Today's Dietitian - April 2016

Evidence shows soy can improve heart health due to its rich nutrient profile.

SoyfoodsHeart Disease

Busting the Top 10 Carb Myths

Update on the National Diabetes Prevention Program

The 2015–2020 Dietary Guidelines Experts Weigh In

NATIONAL SOYFOODS MONTH

CONFERENCE ISSUE

and

www.TodaysDietitian.com

April 2016

Vol. 18 No. 4

The Magazine for Nutrition Professionals

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EDITOR’S SPOT

President & CEO Kathleen Czermanski

Vice President & COO Mara E. Honicker

EDITORIALEditor Judith Riddle

Nutrition Editor Sharon Palmer, RDNEditorial Director Lee DeOrio

Production Editor Kevin O’Brien Editorial Assistants Anthony Fioriglio, Heather Hogstrom, Hadley Turner

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

CDN; Constance Brown-Riggs, MSEd, RD, CDE, CDN; Carol Meerschaert, MBA, RD; Christin L. Seher, MS, RD, LD

ARTArt Director Charles Slack

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FINANCEDirector of Finance Jeff Czermanski

CONTINUING EDUCATIONDirector of Continuing Education Jack Graham

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All articles contained in Today’s Dietitian, including letters to the editor, reviews, and editorials, represent the opinions of the authors, not those of Great Valley Publishing Company, Inc. or any organizations

with which the authors may be affiliated. Great Valley Publishing Company, Inc., its editors, and its editorial advisors do not assume

responsibility for opinions expressed by the authors or individuals quoted in the magazine, for the accuracy of material submitted by the authors, or for any injury to persons or property resulting from reference to ideas or

products discussed in the editorial copy or the advertisements.

Judy

PRAISING SOYFOODSI have never been one to eat tofu, tempeh, miso, or other types of soyfoods, but as I reflect on the amazing health benefits of soy this month, I think I may give some of the delicious-sounding recipes available a try. Soyfoods are rich in calcium, iron, fiber, and protein, and research has

found they can help prevent and improve some of the top health issues facing women today such as heart disease and high blood pressure; osteoporosis; certain cancers; and menopausal symptoms like hot flashes, night sweats, and insomnia. Soyfoods are capable of providing these health benefits because of their fatty acid profiles, high-quality protein, and isoflavone content.

Whole soybeans are about 40% fat as a percentage of calories, but the fat is predominantly polyunsaturated and monounsaturated, making it a valuable contributor to heart health. What’s more, soybeans are full of protein. One-half cup of cooked soybeans has about 15 g, which is approximately twice the amount found in other legumes. And the quality of soy protein is equivalent to that of animal foods and is higher than other plant proteins. The isoflavones in soy are phytoestrogens (plant estrogens), which have a mild estrogenic effect in the body that can decrease hot flashes and other nagging menopausal symptoms. To learn more about isoflavones’ effects in menopausal women, read “Are Menopause Supplements Effective?” in the March issue of Today’s Dietitian.

This month, we’re featuring an article on soy’s positive effects on heart health in “Soyfoods and Heart Disease,” on page 18. In honor of National Soyfoods Month, the article discusses the history and popularity of soyfoods dating back centuries, reviews the latest research on soy’s association with lower heart disease and cancer risk, and provides strategies to help dietitians counsel clients.

Also in this issue are articles on the National Diabetes Prevention Program, what RDs think about the 2015–2020 Dietary Guidelines for Americans, dietitians in home health care, and busting carbohydrate myths. Please enjoy the issue!

Judith [email protected]

4 today’s dietitian april 2016

FEATURES

18 Soyfoods and Heart Disease Evidence shows soyfoods can improve heart health due to their rich fatty acid, protein, and isoflavone content.

24 Update on the National Diabetes Prevention Program Learn what the National DPP is all about and how dietitians can get involved.

30 Busting the Top 10 Carb Myths Today’s Dietitian speaks with nutrition professionals to distinguish truth from error.

34 The 2015–2020 Dietary Guidelines Experts weigh in on the new guidelines and discuss how they could impact the health of Americans.

38 Home Health Care — Dietitians at the Forefront As new health care models that include the expertise of dietitians continue to develop, more opportunities will become available for those who want to work in home health care.

42 CPE Monthly: Stress and Weight Management This continuing education course explores the physiological responses to stress and the effect of stress on weight management.

DEPARTMENTS

4 Editor’s Spot

6 Reader Feedback

7 Ask the Expert

8 Infant/Toddler Nutrition

12 Clinical Nutrition

16 Fitness Foods

48 Focus on Fitness

50 Get to Know …

54 News Bites

57 Personal Computing

58 Health Matters

60 Research Briefs

62 Products + Services

56 Spring Product Showcase

65 Datebook

66 Culinary Corner

CONTENTS APRIL 2016

30 8

Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published monthly by Great Valley Publishing Company, Inc., 3801 Schuylkill Road, Spring City, PA 19475. Periodicals postage paid at Spring City, PA, Post Office and other mailing offices. Permission to reprint may be obtained from the publisher. Reprints: The Reprint Outsource, Inc.: 877-394-7350 or e-mail [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 18, Number 4.

Page 42

april 2016 www.todaysdietitian.com 5

READER FEEDBACK

From Our Twitter Page Popular Tweets, Retweets

February Issue

Cardiac Rehab

@lisarutledgeRD: Helping cardiac patients with heart-healthy eating means busting myths from well-meaning friends and family.

What’s Trending in the Dairy Aisle?

@jlevinsonrd: Great article! My kids have been loving kefir lately!

Creative Ideas to Boost Intake (Fiber)

@wellness4thewin: Loving this article about boosting fiber intake. So many easy, delicious ideas!

From Facebook

“From Farm to Freezer: A Fresh Look at Frozen Produce”philly.comAmy Dunfee: With the push for fresh, consum-ers don’t understand where all the fresh foods come from in winter, and that the farther they come from where they were grown, the less nutrients they have. This is why most people used to can and freeze. But for some reason, freezing and canning fresh foods have gotten a very bad rap. Frozen pro-duce is still good for you.Monica Morgan: Flash frozen is just as good as buying from the farm itself. Because they are flash frozen they maintain their nutritional value just as if you had picked them fresh ... sometimes even in-season fruit can lose one-quarter of its nutritional value in transit from the farms to the grocery stores.Eloise Page: I use a combination of frozen and fresh produce.

CardiacRehab

Protecting Bone Health Among Vegans

Latest Trends in the Dairy Aisle

Nutrition-Focused Physical Exams

RDs combine the art and science of nutrition to reduce morbidity and mortality among patients.

CONFERENCE ISSUE

AMERICAN HEART MONTH


February 2016

Vol. 18 No. 2


Dear Editor,We would like to comment on the article “Popular Fad Diets for 2016,” by Toby Amidor, MS, RD, CDN, which was published in the January 2016 issue of Today’s Dietitian—specifically the section on the Health Management Resources (HMR) diet.

Prominent hospitals, universities, and medical centers have been offering HMR programs for more than 30 years. This hardly sounds like a fad diet. The HMR diet was included in the US News and World Report’s 2016 Best Diets Rankings. It tied for No. 1 in best Fast Weight Loss and ranked No. 2 for best Weight Loss Diet. HMR studies have been reviewed and published in many scientific journals, including the Journal of the Academy of Nutrition and Dietetics, Obesity, and the International Journal of Obesity.

The greatest weight loss success from the HMR diet occurs in the in-clinic program. Clients attend weekly classes and may or may not be medically supervised, based on their BMI, medical history, and current medi-cations. These classes offer support, accountability, and long-term strategies to lose weight and keep it off. The in-clinic program offers two diet options. Decision Free includes low-calorie shakes and entrees, and Healthy Solutions includes low-calorie shakes, entrées, and fruits and vegetables.

Your article states that a low-calorie plan usually will result in weight loss, but it doesn’t teach clients how to control portions and cook healthfully for themselves. Phase II, or the maintenance phase, of the HMR diet is the most important part of the program. We recommend clients join Phase II for 12 to 18 months. During this time, they continue to attend weekly classes in the clinic. They learn to gradually decrease meal replacements and gradually reintroduce healthful foods back into their diet. We emphasize high-volume, low-calorie foods, and focus on label reading, portion control, and healthful cooking.

At our clinic and all of the other HMR clinics across the country, we see patients lose a lot of weight, and more importantly improve their health. They see dramatic improvements in their quality of life. HMR is not a fad diet; it is a lifestyle change.

Ali Jack, RD, HMR Health Educator Sarah Sterling, RD, HMR Health Educator Angela Snyder, RD, HMR Health Educator

Katherine Chubinskaya, MD, HMR Medical Director Vancouver, Washington

WINTER PRODUCT SHOWCASE

Health at Every SizeDietitians Speak Out

Menus of ChangeRevolutionizing the Foodservice Industry

The Calcium DebateDetermine the Correct Requirements


January 2016

Vol. 18 No. 1


Red Meat

Risks and Benefits of

A Review of the Science Plus Strategies to Counsel Patients


HEALTHIER FAST FOODBy Toby Amidor, MS, RD, CDN

Q:My clients often eat at fast food establishments. Can you tell me about the healthful items that have been added

to the menus at some of the more popular chains?

A:As consumer demand for healthier fare on the go has been increasing, many fast food establishments have

been adding more healthful options to their menus. Some chains have been revamping their menus to remove all addi-tives in addition to offering many nutritious selections. The following is a list of some of the more healthful choices nutri-tion professionals can recommend to clients if they choose to include fast food in their eating plans.

Panera BreadIf you haven’t been to your local Panera Bread recently,

you may not know about many of the new healthful options on the menu. Beyond simply adding more nutrient-dense foods, Panera also has publically committed to removing all artifi-cial flavors, colors, preservatives, and sweeteners from its menu items by the end of 2016. Healthful choices include the following:• Whole Fuji Apple Chicken Salad: 550 kcal, 34 g fat, 7 g sat

fat, 29 g protein, 34 g carbs, 580 mg sodium; • Tomato Mozzarella Flatbread: 340 kcal, 18 g fat, 9 g sat fat,

6 g protein, 34 g carbs, 460 mg sodium;• Lentil Quinoa Bowl With Cage-Free Egg: 350 kcal, 11 g fat,

2.5 g sat fat, 18 g protein, 47 g carbs, 1,200 mg sodium; and• All-Natural Turkey Chili (bowl, 11⁄2 cups): 320 kcal, 11 g

fat, 2 g sat fat, 17 g protein, 12 g fiber, 35 g carbs, 1,090 mg sodium.

StarbucksThis coffee chain introduced their Evolution Fresh line of

cold-pressed juices, hot breakfasts, and even a line of health-ful snacks and light meals in their Bistro Boxes. These health-ful choices include the following:• Evolution Fresh Cold-Pressed Sweet Greens and Lemon

(per 16-oz bottle): 100 kcal, 0 g fat, 0 g sat fat, 2 g protein, 22 g carbs, 300 mg sodium;

• Oatmeal With Fresh Blueberries: 220 kcal, 2.5 g fat, 0.5 g sat fat, 5 g protein, 43 g carbs, 125 mg sodium; and

• Protein Bistro Box (with a hard-boiled egg, white Cheddar cheese, apples, grapes, and multigrain bread): 370 kcal, 19 g fat, 6 g sat fat, 13 g protein, 37 g carbs, 460 mg sodium.

McDonald’sIn 2011, McDonald’s added sliced apples to its Happy Meals.

The chain also introduced oatmeal and eventually expanded its salad offerings, many of which include kale and spinach. The following are some of the healthier options from which to choose:• Ranch Snack Wrap (with grilled chicken): 290 kcal, 13 g fat,

4.5 g sat fat, 19 g protein, 25 g carbs, 820 mg sodium;• Premium Southwest Salad (with grilled chicken): 330 kcal,

11 g fat, 4 g sat fat, 33 g protein, 26 g carbs, 920 mg sodium; and

• Fruit and Maple Oatmeal: 290 kcal, 4 g fat, 1.5 g sat fat, 5 g protein, 58 g carbs, 160 mg sodium.

Recommendations for ClientsIf clients choose to eat at fast food restaurants, suggest

they show you the menus from those establishments so you can review them and make recommendations. The nutrition information for fast food chains with more than 20 locations must be made available to the public and usually can be found on their websites. One nutrient that is still very high in foods at most establishments is sodium, so encourage clients to eat out less often and help them select options with fewer calories and less sodium.

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

of the cookbook The Greek Yogurt Kitchen: More Than 130 Delicious, Healthy Recipes

for Every Meal of the Day. She’s also a nutrition expert for FoodNetwork.com

and a contributor to US News Eat + Run, Shape.com, and MensFitness.com.

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.


SNACKING IN YOUNG CHILDRENHelp clients get it rightBy Sharon Palmer, RDN

Here a snack, there a snack, everywhere a snack! It seems like parents of 1- to 4-year-olds don’t dare leave the

house without a battery of snacks on hand, from fish crackers and breakfast cereal in baggies at the park play date to mini pretzels in the car seat on a trip to see Grandma. What was once perceived as a “spoiler of appetites” has now become mainstream eating behavior for young children. In fact, studies document that American children are snacking more now than ever and in greater quantities than ever before. For children aged 2 to 12, an estimated 30% of daily calories are consumed in the form of sweet and salty snacks, and up to 40% of total daily calories are consumed in snacks when sugar-sweetened beverages are included.1

So what’s the problem with all of this snacking? As you may suspect, it’s been linked with childhood obesity. Research sug-gests that greater snacking frequency of energy-dense foods, such as cookies, chips, and sweets, is linked with increased risk of excessive weight gain in childhood. Nearly 1 in 3 American children already are overweight or obese by the time they enter elementary school.1

As any parent of a young child knows, there are many rea-sons to dole out snacks. Right or wrong, parents report sev-eral diverse rationales for offering their children snacks, such as growth promotion, satisfying hunger, keeping kids quiet, celebrating events and holidays, and rewarding behavior and achievements.1

Smart Snacking Does this mean parents must throw out the baby (snacking)

with the bathwater? The answer is a resounding “no!” Accord-ing to the American Academy of Pediatrics (AAP), snacks can make up an important part of early childhood nutrition and are an opportunity to encourage healthful eating. Because young chil-dren have small stomachs, they may not be able to eat enough at meals to meet their nutrient needs, thus a pattern of three

meals with two to three healthful snacks each day may help them meet their needs.2

The crux of the matter lies in helping parents make wise snacking choices for their young children, instead of simply tasty foods that fill the stomach and please the palate. When snacks become such a large part of the overall diet, they need to count by contributing to the foods children need over the course of the day, such as lean proteins, whole grains, fruits, vegeta-bles, and dairy products. MyPlate (choosemyplate.gov) serves as an excellent resource for establishing the correct serving sizes among these important food groups based on age group.

In fact, purposeful, healthful snacking can mean a more bal-anced calorie intake for young children, thus avoiding exces-sive weight gain. A study published in Pediatrics found that when children were offered a healthful snack (cheese and vegeta-bles) and instructed to eat freely while watching a 45-minute cartoon, they ate 72% fewer calories compared with the group given potato chips.3

Beverage choice is of particular significance for creating healthful snacking patterns for young children. The AAP encour-ages healthful beverage choices, such as milk and water, as go-to options, and even states that fruit juice may be a source of unnecessary calories in a child’s diet and potentially harmful to teeth. If parents choose to offer fruit juice, it should be limited to 4 to 6 oz per day.4

INFANT/TODDLER NUTRITION

SMART SNACKS TO THE RESCUERefer to this list of healthful snack suggestions appropriate for children aged 1 to 4:

• Sliced apples, bananas, or nectarines with soft cheese cubes

• Orange sections or strawberries with cottage cheese

• Raisins with dry cereal

• Mini whole-wheat bagel with thinly spread almond butter

• Carrots or green beans (cooked for younger children—texture tolerance varies according to development and age) with hummus

• Plain yogurt mixed with chopped peaches or cherries

• Smoothie blended with milk (or fortified soymilk), vegetables, and fruit

• Whole grain bread with thinly spread peanut butter

• Whole grain crackers with tuna

• Quesadilla with whole grain tortilla and melted cheese

• Blueberry whole grain muffin with milk (or fortified soymilk)

• Banana nut bread spread with cashew butter

— SP


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INFANT/TODDLER NUTRITION

Tips to Guide Smart Snacking Behavior Among Young Children

How do dietitians help parents encourage healthful snacking habits among their young children? The following are some RD-approved tips from our experts.

• Get in touch with hunger cues. “The No. 1 thing I tell my clients is that kids are really great at understanding their own hunger and satiety cues. Remember, they decide how much they will eat and, sometimes, when they will eat. You decide what they will eat. That way they learn to honor their hunger and satiety cues instead of override them, like so many of us adults have learned to do,” says Kelli Shallal, MPH, RD, CPT, a nutrition counseling and communications specialist in Phoenix.

• Balance nutrients in snacks. “Parents don’t realize that, like with adults, it’s important to balance the nutrients in the snack. Kids’ snack choices tend to be super carb rich, such as cheesy crackers, chips, pretzels, or fruit snacks—there’s minimal nutrition and lots of empty calories. I recommend making sure each snack contains a source of protein and produce, like apples and peanut butter or carrots and hummus. This will be satisfying, nutrient and fiber rich, and provide a source of sustained energy,” says Lauren Harris-Pincus, MS, RDN, a nutrition therapist and consultant, and owner of Nutrition Starring YOU, LLC, in the greater New York City area.

• Keep portion sizes reasonable. “Allowing too many snacks or large-portioned snacks can cause kids to not eat as much at mealtime. Offering one small-portioned snack between meals may help improve their appetite and eating behaviors at mealtime,” says Lauren Sharifi, RD, LDN, blogger at Bite of Health Nutrition.

• Fit in whole, nutrient-rich foods. “Young children are often picky eaters, and getting them to eat a well-rounded diet at meal time can be difficult. Snacks can be a way to fit in those foods, spe-cifically fruits, vegetables, whole grains, and dairy,” Sharifi says.

• Make healthful snacks easy and delicious. “Provide young children with healthful choices that are tasty and easy to eat. For example, cut up fruit, portion it into sandwich bags, and keep it in the refrigerator. Make granola or flax ‘power bites’ to keep where the kids can easily access them when they’re hungry. Keep bottles of water and healthful snacks in the car for when you drive to activities and events,” says Kim Melton, RDN, nutri-tion consultant at Nutrition Pro Consulting, a nutrition consult-ing and resources business.

• Put a time limit on snacking. “Adults need to remind chil-dren that a snack is not a meal and put a time limit on snacks. Keep snack time to 10 to 15 minutes. Most younger children don’t recognize when they’re full and will continue to eat as long as food is available,” says Jessica Fishman Levinson, MS, RDN, CDN, founder of Nutritioulicious, a nutrition communications and consulting business in New York City.

• Nix snacks too close to mealtimes. “When parents talk to me about their child not eating a good dinner, my first question to them is what was the last thing they ate and when did they eat it. Knowing what a suitable snack is before mealtime often

staves off a poorly eaten dinner and a negative dinner experi-ence. Vegetables, fruit, and water an hour or so before dinner is perfectly fine. It’s also okay to say, ‘No snacks right now; we are eating in 15 minutes,’” says Robin Plotkin, RDN, LD, a culi-nary and nutrition communications expert and blogger.

— Sharon Palmer, RDN, is the author of Plant-Powered for Life, nutrition editor for Today’s Dietitian, blogger at The Plant-

Powered Blog, and mother of two in Los Angeles.

Pretty as Pink Beet Hummus

Beets lend a sweet flavor and fun fuschia-pink color to this creamy white bean hummus, flavored with garlic and lemons. Serve it with veggies as a kid-friendly dip to promote healthful snacking.

Makes 12 1⁄4-cup servings

Ingredients1 15-oz can cannellini or white beans, rinsed, and

drained1 cup chopped, cooked beets, drained1 large clove garlic, minced1 small lemon, juiced11⁄2 T tahini1 T extra-virgin olive oilSalt and pepper, as desired (optional)Fresh mint for garnish (optional)

Directions1. Add beans, beets, garlic, lemon juice, tahini, and olive oil to a blender container and blend until smooth. 2. Season as desired.3. Pour into a serving container and garnish with fresh mint, as desired.4. Chill until serving time.

Note: Serve with vegetables appropriate for the develop-ment of the child’s age group.

Nutrient Analysis per servingCalories: 68; Total fat: 2 g; Sat fat: 0 g; Trans fat: 0 g; Cholesterol: 0 mg; Sodium: 14 mg; Total carbohydrate: 10 g; Dietary fiber: 2 g; Sugar: 1 g; Protein: 3 g— RECIPE AND IMAGE BY SHARON PALMER, RDN, THE PLANT-POWERED DIETITIAN

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


ADVERTORIAL

Soyfoods Promote Heart HealthSoyfoods potentially reduce coronary heart disease (CHD) risk in multiple ways. Both the fatty acids and the protein in soybeans have been shown to reduce LDL-cholesterol levels, while soy isoflavones may enhance arterial health.

Direct Effects on LDL-CholesterolSoy protein directly lowers LDL-cholesterol. This benefit was formally recognized by the U.S. Foodand Drug Administration in 1999 when it approved a health claim for soyfoods and CHD based on the hypocholesterolemic effect of soy protein.1 Since then, more than 10 countries have approved similar claims.2,3 All meta-analyses of the clinical data have found soy protein statistically significantly

lowers LDL-cholesterol.4,5,6,7

Soyfoods Improve the Fatty Acid Profile of the DietIn contrast to other beans, soybeans are relatively high in fat. Approximately 40 percent of the calories are derived from fatty acids — 12 percent saturated, 29 percent monounsaturated and 59 percent polyunsaturated.8 Approximately 6 percent is α-linolenic acid, the essential omega-3 fatty acid. Because of its widespread use, soybean oil accounts for over 40 percent of both essential fats in American diets.9

Replacing saturated fat in the diet with polyunsaturated fats (PUFAs) reduces LDL-cholesterol levels and CHD risk. A combined analysis of prospective data involving nearly 130,000 participants found that replacing 5 percent of energy intake from saturated fat with equivalent energy intake from PUFAs reduces risk of CHD by 25 percent.10 In fact, in many countries, inadequate intake of PUFAs contributes to CHD mortality more than excess saturated fat intake.11

Beyond LDL-cholesterolProspective epidemiologic research shows major reductions in the risk of coronary events in women who consume soyfoods.12,13 This protective effect cannot be explained by effects on cholesterol alone — the hypotensive effect of soy protein may contribute as well.14 Also, isoflavones, a group of phytoestrogens found in uniquely-rich amounts in soyfoods, have been shown to improve systemic arterial compliance and endothelial function in postmenopausal women.15,16,17

Given the effects on LDL-cholesterol, blood pressure, and arterial health, soyfoods may have a unique role to play in heart-healthful diets.

Comparison of Oil Fatty Acid Profiles

1. Food Labeling: Health Claims; Soy Protein and Coronary Heart Disease, in Federal Register: (Volume 64, Number 206)1999. p. 57699-57733.

2. J Nutr. 138: 1244S, 2008.

3. Benkhedda, K.B., B, et al. Health Canada’s Proposal to Accept a Health Claim about Soy Products and Cholesterol Lowering. Int Food Risk Anal J, 2014. 4:22 | doi: 10.5772/59411.

4. J Am Coll Nutr. 30: 79, 2011.

5. Am J Clin Nutr. 81: 397, 2005.

6. J Nutr. 140: 2302S, 2010.

7. Atherosclerosis 200: 13, 2008.

8. J Agric Food Chem 57: 11174, 2009.

9. Am J Clin Nutr. 93: 950, 2011.

10. J Am Coll Cardiol 66: 1538, 2015.

11. Wang Q et al. Impact of nonoptimal intakes of saturated, polyunsaturated, and trans fat on global burdens of coronary heart disease. J Am Heart Assoc 2016; 5.

12. J Nutr. 133: 2874, 2003.13. Circulation 116: 2553, 2007.14. Br J Nutr. 106: 317, 2011.15. Am J Clin Nutr. 93: 446, 2011.16. Nutr Metab Cardiovasc Dis 22: 182, 2012.17. Am J Clin Nutr. 91: 480, 2010.

Since soyfoods often replace foods high in saturated fat, consuming these foods is likely to improve fatty acid profiles and reduce cholesterol levels and CHD risk.6

This research-based soy health article is provided by the United Soybean Board.For additional soy health information, visit SoyConnection.com.

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% Trace AmountsOLIV

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IMPROVE COMPLIANCE IN DYSPHAGIA PATIENTS By Sharyl A. Samargia, PhD, CCC-SLP

Thickened liquids are commonly prescribed for patients with dysphagia. However, dissatisfaction with and inacces-sibility to thickened liquids frequently results in poor patient compliance. Reduced compliance can lead to dehydration, weight loss, weakness, respiratory illness, and increased risk of falls. In fact, evidence has shown that noncompli-ance by patients prescribed thickened liquid diets correlated to significantly higher mortality rates compared with those who were compliant. Nutrition professionals, caregivers, and patients must be diligent in pursuing options that meet both accessibility and palatability preferences to overcome compliance barriers for patients with swallowing disorders to improve health outcomes and quality of life.

The prevalence of dysphagia in the healthy older adult population ranges between 13.8% and 37.6%.1-5 Cabre and colleagues found that 55% of 134 community dwelling elderly adults >70 years of age diagnosed with pneumonia demonstrated clinical signs of dysphagia.6 Reduced muscle mass, strength,7 range of motion,8 and sensory awareness that occurs due to normal aging can lead to increased oral transit time, delayed swallowing onset, and poor airway protection during swallowing. These symptoms increase the risk of laryngeal penetration and laryngeal aspiration. In addition to normal aging, various neurogenic diagnoses also can result in dysphagia, including the following (percentages represent prevalence rate of dysphagia in people with

these diseases): stroke (38% to 51%),9 dementia (45%),10 and four out of five individuals with Parkinson’s disease.11

Key factors in reducing the incidence of aspiration pneumonia and other negative health outcomes include early identification, effective and efficient intervention, and patient compliance.

Identification and Effective Intervention

A timely assessment by a certified speech-language pathologist experienced in differential diagnosis and implementation of an effective individualized intervention plan can address the first two factors of identification and effective intervention. Changing the rheological properties of the thickened liquid increases the cohesion of the bolus, reduces the flow rate of the bolus through the pharynx,12 and potentially improves clearance

of the bolus. Although the direct effect thickened liquids have on health outcomes remains under investigation, it endures as a common management technique to minimize the risk of aspiration in individuals with dysphagia.13,14 In a survey study investigating the practice patterns of speech-language pathologists, the majority of respondents reported thickened liquids to be an effective method to reduce the risk of aspiration in individuals with dysphagia. Nectarlike liquids were more commonly prescribed than honeylike liquids and were most commonly recommended for characteristics including delayed swallow onset, poor oral control of thin liquids, and laryngeal penetration/aspiration.13

Patient Compliance

Psychosocial FactorsThe third key factor to successful dysphagia management

is patient compliance. Many individuals report the difficulty of following a modified diet of thickened liquids due to affordability, accessibility, and palatability. In a survey done by Garcia, Chambers, and Molander, nearly one-half of the individuals surveyed reported a strong dislike of thickened liquids.13 Another study reported 45% of survey respondents on a modified diet said that eating was no longer an enjoyable experience.15 Leiter and Windsor evaluated a group of geriatric individuals’ compliance to thickened liquids after a five-day period. Patient compliance was expected to be relatively high after such a short period; however, only 35.6% adhered to the dietary modifications.16 Noncompliance may be due to poor palatability and reduced accessibility and/or increased cost of the thickened liquids.

CLINICAL NUTRITION


Another consideration is the reported decreased quality of life in individuals with dysphagia. Psychosocial effects such as depression, isolation, and anxiety17 also could result in poor compliance.

Health OutcomesNoncompliance can lead to

a cascade of negative health sequelae including malnutri-tion, dehydration, weight loss, muscle atrophy, increased risk of falls, and respiratory illness (see Figure 1 online).18

A compelling study by Low and colleagues revealed the serious health consequences of noncompliance. The authors reported that 86% of individuals who made a conscious decision not to comply with speech-language pathologists’ thickened liquid recommendations died. This is a significant contrast to the 39.5% who died despite following dietary recommendations.19 In addition, the degree to which recommendations were followed was correlated with the incidence of chest infections, aspiration pneumonia, and hospital readmissions. Those who were noncompliant

were considerably younger, living at home, and had significantly more hospital admissions and chest infections or aspiration pneumonia than those who complied.

Improving Compliance

Community-Dwelling IndividualsEncouraging patients to follow modified diet recommenda-

tions is important but may be insufficient to prompt them to make such a lifestyle change. Education and training in how

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Table 1 Thickening Options

Brand name Manufacturer

Cornstarch thickeners Thick-It Kent Precision Foods Group

Thick & Easy Hormel Health Labs

Resource ThickenUp Nestle Medical Nutrition

Xanthan gum thickeners Simply Thick (gel) Simply Thick

Thick & Easy Clear (powder) Hormel Health Labs

Resource ThickenUp Clear (powder) Nestle Medical Nutrition

Prethickened liquids Thick-It AquaCare H2O Kent Precision Foods Group

Thick & Easy Hormel Health Labs


CLINICAL NUTRITION

to use the products is essential. Far too often a patient is sent home with the name of a powdered thickener and told to follow the directions on the back of the container. Patients often are unaware of various thickening options (see Table 1 on page 13), how to mix the product with the desired beverage, how the viscosity can change over time and/or temperature, the influ-ence of a particular beverage on the viscosity, creative recipes using thickening products, and how to plan for a social event or dining out experience. Providing resources for various thick-ened liquid options, identifying additional palatable and acces-sible thickened liquids and recipes, and education and training all play important roles in compliance.

Patients in Medical and Long Term Care FacilitiesCornstarch thickeners continue to be the most commonly

used in medical facilities, although use of xanthan gum powders and prethickened beverages is on the rise in acute and subacute facilities. Dietitians and other patient care providers must advocate for the importance of compliance to administrators and work together to identify solutions to this problem. Evidence such as patient health status or change in status, volume of oral intake at mealtimes, and amount of food and liquids refused by the patient may provide important information to help drive the mission of patient compliance in medical facilities.

Thickened Liquids

Instant Food Thickeners: Powders and GelsHistorically, instant food thickeners made from refined

cornstarch have been used to thicken liquids for individuals requiring a modified diet. Cornstarch thickeners are inexpen-sive but they’re high in sugar, may contain gluten, can nega-tively influence taste and smell, add calories, and contribute to constipation. In addition, cornstarch thickeners are unstable, continuing to thicken over time, and don’t thicken different bev-erages consistently. Recently, thickeners using refined xanthan gum have become commercially available. Xanthan gum thick-eners are more stable over time and don’t alter taste or smell but are more expensive, aren’t readily accessible, and can change viscosity over temperature changes. Due to the need for manual mixing, both cornstarch and xanthan gum instant thickeners are subject to human error.

Prethickened Liquids To alleviate human error, medical nutrition companies

began marketing beverages that come prethickened or ready to pour. These beverages maintain their viscosity over time and are convenient for consumers. The prethickened beverage can be added to a number of products, making it very versatile. However, these products are typically more expensive and less accessible to consumers.

Studies comparing thickening products have revealed substantial variability between and within thickened liquid products. For example, prethickened beverages have significantly higher viscosity ratings than beverages thickened with instant food thickeners and tend to be more viscous than recommended in the National Dysphagia Diet standards.20 Statistically significant differences in viscosity values among brands of instant food thickeners have been reported.21,22 Leonard and colleagues reported significant reduction in aspiration rate and lower scores on the penetration-aspiration scale with xanthan gum thickener. Although the aspiration rate was reduced with cornstarch thickener, the difference didn’t reach significance, suggesting xanthan gum may be more effective in reducing aspiration in individuals with dysphagia.23 Interestingly, boluses thickened with cornstarch were more viscous than those thickened with xanthan gum, but they weren’t more effective in minimizing aspiration.23

Naturally Nectarlike LiquidsIn an attempt to identify more palatable and accessible

options for individuals who require thickened liquids, a recent study investigated the viscosity of a variety of commercially made beverages and found 32 products that met the National Dysphagia Diet standards for nectarlike liquids without adding a powder or gel thickener (see Figure 2 online).24 Viscosity was measured using a Brookfield cone plate viscometer with a No. 41 spindle at 50 rpm.24 Of importance, the majority of beverages had a significantly higher viscosity rating when chilled vs room temperature. The beverages listed in Figure 2 aren’t intended to be recommended for all patients who require nectarlike bever-ages, as some may not be thick enough to be therapeutic. Dieti-tians should consult a patient’s speech-language pathologist before recommending any of the beverages in Figure 2.

In a follow up study, the palatability of these “naturally” nectarlike beverages was significantly higher than cornstarch

Table 2 Palatability Ratings Across All Tested Beverages

Fruit juice Dairy Coffee

Most palatable

Least palatable

Naturally nectarlike Naturally nectarlike Naturally nectarlike

Xanthan gum Prethickened Xanthan gum

Cornstarch Xanthan gum Cornstarch

Prethickened Cornstarch Prethickened

— SAMARGIA ET AL, 2014, UNPUBLISHED


thickeners across beverage categories (see Table 2 below).25 Although one might suspect beverages with higher viscosity would be least palatable, there was no correlation between palatability and viscosity values. (See Figure 2 online for the beverages tested and the viscosity ratings.) These findings revealed “naturally thick” beverages can be found on supermarket shelves and are more palatable than those thickened with a powder.

Encouraging PalatabilityPatients and families can access

various dysphagia diet products such as prethickened liquids and thickening powders, including both cornstarch and xanthan gum types, through www.dysphagia-diet.com. If there’s a beverage found at the supermarket that appears to be thick, be sure to ask the speech-language pathologist to determine whether the thickness is appropriate. Patients are encouraged to try a variety of the thickening options in many different beverages to determine those that are most palatable to them. Some patients and their families create their own recipes in order to increase palatability. Although this is encouraged, the family should continually consult with a speech-language pathologist to ensure the beverage is the appropriate thickness. Recipes for thickened liquids can be found in a book entitled Living with Dysphagia: A Food and Beverage Guide for Individuals With Chewing and Swallowing Difficulties, revised by Debra Zwiefelhofer, RDN, LD, for Med-Diet Laboratories, Inc, available through the website listed above.

Moving ForwardSerious health complications often

are associated with dysphagia, par-ticularly for those who don’t comply

with modified diet recommendations. Of equal importance is the nega-tive impact on quality of life. Social interaction within our culture often revolves around food. Individuals with dysphagia frequently feel isolated or restricted due to their dietary needs. It’s imperative that dietitians and others in the medical community edu-cate individuals and families about the multitude of options available for thickened liquids. The medical nutri-tion field has created innovative and unique products to improve palat-ability and versatility, which will allow patients to find options that work for them and ultimately improve com-pliance. As health care providers, we must address compliance head on and encourage patients to adhere to recommendations while we push medical facilities to see past sup-posed costs and do what’s best for our patients.

While timely identification and intervention are imperative in dys-phagia management, more emphasis must be placed on improving patient compliance through continued efforts to make thickened liquids more pal-atable, accessible, and affordable for individuals with dysphagia. In addi-tion, medical facilities need to recog-nize the overall health and economic impact of patient compliance. Con-tinued contributions to this line of research will offer compelling infor-mation to reduce the adverse health effects and reduced quality of life in individuals with dysphagia.

— Sharyl A. Samargia, PhD, CCC-SLP, is an associate professor in

the department of communication sciences and disorders at the University

of Wisconsin at River Falls. Her research interest involves the study of

neuroplasticity as it relates to disorders of voice, motor speech, and swallowing.

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

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BOOST PERFORMANCE WITH BEETSBy Clare Tone, MS, RD

“Eat your vegetables!” This is perhaps the most common refrain from dietitians and

parents alike. We say it for the fiber, vitamin C, and host of B vita-mins; we say it for the potassium, calcium, polyphenols, and bio-flavonoids. But for athletes, there’s yet another reason to invoke this mantra: nitrates.

Nitrates are naturally occurring in all vegetables but are par-ticularly high in beets, which research has shown can improve athletic performance. Nitrates ingested through the diet are converted to nitrite in the body, ultimately increasing nitric oxide levels. Nitric oxide is a potent vasodilator with anti-inflammatory and antiplatelet aggregation properties.1,2 Studies looking at the effects of beetroot juice on athletic performance consistently reveal a reduced use of oxygen during exercise, so researchers are now focused on whether that translates to improved time to exhaustion and race times for athletes.

Exercise Tolerance and Athletic PerformanceMost studies looking at dietary nitrates as a potential ergogenic

aid for elite and recreational athletes have used beetroot juice as the nitrate source. Much research has looked at exercise tolerance, measuring 15% to 25% improvements in time-to-exhaustion in cycling and treadmill running.3-5 A 2014 review article published in Sports Medicine found consensus among research that dietary nitrates reduced the oxygen cost of submaximal exercise and in some cases enhanced exercise tolerance.3 In 2015, the European Journal of Applied Physiology published a double-blind, random-ized crossover study of 16 male team-sport players who received 140 mL of beetroot juice daily for seven days and were asked to perform intermittent cycling. The beetroot juice was found to significantly enhance repeated sprint performance along with improving reaction time.6

When it comes to real-world competition, most athletes are more interested in improvements in performance and the time

it takes to complete an event. The question of whether beetroot juice can improve exercise performance, not just tolerance, has been examined in studies looking at timed trials. In 2011, Medi-cine and Science in Sports and Exercise published a study of nine nonelite but competitive male cyclists. The study was a cross-over design in which the athletes were given 500 mL of beetroot juice or a nitrate-depleted placebo and asked to complete 4- and 16-km timed cycling events. The cyclists receiving the beetroot juice completed both distances 2.7% faster than the cyclists who received the placebo.7 A similar study showed a 1.2% reduction in time to complete a 10-km cycling trial following six days of beet-root juice supplementation.4 However, benefits aren’t reserved solely for competitive athletes willing to consume large doses of beetroot juice. In 2012, the Journal of the Academy of Nutrition and Dietetics published a double-blind, placebo-controlled crossover trial in which 11 recreationally fit men and women completed a 5-km running trial on the treadmill 75 minutes after consuming roasted beets. Not only did the beet-eaters run at a faster velocity but also their perceived level of exertion was significantly lower.8

Some studies looking at the effects of beetroot juice on highly trained endurance athletes conflict with those that examined nonelite athletes, which may relate to the way nitric oxide is gen-erated in elite vs nonelite competitors. For example, a study of highly trained cyclists completing a 50-mile time trial showed an inverse correlation between beetroot juice and time to comple-tion.3 In another study, trained cyclists didn’t cover more distance in one hour of cycling following beetroot juice ingestion compared with placebo.3 In normal conditions, when there’s ample oxygen present in body tissues, enzymes convert the amino acid argi-nine to nitric oxide. But when oxygen levels are low—as may be the case during exercise among less trained athletes—the pro-duction of nitric oxide relies on conversion from dietary nitrates. It’s hypothesized that athletes training at the elite level may have higher capillary delivery of oxygen to their tissues, allowing nitric oxide to be made from arginine rather than dietary nitrates,3 thereby preventing them from benefiting directly from beetroot juice intake in these studies.

Recommendations for AthletesFor potential ergogenic benefits of dietary nitrates, study doses

of beetroot juice varied between 140 mL and 500 mL per day for several days before the event. Studies in which athletes received beetroot juice for three days or fewer before the event didn’t show consistent gains in exercise tolerance or performance. On event day, beetroot juice should be consumed 11⁄2 to three hours ahead of the event to most closely match the dosing schedule used in studies. So far, research suggests events between five and 30 minutes in duration may see the best gains from dietary nitrates, and recreational athletes may benefit more than highly trained endurance athletes.

From the Lab to the KitchenWith vibrant hues from gold to red, and a mildly sweet flavor

to match, it’s easy to include beets in the diet. Red and golden

FITNESS FOODS


beets are a cultivated variety of Beta vulgaris, grown for their edible taproot, thus the common name “beetroot.” Perhaps red beets have gotten a bad rap from a related variety, the sugar beet, grown specifically for their taproot rich in natural sugars, which must undergo multiple stages of processing to yield white table sugar—essentially the same as sugar derived from sugar cane.

In contrast, red and golden beets are packed with nutrients. Along with their high nitrate content, a single beet that has a diameter of 2 inches provides 2 g fiber, 266 mg potassium, 64 mg sodium, 89 mg folate, 27 IU vitamin A, less than 6 g sugar, and 35 kcal.9

Beets can be eaten raw, juiced, or cooked. Because of their dark red pigment, beets can be messy to handle. Roasting beets brings out their full flavor while minimizing contact with the deep red pigment. After roasting, simply wrap the cooled beet in a paper towel and rub gently to slip off the skins. Keep roasted beets on hand in the refrigerator for a quick addition to salads like the accompanying recipe.

— Clare Tone, MS, RD, is a freelance writer, high-altitude gardener, and nutrition instructor at Metropolitan State

University of Denver.

Roasted Beet Salad With Goat Cheese and Sherry-Walnut Vinaigrette

Serves 8

Ingredients10 small red or golden beets, roasted1⁄2 cup sherry vinegar1 tsp Dijon mustard1⁄4 tsp agave or honey1⁄2 clove garlic, finely chopped1⁄2 cup walnut oil1⁄4 cup olive oil11⁄4 tsp saltGround black pepper, to taste1 lb baby spinach, roughly chopped5 oz arugula, roughly chopped1⁄2 cup toasted walnuts4 oz crumbled goat cheese

Directions

To Roast Beets:1. Preheat oven to 400˚ F.2. Trim greens to about 1 inch above the root bulb. 3. Wash root bulb and place in covered roasting pan. Alternatively, beets can be wrapped in aluminum foil.4. Roast beets for about one hour or until easily pierced by a metal skewer or fork.

Vinaigrette:Whisk together vinegar, mustard, agave or honey, and garlic. Whisk in the oils, salt, and pepper.

Salad:Cut beets into bite-size pieces and mix with half the vin-aigrette. Mix greens with the rest of the vinaigrette. Top greens with beets, walnuts, and goat cheese.

Nutrient Analysis per servingCalories: 180; Total fat: 14 g; Sat fat: 3.5 g; Cholesterol: 5 mg; Sodium: 240 mg; Carbohydrates: 9 g, Dietary fiber: 3 g; Sugar: 4 g; Protein: 6 g— RECIPE COURTESY OF WHOLE FOODS MARKET. VISIT WHOLEFOODSMARKET.COM FOR MORE GREAT RECIPES.

203-576-4947

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Master of Science in Nutrition



iets that are predominantly based on plant foods have been associated with reduced risk of heart disease. This is most likely due to their lower saturated fat content and higher contents of fiber and beneficial phytochemicals, including antioxidants. According to

recent research, incorporating soyfoods into plant-based diets may provide additional benefits. These foods have been linked to lower risk of heart disease not only because of their beneficial fatty acid profiles but also because of their protein and isoflavone content.

Soyfoods have a rich nutritional profile as well as a rich history, as they have been enjoyed by various cultures for hundreds of years.

Rich HistoryFrom both a culinary and nutritional standpoint, beans—

including soybeans—are critical to the culinary traditions of populations consuming plant-based diets. In many Asian countries, soybeans and the foods made from them—tofu, soymilk, miso, tempeh, okara, and natto—have been impor-tant in diets for centuries. And they continue to play essential roles in the modern cuisine of these countries.

In Japan, tofu, miso, and natto are the most commonly consumed soyfoods.1 Soymilk, tofu, and processed soy

products are frequent parts of meals in China, although the type and amount of soy consumed varies widely throughout the country.2 The fermented soy product tempeh is consid-ered to be the national food of Indonesia, where it’s used in snacks or meals as a boiled or fried dish.3 Despite the popu-larity of tempeh in this country, however, almost one-half of all soy consumed in Indonesia is tofu.4

Although all beans are rich in protein, soybeans are excep-tional for both their quality and quantity of this nutrient. One-half cup of cooked soybeans provides approximately 15 g protein, which is about twice the amount found in other legumes. Based on the protein digestibility-corrected amino acid score, the quality of soy protein is equivalent to protein from animal foods and is higher than other plant proteins. Many soyfoods also are good sources of calcium, making a potentially important contribution to bone health in popula-tions where dairy foods are seldom consumed. They also pro-vide a significant source of iron, which is present in a form that appears to be well absorbed even in the presence of phytate.5

In Western countries, soyfoods are increasingly popular as a way of exploring Asian cuisine and as a replacement for meat and dairy products among those eating plant-based diets. Tofu is used to replace eggs as breakfast items, meat or chicken in stir-fries, and cream or soft cheeses in recipes. Soymilk is a popular choice among people who prefer plant-based milks as a beverage or in cooking. The


and

DBy VIRGINIA MESSINA, MPH, RD



Evidence shows

soyfoods can improve

heart health due

to their rich fatty

acid, protein, and

isoflavone content.

food industry has long used isolated and concentrated soy proteins as functional ingredients, and they’re important for producing meat analogs for vegetarians and others looking to reduce meat intake.

The popularity of soyfoods has been due to their rich nutri-ent content and versatility. A new focus of interest, however, which dates to the early 1990s, is the health effects of phyto-nutrients such as isoflavones. These phytoestrogens may play a role in reducing cancer risk6 and may be useful in managing menopause symptoms.7

Although isoflavones also may have a role in protecting against heart disease, much of the focus in this area has returned to the macronutrient content of soybeans—namely, their protein and fatty acid composition.

Heart Disease Incidence and Soyfood ConsumptionThree prospective epidemiologic studies have evaluated

the association between soy intake and coronary heart disease (CHD) among women in Asia. In the Shanghai Women’s Health Study (SWHS), which includes 65,000 postmenopausal women, subjects in the fifth percentile for soy protein consumption had an 86% lower risk of nonfatal myocardial infarction than women in the lowest percentile.2 Among 40,462 women enrolled in the Japan Public Health Center-based (JPHC) study cohort,1 those who consumed soyfoods at least five times per week were one-third less likely to die of CHD compared with women who consumed soyfoods no more than two times per week. Frequent soy consumers also were less likely to have had a stroke.8

In contrast, there were no cardioprotective effects asso-ciated with soyfood consumption in the Singapore Chinese Health Study.9 Nor were soyfoods protective against heart dis-ease in men in either the Shanghai Men’s Health Study10 or in the JPHC,8 suggesting that the effects of soy consumption on heart disease may be gender specific.

While the results from epidemiologic studies are somewhat conflicting regarding soyfood consumption and heart health, clinical research points to an intriguing relationship between certain components of soyfoods and markers of heart disease risk, including LDL cholesterol, blood pressure, and arterial health. Soy’s fatty acid, protein, and isoflavone content may all work toward improving heart health when soyfoods are included in diets.

Fatty Acids in Soyfoods Soybeans are unique among legumes because of their high

fat content. Whole soybeans are about 40% fat as a percentage of calories compared with just 4% fat in pinto beans. The fat content of foods made from soybeans varies considerably depending on whether the whole bean is used. Textured vegetable protein—which is typically made from defatted soy flour—is fat-free, while traditional soyfoods such as tofu, soymilk, and tempeh are closer in fat content to the whole soybean.

The fat from soyfoods is predominately polyunsaturated (~59%) and monounsaturated (~29%).11 Soybeans are among a handful of plant foods that provide both the essential omega-6 fat linoleic acid and the essential omega-3 fat alpha-linolenic acid. One-half cup of cooked soybeans provides between 25% and 35% of the requirement for alpha-linolenic acid.

Recent research shows that replacing saturated fat in the diet with polyunsaturated fat is far more effective at reducing CHD risk than replacing saturated fat with either monounsaturated fat or carbohydrate from whole grains.12 (Replacing saturated fat with carbohydrate from refined grains or added sugar doesn’t reduce risk at all.) There’s also evidence that the high linoleic and alpha-linolenic acid content of soybean oil may be especially helpful for reducing heart disease risk.13,14

Researchers from the University of Toronto estimated that when 25 g of soy protein from soyfoods replace 25 g of protein from commonly consumed sources of protein in the US diet, LDL cholesterol will decrease by approximately 4% because of the favorable change in the fatty acid composition of the diet.15

Soy Protein and LDL Cholesterol LevelsTheir fatty acid profile makes soyfoods, like all plant foods,

a potentially valuable part of heart-healthy diets. Their protein content, however, may make them unique among plant foods in protecting against heart disease.

In 1999, the FDA approved a health claim for soyfoods and heart disease based on the cholesterol-lowering effects of soy protein.16 Similar claims have been approved in more than 10 other countries since 1999.17 The most recent country to regis-ter a claim was Canada in 2014.18

The FDA established 25 g of soy protein per day as the intake threshold for cholesterol reduction. This is the amount found in about three servings of tofu or soymilk. Some but not all evidence suggests that lower amounts of soy protein may lower cholesterol.19

Meta-analyses of clinical trials published since 2005 indicate that soy protein lowers LDL cholesterol by 4% to 6%,15,20-23 which is similar to cholesterol-lowering effects of soluble fiber.24 Compared with drug intervention, this is a modest reduction, but it’s enough to produce meaningful protection from heart disease. Each 1% reduction in cholesterol is estimated to lower risk of CHD by 1% to 2%,25,26 suggesting that soy protein alone could reduce heart disease risk by anywhere from 4% to 12%.

Furthermore, soy protein has been shown to lower circu-lating triglyceride levels by approximately 5% to 10% with-out affecting HDL cholesterol and may, in fact, increase HDL


cholesterol by 1% to 3%.20 This again may be clinically relevant since each 1% or 1-mg increase in HDL cholesterol lowers CHD risk by 2% to 3%.27 There’s some debate about whether or not elevated triglyceride levels alone predict heart disease risk.28 However, elevated postprandial triglyceride levels may be an important risk factor for heart disease; limited research suggests soy lowers this CHD risk factor.29

Health Benefits Beyond Serum CholesterolThe magnitude of reduction in heart disease risk among

women in studies like the SWHS and JPHC suggest that the coronary benefits of consuming soyfoods go beyond what would be expected from cholesterol reduction alone. Additional protection may come from effects of isoflavones on endothelial function.

A recent meta-analysis found that soy improved endothelial function in postmenopausal women but only in those who had impaired endothelial function at baseline.30 A second meta-analysis found modest beneficial effects of soy consumption on endothelial function whether or not endothelial function was impaired at enrollment.31

In the Women’s Isoflavone Soy Health study, carotid intima-media thickness (CIMT) progression was 16% lower in women consuming isoflavone-rich soy protein (containing 91 mg of isoflavones, or the amount in three to four servings of tradi-tional soyfoods such as tofu, tempeh, or soymilk) compared with women consuming milk protein.32 While the results weren’t statistically significant, an interesting finding was that CIMT progression was reduced to a much greater extent in women who were in early menopause. This is consistent with

Protein, Fatty Acid, and Isoflavone Content of Selected Soyfoods

Calories Protein (g) Total Fat (g)Total PUFA (g)

Linoleic Acid (g)

Alpha-Linolenic Acid (g)

Isoflavones (mg)

Soybeans, 1⁄2 cup cooked

148 15.7 7.71 4.35 3.84 0.51 56

Soynuts, 1⁄4 cup dry roasted

104 10 5 2.84 2.5 0.33 34.53

Edamame, 1⁄2 cup cooked

127 11.12 5.76 2.71 2.39 0.32 16.1

Tofu, firm, 1⁄5 block

76 9 4.79 2.42 2.17 0.24 20.6

Tofu, silken, 1⁄5 block

43 4.37 2.28 1.18 0 0 16.41

Soymilk, 1 cup 110 8 4.5 2.5 0 0 25.43

Tempeh, 1⁄2 cup cooked

159 16.84 8.96 3.57 3.36 0.21 50

Miso, 1⁄4 cup 136 8.68 4.08 1.96 1.68 0.28 28

Textured vegetable protein, 1⁄4 cup unprepared

80 12 0 0 0 0 0

Vegetarian chicken patty

136 15.3 5.95 3.2 0 0 3.12

Soy yogurt, 1 container

150 5.99 4 0 0 0 75.29

Soy flour, defatted, 1⁄4 cup

86 3.4 0.08 0.03 0.03 0.01 9.96

Soy protein powder, 1 scoop, 45 g

175 25 2.5 1.21 1.07 0.14 0

Soy protein isolate, 1 oz

95 25 0.96 0.47 0.41 0.05 25.8

Soy protein concentrate, aqueous wash, 1 oz*

93 18 0.13 0.06 0.05 0.01 27

*Alcohol washed soy protein concentrate is much lower in isoflavones. — SOURCES: USDA, FOOD PACKAGES


the estrogen timing hypothesis, which maintains that exposure to estrogenlike compounds leads to dramatic reductions in heart disease risk when begun soon after menopause, but has less effect in later years.33

Several studies have shown that soy and/or isoflavones improve systemic arterial compliance, another measure of arterial health.34 Finally, soy may reduce LDL oxidation and increase LDL particle size, both of which can be expected to reduce risk of heart disease.35,36 However, study findings are limited and/or inconsistent regarding these factors.

Potential effects of soy isoflavones are intriguing since they could explain gender differences in outcomes from epidemi-ologic studies on soy and heart health. Particularly in stud-ies where soy protein intake may have been too low to provide protection, women may have reaped benefits from isoflavone intake that weren’t relevant in male subjects.

Impact on Blood PressureApproximately one decade ago, the authors of a commen-

tary published in the Canadian Medical Association Journal suggested that soy protein could be the next antihypertension agent.37 But it wasn’t until Harvard University researchers showed in 2007 that soy dramatically lowered blood pres-sure that the hypotensive effects of soy received widespread attention.38 In this study, 25 g of protein intake per day from soynuts lowered systolic and diastolic blood pressure by

9.9% and 6.8%, respectively, in hypertensive women, and by 5.2% and 2.9%, respectively, in normotensive women. A few years before that, Spanish researchers already had shown that soymilk (500 mL twice per day) had similar benefits, reducing blood pressure by 16 mm Hg to 18 mm Hg in com-parison with cow’s milk.39

However, while four recently published meta-analyses of the clinical data found reductions in blood pressure with con-sumption of soy protein, the effects were much smaller.40-43 Since many of the trials that showed effects didn’t have blood pressure as a primary focus of the study, more research is needed to determine the relationship of soy consumption to blood pressure.

Soyfoods as Part of a Heart-Healthy DietOverall, what the research has found is that incorporating

more legumes and other plant foods into diets is beneficial for reducing heart disease risk because of favorable changes in the fatty acid profile of the diet. Soyfoods can be an important part of this approach since they’re a good source of both essential fatty acids and are especially versatile as replacements for meat, dairy products, and eggs. In addition, research shows that soy protein lowers blood cholesterol levels and that soy consumption may improve blood pressure and arterial health.

The findings regarding soyfoods and heart health are encouraging, but reducing risk of heart disease requires a comprehensive approach, not the addition of a single food item. For example, the portfolio diet developed at the Univer-sity of Toronto has had dramatic effects on blood cholesterol levels, reducing them by as much as 30%.44 The diet combines dietary factors such as heart-healthy fats, phytosterols, nuts, and fiber as well as 23 g of soy protein from foods such as soy-milk, tofu, and soy-based meat substitutes for each 1,000 kcal consumed. Each of the major elements of the portfolio diet has been shown to independently lower cholesterol. Recently, this diet also has been found to lower blood pressure even more effectively than the DASH diet.45

More research is needed on some aspects of soyfoods and heart disease reduction such as the effects of soy isofla-vones on certain risk factors. However, it’s clear that soyfoods can play a useful role in comprehensive approaches to heart health that include a healthful diet, exercise, and smoking ces-sation. About three servings per day of soyfoods will likely pro-vide the amount of soy protein and isoflavones that have been found to be beneficial in studies.

— Virginia Messina, MPH, RD, is a writer and speaker on vegetarian and vegan diets for the public and health

professionals. She’s coauthor of Vegan for Life, Vegan for Her, and Never Too Late to Go Vegan, as well as a textbook on vegetarian

nutrition for dietitians. Her website is TheVeganRD.com.



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By Juliann Schaeffer

National DiabetesPrevention Program

Update on the

Amassive, multifaceted problem often requires a solution of the same propor-tions. Diabetes is a health crisis dietitians know well, and the numbers of those who have the disease or may develop it are staggering. But through the National Dia-

betes Prevention Program (National DPP), the Centers for Disease Control and Prevention (CDC), along with hundreds of organizations, stakeholders, and trained professionals are working to reach and then help mil-lions of Americans delay and possibly prevent the onset of type 2 diabetes.

The CDC estimates that 29.1 million Americans have diabetes, and 8 million of them don’t even know it. What’s worse, prediabetes affects even more people—an estimated 86 million people aged 20 and older. The vast majority, about 90% of people with elevated blood glucose that isn’t high enough to be considered diabe-tes, have yet to be diagnosed.

That’s crucial, because prediabetes not only puts people at higher risk of developing type 2 diabetes, it also puts them at higher risk of heart disease and stroke, according to the 2014 National Diabetes Sta-tistics Report. But if the CDC and a whole host of other organizations across the country have anything to say about it, type 2 diabetes won’t be a reality for the many millions of Americans they seek to reach through the National DPP.

What Is the National DPP?Established five years ago, the National DPP is the

largest effort of its kind to prevent type 2 diabetes. Man-aged by the CDC, the National DPP is a framework built on the National Institutes of Health’s landmark DPP study that concluded in 2002, which showed lifestyle modifications, including healthful eating, moderate weight loss, and regular physical activity, provide a huge potential to delay or even prevent type 2 diabetes.

The original DPP, a randomized controlled trial that included participants at high risk of diabetes, found that a structured lifestyle program that stressed small but consistent changes, such as healthful eating habits and regular physical activity, showed significant results.

Specifically, participants who lost 5% to 7% of their body weight (approximately 10 lbs for a 200-lb person) and aimed for 150 minutes of physical activity per week cut their risk of developing type 2 diabetes by 58%.

As researchers continue to follow up with these same participants, the results are proving even more optimistic. A decade since the original DPP study began, a 2009 follow-up study showed the lifestyle intervention continued to outperform metformin and placebo groups, with participants who completed a dia-betes prevention lifestyle program still roughly one-third less likely to develop type 2 diabetes.

Built on what was learned from the original DPP study, the National DPP was developed for use as a framework to implement the dietary and lifestyle inter-ventions used in the DPP clinical trial proven effective for preventing type 2 diabetes in people at high risk. Its goal is at once ambitious and acutely needed: to reach the 86 million people with prediabetes in this nation to help them avoid the health repercussions of type 2 dia-betes—and help the country avoid the significant health care costs that go along with that diagnosis.

In effect, the National DPP is a yearlong classroom- or online-based program that teaches basic nutrition principles and physical activity components proven to decrease the risk of type 2 diabetes. In the year-long program, participants attend a minimum of 16 weekly classes during the first six months, with monthly classes thereafter. The CDC posts a curriculum that instructors can use, and lessons can be customized to an extent. Or, if an organization believes its own cur-riculum meets the national standards, it can submit it for CDC review and approval. Class topics range from how to eat healthfully to how to integrate more physical activity, such as walking, into one’s lifestyle, in addition to stress management coping strategies—all with the goal to effect long-term lifestyle change.

“At each session, the participants are privately weighed and given a food/activity tracker to fill out and hand in at every meeting, and the coach facilitates the group in a lesson, encouraging as much participation from each person as possible,” says Kim James, RD, LDN, DPP program coordinator for NorthCrest Medical

Learn what the National DPP is all about and how dietitians can get involved.


Center Endocrinology Clinic. While the CDC leads this fight, it’s hardly fighting alone. Organizations such as the YMCA and the American Association of Diabetes Educators (AADE), compa-nies including L.L. Bean, health insurance plans, universities, and health organizations have joined the battle.

“The National DPP framework brings together all kinds of stakeholders, and that’s really at the heart of the National DPP,” says Ann Albright, PhD, RD, director of the division of diabetes translation at the CDC. “It serves as our backbone, allowing us all to coordinate, coalesce, and organize our efforts to prevent type 2 diabetes through this proven lifestyle intervention.”

What’s involved in the National DPP framework? The fol-lowing are the four main components: workforce training, quality assurance, implementation, and marketing.

Workforce Training As Albright stresses, a skilled workforce is needed to

deliver this intervention on a mass scale. But that doesn’t mean only health professionals are delivering this program—and that’s a good thing, she says.

“The evidence has demonstrated that you can have both health professionals and trained laypeople deliver this inter-vention,” she says.

Joining forces is key, Albright says, who notes that some of the most effective National DPP programs have laypersons and dietitians teaching classes and working with participants together. While the CDC doesn’t train or credential coaches, it does credential and recognize organizations, who then deliver the program and provide support and oversight to their coaches and staff. The CDC also offers a set of approved curriculum on its website, though organizations can submit their own curricu-lum for approval, if they so choose. According to Albright, more than 8,000 coaches are trained to deliver this program today.

Quality Assurance“This is where the CDC plays a very key role,” Albright says.

Noting that the CDC doesn’t own the National DPP, Albright says it serves as the manager of the program to ensure its progress and successful implementation.

To ensure those ends, the CDC runs a recognition program, which involves the establishment of a set of national standards for the lifestyle program. Organizations apply and can receive full CDC recognition after running the program successfully for two years. One aspect of this involves National DPP sites collecting a core set of deidentified data that the CDC then uses to monitor the quality and performance of the national program as a whole.

According to numbers from January 20, 2016, Albright says 790 organizations were participating in the National DPP, 46 of which have submitted at least two years of successful data and thus achieved full CDC recognition. As of that date, there were 34,678 active participants in the national program, with virtual programs offered in every state including Washington, D.C., and in-person programs in 48 states and Washington, D.C.

ImplementationThis component involves the nuts and bolts of the program:

who is delivering it, where it’s being delivered, and how it’s being reimbursed. Albright stresses that she never wanted to depend on grant dollars alone to sustain this program—because she wants it to be sustained long-term. As such, she and the CDC have worked to get this program reimbursed, wherever possible.

And there’s progress to note. As of January 2016, Albright says about 40 health plans currently are providing some form of coverage for the National DPP, including United Health-Care and BlueCross BlueShield of Florida. She’s looking to bring more health plans on board as the program continues to show efficacy.

“We’re also very involved with CMS [the Centers for Medicare & Medicaid Services], and we’ve been making important progress toward Medicare coverage. We are also embarking on a demonstration project with a few states to look at the Medicaid population,” she says.

Of the 35,000-plus people involved in the program so far, Albright is pleased to note that average weight lost for eligible participants who have completed the one-year program and attended at least four sessions from the data they’ve received is about 4.7%. “Our standards require 5% to 7%, so as an entire country, we’re almost to that goal,” she says.

One new development to note: As of 2015, the CDC now allows organizations delivering the National DPP virtually to be eligible for recognition. “Prior to that, we were only recogniz-ing in-person delivery, because the evidence wasn’t quite there yet,” she says. “We have significant and sufficient evidence now for virtual delivery.”

Albright says the same standards apply to virtual deliv-ery programs as in-person delivery, but she’s hopeful this will allow the program to scale and expand its reach sufficiently.

MarketingThe last component of the National DPP involves spread-

ing awareness—a huge issue, considering only 10% of people with prediabetes know they have it. But there’s progress to note here, too.

The CDC, along with the American Diabetes Association (ADA) and the American Medical Association, in partnership with the Ad Council, launched the first public awareness campaign in January 2016 that focuses on prediabetes. It uses humor to help people identify their risk, and DoIHavePrediabetes.org offers a simple test that helps people determine whether they may have prediabetes. The three-year campaign also involves a texting component that gives people periodic updates and reminders about what it means to live a healthful lifestyle.

National DPP Sites Across the NationSo what does implementation of the National DPP look

like? Here, Today’s Dietitian profiles several National DPP sites that have full CDC recognition. All work within the same


framework to meet the same goal, while tweaking the details to maximize efficacy in their particular location for the popula-tion they’re trying to reach.

KentuckyBaptist Health Lexington applied to become an AADE-

funded National DPP delivery site in 2013, and last May they achieved full recognition from the CDC. Since then, the facil-ity has offered the program to grant participants, employees, companies, and even the public.

“We are growing and adding about one new [educational] class about every eight weeks or so,” says Kathleen Stanley, MSEd, CDE, RD, LD, BC-ADM, MLDE, diabetes education program coordinator at Baptist Health Lexington in Lexington, Kentucky. “We offer classes off campus at businesses and companies as well.”

Since Kentucky has one insurer that provides coverage for the DPP, Stanley says they work closely with that insurer as a referral source for members who are eligible for DPP based on their screening criteria and initiatives.

This program currently is taught by only RDs or RNs. In addition to providing evidence-based diabetes education, Stanley says instructors make a point to put a creative spin on things. “We also supplement the program with optional extra classes such as grocery shopping tours, guest speakers, tours of local gyms, and other events,” she says, noting that she believes the hospital affiliation gives participants an extra level of comfort and confidence in the program.

In addition to the measurable successes seen by weight and BMI reductions and physical activity increases, Stanley says she sees even more in successes that can’t be measured, including participants’ positive attitudes, new friendships being formed, new strategies learned for coping with barriers, and empowerment.

Stanley says dietitians have a very real role to play in the National DPP. “This program provides a unique opportunity for dietitians to address the topic of weight loss in a comprehen-sive, evidenced-based group program in a variety of settings,” she says.

Not only can the program help improve community health but it also could increase business for RDs in the future. “Because participants come for a full year in the program, the RD instruc-tor helps to develop relationships with individuals who are oth-erwise healthy, but may develop relationships with your facility in the future because of the experience of a DPP,” she says.

TennesseeThe National DPP program at NorthCrest Medical Center

Endocrinology Clinic in Springfield, Tennessee, located 30 miles north of Nashville, also became an AADE-funded National DPP delivery site, with the center offering its first class in June 2013. NorthCrest is the first in the state of Tennessee to receive full recognition from the CDC for its National DPP program.

James says that the South has the unfortunate distinction of leading the nation in obesity, inactivity, and diabetes incidence. And though the center has had an ADA-accredited DSME (Dia-betes Self-Management Education) program in place since 1993, capturing individuals before the onset of diabetes wasn’t being effectively addressed.

“Although physicians were clinically identifying individuals with prediabetes, the best we could offer was a free one-time 30-minute session since prediabetes is not a reimbursable diagnosis in Tennessee. This brief encounter cannot begin to

THE YMCA’S NATIONWIDE DPP REACH

The YMCA has been a part of the National Diabetes Prevention Program (DPP) since 2009 and has contin-ued to grow. “The YMCA’s Diabetes Prevention Program has expanded from two YMCA associations with a hand-ful of program sites in two states in 2009 to more than 220 Y associations delivering the program at more than 1,400 program sites in 44 states at the end of 2015,” says Heather Hodge, director of chronic disease pre-vention programs for YMCA of the USA.

In a YMCA fact sheet on its National DPP program, the number of participants who attended at least one program session at one of the Y’s national sites totaled nearly 40,000. Average weight loss at the end of the year sits at 5.4%.

Participants of the YMCA’s DPP program must qualify with specific eligibility criteria beyond being overweight, similar to other National DPP programs. But Hodge stresses that YMCA’s DPP isn’t a weight-loss program.

“Throughout the yearlong intervention, participants work in a small, supportive group with a trained coach who must successfully pass standardized curriculum train-ing,” Hodge says, adding that dietitians have been involved in the program as lifestyle coaches or providers of diet and nutrition guidance beyond the scope of the program. In the latter case, the Y will refer the participant to a dietitian for support outside of the program, she says.

Since more than 80% of US households live within five miles of a YMCA, it has the ability to reach many people, Hodge says. The program has seen significant growth thus far and expects to expand the program even further as demand increases.

“Y-USA plans to continue to scale the program to meet local Y interest and community need,” Hodge says. “By the end of 2017, the program will be available in over 300 Y associations all across the US, serving nearly 70,000 people.”

— JS


scratch the surface of the help that prediabetics need to delay or prevent their slide towards type 2 diabetes,” she says.

Through the National DPP program, NorthCrest now offers participants 24 hours of group session time over 12 months.

As demand has increased, NorthCrest continues to expand the program as necessary, bringing on new coaches and plan-ning to offer a program for Spanish-speaking adults in the near future. “We also incorporate a mentoring program for graduates who want to stay involved by having one to two of them serve as ‘helpers’ who come to each meeting to assist the coach and participants,” James says. “A helper can set up the room, pass out lessons, collect completed food logs, and give encouragement and empathy to participants who may be struggling to meet their program goals.”

In addition to the physical transformations of program participants due to weight loss and improvements in lab results, James says she also has observed positive changes in demeanor and attitudes, from “gloomy to sunny and from hopeless to hope-filled.”

NorthCrest currently is working to bring employers and third-party payers on board in the near future to make reimbursement for a prediabetes diagnosis a covered medical cost.

“I would encourage any dietitian who has a passion for well-ness and prevention to consider bringing the DPP to their worksite by becoming a trained coach,” James says. “It has been one of the most satisfying things I’ve ever done in my 26-year career. To have the luxury of 24 hours of class time over one year and be able to watch the transformation that takes place is wonderful.”

CaliforniaIn Los Angeles, an organization called Black Women for

Wellness (BWW), a 501(c)3 nonprofit, member-centered, community-based organization, is offering a multigenera-tional approach to addressing health disparities impacting black women and girls through education, empowerment, and advocacy. Working with the Black Women’s Health Imperative through a cooperative agreement with the CDC since 2013 (through a program called Change Your Life-style. Change Your Life. [CYL2]) as well as the Los Angeles County of Public Health, BWW is now in its fourth year as a National DPP provider, says Janette Robinson Flint, BWW’s executive director. (The organization doesn’t currently use dietitians, but they do see the value of adding RDs on staff as the program scales.)

“BWW has always been concerned about the health dispari-ties that plague our communities and the prevalence of chronic diseases such as obesity, cancers, heart disease, stroke, and dia-betes,” says Willie Duncan, senior program manager for BWW.

Flint points to the disparities in life expectancy, for exam-ple, that show average black life expectancy at 75.6 years, at least five years shorter than that of white, Latino, and Asian averages. Obesity rates also are higher for blacks (31%) and Latinos (32%) than whites (18%). The statistics that show how

these and other health disparities disproportionately affect black men and women are telling, and BWW hopes to hit those numbers head on with their National DPP program.

“The main goal of CYL2 is to decrease the number of people being diagnosed as diabetic in our community through this evidence-based program that focuses on a coaching model, group support, increasing physical activity, improving food choices, and losing body weight,” Flint says.

Holding to the national framework on class frequency and curriculum, BWW tailors the program at its six sites throughout the Los Angeles area to ensure it’s meeting the needs of participants.

“For example, BWW’s Kitchen Divas program uses a plant-based approach to encourage our community to eat more veg-etables, fruits, and plant-based foods to lower the incidence of chronic diseases,” Flint says. “The coaching and group environment is a critical component as they aid in behavioral change by working though obstacles, encouraging through stumbles, and celebrating and sharing successes.”

BWW adapts its program to the community it serves, which means it includes culturally relevant themes, images, and sayings, where appropriate. “CYL2 understands the particu-lar struggles and obstacles that might hinder members of our communities and works to combat factors such as economic, social, environmental, and health inequities,” Flint says.

As the program has expanded, the CYL2 team increased from three lifestyle coaches to 10 passionate and dedicated community health educators. “Our team includes nutritionists, physical fitness specialists, and experienced health experts who are expanding the impact of the program,” Flint says.


Thus far, the program’s third-year numbers have surpassed national expectations. In year three, BWW saw an average decrease of 7.9% in BMI in the first 16 weeks and an average weight loss of 6.6%.

To get maximum success and buy-in from participants, Flint asks dietitians to dig beyond personal responsibility to con-sider what cultural and environmental factors (and inequali-ties) may be affecting someone’s willingness to change.

“Working in the community has allowed us to see the bar-riers and obstacles facing our DPP participants such as family and community support, access to healthful foods, access to grocery stores vs fast food restaurants, access to safe parks and spaces for physical activity, and pervasive advertising and marketing that triggers us to make certain food choices,” she says.

Virtual DeliveryCappa Health, based in Scottsdale, Arizona, is currently

a virtual provider of the National DPP through the CDC with pending recognition status. “From this experience, we real-ized our virtual tool would allow us to deliver this proven program to a far larger number of participants,” says Jody Pannozzo, RD, vice president of hiring and training for Cappa Health. “The static nature of the class meeting times created difficulties for the attendees who were juggling busy lives. It became clear that a version of this program that allowed par-ticipants the flexibility to participate when and where they could was needed.”

Pannozzo says the company also noticed that virtual daily tracking tools provided more accuracy and accountability than traditional paper tracking done in the classroom setting.

The program, which currently is awaiting CDC recognition status, involves four main components in both English- and Spanish-speaking versions. Educational videos help highlight the core curriculum and provide visual examples (available on the app and the website) for participants to watch at their con-venience. Weight, food intake, beverage intake, activity, sleep, stress, and energy are tracked via the mobile app or website.

“Rather than text explanations of food intake, photo journal-ing allows for a more accurate record of portion sizes and food balance,” Pannozzo says. “Participants can review anything that’s previously tracked and see progress on colorful charts.”

A certified lifestyle coach who’s also a dietitian provides participants feedback and recommendations. “Our dietitians also take participants through hands-on skill building activi-ties and goal-setting activities to reinforce the material,” Pan-nozzo says.

Even though the program is delivered virtually, there’s still a community aspect. Instead of participating with their peers in person, participants in this program communicate by posting questions, comments, and messages of support in the com-munity forum.

While the Cappa Health program includes the core goals of the National DPP, Pannozzo says it goes a step beyond to

provide more updated information on intuitive/mindful eating, whole foods, functional foods, and micro- and macronutrients.

“We want dietitians to know that this program is working and is changing lives,” Pannozzo says. “On a daily basis, we are proving the value of dietetics as shown by the testimonials and feedback we get from our clients. The curriculum is solid, but the fact that it is a dietitian guiding the participants through the yearlong program is making a difference.”

Get InvolvedThere are more than enough people who still can par-

ticipate in the National DPP, so Albright encourages dieti-tians to get involved if they haven’t already. “I want to be sure dietitians know there are many [RDs] involved in the National DPP. They’re serving as coaches and coordinators. They’re helping to train coaches. There are millions of people who need this intervention, and we’ve got to link arms and forces. I encourage dietitians to look and see who in their commu-nity is already delivering this program and what ways they can connect.”

The CDC website has a wealth of information on the National DPP. To find out what organizations are participating, the CDC has a registry of recognized organizations at https://nccd.cdc.gov/DDT_DPRP/Registry.aspx. If dietitians want to receive train-ing to deliver the program, they should visit the CDC website for the list of training organizations that have signed a Memoran-dum of Understanding with the CDC. RDs who work with orga-nizations that have programs that meet the national standards and want to get CDC recognition should apply for it. Dietitians who are using a curriculum the CDC hasn’t yet approved will need to submit their curriculum for CDC approval.

“There’s a conversation out there about this program being delivered by community health workers and laypeople,” says Joanna M. Craver, BS, MNM, associate director of prevention for the AADE. “And while that certainly has a place in the imple-mentation of this program nationwide, I think it’s still important that we include clinically trained and educated professionals in the overall implementation of the program to ensure it sticks to the high-quality standards to ensure its effectiveness.

“I think the takeaway is to look at this from multiple angles,” Craver continues. “Not only can RDs talk to their patients about this program but they can also look into overseeing and scaling multiple programs in multiple locations because of the large number of people affected.”

— Juliann Schaeffer is a freelance health writer and editor based outside Allentown, Pennsylvania, and a frequent

contributor to Today’s Dietitian.

ResourceDiabetes Prevention Program Research Group, Knowler

WC, Fowler SE, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-1686.


( )Today’s Dietitian speaks with nutrition professionals to

distinguish truth from error.

BY CARRIE DENNETT, MPH, RDN, CD

BUSTING THE TOP

here was a time when fat was the most-maligned macronutrient. Now, carbohydrates seem to be nutrition public enemy No. 1. From the Atkins diet and the South Beach Diet to Grain Brain and Wheat Belly, carbs are getting a bad rap. And while some carbs, such as fruits and vegetables, get a thumbs up from Paleo proponents, grains, dairy, and legumes

are considered a no-no. Is this fear of carbs really warranted? According to nutrition research, the answer is a qualified no—the devil is in the details.

As dietitians know from Nutrition 101, carbohydrates come from plants, and many plant foods are rich in the vitamins, minerals, phytochemicals, and fiber that are vital to good health. Research shows that Mediterranean-style and other plant-based diets with high fiber content and low glycemic load have a beneficial effect on glucose metabolism, whereas dietary patterns high in meat are associated with an increased risk of type 2 diabetes.1

Although grains may be the most controversial carb, results of several studies suggest whole grains, but not refined grains, are protective against type 2 diabetes.2 The intact nutrients and fiber in whole grains, together with their lower glycemic index and glycemic load, may improve insulin sensitivity and glucose metabolism, while refined grains are lower in fiber and nutri-ents and have a higher glycemic index or glycemic load.2 This supports recommendations in the 2015–2020 Dietary Guidelines for Americans that at least one-half of all grain intake should come from whole grains.2,3 Glycemic index is a measure of how the carbohydrate in a specific food raises blood sugar; glycemic load is based on how much of that food’s carbohydrate is eaten.

David Jenkins, MD, PhD, DSc, Canada research chair of nutri-tion and metabolism in the University of Toronto’s department of nutritional sciences, and developer of the glycemic index,4 says that bread and pasta can be healthful carbohydrate sources if the pasta is cooked al dente and the bread is very dense, unsweet-ened, and packed with intact grains.

Cereal, or grain, fiber is associated with a reduced risk of type 2 diabetes and cardiovascular disease (CVD).2,5 Analysis of data from the Nurses’ Health Study and the Health Profes-sionals Follow-Up Study found that higher whole grain intake was associated with reduced mortality, especially deaths due to CVD.6 These results were independent of other demographic and lifestyle predictors of mortality, including overall dietary quality. Similarly, results from the prospective NIH-AARP Diet and Health Study, which followed 367,442 individuals for 14 years, found that intake of whole grains was associated with a lower risk of death from all causes.7 Furthermore, whole grains contribute to intestinal health and a healthy weight.

In spite of this research, carb-phobia, especially grain-phobia and fruit-phobia, persists. That’s unfortunate, because fruits, whole grains, and many other carbohydrate-rich foods, includ-ing legumes and starchy vegetables, offer good nutrition as well as pleasure. Following are the top 10 myths that get in the way of many people consuming carbohydrates.

MYTH 1 Only Breads and Grains Contain Carbs

One irony about carb-phobia is many people can’t accurately define what it is they’re afraid of. Mandy Unanski Enright, MS, RDN, RYT, owner of Nutrition Nuptials in Red Bank, New Jersey, says that when she asks clients what type of foods contain carbs, they always respond with bread, pasta, and rice. “So this takes some educating that most plant-based foods contain carbs to some extent, along with milk products. And all are important for a healthful diet.”

“I don’t think most people realize that fruits and vegeta-bles are carbs,” says Lainey Younkin, MS, RD, LDN, owner of Lainey Younkin Nutrition in Boston. “I always find it interesting and funny when someone wants to cut out carbs but wants to eat healthfully. I’m like, ‘Do you know that fruits and vegeta-bles are carbs?’ When they think carbs, they’re thinking about bread, pasta, and rice. So I always clarify between healthful carbs—ones that are high in fiber and low in sugar—and not-so-healthful carbs.”

MYTH 2 Carbs Are Fattening

Several studies have found that whole grain intake is associ-ated with a reduced risk of weight gain,2,8,9 and similar associa-tions have been observed between fruit intake and weight,8,10,11 provided that calorie needs aren’t exceeded.12 But that’s not what sells diet books.

“I have many clients who tell me that they don’t eat carbs because they are ‘fattening,’” says Lindsey Pine, MS, RDN, CSSD, CLT, Los Angeles-based owner of TastyBalanceNutrition.com. “However, when we discuss their food logs, there are carbs all over the place—bananas and other fruit, oatmeal, protein bars, etc. They think they aren’t eating carbs when in fact they don’t know what a carb is in the first place.”

While many studies have found low-carb diets to be more effective for weight loss than low-fat diets in the short term, in longer-term follow-up both approaches produce modest weight loss at best.13,14 Kathy McManus, MS, RD, LDN, director of nutrition at Brigham and Women’s Hospital in Boston and one of the investigators for the Preventing Overweight Using Novel

T

10 CARB MYTHSapril 2016 www.todaysdietitian.com 31

Dietary Strategies (POUNDS LOST) study, says that calories matter more than macronutrient ratios. The POUNDS LOST study examined the effects of four heart-healthy diets varying in fat, protein, and carbohydrate composition on weight loss and long-term maintenance.15

“The POUNDS LOST trial showed that reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrient they emphasize,” she says. “This means that we can individualize healthful meal patterns based on cultural and personal preferences to support weight loss. Individualized plans can help with sustaining long-term adherence.”

David Ludwig, MD, PhD, a professor in the department of nutrition at Harvard T.H. Chan School of Public Health, direc-tor of the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital, and author of Always Hungry? Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Per-manently, says that while a low-fat diet high in processed car-bohydrates can program the body for excessive weight gain, a diet with moderate amounts of minimally processed carbohy-drates, along with healthful fats, does not.

MYTH 3 All White Foods Are Unhealthful

“The most common comment I get is ‘All white food is bad,’ or ‘My doctor told me to stay away from anything white,’ or even better: ‘Those white foods will kill you,’” says Erin McNamara, RDN, LD, nutrition services manager and lead clinical dietitian at Cass Regional Medical Center in Harrisonville, Missouri, who blogs at www.erindishes.com.

Enright agrees. “I hear a lot from clients that they avoid ‘white foods.’ The one that always gets a bad rap is the poor potato, which is a great source of potassium, vitamin C, and some fiber if the skin is eaten.”

One obvious flaw with the “no white foods” concept is that while white rice and white flour are refined and missing the fiber and nutrients found in their whole grain counterparts, many white foods are high in nutrients, including cauliflower, mushrooms, and the allium family (eg, garlic, onions, and leeks). As for potatoes, that depends. Ludwig says that the classic white, starchy russet potato has a glycemic load simi-lar to that of white bread, so both can cause unhealthful eleva-tions in blood sugar; other potatoes, including yellow-, red- and purple-skinned varieties, are “in a different category” because they have a moderate glycemic load.

MYTH 4 Low-Carb Diets Are Healthier

Low-carb diets have been shown to improve some meta-bolic markers, including blood lipids and insulin sensitivity,16 but a 2013 meta-analysis suggests that they don’t reduce the risk of CVD and overall mortality. In fact, carbohydrate restriction was linked with a 30% increased risk of mortality from all causes, and a slightly increased risk of cardiovas-cular events.17 Carbohydrate intake of only 15% below rec-ommendations has been associated with reduced vascular health, independent of major CVD risk confounders, likely due

to decreased intake of fiber, fruit, or root vegetables, and/or increased consumption of protein-dense products such as meat and dairy.18

Kelly Jones, MS, RD, CSSD, LDN, is an assistant professor of nutrition and exercise science at Bucks County Community College in Newtown, Pennsylvania, owner of EatRealLiveWell.com, and director of nutrition at Newtown Athletic Club, where she teaches a class called “The Truth About Carbs.” “It is amazing how many people hear and think they should consume high-protein snacks/foods to fuel a workout,” she says.

Ludwig agrees with the evidence suggesting that low-carb diets can produce favorable metabolic shifts in the short term,19 but feels that sticking to a low-carb diet for longer periods isn’t necessary. “For most people, we can accom-plish most of the benefits by targeting the highly processed carbohydrates and still enjoying the taste and diversity of natural carbohydrates.”

MYTH 5 Carbs Cause Inflammation

Some dietitians say the top reason clients avoid carbs is because they believe they are “bad for you,” Enright says. “This of course leads to more probing of what exactly they mean by ‘bad.’ Usually it winds up referring to weight gain, but some-times you hear claims about inflammation, or that they can cause diabetes.”

Chronic inflammation is a concern because it may be an intermediary between obesity and cancer, CVD, and other chronic diseases.20 One reason that whole grains may reduce the risk of type 2 diabetes is by reducing inflammation.21,22 High intake of whole grains has been shown to reduce concentra-tions of inflammatory markers, including C-reactive protein and increase blood concentrations of adiponectin, a cytokine released by adipocytes (fat cells) that increases insulin sensi-tivity and reduces inflammation.2

In addition, laboratory research and human feeding trials both have found that whole grains and other whole plant foods, as well as their constituent parts, such as insoluble fiber, magne-sium, and phytochemicals, consistently have beneficial effects on glucose metabolism, blood lipids, endothelial function, anti-oxidant activity, and inflammation.6

MYTH 6 Avoid Fruit Due to High Sugar Content

Chere Bork, MS, RDN, owner of Savor Your Life Today (www.cherebork.com), says she sees many clients who are confused about fruit. “Many are just starting to realize that fruits are carbs, and they want to eliminate them now. I see some clients eating the produce aisle in their blender and others moderate because they’re afraid to put more in.”

Enright says she sees similar issues. “I have to educate that the sugars found in fruit are natural sources and are different from the sugars that are added to foods and beverages.”

While it’s true that the main source of calories in whole fruit is sugar, predominantly fructose, Ludwig says that those sugars are sequestered, surrounded by fiber, in the fruit’s cellular


structure. “You’d never get a surge of fructose that would take a hit on the liver or a surge of glucose that would cause a surge in insulin,” he says. “It’s the added sugars that cause a problem.”

Gabriele Riccardi, MD, FAHA, a professor of endocrinology and metabolic diseases at Federico II University in Naples, Italy, says research has shown that increased consumption of fruit and berries is associated with a lower risk of type 2 diabetes. “This is particularly true for fruit that’s fiber rich like apples, pears, kiwi, and strawberries,” he says.

Jenkins also says a healthful, lower glycemic index diet can include temperate climate fruit like apples and oranges and all sorts of berries.

MYTH 7 Sugar-Free = Carb-Free

Beth Lutton, RD, LDN, a dietitian at Mainline Medical Associ-ates in Altoona, Pennsylvania, says she has patients who don’t eat fruit or yogurt because they have a lot of sugar in them, yet they will eat pretzels or rice cakes in unlimited amounts.

Ludwig says that one of the big misconceptions about carbs, fostered in part by the old Food Guide Pyramid, is that all sugars are bad and all starches are good, because even highly pro-cessed starches were placed at the base of the pyramid, while sugars were at the top. “White bread raises insulin and glucose more than table sugar,” he says. This misconception further highlights the fact that many clients don’t fully understand what a carb is or how it behaves in the body.

MYTH 8 All Carbs Are the Same No Matter Where They Come From

Clients also may not understand that quality counts. Jones says she often hears that people with diabetes, especially those with type 1, perceive all carbs as created equal, whether they come from soda, sugary cereal, or quinoa.

“I am often discussing with clients and families the differ-ences between refined grains and whole grains,” says Suzanne Farrell, MS, RD, owner of CherryCreekNutrition.com in Denver. “I also occasionally have clients unsure about various fruits and whether some are too high in sugar. There’s also confusion about the potato and if it can be included or not in their plan.”

Jenkins says that “not all carbs behave the same way in the body,” and that many traditional carbohydrate-rich foods pro-vide health benefits because they have a low glycemic index or low glycemic load and are rich in fiber and nutrients.

“Both quantity and quality of carbohydrate foods must be considered, but the latter is more important,” Riccardi says, adding that healthful carbohydrate foods including whole grains, legumes, most vegetables, fiber-rich fruits, pasta, and low-fat dairy can be consumed without major concerns, provided indi-viduals stay within their calorie requirements.23 “Conversely, refined carbohydrate foods with a high glycemic index should be consumed in limited amounts since they’re rapidly digested and induce a sharper postprandial rise in blood glucose; this is relevant for appetite regulation and the risk of developing type 2 diabetes,” he says.

MYTH 9 All Simple Carbs Are Bad; All Complex Carbs Are Good

On the flip side, Jones says she often hears, “All simple carbs are ‘bad’ and all complex are ‘good,’ while lactose and bananas are simple and white bread is actually a complex starch.”

Just as a simple carb (sugar) may come packaged in an apple, a glass of milk, or a can of soda, complex carbohydrates (starch and fiber) also come in both whole and processed forms, and Ludwig points out that whole grain bread can be highly pro-cessed. “Whole kernel grains like buckwheat, quinoa, and wheat berries have much more nutrition and they digest more slowly.”

MYTH 10 The Glycemic Index Is All That Matters

The glycemic index has led many clients and patients to believe that it’s better to eat a chocolate candy bar than a carrot or a slice of watermelon because the candy bar has a lower glyce-mic index value. However, experts say a food’s glycemic index value shouldn’t be used in isolation, but should be considered alongside the food’s other qualities, such as calories, nutrients, and fiber, when considering the impact of diet on health. The glycemic load of the food—and the overall meal—may be more critical for supporting healthful blood sugar levels.24

Diets with a high glycemic load rapidly increase blood glu-cose and insulin levels, while diets with a low glycemic load moderate these responses, and evidence suggests that diets with a low glycemic load may be associated with lower levels of inflammation.24 While the glycemic load of the diet can be reduced by decreasing total carbohydrate intake, evidence sug-gests that restricting total carbohydrates may have adverse effects on health.18 Altering the quality of carbohydrate foods may be the smarter, more healthful move.25

One 2012 intervention study of 82 adults found that in diets with equal macronutrient compositions (including 55% from carbs), a diet with a low glycemic load resulted in lowered C-reactive protein and increased adiponectin in overweight and obese participants.26

Bearers of Truth

As nutrition experts, it falls to dietitians to be the voices of reason heard above the din. “Well-educated people are teaching their children to eat high protein and low carb because they truly think that it is a healthy diet,” says Julie Satterfeal, MS, RDN, LD, owner of Triple Braided Nutrition and Wellness (www.triplebraided.com) in Huntsville, Alabama. “Fad diet proponents/promoters are doing a better job getting their false message out than we are as the nutrition professionals. I sure hope that we can turn this around.”

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times and speaks

frequently on nutrition-related topics.



By David Yeager

Experts tell Today’s Dietitian what they think about them and how they could impact the health of Americans.

The2015–2020

DIETARYGUIDELINES

When the 2015–2020 Dietary Guidelines for Americans were released on January 7, there were some notable changes. Out are recommended limits on dietary cholesterol. In are recommended curbs

on added sugars and updated guidance on sodium intake. Overall, there’s a greater focus on dietary patterns as opposed to specific foods and food groups. In addition to offering guidance to the general public and health care professionals, the guidelines are used by federally funded programs such as the National School Lunch Program and WIC to help determine the types of foods, serving sizes, and menus that will be offered. The guidelines’ recommendations also have been incorporated into the newly revised USDA Choose MyPlate program.

Updated every five years as a joint report of the US Department of Health & Human Services (HHS) and the USDA, the stated goal of the guidelines is to “encourage Americans to adopt a series of science-based recommen-dations to improve how they eat to reduce obesity and pre-vent chronic diseases like type 2 diabetes, hypertension, and heart disease.”1 With obesity affecting more than one-third of American adults—78.6 million people—and obe-sity-related diseases ranking among the leading causes of death in the United States,2 it stands to reason that the guidelines should continue to focus on disease prevention. Whether they go far enough in advancing this cause has generated a spirited debate among health care experts.

What’s NewOne change that nearly everyone agrees is beneficial is

the recommendation that added sugars be limited to less than 10% of a person’s total daily caloric intake.3 This rec-ommendation doesn’t include naturally occurring sugars. Although people shouldn’t be surprised that they need to cut back on sugar, this is the first time specific limits for added sugars have been included in the guidelines. Because it’s a new recommendation, and current food labels don’t separate naturally occurring sugars from added sugars, some people may have difficulty discerning the difference between them, says Lisa Jones, MA, RDN, LDN, FAND, a spokesperson for the Pennsylvania Acad-emy of Nutrition and Dietetics.

“I think it’s definitely a source of confusion,” Jones says, adding that information about added sugars cur-rently isn’t on food and beverage labels. “The expectation is that added sugars will be included on food and beverage labels, but no changes [to labels] can be made until the FDA [issues its final ruling].”

Jones says dietitians can help consumers better understand this guideline by putting it in context. She adds that many people are unaware of the amounts of

added sugars in common foods. For example, many sodas, coffee-based drinks, and energy drinks can have significant amounts of added sugar. Although these drinks don’t specifically list added sugars on their food labels, most of them don’t contain ingredients with natu-rally occurring sugars.3

“In terms of translating the guideline for consumers, if you consider a 2,000 calorie diet, 10% of 2,000 calories equals 200 calories of added sugar. There are approxi-mately 200 calories in 50 g of sugar,” Jones says. “If you look at sodas, there are approximately 35 g of sugar in a 12-oz can of soda, and that puts a person close to the recommended daily intake. Even nonsoda beverages can have significant amounts of sugar, so it’s still very impor-tant to read labels.”

Caffeine, although not a nutrient, also was mentioned for the first time in the guidelines. The guidelines don’t rec-ommend caffeine consumption, but they note that moder-ate consumption in healthy adults—400 mg or less per day, between three and five 8-oz cups—isn’t associated with an increased risk of major chronic disease, such as cancer, or premature death.3 The guidelines also mention that there isn’t much data available on the health effects of energy drinks.3 Sarah Krieger, MPH, RDN, a spokesperson for the Academy of Nutrition and Dietetics, would like to see more specific guidance on caffeine in the 2020 guidelines.

“I work mainly with the under-18 crowd, so for 2020 I would love to see them mention that caffeine is not appro-priate for people under 18, and it has affected health care costs,” Krieger says. “There have been more emergency room visits because of caffeine, whether it’s in supple-ments or energy drinks. The recommendation is 400 mg or less per day,3 regardless of where you’re getting that caffeine from.”

Another change was the shift in guidance on sodium intake. The 2010 guidelines recommended 2,300 mg or less per day for adults over 14, but 1,500 mg per day or less for African Americans, people over 51, and those who have hypertension, diabetes, or chronic kidney dis-ease. In other words, the 2010 guidelines recommended that about one-half of the US population consumes 1,500 mg per day or less of sodium.4 The 2015 guidelines rec-ommend 2,300 mg per day or less for people 14 and older and 1,500 mg per day or less for people with hyperten-sion or prehypertension.3

The 2010 sodium guideline recommendations for 1,500 mg of sodium for a targeted group of people “were very specific and extreme and very hard to follow, so they changed the guideline to what it had been [before 2010]; [the 2015 guidelines are] not targeting any specific ethnic or racial or age groups. I think it’s moving in the right direction because people took offense to those


guidelines,” Krieger says. “Following a diet with 1,500 mg or less of sodium is very difficult, and these guidelines are really geared toward healthy people and food programs.”

There’s also new guidance for cholesterol and fat. The 2010 guidelines recommended 300 mg per day or less of cholesterol, which is equivalent to about two medium-sized eggs.4 The new guidelines don’t recommend any limits, but Jones and Krieger agree that people still need to be cognizant of the cholesterol-containing foods they consume.

In addition to removing cholesterol-limiting recommen-dations, the new guidelines support overall fat consumption according to levels established in the Acceptable Macronutrient Distribution Range, with a shift towards replacing less healthful fats (saturated and trans fats) with more healthful fats (unsatu-rated fats). And they continue to recommend limiting consump-tion of saturated fats to less than 10% of total calories.3 For a 2,000 kcal diet, this amounts to 200 kcal per day from saturated fat. All fats contain 9 kcal per gram so the target for a 2,000 kcal diet is approximately 22 g or less of saturated fat per day. Jones and Krieger agree with the new guideline recommendations that people should replace saturated fats, which are more prevalent in red meat and dairy products, with unsaturated fats, which are more prevalent in vegetable oils and nuts, whenever possible.

“We want to focus on consuming less saturated fat,” Krieger says. “A lot of those foods happen to have cholesterol anyway, but we don’t want to focus on cholesterol; we want to focus on limiting saturated fats.” Indeed, the 2015 Dietary Guidelines limit cholesterol intake indirectly by limiting saturated fat intake.

Perhaps the biggest change from previous guidelines is the focus on eating patterns.3 Rather than narrowly prescribing or proscribing specific foods, the new guidelines allow for variation among many different lifestyles. Jones and Krieger see this shift as a positive development that addresses the needs of a widely diverse American public, which in turn can help nutrition professionals counsel clients and patients more effectively. “One size does not fit all,” Jones says. “You have to cater to the audience that you’re speaking to.”

The guidelines suggest the following three types of eating patterns that can support the goal of disease prevention: a healthy US-style, a healthy Mediterranean-style, and a healthy vegetarian-style pattern.3 Each pattern emphasizes fruits, vegetables, legumes, nuts, and whole grains.3 The healthy US-style pattern is similar to the recommended dietary pattern from the 2010 guidelines, with a few changes added to reflect the current recommendations.3 The Mediterranean-style pat-tern contains more fruit and seafood and less dairy than the US-style pattern, and is geared toward adults because chil-dren weren’t included in the studies that were used to modify the pattern.3 The vegetarian-style pattern is based on the US-style pattern, including eggs and dairy but without the meat, poultry, and seafood.3 The vegetarian-style pattern also con-tains higher amounts of soy products, legumes, nuts and seeds, and whole grains.3

Business as Usual?The guidelines are based on recommendations from the

Scientific Report of the 2015 Dietary Guidelines Advisory Committee (DGAC). In February 2015, the DGAC submitted its scientific report to the secretaries of HHS and the USDA to undergo an evidence analysis process that included a public comment period.5 While many in the nutrition profession believe that the 2015 guidelines more accurately reflect the way Americans should eat, some health care experts believe the guidelines don’t adequately reflect the scientific findings on which they’re based. David Katz, MD, MPH, FACPM, FACP, founding director of Yale University’s Yale-Griffin Prevention Research Center, president of the American College of Lifestyle Medicine, and founder of the True Health Initiative, is among those who believe that much of the advisory committee’s work was lost in the translation. Specifically, the USDA and HHS removed the DGAC’s discussion on sustainability, stating that “because this is a matter of scope, the dietary guidelines aren’t the appropriate vehicle for this important policy conversation.” Recommendations to require labeling of added sugars and establish a percent DV also weren’t included in the final 2015–2020 Dietary Guidelines for Americans, although the FDA proposed adding this information to labels in 2014.

“The scientific [DGAC] part of this process was excellent. The big problem is the political process that diluted the final [Dietary Guidelines for Americans] report,” Katz says. “Essentially, what happened, under the influence of lobbying and politics, is that the perfect clarity and all the right messages in the Dietary Guidelines Advisory Committee Report were translated into undecipherable gobbledygook [in the Dietary Guidelines for Americans]. And it’s not that they’re wrong, it’s that they don’t say anything.”

Of specific concern to Katz is that the Executive Summary of the Dietary Guidelines for Americans states that the report will discuss foods, rather than nutrients. Although the guide-lines mention specific foods Americans should eat, they don’t


mention specific foods to avoid. Katz says this lack of specific-ity makes it difficult, if not impossible, for people to compare their potential food choices.

“It’s overt hypocrisy,” Katz says. “[Reading the Dietary Guidelines for Americans is] a sort of window into the world of clever politicians. When the official dietary guidelines talk about what we should eat, they’re quite clear. When they talk about what we shouldn’t eat, they immediately convert to nutrient-speak. ‘Cut down on your saturated fat, but we’re not going to tell you what you shouldn’t eat, and perish the thought that you should have fewer pepperoni pizzas. Cut down on your sugar intake, but we’re not going to say, ‘When you’re thirsty, drink water instead of soda,’ because our friends at Coca-Cola wouldn’t like that.’”

The few areas of the guidelines that Katz feels are worthwhile are the parts that were taken directly from the DGAC report. For example, he thinks that removing cholesterol and overall fat limits, in favor of recommending fewer saturated fats, is a good idea. He also believes that ignoring the importance of sustain-able food systems, which appeared in the original DGAC report, is a grave disservice to the public because environmental and sustainability issues will affect the nation’s ability to produce the food it needs in the coming decades. He notes that an emphasis on sustainability aligns with the opinions of many nutrition and food systems experts in North America and Europe.6

Katz and others feel that another critical omission in the 2015–2020 Dietary Guidelines is a discussion on processed and red meats, which originally appeared in the DGAC report. In October 2015, the International Agency for Research on Cancer, which is the cancer agency of the World Health Organization, published a report in The Lancet Oncology that classifies processed meat as a carcinogen and red meat as a probable carcinogen.7 By avoiding discussion on potentially unhealthful food choices, Katz feels that the Dietary Guidelines for Americans fail to serve the public interest. He feels so strongly about it that he’s posted an online petition on Change.org to change the name of the guidelines to something other than Dietary Guidelines for Americans, which he feels is a misleading name.

“Americans should be able to read these guidelines and get the best current thinking on what we should be eating for our health,” Katz says. “The best thinking about what’s good for the people and the planet should not be for sale to the highest bidder.”

Informing the PublicTo help provide the most up-to-date scientific information

to the public, Katz founded the True Health Initiative, which aims to prevent chronic disease and premature death by building a movement around the fundamentals of healthful living. Rather than deferring to policymakers, he believes nutrition experts and average citizens can use science-based research to improve public health. Although some experts

may have different areas of emphasis, he says there’s general agreement about the components of a healthful diet,8 and dietitians can play a crucial role in the conversation.

“The confusion that seems to be holding us up is pseudo-confusion, but I think common sense is enough to get us past it. The way to rally people is to focus on areas of broad agree-ment, rather than the areas of narrow disagreement. Vegans and Paleos don’t agree about everything, yet the experts in the vegan diet camp and the experts in the Paleo diet camp advocate diets that are much more alike than different. And they’re much more like one another than either is like the typ-ical American diet. I think that’s an important message that dietitians could convey to their clients,” Katz says. “Translat-ing general guidance into personal behavior requires expert coaching, and dietitians are particularly suited to offer that, but I would encourage them to refer their clients to the DGAC report, rather than the Dietary Guidelines for Americans.”

In addition to providing nutrition education and helping people understand the guidelines, dietitians also can make a significant impact by teaching essential skills. Jones says cooking and label reading are two areas where her clients often struggle.

“Some of the clients I talk to don’t even look at labels because they find them so confusing,” Jones says. “So coming up with ways to help them make that information more action-able, such as focusing on sugar and sodium for clients with diabetes, can make the labels easier to understand and use.”

Krieger says many consumers find shopping for healthful foods challenging because of the vast array of food products. She recommends teaching people how to use Choose MyPlate to develop and maintain a healthful eating style. She says Choose MyPlate is a good place to start because it’s designed to be the consumer-friendly interpretation of the Dietary Guidelines for Americans, and the website has been updated to be more user friendly. Armed with some useful nutrition information, shopping for healthful foods is much easier.

“When I grocery shop, one-half of my cart is fruits and vegetables, one-quarter of it is lean protein, whether it comes from animals or not, and one-quarter of it is whole grains. Once you start shopping that way, there’s a wide variety within those food groups,” Krieger says. “Switch it up every time you shop. The combinations are endless. Depending on ethnic cuisines or what’s in season, there are so many things to eat that we should never get bored. Eating a wide variety of many different foods is really the foundation of eating an overall healthful diet for your entire life.”

— David Yeager is a freelance writer and editor based in southeastern Pennsylvania.



There was a time when doctors’ house calls were the norm. In the 1930s, about 40% of all doctor-patient interactions were in homes. This prac-tice went by the wayside when medical insurance replaced pay-as-you-go service and malpractice insurance fees increased so much that doctors

could no longer afford to work solo, but had to band together in groups. While it remains rare for physicians to make house calls, a home health care movement is growing and the most forward-thinking institutions are including dietitians in that model.

According to the National Association for Home Care & Hospice, today approximately 12 million individuals receive health care services in their home. It’s believed that by 2020, home health care professionals will have grown by more than 1.3 million (a 70% increase), according to the Bureau of Labor Statistics. Though nursing positions have been the primary role in home care, many agencies bring in dietitians on an as-needed basis. But some are already employing them full-time.

There’s great opportunity for dietitians in the field of home health care. According to Sara Swiderski-Dandinidis, MBA, RDN, LDN, director of dietitian services for Dietitians at Home, a home-based nutrition therapy and education company based in Chicago, their dietitians work full eight-hour days seeing patients ranging in age from 30 to 100 (though most are between 65 and 80 years old). The only difference is the set-ting—it’s the patients’ homes.

“We are reviewing charts in the morning or night before we go to see the patient and then driving to our appointments for the day,” Swiderski-Dandinidis says. “We want our practition-ers to see at least six patients per day, and they usually see 100 to 120 per month. During the day you may answer calls from patients, doctors, and nurses, and you may be calling to ask doctors about the patient you’re seeing and what the plan of care goals are for that patient. Also, we have opportunities for dietitians to do presentations to groups that are interested in our services or on nutrition topics in general.”

Swiderski-Dandinidis says that pay levels can vary based on the type of position being covered. For example, home care dietitians may be paid per visit, one-half base salary and one-half compensation, or a flat salary. She adds that Dietitians at Home does a one-half base and one-half compensation pay model.

An Ever-Changing Environment Angel Planells, MS, RDN, has been working in home-based

primary care since 2008 for the VA, first in New York and more recently (since 2011) in Seattle. He works with elderly veterans who have any condition that may require the services of a dietitian. That includes obesity, diabetes, malnutrition, or sometimes just aging and the need for a better dietary plan. Planells admits it’s hard to describe a typical day since no two days are alike. Each day can bring new people and a new direction. That’s one thing he loves about his job, but he says it can be either a benefit or a drawback, depending on the person.

“Any time you walk into someone’s home—their environ-ment—you need to be prepared to think on your feet,” Planells says. “It’s very different from a clinical setting where, for the most part, you know what to expect when you walk into a room. In the home-based setting, you can’t just walk in and begin dic-tating what they need to do. It’s more important in this setting to develop a rapport first. There’s a lot more relationship building and trust that needs to be established in the home setting.”

Some tasks Planells says he may perform during a typical in-home visit include not only discussing nutrition and daily eating habits but also looking inside the patient’s pantry and refrigerator to “get an accurate snapshot of the life of the client.” Planells says he’s looking to see whether the client eats lots of fruits and vegetables or mostly processed foods. “If the client consumes a lot of processed foods, we will try to make gradual changes toward a better quality diet,” Planells says. “If the client consumes a lot of fruits and vegetables, we can provide support and encouragement for the great effort already being done.”

HEALTH CAREDietitians at the Forefront

HOME


As new health care models

that include the expertise

of dietitians continue to

develop, more opportunities

will become available for

those who want to work in

home health care.

By LINDSEY GETZ

But even before that, Planells says he focuses on relationship building, so the majority of the first visit may include just talking. Since visits are longer and there’s drive time to account for, Planells says the home health care model means seeing fewer people in one day. That’s a big difference from the clinical setting, but Planells feels a home visit can have a major impact and is incredibly valuable despite seeing fewer patients in one day.

Another big difference when working in the home care setting is that dietitians don’t have immediate access to other members of a health care team. Sarah Hults, RDN, LDN, CDE, senior dietitian with Dietitians at Home, says that in the clinical setting you have easy access to doctors and colleagues when you need to consult one another, but she says modern technology helps bridge the gap.

“We are outfitted with mobile phones and are able to still converse with doctors and our fellow dietitians,” Hults says. “We are lucky that we work with doctors who really appreciate the dietitian’s role and are always willing to take our call.”

And of course there’s the fact that going into someone’s home can—at times—feel unnerving. There’s the question of safety that dietitians don’t have to worry about in a hospital setting.

“In a clinical setting, there are police and security on staff that are always available should a patient become unruly or a provider find him or herself in a violent situation,” Planells says. “When you’re going into someone’s home, you’re going in alone. The VA offers safety training courses to prepare us. You must always be mindful of your situation, from where you park your vehicle, so that you can quickly leave if you have to, to where you stand in the home, so that you can’t be cornered or trapped.”

Sowmya Venkat, MS, RDN, LDN, senior dietitian with Dietitians at Home, agrees that it’s always a challenge to walk into the unknown. She says dietitians who provide care in the home need to be able to “think fast on their feet and have a lot of mental strength and self-confidence.”

“Our training emphasizes that safety comes first,” Venkat adds. “If you walk into a home and get this sense that some-thing isn’t right, then we’d say to trust that sense. Maybe there’s another family member in the home that seems aggressive or something about the situation is uncomfort-able—then it’s always best to leave. We’re trained to recognize a potentially dangerous situation and to trust our instincts.”

Making a Difference There’s no doubt that working directly in the home can

pose some challenges, but it also can create opportunities ripe for success. Working with patients in their own envi-ronment and developing a true sense of trust with them can open the door for real change. Swiderski-Dandinidis says that working in the home setting gives you “information at your fingertips”—and that can be invaluable when making a differ-ence in patients’ lives.

“In the acute care setting, where I worked for some time, you often question whether the information patients provide is fully

credible. Maybe the patient forgot or purposely didn’t mention certain details,” Swiderski-Dandinidis says. “But in the patient’s home, you get to see their actual environment. You can open their fridge, have access to their pantry, and can observe their lifestyle in real time. That kind of information at your fingertips can guide the process and make you much more effective.”

In the home care setting, Swiderski-Dandinidis says dietitians can address factors inhibiting progress, such as smoking, much more in-depth. While patients can’t smoke in a hospital and may even lie about the habit, it’s not so easy to hide this in the home.

“Smoking is a barrier to learning and understanding how diabetes affects the body,” Swiderski-Dandinidis says. “Sometimes, we first have to get over that barrier before we can really address nutritional changes. That’s often a conversation that comes up based on an inspection of the home, which may have never been addressed in the acute care setting.”

The ability to implement change at the home care level can be exciting and rewarding. Dianne Cabelus, RN, CNN, a nursing supervisor at Partners Health Care at Home Private Care, located in the greater Boston area, performs nutrition assessments when visiting patients in her role as a certified nurse nutritionist. She says patients often are more receptive to information in their own home and that success is more likely achieved.

“While in the hospital, patients get a lot of information thrown at them and nutrition recommendations can easily get overlooked,” Cabelus says. “But in the home, it’s easier for them to listen and easier for the health care provider to truly evaluate their situation and monitor their progress. When you see modifications actually put into play in their own environ-ment, it’s incredibly rewarding. I can see that the patient did buy that diabetic cookbook we talked about or that they redid their pantry with healthier options. You don’t get to see those changes come to fruition in the clinical setting.”

Above and BeyondAs dietitians spend time in their patients’ homes, it isn’t

uncommon for them to take on new roles. For example, Swiderski-Dandinidis says Dietitians at Home has expanded

Staff of RDs from Dietitians at Home, a home-based nutrition therapy and education company in Chicago.


the dietitian’s role to include new tasks and responsibilities for diabetes patients. She says that with the right resources and training, RDs easily can adopt additional roles that make them incredibly valuable in the home health care model.

“We have made dietitians competent in finger stick lab work, [taking] blood pressure, checking for edema, and running lipid panels, all in the home,” Swiderski-Dandinidis says. “We’re trained to assess the risk level of our patients with diabetes and we’re frequently able to prevent compli-cations as a result. We are keeping patients out of the emer-gency room because we’re recognizing risk factors and making changes.”

Julia Nicolini, RDN, LDN, sales and marketing director at Dietitians at Home, says that because dietitians working in the home care setting can look at the “big picture,” they can ensure their patients’ needs for social services are met.

“For instance, if the patient doesn’t have much food in the home, we can explore whether they’re getting Meals on Wheels or are set up with food pantries in the area,” Nicolini says. “By actually going into the home, we can ask ourselves ‘Is this person OK?’—not only from a nutritional standpoint but a social standpoint as well. Are they set up with the services they need? And if they’re not, the question becomes, ‘What calls do we need to make?’”

When working in the home, especially in ethnically diverse areas, it’s also important to consider potential language and cultural differences.

“There’s an important multicultural aspect to this kind of work,” Venkat says. “It’s important to understand what might work for a particular culture—and what might not. I speak three languages. When I see Indian patients, I’m able to con-nect with them in their language and because I understand their food and their culture, they’re able to better connect with me. Sometimes that can play a huge part in success.”

Planells says that being a “people person” may not be a skill set that’s taught, but a dietitian who is one will have more success with patients.

“An introvert can still work in the clinical setting as the level of conversation doesn’t have to go beyond small talk,” Planells says. “You can ask your questions and still get the

job done. But it would be difficult to be an introvert in the home care setting. It goes back to the importance of building relationships and trust—especially when you’re seeing the patient on an ongoing basis. In rounds, you may not be with one patient more than 20 minutes, but in the home care setting I’ve spent as much as an hour and a half in one home. It’s just a very different model.”

Room for GrowthWhen it comes to the dietitian’s role in the home health

care movement, there’s room for growth. Planells says the VA understands the role nutrition plays in overall health and wellness and as a result is invested in employing many dietitians. But the numbers of RDs in other health care organizations remain low. Nicolini says that to the best of her knowledge, of the approximately 600 home health agencies in their state, only two of those agencies have full-time dietitians.

“This concept of home health care is lacking when it comes to dietetics,” Nicolini says. “Part of the issue is that Medicare sets guidelines as to what is covered. The majority of our patients have diabetes, though we also see those with chronic kidney disease and those who are postkidney transplant, if it’s been in the last 36 months. We do hope that the future will include coverage of more diagnoses, as there are so many other conditions where nutrition can play a significant role in wellness.”

Cabelus says she would love to see more dietitians become part of the team. “Nutrition isn’t considered nearly as often as it should be in health care in general,” Cabelus says. “Most home care agencies work with dietitians on a per diem basis, but it would be great to see more of them integrated into the whole system.”

Swiderski-Dandinidis says it starts with an open mind in school. Program directors need to talk to students about home health care and discuss it as part of the future.

“With the aging baby boomer population, we do believe that home health care is the way of the future,” Swiderski-Dandini-dis says. “If the stars align, as we believe they will, more diag-noses are going to be covered by insurance, and dietitians will be seeing even more patients in their homes. Students need to start learning about this model and the required skill set early on—in school, but also in their internships.”

In the home health care model, dietitians may truly have the opportunity to shine. “I’ve always felt like dietitians should pass the baton off to each other from acute care to home,” Swiderski-Dandinidis adds. “With home health care, dieti-tians can truly challenge themselves in a big way. They have the opportunity to really make a difference and perhaps to do more in the system than they ever thought possible. We believe this is the future.”

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

An RD shows a patient how to use a glucometer in her home.

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STRESS AND WEIGHT MANAGEMENTBy Monica Lebre, MS, RDN, LDNLearn about the body’s physiological responses to stress and the effect stress has on weight control.

It’s no secret that we live in a fast-paced world. As a result of work responsibilities, demands of home life, and other everyday challenges, many people feel overwhelmed and pulled in differ-ent directions. It’s not surprising, therefore, that a 2007 poll by the American Psychological Association found that one-third of people in the United States report experiencing extreme levels of stress.1 At the same time, the obesity epidemic continues to spread. From 2011 to 2012, 69% of adults aged 20 or older were overweight or obese.2 According to the Centers for Disease Con-trol and Prevention (CDC), the rates of overweight and obesity in adults more than doubled between 1976 and 1980 and between 2009 and 2010.3 In addition, it’s well known that many individu-als reach for comfort foods to relieve stress. Given the preva-lence of stress and the rise in obesity, it’s imperative to look at the relationship between these two conditions.

Nutrition professionals are trained to understand the multi-factorial aspects of obesity. While their focus on helping clients improve eating behaviors and increase physical activity is vital for bettering overweight and obesity outcomes, research suggests that RDs’ efforts to understand the effects of stress on weight management may be equally important.

This continuing education course explores the physiological responses to stress and the effect of stress on weight management.

Stress in the United StatesStress has been defined as “the generalized, nonspecific

response of the body to any factor that overwhelms, or threat-ens to overwhelm, the body’s compensatory abilities to maintain homeostasis.”4 The American Psychological Association (APA) prepares an annual report called “Stress in America,” the most recent of which, released in February 2015, indicates an improve-ment in stress between 2007 and 2014. In 2007, participants on average rated their stress as 6.2 on a scale from one to 10, with one being little stress and 10 being high stress. In 2014, partici-pants averaged a 4.9 rating.5

Seventy-five percent of Americans reported experiencing at least one symptom of stress, such as depression/sadness, anx-iety, fatigue, and irritability, within the month before the APA’s survey.5 The causes of stress may pertain to money, work, the economy, family responsibilities, and personal health concerns.5 Studies suggest that 40% of individuals view their jobs as being very or extremely stressful.6 A report by the CDC indicates that individuals attribute more health complaints to work stress than to family problems or even financial burdens.6 Nearly three-fourths of adults, however, report feeling stressed about money at least some of the time, and nearly one-fourth say they experi-ence extreme stress about money.5

According to the CDC, many studies have identified common health complaints associated with stress, including cardiovascular disease, musculoskeletal disorders, psychological disorders, and workplace injury.6 In addition, research is under way to examine the relationship between chronic stress and weight management. More studies are needed in these areas. Given the outcomes already indicating the relationship between stress and disease

CPE MONTHLY

COURSE CREDIT: 2 CPEUs

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

1. Differentiate between acute and chronic stress and their physiological responses.

2. Evaluate the effects of chronic stress on weight.

3. Identify stress hormones and their influence on appetite.

4. Counsel clients about their perceived need for com-fort food during stress.

Suggested CDR Learning Codes 4090, 5370

Suggested CDR Performance Indicators 8.3.6, 9.6.1

CPE Level 2


states, and the emerging data suggesting a link with overweight and obesity, it’s vital that RDs educate clients on stress control to help improve their quality of life and at the same time prevent or manage overweight and obesity.

Acute vs Chronic Stress Acute and chronic stress can produce different physiological

reactions, yet both can result in an increase in hunger. During acute bouts of stress, the sympathetic adrenal medullary system mounts a response to the stressful stimuli, releasing adrenaline, a catecholamine.7 This is commonly called the fight-or-flight response. The adrenaline produces physiological effects, includ-ing elevated blood pressure, increased heart rate, and shunting of blood from nonessential organs including the kidneys, skin, and digestive system to the muscles and brain to make them better able to fight or flee.8 This form of stress response occurs most often in reaction to dangerous events such as running for one’s life or fleeing from an intense situation.

Once the acute stressful event has subsided, the hypothal-amic-pituitary adrenal (HPA) axis is activated. The HPA axis is responsible for the body’s response to chronic or prolonged stress. The HPA axis comprises the paraventricular nucleus of the hypothalamus, the anterior lobe of the pituitary gland, and the adrenal gland. In response to stressful stimuli, the hypothalamus produces corticotropin-releasing factor (also known as cortico-tropin-releasing hormone [CRH]), the primary regulator of the HPA axis. This stimulates the adrenal cortex, the outer region of the adrenal glands, to secrete adrenocorticotropic hormone, which in turn stimulates the adrenal glands to secrete the hor-mone cortisol.9 Cortisol increases appetite, which is beneficial because nutrients are expended during the physical response to the stressful event (ie, calories burned during a fleeing situa-tion). If activation of this acute stress response system becomes chronic, such as in prolonged psychological stress, secretion of cortisol also occurs. Since an actual fight-or-flight response doesn’t occur in chronic stress, there’s no resulting nutrient depletion and therefore no need for replenishment. Neverthe-less, the secretion of cortisol increases hunger, leading individu-als to consume more food, creating the potential for weight gain.

Stress Hormones and Appetite RegulationAdrenaline, also called epinephrine, is produced in the adre-

nal medulla, the inner region of the adrenal glands. Adrenaline is responsible for glycogen breakdown in the liver and fat break-down in adipose tissue to make fuel available to the heart and skeletal muscle in times of need.10 Initially, the release of adren-aline, which predominately occurs during acute bouts of stress, decreases appetite.8 This happens due to the shunting of blood from the digestive system to areas with more immediate need.

When adrenaline production decreases after the acute stress-ful event, cortisol production increases.11 Cortisol, produced in the adrenal cortex, is known to stimulate appetite and is thought to be especially important after fight-or-flight situations to replen-ish calories expended during the event.

Cortisol is involved in the metabolism of carbohydrates, protein, and fats. It’s the body’s main glucocorticoid, the principal hormone involved in stress regulation.10 It’s considered the primary culprit in stress-induced weight gain as it is responsible for increased hunger after stress, whether acute or chronic.10 The possibility that cortisol levels are related to obesity and metabolic disease was first recognized during clinical assessments of patients with Cushing’s syndrome, a condition in which an individual has high levels of cortisol.12 Upper body obesity was observed in patients who had chronically elevated cortisol levels.13

Cortisol secretion and the HPA axis appear to be directly corre-lated. It’s thought that a chronic activation of the HPA axis, possibly due to a secretion of CRH, results in chronic secretion of cortisol, which increases appetite and the potential for weight gain.14,15

CRH is secreted by the paraventricular nucleus of the hypo-thalamus in response to stress.9 It initially decreases appetite; however, this isn’t a long-term effect as cortisol is released shortly after the stress-inducing event, resulting in a subsequent increase in appetite.16 George and colleagues assessed the effect of an injection of CRH on food intake in a double-blind, placebo-controlled study involving 14 healthy, nonobese individuals. Eight participants were given the placebo, a saline injection, while six were injected with CRH. Subjects were then presented with snack baskets containing high-fat sweet snacks, high-fat salty snacks, low-fat sweet snacks, and low-fat salty snacks. Analysis of particular snack consumption wasn’t assessed; the goal was to assess the total consumption after the injection and placebo. Subjects that had been injected with CRH had markedly elevated cortisol levels compared with those who received the placebo. Those injected with CRH also ate more compared with those in the placebo group. Peak cortisol levels were directly related to both caloric intake and food consumption.17

This study suggests that elevated cortisol levels as a result of CRH injections lead to increased total food consumption and overall total caloric intake. The study findings highlight the poten-tial role elevated CRH and cortisol may play in contributing to an increase in obesity. Although its sample size was small, this study adds to research findings indicating a link between CRH, the HPA axis stress response system, and eating behaviors.17

The hormones ghrelin and leptin, which play a significant role in appetite regulation, aren’t considered stress-response hor-mones, but they do warrant attention. Ghrelin, a hormone produced mainly in the stomach, is involved in the stimulation of hunger. It generally increases before meals and decreases after meals.10

Come to the Today’s Dietitian 2016 Spring Symposium!

Register until April 15 for $349!TodaysDietitian.com/SS16


CPE MONTHLY

Leptin, which is secreted from adipose cells, decreases appe-tite and increases energy stores. Ghrelin and leptin are antago-nists in appetite regulation; ghrelin increases appetite and leptin decreases it. Although the mechanism isn’t well understood, leptin is thought to have an effect on increasing CRH.10

Rouach and colleagues designed a study to assess whether ghrelin is associated with an increase in food intake in individuals under stress.18 Twenty-four subjects—16 women and eight men—were divided into three groups: an obese group, a normal-weight group, and an obese group with a history of binge eating disorder. The study aimed to be consistent with the ratio of men to women within each group. All three groups were tasked with the same stressor activity—a speech for a job interview, recorded to increase the pressure and add to the psychological stress. Subjects were then asked to complete a questionnaire about their urge to eat before and after the stressful event. Ghrelin blood samples were obtained before and immediately after the stressful event, as well as 20, 40, and 60 minutes afterward. All groups reported more subjective perceived stress after the stress test. There was an increase in blood pressure in all subjects, but heart rate remained stable and even decreased toward the end of the stressor. Most subjects denied an urge to eat before and after the stressful event but those who did have an urge to eat tended to be in the obese with binge eating disorder group. Cortisol levels were tested and found to be elevated in 13 of the 24 individuals who were classi-fied as “cortisol responders.” Ghrelin levels increased in cortisol responders but not in the cortisol nonresponders.18

The study is the first to indicate that psychological stress increases ghrelin levels, but Rouach and colleagues indicate that more research is needed to assess the correlation between ghre-lin and cortisol.18 This study suggests that the increased associa-tion between such hormones might increase appetite, and, thus, intake, resulting in potential weight gain in stressful situations.

Stress and Comfort EatingIn addition to the physiological response to stress, it’s equally

important to consider how individuals cope with stress. Thirty-three percent of Americans report eating too much and/or eating unhealthful foods as a result of high stress.5 Although findings have been mixed, some studies suggest that stress may lead to an increased intake of comfort food, which generally may be classified as high in fat and calories yet low in nutrient density.19,20

Some human studies have shown positive correlations between stress response and an increased consumption of high-calorie, high-fat foods. A 2003 study by Ng and Jeffery explored the asso-ciations between stress and diet, and physical activity and smok-ing.19 The study relied on data from a research trial on smoking cessation in workplaces involving 6,620 women and 5,490 men in 26 worksites in Minnesota. Each participant was asked to com-plete a survey related to stress, fat consumption, physical activity, smoking, and alcohol use. Results suggest that individuals who had a higher rate of perceived stress had a higher fat intake and generally performed less physical activity. In this study, there was no significant difference in outcomes between men and women.19

In another study, 68 men and women were recruited from the University of London to take part in a study of perceived hunger associated with a stressful stimulus.20 The partici-pants in the intervention group were led to believe they would be participating in a speech presentation. The control group, for the same duration, was given a nonstressful task of listen-ing to emotionally neutral text. The researchers’ goal was to assess how the level of stress would affect food intake. Study participants were all generally healthy, nonobese individuals, equally and randomly divided into the control and intervention groups. Participants were asked to avoid food for four hours before the study to elicit hunger. Before being offered food, each group was provided with pictures of the foods to be consumed to assess appetite ratings on the different varieties of foods. Each group was then allowed to eat freely for 15 minutes from a buffet lunch. The foods pictured and available at the buffet lunch included bland high-fat and low-fat foods, sweet, and salty foods. Results indicated that there was no significant dif-ference between the intervention and control groups in amount of total food consumed. The participants rated the photos to indicate which they most desired, revealing that high-fat sweet foods were the most liked and salty low-fat foods were the least liked. Self-reported stressed emotional eaters were noted to consume more sweet high-fat foods and a more calorie-dense meal compared with the unstressed and nonemotional eaters.20 This suggests that although there was little difference in the overall amount of intake, emotional eaters gravitated toward high-fat and high-sweet snack foods.

Another study by Wardle and colleagues assessed the rela-tionship between high- and low-workload stress periods and food intake, while also assessing whether the participants’ tendency to restrict eating behaviors affected food intake during periods of stress.21 Participants were recruited from a large department store in London. A total of 90 individuals took part in the study; 71 participants completed all four assessments.

The first assessment consisted of a standardized question-naire to evaluate restrained eating as well as a 24-hour food recall; the other three assessments evaluated a 24-hour recall, each participant’s weight, and ratings of subjective stress and emotional well-being. Assessments were completed at varying times of the year. The 24-hour recall was completed with the assistance of a dietitian. The dietary data indicated a modest increase in energy, fat, and sugar intake in periods of high-workload stress compared with low-workload stress. In addi-tion, results indicated that restrained eaters (who were mostly women) not only ate more overall but also ate more sweet and high-fat foods in the high-workload stress session. The results of this study found that individuals tend to choose large food quantities, specifically sweet and fatty foods, when under high amounts of perceived stress.21

While studies of humans yield variable results with respect to stress and food intake, animal studies consistently show increased food intake in response to stressful stimuli.22,23 Several animal studies have assessed appetite stimulation from perceived acute


and chronic stress. Studies indicate that severe stressors decrease appetite and food intake while mild stressors are dependent on the type of food provided. For example, researchers found that if mildly stressed rats were presented with a highly palatable food (in this case sweetened milk) and their regular rat chow, they were more likely to consume the highly palatable food than they were to consume their regular rat chow.14,15 This suggests that animals in chronic stressful situations might experience increased appetite for sweetened or higher fat foods.

These studies lend credence to the suggestion that individuals who eat under stress may have a desire for higher calorie, higher fat foods. There’s limited long-term research to assess the rela-tionship between weight gain and dietary habits related to stress response, but the findings of existing studies suggest that these individuals would be at a higher risk of weight gain given the caloric density of their overall dietary intake. In addition, those who choose high-calorie, high-fat snack foods in addition to their regular meals may experience weight gain given the excess calories.

Stress and Gender DifferencesAlthough most of the previously mentioned studies related to

stress eating indicate no significant difference when accounting for gender, some studies have shown there’s a difference in weight gain related to stress between men and women. According to the APA, women generally report a higher level of stress than men: 5.2 vs 4.5 on a 10-point scale in 2014 vs 6.3 vs 6 in 2007, respec-tively.5 In addition, women who say their stress is high, particularly when involving money, are more likely to report they engage in sedentary or unhealthful behaviors to manage their stress. Some of these reported activities include watching television/movies for more than two hours per day, surfing the Internet, napping/sleeping, eating, drinking alcohol, or smoking.5

Vicennati and colleagues performed a retrospective study to assess how a stressful event influenced weight gain among three groups of women.24 The study looked at women who rap-idly gained weight after a stressful event, women who devel-oped obesity unrelated to a stressful event, and a control group of healthy-weight women. The study measured their anthro-pometric, metabolic, and hormonal status, including insulin, 24-hour urinary free cortisol, and sex hormones. Three groups were observed: 14 women in the stress-related obesity group, 21 women in the nonstress-related obesity group, and 21 healthy-weight women in the control group. All women were premeno-pausal and of similar age.

The study revealed no significant difference in anthropomet-rics, the age at which weight gain began, or body weight before weight gain among the stress-related and the nonstress-related groups. Weight gain results indicated that the women in the stress-ful event group gained weight faster and at a higher rate than did the nonstress-related group. Women in the stress group also had higher levels of 24-hour urinary free cortisol, which resulted in a significant correlation between the urinary free cortisol and the time and amount of weight gain. The 24-hour urinary free cortisol excretion rate is used as a measure of HPA axis activity.

Therefore, given the elevated 24-hour urinary free cortisol, this study further emphasizes that the prolonged stress-related hyper-activity of the HPA axis can affect weight gain and thus result in obesity.24 These results may indicate that the HPA axis is affected by sex hormones, but more studies also are needed in this area.

In another study, Barry and Petry set out to assess the rela-tionship among BMI, gender, and stressful life events using the National Epidemiological Survey on Alcohol and Related condi-tions, a survey taken by the National Institute on Alcohol Abuse and Alcoholism to assess data related to alcohol and a range of comorbid disorders.25 The survey’s target population included noninstitutionalized US civilians aged 18 or older from all 50 states and the District of Columbia. Data were collected between 2001 and 2002 to assess the prevalence of alcohol use and associated physical and emotional disturbances.

Stressful life events were divided into the following four cat-egories: health, job, social, and legal. A total of 43,093 individu-als responded to the survey with a resultant 41,217 respondents after exclusions. Individuals who were pregnant or didn’t provide their height and weight, making it impossible to calculate their BMI, were excluded from the study. Of the 41,217 participants included in the study, 23,058 were women and 18,159 were men. The researchers found an association between an increased number of stressful life events and an increase in BMI in both men and women. Women who were moderately overweight were more likely than normal-weight women to experience several stressors; among men, increased stressors were noted only in the obese and extremely obese BMI categories.25 This study supports the idea that women with more stressful life events are more likely to be overweight or obese compared with their normal-weight peers. In addition, the study supports the idea that women may be more susceptible to overweight and obesity compared with men.

These studies suggest that physiological and emotional stress factors may contribute to obesity among both men and women. Further research in this area may provide insight into strategies to combat obesity, focused on methods for coping with stress and limiting emotional stress eating.

Putting It Into PracticeTo help their clients, dietitians must be aware of all factors that

affect weight management, including stress. RDs should focus primarily on recommending a healthful, balanced diet, rich in nutrient-dense, plant-based foods and naturally occurring anti-oxidants, and encouraging exercise as the main focus of weight management. However, it’s important for nutrition professionals to assess stress when completing a nutrition assessment and evaluate how it may affect an individual’s dietary habits. It may be prudent to discuss with clients the importance of stress man-agement in attaining their weight management goals.

During the nutrition assessment, if comfort eating to relieve stress is an identified issue, methods to combat emotional eating should be discussed within the RD’s scope of practice. Such methods could include encouraging mindful eating, attempting


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calming activities appropriate to the specific individual, encour-aging nonfood activities as distractors from stress, as well as ensuring adequate sleep.

According to the APA report “Stress in America,” activities that individuals report using to manage stress include listening to music, exercising or walking, watching television, reading, and spending time with friends and family.5 RDs not only can be instrumental in helping clients find alternate nonfood activities to manage stress, but also can continue to encourage such activi-ties during follow-up appointments.

Furthermore, RDs should maintain a multidisciplinary network so they can refer clients to other health care professionals who specialize in stress management and can help them meet their long-term weight-management goals.

Complex FactorsThe physiological and psychological aspects of stress on weight

gain are complex and multifactorial. Recent research has pro-vided insight into how stress affects weight management, but more research is needed to further assess the extent to which high psychological stress levels may influence weight gain and, more important, individuals’ long-term weight management goals. The RD is in a unique position to help clients apply research find-ings to meet weight management challenges.

— Monica Lebre, MS, RDN, LDN, is a private practitioner in Massachusetts and an adjunct lecturer

at Northeastern University and Bridgewater State University. She’s also a consultant and freelance writer

specializing in weight management.

References1. Stress tip sheet. American Psychological Association web-

site. http://www.apa.org/news/press/releases/2007/10/stress-tips.aspx. Updated October 5, 2007. Accessed July 13, 2015.

2. Obesity and overweight. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/fastats/obesity-overweight.htm. Updated September 30, 2015. Accessed December 2015.

3. Prevalence of overweight, obesity, and extreme obesity among adults: United States, trends 1960-1962 through 2009-2010. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/data/hestat/obesity_adult_09_10/obesity_adult_09_10.htm. Updated September 13, 2012. Accessed July 13, 2015.

4. Sherwood L. Human Physiology: From Cells to Systems. 4th ed. Boston: Cengage Learning; 2001.

5. American Psychological Association. Stress in America: paying with our health. https://www.apa.org/news/press/releases/stress/2014/stress-report.pdf. Published February 4, 2015. Accessed February 5, 2015.

6. Stress … at work. Centers for Disease Control and Pre-vention website. http://www.cdc.gov/niosh/docs/99-101/.

Updated June 6, 2014. Accessed January 10, 2015.7. Cohen JI. Stress and mental health: a biobehavioral per-

spective. Issues Ment Health Nurs. 2000;21(2):185-202.8. Halford JC. Pharmacology of appetite suppression:

implication for the treatment of obesity. Curr Drug Targets. 2001;2(4):353-370.

9. Smith SM, Vale WW. The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine response to stress. Dialogues Clin Neurosci. 2006;8(4):383-395.

10. Medeiros DM, Wildman REC. Advanced Human Nutrition. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2013.

11. Takeda E, Terao J, Nakaya Y, et al. Stress control and human nutrition. J Med Invest. 2004;51(3-4):139-145.

12. Cushing syndrome. MedlinePlus website. https://www.nlm.nih.gov/medlineplus/ency/article/000410.htm. Updated November 7, 2013. Accessed August 25, 2015.

13. Nieuwenhuizen AG, Rutters F. The hypothalamic-pituitary-adrenal-axis in the regulation of energy balance. Physiol Behav. 2008;94(2):169-177.

14. Rowland NE, Antelman SM. Stress-induced hyperphagia and obesity in rats: a possible model for understanding human obesity. Science. 1976;191(4224):310-312.

15. Wallach MB, Dawber M, McMahon M, Rogers C. A new anorexigen assay: stress-induced hyperphagia in rats. Pharmacol Biochem Behav. 1977;6(5):529-531.

16. Spencer SJ, Tilbrook A. The glucocorticoid contribution to obesity. Stress. 2011;14(3):233-246.

17. George SA, Khan S, Briggs H, Abelson JL. CRH-stimu-lated cortisol release and food intake in healthy, non-obese adults. Psychoneuroendocrinology. 2010;35(4):607-612.

18. Rouach V, Bloch M, Rosenberg N, et al. The acute ghre-lin response to a psychological stress challenge does not pre-dict the post-stress urge to eat. Psychoneuroendocrinology. 2007;32(6):693-702.

19. Ng DM, Jeffery RW. Relationships between perceived stress and health behaviors in a sample of working adults. Health Psychol. 2003;22(6):638-642.

20. Oliver G, Wardle J, Gibson EL. Stress and food choice: a laboratory study. Psychosom Med. 2000;62(6):853-865.

21. Wardle J, Steptoe A, Oliver G, Lipsey Z. Stress, dietary restraint and food intake. J Psychosom Res. 2000;48(2);195-202.

22. Harris RB, Zhou J, Youngblood BD, Rybkin II, Smagin GN, Ryan DH. Effect of repeated stress on body weight and body composition of rats fed low- and high-fat diets. Am J Physiol. 1998;275(6 Pt 2):R1928-R1938.

23. Martí O, Martí J, Armario A. Effects of chronic stress on food intake in rats: influence of stressor intensity and duration of daily exposure. Physiol Behav. 1994;55(4):747-753.

24. Vicennati V, Pasqui F, Cavazza C, Pagotto U, Pasquali R. Stress-related development of obesity and cortisol in women. Obesity (Silver Spring). 2009;17(9):1678-1683.

25. Barry D, Petry N. Gender differences in associations between stressful life events and body mass index. Prev Med. 2008;47(5):498-503.


CPE Monthly Examination

1. Which of the following conditions have been most closely associated with stress?

a. Renal diseaseb. Cardiovascular diseasec. Thyroid diseased. Cancer

2. Which of the following do most individuals report being one of their biggest stressors?

a. Health concernsb. Friends and familyc. Job/careerd. Lack of sleep

3. What system is responsible for the “fight or flight” response?

a. The hypothalamic-pituitary adrenal (HPA) axisb. The sympathetic adrenal medullary systemc. The endocrine systemd. The cardiovascular system

4. What system is primarily responsible for the effects that take place in the body during chronic stress?

a. HPA axisb. Sympathetic adrenal medullary systemc. Endocrine systemd. Cardiovascular system

5. Which hormone is considered part of the stress response?

a. Cortisolb. Leptinc. Norepinephrined. Ghrelin

6. Which hormone is known to increase appetite?a. Corticotropin-releasing hormone (CRH)b. Adrenalinec. Leptind. Ghrelin

7. Which hormone is known as the primary regulator of the HPA axis?

a. Cortisolb. CRHc. Leptind. Adrenaline

8. In the Ng and Jeffery study, participants with higher perceived stress did which of the following compared with their nonstressed peers?

a. Consumed more sweet foods b. Consumed more high-fat foodsc. Consumed fewer high-fat foods d. Consumed more total calories

9. In the Oliver and colleagues study, which assessed hunger associated with stressful stimuli, participants who classified themselves as emotional eaters preferred which of the following?

a. Salty foodsb. High-fat foodsc. High-fat, sweet snack-type foodsd. Sweet foods

10. What is a potential cause for chronic stress and weight gain?

a. Chronic activation of the HPA axisb. Low calorie intakec. Low cortisol levelsd. Low ghrelin levels

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.

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].


EXERCISE AS AUTISM THERAPYBy Jennifer Van Pelt, MA

April is National Autism Awareness Month. I’ll be reviewing some recently published evidence supporting the benefits of some types of exercise for children and adolescents with autism spectrum disorder (ASD). I’ll also discuss some recent fitness trends for those with ASD, including dedicated gyms and spe-cialized trainer certifications.

The National Institute of Mental Health defines ASD as a group of neurobiological and developmental disabilities characterized by social, communication, and behavioral symptoms, including the following: • persistent deficits in communication and social interactions

across multiple contexts;• restricted, repetitive patterns of behavior, interests, or

activities; • repetitive or ritualistic movements, postures, or sounds

(referred to as stereotypy, eg, body rocking);• presentation of symptoms in the early developmental

period (ie, the first two years of life); and• clinically significant impairment in social, occupational, or

other important areas of functioning.1

The word “spectrum” refers to the wide range of symptoms, functional skills, and levels of impairment that can occur in ASD; some children may have only mild expression of the above symptoms, while others may be severely disabled.

According to the Centers for Disease Control and Prevention, ASD occurs in one in 68 births in the United States. From 2000 to 2010, the prevalence of ASD in American children increased by almost 120%, making it the fastest growing developmental dis-ability. ASD is approximately five times more common among boys than girls.2

Prevalence of ObesityAmerican youth with ASD have a greater risk of overweight

and obesity than other children, and this risk continues into adulthood. American teens with autism are more than twice as likely to be obese as those who don’t have a developmental disorder. A large study demonstrated that adolescents with a

developmental disorder and obesity had the highest prevalence of common respiratory, gastrointestinal, dermatological, and neurological symptoms.3

The reason overweight and obesity are more prevalent among children and adolescents with ASD is because they face many barriers to regular exercise. Some of these barriers—accessibility of children’s fitness programs/facilities, cost, and time—are no different from other children. But symptoms of ASD add to those barriers. Motor issues, like low muscle strength, poor balance, and gait irregularities, can make participation in simple exercise activities, such as walking or bouncing on a trampoline, very challenging. Social anxiety and difficulty with social communication and interaction can prevent playing sports or participation in games with other children.

The benefits of regular appropriate exercise for youth with ASD go beyond weight loss and improved physical health. Recent studies have shown that some types of exercise also can improve ASD symptoms and behaviors. A January 2016 systematic review of 13 published studies on exercise interventions in children aged 16 or younger with ASD evaluated behavioral outcomes associated with different types of activities. The researchers found that jogging, horseback riding, martial arts, swimming, yoga, and dance improved some ASD behavioral symptoms, such as stereotypy, social-emotional functioning, attention, and cognition. Horseback riding and martial arts had the greatest effect. The researchers caution that different exercise activities may have different effects for each individual, depending on the type and severity of symptoms. For instance, martial arts training may appeal to children with ASD who thrive on structure, while jogging and swimming may not provide enough structure. However, jogging and swimming, which are more solitary, may appeal to children for whom social interaction is challenging.4

Finding appropriate activities and settings for regular exercise for children and adolescents with ASD may be challenging, especially if symptoms necessitate one-on-one supervision and instruction. However, fitness opportunities for this special population are steadily increasing.

Fitness Facilities AvailableIn May 2014, the first-ever dedicated fitness center specializing

in training clients with ASD opened its doors in Florida. The ASD Fitness Center was constructed as a completely sensory-friendly environment, with lighting, flooring, and color scheme designed to be calming and inviting to those who might be overstimulated by the bright colors that are typical in many youth fitness center settings. The 5,000-square-foot fitness center offers one-on-one personal training, as well as adaptive karate, yoga, cardio, and hip hop dance classes for children, adolescents, and young adults with ASD. The center also offers personalized individual fitness programs and optional goal-setting for nutrition and functional skills. All trainers and class instructors have a background in special education. A separate workout is available for parents and guardians while ASD clients are exercising. Additional information is available at their website, www.asdfitnesscenter.com.

FOCUS ON FITNESS


Some children with ASD may prefer settings with more varied activities that still offer exercise opportunities. A franchise, We Rock the Spectrum (www.wrtsfranchise.com), has more than 30 facilities across the United States and offers a variety of activities for children with ASD. Dubbed a “sensory gym,” We Rock the Spectrum centers feature occupational therapy-based equipment to work on different areas of the body and different skills. The facilities offer yoga and dance classes, and some of the sensory equipment, such as trampolines, monkey bars, and ziplines, can provide physical conditioning for ASD children. Arts and crafts activities also are offered.

ASD Fitness and We Rock the Spectrum are only two of the many fitness options available for children and adolescents with ASD. Recently, predesigned fitness programs and ASD fitness consultants also have emerged in the field of ASD fit-ness to assist with program implementation in schools, com-munity centers, and at home.

Opportunities for CertificationsSpecialized fitness trainings and instructor certifications

for special needs clients are also now available. The Ameri-can College of Sports Medicine (ACSM), in collaboration with the National Center on Health, Physical Activity and Disabil-ity, offers the Certified Inclusive Fitness Trainer (CIFT) certi-fication. This program trains fitness professionals to assess, develop, and implement individualized exercise programming for healthy or medically cleared individuals with physical, sensory, or cognitive disabilities. CIFTs learn safe, adapted exercise techniques, current Americans with Disabilities Act policies relevant to recreational facilities, and standards for facility design. According to the ACSM, CIFTs typically work in public health and community settings, but opportunities in dedicated ASD gyms are now becoming more common. Additional information can be found at certification.acsm.org/specialty-certifications.

Eric Chessen is considered the leading expert in ASD fitness. His website, Autism Fitness (autismfitness.com), provides numerous resources for fitness professionals and parents interested in exercise for children with ASD. He also offers in-person and online/Skype training for fitness professionals in ASD fitness program design and delivery.

As the prevalence of ASD continues to rise, expect more research to be published that helps to refine exercise rec-ommendations for youth with ASD. And, expect fitness facilities and programs dedicated to serving clients with ASD to also increase in number.

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

Pennsylvania area.

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MAYE MUSKModeling Healthful Habits and Striking the Perfect PoseBy Juliann Schaeffer

Maye Musk, MS, RDN, is no stranger to success. She has run a busy nutrition practice for the past four decades while living in eight cities and three countries, including South Africa. Musk is also a teacher and speaker and relays healthful messages to consumers in various media-related capacities. She has embraced social media as a means to reach the masses by being active on Instagram, Twitter, and YouTube, among other outlets.

For her nutrition expertise and entrepreneurism, she was awarded with the Outstanding Nutrition Entrepreneur Award in 2006. And she continues to speak on important nutrition issues to companies, hospitals, and universities the world over.

For the past 50 years, she also has worked as a professional model—and a successful one at that. As a model, she’s flown across the world for various gigs in Munich, Amsterdam, Cape Town, and the Bahamas. Notably, she’s the first dietitian to appear on a cereal box and she graced the cover of New York magazine in 2011, where she posed for what turned out to be a controversial photo that portrayed her as, seemingly, naked and pregnant. She was 63 at the time.

Not to mention she has raised three successful chil-dren, one of whom is Elon Musk, billionaire CEO of SpaceX and electric car man-ufacturer Tesla. Is achieve-ment in their genes? It seems plausible, but Musk assures she has worked hard for every bit of her success, and the same goes for her children. One thing is for sure: Her pace has yet to brake.

If you didn’t know her, you may be inclined to assume that Musk’s modeling career somewhat has dwindled, now that she’s in her 60s. You might think she’d be focusing solely on her nutrition practice these days. Not so—not even close.

Musk’s modeling business is booming. “Due to the high demand for women represent-

ing the 60s age group in the modeling industry, my workday changes day by day as I model for editorial, print, or runway jobs while balancing bookings for media interviews and pre-sentations,” she says.

You also may presume that her slim figure comes nat-urally. Turns out, as you’ll read below, she works at that, too. And she sees a great deal of importance in keeping up appearances, not just for models but RDs as well, for the sake of confidence.

“We can’t fight genetics, but we can change environmental influences,” she says. “We need to eat well, be active, look good, and show confidence.”

Musk sees a polished appearance as a necessity in today’s nutrition industry—and media work as a necessary means to educating consumers on what real nutrition experts look like.

“RDs or RDNs should be spending a great deal of their time doing media work so the public will know we’re the experts in nutrition,” she says. “Let people know what a great profession we are.”

Today’s Dietitian (TD): What do you enjoy most about your job or dietetics in general?Musk: My self-employed dietetics career has given me flex-ibility and enabled me to work in three countries (rewrit-ing dietetic registration exams) and eight cities. Having my own practice and scheduling my talks and travels also has allowed me to continue modeling for more than 50 years.

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TD: Who or what inspires you and keeps you motivated? Musk: I wake up every morning excited to learn more and explore business opportunities. I still see many more challenges, which I find exciting.

TD: How has your modeling career either changed or helped to mold your approach to nutrition counseling?Musk: As a model, I have to maintain my weight. This is not easy, as I have to eat well most of the time. There’s always pressure to resist temptation. When I give in and overeat, my weight shoots up by 2 lbs overnight. This takes two weeks of perfect eating to lose the 2 lbs. I’m a perfect size six, which is big as a model but acceptable for my age. I was a plus-size model and overweight dietitian for 10 years. Although I seemed happy, waking up in the morning and having nothing fit made me sad. I remember that feeling when I wanted to overeat, and how difficult it was to lose a lot of weight, so I use strategies and willpower to resist temptation.

TD: From running nutrition businesses in eight cities and three countries, did you find that your approach or style changed based on where you were working? If so, please explain. Musk: In South Africa, my clients weren’t fooled by quick-fix diets; they knew it was a long and hard process. In Canada and the United States, more time is needed to listen to clients, as they really want instant success. All around, the problem is the same though—too much of eating the wrong food, which needs to be replaced by meal and snack plans to help control hunger and fullness.

TD: Do you have a nutrition mentor?Musk: I do not. I started my practice at the age of 22 and there was no one to guide me. However, I’ve met many wonderful dietitians and each one has given me some good ideas and motivated me.

TD: Your book, Feel Fantastic, is described as a complete encyclopedia of good health habits. What’s the most important health habit, from your perspective, that you wish everyone would adopt today?Musk: Eat more fruits and vegetables. It sounds easy, but no

one does that. When you’re full of nutritious, high-water foods, you don’t have that much room for fatty and sweet foods.

TD: Proudest career accomplishment?Musk: Being acknowledged by my American peers for the Outstanding Nutrition Entrepreneur Award in recognition of Excellence in Entrepreneurism and Dedication to the Field of Nutrition.

TD: What five items are always in your kitchen and why?Musk: Fruits, vegetables, legumes, dairy, and cereal are a must for my kitchen. I love these foods because they’re high in nutrients and keep me full.

TD: Favorite food or food custom from a country you’ve lived in?Musk: In South Africa, when go into someone’s home, you’re always offered a cup of tea. I miss that welcoming gesture.

TD: What foods do you crave?Musk: I crave sweet foods, so I never have them around. When I go out for dinner, I never order dessert. However, if someone else does, I warn them that I’ll finish it before they can even touch it.

TD: What’s your preferred form of physical activity?Musk: I’ve never been good at sports. I don’t like being active and find it boring. I force myself to go to the gym for 30 minutes on the stationary bike while working on Instagram, and then do weights and stretches while watching the news. I also walk my dog four times a day while checking e-mail.

TD: What activities or enjoyment fills your downtime?Musk: I love spending time with my children and grandchil-dren. They are so much fun! I also like to watch TV at night. My dog will call me to my bed if I’m on the computer.

TD: Best tip for eating healthfully while traveling?Musk: Plan ahead. I always pack nuts and dried fruit so I don’t get hungry. Hunger is dangerous. Besides becoming irritable, you also grab the nearest food, which is never healthful.

TD: What’s something most people might be surprised to learn about you?Musk: People are always surprised that I’m not naturally slim. No, I’m not! Please admire me for keeping my weight down. It’s a daily and hourly challenge. Also, I speak four languages: English, Afrikaans (Dutch), French, and German.

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

contributor to Today’s Dietitian.

“ We can’t fight genetics, but we can change environmental influences. We need to eat well, be active, look good, and show confidence.”


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Sunday, May 15

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12:00 PM – 3:30 PM WRITING WORKSHOP: From Practice to the Page Constance Brown-Riggs, MSEd, RD, CDE, CDN, and Tamara Jeffries, MFA

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All Are Not the SameDietary Variations Among Hispanics and Latinos with Diabetes

Nilda Benmaor, MS, RDN, CDE

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NEWS BITES

Emojis May Help Reduce Kids’ Food Waste

Those expressive faces in text messages may do more than tell someone you’re ROTFL. Sensory analysis researchers at Kansas State University Olathe believe the icons also may reduce the amount of food thrown away during school lunches by knowing whether kids feel :) or :( about the meal.

Marianne Swaney-Stueve, PhD, a research assistant pro-fessor of human nutrition and manager of the Sensory and Consumer Research Center at K-State Olathe, and Katy Gallo, a Kansas State University doctoral student in human nutrition based in Fairfield, Connecticut, are using emoji faces—icons used with smartphones and electronic communication—as a way to measure the emotions kids feel about certain foods.

“Kids tend to be very positive,” Gallo says. “Even if they say they like a food, that doesn’t guarantee they’re going to eat it or choose to order it from a menu. We really wanted a way to look at the emotions associated with the foods kids are inter-acting with beyond whether or not they like something. We also wanted to give them some terminology to help them explain their response to food.”

The project began when a company that makes school lunches contacted Swaney-Stueve about conducting sensory analysis research that would help reduce the amount of food grade school students threw away from school lunches.

Swaney-Stueve and Gallo believe emojis may offer a stan-dardized way of measuring the emotions kids feel about foods as well as capture a level of satisfaction about a food that a child may be unable or unwilling to fully express.

To measure these emotional responses, researchers are surveying kids from local schools about certain foods. During small focus groups with children aged 8 to 12, researchers asked kids how their favorite food made them feel. Reponses included “happy” and “guilty.” When asked about foods they didn’t like, responses included “sad,” “angry,” and “disappointed.”

Participants also sampled foods, including plain oatmeal and Japanese soda, and shared their thoughts using an extensive list of words or emoji faces believed to be appro-priate for kids and food. A subset of emojis and emotion words were selected based on kids’ frequency of use and to avoid redundancy.

Research is now being conducted in Olathe, Kansas, to compare the use of these emojis and emotion words on foods such as baby carrots, fresh spinach, cheese cubes, orange juice, chocolate-flavored Teddy Grahams, white bread, white grapes, and lychee-flavored gummy candies. This will help refine the emotion questionnaire using emojis and words that were most applicable to this age group.

Swaney-Stueve and Gallo are finding that often it’s the emojis, though, that are helping the taste testers articulate their feelings.

“Some of the things we noticed in these focus groups are that the kids are making a face or saying things like ‘blech’ and that they don’t necessarily know what word attaches to those reactions,” Gallo says. “However, we’ve seen that many can look at an emoji and feel that a certain face shows what they’re trying to convey.”

Researchers also asked participants about their thoughts on the word- and emoji-based ratings.

Older participants tended to use emojis more than words, particularly later in the day. Researchers hypothesized this was because they were tired of using words after school and were very familiar with texting applications. Others favored emojis because they said the faces could express emotions they didn’t have words for and that the words on the list didn’t capture how they felt. Kids who were well-read, though, felt the emojis were too ambiguous and preferred to use words for their responses, Swaney-Stueve says.

In addition to polling American children, Swaney-Stueve and Gallo are working with the University of Ghana in Africa. They’re polling students at 10 different schools in Accra, Ghana, about their emotional response to foods to examine whether cultural differences exist.

The first test looked at students’ responses to the snack packs containing a crackers and cheese food product. Most kids expressed disgust based on the snack’s appearance but later expressed disappointment that Ghana didn’t carry the product after taste testing it.

Swaney-Stueve has found that students in Ghana are familiar with emojis and frequently used them in their responses. Based on the preliminary tests, emojis may offer a standardized, universal system for sensory analysis researchers, she says.

“Language is really nuanced and one word may mean something slightly different when it’s translated into another language,” Swaney-Stueve says. “Emojis don’t change, though. Facial expressions are pretty univer-sal, and with the basic set of facial emojis that we’re using, they’re also cross-cultural.”— SOURCE: KANSAS STATE UNIVERSITY


Simplified Nutrition Labels Lead to More Healthful ChoicesWhen it comes to making more healthful food purchases

in our nation’s grocery stores, the simpler the nutritional packaging is, the better. In fact, if consumers only have to look at a single number—a score that represents the nutritional value of what’s inside the packaging—they’re more likely to buy more healthful products, according to a study involving research performed at the University of Pittsburgh.

The study, published in the Journal of Marketing Research, was coauthored by J. Jeffrey Inman, PhD, an associate dean for research and faculty, the Albert Wesley Frey Professor of Marketing, and a professor of business administration at Pitt’s Joseph M. Katz Graduate School of Business, and Hristina Nikolova, PhD, the Coughlin Sesquicentennial Assistant Professor of Marketing at the Carroll School of Management at Boston College. The study involved more than 535,000 shoppers, eight different food categories, and a major grocery store chain that utilized the NuVal (short for Nutritional Value) simplified scoring system.

“The benefit of the NuVal system is that it takes all the nutritional information available on the nutritional label and basically summarizes it into one score that is displayed on the shelf pricing tag,” Nikolova says. “The NuVal scores allow shoppers to easily find healthier products.”

The NuVal System scores food products on a scale of 1 to 100—the higher the score, the better the nutrition. It’s available in more than 1,600 stores in the United States and was developed by a team of nutrition, public health, and medical experts after the 1990 Nutrition Labeling and Education Act (NLEA) failed to reduce the nation’s obesity rate. NLEA mandated that nutritional labels list ingredients such as fat content, sodium, calories, and carbohydrates. While well-intentioned, the labels “are somewhat difficult and time consuming to understand,” according to the study, because shoppers look at the product packaging and have to “combine all the information into an overall evaluation.” Researchers cite a 2012 Nielsen study that found that 59% of grocery shoppers experience difficulty in understanding nutrition facts on product packaging.

“Our study indicated that the NuVal nutritional scale had an immediate and powerful impact on shopper’s decisions,” Inman says. “They changed their purchasing behavior to pick healthier choices, and they switched to higher-scoring products. In fact, the simplified nutritional information boosted healthy choices by over 20%.”

Researchers worked with the grocery store chain that began implementing the NuVal scoring system in its stores in 2008. The chain provided dates for when the NuVal scores were introduced for the eight food categories

examined—frozen pizza, tomato products, soup, salad dressing, yogurt, spaghetti sauce, granola bars, and ice cream. The study compared purchases of more than 535,000 frequent shoppers in the six-month prerollout period and the six-month postrollout period.

Researchers say NuVal—or any kind of point-of-sale (POS) nutrition scoring system—also helps save time.

“Thinking about the limited time that you have to go and do your grocery shopping, you don’t have time to pick up every product, look at the label, take another product, and com-pare the labels on all the different ingredients, so it helps with that as well—it facilitates the shopping,” Nikolova says.

Given the ease of use, and America’s increased focus on health, the study found that consumers using POS nutritional scoring systems tended to gravitate toward products with higher nutritional scores, regardless of the price. In fact, price sensitivity in the grocery chain the study examined decreased by 19%, while overall sales increased.

In addition, researchers found that although consumers were paying less attention to price, they actually paid more attention to a store’s promotions.

“Our study also revealed that shoppers became less price sensitive and more promotion sensitive following the introduction of the food scoring system,” Inman says. “The new nutrition scores help to justify the price. This means that grocery stores were able to create a win-win by help-ing their customers make healthier choices, while also increasing sales at their store.”

“Instead of thinking about reducing prices as a way to increase sales, stores can think about highlighting their promotions in the store,” Nikolova says. “After the introduction of a POS simplified nutrition scoring system, shoppers start paying more attention to nutrition, and they have less attention to devote to other factors in their shopping decisions, such as price, for example. They are then looking for shopping heuristics that would save them mental energy—anything that makes their decisions easier. Promotions, which are usually prominently highlighted in the store, are one such heuristic. Thus, shoppers become more sensitive to promotions.”

The study’s message is aimed at creating more health-ful choices for consumers and a more healthful bottom line for retailers.

“It’s a big initiative,” Inman and Nikolova summarize. “Stores that don’t implement a simplified nutrition scoring system risk being at a competitive disadvantage if a nearby competitor implements a simplified nutrition scoring system. Stores that already have NuVal are doing some-thing beneficial for their customers.”— SOURCE: UNIVERSITY OF PITTSBURGH


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PROTECT YOUR DATA ON THE ROADBy Reid GoldsboroughVPN services help keep your information safe and where it belongs.

Whether you’re traveling or simply away from your home or office with a laptop or tablet computer, you should take the same kind of care with your data as you do with your wallet and other valuables. Some of the data protections you take while stationary apply to traveling, but there are additional traveling protections that are worth their effort. The most commonly recommended traveling protection is a virtual private network (VPN) service.

What Is a VPN?A public VPN creates a private network within the larger

public Internet, as if you were connecting through a fiber or coaxial cable that linked only your machine and the machine you’re connecting to. The main benefit is increased security, and it accomplishes this through dedicated servers and encryption. When you send an e-mail or view a website through a public VPN, those data travel through a server computer of the VPN company you’re using. Thus, it seems to others as if they’re coming from that computer, not yours. Through VPN software installed on your computer as well as the server computer, the data also are encrypted, so if they’re intercepted they’re impossible to read.

VPNs are useful because the free or low-cost Wi-Fi ser-vices provided by many hotels, airports, libraries, bookstores, and coffee shops typically aren’t secure connections. A secure connection requires you to type in a security key or password provided to you by the facility. The best Wi-Fi security today is WPA2 (Wi-Fi Protected Access II), with its predecessor WPA a step behind. WEP (Wired Equivalent Privacy) is even less secure. And many facilities offering free Wi-Fi provide only unsecured connections, with no password required.

Risks of Unsecure DataWith your own Internet connection and unsecured Wi-Fi,

neighbors or passing drivers can log on to your network and use your Internet connection, which at the least could slow you down. With the Internet connection at a coffee shop or airport and unsecured Wi-Fi, other users of the particular Wi-Fi network can intercept and read your data with the right software. Such software is called packet analyzers or “sniffers.” It serves the legitimate purpose of letting companies analyze their network traffic to best use its bandwidth or to monitor intrusion attempts. But a bad guy sitting two seats down from you at Starbucks can use the same software.

At a coffee shop, not long ago, someone captured my e-mail address and password and the addresses of people I e-mailed. The next day my e-mail recipients got an e-mail impersonating me and making me sound foolish. However, the repercussions could have been worse than a sophomoric joke, so I now use a VPN service. Three VPN services with good reviews in the computer press and anecdotally from fellow users are Hotspot Shield (www.anchorfree.com), WiTopia (www.witopia.net), and Private Internet Access (www.privateinternetaccess.com).

With some VPN software, a free, limited version exists. But when you’re protecting yourself in this way, it probably makes sense to spring for the beefed-up pay version. You simply download and install the software before you use a public Wi-Fi hotspot. You can keep the software running all the time, or you can disable it temporarily when you’re back to using a secure business or home connection. Other benefits of VPNs are anonymous browsing and access to content in foreign countries that may be restricted to US users. In some cases, with VPN vendors that have lots of servers, your Internet speeds may increase. In other cases, speeds can slow down slightly or remain about the same.

Sometimes a VPN can cause problems in connecting with websites or retrieving e-mail. In such cases all that’s typically needed is temporarily disabling the VPN software and immediately turning it back on again. Other times, if you’ve paid for the full, fast version of a VPN service, it may mistakenly indicate you’re using the limited, slow, free version. In such cases all that’s typically needed is logging on to the VPN vendor’s website, logging off, and logging back on again. Even with a VPN service, it’s important to use good passwords. Don’t reuse the same passwords. Long passphrases are more effective than short words such as “password.”

Far from everyone who uses a laptop or notebook on the road uses a VPN service. As with much in life, the level of Internet security depends on how much of a risk you’re willing to take. If all you’re doing is surfing websites for fun, you have less to worry about. If you’re doing online banking or shopping, you have more exposure and should consider a VPN vendor.

— Reid Goldsborough is a syndicated columnist and author of the book Straight Talk About the Information Superhighway. He can

be reached at [email protected] or www.reidgold.com.

PERSONAL COMPUTING


HEALTH MATTERS

Vitamin D-Rich Foods During Pregnancy May Reduce Children’s Allergy Risk

Higher intake of foods containing vitamin D during pregnancy—but not supplemental vitamin D intake—is associated with reduced risk of development of allergies in children, according to a study led by an investigator from the Icahn School of Medicine at Mount Sinai and published in The Journal of Allergy and Clinical Immunology.

The research team conducted a prospective study of 1,248 mothers and their children in the United States over time, from the first trimester of pregnancy until the children reached about 7 years old. They found that higher intake of food-based vitamin D (equivalent to the amount of vitamin D in an 8-oz serving of milk per day) during pregnancy was associated with 20% less hay fever at school age. There was no risk reduction linked to vitamin D intake by supplement.

“Expectant mothers have questions about what they should eat during pregnancy, and our study shows that it’s important to consider the source of nutrients in a mother’s

diet,” says Supinda Bunyavanich, MD, MPH, an assistant professor in the department of pediatrics, department of genetics and genomic sciences, and The Mindich Child Health and Development Institute at the Icahn School of Medicine at Mount Sinai. Foods that contain vitamin D include fish, eggs, dairy products, mushrooms, and cereals.

Vitamin D modulates the immune system, and its potential role in asthma and allergy has been of interest. Many prior studies have examined vitamin D and allergy outcomes at single points in time, but this study comprehensively assessed vitamin D levels at multiple points (during pregnancy, at birth, and at school age) and by different methods (food frequency questionnaire and tests of serum 25[OH]D levels in both the mothers and school-age children).

“This study may influence nutritional counseling and recommendations to expectant moms to include vitamin D-rich foods in their diets,” Bunyavanich says.— SOURCE: MOUNT SINAI HEALTH SYSTEM

Lifelong Physical Activity Increases Bone Density in MenMen have many reasons to add high-

impact activity and resistance training to their exercise regimens; these reasons include building muscle and shedding fat. Now a University of Missouri (MU) researcher has determined another significant benefit to these activities: building bone mass. The study found that individuals who continuously participated in high-impact activities, such as jogging and tennis, during adolescence and young adulthood had greater hip and lumbar spine bone mineral density than those who didn’t.

“While osteoporosis is commonly associated with only postmenopausal women, it is, in fact, a serious issue for men as well,” says Pamela Hinton, PhD, an associate professor in the department of nutrition and exercise physiology in the MU College of Human Environmental Sciences. “Indeed, research has shown that the consequences of osteoporosis can be much worse for men, as they are less likely to be diagnosed and are at a greater mortality risk from fractures that occur as a result of a fall.”

In studying factors that protect against osteoporosis for men, Hinton aimed to understand the connection between

bone-loading exercise during adoles-cence and young adulthood, when the skeleton is still growing, and bone mass in middle age. In the study, she analyzed data from the physical histories of 203 males aged 30 to 65 years. Participants’ sports and exercise histories varied, both in type and level of activity, and the length of time spent doing various physi-cal activities also differed.

Hinton’s research found that exercise-associated bone loading during adolescence and young adulthood benefited bone density in adulthood. Moreover, she found that high-impact activity during growth and adulthood is an important determinant for bone health later in life.

“The most important take-away is that if you are healthy, it is never too late to begin high-impact activities or resistance training to improve bone mineral density,” Hinton says. “While activity during skeletal growth is significant, we also saw pos-itive associations between such physical activity and bone density at all ages. So even middle-aged men who spent their teenage years sitting on the couch could see benefits from beginning a bone-strengthening exercise program.”— SOURCE: UNIVERSITY OF MISSOURI HEALTH


RESEARCH BRIEFS

Unraveling the Enigma of Salty Taste Detection

Public health efforts to reduce dietary sodium intake have been hindered by an incomplete understanding of the complex process by which humans and other mammals detect salty taste.

Now, a multidisciplinary team from the Monell Chemical Senses Center in Philadelphia has further characterized the identity and functionality of salt-responding taste cells on the tongue. The knowledge may lead to novel approaches to develop salt replacers or enhancers that can help reduce the sodium content of food.

“Understanding more about the mechanisms involved in detecting salt taste moves us closer to developing strategies to reduce the amount of salt in our food while still retaining the salty taste that people enjoy,” says the study’s lead author Brian Lewandowski, PhD, a neurophysiologist at Monell.

‘Salt’ is a chemical term that describes a compound made of positively and negatively charged ions; the most well-known example is sodium chloride (NaCl). The primary process by which mammals detect NaCl, common table salt, is well understood, and occurs via a sodium receptor known as ENaC (epithelial sodium channel). The ENaC receptor responds almost exclusively to sodium (Na+) salts and isn’t influenced by the salt’s negative ion (eg, Cl-).

However, scientists know that a second salt-sensing recep-tor also exists, but much about this receptor, including its identity, remains unknown. Like ENaC, the second receptor detects sodium salts, but it also is sensitive to nonsodium salts such as potassium chloride (KCl), which is frequently used to replace sodium in foods.

Unlike the ENaC receptor, this second receptor for salt taste is affected by the size of the salt’s negative ion such that salts with smaller negative ions taste saltier. For this reason, sodium chlo-ride, a salt with a small negative ion, tastes saltier than sodium gluconate (Na(C6H11O7)), which has a very large negative ion.

In the recent study, published in the Journal of Neuroscience, Monell researchers identified the taste cells involved in this

second salt taste mechanism and increased understanding of how they function.

To identify and study the cells involved in the second salt pathway, the Monell researchers first needed to address sev-eral challenges related to taste physiology. Taste cells, includ-ing those that contain the various types of taste receptors, are tightly grouped together in structures known as taste buds. This clustering enables the cells to communicate with one another but also makes it difficult for scientists to distin-guish between a given cell’s direct response and one indirectly caused by a message from a neighboring cell.

In addition, the tight junctions that hold taste cells together form a nearly impenetrable barrier that restricts the move-ment of larger ions, making it difficult to directly compare how different sized ions affect taste cell function.

To eliminate cell-to-cell communication and the tight junc-tions, the Monell scientists used a rodent model and applied sophisticated neurophysiological techniques to isolate single living taste cells. They then measured the isolated taste cells’ responses to different salts to classify the cells and identify those involved in the second salt pathway.

The isolated second pathway cells were found to be a subset of what are known as Type III taste cells, which are also thought to be involved in detecting sour taste.

Subsequent experiments with the isolated second path-way cells revealed that negative ions still influenced the cells’ response to a given salt, with the effect of the negative ion remaining dependent on the ion’s size.

Since the scientists had eliminated the tight junctions between cells, they concluded that this result wasn’t an indi-rect effect of the ion’s size (as a previous theory had sug-gested), but instead indicated a direct interaction between the taste cell and the negative ion.

Thus, unlike the ENaC pathway, both positive and nega-tive ions directly interact with cells involved in the second salt pathway to influence how these cells respond to salts.

By knowing which cells to study and more about how they interact with salts, the team can now focus on determining the identity of the second salt receptor.

“Now that we have isolated and better understand the cells involved in the second salt taste pathway, we can begin to study them in more detail,” says study author Alexander Bachmanov, PhD, DVM, a behavioral geneticist at Monell. “We now will analyze these cells to determine which genes and proteins are expressed and which are important for sensing salty taste. This should help us pinpoint the specific receptor mechanism.”

The new findings provide an important step toward a more complete understanding of salty taste and how it’s detected. After more pieces of the system are decoded, scientists may be able to identify alternative approaches to activate salty taste and alleviate the negative health consequences of sodium overconsumption.— SOURCE: MONELL CHEMICAL SENSES CENTER


Teen Weight Gain on Injectable Contraceptive May Depend on Micronutrient Intake

Each year, thousands of teenage girls decide to use the injectable contraceptive depot medroxyprogesterone acetate (DMPA). They’re drawn to DMPA’s long-acting convenience (it’s injected just four times per year) and near 100% efficacy. However, for some, the drug causes significant and seemingly unstoppable weight gain.

With no good explanation for what causes the pounds to pack on, or a way to predict who will gain weight, phy-sicians counsel all their teen DMPA patients to eat less food. But in some adolescent patients, even low-calorie diets don’t appear to stave off the increase in BMI.

“Studies have looked at race, socioeconomic factors, calorie intake—and not one of these has been conclusively linked to the kind of weight gain trajectory that we see in some girls who are on DMPA,” says Andrea Bonny, MD, an adolescent medicine expert at Nationwide Children’s Hospital in Columbus, Ohio, and an assistant professor of pediatrics at The Ohio State University College of Medicine.

However, a study Bonny conducted shows that the answer may be found in the quality of a teen’s diet vs the quantity. In her research, teens using DMPA were less likely to gain weight if their diets were rich in three nutrients: dietary fiber, magnesium, and linoleic acid— a type of omega-6 fatty acid. Girls whose diets were lower in those nutrients tended to gain weight rapidly and consistently over a period of one year.

Bonny’s research team analyzed the girls’ exercise habits and daily intake of calories, fat, protein, and car-bohydrates, as well as different types of micronutrients. BMI was checked at the beginning, middle, and end of the study. The researchers didn’t find a correlation between increased BMI and any of the other dietary or lifestyle fac-tors, but observed a connection between less weight gain and intake of specific micronutrients.

“Fiber, magnesium, and linoleic acid are typically found in a diet rich in legumes, leafy vegetables, nuts, and fruits—basically, healthy, fresh food,” Bonny says. “The message we need to be giving girls taking DMPA is to eat better, not less.”

Clues From Postmenopausal MetabolismResearch indicates that 1 in 4 DMPA users will expe-

rience excessive weight gain (greater than 5% of their original BMI) within six months of their first injection. For these girls, lean body mass is steadily replaced by fat tissue—an effect that doesn’t plateau over time.

Bonny, who’s been studying hormonal contraceptives for more than 15 years, says she’s always been curious about why DMPA caused such significant weight gain in some teens, but not others.

“I knew it couldn’t be as simple as just telling these girls to eat less food. There are literally thousands of dietary factors that could be at play,” she says.

Because DMPA significantly lowers estrogen pro-duction, Bonny turned to nutritional research that had been done with postmenopausal women for clues. Many studies in this population indicated that food intake couldn’t explain why some women tended to gain more weight after menopause than others. Further, there was research suggesting that micronutrient consumption could impact postmenopausal metabolism.

With support from Ohio State’s Center for Clinical and Translational Science, Bonny’s research team was able to comb through past research to identify the top 30 nutrients that were most likely to influence the growth of fat tissue in a low-estrogen environment. Bonny’s team then enrolled 45 adolescents from a local clinic and analyzed their diets over a 12-month period while they were on DMPA.

While most girls in the study did gain body mass and lose lean mass, Bonny says her data strongly suggest that there’s more at play than just the amount of food consumed—which is the first step in predicting and possibly preventing weight gain among teen DMPA users.

A Pretzel a Day …While DMPA remains a very popular choice among

urban teens, a healthful diet can be hard to come by.“Many girls who live in urban areas don’t always have

access to fresh produce,” Bonny says. “The message of ‘eat better’ is a good start, but we need to keep looking for options and answers.”

Bonny hopes her next study will offer both. She’s cur-rently planning a clinical trial to see if a pretzel snack containing linoleic acid and fiber can help obese girls on DMPA maintain or lose weight vs overweight girls on DMPA who don’t eat the snack.

“I think as we explore this more, we may find that some people’s fat tissue has a biological sensitivity to DMPA, and that the micronutrients may offer a sort of protective effect,” Bonny says.— SOURCE: THE OHIO STATE UNIVERSITY CENTER FOR CLINICAL AND TRANSLATIONAL SCIENCE


PRODUCTS + SERVICES

Stouffer’s No. 1 Alfredo Sauce Is Now Gluten-Free

Stouffer’s has announced that its operator-preferred Alfredo sauces are now gluten-free. Stouffer’s Alfredo Sauce and Alfredo Parmigiana Sauce are crafted with real cream, combined with aged Parmesan, and then lightly seasoned with ground black pepper. With true scratchmade taste and heat-and-serve ease, these sauces lay the foundation for consistent, flavorful entrées that also are gluten-free. Add Stouffer’s Alfredo Sauce to a gluten-free crust and top with chicken, asparagus, and sun-dried tomatoes for a signature pizza entrée, or combine with penne pasta, shrimp, and kale for a classic pasta dish.

For more information, visit www.stouffers.com.

Motive Pure Introduces Liquid Electrolyte Concentrates

To help athletes recharge on the go, Motive Pure offers portable electrolyte concentrations. Motive Pure Electrolyte Hydration concentrates are available in portable 1-oz bottles. Simply add the liquid concentrate to water for flavor and an energy boost.

The electrolyte concentrates are calorie-free and come in five flavors: Berry, Lemon-Lime, Orange, Grape, and Pink Lemonade. The concentrates are sweetened with Stevia sweetener and natural fruit flavor. Consumers can mix the 1-oz portions of concentrate with varying amounts of water to their desired taste. Motive Pure is available in multipacks of convenient 1-oz bottles or can be delivered on a monthly basis.

For more information, visit www.motivepure.com.

New Allergen-Free Roasting Process Debuts

SunButter has begun dry roasting its sunflower kernel on new equipment solely dedicated to produc-ing its sunflower seed butter. SunButter’s Sunflower Butter now will be produced in one continuous pro-cess, avoiding any risk of cross-contamination, to ensure a finished product that’s free from all of the top eight food allergens. While SunButter Sunflower Spread always has been free of peanuts, tree nuts, dairy, eggs, wheat, fish, and shellfish, their new roast-ing process makes them safe for consumers with soy allergies. SunButter also is free of sesame products.

For more information, visit www.sunbutter.com.

Protein Powders With Probiotics Debut

Bob’s Red Mill launches a new line of plant-based Nutritional Booster Protein Powders. The new Nutritional Boosters, which make use of pea protein, are available in four varieties: Protein and Fiber, Chai Protein Powder, Chocolate Protein Powder, and Vanilla Protein Powder.

The new Nutritional Booster Protein Powders contain 20 g of protein per serving, along with beneficial probiotics, prebiotic fiber, and heart-healthy omega-3 fatty acids. Each product is vegan, gluten-free, and soy-free, and is an excellent source of iron. The Vanilla, Chocolate, and Chai Nutritional Boosters are naturally sweetened with monk fruit extract. The unflavored, unsweetened Protein & Fiber Nutritional Booster gets an additional dose of fiber from psyllium fiber powder. The entire line makes use of a powerful blend of pea protein, chia seeds, and chicory root fiber.

The Nutritional Boosters can easily be mixed with water for a quick protein shake, or blended with fruit and milk or yogurt for smoothies.

For more information, visit www.bobsredmill.com.

Pascha Unveils Allergen-Free Organic Dark Chocolate

Pascha introduces dark chocolate free from the nine most common food allergens. Pascha’s chocolates were created specifically for those who can’t risk cross-contact with allergens such as peanuts, tree nuts, soy, and milk that occurs in most chocolate factories.

All of Pascha’s products are certified organic, vegan, kosher, gluten-free, non-GMO, and fair trade. Pascha offers three varieties of chocolate chips with 55% to 100% cacao, and three types of miniature chocolate bars ranging from 55% to 85% cacao. They also boast a wide range of full-size chocolate bars including smooth plain varieties of differ-ing percentages of cacao, and bars with cacao nibs, organic Arabica coffee, maca root, goldenberries, or lucuma, a nutritious Latin American fruit.

For more information, visit www.paschachocolate.com.


Simply 7 Unveils New Line of Kale Chips

Simply 7, a company popular for quinoa, lentil, and hummus chips, announces the launch of new kale chips. While kale chips have been around for a while, the Simply 7 kale chip is the first of its kind. It differs from a traditional kale chip because it’s made from green curly kale and real potatoes—so you get the health benefits of a traditional kale chip (nearly 80% of the recommended daily intake of vitamin K) with the crunch of a traditional potato chip but without artificial ingredients.

All Simply 7 ingredients are made with only all-natural and simple, easy-to-understand ingredients, and are non-GMO, gluten-free, and kosher certified.

The kale chips will be available in three flavors: Sea Salt, Dill Pickle, and Lemon & Olive Oil. All varieties contain about 55% fewer kcal from fat and higher nutrient levels than regular potato chips.

For more information, visit www.simply7snacks.com.

New Line of Organic Baby Food Pouches Released

Happy Family Brands introduces Clearly Crafted, a new line of organic, completely transparent baby food pouches. Happy Family started offering baby food in a convenient pouch in 2006, and is the first national baby food brand to introduce a clear pouch.

Parents can now see the food inside the pouch before purchasing, and the recipe for each pouch will be printed on the back of the product. The transparent pouches also allow babies to become familiar with the colors of fruits and vegetables at a very young age, which can lead to healthful choices throughout life. The website www.HappyFarms.com launches in conjunction with the Clearly Crafted pouches, which shows parents where the fruits and veggies in the pouches come from.

The Clearly Crafted line consists of 12 brand new organic flavors, including two stage 1 flavors for babies four months and older and 10 stage 2 flavors for babies 6 months and older. Some of the new flavors are Apples, Kale & Avocados; Apples, Guavas & Beets; and Apples, Pumpkin & Carrots.

For more information, visit www.happyfamily brands.com.

Organic Tea Crystals Offer a Healthful Instant Tea Option

Pique Tea announces the release of their new line of tea in the form of organic tea crystals. Pique Tea Crystals dissolve completely in water and offer an easy way to enjoy a cup of tea instantly, at any time and anywhere, without compromising flavor or nutrients.

Pique Tea Crystals use organic whole leaves sourced directly from trusted tea farms at their peak of freshness. Available in convenient single serve sachets, Pique Tea Crystals provide the delicious flavor and rich nutrients of exceptional loose-leaf tea without any artificial flavorings, preservatives, or sugar.

Pique Tea Crystals are available in five varieties: English Breakfast, Earl Grey, Mint Sencha Green, Sencha Green, and Jasmine.

For more information, visit www.piquetea.com.

New Roll-Out of Convenient, Gluten-Free Entrées

Five new frozen meals are being added to Amy’s line of convenient entrées. All are vegetarian and gluten-free, joining the company’s robust line of more than 100 easy, gluten-free meals. The new offerings include the following:

• Breakfast Scramble features organic tofu scram-bled with organic mushrooms, onions, and broccoli along with country-style potatoes and meatless sau-sage on the side.

• Chili Mac features Amy’s original comforting mac & cheese made with organic rice pasta combined with slightly spicy chili.

• Harvest Casserole Bowl is an excellent source of protein and a combination of organic beans, grains, and greens with organic kale and chard, golden fire-roasted sweet potatoes, quinoa, tofu, and roasted pumpkin seeds for texture and flavor.

• 3 Cheese & Kale Bake features Amy’s classic mac & cheese with rice pasta and additional cheeses for an extra flavor boost. Kale adds texture, color, and nutri-tion, while maintaining the dish’s smooth “comfort food” feel.

• Vegan Cheeze & Black Bean Enchilada boasts a harmony of veggies, beans, chiles, and a special non-dairy, provolone-style cheeze, all wrapped up in a corn tortilla and topped with Amy’s enchilada sauce.

For more information, visit www.amys.com.


PRODUCTS + SERVICES

Sprouted Grain Breakfast Options Now Available

To add to their line of sprouted grain breads, Ezekiel 4:9 introduces new sprouted grain options for breakfast: Sprouted Grain Waffles and Flax English Muffins.

The new Sprouted Grain Waffles are vegan, cer-tified organic, and diabetes friendly. With six differ-ent sprouted grains, legumes, and seeds (wheat, barley, lentils, soybeans, spelt, and millet), the waf-fles are a complete protein with nine essential amino acids. Sprouting maximizes nutrition and digestion and lowers the grains’ glycemic index. The Sprouted Grain Waffles are an excellent source of fiber, pro-tein, manganese, phosphorus, and magnesium, and are available in four varieties: Original, Golden Flax, Blueberry, and Apple Nut.

The Flax English Muffins, which join Ezekiel 4:9’s line of sprouted grain English muffins, are vegan, certified organic, made with sprouted flaxseeds for a dose of omega-3 and omega-6 fatty acids, and a good source of fiber, protein, thiamine, and magnesium.

For more information, visit www.foodforlife.com.

SweetLeaf Offers Natural Sugar-Free Sweetener

SweetLeaf Natural Stevia Sweetener is a calorie-free, gluten-free alternative to sugar and artificial sweeteners, with its sweetness produced naturally from the leaves of the stevia plant. It’s appropriate for those looking to cut added-sugar calories and for people with diabetes. SweetLeaf’s original Stevia is available in certified organic and conventional varieties in shakers and traditional packets.

SweetLeaf also produces Liquid Stevia Sweet Drops in 20 different varieties to add sweetness and flavor to food dishes, and liquid Water Drops in four fruit-flavored variet-ies (Peach Mango, Raspberry Lemonade, Strawberry Kiwi, and Lemon Lime), which can be added to plain water to make a sweet, calorie-free flavored drink.

For more information, visit www.sweetleaf.com.

Coffee Fruit Used in New Energized Hot Cereals

Earnest Eats announced the addition of a new line of hot cereals to its family of supergrain products, Earnest Eats Energized Hot Cereals. The new Energized line uses the coffee fruit for natural energy. Available in three flavors—A.M. Trail Mix, Cherry Almond, and Mocha Nut—the new line is 97% organic, wheat-free, and vegan. The cereals deliver sustained morning energy with superfood grains such as amaranth and quinoa, coconut oil, and coffee fruit, a sustainable fruit high in fiber with a mild amount of natural caffeine.

The coffee cherry is the fruit that surrounds the coffee bean and is typically discarded as the beans are processed, leading to millions of pounds left as waste by the streams and rivers where coffee is grown. Earnest Eats Energized Hot Cereals integrates this ingredient in a sustainable way, giving it a new life as a nourishing food.

In addition to its sustainability and nutritional bene-fits, coffee fruit has a unique roasty flavor—not a coffee flavor—that complements the Earnest Eats supergrain blend. Coffee fruit also adds a subtle caffeine lift, equal to one-quarter cup of coffee per serving.

Earnest Eats are available in single-serve cups to take on the go, as well as in bulk for foodservice.

For more information, visit www.earnesteats.com.

SmartFruit Boasts New Varieties of Whole-Fruit Juice

SmartFruit, a Brooklyn-based manufacturer of all-natu-ral fruit mixes, provides an affordable, convenient alternative to fresh produce for smoothies and juices.

SmartFruit has taken the hassle out of healthy by putting everything needed for a fruity drink into one simple bottle. Instead of purchasing different fruits or flavors to mix together, SmartFruit provides fruit juice in delicious premade combinations.

SmartFruit releases four new varieties: Wild Watermelon, Superfruit All-Stars, Tropical Harmony, and Harvest Reds. Just like their original flavors, these new flavors are all natu-ral, 100% juice, non-GMO, shelf-stable fruit in a bottle that contains no added sugar, preservatives, or artificial color-ings, and includes three servings of fruit per bottle. Smart-Fruit can be blended with ice for a smoothie or mixed with water and served as a cool and refreshing beverage.

For more information, visit www.drinksmartfruit.com.


APRIL 15-17, 2016ACADEMY OF NUTRITION AND DIETETICS WEIGHT MANAGEMENT DIETETIC PRACTICE GROUP SYMPOSIUMBaltimore, Marylandhttp://wmdpg.org

APRIL 21-22, 2016IDAHO ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETINGPocatello, Idahowww.eatrightidaho.org

APRIL 21-22, 2016MICHIGAN ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE Lansing, Michiganwww.eatrightmich.org

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

APRIL 21-23, 2016CALIFORNIA ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE AND EXHIBITIONRiverside, Californiawww.dietitian.org

APRIL 22, 2016 MARYLAND ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETING Linthicum Heights, Marylandwww.eatwellmd.org

APRIL 27 – MAY 1, 2016NATIONAL KIDNEY FOUNDATION SPRING CLINICAL MEETINGSBoston, Massachusettswww.kidney.org/spring-clinical

MAY 7-15; MAY 21-29, 2016ACADEMY OF NUTRITION AND DIETETICS FOOD & CULINARY PROFESSIONALS DIETETIC PRACTICE GROUP CULINARY TRIP ABROADLisbon, Portugalwww.foodculinaryprofs.org

JULY 29-30, 2016INTERNATIONAL CONFERENCE ON NUTRITION IN MEDICINEWashington, D.C.www.ICNM16.org

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MUSHROOMSBy Jessica Fishman Levinson, MS, RDN, CDNInclude these rich, earthy powerhouses in your spring dishes.

Today, mushrooms are a staple in the produce aisle of almost every grocery store, but it wasn’t until the late 19th century that mushroom production began in the United States.

There are many varieties of mushrooms, the most common of which are white button, with a fairly mild flavor, and brown crimini (also known as baby bellas), with a deeper, earthier flavor. Both of these types of mushrooms take about three months to grow before they’re harvested by hand. Portabella mushrooms are grown like white and brown mushrooms and are a more mature version of brown crimini mushrooms due to their longer growing period. Portabellas are known for their meatlike texture and flavor and often are used as a vegetar-ian substitute for burgers.

Specialty mushrooms like oyster, shiitake, maitake (also known as hen-of-the-woods), and enoki take longer to grow and require more hands-on involvement, which accounts for their higher price tag. They range in flavor from delicate and light to rich, meaty, and woodsy.

While we often encourage clients to eat brightly colored fruits and vegetables, we can’t discount the nutritional benefits of mushrooms. They’re low in calories, and one serving of mushrooms is a good-to-excellent source of selenium, potassium, and the B vitamins ribofla-vin, niacin, and pantothenic acid. Mushrooms exposed to ultraviolet light also are an excellent source of vitamin D.

Mushrooms can be enjoyed raw in salads or cooked and added to stir-fries, pasta, sauces, pizza, omelets, and numerous other dishes. They’re the perfect food to blend with meat to make burgers, meat-loaf, and meatballs, which can be an effective way to reduce calorie and fat intake while still feeling satiated.1,2

— Jessica Fishman Levinson, MS, RDN, CDN, is a New York-based nutrition consultant, writer, and recipe developer, and the founder of

Nutritioulicious (www.nutritioulicious.com).

CULINARY CORNER

Baked Mushroom Leek Frittata

Meaty mushrooms and sweet leeks are a classic combination that pair beautifully in this easy and nutritious frittata that’s perfect for a weeknight dinner or your next weekend brunch.

Serves 4 to 6

Ingredients2 tsp olive oil1 medium leek, white and light green parts only,

cut in half lengthwise and thinly sliced8 oz sliced mushrooms (any type; for this recipe,

I used a mix of shiitake and baby bella)1 T water1 clove garlic, minced1 T chopped fresh thyme1⁄2 tsp kosher salt, dividedFreshly ground pepper, to taste6 large eggs1 cup evaporated skim milk1 cup (4 oz) shredded Parmesan cheese, divided

Directions1. Preheat oven to 375˚ F. Spray a 9-inch pie dish with cooking spray and set aside. 2. Heat olive oil in a large skillet over medium-high heat. Add leeks and sauté three minutes, until soft-ened. Add mushrooms and sauté five to six minutes until softened and most of the water has evaporated. Add 1 T water to deglaze the pan. 3. Stir in garlic, thyme, 1⁄4 tsp salt, and pepper, and cook one minute until fragrant. Remove from heat. 4. In a medium bowl, whisk together eggs, evapo-rated skim milk, remaining 1⁄4 tsp salt, and pepper, to taste. 5. Sprinkle 3⁄4 cup of cheese in bottom of pie dish and top with mushroom and leek mixture. Pour egg mix-ture on top and sprinkle with remaining 1⁄4 cup cheese. 6. Bake frittata for 30 minutes until top is puffed and golden brown.

Nutrient Analysis per serving(Serving 4) Calories: 323; Total fat: 17 g; Sat fat: 8 g; Trans fat: 0 g; Cholesterol: 302 mg; Sodium: 915 mg; Total carbohydrate: 14 g; Dietary fiber: 1 g; Sugar: 9 g; Protein: 27 g

(Serving 6) Calories: 216; Total fat: 12 g; Sat fat: 5 g; Trans fat: 0 g; Cholesterol: 201 mg; Sodium: 610 mg; Total carbohydrate: 10 g; Dietary fiber: 1 g; Sugar: 6 g; Protein: 18 gFor references, view this article on

our website at www.TodaysDietitian.com.


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Today's Dietitian - April 2016

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Transcript of Today's Dietitian - April 2016