may reject detox on the above principle, she says a proper detoxification regimen can look similar to an overall healthful eating plan, and that research exists supporting nutrition’s role in the detoxification process. In Foroutan’s eyes, the detoxification debate largely is an issue of semantics. “The term ‘detoxification’ has been co-opted and overused by nonscientific practitioners, self-educated consumers, and the media, resulting in the large-scale rejection of the term detoxification by scientific practitioners, including RDs who are weary of the term and the practice,” she says. “The problem is, when many RDs hear the word detoxification, they instantly think of the popculture version of detox rather than the systemic support of this critical physiological process. “On the one hand, we have untrained health ‘experts’ talking about cleansing and detoxification in nonscientific terms, often in the context of products that make exaggerated claims,” she continues. “In response, practitioners meet these claims with appropriate skepticism, especially since detoxification pathways aren’t typically included as part of our RD training.” But the insistence that there’s no evidence in support of detoxification simply is untrue, she emphasizes. “RDs need to better understand what detoxification actually is from a physiological perspective to be able to evaluate the research and understand the whys and hows of a medical detoxification protocol. Detoxification in medical terms isn’t synonymous with popular cleanses, juice fasts, or water fasts, though a medical nutrition therapy detox may include an elimination diet.” Sheila Dean, DSc, RD, LD, CCN, CDE, an integrative medicine nutritionist and adjunct professor at the USF Health Morsani College of Medicine, agrees: “The words ‘toxin’ and ‘detox’ mean different things to different people. It means different things to the layperson and even among the scientific community, even within the field of dietetics. I don’t believe that there’s consensus and, in my opinion, it’s more about a lack of understanding than a lack of scientific research.” Foroutan says that integrative and functional medicine RDs, and even the integrative and functional medicine community as a whole, largely agree about the benefits of assisting the detoxification process through diet, supplements, and lifestyle protocols. She even sees the beginnings of a paradigm shift in the general dietetics community. Whereas five years ago educational sessions at the Food & Nutrition Conference & Expo (FNCE) were devoted to debunking the myth of detoxification, now sessions on the topic address the specifics of “what is it, why is it important, and who needs it,” she says. “While detoxification is still controversial within the medical mainstream, we’re seeing more sessions at FNCE aimed at the research to support detoxification protocols, so I think more and more practitioners will be looking at detoxification with less suspicion and skepticism, and more from a perspective of scientific curiosity,” Foroutan adds.

march 2014 www.todaysdietitian.com 35

Three Bean Salad

Kathie Madonna Swift, MS, RDN, LDN, an integrative medicine nutritionist and the author of The Inside Tract, Your Good Gut Guide to Great Digestive Health, who gave a presentation on detoxification at FNCE 2013, notes the importance of debate itself and appreciates the fact that RDs aren’t quick to accept any nutritional therapy without science-driven evidence. “Scientific debate is good, and I think there should always be debate whether it’s about detoxification or diabetes,” she says, adding that she believes more education is needed across the RD community on the specifics behind the detoxification process and the role nutrition plays. “There’s absolutely research to support the use of detoxification protocols,” Foroutan says, noting that the human body is constantly in some state of detox every minute of every day. “Without being able to detox, you would die. So this debate isn’t a question of if detoxification happens or matters; this is a question of who needs additional detoxification support and who may benefit from it.” And this debate, as Foroutan and others concede, still is ongoing, as researchers evaluate how particular foods may speed up the detoxification process and test specific clinical detoxification protocols in clinical trials. There still are many unknowns, but that isn’t stopping integrative nutrition and other health experts from perusing what Foroutan says is promising research to date and translating it into nutrition counseling advice that could help many clients dealing with the myriad toxins they’re exposed to every day.

The Process So what does the detoxification process entail? Spanning professional organizations and textbooks, the actual definition of detoxification varies slightly. But in general terms, detoxification is a natural process by which the human body rids itself of xenobiotics and endotoxins. “Physiologically speaking, detoxification is the primary biochemical process for removing toxins by converting non–water-soluble toxic compounds into watersoluble compounds that can be eliminated through urine, sweat, bile, or feces,” Foroutan explains, noting that these processes primarily occur in the liver and are influenced by genetics and the environment, including diet.

36 today’s dietitian march 2014

In general terms, the detoxification process involves two, potentially three, phases. “Phase 1 enzyme activities include oxidation, reduction, and hydrolysis reactions during which the chemical [or toxin] is ‘activated’ to a more unstable, reactive form,” Foroutan says, adding that the cytochrome P450 is the family of enzymes responsible for phase 1.1,2 “Most pharmaceutical drugs are metabolized via phase 1 detoxification as well as endogenous toxins like steroids,” she says. More is known about phase 1 enzyme systems through research conducted on the metabolism of pharmaceutical drugs, she adds. This process creates an unstable intermediary metabolite (free radical) that’s further metabolized in phase 2, becoming a water-soluble molecule that can then be excreted through urine or bile.1,2 In research that’s still under way, Foroutan says a third step of detoxification has been suggested “in which an energy-dependent ‘antiporter’ pumps xenobiotics out of the enterocytes, which would decrease the intracellular concentration of that toxin.”2 She says this is thought to provide additional opportunities for phase 1 detoxification to occur before a toxin reenters circulation via the portal vein.1 “It’s hypothesized that when xenobiotics enter the intestinal enterocyte, some get ‘effluxed’ or pumped back into the intestinal lumen by an ‘efflux’ protein, p-glycoprotein,” Foroutan explains. “Glutathione is a required cofactor, and the purpose is thought to provide additional opportunities for phase 1 detoxification to occur before the toxin reenters circulation via the portal vein.”1,2 “When the body detects high xenobiotic loads, phase 1 and phase 2 enzymes normally are induced so that more enzymes are present and detoxification occurs at an increased rate,” she continues. “However, some toxic compounds, like those in cigarette smoke and charbroiled meats, increase phase 1 but not phase 2 enzymes, resulting in high levels of unstable intermediate molecules that can trigger free radical damage. This increase in circulating free radicals may be part of the mechanism linking the cancer-promoting toxins in cigarette smoke and charbroiled meats to increased cancer risk.”3 Dean notes that it’s important to understand that xenobiotics include much more than just the obvious toxic offenders, such as cigarette smoke and lead. In fact, the past 50 years have seen tens of thousands of new synthetic compounds introduced into the environment.3 A simple look at a person’s morning routine shows the potential for being exposed to chemical compounds in deodorant, shampoo, and makeup, not to mention artificial substances and heavy metals ingested through food or chemicals inhaled through air-sanitizing products or air pollutants. Much of the details of just how these toxins affect the human body still is to come, but in a January 2011 article in Human and Experimental Toxicology, Stephen Genuis, MD, a clinical professor at the University of Alberta and a key researcher of toxins and detoxification explains the potential health implications: “There is compelling evidence that various chemical agents are important determinants of myriad health afflictions—several xenobiotics

have the potential to disrupt reproductive, developmental, and neurological processes, and some agents in common use have carcinogenic, epigenetic, endocrine-disrupting, and immunealtering action. Some toxicants appear to have biological effects at miniscule levels, and certain chemical compounds are persistent and bioaccumulative within the human body.”4 This highly toxic environment, argues Mary Purdy, MS, RDN, an integrative medicine nutritionist, is in large part why the human body needs assistance with a natural process it’s been performing on its own for centuries. “I am well aware that our bodies are equipped with a system to eliminate the daily toxins we produce as well as some outside toxic compounds to which we are exposed daily,” she says, “but in this day and age, we are overloaded with toxic compounds—from pollution to pesticides to the myriad of chemicals in our household and personal care products as well as the plasticizers used in everyday food and nonfood items, the dozens of additives, preservatives, and other chemicals in our food. “We have a significant body burden going on here, and I imagine a sort of traffic jam going on in our livers,” she adds, noting that a person’s genetic makeup (having genetic variations in liver enzymes that can decrease the body’s ability to detoxify substances) also may cause someone to have impaired detox capabilities through no fault of their own.5

Nutrition’s Role So the question is can diet be used to aid the body’s natural detoxification process? As Dean explains, the detoxification system already depends on specific nutrients from the diet, and although research on using specific foods in clinical practice to aid detoxification still is in its infancy, certain foods and nutrients have been found to be associated with the upregulation, or inducing, of detoxification enzymes, leading to more enzymes being present and a faster rate of xenobiotic detoxification.2 “When something is upregulated, it’s ‘turned on’ or activity is enhanced,” Foroutan explains. “And when it’s downregulated, it’s ‘turned off’ or blunted. So, in this case, upregulation of an enzyme pathway by a gene would mean more of that enzyme will be produced and secreted, assuming the proper cofactors are present in adequate amounts.” So eating certain foods has great potential to help facilitate or speed up the detoxification process, she says. In general, B vitamins, glutathione (the body’s main detoxifying antioxidant), and flavonoids have been shown to assist phase 1 detoxification, whereas all major conjugation reactions in phase 2 require micronutrient coenzymes, including glycine, N-acetylcysteine (NAC), and B vitamins.6,7 “Phase 2 detox is dependent on nutritional status and genetic variability,” Foroutan says. While a typical detoxification protocol recommended by integrative medicine nutritionists as MNT is based on whole foods, it takes into account the emerging and past research on how certain foods could help the detoxification process along,

whether by speeding it up or making it more efficient. “Some foods upregulate CYP450 enzymes that regulate phase 1 detoxification; others provide fiber to bind to toxins within the intestine for elimination in stool,” Dean says. For example, the phytochemicals that induce phase 2 enzymes can be found in cruciferous vegetables, onions, and garlic.8 Fiber intake supports regular elimination, which is crucial for excreting toxins through the bile and stool, Foroutan says, noting that brown rice fiber may be particularly beneficial in eliminating fat-soluble toxins. Turmeric/curcumin has shown promise in protecting the gallbladder and promoting bile flow,9 and research has shown the potential for pomegranate/ellagic acid in assisting detoxification pathways.10 Much research has focused on green tea’s potential benefits in detoxification, according to Purdy, and one study showed its particular promise in promoting the induction of phase 2 detox enzymes.11,12 Foroutan notes that research has shown promise for various other foods in assisting the detoxification process, including high-quality proteins, artichokes, watercress, cilantro, and apples.12 In addition, laboratory and animal studies have shown how supplementation may aid the detoxification process, such as with NAC and glutathione.13-15 “The former is the precursor to glutathione, and glutathione is the master detoxifier in the body,” Foroutan says. “Since it’s thought that glutathione doesn’t ‘survive’ digestion, NAC is recommended to increase glutathione stores.” She also says research has shown that milk thistle may support glutathione production and, as such, research has looked into its potential application in ameliorating long-term hepatic and cardiovascular effects of cancer treatment.16-18 Admitting that research on clinical detoxification methods, especially related to diet, still is in its infancy, Genuis says he believes nutrition is “absolutely essential for proper detoxification and optimal health. Endogenous mechanisms of detoxification are totally dependent on nutrient sufficiency to allow the body to carry out various requisite functions such as conjugation in the liver—requiring glutathione—and glycine to facilitate water solubility of various compounds.” Even though nutrition’s role in detoxification is an emerging science and the specifics of what foods aid detoxification most (and how) still is under way, Genuis urges nutrition professionals, including RDs, to stay abreast of the research on this subject and use their nutrition expertise in a clinical health care team approach to address the complete picture of patients’ health, which he says includes assessing toxin exposure and aiding efficient detoxification processes. “Sadly, medical graduates are not adequately trained to address the nutritional needs of patients, including those biochemical nutrients required for detoxification,” he says. “Accordingly, the role of nutrition professionals as part of the contemporary health care team to assess and advise with various matters, including detoxification, is paramount.”

march 2014 www.todaysdietitian.com 37

Detox in Clinical Practice When determining whether a detoxification protocol may benefit a client, qualified RDs often will assess a person’s toxic exposure and genetic profile with one or more of a variety of tools and tests. While an in-depth discussion of these testing methods is beyond the scope of this article, Swift says the Quick Environmental Exposure and Sensitivity Inventory (QEESI), a validated evidence-based questionnaire,19 developed by Claudia Miller, MD, MS, as well as genomic profiles, heavy metal panels, and organic acid tests are some of the more common and useful screening and assessment tools used today. “A practitioner can request blood or urine profiles to test for specific toxic accumulation in the body, and gene panels can be done via blood testing or cheek swab tests,” Foroutan says. However, Swift notes that the search for reliable biomarkers to accurately assess toxicity and chemical and environmental sensitivities continues.20 Encouraged by the research conducted so far, many integrative medicine nutritionists and other health professionals are including detoxification protocols in their clinical practice.21 Because research still is under way regarding the details of how food can be used as a clinical detoxification tool, no one detoxification protocol currently exists, leaving health practitioners to review the research and interpret how that translates to clinical practice. According to Foroutan, she believes there are many different ways to think of detoxification in terms of MNT. “There is the general advice for supporting detoxification pathways that can and should be done year-round, such as eating more cruciferous vegetables and high-antioxidant foods, choosing organic foods [to minimize pesticides and other toxins], drinking green tea and more water, establishing optimal bowel habits, working up a sweat regularly, and reducing contact

Resources Centers for Disease Control and Prevention Toxicology and Risk Assessment Conference www.cdc.gov/niosh/conferences/TRAC Dietitians in Integrative and Functional Medicine http://integrativerd.org Environmental Working Group www.ewg.org Institute for Functional Medicine www.functionalmedicine.org University of Wisconsin Integrative Medicine Program Detox handout www.fammed.wisc.edu/sites/default/files//webfmuploads/documents/outreach/im/handout_detoxplan.pdf

with external toxins,” she says, adding that she believes this advice could benefit many clients. For people who might have tested high for a particular metal, for example, she says a formal, short-term detoxification plan could be an intervention to systematically help the body release and excrete toxins. “For healthy people with moderate exposure to toxins, I typically recommend a targeted detoxification protocol once to twice a year during seasonal shifts—spring and fall,” Forouton says. “For someone who’s tested for bioaccumulation of specific toxins, like mercury, lead, parabens, plastics, or other kinds of industrial products, or when there’s evidence of hormonal disruption, the intervention may last for a longer period of time and would involve retesting.” Certainly, detoxification regimens are highly individualized and should be customized to the client based on the person’s habits, lifestyle, environmental exposure, and genetic makeup. But at its core, detoxification is a straightforward prescription: “It’s as simple as R and R: remove and replace,” Swift says. “You look at what do we need to think about removing from this person’s diet, which are the foods that precipitate metabolic endotoxemia and adverse reactions [foods related to the Western diet such as refined sugars, trans fats, and saturated fats], and then what do we need to think about replacing those foods with [such as foods with fiber, flavonoids, and antioxidants along with lifestyle modalities that support the body’s healing potential].” Metabolic endotoxemia, as Foroutan describes, is a subclinical increase in circulating “endotoxins” that triggers an inflammatory cascade that has been linked to chronic disease, including diabetes.22 “There’s no doubt in my mind that certain foods can both impair and enhance liver function,” Purdy says, adding that her vision of a detox diet is “short term—about one to three weeks— based on eating healthful whole foods—eg, vegetables, fruits, nuts, seeds, beans, whole grains, herbs and spices—as well as eliminating foods that may add to the traffic jam or cause additional inflammation for some people such as refined sugar and certain food additives or preservatives.” Based on the research to date, integrative nutrition professionals acknowledge there’s still much to learn about what an effective clinical detoxification protocol looks like as well as how best to determine which clients are in need of such. For now, health professionals interested in learning more about past and ongoing research are encouraged to seek further information from the Academy’s Dietitians in Integrative and Functional Medicine Dietetic Practice Group or the Institute for Functional Medicine (see Resources).

Safety Considerations Foroutan says that eating detoxifying foods, beverages, and spices almost always is beneficial, but because of the lack of evidence-based, peer-reviewed clinical trials evaluating specific detoxification protocols, she says certain patient populations, such as pregnant and breast-feeding women, shouldn’t follow

any vigorous detox program due to the potential for toxins to be released to the fetus or through breast milk. Purdy says this caution applies to young children as well and says nutrition professionals also should exercise caution when working with clients taking medication because this requires specific knowledge of drug metabolism. In general, further research is needed to determine the safety and efficacy of using specific clinical detoxification therapies among specific patient populations.21 Overall, however, the basics of a detoxification program are safe and can benefit almost anyone, Foroutan says. “I believe that anyone can do a detox if it’s just about increasing and focusing solely on eating whole foods and eliminating processed foods. That kind of diet will benefit everyone,” she says. “I think it’s really important that dietitians not be turned off by the word detoxification but start embracing it, understanding that their programs likely are already supporting detoxification for people,” she continues. “It’s just a different way of looking at a healthful lifestyle. We always recommend whole foods and exercise, and so much of what we’re already doing can be considered detoxifying. “Detoxification is an important part of health and healing, and it can be supported by diet and lifestyle,” she notes. “The question for practitioners will always be: How can I help my patients feel better and be healthier? Detoxification surely has a role to play there because so many steps in the detoxification pathway are dependent on nutrient status.” — Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania, and a frequent contributor to Today’s Dietitian.

References 1. Jeffer EH. Detoxification basics. The Proceedings from the 13th International Symposium of the Institute for Functional Medicine, Managing Biotransformation: The Metabolic, Genomic, and Detoxification Balance Points. Altern Thera Health Med. 2007;13(2):S96-S97. 2. Liska DJ. The detoxification enzyme systems. Altern Med Rev. 1998;3(3):187-198. 3. Nebert DW, Petersen DD, Puga A. Human AH locus polymorphism and cancer: inducibility of CYP1A1 and other genes by combustion products and dioxin. Pharmacogenetics. 1991;1(2):68-78. 4. Genuis SJ. Elimination of persistent toxicants from the human body. Hum Exp Toxicol. 2011;30(1):3-18. 5. West WL, Knight EM, Pradhan S, Hinds TS. Interpatient variability: genetic predisposition and other genetic factors. J Clin Pharmacol. 1997;37(7):635-648. 6. Patterson RE, Eaton DL, Potter JD. The genetic revolution: change and challenge for the dietetic profession. J Am Diet Assoc. 1999;99(11):1412-1420. 7. Bralley E, Redmond E. Laboratory markers of toxins

and detoxification. http://www.metametrix.com/learningcenter/presentations/2008/laboratory-markers-of-toxinsand-detoxification. Accessed July 2011. 8. Konsue N, Ioannides C. Modulation of carcinogenmetabolising cytochromes P450 in human liver by the chemopreventive phytochemical phenethyl isothiocyanate, a constituent of cruciferous vegetables. Toxicology. 2010;268(3):184-190. 9. Rasyid A, Rahman AR, Jaalam K, Lelo A. Effect of different curcumin dosages on human gall bladder. Asia Pac J Clin Nutr. 2002;11(4):314-318. 10. Barch DH, Rundhaugen LM, Stoner GD, Pillay NS, Rosche WA. Structure-function relationships of the dietary anticarcinogen ellagic acid. Carcinogenesis. 1996;17(2):265-269. 11. Ferguson LR. Nutrigenomics approaches to functional foods. J Am Diet Assoc. 2009;109(3):452-458. 12. Jeffer EH. Diet and detoxification enzymes. The Proceedings from the 13th International Symposium of the Institute for Functional Medicine, Managing Biotransformation: The Metabolic, Genomic, and Detoxification Balance Points. Altern Thera Health Med. 2007;13(2):S98-S99. 13. Barch DH, Rundhaugen LM, Pillay NS. Ellagic acid induces transcription of the rat glutathione S-transferase-Ya gene. Carcinogenesis. 1995;16(3):665-668. 14. Nourani MR, Azimzadeh S, Ghanei M, Imani Fooladi AA. Expression of glutathione S-transferase variants in human airway wall after long-term response to sulfur mustard. J Recept Signal Transduct Res. 2013;Epub ahead of print. 15. Ogasawara Y, Takeda Y, Takayama H, et al. Significance of the rapid increase in GSH levels in the protective response to cadmium exposure through phosphorylated Nrf2 signaling in Jurkat T-cells. Free Radic Biol Med. 2014;Epub ahead of print. 16. Wellington K, Jarvis B. Silymarin: a review of its clinical properties in the management of hepatic disorders. BioDrugs. 2001;15(7):465-489. 17. Greenlee H, Abascal K, Yarnell E, Ladas E. Clinical applications of Silybum marianum in oncology. Integr Cancer Ther. 2007;6(2):158-165. 18. Malekinejad H, Rezabakhsh A, Rahmani F, Hobbenaghi R. Silymarin regulates the cytochrome P450 3A2 and glutathione peroxides in the liver of streptozotocin-induced diabetic rats. Phytomedicine. 2012;19(7):583-590. 19. Dupas D, Dagorne MA. Multiple chemical sensitivity: a diagnosis not to be missed. Rev Mal Respir. 2013;30(2):99-104. 20. De Luca C, Raskovic D, Pacifico V, Thai JC, Korkina L. The search for reliable biomarkers of disease in multiple chemical sensitivity and other environmental intolerances. Int J Environ Res Public Health. 2011;8(7):2770-2797. 21. Allen J, Montalto M, Lovejoy J, Weber W. Detoxification in naturopathic medicine: a survey. J Altern Complement Med. 2011;17(12):1175-1180. 22. Boroni Moreira AP, de Cássia Gonçalves Alfenas R. The influence of endotoxemia on the molecular mechanisms of insulin resistance. Nutr Hosp. 2012;27(2):382-390.

march 2014 www.todaysdietitian.com 39

Taking the

SNAP Challenge Through the personal pages of their diaries, five RDs describe the experiences that gave them a new appreciation for families who are food insecure. By SHARON PALMER, RD

or many dietitians, whether they’re employed with a hospital, WIC, supermarket, or outpatient clinic, helping people feed their families nutritious food within their budget can be one of the most important—and rewarding—achievements of their career. Currently, one in six people in the United States struggles with hunger. In 2012, 49 million Americans (33.1 million adults and 15.9 million children) were food insecure, defined as reduced food intake or disrupted eating patterns in a household due to lack of money or other resources.1 Battling food insecurity has long been a primary goal of the Academy of Nutrition and Dietetics (the Academy). The Academy states that it’s committed to improving the health of Americans by ensuring they have access to a healthful, safe, and adequate food supply through protecting and strengthening the Supplemental Nutrition Assistance Program (SNAP),2 a key initiative in our nation’s nutrition safety net. SNAP, WIC, the National School Lunch Program, and the School Breakfast Program form the core of a network of national nutrition assistance programs designed to increase food security.

A Snapshot of SNAP Formerly known as the Federal Food Stamp Program, SNAP is the largest program in the domestic hunger safety net, offering nutrition assistance to millions of eligible low-income individuals, families, and communities. The first Food Stamp Program, which allotted stamps to purchase agricultural surpluses, dates back to 1939 and is credited to its first administrator, Milo Perkins, who was quoted as saying, “We got a picture of a gorge, with farm surpluses on one cliff and undernourished city folks with outstretched hands on the other. We set out to find a practical way to build a bridge across that chasm.”3 Since then, the Food Stamp Program slowly has evolved to what it is today. Recipients can use the benefits to buy food, from authorized stores, that will be consumed at home. In 2012, 82% of benefits were redeemed in supermarkets and superstores.

Nationwide, there were 3,214 farmers’ markets and farmers who sold directly to consumers with food stamp benefits.4 The amount in benefits a household receives is called an allotment, the household’s net monthly income multiplied by 0.3, which is subtracted from the maximum allotment for the household size. The calculation is based on the projection that SNAP households are expected to spend about 30% of their resources on food. For a household of four, for example, the maximum monthly allotment is $632.5 Since November 1, 2013, SNAP has been in the news because of the elimination of the temporary increase in benefits included in the American Recovery and Reinvestment Act of 2009. Ultimately, Congress did not continue that $11 billion increase. The recently passed farm bill that funds SNAP also included an additional $8 billion in cuts over ten years, according to the Wall Street Journal. Together those reductions will result in an estimated drop of $90 in SNAP benefits per month for a family of four, according to Mother Jones Earth News. Studies have shown that SNAP helps reduce food insecurity. An August 2013 USDA study found that participating in SNAP for six months was associated with a decrease in food insecurity of about 5 to 10 percentage points. SNAP was associated with lower percentages of households that were food insecure, that experienced very low food security, and that had children who were food insecure.6 “As RDs, we know that enough healthful food at all stages of development keeps people healthy and prevents chronic diseases. SNAP helps to improve diets,” says Karen Ehrens, RD, LRD, past chair of the Academy’s Legislative and Public Policy Committee who also works with the North Dakota Department of Health to coordinate the Creating a Hunger Free North Dakota Coalition.

Getting Acquainted With SNAP It’s important for dietitians to understand this nutrition program even though they may not work directly with SNAP recipients. “All RDs can and should be mindful of how we can advocate for a healthy food system,”

march 2014 www.todaysdietitian.com 41

says Brooke Nissim-Sabat, MS, RD, LD, an assistant professor of foods and nutrition at Pierpont Community and Technical College in West Virginia. “Working to alleviate hunger is an undeniable part of our profession, and RDs are poised to work toward solutions. Food is at the heart of our profession, and promoting access to nutritious choices for our vulnerable populations is some of the most important work an RD can do.” “Every day, in any job an RD has, we make recommendations about what people should eat to be healthiest,” Ehrens says. “We all need to understand how easy, difficult, or even impossible our recommendations might be based on a client’s background, which includes their health status, personal preferences, motivation, living circumstances, and ability to access healthful food. Helping people access the healthiest foods within the limits of their resources I hope is a goal that each of us works toward. Understanding SNAP can help us understand how to help people make food choices.”

Five RDs Take the SNAP Challenge To understand SNAP firsthand, Ehrens, Nissim-Sabat, and many other dietitians have taken what’s called the SNAP challenge to find out what it’s like to live on a limited food budget of about $4.50 per person per day as both a hunger awareness statement and a way to better appreciate the challenges that food-insecure clients and patients face every day. Others, from restaurant CEOs and congressman to journalists, have tried it, too. Today’s Dietitian shares real-life stories of five RDs who took the SNAP challenge last fall through the encouragement of the HEN DPG. If you’re interested in taking a SNAP challenge, you can find out more information on the Food Research and Action Center website (www.frac.org).

Lisa Dierks, RD, LD

A mother of three, Dierks is nutrition manager at the Mayo Clinic and lives in Wanamingo, Minnesota. Here’s an excerpt from Dierks’ SNAP challenge diary.

Day 1: For ease of writing, I’m going to use some Twitter abbreviations for family members: DH = darling husband, DS14 = darling son 14-year-old, DS11 = darling son 11-yearold, and DS5 = darling son 5-year-old. After working a full day, I hopped on my commuter bus for the 45-minute ride home. DH and DS11 called me to ask what’s for supper because basketball practice was at 6 pm. I told them they’d have to eat a peanut butter sandwich, yogurt, or fruit for a snack to hold them over. I was greeted at the door by DS5 tossing a half-eaten apple into 42 today’s dietitian march 2014

the garbage and DS14 complaining about wanting supper and “why do we have to eat like poor people?” (He is a good kid, just your typical teenager.) For breakfast and an after-school snack, DS11 and DS5 helped me make peanut butter/banana/oatmeal muffins. The batch made 22. I thought I could get by with eating one muffin per day, but after going to the gym this morning, I had to eat two to fill up. We have oatmeal for when the muffins run out. For lunch, DH and I will either take leftovers from the evening meal or a peanut butter sandwich. To round out the meal, we can have yogurt, fresh fruit, and raw veggies. Our decision for what to prepare for supper was based on the desire to dispel comments we’ve heard from both sides of the SNAP argument, such as “People on SNAP only buy processed junk” and “People on SNAP can buy only beans and rice.” It was our goal to see if we could have a healthful meal that included fruits and vegetables, and everyone would leave the table satisfied. Tonight’s meal was chili beef cornbread bake, green beans, and unsweetened applesauce. I also had some carrot and celery sticks left from my lunch that I put on the table rather than throwing them away. DS14 had this evening’s parting comments: “Wow, Mom, this was really good. I thought when you said we were doing this that we had to eat ramen noodles, Hamburger Helper, and TV dinners. I didn’t know it would be real food. I also thought I couldn’t have seconds and would have to be hungry. And I was really surprised that there were fresh vegetables on the table; I thought we were eating canned veggies.” Isn’t it interesting how experience can change our perceptions? Day 3: DH, DS14, and DS11 had Boy Scouts at 6:30, so they ate a bowl of cold cereal and will eat supper when they get home. I think they were hoping for pizza. For tonight’s menu, I chose fish for a couple of reasons: The 2010 Dietary Guidelines recommend we increase our consumption of fish to 8 oz per week, but could we afford it? And I wanted to get DH more involved in this week’s challenge. I scanned the grocery ads and found cod at $6.98/lb. If I bought one pound and cut it into five pieces, we’d have a little more than 3 oz each. It seemed that we could afford one meal of cod, but two meals were out of the question. What would it take to meet the guidelines for our family if we chose local fish? After all, we live in the “Land of 10,000 Lakes.” Here are some of DH’s thoughts: Fishing is free in Minnesota state parks, but the closest one to us with good fishing is more than one hour away. A license costs $22, and we still need to drive about 30 minutes to get to a good spot. Bait would be about $3 per trip. There are daily limits and possession limits for every kind of fish. You can’t fish all year long, and many waterways are closed from one to three months in the spring for spawning. Then there’s the time factor; DH and I both work full-time, and the kids are busy with activities. Needless to say, the avid fisherman thought

I was crazy to think that we could catch enough local fish to sustain our fish intake and meet the guidelines. So what did I do? I made Curried Tomato Cod with barley and sweet potato. Everyone also had a fresh pear. Total bill: $14.68. Day 6: I asked everyone what they were thankful for after doing the challenge. Responses included having enough food to eat for the week; creative recipes from basic ingredients; peanut butter sandwiches (that’s from DS5); having enough food to eat all the time, and that the food was better than I thought it was going to be; a family to share meals with, that when I ask my mom if a friend can stay for supper the answer is always yes and that we don’t worry about having enough; being able to share our story with friends; and making new friends through our storytelling.

Brooke Nissim-Sabat, MS, RD, LD

Living in the community of Fairmont, West Virginia, Nissim-Sabat took the SNAP challenge with her husband. Here’s what she recalls from her experience.

We devoted one week to eating on about $4.50 per person per day and found ourselves counting pennies as the day wore on into evening. The protein-rich foods and fresh produce were some of the more costly; it would be very easy to fall back on nutrient-poor, energy-dense choices. It’s clear to me how, when money is limited, families can think in terms of total calories rather than nutritional quality. I found myself much more cognizant of food waste and acutely aware of hunger and satiety. Even as an RD with hundreds of low-cost recipes at my fingertips, I still was preoccupied with having enough money to last the whole week and stretching out my meals. I did little snacking and consumed only about 1,200 to 1,300 kcal/day, which isn’t enough for me to maintain a healthful weight and is difficult to meet my nutrient needs. I normally take great pleasure in eating and enjoying meals with loved ones; this week felt much more utilitarian. Eating local and sustainable foods became quite difficult. For example, one egg as part of a dozen from the farmers’ market might work out to be $0.29, while one egg from the discount grocery store might cost $0.11—less than half as much. Many people don’t bat an eye at paying $3.50 per dozen for fresh eggs from hens who live on pasture, but when money is this tight and you can’t keep your own chickens, it’s a different perspective. Luckily, dried beans and lentils always are in heavy rotation in our household, and for this week, we barely strayed from legumes at all. Here’s a sample day’s menu: Breakfast: plain yogurt, one banana, one boiled egg, and coffee with a splash of half and half (a complete splurge)

Lunch: 1⁄2 can of tuna with a squirt of mayo, 1 slice of whole wheat bread, 1 cup of baby carrots Dinner: 1 cup of cooked black beans (from dried), 1 cup of cooked brown rice (from dried), 11⁄2 cups of spinach cooked with one pat of butter Snack: 1 small apple Total cost: $4.04 My analysis of this day indicates I consumed approximately 1,250 kcal, which is much lower than the amount I require to maintain my weight. I exceeded my Dietary Reference Intake for protein, coming in at about 67 g, and had about 183 g of carbohydrates with 32 g of fiber; the beans went a long way toward helping me meet many of my nutrient goals. I met my needs for vitamin A thanks to the carrots, and had plenty of folate and magnesium, again because of the liberal plant proteins. On the other hand, on this day, I was very low in vitamins C and E as well as calcium and iron. Because my husband is very active, he fell short of many of his nutrient needs. He toughed it out though, going to bed hungry rather than staying awake and ruminating on what to eat that might cut into the next day’s budget. At this point, I tried to talk him out of it, but he took the challenge seriously. When the challenge was over, we had the luxury of going back to our eating habits: purchasing organic ingredients, dining out, preparing new dishes that require an investment of ingredients. Individuals and families who qualify for SNAP don’t have these prospects; rather, their experience in poverty may run generations deep with no sign of letting up. This experience strengthened my resolve to not only make individualized recommendations that are sensitive to my clientele but also to continue working to improve access to a healthful, sustainable food supply for everyone.

Kristina DeMuth, RD

DeMuth, a University of Minnesota MPHN candidate, chronicled her experience on her blog, http://for-i-was-hungry.blogspot.com. Here are some highlights.

I decided to take the SNAP challenge because hunger and poverty are at the core of the work I do. I spent one year living in Haiti and came home wanting to learn more about the hunger that not only exists in other parts of the world but also here in my home country. Doing the SNAP challenge for one week will never equate with the experience of people who live on SNAP benefits day to day. However, engaging in the week-long activity provided me a window of insight to various challenges people may face living on tight budgets here in America. I also wanted to see if

march 2014 www.todaysdietitian.com 43

it was possible to consume an entire whole, plant-based diet on fewer than $4 per day. For the first few days of the challenge, I felt extremely hungry. I was afraid of running out of food by the end of the week, so I didn’t eat as much as I could have and should have. Surprisingly, however, I ended up with leftover food at the end of my challenge and only ended up consuming about $25 worth of food for the week. Shopping for the challenge was exciting when I found great deals, but it also was mentally exhausting as I tried to decide which foods to buy, determine whether I had enough money, and prioritize my food list. I realized that while shopping, I had the luxury of going to three different locations to get my food for the week. I also had the luxury to shop at a farmers’ market. These are situations that people living on a budget may have to face: what stores to shop at, how to be savvy with coupons and deals, and even consider the transportation to get to various stores. I also realized on the second day of the challenge that I needed to give up coffee to incorporate peanut butter into my meal plans. Originally, I avoided purchasing peanut butter because the ingredient list on the cheapest peanut butter had

ingredients I usually avoid (added sugar, palm oil). I caved in on the second day and decided that I’d just eat the cheap peanut butter to meet my dietary needs. Also, I chose to eat entirely from scratch, which can save an extraordinary amount of money; however, it does require some basic cooking and baking skills, resources for preparing and storing foods, and the confidence to try new things. I realize that not everyone is like me. Not everyone feels confident in the kitchen, and not everyone likes to be creative with food. The following are foods I ate throughout my challenge: Breakfast: oatmeal banana pancakes with peanut butter, oats cooked in a slow cooker overnight with banana and peanut butter, and a sweet potato oatmeal casserole Snacks: Almost daily, I ate carrots, an apple, and pumpkin seeds (saved those from my pumpkin). I also used leftover frozen pumpkin to make pumpkin ice cream, and I made homemade air-popped corn. Lunch and dinner: Lunch consisted of leftovers from the night before. I made creamy tomato soup (made with tofu), pumpkin soup, veggie burgers with sweet potato and roasted vegetables, lentil-oat meatballs, carrot-ginger soup, lentil apple and sweet potatoes with vegetables, and peanut butter. I ate incredibly healthy and at a very low cost. The cost of plant proteins vs. organic animal-based proteins was much more economical. A serving of lentils costs $0.10 (13 g of protein); organic quinoa costs $0.30 per serving (6 g of protein); and edamame costs $0.50 per serving (13 g of protein). Eating less expensive protein increases the amount of money you can spend on fruits and vegetables. Recently, I spoke with a few parents who use SNAP benefits. Some of them don’t think they’d be able to eat as healthfully without the SNAP program. I was surprised by how many of the parents said they cook from home because it’s cheaper. Perhaps there are many misconceptions about what people’s lives are like on a tight budget.

Elizabeth Lee, MS, RD

Working in Orange County, California, as an outpatient dietitian and blog writer at Healing Foodie, Lee shares a glimpse of her experience during the SNAP challenge.

I took the SNAP challenge for one week because I thought it’d give me a glimpse into some of the food struggles that millions face each day. For the most part, I was able to manage the week on the SNAP budget because I have basic cooking skills, time, and a functional kitchen. For some low-income families, those three essentials may not be available to them. Unprocessed

whole foods often are cheaper than convenience foods, such as microwavable meals and fast foods. To say that it costs much to eat well may not be true. However, not everyone has the ability to turn fresh ingredients into meals.   Not being able to afford certain organic produce while knowing they belong to the Dirty Dozen list or organic ground turkey when conventional was found to contain the highest amount of antibiotic-resistant bacteria was difficult. Shopping for the week required either lots of arm strength and strong walking legs or a car. It would have been nearly impossible for me to buy everything I needed if I was taking public transportation. I felt that I ate healthfully on the budget, perhaps even more so than usual because I didn’t have extra money to spend on prepackaged snacks. Here’s a sample of what I ate: Breakfast: chia oatmeal topped with 1⁄2 banana Lunch: leftovers from the night before  Afternoon snack: apple   Dinner: two-bean and yam turkey chili

Karen Ehrens, RD, LRD

Ehrens, past chair of the Academy’s Legislative and Public Policy Committee, shares a few pages from her diary during the SNAP challenge, which she took with her husband and 15-year-old daughter in North Dakota. Day 1: Feeling humbled and grateful for the food skills and knowledge we have. We’ve been blessed and have had the opportunity to work toward having many resources, such as a well-stocked pantry, cooking tools, pots and pans, a great stove, and refrigerator. Many in our country don’t start out with nearly this much. Grocery shopping takes a long time when you need to budget down to the penny. We spent our dinner conversation planning. More time afterwards discussing. Went to two stores and tried to guess which one would have the lower prices on certain items; I lost a couple of bets. We saved $0.10 by bringing our own bags to Target. Small victories. Tired from making so many choices. Fully recognizing that our choices were small potatoes compared to really hard choices others face day in and day out. Honestly, the hardest thing to deal with during this challenge was not being able to access the food in our pantry and recognizing how hard it could be to build a pantry on a very limited budget. How can you purchase for the future while trying to meet today’s needs first? I could have blown my day’s worth of resources on one jar of spices that I might need to make a delicious recipe. We groaned when we cut into the pear and found half of it bad, leaving less to eat at supper. My husband returned the

pear to the grocery store, and they gave us double our money back. Because we weren’t working, have a reliable car, and live just under one mile from the store, we could do this. Not the case for many others relying on SNAP benefits. Day 2: Preoccupied by thoughts of food. Can’t sleep. Trying to make sure there will be enough food for the short five days of this challenge. We convinced our 15-year-old daughter to join in, so we have her share of $4.25/day as well. For her, we’re getting by with a modified version. We’ll run out of milk by the end of the challenge, so I’ll make sure she has milk each day. I can’t knowingly shortchange my growing daughter with food. Day 4: As of this morning, my daughter, Emily, finished off the milk. There’s more in our fridge, so she’ll have that. But for those other parents out there who don’t have more milk in their fridges or bread in the breadbox, what do they do? Eat less? Not pay a bill? Ask a neighbor? Visit a food pantry? Day 5: So glad to report that although we ran out of some foods, we still have some left. Our family will be using peanut butter to hold together our last day of the challenge. Emily is so glad. She and my husband will be having peanut butter for breakfast, and I’ll have a peanut butter/banana tortilla rollup for lunch. For supper, it’ll be a mishmash of what’s left: a couple of eggs, two small zucchinis, a small bit of chicken lunchmeat, two slices of bread, and yogurt. The fifth and last day of our challenge was a roller coaster ride. It started in the morning after I posted the recording of the interview about our SNAP challenge experience online. I went to the Facebook page of the television station where the link was posted and started reading the comments that started to pour in. I should have put on a flak jacket first. The comments judged, derided, and attempted to shame people who accept assistance: “Those people have cell phones and fancy jeans.” “They fill up their carts with soda and chips.” “I pulled myself up by my bootstraps.” These sent my stomach churning; 83% of the households receiving SNAP benefits have a child, a senior, or a disabled person living in them. We did it. We pulled it together. But to anyone who says that this is “taking the easy way out,” I encourage you to try it yourself. It will change how you think about how people access what’s necessary for all human life: food. — Sharon Palmer, RD, is a Los Angeles-based foodie, the author of The Plant-Powered Diet, the editor of the Environmental Nutrition newsletter, and a contributing editor at Today’s Dietitian.

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

march 2014 www.todaysdietitian.com 45

CPE MONTHLY

2004 report, cited by most recent reviews, stated that the economic burden of diverticular disease exceeds $4 billion every year; the actual current figure likely is significantly higher. As life expectancy has increased since diverticular disease was first described in 1920, the prevalence of the disease also has grown. It was relatively rare in 1930, with a prevalence of only 5% to 10%. It now affects 33% of all Americans by the age of 50, 50% by age 60, and 66% by age 80, with similar rates in Canada.4,5 As the North American population continues to age, the burden of diverticular disease certainly will rise. This continuing education course reviews diverticular disease, including its epidemiology, and the evidence for nutrition and lifestyle factors in disease development, exacerbation, and recurrence.

Symptoms, Clinical Manifestations, and Diagnosis

DIVERTICULAR DISEASE

A Reexamination of the Fiber Hypothesis By Tonia Reinhard, MS, RD Ask a roomful of dietitians about a dietary factor that has solid evidence for helping to prevent a disease, and chances are many would pick fiber and the prevention of diverticulosis. That’s why a recent study from the University of North Carolina has everyone interested in nutrition and gastrointestinal disease scratching their heads.1 It also has motivated many nutrition professionals to go back to the original theory linking fiber to gastrointestinal disease and reevaluate earlier studies that generated or supported the theory. Diverticular disease subsumes an array of clinical states that begins with herniation of the colonic mucosa and muscularis mucosa through the intestinal wall, and although it can occur in any part of the intestine, the colon—particularly the sigmoid colon—is the area typically affected.2 The presence of one herniation—a saccular protrusion or outpouching—is a diverticulum (plural: diverticula), and the presence of diverticula indicates diverticulosis. Diverticulitis is a complication of diverticulosis that indicates inflammation of one or more diverticulum. Other complications that can arise from diverticulitis include intestinal obstruction, bleeding, abscess, fistula, and perforation. In addition to being a complication, diverticulitis represents a flare-up of diverticulosis and, after it subsides into a period of remission, reverts back to the state of diverticulosis. Diverticular disease certainly warrants closer scrutiny based on the toll it exacts on the people it affects, the substantial health care costs incurred for its treatment, and the serious complications it can cause. According to a 2008 report from the National Institutes of Health (NIH), it was the underlying cause of death among 58% of death certificates on which it was listed.3 A

46 today’s dietitian march 2014

The majority of people with diverticular disease have asymptomatic diverticulosis. However, 25% of those with diverticulosis experience occasional bloating, flatulence, pain, and disordered intestinal motility resulting in either diarrhea or constipation, known as symptomatic diverticulosis.6,7 For most people, the symptoms usually improve after a bowel movement. However, because the symptoms are nonspecific, there’s considerable overlap with irritable bowel syndrome (IBS), an important disease in differential diagnosis.8 Of those with symptomatic diverticulosis, about 25% will develop complications such as diverticulitis, termed complicated diverticular disease.2 The symptoms of diverticulitis include nausea, vomiting, abdominal distension, left lower quadrant pain, intestinal spasms, fever, and bleeding. Of these

COURSE CREDIT: 2 CPEUs

LEARNING OBJECTIVES

After completing this continuing education course, nutrition professionals should be better able to: 1. Distinguish between the various forms and stages of

diverticular disease. 2. A ssess the public health significance of diverticular

disease relative to its prevalence in the population, potential complications, and related health care costs. 3. Evaluate the role of dietary fiber and other nutritional

factors in the development or exacerbation of diverticular disease. 4. Provide an evidence-based rationale for all nutrition

recommendations for diverticular disease.

Suggested CDR Learning Codes 2070, 4040, 5220; Level 2

symptoms, left lower quadrant pain is most common, affecting 93% to 100% of patients seeking treatment.7 Some studies have indicated that the symptoms and disease are more severe in people younger than the age of 40, although others haven’t reported this correlation,9-11 and diverticular disease is more common among men and people who are obese.12 In Asia, diverticular disease is more common in the right colon, in contrast to Western countries where the left colon typically is affected, suggesting that genetic and environmental factors may play a role in disease development.13,14 When the disease occurs in the right colon, it can be misdiagnosed as appendicitis. In Asians under the age of 40, it’s more common in the left colon, with one study showing that 97.5% of patients in that age group had the left-sided type.13 Since most people with diverticulosis are asymptomatic, diagnosis typically occurs as the result of undergoing a colonoscopy or double-contrast barium enema for routine screening or investigating other symptoms.15 Diverticulitis most commonly is diagnosed when an acute attack results in an emergency hospital admission. In this setting, endoscopy usually isn’t indicated and, if performed, requires extreme caution to prevent perforation, as even air insufflation can cause a sealed perforation to rupture.7 Typically, a diverticulitis diagnosis begins with a comprehensive history and physical examination, complete blood count, abdominal radiography, and urinalysis. Physicians may order other tests when these clinical assessments fail to provide a diagnosis, including ultrasound, CT, and water-soluble contrast enema, which is safer in emergency settings. Differential diagnosis becomes important when distinguishing diverticulitis from appendicitis, bowel obstruction, IBS, and colorectal cancer, which all can coincide with diverticular disease.

Complications Diverticulitis represents a complication of diverticulosis, in that it arises from diverticulum inflammation and/or infection. In uncomplicated or simple diverticulitis, which represents about 75% of cases of the condition, the resulting inflammation isn’t severe and if the perforation is small, it’s enveloped by pericolic fat, or the fat surrounding the colon that includes subserosal, retroperitoneal, and mesenteric fat, reducing the risk of infection or more severe complications. However, several complications can arise when the original perforation isn’t well contained, such as complicated diverticulitis. Other serious complications include a major perforation, bleeding, bowel obstruction, fistula, abscess, phlegmon (diffuse inflammation with purulent exudate), abscess, adjacent organ involvement, and sepsis.

Medical Treatment The rate of surgical intervention in complicated diverticulitis dropped from 17.4% to 14.4% from 1999 to 2005, with more emphasis on conservative treatment when possible.16

EARN UP TO 14 CPEUs! Registration is open for our 2014 Spring Symposium from May 18 to 20 in Las Vegas. Visit www.TodaysDietitian.com/ss14 to reserve your place at this education and networking event, featuring some of the nation’s most respected dietitians leading our program of sessions.

Conservative treatment for simple diverticulitis consists of consuming a low-fiber diet and taking oral antibiotics on an outpatient basis.17 If abdominal pain and tenderness are more severe, the patient will require hospitalization, particularly if the patient can’t tolerate oral feedings and continues to experience a fever. In this case, treatment includes bowel rest, IV fluids, and antibiotics. Surgery may be required for serious complications such as obstruction, major perforations, abscesses, fistula, and phlegmon.

Nutrition Recommendations In the hospital, a patient suspected of having diverticulitis typically should consume nothing by mouth before testing. Once the diagnosis is made, the patient may require enteral nutrition if bowel obstruction occurs or if the ileocecal valve is incompetent and distension arises in the small intestine. If there are no other serious complications, the patient will progress to nutrition therapy. The medical nutrition therapy for acute diverticulitis consists of instructing the patient to follow a low-fiber diet (10 to 15 g/day) for a short time after the attack and then increase fiber gradually to reach and maintain a high-fiber diet with adequate hydration.18 The current recommendation for daily fiber intake is 25 g for most adult women and up to 38 g for men. This actually represents a high fiber intake, as the average male and female consume approximately 50% and 62%, respectively, of the recommended level.19 Many older patients who have had diverticular disease for several years still avoid certain foods such as small seeds, nuts, and popcorn that once were believed to precipitate an attack of diverticulitis, intestinal bleeding, or both. However, both the NIH and a large prospective study of more than 47,000 men reported no evidence to support that belief.20 To the contrary, the study results indicated that these foods actually may be associated with a lower risk of diverticular disease.

Etiology, Pathophysiology, and Risk Factors The search for the cause of diverticular disease began with a hypothesis by two British surgeons, Neil Painter and Denis Burkitt, published in 1971.21 Their review of medical textbooks revealed no mention of the disease since 1916, but they noted that the prevalence had skyrocketed during the years before their paper. They observed that diverticular disease practically

march 2014 www.todaysdietitian.com 47

was nonexistent in less economically developed countries such as Africa while common in Western countries. Furthermore, as less economically developed countries became more industrialized, the rate of diverticular disease increased concomitantly. Painter and Burkitt theorized that this geographic variation was linked to dietary fiber, with intake decreasing as countries became more industrialized. They postulated that as diets become more Westernized, they contained significantly less fiber, precipitating the development of diverticular disease. Indeed, the title of their article labels diverticular disease as “a deficiency disease of Western civilization.” This “fiber hypothesis” has prevailed since their paper was published and, although it was somewhat controversial in research circles, only recently has it been challenged in earnest. The fiber hypothesis posits that the disease’s pathogenesis begins with colonic segmentation, the process by which the contents of the large intestine move forward, a nonpropagated rhythmic contraction. This is different from peristalsis, the process that moves the food mass forward in the small intestine, which is a propagated wave. The fiber hypothesis proposes that a low-fiber diet causes segmentation to occur more frequently and efficiently, which results in higher localized intraluminal pressure. Higher intraluminal pressure, in conjunction with weakened colonic musculature, which occurs in aging, favors the development of diverticular disease. Painter and Burkitt proposed that fiber protects against high intraluminal pressure by producing higher-volume feces, which in turn increases colonic diameter. This may seem counterintuitive, but it’s based on a variation of the Law of LaPlace. This law states that the pressure within a cylinder, which the intestine essentially is, equals the tension on the wall divided by the radius.22 Relative to the colon, intraluminal pressure then is inversely proportional to the radius, so as fiber distends the colon and increases its radius, pressure inside the colon is reduced. In addition, Painter and Burkitt noted that because of the higher fiber content of the African diet, which was the focus of their study, “Food residue passes through the African’s gut within 48 hours, whereas in an Englishman this may take more than twice as long.” The shorter transit time results in lower water reabsorption, so the colon propels a less viscous fecal mass that generates lower pressure, much less conducive to the formation of diverticula. Given this presumably reasonable rationale and epidemiologic evidence, it’s not surprising that the fiber hypothesis has been so resilient.

intestinal motility slows, although studies have demonstrated conflicting results regarding this.24 Slower motility results in higher colonic water reabsorption and harder feces, which causes excessive straining and higher intraluminal pressure. Another factor in aging that makes herniation more likely is the reduction in neurons containing nitric oxide in the myenteric plexus.25 These nerve cells play a role in receptive relaxation, a vagovagal reflex. These reflexes control muscular contraction to propel food through the gastrointestinal tract, and colonic receptive relaxation is important in allowing for expansion to accommodate and propel the fecal mass with lower intraluminal pressure. In addition, the residual nitric oxide–containing neurons may be less functional. Chronic use of laxatives over a long period of time could potentially damage the colon, a condition gastroenterologists have dubbed the “cathartic colon,” making it more susceptible to diverticular disease and other gastrointestinal disorders.26 Although most practitioners subscribe to this belief and caution patients based on it, some researchers believe evidence is lacking.27

Genetics The geographic variation in right or left colon diverticular disease suggests to some researchers that genetic differences in those populations are important in disease development.28 In addition, the fact that individuals who have certain genetic disorders are more susceptible to developing diverticula suggests a role for genetics in diverticular disease. These disorders include Ehlers-Danlos syndrome, Williams-Beuren syndrome, CoffinLowry syndrome, and polycystic kidney disease, and researchers have identified the specific genetic mutations. One study reported that among people with end-stage polycystic kidney disease, the rate of diverticula was 83%.29 The defective genes in these disorders may be related to diverticular disease via the smooth muscle accumulation of collagen and elastin. A recent study in Denmark analyzed diverticular disease cases using a national patient registry, which included 10,420 siblings and 923 twins.30 The study of familial aggregation of diverticular disease showed that the relative risk among siblings was 2.92 compared with the general population. The relationship was even stronger for diverticular disease cases requiring hospitalization or surgery. When one monozygotic twin had diverticular disease, the relative risk for the other twin was 14.5. In dizygotic twins, the relative risk was 5.5, and the effect was stronger for females compared with males. On the basis of their results, the researchers concluded that genetic factors contribute 53% of the susceptibility to diverticular disease.

Effects of Aging The strong association of age with the presence of diverticular disease argues for the important role of the aging process in the disease. In 2005, the American Gastroenterological Association issued a committee report on the impact of the aging population on gastroenterology practice, education, and research.23 The authors noted that aging causes an increase in collagen in the colonic wall, with a concomitant reduction in tensile strength, that makes herniation more likely. In addition, with advancing age,

48 today’s dietitian march 2014

Obesity Although fiber has been the dietary focus related to diverticular disease, with researchers citing the rise in the disease’s prevalence as fiber intake declined, several aspects of diet and lifestyle have paralleled this relationship. Chief among these is BMI and obesity. A national task force on obesity that convened in 2000 pointed to an association between obesity and diverticular disease, and

researchers have provided evidence for an association between diverticular disease and BMI.31 Strate and colleagues conducted a prospective study of 47,228 male health professionals and evaluated several parameters with respect to diverticular disease that included BMI, waist circumference, and waist-to-hip ratio.12 All three parameters increased the risk of diverticular disease and diverticular bleeding, with relative risks ranging from 1.56 for waist circumference and diverticulitis to 3.19 for those with a BMI higher than 30 and diverticular bleeding. The Strate study showed a link between obesity and both diverticulitis and diverticular bleeding but not diverticulosis. This may suggest that obesity affects diverticular bleeding risk via metabolic pathways related to vascular integrity.32 Another possible mechanism is that obesity alters gut microbiota, which would be conducive to diverticular disease, since researchers have proposed that microflora may affect the development of diverticular disease.33,34 Perhaps a more likely mechanism linking obesity to diverticular disease relates to inflammation, particularly in light of numerous recent studies describing a state of chronic low-grade systemic inflammation in people who are obese.35,36 Whether inflammation is an etiologic process or a consequence of obesity, it’s clear that adipose tissue secretes various cytokines, proinflammatory compounds with local and systemic effects. And relative to diverticular disease, both human and animal studies have reported a rise in plasma inflammatory markers with aging.37,38 Chronic inflammation also can cause changes in intestinal motility and sensation, which are important in diverticular disease, by affecting alterations in the function of smooth muscle, intestinal nerves, and epithelial cells.39 Further support for this mechanism are data from the Strate study showing that waist-to-hip ratio—a superior indicator of visceral adipose tissue, which is more metabolically active than subcutaneous fat—was significantly correlated to diverticular disease. However, research evidence is lacking regarding an association between inflammation and diverticular disease, with some data showing no difference in fecal inflammatory markers between diverticular disease subjects and controls.40 Further, one study reported a reduced risk of diverticular disease in patients with inflammatory bowel disease, suggesting that inflammation actually may be protective.41

IBS In addition to being important for a differential diagnosis, IBS appears to significantly increase the risk of diverticular disease. A 2009 cross-sectional survey reported that subjects with IBS were much more likely to have diverticulosis than were subjects without IBS, and subjects aged 65 and older with IBS had a ninefold increased risk of diverticulosis.8 Although the reason for the association is unclear, the authors suggested several possible mechanisms. Noting the higher risk in older individuals, they posited that IBS may act in conjunction with the aging-related changes in smooth muscle and neurons to promote the development of diverticular disease.23-25 Another possible mechanism is that bacterial overgrowth, a consequence of diverticula-induced stasis of colonic contents, may

cause chronic low-grade inflammation. In turn, inflammation sensitizes afferent neurons, giving rise to visceral hypersensitivity and hypermotility, which are hallmark features of IBS.

Other Risk Factors Studies have pointed to several other risk factors for diverticular disease, including physical inactivity,42 red meat consumption,43 a meat- vs. plant-based diet,44 higher socioeconomic status,45 hypertension,46 and parity.45 Some of these variables may be related to other risk factors (eg, physical inactivity and obesity, hypertension and obesity, vegetarian diet and fiber). However, the studies for these other factors are limited in number and scope.

Fiber Hypothesis Revisited Although many embraced Painter and Burkitt’s fiber hypothesis, some researchers were skeptical. Most objections began with the obvious: Aside from dietary fiber intake, there are numerous differences between populations in industrialized countries and those in less economically developed countries that could relate to diverticular disease. These differences range from life expectancy to posture during bowel emptying. The latter difference formed the basis for a compelling case for sitting vs. squatting as promoting diverticular disease.47 In 1988, Sikirov argued that the level of straining in the sitting posture during bowel emptying was three times higher than that in the squatting posture.47 Most of the evidence for the fiber hypothesis comes from epidemiologic studies and small clinical trials, and even these have yielded conflicting results. The potential flaw in the former types of studies (ecologic fallacy) points to the problem of using population-based data to reflect an individual’s risk. Reviews of the studies arrived at similar conclusions regarding the fact that the hypothesis represents a plausible physiologic mechanism, although the evidence isn’t as strong as one might prefer.2,28,48 The Health Professionals Follow-Up Study provided some of the more compelling evidence for the fiber hypothesis.42 In this large prospective study, insoluble fiber intake was inversely correlated with the risk of diverticular disease, particularly for cellulose. However, there had been several missing links between the hypothesis and the data. For example, many assume that constipation, which leads to straining and high intraluminal pressure, plays a causative role in the development of diverticular disease. But Jung’s large population-based study on the association between IBS and diverticular disease showed that diarrhea-predominant IBS was the strongest predictor of diverticular disease.8 In addition, a recent study reported that fiber didn’t improve stool consistency or painful defecation,49 and a meta-analysis reported that constipation was reduced by lowering dietary fiber intake.50 While these studies showing that constipation isn’t linked to diverticular disease and that fiber doesn’t provide a benefit for constipation seem counterintuitive, they set the stage for a study that perhaps more than any other calls into question the validity of the fiber hypothesis. Peery and colleagues conducted

march 2014 www.todaysdietitian.com 49

a cross-sectional study of 2,104 subjects aged 30 to 80.1 The researchers had access to colonoscopy reports on the subjects, a parameter typically not included in previous studies. The results didn’t show a correlation between diverticulosis and red meat intake or physical inactivity, as had previous studies. In addition, low fiber intake wasn’t associated with diverticulosis; rather, high fiber intake was positively correlated to the disease. Even more stunning was the dose-response relationship between fiber intake and the number of diverticula, with the highest quartile of intake associated with the presence of more than three diverticula. In addition, constipation wasn’t a risk factor, and subjects who had more frequent bowel movements (more than 15 per week vs. fewer than seven per week) had a 70% greater risk of diverticulosis.1 In attempting to reconcile the study results with the fiber hypothesis, the first possible consideration is that patients seeking a colonoscopy may have had previous symptoms and either started a high-fiber diet on their own or on the advice of their physicians. However, most of the colonoscopies were for routine screening. In addition, the researchers excluded a subset of subjects who previously had undergone colonoscopies with no change in the data. The finding that frequent bowel movements were associated with a higher risk, while seeming to counter the fiber hypothesis, supports Jung’s study that reported higher diverticulosis risk with diarrhea-predominant IBS.8 In addition, since the sitting vs. squatting theory47 suggests that the sitting position causes high intraluminal pressure, more frequent bowel movements would be expected to result in a condition of higher colonic pressures. The Peery study results don’t challenge the value of fiber for people who have diverticulosis or who have had diverticulitis and other diverticular complications. The reason high fiber intake may not help prevent diverticulosis may be related to different physiologic mechanisms that lead to the development of diverticulosis rather than diverticulitis. However, the results do raise an intriguing conundrum: High fiber may be beneficial for patients who have diverticulitis, but it actually may promote the development of diverticulosis in individuals with no prior diverticular disease, putting them at risk of diverticulitis.

Treatment: Nutrition and Lifestyle Recommendations Although the Peery study has raised questions about the benefits of dietary fiber for preventing diverticulosis, the recommendations at this time remain the same. The main rationale for this is that although a high intake of dietary fiber may not help prevent diverticulosis, and indeed may promote it, still there’s evidence that fiber reduces the risk of diverticular disease complications. So for patients who have diverticulosis and those who have had diverticulitis, which is the triggering event for most patient contact with an RD, high fiber intake is beneficial. And for patients recovering from diverticulitis, the short-term low-fiber and long-term high-fiber approach still applies. Moreover, the abundance of research shows other health benefits of fiber, such as the prevention and treatment of cardiovascular disease, diabetes, and some cancers. Some of these benefits specifically are related to soluble fiber, which also

50 today’s dietitian march 2014

appears to positively affect intestinal flora. In addition, soluble fiber is a substrate for the production of short-chain fatty acids, which serve as a fuel source for colonic cells. In light of the gut microorganisms’ potential role in diverticular disease, it may be useful to ensure that patients include adequate amounts of soluble fiber as they increase total fiber intake. Since most Americans consume about 50% of the recommended level of fiber, attaining the full amount would be an appropriate goal. Obesity—especially abdominal obesity—appears to be an important risk factor for diverticular disease. In addition, as with fiber, strong evidence links obesity to several chronic diseases. For both reasons, modest weight loss in patients who are obese and maintaining a healthy body weight in others is an important component of nutrition and lifestyle recommendations in diverticular disease. Another aspect of lifestyle that may be helpful, despite scant evidence linking it to diverticular disease, is to engage in consistent physical activity in an effort to achieve and maintain a healthy weight. Lastly, if further evidence strengthens inflammation’s potential role in the development of diverticular disease, it may indicate an important dietary consideration. Some foods, such as fruits and vegetables, lower the level of plasma inflammatory markers, while other foods and cooking methods increase these markers. Foods that promote inflammation are those containing significant amounts of starch and sugar but small amounts of fiber. The grilling method of cooking meats, poultry, and fish also promotes inflammation by forming advanced glycation end products. Even without more evidence, as with fiber and physical activity, foods that lower systemic inflammation also are associated with a reduced risk of several chronic diseases.

Advice for RDs Until further research corroborates the Peery study, RDs can be confident in current nutritional recommendations for patients and clients who have had diverticulitis, if not diverticulosis. The nutrition and lifestyle recommendations that may be beneficial for diverticular disease parallel those that RDs routinely emphasize in various practice settings. As with many controversial topics in the field of nutrition and dietetics, it’s important for RDs to continue to stay abreast of current research. Dietetic practice must be based on available evidence and not on concepts that have simply become accepted over time. — Tonia Reinhard, MS, RD, is director of the coordinated program in dietetics and clinical nutrition course director in Detroit’s Wayne State University School of Medicine, and the author of Gastrointestinal Disorders and Nutrition, Superfoods: The Healthiest Foods on the Planet, The Clinical Dietitian’s Essential Pocket Guide, and The Vitamin Sourcebook. She also is a past president of the Michigan Academy of Nutrition and Dietetics.

For references and two patient handouts, view this article on our website at www.TodaysDietitian.com.

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

CPE Monthly Examination 1. In distinguishing the various terms related to diverticulosis, diverticulitis, and diverticular disease, to what does the latter term refer? a. The inflammation and infection of diverticula lining the intestinal tract b. The presence of more than one diverticulum typically in the sigmoid colon c. Any complication caused by the inflammation and infection of diverticula d. Various clinical states with herniation of intestinal mucosa through the wall 2. Painter and Burkitt’s fiber hypothesis posits that dietary fiber played a causative role in diverticulosis under which of the following conditions of intake? a. Total fiber excess b. Insoluble fiber excess c. Soluble fiber deficiency d. Total fiber deficiency 3. A 50-year-old patient has undergone her first colonoscopy, which showed no abnormalities. Your assessment of her dietary intake shows no deficient levels of any nutrients. However, she has a family history of diverticulitis, and she asks you whether she should begin fiber supplementation. Based on recent evidence, what is your answer? a. No, high fiber intake may promote diverticulosis. b. Yes, high fiber intake may prevent diverticulitis. c. No, red meat is more likely to cause diverticulosis. d. Yes, you have a strong family history of diverticulitis. 4. In light of recent studies, the role of a high-fiber diet in potentially promoting diverticulosis may be related to high intraluminal pressure as a result of which of the following? a. Lower colonic microbial flora levels b. Higher frequency of bowel movements c. Higher water reabsorption in the colon d. Lower sensitization of colonic mucosa 5. Most people with diverticulosis are asymptomatic, but among the 25% with symptomatic disease, the mortality rate for specific complications is as high as what percentage? a. 5 b. 20 c. 35 d. 75

6. What is one mechanism by which obesity has emerged as an important risk factor for the development of diverticular disease? a. Promotion of inflammation b. Excessive caloric intake c. Reduction in physical activity d. Increased intraluminal pressure 7. You’re instructing a patient admitted with diverticulitis about nutrition recommendations for discharge. He has a long history of diverticular disease and tells you that he avoids nuts and popcorn because they may trigger an attack. What should you tell him? a. There’s sound evidence for avoiding these foods. b. Those foods may reduce the risk. c. The risk depends on the type of nuts. d. Avoid popcorn if it causes diarrhea. 8. Based on current evidence, physical inactivity may be an important risk factor for diverticular disease for which of the following reasons? a. It promotes low fiber intake. b. It weakens colonic muscle. c. It contributes to obesity. d. It causes high colonic pressure. 9. Which of the following gastrointestinal disorders is associated with a higher risk of diverticular disease? a. Idiopathic constipation b. Irritable bowel syndrome c. Inflammatory bowel disease d. Gastroesophageal reflux 10. A 40-year-old man is admitted to the hospital via the emergency department on nothing-by-mouth status with a diagnosis of diverticulitis. Testing has revealed that the ileocecal valve is incompetent with small-bowel distension. What may be the appropriate medical nutrition therapy? a. Parenteral nutrition b. Low-fiber oral diet c. Enteral nutrition d. Full liquid oral diet

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.

march 2014 www.todaysdietitian.com 51

SUPPLEMENT SPOTLIGHT

OMEGA-3 SUPPLEMENTATION Help Clients Sort Through the Fish Oil Facts By Linda Antinoro, JD, RD, LDN, CDE Despite recent published reports suggesting that omega-3 supplements lack the cardiovascular health benefits they once claimed and could be associated with various health risks, many people continue to use them. According to the 2014 ConsumerLab.com survey of 10,000 supplement users, fish/marine oil supplements still were popular, with 67.2% of respondents using them. This consumption may not be bad. Research on omega-3s suggests that these supplements may be useful and even necessary for people with very high triglyceride levels, pregnant and nursing women, and individuals who have difficulty eating oily fish twice per week.

Cardiovascular Connection Previous clinical trials of fish oil supplements often have associated omega-3 supplementation with heart health benefits. The GISSI Prevenzione study, for example, published in the August 1999 issue of the Lancet, followed 1,324 patients and found that the group who received a 1-g dose of an omega-3 supplement each day for 31⁄2 years significantly reduced the risk of death, nonfatal myocardial infarction, and nonfatal stroke among those who had survived a recent myocardial infarction.1 Fast-forward to a 2013 study involving more than 12,000 patients at high risk of a heart attack who were randomized to receive either 1,000 mg of fish oil per day or a placebo.2 After five years, there was no reduction in cardiovascular mortality and morbidity. A meta-analysis of 20 studies published in the September 2012 issue of The Journal of the American Medical Association supports a similar conclusion. Patients who received an average dose of 1.51 g of omega-3 supplements per day for

52 today’s dietitian march 2014

a median treatment duration of two years didn’t experience a lower risk of myocardial infarction, stroke, cardiac death, sudden death, or all-cause mortality.3 However, Dariush Mozaffarian, MD, DrPH, a cardiologist and epidemiologist at Harvard Medical School, points out that the other research did find that omega-3s lowered the risk of cardiac death by 10%. A possible reason for the seemingly contradictory results between the earlier and more recent studies on omega-3 supplementation, according to researchers, is that most of the later trials involve people with established heart disease who already are being treated with various medications, such as antihypertensives, antiarrhythmics, and statins.4 For example, in the GISSI trial, only 5% of patients received statins at baseline. Patients already using cardioprotective agents may not experience further benefits when given omega-3 supplements since drug therapy can mimic or mask the actions of omega-3 supplements by lowering blood pressure, blood lipid levels, or inflammation.4 Plus, what’s unknown at this time is whether omega-3 supplements will help thwart cardiac problems in healthy people or those at low risk of heart disease. The Vitamin D and Omega-3 Trial (VITAL), an ongoing study of 20,000 men and women investigating whether taking daily supplements of vitamin D3 (2,000 IU) or omega-3s (1 g) lowers the risk of developing cancer, heart disease, and stroke in people who don’t have a prior history of these illnesses, hopes to answer this question. One consistent benefit demonstrated by research on omega-3 supplements is that they can improve hypertriglyceridemia. The American Heart Association endorses 2 to 4 g of EPA and DHA per day in capsule form under a physician’s supervision for those individuals who need to lower their triglyceride levels. Even modest doses work to some degree. In one study, triglyceride levels dropped 14.5 mg/dL more in patients who took a 1-g capsule containing 465 mg of EPA and 375 mg of DHA compared with those who received a placebo.5 Though triglyceride reduction didn’t decrease the rate of cardiovascular events in this study, lowering triglycerides still is a worthwhile goal because extremely elevated triglycerides can contribute to pancreatitis.4

Prostate Cancer A study published in the August 2013 issue of the Journal of the National Cancer Institute examined the association between blood levels of omega-3 fatty acids and prostate cancer risk among men who participated in the Selenium and Vitamin E Cancer Prevention Trial (SELECT). The researchers found that men who had higher blood levels of omega-3 fatty acids were more likely to develop prostate cancer.6 Many headlines followed, erroneously singling out fish oil supplements as the culprit. According to Theodore Brasky, PhD, the lead researcher of the study, “Only a minority of the men in the study took supplements.” While researchers saw a correlation and not a causeand-effect relationship, it still may be prudent for men to avoid

large doses of omega-3s whether EPA and DHA Content in Fish from excessive fatty fish intake or Type EPA (mg) DHA (mg) Combined Total (mg)* supplements, he says. Conversely, a study published Herring, Pacific, cooked 1,408 1,001 2,409 in the January issue of Cancer Prevention Research found that Anchovy, canned in oil 865 1,465 2,330 men with prostate cancer who ate a low-fat diet and took fish oil Salmon, sockeye, cooked 470 920 1,390 supplements had lower levels Mackerel, Atlantic, cooked 571 792 1,363 of serum proinflammatory eicosanoids and a lower cell Trout, rainbow, wild, cooked 530 589 1,119 cycle progression score—a measurement used to predict Sardines, Atlantic, canned in oil 536 577 1,113 cancer recurrence—than men who ate a typical Western diet.7 Tuna, white, canned in water 264 713 977 Subjects received 5 g of fish oil per * Amount for combined EPA and DHA listed from highest to lowest in milligrams per 4-oz serving day consisting of five 1-g capsules — Source: USDA National Nutrient Database for Standard Release, Release 26 each containing 200 mg of EPA and 367 mg of DHA. The American Heart Association agrees with this recommenThe researchers acknowledge that they couldn’t determine dation for healthy people who don’t have documented coronary whether either treatment alone would have produced the same heart disease (CHD), although it acknowledges that patients with results. They combined the two interventions based on precliniCHD probably need closer to 1 g of EPA and DHA combined per cal trials that showed a decrease in the development and proday, and that this amount may require the addition of omega-3 gression of prostate cancer associated with reducing the ratio of supplementation. The association discourages exceeding omega-6 to omega-3 fatty acids and lowering dietary fat intake. 3 g/day from capsules unless under the guidance of a trained health care professional.

Pregnancy and Postpartum

Omega-3 supplementation also has been found to benefit the health of infants and pregnant women. Omega-3s assist in the normal development and functioning of the brain and retinas in fetuses and infants. According to the International Society for the Study of Fatty Acids and Lipids, pregnant and lactating women need 300 mg of DHA per day.8 Research shows that 200 to 300 mg of omega-3 fatty acids per day, particularly DHA, is associated with improved infant health outcomes such as visual and cognitive development. It’s been suggested that nursing mothers should take 200 to 300 mg of omega-3 fatty acids so the nutrients can pass through breast milk to their babies. Dietitians can encourage pregnant women to eat fish low in mercury, such as salmon and sardines, as well as DHA-fortified foods. But if clients don’t eat enough or choose to avoid these foods, omega-3 supplements are an option.

Bottom Line When counseling clients about omega-3 intake, inform them that consumption is important because our bodies can’t make these essential fatty acids on their own. Tell them that they should obtain omega-3s through food first whenever possible. Explain that while plant-based omega-3s such as walnuts, chia seeds, and ground flax have alpha-linolenic acid and other nutritional merits, the body converts alpha-linolenic acid into EPA and DHA at rather low levels. Finally, if clients have difficulty consuming enough omega-3s, give them guidance based on their health status to determine the correct dosage of omega-3 supplements they should take daily. — Linda Antinoro, JD, RD, LDN, CDE, is a freelance writer and part of the Nutrition Consultation Service at Brigham and Women’s Hospital in Boston.

Optimal Omega-3 Doses Most medical experts and health organizations recommend individuals get 250 to 500 mg of EPA and DHA per day, first from fatty fish and then from supplements. According to the 2010 Dietary Guidelines, the mean intake of seafood in the United States is approximately 31⁄2 oz per week. Increasing intake to 8 oz per week provides an average consumption of 250 mg of EPA and DHA per day.

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

march 2014 www.todaysdietitian.com 53

BOOKSHELF

Clean Food, Revised Edition: A Seasonal Guide to Eating Close to the Source By Terry Walters 2012, Sterling Epicure Hardcover, 368 pages, $30

As an advocate of unprocessed, seasonally inspired whole foods, Walters offers more than 250 recipes in an effort to get people to choose minimally processed foods, those that are “close to the source.” In the revised edition of Clean Food, Walters offers an array of delicious whole plantinspired recipes divided into sections according to the four seasons and driven by the fruits and vegetables available and in season during that time of year. Each of the four season sections offers a variety of recipes divided into categories such as dips and dressings, vegetables, grains, and desserts, with some seasons offering additional categories for sea vegetables and soy-based proteins such as tofu and tempeh. In the first portion of the book, Walters uses a gentle approach to encourage individuals to adopt a “cleaner” lifestyle by addressing issues such as stress management and the importance of family mealtime. Refreshing in her nondiet, holistic approach, her tips may be beneficial for individuals aiming to adopt an eating pattern of less processed, whole plant foods or wanting to try their hand at new plant-based recipes. An index defining many less commonly understood “clean” foods also is a helpful reference for many of her recipes. Walters’ recipes are out of the box yet simple and unintimidating in the hopes of motivating individuals to eat more home-cooked meals. After reviewing all the recipes, I was inspired to pull out my food processor and make a batch of pesto required for her delicious Pesto Pasta Salad and her Summer Rolls With Lemon Basil Pesto—both of which were personal favorites as I continued cooking from the recipe collection. It may be important to note that all the recipes have been revised to be gluten free or include gluten-free variations. All the recipes are vegan, too. Eating clean is a popular trend and, based on the recipes found in Clean Food, it’s one that dietitians and other health professionals can feel good about using in their practice and recommending to their clients and patients. In fact, many

dietitians may find that the clean-eating philosophy runs congruently with their current recommendations of eating more fruits, vegetables, whole grains, and heart-healthy fats. I love this book for its inspiring plant-based recipes and appreciation of choosing seasonal, local foods. At the same time, for dietitians seeking science-based nutritional information or for meat-loving clients not yet ready to completely give up animal protein, this book may serve as a wonderful accompaniment—but not a primary resource—to their cookbook or nutrition resource collection. — McKenzie Hall, RD, is a cofounder of Nourish RDs, a nutrition communications and consulting business based in Los Angeles.

Delish Diabetes Cookbook: 70 Delicious and Healthy Recipes for Every Meal By the editors of Delish 2013, Hearst Books Hardcover, 160 pages, $14.95

Delish.com has detoured from its typical online content to offer the Delish Diabetes Cookbook, featuring 70 diabetes-targeted recipes. The cookbook aims to help people with diabetes answer possibly their most common question: “What should I eat?” Included are recipes suitable for breakfast, lunch, light meals, main courses, and desserts. Readers also will find a seven-day menu, using recipes from the book for each meal, and many of the dishes need only a green salad to complete a lunch or dinner meal. As you know, we eat with our eyes, and it was the tantalizing, mouthwatering photos for every recipe that first caught my attention. The photos themselves will motivate you to try the recipes—and you may need that extra motivation. The main courses, for example, are relatively complex recipes, and most are estimated to take close to an hour for preparation and cooking. I decided to put a couple of the recipes to the test, choosing the Carrot and Lentil Soup With Caraway Toast and the Eggplant, Tomato, and Leek Lasagna. The soup was slightly bland, but a dash of salt and pepper greatly enhanced the flavor

(although increased the sodium, too). The soup and toast overall were unique recipes and fairly easy to prepare. However, I was disappointed with the length of time needed to prepare the lasagna. The recipe stated a prep and cook time of one hour, but cook time alone took one hour. The recipe was tasty and filling served with a side salad, though, and if you’re willing to take the time, I’m betting all the dishes will be worth the effort. Nutrition information is provided for each recipe, which makes it easier for people with diabetes to assess whether the dish is a good fit for their personal meal plan. However, the recipes included in the seven-day menu aren’t consistently the same carbohydrate content day to day, so patients will need to make adjustments to add or subtract grams of carbs. You may want to caution your clients about salt content, as several of the recipes were high in sodium. People with diabetes are at higher risk of heart disease and high blood pressure. Remind your clients that the 2010 Dietary Guidelines set a limit of 1,500 mg of sodium per day. An emphasis on glycemic index was noted in the cookbook overview and in the nutrient analysis of each recipe. At the same time, the authors explain that the American Diabetes Association recommends focusing on total carbohydrate content of foods as the best option for diet management. This cookbook does bring unique recipes to the table and is a great resource for international dishes. And while it’s not a jackpot of quick and simple diabetes-friendly meals, the photos and the interesting variety of ingredients may help cooks slow down and enjoy preparing real meals. — Toby Smithson, RDN, LDN, CDE, is a national spokesperson for the Academy of Nutrition and Dietetics. She’s the founder of DiabetesEveryDay.com and a coauthor of Diabetes Meal Planning and Nutrition for Dummies.

Gluten-Free on a Shoestring Quick & Easy: 100 Recipes for the Food You Love — Fast! By Nicole Hunn 2012, Da Capo Lifelong Press Paperback, 256 pages, $19

Gluten-Free on a Shoestring is a cookbook written by a gluten-free blogger and, most importantly, the mother of a son with celiac disease. The book focuses on shortcuts to help save readers time and money while preparing glutenfree meals, snacks, and desserts. The title boasts 100

recipes, but actually there are 102 thanks to two holdovers from an earlier cookbook by Dunn. The first two chapters detail “quick and easy basics,” which highlight some of her most relied-on gluten-free convenience food products that can be incorporated into the recipes, and “make-it-snappy kitchen tools and equipment.” The ensuing chapters contain the recipes and include breakfast and brunch selections, quick breads, meatless dishes, weekday workday dinners, and shortcut desserts. Though most of the recipes are designed to take fewer than 40 minutes to prepare and each one states an active time (time actually spent carrying out the recipe directions) and inactive time (how long a dish spends in the oven or freezer or until it’s fully cooked), Hunn does warn the total time stated for each recipe is an estimate. Some level of basic cooking fluency is assumed. Each recipe also includes a Shoestring Savings box in which costs are compared between making the recipe or purchasing a similar item that’s already prepared. It’s a useful way for the reader to see the money he or she will save by preparing instead of buying varying items. The major concern I had with one recipe (German Pancakes) was the suggestion that you could leave the eggs and milk out on the counter right before going to bed and then combine all the ingredients in the morning and pop them in the oven. Hunn mentions this as a possibility so the recipe can be used as a quick weekday breakfast despite the ingredients ideally needing to be at room temperature. For food safety purposes, this recommendation should be deleted. Overall, this book will benefit anyone but especially those who must follow a gluten-free diet and don’t want to spend an inordinate amount of time in the kitchen or pay a small fortune to routinely buy already-prepared gluten-free items. — Linda Antinoro, JD, RD, LDN, is a freelance writer and part of the Nutrition Consultation Service at Brigham and Women’s Hospital in Boston.

FOCUS ON FITNESS

SENIOR FITNESS

Moving Toward Fall Prevention By Jennifer Van Pelt, MA When most people think about aging and health, they focus on the cardiovascular system and cancer, which figure prominently in media messages to older adults. But a significant contributor to poor health for seniors isn’t a disease; it’s a lack of mobility. In fact, the Centers for Disease Control and Prevention (CDC) has flagged mobility as “fundamental to everyday life and central to an understanding of health and well-being among older populations. Impaired mobility is associated with a variety of adverse health outcomes.”1 Older adults lacking the ability to move well have a higher risk of falling. CDC statistics show that one in three adults aged 65 and older falls each year. Of these, up to 30% sustain moderate to severe injuries that affect mobility and the ability to live independently as well as increase the risk of early death. In 2010, the CDC calculated that falls among older adults cost $30 billion in direct medical costs. By 2020, it estimates that this cost will reach almost $55 billion.2

Fall Prevention Benefits and More Staying active and strong is the best defense against fallrelated injuries. While it’s possible to minimize fall risk in an older adult’s environment (eg, installing treads on stairs, handles on walls), accidents still happen. But having strong muscles and flexible joints helps reduce the severity of fallrelated injuries in this population. Senior exercise specialists and medical professionals have designed specific fall prevention programs for older adults. Accessible for any fitness level, these programs consist of exercises that focus on gait, balance, and functional training for daily living activities. Exercises in fall prevention programs may include heel-toe walking along a line, standing on one foot, sit-tostand from a chair, and tai chi, a slow martial arts–based exercise. A recent systematic review and meta-analysis of 17 randomized controlled trials (totaling more than 4,000 participants) that

56 today’s dietitian march 2014

evaluated fall prevention exercise programs found that these programs are effective for preventing fall-related injuries and reducing the rate of falls requiring medical attention. The researchers also found that fall prevention exercise programs reduced the rate and risk of falls requiring medical care by approximately 30% and the risk of fall-related fractures by 61%. All programs emphasized balance training, though strength exercises and other movements also were performed, depending on the program. The researchers concluded that there’s “ample evidence that these programs improve balance ability.”3 In addition to the advantages associated with fall prevention, exercise provides social, emotional, and cognitive benefits for seniors. Group activities such as dancing and fitness classes yield opportunities for socializing with peers and developing ongoing positive relationships. Studies have shown that regular exercise, especially group activities, can improve mood, reduce memory loss, and maintain brain fitness.4-6 Most younger older adults (aged 60 to 65) grew up hearing about the benefits of staying in shape. More likely to be active already, adults in this age group may need only guidance on

RESOURCES With the rapidly increasing aging population, resources and opportunities in older adult fitness also are growing. The following links provide information on fall prevention programs and specialized older adult fitness certifications: • American Council on Exercise senior fitness specialty certification: www.acefitness.org/fitness-certifications/ specialty-certifications/senior-fitness.aspx • American Senior Fitness Association resources and trainings: www.seniorfitness.net/index.htm • Fall Prevention Center of Excellence: http://stopfalls.org • Fallproof! A Comprehensive Balance and Mobility Training Program by Debra J. Rose • Healthways Silver Sneakers fitness programs and instructor training: www.silversneakers.com • International Sports Sciences Association senior fitness certification: www.issaonline.edu/certification/ senior-fitness-certification • National Council on Aging Center for Healthy Aging Fall Prevention: www.ncoa.org/improve-health/ center-for-healthy-aging/falls-prevention