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ASPEN CONFERENCE ISSUE Vol. 17 No. 12

The Magazine for Nutrition Professionals

December 2015

Maintaining Weight Loss Over the Holidays RDs share their top 10 tips for shedding unwanted pounds during this festive season.

INSIDE

2016

Resource Guide Popular Nutrition Trends for 2016 Managing Short Bowel Syndrome in PN Patients Gluten-Free Living and Emotional Health

www.TodaysDietitian.com

BE THERE FOR YOUR PATIENTS EVEN WHEN YOU’RE NOT

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DIAGNOSIS IS ONLY THE BEGINNING OF THEIR JOURNEY We created Neocate Footsteps™ for everything after. Only Neocate Footsteps has a unique and comprehensive set of resources created to help clinicians, parents and patients at every major milestone of their food allergy or GI journey. Tell your families and ask your rep about Neocate Footsteps today. Neocate.com/Footsteps Food Allergy Living Blog | Financial Navigator | Recipes | Toolbox | Nutrition Specialists | Facebook | Online Support | YouTube ©2015 Nutricia North America

Know the difference. Make a difference.

The potent probiotic medical food VSL#3 provides clinically proven benefits in the dietary management of UC and an ileal pouch. Recognized by the ACG Practice Parameter Committee1 and the Cochrane Library2 as an effective tool for the management of pouchitis. VSL#3 adds billions of bacteria to the microbial barrier restoring balance and diversity in the GI tract.3 Knowing the difference makes all the difference when it comes to probiotic health. References: 1. Kornblut A, et al. Am J Gastroenterol. 2004;99(7):1371-1385. 2. Holubar SD, et al. The Cochrane Library. 2010, Issue 6. 3. Gionchetti P, et al. Gastroenterology, 2000;119(2):305-309.

VSL#3 is for the dietary management of UC, an ileal pouch and IBS. It is a high potency probiotic medical food that must be used under medical supervision. Made in U.S.A. Distributed by Sigma-Tau Pharmaceuticals, Inc. Gaithersburg, M.D. ÂŠ2015 Sigma-Tau Pharmaceuticals. All rights reserved V1166 2/15

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EDITOR’S SPOT

THE 2015 DGA AND THE RED MEAT DEBATE According to presenters at the Food & Nutrition Conference & Expo® in October, the 2015 Dietary Guidelines for Americans (DGA) will soon be released. As you know, the 2015 Dietary Guidelines Advisory Committee (DGAC) report practically came under fire in recent months from the USDA and Health and Human Services (HHS). In my opinion, the agencies unjustly criticized some of the report’s recommendations despite the rigorous review of nutrition science by the best medical researchers in the country. Many RDs sent letters to Congress to defend the report’s integrity and the evidence analysis process. I almost sent a letter to defend the report, but I didn’t since I’m not a dietitian. The USDA and HHS removed the DGAC’s discussion on sustainability, stating that “ … because this is a matter of scope, the dietary guidelines aren’t the appropriate vehicle for this important policy conversation.” To me, this statement was a slap in the face to all the environmentally savvy dietitians on the frontlines of the sustainability movement. In addition, the North American Meat Institute (NAMI) became defensive due to the DGAC’s recommendation to eat more plantbased foods and less red meat and processed meat. According to a February 19, 2015, article on foodnavigator-usa.com, NAMI said the recommendations were “flawed” and “nonsensical.” Strong language, considering the decades of research associating red meat and processed meat intake with higher risks of cancer. Not to mention the recent report from the World Health Organization’s International Agency for Research on Cancer (IARC) that found positive associations between red meat (eg, beef, veal, pork, lamb) and cancers of the pancreas, prostate, and colon, and between processed meat (eg, bacon, ham, sausage, hot dogs) and stomach cancer. NAMI called the IARC report a “dramatic and alarmist overreach.” NAMI would feel this way, since its purpose and mission is to support the meat industry. But as dietitians, you must consider what the entire body of evidence shows, and counsel clients accordingly. Next month, Today’s Dietitian (TD) will review the research on red meat and offer tips for counseling patients. In this issue, you’ll find articles on gluten-free living and emotional health, popular nutrition trends for 2016, and the top 10 tips for maintaining weight loss during the holidays. The staff of TD wishes you a happy holiday season. Please enjoy the issue!

Judy Judith Riddle Editor TDeditor@gvpub.com

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

© 2015 Great Valley Publishing Company, Inc. Phone: 610-948-9500 Fax: 610-948-7202 Editorial e-mail: TDeditor@gvpub.com Sales e-mail: sales@gvpub.com Website: www.TodaysDietitian.com Subscription e-mail: subscriptions@gvpub.com Ad fax: 610-948-4202 Ad artwork e-mail: TDads@gvpub.com All articles contained in Today’s Dietitian, including letters to the editor, reviews, and editorials, represent the opinions of the authors, not those of Great Valley Publishing Company, Inc. or any organizations with which the authors may be affiliated. Great Valley Publishing Company, Inc., its editors, and its editorial advisors do not assume responsibility for opinions expressed by the authors or individuals quoted in the magazine, for the accuracy of material submitted by the authors, or for any injury to persons or property resulting from reference to ideas or products discussed in the editorial copy or the advertisements.

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VEGETARIAN,

CONTENTS

DECEMBER 2015

FEATURES

DEPARTMENTS

Maintaining Weight Loss Over the Holidays Expert

Editor’s Spot

dietitians share their top 10 strategies for shedding unwanted pounds during this festive season.

Reader Feedback

Popular Nutrition Trends for 2016 RDs weigh in on what products will be trending in the new year ahead.

Short Bowel Syndrome in Adult PN Patients Short bowel

syndrome is a complex condition affecting the gastrointestinal tract. Learn more about its pathophysiology and treatment and management strategies to improve patient care.

18 Foodservice Forum

26 30

luten-Free Living and Emotional Health — What G Every Dietitian Must Know A deeper understanding of the impact of celiac disease and the gluten-free diet on mental health and quality of life can help dietitians improve counseling and dietary compliance.

10 Ask the Expert Retail Dietitian

14 Conference Currents Digestive Wellness

52 Focus on Fitness 54 Bookshelf 56 Get to Know… 58 2016 Annual Resource Guide 61

Research Brief

62 News Bites

Teen Nutrition Leaders Two brilliant, award-winning

64 Datebook

teenagers are improving the health and wellness of people in their communities with a focus on nutrition.

66 Culinary Corner

CPE Monthly: Obesity: Beyond Cardiovascular Disease and Diabetes This continuing education course explores obesity’s far reach and ill effects in lesser-described conditions.

Page 44

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 17, Number 12.

6 today’s dietitian december 2015

CONSISTENTLY WINNING AWARDS FOR TASTE AND INNOVATION

READER FEEDBACK

From Facebook “The Essential Nutrient You Need for Strong Bones That You’re Probably Not Getting” www.prevention.com

From Our Twitter Page Popular Tweets, Retweets November Issue AMERICAN

DIABETES

Kelly Greer: Really glad this is finally getting out! I just told my MD last week about this. I said, “What are you telling your menopausal women about calcium?” He said that he recommends getting it from food—about 500 mg. I said what about vitamin K2? He said he would look it up because he wasn’t aware of it. Now he is a good doctor, but this info isn’t getting out there. I’m glad that a fellow RD is getting the word out. Thank you. David Jackson: Research has been performed on mice, but it still isn’t 100% certain that the same metabolism pathway happens in humans. But the results show that [vitamin] K1 is converted to K2. We get K1 from plant sources and K2 from animals. It’s definitely an intriguing vitamin, and a much ignored one too.

Treasures of Frozen Produce

“9 Things I Tell My Patients as a Registered Dietitian”

@DhammaDish: Thanks for [the article] “Plant-Based Diets for the Whole Family”—sound, helpful info for families like ours, such as dispelling protein combo myths.

www.self.com

Beth Gordon: #9 Don’t let a slip become a fall. This is a great omen! Jill Rohlfs: Love #5! Never heard that saying before. “Eat vegetables. Always and in all ways.” Heba Haida: Amazing tips; I use more than half of those at my sessions too!

“Choose This, Not That: Don’t Be Tricked Into Eating the Wrong Halloween Treat” US News & World Report Eat + Run Blog

Melanie Driscoll: No horror, just moderation! I love the use of Halloween terminology incorporated into this piece. There’s also a lot of good information here. However, I am concerned that polarizing foods as bad and good may be misinterpreted by the public. We have to note that foods such as HFCS [high fructose corn syrup] can be used in medical nutrition therapy (MNT) effectively. Beth Marshall: HFCS is recognized in the body exactly the same as any other sugar. There are many functional foods used in MNT that use HFCS to add calories to help those that are ill in hospital settings. Perhaps the message should be, “[F]ind a piece or two of your favorite candy after dinner and savor it” instead of scaring people away from a couple bites of something they may indulge in only a couple times a year anyway. It’s about moderation and what your diet looks like globally, not at one sitting.

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Vol. 17 No. 11

The Magazine

’Tis the Season for

@linsey_nunley: The article on frozen produce was amazing! Great information! @FrozenFoodFacts: Discover the treasures of frozen produce as featured in this month’s Today’s Dietitian.

MONTH

November 2015

for Nutrition

PUMPKIN

Professional s

Learn about its history, folklore, and ways to prepare it for the holidays

INSIDE

Health Benefi of Grass-Fed ts Conventional vs Beef

Diabetes Product Showcase

Treasures of Frozen Produ ce Latest Weigh t-Loss Drugs for Diabe sity

www.TodaysDie titian.com

@26_dragonfly: Love this article! Treasures of Frozen Produce. Thank you.

October Issue Plant-Based Diets for the Whole Family

Taking On Information Overload @GilleanMSRD: Great evidencebased responses to common nutrition questions from Karen Collins, MS, RDN, CDN, FAND.

CO N FE

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IS SU E

Nutrition azine for The Mag

d Diets Pforlant-Base le Family the W ho

Vol. 17 No.

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2015 October

Autumn Pumpkin Soup

etarian nned veg l Well-pla be healthfu diets can of all ages. for people

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Avoidant/Restrictive Food Intake Disorder (Eating Disorders)

Grains Seeds and y Aisle in the Dair ography Food Phot With Mastery one a Smartph

FALL

SHOWCASE

@morethanfoodinc: Or picky eating may be a sensory integration issue. Effective RDs query with genuine curiosity.

Diabetes-Eating Disorder Combination Requires Integrated Treatment (Dynamics of Diabetes) @MarciRD: Thrilled to see Today’s Dietitian highlighting diabetes and eating disorders—agree that combining expertise is key!

September Issue In Pursuit of Graduate Degrees (Practice Matters) @kitty_cat234: Thank you for the article “In Pursuit of Graduate Degrees.” Just read it and solidified my decision to pursue my MS!

.com ysDietitian www.Toda

Some things are meant to happen every day...

...like eating yogurt. The USDA recommends 3 servings of dairy every day. 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 also can be an excellent source of high-quality protein, which helps with satiety, and promotes muscle and bone health. In addition, epidemiological studies in healthy populations show that frequent yogurt consumption, as part of a healthy diet, is associated with less weight gain over time, healthy levels of systolic blood pressure and circulating glucose within the normal range. Eating one yogurt every day is an important first step toward achieving a balanced diet and a healthy lifestyle.

Recommend one yogurt every day.

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ASK THE EXPERT The Diet

THE CANDIDA DIET

Does It Really Prevent Yeast Infections? By Toby Amidor, MS, RD, CDN

My clients have been asking about the Candida Diet, which is said to help prevent Candida, or yeast, infections. Can you share some background on yeast infections, what the Candida Diet entails, and how it purportedly prevents these infections? About 75% of women will get a vaginal yeast infection during their lifetime, and 90% of people with HIV/AIDS develop Candida infections.1 Candidiasis is an infection caused by Candida albicans, a yeastlike fungus. It can infect the mouth, skin, stomach, urinary tract, and vagina. Oral infections, called oral thrush, are more common in infants, older adults, and people with weakened immune systems. Some people have recurring yeast infections and are now turning to the Candida Diet to help prevent and/or cure them.

Causes Humans naturally have small amounts of Candida that live in the mouth, stomach, and vagina and don’t cause any infections. Candidiasis, however, occurs when there’s an overgrowth of the fungus, which may be caused by numerous factors including taking certain medications (eg, corticosteroids, antibiotics, certain birth control pills), having a bacterial infection, pregnancy, being overweight, or several health conditions such as HIV/AIDS, cancer, and psoriasis.1

The Research Some studies suggest that reducing dietary sugar may help prevent Candida infections. In the body, Candida adhesion involves the human epithelial cells. Some carbohydrates have been found to help bind the Candida to the epithelial cells better than others. One study published in Microbial Ecology in Health and Disease looked at the dietary influence of various carbohydrates in vitro on the adherence of Candida to human epithelial cells.2 The study examined the effect of various carbohydrates including fructose, galactose, glucose, maltose, sorbitol, and sucrose. The results found that galactose and glucose promoted a higher adhesion as compared with maltose and fructose. Further, xylitol significantly reduced adherence of Candida to epithelial cells.

10 today’s dietitian december 2015

According to Laurie Meyer, MS, RDN, CD, president of Laurie Meyer Nutrition in Milwaukee, who specializes in functional medicine and uses the Mediator Release Test (MRT) to determine food sensitivities, “The Candida Diet was a fad years ago, but Candida infection is real, and according to the CDC [Centers for Disease Control and Prevention], Candida infection may be on the rise in hospitals.” However, there isn’t any research on the Candida Diet. As such, there are no specific dietary guidelines, but Candida Diet advocates recommend the following dietary changes for improvement: • Avoid carbohydrates: Supporters believe that Candida thrives on simple sugars and recommend removing them, along with low-fiber carbohydrates (eg, white bread). • Avoid yeast-containing foods: Examples include beer, wine, vinegar, baked goods, and mushrooms. • Use probiotics: Advocates say this will help introduce more “healthy” bacteria to the gut to help prevent a build-up of Candida. Yogurt with probiotics and/or supplements may be recommended. • Candida cleanse: These types of diets tend to begin with detoxification, where fasting may be promoted, or a diet restricted to vegetable juice, colon cleansing, or consumption of herbs with antifungal properties. The issue with many of these recommendations is that a variety of foods are restricted, which can lead to deficiencies in certain nutrients; in those with a weakened immune system, dietary restriction can cause a decrease in consumption of nutrients necessary to improve immune system function. In addition, there isn’t enough research to suggest that dietary strategies help resolve Candida infections. However, in her 26 years in private practice, Meyer has found that “many people with Candida can actually have a gluten sensitivity or other food sensitivity. Once those are corrected, the Candida may improve.” This is why it’s so important to determine why the person is prone to Candida infection and where the MRT test can come into play, she says. For those with a Candida infection, Meyer recommends a diet that boosts immune function, beneficial bacteria, fiber, and nutrients, while decreasing sugar and processed foods. — Toby Amidor, MS, RD, CDN, is the founder of Toby Amidor Nutrition (http:// tobyamidornutrition.com) and the author of the cookbook The Greek Yogurt Kitchen: More Than 130 Delicious, Healthy Recipes for Every Meal of the Day. She’s also a nutrition expert for FoodNetwork.com and a contributor to US News Eat + Run, Shape.com, and MensFitness.com.

For references, view this article on our website at www.TodaysDietitian.com. Send your questions to Ask the Expert at TDeditor@gvpub.com or send a tweet to @tobyamidor.

RETAIL DIETITIAN

PERFECTING THE SUPERMARKET FOOD DEMO A Practical Guide to Planning and Hosting In-Store Food Demonstrations By Barbara Ruhs, MS, RDN, LDN These days, more and more retail dietitians are hosting in-store food demonstrations, or demos, to introduce shoppers to new nutritious products and ingredients, provide nutrition education and expertise, and show them how to cook healthful meals using healthful ingredients. Food demos create in-store excitement, draw crowds eager to sample new foods, and, most importantly for the supermarket, have the potential to boost grocery sales. During food demos, dietitians entice shoppers by preparing a variety of healthful foods or recipes and offering samples. “Food experiences are a very powerful way to get customers to try new things,” says Julie McMillin, RD, LD, assistant vice president of retail dietetics at Hy-Vee, Inc, a supermarket chain based in Des Moines, Iowa, that employs nearly 230 in-store dietitians who host one to two food demos per week. Dietitians who aren’t working in the supermarket industry but would like to host in-store food demos can contact the corporate office of their local grocery store chain or a nearby store itself and present the idea to management, and include discussion on the fact that food demos offer benefits to customers and the stores themselves that host them. In-store food demos not only encourage shoppers to sample new foods but also prompt them to buy the foods they’ve tasted, which increases store sales. According to an article published in the October 2014 issue of The Atlantic, called “The Psychology Behind Costco’s Free Samples,” food samples have increased sales as much as 2,000% for the chain in some cases.1 Hosting food demos is a popular practice and as supermarkets become more of a place to socialize, the trend to offer food samples will continue

to grow.2 The Packer’s Fresh Trends 2013 annual survey reported that 49% of customers said they “could be enticed to buy a new item after trying it.” Of course, hosting successful food demos requires advanced planning on the part of RDs and other staff members. Meredith McGrath, RD, LDN, the corporate dietitian for Redner’s Warehouse Markets, based in Reading, Pennsylvania, says that food and culinary demonstrations are a team effort, so there’s much preparation and coordination that occurs behind the scenes. McGrath plans weekly food demonstrations that are hosted in the top 20 Redner’s stores, but she relies on store personnel, whom she refers to as “ambassadors,” to execute the demos because they’re familiar with the stores and know their customer base. The goal of Redner’s food demo program, which she introduced three years ago, is to highlight meal solutions for families. Vendor sponsors make it possible to cover the costs of the program and contribute to the growth of the marketing platform. It’s a win-win for everyone involved, McGrath says. “It generates more revenue for the retailer, grows sales for food industry partners, and provides customers with the convenience of finding all of the ingredients in one place to prepare a healthful, easy recipe at home,” she says. Hosting in-store food demos at a local supermarket also offers a great opportunity for dietitians to position themselves as the food and nutrition experts in their community. Whether dietitians are already employed by supermarket chains or are unaffiliated with the grocery industry, the following strategies can help them plan and host successful in-store food demos to promote healthful products, provide nutrition information, and increase store sales.

Learn Food Safety Guidelines Before dietitians begin planning their first in-store food demo, they must educate themselves about food safety. Food safety is one of the primary concerns when planning a food demo, so RDs must learn their local and state food safety and sanitation guidelines. In most places, anyone serving food to the public is required to have some training or certification in food safety and food handling. Check with your local department of environmental health, where they will likely direct you to ServSafe, a nationally recognized food safety training program administered by the National Restaurant Association (www.servesafe.com). To cover the basics, it’s important that anyone serving or handling food is free from illness. Hair must be pulled back or confined in a hairnet, and hand washing with soap and water for 20 seconds before preparing and offering samples is imperative. Keeping a container of liquid hand sanitizer at your demo station is a good idea. All ingredients, utensils, and equipment should be thoroughly cleaned before and during the demonstration to avoid cross-contamination. Never leave your demonstration table unattended, and choose recipes that don’t require you to keep hot or cold foods at specific

december 2015 www.todaysdietitian.com 11

RETAIL DIETITIAN temperatures to avoid spoilage or other food safety concerns. No-cook, easy-prep, simple-ingredient recipes are the easiest to work with to avoid food safety issues.

Begin Advanced Planning During the planning stage, dietitians should prepare more information for the person performing the food demo than what they think they need, such as talking points, prices of ingredients, potential allergens, nutrition information, information on cooking techniques, and more, says Trish Farano, DTR, test kitchen manager/nutritionist for Dierbergs School of Cooking at Dierbergs Markets, Inc, based in Des Peres, Missouri. Farano says review the logistics of every food demo, addressing each step of the process. “Do they need a cutting board and a knife? Where in the store will they find disposable gloves? At the conclusion of the demo, where will they wash their hands, utensils, and other equipment?” Creating a checklist of ingredients, preparation steps, equipment needs, serving supplies, cleaning tools, and education materials required for a food demo can be useful to ensure nothing is forgotten. Dietitians should always display the recipe they’re making, provide recipe cards for customers, and a shopping list for those who stop by for a sample. “Be prepared, have enough product to make a few batches of samples, and have products and ingredients on display along with your recipe,” McMillin says.

G E T YO U R C O M P L I M E N TA R Y

CHRISTMAS GUIDE at www.healthyyouinoneminute.com

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12 today’s dietitian december 2015

Consider Logistics When Selecting Recipes Some of the challenges facing dietitians who host food demos include not having easy access to electrical outlets, available refrigerator and freezer storage, demonstration tables, hand-washing areas, and garbage containers. It’s best to choose easy-to-prepare, no-cook recipes requiring five or fewer ingredients. The more complicated a recipe, the more time RDs will need to prepare and the more likely they’ll make mistakes. “Consider your audience,” McMillin says. “Do they want to spend hours in the kitchen preparing recipes or are they looking for easy, affordable ideas that can be prepared once and enjoyed twice as leftovers?” In addition, RDs should make sure the store is well stocked with all of the ingredients and that shoppers can find them.

Estimate Number of Samples Needed Calculating the number of samples needed in advance can be determined based on the budget or the duration of the demonstration. Joy Blakeslee, RD, director of the culinary studio for Publicis’ MSL Group, a public relations agency based in Seattle, says that she calculates how many samples she will need based on how many samples she can comfortably hand out per minute, while also taking into account the amount of time it takes to share a few of her top talking points. “It’s safe to plan one to two samples per minute or 60 to 120 samples per hour.” Most food demonstrations are no longer than four hours, and it’s typical to offer a smaller portion than an actual serving. For example, for liquid samples, it’s practical to offer 1-oz servings. For other foods, it’s reasonable to estimate that your sample size should be one-quarter of the serving size called for in the recipe.

Deliver Nutrition Messages Hannaford Supermarkets, based in Scarborough, Maine, has stores throughout New England that feature weekly food demos in stores, at community events, and on local television. Marilyn Mills, MS, RD, LD, CDE, a dietitian for Hannaford located in Manchester, New Hampshire, says that familiarity with ingredients is critical. The dietitians at Hannaford use carefully selected products from sponsors in their recipes and use demonstrations to communicate science-based information about healthful eating. Mills says she does plenty of research in advance so she can select tips, historical facts, and fun nutrition trivia to entice customers with samples. “The more fun or enjoyment customers can have with food preparation, the more likely they will go home and prepare it themselves,” Mills says, adding that she’s had several customers come back to the store and recount their experiences making some of her recipes. Recently, Mills hosted a demo that featured lemon zest and was delighted to see customers purchasing the kitchen gadget to make the zest for the recipe.

Glutagest - 1:2 Vert OUTLINED.pdf

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Food demos offer dietitians unique opportunities for teachable moments that make nutrition come alive through the senses, Mills says. Reinforcing the benefits of eating more fruits and vegetables, and lowering sodium and added sugar in the diet are a few of the messages that can be effectively communicated during a food demo. Blakeslee says she likes to help shoppers develop more confidence in the kitchen during her food demos. Being located in the Pacific Northwest, she often touts the benefits of seafood and demonstrates how delicious and easy it is to cook frozen fish. It’s an affordable and quick meal solution for protein-hungry shoppers that usually pay double for prepared foods with far fewer nutritional benefits, she says.

Measure Results Farano says that on the days she hosts food demos, she can calculate how much product sales have increased. McMillin does the same. In fact, both Farano and McMillin provide sales projections to in-store dietitians for demos and regularly track the impact of the interactions between dietitians and shoppers. A 2013 study performed by the Cornell Food and Brand Lab, published in Advances in Consumer Research showed that shoppers given a healthy (apple) vs unhealthy (cookie) food sample during shopping could influence subsequent choices in their shopping baskets in a positive way. For example, those shoppers given an apple vs a cookie spent more money on fruits and vegetables compared with the cookie eaters. Food sampling can be as simple as offering a customer a slice of fruit, although a food demo usually involves more preparation. In either case, offering a taste or sample of food during a shopping trip is a strategy that many supermarkets can use to enhance the shopping experience as well as the bottom line.3

CMY

Proof Is in the Pudding In-store food demos offer dietitians an opportunity to work with a prop they know best—food. Food safety, logistics, and planning are some of the key pieces to hosting successful food demos in stores that lead to increased sales and healthier shopping behavior. — Barbara Ruhs, MS, RDN, LDN, is a former supermarket dietitian based in Phoenix. She’s a consultant to food companies, commodity groups, and supermarkets, and coordinates the annual Oldways Supermarket Dietitian Symposium.

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

december 2015 www.todaysdietitian.com 13

CONFERENCE CURRENTS

THE BEST OF FNCE® 2015 By Densie Webb, PhD, RD

Learning opportunities abounded at this year’s conference. Approximately 10,000 dietitians, dietetic technicians, students, and interns from the United States and abroad flocked to the Music City Center in Nashville, Tennessee, from October 3 to 6, for the Academy of Nutrition and Dietetics’ Annual Food & Nutrition Conference & Expo® (FNCE®). The conference featured the latest in nutrition research and clinical practice standards, new specialty food products, and cooking demonstrations of healthful, mouthwatering dishes, and provided the opportunity for attendees to exchange insights and information. While the consensus was that the meeting was a fabulous learning experience, “overwhelming” seemed to be a running theme, especially for first-timers. Today’s Dietitian spoke with attendees in sessions, on the exhibit floor, and at cooking demonstrations to get their impressions of the meeting and ask what their top nutrition takeaways were. Here’s what they said:

Overall Impressions Lee Wallace, EdD, RDN, LDN, FADA, FAND, didn’t have to travel far, as she lives in Memphis, Tennessee. She’s the chief of nutrition at the Boling Center for Developmental Disabilities at the University of Tennessee Health Sciences Center. As one of her duties, she teaches cooking techniques to families and group home residents, so she found the cooking demonstrations to be especially helpful. Gluten-free products were prevalent again this year, as they have been for

14 today’s dietitian december 2015

the last several years, and Wallace was grateful. “I was interested in the glutenfree snacks and crackers, as some children with autism whom I counsel are on gluten-free diets.” She says that finding gluten-free foods that kids will eat can be challenging. Wallace also was pleased to find several vendors offering some unusual low-protein foods, which she often needs for children she counsels with phenylketonuria. In addition, she noticed more Level 2 and Level 3 sessions this year, which translated into more detailed information, and she plans to share everything she learned with fellow dietitians at the monthly dietetics meeting she attends in Memphis. Kimberly McKnight, a dietetics intern at Marywood University in Scranton, Pennsylvania, was a first-timer at FNCE®, saying, “It’s overwhelming but exciting. I think every RD and intern should come here at least once in their careers, and I definitely hope to come again.” Andrea Kirkland, MS, RD, a nutrition writer, editor, and communications consultant from Birmingham, Alabama, said the meeting made her realize how important it is for dietitians to use social media as a marketing tool. She was pleased to see experienced RDs help the less experienced ones in this area. Kirkland also was surprised to see sessions on the Paleo diet that aimed to help dietitians dispel myths when counseling clients and patients. A session on integrative medicine she attended helped her redefine the concept of “detox diets” in a positive way that she can relay in her communication efforts.

“ Every session was informative and offered practical information that will be helpful for clients. I work with a geriatric population and the information I’ve gathered will be very helpful for the outpatient population.” — Jana Mowrer, MPH, RDN

It also was the first time that Jana Mowrer, MPH, RDN, of Genesis Healthcare in Clovis, California, attended the conference. While she had spoken with other dietitians who had been to meetings before about what to anticipate, the conference was still much more than she expected. “Every session was informative and offered practical information

that will be helpful for clients. I work with a geriatric population and the information I’ve gathered will be very helpful for the outpatient population.” She says her clients tend to have an array of chronic medical issues, especially endocrine disorders, and she learned some valuable diet strategies that may help them. Her favorite session was the opening session with Doug Rauch, the past president of Trader Joe’s. In his speech, Rauch argued that dietitians must change their views of malnutrition and what that looks like in our society. Mowrer says her takeaway from this session was that “we think of being skinny and wasted as being malnourished, but that’s not always the case.” Connie Gonzales, from the TriStar Hendersonville Medical Center in Hendersonville, Tennessee, says it also was her first time attending FNCE®. “It’s a huge venue. I’m here to learn more about food cultures, and I found a lot of practical applications of new information in the sessions I’ve attended.” She was especially interested in a session she attended on food insecurity. She learned that much food is wasted in the United States, yet many institutions won’t donate unused food because of liability issues related to outbreaks of foodborne illness or contaminated food that the donating organization has no control over. “It made me want to go out and connect with food banks,” she says. In the cooking demonstration she attended, Gonzales learned new information about the many health benefits of avocados and pistachios. She also says that a session on

sugar consumption in the United States opened her eyes. “I’m all for having a choice, but after seeing the numbers— the amount of sugar actually consumed every day—it’s hard to ignore.” But, she adds, employees often are resistant to eliminating or reducing the availability of sugary drinks in the workplace. It remains a challenge to implement. Julia Kaesberg, a graduate student from Miami University, was interested in learning more about internship opportunities, but was a bit overwhelmed by the Internship Fair held at the Renaissance Nashville Hotel. “There were over 100 internships with representatives to talk to. I had a list of five that I really wanted to meet with. It was a small room, so it felt a bit disorganized at first, but it was much better once I sat down to talk with the programs’ representatives and I was able to get an impression of the culture of each of the programs.” Victoria Thompson, an undergraduate student, also from Miami University, collected samples of more new products than she expected and was impressed with all the sessions she attended. “I’m used to listening to focused presentations in school, but in some of the sessions at FNCE® I walked away feeling like I learned more than I do in class.” So, another FNCE® has come and gone. Start planning for FNCE® 2016 in Boston—hope to see you there! — Densie Webb, PhD, RD, is a freelance writer, editor, and industry consultant based in Austin, Texas.

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december 2015 www.todaysdietitian.com 15

DIGESTIVE WELLNESS

will discuss the impact of lactose intolerance on health disparities in minority populations, define lactose intolerance and lactose maldigestion, and provide strategies to help clients and patients close the nutrient intake gap and improve health equity.

Minority Health and Nutrients of Concern

LACTOSE INTOLERANCE AND NUTRIENT DISPARITIES By Constance Brown-Riggs, MSEd, RD, CDE, CDN

Higher prevalence of chronic disease in minorities is linked with a lack of dairy food consumption. Closing the nutrition disparities gap is key to improving overall population health. The 2015 Dietary Guidelines Advisory Committee (DGAC) stressed the need to address health disparities as a critical part of achieving a vision of health for all Americans.1 The 2015 DGAC found that vitamins A, D, E, and C; folate; calcium; magnesium; fiber; and potassium are nutrients that continue to be underconsumed by many Americans. Of these underconsumed nutrients, calcium, vitamin D, potassium, and fiber are classified as nutrients of public health concern. This is because their underconsumption is associated with adverse health outcomes such as overweight, obesity, diabetes, and cardiovascular disease, which disproportionately plague minority populations.1 The 2010 Dietary Guidelines for Americans (DGA) recommend three servings per day of low-fat and fat-free milk and milk products, such as yogurt and cheese, to help close the gap on calcium, vitamin D, and potassium.2 This advice—although well intentioned—often is culturally challenging for many black and Hispanic Americans who believe they’re lactose intolerant. Lactose intolerance, real or perceived, resulting in selfrestriction of dairy foods has been identified by the National Institutes of Health as a public health problem.3 This article

16 today’s dietitian december 2015

The prevalence of obesity, diabetes, and heart disease is higher in minority populations than in white populations and has been linked to the underconsumption of dairy products. Specifically, from 2011 to 2012, the highest prevalence of obesity was among black American adults followed by Hispanic American adults.4 In 2011, the prevalence of diabetes among black American adults was nearly twice as high as that among white American adults,5 and the prevalence of heart disease was greatest in black Americans compared with Hispanic and white Americans. In addition, death rates from these diseases are higher among black Americans. For example, in 2013, death rates from heart disease were highest among black Americans compared with other racial populations,6 and black Americans are twice as likely to die from diabetes complications.6 Health disparities also exist in population access to affordable healthful foods, with low-income populations bearing a greater burden (see Table on page 17).

Lactose Intolerance vs Lactose Maldigestion Lactose is a naturally occurring sugar found in yogurt and other milk products. During digestion, an intestinal enzyme called lactase breaks down lactose into two smaller, more easily digested sugars: glucose and galactose. Lactose intolerance often is misunderstood. It’s a condition in which people have gastrointestinal disturbances—such as bloating, diarrhea, and gas—after eating or drinking milk or milk products. Barbara Baron, RDN, owner of Barbara Baron Associates in Old Bridge, New Jersey, and known as The Family Meals Dietitian says, “the gastrointestinal disturbances occur after eating an amount of lactose that’s greater than the body’s ability to digest and absorb. When not digested, the healthy bacteria ferment the lactose in the intestinal tract. This fermentation produces uncomfortable symptoms such as gas, stomach pain, or bloating.” Lactose maldigestion is the incomplete digestion of lactose due to a lactase deficiency. “However, not everyone with low lactase is lactose intolerant,” Baron says. “Some people with lower lactase levels may not experience the digestive discomfort when they consume milk or milk products. For example, an individual with lactose maldigestion may consume 12 g of

lactose—the amount of lactose in one cup of milk without symptoms, but be intolerant to 24 g, which is the amount in two cups of milk.”

Yogurt and Lactose Intolerance

Mean Intakes of Nutrients of Concern From Food and Beverages by Income as a Percentage of the Poverty Threshold, all ages 2+ Calcium (mg/d)

Vitamin D (IU/d)

Potassium (mg/d)

Under 131% poverty

977

208

2,451

131% to 185% poverty

973

192

2,499

According to the 2010 DGA, 1,061 220 2,735 Over 185% poverty evidence shows that the intake of — A DAPTED FROM THE SCIENTIFIC REPORT OF THE 2015 DIETARY GUIDELINES ADVISORY COMMITTEE, PART D. CHAPTER 1: FOOD AND milk and milk products is associated NUTRIENT INTAKES AND HEALTH: CURRENT STATUS AND TRENDS, P. 91 with a reduced risk of cardiovascular disease, type 2 diabetes, and high the WIC pilot study were instrumental in the approval of yogurt blood pressure in adults—disease states that affect black and as a low-lactose substitution for milk, and it was added to the Hispanic Americans at disproportionate rates.1 Unfortunately, many black and Hispanic Americans are revised WIC food packages, effective April 2015.9 missing out on the health benefits of dairy because they Closing the Nutrient Intake Gap believe they’re lactose intolerant. Angela Lemond, RDN, CSP, In their joint 2013 consensus statement on lactose intolLD, spokesperson for the Academy of Nutrition and Dietetics, erance, The National Medical Association and the National finds this to be the case with many of her patients. She says Hispanic Medical Association recommend three servings of perceived lactose intolerance can be generational. “If their low-fat dairy per day as a means of closing the nutrient intake grandparents and parents never ate dairy and the family has gap. Moreover, the consensus statement encourages health always kept dairy out of their diet, the patient assumes they care providers to help patients with real or perceived lactose can’t tolerate it.” In fact, current research shows that nearly intolerance employ strategies to achieve the recommended 20% of black Americans and 10% of Hispanic Americans dairy food intake levels. consider themselves lactose intolerant.7 Yogurt can help these individuals with lactose intolerance Baron offers the following strategies: • For patients who experience gastrointestinal discomfort meet their dairy requirements and obtain critical nutrients from milk, recommend they start with about 4 oz of milk of concern. Lemond, who’s lactose intolerant, says, “I notice and drink it with a meal. This helps to slow down and when I drink a glass of milk I have symptoms, but yogurt improve the digestion of lactose. doesn’t bother me.” Yogurt is a more easily digestible alter• Suggest clients make soups, pancakes, and oatmeal with native to milk, because of the presence of lactase-producing lactose-free milk or yogurt. On average, yogurt contains yogurt cultures, and on average yogurt contains less lactose less lactose than milk, making it a more easily digested per serving than milk.8 Research shows that yogurt not only is nutrient dense dairy option. • Recommend hard cheeses like Swiss and cheddar. They’re but also can address income-related disparities in diet low in lactose and excellent sources of calcium and protein. quality, as evidenced in the WIC pilot study published in the • Encourage patients to explore the dairy aisle in the May-June 2010 issue of the Journal of Nutrition Education supermarket. There are many choices of milk, cheese, and Behavior. The study was conducted in response to the and yogurt they can purchase that will help them meet Institute of Medicine (IOM) of the National Academies’ report their dairy requirements. “WIC Food Packages: Time for a Change,” identifying the Employing these strategies can help minorities receive need for WIC to address the nutritional needs of individuals all the heath benefits of dairy and support health equity in who avoid milk due to cultural food preferences or lactose these populations. maldigestion. In the report, the IOM recommended yogurt be added as a substitute for part of the WIC participants — Constance Brown-Riggs, MSEd, RD, CDE, CDN, is nutrition milk allowance. To address this recommendation, the USDA, advisor for the Dannon One Yogurt Every Day Initiative; a which manages WIC, first needed to determine the cost past national spokesperson for the Academy of Nutrition and implications of adding yogurt and whether WIC participants Dietetics, specializing in African American nutrition; and author would accept yogurt.9 of the African American Guide to Living Well With Diabetes and The study concluded that yogurt was a popular substitute Eating Soulfully and Healthfully With Diabetes. for milk that provided an option for the dietary needs of WIC participants who were either lactose intolerant or irregular milk drinkers. Adding yogurt also removed participants’ For references, view this article on perceived cost barrier and addressed income-related our website at www.TodaysDietitian.com. disparities that affect diet quality.10 These positive results from

december 2015 www.todaysdietitian.com 17

FOODSERVICE FORUM

CAMPUS DINING AT ITS FINEST By David Yeager

Today’s Dietitian profiles some of the top dining services that made the Best Campus Food List in The Princeton Review.

recently has been able to offer additional varieties of freshly cut fruit, such as pineapple, melon, and berries, by buying it from a processor in nearby Rhode Island. “We’re able to offer some new varieties of cut fruit in 8-oz portions at some of our retail locations that students are excited to buy because we’ve taken all of the cleaning out of it, and it’s comparable to something they might buy in a local Whole Foods or a store like that,” says Patricia Klos, the director of dining and business at Tufts. “Although the food wasn’t grown here, the students know that it was processed here, so it makes them feel better about the product.” Klos says students are much more knowledgeable about food and sustainability than they were a decade ago, and local sourcing is important to them. Two new programs that Tufts has started working with are Red Tomato and Red’s Best. Red Tomato works with local growers to get their produce to market, and Tufts has been able to source some produce through the program. Red’s Best is a local fishery that provides local fish.

University of San Diego

High school graduates evaluate many factors when choosing a college. Academic programs, graduation rates, job placement opportunities, and campus life often are near the top of the list. However, one aspect of campus life that students have paid more attention to in recent years is the quality of the food served. Rob Franek, the senior vice president and publisher of The Princeton Review and author of The Best 380 Colleges, says students have become more demanding consumers in the 16 years that he’s been working at The Princeton Review, and schools are taking notice. “A quality dining experience is one of the things that’s going to factor into students’ decisions when they’re choosing a school, and that’s one area where schools are competing for students,” Franek says. “Dining has tectonically changed on campus, for the better. Not only are there many options, but it’s [also] no longer three meals a day during the week, two meals Saturday, and two meals Sunday. Now, it’s eating to accommodate your schedule, eating at a variety of locations, and eating a wide variety of foods, with ingredients that are fresh, local, and sustainable.” Each year, The Princeton Review publishes a Best Campus Food list, highlighting 20 schools that provide excellent foodservice. Today’s Dietitian speaks to some of the schools that made the list to provide dietitians with a sample of their diverse offerings. Here are a few of this year’s winners:

Another school that gets high marks for sustainability is the University of San Diego. In addition to doing its own composting, the university has a biodigester that uses enzymes to turn noncompostable food matter into gray water that can be processed by the local water system. The school also provides community gardens for student use. Cuisines from around the world are a staple. Some recent options offered include Korean food and dishes from the Greek Islands. In the near future, Malaysian and Middle Eastern food will be featured. The school’s food truck, Torero Tu Go, is the first college self-operated food truck on the West Coast. It serves a seasonal menu that reflects San Diego’s diverse cultural influences, including Italian, Mediterranean, Mexican, Portuguese, and Asian. To keep abreast of new trends, the university maintains a partnership with the Culinary Institute of America in Napa to train its chefs. Dining department members also meet with students monthly to find out what they want. Carol Norman, the director of dining services at the University of San Diego, says many students currently are interested in vegan, glutenfree, and allergen-free entrées. “Our students know what they want, and they’re more experienced [than years past],” Norman says. “Many students have traveled abroad, and when they come back, they bring back new ideas.”

Tufts University, Medford, Massachusetts

Bryn Mawr College, Bryn Mawr, Pennsylvania

Tufts made the list for serving local, organic, and fair-trade products, as well as providing biodegradable trays, plates, and bowls. They also offer a Bring Your Own Mug program that reduces waste and helps students save money. The school

New ideas also can extend to food presentation. Every year the foodservice staff at Bryn Mawr College serves a theme meal in December. This year’s theme is Star Wars. Themes of previous years have included Black History Month, a French

18 today’s dietitian december 2015

Peasants’ Lunch, and a Hogwarts Dinner, which has been so popular that the school repeats it every five years. Students and staff are encouraged to audition to play the parts of people who figure prominently in the theme. The college’s menu committee consists of production managers, chefs, and cooks who develop weekly menus, discuss upcoming specials, and consider student requests. About onethird of Bryn Mawr’s approximately 1,300 students work in dining services. Freshmen who want a campus job are required to work for dining services, and many choose to remain. Bernie Chung-Templeton, the executive director of dining services at Bryn Mawr College and Haverford College, says the dining staff try to make it the best possible work experience by fostering a community spirit and sponsoring employee events such as Easter egg dyeing and karaoke singing. “We consider ourselves mentors,” Chung-Templeton says. “I don’t believe foodservices’ role is to make 18-year-olds eat healthful, but I do believe that it’s our responsibility to provide healthful foods and encourage healthy choosing. Because they’re 18 and they can make choices, I feel like I have a slight role to make sure that they have all of what they need and some of what they want.”

Washington University in St. Louis Encouraging students to choose healthful foods is an increasingly important aspect of campus dining. Washington University in St. Louis offers a Dine With the Dietitian program that has been extremely popular. The program has existed for 12 years, but five years ago the school opened a demonstration kitchen, called Studio 40, where the program is held. Connie Diekman, RD, the director of campus nutrition, develops the nutrition themes each month and Sara Cox, the research and development chef at the university, develops the menus and conducts the demonstrations. “After I get the themes for the classes, I try to do three courses for them, highlighting whatever the message is,” Cox says. “For example, the most recent class we did was centered around fat facts and fiction, so I kind of ran with the idea of taking foods that are normally very unhealthful, as far as the fats go, and turning them into healthier options. Other times I’ll be more literal and just pick the foods that are high in whichever nutrient we’re talking about.” Along with Dine With the Dietitian, the culinary team teach hands-on classes and demonstration classes. Hands-on classes for October included a Haunted Dinner and Cupcake Wars. Demonstration classes ranged from Dia de los Muertos to Hide & Seek: The Vegetable Edition to Smoke and Blues. Diekman says the demonstration kitchen is helping Washington University work toward goals it’s trying to meet as part of a three-year Partnership for a Healthier America commitment.

University of Massachusetts, Amherst Feeding and educating students is a core goal of many university and college dining programs. Realizing that everything they serve affects students in some way, the University of

Massachusetts, Amherst (UMass Amherst) has become the first university in the United States to qualify for SPE certification, which recognizes a foodservice establishment’s commitment to nutrition, sustainability, and its customers’ well-being. Christopher Howland, the director of purchasing and marketing of auxiliary enterprises at UMass Amherst, says the university decided to obtain the certification because it wanted to rethink its menu program, and many menu items already met SPE specifications. The school also presents theme meals such as Farm to Fork; All Tricks, No Treats; and Flavors of Canada, and every year they invite foodservice representatives from the Top 10 schools on The Princeton Review’s list to cook some of their specialties for UMass Amherst students. In addition, the dining service serves 15 different cuisines from around the world: sushi, stir-fry, noodle bowls, and pho currently are student favorites. In addition, the dining service is trying to reduce red meat consumption by promoting seafood and Mediterranean dishes that feature grains such as bulgur and farro. “We have a professor who will be giving a presentation about omega-3s as they relate to seafood we get from Alaska: What are omega-3s? How do they work? This is something that’s very interesting to students,” Howland says. “And we try to keep the menu as diverse as possible because the food IQ of students is far beyond [what it was 10 years ago].”

Bowdoin College, Brunswick, Maine Seafood also is popular at Bowdoin College in Brunswick, Maine. Fish chowder is a favorite dish, and the school partners with the Gulf of Maine Research Institute to feature local seafood, such as mussels and clams, and underutilized fish, such as pollock and red fish. In addition, the school has had an organic garden since 2005 that supplies some of its produce, and dining staff and student volunteers make the dining halls’ maple syrup each year. The college also has a meat room, so all of the meat preparation is separated from the rest of the kitchen, and the hamburgers are made from local beef. Two dining halls serve Bowdoin’s approximately 1,800 students, and the menus are never the same. Mary Lou Kennedy, the director of dining and bookstore services, says the salad bar and ethnic foods are popular. Students and faculty often make suggestions that the menu planning teams try to incorporate, which can be anything from meals that relate to certain class curricula to “Just Like Home Night.” And, similar to other schools, Bowdoin’s students are more interested than ever in what’s for dinner. “They work incredibly hard on their academics and they have so much going on, but they stop for dinner. They truly stop and take some time to eat, talk, and relax,” Kennedy says. “And they take time to really think about what they’re eating. They’re more aware now [than they have been in the past], and they’re choosing more local, sustainable, and plant-based foods.” — David Yeager is a freelance writer and editor based in southeastern Pennsylvania.

december 2015 www.todaysdietitian.com 19

Expert dietitians share their top 10 strategies for shedding unwanted pounds during this festive season.

Maintaining Weight Loss Over the

Holidays By BETH W. ORENSTEIN

any clients and patients have made great progress losing weight throughout the past year. Some have met their weightloss goals while others are close to meeting their target. You want them to keep up the momentum and not risk packing on the pounds during the remainder of the holiday season. Thanksgiving may be behind us, but the festivities leading up to the New Year celebrations are in full swing and may make it hard for clients, who have demonstrated amazing resolve, to maintain healthful eating habits and continue to lose weight. Today’s Dietitian asks three RDs who specialize in weight management to share their top 10 tips for maintaining weight loss during the holidays. All three experts agree that the key to weight loss maintenance this time of year is to plan a strategy from the first party invitation right up to New Year’s Day when clients are inclined to make resolutions about their dietary habits. Following are their top 10 strategies RDs can share with clients.

Bring a Diet-Friendly Dish

Suggest clients bring a tasty, low-calorie, nutrient-dense dish that’s favorable to their weight-loss plan, says Sara Haas, RDN, LDN, a Chicago-based spokesperson for the Academy of Nutrition and Dietetics, and a graduate of The Cooking and Hospitality Institute of Chicago’s Le Cordon Bleu Program. If clients bring a dish that fits into their healthful eating plan, she says they’ll have something they can fall back on. And the host likely will appreciate

the offer. “No one wants to make everything for a party themselves,” Haas says. Clients can bring a vegetable-rich salad with a touch of healthful fat, a whole-grain side dish, grilled vegetables, a fruit platter, or a smoked salmon platter. In addition, clients can make some weight-loss friendly swaps in the dishes they bring. “You can usually reduce the sugar in a recipe by at least one-third and up to one-half without anyone noticing,” says Caroline Kaufman, MS, RDN, a Los Angeles-based nutrition expert and blogger at CarolineKaufman. com. Clients can use applesauce or prune purée for half the fat in a recipe. They can use cooking sprays to coat pans instead of rubbing butter on them. And they can thicken soups with puréed vegetables such as potatoes and carrots or cooked risotto rice instead of adding cream, Kaufman adds.

Eat Light Before the Party

If clients starve themselves all day to save their appetites and all their calories for the dinner party, more than likely they’ll overeat—and probably the first thing they see, which may be pigs in a blanket or some tempting fried concoction, Kaufman says. As an alternative, it’s better to eat lightly before the party. For example, clients can eat a piece of highfiber fruit or Greek yogurt to quell their hunger pangs, says Bonnie Taub-Dix, MA, RDN, CDN, owner of BetterThanDieting.com and author of Read It Before You Eat It. Greek yogurt is high in protein, which helps promote fullness. “And it’s not going to make a dent in your calorie budget, so it’s not a big deal if you have a cup ahead of time and still eat at the party.”

december 2015 www.todaysdietitian.com 21

Survey the Field

Recommend clients look at all the options on the buffet table before filling their plates, Kaufman says. That way, they quickly can identify and choose the healthier options and enjoy a more healthful, lower-in-calorie meal than if they were to randomly choose the first foods they see, she says. Their goal should be to fill one-half of their plates with fruits and vegetables, one-quarter with a lean protein, and one-quarter with whole grains, with a touch of healthful fat. Remind clients to always use a plate because it will help them measure their portions and fill their plates before they begin eating so they’re aware of how much they’re about to consume, TaubDix says. Clients will tend to eat more—and, as a result, weigh more—if they don’t watch their portions, she says. If clients are meeting with friends at a restaurant, suggest they read the menu online ahead of time to determine what they will order. Recommend they not be shy about asking for substitutions (eg, steamed vegetables or tossed salad rather than fries or chips) or ordering appetizers rather than entrées for their meal. In addition, suggest clients choose grilled or broiled leaner cuts of meat, fish, or poultry, and avoid heavy cream sauces, Haas says.

Start Small

Dietitians also can encourage clients to eat smaller portions by suggesting they use six-inch appetizer or dessert plates rather than 12-inch dinner plates for their meals. Clients are more inclined to feel as though they’re eating more than they are when using smaller plates, Taub-Dix says. According to a September 2015 online study published in The Cochrane Database of Systemic Reviews, adults consistently selected and ate more when they used larger tableware.1

Skinny Up on the Drinks

Plate size matters and so does the type of beverage clients choose to drink. Clients can avoid drinking the many excess calories often hidden in sugary and alcoholic beverages

by developing a plan of action. Before clients walk in the door to a party, they should set a limit on how much they will drink, Haas says. They should tell themselves, “I’m only going to have one drink,” and then hold fast to that rule. Otherwise, they could find themselves drinking enough calories to do some damage to their hard-won weight loss. The lowest-calorie choice is a 4-oz glass of champagne, which contains about 80 kcal. A 5-oz glass of red or white wine has about 120 to 125 kcal. One trick to reduce calories is to add sparkling water to turn the drink into a spritzer. Another strategy is to make every other drink a glass of water or sparkling water. Drinking water will help clients stay hydrated as well as slow down their consumption of calorie-laden beverages. Clients can save hundreds of calories by not choosing alcoholic drinks made with syrup, sour mix, sugary fruit juices, or creamy additives. These drinks are like desserts and can contain more than 500 kcal each. If clients want a mixed drink, suggest they choose those made with club soda or tonic water. “And if you really don’t want to drink, make yourself the designated driver,” Taub-Dix says. That way, the client won’t feel self-conscious about being the only one without a glass in his or her hand.

Position Oneself for Success

Another way to prevent overeating at a holiday party is to sit away from the buffet table. Clients are more likely to pick and eat more than they realize when they’re standing next to a table full of food, Taub-Dix says. Clients also should avoid standing by the kitchen door where the servers are exiting and where they’re more likely to fill their plates and refill their glasses. If clients want more food, they should make sure it’s a conscious effort to get up and get it. Moreover, recommend clients spend more time on the dance floor than at the buffet table. “When you get up to dance, you’re not only not eating but you’re also burning off holiday calories,” Taub-Dix says.

Butternut Squash With Brown Sugar Roasted Pecans This recipe embraces the flavors of the holiday season. Serves 4 (1⁄2 cup portions)

Ingredients 1 T packed brown sugar 1 T water 1 ⁄4 tsp ground cinnamon 1 ⁄4 tsp sea or kosher salt 1 ⁄2 cup pecan halves 1 butternut squash (about 11⁄2 lbs), peeled, seeded, and cut into 1-in cubes 1 T olive oil Salt, to taste

22 today’s dietitian december 2015

Don’t Say ‘No’ to Everything

While it’s important for clients to watch the amount of food they eat, no food should be totally off limits. “Deny yourself your favorite holiday treat, and you’re either going to make yourself sad, or eat lots of other food you don’t really care about in an attempt to satisfy that craving,” Kaufman says. It’s all about portion control. “If your sister makes the world’s best pumpkin pie, cut yourself a thin slice and enjoy the heck out of it. As soon as [the pie] stops tasting as good as that first magical bite, put your fork down. If there’s still some left on your plate, get away if you can—stand up and go talk to some friends and family. Take a quick bathroom break, or have the waiter take your plate away.” The less you have to rely on willpower, the better, Kaufman adds. Often, a tiny bite of something can satisfy you, Haas says. If you can’t have just a taste of that cream or pecan pie, opt for meringues, a handful of sugared nuts, or fruit from the fondue bar with a little bit of healthful dark chocolate, Haas adds.

Choose Wisely

While having a small portion of high-calorie holiday treats is OK, it’s best that clients fill up on the lowercalorie, nutrient-dense offerings available, Haas says. She recommends cocktail shrimp instead of cheese balls; sliced carrots and cucumbers rather than chips; and hummus or salsa rather than dips made with mayonnaise or sour cream. A cucumber slice with a little hummus on top is just as tasty and has fewer calories than a potato chip coated in full-fat dip, she says. “Think outside the box.” When it comes to salads, educate clients that the term “salad” doesn’t always mean “healthful” since some ingredients can significantly increase the calorie and fat content of the meal. Inform clients that a tossed salad with a spritz of vinaigrette dressing is a good choice, but a salad loaded with dried fruit, bacon, croutons, nuts, and full-fat cheese smothered in a creamy dressing can be a diet disaster, Haas says.

Black pepper, to taste 1 tsp fresh thyme leaves, chopped 2 T crumbled feta cheese

Instructions 1. Preheat oven to 400˚ F and line one large rimmed baking

sheet and one small rimmed baking sheet with foil or parchment paper. If using foil to line the baking sheets, spray the foil generously with nonstick cooking spray. 2. To a medium-size saucepan, add the brown sugar and water and bring to just a boil over medium heat. Stir with a spoon to dissolve the sugar. Add the ground cinnamon and salt and then the pecan halves. Cook, stirring constantly with a spoon, about 1 minute or until the mixture has thickened and the pecans appear coated. Spread the pecans evenly onto the small rimmed baking sheet, and place them in the oven for 5 minutes. Remove the pan from the oven and place it on a wire

At the main meal, recommend clients choose leaner cuts of meat such as white meat turkey or chicken rather than fatty cuts of beef or pork. Moreover, encourage them to avoid eating the skin on turkey or chicken so they can save an extra 150 kcal or more, Haas says.

Avoid Temptation

And when they go grocery shopping, suggest clients don’t buy calorie-dense foods and snacks over the holidays that they know they can’t resist. “If you know you’ll binge on gingerbread cookies, don’t buy them,” Kaufman says. If clients want one as a treat, urge them to find a bakery that sells them and buy just one. Or, recommend they bake a batch and give them to family and friends, and save only one or two for themselves. Remember, Kaufman says, willpower is a depleting resource. “The less you use, the more you have for later,” she says.

Encourage Those Who Overindulge

If clients indulge at one or two events, it’s not a crisis. “One unhealthful meal isn’t going to make you gain weight,” Kaufman says, “just like one salad isn’t going to make you lose it.” Tell clients to enjoy themselves on those special occasions and start their normal, healthful routine the next morning, she says. It’s important for clients to know that while food often is the focus of the holiday season, they can surround themselves with healthful options and balance their time socializing with family members and friends. — Beth W. Orenstein is a freelance food writer based in Northampton, Pennsylvania.

Reference 1. Hollands GJ, Shemilt I, Marteau TM, et al. Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco. Cochrane Database Syst Rev. 2015;(9):CD011045.

rack to allow the pecans to cool. 3. Place the cubed butternut squash in a large mixing bowl.

Add the oil as well as the salt and pepper, to taste, and toss to coat. Spread the butternut squash out in an even layer onto the large rimmed baking sheet. Roast, stirring occasionally, until the butternut squash is tender and lightly brown, about 30 to 35 minutes. 4. Carefully transfer the roasted butternut squash back to the large mixing bowl. Roughly chop the pecans and add them to the squash along with the chopped fresh thyme and the feta cheese. Toss to combine.

Nutrient Analysis per 1⁄2-cup serving Calories: 205; Protein: 3 g; Carbohydrates: 22 g; Fiber: 4 g; Sugar: 7 g; Fat: 13 g; Sat fat: 2 g; Cholesterol: 4 mg; Sodium: 281 mg — RECIPE AND PHOTO COURTESY OF SARA HAAS, RDN, LDN.

december 2015 www.todaysdietitian.com 23

Whole-Wheat Blueberry Zucchini Muffins

Directions 1. Heat oven to 350˚ F. Grease a 12-cup muffin tin or use

These whole-wheat blueberry zucchini muffins, studded with walnuts and naturally sweetened with maple syrup and orange zest, can be a great low-calorie holiday dessert. Makes 12 muffins

Ingredients 11⁄4 cups + 1 T white whole wheat flour 1 ⁄4 tsp baking soda 1 tsp cinnamon 1 ⁄2 cup walnuts, chopped 1 ⁄4 tsp salt 1 ⁄2 cup pure maple syrup 1 cup grated zucchini (about 1 medium zucchini) 1 ⁄2 cup low-fat milk (any type of milk will work, eg, almond, coconut) 1 tsp vanilla extract 1 egg 2 T olive oil 1 T orange zest (about 1 medium orange) 3 ⁄4 cup fresh or frozen blueberries (if frozen, do not defrost)

muffin liners coated with nonstick spray. 2. Mix together the dry ingredients in a large bowl: 11⁄4 cups

flour, baking soda, cinnamon, walnuts, and salt; set aside. 3. Combine the wet ingredients in another bowl: maple syrup, zucchini, low-fat milk, vanilla extract, egg, olive oil, and orange zest. 4. Make a well in the center of the dry ingredients and pour the wet ingredients inside. Stir the wet ingredients into the dry ingredients until just blended. It’s OK if there are lumps. 5. Gently toss blueberries in 1 T of flour to coat. Stir the blueberries into the batter. Spoon the batter into the muffin tins, filling them about 3⁄4 of the way full. 6. Bake for 19 to 22 minutes until a toothpick inserted into the center of a muffin comes out clean. Cool tin on a wire rack for 10 minutes and then transfer individual muffins to a wire rack to cool completely.

Nutrient Analysis per serving (1 muffin) Calories: 160; Protein: 4 g; Carbohydrates: 24 g; Fiber: 3 g; Fat: 7 g; Sat fat: 1 g; Trans fat: 0 g; Cholesterol: 30 mg; Sodium: 95 mg — RECIPE AND PHOTO COURTESY OF CAROLINE KAUFMAN, MS, RDN.

24 today’s dietitian december 2015

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Popular Nutrition Trends for

By Densie

Webb, PhD, RD

ach year, nutrition trends that were once all the rage fade away and new trends emerge, sometimes making headlines. While a few trends, like gluten-free products, seem to be long-lived, others, like vitamin waters or fat-free cookies, see their heyday and then are relegated to the back row of the nutrition show. So, it’s that time again—time to look into the nutrition crystal ball for 2016 and see what’s new, what’s hot, and what you can expect clients and patients to quiz you about in the coming months. To find out what to expect, Today’s Dietitian speaks with several nutrition experts to determine what products and categories will be the most popular this year and on the minds of clients and patients in 2016. Here’s what they forecast:

desserts. She says, “While exclusive juice diets are billed as ‘cleanses’ or ‘detoxes,’ the one ingredient with the most ‘detoxing’ power—fiber—is trashed after the juice is squeezed out.” Not so with soups, which often contain whole vegetables and, in the case of breakfast soups, fruit. The soups keep the fiber, seeds, rind, and pulp that juicing often discards. “It’s trending in Los Angeles, with soups sold in to-go jars, similar to pressed juices.” There are breakfast soups, known as smoothie bowls, and even dessert soups. McKenzie Hall, RDN, cofounder of NourishRDs, a nutrition communications and consulting company, says that because you have to sit down and eat with a spoon, breakfast smoothie bowls encourage people to enjoy their breakfast more mindfully.

Souping

While sprouted grains have been around for a while, our forecasters predict that they’ll become more mainstream. “Sprouting provides increased vitamins and minerals, antioxidants, increased digestibility, and nutrient absorption,” says Melissa Joy Dobbins, MS, RDN, CDE, a nutrition blogger and consultant for Way Better Snacks, a company that produces sprouted grain chips and crackers. Sprouting, she says, creates enzymes that make plant proteins, essential

“Souping is the new juicing,” says Rachel Beller, MS, RDN, CEO of Beller Nutritional Institute and author of Eat to Lose, Eat to Win: Your Grab-N-Go Action Plan for a Slimmer, Healthier You. “It’s definitely on the horizon for 2016.” She’s not referring to bone broth diets that encourage you to sip on soup before a meal to tame your appetite but rather to exclusive souping meal plans that even include

26 today’s dietitian december 2015

Sprouted Grains

RDs weigh in on what products will be trending in the new year ahead.

Beet Hummus with Goat Cheese

fatty acids, starches, and vitamins more available for absorption. According to Oldways Whole Grain Council, a nonprofit nutrition education organization based in Boston, some research suggests that sprouted buckwheat can decrease blood pressure and help protect against fatty liver; and sprouted brown rice can help reduce blood glucose levels and improve immune function in breast-feeding mothers. In addition to chips and crackers, you also can expect a wider variety of sprouted food products. At the Academy of Nutrition and Dietetics’ 2015 Food & Nutrition Conference & Expo® (FNCE®) in Nashville, Tennessee, several companies displayed their sprouted grain products, including grain cereals, snack bars, and rice and risotto mixes.

More Products With Less Sugar According to Matthew Kadey, MSc, RD, cookbook author and food writer, companies will be under increasing pressure to reduce the added sugar content of their products and, as a result, will be turning to more of the so-called ‘natural sweeteners,’ like stevia, maple syrup, agave syrup, monk fruit, date sugar, and coconut palm sugar. Some provide as many calories as table sugar, others contain fewer calories, and some, like stevia, are calorie-free. While certain natural sweeteners, like date sugar, provide nutrients absent from table sugar, there’s little or no research to suggest that alternative natural sweeteners provide any health benefits. Americans consume upwards of 22 teaspoons of added sugar per day and there’s no debate that this amount should be reduced significantly; the response to this statistic has been a virtual “war on sugar.” Google “war on sugar” and you’ll find that chef Jamie Oliver has declared a personal war on the sweet stuff. Look again, and you’ll find articles in The New Yorker, Bloomberg View, Huffington Post, and The Washington Post all declaring a war on sugar. As Kadey remarked, there will be greater demand and increased offerings of products containing reduced amounts of sugar, replaced with one or more of these natural sweeteners, many of which are metabolized by the body no differently than sucrose. Be prepared to answer consumer questions about all of them.

Probiotic Push Probiotics have been around for a while. Those “good bacteria,” like L Acidophilus, L plantarum, L rhamnosus, and L reuteri, have been found in yogurts and yogurtlike products for a long time. However, Sarah-Jane Bedwell, RD, LDN, a Nashville-based dietitian, says, “Looking forward to 2016, it won’t be uncommon to find probiotic-fortified foods and beverages, such as orange juice, cereals, and waters.” At the Natural Products Expo East in 2015, there also were vegan buttery spreads made from virgin coconut oil with probiotics added; microwaveable, high-protein muffins with probiotics; and organic fruit and vegetable juices, sweetened with maple syrup and with probiotics added. And it’s not just about improving intestinal health. There’s an important gut/brain connection you may be hearing more about. Research suggests that probiotics may be helpful in treating symptoms of depression. Whether or not there are enough live, active good bacteria in these new products to improve health is another question.

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Full-Fat Dairy According to Hall, “Now that people are starting to embrace more fat in their diets, I think we’ll continue to see more fullfat and reduced-fat (as opposed to fat-free) dairy products being used.” Gregory Miller, PhD, MACN, president of the Dairy Research Institute, confirmed Hall’s observation. “Consumption of wholemilk dairy products is on the rise as part of a whole, natural, and real trend. And there’s a growing understanding that milk fat isn’t bad for you and may actually be good for you.” A survey conducted by IRi, a company specializing in predictive analytics in consumer markets, found that whole milk sales have gradually increased from 27.9% of the retail market in 2010 to 32.1% in 2015. Milk fat contains bioactive compounds, such as conjugated linoleic acid, a fat that research suggests may decrease the risk of coronary heart disease and depress cancer cell growth. The trend may be catching up with the research. In 2013, three comprehensive, independent reviews, published in the American Journal of Clinical Nutrition, the Journal of the American Heart Association, and the European Journal of Nutrition, concluded that there’s no association between dairy fat or high-fat dairy foods and obesity, type 2 diabetes, or cardiometabolic risk, and they may be inversely associated with obesity risk. Not everyone agrees with these findings; the DASH diet and MyPlate still recommend consuming low-fat or nonfat dairy products. While the Scientific Report of the 2015 US Dietary Guidelines Advisory Committee (DGAC) pointed out that “consumption of dairy foods provides numerous health benefits, including lower risk of diabetes, metabolic syndrome, CVD [cardiovascular disease], and obesity,” the evidence on dairy fat wasn’t specifically addressed.

The Pluses of Pulses Pulses are lentils, dry beans, beans, and chickpeas to clients and patients. The United Nations is so certain that pulses will peak in popularity that it has dubbed 2016 the International Year of Pulses (IYP). The aim of IYP 2016 is to heighten public awareness of the nutritional benefits of pulses as part of sustainable food production, aimed towards food security and nutrition. According to the United Nations’ Food and Agriculture Organization, pulses are a vital source of plant-based proteins and amino acids for people around the globe and should be eaten as part of a healthful diet to address obesity, as well as to prevent and help manage chronic diseases such as diabetes, coronary conditions, and cancer; they’re also an important source of plant-based protein

for animals. In addition, pulses come from plants that have nitrogen-fixing properties, which can contribute to increasing soil fertility and have a positive impact on the environment. Cynthia Sass, MPH, MA, RD, CSSD, a nutrition blogger and author of Slim Down Now: Shed Pounds and Inches With Real Food, Real Fast, says she has devoted an entire chapter in her book to the health and weight-loss benefits of pulses, along with an eating plan that includes one serving of pulses per day. At FNCE® 2015, pulses were on display as snack bars and snacking crisps, in prepackaged salads with edamame and roasted soy nuts, and in soups.

Better With Beets Beets have long been at the bottom of the vegetable hierarchy, as any fan of the show The Office can attest. When the character Dwight Schrute talks about his beet farm, his boss Michael Scott tells him, “Dwight, beets are the worst; nobody likes beets!” Well, food companies are now betting that the tide has turned and beets increasingly will be found on American tables. Beet juice—alone and combined with passion fruit juice—was on display at FNCE® 2015, along with beet hummus and beet-infused sports drinks. Consuming more beets would be a good thing, because they’re rich in betalains, antioxidant compounds; folate; fiber; and the minerals manganese, potassium, copper, and magnesium. A 2015 review of beets and their health benefits in the journal Nutrients found that consumption of beets and beet concentrate holds promise as a treatment for oxidative stress and inflammation. Its constituents possess potent antioxidant, anti-inflammatory, and chemopreventive activity. So be ready with answers to questions about beets.

Relaxing Cholesterol Restrictions Since the 1970s, the generally accepted recommendation regarding dietary cholesterol has been to limit intake to no more than 300 mg/day. But the 2015 DGAC, which reviews the latest research and makes recommendations for the US Dietary Guidelines for Americans, has for the first time taken a step back from the 300 mg/day rule. This is what the DGAC report said: “Previously, the Dietary Guidelines for Americans recommended that cholesterol intake be limited to no more than 300 mg/day. The 2015 Dietary Guidelines Advisory Committee will not bring forward this recommendation because available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol … Cholesterol is not a nutrient of concern for overconsumption.” Because the average US daily intake of dietary cholesterol already is less than 300 mg, it’s no longer considered a nutrient of concern. Whether or not dietary cholesterol in excess of that amount affects risk of coronary artery disease or risk of diabetes is still unclear. And because the guidelines likely will be issued at either the end of 2015 or the beginning of 2016, expect to get many questions in 2016 about whether dietary cholesterol still matters and how much is too much.

Sustainable Diets Another first for the 2015 DGAC report was the mention of sustainable diets as part of the recommendations for

achieving a healthful diet. The report defines sustainable diets as “a pattern of eating that promotes health and well-being and provides food security for the present population while sustaining human and natural resources for future generations.” The report goes on to state, “The environmental impact of food production is considerable and if natural resources such as land, water, and energy are not conserved and managed optimally, they will be strained and potentially lost. The global production of food is responsible for 80% of deforestation, more than 70% of fresh water use, and up to 30% of human-generated greenhouse gas … emissions. It also is the largest cause of species biodiversity loss.” Nevertheless, the USDA has recently stated publicly that the US Dietary Guidelines are not the appropriate vehicle for promoting sustainability, so dietitians won’t see it mentioned or explained in the 2015 guidelines when they’re released. Still, there will likely be more emphasis on food products in the market and on dietary patterns that are more sustainable for the planet. Be armed with information about what a sustainable diet is and advice on how to eat sustainably.

Managing Food Waste Related to the sustainability movement is the growing emphasis on reducing food waste in restaurants, hospitals, and grocery stores as well as in the home, where 60% of food waste occurs. Here’s another sobering statistic from Andrew Shakman, food waste prevention advocate and cofounder of LeanPath, a nonprofit organization developed to prevent and minimize foods waste through computerized food waste monitoring systems: one-half of all the food in the United States is wasted farm to fork, yet there are 870 million hungry people on the planet. To learn more about the specifics of reducing food waste, visit the Environmental Protection Agency website at www2.epa.gov/sustainable-managementfood/food-recovery-hierarchy and read the book American Wasteland: How America Throws Away Nearly Half of Its Food (and What We Can Do About It) by Jonathan Bloom. The FDA and the USDA have established a joint goal to reduce food waste by 50% by the year 2030. In the next few years, expect to address more questions about how to cut food waste in the home.

Renewed Push for Protein Researcher Douglas Paddon-Jones, PhD, FACSM, from the University of Texas Medical Branch in Galveston, says we can expect more research on the benefits of increased intakes of high-quality protein in middle-aged men and women. Much of the protein research to date, he says, has been in young and older populations. But the National Institutes of Health is calling for more research proposals that focus on protein intakes and its health effects in the middleaged population. Keeping up with the latest protein research will better prepare dietitians to make protein recommendations for everyone they counsel. — Densie Webb, PhD, RD, is a freelance writer, editor, and industry consultant based in Austin, Texas.

december 2015 www.todaysdietitian.com 29

Short bowel syndrome is a complex condition affecting the GI tract. Learn more about its pathophysiology and treatment and management strategies to improve patient care.

SHORT BOWEL

SYNDROME in

Adult PN Patients By Mandy L. Corrigan, MPH, RD, CNSC, FAND

aring for adult parenteral nutrition (PN) patients who have various disease states often is challenging for the clinical dietitian. One disease that’s particularly complex when it comes to treatment and management is short bowel syndrome (SBS). SBS is characterized by malabsorption of nutrients, fluids, and electrolytes following intestinal resections or damage to the functional capacity of the intestine. Because the anatomy of SBS patients varies widely, the heterogeneity of this population doesn’t lend itself well to the completion of large prospective randomized trials. Most of the scientific knowledge of nutritional management of SBS comes from best practices based on trials completed with small groups of patients. Nutritional, medical, and surgical interventions to treat SBS depend on patients’ individual needs and therefore bring unique challenges for clinicians.1 Fluids, electrolytes, micronutrients, oral diet modifications, medications to manage bowel motility, and PN management are areas dietitians can address in accordance with a nutrition care plan for SBS patients. It’s imperative to assess nutrients provided by the enteral (oral or enteral tube feeding) and parenteral routes. “Eating food has important benefits for quality of life, even for HPN [home parenteral nutrition]-dependent patients with short bowel syndrome,” says Marion Winkler, PhD, RD, CNSC, surgical nutrition specialist at Rhode Island Hospital. “Dietitians can help patients address four important

roles of food, although not every patient will eat for the same reasons. These include socialization (eating for taste, pleasure, comfort, and belonging), health benefits and immune enhancement, gastrointestinal (GI)-symptom management (although diarrhea often has no rhyme or reason), and energy and nutrient contribution (especially if receiving supplemental PN). I always recommend that my patients eat small meals frequently throughout the day and chew, chew, chew and sip, sip, sip.” This article will provide a brief overview of the pathophysiology of SBS and practical nutrition treatment strategies for clinicians managing adult patients.

Population Impact While the Crohn’s and Colitis Foundation of America estimates that 10,000 to 20,000 adult patients in the United States have SBS, more accurate incidence and prevalence data remain relatively unknown. There is no US patient database for SBS, and it would be difficult to determine these figures based on PN registries from international countries since the incidence and prevalence vary widely by country and region.

Defining SBS SBS is characterized by malabsorption due to either surgical resection or functional loss of the small intestine in which the length remains but the bowel functions abnormally. These factors prevent normal absorption of fluid, micronutrients,

december 2015 www.todaysdietitian.com 31

macronutrients, and electrolytes.1,2 The length of small bowel that remains often defines the severity of SBS, but this is only a small piece of the puzzle because the quality of the remaining anatomy plays an important role. Most SBS patients will require the use of PN in the immediate postoperative phase after a large intestinal resection; however, not all patients will require lifelong PN support. The potential for regaining nutritional autonomy via the enteral route depends on the amount, location, and quality of the remaining small bowel, as well as the presence or absence of the ileocecal valve and the colon. It’s imperative to understand what has been surgically resected and the current anatomy that remains to direct the nutrition care plan. In general, patients with at least 100 to 150 cm of functional small bowel without a colon or 60 to 90 cm with a fully functional colon in continuity can be successfully weaned from PN.2,3 In the two years following resection, the bowel is in an adaptation phase.

Intestinal Resection and Nutritional Consequences Common features of SBS are rapid transit of intestinal contents through the intestinal tract and malabsorption of microand macronutrients due to the loss of surface area. The type of resection provides clues to the nutrition challenges patients will encounter. Jejunal ileal resections (in which a portion of the jejunum and some ileum are resected and the remaining portions are in continuity with the colon) generally are well tolerated. This type of resection preserves the ileocecal valve (responsible for preventing the reflux of bacteria between the ileum and colon and regulating motility); vitamin B12 production is maintained, and the ileum can adapt to assume some of the functions of the jejunum that was resected. In general, patients with a jejunal ileal resection do better from an absorption standpoint compared with other types of intestinal resections.3,4 With jejunal resections, gastric acid hypersecretion may be problematic (which will be discussed more in the following section). Retaining the colon also lends itself to enhanced fluid and calorie absorption. Large ileal resections leading to jejunum anastomosed to the colon is more problematic compared with jejunal ileal resections. These patients often will require supplemental vitamin B12, have bile salt malabsorption, fat soluble vitamin malabsorption, potential for small bowel bacterial overgrowth due to loss of the ileocecal valve, and higher fluid losses due to rapid intestinal transit. Patients with a jejunostomy (no colon in continuity) are most challenging to manage since the jejunum can’t adapt to take on the functions of the lost portion of the ileum. SBS patients with a jejunostomy have high-volume fluid and electrolyte losses, micronutrient deficiencies (especially zinc and copper), and rapid intestinal transit leading to malabsorption. Often, these patients will require high-volume PN solutions and are most likely to require parenteral support long-term.

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Treatment and Management Challenges Not only are patients with SBS plagued by rapid transit of intestinal contents through the GI tract, they often experience gastric acid hypersecretion, fluid and electrolyte abnormalities, weight loss due to malabsorption of macronutrients, and bacterial overgrowth, and they require diet modifications.5 An interdisciplinary team approach to managing these patients can address all facets of the nutrition, medical, and surgical care plan to maximize intestinal adaptation, prevent complications, and preserve quality of life. “Parenteral nutrition management of patients with short bowel syndrome can be done safely and effectively by routinely monitoring clinical and laboratory parameters in close cooperation with the patient, PN solution supplier, and the patient’s medical team,” says Ezra Steiger, MD, FACS, FASPEN, a professor of surgery at the Cleveland Clinic in Ohio.

Gastric Acid Hypersecretion Following a large intestinal resection, especially a large jejunal surface area loss, the mechanism that controls gastric acid production is compromised. This can continue for roughly six months postoperatively and lead to several problems. First, the volume of gastric secretions increases, pushing a higher volume of secretions into the GI tract. Second, the high acid content alters the pH of the intestinal tract and can denature the pancreatic sections that are composed of pancreatic enzymes and bicarbonate, which enter the duodenum. As a result, it’s prudent for dietitians to ensure patients are receiving either a histamine2-receptor antagonist or proton pump inhibitor, both of which decrease gastric acid production.5

Fluid Challenges Patients with an enterostomy, jejunostomy, or ileostomy have higher fluid requirements compared with patients who have a colon in continuity. Having at least one-half of the colon is equivalent to having an additional functionality of 50 cm of small bowel. The improved fluid and sodium absorption due to having a colon in continuity enables the colon to ferment undigested carbohydrates into short chain fatty acids for additional energy absorption,3,5 which can be a valuable source of calories for patients with malabsorption. Moreover, patients with SBS may develop physical signs and symptoms of dehydration well before changes in biochemical studies are seen.6 RDs can look at the volume of urine patients produce (the goal is a minimum of 1,200 mL/day) to guide oral or IV fluid delivery, and monitor vital signs and physical symptoms. Signs of dehydration may include dizziness or lightheadedness, dark or concentrated urine, dry mucous membranes, excessive thirst, and sunken eyes. Often, patients with SBS experience a high volume of GI fluid losses, and their natural reaction is to consume more fluid in response to thirst sensations. However, consuming more fluid can lead to greater fluid losses and worsen dehydration. IV fluids and PN solutions, which aren’t associated

Toolbox for Clinical RDs Consider the following six factors and the management strategies under each when caring for patients with short bowel syndrome (SBS) who are receiving parenteral nutrition (PN).

1. Anatomy • No two SBS patients are exactly alike, so it’s important for clinical dietitians to learn all they can about the individual needs of patients. Determine what part of the small or large bowel has been resected, whether the ileocecal valve remains, and if the patient has a colon in continuity with the small intestine. In addition, establish the length/functional quality of the remaining small bowel. • Know where vitamins, minerals, and electrolytes are absorbed to anticipate what deficiencies patients may have if a certain area of the bowel is surgically absent. • Learn the anatomy of the gastrointestinal (GI) tract to facilitate evaluating which diet modifications patients may benefit from and prevent unnecessary dietary restrictions.

2. Fluids • Monitor fluid status closely and evaluate for physical signs of dehydration such as dizziness, lightheadedness, decreased urine output, darker color urine, excessive thirst, dry mucous membranes, and sunken eyes, and correlate to blood chemistries. In addition, look for high-volume GI losses. • Set a goal for the patient to produce at least 1,200 mL of urine daily. • PN or use of IV fluids guarantees hydration, whereas oral fluids may worsen dehydration. If the patient continues to drink, additional fluid loss via the GI tract may result. • Encourage patients to sip oral rehydration solutions (ORS) slowly throughout the day. ORS activate the sodium glucose co-transport system and turn on a mechanism enabling the bowel to absorb fluid. • Compliance with ORS can be challenging because of the taste; however, patients often report improvements in hydration with their use and by eliminating plain water and hypertonic beverages (ie, simple sugar beverages).

3. Medication Review • If an SBS patient has undergone a major jejunal resection, check to make sure they’re receiving a histamine2-receptor antagonist or proton pump inhibitor to combat gastric acid hypersecretion. • Evaluate a patient’s medication list for antidiarrheal agents (eg, Imodium, diphenoxylate-atropine, codeine, tincture of opium) and antisecretory agents (eg, octreotide, clonidine). It’s important to know what medications are being prescribed at what dosage, and the time they’ve given. • Schedule the administration of antidiarrheal medications 30 to 60 minutes before meals instead of after meals or on an as-needed basis. This gives antidiarrheal agents an opportunity to slow peristalsis so food has the most contact with the bowel for absorption. • Choose medications in either capsule or tablet form. Liquid medications contain sorbitol for palatability, which can cause nausea, vomiting, abdominal cramping, dry mouth, and osmotic diarrhea, and increase fluid and electrolyte losses. Often, liquid medications are prescribed to SBS patients to facilitate absorption, but this isn’t always the case as they may contribute to diarrhea.

4. Stool/Enterostomy Output Characteristics • Dietitians should talk to patients about the consistency, color, and volume of diarrhea or enterostomy output to determine patients’ response to medications, assess fluid status, and help guide the nutrition care plan.

5. Oral Supplements and Vitamins • Encourage patients to add oral nutrition supplements to their diets that are low in carbohydrates/simple sugars. (The “no added sugar” or “diabetes” formulations can benefit patients if sipped slowly.) Oral supplements can benefit SBS patients who can’t consume enough calories while they’re being weaned from PN to an oral diet. • Chewable, complete multivitamins are preferred over liquid vitamins that contain sorbitol.

6. Infection Prevention • Urge patients to practice good hand hygiene before preparing PN solutions to prevent any fecal material from coming into contact with catheters. • An ethanol lock may help prevent catheter-associated blood stream infections, but it doesn’t take the place of good catheter care and hand hygiene practices.1 — MLC

Reference 1. John BK, Khan MA, Speerhas R, et al. Ethanol lock therapy in reducing catheter-related bloodstream infection in adult home parenteral nutrition patients: results of a retrospective study. JPEN J Parenter Enteral Nutr. 2012;36(5):603-610.

december 2015 www.todaysdietitian.com 33

with malabsorption, can improve and maintain hydration status in SBS patients. RDs must educate patients about diet modifications that will reduce fluid losses, encourage them to monitor their fluid balance, and ensure they learn to recognize signs and symptoms of dehydration. Patients can sip oral rehydration solutions throughout the day, although they should limit hypertonic beverages, as these also may lead to excess fluid losses via the GI tract.5

Electrolyte Challenges Fluid losses often are coupled with electrolyte losses. Frequent electrolyte imbalances seen in patients with SBS come from great losses of sodium, potassium, magnesium, bicarbonate, and chloride from the GI tract. Tables that quantify electrolyte content of various types of GI losses have been published in the literature.5,7 When making adjustments to electrolytes within PN solutions, RDs can evaluate serum electrolyte levels, calculate approximate additional electrolyte requirements based on the type of anatomy and volume of GI losses (eg, from tables that provide approximate electrolyte content of GI secretions), and assess IV electrolyte infusions provided apart from PN solutions. It’s important to remember that as GI losses and malabsorption are better controlled with dietary modifications and medications, electrolyte losses may not be as severe and PN solutions may need adjustments to prevent excessive serum electrolyte values. Electrolytes are best repleted and maintained when delivered through the IV route. Oral or liquid electrolyte delivery via the enteral route is plagued by malabsorption in SBS patients and leads to inconsistent serum levels. When RDs observe electrolyte imbalances, it’s critical to inquire about any physical symptoms associated with that electrolyte during the patient interview.

Oral Diet Modifications While making dietary modifications, it’s important to remember that digestion starts in the mouth with the help of the enzymes lingual lipase and salivary amylase. In addition, chewing food thoroughly is essential to preparing the food for the lower GI tract. The prescribed diet for patients with SBS comprises eating small amounts of food frequently throughout the day (eg, three small meals and three snacks), separating foods from liquids, sipping liquids slowly throughout the day, avoiding simple sugars or concentrated sweets as well as salty and starchy foods. This pattern of eating allows for optimal absorption of nutrients. Patients with an enterostomy can consume a diet with a fat content of 30% to 40% of total calories, whereas patients with a colon in continuity fare better following a diet with a fat content of 20% to 30% of total calories and a carbohydrate content of 50% to 60% of total calories.2,8 Overall, RDs should encourage polyphagia (ie, patients should eat nutrient-dense foods that are higher in calories than expected to meet energy needs), to offset some of the malabsorption these patients experience.

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Long-Term PN Considerations and Social Support Managing patients on short-term PN infusions in a hospital is much different from managing patients requiring long-term PN in the home setting. Maintaining quality of life is an important goal for patients requiring PN and long-term diet modifications due to SBS. Clinical considerations related to schedules and equipment modifications can enhance PN delivery in the home setting. Cycled infusions are used in place of continuous around the clock PN infusions. Patients on home PN often are mobile. They carry portable-sized ambulatory pumps in backpacks that allow for more movement during cycled infusions.5 RDs can counsel and encourage patients, and support long-term nutrition modifications with continuous reinforcement. Long-term patients often benefit from support not only from family, friends, and caregivers, but organizations such as the Oley Foundation and the SBS Foundation that offer education and advocacy to SBS patients and those receiving enteral nutrition or PN outside the hospital setting. RDs can refer patients to organizations such as these to connect with others who have similar conditions.

Infection Prevention Another consideration is the risk of blood stream infections in patients who use a central venous catheter for PN delivery. Prevention is key, so it’s important for RDs to encourage patients to practice good hand hygiene. Hand hygiene and the aseptic technique are important to practice when patients are preparing to hook up PN solutions, priming tubing, adding additives to the PN bag, or providing routine line care, which involves changing the end cap, dressing, and skin/catheter site care. Patients with SBS are prone to experiencing a large volume of stool losses, so it’s imperative to keep the end of the central venous catheter from coming in contact with stool and away from enterostomy bags. Encouraging patients to practice good hand hygiene may seem simple, but continued reminders and education can play a role in prevention.9

Optimal Patient Care Is Possible Caring for patients with SBS can be challenging medically and nutritionally. However, dietitians who develop an in-depth understanding of SBS, its nutritional consequences, and the treatment and management challenges associated with it, and who work with an interdisciplinary team will be well equipped to care for SBS patients, promote positive outcomes, and preserve quality of life. — Mandy L. Corrigan, MPH, RD, CNSC, FAND, is a nutrition support clinician and consultant in St. Louis.

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

CO NFE REN CE ISS UE Vol. 17 No. 10

October 2015

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GLUTEN-FREE LIVING AND

EMOTIONAL HEALTH What Every Dietitian Must Know By JUDITH C. THALHEIMER, RD, LDN

strictly gluten-free diet is the only treatment for celiac disease. Without it, patients suffer symptoms such as gastrointestinal (GI) distress, weight loss, fatigue, and delayed growth, and put themselves at risk of other autoimmune disorders and intestinal cancers. And yet, a significant percentage of people with celiac disease report less than strict adherence to their prescribed diet. In a disease where noncompliance often leads to severe and immediate discomfort, with real and significant long-term consequences, understanding the factors that lead to dietary lapses is essential to improving treatment. It’s difficult to measure how well people with celiac disease stick to the gluten-free diet, but a 2009 review by Hall and colleagues found studies indicating that anywhere from 42% to 91% of celiac disease patients report strict adherence.1 In a 2012 study by Anne Lee, EdD, RDN, LD, and colleagues, 98% of celiac patients surveyed initially said they comply with necessary dietary restrictions, but when asked more specific questions the vast majority admitted to times when they knowingly ate gluten.2 “Up to 81% of men and 88% of women said they would tend to cheat in social settings like weddings, birthdays, family gatherings, or when they were out with friends,” says Lee, who serves as professionals manager for the gluten-free food company Dr. Schar USA, Inc.

Factors in Noncompliance Patients who are knowledgeable about celiac disease and have a good understanding of the diet are seemingly more able and willing to comply with dietary restrictions than those with less knowledge, but lack of knowledge isn’t the only factor in

36 today’s dietitian december 2015

noncompliance.3,4 In studies, patients cite the restrictive, difficultto-follow nature of the diet, discomfort in social settings, poor taste of food, lack of available gluten-free food choices in stores and restaurants, asymptomatic disease, and cost as reasons for nonadherence, but the main theme appears to be the impact the diet has on overall quality of life.2,5 Numerous studies have found that celiac disease patients report a reduced quality of life.2,4,6 “Our study on living with celiac disease found that the strict nature of the gluten-free diet has a serious impact on an individual’s quality of life, especially in the social domain,” Lee says. “There’s such a huge social aspect to eating.” Forty-five percent of the celiac respondents reported that their physical health affected interaction with family, friends, or social groups. Problems were particularly acute for people diagnosed in adulthood, especially during the first two to five years after diagnosis.2 While following the diet appears to get easier over time, dining out and travel remain problematic.2 In Lee’s study, 25% of the females and 28% of the males chose not to dine out at all in the first two to five years after diagnosis.2 A separate study of children with celiac disease and their families found that 17% of families avoided traveling, and 46% avoided eating out in restaurants.5 “Food and eating are such a big part of our day-to-day lives, and so integral to socializing,” says Mi-Young Ryee, PhD, a pediatric psychologist at Children’s National Health System in Washington, D.C. “The gluten-free diet can be really challenging to follow.” According to Chynna Foucek, a senior at Rice University and the founder of the College Student With Celiac blog, “There’s a feeling that you don’t want to talk about your disease in social situations.

A deeper understanding of the impact of celiac disease and the gluten-free diet on mental health and quality of life can help RDs improve counseling and dietary compliance.

Friends want to go grab a bite to eat, or order a pizza, or go to a party. There’s a fear of missing out on social experiences.” Children also are impacted. “It can be very difficult for children to be singled out as different,” Ryee says. “The pediatric population I see has to contend with birthday parties, school events, and daily lunches in the cafeteria.” Marilyn G. Geller, MSPH, CEO of the Celiac Disease Foundation, saw firsthand how difficult life can be for young people with celiac disease. “My son was bullied,” Geller says. “There was name calling, even by teammates and friends. People actually threw toast on our lawn. Children and adolescents may not have the coping skills to deal with this kind of thing.” The National Foundation for Celiac Awareness describes initiating and adhering to a gluten-free diet as “a life change that requires major emotional and physical adjustments … [which] can take a toll on mental health” and “cause frustration, stress, and anger.”7 In addition to lower quality-of-life scores than their peers, people with celiac disease have higher rates of anxiety and depression.1,4,8 “It’s normal for patients to go through the stages of grief after diagnosis,” says Janelle Smith, MS, RD, who serves as “Ask the Dietitian” for the Celiac Disease Foundation and is a celiac sufferer herself. “The diagnosis is a loss of your previous lifestyle. Many people are in denial, or express anger, or they bargain with themselves, saying, ‘Oh, I’ll just have a little bit.’ Experiencing depression from this sense of loss is very reasonable.” Compounding the emotional effects of the diagnosis and diet is the fact that psychological changes actually are symptoms of celiac disease, most likely due to its biochemical effects.6 “Prior to diagnosis, people with celiac disease may present with symptoms such as changes in mood, sleep, and appetite, and difficulties with concentration, and there may be concerns for depression and anxiety,” Ryee says. “In fact, some patients are treated by mental health professionals for extended periods before celiac disease is properly identified and treated.” Smith experienced this phenomenon firsthand. “Depression was my primary symptom,” Smith says. “After my diagnosis, I started a gluten-free diet, and my depression resolved.” These psychological symptoms also may affect quality of life and dietary adherence.6 A 2013 study by Sainsbury and colleagues concluded that the reduced quality of life in celiac disease is more strongly associated with depression than GI symptoms. The researchers recommended that celiac disease management should include the provision of psychological coping skills.9

Counseling Strategies “When we counsel celiac patients, we have to remember this is not just a dietary change,” Lee says. “We’re asking people to absolutely change the way they live. There’s no wiggle room in this diet. The good news is we can provide them with ways to make it easier.”

Educate Beyond Diet A strong understanding of celiac disease and how to follow a gluten-free diet is essential for patients to improve their health, but counseling that goes beyond these basics can further increase

38 today’s dietitian december 2015

TOOLS FOR DIETITIANS AND PATIENTS The following resources include a sample of the many websites and smartphone apps providing counseling guidelines, educational materials, patient resources, and support groups for RDs and clients. • Academy of Nutrition and Dietetics Celiac Disease (CD) Guideline (2009) (www.andeal.org/topic. cfm?menu=5279) • Find Me Gluten Free app by Gluten Free Classes, LLC (www.findmeglutenfree.com) • National Foundation for Celiac Awareness (www. celiaccentral.org) • Celiac Disease Foundation (www.celiac.org) • Gluten-Free Living: Gluten-Free Resources and Support (www.glutenfreeliving.com/gluten-free/ resources-support) • National Institutes of Health Celiac Disease Awareness Campaign Educational Materials and Resources (www.celiac.nih.gov/materials.aspx) — JCT

compliance and improve well-being and overall quality of life.7 Smith recommends providing diet education that includes information on real vs perceived restrictions. “There’s a lot of misinformation out there,” Smith says. “I see patients unnecessarily eliminating grains like corn or rice because something they read on the Internet incorrectly said these foods contain gluten. Outdated information is a problem as well. Ingredients like maltodextrin and distilled vinegar were once thought to contain gluten but actually don’t. These unnecessary restrictions add to an already burdensome diet.” Geller adds coffee to the list of foods mistakenly thought to cause a cross-reaction in celiac patients. Smith says, “By keeping to an evidence-based approach, dietitians can bring down the level of fear in our patients.”

Be Positive and Empowering Lee stresses the importance of being positive. “We need to teach patients to take charge of their diet and lifestyle,” Lee says. “You’re giving the client a prescription for health. This diet is going to change their life. We need to approach our counseling in a positive way. Instead of ‘don’t do this,’ say ‘you can do this.’ Now they have the opportunity to be healthy. For many people this is a different way of looking at a diet. This is a positive, healthful lifestyle that happens to be gluten-free.” The key to this positive thinking, Lee says, is empowerment. “Helping the client to feel in control is essential,” she says. “In addition to teaching them what foods they can’t eat, show them where to look in the supermarket for foods they can eat; tell parents about accommodations that are available by law at schools; show teens mobile apps that direct

them to the nearest restaurant with a gluten-free menu, so that when friends want to grab a bite to eat the teen with celiac disease can take charge and lead the way.” Foucek benefitted greatly from this type of approach in her nutrition counseling. “My RD provided perspective,” Foucek says. “She helped me see that you can find ways to be socially engaged without eating gluten. She also taught me how to be overprepared: If you know you’re going to a party or a game, do your research. Are there gluten-free options there? And don’t be afraid to tell your host what you need. She also helped me understand that I’m doing this to protect my body and save myself from other diseases and death. Understanding the long-term health benefits gave me more motivation.”

Build Skills Modeling and role-playing can help foster this feeling of empowerment. Smith recommends modeling communication and assertiveness for patients. “Role play how they will order gluten-free at a restaurant or speak to family members about their dietary needs,” Smith says. “This brings about self-efficacy, a personal belief that they can do what needs to be done, and that leads to increased acceptance of the lifestyle, enhanced confidence, and improved compliance.” Foucek found role-playing helpful for her personally, and also recommends involving the entire family. “My RD educated the whole family, even my seven-year-old sister,” she says. “Everyone in your life is affected by these lifestyle changes, and they all need to be educated and on board.” Teenagers may present specific challenges. “When dealing with kids and teens, it’s developmentally typical for them to have times when they’re tempted to stray from the gluten-free diet,” Ryee says. “RDs can help teens make healthful choices by making sure they have really good knowledge and understand the impact of eating gluten, and by helping them build in supports at school, [during] activities, and in social situations. They’re all going to have their moments. Help them manage and cope with it instead of making the environment really punitive. But do watch out for particularly extreme behavior that warrants outside help.”

Link to Support Support groups, forums, blogs, and social media outlets like Facebook and Twitter can be useful in helping people with celiac disease gain confidence and learn coping strategies.7 “Books and online resources can offer really helpful tips and tricks,” Foucek says, “plus support and inspiration from others going through the same thing.” Research supports this idea. “Support increases quality-oflife scores,” Lee says, “but our research showed that face-toface support groups work the best.” According to Foucek, “when you meet other people, you form a bond with them. This is a very supportive community. People are eager to share their stories and what works for them.” Lee recommends referring clients to celiac support groups and websites, and offering advice for accessing groups when

they’re traveling. “Additionally,” says Lee, “we as dietitians have an opportunity to provide that face-to-face support and guidance to change quality of life and ultimately dietary adherence.”

Take a Team Approach “Celiac disease isn’t just a dietary change, it’s a lifelong chronic illness that benefits from mental health care,” Smith says. “The RD should be part of an interdisciplinary team, communicating and participating with the primary care provider and gastroenterologist but also with mental health providers to manage health outcomes. Since we aren’t trained in mental health, we need to know when to refer to someone who is. Having a team approach makes this referral easier and helps to remove the stigma many people still attach to seeking mental health care.” The team approach also helps when it comes to managing ongoing symptoms. “Many people with celiac disease have undiagnosed coexisting conditions like fructose or lactose intolerance, or small intestinal bacterial overgrowth,” Smith says. “They may be mistakenly attributing those symptoms to hidden gluten, leading them to eliminate extra foods, and increasing their burden, their fear, and their anxiety.” An RD is in the perfect position to spot a problem and work with the rest of the medical team to determine what action is necessary. To facilitate this team approach and improve understanding of the medical and psychological factors of celiac disease, the Celiac Disease Foundation and the Children’s National Health System are developing a program to cross-train health care providers. “Children with anxiety and depression are seeing psychologists who are unaware that these may be symptoms of celiac disease. They’re too often diagnosed with ADD/ADHD, depression, and other psychosocial disorders long before their celiac diagnosis,” Geller says. “We’re creating print and digital materials as well as live programs to teach mental health professionals to recognize signs and symptoms of celiac disease, and to help primary care providers and others, including RDs, to recognize the psychosocial component of this disease and make referrals.” The program is set to debut at the Celiac Disease National Conference & Gluten-Free Expo April 30 to May 1, 2016. Awareness of the psychological component of celiac disease, the emotional and psychosocial impact of diagnosis, and barriers to adherence to a strict gluten-free diet can help nutrition professionals improve their work with these patients. Coupled with appropriate referrals, empathetic counseling that empowers clients and gives them the tools they need to navigate their lives without gluten can greatly enhance not only dietary compliance but also the client’s quality of life. — Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer, a community educator, and the principal of JTRD Nutrition Education Services.

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

december 2015 www.todaysdietitian.com 39

Below: Sophie Bernstein Right (left to right): Susan Epstein, Sophie Bernstein, and Adele Corvin

alth and e h e h t g improvin n nutrition. e r a s r e g a o ning teen ities with a focus in w d r a mmun ant, aw Two brilli people in their co of wellness

Above: Lauren Maunus Left (left to right): Susan Epstein, Lauren Maunus, and Adele Corvin

AN BY JULI

he determined efforts of two teenagers has shown that age is no obstacle for those who want something badly enough—and what these youths in particular wanted was to improve the health and wellness of people in their community and beyond. Sophie Bernstein, 15, from St. Louis, and Lauren Maunus, 17, from Palm City, Florida, were recently awarded for their individual efforts with the 2015 Diller Teen Tikkun Olam Award, which recognizes “Generation Z-ers” and millennials for their commitment to social good. While current and previous award-winning projects range in their subject matter and intention, such as public policy, education, science, and the environment, Bernstein and Maunus have focused on spreading a message of health and wellness with a particular nutrition component. Bernstein’s project, which mobilized her community to fight hunger and promote nutrition in low-income communities, established vegetable gardens in area preschools. Maunus took her inspiration from the near death of her sister due to a nut allergy and has lobbied for better food labeling and nutrition policies in area public schools and now across the country. To celebrate two future leaders in the nutrition community, Today’s Dietitian speaks with these teens about their awardwinning projects.

— PHOTOS BY CHRISTOPHER SHAW

Behind the Award The Diller Teen Tikkun Olam Awards are an annual recognition of a group of teenagers who are leading different volunteer projects across the country, all with a singular focus to change the world for the better. In its ninth year, the Helen Diller Family Foundation, a supporting foundation of the Jewish Community Federation of San Francisco, the Peninsula, Marin, and Sonoma Counties in California, gave the 2015 award to 15 teens. Helen Diller, who passed away earlier this year, was a Bay Area philanthropist who dedicated her life to social good, including endeavors that furthered medical research and social responsibility. Diller’s Jewish heritage also was close to her heart, which is why this award recognizes youths who identify as Jewish. Award recipients, who each receive $36,000 to further their cause or education, are chosen for exemplifying the spirit of tikkun olam, which is a Jewish concept that refers to repairing the world. Since its inception, the foundation has awarded more than $2.5 million to teens who seek to improve the world around them in some way.

EF N SCHA

FE R

Inspiring Healthful Eating With Preschool Gardens Bernstein, a sophomore at Clayton High School in St. Louis, says she always wanted a vegetable garden but was thwarted by her parents’ initial opposition. Instead, a trip to one of her local food banks helped her cook up an idea to establish a garden to fight both childhood hunger and obesity. Her initial inspiration started as a bat mitzvah project in 2013 to supplement local food banks with the harvest of a backyard garden. Yet upon her first trip to deliver her harvest spoils, what she saw left her disappointed. “When delivering the produce from my garden to area food banks with my mom, I was surprised to see shelves at the food banks stocked with sugary juices, cookies, and salty snacks,” she says. “There were limited fresh produce options and even fewer healthful nonperishable items like beans, whole wheat products, and low-sodium soups.” Acknowledging the high incidence of both childhood obesity and childhood hunger in her state, Bernstein sprung into action. As the summer garden season ended, she started hosting healthful food drives, collecting peanut butter, healthier canned soups, and beans to offer food banks more wholesome fare. But she didn’t stop there. Bernstein took that one garden and multiplied it, building raised-bed vegetable gardens at several area preschools. She was not only able to supplement food banks with more garden foods but also to educate preschoolers in low-income communities on the benefits of healthful eating along the way. With the help of several grants and volunteers from her community, Go Healthy St. Louis became a reality. Seeking to raise awareness of childhood hunger and the increasing rate of childhood obesity in the St. Louis metropolitan area, Bernstein says the project comprises young volunteers committed to increasing the amount of fresh, healthful produce available at food banks and at low-income childcare facilities. “All the produce that we grow in the raised garden beds is harvested and donated to area food banks, utilized for lunch at the preschool facilities, and/or given to the families in need at the schools and shelters,” she says. With the assistance of more than 750 volunteers that she recruited and trained, Go Healthy St. Louis has donated garden crops to St. Louis Food Bank, Operation Food Search, and the Harvey Kornblum Jewish Food Pantry. Her gardens now total 18, all at area preschools and shelters serving lowincome populations. “Together, we’ve donated more than 5,000 pounds of fresh produce,” Bernstein says. To further her message, she also has developed a gardening tool kit, newsletter, and workshop materials for more than

december 2015 www.todaysdietitian.com 41

1,200 teens who attend the monthly garden workshops she leads at synagogues, churches, and schools. Building these gardens at local preschools wasn’t a coincidence. Bernstein has used these locations to open the eyes of young children to the basics of healthful eating. “To engage young children in the gardening process, we invite them to help with planting the seeds and seedlings,” she says. “We read books to the children about gardening and healthful habits, play games, and incorporate art projects to help raise awareness of healthful eating.” The children at these preschools also help maintain the gardens, with the help of their teachers. The harvests are then used in school lunches or snacks, such as freshly sliced carrots, green and red peppers, and cucumbers with or without hummus for afternoon snack time. Produce also is given to the families at the schools and shelters. Bernstein says the greater goal of these gardening steps is to build a healthful foundation and encourage youth to make healthier food choices. Those conversations can never start early enough. Her favorite part of the entire project? Watching preschoolers get their hands dirty. “Many of the children at the shelter and at the area preschools never had the opportunity to take care of and water vegetable plants and watch tomatoes and cucumbers grow or pick them fresh for their meals,” Bernstein says. “And most of the children had very limited access to a variety of fresh fruits and vegetables.”

“ Nutrition affects each one of us, and we can all make a difference in improving our own health and society’s health by being educated and engaged in our nutrition choices.” — Lauren Maunus, 17

From leading gardening workshops to recruiting volunteers on a regular basis, it hasn’t been easy. But Bernstein says she’s learned invaluable lessons through her efforts, most notably that anyone, no matter their age, can truly make an impact to improve the overall health of their community. “Our goal is to educate young children on the importance of gardening and eating fresh produce while making a sustainable impact in our community,” she says. With the spoils from this award, she plans to grow and expand this project, both in greater St. Louis and nationwide. Toward

42 today’s dietitian december 2015

that end goal, Bernstein is currently working with SafeTEEN Coalition in New York and students at three high schools in Indiana to provide advice and support to build more gardens in low-income communities throughout the nation. For the recognition, she’s thankful because it’s giving her the opportunity to remind all young people of their limitless potential for good, particularly in fighting today’s biggest nutrition challenges. “I encourage all young people to take action and help solve public health challenges like obesity, smoking, and to raise awareness for healthful eating in their communities and make an impact,” she says.

Spreading Allergen Awareness in Schools Maunus, now a freshman at Brown University in Providence, Rhode Island, never envisioned herself as a food allergy advocate until one critical moment in January 2002 changed everything. “One moment we were frolicking on the beach; the next, I watched in horror as my 2-year-old sister nearly died from eating a cashew,” she explains. Maunus’ sister, Rachel, got the necessary medical treatment and survived the anaphylactic attack. But as she was diagnosed with a life-threatening tree nut allergy, the family was told that just one bite of a nut could be fatal. “Rachel’s life became a minefield,” says Maunus, noting that she couldn’t just stand by and hope her sister would be safe. “I had to stand up for her, serve as her advocate.” And what an advocate she became. After learning that some 6 million other children just like Rachel were lacking access to critical allergen information at school, Maunus sought to change nutrition policy in schools. “While a daily trip to the school cafeteria is a time for lunch and to socialize for most students, it can be a scary, life-threatening ordeal for Rachel and the 6 million students like her,” she says. “Federal law mandates that all food items identify allergens, but shockingly, this does not apply to public schools.” Maunus is referring to the Food Allergen Labeling and Consumer Protection Act (FALCPA) of 2004 that requires all food manufacturers and retail and foodservice establishments that sell packaged FDA-regulated foods to clearly list on food labels any of the eight most common allergens the food contains. Unlike FALCPA, the Centers for Disease Control and Prevention (CDC) Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs, published in 2013, doesn’t mandate that all packaged foods sold in school cafeterias list food allergens on labels, although reading the labels of prepackaged foods sold is highly recommended. “I was determined to seek solutions to the notion that [kids with food allergies] were destined to live their lives in fear.”

Maunus’ advocacy efforts began four years ago, when she was a freshman in high school. As a Youth in Government delegate, she drafted a bill to improve best practices in school food allergy management and was awarded “Best Bill in the House” out of 700 other youth delegates. That success had her head spinning with potential. “I realized that I had the potential to effect meaningful change, and methodically sought to make the bill a part of Florida law,” she says. Her overall mission is to reform national school nutrition policy to improve best practices for students suffering from allergies, obesity, and other diet-related illnesses by identifying the top eight allergens and other nutritional information for all items offered in each of the nation’s nearly 100,000 public schools. “Providing potentially life-saving allergen and nutrition information educates, empowers, and engages students in their nutrition while keeping allergic students safe at school,” she says. Offering allergen and other nutritional information doesn’t just help those with food allergies. “Nutrition affects each one of us, and we can all make a difference in improving our own health and society’s health by being educated and engaged in our nutrition choices,” she says. “Reading labels to see what is in the food we eat is a great first step to engaged nutrition!” In her efforts to reform national school nutrition policy to improve best practices for students, she made huge inroads, but not without encountering some setbacks. She says her biggest challenge was being one small 13-year-old voice and communicating a compelling argument to overworked, underfunded, adult decision makers. “I was rejected by both local and state government officials who felt I had a great idea, but immediately responded, ‘Who is going to pay for it?’ “I had to demonstrate how my idea was operationally feasible in a state with 67 [counties having] school districts with a wide range of budgets and resources,” she says. “Additionally, I had to convince legislators from districts that derive revenue (and campaign contributions) from the dairy industry that disclosing ‘contains milk’ is intended to save lives, not to hurt their business interests.” Maunus let neither money nor liability, or even special interests, stand in her way. Any objections only intensified her resolve. After working with software company Nutrislice to improve their product’s allergen identification component, she then helped introduce the software to Martin County’s Food Service Department and the Florida Department of Agriculture and Consumer Services. In addition to filtering for allergens, the software also provides comprehensive nutritional information via school district-hosted websites and a mobile application. “The app is specific to each meal, each day, for each school, connecting

the bridge between the end users (the students), the school district, and the food suppliers,” says Maunus, noting that the app adds no extra cost to school districts, as it actually saves labor expenses by eliminating the need to manually input nutritional and allergen information. “Additionally, the software allows the information to be managed at the district level, improving standardization,” she adds. “Most importantly, the app empowers the entire school community to make informed decisions regarding their nutrition, making the cafeteria a safer and healthier environment.” From this experience, Maunus lobbied her way to success. “I led a grassroots campaign, engaging the support of local legislators, school board members, and medical and education organizations,” she says. And, despite some opposition to stray from the norm, she convinced her local school board to pilot the technology. Determined to reach more students with such nutrition information, she then took her voice to Tallahassee, the state capital of Florida. After two years of support, guidance, negotiation, and collaboration, Florida’s Department of Agriculture has implemented this software in school districts in each of Florida’s 67 counties. “My project has resulted in a widespread increase in awareness, giving voice to this serious public health issue,” she says. “Additionally, students, parents, and school faculty are now trained in food allergy management, including emergency preparedness, cross-contamination, and label reading.” But Maunus still wasn’t stopping. In the past two years, she has worked with numerous officials and organizations, including the USDA, the CDC, national allergy organizations, and even First Lady Michelle Obama’s Let’s Move campaign, to scale her project nationwide. “Collaborating with national food allergy, nutrition, and governmental organizations, I envision utilizing the gains of my project as an integral component of a national school nutrition omnibus bill, serving as guidance for the 2015 reauthorization of the USDA Child Nutrition Act,” she says. These days Maunus is studying environmental studies at Brown University, and her lofty goal is to ensure that environmental justice for all includes nutrition as an important part of a greater whole. “Whether it be improving access to healthful foods for those who live in food deserts or safeguarding the lives of members of frontline communities at risk of climate change, I foresee working with an NGO [nongovernmental organization] to promote sustainability and climate action while disseminating the message that environmental security is a fundamental human right,” Maunus says. — Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania, and a frequent contributor to Today’s Dietitian.

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CPE MONTHLY The Disease of Obesity

OBESITY: BEYOND CARDIOVASCULAR DISEASE AND DIABETES By Lillian Craggs-Dino, DHA, RDN, LDN

Learn about obesity’s far reach and ill effects in lesser-described conditions. Despite more attention and focus on obesity as a national and global pandemic from the scientific, health care, and political communities, high rates continue to prevail. Nearly 35% of the US adult population is obese,1 and, according to the World Health Organization (WHO), deaths linked to obesity have surpassed deaths caused by being underweight.2 According to the systematic Global Burden of Disease Study 2010, deaths attributable to malnutrition, infectious disease, and maternalchild diseases are on the decline compared to 20 years ago and are surpassed by noncommunicable diseases of obesity such as heart disease and cancer.3 Beyond mortality alone, obesity is irrefutably responsible for increasing the risk of developing some of the leading causes of preventable chronic conditions. For example, obesity has been widely discussed for its role in diseases of the cardiovascular system such as heart disease and stroke; the endocrine system, such as diabetes; and the digestive system, such as fatty liver or gallbladder disease. But while those diseases get the lion’s share of media and research attention, other diseases have been associated with obesity. This continuing education course discusses those conditions uniquely influenced by obesity to elucidate the devastating reach of this disease beyond that which is commonly discussed. The etiology of obesity will be discussed within the context of its central role in obesity hypoventilation syndrome (OHS), sexual dysfunction, and infectious disease. The essential role of the RD in obesity treatment and optimizing nutrition status in those with these obesity-related comorbid conditions is also described.

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While the consequences of obesity are undisputed, defining obesity itself as either a chronic disease or merely a condition that precedes and causes other systemic diseases is highly debated. In June 2013, the American Medical Association (AMA) declared obesity a disease, reaching a milestone in the effort to improve the lives of those who suffer from obesity.4 However, this statement also aroused passionate debate among health care practitioners, patients, federal institutions, and industries about whether obesity is in itself a bona fide disease or merely a condition that increases risk factors for subsequent disease. Proponents of the disease classification claim that obesity is a pathophysiological illness that dramatically reduces quality of life, causes or exacerbates weight-related conditions, and shortens the life span.4 Proponents of the obesity disease definition include prominent national and international medical, governmental, scientific, and academic societies such as the WHO, the American Society for Metabolic and Bariatric Surgery, the Obesity Society, and American Association of Clinical Endocrinology.5-8 Many proponents hope that recognizing obesity as a disease will extend advocacy, education, and research toward prevention and treatment to improve the lives of those affected. It’s their hope that greater professional and public awareness will also result in extended insurance coverage for the identification, prevention, and treatment of obesity; influence public policy; and eliminate the social stigma that often surrounds obesity. However, some members of the medical, scientific, and academic communities oppose the obesity definition, and

COURSE CREDIT: 2 CPEUs

LEARNING OBJECTIVES After completing this continuing education course, nutrition professionals should be better able to: 1. Describe the etiology of obesity. 2. Explain the implications of other more obscure

conditions associated with obesity. 3. Counsel patients about potential treatments for

obesity and associated conditions. 4. Evaluate current research as it applies to obesity

prevention and treatment. Suggested CDR Learning Codes 3030, 4050, 5370 Suggested CDR Performance Indicators 8.3.6, 10.2.2, 12.2.1, 12.3.7 CPE Level 2

claim that obesity can’t be defined as a disease because the tool used to diagnose it, BMI, is flawed and doesn’t actually measure body fat accumulation as defined by the WHO. The WHO defines obesity as “abnormal or excessive fat accumulation that may affect health.”2 BMI was designed as a tool to screen obesity risk at the population level and doesn’t indicate the level of fat or body composition of an individual. For example, a person with what is categorized as normal BMI (18.924.9) may actually have excessive adipose tissue and display fat-related comorbidities.2 In addition, research shows that not all people who suffer from obesity suffer from other diseases and are “metabolically healthy.”9 Antony D. Karelis, PhD, asserted some obese individuals appear to be metabolically protected from obesity-related complications and conditions. He commented on a study that showed more than one-third of obese individuals had favorable metabolic profiles, eg, normal blood pressure, lipids, insulin sensitivity, and normal inflammatory markers like C-reactive proteins.9 In addition, there’s no universal and authoritative definition of “disease.” Many definitions of “disease” can be found in literature and are typically associated with the system or structure that’s afflicted, such as Crohn’s disease. According to Merriam-Webster’s online medical dictionary, disease is defined as “an impairment of the normal state of the living animal or plant body or one of its parts that interrupts or modifies the performance of the vital functions, is typically manifested by distinguishing signs and symptoms, and is a response to environmental factors (such as malnutrition, industrial hazards, or climate), to specific infective agents (such as worms, bacteria, or viruses), to inherent defects of the organism (such as genetic anomalies), or to combinations of these factors.”10 Opponents argue obesity doesn’t meet the definition and criteria of “disease” in some interpretations, and it remains unclear if the newly recognized classification will improve health outcomes. Even the AMA’s own Council on Scientific Affairs disputed the ruling, requested a review of the evidence, and settled on regarding obesity as a “disorder” or “condition” rather than a medical disease.4 However, despite the often-heated debate over whether obesity is a disease, a condition, or a risk factor, one thing is readily accepted: There is a positive association among increasing BMI, obesity, and weight-related comorbid conditions.5,6,11 In total, more than 60 conditions, such as type 2 diabetes mellitus, hypertension, cardiovascular disease, stroke, gallbladder disease, and even certain cancers, spanning every organ system, are positively associated with obesity.5,11-13 Following a brief overview of the etiology of obesity, this course describes the following conditions: OHS, sexual dysfunction, and infectious disease.

Etiology and Consequences of Obesity Obesity is recognized as a modern pandemic with concomitant multifactorial and complex causes.11-13 Energy imbalance induced by excessive caloric intake and reduced caloric

Come to the Today’s Dietitian 2016 Spring Symposium! Register Now for only $325 until 12/31/15!

Todaysdietitian.com/SS16 expenditure from inactivity are recognized as leading causes of obesity.1,2,11,13 Other contributing factors to obesity are less clear but appear to involve genetics, metabolism, culture, environment, psychology, and secondary diseases such as hypothyroidism and Cushing’s syndrome.11-13 Increased technology, urbanization, and changes in food acquisition and preparation have been shown to contribute to obesity. Nutrient-poor, calorie-dense food choices and inconsistent eating patterns also are factors. Research shows reduced intake of healthful foods such as fruits and vegetables along with increased intake of sugar and processed foods, and poor dietary eating patterns such as fad dieting or skipping meals, contribute to obesity.11-15 Obesity is detrimental to the welfare of the individual, society, and the economics of the country.12,16,17 The tangible burden of obesity is expressed as morbidity and mortality and in terms of prevalence and relationship to chronic diseases.9,16,17 Obesity is a major contributing cause of comorbid conditions that affect the physiology of all major organ systems of the human body. Over the course of a lifetime, it increases one’s risk for endocrine dysfunction, cardiovascular diseases, gastrointestinal diseases, pulmonary diseases, musculoskeletal disorders, sexual and reproductive disorders, and certain cancers.11-13,17,18 Coined terms such as “diabesity” denote the widely accepted and prevalent relationship between type 2 diabetes and obesity. Hypertension, osteoarthritis, dyslipidemia, myocardial infarction, and thrombosis are the more commonly reported consequences of obesity.17,18 While the aforementioned comorbidities have been widely researched, dietitians should be aware of lesser-discussed conditions of obesity in order to perform better nutritionfocused physical exams and provide subsequent medical nutrition therapy and obesity treatment/prevention strategies. These include OHS, sexual dysfunction, and infectious disease.

OHS OHS, also known as Pickwickian Syndrome, is a respiratory disorder characterized by dysfunctional breathing and absence of deep breathing that leads to high levels of carbon dioxide (hypercapnia) and low levels of oxygen (hypoxia) in the blood.19-21 OHS is more prevalent in patients who present with a triad of these conditions: obesity, hypoventilation while awake, and coexisting sleep-disordered breathing (sleep apnea) not caused by medications, neurologic, neuromuscular,

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CPE MONTHLY or cardiopulmonary explanation for the hypoventilation and carbon dioxide retention.19-21 Research shows there is a higher incidence of OHS in middle-aged males.19 According to Chau and colleagues, OHS is defined as hypercapnia (too much carbon dioxide in the blood) while awake caused by hypoventilation during the daytime, and this is what differentiates OHS from sleep apnea and other chronic obstructive pulmonary disorders.21 Approximately 90% of patients with OHS also present with obstructive sleep apnea (OSA).21 Serious complications of OHS include respiratory acidosis, hypertension, pulmonary hypertension, pulmonary embolism, cor pulomonale (enlargement and failure of the right ventricle of the heart), and subsequent heart failure, as well as compromised quality of life relating to depression, fatigue, sexual dysfunction, headaches, migraines, and daytime sleepiness.21 OHS is positively correlated with BMI.19-21 Not all patients with obesity present with OHS; however, all OHS cases present with BMIs greater than 30 kg/m2. As such, cases of OHS are predicted to increase with the rising obesity epidemic.20,21 The exact cause of OHS is unknown but experts suggest causes of OHS could be rooted (either alone or in tandem) in the following: abnormal leptin levels, labored breathing due to central adiposity, and impaired compensatory response to hypercapnia due to obstructive apneas and sleep apneas.20-25 Leptin, a protein produced by adipose tissue, functions to control appetite and energy expenditure.23-25 The normal response of leptin in proportion to fat storage is to signal the hypothalamus to decrease appetite and food intake and increase metabolism and energy expenditure.23-25 Those with obesity are theorized as having leptin resistance, which is then believed to promote OHS.23-25 Leptin plays a physiologic role beyond metabolism and control of food intake. Leptin is known also to influence the immune system, stimulate proinflammatory cytokines, increase the sympathetic nervous system to control endothelial function, and regulate blood pressure.23-25 Leptin also plays a role in respiratory function by modulating the development of lung tissue and stimulating respiratory control.23-25 Malli and colleagues reviewed evidence that indicates leptin regulates lung tissue growth and maturity and stimulates ventilation. However, in animal models using the mutated ob/ob mice that are obese, it’s believed that leptin-resistance is positively correlated with OHS by increasing the frequency of breathing, minute ventilation, and tidal volume. This, in turn, can elevate arterial pressure of carbon dioxide and depress the hypercapnic ventilator response often seen in OHS.23 It’s unclear, however, whether high serum leptin is a cause or consequence of OHS.23-25 Central adiposity is also believed to play a role in OHS. Central adiposity is defined as an excessive accumulation of abdominal fat often associated with the “apple” body shape. Waist measurements of 40 inches or greater in men and 35 inches or greater in women indicate higher visceral fat and central adiposity.19,20 So far research has shown that those with

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central adiposity are at increased risk of diabetes, heart disease, and metabolic syndrome.1,2,5,6,11,13 With relation to OHS, central adiposity is believed to hinder the normal breathing mechanism by imposing an excessive load on the organs of the respiratory system and impairing the respiratory muscles and diaphragm, thus increasing the resistance of the upper airway. This in turn causes shallow breathing which then leads to hypoventilation and subsequent hypercapnia.19,21 In addition, central adiposity adversely affects the mobility of the diaphragm leading to reduced lung volumes and contributing further to hypoxemia and hypercapnia, causing respiratory acidosis.19,21 Disruption of appropriate compensatory response to hypercapnia is marked by hypoventilation, impaired respiratory mechanics, and reduced lung volumes.19,21

OHS and the Role of Nutrition and RDs Patients with OHS often present with symptoms of fatigue, morning headaches, choking at night, excessive daytime sleepiness (hypersomnolence), edema of the lower extremities, dyspnea, and loud snoring.19-21 Performing a nutritionfocused physical examination (NFPE) of these patients is appropriate. A NFPE is a system-based assessment of each region of the body. In patients presenting with OHS, the NFPE may reveal cyanosis of the lips, skin, fingers, and toes, and edema of the extremities. See Table 1 online for a general summary of a NFPE. The medical goals in treating patients with OHS include improving gas exchange, lung volume, and central respiratory drive.19-21,25 These goals are accomplished by some or all of the following: using continuous positive airway pressure (C-PAP) and bilevel positive airway pressure (Bi-PAP) machines, medications such as medroxyprogesterone, acetazolamide, and theophylline, and weight loss through either conventional or surgical means.19,21-27 When counseling obese patients with OHS through dietary and behavioral modification, dietitians should provide nutrition guidance specific to this condition, including promoting the restriction of alcoholic beverages, since alcohol depresses the respiratory system.28 In addition, patients should be advised about food-drug interactions. For example, patients prescribed theophylline should restrict caffeine-containing foods such as coffee, tea, cola, and chocolate because caffeine can increase the side effects of theophylline and cause nausea, vomiting, insomnia, irregular heartbeat, and seizures.28 Bariatric surgery, when leading to weight loss, has been shown to improve pulmonary function and gas exchange in patients with OHS.22,26 Marti-Valeri and colleagues showed improvement of hypoxemia, a reduction of hypercapnia, and reduction in the need for C-PAP or Bi-PAP one year after achieving significant weight loss with gastric bypass surgery. The researchers concluded that improvement of arterial blood gases and respiratory function was directly related to the percentage of weight loss at one year after surgery.26 However, bariatric surgery isn’t without nutritional risk, and when

undergone by patients, RDs must be sure to provide thorough postsurgical bariatric nutrition guidelines.

Obesity and Sexual and Reproductive Dysfunction As previously mentioned, metabolic consequences of obesity, notably hypertension, diabetes mellitus, and dyslipidemia, are well documented.1-6,11-13,17 The triad of these conditions is appropriately coined the metabolic syndrome. A direct consequence of metabolic syndrome and obesity is sexual dysfunction in men and women.29 Sexual dysfunction in men manifests as erectile dysfunction (ED) and is defined as the “consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual activity.”29 Female sexual dysfunction (FSD) is defined as “persistent or recurrent disorders of sexual interest/desire, disorders of the subjective and genital arousal, orgasmic disorders, and pain and difficulty with attempted or incomplete intercourse.”29 In addition to contributing to FSD, obesity increases the risk of reproductive disorders such as polycystic ovary syndrome and infertility, and complications of preconception and pregnancy such as gestational diabetes mellitus (GDM), preeclampsia, and gestational hypertension.29,30

Obesity and Sexual and Reproductive Dysfunction in Males ED was once thought of as a natural consequence of the aging process. However, results of the Health Professional’s Follow Up Study (HPFS) identified several modifiable health behaviors associated with erectile and sexual function.31 The HPFS, a prospective clinical study sponsored by Harvard’s School of Public Health in collaboration with the National Cancer Institute that began in 1986, is investigating the relationship between nutritionally related factors and diet on diseases such as cardiovascular, cancer, and others within the male population.32 The subjects recruited are employed in the health professions such as osteopathic doctors, pharmacists, veterinarians, dentists, podiatrists, and optometrists.32 One area being studied by the HPFS is the influence obesity and BMI has on disease. The HPFS shows that body leanness and physical activity are strongly associated with reduced risk of ED.31 The HPFS showed that subjects with a BMI greater than 28 kg/m2 had a 30% higher risk for ED.31 Risk factors including increased BMI, physical inactivity, smoking, and alcohol consumption increased prevalence of ED.31 This study also showed that central adiposity, insulin resistance, systemic inflammation and circulation of proinflammatory cytokines, and endothelial dysfunction were all commonly observed in obese men with ED.31 In 2000, Derby and colleagues examined the association between obesity, lifestyle factors, and risk of developing ED in 593 men.33 The researchers showed that men who had a BMI greater than 50 kg/m2 had a higher incidence of ED compared to men with a normal BMI. In another study investigating the relationship between obesity and coronary heart disease risk factors as predictors of ED among 570 subjects, researchers

found that a BMI greater than 28 kg/m2 was a significant predictor of ED independent of hypercholesterolemia and age.34 Esposito and colleagues asserted that men with ED were more likely to have greater central adiposity and increased waist measurement, obesity, and concurrently high blood pressure and hypercholesterolemia.35 Corona and colleagues concurred that the most prevalent form of sexual dysfunction in men with metabolic syndrome was ED, with 96% of obese men presenting with this condition.36 In addition, 40% of men with metabolic syndrome expressed suppressed sexual desire and 5% exhibited delayed ejaculation. Compared to healthy, nonobese men, low levels of testosterone and subsequent hypogonadism was observed to be more prevalent in aging, obese men with metabolic syndrome.36 While pharmacological agents such as sildenafil (Viagra) or tadalfil (Cialis) are the standard first-line treatment for most patients with ED, limited studies have shown some naturally occurring nutrients, such as arginine, maca, ginseng, ginkgo biloba, and DHEA, to improve ED in certain cases.37 Arginine is an amino acid found in nuts, legumes, seafood, poultry, eggs, and some vegetables. L-arginine is the precursor of nitric oxide, integral to the proper vascular and endothelial function necessary for erection.37 Ginseng, ginkgo biloba, and maca root have also been shown to influence the function of nitric oxide, whereas DHEA shows limited use as a sexual enhancer.37 While further research is needed to gain insight on the relationship between these nutrients and ED treatment, RDs should be aware of what foods naturally contain these components to better educate their patients and practice prudence when recommending these nutrients in the supplement form. The RD can influence positive treatment of ED by counseling the patient about weight loss and treatment for metabolic syndrome. In particular, the Dietary Approaches to Stop Hypertension (DASH) diet is clinically shown to reduce hypertension and may indirectly prove useful in the treatment of ED. Using a systematic literature search on the role or effect of diet on ED, Esposito and colleagues showed that diets high in fruits, vegetables, whole grains, nuts, and fish, and low in red meat and processed grains showed more effectiveness in ameliorating ED.38 These types of foods are typically represented in Mediterranean and DASH diets and are believed to improve ED indirectly by having positive effects on blood pressure, reducing inflammation and oxidative stress, and improving cardiac and endothelial function.38 Until any new evidence emerges on how nutrition may improve ED directly, any dietary recommendations specific to patients with ED would do well to stick to the preceding parameters.

Obesity and Sexual and Reproductive Dysfunction in Females Research investigating the relationship between obesity and FSD is scarce. In an early study by Kirchengast and colleagues (1996), the researchers found a positive relationship among body weight, BMI, and degree of reduced sexual interest.39 The researchers were investigating the relationship among body

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CPE MONTHLY composition, androgen levels, and sexual interest in 171 postmenopausal women and found those with higher body weight and higher subcutaneous fat in the chest, waist, and hips suffered from sexual disinterest.39 In a more recent study, Esposito and colleagues (2008) showed that obesity negatively affected several aspects characteristic of FSD including arousal, lubrication, and satisfaction.40 Using the Female Sexual Function Index (FSFI), a 19-item, validated self-report questionnaire, the researchers identified a negative relationship among body weight, sexual function, and abnormal FSFI score.40 However, unlike the results from Kirchengast and colleagues, these researchers reported that central fat distribution didn’t correlate with the FSFI score and suggests the total fat amount rather than its distribution affects greater FSD.40 Women with metabolic syndrome also have an increased prevalence of FSD compared to women without metabolic syndrome.41 These results suggest that these patients may also benefit from the DASH diet as an initial treatment for metabolic syndrome.41 More research has been done on the effects of obesity in pregnancy with regard to maternal complications during preconception and pregnancy, as well as postpartum consequences and fetal complications both during development and postnatal. In a multicenter, prospective study, Weiss and colleagues associated an increased risk for GDM, gestational hypertension, preeclampsia, and fetal macrosomia in obese mothers with BMIs of 30 to 39.9 compared with those less than 30.42 Regarding preconception, obesity negatively affects the fertility of women and is linked to neuroendocrine and ovarian dysfunction.42 Early reproductive dysfunction seen with obesity includes precocious menarche (early puberty before the age of 8), irregular menstrual cycles, dysmenorrhea (painful menstrual cycle), amenorrhea (absence of menstrual cycle), and chronic anovulation (absence of ovulation).43 Obesity is also an independent risk factor for miscarriage in women who conceive through in vitro fertilization.44 Obesity and antepartum complications include increased risk for GDM, hypertensive disorder, preeclampsia, thromboembolism, intrauterine fetal death, and stillbirth.45 The exact causes of preeclampsia in obese women isn’t known, but it’s suspected to be caused by increased oxidative stress and altered vascular function caused by infiltration of white blood cells called neutrophils.46 Preeclampsia—diagnosed by the presence of a systolic and diastolic pressure of >140 and >90 mm Hg, respectively, and concomitant 24-hour proteinuria >0.3 g—is a cause of maternal morbidity and mortality. Some estimates show that up to 15% of maternal deaths can be directly attributed to preeclampsia and eclampsia.47 It’s hypothesized that nutrition plays a role in preventing preeclampsia. While it is known that obesity increases the risk of preeclampsia, it’s surmised that calcium, vitamin E, arginine, folate, oleic acid, and carotenoids can play a role in the prevention of preeclampsia, although the exact contributing mechanism is unknown.48

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Obese women also have higher incidences of intrapartum complications such as poor labor progress. Sheiner and colleagues found that obesity is an independent risk factor for the need for Cesarean birth.49 In addition, obesity is associated with increased need for labor induction with a significantly greater risk of uterine dehiscence, rupture, morbidity, and injury to the newborn.50 Maternal obesity also affects the gestational weight for age of neonates. Macrosomia, excessive birth weight, has increased and can be attributed to increased insulin resistance and higher plasma triglycerides of the mother that can be transferred to the growing fetus.51 Fetal hyperinsulinemia may also contribute to macrosomia.51 For these women, nutrition counseling to prevent/control GDM is necessary to reduce the risk of these fetal comorbidities. GDM is defined as the presence of diabetes in varying degrees during pregnancy.52 Abnormally high blood glucose, carbohydrate intolerance, and ketonuria, excretion of ketones in the urine, are common symptoms of GDM.52 The strategies of MNT for GDM include emphasizing low-fat, low-sugar, and carbohydrate-controlled food choices with moderate energy restriction, and promoting appropriate weight gain during pregnancy.52,53 Achieving normal glucose levels and preventing excretion of ketones, while meeting the nutritional needs of both mother and fetus, is also a goal and can be best achieved with patient-centered MNT facilitated by an RD.53

Obesity and the Influence on Infectious Disease The WHO defines an infectious disease as one that can be spread from person to person either indirectly or directly and is caused by microorganisms such as bacteria, viruses, parasites, or fungi.54 Epidemics of infectious diseases have been documented throughout history. From the bubonic plague in the 14th century to the more current HIV, malaria, and influenza that continue to devastate populations in the 21st century, infectious disease hasn’t been obliterated. However, advancements in medicines such as antibiotics and antivirals, and procedures such as the practice of vaccination, universal precautions and sterile environments, have made a significant contribution to saving lives and reducing human suffering. According to the Centers for Disease Control and Prevention, infectious disease causing polio, smallpox, tetanus, diphtheria, measles, mumps, and rubella have nearly been eradicated.55 However, as incidence of infectious disease waned, noninfectious, noncommunicable, chronic disease prevails as the major cause of death and disability on a global scale. Chronic, noninfectious diseases such as obesity, diabetes, heart disease, and others leads to a death toll greater than that seen with infectious diseases including HIV, malaria, and tuberculosis.54,56 According to the WHO, today more than 60% of total deaths worldwide are attributed to chronic disease.56 Paradoxically, while defined as a chronic disease by the AMA and a risk factor for noncommunicable disease by the WHO, obesity is shown to increase the risk of infectious disease.56 As obesity is regarded as inflammatory and

immunosuppressive, studies show obese individuals have impaired immune function, leaving them more susceptible to infectious diseases such as tuberculosis, influenza, coxsackie virus, encephalomyocarditis, and helicobacter pylori.57 Obese and hospitalized patients are also at greater risk for nosocomial infections and secondary infections such as sepsis, pneumonia, wound and surgical-site infections, and bacteremia.58 In addition, as previously described, since obesity compromises the pulmonary system, hospitalized obese patients are at higher risk for respiratory infections.59 One explanation for increased susceptibility relates to how obesity negatively affects the immune system by impairing the function and amount of specific cellular players of the immune response.57 Obesity is shown to decrease the overall number of lymphocytes, specifically the macrophages, T-cells, B-cells, and natural killer cells.57,60 In addition to lowering the amount of immune cells, obesity negatively affects the activity of these cells and reduces the body’s ability to respond to pathogenic activity.60 Since obesity is considered systemically inflammatory, there’s increased circulation of tumor necrosis factor (proinflammatory) with concomitant decrease or dysregulation in other immune-mediated cytokines.60 Obesity is considered an independent risk factor for morbidity and mortality from H1N1 influenza. Louie and colleagues noted extreme obesity was associated with increased odds of death from H1N1.61 In a prospective, observational and multicenter study, Diaz and colleagues found patients admitted to the ICU in Spain who were infected with H1N1 and concomitantly obese with a BMI greater than 30, utilized more health care resources because they required longer mechanical ventilation, longer ICU stay, and longer overall hospitalization. In this study, increased mortality was not observed.62 Research also finds obesity to negatively affect the response to vaccinations by decreasing the body’s ability to produce protective antibodies. Sheridan and colleagues showed that high BMIs positively correlated to declining antibody titers after influenza vaccination.63 In addition, obesity decreased the function of CD8+ receptors and memory T-cells, thereby reducing the immune system’s ability to protect the body from progression and rapid severity of the influenza disease.57 Studies have shown reduced efficacy of other vaccines such as the hepatitis B vaccine. Young and colleagues found that a standard three-dose vaccination of hepatitis B had only a 71% protection rate in subjects who had BMIs of 30 or higher compared to 91% in lean subjects.64 Conclusions from these studies imply that response to vaccinations may be suboptimal for obese patients, thereby providing limited protection.

Nutrition and the Immune System What does this all mean for the nutrition professional? The immune system is highly complex and intricately intertwined with nutrition. See Table 2 online for a summary of nutrients, their function in the immune system, and foods that contain that particular nutrient.

Nutrients that affect the immune system function either synergistically or antagonistically, and their availability or deficiency may enhance or impair the immune system.65 For example, a deficiency of both selenium and vitamin E is shown to impair thymus function, deplete lymphocytes, and subsequently suppress humoral immunity responsible for antibody production.65 Vitamin E deficiency is also linked to higher production of prostaglandins, which are immunosuppressive. Vitamins A and D have a synergistic effect on the maturation and function of monocytes. Vitamins E and C also have a synergistic effect on the reduction of the immunosuppressive arachidonic acid. Zinc deficiency is highly associated with a suppressed immune system by restraining the function of the thymus gland, lymphocyte production, and development and B-cell function.65 This information is relevant to the nutrition professional because obesity itself is a form of malnutrition that presents commonly with vitamin and mineral deficiencies. Research shows obese individuals present with deficiencies in vitamin D, thiamin, folic acid, iron, B12, zinc, phosphorus, B6, and potassium.66 In addition, Kaider-Person and colleagues found that serum levels of vitamins A, E, and C are also significantly lower in obese individuals than in the nonobese population.67 Since more research needs to be done on the effects of individual nutrient supplementation, a dietary recommendation RDs can make is to encourage their clients to follow a balanced diet consisting of nutrient-dense foods. If individual nutrient supplementation is recommended to treat a particular deficiency, dietitians should be aware that the interactions of nutrients with the immune system may have a synergistic or antagonistic effect, and the goal should be to avoid excessive intakes of singular nutrients. Laboratory studies to monitor vitamins and minerals should be incorporated as a part of an interdisciplinary and patient-centered approach to care.

Current Treatment Modalities for Obesity While this article addresses the less-discussed conditions caused by obesity and their treatment, treating obesity involves prevention, which is the goal of many local and federal initiatives. However, for those who already suffer from this disease and related consequences, a variety of successful treatment options exist. It’s broadly recognized that a weight loss of 5% to 15% significantly reduces health-related risks of obesity.68,69 Recognized treatment modalities include individualized, interdisciplinary programs that promote lifestyle changes through regimens tailored to address the psychosocial, dietary, and physical activity requirements for weight loss.68,69 Pharmacotherapy and antiobesity drugs have been developed and are intended to be used in conjunction with these traditional obesity treatment programs. According to the National Institutes of Health’s 57-NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, weight loss drugs can be useful in patients with BMIs

december 2015 www.todaysdietitian.com 49

CPE MONTHLY greater than 30 with no concomitant risk factors in conjunction with weight loss programs and continued monitoring by a physician for efficacy and safety.69 Weight loss medications haven’t been shown to be without risks. In the early 1970s, fenfluramine was introduced as an appetite suppressant and weight loss medication. However, in 1997, fenfluramine (Fen-Phen, brand names: Adipex-P, Fastin, et al) was taken off the market because of pulmonary and cardiovascular safety concerns. In 1997, sibutramine (brand name: Meridia) was subsequently approved by the FDA but removed from the market in 2010 as a result of concerns about cardiovascular safety.70 Currently used antiobesity medications are: orlistat (overthe-counter name: Alli; prescription strength: Xenical), lorcaserin (brand name Belviq), and phentermine/topiramate combination (brand name: Qsymia). While lorcaserin and phentermine/topiramate are the first two new antiobesity medications approved in more than 13 years, and double-blind clinical trials on both showed positive results in efficacy and safety, the FDA is requiring long-term postmarketing studies to include outcomes trials on cardiovascular risk.71 Metabolic and bariatric surgery is recognized as a longterm treatment option for obesity.72 Historically, there have been many surgical variations of bariatric surgery including the jejunoileal bypass and the vertical banded gastroplasty. However, these procedures are no longer performed, partly because of high complication rates and the advent of newer, safer procedures. The four major bariatric procedures performed worldwide are biliopancreatic diversion with/ without duodenal switch, the adjustable gastric band, the Roux-en-Y gastric bypass, and the sleeve gastrectomy, with the latter becoming the fastest-growing bariatric procedure worldwide because of successful patient outcomes and fewer complications.72 (“Vertical Sleeve Gastrectomy — Considerations and Nutritional Implications,” a course by this author, is available at www.todaysdietitian.com/pdf/courses/ CraggsDinoVSG.pdf.) The total number of bariatric surgeries performed worldwide from 2008 to 2011 exceeded 340,000.72 In 2011, the United States and Canada performed more than 101,000 bariatric surgeries and more than 19% were sleeve gastrectomy.72 Reductions in BMI at one year for the gastric bypass, sleeve gastrectomy, and adjustable gastric band were 15.34, 11.87, and 7.05, respectively, indicating positive weight loss outcomes.73 In addition to positive weight loss, the popularity of bariatric surgery comes from effective amelioration of comorbid conditions such as type 2 diabetes, hypertension, and OSA.73 Hutter and colleagues reported that patients who underwent gastric bypass experienced an 83%, 79%, and 66% remission of type 2 diabetes, hypertension, and hyperlipidemia and OSA, respectively.73 In the Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) Trial, a recent single-center, three-arm, randomized, controlled study, 150 patients were randomized into one of three intervention

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groups. Group 1 received no bariatric surgery but received MNT to treat diabetes according to the guidelines of the American Diabetes Association. This intervention included lifestyle counseling, weight management, home glucose monitoring, and pharmacotherapy using the incretins.74 Groups 2 and 3, respectively, received MNT and bariatric surgery, the sleeve gastrectomy, or the gastric bypass. Eligibility criteria included patients with uncontrolled type 2 diabetes of more than eight years, an A1c greater than 7%, (mean A1c was 8.9% to 9.5%) and metabolic syndrome (high lipids, high Bp); between the ages of 20 and 60 with a BMI from 27 to 43. All patients were treated with glucose-, lipid-, and blood pressure-lowering medications.74 Results showed that rapid improvement was seen in the first three months with surgery compared with a more gradual improvement with medical therapy. Interestingly, the surgical group showed more positive outcomes in terms of medication usage. The average number of diabetes medications per patient per day increased in the medical therapy group, but significantly decreased in the surgical groups. Insulin remained high at 38% in the medical therapy group, but was reduced to 4% and 8% in the gastric bypass and sleeve gastrectomy groups, respectively. In addition, there was an increase in HDL and a reduction in total cholesterol after the surgeries compared to that achieved through medical therapy.74

Conclusion While there’s disagreement about whether obesity is a disease or condition, it’s universally accepted that obesity causes conditions that can lower quality of life and endanger the overall health and well-being of the individual. This article highlights the lesser-mentioned disorders of obesity to bring to the forefront the magnitude and far-reaching negative health effects. The role of RDs is to work collaboratively across programs and in an interdisciplinary approach with other health care professionals. While it’s ideal to prevent obesity in the first place, nutrition professionals can assess the individual needs of patients with existing obesity and make dietary recommendations based on their specific needs and comorbid influences. Obesity itself is complicated to treat. However, with the help of RDs, there’s hope for patients who suffer from obesity and its consequences. RDs can affect and positively influence patients’ well-being through appropriate and patient-centered nutrition recommendations. — Lillian Craggs-Dino, DHA, RDN, LDN, is a national and international speaker, a freelance food and nutrition writer, and a practicing bariatric dietitian and support group coordinator for a renowned bariatric program in South Florida.

For references and tables, 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. According to proponents of declaring obesity as a

disease, doing so will: a. E xtend advocacy for research for prevention and treatment of obesity b. Minimize insurance coverage for the identification, prevention, and treatment of obesity c. Increase social stigma associated with obesity d. Decrease professional and public awareness about obesity 2. Which of the following best describes obesity?

a. A metabolic disease b. Primarily environmentally dictated c. Independent of psychosocial influences d. Caused by eucaloric intake 3. Which of the following increases the risk for obesity

hypoventilation syndrome (OHS)? a. A BMI less than 25 b. Central adiposity c. Having a pear-shaped body composition d. A good night’s sleep 4. Results of a nutrition-focused physical exam on a

patient who presents with OHS are likely to show which of the following? a. Temporal wasting b. Cyanosis of the lips and skin c. Ascites d. Bitot’s spots

6. Which vitamin is an antioxidant that influences the function of lymphocytes? a. Vitamin C b. Vitamin B12 c. Selenium d. Folic acid 7. Which micronutrient influences the bactericidal activity of macrophages? a. Zinc b. Vitamin A c. Vitamin D d. Iron 8. Which micronutrient(s) influence the function of the white blood cells called neutrophils? a. Selenium b. Copper c. Zinc d. All of the above 9. The Surgical Therapy and Medications Potentially

Eradicate Diabetes Efficiently Trial was a controlled randomized study that investigated the effects of which of the following? a. MNT to treat obesity b. Medications to eradicate obesity c. Bariatric surgery on diabetes mellitus d. BMI and risk of comorbidities 10. Which medication is no longer available to treat

5. Effects of obesity on pregnancy include which of the

following? a. Lower risk for gestational diabetes b. Lower risk for gestational hypertension c. Lower risk for preeclampsia d. Higher risk for complications during natural labor and delivery

obesity? a. Lorcaserin b. Phentermine/topiramate combination c. Fenfluramine d. Orlistat

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.

december 2015 www.todaysdietitian.com 51

FOCUS ON FITNESS

BARRE WORKOUTS Low in Impact, High in Benefit By Jennifer Van Pelt, MA We all admire the lean, strong dancer’s body. Barre workouts, based on the barre exercises performed by ballet dancers, promise to help sculpt your body into that of a dancer and have rapidly grown in popularity over the last year. As with all trendy new exercises, your clients may be asking, “Should I try it?” The “classic” barre workouts use only body weight and movements at the barre, with participants lined up along the barre like ballet dancers. However, the high interest in barre classes has led some companies and instructors to incorporate other exercises into the routine. Called fusion barre workouts, these hybrid classes may add strength training with weights or resistance bands, stretching and strength moves with small exercise balls, Pilatesbased movements, yoga poses, interval training, or body weight exercises (eg, push-ups) on a mat beside the barre. Most barre workouts are performed barefoot, although fusion barre workouts might require athletic shoes depending on the exercises included in the class. With marketing messages focused on achieving long, lean muscles and ballet dancer bodies, barre workouts appeal mostly to women, who may be intimidated by boot camp-style classes and heavy weight lifting to gain muscular strength and endurance.

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The fitness benefits of barre workouts include the following: • Low or no impact: Generally performed without shoes, barre workouts involve low- or no-impact movements that work muscles without the stress on joints. However, low impact doesn’t mean low intensity. • Targeted muscles: The isometric barre exercises target all lower body muscles, including the gluteus minimus, hip adductors, and lateral rotators (smaller muscles around the hip area), by making subtle changes in the angle of leg lifts or body and leg positioning. Workouts like CrossFit and cycling usually only target the larger muscle groups—the gluteus maximus, quadriceps, and hamstrings. • Core strengthening: The stability of the body during leg movements and other barre exercises comes from the core muscles (abdominals, back, hips). To advance to more challenging barre exercises, participants must learn how to engage and strengthen their core muscles. • Improved balance: Barre exercises performed on one leg and on the toes help improve balance, an often overlooked component of physical fitness. • Pregnancy-friendly: Classic barre workouts that perform all movements at the barre may be a good alternative form of exercise during the later stages of pregnancy. For fit pregnant women, stopping certain exercises after the first trimester (eg, those performed lying on the back or belly) leaves them with few options for maintaining core strength. Provided there are no other restrictions on exercise or health issues, pregnant women may want to try a barre workout class. • Mind-body awareness: Like yoga and Pilates, barre workouts involve mental focus and awareness of the body. Small, repetitive movements that generate a burn require not only physical but also mental endurance. The effectiveness and durability of barre workouts relative to other types of workouts are being addressed by fitness media sources like Shape and Fitness magazines. Unlike other activities, such as Spinning, Zumba, yoga, and weight lifting classes, barre workouts don’t appear to have been studied and no research articles have been published on their physiological benefits and/or risks. The repetitive movements during barre workouts may cause stress injuries for some participants, especially if they use the same muscle groups in other activities. In addition, some leg positions may not be appropriate for participants with hip or knee arthritis. In the absence of published scientific studies, I reviewed online news articles, blogs by barre workout participants, and websites of barre workout providers. Based on that review, I learned the following: • There are approximately 800 barre-related franchises or studios currently operating in the United States. Barre workouts also are offered at gyms, yoga studios, and boutique fitness studios and may not have been included in the estimated number of facilities offering barre workouts. • Barre workouts are offered online, and can easily be

performed at home with either a portable barre or a sturdy chair or countertop of an appropriate height. Numerous barre workout DVDs also are available. • Instructor certifications specifically for barre workouts are being offered by several branded barre workout companies, by the American Council on Exercise (see www.acefitness.org/continuingeducation/ courseapproved/4a586zx7/fit-in-60-barre-certification), and by the International Ballet Barre Fitness Association (see http://barrecertification.com). • Barre workouts vary considerably depending on the instructor and the facility. Dance and yoga studios seem to offer more “classical” barre workouts based on traditional ballet, Pilates, and yoga movements. Gyms seem to offer more athletic barre options, including “cardio barre” workouts. According to barre workout participant blogs, a “love it or hate it” reaction is common. The atmosphere of the barre facility, the instructor personality, and class type seem to affect whether a participant will continue regular barre workouts.

Advice for Clients As with any new exercise activity, clients interested in barre workouts should do their research and choose the best type of class to suit their fitness level. Encourage clients who are new to exercise or deconditioned to look for an introductory class that’s shorter and provides an introduction to barre movements. Clients with arthritis

shouldn’t exclude the possibility of barre workouts; instructors should be able to provide modifications for any movements that put strain on arthritic joints. Athletic clients may find fusion barre classes with integrated traditional strength training movements more appealing. Pregnant clients should obtain a doctor’s clearance before trying barre workouts and also ask the instructor for pregnancy modifications. Clients who are familiar with Pilates likely will have the easiest transition to a barre workout due to the core strength focus and dance-based leg exercises in Pilates. Since many yoga studios have branched out into offering barre classes, clients may find some beginning and introductory classes there, as instructors introduce yoga participants to the benefits of barre workouts. The qualifications and personality of the barre instructor should also be considered. While barre certification isn’t necessarily a requirement, instructors should have a group fitness industry certification and training in barre exercises. Clients who like to be pushed may prefer instructors with a more traditional, strict “boot camp” attitude, while others may prefer instructors with a gentler style. Barre workouts won’t be the right fit for everyone, but they’re certainly worth trying because of their fitness benefits. — Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Reading, Pennsylvania, area.

STAND OUT

FROM THE CROWD. You bring a unique set of skills and personality traits to any workplace. You have the education, experience, and drive to succeed. You just need that next great opportunity to put it all on display. Visit AlliedHealthCareers.com to post your résumé and find the kind of opportunities that will allow you to stand out from the crowd. Set up custom job alerts to have opportunities that match your criteria delivered to your inbox. Our online job board presents hundreds of current openings for qualified professionals in dietetics. Once you find the ones that are right for you, apply and give yourself the chance to shine.

december 2015 www.todaysdietitian.com 53

BOOKSHELF Diabetes: 365 Tips for Living Well: Expert Advice to Help You Thrive Each Day By Susan Weiner, MS, RDN, CDE, CDN, and Paula Ford-Martin July 2015, demosHEALTH Paperback, 152 pages, $16.95

Authors Susan Weiner, MS, RDN, CDE, CDN, a dietitian based in New York, and Paula Ford-Martin, a health writer and editor based in Connecticut, have an informative, evidencebased book about diabetes. What sets this book apart from other diabetes books is the way in which it’s organized. Each chapter is dedicated to one month of the year and includes one tip or fact for each day within that month. These tips are relevant to the seasons, holidays, weather, and even major sporting events. For example, the first chapter is dedicated to the month of January, so the tips for that month are centered on resolutions and new beginnings. Each month has timely health messages in addition to random facts. The message for February 3 is “Bundle Up Your Blood Sugar Meter,” which informs readers that freezing temperatures can negatively affect the accuracy of blood glucose testing supplies. The tip states: “Freezing temperatures can affect the accuracy of your blood sugar testing supplies. If you are braving the elements outdoors for skiing or snowman building, make sure your meter and strips stay warm by storing them in an insulated bag. The same goes for insulin: Frozen insulin is ineffective insulin.” In essence, Diabetes: 365 Tips for Living Well is akin to having a calendar within a book that you’d pull out each day to garner some new diabetes, health, or nutrition knowledge. While I like the idea of providing information in small doses, I think the medium in which this information is provided to consumers would be better suited in a perforated/tear sheet desk calendar or an app that alerts the user’s phone with a new message each morning. Perhaps this can be an idea for a future publication by these authors. Weiner maintains a website and blog at www.susanweiner nutrition.com, and Ford-Martin highlights her recent work and services at www.wordcrafts.com.

— Janice H. Dada, MPH, RD, CSSD, CDE, CHES, is a dietitian in private practice and consulting (SoCal Nutrition & Wellness, www.socalnw.com), and an adjunct faculty member at Chapman University and UC Irvine. Follow her on Instagram and Twitter @SoCalRD.

Gluten-Free Classic Snacks: 100 Recipes for the Brand-Name Treats You Love By Nicole Hunn April 2015, DaCapo Press Paperback, 310 pages, $19.99

Clients and patients with celiac disease or nonceliac gluten sensitivity who want to eat a gluten-free version of an indulgent chocolate treat or cream-filled snack cake they can’t find on store shelves may be interested in Nicole Hunn’s Gluten-Free Classic Snacks. The book features recipes for brand-name breakfast foods, snacks, and desserts that have been sold in grocery stores for years, such as Strawberries & Cream Quaker Instant Oatmeal, Weight Watchers Chocolate Brownies, Fiber One Chewy Bars Oats and Chocolate, Keebler Club Crackers, Nabisco Nilla Wafers, Kellogg’s Pop-Tarts Toaster Pastries, and Drake’s Coffee Cakes. Popular treats from Nature Valley, Entenmann’s, Pepperidge Farm, Little Debbie, and the Girl Scouts also are featured. “Most of the companies that make the original versions of these snacks are likely never going to offer a packaged gluten-free version,” Hunn writes, noting that every recipe in the book originated from the list of ingredients on the manufacturer’s package. Cleverly organized into categories such as cookies, snack cakes, breakfast and fruity treats, crackers, and candy, the author begins with a comprehensive chapter on all of the basics clients will need to know to re-create

the brand-name products. The author provides a helpful overview of gluten-free flours and homemade flour blend recipes. Readers are privy to a summary of essential ingredients and substitutions. Kitchen tools and equipment also are discussed, as are tips and tricks for making the mouthwatering treats. Hunn begins each recipe with a paragraph sprinkled with her personal sentiments, as well as baking tips and variations to try. The recipes appear straightforward and easy to follow. Lots of full-page, color photos enhance the book along with an index listing the featured recipes. The author, who cooks gluten-free foods and desserts for her family and is the creator of the Gluten-Free on a Shoestring book series and blog, has been featured in The New York Times and Better Homes & Gardens, among other prominent publications. In fact, the recipes in Gluten-Free Classic Snacks were designed with a budget in mind, too. Yum, yum, and triple yum was my gut reaction (pun intended) upon discovering Gluten-Free Classic Snacks. Clients are sure to enjoy this refreshing take on gluten-free living. — Karen Appold is a freelance medical writer and editor based in Lehigh Valley, Pennsylvania.

The Science of Skinny Cookbook: 175 Healthy Recipes to Help You Stop Dieting — and Eat for Life! By Dee McCaffrey, CDC December 2014, DaCapo Press Paperback, 336 pages, $17.99

For author Dee McCaffrey, CDC, the “science of skinny” isn’t simply a catch phrase bandied about in nutrition education circles. Rather, it’s a concept that she had personally embraced during her journey to lose 100 lbs and keep them off for more than 20 years. In The Science of Skinny Cookbook, McCaffrey revisits many of the

concepts found in her original book The Science of Skinny, but she also includes a wealth of recipes that celebrate a healthful way of eating for life. McCaffrey is quick to assert that while the term “skinny” figures prominently throughout her book, the cookbook is much more about shedding pounds in a healthful way by eating nutritious foods and improving overall health. In her first book The Science of Skinny, McCaffrey, an organic chemist and certified diet counselor and nutrition educator, evaluated the relationship between chemical food additives and health. McCaffrey’s motivation to write The Science of Skinny Cookbook happened as a result of her chemistry background. Back when she was working at a laboratory in college, she happened to glance at the ingredients list on a box of cake mix that she was about to prepare. One particular ingredient caught her attention: sodium lauryl sulfate, the same chemical she used in the lab to test for water pollutants—and the same chemical that’s used in cosmetics, shampoos, laundry detergents, and other cleaning products. From that moment on, McCaffrey was determined to begin paying attention to the role chemical food additives play in human health and obesity. The Science of Skinny Cookbook further embraces McCaffrey’s findings by featuring 175 recipes that help users ditch the junk food and incorporate natural whole foods into their diet. While there are a plethora of natural food cookbooks available, McCaffrey educates readers long before they begin making any of the recipes. McCaffrey devotes more than 50 pages to explaining the nuances of “foods that steal, foods that heal.” She later discusses the unprocessed foods and ingredients every kitchen should have. In addition, McCaffrey offers healthful alternatives to processed ingredients that readers may use in their favorite recipes. The recipes found in the cookbook are simple to make, budget friendly, and minimally processed. And they appear to offer a wealth of options to satisfy a variety of palates, including Joyful Chocolate Almond Bars, Herb-Crusted Salmon, Thai Basil Chicken, and Rosemary-Topped Flourless Cornbread. The cookbook encourages readers to change the way they think about dieting. Rather than focusing exclusively on losing weight, McCaffrey provides the knowledge and motivation they need to change the way they eat for life. — Maura Keller is a freelance writer based in Minneapolis.

GET TO KNOW…

REBECCA SCRITCHFIELD Advocating Health and Happiness Through Wellness, Not Weight Loss By Juliann Schaeffer As founder and CEO of Capitol Nutrition Group, LLC, and Rebecca Scritchfield Media, LLC, Rebecca Scritchfield, MA, RDN, HFS, has used her “health hat” to spread healthful nutrition messaging across a variety of media channels. She’s appeared on national television shows such as “Today” and on Oprah Winfrey’s OWN channel. She’s shot corporate wellness videos for Allstate Insurance and Bayer Healthcare. She’s worked with dozens of food- and healthrelated brands in various ways, and she’s even working on her first book. Such national exposure has allowed her to reach millions with her message that happiness comes from being well, not losing weight. But what does Scritchfield say is her biggest career highlight? Counseling clients and the difference she’s made by helping them embrace these seemingly simple principles. “They inspire me with their courage to face challenges head-on and their perseverance to be the person they want to become,” she says. “Counseling has taught me that people are more alike than different. It’s fascinating to explore the irrevocable connections of food to health, happiness, and community.” Health and happiness: It’s not only the subject of her book but also the foundation for much of her success. And that focus starts with her. “I take anywhere from five to 15 minutes each morning, usually while I’m getting ready or having my first cup of coffee, to have a quick business meeting with

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myself,” she says. “The agenda is the same each day: the business of Rebecca’s well-being.” It’s a self check-in of sorts to monitor how she’s feeling and what she can do to ensure she’s at her best every day. And that focus on wellness follows her, whether she’s counseling clients or working on any of the various nutrition gigs afforded through her media company. Scritchfield acknowledges one of the biggest challenges she faces is time management, and ensuring all opportunities coming her way are handled effectively and efficiently. “As an eternal optimist, I have the fatal flaw of accidentally overcrowding my calendar thinking that I can get a task that really needs an hour done in 20 minutes,” she says, noting that running her own business makes it especially difficult to discern where work ends and personal priorities begin. “I think entrepreneurs are particularly challenged because it’s your business. Nobody will care about it more than you and there’s always a new opportunity around the corner.” To find a balance that works for her, she’s found scheduling her days down to the minute helps to keep her business on track—without sacrificing her personal life. “I even schedule my lunch, workout time, and the ‘buzzer’ for the end of my workday when I need to transition to fixing dinner,” she says. By putting her own wellness front and center, Scritchfield knows just how to overcome her limitations while capitalizing on her strengths—such as working on her book in the morning hours, when she’s most productive. Taking a multitude of mini-breaks to keep her brain fresh is also on the daily to-do list. “Oh, and I work standing up,” she says of another trick to working (and keeping) well. “I highly recommend it.” Today’s Dietitian (TD): What do you enjoy most about your job or dietetics in general? Scritchfield: Having some sort of validation that I’m making someone’s life better—whether it’s hearing, “This was really helpful,” “I’m happier now,” or “You’ve changed my life.” TD: What inspires you and keeps you motivated? Scritchfield: Knowing that people are really struggling with reconciling their health and happiness. In particular, they’ve been emotionally damaged by dieting and calorie control tactics in the name of health, and they realize that they need something more sustainable that makes them feel good, both inside and out. TD: You have two daughters. How has motherhood either changed or helped to mold your approach to nutrition counseling? Scritchfield: Becoming a mom has made me even more empathic toward being busy and feeling overwhelmed. I’ve witnessed how women in my family put themselves last and their health suffered. While becoming a mom didn’t convince

“ I don’t put people on weight loss plans because diets don’t work in the long term for most people. Instead, I place a focus on a person’s desires, interests, and curiosities around what it means to live a healthful life.” me that it’s OK to put myself last, I could really feel why so many moms and busy women struggle with the idea. TD: What’s one lesson that motherhood has taught you that can be applied to nutrition counseling? Scritchfield: There will be highs and lows. TD: In your opinion, what’s the most important nutrition message RDs should be communicating today? Scritchfield: “I’m listening.” All too often our advice is filled with “shoulds” and “to-dos,” but we need to be talking less and listening more. Intrinsic motivation is based on an individual’s interest and curiosity. It’s most likely to lead to long-term change. This approach respects individuals and their power of choice. Even those who don’t work in counseling settings can do more listening by offering ideas that support flexibility and discourage the idea that extreme approaches and rules aren’t necessary for health, and can in many ways be detrimental. TD: You advocate a weight-neutral, nondiet approach to nutrition counseling. Can you explain what this is and why you believe it to be an effective counseling strategy? Scritchfield: I don’t put people on weight loss plans because diets don’t work in the long term for most people. Instead, I place a focus on a person’s desires, interests, and curiosities around what it means to live a healthful life. I embrace the Health at Every Size principles, which include respectful care and enjoyable movement, and the evidencebased Intuitive Eating model by Evelyn Tribole, MS, RDN, and Elyse Resch, MS, RDN, CEDRD. I also use motivational interviewing as a tool for evoking hope and implementing a tailored plan for lasting change. TD: If you could offer your fellow RDs only one piece of advice, what would it be? Scritchfield: Always be a student. Lifelong learning will help you reach your best possible self. TD: What are your biggest aspirations? Scritchfield: My hope is that I can be part of a culture change in our society, in which health providers refrain from judging people’s health based on their weight and shape.

In particular, I’d like to contribute to the knowledge that health and happiness go hand-in-hand. Enjoying a healthful life that works for you will contribute to a satisfying and meaningful life. TD: List the top two gripes you hear from people about getting healthy and fit and your response to those gripes. Scritchfield: 1. “This is just too hard.” 2. “I’m not sure I can do this.” My response: “Describe a time when you were successful at something else.” This helps the person recall their resources and that their past efforts have led to success. TD: What’s your best advice for moms who can’t seem to get their children to have a healthful relationship with food? Scritchfield: I’m a huge fan of Ellyn Satter, MS, RDN, MSSW. Her eating competence models are evidence-based, clinically tested, and effective. I’d use her “division of responsibility” strategies, which include providing a variety of nutritious foods and an enjoyable eating environment while allowing growing kids to choose how much they eat. Satter’s books and resources can help the entire family heal their relationship with food. TD: What activities/enjoyment fills your downtime? Scritchfield: I love to listen to audiobooks while walking in nature. I do adult coloring book pages and give them away as gifts. — Juliann Schaeffer is a freelance health writer and editor based in Alburtis, Pennsylvania, and a frequent contributor to Today’s Dietitian.

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Non Celiac Gluten Sensitivity?? Above IBS Condition is described as the result of either or both occurrences: •High fructan levels in wheat (FODMAPS) (See 1st in series) •Amylase/Trypsin inhibitors in wheat kernel (See 3rd in series) Neither have anything to do with gluten so a more accurate label is: Modern Day wheat intolerance Syndrome

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december 2015 www.todaysdietitian.com 57

2016 ANNUAL RESOURCE GUIDE

ALTERNATIVE/COMPLEMENTARY CARE

Duke Integrative Medicine..................................59 Maryland University of Integrative Health........60 Salba Smart Natural Products, LLC.................. 61 The University of Chicago Celiac Disease Center................................................. 61 ASSOCIATIONS

Celiac Support Association.................................59 CONVENIENCE FOODS

Nasoya..................................................................60 Omega3 Innovations............................................60 Partners, A Tasteful Choice Company...............60 DIABETES CARE

Arctic Zero Fit Frozen Desserts.........................59 International Conference On Nutrition in Medicine.......................................................60 J & J Snack Foods Corp.......................................60 Nasoya..................................................................60 Nature’s Legacy...................................................60 Omega3 Innovations............................................60 Salba Smart Natural Products, LLC.................. 61 The University of Chicago Celiac Disease Center................................................. 61

Partners, A Tasteful Choice Company...............60 Salba Smart Natural Products, LLC.................. 61 GLUTEN-FREE

Almond Board of California................................59 Arctic Zero Fit Frozen Desserts.........................59 Authentic Foods...................................................59 Celiac Support Association.................................59 Cera Products, Inc...............................................59 Glutagest..............................................................59 Hodgson Mill........................................................60 J & J Snack Foods Corp.......................................60 Omega3 Innovations............................................60 Partners, A Tasteful Choice Company...............60 Salba Smart Natural Products, LLC.................. 61 The University of Chicago Celiac Disease Center................................................. 61 HEART HEALTH

ORGANICS

Hodgson Mill........................................................60 Nasoya..................................................................60 Nature’s Legacy...................................................60 Partners, A Tasteful Choice Company...............60 Salba Smart Natural Products, LLC.................. 61 PEDIATRIC HEALTH

Cera Products, Inc...............................................59 Hodgson Mill........................................................60 J & J Snack Foods Corp.......................................60 The University of Chicago Celiac Disease Center................................................. 61 PHARMACEUTICAL

Cera Products, Inc...............................................59 SOY

Nasoya..................................................................60 Hodgson Mill ........................................................... International Conference On Nutrition in Medicine.......................................................60

Celiac Support Association.................................59

Almond Board of California................................59 Authentic Foods...................................................59 Hodgson Mill........................................................60 International Conference On Nutrition in Medicine.......................................................60 Nasoya..................................................................60 Nature’s Legacy...................................................60 Omega3 Innovations............................................60 Partners, A Tasteful Choice Company...............60 Salba Smart Natural Products, LLC.................. 61

EDUCATION

LONG TERM CARE

Almond Board of California................................59 Bastyr University.................................................59 Celiac Support Association.................................59 Duke Integrative Medicine..................................59 Maryland University of Integrative Health........60 The Nutrition Company.......................................60 The University of Chicago Celiac Disease Center................................................. 61

Cera Products, Inc...............................................59 Glutagest..............................................................59 J & J Snack Foods Corp.......................................60

TREATMENT CENTERS

MEDICAL FOODS

VEGETARIAN/VEGAN

Authentic Foods...................................................59 Celiac Support Association.................................59 Cera Products, Inc...............................................59 DermaRite Industries LLC...................................... Omega3 Innovations............................................60 Salba Smart Natural Products, LLC.................. 61

Almond Board of California................................59 Authentic Foods...................................................59 Glutagest..............................................................59 Hodgson Mill........................................................60 International Conference On Nutrition in Medicine.......................................................60 J & J Snack Foods Corp.......................................60 Nasoya..................................................................60 Salba Smart Natural Products, LLC.................. 61

EATING DISORDERS CENTERS

FITNESS

Almond Board of California................................59 Hodgson Mill........................................................60 Nasoya..................................................................60 Nature’s Legacy...................................................60 Salba Smart Natural Products, LLC.................. 61

NUTRIENT ANALYSIS COMPUTER SOFTWARE

The Nutrition Company.......................................60

FOOD ALLERGY/INTOLERANCE

NUTRITIOUS FOODS

Arctic Zero Fit Frozen Desserts.........................59 Authentic Foods...................................................59 Celiac Support Association.................................59 Glutagest..............................................................59 Hodgson Mill........................................................60 J & J Snack Foods Corp.......................................60 Nature’s Legacy...................................................60 Partners, A Tasteful Choice Company...............60 Salba Smart Natural Products, LLC.................. 61 The University of Chicago Celiac Disease Center................................................. 61

Almond Board of California................................59 Authentic Foods...................................................59 Celiac Support Association.................................59 Hodgson Mill........................................................60 International Conference On Nutrition in Medicine.......................................................60 Nasoya..................................................................60 Nature’s Legacy...................................................60 Partners, A Tasteful Choice Company...............60 Salba Smart Natural Products, LLC.................. 61 The University of Chicago Celiac Disease Center................................................. 61

FOOD INGREDIENTS

Authentic Foods...................................................59 Celiac Support Association.................................59 Salba Smart Natural Products, LLC.................. 61 FOODSERVICE

Authentic Foods...................................................59 Hodgson Mill........................................................60 J & J Snack Foods Corp.......................................60 FUNCTIONAL FOODS/BEVERAGES

Arctic Zero Fit Frozen Desserts.........................59 Cera Products, Inc...............................................59 J & J Snack Foods Corp.......................................60

58 today’s dietitian december 2015

OBESITY

Hodgson Mill........................................................60 International Conference On Nutrition in Medicine.......................................................60 Nasoya..................................................................60 Salba Smart Natural Products, LLC.................. 61 ORAL HEALTH

J & J Snack Foods Corp.......................................60 The University of Chicago Celiac Disease Center................................................. 61

SUPPLEMENTS

Cera Products, Inc...............................................59 Glutagest..............................................................59 Omega3 Innovations............................................60 TECHNOLOGY

The Nutrition Company.......................................60 Cera Products, Inc...............................................59 J & J Snack Foods Corp.......................................60

WEIGHT MANAGEMENT

Arctic Zero Fit Frozen Desserts.........................59 Hodgson Mill........................................................60 International Conference On Nutrition in Medicine.......................................................60 J & J Snack Foods Corp.......................................60 Nasoya..................................................................60 Nature’s Legacy...................................................60 Omega3 Innovations............................................60 Partners, A Tasteful Choice Company...............60 Salba Smart Natural Products, LLC.................. 61 WHOLE GRAINS

Hodgson Mill........................................................60 International Conference On Nutrition in Medicine.......................................................60 Nature’s Legacy...................................................60 Omega3 Innovations............................................60 Partners, A Tasteful Choice Company...............60 Salba Smart Natural Products, LLC.................. 61 WOMEN’S HEALTH

Cera Products, Inc...............................................59 Glutagest..............................................................59 Hodgson Mill........................................................60 Nasoya..................................................................60 The University of Chicago Celiac Disease Center................................................. 61

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2016 ANNUAL RESOURCE GUIDE

July 29 & 30, 2016 Washington, D.C. Don’t miss the most stimulating medical conference of 2016.

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60 today’s dietitian december 2015

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Live links to each of these brands will be posted on our website at www.TodaysDietitian.com/ annualresourceguide for 12 months.

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PROVISION OF MENTAL HEALTH CARE SERVICES CRITICAL FOR KIDS WITH FOOD ALLERGIES Routine mental health screenings of children are recommended by various pediatric societies. Now, a study from Mount Sinai questions the wisdom of such guidelines. Findings from a large-scale screening effort in a pediatric food allergy clinic, made by researchers at the Icahn School of Medicine at Mount Sinai and led by Eyal Shemesh, MD, were first published online in The Journal of Pediatrics. “Children who live with food allergies go through a unique struggle in life— one where they may feel stigmatized, and this could have an effect on their mental health,” says Shemesh, an associate professor of pediatrics and psychiatry and chief of the division of behavioral and developmental pediatrics at the Icahn School of Medicine at Mount Sinai. “We’ve shown that within a highly specialized program that ensures support for mental health needs, screening for mental health problems such as anxiety, bullying, and reduced quality of life doesn’t result in a better rate of successful referrals for evaluation and treatment. The unexpected finding from this study is that it’s probably better to refocus our efforts towards making sure these children have access to behavioral health services when they need them, rather than spending some of those resources on screening.” The data collected by Shemesh and his team were culled from a review of more than 3,000 patient encounters as part of the EMPOWER (Enhancing, Managing, and PrOmoting WEll-being and Resiliency) Program within the Jaffe Food Allergy Institute at Mount Sinai, making it the largest controlled study of the effect of mental health screenings of pediatric patients seen in specialty care clinics. EMPOWER provides free mental health consultations for children with food allergies and is unique to Mount Sinai; through the study, Shemesh and his research team hoped to determine whether such screening necessarily resulted in an increased rate of consultations. Of the more than 3,000 patient encounters during the study period, approximately one-half were screened and one-half were not. There was no difference in the rate of successful (ie, completed) mental health evaluations in the screened vs the nonscreened cohort, leading researchers to state that screenings did not necessarily lead to an enhanced rate of receipt of follow-up mental health services, even though these services were offered for free. In their study conclusion, Shemesh and his team advocate that available resources may be better spent ensuring the availability of mental health care rather than focusing on screening. Those results are relevant to children with food allergies as well as to the provision of care in other pediatric care settings. — SOURCE: MOUNT SINAI MEDICAL CENTER

december 2015 www.todaysdietitian.com 61

NEWS BITES

Battling Obesity in the Classroom With Exercise There’s another burst of seat-bouncing, giggling, and shouting in researcher Rebecca Hasson’s simulated classroom at the University of Michigan (UM) as Hasson catches study participant Marcus Patton cheating at the board game Sorry!. Patton isn’t having it. “How do you call that cheating?” demands Patton, an 11-year-old cyclone of energy. Patton admits it’s tough to sit still. Like millions of other US middle and grade school kids, he gets scant exercise during school because budget and time restraints have slashed recess and lunch periods. Hasson, an assistant professor at the UM School of Kinesiology, seeks to remedy that problem by studying kids like Patton in a collaborative research project called Active Classroom. Partners include UM’s School of Public Health Momentum Center, Taubman College of Architecture and Urban Planning, and School of Education. Researchers hope to find ways to redesign classrooms and develop a curriculum to add in two-minute exercise breaks throughout the day—”a prescription for physical activity”—and incorporate the additional fitness as seamlessly as possible for teachers. Clarke Fields, 9, and Patton, are between activity breaks now, meaning they’ll play games, watch television, or do something else sedentary between one of the 20 activity breaks. That’s 40 minutes of exercise by the end of the school day—but still only two-thirds of the recommended 60 minutes per day for kids. Hasson’s physical activity study differs from others in that it focuses on the built and curricular environments rather than solely focusing on behaviors, nutrition, and exercise. Her initial findings are promising: By incorporating low-, medium-, or high-intensity activity, kids may burn 100 to

62 today’s dietitian december 2015

300 more kcal per day. She found they quickly refocused on schoolwork after the activities, and none reported disliking the exercise. Their enthusiasm shows. Patton and Fields snap to attention when Hasson shouts: “Ready for an activity break?” They jump up and record their resting heart rates. A Nicki Minaj song pumps out of the computer and they’re off: Two minutes of high-intensity jumping jacks, skiers, butt kicks, and high-knees. Hasson, who’s also a former competitive volleyball player, jumps and kicks along with them, shouting encouragement. “Time!” The students, breathless and smiling, shout out heart rates and perceived exertion scores and Hasson writes them on a whiteboard. After the exercise, students take a quick math test to gauge how easily they reset back to learning mode. By the end of this first study phase, researchers also will know which intensities and exercises are best for weight management, fitness, cognition, and other factors that impact a child’s well-being in and out of the classroom. The other essential parts of the research are “playable” hallways and classrooms. Hallways could be designed with pathways or longer routes and encourage room-toroom movement or activities like hopscotch. Classes might include furniture that teachers can store or rearrange and structures such as climbing walls. Patton’s mother, Tabia, arrives during another activity break. She teaches elementary school and supports Hasson’s goal but remains guarded. Climbing walls in a classroom with 30 kids? That sounds hard to manage. Still, she says she’d love to be able to do this in her classroom. “When (Marcus) has to sit for long periods of time, it’s hard for him to focus,” Tabia Patton says, and she knows this is true for many kids. Hasson understands if teachers are concerned. “The kids will be an easy sell,” she says. Indeed, their self-reported perceived exertion is almost always much lower than their actual exertion, which means they’re working much harder than they feel like they are. They also report enjoying the exercise days more than the sedentary days when they’re instructed to use a tablet. The biggest challenge will be convincing overworked teachers and pressured administrators that it’s doable, Hasson says. Hasson’s next step is to partner with teachers like Tabia Patton in the Ann Arbor and Ypsilanti elementary schools to pilot this project in an actual classroom, with the long-term goal of implementing the project nationwide. With waistlines expanding and lifespans shortening, she says it’s a public health priority. “This generation of kids is expected to live two to five [fewer] years than their parents, and this problem is directly related to diet and physical inactivity,” Hasson says. — SOURCE: UNIVERSITY OF MICHIGAN

Pumpkin Foods May Not Live Up to Their Healthful Reputation Pumpkin products proliferate this time of year—not just traditional pies and breads but also whimsical goodies that may not live up to the pumpkin’s healthful reputation. Appealing to palates are pumpkin donuts, pumpkin ice cream, pumpkin lattes—even chocolate pumpkin candy. “If you believe the sales pitch, the pumpkin is the happiest, healthiest food ever,” says Suzy Weems, PhD, RD, a professor of nutrition sciences at Baylor University’s College of Health and Human Sciences. But a balancing act is important, Weems says. Pumpkin pluses include the following: • Fiber: This is a bonus for dieters who want to feel full. • Zeaxanthin: It’s a boon as a weapon against age-related macular degeneration and impaired eyesight. • Low in cholesterol and high in vitamin A: These factors make for healthful skin and eyes and also aid in fighting cancer. • Heart-healthy phytosterols: They’re found in pumpkin seeds. • Magnesium, manganese, copper, phosphorus, protein, zinc, and iron: The combination makes a

veritable “cocktail” for energy, growth, and a top-notch immune system. Pumpkin downsides include the following: • Pumpkin snacks: “Pumpkin-laced candy is still candy,” Weems says. “Pumpkin seeds are good for making you feel full, but the fat doesn’t disappear when you roast and eat them.” • Pumpkin desserts: “Be sure to notice how much pumpkin is really in it, that it’s not just the flavoring.” • Pumpkin in coffee or for breakfast: “A pumpkin latte isn’t going to mean any fewer calories if it’s made with a full-fat milk or syrup. And pumpkin doughnuts still have sugar.” Pumpkin is “delightful, but it’s not a magic bullet,” Weems cautions. “Take a look at the total calories: If you have diabetes, look at the sugar and total carbohydrates; if you have cardiovascular disease, look at the fat. Always be sure to read the container or the wrapper.” Looking for some healthful pumpkin recipes that contain lots of nutrients? Check out the cover story in the November issue of Today’s Dietitian. — SOURCE: BAYLOR UNIVERSITY

‘Get FRUVED’ Activities Promote a Healthful Campus Lifestyle Students at South Dakota State University (SDSU) are carving the pathway toward a healthier college experience with the Get FRUVED—Get your FRUits and VEgetables— social marketing campaign. Get FRUVED is a USDA-funded research study developed by students for students to create a campus environment that supports healthful eating, physical activity, and stress reduction. It’s a multi-institutional project with three other universities—the University of Tennessee, West Virginia University, and the University of Florida. “We have a wide range of events planned for the year and students will benefit from each event differently,” says Krista Leischner, a graduate research assistant and campus cocoordinator of Get FRUVED. “We’re aiming to create healthier lifestyles, not just a healthier day or two.” Sunrise yoga, cooking demonstrations, a food drive, and bubble meditation were a few of the fall events. “Each event incorporates a different component of healthful living,” says Andrea Hanson, a graduate research assistant and campus cocoordinator of Get FRUVED. “I would like students to learn that the key to a healthful lifestyle is maintaining balance. All Get FRUVED events will affect students in unique ways, and attending more than one event will encourage students to strive for this balance in their own lives.” Participating students were surveyed for beginning baseline measurements including weight, height, physical activity, sleep patterns, and ability to manage stress. Next spring, Hanson

and Leischner will assess outcomes. “This community-based process brings in the target audience to develop the material,” says Kendra Kattelmann, director of the didactic program in dietetics at SDSU. “We have students from several majors helping with the project, so we’re getting ideas and input from students with varying educational interests and outlooks.” The group of students involved in Get FRUVED also will assess the campus environment and the perimeter around campus, looking for wellness indicators such as walkability, bikeability, and healthful dining and vending options. Through the USDA, Kattelmann is part of a multistate consortium that carries out activities to support obesity prevention. Kattelmann and SDSU students work closely with partner institutions to share ideas, events, and feedback. “It’s great to connect with universities around the country. The resources and skills that one university might lack, the other partner university might excel at. We’re bringing our goals together to make a healthful lifestyle easier for students.” When the project wraps in two years, the environment and students will be reassessed to calculate improvements. “We’re hoping to use this project as a toolkit to change behaviors,” Kattelmann says. “By assessing the campus environment, in addition to promoting healthful activities and events, we’re taking steps toward making the healthier choice the easier choice.” — SOURCE: SOUTH DAKOTA STATE UNIVERSITY

december 2015 www.todaysdietitian.com 63

DATEBOOK JANUARY 16-19, 2016

APRIL 8-10, 2016

APRIL 21-23, 2016

AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION CLINICAL NUTRITION WEEK Austin, Texas www.nutritioncare.org

ACADEMY OF NUTRITION AND DIETETICS SPORTS, CARDIOVASCULAR, AND WELLNESS NUTRITION DIETETIC PRACTICE GROUP 32ND ANNUAL SYMPOSIUM: “PRESCRIPTIONS FOR SUSTAINABLE HEALTH, PERFORMANCE AND PRACTICE” Portland, Oregon www.scndpg.org/2016-symposium

CALIFORNIA ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE Riverside, California www.dietitian.org

APRIL 15-17, 2016

MAY 7-15; MAY 21-29, 2016

ACADEMY OF NUTRITION AND DIETETICS WEIGHT MANAGEMENT DIETETIC PRACTICE GROUP SYMPOSIUM Baltimore, Maryland http://wmdpg.org

ACADEMY OF NUTRITION AND DIETETICS FOOD & CULINARY PROFESSIONALS DIETETIC PRACTICE GROUP CULINARY TRIP ABROAD Lisbon, Portugal www.foodculinaryprofs.org

APRIL 20-22, 2016

MAY 19-21, 2016

IDAHO ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETING Pocatello, Idaho www.eatrightidaho.org

NEW YORK STATE ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETING & EXPO Tarrytown, New York www.eatrightny.org

JANUARY 17-19, 2016

SCHOOL NUTRITION ASSOCIATION INDUSTRY CONFERENCE San Diego, California www.schoolnutrition.org FEBRUARY 21-27, 2016

NATIONAL EATING DISORDER AWARENESS WEEK https://mentalhealthscreening.org MARCH 4-7, 2016

AMERICAN ACADEMY OF ALLERGY, ASTHMA & IMMUNOLOGY ANNUAL MEETING Los Angeles, California www.aaaai.org MARCH 12-15, 2016

AMERICAN SOCIETY OF PREVENTIVE ONCOLOGY ANNUAL MEETING Columbus, Ohio www.aspo.org MARCH 16-17, 2016

GEORGIA ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE & EXHIBITION Atlanta, Georgia www.eatrightgeorgia.org APRIL 2-6, 2016

AMERICAN SOCIETY FOR NUTRITION SCIENTIFIC SESSIONS AT EXPERIMENTAL BIOLOGY San Diego, California www.nutrition.org APRIL 7-8, 2016

ILLINOIS ACADEMY OF NUTRITION AND DIETETICS SPRING ASSEMBLY Oak Brook, Illinois www.eatrightillinois.org

APRIL 27 – MAY 1, 2016

NATIONAL KIDNEY FOUNDATION SPRING CLINICAL MEETINGS Boston, Massachusetts www.kidney.org/spring-clinical

APRIL 20-22, 2016

NEBRASKA ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE AND MEETING Lincoln, Nebraska www.eatrightnebraska.org APRIL 21-22, 2016

MICHIGAN ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE AND MEETING Lansing, Michigan www.eatrightmich.org

Datebook listings are offered to all nonprofit organizations and associations for their meetings. Paid listings are guaranteed inclusion. All for-profit organizations are paid listings. Call for rates and availability. Call 610-948-9500 Fax 610-948-7202 E-mail TDeditor@gvpub.com Send Write with your listing two months before publication of issue.

ADVERTISER INDEX

For advertising information, please call 800-278-4400 or visit our website at www.TodaysDietitian.com.

Bush’s, kidslikebeans.com......................................................................................................................... 5 Chelan Fresh, www.healthyyouinoneminute.com................................................................................... 12 Duke Integrative Medicine, www.dukeim.org/transform....................................................................... 15 Food For Life Baking Company, www.foodforlife.com............................................................................ 67 Glutagest, www.glutagest.com............................................................................................................... 13 Nutricia North America, www.neocate.com.............................................................................................. 2 Purity Foods, www.natureslegacyforlife.com......................................................................................... 57 Sigma-Tau Pharmaceuticals / VSL #3, www.vsl3.com............................................................................. 3 Sunbutter, www.sunbutter.com............................................................................................................... 68 The Dannon Company, www.oneyogurteveryday.com.............................................................................. 9 Wisdom/Sweetleaf, www.sweetleaf.com.................................................................................................. 7 This index is a service to our readers. The publisher assumes no liability for errors or omissions.

64 today’s dietitian december 2015

ILLUMINATING. ENLIGHTENING. ELUCIDATING. GIVE YOURSELF THE GIFT OF EDUCATION AND DELIGHT IN OUR 2016 SESSIONS Join us in sunny Orlando May 15-18 for the 2016 Today’s Dietitian Spring Symposium. Network with peers, sample new products, and earn more than 15 CEUs by choosing from sessions presented by some of the brightest stars in nutrition and dietetics. Here’s a “nice list” of sessions, with more to unwrap very soon. Extra Virgin, Extra Health: Science Beyond Olive Oils Janet Bond Brill, PhD, RDN, CSSD, FAND

The Obesity Challenge: Aging, Obesity and Long-Term Health Care Becky Dorner, RDN, LD, FAND

Gut Health: A Holistic Approach Kathie Madonna Swift, MS, RDN, LDN, FAND, EBQ

Supermarket Tours for Today’s Dietitian Barbara Ruhs, MS, RDN, LDN

Hispanic Dietary Variation Nilda Benmaor, MS, RDN, CDE

Today’s Food Conversation Amy Myrdal Miller, MS, RDN, FAND

Longevity Foods: Learning from Centenarians Around the World Sue Linja, RDN, LD, and Seanne Safaii, PhD, RDN, LD

Who Needs the Media? Creative Solutions to Increase Your Visibility and Build Your Brand Melissa Joy Dobbins, MS, RDN, CDE

Namaste for Nutrition: Integrating Yoga Into Your Nutrition Practice Kara Lydon, RD, LDN, RYT

Women and the Big Cs: Reducing Risk of Cancer and CVD Karen Collins, MS, RDN, CDN, FAND

Nutrition Mythbusting Jill Weisenberger, MS, RDN, CDE, FAND

Writing Workshop: From Practice to the Page Constance Brown-Riggs, MSEd, RD, CDE, CDN, and Tamara Jefferies, MFA

Stay tuned for our announcement of all of our 2016 session titles, from presenters including: Toby Amidor, MS, RD, CDN (New Dietary Guidelines) Jenna Bell, PhD, RD (Snacking Patterns) Katie Cavuto, MS, RDN, Chef (Mindfulness)

To register online or apply for one of our remaining scholarships, visit www.TodaysDietitian.com/ss16.

Sharon Palmer, RDN (Sustainability) Robin Plotkin, RD, LD (Cravings and Food Behaviors) Hope Warshaw, MMSc, RD, CDE, BC-ADM (Diabetes News)

2016 SPRING SYMPOSIUM

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EARLY BIRD REGISTRATION! $325 until December 31, 2015!

CULINARY CORNER baked with chicken or beef for dinner. They also can be added to baked goods like this Cranberry Orange Bread, perfect for celebrating the holiday season. — Jessica Fishman Levinson, MS, RDN, CDN, is a New Yorkbased nutrition consultant, writer, and recipe developer, and the founder of Nutritioulicious (www.nutritioulicious.com).

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

CELEBRATE THE HOLIDAYS WITH CRANBERRIES By Jessica Fishman Levinson, MS, RDN, CDN The holiday season is upon us. While everyone’s sipping eggnog and delighting in gingerbread cookies, I like to celebrate one of the most nutritious fruits of the season—cranberries. While cranberries are most often associated with a sauce or their sweeter dried form, fresh and frozen cranberries will make your mouth pucker with their tartness. Although many of your clients may feel intimidated to work with fresh and frozen cranberries, they’re actually easy to cook and bake with, and their nutritional qualities are impressive. One of the most well-known benefits associated with cranberries, especially as juice, is that they can help maintain a healthy urinary tract and prevent urinary tract infections.1,2 But the benefits go well beyond urinary tract health. Research over the years has shown an association between cranberry consumption and lower levels of C-reactive protein, an indicator of inflammation in the body; inhibition of bacteria associated with gum disease and stomach ulcers; and protection against cardiovascular health risks including hypertension and dyslipidemia.3-7 These benefits mainly are due to the high phytochemical content in cranberries, particularly proanthocyanidins, a subclass of flavonoids with antioxidant properties. Cranberries are native to North America and are grown on low vines in sunken beds called bogs. Cranberries are harvested in the fall, which is when clients will find them fresh in the produce aisle, but they’re sold year round frozen, dried, canned, or as juice. One cup of fresh chopped cranberries is a good source of fiber and vitamin C. When buying dried and canned cranberries, clients should look for added sugars and adjust their total daily sugar intake accordingly. Inspire your clients to try cranberries in other ways besides dried as part of their trail mix. Fresh, frozen, or dried cranberries can be added to whole grains like quinoa and wild rice for a side dish, stirred into oatmeal for breakfast, or

66 today’s dietitian december 2015

Cranberry Orange Bread Celebrate the holiday season with this sweet and tart bread made with antioxidant-rich cranberries and vitamin C-rich oranges. Makes 16 one-slice servings

Ingredients Cooking spray 2 cups (250 g) white whole-wheat flour 3 ⁄4 cup sugar 1 ⁄2 tsp baking soda 1 tsp baking powder 1 ⁄2 tsp table salt 1 ⁄2 tsp cinnamon 1 ⁄2 cup canola oil 2 large eggs 3 ⁄4 cup freshly squeezed orange juice 1 T orange zest 1 cup fresh or frozen cranberries, halved

Directions 1. Preheat oven to bake at 350˚ F. Grease a loaf pan with cooking spray and set aside. 2. In a large mixing bowl, whisk together flour, sugar, baking soda, baking powder, salt, and cinnamon. 3. In a small mixing bowl, whisk together oil, eggs, orange juice, and orange zest. 4. Pour wet ingredients into dry ingredients and whisk until just combined. Do not overmix. Fold in the cranberries and let batter stand about 10 minutes. 5. Pour batter into greased loaf pan and bake 55 minutes to 1 hour. Loosely cover the loaf pan with foil about halfway through baking to ensure the top doesn’t get too well done.

Nutrient Analysis per serving Calories: 172; Total fat: 7 g; Sat fat: <1 g; Trans fat: 0 g; Cholesterol: 0 mg; Sodium: 150 mg; Total carbohydrate: 24 g; Dietary fiber: 3 g; Sugar: 11 g; Protein: 3 g; Vitamin C: 7 mg

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Wheat, Filtered INGREDIENTS: Organic SproutedOrganic Sprouted Water, Organic Sprouted Barley,Organic Sprouted Chia Millet, Organic Malted Barley, Seeds, Organic Sprouted Serving Size 2 Waffles (100g) Seeds, Organic Sprouted Flax , Organic Sesame Servings Per Container 3 Lentils, Organic Sprouted Soybeans Mesquite Bean Pods, Seeds, Organic Vanilla, Organic Nopal Cactus, Sea Amount Per Serving Sprouted Spelt, Organic Fat 45 Organic Annato Seeds. Calories 230 Calories from Salt, Organic % Daily Value* SOY. 8% CONTAINS: WHEAT, and Total Fat 5g practices are used to segregate ingredients 5% Good manufacturing wheat, soy, and tree nuts. Saturated Fat 1g products in a facility that also processes Trans Fat 0g Life Baking Co., Inc. 0% Food for Cholesterol 0mg Doherty St. Corona, CA 92879 9% 2991 E. 797-5090 Sodium 220mg 12% (800) Total Carbohydrate 37g M-Th 8-5pm, Fri 8-2pm 32% Dietary Fiber 8g Certified Organic by Quality Assurance Sugars 2g International Protein 9g 100% Recycled Paperboard C 6% Vitamin A 0% Vitamin Iron 15% Calcium 6% HEATING E 7% Riboflavin 8% Vitamin e 11% INSTRUCTIONS Vitamin B6 0% Thiamin 6% Vitamin B12 4% Niacin se 105% Magnesium 25% Mangane Phosphorus 22% Zinc 11% Pantothenic Acid 7%

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HEATING INSTRUCTIONS

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tu i p tures ip of black of 7%lstintand ed in the Holy Scrip Millet built out ibed Boxess and describ Ass descr A Lenti overprinted on SKU color t and Barley and Bean iel 4:9 “Take also unto thee Wheain one vessel and make bread of it...” – Ezek and Spelt and put them PAREVE

PAREVE

) 6 WAFFLES NET WT 10.6 OZ (300g

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VEGAN

ERVING SUGGESTION SSERVING

9g 10g

PAREVE

6 WAFFLES NET WT 10.6 OZ (300g)

10g

ESSENTIAL AMINO ACIDS CONTAINS

10g

ESSENTIAL AMINO ACIDS CONTAINS

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