Pages 3

CONFERENCE ISSUE
Vol. 16 No. 7
July 2014
The Magazine for Nutrition Professionals
Substituting Palm Oil

for Trans Fat
Is Palm Oil a Good Alternative
for Human Health
and the Environment?
Spring
Symposi
um
Highligh
ts
Diabetes and
Cardiovascular Damage
Tips for Adding More
Veggies at Breakfast
RDs Debate the FDAs
Proposed Nutrition
Facts Label
www.TodaysDietitian.com
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Power the Day with Daisy

DISCOVER THE BENEFITS THAT COME WITH NUTR ITION AND TASTE .
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Encourage your patients and clients to make the

most of their protein consumption. Studies show
that consuming 20 to 30 grams of protein at each
mealinstead of one large meal high in protein
can maximize muscle synthesis, which is critical
for everyone.1
Stay On Track
Research suggests that when people eat

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fat. 2,3 Part of this means starting the day with
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Cottage cheese is so convenient and versatile;

you can enjoy it for breakfast, lunch, dinner or a
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References:
1. Leidy HJ, Armstrong CL, Tang M, Mattes RD, Campbell WW: The influence of higher protein intake and greater eating frequency on appetite control in overweight and obese men. Obesity (Silver Spring) 2010, 18:17251732.
2. Purslow LR, et al. Energy intake at breakfast and weight change: Prospective study of 6,764 middle-aged men and women. American Journal of Epidemiology. 2008;167:188
3. Kant AK, et al. Association of breakfast energy density with diet quality and body mass index in American adults: National Health and Nutrition Examination Surveys, 1999-2004. American Journal of Clinical Nutrition. 2008;88:1396.
EDITORS SPOT
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
Graphic Designer Erin Prosini
Junior Graphic Designer Victoria Tuturice
ADMINISTRATION
Administrative Manager Helen Bommarito
Administrative Assistants Pat Plumley, Susan Yanulevich
Executive Assistant Matt Czermanski
Systems Manager Jeff Czermanski
Systems Consultant Mike Davey
FINANCE
Director of Finance Jeff Czermanski
CONTINUING EDUCATION
Director of Continuing Education Jack Graham
Continuing Education Editor Kate Jackson
Continuing Education Coordinator Leara Angello
Continuing Education Assistant Susan Graver
CIRCULATION
Circulation Manager Nicole Hunchar
MARKETING AND ADVERTISING
Publisher Mara E. Honicker
Director of Marketing and Digital Media Jason Frenchman
Web Designer/Marketing Assistant Jessica McGurk
Marketing Coordinator Leara Angello
Sales Manager Brian Ohl
Associate Sales Manager Peter J. Burke
Senior Account Executives Sue Aldinger, Gigi Grillot,
Diana Kempster, Beth VanOstenbridge
Account Executives Victor Ciervo, Dan Healey, Patricia McLaughlin
Sales Coordinator Joe Reilly
2014 Great Valley Publishing Company, Inc.

Phone: 610-948-9500 Fax: 610-948-7202
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All articles contained in Todays Dietitian, including letters to
the editor, reviews, and editorials, represent the opinions of the authors,
not those of Great Valley Publishing Company, Inc. or any organizations
with which the authors may be affiliated. Great Valley Publishing
Company, Inc., its editors, and its editorial advisors do not assume
responsibility for opinions expressed by the authors or individuals quoted
in the magazine, for the accuracy of material submitted by the authors, or
for any injury to persons or property resulting from reference to ideas or
products discussed in the editorial copy or the advertisements.
SUSTAINABLE
HOSPITAL FOOD
Earlier this year, I sat in on a roundtable
discussion about innovative, sustainable
foodservice programs in hospitals, led by
the Healthier Hospital Initiative (HHI), an
organization that provides hospitals with
free tools and resources to serve healthful
food options and develop sustainable food
systems that will benefit patients, staff, the community, and
the environment. While some hospitals continue to serve
processed foods that contain preservatives and are high
in fat, sodium, and sugar, several others are making great
strides and leading the way toward establishing healthier,
more sustainable foodservice systems.
Some of the biggest players driving sustainable foodservice across the health care industry participated in the
roundtable, including Kaiser Permanente, Stanford Hospital &
Clinics, and Inova Health System. These hospitals are developing healthier menus, banning sugar-laden beverages, and
working with local farmers to purchase sustainably grown
produce. Theyre also reclaiming city lots for organic farming, reducing the amount of meat they purchase and serve,
buying more fair trade and organic products, growing their
own food in greenhouses on site, and creating more energy
efficient kitchens.
These are major steps forward for the health care industry,
considering that in the recent past staff members and visitors
often were hard pressed to find a single low-fat, cholesterolfree entre in their hospital cafeterias. Youd think that the
very institutions providing health care and treating and
managing disease would have served healthful foods in
their cafeterias from their inception. Nonetheless the tide
has turned, and Todays Dietitian has reported on the latest
developments in the feature article Sustainable Hospital
Foodservice on page 34.
Also in this issue are articles on the association between
diabetes and heart disease caused by oxidative stress, the
pending FDA food labeling proposal, and whether wed be
better off substituting palm oil for trans fat in the food supply.
Tell us what you think about these articles on our Facebook
and Twitter pages, and enjoy the rest of the issue!
Judy
Judith Riddle
Editor
TDeditor@gvpub.com
july 2014 www.todaysdietitian.com 5
CONTENTS
40
JULY 2014
12
FEATURES
DEPARTMENTS
20
Substituting Palm Oil for Trans Fat The FDAs proposal to
Editors Spot
ban trans fat has increased demand for palm oil, but is palm oil a
good alternative for human health and the environment?
Reader Feedback
News Bites
oxidative stress and whether antioxidants may play a role in

protecting cardiovascular health.
10
Ask the Expert
12
Allergy & Intolerance Awareness
Todays Dietitians Spring Symposium

A Spectacular Extravaganza Attendees raved about the
16
Digestive Wellness
18
Omega Fats
56
Focus on Fitness
58
Get to Know
60
Bookshelf
62
Products +Services
65
Datebook
66
Culinary Corner
24
28
Diabetes and Cardiovascular Damage Experts discuss
conference, calling it a huge sucess.
34
Sustainable Hospital Foodservice Todays Dietitian proles

the top health systems in the country that are driving change.
40
Veggies at Breakfast The most important meal of the day

provides clients and patients with the perfect opportunity to eat
more vegetables and meet dietary requirements.
44
The Nutrition Facts Label Dietitians speak out about the

FDAs proposed changes, what more should be done, and how the
updates will impact public health.
48
CPE Monthly: Vitamin Ds Role in Health This course

discusses the nutrients functions in the body and how to assess
appropriate blood levels according to the latest research.
Page 48
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$95 per year; Single issue: $5. Todays Dietitian Volume 16, Number 7.
READER FEEDBACK
Letter to the Editor

I loved the article Dietitians and Their
Weight Struggles that was published
in the May issue of Todays Dietitian. Its
good to bring up the issue of weight, raise
awareness, and encourage tolerance
among others and ourselves no matter
what our size. Thank you!
National Celiac Disease Awareness Month

Vol. 16 No. 5
Mayy 2014
From Our Twitter Page
The
Th
e Magazine
Magazine ffor
or Nutrition
Nutrition Professionals
SILENT
CELIAC DISEASE
Atypical Signs and Symptoms
Often Delay Proper Diagnosis
and Treatment
Popular Tweets, Retweets
INSIDE
Gluten-Free
Resource
Guide
Spring Symposium Issue
Experts Decipher
the Farm Bills Impact
Can Overweight RDs
Still Be Effective?
RDs speak out

about whether
they can be
effective nutrition
counselors
when theyre
overweight.
Elaine Mazgelis, RD, LDN, IBCLC

Cambridge-Somerville WIC, Massachusetts
Dietitians
and their
Weight Struggles
By JULIANN SCHAEFFER
32 todays dietitian may 2014
From Our Facebook Wall
n a culture that places so much emphasis on physical

appearance, and weight in particular, its no surprise that
many people have a love-hate relationship with the size of
their bodies. A clients weight loss one week can lead to
sheer jubilation, followed by extreme guilt and shame after
he or she falls off the diet wagon soon after.
Many RDs can relate to their clients weight struggles through
their own past experiences. But what happens when a dietitians
weight issues arent a thing of the past? Can dietitians who have
been trained in diet and nutrition be effective nutrition counselors if they still battle with weight themselves? And how much (or
how little) weight denotes such a struggle anyway?
Its a hot-button issue, one about which many RDs are passionate. But this dietitian weight debate has many sidesand,
for some, the issue really isnt about weight at all.
Weight Matters (or Does It?)

When it comes to the size of a dietitians body, does weight
matter? According to Susan Linke, MBA, MS, RD, LD, CLT, a
Texas-based dietitian who works primarily with patients who
have food sensitivities, this answer depends on the type of
advice an RD is giving clients.
For dietitians offering total parenteral nutrition guidance
or designing menus in a hospital ofce, Linke says people are
looking for specialized expertise in these cases, and weight
may not matter. But when clients are seeking advice on healthful eating or weight management, then theyre looking for role
models, she says, and weight absolutely is an issueand an
RDs image is important.
People do judge by appearance, and we are walking billboards, Linke says. If someone has a weight issue, then in my
opinion, they should choose a specialty that does not conict
with being overweight.
With the level of competition in the marketplace, Linke
believes its even more important for RDs to compete using
appearance as well as knowledge. If you cant make it work
for you, how can you make the case for someone else? she
says. Ive seen others counter this by saying that people need
to learn to look beyond the physical, but the reality is that health
care is a business, and people do judge you by appearance. Is it
right or wrong? That doesnt make a difference. Its a business,
and it is what it is whether we like it or not.
But a patients judgment, often based on unrealistic cultural expectations, doesnt take away from a dietitians knowledge base, says Jessica Wilson, MS, RD, owner of My Kitchen
Dietitian and PR/social media chair for the Association for Size
Diversity and Health, an international organization that promotes Health at Every Size principles. According to the organizations website, its mission is to promote education, research,
and the provision of services which enhance health and wellbeing, and which are free from weight-based assumptions and
weight discrimination. Health is measured by many factors,
including the right to be peaceful in ones body.
It may matter to the patient because of this countrys preoccupation with getting rid of fat people and negative media
images of people in fatter bodies, Wilson says. But I do not
believe that the RDs weight impacts their ability or knowledge. I dont see how the presentation of someones body would
detract from their knowledge. Do shorter RDs know more than
taller ones? Does skin tone play a role in knowledge?
RDs as Role Models

Yet whether its a dietitian or a cardiologist, Linke says
appearance matters because clients are using that
information in part to choose the health care professional
they believe is most likely to help themand shed do the
same. I wouldnt think much of advice from a cardiologist if
I knew he had had a heart attack, she says. Yes, genetics
might play a role, but Id rather listen to one thats t and has
good cardiovascular health.
People have choices, Linke adds. If given the choice
between someone that practices what they preach and
someone that seemingly doesnt, the public will usually
choose to get advice from someone thats practicing what
they preach. If it doesnt work for the practitioner, how will it
work for the patient?
Lisa Ellis, MS, RD, CDN, a New York-based dietitian, agrees
that as role models, how RDs present themselves is important.
Advice on regulating eating disorders coming from someone
who even appears to be at the mercy of his or her own eating
disorder may lack credibility, even if that advice was sound,
she says. On the other hand, an RD need not have a perfect
physique, just one that appears healthy.
Weight standards should be irrelevant so long as the RD is
healthy, both physically and attitudinally, Ellis continues. RDs,
like many professionals, stake the vitality of their businesses
on their client pools. An RD who appears to be unhealthy may
seem to be a less-than-credible health care professional to clients and may not keep those clients very long. This is likely a
case of the market determining its own standards.
But what does it truly mean to practice what you preach, and
what does healthy even look like? According to Sharon Salomon,
MS, RD, a dietitian who previously wrote the article Confessions of a Fat Dietitian for Todays Dietitian, this phrase brings
up more questions than answers, and she notes that anyone
(RD or client) would be hard-pressed to determine the healthfulness of her daily habits simply by looking at her.
Practice what they preach? she says. You mean eat
healthy foods? Does eating broccoli mean that youre going
to be thin? And are all thin people healthy? What is a healthy
weight? Is it weight, BMI, or waist circumference? Is it having
good cholesterol levels, low triglycerides, a strong heart,
regardless of weight? And how do you know that I do or do not
practice what I preach? You cannot tell by looking at me.
We cannot make assumptions about peoples lifestyles and
behaviors based on what they look like, Wilson says, noting
may 2014 www.todaysdietitian.com 33
May Issue
Easy Ways to Sneak in More Fruits and Veggies
Dietitians and Their Weight Struggles
www.huffingtonpost.com
@GinaMonkRD: Happiness and health are more

important than weight! Dietitians arent diet
enforcers, and weight is rarely the real problem. I
wish it was understood that real dietitians dont put
people on diets but focus on healthier habits and
exercise instead.
Monica Hoffman Fintel: Really nice way to encourage

clients they can eat more veggies and fruit! Love the
concrete advice, not just eat more.
Fed Up Asks, Are All Calories Equal?
www.nytimes.com
Caleb Frazier: I havent seen it yet and Im sure it

makes some excellent points, but if the focal point
of the film is that sugar is the sole ingredient that
ails us and reduction of sugar alone is the panacea for obesity, it may be misguided. Most everyone
does consume too much sugar, but processed foods
with added sugar often contain additional added
oils, added salt, and may be produced with refined
starch. Americans also consume an excess of lowquality and high-fat factory-farmed meat and dairy
products and not nearly enough unprocessed whole
foods: vegetables, fruits, beans, intact whole grains.
Id be interested to see if the film addresses any of
these issues as well.
Melissa Mitri: Im happy to see a movie on nutrition
and our food supply, which is being given so much
press and attention. Based on what I know about the
film thus far, it does seem to heavily blame added
sugars for the obesity epidemic. While this is part of
the problem since it isnt easy for consumers to spot
these foods laden with sugar all the time, I dont
think just sugar is to blame at all. And recommending that we take the Fed Up Challenge for 10 days
by limiting sugars may give a false sense that this is
the solution to the epidemic.
@MEuzarraga: The dietitian weight struggle article

was an eye opener. Great read! I think as a society
health needs to be redefined.
@Uleary: Compassion to help and educate others
shouldnt be judged on how you look.
@morethanfoodinc: The conversation changes when
you substitute health for weight. Then the answer is
always yes!
@eatingpermitRD: Weight stigma alive and well,
especially in our profession. We have the power to
change it!
@wholify: Very important discussion about weight and
dietitians in Todays Dietitian.
@BVMRD: You bet I can be an effective counselor. My
weight says nothing about my ability as a dietitian.
Benefits of Physical Activity (Dynamics of Diabetes)

@lilfitbirdie: Physical activity is the most effective tool
without side effects for diabetes managementand
its cost-effective too!
Getting Beginners in Shape for Summer

(Focus on Fitness)
@MelissaTraubRD: Great tips to help prevent injuries
and help people become more active consistently!
NEWS BITES
Vitamin D Provides Little

Benefit in Asthma Treatment
Adding vitamin D to asthma treatment to improve breathing appears to benefit only patients who achieve sufficient
blood levels of the supplement. Overall, the ability to control asthma didnt differ between a study group that received
vitamin D supplements and a group that received placebo,
according to new research at Washington University School of
Medicine in St Louis.
Previous studies suggested that if you have asthma and
low levels of vitamin D in the blood, you have worse lung
function, more asthma attacks, and more emergency room
visits than asthma patients with higher vitamin D levels,
says Mario Castro, MD, MPH, the Alan A. and Edith L. Wolff
Professor of Pulmonary and Critical Care Medicine. This is
the first randomized controlled trial to investigate whether
taking vitamin D supplements can improve asthma control.
Low levels of vitamin D may play a role in many medical
problems. In this clinical trial, the investigators studied 408
adult patients at nine major US medical centers. All patients
had a diagnosis of mild to moderate asthma, and all had
whats considered deficient blood levels of vitamin D, with
an average of 18 ng/mL. Measures below 30 are considered
abnormal. All patients took an inhaled steroid daily to control
their asthma, and they had rescue inhalers in the event of an
asthma attack.
The patients were randomly assigned to one of two groups.
The treatment group received a loading dose of 100,000 IU of
vitamin D3 followed by daily doses of 4,000 IU, and the placebo
group received identical looking but inactive capsules.
The investigators found no differences between the two
groups in all major measures of asthma control. The groups
showed no significant differences in the number of treatment
failures requiring patients to take more medication, in the
8 todays dietitian july 2014
number of asthma attacks, and in their need for emergency

care. Patients taking vitamin D didnt report improved quality
of life, based on questionnaires.
One way the groups differed, however, was in how successfully they were able to reduce their daily dosages of inhaled
steroids. After the studys first 12 weeks, if the patients
asthma was well controlled, the investigators cut down
one-half the daily dose of inhaled steroid, reducing it from
320 mcg/day to 160. After eight more weeks, if the disease
remained controlled, they cut the dose to one-half again. While
both groups were able to taper off their doses of inhaled steroid, the vitamin D group was able to reduce its medication
more. By the end of the 28-week study, the vitamin D group
was taking an average of 111 mcg/day, and the placebo group
was taking an average of 126.
The difference was small15 mcg of steroid per day
but statistically significant, Castro says. Over the long term,
even that small amount may have an important impact on
reducing side effects of inhaled steroids. Although inhaled
steroids work very well in controlling asthma, patients dont
like them because they cause weight gain and increase the
risk of diabetes and high blood pressure. Anything we can do
to reduce the amount they need is important.
The investigators also note that despite taking large doses
of vitamin D, not all patients in the treatment group achieved
what are considered sufficient blood levels of vitamin D. After
taking the supplements, 18% of the treatment group still
had blood levels of vitamin D below 30 ng/mL. The reason
that some patients didnt appear to respond to the vitamin D
supplements is unclear, though the investigators note that
these patients were more likely to be overweight or obese.
When they looked only at the 82% of patients who received
vitamin D supplements and showed an increase in their
blood vitamin D levels above the critical threshold, Castro
says they saw some intriguing results. Compared with
placebo, the patients in the treatment group that achieved
vitamin D sufficiency in the blood (with an average of 42 ng/mL)
did show improved asthma control. They had 40% fewer
treatment failures that required more medication and onehalf the number of asthma attacks.
Were encouraged by this result, but we have to be careful,
Castro says. Our study was designed to look at the entire
group that received vitamin D supplements, not just those who
achieved higher levels of vitamin D in the blood. We need more
studies looking at this question, but Im paying attention to
vitamin D levels in my patients.
We dont know the long-term effects of supplementing
vitamin D, he adds. In our study, it appears safe. Patients
reported no side effects, and its inexpensive. If I have a patient
with a history of multiple asthma attacks, Ill consider looking at
vitamin D levels, and if theyre low, giving a supplement. But you
have to monitor the blood levels to see if its having an effect.
SOURCE: WASHINGTON UNIVERSITY IN ST LOUIS
Study Exposes Risk of Nutritional Deficiencies in Obese Teens

A new study exposes the risk of nutritional deficiencies
in severely obese teens, both those who had weight-loss
surgery and those who didnt.
At least five years after undergoing gastric bypass surgery, teens and young adults maintained significant weight
loss but were at risk of nutritional deficiencies, particularly
low iron, mild anemia, and low vitamin D. The study also
found low iron and low vitamin D in severely obese teens
who didnt undergo weight-loss surgery as well as low
levels of protein in their blood.
We knew there were nutritional difficulties in teens who
had undergone bariatric surgery, but everyone thought it
was primarily the surgery that caused these problems since
gastric bypass excludes the portion of the small intestine
where many nutrients, especially iron, are most absorbed,
says Stavra Xanthakos, MD, MS, medical director of the
Surgical Weight Loss Program for Teens at Cincinnati Childrens Hospital Medical Center and a study coauthor. What
this shows us is that nutritional deficiencies occur even in
teens who dont undergo surgery. Severely obese patients
should be screened for nutritional deficiencies, regardless
of whether theyve undergone weight-loss surgery.
The researchers studied 79 obese teens who either
received weight-loss surgery or were evaluated but didnt
receive surgery. The patients were evaluated between 2001
and 2007, and contacted to participate in the study between
2011 and 2014.
Eight years on average after surgery, these patients had
experienced durable and significant weight loss, about
28%, Xanthakos says. Those who didnt receive surgery
hadnt lost weight.
SOURCE: CINCINNATI CHILDRENS HOSPITAL MEDICAL CENTER
Coffee Consumption May Reduce Type 2 Diabetes Risk

People who increased the amount of coffee they drank
each day by more than 1 cup over a four-year period
had an 11% lower risk of type 2 diabetes than those who
made no changes to their coffee consumption, according to a new study led by Harvard School of Public Health
researchers. In addition, the study found that those who
decreased their coffee consumption by more than 1 cup
per day increased their type 2
diabetes risk by 17%. The study
appeared online in Diabetologia.
Our findings confirm those
of previous studies that showed
that higher coffee consumption
was associated with lower type
2 diabetes risk, says Shilpa
Bhupathiraju, PhD, lead author
and a research fellow in the
department of nutrition. Most
importantly, they provide new evidence that changes in
coffee consumption habit can affect type 2 diabetes risk
in a relatively short period of time.
The researchers analyzed data on caffeinated and
decaffeinated coffee and caffeinated tea consumption by
48,464 women in the Brigham and Womens Hospital
based Nurses Health Study (1986-2006); 47,510 women
in Nurses Health Study II (1991-2007); and 27,759 men in

the Health Professionals Follow-Up Study (1986-2006).
Participants diets were evaluated every four years with
a questionnaire, and those who self-reported type 2
diabetes completed additional questionnaires. A total of
7,269 cases of type 2 diabetes were documented.
One cup of coffee was defined
as 8 oz, black, or with a small
amount of milk and/or sugar.
Those who lowered their daily
coffee consumption by more
than 1 cup (median change =
2 cups/day) had a 17% higher risk
of diabetes. Changes in decaffeinated coffee consumption and
caffeinated tea consumption
werent associated with changes
in the risk of type 2 diabetes.
These findings further demonstrate that, for most people, coffee may have health
benefits, says Frank Hu, MD, MPH, PhD, senior author
and a professor of nutrition and epidemiology. But coffee
is only one of many factors that influence diabetes risk.
More importantly, individuals should watch their weight
and be physically active.
SOURCE: HARVARD SCHOOL OF PUBLIC HEALTH
ASK THE EXPERT
help consumers make nutritionally informed choices when

prompted, especially those with the lowest education level.
Benefits to Consumers
UNDERSTANDING
FACTS UP FRONT
By Toby Amidor, MS, RD, CDN
Q:
A:
Ive seen the Facts Up Front panel on several food products. Can you explain what it is and how it will help
consumers?
The Facts Up Front panel is a voluntary nutrition labeling
system developed by the Grocery Manufacturers Association and the Food Marketing Institute to help consumers make
more informed choices about the foods they buy. The initiative
is aligned with the FDA and USDA guidelines and regulations,
including the 2010 Dietary Guidelines for Americans. The icon
began appearing in the marketplace in late 2011, and its presence continues to grow in stores nationwide.
The nutrition information displayed on the Facts Up Front
panel includes serving size, calories, saturated fat, sodium,
and sugar. The label also can display a maximum of two
encouraged nutrients whose consumption is promoted in
order to achieve a nutrient-dense diet. Examples include
fiber, calcium, potassium, protein, iron, and vitamins A, C,
and D. In order for the nutrient to be displayed on the Facts
Up Front panel, the product must contain at least 10% of the
recommended Daily Value (DV).
Before developing this front-of-label program, the Grocery
Manufacturers Association commissioned the International
Food Information Council Foundation to conduct consumer
research. Nearly 7,400 nationally representative primary grocery shoppers took an interactive online survey to evaluate
their comprehension, ease of understanding, and interpretation of nutrition information on food products using the Facts
Up Front panel. The study concluded that Facts Up Front may
Many consumers may feel overwhelmed by the Nutrition

Facts panel, as they find it confusing and cant figure out
the math (eg, % DV). According to culinary nutritionist Robin
Plotkin, RD, LD, an advisor for Facts Up Front, The at-aglance factor is really why Facts Up Front is beneficial to the
public. Were so used to receiving information in snippets and
blurbs these days. The Facts Up Front label delivers important
nutrient information in a way thats palatable to consumers. In
addition, she says, The label makes it easy to zero in on one to
two nutrients without being overwhelming.
Our consumers want fact-based information on calories,
saturated fat, sugar, and sodium, says Julie McMillin, RD, LD,
director of health and wellness for supermarket chain Hy-Vee.
Facts Up Front puts this information right on the front of packages where its easiest to find, helping them make knowledgeable decisions for themselves and their families.
Benefits to Dietetic Professionals

Nutrition professionals can use the Facts Up Front panel
in both a clinical and supermarket setting to complement the
information provided during educational sessions. RDs can
utilize Facts Up Front as a teaching tool because of its simplistic yet powerful messages, Plotkin says. They also can refer
clients to the Facts Up Front website (www.factsupfront.org),
which contains helpful resources, including shopping and meal
planning tips, healthful recipes, a nutrition calculator, and a
nutrition quiz.
In addition, the website provides information to help dietetic
professionals stay abreast of current research on industry
progress as well as current science related to food labeling
research. Theres also information available to assist nutrition
professionals in conducting a supermarket tour with clients.
Toby Amidor, MS, RD, CDN, is
the founder of Toby Amidor Nutrition
(http://tobyamidornutrition.com) and
author of the cookbook The Greek Yogurt
Kitchen. Shes also a nutrition expert for
FoodNetwork.com and contributor
to US News Eat + Run.
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.
The USDA recommends

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Recent epidemiological studies in healthy
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Eating one yogurt every day is an important first
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ALLERGY & INTOLERANCE AWARENESS
Its important for RDs to know that

the location in which potentially food
allergic clients live may influence the
type of food allergy they develop. Practitioners also should be alert to a clients
or patients reported symptoms consistent with food allergies, which can vary
from mild to severe and include gastrointestinal symptoms such as nausea,
vomiting, and diarrhea and respiratory
and skin reactions.
Food allergies often are overlooked
and may be misdiagnosed, but RDs can
play an important role in helping clients
at risk get properly diagnosed and educated to manage their allergy.
Sensitization vs. True Allergy
FOOD ALLERGY
SENSITIZATION
New Study Finds Geography Plays a Role

By Sherry Coleman Collins, MS, RDN, LD
When it comes to allergies, there seems to be no escape for
those who are predisposed to developing them, according to
a recent study that examined the prevalence of allergic sensitization across the United States using data from the National
Health and Nutrition Examination Survey (NHANES) 2005-2006.
The study, which includes 10,348 participants, found that the
overall prevalence of allergic sensitization doesnt differ from
region to region in the United States, although sensitization to
specific allergens and allergen types shows regional variation.1
The research shows that 44.6% of Americans aged 6 and
older had positive test results for serum immunoglobulin E
(IgE) antibodies for at least one of 19 allergens, with 16.2%
having positive serum IgE tests related to at least one of four
foods tested (egg, cows milk, shrimp, and peanut). The study
also found that 36.2% of children aged 1 to 5 were sensitized
to at least one allergen, such as dust, pollen, or food, and that
the prevalence of food sensitization was significantly higher in
28% of children under the age of 6.1
Researchers suggest that individuals predisposed to developing allergies will become allergic to something in their environment or to food, regardless of where they live. Furthermore, they
found that while allergic sensitization rates are about the same
no matter where people lived in the United States, differences
existed among the types of allergens that caused reactions.
Sensitization and true allergy arent

the same. Although allergic sensitization is a major risk factor for allergic
disease, it is not synonymous with allergic disease, says Pivi Salo, PhD, lead author of the NHANES
study and a researcher in the Environmental Cardiopulmonary Disease Group in the National Institute of Environmental
Health Sciences division of intramural research. Assessment
of allergen-specific IgE antibodies with serologic analysesor
skin test challengesconfirms allergic sensitization, whereas
subjects clinical history and physical examination remain
important cornerstones of the diagnosis of allergic disease.
Moreover, an individual can be sensitized to a substance or food
yet never manifest a clinical allergic reaction.
Skin prick tests and serum blood tests check for IgE antibodies to specific proteins. Positive tests indicate that sensitization
has occurred. The more drastic the positive result, as evidenced
by a larger wheal size (the large red bump that appears at the
site of the skin prick) or higher numbers of IgE antibodies in the
blood, the more likely an individual has a true allergy. However,
its important to recognize that false-positives are common,
occurring in up to 60% of blood tests and skin prick tests.2
Oral food challenges are the gold standard for diagnosing
food allergies, but they tend to be time consuming, expensive,
and subject study participants to potentially severe allergic reactions [which isnt feasible in large-scale studies], Salo says.
Some physicians, patients, and parents are hesitant to perform
and undergo oral food challenges, but a food allergy diagnosis is
life altering, so ensuring its accuracy should be paramount.
Recent research has shown that allergic individuals experience an improved quality of life when they undergo oral food
challenges to test for tolerance, even those who have an allergic
reaction to the food allergen and fail the oral food challenge.3
Therefore, people who have a low risk of anaphylaxis should
2012 -12.28 Today's Dietician Half Page Vert_Layout 1 1/3/13 11:46 AM Pag
be encouraged to participate in oral food challenges to help

ensure an accurate diagnosis and also determine if and
when they will or have outgrown a food allergy.
Oral Allergy Syndrome,

Cross-Reactivity, and Clustering
practice to assist my patients

in the management of food
sensitivity and intolerance
Lea Russell, MBA, RD, LD/N

Nutrition Health Services, Tampa, Florida
www.nutritionhealthservices.com
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Just as the substances people are allergic to vary country

by country, so do the triggers that cause allergic reactions
and the ways in which people respond to the allergens. Individuals may respond to allergens by developing oral allergy
syndrome or through cross-reactivity or clustering.
Oral allergy syndrome is a condition in which an individual whos allergic to certain pollens (eg, birch tree pollen)
will experience itching and swelling in the oral cavity after
eating raw fruits and vegetables. Typically, cooked vegetables and fruits arent an issue. Its unknown what really
triggers an allergic response and cross-reactivities, particularly in the case of oral allergy syndrome, says Soheila
Maleki, PhD, lead research scientist for USDA Food Allergy
Research. Similarities in proteins of inhalant allergens
[eg, dust mites] and food allergens indicate that there
could be potentially similar triggers for most food allergies. In fact, disagreement exists among experts about
whether oral allergy syndrome represents a true food
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According to the NHANES study, individuals in the South

were more likely to develop allergies to eggs, cows milk,
shrimp, and peanuts.1 Researchers dont know why allergy
rates to these foods are higher in the South than in other
areas. Salo says the study wasnt meant to identify a causal
relationship between allergy and geography, so further
research is needed.
In support of geographic influences on allergic
sensitization, an international study by Dalal and colleagues
highlighted the prevalence of sesame allergy in Israel and
differences in the types of food allergies among allergic
individuals living in various countries.4 In this study,
researchers identified eggs as the top allergen for five
of seven countries (Australia, France, Israel, Japan, and
Spain), but there were great variations among the allergenic
foods that ranked highest from country to country. Italys
top food allergen is fish, while Singapores is birds nest (an
ingredient commonly eaten as a regional delicacy).4 Other
allergens include various fruits, vegetables, lentils, nuts,
wheat, and mustard.
Since sensitization results from exposure to specific
proteins, researchers say it makes sense that these foods
reflect the diet of the individuals in a certain region or country, and that individuals wont develop allergies to foods
theyve never eaten.
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Cross-reactivity is unpredictable among individuals,

but patterns exist. For instance, people who are allergic to cockroaches and dust mites are more likely to be
allergic to shrimp. Likewise, those allergic to birch tree
pollen may be at higher risk of a peanut allergy. Moreover,
approximately one-third of people who have a peanut
allergy also are allergic to tree nuts.
Clustering occurs when a person whos sensitized to
one allergen in a group of similar entities is more likely to
be allergic to something else within the group. Allergies
tended to aggregate in groups of allergens that were similar, Salo says of her NHANES study. In NHANES 20052006, the 19 allergen-specific IgEs grouped into seven
clusters. This suggests that a person whos sensitized
to one allergen in the cluster is more likely to be allergic
to another allergen in this cluster. For example, people
sensitized to cats were more likely to be allergic to dogs,
and those who were sensitized to a plant-related allergen were more likely to be allergic to other plant-related
allergens and so forth.
PATIENT FOLLOW-UP
Since individuals may outgrow food allergies, its important for clients and patients to see an allergist regularly for
reevaluation.
To determine the status of a patients allergy, an allergist
may administer a skin prick or blood serum immunoglobulin
E test. Based on the size of the wheal (the red bump that surfaces on the skin indicating sensitization), blood test results,
and other diagnostic criteria, the physician will determine
whether a true allergy persists.
If the physician believes the patient is at low risk of
a serious reaction, he or she may conduct an oral food
challenge. Because of the potential for a serious and lifethreatening reaction, oral food challenges always should
be conducted in an allergists or physicians office. Previous
reactions dont guarantee how mild or severe future
reactions will be, and variations may occur from reaction to
reaction and between allergic individuals. Even patients who
have experienced mild allergy symptoms may experience
anaphylaxis. Therefore, those who undergo an oral food
challenge typically remain under medical supervision for two
hours after ingesting the allergenic food, although reactions
may occur several hours after the food has been eaten.
Practice Application
SCC
As new research emerges, it will provide additional

information to expand the body of knowledge about food
allergies, diagnosis, and management. Thus far, the
medical community knows that sensitization isnt the
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References
same as a true allergy, and nutrition professionals can play

an important role in helping clients and patients understand
the difference. In fact, the prevalence of true food allergy
is significantly less than the prevalence of sensitization,
according to the new NHANES study. Researchers estimate
that the prevalence of true food allergy is up to 8% in children
and less than 4% in adults.5,6 Geography plays a role in
the type of allergy individuals develop, possibly due to the
differences in environmental and dietary factors, as well as
cross-reactivity and clustering.
RDNs should be more aware of the potential for allergies
in their patients, says Kate Scarlata, RDN, LDN, a digestive
disorders expert and the author of The Complete Idiots Guide
to Eating Well With IBS. Since allergies in children seem
more prevalent in metropolitan areas and in our southern
states, RDNs working with patients in these areas should
be even more vigilant in noting symptoms that may indicate
an allergic reaction and refer patients to allergists for
appropriate work up. Practitioners should be familiar with
recognizing signs and symptoms of food allergies and be
prepared to assist clients with education and referrals to
improve patient care.
Sherry Coleman Collins, MS, RDN, LD, is a private practitioner
in Atlanta specializing in food allergies and sensitivities,
8.5 X 5.5_Today'sDietitianAd.qrk:Layout
1 6/17/14and
10:14
AM Page
19
digestive disorders,
nutrition
communications.
1. Salo PM, Arbes SJ, Jaramillo R, et al. Prevalence of

allergic sensitization in the United States: Results from the
National Health and Nutrition Examination Survey (NHANES)
2005-2006 [published online February 9, 2014]. J Allergy Clin
Immunol. doi: 10.1016/j.jaci.2013.12.1071.
2. Blood tests. Food Allergy Research & Education website.
http://www.foodallergy.org/diagnosis-and-testing/blood-tests.
Accessed April 27, 2014.
3. Franxman TJ, Howe LE, Greenhawt MJ. Oral food
challenge and food allergy quality of life in caregivers of
food allergic children. J Allergy Clin Immunol. 2013;131
(2 Suppl):AB57.
4. Dalal I, Binson I, Reifen R, et al. Food allergy is a matter
of geography after all: sesame as a major cause of severe IgEmediated food allergic reactions among infants and young
children in Israel. Allergy. 2002;57(4):362-365.
5. Gupta RS, Springston EE, Warrier MR, et al. The prevalence, severity, and distribution of childhood food allergy in the
United States. Pediatrics. 2011;128(1):e9-e17.
6. NIAID-Sponsored Expert Panel, Boyce JA, Assaad A, et al.
Guidelines for the diagnosis and management of food allergy in
the United States: report of the NIAID-sponsored expert panel.
J Allergy Clin Immunol. 2010;126(6 Suppl):S1-S58.
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DIGESTIVE WELLNESS
Causes
GASTROPARESIS
By Jessica Jones, MS, RD
Dietitians play an important role

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

Symptoms of gastroparesis can range from mild to severe,
depending on the individual. The most common include nausea,
vomiting, and early satiety.
Since food doesnt move through the stomach at a normal
pace, many patients report feeling full and bloated after
eating. The feeling of fullness can result in inadequate food
intake, which can lead to malnutrition and vitamin and mineral
deficiencies. The nausea and vomiting in some patients is
so severe that they really have to work hard to get enough
nutrition, says Marcia Nahikian-Nelms, PhD, RDN, LD, CNSC,
a clinical professor and the director of the dietetic internship
program at Ohio State University.
Moreover, food that remains in the stomach for extended
periods of time can ferment and cause bacterial overgrowth.
Subsequently, the food can harden into masses called bezoars,
which cause nausea and vomiting and can lead to a stomach
obstruction, according to the American College of Gastroenterology. In some cases, the bezoars can block foods passageway
into the small intestine.1
Many conditions can cause gastroparesis, but diabetes is one

of the most common etiologies. Neuropathy, which is a diabetes
complication, can damage the vagus nerve, one of the primary
autonomic controls for gastric emptying, Nahikian-Nelms says.
Hyperglycemia also can cause delays in gastric emptying,
which can further exacerbate symptoms. When glucose rises
in diabetes patients, it slows stomach emptying so theyre more
prone to having gastrointestinal symptoms, says Henry Parkman, MD, a professor of medicine and the director of the GI
Motility Laboratory at Temple University in Philadelphia. The
interesting thing is, its like a vicious cycle because the delay in
gastric emptying also can cause [patients] to have trouble controlling their glucose.
The American Diabetes Association says individuals with
diabetes dealing with gastroparesis may need to administer insulin more often, administer insulin after eating instead
of before, or frequently check their blood glucose levels and
administer insulin when needed.
While a high percentage of gastroparesis has been
reported in people with type 1 (40%) and type 2 diabetes (10%
to 20%), its possible these numbers are inflated because the
studies were conducted at tertiary academic medical centers,
in which the prevalence of gastroparesis is noted to be higher
than the general population.2 A January 2013 study published in the American Journal of Gastroenterology estimates
that the community prevalence of gastroparesis is closer to
approximately 5% in type 1 diabetes patients and 1% in type 2
patients.2
Other causes of gastroparesis include stomach or vagus
nerve surgery, systemic disorders such as scleroderma,
neurological conditions such as Parkinsons disease, and
medications such as narcotics, calcium channel blockers, and
tricyclic antidepressants.2 Although rare, gastroparesis also
can appear in individuals with anorexia nervosa, since issues
with gastric emptying and reduced stomach contractions can
develop with this eating disorder.3 Moreover, about one-third of
gastroparesis cases are considered idiopathic, meaning they
have no known cause.3
Gastroparesis also is seen more in women than men. I
did some research a while ago on the female reproductive
hormones estrogen and progesterone, and those seem to
delay stomach emptying, Parkman says. More recent
research suggests that females [may] have differences in
the way they metabolize some of the neurotransmitters that
govern gastric motility.
Diagnosis
Physicians can diagnose gastroparesis in several ways. If
patients present with symptoms consistent with the disease,
theyre likely to first undergo an upper endoscopy to rule
out any mechanical obstruction or ulcer. If no obstruction is
present, the next step usually is scintigraphy, a diagnostic
test considered the gold standard for measuring the rate at

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

Once a patient is diagnosed with gastroparesis, dietitians
begin administering medical nutrition therapy (MNT), which
usually is the first line of treatment. Dietitians can really play
a major role in guiding patients in the right way and helping
patients feel better, Khodadadian says. Nutrition counseling
with the dietitian is critical.
RDs who administer MNT to patients should encourage them
to eat small but frequent meals (six to 10) per day to decrease
bloating, early satiety, and other symptoms.
Food choices are just as important as reducing the amount
of food eaten at each meal. As far as the choice of foods,
we emphasize low-fat foods because high-fat foods have a
longer gastric emptying time, Nahikian-Nelms says. The
Academy of Nutrition and Dietetics agrees but states that liquids that contain fat, such as milkshakes, can be tolerated
and provide extra calories.
In addition, low-fiber foods are recommended because
fiber is known to slow gastric emptying, Nahikian-Nelms
says. Dietitians also should suggest patients eat lowresidue foods such as refined breads, white rice, and white
pasta, plus cooked vegetables and canned fruit because
theyre better tolerated than fresh fruits and vegetables.
The Nutrition Care Manual recommends patients consume
skim milk, instant breakfast beverages, yogurt, pudding,
custard, smoothies, pured foods, and soup. Theres a
subgroup of patients who have more difficulty with solid
foods. They tend to do better with pured or liquid foods,
Khodadadian says.
He also recommends patients avoid carbonated beverages,
alcohol, and smoking, which can slow down gastric emptying.
Light physical activity after meals can help speed up
gastric emptying rates, so RDs should suggest patients take
a walk after eating to improve digestion instead of lying down
after meals.
(To review a more comprehensive dietary guideline for
gastroparesis, visit www.medicine.virginia.edu/clinical/
departments/medicine/divisions/digestive-health/nutritionsupport-team/patient-education/Gastroparesis%20
SHORT%2010-10.pdf.)
Other Treatments
If MNT doesnt completely alleviate symptoms, medications
also can be used to treat gastroparesis. We have prokinetic
agents that help speed up stomach emptying, such as metoclopramide [Reglan], domperidone [Motilium), and erythromycin,
Parkman says. Metoclopramide is the only FDA-approved drug
for gastroparesis; the other two are used off label. We [also]
have antiemetic agents that are good for reducing nausea and
vomiting. Common antiemetic medications include diphenhydramine (Benadryl) and ondansetron (Zofran).
While medications can help reduce symptoms, they arent a
panacea. For example, metoclopramide must empty through
the stomach, so this can be an issue in patients with delayed
gastric emptying, Parkman says. The National Institutes of
Health and the FDA know that more medications are needed to
treat this disease. Pharmaceutical companies are looking at
novel ways to treat gastroparesis, he says.
Instead of administering metoclopramide orally in tablet
form, companies are researching ways to give it to patients in
a nasal spray so it bypasses the stomach and gets absorbed
through the nasal mucosa to speed up gastric emptying,
Parkman adds.
When medications and dietary changes arent enough to
treat gastroparesis, enteral nutrition is an option. Theres a
subgroup of patients who ultimately need enteral nutrition.
[They] have persistent weight loss and are unable to control
their symptoms, Khodadadian says. In these cases, a jejunostomy is inserted into the small intestine to provide the proper
nutrition to patients. This is preferred because it bypasses the
stomach, he says.
Making the Difficult Easy

Regardless of the interventions prescribed, dietitians
must remember how imperative their role is in gastroparesis
treatment.
Nahikian-Nelms recalls a recent encounter she had with
a patient when discussing the recommendation of six small
meals per day. He said, People tell me that all the time, but I
have no idea what that means. How do I get six meals in? What
do I do? Its easy to forget that people have a hard time translating [health care] recommendations into actual foods and
actual meal plans. Having that very specific plan for him made
all the difference in the world.
Jessica Jones, MS, RD, is a nutrition communications
specialist and the cohost of Food Heaven Made Easy, a weekly
Web series that demonstrates how to prepare nutrient-dense,
delicious, and budget-friendly plant-based recipes while
providing scientifically sound nutrition information.
For references, view this article on

our website at www.TodaysDietitian.com.
OMEGA FATS
SPOTLIGHT ON
STEARIDONIC ACID
Learn More About This

Alternative Omega-3 Fatty Acid
By Amelia R. Sherry
Despite recommendations from the American Heart
Association and other health organizations regarding omega-3
fatty acid intake, a significant number of Americans are
consuming less than one-half of the recommended 8 oz of
fish per weekor the 250 mg of EPA and DHA per day.1,2 This
shortfall can be considered even more dramatic for individuals
with cardiovascular disease (CVD) and those battling elevated
triglycerides, for whom a daily dose of 1 g of EPA and DHA and
2 to 4 g of EPA and DHA, respectively, are recommended
nearly 10 to 20 times the amounts currently consumed.3
In addition to eating fish twice per week, many dietitians
recommend consuming foods rich in alpha-linolenic acid
(ALA), a long-chain fatty acid precursor found in plant foods
such as ground flax to help boost omega-3 intake. RDs also
may suggest supplements if clients and patients cant consume the recommended amounts through diet alone, have
high triglycerides, or avoid fish due to concerns about mercury
content or other reasons.
To increase omega-3 fatty acid intake, food manufacturers
are fortifying eggs and milk with these acids. One omega-3
theyre particularly focusing on is stearidonic acid (SDA), which
is expected to appear on store shelves in soybean oil derived
from genetically modified (GM) soybeans.
What Is SDA?
Like ALA, SDA is a shorter long-chain omega-3 fatty acid
composed of 18 carbons, making it a precursor to longer longchain fatty acids such as EPA and DHA. Unlike ALA, SDA has
four double bonds existing at the third, sixth, ninth, and 12th
carbons and, more notably, it doesnt require the rate-limiting
enzyme desaturase to convert to a longer chain fatty acid.4
Considered an omega-3 fatty acid to watch, SDA is emerging

as an alternative nonfish source of omega-3s for at least two
reasons. While ALA-rich foods often are recommended as an
additional or alternative source of omega-3s for those who dont
or cant consume fish, most dietitians know that the conversion
of ALA to longer long-chain fatty acids is inefficient. Specifically,
its estimated that anywhere from less than 5% to 21% of ALA
converts to EPA (with sex and omega-6 intake impacting the
amount), while less than 1% to 9% of ALA converts to DHA.4-7
By comparison, an increasing number of studies, largely
funded by Monsanto, developer of the genetically engineered
SDA-enriched soybean oil, are showing SDA to have a superior
ability to convert to EPA over ALA. For example, foods supplemented with SDA-enriched soybean oil were found to raise EPA
concentrations in red blood cell membranes with approximately
17% to 41% of the efficiency of EPA on a gram-for-gram basis,
a conversion efficiency three to five times higher than that of
ALA.7 Moreover, a meta-analysis reported that EPA levels in red
blood cells were twice as high when subjects consumed SDA
compared with ALA.8
In a 2009 review article on SDA research, Jay Whelan, PhD,
MPH, a professor and the head of the department of nutrition
at the University of Tennessee, concluded that while SDA may
not replace fish as a dietary source of omega-3 long-chain fatty
acids, it may be a prominent substitute for EPA in foods fortified
with omega-3 polyunsaturated fatty acids. Whelan supported
his conclusion by referring to evidence demonstrating that
SDA consumption leads to a fivefold increase in EPA levels in
plasma, neutrophil, heart, and erythrocyte phospholipids.9
Whelans review also suggested that SDA doesnt affect DHA
levels, which is in line with more recent studies. SDA can be
converted to EPA and, theoretically, EPA can be converted to
DHA, he explains. In reality, only DHA changes DHA in the
tissues when consuming a typical Western diet, which is why
he doesnt advocate consuming SDA-fortified foods in place of
fish or fish oils containing both EPA and DHA.
A second reason SDA likely is attracting the interest of food
scientists as a potential source of omega-3s is that its less
unsaturated than EPA, making it more stable in foods.9 Since
SDA is less susceptible to oxidation, its less likely to be prone
to off flavors, Whelan says.
Dietary Sources
A limited number of foods contain small amounts of SDA,
including some seed oils, such as hemp and Echium; certain
fish, such as sardines and herring; and algae. To date, the
American diet contains such low amounts of SDA that it hasnt
been measured.8 Of course, if genetically modified, SDAenriched soybeans and soybean oil hit the consumer market,
this may changeand it looks like it will.
In 2009, Monsanto obtained Generally Recognized as Safe
status from the FDA for SDA-enriched omega-3 soybean oil.10 In
April 2013, the company announced a combined effort with DSM
Nutritional Products to bring the SDA-enriched soybean oil to
the marketplace. Monsanto will sell its SDA-enriched soybean

seeds to farmers, and DSM Nutritional Products will have the
exclusive global rights to brand, market, package, and sell the
SDA soybean oil to the food industry.11
Richard S. Wilkes, CFS, director of food applications for Monsanto, says the oil was created by inserting an enzyme responsible for increasing the conversion of ALA in soybean oil to SDA,
which then is extracted from the seeds. Since soybean oil already
is added to various foods, Wilkes considers it an efficient way to
bring SDA to consumers. Specifically, it can be used in dairy and
soy beverages, dressings, granola bars, margarine-type spreads,
mayonnaise, peanut butter, smoothies, yogurt, and yogurt drinks.
As of this writing, neither Monsanto nor DSM Nutritional
Products has confirmed when products containing the oil will
hit store shelves.
Impact on Overall Health

In addition to raising EPA levels, some research has
shown that SDA reduces elevated triglycerides. However,
further comparative studies on healthy and unhealthy
individuals are needed before researchers can consider SDA
a potent protector of cardiovascular health.12,13
Moreover, questions remain about how SDAs inability to
raise DHA levels may impact overall health. Were playing
with fatty acids that affect localized, cell-specific, hormonelike
activity and play somewhat differing roles in disease, says
Libby Mills, MS, RDN, LDN, a spokesperson for the Academy
of Nutrition and Dietetics (the Academy). We know that
EPA works primarily on inflammation, while DHA increases
permeability of cell membranes, which is especially important
for pregnant women and childrens brain development, and
reduces atherosclerosis by blocking LDL from getting into
vessels. What we dont know is what the long-term effects of
playing with the ratio of EPA and DHA may be.
Gretchen K. Vannice, MS, RDN, author of the Omega-3
Handbook and coauthor of the Academys position paper on
dietary fatty acids, raises additional concerns about how SDAenriched soybean oil products will be marketed to consumers.
If foods are labeled as a general source of omega-3s, for
example, this could lead to problems. Its important that
people know that if they choose to eat food products containing
SDA-enriched soybean oil, they will not get DHA. This is critical
information for the elderly and women who are pregnant and
lactating, since DHA is important for infant development,
cognitive health, and vision maintenance, in addition to heart
health, she explains. When food manufacturers take the
product to market, they should be very clear that SDAenriched soybean oils give zero DHA.
Who Can Benefit From SDA?

Theoretically, the same individuals who rely on ALAcontaining foods to increase their omega-3 intake may benefit
from adding SDA to their diet. This includes vegetarians,
vegans, and anyone else who consumes little to no fish.
In practice, turning to food products containing SDAenriched soybean oil to help clients and patients reach
recommended levels of omega-3s may not make much sense,
according to Mills. Overall, too many calories are already
coming from dietary fat, she says, adding that dietary fat
consumption in the United States has increased by two-thirds
since the 1950s. Based on conversion rates in studies, clients
and patients need up to nine times the amount of SDA as EPA
to reach recommended intakes, which means eating a lot of
extra fat from oil or getting very little EPA, she says.
Counseling Tips
Its important for clients, patients, and consumers to know
that if they choose to eat food products containing SDAenriched soybean oil, its a GM product that provides limited
amounts of EPA and no DHA. RDs looking for an alternative
source of omega-3s for vegetarian and vegan clients and
patients can recommend algae-derived supplements
containing both EPA and DHA, Vannice says.
For people who ask whether they should consume products
containing SDA-enriched soybean oil to lower their heart disease
risk, dietitians can suggest they eat more anti-inflammatory
foods and spices containing ALA and phytochemicals, such as
cruciferous vegetables, complex carbohydrates, blueberries,
turmeric, and ginger, to receive the same health benefits without
adding extra fat and oils to their diet, Mills says. We also can
recommend avoiding excess consumption of alcohol, sugar, and
refined grains as well as behaviors such as smoking, which all
contribute to inflammation, she says.
Bottom Line
As new omega-3 fortified foods hit store shelves, dietitians
should be prepared to counsel clients and patients about
reading ingredient labels to learn the source of these fats. If
SDA-enriched soybean oil is listed, dietitians should explain
that its derived from GM soybeans, and that it may raise EPA
levels but wont provide DHA.
For the elderly and pregnant and lactating women, RDs
should further explain why DHA is important. For overweight
patients and those at risk of CVD, RDs should mention that high
amounts of the food product would need to be consumed
along with unnecessary fat and caloriesto get significant
amounts of EPA.
For all clients and patients, traditional sources of omega-3
fatty acids, such as oily fish, fish oil supplements, and algaederived supplements, still should be consumed to reach
recommended EPA and DHA intake.
Amelia R. Sherry is a freelance writer, graduate nutrition
student, and founder of the blog FeedingIsla.com.

Substituting Palm Oil

for Trans Fat
The FDAs proposal to ban trans fat has increased
demand for palm oil, but is palm oil a good alternative
for human health and the environment?
By Beth Anne Conlon, MS, RDN, and Ashley M. Colpaart, MS, RDN
n November 2013, the FDA gave public health professionals a reason to celebrate by publishing a formal Federal
Register notice proposing a ban on partially hydrogenated
oils on the grounds that theyre no longer generally recognized as safe for use in food.
For decades, efforts have been made to reduce or eliminate the use and intake of partially hydrogenated oils, which
are found in commonly eaten foods such as margarines and
spreads, baked goods, fried foods, frozen pies and pizzas, and
savory snacks. This is because partially hydrogenated oils are
the primary source of trans fatty acids in the food supply, and
trans fatty acid intake poses a risk of cardiovascular disease.
In response to a 2006 FDA ruling mandating the labeling of
trans fatty acids on the Nutrition Facts label, food manufacturers began eliminating trans fats from their products. Due to
the unique properties of partially hydrogenated oils, companies
began substituting them with palm oil, a naturally trans fat
free oil, increasing imports to the United States by nearly 60%
over the past seven years. An FDA ban on the commercial use
of trans fats likely will increase the demand, but palm oils high
saturated fat content and the destruction of tropical forests,
where palm plantations are planted, are raising red flags for
public health and environmental groups.
Its important for RDs to educate themselves on the impact
of palm oil consumption and cultivation so they can work with
key stakeholdersfood manufacturers, environmental organizations, and consumersto advocate for and develop innovative solutions to strike a balance between whats best for
the publics health and whats best for the environment.
This article will review the history of the use of partially
hydrogenated oils in the food supply and their health effects,
discuss the environmental impact of increased palm oil production, and highlight opportunities for RDs to take action and
raise awareness about palm oil and the broader implications
of the foods consumers eat.
History and Regulation

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

the 1970s, palm oil, which is high in saturated fat and was
widely used in commercial foods at the time, was in direct
competition with US subsidized crops such as soybean, corn,
and cottonseed oils, which were lower in saturated fat (about
16% saturated fat). In response, an antitropical oil campaign
was launched, alerting the public to the dangers of highly
saturated fat products and urging American food companies
to remove palm and coconut oils (also high in saturated fat)
from their products.1
The highly subsidized cost of and easy access to commodity
seed oil led companies to announce they would switch to vegetable oils containing unsaturated fats. But palm oil is odorless,
tasteless, and solid at room temperature, making it ideal for
enhancing the texture, mouthfeel, and shelf life of commercial
food products.2
To obtain the same unique properties palm oil offers, the
food industry employed the novel process of hydrogenation,
which adds hydrogen atoms to oils, converting unsaturated
oils, once liquid at room temperature, into hydrogenated or
partially hydrogenated oils, now solid or semisolid, respectively, at room temperature. Consequently, during the hydrogenation process, some of the cis (crooked) double bonds
break and randomly reorganize into trans (straight) double
bonds, introducing artificial trans fat bonds into the oil.2
Partially hydrogenated oils contain more artificial trans fats
than fully hydrogenated oils because their carbon atoms arent
fully saturated, leaving room for trans double bond formation.
Both partially and fully hydrogenated oils are highly customizable for a variety of manufacturing applications, including
frying and baking.1
Health Consequences Emerge

Originally, consumer advocacy groups such as the
Center for Science in the Public Interest (CSPI), a nonprofit
organization that advocates for issues such as consumer
health, nutrition, and food safety, praised food manufacturers
for switching from saturated fats to partially hydrogenated
oils.1 Before the advent of hydrogenation, the only trans fatty
acids humans consumed came from the natural sources:
meat and dairy.
The industrywide adoption of partially hydrogenated oils
in cakes, cookies, pies, and pastries contributed to dramatic
increases in intake, making partially hydrogenated oils the
primary dietary source of industrially produced trans fatty
acids. Research emerged in the 1990s connecting higher
intakes of trans fats with an increased risk of CHD, the
No. 1 killer of Americans. Mechanistically, trans fats fuel the
increase of LDL cholesterol and decrease HDL cholesterol,
promoting coronary artery calcification.
Cumulative evidence guided the AHAs decision to recommend that individuals limit their intake of trans fat to less
than 1% of total daily calories as part of a healthful lifestyle to

encourage cardiovascular health2 and led to an FDA ruling in
2006 mandating the labeling of trans fat on the Nutrition Facts
label. But a loophole allowing products containing fewer than
0.5 g of trans fat per serving to be labeled as 0 g left a low level
of trans fat in foods. Consuming several servings of products
containing almost 0.5 g of trans fat will exceed the daily limits
the AHA recommended.3
If the FDAs trans fat ban is finalized, food manufacturers will no longer be permitted to sell or use partially hydrogenated oils in food products without FDA approval for use
as a food additive and will again be in search of a suitable
replacement. According to the public comment submitted by
the Institute for Shortening and Edible Oils, a nonprofit trade
association representing the refiners of edible fats and oils
in the United States, The industry believes palm oil and its
fractions will likely be the initial replacement ingredient of
choice for many PHOs [partially hydrogenated oils] in applications requiring functional characteristics from the shortening. Further, The global supplies of palm oil are sufficient
to handle the expected increase in demand that would result
from the total elimination of PHOs.
Baked goods and certain other products require a hard
fatone with a high melting pointin their preparation, so
another hard fat must be used to replace partially hydrogenated oils, explains Michael F. Jacobson, PhD, cofounder
and executive director of the CSPI. Butter or lard would
usually work, but palm oil is cheaper and is of plant origin.
All are less harmful to health than partially hydrogenated
oil high in trans fat.
But is swapping partially hydrogenated oils for palm oil a
fair trade? The use of palm oil is not without unintended consequences, says Judith Wylie-Rosett, EdD, RD, a professor in
the department of epidemiology and population health and the
Atran Foundation chair in social medicine at the Albert Einstein
College of Medicine in the Bronx, New York. Palm oil contains
a high proportion of saturated fat, which we know also has
adverse health effects.
Saturated fats, similar to trans fats, raise LDL cholesterol
but are safer to consume at higher quantities than trans fats.
The AHA and the Dietary Guidelines for Americans recommend keeping saturated fat intake at less than 7% and at 10%
of energy intake, respectively.2,4 A threshold effect of lower
intakes of trans fat, which includes naturally occurring trans
fatty acids, hasnt yet been established.5
Its possible that establishing a tolerable lower limit of trans
fatty acids in foods would be less deleterious on health than
increasing the saturated fat content. We need to weight the
options very carefully, Wylie-Rosett says. We should examine
the history of saturated fats and consider their health effects.
We cant just assume that palm oil is the better replacement
because its a natural source. Natural doesnt necessarily
equate to healthy.
Environmental Concern
According to Jacobson, Palm oil suffers from at least two
problems: It boosts cholesterol levels, and most palm oil is
imported from Malaysia or Indonesia, where the expansion of
oil palm plantations has devastated the environment.
Palm oil is derived from the fruit, seed, or kernel of oil palm
trees, which are native to Africa but grown in the tropics of
Southeast Asia. Indonesia and Malaysia are the leading exporters of palm oil.6
The large-scale and mostly [more than 90%] unsustainable production of palm oil is causing unprecedented rates of
deforestation, wildlife depletion, greenhouse gas emissions,
and human conflicts in affected areas, says Ashley Schaeffer
Yildiz, palm oil campaigner for the Rainforest Action Network
(RAN). Indonesia was once home to 170 million hectares
(1 hectare is approximately 2.5 acres) of biologically diverse
rainforests, and today only approximately one-half remain
which is the size of Texas and Florida combined. According to
RAN, 18 million more hectares of rainforests will be converted
into palm oil plantations by 2020.7 Nearly 75% of global palm
oil is used in food products and cooking, making palm oil one of
the largest food environment issues today.
The islands of Borneo and Sumatra are at the height of the
palm oil debate. These highly desirable areas contain rich,
low-lying forests and wetlands that provide ideal conditions
for the oil palm trees to grow. However, these also are the
only remaining places on earth where tigers, rhinoceroses,
orangutans, elephants, leopards, and other wildlife coexist.
Many environmental awareness campaigns are using the
image of orangutans to build awareness. This is literally
because of their faces, says Richard Zimmerman, executive
director of the nonprofit organization Orangutan Outreach.
Theyre so much like us, it is uncanny. Its impossible to
look into the eyes of a baby orangutan that has lost his or
her mother because of palm oil and not feel compassion;
they remind people of their own babies. Imagine, these little
angels are now homeless and orphaned so that people can
have snack foods that are creamier with a longer shelf life.
The situation facing the orangutans in the wild is critical.
Entire populations are being wiped out as forests are
destroyed. Orangutans are being cut off from one another,
leading to genetic collapse. Without habitat, they simply
will not survive in the wild. They will be limited to zoos,
Zimmerman says.
The long-term goal of Orangutan Outreach, which partners
with many organizations on the ground in Indonesia, is to
prevent this from happening. We want to see all physically
healthy orangutans living in the wildin safe, protected
forests with minimal intrusion by humansfar away from
poachers, loggers, miners, and palm oil companies. For all
other orangutans that have been injured or disabled from palm
oil production and other human activities, we want them to
be able to live out their lives in dignity in long-term sanctuary
care free of cages. This will require long-term attention,

commitment, and funding, but we feel they deserve nothing
less, Zimmerman says.
Furthermore, palm oil poses other threats in addition to
wildlife reduction and extinction. Indonesia currently is the
worlds third largest emitter of greenhouse gases after the
United States and China, with 85% of its emissions coming
from rainforest and peatland degradation.8 Corporate land
grabbing (the seizing of land by a nation, state, or organization,
especially illegally, underhandedly, or unfairly) often is used to
obtain land and results in increased food insecurity, child labor,
and forced labor. For these reasons, palm oil that stems from
deforestation, wildlife endangerment, and human conflicts is
being referred to as unsustainable or conflict palm oil, with
the latter being more appropriate, Schaeffer Yildiz says.
The good news, according to Jacobson, is that solutions to
the palm oil debate do exist. Interesterified oils appear to be
safe; theyre made from soybean oil and typically include more
polyunsaturated fatty acids than palm oil, he says. Mixtures
of cottonseed, high-oleic canola, and other oils might work,
depending on the application.If companies must use palm oil,
they should at least use palm oil thats sustainably produced
either outside of Southeast Asia or on land certified by the
Roundtable on Sustainable Palm Oil [RSPO].
The RSPO was established in 2004, consisting of more
than 1,000 members representing 50 different countries, and
charged with ensuring that no new forests or conservation
areas are cleared for palm oil plantations and that current
plantations uphold human rights laws. Presently, 16% of the
worlds supply of palm oil is derived from RSPO-certified
plantations. According to Schaeffer Yildiz, Consumers are
being misled. Many of the companies that use the RSPO label
are in fact still causing rainforest and peatland destruction,
largely due to a lack of transparency in the palm oil supplier
chain. For this reason, RAN is encouraging companies to use
the term responsible palm oil to indicate that their palm oil
has been produced from traceable suppliers that dont engage
in deforestation, species extinction, high greenhouse gas
emissions, or human rights violations.
The big environmental groups have done an excellent job
recently of getting large companies, of which many already
belong to the RSPO, to commit to responsible palm oil, Zimmerman says. The RSPOs definition of sustainability is a
step in the right direction, but it isnt enough.
RAN coined the term The Snack Food 20 to describe 20
household names to target for commitments to change. The
Snack Food 20 have significant buying power, Schaeffer Yildiz
says. Since we launched our Last Stand of the Orangutan
campaign in September 2013, weve witnessed a huge shift in
the palm oil sector. Several companies have recently strengthened their commitment to eliminate conflict palm oil from
their supply chain, and others are in the process of doing so.
But a number of companies have failed to take action.
Companies need to completely eliminate deforestation from

their supply chains, Zimmerman says. Standing forests must
be left intact. Until all palm oil comes from traceable, conflictfree, deforestation-free sources, we must continue to fight it.
What RDs Can Do

Food and nutrition professionals can help by raising awareness about the greater implications of human diets. A healthful
diet is one that weighs the overall footprint of the food one eats
to encompass nutritional, environmental, and social impacts.
Food manufacturers have been looking at this issue for a while,
but the foodservice industry, private label grocers, and institutional settings could have a huge impact in transforming the
palm oil sector if they were educated and mobilized. With the
palm oil debate now in the public sphere, RDs and health professionals can become leaders in these issues.
To begin taking action, RDs can do the following:
Write, call, and petition companies to use responsible palm
oil in the products they make and sell.
Help companies follow through on their commitments to use
responsible palm oil through positive feedback. Let them
know youre happy with their decision and are more likely
to recommend their products to clients and patients over a
company that hasnt committed to responsible palm oil.
Tell clients and patients that palm oil largely is found in
processed foods, of which they should limit their intake,
according to the 2010 Dietary Guidelines for Americans and
leading health organizations.
Teach consumers how to read labels and spot hidden forms
of palm oil or oil mixtures.
Engage the public in healthful discussions by informing them
about conflict palm oil using social media sites and blogging.
Contact an environmental organization thats fighting
against conflict palm oil and ask them for ways in which
nutrition professionals can lend their expertise to help.
Join the Hunger and Environmental Nutrition Dietetic Practice
Group, whose mission is to empower members to be leaders
in sustainable and accessible food and water systems.
Beth Anne Conlon, MS, RDN, is a doctoral candidate in the
biomedical sciences, clinical investigation track at the
Albert Einstein College of Medicine in the Bronx, New York.
She conducts research on behavioral and lifestyle
interventions to improve cardiometabolic health.
Ashley M. Colpaart, MS, RDN, is past chair of the Hunger
and Environmental Nutrition Dietetic Practice Group and
a doctoral candidate in interdisciplinary studies in food science
and food safety at Colorado State University in Fort Collins.

Diabetes
Cardiovascular
Damage
and
Can
Antioxidants
Reduce
the Risk?
BY DENSIE WEBB, PHD, RD
iabetes and its cardiovascular complications are

an epidemic in the making. An estimated 8.3% of
the US population has diabetes (90% to 95% of
those have type 2 diabetes), while 35% of adults
older than age 20 have prediabetes, and most
dont know they have it.1 Fifty percent of adults
aged 65 and older have diabetes, and according
to a recent report, if the current pattern continues, by 2020,
more than one-half of the people in the United States either
will have prediabetes or diabetes.2
These statistics are more sobering when considering
that diabetes increases the risk of cardiovascular disease
(CVD) three- to eightfold.3,4 Diabetes makes the heart more
vulnerable to injury and more susceptible to heart failure.5 It
isnt surprising then that nearly 25 million adults in the United
States have been diagnosed with diabetes and coronary
artery atherosclerosis.5
Oxidative stress, in large part, contributes to cardiovascular complications associated with diabetes,4 caused by an
imbalance between damaging free radicals and the bodys
antioxidant defenses, which is linked to cellular dysfunctions
that lead to various diseases such as CVD.6
What Is Oxidative Stress?

Diabetes is associated with a state of increased oxidative stress, says Angela Ginn, RDN, LDN, CDE, a spokesperson for the Academy of Nutrition and Dietetics. Studies have
shown that the metabolism of excessive glucose and free
fatty acids that occurs with diabetes and insulin resistance
increases oxidative stress and may accelerate the development of complications.7
Oxidative stress results from the production of oxidizing
compounds (free radicals) in cells that exceeds the bodys
natural antioxidant defense system and can destroy cardiac
tissue and promote atherosclerosis. Chemically, free
radicals are highly reactive and form when oxygen interacts
with certain molecules in the body. They also result from
exposure to cigarette smoke, ultraviolet rays, pollutants
and chemicals, alcohol, and saturated fat and are found in
disproportionate levels in those with diabetes.8 The initial
trigger by which high blood glucose levels impair vascular
function is an imbalance between nitric oxide availability and
reactive free radicals.9 Nitric oxide, an anti-inflammatory
and antiatherosclerotic molecule, can relax blood vessels
and increase blood flow to tissues, but the nitric oxide
system is compromised in the presence of excessive free
radicals, resulting in hypertension and insulin resistance
and further impairing the nitric oxide system, creating a
downward spiral of cardiovascular damage.
Once formed, these free radicals set off a chain reaction of

creating even more free radicals. Hyperglycemia, hyperlipidemia, and insulin resistance, which are hallmarks of diabetes,
enhance oxidative stress. The production of the oxidant superoxide is the major cause of diabetes tissue damage and responsible for inactivating antiatherosclerotic enzymes.4
Not only does oxidative stress cause damage, it impairs the
hearts ability to respond to stressors, such as a lack of blood
flow and oxygen, and can cause inflammation that lingers even
after blood sugar is normalized.4 The downward spiral of free
radical formation and damage to the systems designed to neutralize them can result in disease.10
How to Treat Oxidative Stress

Vitamin E is one of the most common antioxidant compounds
suggested to reduce oxidative damage in patients with and
without diabetes. Several observational, epidemiological studies have suggested that both dietary vitamin E and vitamin E
supplements may decrease CVD risk.11,12 While only one looked
specifically at diabetes patients, approximately 30% of patients
with CVD have diabetes.11
Some population studies also have suggested that vitamin C
may offer similar protection. However, several prospective clinical trials have found that antioxidant supplements provide no
consistent cardiovascular benefits.12
Vitamin E
Arguably, vitamin E is the most widely studied and consumed antioxidant compound in the hope of reducing CVD risk
in populations with and without diabetes. Although antioxidant
treatments, including vitamin E, show benefits in animals with
diabetes, research has failed to show that supplements consistently provide any heart health benefits in clinical trials.13
In the Physicians Health Study II, men taking 400 IU of vitamin
E every other day for eight years obtained no cardiovascular benefits. In fact, an increased risk of hemorrhagic stroke occurred.14
A meta-analysis of more than 135,000 individuals treated
with vitamin E concluded that high-dose vitamin E (more than
400 IU/day) slightly increased the risk of death.15
The contradictory results of vitamin E protecting against cardiovascular complications has prevented researchers from recommending high-dose supplemental vitamin E. Moreover, further
study has revealed that it may be only a subgroup of diabetes
patients with a certain genotype called Hp2-2 who are likely to benefit from vitamin E supplementation, and that supplementation in
diabetes patients without the Hp2-2 genotype may be harmful.11
In most Western populations, about 36% of diabetes
patients have the Hp2-2 genotype. However, in Southeast
Asia, approximately 90% of the diabetes population has the
Among those with the vitamin-Eresponsive genotype, adding

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

may not apply to others.11 Pharmacogenetic testing allows the
health care provider to tailor treatment to a patients unique
genetic makeup, Ginn says, but the jury is still out.
While there appears to be no difference in the distribution
of the genotype among diabetes patients, studies have
established that the Hp genotype can predict CVD risk. The
specific Hp2-2 genotype appears to predict who among
diabetes patients will benefit from vitamin E supplementation.
While population studies suggest that vitamin C in

supplemental or dietary form may improve inflammatory
markers (indicators of oxidation in the body), its unclear
whether vitamin C intake reduces CVD risk among diabetes
patients.19 It does appear to decrease fasting insulin levels and
improve insulin action, though.20
Two large-scale, long-term trials that tested 500 mg/day of
supplemental vitamin C found it had no effect in women at high
risk of CVD or in men for preventing CVD.14,21
In a study of 315 patients, among those taking a combination of vitamin C (average intake of 500 mg/day) and vitamin E
(average intake of 400 IU/day) supplements for three months,
there were no improvements in body weight, hemoglobin A1c,
LDL, or triglycerides in those with either metabolic syndrome
or type 2 diabetes.22
Studies in which people took 800 to 3,000 mg/day of vitamin
C have found no significant differences in fasting glucose or
fasting insulin levels or specific inflammation markers.23-25
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However, one study showed improved levels of free radicals in

patients who took 1,000 mg/day of vitamin C for four months.26
While the effectiveness of antioxidant supplements appears
to be determined by genetic predisposition so is the extent to
which tissue damage likely is to occur.4 Furthermore, it seems
as though oxidative stress is only one factor contributing to diabetes complications; thus, antioxidant treatment most likely
would be more effective if it were coupled with other treatments
for diabetes complications.7
Glutathione
Sometimes referred to as the master antioxidant, glutathione, a tripeptide, is the most abundant antioxidant in animal
tissues and one of the most powerful. Its responsible for
several metabolic functions, including intracellular defense
against oxidative stress such as from toxins, drugs, and carcinogens.27 Gluathione is an important defense mechanism
against damage to the heart, Ginn says.
Glutathione depletion can occur from diabetes and aging,28
and levels also are affected by genotypes.29 Freshly prepared
meats are relatively high in glutathione, while fruits and vegetables have moderate to high amounts and dairy products, cereals,
and breads generally are low in the antioxidant. Frozen foods have
similar amounts as fresh foods, but other forms of processing and
preservation usually result in extensive loss of the antioxidant.30
When consumed, glutathione is broken down into its constituent amino acids, including cysteine. Available cysteine
primarily determines glutathione concentrations in cells.

N-acetyl cysteine (NAC) supplements sometimes are used to
provide cysteine and increase glutathione levels.31 However,
studies havent consistently found that NAC supplementation
increases glutathione levels.27
Can Oxidative Damage Be Prevented?

While researchers continue to study antioxidant compounds
and the medical community waits for genetic phenotypes to be
identified and genetic testing to be perfected, the only proven
way to prevent the oxidative damage associated with type 2
diabetes is to prevent the disease from occurring through
diet and lifestyle changes, which include regular exercise and
maintaining a healthy weight. Eating a diet rich in fruits and
vegetables provides antioxidants shown to reduce oxidative
damage and may provide protection against free radical damage.
Healthy eating, physical activity, and blood glucose control
are the pillars of prevention of diabetes and diabetes-related
complications, Ginn says.
Densie Webb, PhD, RD, is a freelance writer, editor,
and industry consultant based in Austin, Texas.

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2 0 1 4
SPRING SYMPOSIUM
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Collaboration With the NDA

The Nevada Dietetic Association (NDA) and Todays Dietitian worked
in tandem during the symposium. The NDA held its annual meeting and
awards ceremony plus its student poster session, which it made available
to conference attendees. Nineteen poster presenters from the University
of Nevada, Las Vegas (UNLV) discussed their research on topics such as
COPD, burns, refeeding syndrome, HIV/AIDS, celiac disease, and dietary
guidance for Roux-en-Y gastric bypass patients.
Moreover, an enthusiastic team of student volunteers from the dietetics
programs at UNLV; the University of Nevada, Reno; and Truckee Meadows
Community College in Reno, helped symposium attendees navigate their way
through the conference center, oversaw the Q&A segments of the continuing
education sessions, answered questions about the event, and packed tote
bags with programs, product samples, and other important information.
Daniel Lingle, a dietetics student at Truckee Meadows Community College,
said he especially liked the diversity of specialties among the attending
nutrition professionals. I enjoyed listening to the various presentations about
public relations, social media, and geriatrics. They were highly informative
and inspiring, he said.
Todays Dietitian had an incredible experience working with the university students and the NDA. The symposium afforded chapter members
networking opportunities with peers from around the country and gave
attendees a chance to learn about Las Vegas and its local dietetics chapter.
Poolside Party
To kick off the symposium in grand style, Todays Dietitian hosted a
two-hour poolside welcome reception, a preshow party and networking
opportunity for attendees, in the Tropicanas Beach Club, where everyone
enjoyed soft drinks, cocktails, and tasty hot and cold hors doeuvres, crudit, and desserts.
There was so much food, laughter, and good conversation that one
attendee cancelled her dinner reservations shed made previously because
she didnt realize there was going to be so much food and great company.
It was well organized, a good turnout, and the food was good! said Sanam
Shahrokhinia, MS, RD, a clinical dietitian at Cedars-Sinai Medical Center
in Los Angeles.
Sidesplitting Keynote
The next morning, attendees were greeted with nutritious Kelloggs breakfast cereals, fresh fruit, yogurt, coffee, tea, and juice along with hilarious
keynote speaker Brad Nieder, MD, known as The Healthy Humorist, who
blends health care humor with wellness advice. With many funny one-liners
and amusing stories, Nieder, who gave up emergency medicine to become
a comedian, explained how laughter really is good medicine for managing
pain, boosting the immune system, and relieving stress.
It was genius that you invited a comedian who had a health background,
Khan said. He set the tone and the mood for the next few days. He put a
smile on everyones face. You dont get that at every conference.
Cathy Armacost, MS, RD, a faculty member at Spokane Community College in Washington and a USA certified triathlon coach agreed: Dr. Nieder
was a wonderful way to start the day.
Here are some of Nieders most memorable

one-liners:
Laughing can keep us young and slow the aging
process.
Laughter can make you feel eight years younger
and help you live eight years longer.
According to one study, women undergoing in
vitro fertilization had more success if they were
entertained by a clown.
Forget the gym, the treadmill, and the personal
trainer. Laughing is jogging for the innards.
Humor is a way to get a point across.
The easiest thing you can do is smile. Smiles
produce the same physiological effects as
laughter. You may feel better and brighten the day
of someone who receives your smile.
SYMPOSIUM PHOTOS BY AMY BORNALO AND KEVIN PORTILLO; TROPICANA IMAGES COURTESY OF THE TROPICANA LAS VEGAS
So to all the nutrition professionals out there,

remember to smile and laugh for a healthier, happier
present and future.
Crme de la Crme Presenters

After Nieders entertaining performance, the true
A-listers in the nutrition profession presented an
incredible lineup of continuing education sessions
on some of the hottest topics in dietetics. Todays
Dietitians all-stars were:
Toby Amidor, MS, RD, CDN, founder of Toby
Amidor Nutrition;
Jenna Bell, PhD, RD, senior vice president
and director of food and wellness at Pollock
Communications;
Constance Brown-Riggs, MSEd, RD, CDE, CDN,
nutrition advisor for the Dannon One Yogurt Every Day Initiative;
Karen Collins, MS, RDN, CDN, FAND, nutrition advisor for the
American Institute for Cancer Research;

Becky Dorner, RDN, LD, FAND, founder and president of Becky
Dorner & Associates;

Sharon Palmer, RD, author, speaker, and contributing editor to
Todays Dietitian;
Robin Plotkin, RD, LD, a Texas-based culinary and nutrition
communications professional;
Barbara Ruhs, MS, RD, LDN, a former supermarket dietitian who
currently operates consulting business NeighborhoodNutrition.com;

Jill Weisenberger, MS, RDN, CDE, FAND, a private practitioner in
Newport News, Virginia; and

Dana Angelo White, MS, RD, ATC, an assistant clinical faculty member
and sports dietitian at Quinnipiac University in Hamden, Connecticut.

The topics that captivated the attendees attention included fad diets,
plant-based eating, diabetes, social media, retail dietetics careers, dietary

supplements, and sustainability, plus two professional development roundtables on business development and the value of writing and speaking. The
caliber of speakers was phenomenal, Wilson said. It was nice to see RDs
present on current and relevant topics that are so timely for practitioners.
According to Erika Rothacker, RDN, LD, of Wellness Coaches USA, a
national provider of on-site wellness coaching delivered to workplace
employees, The lectures were amazing, and there were so many people
from other states. I met so many women who were awesome.
The symposium was so well organized and well managed timewise [in
addition to] the room arrangement, temperature, nutritious meals and, most
of all, well-chosen and brilliant speakers, added Rose Quirante, MS, RD,
LD, a renal dietitian at the Renal Center of Port Arthur in Texas.
Book Signings, Tasty Treats, Delectable Lunches

During the morning and afternoon breaks, attendees enjoyed the book
and product showcase where they could meet some of the session speakers who were authors to discuss and purchase their latest books. BrownRiggs, author of the African American Guide to Living Well With Diabetes;
Palmer, author of The Plant-Powered Diet; Weisenberger, author of Diabetes Weight LossWeek by Week; and Dorner, author of the Diet and Nutrition
Care Manual, Policy & Procedure Manual, and various other continuing education resources, autographed books and other materials for purchasers.
Todays Dietitians sponsor companiesAlmased,

Daisy Brand Cottage Cheese, Diabetes Sentry, Go Veggie!,
INBalance Health Corp, Kellogg Company, and Walden
Farmsdiscussed their newest products and provided
samples for attendees to taste and eventually tout to clients and patients. Daisy Brand Cottage Cheese provided
mixed berry parfaits for the Tuesday morning break.
The lunch offerings also were a huge hit with attendees. I was very happy that healthy food was served,
especially the vegetarian lunch, said Kristine Duncan,
MS, RDN, CDE, an adjunct nutrition instructor at Skagit
Valley College in Mount Vernon, Washington.
Salads, fresh fruit, and a burger bar featuring MorningStar Farms veggie burgers in spicy black bean,
roasted garlic and quinoa, and buffalo chicken were
served on the first day of the symposium, along with
a variety of beverages. I loved the great lunches provided, said Carol Curtis, RD, CD, a dietitian at Memorial Hospital of South Bend in Indiana. It was good to
test the MorningStar products.
On the second day of the symposium, a Tuscan
buffet lunch was composed of sausage kale soup,
Caesar salad, caprese salad, grilled vegetables, and
a variety of pasta dishes. Fresh fruit, tiramisu, and

cannolis graced the dessert table. From day one, the
foods and snacks conveyed the message that you can
eat healthfully no matter where youre at, said Avelina San Juan-Roberto, MS, RDN, LD, who practices
in Henderson, Nevada.
Morning Yoga
Of course, the symposium didnt include all work
and no time for meditation and relaxation. On the
second day, attendees were invited to an invigorating
yoga session led by Las Vegas yogini Angie NegreteMarkle in the hotels outdoor Wedding Chapel courtyard. Participants engaged in a tranquil workout amid
the sweet scent of fresh flowers and soothing sounds
of a waterfall. Afterward, they were encouraged to
eat a quick grab-and-go, healthful breakfast that
included Special K products, apples, and bananas.
Moving Full Speed Ahead

All in all, the Todays Dietitians Spring Symposium
was a great success. Feedback from attendees was
nothing but positive, and many eagerly asked when
and where are we planning to have it next year. One of the things I liked
the best about the symposium was that we got to hear our industry leaders
validate and support the type of care were trying to provide our patients
in our own facilities, said Lisa Sherman, MEd, RDN, LD, who works in the
division of mental health and developmental services at Rawson-Neal Psychiatric Hospital in Las Vegas. The presenters were so inspiring. They
inspired us to do our best.
I appreciated the variety of session topics that were offered, which
enabled me to carefully select those sessions that were of the most benefit
to me personally and professionally, said Jenny Favret, MS, RD, LDN, an
eating disorder specialist for the Duke Healthy Lifestyles Program at Duke
Childrens Hospital & Health Center in Durham, North Carolina.
Next years symposium currently is in the planning stages. Much like the
first symposium, it will include a stellar lineup of top-tier presenters and
even greater opportunities to network and participate in continuing education sessions. We look forward to seeing you next year!
Judith Riddle is editor of Todays Dietitian.
Hospital
Sustainable
Foodservice
By Juliann
he sustainability movement has hit health

care, as hospitals are making great progress
toward establishing healthier, more sustainable
foodservice for patients and their families. Many of
these green efforts are influenced, at least in part,
by the Healthier Hospitals Initiative (HHI), a national campaign
to improve environmental health and sustainability in the health
care sector. Healthier food is one of six challenges that form
the basis of the HHIs campaign, providing resources, insight,
and support any hospital or health system can adapt to develop
sustainable foodservice programs.
Seema Wadhwa, director of the HHI and director of sustainability for Inova Health System in Virginia, has been pursuing various sustainability goals over the past few years as
part of her role with Inova, and the health systems efforts
were summarized in the organizations 2012 sustainability
report, which also illustrated the reasoning behind why such
efforts are pivotal for patients and the planet. Inova recognizes that food has a direct, measurable impact on human
health, the report states. We also acknowledge that the
current global food production system in the US is unhealthy
for both humans and the environment. Highly processed,
calorie-laden junk foods have become easier and cheaper
to access than natural, nutrient-rich food items. Antibiotics
are used as a growth stimulator rather than to treat illness
in livestock. Crops and livestock are grown using practices
that pollute our water, air, and land. The majority of our food
is produced in a way that sacrifices long-term well-being for
instant profits.
The HHI, for one, is working to change the status quo in hospital foodservice to adopt more sustainable practices. The
HHI is a national movement to implement a completely new
approach to improving environmental health and sustainability within the health care sector, says Patti Oliver, MS, RD,
MBA, director of nutrition for UCLA Health in California. Its
Schaeffer
intended to accelerate the greening of health care by offering

a free way for hospitals to introduce sustainable practices into
their daily operations. Twelve of the largest, most influential US
health systems, comprising over 490 hospitals with more than
$20 billion in purchasing power, have partnered with Health
Care Without Harm, the Center for Health Design, and Practice
Greenhealth to create the HHI as a guide for hospitals to reduce
energy use and waste, choose safer and less toxic products,
purchase environmentally responsible products, and serve
healthier foods.
Thus far, the HHI has grown to include nearly 1,000 hospitals in all 50 states and the District of Columbia. According to
Oliver, the HHI issued its first milestone report last year, based
on 2012 data, and the findings are promising. In the report,
data indicate that HHI hospitals have reduced their environmental footprint, lowered costs, and improved patient health
by incorporating sustainability initiatives into their business
models, she says. This is the first time hospitals have quantified sustainability efforts by collecting and reporting data to
show movement.
Whether with help from HHI tools or on their own, smaller
hospitals and large health systems alike are revising their
menus with a healthful twist, incorporating more local and seasonal food products, offering more vegetarian meals, and buying
more organic, fair trade, and sustainably grown beverages and
foods. There still are many health systems that have yet to see
the importance of sustainability efforts, and plenty of work still
must be done, but the health systems interviewed here are leading the movement in health care, demonstrating there isnt just
one look to sustainable foodservice in health care.
UCLA Health System

Based in Los Angeles, UCLA Health System comprises
Ronald Reagan UCLA Medical Center; UCLA Medical Center,
Santa Monica; the Resnick Neuropsychiatric Hospital at UCLA;
Todays Dietitian profiles

the top health systems
in the country that
are driving change.
Mattel Childrens Hospital UCLA; the UCLA Medical Group; and

more than 150 primary care and specialty care offices throughout the region, so the system feeds many mouths through its
foodservice operations.
We serve 3.4 million meals annually at our hospital campuses in Westwood and Santa Monica, Oliver says, adding
that the foodservice program covers inpatient meals at each
hospital as well as several retail locations on both campuses
and a large catering operation. We provide a hotel-style
room service for patients whereby they can order from a
menu featuring more than 40 different ethnically and culturally diverse entres, including vegetarian and vegan options.
While the foodservice menu boasts a multitude of ethnic and
cultural foods, theres one item you wont find: fried foods. We
completely eliminated fried foods from all of our menus several years ago, Oliver says, and we decreased the price of the
salad bar from $6.99/lb to $4.99/lb to encourage consumption
of fruits and vegetables.
We have a huge salad bar and a made-to-order sandwich
deli alongside made-to-order sushi, an international corner,
and a hot line with a variety of entres, she says of the many
healthful items that have replaced the previous fried offerings.
We also still offer a grill with burgers and sandwiches, pizza,
and El Pollo Loco, but even the vendors have no fried foods.
Not only are menu items healthier for patients in terms of
nutrient composition, but theyre also more sustainable. The
organizations sustainability policy set a goal to make 20% of
food purchases sustainable by 2020. We surpassed that goal in
early 2013 by having 24% sustainable purchases, Oliver says.
Our recent conversion to some sustainable cuts of meat will
increase our percentage above its current level.
For UCLA, sustainable means using a high percentage of
locally grown and organic produce, which is labeled at the salad
bar. We also post a map showing the location where all of our
produce originated, Oliver says.
The organization participates in Meatless Mondays to reduce
its meat purchases, offering a fully vegetarian menu every
Monday. You can still get a hamburger if you request it, Oliver
explains, but all of our daily specials are meat-free and we
post education on the 10 reasons to eat less meat.
Not only does that mean fewer meat purchases overall, but
UCLA Health System also has made efforts to ensure that the
meat they do buy is better quality. (This relates to one of the HHI
initiatives for balanced menus, which asks health systems to
use less meat and better-quality meat.) We recently started
purchasing antibiotic-free chicken breasts, beef patties, and
ground beef, Oliver says. This constitutes approximately 30%
of our meat purchases.
In addition, 70% of disposables used throughout the
foodservice program, such as utensils and plates, are
compostable; 20% are recyclable; and 10% still go to landfills, though Oliver notes that the University of Californias
overarching sustainable practices policy, which was developed by the 10 UC campuses, including UCLA, set a goal to
have zero waste go to landfills by 2020.
We also sell reusable UCLA Health coffee mugs and give
discounts on coffee to patrons who bring any reusable mug,
she says, adding that in 2013, all UCLA Health staff members were given a reusable water bottle to encourage the use
of refillable hydration stations that are available across the
UCLA campus.
Inova Health System

Inova, a not-for-profit health care system based in Northern
Virginia, serves more than 2 million people each year throughout the metro DC area through the systems five hospitals. In
addition to being one of the founding HHI systems, in 2012, the
health system developed the Inova IMPACT platform, which
guides its overall sustainability strategy. This platform breaks
down all efforts into three distinct branches: healthfulness,
sustainability, and connectivity. Thus far, the health system has
made big strides in each one of these categories, and it has
even bigger plans for the future.
Regarding healthfulness, Inova has made numerous menu
changes in an effort to ensure everyone within its hospitals has
access to fresh, nutritious, and health-promoting foods. In
2012, Inovas Food Services team conducted cafeteria audits
across the system to establish baseline levels of healthfulness,
according to Inovas sustainability report. They used the
results to inform changes such as the repositioning of less
healthful food items, the installment of weekly produce stands
in cafeterias, and the switch from fried to baked for certain
popular grill items.
According to the report, at least one daily vegetarian option
was added to the hot food station, and many snacks that didnt
meet the healthfulness guidelines were replaced with more
nutritious options or eliminated altogether.
Inova continues to work toward meeting several healthfulness goals, including reducing fried foods and sweetened beverages; offering more fruits and vegetables and fresh, seasonal
produce; and moving away from processed foods.
Regarding sustainability, Inova has taken steps toward
purchasing more locally grown food products. Last year, Inova
was able to double our local food spend, Wadhwa says. We
also have partnered with local farmers for [an organic] CSA
[community-supported agriculture] program.
Moreover, All coffee was switched to fair trade, says
Carolyn Billetdeaux, of Inovas Office of Sustainability. Weve
started to track our meat [in 2013] to create a baseline for [an
effort toward reducing Inovas meat spending] and are working
on carbon foodprinting.
The third branch of Inovas sustainability program extends
its efforts beyond Inovas facility walls and seeks to bring the
healthful and sustainable food conversation to the community.
To do that, Inova established a mobile farmers market that

brings local produce into areas with few healthful options. In
addition, the health systems Double Dollars Program provides
an incentive for food stamp recipients at four local farmers
markets as well as the mobile market so they can purchase
fresh and local foods. Through this effort, Inova matched the
first $10 in SNAP [Supplemental Nutrition Assistant Program]
purchases at four local farmers markets, as well as at a Mobile
Farm Market, according to Inovas sustainability report. SNAP
is a key initiative in the nations nutrition safety net.
To help get more people talking about these issues and
incorporating sustainability efforts into their daily lives, Inova
also offers cooking classes that help inform people about what
healthful and sustainable really mean. Carolyn Billetdeaux has
been a champion and also produced a sustainable cookbook
and local ingredient guide, says Wadhwa, who credits Inovas
foundation of a strong team, including Billetdeaux, for the
health systems sustainability successes.
Kaiser Permanente
Kaiser Permanente, which serves upward of 9 million members in eight states and the District of Columbia, was among the
12 health care systems that helped to launch the HHI. However,
its efforts toward offering more healthful food options arent
new; it began almost a decade ago.
Kaiser Permanente developed healthy nutrition standards
in 2005 as part of our Healthy Picks program, says Jan C.
Villarante, MS, RD, director of national nutrition services,
procurement, and supply. Healthy Picks standards are based on
evidence-based research. The program then evolved to include
sustainable food criteria into our foodservice program as well.
Part of that evolution came through Kaiser Permanentes
Environmentally Preferable Purchasing Policy, which it developed in 2008, as well as detailed sustainable food purchasing
criteria developed the year after. In 2012, we launched our Sustainable Food Scorecard, which we used in our RFP [request
for proposal] and contracting process to set sustainability standards within the industry, says Kathleen M. Reed, sustainable
food program manager and national farmers market coordinator. We achieved an 18% sustainable food spend in 2013.
In 2012, Kaiser Permanente and its 38 hospitals teamed up
with Partnership for a Healthier America, for which it made
a commitment to deliver healthier food and beverage options
throughout its facilities, Villarante says. Through this partnership, Kaiser Permanente implemented menu labeling in
the cafeteria to give patrons more nutrition information at the
point of sale, instituted healthy-only marketing, and introduced
healthier sides, entres, and beverages.
Kaiser Permanente purchases about 590 tons of sustainably and locally and/or sustainably grown fruits and vegetables
annually, which are served on patient menus and in cafeterias
across the organization, Reed says, noting that many vending
machines offer fair trade coffee and tea. Kaiser Permanentes

Hawaii hospital also serves about 1,800 lbs of local, seasonal
seafood annually in its cafeteria and patient meals.
In addition, milk and yogurt, which are offered with many
patient meals, cafeterias, and vending machines, are free of
the growth hormone rBGH. And Northern California patients
who order from the patient menu can choose cage-free, certified humanely raised and handled eggs and beef burgers made
from animals raised without antibiotics or added hormones.
Kaiser Permanente projects to purchase more than 200,000 lbs
of meats raised without antibiotics in 2014.
With regard to this beef, and meat overall, there will be less
of it on the menu in the years ahead. Kaiser Permanente has
been making efforts to reduce the meat on our patient menus
by increasing the vegetarian options on our patient and cafeteria menus and serving more vegetarian items as the house
choice on our patient menus, Villarante says, adding that the
health system already has made some headway. Kaiser Permanente reduced beef purchases by 18% in 2013.
Other Sustainable Standouts

Through its subsidiaries, Tenet Healthcare Corporation, an
HHI sponsor organization, operates 77 hospitals, 189 outpatient centers, and Conifer Health Solutions, which offers business process solutions to more than 700 hospitals and other
clients nationwide.
Many of Tenets hospitals have incorporated more local produce, meat, and dairy options into their foodservice operations,
but Sierra Vista Regional Medical Center in San Luis Obispo,
California, in particular, has made great inroads in converting
its beverage offerings into healthier options. Currently, 75% of
drink offerings are water, unflavored sparkling water, and other
nonsugary beverages, and soda machines are nowhere in sight.
To further reduce waste, the hospital also eliminated bottled water for all hospital functions and catering events, says
Melinda Lokey, director of human resources administration,
who serves as the sustainability champion for Tenets sustainability efforts.
And its not just large health systems that are getting in on
the sustainability movement. Resolute Health, which Tenet
recently acquired, is a new health and wellness company in New
Braunfels, Texas, that focuses on preventive health measures
and changing the delivery of health care. Through its Sow
Healthy Garden program, Resolute Health sponsors 10 school
gardens with the local Comal County School District. In addition
to several community health centers, including the Center for
Wellbeing, Resolute Health was set to open a new full-service
hospital in June, and while it may be just opening, the hospital
has its feet firmly planted in healthful and sustainable practices.
The hospital will open with a reusable to-go container
program and composting, says Dion Turner, RDN, food and
nutrition director for Resolute Health. Our local organic farm is
15 miles away in Seguin and will be growing most of our produce.

We have selected local vendors for grass-fed meat, organic
tamales and tortillas, and cold-pressed healing juices. No
Styrofoam products will be found in our foodservice operations,
and we look at purchasing minimally packaged items.
According to Turner, the patient room service menu still will
showcase comfort foods, but they will be homemade and given
a healthful twist. The hospital will have plenty of fresh vegetables and will have a Meatless Monday menu all day in our Leaf
caf, she adds. The local organic vegetarian tamales are one
item that we expect to have every Monday.
Rex Healthcare in Raleigh, North Carolina, a member of UNC
Health Care, is a private, not-for-profit health care system that
serves more than 4,000 meals each day to patients and customers at three ancillary locations. Chef Jim McGrody is director of culinary and nutrition services at Rex, and hes made it a
personal quest to change the way hospital food is prepared and
served. Two years ago, the health care system removed fried
foods from its menus and replaced them with a wide variety of
whole grain options.
At Rex, fresh food reigns, and some of those ingredients
couldnt get much fresher, coming from a nearby courtyard. An herb garden, located in a courtyard near the caf,
was planted more than four years ago to encourage the use
of fresh herbs in daily cooking. Every attempt is made to
buy as much produce as possible from local North Carolina
farms, McGrody says, adding that educating patients and
visitors about these efforts is important as well. Information about the food we buy and prepare in the caf is posted
on a bulletin board to let customers know where our food
comes from.
Floridas Lee Memorial Health System, which includes five
acute care hospitals and two specialty hospitals, provides more
than 1.5 million inpatient and outpatient meals annually and
more than 5 million meals overall.
According to Larry Altier, systems director for food and
nutrition services, over the past three years, the health
system has made several sustainability improvements. In
addition to revising hospital menus to be lower in sodium and
fat, Lee Memorial also has substantially increased its local
food buys. Well over 44% of our vendors [offer] sustainable,
local products, Altier says. During peak growing months in
Florida, our produce can be as much as 88% local. Were also
working with a local urban grower to provide us with customgrown organic produce.
One foodservice vendor that has embraced the
sustainability concept is ARAMARK. Advocate Health Care,
a founding and sponsoring system of the HHI based in
Downers Grove, Illinois, worked with ARAMARK to introduce
compostable plates and bowls in its retail cafeterias and
compost food waste at select hospitals. The system also
establishes farmers markets at many hospitals during the
summer and promotes the use of reusable cups and mugs

to reduce waste and recycles plastic, glass, aluminum, and
paper, says Mary Larsen, MS, Advocates environmental
stewardship manager.
Sustainability efforts of Sodexos foodservice program
also are evolving, according to Debbie Petitpain, MS, RDN,
Sodexo wellness nutrition coordinator. Five years ago, we
upgraded our traditional patient tray line to room service,
which allowed us to reduce food waste as well as increase
patient satisfaction, Petitpain says. Eighteen months ago,
we started composting our patient tray waste and kitchen
scraps, and since starting this program have diverted over
90 tons of food waste from the landfill.
In addition, national food and dining management services company Unidine Corporation has initiated green
improvements over the past few years. Unidines Fresh
Food Pledge, which is its pledge to use authentic food from
scratch using fresh, responsibly sourced, seasonal ingredients and guided by environmentally responsible practices,
avoiding additives, chemicals, and preservatives, is used to
guide the culinary program and results in less waste, says
Ellen Lowre, RD, vice president of nutrition, health, and wellness. For example, if asparagus is on the menu Monday,
then cream of asparagus soup is planned for Tuesday so no
asparagus goes to waste.
Abounding Benefits
According to Oliver, its not just patients who are benefitting from these efforts toward establishing more sustainable
health care foodservice programs. Everyone benefits from the
healthy and sustainable initiatives weve embraced, she says,
whether thats in terms of personal health or an investment in
the future of the environment.
More than just patients, sustainability is about populations,
Wadhwa says. Inova sees sustainability as an upstream opportunity to focus on population health, she says.
In addition to patient and environmental health improvements, Reed says sustainability efforts can go a long way to
help local economies. Our local produce sourcing supports
small-to-medium scale local farmers and puts money back
into our local economy, she says. Our sourcing of sustainable
produce, dairy, meat, and poultry supports the human health of
consumers and the environmental health of the communities
where the food is grown.
And it doesnt taste too bad, either. Another great benefit is the quality and taste of the food provided to our patients,
employees, and visitors, all of which enhances their dining
experience, she says.
Juliann Schaeffer is a freelance writer
and editor based in Alburtis, Pennsylvania,
and a frequent contributor to Todays Dietitian.
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The most important meal of the day

provides clients and patients the perfect
opportunity to eat more vegetables
and meet dietary requirements.
BY LINDSEY GETZ
By
adulthood, people should be eating as many as 3

cups of vegetables per day, depending on their age
and sex. Unfortunately, most people dont even
come close to that number: A State of the Plate
survey conducted by the Produce for Better Health
Foundation found that the average person consumes 1.8 cups of
fruits and vegetables per day.
If your clients and patients are trying to pack more vegetables
into their day and are falling short, recommend they add veggies to
their breakfast plate. Bear in mind, however, that you also may be
addressing the fact that many clients may not be eating a wholesome breakfast or may be skipping it all together.
Most Important Meal

Many people dont eat their first vegetable of the day until dinner,
according to Sharon Palmer, RD, author of The Plant-Powered Diet
and Plant-Powered for Life. At that point, its probably too late to fit
in the full 2 or 3 cups recommended. Plus you dont gain the benefits of a good source of phytochemical-rich foods with antioxidant
and anti-inflammatory compounds pumping through your body all
day, she says. So why not try to include vegetables in the diet at the
very start of the day? Many cultures eat vegetables for breakfast,
and theres no reason we cant either. By eating them for breakfast,
youre fitting in those important servings and getting more fiber
and more nutrients to boost your day. Plus you can cut down on
unwanted calories by filling up on these plant foods.
In fact, filling up at breakfast may promote a healthier weight

as well. According to a study published in July 2013 in Obesity,
eating a large breakfast rather than a large dinner helps take
advantage of the natural fluctuations in the bodys metabolic cycle
and reduces carbohydrate cravings. Often, were used to eating
our biggest meal of the day at dinner, but that might not be the
best way to go, Palmer says. However, its important to make
sure that breakfast isnt just a refined carb, saturated fat mess. I
recommend servings from all major food groups: protein, whole
grains, fruits, and veggies.
Beyond promoting a healthy weight, eating breakfast has several other benefits. Its long been touted as the most important
meal of the day, and that largely has to do with getting the day
off to a good start. Eating a nutritious breakfast can get your
day started on the right foot, says San Francisco-based dietitian
Kaley Todd, MS, RD. It breaks your night fast and jump-starts
your metabolism. Studies have linked breakfast consumption to
lower risk of chronic diseases, better weight management, and
improved mental performance.
After sleeping seven or eight hours, eating breakfast in the
morningtypically within an hour of waking upis a great way to
renourish and fuel the body to start the day, adds Barbara Ruhs,
MS, RD, LDN, a former supermarket dietitian and the owner of
Neighborhood Nutrition in Phoenix. Eating breakfast helps us
to bring our blood sugar back to normal, fueling our brains for
the day ahead.
41
Solutions to Skipping
But Ruhs knows that despite its importance, many people skip
breakfast. I think many people opt for more sleep instead of waking
up and allowing enough time for breakfast, she says. Eating anything is better than nothing; however, you get out what you put in. If
you fuel yourself with a healthful and balanced breakfast, you will
get more brain-power bang for your buck.
The International Food Information Council Foundation did
a survey that found that even though 93% of Americans agree
breakfast is the most important meal of the day, only 44% are
actually eating it, says Elizabeth Pivonka, PhD, RD, president
and CEO of the Produce for Better Health Foundation. Mornings
are very busy and hectic, and I believe thats the biggest reason
more than half are skipping breakfast.
Americans are skipping breakfast for other reasons as well,
says Amy Myrdal Miller, MS, RDN, senior director of programs
and culinary nutrition for The Culinary Institute of America. Some
people think theyre too busy even though there are many very
quick, easy breakfast options, she says. Others think that eating
breakfast makes them hungrier than if they skip breakfast, but
this can be overcome by choosing more healthful breakfast foods.
Highglycemic-load breakfasts such as orange juice, a sweetened refined grain cereal, and nonfat milk will leave people feeling quite hungry only a few hours later. But a lower-glycemic-load
breakfast such as a whole orange, whole grain breakfast cereal,
nonfat milk, and some nuts or nut butter will leave people feeling
satisfied for a much longer period of time.
And, of course, adding veggies to the breakfast meal also is a
wholesome way to fill up. Todd says she urges people to include a
variety of vegetables throughout the day to maximize their nutrient intake. Vegetables typically are a nutrient dense food with
minimal calories, meaning a big nutritional bang that wont add
inches to the waistline, she says.
However, even those who are eating breakfast tend to shy away
from incorporating veggies. Ruhs says she doesnt think its an
aversion to veggies at breakfast; its simply not a natural consideration. In America, vegetables traditionally have been associated
with lunch and, even more so, with dinner. But helping to change
your clients and patients mindsets may be as simple as giving
them ideas and recipes but also may require helping them find
solutions to some of their nutrition struggles.
Helpful Hints for Success

Sometimes, just trying to get out the door on time in the morning can be a struggle, let alone trying to eat healthfully. Thats why
Pivonka says dietitians should suggest foods that are easy to fit
into a busy schedule. Tomato juice is a great way to get some vegetables quickly, she says. People often need to be reminded that
they can incorporate fruits and vegetables in all formscanned,
frozen, fresh, or driedin order to find ways to incorporate more.
Foods that can be taken on the go definitely are a key to success. A lot of people I talk to have problems fitting in a wholesome breakfast on the run, Palmer says. Some people wait to
eat breakfast until they get to work or school and then their choices
may be limited to less-than-stellar food options.
RDs may need to remind clients that adding veggies can be

simple, and they can be eaten on the run. Some cultures slice
vegetables over a breakfast sandwich, such as radishes, cucumbers, tomato slices, or lettuce leaves, Palmer says. Just spread
whole grain bread with hummus, tahini, or nut butter and pile it with
delicious, crisp vegetables. Thats an easy, packable breakfast.
[Suggesting] quick, easy, and affordable breakfast ideas that
incorporate veggies is the best way to encourage others to gobble
up produce in the morning, Ruhs adds. Grab and go is the way to
go for breakfast, and creating vegetable-inspired breakfast plans
that accomplish this can go a long way. The smoothie and juicing
folks are breaking barriers in this realm.
Smoothies definitely are a simple way to squeeze more vegetables in, Myrdal Miller agrees. Consider adding canned, drained,
rinsed beans to berry-based smoothies for some extra fiber and
protein, she says. Dark leafy greens go great with citrus-based
smoothies, and baked sweet potatoes are a wonderful addition to
apple-based smoothies with cinnamon.
But Myrdal Miller says eggs truly are the gateway to fitting in
more vegetables at breakfast time. Vegetables, including beans,
can be added to omelets and breakfast sandwiches, she says.
Breakfast burritos and tacos are gaining in popularity, and vegetables easily can be incorporated into the filling with a vegetablebased salsa that can be used as a condiment.
Eating leftovers is another morning vegetable option, Pivonka
suggests. If you had a healthful vegetarian pizza for dinner, have
some cold for breakfast, she says. This is an easy way to get
some extra vegetables in the morning.
Todd says mixing leftover vegetables from dinner into your
breakfast meal also is quick and easy since the vegetables already
are cooked. Making a quick morning hash with sweet potatoes
and leftover vegetables can be a delicious way to kick off your
morning while also sneaking in a serving of vegetables, she says.
Vegetables also can be baked into muffins. Adding pured
pumpkin or shredded carrots or zucchini to your whole grain
muffins is a great way to incorporate vegetables, Todd says.
Make a big batch and freeze the extras for a quick, veggiepacked treat on the run.
While vegetables at breakfast may be a new idea for clients, its
one they can come to embrace. After all, many other cultures have
long been getting their veggies during the morning meal. Vegetables at breakfast may seem foreign to Americans, but there are
many cultures and cuisines from around the world that include
vegetables at every meal, including breakfast, Myrdal Miller
says. Theres a wonderful savory Bolivian quinoa breakfast pudding thats topped with roasted peppers and an aged cows milk
cheese. In Turkey, eggs are scrambled with vegetables to create a
dish called menemen. In Italy, a savory breakfast porridge is made
from dried, ground fava beans. And in India, dal [cooked lentils] is
a common breakfast food. With some good ideas, Americans can
be on board with more vegetables at breakfast, too.
Lindsey Getz is a freelance writer based
in Royersford, Pennsylvania.
Veggie Recipes
Sunshine Tofu Scramble

Serves 2
Ingredients
1 tsp extra virgin olive oil
1 clove garlic, minced
1
2 small onion, diced
1 small yellow summer squash, sliced
1
2 yellow bell pepper, diced
1 cup sliced mushrooms
5 oz extra firm tofu (12 package), cubed
1 tsp oregano
Black pepper and salt to taste
2. Fill a saut pan with 112 inches of water, add the vinegar,
and bring to a simmer. Break 1 egg into a small bowl, then

carefully pour it into the water and vinegar mixture. Repeat
with second egg, spacing them so they dont touch. Poach at
a gentle simmer until the whites are firm but the yolks are
still runny, 3 to 4 minutes. With a slotted spoon, transfer the
eggs to paper towels and season with salt and pepper.
3. Divide quinoa and vegetable mixture between two plates
or bowls. Top each with an egg and half of the Parmesan
cheese and sliced avocado.
Nutrient Analysis per serving

Calories: 350; Total fat: 22 g; Sat fat: 5 g; Cholesterol: 190 mg;
Sodium: 250 mg; Total carbohydrate: 26 g; Fiber: 7 g;
Sugars: 2 g; Protein: 15 g
RECIPE COURTESY OF KALEY TODD, MS, RD
Directions
1. Heat oil in a skillet. Add garlic, onion, and squash, and saut
for 3 minutes.
2. Add bell pepper, sliced mushrooms, tofu, oregano, and
seasonings. Saut for an additional 5 minutes until vegetables
are tender.
Pumpkin Pecan Spiced Pancakes
Ingredients

Sodium: 13 mg; Total carbohydrate: 12 g; Fiber: 4 g; Sugars:
6 g; Protein: 9 g
RECIPE COURTESY OF SHARON PALMER, RD
Morning Grain Goodness

Serves 2
Ingredients
1 T olive oil
1 cup mixed raw vegetables, diced (try zucchini,
asparagus, mushrooms, and broccoli), or leftover
cooked vegetables
1 cup raw spinach
Salt and pepper, to taste
1 cup cooked quinoa or brown rice
1 tsp vinegar
2 large eggs
2 T grated Parmesan cheese
1
2 sliced avocado
Directions
Makes 8 pancakes
1 cup unsweetened plant-based milk

1
2 cup water
5 T canned pumpkin
2 T canola oil
2 T maple syrup
2 tsp egg replacer
1 cup white whole wheat flour
1 T baking powder
1 tsp ground cinnamon
1
2 tsp ground nutmeg
1
4 cup chopped pecans
1 T ground flaxseeds
Directions
1. Combine plant-based milk, water, pumpkin, canola oil,
maple syrup, and egg replacer in a medium bowl.
2. Add white whole wheat flour, baking powder, cinnamon,
nutmeg, pecans, and flaxseeds, and stir just until well
combined, being careful not to overwork the batter. Let stand
for 10 minutes.
3. Heat a griddle on its low setting (or heat a skillet over low
heat) and spray with nonstick cooking spray. Ladle 13 cup
pancake batter onto griddle and cook until golden on both
sides and cooked through (about 4 to 5 minutes on each side).
4. Repeat the process to make 8 pancakes.
1. Add oil to a medium skillet over medium heat. Add
mixture of raw vegetables, and cook until slightly tender

(skip this step if using cooked vegetables). Add spinach
to vegetables, and cook until wilted. Season with salt and
pepper. Mix in quinoa or brown rice, and heat until warm.

Sodium: 160 mg; Total carbohydrate: 18 g; Fiber: 4 g; Sugars:
6 g; Protein: 4 g
RECIPE COURTESY OF SHARON PALMER, RD
Nutrition Facts
Label
The
Dietitians speak out about the FDAs proposed

changes, what more should be done, and how
the updates will impact public health.
By DAVID YEAGER
uch has changed in nutrition science since

the Nutrition Labeling and Education Act,
signed into law in 1990, mandated that
nutrition labels be placed on packaged
foods. However, the labels themselves
havent changed to reflect the science, with the exception
of listing trans fat content beginning in 2006.
Later this year, however, the Nutrition Facts label will get
a significant facelift. The FDA issued two proposed rules in
March that were open for public comment until June 2. The
final rules, which will revamp the labels and bring them more
in line with the latest nutrition science and how people eat
today, will take effect 60 days after theyre published in the
Federal Register, and manufacturers will have two years to
bring their labels into compliance.
Many dietitians believe its time to update the Nutrition Facts
label. Although it was an improvement over previous labeling
efforts, there were limitations. Janet Colson, PhD, RD, a
professor in the nutrition and food science program at Middle
Tennessee State University, says the proposed changes will
provide more relevant information in an easier-to-understand
format for average consumers. For example, in the 1990s,
most dietary advice focused on reducing total fat, saturated
fat, and cholesterol, and the general consensus of the nutrition
community was that all sugars are basically the same, she
says. In fact, one of the leading nutrition textbooks [of that
time] emphasized that the only problem with added sugar was
that it causes cavities. After years of research, evidence on the
effects of added sugars vs. natural sugars shows they have
different effects on health. The public needs to be able to use
the food label to determine the difference.
What Lies Ahead

One of the most significant proposed changes to the
Nutrition Facts label will be the inclusion of added sugars.
The 2010 Dietary Guidelines for Americans state that the US
populations sugar intake is too high. In fact, the American
Heart Association, the American Academy of Pediatrics,
the Institute of Medicine, and the World Health Organization
recommend people decrease their intake of added sugars,
according to the FDA.
On average, Americans get 16% of their total calories from
added sugars, and the major sources are soda, energy and
sports drinks, sugar-sweetened fruit drinks, grain- and dairybased desserts, and candy. Theres no specific recommendation for added sugar intake, but by listing added sugars
separate from naturally occurring sugars on nutrition labels,
the FDA hopes to make consumers aware of how much extra
sugar theyre getting in a given food.
Removing the calories from fat line is another proposed
change. Current research indicates that total fat is less
important to overall health than the types of fat a person

consumes. Moreover, FDA consumer research has found
that calories from fat make no difference in a persons
ability to judge the relative healthfulness of a product.
Values for total fat, saturated fat, and trans fat will remain
on the label, though.
The new labels also will more prominently display the
number of calories per serving and adjust serving sizes to
reflect what people actually eat, which is required by law,
rather than what they should eat, especially since Americans
are eating larger portions today than they were 20 years ago.
For example, a typical serving size of ice cream is listed as
1
2 cup, and whats being proposed is that they increase that
to a full cup, which is a more realistic serving size, says Liz
Weinandy, MPH, RD, LD, an outpatient dietitian at The Ohio
State University Wexner Medical Center. The serving size is
whats listed on the label, and the portion size is what a person
would eat. So theyre starting to get the portion size and the
serving size to be closer to the same thing, which would make
the labels much more realistic and easier to understand.
Some food containers will list total calories depending on
whether someone likely will eat or drink the entire package
content in one sitting. Weinandy says this can be a useful tool
for someone who drinks a 20-oz bottle of soda, for example,
because labels on these products currently list multiple servings. If someone eats a whole bag of potato chips or a container
of ice cream each week, it will be easier for them to see how
many extra calories theyre consuming over time, she adds.
Vitamins and minerals such as calcium, vitamin D, potassium, and iron also may be added to the Nutrition Facts
labels. These proposed revisions are based on data from the
National Health and Nutrition Examination Survey and focus
on nutrients that most Americans dont adequately consume.
Currently, vitamin D and potassium arent required on nutrition labels. Values for vitamins A and C would no longer be
required because most Americans get plenty of these nutrients, although manufacturers can include them voluntarily.
Additionally, rather than listing the percent Daily Values
a food provides, the labels will list the specific amounts of
those nutrients in micrograms and milligrams. When we
talk to clients, we tell them how many grams or micrograms
they need of that nutrient, says Erin Winterhalter, MPH,
RD, LDN, CDE, director of the MacDonald Center for Obesity
Prevention and Education in Villanova Universitys College of
Nursing. We dont say, You need three foods that have 20%
of your Daily Value of vitamin D; that doesnt translate well
for the consumer. The consumer is looking for the number of
milligrams that they need each day. We tell them, You need
1,000 mg of calcium per day, and this foods going to give you
200 of that. So now well be able to explain it in laymens
terms for them with the help of the food label.
Need for More Improvements

Although most dietitians agree that these changes are
overdue, some have suggestions for further improving the
labels. Colson would like to see folic acid values included,
and Weinandy says larger print would be helpful for older
consumers. And while serving sizes on approximately 17%
of products would be updated, some say theres still potential for confusion.
These serving size changes arent harmonious across
all food categories, says Rene Ficek, RD, LDN, CDE, lead
nutrition expert at Seattle Suttons Healthy Eating, a freshly
prepared healthful meal service. In fact, the new label
changes could make this gap even bigger. For instance,
serving sizes on packages should match with serving sizes
listed in the Dietary Guidelines for Americans. However, food
manufacturers differ widely [on how they list serving sizes].
We need to ask ourselves, What is an actual serving for
Americans, and what should it be? she continues. Some
people eat a pint of ice cream by themselves. If the FDA stated
that an entire pint of ice cream was the actual serving size, it
could encourage overeating, which is exactly what the labels
are aiming to avoid. It would be ideal if the USDA and FDA
could work together to present one seamless, clear message
to consumers, but unfortunately the new labels dont go far
enough in this category.
Another common criticism of the proposed changes is that
the labels rely on a 2,000-kcal diet to derive the percent Daily
Values. Many dietitians interviewed for this article say that,
because nutritional needs vary widely among individuals,
the percent Daily Values arent particularly helpful, and they
Resources
Overview of label changes: www.fda.gov/Food/
GuidanceRegulation/GuidanceDocumentsRegulatory
Information/LabelingNutrition/ucm385663.htm
Fact sheet on proposed changes: www.fda.gov/
Food/GuidanceRegulation/GuidanceDocuments
RegulatoryInformation/LabelingNutrition/
ucm387533.htm
Proposed rule for revising food labels: www.fed
eralregister.gov/articles/2014/03/03/2014-04387/
food-labeling-revision-of-the-nutrition-and-supple
ment-facts-labels
Proposed rule to adjust serving sizes on food labels:
www.federalregister.gov/articles/2014/03/03/201404385/food-labeling-serving-sizes-of-foods-that-canreasonably-be-consumed-at-one-eating-occasion
dont refer to them when educating clients. What would be

helpful, they say, is more guidance about how the amount of
nutrients relate to diet.
Identifiable colors on the labellike our red, yellow, and
green stoplight systemmay work here, Winterhalter says.
If the product is low in sodium, lets highlight that and mark it
in green. If its a high-sodium food, the label could reflect this
information in red. By adding color or images, like a thumbs up
or thumbs down symbol, you lower the literacy level required
to read the label, and it instantly becomes easier for all
consumers to understand.
Dietitians also hope for more transparency about food
ingredients. Blanket statements such as natural flavors are
of little value to consumers. Although known allergens must
be stated on the label, other ingredients that may affect health
can be hidden.
Id like to see caffeine content listed, Weinandy says.
I think this is really important. Right now, a lot of products
dont have to disclose the amount of caffeine thats in them. In
general, energy drinks are the main culprit. When you see a
product that says high energy or gives you energy, it may say
something like with added B vitamins or with ginseng on the
front label, and people think that theyre getting energy because
of added vitamins or herbs. But what a lot of companies are
doing is theyre actually adding caffeine and, of course, we dont
have any idea how much. Sometimes, even if you call them, they
wont provide that information. The energy drinks are really
a concern, especially for adolescents who might drink them
frequently or people with cardiac problems.
New Labels Impact

How much of an effect can a simple food label have on
public health? Although it may not be a bombshell, over time
its influence could be substantial.
For example, the proposed changes could help make a dent
in the obesity epidemic by putting pressure on manufacturers
to reduce the added sugar content in their products. Hopefully, it will affect the manufacturers in the same way as when
trans fats were separated out on the label, says Christine
Santori, RDN, CDN, program manager of the Center for Weight
Management at Syosset Hospital in New York, part of the North
Shore-LIJ Health System. It pushed many manufacturers to
either not add [trans fat] in their food products or change their
formulations a bit, so Im hoping that may be the case as well
when it comes to added sugars, that manufacturers will start
reducing the amount of added sugars they put in products.
For the most part, many dietitians believe the proposed
changes will make nutrition labels more useful and help them
educate consumers. The changes include areas that many of
them emphasize, such as essential vitamins and minerals,
good vs. bad carbohydrates, and appropriate calorie, sodium,
and fiber intake.
The new labels will be a valuable resource in working with

obese, diabetic, or hypertensive patients as well as counseling clients who simply want to plan healthier diets, Colson
says. Obesity and diabetes are at an all-time high. If we, as
dietitians, educate the public on the need for healthful eating
and convey simple messagessuch as, try to limit sodium to
1,500 mg a day; aim for about 100 kcal per snack or 500 kcal
per meal; eat at least 25 g of fiber each day to avoid constipation; or teens need 1,300 mg of calcium each day and adults
need 1,000 mgthe public can use information on food labels
to improve their diets.
Ultimately, though, its up to consumers to take advantage
of the tools at their disposal. For those who already eat a
nutritious, well-balanced diet, the new labels probably wont
change their buying habits, Ficek says, but for those who eat a
lot of processed foods, the proposed changes may encourage
them to give calories, serving sizes, and added sugars a
second thought.
Easier-to-understand labels are a step in the right direction,
but much of the responsibility for public health falls on the
public, dietitians say. To make a significant dent in obesity and
the conditions associated with it, continued public outreach is
essential. Certainly, the label changes would be helpful for
the people who are reading them, but somehow we have to
The Premier Independent

nt
Online Resource for
Nutrition Professionals!
get the people who arent turning the package over to look at
the label, Santori says. If we can affect those folks and have
them care a little bit more about whats in the package, that
would possibly alter the obesity epidemic.
One piece of good news is that more people than ever are
reading nutrition labels. Weinandy says more than one-half of
consumers read labels, and that number has been increasing.
Dietitians hope that eventually the labels will have a trickledown effect on Americans health.
But while more people are paying attention to what they
eat, theres still more to be done. After more than 20 years, it
will take some time for people to get used to the new labels.
As with any change, there will be an adjustment time for
consumers, Ficek says. Any changes to the Nutrition Facts
panel need to be part of an overall education effort. If no one
understands his or her calorie needs for the day, none of this
will make sense for consumers. Dietitians will be an integral
part of this education to help consumers in the long run by
translating nutrition information to the public. I believe many
consumers will find the changes both important and relevant
to their personal needs.
David Yeager is a freelance writer and editor
in Royersford, Pennsylvania.
Tod
aysD Visit
ietit
ian.
com
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47
CPE MONTHLY
VITAMIN Ds ROLE IN HEALTH

Deterministic or Indeterminate?
By Stephanie Dunne and Jenna A. Bell, PhD, RD

Although the name suggests otherwise, vitamin D isnt
a vitamin because its not an essential element of the diet.
Rather, its a prohormone synthesized by the skin when its
exposed to ultraviolet B (UVB) radiation.1 Yet despite the bodys
ability to produce vitamin D and its availability in some foods,
estimates indicate that 50% of children and adults worldwide
have insufficient amounts of vitamin D in their bodies.2 From
Canada to South Africa and every latitude in between, vitamin
D deficiency appears to be common, and it may be causing a
wide range of health issues.2
This continuing education course explores how the body
absorbs and metabolizes vitamin D, discusses its functions in
the human body, explains how to evaluate appropriate blood
levels based on the latest research, and identifies sources of
the nutrient.
Absorption and Metabolism

Vitamin D comes in two major forms: vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Primarily, vitamin D2
is manufactured and used to fortify foods, while vitamin D3 is
synthesized in the skin and naturally available in some animalbased foods. Commercially manufactured supplements contain
either form.3 Because these two forms have identical metabolism and function, the term vitamin D is used to represent
both vitamins D2 and D3 unless specified.
Although vitamin D is available in both foods

and supplements, sun exposure is the most
significant source for most people.4 When UVB
rays hit the skin, approximately 10% to 15% of the
7-dehydrocholesterol found in the skin is converted
to previtamin D3. In a thermal-dependent reaction,
previtamin D3 then is isomerized to vitamin D3
before being bound to vitamin Dbinding protein
and released into the circulating blood.1,5
Vitamin D3 then travels to the liver, where its
hydroxylated to calcidiol, or 25-hydroxyvitamin D
[25(OH)D]. Calcidiol then is carried to the kidneys
and other tissues, where its enzymatically
converted to its active form, calcitriol or 1alpha,
25(OH)2D.5 The conversion from calcidiol to
calcitriol primarily occurs in the kidneys but also
can occur in muscle tissue; the cells of the colon,
prostate, pancreas, lungs, skin, breasts, and
brain; and the immune system.1,2,5
When people ingest vitamin D from food
sources, the intestines epithelial cells absorb the
vitamin D and carry it via chylomicrons through
the lymphatic system and into the circulatory
system.5 From the chylomicrons, vitamin D may be
transferred to the vitamin Dbinding protein and released into
the liver, or it may stay in the chylomicron where it will be taken
up by the liver, which is the last stop for the chylomicron after
circulating in the body.1 Once in the liver, dietary vitamin D follows
the same activation path as that produced from UVB rays by
being hydroxylated into 25(OH)D and then into 1alpha,25(OH)2D.
Calcitriol is a self-limiting entity. High levels reduce the kidneys production of 25-hydroxyvitamin D-1alpha-hydroxylase,
which lessens the amount of calcidiol thats converted to
calcitriol.5 Calcitriol also upregulates the production of
25-hydroxyvitamin D-24-hydroxylase, an enzyme in the kidneys
COURSE CREDIT: 2 CPEUs
LEARNING OBJECTIVES
After completing this continuing education course,

nutrition professionals should be better able to:
1. A ssess vitamin Ds life cycle in the body.
2. Evaluate vitamin Ds involvement in various aspects
of health.
3. Determine recommended intakes of vitamin D.
4. Distinguish the sources of vitamin D.
Suggested CDR Learning Codes

2000, 2020, 2090, 4030; Level 2
and other tissues thats responsible for inactivating both

calcidiol and calcitriol. Once vitamin D has been inactivated by
being turned into either 24,25(OH)2D or calcitroic acid, it returns
to the liver where its added to bile and excreted in the feces.1
Functions of Vitamin D
Since Polish physician Jerdrzei Sniadecki realized that
rickets, the bone-deforming disease in children, could be
prevented and cured with sunlight, vitamin D has been well
established as an essential part of calcium and phosphorus
homeostasis and therefore bone maintenance.2,3 Specifically,
calcitriol increases calcium and phosphorus absorption from
the intestine and prevents the kidneys from excreting calcium
and phosphate. Calcitriol also stimulates preosteoclasts to
mature into osteoclasts, which break down bone and release
calcium and phosphate into the blood. In an effort to recover
homeostasis, parathyroid hormone (PTH) triggers both of these
mechanisms when serum calcium and phosphate levels have
dropped too low.5,6
Since there are numerous vitamin D receptors throughout
the body, it appears that the nutrient has many other functions
beyond bone health.5 In fact, vitamin D directly or indirectly
influences as much as 5% of the genes in the human genome.3
Also, between 200 and 600 genes are primary targets of vitamin
D, as theyre directly involved with vitamin D receptors. As the
direct effect, vitamin D may cause an increase or decrease in
the expression of the target gene depending on the gene itself.1,7
In addition to genetic influences, vitamin D receptors are
found in the membranes of many cells, including those in the
brain, gonads, skin, vascular smooth muscle, and immune
system. These receptors allow vitamin D to trigger secondary
messengers within some cells, causing a rapid hormonelike
response that doesnt involve genetic changes.1,2,5
Few studies regarding vitamin Ds effect on various conditions
have been randomized controlled trials. In fact, most studies
have been observational and show correlation but cant prove
causation.4,6 Therefore, its possible that sociodemographic
factors, lifestyle choices, and metabolic health are confounding
factors in studies reporting vitamin Ds impact on health.4
That being said, the epidemiologic evidence and scientific
studies showing that vitamin Ds effects go beyond bone health
are increasing. For example, infants who received 2,000 IU/day
of a vitamin D supplement had an 88% lower risk of developing
type 1 diabetes by the age of 32, and normotensive children given
2,000 IU/day had significantly lower arterial wall stiffness after
16 weeks compared with children who were given only 400 IU/day.6
Another study showed that children given 1,200 IU of vitamin
D per day for four months during the winter reduced their risk
of an influenza A infection by more than 40%.2 And pregnant
women deficient in vitamin D seem to be at greater risk of
preeclampsia and cesarean section.6
The following are some of the ways vitamin D appears to
maintain health1-5:
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Cancer: suppresses the proliferation of and stimulates the
differentiation and apoptosis of some kinds of cancer cells,

especially breast, prostate, and colon;
Diabetes: triggers the transcription of the insulin receptor
gene in peripheral target cells and activates the release of
insulin from the pancreas beta cells;
Cardiovascular disease: decreases PTH levels and
the release of renin by the kidneys, which helps reduce
blood pressure;
Muscular function: increases calcium uptake by muscles
and stimulates the intracellular release of calcium within the
muscle to maintain appropriate muscle contraction;
Immunity: upregulates macrophages production of
cathelicidin, a protein that helps them fight conditions
such as upper respiratory infections and tuberculosis;
Parkinsons disease, Alzheimers disease, depression, and
schizophrenia: prevents the loss of dopaminergic neurons in
the brain; and
Multiple sclerosis, rheumatoid arthritis, Crohns disease,
and type 1 diabetes: suppresses the autoimmune response.
Although scientific studies havent proven these effects,
theyre considered plausible because of the interaction between
the regulating mechanisms of these conditions and vitamin
D levels. For example, PTH modulates vasoconstriction and
blood pressure, and is the principal activator of the renal gene
CYP27B1. PTH concentrations rise when serum levels of vitamin D drop too low, which increases calcidiol activation.1,8 On
the other hand, cytokines are responsible for the upregulation of the gene CYP27B1 in macrophages and the subsequent
impact of calcitriol on the immune system.1
Recommended Blood Levels

Calcidiol, the inactive form of vitamin D, is the most abundant
form found in the blood and the one used as a primary marker
of vitamin D status.5 Calcitriol isnt considered a useful marker
of vitamin D levels because it can remain within normal limits
even when hypovitaminosis D is present. In addition, low
calcitriol levels may be the result of kidney disease rather
than an indicator of vitamin D synthesis or intake.9
Normal circulating levels of calcidiol reach 25 to 200 nmol/L,

although its uncommon to see average values in population
studies above 30 to 32 nmol/L.1,6 The Institute of Medicine (IOM)
defines vitamin D deficiency as a serum calcidiol level below
20 nmol/L, indicating that this is the minimum advisable level
for the general population and not for any populations with
special considerations related to vitamin D.10
However, some experts say this level was chosen based
solely on vitamin Ds effect on bone health, even though
evidence of osteomalacia in adults still may be seen until
serum levels reach at least 30 nmol/L.2 Moreover, 30 nmol/L
appears to be the threshold for preventing hip and nonvertebral
fracture, and PTH levels plateau between 30 and 40 nmol/L,
indicating there still is a risk of bone remodeling until this level
of serum calcidiol is achieved.6
The IOM also indicates that vitamin D insufficiency occurs
when serum calcidiol levels drop below 50 nmol/L. If a persons
vitamin D level is insufficient but not deficient, it means the
persons risk of developing osteomalacia or another problem
with bone mineralization is higher. Because of the seasonal
variations seen in vitamin D status and bone resorption, a
serum level of at least 80 nmol/L may need to be obtained in
the summer to ensure serum levels dont fall below 50 nmol/L
during the winter months.5
Beyond bone health, some experts suggest that a serum
vitamin D level of more than 75 nmol/L is necessary to
positively impact long-latency diseases.8 Specifically, at
80 nmol/L, vitamin D no longer is the limiting factor for
calcium absorption from the intestine. At 90 to 100 nmol/L,
lower extremity function, dental health, and blood pressure
are optimized, while the risk of fall, fracture, cardiovascular
disease, all-cause mortality, and colorectal cancer are
reduced.5,11 In fact, falls werent reduced in people aged 65 and
older when serum vitamin D levels were below 60 nmol/L.11
Obviously, these suggested levels are significantly higher than
the levels currently recommended by the IOM.
The IOM indicates that a serum 25(OH)D level higher than
125 nmol/L puts a person at increased risk of vitamin D excess,
which can lead to hypercalcemia and overcalcification of
bone, soft tissues, the heart, and the kidneys.7,8 Most studies
in children and adults have shown that hypercalcemia doesnt
occur even with serum vitamin D levels of 150 nmol/L, and
some studies have indicated serum calcium remained within
normal limits until serum calcidiol levels were higher than
240 nmol/L.6,7 Specifically, in a meta-analysis of 28 trials,
average serum calcium didnt change even when calcidiol was
higher than 600 nmol/L. In these studies, hypercalcemia was
observed in isolated situations, such as when a participant
had primary hyperparathyroidism or Williams syndrome or
when high calcium intake coincided with high vitamin D intake.
The hypercalcemia often resolved on a second test, indicating
that the initial high serum calcium likely resulted from a
contributing factor other than high vitamin D intake.2,6,11
Its worth noting that many options exist for measuring

the amount of calcidiol in the blood: chemiluminescence
immunoassay, radioimmunoassay, liquid chromatography,
high-performance liquid chromatography, and liquid
chromatographytandem mass spectrometry. However, the
various tests return different results. For example, in one
study, the number of participants with normal calcidiol levels
was 19.9% with chemiluminescence immunoassay and 31.7%
with liquid chromatographytandem mass spectrometry.8
Also, the testing reagents may respond differently to vitamin
D2 metabolites than to those from vitamin D3.
The problem of inconsistency should improve since reference materials from the US National Institute of Standardization were made available in 2010, although standardized
reporting and interlaboratory comparison still are needed.9
However, the Endocrine Society indicates that all methods for
vitamin D measurement are valid as long as the reference
range for the chosen method indicates the target calcidiol level
is above the current minimum recommendation.6
Hypo- and Hypervitaminosis D

With all of the proven and possible effects, its clear that vitamin D is required for good health. However, various factors can
contribute to too low or too high vitamin D levels and should be
taken into consideration when RDs counsel clients or patients
on whether they should be tested.
Primarily, hypovitaminosis D results from lifestyle changes
that have occurred in the past few decades.9 Reduced sun exposure from clothing, more time spent indoors, and increased sunscreen use all inhibit the skins synthesis of vitamin D.5 Children
and adolescents reduced consumption of vitamin Dfortified
milk also contributes to widespread vitamin D deficiency.6
In addition to diet and sun exposure, other factors related
to health and a healthful lifestyle also seem to affect vitamin D
levels. Lower levels of vitamin D have been observed in people
with the metabolic syndrome, particularly based on their HDL
cholesterol levels and waist circumference.4 One study found that
waist circumference accounted for 1.9% of the variation in vitamin
D status, while BMI explained none of the difference, indicating
that perhaps abdominal adiposity specifically, and not obesity
generally, may be a factor in developing hypovitaminosis D.8
Adipositys impact on vitamin D may be explained by the
increased PTH levels often measured in people who are obese
or because adipocytes sequester vitamin D.4,6 As a result,
people with larger amounts of adipose tissue may be able to
increase their serum calcidiol levels only one-half as much
as people with less fat mass when given similar doses of
vitamin D.6 Also, higher vitamin D levels have been observed
in those who moderately consumed alcohol, didnt smoke, and
had normal blood pressure and serum lipid profiles. These
differences were seen even when taking into account the
difference in vitamin D levels thats expected based on age,
sex, and the month of blood sampling.4
TABLE 1
Important Genes and Their Enzymes Involved in Vitamin D Metabolism1

GENE
ENZYME
LOCATION
CONVERSION
CYP27A1
Vitamin D-25-hydroxylase
Liver
Vitamin D 2 or D 3 calcidiol [25(OH)D]
CYP2R1
Vitamin D-25-hydroxylase
Liver
Vitamin D 2 or D 3 calcidiol [25(OH)D]
CYP27B1
25-hydroxyvitamin D-1alpha-hydroxylase
Kidney and
other tissues
Activation: calcidiol [25(OH)D]

calcitriol [1alpha,25(OH)2D]
CYP24A1
25-hydroxyvitamin D-24-hydroxylase
Kidney and
other tissues
Inactivation: calcitriol or calcidiol

24,25(OH)2D or calcitroic acid
For babies and children, breast-feeding with no vitamin D

supplementation has been associated with the risk of deficiency
because human breast milk and colostrum contain very little
vitamin D. Preliminary data suggest that when lactating women
take a daily vitamin D supplement containing 4,000 to 6,000 IU,
they transfer enough vitamin D via breast milk to meet their
babys requirements.6
Regarding uncontrollable factors, aging and skin pigmentation contribute to lower levels of vitamin D. As a person
ages, the skins ability to produce vitamin D when exposed
to UVB rays diminishes.4 Its estimated that people who are
older than 60 can create only one-half as much vitamin D as
those who are younger than 20 when exposed to the same
amount of sunlight.12
People with darker skin pigmentation are at risk of having
lower vitamin D levels due to competition for UVB ray absorption caused by melanin.5,13 Those with a naturally dark skin tone
require three to five times longer sun exposure to make the
same amount of vitamin D in the skin as do those with a very
light skin tone.6
Certain conditions also can negatively affect vitamin D
status. Conditions that produce granulomas (small areas of
inflammation caused by tissue injury) can increase the conversion of calcidiol to calcitriol, which can lead to hypercalciuria
and hypercalcemia.6 Granulomatous disorders include sarcoidosis, tuberculosis, chronic fungal infections, and some lymphomas. Some malabsorption syndromes, such as cystic fibrosis
and inflammatory bowel disease, also can cause decreased
absorption of dietary vitamin D.2
In addition to some medical conditions, various medications can affect vitamin D levels. Among the drugs that may
cause increased vitamin D catabolism are anticonvulsants,
glucocorticoids, antifungals such as ketoconazole, and highly
active antiretroviral therapy for AIDS. Taking these medicines
may require individuals to obtain two to three times more than
the recommended amount of vitamin D for their age group to
reach the recommended level of serum calcidiol.5 In contrast,

exogenous hormones have been shown to increase vitamin D
levels, possibly because of the increased concentration of
vitamin Dbinding protein.8
Although rare, genetic mutations can lead to rickets or
osteomalacia because of the impact on vitamin D metabolism
and function. As with the production of all human enzymes,
certain genes are responsible for providing the instructions for
creating the enzyme. As illustrated in Table 1 above, there are
multiple genes involved in creating the enzymes responsible
for vitamin D activation and inactivation. Additional genes are
responsible for creating the proteins that allow cells to absorb
vitamin D from the blood. If one or more of these genes dont
produce the necessary enzymes or vitamin D receptors, the
same outcomes as seen in vitamin D deficiency can result.1
The pathology of genetic mutations that lead to rickets
or osteomalacia often is described as vitamin Ddependent
rickets or pseudovitamin D deficiency rickets because the
problem lies with vitamin D activation or absorption rather than
being a true vitamin D deficiency.5 The following are genetic
mutations that influence vitamin D function1,5:
CYP27A1: causes a bile acid and lipid metabolism disorder
and may result in low calcidiol levels;
CYP2R1: results in low levels of vitamin D-25-hydroxylase
and calcidiol;
CYP27B1: marked by decreased levels of calcitriol and
normal serum levels of calcidiol;
Vitamin D receptor coding gene: marked by increased
calcitriol levels;
Hormone response elementbinding protein: limits
vitamin D receptor binding; and
CYP24A1: marked by increased serum vitamin D and calcium.
Although hypovitaminosis D is more common, hypervitaminosis D can occur and primarily results in hypercalcemia
and overcalcification of bone, soft tissues, the heart, blood
vessels, and kidneys, as mentioned previously.7,8 Symptoms
TABLE 2
Daily Vitamin D Dietary Reference Intakes for All Life Stages3

LIFE STAGE
ADEQUATE INTAKE
ESTIMATED AVERAGE
REQUIREMENT
RECOMMENDED DIETARY
ALLOWANCE
Infants: 0 to 12 months
400 IU
----------
----------
Children: 1 to 8 years
----------
400 IU
600 IU
Adolescents: 9 to 18 years
----------
400 IU
600 IU
Adults: 19 to 70 years
----------
400 IU
600 IU
Adults: 70+ years
----------
400 IU
800 IU
Pregnancy/lactation
----------
400 IU
600 IU
Note that 100 IU = 2.5 mcg.
of hypervitaminosis D include anorexia, dry mouth, a metallic

taste, nausea, vomiting, constipation, and diarrhea. With longterm oversupplementation, additional symptoms may include
polydipsia, depression, headache, drowsiness, and weakness.
Elevated vitamin D levels may cause abnormally elevated
serum values for blood urea nitrogen, creatinine, aspartate
aminotransferase, alanine aminotransferase, and cholesterol
and elevated urinary values of calcium, phosphorus, and albumin. Toxicity also can cause poor growth in children.14
Because the cost of testing can be high and many people
seem to be deficient because of insufficient sun exposure and
low dietary intake, most experts dont recommend population
testing for vitamin D status. In fact, the test results for most
people are expected to indicate deficiency unless people
recently have been exposed to the sun and/or are taking a
vitamin D supplement.
However, there are some situations for which testing is
warranted and recommended. Situations for which vitamin D
testing is indicated to confirm hypo- or hypervitaminosis D so
recommendations for correction can be made, as appropriate,
include the following2,3,6:
bone diseases (eg, rickets, osteomalacia, osteoporosis);
chronic kidney disease or nephrotic syndrome;
hepatic failure;
malabsorption syndromes (eg, cystic fibrosis, inflammatory
bowel disease, bariatric surgery, radiation enteritis,
Whipples disease, celiac disease);
primary hyperparathyroidism;
when taking certain medications (eg, antiseizures,
glucocorticoids, highly active antiretroviral therapy,
exogenous hormones);
in older adults with a history of falls or nontraumatic
fractures;
in children and adults who are obese;
granulomatous disorders (eg, sarcoidosis, tuberculosis,
histoplasmosis, coccidiomycosis, berylliosis,

some lymphomas);
hereditary phosphate-losing disorders;
pseudovitamin D deficiency rickets; and
vitamin Dresistant rickets.
Recommended Intake
In 2011, the IOM published Dietary Reference Intakes for
Calcium and Vitamin D to update the information provided in its
1997 report.3 With new data and the ability to integrate older data
sets, the IOM established Adequate Intake levels for infants and
Estimated Average Requirement and Recommended Dietary
Allowance levels for children and adults (see Table 2 above).
Because the amount of vitamin D the skin produces when
exposed to UVB rays is influenced by many factors, the IOM is
unable to recommend an amount of sun exposure that would
ensure adequate vitamin D production for all people.3 As such,
the Dietary Reference Intakes are limited to dietary intake and
assume minimal sun exposure. In addition, the report indicates
that the values are based on dose-response relationships for
bone health only, as data are inconclusive regarding vitamin Ds
effect on other health factors.
The IOM has concluded theres no evidence that serum
calcidiol levels higher than 50 nmol/L provide additional
benefits to bone health. It predicts that a daily intake of 600 IU
will result in an average serum calcidiol level of 63 nmol/L for
children and adults of all ages in northern latitudes during the
winter, when sun exposure likely is the lowest for the year.3,5
In contrast to the IOMs recommendation, the Endocrine
Society indicates that individuals may need a dietary intake of as
much as 1,500 IU of vitamin D per day to ensure serum calcidiol
consistently is higher than 30 nmol/L. This indication is based
on the societys estimation that people of normal weight need
100 IU/day to increase their serum calcidiol level by 1 ng/mL,
and that most people are deficient in vitamin D.6
In addition, a review by Bischoff-Ferrari and

colleagues found that only 66% of adults can
achieve a serum calcidiol level of at least
50 nmol/L when following the IOMs Estimated
Average Requirement for vitamin D. Most healthy
adults of all ages achieved what some consider
to be the optimal calcidiol level of 75 to 110
nmol/L when consuming 1,800 to 4,000 IU/day
for at least 42 days.11
As mentioned previously, many factors determine individuals vitamin D status based on their
ability to absorb, metabolize, and utilize it. After
assessing for conditions that may contribute to
hypo- or hypervitaminosis D and the amount of sun
exposure that will contribute to vitamin D synthesis, an individualized recommendation for dietary
intake can be established using the Recommended
Dietary Allowances as a guideline.
The zenith angle of the sun is impacted by latitude,

season, and time of the day. The larger the angle,
the more vitamin D the skin can produce with
uninhibited exposure to sunlight.
Larger
Zenith Angle
Summer at
Midday
Smaller
Zenith Angle
Winter or
Sunset
Sources of Vitamin D
Sunlight is the most efficient source of vitamin
D for people. An adult wearing a bathing suit with
enough sun exposure to cause a slight pinkness to the skin
gets the same amount of vitamin D as does one who ingests
20,000 IU of vitamin D.2 In addition, vitamin D produced by the
skin seems to stay in the body longer than does vitamin D from
dietary sources or supplements.6
However, warnings from health organizations that excess
sun exposure causes skin cancer has resulted in many people
wearing extra clothing and using sunscreen while outside, which
severely reduces the amount of vitamin D produced by the skin.
To put it in perspective, using an SPF 30 sunscreen reduces the
bodys ability to synthesize vitamin D by at least 95%.6
In addition to sunscreen and clothing, the angle of the sun
influences how much vitamin D can be produced from sun exposure. The zenith angle of the sun represents the angle at which
the rays of the sun hit the earth, and its affected by latitude,
season, and time of day, as demonstrated in the image above.6
As an example, people at 52N latitude get about one-half of
the annual UVB rays as do people at 40N latitude.12 For people
above 33N latitude and below 33S latitude, the angle of the sun
is too low during the winter months to produce any vitamin D in the
skin, regardless of duration of exposure.6 The smaller the zenith
angle of the sun, the less vitamin D can be produced by the skin.
Skin cancer is a serious health risk related to sun exposure,
and precautionary measures should be taken. However, occupational and sensible sun exposure hasnt been shown to significantly increase the risk of nonmelanoma skin cancer.2 Also,
sensible sun exposure results in higher vitamin D levels, which
may decrease the incidence of melanoma due to growth inhibition and apoptosis promotion.12
Finally, warnings about skin cancer dont take into account
that more deaths occur each year from internal cancers and
disorders potentially associated with low vitamin D levels than

from high UV light exposure (63,000 vs. 10,000 annually).12
Of course, given that many people cant generate enough vitamin D from sun exposure due to factors such as latitude, indoor
lifestyle, and skin pigmentation, dietary sources also should be
considered. As mentioned, dietary sources include both vitamin
D3 from animal sources and vitamin D2 from plant sources.5
Although some studies have indicated that vitamin D3 has a
higher potency in the body than does vitamin D2, not all studies
have reached the same conclusion, and differentiation hasnt
proven to be necessary.1,6 As indicated in Table 3 on page 54,
foods that are naturally high in vitamin D include salmon, sardines, herring, and other oily fish as well as cod liver oil, egg
yolks, and sun-exposed mushrooms.1,2
In the United States, many foods are fortified with vitamin
D manufactured by UV irradiation of ergosterol produced by
yeast. Fortified foods contain approximately 100 IU per serving
and include many dairy products, such as milk, yogurt, butter,
and cheese; orange juices; margarines; breakfast cereals;
and infant formulas.2
Vitamin D is available in commercial supplements and some
multivitamins or in pharmaceutical formulations. Physicians
can prescribe a liquid supplement with 8,000 IU/mL for infants
and younger children or a gelatin capsule with 50,000 IU for
older children and adults. Vitamin D supplements are available
with as little as 400 or as many as 50,000 IU per serving.
In addition to straight vitamin D supplements, many
multivitamins contain 400 to 1,000 IU of vitamin D, and many
commercial calcium supplements also contain vitamin D
because of the relationship between the two micronutrients.
Supplementation is effective at maintaining serum levels
TABLE 3
Selected Food Sources of Vitamin D15

FOOD
SERVING SIZE
APPROX. IU/SERVING
Cod liver oil
1T
1,360
Raw maitake mushrooms, diced
1 cup
786
Swordfish, cooked
3 oz
706
Salmon, sockeye, cooked
3 oz
447
Fortified skim milk
1 cup
120
Fortified orange juice
1 cup
100
Whole Grain TOTAL cereal
4 cup
100
Fortified nonfat yogurt with fruit
6 oz
88
Tuna, canned in water, drained
3 oz
68
Fortified margarine
1T
64
Egg, chicken, whole, scrambled
44
Note that 100 IU = 2.5 mcg.
when taken at various intervals, including daily, weekly, and

every four months.6 Vitamin D supplements and multivitamins
can be taken with or without food.14
The Challenges of Putting It Into Practice

In recent years, the prohormone known as vitamin D has
been getting attention for its potential role in a host of health
issues, from autoimmune diseases to cancer. Despite mounting
data from observational studies, the IOM has reported that
conclusive evidence from randomized controlled trials is
insufficient to declare that vitamin D plays a definitive role in
conditions beyond those related to bone health.3 While the
Endocrine Society and other experts agree that the evidence still
is building, they argue that the potential for benefit outweighs
the risk of harm in recommending higher vitamin D intake
levels.5 As a result, RDs should be aware that an optimal serum
calcidiol level is higher than 30 nmol/L and can be as high as
75 nmol/L without causing adverse effects and potentially
protecting the person from long-latency diseases.3,5
To reach an appropriate serum calcidiol level, the IOM
recommends a daily vitamin D intake of 400 IU in the first
year of life, 600 IU until the age of 70, and 800 IU from age 70
onward.3 However, given the many genetic, environmental, and
metabolic factors that influence vitamin D status, RDs may
need to counsel clients or patients to ingest two to three times
the recommended amount to achieve the desired result. The
Endocrine Society suggests that children and adolescents may
need up to 1,000 IU/day and people older than 18 may need
1,500 to 2,000 IU/day to consistently achieve blood calcidiol

levels higher than 30 nmol/L.6 RDs may be concerned that
the higher intake levels will cause toxicity in the form of
hypercalcemia, but that toxicity typically isnt seen until intake
exceeds 10,000 IU/day for several months.2,6
In waiting for future research to clarify vitamin Ds role in the
human body and the necessary intake to achieve the required
levels, RDs should use the Recommended Dietary Allowance
as the minimum intake that ensures their clients and patients
can maintain bone health. Then, when individualizing the
recommendation, RDs should consider lifestyle, environmental
factors, malabsorption issues, medication use, genetic
mutations, and other health conditions that can increase or
decrease skin synthesis, metabolism, and usability of vitamin D.
Stephanie Dunne is a graduate student in nutrition and a
dietetic intern at Lehman College in the Bronx, New York.
Jenna A. Bell, PhD, RD, is senior vice president and director
of food and wellness at Pollock Communications in New York City;
the 2013-2014 chair of the Sports, Cardiovascular, and Wellness
Nutrition Dietetic Practice Group; and a coauthor of Energy to Burn:
The Ultimate Food & Nutrition Guide to Fuel Your Active Lifestyle.

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. Vitamin D is considered to be which of the following?
a. Vitamin
b. Hormone
c. Prohormone
d. Antioxidant
6. Which of the following foods has the highest content
of vitamin D per serving?

a. Cod liver oil
b. Sun-dried mushrooms
c. Swordfish
d. Fortified skim milk
2. Which of the following genetic mutations can result in
normal levels of 25-hydroxyvitamin D [25(OH)D] and low

levels of 1alpha,25(OH)2D?
a. CYP27A1
b. CYP27B1
c. CYP2R1
d. CYP24A1
7. The sun is too low during the winter months to
produce any vitamin D in the skin above and below

which north/south parallel?
a. 20
b. 33
c. 40
d. 52
3. Vitamin D testing specifically is recommended for
which of the following groups?

a. People with liver failure
b. People who live north of 45N latitude
c. All adults older than 65
d. Everyone
8. Vitamin D is associated with bone health because it
does which of the following?

a. Stimulates osteoblasts
b. Increases phosphorus excretion
c. Reduces parathyroid hormone release
d. Increases calcium absorption from the intestine
4. Which of the following is the active form of vitamin D

9. The Institute of Medicine identifies vitamin D
in the body?
a. Calcitroic acid
b. Calcidiol
c. Calcitriol
d. 24,25(OH)2D
5. Beyond bone health, vitamin D seems to help
maintain health in which of the following ways?

a. Maintaining kidney function
b. Supporting muscle growth
c. Promoting weight loss
d. Suppressing the autoimmune response
deficiency as serum calcidiol levels below which of the

following levels?
a. 15 nmol/L
b. 20 nmol/L
c. 32 nmol/L
d. 50 nmol/L
10. Each serving of foods fortified with vitamin D contain
approximately which of the following amounts?

a. 2.5 mcg (100 IU)
b. 25 mcg (1,000 IU)
c. 40 mcg (1,600 IU)
d. 100 mcg (4,000 IU)
For more information, call our continuing education division toll-free at

877-925-CELL (2355) M-F 9 am to 5 pm ET or e-mail CE@gvpub.com.
FOCUS ON FITNESS
EXERCISE WITH AN
AUTOIMMUNE DISEASE
Clients May Need to Modify Activity Type

and Intensity to Maintain Optimal Health
By Jennifer Van Pelt, MA
Ten years ago, I was teaching eight advanced fitness classes
each week, working full-time as a writer, walking the dog a few
brisk miles every day, and maintaining a house and yard. Then,
all of a sudden, I needed long naps to get through the day,
and walking up the stairs became a major effort. My endless
energy was replaced by constant fatigue and all-over muscle
and joint pain.
After a long year of undergoing medical tests and seeing
doctors, I was diagnosed with autoimmune thyroid disease and
either fibromyalgia or the early stages of another autoimmune
condition, such as lupus. Even on appropriate thyroid hormone
therapy, muscle relaxants, and pain medications, I still struggle
daily with pain and fatigue but manage to maintain my fitness,
albeit at a much lower level than before. Senior fitness and
yoga classes and resistance exercises with 2-lb weights have
replaced hard-core kickboxing boot camp classes and strength
training with 20-lb barbells.
Ive chosen to share my experience to give readers some
idea of what clients with autoimmune disease face when
advised to exercise. When diagnosed, I was in great shape and
used to exercising, including high-intensity and high-impact
activities. As a former competitive swimmer and long-time
fitness instructor, I always have been motivated to stay fit, and
my motivation carried me through the challenges of adjusting
to living with an autoimmune disease. So if exercising regularly
is a struggle for someone like me,

imagine how difficult it must be for
clients who didnt really exercise or
enjoy physical activity before they
developed an autoimmune condition.
Despite the existence of a large
volume of medical literature and
detailed diagnostic criteria on autoimmune diseases, they remain somewhat of a medical mystery. There are
no cures, and though many different
therapies are used, patients continue to deal with symptom flares and
chronic pain and fatigue. The type of
autoimmune diseases your clients
may have include rheumatoid arthritis, systemic lupus erythematosus,
Sjgrens syndrome, autoimmune
thyroiditis (also called Hashimotos
disease), type 1 diabetes, and multiple sclerosis. (Note: Type 1 diabetes does cause fatigue but
generally doesnt have the associated muscle and joint pains
of the other autoimmune diseases. Insulin levels, rather than
pain and fatigue, mostly affect exercise. Therefore, information in this article focuses on the other autoimmune conditions. Exercise recommendations for type 1 diabetes are more
similar to those for type 2 diabetes. Multiple sclerosis may be
progressive, and patients often have severe movement limitations unique to this disease. Exercising with multiple sclerosis
will be covered in a future article.)
Fibromyalgia, although not classified as an autoimmune
condition, manifests with similar symptoms and may occur
in conjunction with other autoimmune diseases. Hence, any
exercise recommendations here can apply to clients with
fibromyalgia as well.
What Does the Research Say?

Clinical guidelines for autoimmune diseases note that
regular exercise may be beneficial, but they dont specify
the types of exercises. Several recent studies have reported
exercises benefits for autoimmune conditions, including the
following:
Rheumatoid arthritis: Aerobic and resistance training
significantly improved cardiorespiratory fitness, cardiovascular disease risk factors, and autoimmune disease activity and
severity.1,2 A specially designed upper extremity exercise training program along with home exercise reduced upper body
disability and improved function and grip strength.3 And twiceweekly small group tai chi improved psychological health and
social well-being in those with rheumatoid arthritis.4
Lupus: One hour of walking three times weekly improved
vascular function and aerobic capacity without worsening
disease activity.5 Regular exercise improved fatigue, depression, pain, and quality of life in patients with lupus.2,6
Sjgrens syndrome: Nordic walking, or fitness walking
with specially designed walking poles, for 45 minutes
three times weekly significantly improved aerobic fitness,
fatigue, and depression in women with Sjgrens syndrome.7
Moderate- to high-intensity exercise positively affected
fatigue, physical function, depression, and aerobic fitness in
patients with the disease.6
Exercise Recommendations
For those with autoimmune conditions or fibromyalgia,
theres a fine line between the right amount of exercise and too
much. Exercise not only affects the musculoskeletal system
but also impacts body chemistry by increasing or decreasing
chemicals that contribute to inflammation. Too much exercise
can produce inflammatory chemicals, thereby increasing pain
and causing autoimmune flares, but regular exercise of the
appropriate intensity and duration can decrease inflammation
and improve overall functioning and pain.2
How can clients figure out what works for them? Clients with
a previously high level of fitness who exercised vigorously likely
will exercise too much. For me, vigorous exercise feels great
while Im doing it, but several hours to a day after an intense
workout, Ill have a flare in muscular pain and fatigue that even
makes sitting and typing at my computer challenging. Modifying the type and time of my exercise has helped. For instance,
doing a vigorous but low-impact activity (eg, stationary cycling,
active yoga) in the evening allows my body to recover overnight
and lessens the likelihood of flares.
Athletic clients with an autoimmune disease may require
counseling on modifications and moderation in exercise intensity and duration. They should be encouraged to remain motivated even if their activity level must be decreased significantly
for a while. After all, Sjgrens syndrome caused tennis champ
Venus Williams to withdraw from competition and training for
several years. Shes just now, three years after her diagnosis,
returning to competition after learning to manage her disease
in combination with her athletic training.
Clients at a lower level of fitness may not exercise enough
to see positive results. These clients may benefit from supervised exercise programs with instructors experienced in
working with movement limitations and medical conditions.
Fitness classes designed for seniors, beginners, or those with
fibromyalgia may provide social support and motivation as
well as health benefits.
In general, the following exercises are appropriate for most
clients with autoimmune diseases:
aquatic exercise, especially in warmer water;
gentle yoga, chair yoga, and stretching;
tai chi and qi gong;
walking;
stationary cycling;
resistance exercises with bands and light weights; and
low-impact aerobics (eg, dance-based, marching/walking-
based movements).
Monitoring reactions to different types and duration of
exercise in a pain or symptom journal can help determine
the best amount and type of exercise for your clients with
autoimmune disease and/or fibromyalgia.
A word of caution: Published clinical studies and exercise
recommendations are for those with mild to moderate disease
activity. Patients with more severe lupus often have cardiac
and renal involvement that may preclude certain types of exercise. Patients with more advanced rheumatoid arthritis may
have joints so deformed that certain exercises arent comfortable or even possible. Consulting with a physician for guidance
on appropriate exercise is necessary for these clients.
Jennifer Van Pelt, MA, is a certified group fitness instructor
and health care research analyst/consultant
in the Reading, Pennsylvania, area.
References
1. Stavropoulos-Kalinoglou A, Metsios GS, Veldhuijzen
van Zanten JJ, Nightingale P, Kitas GD, Koutedakis Y.
Individualised aerobic and resistance exercise training
improves cardiorespiratory fitness and reduces
cardiovascular risk in patients with rheumatoid arthritis.
Ann Rheum Dis. 2013;72(11):1819-1825.
2. Thomas JL. Helpful or harmful? Potential effects of
exercise on select inflammatory conditions. Phys Sportsmed.
2013;41(4):93-100.
3. Manning VL, Hurley MV, Scott DL, Coker B, Choy E,
Bearne LM. Education, self-management, and upper
extremity exercise training in people with rheumatoid
arthritis: a randomized controlled trial. Arthritis Care Res
(Hoboken). 2014;66(2):217-227.
4. Waite-Jones JM, Hale CA, Lee HY. Psychosocial effects
of tai chi exercise on people with rheumatoid arthritis. J Clin
Nurs. 2013;22(21-22):3053-3061.
5. dos Reis-Neto ET, da Silva AE, Monteiro CM, de Camargo
LM, Sato EI. Supervised physical exercise improves endothelial
function in patients with systemic lupus erythematosus.
Rheumatology (Oxford). 2013;52(12):2187-2195.
6. Strmbeck B, Jacobsson LT. The role of exercise in the
rehabilitation of patients with systemic lupus erythematosus
and patients with primary Sjgrens syndrome. Curr Opin
Rheumatol. 2007;19(2):197-203.
7. Strmbeck BE, Theander E, Jacobsson LT. Effects
of exercise on aerobic capacity and fatigue in women
with primary Sjgrens syndrome. Rheumatology (Oxford).
2007;46(5):868-871.
GET TO KNOW
KAREN COLLINS
Promoting Nutritions Big Picture Through

Smart Bytes and Small Changes
By Juliann Schaeffer
Karen Collins, MS, RDN, CDN, FAND, a nutrition consultant,
speaker, and writer, has been preaching healthfulness for more
than 25 years. In addition to one-on-one counseling through her
long-time western New York private practice as well as nationwide presentations, she espouses her messages through her
blog, Smart Bytes (http://karencollinsnutrition.com).
With a trademarked tagline of taking nutrition from daunting to doable, Collins works to dig past the superficial healthy
headlines that bombard (and confuse) consumers daily to
determine what the latest research really says about how food
can help people become healthier and happier. And, according
to Collins, that usually means small changes.
I think we need to help people identify the priority changes
for them and then find and see the value in small steps they can
take, she says. People are bombarded with messages that
can make them feel perfection is needed in order to make a
difference, and thats not what research shows.
According to Collins, those small changes could provide
even bigger dividends if people spent more time in the
kitchen. I think we need to help people get more comfortable
cooking at home, mindfully enjoying food prepared with fresh
flavors, instead of thinking that either eating out or using

highly processed foods are the only options when they feel
rushed, she says.
One of Collins specialties is cancer prevention, and she
lends her nutritional expertise to the American Institute for
Cancer Research (AICR) as a nutrition advisor. Shes also
the author of a weekly syndicated column for the AICR called
Health Talk and coauthor of the Nutrition and Cancer
Prevention chapter in the third edition of The Clinical Guide to
Oncology Nutrition, published by the Oncology Nutrition Dietetic
Practice Group of the Academy of Nutrition and Dietetics (the
Academy). Deeply involved in numerous Academy dietetic
practice groups, she serves as codirector of the Sports,
Cardiovascular, and Wellness Nutrition (SCAN) Dietetic
Practice Groups Wellness and Cardiovascular subunit.
With her hand in so many pots, so to speak, Collins day
could have her focusing on any number of nutrition-related
tasks: a webinar presentation, a blog posting, or content
review for the AICR. I try to start the day focused on whatever project demands the most intense and creative thinking,
she says, admitting that in addition to numerous administrative tasks, self-employment definitely has its perks. One great
thing about being self-employed is that I can take time out to
refresh with midday physical activity, like a tae kwon do class
or a quick walk.
Plus, Collins says, the greatest perks of working in the
nutrition field are definitely the excitement of keeping up with
constantly changing research and the satisfaction that comes
from passing that knowledge on to people so they can better
their lives.
Todays Dietitian (TD): What is your proudest career
accomplishment?
Collins: I feel incredibly lucky with the opportunities Ive had
for work, through which I hope to make a difference. I feel both
honored and humbled to have had the chance to contribute
in various ways to the AICRs important work. Receiving the
SCAN Dietetic Practice Group award for Excellence in Practice
in Wellness Nutrition certainly means a tremendous amount
to me. Honestly, though, during many years in private practice,
its been a true privilege helping individuals create healthier
lifestyles and seeing the impact in their lives, and I value that
part of my career, too.
TD: Youve written a great deal about how heart disease,
diabetes, and cancer are interrelated. What are the most
important points nutrition professionals should know about
this topic?
Collins: When I speak about this at health professional conferences, people often comment about problems of todays
specialization silos. We need to recognize the significant
overlap between diabetes, heart disease, and cancer. We can
promote choices for overall health, even when we temporarily focus on one particular problem. Fortunately, eating patterns focused on vegetables, fruits, whole grains, and beans
and supporting a healthy weight offer the potential to protect against all three diseases. And no single eating pattern is
essential to achieve this. In fact, thats the subject of a health
professionals webinar I did with Sharon Palmer, RD, which is
offered for free on the AICR website. (For more information
on the webinar, visit www.aicr.org/health-professionals/ce/
webinars/eating-patterns-to-lower-cancer-risk.html.)
TD: From the many nutrition and health conferences and
seminars youve presented, whats one insight, either from a
copresenter or from an audience member, that struck you or
has stuck with you, and why?
Collins: A big take-home lesson for me from health professional and consumer audiences is how easy it is for people to
get overwhelmed by the constant barrage of headlines about
new research findings. Studies are not all equal, and its important that when sharing messages about healthful eating, we
base them on the big picture of overall research. People need
help setting priorities for choices backed by strong evidence as
most likely to make a difference. In fact, that was the inspiration
behind creating my Smart Bytes blog, which focuses on putting
research in perspective and making choices based on it doable.
TD: Give us a peek inside your refrigerator or cupboard.
What are the mainstays always in your kitchen, and what
seasonal foods do you most look forward to stocking them
with in the summer?
Collins: I love the arrival of summer and all its fresh vegetables and fruits! I look forward to all the tomatoes, peppers,
corn on the cob, and fresh greens and to the raspberry and
blueberry seasons.
Still, I keep my freezer and pantry stocked all year round so I
always have the essentials on hand. My freezer is always loaded
with bags of vegetables like chopped spinach, artichoke hearts,
and squash plus lots of frozen berries and peaches. My pantry
always has tomatoes because theyre the foundation of so many
dishes I make. Other essentials are canned black, kidney, and
garbanzo beans; dried lentils; and whole grains such as quinoa
and whole wheat couscous and pasta. Because I add nuts to
so many salads and other dishes, I always keep a stash. And I
count on knowing Ive always got a wide variety of herbs, spices,
and flavored vinegars handy.
TD: Is it true that you have a purple belt in tae kwon do,
and what led you to this discipline?
Collins: Yes, although Im not someone that most people would
expect to love something like tae kwon do, and it was never
something Id even considered. An instructor in an aerobicstype kickboxing class suggested I give it a try. To my surprise, I
loved it from the start. Its a fabulous way to exercise both body
and mind. And since you cant focus on anything else while
youre doing tae kwon do, its a terrific emotional refresher and
stress buster.
TD: How has tae kwon do helped mold your nutrition
philosophy?
Collins: It has shaped the way I communicate messages
about nutrition. The first time I was being tested to progress
to a new belt, I passed everything else, but when I tried to
break my board, I just couldnt. My instructor said, Youre
seeing the board as a barrier and letting it stop you. You have
to look beyond the board and kick through it. He was right: I
changed perspective, and I broke the board. Instantly, I saw
it as a metaphor for all the walls my clients were seeing. I
want to be the voice reminding people that even when we see
barriers, that doesnt mean we cant break through.
TD: Whats a great summer vegetable dish to serve a crowd?
Collins: I always aim to offer a variety of vegetables that taste
so good that theyre the highlight of a meal. The taste of fresh
summer vegetables is so wonderful, I dont like to do anything
that masks it. Instead, I just aim for an interesting color and
flavor combination from the choices that look good when Im
shopping and add in a substantial dose of a fresh herb like basil
or cilantro. I love flavored vinegars, but sometimes a simple olive
oil and lemon dressing is the refreshing note that ties everything
together and lets the flavors of the vegetables stand out. I do love
to grill vegetables, too. Its funny, but its those simple combinations that people get all excited about when we entertain.
TD: What about a refreshing summer fruit dessert recipe?
Collins: Thats easy: wash and enjoy! Summer peaches are
great grilled, too.
TD: Favorite place or way to relax and unwind?
Collins: My favorite ways to unwind are to spend time with
family or girlfriends and to be outside in fresh air. My husband
and I are empty nesters now, so time with our sons is truly
preciousand we really have fun together. Time talking with
sisters and girlfriends who get you is truly a gift. And being
outside revives me on every level. Theres the peace of mind
from quietly walking my dog or sitting near water, or the
exhilaration of cross-country skiing or doing an interval walkrun. I believe in outdoor playtime, too. I love to pull out croquet
or bocce when friends come over in the summer instead of
just sitting around.
Juliann Schaeffer is a freelance writer
and editor based in Alburtis, Pennsylvania,
and a frequent contributor to Todays Dietitian.
BOOKSHELF
Weelicious Lunches: Think Outside the Lunch Box

With More Than 160 Happier Meals
By Catherine McCord
2013, William Morrow
Hardcover, 320 pages, $29.99
If you arent already

familiar with Catherine
McCord, I suggest you
check out her awardwinning website (http://
weelicious.com) to get a
taste of what youll find
in Weelicious Lunches.
You may think this is
just a cookbook for kids,
but its full of meals
that will satisfy every
family member. McCord
focuses on recipes the entire family will enjoy but often adds a
bit of flare that kids especially will love, such as heart-shaped
sandwiches or mini pretzel bites.
This book is broken into two parts: School Lunch Solutions and Recipes. In the section on school lunches,
McCord discusses some key principles to creating great
lunches, including methods to engage all five senses, musthave food groups, great containers to use, and strategies to
deal with food allergies and picky eaters. I love the colorful
pages picturing beautiful lunch ideas for fruits, vegetables,
proteins, carbohydrates, and pantry staples.
McCord simplifies lunchtime prep even further with her
Weelicious Lunches Allergy Guide, which organizes each
of the books recipes into a chart that indicates whether its
gluten-, nut-, egg-, or dairy-free. This chart is handy for
parents of children with allergies or those whose children
attend schools with food restrictions.
The second part of the book, and the largest component,
includes innovative, tasty, and nutritious recipes for salads,
soups, sandwiches, pizzas, PB&Js, main events, veggies, dips
and spreads, snacks, and desserts. You may be wondering
how there could be a whole section devoted to PB&J. McCord
takes this classic and gets adventurous with creations such
as apple ring PB&J (apples are used in place of bread),
peanut butter pancake sandwiches, PB&J pop-tarts, and
chocolate PB&J cups.
Weelicious Lunches also provides healthful recipes for

many of the processed treats that often are marketed to
kids, such as animal crackers, chocolate chip granola bars,
chocolate-hazelnut spread, whole grain fruit-filled bars,
fruit leather, and whole wheat cheddar crackers. Using
McCords recipes, its easy to prepare fresh, homemade,
and more nutritious versions of these popular snacks.
Overall, I highly recommend this book. I had an 8-year-old
boy and his mother in my office the other day, and when he
started looking at the recipes in this book, his excitement went
through the roof. Weelicious Lunches is a great resource for
dietitians and parents alike.
Janice H. Dada, MPH, RD, CSSD, CDE, CHES,
owns SoCal Nutrition & Wellness, a private practice
and consulting business in Newport Beach, California.
Shes also a freelance writer and works in education.
Gluten Freedom: The Nations Leading Expert

Offers the Essential Guide to a Healthy,
Gluten-Free Lifestyle
By Alessio Fasano, MD, and Susie Flaherty
2014, Turner Publishing
Hardcover, 320 pages, $24.95
Written by world-renowned gastroenterologist Alessio

Fasano, Gluten Freedom covers the latest research and
controversies on gluten-related disorders. The book
conveys complex scientific
discoveries in concise,
simple terms, making it a
great resource both for RDs
and consumers.
Its easy to forget that
before Fasanos landmark
2003 study, celiac disease
virtually was unheard of
in the United States, and
studying the condition was
considered professional
suicide. The first section
of the book, Gluten
Enters the Picture,
gives a behind-the-scenes scoop on the discovery of celiac

disease and how our understanding of it has evolved through
the years. Fasano covers gluten sensitivity and how gut
permeability may hold the key to unlocking our understanding
of all autoimmune diseases. He even addresses the commonly
held misconception that everyone should eat gluten-free.
Part two, Learning to Live Without Gluten, gets down to
the nuts and bolts of reading labels, setting up a gluten-free
household, and dining out,. Readers even get a peek at some
of Fasanos favorite recipes from his native Italy.
Part three, Gluten-Free for Life, gives sage advice for staying gluten-free during pregnancy, childhood, family celebrations, college, and the aging process. Pam Cureton, RD, LDN,
with whom Fasano has worked closely for more than a decade,
shares tips throughout the book. Fasano advocates that people
with gluten disorders work with an experienced RD.
The fourth section, Going Beyond Gluten, focuses on the
future of celiac disease treatment. Fasano paints a picture of
promising experimental treatments, therapies, and possible
methods for preventing celiac disease down the road. He also
provides updates on controversial research about the ideal time
to introduce gluten to infants.
While Gluten Freedom wouldnt be my first choice for a newly
diagnosed client because its an advanced look at the research
and managing specific circumstances and devotes only a few
chapters to the basics, I plan to keep a copy in each of my offices.
Its a must-read for any RD with clients who have gluten-related
disorders and are motivated. Its the most accurate, comprehensive, and current guide to understanding why and how gluten can
cause problems and to help separate fact from fiction.
Cheryl Harris, MPH, RD, is a freelance writer and speaker
who works in private practice in northern Virginia,
specializing in helping clients live and love a gluten-free diet.
Boosting Brain Function

and Memory Through Nutrition
By Deralee Scanlon, RD
2013, Beverly Glen Nutrition
Softcover, 110 pages, $9.95
For older adults who complain about entering a room and

forgetting why they went in there or frequently losing their
car keys, they arent alone. A recent report by the Centers
for Disease Control and

Prevention states that
one in eight older adults
experiences some kind of
memory loss.
In Boosting Brain
Function and Memory
Through Nutrition,
Deralee Scanlon uses
her award-winning
nutritional skills to help
put the brakes on mental
decline. An older adult
herself, Scanlon devoted
more than a year to
researching and analyzing
scientific studies and attending brain health conferences and
webinars. In her book, she combines this information with her
knowledge of food as medicine and dietary supplements.
The practical guide begins with a short and straightforward
overview of the brains regions and functions, followed by a
discussion of the three main causes of age-related memory
loss: inactivity, lack of mental exercise and stimulation, and
lack of essential brain nutrition. Scanlon then explores the
foods that contain the essential daily nutrients the brain needs:
protein, carbohydrates, and healthful fats.
The bulk of the book is dedicated to detailing brain-friendly
micronutrients (ie, protective vitamins and minerals). For each
one, Scanlon explains how it works, how it benefits the brain,
how much to take, any side effects, symptoms of deficiencies,
research findings, and foods that contain it.
Information on the value of probiotics, aromatherapy, and
water complete the books content, along with an easy-todrink fresh juice recipe. The book concludes with a lengthy
reference list.
Scanlons take-home message to readers is that they have
the power to reduce the rate at which their brain shrinks,
lower their risk of mental decline, and improve their memories
by following a healthful lifestyle, including losing weight and
eating foods that boost brain function. As she puts it, Use it,
feed it, or lose it.
Karen Appold is a freelance medical writer and editor
based in Pennsylvanias Lehigh Valley.
PRODUCTS + SERVICES
Snyders of Hanover
Expands GF Pretzel Line
Snyders of Hanover has launched two
new gluten-free pretzel varieties. The
expanded line includes Gluten Free Honey
Mustard & Onion Pretzel Sticks, Gluten
Free Hot Buffalo Wing Pretzel Sticks,
Gluten Free Mini Pretzels, Gluten Free
Pretzel Sticks, and an eight-pack of Gluten
Free 100-Calorie Pretzel Sticks.
Certified by the Gluten-Free Certification Organization,
Snyders of Hanovers gluten-free pretzels also are free of
dairy, casein, and eggs.
To help shoppers better identify the gluten-free pretzel
options, Snyders of Hanover also has introduced a new
packaging design.
For more information, visit www.snydersofhanover.com.
gardein Releases
Gluten-Free Line
gardein has announced the addition of three gluten-free products: beefless ground, veggie burger, and
black bean burger. For meat and veggie lovers alike,
these gluten-free products are made with non-GMO
soy, pea proteins, and vegetables.
With 84% less fat than regular ground beef and a
meatlike texture, gardein beefless ground is a healthful and easy alternative, with 24% of the Daily Value of
protein, 3 g of fiber, and only 1.5 g of total fat. A combination of veggies makes the gardein veggie burger
an excellent source of vitamin A and a good source of
fiber, with 3 g of fiber and 5 g of total fat. The gardein
black bean burger has 7 g of fiber and 6 g of total fat.
For more information, visit http://gardein.com.
Robbies Offers Low-Sodium,

Gluten-Free Sauces
Robbies Naturals offers a product line of flavorful lowsodium, gluten-free sauces, including worcestershire sauce,
hickory barbeque sauce, sweet and sour sauce, garlic sauce,
ketchup, and steak sauce.
All of Robbies sauces are low in sodium, gluten-free, and
made with all-natural ingredients. The hickory barbeque
sauce has only 40 mg of sodium per serving, is fat-free, and
contains no high-fructose corn syrup.
For more information, visit www.robbiesnaturals.com.
Massel Introduces GF
Concentrated Liquid Stock
Massel has introduced a concentrated liquid stock,
which is the essence of liquid stock/broth in a 3.8-oz
pouch that creates 2 qts of stock just by adding water
and can be refrigerated for up to 10 days after opening.
The all-natural stocks come in three flavors: a
vegetable blend and vegan chicken- and beef-style
blends with all of the savory richness of meat but
made using only vegetable ingredients. They feature
premium vegetables and herbs, extra-virgin olive oil,
and sea salt. Theyre also gluten-free, lower sodium,
lactose-free, cholesterol-free, trans fatfree, and
kosher certified and have no added MSG or GMOs.
For more information, visit www.massel.com.
PINES Beet Juice Powder

Offer Veggies in a Bottle
PINES International makes it easy to incorporate the benefits of beets into a healthful diet with its Beet Juice Powder,
which can be added to water, juice, or yogurt; whipped into a
smoothie; or added to desserts.
Beets have been the subject of many research studies
that have reported health benefits from reducing anemia to
providing more stamina to athletes. In addition, beets are a
dietary source of antioxidants, naturally occurring nitrates,
betalain, and folate.
For more information, visit www.wheatgrass.com.
SOS Rehydration Drink

Launches Blueberry Flavor
SOS, a rehydration drink comprising the right balance
of electrolytes for optimum hydration, has announced
that all products are now 100% free of
artificial sweeteners, preservatives,
flavors, and colors. The company also is
launching a blueberry flavor.
SOS has six times the electrolytes of
a normal sports drink and 27% more
electrolytes than coconut water with
one-half the calories and sugar. An SOS mixed with
water helps the body absorb three times more water
than drinking water alone.
For more information, visit www.sosrehydrate.com.
Way Better Snacks Sprouted

Pita and Tortilla Chips
Way Better Snacks has introduced a line of Simply Sprouted
Pita-ahh Chips and has added two flavors to its tortilla chip line.
Simply Sprouted Pita-ahh Chips feature sprouted Red Fife
and spelt that are combined with other unprocessed ingredients to create three varieties: Toasted Garlic, Smoked
Havarti, and Sea Salt.
The two new varieties of tortilla
chips are Simply Spicy Sriracha, which
combines a hot flavor with the benefits
of sprouted kale seeds, and Simply
Tangy Mustard & Onion, which delivers
bold, tangy-mustard deliciousness
with sprouted mustard seeds.
In addition to the sprouted ingredients, the chips are
Certified Non-GMO Project Verified, kosher, vegan, an
excellent source of whole grains, low sodium, and a good
source of fiber. The tortilla chips also are certified gluten-free.
For more information, visit www.gowaybetter.com.
LRABAR Rolls Out

ALT Protein Bar
LRABAR has launched ALT, a bar made with 10 g of
field pea protein. The ALT flavors emulate the desserts
they are named after but are made with nine or fewer
ingredients. The flavors are Cinnamon Apple Crisp,
Peanut Butter Cookie, Pumpkin Pie, and Lemon Pound
Cake, with more expected soon.
ALT offers a gluten-free, non-GMO, dairy-free,
vegan, and kosher bar with added protein. Its wrapper
is made from 31% plant-based material.
For more information, visit www.larabar.com.
Bear Naked Debuts

Honey Almond Protein Flavor
Bear Naked granola has introduced a new flavor, Honey
Almond Protein. Made with soft-baked whole grain oats,
honey, and roasted almonds, Honey Almond has 10 g of
protein per serving.
Like all Bear Naked products, the Honey Almond Protein is
made with natural ingredients that are minimally processed
and free of hydrogenated oils, high-fructose corn syrup, and
artificial preservatives.
For more information, visit www.bearnaked.com.
KettlePop Offers USDA

Organic Kettle Corn Snacks
KettlePop uses organic, non-GMO ingredients and
tops the popcorn with preservative-free flavorings
for its cheese, caramel corn, kettle corn chocolate
drizzles, and caramel chocolate drizzles popcorn
offerings. And the company now offers organic sea
salt and organic kettle corn as well.
For more information, visit www.kettlepop.com.
Wonderfully Raw Adds Brussel

Bytes, Snip Chips to Offerings
Wonderfully Raw has added two new lines to its allnatural, gluten-free, vegan-friendly snack foods: Brussel
Bytes and Snip Chips.
Brussel Bytes, made from organic Brussels sprouts and
organic pumpkin seeds and tossed in a tasty coating, come in
Chili Pumpkin Seed Crunch and Tamarind Apple Crunch. Snip
Chips, a combination of organic parsnips and
organic coconut, are high in fiber, omega-3,
potassium, and vitamins C, E, and K. They
come in Cheesy Herb Truffle, Chipotle Lime
Cilantro, and Dill Pickle flavors.
The Wonderfully Raw collection also
includes the original Coco-Roons, sweetened with organic maple syrup and available in flavors such as
Brownie, Apple Pie, Lemon Pie, Vanilla Maple, and Cacao Nib.
For more information, visit http://mycocoroons.com.
Foxys Pash Hits New

Shelves on West Coast
Foxys Pash offers all-natural frozen yogurt with a
fraction of the sugar, fat, and calories of many frozen
desserts. Pash is specially churned before adding the
richness of flavors such as non-GMO organic chocolate, natural tangerine, and California strawberries.
Foxys Pash recently added the flavors Fancy Pash
(dark chocolate and tangerine zest) and Frisky Pash
(pecan and praline crunch) to its range of products:
Cheeky Pash (mango and passionfruit smoothie),
Naughty Pash (honeycomb and caramel chunks),
Sassy Pash (vanilla bean and strawberry chunks),
and Sneaky Pash (wild berry and chocolate flakes).
For more information, visit www.foxyspash.com.
PA FL OR CA
DIETITIAN
Full-Time
Norristown State Hospital
1001 Sterigere Street
Norristown, PA
Clinical Dietitian, R.D. (Full Time or Part Time)

Baker City, Oregon
CLINICAL DIETITIAN
Putnam Community Medical Center,
located in Palatka, FL, is currently seeking
to ll a Full Time Clinical Dietitian.
Responsibilities include: Maintenance of
high nutritional standards, provisions of
appropriate diets to patients, being the
liaison with patients, nurses, and physicians,
review and evaluation of patient diets, and
participation in nutritional care committees.
Salary:
$38,709 $58,517
Benefits:
health insurance
retirement plan
23523
paid leave
(vacation, sick, holiday, personal)
Todays Dietitian
prescription/hearing
dental/vision
1/8 Page (2.292 x 3.948)
parking
Requirements include: Bachelors degree

with specialization in dietetics or nutrition,
registered member of the Academy of
Nutrition and Dietetics (diabetes educator
preferred), and 2 years experience as
dietitian in a hospital setting.
July 2014
Applicants must be Dietitian (RD)
jlr
Call Recruiter: 610-313-1082
For more information and to apply,

please visit our website at www.pcmc.com.
EOE
EOE
CLINICAL DIETITIAN
Would you like to become a part
of a hospital system that is dedicated to
superior service to patients, to employees,
and to volunteers? Our warm, friendly family of
employees is what makes Hi-Desert Medical
Center a great place to work. Located in the
beautiful High Desert, just 30 minutes from
Palm Springs, Hi-Desert Medical Center offers a
competitive salary and benefits package.
We have an opportunity for you in our
Long Term Continuing Care Center.
Registered Dietitian (Full-Time)

For immediate consideration, call 760-366-6426 or
check our website at www.hdmc.org to download
an application and receive information regarding
our benefit package.
Pomona Valley Hospital seeks to recruit an

experienced Clinical Dietitian to serve our acute
care 453-bed not-for-profit organization.
The Clinical Dietitian will assess and care for
patients at nutritional risk, approve programs &
menus related to nutritional care, participate in
case conference, perform regular clinical rounds,
and maintain discharge planning activities.
He/she will also train, educate, support, and
monitor fellow Associates providing direct
nutritional care. Applicants must have a current
CDR, 2 years of experience, and excellent
communication skills. Preferred candidates will
possess a Bachelors degree in Food & Nutrition
and/or bi-lingual proficiency. This position is
being offered at full-time days with a competitive
benefits package.
All eligible applicants should apply at
www.pvhmc.org
Resumes may be mailed to 6601 White

Feather Road, Joshua Tree, Ca. 92252
or e-mailed to hr@hdmc.org.
TodaysDietitian.com
YOUR FEEDBACK
IS IMPORTANT!
E-mail your comments
or suggestions to the editor at
TDeditor@gvpub.com
or write to
Todays Dietitian
3801 Schuylkill Road
Spring City, PA 19475
Website!

website_chkout_1-12.indd 1
2/11/14 2:19 PM
Qualifications Include: Completion of an accredited

school of Dietetics with a degree as a Dietitian
(experience in a clinical, hospital-based setting
preferred), licensed and registered in Oregon as a
Dietitian, must be able to problem-solve independently,
time management skills, multi-tasking,
and able to work without direct supervision.
Saint Alphonsus Health System offers competitive
compensation and a comprehensive benefits package.
To apply, please visit our website:
www.saintalphonsus.org/bakercity
Whether youre a nutrition professional

or a consumer looking for trustworthy
guidance, the Todays Dietitian
Health & Nutrition Center is a free
online resource packed with useful
information that can benefit anyone.
Great reference for clients,
family, and friends!
Healthy, delicious recipes
Gluten-free, plant-based,
and diabetes-friendly dishes
Cooking tips
Expert fitness and
lifestyle advice
a free
online
resource!
Visit and share the link at

TodaysDietitian.com/healthandnutrition
EOE
Check
out our
Beautiful Baker City is located in the verdant valley

between the Wallowa and Elkhorn Mountains in eastern
Oregon, 130 miles northeast of Boise, Idaho, on I-84.
Known for its Anthony Lakes Ski area and being on the
historic Oregon Trail, it is an outdoor lovers paradise
with fishing, camping, skiing, rock hunting,
and jet-boating nearby.
DATEBOOK
AUGUST 10-14, 2014

BEGINNING JULY 1, 2014
REGISTRATION NOW OPEN

FOR THE 2014 RENFREW
CENTER FOUNDATION EATING
DISORDERS CONFERENCE FOR
PROFESSIONALS: FEMINIST
RELATIONAL PERSPECTIVES
AND BEYOND: THE PRACTICE
OF PRACTICE
November 14-16, 2014
Philadelphia, Pennsylvania
17.5 continuing education credits
available
Contact: Debbie Lucker
Phone: 877-367-3383
E-mail: dlucker@renfrewcenter.com
www.renfrewconference.com
AUGUST 6-9, 2014
AMERICAN ASSOCIATION OF
DIABETES EDUCATORS ANNUAL
MEETING
Orlando, Florida
www.diabeteseducator.org
ASSOCIATION OF CORRECTIONAL
FOOD SERVICE AFFILIATES ANNUAL
INTERNATIONAL CONFERENCE
St Louis, Missouri
www.acfsa.org
MARKETPLACE
AUGUST 13-17, 2014
IDEA WORLD FITNESS CONVENTION

Anaheim, California
www.ideafit.com
SEPTEMBER 2-5, 2014
14TH INTERNATIONAL NUTRITION

& DIAGNOSTICS CONFERENCE
Prague, Czech Republic
www.indc.cz/en
SEPTEMBER 8-10, 2014
NATIONAL WIC ASSOCIATION

NUTRITION EDUCATION AND
BREASTFEEDING CONFERENCE
& EXHIBITS
Atlanta, Georgia
www.nwica.org
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ADVERTISER INDEX
For advertising information, please call 800-278-4400 or visit our website

at www.TodaysDietitian.com.
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LC Foods Corporation, www.holdthecarbs.com............................26
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This index is a service to our readers. The publisher assumes no liability for errors
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Bakery On Main introduces 12 new ways to put a smile on those

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CULINARY CORNER
Its better if you can buy Brussels sprouts still on the stalk
because theyre usually fresher and a little cheaper.
In reality, it isnt hard to get kids to eat vegetables. As simple
(and challenging) as it sounds, all you need to do is make them
taste good. And roasting nearly any vegetable gives you a leg up
in the flavor department. Sure it takes a few tries, maybe even
a dozen, but one day it clicks. And who knows, you may even
impress your pediatrician.
Bryan Roof, RD, LDN, is a chef, dietitian, and food writer
living in Boston. Follow him on Twitter @bryanroof.
Roasted Brussels Sprouts Salad
BRUSSELS SPROUTS
Good Things Come in Small Packages

By Bryan Roof, RD, LDN
When my daughter, Layla, was 3, the doctor asked her
what she was looking forward to eating at Thanksgiving. Her
response: Brussels sprouts. Judging by her doctors reaction,
that wasnt a common answer.
Although my family has a deep appreciation for Brussels
sprouts, we dont reserve them just for the holidays. We roast
them year-round with olive oil and salt for a bare-bones
approach and then dress them up with caramelized onions and
bacon on special occasions.
Despite my daughters infatuation and their current
trendiness, Brussels sprouts have had a varied history. They
were developed in Belgium in the 13th century through artificial
selection and always have suffered a bit in popularity. A poll
conducted in the United States actually placed them near the
top of the countrys list of most hated vegetables. It does seem
that every other horror story about being force-fed veggies as a
child involves boiled Brussels sprouts. The scars run deep for
some, I suppose.
Still, these miniature cabbages have plenty to offer. They
take well to various cooking methods, including blanching,
sauting, and deep-frying. Theyre great shaved thin and eaten
raw in salads, and the aforementioned roasting especially is
appealing to kids because it brings out the inherent sweet, nutty
flavors. Not to mention, the intense heat of a hot oven drives
off any offensive cabbage-y odors and renders the thin outer
leaves crackly, like cruciferous chips.
Although you can find them most of the year, Brussels
sprouts are in season in late fall and early winter, and thats
when they tend to taste the sweetest. When shopping, look for
small sprouts, which are sweeter and more tender than large
ones. Large sprouts also are slightly more woody and fibrous.
Serves 4
Ingredients
2 lbs Brussels sprouts, stemmed and halved
4 T extra-virgin olive oil, divided
1
2 tsp fine sea salt
4 garlic cloves, minced
4 anchovies, minced
1 T fresh lemon juice
1
2 tsp Aleppo pepper or 14 tsp red pepper flakes
1 cup fresh parsley leaves
1 cup sliced red onion
1
2 cup blanched hazelnuts
Directions
1. Adjust the oven rack to the middle position and heat
the oven to 425F. Toss the Brussels sprouts with 2 T

oil and 12 tsp salt. Spread the sprouts on a rimmed
baking sheet, cut sides down. Roast until tender, deep
brown, and crispy on the edges, about 20 minutes. Let
sprouts cool on the baking sheet for 10 minutes.
2. Meanwhile, combine the remaining 2 T olive oil,
garlic, and anchovies in a small saucepan and set over
low heat. Cook until the garlic is straw-colored and
fragrant, 5 to 7 minutes. Remove from heat, and stir in
the lemon juice and Aleppo pepper.
3. Transfer the Brussels sprouts to a large bowl. Add
the parsley, onion, hazelnuts, and dressing, and toss
to combine. Adjust the seasoning with salt and Aleppo
pepper to taste. Serve.

Calories: 330; Total fat: 24 g; Sat fat: 3 g; Trans fat: 0 g;
Cholesterol: 5 mg; Sodium: 500 mg; Total carbohydrate:
26 g; Fiber: 10 g; Sugars: 6 g; Protein: 11 g
Help Patients Comply Deliciously

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Great Taste and Calorie Free. How does Walden Farms do it?
Walden Farms Salad Dressings, AMAZIN Mayo, New Flavored Mayos and Pasta Sauces are
also made with natural flavors including Toasted Asian Sesame, Zesty Ginger, Real Honey,
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Roasted Garlic, Minced Onion and so much more.
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Chocolate Dip Caramel Dip Marshmallow Dip Chocolate Syrup Caramel Syrup Pancake Syrup Fruit Syrups Fruit Spreads Peanut Spread Chocolate Peanut Spread
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Be healthy now.
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The everyday decisions we make regarding our health early in life will inevitably
affect our quality of life and wellbeing later on. Managing stress levels, eating well,
and staying active are all important lifestyle factors that contribute to overall good
health. Including Carlson Norwegian fish oils as part of a daily routine is just another
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lifestyle today.
888-234-5656 | www.carlsonlabs.com
*These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.

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CONFERENCE ISSUE

The Magazine for Nutrition Professionals

Substituting Palm Oil

Tyson Red Label

Tyson Timeless Recipe

MORE day parts. MORE price points. MORE quality.

Palm Oil The Natural and Healthy

To Learn More download

Saturated Fat Hypothesis:

IOI Loders Croklaan

RDs & Nutrition

For 15 years, Todays Dietitian has been a trusted

Visit CE.TodaysDietitian.com and earn CPEUs from the range of self-study

Power the Day with Daisy

Encourage your patients and clients to make the

Research suggests that when people eat

Variety The Spice of Life

Cottage cheese is so convenient and versatile;

Better Ingredients: Thats the

Daisy Low Fat Cottage Cheese is made with

Add Daisy to the healthy foods you already recommend.

2014 Great Valley Publishing Company, Inc.

july 2014 www.todaysdietitian.com 5

Substituting Palm Oil for Trans Fat The FDAs proposal to

oxidative stress and whether antioxidants may play a role in

Ask the Expert

Allergy & Intolerance Awareness

Todays Dietitians Spring Symposium

Diabetes and Cardiovascular Damage Experts discuss

conference, calling it a huge sucess.

Sustainable Hospital Foodservice Todays Dietitian proles

Veggies at Breakfast The most important meal of the day

The Nutrition Facts Label Dietitians speak out about the

CPE Monthly: Vitamin Ds Role in Health This course

Letter to the Editor

National Celiac Disease Awareness Month

From Our Twitter Page

Popular Tweets, Retweets

Spring Symposium Issue

RDs speak out

Elaine Mazgelis, RD, LDN, IBCLC

32 todays dietitian may 2014

From Our Facebook Wall

n a culture that places so much emphasis on physical

Weight Matters (or Does It?)

RDs as Role Models

may 2014 www.todaysdietitian.com 33

Easy Ways to Sneak in More Fruits and Veggies

Dietitians and Their Weight Struggles

@GinaMonkRD: Happiness and health are more

Monica Hoffman Fintel: Really nice way to encourage

Caleb Frazier: I havent seen it yet and Im sure it

@MEuzarraga: The dietitian weight struggle article

Benefits of Physical Activity (Dynamics of Diabetes)

Getting Beginners in Shape for Summer

july 2014 www.todaysdietitian.com 7

Vitamin D Provides Little

8 todays dietitian july 2014

number of asthma attacks, and in their need for emergency

Study Exposes Risk of Nutritional Deficiencies in Obese Teens

Coffee Consumption May Reduce Type 2 Diabetes Risk

in Nurses Health Study II (1991-2007); and 27,759 men in

july 2014 www.todaysdietitian.com 9