pages-3

Substituting Palm OilTrans Fat

Is Palm Oil a Good Alternative for Human Health and the Environment?

forSpring Symposium

Highlights

Diabetes andCardiovascular Damage

Tips for Adding More Veggies at Breakfast

RDs Debate the FDA’s Proposed Nutrition Facts Label

July 2014

Vol. 16 No. 7

The Magazine for Nutrition Professionals

CONFERENCE ISSUE

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EDITOR’S SPOT

President & CEO Kathleen Czermanski

Vice President & COO Mara E. Honicker

EDITORIALEditor Judith Riddle

Editorial Director Jim Knaub Senior Production Editor Tracy Denninger

Editorial Assistants Heather Hogstrom, Leesha LentzContributing Editor Sharon Palmer, RD

Editorial Advisory Board Dina Aronson, RD; Jenna A. Bell, PhD, RD; Janet Bond Brill, PhD, RD, CSSD, LDN; Marlisa Brown, MS, RD, CDE, CDN;

Constance Brown-Riggs, MSEd, RD, CDE, CDN; Carol Meerschaert, MBA, RD; Sharon Palmer, RD;

Christin L. Seher, MS, RD, LD

ARTArt Director Charles Slack

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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.

SUSTAINABLE HOSPITAL FOOD

Earlier this year, I sat in on a roundtable discussion about innovative, sustainable foodservice programs in hospitals, led by the Healthier Hospital Initiative (HHI), an organization that provides hospitals with free tools and resources to serve healthful food options and develop sustainable food

systems that will benefit patients, staff, the community, and the environment. While some hospitals continue to serve processed foods that contain preservatives and are high in fat, sodium, and sugar, several others are making great strides and leading the way toward establishing healthier, more sustainable foodservice systems.

Some of the biggest players driving sustainable food-service across the health care industry participated in the roundtable, including Kaiser Permanente, Stanford Hospital & Clinics, and Inova Health System. These hospitals are devel-oping healthier menus, banning sugar-laden beverages, and working with local farmers to purchase sustainably grown produce. They’re also reclaiming city lots for organic farm-ing, reducing the amount of meat they purchase and serve, buying more fair trade and organic products, growing their own food in greenhouses on site, and creating more energy efficient kitchens.

These are major steps forward for the health care industry, considering that in the recent past staff members and visitors often were hard pressed to find a single low-fat, cholesterol-free entrée in their hospital cafeterias. You’d think that the very institutions providing health care and treating and managing disease would have served healthful foods in their cafeterias from their inception. Nonetheless the tide has turned, and Today’s Dietitian has reported on the latest developments in the feature article “Sustainable Hospital Foodservice” on page 34.

Also in this issue are articles on the association between diabetes and heart disease caused by oxidative stress, the pending FDA food labeling proposal, and whether we’d be better off substituting palm oil for trans fat in the food supply. Tell us what you think about these articles on our Facebook and Twitter pages, and enjoy the rest of the issue!

Judith [email protected]

Judy

july 2014 www.todaysdietitian.com 5

FEATURES

20 Substituting Palm Oil for Trans Fat The FDA’s proposal to ban trans fat has increased demand for palm oil, but is palm oil a good alternative for human health and the environment?

24 Diabetes and Cardiovascular Damage Experts discuss oxidative stress and whether antioxidants may play a role in protecting cardiovascular health.

28 Today’s Dietitian’s Spring Symposium — A Spectacular Extravaganza Attendees raved about the conference, calling it a huge sucess.

34 Sustainable Hospital Foodservice Today’s Dietitian profi les the top health systems in the country that are driving change.

40 Veggies at Breakfast The most important meal of the day provides clients and patients with the perfect opportunity to eat more vegetables and meet dietary requirements.

44 The Nutrition Facts Label Dietitians speak out about the FDA’s proposed changes, what more should be done, and how the updates will impact public health.

48 CPE Monthly: Vitamin D’s Role in Health This course discusses the nutrient’s functions in the body and how to assess appropriate blood levels according to the latest research.

DEPARTMENTS

5 Editor’s Spot

7 Reader Feedback

8 News Bites

10 Ask the Expert

12 Allergy & Intolerance Awareness

16 Digestive Wellness

18 Omega Fats

56 Focus on Fitness

58 Get to Know

60 Bookshelf

62 Products +Services

65 Datebook

66 Culinary Corner

CONTENTS JULY 2014

1240

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 Offi ce and other mailing offi ces. Permission to reprint may be obtained from the publisher. REPRINTS: The Reprint Outsource, Inc.: 877-394-7350 or e-mail [email protected] NOTE: For subscription changes of address, please write to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on last label. POSTMASTER: Send address changes to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Subscription Rates — Domestic: $14.99 per year; Canada: $48 per year; Foreign: $95 per year; Single issue: $5. Today’s Dietitian Volume 16, Number 7.

Page 48

Letter to the EditorI loved the article “Dietitians and Their Weight Struggles” that was published in the May issue of Today’s Dietitian. It’s good to bring up the issue of weight, raise awareness, and encourage tolerance among others and ourselves no matter what our size. Thank you!

Elaine Mazgelis, RD, LDN, IBCLC Cambridge-Somerville WIC, Massachusetts

READER FEEDBACK

From Our Twitter Page Popular Tweets, Retweets

May Issue

“Dietitians and Their Weight Struggles”

@GinaMonkRD: Happiness and health are more important than weight! Dietitians aren’t diet enforcers, and weight is rarely the real problem. I wish it was understood that real dietitians don’t put people on diets but focus on healthier habits and exercise instead.

@MEuzarraga: The dietitian weight struggle article was an eye opener. Great read! I think as a society health needs to be redefined.

@Uleary: Compassion to help and educate others shouldn’t be judged on how you look.

@morethanfoodinc: The conversation changes when you substitute health for weight. Then the answer is always yes!

@eatingpermitRD: Weight stigma alive and well, especially in our profession. We have the power to change it!

@wholify: Very important discussion about weight and dietitians in Today’s Dietitian.

@BVMRD: You bet I can be an effective counselor. My weight says nothing about my ability as a dietitian.

“Benefits of Physical Activity” (Dynamics of Diabetes)

@lilfitbirdie: Physical activity is the most effective tool without side effects for diabetes management—and it’s cost-effective too!

“Getting Beginners in Shape for Summer” (Focus on Fitness)

@MelissaTraubRD: Great tips to help prevent injuries and help people become more active consistently!

From Our Facebook Wall

“Easy Ways to Sneak in More Fruits and Veggies”www.huffingtonpost.comMonica Hoffman Fintel: Really nice way to encourage clients they can eat more veggies and fruit! Love the concrete advice, not just “eat more.”

“‘Fed Up’ Asks, Are All Calories Equal?”www.nytimes.comCaleb Frazier: I haven’t seen it yet and I’m sure it makes some excellent points, but if the focal point of the film is that sugar is the sole ingredient that ails us and reduction of sugar alone is the pana-cea for obesity, it may be misguided. Most everyone does consume too much sugar, but processed foods with added sugar often contain additional added oils, added salt, and may be produced with refined starch. Americans also consume an excess of low-quality and high-fat factory-farmed meat and dairy products and not nearly enough unprocessed whole foods: vegetables, fruits, beans, intact whole grains. I’d be interested to see if the film addresses any of these issues as well.Melissa Mitri: I’m happy to see a movie on nutrition and our food supply, which is being given so much press and attention. Based on what I know about the film thus far, it does seem to heavily blame added sugars for the obesity epidemic. While this is part of the problem since it isn’t easy for consumers to spot these foods laden with sugar all the time, I don’t think just sugar is to blame at all. And recommend-ing that we take the “Fed Up Challenge” for 10 days by limiting sugars may give a false sense that this is the solution to the epidemic.

SILENT CELIAC DISEASEAtypical Signs and Symptoms Often Delay Proper Diagnosis and Treatment INSIDE

Gluten-Free Resource

Guide

Experts Decipher the Farm Bill’s Impact

Can Overweight RDs Still Be Effective?

Spring Symposium Issue


May 2014

Vol. 16 No. 5

The Magazine for Nutrition ProfessionalsMay 2014y

Vol. 16 No. 5

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National Celiac Disease Awareness Month

n a culture that places so much emphasis on physical appearance, and weight in particular, it’s no surprise that many people have a love-hate relationship with the size of their bodies. A client’s weight loss one week can lead to sheer jubilation, followed by extreme guilt and shame after he or she “falls off the diet wagon” soon after.

Many RDs can relate to their clients’ weight struggles through their own past experiences. But what happens when a dietitian’s weight issues aren’t a thing of the past? Can dietitians who have been trained in diet and nutrition be effective nutrition counsel-ors if they still battle with weight themselves? And how much (or how little) weight denotes such a struggle anyway?

It’s a hot-button issue, one about which many RDs are pas-sionate. But this dietitian weight debate has many sides—and, for some, the issue really isn’t about weight at all.

Weight Matters (or Does It?)When it comes to the size of a dietitian’s body, does weight

matter? According to Susan Linke, MBA, MS, RD, LD, CLT, a Texas-based dietitian who works primarily with patients who have food sensitivities, this answer depends on the type of advice an RD is giving clients.

For dietitians offering total parenteral nutrition guidance or designing menus in a hospital offi ce, Linke says people are looking for specialized expertise in these cases, and weight may not matter. But when clients are seeking advice on health-ful eating or weight management, then they’re looking for role models, she says, and weight absolutely is an issue—and an RD’s image is important.

“People do judge by appearance, and we are walking bill-boards,” Linke says. “If someone has a weight issue, then in my opinion, they should choose a specialty that does not confl ict with being overweight.”

With the level of competition in the marketplace, Linke believes it’s even more important for RDs to compete using appearance as well as knowledge. “If you can’t make it work for you, how can you make the case for someone else?” she says. “I’ve seen others counter this by saying that people need to learn to look beyond the physical, but the reality is that health care is a business, and people do judge you by appearance. Is it right or wrong? That doesn’t make a difference. It’s a business, and it is what it is whether we like it or not.”

But a patient’s judgment, often based on unrealistic cul-tural expectations, doesn’t take away from a dietitian’s knowl-edge base, says Jessica Wilson, MS, RD, owner of My Kitchen Dietitian and PR/social media chair for the Association for Size Diversity and Health, an international organization that pro-motes Health at Every Size principles. According to the organi-zation’s website, its mission is to “promote education, research, and the provision of services which enhance health and well-being, and which are free from weight-based assumptions and weight discrimination. Health is measured by many factors, including the right to be peaceful in one’s body.”

“It may matter to the patient because of this country’s pre-occupation with getting rid of fat people and negative media images of people in fatter bodies,” Wilson says. “But I do not believe that the RD’s weight impacts their ability or knowl-edge. I don’t see how the presentation of someone’s body would detract from their knowledge. Do shorter RDs know more than taller ones? Does skin tone play a role in knowledge?”

RDs as Role ModelsYet whether it’s a dietitian or a cardiologist, Linke says

appearance matters because clients are using that information in part to choose the health care professional they believe is most likely to help them—and she’d do the same. “I wouldn’t think much of advice from a cardiologist if I knew he had had a heart attack,” she says. “Yes, genetics might play a role, but I’d rather listen to one that’s fi t and has good cardiovascular health.

“People have choices,” Linke adds. “If given the choice between someone that practices what they preach and someone that seemingly doesn’t, the public will usually choose to get advice from someone that’s practicing what they preach. If it doesn’t work for the practitioner, how will it work for the patient?”

Lisa Ellis, MS, RD, CDN, a New York-based dietitian, agrees that as role models, how RDs present themselves is important. “Advice on regulating eating disorders coming from someone who even appears to be at the mercy of his or her own eating disorder may lack credibility, even if that advice was sound,” she says. “On the other hand, an RD need not have a perfect physique, just one that appears healthy.

“Weight standards should be irrelevant so long as the RD is healthy, both physically and attitudinally,” Ellis continues. “RDs, like many professionals, stake the vitality of their businesses on their client pools. An RD who appears to be unhealthy may seem to be a less-than-credible health care professional to cli-ents and may not keep those clients very long. This is likely a case of the market determining its own standards.”

But what does it truly mean to practice what you preach, and what does healthy even look like? According to Sharon Salomon,MS, RD, a dietitian who previously wrote the article “Confes-sions of a Fat Dietitian” for Today’s Dietitian, this phrase brings up more questions than answers, and she notes that anyone (RD or client) would be hard-pressed to determine the health-fulness of her daily habits simply by looking at her.

“Practice what they preach?” she says. “You mean eat healthy foods? Does eating broccoli mean that you’re going to be thin? And are all thin people healthy? What is a healthy weight? Is it weight, BMI, or waist circumference? Is it having good cholesterol levels, low triglycerides, a strong heart, regardless of weight? And how do you know that I do or do not practice what I preach? You cannot tell by looking at me.”

“We cannot make assumptions about people’s lifestyles and behaviors based on what they look like,” Wilson says, noting

Weight StrugglesDietitians

By JULIANN SCHAEFFER

RDs speak out about whether

they can be effective nutrition

counselors when they’re overweight.

and their

I

32 today’s dietitian may 2014 may 2014 www.todaysdietitian.com 33


NEWS BITES

Vitamin D Provides Little Benefit in Asthma Treatment

Adding vitamin D to asthma treatment to improve breath-ing appears to benefit only patients who achieve sufficient blood levels of the supplement. Overall, the ability to con-trol asthma didn’t differ between a study group that received vitamin D supplements and a group that received placebo, according to new research at Washington University School of Medicine in St Louis.

“Previous studies suggested that if you have asthma and low levels of vitamin D in the blood, you have worse lung function, more asthma attacks, and more emergency room visits than asthma patients with higher vitamin D levels,” says Mario Castro, MD, MPH, the Alan A. and Edith L. Wolff Professor of Pulmonary and Critical Care Medicine. “This is the first randomized controlled trial to investigate whether taking vitamin D supplements can improve asthma control.”

Low levels of vitamin D may play a role in many medical problems. In this clinical trial, the investigators studied 408 adult patients at nine major US medical centers. All patients had a diagnosis of mild to moderate asthma, and all had what’s considered deficient blood levels of vitamin D, with an average of 18 ng/mL. Measures below 30 are considered abnormal. All patients took an inhaled steroid daily to control their asthma, and they had rescue inhalers in the event of an asthma attack.

The patients were randomly assigned to one of two groups. The treatment group received a loading dose of 100,000 IU of vitamin D3 followed by daily doses of 4,000 IU, and the placebo group received identical looking but inactive capsules.

The investigators found no differences between the two groups in all major measures of asthma control. The groups showed no significant differences in the number of treatment failures requiring patients to take more medication, in the

number of asthma attacks, and in their need for emergency care. Patients taking vitamin D didn’t report improved quality of life, based on questionnaires.

One way the groups differed, however, was in how success-fully they were able to reduce their daily dosages of inhaled steroids. After the study’s first 12 weeks, if the patient’s asthma was well controlled, the investigators cut down one-half the daily dose of inhaled steroid, reducing it from 320 mcg/day to 160. After eight more weeks, if the disease remained controlled, they cut the dose to one-half again. While both groups were able to taper off their doses of inhaled ste-roid, the vitamin D group was able to reduce its medication more. By the end of the 28-week study, the vitamin D group was taking an average of 111 mcg/day, and the placebo group was taking an average of 126.

“The difference was small—15 mcg of steroid per day—but statistically significant,” Castro says. “Over the long term, even that small amount may have an important impact on reducing side effects of inhaled steroids. Although inhaled steroids work very well in controlling asthma, patients don’t like them because they cause weight gain and increase the risk of diabetes and high blood pressure. Anything we can do to reduce the amount they need is important.”

The investigators also note that despite taking large doses of vitamin D, not all patients in the treatment group achieved what are considered sufficient blood levels of vitamin D. After taking the supplements, 18% of the treatment group still had blood levels of vitamin D below 30 ng/mL. The reason that some patients didn’t appear to respond to the vitamin D supplements is unclear, though the investigators note that these patients were more likely to be overweight or obese.

When they looked only at the 82% of patients who received vitamin D supplements and showed an increase in their blood vitamin D levels above the critical threshold, Castro says they saw some intriguing results. Compared with placebo, the patients in the treatment group that achieved vitamin D sufficiency in the blood (with an average of 42 ng/mL) did show improved asthma control. They had 40% fewer treatment failures that required more medication and one-half the number of asthma attacks.

“We’re encouraged by this result, but we have to be careful,” Castro says. “Our study was designed to look at the entire group that received vitamin D supplements, not just those who achieved higher levels of vitamin D in the blood. We need more studies looking at this question, but I’m paying attention to vitamin D levels in my patients.

“We don’t know the long-term effects of supplementing vitamin D,” he adds. “In our study, it appears safe. Patients reported no side effects, and it’s inexpensive. If I have a patient with a history of multiple asthma attacks, I’ll consider looking at vitamin D levels, and if they’re low, giving a supplement. But you have to monitor the blood levels to see if it’s having an effect.”— SOURCE: WASHINGTON UNIVERSITY IN ST LOUIS

8 today’s dietitian july 2014

Coffee Consumption May Reduce Type 2 Diabetes RiskPeople who increased the amount of coffee they drank

each day by more than 1 cup over a four-year period had an 11% lower risk of type 2 diabetes than those who made no changes to their coffee consumption, accord-ing to a new study led by Harvard School of Public Health researchers. In addition, the study found that those who decreased their coffee con-sumption by more than 1 cup per day increased their type 2 diabetes risk by 17%. The study appeared online in Diabetologia.

“Our findings confirm those of previous studies that showed that higher coffee consumption was associated with lower type 2 diabetes risk,” says Shilpa Bhupathiraju, PhD, lead author and a research fellow in the department of nutrition. “Most importantly, they provide new evidence that changes in coffee consumption habit can affect type 2 diabetes risk in a relatively short period of time.”

The researchers analyzed data on caffeinated and decaffeinated coffee and caffeinated tea consumption by 48,464 women in the Brigham and Women’s Hospital–based Nurses’ Health Study (1986-2006); 47,510 women

in Nurses’ Health Study II (1991-2007); and 27,759 men in the Health Professionals Follow-Up Study (1986-2006). Participants’ diets were evaluated every four years with a questionnaire, and those who self-reported type 2 diabetes completed additional questionnaires. A total of 7,269 cases of type 2 diabetes were documented.

One cup of coffee was defined as 8 oz, black, or with a small amount of milk and/or sugar. Those who lowered their daily coffee consumption by more than 1 cup (median change = 2 cups/day) had a 17% higher risk of diabetes. Changes in decaf-feinated coffee consumption and caffeinated tea consumption weren’t associated with changes in the risk of type 2 diabetes.

“These findings further dem-onstrate that, for most people, coffee may have health benefits,” says Frank Hu, MD, MPH, PhD, senior author and a professor of nutrition and epidemiology. “But coffee is only one of many factors that influence diabetes risk. More importantly, individuals should watch their weight and be physically active.”— SOURCE: HARVARD SCHOOL OF PUBLIC HEALTH

Study Exposes Risk of Nutritional Deficiencies in Obese TeensA new study exposes the risk of nutritional deficiencies

in severely obese teens, both those who had weight-loss surgery and those who didn’t.

At least five years after undergoing gastric bypass sur-gery, teens and young adults maintained significant weight loss but were at risk of nutritional deficiencies, particularly low iron, mild anemia, and low vitamin D. The study also found low iron and low vitamin D in severely obese teens who didn’t undergo weight-loss surgery as well as low levels of protein in their blood.

“We knew there were nutritional difficulties in teens who had undergone bariatric surgery, but everyone thought it was primarily the surgery that caused these problems since gastric bypass excludes the portion of the small intestine where many nutrients, especially iron, are most absorbed,” says Stavra Xanthakos, MD, MS, medical director of the

Surgical Weight Loss Program for Teens at Cincinnati Chil-dren’s Hospital Medical Center and a study coauthor. “What this shows us is that nutritional deficiencies occur even in teens who don’t undergo surgery. Severely obese patients should be screened for nutritional deficiencies, regardless of whether they’ve undergone weight-loss surgery.”

The researchers studied 79 obese teens who either received weight-loss surgery or were evaluated but didn’t receive surgery. The patients were evaluated between 2001 and 2007, and contacted to participate in the study between 2011 and 2014.

Eight years on average after surgery, these patients had experienced “durable and significant” weight loss, about 28%, Xanthakos says. Those who didn’t receive surgery hadn’t lost weight.— SOURCE: CINCINNATI CHILDREN’S HOSPITAL MEDICAL CENTER


UNDERSTANDING FACTS UP FRONTBy Toby Amidor, MS, RD, CDN

Q: I’ve seen the Facts Up Front panel on several food prod-ucts. Can you explain what it is and how it will help

consumers?

A:The Facts Up Front panel is a voluntary nutrition labeling system developed by the Grocery Manufacturers Associ-

ation and the Food Marketing Institute to help consumers make more informed choices about the foods they buy. The initiative is aligned with the FDA and USDA guidelines and regulations, including the 2010 Dietary Guidelines for Americans. The icon began appearing in the marketplace in late 2011, and its pres-ence continues to grow in stores nationwide.

The nutrition information displayed on the Facts Up Front panel includes serving size, calories, saturated fat, sodium, and sugar. The label also can display a maximum of two encouraged nutrients whose consumption is promoted in order to achieve a nutrient-dense diet. Examples include fiber, calcium, potassium, protein, iron, and vitamins A, C, and D. In order for the nutrient to be displayed on the Facts Up Front panel, the product must contain at least 10% of the recommended Daily Value (DV).

Before developing this front-of-label program, the Grocery Manufacturers Association commissioned the International Food Information Council Foundation to conduct consumer research. Nearly 7,400 nationally representative primary gro-cery shoppers took an interactive online survey to evaluate their comprehension, ease of understanding, and interpreta-tion of nutrition information on food products using the Facts Up Front panel. The study concluded that Facts Up Front may

help consumers make nutritionally informed choices when prompted, especially those with the lowest education level.

Benefits to ConsumersMany consumers may feel overwhelmed by the Nutrition

Facts panel, as they find it confusing and can’t figure out the math (eg, % DV). According to culinary nutritionist Robin Plotkin, RD, LD, an advisor for Facts Up Front, “The at-a-glance factor is really why Facts Up Front is beneficial to the public. We’re so used to receiving information in snippets and blurbs these days. The Facts Up Front label delivers important nutrient information in a way that’s palatable to consumers.” In addition, she says, “The label makes it easy to zero in on one to two nutrients without being overwhelming.”

“Our consumers want fact-based information on calories, saturated fat, sugar, and sodium,” says Julie McMillin, RD, LD, director of health and wellness for supermarket chain Hy-Vee. “Facts Up Front puts this information right on the front of pack-ages where it’s easiest to find, helping them make knowledge-able decisions for themselves and their families.”

Benefits to Dietetic ProfessionalsNutrition professionals can use the Facts Up Front panel

in both a clinical and supermarket setting to complement the information provided during educational sessions. “RDs can utilize Facts Up Front as a teaching tool because of its simplis-tic yet powerful messages,” Plotkin says. They also can refer clients to the Facts Up Front website (www.factsupfront.org), which contains helpful resources, including shopping and meal planning tips, healthful recipes, a nutrition calculator, and a nutrition quiz.

In addition, the website provides information to help dietetic professionals stay abreast of current research on industry progress as well as current science related to food labeling research. There’s also information available to assist nutrition professionals in conducting a supermarket tour with clients.

— Toby Amidor, MS, RD, CDN, is the founder of Toby Amidor Nutrition (http://tobyamidornutrition.com) and

author of the cookbook The Greek Yogurt Kitchen. She’s also a nutrition expert for

FoodNetwork.com and contributor to US News Eat + Run.

ASK THE EXPERT

Have questions about nutrition trends, patient care, and other dietetics issues you’d like to ask our expert?

Send your questions to Ask the Expert at [email protected] or send a tweet to @tobyamidor.


The USDA recommends3 servings of dairy every day.

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

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FOOD ALLERGY SENSITIZATIONNew Study Finds Geography Plays a RoleBy Sherry Coleman Collins, MS, RDN, LD

When it comes to allergies, there seems to be no escape for those who are predisposed to developing them, according to a recent study that examined the prevalence of allergic sensi-tization across the United States using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2006. The study, which includes 10,348 participants, found that the overall prevalence of allergic sensitization doesn’t differ from region to region in the United States, although sensitization to specific allergens and allergen types shows regional variation.1

The research shows that 44.6% of Americans aged 6 and older had positive test results for serum immunoglobulin E (IgE) antibodies for at least one of 19 allergens, with 16.2% having positive serum IgE tests related to at least one of four foods tested (egg, cow’s milk, shrimp, and peanut). The study also found that 36.2% of children aged 1 to 5 were sensitized to at least one allergen, such as dust, pollen, or food, and that the prevalence of food sensitization was significantly higher in 28% of children under the age of 6.1

Researchers suggest that individuals predisposed to develop-ing allergies will become allergic to something in their environ-ment or to food, regardless of where they live. Furthermore, they found that while allergic sensitization rates are about the same no matter where people lived in the United States, differences existed among the types of allergens that caused reactions.

It’s important for RDs to know that the location in which potentially food allergic clients live may influence the type of food allergy they develop. Practi-tioners also should be alert to a client’s or patient’s reported symptoms consis-tent with food allergies, which can vary from mild to severe and include gastro-intestinal symptoms such as nausea, vomiting, and diarrhea and respiratory and skin reactions.

Food allergies often are overlooked and may be misdiagnosed, but RDs can play an important role in helping clients at risk get properly diagnosed and edu-cated to manage their allergy.

Sensitization vs. True AllergySensitization and true allergy aren’t

the same. “Although allergic sensitiza-tion is a major risk factor for allergic disease, it is not synonymous with aller-

gic disease,” says Päivi Salo, PhD, lead author of the NHANES study and a researcher in the Environmental Cardiopulmo-nary Disease Group in the National Institute of Environmental Health Sciences’ division of intramural research. “Assessment of allergen-specific IgE antibodies with serologic analyses—or skin test challenges—confirms allergic sensitization, whereas subject’s clinical history and physical examination remain important cornerstones of the diagnosis of allergic disease.” Moreover, an individual can be sensitized to a substance or food yet never manifest a clinical allergic reaction.

Skin prick tests and serum blood tests check for IgE antibod-ies to specific proteins. Positive tests indicate that sensitization has occurred. The more drastic the positive result, as evidenced by a larger wheal size (the large red bump that appears at the site of the skin prick) or higher numbers of IgE antibodies in the blood, the more likely an individual has a true allergy. However, it’s important to recognize that false-positives are common, occurring in up to 60% of blood tests and skin prick tests.2

Oral food challenges are the gold standard for diagnosing food allergies, but “they tend to be time consuming, expensive, and subject study participants to potentially severe allergic reac-tions [which isn’t feasible in large-scale studies],” Salo says. Some physicians, patients, and parents are hesitant to perform and undergo oral food challenges, but a food allergy diagnosis is life altering, so ensuring its accuracy should be paramount.

Recent research has shown that allergic individuals expe-rience an improved quality of life when they undergo oral food challenges to test for tolerance, even those who have an allergic reaction to the food allergen and fail the oral food challenge.3 Therefore, people who have a low risk of anaphylaxis should

ALLERGY & INTOLERANCE AWARENESS


be encouraged to participate in oral food challenges to help ensure an accurate diagnosis and also determine if and when they will or have outgrown a food allergy.

Where You Are and What You EatAccording to the NHANES study, individuals in the South

were more likely to develop allergies to eggs, cow’s milk, shrimp, and peanuts.1 Researchers don’t know why allergy rates to these foods are higher in the South than in other areas. Salo says the study wasn’t meant to identify a causal relationship between allergy and geography, so further research is needed.

In support of geographic influences on allergic sensitization, an international study by Dalal and colleagues highlighted the prevalence of sesame allergy in Israel and differences in the types of food allergies among allergic individuals living in various countries.4 In this study, researchers identified eggs as the top allergen for five of seven countries (Australia, France, Israel, Japan, and Spain), but there were great variations among the allergenic foods that ranked highest from country to country. Italy’s top food allergen is fish, while Singapore’s is bird’s nest (an ingredient commonly eaten as a regional delicacy).4 Other allergens include various fruits, vegetables, lentils, nuts, wheat, and mustard.

Since sensitization results from exposure to specific proteins, researchers say it makes sense that these foods reflect the diet of the individuals in a certain region or coun-try, and that individuals won’t develop allergies to foods they’ve never eaten.

Oral Allergy Syndrome, Cross-Reactivity, and Clustering

Just as the substances people are allergic to vary country by country, so do the triggers that cause allergic reactions and the ways in which people respond to the allergens. Indi-viduals may respond to allergens by developing oral allergy syndrome or through cross-reactivity or clustering.

Oral allergy syndrome is a condition in which an individ-ual who’s allergic to certain pollens (eg, birch tree pollen) will experience itching and swelling in the oral cavity after eating raw fruits and vegetables. Typically, cooked vege-tables and fruits aren’t an issue. “It’s unknown what really triggers an allergic response and cross-reactivities, par-ticularly in the case of oral allergy syndrome,” says Soheila Maleki, PhD, lead research scientist for USDA Food Allergy Research. “Similarities in proteins of inhalant allergens [eg, dust mites] and food allergens indicate that there could be potentially similar triggers for most food aller-gies.” In fact, disagreement exists among experts about whether oral allergy syndrome represents a true food allergy or is simply a false reaction to similar proteins.

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Cross-reactivity is unpredictable among individuals, but patterns exist. For instance, people who are aller-gic to cockroaches and dust mites are more likely to be allergic to shrimp. Likewise, those allergic to birch tree pollen may be at higher risk of a peanut allergy. Moreover, approximately one-third of people who have a peanut allergy also are allergic to tree nuts.

Clustering occurs when a person who’s sensitized to one allergen in a group of similar entities is more likely to be allergic to something else within the group. “Allergies tended to aggregate in groups of allergens that were sim-ilar,” Salo says of her NHANES study. “In NHANES 2005-2006, the 19 allergen-specific IgEs grouped into seven clusters. This suggests that a person who’s sensitized to one allergen in the cluster is more likely to be allergic to another allergen in this cluster. For example, people sensitized to cats were more likely to be allergic to dogs, and those who were sensitized to a plant-related aller-gen were more likely to be allergic to other plant-related allergens and so forth.”

Practice ApplicationAs new research emerges, it will provide additional

information to expand the body of knowledge about food allergies, diagnosis, and management. Thus far, the medical community knows that sensitization isn’t the

PATIENT FOLLOW-UPSince individuals may outgrow food allergies, it’s impor-

tant for clients and patients to see an allergist regularly for reevaluation.

To determine the status of a patient’s allergy, an allergist may administer a skin prick or blood serum immunoglobulin E test. Based on the size of the wheal (the red bump that sur-faces on the skin indicating sensitization), blood test results, and other diagnostic criteria, the physician will determine whether a true allergy persists.

If the physician believes the patient is at low risk of a serious reaction, he or she may conduct an oral food challenge. Because of the potential for a serious and life-threatening reaction, oral food challenges always should be conducted in an allergist’s or physician’s office. Previous reactions don’t guarantee how mild or severe future reactions will be, and variations may occur from reaction to reaction and between allergic individuals. Even patients who have experienced mild allergy symptoms may experience anaphylaxis. Therefore, those who undergo an oral food challenge typically remain under medical supervision for two hours after ingesting the allergenic food, although reactions may occur several hours after the food has been eaten.

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same as a true allergy, and nutrition professionals can play an important role in helping clients and patients understand the difference. In fact, the prevalence of true food allergy is significantly less than the prevalence of sensitization, according to the new NHANES study. Researchers estimate that the prevalence of true food allergy is up to 8% in children and less than 4% in adults.5,6 Geography plays a role in the type of allergy individuals develop, possibly due to the differences in environmental and dietary factors, as well as cross-reactivity and clustering.

“RDNs should be more aware of the potential for allergies in their patients,” says Kate Scarlata, RDN, LDN, a digestive disorders expert and the author of The Complete Idiot’s Guide to Eating Well With IBS. “Since allergies in children seem more prevalent in metropolitan areas and in our southern states, RDNs working with patients in these areas should be even more vigilant in noting symptoms that may indicate an allergic reaction and refer patients to allergists for appropriate work up.” Practitioners should be familiar with recognizing signs and symptoms of food allergies and be prepared to assist clients with education and referrals to improve patient care.

— Sherry Coleman Collins, MS, RDN, LD, is a private practitioner in Atlanta specializing in food allergies and sensitivities,

digestive disorders, and nutrition communications.

References1. Salo PM, Arbes SJ, Jaramillo R, et al. Prevalence of

allergic sensitization in the United States: Results from the National Health and Nutrition Examination Survey (NHANES) 2005-2006 [published online February 9, 2014]. J Allergy Clin Immunol. doi: 10.1016/j.jaci.2013.12.1071.

2. Blood tests. Food Allergy Research & Education website. http://www.foodallergy.org/diagnosis-and-testing/blood-tests. Accessed April 27, 2014.

3. Franxman TJ, Howe LE, Greenhawt MJ. Oral food challenge and food allergy quality of life in caregivers of food allergic children. J Allergy Clin Immunol. 2013;131 (2 Suppl):AB57.

4. Dalal I, Binson I, Reifen R, et al. Food allergy is a matter of geography after all: sesame as a major cause of severe IgE-mediated food allergic reactions among infants and young children in Israel. Allergy. 2002;57(4):362-365.

5. Gupta RS, Springston EE, Warrier MR, et al. The preva-lence, severity, and distribution of childhood food allergy in the United States. Pediatrics. 2011;128(1):e9-e17.

6. NIAID-Sponsored Expert Panel, Boyce JA, Assa’ad A, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126(6 Suppl):S1-S58.

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DIGESTIVE WELLNESS

GASTROPARESISBy Jessica Jones, MS, RDDietitians play an important role in its treatment and management.

Gastroparesis, or delayed gastric emptying, is a condition in which the stomach takes longer than it should to pass its contents to the small intestine. This “stomach paralysis” results in a host of uncomfortable symptoms that can greatly reduce the quality of life for its sufferers.

Signs and SymptomsSymptoms of gastroparesis can range from mild to severe,

depending on the individual. The most common include nausea, vomiting, and early satiety.

Since food doesn’t move through the stomach at a normal pace, many patients report feeling full and bloated after eating. The feeling of fullness can result in inadequate food intake, which can lead to malnutrition and vitamin and mineral deficiencies. “The nausea and vomiting in some patients is so severe that they really have to work hard to get enough nutrition,” says Marcia Nahikian-Nelms, PhD, RDN, LD, CNSC, a clinical professor and the director of the dietetic internship program at Ohio State University.

Moreover, food that remains in the stomach for extended periods of time can ferment and cause bacterial overgrowth. Subsequently, the food can harden into masses called bezoars, which cause nausea and vomiting and can lead to a stomach obstruction, according to the American College of Gastroenter-ology. In some cases, the bezoars can block food’s passageway into the small intestine.1

CausesMany conditions can cause gastroparesis, but diabetes is one

of the most common etiologies. Neuropathy, which is a diabetes complication, can damage the vagus nerve, one of the primary autonomic controls for gastric emptying, Nahikian-Nelms says.

Hyperglycemia also can cause delays in gastric emptying, which can further exacerbate symptoms. When glucose rises in diabetes patients, it slows stomach emptying so they’re more prone to having gastrointestinal symptoms, says Henry Park-man, MD, a professor of medicine and the director of the GI Motility Laboratory at Temple University in Philadelphia. “The interesting thing is, it’s like a vicious cycle because the delay in gastric emptying also can cause [patients] to have trouble con-trolling their glucose.”

The American Diabetes Association says individuals with diabetes dealing with gastroparesis may need to adminis-ter insulin more often, administer insulin after eating instead of before, or frequently check their blood glucose levels and administer insulin when needed.

While a high percentage of gastroparesis has been reported in people with type 1 (40%) and type 2 diabetes (10% to 20%), it’s possible these numbers are inflated because the studies were conducted at tertiary academic medical centers, in which the prevalence of gastroparesis is noted to be higher than the general population.2 A January 2013 study pub-lished in the American Journal of Gastroenterology estimates that the community prevalence of gastroparesis is closer to approximately 5% in type 1 diabetes patients and 1% in type 2 patients.2

Other causes of gastroparesis include stomach or vagus nerve surgery, systemic disorders such as scleroderma, neurological conditions such as Parkinson’s disease, and medications such as narcotics, calcium channel blockers, and tricyclic antidepressants.2 Although rare, gastroparesis also can appear in individuals with anorexia nervosa, since issues with gastric emptying and reduced stomach contractions can develop with this eating disorder.3 Moreover, about one-third of gastroparesis cases are considered idiopathic, meaning they have no known cause.3

Gastroparesis also is seen more in women than men. “I did some research a while ago on the female reproductive hormones estrogen and progesterone, and those seem to delay stomach emptying,” Parkman says. “More recent research suggests that females [may] have differences in the way they metabolize some of the neurotransmitters that govern gastric motility.”

DiagnosisPhysicians can diagnose gastroparesis in several ways. If

patients present with symptoms consistent with the disease, they’re likely to first undergo an upper endoscopy to rule out any mechanical obstruction or ulcer. If no obstruction is present, the next step usually is scintigraphy, a diagnostic


test considered the gold standard for measuring the rate at which solids and liquids empty from the stomach in a four-hour period.

During the test, patients consume solid foods and liquids with a small amount radioactive material, and examiners identify the rate of gastric emptying at one-hour intervals. “If the study is positive, which is usually defined by gastric retention of more than 10% in four hours, then that would help to confirm our diagnosis,” says Shawn Khodadadian, MD, a gastroenterologist and the director of clinical nutrition in the gastroenterology division at Lenox Hill Hospital in New York City.

Medical Nutrition TherapyOnce a patient is diagnosed with gastroparesis, dietitians

begin administering medical nutrition therapy (MNT), which usually is the first line of treatment. “Dietitians can really play a major role in guiding patients in the right way and helping patients feel better,” Khodadadian says. “Nutrition counseling with the dietitian is critical.”

RDs who administer MNT to patients should encourage them to eat small but frequent meals (six to 10) per day to decrease bloating, early satiety, and other symptoms.

Food choices are just as important as reducing the amount of food eaten at each meal. “As far as the choice of foods, we emphasize low-fat foods because high-fat foods have a longer gastric emptying time,” Nahikian-Nelms says. The Academy of Nutrition and Dietetics agrees but states that liq-uids that contain fat, such as milkshakes, can be tolerated and provide extra calories.

In addition, low-fiber foods are recommended because fiber is known to slow gastric emptying, Nahikian-Nelms says. Dietitians also should suggest patients eat low-residue foods such as refined breads, white rice, and white pasta, plus cooked vegetables and canned fruit because they’re better tolerated than fresh fruits and vegetables. The Nutrition Care Manual recommends patients consume skim milk, instant breakfast beverages, yogurt, pudding, custard, smoothies, puréed foods, and soup. “There’s a subgroup of patients who have more difficulty with solid foods. They tend to do better with puréed or liquid foods,” Khodadadian says.

He also recommends patients avoid carbonated beverages, alcohol, and smoking, which can slow down gastric emptying.

Light physical activity after meals can help speed up gastric emptying rates, so RDs should suggest patients take a walk after eating to improve digestion instead of lying down after meals.

(To review a more comprehensive dietary guideline for gastroparesis, visit www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/patient-education/Gastroparesis%20SHORT%2010-10.pdf.)

Other TreatmentsIf MNT doesn’t completely alleviate symptoms, medications

also can be used to treat gastroparesis. “We have prokinetic agents that help speed up stomach emptying, such as metoclo-pramide [Reglan], domperidone [Motilium), and erythromycin,” Parkman says. Metoclopramide is the only FDA-approved drug for gastroparesis; the other two are used off label. “We [also] have antiemetic agents that are good for reducing nausea and vomiting.” Common antiemetic medications include diphen-hydramine (Benadryl) and ondansetron (Zofran).

While medications can help reduce symptoms, they aren’t a panacea. For example, metoclopramide must empty through the stomach, so this can be an issue in patients with delayed gastric emptying, Parkman says. The National Institutes of Health and the FDA know that more medications are needed to treat this disease. “Pharmaceutical companies are looking at novel ways to treat gastroparesis,” he says.

Instead of administering metoclopramide orally in tablet form, companies are researching ways to give it to patients in a nasal spray so it bypasses the stomach and gets absorbed through the nasal mucosa to speed up gastric emptying, Parkman adds.

When medications and dietary changes aren’t enough to treat gastroparesis, enteral nutrition is an option. “There’s a subgroup of patients who ultimately need enteral nutrition. [They] have persistent weight loss and are unable to control their symptoms,” Khodadadian says. In these cases, a jejunos-tomy is inserted into the small intestine to provide the proper nutrition to patients. This is preferred because it bypasses the stomach, he says.

Making the Difficult EasyRegardless of the interventions prescribed, dietitians

must remember how imperative their role is in gastroparesis treatment.

Nahikian-Nelms recalls a recent encounter she had with a patient when discussing the recommendation of six small meals per day. “He said, ‘People tell me that all the time, but I have no idea what that means. How do I get six meals in? What do I do?’ It’s easy to forget that people have a hard time trans-lating [health care] recommendations into actual foods and actual meal plans. Having that very specific plan for him made all the difference in the world.”

— Jessica Jones, MS, RD, is a nutrition communications specialist and the cohost of Food Heaven Made Easy, a weekly

Web series that demonstrates how to prepare nutrient-dense, delicious, and budget-friendly plant-based recipes while

providing scientifically sound nutrition information.

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


OMEGA FATS

SPOTLIGHT ON STEARIDONIC ACID Learn More About This Alternative Omega-3 Fatty AcidBy Amelia R. Sherry

Despite recommendations from the American Heart Association and other health organizations regarding omega-3 fatty acid intake, a significant number of Americans are consuming less than one-half of the recommended 8 oz of fish per week—or the 250 mg of EPA and DHA per day.1,2 This shortfall can be considered even more dramatic for individuals with cardiovascular disease (CVD) and those battling elevated triglycerides, for whom a daily dose of 1 g of EPA and DHA and 2 to 4 g of EPA and DHA, respectively, are recommended—nearly 10 to 20 times the amounts currently consumed.3

In addition to eating fish twice per week, many dietitians recommend consuming foods rich in alpha-linolenic acid (ALA), a long-chain fatty acid precursor found in plant foods such as ground flax to help boost omega-3 intake. RDs also may suggest supplements if clients and patients can’t con-sume the recommended amounts through diet alone, have high triglycerides, or avoid fish due to concerns about mercury content or other reasons.

To increase omega-3 fatty acid intake, food manufacturers are fortifying eggs and milk with these acids. One omega-3 they’re particularly focusing on is stearidonic acid (SDA), which is expected to appear on store shelves in soybean oil derived from genetically modified (GM) soybeans.

What Is SDA?Like ALA, SDA is a shorter long-chain omega-3 fatty acid

composed of 18 carbons, making it a precursor to longer long-chain fatty acids such as EPA and DHA. Unlike ALA, SDA has four double bonds existing at the third, sixth, ninth, and 12th carbons and, more notably, it doesn’t require the rate-limiting enzyme desaturase to convert to a longer chain fatty acid.4

Considered an omega-3 fatty acid to watch, SDA is emerging as an alternative nonfish source of omega-3s for at least two reasons. While ALA-rich foods often are recommended as an additional or alternative source of omega-3s for those who don’t or can’t consume fish, most dietitians know that the conversion of ALA to longer long-chain fatty acids is inefficient. Specifically, it’s estimated that anywhere from less than 5% to 21% of ALA converts to EPA (with sex and omega-6 intake impacting the amount), while less than 1% to 9% of ALA converts to DHA.4-7

By comparison, an increasing number of studies, largely funded by Monsanto, developer of the genetically engineered SDA-enriched soybean oil, are showing SDA to have a superior ability to convert to EPA over ALA. For example, foods supple-mented with SDA-enriched soybean oil were found to raise EPA concentrations in red blood cell membranes with approximately 17% to 41% of the efficiency of EPA on a gram-for-gram basis, a conversion efficiency three to five times higher than that of ALA.7 Moreover, a meta-analysis reported that EPA levels in red blood cells were twice as high when subjects consumed SDA compared with ALA.8

In a 2009 review article on SDA research, Jay Whelan, PhD, MPH, a professor and the head of the department of nutrition at the University of Tennessee, concluded that while SDA may not replace fish as a dietary source of omega-3 long-chain fatty acids, it may be a prominent substitute for EPA in foods fortified with omega-3 polyunsaturated fatty acids. Whelan supported his conclusion by referring to evidence demonstrating that SDA consumption leads to a fivefold increase in EPA levels in plasma, neutrophil, heart, and erythrocyte phospholipids.9

Whelan’s review also suggested that SDA doesn’t affect DHA levels, which is in line with more recent studies. “SDA can be converted to EPA and, theoretically, EPA can be converted to DHA,” he explains. “In reality, only DHA changes DHA in the tissues when consuming a typical Western diet,” which is why he doesn’t advocate consuming SDA-fortified foods in place of fish or fish oils containing both EPA and DHA.

A second reason SDA likely is attracting the interest of food scientists as a potential source of omega-3s is that it’s less unsaturated than EPA, making it more stable in foods.9 Since SDA is less susceptible to oxidation, “it’s less likely to be prone to ‘off’ flavors,” Whelan says.

Dietary SourcesA limited number of foods contain small amounts of SDA,

including some seed oils, such as hemp and Echium; certain fish, such as sardines and herring; and algae. To date, the American diet contains such low amounts of SDA that it hasn’t been measured.8 Of course, if genetically modified, SDA-enriched soybeans and soybean oil hit the consumer market, this may change—and it looks like it will.

In 2009, Monsanto obtained Generally Recognized as Safe status from the FDA for SDA-enriched omega-3 soybean oil.10 In April 2013, the company announced a combined effort with DSM Nutritional Products to bring the SDA-enriched soybean oil to


the marketplace. Monsanto will sell its SDA-enriched soybean seeds to farmers, and DSM Nutritional Products will have “the exclusive global rights to brand, market, package, and sell the SDA soybean oil to the food industry.”11

Richard S. Wilkes, CFS, director of food applications for Mon-santo, says the oil was created by inserting an enzyme respon-sible for increasing the conversion of ALA in soybean oil to SDA, which then is extracted from the seeds. Since soybean oil already is added to various foods, Wilkes considers it an efficient way to bring SDA to consumers. Specifically, it can be used in dairy and soy beverages, dressings, granola bars, margarine-type spreads, mayonnaise, peanut butter, smoothies, yogurt, and yogurt drinks.

As of this writing, neither Monsanto nor DSM Nutritional Products has confirmed when products containing the oil will hit store shelves.

Impact on Overall Health In addition to raising EPA levels, some research has

shown that SDA reduces elevated triglycerides. However, further comparative studies on healthy and unhealthy individuals are needed before researchers can consider SDA a potent protector of cardiovascular health.12,13

Moreover, questions remain about how SDA’s inability to raise DHA levels may impact overall health. “We’re playing with fatty acids that affect localized, cell-specific, hormonelike activity and play somewhat differing roles in disease,” says Libby Mills, MS, RDN, LDN, a spokesperson for the Academy of Nutrition and Dietetics (the Academy). “We know that EPA works primarily on inflammation, while DHA increases permeability of cell membranes, which is especially important for pregnant women and children’s brain development, and reduces atherosclerosis by blocking LDL from getting into vessels. What we don’t know is what the long-term effects of playing with the ratio of EPA and DHA may be.”

Gretchen K. Vannice, MS, RDN, author of the Omega-3 Handbook and coauthor of the Academy’s position paper on dietary fatty acids, raises additional concerns about how SDA-enriched soybean oil products will be marketed to consumers. If foods are labeled as a general source of omega-3s, for example, this could lead to problems. “It’s important that people know that if they choose to eat food products containing SDA-enriched soybean oil, they will not get DHA. This is critical information for the elderly and women who are pregnant and lactating, since DHA is important for infant development, cognitive health, and vision maintenance, in addition to heart health,” she explains. “When food manufacturers take the product to market, they should be very clear that SDA-enriched soybean oils give zero DHA.”

Who Can Benefit From SDA?Theoretically, the same individuals who rely on ALA-

containing foods to increase their omega-3 intake may benefit from adding SDA to their diet. This includes vegetarians, vegans, and anyone else who consumes little to no fish.

In practice, turning to food products containing SDA-enriched soybean oil to help clients and patients reach recommended levels of omega-3s may not make much sense, according to Mills. “Overall, too many calories are already coming from dietary fat,” she says, adding that dietary fat consumption in the United States has increased by two-thirds since the 1950s. Based on conversion rates in studies, clients and patients need up to nine times the amount of SDA as EPA to reach recommended intakes, “which means eating a lot of extra fat from oil or getting very little EPA,” she says.

Counseling TipsIt’s important for clients, patients, and consumers to know

that if they choose to eat food products containing SDA-enriched soybean oil, it’s a GM product that provides limited amounts of EPA and no DHA. RDs looking for an alternative source of omega-3s for vegetarian and vegan clients and patients can recommend algae-derived supplements containing both EPA and DHA, Vannice says.

For people who ask whether they should consume products containing SDA-enriched soybean oil to lower their heart disease risk, dietitians can suggest they eat more anti-inflammatory foods and spices containing ALA and phytochemicals, such as cruciferous vegetables, complex carbohydrates, blueberries, turmeric, and ginger, to receive the same health benefits without adding extra fat and oils to their diet, Mills says. “We also can recommend avoiding excess consumption of alcohol, sugar, and refined grains as well as behaviors such as smoking, which all contribute to inflammation,” she says.

Bottom LineAs new omega-3 fortified foods hit store shelves, dietitians

should be prepared to counsel clients and patients about reading ingredient labels to learn the source of these fats. If SDA-enriched soybean oil is listed, dietitians should explain that it’s derived from GM soybeans, and that it may raise EPA levels but won’t provide DHA.

For the elderly and pregnant and lactating women, RDs should further explain why DHA is important. For overweight patients and those at risk of CVD, RDs should mention that high amounts of the food product would need to be consumed—along with unnecessary fat and calories—to get significant amounts of EPA.

For all clients and patients, traditional sources of omega-3 fatty acids, such as oily fish, fish oil supplements, and algae-derived supplements, still should be consumed to reach recommended EPA and DHA intake.

— Amelia R. Sherry is a freelance writer, graduate nutrition student, and founder of the blog FeedingIsla.com.



The FDA’s proposal to ban trans fat has increased demand for palm oil, but is palm oil a good alternative

for human health and the environment?

By Beth Anne Conlon, MS, RDN, and Ashley M. Colpaart, MS, RDN

Substituting Palm OilTrans Fatfor


n November 2013, the FDA gave public health profession-als a reason to celebrate by publishing a formal Federal Register notice proposing a ban on partially hydrogenated oils on the grounds that they’re no longer generally recog-nized as safe for use in food.

For decades, efforts have been made to reduce or elimi-nate the use and intake of partially hydrogenated oils, which are found in commonly eaten foods such as margarines and spreads, baked goods, fried foods, frozen pies and pizzas, and savory snacks. This is because partially hydrogenated oils are the primary source of trans fatty acids in the food supply, and trans fatty acid intake poses a risk of cardiovascular disease.

In response to a 2006 FDA ruling mandating the labeling of trans fatty acids on the Nutrition Facts label, food manufactur-ers began eliminating trans fats from their products. Due to the unique properties of partially hydrogenated oils, companies began substituting them with palm oil, a naturally trans fat–free oil, increasing imports to the United States by nearly 60% over the past seven years. An FDA ban on the commercial use of trans fats likely will increase the demand, but palm oil’s high saturated fat content and the destruction of tropical forests, where palm plantations are planted, are raising red flags for public health and environmental groups.

It’s important for RDs to educate themselves on the impact of palm oil consumption and cultivation so they can work with key stakeholders—food manufacturers, environmental orga-nizations, and consumers—to advocate for and develop inno-vative solutions to strike a balance between what’s best for the public’s health and what’s best for the environment.

This article will review the history of the use of partially hydrogenated oils in the food supply and their health effects, discuss the environmental impact of increased palm oil pro-duction, and highlight opportunities for RDs to take action and raise awareness about palm oil and the broader implications of the foods consumers eat.

History and RegulationFood manufacturers are adept at responding to changing

health and consumer trends, manufacturing and labeling regulations, and foreign and domestic commodity trade pressures. In 1968, the American Heart Association (AHA) presented the first quantitative dietary recommendations affirming that Americans should consume 30% to 35% of calories from fat (later to be reduced to less than 30%), less than 10% of calories from saturated fat, and less than 300 mg/day of cholesterol. These recommendations were based on the hypothesis that excessive dietary fat intake raises cholesterol levels, thus increasing the risk of coronary heart disease (CHD). Consequently, growing consumer fear of fat prompted food manufacturers to reformulate products to be marketed with more diet-friendly descriptors such as “low-fat” or “fat-free.”

While fat phobia was sweeping the nation throughout the 1970s, palm oil, which is high in saturated fat and was widely used in commercial foods at the time, was in direct competition with US subsidized crops such as soybean, corn, and cottonseed oils, which were lower in saturated fat (about 16% saturated fat). In response, an antitropical oil campaign was launched, alerting the public to the dangers of highly saturated fat products and urging American food companies to remove palm and coconut oils (also high in saturated fat) from their products.1

The highly subsidized cost of and easy access to commodity seed oil led companies to announce they would switch to vege-table oils containing unsaturated fats. But palm oil is odorless, tasteless, and solid at room temperature, making it ideal for enhancing the texture, mouthfeel, and shelf life of commercial food products.2

To obtain the same unique properties palm oil offers, the food industry employed the novel process of hydrogenation, which adds hydrogen atoms to oils, converting unsaturated oils, once liquid at room temperature, into hydrogenated or partially hydrogenated oils, now solid or semisolid, respec-tively, at room temperature. Consequently, during the hydro-genation process, some of the cis (crooked) double bonds break and randomly reorganize into trans (straight) double bonds, introducing artificial trans fat bonds into the oil.2

Partially hydrogenated oils contain more artificial trans fats than fully hydrogenated oils because their carbon atoms aren’t fully saturated, leaving room for trans double bond formation. Both partially and fully hydrogenated oils are highly custom-izable for a variety of manufacturing applications, including frying and baking.1

Health Consequences EmergeOriginally, consumer advocacy groups such as the

Center for Science in the Public Interest (CSPI), a nonprofit organization that advocates for issues such as consumer health, nutrition, and food safety, praised food manufacturers for switching from saturated fats to partially hydrogenated oils.1 Before the advent of hydrogenation, the only trans fatty acids humans consumed came from the natural sources: meat and dairy.

The industrywide adoption of partially hydrogenated oils in cakes, cookies, pies, and pastries contributed to dramatic increases in intake, making partially hydrogenated oils the primary dietary source of industrially produced trans fatty acids. Research emerged in the 1990s connecting higher intakes of trans fats with an increased risk of CHD, the No. 1 killer of Americans. Mechanistically, trans fats fuel the increase of LDL cholesterol and decrease HDL cholesterol, promoting coronary artery calcification.

Cumulative evidence guided the AHA’s decision to recom-mend that individuals limit their intake of trans fat to less

I


than 1% of total daily calories as part of a healthful lifestyle to encourage cardiovascular health2 and led to an FDA ruling in 2006 mandating the labeling of trans fat on the Nutrition Facts label. But a loophole allowing products containing fewer than 0.5 g of trans fat per serving to be labeled as 0 g left a low level of trans fat in foods. Consuming several servings of products containing almost 0.5 g of trans fat will exceed the daily limits the AHA recommended.3

If the FDA’s trans fat ban is finalized, food manufactur-ers will no longer be permitted to sell or use partially hydro-genated oils in food products without FDA approval for use as a food additive and will again be in search of a suitable replacement. According to the public comment submitted by the Institute for Shortening and Edible Oils, a nonprofit trade association representing the refiners of edible fats and oils in the United States, “The industry believes palm oil and its fractions will likely be the initial replacement ingredient of choice for many PHOs [partially hydrogenated oils] in applica-tions requiring functional characteristics from the shorten-ing.” Further, “The global supplies of palm oil are sufficient to handle the expected increase in demand that would result from the total elimination of PHOs.”

“Baked goods and certain other products require a hard fat—one with a high melting point—in their preparation, so another hard fat must be used to replace partially hydroge-nated oils,” explains Michael F. Jacobson, PhD, cofounder and executive director of the CSPI. “Butter or lard would usually work, but palm oil is cheaper and is of plant origin. All are less harmful to health than partially hydrogenated oil high in trans fat.”

But is swapping partially hydrogenated oils for palm oil a fair trade? “The use of palm oil is not without unintended con-sequences,” says Judith Wylie-Rosett, EdD, RD, a professor in the department of epidemiology and population health and the Atran Foundation chair in social medicine at the Albert Einstein College of Medicine in the Bronx, New York. “Palm oil contains a high proportion of saturated fat, which we know also has adverse health effects.”

Saturated fats, similar to trans fats, raise LDL cholesterol but are safer to consume at higher quantities than trans fats. The AHA and the Dietary Guidelines for Americans recom-mend keeping saturated fat intake at less than 7% and at 10% of energy intake, respectively.2,4 A threshold effect of lower intakes of trans fat, which includes naturally occurring trans fatty acids, hasn’t yet been established.5

It’s possible that establishing a tolerable lower limit of trans fatty acids in foods would be less deleterious on health than increasing the saturated fat content. “We need to weight the options very carefully,” Wylie-Rosett says. “We should examine the history of saturated fats and consider their health effects. We can’t just assume that palm oil is the better replacement because it’s a natural source. Natural doesn’t necessarily equate to healthy.”

Environmental Concern According to Jacobson, “Palm oil suffers from at least two

problems: It boosts cholesterol levels, and most palm oil is imported from Malaysia or Indonesia, where the expansion of oil palm plantations has devastated the environment.”

Palm oil is derived from the fruit, seed, or kernel of oil palm trees, which are native to Africa but grown in the tropics of Southeast Asia. Indonesia and Malaysia are the leading export-ers of palm oil.6

“The large-scale and mostly [more than 90%] unsustain-able production of palm oil is causing unprecedented rates of deforestation, wildlife depletion, greenhouse gas emissions, and human conflicts in affected areas,” says Ashley Schaeffer Yildiz, palm oil campaigner for the Rainforest Action Network (RAN). Indonesia was once home to 170 million hectares (1 hectare is approximately 2.5 acres) of biologically diverse rainforests, and today only approximately one-half remain—which is the size of Texas and Florida combined. According to RAN, 18 million more hectares of rainforests will be converted into palm oil plantations by 2020.7 Nearly 75% of global palm oil is used in food products and cooking, making palm oil one of the largest food environment issues today.

The islands of Borneo and Sumatra are at the height of the palm oil debate. These highly desirable areas contain rich, low-lying forests and wetlands that provide ideal conditions for the oil palm trees to grow. However, these also are the only remaining places on earth where tigers, rhinoceroses, orangutans, elephants, leopards, and other wildlife coexist. Many environmental awareness campaigns are using the image of orangutans to build awareness. “This is literally because of their faces,” says Richard Zimmerman, executive director of the nonprofit organization Orangutan Outreach. “They’re so much like us, it is uncanny. It’s impossible to look into the eyes of a baby orangutan that has lost his or her mother because of palm oil and not feel compassion; they remind people of their own babies. Imagine, these little angels are now homeless and orphaned so that people can have snack foods that are creamier with a longer shelf life.”

The situation facing the orangutans in the wild is critical. “Entire populations are being wiped out as forests are destroyed. Orangutans are being cut off from one another, leading to genetic collapse. Without habitat, they simply will not survive in the wild. They will be limited to zoos,” Zimmerman says.

The long-term goal of Orangutan Outreach, which partners with many organizations on the ground in Indonesia, is to prevent this from happening. “We want to see all physically healthy orangutans living in the wild—in safe, protected forests with minimal intrusion by humans—far away from poachers, loggers, miners, and palm oil companies. For all other orangutans that have been injured or disabled from palm oil production and other human activities, we want them to be able to live out their lives in dignity in long-term sanctuary


care free of cages. This will require long-term attention, commitment, and funding, but we feel they deserve nothing less,” Zimmerman says.

Furthermore, palm oil poses other threats in addition to wildlife reduction and extinction. Indonesia currently is the world’s third largest emitter of greenhouse gases after the United States and China, with 85% of its emissions coming from rainforest and peatland degradation.8 Corporate land grabbing (the seizing of land by a nation, state, or organization, especially illegally, underhandedly, or unfairly) often is used to obtain land and results in increased food insecurity, child labor, and forced labor. “For these reasons, palm oil that stems from deforestation, wildlife endangerment, and human conflicts is being referred to as ‘unsustainable’ or ‘conflict’ palm oil, with the latter being more appropriate,” Schaeffer Yildiz says.

The good news, according to Jacobson, is that solutions to the palm oil debate do exist. “Interesterified oils appear to be safe; they’re made from soybean oil and typically include more polyunsaturated fatty acids than palm oil,” he says. “Mixtures of cottonseed, high-oleic canola, and other oils might work, depending on the application. If companies must use palm oil, they should at least use palm oil that’s sustainably produced either outside of Southeast Asia or on land certified by the Roundtable on Sustainable Palm Oil [RSPO].”

The RSPO was established in 2004, consisting of more than 1,000 members representing 50 different countries, and charged with ensuring that no new forests or conservation areas are cleared for palm oil plantations and that current plantations uphold human rights laws. Presently, 16% of the world’s supply of palm oil is derived from RSPO-certified plantations. According to Schaeffer Yildiz, “Consumers are being misled. Many of the companies that use the RSPO label are in fact still causing rainforest and peatland destruction, largely due to a lack of transparency in the palm oil supplier chain. For this reason, RAN is encouraging companies to use the term ‘responsible’ palm oil to indicate that their palm oil has been produced from traceable suppliers that don’t engage in deforestation, species extinction, high greenhouse gas emissions, or human rights violations.”

“The big environmental groups have done an excellent job recently of getting large companies, of which many already belong to the RSPO, to commit to responsible palm oil,” Zim-merman says. “The RSPO’s definition of sustainability is a step in the right direction, but it isn’t enough.”

RAN coined the term “The Snack Food 20” to describe 20 household names to target for commitments to change. “The Snack Food 20 have significant buying power,” Schaeffer Yildiz says. “Since we launched our Last Stand of the Orangutan campaign in September 2013, we’ve witnessed a huge shift in the palm oil sector. Several companies have recently strength-ened their commitment to eliminate conflict palm oil from their supply chain, and others are in the process of doing so. But a number of companies have failed to take action.”

“Companies need to completely eliminate deforestation from their supply chains,” Zimmerman says. “Standing forests must be left intact. Until all palm oil comes from traceable, conflict-free, deforestation-free sources, we must continue to fight it.”

What RDs Can Do Food and nutrition professionals can help by raising aware-

ness about the greater implications of human diets. A healthful diet is one that weighs the overall footprint of the food one eats to encompass nutritional, environmental, and social impacts. Food manufacturers have been looking at this issue for a while, but the foodservice industry, private label grocers, and insti-tutional settings could have a huge impact in transforming the palm oil sector if they were educated and mobilized. With the palm oil debate now in the public sphere, RDs and health pro-fessionals can become leaders in these issues.

To begin taking action, RDs can do the following:•Write, call, and petition companies to use responsible palm

oil in the products they make and sell.•Help companies follow through on their commitments to use

responsible palm oil through positive feedback. Let them know you’re happy with their decision and are more likely to recommend their products to clients and patients over a company that hasn’t committed to responsible palm oil.•Tell clients and patients that palm oil largely is found in

processed foods, of which they should limit their intake, according to the 2010 Dietary Guidelines for Americans and leading health organizations. •Teach consumers how to read labels and spot hidden forms

of palm oil or oil mixtures. •Engage the public in healthful discussions by informing them

about conflict palm oil using social media sites and blogging.•Contact an environmental organization that’s fighting

against conflict palm oil and ask them for ways in which nutrition professionals can lend their expertise to help.•Join the Hunger and Environmental Nutrition Dietetic Practice

Group, whose mission is to “empower members to be leaders in sustainable and accessible food and water systems.”

— Beth Anne Conlon, MS, RDN, is a doctoral candidate in the biomedical sciences, clinical investigation track at the

Albert Einstein College of Medicine in the Bronx, New York. She conducts research on behavioral and lifestyle

interventions to improve cardiometabolic health.

— Ashley M. Colpaart, MS, RDN, is past chair of the Hunger and Environmental Nutrition Dietetic Practice Group and

a doctoral candidate in interdisciplinary studies in food science and food safety at Colorado State University in Fort Collins.



Can Antioxidants Reduce the Risk?

DiabetesCardiovascularDamage

and


Diabetes and its cardiovascular complications are an epidemic in the making. An estimated 8.3% of the US population has diabetes (90% to 95% of those have type 2 diabetes), while 35% of adults older than age 20 have prediabetes, and most don’t know they have it.1 Fifty percent of adults aged 65 and older have diabetes, and according

to a recent report, if the current pattern continues, by 2020, more than one-half of the people in the United States either will have prediabetes or diabetes.2

These statistics are more sobering when considering that diabetes increases the risk of cardiovascular disease (CVD) three- to eightfold.3,4 Diabetes makes the heart more vulnerable to injury and more susceptible to heart failure.5 It isn’t surprising then that nearly 25 million adults in the United States have been diagnosed with diabetes and coronary artery atherosclerosis.5

Oxidative stress, in large part, contributes to cardiovas-cular complications associated with diabetes,4 caused by an imbalance between damaging free radicals and the body’s antioxidant defenses, which is linked to cellular dysfunctions that lead to various diseases such as CVD.6

What Is Oxidative Stress?“Diabetes is associated with a state of increased oxida-

tive stress,” says Angela Ginn, RDN, LDN, CDE, a spokesper-son for the Academy of Nutrition and Dietetics. Studies have shown that the metabolism of excessive glucose and free fatty acids that occurs with diabetes and insulin resistance increases oxidative stress and may accelerate the develop-ment of complications.7

Oxidative stress results from the production of oxidizing compounds (free radicals) in cells that exceeds the body’s natural antioxidant defense system and can destroy cardiac tissue and promote atherosclerosis. Chemically, free radicals are highly reactive and form when oxygen interacts with certain molecules in the body. They also result from exposure to cigarette smoke, ultraviolet rays, pollutants and chemicals, alcohol, and saturated fat and are found in disproportionate levels in those with diabetes.8 The initial trigger by which high blood glucose levels impair vascular function is an imbalance between nitric oxide availability and reactive free radicals.9 Nitric oxide, an anti-inflammatory and antiatherosclerotic molecule, can relax blood vessels and increase blood flow to tissues, but the nitric oxide system is compromised in the presence of excessive free radicals, resulting in hypertension and insulin resistance and further impairing the nitric oxide system, creating a downward spiral of cardiovascular damage.

Once formed, these free radicals set off a chain reaction of creating even more free radicals. Hyperglycemia, hyperlipid-emia, and insulin resistance, which are hallmarks of diabetes, enhance oxidative stress. The production of the oxidant superox-ide is the major cause of diabetes tissue damage and responsi-ble for inactivating antiatherosclerotic enzymes.4

Not only does oxidative stress cause damage, it impairs the heart’s ability to respond to stressors, such as a lack of blood flow and oxygen, and can cause inflammation that lingers even after blood sugar is normalized.4 The downward spiral of free radical formation and damage to the systems designed to neu-tralize them can result in disease.10

How to Treat Oxidative StressVitamin E is one of the most common antioxidant compounds

suggested to reduce oxidative damage in patients with and without diabetes. Several observational, epidemiological stud-ies have suggested that both dietary vitamin E and vitamin E supplements may decrease CVD risk.11,12 While only one looked specifically at diabetes patients, approximately 30% of patients with CVD have diabetes.11

Some population studies also have suggested that vitamin C may offer similar protection. However, several prospective clin-ical trials have found that antioxidant supplements provide no consistent cardiovascular benefits.12

Vitamin EArguably, vitamin E is the most widely studied and con-

sumed antioxidant compound in the hope of reducing CVD risk in populations with and without diabetes. Although antioxidant treatments, including vitamin E, show benefits in animals with diabetes, research has failed to show that supplements con-sistently provide any heart health benefits in clinical trials.13

In the Physicians Health Study II, men taking 400 IU of vitamin E every other day for eight years obtained no cardiovascular ben-efits. In fact, an increased risk of hemorrhagic stroke occurred.14

A meta-analysis of more than 135,000 individuals treated with vitamin E concluded that high-dose vitamin E (more than 400 IU/day) slightly increased the risk of death.15

The contradictory results of vitamin E protecting against car-diovascular complications has prevented researchers from rec-ommending high-dose supplemental vitamin E. Moreover, further study has revealed that it may be only a subgroup of diabetes patients with a certain genotype called Hp2-2 who are likely to ben-efit from vitamin E supplementation, and that supplementation in diabetes patients without the Hp2-2 genotype may be harmful.11

In most Western populations, about 36% of diabetes patients have the Hp2-2 genotype. However, in Southeast Asia, approximately 90% of the diabetes population has the

BY DENSIE WEBB, PHD, RD


genotype, suggesting that the study findings of one population may not apply to others.11 “Pharmacogenetic testing allows the health care provider to tailor treatment to a patient’s unique genetic makeup,” Ginn says, “but the jury is still out.”

While there appears to be no difference in the distribution of the genotype among diabetes patients, studies have established that the Hp genotype can predict CVD risk. The specific Hp2-2 genotype appears to predict who among diabetes patients will benefit from vitamin E supplementation.

Among those with the vitamin-E–responsive genotype, adding statins to the mix reduces risk even further.16 Both the Heart Outcomes Prevention Evaluation (HOPE) study and the ICARE study found diabetes patients with the Hp2-2 genotype who took vitamin E supplements at 400 IU/day experienced a 50% reduction in myocardial infarction, cardiovascular death, and overall incidences of cardiovascular events, respectively.17,18

Vitamin CWhile population studies suggest that vitamin C in

supplemental or dietary form may improve inflammatory markers (indicators of oxidation in the body), it’s unclear whether vitamin C intake reduces CVD risk among diabetes patients.19 It does appear to decrease fasting insulin levels and improve insulin action, though.20

Two large-scale, long-term trials that tested 500 mg/day of supplemental vitamin C found it had no effect in women at high risk of CVD or in men for preventing CVD.14,21

In a study of 315 patients, among those taking a combina-tion of vitamin C (average intake of 500 mg/day) and vitamin E (average intake of 400 IU/day) supplements for three months, there were no improvements in body weight, hemoglobin A1c, LDL, or triglycerides in those with either metabolic syndrome or type 2 diabetes.22

Studies in which people took 800 to 3,000 mg/day of vitamin C have found no significant differences in fasting glucose or fasting insulin levels or specific inflammation markers.23-25

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However, one study showed improved levels of free radicals in patients who took 1,000 mg/day of vitamin C for four months.26

While the effectiveness of antioxidant supplements appears to be determined by genetic predisposition so is the extent to which tissue damage likely is to occur.4 Furthermore, it seems as though oxidative stress is only one factor contributing to dia-betes complications; thus, antioxidant treatment most likely would be more effective if it were coupled with other treatments for diabetes complications.7

GlutathioneSometimes referred to as the “master antioxidant,” gluta-

thione, a tripeptide, is the most abundant antioxidant in animal tissues and one of the most powerful. It’s responsible for several metabolic functions, including intracellular defense against oxidative stress such as from toxins, drugs, and car-cinogens.27 “Gluathione is an important defense mechanism against damage to the heart,” Ginn says.

Glutathione depletion can occur from diabetes and aging,28 and levels also are affected by genotypes.29 Freshly prepared meats are relatively high in glutathione, while fruits and vegeta-bles have moderate to high amounts and dairy products, cereals, and breads generally are low in the antioxidant. Frozen foods have similar amounts as fresh foods, but other forms of processing and preservation usually result in extensive loss of the antioxidant.30

When consumed, glutathione is broken down into its con-stituent amino acids, including cysteine. Available cysteine

primarily determines glutathione concentrations in cells. N-acetyl cysteine (NAC) supplements sometimes are used to provide cysteine and increase glutathione levels.31 However, studies haven’t consistently found that NAC supplementation increases glutathione levels.27

Can Oxidative Damage Be Prevented?While researchers continue to study antioxidant compounds

and the medical community waits for genetic phenotypes to be identified and genetic testing to be perfected, the only proven way to prevent the oxidative damage associated with type 2 diabetes is to prevent the disease from occurring through diet and lifestyle changes, which include regular exercise and maintaining a healthy weight. Eating a diet rich in fruits and vegetables provides antioxidants shown to reduce oxidative damage and may provide protection against free radical damage.

“Healthy eating, physical activity, and blood glucose control are the pillars of prevention of diabetes and diabetes-related complications,” Ginn says.

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


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fter several months of fastidious planning and attention to many

logistical details, 275-plus enthusiastic nutrition professionals from

across the country attended Today’s Dietitian’s fi rst annual Spring

Symposium at the Tropicana Las Vegas from May 18 to 20. Accord-

ing to many attendees, the symposium was an extraordinary event

and a huge success. They said everything it offered them profes-

sionally and educationally was invaluable.

During the three days, the event provided dietetics professionals various oppor-

tunities to obtain one year’s worth of continuing education credits and network with

fellow colleagues. “The location of the symposium was great, and I liked the small,

intimate setting,” said Christy Wilson, RD, who specializes in employee wellness at

the University of Arizona in Tucson. “You were able to get your questions answered,

and I’m looking forward to the next symposium.”

Nabeelah Khan, senior food and nutrition manager at Edelman, a public relations

fi rm in Chicago, agreed: “I really liked the intimate nature of the conference. The sheer

numbers made it easier to connect with colleagues and presenters.”

A Spectacular Extravaganza!

28

By JUDITH RIDDLE

Here are some of Nieder’s most memorable one-liners: •“Laughing can keep us young and slow the aging

process.”•“Laughter can make you feel eight years younger

and help you live eight years longer.”•“According to one study, women undergoing in

vitro fertilization had more success if they were entertained by a clown.”•“Forget the gym, the treadmill, and the personal

trainer. Laughing is jogging for the innards.”•“Humor is a way to get a point across.”•“The easiest thing you can do is smile. Smiles

produce the same physiological effects as laughter. You may feel better and brighten the day of someone who receives your smile.”

Collaboration With the NDAThe Nevada Dietetic Association (NDA) and Today’s Dietitian worked

in tandem during the symposium. The NDA held its annual meeting and awards ceremony plus its student poster session, which it made available to conference attendees. Nineteen poster presenters from the University of Nevada, Las Vegas (UNLV) discussed their research on topics such as COPD, burns, refeeding syndrome, HIV/AIDS, celiac disease, and dietary guidance for Roux-en-Y gastric bypass patients.

Moreover, an enthusiastic team of student volunteers from the dietetics programs at UNLV; the University of Nevada, Reno; and Truckee Meadows Community College in Reno, helped symposium attendees navigate their way through the conference center, oversaw the Q&A segments of the continuing education sessions, answered questions about the event, and packed tote bags with programs, product samples, and other important information.

Daniel Lingle, a dietetics student at Truckee Meadows Community College, said he especially liked the diversity of specialties among the attending nutrition professionals. “I enjoyed listening to the various presentations about public relations, social media, and geriatrics. They were highly informative and inspiring,” he said.

Today’s Dietitian had an incredible experience working with the univer-sity students and the NDA. The symposium afforded chapter members networking opportunities with peers from around the country and gave attendees a chance to learn about Las Vegas and its local dietetics chapter.

Poolside PartyTo kick off the symposium in grand style, Today’s Dietitian hosted a

two-hour poolside welcome reception, a preshow party and networking opportunity for attendees, in the Tropicana’s Beach Club, where everyone enjoyed soft drinks, cocktails, and tasty hot and cold hors d’oeuvres, cru-dité, and desserts.

There was so much food, laughter, and good conversation that one attendee cancelled her dinner reservations she’d made previously because she didn’t realize there was going to be so much food and great company. “It was well organized, a good turnout, and the food was good!” said Sanam Shahrokhinia, MS, RD, a clinical dietitian at Cedars-Sinai Medical Center in Los Angeles.

Sidesplitting KeynoteThe next morning, attendees were greeted with nutritious Kellogg’s break-

fast cereals, fresh fruit, yogurt, coffee, tea, and juice along with hilarious keynote speaker Brad Nieder, MD, known as “The Healthy Humorist,” who blends health care humor with wellness advice. With many funny one-liners and amusing stories, Nieder, who gave up emergency medicine to become a comedian, explained how laughter really is good medicine for managing pain, boosting the immune system, and relieving stress.

“It was genius that you invited a comedian who had a health background,” Khan said. “He set the tone and the mood for the next few days. He put a smile on everyone’s face. You don’t get that at every conference.”

Cathy Armacost, MS, RD, a faculty member at Spokane Community Col-lege in Washington and a USA certified triathlon coach agreed: “Dr. Nieder was a wonderful way to start the day.”

SPRING SYMPOSIUM

LAS VEGAS, NEVADAMAY 18-20, 2014

2 0 1 4


So to all the nutrition professionals out there, remember to smile and laugh for a healthier, happier present and future.

Crème de la Crème PresentersAfter Nieder’s entertaining performance, the true

A-listers in the nutrition profession presented an incredible lineup of continuing education sessions on some of the hottest topics in dietetics. Today’s Dietitian’s all-stars were:•Toby Amidor, MS, RD, CDN, founder of Toby

Amidor Nutrition; •Jenna Bell, PhD, RD, senior vice president

and director of food and wellness at Pollock Communications; •Constance Brown-Riggs, MSEd, RD, CDE, CDN,

nutrition advisor for the Dannon One Yogurt Every Day Initiative; •Karen Collins, MS, RDN, CDN, FAND, nutrition advisor for the

American Institute for Cancer Research; •Becky Dorner, RDN, LD, FAND, founder and president of Becky

Dorner & Associates; •Sharon Palmer, RD, author, speaker, and contributing editor to

Today’s Dietitian; •Robin Plotkin, RD, LD, a Texas-based culinary and nutrition

communications professional; •Barbara Ruhs, MS, RD, LDN, a former supermarket dietitian who

currently operates consulting business NeighborhoodNutrition.com; •Jill Weisenberger, MS, RDN, CDE, FAND, a private practitioner in

Newport News, Virginia; and •Dana Angelo White, MS, RD, ATC, an assistant clinical faculty member

and sports dietitian at Quinnipiac University in Hamden, Connecticut. The topics that captivated the attendees’ attention included fad diets,


— SYMPOSIUM PHOTOS BY AMY BORNALO AND KEVIN PORTILLO; TROPICANA IMAGES COURTESY OF THE TROPICANA LAS VEGAS

Today’s Dietitian’s sponsor companies—Almased, Daisy Brand Cottage Cheese, Diabetes Sentry, Go Veggie!, INBalance Health Corp, Kellogg Company, and Walden Farms—discussed their newest products and provided samples for attendees to taste and eventually tout to cli-ents and patients. Daisy Brand Cottage Cheese provided mixed berry parfaits for the Tuesday morning break.

The lunch offerings also were a huge hit with attend-ees. “I was very happy that healthy food was served, especially the vegetarian lunch,” said Kristine Duncan, MS, RDN, CDE, an adjunct nutrition instructor at Skagit Valley College in Mount Vernon, Washington.

Salads, fresh fruit, and a burger bar featuring Morn-ingStar Farms’ veggie burgers in spicy black bean, roasted garlic and quinoa, and buffalo chicken were served on the first day of the symposium, along with a variety of beverages. “I loved the great lunches pro-vided,” said Carol Curtis, RD, CD, a dietitian at Memo-rial Hospital of South Bend in Indiana. “It was good to test the MorningStar products.”

On the second day of the symposium, a Tuscan buffet lunch was composed of sausage kale soup, Caesar salad, caprese salad, grilled vegetables, and

plant-based eating, diabetes, social media, retail dietetics careers, dietary supplements, and sustainability, plus two professional development round-tables on business development and the value of writing and speaking. “The caliber of speakers was phenomenal,” Wilson said. “It was nice to see RDs present on current and relevant topics that are so timely for practitioners.”

According to Erika Rothacker, RDN, LD, of Wellness Coaches USA, a national provider of on-site wellness coaching delivered to workplace employees, “The lectures were amazing, and there were so many people from other states. I met so many women who were awesome.”

“The symposium was so well organized and well managed timewise [in addition to] the room arrangement, temperature, nutritious meals and, most of all, well-chosen and brilliant speakers,” added Rose Quirante, MS, RD, LD, a renal dietitian at the Renal Center of Port Arthur in Texas.

Book Signings, Tasty Treats, Delectable LunchesDuring the morning and afternoon breaks, attendees enjoyed the book

and product showcase where they could meet some of the session speak-ers who were authors to discuss and purchase their latest books. Brown-Riggs, author of the African American Guide to Living Well With Diabetes; Palmer, author of The Plant-Powered Diet; Weisenberger, author of Diabe-tes Weight Loss—Week by Week; and Dorner, author of the Diet and Nutrition Care Manual, Policy & Procedure Manual, and various other continuing edu-cation resources, autographed books and other materials for purchasers.


and where are we planning to have it next year. “One of the things I liked the best about the symposium was that we got to hear our industry leaders validate and support the type of care we’re trying to provide our patients in our own facilities,” said Lisa Sherman, MEd, RDN, LD, who works in the division of mental health and developmental services at Rawson-Neal Psy-chiatric Hospital in Las Vegas. “The presenters were so inspiring. They inspired us to do our best.”

“I appreciated the variety of session topics that were offered, which enabled me to carefully select those sessions that were of the most benefit to me personally and professionally,” said Jenny Favret, MS, RD, LDN, an eating disorder specialist for the Duke Healthy Lifestyles Program at Duke Children’s Hospital & Health Center in Durham, North Carolina.

Next year’s symposium currently is in the planning stages. Much like the first symposium, it will include a stellar lineup of top-tier presenters and even greater opportunities to network and participate in continuing educa-tion sessions. We look forward to seeing you next year!

— Judith Riddle is editor of Today’s Dietitian.

a variety of pasta dishes. Fresh fruit, tiramisu, and cannolis graced the dessert table. “From day one, the foods and snacks conveyed the message that you can eat healthfully no matter where you’re at,” said Ave-lina San Juan-Roberto, MS, RDN, LD, who practices in Henderson, Nevada.

Morning YogaOf course, the symposium didn’t include all work

and no time for meditation and relaxation. On the second day, attendees were invited to an invigorating yoga session led by Las Vegas yogini Angie Negrete-Markle in the hotel’s outdoor Wedding Chapel court-yard. Participants engaged in a tranquil workout amid the sweet scent of fresh flowers and soothing sounds of a waterfall. Afterward, they were encouraged to eat a quick grab-and-go, healthful breakfast that included Special K products, apples, and bananas.

Moving Full Speed AheadAll in all, the Today’s Dietitian’s Spring Symposium

was a great success. Feedback from attendees was nothing but positive, and many eagerly asked when


The sustainability movement has hit health care, as hospitals are making great progress toward establishing healthier, more sustainable foodservice for patients and their families. Many of these green efforts are influenced, at least in part,

by the Healthier Hospitals Initiative (HHI), a national campaign to improve environmental health and sustainability in the health care sector. Healthier food is one of six challenges that form the basis of the HHI’s campaign, providing resources, insight, and support any hospital or health system can adapt to develop sustainable foodservice programs.

Seema Wadhwa, director of the HHI and director of sus-tainability for Inova Health System in Virginia, has been pur-suing various sustainability goals over the past few years as part of her role with Inova, and the health system’s efforts were summarized in the organization’s 2012 sustainability report, which also illustrated the reasoning behind why such efforts are pivotal for patients and the planet. “Inova recog-nizes that food has a direct, measurable impact on human health,” the report states. “We also acknowledge that the current global food production system in the US is unhealthy for both humans and the environment. Highly processed, calorie-laden junk foods have become easier and cheaper to access than natural, nutrient-rich food items. Antibiotics are used as a growth stimulator rather than to treat illness in livestock. Crops and livestock are grown using practices that pollute our water, air, and land. The majority of our food is produced in a way that sacrifices long-term well-being for instant profits.”

The HHI, for one, is working to change the status quo in hos-pital foodservice to adopt more sustainable practices. “The HHI is a national movement to implement a completely new approach to improving environmental health and sustainabil-ity within the health care sector,” says Patti Oliver, MS, RD, MBA, director of nutrition for UCLA Health in California. “It’s

intended to accelerate the greening of health care by offering a free way for hospitals to introduce sustainable practices into their daily operations. Twelve of the largest, most influential US health systems, comprising over 490 hospitals with more than $20 billion in purchasing power, have partnered with Health Care Without Harm, the Center for Health Design, and Practice Greenhealth to create the HHI as a guide for hospitals to reduce energy use and waste, choose safer and less toxic products, purchase environmentally responsible products, and serve healthier foods.”

Thus far, the HHI has grown to include nearly 1,000 hospi-tals in all 50 states and the District of Columbia. According to Oliver, the HHI issued its first milestone report last year, based on 2012 data, and the findings are promising. “In the report, data indicate that HHI hospitals have reduced their environ-mental footprint, lowered costs, and improved patient health by incorporating sustainability initiatives into their business models,” she says. “This is the first time hospitals have quan-tified sustainability efforts by collecting and reporting data to show movement.”

Whether with help from HHI tools or on their own, smaller hospitals and large health systems alike are revising their menus with a healthful twist, incorporating more local and sea-sonal food products, offering more vegetarian meals, and buying more organic, fair trade, and sustainably grown beverages and foods. There still are many health systems that have yet to see the importance of sustainability efforts, and plenty of work still must be done, but the health systems interviewed here are lead-ing the movement in health care, demonstrating there isn’t just one look to sustainable foodservice in health care.

UCLA Health SystemBased in Los Angeles, UCLA Health System comprises

Ronald Reagan UCLA Medical Center; UCLA Medical Center, Santa Monica; the Resnick Neuropsychiatric Hospital at UCLA;

Sustainable HospitalFoodservice

By Juliann Schaeffer


Today’s Dietitian profi les the top health systems

in the country that are driving change.

Mattel Children’s Hospital UCLA; the UCLA Medical Group; and more than 150 primary care and specialty care offices through-out the region, so the system feeds many mouths through its foodservice operations.

“We serve 3.4 million meals annually at our hospital cam-puses in Westwood and Santa Monica,” Oliver says, adding that the foodservice program covers inpatient meals at each hospital as well as several retail locations on both campuses and a large catering operation. “We provide a hotel-style room service for patients whereby they can order from a menu featuring more than 40 different ethnically and cultur-ally diverse entrées, including vegetarian and vegan options.”

While the foodservice menu boasts a multitude of ethnic and cultural foods, there’s one item you won’t find: fried foods. “We completely eliminated fried foods from all of our menus sev-eral years ago,” Oliver says, “and we decreased the price of the salad bar from $6.99/lb to $4.99/lb to encourage consumption of fruits and vegetables.

“We have a huge salad bar and a made-to-order sandwich deli alongside made-to-order sushi, an international corner, and a hot line with a variety of entrées,” she says of the many healthful items that have replaced the previous fried offerings. “We also still offer a grill with burgers and sandwiches, pizza, and El Pollo Loco, but even the vendors have no fried foods.”

Not only are menu items healthier for patients in terms of nutrient composition, but they’re also more sustainable. The organization’s sustainability policy set a goal to make 20% of food purchases sustainable by 2020. “We surpassed that goal in early 2013 by having 24% sustainable purchases,” Oliver says. “Our recent conversion to some sustainable cuts of meat will increase our percentage above its current level.”

For UCLA, sustainable means using a high percentage of locally grown and organic produce, which is labeled at the salad bar. “We also post a map showing the location where all of our produce originated,” Oliver says.

The organization participates in Meatless Mondays to reduce its meat purchases, offering a fully vegetarian menu every Monday. “You can still get a hamburger if you request it,” Oliver explains, “but all of our daily specials are meat-free and we post education on the 10 reasons to eat less meat.”

Not only does that mean fewer meat purchases overall, but UCLA Health System also has made efforts to ensure that the meat they do buy is better quality. (This relates to one of the HHI initiatives for balanced menus, which asks health systems to use less meat and better-quality meat.) “We recently started purchasing antibiotic-free chicken breasts, beef patties, and ground beef,” Oliver says. “This constitutes approximately 30% of our meat purchases.”

In addition, 70% of disposables used throughout the foodservice program, such as utensils and plates, are compostable; 20% are recyclable; and 10% still go to land-fills, though Oliver notes that the University of California’s

overarching sustainable practices policy, which was devel-oped by the 10 UC campuses, including UCLA, set a goal to have zero waste go to landfills by 2020.

“We also sell reusable UCLA Health coffee mugs and give discounts on coffee to patrons who bring any reusable mug,” she says, adding that in 2013, all UCLA Health staff mem-bers were given a reusable water bottle to encourage the use of refillable hydration stations that are available across the UCLA campus.

Inova Health SystemInova, a not-for-profit health care system based in Northern

Virginia, serves more than 2 million people each year through-out the metro DC area through the system’s five hospitals. In addition to being one of the founding HHI systems, in 2012, the health system developed the Inova IMPACT platform, which guides its overall sustainability strategy. This platform breaks down all efforts into three distinct branches: healthfulness, sustainability, and connectivity. Thus far, the health system has made big strides in each one of these categories, and it has even bigger plans for the future.

Regarding healthfulness, Inova has made numerous menu changes in an effort to ensure everyone within its hospitals has access to fresh, nutritious, and health-promoting foods. “In 2012, Inova’s Food Services team conducted cafeteria audits across the system to establish baseline levels of healthfulness,” according to Inova’s sustainability report. “They used the results to inform changes such as the repositioning of less healthful food items, the installment of weekly produce stands in cafeterias, and the switch from fried to baked for certain popular grill items.”

According to the report, at least one daily vegetarian option was added to the hot food station, and many snacks that didn’t meet the healthfulness guidelines were replaced with more nutritious options or eliminated altogether.

Inova continues to work toward meeting several healthful-ness goals, including reducing fried foods and sweetened bev-erages; offering more fruits and vegetables and fresh, seasonal produce; and moving away from processed foods.

Regarding sustainability, Inova has taken steps toward purchasing more locally grown food products. “Last year, Inova was able to double our local food spend,” Wadhwa says. “We also have partnered with local farmers for [an organic] CSA [community-supported agriculture] program.”

Moreover, “All coffee was switched to fair trade,” says Carolyn Billetdeaux, of Inova’s Office of Sustainability. “We’ve started to track our meat [in 2013] to create a baseline for [an effort toward reducing Inova’s meat spending] and are working on carbon foodprinting.”

The third branch of Inova’s sustainability program extends its efforts beyond Inova’s facility walls and seeks to bring the healthful and sustainable food conversation to the community.


To do that, Inova established a mobile farmers’ market that brings local produce into areas with few healthful options. In addition, the health system’s Double Dollars Program provides an incentive for food stamp recipients at four local farmers’ markets as well as the mobile market so they can purchase fresh and local foods. “Through this effort, Inova matched the first $10 in SNAP [Supplemental Nutrition Assistant Program] purchases at four local farmers’ markets, as well as at a Mobile Farm Market,” according to Inova’s sustainability report. SNAP is a key initiative in the nation’s nutrition safety net.

To help get more people talking about these issues and incorporating sustainability efforts into their daily lives, Inova also offers cooking classes that help inform people about what healthful and sustainable really mean. “Carolyn Billetdeaux has been a champion and also produced a sustainable cookbook and local ingredient guide,” says Wadhwa, who credits Inova’s foundation of a strong team, including Billetdeaux, for the health system’s sustainability successes.

Kaiser PermanenteKaiser Permanente, which serves upward of 9 million mem-

bers in eight states and the District of Columbia, was among the 12 health care systems that helped to launch the HHI. However, its efforts toward offering more healthful food options aren’t new; it began almost a decade ago.

“Kaiser Permanente developed healthy nutrition standards in 2005 as part of our Healthy Picks program,” says Jan C. Villarante, MS, RD, director of national nutrition services, procurement, and supply. “Healthy Picks standards are based on evidence-based research. The program then evolved to include sustainable food criteria into our foodservice program as well.”

Part of that evolution came through Kaiser Permanente’s Environmentally Preferable Purchasing Policy, which it devel-oped in 2008, as well as detailed sustainable food purchasing criteria developed the year after. “In 2012, we launched our Sus-tainable Food Scorecard, which we used in our RFP [request for proposal] and contracting process to set sustainability stan-dards within the industry,” says Kathleen M. Reed, sustainable food program manager and national farmers’ market coordina-tor. “We achieved an 18% sustainable food spend in 2013.”

In 2012, Kaiser Permanente and its 38 hospitals teamed up with Partnership for a Healthier America, for which it made a commitment to deliver healthier food and beverage options throughout its facilities, Villarante says. Through this part-nership, Kaiser Permanente implemented menu labeling in the cafeteria to give patrons more nutrition information at the point of sale, instituted healthy-only marketing, and introduced healthier sides, entrées, and beverages.

“Kaiser Permanente purchases about 590 tons of sustain-ably and locally and/or sustainably grown fruits and vegetables annually, which are served on patient menus and in cafeterias across the organization,” Reed says, noting that many vending

machines offer fair trade coffee and tea. Kaiser Permanente’s Hawaii hospital also serves about 1,800 lbs of local, seasonal seafood annually in its cafeteria and patient meals.

In addition, milk and yogurt, which are offered with many patient meals, cafeterias, and vending machines, are free of the growth hormone rBGH. And Northern California patients who order from the patient menu can choose cage-free, certi-fied humanely raised and handled eggs and beef burgers made from animals raised without antibiotics or added hormones. Kaiser Permanente projects to purchase more than 200,000 lbs of meats raised without antibiotics in 2014.

With regard to this beef, and meat overall, there will be less of it on the menu in the years ahead. “Kaiser Permanente has been making efforts to reduce the meat on our patient menus by increasing the vegetarian options on our patient and cafe-teria menus and serving more vegetarian items as the house choice on our patient menus,” Villarante says, adding that the health system already has made some headway. “Kaiser Per-manente reduced beef purchases by 18% in 2013.”

Other Sustainable StandoutsThrough its subsidiaries, Tenet Healthcare Corporation, an

HHI sponsor organization, operates 77 hospitals, 189 outpa-tient centers, and Conifer Health Solutions, which offers busi-ness process solutions to more than 700 hospitals and other clients nationwide.

Many of Tenet’s hospitals have incorporated more local pro-duce, meat, and dairy options into their foodservice operations, but Sierra Vista Regional Medical Center in San Luis Obispo, California, in particular, has made great inroads in converting its beverage offerings into healthier options. Currently, 75% of drink offerings are water, unflavored sparkling water, and other nonsugary beverages, and soda machines are nowhere in sight.

To further reduce waste, the hospital also eliminated bot-tled water for all hospital functions and catering events, says Melinda Lokey, director of human resources administration, who serves as the “sustainability champion” for Tenet’s sus-tainability efforts.

And it’s not just large health systems that are getting in on the sustainability movement. Resolute Health, which Tenet recently acquired, is a new health and wellness company in New Braunfels, Texas, that focuses on preventive health measures and changing the delivery of health care. Through its Sow Healthy Garden program, Resolute Health sponsors 10 school gardens with the local Comal County School District. In addition to several community health centers, including the Center for Wellbeing, Resolute Health was set to open a new full-service hospital in June, and while it may be just opening, the hospital has its feet firmly planted in healthful and sustainable practices.

“The hospital will open with a reusable to-go container program and composting,” says Dion Turner, RDN, food and nutrition director for Resolute Health. “Our local organic farm is


15 miles away in Seguin and will be growing most of our produce. We have selected local vendors for grass-fed meat, organic tamales and tortillas, and cold-pressed healing juices. No Styrofoam products will be found in our foodservice operations, and we look at purchasing minimally packaged items.”

According to Turner, the patient room service menu still will showcase comfort foods, but they will be homemade and given a healthful twist. “The hospital will have plenty of fresh vegeta-bles and will have a Meatless Monday menu all day in our Leaf café,” she adds. “The local organic vegetarian tamales are one item that we expect to have every Monday.”

Rex Healthcare in Raleigh, North Carolina, a member of UNC Health Care, is a private, not-for-profit health care system that serves more than 4,000 meals each day to patients and cus-tomers at three ancillary locations. Chef Jim McGrody is direc-tor of culinary and nutrition services at Rex, and he’s made it a personal quest to change the way hospital food is prepared and served. Two years ago, the health care system removed fried foods from its menus and replaced them with a wide variety of whole grain options.

At Rex, fresh food reigns, and some of those ingredients couldn’t get much fresher, coming from a nearby court-yard. “An herb garden, located in a courtyard near the café, was planted more than four years ago to encourage the use of fresh herbs in daily cooking. Every attempt is made to buy as much produce as possible from local North Carolina farms,” McGrody says, adding that educating patients and visitors about these efforts is important as well. “Informa-tion about the food we buy and prepare in the café is posted on a bulletin board to let customers know where our food comes from.”

Florida’s Lee Memorial Health System, which includes five acute care hospitals and two specialty hospitals, provides more than 1.5 million inpatient and outpatient meals annually and more than 5 million meals overall.

According to Larry Altier, systems director for food and nutrition services, over the past three years, the health system has made several sustainability improvements. In addition to revising hospital menus to be lower in sodium and fat, Lee Memorial also has substantially increased its local food buys. “Well over 44% of our vendors [offer] sustainable, local products,” Altier says. “During peak growing months in Florida, our produce can be as much as 88% local. We’re also working with a local urban grower to provide us with custom-grown organic produce.”

One foodservice vendor that has embraced the sustainability concept is ARAMARK. Advocate Health Care, a founding and sponsoring system of the HHI based in Downers Grove, Illinois, worked with ARAMARK to introduce compostable plates and bowls in its retail cafeterias and compost food waste at select hospitals. The system also establishes farmers’ markets at many hospitals during the

summer and promotes the use of reusable cups and mugs to reduce waste and recycles plastic, glass, aluminum, and paper, says Mary Larsen, MS, Advocate’s environmental stewardship manager.

Sustainability efforts of Sodexo’s foodservice program also are evolving, according to Debbie Petitpain, MS, RDN, Sodexo wellness nutrition coordinator. “Five years ago, we upgraded our traditional patient tray line to room service, which allowed us to reduce food waste as well as increase patient satisfaction,” Petitpain says. “Eighteen months ago, we started composting our patient tray waste and kitchen scraps, and since starting this program have diverted over 90 tons of food waste from the landfill.”

In addition, national food and dining management ser-vices company Unidine Corporation has initiated green improvements over the past few years. “Unidine’s Fresh Food Pledge, which is its pledge to use authentic food from scratch using fresh, responsibly sourced, seasonal ingredi-ents and guided by environmentally responsible practices, avoiding additives, chemicals, and preservatives, is used to guide the culinary program and results in less waste,” says Ellen Lowre, RD, vice president of nutrition, health, and well-ness. “For example, if asparagus is on the menu Monday, then cream of asparagus soup is planned for Tuesday so no asparagus goes to waste.”

Abounding BenefitsAccording to Oliver, it’s not just patients who are benefit-

ting from these efforts toward establishing more sustainable health care foodservice programs. “Everyone benefits from the healthy and sustainable initiatives we’ve embraced,” she says, “whether that’s in terms of personal health or an investment in the future of the environment.”

More than just patients, sustainability is about populations, Wadhwa says. “Inova sees sustainability as an upstream oppor-tunity to focus on population health,” she says.

In addition to patient and environmental health improve-ments, Reed says sustainability efforts can go a long way to help local economies. “Our local produce sourcing supports small-to-medium scale local farmers and puts money back into our local economy,” she says. “Our sourcing of sustainable produce, dairy, meat, and poultry supports the human health of consumers and the environmental health of the communities where the food is grown.”

And it doesn’t taste too bad, either. “Another great bene-fit is the quality and taste of the food provided to our patients, employees, and visitors, all of which enhances their dining experience,” she 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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Family-Based

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TD Q & A

The Pros and

Cons of GMOs

CONFERENCE ISSUE

April 2014

Vol. 16 No. 4



Family-Based

Approaches

to Weight Loss

Vegetarian Diets

and Older Women

TD Q & ADThe Pros and

Cons of GMOs

April 2014

Vol. 16 No. 4

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The most important meal of the day provides clients and patients the perfect

opportunity to eat more vegetables and meet dietary requirements.

adulthood, people should be eating as many as 3 cups of vegetables per day, depending on their age and sex. Unfortunately, most people don’t even come close to that number: A State of the Plate survey conducted by the Produce for Better Health

Foundation found that the average person consumes 1.8 cups of fruits and vegetables per day.

If your clients and patients are trying to pack more vegetables into their day and are falling short, recommend they add veggies to their breakfast plate. Bear in mind, however, that you also may be addressing the fact that many clients may not be eating a whole-some breakfast or may be skipping it all together.

Most Important Meal Many people don’t eat their first vegetable of the day until dinner,

according to Sharon Palmer, RD, author of The Plant-Powered Diet and Plant-Powered for Life. At that point, it’s probably too late to fit in the full 2 or 3 cups recommended. “Plus you don’t gain the ben-efits of a good source of phytochemical-rich foods with antioxidant and anti-inflammatory compounds pumping through your body all day,” she says. “So why not try to include vegetables in the diet at the very start of the day? Many cultures eat vegetables for breakfast, and there’s no reason we can’t either. By eating them for breakfast, you’re fitting in those important servings and getting more fiber and more nutrients to boost your day. Plus you can cut down on unwanted calories by filling up on these plant foods.”

In fact, filling up at breakfast may promote a healthier weight as well. According to a study published in July 2013 in Obesity, eating a large breakfast rather than a large dinner helps take advantage of the natural fluctuations in the body’s metabolic cycle and reduces carbohydrate cravings. “Often, we’re used to eating our biggest meal of the day at dinner, but that might not be the best way to go,” Palmer says. “However, it’s important to make sure that breakfast isn’t just a refined carb, saturated fat mess. I recommend servings from all major food groups: protein, whole grains, fruits, and veggies.”

Beyond promoting a healthy weight, eating breakfast has sev-eral other benefits. It’s long been touted as the “most important meal of the day,” and that largely has to do with getting the day off to a good start. “Eating a nutritious breakfast can get your day started on the right foot,” says San Francisco-based dietitian Kaley Todd, MS, RD. “It breaks your night fast and jump-starts your metabolism. Studies have linked breakfast consumption to lower risk of chronic diseases, better weight management, and improved mental performance.”

“After sleeping seven or eight hours, eating breakfast in the morning—typically within an hour of waking up—is a great way to renourish and fuel the body to start the day,” adds Barbara Ruhs, MS, RD, LDN, a former supermarket dietitian and the owner of Neighborhood Nutrition in Phoenix. “Eating breakfast helps us to bring our blood sugar back to normal, fueling our brains for the day ahead.”

By

BY LINDSEY GETZ

– 41 –

Solutions to SkippingBut Ruhs knows that despite its importance, many people skip

breakfast. “I think many people opt for more sleep instead of waking up and allowing enough time for breakfast,” she says. “Eating any-thing is better than nothing; however, you get out what you put in. If you fuel yourself with a healthful and balanced breakfast, you will get more brain-power bang for your buck.”

“The International Food Information Council Foundation did a survey that found that even though 93% of Americans agree breakfast is the most important meal of the day, only 44% are actually eating it,” says Elizabeth Pivonka, PhD, RD, president and CEO of the Produce for Better Health Foundation. “Mornings are very busy and hectic, and I believe that’s the biggest reason more than half are skipping breakfast.”

Americans are skipping breakfast for other reasons as well, says Amy Myrdal Miller, MS, RDN, senior director of programs and culinary nutrition for The Culinary Institute of America. “Some people think they’re too busy even though there are many very quick, easy breakfast options,” she says. “Others think that eating breakfast makes them hungrier than if they skip breakfast, but this can be overcome by choosing more healthful breakfast foods. High–glycemic-load breakfasts such as orange juice, a sweet-ened refined grain cereal, and nonfat milk will leave people feel-ing quite hungry only a few hours later. But a lower-glycemic-load breakfast such as a whole orange, whole grain breakfast cereal, nonfat milk, and some nuts or nut butter will leave people feeling satisfied for a much longer period of time.”

And, of course, adding veggies to the breakfast meal also is a wholesome way to fill up. Todd says she urges people to include a variety of vegetables throughout the day to maximize their nutri-ent intake. “Vegetables typically are a nutrient dense food with minimal calories, meaning a big nutritional bang that won’t add inches to the waistline,” she says.

However, even those who are eating breakfast tend to shy away from incorporating veggies. Ruhs says she doesn’t think it’s an aversion to veggies at breakfast; it’s simply not a natural consid-eration. In America, vegetables traditionally have been associated with lunch and, even more so, with dinner. But helping to change your clients’ and patients’ mindsets may be as simple as giving them ideas and recipes but also may require helping them find solutions to some of their nutrition struggles.

Helpful Hints for SuccessSometimes, just trying to get out the door on time in the morn-

ing can be a struggle, let alone trying to eat healthfully. That’s why Pivonka says dietitians should suggest foods that are easy to fit into a busy schedule. “Tomato juice is a great way to get some veg-etables quickly,” she says. “People often need to be reminded that they can incorporate fruits and vegetables in all forms—canned, frozen, fresh, or dried—in order to find ways to incorporate more.”

Foods that can be taken on the go definitely are a key to suc-cess. “A lot of people I talk to have problems fitting in a whole-some breakfast on the run,” Palmer says. “Some people wait to eat breakfast until they get to work or school and then their choices may be limited to less-than-stellar food options.”

RDs may need to remind clients that adding veggies can be simple, and they can be eaten on the run. “Some cultures slice vegetables over a breakfast sandwich, such as radishes, cucum-bers, tomato slices, or lettuce leaves,” Palmer says. “Just spread whole grain bread with hummus, tahini, or nut butter and pile it with delicious, crisp vegetables. That’s an easy, packable breakfast.”

“[Suggesting] quick, easy, and affordable breakfast ideas that incorporate veggies is the best way to encourage others to gobble up produce in the morning,” Ruhs adds. “Grab and go is the way to go for breakfast, and creating vegetable-inspired breakfast plans that accomplish this can go a long way. The smoothie and juicing folks are breaking barriers in this realm.”

Smoothies definitely are a simple way to squeeze more vegeta-bles in, Myrdal Miller agrees. “Consider adding canned, drained, rinsed beans to berry-based smoothies for some extra fiber and protein,” she says. “Dark leafy greens go great with citrus-based smoothies, and baked sweet potatoes are a wonderful addition to apple-based smoothies with cinnamon.”

But Myrdal Miller says eggs truly are the gateway to fitting in more vegetables at breakfast time. “Vegetables, including beans, can be added to omelets and breakfast sandwiches,” she says. “Breakfast burritos and tacos are gaining in popularity, and veg-etables easily can be incorporated into the filling with a vegetable-based salsa that can be used as a condiment.”

Eating leftovers is another morning vegetable option, Pivonka suggests. “If you had a healthful vegetarian pizza for dinner, have some cold for breakfast,” she says. “This is an easy way to get some extra vegetables in the morning.”

Todd says mixing leftover vegetables from dinner into your breakfast meal also is quick and easy since the vegetables already are cooked. “Making a quick morning hash with sweet potatoes and leftover vegetables can be a delicious way to kick off your morning while also sneaking in a serving of vegetables,” she says.

Vegetables also can be baked into muffins. “Adding puréed pumpkin or shredded carrots or zucchini to your whole grain muffins is a great way to incorporate vegetables,” Todd says. “Make a big batch and freeze the extras for a quick, veggie-packed treat on the run.”

While vegetables at breakfast may be a new idea for clients, it’s one they can come to embrace. After all, many other cultures have long been getting their veggies during the morning meal. “Vege-tables at breakfast may seem foreign to Americans, but there are many cultures and cuisines from around the world that include vegetables at every meal, including breakfast,” Myrdal Miller says. “There’s a wonderful savory Bolivian quinoa breakfast pud-ding that’s topped with roasted peppers and an aged cow’s milk cheese. In Turkey, eggs are scrambled with vegetables to create a dish called menemen. In Italy, a savory breakfast porridge is made from dried, ground fava beans. And in India, dal [cooked lentils] is a common breakfast food. With some good ideas, Americans can be on board with more vegetables at breakfast, too.”

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.


Sunshine Tofu ScrambleServes 2

Ingredients1 tsp extra virgin olive oil1 clove garlic, minced1⁄2 small onion, diced1 small yellow summer squash, sliced1⁄2 yellow bell pepper, diced1 cup sliced mushrooms5 oz extra firm tofu (1⁄2 package), cubed1 tsp oreganoBlack pepper and salt to taste

Directions1. Heat oil in a skillet. Add garlic, onion, and squash, and sauté for 3 minutes.2. Add bell pepper, sliced mushrooms, tofu, oregano, and seasonings. Sauté for an additional 5 minutes until vegetables are tender.

Nutrient Analysis per servingCalories: 125; Total fat: 6 g; Sat fat: 1 g; Cholesterol: 0 mg; Sodium: 13 mg; Total carbohydrate: 12 g; Fiber: 4 g; Sugars: 6 g; Protein: 9 g — RECIPE COURTESY OF SHARON PALMER, RD

Morning Grain GoodnessServes 2

Ingredients1 T olive oil1 cup mixed raw vegetables, diced (try zucchini,

asparagus, mushrooms, and broccoli), or leftover cooked vegetables

1 cup raw spinachSalt and pepper, to taste1 cup cooked quinoa or brown rice1 tsp vinegar2 large eggs2 T grated Parmesan cheese1⁄2 sliced avocado

Directions1. Add oil to a medium skillet over medium heat. Add mixture of raw vegetables, and cook until slightly tender (skip this step if using cooked vegetables). Add spinach to vegetables, and cook until wilted. Season with salt and pepper. Mix in quinoa or brown rice, and heat until warm.

2. Fill a sauté pan with 11⁄2 inches of water, add the vinegar, and bring to a simmer. Break 1 egg into a small bowl, then carefully pour it into the water and vinegar mixture. Repeat with second egg, spacing them so they don’t touch. Poach at a gentle simmer until the whites are firm but the yolks are still runny, 3 to 4 minutes. With a slotted spoon, transfer the eggs to paper towels and season with salt and pepper.3. Divide quinoa and vegetable mixture between two plates or bowls. Top each with an egg and half of the Parmesan cheese and sliced avocado.

Nutrient Analysis per servingCalories: 350; Total fat: 22 g; Sat fat: 5 g; Cholesterol: 190 mg; Sodium: 250 mg; Total carbohydrate: 26 g; Fiber: 7 g; Sugars: 2 g; Protein: 15 g— RECIPE COURTESY OF KALEY TODD, MS, RD

Pumpkin Pecan Spiced PancakesMakes 8 pancakes

Ingredients1 cup unsweetened plant-based milk1⁄2 cup water5 T canned pumpkin2 T canola oil2 T maple syrup2 tsp egg replacer1 cup white whole wheat flour1 T baking powder1 tsp ground cinnamon1⁄2 tsp ground nutmeg1⁄4 cup chopped pecans 1 T ground flaxseeds

Directions1. Combine plant-based milk, water, pumpkin, canola oil, maple syrup, and egg replacer in a medium bowl.2. Add white whole wheat flour, baking powder, cinnamon, nutmeg, pecans, and flaxseeds, and stir just until well combined, being careful not to overwork the batter. Let stand for 10 minutes.3. Heat a griddle on its low setting (or heat a skillet over low heat) and spray with nonstick cooking spray. Ladle 1⁄3 cup pancake batter onto griddle and cook until golden on both sides and cooked through (about 4 to 5 minutes on each side). 4. Repeat the process to make 8 pancakes.

Nutrient Analysis per servingCalories: 132; Total fat: 6 g; Sat fat: 1 g; Cholesterol: 0 mg; Sodium: 160 mg; Total carbohydrate: 18 g; Fiber: 4 g; Sugars: 6 g; Protein: 4 g — RECIPE COURTESY OF SHARON PALMER, RD

Veggie Recipes


By DAVID YEAGER

Nutrition Facts Label

The

Dietitians speak out about the FDA’s proposed changes, what more should be done, and how the updates will impact public health.

uch has changed in nutrition science since the Nutrition Labeling and Education Act, signed into law in 1990, mandated that nutrition labels be placed on packaged foods. However, the labels themselves

haven’t changed to reflect the science, with the exception of listing trans fat content beginning in 2006.

Later this year, however, the Nutrition Facts label will get a significant facelift. The FDA issued two proposed rules in March that were open for public comment until June 2. The final rules, which will revamp the labels and bring them more in line with the latest nutrition science and how people eat today, will take effect 60 days after they’re published in the Federal Register, and manufacturers will have two years to bring their labels into compliance.

Many dietitians believe it’s time to update the Nutrition Facts label. Although it was an improvement over previous labeling efforts, there were limitations. Janet Colson, PhD, RD, a professor in the nutrition and food science program at Middle Tennessee State University, says the proposed changes will provide more relevant information in an easier-to-understand format for average consumers. “For example, in the 1990s, most dietary advice focused on reducing total fat, saturated fat, and cholesterol, and the general consensus of the nutrition community was that all sugars are basically the same,” she says. “In fact, one of the leading nutrition textbooks [of that time] emphasized that the only problem with added sugar was that it causes cavities. After years of research, evidence on the effects of added sugars vs. natural sugars shows they have different effects on health. The public needs to be able to use the food label to determine the difference.”

What Lies Ahead One of the most significant proposed changes to the

Nutrition Facts label will be the inclusion of added sugars. The 2010 Dietary Guidelines for Americans state that the US population’s sugar intake is too high. In fact, the American Heart Association, the American Academy of Pediatrics, the Institute of Medicine, and the World Health Organization recommend people decrease their intake of added sugars, according to the FDA.

On average, Americans get 16% of their total calories from added sugars, and the major sources are soda, energy and sports drinks, sugar-sweetened fruit drinks, grain- and dairy-based desserts, and candy. There’s no specific recommen-dation for added sugar intake, but by listing added sugars separate from naturally occurring sugars on nutrition labels, the FDA hopes to make consumers aware of how much extra sugar they’re getting in a given food.

Removing the calories from fat line is another proposed change. Current research indicates that total fat is less

important to overall health than the types of fat a person consumes. Moreover, FDA consumer research has found that calories from fat make no difference in a person’s ability to judge the relative healthfulness of a product. Values for total fat, saturated fat, and trans fat will remain on the label, though.

The new labels also will more prominently display the number of calories per serving and adjust serving sizes to reflect what people actually eat, which is required by law, rather than what they should eat, especially since Americans are eating larger portions today than they were 20 years ago. “For example, a typical serving size of ice cream is listed as 1⁄2 cup, and what’s being proposed is that they increase that to a full cup, which is a more realistic serving size,” says Liz Weinandy, MPH, RD, LD, an outpatient dietitian at The Ohio State University Wexner Medical Center. “The serving size is what’s listed on the label, and the portion size is what a person would eat. So they’re starting to get the portion size and the serving size to be closer to the same thing, which would make the labels much more realistic and easier to understand.”

Some food containers will list total calories depending on whether someone likely will eat or drink the entire package content in one sitting. Weinandy says this can be a useful tool for someone who drinks a 20-oz bottle of soda, for example, because labels on these products currently list multiple serv-ings. If someone eats a whole bag of potato chips or a container of ice cream each week, it will be easier for them to see how many extra calories they’re consuming over time, she adds.

Vitamins and minerals such as calcium, vitamin D, potas-sium, and iron also may be added to the Nutrition Facts labels. These proposed revisions are based on data from the National Health and Nutrition Examination Survey and focus on nutrients that most Americans don’t adequately consume. Currently, vitamin D and potassium aren’t required on nutri-tion labels. Values for vitamins A and C would no longer be required because most Americans get plenty of these nutri-ents, although manufacturers can include them voluntarily.

Additionally, rather than listing the percent Daily Values a food provides, the labels will list the specific amounts of those nutrients in micrograms and milligrams. “When we talk to clients, we tell them how many grams or micrograms they need of that nutrient,” says Erin Winterhalter, MPH, RD, LDN, CDE, director of the MacDonald Center for Obesity Prevention and Education in Villanova University’s College of Nursing. “We don’t say, ‘You need three foods that have 20% of your Daily Value of vitamin D’; that doesn’t translate well for the consumer. The consumer is looking for the number of milligrams that they need each day. We tell them, ‘You need 1,000 mg of calcium per day, and this food’s going to give you 200 of that.’ So now we’ll be able to explain it in laymen’s terms for them with the help of the food label.”

M


Need for More ImprovementsAlthough most dietitians agree that these changes are

overdue, some have suggestions for further improving the labels. Colson would like to see folic acid values included, and Weinandy says larger print would be helpful for older consumers. And while serving sizes on approximately 17% of products would be updated, some say there’s still poten-tial for confusion.

“These serving size changes aren’t harmonious across all food categories,” says Rene Ficek, RD, LDN, CDE, lead nutrition expert at Seattle Sutton’s Healthy Eating, a freshly prepared healthful meal service. “In fact, the new label changes could make this gap even bigger. For instance, serving sizes on packages should match with serving sizes listed in the Dietary Guidelines for Americans. However, food manufacturers differ widely [on how they list serving sizes].

“We need to ask ourselves, ‘What is an actual serving for Americans, and what should it be?’” she continues. “Some people eat a pint of ice cream by themselves. If the FDA stated that an entire pint of ice cream was the actual serving size, it could encourage overeating, which is exactly what the labels are aiming to avoid. It would be ideal if the USDA and FDA could work together to present one seamless, clear message to consumers, but unfortunately the new labels don’t go far enough in this category.”

Another common criticism of the proposed changes is that the labels rely on a 2,000-kcal diet to derive the percent Daily Values. Many dietitians interviewed for this article say that, because nutritional needs vary widely among individuals, the percent Daily Values aren’t particularly helpful, and they

don’t refer to them when educating clients. What would be helpful, they say, is more guidance about how the amount of nutrients relate to diet.

“Identifiable colors on the label—like our red, yellow, and green stoplight system—may work here,” Winterhalter says. “If the product is low in sodium, let’s highlight that and mark it in green. If it’s a high-sodium food, the label could reflect this information in red. By adding color or images, like a thumbs up or thumbs down symbol, you lower the literacy level required to read the label, and it instantly becomes easier for all consumers to understand.”

Dietitians also hope for more transparency about food ingredients. Blanket statements such as “natural flavors” are of little value to consumers. Although known allergens must be stated on the label, other ingredients that may affect health can be hidden.

“I’d like to see caffeine content listed,” Weinandy says. “I think this is really important. Right now, a lot of products don’t have to disclose the amount of caffeine that’s in them. In general, energy drinks are the main culprit. When you see a product that says ‘high energy’ or ‘gives you energy,’ it may say something like ‘with added B vitamins’ or ‘with ginseng’ on the front label, and people think that they’re getting energy because of added vitamins or herbs. But what a lot of companies are doing is they’re actually adding caffeine and, of course, we don’t have any idea how much. Sometimes, even if you call them, they won’t provide that information. The energy drinks are really a concern, especially for adolescents who might drink them frequently or people with cardiac problems.”

New Label’s ImpactHow much of an effect can a simple food label have on

public health? Although it may not be a bombshell, over time its influence could be substantial.

For example, the proposed changes could help make a dent in the obesity epidemic by putting pressure on manufacturers to reduce the added sugar content in their products. “Hope-fully, it will affect the manufacturers in the same way as when trans fats were separated out on the label,” says Christine Santori, RDN, CDN, program manager of the Center for Weight Management at Syosset Hospital in New York, part of the North Shore-LIJ Health System. “It pushed many manufacturers to either not add [trans fat] in their food products or change their formulations a bit, so I’m hoping that may be the case as well when it comes to added sugars, that manufacturers will start reducing the amount of added sugars they put in products.”

For the most part, many dietitians believe the proposed changes will make nutrition labels more useful and help them educate consumers. The changes include areas that many of them emphasize, such as essential vitamins and minerals, good vs. bad carbohydrates, and appropriate calorie, sodium, and fiber intake.

Resources•Overview of label changes: www.fda.gov/Food/

GuidanceRegulation/GuidanceDocumentsRegulatory Information/LabelingNutrition/ucm385663.htm

•Fact sheet on proposed changes: www.fda.gov/ Food/GuidanceRegulation/GuidanceDocuments RegulatoryInformation/LabelingNutrition/ucm387533.htm

•Proposed rule for revising food labels: www.fed eralregister.gov/articles/2014/03/03/2014-04387/food-labeling-revision-of-the-nutrition-and-supple ment-facts-labels

•Proposed rule to adjust serving sizes on food labels: www.federalregister.gov/articles/2014/03/03/2014- 04385/food-labeling-serving-sizes-of-foods-that-can- reasonably-be-consumed-at-one-eating-occasion


“The new labels will be a valuable resource in working with obese, diabetic, or hypertensive patients as well as counsel-ing clients who simply want to plan healthier diets,” Colson says. “Obesity and diabetes are at an all-time high. If we, as dietitians, educate the public on the need for healthful eating and convey simple messages—such as, try to limit sodium to 1,500 mg a day; aim for about 100 kcal per snack or 500 kcal per meal; eat at least 25 g of fiber each day to avoid constipa-tion; or teens need 1,300 mg of calcium each day and adults need 1,000 mg—the public can use information on food labels to improve their diets.”

Ultimately, though, it’s up to consumers to take advantage of the tools at their disposal. For those who already eat a nutritious, well-balanced diet, the new labels probably won’t change their buying habits, Ficek says, but for those who eat a lot of processed foods, the proposed changes may encourage them to give calories, serving sizes, and added sugars a second thought.

Easier-to-understand labels are a step in the right direction, but much of the responsibility for public health falls on the public, dietitians say. To make a significant dent in obesity and the conditions associated with it, continued public outreach is essential. “Certainly, the label changes would be helpful for the people who are reading them, but somehow we have to

get the people who aren’t turning the package over to look at the label,” Santori says. “If we can affect those folks and have them care a little bit more about what’s in the package, that would possibly alter the obesity epidemic.”

One piece of good news is that more people than ever are reading nutrition labels. Weinandy says more than one-half of consumers read labels, and that number has been increasing. Dietitians hope that eventually the labels will have a trickle-down effect on Americans’ health.

But while more people are paying attention to what they eat, there’s still more to be done. After more than 20 years, it will take some time for people to get used to the new labels. “As with any change, there will be an adjustment time for consumers,” Ficek says. “Any changes to the Nutrition Facts panel need to be part of an overall education effort. If no one understands his or her calorie needs for the day, none of this will make sense for consumers. Dietitians will be an integral part of this education to help consumers in the long run by translating nutrition information to the public. I believe many consumers will find the changes both important and relevant to their personal needs.”

— David Yeager is a freelance writer and editor in Royersford, Pennsylvania.

The most reliable and independent online resource available for the nutrition professional

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Industry Trends. News. Information.Our website is a popular and reliable research tool that dietitians and nutrition professionals count on for accurate and current information. Our site offers a clearly organized article archive featuring key topics such as diabetes management, heart health, weight control, nutrition research, supplements, food allergies, gluten free, vegan/vegetarian diets, and much more. For those looking for continuing education credits, our CE Learning Library offers a range of self-study courses, webinars, and books for professionals to learn and earn their CPEUs.

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VITAMIN D’s ROLE IN HEALTH Deterministic or Indeterminate?By Stephanie Dunne and Jenna A. Bell, PhD, RD

Although the name suggests otherwise, vitamin D isn’t a vitamin because it’s not an essential element of the diet. Rather, it’s a prohormone synthesized by the skin when it’s exposed to ultraviolet B (UVB) radiation.1 Yet despite the body’s ability to produce vitamin D and its availability in some foods, estimates indicate that 50% of children and adults worldwide have insufficient amounts of vitamin D in their bodies.2 From Canada to South Africa and every latitude in between, vitamin D deficiency appears to be common, and it may be causing a wide range of health issues.2

This continuing education course explores how the body absorbs and metabolizes vitamin D, discusses its functions in the human body, explains how to evaluate appropriate blood levels based on the latest research, and identifies sources of the nutrient.

Absorption and MetabolismVitamin D comes in two major forms: vitamin D2 (ergocal-

ciferol) and vitamin D3 (cholecalciferol). Primarily, vitamin D2 is manufactured and used to fortify foods, while vitamin D3 is synthesized in the skin and naturally available in some animal-based foods. Commercially manufactured supplements contain either form.3 Because these two forms have identical metab-olism and function, the term “vitamin D” is used to represent both vitamins D2 and D3 unless specified.

Although vitamin D is available in both foods and supplements, sun exposure is the most significant source for most people.4 When UVB rays hit the skin, approximately 10% to 15% of the 7-dehydrocholesterol found in the skin is converted to pre–vitamin D3. In a thermal-dependent reaction, pre–vitamin D3 then is isomerized to vitamin D3 before being bound to vitamin D–binding protein and released into the circulating blood.1,5

Vitamin D3 then travels to the liver, where it’s hydroxylated to calcidiol, or 25-hydroxyvitamin D [25(OH)D]. Calcidiol then is carried to the kidneys and other tissues, where it’s enzymatically converted to its active form, calcitriol or 1alpha, 25(OH)2D.5 The conversion from calcidiol to calcitriol primarily occurs in the kidneys but also can occur in muscle tissue; the cells of the colon, prostate, pancreas, lungs, skin, breasts, and brain; and the immune system.1,2,5

When people ingest vitamin D from food sources, the intestine’s epithelial cells absorb the vitamin D and carry it via chylomicrons through the lymphatic system and into the circulatory system.5 From the chylomicrons, vitamin D may be

transferred to the vitamin D–binding protein and released into the liver, or it may stay in the chylomicron where it will be taken up by the liver, which is the last stop for the chylomicron after circulating in the body.1 Once in the liver, dietary vitamin D follows the same activation path as that produced from UVB rays by being hydroxylated into 25(OH)D and then into 1alpha,25(OH)2D.

Calcitriol is a self-limiting entity. High levels reduce the kid-ney’s production of 25-hydroxyvitamin D-1alpha-hydroxylase, which lessens the amount of calcidiol that’s converted to calcitriol.5 Calcitriol also upregulates the production of 25-hydroxyvitamin D-24-hydroxylase, an enzyme in the kidneys

CPE MONTHLY

COURSE CREDIT: 2 CPEUs

LEARNING OBJECTIVESAfter completing this continuing education course, nutrition professionals should be better able to:

1. Assess vitamin D’s life cycle in the body.

2. Evaluate vitamin D’s involvement in various aspects of health.

3. Determine recommended intakes of vitamin D.

4. Distinguish the sources of vitamin D.

Suggested CDR Learning Codes 2000, 2020, 2090, 4030; Level 2


and other tissues that’s responsible for inactivating both calcidiol and calcitriol. Once vitamin D has been inactivated by being turned into either 24,25(OH)2D or calcitroic acid, it returns to the liver where it’s added to bile and excreted in the feces.1

Functions of Vitamin DSince Polish physician Jerdrzei Sniadecki realized that

rickets, the bone-deforming disease in children, could be prevented and cured with sunlight, vitamin D has been well established as an essential part of calcium and phosphorus homeostasis and therefore bone maintenance.2,3 Specifically, calcitriol increases calcium and phosphorus absorption from the intestine and prevents the kidneys from excreting calcium and phosphate. Calcitriol also stimulates preosteoclasts to mature into osteoclasts, which break down bone and release calcium and phosphate into the blood. In an effort to recover homeostasis, parathyroid hormone (PTH) triggers both of these mechanisms when serum calcium and phosphate levels have dropped too low.5,6

Since there are numerous vitamin D receptors throughout the body, it appears that the nutrient has many other functions beyond bone health.5 In fact, vitamin D directly or indirectly influences as much as 5% of the genes in the human genome.3 Also, between 200 and 600 genes are primary targets of vitamin D, as they’re directly involved with vitamin D receptors. As the direct effect, vitamin D may cause an increase or decrease in the expression of the target gene depending on the gene itself.1,7

In addition to genetic influences, vitamin D receptors are found in the membranes of many cells, including those in the brain, gonads, skin, vascular smooth muscle, and immune system. These receptors allow vitamin D to trigger secondary messengers within some cells, causing a rapid hormonelike response that doesn’t involve genetic changes.1,2,5

Few studies regarding vitamin D’s effect on various conditions have been randomized controlled trials. In fact, most studies have been observational and show correlation but can’t prove causation.4,6 Therefore, it’s possible that sociodemographic factors, lifestyle choices, and metabolic health are confounding factors in studies reporting vitamin D’s impact on health.4

That being said, the epidemiologic evidence and scientific studies showing that vitamin D’s effects go beyond bone health are increasing. For example, infants who received 2,000 IU/day of a vitamin D supplement had an 88% lower risk of developing type 1 diabetes by the age of 32, and normotensive children given 2,000 IU/day had significantly lower arterial wall stiffness after 16 weeks compared with children who were given only 400 IU/day.6

Another study showed that children given 1,200 IU of vitamin D per day for four months during the winter reduced their risk of an influenza A infection by more than 40%.2 And pregnant women deficient in vitamin D seem to be at greater risk of preeclampsia and cesarean section.6

The following are some of the ways vitamin D appears to maintain health1-5:

•Cancer: suppresses the proliferation of and stimulates the differentiation and apoptosis of some kinds of cancer cells, especially breast, prostate, and colon;•Diabetes: triggers the transcription of the insulin receptor

gene in peripheral target cells and activates the release of insulin from the pancreas’ beta cells;•Cardiovascular disease: decreases PTH levels and

the release of renin by the kidneys, which helps reduce blood pressure;•Muscular function: increases calcium uptake by muscles

and stimulates the intracellular release of calcium within the muscle to maintain appropriate muscle contraction;• Immunity: upregulates macrophages’ production of

cathelicidin, a protein that helps them fight conditions such as upper respiratory infections and tuberculosis;•Parkinson’s disease, Alzheimer’s disease, depression, and

schizophrenia: prevents the loss of dopaminergic neurons in the brain; and•Multiple sclerosis, rheumatoid arthritis, Crohn’s disease,

and type 1 diabetes: suppresses the autoimmune response.Although scientific studies haven’t proven these effects,

they’re considered plausible because of the interaction between the regulating mechanisms of these conditions and vitamin D levels. For example, PTH modulates vasoconstriction and blood pressure, and is the principal activator of the renal gene CYP27B1. PTH concentrations rise when serum levels of vita-min D drop too low, which increases calcidiol activation.1,8 On the other hand, cytokines are responsible for the upregula-tion of the gene CYP27B1 in macrophages and the subsequent impact of calcitriol on the immune system.1

Recommended Blood LevelsCalcidiol, the inactive form of vitamin D, is the most abundant

form found in the blood and the one used as a primary marker of vitamin D status.5 Calcitriol isn’t considered a useful marker of vitamin D levels because it can remain within normal limits even when hypovitaminosis D is present. In addition, low calcitriol levels may be the result of kidney disease rather than an indicator of vitamin D synthesis or intake.9

CALL FOR PRESENTERS

2015 Today’s Dietitian SymposiumWe are currently accepting abstracts for presentations for our 2015 symposium. Individual or group proposals for 60- or 90-minute continuing professional education sessions will be accepted through July 18, 2014. Please

provide a written summary of no more than 250 words as a Word file via e-mail to [email protected].


Normal circulating levels of calcidiol reach 25 to 200 nmol/L, although it’s uncommon to see average values in population studies above 30 to 32 nmol/L.1,6 The Institute of Medicine (IOM) defines vitamin D deficiency as a serum calcidiol level below 20 nmol/L, indicating that this is the minimum advisable level for the general population and not for any populations with special considerations related to vitamin D.10

However, some experts say this level was chosen based solely on vitamin D’s effect on bone health, even though evidence of osteomalacia in adults still may be seen until serum levels reach at least 30 nmol/L.2 Moreover, 30 nmol/L appears to be the threshold for preventing hip and nonvertebral fracture, and PTH levels plateau between 30 and 40 nmol/L, indicating there still is a risk of bone remodeling until this level of serum calcidiol is achieved.6

The IOM also indicates that vitamin D insufficiency occurs when serum calcidiol levels drop below 50 nmol/L. If a person’s vitamin D level is insufficient but not deficient, it means the person’s risk of developing osteomalacia or another problem with bone mineralization is higher. Because of the seasonal variations seen in vitamin D status and bone resorption, a serum level of at least 80 nmol/L may need to be obtained in the summer to ensure serum levels don’t fall below 50 nmol/L during the winter months.5

Beyond bone health, some experts suggest that a serum vitamin D level of more than 75 nmol/L is necessary to positively impact long-latency diseases.8 Specifically, at 80 nmol/L, vitamin D no longer is the limiting factor for calcium absorption from the intestine. At 90 to 100 nmol/L, lower extremity function, dental health, and blood pressure are optimized, while the risk of fall, fracture, cardiovascular disease, all-cause mortality, and colorectal cancer are reduced.5,11 In fact, falls weren’t reduced in people aged 65 and older when serum vitamin D levels were below 60 nmol/L.11 Obviously, these suggested levels are significantly higher than the levels currently recommended by the IOM.

The IOM indicates that a serum 25(OH)D level higher than 125 nmol/L puts a person at increased risk of vitamin D excess, which can lead to hypercalcemia and overcalcification of bone, soft tissues, the heart, and the kidneys.7,8 Most studies in children and adults have shown that hypercalcemia doesn’t occur even with serum vitamin D levels of 150 nmol/L, and some studies have indicated serum calcium remained within normal limits until serum calcidiol levels were higher than 240 nmol/L.6,7 Specifically, in a meta-analysis of 28 trials, average serum calcium didn’t change even when calcidiol was higher than 600 nmol/L. In these studies, hypercalcemia was observed in isolated situations, such as when a participant had primary hyperparathyroidism or Williams syndrome or when high calcium intake coincided with high vitamin D intake. The hypercalcemia often resolved on a second test, indicating that the initial high serum calcium likely resulted from a contributing factor other than high vitamin D intake.2,6,11

It’s worth noting that many options exist for measuring the amount of calcidiol in the blood: chemiluminescence immunoassay, radioimmunoassay, liquid chromatography, high-performance liquid chromatography, and liquid chromatography–tandem mass spectrometry. However, the various tests return different results. For example, in one study, the number of participants with normal calcidiol levels was 19.9% with chemiluminescence immunoassay and 31.7% with liquid chromatography–tandem mass spectrometry.8 Also, the testing reagents may respond differently to vitamin D2 metabolites than to those from vitamin D3.

The problem of inconsistency should improve since refer-ence materials from the US National Institute of Standard-ization were made available in 2010, although standardized reporting and interlaboratory comparison still are needed.9 However, the Endocrine Society indicates that all methods for vitamin D measurement are valid as long as the reference range for the chosen method indicates the target calcidiol level is above the current minimum recommendation.6

Hypo- and Hypervitaminosis DWith all of the proven and possible effects, it’s clear that vita-

min D is required for good health. However, various factors can contribute to too low or too high vitamin D levels and should be taken into consideration when RDs counsel clients or patients on whether they should be tested.

Primarily, hypovitaminosis D results from lifestyle changes that have occurred in the past few decades.9 Reduced sun expo-sure from clothing, more time spent indoors, and increased sun-screen use all inhibit the skin’s synthesis of vitamin D.5 Children and adolescents’ reduced consumption of vitamin D–fortified milk also contributes to widespread vitamin D deficiency.6

In addition to diet and sun exposure, other factors related to health and a healthful lifestyle also seem to affect vitamin D levels. Lower levels of vitamin D have been observed in people with the metabolic syndrome, particularly based on their HDL cholesterol levels and waist circumference.4 One study found that waist circumference accounted for 1.9% of the variation in vitamin D status, while BMI explained none of the difference, indicating that perhaps abdominal adiposity specifically, and not obesity generally, may be a factor in developing hypovitaminosis D.8

Adiposity’s impact on vitamin D may be explained by the increased PTH levels often measured in people who are obese or because adipocytes sequester vitamin D.4,6 As a result, people with larger amounts of adipose tissue may be able to increase their serum calcidiol levels only one-half as much as people with less fat mass when given similar doses of vitamin D.6 Also, higher vitamin D levels have been observed in those who moderately consumed alcohol, didn’t smoke, and had normal blood pressure and serum lipid profiles. These differences were seen even when taking into account the difference in vitamin D levels that’s expected based on age, sex, and the month of blood sampling.4


For babies and children, breast-feeding with no vitamin D supplementation has been associated with the risk of deficiency because human breast milk and colostrum contain very little vitamin D. Preliminary data suggest that when lactating women take a daily vitamin D supplement containing 4,000 to 6,000 IU, they transfer enough vitamin D via breast milk to meet their baby’s requirements.6

Regarding uncontrollable factors, aging and skin pigmen-tation contribute to lower levels of vitamin D. As a person ages, the skin’s ability to produce vitamin D when exposed to UVB rays diminishes.4 It’s estimated that people who are older than 60 can create only one-half as much vitamin D as those who are younger than 20 when exposed to the same amount of sunlight.12

People with darker skin pigmentation are at risk of having lower vitamin D levels due to competition for UVB ray absorp-tion caused by melanin.5,13 Those with a naturally dark skin tone require three to five times longer sun exposure to make the same amount of vitamin D in the skin as do those with a very light skin tone.6

Certain conditions also can negatively affect vitamin D status. Conditions that produce granulomas (small areas of inflammation caused by tissue injury) can increase the conver-sion of calcidiol to calcitriol, which can lead to hypercalciuria and hypercalcemia.6 Granulomatous disorders include sarcoid-osis, tuberculosis, chronic fungal infections, and some lympho-mas. Some malabsorption syndromes, such as cystic fibrosis and inflammatory bowel disease, also can cause decreased absorption of dietary vitamin D.2

In addition to some medical conditions, various medica-tions can affect vitamin D levels. Among the drugs that may cause increased vitamin D catabolism are anticonvulsants, glucocorticoids, antifungals such as ketoconazole, and highly active antiretroviral therapy for AIDS. Taking these medicines may require individuals to obtain two to three times more than the recommended amount of vitamin D for their age group to

reach the recommended level of serum calcidiol.5 In contrast, exogenous hormones have been shown to increase vitamin D levels, possibly because of the increased concentration of vitamin D–binding protein.8

Although rare, genetic mutations can lead to rickets or osteomalacia because of the impact on vitamin D metabolism and function. As with the production of all human enzymes, certain genes are responsible for providing the instructions for creating the enzyme. As illustrated in Table 1 above, there are multiple genes involved in creating the enzymes responsible for vitamin D activation and inactivation. Additional genes are responsible for creating the proteins that allow cells to absorb vitamin D from the blood. If one or more of these genes don’t produce the necessary enzymes or vitamin D receptors, the same outcomes as seen in vitamin D deficiency can result.1

The pathology of genetic mutations that lead to rickets or osteomalacia often is described as vitamin D–dependent rickets or pseudo–vitamin D deficiency rickets because the problem lies with vitamin D activation or absorption rather than being a true vitamin D deficiency.5 The following are genetic mutations that influence vitamin D function1,5:•CYP27A1: causes a bile acid and lipid metabolism disorder

and may result in low calcidiol levels;•CYP2R1: results in low levels of vitamin D-25-hydroxylase

and calcidiol;•CYP27B1: marked by decreased levels of calcitriol and

normal serum levels of calcidiol;•Vitamin D receptor coding gene: marked by increased

calcitriol levels;•Hormone response element–binding protein: limits

vitamin D receptor binding; and•CYP24A1: marked by increased serum vitamin D and calcium.

Although hypovitaminosis D is more common, hypervita-minosis D can occur and primarily results in hypercalcemia and overcalcification of bone, soft tissues, the heart, blood vessels, and kidneys, as mentioned previously.7,8 Symptoms

TABLE 1

Important Genes and Their Enzymes Involved in Vitamin D Metabolism1

GENE ENZYME LOCATION CONVERSION

CYP27A1 Vitamin D-25-hydroxylase Liver Vitamin D2 or D3 ➔ calcidiol [25(OH)D]

CYP2R1 Vitamin D-25-hydroxylase Liver Vitamin D2 or D3 ➔ calcidiol [25(OH)D]

CYP27B1 25-hydroxyvitamin D-1alpha-hydroxylase Kidney and other tissues

Activation: calcidiol [25(OH)D] ➔ calcitriol [1alpha,25(OH)2D]

CYP24A1 25-hydroxyvitamin D-24-hydroxylase Kidney and other tissues

Inactivation: calcitriol or calcidiol ➔ 24,25(OH)2D or calcitroic acid


of hypervitaminosis D include anorexia, dry mouth, a metallic taste, nausea, vomiting, constipation, and diarrhea. With long-term oversupplementation, additional symptoms may include polydipsia, depression, headache, drowsiness, and weakness.

Elevated vitamin D levels may cause abnormally elevated serum values for blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase, and cholesterol and elevated urinary values of calcium, phosphorus, and albu-min. Toxicity also can cause poor growth in children.14

Because the cost of testing can be high and many people seem to be deficient because of insufficient sun exposure and low dietary intake, most experts don’t recommend population testing for vitamin D status. In fact, the test results for most people are expected to indicate deficiency unless people recently have been exposed to the sun and/or are taking a vitamin D supplement.

However, there are some situations for which testing is warranted and recommended. Situations for which vitamin D testing is indicated to confirm hypo- or hypervitaminosis D so recommendations for correction can be made, as appropriate, include the following2,3,6:•bone diseases (eg, rickets, osteomalacia, osteoporosis);•chronic kidney disease or nephrotic syndrome; •hepatic failure;•malabsorption syndromes (eg, cystic fibrosis, inflammatory

bowel disease, bariatric surgery, radiation enteritis, Whipple’s disease, celiac disease);•primary hyperparathyroidism;•when taking certain medications (eg, antiseizures,

glucocorticoids, highly active antiretroviral therapy, exogenous hormones);• in older adults with a history of falls or nontraumatic

fractures;• in children and adults who are obese;•granulomatous disorders (eg, sarcoidosis, tuberculosis,

histoplasmosis, coccidiomycosis, berylliosis, some lymphomas);•hereditary phosphate-losing disorders;•pseudo–vitamin D deficiency rickets; and•vitamin D–resistant rickets.

Recommended IntakeIn 2011, the IOM published Dietary Reference Intakes for

Calcium and Vitamin D to update the information provided in its 1997 report.3 With new data and the ability to integrate older data sets, the IOM established Adequate Intake levels for infants and Estimated Average Requirement and Recommended Dietary Allowance levels for children and adults (see Table 2 above).

Because the amount of vitamin D the skin produces when exposed to UVB rays is influenced by many factors, the IOM is unable to recommend an amount of sun exposure that would ensure adequate vitamin D production for all people.3 As such, the Dietary Reference Intakes are limited to dietary intake and assume minimal sun exposure. In addition, the report indicates that the values are based on dose-response relationships for bone health only, as data are inconclusive regarding vitamin D’s effect on other health factors.

The IOM has concluded there’s no evidence that serum calcidiol levels higher than 50 nmol/L provide additional benefits to bone health. It predicts that a daily intake of 600 IU will result in an average serum calcidiol level of 63 nmol/L for children and adults of all ages in northern latitudes during the winter, when sun exposure likely is the lowest for the year.3,5

In contrast to the IOM’s recommendation, the Endocrine Society indicates that individuals may need a dietary intake of as much as 1,500 IU of vitamin D per day to ensure serum calcidiol consistently is higher than 30 nmol/L. This indication is based on the society’s estimation that people of normal weight need 100 IU/day to increase their serum calcidiol level by 1 ng/mL, and that most people are deficient in vitamin D.6

TABLE 2

Daily Vitamin D Dietary Reference Intakes for All Life Stages3

LIFE STAGE ADEQUATE INTAKE ESTIMATED AVERAGE REQUIREMENT

RECOMMENDED DIETARY ALLOWANCE

Infants: 0 to 12 months 400 IU ---------- ----------

Children: 1 to 8 years ---------- 400 IU 600 IU

Adolescents: 9 to 18 years ---------- 400 IU 600 IU

Adults: 19 to 70 years ---------- 400 IU 600 IU

Adults: 70+ years ---------- 400 IU 800 IU

Pregnancy/lactation ---------- 400 IU 600 IU

Note that 100 IU = 2.5 mcg.


In addition, a review by Bischoff-Ferrari and colleagues found that only 66% of adults can achieve a serum calcidiol level of at least 50 nmol/L when following the IOM’s Estimated Average Requirement for vitamin D. Most healthy adults of all ages achieved what some consider to be the optimal calcidiol level of 75 to 110 nmol/L when consuming 1,800 to 4,000 IU/day for at least 42 days.11

As mentioned previously, many factors deter-mine individuals’ vitamin D status based on their ability to absorb, metabolize, and utilize it. After assessing for conditions that may contribute to hypo- or hypervitaminosis D and the amount of sun exposure that will contribute to vitamin D synthe-sis, an individualized recommendation for dietary intake can be established using the Recommended Dietary Allowances as a guideline.

Sources of Vitamin DSunlight is the most efficient source of vitamin

D for people. An adult wearing a bathing suit with enough sun exposure to cause a slight pinkness to the skin gets the same amount of vitamin D as does one who ingests 20,000 IU of vitamin D.2 In addition, vitamin D produced by the skin seems to stay in the body longer than does vitamin D from dietary sources or supplements.6

However, warnings from health organizations that excess sun exposure causes skin cancer has resulted in many people wearing extra clothing and using sunscreen while outside, which severely reduces the amount of vitamin D produced by the skin. To put it in perspective, using an SPF 30 sunscreen reduces the body’s ability to synthesize vitamin D by at least 95%.6

In addition to sunscreen and clothing, the angle of the sun influences how much vitamin D can be produced from sun expo-sure. The zenith angle of the sun represents the angle at which the rays of the sun hit the earth, and it’s affected by latitude, season, and time of day, as demonstrated in the image above.6

As an example, people at 52˚N latitude get about one-half of the annual UVB rays as do people at 40˚N latitude.12 For people above 33˚N latitude and below 33˚S latitude, the angle of the sun is too low during the winter months to produce any vitamin D in the skin, regardless of duration of exposure.6 The smaller the zenith angle of the sun, the less vitamin D can be produced by the skin.

Skin cancer is a serious health risk related to sun exposure, and precautionary measures should be taken. However, occu-pational and sensible sun exposure hasn’t been shown to sig-nificantly increase the risk of nonmelanoma skin cancer.2 Also, sensible sun exposure results in higher vitamin D levels, which may decrease the incidence of melanoma due to growth inhibi-tion and apoptosis promotion.12

Finally, warnings about skin cancer don’t take into account that more deaths occur each year from internal cancers and

disorders potentially associated with low vitamin D levels than from high UV light exposure (63,000 vs. 10,000 annually).12

Of course, given that many people can’t generate enough vita-min D from sun exposure due to factors such as latitude, indoor lifestyle, and skin pigmentation, dietary sources also should be considered. As mentioned, dietary sources include both vitamin D3 from animal sources and vitamin D2 from plant sources.5

Although some studies have indicated that vitamin D3 has a higher potency in the body than does vitamin D2, not all studies have reached the same conclusion, and differentiation hasn’t proven to be necessary.1,6 As indicated in Table 3 on page 54, foods that are naturally high in vitamin D include salmon, sar-dines, herring, and other oily fish as well as cod liver oil, egg yolks, and sun-exposed mushrooms.1,2

In the United States, many foods are fortified with vitamin D manufactured by UV irradiation of ergosterol produced by yeast. Fortified foods contain approximately 100 IU per serving and include many dairy products, such as milk, yogurt, butter, and cheese; orange juices; margarines; breakfast cereals; and infant formulas.2

Vitamin D is available in commercial supplements and some multivitamins or in pharmaceutical formulations. Physicians can prescribe a liquid supplement with 8,000 IU/mL for infants and younger children or a gelatin capsule with 50,000 IU for older children and adults. Vitamin D supplements are available with as little as 400 or as many as 50,000 IU per serving.

In addition to straight vitamin D supplements, many multivitamins contain 400 to 1,000 IU of vitamin D, and many commercial calcium supplements also contain vitamin D because of the relationship between the two micronutrients. Supplementation is effective at maintaining serum levels

The zenith angle of the sun is impacted by latitude, season, and time of the day. The larger the angle,

the more vitamin D the skin can produce with uninhibited exposure to sunlight.

Summer at Midday

Winter or Sunset

Larger Zenith Angle Smaller

Zenith Angle


when taken at various intervals, including daily, weekly, and every four months.6 Vitamin D supplements and multivitamins can be taken with or without food.14

The Challenges of Putting It Into PracticeIn recent years, the prohormone known as vitamin D has

been getting attention for its potential role in a host of health issues, from autoimmune diseases to cancer. Despite mounting data from observational studies, the IOM has reported that conclusive evidence from randomized controlled trials is insufficient to declare that vitamin D plays a definitive role in conditions beyond those related to bone health.3 While the Endocrine Society and other experts agree that the evidence still is building, they argue that the potential for benefit outweighs the risk of harm in recommending higher vitamin D intake levels.5 As a result, RDs should be aware that an optimal serum calcidiol level is higher than 30 nmol/L and can be as high as 75 nmol/L without causing adverse effects and potentially protecting the person from long-latency diseases.3,5

To reach an appropriate serum calcidiol level, the IOM recommends a daily vitamin D intake of 400 IU in the first year of life, 600 IU until the age of 70, and 800 IU from age 70 onward.3 However, given the many genetic, environmental, and metabolic factors that influence vitamin D status, RDs may need to counsel clients or patients to ingest two to three times the recommended amount to achieve the desired result. The Endocrine Society suggests that children and adolescents may need up to 1,000 IU/day and people older than 18 may need

1,500 to 2,000 IU/day to consistently achieve blood calcidiol levels higher than 30 nmol/L.6 RDs may be concerned that the higher intake levels will cause toxicity in the form of hypercalcemia, but that toxicity typically isn’t seen until intake exceeds 10,000 IU/day for several months.2,6

In waiting for future research to clarify vitamin D’s role in the human body and the necessary intake to achieve the required levels, RDs should use the Recommended Dietary Allowance as the minimum intake that ensures their clients and patients can maintain bone health. Then, when individualizing the recommendation, RDs should consider lifestyle, environmental factors, malabsorption issues, medication use, genetic mutations, and other health conditions that can increase or decrease skin synthesis, metabolism, and usability of vitamin D.

— Stephanie Dunne is a graduate student in nutrition and a dietetic intern at Lehman College in the Bronx, New York.

— Jenna A. Bell, PhD, RD, is senior vice president and director of food and wellness at Pollock Communications in New York City;

the 2013-2014 chair of the Sports, Cardiovascular, and Wellness Nutrition Dietetic Practice Group; and a coauthor of Energy to Burn:

The Ultimate Food & Nutrition Guide to Fuel Your Active Lifestyle.

TABLE 3

Selected Food Sources of Vitamin D15

FOOD SERVING SIZE APPROX. IU/SERVING

Cod liver oil 1 T 1,360

Raw maitake mushrooms, diced 1 cup 786

Swordfish, cooked 3 oz 706

Salmon, sockeye, cooked 3 oz 447

Fortified skim milk 1 cup 120

Fortified orange juice 1 cup 100

Whole Grain TOTAL cereal 3⁄4 cup 100

Fortified nonfat yogurt with fruit 6 oz 88

Tuna, canned in water, drained 3 oz 68

Fortified margarine 1 T 64

Egg, chicken, whole, scrambled 1 44

Note that 100 IU = 2.5 mcg.



CPE Monthly Examination

1. Vitamin D is considered to be which of the following?

a. Vitamin

b. Hormone

c. Prohormone

d. Antioxidant

2. Which of the following genetic mutations can result in

normal levels of 25-hydroxyvitamin D [25(OH)D] and low

levels of 1alpha,25(OH)2D?

a. CYP27A1

b. CYP27B1

c. CYP2R1

d. CYP24A1

3. Vitamin D testing specifically is recommended for

which of the following groups?

a. People with liver failure

b. People who live north of 45˚N latitude

c. All adults older than 65

d. Everyone

4. Which of the following is the active form of vitamin D

in the body?

a. Calcitroic acid

b. Calcidiol

c. Calcitriol

d. 24,25(OH)2D

5. Beyond bone health, vitamin D seems to help

maintain health in which of the following ways?

a. Maintaining kidney function

b. Supporting muscle growth

c. Promoting weight loss

d. Suppressing the autoimmune response

6. Which of the following foods has the highest content

of vitamin D per serving?

a. Cod liver oil

b. Sun-dried mushrooms

c. Swordfish

d. Fortified skim milk

7. The sun is too low during the winter months to

produce any vitamin D in the skin above and below

which north/south parallel?

a. 20˚

b. 33˚

c. 40˚

d. 52˚

8. Vitamin D is associated with bone health because it

does which of the following?

a. Stimulates osteoblasts

b. Increases phosphorus excretion

c. Reduces parathyroid hormone release

d. Increases calcium absorption from the intestine

9. The Institute of Medicine identifies vitamin D

deficiency as serum calcidiol levels below which of the

following levels?

a. 15 nmol/L

b. 20 nmol/L

c. 32 nmol/L

d. 50 nmol/L

10. Each serving of foods fortified with vitamin D contain

approximately which of the following amounts?

a. 2.5 mcg (100 IU)

b. 25 mcg (1,000 IU)

c. 40 mcg (1,600 IU)

d. 100 mcg (4,000 IU)

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 [email protected].

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.


EXERCISE WITH AN AUTOIMMUNE DISEASEClients May Need to Modify Activity Type and Intensity to Maintain Optimal HealthBy Jennifer Van Pelt, MA

Ten years ago, I was teaching eight advanced fitness classes each week, working full-time as a writer, walking the dog a few brisk miles every day, and maintaining a house and yard. Then, all of a sudden, I needed long naps to get through the day, and walking up the stairs became a major effort. My endless energy was replaced by constant fatigue and all-over muscle and joint pain.

After a long year of undergoing medical tests and seeing doctors, I was diagnosed with autoimmune thyroid disease and either fibromyalgia or the early stages of another autoimmune condition, such as lupus. Even on appropriate thyroid hormone therapy, muscle relaxants, and pain medications, I still struggle daily with pain and fatigue but manage to maintain my fitness, albeit at a much lower level than before. Senior fitness and yoga classes and resistance exercises with 2-lb weights have replaced hard-core kickboxing boot camp classes and strength training with 20-lb barbells.

I’ve chosen to share my experience to give readers some idea of what clients with autoimmune disease face when advised to exercise. When diagnosed, I was in great shape and used to exercising, including high-intensity and high-impact activities. As a former competitive swimmer and long-time fitness instructor, I always have been motivated to stay fit, and my motivation carried me through the challenges of adjusting to living with an autoimmune disease. So if exercising regularly

is a struggle for someone like me, imagine how difficult it must be for clients who didn’t really exercise or enjoy physical activity before they developed an autoimmune condition.

Despite the existence of a large volume of medical literature and detailed diagnostic criteria on auto-immune diseases, they remain some-what of a medical mystery. There are no cures, and though many different therapies are used, patients con-tinue to deal with symptom flares and chronic pain and fatigue. The type of autoimmune diseases your clients may have include rheumatoid arthri-tis, systemic lupus erythematosus, Sjögren’s syndrome, autoimmune thyroiditis (also called Hashimoto’s disease), type 1 diabetes, and mul-

tiple sclerosis. (Note: Type 1 diabetes does cause fatigue but generally doesn’t have the associated muscle and joint pains of the other autoimmune diseases. Insulin levels, rather than pain and fatigue, mostly affect exercise. Therefore, informa-tion in this article focuses on the other autoimmune condi-tions. Exercise recommendations for type 1 diabetes are more similar to those for type 2 diabetes. Multiple sclerosis may be progressive, and patients often have severe movement limita-tions unique to this disease. Exercising with multiple sclerosis will be covered in a future article.)

Fibromyalgia, although not classified as an autoimmune condition, manifests with similar symptoms and may occur in conjunction with other autoimmune diseases. Hence, any exercise recommendations here can apply to clients with fibromyalgia as well.

What Does the Research Say?Clinical guidelines for autoimmune diseases note that

regular exercise may be beneficial, but they don’t specify the types of exercises. Several recent studies have reported exercise’s benefits for autoimmune conditions, including the following:

• Rheumatoid arthritis: Aerobic and resistance training significantly improved cardiorespiratory fitness, cardiovascu-lar disease risk factors, and autoimmune disease activity and severity.1,2 A specially designed upper extremity exercise train-ing program along with home exercise reduced upper body disability and improved function and grip strength.3 And twice-weekly small group tai chi improved psychological health and social well-being in those with rheumatoid arthritis.4

• Lupus: One hour of walking three times weekly improved vascular function and aerobic capacity without worsening

FOCUS ON FITNESS


disease activity.5 Regular exercise improved fatigue, depres-sion, pain, and quality of life in patients with lupus.2,6

• Sjögren’s syndrome: Nordic walking, or fitness walking with specially designed walking poles, for 45 minutes three times weekly significantly improved aerobic fitness, fatigue, and depression in women with Sjögren’s syndrome.7 Moderate- to high-intensity exercise positively affected fatigue, physical function, depression, and aerobic fitness in patients with the disease.6

Exercise RecommendationsFor those with autoimmune conditions or fibromyalgia,

there’s a fine line between the right amount of exercise and too much. Exercise not only affects the musculoskeletal system but also impacts body chemistry by increasing or decreasing chemicals that contribute to inflammation. Too much exercise can produce inflammatory chemicals, thereby increasing pain and causing autoimmune flares, but regular exercise of the appropriate intensity and duration can decrease inflammation and improve overall functioning and pain.2

How can clients figure out what works for them? Clients with a previously high level of fitness who exercised vigorously likely will exercise too much. For me, vigorous exercise feels great while I’m doing it, but several hours to a day after an intense workout, I’ll have a flare in muscular pain and fatigue that even makes sitting and typing at my computer challenging. Modify-ing the type and time of my exercise has helped. For instance, doing a vigorous but low-impact activity (eg, stationary cycling, active yoga) in the evening allows my body to recover overnight and lessens the likelihood of flares.

Athletic clients with an autoimmune disease may require counseling on modifications and moderation in exercise inten-sity and duration. They should be encouraged to remain moti-vated even if their activity level must be decreased significantly for a while. After all, Sjögren’s syndrome caused tennis champ Venus Williams to withdraw from competition and training for several years. She’s just now, three years after her diagnosis, returning to competition after learning to manage her disease in combination with her athletic training.

Clients at a lower level of fitness may not exercise enough to see positive results. These clients may benefit from super-vised exercise programs with instructors experienced in working with movement limitations and medical conditions. Fitness classes designed for seniors, beginners, or those with fibromyalgia may provide social support and motivation as well as health benefits.

In general, the following exercises are appropriate for most clients with autoimmune diseases:•aquatic exercise, especially in warmer water;•gentle yoga, chair yoga, and stretching;• tai chi and qi gong;•walking;

•stationary cycling;•resistance exercises with bands and light weights; and• low-impact aerobics (eg, dance-based, marching/walking-

based movements).Monitoring reactions to different types and duration of

exercise in a pain or symptom journal can help determine the best amount and type of exercise for your clients with autoimmune disease and/or fibromyalgia.

A word of caution: Published clinical studies and exercise recommendations are for those with mild to moderate disease activity. Patients with more severe lupus often have cardiac and renal involvement that may preclude certain types of exer-cise. Patients with more advanced rheumatoid arthritis may have joints so deformed that certain exercises aren’t comfort-able or even possible. Consulting with a physician for guidance on appropriate exercise is necessary for these clients.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care research analyst/consultant

in the Reading, Pennsylvania, area.

References1. Stavropoulos-Kalinoglou A, Metsios GS, Veldhuijzen

van Zanten JJ, Nightingale P, Kitas GD, Koutedakis Y. Individualised aerobic and resistance exercise training improves cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis. Ann Rheum Dis. 2013;72(11):1819-1825.

2. Thomas JL. Helpful or harmful? Potential effects of exercise on select inflammatory conditions. Phys Sportsmed. 2013;41(4):93-100.

3. Manning VL, Hurley MV, Scott DL, Coker B, Choy E, Bearne LM. Education, self-management, and upper extremity exercise training in people with rheumatoid arthritis: a randomized controlled trial. Arthritis Care Res (Hoboken). 2014;66(2):217-227.

4. Waite-Jones JM, Hale CA, Lee HY. Psychosocial effects of tai chi exercise on people with rheumatoid arthritis. J Clin Nurs. 2013;22(21-22):3053-3061.

5. dos Reis-Neto ET, da Silva AE, Monteiro CM, de Camargo LM, Sato EI. Supervised physical exercise improves endothelial function in patients with systemic lupus erythematosus. Rheumatology (Oxford). 2013;52(12):2187-2195.

6. Strömbeck B, Jacobsson LT. The role of exercise in the rehabilitation of patients with systemic lupus erythematosus and patients with primary Sjögren’s syndrome. Curr Opin Rheumatol. 2007;19(2):197-203.

7. Strömbeck BE, Theander E, Jacobsson LT. Effects of exercise on aerobic capacity and fatigue in women with primary Sjögren’s syndrome. Rheumatology (Oxford). 2007;46(5):868-871.


GET TO KNOW…

KAREN COLLINSPromoting Nutrition’s Big Picture Through Smart Bytes and Small ChangesBy Juliann Schaeffer

Karen Collins, MS, RDN, CDN, FAND, a nutrition consultant, speaker, and writer, has been preaching healthfulness for more than 25 years. In addition to one-on-one counseling through her long-time western New York private practice as well as nation-wide presentations, she espouses her messages through her blog, Smart Bytes (http://karencollinsnutrition.com).

With a trademarked tagline of “taking nutrition from daunt-ing to doable,” Collins works to dig past the superficial healthy headlines that bombard (and confuse) consumers daily to determine what the latest research really says about how food can help people become healthier and happier. And, according to Collins, that usually means small changes.

“I think we need to help people identify the priority changes for them and then find and see the value in small steps they can take,” she says. “People are bombarded with messages that can make them feel perfection is needed in order to make a difference, and that’s not what research shows.”

According to Collins, those small changes could provide even bigger dividends if people spent more time in the kitchen. “I think we need to help people get more comfortable cooking at home, mindfully enjoying food prepared with fresh

flavors, instead of thinking that either eating out or using highly processed foods are the only options when they feel rushed,” she says.

One of Collins’ specialties is cancer prevention, and she lends her nutritional expertise to the American Institute for Cancer Research (AICR) as a nutrition advisor. She’s also the author of a weekly syndicated column for the AICR called “Health Talk” and coauthor of the “Nutrition and Cancer Prevention” chapter in the third edition of The Clinical Guide to Oncology Nutrition, published by the Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics (the Academy). Deeply involved in numerous Academy dietetic practice groups, she serves as codirector of the Sports, Cardiovascular, and Wellness Nutrition (SCAN) Dietetic Practice Group’s Wellness and Cardiovascular subunit.

With her hand in so many pots, so to speak, Collins’ day could have her focusing on any number of nutrition-related tasks: a webinar presentation, a blog posting, or content review for the AICR. “I try to start the day focused on what-ever project demands the most intense and creative thinking,” she says, admitting that in addition to numerous administra-tive tasks, self-employment definitely has its perks. “One great thing about being self-employed is that I can take time out to refresh with midday physical activity, like a tae kwon do class or a quick walk.”

Plus, Collins says, the greatest perks of working in the nutrition field are definitely the excitement of keeping up with constantly changing research and the satisfaction that comes from passing that knowledge on to people so they can better their lives.

Today’s Dietitian (TD): What is your proudest career accomplishment?Collins: I feel incredibly lucky with the opportunities I’ve had for work, through which I hope to make a difference. I feel both honored and humbled to have had the chance to contribute in various ways to the AICR’s important work. Receiving the SCAN Dietetic Practice Group award for Excellence in Practice in Wellness Nutrition certainly means a tremendous amount to me. Honestly, though, during many years in private practice, it’s been a true privilege helping individuals create healthier lifestyles and seeing the impact in their lives, and I value that part of my career, too.

TD: You’ve written a great deal about how heart disease, diabetes, and cancer are interrelated. What are the most important points nutrition professionals should know about this topic?Collins: When I speak about this at health professional con-ferences, people often comment about problems of today’s specialization “silos.” We need to recognize the significant overlap between diabetes, heart disease, and cancer. We can


promote choices for overall health, even when we temporar-ily focus on one particular problem. Fortunately, eating pat-terns focused on vegetables, fruits, whole grains, and beans and supporting a healthy weight offer the potential to pro-tect against all three diseases. And no single eating pattern is essential to achieve this. In fact, that’s the subject of a health professionals webinar I did with Sharon Palmer, RD, which is offered for free on the AICR website. (For more information on the webinar, visit www.aicr.org/health-professionals/ce/webinars/eating-patterns-to-lower-cancer-risk.html.)

TD: From the many nutrition and health conferences and seminars you’ve presented, what’s one insight, either from a copresenter or from an audience member, that struck you or has stuck with you, and why?Collins: A big take-home lesson for me from health profes-sional and consumer audiences is how easy it is for people to get overwhelmed by the constant barrage of headlines about new research findings. Studies are not all equal, and it’s impor-tant that when sharing messages about healthful eating, we base them on the big picture of overall research. People need help setting priorities for choices backed by strong evidence as most likely to make a difference. In fact, that was the inspiration behind creating my Smart Bytes blog, which focuses on putting research in perspective and making choices based on it doable.

TD: Give us a peek inside your refrigerator or cupboard. What are the mainstays always in your kitchen, and what seasonal foods do you most look forward to stocking them with in the summer?Collins: I love the arrival of summer and all its fresh vegeta-bles and fruits! I look forward to all the tomatoes, peppers, corn on the cob, and fresh greens and to the raspberry and blueberry seasons.

Still, I keep my freezer and pantry stocked all year round so I always have the essentials on hand. My freezer is always loaded with bags of vegetables like chopped spinach, artichoke hearts, and squash plus lots of frozen berries and peaches. My pantry always has tomatoes because they’re the foundation of so many dishes I make. Other essentials are canned black, kidney, and garbanzo beans; dried lentils; and whole grains such as quinoa and whole wheat couscous and pasta. Because I add nuts to so many salads and other dishes, I always keep a stash. And I count on knowing I’ve always got a wide variety of herbs, spices, and flavored vinegars handy.

TD: Is it true that you have a purple belt in tae kwon do, and what led you to this discipline?Collins: Yes, although I’m not someone that most people would expect to love something like tae kwon do, and it was never something I’d even considered. An instructor in an aerobics-type kickboxing class suggested I give it a try. To my surprise, I

loved it from the start. It’s a fabulous way to exercise both body and mind. And since you can’t focus on anything else while you’re doing tae kwon do, it’s a terrific emotional refresher and stress buster.

TD: How has tae kwon do helped mold your nutrition philosophy?Collins: It has shaped the way I communicate messages about nutrition. The first time I was being tested to progress to a new belt, I passed everything else, but when I tried to break my board, I just couldn’t. My instructor said, “You’re seeing the board as a barrier and letting it stop you. You have to look beyond the board and kick through it.” He was right: I changed perspective, and I broke the board. Instantly, I saw it as a metaphor for all the walls my clients were seeing. I want to be the voice reminding people that even when we see barriers, that doesn’t mean we can’t break through.

TD: What’s a great summer vegetable dish to serve a crowd?Collins: I always aim to offer a variety of vegetables that taste so good that they’re the highlight of a meal. The taste of fresh summer vegetables is so wonderful, I don’t like to do anything that masks it. Instead, I just aim for an interesting color and flavor combination from the choices that look good when I’m shopping and add in a substantial dose of a fresh herb like basil or cilantro. I love flavored vinegars, but sometimes a simple olive oil and lemon dressing is the refreshing note that ties everything together and lets the flavors of the vegetables stand out. I do love to grill vegetables, too. It’s funny, but it’s those simple combina-tions that people get all excited about when we entertain.

TD: What about a refreshing summer fruit dessert recipe?Collins: That’s easy: wash and enjoy! Summer peaches are great grilled, too.

TD: Favorite place or way to relax and unwind?Collins: My favorite ways to unwind are to spend time with family or girlfriends and to be outside in fresh air. My husband and I are empty nesters now, so time with our sons is truly precious—and we really have fun together. Time talking with sisters and girlfriends who “get” you is truly a gift. And being outside revives me on every level. There’s the peace of mind from quietly walking my dog or sitting near water, or the exhilaration of cross-country skiing or doing an interval walk-run. I believe in outdoor playtime, too. I love to pull out croquet or bocce when friends come over in the summer instead of just sitting around.

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania,

and a frequent contributor to Today’s Dietitian.


Weelicious Lunches: Think Outside the Lunch Box With More Than 160 Happier MealsBy Catherine McCord2013, William MorrowHardcover, 320 pages, $29.99

If you aren’t already familiar with Catherine McCord, I suggest you check out her award-winning website (http://weelicious.com) to get a taste of what you’ll find in Weelicious Lunches. You may think this is just a cookbook for kids, but it’s full of meals that will satisfy every family member. McCord focuses on recipes the entire family will enjoy but often adds a bit of flare that kids especially will love, such as heart-shaped sandwiches or mini pretzel bites.

This book is broken into two parts: “School Lunch Solu-tions” and “Recipes.” In the section on school lunches, McCord discusses some key principles to creating great lunches, including methods to engage all five senses, must-have food groups, great containers to use, and strategies to deal with food allergies and picky eaters. I love the colorful pages picturing beautiful lunch ideas for fruits, vegetables, proteins, carbohydrates, and pantry staples.

McCord simplifies lunchtime prep even further with her “Weelicious Lunches Allergy Guide,” which organizes each of the book’s recipes into a chart that indicates whether it’s gluten-, nut-, egg-, or dairy-free. This chart is handy for parents of children with allergies or those whose children attend schools with food restrictions.

The second part of the book, and the largest component, includes innovative, tasty, and nutritious recipes for salads, soups, sandwiches, pizzas, PB&Js, main events, veggies, dips and spreads, snacks, and desserts. You may be wondering how there could be a whole section devoted to PB&J. McCord takes this classic and gets adventurous with creations such as apple ring PB&J (apples are used in place of bread), peanut butter pancake sandwiches, PB&J “pop-tarts,” and chocolate PB&J cups.

Weelicious Lunches also provides healthful recipes for many of the processed treats that often are marketed to kids, such as animal crackers, chocolate chip granola bars, chocolate-hazelnut spread, whole grain fruit-filled bars, fruit leather, and whole wheat cheddar crackers. Using McCord’s recipes, it’s easy to prepare fresh, homemade, and more nutritious versions of these popular snacks.

Overall, I highly recommend this book. I had an 8-year-old boy and his mother in my office the other day, and when he started looking at the recipes in this book, his excitement went through the roof. Weelicious Lunches is a great resource for dietitians and parents alike.

— Janice H. Dada, MPH, RD, CSSD, CDE, CHES, owns SoCal Nutrition & Wellness, a private practice

and consulting business in Newport Beach, California. She’s also a freelance writer and works in education.

Gluten Freedom: The Nation’s Leading Expert Offers the Essential Guide to a Healthy, Gluten-Free LifestyleBy Alessio Fasano, MD, and Susie Flaherty2014, Turner PublishingHardcover, 320 pages, $24.95

Written by world-renowned gastroenterologist Alessio Fasano, Gluten Freedom covers the latest research and controversies on gluten-related disorders. The book conveys complex scientific discoveries in concise, simple terms, making it a great resource both for RDs and consumers.

It’s easy to forget that before Fasano’s landmark 2003 study, celiac disease virtually was unheard of in the United States, and studying the condition was considered professional suicide. The first section of the book, “Gluten Enters the Picture,”

BOOKSHELF

gives a behind-the-scenes scoop on the discovery of celiac disease and how our understanding of it has evolved through the years. Fasano covers gluten sensitivity and how gut permeability may hold the key to unlocking our understanding of all autoimmune diseases. He even addresses the commonly held misconception that everyone should eat gluten-free.

Part two, “Learning to Live Without Gluten,” gets down to the nuts and bolts of reading labels, setting up a gluten-free household, and dining out,. Readers even get a peek at some of Fasano’s favorite recipes from his native Italy.

Part three, “Gluten-Free for Life,” gives sage advice for stay-ing gluten-free during pregnancy, childhood, family celebra-tions, college, and the aging process. Pam Cureton, RD, LDN, with whom Fasano has worked closely for more than a decade, shares tips throughout the book. Fasano advocates that people with gluten disorders work with an experienced RD.

The fourth section, “Going Beyond Gluten,” focuses on the future of celiac disease treatment. Fasano paints a picture of promising experimental treatments, therapies, and possible methods for preventing celiac disease down the road. He also provides updates on controversial research about the ideal time to introduce gluten to infants.

While Gluten Freedom wouldn’t be my first choice for a newly diagnosed client because it’s an advanced look at the research and managing specific circumstances and devotes only a few chapters to the basics, I plan to keep a copy in each of my offices. It’s a must-read for any RD with clients who have gluten-related disorders and are motivated. It’s the most accurate, comprehen-sive, and current guide to understanding why and how gluten can cause problems and to help separate fact from fiction.

— Cheryl Harris, MPH, RD, is a freelance writer and speaker who works in private practice in northern Virginia,

specializing in helping clients live and love a gluten-free diet.

Boosting Brain Function and Memory Through NutritionBy Deralee Scanlon, RD2013, Beverly Glen NutritionSoftcover, 110 pages, $9.95

For older adults who complain about entering a room and forgetting why they went in there or frequently losing their car keys, they aren’t alone. A recent report by the Centers

for Disease Control and Prevention states that one in eight older adults experiences some kind of memory loss.

In Boosting Brain Function and Memory Through Nutrition, Deralee Scanlon uses her award-winning nutritional skills to help put the brakes on mental decline. An older adult herself, Scanlon devoted more than a year to researching and analyzing scientific studies and attending brain health conferences and webinars. In her book, she combines this information with her knowledge of food as medicine and dietary supplements.

The practical guide begins with a short and straightforward overview of the brain’s regions and functions, followed by a discussion of the three main causes of age-related memory loss: inactivity, lack of mental exercise and stimulation, and lack of essential brain nutrition. Scanlon then explores the foods that contain the essential daily nutrients the brain needs: protein, carbohydrates, and healthful fats.

The bulk of the book is dedicated to detailing brain-friendly micronutrients (ie, protective vitamins and minerals). For each one, Scanlon explains how it works, how it benefits the brain, how much to take, any side effects, symptoms of deficiencies, research findings, and foods that contain it.

Information on the value of probiotics, aromatherapy, and water complete the book’s content, along with an easy-to-drink fresh juice recipe. The book concludes with a lengthy reference list.

Scanlon’s take-home message to readers is that they have the power to reduce the rate at which their brain shrinks, lower their risk of mental decline, and improve their memories by following a healthful lifestyle, including losing weight and eating foods that boost brain function. As she puts it, “Use it, feed it, or lose it.”

— Karen Appold is a freelance medical writer and editor based in Pennsylvania’s Lehigh Valley.

PRODUCTS + SERVICES

Robbie’s Offers Low-Sodium, Gluten-Free Sauces

Robbie’s Naturals offers a product line of flavorful low-sodium, gluten-free sauces, including worcestershire sauce, hickory barbeque sauce, sweet and sour sauce, garlic sauce, ketchup, and steak sauce.

All of Robbie’s sauces are low in sodium, gluten-free, and made with all-natural ingredients. The hickory barbeque sauce has only 40 mg of sodium per serving, is fat-free, and contains no high-fructose corn syrup.

For more information, visit www.robbiesnaturals.com.

gardein Releases Gluten-Free Line

gardein has announced the addition of three glu-ten-free products: beefless ground, veggie burger, and black bean burger. For meat and veggie lovers alike, these gluten-free products are made with non-GMO soy, pea proteins, and vegetables.

With 84% less fat than regular ground beef and a meatlike texture, gardein beefless ground is a health-ful and easy alternative, with 24% of the Daily Value of protein, 3 g of fiber, and only 1.5 g of total fat. A com-bination of veggies makes the gardein veggie burger an excellent source of vitamin A and a good source of fiber, with 3 g of fiber and 5 g of total fat. The gardein black bean burger has 7 g of fiber and 6 g of total fat.

For more information, visit http://gardein.com.

Snyder’s of Hanover Expands GF Pretzel Line

Snyder’s of Hanover has launched two new gluten-free pretzel varieties. The expanded line includes Gluten Free Honey Mustard & Onion Pretzel Sticks, Gluten Free Hot Buffalo Wing Pretzel Sticks, Gluten Free Mini Pretzels, Gluten Free Pretzel Sticks, and an eight-pack of Gluten Free 100-Calorie Pretzel Sticks.

Certified by the Gluten-Free Certification Organization, Snyder’s of Hanover’s gluten-free pretzels also are free of dairy, casein, and eggs.

To help shoppers better identify the gluten-free pretzel options, Snyder’s of Hanover also has introduced a new packaging design.

For more information, visit www.snydersofhanover.com.

SOS Rehydration Drink Launches Blueberry Flavor

SOS, a rehydration drink comprising the right balance of electrolytes for optimum hydration, has announced that all products are now 100% free of artificial sweeteners, preservatives, flavors, and colors. The company also is launching a blueberry flavor.

SOS has six times the electrolytes of a normal sports drink and 27% more electrolytes than coconut water with one-half the calories and sugar. An SOS mixed with water helps the body absorb three times more water than drinking water alone.

For more information, visit www.sosrehydrate.com.

PINES Beet Juice Powder Offer Veggies in a Bottle

PINES International makes it easy to incorporate the ben-efits of beets into a healthful diet with its Beet Juice Powder, which can be added to water, juice, or yogurt; whipped into a smoothie; or added to desserts.

Beets have been the subject of many research studies that have reported health benefits from reducing anemia to providing more stamina to athletes. In addition, beets are a dietary source of antioxidants, naturally occurring nitrates, betalain, and folate.

For more information, visit www.wheatgrass.com.

Massel Introduces GF Concentrated Liquid Stock

Massel has introduced a concentrated liquid stock, which is the essence of liquid stock/broth in a 3.8-oz pouch that creates 2 qts of stock just by adding water and can be refrigerated for up to 10 days after opening.

The all-natural stocks come in three flavors: a vegetable blend and vegan chicken- and beef-style blends with all of the savory richness of meat but made using only vegetable ingredients. They feature premium vegetables and herbs, extra-virgin olive oil, and sea salt. They’re also gluten-free, lower sodium, lactose-free, cholesterol-free, trans fat–free, and kosher certified and have no added MSG or GMOs.

For more information, visit www.massel.com.


LÄRABAR Rolls Out ALT Protein Bar

LÄRABAR has launched ALT, a bar made with 10 g of field pea protein. The ALT flavors emulate the desserts they are named after but are made with nine or fewer ingredients. The flavors are Cinnamon Apple Crisp, Peanut Butter Cookie, Pumpkin Pie, and Lemon Pound Cake, with more expected soon.

ALT offers a gluten-free, non-GMO, dairy-free, vegan, and kosher bar with added protein. Its wrapper is made from 31% plant-based material.

For more information, visit www.larabar.com.

KettlePop Offers USDA Organic Kettle Corn Snacks

KettlePop uses organic, non-GMO ingredients and tops the popcorn with preservative-free flavorings for its cheese, caramel corn, kettle corn chocolate drizzles, and caramel chocolate drizzles popcorn offerings. And the company now offers organic sea salt and organic kettle corn as well.

For more information, visit www.kettlepop.com.

Bear Naked Debuts Honey Almond Protein Flavor

Bear Naked granola has introduced a new flavor, Honey Almond Protein. Made with soft-baked whole grain oats, honey, and roasted almonds, Honey Almond has 10 g of protein per serving.

Like all Bear Naked products, the Honey Almond Protein is made with natural ingredients that are minimally processed and free of hydrogenated oils, high-fructose corn syrup, and artificial preservatives.

For more information, visit www.bearnaked.com.

Foxy’s Pash Hits New Shelves on West Coast

Foxy’s Pash offers all-natural frozen yogurt with a fraction of the sugar, fat, and calories of many frozen desserts. Pash is specially churned before adding the richness of flavors such as non-GMO organic choco-late, natural tangerine, and California strawberries.

Foxy’s Pash recently added the flavors Fancy Pash (dark chocolate and tangerine zest) and Frisky Pash (pecan and praline crunch) to its range of products: Cheeky Pash (mango and passionfruit smoothie), Naughty Pash (honeycomb and caramel chunks), Sassy Pash (vanilla bean and strawberry chunks), and Sneaky Pash (wild berry and chocolate flakes).

For more information, visit www.foxyspash.com.

Way Better Snacks Sprouted Pita and Tortilla Chips

Way Better Snacks has introduced a line of Simply Sprouted Pita-ahh Chips and has added two flavors to its tortilla chip line.

Simply Sprouted Pita-ahh Chips feature sprouted Red Fife and spelt that are combined with other unprocessed ingre-dients to create three varieties: Toasted Garlic, Smoked Havarti, and Sea Salt.

The two new varieties of tortilla chips are Simply Spicy Sriracha, which combines a hot flavor with the benefits of sprouted kale seeds, and Simply Tangy Mustard & Onion, which delivers bold, tangy-mustard deliciousness with sprouted mustard seeds.

In addition to the sprouted ingredients, the chips are Certified Non-GMO Project Verified, kosher, vegan, an excellent source of whole grains, low sodium, and a good source of fiber. The tortilla chips also are certified gluten-free.

For more information, visit www.gowaybetter.com.

Wonderfully Raw Adds Brussel Bytes, Snip Chips to Offerings

Wonderfully Raw has added two new lines to its all-natural, gluten-free, vegan-friendly snack foods: Brussel Bytes and Snip Chips.

Brussel Bytes, made from organic Brussels sprouts and organic pumpkin seeds and tossed in a tasty coating, come in Chili Pumpkin Seed Crunch and Tamarind Apple Crunch. Snip Chips, a combination of organic parsnips and organic coconut, are high in fiber, omega-3, potassium, and vitamins C, E, and K. They come in Cheesy Herb Truffle, Chipotle Lime Cilantro, and Dill Pickle flavors.

The Wonderfully Raw collection also includes the original Coco-Roons, sweet-ened with organic maple syrup and available in flavors such as Brownie, Apple Pie, Lemon Pie, Vanilla Maple, and Cacao Nib.

For more information, visit http://mycocoroons.com.


Would you like to become a part of a hospital system that is dedicated to

superior service to patients, to employees, and to volunteers? Our warm, friendly family of employees is what makes Hi-Desert Medical Center a great place to work. Located in the beautiful High Desert, just 30 minutes from

Palm Springs, Hi-Desert Medical Center offers a competitive salary and benefi ts package.

We have an opportunity for you in our Long Term Continuing Care Center.

Registered Dietitian (Full-Time)

For immediate consideration, call 760-366-6426 or check our website at www.hdmc.org to download an application and receive information regarding

our benefi t package.

Resumes may be mailed to 6601 White Feather Road, Joshua Tree, Ca. 92252

or e-mailed to [email protected].

EOE

Clinical Dietitian, R.D. (Full Time or Part Time)Baker City, Oregon

Beautiful Baker City is located in the verdant valley between the Wallowa and Elkhorn Mountains in eastern Oregon, 130 miles northeast of Boise, Idaho, on I-84.

Known for its Anthony Lakes Ski area and being on the historic Oregon Trail, it is an outdoor lover’s paradise

with fi shing, camping, skiing, rock hunting, and jet-boating nearby.

Qualifi cations Include: Completion of an accredited school of Dietetics with a degree as a Dietitian (experience in a clinical, hospital-based setting

preferred), licensed and registered in Oregon as a Dietitian, must be able to problem-solve independently,

time management skills, multi-tasking, and able to work without direct supervision.

Saint Alphonsus Health System offers competitive compensation and a comprehensive benefi ts package.

To apply, please visit our website: www.saintalphonsus.org/bakercity

DIETITIANFull-Time

Norristown State Hospital1001 Sterigere Street

Norristown, PA

Salary:$38,709 – $58,517

Benefi ts:• health insurance• retirement plan

• paid leave (vacation, sick, holiday, personal)

• prescription/hearing• dental/vision

• parking

Applicants must be Dietitian (RD)Call Recruiter: 610-313-1082

EOE

CLINICAL DIETITIANPutnam Community Medical Center,

located in Palatka, FL, is currently seeking to fi ll a Full Time Clinical Dietitian.

Responsibilities include: Maintenance of high nutritional standards, provisions of appropriate diets to patients, being the

liaison with patients, nurses, and physicians, review and evaluation of patient diets, and participation in nutritional care committees.

Requirements include: Bachelor’s degree with specialization in dietetics or nutrition,

registered member of the Academy of Nutrition and Dietetics (diabetes educator

preferred), and 2 years’ experience as dietitian in a hospital setting.

For more information and to apply, please visit our website at www.pcmcfl .com.

EOE

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23523Today’s Dietitian1/8 Page (2.292 x 3.948”)July 2014jlr

Pomona Valley Hospital seeks to recruit an experienced Clinical Dietitian to serve our acute care 453-bed not-for-profit organization.

The Clinical Dietitian will assess and care for patients at nutritional risk, approve programs & menus related to nutritional care, participate in case conference, perform regular clinical rounds, and maintain discharge planning activities. He/she will also train, educate, support, and monitor fellow Associates providing direct nutritional care. Applicants must have a current CDR, 2 years of experience, and excellent communication skills. Preferred candidates will possess a Bachelor’s degree in Food & Nutrition and/or bi-lingual proficiency. This position is being offered at full-time days with a competitive benefits package.

All eligible applicants should apply atwww.pvhmc.org

CLINICAL DIETITIAN

AUGUST 6-9, 2014AMERICAN ASSOCIATION OF DIABETES EDUCATORS ANNUAL MEETINGOrlando, Floridawww.diabeteseducator.org

AUGUST 10-14, 2014ASSOCIATION OF CORRECTIONAL FOOD SERVICE AFFILIATES ANNUAL INTERNATIONAL CONFERENCESt Louis, Missouriwww.acfsa.org

AUGUST 13-17, 2014IDEA WORLD FITNESS CONVENTIONAnaheim, Californiawww.ideafit.com

SEPTEMBER 2-5, 201414TH INTERNATIONAL NUTRITION & DIAGNOSTICS CONFERENCEPrague, Czech Republicwww.indc.cz/en

SEPTEMBER 8-10, 2014NATIONAL WIC ASSOCIATION NUTRITION EDUCATION AND BREASTFEEDING CONFERENCE & EXHIBITSAtlanta, Georgiawww.nwica.org

DATEBOOK

MARKETPLACE

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

Bakery on Main, www.bakeryonmain.com ....................................65

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The Dannon Company, www.oneyogurteveryday.com ..................11

Dietmaster Systems, www.dietmaster.com ..................................65

IOI Loders Croklaan, www.croklaan.com ........................................3

LC Foods Corporation, www.holdthecarbs.com ...........................26

McKee Foods, www.fieldstonebakery.com ...................................14

Nurture Inc, www.happyfamilybrands.com ..................................27

Tyson Foods, www.tysonfoods.com ................................................2

Walden Farms, www.waldenfarms.com ........................................67

Wonder Natural Foods, www.betternpeanutbutter.com ...............15

This index is a service to our readers. The publisher assumes no liability for errors or omissions.

BEGINNING JULY 1, 2014REGISTRATION NOW OPEN FOR THE 2014 RENFREW CENTER FOUNDATION EATING DISORDERS CONFERENCE FOR PROFESSIONALS: “FEMINIST RELATIONAL PERSPECTIVES AND BEYOND: THE ‘PRACTICE’ OF PRACTICE”November 14-16, 2014Philadelphia, Pennsylvania17.5 continuing education credits

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BRUSSELS SPROUTSGood Things Come in Small PackagesBy Bryan Roof, RD, LDN

When my daughter, Layla, was 3, the doctor asked her what she was looking forward to eating at Thanksgiving. Her response: Brussels sprouts. Judging by her doctor’s reaction, that wasn’t a common answer.

Although my family has a deep appreciation for Brussels sprouts, we don’t reserve them just for the holidays. We roast them year-round with olive oil and salt for a bare-bones approach and then dress them up with caramelized onions and bacon on special occasions.

Despite my daughter’s infatuation and their current trendiness, Brussels sprouts have had a varied history. They were developed in Belgium in the 13th century through artificial selection and always have suffered a bit in popularity. A poll conducted in the United States actually placed them near the top of the country’s list of most hated vegetables. It does seem that every other horror story about being force-fed veggies as a child involves boiled Brussels sprouts. The scars run deep for some, I suppose.

Still, these miniature cabbages have plenty to offer. They take well to various cooking methods, including blanching, sautéing, and deep-frying. They’re great shaved thin and eaten raw in salads, and the aforementioned roasting especially is appealing to kids because it brings out the inherent sweet, nutty flavors. Not to mention, the intense heat of a hot oven drives off any offensive cabbage-y odors and renders the thin outer leaves crackly, like cruciferous chips.

Although you can find them most of the year, Brussels sprouts are in season in late fall and early winter, and that’s when they tend to taste the sweetest. When shopping, look for small sprouts, which are sweeter and more tender than large ones. Large sprouts also are slightly more woody and fibrous.

It’s better if you can buy Brussels sprouts still on the stalk because they’re usually fresher and a little cheaper.

In reality, it isn’t hard to get kids to eat vegetables. As simple (and challenging) as it sounds, all you need to do is make them taste good. And roasting nearly any vegetable gives you a leg up in the flavor department. Sure it takes a few tries, maybe even a dozen, but one day it clicks. And who knows, you may even impress your pediatrician.

— Bryan Roof, RD, LDN, is a chef, dietitian, and food writer living in Boston. Follow him on Twitter @bryanroof.

CULINARY CORNER

Roasted Brussels Sprouts Salad

Serves 4

Ingredients2 lbs Brussels sprouts, stemmed and halved4 T extra-virgin olive oil, divided1⁄2 tsp fine sea salt4 garlic cloves, minced4 anchovies, minced1 T fresh lemon juice1⁄2 tsp Aleppo pepper or 1⁄4 tsp red pepper flakes1 cup fresh parsley leaves1 cup sliced red onion1⁄2 cup blanched hazelnuts

Directions1. Adjust the oven rack to the middle position and heat the oven to 425˚F. Toss the Brussels sprouts with 2 T oil and 1⁄2 tsp salt. Spread the sprouts on a rimmed baking sheet, cut sides down. Roast until tender, deep brown, and crispy on the edges, about 20 minutes. Let sprouts cool on the baking sheet for 10 minutes.2. Meanwhile, combine the remaining 2 T olive oil, garlic, and anchovies in a small saucepan and set over low heat. Cook until the garlic is straw-colored and fragrant, 5 to 7 minutes. Remove from heat, and stir in the lemon juice and Aleppo pepper.3. Transfer the Brussels sprouts to a large bowl. Add the parsley, onion, hazelnuts, and dressing, and toss to combine. Adjust the seasoning with salt and Aleppo pepper to taste. Serve.

Nutrient Analysis per servingCalories: 330; Total fat: 24 g; Sat fat: 3 g; Trans fat: 0 g;

Cholesterol: 5 mg; Sodium: 500 mg; Total carbohydrate: 26 g; Fiber: 10 g; Sugars: 6 g; Protein: 11 g


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