Page 1

American Diabetes Month Vol. 19 No. 11

November 2017

The Magazine for Nutrition Professionals

RDs’ Favorite Holiday Recipes Keeping Traditional Foods Nutritious and Delicious

How Children Are Changing the Face of Diabetes Choline’s Important Role in Overall Health Latest Trends in Frozen Desserts

Stay Current with










19 Vol.

nals essio Prof tion Nutri e for azin Mag The

nutrition ctive entire ing the most effeing Target seems nment lthful eat enviro ng hea ouragi group. for enc age this among


e ws th revie lar ian ietit is popu th y’s D Toda e behind tener. ee scienc orie sw al no-c

Is the Variety Life of Spice

lt Fitness Older Adu Expand s Program

VEGAN CLIENTS Learn about 10 strategies to help meet the nutrient needs of this unique population.



Septem ber 2017

Vol. 19


The Bes Chicago tDoinf ing The Ma gazine for

stible? Indige ’s New

The FDA of Fiber n Definitio

m Dietiti odays ww w.T

The Future of Nutrigenomics

No. 9


Nutrition Profes sionals


May 2017

With forks held high, get to sink your ready world-class teeth into delicious, cuisine.

Diet vs



Med Puinlse iterr the s anea n

a deterren to healthfu l eating? t Discove Versa tility culinar r its many y uses. m daysDie ww w.To

Graphic Design Made Easy to Improve Patient Care


Lear n they about th ca ei with n be nu r rich hi tr st in th Dayboat is cu itious an or y and scallo ps, ltura ho d savor y zucch l eatin delicio w ini cake, and summ g st yl us er squas h purée e. from BLVD

The W he Culprits at Se Be nsiti hind vitie s Blue Mak Zones Pr Acro es Strid oject ss th es e Co untr y Stra te Iden gies to Food tif y and End Inse w.Today curit ww sDietitia y


ww w.T odays Dietiti m

For over 15 years, Today’s Dietitian has offered timely articles on a wide range of nutrition-related topics, including culinary trends, long-term care issues, new products and technologies, clinical concerns, career strategies, and research updates that make the magazine an essential information guide and career development resource for nutrition professionals. Be sure to check out our CE Learning Library for the credits you need! Join the 110,000 professionals who already read our magazine each month.

To subscribe, visit us online at



Vol. 19

The Mag azine for

Food Are theyFears

Aquaf aba’s

llenges Reta ve Cha Rise Abo

am ’s Te fers USDAtion Of fits Nutri ter Bene Grea

trition for Nu

Determ Statins approa ine the best ch CVD risk to lowerin g .

Feeling itians il Diet

t oduc od Pr rs RD Fo preneu Entre

The Magazine for Nutrition Professionals sionals Profes

Is A2 Beta-Casein in Milk the Solution for Dairy Intolerance?

ueeze the Sq

enu rk M e Pa Themeovers Mak


No. 8


6 No.

Nutritiotinon for Educa oolers h ia’s Presc



2017 June

2017 August

Vol. 19

October 2017

gazine The Ma


Vol. 19 No. 10


Nutri tionIN Pr Glut SIDofEessio en-Fr nals Re ee sour Guide ce


No. 5


The USP Verified Mark on a Nature Made product tells you that it has been independently verified for quality, purity, and potency. Want to learn more? visit ‡ Based on US News & World Report – Pharmacy Times Survey †These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease.

For patients with

UC, IBS, and Pouchitis... VSL#3® 900 Delivers Diversity and Viability with Safe, Proven Clinical Results Diversity & Viability ■



8 diverse bacterial strains at the therapeutic level of 900 billion CFUs offer a range of benefits over single strain options1, 2 VSL#3® is a refrigerated therapeutic probiotic that has been shown to survive stomach acids and colonize the GI tract to help restore bacterial balance3

Safe ■

VSL#3® is generally safe and well tolerated VSL#3® is considered safe with standard of care treatments including 5-ASA* at doses up to 3.6 trillion CFUs per day4,5,6

Proven Results ■

In multiple controlled clinical trials, dietary management with VSL#3® has been shown to address symptoms of UC, IBS, and pouchitis when added to SOC therapies by supplying the nutritional needs of these conditions.


Add VSL#3® 900 to your patient’s SOC treatment for proven results in UC, IBS, and pouchitis

For more information and to learn how VSL#3® 900 can help your patients, go to

VSL#3® is a probiotic medical food intended for the dietary management of UC, IBS, and an ileal pouch.

Manufactured and Distributed by: Alfasigma USA, Inc., Covington, LA 70433 All rights reserved. ©2017 Alfasigma USA, Inc. 9/17 6071-013

References: 1. VSL#3 PI 2017. 2. Shen J, Zuo Z-X, Mao A-P. Inflamm Bowel Dis. 2014;20(1):21-35. 3. Khalighi A, Behdani R, Kouhestani S. Probiotics and Prebiotics in Human Nutrition and Health. 2013. 4. Sood A, Midha V, Makharia GK, et al. Clin Gastroenterol Hepatol. 2009;7(11):1202-1209, 1209.e1. 5. Tursi A, Brandimarte G, Papa A, et al. Am J Gastroenterol. 2010;105(10):2218-2227. 6. Kim HJ, Vazquez Roque MI, Camilleri M, et al. Neurogastroenterol Motil. 2005;17(5):687-696. *SOC medications included oral mesalamine, azathioprine, and 6-mercaptopurine.


TIME TO UP THE ANTE As a journalist, editor, and author who’s covered a wide variety of health care topics for many years, I’ve learned time and again that increased risk of CVD, dental problems, dementia, and nerve, kidney, and eye diseases are common complications associated with diabetes. But I didn’t know that hearing loss also was a common complication that certified diabetes educators can help patients avoid by consistently using screening and evaluation tools in practice to identify hearing impairment and balance issues. In August, at the American Association of Diabetes Educators (AADE) conference, I sat in a room packed with RDs/CDEs to listen to the presentation “The Diabetic Ear: Collaboration of the Audiologist and Diabetes Educator.” Most diabetes educators know that hearing loss is a common complication and have had training in this area, but many rarely or never refer patients for hearing screening, and most don’t use hearing screening tools, according to presenter Kathryn Dowd, MEd, AuD, FNAP, audiologist and president of Hearing Solution Center, Inc, in Charlotte, North Carolina. Dowd discussed the association between diabetes and hearing loss, screening and evaluation tools diabetes educators can use, diagnosis and treatment options, making referrals, and patient comanagement strategies. If you didn’t attend the session, I urge you to download the PowerPoint presentation on the AADE website and begin thinking about implementing these tools and making more patient referrals if you haven’t already. According to the American Diabetes Association, hearing loss is twice as common in people with diabetes and 30% higher in those with prediabetes. So the need for prevention and treatment is great in this population. In honor of American Diabetes Month, Today’s Dietitian is featuring the articles “Children Changing the Face of Type 2 Diabetes” on page 32, and “Caring for Patients’ Psychosocial Needs” in the Dynamics of Diabetes department on page 12. Also in this issue are articles on dietitians’ favorite holiday recipes, choline, the DASH diet, and frozen desserts. Please enjoy the issue!

Judy Judith Riddle Editor

4  today’s dietitian  november 2017

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

© 2017 Great Valley Publishing Company, Inc. Phone: 610-948-9500 Fax: 610-948-7202 Editorial e-mail: Sales e-mail: Website: Subscription e-mail: Ad fax: 610-948-4202 Ad artwork e-mail: 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.


Refreshing & Hydrating

sugar free

thickened peach mango drink

available in Nectar Consistency lDDSI Levels 2 Honey Consistency lDDSI Levels 3

t s e B e h t y l r a Cle CLEAR

Visit to learn about our complete line of Thick & EasyŽ Beverages Š 2017 Hormel Foods, LLC All Rights Reserved








RDs’ Favorite Holiday RecipesDietitians share healthful and nutritious takes on their most cherished holiday dishes.

4 Editor’s Spot

Children Changing the Face of Type 2 DiabetesAs more children are diagnosed with type 2 diabetes, RDs must augment their counseling strategies to treat not only children but also their families.

10 Ask the Expert



Choline Under the MicroscopeThough largely underconsumed and underappreciated, this essential nutrient is poised to become the new darling of the dietetics world.


Frozen Dessert InnovationsClients’ favorite scoops, pops, and bars get healthful and allergy-friendly makeovers.


The Celebrated DASH DietResearch shows it’s the most effective eating pattern for lowering blood pressure, so how can dietitians get their clients more excited about its virtues?


CPE Monthly: Postbariatric Body Contouring Surgery

8 Reader Feedback 12 Dynamics of Diabetes 14 Herbs and Spices 16 Integrative Nutrition 18 Probiotics 22 The Retail RD 58 Focus on Fitness 60 Get to Know … 62 Bookshelf 64 Diabetes Product Showcase 65 Datebook 66 Culinary Corner

This continuing education course explores the dietitian’s role in counseling and educating patients considering body contouring procedures after bariatric surgery and/or massive weight loss.

Page 50

Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published monthly by Great Valley Publishing Company, Inc., 3801 Schuylkill Road, Spring City, PA 19475. Periodicals postage paid at Spring City, PA, Post Office and other mailing offices. Permission to reprint may be obtained from the publisher. Reprints: Wright’s Media: 877-652-5295 Note: For subscription changes of address, please write to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on last label. Postmaster: Send address changes to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Subscription Rates — Domestic: $14.99 per year; Canada: $48 per year; Foreign: $95 per year; Single issue: $5. Today’s Dietitian Volume 19, Number 11.

6  today’s dietitian  november 2017

Carlson Olive your Heart™ ✔ Promotes cardiovascular system health* ✔ Premium Greek extra virgin olive oil ✔ Sustainably-sourced Norwegian marine oil ✔ 1,480 mg of omega-3s per serving Olive your Heart™ blends cold-pressed Greek Terra Creta extra virgin olive oil with premium Norwegian marine oil sourced from deep, cold-water fish. Each serving provides 1,480 mg of omega-3s, including EPA and DHA. Olive your Heart™ is mild and smooth, and makes it easy and delicious to add heart healthy nutrients into your diet.

888-234-5656 | *These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.

READER FEEDBACK From Our Facebook Page

“Nutrition Science Isn’t Broken, It’s Just Wicked Hard”

Allison Koch: Fabulous. Thanks for posting! Janis Honeycutt: Yes, it’s a bit more difficult than knowing the four basic food groups and all the current fad diets. Stephanie Ledbetter Turkel: Great title!

From Our Twitter Feed Popular Tweets, Retweets

RD Lounge Got Picky Eaters? 10 Tasty Tips for Turning the Tide @NCommunicator: Some really fun ideas here.

“Nutritional Yeast Is Tasty, Versatile, and Easy to Use”

Jen Dahlke: I’ve tried it; it’s definitely not the same. Really hoping I can have cheese again in a few weeks. I’m going to eat all the pizza. Heather Curtis: I’ve tried brewer’s yeast but never nutritional yeast. “Veganism: Plant-Based Diets and Eating Disorders” (Webinar) Michele Redmond: I’m signed up! I’m doing a FNCE® cooking demo on vegan meals omnivores will love, so this will add extra inspiration! “Mindset Plays a Big Role in Weight Loss Success”

Encouraging Patients to Eat More Legumes @Food4Gut_Health: Interesting tips for encouraging clients to include more legumes in their diets. @FitNutAnita: I have a lot of love for legumes. Nutrition facts and tips here.

September Issue

@EverydayRD: Haunted by food fears with every bite you take? Mindy Hermann, MBA, RDN, and colleagues put things into perspective.

The Best of Chicago Dining With forks held high, get ready to sink your teeth into delicious, world-class cuisine.

Dayboat scallops, savory zucchini cake, and summer squash purée from BLVD

Aquafaba’s Versatility

“Encouraging Patients to Eat More Legumes”

August Issue

8  today’s dietitian  november 2017

The Magazine for Nutrition Professiona ls

Diet vs Statins

Crystal Vasquez: Food rules still lead to restriction and diet mentality. Intuitive eating/mindful eating is not a weight loss gimmick or tool. When weight loss is brought into the picture, food rules and dos and don’ts move to the forefront and define the overall relationship with food. Wendy S. Chatham: This is why I’ve decided to become a certified intuitive eating coach.

Maggie McCarthy: I’m not sure where the idea to call them pulses came from, but it just doesn’t work for me. ‘How often do you eat pulses?’ … See, it doesn’t work. I like that you’re calling them legumes. Rachel Zisman: Yes! This makes me want some.

Vol. 19 No. 9

September 2017


Food Fears

@EatRightCbus: Have you tried cooking or baking with aquafaba yet? Learn more about this versatile ingredient in Today’s Dietitian.

Determine the best approach to lowering CVD risk.

Food Fears

Are they a deterrent to healthful eating?

Aquafaba’s Versatility

Discover its many culinary uses.

Image-Based Dietary Assessments @gethealthie: Great read for all nutrition professionals.

ASK THE EXPERT at 0.1 mg/day for one month followed by 0.5 mg/day for two months improved joint pain and swelling.2 However, a similar study published in 1999 in Arthritis & Rheumatology using the same dosage as the aforementioned study continued supplementation for five months, with results showing no improvements.3 A 2008 study published in Nutrition Journal found that collagen supplementation had short-term effects in relieving pain in subjects with osteoarthritis; however, the authors questioned whether the effects are long lasting.4



Q: A:

Lately, I’ve been hearing that collagen peptides help alleviate bone and joint issues. What exactly are collagen peptides, and are their health claims evidence based? Collagen is a protein that’s part of bone, cartilage, and other tissues in humans and animals. People consume collagen from animals, such as chicken, bone broth (though bone broth has little collagen in it), or supplements. Collagen peptides are the broken down and more easily absorbed protein fragments of collagen, but most sources use the terms interchangeably. You’ll find many Paleo advocates promoting collagen peptides, touting their ability to decrease joint pain associated with arthritis and surgery and improve overall bone and joint health. However, clinical studies on the role of collagen peptides in bone and joint health are limited.

Research A 2016 systematic review published in BMC Medicine looked at 197 studies starting in January 1980.1 Researchers found that based on the available literature, a significant amount of in vitro and in vivo evidence exists on many collagen peptides. They also found that several collagen peptides helped upregulate bone healing response in experimental models and potentially could be used for future clinical applications. However, based on the limited number of peptides studied in clinical trials, researchers have determined the results are limited and more research is needed. Evidence also shows conflicting results, specifically regarding the effects of collagen on rheumatoid arthritis. A 1993 study published in Science found that taking collagen orally

10  today’s dietitian  november 2017

According to the Therapeutic Research Center Natural Medicines database, collagen type II—a major structural protein responsible for tensile strength and toughness in the cartilage—taken orally is possibly safe in doses up to 2.5 mg/day for no more than 24 weeks.5 Other collagen products, including bovine collagen, have caused allergic reactions. Possible side effects include nausea, heartburn, diarrhea, constipation, drowsiness, skin reactions, and headache. There are no known interactions with drugs, foods, herbs, and supplements at this time.

Recommendations for Practitioners Some RDs recommend collagen supplements when counseling athletes. “Many in the Paleo community tout collagen for helping with skin, gut, and joint health in addition to improving performance,” says Kim Feeney, MS, RD, CSSD, LD, CSCS, a sports performance dietitian for the US Air Force located in San Antonio. “There is research supporting some of these claims, but it is likely not the silver bullet it is described to be.” Feeney believes the potential benefits of appropriately using a collagen supplementation protocol in conjunction with physical therapy outweigh any risks associated with taking the supplement. However, if a client chooses to take collagen supplements, they shouldn’t be educated only about the potential side effects but also be made aware of the lack of clinical trials, especially since there isn’t evidence of long-term efficacy. — Toby Amidor, MS, RD, CDN, is the founder of Toby Amidor Nutrition (http:// and the author of the cookbook The Greek Yogurt Kitchen: More Than 130 Delicious, Healthy Recipes for Every Meal of the Day and The Healthy Meal Prep Cookbook. She’s a nutrition expert for and a contributor to US News Eat + Run and

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


Sharpen Your Competitive Edge in Nutrition LEARN through case-based presentations by experienced clinicians, researchers, and other experts NETWORK with nutrition-support professionals from many specialties across the globe EXPLORE the latest science on caring for pediatrics and adult patients DISCOVER new solutions and make new contacts in the Exhibit Hall EARN CE hours REGISTER by January 10 and save $100* at or call 301.587.7316 *Over the onsite rate



A Review of the American Diabetes Association’s Latest Position Statement By Andrea N. Giancoli, MPH, RD Emotional, social, environmental, and behavioral issues, also known as psychosocial factors, can have a significant impact on diabetes management, clinical outcomes, and personal well-being. In fact, people with diabetes are at higher risk of depression and anxiety, and the prevalence of diabetes distress in adults is common at 18% to 45%. To address the need for psychosocial care, the American Diabetes Association (ADA) published a position statement, “Psychosocial Care for People With Diabetes,” which reflects the latest diabetes evidence and recommendations in the mental and behavioral health arena. Today’s Dietitian reviews the position statement and how it impacts dietitians working with patients with diabetes.

ADA Position Statement Purpose The purpose of the position statement is twofold, according to coauthor Mary De Groot, PhD, an associate professor of medicine and acting director of the Diabetes Translational Research Center at Indiana University. “One is to highlight the state of the evidence for the psychosocial care of people with diabetes. And two, where we don’t have evidence, to add aspirational elements to where we need to move in terms of the psychosocial care of people with diabetes.” The position statement lays out specific guidelines for psychosocial care and assessments that are now part of the ADA’s

12  today’s dietitian  november 2017

most recent Standards of Medical Care in Diabetes published in January, says coauthor and licensed psychologist Korey Hood, PhD, a professor of pediatrics and psychology and behavioral sciences at Stanford University. The position statement is organized into “a set of general considerations that apply widely to most if not all populations and to all kinds of settings. Then there are more specific recommendations that have to do with particular clinical presentations and different parts of the life span,” De Groot says. For general considerations, De Groot says the position statement makes recommendations along two different continuums: “One is across the lifespan and across the course of diabetes as a disease. The course of diabetes as a disease differs depending on the type of diabetes and differs from person to person.” She adds that within the paper is a list of “different categories of the course of disease. There are different considerations when someone is newly diagnosed than there are for someone developing complications later in life and everything in between. For example, it’s important for dietitians to be cognizant of where patients are on the continuum and how it can affect self-management of the disease. If patients experience significant life changes such as marriage, divorce, job change, or loss, for example, their self-care routines and clinical outcomes can be significantly altered. “The other continuum is between normative experiences (eg, common adjustment reactions after diagnosis, such as fear, anger, or grief) that are part of living with a chronic illness like diabetes and those that are problematic, impairing a person’s ability to engage in self-care or to live a high quality of life,” De Groot continues. Within this continuum are two categories of recommendations for providers. The first recommendations address those normative experiences. The second set of recommendations are directed at behavioral health providers and “speak to psychosocial issues that cause problems or raise challenges for people that impair them in some way, whether that’s impairing them in their ability to manage their diabetes or creating impairment in other ways. Depression is an example,” De Groot says, adding that dietitians are in a unique position to listen for or assess diabetes distress and

then take that information “to not only talk about the foodrelated aspects of that distress but what parts of a person’s meal plan they are struggling with most.” The position statement offers a comprehensive catalog of questionnaires and surveys for providers to use to assess where patients land on the continuum of depression, anxiety, eating disorders, and diabetes distress, which can be defined as “distress specific to the experience of living with diabetes and typically is along multiple dimensions including the emotional burden of the disease and having to manage an aspect of health 24/7, 365 days per year,” De Groot says. It also provides tools for providers to assess cognition in older adults, chronic pain, health literacy, self-care efficacy, and adherence to self-care.

Patient Impact Key to the position statement is for providers to engage in patient-focused care. “Begin where the patient is ready to begin,” says De Groot, emphasizing that it’s important to “recognize patients are at the center of their own care with a chronic illness like diabetes, whether they have type 1 or type 2. Patients engage in that care within the context of family, neighborhoods, community, organizations, and workplaces.” Many providers in their own practices probably already are engaging in collaborative patient-centered care and addressing psychosocial factors, such as assessing for anxiety, disordered eating, and cognition in older adults. For these providers, Hood predicts little will change, and they’ll continue their psychosocially minded practice. “But there is a large percentage of providers in specialty diabetes care clinics or in primary care practices who are not or don’t have the resources to do this,” he says. The position statement enables those providers to “identify where are the priorities and what are the sections to work on. An example could be they want to make sure that every patient who comes in to the practice has some screening for depression or diabetes distress. “They can then look at the statement and say, ‘This is a way we can do this. Here are some questionnaires, and here is a format for it,’” Hood explains. The position statement also offers measuring tools to evaluate self-care efficacy, adherence to self-care health literacy, and chronic pain.

Addressing Psychosocial Factors and Care “Dietitians play a critical role in helping to identify when people are struggling with psychosocial issues and serve an important role in facilitating connecting patients with the resources,” De Groot says. The following strategies can help RDs address psychosocial needs with their patients: • Empathize with the patient and build rapport. It’s essential to frame your mindset. “The person in front of you is not just a person with diabetes but a person with diabetes in a broader context. Taking a little bit of time to understand that and the barriers and demands on them is really the first step.

The second is normalizing or validating that this can be really tough. I don’t know that is always communicated well to the people we work with. It takes a little bit of connecting with the person,” Hood says. • Identify, evaluate, and assess. Distinguish the types of psychosocial issues experienced in your practice, and evaluate which tools are appropriate to screen patients for these issues (eg, diabetes distress, depression, anxiety, and eating disorders). Screen for psychosocial issues at the first visit and then as appropriate, particularly when there has been a change in the patient’s life (eg, work change, family dynamics, medication changes, or aging). To save time, have patients complete a questionnaire or survey while sitting in the waiting room. • Ensure goals are patient centered and not provider centered. Actively listen to patients, Hood suggests. “If one of your goals is to do a certain thing but the person has given you some information that makes you think that’s not going to work well for them, then taking the time to connect with them will help in that situation.” For example, if a dietitian wants to provide a client healthful recipes and teach home cooking skills but learns the client is a single mother who works three jobs, it’s likely she’ll have little time to prepare home-cooked meals. Rather, the dietitian can help the client assess her food environment and identify ways to make more healthful choices within the context of that environment that can help relieve some of the stress of disease management. • Identify mental and behavioral health providers familiar with diabetes management so you can make referrals outside of your scope of practice. The ADA and the American Psychological Association have partnered to train more psychologists in diabetes care and the psychosocial factors influencing aspects of managing the disease. Individuals who complete the training are included in a directory of mental health providers with expertise in diabetes care. • Know when to make referrals to mental health providers. Hood suggests implementing a systematic screening tool with a scoring system that includes language on what to say to patients and helps determine whether there’s a need for a referral. “Depression is relevant for referral, as is anxiety, which impairs people’s ability to manage their diabetes,” De Groot says. “Any time there are symptoms associated with severe mental illness, if the person isn’t already connected to mental health care providers, then a referral would be appropriate,” De Groot says. The position statement lists several validated screening tools dietitians can use to assess psychosocial issues, available at http://care. • Stay tuned for an implementation guide based on the position statement’s recommendations. The ADA may release the tool as early as mid-2018, Hood says. — Andrea N. Giancoli, MPH, RD, is a freelance nutrition writer, editor, and consultant in Hermosa Beach, California.

november 2017  13


Bean and Barley Chili


Using a variety of herbs and spices can add pizazz to any dish and meal plan. Flavor, or lack thereof, is a common contributing factor to the frustration clients can feel when struggling to make changes to their diets. Often this is due to a lack of knowledge or skill in the kitchen. Helping clients navigate the grocery store (and the pantry) can help boost their confidence in home cooking. A great place to start is with herbs and spices because they can help reduce the need for excess salt, sugar, and fat so often used to create flavorful dishes. The health benefits of herbs and spices are plentiful due to the variety of vitamins and antioxidants they contain that may play a role in preventing inflammation and chronic disease. Herbs and spices can do amazing things for food, as they’re powerful tools that stimulate appetite and satisfy taste buds. A simple baked potato may taste bland on its own, but add some yogurt, dill, cayenne, and a squeeze of lemon juice and you’ve created an elevated and more enjoyable flavor experience.

Building Flavor Cooking with herbs and spices, combined with a few basic cooking techniques, can build flavor without any added salt, sugar, or fat and can take a side dish from basic to tasty. Clients can use the following five methods separately or together in a variety of ways to take flavors from bland to bold. • Sauté diced aromatic vegetables. Aromatics, such as onions, garlic, celery, carrots, and mushrooms, help to enhance not only the flavor of food but also the aroma, stimulating the senses before the food even enters the mouth. The basic mirepoix (a culinary term for a mixture of cut vegetables, herbs, and spices used for flavoring) is a classic example

14  today’s dietitian  november 2017

of aromatic vegetables used to flavor soups, stews, and other types of dishes. • Add fragrant spices, such as ground cumin, turmeric, and red pepper flakes to a pot or pan, with a small amount of oil (approximately 1 to 2 tsp) before cooking vegetables or grains. Referred to as “blooming” the spices, it provides a deeper and more complex flavor to the final dish. This particular combination of spices adds a warm flavor that can be described as peppery with citrus undertones. • Use low-salt or no-salt stock instead of water. Stocks can provide a range of flavors, from subtle and light with a vegetable stock to hearty and rich with a beef stock. • Mix in fresh chopped herbs once the grain or vegetable is cooked to add color, flavor, and texture. Adding minced parsley, for example, creates a grassy flavor, while mint adds a sweeter peppermint touch. • Add acid. The key to brightening a dish is to add acid; specifically, citric acids such as lemon and lime juice. If a dish tastes flat or too fatty/oily, a small squeeze of lemon juice cuts through and energizes the dish, making the flavor pop. The following Bean and Barley Chili recipe demonstrates how to use some of the methods to build flavor around a simple dish using a basic Latin flavor profile. — Chef Abbie Gellman, MS, RD, CDN, is a New Yorkbased culinary nutrition expert and recipe/product developer. You can find her recipes, videos, and articles at and

Bean and Barley Chili This recipe showcases the Latin spice profile to build flavor around a basic vegan entrée. Serves 5

Ingredients Beans Half-pound dry beans, any mixture. For this recipe, I like pinto, white, and black beans, but use any type you prefer.

Chili 2 tsp extra virgin olive oil 1 onion, diced 1 green or red bell pepper, diced 1 clove garlic, minced 1 T tomato paste 1 ⁄2 tsp ground cumin 1 ⁄4 tsp chili powder 6 oz vegetable stock, low sodium 1 ⁄3 cup barley, pearled 3 plum tomatoes, diced

2 tsp unsweetened cocoa powder 1 ⁄3 cup chipotle pepper in adobo sauce, chopped 1 tsp maple syrup 1 ⁄4 cup water 1 ⁄4 tsp kosher salt 1 ⁄8 tsp ground black pepper Sour cream or yogurt, shredded cheddar cheese, avocado (optional garnish)

Creating Personalized Flavor Combinations How do we know which herbs and spices play well with one other? Below are some general flavor combinations with the basic lists included. Within each flavor profile, encourage clients to experiment with as many spices as desired until they find the perfect flavor. Start out small, with 1⁄2 tsp of each dried herb or spice (or 2 tsp of fresh herbs) and go from there. It’s easy to add flavor, but it can be a challenge to lighten it up once herbs and spices have been added to a dish.

Winning Herb and Spice Combinations



Beans 1. Soak beans overnight in a bowl with water

covering them by a few inches. The next day, drain and rinse beans, then transfer them to a pot, cover with water, and bring to a boil over medium-high heat. Reduce to a simmer and leave undisturbed for an hour. If not yet cooked through at one hour, keep at a gentle simmer and begin checking every 20 to 30 minutes, adding water as necessary and tasting for doneness. Once done, drain, add a pinch of salt, and set aside.


Lemongrass, ginger, mint, kaffir lime leaves, lime, curry powder, turmeric, coriander seeds, chiles, garlic, cilantro, five-spice powder, red pepper flakes, bay leaves, miso, scallion


Adobo, allspice, annatto seeds, black pepper, chile peppers, cinnamon, cloves, garlic, ginger, Jamaican jerk, lime, mace, mojo, nutmeg, onion, thyme


Red pepper flakes, chiles, saffron, mint, cumin seeds, coriander seeds, cilantro, garlic, turmeric, nutmeg, cinnamon, ginger, cloves, cardamom seeds, mustard seeds, sesame seeds, curry powder, onion


Chiles, oregano, chili powder, cumin seeds, sesame seeds, cinnamon, cilantro, adobo, citrus, garlic, onion


Garlic, basil, oregano, parsley, rosemary, bay leaves, nutmeg, fennel seeds, red pepper flakes, marjoram, sage, saffron, mint

Middle Eastern

Allspice, oregano, marjoram, mint, sesame seeds, garlic, cinnamon, cumin seeds, coriander seeds, cilantro, saffron, tahini

Moroccan/North African

Red pepper flakes, cumin seeds, coriander seeds, cilantro, mint, saffron, garlic, cinnamon, ginger, turmeric


Basil, bay leaf, cayenne, cinnamon, cloves, garlic, mint, nutmeg, paprika, parsley, rosemary, saffron, sage, tarragon, thyme, vanilla

* Note: Don’t season the beans while cooking; this will toughen them, and they won’t cook through.

Chili 1. Heat Dutch oven or large pot on medium-high

heat, add olive oil, then sauté onion, red bell pepper, and garlic. 2. Add tomato paste, cumin, and chili powder to create a paste and sauté for another minute. 3. Add vegetable stock, beans, and barley. Cook for 15 minutes. 4. Add tomatoes and cook for another 40 minutes until barley is tender. Add more stock or water if barley absorbs all of the liquid too quickly. 5. Add cocoa powder, chipotle pepper, maple syrup, and water (to loosen if necessary). Add salt and pepper. 6. Add garnish (optional) and enjoy. * Note: You can use two cups of canned beans, rinsed and drained, in place of dry beans if preferred. Nutrient Analysis per serving Calories: 310; Total fat: 4 g; Sat fat: 1 g; Sodium: 150 mg; Total carbohydrate: 58 g; Dietary fiber: 17 g; Sugars: 8 g; Protein: 15 g — SOURCE: RECIPE AND PHOTO COURTESY OF CHEF ABBIE GELLMAN, MS, RD, CDN, A NEW YORK-BASED CULINARY NUTRITION EXPERT AND RECIPE/PRODUCT DEVELOPER

For additional recipe, view this article on our website at


The following are some basic pairings based on the groupings in the table that can be used as starting points: • Eggplant with Italian seasonings: basil, oregano, thyme, garlic; • Black Beans with Latin-style seasonings: chili powder, garlic, onion, cumin, cinnamon; and • Carrots with Indian-style seasonings: curry powder, ground ginger, black pepper, onion, garlic.

november 2017  15

INTEGRATIVE NUTRITION content.5-7 It appears to increase cholesterol excretion while inhibiting cholesterol production in the liver.7 A 2013 Cochrane review found that artichoke leaf extract improved cholesterol levels modestly but the results weren’t compelling enough to recommend it as a treatment option.8 Side effects are minimal, but the extract may cause an allergic reaction, especially in those with ragweed allergies.4



Nutraceuticals can boost and complement diet and lifestyle interventions. “I don’t want to go on a statin” is a common refrain among patients seeking nutrition counseling for rising cholesterol levels. While a smart diet and physical activity plan can help manage hyperlipidemia, it isn’t always enough to budge the numbers to desired levels. One issue is that dietary components with potential cholesterol-lowering activity may be present in relatively small amounts in food. That’s where nutraceuticals can be a valuable part of an integrative nutrition strategy. Nutraceuticals are fortified foods or dietary supplements that have benefits in addition to their nutritional value.

The Science High blood cholesterol is one of the top 10 conditions for which people use complementary or integrative health practices such as dietary supplements,1 but Robin Foroutan, MS, RDN, HHC, a New York-based integrative dietitian and national spokesperson for the Academy of Nutrition and Dietetics, says it’s important to remember that people have high cholesterol for different reasons. “Some people are overproducing cholesterol, others are overabsorbing cholesterol—and some people are doing both,” she says. “So when you’re putting together your plan, it can be helpful to address both of these aspects. But the most important thing to keep in mind is to get chronic inflammation under control.”2,3 To that end, the following are some nutraceuticals to consider.

A bitter, intensely yellow substance from the bark, roots, and stems of plants in the genus Berberis, including the barberry plant, berberine has been shown to reduce total and LDL cholesterol and triglycerides, possibly reducing LDL by 20%.9 Berberine improves LDL uptake in the liver, similar to statins, and it may have a synergistic effect with statins, an idea that has been confirmed in cell culture, as well as in animal and a few human studies.10,11 The FDA hasn’t released specific claims on berberine’s safety and efficacy, and most clinical trials, which used 0.5 to 1.5 g/day, have been done only in Asian populations.9

Bergamot Bergamot extract supplements have been shown in a clinical trial to significantly lower total cholesterol, triglycerides, and LDL, especially small, dense LDL particles.12 Bergamot may inhibit cholesterol production and improve LDL uptake from the bloodstream.12,13 It also may raise HDL.6 These effects likely are due to bergamot’s high flavonoid content.6,12

Fiber A 2016 Cochrane review found that all types of dietary fiber may reduce total and LDL cholesterol,14 but notable sources are barley and oats, which are rich in beta-glucan and blond psyllium fiber.4,15 Remember that increasing fiber too quickly may cause digestive distress.

Flaxseed Flaxseed may lower total and LDL cholesterol even in patients who already are taking statins,16 although studies of various flaxseed preparations have shown mixed results. A 2009 review of the scientific research on flaxseed for lowering cholesterol found modest improvements in cholesterol, seen more often in postmenopausal women and in people with high initial cholesterol levels.17 A 2014 study found that 30 g/day of roasted flaxseed powder reduced total and LDL cholesterol as well as triglycerides.18 Flaxseed may interact with some blood-thinning medications, such as aspirin, clopidogrel, and warfarin.4

Artichoke Leaf Extract Artichoke (Cynara scolymus) leaf extract is marketed as an aid to lowering total and LDL cholesterol.4 It also may help raise HDL cholesterol and reduce inflammation thanks to its polyphenol

16  today’s dietitian  november 2017

Garlic Allicin, the major bioactive compound in garlic, has antiinflammatory effects and appears to inhibit cholesterol

synthesis and intestinal absorption.10,19 In vitro and animal studies have supported garlic’s cholesterol-lowering effects, but human studies have shown conflicting results.20 Overall, aged garlic extract and garlic powder supplements appear to have modest total cholesterol-lowering effects similar to those of diet modification alone.20 However, a study funded by the National Center for Complementary and Integrative Health on the safety and efficacy of three garlic preparations (fresh garlic, dried powdered garlic tablets, and aged garlic extract tablets) for lowering blood cholesterol levels found no effect.21 Although garlic supplements appear to be safe for most adults, they can thin the blood.1

Plant Sterols and Stanols Phytosterols and their derivatives, stanols, are structurally similar to cholesterol and reduce absorption of dietary cholesterol in the intestines by competing with it.9 This leads to improved liver uptake of LDL from the bloodstream.10 Sterols are found in small amounts in fruits, vegetables, nuts, seeds, cereals, legumes, and vegetable oils,9 as well as oral supplements and certain foods including margarine, orange juice, and yogurt.4 The average dietary consumption is about 300 mg/day, although vegetarians may get double that.9 “If increasing dietary fiber or natural sources of plant sterols is not easy, 2 g of plant sterols in supplemental form has been shown to be an effective option as a strategy for reducing high LDL cholesterol,” says Mary Purdy, MS, RDN, chair of Dietitians in Integrative and Functional Medicine, a dietetic practice group of the Academy of Nutrition and Dietetics.22

Red Yeast Rice A Chinese herbal supplement produced by fermenting rice with the yeast Monascus purpureus, red yeast rice contains substances called monacolins. One of these, monacolin K, is virtually identical to the cholesterol-lowering drug lovastatin,9 with both inhibiting cholesterol synthesis in the liver.23 The FDA doesn’t allow red yeast rice products with more than trace amounts of monacolin K to be sold as dietary supplements,24 because monacolin K can have the same side effects and drug interactions as lovastatin.25 Formulations with monacolin K have been shown to be effective in lowering total and LDL cholesterol,26-28 but other monacolins may lower cholesterol too.24 Red yeast rice also contains phytosterols, which inhibit cholesterol absorption, and fiber and niacin, which have their own cholesterol-lowering effects.9 Because there’s no way to know how much monacolin K is in a particular red yeast rice product—despite FDA regulations, it may show up in products in the United States—many experts believe more regulation is needed before recommending any formulation.29

Soyfoods Whole soyfoods such as edamame, soymilk, tofu, and tempeh may inhibit cholesterol production and increase uptake

from the bloodstream, reducing LDL by 4% to 13%.9,11,30 This is due to a variety of compounds in whole soy, including proteins, isoflavones, phytosterols, and beta-glucan.9,30,31 Soy also has anti-inflammatory effects.31 The FDA allows the health claim that diets low in saturated fat and cholesterol and include soy protein may reduce heart disease risk. The daily dietary intake of soy protein associated with reduced heart disease risk is 25 g or more.32

Integrating Nutraceuticals Into Practice Who might benefit most from nutraceuticals? For patients who have low to moderate cardiovascular risk and need to reduce LDL only slightly, using nutraceuticals in addition to dietary therapy might make it easier to reach and sustain target goals.10,11 They also may present an alternative for patients who can’t take statins due to side effects.10,11 Occupying the middle ground is combination therapy: Using nutraceuticals such as berberine or phytosterols that have a mode of action different from statins may increase the statin’s effectiveness, possibly allowing patients to reduce their dose.10,13 When it comes to dietary interventions, it’s important to focus on more than just dietary fat. “Fats usually get most of the attention when it comes to serum cholesterol and for good reason—obviously, avoiding trans fats completely and limiting saturated fats are important,” Foroutan says. “But research also has linked heart disease and high cholesterol with diets high in added sugars and processed carbohydrates.” Smart strategies include helping patients emphasize healthful sources of polyunsaturated and monounsaturated fats, including nuts and avocados, which have been shown to help reduce LDL. Purdy says the polyphenols in olive oil have been shown to specifically reduce levels of oxidized LDL, a key contributor to arterial plaque.33 Helping patients incorporate more high-fiber foods such as oatmeal, oat bran, beans and lentils, fruits, and vegetables may reduce reliance on commercial baked goods and snack foods. This has the dual benefit of reducing unhealthful fats and refined carbohydrates, two major contributors to chronic inflammation. “As with other chronic conditions, addressing inflammation is critical,” Foroutan says. “Best strategies include supplementing with omega-3 fatty acids, following a phytonutrient-rich anti-inflammatory diet, exercising regularly to raise HDL levels, and balancing blood sugar. All these things work together to support cardiovascular health.” — Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times and speaks frequently on nutritionrelated topics. She also provides nutrition counseling via the Menu for Change program in Seattle.

For references, view this article on our website at

november 2017  17



Research suggests supplementation may help prevent allergic disease and other conditions in infants. In her 28th week of pregnancy, Melissa visited her midwife for a regular checkup, where she was advised to begin taking an over-the-counter probiotic supplement. Although Melissa wasn’t opposed to taking probiotics, she questioned the science behind the recommendation. Her midwife said she didn’t know the specifics about the research but that it was considered good for maternal and infant health. It turns out there are mixed results in the literature regarding probiotics and pregnancy. To make evidence-based recommendations, it’s essential to wade through the clutter. Probiotics (and, more recently, prebiotics) are showing up in one food product after another—not just in all of the traditional places such as yogurt and sauerkraut but also in beverages, snack bars, and, of course, supplements. There’s a great deal of research being conducted on probiotics’ impact on the microbiome—whether they may help treat or prevent illness. Although pregnancy isn’t an illness, there’s enough research in the areas of maternal and infant health to consider using probiotics in some cases.

Potential Benefits Research on probiotic use is evolving at breakneck speed. Manipulating the gut microbiota to promote good health before, during, and after pregnancy often is recommended to promote maternal and infant health and enhance good health later in life. There’s convincing research in some of these areas, but research in other areas remains incomplete.

Healthy Mothers Maternal health is paramount to an uncomplicated pregnancy and delivery and a healthy baby. Of course, pregnancy is

18  today’s dietitian  november 2017

a completely normal condition and not akin to disease. However, researchers are studying probiotics for the possible treatment of some common conditions that may occur in pregnancy that range from minor to serious. One of the most common conditions that can cause discomfort for pregnant women is constipation. Often the result of hormones that cause the smooth muscle in the gastrointestinal (GI) tract to relax, dietary manipulation that includes increasing fiber and fluids can help reduce constipation. Probiotics may be a good additional nutrition therapy, too. While several studies have found that yogurt can treat constipation, few studies have been done in a pregnant population. In one randomized controlled trial of 60 women, researchers found that 300 g of probiotic-enriched yogurt (Bifidobacterium and Lactobacillus 4.8 × 1010 [CFU]) per day alleviated constipation better than conventional yogurt among pregnant women.1 Elizabeth Ward, MS, RD, Boston-based author of Expect the Best: Your Guide to Healthy Eating Before, During and After Pregnancy, says, “Probiotics may help to ease some of the GI problems that women face during pregnancy, including constipation. I recommend including probiotic foods such as fermented dairy products like yogurt and kefir every day over probiotic supplements.” Ward also mentions the need for prebiotics in the form of fiber, recommending at least 30 g of fiber each day from whole foods such as whole grains, fruits and vegetables (including legumes), and nuts and seeds. Another common condition during pregnancy is gestational diabetes mellitus (GDM). A small number of studies suggest potential protection with the use of probiotic supplements. Julian Crane, MB, BS, FRCP, FRACP, a professor in the department of medicine at the University of Otago, Wellington, New Zealand, says, “We (and others) have found a reduction in gestational diabetes mellitus.” In fact, in a study published in January 2017, Crane and his colleagues published a randomized controlled trial in which subjects (n=373) either took Lactobacillus rhamnosus HN001 or a placebo. Those who took the probiotic had a significantly lower incidence of GDM than those who didn’t (2.1% vs 6.5%).2 A previously published randomized controlled trial found no protection against gestational diabetes with the use of Lactobacillus salivarius UCC118, perhaps indicating the difference in efficacy of the strain.3 Other factors could be dosage, duration of treatment, timing of delivery (early vs later in pregnancy), or other genetic or environmental differences between the study groups. With regard to future and ongoing research, Crane says, “Other areas of interest with probiotics and maternal health would include vaginal infections during pregnancy and possible mental health given there’s a considerable interest in the whole area of probiotics and possible brain effects.” More research is needed to fully understand the impact of probiotic supplements on maternal health. Although current research prevents clinicians from making specific recommendations for probiotic supplementation in pregnancy, a review of studies evaluating the safety of Lactobacillus and Bifidobacterium showed no risk to expectant mothers or newborns.4,5


Calorie Free • Carb Free • Cholesterol Free • Dairy Free • Fat Free • Gluten Free • Kosher

©2017 PANOS brands ®

Simple Answers for Your Patients “The Walden Way ™ ”

Salad Dressings & Condiments

| Syrups & Coffee Creamers | Fruit & Peanut Spread | Veggie/Chip & Dessert Dips | BBQ & Pasta Sauces

PROBIOTICS Healthy Babies The development of the infant microbiome is a key area of study, and it’s known that there are a variety of contributing factors and situations that impact differences in microbial colonization among infants. Differences in the microbiome have been linked to increased allergy risk. Presently, there’s support for the use of probiotics to prevent eczema. Since eczema is a precursor to a variety of atopic conditions (eg, food allergies and asthma), and because it causes a great deal of suffering, reducing or preventing it is important. About 10.7% of children younger than 18 have eczema, and about 37% of those with moderate to severe eczema go on to develop food allergies, according to the American College of Allergy, Asthma and Immunology.6,7 While researchers continue to learn about the connection, controlling eczema may be one way to reduce the development of food allergies. Two separate systematic meta-analyses found a reduction in eczema risk among the offspring of mothers who took probiotic supplements during pregnancy.8,9 However, these two reviews had some limitations, so they were considered low quality. In fact, in a letter to the editor published in the Journal of Allergy and Clinical Immunology, one group of researchers and physicians said they question the value of the study by Cuello-Garcia and colleagues and these types of meta-analyses on the basis that it’s impossible to recommend to patients a specific probiotic strain they should take, in what dosage, and for how long based on the current research.10 According to Susan Prescott, MD, PhD, an internationally acclaimed pediatrician and immunologist from the University



of Western Australia, a member of the World Allergy Organization (WAO) expert panel, and author of the new book Secret Life of Your Microbiome: Why Nature and Biodiversity Are Essential to Health and Happiness, the issues with the research considered by the WAO include “the heterogeneity of studies, variety of strains, small and diverse population studies, and numerous other factors.” However, Prescott says, “this does not mean that microbes don’t have a significant effect on immune development.” The WAO recommends supplementation in certain instances.11 According to the World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Probiotics, clinicians should recommend probiotics to women at high risk of having an allergic child, those who breast-feed infants who are at high risk, and to infants who are predisposed to the development of allergy. According to the guidelines, “High risk for allergy in a child is defined as biological parent or sibling with existing or history of allergic rhinitis, asthma, eczema, or food allergy.” In addition, the guidelines say that although the quality of the evidence may be low, the possible net effect is worth supplementation, since the risk of negative impact is low.

Studies to Watch One of the studies to watch for is the Probiotics in Pregnancy (PiP) Study, a multicenter, multinational study that has recruited pregnant women to research the effect of L rhamnosus HN001 in early pregnancy through breast-feeding. Researchers expect administration to reduce the rate of infant

% of

Americans don’t get enough

Choline is an essential nutrient critical for fetal brain development and brain function. It has also been associated with improved cognitive performance in adults.

Two large eggs provide over half the recommended choline requirement for most people.

Find resources on choline & other topics at: Contact us at: *Wallace TC, et al. Nutrients. 2017;9(8).

eczema and atopic sensitization at 12 months. Researchers also are studying the impact of supplementation on GDM, bacterial vaginosis, and group B streptococcal vaginal colonization before birth, and depression and anxiety postpartum.12 Another study to keep an eye on is The Environmental Determinants of Diabetes in the Young (TEDDY), also a multicenter, multinational study. The TEDDY study is exploring the causes of type 1 diabetes mellitus to understand what interventions could help reduce the risk of its development. These researchers are exploring the interaction between genes and environmental contributors. The study is ongoing, but in 2015, researchers presented early data that showed a reduction of 33% in autoimmunity, based on the development of autoantibodies (antibodies to one’s own cells) after infant supplementation with probiotics starting in the first month of life. Although promising, more research is needed to confirm these findings.13

The Bottom Line As with most topics in nutrition and health, more goodquality research is needed to better understand which probiotics work best, in what doses, and for how long in which populations. Until then, the basic takeaways can be summed up as follows: • Probiotics generally are considered safe during pregnancy. • Supplementation should be considered in specific instances. • Probiotics from food are safe and nutritious for all clients. Probiotic foods are a safe way for pregnant women to introduce and consume healthful microbes during pregnancy and may provide other positive nutritional benefits. These may

include foods such as fermented sauerkraut (a source of fiber), and yogurt and kefir (providing calcium and vitamin D). Pregnant clients should avoid unpasteurized milk and juice products because of the risk of foodborne illness. Prescott says whole foods and fermented foods are the best approach for most people. However, “there may be a role for supplements in some situations as long as they’re seen as supplements and not replacements for healthful nutrition,” she says. Exact recommendations for dosing remain to be determined. As with all of nutrition counseling, dietitians should tailor recommendations to the individual patient and make recommendations in accordance with cultural preferences. Pregnant women who fall into the high-risk category are good candidates for probiotic supplements. In fact, regular consumption of safe, whole, fermented, and probiotic foods may benefit all patients. Finally, research on the benefits of probiotics is growing and dietitians should continue to follow the research in this area to provide the best evidence-based guidelines to use in practice. — Sherry Coleman Collins, MS, RDN, LD, is president of Southern Fried Nutrition Services in Atlanta, specializing in food allergies and sensitivities, digestive disorders, and nutrition communications. Find her on social media @DietitianSherry and at

For references, view this article on our website at

A Trusted Product of Dietitians for Over 80 Years • Helps support healthy weight+

FREE PATIENT SAMPLES! Go to for your free patient samples.

t H e a r hy t Heal

• Helps support healthy blood sugar levels+ • Helps lower cholesterol to promote heart health*

Available at Supercenters and Fine Retailers Nationwide *For lowering cholesterol to promote heart health. Diets low in saturated fat and cholesterol that include 7 grams of soluble fiber per day from psyllium husk as in Konsyl Original Formula may reduce the risk of heart disease by lowering cholesterol. One adult dose of Konsyl Original Formula has 3 grams of this soluble fiber. **More psyllium fiber per dose than the leading brands.

+These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.

Konsyl Pharmaceuticals, Inc. 8050 Industrial Park Rd • Easton, MD 21601 • 800.356.6795 • Customer Service Hours: M-F 8:30am to 5pm ET

THE RETAIL RD with pricing strategies (eg, temporary price reductions and coupons), dietitians can maximize supermarkets’ efforts to increase the appeal of more healthful products in stores and further demonstrate their own value.2,3 A 2010 national survey found that 66% of shoppers are receptive to programs or services that help them make more healthful choices while shopping.1 Dietitians in supermarkets are perfectly positioned to educate shoppers and transform instore efforts.

Product Displays


Further your career and enhance benefits for shoppers by knowing and increasing your value. In working with many retail RDs over the years, quantifying return on investment (ROI) for their positions and programs is a challenge they face. Relating the impact of RD services to common retail metrics such as sales, basket size, and customer loyalty isn’t something to which RDs typically are exposed in their dietetics training, and they may not have been trained to do this while working for a supermarket retailer. However, there’s nothing more powerful than the ability to prove your value through ROI, whether when working for a supermarket or in any other dietetics position. A simple way to think about ROI as a dietitian is to consider whether your salary and benefits are offset by the supermarket’s profits from the services you provide. Because supermarkets operate on slim profit margins to begin with, it’s extremely important for retail RDs to be conscious of their contribution to the bottom line and how they influence grocery sales. This article focuses on ways retail RDs can quantify ROI for their position and services.

Retail Promotional Tools According to Retail Grocery Store Marketing Strategies and Obesity: An Integrative Review, a study in the American Journal of Preventive Medicine, 39% of products in consumer’s baskets were influenced by retailer promotions.1 By combining typical retail-based promotion strategies (such as in-store displays, food samples/demos, and point-of-purchase signage)

22  today’s dietitian  november 2017

An estimated 70% of all consumer purchasing decisions are made at the shelf, which is why merchandising displays and placement have a powerful influence on shoppers.4,5 Increasing the selection, convenience, and visibility of more healthful options has been shown to increase sales and can be accomplished by creating a designated health-themed display on an end-cap or other hightraffic area of the store.6 IRI Worldwide reports that more than one-quarter of volume, on average, is sold with merchandising support.7 To put this knowledge into action, The Food Trust has published “Supermarket Strategies to Encourage Healthy Eating,” a toolkit that provides a blueprint for effective retail strategies that include in-store marketing tips, such as creating designated promotional shelf space for more healthful products or using shelf space, position, and end-cap displays to promote more healthful food items.8 To calculate the ROI of displays, it’s important to establish a baseline of sales of the product. For example, if you’re promoting a whole grain cereal featured on an end-cap display that also lives in the cereal aisle, you can measure sales of that particular cereal or brand family (a group of related brands) when it isn’t on display and is similar in price. Typically, I’d recommend measuring both using the same duration or timeframe, whether it’s for one week or four weeks. The increased sales volume generated by the feature display is called incremental lift. Another easy way to compare sales is to look at the 52-week average and compare it with the previous year’s 52 weeks. A note about tracking sales for brand families: In most cases, products that are part of a brand family have multiple UPCs, meaning that if you’re featuring whole-grain Cheerios, several other cereals that are line-priced with this cereal also will be on sale. When you pull a data report by UPC, it’s important for analysis purposes to separate the SKUs, or stock keeping units, that were on the display.

KNOW YOUR NUMBERS In most cases, sales and profitability data are the gold standard in measuring return on investment (ROI). However, there are many other numbers that are meaningful in proving the value and impact of retail RD services. Some important numbers to track with regard to ROI and overall impact include the following: • the number of stores in which an RD has a display

(the more, the better); • the distribution/circulation of publications

featuring the RD or promoted products; • the number of publications printed for in-store

customer pick-up; • the number of in-store signs or nutrition tags

executed per week, month, or year (it’s valuable to gather statistics on promoted/tagged products); and • the number of media and social media impressions

(eg, how many total followers or how many likes or comments are generated for a particular post or party). If you’re struggling to measure ROI, please submit questions or comments to Barbara Ruhs, MS, RDN, @BarbRuhsRD on Twitter and Instagram. — BR

of samples taken by individual customers, and customer surveys can be used to gather more qualitative data.

Direct Revenues In addition to retail-based strategies, dietitians seeking to demonstrate ROI can consider direct revenue sources. Food manufacturers and fresh produce organizations are accustomed to negotiating promotional programs with retailers. Retail RDs who use in-store displays, demos, sampling, and point-of-purchase nutrition labels or signage can establish a sponsorship fee in which companies pay for weekly or monthly promotions. Retail RDs also function as advocates for customer health and can play an important role in providing timely nutrition education that guides shoppers in specific food selections. In establishing sponsorship fees, a good place to start is to consider the annual costs to run a retail RD platform, including marketing materials, in-store activation, and your salary. Some retail RDs may have the physical space to offer fee-for-service counseling services, culinary classes, and other nutrition services that can be a great revenue source. Although there are limited published data on ROI for health care services dietitians provide in the retail environment, revenue generated by these services is related directly to the RDs offering the services. Furthermore, dietitians can make the case that they’re attracting potential new customers, enhancing customer loyalty, and increasing basket size. To measure this, retail RDs must collect data on these customers and track their loyalty card data if possible.

Benefits of Analyzing the Data Demos, Sampling, and Point of Purchase The addition of food demos and sampling is an effective tool for dietitians to employ when seeking to prove ROI and have a significant impact on sales. “The Psychology Behind Costco’s Free Samples,” an article published in The Atlantic in 2014, cited that in some cases, retailers have boosted sales by 2,000% by offering samples.9 In the supermarket intervention Eat Right-Live Well, executed in Baltimore, there was a 23.1% increase in the sales of promoted healthful products from pre- to postintervention by combining nutrition education, food sampling, point-of-purchase labeling, and pricing strategies.10 This research paper is particularly valuable for RDs in the planning stages to promote specific products, as it includes sales data for a variety of food categories promoted that can be used as a metric or guide in estimated ROI. Dietitians can measure the impact of demos and sampling in a few different ways. They can review store sales of a product or unit movement each day a demo was conducted and compare the results with the previous week’s sales or movement. Of course, if your store runs out of the product the day you’re sampling, that’s also an easy way to gauge success of your demo. Retail RDs also can choose to evaluate in-store demos by counting the number

Whether you’re a self-employed RD or working for a supermarket or any other type of organization, being able to quantify your value is a powerful tool that can be used to pitch new business, expand your dietitian team, or justify an increase in salary. Retail RDs can benefit by studying and implementing successful retail-based strategies such as in-store displays, sampling programs, and point-of-purchase signs or tags that impact sales. In addition, retail RDs should consider working with and learning from their retailer’s customer insights and loyalty analysts, who collect and measure sales data. Working with category managers to gain insights into key metrics and strategies to measure sales impact also can be valuable. Being creative, learning how to evaluate success in the retail environment, and finding ways to generate sales using the unique skills and qualifications of RDs can impact retail and the health of customers now and into the future. — Barbara Ruhs, MS, RDN, is a retail health expert to supermarkets and food companies and founder of the Oldways Supermarket Dietitian Symposium.

For references, view this article on our website at

november 2017  23


he winter holiday season is a time full of family and feasting, tradition, and temptation. Holiday meals often are built around family-favorite recipes that are comforting in their familiarity but aren’t necessarily the most healthful of choices. “Growing up back in the 1960s and ’70s, I have fond memories of my nana’s luscious lemon spongecake and my mom’s super-sweet sweet potato casserole,” says Liz Weiss, MS, RDN, creator of the family food podcast, blog, and website Liz’s Healthy Table, author of the new coloring book series Color, Cook, Eat!, and coauthor, with Janice Newel Bissex, MS, RD, of the cookbooks No Whine With Dinner and The Moms’ Guide to Meal Makeovers. Carolyn O’Neil, MS, RDN, who was born in her mother’s native Scotland but grew up on the gulf coast of Florida in a family that loved to throw big dinner parties (even though they didn’t have a dishwasher), recognizes that excess comes with the territory at holiday time. “Holidays are times for indulgence, but as a registered dietitian nutritionist I like to treat family and friends to comfort foods with a twist,” says O’Neil, an award-winning food and travel writer,

television personality, blogger at TheHappyHealthyKitchen. com, and author of The Slim Down South Cookbook and The Dish on Eating Healthy and Being Fabulous! “Smart ingredients can lighten a dish a bit, and big flavors add enjoyment to sensible portions.” Other nutrition professionals try to create new healthful traditions for their family and friends. “I always try to make something simple, seasonal, delicious, and vibrantly healthy,” says Maggie Moon, MS, RDN, associate director of nutrition communications at The Wonderful Company in southern California and author of The MIND Diet. “Ultimately, I want my loved ones to live long and healthy lives, so tasty yet ridiculously healthful food is my love language.” Mixing lighter versions of comfort foods with healthful choices may satisfy all tastes. “I like to have the right balance of indulgent and healthfulness throughout the holidays,” says Michelle Dudash, RDN, a Cordon Bleucertified chef and author of Clean Eating for Busy Families. “I don’t believe in going all or nothing. If everything is drenched in butter, you may feel a little nauseous afterward. If you go too ‘low’ or ‘no’ across the board, the meal isn’t as special and satisfying.”


Nutrition experts offer tips for keeping time-honored traditions both delicious and nutritious.

Planning is key to striking the right balance. “I find I really do have to plan my menus and recipes carefully,” O’Neil says. “Usually everything that everyone else brings isn’t healthful, so I concentrate on bringing a healthful harvest of dishes to the holiday table.” Planning also can ensure the hosts get to enjoy the celebration along with their guests. “If you choose simple dishes, you won’t be stuck in the kitchen (or getting in anyone’s way) for long,” Moon says. Janis Jibrin, MS, RD, author of The Pescetarian Plan and an adjunct professor of nutrition at American University in Washington, D.C., says that the stove and oven tend to be overflowing when preparing a large meal. “Finding dishes that can be made ahead or that don’t require heating, like a cold vegetable side, can free up cooking space and save time,” Jibrin says.

Time for Traditions No matter what holiday is being celebrated, or what cultural background the celebrants bring to the table, most people can point to traditions (food and nonfood) that define the holidays for them. “Growing up as a kid with my great-grandmother, we were always surrounded by her Lebanese dishes during special occasions, including Thanksgiving and Christmas,” Dudash says. “Raw kibbe, tabouli, chopped salad with lemon vinaigrette, and unleavened bread were staples.” A theme that resonated with all of the RDs interviewed for this article was the importance of both reliving and creating childhood memories. “I loved sitting between my mother and nana and assisting them with the Thanksgiving meal,” says Weiss, who grew up outside of New York City and now lives in Massachusetts. For O’Neil, it’s the togetherness that resonates. “The holidays bring to mind one thing first: setting and sitting at a very big table. As a child, I remember the job of finding chairs around the house to fit as many guests as possible at the dining room table. The best part was setting up the folding chairs for the kids’ table. We had our own flowers and fancy plates too.” Cooking for large gatherings is a great time to involve children in food preparation. “Weeks before Christmas, my girls love baking Christmas cookies,” Dudash says. “I am always in search of the perfect Christmas cut-out cookie recipe, trying a different one each year. And now that my daughter is 8 years old, I let her take the reigns with rolling out, cutting, and decorating, and my toddler helps, too. It was somewhat trying for me at first, with my five-star restaurant background where everything has to be perfect. But my girls love doing everything on their own. So the cookies don’t turn out perfect, but the girls are so proud of their efforts. And they still taste good.” — Judith C. Thalheimer, RD, LDN, is a nutrition writer and speaker based outside Philadelphia, Pennsylvania.

26  today’s dietitian  november 2017

Brussels Sprouts Marinated With Sesame and Rice Wine Vinegar “Thanks to my father’s job with the State Department, I grew up in Greece, Lebanon, and Italy, so my food influences are firmly Arab/Mediterranean,” says Janis Jibrin, MS, RD, “but on holidays, my Iowan mother’s traditions trumped those of my Syrian father. We had turkey, Waldorf salad, sweet potatoes, and the like.” Many dishes served at holiday meals tend to be heavy and fatty, so Jibrin offers this light side dish to provide balance. “While I love roasted or sautéed Brussels sprouts, eating them raw with just a little vinegar and sesame seeds is so refreshing.” This cold, no-cook dish also frees up stovetop space. “It’s not just the stovetop that overflows,” Jibrin says, “there’s also no room in the oven. So, last Thanksgiving I bought an electric turkey roaster that promised to roast the turkey in three hours. Well, five hours later we got so hungry we sat down to a table laden with vegetarian options (including these Brussels sprouts) and had the turkey for dessert!”

If eating raw Brussels sprouts sounds odd to you, just think “baby cabbage.” Also try this same recipe with other thinly sliced or shredded vegetables such as carrots, kale, cabbage, celery, cucumber, or turnips. Serves 4

Ingredients 4 cups Brussels sprouts, ends removed and thinly sliced 2 T sesame seeds 2 tsp sesame oil 1 T seasoned rice vinegar 1 ⁄8 tsp salt

Directions 1. Place the Brussels sprouts,

sesame seeds, sesame oil, vinegar, and salt in a bowl and mix thoroughly. 2. Cover and let sit at room temperature for at least 15 minutes and up to three hours. Serve immediately or refrigerate and serve chilled. Nutrient Analysis per serving Calories: 88; Total fat: 5 g; Sat fat: <1 g; Cholesterol: 0 mg; Sodium: 97 mg; Total carbohydrate: 9 g; Dietary fiber: 4 g; Sugars: 2 g; Protein: 4 g — RECIPE USED WITH PERMISSION FROM THE PESCETARIAN PLAN (BALLANTINE 2014); PHOTO BY JOHN COCHRAN

Chopped Salad With Israeli Couscous, Smoked Salmon, and Creamy Pesto For Michelle Dudash, RDN, Christmas is a time of togetherness. “I love seeing Christmas through the lens of my children,” Dudash says. “They get so excited about all of the traditions and activities.” Dudash’s submission proves that a recipe doesn’t have to meet a narrow focus of so-called traditional holiday foods to be a favorite. “I started making this recipe for our Christmas Eve party buffet five years ago,” Dudash says. “One year I brought a different dish and people asked where it was. So it has become a delicious tradition. It’s a very substantial salad, so it still catches guests’ attention among even the most decadent and classic of holiday dishes.”

Serves 4

Ingredients Salad 11⁄3 cups cooked Israeli (pearled) couscous (whole-grain preferred) (or you may use quinoa) 3 tsp expeller-pressed grapeseed or canola oil, divided 1 ear of corn (or 1 cup frozen corn, thawed) 4 cups arugula, chopped (or use baby spinach) 1 cup diced tomatoes (about 1 large) 1 (4-oz) package smoked wild Alaskan salmon, diced 1⁄4 inch (about 1 cup) 1 ⁄2 cup golden raisins, chopped through twice 1 ⁄4 cup shredded Asiago cheese (or use Parmesan) 1 ⁄4 cup roasted pepitas (shelled pumpkin

seeds, or use chopped roasted almonds)

Dressing 3 T low-fat milk 2 T olive oil or sunflower oil mayonnaise 2 T nonfat plain Greek yogurt 1 T + 1 tsp basil pesto 1 T minced shallots or red onion 1 tsp lemon juice 1 ⁄4 tsp freshly ground black pepper

Directions 1. Prepare couscous accord-

ing to package directions. Toss with 2 tsp of the oil to prevent sticking and spread mixture on a plate to cool it quickly. 2. Heat a medium sauté pan over medium heat and add 1 tsp of oil. Place the ear of corn into the pan and blister on one side, about 1 minute. Continue to cook and turn corn until all sides are blistered; remove pan from heat

and let cool slightly. Stand the cob up on a cutting board and, holding it firmly, cut the kernels off the cob. 3. Whisk together all of the dressing ingredients. 4. When ready to serve, combine the couscous, corn, and remaining salad ingredients and pour the dressing on top. Toss well. Salad may be served immediately and will stay fresh for a few hours. Tip: Corn and tomatoes peak in summer and fall. Substitute 1 cup frozen, canned, or freeze-dried corn (no need to blister) and 1⁄4 cup sun-dried tomatoes in oil, drained, during the off season. Nutrient Analysis per serving (2 cups) Calories: 379; Total fat: 18 g; Sat fat: 3 g; Cholesterol: 20 mg; Sodium: 524 mg; Total carbohydrate: 41 g; Dietary fiber: 4 g; Protein: 18 g — RECIPE AND PHOTO REPRINTED WITH PERMISSION FROM CLEAN EATING FOR BUSY FAMILIES: GET MEALS ON THE TABLE IN MINUTES WITH SIMPLE AND SATISFYING WHOLE-FOODS RECIPES YOU AND YOUR KIDS WILL LOVE BY MICHELLE DUDASH, RD (FAIR WINDS PRESS, DECEMBER 2012)

pizzelle iron and clamp the handles together with the handle clamp. 6. Cook for about 40 seconds, until the cookie is lightly browned. Remove with a spatula and transfer to a wire rack to cool. Nutrient Analysis per serving (1 cookie) Calories: 90; Total fat: 6 g; Sat fat: 3.5 g; Cholesterol: 25 mg; Sodium: 8 mg; Total carbohydrate: 8 g; Dietary fiber: 1 g; Sugars: 4 g; Protein: 2 g

Coconut Almond Pizzelles “For as long as I can remember, my dad made pizzelles at the holidays,” says Janice Newell Bissex, MS, RDN, a family nutrition expert, blogger at, and cookbook author who grew up outside of Boston in a close-knit family of seven. “Always patient, he would fire up the pizzelle iron, spoon the batter onto the hot iron, set his timer, and then gently transfer the soft pizzelles to a cooling rack. A couple of years ago, I spent the afternoon with him and he taught me how to make this special treat. My first several attempts resulted in torn and misshapen cookies, but under his patient and watchful eye I managed to figure out the proper technique. My dad passed away this year, so it will be up to me to continue the pizzelle tradition with my family.” Serves 30 Replacing one-half of the allpurpose flour in a traditional pizzelle recipe with almond flour and decreasing the sugar results in a cookie with twice the fiber and protein and one-third less sugar … but all of the flavor!


Ingredients 3 large eggs 1 ⁄2 cup granulated sugar 1 ⁄2 cup coconut oil, melted and cooled 11⁄2 tsp anise extract 1 tsp vanilla extract 1 cup almond flour 1 cup all-purpose flour 2 tsp baking powder 1 ⁄8 tsp ground cinnamon

Directions 1. Lightly oil or coat the piz-

zelle iron with nonstick cooking spray and plug it in to preheat. 2. Combine eggs and sugar in a medium bowl and beat on medium speed or whisk by hand until well blended. Add the coconut oil, anise, and vanilla, and beat until blended. Scrape down the sides of the bowl if necessary. 3. In a separate bowl, whisk together the almond flour, flour, baking powder, and cinnamon. 4. At slow speed, gradually beat the flour mixture into the liquid mixture until just combined. 5. Place one heaping teaspoon at a time in the center of each of the grids of the

28  today’s dietitian  november 2017

Pecan-Topped, Slightly-Sweet Sweet Potato Casserole

that she’s all grown up, Weiss is a big contributor to the holiday meal. “As a dietitian, I’m always asked to bring a vegetable side dish to Thanksgiving dinner,” she says, “so naturally, I bring three: roasted baby carrots with fresh thyme, Brussels sprouts gratin made with low-fat milk instead of heavy cream, and this modern (no marshmallow) version of sweet potato casserole. At Thanksgiving dinner, many people like to take a little bit of this and a little bit of that. So even though I say this casserole serves eight, at the holidays it likely will yield 10 servings.” Serves 8

“Thanksgiving is my favorite holiday of the year,” says Liz Weiss, MS, RDN, a mom of two with a specialty in family nutrition. “I was a foodie from an early age and was always seated between the other two foodies at the table: my mom and my nana.” Now

Ingredients 3 lbs sweet potatoes 2 T extra virgin olive oil or melted virgin coconut oil, divided

3 T orange juice 2 T brown sugar, divided 1 tsp orange zest 1 ⁄2 tsp ground cinnamon, divided 1 ⁄4 tsp kosher salt 1 ⁄8 tsp ground ginger 1 ⁄2 cup roughly chopped pecans

Directions 1. Preheat oven to 400˚ F. 2. Place the sweet potatoes

on a foil-lined baking sheet. Pierce each potato several times with the tip of a sharp knife. Brush the potatoes with 1 T of oil and sprinkle with a pinch of kosher salt. 3. Bake until very tender, 45 minutes to an hour. Remove from the oven and reduce the heat to 350˚ F. 4. When the potatoes are cool enough to handle, cut them in half, scoop out the flesh into a bowl, and mash until smooth. (You will have about 4 cups.) Stir in the orange juice, 1 T of the brown sugar, orange zest, 1⁄4 tsp of the cinnamon, salt, and ginger. Place in an 8 X 8-inch baking dish and smooth the top with a rubber spatula. 5. To make the topping, place the remaining brown sugar, oil, cinnamon, and the pecans in a bowl and stir to combine. Sprinkle the mixture over the sweet potatoes. Bake until the nuts are toasted and the casserole is heated through, about 30 minutes. Nutrient Analysis per serving (1⁄2 cup) Calories: 207; Total fat: 8.5 g; Sat fat: 1 g; Cholesterol: 0 mg; Sodium: 120 mg; Total carbohydrate: 31 g; Dietary fiber: 5 g; Sugars: 12 g; Protein 3 g — RECIPE AND PHOTO COURTESY OF LIZ WEISS, MS, RDN, THE VOICE BEHIND THE FAMILY FOOD PODCAST LIZ’S HEALTHY TABLE AND THE BLOG AND WEBSITE OF THE SAME NAME. LIZ HAS WRITTEN SEVERAL COOKBOOKS INCLUDING NO WHINE WITH DINNER: 150 HEALTHY KID-TESTED RECIPES FROM THE MEAL MAKEOVER MOMS; THE MOMS’ GUIDE TO MEAL MAKEOVERS: IMPROVING THE WAY YOUR FAMILY EATS, ONE MEAL AT A TIME!; AND THE PLAYFUL NEW COLORING BOOK SERIES COLOR, COOK, EAT!

Jeweled Holiday Acorn Squash “Come Christmastime, my family gathers at my parents’ home in southern California,” says Maggie Moon, MS, RDN, a first-generation Korean American who was raised in southern California where her mother and grandmother ruled the kitchen. They had traditional Korean food made from scratch and encouraged Moon to learn about the fruits and vegetables of California. Today, their table is a meld of fresh California produce and traditional Korean flavors. “There’s a single pomegranate tree in our backyard, and every winter my mom saves the best one for me. This simple side dish is a way to honor those precious jewels of winter.”

Serves 6

Ingredients 2 small acorn squash, 2-3 lbs each, cut into 1-inch rings (about three rings per squash) 2 T extra virgin olive oil 1 tsp curry powder Salt and pepper, to taste 1 ⁄2 cup pistachio kernels 1 ⁄2 cup pomegranate arils (1 small pomegranate; you may have extra)

Directions 1. Preheat oven to 400˚ F. 2. Remove pomegranate arils

by quartering the pomegranate and loosening arils from the skin underwater in a large bowl; drain. 3. On a large baking sheet, arrange acorn squash rings in a single layer. Drizzle with

olive oil, curry powder, and salt and pepper to taste. Toss to combine. 4. Bake for 20 minutes or to desired doneness (fork should easily pierce the skin). Allow to cool for at least 10 minutes, season to taste. 5. Transfer to serving platter and generously garnish with pistachios and pomegranate arils. Serve immediately. Tip: Use a circular ravioli or cookie cutter to remove seeds from each squash ring. This

makes it easy to have a visually pleasing center cut out with clean edges. Nutrient Analysis per serving Calories: 240; Total fat: 10 g; Sat fat: 1.5 g; Cholesterol: 0 mg; Sodium: 10 mg; Total carbohydrate: 38 g; Dietary fiber: 11 g; Sugars: 7 g; Protein: 5 g — RECIPE AND PHOTO COURTESY OF MAGGIE MOON, MS, RDN, AUTHOR OF THE MIND DIET, OWNER AT MINDDIETMEALS.COM, AND A HEALTH COMMUNICATIONS MANAGER FOR POM WONDERFUL

november 2017  29

Baked Smokin’ Mac & Cheese “My favorite holiday tradition is the unwritten rule of dressing up, using the good china, eating together, eating the same foods, and eating at the same time,” says Carolyn O’Neil, MS, RDN. “When I was a child, everyone assembled around a big table with napkins in laps ready to begin the mad passing of gravy and cranberry sauce. In the busy, schedule-crazy world of today, that unfortunately doesn’t happen very often anymore.” For many people, that big family meal wouldn’t be complete without certain (not-so-healthful) dishes. Finding ways to tweak those recipes to make them more nutritious without sacrificing taste can help families keep their traditions and their health. “This recipe from my Slim Down South Cookbook brings traditional

taste to the table with a contemporary eye on nutrition,” O’Neil says. Serves 8 Creamy, cheesy, a crunchy topping, and plenty of carbs— no wonder mac and cheese is the ultimate comfort food. It’s even made appearances as a side on Southern meatand-three plates. Not only is this version lighter but it’s got a little ham, too. Use elbow pasta if you can’t find cellentani.

Ingredients 1 lb uncooked cellentani (corkscrew) pasta 2 T butter 1 ⁄4 cup all-purpose flour 3 cups fat-free milk 1 (12-oz) can fat-free evaporated milk 1 cup (4 oz) shredded smoked Gouda cheese

30  today’s dietitian  november 2017

⁄2 cup (2 oz) shredded 1.5% reduced-fat sharp Cheddar cheese 3 oz fat-free cream cheese, softened 1 ⁄2 tsp salt 1 ⁄4 tsp ground red pepper, divided 1 (8-oz) package chopped smoked ham Vegetable cooking spray 11⁄4 cups cornflakes cereal, crushed 1 T butter, melted 1

Directions 1. Preheat oven to 350˚ F.

Prepare cellentani pasta according to package directions. 2. Meanwhile, melt 2 T butter in a Dutch oven over medium heat. Gradually whisk in flour; cook, whisking constantly, 1 minute. Gradually whisk in milk and evaporated milk

until smooth; cook, whisking constantly, 8 to 10 minutes or until slightly thickened. Whisk in Gouda cheese, next three ingredients, and 1⁄8 tsp ground red pepper until smooth. Remove from heat, and stir in ham and pasta. 3. Pour pasta mixture into a 13 X 9-inch baking dish coated with cooking spray. Stir together crushed cereal, 1 T melted butter, and remaining 1⁄8 tsp ground red pepper; sprinkle over pasta mixture. 4. Bake at 350˚ F for 30 minutes or until golden and bubbly. Let stand 5 minutes before serving. Nutrient Analysis per serving Calories: 447; Total fat: 10 g; Sat fat: 4 g; Cholesterol: 42 mg; Sodium: 903 mg; Total carbohydrate: 62 g; Dietary fiber: 2 g; Sugars: 14 g; Protein 26 g — RECIPE AND PHOTO COURTESY OF CAROLYN O’NEIL, MS, RDN, AND SOUTHERN LIVING’S THE SLIM DOWN SOUTH COOKBOOK

RDs & Nutrition Professionals! Need continuing education credits for recertification or career development? Our Learning Library is always open!

Visit and earn CPEUs from the range of self-study courses, articles, webinars, and books in our CE Learning Library. Log on, create an account, and enjoy our low-stress, cost-efficient way to earn the credits you need.

Visit and earn CPEUs from the range of self-study courses, articles, webinars, and books in our CE Learning Library.




By Constance Brown-Riggs, MSEd, RD, CDE, CDN

As more children are diagnosed with type 2 diabetes, RDs and diabetes educators need to know how to effectively counsel them.


ver the past 10 years, the face of diabetes has changed dramatically. Type 2 diabetes—once thought of as an obese adult disease, is emerging rapidly in children and adolescents. According to a 2016 consensus report published in Diabetes Care, there are 5,000 new cases each year in the United States, and the prevalence increases with age, tripling from age 10 to 14 years to 15 to 18 years. Although diabetes rates in adult men and women are similar, adolescent girls have a 60% higher prevalence rate than boys.1 Even more troubling, the majority of new cases are among youth of minority racial and ethnic groups. Ethnic disparities also are apparent in death rates. Mortality rates of African American children with diabetes are more than twice as high as those for their white peers and more than three times higher than those for Hispanic children.2,3 It’s projected that by 2050 the prevalence of type 2 diabetes in youth will increase four-fold to more than 80,000.4 This article will describe the pathophysiology, risk factors, signs and symptoms, complications, and management of type 2 diabetes in youth and will provide strategies for diabetes educators counseling children with type 2 diabetes and their parents.

Obesity a Major Risk Factor It’s been said that the 21st century is an unprecedented diabetogenic era in human history, and the number of children diagnosed with type 2 diabetes continues to soar exponentially.5 Compared with their normal-weight counterparts, children who are obese have a quadrupled risk of developing type 2 diabetes.6 Although childhood obesity, a major risk factor for type 2 diabetes, isn’t increasing in the United States, the prevalence of type 2 diabetes in children has increased three-fold. This prevalence is due in large part to the fact that the degree of obesity in affected children is increasing.7 Obese children are hyperinsulinemic; they have approximately 40% lower insulin-stimulated glucose metabolism than nonobese children.8 Childhood obesity rates are higher among minorities, and there’s evidence that African American children may have a genetic predisposition to insulin resistance, putting them at increased risk of type 2 diabetes. African American children aged 7 to 11 have significantly higher insulin levels than agematched white children.8

Signs and Symptoms Most children with type 2 diabetes are obese or extremely obese at diagnosis and present with glucose in the urine without ketones, no or mild polyuria and polydipsia, and little or

no weight loss. Children with type 2 diabetes usually are diagnosed over the age of 10 in middle to late puberty. Increased growth hormone secretion during puberty contributes to insulin resistance and resulting high insulin levels.8 Distinguishing between type 1 and type 2 diabetes at diagnosis is important—although not always easy, because treatment regimens, educational approaches, dietary advice, and outcomes differ markedly between patients with the two diagnoses.9 Overweight and obesity are common in children with type 1 and type 2 diabetes. “Today, the challenge with determining type 1 and type 2 diabetes is that children with type 2 are generally very overweight or obese and have such severe insulin resistance. Some children present with a hemoglobin A1c of greater than 10% and the three P’s (polyuria, polydipsia, polyphagia), resulting in the need for insulin. These are the classic signs and symptoms of type 1 diabetes; however, after further testing with blood work, type 1 diabetes is ruled out,” says Kimberly Philbin, RD, CDN, a practice dietitian in the division of pediatric endocrinology at Cohen Children’s Medical Center in Lake Success, New York. Further testing may include fasting insulin levels, C-peptide, and insulin autoantibodies.8 Up to 33% of children in particular ethnic groups—primarily African Americans—have ketones in their urine at diagnosis, and 5% to 25% have ketoacidosis at diagnosis. It’s very rare for children with type 2 diabetes to present with a hyperglycemic hyperosmolar coma. These clinical features often delay the confirmation of the type of diabetes for months.8 Marina Chaparro, MPH, RDN, CDE, a clinical dietitian and national spokesperson for the Academy of Nutrition and Dietetics, says, “It is possible to see overweight kids with newly diagnosed type 1 diabetes and even with some clinical signs of insulin resistance, all due to the excess weight. Insulin antibodies should be assessed in all children upon diagnosis to determine the correct pathogenesis and provide appropriate treatment.” Typical characteristics of type 2 diabetes include the following:8 • slow onset; • overweight or obese patients from a minority group (Native Americans, African Americans, and Pacific Islanders); • signs of insulin resistance (eg, acanthosis nigricans, hypertension, polycystic ovary syndrome [PCOS], dyslipidemia); • retinopathy; and • strong family history of type 2 diabetes.

Screening The American Diabetes Association 2017 Standards of Medical Care in Diabetes recommend screening for prediabetes and type 2 diabetes in children who are overweight or obese and who have two or more of the following risk factors for diabetes:

november 2017  33

• family history of type 2 diabetes in a first-degree or second-

degree relative; • minority race or ethnicity (eg, Native American, African American, Latino, Asian, or Pacific Islander); • signs of insulin resistance or conditions associated with insulin resistance (eg, acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for-gestational-age birth weight); and • maternal history of diabetes or gestational diabetes during the child’s gestation.9 Screening should start at age 10 or at the onset of puberty, whichever is earlier. Subsequent screening should be performed every three years. A fasting plasma glucose test is the preferred screening study; if clinical suspicion is high but fasting blood glucose is normal (<100 mg/dL), an oral glucose tolerance test should be considered.9

Pathophysiology and Complications Insulin resistance and nonautoimmune beta-cell failure are the hallmarks of type 2 diabetes in children and adults. However, children exhibit a rapidly progressive betacell decline and accelerated development of diabetes complications.1 “Children with type 2 diabetes are affected differently than adults with diabetes. Studies in children with type 2 diabetes point to a faster and more severe progression of diabetes-related complications,” Chaparro says. The TODAY (Treatment Options for type 2 Diabetes in Adolescents and Youth) study showed the loss of glycemic control was three- to four-fold higher in adolescents and youth than rates observed in adults.1 Moreover, youth with type 2 diabetes experience diabetes complications at a greater rate than children with type 1 diabetes. “The earlier the onset, the earlier the complications. Some studies estimate that children with type 2 diabetes may develop some type of diabetes complication as early as age 21,” Chaparro says. In a study published in the February 2017 issue of the Journal of the American Medical Association, researchers examined how quickly and often youth developed signs of kidney, nerve, and eye diseases, which are among the most common diabetes complications. They also measured several risk factors for heart disease. Surprisingly, after having diabetes for less than eight years, at age 21 one in three patients with type 1 diabetes and almost three in four patients with type 2 diabetes had at least one of the following complications or comorbidities: diabetic kidney disease, retinopathy, peripheral neuropathy, arterial stiffness, or hypertension.10,11 (See table for more information about type 1 vs type 2 diabetes.) It should be noted, most of the patients with type 2 diabetes in the study were African American (43%), followed by white (26%), Latino (21%), Native American (7%), or other (3%), and most were obese (72%) or overweight (18%). Most (41%) came from families in the lowest annual household income category (<$25,000 per year).11

34  today’s dietitian  november 2017

Management Generally, the treatment goals for youth with type 2 diabetes are the same as those for youth with type 1 diabetes, including blood glucose control and management of obesity, dyslipidemia, hypertension, and microvascular complications.9 The American Academy of Pediatrics Clinical Practice Guidelines for children with type 2 diabetes suggest that clinicians incorporate the Academy of Nutrition and Dietetics’ Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines at the time of diagnosis and as part of ongoing management.12 (See for the full practice guidelines.) Pharmacotherapy for youth with type 2 diabetes is limited. “Unfortunately, there are limited therapeutic treatments for children with type 2 diabetes due to the lack of available clinical data in this population. Typically, insulin and metformin are the two medications used in children with diabetes,” Chaparro says. However, new drugs such as dipeptidyl peptidase inhibitors or glucagonlike peptide-1 mimetics are in development for treatment of youth with type 2 diabetes.8 Type 2 diabetes has a disproportionate impact on youth of ethnic/racial minorities and from disadvantaged backgrounds; it also often occurs in complex psychosocial and cultural environments that make lasting lifestyle change difficult to achieve and adherence to medical recommendations a struggle.1 The following strategies can help improve outcomes in dietitians’ pediatric patients with type 2 diabetes: • Dispel myths. Behavior change recommendations must take into account families’ health beliefs and behaviors. Often, parents of children diagnosed with type 2 diabetes have preconceived notions about diabetes—typically based on myths. Marla C. Solomon, RD, LDN, CDE, a dietitian and diabetes educator in pediatric endocrinology at the University of Illinois Hospital & Health Sciences System in Chicago, says, “A family’s understanding of the disease may impact a child with type 2 diabetes. Many people will say, ‘You have sugar,’ when referring to diabetes. They believe all you need to do is avoid sugar and diabetes will go away.” • Treat the parent first. Chaparro suggests you shift the focus away from the child and onto the parent. “You treat the parent first, and then you treat the child. Parental obesity is a big predictor of kids being overweight, so it’s crucial to assess parent’s attitudes and perceptions of diabetes, obesity, and eating habits. Based on what we know, lifestyle modifications that only encompass diet and exercise have a very low success rate. It’s only until medications are introduced that some parents begin to think of diabetes as something serious. That being said, key aspects of the nutrition counseling involve individualization and constant follow-up,” Chaparro says. • Make culturally appropriate recommendations. Solomon says, “As registered dietitians, we need to demonstrate how all cultural and heritage foods can fit into [the child’s] life with

Clinical Characteristics of Children With Type 1 and Type 2 Diabetes8,9,12 Clinical Characteristics

Type 1

Type 2

Age at Diagnosis

Preschool to adolescents

>10 years


Uncommon (although prevalence increasing parallel to the obesity epidemic)



Male and female equal

Females 60% higher prevalence


5% of children with type 1 diabetes have relatives with type 1.

75% to 100% of children with type 2 diabetes have relatives with type 2.


Predominantly white

Predominantly African American, Hispanic, Asian, and Native American

Beta-Cell Autoantibodies Present

85% to 98%


Insulin, C-Peptide Levels





5% to 25% in ethnic minorities, primarily African American

Associated Disorders

Autoimmune disorders (thyroid, adrenal, vitiligo, celiac disease)

Acanthosis nigricans, polycystic ovary syndrome, metabolic syndrome

diabetes. Focus on the portion sizes, not elimination.” Solomon prefers to avoid the complexity of carbohydrate counting and uses MyPlate to focus on portion control. • Involve the entire family. A family-centered approach to nutrition and lifestyle modification is essential for children with type 2 diabetes. Philbin says, “When dealing with children, the whole family must be involved and willing to make behavior changes; otherwise, the goals you set with them will not be effective. The parents and older siblings, if any, must act as healthy role models for the child.” • Avoid labeling food. “As some people use the word ‘bad’ when describing a child’s actions, they also will use the word ‘bad’ when talking about food. We want food and nutrition to be positively presented so that no other family member will blame the child with diabetes for taking away their favorite items. This prevents the child with diabetes from feeling different. In this world, we want all children to be included vs excluded, even with diabetes,” Solomon says. There are no foods that are off limits. Parents should be taught to monitor how different foods affect their child’s blood glucose. They may need to decrease portions or redistribute carbohydrate foods to keep blood glucose in the child’s target range. • Be sensitive to family resources. Most children with type 2 diabetes are from ethnic minority groups and families in the lowest annual household income category.11 “There are many psychosocial challenges in children with type 2 diabetes, including home environment, single parenting, juggling work and home life, limited safe areas for exercise, and food deserts. Also, many African American women, and even men, will accept a larger body image even though it’s

a risk factor for diabetes, as they say, ‘It runs in the family,’” Solomon says. Lifestyle intervention strategies must take into account the family psychosocial challenges.

Future Directions The face of type 2 diabetes will continue to change. As mentioned, it’s projected that by 2050 the prevalence of type 2 diabetes in youth will increase four-fold. The increasing number of children with type 2 diabetes will present unique challenges for health care providers who care for them. A disproportionate number of children diagnosed with type 2 diabetes are of ethnic/racial minorities and from disadvantaged backgrounds, making sustained lifestyle change and medical adherence extremely difficult. Nutrition professionals who desire to work with this population must be skilled in behavior modification techniques for adults and children, culturally competent, and knowledgeable about food insecurity. — Constance Brown-Riggs, MSEd, RD, CDE, CDN, is a member of the board of directors for the American Association of Diabetes Educators; a past national spokesperson for the Academy of Nutrition and Dietetics, specializing in African American nutrition; and author of The African American Guide to Living Well With Diabetes and Eating Soulfully and Healthfully With Diabetes. Her latest book, Diabetes Guide to Enjoying Foods of the World, was published in September 2017 by the Academy of Nutrition and Dietetics.

For references, view this article on our website at

november 2017  35

Choline Under the Microscope By Jill Weisenberger, MS, RDN, CDE, CHWC, FAND


the world of nutrition, choline hardly is a household word. Having been identified as an essential nutrient by the US National Academies of Medicine Food and Nutrition Board only in 1998,1 choline remains under the radar of most consumers and many health care professionals. But with all of choline’s important roles, it may soon become the darling of the nutrition world. Choline is important to development before birth and throughout the entire life cycle. Unfortunately, recent National Health and Nutrition Examination Survey data suggest that a mere 8% of adults meet or exceed the Adequate Intake (AI) for choline.2 Because few foods are good sources of this essential nutrient, supplements may be necessary.

Choline in the Body Made by the body in small amounts, choline isn’t a true vitamin, as it doesn’t function as a coenzyme. Rather, it’s a vitaminlike compound that provides building material for several important compounds with diverse functions and interacts with folate and other nutrients. Along with endogenous sources, dietary choline is required to meet the long list of the body’s demands. Among its many roles, choline is needed for methyl donation, neurotransmitter synthesis, cell membrane signaling, and lipid transport.1,3 Most of the choline in the body exists as phosphatidylcholine, a phospholipid and essential structural component of cell membranes. Moreover, choline is a precursor to acetylcholine, a neurotransmitter and nonneuronal cell signaling compound involved in muscle control, memory, mood, and other nervous system functions.3 As a major dietary source of methyl groups, choline plays a role in gene

36  today’s dietitian  november 2017

expression, cell membrane signaling, stabilization of DNA, homocysteine reduction, detoxification, and lipid transport and metabolism.1,2 Folate also is a major source of methyl groups, so folate status impacts choline requirements and vice versa. If one of these nutrients is low, the dietary requirement for the other is increased. Common genetic polymorphisms in folate and choline metabolizing genes alter the metabolic use of choline in ways that increase the demand for dietary choline.4

Requirements and Usual Intakes Choline needs are influenced by stage of life, gender, ability to produce choline endogenously, and genetic variations, as well as the amount of folate and other nutrients in the diet.3 The Food and Nutrition Board found no research adequate to set an Estimated Average Requirement or Recommended Dietary Allowance. The AIs for choline for infants are based on the average intake from human breast milk.5 For other ages, the AI reflects the level necessary to prevent liver damage in adults (see Table 1 on page 39). “Choline intakes are suboptimal,” says Taylor C. Wallace, PhD, CFS, FACN, a professor in the department of food and nutrition studies at George Mason University in Fairfax, Virginia, and principal at the Think Healthy Group, a consulting, advertising, and medical communications firm that serves the pharmaceutical, chemical, and agricultural industries across the Asian Pacific region in Sydney, Melbourne, Auckland, Singapore, Seoul, and Hong Kong. Research coconducted by Wallace finds that about 89% of Americans older than age 2 and almost 92% of pregnant women fail to consume adequate amounts of choline.2 In general, men are more likely to meet

Itâ&#x20AC;&#x2122;s an essential nutrient thatâ&#x20AC;&#x2122;s underconsumed and underappreciated but so important to overall health.

their age and gender-specific AI than women because they consume more food and calories. Children aged 9 and older are unlikely to consume enough choline, and teenagers between the ages of 14 and 18 are the least likely group to consume choline at or above the AI. The group most likely to meet their choline needs is children between the ages of 2 and 8, Wallace says, because this age group typically consumes considerable amounts of milk and eggs, which naturally supply choline, and they often consume cholinefortified processed foods while the other groups don’t.

Choline in the Diet Though tiny amounts of choline are found in many foods, this nutrient is relatively scarce in the diet. However, good sources of choline include eggs, liver, meats, seafood, and dairy. “If you’re vegetarian, you have a big problem. It’s almost completely impossible to get enough choline from plant foods alone,” Wallace says. The best vegetarian sources of naturally occurring choline are quinoa, nuts, potatoes, and some vegetables such as broccoli (see Table 2 on page 39). Even a well-crafted diet likely is low in choline. The 2015– 2020 Dietary Guidelines for Americans identify choline as an underconsumed nutrient.6 The USDA Food Patterns, as outlined in the Dietary Guidelines, offer dietary recommendations. An analysis found that the recommended amounts of each food group in the USDA Food Patterns met or came close to meeting almost all nutrient goals. However, adequacy goals weren’t met for choline, nor were they met for potassium, vitamin D, and vitamin E.6 This underscores the scarcity of choline in the food supply, Wallace says.

Choline and Health Choline is essential for good health at all ages and stages of life, and it’s being studied for its association with desirable health outcomes.

Pregnancy and Lactation In June, the American Medical Association announced its support for the addition of choline in all prenatal vitamins to ensure proper development of a baby’s brain and spinal cord.7 Currently, prenatal vitamins routinely provide 0 to 55 mg choline, though the AI during pregnancy is 450 mg per day. “I was very pleased to learn of this recommendation,” says Marie Caudill, PhD, RD, a professor in the division of nutritional sciences at Cornell University in Ithaca, New York. “Like folate, choline is required for cellular division and methylation reactions, both of which are accelerated during human pregnancy. And choline is needed to make acetylcholine, phosphatidylcholine, and sphingomyelin, all of which play a critical role in brain development and function,” she adds. Though the mechanism is unclear, choline appears to be important for the prevention of neural tube defects. Animal studies and some human studies support that prenatal choline supplementation improves brain development.

38  today’s dietitian  november 2017

According to Caudill, rodents born to mothers supplemented with choline show improved memory and learning compared with rodents of mothers that didn’t consume additional choline. In other animal studies, choline was associated with greater emotional regulation. Human infants born to supplemented moms showed better attention by blocking out unnecessary information. In Caudill’s own research, babies born to moms who consumed additional choline could more quickly process information, which was measured by tracking the infants’ eye movements toward visual stimuli in their peripheral vision. Studies also have shown beneficial effects on biomarkers of placental development. Among women supplemented with choline in the last trimester of pregnancy, there was decreased production of a biomarker linked to poor placental health, Caudill says. Even stress reactivity is reduced in neonates when their moms receive additional choline during the final trimester of pregnancy. Caudill explains that choline’s role as a methyl donor leads to decreased cortisol at birth. This demonstrates an important epigenetic effect, she adds. Additional research in Caudill’s lab found that giving women of childbearing age supplemental choline along with DHA supplements enhanced red blood cell DHA content compared with women receiving DHA supplements alone. Theoretically, this would lead to greater incorporation of DHA in fetal neuronal tissue. For lactation, the AI for choline is even higher than it is for pregnancy. Breast milk is rich in choline, underscoring the importance of this nutrient to the infant and the likelihood of depleted stores for the mom.

Muscle Function Because choline is a precursor to acetylcholine and phosphatidylcholine, it plays a role in muscle cell communication and function, Wallace says. Thus, athletes likely have greater performance when choline stores are adequate, he adds.

Cardiovascular Health Some population studies find that individuals with the highest dietary choline intakes are the most likely to have low levels of inflammation markers such as C-reactive protein.1 In theory, this could suggest a role of choline in the prevention of some chronic diseases related to inflammation, such as heart disease and some types of cancer. In its role as a methyl donor, choline is involved in the conversion of the amino acid homocysteine to methionine. Though not known to be a causative factor, elevated levels of homocysteine are linked to a greater risk of CVD and other chronic conditions. Recently, questions were raised about a potential role of choline in the development of CVD. For example, a small human study found that choline supplementation increased plasma levels of a metabolite studied as a


Choline (mg) per serving

Beef liver, pan fried, 3 oz


cardiovascular events.” This doesn’t prove that TMAO is a causative agent, she says. Instead, sicker individuals may have a different makeup of intestinal microbes resulting in higher TMAO levels. And they may have some renal impairment, which reduces the renal excretion of TMAO, leaving higher concentrations within the body. In addition, Caudill notes that fish, which is widely considered heart healthy, is one of the greatest sources of dietary TMAO. A recent systematic review and metaanalysis found no association between dietary choline and incident CVD. One of two studies looking at phosphatidylcholine and CVD mortality found a positive association.9 Caudill suggests more studies are needed before recommendations are made to limit choline-containing foods, especially since intakes are already below AI levels. “Whether these risks are causal and for whom they are relevant requires further evidence from randomized controlled trials.”

Hard boiled egg, 1 large


Cognition in Adults

Beef top round, lean, braised, 3 oz


Soybeans, roasted, 1⁄2 cup


Cod fish, cooked with dry heat, 3 oz


Shiitake mushrooms, cooked, 1⁄2 cup


Kidney beans, canned, 1⁄2 cup


Quinoa, cooked, 1 cup


1% milk, 1 cup


Broccoli, cooked and chopped, 1⁄2 cup


Russet potato, baked, 6 oz


Peanuts, dry roasted, 1⁄4 cup


Sunflower seeds, oil roasted, 1⁄4 cup


Table 1 Adequate Choline Intake Age

Male (mg/day)

Female (mg/day)

Pregnancy (mg/day)

Lactation (mg/day)

Birth to 6 months



7-12 months



1-3 years



4-8 years



9-13 years



14-18 years





19+ years






Table 2 Dietary Sources of Choline


possible atherogenic compound and led to increased platelet aggregation.8 Caudill explains that instead of being absorbed, some choline travels to the large intestine, where microbes can convert it to trimethylamine (TMA). TMA then travels to the liver where it becomes TMA N-oxide (TMAO). “In mouse models, TMAO exacerbates atherosclerosis,” Caudill explains. “And individuals at high risk of CVD tend to have higher levels of TMAO and greater risk of subsequent

As the precursor to acetylcholine, choline is connected with cholinergic neural networks associated with memory. This relationship has scientists wondering whether choline plays a role in slowing cognitive decline in aging. Though research is limited, data from the Framingham Heart Study Offspring cohort find that higher choline intake is related to better memory performance.10

When Intakes Are Inadequate Choline deficiency manifests as nonalcoholic fatty liver disease because choline is required for the synthesis of very low-density lipoprotein particles, which transport fat from the liver. Without adequate choline, liver fat accumulates, leading to steatosis and potentially to liver damage. Adults fed total parenteral nutrition devoid of choline but adequate in other nutrients developed fatty liver, which resolved when choline was administered.1 In a separate study, when adults were deprived of dietary choline, 80% of men and 77% of postmenopausal women developed fatty liver or muscle damage. Fewer premenopausal women developed signs of organ dysfunction, presumably because estrogen upregulates de novo synthesis of choline. Again, choline intake reversed signs of damage.11

november 2017  39

Table 3 Tolerable Upper Intake Levels for Choline Age

Male (mg/day)

Female (mg/day)

Pregnancy (mg/day)

Lactation (mg/day)

Infants birth to 12 months

Not possible to establish. Breast milk, formula, and food should be the only sources of choline for infants.

1-3 years



4-8 years



9-13 years



14-18 years





19+ years






Choline deficiency is rare among healthy nonpregnant individuals likely because of endogenous choline synthesis and because small amounts of choline are present in a variety of foods.3 When levels are suboptimal, choline from the kidneys, lungs, and intestines is redistributed to the liver and brain.1 While deficiency is rare, insufficiency is the norm, as Wallace’s data make clear. With all of choline’s roles, it makes sense that people will have better long-term outcomes if they consume adequate choline throughout their lives. Low intakes of choline may predispose an individual to early cognitive decline and other health problems, Wallace explains. Improving choline status will require a multipronged approach. Since most people fail to meet the AI for choline and no subpopulation has exceeded the Upper Limit, Wallace supports a greater public health effort to encourage increased intake of choline from foods and supplements. Particularly, pregnant and lactating women will benefit from supplementation, he says. He also calls for additional research and review of the research by the National Academies of Medicine to set an Estimated Average Requirement and Recommended Dietary Allowance. Furthermore, educating dietitians, physicians, and other health care providers could spur a trickle-down effect to improve consumer awareness of choline and the nutrient’s vital roles in human health. In addition, Wallace sees a role for voluntary fortification of staple food products such as cereals and grains.

Counseling Clients To help clients meet their choline needs, it’s important to carefully assess their eating patterns and unique situations, says Elizabeth Ward, MS, RD, author of Expect the Best: Your Guide to Healthy Eating, Before, During and After Pregnancy. With the critical need for choline during fetal development and infancy, choline-containing vitamins are important for pregnant and breast-feeding moms. “Right now, the choline levels in prenatal vitamins and other vitamins are variable,”

40  today’s dietitian  november 2017

Ward says. That may soon change because of the American Medical Association recommendation. Infant formula, too, should contain choline. The FDA requires that it be present in infant formulas, but the levels also may vary, Ward says. She advises parents to discuss their choice of formula with their infant’s pediatrician. Consumers may soon find it easier to identify foods containing choline. The FDA recently set a DV of 550 mg for choline for anyone aged 4 and older. This opens the door for manufacturers to voluntarily label choline on the Nutrition Facts panel. Foods with at least 55 mg of choline per serving are considered good sources, and those with at least 110 mg of choline may be called excellent sources. Both consumers and dietitians will find the choline content of various foods in the USDA Food Composition Databases. Excessive intakes of choline are associated with a fishy body odor, low blood pressure, liver toxicity, vomiting, and excessive sweating and salivation (see Table 3 above).3 When discussing supplements with older clients and patients, Caudill encourages caution. It’s best to be conservative with older individuals since choline is involved in cellular division and could possibly accelerate an undiagnosed cancer. For now, aim to reach the AI with food, adding supplements only if necessary and only to the AI level, she says. — Jill Weisenberger, MS, RDN, CDE, CHWC, FAND, is a freelance writer and a nutrition and diabetes consultant to the food industry, including Egg Nutrition Center, Omega-9 Oils, and Balchem Corporation, a supplier of choline and other nutritional ingredients. She has a private practice in Newport News, Virginia, and is the author of the bestselling Diabetes Weight Loss — Week by Week.

For references, view this article on our website at


ISS UE Vol. 19 No. 9

September 2017

The Magazine for




Nutrition Profess ionals

The Best of Chicago Dining



8 Vol. 19 No.

fessionals With forks held high, Proready ionget Nutrit into delicious, teeth sink to Ma ine for gazyour The world-class cuisine.



2017 August

Nutrition n for Educatioolers Prescho

Diet vs Statins

Determine the best approach to lowering CVD risk.

nutrition the entire effective Targeting nt seems most eating me environ aging healthful for encour age group. this among

Today’s Dietitian contains practical articles loaded with information that every nutrition professional needs to know PLUS the opportunity to earn 2 CE credits by reading the CPE Monthly article and taking a short online exam.

Food Fears

Are they a deterrent to healthful eating?

Aquafaba’s Versat ility

Discover its many culinary uses.

Is the Variety Life Spice of

t Fitness Older Adul s Expand Program

eeze the Squ Feeling itians

Octob er 201 7




Lear n 10 st about ra to he tegies lp m eet th nutr ient e need of th s is popu unique lation .


Dayboat scallops, savory zucchini cake, and summer squash purée from BLVD


E Vol. 19

The M agaz ine fo r

No. 10

Nutrit ion Pr ofessi onals


Is A2 Milk Beta-Cas Dairy the Solu ein tionietit Into.Tod aysD fo leran www ce? r

Retail Diet Challenges e Rise Abov

The Fu Nutri ture of geno mics

tible? Indiges New

’s The FDA r n of Fibe Definitio

Grap Mad hic Desig e Patie Easy to n Impr nt Ca ove re

Phone: 800-278-4400 • E-mail: ww w.T oday sDiet itian.c om

Do you wish to begin or renew your subscription to Today’s Dietitian? ❑ YES, please begin/renew my subscription. ❑ No thanks. Signature______________________________________________________________________ Date________________ Signature and date required for processing. Incomplete forms will not be processed.

Name_____________________________________________________________________________________________ Phone_____________________________________________________________________________________________ Facility_____________________________________________________________________________________________ Address_____________________________________________________________________________________________ City____________________________________________________ State__________________ Zip_________________ E-mail*____________________________________________________________________________________________ *E-mail address will primarily be used for renewals, e-newsletters, and digital editions.

❑ 1 Year - $14.99 (12 issues)

❑ 2 Years - $28.50 (24 issues)

❑ 3 Years - $39.99 (36 issues)

For print subscriptions in Canada or other locations outside the U.S., please e-mail or call for pricing. Subscriptions are nonrefundable.

Payment Options (select one): ❑ Check made out to Today’s Dietitian ❑ Money Order ❑ Visa ❑ MasterCard ❑ AMEX

Credit Card No.____________________________________ Security Code_______________ Exp.Date___________________ CHOOSE THE DESIGNATION THAT BEST DESCRIBES YOUR CREDENTIALS: ❑ RD ❑ RDE ❑ DTR ❑ LD ❑ CDM ❑ CDE ❑ Other____________________

CHOOSE THE TITLE THAT BEST DESCRIBES YOU: ❑ Foodservice Manager ❑ Clinical Nutrition Manager ❑ Consultant Dietitian ❑ Dietetic Technician ❑ Educator ❑ Dietitian in Private Practice ❑ Clinical Dietitian ❑ Food and Culinary Professional ❑ Director ❑ Student ❑ Other____________________

CHOOSE YOUR WORK SETTING: ❑ Hospital ❑ Nursing Home/Long-Term Care Facility ❑ State Dept. of Public Health ❑ HMO ❑ College/University/School District ❑ Government Agency ❑ Food Company ❑ Retail/Grocery ❑ Pharmaceutical Company ❑ Nutrition-Related Company ❑ Hotel ❑ Correctional Facility ❑ Private Practice ❑ Other____________________

THREE EASY WAYS TO SUBSCRIBE OR RENEW: Online at • Fax this form to 610-819-1214 • Mail form and payment to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475 INCOMPLETE FORMS WILL NOT BE PROCESSED.

CODE: 110617

Frozen Dessert

Innovations F rozen desserts such as ice creams and fruit pops are American staples for both after-dinner treats and midday snacks. According to industry stats from Statistica, ice cream and other frozen novelties had combined sales of $2.6 billion in 2016, making it the largest segment of the frozen food category. But the big business of frozen desserts hasn’t always been the best for Americans’ bellies, with ice creams and other frozen treats traditionally containing lots of calories, fat, and sugar. As consumers demand more healthful, less processed foods, frozen dessert manufacturers are taking notice and responding in novel ways. In this article, Today’s Dietitian delves into the frozen dessert case to see what’s new and what’s trending, offering RDs’ takes on a sampling of products on which clients may seek your guidance as they decipher how best to indulge a sweet tooth while staying healthful during the holiday season and beyond.

Trends and Factors at Play

The freezer aisles are showcasing more healthful and special diet-friendly versions of favorite indulgences.

Nutrition for Wellness program and teaches core courses at Bastyr University in California. Malik offers his take on what’s behind this recent expansion of “free from” frozen novelties: “Given the increased awareness of food allergies and food sensitivities, I’ve seen a spike in the number of dairy-free, gluten-free, and vegan frozen dessert options. Many companies also have begun labeling their products as non-GMO. “Some of these desserts may have been vegan and dairy- or gluten-free to begin with (eg, frozen fruit bars made with real fruit), but companies are now making sure the consumer sees these claims front and center,” Malik adds. Bauer says she wouldn’t be surprised to see “cleaner” versions of frozen desserts continue to gain popularity. “Sweet, frozen treats are a huge draw for people,” she says. “If food companies continue to market a health or good-for-you angle, they’ll definitely appeal to a larger group of health-conscious consumers.”

New and Noteworthy

Glance in your local grocery store’s frozen dessert case, and According to nutrition experts interviewed, consumers are you’ll likely find dairy-free, gluten-free, low-sugar, and vegan demanding higher health quotients from the foods they puroptions. In addition, there are portion-controlled varieties of the chase—and desserts are no exception. more indulgent treats. Here’s a sampling of what’s trending, with “People are focused on filling their carts with cleaner, more nutritional info and dietitian perspectives to help guide clients natural foods, and it’s not surprising that this trend has found its toward the best dessert options for them. way to the frozen foods section, too,” says Joy Bauer, MS, RDN, Nondairy and Vegan Options CDN, health and nutrition expert for NBC’s TODAY show, bestsellBauer has seen a recent surge in plant-based frozen desing author of From Junk Food to Joy Food: All the Foods You Love sert options. “Companies are using coconut milk, almond milk, to Eat … Only Better, and founder of Nourish Snacks. “As a result, and other nondairy milks to create a creamy experience withmanufacturers are looking to remove preservatives, [artificial] out using cow’s milk. This is good news for vegans and lactosecolorings, artificial sweeteners, and other junk from ice creams, intolerant folks,” she says. ice pops, and other chilly treats. Instead, food companies are One of Dudash’s favorites in this vein is Luna & Larry’s Cocoincorporating more wholesome ingredients in their products.” nut Bliss, which she says looks, tastes, and feels like ice cream Michelle Dudash, RDN, Cordon Bleu-certified chef and author but is made with coconut milk. of Clean Eating for Busy Families, also has noticed this trend. “This is still a very calorically rich product and is high in sat“Manufacturers have really cleaned up the ingredients lists, urated fat,” she explains. “This is geared toward someone who and I have no doubt this is in response to consumer demand for wants to go more plant based or dairy-free. If neither of those clean labeling,” she says. is your goal, you’re better off with a light ice cream.” Products geared toward modified diets free of gluten, dairy, A 1⁄2-cup serving of Luna & Larry’s Cinnamon and the top eight allergens, also are trending, Chocolate Fusion flavor provides 240 kcal, 18 g says Neal Malik, DrPH, MPH, RDN, CHES, By JULIANN SCHAEFFER fat (16 g saturated fat), 1 g protein, and 13 g sugar. EP-C, who leads the Master of Science in

november 2017  43

More mainstream brands also are getting in on the nondairy game. Häagen-Dazs introduced four nondairy ice cream flavors in the summer of 2017. A 1⁄2 -cup serving of its Coconut Caramel nondairy ice cream is coconut cream based and totals 240 kcal, 11 g fat (all saturated), 1 g protein, and 19 g sugar. Popular lowcalorie, low-sugar ice cream brand Halo Top recently released vegan and soy-free ice cream varieties including Chocolate Covered Banana, Cinnamon Roll, Peanut Butter Cup, and Oatmeal Cookie. These nondairy varieties contain 280 to 360 kcal, 12 g protein, and 16 to 24 g sugar per pint. Ben & Jerry’s also bent to consumer demand, offering a nondairy line (expanded with three more flavors in 2017) made with almond milk. A 1⁄2 -cup serving of its nondairy Cherry Garcia provides 240 kcal, 12 g fat (8 g saturated), 2 g protein, and 25 g sugar.

Low-Sugar Ice Creams Bauer sees low-sugar frozen treats as another way companies are trying to offer consumers a less indulgent way to treat themselves. “That’s because people want to satisfy the urge in a healthier way,” she says. Two low-sugar ice cream options available today include Halo Top and Enlightened Snacks. Since 2012, Halo Top has offered a range of low-calorie, high-protein, and low-sugar ice cream flavors, averaging 20 to 24 g protein and 240 to 360 kcal per pint (with five servings per pint). Halo Top cuts sugar by using organic stevia and erythritol while using egg whites to rival traditional ice cream’s creamy, decadent texture. With more than a dozen flavors available, Halo Top recently announced seven new flavors, including Pancakes & Waffles, Cinnamon Roll, and Green Tea Mochi. Enlightened is another brand seeking to sway consumers with low-sugar ice cream options using monk fruit extract and erythritol. Launched in 2013, Enlightened offers high-protein, low-sugar ice cream bars and pints. The brand’s 22 flavors include Bananas Foster, Birthday Cake, Black Cherry Chocolate Chip, and Sea Salt Caramel. Pints range from 240 to 400 kcal (or 60 to 100 kcal per serving). Its Sea Salt Caramel has 7 g protein and 5 g sugar per serving, similar to Halo Top’s 5 g protein and 7 g sugar per serving for the same flavor.

Portion-Controlled Bites and Bars Want a frozen treat that’s portioned for you? “Portion-sized or bite-sized desserts are also a big sell with consumers—they want to enjoy their favorite foods without the temptation of overdoing it,” Bauer says. A favorite of Dudash’s is Diana’s Bananas Banana Babies, which are banana halves dipped in dark chocolate. “It’s just a whole banana dipped in chocolate, which counts toward your fruit servings and also provides nutrients like fiber, vitamin C, and phytonutrients,” she says. Dole Dippers are another take on chocolate-covered fruit, available in pineapple, banana, and strawberry varieties. Four of the dark chocolate-covered banana slices contain 100 kcal, 4.5 g fat (3 g saturated), 4 g fiber, and 7 g sugar.

44  today’s dietitian  november 2017

Another bite-sized frozen snack is My/Mo Mochi Ice Cream, a snack made with a scoop of ice cream wrapped in a soft dough. The new six-pack boxes are available in seven flavors, including mango, strawberry, and green tea, and each ball contains 110 kcal. The green tea flavor has 3 g fat (2 saturated) and 11 g sugar. “I’m also seeing mini versions of favorites, like Lil’ Drums being less than half the size of the original Drumstick,” says Dudash of another portion-controlled option for little hands. “I buy the Lil’ Drums for my daughters, since I feel better knowing they’ll have more room left in their tummies for nutrient-rich foods.”

Fresh Takes on Indulgences While some companies reformulate ingredients to offer more healthful frozen treats, others take a different tack, embracing the concept of indulgence in new ways. Drew Harrington, cofounder of Yasso Frozen Greek Yogurt, admits the pendulum of consumer demand is shifting toward healthfulness, and nutritional benchmarks for calories, protein, and sugar are important purchase motivators. But he admits taste reigns supreme. That sentiment is illustrated in Yasso’s new Frozen Greek Yogurt Sandwiches in Mint & Vanilla; each sandwich (a round, dark chocolate wafer that holds a thick layer of Greek yogurt) contains 120 kcal and 5 g protein. Yasso expanded its line of frozen Greek yogurt bars, with similarly indulgent flavors such as Toffee Caramel Chocolate Chip. One bar provides 100 kcal, 2.5 g fat, 5 g protein, and 14 g sugar. Marlene Schmidt, nutrition health and wellness manager for Nestlé USA, says Nestlé’s answer to changing consumer demands isn’t avoiding the indulgence factor. “A huge number of shoppers still head to the ice cream aisle looking for pure indulgence,” she says. Schmidt recognizes that shoppers seek this indulgence looking for simpler, more natural ingredients. “Our consumers’ preferences guide our recipe work,” she says. “Many of our products now feature fewer ingredients that consumers are likely to find in their own kitchens, which we know consumers are seeking more and more.” Dudash likes Edy’s Slow Churned Light Ice Cream for those reasons. “It has been out for a number of years, but it remains

a great-tasting product, with half the fat and a third fewer calories than regular ice cream,” she says. One of Nestlé’s newer offerings includes the Skinny Cow Protein Packed Indulgence ice cream line. The four flavors, including Mint Chip Mashup and Oh My! Vanilla Bean, range from 330 to 370 kcal and contain more than 22 g protein in the full 14-oz container, or 6 g protein and around 3 g fat per serving. While these products will be part of a more limited launch in 2017, Schmidt says they’ll become more widely available in 2018. Another of Nestlé’s newer indulgences: Skinny Cow Greek Frozen Yogurt Bars. Two indulgent flavors include Salt-Kissed Caramel and Chocolate Fudgetastic Swirl. One bar of the SaltKissed Caramel totals 100 kcal, 2 g fat, 13 g sugar, and 5 g protein.

Better-for-You Fruit Pops Adding more real fruit to frozen pops is another way brands are boosting healthfulness in their frozen desserts. “Icy fruity pops favored by children now have a whole new crop of options,” Dudash says. “The one I buy my kids that they love is Nestlé’s Outshine Fruit Bars, which are made with mostly just cane sugar and real fruit. Plus, they got creative with coloring them with real foods, not artificial food dyes.” According to Schmidt, the Outshine brand has improved the ingredients in eight of its popular Fruit Bar flavors, now made with an average of 77% more real fruit or fruit juice and 11% less sugar. The brand also has launched a new Watermelon flavor that has fruit as the first ingredient. One Watermelon bar comes in at 50 kcal, 0 g fat, and 13 g sugar. Bauer likes Outshine for fruit pops as well as GoodPop, which recently introduced new Orange N’ Cream and Organic Freezer Pops. One Orange N’ Cream pop totals 80 kcal, 4.5 g fat, and 9 g sugar. The Organic Freezer Pops are USDA Certified Organic, non-GMO, Certified Kosher, and each contain 100% fruit juice, 40 to 45 kcal, 0 g added sugars, 8 to 9 g total sugars, and are fatfree, gluten-free, and free from the top eight allergens.

Malik believes one of the fastest and most effective ways to evaluate whether a product is nutritious is to focus on the ingredients list. “Because ingredients are listed by weight, by looking at the first five ingredients, we can quickly determine whether the food is a nutritious option. For example, if someone is purchasing a fruit popsicle, the first ingredient should ideally be fruit, not high-fructose corn syrup. And if a product has more than five ingredients, we can probably assume that it contains some additives or artificial preservatives.” When it comes to frozen desserts, Dudash says the biggest nutritional offenders can be added sugars, saturated fat, and total calories. Having clients focus on those nutrition markers can lead them to more healthful options. “Considering 22 g is the daily limit for saturated fat for someone on a 2,000-kcal diet, I would say that anything over 5 g saturated fat per serving in a frozen treat is probably too high for your daily budget,” she says. “For added sugars, until the new labeling laws come into play, it’s hard to tell how much added sugars a treat contains since the total sugar on the label includes the naturally occurring sugars from milk and fruit. “Like anything else, frozen treats can run the gamut from totally healthful to a diet disaster, so choose wisely,” Bauer advises consumers. “It’s important to look at the ingredients list and the Nutrition Facts panel to see whether a product deserves a spot in your cart and freezer.” — Juliann Schaeffer is a freelance food and health writer based outside of Allentown, Pennsylvania, and a frequent contributor to Today’s Dietitian.

Nutrition Takeaways With so many trends and new products to consider, dietitians are well positioned to help consumers make sense of it all. Sometimes the best option may well depend on a person’s biggest nutrition challenges. “Individually wrapped items are perfect for someone who’s challenged by controlling their portions, or someone who isn’t going to take the time to portion their ice cream into a dish,” Dudash says. Malik recommends dietitians caution clients who want to choose “free from” desserts. “We need to be careful when manufacturers are removing ingredients from their products because sometimes other less desirable nutrients are added to make up for this deficit,” he says. “For example, a dairy-free product may be higher in sugar and lower in calcium depending on the type of milk substitute used. If gluten is removed, we need to ask what’s being added in its place. In some cases, this may include additives and preservatives that we may want to avoid. If a product is sugar-free, then it may not be fat-free, and vice versa.”

november 2017  45



DASH Diet By Densie Webb, PhD, RD

his year marks the 20th anniversary of the DASH (Dietary Approaches to Stop Hypertension) diet. The diet, which emphasizes foods rich in protein, fiber, potassium, magnesium, and calcium (fruits and vegetables, beans, nuts, whole grains, and low-fat dairy), has been shown time and again to be effective in lowering elevated blood pressure. More recent research has suggested it also can be effective in reducing inflammation markers, lowering the risk of developing kidney disease (a common complication of hypertension), and decreasing levels of low-density lipoproteins (an established risk factor for CVD) and several types of cancer. Each year, US News & World Report ranks the best diets based on expert advice in areas such as ease of compliance, weight loss results, and effectiveness against CVD and diabetes. The DASH diet has come in at number one for seven years in a row. So why isn’t DASH the dietary darling, with thousands of consumers clamoring to get the latest information as they do for the likes of Paleo, Atkins, the Alkaline Diet, or Whole30? That’s a good question.

Hypertension Blood pressure is the measure of the force of blood flowing through blood vessels. Almost 86 million people in the United States have high blood pressure, and only one-half have it under control. About 13 million US adults with hypertension aren’t even aware they have it and are going untreated.1 There are many causes of hypertension, but whatever the cause, the harmful repercussions include damaged arteries, aneurysms, enlarged heart, transient ischemic attack, stroke, dementia, kidney failure, retinopathy, sexual dysfunction in men, sleep apnea, and bone loss. That makes controlling blood pressure critical for

46  today’s dietitian  november 2017

disease prevention.2 High blood pressure can be defined as a reading higher than 140/90 mm Hg. Prehypertension is between 120/80 mm Hg and 139/89 mm Hg. Prehypertension is likely to become hypertension unless lifestyle changes, including diet, are made.2 The DASH diet is rich in several nutrients known to play important roles in regulating blood pressure, including potassium, magnesium, and calcium, and is lower in sodium and saturated fat than the typical American diet.

DASH Research While sodium reduction alone often is a physician’s go-to recommendation for lowering blood pressure, the DASH diet shows that reducing blood pressure through diet is the result of combining a team of nutrients—and sodium isn’t the standout. It’s the symbiosis of the DASH nutrients working together that makes the difference. The DASH dietary pattern consistently has proven to be effective for lowering blood pressure in diverse populations, including men, women, white individuals, and in those of various races and ethnicities who have either prehypertension or hypertension.3 The original study to examine the efficacy of the DASH diet was conducted at four sites as a randomized controlled feeding study. While the diet provided 3,600 mg of sodium per day—significantly more than the current recommendation of 2,300 mg—it showed significant reductions in blood pressure as quickly as two weeks after the start of the diet, suggesting that the combination of foods and nutrients is what provides the greatest blood pressure-lowering effects.4 Since then, several studies have shown the DASH dietary pattern to have a wide range of benefits. A recent examination of National Health and Nutrition Examination Survey (NHANES) data found that following a DASH-style diet was associated with metabolic health (eg, fasting glucose, insulin

Research shows itâ&#x20AC;&#x2122;s the most effective eating pattern for lowering blood pressure, so how can dietitians get clients more excited about its virtues?

resistance, C-reactive protein, and high-density lipoproteins) in young, healthy overweight, and obese individuals.5 As part of the Atherosclerosis Risk in Communities Study, it was found that participants with the lowest DASH scores were 16% more likely to develop kidney disease than those with the highest scores, even after taking into account several factors, such as smoking status, physical activity, and hypertension. DASH scores (there are more than one) are a way to compare an individual’s diet with the DASH dietary pattern. Of the individual components of the DASH diet score, high intakes of nuts, legumes, and low-fat dairy products were associated with reduced risk of kidney disease.6 A systematic review and meta-analysis of observational prospective studies found that a DASH-style diet decreases the risk of heart failure by 29%, coronary heart disease by 21%, and stroke by 19%.7 Data from the Multiethnic Cohort study, which included black, Native Hawaiian, Japanese American, Latino, and white individuals, found that following a DASH-style diet significantly reduced the risk for colorectal cancer. The overall effect was greater in men than in women and was less strong among blacks compared with the other racial/ethnic groups.5 Recommended by the 2015–2020 Dietary Guidelines for Americans as a healthful dietary pattern,8 the DASH diet is an amalgam of every healthful eating recommendation that health and nutrition experts have been making for decades, eg, eat more fruits and vegetables, low-fat dairy, nuts and seeds, beans, and whole grains, and lower intake of sodium and sugar.

Few DASH Followers Despite the overwhelming evidence that the DASH diet can reduce high blood pressure, and the growing number of studies suggesting that it can lower the risk of several other chronic diseases, few people adopt the DASH as their primary eating pattern. Data from the 1988–2004 NHANES found that only 20% of those surveyed met even one-half of the recommended levels of nutrients found in the DASH diet.9 An analysis of the data from 2007–2012 NHANES found that the average DASH score was 2.6 out of a possible nine. The score was based on nine nutrients: sodium, cholesterol, saturated fat, total fat, protein, calcium, magnesium, potassium, and fiber.10 One of the possible reasons DASH hasn’t gained a foothold in the American obsession with diet is that it isn’t a diet for weight loss; it’s a dietary pattern designed for disease prevention and improved health. It’s not the easiest diet to follow for life, and the name isn’t as catchy as, say, Whole30. “DASH may need a rebranding,” says Dori Steinberg, PhD, RD, an assistant professor at the Duke Global Institute, Durham, North Carolina. Steinberg agrees that it’s not the most appealing name, and few consumers know what DASH stands for. Marla Heller, MS, RDN, author of four books on the DASH diet, including The DASH Diet Action Plan and The Everyday DASH Diet Cookbook, says that in her experience, people think that DASH refers to the seasoning of the same name. Any diet that’s low in saturated fat is tough to follow, even with intensive dietary counseling.11 To address that issue, a

48  today’s dietitian  november 2017

study by Chiu and colleagues published in 2016 examined the effectiveness of a DASH dietary pattern that was much higher in both total fat (40% of calories vs 27% of calories) and saturated fat (14% of calories vs 8% of calories) and found that when the rest of the diet is followed, the benefits on blood pressure and blood lipids were the same. While the higher-fat diet was higher in total fat and saturated fat, and provided more full-fat dairy than the original DASH diet, it provided more vegetables, more nuts and legumes, less sugar, and less fruit and fruit juice. The higher-fat version might make it easier to follow and stick with over the long term. However, Heller says the study sample size was small and the study was of a short duration.

DASH Apps Mobile apps are being developed to increase compliance with the DASH plan. The DASH Cloud is one such app in development at the Duke Global Health Institute. “We’re trying to see how we can leverage technology to promote DASH,” Steinberg says. There are thousands of diet and fitness apps to track calories and activity, she says, but few focus on diet quality. It’s currently in the testing stage. Steinberg works with one of the original developers of the DASH diet, and she says they want people to be aware of all the nutrients that lower blood pressure. The goal is to pair the DASH Cloud with a good diet tracker app and offer messaging to users that provides ways to increase their DASH score throughout the day. However, not everyone agrees that apps are the way to go. “I think that too much reliance on outside factors, such as an app, doesn’t create habits that make it easy to follow a healthful eating plan for a lifetime,” Heller says.

Affordability and Environmental Impact Previous research has found that dietary costs are strongly associated with diet quality.12 Following the DASH dietary pattern is no exception. The study, which was conducted in the United Kingdom (UK), found that the closer the adherence to the DASH dietary pattern, the greater the dietary costs. Those with the highest DASH scores had 18% greater food costs than those with the lowest DASH scores. Fast food is cheap; foods in the DASH diet, such as fresh fruits and vegetables and nuts, tend to be more expensive. In fact, a recent study suggested that the likelihood of consuming a DASH-like diet was dependent on both geographic and economic access.13 The study was conducted in the UK, but there’s no reason the findings wouldn’t apply to the United States. The researchers found that the likelihood of consuming a DASH-like diet was 58% lower in households with the lowest dietary costs. And those living the farthest from any supermarket were 15% less likely to consume DASH-like diets. In addition to being a diet for good health, DASH is also good for the planet. The UK study found that the more closely the dietary pattern resembled the DASH diet, the lower the associated greenhouse gas production.12

Recommendations Heller says offering practical advice can make following the DASH plan easier and longer lasting. The DASH dietary pattern isn’t for the short term, she says; it’s for life. “If a plan

Following the DASH Eating Plan Use this chart to help clients plan their menus—or take it with them when they go to the store. Food group


Servings per day 1,600 kcal

2,000 kcal

2,600 kcal




Serving sizes

Examples and notes

Significance of each food group to the DASH eating plan

1 slice bread

Whole wheat bread and rolls, whole wheat pasta, English muffin, pita bread, bagel, cereals, grits, oatmeal, brown rice, unsalted pretzels and popcorn

Major sources of energy and fiber

Apples, apricots, bananas, dates, grapes, oranges, grapefruit, grapefruit juice, mangoes, melons, peaches, pineapples, raisins, strawberries, tangerines

Rich sources of potassium, magnesium, and fiber

Fat-free (skim) or low-fat (2%) milk or buttermilk; fat-free, low-fat, or reduced-fat cheese, fat-free or low-fat regular or frozen yogurt

Major sources of calcium and protein

Select only lean meats; trim away visible fat; broil, roast, or poach; remove skin from poultry

Rich sources of protein and magnesium

Almonds, hazelnuts, mixed nuts, peanuts, walnuts, sunflower seeds, peanut butter, kidney beans, lentils, split peas

Rich sources of energy, magnesium, protein, and fiber

Fat-free (skim) or low-fat (2%) milk or buttermilk; fat-free, low-fat, or reduced-fat cheese, fat-free or low-fat regular or frozen yogurt

The DASH study had 27% of calories as fat, including fat in or added to foods

Fruit-flavored gelatin, fruit punch, hard candy, jelly, maple syrup, sorbet and ices, sugar

Sweets should be low in fat

1 oz dry cereal ⁄2 cup cooked rice, pasta, or cereal






1 medium fruit ⁄4 cup dried fruit


⁄2 cup fresh, frozen, or canned fruit


⁄2 cup fruit juice


Fat-free or lowfat milk and milk products


Lean meats, poultry, and fish




1 cup milk or yogurt 11⁄2 oz cheese

6 or fewer


1 oz cooked meats, poultry or fish 1 egg

Nuts, seeds, and legumes

3 per week



⁄2 cup or 11⁄2 oz nuts


2 T peanut butter 2 T or 1⁄2 oz seeds ⁄2 cup cooked legumes (dry beans and peas)


Fats and oils




1 tsp soft margarine 1 tsp vegetable oil 1 T mayonnaise 2 T salad dressing

Sweets and added sugars


5 or fewer per week


1 T sugar 1 T jelly or jam ⁄2 cup sorbet, gelatin


1 cup lemonade * Whole grains are recommended for most grain servings as a good source of fibers and nutrients. † Serving sizes vary between 1⁄2 cup and 11⁄4 cups, depending on cereal type. Check the product’s Nutrition Facts label. ‡ Because eggs are high in cholesterol, limit egg yolk intake to no more than four per week; two egg whites have the same protein content as 1 oz of meat. § Fat content changes serving amount for fats and oils. For example, 1 T of regular salad dressing equals one serving; 1 T of a low-fat dressing equals one-half serving; and 1 T of a fat-free dressing equals zero servings. — Source: National Heart, Lung, and Blood Institute

can’t be sustained,” she says, “why go to the trouble of trying to follow it in the first place?” She offers the following suggestions to help clients and patients follow the DASH diet: • Use frozen fruits and vegetables; it’s a more economical way to increase fruit and vegetable intake, which is a major component of the DASH diet. • Fill half the plate with nonstarchy vegetables, and include a lean protein-rich food. • Add a salad, preferably with an olive oil-based dressing, and fruit for dessert. • Eat fruit, raw veggies, yogurt, cheese, nuts, or hard-boiled eggs for snacks. • At breakfast, choose a whole grain such as toast or cereal that’s low in added sugars.

• Have milk as hot chocolate or a latte to make it

more appealing. • Always balance snacks and meals with something protein-

rich (eg, cheese, eggs, nuts, yogurt) and something bulky and filling (eg, fruits or veggies). • Remember that DASH isn’t a diet; it’s a lifestyle change to reduce the risk of chronic disease. — Densie Webb, PhD, RD, is a freelance writer, editor, and consultant based in Austin, Texas.

For references, view this article on our website at

november 2017  49



Learn about the dietitian’s important role in counseling and educating patients. Most bariatric dietitians witness significant physical and behavioral transformations while working with patients throughout the preoperative and postoperative period. It can be gratifying to celebrate patients’ rapid weight loss and the joy of those who have never lived within the normal BMI range. However, once this “honeymoon phase” passes, many patients become dissatisfied and discouraged despite this progress due to unsightly sagging, excess skin. Even for patients who anticipate this outcome, the loose skin can remain a distressing reminder of their preoperative selves. As a result, an increasing number of bariatric patients consider body contouring surgery (BCS) to remove excess skin that remains after rapid, massive weight loss.1,2 This continuing education course explores the dietitian’s role in counseling and educating patients considering body contouring procedures after bariatric surgery and/or massive weight loss. Some bariatric patients seek body contouring procedures when excess skin from massive weight loss negatively affects body image and health-related quality of life (HRQoL). Dietitians can help patients optimize nutrition before BCS within the guidelines of the bariatric diet, educate them about nutrition and wound healing, and inform them about nutrition recommendations to maintain outcomes after surgery. Excess skin may lead to significant physical and psychosocial impairments, particularly because patients find that they can’t minimize skin laxity with increased physical activity or targeted exercise.1 Residual skin limits mobility and physical

50  today’s dietitian  november 2017

activity, leading to discomfort, irritation, infection, impaired posture, and problems with the fit of clothing.3-6 Barriers to psychosocial functioning include profound dissatisfaction with appearance, impaired self-esteem and body image, and diminished quality of life.1,6-9 Excess skin also may impede further weight loss or trigger weight regain.3 Patients considering BCS aren’t always required to meet with an RD before surgery, but as integral members of multidisciplinary treatment teams, dietitians working with postoperative bariatric patients considering BCS after massive weight loss can play an important role in enhancing optimal postsurgical outcomes, particularly in decreasing risk of delays and complications with wound healing through proper nutrition. In addition to reinforcing necessary long-term nutrition and lifestyle changes required to achieve weight loss goals, RDs have an opportunity to further educate patients about BCS procedures, discuss unrealistic expectations and limitations of BCS, and provide additional support, especially when rapport between the RD and patient has been previously established. Data concerning BCS following bariatric surgery and massive weight loss are limited, and most involve patients who had


LEARNING OBJECTIVES After completing this continuing education course, nutrition professionals should be better able to: 1. Evaluate and explain the importance of the dietitian’s role in counseling and educating patients considering body contouring procedures after bariatric surgery and/or massive weight loss. 2. Counsel patients on nutritional considerations involved in body contouring procedures after bariatric surgery and/or massive weight loss. 3. Distinguish ideal candidates, contraindications, and common complications for body contouring procedures. 4. Describe the effects of bariatric surgery on body image, health-related quality of life, and desire for body contouring surgery. Suggested CDR Learning Codes 5125, 5370, 5390 Suggested CDR Performance Indicators 9.6.3, 9.6.4, 9.6.6, 10.2.5 CPE Level 2

gastric bypass surgery. Existing research has shown significant improvements in body image and health- and weightrelated quality of life after gastric bypass surgery.10 However, there’s additional evidence to suggest that as many as twothirds of patients experience body image dissatisfaction from excess skin following bariatric surgery.5 Dissatisfaction with excess skin in particular is a strong motivator in the decision to seek BCS after bariatric surgery.10 In a study on bariatric surgery and body contouring, body image, and quality of life, Song and colleagues found that patients undergoing bariatric surgery experience improvements in body image and quality of life, and BCS after bariatric surgery results in further improvements in body image.11 de Zwaan and colleagues noted that patients who have BCS following bariatric surgery reported greater satisfaction with overall appearance, specific body areas, and physical functioning compared with bariatric surgery patients who didn’t undergo BCS.8 Modarressi and colleagues found that patients’ HRQoL after massive weight loss via bariatric surgery was impaired due to excess skin; HRQoL improved significantly after BCS compared with patients who had gastric bypass and no BCS.12 In addition, this study showed significant improvement in all subdomains of HRQoL after BCS: self-esteem, social life, sexual activity, work ability, and physical activity.12 These improvements remained stable over time, despite the visible scarring from BCS.12

Body Contouring Procedures According to the American Society of Plastic Surgeons, demand for BCS is on the rise;13 more than 50,000 body contouring procedures after massive weight loss were performed in 2015.14 Because patients often express greatest dissatisfaction with the excess skin at the waist/abdomen, abdominoplasty consistently has ranked as the most commonly performed BCS procedure after massive weight loss, and patients rated greater satisfaction with this area after BCS.4,8,14 Major skin excess over many areas of the body after massive weight loss develops after a stressful process of expansion during obesity, followed by deflation during rapid, massive weight loss.6 Skin laxity and tissue retraction are due to fractured elastin fibers and influenced by multiple factors, including the patient’s age, gender, age before weight loss, amount of weight loss, speed of weight loss, degree of sun exposure, and genetic predisposition.5,6,15 After massive weight loss, the typical patient experiences significant changes in form, shape, and contour of the face, arms, breasts, abdomen, back, buttocks, and thighs.4 Because skin in these areas after massive weight loss doesn’t contract adequately, minimally invasive contouring procedures don’t provide satisfactory results in correction of lost shape or form, and excisional procedures are required.1 In addition, for optimum results, BCS often requires multiple procedures, many of which are complex and labor intensive.2


Join us for the 2018 Spring Symposium Advance Registration just $199 May 20–23 in Austin, Texas Lower Body As noted, the areas of greatest concern to most patients after massive weight loss are the waist and abdomen.1 The most basic BCS to address excess skin in the abdominal area and any medical conditions resulting from skin-fold irritation is the panniculectomy, the excision of the pannus, or apron of excess skin hanging below the umbilicus.1 Because this procedure involves only excision and doesn’t tighten the abdominal muscles, an abdominoplasty may be preferable for better abdominal contour and more aesthetically pleasing results.1 Women considering abdominoplasty who plan to become pregnant should be advised that future pregnancy will minimize the results of abdominoplasty. A lower body lift is a more extensive, complex BCS procedure that combines circumferential abdominoplasty with a lateral (outer) thigh and buttock lift.1 In addition to contour enhancement from abdominoplasty, the lower body lift is indicated for improvement of outer thigh (“saddlebag”), groin, and buttock ptosis (drooping).1 A medial (inner) thigh lift is indicated to improve the contour of excess skin and localized fat deposits and may be combined with a lower body lift.1

Upper Body Brachioplasty (arm lift) is indicated to correct sagging of the upper arms (“bat wings”) that generally prove resistant to exercise. It should be noted that brachioplasty (and medial thigh lifts) often result in extensive and hypertrophic scarring.1 Massive weight loss can lead to considerable changes in breast shape and volume in both male and female patients.1 Mastopexy (breast lift) will elevate and reshape sagging breasts, and breast augmentation can be performed at the time of mastopexy in female patients interested in this procedure.1 Because breast skin in male patients can become quite ptotic, reduction also is an option for men after massive weight loss.6 The notion of combining multiple BCS procedures may appeal to many patients due to an assumed reduction in total recovery time, cost, and time off from work.6 However, combined procedures may involve extended surgical times and administration of anesthesia, increased blood loss, greater postoperative pain, and increased risk of complications (eg, deep venous thrombosis and pulmonary embolus).6

november 2017  51

CPE MONTHLY Candidates, Contraindications, and Complications Careful evaluation and selection of BCS candidates is critical to achieving successful patient outcomes and maximum patient benefit.1 When patients are considering BCS, they should be advised to reach their ideal body weight (+/- 3 kg) and maintain it over a six- to 12-month period after massive weight loss.1,5,6 For patients who follow nutrition and physical activity guidelines, this typically occurs 12 to 24 months after bariatric surgery.1,5 Smoking is considered a chief contraindication to any surgical procedure and is associated with higher complication rates in BCS; candidates must be nonsmokers to facilitate recovery and wound healing.1,6 Additional contraindications to single or combined BCS procedures include history of deep venous thrombosis or clotting disorders, high residual BMI, uncontrolled diabetes, or substantial medical risk factors (eg, adverse reactions to anesthesia).1,6 Patients considering BCS must be psychologically stable with reasonably accurate body perception, adequate supports, realistic expectations, and an understanding of the possible risks and benefits of BCS.1,6 Patients should be counseled preoperatively about limitations and potential complications associated with each considered BCS procedure, including inevitable (and possibly hypertrophic) scarring, risk of skin relaxation over time, and the possibility that multiple procedures or revisions may be necessary to achieve desired results.1,5,6 Though BCS after bariatric surgery is related to improvements in quality of life, self-confidence, and body image,3,8,10,11 it also can cause some patients to become dissatisfied with other parts of their bodies; this may be because as patients approach their ideal appearance, their ideals may shift.16 Some patients may desire BCS due to an erroneous belief that a correction in physical appearance will lead to a problem-free life.3 Therefore, body dysmorphic disorder, a condition involving an obsessive preoccupation with and distorted perception of one’s own appearance, is a contraindication to BCS after massive weight loss. Complication rates of 20% to 75% have been reported in patients after BCS following bariatric surgery, involving several categories of wound healing, including wound healing disturbance, delayed wound healing, wound infection, hematoma, and seroma.17-21 There are several reasons for this increased rate of complications in this patient population. Complications occur more frequently in postbariatric surgery patients with the removal of large volumes of tissue, as in extensive BCS operations and multiple procedures combined in two or more stages.22 A BMI of >25 may triple a patient’s risk of postoperative complications.23 Furthermore, many bariatric patients considering BCS may be deficient in certain macronutrients and micronutrients that are essential for wound healing.24 A thorough nutrition assessment is critical to ensure adequate nutritional status before BCS, as malnourished patients are at greater risk of postoperative wound healing issues and infection following bariatric surgery and BCS.1,5 Because

52  today’s dietitian  november 2017

adequate protein intake is essential in this patient population, patients demonstrating aversion to protein-rich foods aren’t ideal candidates for BCS.5

Nutritional Risks and Deficiencies Types of bariatric procedures typically are categorized by mechanisms of action: restrictive, malabsorptive, or a combination of procedures that restrict stomach capacity and alter gut-brain communication (eg, gut hormone secretions).25 The adjustable gastric band (AGB) is a purely restrictive procedure, while the Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) are combined procedures with more favorable long-term weight loss outcomes. RYGB and AGB were the two most requested bariatric procedures in the United States in recent years.25 The AGB has diminished in popularity due to banding complications (eg, erosion, slippage), lack of patient compliance, and lower relative long-term weight loss compared with combined procedures.26,27 As AGB procedures have decreased, RYGB has remained the gold standard of bariatric surgery procedures, and VSG has become the fastest-growing bariatric surgery procedure worldwide.28 Regardless of procedure, current data indicate that many patients develop protein-calorie malnutrition as well as various vitamin and mineral deficiencies after bariatric surgery.5,27,29 These deficiencies may begin to present as early as the latter half of the first postoperative year.5,18 The following factors contribute to the risk of nutritional deficiencies in patients following any type of bariatric surgery: • All forms of bariatric surgery restrict calorie and nutrient intake. At the one year postoperative point, most patients set a minimum daily protein goal of 60 to 80 g per day.25 A 1,000 kcal/day average intake isn’t uncommon at this postoperative stage.30,31 • Many patients experience food intolerance after bariatric surgery, including intolerance to red meat and/or dense proteins and dairy products.15,24 Others practice extreme carbohydrate restriction15 or develop other maladaptive eating behaviors.9,32 • Despite emphasis on vitamin and mineral guidelines beginning in preoperative nutrition visits, postoperative patient compliance with daily multivitamin supplementation is notoriously low and inconsistent across all procedures (60% or less).30 • Though several sets of bariatric nutrition practice guidelines and recommendations exist from the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic and Bariatric Surgery, there’s no universal bariatric diet.28,33 This variability in recommended dietary guidelines may contribute to inconsistent patient compliance; patients often seek online support and share/compare their own recommendations with one another. Though VSG is a more recent bariatric procedure and research is comparatively limited, available data suggest that VSG and RYGB are similar in terms of nutritional risk of protein and micronutrient deficiencies.27,28 Despite AGB’s categorization

as a restrictive procedure, patients who undergo it are still at risk of nutritional deficiencies; studies have shown patients after gastric band surgery with folate, vitamin B12, and iron deficiencies, as well as bone loss.15,29 These studies and others highlight the importance of RDs’ ongoing assessment of patient adherence to recommended guidelines for protein intake and vitamin and mineral supplementation after any form of bariatric surgery. With careful monitoring and follow-up, RDs should individualize supplementation recommendations for each patient based on nutritional intake and status.25 Thiamine (vitamin B1) deficiency is seen more frequently in bariatric patients, particularly those with prolonged episodes of vomiting, excessively low carbohydrate intake, or malabsorption issues.15,30,34 A dose of 50 to 100 mg daily is recommended for patients at risk of thiamine deficiency.15,29 Over time, bariatric patients decrease contact with their bariatric team members and many discontinue follow-up, which makes nutritional monitoring difficult. Bariatric patients are encouraged to seek annual screening for nutrient deficiencies.35 Without regular follow-up and monitoring, these patients may seek BCS unaware of or unconcerned about potential deficiencies that could affect wound healing, infection risk, and immune system suppression, and these risks may increase over time.35,36 Several studies have reported that significant deficiencies in protein, vitamin A, vitamin B12, 25-hydroxy vitamin D, zinc, iron, ferritin, selenium, and folate are present in patients one year after bariatric surgery.15,35,37 Additional studies of bariatric patients have shown deficiencies in vitamin A, vitamin B12, and iron when those patients were evaluated one month before scheduled reconstructive surgery.36,38 All forms of bariatric surgery markedly increase a patient’s risk of iron deficiency anemia.15 In terms of supplementation, patients are encouraged to pair 2,000 mg of vitamin C (ascorbic acid) with the recommended oral iron tablet to enhance absorption by increasing acidity levels.25 (It should be noted that calcium inhibits iron absorption, so patients taking calcium citrate with vitamin D supplements as recommended should take them at least two hours apart from iron supplements.)25 In addition to its role in iron absorption, vitamin C is extremely beneficial for wound healing as well, as it helps to reduce collagen deficiency and wound infections.15,39 Moreover, copper deficiency, an underlying cause of anemia in patients who have had bariatric surgery, may be present, but low levels of this trace element aren’t easy to detect.40 Supplementation with a daily multivitamin containing 2 mg copper is recommended when indicated.33 Several studies have found that wound healing and immune system optimization are enhanced by specific nutrients, including protein, the amino acids arginine and glutamine, vitamin A, vitamin B12, thiamine, vitamin C, folate, iron, zinc, and selenium.15,21,29,36,38 Supplementation with these nutrients has been shown to reduce postoperative complication rates in bariatric patient populations.15,29,36

Surgeons evaluating this patient population for BCS must be informed of these nutritional deficiencies, which can be minimized by adhering to recommended nutrition guidelines.36 Surgeons who perform BCS must be aware of the patients’ bariatric procedures and ensure appropriate intake for wound healing and successful recovery.5 While optimal nutrient values to promote wound healing in patients who have had bariatric surgery haven’t been established, current data suggest that protein, arginine, glutamine, and associated micronutrients mentioned above have beneficial effects on wound healing and the immune system.15

RD Impact: Windows of Opportunity Dietitians frequently have the most patient contact of any bariatric team member preoperatively, providing numerous opportunities to frankly discuss realistic weight loss goals and expectations with patients. As bariatric surgery increases in popularity, more often patients initiate conversations about excess skin and BCS during preoperative visits. They increasingly want to know if dietary modification or certain exercises will prevent excess skin after massive weight loss. Patients will benefit from counseling about the possibility of BCS in the early stages of the preoperative bariatric surgery process.5 By establishing rapport with these patients and approaching them with this discussion early, RDs teach patients to trust them to provide evidence-based and current information and offer a supportive, but reality-based, focus. Dietitians should clearly explain to patients that bariatric surgery is not a magic bullet and that maintaining weight loss requires sustained effort. Similarly, RDs should advise patients considering BCS that attention to nutrition and physical activity recommendations is required, as returning to former eating habits and weight regain will minimize the appearance of the recontoured areas.4 Dietitians have another opportunity to meet patients previously lost to follow-up at a critical time period. Often, patients hit a weight loss plateau at the nine-month to one-year point after bariatric surgery. At this time, maladaptive eating habits may reemerge, concurrently with feelings of discouragement and disappointment from excess skin.5 If patients don’t have adequate coping skills, the potential for weight regain, substance abuse, emotional eating, or other problematic behaviors increases. Life-threatening comorbidities that existed before bariatric surgery may be replaced with concerns about

november 2017  53

CPE MONTHLY excess skin.16 This skin can discourage patients after massive weight loss and derail motivation and weight maintenance; providing appropriate preoperative education, RDs share the responsibility to prepare patients for the possibility of excess skin, help them develop coping skills, and increase chances of keeping that weight off. A surgeon’s definition of a satisfactory outcome may not match a patient’s, and patient and surgeon may not perceive BCS outcomes in the same way. When dietitians engage in an open discussion early in preoperative nutrition counseling sessions about potential BCS procedures, they can better inform patients about the limitations of BCS and help them develop, set, and modify realistic expectations and goals for achievable outcomes of their selected procedures.1,5 The RD’s role is to educate patients about optimizing nutrition before BCS within the guidelines of a bariatric diet,5 the link between nutrition and wound healing complications, as well as other concerns related to BCS.41 Dietitians can reinforce the importance of preventing weight regain, especially for those considering BCS in the abdominal area. Educating potential bariatric surgery patients about excess skin after significant weight loss and the possible need for BCS may help them form more realistic expectations for bariatric surgery outcomes and be better prepared for BCS.4

Multidisciplinary Team Approach To adequately prepare and inform bariatric patients who are considering BCS, however, extensive preoperative education by the entire multidisciplinary team of health care providers is required.6 As members of multidisciplinary teams, dietitians, in collaboration with other health care providers, can make an impact on patients before, during, and after bariatric or BCS procedures. Follow-up visits should be coordinated and monitored with the cosmetic surgeon and the bariatric team, including the bariatric surgeon, physician assistant, RD, registered nurses, and behavioral health professionals. Many RDs facilitate or cofacilitate support groups along with other staff members of bariatric center teams to provide patients with comprehensive education along with a familiar face and supportive guidance. In safe, confidential environments, support groups offer patients at all stages of the bariatric surgery process a chance to communicate with others struggling with similar challenges.42 In the case of BCS, bariatric support group facilitators welcome guest speakers such as reconstructive surgeons to give presentations about body contouring procedures directly to patients. Just as some patients who seek bariatric surgery are deemed inappropriate candidates, certain patients who desire BCS also may be inappropriate. Some patients have an erroneous belief that, similar to bariatric surgery and massive weight loss, BCS will solve all of life’s problems. Patients with this ingrained “quick fix” mentality may benefit from a referral to behavioral health counseling. Depending on

54  today’s dietitian  november 2017

the RD’s interaction with the other members of the bariatric team, patient referrals to behavioral health providers may be a simple process or require multiple steps. This referral process varies by bariatric center. Like massive weight loss, BCS may affect patient relationships and coping skills.16 Patients also may receive increased attention following BCS, and this may disrupt relationships. For some patients, this attention is positive, but for other people in patients’ lives, such as romantic partners, it may be a negative experience. Furthermore, the attention is temporary; RDs must help patients prepare for the inevitable fact that at some point the compliments and attention will stop coming.16 Because many body image problems develop or recur at 12 to 18 months after bariatric surgery, a time when weight is stabilizing, this is a critical period for interventions.16 It’s important to monitor patients during this time period and refer to behavioral health counseling as appropriate (eg, for relationship counseling, depression, body image disturbance, and medication management).43 An inability to obtain insurance reimbursement and overall expenses prevent many patients from having BCS.41 Though most insurance carriers will cover well-documented “medically necessary” procedures in this patient population (such as panniculectomy), other procedures are rarely covered.6 RDs should remind patients that BCS procedures usually result in a significant out-of-pocket expense.3,10 Some bariatric centers refer patients to financial counselors, and some cosmetic surgeons offer installment plans to assist with financing BCS procedures.

Future Considerations The issue of excess skin after bariatric surgery is underappreciated, and its impact on patient HRQoL and body image is underexamined. Though weight loss after bariatric surgery is linked with initial improvement in patient quality of life, excess skin can lead to increased dysphoria and depression.9,16,43 Research to date largely has been focused on gastric bypass patients; further studies involving patients who had VSG procedures are warranted. More research is needed concerning the effect of body contouring after bariatric surgery on HRQoL and related areas to increase awareness of this topic, improve patient outcomes, and enable health care providers to develop more compassionate and comprehensive programs that address the needs of bariatric patients. — Mireille Blacke, MA, RD, CD-N, is an adjunct professor at the University of Saint Joseph in West Hartford, Connecticut; a bariatric dietitian at Bariatric Center at Saint Francis in Farmington, Connecticut; and a freelance health and nutrition writer.

For references, view this article on our website at

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

CPE Monthly Examination 1. What is the most commonly requested body contour-

ing surgical procedure after bariatric surgery? a. Abdominoplasty b. Brachioplasty c. Circumferential body lift d. Mastopexy 2. Primary nutritional risks of the postbariatric surgery patient contemplating body contouring surgery (BCS) are due mainly to which of the following? a. Inconsistent use of protein supplement shakes b. Increased daily intake of saturated fat and processed foods c. Deficiency from restriction, malabsorption, or digestion problems d. Sedentary lifestyle or physical inactivity 3. The greatest risk of nutrient deficiency postopera-

tively is seen after which of the following bariatric surgery procedures? a. Restrictive b. Malabsorptive c. Restrictive/malabsorptive combined procedure d. All bariatric surgery procedures present equal risk of nutrient deficiency postoperatively. 4. The chief contraindication to BCS (eg, abdominoplasty) after massive weight loss is which of the following? a. Smoking b. Anxiety disorder c. Unrealistic expectations of surgical outcomes d. Uncontrolled diabetes 5. What is ptosis?

a. Abdominal wall laxity b. Drooping of a body part c. Scarring d. Deficiency from malabsorption

6. A deficiency of which of the following micronutrients can be an underlying and often undetected cause of anemia in patients who have had bariatric surgery? a. Copper b. Ascorbic acid c. Riboflavin d. Calcium 7. Ideal candidates for abdominoplasty after massive weight loss do which of the following? a. P  lan to become pregnant within five years after surgery b. Approach a BMI in the overweight range c. Report 60 minutes of physical activity at least four days per week d. Have realistic expectations of BCS outcomes 8. What two amino acids most significantly affect optimal healing of surgical wounds after BCS? a. Methionine and cysteine b. Arginine and glutamine c. Lysine and glutamine d. Lysine and proline 9. Two thousand milligrams of vitamin C are recommended daily for wound healing after body contouring procedures to reduce which of the following? a. Collagen deficiency and wound infections b. Anemia-related fatigue and weakness c. Blood coagulation problems d. Risk of macrocytic anemia 10. Which postoperative time period is the most critical

for interventions involving body image? a. 3 to 6 months b. 6 to 12 months c. 12 to 18 months d. 18 to 24 months

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

november 2017â&#x20AC;&#x201A; www.todaysdietitian.comâ&#x20AC;&#x192; 55

Reasons to be As the holidays come into view, we at Today’s Dietitian have many reasons to be thankful.

We’re thankful for registered dietitians and nutrition professionals. Not only do you provide advice, counsel, and science-based help to those in need, but you’ve been a loyal and engaging audience of our magazine, website, e-Newsletter, and social media networks. Thank you for your continued support and stay tuned for more timely content, written especially for you.

We’re thankful to provide continuing education, like our CE Learning Library courses and webinars. Continuing education is important to any dietitian’s career and we’re committed to offering professionals the topics, subject matter, and expert presenters that will nourish the mind, revitalize the spirit, and fortify your professional foundation.

W E A RE T H A N K FU L F O R O U R 2018 S P RI N G S Y M P O S I U M S P O N S O R S

Thankful We’re also thankful that, because of your passion for learning and the generosity of our sponsors, we can host our annual Spring Symposium.

We invite you to join us for our 5th annual continuing education and networking event for dietitians and nutrition professionals on May 20–23 at the Hyatt Regency in Austin, Texas. We’ll feature a diverse program of sessions and workshops offering 15 CEUs or more, plus the opportunity to engage with our sponsors and network with fellow dietitians.

Finally, we’re thankful we’ve been able to extend our $199 Advance Registration rate through Thursday, November 30. We hope you’ll take advantage of this special rate while it lasts. For more information and to register, visit

W E A RE T H A N K FU L F O R O U R 2018 S P RI N G S Y M P O S I U M S P O N S O R S




Health Benefits for Both Young and Old Jennifer Van Pelt, MA Pilates (pronounced pi-LAH-teez) is named after its creator, Joseph Pilates, who originally called it “contrology” when he introduced this exercise method in the 1920s in New York City. A full-body workout that focuses primarily on the larger core muscles (abdominals, back, hips, thighs), Pilates can be performed either as floor exercises on a mat or on specially designed equipment. Pilates exercises are done in a specific sequence, designed as a system to provide full-body benefits, including increased strength and flexibility and improved posture and balance. Because Pilates is performed using certain breath patterns, such as deep diaphragmatic and lateral breathing, it’s considered a mind-body exercise modality. Since I last wrote about Pilates in 2012, its popularity and press coverage has fluctuated and often has been overshadowed by news about other fitness activities (eg, yoga and trendy new workouts such as Pound). Pilates generally is considered a niche workout for dancers and athletes and isn’t as commonly offered in gyms, mainly because it requires specialized training to instruct both mat and equipment-based Pilates (eg, Pilates Reformer equipment). Pilates instructors most often teach in dedicated Pilates studios, private boutique fitness studios, and yoga studios. Mat Pilates generally is taught in a class format, while equipment-based Pilates is taught one on one or in a small group. Pilates can, therefore, be more expensive than other fitness activities, and expense may limit regular participation. In 2016, the Pilates Method Alliance, a professional association for Pilates instructors and Pilates Anytime, an online Pilates studio offering subscription-based video classes, conducted a survey of the Pilates industry in the United States. The survey showed that 50% of respondents cited cost as the primary reason for no longer practicing Pilates. The survey also revealed that the majority of Pilates practitioners are women aged 35 and older. More than 40% of those surveyed were aged 55 and older, indicating that Pilates is particularly appealing to the baby

58  today’s dietitian  november 2017

boomer generation. When asked why they practiced Pilates, 80% of respondents replied that it “is for people my age.”1 Older surveyed Pilates practitioners recognize the benefits of Pilates for aging adults—benefits that are supported by recently published research studies. An August 2017 systematic review and meta-analysis of 15 randomized controlled trials that studied Pilates in those older than age 60 found significant improvements in dynamic, static, and overall balance compared with other balance and fall prevention training approaches.2 Two smaller randomized trials also found significant improvements in lower-body strength, aerobic conditioning, overall balance, and confidence in balance when older adults practiced Pilates compared with other balance exercises.3,4 The Pilates survey revealed that only 10% of those surveyed were aged 18 to 34, possibly indicating that the Pilates industry isn’t effectively marketing to younger exercisers. Or perhaps Pilates and its benefits aren’t as apparent to younger exercisers. YouTube celebrity Cassey Ho is successfully marketing her POP Pilates ( program, a choreographed mat Pilates workout, in online and gym class formats taught by licensed instructors. With faster movements set to upbeat current pop music, POP Pilates is intended specifically to attract younger exercisers and those bored with traditionally sequenced Pilates classes. Cost also may be a deterrent for younger exercisers as well as those looking for inexpensive ways and places to work out. Less expensive online classes, such as POP Pilates, may increase Pilates participation. Overall interest in Pilates is expected to grow over the next few years due to the following, which also may increase accessibility and affordability: • Barre workouts—currently a popular trend—incorporate Pilates exercises, increasing interest in Pilates for sculpting and strengthening. Frequently offered in yoga studios, barre workouts have introduced yoga practitioners to Pilates as complementary to yoga. • Affordable home Pilates equipment, such as the AeroPilates brand, is being marketed online and by home shopping TV networks. Equipment-based Pilates workouts usually are more expensive and less accessible, since they require oneon-one work with a certified Pilates instructor using dedicated Pilates equipment not typically available in most gyms. Home Pilates equipment has expanded the market and exposure for equipment-based Pilates workouts to all exercisers—not just dancers and athletes. • Online fitness video streaming services are offering more affordable alternatives to in-person Pilates classes. For example, Pilates Anytime offers thousands of Pilates classes for all fitness levels for a monthly subscription fee that’s a fraction of the cost of a gym membership or in-person Pilates studio classes ( also offers Pilates videos with its Prime Video service. • Research into the clinical applications of Pilates is vigorous, and Pilates is being used for medical rehabilitation

applications. Positive results have generated interest from the clinical community in using Pilates exercises in conjunction with physical therapy and therapeutic rehabilitation for various medical conditions. In the 2016 Pilates survey, 95% of respondents indicated they practiced Pilates regularly because it “is good for you,” and cited benefits of improved muscle tone and flexibility, enhanced performance, and stress relief.1 Recently published evidence suggests that Pilates also can benefit individuals with certain medical conditions. For those familiar with the founder of Pilates, the potential clinical benefits of his exercise method shouldn’t be surprising—he developed Pilates after experiencing the benefits of exercise as a sickly adolescent and after rigging hospital beds to act as exercise equipment for bedridden patients. Thus, Pilates has therapeutic origins that now seem to be attracting the interest of the medical community. The following clinical studies have found that Pilates has particular benefits for women after breast cancer treatment, those who’ve had a stroke, and individuals with juvenile idiopathic arthritis (JIA): • A January 2017 randomized study found that Pilates significantly reduced the severity of lymphedema compared with standard lymphedema exercises in women being treated for lymphedema following breast cancer treatment. Patients who practiced Pilates for eight weeks also showed significant improvements in overall quality of life, upper extremity functional scores, and social appearance anxiety.5

• Eight weeks of modified mat-based Pilates exercises also significantly improved gait in poststroke patients, including stride length, walking speed, balance, and knee and hip range of motion.6,7 • The Ottawa Panel, a Canadian medical organization that develops evidence-based clinical guidelines, added Pilates to its recommendations for the management of JIA. Their review of evidence found that Pilates improves quality of life, function, pain, and range of motion in children with JIA. Pilates received the strongest level of recommendation and resulted in improvement in more outcomes than other evaluated exercises (eg, aquatic exercise, home exercise, and cardio-karate).8 Pilates is worth recommending to clients due to its wide range of health benefits. (For information on Pilates for low back pain, see my April 2012 Focus on Fitness column.) New online video streaming options and DVDs are ideal for clients who don’t want to or can’t spend money on studio classes. For those with movement limitations or beginning exercisers, Pilates can be modified to meet the needs of anybody. Pilates can even be done seated in a chair. As Joseph Pilates said, “Change happens through movement, and movement heals.” — Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Reading, Pennsylvania, area.

For references, view this article on our website at

WHERE RDs BLOG FOR RDs Enjoy a blog where the real nutrition experts post opinions and insights from the RD’s point of view. We cover a wide range of topics and our bloggers represent many different facets and philosophies within nutrition and dietetics. We welcome comments from all fellow dietitians and encourage you to share with colleagues.

Visit often for updates and join the conversation!

november 2017  59


Vogliano working on a food waste presentation, assisting with literature reviews for Cambridge researchers assessing local food systems of developing island nations, or even consulting with companies on sustainable nutrition initiatives. Though the projects may vary with the season (and season of life), the endeavors Vogliano takes on have a common thread: improving food systems. Speaking of seasons of life, Vogliano is set to start a brand new one—halfway across the world. Keep reading to find out what has him relocating to New Zealand and what goals he seeks to accomplish there.


Promoting Food Principles Good for People and the Planet By Juliann Schaeffer Chris Vogliano, MS, RDN, has a passion for food sustainability. But he didn’t exactly enter dietetics with the intention to save the planet from food waste while ensuring every person has access to healthful food along the way; that fervor found him. “I have always had a passion for creating a sustainable and waste-free food system that’s healthful for both people and the planet. But I went into dietetics expecting to be a clinical dietitian,” Vogliano says. “Boy, was I wrong. After seeing the immense amount of food being wasted, learning about food insecurity, and beginning to understand the pressure our current agriculture system puts on our planet, I knew I had to focus my attention on sustainability. To me, it really didn’t seem like an option.” Thus far in his career, Vogliano’s food sustainability focus has taken many forms, including working as the nutrition manager at the Greater Cleveland Food Bank, serving as a sustainable agriculture research fellow for the Academy of Nutrition and Dietetics Foundation, and teaching a sustainable food systems course at the University of Washington this past spring. “Whatever the role, my primary motivation is to help improve global food security while lessening our environmental impact on the planet,” he says. What does improving global food security look like on a daily to-do list? It changes with the day, but it could be

60  today’s dietitian  november 2017

Today’s Dietitian (TD): What were the biggest obstacles or challenges you faced in your career, and how did you overcome them? Vogliano: One of my biggest challenges was an internal obstacle more than anything else. Growing up in a middleclass family, I was never faced with living in poverty. When I first started my career, I had idealistic ways of eating, purchasing, and preparing foods. I learned quickly that life isn’t always so simple. Working with low-income clients was one of the best things that’s ever happened to me. As dietitians, it’s easy to assume that our clients can afford or have access to fresh fruits and vegetables or even a refrigerator. I figured there was only one true way to empathize and try to understand the struggles of these clients: sit down and start having conversations with people. I shared many meals at soup kitchens and food pantries, simply listening to clients about the struggles they were faced with on a daily basis. While I may never know what it’s like to be food insecure, at least I can now better empathize with people who experience this reality. TD: What led you to focus your career on sustainability issues? Vogliano: It wasn’t until earning a master’s degree at Kent State University that I started understanding the complexities of food security and food access. I began volunteering at the local chapter of The Campus Kitchens Project, which helped recover food from the local community and repurpose it into meals for low-income community members. Up until this point, I was unaware of the troubles many of my community members faced by not being able to afford healthful food. This is when my eyes were opened to the complex issue known as food insecurity. I was astounded by the passion and dedication of those volunteering for The Campus Kitchens Project. After volunteering a few times, I began noticing that the food being served—while delicious—was not the healthiest. Surely there had to be a way to serve both tasty and nutritious dishes. This is what led me to begin a nutrition outreach program at Kent State, where I was able to recruit undergraduate and graduate nutrition students to teach nutrition education lessons at local food pantries.

TD: What is your proudest career accomplishment? Vogliano: While I could spit out my résumé here and list various presentations and publications, I think my proudest career accomplishment is much more simplistic. I remember working at the Greater Cleveland Food Bank and having a massive amount of eggplants shipped to us for distribution. Let me tell you, inner city Clevelanders are not highly exposed to eggplants, and many of them do not know how to prepare them. I knew if I didn’t take action that there would be a significant amount of food waste and lost nutrition potential.

Traditionally, sustainability may not have overlapped with nutrition, but I strongly believe dietitians are one of the best-suited health professionals for the job. I quickly teamed up with my nutrition educators and volunteers to help teach program managers and clients how to easily prepare and cook these purple beauties. Before you know it, they were one of the most popular items at many of the pantries throughout the community. It’s amazing how reducing a small barrier can have such a profound impact! TD: You’re moving to New Zealand to pursue a PhD in sustainable food systems. What spurred this next career step, and what do you hope to accomplish through this new educational effort? Vogliano: Yes, it’s crazy to think about, actually. I have never lived abroad and am very much looking forward to it. Having worked on a variety of sustainable nutrition projects, I personally find this to be the most fascinating area of dietetics. Traditionally, sustainability may not have overlapped with nutrition, but I strongly believe dietitians are one of the best-suited health professionals for the job. It surprises me to see global health organizations making nutrition policy decisions without the consultation or advice from registered dietitians. We are the food and nutrition experts, and I believe we absolutely deserve a place at the table when these important decisions are being made. My main goal in pursing my PhD in public health and sustainable food systems is to better prepare myself to confidently enter the global health sector. As our world becomes increasingly global, and lowerincome countries rise to the middle class, diets begin shifting toward that of our own American diet (eg, more processing, more meat, fewer plants). We’ve seen what our diet has done to us, and I hope to help prevent other countries from making the same mistakes we have.

TD: What are your top three recommendations for making your diet more sustainable? Vogliano: While there are a variety of ways to tweak our diet toward a more sustainable one, my top three recommendations would be: • Waste less food. This one is huge. We currently waste 30% to 40% of all food produced, and the majority of that happens with us: consumers. Food takes up an abundant amount of resources, and it’s frankly too good to waste. • Swap the beef with beans. Beans, or legumes, are not only packed with abundant protein and fiber, but they also help fix nitrogen in the soil, which is excellent for the health of the planet. • Cut back on portion sizes. This message is consistent with what we have been saying for a while now, but now we have even more reason to do so. Overeating is technically a form of food waste, too, and contributes to disease and a waste of resources used to produce the food. TD: What advice do you have for nutrition professionals who want to be more sustainable eaters (and consumers) or promote sustainable efforts in their community or nationwide? Vogliano: I truly believe that any dietitian, whether working in long term care or in schools, can make a difference. Any little step to reducing the amount of food waste—such as adjusting meals to being eco-friendlier or simply swapping out Styrofoam cups for a more sustainable option—can all collectively make a major impact. Just think what would happen if all 100,000-plus dietitians made one small change in their practice. TD: Describe your nutrition philosophy. Vogliano: Nutrition can seem overly complex, but it doesn’t have to be. As long as we are listening to our body, eating the appropriate number of calories, and sourcing most of our food from fruits, vegetables, whole grains, and legumes, we shouldn’t sweat the small things. It’s okay to have that piece of chocolate cake. TD: What brings you joy outside of work? Vogliano: My friends and family are everything to me. I cherish the relationships I have built over the years and wouldn’t be where I am today without their love and support. As I continue to move around, I try my hardest to stay in touch with my best friends—whether I’m across the country or across the world. TD: What’s one thing people might be surprised to learn about you? Vogliano: I was a wedding photographer in my past life. And I love hula hooping—sometimes even while it’s on fire! — Juliann Schaeffer is a freelance food and health writer based outside of Allentown, Pennsylvania, and a frequent contributor to Today’s Dietitian.

november 2017  61

BOOKSHELF The New Diabetes Cookbook: 100 Mouthwatering, Seasonal, Whole-Food Recipes By Kate Gardner, MS, RD 2015, Sterling Epicure Paperback, 216 pages, $21.95

Finally, a diabetes cookbook that doesn’t promote the use of artificial sweeteners or ingredients made in a laboratory! Kate Gardner, MS, RD, is an East Coast-based dietitian currently pursuing her PhD at Columbia University in New York and offering nutrition consulting services in New York and Connecticut. Her book, The New Diabetes Cookbook, embraces an abundance of plant-based whole foods and is filled with beautiful colorful photos of her delicious recipes. Gardner’s book begins with some basic information for people with diabetes and a preview of the types of foods that will be included in its pages. She mentions that people with diabetes should eat 45 to 60 g carbohydrate per meal. No recipe in the book contains more than 45 g carbohydrate; some contain much less. Gardner provides menu ideas that enable individuals to assemble a meal that will provide the right amount of carbs for their unique needs. For example, she lists a “Quick Meal” idea that includes her Farmhouse Salad with 41 g carbs plus the French Toast Quiche with Strawberries and Basil for dessert with 13 g carbs, for a total of 54 g carbs. The New Diabetes Cookbook is broken into chapters with recipes for appetizers, soups, and salads; main dishes; side dishes; and desserts. Each recipe page includes information about the dish and its ingredients, an ingredient list, step-bystep directions, cooking notes, and nutrition information. The nutrition information included is what you’d see on a nutrition facts label, but doesn’t include any vitamin and mineral sources (other than sodium). The last segment of this book contains a question and answer section. Here, the author answers questions about sugar, artificial sweeteners, weight management, and eating out. I greatly appreciate her emphasis on unprocessed, whole foods. Far too often, people with diabetes are taught to eat sugar-free processed foods to keep blood sugar levels in check. Gardner highlights that desserts with real sugar still

can be consumed in moderation and discusses how the combination of protein, fat, and fiber aid in slowing down the glucose rise. I’ll definitely recommend this cookbook to my clients, with or without diabetes. — Janice H. Dada, MPH, RD, CDE, maintains a Newport Beach, California, private practice and consulting business (SoCal Nutrition & Wellness, Follow her on Twitter and Instagram @SoCalRD.

Healing Superfoods for Anti-Aging: Stay Younger, Live Longer By Karen Ansel, MS, RDN, CDN 2017, Hearst Hardcover, 248 pages, $19.95

Karen Ansel, MS, RDN, CDN, is a nationally recognized nutrition expert who’s shared her knowledge with a variety of publications, corporations, and consumers as a consultant, journalist, author, and recipe developer. She’s a contributing editor for Woman’s Day magazine and the coauthor of The Baby & Toddler Cookbook: Fresh, Homemade Foods for a Healthy Start and Healthy in a Hurry: Simple, Wholesome Recipes for Every Meal of the Day. Ansel is a past spokesperson for the Academy of Nutrition and Dietetics and was previously an adjunct instructor in the department of nutrition, food studies, and public health at New York University. Healing Superfoods for Anti-Aging is an easy-to-read evidence-based guide to help individuals make food choices that maximize wellness and prevent illnesses that often occur as a result of aging. The book is divided into two parts: one that focuses on nutrients that play a role in preventing age-related diseases, such as diabetes and Alzheimer’s, and another that focuses on nutrients that may reverse physical signs of aging to help readers look and feel younger. Each chapter explores key “supernutrients” and foods in which they’re found, such as salmon, blueberries, and leafy greens. Ansel not only discusses antiaging nutrients and foods

but also provides useful nutrition advice, including food prep tips and explanations of nutrition trends. To make the book’s information applicable, each section ends with tidbits such as “quick ideas” and “smart tips” meant to educate readers on how to incorporate antiaging superfoods into their diets. The book ends with a collection of recipes and specialized meal plans that include focus foods mentioned in previous chapters. Although Ansel cites several studies to support her claims throughout the book, there isn’t a bibliography included for readers to reference. There’s also a significant amount of information contained within the 248 pages, which may be overwhelming for some readers with less basic nutrition knowledge, and the recipe section contains only a few pictures. Despite these minor downsides, this book is a useful resource on how to age happily and healthfully. — Brianna Elliott, RD, LD, is a nutrition specialist for a nonprofit meal delivery program in Minneapolis. She blogs at and is a contributing writer to several nutrition websites including Authority Nutrition.

Rise & Shine: Better Breakfasts for Busy Mornings By Katie Sullivan Morford, MS, RD 2016, Roost Books Hardcover, 213 pages, $24.95

Katie Sullivan Morford, MS, RD, is a blogger, cookbook author, and recipe developer with multiple award nominations. Her successful track record with churning out consumer-oriented nutrition materials makes it no surprise that Rise & Shine is a solid collection of delicious, downright gorgeous recipes and nutrition advice meant to help elevate the morning meal. In line with her previous work such as her blog, Mom’s Kitchen Handbook, and her cookbook Best Lunch Box Ever: Ideas and Recipes for School Lunches Kids Will Love, this resource is designed with busy families in mind; however, the recipes are sophisticated and lend themselves to a larger demographic, including childless couples, college-aged kids, and working singles. Callouts throughout the book assist readers in tailoring

recipes to younger children’s tastes, but also to creating freezable individual servings that are suitable grab-and-go options for self-sufficient teens or adults. To begin, readers are presented with a simple yet compelling explanation of the research-backed benefits of regularly eating a morning meal. In addition, there’s a brief overview of the elements (including nutrient types and percentages) that make up a balanced breakfast. (The author cites the Academy of Nutrition and Dietetics’ 2014 breakfast recommendations as the basis of the overview.) The author thoughtfully adds that she doesn’t feel it necessary to painstakingly calculate the nutrients of every breakfast meal. Instead, she offers eight easier-to-follow tips for readers to focus on, such as upping fruits and vegetables, relying less on packaged foods, getting plenty of protein, and keeping an eye on added sugars. The generalized advice can help consumers feel less overwhelmed, as well as serve as a resource for RDs who aren’t already in the practice of boiling down these recommendations into quick, manageable tips. Also included in the book’s first chapter is a reliable and easyto-understand buying guide meant to help readers make educated decisions when it comes to picking up breakfast staples. Morford does an excellent job of providing gentle guidance on the dizzying array of breads, eggs, milks, and yogurts without professing to know exactly what’s best for every family and budget. The highlight of the book is, of course, the collection of 75 beautiful, balanced breakfast recipes. Nine recipe chapters are broken into basic categories such as “Smoothies and Drinks,” “Everyday Eggs,” and “Toast.” The last chapter, “Weekend Favorites,” showcases longer, more involved recipes meant for days when there’s time to linger in the kitchen or even entertain. Sprinkled throughout are fun, helpful tips such as what to do with extra pumpkin or browning bananas and the importance of giving plant-based milks a good shake before drinking (because the added calcium can settle at the bottom). In keeping with her realistic point of view, Morford comments on bacon, offering healthful advice for those who’d like to work it into breakfast. Overall, the book is an excellent resource for clients (families, singletons, and others) looking to make breakfast more nutritious, wholesome, and exciting. Morford has assembled a wonderful balance of cooking, prepping, and shopping advice that’s densely packed with fresh and trustworthy tips that dietitians and savvy consumers will appreciate. — Amelia Sherry, RDN, CDN, is a nutrition counselor in the division of pediatric endocrinology at Icahn School of Medicine at Mount Sinai in New York City.

Sponsored Content

Diabetes Product

Showcase Are you a RD (or RDN) who works with people who have prediabetes or diabetes? Ongoing, successful self-management means finding the nutritional piece of the puzzle and knowing where to place it in order to deal with the challenges of everyday life. Becoming a Certified Diabetes Educator® (CDE®) helps people with prediabetes or diabetes, providers, colleagues, and employers easily recognize your knowledge, experience, and ability to support positive outcomes.

Sparkling Bitters® is a unique sparkling water lightly flavored with all-natural tonic bitters. Available in Classic Aromatic, Grapefruit Mint, Meyer Lemon, White Peach and Pear Ginger, our one-of-a-kind, thirst quenching bubbly does not contain sugar, sweeteners, calories or anything artificial. The bitter taste provides a host of well-documented health benefits for digestive health including aiding digestion, curbing sugar cravings, relieving heartburn and bloating, and supporting liver functions. Live Better, Drink Bitter.™

Learn more about the value of CDE certification to RDs/RDNs and to those they serve: or visit


Annual Resource Guide JANUARY ISSUE

Fresh Ideas Showcase

Calcium has never tasted so good! Our dark chocolate bar is above and beyond your ordinary calcium supplement options. Made from Bean to Bar Cacao Chocolate, TruCal® Calcium and Vitamin D, it provides an all natural, great tasting option for your daily calcium regimen. • 2g Sugar 4g Carbohydrate (1g fiber) • 65% Dark Chocolate • 500mg Calcium • 500mg Vitamin D • Gluten Free • Kosher • Non-GMO





9 Vol. 19 No.

October 2017

The Magazine for Nutrition Professionals July 2017


f est oin ing The B oD g a ic Ch

2017 September

The Maga zine for Nutri tion Profe ssionals


Today’s Dietiti Spring Sympo an sium Highlights

Learn about 10 strategies to help meet the nutrient needs of this unique population.

ready h, get us, held higinto delicio forks With your teeth e. k cuisin to sin -class world

Dayboat scallops, savory cake, zucchini and summer squash purée from BLVD

page 26

Diabetes Management & Nutrition Guide

Is A2 Beta-Casein in Milk the Solution for Dairy Intolerance?

Learn to better manage hypoglycemia, counsel patients on developing the best dietary patterns for disease prevention, and more.

The Future of Nutrigenomics Statins Diet vs the best ine

g Determ to lowerin approach CVD risk.

Are they a eating? ul to healthf

Versatility Aquafaba’s many its Discover culinar y uses.

Delicious Fruit Forward Desse rts

Graphic Design Made Easy to Improve Patient Care

Food Fears deterrent

Prebiotics’ Role in Treating Lacto Intolerance se www.TodaysD www.TodaysD

To advertise call: 877-822-5808

Use code TODAY10 to get 10% off your order! 64  today’s dietitian  november 2017

EN CE ISS UE Vol. 19 No. 7


ls ion Professiona zine for Nutrit The Maga







Unidine is one the fastest growing food and dining management companies in the country, serving 32 million meals across 26 states in the healthcare, senior living, and corporate dining sectors. We are committed to scratch cooking with fresh, seasonal, responsibly sourced ingredients. We believe that a high quality dining program focused on the health and wellness of the people it serves can be a true benefit for employees and a differentiator amongst employers in competitive hiring markets. Below are some of the current openings with Unidine: Part-time and full-time Registered Dietitian openings in TX, MA, NC, SC, MD, CA, NY, MI, MN, IN Patient Experience Manager in TX Patient Services Supervisor in NY Dining Services Director in IN and NC Visit our careers page at careers/ to view a full listing of all open positions or reach out directly to the Talent Acquisition team at

FEBRUARY 26 – MARCH 4, 2018

APRIL 10-14, 2018

APRIL 19-20, 2018




APRIL 11-13, 2018

APRIL 19-20, 2018



APRIL 12-14, 2018

APRIL 20-27; JUNE 8-15, 2018




APRIL 5-7, 2018

APRIL 13-14, 2018



MARCH 2-5, 2018


APRIL 5-7, 2018


APRIL 15-17, 2018


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

november 2017  65

CULINARY CORNER Oaxacan-Style Black Bean Soup This soup is inspired by Chef Iliana de la Vega, an expert in the culinary traditions of Oaxaca, Mexico. Take the time to find the key ingredients that will make this soup a standout. You can find avocado leaves either fresh or dried at Mexican supermarkets or online. I like to embellish this soup with a variety of toppings, which makes it fun to customize at the table. To keep things simple, though, I’ve included more traditional toppings below. Serves 4


Try This Simple Mexican Soup With a Kick By Chef Garrett Berdan, RDN, LD My wife and I engage in a monthly food tradition with friends: Soup Night. The two of us, and two other couples, have been taking turns hosting Soup Night at our respective homes for more than four years. It’s a terrific way to keep up with each other, and it has become an important part of our personal community and support system. The meals, centered around soup, usually are simple, though we all occasionally bring our A-game to show off our culinary chops. The success of Soup Night is due to keeping it (mostly) simple and scheduling the next Soup Night at the end of every Soup Night. Over the years, we’ve eaten soups from all around the globe and soups that were inspired by the season. One of our favorites is OaxacanStyle Black Bean Soup with embellishments. I learned to make this soup while watching Chef Iliana de la Vega give a demonstration at the Culinary Institute of America in San Antonio. Chef Iliana is the founder and chef of El Naranjo Restaurant & Bar in Austin, Texas, though it was originally in Oaxaca City, Mexico. The soup is simple yet complex with flavor, and the embellishments make it even more exciting. It isn’t only the ingredients that add flavor to this soup; it’s also the culinary techniques used to develop the flavors. Frying the garlic and onion in the oil until deeply caramelized gives the soup an important toasted flavor. And avocado leaf is the secret ingredient that gives the soup a wonderful distinctive flavor that will keep your guests guessing. My variation of this recipe honors the traditional techniques and ingredients to create a simple, flavorful, and affordable meal. Serving soup is a delicious way to deliver the great flavors of vegetables, herbs, spices, legumes, whole grains, and sometimes a bit of meat or seafood. With a base of puréed black beans, the soup is rich in dietary fiber and potassium, plus it adds to the three cups of legumes per week recommended by the Dietary Guidelines for Americans. The toppings could include cooked shredded chicken breast for additional protein, if desired. Soup Night doesn’t need to be complicated or fancy; it just requires a pot of nourishing soup and good company. — Chef Garrett Berdan, RDN, LD, is a culinary nutrition consultant from the Pacific Northwest. Find him at, on Twitter @garrettberdan, and

66  today’s dietitian  november 2017

Ingredients 1 ⁄2 large white onion 2 T canola oil 2 large cloves fresh garlic, crushed 2 fresh or dried avocado leaves 2 dried Pasilla chiles, stem and seeds removed 2 15-oz cans black beans, no salt added, with liquid 1 ⁄2 tsp salt 1 medium Hass avocado, firm ripe, small dice 1 ⁄4 cup Cotija cheese, crumbled

Directions 1. Cut the white onion half into two quarters. Reserve one

quarter whole; dice the remaining quarter into small dice and set aside. 2. Heat a large saucepan or Dutch oven over medium heat. Add the canola oil and heat until it begins to shimmer. Add the crushed garlic clove and intact quarter white onion, and fry until the garlic becomes dark golden brown and has flavored the oil, and the onion is browned on one side. Remove the garlic clove and discard. Place the browned onion quarter in a blender. 3. Add the avocado leaves and the Pasilla chiles to the hot oil. Fry briefly to release their flavors into the oil, about 5 seconds on each side for the Pasilla chiles. Transfer the avocado leaves and Pasilla chiles to the blender with the onion. Remove the pan from the heat. 4. Add the canned black beans with their liquid and the salt to the blender and purée until very smooth. Add up to 1 cup of additional water, if needed, to create a thin purée. 5. Return the pan to medium-high heat and pour the bean purée into the hot oil. Bring to a low boil, then reduce to a simmer and cook for about 5 to 10 minutes just to thicken the soup slightly. 6. Place the diced white onion, diced avocado, and crumbled Cotija cheese on the table in separate serving bowls. Serve the puréed bean soup and top with the diced white onion, avocado, and Cotija cheese. Nutrient Analysis per serving Calories: 313; Total fat: 13 g; Sat fat: 3 g; Trans fat: 0 g; Cholesterol: 9 mg; Sodium: 392 mg; Total carbohydrate: 38 g; Dietary fiber: 15 g; Sugars: 1 g; Protein: 15 g

Evidence-Based and Affordable Weight Loss TOPS® has helped millions in the U.S. and Canada lose weight and keep it off since 1948. We emphasize slow and steady lifestyle changes that lead to lasting weight loss and better health. Refer your patients to a local chapter or offer TOPS® as a class for your prediabetes and diabetes patients. Our expert-written, peer-reviewed curriculum is easy to implement and is a great use of staff time.


Research Proves It… TOPS® works as well as commercial programs, but costs less. Participants experience a clinically significant weight loss.1

Free Materials Available… As a part of our mission, TOPS® provides free patient education and referral materials.

Request yours by contacting our TOPS® Wellness Team! Alyssa McNamee 414-482-4620 - Ext. 43

Maggie Thorison 414-482-4620 - Ext. 23

Real People. Real Weight Loss.® 1

Determining the Effectiveness of Take Off Pounds Sensibly (TOPS), a Nationally Available Nonprofit Weight-Loss Program. Obesity Journal Intervention and Prevention. Volume 19, Number 3, March 2011. Nia S. Mitchell, L. Miriam Dickinson, Allison Kempe, & Adam G. Tsai.


Clinically Proven Water Extract of Cinnamon

For healthy blood sugar levels, naturally.*† Our patented water extraction process removes cinnamon’s undesirable elements and concentrates its beneficial active elements. The result is a concentrated 10:1 potency versus regular cinnamon supplements and provides clinically proven support for healthy blood sugar levels, naturally.*†

2 CinSulin Capsules

10 Regular Cinnamon Capsules

Visit for more information

Profile for igmhsynfgv