Today S Dietitian October 2023

CONFERENCE ISSUE
V l. 25
Vo
Vol. 25 No. 8
No.
October
Octo
Oc tobe
to be
er 20
2
2023
2
23 The
T he Magazine
Magazine for
for Nutrition
Nutrition Professionals
P rof e s s i o nal s
Ready-to-Eat
Breakfast
Cereals
Expert Strategies to
Help Clients Choose
Healthful Options
Managing Children
and Sugar Intake
Is Artificial Intelligence
Ready for Use
in Dietetics?
Learn the Six Pillars

of Lifestyle Medicine
to Improve Patient Care WWW.TODAYSDIETITIAN.COM
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Put Research into Practice

The idea of food is medicine received renewed attention from the
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*While the study’s findings cannot establish causality or be generalized to all populations, they suggest a
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Cont ents
VOLUME 25 • NUMBER 8 OCTOBER 2023
16
D E PA R T M E N T S
6 Editor’s Spot
34 8 Ask the Expert
10 Children’s Health
F E AT U R E S 12 Healthful Snacking
16 Probiotics
24 Ready-to-Eat Breakfast
Cereals RTE cereals sit center stage
on many breakfast tables, but not all
38 Artificial Intelligence in MNT
AI technology is on the rise and
making exciting inroads in medicine.
20 Pulses
of them are healthful. Take a deep Learn about the latest research, how 54 Focus on Fitness
dive into what they offer nutritionally it’s being used in health care, and its
and the brands that stand above the potential applications in dietetics.
56 Get to Know …
rest. After all, clients want to know. 58 Health Matters
30 Children & Sugar

Consumption While experts
42 Lifestyle Medicine’s Six
Pillars Nutrition. Physical activity.
Strong social connections. RDs
60 Products + Services
62 Fall Showcase
agree that limiting sweets is more have an important part to play in
beneficial to children’s health, encouraging patients to practice 63 News Bites
over restricting sugar intake may these lifestyle principles that have a
negatively impact their relationship long history of successfully fighting
65 Datebook
with food long term and potentially chronic disease. 66 Culinary Corner
lead to other unforeseen challenges.
34 Supplements & Cancer

A cancer diagnosis is scary for
48 CPE Monthly: Nutrition
and Skin Health This continuing
education course reviews the
patients, often leading them to relationship between nutrition and
take additional nutrients, herbs, skin health and looks at research
or botanicals. But RDs must know studies that investigate this
these remedies can cause adverse relationship and nutrition’s effect
effects when combined with on certain skin disorders.
prescribed treatments. 48
Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published nine times a year in Jan, Feb, March, April, May, June, Aug, Oct, and Nov by Great Valley Publishing Company, 3801 Schuylkill Road, Spring City, PA 19475.
Periodicals postage paid at Spring City, PA, Post Office and other mailing offices. Permission to reprint may be obtained from the publisher. Reprints: Wright’s Media: 877-652-5295 Note: For subscription changes of address, please write
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last label. Postmaster: Send address changes to Today’s Dietitian, PO Box 2026, Langhorne, PA 19047. Subscription Rates — Domestic: $14.99 per year; Canada: $29.99 per year. Single issue: $5. Today’s Dietitian Volume 25, Number 8.
4 TODAY’S DIETITIAN • OCTOBER 2023

NEW NEWS!
NEW RESEARCH INVESTIGATES THE LINK
BETWEEN ALMONDS AND THESE THREE
KEY AREAS: EXERCISE RECOVERY, PREDIABETES
AND SKIN HEALTH.
Almonds have been considered healthy for years, but

studies continue to find that almonds have nutritional
significance in a variety of ways, for a variety of health
plans. More than just a healthy snack, almonds are proving
to be on a level of their own in the healthy food category.
Exciting new research studies are emerging in the areas of

skin health, exercise recovery and prediabetes.
Want to learn more? Read all about the studies

exploring these topics at Almonds.com/Resources.
© 2023 Almond Board of California.

All rights reserved.
Editor’s Spot
Exploring AI in Health Care EXECUTIVE

Chief Executive Officer Mara E. Honicker
Chief Operating Officer Jack Graham
A
s technology continues to advance in every industry and
EDITORIAL
profession in the United States and around the world, Editor Judith Riddle
dietitians will see ongoing development and implemen- Nutrition Editor Sharon Palmer, MSFS, RDN
tation of artificial intelligence (AI) in health care that Editorial Department Manager Dave Yeager
Production Editor Heather Hogstrom
they potentially could apply to dietetics in the near future. Assistant Editor Chris Baldwin
AI is a specialty in computer science that focuses on creating Editorial Assistant Josh Hildebrand
systems that replicate the thought processes Editorial Advisory Board Toby Amidor, MS, RD, CDN, FAND;
Dina Aronson, MS, RDN; Constance Brown-Riggs, MSEd, RD, CDCES, CDN;
and decision-making abilities of human Karen Collins, MS, RDN, CDN, FAND; Carrie Dennett, MPH, RDN, LD;
beings via computer algorithms. These Jill Weisenberger, MS, RDN, CDCES, CHWC, FAND
systems accomplish this amazing feat by
ART
consuming and processing tons of data and Art Director Charles Slack
learning from their past to streamline and Senior Graphic Designer Erin Faccenda
improve future outcomes. This technology
ADMINISTRATION
could prove a boon for RDs when creating Administrative Manager/Human Resources Janet Renz
personalized diet and nutrition care plans for patients with Administrative Assistant Jennifer Mest
diabetes, heart disease, and other health conditions. Executive Assistant Matt Czermanski
Systems Manager Jeff Czermanski
If you didn’t know, the groundwork for creating machines
that think and perform tasks like humans was laid in the early CONTINUING EDUCATION
Director of Continuing Education Jack Graham
1900s, when Japanese professor Makoto Nishimura invented the
Director of Professional Development Leslie Cimei
first robot named Gakutensoku that opened and closed its eyes, Senior Manager Education and Accreditation Susan Prentice
moved its neck, and smiled, and when John W. Belcher of Newton, Continuing Education Coordinator Jennifer Kirkegaard
Massachusetts, created a female automaton that could walk, Customer Support Associate Jennifer Mest
Program Planner Ginger Hultin, MS, RDN
talk, sing, and write. LMS Coordinator Susan Graver
In the 1950s, AI was born when Arthur Samuel, PhD, a com-
puter scientist, developed programs to play championship level CIRCULATION
Circulation Director Susan Wood
checkers and chess, and when computer science pioneer John
McCarthy, PhD, coined the term “artificial intelligence” in asso- MARKETING AND ADVERTISING
Publisher Mara E. Honicker
ciation with a workshop he taught at Dartmouth College, and cre-
Associate Publisher Peter J. Burke
ated the first programming language for AI research used today. Director of Marketing and Digital Media Tim Rinda
Currently, AI algorithms are used by smartphones, digital Web Designer Jessica McGurk
assistants like Siri and Alexa, social media platforms, navigation Junior Digital Designer Emma Connolly
Email Marketing Coordinator Ryan Humphreys
apps, search engines (eg, Google, Yahoo), self-driving cars, and Social Media Associate Nicole Pratt
online shopping and e-commerce platforms. They’re also used for Director of Events and Sponsorships Gigi Grillot
creating robots in the aerospace, manufacturing, and hospitality Events and Sponsorships Manager Andrea Rizzoni
Events and Sponsorships Sales Executive Mildred Nieman
industries; gaming; advertising and marketing; and health care. Director of Sales Brian Ohl
Hospitals and clinics use robotics and predictive software Senior Account Executives Diana Kempster,
programs for early disease diagnosis that can analyze patterns Brian Sheerin, Beth VanOstenbridge
Account Executives Drew Murdock
and data to foresee when and how patients are likely to develop
specific diseases. They also use programs to track disease devel- FOUNDER EMERITUS
opment and determine new drug applications and harmful inter- Kathleen Czermanski
actions among different medications.
At present, clinicians are using and further exploring AI algo- © 2023 Great Valley Publishing Company
rithms and applications in cardiovascular medicine, diabetes
Phone: 610-948-9500 Fax: 610-948-7202
management, renal health, eating disorders and disordered eat- Editorial e-mail: [email protected]
ing, and weight management. And while there’s still a way to go Sales e-mail: [email protected]
to further develop AI applications in these specialties, RDs poten- Website: www.TodaysDietitian.com
Subscription e-mail: [email protected]
tially can use what’s available and look forward to future develop- Ad fax: 610-948-4202 Ad artwork e-mail: [email protected]
ments to improve patient care. All content contained in Today’s Dietitian represents the opinions of the authors, not
To learn more about AI research and its applications in health those of Great Valley Publishing Company (“GVP”) or any organizations with which
the authors may be affiliated. GVP and its employees and agents do not assume
care, turn to “Artificial Intelligence in MNT,” on page 38. responsibility for opinions expressed by the authors or individuals quoted in the
magazine; for the accuracy of material submitted by authors or advertisers; or for
Also in this issue are articles on supplement use and cancer, any injury to persons or property resulting from reference to ideas or products
children and sugar consumption, lifestyle medicine, and ready- discussed in the editorial copy or the advertisements.
to-eat breakfast cereals. Please enjoy this month’s edition! All content contained in Today’s Dietitian is created for informational purposes only and
shall not be construed to diagnose, cure, or treat any medical, health, or other condition.
Moreover, the content in Today’s Dietitian is no substitute for individual patient/client
assessment based upon the professional’s examination of each patient/client and
— Judith Riddle, Editor consideration of laboratory data and other factors unique to the patient/client.
[email protected] CONTENT CONTAINED IN TODAY’S DIETITIAN SHALL NOT BE CONSTRUED TO
CONSTITUTE PROFESSIONAL MEDICAL, HEALTH, LEGAL, TAX, OR FINANCIAL ADVICE.

hone
MED DIET’S PERFECT PARTNER
IN HEALTHY SNACKING
WITH HONEY AS PART OF A MED DIET

PLAN, SMART SNACKING CAN BE EASY.
Snacking can make or break a diet plan, and the

Med Diet is no different. The Med Diet consistently
ranks at the top of recommended plans, and evidence
suggests that including honey can make it easier for
your clients to keep eating healthfully. Honey is the
perfect all-natural addition for healthy snacks like
fruits, grains and yogurt, and it provides benefits
like antioxidants and prebiotics. Plus, eating honey
supports beekeepers, who in turn support the honey
bees so crucial to pollinating the global food supply.
So as you guide your clients toward making healthy

choices, know that choosing honey isn’t just great for
their nutrition—it helps beekeepers, honey bees and,
indeed, people all over the world.
VISIT HONEY.COM/NUTRITION TO LEARN MORE.
Overcash and Crusan. Curr Dev Nutr, July 23, 2022, 6(7).
© 2023 National Honey Board. All rights reserved.
Ask the Expert By Toby Amidor, MS, RD, CDN, FAND
commercial infant formulas to ensure

Product they meet minimum nutrition and safety
requirements. If the formula’s nutritional
Recalls value or safety recommendations don’t

meet standards, including the minimum
30 nutrients required, federal law allows
Q There have been several food

recalls that clients have asked
me about. Can you explain the process
the FDA to issue a mandatory recall.4
Food companies usually authorize a
recall voluntarily if they find a product
involved regarding food recalls and to be potentially harmful to consumers if
provide recommendations on how to used or consumed. Typically, a company
counsel clients? will work with the FDA to alert the
A: About one in six Americans gets sick public, publicize the recall, and outline
from a foodborne illness every year.1 steps for consumers to take to minimize
Although it appears there’s been an harm and illness if they purchased the question. If clients believe they have a
increase in food recalls, the numbers have affected product. recalled product they haven’t used or con-
decreased over the past few years.2 To sumed, they can access a full list of prod-
counsel clients, it’s important for dietetics Ensuring Food Supply Safety uct recalls, including lot numbers, the
professionals to understand the process of While it may seem as though recalls store(s) that sold it, and specific package
a food recall. Below, you’ll learn what hap- often occur, RDs can make consumers sizes on the US Department of Health and
pens when there’s a food recall and how aware that the US food supply ranks high Human Services website (foodsafety.gov).9
to provide clients with information and for safety. According to The Economist’s The USDA’s Food Safety and Inspection
resources if they’ve been affected. Global Food Security Index,5 which mea- Service also posts recalls on its website at
sures foods’ affordability, availability, www.fsis.usda.gov/recalls.10
Why Are Foods Recalled? quality, safety, sustainability, and adap- RDs can instruct clients to not open,
Food products can be recalled for a variety tation (the quantifiable risks that may consume, or donate a product that
of reasons. They may contain a patho- occur from changes in available natural matches the description on the recall
genic or physical contaminant or be resources)—the United States ranks 13 notice. Instead, clients should return the
misbranded. Pathogenic contamination out of 131 countries. And since 2012, the product to the store for a refund or dis-
occurs when a harmful pathogenic micro- United States has moved up 25 positions pose of it in accordance with the instruc-
organism, such as Salmonella or E. coli, is for food safety indicators. tions provided in the recall notice.
transferred to the food. Physical contami- Since the Food Safety Modernization If clients believe they’ve eaten a
nation occurs when a foreign object, such Act of 2011, there’s been a drastic improve- recalled food or are exhibiting any symp-
as metal or plastic, is found in the food. ment in food supply regulation.6 Several toms, RDs should refer them to their phy-
Misbranding is the most common rea- guidelines in the law are responsible for sician for further evaluation. I
son for recalls and often occurs when an this improvement. Currently, all facilities
undeclared allergen, like soy or nuts, or an are required to have a preventative con- Toby Amidor, MS, RD,
undeclared substance, like food coloring, trol plan, enhanced produce safety rules, CDN, FAND, is founder
is in the product or if an incorrect label and more frequent FDA facility inspec- of Toby Amidor Nutrition
is placed on the product. According to a tions. Facilities must give the FDA access (tobyamidornutrition.
2022 analysis of FDA data by the Sedg- to food safety records, greater authority com) and a Wall Street
wick organization, undeclared allergens over imported food, and comply with the Journal bestselling
accounted for 43.5% of food recalls.3 agency to issue mandatory recalls. author. She’s written 10
Foodservice operators usually test food In addition, advanced technology has cookbooks, including
through inspections and safety checks. been developed to help reduce cases of the upcoming Up Your Veggies: Flexitarian
The FDA and USDA Food Service and foodborne illness, including the FDA’s Recipes for the Entire Family (October
Inspection Service conduct their own GenomeTrakr Network.7 This technol- 2023) and Diabetes Create Your Plate Meal
safety checks; however, consumers also ogy helps the agency quickly respond to Prep Cookbook: 100 Delicious Plate Method
may alert companies if they become aware outbreaks and also allows for surveillance Recipes. She’s also a nutrition expert for
of a food safety issue. of foodborne pathogens. Since adopting FoodNetwork.com and a contributor to U.S.
whole genome sequencing for Listeria out- News and other national outlets.
The Process breaks, the average number of Listeria ill-
The FDA can issue mandatory food and nesses per outbreak has dropped by 50%.8
supplement recalls if it believes a food or For references, view this article on our
supplement has been adulterated, mis- Recommendations for RDs website at www.TodaysDietitian.com.
branded, or can cause serious adverse When clients have questions about food Send your questions to Ask the Expert
health effects; however, infant formula and supplement recalls, dietetics profes- at [email protected]
falls under its own set of regulations sionals should ask whether they’ve used or send a tweet to @tobyamidor.
and procedures. The agency regulates or consumed the food or supplement in

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by not attending the
2024 Today’s Dietitian Spring
Symposium?
Join your colleagues from May 19–22, 2024, for four days of learning,
camaraderie, networking, and more at the 2024 Today’s Dietitian
Spring Symposium in Salt Lake City, Utah.
Check out highlights from the 2023 Symposium

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Register Today at tdsymposium.com

Children’s Health
surrounding food and nutrition that dis-

ADD SOY Act Provides School proportionately impact people of color.
We know that cow’s milk is making our
Children With a Dairy-Free Option children sick, and not providing an option
is unjust and unconscionable. The fact
When Switch4Good Executive Director Richard B. Russell National School Lunch that so many kids are throwing out those
Dotsie Bausch learned that a USDA study Act was signed into law. The end of World unopened milk cartons is an enormous
revealed that 29% of the cartons of milk War II left America with an overabun- waste of taxpayer money,” Bausch says.
served as part of the National School dance of supplies, including milk. Presi- Key bipartisan support for the ADD
Lunch Program (NSLP) are thrown in the dent Harry S. Truman directed that the SOY Act in the Senate will be announced
garbage, effectively tossing $300 million milk be sent to schools. The NSLP pro- soon. Before introducing the bill, 31 mem-
in tax dollars into the trash each year, vides 47% of the daily caloric intake of the bers of Congress wrote to Agriculture
it didn’t seem right to her. Cow’s milk children in the program. Throwing out Secretary Thomas Vilsack to address the
doesn’t sit right with two-thirds of the the milk, estimated at 45 million gallons dairy industry monopoly in the NSLP.
human population in the form of lac- per year, means the kids are missing a siz- The letter specifically asks that soy milk
tose intolerance or a dairy allergy, which able portion of their daily nutrition. be made an available alternative to cow’s
means that a significant portion of the 30 Cow’s milk is the most common food milk. However, Vilsack ignored Congress’s
million American children who receive allergen that impacts infants and young request. Subsequently, a letter was sent
meals as part of NSLP are suffering the children. Symptoms include rashes, hives, to the White House Equity Commission
consequences—either from an adverse wheezing, vomiting, and anaphylaxis. In from multiple civil rights, social justice,
reaction to drinking milk or by missing fact, dairy milk has become the leading and health organizations, including the
out on important nutrition after discard- cause of food allergen death. Long-term National Urban League, which called on
ing the milk. Presently, there’s no dairy- effects of lactose intolerance include com- the USDA to end dietary racism. This let-
free milk option available for kids in the promised immune systems and respiratory, ter also was ignored by the Commission.
NSLP, which inspired the ADD SOY Act gastrointestinal, and skin problems. These “This summer is crucial for ADD SOY.
(Addressing Digestive Distress in Stom- debilitating symptoms have a profound We need people to write or call their rep-
achs of Our Youth), a bipartisan bill intro- negative impact on kids’ ability to concen- resentatives, asking them to support the
duced to the US House of Representatives trate and focus on their school lessons. act. If thousands of their constituents
by Troy Carter (D-LA) and Nancy Mace According to the National Institutes call or write, they have no choice but to
(R-SC) as H.R. 1619. of Health, the majority of all people have pay attention and get on board. Getting
Bausch was in Washington to meet a decreased ability to digest lactose after as many signatures as possible is our top
with representatives in an effort to get the infancy. Research shows that up to 80% priority. It’s an absolute must. We need
ADD SOY Act added as an amendment of Black and Latin Americans, more people to put pressure on Congress to pass
to the Richard B. Russell National School than 80% of Native Americans, and up the ADD SOY Act in order to stop this gov-
Lunch Act. Joining her was 18-year-old to 95% of Asian Americans are lactose ernment waste and right this wrong that’s
Marielle Williamson, who sued the USDA intolerant. Thus, placing a carton of hurting our children,” Bausch says.
and the Los Angeles Unified School Dis- milk on breakfast and lunch trays for The Switch4Good website has a form
trict last May for violating her rights, children participating in the NSLP, which letter readily available that can quickly
forcing her to praise dairy cow’s milk in is the requirement for those meals to be and easily be sent to the signer’s jurisdic-
addition to the literature she was distrib- reimbursed by the USDA, is a mandate tional representatives, available at https://
uting to students at her high school about that unfairly impacts a higher percentage switch4good.org/add-soy-act/.
dairy-free milk alternatives. of Black and indigenous children and Williamson told The Washington Post
The 2020–2025 Dietary guidelines for children of color. that “People don’t really like to drink
Americans recognizes fortified soy milk “When you sit in the classroom wheez- cow’s milk anymore, and they have other
as a nutritional equivalent to dairy cow’s ing, coughing, and your stomach is cramp- sources of dairy.”
milk, thus making it available as an option ing, it makes concentrating on your studies The ADD SOY Act will make an alter-
in the NSLP, which seemed like an ideal nearly impossible. Cow’s milk could very native source available to our nation’s
solution to Bausch. Schools aren’t cur- well be the reason there’s a learning gap school children.
rently reimbursed if they provide soy milk between Black and white children,” says SOURCE: SWITCH4GOOD
as an option, yet the USDA is reimbursing Milton Mills, PhD, a critical

public schools for cow’s milk to the tune care physician who practices in
of $1 billion annually—even though they Washington, D.C.
know children are dumping $300 million “With a larger portion of those
dollars of milk directly into the trash. A participating in the National
2015 study revealed that an astonishing School Lunch Program being
73% of US dairy income came from gov- children of color, putting cartons
ernment programs like the NSLP. of milk on their trays is a form
The placement of milk on students’ of racism—dietary racism. It’s
lunch trays dates back to 1946 when the systemic, structural inequities

lacroixwater.com ©LACROIX BEVERAGES, INC · ALL RIGHTS RESERVED @lacroixwater
Healthful Snacking By Mindy Hermann, MBA, RDN
Snackification of Vegetables
Many of today’s brands put plants front
and center rather than disguising or
hiding them in formulations. “A plant-
forward trend has emerged, as shoppers
seek nutrient-dense options with
recognizable ingredients,” says Monica
Watrous, managing editor of Food
Business News and Food Entrepreneur at
Sosland Publishing Company in Kansas
City. “Think jackfruit jerky, carrot chews,
zucchini chips, and mushroom crisps, to
name just a few.”
Single-serve bags of baby carrots
seem so yesterday compared with
the growing array of fresh vegetables
processed and packaged for easy
snacking. Here are a few standout
companies and products pushing plant-
based snacking forward:
• Poshi (Power of Simple Healthy Ingre-

dients), a snack manufacturer based in
Peru, whose products are distributed
by Miami’s Elma Farms, offers single-
serve snack pouches of marinated
green beans, cauliflower, asparagus,
and artichokes.
• Terra Real Vegetable Chips, based in
Honduras and distributed by Hain
Celestial, was one of the first brands
Plant-Based Snacks to expand beyond the potato chip. The
company’s original snack blend is a
Going Beyond Potatoes and Corn combination of batata, sweet potato,
parsnip, and taro.
F
or consumers who grew up by the proliferation of plant-based snacks • Confetti Lovely Vegetable Chips, pro-
before the term “plant based” in the marketplace. What’s driving snack duced in Singapore and “Upcycled Cer-
became a thing, potato chips innovation “is changing consumer atti- tified,” offers an expanded assortment
and corn chips had the exclu- tudes toward health along with con- of sliced “ugly” vegetables, including
sive rights on the early plant-derived sumer expectations that healthful options carrots, okras, and radishes. The veg-
snacks market. That all has changed in should be available for all types of foods etables are slow baked to help retain
2023. Today’s snack aisle offers not only they eat, including snacks,” Williams says. their nutrients.
plant-centric flavors like hot peppers, “In fact, over the past year, one-third of • California-based Root Foods offers
lime, herbs, and dill pickle but also snacks consumers we surveyed report increasing four varieties of crispy vegetable
made from various forms of vegetables, snacks with added health benefits.” snacks: zucchini; tomato; onion; and a
such as carrots, green peas, and kale. Several Innova surveys explore snack- mix made of whole and cut asparagus,
According to SNAC International, a ing attitudes and behaviors. Participants green beans, zucchini, okra, bell
trade association for the snack industry, in the company’s most recent survey peppers, and broccoli.
88% of snack consumers say flavor is on snacking named health as the num- • Rhythm Snacks, headquartered in
important when making snack choices, ber two reason—taste being number Austin, Texas, has a product line that
and snack producers are finding one—for consuming plant-based jerky includes a range of seasoned vegeta-
inspiration for new, interesting flavors snacks. Williams adds that because bles, including kale, shishito peppers,
from around the world to meet the today’s time-strapped consumers must jicama, and beet chips that are crisped
demand for new, innovative products, be able to read labels at a glance, eye- at a low temperature.
including plant-based options. catching buzzwords like “plant-based” • New York City-based Popadelics
can help them make quick, health- offers three different flavors of crispy,
Health Expectations and Snacking focused decisions. “Plant-based” also is seasoned, dried mushrooms—truffle
Lu Ann Williams, global insights director less polarizing than the term “vegan” on and parmesan, Thai chili, and rose-
for Innova Market Insights, isn’t surprised front-of-pack labels. mary and salt.

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Healthful Snacking
Plant-Based Jerky and other types of animal jerky. Many with Tomato & Poblano Pepper, Ginger
Even the classic snack, beef jerky, has a companies are putting their own spin Teriyaki, or Sweet Barbecue flavors.
plant-derived alternative. Plant-based on the snack, such as Jack & Friends in California-based Beyond Meat, best
jerky can feature a range of vegetable New York City, which distributes jerky known for its burgers, also offers three
bases that are processed to replicate beef made from jackfruit and pea protein varieties of jerky, including Original,
POPULAR PLANT-BASED SNACKS ON THE MARKET

Product Plant-Based–Related Claims Main Plant Ingredients Key Nutrients/Serving
WHOLE VEGETABLES
Poshi Cauliflower vegan cauliflower, vinegar 10 kcal, 0 g fat, 110 mg sodium,
1 g fiber (45 g)
Terra Original Real Vegetable Chips vegan, real vegetables taro, yuca, batata, sweet 200 kcal, 12 g fat, 110 mg
potato sodium, 3 g fiber (40 g)
Confetti Lovely Veggie Chips nutrient dense, gluten-free, plant vegetables 150 kcal, 9 g fat, 160 mg
based, good source of fiber sodium, 5 g fiber (35 g)
Root Zucchini Chips vegan, approximately 2 lbs fresh zucchini 130 kcal, 8 g fat, 15 mg sodium,
zucchini per 3-oz bag 3 g fiber (28 g)
Rhythm Original Organic Kale Chips vegan, excellent source of calcium, kale, sunflower seeds, tahini 160 kcal, 12 g fat, 240 mg
vitamins A and K; good source of sodium, 3 g fiber (28 g)
iron, potassium
Popadelics Crunchy vegan dried shiitake mushrooms 180 kcal, 9 g fat, 250 mg
Mushroom Chips sodium, 6 g fiber (40 g)
PLANT-BASED JERKY
Jack & Tom Tomato & Poblano plant based, vegan, good source of jackfruit, poblano peppers, 80 kcal, 1 g fat, 270 mg sodium,
Pepper Vegan Jerky protein and fiber tomato paste, pea protein 4 g fiber, 7 g protein (28 g)
Beyond Meat Jerky plant-based protein, no soy mung bean protein, pea 90 kcal, 2 g fat, 500 mg sodium,
protein, oat bran, and fiber 1 g fiber, 10 g protein (30 g)
Louisville Vegan Jerky Co Smoky non-GMO soy, plant based textured soy protein 80 kcal, 3 g fat, 250 mg sodium,
Carolina BBQ 2 g fiber, 5 g protein (28 g)
Pan’s Original Mushroom Jerky plant based, vegan shiitake mushrooms 110 kcal, 7 g fat, 190 mg sodium,
6 g fiber, 1 g protein (30 g)
PUFFS
Vegan Rob’s Sorghum plant based, good source of sorghum grain meal, 170 kcal, 9 g fat, 210 mg sodium,
Cauliflower Puff s vitamin C cauliflower, onion, and 0 g fiber (28 g)
garlic powder
Talia Chickpea Snacks Sea plant based, vegan, high fiber chickpea flour, lentil flour, 110 kcal, 4 g fat, 420 mg
Salt Puff s rice flour, corn flour sodium, 4 g fiber (28 g)
FRUIT SNACKS
RIND Apple Chips whole fruit maximizes nutrition and apples 100 kcal, 0 g fat, 0 g sodium, 1 g
minimizes food waste, vegan fiber (28 g)
Barnana Organic Plantain Scoops upcycled certified green plantains 140 kcal, 8 g fat, 65 mg sodium,
4 g fiber (28 g)
Live Crispy 35 Blueberries + 1 zero added sugars, vegan, real plants pineapple, blueberry 80 kcal, 0 g fat, 0 mg sodium,
Pineapple 1 g fiber (28 g)
SOURCE: COMPANY WEBSITES. THIS TABLE REPRESENTS ONLY A SAMPLE OF THE MANY PLANT-BASED DAIRY ALTERNATIVES ON THE MARKET.

Teriyaki, and Hot and Spicy, which are all Meanwhile, Talia Sea Salt Puffs, produced which help support a more diverse
made with legume-based protein, brown in Turkey, use chickpea and lentil flours, microbiome. Liz McMahon, MPH, RDN,
sugar, oil, and additional seasonings. which boost fiber and protein. LDN, a Pennsylvania-based digestive
Then there’s Louisville Vegan Jerky Co’s health practitioner, says, “People with IBS
jerky, which is available in classic flavors Fruit Snack Equivalents [irritable bowel syndrome] can choose
such as Smoky Carolina BBQ, Maple Although fruit snacks often don’t claim from FODMAP-friendly options, such as
Bacon, and Pepperoni. Its textured soy to be plant-based, several products sweet potato or plantain chips, roasted
protein base allows replication of the offer a convenient alternative to fresh chickpeas, and freeze-dried low-FODMAP
texture of meat-based jerky; however, fruit. Increased attention to food waste berries and citrus.” She cautions that
mushrooms and mycelium increasingly reduction has sparked the introduction plant-derived snacks may be seasoned
are being used in the industry as the of fruit snacks made from whole fruit, with garlic and onion, which are high-
base for plant-based jerky because including the peel, from companies like FODMAP choices.
they require less processing than many Rind, Barnana, and others. In addition, Nutrition benefits also aren’t guaran-
plant-based ingredients and offer a more many fruit snacks claim the fresh fruit teed. Elizabeth Ward, RDN, a nutrition com-
jerkylike texture. equivalent on the front of the package. munications consultant in the Boston area,
says, “While plant-based snacks are a step
Puffs Plus Veggies Is Plant-Based Better? in the right direction, it doesn’t mean they’re
Puffs also are highly adaptable to plant- The term “plant based” doesn’t guarantee automatically low in calories or high in
based modifications with the addition of that a snack is better for the environment essential nutrients, such as fiber. … So don’t
vegetable powder to a starch base. Com- than its traditional counterpart. Prod- give plant-based snacks a free pass. Always
panies are putting their own spins on the ucts with packaging language describ- read the label to find out what they offer, or
classic snack form, like New York-based ing their mission, whether it’s food waste don’t offer. They also may be less filling than
Vegan Rob’s, which adds powder from reduction, organic cultivation, regenera- whole fruits and vegetables.” I
Brussels sprouts or cauliflower plus onion tive agriculture, or other environmental
and garlic to its plant-based sorghum actions, may help make a difference. Mindy Hermann, MBA, RDN, is a food and
meal puffs. Its Cauliflower Puffs contain Plant-based snacks also can be an nutrition communications specialist in metro
enough cauliflower to qualify for a con- attractive option for gut health because New York and a market research consultant to
tent claim as a good source of vitamin C. they provide both fiber and plant diversity, Innova Market Insights in Arnhem, Netherlands.
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Probiotics By Carrie Dennett, MPH, RDN
have several functions, including mod-

ulating the secretion of hormones that
can increase insulin sensitivity and
satiety and decrease inflammation.1
• Differences in microbial populations
also have been observed when compar-
ing patients with diabetic nephropathy,
type 2 diabetes patients without renal
disease, and healthy individuals.3
• Some microbes metabolize trimethyl-
amine from dietary choline and car-
nitine, which is converted in the liver
to trimethylamine-N-oxide (TMAO).
Patients with type 2 diabetes have
elevated TMAO levels, although it’s
unclear whether high TMAO levels
cause diabetes.2
• Some stool studies also have observed
increased expression of microbial
stress genes—adaptations that help
microbes adapt to adverse changes in
nutrient supply or other aspects of their
environment—which has been linked
to insulin resistance, pancreatic beta-
cell dysfunction, impaired glucose tol-
erance, and type 2 diabetes.1
The health and composition of the gut

microbiota are influenced by diet and
lifestyle factors, including alcohol intake
and the use of antibiotics, other medica-
tions, and probiotics and prebiotics.1 The
official definition of probiotics, as agreed
on by the International Scientific Associa-
tion for Probiotics and Prebiotics, is that
Probiotics and Diabetes they’re live microorganisms that, when

administered in adequate amounts, con-
fer a health benefit on the host. While cer-
Can gut health management help prevent
tain fermented foods may contain strains
or manage type 2 diabetes? of probiotic bacteria, most of these foods
wouldn’t be considered probiotics them-
A
s consumers become more permeability, immune function, satiety, selves because bacterial strains may vary
aware of the role gut health digestion, and nutrient absorption, among from batch to batch and because they may
has in overall health and other important functions.1 Dysbiosis, not be present in sufficient numbers to
chronic disease, many are the alteration of a healthy microbiota, is produce a health benefit.
considering probiotic supplements associated with low-grade inflammation, Preliminary studies suggest that alter-
to support their gut microbiota. insulin resistance, and type 2 diabetes.2 ing the composition of the gut micro-
Unfortunately, the hype around the biota with probiotic supplementation
potential health benefits of probiotics Differences in Microbiota may improve type 2 diabetes by reducing
currently is overstated once claims are Composition proinflammatory cytokines, intestinal
evaluated in the context of research- Numerous research studies have observed permeability, and oxidative stress via mul-
based evidence. So what does this mean relative increases in some bacterial spe- tiple pathways, including SCFA forma-
for the claims that probiotics can help cies and decreases in others in the stool of tion.4 While results from animal studies
prevent or manage type 2 diabetes? participants with type 2 diabetes. Exam- on the benefits of probiotics for improv-
Certainly, the gut microbiota is a ples include the following: ing glucose metabolism and insulin sen-
contributing factor in the develop- sitivity have been promising, research
ment and progression of type 2 diabe- • Decreases in bacterial species that pro- on humans has produced inconsistent
tes. Gut microbes and their metabolites duce short-chain fatty acids (SCFAs) results.5,6 Still, a 2020 meta-analysis of 15
strongly influence host metabolism, gut via fermentation of dietary fiber. SCFAs randomized controlled trials involving

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Probiotics
902 patients found that the groups ran- to reduce postprandial blood glucose in meet quality standards appropriate for
domized to take probiotics saw statisti- people with type 2 diabetes, giving it a that population, preferably verified by an
cally significant reductions in hemoglobin level 2 recommendation11; however, sev- independent third party.15 For example,
A1c, fasting blood glucose, and insulin eral bacterial species used in commercial despite excitement about A. muciniphila,
resistance, compared with patients taking probiotic supplement products, includ- because it’s a mucin-degrading bacte-
a placebo, despite differences in the dosing some Lactobacillus and Bifidobacte- ria—mucin is the main glycoprotein in
age and duration of probiotic treatment rium species, have reduced fasting blood the mucus layer that protects the intesti-
among the studies.5 glucose levels in human and animal nal barrier—there’s concern that exces-
studies.2,4 sive enrichment of that species in certain
Studies and Their Findings Some studies also have looked at intestinal environments may be harmful.
In a 2023 review article, Akkermansia the combined effects of probiotics and For instance, it may not be safe to use in
muciniphila—a bacterium first “discov- berberine, a bioactive plant compound patients with endocrine or gynecologi-
ered” and isolated in 2004, and which that has a long history in traditional cal disorders that increase risk of inflam-
represents approximately 1% to 3% of Chinese medicine. Independently, matory bowel disease, such as polycystic
the total gut microbiota in healthy peo- berberine has been shown in studies to ovary syndrome or endometriosis. More-
ple7—was called the “‘next generation lower blood glucose in patients with type over, patients with Parkinson’s disease
probiotic’ for alleviating metabolic dis- 2 diabetes, although the mechanism to or multiple sclerosis already may have an
orders and the inflammatory response.” achieve this is unknown.12 overabundance of A. muciniphila.16
For example, propionate, an SCFA pro- The Probiotics and BBR on the Efficacy A 2021 Cochrane Review concluded
duced by A. muciniphila metabolism, and Change of Gut Microbiota in Patients that low-quality evidence from six
has been shown to stimulate glucagon- with Newly Diagnosed Type 2 Diabetes placebo-controlled studies involving 1,440
like peptide-1, a hormone with functions randomized controlled trial compared patients hasn’t clearly identified the effect
including stimulating insulin secretion.8 the effects of probiotics plus berberine, of probiotics on the risk of gestational
Another 2023 review had a similar assess- berberine plus placebo, or probiotics diabetes, which is a long-term risk factor
ment, emphasizing that A. muciniphila plus placebo with that of placebo for type 2 diabetes.17 Importantly, the
has a well-documented role in improving alone in 466 patients. After 12 weeks authors note that while they found no
several metabolic pathways, which makes of treatment, the probiotic-berberine solid evidence of the benefit of using
it a key element in the pathogenesis of group and the berberine-placebo group probiotics to prevent gestational diabetes,
several human diseases. The authors note had similar statistically significant they found that high-quality evidence
that, in addition to stimulating glucagon- reductions in HbA1c compared with suggests that probiotics may increase the
like peptide-1, this bacterium can reduce the probiotic-placebo and placebo risk of preeclampsia.
the expression of glucose and fructose alone groups. The researchers found
receptors in the small intestine, reducing that berberine enhanced populations Bottom Line
absorption of carbohydrates.7 of several bacterial species that also are These findings serve as a good reminder
Two randomized, double-blinded, enhanced by treatment with metformin.13 that much of the research on probiotics
placebo-controlled trials have demon- A separate 18-week randomized, double- and glucose metabolism is in animal mod-
strated that supplementation with A. blinded, parallel-controlled study of els, and mechanisms to explain observed
muciniphila has benefits for blood glu- 300 patients newly diagnosed with benefits aren’t fully explained. Additional
cose control. A 2019 exploratory study hyperglycemia compared the effects of research may shine light on those mecha-
published in Nature Medicine found that berberine, Bifidobacterium, berberine nisms, as well as a better understanding
A. muciniphila improved insulin sensi- plus Bifidobacterium, and placebo. of the relative risks and benefits for dif-
tivity compared with placebo.9 A small Compared with the placebo group, the ferent patient populations. In the mean-
2020 company-funded-and-run proof-of- berberine plus Bifidobacterium group saw time, knowing the current limitations of
concept study that used a novel probiotic a significant reduction in fasting blood the research can help dietitians counsel
formulation containing A. muciniphila glucose, two-hour postprandial glucose, clients and patients who want to know
along with Clostridium beijerinckii, Clos- and HbA1c. The berberine-only group if they should take probiotics to manage
tridium butyricum, Bifidobacterium infan- also saw a small reduction in two-hour their blood sugar—especially patients
tis, Anaerobutyricum hallii, and inulin—a postprandial glucose.14 who may think that probiotics are more
type of prebiotic fiber—found that among powerful than they actually are. I
participants with type 2 diabetes cur- Safety Considerations
rently using metformin, the group taking Because healthy consumers and certain Carrie Dennett, MPH, RDN, is the nutrition
the formulation experienced statistically patient populations use probiotics, the columnist for The Seattle Times, owner of
significant decreases in postprandial International Scientific Association for Nutrition By Carrie, and author of Healthy
glucose levels (36.1 mg/dL) and HbA1c Probiotics and Prebiotics published a for Your Life: A Non-Diet Approach to
levels (0.6%) at week 12, when compared perspective piece on emerging issues in Optimal Well-being.
with placebo. No change in fasting glu- probiotic safety earlier this year in the
cose levels was observed.10 Currently, this journal Gut Microbes. The authors explain For references, view this article on our
formulation is the only one established by probiotics targeted for patient popula- website at www.TodaysDietitian.com.
the Alliance for Education on Probiotics tions should undergo stringent testing to

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Pulses By Karen Collins, MS, RDN, CDN, FAND
However, major dietary recommenda-

tions from the American Heart Association,
the American Diabetes Association, and the
American Institute for Cancer Research,
which focused on reducing specific health
risks, all include pulses as part of a dietary
pattern to promote cardiovascular health,
manage diabetes and prediabetes, and
reduce risk of cancer.4-7 Yet, none include
specified amounts.
Nutritional Benefits
Pulses are advantageous to a health-
promoting diet due to the nutrients and
compounds they provide and can serve as
replacements for foods that should be lim-
ited in a healthful dietary pattern. Pulses
boost nutrient-density and offer typi-
cally underconsumed nutrients. Calcium,
potassium, dietary fiber, and vitamin
D are underconsumed and are a public
health concern for the general US popula-
tion, according to the DGA.3 Iron is also a
part of that list for female adolescents and
women of childbearing age. Pulses are
flagged as nutrient-dense sources of three
of these five nutrients, including potas-
sium, dietary fiber, and iron. In addition,
Are Pulses a Misunderstood the DGA notes that protein is undercon-

sumed by many adolescent females and
adults aged 71 and older and highlights
Food Group? beans, peas, and lentils as a food category
that’s underconsumed in these popula-
Help clients bypass misconceptions and include more tions and could help fill that gap. Many
of these nutritional gems. pulses also are good sources of folate and
magnesium, which also are classified by
S
ome people use the term “pulses” are grouped with starchy vegetables, the DGA as underconsumed nutrients.
interchangeably with “legumes.” while the rest are with “other vegeta- People who consume pulses have
However, legumes encompass bles” such as celery, cabbage, onions, higher calorie-adjusted intakes of dietary
a broad category of plants with and peppers.3 fiber, folate, and magnesium than those
seeds that grow in pods. The differences • Oilseed legumes are nutritionally who consume none, according to an
among legumes lead to distinct nutri- unique because they’re higher in fat analysis of National Health and Nutrition
tional profiles. The most common types (primarily unsaturated) and lower in Examination Survey data.8 And those
fall into three categories1,2: fiber than other legumes. Peanuts and who consume higher amounts—just
soybeans are the two major examples. under 0.5 cup equivalents per day—
• Pulses are the dry edible seeds also have higher energy-adjusted
from within a pod. Although there Inconsistent Guidelines intakes of potassium, zinc, iron, and
are multiple types and hundreds In the Healthy US-style or Mediterra- choline compared with nonconsumers.
of specific examples, pulses in the nean dietary pattern, adults are advised The National Health and Nutrition
United States often are grouped into to consume 1½ cups of pulses per week Examination Survey is an observational,
four main types: dry beans, dry peas, in a 2,000-kcal/day diet, according cross-sectional study, so it’s possible that
chickpeas, and lentils. to the 2020–2025 DGA (where they’re people who consume more pulses also
• Undried (fresh or green) legumes are listed under the Beans, Peas, Lentils make other dietary choices that increase
harvested while still green (before dry- subgroup of vegetables). 3 The DGA consumption of these nutrients.
ing). They can be consumed with their vegetarian dietary pattern calls for an
pods (eg, green beans and sugar snap additional 6 cups per week in a 2,000- Pulse Consumption Promotes Health
peas) or without their pods (eg, green kcal/day diet as part of protein-supply-
peas). In the 2020–2025 Dietary Guide- ing foods, for a total of about 7½ cups of • Cardiometabolic health: Prospective
lines for Americans (DGA), green peas pulses per week. observational studies show that

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Pulses
regular pulse or total legume barriers they face and then providing rele- regularly include them, they often build
consumption is associated with vant education and coaching that address up a tolerance. Commercial digestive aids
lower risk of CVD.9 In randomized those barriers. with alpha-galactosidase can alleviate
intervention trials lasting at least “In my practice, patients report that digestive discomfort, if needed.
four weeks that analyzed effects on they didn’t grow up eating beans or that
markers of cardiometabolic health, they don’t like the taste and have limited Pulses Are Flexible
legumes, which included pulses and knowledge of how to prepare beans,” says In addition to addressing barriers with
soyfoods, were the second strongest Maya Feller, MS, RD, CDN, author of Eat- clients, dietitians can provide examples
out of 10 food groups for reducing LDL ing From Our Roots: 80+ Healthy Home- of how they can prepare pulses that cater
cholesterol.10 And in combined analysis Cooked Favorites From Cultures Around to a variety of individual and cultural
of all 10 biomarkers of cardiometabolic the World, based in Brooklyn, New York. preferences to encourage more frequent
health (including those related to RDs also can provide clients with consumption. “[Pulses are] incorporated
lipids, glycemic control, blood pressure, strategies to prepare pulses. “The soaking into marinades, purées, soups, and stews,”
and inflammation), the effects of and cooking process for dry pulses is Feller says. “I often encourage people to
legumes again were rated second. often a barrier for US consumers to start with flavors that are familiar and
• Cancer risk: Pulses go a long way to help prepare them at home,” says Madison branch out to ones that are new.”
fill the gap in dietary fiber in Western Jacobson, director of marketing for the Jacobson says, “Swapping in pulses for
diets to help fulfill the recommendation USA Dry Pea and Lentil Council and the other ingredients in familiar dishes
for at least 30 g fiber per day to reduce American Pulse Association in Moscow, people regularly consume” offers a
cancer risk.6 However, although pulses Idaho. “Many consumers are unaware realistic path to including more pulses.
often are recommended as part of a diet that split peas and lentils do not require Examples Jacobson suggests include
to reduce cancer risk, research hasn’t yet soaking before cooking. And both will replacing half or all of the meat for tacos
shown a consistent association of pulse cook in 45 minutes or less.” Canned and with seasoned lentils, replacing half or
consumption with lower risk of cancer— frozen pulses offer a solution if soaking and all of the ricotta in lasagna with pureed
whether overall or specific types.6,11 cooking time is too much of a barrier, and white beans, and replacing up to half the
• Role in a healthful dietary pattern: a pressure cooker can significantly reduce cheese sauce in macaroni and cheese
Healthy Eating Index scores for a the time needed to prepare dry pulses. with pureed yellow split peas.
healthful dietary pattern reflect pulse In addition, media headlines based
consumption that aligns with current on research taken out of context may Bottom Line
recommendations and are associated instill fears of lectin compounds in pulses. Plant-focused dietary patterns come in
with key metrics of better health.12,13 Claims linking lectins to chronic inflam- many different forms. Even for people
The question is whether more frequent mation and gut damage are based on who don’t want to eat exclusively plant
consumption, such as a half-cup daily, laboratory studies using isolated lectins or foods, pulses play an important role in
will create a dietary pattern that better raw beans.14 However, lectins are neutral- the DASH, Mediterranean, flexitarian,
supports health. Those who favor ized in cooking, and since they’re water and other plant-forward diets. Pairing
recommending increased amounts of soluble, they’re largely removed by cook- pulses with modest portions of animal
pulses note that the overall impact of ing or canning in water. foods can enhance nutrient density while
pulses’ nutrient quality, and value as a Some people may fear that pulses reducing food costs.
replacement for other foods, is diluted are “fattening” or that they will Clients can add pulses to curries, chili,
when it’s averaged over several days.1 impede blood sugar management. casseroles, and stir-fries—with or without
Dietitians should explain that pulses poultry, seafood, or meat. At breakfast,
Overcoming Barriers are categorized as low in calorie density bean or lentil burritos and tostadas can
Dietitians can facilitate greater con- and that greater consumption of be a great solution. In addition, clients
sumption of pulses by asking clients what pulses and other legumes is associated can blend pulses into smoothies or dips.
with a decreased risk of weight gain, And roasted pulses, whether store bought
overweight, and obesity, and better or homemade, make healthful snacks or
glycemic control.10,15 In randomized, salad toppings. I
Resources controlled human intervention trials,

people achieved modest weight loss and Karen Collins, MS, RDN, CDN, FAND, is
The following organizations provide lower body fat by eating a serving of nutrition advisor to the American Institute for
dietitians with recipes, tip sheets, pulses daily, even without intentionally Cancer Research. She offers research reviews
research summaries, and social reducing total calories.16 on her website (https://karencollinsnutrition.
media inspiration: Finally, it’s time to address the ele- com) and is creator of the Daunting to Doable
phant in the room: gas production. Nutrition Pro Circle, a membership program
• The American Pulse Association:
Gut bacteria produce gas as they form for dietitians only.
https://pulses.org/us
beneficial short-chain fatty acids from
• Lentils.org (funded by prebiotic compounds in pulses. However, For references, view this article on our
Saskatchewan Pulse Growers): dietitians can explain that when peo- website at www.TodaysDietitian.com.
www.lentils.org ple gradually increase these foods and

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Ready-to-Eat
Breakfast
Cereals
Expert Strategies to Help Clients
Choose Healthful Options
By Densie Webb, PhD, RD consume RTE cereal had 29% higher
total dairy intake, 61% higher whole grain
intake, and a higher diet quality overall
than children who didn’t eat RTE cereal.4
T
he adage “Breakfast is the most important meal of Cereals are made from processed grains,
the day” is a truism that has been held for years, and including wheat, rice, and oats, and can
be puffed, flaked, or shredded with any
there’s research to suggest there may be something number of added nutrients. But not all RTE
to those words.1 If breakfast is, indeed, the most cereals are nutritionally equal. A significant
percentage contain unhealthful levels
important meal of the day, it stands to reason why of added sugars. Perhaps more than any
ready-to-eat (RTE) cereals have been dubbed by other product category, RTE cereals vary
tremendously in almost every nutrient—
some as the king of the breakfast table and that nine in 10 Americans calories, protein, sugars, fats, and fiber, not
say they’ve eaten RTE cereals for breakfast, according to Mintel Group, to mention the great variations in number
and amounts of vitamins and minerals
a market research firm. RTE cereals also are growing as a snack food, as
listed on the Nutrition Facts panel. Then
43% of those surveyed by Mintel have eaten RTE cereal as a snack.2 The there’s the question of whether a cereal is
most recent Mintel report predicted the cereal market will grow by 18% organic, certified kosher, vegan, non-GMO,
or gluten-free, which isn’t indicated in the
in the next five years, reaching $160 billion by 2028.3 chart on pages 26 and 27 but is displayed
on the product label. There are more than
enough products from which to choose.
The Post brand alone lists 27 lines of
Breakfast cereals are quick, convenient, Andrea Mathis, MA, RDN, LD, owner of cereal on its website, and within each line,
relatively inexpensive per serving, and Beautiful Eats & Things and author of The there may be at least three or four distinct
many provide a bevy of added and natu- Complete Book of Smoothies: 115 Healthy variations, offering everything from
rally occurring nutrients. “As a registered Recipes to Nourish, Heal, and Energize. healthful high fiber cereals to sugar-laden
dietitian and busy mom, I often recom- While the outcome depends on the type of cereals for children. The cereal aisle in
mend cereal as a convenient way to add cereal consumed, a study using NHANES most supermarkets typically offers more
a few extra nutrients to breakfast,” says 2015–2016 data found that children who choices than any other section, making it

difficult for clients and patients to make “I view serving sizes as a guide, not as a
healthful choices that align with their ‘rule.’ We all have different nutritional
READY-TO-EAT CEREAL
health goals, tastes, and budgets. “RTE needs,” Mathis says.
cereal is one of the few foods enjoyed by
people across the different stages of life,” • Calories. The calorie levels of the cereals Cereals Serving Size
says Vandana R. Sheth, RDN, CDCES, in the chart, which are representative of
FAND, a Los Angeles-based nutrition all RTE cereals, range from a low of 90 kcal
counselor and owner of a private practice. for a ⅔-cup serving to a high of 280 kcal HIGH FIBER (5 G OR MORE PER SERVING)
“Since cost is a growing concern for many per ½-cup serving—a three-fold differ- Kellogg’s All-Bran ⅔ cup
people, cereal can be a cost-effective way to ence in calorie counts.
get many key nutrients.”
• Protein. There aren’t a large number of
Cereal Nutrition cereals that boast a high-protein content. Kellogg’s Cracklin’ Oat Bran ¾ cup
The chart provided serves as a sample of The few listed in the chart range from 10 to
the types of RTE cereal brands, varieties, 20 g protein per serving. However, several
and nutrition profiles available on the other cereals considered high fiber also
Post Grape-Nuts Original ½ cup
market. The chart groups them according provide as much as 11 g protein per serving.
to major selling points: high fiber, high
protein, granolas, and children’s. Some • Carbohydrates. All cereals are rich
Kellogg’s Frosted Mini-Wheats 25 biscuits
of the categories and nutrient attributes sources of carbohydrates, but many are Bite Size
in the chart overlap. For example, a cereal refined, which can cause blood glucose
Cascadian Farm Organic 1¼ cups
may be in the high fiber section but also levels to spike, especially if eaten as a Multi-Grain Squares
is high in protein. Another cereal may snack without milk. Anderson Haynes
be grouped in the high fiber category emphasizes that, in fact, many cereals are
but also contains as much sugar as one considered to be ultraprocessed foods. HIGH PROTEIN (5 G OR MORE PER SERVING)
of the children’s cereals. Few cereals are Consumption of ultraprocessed foods
Post Premier Protein Chocolate 1 cup
easily classified. Here’s a discussion on the has been associated with several chronic Almond
average serving sizes and nutrients RTE health conditions, including hyperten-
cereals contain. sion, diabetes, heart disease, and demen- Kashi GO Peanut Butter Crunch ¾ cup
tia. But other cereals are less refined and
• Serving Size. None of the nutrients are excellent sources of fiber. The car-
GRANOLA AND MUESLI
found in RTE cereals can be discussed bohydrate contents of the cereals in the
without factoring in serving sizes, chart range from 14 g per serving (for a Bear Naked Granola Protein ½ cup
which vary greatly. Serving sizes in the high-protein cereal) to 54 g per serving for Honey Almond
chart range from ½ cup to 1⅓ cups— an organic, multigrain cereal. Quaker Simply Granola, Oats, ⅔ cup
almost a three-fold difference. Some Honey, Raisins & Almonds
products not in the chart but available • Added Sugars. The grams of added
Quaker Protein Granola Oats, ¾ cup
at the supermarket suggest a serving sugars per serving are listed under Chocolate & Almonds
as small as ¼ cup. Often, the more carbohydrates, but it wasn’t always that
calorie-dense the cereal, the smaller way. Added sugars became a part of 365 Whole Foods Market Organic ½ cup
Oat & Honey Granola
the serving size, as is the case with the Nutrition Facts panel in 2016 when
granolas. Clients and patients should be the FDA revamped the label, changing
aware of the differences. If, for example, how nutrition information was listed, CHILDREN’S
they’re focusing only on fewer calories rearranging the order in which it was
on the Nutrition Facts panel and dish listed, and providing the amount of added Kellogg’s Fruit Loops 1⅓ cups
up a large serving, the calorie count sugars per serving in a product. The
for breakfast will be much larger than cereals in the chart range from 0 g to 16 g
intended. “Each person has different (4 tsp) per serving of added sugars. While Cascadian Farm Organic 1 cup
needs, and their portions are likely to it isn’t surprising that, of the cereals in Gluten-Free Fruitful O’s
differ from what’s the suggested serving the chart, a children’s cereal contained
Lucky Charms Magic Gems 1 cup
size,” says Sue-Ellen Anderson Haynes, the most added sugars, surprisingly,
MS, RDN, CDCES, CPT, LDN, founder of three high fiber cereals contained almost
360Girls&Women, LLC, in Hopkinton, as much added sugars (12 g to 15 g per Cheerios, Gluten-Free, Original 1½ cups
Massachusetts, a private practice serving). “A rule of thumb is to choose
offering holistic health and wellness cereals, granolas, etc, with 5% of the Daily
services for girls and women. But the Value (DV) or less of added sugars per Kellogg’s Frosted Flakes 1 cup
serving size isn’t always indicative of serving,” Anderson Haynes says. “The
the nutrient contribution. Some cereals American Heart Association sets a daily
that suggest smaller servings still sugar limit to 38 g (9 tsp) for men, 24 g
contribute significant amounts of a (6 tsp) for women, and less than 24 g (6 tsp)
wide variety of vitamins and minerals. for children aged 6 to 18. Several cereals

COMPARISONS*
Nutrients
Sodium (20% DV or more, unless
Calories Protein (g) Carbohydrates (g) Added Sugars (g) Fat (g) Fiber (g) (mg) otherwise noted)
120 5 36 8 2 12 95 Iron, thiamin,

riboflavin, niacin,
vitamin B 6 , folate,
vitamin B 12
230 4 41 15 8 7 65 Iron, thiamin,

riboflavin, niacin,
vitamin B 12
200 6 47 0 1 7 280 Iron, thiamin, niacin,

phophorus, zinc
210 5 51 12 1.5 6 10 Iron, folate
260 6 54 9 1.5 5 240 N/A**
180 20 14 4 5 2 260 N/A**
220 10 31 9 9 8 130 N/A**
280 11 29 10 15 5 80 N/A**
270 7 51 9 7 7 35 N/A**
250 10 41 11 6 4 75 N/A**
240 5 40 15 7 3 50 N/A**
150 2 34 12 1.5 2 210 Iron, vitamin C,

thiamin, riboflavin,
niacin, vitamin B 6 ,
folate, vitamin B 12
150 2 33 11 1.5 2 100 N/A**
140 3 30 12 1.5 2 220 Vitamin D, iron,

vitamin B 12 , zinc
140 5 29 1 2.5 4 190 Vitamin D, iron,

thiamin, vitamin B 6 ,
vitamin B 12
130 2 33 12 0 1 190 Iron thiamin, riboflavin,

niacin, vitamin B 6 ,
folate***, vitamin B 12
*SOURCE: COMPANY WEBSITES. THE PRODUCTS IN THIS CHART REPRESENT A SAMPLE OF THE READY-TO-EAT CEREALS ON THE MARKET, AND THE NUMBERS REFLECT DRY CEREAL AS PACKAGED.
**N/A. NO NUTRIENTS PRESENT AT 20% DV OR GREATER.
***FOLATE IS PRESENT AS FOLIC ACID IN ALL FORTIFIED CEREALS.
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM 27

However, not all nutri- healthful or more healthful than those
tion experts agree that RTE that don’t boast those claims. Neither
cereals are a good choice for does containing the word “organic”
breakfast or snacks. “I would in the name always indicate a more
not recommend RTE cere- healthful nutrition profile. Some
als as a good breakfast choice organic cereals, especially granolas,
for several reasons,” Ander- can be high in added sugars. A recent
son Haynes says. “First, they study from Columbia, South America,
digest quickly, raising blood found that “nearly all” RTE cereals with
provide as much as one-half the daily sugar quickly, often leaving you unsatis- nutrition and nature-related claims
recommended limit in a single serving. fied.” Instead, she recommends quick-fix were high in calories and sugars.8 The
alternatives, such as a protein smoothie or truth resides on Nutrition Facts panels
• Sodium. RTE cereals usually aren’t con- a yogurt bowl with fruit, nuts, and seeds. and ingredient labels.
sidered a sodium source to be concerned • Recommend adding toppings to
about. But while they don’t contain as Cereal Research increase the nutritional value of RTE
much sodium as fast food or chips, if Studying the effects of RTE cereal intake cereals. “A few add-ons that I recom-
sodium is severely restricted, it’s impor- on health is tricky because of the huge mend to clients include seeds (chia,
tant to be aware of the sodium content of variation in RTE cereal products. Stud- flax, pumpkin, sunflower), nuts
RTE cereals, which ranges from 0 mg per ies are limited to examining populations (almonds, pistachios, walnuts, pecans),
serving to 280 mg per serving for those in and surveying RTE cereal consumption or fruits (berries, chopped apple, sliced
the chart. Some products available in the high fiber cereal consumption vs health banana), and spices (cinnamon or a
supermarket contain even more. parameters such as blood glucose or cho- splash of vanilla),” Sheth says.
lesterol. The effect on diseases, such as • Remind clients and patients that the
• Vitamins and minerals. RTE cereal is CVD, type 2 diabetes, or cancer, are also total calorie count and nutrient con-
an important source of nutrients in the population studies. Clinical studies that tent will depend on whether they add
American diet.5 The chart lists only those would focus on the health effects of spe- whole milk, skim milk, almond milk,
nutrients that are 20% DV or higher—the cific types of RTE cereals are impractical oat milk, or soy milk to their cereal.
amount that the FDA considers a “high” because of the cost of conducting such Some Nutrition Facts panels provide
level of a nutrient. Other nutrients than long-term studies, and findings may not nutrition for both dry cereal and a serv-
those listed often are present but in “low” be applicable to all RTE cereals. ing of the cereal with cow’s milk.
amounts—5% DV or less, according to A prospective study from Harvard • Give examples of RTE cereals that are
the FDA. Of the cereals in the chart, none School of Public Health several years ago high in fiber but not high in added sugars.
of the levels of vitamins and minerals in suggested that eating cereal fiber was a And show them how to identify added
10 of them were enough to be classified potentially protective factor against death sugars on the labels of RTE cereals.
as “high” levels. The nutrients present at from CVD, respiratory disease, and infec- • Suggest RTE cereals that are fortified
high levels are mostly the result of forti- tions.7 A systematic review of the avail- with several vitamins and minerals if cli-
fication. Most cereals are fortified with able evidence in 2014 found that regular ents want a vitamin and mineral boost.
multiple nutrients. Iron is the nutrient RTE breakfast cereal consumption was
that cereals are most often fortified with, associated with a lower BMI and less risk Bottom Line
followed by the B vitamins, folate, thia- of overweight or obesity.1 The review also Most nutrition experts agree that, when
min, riboflavin, and niacin. A few provide found that RTE cereal consumption was chosen wisely, RTE cereals offer a con-
high levels of vitamin C, copper, or man- associated with diets that were lower in fat venient, nutritious option for breakfast
ganese. Consumers may be surprised to but not with increased intakes of sodium and snacks. The RTE cereal products to
find that several cereals thought to be the or energy and that regular consumption choose from can be overwhelming for cli-
most healthful often aren’t fortified at all helped to ensure adequate nutrient intake ents and patients—and even for RDs. New
and, as a result, are low in several nutri- and suggested that it may help to reduce products are constantly being introduced.
ents. For example, granolas and organic the risk of developing CVD or diabetes. It’s important to keep on top of what’s in
cereals typically aren’t fortified, and while the cereal aisle. Counseling those clients
they may be high in fiber or low in sugar, Recommendations and patients who make RTE cereals a reg-
they fail to provide much in the way of Since there are so many RTE cereals on ular part of their diets on how to choose
vitamins and minerals. Calcium isn’t a the market, the following tips can help the best options for their tastes and health
nutrient found in cereals, but adding cow’s RDs educate clients on what to look for goals can have a positive effect on their
milk or a calcium-fortified plant milk will and consider next time they’re in the vitamin, mineral, and fiber intakes. I
add that mineral. Data from the National grocery store.
Heart, Lung, and Blood Institute Growth Densie Webb, PhD, RD, is a freelance writer,
and Health Study show that after adjust- • Counsel clients and patients to ignore editor, and industry consultant based in
ing for energy intake, cereal consumption the meaning behind a cereal that has Austin, Texas.
was related to an increased intake of fiber, the term “nature” or “fruit” in its title.
calcium, iron, folic acid, vitamin C, and While these terms give consumers the For references, view this article on our
zinc, as well as a decreased intake of fat impression the products are healthful, website at www.TodaysDietitian.com.
and cholesterol.6 they’re not an indication that they’re

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Children & Sugar
Striking a balance between over restriction
and adherence to current guidelines.
Consumption By Joanna Foley, RD
S
ugar consumption What the Current Guidelines own homes, their child’s health is still
has been under much Recommend influenced by the world around them.
Dietitians know that consuming sugar in • Socioeconomic status. A family’s
scrutiny with regard excess can lead to increased risk of type 2 financial status is a significant factor to
to children’s diets. diabetes, obesity, heart disease, fatty liver consider when trying to meet the DGAs.
disease, and other illnesses.1 For these “Sugar is cheap and, as one of the US’s top
Since excessive sugar reasons, many health organizations have food preservatives, often finds itself in
intake can have nega- developed guidelines for limiting intake many processed and shelf-stable foods,”
tive health impacts, parents and of added sugars for children and adults. Shah says, adding that families that have
The American Heart Association lower incomes tend to consume diets
caregivers are told to give their developed stricter guidelines, recom- higher in added sugars than those with
children foods and snacks that mending that children and teens con- higher incomes.6
contain less sugar.1 While these sume less than 6 tsp (or 25 g) added • Health literacy. Not all consumers
sugars per day and to drink no more read nutrition labels and ingredient lists,
messages have positive inten- than 8 oz of sugar-sweetened beverages which can be tedious and confusing. And
tions, they may fail to take into per week.3 However, the CDC reports those who take the time to read them may
that the average daily intake of added not know that sugar often disguises itself
account other factors, such as
sugars was 17 tsp for children aged 2 to under different names. “Sugar hides under
the potential to over restrict 19 from 2017 to 2018, which is far above many other names (such as honey and
sugar and barriers to meeting these guidelines.4 high-fructose corn syrup, maple syrup, or
molasses) and can sneak into seemingly
the 2020–2025 Dietary Guide- Obstacles to Achieving Goals healthful packaged and prepared foods,”
lines for Americans (DGAs) for There are many barriers that arise when Shah says. “There’s also the common con-
sugar consumption. trying to meet the DGAs for consumption fusion between natural sugars, such as
of added sugars for children. These may fructose in whole fruits or lactose in dairy
Moreover, the way parents and care- include the following: foods, vs added sugars.”
givers perceive foods containing sugar • Practicality. Another reason many
inside and outside the home can have • Shared caretaking. Parents may find it families find it challenging to limit
a large impact on a child’s relationship difficult to monitor their children’s sugar their children’s sugar intake is because
with sweets, impacting how much they intake because they may be at school, at many convenience and packaged foods
eat and how they view these foods them- an event, or under someone else’s super- and snacks they rely on contain added
selves. When sugar is demonized and/or vision. “Kids often spend time outside of sugars. In the midst of busy lives,
overly restricted, children potentially can the home with adults who are not their parents and caregivers often find it
develop disordered eating habits, which primary caretakers,” says Erin Shah, RD, impractical to prepare most meals and
parents unwittingly may overlook. What’s CDE, a former leader of high-risk infants snacks from scratch or use only whole
more, restricting sugar is challenging for at Kaiser Permanente Anaheim Medical food ingredients.
families in today’s food culture, so meet- Center in Anaheim, California. “Whether • Culture and ethnic background. Due to
ing the DGAs may not be practical. These it be daycare or school, grandparents or the many different cultural practices,
issues make the topic of sugar intake and friends’ houses, birthday parties, or other ethnic backgrounds, and eating hab-
children more complicated and one that special events, parents aren’t the only its, some populations tend to consume
deserves proper attention. ones in control of the child’s food options more or less sugar than those of other
Thus, it’s important for dietitians to or choices.” In fact, a 2022 study showed ethnicities. According to CDC data
help parents and caregivers better under- that the caregiver type, especially grand- from 2017 to 2018, non-Hispanic Black
stand how to navigate sugar consump- parents, is a significant predictor of a children aged 2 to 19 consumed the
tion with their children to enable them to child’s health status, including BMI, diet, most added sugars compared with non-
foster a healthy relationship with sugar and food security.5 So, while parents may Hispanic white children, Hispanic chil-
and support their overall health. be able to control sugar intake in their dren, and non-Hispanic Asian children.

• Increased desire. Research has on a pedestal, making them something take them into consideration when
shown that children are born with a child is more likely to obsess over,” addressing sugar with their children.
a desire for sweet flavors.7 In fact, Karges says. “It also runs the risk of
most have a stronger preference for detaching a child from their innate Counseling Strategies
sugar compared with adults, which intuitive eating abilities. This can Taking into account the possible con-
isn’t a result of the culture in which cause a child to begin to ignore what sequences of overly restricting sugar
they live. Some researchers believe a their bodies need in favor of following and the obstacles to meeting dietary
child’s strong desire for sugar may be external rules for eating, which guidelines for sugar consumption in
associated with their growing bodies disrupts their ability to self-regulate children makes nutrition counseling
since sugar provides a quick source of their intake,” Karges says. more complex.
energy and calories.8 • Disordered eating behaviors. “Some The good news is that sugar doesn’t
Dietitians should take these obsta- kids who have diets that are overly have to be off limits. It’s possible for chil-
cles into consideration when devising a restricted may end up engaging in dren to consume sweetened foods and
child’s diet and providing recommenda- behaviors like hoarding or sneak- enjoy desserts while still consuming an
tions to parents and caregivers. ing food,” says Krystyn Parks, MS, RD, amount of sugar that isn’t likely to raise
IBCLC, owner of Feeding Made Easy, the risk of disease.
When Restricting Sugar Backfires based in Orange County, California. Dietitians can share the following
In addition to the many potential bar- This can lead to long-term disordered tips (based on professional experience
riers that can limit children’s sugar eating habits, emotional eating, or and anecdotal evidence) with parents
intake comes the issue of problem- symptoms of eating disorders.11 and caregivers to navigate sugar intake
atic eating behaviors when sugar is • Poor relationship with sugar and/or inside and outside the household.
too restricted. “Because of the volume themselves. Children are at risk of
1
of fear-mongering messages parents internalizing shame, fear, and judg- Keep foods neutral, includ-
constantly receive about sugar and ment around eating sweets when ing sugar. Encourage parents
kids, many caregivers may believe they’re “categorized as ‘healthy’ vs to avoid labeling or catego-
that by restricting sugar in their ‘unhealthy’ or ‘good vs bad,’” Karges rizing foods as “healthful” vs
home, they’re taking steps to improve says. And since children are concrete “unhealthful” and “good vs bad.” Parks
their child’s health and well-being,” thinkers developmentally, they’re more suggests, “When talking about sweets
says Crystal Karges, MS, RDN, IBCLC, likely to translate messages around and desserts, I usually recommend
founder of Crystal Karges Nutrition, food more literally. For example, a treating them as you would treat any
a private practice based in San Diego, child who hears, “Eating too many other food. Refer to them by their
specializing in intuitive eating for sweets is bad for you,” may translate name instead of calling them a treat or
mothers and families. “While well- this message to mean, “I am bad for reward.” Karges adds, “This helps cre-
intended, the potential consequences eating sweets,” Karges says. ate an emotionally equal playing field
of restricting sugar cannot be over- • Preoccupation with sugar. Children for all foods from which children can
stated, especially as a child gets older who are restricted from eating sweets learn to eat based on the embodied
and begins getting exposed to sweets may appear anxious when sweets aren’t experience of what feels best in their
outside the home.” available or throw a tantrum when bodies (sans judgment or shame).”
Some potential problematic eating requests for sweets are denied. And
2
behaviors that warrant attention may there may be visible signs of distress Allow frequent access with-
include the following: when children attempt to access sweets out conditions. While sugar
or incessantly ask or nag when sweets shouldn’t compose the bulk
• Overeating. Overly restricting become available, Karges says. “Restric- of a child’s diet, RDs should
sugar can lead to children desiring and tion also can lead to intense preoccupa- remind parents that they don’t need to
consuming more. One study found that tion. In this case, a child may be unable overly restrict it. “We want our children
girls whose mothers engaged in restric- to focus on other activities due to the to learn to listen to and trust their own
tive feeding practices had higher rates obsessiveness of having sweets. This bodies. We can communicate this to
of overeating and eating in the absence may make it challenging for [the child] them by providing them with reliable
of hunger.9 to engage in childhood activities impor- access to sweets alongside other foods
One form of restriction that’s tant for development and growth.” they’re learning to eat, refraining from
common in many households is micromanaging how and what they
reserving sweets for only special It’s important to keep in mind that choose to eat from the foods we pro-
occasions or using them as a reward. some of these troublesome eating behav- vide,” Karges says.
However, research shows that these iors are based on anecdotal evidence Parks recommends caregivers avoid
practices may cause some children and knowledge of the way a child’s brain setting conditions for when their chil-
to crave them more and eat them in works and develops. While all of these dren can have desserts or other sweet
excess when they’re available.10 “Using behaviors may not be supported by foods. She says that “for many fami-
desserts as a reward elevates sweets research, parents and caregivers should lies, offering the dessert with the meal,

instead of after the meal, can help take children to eat these nutritious foods, sugar consumption and that they don’t
some of the obsession [away from] the they shouldn’t avoid this practice. have to micromanage sugar intake
dessert. Many kids will actually eat or overly prevent their children from
5
more of their other foods when the Control what you can and not eating too many sweets. According
dessert is available throughout the full worry about the rest. Because to Karges, “The main messages care-
meal because they don’t feel the need it’s important to encourage givers should send to their children
to save room for it.” children to eat and enjoy foods around sweets should center around
other than those that are sweet, parents body trust, safety, reliability, and
3
Think about the big picture. should fill their homes with a variety access. We want our children to believe
How much sugar children eat of healthful and practical foods, such that sweets are safe, that sweets are an
is just one of many factors as whole grains, fruits, and vegetables. enjoyable part of eating—not some-
influencing their overall They can offer these foods to their chil- thing to stress over or worry about.”
health. RDs should remind caregivers dren regularly without the need for With practice, parents will learn to
to also focus on how much physical coercion. This will enable parents to be attuned to their children’s needs,
activity their children are getting relax more when their children attend which will enable them to take a pro-
and the status of their overall eating parties or other activities where sweets active approach to offering sweets
habits. They also should be reminded will be served. Parents will know intentionally and at a frequency that
that a healthful eating environment they’re doing their part at home and be will help their children build a positive
isn’t just about nutrition. It includes more inclined to trust their children to relationship with all foods. I
feeling safe, comfortable, and self-regulate their appetite for sweets.
connected to others. Joanna Foley, RD, is a freelance health
It’s important for RDs to remem- writer and author of two cookbooks, based
4
Be practical. Food needs to taste ber that each child is unique and that in San Diego. Learn more about her writing
good in order for kids to eat it.12 parents have their own opinions about services at joannafoleynutrition.com/press.
So, if parents drizzle a small how to address sugar in and outside
amount of honey on yogurt of their household. Ultimately, RDs For references, view this article on our
or include a dollop of whipped cream should emphasize to caregivers that website at www.TodaysDietitian.com.
on top of berries to encourage their there isn’t one “right way” to approach

SUPPLEMENTS &
In the United States, more than one-third (36%) of
adults with cancer use some form of complementary
and alternative medicine, which may include dietary
supplements, according to the National Cancer Insti-
tute.1 A 2008 systematic review of studies assess-
ing supplement use among cancer survivors found
that between 14% and 32% of survivors began using
dietary supplements after they received a cancer
diagnosis, with breast cancer survivors reporting the
highest use,2 and a 2022 study found that 19% of peo-
ple in remission from cancer believe that dietary sup-
plements reduce the risk of their cancer returning.3
“People take supplements for a variety of reasons. They either
feel better or they think it’s going to help,” says Mary Marian, DCN,
RDN, CSO, FAND, a professor of practice at the University of Ari-
zona’s School of Nutritional Science and Wellness. She says can-
cer patients may have family and friends telling them they know
someone whose cancer was cured because they took a certain sup-
plement, which may cause the patient to consult alternative practi-
tioners who recommend supplements or even sell them.
Because dietary supplements are regulated as food rather than
as drugs, the FDA doesn’t evaluate or approve supplements unless
they make specific claims about disease prevention or treatment.
All supplements are considered “safe” by the government until they
are proven unsafe. There’s also no guarantee that a supplement
contains only the ingredients on the label or that it has the exact
amount of nutrient, herb, or botanical in it that the label claims it
has. In addition, the FDA hasn’t approved the use of dietary supple-
ments as a treatment for cancer.
Marian Neuhouser, PhD, RD, head of the Cancer Prevention
Program at Fred Hutchinson Cancer Research Center in Seattle,
says one possible but often overlooked harm of turning to dietary
When are they supplements during cancer treatment is financial hardship. “Many
people, including many cancer patients, often spend hundreds of
dollars of months on supplements, and they already have a lot of
beneficial, out-of-pocket expenditures, they’re missing work, there may be
caregivers who have to miss work to take people to appointments.
and when are There’s a lot of financial toxicity associated with cancer treatment.”
Neuhouser says another potential harm is that dietary supple-
ments may offer a false sense of security for cancer patients that
they harmful? they’re going to improve their health or their outcomes. “That’s where
the science doesn’t match up with the claims,” she says. “We really
don’t have solid data on whether using all of these supplements on
By Carrie Dennett, MPH, RDN top of all of the different treatments actually improves the outcomes.”
Potential Supplement-Treatment Interactions
CANCER
A 2023 study that used social media to recruit women undergoing
breast cancer treatment to fill out an online questionnaire found
that 89.5% of participants reported current vitamin/mineral use,
especially calcium, multivitamins, and vitamins C and D.4 More
than 67% reported current use of natural product-derived dietary
supplements, especially probiotics, turmeric, fish oil/omega-3 fatty
acids, melatonin, and cannabis. Around one-half of the women

reported using at least three products to improve outcomes and
concurrently, and 23% of women under- reduce oxidative damage
going chemotherapy were using supple- to healthy cells from che-
ments with possible adverse effects.4 motherapy and radiother-
Even though dietary supplements apy, potentially allowing
aren’t drugs, people take them because for higher doses. However,
they expect that they’ll have a positive what researchers started to
effect. While some supplements, such as find was that in higher therapeutic doses, well established that in humans, St. John’s
daily multivitamins, don’t appear to affect antioxidants might instead promote Wort increases the production of the cyto-
cancer survival or recurrence—or cancer cancer progression and increase overall chrome P450 isoenzyme 3A4 (CYP3A4),
treatment—elements in certain herbs and mortality in some patients—and that anti- a liver enzyme that breaks down certain
supplements may affect how the body pro- oxidants’ ability to reduce the toxicity of chemicals and toxins—including agents
cesses chemotherapy drugs when taken at chemotherapy and radiotherapy may also used in some chemotherapy drugs, includ-
the same time. For example, some supple- make treatment less effective by counter- ing imatinib, docetaxel, and irinotecan.
ments can interfere with specific enzymes acting the reactive oxygen species that are Taking St. John’s Wort concurrently with
or other components of the drug that affect supposed to be killing cancer cells.6 these drugs can decrease their bioavail-
how the drug is transported and metabo- The results of a Phase III breast cancer ability by 12% to 42%.14
lized.1 In some cases, this can make the drug trial published in 2020 found that Other herbs that may have a significant
drugs less effective in fighting cancer cells. patients who reported taking any antioxi- adverse effect on how the body metabo-
In other cases, it can make the drugs more dant supplement—carotenoids, coenzyme lizes chemotherapy drugs include garlic,
toxic to the body than intended. Q10, or vitamins A, C, and E—both before ginkgo, echinacea, ginseng, and kava.
Researchers from Yale University’s Life- and during postsurgical chemotherapy In addition, polyphenols found in many
style Exercise and Nutrition study asked were 41% more likely to have their breast herbs and teas may affect enzymes that
151 breast cancer survivors who partici- cancer return. This association was not help process chemotherapy drugs, which
pated in the study about their dietary sup- seen with multivitamin use, likely because can cause resistance to drugs such as
plement use: 120 of the women (80%) were the amounts of individual antioxidants vincristine, vinblastine, taxanes, anthra-
taking a dietary supplement, 72 women are lower than they are in single-nutrient cyclines, tamoxifen, and tyrosine kinase
(60%) were taking three or more formula- supplements.7 However, a 2021 meta- inhibitors.15 A 2021 review found poten-
tions, and 29 women (24%) were taking analysis of more than 17,000 breast cancer tial interactions between 261 herbs, foods,
five or more. Of the 54 different supple- survivors found that postdiagnosis use of and dietary supplements and 117 antican-
ment formulations reported, 33% had antioxidant supplements wasn’t associ- cer drugs via interactions with various
potential interactions with Tamoxifen or ated with overall mortality.8 cytochrome P450 isoenzymes.16
aromatase inhibitors—estrogen-blocking A 2017 review authored by Marian A 2018 review concluded that melato-
drugs taken as part of breast cancer treat- looked at the research on dietary nin is the only compound whose use is
ment. Most of these potential interactions supplements commonly used by supported by sufficient safety and effi-
(87%) were associated with herbal prepa- cancer survivors.9 She wrote that it’s cacy data from randomized controlled
rations,5 which, along with higher-dose difficult to determine the true impact trials to prolong survival in patients with
antioxidant supplements, are of most con- of using antioxidant supplements advanced cancer. The authors wrote that
cern when used during cancer treatment. during treatment because most studies other supplements, including curcumin,
have used various types and doses of green tea, EPA, DHA, and artemisinin, are
Antioxidants antioxidants and have included patients well-tolerated and potentially effective
Because radiation, chemotherapy, and undergoing a variety of treatment in combination with conventional treat-
many other anticancer drugs generate regimens with numerous types of cancer. ments, but large randomized controlled
reactive oxygen species, or free radicals— trials are needed to fully investigate these
unstable molecules that react with other Herbs and Nutraceuticals supplements’ role within complex drug
molecules in a cell, causing DNA dam- Some herbal medicines and other nutra- treatment strategies for cancer.17
age—to kill cancer cells, many cancer ceuticals—foods or parts of foods that
patients take antioxidant nutrient supple- allegedly provide the body with health ben- Honoring the Uncertainty
ments with the intention of protecting efits beyond basic nutritional value—can “We just don’t know, especially with some
healthy cells and reducing treatment side interfere with cancer treatment in another of the newer immunotherapies, how taking
effects. Common dietary antioxidants way by altering how the liver metabolizes all of these myriad supplements will result
include vitamins A, C, and E; beta-caro- chemotherapy drugs. For example, St. in benefits or harms,” Neuhouser says.
tene; and other carotenoids, glutathione, John’s Wort—an “herbal antidepressant” Marian says some of her patients have
and flavonoids, such as those found in soy also commonly used by cancer patients— brought bags full of supplements they’re
and green tea. has been shown to inhibit tumor growth taking to their appointments. She says
Antioxidants have well-defined anti- in triple-negative breast cancer10 and the large quantity of supplements is con-
cancer effects that theoretically make colorectal cancer in rodents11 as well as cerning, given the unknowns about how
them a promising way to reduce the initia- suppress cell proliferation and/or increase supplements may interact with their
tion, progression, and spread of cancer cell death in lab samples of human breast treatment and how the supplements may
cells. Antioxidants were initially stud- cancer cells12 and metastatic melanoma interact with each other. “I think when
ied in cancer patients for their potential cells,13 to cite a few examples. However, it’s there’s the unknown, you have to be super

cautious about the potential for adverse can lead to calcium loss or otherwise information from them,” she says. “I think
effects, even if we don’t know whether contribute to bone loss, so doctors may sometimes they just feel better taking their
they could happen or not, because the fact prescribe supplemental calcium and supplements. I ask, ‘How would you feel if I
that we don’t know is something to be vitamin D.21 Some patients may find it recommend that you don’t take all of these?
concerned about.” difficult to meet their nutrient needs Are you going to be at loss because you feel
from food—this includes patients who like it’s providing you some benefit?’ I think
Food vs Supplements have trouble eating due to nausea or lack it’s really important to establish what’s the
While adequate macro- and micronu- of appetite, or difficulty swallowing due bond with the supplement use when you’re
trients, along with beneficial food com- to radiation around the mouth or neck, counseling people.”
pounds such as flavonoids, curcumin, as well as those who have absorption Neuhouser suggests dietitians ask
epigallocatechin gallate from green tea, difficulties due to the surgical removal of patients to bring in their supplements, so
resveratrol, and quercetin can support the part of their stomach or intestines, and they can do a thorough assessment. “Ask
body during cancer treatment, more isn’t those who follow a strict vegan diet and if any supplement use has changed since
necessarily better, and may even be worse. may be deficient in vitamin B12 .23 they started treatment. Ask them, ‘Why
The World Cancer Research Fund Neuhouser says the patient’s nutri- are you taking these?’ and ‘What do you
states that there’s no strong evidence that tional status when they enter cancer treat- hope to get from them?’ Do some addi-
dietary supplements, apart from calcium ment is a key consideration. “An elderly tional probing to find out what the moti-
for colorectal cancer, can reduce cancer person may already have low oral intake, vation is to take additional supplement
risk. Both the World Cancer Research possibly due to poor dentition or low appe- during treatment,” she says. “Dietitians
Fund and the American Institute for Can- tite. They may be a little underweight, can also try to point out to patients how
cer Research recommend meeting nutri- then add chemo and/or radiation on top much they’re spending on these supple-
tional needs from diet alone, stating that of that. Or maybe they come into cancer ments and what else they could spend that
a healthful diet is more likely to protect treatment with a preexisting condition money on. Maybe they are finding it hard
against cancer than dietary supplements, that may make it difficult to manage both to cook and they could use that money to
because eating whole foods allows the conditions simultaneously. I think hav- get meals delivered.”
body to absorb a whole range of vitamins, ing a comprehensive nutrition assessment Marian says, “Let’s say a head and
minerals, and antioxidants that work when someone starts treatment is impor- neck cancer patient is taking high
together to protect health.18-20 tant, so the type of nutrition plan that’s doses of vitamin C and says, ‘Oh, well,
Despite uniform recommendations recommended may be tailored.” my oncologist didn’t say there was a
from major cancer organizations, cancer Marian says that if someone’s going problem with that.’ I’ll explain to them
patients continue to use supplements dur- through treatment and they’re not what the potential problem is, but I’ll
ing treatment, sometimes without their eating well and possibly losing weight, a also say, ‘Well, I would just go back and
health care providers knowing. One 2008 multivitamin may help them. “Maybe they ask your oncologist again,’ because you
systematic review found that up to 68% of tolerate the treatment better. Maybe their know I want them to feel comfortable
physicians are either unaware of supple- white blood cell count comes up faster. in the information that their oncologist
ment use in their cancer patients, or Those things are hard to measure as far is giving them. And if the radiation
they’re aware but didn’t record that infor- as outcomes, but maybe they’re worth oncologist, who knows more about the
mation in patients’ charts.2 Is the message thinking about.” radiation side of things, really feels like
not getting out, are providers not asking Neuhouser says there’s nothing vitamin C isn’t going to be a problem,
the right questions, or are patients ignor- to contraindicate a multivitamin or then who am I to say that it’s going to
ing evidence-based advice because they’re multivitamin with minerals, especially be? But the oncologist isn’t going to do a
scared and want to throw everything they during treatment when oral intake may diet history and say, ‘Let’s see how much
have at this major health crisis? be impaired. In fact, observational data vitamin C you’re getting from other
“I think the message isn’t getting out from colorectal and breast cancer cohorts things.’ It’s just complicated. You have
there from providers and dietitians,” Neu- in which 50% to 72% of patients were to be up to date on the literature and
houser says. “The supplement industry is self-prescribing multivitamins showed look at the whole picture and know what
very powerful. The advertising is powerful. neither beneficial nor harmful effects of potential micronutrient deficiencies can
There are more supplements for sale than these supplements on toxicity or survival.6 arise and what potential complications
types of foods. They’re a very prolific indus- “A multi will have antioxidants in the are of having too much or too little of
try and marketing works. And cancer is a appropriate amounts,” Neuhouser says. something and kind of balance your
very scary diagnosis, as we all know, so it’s “Formulations that combine herbs with suggestions on that.” I
easy for patients to want to do everything vitamins or minerals … those are the ones
they can to improve their outcomes. But where we don’t have the data to confirm Carrie Dennett, MPH, RDN, is the nutrition
what they may not realize is that not only is benefits or harms.” columnist for The Seattle Times, owner of
this a very expensive way to do it but it may Nutrition By Carrie, and author of Healthy
not be effective and it may cause harm.” How to Counsel Patients for Your Life: A Non-Diet Approach to
Marian says she always asks about supple- Optimal Well-being.
When Are Supplements Needed? ments when first meeting with a patient.
Some dietary supplements may be “I kind of just roll in the supplements right For references, view this article on our
beneficial during cancer treatment. after asking about the medication so it’s not website at www.TodaysDietitian.com.
For example, some cancer treatments a judgmental kind of thing. I’m just eliciting

By Sophia Condic, MS, RDN
ARTIFICIAL
INTELLIGENCE in
MNT
Limited research
suggests RDs may
be able to use this
innovative technology
in the near future to
improve patient care.
A
rtificial intelligence (AI) is becoming AI in Inpatient Settings
the newest celebrity in dietetics. How RDs Can Integrate AI in MNT
According to the Agency for Healthcare
Nutrition professionals and the Research and Quality, some of the most
greater medical community at large common conditions responsible for hospi-
tal admissions in 2018 were heart failure,
are excited about this technology diabetes with complications, and acute
and are learning more about it every and unspecified renal failure.3 These are
some of the more common diseases RDs
day. However, it may take some time before clinicians in treat in inpatient settings. During their
initial assessments of such patients, RDs
various specialties can harness all it has to offer to fully have to access anthropometric data.
integrate it into daily practice and make a considerable Research suggests dietitians may be able
to obtain this information easier than
impact on patient care. they do currently through a subset of AI
called machine learning (ML).
IBM says AI “leverages computers and and surgery to help physicians diagnose
machines to mimic the problem-solving diseases and identify tumors through Heart Failure
and decision-making capabilities of the new algorithms, thereby leading to less ML uses algorithms to analyze large
human mind.”1 In other words, AI learns invasive surgery through the da Vinci amounts of data, learn from the insights,
from the experts and makes an educated surgical AI system.2 and make informed decisions. It imitates
guess on an outcome.1 To date, no AI research has been the way humans learn, gradually improv-
AI research in the health care field done in the field of MNT. However, ing over time.4-6 This subset of AI can be
has shown that technology and humans there have been some studies con- important in relation to heart failure since
can work together to diagnose, treat, and ducted over the past couple of years research is showing that “ML methods
educate those who have heart failure, on AI applications for heart failure, can handle temporal, large-volume, and
diabetes, renal disease, disordered eating diabetes, and chronic kidney disease multimodality data (eg, sound, language,
patterns and eating disorders, and over- (CKD) in inpatient and outpatient set- tabular EHR, imaging, and metabo-
weight or obesity. Current AI research tings that may help prepare RDs for the lomic data).”5 This type of data can be
has been applied in radiology, pathology, future of AI in dietetics. used to understand a diagnosis and then

To date, no AI research has been done
personalize treatment options for patients can “help identify in the field of MNT. However, there have
with heart failure in inpatient settings. clinical variables been some studies conducted over the
In the past, AI had been used for select- that can influ-
ing patients who may respond to cardiac ence a patient’s past couple of years on AI applications
resynchronization therapy and collecting HbA1c response.”8
continuous data through implanted sen- Although CBR and
for heart failure, diabetes, and chronic
sors.5,7 However, new research is showing CDS tools may be kidney disease in inpatient and outpatient
that AI can benefit those with heart failure able to improve
in other ways by including other health how efficiently RDs
settings hat may help prepare RDs for the
professionals, such as RDs who are part of assess patients with future of AI in dietetics.
a health care team in an inpatient setting. diabetes, there isn’t
Although there hasn’t been much enough evidence
research showing how RDs can use ML currently to deter-
or how ML can make their jobs easier in mine whether both of these systems can AI, the “results of CT perfusion imaging
inpatient settings, Averbuch and colleagues produce accurate and consistent results [became] more conclusive to analysis
stated that in relation to heart failure, “ML or whether they may replace RDs. How- and comparison.”10 Because of AI, the
algorithms can be used to provide recom- ever, CBR and CDS tools may be used as a researchers could evaluate participants’
mendations to clinicians regarding optimal resource in MNT for patients with diabe- renal status throughout the study and
sequencing and dosing of evidence-based tes in inpatient settings. RDs can use CBR determine that the H2H program can be
therapies.”6 Even though the researchers to help personalize meal plans for patients used to monitor patients who have CKD.10
didn’t specify the care RDs provide through with diabetes, while CDS tools can pro-
MNT, future research can focus on how vide the data needed to track patients’ AI in Outpatient Settings
these algorithms may be able to generate HbA1c. This will enable RDs to educate
nutrition recommendations specific for patients on managing their diabetes and How RDs Can Integrate AI in MNT
patients with heart failure in inpatient set- preventing future hospitalizations.8 Just as some patients visit with RDs in the
tings. For example, in the future, research- hospital, others may see them in outpatient
ers can conduct studies that implement ML Chronic Kidney Disease settings. According to Sarah Klemm, RDN,
algorithms to generate personalized MNT Dietitians also have to monitor patients CD, LDN, manager of nutrition information
recommendations for patients with heart with renal failure so patients can avoid services for the Academy of Nutrition and
failure. From there, researchers can test hospitalizations. Individuals with renal Dietetics in Chicago, some of the more com-
whether the algorithms produced an accu- failure also may be on dialysis and at risk mon reasons patients see RDs in the outpa-
rate result and if these algorithms, in turn, of comorbidities such as CVD, dyslipid- tient setting include diabetes management,
can work as an additional resource for RDs. emia, and anemia.9 Despite having pre- disordered eating patterns and eating
existing conditions, a study by Chen and disorders, and weight loss.11 Although there
Diabetes colleagues showed that AI can be used to isn’t enough research to determine whether
In addition to heart failure, research- confirm the efficacy of an at-home renal or not AI will replace RDs in outpatient
ers are focusing on AI applications for care program, which might be a step settings, there’s been some evidence show-
patients with diabetes in inpatient set- toward integrating AI in MNT. ing that AI presented through mobile apps
tings. One AI technique used extensively The purpose of the study was to evalu- and algorithms may encourage patients to
in diabetes care is case-based reasoning ate a hospital-to-home (H2H) program reach their nutrition goals more effectively
(CBR), an experience-based approach involving 120 participants with stage than before. This research has been preva-
to solving new problems. According to 3 to 5 CKD. They were admitted to a lent in diabetes management.
a study by Ellahham, the goal of CBR is Chinese hospital from March 2019 to According to a study by Ellahham,
to develop better solutions for manag- March 2021.10 Half of the participants mobile apps that use AI technology
ing diabetes based on data from past were placed in the experimental group enable people with diabetes to take better
experiences. For example, the 4 Diabetes that incorporated the internet-based control of their condition through self-
Support System, an example of CBR used H2H program.10 The group had access to management.8 For example, the One
in diabetes care, can “automatically online resources from an RD, such as rec- Drop Mobile app that was tested on 1,288
detect problems in control of blood glu- ipes and nutrition education handouts.10 participants with diabetes over four
cose, propose solutions to the detected The remaining half of the participants months reminded them to take their
problems, and remember the effective were in the control group and didn’t have medication, set goals, and view data
and ineffective solutions for individual access to the H2H program.10 about their health.8 After the intervention,
patients.” CBR also has been used to Despite the differences between the Ellahham reported that there was “a 1.07%
optimize and personalize insulin ther- two groups, all of the participants had to 1.27% absolute reduction in HbA1c
apy for a wide range of meal situations.8 their renal status monitored with the use during a median four months of using the
Researchers also are studying AI-based of AI. Everyone had CT images done on app.”8 Furthermore, another intervention
clinical decision support (CDS) tools to their kidneys before and after the study.10 program called FareWell, which was
improve diabetes management. These At first, the CT images weren’t clear; accessible through a mobile app, was tested
tools, with the use of ML, can make short- however, once the wavelength trans- on 118 adults with diabetes who had an
and long-term predictions about HbA1c form denoising algorithm was incorpo- HbA1c greater than 6.5% for 12 weeks.8 The
after patients start insulin therapy and rated into the imaging system through goal of this program through the app was to

encourage participants to consider a plant- Nevertheless, there are other AI and weight loss goals, RDs can do their
based diet and regular exercise.8 At the end tools RDs can use to help patients with part by learning more about AI in the
of the study, 28% of participants had an disordered eating patterns and eating health care field to understand how it
HbA1c lower than 6.5%, and more than 86% disorders. Petrauskas and colleagues may impact MNT in the future.
continued to use the app after the study.8 examined a CDS system (CDSS) to
In addition to mobile apps, research- predict the risk of eating disorders What the Future Holds
ers are testing algorithms to determine in 83 participants with dementia.14 Like any up-and-coming innovative
whether they may benefit patients with The CDSS was 90.36% accurate for technology, AI is making great inroads
diabetes in outpatient settings. Joshua predicting eating disorders, leading in the medical field overall and trying to
and colleagues examined the Smart Plate researchers to conclude that “compared find its place in dietetics. And while
Health to Eat, a technological innova- to the resident geriatricians, the CDSS is currently, there haven’t been many
tion that enables patients with diabetes more accurate in diagnosing … eating studies demonstrating how dietitians
to determine the type of food, weight, and disorders in dementia.”14 While more can implement AI in MNT, research
nutrients contained in the foods they eat research will confirm whether CDSS can suggests the possibilities.
to help them meet their nutrition goals. run independently to assess risk factors For example, future research may
The study included 50 types of food with for eating disorders, this AI tool may be examine how AI can generate assess-
a total of 30,800 foods using the YOLOv5s implemented in MNT in the future. RDs ment plans, PES statements, and per-
algorithm that identified, analyzed nutri- who work in outpatient settings may be able sonalized goals based on clients’ data. In
ent values, and estimated the weight of to use CDSS after a nutrition assessment to addition, as more studies emerge, there
the foods studied.12 Researchers found quickly determine whether a client is at risk will be more opportunities for RDs to join
that the YOLOv5s algorithm “showed good of an eating disorder. From there, dietitians research teams to study and understand
identification accuracy in the analysis of can make additional referrals to provide the impact of AI in MNT. When Chen and
four types of food, including rice, braised patients with the care they need. colleagues added an RD to their research
quail eggs in soy sauce, spicy beef soup, But while the use of AI tools to provide team, they could provide nutrition edu-
and dried radish, with accuracy for weight MNT looks promising for clients with cation materials to participants in their
and nutrition.”12 Although researchers are diabetes, disordered eating patterns, and experimental group and therefore now
still testing food and nutrient identifica- eating disorders, there isn’t enough evi- understand how MNT and AI can work
tion algorithms like YOLOv5s, there may dence to determine whether they can be together to improve health outcomes.10
be a future for them for people with diabe- used to monitor weight management or More research will determine how AI
tes in outpatient settings.12 In the future, weight loss goals. may change the workflow for RDs or have
RDs may be able to recommend programs For example, Oh and colleagues the potential to replace them in the future.
with these algorithms to their patients so reviewed nine studies to investigate However, as dietitians wait for more AI
they can have an additional resource as whether Chatbot (voice-activated applica- research to surface, they can learn more
they keep their nutrition goals on track. tions like Amazon’s Alexa or Apple’s Siri) about the technology in the health care
Mobile apps and algorithms also can had an impact on changing health behav- field through peer-reviewed literature
help individuals who have disordered iors such as physical activity, healthful and zero in on studies that include RDs
eating patterns and eating disorders. eating, and weight management.15 The on the research team so they can educate
Braun-Trocchio and colleagues stud- research team found there were no defini- patients on new AI applications and help
ied the HALO app used to generate a tive conclusions on whether Chatbot could them reach their health goals in new and
body composition scan on 98 partici- affect weight management behaviors.15 innovative ways.
pants.13 The goal of the study was to bet- Moreover, Chew and colleagues AI has been and will continue to be a hot
ter understand body image issues and reviewed 66 studies to determine whether topic among health care professionals, and
compare the results with the partici- AI could be used to help participants lose this trend will keep growing as research-
pants’ perceived body, ideal body, and a weight.16 The studies were separated into ers learn more about the efficiency of AI in
body their partner would find attractive three categories based on what type of AI assessing and monitoring patients. I
through a visual analog scale.13 After application was used in each study.16 Most
participants used the app and completed studies used machine perception, which Sophia Condic, MS, RDN, is a Michigan-
a questionnaire related to their body focused on using AI to recognize foods based dietitian who’s currently working in
image, the researchers could determine and behaviors.16 Other studies used AI to a community clinic. She earned a Bachelor
there was a mean difference between predict health behaviors, such as weight of Integrative Studies at Oakland University
the app and the participants’ perspec- loss and emotional eating, or collect per- and completed the Coordinated Program in
tives about body image.13 Although more sonalized data to provide feedback to a Dietetics and a Master of Science in Clinical
research is needed to establish whether participant.16 However, after analyzing Dietetics at Grand Valley State University.
mobile apps, such as the HALO app, the efficacy of the AI applications used in She has previously written for Today’s
will be applicable to RDs in outpatient the studies, Chew and colleagues said that Dietitian and for the Dietitians in Business and
settings, there’s a possibility that dieti- “Only six studies reported average weight Communications Practice Group through the
tians could still screen patients at risk losses (2.4 to 4.7%), of which two were sta- Academy of Nutrition and Dietetics.
of disordered eating patterns and eat- tistically significant.”16
ing disorders, which could alert them to Despite these findings that there isn’t For references, view this article on our
intervene and make personalized recom- enough research yet to use AI applica- website at www.TodaysDietitian.com.
mendations and referrals. tions to establish weight management

Lifestyle Medicine’s
F
rom well-respected medical organizations to health it’s much more a rising tide than a fleet-
ing trend. Lifestyle medicine is here to
and wellness influencers, many seem to tout the stay, and dietitians have a crucial role
to play in practicing this modality to
benefits of lifestyle medicine. However, the concept of address the nation’s top chronic diseases.
using lifestyle as medicine is nothing new. In fact, it
What Is Lifestyle Medicine?
may just be the future of health care. According to the American College of
Lifestyle Medicine (ACLM), lifestyle
The use of lifestyle interventions to to lifestyle pillars such as strong social medicine is “a medical specialty that
maintain or regain health dates back as connections and daily physical activity.2 uses therapeutic lifestyle interventions
far as Hippocrates 2,500 years ago.1 Cul- And, of course, dietitians have long been as a primary modality to treat chronic
tures around the world have long relied championing the therapeutic benefits of conditions, including but not limited to
on lifestyle to stay healthy and ward off food, another lifestyle pillar. CVDs, type 2 diabetes, and obesity.”3
disease. Pockets of the world with the Although lifestyle medicine may seem Health care providers trained in
highest concentrations of centenar- like the newest fad, its long history and lifestyle medicine use evidence-based,
ians, called Blue Zones, credit longevity the strong science supporting it ensure prescriptive lifestyle interventions such
Six Pillars
Expert Strategies for
Applying a Revolutionary
Evidence-Based Approach
By Kayli Anderson, MS, RDN, DipACLM, ACSM-EP
as nutrition, physical activity, restor- medications or procedures, also can physical inactivity are considered the
ative sleep, stress management, social be used, but only as supplementary leading causes of mortality in the United
connection, and avoidance of risky to lifestyle change. Lifestyle medicine States.4 Lifestyle medicine is designed
substances to address disease. The use certainly can be used for disease pre- to address these destructive lifestyle
of these modalities, known as the six vention, but the focus is primarily on factors. Studies of intensive therapeu-
pillars of lifestyle medicine, prevent and treatment, reducing disease severity, tic lifestyle change programs, such as
treat many of the nation’s most devastat- and sometimes the reversal of existing the Pritikin program and the Ornish
ing chronic diseases and is backed by a disease. Lifestyle medicine goes beyond program, in which participants make
wealth of scientific evidence. just helping the healthy get healthier. It significant changes to their lifestyles,
Although some overlap exists aims to significantly improve disease have shown impressive improvements in
between lifestyle medicine and other markers and quality of life for patients markers of diabetes and coronary heart
fields like integrative medicine or pre- who need it most. disease.5-7 Many large epidemiologic
ventative medicine, lifestyle medicine is studies also shine light on how lifestyle
unique. In lifestyle medicine, evidence- Is Lifestyle Medicine Worth Its behaviors impact health. The Nurses’
based lifestyle changes are prescribed Weight in Gold? Health Study concluded that by adopt-
as first line treatment for disease. Other For starters, lifestyle factors such as ing a set of healthful lifestyle behaviors,
evidence-based interventions, such as tobacco and alcohol use, poor diet, and more than 80% of heart disease and

1
more than 91% of diabetes could be elimi- Nutrition
nated in women.8 The ability of dietary Every dietitian knows that food
changes to improve cardiovascular and influences health, and the field
type 2 diabetes outcomes as well as cancer of lifestyle medicine agrees that
risk reduction also are well documented.9 it’s one of the most important pillars.
Along with convincing evidence, life- Based on scientific evidence, the
style medicine is well positioned to help ACLM has defined a recommended diet
achieve what’s known as the Quadruple in their dietary position statement: “For
Aim in health care: “To enhance patient the treatment, reversal, and prevention
experience, improve population health, of lifestyle-related chronic disease, the
reduce costs, and improve the work life ACLM recommends an eating plan based
of health care providers.”1 It also restores predominantly on a variety of minimally
career passion for many providers. In processed vegetables, fruits, whole grains,
the age of health care burnout, this is an legumes, nuts, and seeds.”3 This dietary
important bonus of lifestyle medicine. approach centered on whole plant foods
has been shown to support disease pre-
Who’s Leading the Charge? vention, treatment, and risk reduction,
At the forefront of the lifestyle medicine which is the aim of lifestyle medicine.9
wave is the ACLM, a medical society that If using this dietary approach within
provides quality education and resources the context of lifestyle medicine is new
to health care professionals committed to you, in collaboration with the recent
to the practice of lifestyle medicine. With White House Conference on Hunger,
lifestyle medicine education sorely lack- Nutrition and Health, the ACLM now
ing in pre- and postprofessional training offers the Lifestyle Medicine & Food as
for most health care providers, the ACLM Medicine Essentials course bundle.10
offers these crucial learning opportunities Paulina Shetty, MS, RDN, CPT, DipACLM, move more throughout the week and sup-
for providers through continuing educa- senior director of education at ACLM, porting them in working through their
tion courses, conferences, and lifestyle describes the bundle as “an introduction barriers to exercise also is critical.
medicine board certification. to the field of lifestyle medicine and nutri-
3
While it started as a physician-only tion for prevention, longevity, treatment, Stress Management
organization, the ACLM now serves a and risk reduction that’s 5.5 hours of CE.” According to a 2020 report
global community of professionals across The ACLM also offers an array of nutrition issued by the American
the spectrum of health care, including education resources for use with patients, Psychological Association, the
dietitians, researchers, and health care including a Whole Food Plant-Based Plate, United States is experiencing a stress-
executives. The ACLM recognizes dieti- a Food as Medicine Jumpstart Guide, and related mental health epidemic that
tians as a key part of successful lifestyle a Culinary Medicine Curriculum. seeps into all areas of health.14 Stress has
medicine outcomes. The medical society been linked to coronary artery disease,
2
also sees community and public health Physical Activity heart failure, rheumatoid arthritis, and
entities as critical pieces of the life- Physical activity earns its various mental illnesses like anxiety.15
style medicine puzzle. Because of this, it place as one of the six pillars For any dietitian who’s helped clients
engages in advocacy initiatives to help of lifestyle medicine, as it navigate stressors to improve their
move toward lifestyle medicine as the positively impacts seven of the 10 relationship with food or nutrition
foundation of all health care. In the world most common chronic diseases.11 Plus, status, this is no surprise.
of lifestyle medicine, the ACLM is at its discussing this important pillar with It’s important to note that not all stress
core providing innovative resources, con- clients and patients pays off. One study is bad. Moderate stress tends to improve
necting like-minded stakeholders, and found that promoting physical activity performance. It’s when stress reaches high
transforming health care. in a primary care setting significantly levels and becomes chronic that a person’s
increased the activity level of patients health is negatively impacted. Along with
The Six Pillars for up to one year.12 screening and referrals for more advanced
The ACLM identifies six areas of life- Even if dietitians aren’t trained in exer- mental health conditions, lifestyle medi-
style that can be used therapeutically cise physiology or a related field, sharing cine employs many different stress manage-
to improve health outcomes: nutri- the Department of Health and Human ment techniques to target chronic stress and
tion, physical activity, restorative sleep, Services’ Physical Activity Guidelines with improve health outcomes. The list of tech-
stress management, social connection, clients can go a long way. The guidelines niques includes spending time in nature,
and avoidance of risky substances. By recommend at least 150 minutes per week meditation, and mindfulness as well as other
incorporating five of the pillars along- of moderate-intensity activity and two lifestyle medicine pillars like improved sleep,
side nutrition, dietitians can employ the or more strength training sessions that exercise, and nutrition.15 Since all of the pil-
whole-person approach of lifestyle medi- incorporate all major muscle groups.13 lars of lifestyle medicine are interconnected,
cine with their clients. Helping clients discover simple ways to improving one can help improve others.

How to Apply Lifestyle Medicine
Dietitians who are interested in lifestyle
medicine and want to know how to apply
it to daily practice can take the following
four steps.
Broaden Your Education

As experts in nutrition, dietitians have
a head start when it comes to lifestyle
medicine. Becoming educated in the
other five pillars gives dietitians the
ability to take a whole-person approach
with patients. The ACLM offers a plethora
of CE courses. Shetty describes how
lifestyle medicine education enhances
a dietitian’s existing training and gives
them an edge. “While RDNs receive
expert training in nutrition science,
prevention, and medical nutrition
therapy for chronic and acute diseases
and conditions, lifestyle medicine focuses
on not only prevention and treatment
but also evidence-based nutrition for
remission of chronic diseases and
conditions. Not only does lifestyle
4
Restorative Sleep loneliness to the forefront of health. medicine focus on therapeutically
Poor sleep is connected to A 2020 report from the National dosed nutrition for remission but it also
higher rates of chronic disease, Academies of Sciences, Engineering, includes well-rounded education on the
morbidity, and mortality.16 and Medicine states that loneliness other pillars.”
Lifestyle medicine also emphasizes that and isolation are associated with Educational offerings include the pre-
without adequate sleep, it’s much more higher incidence of premature viously mentioned Lifestyle Medicine
difficult for people to build momentum mortality.17 Conversely, positive social & Food as Medicine Essentials course
with other lifestyle medicine pillars connection has been associated with bundle and the Foundations of Lifestyle
such as good nutrition or consistent better health outcomes.18 Medicine Board Review, a self-paced
exercise. Although the amount of When it comes to social connection, 30-hour CE course to prepare those seek-
sleep needed varies slightly from person screening and referrals are key. Once ing lifestyle medicine certification. Dieti-
to person, eight hours still stands as at-risk patients are identified, lifestyle tians also can attend the ACLM’s annual
the best average recommendation for medicine providers can help connect conference in the fall.
most adults.16 them to social support resources in their
Upgrading clients’ sleep quality usually communities. True to the interdependent Get Certified
requires a deep dive into the other lifestyle nature of lifestyle medicine, tending to If RDs want to take their lifestyle medicine
medicine pillars, taking a critical look at social connection has the power to help expertise to the next level, they can get
eating habits, caffeine intake, physical bolster all other areas of lifestyle for board certified in lifestyle medicine. Alex-
activity, substance use, and stress levels. clients and patients. andra Regalado, RDN, DipACLM, certified
Improving these pillars greatly supports health and well-being coach, clinical out-
6
better sleep. Sleep hygiene strategies such Avoidance of Risky patient dietitian at Stanford Health Care,
as reducing screen time and setting up Substances and secretary of the ACLM Registered
a bedroom environment that promotes The final pillar of lifestyle Dietitian Member Interest Group, has
sleep also are emphasized in lifestyle medicine addresses the use of experienced the benefit of certification
medicine. In addition, working with a tobacco, alcohol, and recreational drugs. firsthand. “Certification has enhanced my
physician to address sleep issues like sleep Along with the direct health effects of ability to provide patient-centered care
apnea is key. these substances, there are indirect and given me the opportunity to connect
effects on food choices, sleep, and stress with like-minded professionals commit-
5
Social Connection management. The lifestyle medicine ted to preventing, treating, and reversing
Perhaps the most unexpected approach calls for identifying patients chronic conditions.”
pillar of lifestyle medicine is who use these substances and referring Alison Ozgur, MAT, MHS, RDN, DipA-
positive social connection, them to evidence-based resources CLM, the director of wellness programs
keeping in mind that the COVID-19 for cessation or supporting them in for the Center of Nutrition Studies, agrees.
pandemic brought isolation and balanced use.19 “I have worked as a registered dietitian for

between the sleep or stress pillars, for
example, and how these areas may be
affecting a patient in the nutrition
pillar. My questions can then be more
pointed, more guided, when I do my
initial assessment.”
Being part of a lifestyle medicine
team also means that all providers
reinforce lifestyle medicine messag-
ing. “What’s great is that when patients
come into my consult room, they have
a better understanding and are more
receptive to the recommendations we’re
making around a plant-based eating
pattern because the lifestyle medicine
approach has been validated by the phy-
sician,” Correa says.
For RDs interested in being part of a
lifestyle medicine team, the ACLM offers
resources on how to structure lifestyle
medicine programs, reimbursement edu-
cation, and many networking opportuni-
ties. If dietitians don’t have a team, they
still can incorporate lifestyle medicine
into their work. Correa says dietitians
22 years, and while I believe that nutri- approach to care, aiming to treat the can “help patients make the connections
tion is the foundation of wellness and root cause of disease and improve between how the other pillars can deeply
disease prevention, we cannot overlook overall health outcomes. Lifestyle affect eating patterns, relationship with
the other lifestyle pieces that must be medicine–certified registered dietitians food, and management of chronic con-
practiced in order to achieve optimal understand that chronic diseases can ditions,” adding that the relationship
health.” For that reason, Ozgur chose be prevented, managed, and perhaps between exercise and blood glucose con-
to obtain lifestyle medicine board cer- even reversed by utilizing a lifestyle trol and the relationship between eating
tification. “It was essential for me to medicine approach. This type of patterns and sleep are two examples.
strengthen my knowledge and expertise approach, enhanced by the use of health
in the other pillars of lifestyle medicine. behavior change coaching skills, can Get Involved With the ACLM
As a result, my clients and workshop decrease health care spending for both The ACLM is the hub of lifestyle medi-
participants achieve better results with employers and patients, improve overall cine, so becoming a member is an impor-
their health goals.” health outcomes, and help activate tant first step in becoming a lifestyle
patient autonomy and motivation for medicine expert. The organization has
Partner With Other Lifestyle sustainable, lifelong behavior change.” much to offer dietitians, including a Reg-
Medicine Providers Lilian Correa, MA, MPH, RDN, istered Dietitian Member Interest Group;
The practice of lifestyle medicine is DipACLM, a dietitian at Bellevue working groups organized by specialties,
meant to be interdisciplinary, and dieti- Hospital lifestyle medicine program in including culinary medicine and wom-
tians are considered an invaluable part New York City, also knows the power of en’s health; patient-facing resources;
of the lifestyle medicine health care the lifestyle medicine team approach. an annual conference; and countless
team. Dietitians can join forces with NYC Health + Hospitals recently networking opportunities. Joining the
physicians, health systems, or private expanded Bellevue’s innovative program ACLM plugs you into the epicenter of
practices interested in implementing the across New York City, and Correa serves lifestyle medicine. I
lifestyle medicine model of care. as director of education and training for
Sherry Valente, MA, RD, LDN, the expansion. “In our team approach, Kayli Anderson, MS, RDN, DipACLM,
CDCES, DipACLM, is product manager for example, what’s great is that the ACSM-EP, is founder of the women’s
of nutrition and lifestyle medicine physician helps to identify nutrition- health website Plant-based Mavens
at Premise Health in Brentwood, related issues to address by taking a (plantbasedmavens.com) and lead faculty
Tennessee, a leading direct health detailed food history during the initial of the American College of Lifestyle
care provider that employs more than visit. This history, which is part of the Medicine’s Food as Medicine course.
50 dietitians. With dietitians as a key physician’s initial assessment in all six
part of their health care teams, Valente pillars of lifestyle medicine, gives the For references, view this article on our
says, “Many health care employers are RDN a great blueprint from which to website at www.TodaysDietitian.com.
moving toward a lifestyle medicine work. I can begin to see the connections

10 TH ANNUAL SPR
ING SYMPOSIUM
ISSUE
Vol. 25 No. 5
May 2023
The Magazine for
North African Roots

Nutrition Professionals
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Knowing the origins
Vol. 25
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CPE Monthly By Denine Rogers, MS, RDN, LD, FAND
nutrition and nutrients from birth to death.

Different nutritional deficiencies of macro-
nutrients and micronutrients can cause
negative skin signs and symptoms. Macro-
nutrients, vitamins, and essential minerals
work together to maintain the skin’s barrier
functions. A macronutrient and micronu-
trient deficiency in protein, zinc, and
B vitamins can cause cheilitis, characterized
by dry, scaly, and fissured lips. A deficiency
in essential fatty acids can cause xerosis,
described as scaly skin that can cause dis-
comfort, itchiness, and inflammation.2
Skin Conditions and Disorders

For some skin conditions, improvements
in diet and nutrition have long been con-
sidered an important treatment strat-
egy. However, as emerging research has
demonstrated, dietary changes also may
play a role in treatment for a wider vari-
ety of skin diseases. What follows are four
primary skin conditions and disorders for
Nutrition and Skin Health which dietary changes may be advised as
one component of treatment.
Discovering the Connection and Evidence-Based
Treatment Options for Patients Acne Vulgaris
Acne vulgaris is a chronic inflammatory
The Diet and Dermatology Link
C
lients often seek dietary advice skin disorder among teenagers, young
from dermatologists, not dieti- The effects diet has on skin health can adults, and some older adults that occurs
tians, even though they fre- be positive or negative, mainly due to the when hair follicles get plugged with sebum
quently associate their skin nutrients (or lack of nutrients) in food. and dead skin cells. Acne is more com-
diseases with the foods they eat. Dieti- Skin is complex and specialized, and mon in developed countries than in less
tians know that nutrition has been shown serves multiple functions. It’s the largest industrialized regions. And in some popu-
to help alleviate certain skin disorders, organ of the body, weighing in at 8 lbs (3.6 lations, acne development is associated
but for decades other health care profes- kg) and spanning 22 square feet (2 square with the adoption of a Western diet.4
sionals have presumed that many com- meters) for adults.2 Skin provides a bar-
mon skin disorders are unrelated to diet. rier function to prevent internal water
However, recent studies show significant loss and protects the body from external
COURSE CREDIT: 2 CPEUs
evidence that diet and nutrition can affect environmental agents, including infec-
some dermatological conditions. tious organisms, chemicals, radiation, Learning Objectives
Skin diseases are prevalent among noise, and diet.3 After completing this continuing
Americans—and costly. The Academy of There are three crucial skin layers: the education course, nutrition
Dermatology states that skin disorders epidermis, dermis, and hypodermis.2 The professionals should be better able to:
will affect 84.5 million Americans or epidermis, the outermost layer, serves as a 1. Distinguish the foods, dietary patterns,
one in four.1 Skin conditions cost the waterproof barrier and creates skin tone. and lifestyles that can positively and
United States health care system $75 The dermis beneath the epidermis con- negatively affect skin health.
billion in medical and preventative tains tough connective tissue, hair fol-
2. Examine nutrition’s effect on skin
care, including prescription and licles, and sweat glands. This layer of skin
disorders such as eczema, acne,
nonprescription drug costs.1 transports blood and fights infections.
psoriasis, and rosacea.
This continuing education course The hypodermis is the subcutaneous fat
reviews the relationship between nutri- and deepest layer of skin. This layer of 3. Counsel clients on how to implement
nutrition and lifestyle changes that help
tion and skin health based on current fatty tissue helps insulate the body from
manage skin diseases.
research, discusses skin conditions for heat and cold and protects the body from
which nutrition traditionally has been injuries. It also provides padding to cush- 4. Demonstrate how dietitians and
an unrecognized treatment option, and ion internal organs, muscles, and bones.2 dermatologists can work together to
focuses on how the expertise of dietitians It’s vital that all of the skin’s functions, improve their clients’ skin health.
and dermatologists are both needed for along with the development and replace- CPE Level 2
proper treatment. ment of these tissues, receive adequate

The factors that contribute to the milk consumption and acne. There was no weren’t treated with zinc, suggesting that
formation of acne include the following: significant relationship between yogurt zinc is effective for treating acne, par-
and cheese and acne development. Results ticularly when used as monotherapy or
• genetic predispositions; of the present meta-analysis recommend adjunctive treatment.12
• hormonal abnormalities (eg, consuming yogurt or cheese to avoid However, not all individual trials show
androgens); acne creation. Further investigations are beneficial results. In one large open-label
• immunological disorders; and needed, especially randomized controlled clinical trial, 100 patients were equally
• psychological, environmental, and trials, to confirm the effect of milk and randomized to receive zinc sulfate or
iatrogenic factors.5 dairy products on acne development.9 lymecycline (tetracycline acne medica-
tion). Patients took 200 mg of zinc sulfate
Trigger Foods Associated Beneficial Interventions for Acne twice daily for 12 weeks, which was at
With Acne Other studies suggest that certain dietary least as effective as 300 mg lymecycline
Researchers have hypothesized that diet interventions and micronutrient supple- daily to reduce acne severity. Results
may play a part in the pathogenesis of mentation may have a positive effect on showed that patients who received the
acne vulgaris, and some food products acne treatment. zinc sulfate experienced modest improve-
may be a trigger.5 ments in their quality of life.13
Low-Glycemic Load Diet
High-Glycemic Load Diet In one study, 32 participants with mild- Niacinamide
A high-glycemic load diet consists of high- to-moderate acne were randomized Niacinamide, also known as nicotin-
carbohydrate foods such as refined sug- to either a low-glycemic load diet or a amide, is one form of vitamin B3 and the
ars, grains, milk, and dairy products. This high-glycemic load diet for 10 weeks.10 amide derivative of niacin. Oral niacina-
diet can raise blood glucose levels, cause Those on a low-glycemic load diet mide has been studied in combination
the body to produce more insulin, and demonstrated significant reductions in with other ingredients for the treatment
stimulate sebum production and seba- noninflammatory and inflammatory of acne. In preliminary clinical research,
ceous cell proliferation.6 lesion counts, more minor sebaceous oral niacinamide was reported to improve
glands, decreased inflammation, and acne when used in combination with
Dairy Products reduced acne severity grading.10 zinc, copper, and folic acid (marketed
Dairy remains a prominent dietary compo- Although more studies are necessary as Nicomide [Nic/Zn]). In an open-label,
nent for most Western societies. The first to understand the underlying pathways multicenter, prospective cohort study,
studies on the association between dairy of acne, incorporating low-glycemic foods 198 patients with acne vulgaris received
and acne were conducted in the 1940s. Two may help reduce the number of visible 750 mg nicotinamide, 25 mg zinc, 1.5 mg
prospective historical studies were done in lesions. Additional research studies are copper, and 500 mcg folic acid. By week
2004 and 2008 that showed a positive cor- required with larger sample sizes combin- four, a relatively short treatment period,
relation between acne and milk consump- ing a low-glycemic load diet and restricted 79% of patients reported their improve-
tion, which may be due to the presence of intake of cow’s milk products.11 ment in appearance as much better com-
hormones and bioactive molecules, as well pared with those who stated there was no
as milk’s effect through the insulinlike Zinc change in their condition.14
growth factor pathway. Dairy intake may According to a systematic review and In a multicenter, open-label, eight-
aggravate acne on several levels through meta-analysis of 25 small, low-quality week prospective study, dermatologists
these pathways, including increased oil clinical trials that included 2,445 partici- enrolled 235 post adolescent women with
production, inflammation, and abnormal pants, patients with acne have decreased inflammatory acne vulgaris. Research-
hormonal activity.7,8 serum zinc levels compared with controls, ers evaluated the efficacy of adding one
A meta-analysis of 14 observational suggesting that taking 137 to 300 mg of to four tablets of NicAzel (nicotinamide,
studies evaluated the relationship zinc sulfate or zinc gluconate twice daily azelaic acid, zinc, pyridoxine, copper, and
between milk and dairy products and acne by mouth can modestly improve acne folic acid) daily to patients’ current acne
development. This meta-analysis found compared with placebo. Participants who treatment regimen. In eight weeks, 88% of
a positive relationship between dairy, were treated with zinc had a significant patients experienced a visible reduction
whole milk, whole fat, low-fat, and skim improvement compared with those who in inflammatory lesions, and 81% rated
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CPE Monthly
their appearance as much better than at double-blinded placebo-controlled food diseases in high-risk children, particularly
baseline. Seventy-six percent of patients challenge test is required.20 with AD, with pHF-W and eHF-C, which
thought NicAzel was at least as effective 3. A T-cell–mediated reaction, or sys- persisted for 10 years without rebound,
as previous treatment with oral antibi- temic contact dermatitis, a type of eczema, whereas eHF-W showed no significant
otics.15 It’s unclear whether the effects is screened via patch testing. The most risk reduction.24
in these studies are due to niacinamide, common cause of systemic contact derma- Clinical research also shows that
other ingredients, or combinations. titis is Balsam of Peru, a sticky aromatic eHF-C is equally effective as pHF-W for
liquid that comes from the bark of the reducing the risk of AD in infants. This
Atopic Dermatitis (Eczema) Myroxolon balsamum tree native to El Sal- meta-analysis demonstrated that pHF-W
Affecting more than 9.6 million chil- vador. It contains cinnaminic acid, vanillin, (557 infants) vs eHF-W (559 infants) and
dren and about 16.5 million adults in the essential oils, and other compounds, and pHF-W vs eHF-C (580 infants) were shown
United States, atopic dermatitis (AD) is can be included in perfumes, deodorants, to be effective in the prevention of AD. For
the most common type of eczema.16 A and cosmetics, as well as tea and coffee, infants that can’t have breast milk exclu-
chronic condition, it can come and go for food flavorings, and other products. Ingest- sively, these formulas are a positive alter-
years or throughout life and overlap with ing or coming in contact with products native based on cost-effectiveness.25
other eczema types. In those with AD, the containing Balsam of Peru can cause an
immune system becomes dysfunctional immune response in the skin, character- Probiotics
and overactive, causing inflammation ized by dry itchy skin, and bumps and Increasing evidence suggests that chil-
that damages the skin barrier, leaving the blisters.21 Some people allergic to fragrance dren who develop AD have reduced
area dry and prone to itching. With darker additives may experience a cutaneous flare diversity in their gut microbiota. Oral
skin tones, rashes may become purple, after ingesting certain foods, such as toma- probiotics, especially certain combina-
brown, or grayish; in lighter skin, rashes toes, citrus, or cinnamon.22 tion products of lactobacilli species, seem
may become red.17 beneficial for AD prevention in children,
Research has shown that some people Beneficial Interventions for AD though there’s conflicting evidence on
with eczema, especially AD, have a genetic Despite the complexities of AD, there are their use for treating AD. A meta-analysis
mutation responsible for producing filag- certain food products individuals can con- of the available clinical research shows
grin, described by the National Eczema sume to treat the condition, but research that using probiotics in conjunction with
Association as a protein that helps the shows that two in particular are likely to standard treatment doesn’t improve
body maintain a healthy, protective bar- be more effective treatment options. patient-rated symptoms or quality of life
rier on the top layer of the skin. Without in adults or children with AD compared
enough filaggrin to build a strong skin Casein Peptides with standard therapy alone.26
barrier, the moisture from our skin can In a meta-analysis of clinical trials and However, research shows that the pro-
escape, and bacteria, viruses, and other intervention studies, researchers found biotic species Lacticaseibacillus paracasei,
containments can enter. This causes a statistically significant 45% reduced Lacticaseibacillus rhamnosus, and Lactiplan-
many people with AD to develop very dry risk of AD among infants aged 0 to 12 tibacillus plantarum are promising treat-
and infection-prone skin.17 months who received 100% whey protein ments. In a double-blinded, randomized,
partially hydrolyzed formula compared placebo-controlled clinical trial, research-
Trigger Foods That Cause AD with infants who received intact protein ers enrolled 60 patients aged between 6
Many allergenic foods interact with cow’s milk formula, based on the analysis months and 19 years with mild, moderate,
and sometimes cause AD. The six of data from each study that most closely or severe AD. Of the 60 patients, 40 com-
common allergenic foods that may represented the formula intake period. In pleted the study, and there were 24 probi-
trigger an AD flare include milk, eggs, most studies, these data were available otic interventions and 16 placebo. After
wheat, soy, seafood, and nuts, and they before the introduction of solid foods.23 treatment for six months, children and ado-
may do so through the following three In the prospective German Infant lescents with AD in the probiotics group
primary processes18: Nutritional Intervention study, 2,252 experienced a significant clinical response
children for the first four months of age to a mixture of Lactobacillus rhamnosus,
1. Type 1 or immediate-type hyper- were randomly assigned to receive one of Lactobacillus acidophilus, Lactobacillus
sensitivity, otherwise known as immuno- the following four blinded formulas as a paracasei, and Bifidobacterium lactis.27
globulin E–mediated allergy, may trigger breast milk substitute, if necessary:
a flare within minutes to hours. Dietitians Fermented Milk
or allergists can screen individuals for • partially hydrolyzed whey formula In a clinical research study, 415 pregnant
this allergy through a skin prick or blood (pHF-W); women from 36 weeks gestation to three
test, but further confirmation requires a • extensively hydrolyzed whey formula months postpartum randomly received
double-blinded, placebo-controlled food (eHF-W); fermented milk or placebo milk. Patients
challenge due to a high rate of false posi- • extensively hydrolyzed casein formula who drank 250 mL of fermented milk
tive results.19 (eHF-C); and containing Lactobacillus rhamnosus GG,
2. Late eczematous reaction, or • standard cow’s milk formula. Lactobacillus acidophilus, and Bifidobacte-
AD flare-up, may occur 48 hours after rium animalis reduced their child’s risk of
ingesting these trigger foods. If the After 10 years of follow up, the results developing AD by age 6 by approximately
immunological process is unknown, a showed a cumulative incidence of allergic 52% compared with placebo milk.28

Galacto-Oligosaccharides symptoms and disease severity. One of the Beneficial Interventions
Galacto-oligosaccharides in syrup or most critical environmental factors for for Psoriasis
formula, along with probiotics or fructo- patients with psoriasis is diet. Improper
oligosaccharides, may reduce the risk of nutrition, poor weight status, and meta- Low-Calorie Diet
AD development in infants at risk of atopy, bolic diseases may increase clinical symp- and Mediterranean Diet
an exaggerated IgE-mediated immune toms or even trigger the disease process.31 Studies suggest that preventing weight
response that stems from a genetic ten- Recent studies have suggested that gain, managing average body weight, and
dency to develop allergic diseases such when there’s better control of psoriasis reducing body mass may lower the inci-
as allergic rhinitis, asthma, and AD. In inflammation, the risk of CVD, stroke, dence of psoriasis.39
a prospective, double-blinded, placebo- metabolic syndrome, and other dis- One study showed 37 adult patients
controlled study, healthy term infants at eases associated with inflammation who were overweight or obese and never
risk of atopy were fed either a prebiotic- decreases.32 treated with drugs for stable chronic
supplemented or placebo-supplemented plaque psoriasis were placed on a 10-week,
hypoallergenic formula during the first six Trigger Foods That Cause Psoriasis two-phase weight loss program consist-
months of life. Following this intervention ing of a four-week protein-sparing, very-
period, follow-up continued until age 5. Gluten low-calorie ketogenic diet, and a six-week
Ninety-two children (50 in the placebo One trigger that may cause psoriasis in balanced, low-calorie Mediterranean-
group and 42 in the intervention group) some patients is gluten-containing foods. style diet. The results showed that adult
completed the follow-up. The five-year Clinicians should test patients who have patients on the low-calorie Mediterranean
cumulative incidences of allergic mani- gastrointestinal symptoms for immuno- diet had a significant reduction in the
festation and AD were significantly lower globulin A antibodies to determine whether body surface area and an improvement
in the prebiotic-supplemented group than they have celiac disease.33 Testing patients in itch severity. This demonstrated that
in the placebo group. When started early for immunoglobulin A antibodies is vital dietary intervention is an effective first-
in life, oligosaccharide prebiotics have a since they’re produced in the small intestine line strategy to reduce psoriasis severity.
protective effect against allergic manifes- where gluten causes inflammation and irri- Bodyweight reduction through a low-
tations in high-risk infants.29 tation in those who are sensitive.34 calorie diet may help decrease visceral
One study, however, had opposite Research studies suggest psoriasis and fatty tissue while increasing ketone bod-
results. Two hundred twenty-six healthy, celiac disease share common genetics ies and diminishing the inflammatory
formula-fed, term infants were randomly and inflammatory pathways. One large response linked to psoriasis and obesity.40
assigned to one of three study formula study found that 25,341 patients with
groups. The groups consisted of a control psoriasis had a 2.2-fold risk of being Gluten-Free Diets
group, a PG4 group (ie, control formula diagnosed with celiac disease compared A gluten-free diet may improve psoriasis
supplemented with 4 g/L of a prebiotic with matched controls.35 in individuals with gluten sensitivity or
blend containing polydextrose [PDX] and Another study, however, found no asso- celiac disease. An open-label research
galacto-oligosaccharides [GOS]), and a ciation between gluten intake and new study included 30 individuals with
PGL8 group (ie, control formula supple- onset of psoriasis. This cohort study of psoriasis and elevated immunoglobulin A
mented with 8 g/L of a prebiotic blend 85,185 women in the psoriasis analysis arm antibodies to gliadin. Researchers started
containing PDX, GOS, and lactulose). The of the study used food frequency question- participants on a gluten-free diet for three
results showed that the formula contain- naires to calculate the gluten content in months, followed by a regular diet for
ing 4 g/L of PDX and GOS (1:1 ratio) given their diets every four years. The results three months. After a three-month gluten-
as often as necessary for approximately showed that increased gluten intake wasn’t free diet, the mean Psoriasis Area and
four months increased the potential of associated with any outcomes.36 Severity Index score in all 30 participants
developing AD as an adverse effect up to improved. All participants were allowed
11% compared with a control formula.30 Obesity to continue with their topical or systemic
Obesity is likely a predisposition to psoriasis treatment. After discontinuing
Psoriasis psoriasis and is suggested as one of the the gluten-free diet and initiating the
Psoriasis is an inflammatory, chronic skin main factors of chronic inflammatory regular diet, 18 subjects began systemic or
disease that significantly affects patients’ processes associated with psoriasis.37 A local therapy for worsening psoriasis.41
quality of life. It’s a condition in which large population-based Norwegian study,
skin cells build up and form scales and including approximately 35,000 subjects, Vitamin D
itchy, dry patches. The cause of psoriasis showed an association between metabolic Vitamin D supplementation is a promis-
is unknown, but there are several reasons syndrome and increased risk of psoriasis. ing treatment for psoriasis. Calcitriol, the
why it may develop. Psoriasis is a T-cell– The analysis of metabolic factors suggested naturally occurring active form of vita-
mediated autoimmune dermatological that this positive association could have min D3 (cholecalciferol), has long been
disorder and is considered a multifacto- been attributed to adiposity.38 A poor diet used for topical psoriasis therapy. In two
rial disabling condition caused by the that provides a significant number of randomized, double-blinded clinical tri-
interaction between genetic and environ- high-calorie foods and is low in nutritional als, twice-daily application of calcitriol
mental triggers. Environmental factors quality has contributed to increased body ointment for eight weeks resulted in
such as emotional stress and smoking weight and metabolic diseases, increasing clearing or minimal residual psoriasis in
can negatively influence the onset of psoriatic inflammation. approximately 34% of patients, compared

CPE Monthly
with 12% to 22.5% of patients treated with of a gut-to-skin connection in rosacea. educational resources to help prevent
placebo. Calcitriol ointment is an effec- A population-based cohort study of them from relying on those less reliable.
tive, safe, and well-tolerated topical pso- approximately 50,000 Danish patients 2. Team up with dermatologists to
riasis therapy.42 with rosacea found that the prevalence of encourage patients to reduce the risk of eat-
But while the calcitriol topical treat- celiac disease, Crohn’s disease, ulcerative ing allergenic foods and using products with
ment is well established and represents an colitis, Helicobacter pylori infection, small allergenic ingredients associated with their
effective and safe treatment option with intestinal bacterial overgrowth, and skin disease by adopting a more nutritious
or without topical steroids, the beneficial irritable bowel syndrome was greater diet in tandem with medical interventions.
effects of vitamin D oral supplementa- overall among those with rosacea 3. Develop and provide customized
tion in general don’t seem to prevent or compared with controls.48 There’s a lack of care plans in writing to meet patients’ and
improve psoriasis symptoms. The find- clinical trial research about the possible their families’ needs. Prepare to review
ings of a clinical study of 65 older adults treatment of rosacea with probiotics and and modify these care plans at follow-up
with mild psoriasis show that taking the microbiome; therefore, more research visits as the disease state changes, since
200,000 IU of oral vitamin D3 followed by is necessary to further understand this patients and caregivers may forget or mis-
100,000 IU of vitamin D3 monthly for one gut-to-skin connection. understand skin care recommendations
year doesn’t affect the severity or spread of without written step-by-step instructions.
psoriasis when compared with placebo.43 Beneficial Interventions for Rosacea 4. Teach the same fundamental con-
The only promising research for treat- cepts and reinforce the same messages
Rosacea ing rosacea has focused on the use of the dermatologist delivers to patients and
Rosacea is a common chronic inflamma- topical 90% medical-grade kanuka honey caregivers. Dermatologists and dietitians
tory skin condition that primarily affects and 10% glycerine (Honevo). A clinical can provide one-on-one communication
the face with flushing and redness. The research study of 138 adults shows that with patients and written nutrition and
redness from rosacea becomes ruddier applying Honevo twice daily for eight skin health home care action plans. In
and more persistent over time. There’s weeks to the affected areas and washing it addition, dietitians and dermatologists
no cure, and its causes are unknown. If off after 30 to 60 minutes is more effective together can hold group discussions and
left untreated, inflammatory bumps and than Cetomacrogol cream, an emollient, teach in classroom settings to educate
pimples often develop. The individuals for improving rosacea symptoms. Roughly patients about nutrition and skin health.
at greatest risk have fair skin and tend to twice as many patients responded to Hon- 5. Recommend patients and caregivers
flush or blush easily.44 evo compared with Cetomacrogol cream.49 review advice they receive from friends,
family members, and other sources with
Trigger Foods That Cause Rosacea Putting It Into Practice their dietitian and dermatologist. Mak-
Many triggers may exacerbate rosacea Dermatologists can make referrals to ing even minor changes to their treatment
symptoms, including hot temperatures, dietitians who can provide evidence-based regimen can be detrimental, lack benefit,
sun exposure, spicy foods, alcohol con- dietary strategies to address patients’ skin and add unnecessary costs. Maintaining
sumption, exercise, and feelings of anger conditions. To work together, dietitians an open and ongoing dialog with patients,
or embarrassment.45 A survey from the and dermatologists must take a multi- caregivers, and their clinicians may
National Rosacea Society about dietary disciplinary approach to comprehen- improve adherence to treatment plans
triggers patients frequently cited found sively evaluate triggers and responses to and health outcomes.
that, of more than 400 patients, 78% had treatment, address confounding factors,
altered their diet due to rosacea flare-ups. such as dietary and nutrition habits, and Dietitians and dermatologists should
Within this group, 95% reported a consecu- educate patients and families. Currently, meet with one another to discuss each
tive reduction in flares.46 Patients within three programs across the country take a patient’s current and future care plan and
this group break down the food and bever- multidisciplinary approach to treat AD, resolve any issues. These meetings can
age triggers into heat, alcohol, capsaicin, and the clinicians involved have reported prevent miscommunication and ensure
and cinnamaldehyde related.45 Categori- excellent results.50-52 Multidisciplinary patients receive the same information and
cally, hot beverages acted as a trigger: 33% teams that can assist dermatologists’ criti- consistent messages regarding their treat-
described hot coffee as a trigger, while 30% cal role in educating and treating patients ment plan. The ultimate goal of multidis-
named hot tea as a trigger. Alcohol was for their skin diseases and disorders can ciplinary care is to give patients, families,
another frequent cause, with 52% identify- include not only dietitians but also nurse and caregivers the skills and tools they
ing wine as a trigger and 42% identifying practitioners, psychotherapists and psy- need to relieve symptoms at home and
hard liquor as such. Capsaicin is found in chologists, social workers, rehabilitation improve their quality of life. I
certain spices and peppers. Three-quarters therapists, and allergy-immunology fel-
of respondents reported spices as a cause, lows in training. Denine Rogers, MS, RDN, LD, FAND, is an
including hot sauce (54%), cayenne pepper Dietitians can work with dermatolo- integrative and functional dietitian and
(47%), and red pepper (37%). Foods contain- gists in a team effort to help treat patients’ owner of Living Healthy Skincare (www.
ing cinnamaldehyde also were mentioned skin disorders in the following five ways: livinghealthyskincare.com).
as frequent triggers, such as tomatoes
(30%), chocolate (23%), and citrus (22%).45,47 1. Focus on the dermatologist’s evalua- For references, view this article on our
In addition to food triggers, tion of the patient when making initial rec- website at www.TodaysDietitian.com.
research shows there’s a possible role ommendations. RDs also can offer patients

Become a CPE Monthly Pass holder for access to CPE
Monthlies and their associated exams for about $8/credit!
Go to CE.TodaysDietitian.com/CPEMonthlyPass and get
your Pass to Monthly CPEUs.
CPE Monthly Examination

1. Which of the three crucial skin layers brings blood to the 6. What’s the most critical environmental factor that impacts
skin and fights against infection? patients with psoriasis?
a. Hyperdermis a. Emotional stress

b. Epidermis b. Smoking
c. Dermis c. Diet
d. Hypodermis d. Genetics
2. Which of the following isn’t a causal factor that contributes 7. Which trigger food doesn’t exacerbate rosacea symptoms?
to acne formation?
a. Wine
a. Immunological disorders b. Chocolate
b. Hormonal abnormalities c. Hot sauce
c. Genetic predispositions d. Milk
d. Lifestyle conditions
8. In what ways can dietitians and dermatologists take a mul-

3. What’s an effective treatment option beneficial for patients tidisciplinary approach to treating patients’ skin diseases?
who have atopic dermatitis (AD)?
a. Develop and provide customized written care plans to
a. Low-glycemic load diet meet the individual patient’s and family’s needs.
b. Probiotics b. Encourage patients and caregivers to consider
c. Vitamin D following advice from friends, family members, and
d. Kanuka honey other sources for alternative treatments.
c. Discourage patients from taking responsibility for
eating allergenic foods and using products with
4. Balsam of Peru is the most common cause of which skin allergenic ingredients associated with their skin disease.
disorder? d. Suggest dermatologists offer patients diet and nutrition
recommendations.
a. Acne vulgaris
b. AD
c. Psoriasis
9. Which dietary intervention shows a positive effect on
d. Rosacea
acne treatment?
a. Vitamin D
5. Which of the following does the National Eczema Asso- b. Low-calorie diet
ciation describe as a protein that helps the body maintain a c. Low-glycemic load
healthy, protective barrier on the top layer of skin? d. Fermented milk
a. Filaggrin
b. Pustules
10. The Mediterranean diet is a beneficial treatment option
c. Papules
for which of the following skin disorders?
d. Carbuncle
a. Acne vulgaris
b. Rosacea
c. AD
d. Psoriasis
For more information, call our continuing education division toll-free at

877-925-CELL (2355) M-F 9 AM to 5 PM ET or e-mail [email protected].

Focus on Fitness By Kelly Jones, MS, RD, CSSD, LDN
Staying Active During the Winter

Learn how families can overcome the challenges of engaging
in physical activity in the colder months.
T
he weather in early fall is a wel- prioritize physical activity in the upcom- children and adolescents aged 6 to 17, 60
come change for many who ing cooler months. minutes or more of moderate to vigorous
don’t like the summer heat. But physical activity daily is recommended,”
as the season progresses, cooler Physical Activity Guidelines Callins says. “This should include a combi-
weather and darker evenings lead to Umo Callins, MS, RD, CSSD, CPT, owner of nation of aerobic, muscle-strengthening,
families and their children spending more Well Rooted Health and Nutrition and 180 and bone-strengthening activities. Chil-
time indoors. What’s more, family sched- Physique in Oklahoma City, Oklahoma, dren aged 3 to 5 should engage in various
ules become more hectic when school is says that the benefits of meeting the forms of active play throughout the day to
in session, as parents usually work, try to recommended physical activity guidelines enhance growth and development.”
provide balanced meals, and have plenty for children and adults are vast. Physical Krista Williams, CPT, a pregnancy
of other tasks to check off on their to-do activity is associated with “improved and postpartum athleticism coach and
list. Mentally exhausted parents may be cognition and sleep quality, healthy founder of The Strong Mom Project in
more likely to allow their children and bones, and improved mood, with studies Newtown, Pennsylvania, says that adults
themselves to engage in excessive screen showing positive impacts on feelings of are recommended to engage in less
time, reducing the chances of meeting depression,” Callins says. “A sedentary activity than children, a minimum of
physical activity guidelines. lifestyle is associated with higher chances 150 minutes per week. “At a point in time
Despite these challenges, there are of developing type 2 diabetes, heart where we work long hours, sit for long
many fun outdoor and indoor activities disease, and an increased risk of anxiety periods of time, and spend too much time
in which families can participate—and and depression.” in front of screens, we must prioritize
get excited about. This article provides Unfortunately, according to a 2020 meeting these minimums for our own
examples of these activities and strat- study, only 23% of children and adoles- health but also for the example we set
egies to help encourage families to cents meet current recommendations.1 “For for our children.”

Outdoor Family Activities the whole family wind down vs every- balloon and ensure it doesn’t touch the
A 2019 study suggests that a combina- one sitting around the TV or by them- floor or any furniture. The excitement
tion of physical activity and time spent in selves with their tablets. Research also can rise quickly, which can help release
nature may have at least six categories of shows that movement after meals aids endorphins while getting much needed
benefits: physical health, mental health blood sugar management, which can aerobic movement.
and well-being, education and lifelong help prevent diabetes or benefit those • Trampoline parks: Indoor trampoline
learning, active citizenship, crime reduc- who already have the disease. centers are popping up in more neigh-
tion, and reduced antisocial behavior.2 • Outdoor chores: From a young age, borhoods and enable children and
Despite these benefits, however, getting children can help mom and dad wash adults to jump around to their hearts’
started may be easier said than done for the car, plant a vegetable garden, or content, benefiting their cardiorespira-
many families. It may be more realistic pull weeds. “All movement counts,” tory and muscle and bone health. If the
to set a goal to be active together outside Williams says. In fact, studies have children enjoy it, many locations offer
just once per week. Callins emphasizes shown that when children help with memberships and discounts when pur-
that eventually, activity “becomes part of household tasks, they feel a sense of chasing multiple passes.
a family’s routine, allows for more con- accomplishment and may have greater
nection, and contributes to establishing self-competence and self-efficacy in the Supporting Clients
a foundation of what being healthy is all long term.3 Chances are your clients want to be more
about.” Here are some outdoor activities • Winter sports: While not feasible for active while spending quality time with
clients can partake in when the tempera- everyone, families can go skiing, snow- their families. As a mom herself, Callins
ture starts to drop: boarding, or tubing. Or if it’s more says, “It’s important to get to know the
convenient, they can go ice skating and family and what their needs and wants
• Hiking: A family hike doesn’t have to roller skating at a nearby rink in their are. Factor in schedules, preferences,
be challenging or take place on a steep neighborhood. abilities, their budget, and what they
trail. Encourage clients to choose local have access to before making recommen-
trails and pick a new one once a month. Indoor Family Activities dations. Be creative and help make meet-
Nature trails are a great way for chil- When the weather isn’t cooperating or a ing the physical activity guidelines as
dren to stay entertained by birds, bugs, family doesn’t have safe access to out- appealing as possible.” Callins explains
and wildlife while the whole family door spaces, there are still plenty of ways that this personalized and empathetic
enjoys movement together. to get everyone moving indoors. Here are approach will increase success in accom-
• Family playground time: Instead of some examples of indoor activities fami- plishing the activity goals.
standing and watching small children lies can consider: Williams adds, “Just like clients can
play, suggest parents fit in a playground develop harmful ‘food rules,’ they may
workout if their children are indepen- • Family yoga: No one has to be a skilled also develop rules with exercise that
dent. Adults can use steps and monkey yogi to enjoy movement that can might not be the best for their families’
bars to strengthen muscles and bones. improve flexibility and mental well- long-term health.” She recommends
This can set a great example for chil- being. YouTube Kids has plenty of free RDs avoid setting goals related to family
dren. Williams has built her personal kids’ yoga channels, such as “Cosmic members burning a certain number of
training business for moms around Kids Yoga,” which features kid-favorite calories or focusing only on high-intensity
children being present at workouts. characters as the class theme. activities. “In the same way you coach
And she sees first-hand that kids want • Dance parties: Callins suggests a dance clients to improve their relationship
to try the exercises they observe, mim- party or competition. While mood- with food, do the same with exercise.” All
icking their moms and cheering them boosting music can get family mem- movement can be beneficial and worth
on. bers moving any day, recommend they engaging in and even 10-minute spurts
• Field games: Callins suggests clients do so on Fridays to close the week on help build habits to support physical and
use outdoor spaces to play tag, frisbee, a high note while benefiting cardiore- mental health. I
or hacky sack. She also recommends spiratory health. Rotate who chooses
making outdoor obstacle courses. Soc- the music or create a monthly family Kelly Jones, MS, RD, CSSD, LDN, is a board-
cer is a simple game to play outdoors, playlist. certified specialist in sports dietetics, who
or parents can grab a bat, ball, and • Indoor obstacle course: Williams says, consults with national sports organizations,
glove to play with their kids on a local “It doesn’t take much equipment or and a media and nutrition communications
baseball field. space to turn a room into an obstacle expert. Her private practice works with
• Family walks and rides: Williams says, course. Map out a route with furniture, individuals and groups and offers practical
“Sometimes thinking more simply stairs, and common objects like paper resources to support performance for athletes
makes it easier to engage in activity plates, to create a fun challenge for at every level. She also founded and oversees
regularly. You don’t have to enjoy hik- adults and kids.” Student Athlete Nutrition.
ing, biking, or running, or commit a • Balloon keepie uppie: Playing this game
lot of time. Take a walk after dinner or in the house with a soccer ball isn’t the For references, view this article on our
follow your child on a scooter or bike.” safest thing to do, but the whole family website at www.TodaysDietitian.com.
Evening walks after dinner can help can get involved with a slower moving

Get to Know… By Elizabeth S. Goar
against advice, demanded a wholesale

overhaul of its cafeteria menu to meet a
strict set of criteria for calories, saturated
fats, and sugars. The company also banned
all fried foods, sugary beverages, candy,
and most snacks. And these changes had
to be implemented over just one weekend.
“It tanked employee morale and sat-
isfaction. Employees would leave the
building at lunch and bring back two-liter
bottles of soda and jumbo bags of chips to
keep at their desks,” she says.
Compare that with another client for
whom they gradually increased the per-
centage of healthful food options. “Today,
a majority of their employees happily make
healthful food selections at the worksite.”
She adds: “We are guests in each of our
clients’ homes, so it’s not about the Com-
pass Group’s well-being initiatives; it’s
about listening, partnering, and bringing
solutions that will help [them] meet their
well-being and employee health goals.”
It’s Brandstetter’s role to help clients
understand that “perfect” nutrition
criteria often can eliminate so many
options, leaving nothing that people
actually want to eat.
“As dietitians, we tend to want to do
everything perfectly. Sometimes moving the
needle [means] getting past that and being
willing to make incremental changes.”
Today’s Dietitian (TD): How did

you become involved with nutrition
marketing?
Deanne Brandstetter Brandstetter: In my early days with Flik,
I was the only RDN. We had a very small
Finding Creative Solutions to Foodservice Challenges operations support team, so everyone
pitched in everywhere, including market-
A
blizzard that shut down started to revolve again. It really started ing. I learned a lot as a result. Marketing
her rural Ohio college my interest in the culinary arts.” healthful foods is critically important—
campus ignited a passion While Brandstetter’s early years were the way we talk about it and the way we
for foodservice in Deanne spent on the clinical side of the profession, position it to be cool.
Brandstetter, MBA, RDN, CDN, FAND. she never lost her love for foodservice.
At the time, she was a senior in dietetics That continued love eventually landed TD: Can you describe your role as vice
at Miami University and a student her at Flik International, later acquired president of nutrition and wellness at
supervisor in the dining hall. With roads by Compass Group—one of the largest Compass Group?
impassable, she and one chef spent three employers of RDs in the United States— Brandstetter: I have the honor of working
days feeding stranded students with where she’s now vice president of nutrition with 3,000 RDs at Compass Group in just
whatever they could scrounge from the and wellness. She thrives on the challenge about every area of practice. I coordinate
freezer and walk-in coolers. of striking the perfect balance between and collaborate with them to make sure
The dining hall quickly became “a nutrition and flavor to meet the needs of we have common goals and strategies
place of community in the middle of this the company’s clients, which range from and are aligned on key partnerships. I’m
giant blizzard. I worked hard, but it was corporations and health care organiza- also on a team focused on innovation and
exciting and challenging. And it was fun. tions to schools, colleges, and universities. cross-sector sharing, so I get to make sure
It was a challenge, pulling together meals It’s a challenging creative process other parts of our business are all on the
based on just what was available to feed that often requires restraint. Brandstet- same page, and I help promote nutrition,
hundreds of students until the world ter recalls one particular company that, well-being, and healthful living.

TD: How did adding an MBA to your to bring in temporary power, water, and TD: What went into earning the
RDN credentials impact your career? refrigeration, and everything had to meet American Culinary Federation Silver
Brandstetter: I knew I’d need more busi- the health code. I was involved in menu medal for Healthy Cuisine 2000?
ness skills to be successful in the food- development, and there are many require- Brandstetter: Early in my career with Com-
service world. Certainly, when I joined ments for athletes across different coun- pass Group, one of the chefs asked me to
Compass Group, it was critical to under- tries. The Games took place shortly after work with her in a new competition called
stand how a global company works and to September 11, 2001, so there was tremen- Healthy Cuisine 2000. I really thought I
understand different business functions. dous security and an undercurrent of fear. would help her develop a menu and the
We need to be able to operationalize nutri- Some of our plans fell apart because we recipes that match their specific percent-
tion because having great aspirations planned to bring in thousands of trained age criteria for each macronutrient, and
doesn’t get us anywhere unless it’s practi- employees and put them up at a former that would be the extent of my role. But
cal enough to be a win-win scenario. Army barracks. Those wound up being she made it very clear that I also had to
commandeered by the National Guard, cook. Every afternoon I’d get on the train
TD: What’s your most significant so we bussed people in. Many just didn’t to New York City to rehearse. She literally
impact on the field of foodservice? show up because it was so hard to get to gave me culinary training for four or five
Brandstetter: I hope it’s elevating the role the remote locations. They had to ride hours every afternoon.
of the RD. Over the years, I’ve been an the bus, walk quite a distance, then go
advocate for RDs to take on additional through three sets of security. Quite often, TD: Tell us about the International
responsibilities in well-being and health I was jumping out of bed in the middle of WELL Building Institute (IWBI), and
promotion, foodservice operations, and what is your role?
even in sustainability and sustainable Brandstetter: IWBI manages third-party
food systems. The other thing I’m proud of certification of worksites and campuses
is our year-old RDN DEI (diversity, equity, We need to be able to with the goal of helping to create health-
and inclusion) Community Network. promoting sites where people work. It’s
When I took a critical look at the limited
operationalize nutrition not just about building materials. It’s also
diversity among our internal popula- because having great lighting, air and water quality, sound, and
tion of RDs, I knew we had a tremendous many more elements. One of its concepts
opportunity to do better, given the long,
aspirations doesn’t get is “Nourishment,” and I’m on the advisory
proud history of DEI within Compass us anywhere unless it’s board working to make sure the crite-
Group as a whole. With support from our ria are science based and operationally
leaders and plenty of grassroots interest
practical enough to be feasible. I’m also collaborating on addi-
from the RDs, we quickly organized and a win-win scenario. tional criteria that might be added. It has
launched a DEI network focused on things expanded beyond just worksite building,
like elevating cultural humility within and it continues to grow.
our RD population. We revamped reci-
pes and promotions to be more cultur- TD: How important is it for members
ally appropriate and inclusive, recruited the night to mop floors or scrub dishes of the profession to be active in
and retained more RDs with diverse because someone didn’t show up. It was professional associations and other
backgrounds, as well as mentored and exciting but a lot of work. It was one of organizations?
provided outreach to a diverse group of those great experiences where you give a Brandstetter: Obviously, I think it’s very
students to make them aware of careers in big sigh of relief when it’s over. important or I wouldn’t be doing it
nutrition and dietetics. I’m so proud of this myself. Having RDs actively involved
group and the huge difference it’s making. TD: Can you share a little about your and at the table gives us the ability to
Interestingly, over the last five years, the work with nutrition research? showcase our value and make the case
number of individuals in our cohorts Brandstetter: I’m not a researcher. Rather, for higher salaries.
from diverse backgrounds has grown I partner with others to provide an
from about 13% to more than 50%, but we opportunity to use some of our locations TD: What are some of your favorite
don’t know why. Figuring it out would go as living laboratories to test hypotheses. meals or foods?
a long way toward increasing the diversity And, because it’s not nutrition unless it’s Brandstetter: I’m particularly fond of
within the profession, so we’re working on eaten, we look at what tactics work in seafood, and I’ve been working on more
a strategy to identify the factors contrib- nudging people to make more healthful global cuisines. In particular, I love
uting to this sustained growth. choices. We’ve been doing choice regional Indian cuisines. I also love exper-
architecture for years, but now consumer imenting with different cooking tech-
TD: What was it like to direct the behavior psychology is booming and we’re niques, different flavors, spices, and herbs.
nutrition program for the 2002 Winter trying to tap into and apply that research. Sometimes it involves searching them out,
Olympic Games in Salt Lake City? We also do plenty of case studies to test but it’s a particular passion of mine. I
Brandstetter: The Winter Olympics are research in a real-world scenario. Another
challenging because many of the events area of interest is around DEI in our Elizabeth S. Goar is a freelance health writer
are outdoors in remote areas. We had dietetic internship program. based in Benton, Wisconsin.

Health Matters
Unhealthful Beverage Consumption Highest

Among Economically Vulnerable Households
A long-standing and contentiously Lead author Katherine W. Bauer, PhD, with 8.7 times per week for mothers
debated question is the extent to which US an associate professor in the department participating in both WIC and SNAP.
federal food assistance programs contrib- of nutritional sciences at the University Although regular soda intake was low
ute to or deter healthful beverage intake. of Michigan School of Public Health, among children aged 1 to 4, children from
Findings of a new study in the Journal of says, “Few studies have acknowledged households participating in both WIC and
Nutrition Education and Behavior, pub- that families with low income commonly SNAP consumed soda approximately five
lished by Elsevier, show that while bev- participate in multiple food assistance times more frequently than those from
erage intake patterns rarely differed programs. Parents are constantly households not participating in either
between mothers and young children who navigating the different requirements of program. Mothers from households par-
participated only in WIC, only in SNAP, or these programs and working to combine ticipating in both programs also drank
neither program, those whose households benefits in ways that most benefit their bottled water more frequently. These dif-
participated in both programs consumed families. It’s increasingly important to ferences were evident even after account-
high amounts of sugar-sweetened bever- understand how programs work together to ing for sociodemographic differences
ages (SSBs). Bottled water intake, which impact the health of adults and children.” between low-income families that do or
is common among communities with Study data were obtained from an don’t participate in WIC and/or SNAP.
high distrust of tap water and can be an online survey of 493 mothers with young Bauer explains, “Participating in mul-
economic burden for low-income families, children who had given birth at the Uni- tiple programs increases a household’s
was also common among mothers partici- versity of Michigan hospital in Ann Arbor, food-specific purchasing power. Parents
pating in WIC and SNAP. Michigan. These mothers were insured may use their WIC benefits to buy health-
While WIC and SNAP aim to improve by Medicaid at the time of their child’s ful staple foods and save their SNAP ben-
families’ food security, the programs birth, indicating low household income. efits for the small luxuries they can now
operate quite differently. WIC benefits Mothers completed questions about their afford, such as SSBs or bottled water. By
allow the purchase of specific foods and household’s current participation in WIC better understanding the dietary intake
beverages and are available to only preg- or SNAP, their past month’s intake of of families enrolled in multiple food
nant and breast-feeding women and chil- SSBs, their child’s beverage intake, bottled assistance programs, we can think about
dren through age 4. Meanwhile, SNAP water intake, and several sociodemo- strategies that work synergistically across
benefits are available to income-qualify- graphic characteristics. programs to promote food security and
ing households and can be used on nearly Study results showed mothers who improve diet quality, while maintaining
all food and nonalcoholic beverages sold didn’t participate in either WIC or SNAP personal choice for participants.”
at authorized retailers. drank SSBs 4.5 times per week compared SOURCE: ELSEVIER

Why Light-to-Moderate Drinking Is Tied to Better Heart Health
A new study led by investigators from and socioeconomic confounders. The light-to-moderate alcohol would be even
Massachusetts General Hospital, a researchers found that light-to-moder- more effective at reducing heart attacks
founding member of the Mass General ate alcohol consumption was associated and strokes in people who are prone
Brigham health care system, offers an with a substantial reduction in the risk to a chronically higher stress response,
explanation for why light-to-moderate of CVD events, even after accounting such as those with a history of signifi-
alcohol consumption may be associated for those other factors. cant anxiety. They found that, within the
with a lower risk of heart disease. For Next, they studied a subset of 754 indi- 50,000-patient sample, light-to-moder-
the first time, researchers found that viduals who had undergone previous PET/ ate drinking was associated with nearly
alcohol, in light-to-moderate quantities, CT brain imaging (primarily for cancer sur- double the cardiac-protective effect in
was associated with long-term reduc- veillance) to determine the effect of light/ individuals with a history of anxiety com-
tions in stress signaling in the brain. moderate alcohol consumption on resting pared with others.
This impact on the brain’s stress sys- stress-related neural network activity. Yet, while light-to-moderate drink-
tems appeared to significantly account The brain imaging showed reduced ers lowered their risk of CVD, the study
for the reductions in cardiovascular stress signaling in the amygdala, the brain also showed that any amount of alcohol
events seen in light-to-moderate drink- region associated with stress responses, increases the risk of cancer. And at higher
ers participating in the study. Find- in individuals who were light-to-moder- amounts of alcohol consumption—more
ings are published in the Journal of the ate drinkers compared with those who than 14 drinks per week—heart attack
American College of Cardiology. abstained from alcohol or who drank risk started to increase while overall brain
“We aren’t advocating the use of little. And when the investigators looked activity started to decrease (which may be
alcohol to reduce the risk of heart at these individuals’ history of cardio- associated with adverse cognitive health).
attacks or strokes because of other con- vascular events, they found fewer heart The authors conclude that research
cerning effects of alcohol on health,” attacks and strokes in light-to-moder- should focus on finding new interventions
says senior author and cardiologist ate drinkers. “We found that the brain that reduce the brain’s stress activity
Ahmed Tawakol, MD, codirector of changes in light-to-moderate drinkers without the deleterious effects of alcohol.
the Cardiovascular Imaging Research explained a significant portion of the pro- The research team currently is studying
Center at Massachusetts General Hos- tective cardiac effects,” Tawakol says. the effects of exercise, stress-reduction
pital. “We wanted to understand how It’s long been known that alcohol interventions such as meditation, and
light-to-moderate drinking reduces car- reduces the amygdala’s reactivity to pharmacological therapies on stress-
diovascular disease, as demonstrated by threatening stimuli while individuals are associated neural networks and how they
multiple other studies. And if we could drinking. The current study is the first might induce cardiovascular benefits.
find the mechanism, the goal would to indicate that light-to-moderate alco- SOURCE: MASSACHUSETTS GENERAL HOSPITAL
be to find other approaches that could hol consumption has lon-

replicate or induce alcohol’s protec- ger-term neurobiological
tive cardiac effects without the adverse effects in dampening activ-
impacts of alcohol.” ity in the amygdala, which
Previous epidemiologic studies have may have a significant
suggested that light-to-moderate alco- downstream impact on the
hol consumption (one drink per day for cardiovascular system.
women and one to two drinks per day “When the amygdala
for men) is associated with a lower risk of is too alert and vigilant,
CVD. But it was unknown whether alco- the sympathetic nervous
hol was inducing cardiovascular benefits system is heightened, which
or whether light-to-moderate drinkers’ drives up blood pressure
health behaviors, socioeconomic status, and increases heart rate,
or other factors protected their hearts. and triggers the release of
The study, led by Mezue and inflammatory cells,” Tawa-
Osborne, included more than 50,000 kol explains. “If the stress is
individuals enrolled in the Mass Gen- chronic, the result is hyper-
eral Brigham Biobank. The first part tension, increased inflamma-
of the study evaluated the relation- tion, and a substantial risk of
ship between light-to-moderate alco- obesity, diabetes, and car-
hol consumption and major adverse diovascular disease.”
cardiovascular events after adjusting Finally, the investiga-
for a range of genetic, clinical, lifestyle, tors examined whether

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News Bites
Afternoon Exercise Linked

to Better Blood Sugar Levels
for Patients With Type 2
Over 37 million Americans have diabetes, and 90% to 95% of that pop-
ulation are diagnosed with type 2 diabetes. Lifestyle interventions,
such as a healthful diet and a regular physical activity program, are
methods to manage diabetes. A new study from a collaboration of
investigators at Brigham and Women’s Hospital, a founding mem-
ber of the Mass General Brigham health care system, and Joslin Dia-
betes Center, part of Beth Israel Lahey Health, uses data from the
Look AHEAD (Action for Health in Diabetes) study, a randomized
controlled trial that compared an intensive lifestyle intervention
with diabetes support and education in patients diagnosed with
type 2 diabetes and overweight or obesity to track the development
Patient-Directed Nutrition Care
of CVD over time. In the current study, the research team assessed
Empower patients with an app that lets them self-order whether physical activity at certain times of day was associated
from menus that are customized for their personal diet with greater improvement in blood glucose control. Their findings
order, allergy restrictions, and nutrition goals. suggest patients with type 2 diabetes who were physically active in
The app includes Interactive nutrition indicators the afternoon had the largest improvements after one year in the
that help them learn about their food choices as trial. The team’s results are published in Diabetes Care.
they make selections. “In this study, we’ve shown that adults with type 2 diabetes
Learn more about the CBORD Patient app and how it can
had the greatest improvement in glucose control when they were
help reduce bedside order entry and call center volume most active in the afternoon,” says cocorresponding author Jingyi
while improving engagement and satisfaction. Qian, PhD, from the division of sleep and circadian disorders at
the Brigham. “We’ve known that physical activity is beneficial,
but what our study adds is a new understanding that timing of
activity may be important too.”
Physicians recommend that patients with diabetes participate
Visit cbord.com/healthcare
b d /h lth today.
t
in regular physical activity as a method to manage their blood
glucose levels. Elevated blood glucose levels can put people with
type 2 diabetes at risk of heart disease, vision impairment, and
kidney disease.
The team analyzed physical activity data from the first and
fourth years of the Look AHEAD study, which included data from
over 2,400 participants. During the study, participants wore a
waist accelerometry recording device to measure physical activ-
ity. When the Brigham and Joslin team reviewed the data from
year one, they determined that those who engaged in moderate-
to-vigorous physical activity in the afternoon had the greatest
reduction in blood glucose levels. Upon comparing the data from
year four, the afternoon group maintained a reduction in blood glu-
cose levels. In addition, the afternoon group also had the highest
chance of stopping their glucose-lowering/diabetes medications.
The Brigham and Joslin team note that their investigation has
limitations; for example, their study is observational and does not
measure confounding factors like sleep and dietary intake.
WHOLLY® AVOCADO O products
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that is ready when you are. WHOLLY® AVOCADO Diced why time of day of activity may influence blood glucose control.
Avocado can be added to your favorite recipes—the perfect From this, the team may be able to provide specific physical
finishing touch to your salad or soup. WHOLLY® AVOCADO activity recommendations for patients.
Smashed Avocado is perfectly portioned for you to enjoy as “Timing does seem to matter,” says cocorresponding author
a guilt-free snack or with lunch and dinner meals. Perfect for Roeland Middelbeek, MD, an assistant investigator at Joslin
on the go or when a whole avocado is just too much. Diabetes Center. “Going forward, we may have more data and
experimental evidence for patients to give more personalized
www.eatwholly.com/dietician recommendations.”
SOURCE: BRIGHAM AND WOMEN’S HOSPITAL

News Bites
can cause overeating, but

overeating can also lead to
stress and depression.
“The bottom line here is
that we shouldn’t be ignoring
this risk pattern among young
people at university. It’s well
documented that a signifi-
cant portion of students have
unhealthy diets,” she adds.
“The types of foods they’re eat-
ing are linked to obesity. And
this can lead to other health
problems that aren’t just
about chronic disease but also
infectious diseases.”
While Bottorff says stu-
dents should be taught about
healthy eating while at uni-
versity, the onus should be on
the school to provide health-
ful—and affordable—food
options for all students.
“We need to think about
the food environment that
A Student’s Poor Eating Habits we provide students. We need to ensure
that in our cafeterias and vending
Can Lead to a Lifetime of Illness machines, there are healthy food options
so that they can eat on the go but also
A University of British Columbia Okana- Medicine at China’s Jinan University. make healthful food choices.”
gan (UBCO) researcher is cautioning While there’s well-established research It’s not an issue going unnoticed. UBC
that a person’s poor eating habits estab- that links unhealthful diets to many Student Wellness and Food Services work
lished during postsecondary studies chronic diseases, this study aimed to together to address food security and
can contribute to future health issues, show a relationship between poor eating food literacy and recognize that a lack
including obesity, respiratory illnesses, habits and infectious diseases, including of affordable food options, coupled with
and depression. colds and diarrhea. the stress of university life, can negatively
Joan Bottorff, PhD, a professor with Bottorff notes that due to the nature of impact students’ food choices.
UBCO’s School of Nursing, is one of several the study, it wasn’t possible to show cause Food insecure students have access
international researchers who published and effect, but the relationship between to a low-barrier food bank and a meal
a multisite study looking at the eating poor eating habits, obesity, and respira- share program. Meanwhile, UBCO Food
habits of university students. Almost tory illnesses was well supported. Services’ culinary team prioritizes local,
12,000 medical students from 31 univer- “There’s been biomedical research organic, and sustainably sourced ingre-
sities in China participated in the study that also supports this link between obe- dients, and works with an RD to ensure a
that aimed to determine the association sity and infectious diseases, and most wide variety of food options are available
between eating behaviors, obesity, and recently this has been related to COVID- to all diners.
various diseases. 19,” she adds. “We know from some of the Bottorff agrees there have been
The point, Bottorff says, is that many recent publications related to COVID- improvements to food options in cafete-
poor eating habits begin at university and 19, obese people were more likely to rias and notes the drinks in many vend-
can continue for decades. have severe conditions and outcomes. ing machines have been rearranged so
“We know many students consume Reasons that have been offered for this healthier items are at eye level and sugary
high-calorie meals along with sugary foods increased vulnerability include impaired choices are lower down.
and drinks and there’s lots of evidence to breathing from the pressure of extra “I know many postsecondary schools
show those kinds of eating behaviors can weight and poorer inflammatory and are trying to figure out how we can do bet-
lead to obesity,” Bottorff says. “These aren’t immune responses.” ter and are trying to address these prob-
the only habits that lead to obesity, but A typical student diet of high-sugar lems,” she adds. “It’s great, because four or
they’re important and can’t be ruled out.” or high-calorie foods can become a five years ago, we weren’t. So, I think we’re
The study, published recently in Pre- long-term issue as these habits can lead on the right road, but I think we’re a long
ventive Medicine Reports, was led by to obesity. Bottorff says there’s evi- way from finished.”
Shihui Peng, PhD, with the School of dence to show that stress and anxiety SOURCE: UNIVERSITY OF BRITISH COLUMBIA OKANAGAN CAMPUS

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Culinary Corner By Liz Weiss, MS, RDN
Make-Your-Own
Orange-y Snack Mix
Serves 12
This kid-favorite snack has a crunchy

texture and a sweet and savory flavor.
Fortified cereals like the ones used in
this recipe provide important nutrients
for children—B vitamins, calcium, vita-
min D, folate, and zinc—and the complex
carbohydrates in every tasty bite deliver
fuel to hungry trick-or-treaters. Serve in
orange or black bowls for a pop of Hal-
loween fun.
There’s plenty of flexibility with this
recipe. Clients can omit nuts if there’s a
nut allergy in their household, add their
An Orange-Themed Halloween family’s favorite dried fruit (eg, chopped

dried apricots), and choose all sorts of
Get into the spooky spirit with some healthful bite-size pretzel shapes.
holiday snack ideas.
Ingredients
2 cups Corn Chex cereal
I
was never one of those moms support a well-functioning immune
2 cups Rice Chex cereal
who tried to turn Halloween system and eye health, respectively.
2 cups Cheerios cereal
into a “healthy” holiday. Given Here’s a list of orange food ideas for
½ cup lightly salted mixed nuts
my boys’ love of dressing up, some inspiration:
1 cup bite-size mini pretzels
ringing doorbells, and filling their
4 T extra virgin olive oil
plastic pumpkin buckets to the brim • cantaloupe balls;
1½ tsp Worcestershire sauce
with candy, that would have been a • dried apricots;
½ tsp garlic powder
lost cause. I handed out candy just like • carrot sticks and sliced orange bell
¼ tsp onion powder
everyone else in the neighborhood and peppers with hummus;
¼ tsp kosher salt
didn’t worry too much about the boys’ • clementines;
¼ to ½ cup golden raisins
candy haul. After a few days of candy • cheddar cheese sticks;
overload, the appeal of the sugary • mango smoothies made with 100%
Directions
treats would wear off and they’d usu- orange juice, plain yogurt, banana,
1. Heat oven to 250˚ F.
ally forget about it. and frozen mango;
2. In a large bowl, mix together
But there were times I would don • mini pumpkin muffins;
Corn Chex, Rice Chex, Cheerios,
my dietitian cape at Halloween when • homemade snack mix with nuts and
nuts, and pretzels.
it came to pre–trick-or-treat meals raisins (recipe to follow);
3. In separate small bowl, whisk together
and parties. That’s when I’d set out • butternut squash soup topped
olive oil, Worcestershire sauce, garlic
a spread of nutrient-rich, orange- with shredded cheddar cheese and
powder, onion powder, and salt until well
colored foods that my kids and their croutons;
combined.
friends always loved. Presenting those • roasted pumpkin seeds; and
4. Pour over cereal mixture and mix well
foods on Halloween-themed plates • parfait with plain yogurt, diced
until everything is evenly coated.
added to the fun, and as a busy mom mango or pineapple, and granola. I
5. Transfer cereal mixture to ungreased
and dietitian, I felt better knowing my
rimmed baking sheet or roasting pan.
kids were well fed and fueled before Liz Weiss, MS, RDN, is a mom of two grown
Bake for 1 hour, stirring every 15 min-
running out the door. boys with a specialty in family nutrition
utes. Remove from oven, let cool, stir in
When choosing orange-hued foods, and wellness. She shares recipes and
raisins, and store in airtight container at
you and your clients can consider apri- healthful living advice on LizsHealthyTable.
room temperature.
cots and golden raisins for fiber (plus, com and her podcast, EAT, DRINK, LIVE
neither food contains added sugars), LONGER. Weiss is a cooking instructor,
Nutrient Analysis per serving: (½ cup)
carrot sticks and orange bell peppers frequent lifestyle guest on TV shows Calories: 215; Total fat: 8.5 g; Sat fat: 1 g;
with dip for vitamins A and C, and across the country, and a Have a Plant Cholesterol: 0 mg; Sodium: 540 mg; Total
pumpkin muffins or a mango smoothie Ambassador for the Produce for Better carbohydrate: 32 g; Total sugars: 5 g; Dietary
fiber: 2 g; Protein: 3.5 g
for beta carotene and lutein, which Health Foundation.

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34 Supplements & Cancer

4 TODAY’S DIETITIAN • OCTOBER 2023

Almonds have been considered healthy for years, but

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10 TODAY’S DIETITIAN • OCTOBER 2023

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12 TODAY’S DIETITIAN • OCTOBER 2023

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18 TODAY’S DIETITIAN • OCTOBER 2023

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20 TODAY’S DIETITIAN • OCTOBER 2023

As a Passholder it’s as easy as 1-2-3

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