Today's Dietitian June 2014

CONFERENCE ISSUE
Vol. 16 No. 6
June 2014
Athletes
and
Protein
Intake
The Magazine for Nutrition Professionals
MENS
HEALTH
MONTH
FEATURING
Men in Dietetics
Mens Fitness
Experts Discuss
Whether the RDA
Is Adequate
5 Summer
Foodservice
Programs for Kids
Dairys Value in
Disease Prevention
INSIDE
Gluten-Free
Showcase
www.TodaysDietitian.com
CHOICES
THAT YOU CAN TRUST!
11 incredible flavors and
varieties to choose from.
Dietary restrictions should never mean taste restrictions.

One bite of a delicious certified gluten-free NoGii bar and
youll think you just left the candy aisle. Bars that are packed
with premium protein, suitable for a Paleo Diet, or even a
smart choice for the kids. The choice is yours!
GLUTEN-FREE
Solutions For Healthy Families
Elisabeth
Hasselbeck
Available at retailers nationwide
Gluten-Free Mom, Emmy-Award

Winning Talk Show Host, and
New York Times Best-Selling
Author of The G-Free Diet and
Deliciously G-Free
NoGii.com
0.25g
0.44g
0.49g
0.90g
1.09g
0.67g
0.94g
Which serving has the

most s
soluble fiber?
1.38g
0.99g
3.0g
0.58g
1.25g
0.58g
1.12g
0.77g
1.17g
Konsyl Original Formula
Psyllium Fiber
0.61g
1.36g
Just one teaspoon of sugar-free Konsyl Original Formula has 6 grams of

psyllium fiber, equivalent to 3 grams of soluble fiber thats 75% more
psyllium fiber than leading brands!
As part of a healthy lifestyle, the all-natural psyllium contained in Konsyl
products can help your patients lower their cholesterol to promote
heart health.* Psyllium fiber also helps support diabetes management,
digestive health, and a healthy weight.**
1.45g
1.02g
Konsyl fiber supplements have been recommended by health care

professionals for over 50 years. Have you told your patients about
Konsyl Psyllium Fiber?
1.31g
For free professional samples, visit

konsyl.com or call 1-800-356-6795.
Our informative video is available at

konsylfiber.com/healthcarefiberbenefits
0.44g
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facebook.com/konsyl
0.67g
0.44g
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.
0.47g
**These statements have not been evaluated by the FDA. This product
is not intended to diagnose, treat, cure, or prevent any disease.
Betty W. Li, Karen W. Andrews, Pamela R. Pehrsson, Individual Sugars, Soluble, and Insoluble Dietary Fiber Contents of 70 High Consumption Foods,
Journal of Food Composition and Analysis, Volume 15, Issue 6, December 2002, Pages 715-723, ISSN 0889-1575, 10.1006/jfca.2002.1096.
0.15g
EDITORS SPOT
WHERE THERES SMOKE,

IS THERE FIRE?
Im sure you remember the controversial
meta-analysis published in the March issue
of the Annals of Internal Medicine that found
no clear association between saturated fat
consumption and higher heart disease risk
and unsaturated fat consumption and lower
heart disease risk. The study, which is part of
a growing body of research questioning the link between saturated fat and heart disease, sparked a contentious debate among
medical research scientists and nutrition experts.
Many medical researchers were up in arms about the study
because it contradicted a large evidence base represented
in the 2013 AHA/ACC Guideline on Lifestyle Management to
Reduce Cardiovascular Risk, a comprehensive report from
the American College of Cardiology and the American Heart
Association that associates heart health with dietary patterns
low in saturated fats and heart disease with dietary patterns
high in saturated and trans fats.
Many scientists questioned the veracity of the study design,
pointed out inaccuracies in the findings, and even demanded
the study be retracted. The research wasnt retracted, but the
study authors did correct some of their conclusions to reflect
current evidence that wasnt part of their analysis.
Im no scientist, and this could be a prime example of
shoddy research, but I do have some questions. How can
medical researchers and diet and nutrition experts come to
very different conclusions about the role of saturated fats in
the development of cardiovascular disease and stroke after
examining the same volume of evidence? Could it be possible
that not all saturated fat is created equal, as some research
involving coconut oil and dairy suggests?
This controversy brings to mind the adage, Where theres
smoke, theres fire, meaning that maybe, just maybe, theres some
truth somewhere in the research thats questioning saturated fats
association with heart disease and stroke. Is it reasonable to think
that maybe the medical community should look at the evidence of
the contradictory camp a bit more closely to determine why it has
come to its conclusions so a true consensus can be established?
I may be nave, but Id like to think the medical community could
work together toward this end. Share your thoughts about this
ongoing controversy on Today Dietitians Facebook and Twitter
pages, and please enjoy the issue!
Judy
Judith Riddle
Editor
TDeditor@gvpub.com
4 todays dietitian june 2014
President & CEO

Kathleen Czermanski
Vice President & COO
Mara E. Honicker
EDITORIAL
Editor Judith Riddle
Editorial Director Jim Knaub
Senior Production Editor Tracy Denninger
Editorial Assistants Heather Hogstrom, Leesha Lentz
Contributing Editor Sharon Palmer, RD
Editorial Advisory Board Dina Aronson, RD; Jenna A. Bell, PhD, RD;
Janet Bond Brill, PhD, RD, CSSD, LDN; Marlisa Brown, MS, RD, CDE, CDN;
Constance Brown-Riggs, MSEd, RD, CDE, CDN;
Carol Meerschaert, MBA, RD; Sharon Palmer, RD;
Christin L. Seher, MS, RD, LD
ART
Art Director Charles Slack
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ADMINISTRATION
Administrative Manager Helen Bommarito
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FINANCE
Director of Finance Jeff Czermanski
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Director of Continuing Education Jack Graham
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CIRCULATION
Circulation Manager Nicole Hunchar
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the editor, reviews, and editorials, represent the opinions of the authors,
not those of Great Valley Publishing Company, Inc. or any organizations
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Company, Inc., its editors, and its editorial advisors do not assume
responsibility for opinions expressed by the authors or individuals quoted
in the magazine, for the accuracy of material submitted by the authors, or
for any injury to persons or property resulting from reference to ideas or
products discussed in the editorial copy or the advertisements.
The USDA recommends

servings of dairy every day.
Make
yogurt
one of
them!
The American diet is more unbalanced than

ever and in a state of crisis. Americans consume
only about half of the USDA recommended
daily servings of low fat and fat free dairy.
Yogurt is a convenient, nutrient-dense food
that contributes to the recommended 3 daily
servings of dairy. Most yogurts contain nutrients
that are lacking in the American diet, including
calcium, vitamin D and potassium. Yogurt can
be an excellent source of high-quality protein,
which helps with satiety, and promotes muscle
and bone health.
Recent epidemiological studies in healthy
populations also show that frequent yogurt
consumption, as part of a healthy diet,
is associated with less weight gain over time,
healthy levels of systolic blood pressure and
circulating glucose within the normal range.
Eating one yogurt every day is an important first
step toward creating a more balanced diet and
a healthier lifestyle, and improving public health.
Brought to you by
www.oneyogurteveryday.com
2014 The Dannon Company, Inc. All rights reserved.
CONTENTS
JUNE 2014
38
12
FEATURES
DEPARTMENTS
22
Athletes and Protein Intake Experts weigh in on whether
4 Editors Spot
the Recommended Dietary Allowance for highly physically active

people is adequate.
7 Reader Feedback
26
Nourishing Kids in the Summer Learn how five school

districts are offering nutritious meals to underprivileged children
to keep them healthy before starting a new school year.
30
34
38
10 Conference Currents
12 Dynamics of Diabetes
The Lowdown on Dairy Heres a review of the latest evidence
14 Health Matters
on dairys health benefits and its value in disease prevention.
18 Living Gluten Free
Men in Dietetics While women dominate the nutrition
20 Healthful Snacks
profession, more men are entering the field and experiencing

great success in their careers.
51 Personal Computing
Mens Fitness Experts offer tips for helping male clients get fit
54 Get to Know
when time is tight.
44
8 Ask the Expert
52 Focus on Fitness
56 Gluten-Free Showcase
CPE Monthly: Dietary Weight-Loss SupplementsThis
58 Bookshelf
course provides a review of these supplements and what their

labels dont necessarily say.
60 News Bites
62 Products + Services
64 Research Brief
65 Datebook
66 Culinary Corner
Page 44
Todays 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
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$95 per year; Single issue: $5. Todays Dietitian Volume 16, Number 6.
READER FEEDBACK
From Our Facebook Wall
From Our Twitter Page

Popular Tweets, Retweets
GENETICALLY
MODIFIED
FOODS
Todays Dietitian
spoke with dietetics
and food industry
experts about the pros
and cons of genetically
engineered foods and
crops plus their impact
on the environment,
human health, and
global food security.
BY DAVID YEAGER
h debate over genetically engineered (GE) crops

he
a
and foods containing genetically modied (GM)
iingredients or genetically modied organisms
((GMOs) is marked by passionate opinions on
b
both sides. Whether youre pro-GMO, anti-GMO,
o
or unsure, youre most likely familiar with some
o
of the arguments. Opponents cite questions
GMOs effect on human health and ecosystems, their
aboutt GMOs
potential to hasten the evolution of pesticide-resistant insects
and herbicide-resistant weeds, and the undue inuence of
large corporations on agricultural policy as reasons to be
wary. Proponents counter that safety concerns are highly
exaggerated; GE crops reduce the amounts of pesticides and
herbicides that farmers must use; and theyre necessary
for meeting the food needs of a human population that will
continue to grow.
To learn more, Todays Dietitian (TD) asked experts about the
potential effects of this biotechnology on our food supply and
health. The participants in our Q & A are as follows:
Ashley Colpaart, MS, RD, is the 2013-2014 chair of the
Academy of Nutrition and Dietetics Hunger and Environmental
Nutrition Dietetic Practice Group and a doctoral student in
interdisciplinary studies of food science and food safety at
Colorado State University. She previously worked as the farm
to institution coordinator at the Tierra Miguel Foundation.
Gregory Jaffe is the biotechnology project director
for the Center for Science in the Public Interest (CSPI). He
previously served as a trial attorney for the US Department
of Justices environmental and natural resources division and

as senior counsel with the Environmental Protection Agencys
air enforcement division. Hes an international expert on
agricultural biotechnology and biosafety.
Lisa D. Katic, RD, is the president of K Consulting,
specializing in food policy, communications, and education.
She provides strategic counsel for numerous clients in the
food and agriculture industry and is an expert in scientic
and regulatory programs in many areas, including nutrition,
biotechnology, functional foods, food labeling, and obesity. She
was formerly senior director of scientic and nutrition policy
at the Grocery Manufacturers of America and, before that,
associate director of food safety for the International Food
Information Council in Washington, D.C.
Christine McCullum-Gmez, PhD, RD, LD, is a
consultant, writer, and speaker whose areas of expertise
include community food security, public health nutrition,
sustainable food systems, and school and worksite wellness.
She serves as a column editor for the Journal of Hunger and
Environmental Nutrition and has received numerous awards,
including a National Cancer Institute postdoctoral fellowship.
Barbara Ruhs, MS, RD, LDN, is a consultant, writer,
and speaker and the owner of Neighborhood Nutrition, a
company that provides counseling and retail food and health
marketing communications. She also directs the annual
Supermarket Dietitian Symposium in partnership with
Oldways Preservation Trust. She was formerly the dietitian
for Bashas Grocery Stores.
@Nutrolution: Ive been catching up on your mag and

am super pleased with your cutting-edge and relevant
content. Its wonderful to see!
April Issue
CONFERENCE ISSUE
Vol. 16 No. 4
@LaurenPincusRD: Totally
enjoying the April issue of
Todays Dietitian! So many
great articles this month!
ietitian.com 37
april 2014 www.todaysd
The Magazine
Magazine ffor
or Nutrition Professionals
April 2014
Omega
The
Fats
Weight Loss: Counting Calories More Important

Than Eating Little and Often
www.medicalnewstoday.com
Michelle Pelkey: Not surprising, but unfortunately it doesnt

address the nutritional quality of the diet. How many people
are really going to eat the recommended minimum servings
of two fruits and three vegetables, for example, at just one or
two meals a day?
Nutrition A-Z: Simple Sound & Interactive: The concept of a
calorie is a calorie should slowly take a bow and bid farewell
to the world of weight loss because its more than just
calories; the quality of calories consumed is just as important
as quantity.
Caleb Frazier: Eating a higher volume of food low in calorie
density (all vegetables, fruits, beans, intact whole grains) and
much less food high in calorie density (oils, highly processed
foods, fatty animal products, sugar-containing beverages) is
the key to losing weight and keeping it off. No need to count
calories if youre eating the right foods.
Denise Shepherd Barratt: I think the total amount during
the day and the quality are important. Keeping the message
simple is important without so many little rules. Of course an
individual approach is important.
Learn more about

the various types
of omegas and how
they can contribute
to overall health
Family-Based
Approaches
to Weight Loss
Genetically Modified Foods
Vegetarian Diets
and Older Women
TD
DQ&A
The Pros and
Cons of GMOs
Genetically Modified Foods

Pat Creighton: The editorial was a very open-minded commentary on GM ingredients. However, to say that GM crops
have more herbicide and pesticide use is misleading. The
whole point of GM corn, for example, is to reduce the need for
so many applications of spray and to do the spraying before
the crop even emerges on the plants, therefore remaining
away from the toxins. There are pyrethrins and other sprays
being used on organic foods, as they are considered natural, but they are far more toxic than the permitted sprays on
regular ingredients, including GMOs.
NATIONAL
SOYFOODS
MONTH
@mike_hidro: Very
interesting roundtable
discussion on GMOs.
@Kandapillar: Interesting Q & A article on genetically

modified foods. I gained a new perspective on GMOs.
@nybeefnutrition: Thanks for a great GMO resource
for confused consumers. Science and evidence is a
welcome change to the GMO topic.
@JeffNedelman: There may be non-GMO soybeans,
but all the nutritional science about plant-based
protein is based on conventional foods.
@DanicaPelzel: GMOs arent just a black-andwhite issue.
Irritable Bowel Syndrome (CPE Monthly)

@DietistSigrid: Excellent review of IBS and treatment.
Virtual Nutrition Counseling

@alissarumseyRD: Virtual nutrition counseling isnt
for everyone, but advantages definitely outweigh
disadvantages.
@JanelleFutureRD: Appreciated this article about RDs
counseling virtuallysomething I hope to do upon
graduating.
@MMusikerRD: Legal issues for telemedicine and
nutrition for RDNs also must include licensure. Big
gap in the article.
Vegetarian Diets and Older Women

@claire_emma1: An excellent article. Definitely agree
about spreading protein intake throughout the day.
june 2014 www.todaysdietitian.com 7
ASK THE EXPERT

fish: 145F or until flesh is opaque and separates easily
with a fork.
Many meat thermometers have these temperatures built
into the thermometer settings, but these also are more costly,
while a simple bimetallic thermometer sells for about $10.
Dietetics professionals should create a basic fact sheet for
clients with recommended minimum internal temperatures
and a list of potential thermometers to purchase.
Health Concerns
GRILLING BASICS
By Toby Amidor, MS, RD, CDN
Q:
A:
During the summer, many of my clients enjoy grilling

their food. What are some basic grilling guidelines I can
give them to do so safely and healthfully?
There are three topics that should be discussed when
educating clients about healthful grilling: nutrition, food
safety, and health-related concerns.
Nutrition
Its important to emphasize selecting lean protein for the
grill. These include the following:
beef: flank steak, sirloin, tenderloin, top loin, porterhouse,
T-bone steak, and 90% lean ground beef;
poultry: skinless, white meat chicken or turkey and ground
turkey breast;
veal: any fat-trimmed cut;
pork: tenderloin or chops; and
lamb: loin cuts.
The American Heart Association has certified many cuts of
beef and pork as low in fat and saturated fat. Advise clients to
check packaging for its symbol when browsing the meat aisle.
Fish is another healthful protein choice. Salmon, tuna, mahi
mahi, tilapia, and halibut hold up well on the grill.
Also be sure to discuss portion size with clients. Remind clients that eating 12 oz of protein, even if its lean, during a meal
will sabotage healthful eating efforts. Instead, tell them to aim
for 4 to 5 oz of raw meat (equivalent to 3 to 4 oz cooked) or 6 oz
of fish per serving.
Food Safety
Many folks rely on visual cues to determine the doneness of
meat on the grill. According to the USDA, one in four hamburgers turns brown before its been cooked to a safe internal temperature.1 The only way to determine whether meat is cooked
properly is to check the internal temperature with a thermometer. The following is the minimum internal cooking temperature
for commonly grilled items2:
beef, veal, lamb, and pork (chops and steaks): 145F;
ground meat (beef, pork, lamb): 160F;
poultry (chicken and turkey breasts, thighs, legs, wings): 165F;
ground poultry (turkey and chicken): 165F; and
Clients may ask about concerns such as cancer risk from

heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons
(PAHs). Carcinogenic HCAs are formed when amino acids and
creatine react at high cooking temperatures, such as from
grilling, broiling, and frying. PAHs form when fat from grilled food
drips onto hot coals or ceramic bricks and produces smoke. The
chemical travels in the smoke, which then infuses into the foods.
The higher the heat, the more PAHs are formed. Recommended
steps to take to reduce these chemicals include the following:
Trim excess fat off meat and poultry to reduce the drippings.
Dont overcook the food.
Turn the food often, which helps reduce the production of
cancer-causing agents.
Marinate food before cooking, which reduces the amount of
HCAs formed during grilling.
A recent study also examined the link between browning
meat and an increased risk of dementia in both mice and
humans.3 Browning meat in the oven, grill, or frying pan
produces advanced glycation end products (AGEs). Mice fed a
high-AGE diet were found to accumulate dangerous proteins
in the brain and have impaired cognitive function. A short-term
analysis of people aged 60 and older also found a link between
high-AGE levels in the blood and cognitive function. More
research is needed on AGEs; however, a reduction of foodderived AGEs may be an effective strategy to treat dementia.
Toby Amidor, MS, RD, CDN, is the
founder of Toby Amidor Nutrition
(http://tobyamidornutrition.com) and the
author of the cookbook The Greek Yogurt
Kitchen. Shes also a nutrition expert for
FoodNetwork.com and contributor
to US News Eat + Run.
For references, view this article on

our website at www.TodaysDietitian.com.
Have questions about nutrition trends, patient care,
and other dietetics issues youd like to ask our expert?
Send your questions to Ask the Expert at TDeditor@gvpub.com
or send a tweet to @tobyamidor.
2014 The Dannon Company, Inc. All rights reserved. Oikos is a registered trademark of Stonyfield Farm, Inc. and used under license by The Dannon Company, Inc.
CONFERENCE CURRENTS
Obesity Prevention
One priority for nutrition professionals is to reduce the rate
of obesity and its associated diseases, as more than one-third
of adults in the United States currently are obese. Since the
American Medical Association has recognized obesity as a
disease, the ACA will cover obesity screening and counseling
services without copayments under preventive services.
Medicare will pay for screenings and preventive services for
obesity, and counseling services for Medicare participants will
be reimbursed as long as patients show progress and services
are delivered in a primary care setting, Grossi said.
Three Models of Care
THE AFFORDABLE CARE ACT
An Update on the Status of Its Implementation

in Pennsylvania
By Judith Riddle
In April, the Pennsylvania Academy of Nutrition and Dietetics
opened its 81st Annual Meeting and Exhibition at the Historic
Hotel Bethlehem with a general session on a timely topic: the
Affordable Care Act (ACA). Joanne Corte Grossi, MIPP, regional
director of the US Department of Health and Human Services
(HHS), Region III, presented the session and gave attendees
an overview of the ACA and an update on the status of its
implementation in Pennsylvania.
Overview
In her presentation, Grossi told attendees that 13.4% of
the US population is uninsured; $2.8 trillion is spent annually
on health care; 17.2% of our economic output is tied up in the
health care system; 8 million people have signed up for private
insurance in the health care insurance marketplace; 3 million
young adults have gained insurance coverage as a result of the
ACA; and 3 million youths are enrolled in Medicaid and the Childrens Health Insurance Program.
The ACA provides coverage to young adults up to the age of
26. It strengthens Medicare benefits in that there now are lower
prescription drug costs for those in the donut hole and for
people who need chronic care, and it offers free preventive care
services. The ACA prohibits insurance plans from imposing
lifetime and annual limits on the dollar value of benefits and from
rescinding coverage when people get sick, Grossi explained.
Moreover, the ACA reins in insurance premium rates; prevents denials of coverage, such as for preexisting conditions;
and provides tax cuts that can make health insurance affordable for middle class families and small businesses.
Within the health insurance marketplace, Grossi said there

are three models under which states can offer health care
insurance benefits: state based, federal-state partnerships,
and federally facilitated. State-based health care marketplaces
allow individual states to create and operate their own marketplaces and run certain functions. Federal-state partnerships
allow states to retain responsibilities for managing some customer service and operational functions, but other duties are
relegated to the federal government.
Pennsylvania is a federally facilitated health insurance
marketplace, which is a government-operated online option for
individuals to buy health insurance and for small businesses
to provide insurance for their employees so they can purchase
coverage. Individuals and small businesses can compare health
plans, get questions answered, determine eligibility for lower
out-of-pocket costs, and enroll in health plans.
Marketplace Status in Pennsylvania

To date, Pennsylvania has received $34,832,212 in grants to
implement its health insurance marketplace. Currently, there
are 1.3 million people uninsured in Pennsylvania; 318,000
have enrolled in health insurance, and 600,000 still are
eligible to enroll.
Eight insurance companies are participating in the marketplace, and there are 126 health insurance plans from which
to choose, Grossi said. Whichever health care plan individuals choose to fit their needs, they all will receive ambulatory patient services; emergency services; hospitalization;
maternity and newborn care; mental health and substance
use disorder services, including behavioral health treatment;
prescription drugs; rehabilitative and habilitative services/
devices; laboratory services; preventive and wellness services
and chronic disease management; and pediatric services,
including oral and vision care.
Financial assistance in the form of premium tax credits and
cost-sharing reductions is available. Premium tax credits will
reduce the premium amounts consumers pay each month.
Theyre based on household income and family size within the
taxable year, and theyre available to eligible consumers with
household incomes between 100% and 400% of the federal
poverty level and to those who dont qualify for other health
insurance coverage. In addition, theyre paid monthly to insurers. Cost-sharing reductions lower out-of-pocket costs such as
deductibles, coinsurance, and copayments; theyre generally
available to those with income 250% of the federal poverty level
or below ($29,175 for an individual and $59,625 for a family of
four in 2012); and theyre based on household income and family
size for the taxable year.
In January, Pennsylvania did not choose to expand Medicaid,
which would have allowed 650,000 uninsured people to become
eligible for health insurance under Medicaid. Benefits would
have been 100% federally funded for the first three years (2014
to 2016) and 90% federally funded in 2020. Pennsylvania would
have received $17 billion in the first six years, Grossi said.
Instead, Pennsylvania submitted a proposal called Healthy
Pennsylvania to HHS, its own version of Medicaid expansion to
improve access, ensure quality, and provide affordable health
care to the most vulnerable citizens in a flexible and sustainable
manner, which involves aligning the current Medicaid program
with creating a sustainable Medicaid program.
Relevance to Dietitians
Because much of the focus of the ACA is on preventive health
care services, those in the nutrition profession are continuing
to work hard on Capitol Hill to ensure dietitians are recognized
as the experts in administering intensive behavioral counseling

for obesity prevention and are reimbursed for their services
outside of a primary care setting. At press time, the Treat and
Reduce Obesity Act of 2013, a bipartisan bill that would allow
different types of health care providers, including dietitians, to
offer and be reimbursed for intensive behavioral therapy for
obese Medicare recipients remains in committee. And theres
only a 5% chance the bill will get past committee, the House of
Representatives, and the Senate and be enacted.
In a March 2012 letter addressed to its members, the
Academy of Nutrition and Dietetics stated that registered
dietitians can work with physicians in the primary care
setting and bill incident to the physician or provider. While
this opportunity is not ideal for registered dietitians, it is a
significant first step in Medicares coverage for obesity that
previously did not exist, and we will build upon it.
Moving forward, it will be important for dietitians to keep
abreast of the status of the Treat and Reduce Obesity Act
and work hard to get the bill passed, continue to take the
steps necessary to develop legislation that would allow RDs
to provide reimbursable nutrition counseling services to
prevent obesity, and learn the specifics of the ACA that could
potentially affect daily practice.
Judith Riddle is editor of Todays Dietitian.
The North American Society for Pediatric Gastroenterology,

Hepatology, and Nutrition (NASPGHAN) presents:
2014 NASPGHAN Nutrition Symposium

Saturday, October 25, 2014 Hilton Atlanta, Atlanta, GA
Featuring top nutrition experts discussing:
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Malnutrition
Gluten-free diets for the non-celiac patient
Fiber in health and disease
Growth charts
Nutrition of very low birth weight infants
Round table discussions on:
Food Protein-Induced Enterocolitis Syndrome (FPIES)

Pediatric feeding disorders
Interpreting micronutrient lab values
Intestinal failure
Special Hands-on physical assessment training

Registration fee: $150 (CPNP members), $200 (non-members)
Fee includes registration to the NASPGHAN Annual Meeting.
DYNAMICS OF DIABETES
The following is a discussion of foods and beverages diabetes
patients should include in their diet and those they should limit.
Foods and Beverages to Include
FOODS AND BEVERAGES

FOR HEART HEALTH
Managing Diabetes Isnt Just
About Blood Glucose Control
By Jill Weisenberger, MS, RDN, CDE

Patients with diabetes often focus solely on blood glucose
control to the exclusion of other health parameters. Thats no
surprise since patients easily can measure their blood glucose,
which can jump or plummet quickly and change the way they
feel or put their health at risk.
Controlling blood glucose is critical to preventing longterm microvascular complications such as retinopathy and
neuropathy. But equally important is the health of the heart
and blood vessels because diabetes at least doubles the risk
of heart disease.1 In fact, to prevent heart disease, controlling blood pressure and cholesterol are more important than
blood glucose control.2 Unfortunately, less than 19% of Americans with diabetes have blood glucose, blood pressure, and
cholesterol all at target levels.3
Healthful foods can help meet target levels, but many
patients fear the foods that can protect their hearts because of
their perceived effect on blood glucose. It used to be that diabetes was synonymous with glucose control, says Hope Warshaw,
MMSc, RD, CDE, author of Diabetes Meal Planning Made Easy.
Now with data from numerous long-term research studies,
both in type 1 and 2 diabetes, we know that control of glucose,
lipids, and blood pressure are all key to getting and keeping
people with diabetes healthy in the short and long term.
Patients and nutrition professionals alike frequently
have questions about the role of heart-healthy foods in the
treatment and management of diabetes. Dietary patterns
matter for overall health, explains David Katz, MD, director
of the Yale-Griffin Prevention Research Center and author
of Disease Proof. Yet, he says, its still possible to make a
meaningful contribution one food at a time, especially if the
healthful food added replaces one thats not healthful.
Fruit: All that sugar! is a common refrain dietitians hear

from diabetes patients. Many are shocked that an RD would
recommend they eat fruit or any carbohydrate-rich food.
New York-based dietitian Jennifer Hyman, MS, RD, CDE,
CDN, reminds her patients of the nutrients, phytochemicals,
and health benefits they fail to get when they omit an entire food
group. I try to encourage patients to look at the bigger picture
in terms of total carbohydrates and to aim for a certain range of
carbs at each meal. If they aim for a certain budget of carbs at
meals, it gives the patient the flexibility to choose where those
carbs come from, she explains.
According to the 2010 Dietary Guidelines for Americans,
consuming at least 212 cups of fruits and vegetables each day
is associated with a lower risk of cardiovascular disease (CVD),
including heart attack and stroke. In general, fruits are a rich
source of potassium, a mineral important for healthy blood
pressure because potassium blunts the harmful effects of
sodium. Few Americans consume potassium in amounts equal
to or greater than the Adequate Intake of 4,700 mg per day.4
For patients who shun carbohydrates in general or fruits in
particular, RDs can explain calorie density. With food models,
photos, or real food, dietitians can show patients the volume of
fruit or other carbohydrate-rich foods they can eat that equals
200 kcal then compare that to 200 kcal of meats, oils, and solid
fats. Patients should be impressed by the difference in the
amount of food.
Beans: Rich in dietary fiber, potassium, magnesium, folate,
and a host of phytochemicals, beans are linked to lower blood
pressure and a decreased risk of heart disease. Beans also
have resistant starch, a type of fiber that, when degraded by
the gut microbiota, cause the production of a short-chain fatty
acid that appears to improve insulin action. If eaten in sufficient
quantities, resistant starches can impact postprandial blood
glucose due to both partial digestion and improved insulin
sensitivity, Warshaw says. Eating at least four servings of beans
per week is linked to a 22% lower risk of coronary heart disease
compared with eating them less than once weekly.5
Whole grains: The 2010 Dietary Guidelines state that whole
grain intake may reduce the risk of CVD and is associated with
a lower body weight. Whole grains are sources of magnesium,
iron, selenium, B vitamins, and dietary fiber, with barley and
oats being particularly noteworthy. The FDA allows a health
claim on barley and oat products stating that 3 g of beta-glucan
soluble fiber intake each day, as part of a diet low in saturated
fat and cholesterol, may lower the risk of heart disease. Betaglucan acts in the digestive tract to block cholesterol absorption and may improve insulin action.
Nuts: The FDA allows a similar health claim on packages
of nuts. In pooled data from several studies, researchers found
that including nuts in the diet decreases both total and LDL
cholesterol in a dose-related manner. On average, those who

consumed nuts had a 5.1% reduction in total cholesterol and
a 7.4% decrease in LDL cholesterol. Subjects with elevated
triglycerides had a 10.2% decline in serum triglyceride levels.
Diabetes patients can enjoy eating a mix of nuts because
different types of nuts have health benefits.6
In other research, Katz and colleagues found that adding
walnuts to the diets of patients with diabetes improved both
glycemic control and endothelial function.7
Cooking oils: Replacing saturated fats at approximately
5% to 7% of energy with unsaturated fats improves cardiovascular risk factors.8 Therefore, RDs can encourage patients
to substitute butter, margarine, lard, and shortening with
healthier cooking oils.
In one study, olive oil exhibited a unique benefit. When
researchers gave about 2 T of olive oil daily to participants
with endothelial dysfunction, the participants showed
improved endothelial function compared with participants
in a control group.9 Other appropriate oils include canola,
peanut, soybean, and corn oils.
Because dietary fats dont significantly affect blood glucose,
many people with diabetes tend to consume excessive amounts.
Hyman teaches patients that portion control is an important
concept even when it comes to healthful foods.
Tea: Studies suggest that drinking tea is associated with
a reduced risk of heart attack and stroke and also may help
lower blood pressure.10,11 Flavonoids in tea, especially flavan3-ols, theaflavins, and thearubigins, are strongly linked with
lower CVD risk. The mechanisms seem to involve changes
in cell signaling paths that lead to decreased inflammation,
increased nitric oxide synthesis, decreased platelet aggregation, and potentially other functions, too, says Karen Collins,
MS, RDN, CDN, a speaker and consultant and the author of the
Smart Bytes blog.
Bottled tea, however, has few flavonoids. One great option
for warm weather is to teach people how simple it is to brew
homemade iced tea, Collins adds.
Caution Foods and Beverages

Alcohol: Many consumers have heard that alcohol,
particularly wine, protects the heart. Moderate alcohol
intake also is associated with a reduced risk of type 2 diabetes, beginning with as little as one-half of a standard drink
per day, or 7 g of alcohol.12 High intakes of alcohol, however,
increase the risk of heart troubles and other chronic health
problems, including accidents. Because of this, neither the
American Heart Association nor the American Diabetes
Association recommends that nondrinkers start drinking
alcoholic beverages.
Since many diabetes patients will drink alcohol anyway,
health professionals must caution those taking certain diabetes medications of the increased risk of hypoglycemia and the
proper treatment for it. Dietitians should advise patients to consume alcohol only with carbohydrate-containing foods and to
monitor blood glucose more often than usual, especially before

driving and before bedtime. Some may need to monitor blood
glucose during the night and into the following day because the
development of hypoglycemia can be delayed.
The safe limit for alcohol consumption for diabetes
patients depends on factors such as the medications they
take and blood glucose control.
Red meat: Many people with diabetes eat large amounts of
protein-rich foods, including red meats, because they perceive
these carbohydrate-free foods to be better for their diabetes.
However, red meat, which includes beef, pork, and lamb, is
associated with an increased risk of heart disease. Even lean
red meats likely contribute to higher rates of cardiovascular
problems. A study found that intestinal microbiota metabolizes
carnitine in red meat to form trimethylamine, which can be
metabolized to form trimethylamine-N-oxide, a compound
associated with atherosclerosis.13
The American Diabetes Association recommends diabetes
patients choose lean meats and follow the guidelines for the
general population.
Egg yolks: Eggs are the No. 1 source of cholesterol in
the American diet.4 According to the USDA Nutrition Evidence
Library, a review of epidemiologic studies showed that eating
one egg per day isnt harmful for healthy individuals but
increases CVD risk in people with type 2 diabetes.14 It makes
sense to be prudent, Katz says, but eggs are more likely to
be beneficial, especially if they displace less nutritious food.
Eggs are satiating, contain an ideal protein, and have few
saturated fats, Katz says, who has conducted soon-to-be published research in people with coronary heart disease in which
subjects ate two eggs per day for six weeks. In his study, there
were no adverse effects in lipids or blood vessel function. If
patients are concerned, they can cook with more egg whites
than egg yolks or use an egg substitute.
Counseling Clients
When counseling diabetes patients, its important for dietitians to tell them that managing their disease isnt just about
controlling blood glucose, and that there are many healthful
foods and beverages they can enjoy that promote heart health.
With empathy, RDs can teach the importance of controlling
blood glucose, blood pressure, and cholesterol levels as well as
the benefits of an overall healthful diet that includes a variety of
heart-healthy, wholesome foods.
Jill Weisenberger, MS, RDN, CDE, is a freelance writer
and a nutrition and diabetes consultant to the food industry.
She has a private practice in Newport News, Virginia, and
is the author of Diabetes Weight Loss Week by Week.

HEALTH MATTERS
School Program Improves

Eating Habits, Lowers BMI
Researchers behind a new comprehensive school nutrition
and wellness program say that youll get further by offering
kids a carrotliterally, in this caseand giving them reasons
to be excited about fruits and vegetables rather than harping on
what they should avoid, such as sugar-sweetened beverages.
In a randomized controlled study, the researchers found
fourth graders who participated in the Shaping Health Choices
Program ate substantially more fruits and vegetables and
also lowered their BMI during the school year that the program was implemented. The percentage of fourth graders
who were overweight or obese dropped from 56% to 38% over
the course of the year.
We take the approach that positive messages are going
to be more readily adopted by students than restrictive messages, says Rachel Scherr, PhD, an assistant project scientist
at the University of California, Davis, and one of the studys lead
investigators. For us, the most important thing is that the kids
and their families really enjoyed the program. It was very successful, and I think it was critical that we focused on empowering kids and their families to want to make a change.
The Shaping Healthy Choices Program takes a holistic
approach to engage students, schools, parents, and community partners in building healthful habits. At its core is a curriculum that integrates classroom nutrition activities with physical
activity and gardening. It also includes cooking demonstrations
and recipes, health-related activities for school events, family
newsletters, and guidance for school lunchrooms to encourage
healthful eating, for example, by creating a salad bar.
Four elementary schools in

two California school districts
participated in the study. In each
district, one school adopted the
Shaping Healthy Choices Program over the course of the 20122013 school year while the other
school did not. The researchers assessed several outcomes,
including students BMI, reported
dietary intake, and knowledge
about nutrition at the start and
end of the school year.
Although the analyses still are
under way, preliminary results
from one district show participating children dropped their BMI
percentile by nearly 9 points, from
an average of the 77th percentile to
an average of the 68th percentile.
Participating fourth-grade children who reported eating one or fewer servings of vegetables
per day at the start of the study increased their vegetable intake
by 40%. Students at the school that didnt partake in the Shaping Healthy Choices Program showed no change in BMI, vegetable intake, or nutrition knowledge.
Scherr says the results show that the program really
impacts students health. When we designed the study, we
anticipated short-term outcomes like kids having more knowledge of nutrition or being able to identify more vegetables. We
always had a long-term goal of decreasing BMI, but we didnt
anticipate that it would happen in such a short time frame. We
are thrilled, she says.
The program was designed to be easily integrated into the
Common Core standards being rolled out in 44 US states. The
programs multiple components can be adopted separately or
together, though the study evaluated the effectiveness only of
the full program.
Most components can be implemented at little cost. Some
elements, such as building a school garden or creating a salad
bar, require a small amount of start-up funding.
Theres room for a program like this at all schools, Scherr
says. Its very cost-effective, and its been designed so schools
can adopt the whole program or just the parts that are most
feasible for them.
The researchers plan to make the full program tool kit available online for free by the end of 2014, including professional
development resources to facilitate the programs implementation. Although the researchers played a major role in implementing the program at the test schools during the study, they
believe that most schools will be able to adopt the program
without outside assistance.
SOURCE: FEDERATION OF AMERICAN SOCIETIES FOR EXPERIMENTAL BIOLOGY
Vitamin D Deficiency May Be

Linked to Prostate Cancer
Vitamin D deficiency was an indicator of aggressive
prostate cancer and spread of the disease in white and
black men who underwent their first prostate biopsy
because of abnormal prostate-specific antigen (PSA) and/
or digital rectal examination (DRE) test results, according
to a study published in Clinical Cancer Research.
Vitamin D is a steroid hormone thats known to affect
the growth and differentiation of benign and malignant
prostate cells in prostate cell lines and in animal models
of prostate cancer, says Adam B. Murphy, MD, MBA, an
assistant professor in the department of urology at the
Northwestern University Feinberg School of Medicine in
Chicago. In our study, vitamin D deficiency seemed to be a
predictor of aggressive forms of prostate cancer diagnosis
in European American and African American men.
The stronger associations in African American men
imply that vitamin D deficiency is a bigger contributor
to prostate cancer in African American men compared
with European American men, Murphy adds. Vitamin D
supplementation may be a relevant strategy for preventing
prostate cancer incidence and/or tumor progression in
prostate cancer patients.
The most accurate way to measure vitamin D levels
in the body is to measure levels of 25-hydroxyvitamin D
[25(OH)D] in the blood. The normal range of 25(OH)D is
30 to 80 ng/mL.
In this study, white and black men had 3.66 times and
4.89 times increased odds of having aggressive prostate
cancer (Gleason grade of 4+4 or higher), respectively, and
2.42 times and 4.22 times increased odds of having tumor
stage T2b or higher, respectively, if their 25(OH)D levels
were below 12 ng/mL at the time of prostate biopsy. In
addition, black men had 2.43 times increased odds of being
diagnosed with prostate cancer if their 25(OH)D levels were
below 20 ng/mL.
Between 2009 and 2013, Murphy and colleagues enrolled
667 men aged 40 to 79 who were undergoing their first
prostate biopsy at one of five urology clinics in Chicago following an abnormal PSA or DRE test. Serum 25(OH)D levels
were measured at recruitment. Of the study participants,
273 were black and 275 were white, and 168 men from each
group had a prostate cancer diagnosis from their biopsy.
The researchers found that the mean 25(OH)D levels
were significantly lower among black men (16.7 ng/mL)
compared with white men (19.3 ng/mL). The highest 25(OH)
D level was 71 ng/mL in white men, while it was only 45 ng/
mL in black men.
They categorized the study group into those whose

25(OH)D levels were below 12, 16, 20, and 30 ng/mL and
found a dose-response relationship between tumor grade
and vitamin D level for both white and black men, and the
association held true even after adjusting for potential confounders, including diet, smoking habits, obesity, family
history, and calcium intake.
The researchers also found an association between
lower 25(OH)D levels and those at high and very high risk of
prostate cancer, per National Comprehensive Cancer Network criteria, which take into account prediagnosis PSA
levels, tumor stage, and Gleason grade.
While no association was found between vitamin D deficiency and prostate cancer diagnosis in white men, this
association was significant in black men. Further, the association with disease aggressiveness and cancer spread
was stronger for black men than for white men. Skin color,
which determines cumulative vitamin D levels from sun
exposure, may partly explain the discrepancies observed
between white and black men, Murphy explains.
We will next evaluate genetic polymorphisms in the
pathways of vitamin D metabolism to better understand
the risk alleles underlying this association, Murphy says.
Vitamin D deficiency seems to be important for general
wellness and may be involved in the formation or progression of several human cancers. It would be wise to be
screened for vitamin D deficiency and treated.
SOURCE: AMERICAN ASSOCIATION FOR CANCER RESEARCH
Dietitian: Shake the Salt Habit for Better Health

Newer salt offerings, such as pink Himalayan, may be
exotic, cost more, and frequent the shelves of high-end stores,
but theyre just as bad for you as common table salt, according
to one dietitian.
Typically, people opt for natural vs. processed to avoid
preservatives such as sodium, but in this case, all salt is
sodium, says Ashley Barrient, MEd, LPC, RD, LDN, a clinical
dietitian at the Loyola Center for Metabolic Surgery and
Bariatric Care. Sea salt and table salt have an equivalent
sodium content despite sea salt being deemed less processed
than table salt due to the way its produced.
Barrient says many healthy adults may think monitoring
or lowering salt content doesnt apply to them. Lowering our
sodium intake along with other positive dietary and lifestyle
factors can be a proactive measure to prevent or delay the
onset of certain conditions and improve management of such
conditions long term. Chronic kidney disease, high blood
pressure, diabetes, congestive heart failure, and osteoporosis
are a few of the conditions worsened by high sodium intake.
The 2010 Dietary Guidelines for Americans recommends
Americans aged 2 and older limit their sodium consumption
to 2,300 mg/day, which is equal to 1 tsp of salt. I recommend to my patients that they consume less than 600 mg of
sodium per meal and less than 500 mg of sodium total from
all snacks throughout the day, Barrient says. If youre older
than 51, African American, or have a diagnosis such as diabetes or hypertension, the most recent version of the Dietary
Guidelines for Americans recommends reducing sodium
intake to 1,500 mg per day.
From a weight-loss perspective, a high-sodium diet can
promote fluid retention in individuals with certain medical
conditions, thus making it more challenging to achieve a
desired weight loss, she says. When counseling patients
within a bariatric/weight-loss specialty, sodium intake is one of
many possible contributing factors I investigate if an individual
is experiencing weight regain or a weight loss plateau.
Barrient says that many packaged and prepared foods
have a large amount of sodium. The more we cook at home,
use fresh herbs and spices as opposed to processed, and
visit farmers markets to buy fresh ingredients, the lower our
sodium intake will be as a whole, she says.
SOURCE: LOYOLA UNIVERSITY HEALTH SYSTEM
Resveratrol-Rich Diet Fails to Reduce Deaths, CVD, Cancer

A study of Italians who consume a diet rich in resveratrol, the compound found in red wine, dark chocolate, and
berries, finds they dont live longer than and are as likely to
develop cardiovascular disease (CVD) or cancer as those
who eat or drink smaller amounts of the antioxidant.
The story of resveratrol turns out to be another case
where you get a lot of hype about health benefits that
doesnt stand the test of time, says Richard D. Semba, MD,
MPH, a professor of ophthalmology at the Johns Hopkins
University School of Medicine and leader of the study in
JAMA Internal Medicine. The thinking was that certain
foods are good for you because they contain resveratrol.
We didnt find that at all.
Despite the negative results, Semba says, studies have
shown that the consumption of red wine, dark chocolate,
and berries does reduce inflammation in some people and
still appears to protect the heart. Its just that the benefits,
if they are there, must come from other polyphenols or
substances found in those foodstuffs, he says. These are
complex foods, and all we really know from our study is
that the benefits are probably not due to resveratrol.
The new study didnt include people taking resveratrol
supplements, though few studies thus far have found
benefits associated with them.
Semba is part of an international team of researchers

that, for 15 years, has studied the effects of aging in a group of
people who live in the Chianti region of Italy. For the current
study, the researchers analyzed 24 hours of urine samples
from 783 people over the age of 65 for metabolites of resveratrol. After accounting for factors such as age and sex, the
people with the highest concentration of resveratrol metabolites werent less likely to have died of any cause than those
with no resveratrol found in their urine. The concentration of
resveratrol wasnt associated with inflammatory markers,
CVD, or cancer rates.
The study participants made up a random group of
people living in Tuscany where supplement use is uncommon and consumption of red wine, a specialty of the region,
is the norm. The study participants werent following any
prescribed diets.
Resveratrol also is found in relatively large amounts in
grapes, peanuts, and certain Asiatic plant roots. Excitement over its health benefits followed studies documenting anti-inflammatory effects in lower organisms and
increased life span in mice fed a high-calorie diet rich in
the compound.
SOURCE: JOHNS HOPKINS MEDICINE
HELP YOUR
CLIENTS
SNACK
SMARTER
Did you know the recommended serving of almonds is
one ounce, about 23 almonds? While a single ounce
may sound small, its actually a substantial, satisfying
snack that can help your clients feel full between meals.
To estimate a correct serving size, picture a handful, a
3" x 3" sticky note, a shot glass or a 1/4 cup. Even easier,
just remember: 123. 1 ounce = 23 crunchy almonds.
2014 Almond Board of California. All rights reserved.
LIVING GLUTEN FREE
UNCOVERING HIDDEN
SOURCES OF GLUTEN
What Clients and Patients Must Know

By Megan Tempest, RD
Jaimes naturopathic doctor recently diagnosed her with
nonceliac gluten sensitivity, a disorder characterized by an
adverse food-induced reaction to gluten-containing foods.
Adopting a gluten-free diet alleviated her chronic symptoms,
such as bloating, diarrhea, and frequent migraines. But Jaimes
symptoms occasionally recurred because she unknowingly
consumed gluten hidden in a wide variety of the foods she ate.
Eighteen million Americans are estimated to have nonceliac
gluten sensitivity, six times the number of Americans who have
celiac disease, an autoimmune disorder in which the ingestion
of gluten damages the lining of the small intestine.1 Research
has shown that, to maintain good health, individuals with celiac
disease must eliminate gluten from their diets. They, too, are
affected by eating hidden food sources of gluten.
However, unlike celiac disease, nonceliac gluten sensitivity is
far less understood. Its thought to be immune mediated, but no
definitive test exists for proper diagnosis. People with nonceliac
gluten sensitivity may experience bloating, diarrhea, and constipationsymptoms similar to irritable bowel syndromealong
with fatigue, headache, and bone or joint pain.2,3
In the nonceliac gluten-sensitive population, we dont
know if some people are more sensitive than others, if some
have more severe gastrointestinal responses, or what the
long-term ramifications are of consuming gluten. We havent
identified the biomarkers yet, says Marlisa Brown, MS, RD,
CDE, author of Gluten-Free, Hassle Free. The lack of evidence
makes it difficult to know whether a person with nonceliac
gluten sensitivity can safely ingest small amounts of gluten
periodically or if complete abstinence is necessary, she says.
However, because eating foods containing gluten can cause
gastrointestinal (GI) symptoms for many people with nonceliac gluten sensitivity, they should abstain from eating them
and learn where gluten hides in certain foods, especially

when eating at restaurants.
Gluten is the protein found in wheat, rye, barley, and triticale,
a grain grown specifically to have wheatlike qualities.4 To make
shopping easier for consumers who must eat a gluten-free diet,
many manufacturers have introduced gluten-free versions of
staple pantry items such as pastas, crackers, and breads. And
these products now are or will be clearly marked as gluten free
on their packaging by August to meet the FDAs new gluten-free
labeling requirements, which include a standardized definition
of gluten free on labels.
Foods must contain fewer than 20 parts per million (ppm)
of gluten to be called gluten free. However, even diligent consumers who eat in restaurants accidentally may consume
gluten thats hidden in numerous foods, so its important they
know which foods and types of products have gluten that they
wouldnt think contain the protein. The following is a discussion
of the top six sources of hidden gluten dietitians can share with
clients and patients.
Top 6 Sources of Hidden Gluten

1. Sauces, marinades, and gravies: Gluten may be present
in gravies thickened with flour or in those flavored with soy
sauce or malt vinegar. Soy sauce is a common ingredient in
many marinades and sauces served in restaurants and sold in
grocery stores. Soy sauce contains more than just soybeans,
says Rachel Begun, MS, RDN, CDN, a food and nutrition
consultant, media spokesperson, and blogger at The Gluten
Free RD. Most brands are made with wheat, so choose glutenfree soy sauce or naturally gluten-free tamari instead.
Moreover, wheat flour traditionally is mixed with butter to
form a roux that becomes the base for many cream sauces and
gravies, so clients must be aware of this.
2. Processed meats: Sausages, meatloaf, meatballs, and
other ground meats often contain wheat-based fillers. Breadcrumbs may be added to hamburger patties to bind the meat
and improve texture. Hamburgers made from scratch with
meat labeled 100% ground beef wouldnt contain gluten;
however, many preformed patties, such as those served at
restaurants, may contain wheat.
Imitation crab meat found in prepared seafood salads and
California-style sushi rolls may contain gluten, Brown adds.
And processed deli meats also may harbor hidden gluten by
way of cross-contamination. Deli meats purchased at the deli
counter may be gluten free, but the slicer is likely to be contaminated, Begun says.
3. Vegetarian meat alternatives: Many vegetarian meat
alternatives, such as veggie burgers and vegetarian sausages,
are made with seitan, also known as wheat gluten. Others are
made with gluten-containing flours or breadcrumbs that act as
binders. And while tofu in its unadulterated form is gluten free,
the fried tofu served in restaurants may be fried in a glutencontaining batter or marinated in a soy sauce that contains
wheat. Moreover, imitation bacon typically contains gluten.
4. Soups: Noodles and barley are common soup ingredients

that contain gluten. Less obvious to the average consumer is
the gluten found in cream soups that have been thickened with
flour. Begun suggests clients read labels thoroughly when
purchasing these products. Packaged stock, bouillon, and
soup bases often contain gluten, she adds.
5. Processed potatoes: Whole potatoes found in the produce
department in supermarkets are gluten free, but potato chips
and fries can be hidden sources of gluten. Potato chips may be
seasoned with malt vinegar or contain wheat starch.
Begun offers two reasons to be cautious of French fries:
Restaurants often purchase frozen French fries, which may
have a wheat-containing coating on them to help them fry up
crispier. Secondly, the fryer theyre fried in is contaminated if
its used to fry other items with breading or flour.
6. Restaurant scrambled eggs and omelets: Pure, unadulterated eggs are inherently gluten free; however, restaurants may
add pancake batter to eggs to bulk them up and produce a fluffy
texture. Furthermore, even if the egg mixture is gluten free, it
likely contains gluten from having been cooked on the same grill
as a gluten-containing food such as pancakes, Begun says.
ingredient thats a gluten-containing grain (eg, barley, rye,

spelt wheat) or derived from a gluten-containing grain that has
been processed to remove the gluten (eg, wheat starch) and
the use of that ingredient results in the presence of 20 ppm or
fewer of gluten in the food. In addition, the FDA rule states that
any unavoidable presence of gluten in the food, such as whats
present from cross-contamination, must be less than 20 ppm.5
A study published in the June 2010 issue of the Journal of
the American Dietetic Association examined the potential for
cross-contamination of inherently gluten-free grains at food
processing plants. Researchers sent 22 unopened, inherently
gluten-free grains, seeds, and flours to a company that specializes in gluten analysis. Researchers found that seven samples
of inherently gluten-free grain products contained mean gluten
levels of 20 ppm or higher, and therefore wouldnt be considered gluten free under the FDA rule for gluten-free labeling.
The study raises the issue that if foods arent processed in a
separate facility designated for gluten-free foods, products can
potentially become contaminated with gluten, making it even
more important for consumers to look for products that carry
the gluten-free label.6
Code Words for Hidden Gluten
Empowering Clients and Patients
Clients and patients who must eliminate gluten from their

diets not only must become aware of the many foods in which
gluten can hide, but they also must learn the names of ingredients that masquerade as gluten on ingredient lists. Code words
such as fried, coated, crispy, or crusted should raise
a red flag, alerting clients that the food may contain gluten,
Begun says, noting that these descriptors in particular may
indicate the food is coated in a breading or gluten-containing
flour before its fried.
Moreover, the method by which these foods are cooked
increases the risk of cross-contamination. The chips for the
chips and guacamole may be 100% gluten free, Begun says, but
most restaurants fry them for extra crispiness. If other items containing gluten were fried in the fryer, the chips arent safe to eat.
Malt is another code word that Begun recommends her
clients avoid. Malt in the form of malt extract, malt syrup,
malt flavoring, and malt vinegar is indicative of barley, a
gluten-containing grain that doesnt have to be identified in
common terms on labels as gluten or barley, she explains.
Brown advises consumers to exercise caution when buying
or ordering Asian-style foods. These foods may contain wheat
from soy sauce and rice vinegars. Even some sticky rice may
have starch added to it, she says.
The FDAs ruling certainly will help consumers more accurately identify gluten-free products, while giving restaurants
and food manufacturers firm guidelines to follow. But consumers responsibility to speak up and ask questions cant
be overstated. They have to learn how to ask the right questions and use their best judgment because they cant rely on
the restaurant cooks or the waitstaff to ensure their meal is
gluten free, Brown says. Sometimes the waitstaff is more or
less helpful, depending on their level of knowledge. Even the
restaurants with a gluten-free menu may not even know what
theyre doing. For instance, restaurants unknowingly may
cross-contaminate their plain vegetables by cooking them
with pasta water, Brown explains.
For a person to live in this society and remain socially active,
they cant be told they can only go to gluten-free restaurants,
just as you cant tell them to not attend Grandmas holiday dinner
because the stuffing contains gluten or that they cant attend
a childs communion because the wafers have gluten. Doing
so can really handicap a person and even cause depression,
Brown says, adding that RDs should focus on helping clients
expand their choices and resources rather than limit them. We
should have a goal to help them enjoy their food and experiences
as much as everyone else.
Gluten-Free Labeling
Last August, the FDA established a final rule that standardizes the definition and labeling requirements for gluten-free
products for food manufacturers, imported foods, and restaurants; the deadline for compliance is August 2014.
The final rule states that a food may be labeled as gluten
free if its either inherently gluten free or doesnt contain an
Megan Tempest, RD, is a dietitian at Boulder Community

Hospital in Colorado and a freelance writer.

HEALTHFUL SNACKS
Many of the well-known manufacturers who make these
products also use packaging thats less glossy, designed to look
healthier when they may not be at all, Dierks says, and it seems
to be working.
Clean Curb Appeal
CLEAN SNACKING
One of the Fastest Growing Food Trends

By Lori Zanteson
No longer frowned on, healthful snacking has become a
popular way to quell hunger pangs between meals. Fueled by
the growing trend of clean eating, seemingly healthful items
such as 100% organic fruit and vegetable pouches, raw food
snack bars made with non-GMO quinoa, and gluten-free chips
made from green peas are lining supermarket shelves.
However, beyond the clean packaging and perceived health
benefits, are these snacks really any different from other processed goodies in the grocery aisle?
What It Means to Eat Clean

Eating clean means eating whole foods in their least processed state, according to Michelle Dudash, RDN, author of
Clean Eating for Busy Families. A clean diet includes lots of fruits
and vegetables, nuts and seeds, and humanely treated lean
proteins, she says, but it doesnt rule out entire food groups.
When you eat clean, you get more fiber, which is associated
with so many good things, Dudash explains. Clean foods also
offer more antioxidants, vitamins, minerals, and good fats.
Just as important is what clean foods dont have, such as
excess sodium, because theyre less processed and contain no
trans fats, only those that naturally occur in meats and dairy
products. They also contain less added sugar, such as in the
form of honey and agave, less total sugar, and no artificial food
colorings, which have been associated with attention-deficit
disorder in children, Dudash says.
The increase in healthful snack foods really ramped up
in 2013, and the category continues to grow, says Melissa
Herrmann Dierks, RDN, LDN, CDE, a contributor and advisory
board member for Supermarket Savvy, a nutrition education
business that helps make healthful grocery shopping easier.
Many of these snack foods have been what Dierks describes as
health washed to look like healthful foods. These healthy
snack foods list a variety of front-of-label claims, such as nonGMO, gluten free, and whole grain, and feature ingredients
such as olive oil and flax, she says.
Consumers seem to be drawn to products that have health

claims, whether or not they are scientifically proven, says
Carrie Nielsen, MS, RD, LMNT, a Linden Market Hy-Vee dietitian
in Omaha, Nebraska. A recent remodel doubled the size of her
supermarkets healthful foods section, allowing more space
to introduce the constant flow of new products, among which
are KIND bars, LARABARS, Bear Naked granola, SkinnyPop
popcorn, and Go Raw Super Cookies. The consumers I work
with tend to feel better about their food choices when they seek
out foods with these qualities. There are definitely consumers
who seek out products like this and are more than willing to pay
a higher price and try something new, Nielsen says.
Cleaner packaging and front-of-package claims clearly have
some sway with consumers, but these claims can be confusing.
Labeling popcorn as a non-GMO food may give consumers the
impression that its a healthier option than popcorn without this
label, when the reality is that all popcorn grown in the United
States is non-GMO, Dierks says. This same popcorn also can
be labeled gluten free. Aside from gluten-containing flavorings,
popcorn is naturally gluten free. So a product can be loaded
with fat and sodium, but a consumer will think its a healthful
option from looking at front-of-label claims such as non-GMO
or gluten free, she explains.
A Nutrition Facts panel comparison of these healthful
snacks with other processed foods is the only way to determine
differences in important ingredients, such as fat, sodium,
preservatives, and additives. According to Dierks, there isnt a
significant difference between them, besides a few that may be
a little lower in fat than their traditional counterpart. During
my Supermarket Savvy supermarket tours, I teach clients to
look at the Nutrition Facts panel on the back of the food label
to best assess fat, sodium, and nutrient content, and compare
those numbers to their daily goals, she says.
Behind the Label

However, theres more to healthful snacks than even the
label reveals. Developing healthful snacks is a complex undertaking, according to Roger Clemens, DrPH, chief scientific
officer for The E.T. Horn Company and an adjunct professor of
pharmacology and pharmaceutical sciences in the University of
Southern California School of Pharmacy. Were at a significant
junction to create snack foods that are good for you, satisfying,
economical, and lower calorie. Food is for enjoyment as well as
for nutrition, he says.
But it can be difficult to meet peoples expectations. What
really rules is healthiness is in the eyes of the beholder, he
says. Consumers dont trust the scientists; they trust the
food bloggers.
He adds that much of the perception

Popular Clean Snacks
Whole Food Ingredients
people have about the healthfulness of
Coconut
Bara
Coconut
Simply
Toasted
Chips
foods is tied to what they read and hear
about todays buzzwords and hot topics,
Whole navy beans, cheddar cheese
Beanitos White Cheddar Puffs
such as organic, gluten free, and nonOrganic coconut, sprouted organic sesame
Go Raw Original Super Cookies
seeds, organic dates
GMO, which have become front-of-packSprouted organic sesame seeds, organic
age health claims.
bananas, organic coconut, organic dates,
Go Raw Spirulina Super Chips
Moreover, theres a broad base of
organic spirulina
consumers who represent different
Organic apples, organic blueberries,
Happy Squeeze Twist Blueberry,
organic chia seeds
Apple & Purple Carrot
cultures and expectations. Americans, for
Peanuts, almonds, walnuts, Brazil nuts,
example, like their food to taste sweeter
KIND Nut Delight bar
honey, flaxseeds
than Europeans do, Clemens continues.
Organic kale, organic broccoli,
Peter Rabbit Organics Kale, Broccoli,
People also want their food to look a
and Mango veggie blend
organic mango
certain way. Nobody wants a brown apple,
Quinoa, crispy brown rice, amaranth, flaxseeds,
so scientists need to add the ascorbic acid,
hemp seeds, almonds, walnuts, peanuts,
Pure Organic Ancient Grains
cashew butter, blueberries, apples,
Triple Berry Nut Bar
proper packaging, and cold storage to
cranberries, raspberries
prevent this.
Green peas
The Real Deal Real! Veggie Chips
Food scientists try to tap into what
Organic dates, organic cashews,
Thunderbird Energetica Cashew
people like to eat and want to eat but still
organic figs, carrots
Fig Carrot bar
keep items safe, nutritious, affordable,
shelf stable, and accessible; they work to
bring creativity and innovation to healthful snack foods. SenSqueeze and Peter Rabbit Organics 100% fruit and veggie pure
sory properties such as taste, texture, and mouthfeel are all
pouches, still market to babies and toddlers, theyve gained a
part of that equation. Great work is being done [in food scifollowing from parents who are just as fond of flavors such as
ence], Clemens says.
Kale, Broccoli and Mango, and Pumpkin, Carrot and Apple.
New on the Clean Snack Scene
Fresh Takes on Chips
Hundreds of examples of healthful snacks were on display at

this years Natural Products Expo West in Anaheim, California.
Clean snacks in particular, which are among the fastest growing
snack categories, were widely represented. The following are
some of the hottest trends:
Chips also were well represented at this years expo. Made

with everything from traditional potato and corn to the more
novel parsnips, peas, and beans, attendees could sample a different chip in every aisle. Real! Veggie Chips made with green
peas have 80% less fat than potato chips, offer 112 servings of
vegetables per ounce, and are both vegan and gluten free. Beanitos Puffs are a cheese puff alternative made with navy beans.
Higher in fiber and protein and lower in fat and sodium than traditional snack puffs, Beanitos also are gluten free and non-GMO.
Coconut chips are just as popular. Several companies,
including Dang Foods, Bare Foods Co, and Go Raw, have
toasted and raw varieties in flavors such as Caramel Sea Salt
and Chocolate Bliss. Pumpkin Super Chips and Spirulina Super
Chips are two offerings from Go Raw. These chips are made
with sprouted seeds and dried at a low temperature to release
enzymes that the company says makes them healthier.
Whole Foods Bars

Made with easily recognized whole-foods ingredients, these
snacks come in flavors to suit a variety of tastes. Organic dates,
apricots, almonds, cashews, quinoa, and Himalayan salt are a
sampling of ingredients contained in Thunderbird Energetica
bars, which include flavors such as Cacao Hemp Walnut
and Cashew Fig Carrot. These bars carry multiple front-ofpackage labeling claims, including soy free, gluten free, raw,
vegan, and non-GMO.
Fruit and nut bars, such as Pure Organic Ancient Grains bars
also were showcased at the Expo. These bars add whole grain
quinoa, amaranth, flax, and hemp to its Chocolate Chunk Nut,
Peanut Butter Chocolate, and Triple Berry Nut varieties. The
Fruit & No-Nut Bars from The Good Bean are made with chickpeas instead of nuts and are available in Chocolate Berry, Fruit
& Seeds Trail Mix, and Apricot Coconut.
Fruit and Vegetable Pouches

These convenient grab-and-go snacks have moved beyond
the playground and into the adult world. While companies,
such as Happy Family Organic Superfoods, with its Happy
Options Aplenty
When it comes to clean eating, fruits and vegetables are
about as clean as it gets. Yet theres no denying the convenience, novelty, and fun factor of healthful packaged snacks.
While the produce aisle may offer the best choices, the healthful
snack section has several options, many of which are made with
whole-foods ingredients.
Lori Zanteson is a food, nutrition, and health writer
based in Southern California.
Athletes
and
Protein
Intake
Experts weigh in
on whether the
Recommended
Dietary Allowance
for highly physically
active people is
adequate
BY DENSIE WEBB, PHD, RD
ontroversy exists among medical

experts regarding the role
protein plays in maintaining
optimal health. They debate
about when to consume it, how much to
consume, and what type is best, especially
for athletes and highly active people.
The Recommended Dietary Allowance (RDA) for protein, 0.8 g/kg of body
weight per day, is designed to maintain nitrogen balance in the body for the
average adult; a negative nitrogen balance indicates that muscle is being
broken down and used for energy. (RDAs for protein in children are higher
on a gram-per-body-weight basis than for adults. RDAs also are greater
for women who are pregnant [1.1 g/kg/day] or lactating [1.3 g/kg/day]).1
While maintaining nitrogen balance is critical for health, studies now
suggest that the RDA may not be the amount of protein needed to promote optimal health. To achieve that, they say, more protein is needed,
and studies now suggest that athletes, active people, and older individuals require even more.
Dietary proteins are in a constant state of flux in the body, being broken
down into amino acids, transformed into other compounds, and sometimes
reassembled into other proteins. They also are used for energy, a mechanism that increases when energy intake is low or when protein intake is
inadequate. Muscle protein then becomes a source of energy, resulting in
a negative nitrogen balance. This is a critical concern for athletes, who are
regularly involved in energy-demanding activities.
It stands to reason then that athletes and active individuals would require
more protein, and high-quality proteins, on a daily basis than those who
spend their days sitting at a desk in front of a computer screen. (Highquality proteins contain all nine essential amino acids in amounts similar
to amino acid requirements; animal proteins are higher quality than plant
proteins.) While adequate high-quality protein is critical for good health
and optimal athletic performance, the amount needed isnt the one-sizefits-all recommendation the RDA suggests.
Todays Dietitian spoke with experts to determine the latest protein
requirements for athletes and highly active people.
How Much Is Enough?

While its generally accepted that athletes need more protein than
sedentary people, recommendations vary significantly depending on
the type of athlete, current body weight, total energy intake, whether
weight loss or weight gain is the goal, exercise intensity and duration,
training status, the quality of the dietary protein, and the individuals
age.2 The general rule of thumb is 1.2 to 1.4 g/kg of body weight for
endurance athletes and 1.2 to 1.7 g/kg of body weight for strength and
power athletes, says Christopher Mohr, PhD, RD, a nutrition consultant
and writer and the co-owner of Mohr Results, a weight-loss company in
Louisville, Kentucky. The greater the number of hours in training and the
higher the intensity, the more protein is required.2 Other research has
recommended as much as 2 g/kg of body weight to

prevent muscle loss in athletes who have reduced
their energy intake.3,4
While physical activity increases protein needs, it
also increases the efficiency with which muscles use
dietary protein, even in older individuals. One study
found that a moderate increase in physical activity among a group of older subjects enhanced the
response to protein intake, suggesting that increased
exercise may help prevent and treat muscle loss that
occurs with aging.5
What about the recreational athlete, otherwise
known as the weekend warrior? The research shows
that most people would benefit from added protein,
from increased satiety to increased muscle synthesis,
Mohr says. People generally consume only around
15% to 16% of total calories as protein, so theres certainly room to increase protein intake. Some have suggested that recreational athletes should aim for daily
intakes closer to 1.1 to 1.4 g/kg of body weight per day,
38% to 75% greater than the current RDA.2 Endurance
athletes, such as marathon runners, should be in the
range of 1.2 to 2 g/kg of body weight, and strength athletes, such as weight lifters, should be in the range of
1.4 to 2 g/kg of body weight.2
PROTEIN-RICH FOODS
AND SUPPLEMENTS
Beef tenderloin steak, lean only (3.5 oz): 29 g
Salmon (4 oz): 29 g
NOW Pea Protein Powder (33-g scoop): 24 g
S
wanson Whey Protein Powder
(23-g scoop): 20 g
Solgar Whey to Go Powder (25-g scoop): 20 g
Lentils (1 cup): 18 g
BOOST High Protein Drink (8 oz): 15 g
Greek yogurt (5 oz): 14 g
Kashi GOLEAN cereal (1 cup): 13 g
Skim milk (8 oz): 8 g
Tofu, firm (3.5 oz): 7 g
Egg, large (1 large): 6 g
Beneprotein Instant Protein Powder
(7 g scoop): 6 g
SOURCES: REFERENCE 8 AND COMPANY WEBSITES
According to Nancy Clark, MS, RD, CSSD, a sports nutrition counselor and
the author of Nancy Clarks Sports Nutrition Guidebook, different protein recommendations arent needed for men vs. women. [Theyre] based on grams
per kilogram of body weight, she says. In addition, active people shouldnt
focus on protein alone. Have protein/carbohydrate combinations, protein
to build and repair muscle tissue and carbs to fuel. The ratio of protein to
carbohydrate can vary greatly, depending on protein intake.
Unlike endurance training, single sessions of resistance exercise, regardless of workout length or intensity, dont appear to increase protein use
during the workout itself. However, amino acid uptake after a resistance
training session does increase, indicating that the amino acids are being
used for muscle repair and construction. Protein utilization appears to be
higher for individuals who are less fit.
When beginning endurance training, nitrogen balance may be negative
for the first two weeks, and protein requirements may be higher in the first
week of strength training to support new muscle growth. After one to two
weeks of training, however, typically the body adapts and the protein utilization decreases. In general, adequate calorie and carbohydrate intake
reduces the need for amino acid oxidation for energy and spares dietary
protein and muscle tissue. Protein sparing is based on the concept that if
adequate energy is consumed from carbohydrate and fat then dietary protein is available for protein-unique functions (ie, protein synthesis [tissue,
hormones, neurotransmitters, enzymes, etc]). To protect muscle protein,
consider counseling athletes to temporarily increase protein intake when
starting a new training program or entering a new training phase.2
Type of Protein to Consider

The International Society of Sports Nutrition recommends that highquality proteins be consumed. It highlights milk-derived whey protein
isolate and casein and egg white and soy protein isolate as proteins that
provide essential amino acids that are readily taken up by muscle to optimize nitrogen balance and muscle protein synthesis.6
Research suggests that of all the essential amino acids, leucine may be
the limiting factor in initiating muscle protein synthesis, and that leucinerich proteins may be the best way to boost muscle protein synthesis after
intense physical activity.7 Some researchers suggest that protein quality
based on leucine content is important when consuming small meals or
when the total amount of protein consumed is less than optimal.7
The mixture of proteins in the American diet averages about 8% leucine.
The range of protein thought to stimulate muscle protein synthesis after a
meal is about 2.5 to 3.5 g.7 Dairy products, beef, poultry, seafood, pork, peanuts, beans, lentils, and soybeans are among the foods richest in leucine.8
What about protein powder supplements? Theyre not necessary, Mohr
says. [But] are they convenient for those on the go looking for a quick,
quality meal? Absolutely. Blend with a little milk, veggies, and nuts or nut
butter and you have a great meal to go.
When to Eat Protein

Just as important as the amount and type of protein athletes should eat is
when they should eat it. As a result of physical activity, muscle breaks down.
If protein intake is low, that muscle isnt replaced. Those who are acclimated
to regular exercise experience less muscle protein breakdown.9 However,
protein needs are greater during intense bouts of training. The general consensus is that protein ingestion after exercise, when muscle is most sensitive to nutrient intake, will boost muscle protein synthesis and recovery.10,11
Athletes aside, Most people eat only about 10% to

15% of total protein in the morning, about 20% or so
in the afternoon, and the remainder at dinner. Since
our bodies dont store protein, spreading that intake
more evenly throughout the day would be beneficial,
Mohr says.
Research has shown that adults need at least
30 g of protein at two or more meals to maintain
healthy muscles, says Donald Layman, PhD, professor emeritus in the department of food science
and human nutrition at the University of Illinois at
Urbana-Champaign. Small meals, such as breakfast or lunch, often contain less than 15 g of protein
and provide no benefit to muscle health.
A study recently published in the Journal of Nutrition
found that muscle protein synthesis was 25% higher
when protein was evenly distributed across breakfast, lunch, and dinner compared with a more typical pattern, when most protein was consumed at the
evening meal, even when total protein intake was the
same.12 Protein thats evenly distributed throughout
the day may be especially important for older, physically active adults, as older individuals experience a
resistance to muscle protein synthesis in response
to meals containing less protein; in other words, the
protein threshold to trigger muscle protein synthesis
is higher in older individuals.12
According to Douglas Paddon-Jones, PhD, an associate professor at the University of Texas Medical Branch
PROTEIN SPECIFIC
GUIDELINES
D
evelop a meal plan that will supply
adequate calories, carbohydrate, and
protein each day.
D
istribute the protein equally across meals.
E
mphasize high-quality protein.
B
ase protein intake on weight, not on
percentage of calories.
B
ase protein intake on the individuals sport
and intensity level.
R
ecommend that active, older individuals
boost protein intake, as some may require
more to help preserve muscle mass.
S
uggest protein powders to individuals who
need added protein on the go and whose
calorie intake is low.
DW
at Galveston and a protein researcher, The same

basic model of consuming a moderate amount of highquality protein three times a day applies to different
aged athletes. But moderate for different sized people
might range from 15 g to 40-plus grams per meal.
High-Protein Diets
Since added protein intake is critical for athletes and
physically active people, should they consume a highprotein diet? Instead of recommending protein as grams
per kilogram of body weight, the Institute of Medicine
established an acceptable macronutrient distribution
range for protein at 10% to 35% of total calories for
adults older than 18.1 The Institute of Medicine defines
the acceptable macronutrient distribution range as
a range of intake associated with reduced risk of
chronic diseases while providing adequate intakes of
essential nutrients. The average protein intake in the
United States of 15% of total calories is well within the
acceptable macronutrient distribution range but well
below recommended intakes for most athletes.1,13
Even the 95th percentile of protein intake for US
adults doesnt come close to the highest acceptable
macronutrient distribution range for protein at 35% of
total calories.14 Higher intakes of high-quality protein
recommended for athletes would still be well within
the acceptable macronutrient distribution range.14
Frequently, concerns are expressed about the possible negative health effects of high-protein intakes;
however, an upper limit for protein intake hasnt been
established, though the Dietary Reference Intakes warn
against exceeding the acceptable macronutrient distribution range.1 Its important to bear in mind that if
calories are limited, high protein intake may displace
other important nutrients.
Probably the most common concern expressed is
that high-protein intakes may impair renal function.
Its true that protein intake, beyond that which supports nitrogen balance, promotes urea formation,
and can increase glomerular filtration rate and kidney
nitrogen load. Theres little evidence that the change
in glomerular filtration rate can cause problems in
healthy people, as the clearance of urea becomes
more efficient with higher protein intakes.15 However,
lower protein intakes, based on an individuals weight
and the severity of their condition, are recommended
for those with impaired renal function.
For healthy people, a recent study suggested a maximum intake of 2 to 2.5 g/kg of body weight per day,
totaling 176 g of protein per day for an 80-kg (176-lb)
individual consuming approximately 2,900 kcal daily.16
This translates to about 25% of calories from protein
within the range of 10% to 35% recommended by the 2010
Dietary Guidelines for Americans and the maximum of
35% by the acceptable macronutrient distribution range.
A recent study of overweight and obese individuals with type 2 diabetes

consuming a diet containing 90 to 120 g of protein per day found no effect
on renal function compared with those consuming 55 to 70 g/day, suggesting that higher intakes arent harmful.17
However, increased dietary protein can result in elevated urinary calcium, which may contribute to bone loss and the subsequent development
of osteopenia and osteoporosis. Yet the role protein plays in bone health is
complex. A recent systematic review found that the evidence was inconclusive regarding a significant relationship (either positive or negative)
between protein intake and bone health, but that protein likely provided a
small benefit to bone health.18 Moreover, evidence shows an association
between dietary protein and increased peak bone mass in both young and
older adults.19,20
An interaction exists between calcium and protein intakes; when calcium
intakes are low, a high-protein diet could be detrimental to bone. When
calcium intakes are higher, protein appears to be beneficial. It has been
suggested that protein intakes of greater than 2 g/kg of body weight per
day should be avoided if calcium intake is below 600 mg/day.21
High-protein diets that consist of excessive intakes of 200 to 400 g/day
can exceed the livers ability to convert excess nitrogen to urea and lead to
nausea, diarrhea, and even death.12 I think the biggest message is to avoid
the absurd30-oz steak dinners or carrying around a gallon container of
a protein drink all day, Paddon-Jones says.
Recommendations
Developing an individualized nutrition plan for athletes should take into
account the individuals health history, the sport he or she plays, weekly
training regimens, time of competition, access to food, and travel schedules.
When working with athletes, dietitians must gauge a persons readiness for
change before offering guidance. Moreover, sports nutrition professionals
should discuss the athletes goals and concerns, answer questions, and
ask for the athletes participation in their meal planning.
Densie Webb, PhD, RD, is a freelance writer and industry
consultant based in Austin, Texas.

Nourishing Kids in the
Summer
By Juliann Schaeffer
he summertime comes with longer days and later

bedtimes for kids and a much-needed break from
test taking and homework assignments. Even
though children need to get away from the hustle
and bustle of attending school each day, they
still need healthful meals and snacks for proper development
during their summer vacation. Thats the message of the USDAs
Summer Food Service Program, which aims to fill the summer
food gap for the millions of low-income children aged 2 to 18 who
get free or reduced-price meals during the school year but are
left without such assistance during the summer months.
As good nutrition is essential to both physical and mental
growth, the Summer Food Service Program seeks to offer
opportunities to continue a childs physical and social development while providing nutritious meals during long vacation
periods from school. It helps children return to school ready to
learn, according to the programs website.
First created in 1968 as part of a larger pilot program, the
Summer Food Service Program became its own entity in 1975,
and it reached more than 2 million kids in 2012 through almost
39,000 sites. This program allows operators such as the school

system to continue to offer healthful meals throughout the entire
year, says Jodi Risse, MS, RD, LDN, supervisor of food and
nutrition services for Anne Arundel County Public Schools in
Maryland. Hunger and access to healthful meals are high in the
priority of community needs.
While the USDA governs overall program requirements and
dictates reimbursements and other details, much of the food,
marketing, and other program specifics are determined at the
local level. The program is run by approved local sponsors,
which can include school districts and camps. Each site determines what food to serve and how to spread the word to its
target population.
To reach more children in need, some Summer Food
Service Programs are getting creative. Todays Dietitian
highlights five programs in five states that are using innovative
marketing tools, offering meals during nontraditional hours,
and bringing food to children by truck or the all-familiar
bright-yellow school bus to ensure all kids have access to
healthful food all summer long.
Learn how five school districts are offering nutritious meals to underprivileged
children to keep them healthy before the start of a new school year.
Maryland
Marylands Anne Arundel County Public Schools participate
in the Summer Food Service Program annually, and its continuing to grow and expand each year, Risse says, with participating
school sites attempting to reach the neediest populations. The
program includes breakfasts, snacks, and lunches in a number
of schools, camps, and community locations, she says.
The school sites run on a two-week-cycle menu, with
menu items determined by nutritional value, cost, and student
acceptance. Chicken sandwiches, deli sandwiches, and yogurt
and cheese combos are just a few of the healthier options
provided. We also offer each day a fresh fruit, 100% fruit
juice, and milk, Risse says.
An emphasis on fresh fruits and veggies is a no-brainer for
Anne Arundels program. Each day that we can have a child
excited about a new fruit or vegetable is a win for the county and
a win for the student, Risse says. The menu is developed considering many factors. All sites offer entres, fruits, vegetables,
and milk. Some small sites offer cold entre selections for ease
in delivery. Student acceptance is important at all locations.
According to Risse, one of the biggest challenges the program faces is reaching everyone, particularly those kids who
could benefit from the meals but have no way of getting to the
school sites each day. At school sites, you often miss the children at home without transportation to the site, she says.
To help address this issue, two years ago, the county
embarked on a mobile meals program to bring the meal offerings to the children. The mobile meals are transported in an
Anne Arundel County Public Schools bus, which is bright yellow
and very familiar to the students in our county, Risse says.
Mobile meals stop at seven sites in the western part of the
county. Last year, we served over 6,000 meals at the mobile
meals sites, Risse says. The sites are all located in a needy area
where free and reduced-price meals are approximately 80%.
The mobile meals include the same food offerings as
the traditional school setting. We offer a few of the student
favorites plus a grab-and-go option, she adds.
To spread the word so all kids learn about the summer program specifics, voice, text, and e-mail messages are sent to
parents to provide them with all the necessary details. And if
meal count is any indicator, the marketing seems to be working. Anne Arundel County Public Schools not only gain meals
each summer, we also gain new partners for further expansion, Risse says. Each year, the program grows over 20,000
meals. The efforts of all parties are paying off, and we continue
to expand and reach additional children each summer.
In addition to expanding mobile meal sites and its collaboration with the Anne Arundel County Department of Recreation
and Parks, this year the program is looking at an exciting addition: backpacks of food to sustain kids over the weekend.
This summer were planning to offer backpacks of food to go

home with children every Thursday on the Mobile Meals Bus, as
well as the open sites in schools, she explains. Open sites, which
operate in low-income areas where at least one-half of the children are from households with income at or below 185% of the
federal poverty guidelines, provide meals at no charge to any child
who shows up. Every Thursday, all open and mobile meals sites
will receive a bag of food for each student at the meal site. Were
working with the Department of Health, family and community
partners, and the Anne Arundel County Food Bank. This is a great
way to showcase how our county works with internal and external
partners to best meet the needs of our students and community.
Based on her experience with the summer program, Risse
recommends it to all school nutrition professionals and all RDs
who are interested in getting involved in some way. Not only is
the program financially sound, it provides a much-needed benefit to all children in needy areas during the summer, she says.
Each year, we receive favorable comments and notes that clearly
state the evident. Parents and children arent only happy with
meals but feel this service is something they cannot live without.
New York
Debbi Beauvais, RDN, SNS, a spokesperson for the Academy
of Nutrition and Dietetics, works with summer food programs in
three Rochester, New York, community school districts where
shes the school nutrition director. In all three of these school
districts, we have poverty rates that exceed 50% of the student
population, she says. These are the children we hope will take
advantage of the program in the summer.
According to Beauvais, these programs offer breakfast and
lunch meals at school sites, including Gates Chili School District
and other sites tied to community recreation programs and parks
in the community. She says choosing the sites with the easiest
access can allow for greater turnout and more kids served.
The summer menu runs on a three-week cycle, and much of
the food offerings mirror whats offered during the school year,
with menu items including meatball subs and chicken sandwiches. Peanut butter and jelly sandwiches and yogurt are offered
as substitute entres daily. Our motto is to have something on the
menu every day that every child likes to eat, Beauvais says. In
my experience, hot meals at lunch are more appealing to kids.
Though she admits that some fresh and healthful foods can
cost more, Beauvais says a little creativity can go a long way in
helping programs do more with less. Yes, whole grains, fresh
produce, and lean protein foods tend to cost more, she says.
You have to evaluate the federal reimbursement and your budget
and fit all the pieces of the puzzle together to make it all work.
According to Beauvais, finding volunteers to assist paid program workers can be a huge cost savings. Being a school
nutrition program offering summer meals, we have many
practices in place that reduce costs already, such as cooperative bidding and adequate facilities to prepare and serve food,
she says. And we received a grant from Action for Healthy Kids
that allowed us to purchase the equipment needed to transport
meals to various locations in the community.
Marketing is a huge piece of the program, and she notes that
word of mouth can move mountains to get more children to the
sites. If you serve good food and people enjoy and understand
the program, they will tell others and participation trends up,
Beauvais says. This is my second program year in two school
communities, and I hope to see this increase this summer. Im
in the third year in the other program and saw an increase last
year, as many said they heard about it from friends.
For many, the time spent enjoying the summer meals serves
both as mealtime and social time for not only the kids but the
adults as well. For this reason, Beauvais program offers its
meals at a modest price for adults who bring their children:
$1.50 for breakfast and $3 for lunch.
Beauvais admits shes always looking for more avenues to
expand the summer program and reach more families and says
a mobile food truck may be an addition in the coming years. But
as the program stands, it has reached manyan average of 275
breakfasts and 429 lunches per day in 2013and those many
have shown appreciation in spades.
I have to say that each summer to date the adults bringing
in the children offer many thanks to the staff for these meal
programs, she says. Many are very honest with the struggles
they have to provide meals to their children when school is out.
This is such a rewarding program to be involved with, and its
really valued by the people it serves. It has put a tear in many
of our eyes when you hear the stories of families struggling to
feed their children.
Florida
Robin Safley is the director of the division of food, nutrition,
and wellness at the Florida Department of Agriculture and
Consumer Services, which administers the federal summer
food program to Florida sponsors. We are the pass-through
agency for the reimbursable meal funds distributed to our
sponsors, she explains.
While different sites determine their own meal offerings
based on federal requirements, Safley says each sponsor site
takes into account various location aspects when deciding on
menu choices. Especially since Florida is a melting pot of many
cultures with large pockets of rural and urban areas, Safley
says culture considerations are a must when deciding on specific food offerings. Sponsor sites still are finalizing summer
menus for the 2014 season, but sample menus include turkey
and cheese wraps with pineapple tidbits and Latin hoagie sandwiches with raw baby carrots, both of which come with either
100% fruit juice or low-fat milk.
But where Safley and her staff really make inroads in Floridas summer food programs is their outreach efforts, finding
new ways to get these programs to more children each year.
We provide outreach to our sponsors to build awareness in

their community where the summer feeding sites are located,
she says. We ensure program compliance of our sponsors to
the federal regulations. We work with the Department of Children and Families to identify these households who have children that qualify and overlay that data with our summer sites.
Once those areas are targeted, we continue to work with our
community partners and existing sponsors for expansion.
To spread the word to parents, Safley says the department
has partnered with 2-1-1, a call center that helps parents identify
summer food sites in their area. It also has partnered with the
Department of Children and Families to identify those participating in the Supplemental Nutrition Assistance Program. Once
families are identified, oversized direct mail pieces advertising
the program are mailed to those households.
Billboard marketing, TV/radio advertising, Facebook, and
other avenues are used to reach families in need as well as
myriad community partners that help spread the word. We also
have regionalized our staff, since Florida is uniquely shaped, to
be closer to assist our sponsors with technical visits and assistance, Safley says. This year we also have hired a consultant to
advise faith-based communities on how to become an effective
summer sponsor or summer feeding site.
Weve seen a 16.4% increase in summer meals served in
the last two years, she adds, noting that the department wont
be satisfied until its state summer programs are reaching all
kids in need. Last year, our Florida sponsors served over 2.7
million breakfasts, 6.3 million lunches, 122,000 suppers, and
2.1 million snacks, she says. But the goal of the program is
to reach all 1.6 million children in Florida who are receiving
free and reduced meals throughout the school year. Currently,
were reaching approximately 300,000 of those students.
Through our partnerships, we will continue to identify areas to
increase summer sites/sponsors.
Miami-Dade County Public Schools made the news for introducing food trucks in 2012 as part of its summer program. Safley
says that mobile feeding is a great avenue for expanding reach,
and shes hoping a new app may help the cause. Were working
on launching a Summer Feeding Site mobile app this summer,
she says. The parents/children can locate a summer feeding site
in their area and be able to [use] GPS to [find] the location.
Were also working with our statewide library system to
offer meals during their summer activities, she adds. And
were working with the local housing authorities to bring food to
those children where they live. We continue to encourage and
build capacity through mobile feeding.
Georgia
According to Donna S. Martin, EdS, RDN, LD, SNS, director of
the school nutrition program for Burke County Board of Education
in Georgia, the biggest issue she sees regarding summer feeding
is access. The most common problem is how to access the
children who need the program the most but who do not have
transportation to get to a location that offers the program, she
says. The children that are most needy tend to be in remote rural
locations with no access to a site offering the program.
My program is located in Burke County, Georgia, which is
the second largest land mass county in the state of Georgia,
she adds. The county is extremely rural, with 836 square
miles of land and only 22,000 residents. Fifty percent live in the
main city of Waynesboro and the rest live scattered out all over
the county. We try to reach the children all over the county.
With more than 84% of students qualifying for free and
reduced meals and 63% on food stamps, there are many children to reach over a large area. But Martin and her colleagues
have combated this challenge by taking the food offerings to
kids in buses. We run 14 bus routes all over the county for
eight weeks during the summer, she says. We start the program a week after the last day of school and continue until the
week before schools start back.
According to Martin, the program serves approximately
3,000 meals per day from its buses. Each bus stops at between
six to 10 stops a day, she says. Some stops feed as many as
150 children. They start feeding at 9:30 am and go until 2 pm.
Unlike the food trucks, the buses dont just bring the food to
children; they provide a place for children to eat as well. The
students get on the air-conditioned bus and eat the meal and
then get off and go back home, she explains.
Martin plans the menus and says she aims to offer two hot
meals each week, such as chicken filet sandwiches, and provides cold deli sandwiches the other three days. Beverages of
milk and juice also are offered as well as fresh fruit.
She says the deli turkey breast and ham help to make her
limited budget go further. We also buy some local in-season
fruit, such as peaches, she says. The program follows a weeklong menu, and Martin works hard to ensure the children like
the food and that its easy to eat and prepare. It also cannot be
too messy because the children eat on the bus, she says.
Program staff members distribute fliers to parents the last
week of school as well as to churches, grocery stores, and gas
stations to spread the word about the program and the buses.
We put signs out at the bus stops to let everyone know that
that location is a [summer feeding] site and what time the bus
will be there, she says. Martin works with the local churches
to provide meals for vacation Bible school programs. If our
children go to a vacation Bible school program, they would
usually miss their meal, so we give the meals to those vacation
Bible school programs, she says.
In addition to meeting childrens nutritional needs, the
summer food program is something many kids look forward
to at the end of the school year. Our children get excited
toward the end of school and start asking the bus drivers if
were going to offer the program in the summer, Martin says.
Weve had numerous parents tell us how much the program
means to them and to their children. They say the children love
it, and it helps them so much to know the children get a good
meal. The vacation Bible schools say theyre able to serve
more children because we provide the meals for them, too.
Washington, D.C.
Sandra Schlicker, PhD, deputy state superintendent for the
D.C. Office of the State Superintendent of Education, oversees
the District of Columbia Free Summer Meals Program, which
reaches children in all four quadrants of the city. The district
summer program targets areas in which poor economic conditions exist, areas in which at least 50% of the children are eligible for free or reduced-price meals through the National School
Lunch Program and School Breakfast Programs, she says.
In addition to meeting all federal requirements, Schlicker
says the district program complies with the local D.C. Healthy
Schools Act requirements to ensure that all meals served meet
the meal pattern recommendations of the USDAs Healthier US
School Challenge at the gold level.
Each approved sponsor determines the meals it will serve
based on these requirements as well as cultural and other
considerations. Typical entres offered last summer included
chicken salad on a whole wheat bun with carrots, Ranch dressing, and a mixed fruit cup or a chicken taco salad with black
beans, a whole wheat dinner roll, and a fresh orange.
But Schlicker says creativity relating not just to meal content
but also how and when meals are offered can help expand a
programs reach. For fiscal year 2013, the district encouraged
sponsors and sites to serve meals in the evening, on weekends,
and holidays, she says. The state advocated for the needy
children by urging our sponsors to provide nontraditional
meal service times. After implementing such nontraditional
mealtimes, Schlicker says participation increased 14%.
D.C. has been the No. 1 summer foodservice program in
the country for the past nine years, Schlicker says. Much of
that success she credits to the focus that public officials put
on spotlighting the summer program. Mayor Vincent C. Gray,
our state superintendent, and elected officials highlight the
summer program and are active in the city building relationships with city agencies to sponsor the program, she says.
The mayor is vigorous in placing strong emphasis on a One
City Summer Initiative, with summer kick-off events demonstrating the importance of a holistic approach to maximizing
activities and nutritional opportunities for all district children.
In addition to expanding its practice of offering meals
at nontraditional mealtimes, Schlicker says in the future
the district may explore working with sponsors to institute
mobile feeding sites and having sponsors make meals available during the school year at times when schools are closed
due to inclement weather.
Looking at the Summer Food Service Program as a whole,
Schlicker says she hopes to one day see federal legislation
changed to permit not just two, as currently allowed, but three
meals per day to children during the summer months, which
would provide much more nutritional and other benefits to the
many children in need of a well-balanced meal.
Juliann Schaeffer is a freelance writer and editor based in
Alburtis, Pennsylvania, and a frequent contributor to Todays Dietitian.
Lowdown
The
Dairy
on
A REVIEW ON DAIRYS VALUE

IN DISEASE PREVENTION
BY CONSTANCE BROWN-RIGGS,
MSEd, RD, CDE, CDN
ecades of research support dairy products role

in a healthful diet. The 2010 Dietary Guidelines
for Americans recommend consuming three
daily servings of low-fat and fat-free milk and
milk products, such as yogurt and cheese, to
help close the gap on three of the four nutrients
of public health concern: calcium, potassium, and vitamin D.1 In
addition, the Academy of Nutrition and Dietetics, the American
Heart Association (AHA), and the DASH diet program all make
the same recommendation.
This article will discuss recent evidence of dairys health
benefits and its value in disease prevention and provide strategies to help clients and patients close the nutrient intake gap
and overcome barriers to including dairy in their diets.
Nutrients of Concern
Milk, yogurt, cheese, and other dairy products provide calcium, potassium, and vitamin D to the diet. According to the
Dietary Guidelines evidence rating, moderate evidence shows
that milk and milk product intake is linked to improved bone
health, especially in children and adolescents.1 Moderate evidence also shows that milk and milk product intake is associated with a reduced risk of cardiovascular disease and type
2 diabetes and lower blood pressure in adults.1 The Dietary
Guidelines specifically call for an increased intake of low-fat
and fat-free milk and milk products as a vehicle to close the
nutrient intake gap for calcium, potassium, and vitamin D.
Some experts argue that theres insufficient evidence to support the recommendation of three servings of dairy per day. In a
review of the 2010 Dietary Guidelines, Harvard School of Public
Health researchers found little, if any, evidence that eating
dairy prevents osteoporosis or fractures and considerable evidence that high dairy intake is associated with an increased
risk of fatal prostate and ovarian cancers. According to these
researchers, Americans dont need as much calcium as the
Dietary Guidelines recommend. In fact, they suggest limiting
dairy to one or two servings per day or taking a calcium and
vitamin D supplement instead.2
Based on the evidence Ive seen, theres no need to acquire
dairy products in general or on MyPlate, says Susan Levin, MS,
RD, director of nutrition education for the Physicians Committee for Responsible Medicine in Washington, D.C., who believes
a plant-based diet is a healthier way to meet calcium, potassium, and vitamin D requirements. However, this may be easier
said than done for many people.
Assuming the Recommended Dietary Allowance of 1,000 to
1,500 mg of calcium per day is correct, its difficult, if not impossible, to get that much calcium in the diet without dairy products, says Densie Webb, PhD, RD, an industry consultant in
Austin, Texas. Even products fortified with calcium typically
provide only about 100 mg per serving.
The Adequate Intake for potassium for adults is 4,700 mg/
day. However, in the United States, the consumption of fruits
and vegetables, which are high in potassium, is lower than recommended. As a result, dietary intake of potassium is low and,
as mentioned, is one of the nutrients of concern in the Dietary
Guidelines. Its nearly impossible to meet the potassium recommendations without that third serving of dairy, says KeithThomas Ayoob, EdD, RD, FAND, an associate clinical professor
in the department of pediatrics at Albert Einstein College of
Medicine in the Bronx, New York.
Despite the disagreement over the Dietary Guidelines dairy
recommendations, the preponderance of evidence continues
to support the benefit of dairy as part of a healthful diet and its
value in disease prevention and other chronic conditions.
Acne
For example, the association between diet and acne has
been around for centuries. During the late 1800s and early
1900s, diet commonly was used as an adjunct treatment
for acne. However, during the 1960s, most experts in the
dermatology community believed there were no specific foods
that played a role in acne prevention and treatment. In recent
years, though, there has been a renewed interest in the diet
and acne connection.3
In 2006 and 2008, Adebamowo and colleagues used a prospective cohort method to examine the association between
milk product consumption and acne among 6,094 teenage girls
and 4,273 teenage boys. Study results showed skim milk drinkers had fewer self-reported acne breakouts, but there were
no significant associations between acne breakouts and total,
whole, and low-fat milk consumption.4
These studies suggest a correlation, not a cause-and-effect
relationship, says Karen Kafer, RD, vice president of health
partnerships for the National Dairy Council. More research is
needed to confirm whether specific foods and/or dietary constituents have a direct effect on acne. To date there are no randomized controlled trials investigating the relationship between
frequent dairy or milk consumption and acne incidence.3
A September 2010 study published in Nutrition examined the
effect of the whey milk protein lactoferrin on acne. Participants
were randomly assigned to consume fermented milk with 200
mg of lactoferrin daily or fermented milk alone (placebo group).
The lactoferrin group showed significant improvements in acne,
with significant decreases in inflammatory acne lesion counts
and acne grade.4
Although most evidence suggests that total milk consumption is the most critical dairy component that promotes acne,
theres currently insufficient evidence to recommend milk
restriction as a treatment for patients with acne.3
Allergy
Over the past decade, the incidence and prevalence of food
allergy has increased substantially, leading the American
Academy of Pediatrics (AAP) to reevaluate its previous
recommendations. In 2000, the AAP recommended a delayed
introduction of allergenic foods such as cows milk until age 1

as a means of preventing future allergy development.5
In 2008, after a literature review, the AAPs Committee
on Nutrition and Section on Allergy and Immunology determined there was no convincing evidence for delaying the
introduction of cows milk or other highly allergenic foods
a consensus shared with the European Society for Pediatric
Gastroenterology, Hepatology, and Nutrition Committee and
the Section on Pediatrics of the European Academy of Allergology and Clinical Immunology.5
The new guidelines state that cows milk added to complementary foods in small amounts, such as baked goods, and
other dairy products such as yogurt is safe to introduce as early
as 4 to 6 months of age.5
New data are emerging that suggest the delayed introduction of allergenic foods may increase the risk of food allergies,
and early introduction of highly allergenic foods actually may
reduce the risk.5 The theory behind early introduction is to
gradually acclimate the body so that its less likely to be recognized as an allergen, Ayoob says.
A July 2010 study published in the Journal of Allergy and
Clinical Immunology suggests that immunoglobulin Emediated
cows milk allergy is less common than generally reported, and
early exposure to cows milk protein via infant formula as a supplement to breast-feeding may promote tolerance. However,
the amount of cows milk protein needed to prevent cows milk
allergy wasnt determined in the study.6
Theres also some evidence for pregnant women to eat
common allergens while pregnant so as to help the infant ward
off allergens after birth, but this is in the hypothesis stage and
more research is needed, Ayoob says.
The new guidelines state that pregnant women shouldnt
avoid essential foods such as milk and eggs during pregnancy.
Lactating women are advised to follow the same guidelines as
pregnant women except for infants who manifest signs of allergic disease shortly after birth because treatment may, in some
cases, involve dietary interventions during lactation.3
According to the AAP, current evidence supports the general
notion that highly allergenic foods may be introduced earlier in
the diet as complementary foods. However, whether the early
introduction of highly allergenic foods proves to prevent food
allergies remains unanswered. Intervention studies must be
performed to support the data from observational studies.
Cancer
Milk and dairy products may have beneficial and adverse
effects with regard to the risk of different cancers. In 2007, the
World Cancer Research Fund/American Institute for Cancer
Research (WCRF/AICR) published an authoritative review of
existing evidence relating food, nutrition, and physical activity to
cancer risk and concluded that milk probably has a protective
effect against colorectal cancer, and that diets high in calcium
are a probable cause of prostate cancer.7
In the WCRF/AICR Continuous Update Projects October

2011 review of current scientific evidence, the panel
concluded that the new evidence didnt warrant a change
in its initial judgment, as it was consistent with the 2007
evidence, showing that milk probably protects against
colorectal cancer. In addition, the panel conducted a metaanalysis that found increased milk intake was associated
with a decreased risk of colorectal cancer in eight of 10
new cohort studies. The meta-analysis also showed that
increasing dietary calcium by 200 mg/day lowered risk of
colorectal cancer by 6%. The panel added that any effect of
milk consumption on reducing colorectal cancer risk may be
explained at least in part by increased calcium.
Conversely, The Harvard study provides some of the strongest research against dairy consumption and prostate cancer,
Levin says. In a February 1998 Harvard study of male health
professionals, Giovannucci and colleagues found that men who
drank two or more glasses of milk per day were almost twice
as likely to develop advanced prostate cancer and metastatic
prostate cancer than those who didnt drink milk.8
After a 2011 review, the WCRF/AICR panel stated that theres
substantial and consistent evidence from both cohort and casecontrol studies that a dose-response relationship exists, and
diets high in calcium are a probable cause of prostate cancer.
The AICR advises consuming no more than 1,500 mg of calcium
from diet and supplements daily.
Bone Health
The benefits of dairy in bone health are well-known. The
2010 Dietary Guidelines, the Institute of Medicine, and the AAP
all recognize the importance of dairy foods for bone health,
especially in children and adolescents. However, recent evidence suggests not all dairy products are equally beneficial.
A February 2013 study published online in the Archives
of Osteoporosis found that dairy intake, specifically milk and
yogurt, is associated with higher bone mineral density in the
hip but not in the spine. Researchers reviewed data collected
from food-frequency questionnaires completed by 3,212 participants from the Framingham Offspring study. Participants
dairy intake was compared with bone mineral density measurements, which revealed the benefits of milk and yogurt, while
evidence suggested that cream may adversely influence bone
mineral density.9 Choosing low-fat milk or yogurt over cream
can increase intake of protein, calcium, and vitamin D, which
contribute to normal bone maintenance.
Weight Control, Heart Disease, and Diabetes

In addition to its association with bone health, research
shows that increased milk and yogurt intake is linked to better
weight management, reduced hyperglycemia, and decreased
hypertension, all risk factors for cardiovascular disease. In
a June 2011 prospective study published in The New England
Journal of Medicine, researchers examined three separate
cohorts of more than 120,000 US women and men followed

every four years. Evidence showed that yogurt, fruit, vegetable,
and whole grain consumption was associated with less weight
gain over time, with yogurt having the greatest impact. In the
study, whole milk and cheese consumption was linked with
weight gain over the two decades.10
Other research has found that maintaining a healthy weight
and eating a nutrient-dense diet can help prevent type 2 diabetes. Though research isnt conclusive, some suggest that dairy
products can help prevent the disease, says Jill Weisenberger,
MS, RDN, CDE, author of Diabetes Weight Loss Week by Week.
An August 2013 meta-analysis published in the American
Journal of Clinical Nutrition analyzed 17 studies with data
from more than 370,000 men and women to determine the
relationship between dairy intake and diabetes risk. Evidence
suggests theres a significant inverse association between the
intake of dairy products, low-fat dairy products, and cheese
and type 2 diabetes risk.11 For nearly one extra daily glass
[6.5 oz], milk drinkers had a 13% lower risk of type 2 diabetes,
Weisenberger says.
Moreover, the type of dairy may be beneficial for the prevention
of type 2 diabetes. In a May 2014 study published in Diabetologia,
researchers found that higher consumption of low-fat fermented
dairy products, largely driven by yogurt intake, was associated
with a decreased risk of type 2 diabetes.12
Over the past decade, researchers have investigated the
effect of cows milk on the development of type 1 diabetes, particularly in individuals at high risk of the disease. To date, no
specific dietary factor or nutrient in infancy has been shown to
unequivocally play a role in the development of type 1 diabetes.13 More research is needed to confirm the contribution of
early dietary factors in type 1 diabetes development.13
The AHA and the DASH diet program both recommend
consuming fat-free and low-fat milk and milk products for
optimal health. In a January 2013 study in Nutrition Research,
researchers examined whether yogurt consumption was
associated with better diet quality and metabolic profile
among adults. Yogurt consumers compared with nonyogurt
consumers had higher potassium intakes, lower levels of circulating triglycerides and glucose, and lower systolic blood
pressure and insulin resistance.14
Counseling Clients and Patients

Many individuals miss out on the health benefits of dairy
because of real or perceived lactose intolerance. According to
the National Institutes of Health, an estimated 30 million to 50
million American adults are lactose intolerant. Some ethnic
groups show high levels of intolerance, including about 95%
of Asians, 60% to 80% of blacks and Ashkenazi Jews, and 50%
to 80% of Hispanics. Yogurt can help individuals with lactose
intolerance meet their dairy requirements and obtain calcium,
potassium, and vitamin D. Due to the presence of lactaseproducing yogurt cultures and because it contains less lactose
per serving than milk

on average, yogurt is a
more easily digestible
alternative to milk.10
According to
Weisenberger, clients
and patients can get
three servings of dairy
each day by doing the
following:
Eating 1 cup of low-fat yogurt or
cottage cheese instead of a few
handfuls of potato chips.
Mixing fresh fruit with low-fat
cottage cheese.
Adding one glass of skim or
low-fat milk to a meal instead of tea
or a sugary soda.
Drinking a hot or iced nonfat latt instead of a high-calorie
coffee drink.
Having an 8-oz cup of hot chocolate made with low-fat milk,
cocoa powder, and sugar or a nonnutritive sweetener.
Adding tomatoes, fresh basil, and black pepper to low-fat
cottage cheese for a low-carb snack.
Eating a reduced-fat cheese stick and a handful of
raw veggies.
Emerging Research
A body of evidence is emerging that links milk and other
dairy products to a reduced risk of heart disease, hypertension, obesity, and type 2 diabetes. Currently, theres insufficient evidence to recommend milk restriction as a treatment
for patients with acne. The AAP supports the early introduction of milk into the diet of infants as young as 4 months of age.
Adequate calcium intake from diet and supplements is associated with a lower incidence of colorectal cancer. Conversely, too
much calcium from diet and supplements is associated with an
increased risk of prostate cancer.
Calcium is necessary for bone health, and the AICR recommends nonfat and low-fat dairy products such as milk, yogurt,
and cheese as part of a balanced diet for bone health and
cancer prevention.
Constance Brown-Riggs, MSEd, RD, CDE, CDN, is the
nutrition advisor for the Dannon One Yogurt Every Day Initiative;
a past national spokesperson for the Academy of Nutrition and
Dietetics, specializing in African American nutrition; and the
author of The African American Guide to Living Well With Diabetes
and Eating Soulfully and Healthfully With Diabetes.

Men
While women
dominate the
nutrition profession,
more men are
entering the field
and experiencing
great success in
their careers.
in
Dietetics
ietetics has long been a field dominated by

women. Many surmise that possible stigmas
were formed in the early years with the
professions ties to home economics or the
classic lunch lady role. Unfortunately, these
misperceptions possibly have discouraged more men from
entering into the fieldbut all of that may be changing.
As the dietetics profession has evolved, the push
toward encouraging more men to join the ranks has
increased. Those men who have paved the way have
shown that there are great opportunities for success.
Men in dietetics are doing exciting things, and theyre
encouraging more men to consider entering the field.
Female-Focused Beginning
That sense of a home economics beginning to the
dietetics field certainly may have driven more women
than men into the nutrition profession, says Rick Hall,
MS, RDN, FAND, a writer and speaker and a senior nutrition lecturer at the School of Nutrition and Health Promotion at Arizona State University. Women dominated
this field early on, and when anyone looks at a field so
prevalently occupied by one gender, the natural stigmas
attached to that profession might influence the continuation of that trend, he says. In other words, young men
may look at nutrition as a womans career choice instead
of recognizing it as a unique opportunity to break through
a profession eager for diversity.
Associating a persons sex with professional career
choice certainly isnt limited to the dietetics field. The
predominance of women in nursing is another prime
example. But statistics have shown a nationwide trend of
more men pursuing nursing careers, and many believe
dietetics is next.
The numbers of men in the dietetics profession have
been creeping up slowly, but I believe were on the horizon of seeing a bigger change, says Ethan Bergman,
PhD, RDN, CD, FADA, associate dean in the College of
Education and Professional Studies and a professor of
food science and nutrition at Central Washington University. Just as the nursing profession saw a sudden rise
By Lindsey Getz
in the number of men entering the field, I believe were

poised for that same big growth potential. Men are realizing its a viable profession that works well with both their
professional and personal goals.
The change already is under way, according to Hall.
As a faculty member for one of the largest dietetics programs in the country, Hall says hes been seeing a steady
increase in men pursuing nutrition as a degree option
within the past decade. When I was pursuing my degree,
I often was the only male in the room, he recalls, but
thats no longer the case.
A misinformed public certainly has been a large
part of the battle in encouraging more men to enter the
nutrition field. Many dietitians have expressed frustration over the lack of public understanding about what a
dietitian does and why they may need a dietitian. David
Grotto, MS, RDN, president and founder of Nutrition
Housecall in Chicago and author of The Best Things You
Can Eat, 101 Foods That Could Save Your Life, and 101
Optimal Life Foods, says the misconceptions about the
dietitians role are manifold. Male and female dietitians
alike have had a difficult time educating the public about
exactly what they do and who they are.
I think weve had a hard enough time shaking the image
of the spinster lunch lady with the hairnet, Grotto says.
This is a stereotype that limits both men and women. The
truth is that this profession has so many possibilities, but
often men and women believe their only choices are working in foodservice or being a hospital floor dietitian. Those
are wonderful roles, but the problem is so many students
believe theyre the only career paths for a dietetics degree.
Grotto believes the Academy of Nutrition and Dietetics
(the Academy) has taken important steps to help dispel
some of these stereotypes by educating the public about
what dietitians do and adding the word nutritionist to
the credential, which he says helps clarify the role and
may help attract more men to the field. Todays Dietitian
contacted the National Organization of Men in Nutrition,
a member interest group of the Academy that focuses on
promoting dietetics careers to men, but members didnt
respond before press time.
Having been in this profession for almost 30 years, Im

still having to constantly define what registered dietitian
means, Grotto says. Like it or not, when consumers hear
nutritionist, they have an a-ha moment, and they get it. I
think its a positive direction to not only be more clear about
what we do but to highlight the possibilities of this profession
and define its scope. That will help in actively recruiting both
genders as well as more of a diversity of populations. White
young women shouldnt be the only image that comes to mind
when you hear registered dietitian nutritionist.
Abounding Opportunity
No doubt the dietetics field has much to offer both women
and men. Grotto says hes always had a dream about going
into broadcasting, and becoming a dietitian didnt dash that
dream; it helped make it a reality. In addition to working as a
clinical dietitian, Grotto had the opportunity to host his own
radio show for a decade called Lets Talk Health, Chicago.
There was a time when I bought into the stereotype
that a hospital job was the only career path for a dietitian,
Grotto says. Thats certainly one choiceand a great one
but there are so many more. This amazing profession has
allowed me to work in so many different areas and do so
many different things.
Many male dietitians tell that same story. Manuel
Villacorta, MS, RD, founder of Eating Free, an international
weight management and wellness program; cofounder of
Eat Mentor, a personalized weight-loss app; and author of
Eating Free and Peruvian Power Foods, says the versatility
has been one of the most appealing aspects of the nutrition
profession. Originally, he wanted to become a primary care
physician, so he took premed course requirements at the
University of California, Berkeley. When he took an elective
clinical nutrition class, thats when he had what he calls his
a-ha moment. He already knew he enjoyed cooking, loved the
sciences, and wanted to help people, and attending that class
was when he realized dietetics was a field that had it all.
I have never once regretted my decision to leave the
dream of becoming a physician behind, says Villacorta, who
has worked in public health and private practice in addition to
consulting and spearheading other projects. This has been
an amazing journey, and where I am now is like heaven. I
dont think I would have been able to do all the different things
Ive done with my professional career had I become a doctor. I
would have been tied down.
Although men are a minority in the field, those who have
built successful careers say that being in the minority actually has worked to their advantage. Dietetics has become a
field that craves diversity, and there are many roles to be
filled. Men are in need in our field, says Jim White, RD,
ACSM, HFS, owner and president of Jim White Fitness &
Nutrition Studios. With only 5% of men in the field, that can

be a huge advantage, and there are many dietetics tracks
geared for men. Men can go into private practice, establish
businesses focusing on nutrition and fitness, pursue broadcasting careers in radio and TV, become spokespeople and
industry consultants, and write books.
White says he combined his dietetics degrees with his passion for fitness to create his dream job. In addition to becoming credentialed as an RD, he became certified as a health
fitness specialist by the American College of Sports Medicine
and shortly after opened his first fitness and nutrition studio.
A career in this field does not end at traditional dietetics,
White says. Men can create their own path in the career.
Look for nontraditional career paths and find something
youre passionate about.
Christopher Mohr, PhD, RD, a nutrition consultant and
writer and the co-owner of Mohr Results, a weight-loss company in Louisville, Kentucky, says a dietetics degree allows
for creating your own opportunities. This is exactly how Ive
built my career, he says. Theres a need for quality RDs,
whether that is a man or a woman.
Mohr has been a nutrition spokesperson and consultant
for both media outlets and corporations, including The Dairy
Council, Clif Bar, and Subway. He was the nutrition expert for
The New York Times best seller LL Cool Js Platinum Workout,
and he sits on the advisory board of some major magazines.
And these are just some of the opportunities Mohr has had
throughout his career.
Mohr says it shows the vast level of opportunity that exists
for dietitians in the field. He attributes much of his success
to having mentors that have helped guide him over the years.
They are my coaches, he says. For anyone starting out, I
would advise finding a mentor and being like a sponge, meaning absorb everything you can from them and their experience. My other piece of advice is to network. Get out there and
dont be afraid to ask questions. Introduce yourself at conferences and always ask how you can help.
Blow the Trumpet

While many successful male dietitians are forging the way,
its important that the industry promotes itself so men will be
more inclined to enter the field. This has been and continues
to be a barrier thats preventing more men from pursuing the
degree, says D. Milton Stokes, PhD, MPH, RD, CD-N, owner
of One Source Nutrition, with offices in Stamford and South
Windsor, Connecticut. Many schools dont do enough to promote it, he adds.
High school counselors definitely dont promote dietetics,
but even universities and colleges with dietetics programs
often dont promote the major adequately, Stokes explains.
In my academic position, I see students who came to us
because they or a family member worked with a dietitian,

not because we recruited them. I found dietetics because
my college advisor, who was a botanist, casually mentioned
taking a nutrition class. It was pure happenstance, but once I
was in, I was hooked.
Villacorta says the curricula also can benefit from some
changes. The backbone of the dietetics field is clinical, and
that should definitely be a major part of the curriculum, he
says. But I dont think it should be the only focus. Dietitians are
eager to hear other things they can do with the degree, and I
feel like the learning opportunities should be a little more open
ended. They can talk about how to build a private practice, for
instance, as this is uncommon ground for many dietitians.
Continuing to highlight what men already are doing in the
field also will help change perceptions, Bergman says. We
need to get the word out and show the types of things men
are doing in the profession. I feel like were going to see men
emerge in all areas of dietetics, not just be limited to one
sector of the profession.
And theres plenty that existing male dietitians can do
to help. Im always thinking of ways I can help promote
dietitians and the profession as a whole, Villacorta says.
Doing talks or using social media helps get the word out
about the profession, and that benefits all of us. If were
going to change this perception of dietetics being about
home economics or being only for women, then we need role
models who can get more involved.
Room for All

In the end, dietetics is about everybody, Bergman says.
Access to food is a right, just like water or air, he says.
Everybody needs food. The more we come to realize that, the
more we can encourage dietitians to take the role of food nutrition leaders. Optimizing health through food nutrition is a role
that anybody can playand thats where gender lines cross.
Grotto agrees: Its important we do a better job of encouraging more men to join the field, but we also dont want to
turn this into a man vs. woman thing. All of the opportunity
and versatility that we talk about as attracting men to the
field are the same reasons women are attracted to the profession. It can be a great career choice for everyone.
Lindsey Getz is a freelance writer
based in Royersford, Pennsylvania.
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Tips for Male Clients on How

to Get Fit When Time Is Tight
By DAVID YEAGER
ost men dont spend much time

thinking about their health.
Unless their doctor tells them to
get their blood pressure under
control, lower their cholesterol,
or drop a few pounds, they see no need for concern. In some cases, a doctors warning isnt even
enough to spur them to action. Exercise? Maybe
when I nd the time, you might have heard some
male clients say. Change my diet? Not unless its
a matter of life and death. Unfortunately, epidemiologic evidence shows that regular exercise and
eating healthfully is a matter of life and death.
Heart disease and cancer account for nearly
one-half of all male deaths in the United States.1
Obesity, a signicant risk factor for heart disease,
many cancers, and type 2 diabetes, among other
ills, now affects one-third of American men.2-4 In
addition to controlling weight, strengthening bones
and muscles, improving mood, preventing falls, and
lengthening life spans, regular physical activity has
been shown to reduce the risk of these diseases
and others.5 So why dont more men do it?
For most, time is not on their side. Work, family,
and social responsibilities pile up, and diet and
exercise often take a back seat. Ask any tness
trainer, though, and theyll tell you that its less a
matter of nding time than making time.
It has to be intentional, says Eric Paul Meredith,
MS, RD, LDN, CPT, a tness and nutrition consultant
in Chicago. People need to nd some motivation to
exercise, and they shouldnt wait for the doctor to
tell them to do it. Motivation is an important aspect
of exercise; people make time for things that they
want to do.
You Can Lead a Horse to Water

Because the body deteriorates with age, doing
something to slow that process should be a nobrainer for clients, but many offer excuses for not
exercising. Time generally is the most cited, but
other common reasons include lack of know-how,
support, and access to equipment. Meredith says
all of these issues easily can be overcome.
Aside from working with a trainer at the local
gym, he says there are plenty of ways men can
learn how to get and stay t. Many books, magazine
articles, DVDs, and YouTube videos have ooded
the booming tness market in the past decade.
If male clients want to know how to do a burpee,
they can YouTube it and watch various trainers
and tness enthusiasts demonstrate their favorite

variation. If theyre thinking about competing in a
triathlon, they can nd various training regimens
that athletes and coaches have posted on the Web,
Meredith says.
One way male clients can get and stay motivated
is to nd a gym buddy or two. Each gym buddy can
hold the other accountable for working out. That
type of positive social pressure can be a powerful
force, he adds.
Lack of resources need not be a hurdle, either.
Many gyms now offer discounted rates or very low
monthly fees without requiring a multimonth commitment. For those who prefer to stay at home,
exercise videos and body-weight exercises can be
as effective as pumping iron or sweating it out on
an elliptical machine. Meredith says that boxers
and the military have been using body-weight training for years with great success. Throw in a set of
dumbbells or some tness bands, and theres no
reason a person cant get a workout at home thats
every bit as effective as a gym workout, he explains.
The key for male clients, Meredith says, is to
nd an activity they like. If clients dont like running, boxing, or calisthenics, they wont stick with it
for long. Its also important for them to determine
a baseline tness level. Condence is a signicant
component of exercise. If clients feel they cant
do what a trainer asks, theyll soon begin to avoid
exercise altogether, Meredith says.
Overcoming obstacles is only part of the equation, though. Most men need a reason to exercise. And
while there are many reasons, having a measureable
goal is the best way to ensure they keep doing it. Some
may choose to exercise to compete in an athletic event
(eg, Tough Mudders, 5K, triathlon, marathon), recover
from an injury, shed belly fat, or simply lower cholesterol. Determining these motivating factors requires
active listening, so the most effective trainers are
more than just instructors but counselors as well.
When I discuss goals with a client, he may
initially say, I want to improve my health, but this
is not a goal that a male client will be motivated
by, says Demetrius J. Willis, MS, MBA, RD, LD,
CPT, a program developer for the Lake County,
Illinois, health department and a private tness and
nutrition consultant. As we discuss the real issues
and what brought him to the gym, then we can set
specic goals regarding endurance, strength, lab
test values, ability, or look. These are motivating
topics and goals.
NO TIM
ME TO EXERC
CISE?
THIN
NK AG
GAIN
N
With time at a premium, it can be tough for male clients to
squeeze in a workout, but that doesnt mean they should skip
it, says southeastern, Pennsylvania-based personal trainer
Jay Repko, ISSA-CPT, NSPA-CPT. He says that even if time
is tight, theres still room in a busy schedule to get the heart
pumping and build muscle.
Here, Repko provides a 20-minute workout that consists
of 10 exercises for 50 seconds each, followed by a 10-second
rest; clients are to complete two rounds. If clients dont
know how to perform a particular exercise, suggest they
visit YouTube.com to learn how to do it.
1. Three pushups/10 mountain climbers
2. Six squat jumps/six low squat pulses. At the bottom of a
squat, keeping feet at on the oor, raise and lower the hips
in 2-inch pulses before returning to the upright position.
3. Long jump burpee. Burpees typically are done by jumping
as high as possible after each repetition. For this variant,

jump forward as far as possible. Do a 180 jump turn on
landing and repeat in the opposite direction.
4. Low plank body saw. Get in low plank position (on elbows)
and move forward and back, up on toes, taking your head out
past your hands as far as possible. Keep elbows and toes in
the same spot on the oor.
5. Cross-body single dumbbell row with oblique twist at the
top of the lift25 seconds each arm. Start with feet slightly
more than shoulder-width apart and bend at the waist.
Instead of a typical bent-over row, hold a dumbbell or kettlebell over the foot on the opposite side of the body. In other
words, if the weight is in the right hand, hold it over the left
foot. The motion is the same as a bent-over row, but when
the arm reaches a position parallel with the oor, twist the
hips in the direction of the pull.
6. Four lunge jumps. From a standard lunge position, jump
in the air, moving the rear foot forward and the forward foot
backward. Land in lunge position. Add four close-grip pushups.
7. Two dumbbell squats/bicep curl/shoulder press
8. Knee-to-elbow crunches
9. Five plank jacks/ve half burpees. Planks jacks: From
a low plank position, use the leg and abdominal muscles to

push the toes off the ground and land on toes with feet apart.
Push off again and land with feet together. Half burpees: From
the high plank position, bring both knees to the chest then
throw them back until the legs are at full extension. Repeat.
10. Bear crawl burpees. After the vertical jump, bear crawl
(hands and feet on the ground, similar to the way a bear
stands) forward for ve yards and then backward to the
starting position. Repeat.
Shorter the Better

Whether its a sign of the times or the realization that
two-hour workouts are unnecessary for all but the most
hardcore athletes, shorter workouts are becoming a growing trend. The American Heart Association recommends 30
minutes of moderate-intensity exercise ve days per week
or 25 minutes of vigorous-intensity exercise three days per
week plus two days per week of moderate- to high-intensity
muscle strengthening for overall cardiovascular health.6
Popular tness franchises such as P90X and INSANITY
even have developed shorter workouts, including P90X3
and Focus T25, for the time challenged.
The trainers interviewed for this article agree that one
hour is the optimum amount of time for a workout, but
that doesnt mean people cant benet from shorter workouts. What people do with the time is what counts. Exercise
results largely are determined by intensity.
With 30 minutes, its not like youre cutting your workout in half and youre leaving the other half for another day,
Meredith says. Youre basically taking all of the work you
domaking sure you dont do anything to injure yourself,
of courseputting in the same number of reps, the same
number of sets, but nding a way to condense it. Some
people would think that would be harmful, but its actually
helpful for you to take the same workout youve done in 45
minutes to an hour and put it into 30 minutes. To me, thats
probably as effective as, if not more effective than, working
out for an hour.
Some male clients may believe that strength and cardiovascular training are mutually exclusive, but condensed
workouts that hit all of the major muscle groups can effectively accomplish both tasks. Exercises that use only body
weight or a set of dumbbells can provide the necessary
intensity, Meredith says.
Ask trainers whats the best single exercise for working
the entire body, and their answer likely will be burpees. For
those clients who fondly (or not-so-fondly) remember squat
thrusts from gym class, the burpee is the squat thrusts
muscular older brother. Although burpee variants are
limited only by the imagination, the basic form is as follows:
From a standing position, place the hands at on the oor
in front of the feet, throw the legs back to full extension,
do a push-up, bring the knees back to the chest, stand up,
jump, repeat. This exercise works nearly all of the major
muscle groups in the body while providing a signicant
cardiovascular workout.
Planks are another effective exercise, according to the
trainers interviewed here. In their simplest form, planks
have two variations: high (full) and low (elbow). Picture a
person in push-up position; this is the high plank position.
Put the hands in front and weight on the elbows, and it
becomes the low plank position.
Planks often are held for a period of time,

with multiple repetitions in a set, but the
plank position also can be used as a base for
plank jacks, which basically is pushing the
lower body off the ground with the legs and
abdominal muscles, landing on the toes with
feet apart, pushing off the ground again, and
landing on the toes with feet together.
Planks are performed to build core
strength, which is the term given to the
muscle groups of the abdomen and lower
back. From a high plank position, a person
also can do mountain climbers. For this
exercise, one knee, then the other, is brought
to the chest in an up-and-down motion for a
prescribed number of repetitions. This works
not only the core muscles but also most of
the muscles in the legs.
Other exercises that produce results are
old-fashioned push-ups, pull-ups, squats,
and lunges. Exercises can be done in a
circuit, one after the other, with minimal
to no rest between them, or they can be done as supersets,
essentially a circuit but with fewer exercises, no rest, and
more sets.
Meredith says another useful training protocol is the Tabata
Method. This method requires a person to work hard for 20
seconds, rest for 10 seconds, then repeat for a prescribed
number of rounds.
The good news is that not all of these exercises must be
done during every workout. In fact, its better if theyre not;
variation is an important part of an effective exercise program. Without regular variation, the body reaches a plateau,
a point at which the rate of exercise-induced change begins
to slow down.
Almost anything works for a beginner or someone whos
been inactive for a while, but everybody plateaus eventually, so
you want to avoid that by changing things up periodically, says
Jay Repko, ISSA-CPT, NSPA-CPT, a personal trainer who works
with clients at multiple tness centers in southeastern Pennsylvania. I see so many people who come in at the same time
on the same days of the week and do the same routine every
time. And they never really change their appearance because
your body is smart; it knows what to expect and it adjusts. If
you want to stay with something thats working, thats ne, but
at the rst hint that youre not seeing the changes you want or
youre feeling sluggish and sore, you need to change it up.
Boredom is another reason clients need to include variation. A workout that seemed terric at the outset can become
stale after ve or six weeks. New challenges are one way to
keep the mind and body engaged, and this is an area where
trainers can be especially helpful for men.
In my experience, male clients do not see personal trainers

for long periods of time, Willis says. Most of my male clients
see me for motivation and education. They tend to be on a cycle
of learning and getting motivation from the personal trainer for
a few months then taking a break from the trainer by working
out on their own. After six weeks or so, they come back. This
is different from the experiences Ive had with female clients,
who are more often there for the long haul and build more of a
relationship and a connection with their trainer.
Chicken, Egg, or Protein Shake?

Even if male clients follow all of this exercise advice, it
wont guarantee that theyll improve their heart health, look
good on the beach, or be ready to compete on American
Ninja Warrior. Theres a tendency to think that exercise alone
leads to tness, but thats a false and potentially dangerous
assumption. An extremely important and often overlooked
component of overall health is diet, according to the trainers.
A man may be working out and looking good on the outside,
but if hes consuming lots of saturated fat, likely hes increasing
the amount of plaque in his arteries. In less drastic terms, it
isnt uncommon for a man to exercise faithfully and still not
get the results he wants. Lean and at bellies are made in the
kitchen, not in the gym, Willis says.
Many people sabotage their effort because they dont get
proper nutrition, Repko says. In my estimation, and that of
most trainers, thats 75% of the equation. You can go into the
gym every day and work hard, whether its for 20 minutes or
two hours, but if youre not fueling your body properly, youre
spinning your wheels. What Ive seen is that most people
dont have the discipline and dont want to make changes in

their diet. And I dont necessarily mean a weight-loss diet; Im
talking about the right way to eat.
To maintain an efficient metabolism, Repko says its best
for male clients to eat five or six smaller meals per day spaced
212 to three hours apart. This keeps the body properly fueled
without allowing it to think its fasting, which slows metabolism.
He says most men also dont drink enough water. Water should
be consumed throughout the day and during workouts. For
workouts that take less than an hour, sports drinks arent
necessary, he adds.
Its also a good idea for men to limit simple carbohydrates,
especially highly processed foods, and focus more on carbohydrates that take longer to digest. Meredith says men can
eat starchy vegetables such as corn, potatoes, and peas in
moderation, but carrots, kale, and broccoli are better choices.
Protein is another essential component of a balanced
diet, and lean protein is best. Men should choose lean cuts
of meat and fish as well as vegetable protein. Although
some fat also is necessary, most men eat more than the
recommended 20% to 35% of total calories, and much of it
is saturated fat. Meredith says a good way to monitor eating
habits is to use the USDAs SuperTracker program, which
provides nutrition information on more than 8,000 foods
and enables people to develop personalized nutrition and
physical activity plans.
Willis says its ironic that most people will follow a workout
plan but wont have a nutritious food plan to match, adding
that most last-minute meals are poorly balanced. To provide energy for workouts and allow proper recovery, men
should eat small meals or snacks before and after a workout. Specifically, men should consume preworkout meals 30
to 60 minutes before a workout, and they should consist of
simple carbs, complex carbs, and a little protein, the trainers say. The goal is to provide energy for the workout beforehand. However, if the meal is too big, it will draw blood from
the muscles to the stomach and lead to stomach and muscle
cramps. Good preworkout snacks for men include oatmeal
with berries and cottage cheese, whole wheat toast with
almond butter and a banana, Greek yogurt with berries, or
a scrambled egg on a whole wheat tortilla or bread, Willis
says. If the body isnt fueled properly, it will use muscle as its
energy source during the workout.
Postworkout meals and snacks are similar but should
include a little more protein to repair the microtears that
occur in the muscles during exercise, Willis says. Protein
should be consumed within 30 to 60 minutes after a workout,
he says, suggesting that men stay away from eating meat or
drinking alcohol for at least a couple of hours after exercise.
Instead, they should choose a fruit smoothie, protein shake,
omelet with spinach and veggies, tuna sandwich on whole
wheat bread, or a protein bar with no more than 11 g of sugar
and 15 to 30 g of protein.
For those interested in using protein powders to supplement their nutrition regimen, Meredith says whey protein
isolate (or soy protein isolate for vegans) is best for workout days. Male clients can purchase protein powders at most
nutritional supplement stores. On nonworkout days, casein,
which takes longer for the body to break down, is preferable.
Encouraging Change
If male clients feel overwhelmed about beginning an
exercise regimen and eating more healthfully, dietitians can
encourage them to make small incremental changes, which
ultimately can make a big difference in their personal health
down the road. Some men resist change, but if nutrition
professionals can appeal to what matters most to them,
theyll be more likely to take the first steps toward positive
lifestyle changes.
Whether [a man] loves to exercise or not, he needs to do
somethingeat a little better and exercise a little bitif [he]
wants to see his grandkids or his great-grandkids or beyond
and have a healthy, active retirement, Repko says. Face it, if
he expects to live to 100, close to half of his life is retirement.
If he wants to be able to travel and enjoy his life, he has to keep
himself healthy.
David Yeager is a freelance writer and editor based
in Royersford, Pennsylvania.
References
1. Leading causes of death by age group, race/ethnicity
males, United States, 2010. Centers for Disease Control and
Prevention website. http://www.cdc.gov/men/lcod/2010/LCO
Drace_ethnicityMen2010.pdf.
2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of
obesity among adults: United States, 2011-2012. NCHS Data
Brief. 2013;(131):1-8.
3. What are the health risks of overweight and obesity?
National Heart, Lung, and Blood Institute website.
http://www.nhlbi.nih.gov/health/health-topics/topics/obe/
risks.html. July 13, 2012.
4. Obesity and cancer risk. National Cancer Institute website. http://www.cancer.gov/cancertopics/factsheet/Risk/
obesity. Reviewed January 3, 2012.
5. The benefits of physical activity. Centers for Disease
Control and Prevention website. http://www.cdc.gov/physical
activity/everyone/health. Last updated February 16, 2011.
6. American Heart Association recommendations for physical activity in adults. American Heart Association website.
http://www.heart.org/HEARTORG/GettingHealthy/Physical
Activity/American-Heart-Association-Recommendations-forPhysical-Activity-in-Adults_UCM_307976_Article.jsp. Last
reviewed March 22, 2013.
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CODE: 052714
CPE MONTHLY
FDA Regulation
DIETARY WEIGHT-LOSS
SUPPLEMENTS
What the Labels Dont Tell You
By Lisa S. Brown, PhD, RD, LDN,

and Sarah Churchill, MS
The use of dietary weight-loss supplements is common in
the United States as consumers search for ways to combat
expanding waistlines. In 2011, US consumers spent more than
$30 billion on dietary supplements, including those intended
to promote weight loss.1 A 2008 study found that 34% of people
making a serious attempt to lose weight had tried dietary
weight-loss supplements. Also, those more likely to use such
supplements are women, individuals aged 25 to 34, blacks, Hispanics, individuals in lower income households, and individuals
with less education.2
Many consumers believe that weight-loss supplements
available for purchase in the United States must be safe and
effective. Most dont know that supplements arent regulated
as strictly as prescription medications, and that many supplements are both ineffective and potentially unsafe. In one survey,
approximately one-half of respondents believed that the FDA
evaluated the safety and efficacy of supplements, and approximately two-thirds assumed that the government required supplements to list warnings about potential side effects on their
labels.2 Only one-third of consumers using weight-loss supplements reported discussing the use with a health professional.3
Dietitians play a key role in helping consumers understand
the risks of using dietary weight-loss supplements and how
they differ from regulated medications. To that end, this continuing education course reviews the basic regulatory issues
pertaining to dietary weight-loss supplements, the ingredients commonly used in these supplements, and new concerns
regarding contamination. It also provides a brief overview of
FDA-approved dietary weight-loss supplements.
In the United States, most weight-loss pills are regulated as

dietary supplements. The FDA defines a dietary supplement as
a product intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin,
a mineral, an herb or other botanical, an amino acid, a dietary
substance for use by man to supplement the diet by increasing
the total dietary intake; or a concentrate, metabolite, constituent,
extract, or combination of any ingredient mentioned above.4
Although supplements often are sold in pill form, theyre
regulated as food, not as medication. In contrast to its role pertaining to over-the-counter and prescription medications, the
FDA cant require supplement manufacturers to prove a products safety and efficacy before distribution. Supplements can
be marketed without any documented scientific evidence proving that they work and are safe as long as they dont contain any
ingredients that werent on the market as of October 15, 1994.5
In 1994, Congress passed the Dietary Supplement Health
and Education Act (DSHEA). This legislation placed the onus
of ensuring supplement safety on a products manufacturer
before it offers a product for sale, but it grants the FDA power
to investigate a product associated with reports of adverse
events and prohibit its sale if safety concerns warrant such
action.6 Regulation is markedly different from that of over-thecounter and prescription medications, for which manufacturers
must extensively prove both safety and efficacy first on animals
and then on humans.7
COURSE CREDIT: 2 CPEUs
LEARNING OBJECTIVES
After completing this continuing education course,

nutrition professionals should be better able to:
1. A ssess consumer use and knowledge of dietary
weight-loss supplements.
2. Understand the differences in federal regulations
between dietary weight-loss supplements and

prescription weight-loss medications.
3. Distinguish categories of dietary weight-loss
supplements based on their mechanisms of action.

4. Evaluate potential risks of taking dietary weight-loss
supplements, including contamination and adverse

side effects associated with common ingredients
used in over-the-counter supplements.
5. Examine the factors that place individuals at higher
risk of adverse effects from dietary weight-loss

supplement use.
Suggested CDR Learning Codes

2010, 3070, 3100, 5370, 5420; Level 2
Once approved by the FDA and put on the market, a medication goes into a phase 4 trial intended to monitor its longterm safety. The manufacturer must collect reports of adverse
events and disclose them to the FDA. If enough adverse events
are reported, the FDA may conduct its own investigation and
may choose to ban the medication from the market depending
on its findings.
In contrast, supplement manufacturers dont need to test the
safety and efficacy of their products before distributing them
to consumers and need to comply only with postmarket testing similar to the phase 4 trial of medications. Even that level of
monitoring has been required only since 2007.7
The Dietary Supplement and Nonprescription Drug Consumer Protection Act was passed in 2006 as an amendment
to the Federal Food, Drug, and Cosmetic Act. This amendment
set in place requirements for nonprescription drug companies
and supplement manufacturers to collect and report adverse
events related to their products use.7 For the purposes of
removing a product from the market, the term serious adverse
event is defined as including a life-threatening experience possibly resulting in death, inpatient hospitalization, a persistent
or significant disability or incapacity, or congenital anomaly or
birth defect.7 The 2006 law also mandates that the product label
contain the name and address of the manufacturer or distributor responsible for collecting information about adverse events
caused by a supplement.
The manufacturer must report serious adverse events to
the FDA no more than 15 business days after learning of those
events.8 The FDA may remove a product if the agency can conclude theres a direct link to reported serious adverse events.
Several events must be reported to trigger an investigation,
and then the FDA may decide whether theres enough evidence
that the supplement caused the events and remove the product
from the market.
While this process has led to the removal of at least one
productthe original formulation of the weight-loss supplement Hydroxycut, which will be discussed further belowconsumer advocates believe many adverse events go unreported
and many unsafe products remain on the market. Most consumers are unaware of the reporting process, while others
may associate adverse events with concurrent prescription use
rather than supplement use.9
The DSHEA also grants the FDA some authority over
product labeling. Supplement labels are required to list
all active and inactive ingredients, but even these minimal
requirements arent followed consistently. A 2007 study
found that only 84% of the supplement labels examined
included all active ingredients, and less than 50% contained
all inactive ingredients.10 A 2013 Canadian study found that
out of 44 herbal supplements tested, 59% of the products
had incorrect labels, meaning they contained ingredients
not listed. Of the 44 products, 32% contained substitute
ingredients defined as unlisted ingredients added to the
CALL FOR PRESENTERS

2015 Todays Dietitian Symposium
We are currently accepting abstracts for presentations
at our 2015 symposium. Individual or group proposals
for 90-minute continuing professional education sessions
will be accepted through July 18, 2014. Please provide a
written summary of no more than 250 words as a Word file
via e-mail to symposium@gvpub.com.
product in place of a listed ingredient, which was omitted

from that batch, and 21% contained fillers that were known
allergens such as wheat, rice, and soy.11
The DSHEA clarified the FDAs role in regulating supplements, and amendments to the DSHEA have since strengthened the act and given the FDA more power to ban supplements
before marketing. However, the amendments didnt give the
FDA the authority to regulate supplements in the way many
consumer advocates wanted.
One added provision to the DSHEA is the current Good Manufacturing Practices (cGMPs), which set forth specific mandatory
quality-control measures during the manufacturing and distribution process for all domestic and foreign companies that
distribute products in the United States. The cGMPs include
standards for plant design, manufacturing operations, final
product testing, records maintenance, and processes for handling consumer complaints. The FDA can ban companies that
dont meet the cGMPs.6
In addition to the FDA, the Federal Trade Commission (FTC)
has limited jurisdiction over dietary supplements. The FTC can
sanction companies that make unsubstantiated claims regarding their products effectiveness in advertisements and ban
them from selling their products in the United States.12
While the current regulatory process provides some consumer protections, supplements remain buyer beware items.
Categories of Supplements and Common Ingredients

Widespread supplement use is a concern because many
products contain ingredients that may be dangerous for susceptible individuals or can become dangerous in combination
with other ingredients. Individuals with cardiovascular problems may experience adverse effects from dietary weight-loss
supplements, as many products cause increased metabolism,
which stresses the circulatory system.
Other such supplements interfere with appetite and may
cause issues for individuals with thyroid problems or conditions
that affect the bodys hormonal function. And some supplements may disrupt normal nutrient absorption and metabolism, causing problems for individuals with diabetes and other
metabolic abnormalities.
Based on their mechanisms of action, dietary weight-loss

supplements and ingredients can be classified in the following
categories: stimulants/metabolism boosters, appetite
suppressants, and ingredients that alter the metabolism of
specific nutrients.
Stimulants/Metabolism Boosters
The most common class of ingredients added to weight-loss
supplements are stimulants, which are meant to boost the metabolic rate. The most infamous stimulant, Ephedra sinica, also
known as ma huang, modestly impacts short-term weight loss
when combined with caffeine (about 1 kg/month); no long-term
trials are available.13
In 2002, Health Canada banned the sale of products containing ephedra amid growing concerns that those containing the
caffeine/ephedra combination caused serious cardiovascular
events. The FDA followed suit in the United States in 2004.
After issuing warning statements regarding ephedras
safety, the FDA ruled that recent studies confirmed that ephedra use raises blood pressure and otherwise stresses the circulatory system, effects that have been conclusively linked to
significant and substantial adverse health effects like heart
problems and strokes.14
Bitter orange extract (Citrus aurantium) was used in weightloss supplements before the ban on ephedra, but it became
more widely used after the ban as a substitute ingredient in
ephedra-free products. It contains synephrine, which is similar to ephedrine and may boost metabolic rate while also suppressing appetite.
While the FDA still allows bitter orange to be used in weightloss supplements, there have been concerns that it may be
unsafe in a similar manner as ephedra. A well-known 2006
study tested a single dose of bitter orange on a group of 15
young healthy adults and found that it elevated blood pressure
and heart rate for up to five hours.15
However, other studies using lower doses of the extract
havent found adverse effects on blood pressure and
heart rate. A 2012 review looked at 23 studies involving
360 overweight/obese and normal-weight individuals and
found that bitter orange alone or in combination with other
ingredients didnt appear to raise blood pressure or heart rate
in subjects who consumed it for up to 12 weeks.16 The authors
of the review stressed that studies finding adverse effects
used very high doses.
While it appears from this review that bitter orange likely is
safe to use for up to 12 weeks, it isnt clear whether it leads to
clinically meaningful weight loss. Most studies reviewed in this
paper found no weight-loss difference between the treatment
and placebo groups, and of those who did lose weight, the biggest
difference was 1.4 kg (3.1 lbs) over the course of eight weeks.16
Caffeine is another common stimulant and exists naturally in foods such as coffee, tea, guarana, and yerba
mate, which are ingredients commonly used in weight-loss
supplements. The FDA sets limits on the levels of isolated

caffeine added to soft drinks and alcohol but sets no limit for
dietary supplements, including energy drinks and weightloss supplements.
Caffeine is believed to influence weight loss by increasing energy output and suppressing appetite; however, little
research has been done on caffeines long-term effects on
weight loss. Some evidence suggests that caffeine increases
weight loss when combined with other ingredients. Several
studies have found an impact from caffeine in combination with
other agents, such as ephedra and green tea extract. But concerns remain regarding the safety of these combinations given
the known hazard of the ephedra/caffeine mixture.17
Individuals taking a weight-loss supplement should be
screened for habitual caffeine intake from all sources and cautioned that the combination of the supplement and caffeine
could be dangerous.
Green tea extract commonly is included in weight-loss
formulas either as a source of caffeine or for its catechin
known as epigallocatechin gallate (EGCG). An antioxidant,
EGCG inhibits the breakdown of norepinephrine, which acts
as a hormone and neurotransmitter in the central nervous
system. Maintaining higher circulating norepinephrine
increases both body thermogenesis and fat oxidation and
therefore increases metabolic rate.
Several countries, including France and Spain, have banned
green tea extract because of concerns about hepatoxicity. The
United States evaluated green tea extract but didnt pursue
further action after a 2008 review found that the extract didnt
appear to increase liver damage when used properly.18
In addition to lingering safety concerns, its unclear whether
green tea extract markedly impacts human weight loss. Research
supporting its efficacy primarily comes from animal studies. A
2012 Cochrane review found no statistically significant benefit for
consuming green tea extract for weight loss in humans.19
Appetite Suppressants
Many dietary weight-loss supplements contain ingredients that
boost metabolism and influence appetite at the same time. There
have been a few high-profile supplements on the market in the
past few years that target only appetite, though, and these products often are marketed as safer alternatives for weight loss.
Hoodia is a succulent plant native to southern Africa and a
featured ingredient commonly promoted as suppressing appetite. Of the many types of hoodia, only Hoodia gordonii contains
P57, the active ingredient associated with appetite reduction.
P57 appears to act on the hypothalamus portion of the brain,
increasing adenosine-5-triphosphate (ATP) in nerve cells,
which sends satiety signals that cause individuals to feel as if
theyve just eaten.20
Although advertisements about hoodias purported weightloss benefits also claim that such products cause no side
effects, current research suggests otherwise. There have been
no randomized controlled trials involving humans and only

insufficient data with which to understand dose, duration, and
short- or long-term safety.21 One of the few studies comparing hoodia with a placebo in women found similar amounts of
weight loss, but the group consuming the hoodia reported significantly more nausea and vomiting.22
There also are concerns about potential complications
related to long-term hoodia use. Since hoodia acts on the hypothalamus, which also regulates thirst and body temperature,
its use may lead to dehydration as a result of suppressed thirst.
Other concerns have surfaced regarding the impact of hoodia
on liver function and blood sugar control. No studies are available to determine safety in this regard.
Even if hoodia were safe and effective, production would be
limited based on availability. Hoodia is a rare and protected
plant in most of the countries where it grows, and it takes many
years to mature. Because of the difficulty in obtaining true
Hoodia gordonii (pure plant form), its likely that most products
advertised are counterfeit or contain a nonactive form. Over the
past several years, the FTC has banned several manufacturers
from selling hoodia in the United States because of false claims
that their product contained Hoodia gordonii or a lack of compliance with good manufacturing processes.23
Another appetite suppressant, Sensa, which was created
and marketed by neurologist Alan Hirsch, MD, consists of small
particles called tastants that are sprinkled on food to enhance
the smell. In theory, by enhancing the smell, it will cause individuals to reach satiety earlier.
Hirsch presented his research at the 2008 annual meeting of the National Endocrine Society. Individuals in Hirschs
study lost an average of 30 lbs in six months without changing their diet or lifestyle. This study was never published in a
peer-reviewed journal and hasnt been duplicated by independent researchers. Furthermore, the study presented to the
Endocrine Society involved the use of an inhaled version of the
product and had a select subject population. This group primarily was female (87.4%) and borderline obese. The study group
of 1,436 was compared with a control group of approximately
100 subjects. The trial used a convenience sample and wasnt a
randomized controlled design.24
Sensa is made with both milk and soy, so allergic reactions
may occur in sensitive individuals. Beyond the disclosed allergens, Sensa also contains a natural food dye known as carmine
or natural red 4, which can cause anaphylaxis in susceptible
people. Other more common reactions noted in customer product reviews appearing on Amazon.com include loose and frequent stools, upset stomach, gas, bloating, and dizziness.
Supplements That Change Nutrient

Absorption and Metabolism
While the majority of weight-loss supplements on the
market either boost metabolism or suppress appetite, several
products available are intended to alter the process of nutrient
absorption and/or subsequent metabolism.

Advertised as a fat magnet, chitosan is used to block fat
absorption in the intestine. While theres evidence that this indigestible polysaccharide derived from lobster, crab, and shrimp
shells may block some fat absorption in the gut, it appears that
the amount present in dietary supplements is too low to significantly impact weight. A 2008 Cochrane review found that when
studies of higher quality and longer duration were examined,
chitosan minimally impacted body weight.25
Individuals wishing to try chitosan should be alerted that its
derived from shellfish and can be problematic for those with
allergies. Another potential side effect is gastrointestinal upset
based on nutrient malabsorption. Fat-soluble vitamin absorption also should be assessed in individuals using this product,
since many of the fat-soluble vitamins will pass through the
digestive track bound to fat attached to the chitosan.
Chromium picolinate supposedly promotes weight loss by
altering carbohydrate metabolism. A 2013 review and metaanalysis that looked at 20 human trials found a statistically
significant reduction of body weight in individuals who took
chromium compared with a placebo. However, the authors
questioned its clinical significance given the mere 0.5-kg (1.1lb) difference from the placebo. Moreover, several adverse side
effects were attributed to the chromium supplements, including watery stool, vertigo, headaches, and urticaria (commonly
known as hives).26
Conjugated linoleic acid, a fatty acid commonly found in beef
and dairy, has lipogenesis-suppression properties. It causes
a decrease in the formation of adipose cells and progression
of preadipose cells to mature adipose cells. In addition, it may
decrease appetite by acting on the hypothalamus.
Rodent studies using conjugated linoleic acid have shown
improved body composition with more lean body mass and
less free fat mass. However, a 2010 review found that human
studies dont show similar results. The authors theorized
that dose was the major difference between the animal and
human studies. They also raised a concern that conjugated
linoleic acid increases the amount of free fatty acids in the
blood and could be problematic for individuals who dont burn
the increased fuel provided by the fatty acids for physical
activity, thereby resulting in hyperlipidemia, hyperglycemia,
and lipodystrophy (disturbance of fat metabolism causing fat
to distribute in an abnormal pattern).27
A 2012 review and meta-analysis found that among welldesigned human studies lasting at least six months, there was
no clinically relevant impact on weight lossonly a 1.3-kg
(2.9-lb) additional weight loss in the treatment groupand
body composition.28
Green coffee bean extract comes from raw, unprocessed
green coffee beans and contains the antioxidant chlorogenic
acid, which appears to disrupt the glucose 6 phosphatase
enzyme and reduce the amount of glucose absorbed in the gut.
It gained popularity in 2012 when it was featured on The Dr. Oz
Show. Host Mehmet Oz, MD, had two groups of women either
take a placebo or green coffee bean extract for two weeks. The
group taking the coffee bean extract lost an average of 2 lbs per
person compared with the placebo group, which lost 1 lb.
A 2011 meta-analysis found in three high-quality human
studies that green coffee bean extract had a statistically significant impact on weight loss but only a modest clinical impact:
approximately 2.5 kg (5.5 lbs) over six weeks.29
Safety concerns remain for this supplement based on a
2013 rodent study investigating chlorogenic acid combined
with a high-fat diet. The study found no impact on weight in
mice that took it for 12 weeks, but the mice on a high-fat diet
developed early changes associated with diabetes, including
decreased insulin sensitivity and higher blood sugar levels
between meals.30
Products
In addition to looking at the individual ingredients in dietary
weight-loss supplements, the actual production formulations also may be important because of interactions between
ingredients that change the effect of individual components.
Weight-loss products continually are coming in and out of the
marketplace and often contain ingredients that may interact
and cause problems. Currently, a reformulation of Hydroxycut,
Xenadrine, Zantrex-3, and Herbalife are well-known and widely
available products, but their longevity doesnt necessarily mean
theyre safe. Case reports suggest an association with adverse
side effects for all of these products.
Theres a suggested association between Xenadrine EFX,
which contains caffeine, guarana, and bitter orange, with
headaches, high blood pressure, vasospasm, and stroke.31,32
Twenty case reports between 2003 and 2010 suggest an
association between liver damage and Herbalife.33 One case
report indicates that a woman suffered blurred vision and
seizures after using Zantrex-3 for more than two months; the
product contains caffeine, niacin, and different herbs.34 The
seizures stopped with product discontinuation.
Hydroxycut: A Case Study

One of the best-known, widely advertised and used dietary
weight-loss products on the market is Hydroxycut. Its evolution
provides insight into how the supplement market has adapted
to FDA oversight.
Hydroxycut has undergone two major reformulations in
response to safety concerns. In 2004, Hydroxycut voluntarily
removed its ephedra-containing product from the market when
the FDA announced the ban on ephedra. It introduced an ephedra-free formula almost immediately, which remained on the
market until 2009.
In May 2009, the FDA warned consumers to stop using the
new Hydroxycut formulation because of 23 complaints of liver
injury associated with its use.35 Other reported side effects
included seizures and cardiovascular problems.
In 2010, a case report discussed a 63-year-old woman

who presented with atrial fibrillation symptoms after using
Hydroxycut for two weeks. The ingredient EGCG was cited as
the suspected causative component, which may have blocked a
potassium channel.36
The manufacturer of Hydroxycut voluntarily reformulated
its products again after the 2009 warning. Most of the current
formulas contain a blend of four herbs: Ladys mantle extract
(Alchemilla vulgaris), wild olive extract (Olea europaea), Komijn
extract (Cuminum cyminum), and wild mint extract (Mentha
longifolia). Research on the efficacy of the four-herb blend by
Lovate, the maker of Hydroxycut, found that individuals who
took Hydroxycut in an eight-week trial lost an average of 16.5
lbs compared with those in the placebo group, who lost an average of 2.1 lbs. A similar unpublished study done on Weightlevel,
which contains the same blend of herbs, found similar results.37
Although the new formulations of Hydroxycut appear to be
somewhat effective in inducing weight loss compared with
a placebo, questions remain regarding safety. A 2013 case
report documented a case of ischemic colitis connected with
Hydroxycut use.38
FDA-Approved Prescription Weight-Loss Medications

One reason for the widespread use of over-the-counter
dietary weight-loss supplements may be a lack of prescription
medications. Those that are available are limited in efficacy,
may produce serious side effects, and may be contraindicated
for the individuals who need them most based on medical
comorbidities.
Four FDA approved prescription weight-loss medications are
available: phentermine; phentermine and topiramate extended
release (Qsymia); orlistat (Xenical), and lorcaserin (Belviq).
There also are two others in late-stage trials: liraglutide injection (Victoza) and buproprion/naltrexone (Contrave).
Orlistat is the only obesity medication currently approved by
the FDA for long-term use. Orlistat and its lower-dose overthe-counter version known as alli reduce fat absorption in the
gut by about 25%.39 Studies have shown modest weight loss
with these products but, clinically speaking, its significantly
greater than with placebo. The use of alli resulted in 4.4-kg (9.7lb) vs. 2.1-kg (4.6-lb) weight loss with placebo over six months.
Despite experiencing weight-loss benefits, at least 10%
of those taking orlistat reported adverse effects, including
oily spotting, flatus with discharge, fecal urgency, fatty oily
stool, oily evacuation, flatulence, and soft stools. A smaller
percentage reported abdominal pain, fecal incontinence,
increased defecation, and liquid stools. These effects were
more likely when individuals consumed a higher-fat meal.
Because orlistat also affects the absorption of fat-soluble
vitamins, dietitians will need to discuss its use and address
this problem with any clients using the product.
Phentermine is the oldest FDA-approved weight-loss medication on the market and is approved for short-term use in
patients who are obese.40 Its a stimulant medication similar to

amphetamine and acts as an anorectic by reducing appetite.
Short-term studies show modest effects when used as monotherapy. However, longer-term studies show the body eventually adapts, and the drug loses its effect.41
Phentermine generally is more successful for achieving significant weight loss when combined with other agents. In the
1990s, its popularity increased as one-half of the drug combination known as Fen-Phen. In 1997, fenfluramine, the fen part
of the combination, a metabolism booster, was removed from
the market following 24 reported cases of heart valve problems.42 Despite its continued FDA approval, phentermine has
known side effects and is contraindicated for individuals with
cardiovascular disease.
The newly approved weight-loss medication Qsymia contains a combination of phentermine and the anticonvulsant drug
topiramate (Topamax). The initial clinical trials used to prove
the combinations efficacy found the new drug led to a mean
weight loss of at least 10% of baseline weight, which was sustained for up to two years in more than 50% of subjects.43 Phentermine and topiramate extended release is contraindicated in
individuals with hypothyroid and glaucoma, and should be used
with caution in those with cardiovascular risk factors, as it may
increase heart rate.
Along with phentermine and topiramate extended release,
lorcaserin was approved by the FDA in 2012 for short-term
weight loss.44 It activates the serotonin 2C receptor in the brain,
which induces a feeling of satiety. According to the FDAs report,
approximately 50% of subjects in clinical trials lost up to 5% of
their body weight in 12 weeks. Side effects included issues with
attention, headache, nausea, fatigue, and constipation.
Sibutramine (Meridia) was approved until 2010 when the FDA
removed it from the market because of safety concerns.45 A
literature review suggested that sibutramine increased heart
rate and blood pressure, thus increasing the risk of cardiovascular events. Ceasing production of the drug was controversial because it was effective for modest weight loss, leading to
improvements in insulin resistance, glucose metabolism, and
dyslipidemia.
Supplement Contamination or Mislabeling

While concerns about the safety of the known ingredients
should cause most individuals to question the use of weightloss supplements, a more recent issue regarding the contamination of supplements with prescription medications should be
of even greater concern.
A 2013 study analyzed the composition of nine supplements.
The researchers found that three contained the now banned
weight-loss drug sibutramine, three contained caffeine, and
three contained both caffeine and the antianxiety medication temazepam (Restoril). These products were marketed as
all natural and purely herbal, and these ingredients werent
declared on the label.46
A 2009 study analyzed the active ingredients of a diet supplement purchased over the Internet that led to the death of a
woman in her mid-40s. In addition to prescription weight-loss
medications, the supplement contained prescription diuretics, antiseizure medications, and antidepressants. Some of the
ingredients included phentermine, acetamidophenol, phenobarbital, chlorpheniramine, sibutramine, diazepam (Valium),
mazindol, hydrochlorothizide, fluoxetine (Prozac), and furosemide (Lasix).47 While these medications can benefit certain individuals, consumers must be aware of what ingredients dietary
supplements contain, and their use of these products must be
monitored by a physician.
In Conclusion
Given the rise of obesity, many individuals may experiment with dietary weight-loss supplements for a quick, easy
fix yet are unaware of the associated risks. Unlike medications,
weight-loss supplements are regulated as dietary supplements, a process that doesnt require clinical trials to assess
their efficacy or safety before marketing. The FDA can remove
weight-loss supplements after marketing only when theyre
proven harmful to consumers.
While most dietary weight-loss supplements dont offer
impressive weight-loss benefits, many can cause harmful
side effects, and those most at risk of experiencing adverse
effects may be those who are most inclined to try them based
on their desire to achieve the weight-loss benefits promoted
by the product.
Supplements weight-loss benefits generally are equal to or
less effective than prescription medications and, unlike medications, supplements are poorly monitored by regulatory agencies for purity and consistency of ingredients, making them
more dangerous to consumers.
Given the known side effects of supplements and FDAapproved weight-loss medications, supervision is essential
to protect consumers, as many who take dietary weight-loss
supplements likely arent being monitored by the appropriate
medical professional. Dietitians should work to ensure their clients and patients understand the risks associated with dietary
weight-loss supplements.
Lisa S. Brown, PhD, RD, LDN, is an assistant professor
of nutrition at Simmons College in Boston.
Sarah Churchill, MS, recently completed her
graduate degree in the nutrition and health promotion
program at Simmons College and is a dietetic intern at
Brigham and Womens Hospital in Boston.
For references, a screening form, and a patient handout, view

this article on our website at www.TodaysDietitian.com.
Register or log in on CE.TodaysDietitian.com

to purchase access to complete the online
exam and earn your credit certificate for
2 CPEUs on our CE Learning Library.
CPE Monthly Examination

1. A patient assumes that dietary weight-loss supplements,
6. Weight-loss supplement ingredients can be classified
such as green coffee bean extract, and over-the-counter

medications, including acetaminophen and pseudoephedrine,
are regulated in the same manner. As an RD, how would you
explain the current regulation of supplements?
a. Supplements must go through rigorous animal and
human trials before theyre marketed.
b. Its the manufacturers responsibility to apply for FDA
approval before marketing.
c. The FDA has the power to remove products after
marketing only if the agency can prove the products have
caused serious adverse events.
d. The FDA can remove products after marketing if the
agency can prove the products provide no benefit to the
consumer.
based on their functional mechanism. How would you classify

conjugated linoleic acid?
a. Stimulant
b. Nutrient metabolism changer
c. Appetite suppressant
d. Diuretic
2. The FDA requires which of the following types of
information to be printed on weight-loss supplement labels?

a. A list of active and inactive ingredients as well as the
manufacturers name and address
b. Risks and side effects associated with using the
supplement
c. Date of FDA approval
d. A description of the proper use of the supplement
7. An overweight patient with a soy allergy seeks advice about
using Sensa, a well-known weight-loss supplement intended

to suppress appetite. As an RD, how would you advise this
patient?
a. S
tart using it. Studies show that individuals lost weight
even without altering their lifestyles.
b. Sensa is made with milk and soy, so people with these
allergies should avoid using it.
c. Its safe. Although there are no published trials to date,
theres no evidence regarding adverse reactions.
d. Start using the supplement but monitor whether you
experience any negative side effects.
8. How would you advise a patient looking to take weight-loss
use weight-loss supplements most often?

a. Men
b. Older adults
c. College-educated adults
d. Blacks
supplements containing caffeine?

a. P
eople drink caffeine every day, so these supplements
are safe to use.
b. The FDA sets limits on the amount of caffeine added to
supplements to ensure safety.
c. T
heres extensive research on caffeines long-term
benefits and safety for weight loss.
d. High levels of caffeine combined with other ingredients
can cause adverse effects.
4. Weight-loss supplements use different mechanisms of
9. A patient asks you whether its safe to take a supplement
action in the body to elicit weight loss. Among the different

types, which is the most common class of ingredients in
weight-loss supplements?
a. Stimulants
b. Nutrient metabolism changers
c. Appetite suppressants
d. Diuretics
found on the Internet that claims to be all natural. How would

you advise this patient?
a. T
he FDA strictly regulates the use of the term all
natural, so the product is safe.
b. Prescription medications and other undeclared
ingredients sometimes have been found in certain allnatural products.
c. T
he FDA strictly regulates products sold on the Internet,
so the product is safe.
d. Take the supplement but be alert to negative side effects.
3. Members of which of the following groups of people tend to
5. Certain stimulants, such as ephedra, have been removed
from the market because of health concerns. What is the

major concern associated with this class of ingredients?
a. Dehydration
b. Cardiovascular events
c. Vitamin deficiency
d. Nausea or vomiting
10. Which of the following is the only FDA-approved weight-
loss medication approved for long-term use (more than six

months)?
a. Phentermine
b. Xenical (Orlistat)
c. Phentermine and topiramate extended release (Qsymia)
d. Lorcaserin (Belviq)
For more information, call our continuing education division toll-free at

877-925-CELL (2355) M-F 9 am to 5 pm ET or e-mail CE@gvpub.com.
PERSONAL COMPUTING
OFFICE SUITES
They Can Be a Sweet Deal

By Reid Goldsborough
One of the greatest inventions since the personal computer (PC) is the PC office suite. These software collections
can handle most productivity tasks of a typical small- or homeoffice user or home user.
All major office suites include a word processor, spreadsheet program, and presentation program. Depending on the
suite and the version, it may include other programs such as a
database program, photo editor, desktop publishing program,
diagramming program, and math program. Integrated software for the PC has existed since close to the beginning of PCs,
with Lotus Symphony for DOS, the first popular PC suite, introduced in 1984. Claris AppleWorks for the Apple II computer also
was released that year.
Microsoft began its domination of the office suite market in
1990 with the introduction of Microsoft Office in versions for
Windows and Mac. Today, Microsoft Office remains the leader
by a wide margin.
In recent years, however, Microsoft Offices market strength
has coalesced around large companies that buy in bulk through
site licenses. Microsoft Office today is much like IBM in the past,
for whom the motto You cant go wrong with IBM existed in
the minds of management information systems buyers.
Microsoft Office has a 90% share in the enterprise market,
according to market research firm Gartner. And, according to
market research firm Forrester, only 6% of the companies it
surveyed give employees an alternative to Microsoft Office.
After a long run, Lotus SmartSuite, a successor to Lotus
Symphony, was withdrawn from the market in June 2013.
WordPerfect Office is still around, though barely, with only 1%
of the enterprise market, according to Forrester.
For small- and home-office users, home

users, and students, theres movement toward
other office suites, with LibreOffice and Google
Docs being the most popular alternatives.
Each points to interesting personal computing
trends. LibreOffice is free for all users, Google
Docs for most users.
LibreOffice (www.libreoffice.org) is traditional
software loaded from a computers hard disk.
Its open-source software, meaning that anybody with the programming skills can share in
its development. LibreOffice, the most popular
open-source suite, is available for Microsoft Windows, Mac OS X, and Linux. It consists of a word
processor, spreadsheet program, presentation
program, database management program, drawing program, and math program.
The positives to LibreOffice are its quality
and comprehensiveness, Microsoft Office
compatibility, and free cost. The biggest negative is that its
not 100% Microsoft Office compatible. Complex formatting in
particular can get mangled if a document saved in LibreOffice
is opened in Microsoft Office.
Google Docs (http://docs.google.com) is cloud software
thats accessed through a Web browser when connected to
the Internet. It consists of a word processor, spreadsheet
program, presentation program, drawing program, and forms
program. Its available to users of any Internet platform and
is the most popular cloud office suite. Google Docs is free for
individual and educational users, with fees for business users
starting at $5 per month.
The biggest positives to Google Docs are its portability and
security. You easily can work on documents using different
computers from different locations, and you easily can collaborate on documents in real time with other users. It automatically saves documents to prevent data loss.
The biggest negative is its relatively poor compatibility with
Microsoft Office. Its also not as feature rich as LibreOffice.
Plus, if you cant access the Internet, you cant use the suite.
Apple has an equivalent to LibreOffice, Apple iWork, for
users of its OS X and iOS operating systems, though its not as
robust. Apple recently began offering iWork for free to buyers
of new Apple computers and devices.
Microsoft has an equivalent to Google Docs, Microsoft Office
365, which much like Microsoft Office is relatively expensive.
The charge to enterprises is $20 per user per month.
To determine which office suite is best for you, decide which
one will be the most convenient, will best meet your needs, and
is in line with your budget.
Reid Goldsborough is a syndicated columnist and author of
the book Straight Talk About the Information Superhighway. He can
be reached at reidgoldsborough@gmail.com or reidgold.com.
FOCUS ON FITNESS
exercising during pregnancy include

higher energy and better mood,
enhanced sleep quality, improved
muscular strength and endurance,
better posture, relief from pregnancyassociated back pain, reduced bloating
and swelling, control of gestational
diabetes and pregnancy-related
hypertension, decreased risk of
developing gestational diabetes, and
prevention of excess weight gain and
long-term obesity.
ACOG Guidelines
EXERCISE DURING
PREGNANCY
Use These Current Guidelines

to Counsel Clients
By Jennifer Van Pelt, MA
In the last 10 years, guidelines for exercising while
pregnant have evolved. Previously, medical professionals
had limited pregnant women to walking an easy mile per
day as exercise. Then, low- to moderate-intensity exercise
with a heart rate no higher than 140 beats per minute was
established as a guideline. Older guidelines also indicated that
pregnancy wasnt the time to begin any exercise program.
Within the last five years, as more active women began
continuing higher-intensity exercise during their pregnancies,
the medical and fitness communities responded by advancing
research into the physiology of exercise during pregnancy and
its safety. Today, active women are jogging, swimming, and doing
yoga into their third trimester, and some women are beginning to
exercise regularly for the first time during pregnancy.
However, research published in 2013 in the American Journal of Lifestyle Medicine has revealed that about 85% of pregnant women in the United States dont meet current minimum
exercise guidelines while pregnant despite the proven significant health benefits of daily physical activity for pregnant
women. Excess weight gain during pregnancy and failure to
lose weight in the six months following childbirth contribute
to long-term obesity.
According to the American Congress of Obstetricians and
Gynecologists (ACOG), overall health and fitness benefits to
However, the same factors

that normally make maintaining a
regular exercise regimen difficult,
such as busy schedules, fatigue,
and lack of motivation, also affect
pregnant women, who additionally
must deal with the physical changes
in weight and body shape that affect
balance and coordination and the accompanying feelings
of self-consciousness in public. Nutrition professionals
who work with pregnant women should be prepared to
communicate the many benefits of appropriate exercise
during pregnancy and be knowledgeable of the most current
guidelines and research.
Professional medical and fitness associations have established guidelines for exercise during pregnancy, but the ACOG
should be considered the primary resource. Its guidelines
were issued in 2002 and reaffirmed in 2009; they incorporate
emerging clinical and scientific advances in the understanding of exercise and pregnancy. According to the ACOG, pregnant
women without medical or obstetric complications can follow
exercise recommendations for 30 minutes or more of moderate
exercise daily on most, if not all, days of the week (at least 150
minutes weekly). The ACOG also recommends the following:
a complete health evaluation, including obstetric and
medical risks, for all pregnant women before an
exercise program;
an individual assessment of each physical activity for
potential pregnancy risks; and
avoidance of any activity with a high risk of falling or
abdominal trauma.
The ACOG concluded that recreational and competitive athletes
with uncomplicated pregnancies can remain active but should
modify usual routines as medically indicated. Previously inactive
women and those with medical or obstetric complications should
be evaluated before any exercise recommendations are made.
Physically active women with a history or risk of preterm labor or
fetal growth issues should be advised to reduce exercise activity
in the second and third trimesters.
In 2011, the ACOG released a study detailing exercise intensity and duration, since the 2009 guidelines didnt define moderate intensity. The ACOG guidelines also include detailed
information on contraindications to exercise during pregnancy.
ACSM Guidelines
According to the American College of Sports Medicine
(ACSM), a healthy woman with a normal pregnancy can continue her regular exercise regimen or begin a new exercise
program during pregnancy, with her physician providing guidance on exercise type and duration. The ACSM guidelines
also indicate the following:
Exercises that carry a significant risk of abdominal injury
or fatigue should be modified, and exercising in the prone or
supine positions should be avoided after the first trimester.
Pregnant exercisers should pay special attention to fluid
intake and environmental temperature when exercising to
ensure adequate hydration and avoid heat stress.
Weight-bearing activities that are good choices for pregnant women include walking, jogging, and low-impact aerobics, as long as theyre comfortable for the individual (eg,
jogging may be acceptable for those who ran before pregnancy). Swimming and stationary cycling both are excellent
nonweight-bearing activities to improve maternal fitness;
however, riding a bicycle isnt recommended after the first
trimester due to increased risk of falling associated with
weight and balance changes. Heavy weight lifting and other
activities that require straining as well as exercises involving
air pressure extremes (eg, scuba diving, high-altitude exercise) should be avoided.
Exercise intensity shouldnt exceed prepregnancy levels
and should be moderated based on perceived exertion. Pregnant athletes shouldnt compete, but continuing moderate to
hard exercise intensity is considered safe for women accustomed to intense exercise.
Exercise should be stopped if medical problems or regular
contractions occur after exercise, and a physician should be seen.
For pregnant clients new to exercise, supervised exercise with a trainer or instructor trained in prenatal exercise
is the best option. Many fitness facilities and yoga studios
offer prenatal exercise classes appropriate for beginners to
exercise. For clients with financial or time limitations or who
are self-conscious about exercising in public, many exercise
DVDs are available that follow the ACOG and ACSM pregnancy exercise guidelines.
Post Childbirth
After childbirth, women who wish to exercise should follow
the advice of their physician and gradually ease back into a
routine. Women who were very active exercisers or competitive athletes prepregnancy are at high risk of postpartum injury and complications. Though they may feel ready
to go back to prepregnancy activity levels, jumping back into
RESOURCES
American Congress of Obstetricians and Gynecologists (ACOG) Committee Opinion: Exercise
During Pregnancy and the Postpartum Period
(www.acog.org/Resources_And_Publications/
Committee_Opinions/Committee_on_Obstetric_
Practice/Exercise_During_Pregnancy_and_the_
Postpartum_Period)
ACOG FAQs: Exercise During Pregnancy (www.
acog.org/~/media/For%20Patients/faq119.pdf?dmc
=1&ts=20120219T2315308141)
American College of Sports Medicine Current
Comment: Exercise During Pregnancy
(www.acsm.org/docs/current-comments/
exerciseduringpregnancy.pdf)
Centers for Disease Control and Preventions
Physical Activity: Healthy Pregnant and Postpartum Women (www.cdc.gov/physicalactivity/
everyone/guidelines/pregnancy.html)
Mayo Clinics Pregnancy and Exercise: Baby,
Lets Move! (www.mayoclinic.org/healthyliving/pregnancy-week-by-week/in-depth/
pregnancy-and-exercise/art-20046896)
running, competitions, contact sports, and vigorous workouts

(especially those focused on abdominal muscles) can result
not only in muscular injury and fatigue but also postpartumrelated medical issues such as heavy bleeding, hernia from
exercising with diastasis recti, and genitourinary problems.
Fitness classes and training sessions specifically for new
mothers are more appropriate than returning to advanced
classes too soon.
Other good options are classes designed for both mother
and baby. Mommy and Me yoga classes combine poses for
adults with simultaneous activities for babies; for example, the
mother is in a bridge pose with her baby sitting or lying on the
mothers belly. Strollercize classes combine low-impact aerobic
movements with strengthening exercises, all performed while
pushing a baby in a stroller. Baby Boot Camp and Fit4Mom offer
community classes for pregnant and postpartum mothers.
Joining classes with other pregnant women or new moms
also provides an opportunity for socializing and bonding to help
with the stress associated with pregnancy and having a new baby.
Jennifer Van Pelt, MA, is a certified group fitness
instructor and health care research analyst/
consultant in the Reading, Pennsylvania, area.
GET TO KNOW
According to Rudat, working out of her home allows her to

achieve an optimal work-life balance, making a difference in
the lives of clients while still being around for activities such
as seeing her children to and from the school bus. I love my
one-on-one work with clients and really feeling like I make a
difference at the end of the day, she says.
But, as Rudat explains, motherhood doesnt end where
nutrition counseling begins, as its motherhood itself that
has helped frame her outlook as an RD. I would not be the
dietitian I am today if I hadnt lived through the challenges of
motherhood, she says. My children teach me so much and
keep me humble. Kids arent afraid to point out discrepancies
and are so honest. In fact, each night, at the dinner table when
talking about my day, my 8-year-old twins will often provide
me with great insight and perspective.
APRIL RUDAT
Advocating an Oh Yes You Can! Approach

to Breast-Feeding
By Juliann Schaeffer
Northeastern Pennsylvaniabased dietitian April Rudat,
MSEd, RDN, LDN, started her career in dietetics working with
the clinical side of nutrition and dipping her toes in public
health aspects. But she always wanted to counsel clients in a
more personal setting, and she used her experience of having
twins to help determine where her counseling efforts would
focus. I went on to pursue a masters degree in counseling
while working at a large hospital in several outpatient areas,
gave birth to twins, wrote two books, and then built a private
practice out of my home office, she says.
One of those books, Oh Yes You Can Breastfeed Twins!, is a
practical and educational guide to breast-feeding multiples.
Much of the book is based on the many ups and downs, as well
as questions and confusions, Rudat experienced while breastfeeding her twins (who are now 8 years old). This experience
is a major reason why Rudat is such a big breast-feeding
advocate today. I quickly realized that experience is the best
form of education, she says.
Now she focuses her private practice on eating disorders
and weight management for children, teens, and adults
while finding time to teach three graduate courses at nearby
Marywood University, where shes a campus dietitian.
Todays Dietitian (TD): Who or what inspires you and keeps you
motivated?
Rudat: My clients keep me motivated. If I sense resistance
or have a gut feeling that my client isnt on board with our
collaborative plan, Im motivated to think outside the box and
do something differently. Each time I sit with clients and try
to help them figure out their eating issue, I become more
passionate and more motivated. At times, I feel like a detective
or a scientist, which keeps my motivation alive as well.
TD: In your opinion, whats the most important nutrition
message RDs should be communicating today?
Rudat: Im an advocate for helping a person restore his or her
relationship with food. The media has conflicting messages,
and we live in an environment that promotes disordered eating
behaviors for weight loss. Instead, we should be providing the
public with concise messages related to good nutrition based
on research evidence and help people work toward a healthful
relationship with food.
TD: Youre a big advocate of breast-feeding. Many women
intend to breast-feed but become derailed by any number of
obstacles. What obstacles did you encounter while breastfeeding twins, and how did you overcome them?
Rudat: Early on in my experience breast-feeding twins, I feared
milk supply issues and therefore refused to use formula
despite my premature twins need for quick, extra calories.
To overcome this issue, I nursed on demand, 12 times daily
initially, with feeds sometimes lasting one hour. After daytime
feeds, I pumped for 15 minutes. I felt like a milk machine, but it
was worth it. I was able to exclusively breast-feed my twins for
more than two years.
Confusion was another part of my breast-feeding experience: Do I tandem feed my twins vs. nurse them one at a time?
Am I making enough milk? What is this red bump? Why am I
feeling an itchy sensation?
Any amount of formula you

introduce can interfere with
milk supply. The more satisfied
the baby is from even a little
bit of formula, the less the
baby will demand from the
mother at the breast, thereby
decreasing milk supply.
I quickly realized that experience is the best form of education. I learned nursing my twins one at a time would take up my
entire day and make my nights sleepless, so tandem breastfeeding was the best solution for me. I also learned that as
long as my babies were making plenty of wet and dirty diapers
and growing, that they were getting enough milk from me. I
figured out a red bump can be a sign of a plugged duct, which
can lead to mastitis, and I discovered that rubbing the affected
area in circular motions while in a hot shower can unplug the
duct. Finally, I learned that an itchy sensation while breastfeeding can be a symptom of the fungal infection thrush, which
requires medication for mom and babyor babiesand not
just one prescription for all to share.
TD: If you could offer breast-feeding moms only one piece of
advice, what would it be?
Rudat: Any amount of formula you introduce can interfere with
milk supply. The more satisfied the baby is from even a little bit
of formula, the less the baby will demand from the mother at the
breast, thereby decreasing milk supply. Therefore, whenever
possible, try to get the baby to the breast for nursing on demand.
TD: What about advice for mothers who werent able to
breast-feed as long as they intended and cant get past the
guilt of their decision?
Rudat: Breast is best, and any quantity of breast milk a mother
can provide is great. But not all mothers can breast-feed. Not
all mothers are in a situation to breast-feed. Not all mothers
have the support they need from their families or even the
medical community. And not all mothers are motivated to learn
to breast-feed, and thats OK. Formula is a safe substitute,
and dietetics practitioners shouldnt impart a sense of guilt
to moms who dont breast-feed. As far as a moms personal
guilt for not breast-feeding or not breast-feeding for very
long, its not necessary. She needs to do the best she can in
her situation, and she can provide a positive, loving parenting
experience in many other ways.
My mother, now 62, still feels a sense of guilt for not breastfeeding my siblings and me. However, she did her best with the
knowledge and support she had at the time, and she was the
best mom I could have hoped for, meeting my needs in so many
other ways. Guilt is unnecessary when a mother does the best
she can to love and care for her child.
TD: What are three items you couldnt live without when you
were breast-feeding?
Rudat: I couldnt have survived without my breast-feeding
pillow, my breast pump, and my loveseat, which fit me, my
twins, and my breast-feeding pillow for comfortable feedings.
TD: Whats your preferred form of physical activity?
Rudat: Exercise should be funperiod. If its dreadful, people
cant stick with it. My preferred form of exercise has changed
many times through the years, from walking to fitness classes
to lifting weights to my current routine of running one day and
doing yoga the next.
TD: What activities fill your downtime?
Rudat: In my spare time, I love to take hours to cook an elaborate meal. I love gardening, digging in the dirt with my kids,
and then harvesting and enjoying the bounty. I love biking on
my local rails-to-trails with my husband and children, and my
preferred location would definitely be the beach.
TD: What is the most pertinent nutrition lesson youd like to
pass along to your children?
Rudat: I hope I have already passed along the nutrition lessons
of balanced nutrition, maintaining the philosophy that all foods
can fit into a healthful diet, and intuitive eating based on hunger
and fullness cues. I also hope that I have passed along the
wonderful habit of moving throughout the day and enjoying
daily physical activity vs. being sedentary in front of some kind
of screen or electronic device.
TD: Whats something most people might be surprised to
learn about you?
Rudat: I would love to own a farm. I would love to plant and
harvest enough MyPlate food to nourish my community. I
would love to put fast food out of business and work to get our
food system back to the food system my wonderfully healthy
82-year-old grandmother experienced in her youth: less food
options, less processed food, more food coming from local
farms or your own backyard, more slow food, and more family
time surrounding the meal experience.
Juliann Schaeffer is a freelance writer and editor based in
Alburtis, Pennsylvania, and a frequent contributor
to Todays Dietitian.
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and 12 single-serving lunch and dinner recipes plus a chart
detailing acceptable frozen entres. This frozen-meal option,
which dictates eating two entres at dinner to meet macronutrient targets, as well as some of the dinner recipes, are too
high in sodium for patients restricted to 1,500 mg daily.
A key strength of the book is that it addresses the unique
weight-control challenges of people with diabetes, including
their tendency to lose more muscle mass than other people
as they age. The book emphasizes protein consumption
(20% to 30% of daily calories, patients with renal impairment
excluded) and strength-training exercise to help maintain
lean muscle mass during weight loss. Simple exercises

using resistance bands and hand-held weights are clearly
described and illustrated.
One of the most groundbreaking aspects of the book is the
detailed information on how different diabetes medications
may impact weight-loss efforts so patients can ask their doctor
about substituting weight-loss friendly options. For practitioners, the appendix includes diabetes medication algorithms
meant to guide medication adjustments.
The medication sections alonenot to mention the comprehensive guidance on countless other diabetes topics
likely will make this book a keeper. In addition to self-help
use, The Diabetes Breakthrough could serve as the guidebook
for one-on-one consulting and group weight-loss programs.
Additional supporting resources and videos are included
online at TheDiabetesBreakthrough.com.
Marsha McCulloch, MS, RD, LD, is a nutrition writer
and consultant in South Dakota.
Beyond the Mediterranean Diet:

European Secrets of the Super-Healthy
By Layne Lieberman, MS, RD, CDN
2013, WorldRD
Paperback, 280 pages, $29.95
Layne Lieberman is a self-proclaimed food lover and an

RD with more than 20 years of experience in the supermarket
industry. Her book, Beyond the Mediterranean Diet, is a refreshing read with the overarching message that adopting a healthpromoting lifestyle can be delicious and enjoyable.
Beyond the Mediterranean Diet is divided into three sections.
The first outlines the lifestyle and dietary practices the author
observed in Switzerland, Italy, and Francethree countries
with impressive health statisticsduring her two years as an
expatriate in Europe. This section reviews how cultural foods,
such as chocolate, pasta, and cheese, can be woven into a
healthful eating plan. It was interesting to learn about each
cultures food preferences, its national dietary guidelines, and
myths and facts surrounding each nations food culture.
In the second section, the reader learns how to apply
the Swiss, Italian, and French dietary practices to life in the
United States. Particular emphasis is placed on portion size.
The reader is encouraged to follow Europeans lead and use
Super-Healthy Plates,
or dishes that are 9
inches in diameter, as
well as smaller utensils.
I particularly enjoyed
the segment that outlines principles that
encourage Americans
to change the way they
view food and mealtime
to reflect a more European perspective. This
includes paying more
attention to hunger
cues, turning off electronics and instead socializing during mealtime, and going for
a walk before and after dinner. Its simple advice, but the tips
reinforce the idea that food is meant to be enjoyed. Additional
advice for food shopping and dining out also is provided, with
an emphasis on turning to whole foods and purchasing local,
seasonal foods when possible.
The last section is dedicated to Mediterranean-inspired
recipes that are relatively simple, unintimidating, and made
with wholesome ingredients. I loved creating and tasting the
Bircher Muesli and the Lentils, Roasted Beets, and Tabouleh
Over Arugula.
I truly enjoyed this book. It not only advocates for RDs but
also promotes sustainable habits, overall well-being, and the
importance of enjoying good food.
McKenzie Hall, RD, is a cofounder of NourishRDs, a nutrition
communications and consulting business based in Los Angeles.
Weeknight Wonders: Delicious, Healthy Dinners

in 30 Minutes or Less
By Ellie Krieger, RD
2013, Houghton Mifflin Harcourt
Hardcover, 304 pages, $29.99
RD, Food Network star, and James Beard Awardwinning

cookbook author Ellie Kriegers latest work is full of wonderful
recipes to help families get healthful dinners on the table in
a flash. Not only does Krieger provide great recipes, but she
also offers sound nutrition advice. Her cookbooks arent full
of diet recipes but instead full of recipes using minimally

processed, wholesome ingredients.
Her nutrition philosophy is one that employs her UsuallySometimes-Rarely food lists that were introduced in her book
Small Changes, Big Results. The usually foods include those
that should be used in abundance: vegetables, whole fruits,
beans, nuts and seeds, lean proteins, low-fat dairy, whole
grains, and healthful oils. Sometimes foods are added here
and there for flavor and variety, such as white flour, dark
chocolate, and chicken thighs. Rarely foods include those to
use in moderation: sugar, cream, butter, and full-fat cheese.
The introduction of Weeknight Wonders contains a pantry list of
essentials to have on hand to create the books recipes. In addition, Krieger includes three useful tables that outline cooking
times and instructions for various grains, vegetables, and proteins. The rest of the book is broken up into salads, including
starter, side, and main-course salads; soups and sandwiches;
meat, poultry, seafood, vegetarian, and side dishes; and desserts.
I made several of the dishes in this book for my family,
and they were fantastic. Everyone loved the Taco Pizzas,
which offered a nice variation to the traditional taco. The
Shrimp With Spinach, Garlic, and Smoked Paprika and the
Honey-Mustard Glazed
Salmon With Endive
and Green Apple also
were big hits. Whats
nice about the recipes
is that the home chef
doesnt need to have
every ingredient to
create the dish. For the
ones I made, I often
was missing at least
one ingredient, but the
recipes leave room for,
and inspire, creativity
in cooking.
I can see Weeknight Wonders becoming a highly recommended book in my private practice to clients who ask for
recipe and meal planning guidance. Who isnt looking for delicious, healthful, and fast meals?
Janice H. Dada, MPH, RD, CSSD, CDE, CHES, owns SoCal
Nutrition & Wellness, a private practice and consulting
business in Newport Beach, California.
Shes also a freelance writer and works in education.
NEWS BITES
Most Parents Dont Favor

Bans on Nuts in Schools
Most parents of kids with and without nut allergies dont
support schoolwide bans on nut-containing products,
according to a new University of Michigan C. S. Mott
Childrens Hospital National Poll on Childrens Health.
Schools dont have a single standard for managing
environments for nut-allergic children, and theres no
clear research about which strategy is safest at lunch
or snacktime, says Sarah J. Clark, MPH, associate
director of the National Poll on Childrens Health and an
associate research scientist in the University of Michigan
pediatrics department.
In a poll, parents of elementary schoolaged kids
both with and without nut allergies were asked what they
thought was the best way to handle lunchtime for children
with nut allergies. The most preferred option among
parents of nut-allergic kids was that their children should
eat in a lunchroom with no restrictions on where their
children sit or what other children eat (47%). In contrast,
22% of parents of nut-allergic children thought the best
strategy for their children was a ban on nut-containing
foods in the lunchroom or the school.

For parents of kids without nut
allergies, the most preferred option
was that nut-allergic children eat at a
designated location (a nut-free table)
where nut-containing foods arent
allowed (58% in favor).
Children with allergies to peanuts
or tree nuts must be very careful about
what they eat. These allergies can carry
life-threatening consequences, Clark
says. But the results of this poll show
that parents dont believe theres one
right strategy for keeping nut-allergic
kids safe.
The poll is based on a nationwide
survey of 816 parents of children aged
5 to 12, of which 5% reported their child
has a peanut or tree nut allergy.
Matthew Greenhawt, MD, of the University of Michigan Food Allergy Center,
says the poll shows that parents of unaffected kids also are interested in making
sure nut-allergic children are safe.
These results are reassuring because it
demonstrates parents of unaffected children have empathy and understanding.
That can go a long way toward calming anxiety about sending a food-allergic child to school, he says.
Clark says parents also were asked about their level of
support if their childrens school were to implement different policies for nut-allergic children, with 61% saying
they would support a policy that nut-containing items
arent allowed in classes with a nut-allergic child. These
results provide hope that parents can work together
with the schools to create a safe and mutually agreeable
learning environment for their children, Greenhawt says.
Recent guidelines from the Centers for Disease Control
and Prevention encourage schools to consider the needs
and preferences of nut-allergic children in deciding
whether to designate a nut-free area or restrict nutcontaining products altogether. Greenhawt says this polls
data can help schools struggling with policy questions.
Schools, governments, parents, and doctors who may
be involved in the decisions around school nut policies
shouldnt presume that all parents of nut-allergic children
have the same preferences. Seeking a broad range of
input will help to craft a policy that meets the needs of all
children, he says.
SOURCE: UNIVERSITY OF MICHIGAN HEALTH SYSTEM
Potential Link Found Between Soy Formula and Seizures

A University of Wisconsin-Madison researcher has
detected a higher rate of seizures among children with
autism who were fed infant formula containing soy protein
rather than milk protein.
The study found excess seizures among girls and in the total
sample of 1,949 children. The soy-seizure link reached borderline significance among boys, who comprised 87% of the
children in the Simons Foundation Autism Research Initiative
database. Seizures, caused by uncontrolled electrical currents
in the brain, occur in many neurological disorders, including
epilepsy, Alzheimers disease, Down syndrome, and autism.
Study author Cara Westmark, PhD, a senior scientist in the
universitys neurology department, says her
investigation was sparked by mouse studies of
a drug that, it was hoped, would inhibit seizures
by blocking signals that excite nerve cells. It
was pure serendipity that we happened to look at
soy, she says.
To simplify the mouse study, she replaced the
standard lab chow, which had a variable composition, with a diet containing purified ingredients. Unexpectedly,
that diet reduced the rate of seizures by 50% compared with
standard chow, Westmark says.
We were intrigued that a dietary alteration was as effective
as many medicines in reducing seizure incidence and wanted to
pursue that finding, she says. We found that the main difference
between the diets was the protein source. The standard diet was
soy based, while the purified diet was casein, or dairy based.
The mechanism of action is unknown, but Westmark
points to the high level of plant-derived estrogens in soy
products as a possible cause of the excess seizures.
People eat a lot of soy products, and when Westmark began

to look for the effect in people, she decided to focus on infants,
who may consume nothing but formula. About 25% of infant
formula sold in the United States is based on soy protein.
The vast majority of both groups didnt have seizures. This
isnt saying that all autistic children who eat soy-based formula
are going to develop seizures, Westmark says.
The new study, published in PLOS ONE, showed that children
with autism in the database who were fed soy formula had
2.6 times as many febrile seizures as the children fed nonsoy
formula. That means 4.2% of the soy group had a seizure
associated with a fever compared with 1.6% of the others.
The study wasnt the kind of randomized
clinical trial that can prove causation, according to
Westmark. We can say that we have a potential
association between the use of soy-based formula
and seizures in autistic children; we cant say
that this is cause and effect, she says. We were
fortunate to be granted access to the [Simons
Foundation Autism Research Initiative] database,
but it was not set up to answer the questions we were asking.
Although its possible that seizures also could be more
frequent among children who consume soy formula but dont
have a developmental disability, Theres no data available
at this time to support that, Westmark says. Still, the study
raises concerns, since seizures cause neurological damage
and repeated seizures can develop into a lifelong problem.
This needs to be studied more thoroughly, Westmark
says. If soy formula is lowering the threshold for seizures or
increasing the incidence of seizures, we need to know that.
SOURCE: UNIVERSITY OF WISCONSIN-MADISON
Loyola Teams Up With ProActive Kids to Fight Pediatric Obesity

Loyola University Health System has teamed up with the
ProActive Kids Foundation to help children and their families
in the battle against obesity by offering a free program for
children who have a BMI in the 85th percentile or higher.
The program teaches kids aged 8 to 14 and their family
members fun ways to improve health through exercise,
nutritional lessons, and open discussion. Held for eight
weeks, it provides commitment and support for families
and addresses issues such as fitness, personal health, selfesteem, and body image.
Kids attend a 90-minute program on Mondays and
Wednesdays thats designed just for them. In a safe environment, they can learn how to work out safely, gain confidence
and skills in different athletic outlets, and discuss relationships with food, self-esteem issues, and other personal
struggles. On Fridays, the whole family gets involved. For two

hours, most family members can participate in all components of the program, including learning how to make healthful food choices from a dietitian.
Though every childs experience will be different, ProActiveKids is designed to decrease BMI; develop athletic
skills such as endurance, strength, and flexibility; enhance
self-esteem; improve social behaviors and body image;
and facilitate sustainable positive nutritional behaviors and
decision making.
The program is a community-based, family-centered,
short-term program that can help many families at no cost,
says Garry Sigman, MD, medical director of the Loyola
University Health System Pediatric Weight Management Clinic.
SOURCE: LOYOLA UNIVERSITY HEALTH SYSTEM
PRODUCTS + SERVICES
Nordic Naturals Introduces

Vitamin C Gummies
Nordic Naturals introduces Vitamin
C Gummies, providing 250 mg of vitamin
C per serving. These 100% vegetarian
gummy slices have a tart tangerine
flavor. The product is pectin based and
free of gelatin, artificial colors, artificial flavors,
preservatives, and allergens, including gluten, milk,
eggs, tree nuts, peanuts, and soy.
Vitamin C Gummies dont contain fish oil, so they can
be paired with a Nordic Naturals omega-3 fish oil product.
For more information, visit www.nordicnaturals.com.
Essential Formulas CHIA

OMEGA Line Is NSF Certified
Essential Formulas Incorporateds line of award-winning
CHIA OMEGA formulations recently earned the NSF Certified
for Sport designation from NSF International. These products
comply with the strict standards of NSF/ANSI 173, an American national standard for dietary supplements developed
through a consensus process involving input from regulatory,
industry, sports, and consumer groups.
To earn NSF Certified for Sport certification, the products
were screened for more than 180 banned substances, such as
narcotics, steroids, stimulants, hormones, and other related
substances, along with diuretics and other masking agents.
For more information, visit www.essentialformulas.com.
JTM Products on Forefront

of School Nutrition Trend
JTM Food Group is premiering a line of beef products that incorporates the benefits of mushrooms. The
new products will supplement cafeteria offerings in the
school districts that JTM serves.
The blending of mushrooms with meat provides
schools with a menu solution that expands portion sizes
without adding calories as well as increasing students
vegetable servings. Mushrooms provide more moisture
to fully cooked beef and add nutrients such as vitamin D,
potassium, and antioxidants.
The entire beef with mushroom line is gluten free
and includes various fully cooked preparations, giving
schools the versatility to create many different meals.
For more information, visit www.jtmfoodgroup.com.
Ruby Rockets Frozen Fruit,

Vegetable Pops With Probiotics
Ruby Rockets frozen pops, produced from a blend of organic
fruits and vegetables with probiotics, are a more healthful allnatural snack for summer. Each pop contains only 4 g of naturally occurring sugar and fewer than 35 kcal and is free of dairy,
GMOs, gluten, and high-fructose corn syrup as well as being
vegan and kosher. There also are no artificial colors or flavorings.
The pops are available in three flavors: Galaxy Green, with
kiwis, spinach, avocados, and lemons; Rock-It Red, with strawberries, sweet potatoes, carrots, and beets; and Orbit Orange,
with oranges, sweet potatoes, carrots, and lemons.
For more information, visit www.rubyrockets.com.
Perfect Bar Introduces

Two New Flavors
Perfect Bar (formerly Perfect Foods Bar) has
announced two new flavors, one being its first vegan
bar made with 100% organic ingredients.
Perfect Bars are gluten free, high in protein,
and packed with vitamins; contain 20-plus organic
superfoods; and have an ingredient label thats easy to
pronounce and understand. Plus, theyre sweetened
with honey and contain no refined sugars, artificial
ingredients, or preservatives.
In addition to its five original flavors (Peanut Butter,
Almond Butter, Cranberry Crunch Lite, Carob Chip, and
Fruit and Nut), Perfect Bar recently debuted Vegan Almond
Coconut and Almond Aa Lite.
For more information, visit www.perfectfoodsbar.com.
Healthy Ninja: a High-Fiber,

High-Protein Frozen Treat
Healthy Ninja, a new frozen dessert, has launched its premiere flavor, Strazzleberry (strawberry/raspberry), with more
flavors coming soon.
Healthy Ninja is an all-natural high-performance gourmet ice
cream dessert thats high in protein and fiber with a simple ingredient list: strawberries, water, raspberries, cane sugar, dried milk
powder, dried bean flour, lemon juice, almond paste, chia seeds,
ascorbic acid, guar gum, milk, and tree nuts.
The dessert has 6 g of fiber and combines the power of
beans with chia seeds, which absorb nine times their weight in
water, improving satiety to help with weight management. In
addition, chia prolongs hydration to retain electrolytes during
exercise and exertion. Meanwhile, the strawberries and raspberries provide vitamins and antioxidants.
For more information, visit www.healthyninja.net.
Extend Nutrition Bars Help

Control Blood Sugar
Extend Nutrition offers four products with various
nutrition and health benefits: Extend Bar, Extend Crisps,
Extend Shakes, and Extend Drizzles.
Extend Bar helps people with diabetes maintain a
steady supply of blood glucose to keep levels in healthy
ranges. The low-glycemic formula contains 5 g of uncooked
cornstarch combined with specific amounts of fat, lean
protein, and dietary fiber and is clinically proven to help
control blood sugar for six to nine hours.
In addition, in one study, eating an Extend Nutrition
snack in place of a traditional carbohydrate snack reduced
the number of calories consumed at the next meal by
21% on average. And the same time-release effect helps
improve athletic performance and recovery by providing a
steady glucose supply.
There are gluten-free, kosher, all-natural, lowglycemic, cholesterol-free, high-protein, high-fiber, lowcarbohydrate, and low-sodium options available.
For more information, visit www.extendbar.com.
4AM Glucose Provides

Sustained Glucose Release
4AM Glucose is a product for people with diabetes
taking insulin or medications that cause nocturnal
hypoglycemia. The caplet provides a delayed and
sustained release of glucose.
According to the clinical study by Francine R.
Kaufman, MD, former American Diabetes Association
president, 5 g of raw cornstarch can reduce nocturnal hypoglycemia. Taking digestion efficacy into consideration, 4AM Glucose has 3 g of pure glucose, which
doesnt provide unnecessary calories.
Further, 4AM Glucose delivers glucose only
during the period needed for nighttime low blood
sugar, which is after a few hours of sleep, usually
between 2 and 4 am. Unlike other food products, this
avoids high blood sugar right at bedtime, eliminates
possible morning blood sugar rebounds, and more
accurately targets the time frame when the glucose
is needed.
For more information, visit www.4amglucose.com.
NuGO Protein Bar Lowers Sugar

NuGO STRONGER is a low-sugar, high-protein bar made with
rBGH-free whey, no maltitol or corn syrup, and no soy. Each bar
has 290 to 320 kcal, 25 to 27 g of protein, and 7 to 12 g of fiber, and
is certified gluten free. The bars come in Real Dark Chocolate,
Peanut Cluster, Cookies N Cream, and Caramel Pretzel.
For more information, visit www.nugonutrition.com.
Cooper-Atkins HACCP Manager

Device Now More Secure
Cooper-Atkins has released an HACCP Manager Handheld Device thats more secure. To protect all recorded data,
the login functionality requires users to provide a five-digit
PIN, ensuring the correct username is associated with the
temperature and checklist records collected.
The handheld instrument simplifies both the
recording of food product temperatures and the monitoring of corrective actions in foodservice environments. It features a high level of accuracy (1F) and
an extended temperature range up to 999.9F, stores
as many as 3,000 temperatures, and allows for 1,500
checklist records. A durable rubber boot protects the
water-resistant handheld device and includes a side
storage slot to safely contain thermocouple probes
while not in use.
For more information, visit www.cooper-atkins.com.
Empowered Premium Nutrition

to Fulfill Womens Needs
Empowered Premium Nutrition, in partnership with the
Susan G. Komen Foundation, has developed a product line
formulated specifically for womens immunity and functional
health with a whole-body nutrition and wellness approach. This
gluten-free line has protein powders, supplements and, in the
future, nutrition bars.
The protein meal replacement powder ensures adequate
protein intake. It currently comes in three flavors: I Dream of
Chocolate, Vanilla Vacation, and Berry Good for U. All products are low in lactose and free of artificial flavors, colors, or
sweeteners. Each 150-kcal serving contains 19 g of protein, 1 g
of fat, the probiotic GanedenBC30 to support digestive health,
vitamins, minerals, and antioxidants.
The two supplements are Internal Defense-Antioxidant and
Immune Pro-Probiotic for digestive health.
Nine percent of the sale proceeds from Empowered protein
powders and nutrition bars will go to the Susan G. Komen Foundation to fight breast cancer.
For more information, visit www.empwru.com.
RESEARCH BRIEF
RISING CO2 POSES SIGNIFICANT

THREAT TO HUMAN NUTRITION
At the elevated levels of atmospheric carbon dioxide anticipated by
around 2050, crops that provide a large share of the global population
with most of their dietary zinc and iron will have significantly reduced
concentrations of those nutrients, according to a new study led by the
Harvard School of Public Health. Given that an estimated 2 billion people
suffer from zinc and iron deficiencies, resulting in an annual loss of 63
million life years because of malnutrition, the reduction in these nutrients represents the most significant health threat ever shown to be
associated with climate change.
This study is the first to resolve the question of whether rising CO2
concentrations, which have been increasing steadily since the Industrial Revolution, threaten human nutrition, says Samuel Myers, MD, a
research scientist in the department of environmental health and the
studys lead author. The study appears online in Nature.
Some previous studies of crops grown in greenhouses and chambers
at elevated carbon dioxide levels had found nutrient reductions, but
those studies were criticized for using artificial growing conditions.
Experiments using free air carbon dioxide enrichment (FACE) technology
became the gold standard, as FACE allowed plants to be grown in open
fields at elevated levels of carbon dioxide, but those prior studies had
small sample sizes and were inconclusive.
The researchers analyzed data involving 41 cultivars (genotypes) of
grains and legumes from the C3 and C4 functional groups (plants that
use C3 and C4 carbon fixation) from seven different FACE locations
in Japan, Australia, and the United States. The level of carbon dioxide
across all seven sites was in the range of 546 to 586 parts per million.
The researchers tested

the nutrient concentrations of
the edible portions of wheat
and rice (C3 grains), maize
and sorghum (C4 grains), and
soybeans and field peas (C3
legumes). The results showed
a significant decrease in the
concentrations of zinc, iron,
and protein in C3 grains. For
example, zinc, iron, and protein concentrations in wheat
grains grown at the FACE sites
were reduced by 9.3%, 5.1%,
and 6.3%, respectively, compared with wheat grown at
ambient carbon dioxide levels.
Zinc and iron also were significantly reduced in legumes;
protein wasnt.
The finding that C3 grains
and legumes lost iron and
zinc at elevated carbon dioxide levels is significant. Myers and his colleagues
estimate that 2 billion to 3 billion people around the
world receive 70% or more of their dietary zinc and/
or iron from C3 crops, particularly in the developing world, where zinc and iron deficiency already is
a major health concern.
C4 crops appeared to be less affected by higher
carbon dioxide levels, which is consistent with underlying plant physiology, as C4 plants concentrate
carbon dioxide inside the cell for photosynthesis, so
they may be expected to be less sensitive to extracellular changes in carbon dioxide concentration.
The researchers were surprised to find that zinc
and iron varied substantially across cultivars of rice.
That finding suggests that there could be an opportunity to breed reduced sensitivity to the effect of elevated carbon dioxide into crop cultivars in the future.
In addition to efforts to reduce carbon dioxide
emissions, breeding cultivars with reduced sensitivity
to the gas, biofortification of crops with iron and zinc,
and nutritional supplementation for populations most
impacted could play a role in reducing the human
health impacts of these changes, Myers says.
Humanity is conducting a global experiment by
rapidly altering the environmental conditions on the
only habitable planet we know, he says. As this
experiment unfolds, there will undoubtedly be many
surprises. Finding out that rising CO2 threatens
human nutrition is one such surprise.
SOURCE: HARVARD SCHOOL OF PUBLIC HEALTH
DATEBOOK
JULY 8-12, 2014
AUGUST 13-17, 2014
NOVEMBER 5-6, 2014
NATIONAL ASSOCIATION OF COLLEGE

& UNIVERSITY FOOD SERVICES
NATIONAL CONFERENCE
Baltimore, Maryland
www.nacufs.org
IDEA WORLD FITNESS CONVENTION

Anaheim, California
www.ideafit.com
IOWA ACADEMY OF NUTRITION

AND DIETETICS ANNUAL MEETING
West Des Moines, Iowa
www.eatrightiowa.org
JULY 9-12, 2014
NATIONAL STRENGTH AND

CONDITIONING ASSOCIATION
37TH ANNUAL NATIONAL
CONFERENCE AND EXHIBITION
Las Vegas, Nevada
www.nsca.com
JULY 13-16, 2014
FLORIDA ACADEMY OF NUTRITION AND

DIETETICS 79TH ANNUAL SYMPOSIUM
Fort Lauderdale, Florida
www.eatrightflorida.org
JULY 13-16, 2014
SCHOOL NUTRITION ASSOCIATION

ANNUAL NATIONAL CONFERENCE
Boston, Massachusetts
www.schoolnutrition.org
JULY 23-26, 2014
SEPTEMBER 2-5, 2014
14TH INTERNATIONAL NUTRITION

& DIAGNOSTICS CONFERENCE
Prague, Czech Republic
www.indc.cz/en
AMERICAN DIABETES
ASSOCIATION DIABETES EXPO
Minneapolis, Minnesota
www.diabetes.org
FOOD DAY
A nationwide celebration and
movement for healthful, affordable,
and sustainable food
www.foodday.org
ASSOCIATION OF CORRECTIONAL
FOOD SERVICE AFFILIATES ANNUAL
INTERNATIONAL CONFERENCE
St Louis, Missouri
www.acfsa.org
Call 610.948.9500
Fax 610.948.7202
E-mail TDeditor@gvpub.com
Send Write with your listing two months
before publication of issue.
EMPLOYMENT OPPORTUNITY
Working Together To Achieve Excellent Health
A place to learn.
A place to be.
AMERICAN DIABETES ASSOCIATION

DIABETES EXPO
Houston, Texas
www.diabetes.org
AUGUST 10-14, 2014
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.
OCTOBER 24, 2014
JULY 26, 2014
AMERICAN ASSOCIATION
OF DIABETES EDUCATORS
ANNUAL MEETING
Orlando, Florida
www.diabeteseducator.org
AMERICAN DIABETES ASSOCIATION

DIABETES EXPO
Pittsburgh, Pennsylvania
www.diabetes.org
OCTOBER 11, 2014
INTERNATIONAL LACTATION
CONSULTANT ASSOCIATION
ANNUAL CONFERENCE
Phoenix, Arizona
www.ilca.org
AUGUST 6-9, 2014
NOVEMBER 8, 2014
Through native self-determination and culturally-relevant health systems, we strive

to be the healthiest people. By serving 28,000 patients over a vast 75,000 square
miles, help us continue this legacy while preserving tradition with sensitivity to our
heritage. Join us and enrich your own career and life experiences.
Currently seeking qualified Nurses, Pharmacists and Dieticians for our Diabetes
Prevention and Control Program. Current openings include Diabetes Prevention and
Control Coordinator, Clinical Diabetes Educators, Diabetes Pharmacists and RN Case
Managers. For more information, please contact us or visit our websites today!
YUKON-KUSKOKWIM HEALTH CORPORATION

Headquartered in Bethel, Alaska
www.ykhc.org
(800) 478-8905
www.ykhcjobs.org
CULINARY CORNER
OCTOPUS
was surprised to notice it was an entire octopus, weighing close to

2 lbs. It was flecked with bits of char from the grill and sprinkled
with the same coarse salt as the steak. The plate was flooded with
bright green olive oil with a few just-tender garlic cloves floating
like islands. There also were several potatoes scattered about,
which seemed to absorb the flavors of everything at once. The
octopus was supremely tender and slightly smoky, the narrow
tips of the tentacles crispy from the intense heat of the grill.
This was, perhaps, one of the single best meals Id encountered anywhere. Such a simple dish, done perfectly, had left me
stunned. Perhaps even more stunning that night was my newfound respect for Paulas restaurant picks. Redemption in the
form of grilled octopus? How often does that happen?
Bryan Roof, RD, LDN, is a chef, dietitian, and food writer
living in Boston. Follow him on Twitter @bryanroof.
Simply Grilled to Perfection

By Bryan Roof, RD, LDN
My wife and I had finally broken free. We were alonewithout
kidsand together in Portugal for the first time. I was excited
about exploring Lisbon and mingling with the people, who I was
assured were some of the loveliest on the planet. But I was
especially excited about the food. After all, one of my in-laws
great motivators for watching the kids for five nights was hearing my assessment of the cuisine. That, and I think they love
their grandkids, but theres no way to know for sure.
Our hostess, Paula, was only slightly odd, but slightly more
genuine, and seemed excited about showing us around, despite
not having slept the last 24 hours due to her medical residency.
We shoved off from the airport midmorning to see the sights.
As lunch approached, we walked passed numerous quaintlooking restaurants, some with locals fisting wine and singing
at the bar (always a good sign), as she whet our appetites with
stories of salt cod and heady beef stews. However, when reality
set in and we stopped walking, I found myself at a university
cafeteria lunching on Swedish meatballs, rice pilaf, boiled
carrots and, I think, rice pudding. I had subtle suspicions that
this wasnt entirely Portuguese cuisine.
Needless to say, my expectations for dinner were depressingly
low. That evening, on a narrow downtown side street, among a
row of tan stucco faades, we approached a door. The barely visible plaque to the right read Gravatas. The dcor inside made it
obvious that gravatas meant necktie, and there were as many of
these hanging from the rafters as fish off the Portuguese coastline. Several refrigerated display cases housed two of Portugals
most prized offerings: grass-fed beef and fresh seafood.
The kitchen work seemed to spill into the dining room, and
meat and fish were being butchered in plain sight. The restaurants signature dish, if there was one, was a large slab of raw
steak sprinkled with coarse salt and served on a piping hot stone
that cooked the steak as you ate it, leaving each diner responsible
for flipping his or her own steak occasionally for even cooking.
But I was in Portugal for the seafood more so than the beef,
so, on Paulas insistence, I ordered the grilled octopus. The service was slow but comfortable. When my octopus finally arrived, I
Grilled Octopus
If buying frozen octopus, try to buy those from Spain
or Portugal.
Serves 6
Ingredients
4 cup extra-virgin olive oil
10 garlic cloves, peeled
1
4 tsp red chili flakes
One (5-lb) octopus, beak removed, rinsed
Coarse sea salt and black pepper
1
Directions
1. Adjust the oven rack to the lower-middle position and heat
the oven to 300F. Combine the oil, garlic, and chili flakes in a
Dutch oven or large pot. Warm the oil mixture over mediumlow heat until the garlic is golden, five to 10 minutes.
2. Blot the octopus dry with paper towels and add to the
pot, head side up. Cover, and transfer the pot to the oven.
Bake until a paring knife inserted into the thickest part of
the tentacles meets little to no resistance, about 112 hours,
depending on the size of the octopus. (The octopus will shrink
considerably during cooking.) Remove the pot from the oven
and let the octopus cool in the lidded pot for about 30 minutes.
3. Meanwhile, prepare a medium-hot fire on a charcoal grill.
Transfer the octopus to a large plate, spoon some of the
oil mixture from the pot over top, and season with salt and
pepper. Grill the octopus, turning frequently, until charred
in spots and evenly colored, about 10 minutes. Remove to a
plate, and let the octopus rest for 10 minutes. Remove the
tentacles and serve either whole or cut into pieces, with
some of the remaining oil mixture spooned over top.
Nutrient Analysis per serving

Calories: 300; Total fat: 8 g; Sat fat: 1.5 g; Trans fat: 0 g;
Cholesterol: 145 mg; Sodium: 700 mg; Total carbohydrate:
8 g; Dietary fiber: 0 g; Sugar: 0 g; Protein: 45 g
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Today's Dietitian June 2014

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Athletes and Protein Intake Experts weigh in on whether

Nourishing Kids in the Summer Learn how five school

The Lowdown on Dairy Heres a review of the latest evidence

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Men in Dietetics While women dominate the nutrition

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CPE Monthly: Dietary Weight-Loss SupplementsThis