Todays Dietitian - January 2023

January 2023 Vol. 25 No. 1 The Magazine for Nutrition Professionals Culinary Medicine As more medical schools and physicians embrace this evidence-based fi eld, RDs are helping them close the knowledge gap. Sustainable Product Claims Explained Tips for Helping Clients Snack Mindfully Are Dietary Strategies Best for NAFLD? WWW.TODAYSDIETITIAN.COM

Stay Current with For over 20 years, Today’s Dietitian has offered timely articles on a wide range of nutrition-related topics, including culinary trends, long-term care issues, new products and technologies, clinical concerns, career strategies, and research updates that make the magazine an essential information guide and career development resource for nutrition professionals. Be sure to check out our CE Learning Library for the credits you need! Join the 110,000 professionals who already read our magazine each month. To subscribe, visit us online at www.todaysdietitian.com/subscribe. Fairytale Eggplant at Reyes Mezcaleria August/September 2022 Vol. 24 No. 6 The Magazine for Nutrition Professionals INSIDE Today’s Dietitian Spring Symposium Highlights ORLANDO’S BEST CUISINE Can RDs Help Clients Reverse Prediabetes, Type 2 Diabetes? Experience the Booming Trend in Air Fryer Cooking Black Beans’ Health Benefits and Culinary Uses— Plus Recipes Forget the theme parks—come here for the food! WWW.TODAYSDIETITIAN.COM Functional Beverages Today’s Dietitian examines this burgeoning market and whether its lofty health claims are backed by science. Function Beverag Today’s Today’s Tod Dietitia ietitian a exmineas this bur thisburgeoning geoning market and whet her its her lofty health claims a re b backed by scie nc y sci e. March 2022 Vol. 24 No. 3 The Magazine for Nutrition Professionals CONFERENCE ISSUE TD10 Meet 10 Trailblazing RDs Making a Difference Plant-Based Indian Cooking Made More Simple Nutrition Support in ICU COVID-19 Patients WWW.TODAYSDIETITIAN.COM Th LAND CUI pes arks—come he WWW August/Sep August/Septemb August/Septembe August/Sept mber 2022 ORL B ORL ESTC Can RDs C ean RDs Can RDs He Can RDs Can RD He Can RDs He Can RD Can RDs He an RDs He n RDs He n RDs Can R D s He n RDs He n RDs Can RDs H Can RDs He an RDs He n RDs H Can RDs He Can RDs H an RD C ans H C RDsan H RDs n He RDs n H RDs e H lp Clients Clien lp Clients lp Client lp C lients p Clients Client lp Clien lp Clients lp Clients p Clients lp Clien lp Clients lp Clie nts Clients p C ients p Clients p Clients Reverse Reverse Reverse Prediabete ed abete Prediabete Prediab Prediabe Prediabete Prediabete Prediabete ediabete edi Pr eediabete Prediabete Prediab Prediabete Prediabe Prediabete rediabete ediabete diabetes, Type 2 s, Typ s,eTyp 2 s Typ,e 2 Typ s,e 2 p s, Tye 2p s, Type 2 s, Type 2 Type 2 Type 2 ype 2 T iabete Diabe st Diabees Diabe es? t Diabees?t Diabeets? iabetes? abetes? perie etes? rie pence i peren i perenci perenc i perencie erencie erenc the Bo om the B mi oo the B om the B o omi the Bo the Boom the Boo the Boom th Boom ei Boom ng d in A nd in A nd in A nd in A nd in A d in n d A in A in nd A in d A in ir Fr ye ir F ry r Fry C ir F ye C ir Frye C ir Frye ir Fry e C ir F yer C ir Fryer C ir Fryer C r Fryer C Fryer C Fryer C Fryer Co kinog o ki ong oki o gn Beans’ Health s’ Health ’ Health s’ Health s’HealthBenefits Benefits Be inary Us es ry Uses— ry Uses ry Uses ry Uses— ry Uses— ry Uses — y Uses— y Uses— y Uses— cipes y Uses— s ipe Forget th te p heme a Are Soyfoods Healthful for Kids and Teens? TD Examines the Efficacy of Weight Loss Supplements Dietary Strategies for Hypothalamic Amenorrhea WWW.TODAYSDIETITIAN.COM April/May 2022 Vol. 24 No. 4 The Magazine for Nutrition Professionals 9TH ANNUAL SPRING SYMPOSIUM ISSUE Med Diet Customize the Learn how to adapt this award-winning eating pattern for plant, fish, and meat eaters. onal ges The Magazin E ISS n ort in Patients WWW.TODAY WWW.TODAY Vol. 24 No. 3 ol ne for Nutrition Professional SSUE WWW.TODAYSDIETITIAN.COM V als Learn how RDs and restaurateurs are transforming menus and using technology to lure diners and spark growth. Hypertensive Disorders and Kidney Disease in Pregnancy The Latest Malnutrition Screening Tools for Cancer Outpatients Shaping the Future of Food via Science, Technological Innovations WWW.TODAYSDIETITIAN.COM June/July 2022 Vol. 24 No. 5 The Magazine for Nutrition Professionals Is Foodservice on theRebound? ci C P Expe Trend Black Be Black Be Black B Black B and Culin nd C uli Cn and uliCn nd a Cu nd a Cnd ul C andulin and Cu lin d C uli d Cn uli Plus ulin Plus Reci Are Soyfoods Healthful for Kids and Teens? TD Examines the Efficacy D of Weight Loss Supplements Dietary Strategies for Hypothalamic Amenorrhea April/May 2022 9TH ANNUAL SPR MedDi Customize th Learn how to adapt Learn how to a this aw dapt ard-win eating ning pattern for plant, fish and meat eater , s. M nsforming menus teurs are tran d spark growth. re diners and s nce, WWW.TODAYSDIETITIAN.COM Vol. 24 No. 5 M gazine for Nutrition Professionals e Magazine rvice serv nd? ou RDs present their most-loved nutritious and delicious recipes to share with clients this season. Holiday Dessert Faves AMERICAN DIABETES MONTH Advanced Insulin Delivery Technology That Eases Self-Care Health Benefits of Hemp-Fortified Foods & Beverages Expert Tips for Raising Kids on Plant-Based Diets November/December 2022 Vol. 24 No. 8 The Magazine for Nutrition Professionals WWW.TODAYSDIETITIAN.COM

To help your appropriate patients sustain healthy lifestyles after weight loss surgery, they need support that goes beyond supplements. So when you enroll them in the Nutrition Direct™ program, be sure to share our easy and delicious, bariatric-friendly recipes. © 2021 Endo Pharmaceuticals Inc. All rights reserved. Malvern, PA 19355 NS-05674/December 2021 www.endo.com 1-800-462-ENDO (3636) IT’S THE START OF SOMETHING GOOD! HEALTHY, DELICIOUS RECIPES TO HELP BARIATRIC PATIENTS STAY ON TRACK ENROLLMENT IS SIMPLE See how easy it is to enroll your appropriate patients in the Nutrition Direct™ program. Download the enrollment form to get started today! NUTRITIONDIRECT.COM/ENROLL

Need more inspiration? Visit cannedbeans.org for evidence-based research regarding health benefits, delicious recipes, professional resources and more. Help Your Clients Understand What Canned Beans Can Do! 1. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr. 1999;69:30-42 2. Anderson JW, Baird P, Davis RH, Ferreri S, Knudtson M, Koraym A, et al. Health benefits of dietary fiber. Nutr Rev. 2009;67(4):188-205 3. Leathwood P, Pollet P. Effects of slow release carbohydrates in the form of bean flakes on the evolution of hunger and satiety in man. Appetite. 1988;10(1):1-11. 4. Hosseinpour-Niazi S, Mirmiran P, Sohrab G, Hosseini-Esfahani F, Azizi F. Inverse association between fruit, legume, and cereal fiber and the risk of metabolic syndrome: Tehran lipid and glucose study. Diabetes Res Clin Prac. 2011;94:276-283. 5. Shana J Kim, Russell J de Souza, Vivian L Choo, Vanessa Ha, et al.. Effects of dietary pulse consumption on body weight: a systematic review and meta-analysis of randomized controlled trials. American Journal of Clinical Nutrition, March 2016 DOI: 10.3945/ajcn.115.124677 6. Amarowicz R, Pegg RB. Legumes as a source of natural antioxidants. Eur J Lipid Sci Technol. 2008;110:865-878. CANNED BEANS CAN: Help prevent heart disease1 Lower both total and LDL cholesterol levels1 Promote digestive health2 Improve gut health2 Help control blood glucose levels3,4 Help people lose or maintain weight5 Promote a healthy microbiome2 Help prevent cancer6 #CannedBeansCanDo

DEPARTMENTS 6 Editor’s Spot 7 Reader Feedback 8 Ask the Expert 10 Probiotics 12 Functional Foods 14 Supplements 48 Focus on Fitness 50 Get to Know … 54 Health Matters 58 News Bites 60 Research Briefs 62 Products + Services 64 Datebook 65 Fresh Ideas Showcase 66 Culinary Corner Contents FEATURES 16 Culinary Medicine RDs are teaching med students and physicians about this exciting evidence-based fi eld so they can masterfully blend the art of food and cooking with the science of medicine. 22 Navigating Sustainability With Confi dence Today’s Dietitian takes a fresh look at the continued growth of the sustainability movement and explains how dietitians can make informed decisions about the products they buy and recommend to clients. 26 Snacking With Intention Munching on snacks in between meals is on the rise. Encourage clients to make more nutritious choices while teaching them habits of mindfulness. 30 Nutrition & Nonalcoholic Fatty Liver Disease Here’s an update on nonalcoholic fatty liver disease and how diet and nutrition play a role in its prevention and treatment. 36 Body Positivity in Dietetics Practice The term has strayed from its original meaning, harkening back to the 1960s social justice movements. Learn how it has evolved and ways to eff ectively counsel clients. 40 CPE Monthly: Eye Health and Nutrition This continuing education course explores the role of nutrition in visual development and healthy vision as well as nutritional factors in prevention and treatment of age-related macular degeneration, glaucoma, cataract, dry eye disease, and visual complications of diabetes. 12 VOLUME 25 • NUMBER 1 JANUARY 2023 26 Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published nine times a year in Jan, Feb, March, April, May, June, Aug, Oct, and Nov by Great Valley Publishing Company, 3801 Schuylkill Road, Spring City, PA 19475. Periodicals postage paid at Spring City, PA, Post Offi ce and other mailing offi ces. Permission to reprint may be obtained from the publisher. Reprints: Wright’s Media: 877-652-5295 Note: For subscription changes of address, please write to Today’s Dietitian, PO Box 2026, Langhorne, PA 19047. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on last label. Postmaster: Send address changes to Today’s Dietitian, PO Box 2026, Langhorne, PA 19047. Subscription Rates — Domestic: $14.99 per year; Canada: $29.99 per year. Single issue: $5. Today’s Dietitian Volume 25, Number 1. 40 4 TODAY’S DIETITIAN • JANUARY 2023

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Editor’s Spot EXECUTIVE Chief Executive Officer Mara E. Honicker Chief Operating Officer Jack Graham EDITORIAL Editor Judith Riddle Nutrition Editor Sharon Palmer, MSFS, RDN Editorial Department Manager Dave Yeager Production Editor Heather Hogstrom Associate Editor Nadine Hasenecz-McInerney Editorial Assistant Josh Hildebrand Editorial Advisory Board Toby Amidor, MS, RD, CDN, FAND; Dina Aronson, MS, RDN; Constance Brown-Riggs, MSEd, RD, CDCES, CDN; Karen Collins, MS, RDN, CDN, FAND; Carrie Dennett, MPH, RDN, LD; Jill Weisenberger, MS, RDN, CDCES, CHWC, FAND ART Art Director Charles Slack Senior Graphic Designer Erin Faccenda ADMINISTRATION Administrative Manager/Human Resources Janet Renz Administrative Assistant Jennifer Mest Executive Assistant Matt Czermanski Systems Manager Jeff Czermanski CONTINUING EDUCATION Director of Continuing Education Jack Graham Director of Professional Development Leslie Cimei Senior Manager Education and Accreditation Susan Prentice Continuing Education Coordinator Jennifer Kirkegaard Customer Support Associate Jennifer Mest Program Planner Ginger Hultin, MS, RDN LMS Coordinator Susan Graver CIRCULATION Circulation Director Susan Wood MARKETING AND ADVERTISING Publisher Mara E. Honicker Associate Publisher Peter J. Burke Director of Marketing and Digital Media Tim Rinda Web Designer Jessica McGurk Email Marketing Coordinator Ryan Humphreys Social Media Associate Nicole Pratt Director of Events and Sponsorships Gigi Grillot Events and Sponsorships Manager Andrea Rizzoni Director of Sales Brian Ohl Senior Account Executives Diana Kempster, Beth VanOstenbridge Account Executives Drew Murdock, Brian Sheerin FOUNDER EMERITUS Kathleen Czermanski © 2023 Great Valley Publishing Company Phone: 610-948-9500 Fax: 610-948-7202 Editorial e-mail: [email protected] Sales e-mail: [email protected] Website: www.TodaysDietitian.com Subscription e-mail: [email protected] Ad fax: 610-948-4202 Ad artwork e-mail: [email protected] All 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 affi liated. 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. Nutrition Trends in the New Year Time has flown by and has ushered us into a new year! A new year of exciting career and educational opportunities for RDs as well as sciencebased diet and nutrition trends to explore and include in discussions as you counsel clients, engage in clinical health care, and communicate to the masses via TV segments and social media platforms. Many of the hottest diet and nutrition trends from 2022, such as sustainability, plantbased eating, functional foods, probiotics, and immunity, will spill over into 2023 as new technologies and cutting-edge research continue to advance to improve human and planetary health. Here’s what RDs can expect in the following categories this year: • Sustainability. In 2023, dietitians will learn more about sustainable diets and how to counsel clients to plan menus and choose plant-based whole foods with smaller carbon footprints and minimal processing. More information and educational opportunities will be available on sustainable farming and sourcing practices, closed-loop supply chains, and better solutions to feed food-insecure populations. • Plant-based eating. What’s exciting about the trend in plantbased eating is that food companies are using advanced technologies to develop plant-based products fortified with nutrients in a variety of categories such as fishless seafood (eg, flaked tuna, shellfish, scallops), beef (eg, soy-, grain-, legume-, and pea protein–based alternatives), poultry (eg, chicken analogs), snacks (eg, vegan jerky, vegetable chips, snack bars, and vegan muffins), and sweet treats (eg, vegan donuts, cookies, and cakes). Companies also are introducing more plant-based beverages (eg, plant milks, nut milks, flavored water, sodas, and energy drinks). • Functional foods. Online and in-store retailers will continue to introduce foods and beverages made with cannabidiol, hemp, collagen, psilocybin, and a variety of botanicals such as ginger, ginkgo, ginseng, ashwagandha, and turmeric, as well as those fortified with added vitamins and minerals, omega-3s, and protein. • Probiotics. New research on probiotics suggests they may play a role in lowering the frequency and duration of upper respiratory tract infections, reducing weight gain, insulin resistance, feelings of depression and anxiety, stress, and even infertility. Products touting these messages will follow. • Immunity. More research is underway on the role of food in immune health in all life stages (ie, infancy through older adulthood). Fueling these efforts is the COVID-19 pandemic, prompting manufacturers to develop foods and beverages formulated with added vitamins, minerals, botanicals, and other nutrients to boost immunity. Today’s Dietitian (TD) will cover these and a host of other diet and nutrition trends throughout 2023. Starting with this issue, TD is featuring articles on culinary medicine, sustainability, body positivity, mindful snacking, functional foods, and probiotics. Stay tuned for more coverage of the latest trends, and please enjoy the issue! — Judith Riddle, Editor [email protected] 6 TODAY’S DIETITIAN • JANUARY 2023

Reader Feedback From Our Facebook Page OCTOBER 2022 Curbing Cancer: Dietary Patterns Reduce Risk in Older Adults Optimal Health: I couldn’t agree more. We have to look at the whole diet to succeed in preventing cancer. This approach helps look at those foods that put us at more risk of this disease. Beyond the Female Athlete Triad Kristen Heiberger Thurmond: It makes me so sad that we still see this today. We’ve known these facts for years. I wish parents knew so they would give their growing girls a break. JUNE/JULY 2022 Malnutrition in Cancer Patients Jessica Smoot Younkman: Nice work, Whitney Christie!! APRIL/MAY 2022 Isabel Vasquez (Get to Know…) Lisa Laura: Isabel is fabulous. Feel so lucky to have had her as a student. She is doing amazing work. AUGUST/SEPTEMBER 2022 Are Prediabetes & Type 2 Diabetes Reversible? @BethesdaNEWtri1: #Prediabetes and #type2diabetes—are they reversible? Read more in Today’s Dietitian about periods of “normoglycemia” and remission realities. OCTOBER 2022 Land-Based Salmon Farming @BarbRuhsRD: Raised in the USA just in time for national seafood month! Do you want to learn about #sustainable land-based #salmon farming? Read my latest article in the October 2022 issue of Today’s Dietitian magazine. Exercise and Mental Health @KellyJonesRD: Learn about the mental health benefi ts of movement in Kelly’s Today’s Dietitian column. @CCHP_URMC: Physical activity not only helps us stay physically healthy but it also can positively impact our #mentalhealth. Today’s Dietitian takes a closer look and shares how we can break through barriers that sometimes hold us back from getting active. The WFPB Diet Debate @myDietID: Diet ID’s director of nutrition programming is the author of this new Today’s Dietitian article on Whole Foods Plant Based variants, included in Diet ID’s recognized therapeutic dietary patterns. #wfpb #wholefoodsplantbased Hearty Soups and Stews @LizWeiss: My latest article in Today’s Dietitian magazine is on soups and stews ... a nourishing and budget-friendly canvas for #beans, whole grains, veggies, and fruit. Get my recipe for Barley & Chickpea Stew. #mushrooms #chickpeas #plantforward #bluezones Food Allergies and Health Disparities @DietitianSherry: Did you pick up the conference issue of Today’s Dietitian at #FNCE? Check out my latest contribution about #foodallergies and #healthdisparities. When to Toss Moldy Food @tobyamidor: When should you toss moldy food? It’s my latest in my Today’s Dietitian Ask the Expert column. From Our Twitter Feed JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 7

Herbal Supplements Q Many of my clients are asking about herbal supplements for a variety of health conditions. What’s the best way for dietitians to approach this topic? A: Herbal supplements fall under the umbrella of dietary supplements, which are defined as products that contain a vitamin, mineral, an herb, or other botanical, and are sold in capsule, tablet, powder, liquid, or other form. Many cultures have used herbs as medicine for centuries in the form of traditional Chinese and Ayurvedic medicine. Some herbal supplements have benefits that are supported by science, including ginger, chamomile, and valerian. There has been an influx of herbal supplements gaining popularity among American consumers, such as ginseng and green tea extract. Ginseng has been used as a calming agent in traditional Chinese medicine. It’s also touted to help with memory and thinking skills, Alzheimer’s disease, and depression. Green tea extract is touted to help improve high cholesterol and high blood pressure and prevent heart disease and ovarian cancer. Herbal supplements aren’t regulated by the FDA in the same manner as prescription and over-the-counter medications. The Dietary Supplement Health and Education Act of 1994 set the regulatory framework for herbal supplements. The FDA doesn’t set standards for the contents or nutrient composition of herbal supplements or take responsibility for their safety and effectiveness or labeling claims. Dietary supplement companies are responsible for ensuring they meet product safety standards and labeling requirements.1 What follows are the pros and cons of herbal supplements dietitians can discuss with clients and recommendations to help them choose wisely. Market Growth According to Businesswire, the size of the US herbal supplements market was estimated at $2.2 million USD in 2021 and is projected to reach 4.1 million USD by 2027.2 That’s a 10.6% compound annual growth rate. Consumers are turning to a variety of supplements to help with various health concerns. IFIC’s 2022 Food and Health Survey says that 60% of people who wanted to improve immune function turned to vitamin C, 51% to vitamin D, and 15% to other dietary supplements such as elderberry and echinacea.3 The IFIC survey also found that 30% of respondents took dietary supplements that are supposed to reduce stress or the effects of stress (eg, headaches, fatigue). However, there’s a variety of concerning issues consumers aren’t aware of when it comes to herbal supplements. Various Concerns Since the FDA doesn’t approve labeling claims of herbal supplements before they’re marketed, many claims are misleading. Products may contain lower or higher amounts of certain ingredients or those that aren’t listed on the label. A 2019 study compared the ingredients in herbal supplements with what was written on the label and found that of the 272 products examined, 51% were mislabeled.4 The best way to circumvent this issue is to look for thirdparty certification seals of approval on supplement labels. The three certifying organizations that independently assess supplement quality, purity, potency, ingredient composition, and other criteria are ConsumerLab.com, NSF International, and the US Pharmacopeial Convention. Another issue is dosage. Often, consumers take one supplement for a variety of health problems because it’s marketed as one that can help improve different health challenges. The problem is there’s little research on most herbal supplements regarding proper dosing and length of treatment to help with specific health issues. And while there are some dosing and treatment guidelines for herbal supplements based on short-term studies, more research is needed for consensus. Recommendations to RDs Speaking to clients who want to resolve medical issues with herbal supplements can be challenging. First, dietitians should build rapport with clients so they feel comfortable discussing the herbal supplements they take. Second, RDs should ask why clients are taking a specific supplement or refer them to a physician or specialist. To learn more about herbal supplements, RDs should visit the American Botanical Council (www. herbalgram.org), Consumerlab.com, and the National Institutes of Health Office of Dietary Supplements (https://ods.od.nih. gov) websites. ■ Toby Amidor, MS, RD, CDN, FAND, is founder of Toby Amidor Nutrition (tobyamidornutrition. com) and a Wall Street Journal bestselling author. She’s written nine cookbooks, including Diabetes Create Your Plate Meal Prep Cookbook: 100 Delicious Plate Method Recipes and The Family Immunity Cookbook: 101 Easy Recipes to Boost Health. She’s also a nutrition expert for FoodNetwork.com and a contributor to U.S. News Eat + Run and other national outlets. Ask the Expert By Toby Amidor, MS, RD, CDN, FAND For 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 • JANUARY 2023

WATCH It’s 2023 and everyone’s watching. Watching video, that is. On YouTube, on their favorite news and information websites, on TV via streaming services, all over social media. Continuing education is no exception and webinars have become one of the most popular platforms today for professionals to earn the credits they need. Dietitians have told us they enjoy our presentations because they’re informational, instructive, and interactive. INFORMATIONAL We proudly produce webinars through the Today’s Dietitian CE Learning Library that earn dietitians those important CEUs, as well as provide them with in-depth information and current research on important subjects. INTERACTIVE Our platform allows attendees of our live webinars to ask questions of our presenters both during and after their presentations. Quite often, presenters will make contact information available for webinar attendees to follow up with questions, ask for clarifications, or seek advice. INSTRUCTIVE Our webinars are led by engaging and well-respected professionals in their field on topics vital to RDs’ career development and their treatment of patients and clients. Recent webinar subjects include telehealth, the Mediterranean diet, being a better communicator, plant-based family meals, counseling skills, food claims’ impact on consumer behavior, digestive health, choline, and so much more. Your Knowledge Base Grow Your CEU Total Rise Our Webinars! In addition to the live presentations, all of our webinars are recorded and posted on the CE Learning Library website for viewing and earning CEUs. Visit CE.TodaysDietitian.com/webinars to see what’s coming up and which recorded webinars you’d like to watch and learn from.

The Microbiome’s Effects on Mental Health Can probiotics and prebiotics in food, as well as in supplementation, help improve depression and anxiety? F ollowing multiple years of managing a global pandemic, people seem more in need of ways to manage stress and improve their mental health than ever before. According to a report from the American Psychological Association called Stress in America 2022: Concerned for the Future, Beset by Inflation, Americans are experiencing higher rates of stress and discouragement.1 The survey, conducted between August 18 and September 2, 2022, asked 3,192 Americans to weigh in on their biggest concerns and the role that stress plays in their lives. Driven by negative views on the political climate, survey respondents reported feeling significant stress due to inflation, fear of not having enough money to care for their basic needs, and concerns for personal safety. More than one in four respondents said they couldn’t function normally due to the impact of stress. Notably, the report highlights the fact that many of the stressors are out of the individuals’ control. Yet, there are many mental health–promoting factors that can be controlled, including engaging in exercise, getting enough sleep, developing a positive support system, and maintaining a healthful diet. Can manipulating the gut microbiota also help? The Gut-Brain Axis Research has shown a clear connection between the gut and the brain, referred to as the gut-brain axis. The gutbrain axis describes the bidirectional communication that occurs between the gut microbiota and the brain via the central and enteric nervous systems, sympathetic and parasympathetic nervous systems, and neuroendocrine and neuroimmune pathways.2 The bidirectional communication of the gutbrain axis means the brain can impact the gut, and the gut can influence the brain. How these messages are delivered between the gut and the brain isn’t fully understood, but vitamins metabolized by bacteria in the gut, neurotransmitters, and neuroactive microbial metabolites, such as short-chain fatty acids, all play a part.2 Of course, food provides energy for the brain and nutrients for hormone production. And nutrients help preserve brain function as people age. Specific nutrients and compounds, including omega-3 fatty acids, magnesium, GABA, and L-theanine, all have been associated with improved mood.3 Using food and, if needed, the right kind of supplementation to influence the composition of good bacteria in the gut also appear to be important opportunities to support good mental health. What’s more, it’s known that changes in the microbiome are associated with immune health, weight, and mental Probiotics By Sherry Coleman Collins, MS, RDN, LD 10 TODAY’S DIETITIAN • JANUARY 2023

health.4 With regard to mental health, research has shown there are differences in the gut microbiome between people who have major depressive disorder and those who don’t.5 Since stress and anxiety have been on the rise, so have prescriptions for antidepressants.6 While some of these medications are indicated to treat depression and anxiety, they aren’t always effective and often come with unwanted side effects.6 Importantly, some medications used to treat depression and anxiety, as well as other ubiquitous drugs prescribed for other conditions, such as metformin, proton pump inhibitors, and laxatives, are associated with undesirable changes in the gut microbiota.7 The more drugs one individual takes, the stronger the impact on the gut. Role of Probiotics Since mood is influenced by a variety of factors, treatment for mood disorders is complex and requires a multifaceted approach. In addition to pharmacotherapies, dietary interventions and possibly including probiotics may be an affordable and effective part of the treatment plan without significant side effects. However, research on the efficacy of probiotics associated with improved mood in human subjects is limited. A 2021 review by Bear and colleagues, published in Microorganisms, says that research on the connection between the microbiome and mood has been conducted mostly in animals.8 Few studies, and even fewer controlled trials, have been conducted in humans. Still, what researchers know about this connection is encouraging and should spur innovation and further studies, particularly since treatments for mood disorders come with limited success. Research in humans suggests that probiotics may play a part in managing mood in individuals who don’t experience clinically diagnosed mood disorders. In a study of 38 healthy individuals, daily probiotic supplementation with a probiotic mixture (Lactobacillus fermentum LF16, L rhamnosus LR06, L plantarum LP01, and Bifidobacterium longum BL04) resulted in better sleep and improvements in mood.9 A 2019 randomized, doubleblinded, placebo-controlled study showed that supplementation with Lactobacillus plantarum DR7 reduced stress and anxiety in adult subjects after eight to 12 weeks of use.10 The subjects also reported improved cognitive and memory function. The US Probiotic Guide lists only three products on the market in the United States with research supporting their potential to improve mood: Calm Biotic, InnovixLabs Mood Probiotic, and Yakult brands, which are indicated with Level II evidence along with the disclaimer that the products aren’t a suitable substitute for standard treatment.11 What About Prebiotics? Some experts believe a diet rich in prebiotics also may play a role in improving mood. Kara Landau, APD/AN, known as “The Prebiotic Dietitian,” and founder of Gut Feeling–Gut Health Product Development + Certification, a voluntary certification program for products designated as prebiotic, describes a gut-healthy diet as one “made up of prebiotic rich ingredients, [including] foods that contain prebiotic fibers and resistant starches, as well as polyphenolic compounds.” To increase prebiotics in the diet, she recommends Jerusalem artichokes, chicory root, asparagus, onions, green bananas, green banana flour, resistant potato starch, roasted and then cooled potatoes, whole grains, raw oats (ie, overnight oats), legumes, and lentils. Prebiotics provide the fuel for the good microbes in foods and dietary supplements. In fact, probiotics use prebiotics to produce metabolites such as short-chain fatty acids, which are known to be associated with better mood. Putting It Into Practice At the 2022 Food & Nutrition Conference & Expo™, Hannah D. Holscher, PhD, RD, an associate professor of nutrition and research at the University of Illinois, presented on the dietary and microbial connections to mood and cognition.12 Holscher emphasized that research on the association between the microbiota and mood in humans is limited. However, she recommends practitioners encourage clients and patients to eat a diverse diet with plenty of colorful foods. The diet can include culturally appropriate foods that improve diet quality, as well as fermentable fibers and prebiotics. Research measuring the Mediterranean diet score and the Alternative Healthy Eating Index found that the diets of people with depression and anxiety tended to be poorer in quality.13 With regard to probiotic supplementation, Holscher says it’s important to be selective, recognizing that impacts are strain-specific and dose-dependent with limited human evidence. Since Lactobacillus strains are the most well-studied in the literature for influencing mood, one conservative approach may be to start clients with foods containing lactobacillus bacteria in increasing amounts, along with a diet Holscher describes. Once that has been achieved, dietitians can monitor clients for improvement and adjust as needed. If a supplement is determined to be appropriate, consider using those cited in the US Probiotic Guide, possibly with the addition of prebiotics. Clients should follow the regimen for eight weeks or more before determining its efficacy. Supplements and diet shouldn’t be used in place of medical management of major depressive disorder or anxiety. The growing field of nutritional psychiatry and the emergence of psychobiotics, a term referring to beneficial bacteria that influence bacteria-brain relationships, reflect the opportunities for using food and probiotics to improve mental health.2 Diet is an essential part of supporting good mental health, as the food people eat also can impact their mind and mood. Dietitians should leverage the current research on dietary interventions that support gut health, consider probiotic supplementation where evidence supports it, and work with local mental health professionals to provide referrals when necessary. However, helping clients and patients optimize their diet first is key. Supplementation with probiotics and prebiotics can be part of an effort to help clients feel better physically and mentally. A holistic, multidisciplinary approach will help clients get appropriate treatment that’s more effective with fewer side effects and greater benefits. ■ Sherry Coleman Collins, MS, RDN, LD, is president of Southern Fried Nutrition Services in Atlanta, specializing in food allergies, digestive disorders, and nutrition communications. Visit her on Twitter, Instagram, and Facebook @DietitianSherry. For references, view this article on our website at www.TodaysDietitian.com. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 11

Healthful Foods for the Heart A wider variety of packaged functional food products are hitting grocery store shelves than ever before. These foods are fortified with added nutrients and are formulated to help prevent and manage chronic disease risk factors and chronic diseases themselves, such as type 2 diabetes and heart disease. Many of these functional foods boast the American Heart Association (AHA) health claim due to continued concerns about preventing and better managing heart health and CVD. According to the AHA, nearly one-half of American adults have high blood pressure, and many are unaware they have it.1 According to the CDC, between 2015 and 2018, nearly 12% of adults aged 20 and older had total cholesterol above 240 mg/dL, and about 17% had HDL cholesterol levels below 40 mg/dL.2 The National Diabetes Statistic Report shows that 37.3 million people have diabetes (11.3% of the US population), and 96 million people aged 18 and older have prediabetes (38% of the adult US population).3 These risk factors for heart disease and diabetes and even diabetes itself help contribute to the increasing interest in functional foods. AHA’s Health Claim In 1995, the AHA launched the HeartCheck food and recipe certification program, which specifies foods and recipes that meet the FDA regulatory requirements for heart health claims. At the grocery store, these foods boast the AHA name on the front of the package along with the red heart and white check shield. The foods that showcase the Heart-Check Mark are designed to help consumers make informed choices about the foods they purchase. The Heart-Check Mark serves as an emblem of the program and states: “American Heart Association Certified, Meets Criteria for Heart-Healthy Food,” and features a red heart with a white check mark placed in the middle of it. In addition, “the Heart-Check Mark program helps simplify the overwhelming number of choices consumers see in the grocery aisle, but it’s important to eat a variety of nutritious foods to reduce the risk of heart disease and stroke,” says Shelley Johnson, MJ, RD, operations manager of Heart-Check Programs, at the AHA. “The American Heart Association recommends eating a variety of fruits and vegetables, whole grains, healthful sources of protein like nuts, legumes, fish and seafood, lean meats, and low-fat dairy in addition to adjusting energy intake to achieve or maintain a healthy body weight. It’s important to focus on the overall pattern and stay consistent throughout your life vs looking for quick solutions.” These functional foods must meet strict criteria set forth by the AHA. The standard certification for FDA-regulated products must contain less than 6.5 g total fat, 1 g or less saturated fat and 15% or fewer calories from saturated fat, and less than 0.5 g trans fat per label serving and standard serving size; products containing partially hydrogenated oils aren’t eligible for certification. Products also must contain 20 mg or less of cholesterol. One of four sodium limits is acceptable depending on the specific food category (up to 140 mg, 240 mg, or 360 mg per label serving, or 480 mg per label serving and per standard serving size. Finally, foods must have 10% or more of the DV of one of the following six nutrients: vitamin A, vitamin C, iron, calcium, protein, and dietary fiber.4 There are requirements for many additional food categories, including canned fruit and vegetables, fruit and vegetable juice, grain-based products, grain-based and snack bars, milk and dairy alternatives, smoothies, snacks, and yogurt. A full list of the specific food category guidelines can be found at https://tinyurl.com/2s4zxzjk.4 Market Growth Due to these nutrition requirements and the inclusion of the Heart Check mark on product packaging, sales of these hearthealthy foods are booming. According to the Institute of Food Technologists, sales of foods and beverages with an AHA heart health claim reached $3.4 billion, up 11% for the year ended October 3, 2021.5 For a product to receive the Heart-Check certificate, the “process begins with a product application and an initial business agreement,” Johnson says. “Products are then submitted for a nutritional screening by a registered dietitian. Once final nutrition approval is achieved, a product-specific license is issued, and the final license agreement is signed and the product may display the Heart-Check mark on packaging and promotional materials for one year according to specific guidelines.” Heart Healthy Packaged and Fresh Foods On September 1, 2022, the AHA released an updated list of AHA Heart-Check certified products that meet its nutrition criteria. The document lists the items by food category, product, company, serving size, calories, total fat, saturated fat, sodium, and sugar content per serving.6 Some of the products are packaged, and others are fresh. Below is a sample of foods by category on the AHA list. • S&W Low Sodium Pinto Beans. Food category: beans and legumes; Serving size: 130 g; Calories: 110; Total fat: 0 g; Saturated fat: 0 g; Sodium: 140 mg; Sugars: 1 g • WestSoy Organic Unsweetened Soymilk. Food category: beverages; Serving size: 8 oz; Calories; 100; Total fat: 5 g; Saturated fat: 1 g; Sodium: 35 mg; Sugars: 3 g • Cheerios. Food category: cereal; Serving size: 39 g; Calories; 140; Total fat: 2.5 g; Saturated fat: 0.5 g; Sodium: 190 mg; Sugars: 2 g • StarKist Chunk Light Tuna in Water. Food category: fish & game: canned or Functional Foods By Toby Amidor, MS, RD, CDN, FAND 12 TODAY’S DIETITIAN • JANUARY 2023

processed; Serving size: 74 g; Calories; 70; Total fat: 0.5 g; Saturated Fat: 0 g; Sodium: 150 mg; Sugars: 0 g • Fresh Seedless Watermelon. Food category: fruit: fresh, frozen, or canned; Serving size: 280 g; Calories: 80; Total fat: 0 g; Saturated fat: 0 g; Sodium: 0 mg; Sugars: 17 g • Lean Cuisine Garlic Sesame Noodles with Beef. Food category: main dish/meals; Serving size: 226 g; Calories: 240; Total fat: 4.5 g; Saturated fat: 2 g; Sodium: 510 mg; Sugars: 9 g • Boar’s Head Honey Smoked Turkey Breast. Food category: meat & poultry: canned or processed; Serving size: 56 g; Calories: 60; Total fat: 1 g; Saturated fat: 0 g; Sodium: 420 mg; Sugars: 0 g • Blue Diamond Almonds Lightly Salted. Food category: nuts or seeds; Serving size: 17 g; Calories: 100; Total fat: 9 g; Saturated fat: 0.5 g; Sodium: 25 mg; Sugars: 1 g • Wesson Canola Oil. Food category: oils; Serving size: 1 T; Calories: 120; Total fat: 14 g; Saturated fat: 1 g; Sodium: 0 mg; Sugars: 0 g • Seapoint Farms Organic Edamame Fettuccine. Food category: pasta; Serving size: 56 g; Calories: 200; Total fat: 3 g; Saturated fat: 0.5 g; Sodium: 0 mg; Sugars: 3 g • Idaho Potato – Russets. Food category: potatoes; Serving size: 148 g; Calories: 110; Total fat: 0 g; Saturated Fat: 0 g; Sodium: 0 mg; Sugars: 1 g • Health Valley Organic No Salt Added Tomato Soup. Food category: soup; Serving size: 240 g; Calories: 110; Total fat: 2 g; Saturated fat: 1 g; Sodium: 25 mg; Sugars: 15 g • Bolthouse Farms 100% Carrot Juice. Food category: vegetable juice; Serving size: 8 oz; Calories: 70; Total fat: 0 g; Saturated Fat: 0 g; Sodium: 150 mg; Sugars: 13 g Recommendations for RDs For clients who have been diagnosed with CVD or want to prevent or manage CVD, Johnson recommends using the list of AHA-certified products to help them create a more healthful grocery list and better understand what to look for on nutrition labels when shopping.6 In addition, the AHA has Heart-Check certified recipes that will enable clients to make nutritious meals with the Heart-Check certified products they purchase.7 Dietitians can visit the AHA website links to these recipes and help clients select those that are appropriate for their individual needs and food preferences. In addition to choosing AHAcertified foods, dietitians should educate clients on eating balanced meals and snacks that include fruits, vegetables, whole grains, healthful sources of protein such as nuts, legumes, fish and seafood, lean meats, and low-fat dairy as part of a heart healthy diet. ■ Toby Amidor, MS, RD, CDN, FAND, is founder of Toby Amidor Nutrition (tobyamidornutrition.com) and a Wall Street Journal bestselling author. She’s written nine cookbooks, including Diabetes Create Your Plate Meal Prep Cookbook: 100 Delicious Plate Method Recipes, and The Family Immunity Cookbook: 101 Easy Recipes to Boost Health. She’s also a nutrition expert for FoodNetwork.com and a contributor to U.S. News Eat + Run and other national outlets. For references, view this article on our website at www.TodaysDietitian.com. We have over 20 targeted wellness formulas that start with organically grown garlic. Strong supplements for heart, immunity and overall wellness that are odorless and gentle on the stomach. Take them every day... and live tomorrow to the fullest. Is it really odorless? Find out for yourself. Request a sample at Kyolic.com/sample-request Promo Code: KYOLIC22 O R G A N I C A L L Y G R O W N • O D O R L E S S • Make your long-term health a priority with the Kyolic® Aged Garlic Extract™ formula ƤĸíƤɯǜƤƘɯNJŪƬƐɯƬşĽƏƬĘɯşĘĘđƘ...starting today. A Year From Now, You’ll Be Glad You Started Today. BETTER HEALTH... S T A R T I N G N O W . *These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 13

Do Children Need Supplements? The Honest Answer: It Depends A s any parent of young children knows, kids can be notoriously picky eaters—no vegetables, only smooth textures, only white foods, only pizza. While common wisdom says children can get all the nutrients they need from a healthful diet, a recent poll found that more than one-half of parents say it’s difficult to get their children to eat a wellbalanced diet.1 Some RDs say pediatric dietitians must find a way to counsel and console parents of picky eaters. One of the most common questions parents of young children pose to dietitians is, “Should I give my child a supplement?” Children at Risk Some children are at greater risk of nutrient shortfalls or even deficiencies, including those who follow vegan diets or who have been diagnosed with food allergies or celiac disease. Others at risk include children who drink plenty of sugar-sweetened beverages, those who take certain medications, and others living with food insecurity or who have chronic medical conditions that interfere with nutrient intake or absorption. In light of this, Jill Castle, MS, RDN, an author, a speaker, and founder and CEO of The Nourished Child, says, “I’ve noticed that ‘covering the bases’ has been a trend. Parents worry that their kids aren’t getting what they need, and a supplement gives them peace of mind.” She adds, “Research has shown that kids don’t get all they need from food alone. The goal we all have is to try to encourage children to get nutrients from the foods they eat, but to say it’s possible for everyone, isn’t practical.” A national poll of 1,251 parents with at least one child aged 1 to 10, conducted by the University of Michigan Health, found that one-third of parents say their child is a picky eater, and one-third don’t think their child eats enough fruits and vegetables. The poll also found that three-fourths of parents have given their child a multivitamin. More than 1 in 5 had given their child omega-3 supplements.2 In general, female children and adolescents are more likely to take dietary supplements than males.3 The 2020–2025 Dietary Guidelines for Americans acknowledged that dietary supplements may be useful to compensate for nutrients that would otherwise be underconsumed.4 What’s in Children’s Supplements? A recent study published in the Journal of the Academy of Nutrition and Dietetics found that the most common nutrients (in rank order) found in supplements for children were vitamins C, A, D, E, B6, and B12; zinc; biotin; pantothenic acid; iodine; and folic acid. Of the micronutrients (ie, vitamin D, calcium, and potassium) identified by the 2020–2025 Dietary Guidelines for Americans as nutrients of public health concern, 56% of children’s supplements contained vitamin D, 4% contained calcium, and none contained potassium. In addition, 49% of children’s supplements exceeded the upper tolerable intake level for folic acid, 17% for vitamin A, and Supplements By Densie Webb, PhD, RD 14 TODAY’S DIETITIAN • JANUARY 2023

14% for zinc.5 The FDA doesn’t review or regulate dietary supplement products before they’re marketed. According to the Dietary Supplement Health and Education Act, manufacturers of supplements, whether for children or adults, are solely responsible for ensuring their products are safe and determining that the claims on their labels are accurate and truthful. Too Little vs Too Much Parents’ worries that their children may not be getting enough vitamins and minerals in their diet aren’t unfounded.5 According to the American Academy of Pediatrics (AAP), most children don’t get enough iron and calcium from foods. However, when supplements are introduced, there’s also the risk of children getting too much of one or more nutrients. A study published last year in Nutrition and Health found that more than one-third of 52 child-friendly supplements purchased at US pharmacy chains contained amounts of vitamin A equal to or above the established tolerable upper limit for children aged 1 to 3; almost one-fifth of the samples had similar levels of niacin.6 A study from 2017 found that poison control centers in the United States received a call every 24 minutes, on average, with concerns about dietary supplement exposures in children. Many were herbal supplements, but sweet colorful vitamin and mineral gummies also can pose serious problems if mistaken for candy.7 According to the National Center for Complementary and Integrative Health, about 4,600 children go to the emergency department every year because of ingesting dietary supplements. Most took a vitamin or mineral when unsupervised. Childresistant packaging is required only for dietary supplements that contain 250 mg or more of iron in a single container.8 Large doses of the fat-soluble vitamins (vitamins A, D, E, and K) can be toxic if kids ingest too much. Symptoms of vitamin or mineral toxicity include nausea, headaches, or diarrhea.9 The AAP recommends pediatric health care providers inquire about dietary supplement use among patients.10 However, a recent poll found that among parents who gave their child a dietary supplement, only 43% say they discussed supplement use with their child’s health care provider.1 Nutrition Facts Panels on Supplements Amounts of vitamins and minerals in children’s (and in adults’) supplements vary greatly, and there are an infinite number of nutrient combinations. When checking nutrition facts panels on children’s supplements, it’s important to keep in mind that the % DV listed on most of them is for children and adults aged 4 and older unless otherwise indicated. And like food labels, the % DV is calculated based on 2,000 kcal per day—an amount that doesn’t apply to many young children. The % DVs for children aged 1 to 3 are based on 1,000 kcal per day. Labeling information on children’s supplements is inconsistent at best, making product comparisons difficult. For example, some children’s supplements list one % DV for children aged 1 to 3 on the nutrition facts panel, in addition to the % DV for individuals aged 4 and older, which includes all adults. In addition, the dosage for children is sometimes one-half tablet, something that easily can be overlooked. Products also have been found to list % RI (recommended intake), which isn’t an official term. And the term “natural” on labels doesn’t necessarily mean a supplement is safe. Federal regulations for labeling of dietary supplements, including those for children, are less strict than those for prescription and over-the-counter drugs. The most up-to-date nutrient recommendations from the Institute of Medicine are the Reference Daily Intakes. Note that while the DVs in the chart, which are used on nutrition facts panels, are for only three age groups, the Reference Daily Intakes issued by the Institute of Medicine provide nutrient recommendations for six age groups for children. Still, Castle says, “I think giving a supplement should be based on what children are eating routinely and their nutrition status and not necessarily their age. That being said, it’s important to understand the nutrients [of concern] for different age groups, so you can be on the lookout for inadequacies in their eating patterns.” The nutrient needs of teenagers typically fall somewhere between those of children and adults, making it difficult to assess if they’re getting enough vitamins and minerals through their diets. Bottom Line It’s important to remember that every child is different and may have different nutrient needs. Because of that, most experts, including the AAP, don’t issue blanket recommendations for vitamin and mineral supplements for all children, with the exception of vitamin D and iron for infants. However, a 2021 market report found a significant increase in doctors recommending supplements to children.2 Castle says, “Parents should consult with their pediatrician, and dietitians should also be in communication with the pediatrician, particularly if they’re counseling to correct a known nutrient deficiency.” ■ Densie Webb, PhD, RD, is a writer, editor, and industry consultant based in Austin, Texas. DVs for Some Nutrients of Concern Nutrient Infants through 12 months Children aged 1 through 3 Adults and children aged 4 and older Iron 11 mg 7 mg 18 mg Calcium 260 mg 700 mg 1,300 mg Vitamin A 500 mcg 300 mcg 900 mcg Vitamin C 50 mg 15 mg 90 mg Vitamin D 10 mcg 15 mcg 20 mcg SOURCE: DAILY VALUE ON THE NEW NUTRITION AND SUPPLEMENT FACTS LABELS. FDA WEBSITE. HTTPS://WWW.FDA. GOV/FOOD/NEW-NUTRITION-FACTS-LABEL/DAILY-VALUE-NEW-NUTRITION-AND-SUPPLEMENT-FACTS-LABELS. UPDATED FEBRUARY 25, 2022. For references, view this article on our website at www.TodaysDietitian.com. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 15

While for decades dietitians have been spreading the word and educating clients and patients about how diet either can contribute to or help prevent disease, historically, doctors haven’t been so interested in listening or studying nutrition science. But that’s changing. Enter the emerging field of culinary medicine. Although a consensus definition has yet to be established, culinary medicine is essentially an evidence-based field of medicine that blends the art of food and cooking with the science of medicine.3 The Goldring Center for Culinary Medicine (GCCM) at Tulane University’s School of Medicine, founded in 2012, was the first teaching kitchen operating within a medical school. Now, 11 years later, doctors, medical students, chefs, nurses, and dietitians are listening more than ever. But, according to Jaclyn Albin, MD, FACP, FAAP, an associate professor of internal medicine and pediatrics and director and certified culinary medicine specialist in the culinary medicine program at the UT Southwestern (UTSW) Medical Center and Children’s Health System of Texas, in Dallas, “It’s still in the early days. Much more needs to be done in terms of sustainable funding for educational programs and insurance coverage for patient care in teaching kitchens.” Albin, a tireless supporter and promoter of culinary medicine, says, “There’s tremendous potential for advocacy in the area of culinary medicine.” Nutrition Education in Medical Schools Many individuals in the medical field acknowledge that an evidence-practice gap exists between the knowledge and skill required to counsel patients and the level of nutrition education provided to I t’s no secret that poor dietary and lifestyle habits are the leading modifiable risk factors for chronic diseases, such as type 2 diabetes, CVD, and some types of cancer. Plenty of research supports these associations. A study published in the Journal of the American Medical Association found that diseases relating to diet were the leading causes of death in the United States.1 Internationally, nutrient-rich dietary patterns are associated with a reduced risk of death from all causes.2 Medicıne Culinary A Collaboration, Not a Competition, Between Physicians and Dietitians By Densie Webb, PhD, RD 16 TODAY’S DIETITIAN • JANUARY 2023

medical students.4 In fact, on average, students in medical schools in the United States spend less than 1% of lecture time learning about diet, falling far short of the National Research Council’s recommendation for baseline nutrition curriculum that was set in 1985. The council’s recommendation requires a minimum of 25 to 50 hours of nutrition education in undergraduate medical training.5 A 2018 survey of 248 physicians found that only 13.5% felt adequately trained to discuss nutrition with their patients, and 78.4% said that additional training in nutrition would enable them to provide better clinical care.6 The authors of the survey concluded there exists “a clear deficiency in medical education.” Despite the acknowledged need, a minority of medical schools offer culinary medicine courses, and the courses are seldom mandatory. A recent review of culinary medicine courses and curriculums offered at medical schools in the United States identified programs that used hands-on teaching kitchen experiences. They found significant variability in the length of courses, learner level, instructor type, and application to real-life situations.7 A small study of 10 first-year medical students at the Wayne State University School of Medicine evaluated students who completed a four-part, eight-hour course in culinary nutrition instruction and hands-on cooking.8 At the end of the course, participants said they were better prepared to counsel patients on a healthful diet, and scores on an objective test of culinary knowledge increased significantly immediately after the course and in a two-month follow-up. Similarly, all programs in the review consistently improved student knowledge in nutrition application and positively impacted attitudes about the role of food in health. Increasing health professionals’ knowledge of basic nutrition is only one aspect of culinary medicine in which medical schools are sorely lacking. The 2019 report from the Harvard Law School Food Law and Policy Clinic (FLPC), “Doctoring Our Diet: Policy Tools to Include Nutrition in US Medical Training,” highlighted the current lack of education on diet-related diseases and nutrition that doctors receive over the course of their medical careers and called for greater nutrition education in the medical field. FLPC provides guidance and engages law Resources • Health Meets Food: https://culinarymedicine.org • Teaching Kitchen Collaborative: https://teachingkitchens.org • Nutrition in Medicine (free online curriculum): www.nutritioninmedicine.org • Johnson & Wales Tulane/JWU Culinary Medicine Collaboration: www.jwu. edu/news/2013/02/tulane-jwu-culinary-medicine-collaboration.html • Institute of Lifestyle Medicine, CHEF Coaching Program: www.instituteofl ifestylemedicine.org/?page_id=511 • List of medical schools, nursing schools, and residency programs using components of the Health meets Food® curriculum: https://culinarymedicine.org/culinary-medicine-partner-schools 18 TODAY’S DIETITIAN • JANUARY 2023

students in the practice of food law and policy. The report identified actionable policy approaches to increase nutrition competency of US-trained physicians.9 The report contains several recommendations, but one that potentially could have the biggest impact is “Amend the Liaison Committee on Medical Education accreditation standards to require nutrition education.” The Liaison Committee on Medical Education accredits medical education programs in the United States and Canada. Accreditation is required for eligibility for some federal grant programs. Creating such a requirement for accreditation would serve as an incentive for medical schools to incorporate culinary medicine programs into their curriculums. Just last year, the House of Representatives passed a resolution that encourages medical schools, graduate medical education programs, and other health professional training programs to provide education on nutrition and diet. The resolution also calls upon federal agencies to conduct or fund research that assesses the status of nutrition education in health care professionals’ training and quality of care. While the resolution doesn’t create binding law, FLPC says it represents a step forward in responding to the growing burden of diet-related disease by raising awareness and encouraging future action. Culinary Medicine Curriculums The full spectrum of culinary medicine education includes not only basic nutrition knowledge but also instruction on how to apply that knowledge to diet therapies, often referred to as “Food as Medicine.” Culinary medicine also includes the practical applications that take place in the supermarket and in the kitchen at home. Despite these inroads, there remains a lack of quality control and standardization in nutrition education programs among those offered in medical schools. Some provide basic nutrition education, but only a few offer fully developed culinary medicine curriculums. As part of GCCM, future physicians are educated and trained to understand and apply nutrition in practical ways. The center’s stated goal is to enable medical trainees to assist their patients with diet and lifestyle modifications that improve their health. In addition to training future physicians, GCCM teaches continuing medical education classes for existing medical professionals and offers free nutrition-focused cooking classes to the community. GCCM uses its own curriculum along with hands-on cooking classes to help participants learn how to plan, shop for, and cook food that tastes good and that’s part of healthful eating. Tulane collaborates with Johnson & Wales culinary school in Providence, Rhode Island, to offer culinary classes for medical students. Albin, in a collaborative teaching effort with Milette Siler, MBA-HC, RDN, LD, CCMS, an oncology teaching kitchen manager and culinary medicine lead instructor at UTSW, manages UTSW’s culinary medicine program and teaches nutrition through hands-on cooking classes to medical students, residents, health care professionals, and the community. The program, called Health meets Food, is courseware consisting of more than 30 teaching modules. UTSW offers a culinary medicine elective to medical and TRUST THE SCIENCE Bio-K+ is used in 300 North-American hospitals and has been documented in over 100,000 patient cases in the past 15 years.1 Powered by a trio of powerful strains, our clinically supported probiotics allow you to select from ƳǣǔǔƺȸƺȇɎˢƏɮȒȸɀًǔȒȸȅƏɎɀƏȇƳȵȒɎƺȇƬǣƺɀɎȒƫƺɀɎ suit individual dietary needs and lifestyle. WE INSPIRE WELL+BEING, IT’S WHO WE ARE AND IT’S IN EVERYTHING WE DO. Give your patients the probiotic routine that will help them feel their best! p tal *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. 1 Bio-K+ Internal reporting January 2021 Biokplus.com • 1 (800) 593-2465 * JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 19

other health professional graduate students. The elective includes four modules (12 hours of instruction) each semester. Health meets Food curriculum is available for licensing in the United States. For a small annual fee, more than 60 medical schools, residency programs, and nursing schools currently license the full curriculum. Health meets Food also offers the only certification program in culinary medicine for physicians, nurse practitioners, registered nurses, physician assistants, dietitians, master’s- and doctorate-level nutritionists, pharmacists, and certified diabetes care and education specialists. The Certified Culinary Medicine Specialist program, which consists of 60 hours of continuing medical education, provides nutrition education and teaches culinary skills. It takes about two years to become certified. The hands-on teaching modules, online education, and conference sessions are accredited for dietitians’ continuing education. Certification is valid for five years after successfully passing an examination. After five years, additional coursework is required to maintain certification, similar to maintaining RD status. To date, about 200 professionals have been fully certified with the program. Another major player in the culinary medicine field is the Teaching Kitchen Collaborative (TKC), a joint project of the Harvard T.H. Chan School of Public Health and the Culinary Institute of America. TKC is led by David Eisenberg, MD, who’s also the director of culinary nutrition and an adjunct associate professor of nutrition at the Harvard T.H. Chan School of Public Health. TKC is a nonprofit organization with 45 member organizations, which make up a network of teaching kitchens in libraries, schools, veterans’ hospitals, and medical schools, that use teaching kitchen facilities to enhance personal and public health in medical, community, school, and corporate settings. Officially launched in 2016, TKC sponsors a conference each year, which can count toward CE credits for health professionals. While the network allows for collaboration among the organizations, the curriculums and teaching methods vary among the member organizations and institutions. The Institute of Lifestyle Medicine in Charlestown, Massachusetts, offers the CHEF (Culinary Healthcare Education Fundamental) Coaching Program in an 18-hour, online, evidence-based program focused on culinary coaching. It’s a telemedicine approach to improve nutrition through culinary training, combined with health coaching principles. Physicians’ time with patients is limited, and Rani Polak, MD, MBA, Chef, founding director of the CHEF program, says, “A very important component of the CHEF Coaching training is providing efficient tools for busy physicians that can be incorporated in a short meeting.” The main components of the online instruction, he says, are culinary training, behavioral change strategies, overcoming barriers to home cooking, and implementing culinary medicine in their medical practices. There’s no hands-on instruction, but it provides an option for students who don’t have access to a teaching kitchen. Dietitians vs Physicians Albin says dietitians shouldn’t worry that doctors will encroach on their territory or supplant their role in nutrition education. “There’s plenty of room at the table,” she says. “We need all hands on deck. The collaboration potential with culinary medicine is huge.” Polak emphasizes that point: “The role of RDs in integrative culinary medicine is essential, and the CHEF Coaching training is approved for CE credits by the Academy of Nutrition and Dietetics.” Albin wants medical schools to understand that culinary medicine classes and programs aren’t just about Conferences Several culinary medicine conferences, as well as nutrition conferences with culinary medicine tracks, are being held, some annually. Here are a few conferences focusing on culinary medicine coming up this year: • Healthy Kitchens, Healthy Lives, February 8-10, 2023, in Napa Valley, California. For more information, visit www.healthykitchens.org. • Health meets Food: The Culinary Medicine Conference®, June 8-11, 2023, in Orlando, Florida. For more information, visit https://culinarymedicine.org/ conference. (The recording for the 2022 conference is available for purchase at https://culinarymedicine.org/shop/conferences/2022. • National Culinary Medicine Symposium, Summer 2023 (date TBA), in Missoula, Montana. For more information, visit https://chefdrmike.com/ culinary-medicine/national-culinary-medicine-symposium. 20 TODAY’S DIETITIAN • JANUARY 2023

For references, view this article on our website at www.TodaysDietitian.com. reducing a population’s chronic disease risk. Investing in culinary medicine will elevate each medical school’s mission to provide a well-rounded education for future physicians and help their program attract more applicants. Siler, who serves as a coinstructor with Albin, says, “By offering these classes, we’re not giving physicians all the tools that the RD has to educate patients, but RDs can step up and partner with physicians. Some medical students had never even heard of a dietitian or weren’t familiar with what dietitians do.” Siler says that in Health meets Food, first year students increased their understanding of what a dietitian does and how they contribute to the team from 37% to 93% after attending the culinary medicine elective.10 “We have to accept that the physician is the primary entry point for most patients,” Siler says. “They are the ones who can refer. If a physician doesn’t know what you do, why would they refer?” Thus far, medical students at UTSW have shown great interest in learning about culinary medicine. “The first year we offered the elective classes, we filled 32 slots in 24 seconds (that’s seconds, not hours) and had a waiting list of two to three times that amount.” The students were so eager to get in, she says, that they were misspelling their names on the online application. “Culinary medicine is the most popular elective on campus by a wide margin.” Chef Polak agrees: “Medical schools report that students look for lifestyle medicine courses when they review the medical school curriculum.” In fact, he says, “There are also a number of medical schools that showcase their focus on lifestyle medicine as a marketing strategy to attract students.” Bottom Line The potential to educate medical students and physicians about nutrition and health and its practical application at the supermarket, at home, and in the kitchen, is enormous. Albin says health professionals need to start thinking of nutrition as being a medical intervention, similar to pharmaceuticals. Currently, she says, the main obstacle isn’t a lack of interest from future physicians but a lack of funding. “We cannot meet demand.” Siler suggests, if dietitians are interested in getting involved or initiating a small program for health professionals or their community, they may have to do some digging to find funding sources. “Make sure you’re keeping abreast with what the White House is doing with nutrition funding.” There also are commercial partners, such as Kroger and other supermarket chains, or food companies, including Siggi Yogurt, that may offer grants. Siler also points to TKC’s free seminar on how to start a teaching kitchen (See “Resources” sidebar on page 18). Education in culinary medicine is the future of nutrition education for all health professionals. The search for grants and institutional support, Siler says, is best accomplished with clinical and academic collaboration, a necessary component of every other aspect of culinary medicine. ■ Densie Webb, PhD, RD, is a freelance writer, editor, and industry consultant based in Austin, Texas. Ball State Online Jenni Browning MS, RDN CEO, American Dairy Association of Indiana M.S., Nutrition and Dietetics Much faster than average for all occupations, says the Bureau of Labor Statistics.* In 2024, all applicants eligible to take the registration exam for dietitians must have a graduate degree. If you’re a dietitian today, you can continue your career by earning our fully online M.S. in nutrition and dietetics. Learn more: bsu.edu/online/dietetics *https://www.bls.gov/ooh/healthcare/dietitians-and-nutritionists.htm What’s the job growth outlook for nutrition and dietetic professionals? JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 21

Understand the Various Claims, Make Informed Decisions, and Better Counsel Clients

Seismic Shift Among Consumers and Businesses Whether consumers are purchasing socks or sockeye salmon, brands and companies seem eager to share their sustainability story. Sustainability language now spans the entire retail ecosystem, and concepts have grown to include buzzwords such as “net zero,” “planet positive,” “carbon neutral,” “regenerative agriculture,” “climate justice,” and more. If it feels as though the weighty topic of sustainability is enough to make one’s head spin, you’re not alone. Nearly every major industry is undergoing a seismic shift as companies seek to reduce business risks associated with negative impacts on ecological and social systems and align with global targets laid out in landmark agreements such as the Paris Climate Accords and the 2030 United Nation’s Sustainable Development Goals. They’re also striving to evolve with consumers’ changing attitudes. More than one-half of eaters in the United States say they believe their food choices have an impact on their environment, according to IFIC’s 2022 Food and Health Survey.1 For younger consumers aged 18 to 34, sustainability is table stakes, with 80% of respondents saying they give thought to whether their food and beverage choices are produced in a sustainable way.1 And a 2022 State of Snacking Report by Mondelēz states that 85% of consumers globally desire to purchase snacks from companies actively working to offset their environmental impact.2 Beyond trends or even policy frameworks, sustainability also has become a big business advantage. According to the NYU Stern Center for Sustainable Business’s Sustainable Market Share Index, in 2021, sustainably marketed products grew seven times faster than conventionally marketed products and almost four times faster than the consumer-packaged goods market overall—which means there’s plenty of interest in companies putting a green sheen on their food’s story.3 RDs Play a Key Role With dietitians’ unique positioning across numerous touchpoints of the food system—including the agriculture, retail, culinary, clinical, foodservice, community, research, education, business, and health care sectors—they’re poised to drive meaningful change when it comes to sustainability. But how can RDs keep pace with the fast-moving landscape to effectively help patients and the public make informed decisions about the sustainability of the foods and beverages they buy? Navigating Sustaınability WithConfi dence T he creation of sustainable food and water systems to better achieve human and planetary health is ongoing domestically and globally, as industries and companies from various sectors are under intense pressure to develop new methods, processes, and product formulations to become and remain sustainable. With this push for greater sustainability, Today’s Dietitian takes a fresh look at the continued growth of the sustainability movement and explains how dietitians can make informed decisions about the products they buy and recommend to clients and consumers. By Kate Geagan, MS, RDN JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 23

“The concept of sustainable food can feel instantly overwhelming, as it encompasses many pressing and complex issues, from animal welfare all the way through to public health, labor justice, accessibility, agricultural practices, and beyond,” says Ayten Salahi, MS, RDN, chair-elect of the Hunger and Environmental Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics; executive director of the Planetary Health Collective, a food and climate advocacy organization; and CEO of Aysa Nutrition, a plant-based gastrointestinal nutrition practice. “RDs don’t necessarily need a PhD in agricultural sciences,” Salahi says, “but we do need to be able to discern high- from low-quality research, strategically communicate the most impactful opportunities for action to our communities, and participate in work that helps make the most climate-smart options, the easiest options to access for all.” Companies eager to produce more sustainable products often make bold claims to attract consumers and increase sales. However, determining which sustainability claims are meaningful and regulated and which lack standards that are monitored or enforced can be a challenge. Yet, to solve the climate crisis, it’s important to prevent companies from greenwashing, which is “the act or practice of making a product, policy, activity, etc, appear to be more environmentally friendly or less environmentally damaging than it really is.”4 The United States lacks robust federal reporting on this issue, but a 2021 European Union (EU) review by consumer health authorities found that 42% of online markets made false, exaggerated, or misleading claims regarding sustainability.5 Not all companies make deliberately false or exaggerated claims. But if RDs are more conscious of how brands may communicate information to their advantage, they’ll be able to make more informed decisions, whether it’s understanding sustainability claims on food products or evaluating sustainability messaging contained in industry-sponsored CPE opportunities, research, or materials. Which Seals and Claims Are Meaningful and Verifi able? One way in which companies communicate that their products are sustainable is through third-party seals and certifications on the front of food and beverage packaging. To qualify for these seals and certifications, products must meet a set of requirements and agree to independent inspection and public reporting. Typically, certification programs include a checklist of practices companies must follow (eg, the USDA Organic or the Fair Trade seals). And there are newer seals that include a measurement of outcomes achieved, such as Land to Market’s Ecological Outcome Verification seal, indicating that farmers and ranchers used a methodology to measure regenerative outcomes on their land that include soil health, biodiversity, and ecosystem function. While there’s no single label or logo that comprehensively addresses all aspects of environmental, social justice, or animal welfare concerns, some come closer than others. It’s important for dietitians to learn what these certifications are and what they mean, work with clients to decide which factors are most important to them, and look for the right labels to support their goals (see “Resources” sidebar). Sifting Through Unregulated Claims Unregulated phrases such as “free range,” “cage-free,” “vegetarian fed,” or “pasture raised,” suggest but do not guarantee that standards have been met. These terms, while they sound good to the public, lack a formal verification process or independent oversight, so farm conditions may vary widely among different brands. Other phrases, such as “soil health” or “planet-positive,” are general sustainability concepts that are unregulated, vary in meaning, and are unaccountable. One buzzword currently used in regulated and unregulated contexts is “regenerative.” The term “regenerative agriculture,” widely used and popular among consumers and industry, typically refers to farming practices that focus on improving soil health, crop diversity, and enhancing ecosystems. However, since this term has no formal, universally agreed-on definition, it’s used to describe a wide variety of scenarios (eg, incorporating unspecified amounts of cover crops or pollinator habitat into an otherwise conventional system). Unlike the term “regenerative agriculture,” the thirdparty certification seal is “Regenerative Organic Certified,” which indicates that the product has met a comprehensive set of social justice, ecological, governance, and animal welfare standards. Carbon labeling is another tool companies and retailers are using to communicate carbon emissions data in easy-to-understand “scores.” For example, supermarket retailer Tesco, based in the United Kingdom, made headlines as the first supermarket to place “green scores” (in partnership with the Carbon Trust) on popular everyday staple products to highlight the environmental cost of producing them. In the United States, some brands work with independent auditors to verify and communicate key aspects of specific carbon metrics to consumers—either on the product or the company’s website. While brands tout the value of featuring this data to help the public make informed decisions that align with their values, Deanne Brandstetter, MBA, RDN, CDN, FAND, vice president of nutrition and wellness at Compass Foodservice, says showcasing such information is an evolving area. “While eco-labeling and carbon labeling and claims are rapidly growing, there’s little regulation around these claims and inconsistent processes and methodology around calculating scores,” Brandstetter says. “Until there’s more standardization, RDNs need to understand these limitations and communicate them to clients and patients they advise.” Strategies for Success: What to Look for in Sustainability Claims Despite the many sustainability claims that may be called into question, the following six strategies can help dietitians spot those that are legitimate. 1 GET YOUR BASICS DOWN. Learn about the concepts of sustainability in the article “Cultivating Sustainable, Resilient, and Healthy Food and Water Systems: A NutritionFocused Framework for Action,” published in the June 2020 issue of the Journal of the Academy of Nutrition and Dietetics or the EAT-Lancet Commission on Food, Planet, and Health.6,7 These resources highlight the multiple dimensions of sustainability that dietetics professionals need to consider (eg, sociocultural, nutrition, planetary, and economic) when incorporating sustainability into their work. 24 TODAY’S DIETITIAN • JANUARY 2023

2 APPLY SYSTEMS THINKING. Systems thinking is a more holistic approach to investigating how a set of interrelated factors may contribute to the outcomes being examined. Misleading messages often focus on a single factor related to sustainability, while downplaying others that go against sustainable best practices. For instance, industries may overemphasize one metric (eg, carbon) and minimize others that cause harm (eg, agrochemical flows on watersheds), which can be considered a form of greenwashing, according to the June 30, 2022, article “Greenwashing: Your Guide to Telling Fact From Fiction When It Comes to Corporate Claims,” from the EU Climate Pact.8 3 BE DILIGENT. A single article or continuing education course may not provide the whole picture of sustainability, so research the issues and the industries and seek a variety of reputable sources. Evidence-based resource libraries from RD-led health professional organizations, such as the Planetary Health Collective and Food and Planet, offer a variety of peer-reviewed, published literature to help dietitians make informed decisions and have confidence in their clinical recommendations. 4LOOK FOR ACTIONS, NOT WORDS. To avoid greenwashing, the EU recommends practitioners and consumers observe what a company does, not what it says.8 Some questions to ask to gain a bigger picture of a company’s or industry’s true sustainability practices include the following: “What percentage of a company’s (or industry’s) agricultural footprint uses the sustainable practice it promotes?” “What percentage of total revenue comes from products developed using sustainable methods vs those that were not?” Asking these types of questions is a best practice for investment companies when evaluating potential risk in the food and agriculture sectors and can also be a helpful exercise for dietitians. 5 BUY LOCAL WHEN POSSIBLE. The shorter the supply chain, the less likely sustainability claims will be misrepresented or confusing. Buying local enables individuals to connect more deeply with those producing their food—whether it’s a vertical farming or community garden project in an urban area or a rural farmer or rancher. Samira Zarghami, RD, CDE, an entrepreneur launching socially responsible projects, encourages buying local to bring sustainability to life. “When I spoke to a number of farmers and saw how hard they work on the land and how they truly pour their heart into the work they do, it completely changed my view,” Zarghami says. “I saw the care they gave their animals. I saw that they would sacrifice their family time to tend to the farm: they and the guests at a wedding would all leave to attend the birth of a new animal on the farm.” By forming relationships, Zarghami says, it’s possible to have conversations that can influence practices and share beneficial information. 6 RESPECT EVERYONE’S UNIQUE JOURNEY AND PRIORITIES. Ultimately, it’s our relationship with one another and the planet that’s at the heart of sustainability. Being intentional and thoughtful in how RDs approach the topic is as important as any other aspect of the patient-practitioner relationship. “Consumers are constantly feeling guilty when it comes to making food choices at the store,” Zarghami says. “They’re overwhelmed with facts such as local, seasonal, how it will affect climate change, and now the rise in food costs and impact of COVID-19.” Good food is a celebration of family tradition, cultural foodways, social connection, and pleasure. Keeping these values at the center of dietetics practice is vital for empowering consumers and ensuring we’re guiding clients and patients toward choices that align with their health goals, personal preferences, and values while also evolving the nutrition profession. ■ Kate Geagan, MS, RDN, is an award-winning dietitian and globally recognized thought leader on sustainable diets. She’s the author of Go Green Get Lean: Trim Your Waistline with the Ultimate Low-Carbon Footprint Diet, serves as a strategic partner to some of the world’s leading purpose-driven investment funds and food innovators, and is cofounder of Food + Planet. Resources The following list of organizations and resources can help dietitians get up to speed on what sustainable food labels mean across the food system and build confi dence to evaluate sustainability labeling claims. FOR RDs AND CONSUMERS: Food Print: Food Label Guide (https://foodprint.org/eatingsustainably/food-label-guide/) off ers tools and resources to understand what diff erent sustainability labels mean, which ones are the most meaningful, and which terms are unregulated. It also has a glossary of technical terms such as “rotational grazing.” FOR CLINICIANS: Healthcare Without Harm (https://noharm.org) off ers evidence-based opportunities for clinicians to reduce carbon footprints and promote environmental justice through health care systems. FOR PRODUCERS: The Good Food Purchasing Program (https://goodfoodpurchasing.org) provides technical support to institutions so they can uphold more equitable, sustainable, and transparent food systems through value-driven purchasing frameworks that involve making purchases that align with fair labor, certifi ed humane animal welfare, sustainable seafood, and other values encompassing sustainability. FOR EVERYONE: Friends of the Earth’s 51-page report Spinning Food (https://foe.org/ wp-content/uploads/2017/legacy/FOE_SpinningFoodReport_8-15.pdf) covers the most common ways people can be misled by brands, companies, industries, and stakeholders. — KG For references, view this article on our website at www.TodaysDietitian.com. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 25

The downside, however, is that snacking usually is a less intentional eating occasion than a regular meal. When clients snack, they’re often on the go or eating while distracted, which can disconnect them from their internal hunger and satiety cues. “When people are eating meals, they tend to have more awareness, whereas with snacks, I tend to hear [snacking] much more as a complaint, ‘I’m totally mindlessly snacking,’” says Cheryl Harris, MPH, RD, a dietitian in private practice in Fairfax, Virginia. “What people eat for snacks and how much they eat for snacks tend to be much more mindless.” But that doesn’t mean snacking has to be a thoughtless exercise. It’s possible for clients to learn the habits of mindfulness and incorporate them into snacking habits, potentially with significant health benefits as a result. Here’s how dietitians can help their clients move toward more intentional nibbling. Determinants of Snacking To begin with mindfulness and snacking, it helps to understand what factors affect people’s snack choices—and even their motivation for eating a snack in the first place. One obvious factor that prompts snacking is hunger, yet many people snack when they’re not hungry. This is significant because people who snack due to hunger tend to eat comparatively nutritious snacks, whereas people who snack in T he number of people who snack throughout the day in between meals is on the rise. One recent report found that the average American went from enjoying 505 snacking occasions per year in 2015 to 530 per year in 2020.1 Grazing in between meals can be advantageous. It can boost energy levels during long stretches between meals, and some evidence suggests it can lower cholesterol and blood pressure, improving heart health.2-4 Research shows snacking can boost overall diet quality if the snacks are nutritious.5,6 SNACKING WITH INTENTION Strategies to Help Clients Take a Mindful Eating Approach By Jamie Santa Cruz 26 TODAY’S DIETITIAN • JANUARY 2023

the absence of hunger are inclined to eat more energy-dense snacks, which may, in turn, promote weight gain and lower overall diet quality.7 Factors besides hunger that can influence snacking include the following: • Emotions and psychological stress. Emotional eaters consume higher amounts of energy-dense snacks, especially snacks high in fat and sugar, than those who don’t eat emotionally.8 • Genes. Genetic variations affect a person’s taste receptors and influence their snack preferences.9 • Social messaging and modeling behaviors from family. People who are exposed to social messages that encourage limiting junk food intake consume significantly fewer highcalorie snacks.10 • Physical environment. People who live in neighborhoods with a high prevalence of convenience stores that are stocked with energy-dense snacks tend to have diets lower in nutrition quality.11 • Package sizing. The average package sizes of snacks have increased in recent decades, which has influenced energy intake.5 • Distraction. Eating while distracted— such as while watching TV—is linked to overconsumption.5 • Presence of variety. An increase in the variety of foods available at a given eating event (such as a family dinner) or in a person’s environment overall has been linked to higher consumption within a given meal and in the individual’s diet.12,13 The abundance of snack options in the modern world may therefore influence snack consumption.5 • Time of day. Snacks eaten in the morning generally have more nutritional value, as people are more likely to reach for fruit or yogurt to jumpstart their day.14 By contrast, people tend to gravitate toward savory snacks such as potato chips and tortilla chips in the afternoon and are likely to reach for sweets in the evening.1,14 Fortunately, mindfulness can help clients become more aware of the various factors impacting them and arrive at a place where they’re snacking by choice and with purpose. Introduction to Mindfulness: The Key Principles Asked to define mindful eating, Harris summarizes it this way: “Eating with intention and eating with attention.” To expand on that short definition: mindful eating generally means paying attention to the act of eating, being aware of the taste and texture of food, and being conscious of the emotional and physical JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 27

sensations one feels while eating.15 It also involves making conscious food choices, developing an awareness of the body’s physiological hunger and satiety cues, and eating in response to those cues rather than external cues.15 The idea isn’t to be 100% mindful throughout every single bite of a meal, which would be unrealistic. Rather, it’s about bringing a level of awareness to eating overall, according to Rachael Hartley, RD, LD, a dietitian in private practice in Boston. “That includes the sensory experience—so, what does my food taste like, smell like, is it pleasurable or not—but also the experience we’re having in our body and in our brain while we’re eating food.” In other words, “what thoughts are coming up around this food, what emotions am I experiencing right now, how does my body feel right now in terms of hunger and fullness cues.” Aside from simple awareness, two other essential components of mindfulness are curiosity and nonjudgment, says Narmin Virani, RDN, LDN, a clinical dietitian with Nashville Nutrition Partners. Why is nonjudgment important? When individuals are busy passing judgment, it puts the body and the mind “in a state of stress or stress response,” says Virani, who also serves on the board of directors of the Center for Mindful Eating. When people are in a state of stress or anxiety it’s harder “to connect with our body or pay attention to internal cues.” Benefi ts of Mindfulness and a Word of Caution A basic benefit of mindful eating is that it opens up the opportunity to alter habits that individuals dislike or that are detrimental to their own wellbeing. Most of the time, Harris says, “we’re on autopilot, and we just do what we’ve always done. When we’re mindful, there’s a pause, and we have the opportunity to change our behaviors and do something different.” When applied to eating habits, this can translate into real health benefits. Studies have shown that mindful eating interventions can do the following: • Improve glycemic control in people with diabetes. A pilot study comparing a mindful eating intervention with standard diabetes self-management education found that the mindfulness intervention resulted in an average reduction in A1c levels of -0.83% after three months—slightly better than the A1c reduction observed for those receiving standard diabetes selfmanagement education.16,17 • Aid weight management or prompt weight loss. Mindful eating interventions don’t always result in weight loss. However, one review article examined the efficacy of mindful eating interventions for weight management among individuals with overweight and obesity and found that weight loss was reported in eight out of 16 studies. In several of those studies, the change in weight was small, but in several others, it was significantly greater.15 According to the review, even when mindful eating interventions didn’t result in weight loss, they often still helped participants stabilize their weight.15 • Reduce symptoms of binge eating. A range of studies has examined the impact of mindfulness interventions on symptoms of binge eating in normal-weight and overweight adults, and these studies consistently show that mindfulness improves binge eating symptoms.15 Mindful eating also consistently reduces other eating behaviors linked to obesity, including emotional eating and external eating (ie, eating in response to external cues such as food packaging or time of day).15,18 But a word of caution: while the health benefits of mindful eating are evidencebased, experts on mindful eating say it’s important not to practice it with a particular health goal in mind. In particular, don’t approach mindfulness as a way to get clients to eat “good” foods or as a weight-management tool. “If we’re going into mindful eating trying to use it as a tool to eat less or to choose the ‘right’ foods, it automatically conflicts with that principle of nonjudgment,” says Hartley, who’s also the author of Gentle Nutrition: A Non-Diet Approach to Healthy Eating. In fact, using mindfulness to achieve specific outcomes, such as weight loss, can set clients back. “One of the things we are discovering more and more through research is that 28 TODAY’S DIETITIAN • JANUARY 2023

our body weight is determined by many factors,” Virani says. Diet and exercise play a role, but so do other factors, including stress, sleep, genetics, side effects of medications, and social determinants of health. Unfortunately, mindful eating isn’t associated with these factors. So, if clients have been told that eating mindfully will result in weight loss, it can set them up for much discouragement and self-blame when it doesn’t happen. The key, then, is to focus on how mindfulness can help clients regain intention in their snacking behavior, not how it will help them lose weight. Guide for Helping Clients Practice Mindfulness in Snacking BEFORE THE SNACK “By failing to prepare, you are preparing to fail.” This adage coined by Benjamin Franklin holds as true for mindful snacking as it may for other areas of life. The following are key steps clients can take to prepare themselves before they start snacking: • Use a hunger-fullness scale to decide when to snack. If 1 represents painfully hungry and 10 represents painfully full, clients should eat a snack once they’ve fallen into the 3 to 4 range, meaning they’re very hungry or hungry, respectively, Virani says. • Ask clients to determine what they’re craving. In particular, clients should pay attention to the three T’s: taste, texture, and temperature. For example, do they want something cold and creamy or salty and crunchy? “If you eat the wrong thing, your snack won’t be satisfying and you’ll be left craving something else,” Virani says. Once clients know the kind of snack they’re craving, they can create a nutritionally balanced snack around that information, Virani says. For example, if a client is craving something salty and crunchy, they might eat a portion of chips but balance it out with some protein in the form of nuts, which will not only add nutrition but also help them feel full longer. In this way, she explains, they can honor both satisfaction and nutrition. • Reduce distractions. By nature, many individuals eat snacks while they’re on the go, increasing the risk of choosing less healthful snacks and not paying attention to how much or how little they consume. It may be impossible to eliminate all distractions, but if clients can at least decrease the number of distractions, that’s better than nothing, Hartley says. • Take a pause. Recommend clients take three deep breaths, breathing in slowly before reaching for a snack. “[This] just helps our nervous system regulate, and that can make it easier for us to bring in some mindfulness,” Hartley says. “It’s a really simple practice that most people can do even if they’re eating in front of the TV or eating in front of their desk.” DURING THE SNACK • Focus on a few (not all) mindful bites. It’s too overwhelming for most people to practice awareness while eating the entire snack—and it’s unnecessary, Hartley says. Instead, dietitians can encourage clients to take one mindful bite at the beginning of their snack, again in the middle, and once more at the end, Hartley says. During these mindful bites, clients should consider the sensory experience—what does the snack taste like, what is its texture, what does it smell like? But clients also should observe their emotional and physical experience: How are they feeling emotionally while they’re eating, and how are they feeling in their bodies, especially in terms of hunger cues? • Suggest clients journal their thoughts and emotions. Practicing mental awareness of the thoughts and emotions they experience while snacking is powerful. Getting clients to put pen to paper can be transformative, Harris says. That’s because writing things down can help clients notice patterns around why they’re snacking. And if they’re not snacking due to hunger, that can be eye-opening. For example, Harris says, some clients may notice they consistently snack when tired, bored, or stressed, while others may realize they snack out of habit. Once they notice their patterns, they may want to address the underlying issue prompting them to snack vs assuaging the problem with food. “There’s that possibility of saying, oh, well, maybe I just need more sleep, or maybe I’m in pain so maybe I need to just go to physical therapy, or maybe I really need to deal with that problem with my boss,” Harris says. Often, clients think they have an issue with food. “But after three to four days of nonjudgmental observation, clients usually start seeing, oh, this is why I’m eating. And they can start to address the underlying reason.” • Recommend clients stop snacking when they reach 7 or 8. As mentioned, a 1 on the hunger-fullness scale represents painfully hungry, whereas 10 represents painfully stuffed. Encourage clients to keep tabs on their hunger cues and stop eating their snack before they start feeling overly full, Virani says. BEYOND THE SNACK The advantage of starting with snacking (vs full meals) to learn about mindful eating is that it’s a shorter eating occasion and, therefore, easier to begin the practice, Hartley says. But once clients have learned mindfulness around snack time, they can apply the practice to regular meals and develop an overall pattern of mindfulness around food and eating. As clients do this, it’s important to help them recognize that mindfulness around food also extends beyond mealtime. “It’s easy to focus on the actual chewing,” Harris says, but “ideally we’re talking about the whole process from shopping to ‘How do you think about hunger cues?’ to ‘Are you feeding yourself in the morning?’ to ‘How hungry are you letting yourself get?’ to ‘Are you nourishing yourself throughout the day?’ to ‘What do you do afterward?’” Harris recommends dietitians start small by helping clients to focus initially on just one snack. However, RDs should keep the end in mind: Snacking is a small step toward the larger goal of a holistic lifestyle of mindfulness around food. ■ Jamie Santa Cruz is a freelance writer based in Parker, Colorado. For references, view this article on our website at www.TodaysDietitian.com. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 29

Dietitians have a central role in prevention and treatment.

There are two types of NAFLD: nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). Patients with NAFL have steatosis but little to no inflammation, and typically don’t develop liver damage or complications—unless they progress to NASH. NASH involves steatosis as well as inflammation and liver damage, which can cause fibrosis or liver scarring.4 Fibrosis stage 1 (F1) is minimal scarring, but if scarring progresses to F4, it’s known as cirrhosis, in which the liver is permanently damaged and functionally impaired. F2 is considered a crucial point for therapeutic intervention to prevent liver cancer or end-stage liver disease.5 While NAFLD generally is characterized by progression from NAFL to NASH, it’s unclear which patients will progress and at what rate. Disease progression also may not be linear but rather have periods of disease progression and regression.6 Genetic variations can increase NAFLD severity and raise the risk of progression to cirrhosis.7 Who’s Developing NAFLD? In the United States, experts estimate that about 24% of US adults have NAFLD, but only 1.5% to 6.5% of US adults have NASH.1 Prevalence rates in North America and Europe aren’t increasing as fast as they are in Asia, which is experiencing increased urbanization with an upwardly mobile economic drift that’s accompanied by F atty liver used to be a condition that people associated with heavy alcohol use, but it’s substantially less common than nonalcoholic fatty liver disease (NAFLD). Both conditions involve excess fat buildup in the liver—known as steatosis—but NAFLD is the most common liver disease and the leading cause of liver-related mortality globally. It’s estimated to affect 25% to 30% of people, but a 2021 systematic review and meta-analysis found that the global prevalence was more than 32% and continuing to grow at an alarming rate.1-3 Currently, nutrition and lifestyle interventions are the frontline treatments. Fatty Liver Disease Nutrition& Nonalcoholic By Carrie Dennett, MPH, RDN JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 31

a more sedentary lifestyle and increased consumption of calorie-dense foods.8 NAFLD can affect people of any age, race, or ethnicity. However, people are more likely to develop NAFLD as they get older, and it’s most common among Hispanics, followed by non-Hispanic whites and Asian Americans—including those of East Asian and South Asian descent—and is less common among non-Hispanic Blacks.4,9 As with many diseases, the causes of NAFLD are multifactorial. Diet, lifestyle, and certain health conditions can play a causal role, but so can genetics—which may explain why prevalence is higher in certain racial and ethnic groups.10 Men are more likely to develop NAFLD than women, although data from the National Health and Nutrition Examination Survey (NHANES) suggest that women who were younger in age when they first gave birth have an increased risk of developing NAFLD later in life.3,11 Compared with women who were aged 30 to 32 when they first gave birth (the reference group), women who were younger than 18 had a 54% higher risk, women aged 18 to 20 had a 60% higher risk, those aged 21 to 23 had a 40% greater risk, and those aged 24 to 26 had a 33% greater risk.11 Symptoms and Causes Experts believe the cause of NAFLD may center around the “adipose tissue expandability” hypothesis. The hypothesis proposes that when individuals consume more calories than they use, their subcutaneous adipose tissue (SAT) expands. But once their SAT cells’ capacity to store energy is exceeded and individuals reach their “personal fat threshold”—which can vary widely from person to person—the body starts depositing fat in visceral adipose tissue, skeletal muscle, and organs such as the liver, pancreas, and heart.12 When the liver’s capacity for secreting or oxidizing fatty acids is surpassed, fat starts to accumulate, filling liver cells with large fat droplets, which can damage or scar the cells.13 Several health conditions may increase the risk of accumulating fat in the liver and developing NAFLD, including the following: • insulin resistance or type 2 diabetes; • metabolic syndrome, or one or more of its traits (high blood pressure, high triglycerides, low HDL cholesterol, high blood sugar, large waist circumference); • high total or LDL cholesterol; and • a BMI in the “overweight” or “obese” range, especially among people who gain weight around their abdomen rather than around their hips or shoulders. Research suggests there’s a bidirectional aspect to these associations, as patients with NAFLD have elevated risk of developing CVD, type 2 diabetes, and the conditions associated with metabolic syndrome.14 A 2022 study used data from the UK Biobank to explore whether BMI and waist circumference were causally associated with NAFLD. The authors found that higher waist circumference was causally linked to liver fat accumulation and NAFLD, regardless of BMI, but that BMI itself isn’t linked once waist circumference is factored in. The authors also concluded that the effect of abdominal adiposity on type 2 diabetes risk was substantially larger than the effect of liver fat on type 2 diabetes risk.15 32 TODAY’S DIETITIAN • JANUARY 2023

NAFLD is typically considered a silent disease. Even someone with NASH who has developed cirrhosis may not exhibit symptoms. When symptoms are present, they’re usually limited to fatigue—which could be attributed to many other factors—or discomfort in the upper right side of the abdomen. Diagnosis and Treatment To diagnose NAFLD, health care providers use a patient’s medical history—specifically, a history of health conditions that increase NAFLD risk—a physical exam and blood tests. Increased levels of the liver enzymes alanine aminotransferase and aspartate aminotransferase are suggestive of NAFLD. Blood samples also may be used to calculate Fibrosis-4 or aspartate aminotransferase to platelet ratio index to identify whether advanced liver fibrosis is present.4 Imaging tests such as ultrasound, CT, and MRI can’t diagnose NAFLD by themselves but may be used as part of the diagnostic process. Fibrosis, if present, may show up as nodules in the liver. A liver biopsy can confirm a NASH diagnosis and determine severity, but generally, this isn’t recommended unless there’s suspicion of NASH with advanced fibrosis, cirrhosis, or other forms of advanced liver disease.4 Currently, there are no drug therapies for NAFLD, although potential medications are undergoing clinical trials. While complications of cirrhosis may be treated pharmaceutically or surgically, dietary and lifestyle interventions remain the first-line strategy in managing NAFLD and slowing or preventing its progression. Gradual weight loss of 3% to 5% of total body weight by creating a calorie deficit often is recommended to improve steatosis and prevent NAFL from progressing to NASH, but a weight loss of 7% to 10% may be needed to improve fibrosis and prevent NASH from becoming more severe.4,16 However, interventions of this type may not be appropriate for many patients, including those with a history of eating disorders. And, as with intentional weight loss for any reason, there’s a high likelihood of weight regain.17 Physical activity has been shown to regulate liver fat—including counterbalancing the adverse effects of overfeeding—independent of weight loss or overall adiposity, if the activity is habitual. Physical activity intervention studies have found that observed reductions in liver fat levels during the intervention aren’t sustained if participants return to inactivity post intervention, and other research has observed that habitual inactivity is associated with higher liver fat content.12 So, what activity dose is needed? Data suggest that patients who maintain more than 150 minutes per week of physical activity or who increase their activity level by more than 60 minutes per week have a pronounced decrease in liver enzymes, independent of weight loss.4 Oatmeal Creme Pie #9801 Net Wt. 1.34 oz | Case Ct. 192 Shelf Life 180 Days Snacks You Can't Sna C acks You Can 't Snacks You Can't P drdow Pee Sugar Fig Bars owd dere Sugar Fig Bar s Oatmeal Creme Pie Snowmen atmeal Creme Pie Snowmen al Creme Pie # Fig Bar #9731 Net Wt. 1.5 oz | Case Ct. 192 Shelf Life 180 Days Snack Carts, Grab 'N Go Snacks, Senior Activities, Boxed Meals, Lunch, Catering. Perfect for: ©2023 Fieldstone Bakery say SnowTo JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 33

Role of Nutrition in NAFLD To prevent or manage NAFLD, physical activity paired with a healthful diet are the primary options, pending successful clinical drug trials. Research has evaluated overall dietary patterns as well as macro- and micronutrients, although most micronutrient research has been conducted in animals. Dietary Patterns An analysis of data from the 2017–2018 cycle of the NHANES for 3,900 US adults aged 18 or older found that a healthful, plant-based diet was associated with lower odds of having NAFLD, an association that was stronger in non-Hispanic whites.18 Healthful plant-based diets generally are defined as having a higher intake of fruits, vegetables, whole grains, nuts, legumes, tea, and coffee and a lower intake of refined grains, high-sugar foods, and animal-based foods. One benefit of a healthful plant-based diet is that it contains components that support healthy gut microbiota. Researchers have observed differences in the gut microbiota between patients with NAFLD and those without, but it’s unclear whether this is cause or consequence because most research on this relationship has been conducted on animals.19 Results published in 2022 from a one-year follow up of 5,867 participants aged 55 to 75 from the PREDIMED-Plus trial in Spain, all with BMIs between 27 and 40 kg/m2 , and all with metabolic syndrome, found that higher consumption of ultraprocessed foods and beverages—as defined by the NOVA classification system—was “directly and robustly” associated with higher levels of NAFLDrelated biomarkers.20 Examples of NOVA-defined ultraprocessed foods include soft drinks, sweets and pastries, packaged snack foods, processed meats, preprepared frozen meals, dairy-based desserts, and “instant” products. Low adherence to a Mediterranean diet explained about onehalf of the observed association, saturated and trans fats were responsible for 17% to 21% of the association, fiber explained 15% of the association, and glycemic load (GL) explained 11%. Liver health markers improved as consumption of unprocessed or minimally processed foods increased during follow up. PREDIMED-Plus is a six-year randomized clinical trial assessing the efficacy of a calorie-restricted Mediterranean diet, physical activity promotion, and behavioral support on weight loss and primary prevention of CVD in this population. Multiple studies have found benefits from Mediterranean-type diets in managing NAFLD. One 2018 review of cross-sectional and longitudinal studies found that these diets were associated with lower incidence or severity of NAFLD and, when used as dietary intervention, may improve liver enzyme levels or liver fat independently of BMI.19 However, the authors emphasized that available studies at that time were small and few in number, and more research was needed. They also noted that the Mediterranean diet is rich in polyunsaturated fats as well as nutrients and phytochemicals with antioxidant properties, which may explain the potential promise for NAFLD prevention or management. Macronutrients Isocaloric feeding studies have observed that diets rich in saturated fatty acids tend to cause fat accumulation in the liver, while diets rich in mono- or polyunsaturated fatty acids decrease fat accumulation.13 Multiple studies also have found that, in general, NAFLD patients consume fewer omega-3 fatty acids from fish, seeds, walnuts, or other sources.7 And a recent systematic review and meta-analysis found that omega-3 supplementation of more than 3 g per day can help reduce liver fat and liver enzymes.21 Another systematic review of 15 randomized controlled trials evaluating the effects of low-fat diets vs lowcarb diets on NAFLD found a lack of consensus, in part due to differing definitions of “low-fat” and “low-carb” among the various trials—definitions ranged anywhere from 8% to 45% carbs for low-carb diets and 15% to 30% for low-fat diets. Both types of diets decreased liver enzymes when calories also were reduced, with a more marked improvement observed with low-fat diets.22 It appears that the type of carbohydrate matters more than a precise percentage of carbohydrates in the diet—for general health and for NAFLD alike—and there has been particular focus on intake of added fructose and the glycemic index (GI) and GL of the diet as it relates to NAFLD risk. A 2020 systematic review and meta-analysis published in the British Journal 34 TODAY’S DIETITIAN • JANUARY 2023

of Nutrition analyzed the influence of all foods on NAFLD development and found that added fructose intake in the form of sucrose or high-fructose corn syrup was positively associated with the likelihood of having NAFLD.23 A 2021 review in Nutrients concluded that fructose metabolism is implicated in the development and progression of NAFLD through multiple pathways.24 Notably, one cross-sectional study from Finland found that higher fructose intake was associated with lower risk of NAFLD—but most of the fructose consumed in this population came from fruit, not sugar-sweetened beverages.25 Evidence supporting a low-glycemic diet for prevention or management of NAFLD isn’t as robust as that in support of reducing added sugars.12 However, a crossover trial in which eight healthy men, average age 20, consumed either a high- or low-GI diet for seven days found an increase in liver fat with the high-GI diet, followed by a decrease with the low-GI diet.26 A small intervention study involving children and adolescents with NAFLD found that modest reductions in fructose, GI, and GL resulted in improvements in plasma markers of liver dysfunction.27 Overall, research has failed to reach consistent conclusions on associations between the likelihood of NAFLD and intake of vegetables, fruit, legumes, whole grains, or refined grains.23 Authors of a 2019 review say that large-scale, randomized controlled studies using long-term low-GI and GL diets with equivalent calorie intake to that of control groups are needed to draw conclusions about effects on NAFLD.28 Micronutrients Another analysis of NHANES data from 2001–2016 found that having adequate blood levels of vitamin D was significantly associated with decreased mortality from CVD and all other causes in patients with NAFLD.29 However, the relationship between vitamin D and NAFLD is complex and unclear, and it may be that variations in genes related to vitamin D metabolism are what affect NAFLD risk.30 In the Pioglitazone vs Vitamin E vs Placebo for Treatment of Non-Diabetic Patients With NASH Study, researchers found that a daily 800 IU dose of natural vitamin E from food sources—not synthetic vitamin E—improved NASH. The drug pioglitazone performed no better than placebo.31 The Treatment of Nonalcoholic Fatty Liver Disease in Children trial, which randomized 173 patients aged 8 to 17 to receive 400 IU of the natural form of vitamin E, metformin, or placebo, found that vitamin E improved the most severe form of fatty liver disease in some children, although neither vitamin E nor metformin performed better than placebo in reaching the primary study outcome of sustainably reducing alanine aminotransferase levels.32 However, the American Association for the Study of Liver Diseases currently recommends using only vitamin E in patients without diabetes who have biopsy-proven NASH.4 Counseling Recommendations For dietitians working with clients and patients with NAFLD, or who have high risk of developing it, the most evidence-based nutrition and lifestyle interventions at this time include helping patients do the following7,16: • Reduce dietary fat to 30% of daily calories, replacing saturated fats and trans fats in the diet with unsaturated fats from nuts, seeds, avocados, olives, and olive oil, and especially with omega-3 fatty acids from fish, walnuts, flax, and chia seeds. Multiple studies have found that nut intake is inversely associated with the likelihood of having NAFLD.23 • Limit carbohydrates to 50% of daily calories, and emphasize low-glycemic, high-fiber carbohydrates such as vegetables, whole grains, legumes, and most fruits. • Avoid foods and beverages that contain large amounts of added sugars, especially fructose. • Increase protein to 20% of daily calories from plant sources, fish, and lean, unprocessed animal sources. • Reduce red and processed meats. • Minimize intake of alcohol, which can further damage the liver. • Develop a sustainable physical activity routine of at least 150 minutes per week. While Mediterranean-style dietary patterns, as well as vegetarian/vegan dietary patterns, and the DASH diet are consistent with these individual recommendations, other cultural dietary patterns could be adjusted to meet client preferences. ■ Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Holistic Guide to Optimal Wellness. To prevent or manage NAFLD, physical activity paired with a healthful diet are the primary options, pending successful clinical drug trials. For references, view this article on our website at www.TodaysDietitian.com. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 35

Dietetics Practıce Body Positivityin

Flash forward to 2012 when influencer culture began to take hold of the idea of body positivity, first with plus-size influencers using #BodyPositive and #BoPo on social media, followed by thinner influencers who tended to focus on loving themselves despite body “imperfections” such as cellulite, then finally by corporations that wanted to capitalize on the trend.1 The original body positive movement was about stopping appearancebased oppression, but the more modern manifestation is about expanding what’s viewed as beautiful. Not the same thing. “It really turned into something very different,” says Kimmie Singh, MS, RD, owner of Body Honor Nutrition in New York City. “It’s turned into something that’s quite watered down,” Singh says, adding that today’s body positive movement largely embraces bodies that aren’t really thin, but are still straight size. “They can buy clothing in regular stores and don’t face discrimination at the doctor’s office.” The idea of body positivity in its various forms has been gaining traction as more people are rejecting the idea of weight loss, dieting, and society’s beauty and body standards. This has led to two interesting outcomes. One is that the body positivity movement has been criticized for “normalizing” or even “glorifying” being “overweight” or “obese” and that being “too” body positive could dissuade people from losing weight and that this would impair their health.2 However, this argument ignores the health impacts of externalized weight stigma—the directing of weightbiased attitudes toward higher-weight individuals—a systemic and societal problem, and the internalized weight stigma that can follow. Evidence of the psychological, behavioral, and physiological effects of internalized and/or externalized weight stigma continues to grow. Its negative impacts include depression, anxiety, low feelings of self-worth and selfcompassion, body dissatisfaction and disordered eating, and real or perceived social isolation. Weight stigma also can make individuals believe they have low self-mastery and self-efficacy, which reduces motivation to engage in physical activity or other health-promoting behaviors. It also leads to avoidance of preventive and treatment health care.3 The other outcome is that body positivity has been adopted—some say co-opted—by the weight loss industry as part of its adaptation to the growing nondiet movement. For example, one website for a weight loss medication says that body positivity is improving our self-esteem about how we look, and lists buying clothes that fit; cooking and eating nourishing, healthful meals; avoiding body comparisons; and being physically active as ways to practice body positivity while trying to lose weight. One surgical weight loss website says bariatric surgery is most effective when accompanied by positive body image, and that body positivity, which it defined as rejecting the idea of the “perfect” body in favor of celebrating diverse shapes and sizes, can help people develop healthful eating and exercise habits. While all of the behaviors mentioned can be aligned with body positivity, yoking them to weight loss is, at least on Is weight management one of the clinical applications? By Carrie Dennett, MPH, RDN B ody positivity” is a buzzy catchphrase popular with Instagram influencers, advertisers, and diet companies. But the origins of the body positive movement run much deeper than its current commercialized manifestations. Body positivity has its roots in late 1960s social justice movements created by and for people in marginalized bodies—particularly fat, Black, queer, and disabled bodies—to talk about the oppression they experience in society and fight back against discrimination in the workplace, doctor’s offices, and other public settings. “ JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 37

the surface, counter to both the original intention and the more current manifestations of the body positivity movement. Body Positivity and Weight Loss So, can body positivity—and actively working to build a positive body image— be compatible with intentional weight loss? Can someone feel positive about their body and want to change it at the same time? Those are complicated questions. “It’s really important that each individual is able to decide what to do with their body, and that includes whether to pursue weight loss or not,” Singh says. “That’s body autonomy, but it’s not part of body positivity, and I think it’s important that people be OK with that difference. Pursuing intentional weight loss is so far from something that’s neutral. Fat is so charged because of fatphobia, so pursuing weight loss isn’t really something that’s body positive.” Christine Byrne, MPH, RD, LDN, a Raleigh, North Carolina–based private practice dietitian who focuses on eating disorders and disordered eating, says she doesn’t think it’s the dietitian’s role to tell people how they feel—or should feel—about their bodies or about intentional weight loss. “Perhaps some people are able to cultivate body positivity while also working towards intentional weight loss. That said, I don’t think it’s compatible for us as dietitians to promote body positivity while also promoting or supporting intentional weight loss,” Byrne says. “Body acceptance is key to body positivity, and that means accepting and respecting all bodies as they are.” She also emphasizes that because long-term weight loss isn’t sustainable for most people, when a client fails to lose weight or regains any weight they do lose, this can undermine their body image. “I think you can acknowledge your desire to lose weight while actively working towards body positivity; however, I think that actively pursuing weight loss while actively trying to improve body image can be counterproductive for a lot of people,” says Kristin Jenkins, MS, RDN, a Marylandbased dietitian at Rebecca Bitzer and Associates. “Intentional weight loss focuses on changing our outward appearance instead of changing mindset. It’s extremely difficult to cultivate a sense of body respect and acceptance if you are actively working to change it based on the belief that something about your body is wrong.” Caitlin Beale, MS, RDN, a nutrition writer, and owner of Caitlin Beale Wellness in Sebastopol, California, says that, in her experience with clients, weight loss and body positivity can be compatible, but it’s challenging. “The connection between weight and negative body image or shame about weight runs deep. It’s everywhere, and it’s really challenging to separate the two.” One factor is whether the desire to lose weight only comes from a place of restriction or selfhatred instead of what someone can do to feel good in their body. “Focusing on the why is so important. I find that weight loss becomes a secondary outcome when the why steps away from the scale. You’re working on feeling better in your body because you love it and want to feel your best instead of responding to a negative voice linked to shame and body hatred.” Weight Loss as a “Side Benefi t” When someone is practicing behaviors born out of body positivity or positive body image, it is, of course, possible that weight loss might happen. This has led many people—including dietitians, therapists, book authors, and influencers—to promote the idea that it’s possible to “love yourself thin.” This could be a problem. “There’s so much harmful messaging out there about how loving your body— or healing your trauma, or working towards some other kind of selfgrowth—will lead to weight loss, and it’s just not true,” Byrne says. “It’s also incredibly stigmatizing to larger bodies because it suggests that gaining weight or being at a higher weight means there’s something wrong with the relationship you have with yourself. Sure, learning to respect, accept, and care for your body could lead to weight loss. It could also lead to weight gain, or your weight might stay pretty much the same.” Singh says these kinds of messages can be confusing to patients because it paints their body positivity as conditional, as if they can’t love their bodies unless they lose weight. “It kind of holds on to that common narrative and trope around fatness, that you can’t be a complete person if you’re fat, that you can’t live your best life unless you lose weight,” Singh says. She adds that pushing the narrative that fat people are fat because they’re holding onto trauma is harmful because it further traumatizes people. Jenkins also believes that promoting the “love yourself thin” narrative is misleading. “While some people lose weight, others will gain weight, and still others’ weight will not change at all,” she says. “I see this as an opportunity to challenge the belief that a well-cared-for body is a thin body because healthy bodies come in all shapes and sizes.” Looking Beyond Body Positivity One problem with today’s “watered down” version of body positivity is that it has become synonymous with “body love,” sometimes in a “toxic positivity” way—as if something’s wrong with you if you don’t love your body. That has led many dietitians to reject the term in favor of “body neutrality,” “body respect,” or “body acceptance.” “I don’t use the term ‘body positivity’ with clients because the idea of loving one’s body or feeling positively about it feels out of reach for many people,” Byrne says. “‘Body respect’ is a term I use with clients to describe acts of caring for their bodies—like nourishment, movement, and sleep—in a way that feels good.” “ Changing the internal narrative we have about bodies and weight is an important part of body image improvement,” says Kristin Jenkins, MS, RDN, of Rebecca Bitzer and Associates. 38 TODAY’S DIETITIAN • JANUARY 2023

“I’ll throw around a few different terms and see if that resonates with where they are and where they want to be,” Singh says. “I’ll even encourage people to explore analogies that resonate with them. People are so often used to people having ideas pushed on them. I find it helpful to remind folks that body positivity isn’t a destination; it’s a process.” “I use the term ‘body respect’ to remind clients that we don’t have to love everything about the way our body looks to be able to care for it,” Jenkins says. “I use the terms ‘body acceptance’ and ‘body neutrality’ to help clients understand there can be a middle ground between body loathing and body love. I describe ‘body neutrality’ as simply allowing your body to exist without investing precious energy into loving or hating it. Ultimately, I believe body image occurs on a spectrum and can change from day to day; it can be very freeing to let go of the expectation that we have to always strive for love and positivity.” Science Behind Body Positivity Research on body positivity–related interventions generally comes in the form of interventions serving to increase positive body image. In the last decade or so, researchers and academics have moved beyond a focus on negative body image as a risk factor for poor physical and mental health. Increasingly, the focus has broadened to include how positive body image might promote better health. Positive body image has two main components. One is body acceptance— accepting one’s body as it is, including its functionality and appearance— which includes caring for and respecting one’s body.4-6 The other is body image flexibility, which refers to the ability to openly experience thoughts and feelings about one’s body—even negative ones—without acting on them or trying to change one’s body to stop those thoughts and feelings.4,5,7 Body acceptance isn’t the same thing as body satisfaction, and, in fact, individuals can accept their bodies while at the same time being dissatisfied with them. Research suggests that, among women, body appreciation increases with age, even when body satisfaction does not.8 A 2019 study of 344 college students found that students who appreciated their bodies were more likely to engage in preventive health behaviors, such as eating a healthful diet and engaging in physical activity, but those who were only satisfied with their bodies didn’t have that increased likelihood. Previous research has found that college students who score high for body appreciation are less likely to diet or use weight loss pills, supplements, or shakes.9 Results of the Mayo Clinic’s FAITH! study published in 2021 found that Black women who had no or lower levels of body dissatisfaction had significantly higher intrinsic motivation and integrated regulation for healthful eating. The authors speculated that greater body image dissatisfaction may be mixed with internalized weight stigma, which can increase emotional eating, decrease dietary selfregulation and motivation, and increase the body’s stress response.10 Results of a study that drew from a random subset of individuals who enrolled in Noom, an app-based weight loss program, found that body appreciation and body image flexibility were higher after 16 weeks than they were at the time of enrollment. While there was a positive association between body appreciation and weight loss, there was no such association with body image flexibility. The authors say the results suggest that psychologically oriented weight management may be important to improve body positivity.11 Body Positivity in Practice In light of the research, even body respect, appreciation, or neutrality may feel out of reach for many clients. If clients also are experiencing external weight stigma or struggling with cancer,12 a chronic disease, or mobility issues, this presents additional barriers to feeling anything positive about their bodies. “Changing the internal narrative we have about bodies and weight is an important part of body image improvement,” Jenkins says. “We also can focus on behaviors that reflect body appreciation and body respect.” She says this can feel more challenging for patients with health issues, especially if they’ve been told that weight loss will not only make them feel better about themselves but it also will make them healthier. She emphasizes that self-care practices such as adequately and intuitively nourishing the body, engaging in joyful movement, getting adequate rest, setting boundaries around negative weight and body talk, and managing stress can improve physical and mental health—including increasing a positive body image and feelings of self-worth and improving blood sugar and cholesterol levels—even when weight doesn’t change. Byrne says dietitians may need to take a team approach. “If someone’s body image struggles are negatively impacting their life, they should work with a therapist on processing past traumas and experiences and establishing healthier thought patterns and coping strategies moving forward. If someone has chronic health issues that strain their relationship with their body, a trusted physician can help manage symptoms. If clients seek out a dietitian for weight loss because their weight is limiting their mobility, the dietitian should consider referring them to a physical or occupational therapist who can help them improve mobility or perform daily tasks more easily in the body they’re in right now.” Beale says talking with clients about practicing gratitude for their bodies— instead of looking at them with a critical eye—also can help, although it’s not easy. “Working to shut down the critical voice and focus on all the fantastic ways the body functions also are helpful. I’m still learning (and unlearning) a lot of what I thought was ‘healthful’ surrounding weight, and I’m a professional—so it’s no wonder this is complex for the general public.” Beale says learning about the social justice narratives surrounding weight and body acceptance is important and has forced her to recognize some of her own biases. “We have a long way to go as a profession and a society on the issue, but it’s certainly continuing to grow.” ■ Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy For Your Life: A Holistic Guide to Optimal Wellness. For references, view this article on our website at www.TodaysDietitian.com. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 39

Eye Health and Nutrition I mpaired vision is a major public health problem, with more than 250 million persons experiencing vision loss worldwide and more than 3.4 million Americans aged 40 and older experiencing visual impairment.1,2 Vision loss is one of the 10 most common causes of disability in the United States, potentially leaving individuals unable to drive, read, or travel independently. Moreover, it may require specialized equipment as vision deteriorates. People with visual impairment are more likely to suffer from depression, diabetes, hearing impairment, stroke, falls, and cognitive decline.2 This continuing education course explores the role of nutrition in visual development and healthy vision. Nutritional factors in prevention and treatment of age-related macular degeneration (AMD), glaucoma, cataract, dry eye disease (DED), and visual complications of diabetes will be reviewed. Overview of the Eye Structure The human eye is part of a visual system that includes the eye, neural pathways to the brain, and areas of the brain for interpreting visual signals. The pupil regulates light entering through the cornea. The lens focuses light on the retina, which consists of blood vessels, rods, and cones. These photoreceptors translate light into neural impulses. The millions of cones are concentrated in the macula, allowing for sharp, detailed central vision and color vision. The surrounding rods are responsible for night vision, peripheral vision, and motion detection3 (See Figure). Key Nutrients for Maintaining Eye Health Vitamin A, which plays an essential role in vision, is involved in cell differentiation in the cornea and conjunctival membrane, functions as an antioxidant, and helps convert light into neural signals. Vitamin A is necessary for the formation of rhodopsin, the photoreceptive pigment responsible for low-light vision.4,5 Vitamin A deficiency, which is the leading cause of preventable blindness worldwide,4,6 presents as xerophthalmia, drying of the conjunctiva and cornea and night blindness due to inadequate rhodopsin, the earliest symptom.5,6 There’s a low risk of vitamin A deficiency in developed countries, except in postbariatric surgery patients.7 Vitamin A is obtained from the diet as preformed vitamin A (retinol or retinyl esters from animal sources such as fish oils, eggs, dairy products, and liver) or carotenoids, primarily β-carotene, from plant sources (dark green or yellow/orange vegetables, fruits, and oils).4,6 As a fat-soluble vitamin, it’s better absorbed with dietary fat. Vitamin A circulates in the body in a one-to-one complex with retinolbinding protein.6 Conditions that affect formation of retinol-binding protein, such as proteinuria, protein malnutrition, or zinc deficiency, can contribute to vitamin A deficiency.4 The human eye is susceptible to damage from oxidative stress. Eye tissue has a high oxygen consumption and a high concentration of polyunsaturated fatty acids (PUFAs), and it’s exposed to high-energy visible light, which contributes to the formation of reactive oxygen species that can damage cells.1 Nutrients that function as antioxidants can help mitigate this damage, but excessive intake isn’t helpful.8 Dietary lutein (Lu) and zeaxanthin (Zx) function in the macular pigment of the retina to shield the eye from light damage.8,9 Macular pigment filters blue light and acts in an antioxidant, anti-inflammatory role.9 Lu and Zx are obtained from dietary sources such as green leafy vegetables (kale, spinach, broccoli, and lettuce), egg yolks, wheat, yellow peppers, and yellow corn.8,10 Dietary fat enhances absorption of Lu and Zx. These carotenoids are transported in the body by lipoproteins, with theoretical implications that manipulating lipoprotein levels may affect Lu and Zx levels in the retina.10 Long chain PUFA intake also may impact eye health. DHA, an omega-3 fatty acid found in the photoreceptor cells, provides light protection, helps regenerate corneal nerve cells, and maintains cell membranes.8,11 In addition, omega-3 fatty acids provide anti-inflammatory effects.12 A balanced intake of omega-6 and omega-3 fatty acids seems to be most CPE Monthly By Kathleen Searles, MS, RDN, LD COURSE CREDIT: 2 CPEUs Learning Objectives After completing this continuing education course, nutrition professionals should be better able to: 1. Evaluate the role of vitamin A in normal eye development and vision. 2. Discuss four eye disorders and the dietary or nutrient factors involved in their prevention or treatment. 3. Describe the mechanism of diabetic retinopathy and counsel clients on the best dietary interventions for prevention. Suggested CDR Performance Indicators 8.1.1, 8.1.5, 10.3.7, 10.3.9 CPE Level 2 40 TODAY’S DIETITIAN • JANUARY 2023

beneficial, with an ideal ratio of 4:1 and an acceptable ratio of <10:1.8,12 Dietary sources of omega-3 fatty acids include flaxseeds, flaxseed oil, fish oil, walnuts, chia seeds, hemp seeds, and fatty fish.13,14 Nutrients with antioxidant properties or roles in antioxidant enzyme systems also are being investigated. These include vitamins C, D, and E; zinc; copper; selenium; glutathione; and dietary flavonoids.8,13,15,16 There’s also evidence showing associations between deficiencies in the various B vitamins and eye disorders.17-19 Maternal and Infant Nutrition and Eye Development Because of its role in cell differentiation, vitamin A is an essential nutrient for proper eye development.5 Maternal nutrition plays a key role in the development of vision; ingested maternal vitamin A reaches the infant via the placenta.4,20 The earliest manifestation of maternal vitamin A deficiency is night blindness. Pregnant women with poor diets, infections, diabetes, or gestational diabetes are most at risk.4,6 Those living in less-developed countries also face higher risk. Excessive vitamin A can be teratogenic, so it’s important to ensure adequate but not excessive intake. In 2013, the World Health Organization recommended against routine supplementation, except in places where vitamin A deficiency is a known public health issue.4 Carotenoids are deposited in eye tissue beginning at about 20 weeks gestation.20 During the third trimester of pregnancy, uptake of carotenoids from the placenta accelerates, and fetal rhodopsin levels increase dramatically.9,21 Lu and Zx also play a role in the developing retina. Macular pigment begins accumulating prenatally, with levels detectible at birth and continuing to accumulate until age 7.9 Research is ongoing about the roles of choline, DHA, and arachidonic acid in fetal eye development.22,23 Fortification of infant formulas with DHA has been associated with improvements in visual acuity in full-term infants.24 The third trimester is important for retinal growth when large amounts of DHA are transferred to the fetus via the placenta.9 Retinopathy of prematurity (ROP), the second leading cause of childhood blindness in the United States, is seen in lowbirthweight premature infants. Important risk factors for ROP are extremely low birthweight and gestational age ≤ 30 weeks.25 Vitamin A deficiency can increase the risk of ROP.23 Vitamin E supplementation can significantly reduce the risk of severe ROP in very low-birthweight infants but is recommended primarily for infants who are >34 weeks because of the possibility of increased risk of necrotizing enterocolitis.24 Nutritional Factors in Eye Disorders Age-Related Macular Degeneration AMD is the most common cause of blindness in industrialized countries. One in three individuals over the age of 80 show signs of AMD.26 There are two types of AMD: dry and wet. In dry AMD, photosensitive cells break down. In wet AMD, abnormal blood vessels form under the retina (angiogenesis) causing blurred vision and impaired central vision.3 Angiogenesis is treated with injections that inhibit vascular endothelial growth factor (VEGF) and control edema.3,20 As AMD advances, lipid deposits (drusen) accumulate in the retina. When widespread, the condition is known as geographic atrophy.26 AMD is associated with multiple lifestyle and genetic risk factors, which vary among ethnicities.20,27 Interpretation of AMD studies may be affected by whether genetic risk has been identified. It has been suggested that individuals with two risk alleles may have limited results from both nutrient supplementation and diet manipulation.28 Age is the most significant risk factor for AMD. Other risk factors include smoking, obesity, exposure to ultraviolet and blue light, poverty, light skin color, light iris color, and possibly female sex.3,10,20 Poor nutrition, including from restrictive diets, has been implicated.10 In particular, a low intake of green leafy vegetables and fruit may increase risk.29 The primary studies on nutrition and AMD are the Age-Related Eye Disease Studies, AREDS and AREDS2. These large (>4,000 participants) studies looked at the roles of antioxidant vitamins, minerals, and carotenoids in reducing AMD incidence and progression.30 Participants were individuals aged 55 to 80 from 11 centers nationwide who were at risk of developing AMD. In the three arms of AREDS, researchers compared the effects Visit www.TodaysDietitian.com/SS23 to register for our Spring Symposium! SAVANNAH 2023 JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 41

of supplemental zinc (80 mg zinc oxide with supplemental copper as 2 mg cupric oxide), supplemental antioxidants (500 mg vitamin C, 400 IU vitamin E, and 15 mg β-carotene), or both on AMD development.1,20,30 These nutrients were chosen for their antioxidant and immune-supporting functions.11 Participants were followed for five years, with follow-up after an additional five years.30 For the antioxidants + zinc and copper treatment arm, there was no preventive effect, but there was a 25% reduction in risk of progression to late stages of AMD compared with placebo.1,20,30 (See Table below.) AREDS2 was designed to assess the effect of Lu, Zx, and/or omega-3 PUFA on AMD.20 Some arms of the study used the original AREDS supplement, some used a lower zinc level (25 mg), and some used the supplement without β-carotene.30 An increased risk of lung cancer was found in participants who were smokers or had a history of asbestos exposure who received β-carotene.11 Overall, the findings showed a modest to no-risk reduction for the use of Lu and Zx compared with placebo.26 The Vitamin E, Cataract and AgeRelated Maculopathy Study (n=1,204) looked at the preventive effects of supplemental vitamin E. There was no evidence for the general population to use supplemental vitamin E for prevention or to slow progression of AMD.26,31 Merle and colleagues studied intake of B vitamins and progression to geographic atrophy in AMD. After controlling for multiple variables, they found that high dietary folate intake correlated with a reduced risk of progression to geographic atrophy.18 Gopinath and colleagues looked at 1,760 participants aged 55 and older and found that an elevated total homocysteine level was related to increased risk of AMD as were vitamin B12 and folate deficiencies.17 In the Carotenoids Age-Related Eye Disease Study (CAREDS), Moeller and colleagues evaluated 1,787 women aged 50 to 79 who were in the highest and lowest ranges for Lu and Zx intake. They found a strong inverse relationship between intermediate AMD and vegetable intake, especially green vegetables. In healthy women, they found a statistically significant protective effect of higher Lu and Zx intakes.32 CAREDS also found decreased prevalence of early AMD with increased adherence to a Mediterranean diet.28 In a CAREDS study of vitamin D, Millen and colleagues found the highest risk of AMD in those with deficient vitamin D status and two risk alleles for AMD.16 When Gopinath and colleagues examined intake of flavonoids, specifically those found in apples, oranges and orange juice, and tea, they found a protective effect on AMD prevalence. Study participants who consumed at least one serving of oranges (rich sources of the flavonoid hesperidin) per week had 92% reduced odds of late AMD.15 Summarizing results of various studies, Demmig-Adams and colleagues suggest that individuals can lower the risk of AMD by leading a healthy lifestyle and consuming a diet with ample antioxidants, especially Lu, Zx, and omega-3 fatty acids. The ideal diet is calorically appropriate, low glycemic, and limited in trans and saturated fats, with a desirable omega-6:omega-3 fatty acid ratio. In addition, they recommend a multivitamin/ mineral supplement containing vitamins C, E, β-carotene, zinc, and copper at RDA levels.8 Gopinath and colleagues also recommend high consumption of dark green leafy vegetables, consuming fish at least twice weekly, and including ample fruits, especially oranges.15 Glaucoma Glaucoma is a degenerative retinal neuropathy related to oxidative stress, typically with elevated intraocular pressure.19,33 Risk factors include age over 60, genetics, family history, diabetes, systemic hypotension or hypertension, vasospasm, use of corticosteroids, migraine, obstructive sleep apnea, myopia, and history of eye injury.33 African Caribbean, African American, and Hispanic or Latino individuals are at the greatest risk.33,34 Elevated BMI has been associated with increased intraocular pressure.35 Despite the role of oxidative stress in glaucoma, no clear beneficial role for antioxidant nutrients has emerged.19 In the prospective, population-based Rotterdam Study, those with lower intake of retinol equivalents were at increased risk of primary open-angle glaucoma.36 Ramdas completed a comprehensive systematic review of 46 studies and found no consistent results associating carotenoid intake with glaucoma.13 In a meta-analysis of five studies on vitamin A, two large studies showed a protective effect of dietary intake of retinol equivalents and three showed no significant difference.19 Studies on vitamins and glaucoma have shown varying results for vitamins C and D and thiamin.19 Higher intakes of riboflavin and niacin have been associated with decreased glaucoma risk.36 A review of six studies found no effect of dietary vitamin E intake on glaucoma.19 In a prospective study, Kang and colleagues found no significant relationship between intake of vitamins C and E or carotenoids on the risk of developing primary open-angle glaucoma.35 Elevated intakes or blood levels of minerals including calcium, magnesium, manganese, mercury, and molybdenum have been associated with increased glaucoma risk. For calcium, high supplement intake (800 mg/day or more) is implicated but not dietary calcium. Supplemental selenium used in a randomized controlled trial of cancer patients was associated with increased risk of developing glaucoma. Elevated serum ferritin levels and supplement intake of 18 mg/day or more also have been associated with greater risk.13,37 Data on omega-3 and omega-6 PUFAs show that the ratio of omega-3: omega-6 is CPE Monthly RISK REDUCTION IN VISION LOSS IN AREDS Antioxidant + Zinc and Copper Formulation Zinc + Copper Antioxidants Only Reduction in progression from intermediate to advanced age-related macular degeneration 25% 21% 17% Reduction in risk of central vision loss 19% 11% 10% Reduction in risk of cataract None None None SOURCE: AGE-RELATED EYE DISEASE STUDIES (AREDS, AREDS2). NATIONAL EYE INSTITUTE WEBSITE. HTTPS://WWW. NEI.NIH.GOV/RESEARCH/CLINICAL-TRIALS/AGE-RELATED-EYE-DISEASE-STUDIES-AREDSAREDS2. UPDATED APRIL 13, 2020. LAST ACCESSED MARCH 29, 2022. 42 TODAY’S DIETITIAN • JANUARY 2023

more important than intake of either, with higher ratios increasing the risk of developing glaucoma.13,35 Perez de Arcelus and colleagues studied more than 17,000 participants without glaucoma for a median of 8.2 years. They found no significant effect of omega-3 or omega-6 fatty acids, but those in the highest quintile of omega3:omega-6 had a significantly higher risk of developing glaucoma than those in the lowest quintile.38 Low levels of the antioxidants glutathione and nitric oxide have been noted in some individuals with glaucoma. Dark green leafy vegetables, sources of glutathione and nitric oxide (along with vitamins A, C, and K), have shown a significant protective effect on open-angle glaucoma.13 The Korean National Health and Nutrition Examination Survey found no differences in mean intraocular pressure for any nutrient quartile in participants aged 40 or older.36 The systematic review and meta-analysis by Ramdas and colleagues, found no consistent correlations with glaucoma for plasma or serum levels of any vitamins.19 With few clear trends linking nutrient intake and glaucoma risk, possible guidelines would be to include ample dark green leafy vegetables and sources of vitamins A and C in diets and to avoid excessive supplementation with selenium, calcium, and iron.13,19,37 Cataract Cataract is a condition of clouding or discoloration of the lens of the eye due to damage by light and oxidation, impairing collection and focusing of light on the retina.3,39 Cataract is the leading cause of visual impairment and blindness worldwide.40 There are four main types of cataract: subcapsular, cortical, nuclear, and mixed (nuclear and cortical).40 The primary treatment for cataract is surgical extraction and lens replacement.3 Risk factors for cataract include age, sex, diabetes, educational status, smoking or tobacco chewing, exposure to sunlight, geographic location in lower latitudes, exposure to ultraviolet light, and moderate to heavy alcohol use. Obesity and associated glucose intolerance, insulin resistance, hyperlipidemia, and hypertension also are risk factors.3,39 Adequate intake of vitamin C, which absorbs ultraviolet light, protects eye tissues from oxidative damage.41 Several large studies have examined vitamin C intake on blood levels. The India Study of Age-Related Eye Disease assessed 1,443 rural Indians over age 50. Those with higher plasma vitamin C had decreased risk of cataract.39,41 The European Eye Study found a significantly reduced prevalence of cataract or cataract surgery in those with high daily intakes of fruits, vegetables, and vitamin C (intakes >107 mg).41 The Nutrition Vision Project (NVP), a subgroup of the Nurses’ Health Study, found a 57% reduction in cataract risk for women aged 60 or younger who consumed at least 363 mg vitamin C daily vs those consuming less than 140 mg per day.39 Braakhuis and colleagues analyzed 14 review articles on nutrients and cataract risk and found that dietary vitamin C or low dose supplements reduced the incidence and progression of cataract, but high doses (≥1,000 mg /day) of supplemental vitamin C increased cataract risk by 21%.40 The Swedish Mammography Cohort Study found a 25% increased risk of cataract extraction in those taking vitamin C supplements for more than 10 years, with the greatest effect among those aged 60 or younger.41 Neither the Women’s Health Study, a randomized double-blinded placebo-controlled study, nor the prospective Physicians’ Health Study (11,545 male participants) found a significant relationship between vitamin C intake and cataract.39 The AREDS study didn’t find any effect of supplementation on development or progression of cataract in well-nourished adults.41 Studies of vitamin E have had variable findings.39 For example, the European Eye Study found high daily intakes to be associated with a significantly decreased prevalence of cataract or cataract surgery.41 The Physicians’ Health Study (400 IU vitamin E every other day) and the Vitamin E, Cataract and Age-Related Maculopathy Study (500 IU daily) found no effect on cataract incidence, progression, or extraction.39,42 In the Beaver Dam Eye Study, participants with the highest quintile of Lu intake had a 50% reduction in cataract compared with the lowest quintile.43 In the Braakhuis and colleagues review, higher intakes of Lu and Zx were associated with a 23% lower incidence of nuclear cataracts and carotenoid intakes of 4 to 6 mg per day with decreased rates of cataract surgery.40 The AREDS2 study and a follow-up by Glaser and colleagues found no significant protective effect of β-carotene, Lu, or Zx for any type of cataract.20,39,44 There may be some benefit to increasing carotenoid intake for those with the lowest baseline intake. However, a review of data from thousands of participants didn’t find a relationship between cataract development and blood levels of β- or α-carotene, lycopene, cryptoxanthin, or total carotenoids.39 As cofactors in the enzymatic activation of antioxidants, B vitamins may mitigate cataract risk.44 A review by Weikel and colleagues found that consuming 2 mcg or greater of riboflavin daily may contribute to decreased risk of cortical and nuclear cataract, especially in individuals with malnutrition. Higher levels of thiamin and niacin generally were associated with lower risk.39 In AREDS, dietary intakes of riboflavin and vitamin B12 were inversely associated with nuclear and cortical cataract. The highest quintiles of vitamin B6, niacin, and vitamin B12 were associated with decreased risk of nuclear cataract. Among those taking Centrum vitamins, the highest folate intakes were associated with increased risk of subscapular cataract.44 However, the European Prospective Study Investigation in Cancer and Nutrition (EPIC) Study found no association between cataract risk and B vitamins other than increased risk with high vitamin B12 intake.39 Lower fasting glucose levels are associated with reduced incidence and progression of cataract. In the NVP study, women who consumed greater than 200 g of carbohydrates were more at risk than those consuming less than 185 g. In the Melbourne Visual Impairment Project (n=3,217), participants without diabetes who consumed more than 181 g of carbohydrates daily had a three-fold greater risk of cortical cataract. In the Blue Mountain Eye Study (BMES) cohort of 933 participants, those consuming diets with the highest glycemic index were more likely to develop cortical cataracts over 10 years. AREDS found a similar trend for nuclear cataract.39 Evidence linking fat intake and cataract is conflicting. EPIC found an increased risk of any cataract with elevated blood levels of saturated fat and cholesterol. The BMES found a 30% decreased risk of cortical cataract with >6.8 g per day of PUFAs. In contrast, the NVP study found a 2.3-fold increased risk of nuclear cataract with higher PUFA intake. In the total Nurses’ Health Study, there was a decreased risk of cataract in those with higher intakes of EPA and DHA, but in the NVP subset there was a greater risk with increased omega-3 PUFA intake.39 JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 43

Dietary patterns such as vegetarian diets and the Mediterranean diet may reduce cataract risk.13,39 Current evidence suggests risk reduction can be achieved with a healthy lifestyle including physical activity, no smoking, limited ultraviolet light exposure, and a healthful, lowglycemic index diet rich in fruits, vegetables, and fish.3,39,40 The BMES and EPIC studies associated both low protein intakes and high protein intakes with increased risk of cataract, which suggests a role for decreased meat intake. Recommended daily nutrient targets are 100 g to 150 g of protein and 135 mg of vitamin C. The Clinical Trial of Nutritional Supplements and Age-Related Cataract suggests taking a multivitamin to reduce the risk of nuclear cataracts.39 Dry Eye Disease DED is a syndrome of inadequate tears affecting the ocular surface, cornea, conjunctiva, and lacrimal ducts.12,45 Inflammation is caused by inadequate tear production and/or increased evaporation of tears. DED affects 5% to 30% of individuals over age 50, with higher rates in postmenopausal women, contact lens wearers, and those with autoimmune conditions.12 It also can result from significant time spent on computers, tablets, or smartphones.45 Symptoms include blurry vision, light sensitivity, irritation, and burning or itching eyes. It’s treated with artificial tears and topical corticosteroids.12 The Women’s Health Study found that women with higher dietary intakes of omega-3 PUFAs had lower risk of DED. An elevated ratio of omega-6:omega-3 was associated with elevated risk.46 In the double-blinded clinical trial Dry Eye Assessment and Management Study, the group supplemented with EPA and DHA had less risk than the group supplemented with olive oil. Pellegrini and colleagues reported on two recent metaanalyses of randomized controlled trials, concluding that omega-3 fatty acids are effective in improving DED.12 As mentioned, vitamin A adequacy is important to prevent xerophthalmia. In Western countries, inadequate vitamin A intake is most likely associated with alcohol use disorders, cystic fibrosis, or postbariatric surgery. Other nutrients being studied include vitamin C, vitamin D, selenium, lactoferrin, curcumin, anthocyanins, and flavonoids.12 Evidence-based nutritional treatment for DED consists of adequate omega-3 PUFAs and correcting any existing vitamin deficiencies.12 Diabetes and Eye Health With regard to diabetes, diabetic retinopathy (DR) often is a concern. DR is associated with microvascular damage due to elevated blood glucose. Newer evidence points to the role of inflammation in damaging retinal neural cells early in the course of DR.43,47 The leading cause of preventable blindness among working adults, DR affects about one-third of those with diabetes.43 The prevalence and severity of DR is greater among Hispanics, AfricanCaribbeans, Native Americans, and IndoAsians.48,49 Some evidence shows a risk of worsening DR postbariatric surgery.50 DR progresses through two stages: nonproliferative DR and proliferative DR. In nonproliferative DR, inflammation leads to vascular and neuronal damage in the retina.43,47 Proliferative DR involves angiogenesis similar to wet AMD.51 In both forms, impaired vascularization can cause diabetic macular edema.43 Treatment for DR includes laser therapy, glucocorticoids, and anti-VEGF drugs. Other helpful medications include angiotensin II receptor-blocking drugs and statins. Fenofibrate with statins have slowed progression of DR, with further research ongoing.43,48,52,53 Most analyses have found no relationship between antioxidant intake and DR.52 In one small study (n=67), a supplement (vitamins C, D3, and E; zinc; EPA; DHA; Zx; and Lu, along with other antioxidants) led to significantly improved visual function and macular pigment optical density after six months.49 Higher-plasma Lu levels and high macular pigment optical density are associated with a lower risk of DR development or progression.43 Elevated blood cholesterol, LDL cholesterol, and triglycerides have been associated with the progression of DR, proliferative DR, and diabetic macular edema.48 The cornerstone for DR management is controlling glucose, blood pressure, and plasma lipids. Achieving good glycemic control early in the course of diabetes leads to the best outcomes.48 The PREDIMED study found a decreased incidence of DR with a Mediterranean diet.51 Future directions may include roles for antioxidant nutrients, new pharmaceutical applications, and gene therapy.49,52 Cortical cataracts occur two to five times more frequently in persons with diabetes. Diabetic cortical cataracts appear at an early age and progress faster than those in people without diabetes. The byproducts of high blood glucose levels create oxidative stress and damage cells in the lens.40,41 Those with diabetes also are nearly twice as likely to develop open-angle glaucoma.53 Putting It Into Practice Good eye health depends on good nutrition. RDs can assist clients to move toward higher Healthy Eating Index scores and diet patterns, such as the Mediterranean diet, which have been associated with protection against AMD, DR, cataract, and glaucoma.28,51,54 Clients can be assisted to decrease red meats and increase intakes of vegetables (especially leafy greens), fruits, whole grains, fish, nuts, and legumes.11,17,51,55,56 A variety of nutrients consumed as food is more effective than supplementing with isolated nutrients.40,56 To address the important role of nutrition in prenatal eye development, RDs should assist pregnant women with appropriate weight gain and nutrition to support full-term delivery and adequate birth weight. Pregnant women should be screened for adequate intakes of vitamin A, carotenoids, choline, and DHA, and assisted to meet target intake with dietary changes or supplementation.4,9,20,22 RDs also have a role in DR prevention by supporting clients with diabetes in maintaining good glycemic control, managing hypertension, and controlling lipid levels.48 Appropriate dietary goals would be a Mediterranean-style eating pattern and including dietary carotenoids and omega-3 PUFAs.44,51 Working with optometrists and ophthalmologists to support eye health with good nutrition presents an intriguing opportunity for interprofessional practice, as physicians may feel unprepared to offer detailed nutrition advice. As part of an interdisciplinary team, RDs can help create a more complete health care experience for clients.57 ■ Kathleen Searles, MS, RDN, LD, is a nutrition consultant in private practice. CPE Monthly For references, view this article on our website at www.TodaysDietitian.com. 44 TODAY’S DIETITIAN • JANUARY 2023

CPE Monthly Examination 1. What is xerophthalmia? a. Dry eye disease b. Vitamin A defi ciency disease c. A precursor to cataract d. A complication of diabetic retinopathy 2. If you’re counseling a pregnant woman who complains of poor night vision, what dietary counseling approach is most appropriate? a. Evaluate vitamin E status and recommend adding more vitamin E-rich foods to the diet b. Recommend the Mediterranean diet c. Assess vitamin A status and consider supplementation d. Ensure adequate intake of DHA 3. Which nutrition pattern is most likely to be associated with decreased risk of cataract? a. High intake of antioxidants, especially Lu, Zx, and omega-3 fatty acids b. Adequate omega-3 consumption and correction of any vitamin defi ciencies c. A low-glycemic diet rich in fruits and vegetables with adequate protein and vitamin C d. A diet featuring ample dark green leafy vegetables, good sources of vitamins A and C, and the absence of supplemental selenium and iron 4. Which nutrition pattern is most likely to be associated with decreased risk of glaucoma? a. High intake of antioxidants, especially Lu, Zx, and omega-3 fatty acids b. Adequate omega-3 consumption and correction of any vitamin defi ciencies c. A low-glycemic diet rich in fruits and vegetables with adequate protein and vitamin C d. A diet featuring ample dark green leafy vegetables, good sources of vitamins A and C, and the absence of supplemental selenium and iron 5. Which nutrition pattern is most likely to be associated with decreased risk of age-related macular degeneration (AMD)? a. High intake of antioxidants, especially Lu, Zx, and omega-3 fatty acids b. Adequate omega-3 consumption and correction of any vitamin defi ciencies c. A low-glycemic diet rich in fruits and vegetables with adequate protein and vitamin C d. A diet featuring ample dark green leafy vegetables, good sources of vitamins A and C, and the absence of supplemental selenium and iron 6. Which nutrition pattern is most likely to be associated with decreased risk of dry eye disease? a. High intake of antioxidants, especially Lu, Zx, and omega-3 fatty acids b. Adequate omega-3 consumption and correction of any vitamin defi ciencies c. A low-glycemic diet rich in fruits and vegetables with adequate protein and vitamin C d. A diet featuring ample dark green leafy vegetables, good sources of vitamins A and C, and the absence of supplemental selenium and iron 7. What is the specifi c cause of diabetic retinopathy? a. requent episodes of hypoglycemia in people with diabetes b. A combination of microvascular and neural cell damage in the retina associated with high blood glucose levels c. History of low dietary intake of antioxidants d. Uncontrolled hypertension 8. Which dietary patterns are most consistently associated with general eye health? a. Calorie-restricted high-protein diets b. Vegetarian diets c. Low-glycemic index diets d. Mediterranean-style diets 9. What did the Age-Related Eye Disease Studies, AREDS and AREDS2, conclude about the use of a supplement with vitamins C and E, β-carotene, zinc, and copper? a. The supplement reduces progression to late-stage AMD b. The supplement prevents AMD c. The supplement works better with Lu and Zx d. The supplement has no eff ect on AMD 10. Which of the following best describes the goals for MNT for diabetic retinopathy? a. Increased intake of dark green leafy vegetables and improved serum retinol levels b. Increased protein intake and normalized retinol-binding protein levels c. Good glycemic and hypertension control, and normalized lipid levels d. A low-glycemic index diet and blood glucose monitoring Become a CPE Monthly Pass holder for access to CPE Monthlies and their associated exams for about $8/credit! Go to CE.TodaysDietitian.com/CPEMonthlyPass and get your Pass to Monthly CPEUs. For more information, call our continuing education division toll-free at 877-925-CELL (2355) M-F 9 AM to 5 PM ET or e-mail [email protected]. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 45

www.TodaysDietitian.com/SS23 SAVANNAH 2023 HELP US CELEBRATE OUR MOST ANTICIPATED SPRING SYMPOSIUM TO DATE! Thank you to our growing list of 2023 sponsors MAY 14-17, 2023 #TDinGA Join us in Savannah, Georgia, for the 10th annual Today’s Dietitian Spring Symposium. This event will feature an unsurpassed program that combines a timely and engaging educational experience with lively and fun activities and networking opportunities. Whether you are interested in culture-focused nutrition, culinary medicine, navigating food fears, nutrigenomics, nutrition ethics, or a variety of other topics, the Today’s Dietitian Spring Symposium is the place to be. DON’T WAIT, REGISTER TODAY!

www.TodaysDietitian.com/SS23 Wendy Bazilian DrPH, MA, RDN, ACSM-EP Jen Nguyen RDN, CDN, NASM-CPT Zero to 100: Becoming a Powerhouse in Public Speaking Mascha Davis MPH, RDN Ginger Hultin MS, RDN, CSO Incorporating the Future of Nutrition Into Your Practice: Nutrigenomics Rosanne Rust MS, RDN Liz Weiss MS, RDN TikTok Made Me Eat It: How RDNs Can Empower Consumers to Eat Better by Creating Short Videos on TikTok and Instagram Regan Jones RDN, ACSM-CPT Recipe Editing 101: The Why and How to Perfecting a Recipe Before Publishing Kim Schwabenbauer PhD, MS, RD, CSSD The Female (and Male) Athlete Triad: Updates, Nutrition Implications, and Screening Tools to Prevent Low BMD Kate Scarlata MPH, RDN Navigating Food Fears and Disordered Eating in GI Conditions Jill Weisenberger MS, RDN, CDCES, CHWC, FAND What Should the RDN Do for the 96 Million Adults With Prediabetes? Toby Amidor MS, RD, CDN, FAND Ask the Expert: A Year in Review and a Look Ahead Kristin Kirkpatrick MS, RD Reduced Carb Diets and Disease Risk Reduction — How Low Do You Go? Katie Dodd MS, RDN, CSG, LD, FAND Starting a Side Hustle: Opportunities and First Steps Dianne Polly JD, MS, RD, LDN Ethics for All in a Sometimes Unethical World in 2022 Jaime Schwartz Cohen MS, RD Using Our Nutrition “SciVantage” in Today’s Food Conversation Vandana Sheth RDN, CDCES, FAND Sustainable Traditions: Food, Health, Culture — The Immigrant Experience Taylor Wallace PhD, CFS, FACN Dietitians to the Rescue: Translating Complex High-Quality Research Into Simple Messages to Combat Nutrition Quackery Lauren Harris-Pincus MS, RDN From Allergies to Ethics: Using Public Partners to Help Clients Meet Nutrition Needs Outside of Their Own Kitchen David Katz MD, MPH, FACPM, FACP, FACLM Making the Case for Food as Medicine Interventions Karen Collins MS, RDN, CDN, FAND 40 Years of the American Institute for Cancer Research (AICR) OUR 2023 SPEAKER LINEUP

Intuitive Exercise Today’s Dietitian explores this fresh approach to meeting fi tness goals. I t’s that time again when clients are in search of a fresh start for the new year. After a season filled with holiday cheer, gym memberships and weight loss regimens are now top of mind for many individuals. By now, most RDs have heard of intuitive eating, the nutrition philosophy that teaches you to reject the messages of diet culture and trust your own body’s hunger and fullness cues to make food decisions that are satisfying and nourishing. But what about intuitive exercise? Relying on the same foundational elements as intuitive eating, intuitive exercise is a new way to approach fitness. Just as intuitive eating emphasizes following your hunger and satisfaction cues vs rigid diet rules, intuitive exercise puts self-care and enjoyment at the center of fitness goals in lieu of self-control and obligation. It also puts an end to the common “no pain, no gain” mindset, and it may be the antidote to the short-lived fitness frenzy that descends upon clients this time of year. The Physical Activity Guidelines for Americans recommend adults aim for at least 150 minutes of moderate-intensity physical activity each week. Yet, only half of adults are meeting this recommendation.1 Counseling clients to adopt an intuitive mindset around their fitness goals can help them not only derive more enjoyment from exercise but also discover a routine they can stick with long term. What Is Intuitive Exercise? Also known as active embodiment or mindful exercise, researchers define the practice as “awareness of the senses while moving and attending to one’s bodily cues for when to start and stop exercise, rather than feeling compelled to adhere to a rigid program.”2 In other words, intuitive exercise shifts the focus away from common external factors like the number of calories burned, body shape, and what’s trending on social media. The backbone of intuitive exercise is based on internal factors, namely how exercise makes you feel— energized, destressed, or happy. That’s right; intuitive exercise wants you to enjoy moving your body. Enjoyment looks different for everyone, which is the beauty of following one’s intuition instead of blindly jumping on the latest fitness bandwagon. Some clients may enjoy traditional forms of movement, such as running or lifting weights, while others may need to step off the beaten path to find out what’s enjoyable for them. Intuitive exercise can include activities such as rollerblading, dancing, and playing Frisbee with one’s dog. The internal factors that focus on how exercise makes one feel are called intrinsic motivators. Someone who’s intrinsically motivated to exercise does so for the internal experiences of joy, pleasure, satisfaction, and other inherent benefits, such as improved sleep or relaxation.3 Intrinsic motivation is a key ingredient in building a lifelong habit of exercise. In fact, it may be the strongest predictor of sustaining physical activity.4 The opposite is extrinsic motivation, or deriving motivation to exercise from external factors, such as the number on the scale or seeking praise and avoiding judgment from others.3 Fitspiration images are another example of extrinsic motivators. These images are prevalent on social media and feature bodies that the culture defines as fit or “ideal.” In most cases, they’re presented as inspiration to exercise more, but one study showed that viewing fitspiration images didn’t increase exercise behavior and instead led to greater body dissatisfaction and negative mood in young women.5 Conversely, exercising for intrinsic reasons is associated with better body image and Focus on Fitness By Kayli Anderson, MS, RDN, DipACLM, ACSM-EP 48 TODAY’S DIETITIAN • JANUARY 2023

healthful eating and food behaviors.3 The benefits of intuitive exercise reach far beyond simply getting clients to exercise more—it may help them foster a more healthful relationship with themselves. Intuitive Exercise vs Traditional Exercise Taking an intuitive approach to exercise will require clients to think about exercise differently. Intuitive exercise views movement as a form of self-care vs a form of self-control, which is a subtle but powerful shift. Putting this into practice looks like taking a brisk, refreshing walk the morning after a night out with friends instead of running on a treadmill to burn off last night’s calories. Another difference: Intuitive exercise allows “how the body feels” to guide exercise choices instead of following a rigid regimen despite how the body feels. If a client is recovering from a cold, they may choose gentle yoga instead of a high-intensity workout. Intuitive exercise invites them to ask, “How can I use movement to care for my body?” instead of “How can I use movement to control my body?” This attention to what the body needs is an example of enhancing the mind-body connection or the link between thoughts, behaviors, and physical health. A mindful approach to exercise means becoming more attuned to the body by paying close attention to how the body feels before, during, and after exercise and responding accordingly.6 Intuitive exercise associates movement with pleasure and satisfaction instead of pain or punishment. Many believe exercise needs to be painful or arduous to be effective, but this can be counterproductive. If someone dislikes going to the gym, they may cringe every time the view their scheduled gym time on their calendar. But if this person loves to be outside in nature, swapping the gym for the great outdoors will invite pleasure into their exercise routine. Instead of dreading exercise, they’ll look forward to it. The same goes for exercise intensity. Clients don’t have to run a marathon to see benefits. Even 10-minute bouts of walking throughout the day can provide a short-term mood boost and long-term health benefits. What sets intuitive exercise apart from traditional exercise is its de-emphasis on weight-loss and appearance. While many clients may spend the next few months of 2023 in sweaty fitness classes, intuitive exercise will offer the opportunity to trade weight-focused goals for other exerciserelated benefits. The 2020–2025 Dietary Guidelines for Americans cites improved mood, better sleep, reduced stress levels, improved skeletal health, reduced risk of chronic diseases, and lower rates of depression as some of the many benefits of regular physical activity.7 People who engage in regular exercise also tend to have better body image, even with little or no change in their physical appearance.8 How RDs Can Help Clients Practice Intuitive Exercise Incorporate Intrinsic Motivators Most clients come with a long list of extrinsic motivators—to lose weight or fit into an old pair of jeans. Validate these desires, then help them unearth some intrinsic motivators. For example, ask how did they like to move their body as a child. Often, these activities were driven by intrinsic motivation and can be fun to reintroduce in adulthood. A hula hoop, softball league, or trampoline could be their ticket to sustainable exercise. If they aren’t sure what they enjoy, they might need to experiment with new activities to find the right fit. Another way to foster intrinsic motivation is to connect their health goals to physical activity. If clients want to lower their blood pressure or improve sleep, discuss some fun activities that can help support their goals. Expand the Defi nition of Exercise Exercise doesn’t always mean going to the gym or running a 5K. Use the term “movement” instead of “exercise” to inform clients that any type of body movement counts as physical activity. Tell clients that movement can involve gardening, a dance party, or even housework. For clients who struggle to fit movement into their schedules, suggest they incorporate more activity into their daily lives such as taking the stairs instead of the elevator, parking farther away from the grocery store entrance, or staking hourly breaks from sitting at their desk. Put Satisfaction at the Center Intuitive exercise should feel good, so ask clients what positive feelings do they want to derive from exercise. Some examples include more energy, relaxation, or to have fun. If clients want to have fun, they can buy a pair of rollerblades or join a sand volleyball league. If a client wants to feel relaxed, a yoga class or kayaking may be a great fit. Cultivate the Mind-Body Connection A core part of intuitive exercise is following the body’s cues or connecting the mind and body through mindful awareness. A mindful approach to exercise may feel foreign to clients who are used to powering through workouts regardless of how their body feels. They can start by asking themselves “How am I feeling right now?” before they begin to exercise. They can make a mental note or keep an exercise journal and make adjustments to their choices of physical activity over time. Suggest clients adapt their routine in response to their body’s cues and check in with their body during and after exercise. Did the chosen exercise evoke their desired feelings? If not, help them to make different choices. Swapping the treadmill for a park trail or trading a circuit workout for a walk with a friend might serve their body and mind better. After all, intuitive exercise is about cultivating habits that not only feel good but are flexible and enjoyable enough to last a lifetime. ■ Kayli Anderson, MS, RDN, DipACLM, ACSM-EP, is a certified intuitive eating counselor in Salida, Colorado, and founder of plantbasedmavens.com, a hub for evidencebased women’s health information. Intuitive exercise views movement as a form of selfcare vs a form of self-control, which is a subtle but powerful shift. For references, view this article on our website at www.TodaysDietitian.com. JANUARY 2023 • WWW.TODAYSDIETITIAN.COM 49