Today's Dietitian (February 2020)

Cancer&Cardiovascular CareWWW.TODAYSDIETITIAN.COMTHE HEALTH BENEFITS OF BEETS PLUS RECIPESEXPLORE THE LATEST LACTOSE-FREE DAIRY PRODUCTSCAN CHOLINE CONTRIBUTE TO CVD?An Overview of This Emerging Practice Area CONFERENCE ISSUEFebruary 2020Vol. 22 No. 2The Magazine for Nutrition ProfessionalsAMERICAN HEART MONTH

Real People. Real Weight Loss.®TOPS (Take Off Pounds Sensibly ) has helped millions ®SMin the U.S. and Canada lose weight and keep it off since 1948. We emphasize slow and steady lifestyle changes that lead to lasting weight loss and better health. Refer your patients to a local chapter or offer TOPS®as a class for your prediabetes and diabetes patients. Our expert-written, peer-reviewed curriculum is easy to implement and a great use of staff time. 1 Determining the Effectiveness of Take Off Pounds Sensibly (TOPS), a Nationally Available Nonpro t Weight-Loss Program. Obesity Journal Intervention and Prevention. Volume 19, Number 3, March 2011. Nia S. Mitchell, L. Miriam Dickinson, Allison Kempe, & Adam G. Tsai. Research Proves ItTHOUSANDS OF CHAPTERS AVAILABLETOPS works as well as commercial programs but costs less. ®Participants experience a clinically signi cant weight loss.1Contact TOPS®Outreach & Education ManagerMaggie Thorison414-482-4620 - Ext. 23 [email protected] a part of our mission, TOPS provides free patient ®education and referral materials. Request Your Free Materials!Evidence-Based and Affordable Weight LossVisit our website, www.TOPS.org.

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D E PA R TM E NT S6 Editor’s Spot7 Reader Feedback8 Ask the Expert9 Health Matters12 Children’s Nutrition14 Diabetes18 Senior Wellness54 Focus on Fitness56 Get to Know …58 Bookshelf60 News Bites62 Research Briefs64 Products + Services65 Datebook66 Culinary CornerContentsF EAT UR E S20 Cancer & Cardiovascular Care CVD and cancer are two of the most common and well-recognized causes of morbidity and mortality in the country, and they’re more related than previously thought. A new practice area tackles prevention, treatment, and posttreatment protocols for both diseases.26 Beets These long-overlooked—but now beloved—roots have a history as rich as their flavor. Discover beets’ health benefits and some delicious and healthful recipes to share with clients and whip up in your own kitchen. 30 Spotlight on Lactose-Free Dairy This category omits lactose but certainly not choice. Understand the wide array of lactose- and dairy-free options to help clients select the best products for them. 36 Choline and CVD Does choline intake really increase heart disease risk? Today’s Dietitian delves deep into this controversial claim.40 Picky Eating in Children Some kids outgrow it, but others may develop lifelong disordered eating habits or even eating disorders. RDs can help parents and caregivers prevent, identify, and manage picky eating behaviors to ensure children’s best health and parents’ sanity.46 CPE Monthly: The Disease-Protective Properties of GarlicThis continuing education course assesses current research findings on garlic’s health benefits, summarizes the mechanisms of action of the various compounds found in garlic, and evaluates the safest and most effective way to reap the benefits of this bulb. 12FEBRUARY 2020VOLUME 22 • NUMBER 236Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published monthly 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, 3801 Schuylkill Road, Spring City, PA 19475. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on last label. Postmaster: Send address changes to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Subscription Rates — Domestic: $14.99 per year; Canada: $48 per year; Foreign: $95 per year; Single issue: $5. Today’s Dietitian Volume 22, Number 2.464 TODAY’S DIETITIAN• FEBRUARY 2020

NO MAGIC POWERS. JUST REAL FOOD.Featured recipe: Stuffed Avocado with Black Beans, Corn and Red PeppersWhen it comes to weight management, you know there’s no such thing as an overnight success. Empower your clients to make every choice a healthy one with fresh avocado dishes that satisfy even the pickiest eaters. Visit our extensive library of avocado recipes and access weight management research atLoveOneToday.com/WeightManagementEDUCATIONALRESOURCESMEAL PLANSRESEARCHRECIPES© 2020 Hass Avocado Board. All rights reserved.

Editor’s SpotEXECUTIVEChief Executive Officer Mara E. HonickerChief Operating Officer Jack GrahamEDITORIALEditor Judith RiddleNutrition Editor Sharon Palmer, MSFS, RDNEditorial Director Lee DeOrioProduction Editor Kevin O’Brien Associate Editor Hadley TurnerEditorial Assistant Heather HogstromEditorial Advisory Board Dina Aronson, RD; Jenna A. Bell, PhD, RD; Janet Bond Brill, PhD, RD, CSSD, LDN; Marlisa Brown, MS, RD, CDE, CDN; Constance Brown-Riggs, MSEd, RD, CDE, CDN; Carol Meerschaert, MBA, RD; Christin L. Seher, MS, RD, LDARTArt Director Charles SlackSenior Graphic Designer Erin FaccendaADMINISTRATIONAdministrative Manager Helen BommaritoAdministrative Assistants Pat Plumley, Susan YanulevichExecutive Assistant Matt CzermanskiSystems Manager Jeff CzermanskiSystems Consultant Mike DaveyFINANCEDirector of Finance Jeff CzermanskiCONTINUING EDUCATIONDirector of Continuing Education Jack GrahamAssistant Director of Continuing Education Leslie CimeiContinuing Education Editor Kate Jackson CIRCULATIONCirculation Director Nicole HuncharMARKETING AND ADVERTISINGPublisher Mara E. HonickerDirector of Marketing and Digital Media Jason Frenchman Web Designer/Marketing Assistant Jessica McGurkSponsorship and Event Associate Alex HomerSales Manager Brian OhlAssociate Sales Manager Peter J. BurkeSenior Account Executives Gigi Grillot, Diana Kempster, Beth VanOstenbridgeAccount Executives John Katch, Ann Marie Russo, Stephanie Kusniez, Brian SheerinFOUNDER EMERITUSKathleen Czermanski© 2020 Great Valley Publishing CompanyPhone: 610-948-9500 Fax: 610-948-7202Editorial e-mail: [email protected] Sales e-mail: [email protected] Website: www.TodaysDietitian.com Subscription e-mail: [email protected] fax: 610-948-4202 Ad artwork e-mail: [email protected] content contained in Today’s Dietitian represents the opinions of the authors, not 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 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 any injury to persons or property resulting from reference to ideas or products discussed in the editorial copy or the advertisements.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 consideration of laboratory data and other factors unique to the patient/client.CONTENT CONTAINED IN TODAY’S DIETITIAN SHALL NOT BE CONSTRUED TO CONSTITUTE PROFESSIONAL MEDICAL, HEALTH, LEGAL, TAX, OR FINANCIAL ADVICE.Cancer and Heart DiseaseAfew weeks ago, I read a riveting article about a woman named Toni who was diagnosed with breast cancer at age 29. She underwent a lumpectomy followed by radiation and the chemotherapy drugs cyclophosphamide and doxorubicin. At age 35, she discovered another malignant tumor in her other breast. She then had a double mastectomy and underwent more chemotherapy with the same drugs. Shortly after, she was diagnosed with heart failure due to the cardio-toxic effects of the drugs and would later need a heart transplant. The good news is that she has returned to a normal and active life. She went from running 5Ks to marathons and is encour-aging other female cancer survivors to eat healthfully, exercise regularly, and take care of their hearts. Toni’s story isn’t unique. Many women diagnosed with breast cancer eventually develop heart problems months and even decades later as a result of radiation and chemotherapy treatments. Both modalities can scar or stiffen heart tissue and lead to hypertension, arrhythmias, myocardial ischemia, valvular disease, thromboembolic disease, and pericarditis. Breast cancer therapies and their association with CVD led the American Heart Association to publish a scientific statement in 2018—which reviewed the prevalence of CVD and breast cancer, their common risk factors, and the negative impacts of breast cancer treatments on cardiovascular health—and advocate for continued research in this area. In fact, the link between cancer and heart health is what spawned the emerging field of cardio-oncology, a medical specialty once considered two separate entities (cardiology and oncology), but in reality are inextricably linked. In honor of American Heart Month, cardio-oncology is the subject of our cover story, “Cancer & Cardiovascular Care,” by Karen Collins, MS, RDN, CDN, FAND. In this arti-cle, Collins provides an overview of this burgeoning medi-cal field and discusses cancer treatment, CVD risk, and the key role dietitians can play to improve patient outcomes through diet and nutrition. After reading this article, make sure you turn to the fea-tures on the nutrient content of beets, lactose-free dairy trends, choline and CVD, and picky eating in children. Please enjoy the issue! — Judith Riddle, [email protected] TODAY’S DIETITIAN• FEBRUARY 2020

Today’s Dietitian and Pollock Communications ‘What’s Trending in Nutrition’ Survey@PollockPR: We’re thrilled to announce that our annual trends survey with Today’s Dietitian is officially out! We’re going to be seeing a healthy revolution in 2020 and beyond. Check out the top 10 #superfoods and more insights.@EWatsonWrites: The high-fat, moderate-protein, and ultra-low-carb #ketodiet is likely to remain the top diet trend of 2020, followed by intermittent fasting and “clean eating,” according to a poll of RDs conducted by Pollock Communications and Today’s Dietitian.Today’s Dietitian 2020 Spring Symposium@SharonPalmerRD: So glad to be pre-senting a #sustainablefoodsystems masterclass at Today’s Dietitian’s 2020 Spring Symposium! See you there!@SharonDeSilva5: Looking forward to a great time!RD LOUNGE BLOGFNCE® Food Trends 2019@LizWeiss: Curious about the hottest food trend from #FNCE? Look no fur-ther than plant-based snacks, pizzas, and milks … but don’t forget about the original plants!NOVEMBER/ DECEMBER ISSUEGame-Changing Meds for Severe Hypoglycemia@HopeWarshaw: Pleased to share my important article on new FDA-approved treatments for severe hypo-glycemia in Today’s Dietitian. #RDN #diabetes #T1DThe Impact of Exercise on the Brain@nedshahGIRD: Here are benefits of exercise on the mind!Will Food Allergies Soon Be Eliminated? (Food Allergies/Sensitivities)@PedNutritionGuy: Review of the latest innovative #foodallergy treat-ments by Sherry Coleman Collins, MS, RDN, LD, in Today’s Dietitian, includ-ing oral immunotherapy, epicutane-ous immunotherapy, and importance of dietitians specializing in #allergy man-agement. #nutritionFloat Therapy (Focus on Fitness)@AlyssaRDN: Interesting article in Today’s Dietitian on float therapy. Uses include relieving muscle tension and healing joints, decreases depression and anxiety, and improving insomnia and other sleep problems.OCTOBER ISSUEVegetable-Based Pastas@VandanaShethRD: Nice overview of the wide variety of veg-based pastas. Thanks for the interview, Densie Webb, PhD, RD.Anorexia and the Gut Microbiome@CarrieDennett: Genes, environ-ment, and the gut microbiome all play a role in the development and progres-sion of anorexia nervosa—but which part of that trifecta plays the biggest role? #rdchat #nutrition #anorexia #eatingdisordersFrom Our Twitter FeedHeart-Healthy Holiday EatingStrategies for Counseling Clients, Plus Delicious Healthful Recipes to Celebrate the Festive Season November/December 2019Vol. 21 No. 11The Magazine for Nutrition ProfessionalsAMERICAN DIABETES MONTH2020Wellness & Prevention Resource GuideWWW.TODAYSDIETITIAN.COMNew Game-Changing Meds for Severe Hypoglycemia The Impact of Exercise on Brain Health Frozen Foods Get a Makeover Reader FeedbackFEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  7

Contaminated Herbs and SpicesQSome of my clients are concerned about potentially contaminated herbs and spices on the market. What does the research say, and how can I counsel them effectively?A: Numerous studies have shown that pathogenic microorganisms and heavy metals do appear in some imported herbs and spices and pose a safety risk in some populations, such as those with compromised immune systems. However, the US government and some individual manufacturers have pro-cedures in place to ensure consumers’ safety, and there are steps clients can take when purchasing and using herbs and spices to reduce their risk of being exposed to contaminants. The ResearchMost research has been conducted on contaminants in the form of pathogens, typically Salmonella; heavy metals; and debris such as insects and animal hair.A 2013 study used FDA contamination data from 79 countries during fiscal years 2007–2009. An average of 6.6% of imported spices contained Sal-monella, about twice the average level of all other imported, FDA-regulated foods. Salmonella prevalence was associated with spice properties, extent of processing, and export country. For example, a larger proportion of spices derived from the fruit, seeds, or leaves of a plant were contaminated com-pared with those from the bark or flower of a plant. Salmonella also was more commonly found in larger shipments of ground or cracked capsicum and coriander compared with their whole-spice counterparts. 1Other contaminants were present as well; 12% of spice shipments were adulterated with debris such as insects and animal hair, which could have resulted from inadequate packing or storage conditions. The most commonly contaminated spices included coriander, basil, oregano, sesame seeds, pepper, cumin, and curry powder.1As reported in a 2017 study, the FDA sampled 11 different herbs and spices at a variety of retail establishments throughout the United States. (Previous studies looked at imported spices only during the shipment process, not when those products were available to consumers.) Less than 1% of retail spices were contaminated with Salmonella, likely because herbs and spices undergo a pathogenic reduction treatment, such as irradiation or pasteurization, once they enter the United States and before they reach retail establishments.2Heavy metal, especially lead, contamination also has been a point of con-cern in herbs and spices. Researchers in a 2017 article collected 32 samples of turmeric from Boston-area retail establishments and found a median lead contamination of 0.11 parts per million (ppm)—just above the FDA’s maximum allowable lead level for candy of 0.1 ppm (the FDA hasn’t established limits for lead contami-nation in herbs and spices).3Improving SafetyAs part of the goals of the 2011 Food Safety Mod-ernization Act to strengthen and broaden the FDA’s regulatory authority, the FDA is establishing an accreditation program for third-party certifiers to learn to conduct rigorous food safety audits. The FDA also is developing training centers abroad to train local spice manufacturers better supply chain management to ensure safety. In addition, FDA sci-entists will participate in the Codex Committee on Spices and Culinary Herbs, part of an international organization that sets food safety standards, guide-lines, and codes of practice.4The American Spice Trade Association has pub-lished safety recommendations for spice companies as well as guidelines for companies to distribute to their suppliers and customers. In addition, many 5notable spice brands test the quality and safety of their products; for example, McCormick is a Safe Quality Food Certified Supplier at the highest level possible.6Recommendations for ClientsWhile minimal contamination may be unavoidable, RDs should assure clients that herbs and spices are healthful and generally safe. Suggest clients stick to well-known brands and/or research brands to ensure that quality and safety are utmost priorities. Clients, especially those who are immunocompro-mised or more sensitive to contamination, should add dried spices and herbs during cooking or toast spices before using, as Salmonella is destroyed when heated to 160˚ F.Toby Amidor, MS, RD, CDN, FAND, is the founder of Toby Amidor Nutrition (http://tobyamidornutrition.com) and a Wall Street Journal best-selling author. Her cookbooks include Smart Meal Prep for Beginners, The Easy 5-Ingredient Healthy Cookbook The Healthy Meal , Prep Cookbook The Greek Yogurt Kitchen, , and the forthcoming The Create-Your-Plate Diabetes Cookbook and The Best Rotisserie Chicken Cookbook Ever. She’s a nutrition expert for FoodNetwork.com and a contributor to U.S. News Eat + Run and Muscle&Fitness.com.Ask the Expert By Toby Amidor, MS, RD, CDN, FANDFor references, view this article on our website at www.TodaysDietitian.com. Send your questions to Ask the Expert at [email protected] or send a tweet to @tobyamidor.8 TODAY’S DIETITIAN• FEBRUARY 2020

Health MattersComplete Recovery Remains Elusive to Anorexia PatientsThree in four patients with anorexia nervosa make a par-tial recovery, but just 21% make a full recovery, a mile-stone most likely to signal per-manent remission.These results, and more, are drawn from an online survey of 387 parents, of whom 83% had children with anorexia nervosa, 6% with atypical anorexia ner-vosa—a variant occurring in patients who aren’t underweight—and the remainder with other eating disorders. The findings are reported in a study led by the University of California, San Fran-cisco (UCSF) and published in the Inter-national Journal of Eating Disorders.“This study reminds us that we need to work harder to help individuals with anorexia nervosa who are not respond-ing to standard treatment,” says first author Erin C. Accurso, PhD, clinical director of the UCSF Eating Disorders Program and an assistant professor in the department of psychiatry. “Full recovery means that patients can find joy in their daily life, free from the physi-cal and psychological effects caused by restrictive dieting.”For the study, partial recovery, she says, was defined as showing some improvement but still symptomatic in at least one of the following areas: physi-cal health, eating disorder thoughts and behaviors, social functioning, or mood.Among the 21% (81 patients) who made a complete recovery, 94% had managed to maintain their recovery two years later. “Unfortunately, patients who achieved only partial recovery continued to struggle and were much more suscep-tible to relapse,” Accurso notes.Previous studies have found that around 50% of patients with anorexia nervosa made complete recoveries, but this study had a preponderance of patients with refractory illness. In the current study, approximately one-half had undergone residential therapy, par-tial hospitalization, or intensive outpa-tient treatment, and two-thirds received three or more types of psychological treatment. More than 60% reportedly received family-based treatment, which is recognized as the most effective inter-vention for adolescent anorexia nervosa.“Anorexia nervosa is a complex condition with the highest mortality rate of any psychiatric disorder,” Accurso says. “We know that families are the most important resource in recovery, which is why family-based treatment is the gold standard for adolescent anorexia nervosa.“However, treatment doesn’t work for everyone. Parents are telling us that recovery needs to be approached more holistically, with treatments that extend beyond eating disorder symp-toms to target emotional well-being, cognitive flexibility, and establishment of a meaningful life.”The authors also noted that parents are challenging the field’s definition of recovery.“Parents are schooling us on how it should be defined,” says Accurso, who is affiliated with the UCSF Weill Insti-tute for Neurosciences. “We found that parents have a much broader view of recovery, which included psychologi-cal well-being and building a life worth living. Researchers are missing the mark in defining recovery by weight and/or eating disorder symptoms in the absence of these other factors.”Parents reinforced clinicians’ obser-vations that physical and behavioral recovery, which includes resuming reg-ular eating habits, precede cognitive recovery, in which patients are no longer plagued by extreme fear of weight gain and body image distortion.Among the patients—whose average age was 18, with a five-year history of the disorder—90% were female, 94% were white, and 90% lived in the United States, Canada, the United Kingdom, or Australia.In a follow-up study, Accurso and colleagues will look at how weight restoration, including the goal weight set by a patient’s clinician, impacts the recovery process. SOURCE: UNIVERSITY OF CALIFORNIA, SAN FRANCISCOFEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  9

Health Matters Study Shows Kids and Teens Consuming Fewer Sugary DrinksAccording to a new study in the American Journal of Preventive Medicine, the share of children and ado-lescents consuming sugar-sweetened beverages (SSBs) and the calories they consume from SSBs declined significantly between 2003 and 2014.This decline in consumption was found among children and adolescents in all groups studied, including those participating in the Supplemental Nutrition Assistance Program (SNAP)—one-half of whom are children. However, the study demon-strated that, even with the decline, current levels remain too high, with 61% of all children and 75.6% of SNAP recipients still consuming an SSB on a typical day. (SSBs were defined as any nonalcoholic drink with added sugars, including soda, fruit drinks, and flavored milks, consumed on a given day.)“While the observed declines in children’s sugar-sweetened beverage consumption over the past decade are promising, the less favorable trends among children in SNAP suggest the need for more targeted efforts to reduce sugary drink consumption,” explains lead investigator J. Wyatt Koma, an independent researcher in Washington, D.C.The investigators used nationally representative dietary data for 15,645 children and adolescents (aged 2 to 19) from the 2003 to 2014 National Health and Nutrition Examination Surveys. They classified children according to self-reported participation in the SNAP program and household income: 27.8% were SNAP participants; 15.3% were income-eligible but not SNAP participants; 29.7% had lower incomes that were ineligible for SNAP; and 27.2% had higher incomes that were ineligible for SNAP. The analysis deter-mined the share of children in the vari-ous groups who consumed an SSB on a typical day as well as the per capita daily consumption of SSB calories from 2003 to 2014. This study yielded several significant findings, notably the following:• From 2003 to 2014, the share of chil-dren consuming an SSB on a typical day declined significantly across all SNAP participation groups, primarily driven by declines in soda consump-tion. Among children who were SNAP participants, the percentage drinking SSBs declined from 84.2% to 75.6%, and per capita daily consumption of SSB calories declined from 267 to 182 kcal.• In 2014, nearly 1 in 4 children who were income-eligible for the SNAP program consumed a fruit drink on any given day (SNAP participants: 24.8%; income-eligible nonpartici-pants: 23.4%).• The share of SNAP participants con-suming a sports/energy drink on any given day tripled from 2003 to 2014 (from 2.6% to 8.4%).Although SNAP’s success in reducing hunger and food insecurity in the United States is well documented, public health attention has more recently turned to the secondary goals of the SNAP pro-gram: improving diet quality and pre-venting obesity among participants.Senior author Sara N. Bleich, PhD, a professor in the department of health policy and management at the Harvard T.H. Chan School of Public Health, says, “Current policy debates are considering whether the diet quality of SNAP par-ticipants can be improved by restrict-ing which items can be purchased with SNAP benefits. Our analysis is impor-tant for these discussions. While our results confirm that efforts to decrease SSB consumption over the past decade have been successful, they also suggest that the continued surveillance of chil-dren’s SSB consumption by beverage type is important, given the consump-tion trends for sports/energy drinks and nontraditional SSBs like flavored milks. These trends could reduce or eliminate the past decades’ achievements limiting SSB consumption.”SOURCE: ELSEVIER10 TODAY’S DIETITIAN• FEBRUARY 2020

Healthful Diet Linked to Lower Risk of Hearing LossInvestigators from Brigham and Wom-en’s Hospital have found that eating a healthful diet may reduce the risk of acquired hearing loss. Using longitudi-nal data collected in the Nurses’ Health Study II Conservation of Hearing Study (CHEARS), researchers examined three-year changes in hearing sensitivities and found that women whose eating patterns more closely adhered to commonly rec-ommended healthful dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH) diet, the Alter-nate Mediterranean diet, and the Alter-nate Healthy Index-2010 (AHEI-2010), had a substantially lower risk of decline in hearing sensitivity. The team’s findings are published in the American Journal of Epidemiology.“A common perception is that hearing loss is an inevitable part of the aging pro-cess. However, our research focuses on identifying potentially modifiable risk fac-tors—that is, things that we can change in our diet and lifestyle to prevent hear-ing loss or delay its progression,” says lead author Sharon Curhan, MD, a physi-cian and epidemiologist in the Brigham’s Channing Division of Network Medicine. “The benefits of adherence to healthful dietary patterns have been associated with numerous positive health outcomes, and eating a healthy diet may also help reduce the risk of hearing loss.”Previous studies have suggested that higher intake of specific nutrients and certain foods, such as the carotenoids beta-carotene and beta-cryptoxanthin (found in squash, carrots, oranges, and other fruits and vegetables), folate (found in legumes, leafy greens, and other foods), and long-chain omega-3 fatty acids (found in seafood and fish), were associated with lower risk of self-reported hearing loss. These findings revealed that dietary intake could influence the risk of developing hearing loss, but investigators sought to further understand the connection between diet and hearing loss by capturing overall dietary patterns and objectively measuring longitudinal changes in hearing sensitivities.To do so, the researchers estab-lished 19 geographically diverse test-ing sites across the United States and trained teams of licensed audiologists to follow standardized CHEARS methods. The audiologists measured changes in pure-tone hearing thresholds, the lowest volume that a pitch can be detected by the participant in a given ear, over the course of three years. An audiologist presented tones of different frequencies (0.5, 1, and 2 kHz as low frequencies; 3 kHz and 4 kHz as mid-frequencies; and 6 kHz and 8 kHz as higher frequencies) at variable “loudness” levels, and partici-pants were asked to indicate when they could just barely hear the tone.Using more than 20 years of dietary intake information that was collected every four years beginning in 1991, the researchers investigated how closely participants’ long-term diets resembled some well-established and currently rec-ommended dietary patterns, such as the DASH diet, the Mediterranean diet, and AHEI-2010. Greater adherence to these dietary patterns has been associated with several important health outcomes, including lower risk of heart disease, hypertension, diabetes, stroke, and death as well as healthy aging.The team found that the likelihood of a decline in mid-frequency hearing sen-sitivities was almost 30% lower among those whose diets most closely resem-bled these healthful dietary patterns, compared with women whose diets least resembled the healthful dietary patterns. In the higher frequencies, the odds were up to 25% lower.“The association between diet and hearing sensitivity decline encompassed frequencies that are critical for speech understanding,” Curhan says. “We were surprised that so many women demon-strated hearing decline over such a rel-atively short period of time. The mean age of the women in our study was 59 years; most of our participants were in their 50s and early 60s. This is a younger age than when many people think about having their hearing checked. After only three years, 19% had hearing loss in the low frequencies, 38% had hearing loss in the mid-frequencies, and almost half had hearing loss in the higher frequen-cies. Despite this considerable worsening in their hearing sensitivities, hearing loss among many of these participants would not typically be detected or addressed.”The study included female health care professionals, which enhanced the validity of the health information collected and reduced the variability in educational achievement and socioeconomic status, but the study population was limited to predominantly middle-aged, non-Hispanic white women. The authors note that further research in additional populations is warranted. The team hopes to continue to longitudinally follow the participants in this study with repeated hearing tests over time and is investigating ways to collect research-quality information on tens of thousands of participants for future studies across diverse populations. SOURCE: BRIGHAM AND WOMEN’S HOSPITALFEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  11

Milk Soy Protein IntoleranceDietitians are poised to help identify and treat infants with this uncommon digestive disorder.New moms certainly have plenty to manage. Between recovering from childbirth, sleep deprivation, and the overall adjustment to a new way of life, it’s fair to say that having a new baby may be among the most stressful times in a woman’s life.But many women experience an additional stressor they weren’t expecting: managing their baby’s food intolerance. Milk soy protein intolerance (MSPI) is a condition that affects somewhere between 2% and 5% of infants, often presenting around the infant’s third or fourth week of life. 1Symptoms of MSPI may include mucus and/or blood in the infant’s stool, diarrhea, gas, reflux, and colic. Pediatricians may run a guaiac test to confirm the presence of blood in an infant’s stool, but there’s no specific diagnostic test to con-firm the condition, so the diagnosis generally is believed to be determined once the suspected foods are removed from the infant’s diet and symptoms resolve. This requires either switching the infant to a special formula or having the breast-feeding mother eliminate the suspected foods from her diet, as the milk and soy proteins she consumes pass into her breastmilk. Fortunately, MSPI generally doesn’t last beyond a child’s third year of life and often resolves as early as 10 or 12 months of age. Since cow’s milk protein intolerance alone is more common that the combined milk and soy protein intolerance, parents typically are advised to first eliminate cow’s milk from the mother and/or baby’s diet. If symptoms don’t fully resolve, the family may need to eliminate soy protein and other top allergens.And although milk and soy are among the “top 8” food allergens (the others include wheat, eggs, fish, shell-fish, peanuts, and tree nuts), and an infant’s condition may be referred to informally as an allergy, it’s important to recognize that MSPI isn’t an immu-noglobulin E–mediated food allergy. It also differs from lactose intolerance. The intolerance in MSPI is to the pro-tein component of the offending food (eg, casein in the case of milk), whereas lactose intolerance is characterized by a deficiency in lactase, the enzyme required to break down milk sugar. Chrissy Carroll, MPH, RD, is a Massachusetts-based dietitian with firsthand experience managing MSPI in her breast-fed infant. “Within a few weeks of my son’s birth, we started noticing that he was very fussy and had mucus in his stool.” Carroll says. “When our guaiac test came back positive, we were told to cut dairy [from my diet]. After that didn’t completely alleviate symptoms, we realized we also needed to cut soy and eggs [from my diet].” Carroll considered herself lucky to be working with a pediatrician who had knowledge of MSPI, because many women have a much different experience. “For my first child, my pediatrician was not familiar with MSPI at all,” says Ann Dunaway Teh, MS, RD, owner of Dunaway Dietetics in Marietta, Geor-gia. “I did all of my own research and presented it to him as something to try rather than reflux medicine. He told me to try it if I wanted to but didn’t seem to be interested beyond that in the results.” Children’s Nutrition By Diana K. Rice, RD, LD, CLEC12 TODAY’S DIETITIAN• FEBRUARY 2020

Teh’s maternal instinct was right. She saw a dramatic improvement in her son’s reflux and colic after eliminating dairy from her diet. Fortunately for both Carroll and Teh, they possessed the skills as dietitians to do their own research and learn about and understand their infants’ condi-tion. But for the general public, access to medical professionals who are aware of MSPI can be hit-or-miss, leading many to turn to the internet for answers.“A big problem is that moms are des-perate and cling to inaccurate infor-mation shared in Facebook groups or blogs,” Carroll says. “This type of ‘research’ can be helpful, but it can also be dangerous because it can encour-age additional restrictions that are not always necessary.”Inspired by her own experience, Carroll founded a blog called Dairy-Free for Baby (dairyfreeforbaby.com), an evidence-based online resource for women breast-feeding infants with MSPI. There, she shares creative dairy-free recipes and credible information on managing the condition for women who are suddenly faced with going dairy-free. Because management of MSPI comes during the chaotic time of having a new baby, families are sure to benefit from a supportive medical team that includes the care of a dietitian.For new moms who want to breast-feed, RDs can help by guiding women through a diet free from dairy and pos-sibly soy. A woman should learn not only alternative sources of protein and cal-cium to support her needs for lactation and postpartum recovery but also the many hidden sources of dairy and soy, such as supplements that contain lac-tose. Dietitians also can serve as integral members of the family’s medical sup-port team, coordinating with pediatri-cians and gastroenterologists on when a family should consider eliminating additional allergens and advocating for families who suspect their infants have MSPI when others on the medical team are doubtful or uninformed about the condition.Of course, not all new mothers choose to or can breast-feed. In these cases, special formula is indicated, as infant formula almost always contains either milk or soy proteins. “The initial inter-vention when a milk and/or soy protein intolerance or allergy is identified, and the baby is formula fed, is to change to a hydrolyzed infant formula,” says Nicole Lattanzio, RD, CNSC, CSP, a Phoenix-based dietitian who owns The Baby Dietitian, PLLC, and works with fami-lies to select the most appropriate infant formula. “These formulas are hypoal-lergenic and available over the counter. They’re appropriate for both milk and soy protein intolerances as well as other allergens such as eggs.” However, not all babies respond well to a hydrolyzed formula. “If baby contin-ues to have symptoms of intolerance or allergy with a hydrolyzed formula after about two weeks, the next line of treat-ment is an elemental infant formula,” Lattanzio says. “These formulas are made from 100% free amino acids and are hypoallergenic as well. Elemental formulas are significantly more expen-sive and require a prescription to obtain; therefore they should be used only when necessary.”Dietitians also should support mothers who wish to continue breast-feeding despite pressure to switch to formula from friends, family, and other providers. Lattanzio often finds that providers sometimes see switching to formula as the preferred first line of treatment with MSPI. “I encourage moms to advocate for themselves and their breast-feeding goals. If mom is open to changing her diet and has the education to do so, that should be the first treatment. More times than not, changing mom’s diet leads to improved outcomes in babies with MSPI, and formula is not indicated.”In some cases, formula may serve as a temporary intervention. “It really depends on the baby and if they’re thriving despite having MSPI,” Lattan-zio says. “If baby is having issues with growth and possibly anemia related to MSPI, he or she may need some formula supplementation during the time mom is adjusting her diet.”Since MSPI often resolves near the end of infancy and babies start solids around six months, it’s important for parents to start with solids their chil-dren haven’t reacted to and try only small amounts of the problematic foods under the guidance of a pediatric gas-troenterologist and dietitian once other solids are well tolerated.“I remained dairy-free for about 10 months with both children,” says Teh, whose second child experienced both milk and soy intolerance. “I reintro-duced both foods very slowly. I started with foods that had dairy and soy as ‘hidden’ ingredients, and, when that was tolerated, I slowly advanced to foods that had more dairy or soy in [them]. Sometimes it would be through what I was eating, and other times it may have been in a food I was feeding directly to my baby.”Carroll had a similar experience. “We started with one food category at a time when my son was a year old,” she says. “Luckily, he had outgrown everything!”And though some women may dis-cover that they enjoy having less dairy in their diets long-term, many are ecstatic to relax about reading labels and once again enjoy their favorite foods. “I can’t describe how wonderful it was to eat cheese again,” Carroll proclaims.Diana K. Rice, RD, LD, CLEC, is known as The Baby Steps Dietitian and is the founder of Diana K. Rice Nutrition, LLC, where she works with families to eat well and reduce the stress surrounding their food choices. She specializes in pre- and postnatal nutrition as well as feeding young children and is a strong advocate for cooking with kids, family meals, and body positivity.For reference, view this article on our website at www.TodaysDietitian.com.Milk soy protein intolerance is a condition that affects somewhere between 2% and 5% of infants, often presenting around the infant’s third or fourth week of life. FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  13

Eating Disorders in Type 1 DiabetesA Primer on What They Are, Why They Happen, and How RDs Can HelpWhen Asha Brown was diagnosed with type 1 diabetes at age 5, her father—who also has type 1—taught Brown to manage her diabetes so well that it became second nature to her. In fact, young Brown was proud to be “like her dad.” She and her father were featured in American Diabetes Association fundraising advertisements in the 1990s. But at age 14, Brown became uncomfortable about having the dis-ease. Learning that type 1 diabetes and taking insulin are associated with weight gain, she began omitting insulin occasionally for energy and weight control. This intermittent habit turned into a routine—omitting or not taking enough insulin, bingeing, restricting food, and then promising herself she’d change, only to repeat the cycle. Brown continued this pattern until she was 24. Now in her 30s, she’s recov-ered from her eating disorder but lives with several chronic conditions resulting from a decade’s worth of insulin omission. Until recently, Brown’s condition was called “diabulimia,” a port-manteau of “diabetes” and “bulimia,” and a term with which many RDs likely are familiar. However, this condition now is referred to as ED-DMT1—which loosely stands for “eating disorders in type 1 dia-betes”—meant to more accurately and broadly describe the dual diagnosis of an eating disorder and type 1 diabetes. Brown described her experience with ED-DMT1 to a packed room of diabe-tes educators and RDs at the Ameri-can Association of Diabetes Educators (AADE) annual meeting in Houston in August 2019. Her message to practi-tioners: ED-DMT1 is overlooked and undertreated, and it can kill. Knowing how to speak with younger type 1 diabetes patients can help RDs not only effectively screen for ED-DMT1 but also avoid and discourage lan-guage and patterns of thinking that could unintentionally trigger an eating disorder.Branches of ED-DMT1ED-DMT1 can involve any eating disorder seen in the general population, and each manifests differently within ED-DMT1, including in the following ways :1• Anorexia: Patient will limit or reduce food intake and/or avoid taking insulin.• Bulimia: Patient will binge with com-pensatory behavior such as insulin omission, overexercising, vomiting, and diuretic or laxative abuse. This is the most common eating disorder in type 1 diabetes. 2• Binge eating disorder: Patient will overdose insulin to “justify” a binge.• Purging disorder: Patient will con-sume food normally with compensa-tory behaviors involved in bulimia. In any of these diagnoses, insulin commonly, but not always, is overused, underused, delayed, omitted, or tam-pered with to render it ineffective when used. Compensatory behaviors, food 2,3restriction, and bingeing also can occur in those with type 1 without the patient meeting formal criteria for one of the previously described eating disorders or the more generalized eating disorder, not otherwise specified diagnosis, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5 Editionth; these behaviors are commonly referred to as disordered eating. 4ConsequencesHowever an eating disorder, disordered eating, and insulin misuse manifest, they all can result in young patients Diabetes By Hadley Turner14 TODAY’S DIETITIAN• FEBRUARY 2020

with type 1 experiencing diabetes com-plications—such as retinopathy, kidney disease, and neuropathy—they might otherwise have encountered much later in life or not at all. Jessica Setnick, MS, RD, CEDRD, an eating disorder expert and creator of the Eating Disorders Boot Camp training workshop, explains that “dysfunctional eating and insulin behaviors exacerbate the potential long-term complications of diabetes. Whereas appropriate management of diabetes may stave off those complications for the next 30 or 40 or 50 years, problematic behaviors can cause the complications we’re used to seeing in a 70-year-old person at a much younger age.”Susan Weiner, MS, RDN, CDE, FAADE, a speaker, author, and consul-tant, who copresented the session on ED-DMT1 with Brown at AADE 2019, adds life-threatening diabetic ketoaci-dosis (DKA) as a potential consequence of omitted or reduced insulin. In DKA, the body breaks down fat rapidly when it doesn’t have enough insulin to use glucose as fuel, leading to a buildup of ketones in the bloodstream. Symptoms include weakness and fatigue, frequent urination, excessive thirst, nausea and vomiting, confusion, and shortness of breath. Without immediate treatment at an emergency department, DKA is fatal. 5Increased mortality has been seen in observational studies on insulin restric-tion. In an 11-year study of 234 women with type 1 diabetes (mean age 45), there was a three-fold increased risk of mor-tality with insulin restriction, as well as higher rates of nephropathy and foot problems. Thirty percent had reported insulin restriction at baseline, and mean age of death was younger among these participants (age 45 vs 58). 6PrevalenceAs with eating disorders among the general population, exact figures for ED-DMT1 are unclear due to poor detection. Some studies have esti-mated prevalence of any eating disorder among the population with type 1 to be 10% to 33%, compared with an esti-mated 3.8% among the general popula-tion. Risk of onset is greatest during 7-9the preteen and teen years for all young people, the age range during which many type 1 diagnoses occur. 3Disordered eating patterns that don’t meet the criteria for a formal eating dis-order diagnosis are more common; in one 14-year study of 126 girls aged 9 to 13, nearly 60% at the end of the study (when participants were at average age 23.7 years) reported disordered eating behaviors, with the most common disor-dered behaviors being dieting and insu-lin omission. The young women in this study received typical type 1 diabetes care, but researchers noted that eating disorder and disordered eating behav-iors—especially and most concerning, insulin omission—increased during the course of the study. 7Overall risk of developing an eating disorder is two to three times higher among women and girls with type 1 dia-betes than those in the general popula-tion. There’s no incidence data for men and boys, though they, too, experience ED-DMT1. 2Why the Increased Risk?Why are patients with type 1 so much more likely to develop eating disor-ders and disordered eating behaviors? The reasons aren’t entirely clear, but it’s thought that the emphasis on food that’s necessary to manage type 1 diabetes is a significant factor. There’s carbohy-drate counting, meal planning, blood glucose checks, and the sense of failure when glucose doesn’t fall within the pre-scribed range. It’s a numbers game, Weiner says. “A person with type 1 diabetes is count-ing carbohydrates constantly. They’re constantly timing their insulin. Every-thing they do is constantly being counted,” she says. Weiner emphasizes that multiple factors affect blood glu-cose—including hormone levels, stress, and menstruation—meaning it’s unre-alistic to expect to have “perfect” blood glucose levels all the time, something many people with diabetes don’t real-ize. A desire for complete control—a trait endemic to eating disorders and disor-dered eating patterns—over blood glu-cose levels easily can lead to distorted views of food and unhealthful eating and insulin behaviors.Setnick adds that this hyperfocus on food at such a young age compounds the stress of growing up “in a world of disor-dered eating.” Indeed, adolescents with type 1 diabetes aren’t immune to the typical risk factors for eating disorders and disordered eating, including genetic factors, comorbid psychological disor-ders such as anxiety and depression, trauma, loss, social pressure, media exposure, and unhealthful/abusive rela-tionships. Of note, depression and anxi-ety are more common in type 1 diabetes than in the general population, possibly further increasing eating disorder risk. 1,3In addition, the ways in which health care professionals respond to the emo-tions and visit outcomes of people with type 1 diabetes can trigger—or help pre-vent—an eating disorder and disordered eating behaviors. When people with type 1 visit with a health care professional, many times they’re viewed only in terms of their A1c or blood glucose outcomes as opposed to as a person, Weiner says. “And if [these metrics are] for whatever reason not within a targeted range, the body language of a health care profes-sional, let alone the verbal language of a health care professional, really sets [individuals] off, and they feel blame, shame, and guilt beyond anything we want them to experience,” she says. “This can sometimes lead to negative out-comes” such as eating disorders and dis-ordered eating.Counseling StrategiesHow can RDs avoid making patients with type 1 diabetes feel this blame, shame, and guilt that can lead to disor-dered eating or eating disorders, as well as process the emotions that emerge throughout their diabetes journey? Knowing how to speak with younger type 1 diabetes patients can help RDs not only effectively screen for ED-DMT1 but also avoid and discourage language and patterns of thinking that could unintentionally trigger an eating disorder.FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  15

Weiner and Setnick, as well as Brown during her presentation, offer the fol-lowing practice pointers for RDs, which, while they may not all directly relate to eating disorders or disordered eating, can help young patients feel empowered and enable RDs to provide care when emotional challenges arise:• Look for clinical and behavioral signs of eating disorders and disordered eating. Certain red flags may pop up throughout treatment that could indi-cate an eating disorder or disordered eating. Unexplained high A1c, episodes of DKA, and hypoglycemia can be clini-cal indicators of ED-DMT1. Patients reporting traditional eating disorder symptoms regardless of diabetes status such as excessive exercise, discomfort with eating or taking insulin in front of friends and family, and hoarding food also may be at risk. Changes in weight 1,8may or may not be present, so RDs shouldn’t use this factor alone as evi-dence of an eating disorder.Some common warning signs Weiner has seen in her practice include clients canceling appointments, claiming they can’t upload tracked blood glucose infor-mation onto data sharing software, and not running out of test strips, lancets, or other supplies for checking blood glucose.• Ask questions. Setnick emphasizes the importance of asking patients questions—as many as possible, but “kindly and curiously” without giving off an air of suspicion by asking too many. She suggests: “What are you worried about?”; “How can I support you?”; “What is your understanding so far of the nutrition needs of your condition?”; and “How has your eating changed since your diagnosis?” Asking questions provides “a golden opportunity for the dietitian to offer to clear up any misconceptions, address any fears, and then give the individual confidence that the dietitian is there and willing to answer questions that come up, even between appointments,” Setnick says. However, Setnick says, asking too many questions can give patients the impression that you don’t trust them—they may shut down and feel accused or defensive. Be sure these questions are “open-ended and nonjudgmental,” Weiner adds. In other words, listen more than you speak, and let the patient have the floor. • Listen carefully to the answers.Weiner says RDs sometimes are pro-grammed as “fixers”—they know they have answers for clients and they want to help, especially in the face of a lifelong condition that requires daily, dedicated management. This isn’t necessarily a fault, she says, but it doesn’t always rep-resent what people with diabetes need in a given moment, which is perhaps simply an ear for their feelings to be validated.Setnick agrees: “Sometimes what someone needs isn’t information but affirmation. Don’t try to use informa-tion as a solution for feelings,” she says. For example, “if [a young patient] says, ‘I’m really afraid that if I inject my insu-lin incorrectly, I’ll die,’ the answer is not, ‘Well, I will help teach you how to do it correctly.’ Of course [the patient] needs to be taught how to do it correctly, but someone has to address the fear.”Furthermore, Setnick says, RDs shouldn’t assign feelings to patients or assume how they feel, such as saying to a patient, “You’re so lucky that we have insulin.” The appropriate action is to ask questions about how the patient is feel-ing instead of assuming. Setnick sug-gests queries such as, “How are you coping with this?”; “Do you ever get down about this new diagnosis?”; and “When you get down, what do you do about it?” If the patient is struggling to cope, Setnick suggests adding a mental health professional to the diabetes care team to help them develop healthful coping strategies. • Avoid stigmatizing language. This rec-ommendation is obvious to most if not all RDs, but it may not be obvious what that language looks like when speaking with young people with type 1 diabetes. Weiner stresses using person-first lan-guage (ie, someone is a “person with dia-betes,” not a “diabetic”), a trend that’s starting to catch on with many RDs and other health care professionals. She also recommends asking whether a person has “checked,” not “tested,” his or her blood glucose. “‘Test’ implies pass-fail,” she says. Weiner views the terms “control,” “compliance,” and “adherence” as judgmental and points RDs to the 2017 consensus report “The Use of Language in Diabetes Care and Education” by the American Diabetes Association and AADE (available at https://care.diabetesjournals.org/content/diacare/early/2017/09/26/dci17-0041.full.pdf), which argues these terms connote laziness, carelessness, and a lack of motivation on the patient’s part. This stigmatizing language can lead to poor psychological outcomes such as depression and anxiety and discourage self-care behaviors. Instead, state what the patient does or doesn’t do in objective terms, such as “He takes his medication about half the time.” The consensus report offers other language substitutions when speaking with patients, such as “manage” instead of “control,” and providing suggestions (eg, “Have you tried …”) vs imperatives (eg, “You shouldn’t …”). 10Another instance in which Setnick would be sure to use language carefully is in discussing meeting with a mental health professional. She believes patients with type 1 diabetes and their families often can benefit from mental health counseling to cope with the stresses of managing a chronic condition but avoids saying they “need to see a psy-chologist” or “need to go to counseling.” “In my experience, teens (and some-times parents) can misinterpret that as, ‘This person must think I’m really screwed up,’” she says. Her suggestions: “I’d like us to bring a counselor onto our team,” or “Let’s get some advice from someone who is a specialist in this type of situation.”Diabetes16 TODAY’S DIETITIAN• FEBRUARY 2020

• Don’t use scare tactics. In the vein of language to avoid, both Setnick and Weiner vehemently disagree with using scare tactics such as telling patients the worst possible complications. Set-nick says scare tactics are harmful for any patient—those with type 1 diabetes, eating disorders, and beyond—but they’re especially damaging to patients who already suffer from depression or anxiety.“For example, if [a patient] is anxious, telling them, ‘If you do this wrong, you could die,’ will just make them more anx-ious. If [a patient] is depressed, telling them [the same thing] might make them say, ‘Well, it’s all over anyway, so I might as well give up.’ Everyone interprets information through their own lens, and you don’t know how the person is going to take that information,” she says. • Know when to seek help and make referrals. While Setnick believes all RDs should have a toolbox equipped to help patients with dysfunctional eating behaviors, she says, “If you feel like you’re out of your league, call an eating disorder RD for a professional consulta-tion. Your main question is essentially, ‘Can I provide what this patient needs with some coaching from an expert? Or is it in the best interest of the patient for me to refer them out of my care?’” Setnick says that a strong working relationship with a patient and family sometimes can be equally or more important than eating disorder exper-tise, but if your discomfort or uncer-tainty hampers your ability to provide nutrition care, it’s better to refer the patient to an expert who can then con-sult with you or other members of the patient’s diabetes care team. (She doesn’t recommend a patient work con-currently with two different RDs.) If a patient’s eating issues have progressed beyond outpatient management, an evaluation for an eating disorder pro-gram may be more helpful than general medical or psychiatric hospitalization. Weiner recommends the eating disor-der treatment center Melrose Center, with locations throughout Minnesota, which boasts a program specifically for ED-DMT1. As of early 2020, Alsana, which comprises five eating recovery centers in California, Missouri, and Alabama, offers a treatment plan for ED-DMT1 patients as well. Setnick reminds RDs there’s no “once-and-done” screening for ED-DMT1. As they work with patients, RDs need to “be on the constant lookout for misunder-standing” about diabetes, food, insulin, and other aspects of disease manage-ment. At diagnosis, let families know not only what highs and lows feel like but that they may experience fear, defeat, and other “emotional complications.” Setnick tells new patients, “‘Some people might have a temptation to give up and say this is too hard, and if you start to feel that way, please let me know. Some people start to feel like they have to shut their whole life down in order to take care of this, and if you start to feel like that, please let me know.’ “I think if we can prepare someone for the potential extremes of what they might experience, we can help them feel not as shameful or shocked if and when it does happen,” she continues. “And even more importantly, they’ll know where to turn.”Hadley Turner is associate editor of Today’s Dietitian and RDLounge.com, the blog written for RDs by RDs.For references, view this article on our website at www.TodaysDietitian.com.

Beyond Calcium and Vitamin D Plant Antioxidants Strengthen Bone Health During the past few decades, osteoporosis has emerged as a major public health concern among the boom-ing older adult population. Approximately 10 million Americans have osteoporosis, while another 44 million have low bone density, plac-ing them at increased risk of the condi-tion. Women especially are vulnerable 1to increased bone loss during and after menopause. Medications to treat osteoporosis have been effective, but currently there are no FDA-approved drugs that can help prevent it. Calcium plus vitamin D supplementation along with exer-cise have been the mainstays of preven-tion, but studies on these measures have shown only marginal improvement in slowing bone loss. Although dietary 2,3calcium does lower bone turnover by about 10%, it hasn’t been demonstrated to reduce bone fracture rates. Evidence from research studies con-tinues to suggest that certain vitamins, minerals, food groups, and even dietary patterns play an important role in skele-tal health. For example, greater fruit and vegetable intakes have been associated with higher bone mineral density (BMD), along with less BMD loss over time. 4Recently, the role of plant-derived com-pounds has been examined, based on the idea that certain phytochemicals increase the rate of bone deposition by osteoblasts (cells that secrete the matrix for bone formation) and decrease the rate of bone breakdown by osteoclasts (cells that break down bone). Some stud-ies have implicated oxidative stress in the pathogenesis of osteoporosis. Bone health depends on a dynamic equilibrium maintained between the constant production of new bone via osteoblasts and the resorption of old bone by osteoclast activity. Osteoblasts synthesize collagen and protein for the bone matrix and promote calcification. In osteoporosis, bone mass and density decrease with the loss of bone matrix and mineralization; bone resorption exceeds bone formation, leading to thin, fragile bones subject to spontane-ous fracture.Vitamin CDuring the 15 century, maritime thexplorers suffering from scurvy due to a vitamin C deficiency reported severe bone pain. Yet the significance of vita-min C on bone metabolism has become evident in just the past few decades. Most of the human studies on vitamin C and bone health have been observational but have shown significant positive effects. As an antioxidant, the benefits of vitamin C are regulated through a series of complex mechanisms of interaction essential to building both cartilage and bone by stimulating the production of osteoblasts. Vitamin C also prevents osteoclast differentiation. Although there’s some inconsistency in studies conducted in humans, most conclude that reduced serum vitamin C levels or intake may be associated with the devel-opment of osteoporosis and increased risk of fracture. 5The Framingham Osteoporosis Study (an ancillary study of the Framingham Heart Study) also investigated vitamin C in suppressing osteoclast activity through its antioxidant action. The study reviewed data from food-frequency questionnaires along with BMD among the original cohort of subjects between the ages of 68 and 96. Men with higher 4dietary vitamin C intake showed less femoral neck BMD loss compared with the lowest tertile of dietary vitamin C consumption. For both genders, participants in the highest category of supplemental vitamin C intake had 69% fewer hip fractures compared with nonsupplement users. CarotenoidsDietary carotenoids, especially the bright red carotenoid lycopene, reduce oxida-tive stress associated with the risk of osteoporosis and the levels of bone turn-over as seen in postmenopausal women. 6In the original cohort of the Framing-ham study, lycopene intake was protec-tive against lumbar spine BMD loss in women. Participants with the highest tertile of total carotenoid intake had 46% lower hip fracture risk, and participants with higher lycopene intake had 34% lower risk of hip fracture. Other studies of low lycopene intake have shown signif-icant increases in oxidative stress param-eters, which were reversed with lycopene supplementation. Taken together, these 7,8results suggest a protective role of several carotenoids for BMD and fracture risk in older adults with most consistent results for lycopene intake. Senior Wellness By KC Wright, MS, RDN18 TODAY’S DIETITIAN• FEBRUARY 2020

Plant CompoundsFrequent onion consumption appears to be associated with increased bone density. Three compounds isolated from onions may be responsible: sulf-oxide is believed to work by inhibiting the production of osteoclasts. The other two compounds, the flavonoids querce-tin and kaempferol, have been shown to cause apoptosis (programmed cell death) in mature osteoclasts. Other research has demonstrated that these three compounds stimulate osteoblasts to increase bone deposition. 2Bone resorption (when osteoclasts break down bone tissue and release minerals, resulting in a transfer of cal-cium from bone to the blood) appears to be affected by certain plant com-pounds. Common fruits, such as oranges and prunes; vegetables including toma-toes, green beans, cucumbers, broccoli, and lettuce; the herbs dill, sage, garlic, parsley, thyme, and rosemary previ-ously have been classified to possess bone resorption–inhibiting properties (BRIPs). In a 2015 study, healthy post-9menopausal women were randomized to receive either a diet of at least nine daily servings of vegetables, herbs, and fruit classified as containing BRIPs; nine daily servings of ad lib vegetables; or their usual diet. The group consuming plant foods with the highest content of BRIPs showed a significant decrease in bone turnover markers compared with the other dietary groups. 10Dietary PatternsThe incidence of osteoporosis and asso-ciated fractures is found to be lower in countries that predominantly follow the Mediterranean diet. A key constituent 11of the Mediterranean diet, extra-virgin olive oil (EVOO), contains more than 30 phenolic compounds with antioxidant activities. Polyphenols in EVOO have been shown to stimulate the prolifera-tion of osteoblasts. Recent research has explored the mechanisms of EVOO’s phenolic compounds that underlie the protective effects on bone by study-ing the gene expression of osteoblast-related markers. The findings indicate 12that bone physiology may be modulated by phenolic compounds in EVOO, sup-porting previous observations on their action on osteoblasts at different levels, favoring bone tissue regeneration. The plant compounds in EVOO exert a stim-ulatory effect on markers involved in osteoblast proliferation, differentiation, and maturation. Practice Pearls Traditionally, nutrition research has focused on single nutrients in relation to health. This approach is limited because it doesn’t account for diet quality or nutrient synergy, or that a single nutrient may be too small to detect. Perhaps most important is that isolating nutrients makes it difficult to translate results into dietary recommendations. Recently, researchers confirmed that adequate intake of nutrients from food—but not dietary supplements—is linked to a reduction in poor health outcomes. 13According to Fang Fang Zhang, MD, PhD, an associate professor of nutrition at Tufts University and corresponding author of the study, “While supplement use contributes to an increased level of nutrient intake, there are beneficial associations with nutrients from foods that aren’t seen with supplements.” 14Thus, RDs should continue to practice food first. Diets rich in fruits and vegeta-bles contain both a plethora and expan-sive variety of phytochemicals that have been shown to suppress the proinflam-matory milieu and bone loss associated with aging. Data from the Framingham research suggest that subjects who con-sumed the most fruits, vegetables, and cereal grains had the greatest BMD at all bone sites. It’s important to reinforce the USDA’s dietary guidelines aimed at five to 13 servings of fruits and vegetables daily. 3Demonstrating to seniors what consti-tutes a portion size of these plant foods would be useful, especially since the Centers for Disease Control and Preven-tion reports that only 1 in 10 adults con-sumes enough. 15Adequate calcium and vitamin D intake remain a nutrition focus for bone health. The Recommended Dietary Allowance (RDA) for calcium is 1,000 mg for men and 1,200 mg for women aged 51 to 70; beyond the age of 70, the RDA is 1,200 for both. For best absorption, calcium should be consumed from food in amounts of 300 to 500 mg, as the body can’t absorb more than that at one time. Vitamin D facilitates calcium absorption and thus bone mass and strength. In addition, vitamin D affects muscle performance, balance, and risk of falling. However, it can be difficult, if not impossible, to get an adequate amount of vitamin D from food. The RDA for older adults (both men and women) aged 51 to 70 is 600 IU, and it increases to 800 IU beyond age 70. According to Beth Dawson-Hughes, MD, a professor of medicine and director of the Bone Metabolism Laboratory at Tufts University, vitamin D is limited to “foods that people don’t tend to eat daily like fatty fish.” She 3emphasizes that “a serving of most fortified cereals provides only 40 IU, and a cup of milk has just 100 IU.” Mushrooms, especially if exposed to sunlight, along with other fortified foods, such as dairy, are good sources of vitamin D, but for some people, a dietary supplement may be needed.Dawson-Hughes also recommends protein, as it composes about one-half of bone. She says, “Consuming protein stimulates insulinlike growth factor-1, a growth factor that builds both bone and muscle.” The RDA for protein for adults older than 50 is 46 g for women and 56 g for men, but this is a minimum. Some older adults may need more protein (1 to 1.2 g protein per kilogram of body weight). With increased rates of over-weight and obesity, many older adults also are dieting. Care should be taken to avoid very low-calorie diets, as low BMD has been reported in obese women who consume fewer than 1,000 kcal per day. 16When working with older adults, RDs need to emphasize a plant-based diet with nutrient-dense foods high in bio-available vitamins, minerals, phyto-chemicals, and antioxidants that help to support bone health. RDs can seek opportunities to integrate these rec-ommendations as part of a multidisci-plinary team, serving seniors in both primary care and geriatric settings. KC Wright, MS, RDN, is a research dietitian at Dartmouth Hitchcock Medical Center in New Hampshire and focuses on sustainable nutrition at wildberrycommunications.com.For references, view this article on our website at www.TodaysDietitian.com.FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  19

Cancer Card&

Cardiology and oncology often are considered separate medical fields, yet they frequently intertwine. Cardiovascular health before a cancer diagnosis and cardiovascular effects of cancer treatments both influence health outcomes in cancer survivors. This article explores the growing field of cardio-oncology and potential opportunities for dietitians to play a valuable role. Although cardiovascular risk factors increase in many cancer survivors, discussion of modifying these risk factors during and after cancer treatment, especially through lifestyle, may not be addressed as recommended. Statements from cardiovascular and oncology professional organizations now emphasize the need to promote heart-healthy lifestyles for cancer survivors.1,2 Growth of Cardio-OncologyCurrently, more than 16.9 million people in the United States have a history of cancer. The number of US cancer survivors is predicted to increase further—to more than 22.1 million by 2030—based only on the growth and aging of the population. 3Almost two-thirds of cancer survivors are aged 65 or older. And people living at least five years beyond a 3cancer diagnosis have significant increases in CVD risk factors and a 1.3- to 3.6-fold greater risk of death from CVD compared with age-matched counterparts with no history of cancer. CVD may become even more preva-2lent among oncology patients; the population of aging adults is growing, and continued improvements in suc-cess of cancer treatment bring potential for late effects that can emerge months or even years after comple-tion of cancer treatment. As a result, cardio-oncology 2,3(sometimes called onco-cardiology) programs are grow-ing, dedicated to the prevention and treatment of CVD in patients with cancer. 4Cancer Treatment and CVD RiskIncreased risk of CVD in cancer survivors can reflect combined effects of several factors. These include common age-related changes, direct consequences of cancer treatment, and indirect results of cancer and its treatment (including cardio-respiratory deconditioning and weight gain), acting across multiple body systems. 2Some side effects can occur during cancer treatment, although late effects may go unseen until months or decades after treatment.Efforts to address cardiovascular risk related to cancer therapy often have focused on the early detection and prevention of congestive heart failure. Yet cancer treatments can cause a variety of cardiovascular tox-icities, including cardiac arrhythmias, hypertension, thromboembolism, valvular disease, accelerated ath-erosclerosis and ischemic heart disease, and peripheral vascular disease and stroke.2,5-7To prevent or minimize these effects, work is in progress to identify ways to adjust treatment choice, dose, and timing, or provide additional cardio-protective treatments. Risk identified in cohort studies often reflects older protocols and doesn’t account for advances in methods to reduce cardiotoxicity. Still, although these side effects occur in a minority of patients, the health impact is significant when they do. And survivors with past exposures to cardiotoxic therapies should continue to be considered at increased risk for developing cardiac dysfunction. 1Heart failure is a progressive disorder that can develop during or after cancer treatment. During treat-ment, it can cause interruption or discontinuation of cancer-directed therapy, potentially reducing the chance for long-term survival. It may result as a side 1,3effect of anthracycline chemotherapy (eg, doxorubi-cin), HER2-targeted therapy, or radiation therapy with the heart in the field of treatment. These treatments 6,7commonly are used for breast cancer and certain leuke-mias and lymphomas, including those that are among diovascular CareAn Overview of This Emerging Practice AreaByKaren Collins, MS, RDN, CDN, FANDFEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  21

the most common cancers in children and adolescents. Risk of heart failure is greatest in people with two or more CVD risk factors, and blood pressure management is an important strat-egy in its prevention. 1Ischemia already may be present in many adults, and it can be enhanced by some cancer treatments, including a variety of chemotherapy agents and radiation therapy. 7This may occur through changes in lipid metabolism and inflammation-mediated acceleration of atherosclerosis. Hypertension, smoking, dyslipidemia, and insulin resistance all seem to trigger atherosclerosis by promoting endothelial cells’ expression of adhesion molecules and enabling leukocyte attachment to blood vessel walls.8People at greatest risk of adverse cardiovascular side effects of cancer treatment are those with older age, a history of myocardial infarction or other heart disease, or two or more major risk factors (eg, smoking, hypertension, diabetes, dyslipidemia, obesity). Survivors of childhood cancer also are 1at increased risk of cardiovascular late effects. Current clinical practice guidelines state that clinicians should screen for and actively manage the aforementioned major modifiable CVD risk factors in all patients receiving or previously treated with potentially cardiotoxic treatments. These guidelines also say that a heart-healthy lifestyle, including the role of a healthful diet and exercise, should be discussed as part of their long-term follow-up care.1,9Dietitians, therefore, can be valuable members of the car-dio-oncology health care team with skills to address side effects of cancer treatment that affect the ability to eat and nourish the body, promote dietary choices that affect CVD risk factors, and help set priorities among those choices on an indi-vidual basis. The American Society of Clinical Oncology clini-cal practice guidelines state that patients need to be advised that cardiac dysfunction can be a progressive disorder that initially may be asymptomatic. Therefore, “a heart-healthy lifestyle, including the role of diet and exercise, should be dis-cussed with all patients with cancer before and after comple-tion of their cancer therapy.”1Mutual Risk Factors Both cancer risk and CVD risk are associated with various risk factors, some that can’t be modified (such as family his-tory of the disease) and some that can (through lifestyle choices and/or medical care). One reason for the frequent overlap of cancer and CVD is that age is a steady independent risk factor for both. Although a few cancers (such as neuro-blastoma, nephroblastoma, and certain sarcomas) strike pre-dominantly in childhood, 78% of the new cancer diagnoses in developed countries occurs in those aged 55 and older. How-ever, it’s important to remember that associations between age and onset of both cancer and CVD can be highly influ-enced by modifiable risk factors, including diet, physical activity, BMI, and smoking.8Tobacco SmokingTobacco smoking contributes to all stages of atherosclerosis by decreasing levels of nitric oxide and causing vasomotor dys-function, while the multiple carcinogens it contains signifi-cantly increase cancer risk. Tobacco promotes both CVD and cancer by causing oxidative stress that leads to endothelial and DNA damage and by increasing inflammation.8DiabetesBoth type 1 and type 2 diabetes increase risk of CVD and cancer. Risk from type 2 diabetes involves inflammation, hyperglycemia, hyperinsulinemia, and elevated levels of insu-linlike growth factor (IGF). Elevated triglyceride-rich lipo-8proteins commonly seen in type 2 diabetes increase risk of myocardial infarction and stroke through inflammation and enhanced formation of foam cells that lead to atherosclerosis. 10Chronic hyperinsulinemia and resulting elevated IGF enhance cancer development by promoting cell proliferation and inhib-iting apoptosis (self-destruction of abnormal cells).11-13 Elevated insulin levels also decrease liver production of sex hormone–binding globulin, thus increasing bioavailable estrogen and testosterone, increasing risk of hormone-sensitive cancers. 12In type 1 diabetes, oxidative stress stemming from chronic elevated blood glucose is considered the primary link to CVD, possibly amplified by a dysfunctional immune response.14,15Type 1 diabetes has been associated with increased risk of some cancers, but the link is less well understood at this time. 11Some chemotherapeutic agents can worsen blood glucose control, and radiation therapy can increase risk of develop-ing diabetes. Thus, dietitians’ skills in helping people modify eating habits for better blood sugar levels can be valuable.HyperlipidemiaHyperlipidemia is a well-established risk factor for CVD. LDL cholesterol traditionally has been the primary target for risk reduction, but very LDL, intermediate-density lipoprotein, and other non-HDL cholesterol fractions also are atherogenic.10,16Evidence is inconclusive about any association of serum cho-lesterol and cancer risk. Current evidence suggests that the inverse association between levels of LDL and cancer incidence seen in some studies may be a result of the malignancy. 8CARDIO-ONCOLOGY GUIDELINESAmerican Heart AssociationScientific Statement on Cardio-Oncology Rehabilitation (CORE): www.ahajournals.org/doi/10.1161/CIR.000000 0000000679American Society of Clinical OncologyClinical Practice Guideline on Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: https://ascopubs.org/doi/10.1200/JCO.2016.70.5400National Comprehensive Cancer Network Clinical Practice Guidelines to assess and address survivorship (free after registration): www.nccn.org/professionals/physician_gls/default.aspx22 TODAY’S DIETITIAN• FEBRUARY 2020

HypertensionHypertension is another major established CVD risk factor. It causes structural changes in blood vessels and the heart, which can lead to heart failure, and induces oxidative stress that promotes atherosclerosis. Increased oxidative stress also contributes to increased cancer risk, and, by increasing vascu-lar endothelial growth factor (VEGF), it may potentiate devel-opment or progression of cancer. 8VEGF signaling pathway inhibitor treatments are used for a variety of advanced or metastasized cancers. They block angio-genesis (growth of blood vessels) that supports tumor growth but also can cause or increase hypertension, which indicates success in targeting cancer-blocking effects in blood vessels. 6However, these elevations in blood pressure, whether new or from destabilization of previously controlled hypertension, can lead to heart failure and other forms of CVD, so current reviews emphasize maintaining blood pressure control. 6,7ObesityObesity increases CVD risk by acting through major risk fac-tors (eg, type 2 diabetes and hypertension) and possibly through atherogenic dyslipidemia and emerging risk factors such as insulin resistance, a proinflammatory state, a pro-thrombotic state, and sleep apnea commonly found in people with obesity. Obesity also increases metabolic demands of cardiac output, requiring increased stroke volume, which can lead to increased left ventricular filling pressure and volume overload. Cancer risk due to excess adiposity seems related 8to many of the same conditions, such as inflammation and insulin resistance, as well as increased estrogen production in postmenopausal women. Although most research on body 17fat’s link to chronic disease has used BMI as a marker of over-weight and obesity, this doesn’t address the complexity of body composition or adipose tissue. Dysfunctional adipose tissue, which is characteristic of most, but not all, people with over-weight and obesity, is centrally involved in development of the metabolic disturbances that promote CVD and obesity-related cancers and obesity-associated increased mortality rates.18,19Alcohol DrinkingAlcohol in moderation has been associated with reduced CVD risk in observational studies, although without data from randomized controlled trials. However, this occurs in a 8well-documented “J-shaped dose-effect curve,” with excessive alcohol leading to elevated triglycerides, hypertension, cardiomyopathy, increased cardiovascular events, and all-cause mortality.5,8,20 Evidence shows a causal relationship between alcohol and risk of several cancers.5,8,21 This may involve the genotoxic effect of acetaldehyde (the primary metabolite of alcohol), oxidative stress, increased estrogen levels, effects on folate metabolism (needed for healthy DNA), and alcohol’s ability to serve as a solvent for carcinogens. Increase in cancer risk is most substantial when consumption is beyond moderation (defined as up to one standard drink per day for women and two per day for men). However, even light drinking of up to one drink per day poses some increase in women’s risk of breast cancer and in risk of esophageal and oropharyngeal cancers. (See “Alcohol Consumption and 21Cancer Risk — The Other Side of a Health Halo,” in the April 2018 issue of Today’s Dietitian.)Although alcohol is a well-established risk factor for the development of certain cancers, it’s unclear how postdiagnosis alcohol use affects cancer treatment and long-term survival. One systematic review and meta-analysis shows increased cancer recurrence, but no association with overall mortality. 22As for prevention, cancer survivors are advised to limit alcohol to no more than one drink per day for women or two per day for men. The National Comprehensive Cancer Network clini-9,23cal practice guidelines recommend survivors of liver, esopha-geal, kidney, and head and neck cancers abstain from alcohol. 9Cardio-Oncology RehabilitationCardiac rehabilitation (CR) programs aim to increase cardio-respiratory fitness, decrease anginal symptoms, improve psychosocial well-being, and reduce CVD-related morbid-ity, recurrent hospitalizations, and mortality. These multi-disciplinary efforts provide medical evaluation, prescriptive exercise, education, and counseling and behavioral interven-tions to modify CVD risk factors. CR has been demonstrated to reduce CVD mortality and improve health-related quality of life, and referral to CR is a recognized recommendation for people with acute coronary syndromes. In 2019, the American Heart Association issued a scientific statement proposing a cardio-oncology rehabilitation (CORE) model to adapt the mul-timodality approach of CR (with exercise, nutrition counseling, tobacco cessation interventions, and risk factor assessment) to decrease CVD events in cancer survivors at highest CVD risk. The scientific statement emphasizes that for CORE program effectiveness, CR program staff must be equipped to address both CVD- and cancer-related concerns, including nutrition. 2Exercise TrainingExercise training is the cornerstone of CR and is proven to improve cardiorespiratory fitness and reduce CVD symptoms in people with established CVD. Although more research is needed, controlled intervention trials in a variety of cancer populations show that exercise after cancer treatment is gen-erally safe and may lessen typical declines in cardiorespiratory fitness and muscle strength; reduce fatigue, anxiety, depressive FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  23

symptoms, and sleep disturbances; and improve health-related quality of life.2,24 Exercise’s potential benefits for treatment-related cardiotoxicity, peripheral neuropathy, and cognitive functioning remain uncertain. In addition to its potential for 24reducing risk of several forms of cancer, moderate evidence 21supports postdiagnosis physical activity to improve cancer-specific and all-cause survival following breast, colorectal, and prostate cancer. 25Health professionals need to recognize unique exercise-related needs of some cancer survivors. For example, anemia, compromised immune function, neuropathy, balance problems, an ostomy or indwelling catheter, bone metastases, presence of or risk factors for breast cancer–related lymphedema, and decreased bone density as a result of hormonal treatments may require modifying the type or amount of exercise. A 2018 international roundtable 24of experts developed guidelines for assessing the needs of people during and after cancer therapy, and referring them to appropriate options to support physical activity.24,26NutritionNutrition is a core component of primary and secondary pre-vention of CVD, reducing cancer risk, and lifestyle recom-mendations for cancer survivors. The American Institute for Cancer Research (AICR) recommends that after the acute stage of cancer treatment, people should follow the AICR recommendations for cancer prevention, unless otherwise advised by their health professional. As cancer survivors 21increasingly live longer, they’re at risk of developing new pri-mary cancers as well as other chronic diseases, and these rec-ommendations are appropriate for overall health as well as cancer-specific risk.Guidelines from national organizations specifically for cancer survivors recommend a dietary pattern that’s high in vegetables, fruits, and whole grains; limits red meat and refined sugars; minimizes alcohol; and provides heart-healthy sources of dietary fat.9,23 This pattern is consistent with the AICR recommendations for prevention. For breast cancer survivors, limited evidence suggests foods providing dietary fiber and foods containing soy (in moderation) may reduce all-cause mortality. 21During cancer treatment, and if ability to consume or metabolize food has been impaired by treatment, people may have special nutritional needs. Dietitians can help address taste changes or other side effects. Nutrition is also vital in combination with exercise to help cancer survivors achieve and maintain a healthy weight and body composition, as advised by current recommendations. 2,9Weight alone doesn’t adequately reflect changes in lean body mass, which can dramatically decrease with aging and during cancer treatment. Low lean body mass, whether reflecting unhealthy weight loss or as part of sarcopenic obesity, is associ-ated with poor health outcomes. Androgen deprivation therapy for prostate cancer can cause rapid development of sarcopenic obesity, so preventive attention is appropriate for care. 27Many survivors today have overweight or obesity at the time of their diagnosis, and this often continues or increases following treatment. Prediagnosis obesity increases the risk of 9cancer recurrence, cancer mortality, and all-cause mortality. These associations are most strongly documented for breast cancer, though overweight, obesity, and unintended weight gain also are associated with a worse prognosis for other cancer survivors.2,9,21Research is still unclear about the benefits of promoting weight loss in cancer survivors. Evidence does show reduction in comorbidities and in biomarkers linked with cancer risk and prognosis. Some clinical guidelines for cancer survivors 28encourage those with overweight or obesity to achieve and maintain a weight that’s healthy for them. Identified com-9,23ponents for CORE include addressing the spectrum of weight management issues. 2Through their content knowledge and behavior change pro-motion skills, dietitians can play a valuable role in the growing field of cardio-oncology, whether in specific CORE programs or as part of the overall health care system.Karen Collins, MS, RDN, CDN, FAND, is a nutrition consultant specializing in cancer prevention and cardiometabolic health, and nutrition advisor to the American Institute for Cancer Research.For references, view this article on our website at www.TodaysDietitian.com.CARDIO-ONCOLOGY RESOURCESCANCER SURVIVORSHIP American Institute for Cancer Research Diet, Nutrition, Physical Activity and Cancer: A Global Perspective: The Third Expert Report: www.wcrf.org/dietandcancerThe New American Plate Challenge guides weekly behavior change to meet recommendations: https://napchallenge.orgAmerican Society of Clinical OncologyCancer.Net provides information for cancer survivors on managing side effects: www.cancer.net/coping-with-cancer/physical-emotional-and-social-effects-cancer/managing-physical-side-effectsOncology Nutrition Dietetic Practice GroupEat Right to Fight Cancer provides information for patients and health professionals on dealing with side effects and addressing hot nutrition topics: www.oncologynutrition.org/erfcCARDIOVASCULAR NUTRITION National Lipid AssociationClinician’s Lifestyle Modification Toolbox (with patient education tear sheets): www.lipid.org/clmtUniversity Health Network at the Toronto Rehabilitation InstituteCardiac College offers free videos and handouts: www.healtheuniversity.ca/EN/CardiacCollege/Eating24 TODAY’S DIETITIAN• FEBRUARY 2020

Six delicious fruit-flavored blends make drinking water a daily treat.Adequate hydration is vital and improves body and brain health, improves body and brain health, while also promoting healthy skin.while also promoting healthy skin.SweetLeaf.com

Y You may think of the beetas a humble root vegetable, but this ruby red veggie has an extensive history, diversity, and culi-nary possibility hidden beneath the surface. Discover the origins of the beet we know today, the many shades of color and varieties it comes in, the powerful health benefits asso-ciated with it, and the many ways it can be used and enjoyed in the kitchen.HistoryDespite their array of culinary uses in today’s kitchens, beets weren’t always widely used or consumed. The earliest record of beets’ existence can be traced back to the Egyptians, where beet remains were discovered in Thebes, Egypt. The earliest written mention of the beet is from 8 century BC, when it thwas described as being similar to the radish. 1While it remains unknown whether beets were part of the Egyptian diet, it’s believed that consuming beets origi-nated along the coast of the Mediterranean Sea. Here they were cultivated not for their bulbous root but for their leafy green tops, which were consumed in a similar fashion to Swiss chard. Beet greens were so well liked that ancient 2,3Romans and Greeks developed a method to grow beets in the hot summer months, outside of the normal growing season in the spring and fall.The first account of the root being consumed can be traced back to the early 1500s, either in Germany or Italy. Early beet-root plants more closely resembled a carrot or parsnip than the bulbous shape we recognize today. Beets weren’t always a deep red color, either. Beets in Greek and Roman times were either black or white, as opposed to the red, white, and yellow varieties available today. Worldwide 2consumption of beets didn’t occur until they were recognized as being one of the few vegetables that grew well in the winter. Soon, they became a staple food in northeastern Europe.3In addition to the culinary uses of the greens and root, beets were used to create a form of sugar. In 1747, a Berlin chemist named Andreas Sigismund Marggraf discovered a way to create sucrose from the humble beet. It wasn’t until Marggraf’s student, Franz Achard, perfected the method for extracting sugar from beets that the rise in products such as beet beer, molasses, and other beet sugar–containing foods began to flood the market. This sweet alternative rose in popularity even more when Napoleon banned all sugar imports in 1813. This cut off supplies of both sugar and products made with sugar cane, leaving a wide open market for beet sugar. To this day, beets account 1,3for about 20% to 30% of the world’s sugar production.1,3,4Both the roots and leaves of beets have a history of medici-nal uses as well. The Romans used beets as a treatment for a number of ailments, including constipation and fevers, and in the Middle Ages for illnesses involving digestion and blood.1Beets first made their way to the United States with Euro-pean immigrants in the early 19 century. By then, the beet thhad evolved into its modern-day bulbous shape and deep red hue. With their earthy flavor and vibrant color, beets now are available, used, and enjoyed worldwide.BotanyThe scientific name for the common beetroot plant is Beta vulgaris, which stems from the Latin words for “beet” and “common.” It goes by many other names such as the Euro-pean sugar beet, red garden beet, Harvard beet, blood turnip, mangelwurzel, mangel, spinach beet, and, most commonly, simply a beet. The beetroot plant is an ancestor of the wild sea beet (Beta vulgaris subsp. maritima), which most likely originates from the Mediterranean.4Beta vulgaris encompasses four varieties of plants: Swiss chard, garden beets (simply, beets), mangelwurzel, and sugarBeetsThe History, Myriad Uses, and Health Benefits of These Beloved Roots 26 TODAY’S DIETITIAN• FEBRUARY 2020

ByJESSICA LEVINSON, MS, RDN, CDN

beets. Swiss chard is cultivated solely for its edible leaves, while garden beets are grown for their roots and leaves. Mangelwurzel is most often fed to livestock, while the thick roots of sugar beets are used to make sugar. In addition to the four main varieties found within the Beta vulgaris species, there are also many varieties of the common beet. These include the white Albina Vereduna, the yellow-fleshed Burpee’s Golden, the Italian Chioggia with concentric red and white rings, and multiple varieties of the most com-monly known red beet.1Beets are considered a root vegetable, grown in a similar fashion to carrots, parsnips, and radishes. The bulbous root is attached to purple-green, variegated leaves by long stems that extend above the ground. Beets, which grow best in moist, well-drained soil in full sunlight, can grow upwards of 8 to 12 inches in height. 5Most often, beets require 50 to 70 days from planting to har-vest, but the greens can be trimmed and used before the root matures. Seeds of the beetroot plant can be planted in early 5spring and harvested through October. They do well when planted next to kohlrabi, bush beans, and onions, and have no major troubling insects that affect their growth. However, beet-root plants are sensitive to boron deficiency, which can lead to an undesirable growth called blackspot. Much like other root vegetables, beets are hardy and have a long shelf life if stored in a cool, dark place.2Beet Nutrition and Health BenefitsA 1-cup serving of cooked beets contains roughly 75 kcal, 3 g protein, 17 g carbohydrates, 3 g fiber, and less than 1 g fat. A good source of potassium and folate, beets contain other essen-tial vitamins and minerals, including magnesium, iron, phos-phorus, and B vitamins.6The leafy green tops, often referred to as beet greens, come with a unique nutrient profile. A 1-cup serving of cooked beet greens (with no added fat or seasoning) contains 39 kcal, 4 g protein, 8 g carbohydrates, 4 g fiber, and less than 1 g fat. Beet greens also are an excellent source of vitamins A, C, and K.7Aside from macro- and micronutrients, beets are full of phy-tochemicals, such as phytosterols, betalains such as betanin, nitrates and nitrites, and carotenoids, many of which show poten-tial for boosting cardiovascular health and athletic performance. 8The common beet holds the potential for unique and specific health benefits, mostly associated with the phytochemicals and inorganic compounds found within them. These include phy-tosterols, betanin, and inorganic nitrates.Phytosterols, also known as plant sterols, are cholesterol-like compounds found in plant foods such as beets, Brussels sprouts, almonds, and kidney beans. Some studies have shown that regularly consuming foods containing phytosterols can help lower blood cholesterol levels by slowing the absorption of dietary cholesterol and the production of cholesterol in the liver. One cup of raw beets contains about 45 mg of naturally 9occurring phytosterols.8Betanin not only helps to give beets their blood red color but also has a unique set of potential health benefits. Research has suggested that betanin has antioxidant and anti-inflammatory properties and can help prevent LDL oxidation and DNA damage.10While many consumers have negative perceptions of nitrates and nitrites in food, the truth is that 80% of dietary nitrates come from vegetables, with beets being an especially rich source. When inorganic nitrites are consumed through diet, they’re converted to nitric oxide in the body, which is thought to contribute to the potential blood pressure–reducing effects of dietary patterns high in plant foods such as the DASH diet.11Inorganic nitrates also have been linked to enhancing exer-cise performance. Preliminary studies have shown that con-sumption of beetroot juice helped participants perform exercise faster with a lower perceived energy exertion, as well as improve overall physical performance. Positive results of nitrate supple-mentation are especially prevalent in constant, high-intensity exercise such as running and cycling, but benefits also have been seen in walking and knee extension exercises.12,13Cooking With BeetsBeets have a myriad of culinary possibilities. They tend to have a sweet, yet earthy, flavor, often attributed to the chemical compound geosmin. Research is inconclusive as to whether the beets themselves produce this compound or if it comes from the microbes found in soil. 1Beets can be used and enjoyed in several ways, including raw, boiled, steamed, roasted, and pickled.Raw beets have a very firm texture and therefore aren’t often consumed. Steaming or boiling beets helps to soften the flesh, but preparing beets from their raw form can be a messy ordeal. For clients who don’t want to deal with the mess, beets are avail-able canned whole or sliced. One of the most common traditional ways to enjoy boiled beets is in the Russian soup borscht. This beet-based soup, which has been around since the 14 century, often is made with a mix-thture of beets, onion, potatoes, and carrots, boiled and blended until smooth, flavored with fresh dill, and topped with a dollop of fresh sour cream.2Roasting beets either whole or cubed helps to caramelize the natural sugars within the vegetable, giving them a more intense, sweeter flavor. Golden beets tend to be sweeter and less bitter than red beets. Roasted beets can be enjoyed on their own, as a salad topper, or mixed with other root vegetables such as car-rots, parsnips, and potatoes for a hash.Pickling beets is a popular and long-standing way of prepar-ing this vegetable. Cooked beets are soaked in a brine mixture made of sugar, salt, vinegar, water, and spices. This pickling process not only adds a pleasant flavor, but the vinegar mix-ture also is thought to help the beets retain their vibrant color. Aside from the root, beet greens can be cooked and enjoyed in a similar fashion to other leafy green vegetables such as kale, Swiss chard, and spinach. While beet greens can be consumed raw, they’re especially tasty steamed or sautéed with garlic and oil. Surprisingly, beet greens aren’t as bitter as other greens, but rather lend a mild, sweet flavor, especially when cooked.Jessica Levinson, MS, RDN, CDN, is a nationally recognized nutrition expert with a focus on culinary nutrition and communications. She’s the author of 52-Week Meal Planner: The Complete Guide to Planning Menus, Groceries, Recipes, and More. You can read more of her articles and find her recipes at JessicaLevinson.com. Follow her on Twitter, Instagram, and Facebook jlevinsonrd.@For references, view this article on our website at www.TodaysDietitian.com.28 TODAY’S DIETITIAN• FEBRUARY 2020

Roasted Root Vegetable Salad With Pomegranate Ginger DressingServes 8IngredientsDressing1/2 cup 100% pomegranate juice1 T lemon juice1 tsp freshly grated ginger2 T olive oil1 tsp whole grain Dijon mustard1/4 tsp ground cinnamon1/4 tsp kosher saltFreshly ground black pepper, to tasteSalad1 cup cubed carrots1 cup cubed parsnips1 cup quartered Brussels sprouts2 T olive oil, divided1 cup cubed butternut squash1 cup cubed sweet potatoes1 cup cubed beets6 cups arugula1/4 cup pomegranate seeds1/4 cup toasted pecan halvesDirections1. To make the dressing, in a small bowl or covered Mason jar, com-bine all the dressing ingredients. Whisk together or shake in closed jar until emulsified. Shake again before using.2. Preheat oven to 400˚ F. Line two large baking sheets with aluminum foil or parchment paper.3. On one prepared baking sheet, toss carrots, parsnips, and Brus-sels sprouts with 1 T olive oil. Spread in a single layer.4. On second prepared baking sheet, toss butternut squash, sweet potatoes, and beets with remaining tablespoon olive oil. Spread in a single layer.5. Place both trays in the pre-heated oven and roast until all vegetables are tender and brown in spots, approximately 15 minutes for the tray with carrots and 20 minutes for the tray with butter-nut squash. Stir halfway through cooking time for even browning. Remove from oven and set aside until cool enough to handle.6. In a large bowl, combine arugula with roasted root vegetables, pomegranate seeds, and toasted pecans. Drizzle about two-thirds of the Pomegranate Ginger Dressing over salad and toss to combine. Store remaining dressing in the refrigerator for another use.Nutrient Analysis per serving Calories: 246; Total fat: 8 g; Sat fat: 1 g; Cholesterol: 0 mg; Sodium: 71 mg; Total carbohydrate: 43 g; Sugars: 23 g; Dietary fiber: 5 g; Protein: 3 gRECIPE AND PHOTO COURTESY OF JESSICA LEVINSON, MS, RDN, CDN, CULINARY NUTRITION EXPERT AND RECIPE DEVELOPER. FIND MORE OF HER RECIPES AT JESSICALEVINSON.COM.Beet and Goat Cheese Quinoa SaladServes 4Ingredients1/2 cup dry quinoa1 cup cold water1 T olive oil2 tsp lemon juice1/4 tsp kosher saltFreshly ground black pepper, to taste1 cup cooked, diced beets1/4 cup crumbled goat cheeseDirections1. To prepare the quinoa, place in a small to medium saucepan and add water. Bring to a boil over high heat, then reduce heat, cover, and simmer gently for 10 to 15 minutes, until all the water is absorbed.2. Transfer cooked quinoa to a large bowl and let it cool. Add olive oil, lemon juice, salt, and pepper to taste. Toss to coat the quinoa.3. Add beets and goat cheese and fold into the quinoa mixture. Serve at room tempera-ture or chilled.Nutrient Analysis per serving Calories: 218; Total fat: 12 g; Sat fat: 5 g; Cholesterol: 27 mg; Sodium: 354 mg; Total carbohydrate: 19 g; Sugars: 3 g; Dietary fiber: 2 g; Protein: 10 gRECIPE AND PHOTO COURTESY OF JESSICA LEVINSON, MS, RDN, CDN, CULINARY NUTRITION EXPERT AND RECIPE DEVELOPER. FIND MORE OF HER RECIPES AT JESSICALEVINSON.COM.FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  29

Exciting new product innovations in the lactose-free dairy category con-tinue to draw consumers who would otherwise bypass the aisle. The marketplace for lactose-free products had been relatively limited and stable in the years after the increased availability of lactase enzymes. Options generally featured lactose-free milk and ice cream, along with lactase products for consumers to use with conventional dairy products. But with the increasing popularity of plant-based and naturally lactose-free alternatives to milk and yogurt, the dairy industry has sharpened its focus on eliminating lactose from more of its products. The recent expansion beyond milk and into yogurt, kefir, cottage cheese, and other dairy products—previously avoided by those who can’t handle lactose—enables people who are lactose intolerant to benefit from the variety and nutrient package dairy delivers. Equally exciting are new technologies to reduce lactose while often enhanc-ing nutritional attributes of dairy products. Overview of Lactose IntoleranceLactose intolerance is defined as an inability to digest lactose, the primary carbohydrate in dairy milk. The enzyme lactase, required for lactose digestion, is produced by the villi in the small intestine. Lactase breaks down lac-tose from beverages and foods into two simple sugars, galactose and glucose. These sugars then are absorbed through the intestinal wall and into the bloodstream. Lactose intolerance can result from a primary lack of adequate lactase production, the most common cause and often occurring with age, or a secondary inadequacy resulting from inflamma-tory bowel disease, celiac disease, malnutrition, or other conditions that damage the surface of the small intestine and/or cause atrophy of intestinal villi. People with lactose intolerance can develop symptoms of abdominal pain, bloating, gas, nausea, and/or diarrhea shortly after consuming lactose or up to several hours later. This occurs due to a combination of gut bacteria converting lactose into simple sugars in the large intestine—lactose acting as a prebiotic—and the increased presence Spotlight onLACTOSE-FREEDAIRYBy Mindy Hermann, MBA, RDN30

New products and technologies enable consumers to enjoy dairy and get the nutrients they need.

of fluid in the large intestine to dilute the undigested lactose and resultant simple sugars.Lactase production in the intestine typically is strong in infancy and begins to decline in early childhood, although some infants have a defect in the LCT gene that prevents them from tolerating nonbreastmilk sources of lactose. (Breastmilk contains both lactose and the enzyme lactase.) A majority of adults around the world are lactose intolerant. Across the spectrum of lactose intolerance are people who can’t digest even small amounts and people who can handle a modest dose, according to Kate Scarlata, RDN, LDN, a Massachusetts-based digestive health expert and coauthor of The Low-FODMAP Diet Step by Step. “Monash University in Melbourne, Australia, sets a threshold of 0.5 g of lactose per eating occasion for people who cannot tolerate lactose, but I’ve observed that many of my clients can handle up to 6 g of lactose, the amount in half a cup of fluid milk, per sitting.” Body size and genetic differences also influence degree and symptoms of intolerance. People with a larger body 1mass and those from dairy-consuming cultures tend to be able to handle larger amounts of lactose at a time. Globally, about two-thirds of adults lose some or all of their ability to tolerate lactose after infancy because of decreased expression of the LCT gene and the regulatory MCM6 gene over time. Lactose intolerance is most common among populations of indigenous North American, East Asian, West African, Arab, Jewish, Greek, and Italian descent, and least prevalent in populations from Northern Europe and other regions whose diet regularly includes unfermented dairy products. People 2who are intolerant of lactose are more likely to develop symptoms after consuming conventional fluid milk, yogurt, sour cream, and dairy desserts, as well as whey protein, and least likely to react to hard cheese and other dairy products containing only small amounts of lactose.Lactose on LabelsLactose content is represented by the amount of carbohydrate and total sugars on the Nutrition Facts panel of an unsweet-ened or dairy product or one sweetened with nonnutritive sweeteners. In milk and dairy products that don’t contain sugar or other nutritive sweeteners, the amount of total sugars listed on the label represents lactose content. For example, one cup of plain fluid milk contains 12 g carbohydrate, all from lactose; a lactose-free milk produced traditionally by adding lactase contains the same amount of total sugars as in the milk before treatment with lactase. The now lactose-free milk will taste sweeter than nontreated milk because the lactose has been con-verted to the simple sugars glucose and galactose. Lactose-free milk doesn’t contain added sugars; any added sugars listed on the Nutrition Facts panel can be attributed to nutritive sweet-eners such as cane sugar, honey, and others.Government guidance for a lactose-free claim on fluid milk doesn’t exist in the United States. Globally, lactose-free prod-ucts generally reduce lactose down to 0.5% or 0.1%, although some countries require a reduction down to <0.01%. 3Lactose-Free Fluid MilksLactose-free milk traditionally has been created by treating conventional or organic fluid milk with the lactase enzyme. Lactaid is among the best known of the lactase-treated milks, and the company also produces lactase enzyme tablets to be taken at the same time as dairy consumption. The introduc-tion of ultrafiltration as a processing option has opened the door for a wider variety of lactose-free milks. The brands fair-life, based in Chicago, and Organic Valley, based in La Farge, Wisconsin, both use ultrafiltration to remove some of the lactose from fluid milk. The ultrafiltration process also con-centrates the protein in fluid milk by removing liquid whey. Ultrafiltered milk then is treated with lactase enzyme to con-vert the remaining lactose into simple sugars. Both brands promote their lactose-free milk as having 50% more protein and 50% less sugar than regular milk. Organic Valley also offers a lactose-free, high-protein milkshake.Slate, based in Boston, recently introduced its first prod-uct line, lactose-free chocolate milk in a shelf-stable can. This product is positioned for adults on the go rather than for chil-dren. Slate’s products are ultrafiltered, followed by treatment with lactase. Like other lactose-free chocolate milk produc-ers, Slate sweetens its products with a combination of cane sugar and a nonnutritive sweetener but adds less sugar than many other brands. Slate uses monk fruit, popular for its natu-ral origins; combinations of nonnutritive sweeteners also are common in chocolate milk products. Self-described dairy disruptor JoeFroyo, based in Upland, California, developed a proprietary process for creating a lactose-free cultured dairy base using high-pressure processing, a cold-pasteurization technology best known for producing bottled fresh juices. The company’s Cold-Pressed Creamery line of cold-pressed dairy products includes milk, probiotic cold brew-cold pressed milk beverages, and a “clean label” creamer. Yogurt and KefirSome people who can’t tolerate lactose-containing liquid milk can consume conventional yogurt without developing symp-toms because the live and active cultures in yogurt help break down lactose. In addition, it’s thought that because yogurt travels more slowly than milk through the gastrointestinal tract and since lactic acid bacteria in yogurt survive the stom-ach’s acidic environment, lactic acid bacteria have adequate time to help digest lactose before and while it passes through the small intestine. 3Lactose-free yogurts typically are made from a base of lactose-free milk. The bacterial cultures used to ferment lactose-free yogurt don’t require lactose to grow and flourish. They can feed on all of the macronutrients in milk, as well as on the simple sugars generated from lactose or added for sweetening. Some lactose-free yogurts differentiate themselves by starting with a base of strained or ultrafiltered milk, with its concentrated amounts of protein and lower amounts of lactose. Yogurt cultures and lactase then are intro-duced to remove the remaining lactose. Certain brands add 32 TODAY’S DIETITIAN• FEBRUARY 2020

LACTOSE-FREE PRODUCTSProduct*Serving SizeCaloriesProtein (g)Total Sugars (g)Calcium (% DV)Vitamin D (% DV)MILKfairlife Fat-Free Ultra-Filtered Milk1 cup (240 mL)8013 (26% DV)63025Horizon Organic Lactose- Free Reduced Fat Milk1 cup (240 mL)1308 (16% DV)122515Lactaid Calcium-Enriched Low-Fat 1% Milk1 cup (240 mL)1108 (16% DV)125025Skim Plus Lactose-Free Fat Free Milk1 cup (240 mL)11011 (22% DV)164025Organic Valley Ultra Ultra- Filtered 2% Chocolate Milk1 cup (240 mL)16013 (26% DV)123515Slate Dark Chocolate Milk1 cup (240 mL)12017 (34% DV)93525YOGURT AND KEFIRActivia Strawberry Probiotic Lactose-Free Yogurt4 oz (113 g)904 (8% DV)12150GoodBelly Probiotics Lactose-Free Low Fat Strawberry Yogurt1 5.3-oz container (150 g)13011 (22% DV)15810Green Valley Creamery Lactose-Free Plain Reduced Fat Greek Yogurt3/4 cup (170 g)9016 (32% DV)4120Green Valley Creamery Lactose-Free Organic Plain Low Fat Kefir1 cup (240 mL)13011 (22% DV)11400CHEESECabot Medium Yellow Cheddar Cheese1 oz (28 g)1107 (14% DV)0150Polly-O Low Moisture Whole Milk Mozzarella Cheese1 oz (28 g)907 (14% DV)0150Président Brie Cheese1 oz (28 g)1005 (10% DV)0100Philadelphia Original Cream Cheese1 oz (28 g)1002 (4% DV)120Green Valley Creamery Lactose-Free Cottage Cheese1/2 cup (113 g)11012 (24% DV)26 0Lactaid Cottage Cheese1/2 cup (113 g)11013 (26% DV)480ICE CREAMBeckon Vanilla Ice Cream1/2 cup (99 g)2204 (8% DV)1866Lactaid Vanilla Ice Cream1/2 cup (71 g)1502 (4% DV)1280SOURCE: COMPANY WEBSITES * THIS LIST REPRESENTS A SAMPLING OF MANY LACTOSE-FREE AND LOW-LACTOSE PRODUCTS ON THE MARKET.FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  33

proprietary probiotic strains for specific benefits—for exam-ple, digestive health or immune response. Nevertheless, lactose-free yogurts may or may not be suit-able for a low-FODMAP diet, depending on their source of sweetening. “Eliminating lactose gets rid of a major FODMAP source, but products sweetened with agave, honey, fructose, or certain fruits add a different source of FODMAPs and should be avoided by people trying to eliminate FODMAPs,” Scarlata says.CheesesMost hard cheeses are naturally low in lactose. Lactose is found pri-marily in the whey component of milk and cream, the liquid that’s drained off from curds during the cheese-making process. The curd—sometimes rinsed to remove any remaining whey—eventu-ally is turned into cheese. Any small amount of lactose on the curds is consumed by lactic acid bacteria during the ripening process for making hard cheeses such as parmesan, Swiss, and cheddar.“Many people don’t realize that all cheddar cheese, for example, is lactose-free as a result of the aging process,” explains Sara Wing, RD, health program director at Cabot Creamery in Waitsfield, Vermont. “Cheeses that undergo a nat-ural aging process contain little to no lactose.”Softer cheeses such as Brie and cream cheese contain small amounts of lactose. Their lactose content is low enough (1 to 2 g/oz) to be tolerated by many people who are lactose intolerant as long as the cheeses are consumed in small portions. Cottage cheese, in contrast, must be treated to remove lactose because its curds are packaged in milk or a combination of milk and cream; burrata, a cheese that consists of unfermented cream encased in mozzarella, likewise isn’t lactose-free. Other Dairy ProductsOther dairy products have varying amounts of lactose. Ice cream and frozen desserts are made from cream and milk, both of which contain lactose. Their lactose-free counterparts are created by either starting with lactose-free milk and cream or adding lac-tase to the ice cream mix before freezing. Higher–dairy fat prod-ucts such as butter and ghee contain less lactose because of their low content of fluid whey. During butter production, whey and most of the water-soluble components in milk, including lactose, are removed, thereby reducing the lactose content in butter to <0.1%. Removing milk solids, which have trace amounts of lac-3tose, from butter yields ghee, a lactose-free dairy fat. New TechnologyDuPont recently introduced a new product, Nurica, that splits lactose into glucose and galactose and then connects the two simple sugars to form a nondigestible prebiotic fiber called galacto-oligosaccharide (GOS). GOS has been shown to allevi-ate symptoms of lactose intolerance while stimulating growth of particular strains of beneficial microorganisms. 4According to a representative from DuPont, Nurica offers a combination of benefits that include lactose reduction, sugar reduction, and GOS fibers that are key prebiotic ingredients in infant formula. “It is possible that GOS and other prebiotics could change the microflora in a way that enhances lactose tolerance for some people,” Scarlata says. “However, it’s impor-tant to go slowly. People who have a high concentration of mast cells in their intestine could become more reactive to lactose, as well as GOS and other prebiotics. Also, it’s hard to know which bacteria the lactose and prebiotics are feeding and whether the bacteria are beneficial.”Nurica hasn’t been launched yet in products in North Amer-ica but is approved for use in Europe, the Middle East, Africa, and Latin America. It won’t appear in the ingredient list, but the presence of GOS likely will be highlighted.In the fall of 2019, the start-up Perfect Day launched a limited-edition lactose-free ice cream made from an animal-free dairy protein created through a microflora fermentation process. For protein production, the company adds genes to Trichoderma, a fungus, to enable it to ferment plant sugar into the proteins whey and casein. The fungus doesn’t produce lactose.Implications for PracticePublic health recommendations continue to cite the impor-tance of consuming three dairy servings per day, including among those who can’t tolerate lactose. For people who enjoy 5dairy but can’t tolerate lactose, products labeled lactose-free can replicate the taste and nutrition benefits of dairy with little or no discomfort. “When looking for a lactose-free cheese, first look at the label,” Wing advises. “On every Nutrition Facts panel, you’ll find the amount of total sugar in that food. If it says 0 g, that means there’s no sugar, and no sugar means no lactose.” Because dairy products aren’t culturally significant for all populations, dietetics professionals should tailor their guid-ance to include lactose-free products and strategies when rel-evant and provide other sources of calcium and dairy nutrients for non-Western-style diets.“Each client’s food beliefs, culture, and lifestyle affect their food choices,” says Vandana Sheth, RDN, CDE, FAND, a Los Angeles–based private practitioner, author of My Indian Table: Quick & Tasty Vegetarian Recipes, and spokesperson for the Academy of Nutrition and Dietetics. “When it comes to dairy and dairy products, if a client doesn’t incorporate these and I notice a nutrition gap, I discuss lactose-free products as an option if they would like to try them. Clients who avoid dairy due to a specific belief or lifestyle may find dairy-free alterna-tives to be more acceptable, or they may prefer to avoid dairy products and dairy alternatives altogether. I always encourage my clients to share their cultural food stories with me so I can better help them meet their nutrition goals with or without lactose-free dairy products.”Mindy Hermann, MBA, RDN, is a food and nutrition writer and communications consultant in metropolitan New York.For references, view this article on our website at www.TodaysDietitian.com.34 TODAY’S DIETITIAN• FEBRUARY 2020

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Choline is an essential nutrient that plays a criti-cal role in several biological processes, but one byproduct of its metabolism is a molecule that’s been receiving much negative attention—tri-methylamine N-oxide (TMAO). Since TMAO was first reported as having a link to CVD in 2011, it’s been the focus of hundreds of research stud-ies. However, it remains unclear whether TMAO is a causal link between diet and CVD, or whether it’s simply a possible marker of underlying disease. Because the precursors of TMAO synthesis, including choline, have many health benefits, suggestions that people should limit dietary sources of choline, including eggs and meat, to prevent CVD may be premature. It seems that every day, dietitians learn more about the complex interconnections between nutrition, genes, and the gut microbiota in affecting health. This is one of those cases.Choline and Its Health BenefitsDespite the liver’s ability to synthesize choline, people need dietary choline as well, so the Institute of Medicine recognized choline as an essential nutrient in 1998. There’s no Dietary Reference Intake 1for choline, but the daily Adequate Intake (AI) for adults is 425 mg for women aged 19 and older, 450 mg during pregnancy, and 550 mg for men and lactating women. Recommendations are higher 2during pregnancy and lactation because choline is important for normal fetal and early childhood development, including reducing the risk of several birth defects linked to choline deficiency. Low maternal choline intake and plasma choline levels are associated with higher risk of neural tube defects, even when intake of dietary folate or supplemental folic acid is adequate. In addition, several 3,4randomized controlled trials have shown a beneficial effect of maternal choline supplementation on the brain health of offspring. 1Animal foods, especially eggs, beef, chicken, fish, and milk are the richest sources of choline. What about plant-based eaters? Cruciferous vegetables, certain beans, nuts, seeds, and whole grains also contribute choline to the diet. In spite of that vari-1,2ety, it’s estimated that only 11% of Americans reach the AI. That’s 5concerning, because choline plays a role in the epigenetic reg-ulation of gene expression, is a precursor for synthesis of the 6,7neurotransmitter acetylcholine, and is a component of the major phospholipids in cell membranes. Since choline is essential for 1,3transporting lipids from the liver, choline deficiency can lead to nonalcoholic fatty liver disease (NAFLD), which may be revers-ible with choline repletion through supplementation. Although 3,7most women of childbearing age are resistant to NAFLD because of their high estrogen levels, at least 40% have a polymorphism that removes this protection, so adequate consumption of dietary choline is important. 8So where does TMAO enter the picture? When humans ingest foods containing choline or carnitine, an amino acid derivative, it provides certain gut microbes with the materials to produce tri-methylamine (TMA), which then enters the portal circulation and travels to the liver, where enzymes oxidize TMA to TMAO. Most 9TMAO is excreted in the urine within 24 hours, about one-half of it unchanged, and about one-half being converted to TMA then back to TMAO in the liver. 10About one-third of choline in food is free choline, which gut microbes prefer. Most dietary choline is in the form of the phos-pholipid phosphatidylcholine, which isn’t an efficient TMA pre-cursor. Eggs are rich in choline, while beef is rich in both choline 10and carnitine. However, most of the choline in eggs isn’t free cho-11line but is bound up as part of lecithin, and lecithin also is a weak precursor for TMA. Notably, fish and seafood contain preformed 10TMAO, which protects enzymes in the fish from salt water.11By Carrie Dennett, MPH, RDN, CDCholineCVD and36 TODAY’S DIETITIAN• FEBRUARY 2020

Is there truth to the controversial claim that this essential nutrient puts heart health at risk?

TMAO: Marker, Causal Factor, or Something Else?Elevated TMAO levels are associated with CVD—especially athero-sclerosis—and other poor health outcomes, including the develop-ment or progression of hypertension, diabetes, and renal failure, but is TMAO a causative factor or simply a marker of disease? The 12origins of this question come from a 2011 study from the Cleve-land Clinic, which found an association between elevated fasting plasma levels of TMAO and choline and several types of CVD. The associations held even after adjustment for traditional cardiac risk factors and medications. 13While other studies have found associations between CVD and choline, TMAO, or both, some have not. For example, large popu-lation studies in Japan, the Netherlands, and the United States, including the Atherosclerosis Risk in Communities study, found no link between dietary choline intake and CVD. Unfortunately, these studies didn’t also measure circulating TMAO levels. A 142017 systematic review and meta-analysis in the Journal of the American Heart Association did find that high TMAO levels were a much stronger predictor of cardiovascular events than were elevated levels of its nutrient precursors, including choline. Pro-15posed mechanisms include effects on cholesterol, the hormone angiotensin II—which can raise blood pressure—and increased platelet clumping, possibly leading to blood clots.16,17“In my view, I don’t think they have very good evidence that TMAO is a causative element in the disease process,” says Marie Caudill, PhD, RD, a professor and researcher in the division of nutri-tional sciences at Cornell University in Ithaca, New York. “We’re at association at this point. It’s so murky. Association isn’t causation, but we seem to go down that road anyway.”The 2011 Cleveland Clinic study also added choline or TMAO to the diets of a species of mice that were at elevated risk of developing atherosclerosis, and found that the mice in fact developed athero-sclerosis. However, this species of mice lacks the gene responsible 13for the protein that drives reverse cholesterol transport, Caudill says. Reverse cholesterol transport is a process that removes excess cholesterol from the tissues and delivers it to the liver, where it can be excreted or recycled. “They’re looking at an animal model that doesn’t express all the genes humans do,” she says. “When you add that gene back in, TMAO has no adverse effect.” she says.One headline-grabbing detail of some TMAO studies is that vegans and vegetarians produce far less TMAO after consum-ing its precursor nutrients than do omnivores. For example, 18a 2017 study published in Circulation found that oral choline supplementation of approximately 450 mg choline per day for two months—an amount far above the AI when added to an omnivore diet—led to an increase in fasting blood TMAO levels and a corresponding increase in clumping of blood platelets. These increases were more pronounced in omnivores than they were in vegans and vegetarians and were attenuated by aspirin therapy, possibly because aspirin alters the gut microbe com-munity and interferes with TMAO production. What’s notable 19is that the percentage of platelet clumping varied widely within each diet group after supplementation, suggesting that a third factor led to differences between individuals.In an editorial in AME Medical Journal, Caudill stressed that supplemental choline was a more potent substrate for TMA/TMAO than the phosphatidylcholine from food. Furthermore, the study couldn’t measure hard disease endpoints. “The prob-20lem with surrogate markers is they don’t predict death,” Caudill says. “At the end of the day, what’s important is, does this reduce risk of disease or death?”A Function of Kidney Function? Blood TMAO level depends on several factors, including diet, the composition and function of the gut microbiota, permeabil-ity of the gut-blood barrier—which controls bacterial metab-olites’ access to the bloodstream—genetic regulation of liver enzymes, and how fast we can excrete TMAO in our urine. 16Lowered excretion due to impaired kidney function may have played a role in the results of a 2013 study that fed 40 healthy adults two large hard-boiled eggs, which contained about 250 mg choline, along with 250 mg supplemental choline that was marked so it could be tracked in the body after ingestion. Blood and urine levels of both total TMAO and marked TMAO rose after consumption, although after eight hours total TMAO levels were lower than they were before the challenge. Interestingly, after administering antibiotics and repeating the challenge, TMAO levels didn’t rise, which speaks to the role of the gut microbiota in TMAO production. Also notable? While average TMAO levels were associated with cardiovascular events, they were inversely associated with glomerular filtration rate (GFR). In other words, people with impaired kidney function had trouble clearing TMAO from their systems. 21Caudill says this is a critical detail in TMAO association studies, because most people older than age 55 to 60 are going to have some subclinical kidney impairment. “If your kidneys are slightly com-promised, that’s going to lead to an elevation in TMAO.” Kidney 12function aside, another potential wrinkle in association studies is that some research suggests the wrong player in the choline-TMA-TMAO cycle is being targeted. A 2019 study assessed TMA and TMAO levels in both healthy adults and cardiac patients—unusual, since the studies that have found associations between TMAO and increased cardiovascular risk generally haven’t mea-sured TMA levels. They found that the cardiac patients had TMA levels twice as high as levels in the healthy subjects, and that those levels were inversely correlated with estimated GFR, again sug-gesting that impaired kidney function plays a role. Interestingly, despite the significantly higher TMA levels, the cardiac patients only had slightly higher TMAO levels that didn’t reach statistical significance. The authors also found that TMA, but not TMAO, had biological effects that could harm the circulatory system—specifically, damaging the cells responsible for contracting the heart—and that treatment with TMAO actually protected these cells from damage. Moreover, many studies have found other 22protective functions of TMAO, including keeping cells from losing volume under stress.16,17,23Genetic and Microbial InfluencesDespite many researchers finding associations between TMAO levels and CVD risk and hypothesizing about potential causal mechanisms, no actual mechanisms have been determined. Scientists haven’t yet identified a dedicated TMAO receptor on cells, and little is known about which specific gut microbe spe-cies are the primary producers of TMA. So far, researchers only know which broader bacteria groups are associated with higher or lower circulating TMAO levels. 14“We differ in our gut microbiota,” Caudill says. “Those who are sick have a different gut microbiota than those who are well,” she says. “Those who have colon cancer may have a completely dif-ferent gut microbe population.” For example, Caudill’s group found that TMAO was elevated in women at higher risk of colon cancer in a study that used a subset of participants from the Women’s Health Initiative, but she 38 TODAY’S DIETITIAN• FEBRUARY 2020

says that lowering TMAO in those women wouldn’t lower cancer risk. “TMAO might be a great marker 24for a disrupted gut microbiome, or maybe a marker of greater kidney dysfunction than we thought,” Caudill says. “Then we could start treating the actual problem.”Determining the exact relationship between diet, gut microbes, and disease endpoints will be challenging, but it’s likely an important step in determining who—if anyone—might benefit from nutritional or pharmaceutical interventions to reduce TMAO production. In rats, a high-salt diet can increase plasma TMAO levels, decrease TMAO excretion in urine—and alter the gut microbiota. On 25the pharmaceutical front, the TMAO synthesis pathway has become one of the first gut microbiota targets for drug intervention to prevent CVD. 14Individual genetic variation also may play a role in elevated TMAO levels by increasing enzymatic conversion of TMA to TMAO in the liver by flavin-containing monooxygenases (FMOs). Humans have five FMO genes—and five FMO enzymes—but it’s the conversion of TMA to TMAO by FMO3 that may be a culprit in atherosclerosis and CVD. Several factors can increase FMO3 gene expression—estrogen and insulin increase it, while testos-terone and glucagon repress it. Notably, FMO3 expression is ele-vated in individuals with type 2 diabetes. What’s more, FMO3 17may have adverse effects on blood lipids and glucose indepen-dently of TMAO formation, although more research is needed.13,26Public Health RecommendationsSome research studies that have found associations between TMAO levels and CVD have gone so far as to recommend lim-iting or avoiding choline-rich foods and dietary supplements containing choline. Caudill says this isn’t only premature, but it’s concerning, because following that advice may have unin-tended consequences. “The demand for choline is so high,” she says, adding that there’s evidence that going above the AI may be beneficial in certain populations, while other populations may need to be cautious about supplementing with both choline and folic acid, which can increase cell division. But this requires a nuanced therapeutic approach, not a sweeping public health recommendation.“If you want to go that route, you would have to tell people to reduce their intake of fish,” Caudill says. “You may even have to tell people to eliminate fish.”It’s a conundrum that many fish species contain both TMA and TMAO. Fish intake acutely raises TMAO levels, yet fish is a significant component of the Mediterranean diet and inde-pendently has been shown to benefit cardiovascular health. A 16small 2017 study using participants in the larger European Pro-spective Investigation into Cancer and Nutrition trial to iden-tify blood markers of intake of various foods—for potential use in epidemiologic studies—found that TMAO was a good blood marker of intake of both lean and fatty fish. One 2017 study on 27healthy young men found that blood levels of TMAO were about 50 times higher after consuming fish than they were after con-suming eggs or beef. 28Liz Shaw, MS, RD, CLT, CPT, San Diego–based owner of Shaw’s Simple Swaps and a spokesperson for choline, says it’s important for dietitians to explain what TMAO really is, where it’s found, and what its uses are to demystify some of the headline hype. “We know very well within the RD world that science continues to support the importance of consuming seafood at least twice a week in a healthy diet.” Bottom Line for RDsIf it’s unclear which individuals may benefit from TMAO-lowering strategies, how can dietitians counsel their clients who have concerns?“I think it’s extremely important to always validate a client’s fears and help them recognize a safe and effective approach to rationally treating those fears,” Shaw says. Shaw adds that she thinks there’s enough evidence to support continuing to include foods that naturally may contain TMAO or potentially produce TMAO. “No one food (or compound) is going to be the trigger; it’s their environment, genetics, lifestyle, and nutrition plan that will have the biggest impact on their total health.” Clients who regularly eat eggs and meat tend to get enough choline in their diets, but vegans—and vegetarians who avoid eggs—need to be more thoughtful about meeting the AI. Con-suming foods such as Brussels sprouts, broccoli, cauliflower, soymilk, wheat germ, peanuts, and beans can help, but supple-mental choline may be needed to make up shortfalls.Shaw says she often recommends helping clients take steps to improve the balance of their gut microbiota through their food choices, rather than cutting out choline-rich foods such as fish or eggs. If kidney function is impaired, or insulin resistance is present, she says appropriate medical and dietary therapies are the logical place to start.“We have to show that lowering TMAO levels in blood shows benefit,” Caudill says. Then, she says, we might intervene, with drugs that interrupt the choline-TMA-TMAO pathway, by altering the microbiota, or by altering nutrition. “Right now, there is just no good evidence that in humans elevated TMAO is doing harm.”Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Holistic Guide to Optimal Wellness.For references, view this article on our website at www.TodaysDietitian.com.FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  39

Picky eating is a common problem of childhood. It’s often considered fairly trivial and transient in nature, but in some cases it may lead to inadequate weight gain, nutrient deficiencies, and long-lasting behav-ioral issues that can be difficult to change. For some children, “picky eating” is a sign of a much more serious issue that requires medical intervention and referral to specialist services. Changing food-related behavioral issues that are well entrenched is extremely challenging for par-ents and dietitians alike and requires patience and a great deal of support for the family and child. Fam-ilies are more likely to see success if picky eating behaviors are recognized and addressed early, but if parents’ and caregivers’ concerns are dismissed, as routinely happens, success is less likely to occur. For dietitians, a comprehensive understanding of picky eating is vital to successfully provide care and create effective nutrition care plans. This article discusses parents’ perceptions and behaviors associated with picky eating, explains normal feeding development identification and management of picky eating and feeding disorders in general, and offers practical strategies for man-aging picky eating behaviors. Parents’ Perceptions and Behaviors A study by Byrne and colleagues that examined maternal perceptions of fussy eating in their children found that approximately 30% of moth-ers characterize their children as picky or fussy eaters, a proportion supported by Brown and 1colleagues and Mascola and colleagues. The 2,3perception of a child as a picky eater is highest among mothers of children with a lower weight status or BMI percentile. The most commonly 4reported signs of picky eating in children by par-ents or caregivers are food neophobia, parents’ perception of a limited diet, noted decreased enjoyment of food, rigid or limited behaviors related to food/eating, and slow eating. Par-5ents and caregivers of picky eaters self-identify as those who put more pressure on a child to eat, such as to control the level of intake vs respond-ing to the child’s natural hunger/satiety cues; use bribery as a way of getting their child to eat; and are more likely to be picky eaters themselves.2,6-8These parental behaviors and tendencies are rep-licated in many similar studies and reviews.1,9-13In addition, mothers who admit to using pres-suring techniques are more likely to identify their children as picky eaters. Lumeng and col-leagues found an association between pressuring PickyEating inChildrenA COMPREHENSIVE REVIEW ByRivanna Stuhler, MSc, RD40 TODAY’S DIETITIAN• FEBRUARY 2020

Learn about counseling strategies that will help parents manage picky eating behaviors in their children.

behaviors and picky eating, but no association with poor growth. Brown and colleagues report the same finding. 13 2Byrne and colleagues note variability in perception among parents and caregivers and assert that studies rarely look at actual intake but instead focus on parental perception. 1Thus, it’s difficult to quantify how many of the 30% of per-ceived picky eaters are at risk of failure to thrive, require fur-ther medical investigation for organic causes of picky eating, or need complex medical intervention. Therefore, it’s imper-ative for dietitians to have a thorough understanding of normal feeding development and the commonly seen issues related to picky eating.Normal Development of Eating From Infancy Through ChildhoodNormal eating is the ability to recognize hunger and then eat enough to satiate oneself—recognizing a feeling of fullness. It also encompasses the ability to choose foods one likes and enjoy those foods without an extreme restriction placed on the amount eaten.14,15 Included is the ability to eat for pleasure or for comfort in amounts that aren’t excessive. In her book How to Get Your Kid to Eat … But Not Too Much, Ellyn Satter, MS, RD, states, “Normal eating is flexible. It varies in response to your emotions, your sched-ule, your hunger, and your proximity to food.” While normal eating 14varies from person to person—some people eat small, more fre-quent meals vs three large meals; prefer to snack or not; and differ in how emotionally stimulated/comforted they are by food—it gener-ally encompasses a healthy attitude toward food. Healthy infants and children are born with an innate capacity to eat normally, one that changes based on their experiences and exposure to food.14-16Normal Feeding Development From Infancy Into AdolescenceInfancyBetween birth and 4 to 5 months, sucking from the breast or bottle is how infants receive nutrition. They become more adept at feeding as they grow bigger and stronger and can take in larger volumes more quickly. At around 4 to 6 months of age, they’re able to hold up their torsos and heads and have the oro-motor skills to accept food from a spoon. Many enjoy the tactile nature of playing with food 17and will have no problems getting their hands and faces dirty.14,16,17 They begin to develop a capacity to manage new textures and their chewing skills. Gagging on new textures is extremely common and considered normal as the infant learns new skills related to eating.14-17 However, many parents become quite alarmed when their children gag, as they can’t tell the difference between gagging (normal) and choking (abnormal). If parents or caregivers react strongly each time this happens, children may become less willing to try new textures, as they may be frightened by the reaction of their parents/caregivers. 14As infants approach 1 year of age, they begin to assert their independence. This may present as a reluctance to be spoon fed. However, if given the spoon, these infants may be happy to feed themselves (albeit clumsily), and they’re more willing to feed themselves when presented with finger foods and small, easy-to-manage solids, such as well-cooked pieces of pasta or vegetables, cut fruit, small pieces of cheese, or small pieces of bread with a spread.14,15,17,18ToddlerhoodToddlers are curious explorers, learning to become more autonomous and independent and navigate the world. They have a greater sense of themselves as individuals and like to express it.1,14,15,19 They try to push boundaries, but at the same time appreciate limits, as these provide structure and a sense of safety. They become more skilled at feeding themselves and are capable of progressing to a modified adult diet devoid of choking hazards such as whole nuts, as they don’t have the skills to safely expel these foods. Although their skill sets are 17expanding, they experience neophobia and so may not be will-ing to try or accept new foods.14-16,18 Because growth rates and appetites naturally decrease after 1 year of age, their appetites fluctuate day to day and sometimes even meal to meal.1,4,17Preschool AgeAs children reach preschool and school age, neophobia begins to decrease and in most cases disappears almost entirely.14,15,18Children of this age have more advanced chewing and swal-lowing skills and become more adept at using cutlery. They’re 17more coordinated when eating and drinking and may spill less or be more efficient eaters and drinkers in general. Their appe-tite continues to be variable, as with toddlers, but they’re much more aware of the feeding environment and easily influenced by food-related attitudes around them or the environment in which they eat (eg, if the house is noisy or chaotic, or there’s tension or discord between parents/guardians or family members).14-18School AgeAt this age, children have all of the developmental skills required for eating and can tolerate a regular adult diet. As they may eat one or more meals out of the house each day, they have more freedom regarding what they choose to eat. They have a basic understanding of nutrition and can help with meal planning and preparation.14,15,18They’re heavily influenced by their peers and environment and look to their parents and caregivers to be good role models in relation to attitudes toward food and eating in general. 18AdolescenceAdolescents have much more freedom in terms of eating and drinking. They may have disposable income, which they can spend on snacks or meals while hanging out with friends. They still appreciate having meals provided for them, as they see this as a sign of caring. Adolescence is a period of great influ-14ence, and this is the time when odd eating behaviors or perhaps even signs of eating disorders appear (although some children exhibit signs of eating disorders well before adolescence).14,15,17While teenagers should have freedom around nutrition, par-ents or caregivers still may provide guidance and be aware of any alarming behaviors or changes in eating habits. Roles of Parents and ChildrenThe golden rule when considering who’s responsible for what when feeding children is as follows: “Parents are responsible 42 TODAY’S DIETITIAN• FEBRUARY 2020

for what is presented to eat and the manner in which it is pre-sented. Children are responsible for how much they eat, and even whether they eat.” The child’s role in the feeding rela-14tionship remains fairly static from infanthood to adolescence, while the parents’ or caregivers’ role changes to match the developmental stage of the child. In the newborn stage, infants are learning about the world and their direct caregivers and developing trust. Their primary objective is to have their needs met. The parents’ or caregiv-ers’ role is to meet the needs of young infants by learning their cues and responding to them.9,14,15 This includes feeding infants when they’re hungry but respecting cues that they’re full and not pushing the breast or bottle.12,14 This can be difficult for parents who bottle-feed their infants and feel they have to feed a specific volume of formula on a schedule, as the intake of infants may vary slightly. In later infancy (roughly 5 to 12 months of age), the par-ent’s role is to select the food to offer and progress through textures based on the cues and capacity of the child. Some children may progress to soft solids very quickly, preferring them to puréed foods; others may be a bit more cautious and require more patience and time. If infants trust their food pro-viders, they will be more willing to try new foods or textures. 12The parent’s or caregiver’s understanding of the difference between gagging and choking and responding appropriately also can help foster a safe, trusting environment in which the infant can develop new feeding skills.16,17 Allowing infants to play with food and get messy can be very helpful for feed-ing development, as the tactile nature of this activity can help them develop a positive attitude toward food.12,17Toddlers, as they become more autonomous, push bound-aries. This is a normal part of development but shouldn’t be indulged. Instead, the role of parents or caregivers is to create a structured schedule, routine, and environment for meals and snacks, which should be followed as closely as possible.14,15 Par-ents or caregivers continue to choose the foods to be provided, and the toddler decides whether and how much to eat.14-16 As appetite and intake vary widely during this period of develop-ment, the toddler’s choices should be respected unless there are concerning signs noted, including suboptimal weight gain. As mentioned previously, preschool and school-age children are much more independent and involved in deciding when and whether to eat and may eat out of the house more, particularly with friends.14,15 They should be encouraged to try new foods and explore different cuisines. Whenever possible, fights at the table about eating should be avoided.14-17 At the same time, parents or caregivers should continue to offer consistent and healthful meals, and, sometimes, snacks. The older the children, the more capable they are of choosing and preparing snacks and even getting involved in meal planning and preparation. The role of parents or caregivers remains the same for adolescents, who are almost completely independent when it comes to snack choices and even preparation of some meals. Understanding the developmental stages children go through in relation to food and eating is important for parents and dietitians, as they easily can pick up on red flags that may indicate an emerging feeding disorder.TheFIRSTprenatal gummy with a good source ofCHOLINE.†During pregnancy, CHOLINEis important for fetal brain & spinal cord development.†www.naturemade.com† This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.NEWFEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  43

Identifying Feeding Disorders: Red FlagsFeeding disorders often have many causes, some of which may be related. Causes may be organic, environmental, or behavioral in nature, or a combination of all three factors. 20Regardless of the cause, parents and caregivers who voice con-cerns about their children’s feeding behaviors should never be ignored, as these concerns may turn in to a serious condi-tion requiring medical intervention. It’s important to conduct 6a thorough feeding and behavioral history and take anthro-pometric measures, and a physical examination may be nec-essary to help determine the source of the issue. Even when the problem turns out to be minimal and easily addressed with education or suggestions for behavioral interventions, dietitians should provide constructive and practical recom-mendations to parents and caregivers. Some of these rec-9ommendations may include a shift in the feeding style of the parents, encouraging them to look for and react to their child’s hunger and satiety cues, or a change made to the feeding envi-ronment, such as the removal of distractions. Examples of some common suggested changes can be found in the “Practi-cal Tips for Dietitians” section.Organic causes of feeding disorders include anatomical defects, gastrointestinal (GI) diseases or disorders, and genetic syndromes. These may affect children’s desire to eat as well as 9their mechanical ability to eat or drink. In these cases, devel-opmental readiness, including children’s ability to hold their trunks and heads up, or the ability to chew and swallow safely, also may need to be considered. Anatomical defects such as cleft palate, abnormal facial structure, or laryngomalacia may compromise a child’s capacity to eat or drink normally. Chil-20dren with hyper- or hypotonicity may be at increased risk of reflux, dysphagia, or aspiration and should be carefully assessed for feeding safety. Children with disturbances of the GI tract such as gastroesophageal reflux disease, food allergies, eosin-ophilic esophagitis, or celiac disease may present with food-averse or -avoidant behaviors. Children with various genetic 9,20diseases such as trisomy 21 (ie, Down syndrome) may be at heightened risk of feeding disorders due to the nature of their diagnoses.6,20 These children should be monitored carefully. Environmental factors that may lead to feeding disorders include the home or school environment where the major-ity of meals and the relationship between the child and the adult feeding them (eg, parent, caregiver, teacher) take place. In addition, socioeconomic factors such as income 20and education levels (of the parents/caregivers) and access to food (ie, food security) may affect the feeding environ-ment. A thorough history includes a diet history but also an environmental scan related to meals and feeding practices. This should include questions about where meals take place (eg, at the table? In front of a screen?), how calm or chaotic the feeding environment is, and any alarming behaviors, such as force-feeding, that may be reported by the parents (see table online).Behavioral issues (as outlined in the table) may manifest as a result of undiagnosed organic factors, environmental factors that haven’t been addressed, or, in some cases, traumatic expe-riences from the past (eg, intubation, chemotherapy, resolved GI pathology). Dietitians should be aware that although behav-ioral issues are modifiable, some children who exhibit contin-ued behaviors before and after intervention are at risk of poor growth, failure to thrive, and nutrient deficiencies.3,4,11 Ignor-ing the behaviors reported by caregivers can lead to a long-lasting unhealthy relationship with food and can be extremely stressful for families and clinicians. Indeed, children whose 6picky eating behaviors persist longer than about two years may benefit from additional attention from dietitians and other cli-nicians to determine the best course of action, whether it be ongoing support for caregivers, referral to a specialist team, or referral to a clinician who provides psychological support. 3Children who exhibit behaviors related to feeding without any medical cause respond best to early intervention and sug-gestions for behavior modification (both for the child and the parent/caregiver), as outlined in the section “Practical Tips for Dietitians.” In more difficult cases, referral to a specialist feed-ing team may be required. 9,20Strategies for Managing Picky EatersMany dietitians who work with young children and their fami-lies know that behavioral management of picky eaters is a long and arduous process. As well as providing direction and help-ful strategies, dietitians need to support those providing the food. This may include setting realistic expectations for change (eg, telling caregivers, “This may take a few weeks”); acknowl-edging that parents and caregivers may feel guilt or feel they’re starving their children, even though this isn’t true; and let-ting parents and caregivers know they should expect pushback from their children. Reminding parents to be patient is vital to the success of behavioral management strategies. Coaching parents and caregivers to create healthy feeding environments is a necessary part of any behavioral intervention, as the par-ents’ or caregivers’ feeding styles (eg, controlling feeders who 44 TODAY’S DIETITIAN• FEBRUARY 2020

ignore the children’s hunger/satiety cues, indulgent feeders who give in to the children, or neglectful feeders who don’t pro-vide adequate food or attention) may be a contributing factor to their children’s behavior.9Considerations for Further Medical InterventionChildren who are known to have mechanical difficulty with food should be referred to a specialist feeding team, an occupational therapist, or a speech pathologist for assessment of skills and recommendations for safe feeding. These children may require altered textures, specialized seating (eg, modified or custom-ized wheelchairs, high chairs, or standard seating) or utensils, medication, or aids such as g-tubes to safely feed. Children 9,20with extreme selective eating, developmental delay, or who are thought to have autism spectrum disorder may benefit from a referral to a developmental pediatrician, who can best assess the needs of the child and refer to specialist services. Practical Tips for DietitiansDue to the variety of complex circumstances under which picky eating may occur, dietitians should aim to provide tai-lored advice for each case of picky eating. General guidelines exist, but they may not always work for everyone. Parents and caregivers will respond to suggestions they feel are practi-cal, realistic, achievable, and relevant to their children. Cre-ating a sympathetic and respectful rapport with parents and caregivers can foster trust, which will only serve to help dieti-tians. Parents and caregivers who feel respected and heard are more likely to be open to suggestions. Asking questions in a sensitive manner and reframing or restating these questions if necessary to get the required information can help dieti-tians adapt their therapeutic approach to achieve success. To do this, dietitians must pay close attention to the history and the “story” the parents and caregivers tell, as well as their body language. These are all excellent clues to help guide an impression and plan. Regardless of their impression, dietitians must remember that providing parents and caregivers with several recommen-dations at one time can be overwhelming and may not be prac-tical. Multiple consults may be required to gradually change the behavior of children (and/or that of their caregivers). Picky eating is a complex part of childhood. It may be mild and easily resolved or a more challenging behavioral or medical issue that requires specialist intervention. Dietitians should be aware of the intricacy of this issue so they can advise parents and caregivers and provide the best possible care to their children. For more information, refer to “Guidelines for Managing Picky Eating,” which can be found in the online version of this article.Rivanna Stuhler, MSc, RD, is a Toronto-based acute-care pediatric and private practice dietitian. Stuhler currently specializes in pediatric blood and stem cell transplant and works in private practice with children and adults. Her graduate work focused on quality improvement and patient safety in health care.For references, a sidebar, table, and extended article, view this article on our website at www.TodaysDietitian.com.The Soy Connection health and nutrition newsletter is available online now.Learn about the role of soyfoods in plant-based diets and earn free continuing education credits.EarnFREE CPEswww.SoyConnection.comFEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  45

The Disease-Protective Properties of GarlicGarlic as a flavoring as well as a form of medicine has been well known throughout his-tory. It’s been prized for its healing powers by physicians and healers in countries all over the world, including ancient China, Egypt, India, and Greece. The bulb, for example, was regarded as a powerful antibiotic, a remedy for snakebites, a way to cure constipation and stomachache, and even a relief for colic. Emerging research 1provides considerable evidence for the remedial properties of garlic touted in ancient times and suggests that garlic may offer protective benefits for the heart, brain, and immune system and improve hypertension, fasting blood sugar, and serum lipid levels. However, most of these benefits have been associ-ated in research with garlic supplements rather than dietary garlic.Due to the complexity of garlic’s chemical composition, the exact mech-anisms through which garlic protects against diseases aren’t well understood. 2Processing methods appear to influence the concentration of certain compounds and the overall benefits of garlic prepa-rations. Recent studies have identified a variety of forms of garlic and compounds in them that may have beneficial effects. This continuing education course assesses current research findings on garlic’s health benefits, summarizes the mechanisms of action of the various compounds found in garlic, and evalu-ates the safest and most effective way to reap the benefits of this bulb. The Chemistry Several compounds found in garlic may produce health benefits, but the abun-dance and efficacy of these compounds depend on the preparation technique. The most common garlic preparations include raw or cooked garlic, powder from dried garlic, oil, and aged extract formed by soaking crushed garlic in aqueous solutions. Raw, intact garlic possesses sulfur-containing compounds such as alliin that contribute to its char-acteristic flavor and smell. Crushing or cutting garlic converts these sulfur compounds into active and volatile forms called thiosulfinates, the most well known of which is allicin. Although many individuals believe that allicin is the main compound that contributes to the health benefits of garlic, research shows that this thiosulfinate is unstable in the human body. In the conditions of the body, allicin decomposes into other sulfur-containing compounds and, therefore, isn’t likely a main health-pro-moting compound of garlic. Instead, the 2variety of compounds that develop from allicin are more likely to be responsible for the health benefits of garlic.However, some studies continue to explore the benefits of allicin. Research-ers who have isolated allicin in the lab-oratory have found that it acts as an antioxidant and can trap free radicals. In addition, findings from research on rats suggest that allicin may prevent hyper-tension by fighting oxidative stress and inhibiting the processes that lead to high blood pressure. The implication of these findings for humans is undermined by allicin’s lack of bioavailability in the human body, due to its volatility and rapid decomposition when ingested. 3During the preparation of garlic oil or oil-soluble garlic extracts, more organo-sulfur compounds than those that exist in raw garlic are created. Many of these compounds may demonstrate health benefits, although research on indi-vidual compounds is limited. Garlic oils largely are composed of diallyl sul-fide and diallyl trisulfide, compounds that are the focus of several studies. 2Research focusing on the specific health benefits of garlic oil suggests possible implications for the prevention of osteo-porosis and protection against cer-4,5tain types of cancer. For example, 6,7CPE Monthly By Elizabeth Streit, MS, RDN, LDCOURSE CREDIT: 2 CPEUsLearning ObjectivesAfter completing this continuing edu-cation course, nutrition professionals should be better able to:1. Evaluate garlic’s mechanism of action and the impact of different pro-cessing and preparation methods on garlic’s efficacy.2. Distinguish the effects of garlic from food vs supplement form. 3. Discuss the potential benefits of garlic, including immune-modulating, hypotensive, cholesterol-lowering, neuroprotective, anticancer, and anti-osteoporotic effects.4. Analyze at least two reasons why research on the health benefits of garlic shows contradictory results. Suggested CDR Learning Codes2010, 2020, 4040Suggested CDR Performance Indicators8.1.2, 8.3.1, 8.4.1CPE Level 246 TODAY’S DIETITIAN• FEBRUARY 2020

one study on rats found that garlic oil extract promotes the transfer of calcium in the intestines, which may prevent the reduced bone density that can lead to osteoporosis. Another study showed 5that rats treated with garlic oil devel-oped a significantly lower number of tumors on their livers when exposed to a compound that causes liver cancer.6Aqueous solutions, another common liquid preparation of garlic, lead to the development of water-soluble organosulfur compounds such as S-allyl-cysteine (SAC). SAC is most commonly found in aged garlic extract (AGE), the type of garlic used in several research studies. Researchers suspect the aging process transforms the volatile compounds found in raw garlic into more stable substances, such as SAC, which may have antioxidant activity and protect against heart disease and cancer.2,8,9 Unlike allicin and the organosulfur volatiles found in oil-soluble garlic preparations, SAC has been found to be one of the most bioavailable and active compounds in garlic.2Understanding the complexity of gar-lic’s chemistry is key to assessing past and emerging research about its health benefits. While several factors, including study designs, may contribute to the dif-fering conclusions about garlic’s poten-tial, the variety of forms of garlic used in studies is one of the factors that most influences results. In addition, several studies were performed on rats, used varying doses of garlic, and occurred over a short timeline. This article analyzes the conclu-sions of recent literature while consid-ering the form of garlic used to inform best practice for the use of garlic to pro-tect against disease. More clinical and animal studies, especially those that explore the bioavailability and safety of certain garlic compounds alone and together, are needed. Mechanisms of Action and Health Benefits The following sections summarize the current literature on the health effects of garlic and the possible reasons behind these benefits. Hypertension Researchers who have investigated the hypotensive effects of garlic mostly have focused on AGE. As previously mentioned, AGE contains a high concentration of SAC, one of the most bioavailable and least volatile compounds in garlic. SAC may be able to lower blood pressure, as it can act as an antioxidant and trap reactive oxygen species. SAC also may inhibit the increased expression of a transcription factor that contributes to hypertension and enhance the production of nitric oxide, a vasodilator. 3Ried and colleagues designed stud-ies that test the impact of AGE capsules with varying doses of SAC on hyperten-sion.8,10-12 In a double-blinded random-ized controlled trial with 50 patients with treated yet uncontrolled hyper-tension, the researchers gave the treat-ment group 960 mg AGE with 2.4 mg SAC daily for 12 weeks and gave the con-trol group placebos. Every patient in the trial was taking one or more blood pressure medications at the time of the study. The results showed that in con-junction with these medications, AGE contributed to a significant decrease in systolic blood pressure (10.2 ± 4.3 mm Hg, p=0.03) compared with the placebo. Furthermore, participants tolerated AGE well, and the researchers reported a 92% acceptability of the treatment. 10In a similar study, Ried and colleagues found that individuals with uncon-trolled blood pressure who received 480 mg AGE experienced a significant reduction in their mean systolic blood pressure (11.8 ± 5.4 mm Hg, p=0.006) at the 12-week mark compared with their own blood pressures at baseline. 11Subsequently, Ried and colleagues assessed the effect of an even higher dose of AGE on blood pressure. In this trial, 88 patients with uncon-trolled hypertension received either 1.2 g AGE with 1.2 mg SAC or a placebo for 12 weeks. Each patient also took conventional blood pressure medica-tions, but the differences in medication types weren’t significant among par-ticipants at baseline. The results of this trial were consistent with Ried’s previ-ous studies. The group that received AGE had a significantly lower mean systolic blood pressure (5 ± 2.1 mm Hg, p=0.016) at 12 weeks compared with the start of the trial. These findings suggest that 12garlic, especially AGE, may be a safe and effective adjunct treatment for uncon-trolled high blood pressure. HyperlipidemiaGarlic powder and AGE may provide lipid-lowering benefits through at least two suspected mechanisms. Research suggests that the organosulfur com-pounds in garlic, especially SAC, may inhibit enzymes involved in cholesterol synthesis in the liver. Certain com-13pounds in garlic also may stop LDL oxidation.14Meta-analyses of the existing literature on the beneficial effects of garlic on lipid levels suggest that garlic preparations can significantly reduce total cholesterol levels.15,16 Garlic’s efficacy in reducing total cholesterol appears to depend on the length and type of supplementation. Trials that lasted longer than eight weeks and those that used AGE show a more pronounced cholesterol-lowering effect of garlic. Results of studies assessing 15the efficacy of garlic in reducing LDL or triglyceride levels and increasing HDL levels offer less clear conclusions.Sobenin and colleagues analyzed the effects of time-released 600 mg garlic powder tablets on the lipid levels of 42 men who were aged 35 to 70 and had slightly high cholesterol levels. The par-ticipants were randomized into two groups that received either the garlic Register now for our 2020 Spring Symposium! www.TodaysDietitian.com/SS20FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  47

tablets or a placebo. The results of the study suggest that, along with a heart-healthy diet, garlic powder tablets may provide cholesterol-lowering effects. The total cholesterol and LDL cholesterol levels of the treatment group decreased by 11.5% and 13.8%, respectively, com-pared with those in the placebo group after 12 weeks. 17A study by Seo and colleagues assessed the efficacy of AGE extract on lipid levels in 30 women in their 50s. It showed a sig-nificant decrease in LDL levels in women who consumed 80 mg AGE, those who exercised and took AGE, or those who just exercised and took a placebo, com-pared with those in the group who didn’t exercise and took a placebo. 18These results suggest a possible pro-tective effect of certain garlic supple-ments against elevated lipid levels that may put individuals at risk of heart disease. However, more clinical stud-ies are needed to assess the most effec-tive duration, type, and dose of garlic preparations. Diabetes In some studies, researchers have dem-onstrated that garlic supplements can lower blood sugar levels in individu-als with type 2 diabetes. Ashraf and colleagues recruited 60 patients with fasting blood sugar between 100 and 130 mg/dL and divided them into two groups. Each group received 500 mg of metformin two times per day and either 900 mg of garlic tablets or a placebo. After analyzing fasting blood sugar levels at 24 weeks, the authors concluded that garlic tablets contributed to a sig-nificant 3.12% reduction in these levels for those in the experimental group compared with the control group par-ticipants. The garlic tablets generally were well tolerated, and only one partici-pant reported stomach discomfort. The researchers acknowledge that the mech-anism through which garlic tablets can lower blood sugar isn’t well known, but that garlic appears to promote the secre-tion of insulin. 19Another study by Ashraf and col-leagues analyzed the effect of garlic tab-lets in doses of 300, 600, 900, 1,200, and 1,500 mg per day on both fasting blood sugar and hemoglobin A1c (HbA1c) in 210 individuals with type 2 diabetes. The researchers divided the participants into seven groups; five received one of the doses of garlic, another group received metformin, and a final group took a pla-cebo. Compared with the placebo group, every group that received a dose of garlic had significantly lower fasting blood sugar and HbA1c after 24 weeks. The 20garlic tablets, especially at doses greater than or equal to 900 mg, were compa-rable to metformin in reducing blood sugar and HbA1c. These studies offer very promising support for the use of garlic in diabetes management.Cancer Due to the antioxidant effects of garlic compounds, especially SAC, it appears that garlic also may protect against cancer. Dong and colleagues investi-gated a mechanism through which aged black garlic extract may thwart cancer cell production by performing a study on in vitro colon cancer cells. Their results suggest a promising anticancer mecha-nism, indicating that aged black garlic extract induces cell death in cancer cells by blocking a specific pathway that sig-nals cancer cell growth. 9Additional research on the effects of garlic on cancer has analyzed the impact of garlic oil preparations. Specifically, garlic oil appears to protect against liver cancer that develops from exposure to the environmental carcinogen N-nitroso-diethylamine, found in cheese, processed meats, some alcohol, and agricultural chemicals. Researchers gave rats doses of the carcinogen over 20 weeks to induce nodules on their livers. At the same time, they gave a continuous administration of garlic oil to one group of rats and equal doses of corn oil to the other group. The rats in the garlic oil group had a signifi-cantly lower number of nodules on their livers compared with their counterparts. 6This cancer-protective effect of garlic oil may be due to the induction of phase II liver enzymes that block the development of cancerous nodules. 21Finally, even raw garlic may protect against cancer by upregulating genes that promote cell death. Charron and colleagues found that just a single meal with 5 g (the equivalent of one clove) of raw, crushed garlic activated genes related to apoptosis and destruction of cancer cells. The different types 22and doses used in studies that analyze the protective effects of garlic make it difficult to assess the most beneficial garlic preparations related to cancer prevention. However, the promising results of studies that used AGE, garlic oil, and raw garlic suggest benefits from consuming garlic in any form. Immune System Garlic also may have immunomodu-latory effects and anti-inflammatory activities, such as the inhibition of the proliferation of proinflammatory cyto-kines and stimulation of immune cells. 7Specifically, garlic oil may prevent the activity of Th1 lymphocytes that regu-late the proinflammatory response and enhance the ability of Th2 lymphocytes to produce an anti-inflammatory pro-cess. Liu and colleagues analyzed the effects of garlic oil on Th1 and Th2 lym-phocytes in rats and suggested that the response was dose-dependent; larger doses of garlic oil were more effective at inducing an anti-inflammatory response from Th2 cells over a two-week period. Interestingly, smaller doses of the oil had the opposite effect and stimulated Th1 cell responses. 23Other studies clarify the role of garlic in immune response. For example, a study designed by Nantz and colleagues analyzed the ability of AGE to influ-ence immune cell proliferation. They recruited 120 participants and divided them into two groups, one that received 2.56 g AGE per day and one that received placebos. After 45 days, they analyzed blood samples and found that those who took AGE had significantly more proliferation of two specific immune cells compared with those who didn’t. The researchers hypothesized that AGE may improve the capability of certain immune cells to become activated, lead-ing to a stronger immune reponse.24Strengthening the immune system, especially in those susceptible to infec-tion or illness, is a possible benefit of garlic preparations. Madineh and col-leagues performed a short trial with 94 patients admitted to the ICU to analyze the effect of taking a 400 mg garlic tablet daily for six days on inflammatory blood markers and the occurrence of infec-tions. In comparison with those who took a placebo, patients who received the garlic supplements had a significantly lower body temperature. However, there 25were no other significant differences CPE Monthly48 TODAY’S DIETITIAN• FEBRUARY 2020

between the groups, suggesting the need for additional studies, perhaps with larger sample sizes and longer durations. Brain HealthGarlic preparations, due to their antioxi-dant and anti-inflammatory potential, also may have neuroprotective effects. Specifically, AGE may provide protec-tion against the inflammatory process thought to be related to the development of Alzheimer’s disease. AGE may have this effect due to SAC’s ability to trap reactive oxygen species, as mentioned previously. Based on their work exam-ining neuronal cells of mice that were treated with reactive oxygen species, Ray and colleagues found that AGE protected cells from oxidative damage. Further-26more, since diabetes and cardiovascular risk factors may play a role in the devel-opment of Alzheimer’s, and since garlic appears to protect against those issues as well, AGE could play a significant role in the fight against Alzheimer’s. AGE also may protect the brain after cerebral ischemia. By inducing isch-emia for one hour and then adminis-tering 1.2 mL AGE/kg of weight in rats, Colín-González and colleagues exam-ined the impact of garlic in reducing ischemia-related inflammation. Their results suggested AGE protected against the damage caused by ischemia and diminished the amount of inflammatory markers in the blood after the event. The levels of inflammatory markers in rats that received the AGE were more than 75% lower after the induced ischemia than in the rats that didn’t receive the garlic extract.27Bone Health Certain garlic preparations appear to provide protection against the devel-opment of osteoporosis in women after menopause. The prevalence of osteo-porosis in postmenopausal women may be due to estrogen deficiency and often is treated with estrogen replace-ment therapy. In rats whose ovaries had been removed, garlic oil was found to be as effective as conventional thera-pies in preventing bone loss. The pos-4sible mechanism through which garlic prevents bone mineral loss caused by hormone deficiencies involves the increased transfer of calcium through the intestines. 5A study of 44 women with osteoporo-sis offered different results. Mozaffari-Khosravi and colleagues examined the effect of raw garlic tablets on the pres-ence of proinflammatory cytokines that have been linked to postmeno-pausal bone loss due to their influence on bone resorption. The study included two groups, one whose members took approximately 800 mg garlic per day and another whose members took a placebo. After one month of intervention, the blood levels of one inflammatory cyto-kine were significantly reduced by an average of 47% in the garlic group com-pared with their baseline levels. However, no significant differences in the cytokine levels of the garlic and placebo groups at the end of the study were observed. 28These studies suggest the possibility that garlic supplements may prevent bone loss, but more research is needed. Garlic Preparations, Dosages, and Demonstrated EffectsType of Garlic PreparationDosage, DurationDemonstrated EffectsRaw, crushed5 g, one timeUpregulation of genes related to immunity and apoptosis in humans23Garlic oil20–40 mg/kg, five times/week for 21 weeksPrevention of liver cancer nodule development in rats22Garlic oil100–200 mg/kg, every other day for two weeksModulation of Th1 and Th2 lympho-cytes in rats24Garlic oil100 mg/kg, daily for 30 daysPrevention of bone loss due to hormone deficiency4Garlic powder (encapsulated)600 mg time-released tablet/day for 12 weeksDecrease in total and LDL cholesterol levels in humans17Garlic powder (encapsulated)900 mg/day for 24 weeksDecrease in fasting blood sugar levels in humans with diabetes19Garlic powder (encapsulated)300–1,500 mg/day for 24 weeksDecrease in fasting blood sugar levels and HbA1c in humans with diabetes20Garlic powder (encapsulated)800 mg/day for one monthDecrease in one inflammatory cytokine in humans28,29Garlic powder (encapsulated)600 mg/day for six daysDecrease in body temperature, a marker of infection in humans26Aged garlic extract (AGE) 480–1,200 mg/day for 12 weeksDecrease in systolic blood pressure in humans10-12AGE 80 mg/day for 12 weeksDecrease in LDL cholesterol levels in humans18AGE 2.56 g/day for 45 daysIncrease in immune cell proliferation in humans25FEBRUARY 2020 •WWW.TODAYSDIETITIAN.COM  49

Dosage and TypeThe majority of research on garlic sug-gests several promising benefits of this widely used bulb. The variety of dos-ages and types of garlic preparations appears to contribute significantly to the different and sometimes inconsis-tent observed effects of garlic. Thus, it remains difficult to recommend tangible applications of the reviewed research to dietetics practice. More research, espe-cially on the most effective, safe, and tol-erable types of garlic, is needed. The table on page 49 lists the main forms of commercially available garlic supplements, the dosages at which they have been used in clinical trials or stud-ies using lab rats, and the demonstrated effects. It appears that AGE may be the most well-tolerated form of garlic prepara-tion, in addition to being superior in efficacy and bioavailability. The extrac-tion procedure seems to increase the potency of garlic and eliminate the odor and irritating components of raw garlic that can cause heartburn, burning sen-sations when handling, and related symptoms. AGE is suspected to be safer 2and less toxic than raw or powdered garlic versions.2,10 A study by Hoshino and colleagues about the effects of garlic preparations on the mucosa of the gas-trointestinal (GI) tract of dogs found that AGE didn’t cause any negative effects. This is supported by Ried and 29colleagues’ research, which reported a 92% acceptance rate of AGE from human participants who took it.10Researchers also point to the more stable nature of SAC in AGE when com-pared with volatile compounds, such as allicin.2,10 Whereas allicin may quickly disappear from the blood once digested, SAC doesn’t; it’s thought to be one of the most active components of garlic. The 2stability of SAC makes AGE a supple-ment that can easily be standardized. The minimal side effects associated with AGE make it an appealing alternative to current medications that can cause more serious side effects, such as statins and antihypertensive drugs. Other forms of garlic, such as dehy-drated raw garlic powder and even enteric-coated capsules of garlic powder, may damage GI mucosa and cause stomach irritation. Hoshino and col-leagues found that dehydrated raw garlic powder caused erosion and severe damage in the GI tracts of dogs. Enteric capsules caused reddening and, when taken orally, produced damage in the dogs’ ileums.29Furthermore, long-term use of any supplement raises concerns for toxic-ity. While garlic preparations such as AGE appear to have no adverse effects when consumed in varying doses, more research on the impact of garlic supple-ments over long periods of time is neces-sary. Without a strong base of research to support the suspected minimal side effects of garlic supplements, it’s dif-ficult to make recommendations for a standardized type or dose. Another important consideration is that the FDA doesn’t regulate supplements, which can lead to differences in content and purity among supplements that claim to have a specific amount and/or type of a substance. The actual dose and the one listed on the label may not always cor-respond. Supplements that have been tested by a third party may have a more accurate stated dosage. A serious concern surrounding the use of garlic supplementation is the pos-sible contraindications for people taking certain medications. Individuals taking antihypertensive medications and/or warfarin (Coumadin) often are told to use garlic supplements with caution to prevent bleeding, since garlic also may prevent blood clotting.2,30 However, a 2006 study by Macan and colleagues including 66 patients taking warfarin found that those who also took 5 mL AGE per day for 12 weeks didn’t have an increased risk of hemorrhages compared with those who took a placebo. 31Note on Culinary Garlic Most studies focus on the possible health benefits of garlic supplements, oils, and extracts, and rarely provide information on raw or cooked garlic as it would appear in everyday recipes to participants. However, eating garlic and adding it to food is associated with health ben-efits in observational studies. Most of the studies that assess the relationship between dietary garlic intake and dis-ease risk are focused on cancer. An epi-demiologic study by Jin and colleagues included close to 6,000 Chinese adults and found that people who ate raw garlic two times or more per week over seven years had a 44% lower risk of developing lung cancer.32Epidemiologic studies on the pos-sible link between garlic intake and the prevention of other diseases are limited, and more research is needed. Neverthe-less, culinary garlic has been used to help with ailments for centuries.1Dietitians can instruct patients to increase their use of garlic in the kitchen by recommending recipes with garlic and teaching them how to crush or chop raw garlic cloves.Implications for DietitiansAs the nutrition experts for clients, patients, and the general public, RDs should be aware of the current evidence for the health benefits of garlic. Stud-ies have demonstrated that garlic may improve hypertension, lower choles-terol, protect against cancer, prevent bone loss, lower fasting blood sugar, and strengthen the immune system. While raw and cooked garlic has been used for its medicinal properties for thousands of years, emerging research points to the potential of supplemental forms of garlic, especially AGE. However, con-cerns about the safety and efficacy of garlic supplements remain, and recom-mendations for a standardized dose and type don’t exist. Until more research is available, dietitians and other health professionals should be cautious about recommending garlic supple-ments for health promotion and disease prevention. 30As garlic continues to gain recognition as a functional food and possible alter-native or adjunctive therapy to modern medications, the development of a stan-dardized supplement tested for safety may not be far off. In the meantime, dieti-tians should continue to recommend a predominantly plant-based diet rich in vegetables, fruits, herbs, spices, and tra-ditional flavorings such as garlic. Elizabeth Streit, MS, RDN, LD, is founder of the food blog and business It’s a Veg World After All, a contributing writer for Healthline: Authority Nutrition, and an instructor at Northwestern Health Sciences University.CPE MonthlyFor references, view this article on our website at www.TodaysDietitian.com.50 TODAY’S DIETITIAN• FEBRUARY 2020