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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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
to Today’s Dietitian, PO Box 2026, Langhorne, PA 19047. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on
last label. Postmaster: Send address changes to Today’s Dietitian, 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: TDeditor@gvpub.com
ing, and weight management. And while there’s still a way to go Sales e-mail: sales@gvpub.com
to further develop AI applications in these specialties, RDs poten- Website: www.TodaysDietitian.com
Subscription e-mail: subscriptions@gvpub.com
tially can use what’s available and look forward to future develop- Ad fax: 610-948-4202 Ad artwork e-mail: ads@gvpub.com
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.
TDeditor@gvpub.com CONTENT CONTAINED IN TODAY’S DIETITIAN SHALL NOT BE CONSTRUED TO
CONSTITUTE PROFESSIONAL MEDICAL, HEALTH, LEGAL, TAX, OR FINANCIAL ADVICE.

6 TODAY’S DIETITIAN • OCTOBER 2023

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

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Register Today at tdsymposium.com

Children’s Health
ADD SOY Act Provides School
Children With a Dairy-Free Option
When Switch4Good Executive Director
Dotsie Bausch learned that a USDA study
revealed that 29% of the cartons of milk
served as part of the National School
Lunch Program (NSLP) are thrown in the
garbage, effectively tossing $300 million
in tax dollars into the trash each year,
it didn’t seem right to her. Cow’s milk
doesn’t sit right with two-thirds of the
human population in the form of lac-
tose intolerance or a dairy allergy, which
means that a significant portion of the 30
million American children who receive
meals as part of NSLP are suffering the
consequences—either from an adverse
reaction to drinking milk or by missing
out on important nutrition after discard-
ing the milk. Presently, there’s no dairy-
free milk option available for kids in the
NSLP, which inspired the ADD SOY Act
(Addressing Digestive Distress in Stom-
achs of Our Youth), a bipartisan bill intro-
duced to the US House of Representatives
by Troy Carter (D-LA) and Nancy Mace
(R-SC) as H.R. 1619.
Bausch was in Washington to meet
with representatives in an effort to get the
ADD SOY Act added as an amendment
to the Richard B. Russell National School
Lunch Act. Joining her was 18-year-old
Marielle Williamson, who sued the USDA
and the Los Angeles Unified School Dis-
trict last May for violating her rights,
forcing her to praise dairy cow’s milk in
addition to the literature she was distrib-
uting to students at her high school about
dairy-free milk alternatives.
The 2020–2025 Dietary guidelines for
Americans recognizes fortified soy milk
as a nutritional equivalent to dairy cow’s
milk, thus making it available as an option
in the NSLP, which seemed like an ideal
solution to Bausch. Schools aren’t cur-
rently reimbursed if they provide soy milk
as an option, yet the USDA is reimbursing
public schools for cow’s milk to the tune
of $1 billion annually—even though they
know children are dumping $300 million
dollars of milk directly into the trash. A
2015 study revealed that an astonishing
73% of US dairy income came from gov-
ernment programs like the NSLP.
The placement of milk on students’
lunch trays dates back to 1946 when the
10 TODAY’S DIETITIAN • OCTOBER 2023
Richard B. Russell National School Lunch
Act was signed into law. The end of World
War II left America with an overabun-
dance of supplies, including milk. Presi-
dent Harry S. Truman directed that the
milk be sent to schools. The NSLP pro-
vides 47% of the daily caloric intake of the
children in the program. Throwing out
the milk, estimated at 45 million gallons
per year, means the kids are missing a siz-
able portion of their daily nutrition.
Cow’s milk is the most common food
allergen that impacts infants and young
children. Symptoms include rashes, hives,
wheezing, vomiting, and anaphylaxis. In
fact, dairy milk has become the leading
cause of food allergen death. Long-term
effects of lactose intolerance include com-
promised immune systems and respiratory,
gastrointestinal, and skin problems. These
debilitating symptoms have a profound
negative impact on kids’ ability to concen-
trate and focus on their school lessons.
According to the National Institutes
of Health, the majority of all people have
a decreased ability to digest lactose after
infancy. Research shows that up to 80%
of Black and Latin Americans, more
than 80% of Native Americans, and up
to 95% of Asian Americans are lactose
intolerant. Thus, placing a carton of
milk on breakfast and lunch trays for
children participating in the NSLP, which
is the requirement for those meals to be
reimbursed by the USDA, is a mandate
that unfairly impacts a higher percentage
of Black and indigenous children and
children of color.
“When you sit in the classroom wheez-
ing, coughing, and your stomach is cramp-
ing, it makes concentrating on your studies
nearly impossible. Cow’s milk could very
well be the reason there’s a learning gap
between Black and white children,” says
Milton Mills, PhD, a critical
care physician who practices in
Washington, D.C.
“With a larger portion of those
participating in the National
School Lunch Program being
children of color, putting cartons
of milk on their trays is a form
of racism—dietary racism. It’s
systemic, structural inequities
surrounding food and nutrition that dis-
proportionately impact people of color.
We know that cow’s milk is making our
children sick, and not providing an option
is unjust and unconscionable. The fact
that so many kids are throwing out those
unopened milk cartons is an enormous
waste of taxpayer money,” Bausch says.
Key bipartisan support for the ADD
SOY Act in the Senate will be announced
soon. Before introducing the bill, 31 mem-
bers of Congress wrote to Agriculture
Secretary Thomas Vilsack to address the
dairy industry monopoly in the NSLP.
The letter specifically asks that soy milk
be made an available alternative to cow’s
milk. However, Vilsack ignored Congress’s
request. Subsequently, a letter was sent
to the White House Equity Commission
from multiple civil rights, social justice,
and health organizations, including the
National Urban League, which called on
the USDA to end dietary racism. This let-
ter also was ignored by the Commission.
“This summer is crucial for ADD SOY.
We need people to write or call their rep-
resentatives, asking them to support the
act. If thousands of their constituents
call or write, they have no choice but to
pay attention and get on board. Getting
as many signatures as possible is our top
priority. It’s an absolute must. We need
people to put pressure on Congress to pass
the ADD SOY Act in order to stop this gov-
ernment waste and right this wrong that’s
hurting our children,” Bausch says.
The Switch4Good website has a form
letter readily available that can quickly
and easily be sent to the signer’s jurisdic-
tional representatives, available at https://
switch4good.org/add-soy-act/.
Williamson told The Washington Post
that “People don’t really like to drink
cow’s milk anymore, and they have other
sources of dairy.”
The ADD SOY Act will make an alter-
native source available to our nation’s
school children.
SOURCE: SWITCH4GOOD
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
before the term “plant based”
became a thing, potato chips
and corn chips had the exclu-
sive rights on the early plant-derived
snacks market. That all has changed in
2023. Today’s snack aisle offers not only
plant-centric flavors like hot peppers,
lime, herbs, and dill pickle but also snacks
made from various forms of vegetables,
such as carrots, green peas, and kale.
According to SNAC International, a
trade association for the snack industry,
88% of snack consumers say flavor is
important when making snack choices,
and snack producers are finding
inspiration for new, interesting flavors
from around the world to meet the
demand for new, innovative products,
including plant-based options.
Health Expectations and Snacking
Lu Ann Williams, global insights director
for Innova Market Insights, isn’t surprised
by the proliferation of plant-based snacks
in the marketplace. What’s driving snack
innovation “is changing consumer atti-
tudes toward health along with con-
sumer expectations that healthful options
should be available for all types of foods
they eat, including snacks,” Williams says.
“In fact, over the past year, one-third of
consumers we surveyed report increasing
snacks with added health benefits.”
Several Innova surveys explore snack-
ing attitudes and behaviors. Participants
in the company’s most recent survey
on snacking named health as the num-
ber two reason—taste being number
one—for consuming plant-based jerky
snacks. Williams adds that because
today’s time-strapped consumers must
be able to read labels at a glance, eye-
catching buzzwords like “plant-based”
can help them make quick, health-
focused decisions. “Plant-based” also is
less polarizing than the term “vegan” on
front-of-pack labels.
• Confetti Lovely Vegetable Chips, pro-
duced in Singapore and “Upcycled Cer-
tified,” offers an expanded assortment
of sliced “ugly” vegetables, including
carrots, okras, and radishes. The veg-
etables are slow baked to help retain
their nutrients.
• California-based Root Foods offers
four varieties of crispy vegetable
snacks: zucchini; tomato; onion; and a
mix made of whole and cut asparagus,
green beans, zucchini, okra, bell
peppers, and broccoli.
• Rhythm Snacks, headquartered in
Austin, Texas, has a product line that
includes a range of seasoned vegeta-
bles, including kale, shishito peppers,
jicama, and beet chips that are crisped
at a low temperature.
• New York City-based Popadelics
offers three different flavors of crispy,
seasoned, dried mushrooms—truffle
and parmesan, Thai chili, and rose-
mary and salt.

12 TODAY’S DIETITIAN • OCTOBER 2023

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Healthful Snacking

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

14 TODAY’S DIETITIAN • OCTOBER 2023

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

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Probiotics By Carrie Dennett, MPH, RDN
Probiotics and Diabetes
Can gut health management help prevent
or manage type 2 diabetes?
A
s consumers become more
aware of the role gut health
has in overall health and
chronic disease, many are
considering probiotic supplements
to support their gut microbiota.
Unfortunately, the hype around the
potential health benefits of probiotics
currently is overstated once claims are
evaluated in the context of research-
based evidence. So what does this mean
for the claims that probiotics can help
prevent or manage type 2 diabetes?
Certainly, the gut microbiota is a
contributing factor in the develop-
ment and progression of type 2 diabe-
tes. Gut microbes and their metabolites
strongly influence host metabolism, gut
16 TODAY’S DIETITIAN • OCTOBER 2023
permeability, immune function, satiety,
digestion, and nutrient absorption, among
other important functions.1 Dysbiosis,
the alteration of a healthy microbiota, is
associated with low-grade inflammation,
insulin resistance, and type 2 diabetes.2
Differences in Microbiota
Composition
Numerous research studies have observed
relative increases in some bacterial spe-
cies and decreases in others in the stool of
participants with type 2 diabetes. Exam-
ples include the following:
• Decreases in bacterial species that pro-
duce short-chain fatty acids (SCFAs)
via fermentation of dietary fiber. SCFAs
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
they’re live microorganisms that, when
administered in adequate amounts, con-
fer a health benefit on the host. While cer-
tain fermented foods may contain strains
of probiotic bacteria, most of these foods
wouldn’t be considered probiotics them-
selves because bacterial strains may vary
from batch to batch and because they may
not be present in sufficient numbers to
produce a health benefit.
Preliminary studies suggest that alter-
ing the composition of the gut micro-
biota with probiotic supplementation
may improve type 2 diabetes by reducing
proinflammatory cytokines, intestinal
permeability, and oxidative stress via mul-
tiple pathways, including SCFA forma-
tion.4 While results from animal studies
on the benefits of probiotics for improv-
ing glucose metabolism and insulin sen-
sitivity have been promising, research
on humans has produced inconsistent
results.5,6 Still, a 2020 meta-analysis of 15
randomized controlled trials involving
GET CRACKIN’ WITH PROTEIN POWER.
Probiotics
902 patients found that the groups ran-
domized to take probiotics saw statisti-
cally significant reductions in hemoglobin
A1c, fasting blood glucose, and insulin
resistance, compared with patients taking
a placebo, despite differences in the dos-
age and duration of probiotic treatment
among the studies.5
Studies and Their Findings
In a 2023 review article, Akkermansia
muciniphila—a bacterium first “discov-
ered” and isolated in 2004, and which
represents approximately 1% to 3% of
the total gut microbiota in healthy peo-
ple7—was called the “‘next generation
probiotic’ for alleviating metabolic dis-
orders and the inflammatory response.”
For example, propionate, an SCFA pro-
duced by A. muciniphila metabolism,
has been shown to stimulate glucagon-
like peptide-1, a hormone with functions
including stimulating insulin secretion.8
Another 2023 review had a similar assess-
ment, emphasizing that A. muciniphila
has a well-documented role in improving
several metabolic pathways, which makes
it a key element in the pathogenesis of
several human diseases. The authors note
that, in addition to stimulating glucagon-
like peptide-1, this bacterium can reduce
the expression of glucose and fructose
receptors in the small intestine, reducing
absorption of carbohydrates.7
Two randomized, double-blinded,
placebo-controlled trials have demon-
strated that supplementation with A.
muciniphila has benefits for blood glu-
cose control. A 2019 exploratory study
published in Nature Medicine found that
A. muciniphila improved insulin sensi-
tivity compared with placebo.9 A small
2020 company-funded-and-run proof-of-
concept study that used a novel probiotic
formulation containing A. muciniphila
along with Clostridium beijerinckii, Clos-
tridium butyricum, Bifidobacterium infan-
tis, Anaerobutyricum hallii, and inulin—a
type of prebiotic fiber—found that among
participants with type 2 diabetes cur-
rently using metformin, the group taking
the formulation experienced statistically
significant decreases in postprandial
glucose levels (36.1 mg/dL) and HbA1c
levels (0.6%) at week 12, when compared
with placebo. No change in fasting glu-
cose levels was observed.10 Currently, this
formulation is the only one established by
the Alliance for Education on Probiotics
18 TODAY’S DIETITIAN • OCTOBER 2023
to reduce postprandial blood glucose in
people with type 2 diabetes, giving it a
level 2 recommendation11; however, sev-
eral bacterial species used in commercial
probiotic supplement products, includ-
ing some Lactobacillus and Bifidobacte-
rium species, have reduced fasting blood
glucose levels in human and animal
studies.2,4
Some studies also have looked at
the combined effects of probiotics and
berberine, a bioactive plant compound
that has a long history in traditional
Chinese medicine. Independently,
berberine has been shown in studies to
lower blood glucose in patients with type
2 diabetes, although the mechanism to
achieve this is unknown.12
The Probiotics and BBR on the Efficacy
and Change of Gut Microbiota in Patients
with Newly Diagnosed Type 2 Diabetes
randomized controlled trial compared
the effects of probiotics plus berberine,
berberine plus placebo, or probiotics
plus placebo with that of placebo
alone in 466 patients. After 12 weeks
of treatment, the probiotic-berberine
group and the berberine-placebo group
had similar statistically significant
reductions in HbA1c compared with
the probiotic-placebo and placebo
alone groups. The researchers found
that berberine enhanced populations
of several bacterial species that also are
enhanced by treatment with metformin.13
A separate 18-week randomized, double-
blinded, parallel-controlled study of
300 patients newly diagnosed with
hyperglycemia compared the effects of
berberine, Bifidobacterium, berberine
plus Bifidobacterium, and placebo.
Compared with the placebo group, the
berberine plus Bifidobacterium group saw
a significant reduction in fasting blood
glucose, two-hour postprandial glucose,
and HbA1c. The berberine-only group
also saw a small reduction in two-hour
postprandial glucose.14
Safety Considerations
Because healthy consumers and certain
patient populations use probiotics, the
International Scientific Association for
Probiotics and Prebiotics published a
perspective piece on emerging issues in
probiotic safety earlier this year in the
journal Gut Microbes. The authors explain
probiotics targeted for patient popula-
tions should undergo stringent testing to
meet quality standards appropriate for
that population, preferably verified by an
independent third party.15 For example,
despite excitement about A. muciniphila,
because it’s a mucin-degrading bacte-
ria—mucin is the main glycoprotein in
the mucus layer that protects the intesti-
nal barrier—there’s concern that exces-
sive enrichment of that species in certain
intestinal environments may be harmful.
For instance, it may not be safe to use in
patients with endocrine or gynecologi-
cal disorders that increase risk of inflam-
matory bowel disease, such as polycystic
ovary syndrome or endometriosis. More-
over, patients with Parkinson’s disease
or multiple sclerosis already may have an
overabundance of A. muciniphila.16
A 2021 Cochrane Review concluded
that low-quality evidence from six
placebo-controlled studies involving 1,440
patients hasn’t clearly identified the effect
of probiotics on the risk of gestational
diabetes, which is a long-term risk factor
for type 2 diabetes.17 Importantly, the
authors note that while they found no
solid evidence of the benefit of using
probiotics to prevent gestational diabetes,
they found that high-quality evidence
suggests that probiotics may increase the
risk of preeclampsia.
Bottom Line
These findings serve as a good reminder
that much of the research on probiotics
and glucose metabolism is in animal mod-
els, and mechanisms to explain observed
benefits aren’t fully explained. Additional
research may shine light on those mecha-
nisms, as well as a better understanding
of the relative risks and benefits for dif-
ferent patient populations. In the mean-
time, knowing the current limitations of
the research can help dietitians counsel
clients and patients who want to know
if they should take probiotics to manage
their blood sugar—especially patients
who may think that probiotics are more
powerful than they actually are. I
Carrie Dennett, MPH, RDN, is the nutrition
columnist for The Seattle Times, owner of
Nutrition By Carrie, and author of Healthy
for Your Life: A Non-Diet Approach to
Optimal Well-being.
For references, view this article on our
website at www.TodaysDietitian.com.
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Pulses By Karen Collins, MS, RDN, CDN, FAND
Are Pulses a Misunderstood
Food Group?
Help clients bypass misconceptions and include more
of these nutritional gems.
S
ome people use the term “pulses”
interchangeably with “legumes.”
However, legumes encompass
a broad category of plants with
seeds that grow in pods. The differences
among legumes lead to distinct nutri-
tional profiles. The most common types
fall into three categories1,2:
• Pulses are the dry edible seeds
from within a pod. Although there
are multiple types and hundreds
of specific examples, pulses in the
United States often are grouped into
four main types: dry beans, dry peas,
chickpeas, and lentils.
• Undried (fresh or green) legumes are
harvested while still green (before dry-
ing). They can be consumed with their
pods (eg, green beans and sugar snap
peas) or without their pods (eg, green
peas). In the 2020–2025 Dietary Guide-
lines for Americans (DGA), green peas
20 TODAY’S DIETITIAN • OCTOBER 2023
are grouped with starchy vegetables,
while the rest are with “other vegeta-
bles” such as celery, cabbage, onions,
and peppers.3
• Oilseed legumes are nutritionally
unique because they’re higher in fat
(primarily unsaturated) and lower in
fiber than other legumes. Peanuts and
soybeans are the two major examples.
Inconsistent Guidelines
In the Healthy US-style or Mediterra-
nean dietary pattern, adults are advised
to consume 1½ cups of pulses per week
in a 2,000-kcal/day diet, according
to the 2020–2025 DGA (where they’re
listed under the Beans, Peas, Lentils
subgroup of vegetables). 3 The DGA
vegetarian dietary pattern calls for an
additional 6 cups per week in a 2,000-
kcal/day diet as part of protein-supply-
ing foods, for a total of about 7½ cups of
pulses per week.
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,
the DGA notes that protein is undercon-
sumed by many adolescent females and
adults aged 71 and older and highlights
beans, peas, and lentils as a food category
that’s underconsumed in these popula-
tions and could help fill that gap. Many
pulses also are good sources of folate and
magnesium, which also are classified by
the DGA as underconsumed nutrients.
People who consume pulses have
higher calorie-adjusted intakes of dietary
fiber, folate, and magnesium than those
who consume none, according to an
analysis of National Health and Nutrition
Examination Survey data.8 And those
who consume higher amounts—just
under 0.5 cup equivalents per day—
also have higher energy-adjusted
intakes of potassium, zinc, iron, and
choline compared with nonconsumers.
The National Health and Nutrition
Examination Survey is an observational,
cross-sectional study, so it’s possible that
people who consume more pulses also
make other dietary choices that increase
consumption of these nutrients.
Pulse Consumption Promotes Health
• Cardiometabolic health: Prospective
observational studies show that
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Pulses
regular pulse or total legume
consumption is associated with
lower risk of CVD.9 In randomized
intervention trials lasting at least
four weeks that analyzed effects on
markers of cardiometabolic health,
legumes, which included pulses and
soyfoods, were the second strongest
out of 10 food groups for reducing LDL
cholesterol.10 And in combined analysis
of all 10 biomarkers of cardiometabolic
health (including those related to
lipids, glycemic control, blood pressure,
and inflammation), the effects of
legumes again were rated second.
• Cancer risk: Pulses go a long way to help
fill the gap in dietary fiber in Western
diets to help fulfill the recommendation
for at least 30 g fiber per day to reduce
cancer risk.6 However, although pulses
often are recommended as part of a diet
to reduce cancer risk, research hasn’t yet
shown a consistent association of pulse
consumption with lower risk of cancer—
whether overall or specific types.6,11
• Role in a healthful dietary pattern:
Healthy Eating Index scores for a
healthful dietary pattern reflect pulse
consumption that aligns with current
recommendations and are associated
with key metrics of better health.12,13
The question is whether more frequent
consumption, such as a half-cup daily,
will create a dietary pattern that better
supports health. Those who favor
recommending increased amounts of
pulses note that the overall impact of
pulses’ nutrient quality, and value as a
replacement for other foods, is diluted
when it’s averaged over several days.1
Overcoming Barriers
Dietitians can facilitate greater con-
sumption of pulses by asking clients what
Resources
The following organizations provide
dietitians with recipes, tip sheets,
research summaries, and social
media inspiration:
• The American Pulse Association:
https://pulses.org/us
• Lentils.org (funded by
Saskatchewan Pulse Growers):
www.lentils.org
22 TODAY’S DIETITIAN • OCTOBER 2023
barriers they face and then providing rele-
vant education and coaching that address
those barriers.
“In my practice, patients report that
they didn’t grow up eating beans or that
they don’t like the taste and have limited
knowledge of how to prepare beans,” says
Maya Feller, MS, RD, CDN, author of Eat-
ing From Our Roots: 80+ Healthy Home-
Cooked Favorites From Cultures Around
the World, based in Brooklyn, New York.
RDs also can provide clients with
strategies to prepare pulses. “The soaking
and cooking process for dry pulses is
often a barrier for US consumers to
prepare them at home,” says Madison
Jacobson, director of marketing for the
USA Dry Pea and Lentil Council and the
American Pulse Association in Moscow,
Idaho. “Many consumers are unaware
that split peas and lentils do not require
soaking before cooking. And both will
cook in 45 minutes or less.” Canned and
frozen pulses offer a solution if soaking and
cooking time is too much of a barrier, and
a pressure cooker can significantly reduce
the time needed to prepare dry pulses.
In addition, media headlines based
on research taken out of context may
instill fears of lectin compounds in pulses.
Claims linking lectins to chronic inflam-
mation and gut damage are based on
laboratory studies using isolated lectins or
raw beans.14 However, lectins are neutral-
ized in cooking, and since they’re water
soluble, they’re largely removed by cook-
ing or canning in water.
Some people may fear that pulses
are “fattening” or that they will
impede blood sugar management.
Dietitians should explain that pulses
are categorized as low in calorie density
and that greater consumption of
pulses and other legumes is associated
with a decreased risk of weight gain,
overweight, and obesity, and better
glycemic control.10,15 In randomized,
controlled human intervention trials,
people achieved modest weight loss and
lower body fat by eating a serving of
pulses daily, even without intentionally
reducing total calories.16
Finally, it’s time to address the ele-
phant in the room: gas production.
Gut bacteria produce gas as they form
beneficial short-chain fatty acids from
prebiotic compounds in pulses. However,
dietitians can explain that when peo-
ple gradually increase these foods and
regularly include them, they often build
up a tolerance. Commercial digestive aids
with alpha-galactosidase can alleviate
digestive discomfort, if needed.
Pulses Are Flexible
In addition to addressing barriers with
clients, dietitians can provide examples
of how they can prepare pulses that cater
to a variety of individual and cultural
preferences to encourage more frequent
consumption. “[Pulses are] incorporated
into marinades, purées, soups, and stews,”
Feller says. “I often encourage people to
start with flavors that are familiar and
branch out to ones that are new.”
Jacobson says, “Swapping in pulses for
other ingredients in familiar dishes
people regularly consume” offers a
realistic path to including more pulses.
Examples Jacobson suggests include
replacing half or all of the meat for tacos
with seasoned lentils, replacing half or
all of the ricotta in lasagna with pureed
white beans, and replacing up to half the
cheese sauce in macaroni and cheese
with pureed yellow split peas.
Bottom Line
Plant-focused dietary patterns come in
many different forms. Even for people
who don’t want to eat exclusively plant
foods, pulses play an important role in
the DASH, Mediterranean, flexitarian,
and other plant-forward diets. Pairing
pulses with modest portions of animal
foods can enhance nutrient density while
reducing food costs.
Clients can add pulses to curries, chili,
casseroles, and stir-fries—with or without
poultry, seafood, or meat. At breakfast,
bean or lentil burritos and tostadas can
be a great solution. In addition, clients
can blend pulses into smoothies or dips.
And roasted pulses, whether store bought
or homemade, make healthful snacks or
salad toppings. I
Karen Collins, MS, RDN, CDN, FAND, is
nutrition advisor to the American Institute for
Cancer Research. She offers research reviews
on her website (https://karencollinsnutrition.
com) and is creator of the Daunting to Doable
Nutrition Pro Circle, a membership program
for dietitians only.
For references, view this article on our
website at www.TodaysDietitian.com.
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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

24 TODAY’S DIETITIAN • OCTOBER 2023

difficult for clients and patients to make
healthful choices that align with their
health goals, tastes, and budgets. “RTE
cereal is one of the few foods enjoyed by
people across the different stages of life,”
says Vandana R. Sheth, RDN, CDCES,
FAND, a Los Angeles-based nutrition
counselor and owner of a private practice.
“Since cost is a growing concern for many
people, cereal can be a cost-effective way to
get many key nutrients.”
Cereal Nutrition
The chart provided serves as a sample of
the types of RTE cereal brands, varieties,
and nutrition profiles available on the
market. The chart groups them according
to major selling points: high fiber, high
protein, granolas, and children’s. Some
of the categories and nutrient attributes
in the chart overlap. For example, a cereal
may be in the high fiber section but also
is high in protein. Another cereal may
be grouped in the high fiber category
but also contains as much sugar as one
of the children’s cereals. Few cereals are
easily classified. Here’s a discussion on the
average serving sizes and nutrients RTE
cereals contain.
• Serving Size. None of the nutrients
found in RTE cereals can be discussed
without factoring in serving sizes,
which vary greatly. Serving sizes in the
chart range from ½ cup to 1⅓ cups—
almost a three-fold difference. Some
products not in the chart but available
at the supermarket suggest a serving
as small as ¼ cup. Often, the more
calorie-dense the cereal, the smaller
the serving size, as is the case with
granolas. Clients and patients should be
aware of the differences. If, for example,
they’re focusing only on fewer calories
on the Nutrition Facts panel and dish
up a large serving, the calorie count
for breakfast will be much larger than
intended. “Each person has different
needs, and their portions are likely to
differ from what’s the suggested serving
size,” says Sue-Ellen Anderson Haynes,
MS, RDN, CDCES, CPT, LDN, founder of
360Girls&Women, LLC, in Hopkinton,
Massachusetts, a private practice
offering holistic health and wellness
services for girls and women. But the
serving size isn’t always indicative of
the nutrient contribution. Some cereals
that suggest smaller servings still
contribute significant amounts of a
wide variety of vitamins and minerals.
26 TODAY’S DIETITIAN • OCTOBER 2023
“I view serving sizes as a guide, not as a
‘rule.’ We all have different nutritional
READY-TO-EAT CEREAL
needs,” Mathis says.
• Calories. The calorie levels of the cereals Cereals Serving Size
in the chart, which are representative of
all RTE cereals, range from a low of 90 kcal
for a ⅔-cup serving to a high of 280 kcal HIGH FIBER (5 G OR MORE PER SERVING)
per ½-cup serving—a three-fold differ- Kellogg’s All-Bran ⅔ cup
ence in calorie counts.
• Protein. There aren’t a large number of
cereals that boast a high-protein content. Kellogg’s Cracklin’ Oat Bran ¾ cup
The few listed in the chart range from 10 to
20 g protein per serving. However, several
other cereals considered high fiber also
Post Grape-Nuts Original ½ cup
provide as much as 11 g protein per serving.
• Carbohydrates. All cereals are rich
Kellogg’s Frosted Mini-Wheats 25 biscuits
sources of carbohydrates, but many are Bite Size
refined, which can cause blood glucose
Cascadian Farm Organic 1¼ cups
levels to spike, especially if eaten as a Multi-Grain Squares
snack without milk. Anderson Haynes
emphasizes that, in fact, many cereals are
considered to be ultraprocessed foods. HIGH PROTEIN (5 G OR MORE PER SERVING)
Consumption of ultraprocessed foods
Post Premier Protein Chocolate 1 cup
has been associated with several chronic Almond
health conditions, including hyperten-
sion, diabetes, heart disease, and demen- Kashi GO Peanut Butter Crunch ¾ cup
tia. But other cereals are less refined and
are excellent sources of fiber. The car-
GRANOLA AND MUESLI
bohydrate contents of the cereals in the
chart range from 14 g per serving (for a Bear Naked Granola Protein ½ cup
high-protein cereal) to 54 g per serving for Honey Almond
an organic, multigrain cereal. Quaker Simply Granola, Oats, ⅔ cup
Honey, Raisins & Almonds
• Added Sugars. The grams of added
Quaker Protein Granola Oats, ¾ cup
sugars per serving are listed under Chocolate & Almonds
carbohydrates, but it wasn’t always that
way. Added sugars became a part of 365 Whole Foods Market Organic ½ cup
Oat & Honey Granola
the Nutrition Facts panel in 2016 when
the FDA revamped the label, changing
how nutrition information was listed, CHILDREN’S
rearranging the order in which it was
listed, and providing the amount of added Kellogg’s Fruit Loops 1⅓ cups
sugars per serving in a product. The
cereals in the chart range from 0 g to 16 g
(4 tsp) per serving of added sugars. While Cascadian Farm Organic 1 cup
it isn’t surprising that, of the cereals in Gluten-Free Fruitful O’s
the chart, a children’s cereal contained
Lucky Charms Magic Gems 1 cup
the most added sugars, surprisingly,
three high fiber cereals contained almost
as much added sugars (12 g to 15 g per Cheerios, Gluten-Free, Original 1½ cups
serving). “A rule of thumb is to choose
cereals, granolas, etc, with 5% of the Daily
Value (DV) or less of added sugars per Kellogg’s Frosted Flakes 1 cup
serving,” Anderson Haynes says. “The
American Heart Association sets a daily
sugar limit to 38 g (9 tsp) for men, 24 g
(6 tsp) for women, and less than 24 g (6 tsp)
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 6 , folate,
vitamin B 12

200 6 47 0 1 7 280 Iron, thiamin, niacin,

vitamin B 6 , folate,
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 6 , folate,
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


provide as much as one-half the daily
recommended limit in a single serving.
• Sodium. RTE cereals usually aren’t con-
sidered a sodium source to be concerned
about. But while they don’t contain as
much sodium as fast food or chips, if
sodium is severely restricted, it’s impor-
tant to be aware of the sodium content of
RTE cereals, which ranges from 0 mg per
serving to 280 mg per serving for those in
the chart. Some products available in the
supermarket contain even more.
• Vitamins and minerals. RTE cereal is
an important source of nutrients in the
American diet.5 The chart lists only those
nutrients that are 20% DV or higher—the
amount that the FDA considers a “high”
level of a nutrient. Other nutrients than
those listed often are present but in “low”
amounts—5% DV or less, according to
the FDA. Of the cereals in the chart, none
of the levels of vitamins and minerals in
10 of them were enough to be classified
as “high” levels. The nutrients present at
high levels are mostly the result of forti-
fication. Most cereals are fortified with
multiple nutrients. Iron is the nutrient
that cereals are most often fortified with,
followed by the B vitamins, folate, thia-
min, riboflavin, and niacin. A few provide
high levels of vitamin C, copper, or man-
ganese. Consumers may be surprised to
find that several cereals thought to be the
most healthful often aren’t fortified at all
and, as a result, are low in several nutri-
ents. For example, granolas and organic
cereals typically aren’t fortified, and while
they may be high in fiber or low in sugar,
they fail to provide much in the way of
vitamins and minerals. Calcium isn’t a
nutrient found in cereals, but adding cow’s
milk or a calcium-fortified plant milk will
add that mineral. Data from the National
Heart, Lung, and Blood Institute Growth
and Health Study show that after adjust-
ing for energy intake, cereal consumption
was related to an increased intake of fiber,
calcium, iron, folic acid, vitamin C, and
zinc, as well as a decreased intake of fat
and cholesterol.6
28 TODAY’S DIETITIAN • OCTOBER 2023
However, not all nutri-
tion experts agree that RTE
cereals are a good choice for
breakfast or snacks. “I would
not recommend RTE cere-
als as a good breakfast choice
for several reasons,” Ander-
son Haynes says. “First, they
digest quickly, raising blood
sugar quickly, often leaving you unsatis-
fied.” Instead, she recommends quick-fix
alternatives, such as a protein smoothie or
a yogurt bowl with fruit, nuts, and seeds.
Cereal Research
Studying the effects of RTE cereal intake
on health is tricky because of the huge
variation in RTE cereal products. Stud-
ies are limited to examining populations
and surveying RTE cereal consumption or
high fiber cereal consumption vs health
parameters such as blood glucose or cho-
lesterol. The effect on diseases, such as
CVD, type 2 diabetes, or cancer, are also
population studies. Clinical studies that
would focus on the health effects of spe-
cific types of RTE cereals are impractical
because of the cost of conducting such
long-term studies, and findings may not
be applicable to all RTE cereals.
A prospective study from Harvard
School of Public Health several years ago
suggested that eating cereal fiber was a
potentially protective factor against death
from CVD, respiratory disease, and infec-
tions.7 A systematic review of the avail-
able evidence in 2014 found that regular
RTE breakfast cereal consumption was
associated with a lower BMI and less risk
of overweight or obesity.1 The review also
found that RTE cereal consumption was
associated with diets that were lower in fat
but not with increased intakes of sodium
or energy and that regular consumption
helped to ensure adequate nutrient intake
and suggested that it may help to reduce
the risk of developing CVD or diabetes.
Recommendations
Since there are so many RTE cereals on
the market, the following tips can help
RDs educate clients on what to look for
and consider next time they’re in the
grocery store.
• Counsel clients and patients to ignore
the meaning behind a cereal that has
the term “nature” or “fruit” in its title.
While these terms give consumers the
impression the products are healthful,
they’re not an indication that they’re
healthful or more healthful than those
that don’t boast those claims. Neither
does containing the word “organic”
in the name always indicate a more
healthful nutrition profile. Some
organic cereals, especially granolas,
can be high in added sugars. A recent
study from Columbia, South America,
found that “nearly all” RTE cereals with
nutrition and nature-related claims
were high in calories and sugars.8 The
truth resides on Nutrition Facts panels
and ingredient labels.
• Recommend adding toppings to
increase the nutritional value of RTE
cereals. “A few add-ons that I recom-
mend to clients include seeds (chia,
flax, pumpkin, sunflower), nuts
(almonds, pistachios, walnuts, pecans),
fruits (berries, chopped apple, sliced
banana), and spices (cinnamon or a
splash of vanilla),” Sheth says.
• Remind clients and patients that the
total calorie count and nutrient con-
tent will depend on whether they add
whole milk, skim milk, almond milk,
oat milk, or soy milk to their cereal.
Some Nutrition Facts panels provide
nutrition for both dry cereal and a serv-
ing of the cereal with cow’s milk.
• Give examples of RTE cereals that are
high in fiber but not high in added sugars.
And show them how to identify added
sugars on the labels of RTE cereals.
• Suggest RTE cereals that are fortified
with several vitamins and minerals if cli-
ents want a vitamin and mineral boost.
Bottom Line
Most nutrition experts agree that, when
chosen wisely, RTE cereals offer a con-
venient, nutritious option for breakfast
and snacks. The RTE cereal products to
choose from can be overwhelming for cli-
ents and patients—and even for RDs. New
products are constantly being introduced.
It’s important to keep on top of what’s in
the cereal aisle. Counseling those clients
and patients who make RTE cereals a reg-
ular part of their diets on how to choose
the best options for their tastes and health
goals can have a positive effect on their
vitamin, mineral, and fiber intakes. I
Densie Webb, PhD, RD, is a freelance writer,
editor, and industry consultant based in
Austin, Texas.
For references, view this article on our
website at www.TodaysDietitian.com.
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Children & Sugar
Striking a balance between over restriction
and adherence to current guidelines.
Consumption
S
ugar consumption
has been under much
scrutiny with regard
to children’s diets.
Since excessive sugar
intake can have nega-
tive health impacts, parents and
caregivers are told to give their
children foods and snacks that
contain less sugar.1 While these
messages have positive inten-
tions, they may fail to take into
account other factors, such as
the potential to over restrict
sugar and barriers to meeting
the 2020–2025 Dietary Guide-
lines for Americans (DGAs) for
sugar consumption.
Moreover, the way parents and care-
givers perceive foods containing sugar
inside and outside the home can have
a large impact on a child’s relationship
with sweets, impacting how much they
eat and how they view these foods them-
selves. When sugar is demonized and/or
overly restricted, children potentially can
develop disordered eating habits, which
parents unwittingly may overlook. What’s
more, restricting sugar is challenging for
families in today’s food culture, so meet-
ing the DGAs may not be practical. These
issues make the topic of sugar intake and
children more complicated and one that
deserves proper attention.
Thus, it’s important for dietitians to
help parents and caregivers better under-
stand how to navigate sugar consump-
tion with their children to enable them to
foster a healthy relationship with sugar
and support their overall health.
What the Current Guidelines
Recommend
Dietitians know that consuming sugar in
excess can lead to increased risk of type 2
diabetes, obesity, heart disease, fatty liver
disease, and other illnesses.1 For these
reasons, many health organizations have
developed guidelines for limiting intake
of added sugars for children and adults.
The American Heart Association
developed stricter guidelines, recom-
mending that children and teens con-
sume less than 6 tsp (or 25 g) added
sugars per day and to drink no more
than 8 oz of sugar-sweetened beverages
per week.3 However, the CDC reports
that the average daily intake of added
sugars was 17 tsp for children aged 2 to
19 from 2017 to 2018, which is far above
these guidelines.4
Obstacles to Achieving Goals
There are many barriers that arise when
trying to meet the DGAs for consumption
of added sugars for children. These may
include the following:
• Shared caretaking. Parents may find it
difficult to monitor their children’s sugar
intake because they may be at school, at
an event, or under someone else’s super-
vision. “Kids often spend time outside of
the home with adults who are not their
primary caretakers,” says Erin Shah, RD,
CDE, a former leader of high-risk infants
at Kaiser Permanente Anaheim Medical
Center in Anaheim, California. “Whether
it be daycare or school, grandparents or
friends’ houses, birthday parties, or other
special events, parents aren’t the only
ones in control of the child’s food options
or choices.” In fact, a 2022 study showed
that the caregiver type, especially grand-
parents, is a significant predictor of a
child’s health status, including BMI, diet,
and food security.5 So, while parents may
be able to control sugar intake in their
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
By Joanna Foley, RD
own homes, their child’s health is still
influenced by the world around them.
• Socioeconomic status. A family’s
financial status is a significant factor to
consider when trying to meet the DGAs.
“Sugar is cheap and, as one of the US’s top
food preservatives, often finds itself in
many processed and shelf-stable foods,”
Shah says, adding that families that have
lower incomes tend to consume diets
higher in added sugars than those with
higher incomes.6
• Health literacy. Not all consumers
read nutrition labels and ingredient lists,
which can be tedious and confusing. And
those who take the time to read them may
not know that sugar often disguises itself
under different names. “Sugar hides under
many other names (such as honey and
high-fructose corn syrup, maple syrup, or
molasses) and can sneak into seemingly
healthful packaged and prepared foods,”
Shah says. “There’s also the common con-
fusion between natural sugars, such as
fructose in whole fruits or lactose in dairy
foods, vs added sugars.”
• Practicality. Another reason many
families find it challenging to limit
their children’s sugar intake is because
many convenience and packaged foods
and snacks they rely on contain added
sugars. In the midst of busy lives,
parents and caregivers often find it
impractical to prepare most meals and
snacks from scratch or use only whole
food ingredients.
• Culture and ethnic background. Due to
the many different cultural practices,
ethnic backgrounds, and eating hab-
its, some populations tend to consume
more or less sugar than those of other
ethnicities. According to CDC data
from 2017 to 2018, non-Hispanic Black
children aged 2 to 19 consumed the
most added sugars compared with non-
Hispanic white children, Hispanic chil-
dren, and non-Hispanic Asian children.
31
 • Increased desire. Research has
shown that children are born with
a desire for sweet flavors.7 In fact,
most have a stronger preference for
sugar compared with adults, which
isn’t a result of the culture in which
they live. Some researchers believe a
child’s strong desire for sugar may be
associated with their growing bodies
since sugar provides a quick source of
energy and calories.8
Dietitians should take these obsta-
cles into consideration when devising a
child’s diet and providing recommenda-
tions to parents and caregivers.
When Restricting Sugar Backfires
In addition to the many potential bar-
riers that can limit children’s sugar
intake comes the issue of problem-
atic eating behaviors when sugar is
too restricted. “Because of the volume
of fear-mongering messages parents
constantly receive about sugar and
kids, many caregivers may believe
that by restricting sugar in their
home, they’re taking steps to improve
their child’s health and well-being,”
says Crystal Karges, MS, RDN, IBCLC,
founder of Crystal Karges Nutrition,
a private practice based in San Diego,
specializing in intuitive eating for
mothers and families. “While well-
intended, the potential consequences
of restricting sugar cannot be over-
stated, especially as a child gets older
and begins getting exposed to sweets
outside the home.”
Some potential problematic eating
behaviors that warrant attention may
include the following:
• Overeating. Overly restricting
sugar can lead to children desiring and
consuming more. One study found that
girls whose mothers engaged in restric-
tive feeding practices had higher rates
of overeating and eating in the absence
of hunger.9
One form of restriction that’s
common in many households is
reserving sweets for only special
occasions or using them as a reward.
However, research shows that these
practices may cause some children
to crave them more and eat them in
excess when they’re available.10 “Using
desserts as a reward elevates sweets
32 TODAY’S DIETITIAN • OCTOBER 2023
on a pedestal, making them something
a child is more likely to obsess over,”
Karges says. “It also runs the risk of
detaching a child from their innate
intuitive eating abilities. This can
cause a child to begin to ignore what
their bodies need in favor of following
external rules for eating, which
disrupts their ability to self-regulate
their intake,” Karges says.
• Disordered eating behaviors. “Some
kids who have diets that are overly
restricted may end up engaging in
behaviors like hoarding or sneak-
ing food,” says Krystyn Parks, MS, RD,
IBCLC, owner of Feeding Made Easy,
based in Orange County, California.
This can lead to long-term disordered
eating habits, emotional eating, or
symptoms of eating disorders.11
• Poor relationship with sugar and/or
themselves. Children are at risk of
internalizing shame, fear, and judg-
ment around eating sweets when
they’re “categorized as ‘healthy’ vs
‘unhealthy’ or ‘good vs bad,’” Karges
says. And since children are concrete
thinkers developmentally, they’re more
likely to translate messages around
food more literally. For example, a
child who hears, “Eating too many
sweets is bad for you,” may translate
this message to mean, “I am bad for
eating sweets,” Karges says.
• Preoccupation with sugar. Children
who are restricted from eating sweets
may appear anxious when sweets aren’t
available or throw a tantrum when
requests for sweets are denied. And
there may be visible signs of distress
when children attempt to access sweets
or incessantly ask or nag when sweets
become available, Karges says. “Restric-
tion also can lead to intense preoccupa-
tion. In this case, a child may be unable
to focus on other activities due to the
obsessiveness of having sweets. This
may make it challenging for [the child]
to engage in childhood activities impor-
tant for development and growth.”
It’s important to keep in mind that
some of these troublesome eating behav-
iors are based on anecdotal evidence
and knowledge of the way a child’s brain
works and develops. While all of these
behaviors may not be supported by
research, parents and caregivers should
take them into consideration when
addressing sugar with their children.
Counseling Strategies
Taking into account the possible con-
sequences of overly restricting sugar
and the obstacles to meeting dietary
guidelines for sugar consumption in
children makes nutrition counseling
more complex.
The good news is that sugar doesn’t
have to be off limits. It’s possible for chil-
dren to consume sweetened foods and
enjoy desserts while still consuming an
amount of sugar that isn’t likely to raise
the risk of disease.
Dietitians can share the following
tips (based on professional experience
and anecdotal evidence) with parents
and caregivers to navigate sugar intake
inside and outside the household.
1
Keep foods neutral, includ-
ing sugar. Encourage parents
to avoid labeling or catego-
rizing foods as “healthful” vs
“unhealthful” and “good vs bad.” Parks
suggests, “When talking about sweets
and desserts, I usually recommend
treating them as you would treat any
other food. Refer to them by their
name instead of calling them a treat or
reward.” Karges adds, “This helps cre-
ate an emotionally equal playing field
for all foods from which children can
learn to eat based on the embodied
experience of what feels best in their
bodies (sans judgment or shame).”
2
Allow frequent access with-
out conditions. While sugar
shouldn’t compose the bulk
of a child’s diet, RDs should
remind parents that they don’t need to
overly restrict it. “We want our children
to learn to listen to and trust their own
bodies. We can communicate this to
them by providing them with reliable
access to sweets alongside other foods
they’re learning to eat, refraining from
micromanaging how and what they
choose to eat from the foods we pro-
vide,” Karges says.
Parks recommends caregivers avoid
setting conditions for when their chil-
dren can have desserts or other sweet
foods. She says that “for many fami-
lies, offering the dessert with the meal,
instead of after the meal, can help take
some of the obsession [away from] the
dessert. Many kids will actually eat
more of their other foods when the
dessert is available throughout the full
meal because they don’t feel the need
to save room for it.”
3
Think about the big picture.
How much sugar children eat
is just one of many factors
influencing their overall
health. RDs should remind caregivers
to also focus on how much physical
activity their children are getting
and the status of their overall eating
habits. They also should be reminded
that a healthful eating environment
isn’t just about nutrition. It includes
feeling safe, comfortable, and
connected to others.
4
Be practical. Food needs to taste
good in order for kids to eat it.12
So, if parents drizzle a small
amount of honey on yogurt
or include a dollop of whipped cream
on top of berries to encourage their
children to eat these nutritious foods,
they shouldn’t avoid this practice.
5
Control what you can and not
worry about the rest. Because
it’s important to encourage
children to eat and enjoy foods
other than those that are sweet, parents
should fill their homes with a variety
of healthful and practical foods, such
as whole grains, fruits, and vegetables.
They can offer these foods to their chil-
dren regularly without the need for
coercion. This will enable parents to
relax more when their children attend
parties or other activities where sweets
will be served. Parents will know
they’re doing their part at home and be
more inclined to trust their children to
self-regulate their appetite for sweets.
It’s important for RDs to remem-
ber that each child is unique and that
parents have their own opinions about
how to address sugar in and outside
of their household. Ultimately, RDs
should emphasize to caregivers that
there isn’t one “right way” to approach
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
sugar consumption and that they don’t
have to micromanage sugar intake
or overly prevent their children from
eating too many sweets. According
to Karges, “The main messages care-
givers should send to their children
around sweets should center around
body trust, safety, reliability, and
access. We want our children to believe
that sweets are safe, that sweets are an
enjoyable part of eating—not some-
thing to stress over or worry about.”
With practice, parents will learn to
be attuned to their children’s needs,
which will enable them to take a pro-
active approach to offering sweets
intentionally and at a frequency that
will help their children build a positive
relationship with all foods. I
Joanna Foley, RD, is a freelance health
writer and author of two cookbooks, based
in San Diego. Learn more about her writing
services at joannafoleynutrition.com/press.
For references, view this article on our
website at www.TodaysDietitian.com.
33
SUPPLEMENTS &
34 TODAY’S DIETITIAN • OCTOBER 2023
 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

OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM 35

reported using at least three products
concurrently, and 23% of women under-
going chemotherapy were using supple-
ments with possible adverse effects.4
Even though dietary supplements
aren’t drugs, people take them because
they expect that they’ll have a positive
effect. While some supplements, such as
daily multivitamins, don’t appear to affect
cancer survival or recurrence—or cancer
treatment—elements in certain herbs and
supplements may affect how the body pro-
cesses chemotherapy drugs when taken at
the same time. For example, some supple-
ments can interfere with specific enzymes
or other components of the drug that affect
how the drug is transported and metabo-
lized.1 In some cases, this can make the
drugs less effective in fighting cancer cells.
In other cases, it can make the drugs more
toxic to the body than intended.
Researchers from Yale University’s Life-
style Exercise and Nutrition study asked
151 breast cancer survivors who partici-
pated in the study about their dietary sup-
plement use: 120 of the women (80%) were
taking a dietary supplement, 72 women
(60%) were taking three or more formula-
tions, and 29 women (24%) were taking
five or more. Of the 54 different supple-
ment formulations reported, 33% had
potential interactions with Tamoxifen or
aromatase inhibitors—estrogen-blocking
drugs taken as part of breast cancer treat-
ment. Most of these potential interactions
(87%) were associated with herbal prepa-
rations,5 which, along with higher-dose
antioxidant supplements, are of most con-
cern when used during cancer treatment.
Antioxidants
Because radiation, chemotherapy, and
many other anticancer drugs generate
reactive oxygen species, or free radicals—
unstable molecules that react with other
molecules in a cell, causing DNA dam-
age—to kill cancer cells, many cancer
patients take antioxidant nutrient supple-
ments with the intention of protecting
healthy cells and reducing treatment side
effects. Common dietary antioxidants
include vitamins A, C, and E; beta-caro-
tene; and other carotenoids, glutathione,
and flavonoids, such as those found in soy
and green tea.
Antioxidants have well-defined anti-
cancer effects that theoretically make
them a promising way to reduce the initia-
tion, progression, and spread of cancer
cells. Antioxidants were initially stud-
ied in cancer patients for their potential
36 TODAY’S DIETITIAN • OCTOBER 2023
to improve outcomes and
reduce oxidative damage
to healthy cells from che-
motherapy and radiother-
apy, potentially allowing
for higher doses. However,
what researchers started to
find was that in higher therapeutic doses,
antioxidants might instead promote
cancer progression and increase overall
mortality in some patients—and that anti-
oxidants’ ability to reduce the toxicity of
chemotherapy and radiotherapy may also
make treatment less effective by counter-
acting the reactive oxygen species that are
supposed to be killing cancer cells.6
The results of a Phase III breast cancer
drug trial published in 2020 found that
patients who reported taking any antioxi-
dant supplement—carotenoids, coenzyme
Q10, or vitamins A, C, and E—both before
and during postsurgical chemotherapy
were 41% more likely to have their breast
cancer return. This association was not
seen with multivitamin use, likely because
the amounts of individual antioxidants
are lower than they are in single-nutrient
supplements.7 However, a 2021 meta-
analysis of more than 17,000 breast cancer
survivors found that postdiagnosis use of
antioxidant supplements wasn’t associ-
ated with overall mortality.8
A 2017 review authored by Marian
looked at the research on dietary
supplements commonly used by
cancer survivors.9 She wrote that it’s
difficult to determine the true impact
of using antioxidant supplements
during treatment because most studies
have used various types and doses of
antioxidants and have included patients
undergoing a variety of treatment
regimens with numerous types of cancer.
Herbs and Nutraceuticals
Some herbal medicines and other nutra-
ceuticals—foods or parts of foods that
allegedly provide the body with health ben-
efits beyond basic nutritional value—can
interfere with cancer treatment in another
way by altering how the liver metabolizes
chemotherapy drugs. For example, St.
John’s Wort—an “herbal antidepressant”
also commonly used by cancer patients—
has been shown to inhibit tumor growth
in triple-negative breast cancer10 and
colorectal cancer in rodents11 as well as
suppress cell proliferation and/or increase
cell death in lab samples of human breast
cancer cells12 and metastatic melanoma
cells,13 to cite a few examples. However, it’s
well established that in humans, St. John’s
Wort increases the production of the cyto-
chrome P450 isoenzyme 3A4 (CYP3A4),
a liver enzyme that breaks down certain
chemicals and toxins—including agents
used in some chemotherapy drugs, includ-
ing imatinib, docetaxel, and irinotecan.
Taking St. John’s Wort concurrently with
these drugs can decrease their bioavail-
ability by 12% to 42%.14
Other herbs that may have a significant
adverse effect on how the body metabo-
lizes chemotherapy drugs include garlic,
ginkgo, echinacea, ginseng, and kava.
In addition, polyphenols found in many
herbs and teas may affect enzymes that
help process chemotherapy drugs, which
can cause resistance to drugs such as
vincristine, vinblastine, taxanes, anthra-
cyclines, tamoxifen, and tyrosine kinase
inhibitors.15 A 2021 review found poten-
tial interactions between 261 herbs, foods,
and dietary supplements and 117 antican-
cer drugs via interactions with various
cytochrome P450 isoenzymes.16
A 2018 review concluded that melato-
nin is the only compound whose use is
supported by sufficient safety and effi-
cacy data from randomized controlled
trials to prolong survival in patients with
advanced cancer. The authors wrote that
other supplements, including curcumin,
green tea, EPA, DHA, and artemisinin, are
well-tolerated and potentially effective
in combination with conventional treat-
ments, but large randomized controlled
trials are needed to fully investigate these
supplements’ role within complex drug
treatment strategies for cancer.17
Honoring the Uncertainty
“We just don’t know, especially with some
of the newer immunotherapies, how taking
all of these myriad supplements will result
in benefits or harms,” Neuhouser says.
Marian says some of her patients have
brought bags full of supplements they’re
taking to their appointments. She says
the large quantity of supplements is con-
cerning, given the unknowns about how
supplements may interact with their
treatment and how the supplements may
interact with each other. “I think when
there’s the unknown, you have to be super
cautious about the potential for adverse
effects, even if we don’t know whether
they could happen or not, because the fact
that we don’t know is something to be
concerned about.”
Food vs Supplements
While adequate macro- and micronu-
trients, along with beneficial food com-
pounds such as flavonoids, curcumin,
epigallocatechin gallate from green tea,
resveratrol, and quercetin can support the
body during cancer treatment, more isn’t
necessarily better, and may even be worse.
The World Cancer Research Fund
states that there’s no strong evidence that
dietary supplements, apart from calcium
for colorectal cancer, can reduce cancer
risk. Both the World Cancer Research
Fund and the American Institute for Can-
cer Research recommend meeting nutri-
tional needs from diet alone, stating that
a healthful diet is more likely to protect
against cancer than dietary supplements,
because eating whole foods allows the
body to absorb a whole range of vitamins,
minerals, and antioxidants that work
together to protect health.18-20
Despite uniform recommendations
from major cancer organizations, cancer
patients continue to use supplements dur-
ing treatment, sometimes without their
health care providers knowing. One 2008
systematic review found that up to 68% of
physicians are either unaware of supple-
ment use in their cancer patients, or
they’re aware but didn’t record that infor-
mation in patients’ charts.2 Is the message
not getting out, are providers not asking
the right questions, or are patients ignor-
ing evidence-based advice because they’re
scared and want to throw everything they
have at this major health crisis?
“I think the message isn’t getting out
there from providers and dietitians,” Neu-
houser says. “The supplement industry is
very powerful. The advertising is powerful.
There are more supplements for sale than
types of foods. They’re a very prolific indus-
try and marketing works. And cancer is a
very scary diagnosis, as we all know, so it’s
easy for patients to want to do everything
they can to improve their outcomes. But
what they may not realize is that not only is
this a very expensive way to do it but it may
not be effective and it may cause harm.”
When Are Supplements Needed?
Some dietary supplements may be
beneficial during cancer treatment.
For example, some cancer treatments
can lead to calcium loss or otherwise
contribute to bone loss, so doctors may
prescribe supplemental calcium and
vitamin D.21 Some patients may find it
difficult to meet their nutrient needs
from food—this includes patients who
have trouble eating due to nausea or lack
of appetite, or difficulty swallowing due
to radiation around the mouth or neck,
as well as those who have absorption
difficulties due to the surgical removal of
part of their stomach or intestines, and
those who follow a strict vegan diet and
may be deficient in vitamin B12 .23
Neuhouser says the patient’s nutri-
tional status when they enter cancer treat-
ment is a key consideration. “An elderly
person may already have low oral intake,
possibly due to poor dentition or low appe-
tite. They may be a little underweight,
then add chemo and/or radiation on top
of that. Or maybe they come into cancer
treatment with a preexisting condition
that may make it difficult to manage both
conditions simultaneously. I think hav-
ing a comprehensive nutrition assessment
when someone starts treatment is impor-
tant, so the type of nutrition plan that’s
recommended may be tailored.”
Marian says that if someone’s going
through treatment and they’re not
eating well and possibly losing weight, a
multivitamin may help them. “Maybe they
tolerate the treatment better. Maybe their
white blood cell count comes up faster.
Those things are hard to measure as far
as outcomes, but maybe they’re worth
thinking about.”
Neuhouser says there’s nothing
to contraindicate a multivitamin or
multivitamin with minerals, especially
during treatment when oral intake may
be impaired. In fact, observational data
from colorectal and breast cancer cohorts
in which 50% to 72% of patients were
self-prescribing multivitamins showed
neither beneficial nor harmful effects of
these supplements on toxicity or survival.6
“A multi will have antioxidants in the
appropriate amounts,” Neuhouser says.
“Formulations that combine herbs with
vitamins or minerals … those are the ones
where we don’t have the data to confirm
benefits or harms.”
How to Counsel Patients
Marian says she always asks about supple-
ments when first meeting with a patient.
“I kind of just roll in the supplements right
after asking about the medication so it’s not
a judgmental kind of thing. I’m just eliciting
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
information from them,” she says. “I think
sometimes they just feel better taking their
supplements. I ask, ‘How would you feel if I
recommend that you don’t take all of these?
Are you going to be at loss because you feel
like it’s providing you some benefit?’ I think
it’s really important to establish what’s the
bond with the supplement use when you’re
counseling people.”
Neuhouser suggests dietitians ask
patients to bring in their supplements, so
they can do a thorough assessment. “Ask
if any supplement use has changed since
they started treatment. Ask them, ‘Why
are you taking these?’ and ‘What do you
hope to get from them?’ Do some addi-
tional probing to find out what the moti-
vation is to take additional supplement
during treatment,” she says. “Dietitians
can also try to point out to patients how
much they’re spending on these supple-
ments and what else they could spend that
money on. Maybe they are finding it hard
to cook and they could use that money to
get meals delivered.”
Marian says, “Let’s say a head and
neck cancer patient is taking high
doses of vitamin C and says, ‘Oh, well,
my oncologist didn’t say there was a
problem with that.’ I’ll explain to them
what the potential problem is, but I’ll
also say, ‘Well, I would just go back and
ask your oncologist again,’ because you
know I want them to feel comfortable
in the information that their oncologist
is giving them. And if the radiation
oncologist, who knows more about the
radiation side of things, really feels like
vitamin C isn’t going to be a problem,
then who am I to say that it’s going to
be? But the oncologist isn’t going to do a
diet history and say, ‘Let’s see how much
vitamin C you’re getting from other
things.’ It’s just complicated. You have
to be up to date on the literature and
look at the whole picture and know what
potential micronutrient deficiencies can
arise and what potential complications
are of having too much or too little of
something and kind of balance your
suggestions on that.” I
Carrie Dennett, MPH, RDN, is the nutrition
columnist for The Seattle Times, owner of
Nutrition By Carrie, and author of Healthy
for Your Life: A Non-Diet Approach to
Optimal Well-being.
For references, view this article on our
website at www.TodaysDietitian.com.
37
 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
the newest celebrity in dietetics.
Nutrition professionals and the
greater medical community at large
are excited about this technology
and are learning more about it every
day. However, it may take some time before clinicians in
various specialties can harness all it has to offer to fully
integrate it into daily practice and make a considerable
impact on patient care.
IBM says AI “leverages computers and and surgery to help physicians diagnose
machines to mimic the problem-solving diseases and identify tumors through
and decision-making capabilities of the new algorithms, thereby leading to less
human mind.”1 In other words, AI learns invasive surgery through the da Vinci
from the experts and makes an educated surgical AI system.2
guess on an outcome.1 To date, no AI research has been
AI research in the health care field done in the field of MNT. However,
has shown that technology and humans there have been some studies con-
can work together to diagnose, treat, and ducted over the past couple of years
educate those who have heart failure, on AI applications for heart failure,
diabetes, renal disease, disordered eating diabetes, and chronic kidney disease
patterns and eating disorders, and over- (CKD) in inpatient and outpatient set-
weight or obesity. Current AI research tings that may help prepare RDs for the
has been applied in radiology, pathology, future of AI in dietetics.
AI in Inpatient Settings
How RDs Can Integrate AI in MNT
According to the Agency for Healthcare
Research and Quality, some of the most
common conditions responsible for hospi-
tal admissions in 2018 were heart failure,
diabetes with complications, and acute
and unspecified renal failure.3 These are
some of the more common diseases RDs
treat in inpatient settings. During their
initial assessments of such patients, RDs
have to access anthropometric data.
Research suggests dietitians may be able
to obtain this information easier than
they do currently through a subset of AI
called machine learning (ML).
Heart Failure
ML uses algorithms to analyze large
amounts of data, learn from the insights,
and make informed decisions. It imitates
the way humans learn, gradually improv-
ing over time.4-6 This subset of AI can be
important in relation to heart failure since
research is showing that “ML methods
can handle temporal, large-volume, and
multimodality data (eg, sound, language,
tabular EHR, imaging, and metabo-
lomic data).”5 This type of data can be
used to understand a diagnosis and then

OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM 39


personalize treatment options for patients
with heart failure in inpatient settings.
In the past, AI had been used for select-
ing patients who may respond to cardiac
resynchronization therapy and collecting
continuous data through implanted sen-
sors.5,7 However, new research is showing
that AI can benefit those with heart failure
in other ways by including other health
professionals, such as RDs who are part of
a health care team in an inpatient setting.
Although there hasn’t been much
research showing how RDs can use ML
or how ML can make their jobs easier in
inpatient settings, Averbuch and colleagues
stated that in relation to heart failure, “ML
algorithms can be used to provide recom-
mendations to clinicians regarding optimal
sequencing and dosing of evidence-based
therapies.”6 Even though the researchers
didn’t specify the care RDs provide through
MNT, future research can focus on how
these algorithms may be able to generate
nutrition recommendations specific for
patients with heart failure in inpatient set-
tings. For example, in the future, research-
ers can conduct studies that implement ML
algorithms to generate personalized MNT
recommendations for patients with heart
failure. From there, researchers can test
whether the algorithms produced an accu-
rate result and if these algorithms, in turn,
can work as an additional resource for RDs.
Diabetes
In addition to heart failure, research-
ers are focusing on AI applications for
patients with diabetes in inpatient set-
tings. One AI technique used extensively
in diabetes care is case-based reasoning
(CBR), an experience-based approach
to solving new problems. According to
a study by Ellahham, the goal of CBR is
to develop better solutions for manag-
ing diabetes based on data from past
experiences. For example, the 4 Diabetes
Support System, an example of CBR used
in diabetes care, can “automatically
detect problems in control of blood glu-
cose, propose solutions to the detected
problems, and remember the effective
and ineffective solutions for individual
patients.” CBR also has been used to
optimize and personalize insulin ther-
apy for a wide range of meal situations.8
Researchers also are studying AI-based
clinical decision support (CDS) tools to
improve diabetes management. These
tools, with the use of ML, can make short-
and long-term predictions about HbA1c
after patients start insulin therapy and
40 TODAY’S DIETITIAN • OCTOBER 2023
To date, no AI research has been done
can “help identify in the field of MNT. However, there have
clinical variables been some studies conducted over the
that can influ-
ence a patient’s past couple of years on AI applications
HbA1c response.”8
Although CBR and
for heart failure, diabetes, and chronic
CDS tools may be kidney disease in inpatient and outpatient
able to improve
how efficiently RDs
settings hat may help prepare RDs for the
assess patients with future of AI in dietetics.
diabetes, there isn’t
enough evidence
currently to deter-
mine whether both of these systems can AI, the “results of CT perfusion imaging
produce accurate and consistent results [became] more conclusive to analysis
or whether they may replace RDs. How- and comparison.”10 Because of AI, the
ever, CBR and CDS tools may be used as a researchers could evaluate participants’
resource in MNT for patients with diabe- renal status throughout the study and
tes in inpatient settings. RDs can use CBR determine that the H2H program can be
to help personalize meal plans for patients used to monitor patients who have CKD.10
with diabetes, while CDS tools can pro-
vide the data needed to track patients’ AI in Outpatient Settings
HbA1c. This will enable RDs to educate
patients on managing their diabetes and How RDs Can Integrate AI in MNT
preventing future hospitalizations.8 Just as some patients visit with RDs in the
hospital, others may see them in outpatient
Chronic Kidney Disease settings. According to Sarah Klemm, RDN,
Dietitians also have to monitor patients CD, LDN, manager of nutrition information
with renal failure so patients can avoid services for the Academy of Nutrition and
hospitalizations. Individuals with renal Dietetics in Chicago, some of the more com-
failure also may be on dialysis and at risk mon reasons patients see RDs in the outpa-
of comorbidities such as CVD, dyslipid- tient setting include diabetes management,
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
colleagues showed that AI can be used to isn’t enough research to determine whether
confirm the efficacy of an at-home renal or not AI will replace RDs in outpatient
care program, which might be a step settings, there’s been some evidence show-
toward integrating AI in MNT. ing that AI presented through mobile apps
The purpose of the study was to evalu- and algorithms may encourage patients to
ate a hospital-to-home (H2H) program reach their nutrition goals more effectively
involving 120 participants with stage than before. This research has been preva-
3 to 5 CKD. They were admitted to a lent in diabetes management.
Chinese hospital from March 2019 to According to a study by Ellahham,
March 2021.10 Half of the participants mobile apps that use AI technology
were placed in the experimental group enable people with diabetes to take better
that incorporated the internet-based control of their condition through self-
H2H program.10 The group had access to management.8 For example, the One
online resources from an RD, such as rec- Drop Mobile app that was tested on 1,288
ipes and nutrition education handouts.10 participants with diabetes over four
The remaining half of the participants months reminded them to take their
were in the control group and didn’t have medication, set goals, and view data
access to the H2H program.10 about their health.8 After the intervention,
Despite the differences between the Ellahham reported that there was “a 1.07%
two groups, all of the participants had to 1.27% absolute reduction in HbA1c
their renal status monitored with the use during a median four months of using the
of AI. Everyone had CT images done on app.”8 Furthermore, another intervention
their kidneys before and after the study.10 program called FareWell, which was
At first, the CT images weren’t clear; accessible through a mobile app, was tested
however, once the wavelength trans- on 118 adults with diabetes who had an
form denoising algorithm was incorpo- HbA1c greater than 6.5% for 12 weeks.8 The
rated into the imaging system through goal of this program through the app was to
encourage participants to consider a plant-
based diet and regular exercise.8 At the end
of the study, 28% of participants had an
HbA1c lower than 6.5%, and more than 86%
continued to use the app after the study.8
In addition to mobile apps, research-
ers are testing algorithms to determine
whether they may benefit patients with
diabetes in outpatient settings. Joshua
and colleagues examined the Smart Plate
Health to Eat, a technological innova-
tion that enables patients with diabetes
to determine the type of food, weight, and
nutrients contained in the foods they eat
to help them meet their nutrition goals.
The study included 50 types of food with
a total of 30,800 foods using the YOLOv5s
algorithm that identified, analyzed nutri-
ent values, and estimated the weight of
the foods studied.12 Researchers found
that the YOLOv5s algorithm “showed good
identification accuracy in the analysis of
four types of food, including rice, braised
quail eggs in soy sauce, spicy beef soup,
and dried radish, with accuracy for weight
and nutrition.”12 Although researchers are
still testing food and nutrient identifica-
tion algorithms like YOLOv5s, there may
be a future for them for people with diabe-
tes in outpatient settings.12 In the future,
RDs may be able to recommend programs
with these algorithms to their patients so
they can have an additional resource as
they keep their nutrition goals on track.
Mobile apps and algorithms also can
help individuals who have disordered
eating patterns and eating disorders.
Braun-Trocchio and colleagues stud-
ied the HALO app used to generate a
body composition scan on 98 partici-
pants.13 The goal of the study was to bet-
ter understand body image issues and
compare the results with the partici-
pants’ perceived body, ideal body, and a
body their partner would find attractive
through a visual analog scale.13 After
participants used the app and completed
a questionnaire related to their body
image, the researchers could determine
there was a mean difference between
the app and the participants’ perspec-
tives about body image.13 Although more
research is needed to establish whether
mobile apps, such as the HALO app,
will be applicable to RDs in outpatient
settings, there’s a possibility that dieti-
tians could still screen patients at risk
of disordered eating patterns and eat-
ing disorders, which could alert them to
intervene and make personalized recom-
mendations and referrals.
Nevertheless, there are other AI
tools RDs can use to help patients with
disordered eating patterns and eating
disorders. Petrauskas and colleagues
examined a CDS system (CDSS) to
predict the risk of eating disorders
in 83 participants with dementia.14
The CDSS was 90.36% accurate for
predicting eating disorders, leading
researchers to conclude that “compared
to the resident geriatricians, the CDSS is
more accurate in diagnosing … eating
disorders in dementia.”14 While more
research will confirm whether CDSS can
run independently to assess risk factors
for eating disorders, this AI tool may be
implemented in MNT in the future. RDs
who work in outpatient settings may be able
to use CDSS after a nutrition assessment to
quickly determine whether a client is at risk
of an eating disorder. From there, dietitians
can make additional referrals to provide
patients with the care they need.
But while the use of AI tools to provide
MNT looks promising for clients with
diabetes, disordered eating patterns, and
eating disorders, there isn’t enough evi-
dence to determine whether they can be
used to monitor weight management or
weight loss goals.
For example, Oh and colleagues
reviewed nine studies to investigate
whether Chatbot (voice-activated applica-
tions like Amazon’s Alexa or Apple’s Siri)
had an impact on changing health behav-
iors such as physical activity, healthful
eating, and weight management.15 The
research team found there were no defini-
tive conclusions on whether Chatbot could
affect weight management behaviors.15
Moreover, Chew and colleagues
reviewed 66 studies to determine whether
AI could be used to help participants lose
weight.16 The studies were separated into
three categories based on what type of AI
application was used in each study.16 Most
studies used machine perception, which
focused on using AI to recognize foods
and behaviors.16 Other studies used AI to
predict health behaviors, such as weight
loss and emotional eating, or collect per-
sonalized data to provide feedback to a
participant.16 However, after analyzing
the efficacy of the AI applications used in
the studies, Chew and colleagues said that
“Only six studies reported average weight
losses (2.4 to 4.7%), of which two were sta-
tistically significant.”16
Despite these findings that there isn’t
enough research yet to use AI applica-
tions to establish weight management
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
and weight loss goals, RDs can do their
part by learning more about AI in the
health care field to understand how it
may impact MNT in the future.
What the Future Holds
Like any up-and-coming innovative
technology, AI is making great inroads
in the medical field overall and trying to
find its place in dietetics. And while
currently, there haven’t been many
studies demonstrating how dietitians
can implement AI in MNT, research
suggests the possibilities.
For example, future research may
examine how AI can generate assess-
ment plans, PES statements, and per-
sonalized goals based on clients’ data. In
addition, as more studies emerge, there
will be more opportunities for RDs to join
research teams to study and understand
the impact of AI in MNT. When Chen and
colleagues added an RD to their research
team, they could provide nutrition edu-
cation materials to participants in their
experimental group and therefore now
understand how MNT and AI can work
together to improve health outcomes.10
More research will determine how AI
may change the workflow for RDs or have
the potential to replace them in the future.
However, as dietitians wait for more AI
research to surface, they can learn more
about the technology in the health care
field through peer-reviewed literature
and zero in on studies that include RDs
on the research team so they can educate
patients on new AI applications and help
them reach their health goals in new and
innovative ways.
AI has been and will continue to be a hot
topic among health care professionals, and
this trend will keep growing as research-
ers learn more about the efficiency of AI in
assessing and monitoring patients. I
Sophia Condic, MS, RDN, is a Michigan-
based dietitian who’s currently working in
a community clinic. She earned a Bachelor
of Integrative Studies at Oakland University
and completed the Coordinated Program in
Dietetics and a Master of Science in Clinical
Dietetics at Grand Valley State University.
She has previously written for Today’s
Dietitian and for the Dietitians in Business and
Communications Practice Group through the
Academy of Nutrition and Dietetics.
For references, view this article on our
website at www.TodaysDietitian.com.
41
Lifestyle Medicine’s
F
rom well-respected medical organizations to health
and wellness influencers, many seem to tout the
benefits of lifestyle medicine. However, the concept of
using lifestyle as medicine is nothing new. In fact, it
may just be the future of health care.
The use of lifestyle interventions to to lifestyle pillars such as strong social
maintain or regain health dates back as connections and daily physical activity.2
far as Hippocrates 2,500 years ago.1 Cul- And, of course, dietitians have long been
tures around the world have long relied championing the therapeutic benefits of
on lifestyle to stay healthy and ward off food, another lifestyle pillar.
disease. Pockets of the world with the Although lifestyle medicine may seem
highest concentrations of centenar- like the newest fad, its long history and
ians, called Blue Zones, credit longevity the strong science supporting it ensure
it’s much more a rising tide than a fleet-
ing trend. Lifestyle medicine is here to
stay, and dietitians have a crucial role
to play in practicing this modality to
address the nation’s top chronic diseases.
What Is Lifestyle Medicine?
According to the American College of
Lifestyle Medicine (ACLM), lifestyle
medicine is “a medical specialty that
uses therapeutic lifestyle interventions
as a primary modality to treat chronic
conditions, including but not limited to
CVDs, type 2 diabetes, and obesity.”3
Health care providers trained in
lifestyle medicine use evidence-based,
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-
ative sleep, stress management, social
connection, and avoidance of risky
substances to address disease. The use
of these modalities, known as the six
pillars of lifestyle medicine, prevent and
treat many of the nation’s most devastat-
ing chronic diseases and is backed by a
wealth of scientific evidence.
Although some overlap exists
between lifestyle medicine and other
fields like integrative medicine or pre-
ventative medicine, lifestyle medicine is
unique. In lifestyle medicine, evidence-
based lifestyle changes are prescribed
as first line treatment for disease. Other
evidence-based interventions, such as
medications or procedures, also can
be used, but only as supplementary
to lifestyle change. Lifestyle medicine
certainly can be used for disease pre-
vention, but the focus is primarily on
treatment, reducing disease severity,
and sometimes the reversal of existing
disease. Lifestyle medicine goes beyond
just helping the healthy get healthier. It
aims to significantly improve disease
markers and quality of life for patients
who need it most.
Is Lifestyle Medicine Worth Its
Weight in Gold?
For starters, lifestyle factors such as
tobacco and alcohol use, poor diet, and
physical inactivity are considered the
leading causes of mortality in the United
States.4 Lifestyle medicine is designed
to address these destructive lifestyle
factors. Studies of intensive therapeu-
tic lifestyle change programs, such as
the Pritikin program and the Ornish
program, in which participants make
significant changes to their lifestyles,
have shown impressive improvements in
markers of diabetes and coronary heart
disease.5-7 Many large epidemiologic
studies also shine light on how lifestyle
behaviors impact health. The Nurses’
Health Study concluded that by adopt-
ing a set of healthful lifestyle behaviors,
more than 80% of heart disease and

OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM 43


more than 91% of diabetes could be elimi-
nated in women.8 The ability of dietary
changes to improve cardiovascular and
type 2 diabetes outcomes as well as cancer
risk reduction also are well documented.9
Along with convincing evidence, life-
style medicine is well positioned to help
achieve what’s known as the Quadruple
Aim in health care: “To enhance patient
experience, improve population health,
reduce costs, and improve the work life
of health care providers.”1 It also restores
career passion for many providers. In
the age of health care burnout, this is an
important bonus of lifestyle medicine.
Who’s Leading the Charge?
At the forefront of the lifestyle medicine
wave is the ACLM, a medical society that
provides quality education and resources
to health care professionals committed
to the practice of lifestyle medicine. With
lifestyle medicine education sorely lack-
ing in pre- and postprofessional training
for most health care providers, the ACLM
offers these crucial learning opportunities
for providers through continuing educa-
tion courses, conferences, and lifestyle
medicine board certification.
1
Nutrition
Every dietitian knows that food
influences health, and the field
of lifestyle medicine agrees that
it’s one of the most important pillars.
Based on scientific evidence, the
ACLM has defined a recommended diet
in their dietary position statement: “For
the treatment, reversal, and prevention
of lifestyle-related chronic disease, the
ACLM recommends an eating plan based
predominantly on a variety of minimally
processed vegetables, fruits, whole grains,
legumes, nuts, and seeds.”3 This dietary
approach centered on whole plant foods
has been shown to support disease pre-
vention, treatment, and risk reduction,
which is the aim of lifestyle medicine.9
If using this dietary approach within
the context of lifestyle medicine is new
to you, in collaboration with the recent
White House Conference on Hunger,
Nutrition and Health, the ACLM now
offers the Lifestyle Medicine & Food as
Medicine Essentials course bundle.10
Paulina Shetty, MS, RDN, CPT, DipACLM, move more throughout the week and sup-
senior director of education at ACLM, porting them in working through their
describes the bundle as “an introduction barriers to exercise also is critical.
to the field of lifestyle medicine and nutri-

While it started as a physician-only
organization, the ACLM now serves a
global community of professionals across
the spectrum of health care, including
dietitians, researchers, and health care
executives. The ACLM recognizes dieti-
tians as a key part of successful lifestyle
medicine outcomes. The medical society
tion for prevention, longevity, treatment,
and risk reduction that’s 5.5 hours of CE.”
The ACLM also offers an array of nutrition
education resources for use with patients,
including a Whole Food Plant-Based Plate,
a Food as Medicine Jumpstart Guide, and
a Culinary Medicine Curriculum.
3
Stress Management
According to a 2020 report
issued by the American
Psychological Association, the
United States is experiencing a stress-
related mental health epidemic that
seeps into all areas of health.14 Stress has
been linked to coronary artery disease,

also sees community and public health
entities as critical pieces of the life-
style medicine puzzle. Because of this, it
engages in advocacy initiatives to help
move toward lifestyle medicine as the
foundation of all health care. In the world
of lifestyle medicine, the ACLM is at its
core providing innovative resources, con-
necting like-minded stakeholders, and
transforming health care.
The Six Pillars
The ACLM identifies six areas of life-
style that can be used therapeutically
to improve health outcomes: nutri-
tion, physical activity, restorative sleep,
stress management, social connection,
and avoidance of risky substances. By
incorporating five of the pillars along-
side nutrition, dietitians can employ the
whole-person approach of lifestyle medi-
cine with their clients.
2
Physical Activity
Physical activity earns its
place as one of the six pillars
of lifestyle medicine, as it
positively impacts seven of the 10
most common chronic diseases.11 Plus,
discussing this important pillar with
clients and patients pays off. One study
found that promoting physical activity
in a primary care setting significantly
increased the activity level of patients
for up to one year.12
Even if dietitians aren’t trained in exer-
cise physiology or a related field, sharing
the Department of Health and Human
Services’ Physical Activity Guidelines with
clients can go a long way. The guidelines
recommend at least 150 minutes per week
of moderate-intensity activity and two
or more strength training sessions that
incorporate all major muscle groups.13
Helping clients discover simple ways to
heart failure, rheumatoid arthritis, and
various mental illnesses like anxiety.15
For any dietitian who’s helped clients
navigate stressors to improve their
relationship with food or nutrition
status, this is no surprise.
It’s important to note that not all stress
is bad. Moderate stress tends to improve
performance. It’s when stress reaches high
levels and becomes chronic that a person’s
health is negatively impacted. Along with
screening and referrals for more advanced
mental health conditions, lifestyle medi-
cine employs many different stress manage-
ment techniques to target chronic stress and
improve health outcomes. The list of tech-
niques includes spending time in nature,
meditation, and mindfulness as well as other
lifestyle medicine pillars like improved sleep,
exercise, and nutrition.15 Since all of the pil-
lars of lifestyle medicine are interconnected,
improving one can help improve others.

44 TODAY’S DIETITIAN • OCTOBER 2023


4
Restorative Sleep
Poor sleep is connected to
higher rates of chronic disease,
morbidity, and mortality.16
Lifestyle medicine also emphasizes that
without adequate sleep, it’s much more
difficult for people to build momentum
with other lifestyle medicine pillars
such as good nutrition or consistent
exercise. Although the amount of
sleep needed varies slightly from person
to person, eight hours still stands as
the best average recommendation for
most adults.16
Upgrading clients’ sleep quality usually
requires a deep dive into the other lifestyle
medicine pillars, taking a critical look at
eating habits, caffeine intake, physical
activity, substance use, and stress levels.
Improving these pillars greatly supports
better sleep. Sleep hygiene strategies such
as reducing screen time and setting up
a bedroom environment that promotes
sleep also are emphasized in lifestyle
medicine. In addition, working with a
physician to address sleep issues like sleep
apnea is key.
5
Social Connection
Perhaps the most unexpected
pillar of lifestyle medicine is
positive social connection,
keeping in mind that the COVID-19
pandemic brought isolation and
loneliness to the forefront of health.
A 2020 report from the National
Academies of Sciences, Engineering,
and Medicine states that loneliness
and isolation are associated with
higher incidence of premature
mortality.17 Conversely, positive social
connection has been associated with
better health outcomes.18
When it comes to social connection,
screening and referrals are key. Once
at-risk patients are identified, lifestyle
medicine providers can help connect
them to social support resources in their
communities. True to the interdependent
nature of lifestyle medicine, tending to
social connection has the power to help
bolster all other areas of lifestyle for
clients and patients.
6
Avoidance of Risky
Substances
The final pillar of lifestyle
medicine addresses the use of
tobacco, alcohol, and recreational drugs.
Along with the direct health effects of
these substances, there are indirect
effects on food choices, sleep, and stress
management. The lifestyle medicine
approach calls for identifying patients
who use these substances and referring
them to evidence-based resources
for cessation or supporting them in
balanced use.19
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
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
medicine focus on therapeutically
dosed nutrition for remission but it also
includes well-rounded education on the
other pillars.”
Educational offerings include the pre-
viously mentioned Lifestyle Medicine
& Food as Medicine Essentials course
bundle and the Foundations of Lifestyle
Medicine Board Review, a self-paced
30-hour CE course to prepare those seek-
ing lifestyle medicine certification. Dieti-
tians also can attend the ACLM’s annual
conference in the fall.
Get Certified
If RDs want to take their lifestyle medicine
expertise to the next level, they can get
board certified in lifestyle medicine. Alex-
andra Regalado, RDN, DipACLM, certified
health and well-being coach, clinical out-
patient dietitian at Stanford Health Care,
and secretary of the ACLM Registered
Dietitian Member Interest Group, has
experienced the benefit of certification
firsthand. “Certification has enhanced my
ability to provide patient-centered care
and given me the opportunity to connect
with like-minded professionals commit-
ted to preventing, treating, and reversing
chronic conditions.”
Alison Ozgur, MAT, MHS, RDN, DipA-
CLM, the director of wellness programs
for the Center of Nutrition Studies, agrees.
“I have worked as a registered dietitian for
45

22 years, and while I believe that nutri-
tion is the foundation of wellness and
disease prevention, we cannot overlook
the other lifestyle pieces that must be
practiced in order to achieve optimal
health.” For that reason, Ozgur chose
to obtain lifestyle medicine board cer-
tification. “It was essential for me to
strengthen my knowledge and expertise
in the other pillars of lifestyle medicine.
As a result, my clients and workshop
participants achieve better results with
their health goals.”
Partner With Other Lifestyle
Medicine Providers
The practice of lifestyle medicine is
meant to be interdisciplinary, and dieti-
tians are considered an invaluable part
of the lifestyle medicine health care
team. Dietitians can join forces with
physicians, health systems, or private
practices interested in implementing the
lifestyle medicine model of care.
Sherry Valente, MA, RD, LDN,
CDCES, DipACLM, is product manager
of nutrition and lifestyle medicine
at Premise Health in Brentwood,
Tennessee, a leading direct health
care provider that employs more than
50 dietitians. With dietitians as a key
part of their health care teams, Valente
says, “Many health care employers are
moving toward a lifestyle medicine
46 TODAY’S DIETITIAN • OCTOBER 2023
approach to care, aiming to treat the
root cause of disease and improve
overall health outcomes. Lifestyle
medicine–certified registered dietitians
understand that chronic diseases can
be prevented, managed, and perhaps
even reversed by utilizing a lifestyle
medicine approach. This type of
approach, enhanced by the use of health
behavior change coaching skills, can
decrease health care spending for both
employers and patients, improve overall
health outcomes, and help activate
patient autonomy and motivation for
sustainable, lifelong behavior change.”
Lilian Correa, MA, MPH, RDN,
DipACLM, a dietitian at Bellevue
Hospital lifestyle medicine program in
New York City, also knows the power of
the lifestyle medicine team approach.
NYC Health + Hospitals recently
expanded Bellevue’s innovative program
across New York City, and Correa serves
as director of education and training for
the expansion. “In our team approach,
for example, what’s great is that the
physician helps to identify nutrition-
related issues to address by taking a
detailed food history during the initial
visit. This history, which is part of the
physician’s initial assessment in all six
pillars of lifestyle medicine, gives the
RDN a great blueprint from which to
work. I can begin to see the connections
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
can “help patients make the connections
between how the other pillars can deeply
affect eating patterns, relationship with
food, and management of chronic con-
ditions,” adding that the relationship
between exercise and blood glucose con-
trol and the relationship between eating
patterns and sleep are two examples.
Get Involved With the ACLM
The ACLM is the hub of lifestyle medi-
cine, so becoming a member is an impor-
tant first step in becoming a lifestyle
medicine expert. The organization has
much to offer dietitians, including a Reg-
istered Dietitian Member Interest Group;
working groups organized by specialties,
including culinary medicine and wom-
en’s health; patient-facing resources;
an annual conference; and countless
networking opportunities. Joining the
ACLM plugs you into the epicenter of
lifestyle medicine. I
Kayli Anderson, MS, RDN, DipACLM,
ACSM-EP, is founder of the women’s
health website Plant-based Mavens
(plantbasedmavens.com) and lead faculty
of the American College of Lifestyle
Medicine’s Food as Medicine course.
For references, view this article on our
website at www.TodaysDietitian.com.
 10 TH ANNUAL SPR
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CPE Monthly By Denine Rogers, MS, RDN, LD, FAND
Nutrition and Skin Health
Discovering the Connection and Evidence-Based
Treatment Options for Patients
C
lients often seek dietary advice
from dermatologists, not dieti-
tians, even though they fre-
quently associate their skin
diseases with the foods they eat. Dieti-
tians know that nutrition has been shown
to help alleviate certain skin disorders,
but for decades other health care profes-
sionals have presumed that many com-
mon skin disorders are unrelated to diet.
However, recent studies show significant
evidence that diet and nutrition can affect
some dermatological conditions.
Skin diseases are prevalent among
Americans—and costly. The Academy of
Dermatology states that skin disorders
will affect 84.5 million Americans or
one in four.1 Skin conditions cost the
United States health care system $75
billion in medical and preventative
care, including prescription and
nonprescription drug costs.1
This continuing education course
reviews the relationship between nutri-
tion and skin health based on current
research, discusses skin conditions for
which nutrition traditionally has been
an unrecognized treatment option, and
focuses on how the expertise of dietitians
and dermatologists are both needed for
proper treatment.
48 TODAY’S DIETITIAN • OCTOBER 2023
The Diet and Dermatology Link
The effects diet has on skin health can
be positive or negative, mainly due to the
nutrients (or lack of nutrients) in food.
Skin is complex and specialized, and
serves multiple functions. It’s the largest
organ of the body, weighing in at 8 lbs (3.6
kg) and spanning 22 square feet (2 square
meters) for adults.2 Skin provides a bar-
rier function to prevent internal water
loss and protects the body from external
environmental agents, including infec-
tious organisms, chemicals, radiation,
noise, and diet.3
There are three crucial skin layers: the
epidermis, dermis, and hypodermis.2 The
epidermis, the outermost layer, serves as a
waterproof barrier and creates skin tone.
The dermis beneath the epidermis con-
tains tough connective tissue, hair fol-
licles, and sweat glands. This layer of skin
transports blood and fights infections.
The hypodermis is the subcutaneous fat
and deepest layer of skin. This layer of
fatty tissue helps insulate the body from
heat and cold and protects the body from
injuries. It also provides padding to cush-
ion internal organs, muscles, and bones.2
It’s vital that all of the skin’s functions,
along with the development and replace-
ment of these tissues, receive adequate
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
which dietary changes may be advised as
one component of treatment.
Acne Vulgaris
Acne vulgaris is a chronic inflammatory
skin disorder among teenagers, young
adults, and some older adults that occurs
when hair follicles get plugged with sebum
and dead skin cells. Acne is more com-
mon in developed countries than in less
industrialized regions. And in some popu-
lations, acne development is associated
with the adoption of a Western diet.4
COURSE CREDIT: 2 CPEUs
Learning Objectives
After completing this continuing
education course, nutrition
professionals should be better able to:
1. Distinguish the foods, dietary patterns,
and lifestyles that can positively and
negatively affect skin health.
2. Examine nutrition’s effect on skin
disorders such as eczema, acne,
psoriasis, and rosacea.
3. Counsel clients on how to implement
nutrition and lifestyle changes that help
manage skin diseases.
4. Demonstrate how dietitians and
dermatologists can work together to
improve their clients’ skin health.
CPE Level 2
 The factors that contribute to the
formation of acne include the following:
• genetic predispositions;
• hormonal abnormalities (eg,
androgens);
• immunological disorders; and
• psychological, environmental, and
iatrogenic factors.5
Trigger Foods Associated
With Acne
Researchers have hypothesized that diet
may play a part in the pathogenesis of
acne vulgaris, and some food products
may be a trigger.5
High-Glycemic Load Diet
A high-glycemic load diet consists of high-
carbohydrate foods such as refined sug-
ars, grains, milk, and dairy products. This
diet can raise blood glucose levels, cause
the body to produce more insulin, and
stimulate sebum production and seba-
ceous cell proliferation.6
Dairy Products
Dairy remains a prominent dietary compo-
nent for most Western societies. The first
studies on the association between dairy
and acne were conducted in the 1940s. Two
prospective historical studies were done in
2004 and 2008 that showed a positive cor-
relation between acne and milk consump-
tion, which may be due to the presence of
hormones and bioactive molecules, as well
as milk’s effect through the insulinlike
growth factor pathway. Dairy intake may
aggravate acne on several levels through
these pathways, including increased oil
production, inflammation, and abnormal
hormonal activity.7,8
A meta-analysis of 14 observational
studies evaluated the relationship
between milk and dairy products and acne
development. This meta-analysis found
a positive relationship between dairy,
whole milk, whole fat, low-fat, and skim
milk consumption and acne. There was no
significant relationship between yogurt
and cheese and acne development. Results
of the present meta-analysis recommend
consuming yogurt or cheese to avoid
acne creation. Further investigations are
needed, especially randomized controlled
trials, to confirm the effect of milk and
dairy products on acne development.9
Beneficial Interventions for Acne
Other studies suggest that certain dietary
interventions and micronutrient supple-
mentation may have a positive effect on
acne treatment.
Low-Glycemic Load Diet
In one study, 32 participants with mild-
to-moderate acne were randomized
to either a low-glycemic load diet or a
high-glycemic load diet for 10 weeks.10
Those on a low-glycemic load diet
demonstrated significant reductions in
noninflammatory and inflammatory
lesion counts, more minor sebaceous
glands, decreased inflammation, and
reduced acne severity grading.10
Although more studies are necessary
to understand the underlying pathways
of acne, incorporating low-glycemic foods
may help reduce the number of visible
lesions. Additional research studies are
required with larger sample sizes combin-
ing a low-glycemic load diet and restricted
intake of cow’s milk products.11
Zinc
According to a systematic review and
meta-analysis of 25 small, low-quality
clinical trials that included 2,445 partici-
pants, patients with acne have decreased
serum zinc levels compared with controls,
suggesting that taking 137 to 300 mg of
zinc sulfate or zinc gluconate twice daily
by mouth can modestly improve acne
compared with placebo. Participants who
were treated with zinc had a significant
improvement compared with those who
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OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
weren’t treated with zinc, suggesting that
zinc is effective for treating acne, par-
ticularly when used as monotherapy or
adjunctive treatment.12
However, not all individual trials show
beneficial results. In one large open-label
clinical trial, 100 patients were equally
randomized to receive zinc sulfate or
lymecycline (tetracycline acne medica-
tion). Patients took 200 mg of zinc sulfate
twice daily for 12 weeks, which was at
least as effective as 300 mg lymecycline
daily to reduce acne severity. Results
showed that patients who received the
zinc sulfate experienced modest improve-
ments in their quality of life.13
Niacinamide
Niacinamide, also known as nicotin-
amide, is one form of vitamin B3 and the
amide derivative of niacin. Oral niacina-
mide has been studied in combination
with other ingredients for the treatment
of acne. In preliminary clinical research,
oral niacinamide was reported to improve
acne when used in combination with
zinc, copper, and folic acid (marketed
as Nicomide [Nic/Zn]). In an open-label,
multicenter, prospective cohort study,
198 patients with acne vulgaris received
750 mg nicotinamide, 25 mg zinc, 1.5 mg
copper, and 500 mcg folic acid. By week
four, a relatively short treatment period,
79% of patients reported their improve-
ment in appearance as much better com-
pared with those who stated there was no
change in their condition.14
In a multicenter, open-label, eight-
week prospective study, dermatologists
enrolled 235 post adolescent women with
inflammatory acne vulgaris. Research-
ers evaluated the efficacy of adding one
to four tablets of NicAzel (nicotinamide,
azelaic acid, zinc, pyridoxine, copper, and
folic acid) daily to patients’ current acne
treatment regimen. In eight weeks, 88% of
patients experienced a visible reduction
in inflammatory lesions, and 81% rated
49
CPE Monthly
their appearance as much better than at
baseline. Seventy-six percent of patients
thought NicAzel was at least as effective
as previous treatment with oral antibi-
otics.15 It’s unclear whether the effects
in these studies are due to niacinamide,
other ingredients, or combinations.
Atopic Dermatitis (Eczema)
Affecting more than 9.6 million chil-
dren and about 16.5 million adults in the
United States, atopic dermatitis (AD) is
the most common type of eczema.16 A
chronic condition, it can come and go for
years or throughout life and overlap with
other eczema types. In those with AD, the
immune system becomes dysfunctional
and overactive, causing inflammation
that damages the skin barrier, leaving the
area dry and prone to itching. With darker
skin tones, rashes may become purple,
brown, or grayish; in lighter skin, rashes
may become red.17
Research has shown that some people
with eczema, especially AD, have a genetic
mutation responsible for producing filag-
grin, described by the National Eczema
Association as a protein that helps the
body maintain a healthy, protective bar-
rier on the top layer of the skin. Without
enough filaggrin to build a strong skin
barrier, the moisture from our skin can
escape, and bacteria, viruses, and other
containments can enter. This causes
many people with AD to develop very dry
and infection-prone skin.17
Trigger Foods That Cause AD
Many allergenic foods interact with
and sometimes cause AD. The six
common allergenic foods that may
trigger an AD flare include milk, eggs,
wheat, soy, seafood, and nuts, and they
may do so through the following three
primary processes18:
1. Type 1 or immediate-type hyper-
sensitivity, otherwise known as immuno-
globulin E–mediated allergy, may trigger
a flare within minutes to hours. Dietitians
or allergists can screen individuals for
this allergy through a skin prick or blood
test, but further confirmation requires a
double-blinded, placebo-controlled food
challenge due to a high rate of false posi-
tive results.19
2. Late eczematous reaction, or
AD flare-up, may occur 48 hours after
ingesting these trigger foods. If the
immunological process is unknown, a
50 TODAY’S DIETITIAN • OCTOBER 2023
double-blinded placebo-controlled food
challenge test is required.20
3. A T-cell–mediated reaction, or sys-
temic contact dermatitis, a type of eczema,
is screened via patch testing. The most
common cause of systemic contact derma-
titis is Balsam of Peru, a sticky aromatic
liquid that comes from the bark of the
Myroxolon balsamum tree native to El Sal-
vador. It contains cinnaminic acid, vanillin,
essential oils, and other compounds, and
can be included in perfumes, deodorants,
and cosmetics, as well as tea and coffee,
food flavorings, and other products. Ingest-
ing or coming in contact with products
containing Balsam of Peru can cause an
immune response in the skin, character-
ized by dry itchy skin, and bumps and
blisters.21 Some people allergic to fragrance
additives may experience a cutaneous flare
after ingesting certain foods, such as toma-
toes, citrus, or cinnamon.22
Beneficial Interventions for AD
Despite the complexities of AD, there are
certain food products individuals can con-
sume to treat the condition, but research
shows that two in particular are likely to
be more effective treatment options.
Casein Peptides
In a meta-analysis of clinical trials and
intervention studies, researchers found
a statistically significant 45% reduced
risk of AD among infants aged 0 to 12
months who received 100% whey protein
partially hydrolyzed formula compared
with infants who received intact protein
cow’s milk formula, based on the analysis
of data from each study that most closely
represented the formula intake period. In
most studies, these data were available
before the introduction of solid foods.23
In the prospective German Infant
Nutritional Intervention study, 2,252
children for the first four months of age
were randomly assigned to receive one of
the following four blinded formulas as a
breast milk substitute, if necessary:
• partially hydrolyzed whey formula
(pHF-W);
• extensively hydrolyzed whey formula
(eHF-W);
• extensively hydrolyzed casein formula
(eHF-C); and
• standard cow’s milk formula.
After 10 years of follow up, the results
showed a cumulative incidence of allergic
diseases in high-risk children, particularly
with AD, with pHF-W and eHF-C, which
persisted for 10 years without rebound,
whereas eHF-W showed no significant
risk reduction.24
Clinical research also shows that
eHF-C is equally effective as pHF-W for
reducing the risk of AD in infants. This
meta-analysis demonstrated that pHF-W
(557 infants) vs eHF-W (559 infants) and
pHF-W vs eHF-C (580 infants) were shown
to be effective in the prevention of AD. For
infants that can’t have breast milk exclu-
sively, these formulas are a positive alter-
native based on cost-effectiveness.25
Probiotics
Increasing evidence suggests that chil-
dren who develop AD have reduced
diversity in their gut microbiota. Oral
probiotics, especially certain combina-
tion products of lactobacilli species, seem
beneficial for AD prevention in children,
though there’s conflicting evidence on
their use for treating AD. A meta-analysis
of the available clinical research shows
that using probiotics in conjunction with
standard treatment doesn’t improve
patient-rated symptoms or quality of life
in adults or children with AD compared
with standard therapy alone.26
However, research shows that the pro-
biotic species Lacticaseibacillus paracasei,
Lacticaseibacillus rhamnosus, and Lactiplan-
tibacillus plantarum are promising treat-
ments. In a double-blinded, randomized,
placebo-controlled clinical trial, research-
ers enrolled 60 patients aged between 6
months and 19 years with mild, moderate,
or severe AD. Of the 60 patients, 40 com-
pleted the study, and there were 24 probi-
otic interventions and 16 placebo. After
treatment for six months, children and ado-
lescents with AD in the probiotics group
experienced a significant clinical response
to a mixture of Lactobacillus rhamnosus,
Lactobacillus acidophilus, Lactobacillus
paracasei, and Bifidobacterium lactis.27
Fermented Milk
In a clinical research study, 415 pregnant
women from 36 weeks gestation to three
months postpartum randomly received
fermented milk or placebo milk. Patients
who drank 250 mL of fermented milk
containing Lactobacillus rhamnosus GG,
Lactobacillus acidophilus, and Bifidobacte-
rium animalis reduced their child’s risk of
developing AD by age 6 by approximately
52% compared with placebo milk.28
Galacto-Oligosaccharides
Galacto-oligosaccharides in syrup or
formula, along with probiotics or fructo-
oligosaccharides, may reduce the risk of
AD development in infants at risk of atopy,
an exaggerated IgE-mediated immune
response that stems from a genetic ten-
dency to develop allergic diseases such
as allergic rhinitis, asthma, and AD. In
a prospective, double-blinded, placebo-
controlled study, healthy term infants at
risk of atopy were fed either a prebiotic-
supplemented or placebo-supplemented
hypoallergenic formula during the first six
months of life. Following this intervention
period, follow-up continued until age 5.
Ninety-two children (50 in the placebo
group and 42 in the intervention group)
completed the follow-up. The five-year
cumulative incidences of allergic mani-
festation and AD were significantly lower
in the prebiotic-supplemented group than
in the placebo group. When started early
in life, oligosaccharide prebiotics have a
protective effect against allergic manifes-
tations in high-risk infants.29
One study, however, had opposite
results. Two hundred twenty-six healthy,
formula-fed, term infants were randomly
assigned to one of three study formula
groups. The groups consisted of a control
group, a PG4 group (ie, control formula
supplemented with 4 g/L of a prebiotic
blend containing polydextrose [PDX] and
galacto-oligosaccharides [GOS]), and a
PGL8 group (ie, control formula supple-
mented with 8 g/L of a prebiotic blend
containing PDX, GOS, and lactulose). The
results showed that the formula contain-
ing 4 g/L of PDX and GOS (1:1 ratio) given
as often as necessary for approximately
four months increased the potential of
developing AD as an adverse effect up to
11% compared with a control formula.30
Psoriasis
Psoriasis is an inflammatory, chronic skin
disease that significantly affects patients’
quality of life. It’s a condition in which
skin cells build up and form scales and
itchy, dry patches. The cause of psoriasis
is unknown, but there are several reasons
why it may develop. Psoriasis is a T-cell–
mediated autoimmune dermatological
disorder and is considered a multifacto-
rial disabling condition caused by the
interaction between genetic and environ-
mental triggers. Environmental factors
such as emotional stress and smoking
can negatively influence the onset of
symptoms and disease severity. One of the
most critical environmental factors for
patients with psoriasis is diet. Improper
nutrition, poor weight status, and meta-
bolic diseases may increase clinical symp-
toms or even trigger the disease process.31
Recent studies have suggested that
when there’s better control of psoriasis
inflammation, the risk of CVD, stroke,
metabolic syndrome, and other dis-
eases associated with inflammation
decreases.32
Trigger Foods That Cause Psoriasis
Gluten
One trigger that may cause psoriasis in
some patients is gluten-containing foods.
Clinicians should test patients who have
gastrointestinal symptoms for immuno-
globulin A antibodies to determine whether
they have celiac disease.33 Testing patients
for immunoglobulin A antibodies is vital
since they’re produced in the small intestine
where gluten causes inflammation and irri-
tation in those who are sensitive.34
Research studies suggest psoriasis and
celiac disease share common genetics
and inflammatory pathways. One large
study found that 25,341 patients with
psoriasis had a 2.2-fold risk of being
diagnosed with celiac disease compared
with matched controls.35
Another study, however, found no asso-
ciation between gluten intake and new
onset of psoriasis. This cohort study of
85,185 women in the psoriasis analysis arm
of the study used food frequency question-
naires to calculate the gluten content in
their diets every four years. The results
showed that increased gluten intake wasn’t
associated with any outcomes.36
Obesity
Obesity is likely a predisposition to
psoriasis and is suggested as one of the
main factors of chronic inflammatory
processes associated with psoriasis.37 A
large population-based Norwegian study,
including approximately 35,000 subjects,
showed an association between metabolic
syndrome and increased risk of psoriasis.
The analysis of metabolic factors suggested
that this positive association could have
been attributed to adiposity.38 A poor diet
that provides a significant number of
high-calorie foods and is low in nutritional
quality has contributed to increased body
weight and metabolic diseases, increasing
psoriatic inflammation.
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
Beneficial Interventions
for Psoriasis
Low-Calorie Diet
and Mediterranean Diet
Studies suggest that preventing weight
gain, managing average body weight, and
reducing body mass may lower the inci-
dence of psoriasis.39
One study showed 37 adult patients
who were overweight or obese and never
treated with drugs for stable chronic
plaque psoriasis were placed on a 10-week,
two-phase weight loss program consist-
ing of a four-week protein-sparing, very-
low-calorie ketogenic diet, and a six-week
balanced, low-calorie Mediterranean-
style diet. The results showed that adult
patients on the low-calorie Mediterranean
diet had a significant reduction in the
body surface area and an improvement
in itch severity. This demonstrated that
dietary intervention is an effective first-
line strategy to reduce psoriasis severity.
Bodyweight reduction through a low-
calorie diet may help decrease visceral
fatty tissue while increasing ketone bod-
ies and diminishing the inflammatory
response linked to psoriasis and obesity.40
Gluten-Free Diets
A gluten-free diet may improve psoriasis
in individuals with gluten sensitivity or
celiac disease. An open-label research
study included 30 individuals with
psoriasis and elevated immunoglobulin A
antibodies to gliadin. Researchers started
participants on a gluten-free diet for three
months, followed by a regular diet for
three months. After a three-month gluten-
free diet, the mean Psoriasis Area and
Severity Index score in all 30 participants
improved. All participants were allowed
to continue with their topical or systemic
psoriasis treatment. After discontinuing
the gluten-free diet and initiating the
regular diet, 18 subjects began systemic or
local therapy for worsening psoriasis.41
Vitamin D
Vitamin D supplementation is a promis-
ing treatment for psoriasis. Calcitriol, the
naturally occurring active form of vita-
min D3 (cholecalciferol), has long been
used for topical psoriasis therapy. In two
randomized, double-blinded clinical tri-
als, twice-daily application of calcitriol
ointment for eight weeks resulted in
clearing or minimal residual psoriasis in
approximately 34% of patients, compared
51
CPE Monthly
with 12% to 22.5% of patients treated with
placebo. Calcitriol ointment is an effec-
tive, safe, and well-tolerated topical pso-
riasis therapy.42
But while the calcitriol topical treat-
ment is well established and represents an
effective and safe treatment option with
or without topical steroids, the beneficial
effects of vitamin D oral supplementa-
tion in general don’t seem to prevent or
improve psoriasis symptoms. The find-
ings of a clinical study of 65 older adults
with mild psoriasis show that taking
200,000 IU of oral vitamin D3 followed by
100,000 IU of vitamin D3 monthly for one
year doesn’t affect the severity or spread of
psoriasis when compared with placebo.43
Rosacea
Rosacea is a common chronic inflamma-
tory skin condition that primarily affects
the face with flushing and redness. The
redness from rosacea becomes ruddier
and more persistent over time. There’s
no cure, and its causes are unknown. If
left untreated, inflammatory bumps and
pimples often develop. The individuals
at greatest risk have fair skin and tend to
flush or blush easily.44
Trigger Foods That Cause Rosacea
Many triggers may exacerbate rosacea
symptoms, including hot temperatures,
sun exposure, spicy foods, alcohol con-
sumption, exercise, and feelings of anger
or embarrassment.45 A survey from the
National Rosacea Society about dietary
triggers patients frequently cited found
that, of more than 400 patients, 78% had
altered their diet due to rosacea flare-ups.
Within this group, 95% reported a consecu-
tive reduction in flares.46 Patients within
this group break down the food and bever-
age triggers into heat, alcohol, capsaicin,
and cinnamaldehyde related.45 Categori-
cally, hot beverages acted as a trigger: 33%
described hot coffee as a trigger, while 30%
named hot tea as a trigger. Alcohol was
another frequent cause, with 52% identify-
ing wine as a trigger and 42% identifying
hard liquor as such. Capsaicin is found in
certain spices and peppers. Three-quarters
of respondents reported spices as a cause,
including hot sauce (54%), cayenne pepper
(47%), and red pepper (37%). Foods contain-
ing cinnamaldehyde also were mentioned
as frequent triggers, such as tomatoes
(30%), chocolate (23%), and citrus (22%).45,47
In addition to food triggers,
research shows there’s a possible role
52 TODAY’S DIETITIAN • OCTOBER 2023
of a gut-to-skin connection in rosacea.
A population-based cohort study of
approximately 50,000 Danish patients
with rosacea found that the prevalence of
celiac disease, Crohn’s disease, ulcerative
colitis, Helicobacter pylori infection, small
intestinal bacterial overgrowth, and
irritable bowel syndrome was greater
overall among those with rosacea
compared with controls.48 There’s a lack of
clinical trial research about the possible
treatment of rosacea with probiotics and
the microbiome; therefore, more research
is necessary to further understand this
gut-to-skin connection.
Beneficial Interventions for Rosacea
The only promising research for treat-
ing rosacea has focused on the use of
topical 90% medical-grade kanuka honey
and 10% glycerine (Honevo). A clinical
research study of 138 adults shows that
applying Honevo twice daily for eight
weeks to the affected areas and washing it
off after 30 to 60 minutes is more effective
than Cetomacrogol cream, an emollient,
for improving rosacea symptoms. Roughly
twice as many patients responded to Hon-
evo compared with Cetomacrogol cream.49
Putting It Into Practice
Dermatologists can make referrals to
dietitians who can provide evidence-based
dietary strategies to address patients’ skin
conditions. To work together, dietitians
and dermatologists must take a multi-
disciplinary approach to comprehen-
sively evaluate triggers and responses to
treatment, address confounding factors,
such as dietary and nutrition habits, and
educate patients and families. Currently,
three programs across the country take a
multidisciplinary approach to treat AD,
and the clinicians involved have reported
excellent results.50-52 Multidisciplinary
teams that can assist dermatologists’ criti-
cal role in educating and treating patients
for their skin diseases and disorders can
include not only dietitians but also nurse
practitioners, psychotherapists and psy-
chologists, social workers, rehabilitation
therapists, and allergy-immunology fel-
lows in training.
Dietitians can work with dermatolo-
gists in a team effort to help treat patients’
skin disorders in the following five ways:
1. Focus on the dermatologist’s evalua-
tion of the patient when making initial rec-
ommendations. RDs also can offer patients
educational resources to help prevent
them from relying on those less reliable.
2. Team up with dermatologists to
encourage patients to reduce the risk of eat-
ing allergenic foods and using products with
allergenic ingredients associated with their
skin disease by adopting a more nutritious
diet in tandem with medical interventions.
3. Develop and provide customized
care plans in writing to meet patients’ and
their families’ needs. Prepare to review
and modify these care plans at follow-up
visits as the disease state changes, since
patients and caregivers may forget or mis-
understand skin care recommendations
without written step-by-step instructions.
4. Teach the same fundamental con-
cepts and reinforce the same messages
the dermatologist delivers to patients and
caregivers. Dermatologists and dietitians
can provide one-on-one communication
with patients and written nutrition and
skin health home care action plans. In
addition, dietitians and dermatologists
together can hold group discussions and
teach in classroom settings to educate
patients about nutrition and skin health.
5. Recommend patients and caregivers
review advice they receive from friends,
family members, and other sources with
their dietitian and dermatologist. Mak-
ing even minor changes to their treatment
regimen can be detrimental, lack benefit,
and add unnecessary costs. Maintaining
an open and ongoing dialog with patients,
caregivers, and their clinicians may
improve adherence to treatment plans
and health outcomes.
Dietitians and dermatologists should
meet with one another to discuss each
patient’s current and future care plan and
resolve any issues. These meetings can
prevent miscommunication and ensure
patients receive the same information and
consistent messages regarding their treat-
ment plan. The ultimate goal of multidis-
ciplinary care is to give patients, families,
and caregivers the skills and tools they
need to relieve symptoms at home and
improve their quality of life. I
Denine Rogers, MS, RDN, LD, FAND, is an
integrative and functional dietitian and
owner of Living Healthy Skincare (www.
livinghealthyskincare.com).
For references, view this article on our
website at www.TodaysDietitian.com.
 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
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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 CE@gvpub.com.

OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM 53

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-
come change for many who
don’t like the summer heat. But
as the season progresses, cooler
weather and darker evenings lead to
families and their children spending more
time indoors. What’s more, family sched-
ules become more hectic when school is
in session, as parents usually work, try to
provide balanced meals, and have plenty
of other tasks to check off on their to-do
list. Mentally exhausted parents may be
more likely to allow their children and
themselves to engage in excessive screen
time, reducing the chances of meeting
physical activity guidelines.
Despite these challenges, there are
many fun outdoor and indoor activities
in which families can participate—and
get excited about. This article provides
examples of these activities and strat-
egies to help encourage families to
54 TODAY’S DIETITIAN • OCTOBER 2023
prioritize physical activity in the upcom-
ing cooler months.
Physical Activity Guidelines
Umo Callins, MS, RD, CSSD, CPT, owner of
Well Rooted Health and Nutrition and 180
Physique in Oklahoma City, Oklahoma,
says that the benefits of meeting the
recommended physical activity guidelines
for children and adults are vast. Physical
activity is associated with “improved
cognition and sleep quality, healthy
bones, and improved mood, with studies
showing positive impacts on feelings of
depression,” Callins says. “A sedentary
lifestyle is associated with higher chances
of developing type 2 diabetes, heart
disease, and an increased risk of anxiety
and depression.”
Unfortunately, according to a 2020
study, only 23% of children and adoles-
cents meet current recommendations.1 “For
children and adolescents aged 6 to 17, 60
minutes or more of moderate to vigorous
physical activity daily is recommended,”
Callins says. “This should include a combi-
nation of aerobic, muscle-strengthening,
and bone-strengthening activities. Chil-
dren aged 3 to 5 should engage in various
forms of active play throughout the day to
enhance growth and development.”
Krista Williams, CPT, a pregnancy
and postpartum athleticism coach and
founder of The Strong Mom Project in
Newtown, Pennsylvania, says that adults
are recommended to engage in less
activity than children, a minimum of
150 minutes per week. “At a point in time
where we work long hours, sit for long
periods of time, and spend too much time
in front of screens, we must prioritize
meeting these minimums for our own
health but also for the example we set
for our children.”
Outdoor Family Activities
A 2019 study suggests that a combina-
tion of physical activity and time spent in
nature may have at least six categories of
benefits: physical health, mental health
and well-being, education and lifelong
learning, active citizenship, crime reduc-
tion, and reduced antisocial behavior.2
Despite these benefits, however, getting
started may be easier said than done for
many families. It may be more realistic
to set a goal to be active together outside
just once per week. Callins emphasizes
that eventually, activity “becomes part of
a family’s routine, allows for more con-
nection, and contributes to establishing
a foundation of what being healthy is all
about.” Here are some outdoor activities
clients can partake in when the tempera-
ture starts to drop:
• Hiking: A family hike doesn’t have to
be challenging or take place on a steep
trail. Encourage clients to choose local
trails and pick a new one once a month.
Nature trails are a great way for chil-
dren to stay entertained by birds, bugs,
and wildlife while the whole family
enjoys movement together.
• Family playground time: Instead of
standing and watching small children
play, suggest parents fit in a playground
workout if their children are indepen-
dent. Adults can use steps and monkey
bars to strengthen muscles and bones.
This can set a great example for chil-
dren. Williams has built her personal
training business for moms around
children being present at workouts.
And she sees first-hand that kids want
to try the exercises they observe, mim-
icking their moms and cheering them
on.
• Field games: Callins suggests clients
use outdoor spaces to play tag, frisbee,
or hacky sack. She also recommends
making outdoor obstacle courses. Soc-
cer is a simple game to play outdoors,
or parents can grab a bat, ball, and
glove to play with their kids on a local
baseball field.
• Family walks and rides: Williams says,
“Sometimes thinking more simply
makes it easier to engage in activity
regularly. You don’t have to enjoy hik-
ing, biking, or running, or commit a
lot of time. Take a walk after dinner or
follow your child on a scooter or bike.”
Evening walks after dinner can help
the whole family wind down vs every-
one sitting around the TV or by them-
selves with their tablets. Research also
shows that movement after meals aids
blood sugar management, which can
help prevent diabetes or benefit those
who already have the disease.
• Outdoor chores: From a young age,
children can help mom and dad wash
the car, plant a vegetable garden, or
pull weeds. “All movement counts,”
Williams says. In fact, studies have
shown that when children help with
household tasks, they feel a sense of
accomplishment and may have greater
self-competence and self-efficacy in the
long term.3
• Winter sports: While not feasible for
everyone, families can go skiing, snow-
boarding, or tubing. Or if it’s more
convenient, they can go ice skating and
roller skating at a nearby rink in their
neighborhood.
Indoor Family Activities
When the weather isn’t cooperating or a
family doesn’t have safe access to out-
door spaces, there are still plenty of ways
to get everyone moving indoors. Here are
some examples of indoor activities fami-
lies can consider:
• Family yoga: No one has to be a skilled
yogi to enjoy movement that can
improve flexibility and mental well-
being. YouTube Kids has plenty of free
kids’ yoga channels, such as “Cosmic
Kids Yoga,” which features kid-favorite
characters as the class theme.
• Dance parties: Callins suggests a dance
party or competition. While mood-
boosting music can get family mem-
bers moving any day, recommend they
do so on Fridays to close the week on
a high note while benefiting cardiore-
spiratory health. Rotate who chooses
the music or create a monthly family
playlist.
• Indoor obstacle course: Williams says,
“It doesn’t take much equipment or
space to turn a room into an obstacle
course. Map out a route with furniture,
stairs, and common objects like paper
plates, to create a fun challenge for
adults and kids.”
• Balloon keepie uppie: Playing this game
in the house with a soccer ball isn’t the
safest thing to do, but the whole family
can get involved with a slower moving
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
balloon and ensure it doesn’t touch the
floor or any furniture. The excitement
can rise quickly, which can help release
endorphins while getting much needed
aerobic movement.
• Trampoline parks: Indoor trampoline
centers are popping up in more neigh-
borhoods and enable children and
adults to jump around to their hearts’
content, benefiting their cardiorespira-
tory and muscle and bone health. If the
children enjoy it, many locations offer
memberships and discounts when pur-
chasing multiple passes.
Supporting Clients
Chances are your clients want to be more
active while spending quality time with
their families. As a mom herself, Callins
says, “It’s important to get to know the
family and what their needs and wants
are. Factor in schedules, preferences,
abilities, their budget, and what they
have access to before making recommen-
dations. Be creative and help make meet-
ing the physical activity guidelines as
appealing as possible.” Callins explains
that this personalized and empathetic
approach will increase success in accom-
plishing the activity goals.
Williams adds, “Just like clients can
develop harmful ‘food rules,’ they may
also develop rules with exercise that
might not be the best for their families’
long-term health.” She recommends
RDs avoid setting goals related to family
members burning a certain number of
calories or focusing only on high-intensity
activities. “In the same way you coach
clients to improve their relationship
with food, do the same with exercise.” All
movement can be beneficial and worth
engaging in and even 10-minute spurts
help build habits to support physical and
mental health. I
Kelly Jones, MS, RD, CSSD, LDN, is a board-
certified specialist in sports dietetics, who
consults with national sports organizations,
and a media and nutrition communications
expert. Her private practice works with
individuals and groups and offers practical
resources to support performance for athletes
at every level. She also founded and oversees
Student Athlete Nutrition.
For references, view this article on our
website at www.TodaysDietitian.com.
55
Get to Know… By Elizabeth S. Goar
Deanne Brandstetter
Finding Creative Solutions to Foodservice Challenges
A
blizzard that shut down
her rural Ohio college
campus ignited a passion
for foodservice in Deanne
Brandstetter, MBA, RDN, CDN, FAND.
At the time, she was a senior in dietetics
at Miami University and a student
supervisor in the dining hall. With roads
impassable, she and one chef spent three
days feeding stranded students with
whatever they could scrounge from the
freezer and walk-in coolers.
The dining hall quickly became “a
place of community in the middle of this
giant blizzard. I worked hard, but it was
exciting and challenging. And it was fun.
It was a challenge, pulling together meals
based on just what was available to feed
hundreds of students until the world
56 TODAY’S DIETITIAN • OCTOBER 2023
started to revolve again. It really started
my interest in the culinary arts.”
While Brandstetter’s early years were
spent on the clinical side of the profession,
she never lost her love for foodservice.
That continued love eventually landed
her at Flik International, later acquired
by Compass Group—one of the largest
employers of RDs in the United States—
where she’s now vice president of nutrition
and wellness. She thrives on the challenge
of striking the perfect balance between
nutrition and flavor to meet the needs of
the company’s clients, which range from
corporations and health care organiza-
tions to schools, colleges, and universities.
It’s a challenging creative process
that often requires restraint. Brandstet-
ter recalls one particular company that,
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?
Brandstetter: In my early days with Flik,
I was the only RDN. We had a very small
operations support team, so everyone
pitched in everywhere, including market-
ing. I learned a lot as a result. Marketing
healthful foods is critically important—
the way we talk about it and the way we
position it to be cool.
TD: Can you describe your role as vice
president of nutrition and wellness at
Compass Group?
Brandstetter: I have the honor of working
with 3,000 RDs at Compass Group in just
about every area of practice. I coordinate
and collaborate with them to make sure
we have common goals and strategies
and are aligned on key partnerships. I’m
also on a team focused on innovation and
cross-sector sharing, so I get to make sure
other parts of our business are all on the
same page, and I help promote nutrition,
well-being, and healthful living.
TD: How did adding an MBA to your
RDN credentials impact your career?
Brandstetter: I knew I’d need more busi-
ness skills to be successful in the food-
service world. Certainly, when I joined
Compass Group, it was critical to under-
stand how a global company works and to
understand different business functions.
We need to be able to operationalize nutri-
tion because having great aspirations
doesn’t get us anywhere unless it’s practi-
cal enough to be a win-win scenario.
TD: What’s your most significant
impact on the field of foodservice?
Brandstetter: I hope it’s elevating the role
of the RD. Over the years, I’ve been an
advocate for RDs to take on additional
responsibilities in well-being and health
promotion, foodservice operations, and
even in sustainability and sustainable
food systems. The other thing I’m proud of
is our year-old RDN DEI (diversity, equity,
and inclusion) Community Network.
When I took a critical look at the limited
diversity among our internal popula-
tion of RDs, I knew we had a tremendous
opportunity to do better, given the long,
proud history of DEI within Compass
Group as a whole. With support from our
leaders and plenty of grassroots interest
from the RDs, we quickly organized and
launched a DEI network focused on things
like elevating cultural humility within
our RD population. We revamped reci-
pes and promotions to be more cultur-
ally appropriate and inclusive, recruited
and retained more RDs with diverse
backgrounds, as well as mentored and
provided outreach to a diverse group of
students to make them aware of careers in
nutrition and dietetics. I’m so proud of this
group and the huge difference it’s making.
Interestingly, over the last five years, the
number of individuals in our cohorts
from diverse backgrounds has grown
from about 13% to more than 50%, but we
don’t know why. Figuring it out would go
a long way toward increasing the diversity
within the profession, so we’re working on
a strategy to identify the factors contrib-
uting to this sustained growth.
TD: What was it like to direct the
nutrition program for the 2002 Winter
Olympic Games in Salt Lake City?
Brandstetter: The Winter Olympics are
challenging because many of the events
are outdoors in remote areas. We had
to bring in temporary power, water, and
refrigeration, and everything had to meet
the health code. I was involved in menu
development, and there are many require-
ments for athletes across different coun-
tries. The Games took place shortly after
September 11, 2001, so there was tremen-
dous security and an undercurrent of fear.
Some of our plans fell apart because we
planned to bring in thousands of trained
employees and put them up at a former
Army barracks. Those wound up being
commandeered by the National Guard,
so we bussed people in. Many just didn’t
show up because it was so hard to get to
the remote locations. They had to ride
the bus, walk quite a distance, then go
through three sets of security. Quite often,
I was jumping out of bed in the middle of
We need to be able to
operationalize nutrition
because having great
aspirations doesn’t get
us anywhere unless it’s
practical enough to be
a win-win scenario.
the night to mop floors or scrub dishes
because someone didn’t show up. It was
exciting but a lot of work. It was one of
those great experiences where you give a
big sigh of relief when it’s over.
TD: Can you share a little about your
work with nutrition research?
Brandstetter: I’m not a researcher. Rather,
I partner with others to provide an
opportunity to use some of our locations
as living laboratories to test hypotheses.
And, because it’s not nutrition unless it’s
eaten, we look at what tactics work in
nudging people to make more healthful
choices. We’ve been doing choice
architecture for years, but now consumer
behavior psychology is booming and we’re
trying to tap into and apply that research.
We also do plenty of case studies to test
research in a real-world scenario. Another
area of interest is around DEI in our
dietetic internship program.
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM
TD: What went into earning the
American Culinary Federation Silver
medal for Healthy Cuisine 2000?
Brandstetter: Early in my career with Com-
pass Group, one of the chefs asked me to
work with her in a new competition called
Healthy Cuisine 2000. I really thought I
would help her develop a menu and the
recipes that match their specific percent-
age criteria for each macronutrient, and
that would be the extent of my role. But
she made it very clear that I also had to
cook. Every afternoon I’d get on the train
to New York City to rehearse. She literally
gave me culinary training for four or five
hours every afternoon.
TD: Tell us about the International
WELL Building Institute (IWBI), and
what is your role?
Brandstetter: IWBI manages third-party
certification of worksites and campuses
with the goal of helping to create health-
promoting sites where people work. It’s
not just about building materials. It’s also
lighting, air and water quality, sound, and
many more elements. One of its concepts
is “Nourishment,” and I’m on the advisory
board working to make sure the crite-
ria are science based and operationally
feasible. I’m also collaborating on addi-
tional criteria that might be added. It has
expanded beyond just worksite building,
and it continues to grow.
TD: How important is it for members
of the profession to be active in
professional associations and other
organizations?
Brandstetter: Obviously, I think it’s very
important or I wouldn’t be doing it
myself. Having RDs actively involved
and at the table gives us the ability to
showcase our value and make the case
for higher salaries.
TD: What are some of your favorite
meals or foods?
Brandstetter: I’m particularly fond of
seafood, and I’ve been working on more
global cuisines. In particular, I love
regional Indian cuisines. I also love exper-
imenting with different cooking tech-
niques, different flavors, spices, and herbs.
Sometimes it involves searching them out,
but it’s a particular passion of mine. I
Elizabeth S. Goar is a freelance health writer
based in Benton, Wisconsin.
57
Health Matters
Unhealthful Beverage Consumption Highest
Among Economically Vulnerable Households
A long-standing and contentiously
debated question is the extent to which US
federal food assistance programs contrib-
ute to or deter healthful beverage intake.
Findings of a new study in the Journal of
Nutrition Education and Behavior, pub-
lished by Elsevier, show that while bev-
erage intake patterns rarely differed
between mothers and young children who
participated only in WIC, only in SNAP, or
neither program, those whose households
participated in both programs consumed
high amounts of sugar-sweetened bever-
ages (SSBs). Bottled water intake, which
is common among communities with
high distrust of tap water and can be an
economic burden for low-income families,
was also common among mothers partici-
pating in WIC and SNAP.
While WIC and SNAP aim to improve
families’ food security, the programs
operate quite differently. WIC benefits
allow the purchase of specific foods and
beverages and are available to only preg-
nant and breast-feeding women and chil-
dren through age 4. Meanwhile, SNAP
benefits are available to income-qualify-
ing households and can be used on nearly
all food and nonalcoholic beverages sold
at authorized retailers.
58 TODAY’S DIETITIAN • OCTOBER 2023
Lead author Katherine W. Bauer, PhD,
an associate professor in the department
of nutritional sciences at the University
of Michigan School of Public Health,
says, “Few studies have acknowledged
that families with low income commonly
participate in multiple food assistance
programs. Parents are constantly
navigating the different requirements of
these programs and working to combine
benefits in ways that most benefit their
families. It’s increasingly important to
understand how programs work together to
impact the health of adults and children.”
Study data were obtained from an
online survey of 493 mothers with young
children who had given birth at the Uni-
versity of Michigan hospital in Ann Arbor,
Michigan. These mothers were insured
by Medicaid at the time of their child’s
birth, indicating low household income.
Mothers completed questions about their
household’s current participation in WIC
or SNAP, their past month’s intake of
SSBs, their child’s beverage intake, bottled
water intake, and several sociodemo-
graphic characteristics.
Study results showed mothers who
didn’t participate in either WIC or SNAP
drank SSBs 4.5 times per week compared
with 8.7 times per week for mothers
participating in both WIC and SNAP.
Although regular soda intake was low
among children aged 1 to 4, children from
households participating in both WIC and
SNAP consumed soda approximately five
times more frequently than those from
households not participating in either
program. Mothers from households par-
ticipating in both programs also drank
bottled water more frequently. These dif-
ferences were evident even after account-
ing for sociodemographic differences
between low-income families that do or
don’t participate in WIC and/or SNAP.
Bauer explains, “Participating in mul-
tiple programs increases a household’s
food-specific purchasing power. Parents
may use their WIC benefits to buy health-
ful staple foods and save their SNAP ben-
efits for the small luxuries they can now
afford, such as SSBs or bottled water. By
better understanding the dietary intake
of families enrolled in multiple food
assistance programs, we can think about
strategies that work synergistically across
programs to promote food security and
improve diet quality, while maintaining
personal choice for participants.”
SOURCE: ELSEVIER
Why Light-to-Moderate Drinking Is Tied to Better Heart Health
A new study led by investigators from
Massachusetts General Hospital, a
founding member of the Mass General
Brigham health care system, offers an
explanation for why light-to-moderate
alcohol consumption may be associated
with a lower risk of heart disease. For
the first time, researchers found that
alcohol, in light-to-moderate quantities,
was associated with long-term reduc-
tions in stress signaling in the brain.
This impact on the brain’s stress sys-
tems appeared to significantly account
for the reductions in cardiovascular
events seen in light-to-moderate drink-
ers participating in the study. Find-
ings are published in the Journal of the
American College of Cardiology.
“We aren’t advocating the use of
alcohol to reduce the risk of heart
attacks or strokes because of other con-
cerning effects of alcohol on health,”
says senior author and cardiologist
Ahmed Tawakol, MD, codirector of
the Cardiovascular Imaging Research
Center at Massachusetts General Hos-
pital. “We wanted to understand how
light-to-moderate drinking reduces car-
diovascular disease, as demonstrated by
multiple other studies. And if we could
find the mechanism, the goal would
and socioeconomic confounders. The
researchers found that light-to-moder-
ate alcohol consumption was associated
with a substantial reduction in the risk
of CVD events, even after accounting
for those other factors.
Next, they studied a subset of 754 indi-
viduals who had undergone previous PET/
CT brain imaging (primarily for cancer sur-
veillance) to determine the effect of light/
moderate alcohol consumption on resting
stress-related neural network activity.
The brain imaging showed reduced
stress signaling in the amygdala, the brain
region associated with stress responses,
in individuals who were light-to-moder-
ate drinkers compared with those who
abstained from alcohol or who drank
little. And when the investigators looked
at these individuals’ history of cardio-
vascular events, they found fewer heart
attacks and strokes in light-to-moder-
ate drinkers. “We found that the brain
changes in light-to-moderate drinkers
explained a significant portion of the pro-
tective cardiac effects,” Tawakol says.
It’s long been known that alcohol
reduces the amygdala’s reactivity to
threatening stimuli while individuals are
drinking. The current study is the first
to indicate that light-to-moderate alco-
light-to-moderate alcohol would be even
more effective at reducing heart attacks
and strokes in people who are prone
to a chronically higher stress response,
such as those with a history of signifi-
cant anxiety. They found that, within the
50,000-patient sample, light-to-moder-
ate drinking was associated with nearly
double the cardiac-protective effect in
individuals with a history of anxiety com-
pared with others.
Yet, while light-to-moderate drink-
ers lowered their risk of CVD, the study
also showed that any amount of alcohol
increases the risk of cancer. And at higher
amounts of alcohol consumption—more
than 14 drinks per week—heart attack
risk started to increase while overall brain
activity started to decrease (which may be
associated with adverse cognitive health).
The authors conclude that research
should focus on finding new interventions
that reduce the brain’s stress activity
without the deleterious effects of alcohol.
The research team currently is studying
the effects of exercise, stress-reduction
interventions such as meditation, and
pharmacological therapies on stress-
associated neural networks and how they
might induce cardiovascular benefits.
SOURCE: MASSACHUSETTS GENERAL HOSPITAL

be to find other approaches that could hol consumption has lon-

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

OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM 59

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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
of CVD over time. In the current study, the research team assessed
whether physical activity at certain times of day was associated
with greater improvement in blood glucose control. Their findings
suggest patients with type 2 diabetes who were physically active in
the afternoon had the largest improvements after one year in the
trial. The team’s results are published in Diabetes Care.
“In this study, we’ve shown that adults with type 2 diabetes
had the greatest improvement in glucose control when they were
most active in the afternoon,” says cocorresponding author Jingyi
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
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.
In future studies, the team may test their findings experimen-
tally to investigate the underlying mechanisms that may explain
why time of day of activity may influence blood glucose control.
From this, the team may be able to provide specific physical
activity recommendations for patients.
“Timing does seem to matter,” says cocorresponding author
Roeland Middelbeek, MD, an assistant investigator at Joslin
Diabetes Center. “Going forward, we may have more data and
experimental evidence for patients to give more personalized
recommendations.”
SOURCE: BRIGHAM AND WOMEN’S HOSPITAL
OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM 63
News Bites
A Student’s Poor Eating Habits
Can Lead to a Lifetime of Illness
A University of British Columbia Okana-
gan (UBCO) researcher is cautioning
that a person’s poor eating habits estab-
lished during postsecondary studies
can contribute to future health issues,
including obesity, respiratory illnesses,
and depression.
Joan Bottorff, PhD, a professor with
UBCO’s School of Nursing, is one of several
international researchers who published
a multisite study looking at the eating
habits of university students. Almost
12,000 medical students from 31 univer-
sities in China participated in the study
that aimed to determine the association
between eating behaviors, obesity, and
various diseases.
The point, Bottorff says, is that many
poor eating habits begin at university and
can continue for decades.
“We know many students consume
high-calorie meals along with sugary foods
and drinks and there’s lots of evidence to
show those kinds of eating behaviors can
lead to obesity,” Bottorff says. “These aren’t
the only habits that lead to obesity, but
they’re important and can’t be ruled out.”
The study, published recently in Pre-
ventive Medicine Reports, was led by
Shihui Peng, PhD, with the School of
64 TODAY’S DIETITIAN • OCTOBER 2023
Medicine at China’s Jinan University.
While there’s well-established research
that links unhealthful diets to many
chronic diseases, this study aimed to
show a relationship between poor eating
habits and infectious diseases, including
colds and diarrhea.
Bottorff notes that due to the nature of
the study, it wasn’t possible to show cause
and effect, but the relationship between
poor eating habits, obesity, and respira-
tory illnesses was well supported.
“There’s been biomedical research
that also supports this link between obe-
sity and infectious diseases, and most
recently this has been related to COVID-
19,” she adds. “We know from some of the
recent publications related to COVID-
19, obese people were more likely to
have severe conditions and outcomes.
Reasons that have been offered for this
increased vulnerability include impaired
breathing from the pressure of extra
weight and poorer inflammatory and
immune responses.”
A typical student diet of high-sugar
or high-calorie foods can become a
long-term issue as these habits can lead
to obesity. Bottorff says there’s evi-
dence to show that stress and anxiety
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
we provide students. We need to ensure
that in our cafeterias and vending
machines, there are healthy food options
so that they can eat on the go but also
make healthful food choices.”
It’s not an issue going unnoticed. UBC
Student Wellness and Food Services work
together to address food security and
food literacy and recognize that a lack
of affordable food options, coupled with
the stress of university life, can negatively
impact students’ food choices.
Food insecure students have access
to a low-barrier food bank and a meal
share program. Meanwhile, UBCO Food
Services’ culinary team prioritizes local,
organic, and sustainably sourced ingre-
dients, and works with an RD to ensure a
wide variety of food options are available
to all diners.
Bottorff agrees there have been
improvements to food options in cafete-
rias and notes the drinks in many vend-
ing machines have been rearranged so
healthier items are at eye level and sugary
choices are lower down.
“I know many postsecondary schools
are trying to figure out how we can do bet-
ter and are trying to address these prob-
lems,” she adds. “It’s great, because four or
five years ago, we weren’t. So, I think we’re
on the right road, but I think we’re a long
way from finished.”
SOURCE: UNIVERSITY OF BRITISH COLUMBIA OKANAGAN CAMPUS
Datebook
OCTOBER 9-13, 2023
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OCTOBER 2023 • WWW.TODAYSDIETITIAN.COM 65
Culinary Corner By Liz Weiss, MS, RDN
An Orange-Themed Halloween
Get into the spooky spirit with some healthful
holiday snack ideas.
I
was never one of those moms
who tried to turn Halloween
into a “healthy” holiday. Given
my boys’ love of dressing up,
ringing doorbells, and filling their
plastic pumpkin buckets to the brim
with candy, that would have been a
lost cause. I handed out candy just like
everyone else in the neighborhood and
didn’t worry too much about the boys’
candy haul. After a few days of candy
overload, the appeal of the sugary
treats would wear off and they’d usu-
ally forget about it.
But there were times I would don
my dietitian cape at Halloween when
it came to pre–trick-or-treat meals
and parties. That’s when I’d set out
a spread of nutrient-rich, orange-
colored foods that my kids and their
friends always loved. Presenting those
foods on Halloween-themed plates
added to the fun, and as a busy mom
and dietitian, I felt better knowing my
kids were well fed and fueled before
running out the door.
When choosing orange-hued foods,
you and your clients can consider apri-
cots and golden raisins for fiber (plus,
neither food contains added sugars),
carrot sticks and orange bell peppers
with dip for vitamins A and C, and
pumpkin muffins or a mango smoothie
for beta carotene and lutein, which
66 TODAY’S DIETITIAN • OCTOBER 2023
support a well-functioning immune
system and eye health, respectively.
Here’s a list of orange food ideas for
some inspiration:
• cantaloupe balls;
• dried apricots;
• carrot sticks and sliced orange bell
peppers with hummus;
• clementines;
• cheddar cheese sticks;
• mango smoothies made with 100%
orange juice, plain yogurt, banana,
and frozen mango;
• mini pumpkin muffins;
• homemade snack mix with nuts and
raisins (recipe to follow);
• butternut squash soup topped
with shredded cheddar cheese and
croutons;
• roasted pumpkin seeds; and
• parfait with plain yogurt, diced
mango or pineapple, and granola. I
Liz Weiss, MS, RDN, is a mom of two grown
boys with a specialty in family nutrition
and wellness. She shares recipes and
healthful living advice on LizsHealthyTable.
com and her podcast, EAT, DRINK, LIVE
LONGER. Weiss is a cooking instructor,
frequent lifestyle guest on TV shows
across the country, and a Have a Plant
Ambassador for the Produce for Better
Health Foundation.
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
family’s favorite dried fruit (eg, chopped
dried apricots), and choose all sorts of
bite-size pretzel shapes.
Ingredients
2 cups Corn Chex cereal
2 cups Rice Chex cereal
2 cups Cheerios cereal
½ cup lightly salted mixed nuts
1 cup bite-size mini pretzels
4 T extra virgin olive oil
1½ tsp Worcestershire sauce
½ tsp garlic powder
¼ tsp onion powder
¼ tsp kosher salt
¼ to ½ cup golden raisins
Directions
1. Heat oven to 250˚ F.
2. In a large bowl, mix together
Corn Chex, Rice Chex, Cheerios,
nuts, and pretzels.
3. In separate small bowl, whisk together
olive oil, Worcestershire sauce, garlic
powder, onion powder, and salt until well
combined.
4. Pour over cereal mixture and mix well
until everything is evenly coated.
5. Transfer cereal mixture to ungreased
rimmed baking sheet or roasting pan.
Bake for 1 hour, stirring every 15 min-
utes. Remove from oven, let cool, stir in
raisins, and store in airtight container at
room temperature.
Nutrient Analysis per serving: (½ cup)
Calories: 215; Total fat: 8.5 g; Sat fat: 1 g;
Cholesterol: 0 mg; Sodium: 540 mg; Total
carbohydrate: 32 g; Total sugars: 5 g; Dietary
fiber: 2 g; Protein: 3.5 g
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