Today's Dietitian - August-September 2023

August/September 2023 Vol. 25 No. 7 The Magazine for Nutrition Professionals Seafood Paella from El Five Today’s Dietitian 10th Annual Spring Symposium Highlights NATIONAL CONFERENCE ISSUE Managing Diabetes With Plant-Based Diets The Role of Diet in Parkinson’s Disease Health Benefits of Family Meals for Kids and Adults WWW.TODAYSDIETITIAN.COM Get ready to experience the Mile High City’s diverse, global food scene with a backdrop of the majestic, snowcapped Rocky Mountains. Savor Denver’s Best Cuisine

Nearly one-third of adults surveyed have seen the National Family Meals Month initiative, with 45% of them indicating that as a result they are cooking more meals at home. Once told about the benefits of family meals, 60% of Americans surveyed say they are more likely to share family meals. We need your help to remind consumers that family meals result in better nutrition and are good for both physical and emotional health. Help promote the many benefits of Family Meals Today! www.fmi.org/family-meals/toolkits #FamilyMealsMovement #FamilyMealsMonth Utter J, Larson N, Berge JM, Eisenberg ME, Fulkerson JA, Neumark-Sztainer D. Family meals among parents: Associations with nutritional, social and emotional wellbeing. Preventive Medicine. 2018;113:7-12. doi:10.1016/j.ypmed.2018.05.006 Thirty-five years of research and thousands of studies document the nutritional, physical health, and mental health benefits of Family Meals.

Actor portrayal. © 2022 Endo Pharmaceuticals Inc. All rights reserved. Malvern, PA 19355 NS-05697/February 2022 www.endo.com 1-800-462-ENDO (3636) See program details at NutritionDirect.com/Program or scan this code to learn more. For appropriate patients after bariatric surgery... DISCOVER AN INTEGRATED MICRONUTRIENT SUPPORT PROGRAM

DEPARTMENTS 6 Editor’s Spot 7 Heart Health 8 Ask the Expert 10 Home Health Care 14 Ancient Grains 16 Back to School 56 Focus on Fitness 58 Get to Know … 60 Health Matters 62 Products + Services 64 Datebook 65 News Bite 66 Culinary Corner Contents FEATURES 20 Savor Denver’s Best Cuisine Get your palates ready because FNCE® is coming to Denver. To prepare, find out about the best local spots to grab a bite to eat and experience the diverse international and local flavors of Colorado. 26 Plant-Based Diets & Diabetes More research links plant-based diets with lower risk of type 2 diabetes and better management of type 1 and type 2. Discover how dietitians can use such dietary patterns to assist clients in meeting their health goals. 32 Diet’s Role in Parkinson’s Disease Evidence is mounting in support of key nutrients and the overall diet that can lessen the severity of Parkinsonian signs and symptoms. Read about what early research suggests and how it may impact future recommendations. 36 Fresh Look at Family Meals Food brings people together, but what are the long-term benefits of that togetherness? Today’s Dietitian examines the latest evidence regarding food, socialization, and mental well-being throughout the lifespan. 42 Today’s Dietitian 10th Annual Spring Symposium TD celebrated 10 years of providing symposia to RDs in the coastal city of Savannah. Check out the highlights and photo gallery. Hope to see you next year! 50 CPE Monthly: Nutrition Needs for Aging Adults This continuing education course reviews the leading health concerns of older adults and their dietary needs, macronutrient and fluid recommendations, and plant-based and other diet solutions. 14 VOLUME 25 • NUMBER 7 AUGUST/SEPTEMBER 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 Office and other mailing offices. Permission to reprint may be obtained from the publisher. Reprints: Wright’s Media: 877-652-5295 Note: For subscription changes of address, please write to Today’s Dietitian, PO Box 2026, Langhorne, PA 19047. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on last label. Postmaster: Send address changes to Today’s Dietitian, PO Box 2026, Langhorne, PA 19047. Subscription Rates — Domestic: $14.99 per year; Canada: $29.99 per year. Single issue: $5. Today’s Dietitian Volume 25, Number 7. 50 4 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 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 Assistant Editor Chris Baldwin 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 Junior Digital Designer Emma Connolly Email Marketing Coordinator Ryan Humphreys Social Media Associate Nicole Pratt Director of Events and Sponsorships Gigi Grillot Events and Sponsorships Manager Andrea Rizzoni Events and Sponsorships Sales Executive Mildred Nieman Director of Sales Brian Ohl Senior Account Executives Diana Kempster, Brian Sheerin, Beth VanOstenbridge Account Executives Drew Murdock 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 affiliated. GVP and its employees and agents do not assume responsibility for opinions expressed by the authors or individuals quoted in the magazine; for the accuracy of material submitted by authors or advertisers; or for any injury to persons or property resulting from reference to ideas or products discussed in the editorial copy or the advertisements. All content contained in Today’s Dietitian is created for informational purposes only and shall not be construed to diagnose, cure, or treat any medical, health, or other condition. Moreover, the content in Today’s Dietitian is no substitute for individual patient/client assessment based upon the professional’s examination of each patient/client and consideration of laboratory data and other factors unique to the patient/client. CONTENT CONTAINED IN TODAY’S DIETITIAN SHALL NOT BE CONSTRUED TO CONSTITUTE PROFESSIONAL MEDICAL, HEALTH, LEGAL, TAX, OR FINANCIAL ADVICE. Breaking Bread With Family T here’s much to be said about the research on the benefits of family meals. When I was growing up, my mother celebrated family every day by serving delicious meals. One thing my mother was most known for was her love of cooking—she was a real foodie at heart. She’d spend hours in the kitchen making various dishes for her relatives and neighborhood friends during the holidays, cookouts, and other special occasions. She took great pride in making dishes from scratch, such as turkey tetrazzini, paella, lobster thermidor, shrimp bisque, plum pudding, steamed mussels, freshly baked bread, ice cream, and more. Each night when my mom, dad, brother, and I sat down to eat dinner, we enjoyed these and other gourmet foods, spirited conversations, and laughter. It was a time to check in with one another to discuss our school day and anything else on our minds. Our family meals drew us together and offered other benefits, too. Research has long shown that regularly attended family meals have great health benefits for everyone sitting at the table. Children are more likely to eat more fruits and vegetables, have higher grades in school, have less depression and anxiety, have decreased incidence of eating disorders, and experience less substance and alcohol abuse. Adults are more likely to experience better emotional and mental health, higher self-esteem, improved marital and family relationships, and greater longevity. My mom lived to the ripe old age of 93; my dad lived to the age of 94. In this issue, Today’s Dietitian (TD) features an article called “Fresh Look at Family Meals,” on page 36. In it, TD goes into greater detail about the overall health benefits of family meals throughout the lifespan and provides six family-friendly recipes courtesy of expert culinary dietitians. Moreover, TD is covering another crucial topic: lifestyle medicine. Lifestyle medicine is a medical specialty of old that’s been fine-tuned over the past several years and supported by research. Lifestyle medicine addresses chronic disease risk factors as well as CVDs and type 2 diabetes. Dietitians will learn more about lifestyle medicine’s six pillars, how to apply it to daily practice, and the importance of certification. Also in this issue are articles on plant-based diets and diabetes, nutrition’s role in Parkinson’s disease treatment and management, a dining guide to Denver’s best restaurants, and TD’s 10th annual Spring Symposium highlights, featuring a photo gallery of the TD staff and attendees at workshops, fitness activities, special events, and more. Please enjoy the issue! — Judith Riddle, Editor [email protected] 6 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

Cardiovascular Risk Disparities Among Young People With Type 1 Black and Hispanic children with type 1 diabetes are more likely than their white peers to develop stiffened arteries—a precursor to heart disease and stroke— during the first decade of their diabetes diagnosis, new research finds. All of the higher risk for Hispanic children—and one-fourth of it for Black children—can be explained by socioeconomic and cardiovascular risk factors that could potentially be reduced, according to the study, published in the Journal of the American Heart Association. “That gives us hope that there are things we can try to modify, things we can try to improve,” says lead study author Katherine Sauder, PhD, an associate professor and deputy director of the Life Course Epidemiology of Adiposity and Diabetes Center at the University of Colorado School of Public Health in Aurora. Blood flows much faster along stiff arteries, so the increased flow and pressure of blood can negatively affect organs such as the heart. Artery stiffness typically develops in older adults but can also occur in people with type 1 diabetes, a disease characterized by the body’s inability to produce enough insulin. This type of diabetes is most often diagnosed during childhood, though it can occur at any age. People who have type 1 diabetes are about 10 times more likely to develop CVD than those who don’t have it. Yet research into the prevention of CVD in people with type 1 diabetes has been limited, and what little there is has focused largely on white people. Meanwhile, the incidence of type 1 diabetes in the United States, which has been rising about 2% each year since at least the early 2000s, is growing at an even faster rate among Hispanic and Black populations. In the new study, researchers analyzed data for a racially diverse group of 1,162 children and young adults in the SEARCH for Diabetes in Youth study, which recruited participants from South Carolina, Ohio, Colorado, Washington, and southern California. The children were an average of 9 years old at the time they were diagnosed with type 1 diabetes and enrolled in the study. Carotid femoral pulse wave velocity, considered the gold standard measurement of arterial stiffness, was taken after an average of 11 years of follow-up. The analysis found higher levels of artery stiffness in Black and Hispanic young people, with the biggest gap between Black and white participants. Black participants had 10% higher rates of artery stiffness than white participants. “That sounds small, but these people are in their 20s,” says Sauder, who notes that CVD typically doesn’t appear until a person’s 50s. “The concern is that this gap is going to continue growing. If we can figure out why this difference is, perhaps we can intervene now and maybe there’s a chance to reverse the differences that have built up in the first 10 years of their disease.” While there also was a gap in the rates of artery stiffness between Hispanic and white young adults with type 1 diabetes, that disparity largely disappeared when the researchers controlled for cardiovascular and socioeconomic risk factors. One of the biggest modifiable factors was access to diabetes medications. Another was being overweight. “If we could get Hispanic participants to have the same cardiovascular risk profile as their white peers, blood flow would slow down by 15%,” Sauder says. “If we could get them to have the same economic profile, it would slow down by 27%.” Controlling for these factors, however, did not erase the disparities between Black and white participants. “No matter what factors we looked at, we could only get the difference to decrease about 21%,” Sauder says. “That tells us there are other things going on beyond A1c and BMI and being able to pay for your medications. There are other things driving this.” The new research “offers insight into what might be changing in cardiovascular health in the earlier decades of life for people with type 1 diabetes,” says Risa Wolf, PhD, director of the Pediatric Diabetes Center and an associate professor at the Johns Hopkins Hospital in Baltimore. Wolf was not involved in the study. Understanding what’s driving these disparities could help target critical interventions, she says. “The more you can engage people in care early on, by increasing access to care, adherence to medications, and more consistent follow-up care, the more we may be able to prevent poor cardiovascular outcomes later in life,” Wolf says. One thing the new study did not investigate was how structural racism and the stress it can cause might impact health, Sauder says. Another factor that could be important is the use of advanced diabetes technologies, such as continuous glucose monitors and insulin pumps, to manage blood glucose levels, Wolf says. When blood glucose levels aren’t properly managed, the risk of CVD increases. Recent studies, including one Wolf was involved with, have found significant racial disparities in the prescription and use of these devices among children and adults. But Sauder says that even when advanced diabetes technologies are used, some racial disparities in blood glucose control remain. “It would be great if there was an easy answer, but it’s more complicated than that,” she says. SOURCE: LAURA WILLIAMSON, AMERICAN HEART ASSOCIATION NEWS Heart Health AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 7

NAD+ Supplementation Q My clients have been asking me about nicotinamide adenine dinucleotide (NAD+) in supplement form. What is it, and is there any scientific evidence behind its antiaging marketing claims? A: Celebrities Kendall Jenner and Hailey Bieber are touting the antiaging benefits of NAD+, which have increased consumer demand for this supplement. NAD+ is a component involved in cellular nutrition said to increase cellular energy and support healthy aging. The human body makes NAD+, but the amount produced by the body declines significantly with age, which is why supplementation to combat cellular aging has become so popular. This article discusses cellular nutrition and its importance, the research behind NAD+ supplements on the market, and counseling strategies for RDs. What Is Cellular Nutrition? Cells use nutrients to power bodily functions, but nutrients can be used only if cells are working properly. Cellular nutrition provides cells with the macronutrients (ie, carbohydrates, protein, and fats) and micronutrients (eg, vitamins A and D, folate, zinc) necessary to function efficiently and optimally, which are found in a nutrient-dense and antioxidant-rich diet. Vitamins and minerals play a critical role as cofactors in many cellular processes, while antioxidants help counter cellular oxidative stress.1 Protein, fats, and carbohydrates are used for specific cell functions. According to Taylor Wallace, PhD, CFS, FACN, principal and CEO of the Think Healthy Group, LLC, and an adjunct associate professor at the Friedman School of Nutrition Science and Policy at Tufts University (www.drtaylorwallace.com) in Washington, D.C., “NAD+ levels decline as we get older, and some researchers think it may be linked to related diseases and dysfunctions that occur as a result of aging.” In addition, Mona Rosene, MS, RD, global director of scientific affairs at ChromaDex (https://www.chromadex. com) in Longmont, Colorado, explains that NAD+ is depleted over time due to aging and exposure to different metabolic stressors, including a poor diet high in added sugars and fat, a sedentary lifestyle, and excess sun exposure. “Our research has shown that we lose up to 65% of NAD+ between the ages of 30 and 70,” she says. The Research According to Wallace, several animal models have suggested that supplementation with NAD+ may increase health, improve immunity, enhance athletic performance, and prolong avoidance of agerelated diseases. However, “there’s an absence of clinical evidence in humans, and we know animal models don’t translate to what happens in humans more times than not.” There are several published studies that demonstrate how mitochondrial dysfunction, a hallmark of aging, is closely linked to declining NAD+ levels.2,3 According to Rosene, “Mitochondrial function and health decline over time. NAD+ is known to play a critical role in helping maintain and support mitochondrial health. While we can’t stop the aging process, we do have hacks to slow it down, one of which is supporting cellular and mitochondrial health through supplementing with NAD+ precursors.” This may, therefore, help maintain optimal cellular function and resilience.4 The precursors of NAD+ include nicotinamide mononucleotide (NMN) and nicotinamide riboside (NR), which animal studies have suggested may increase NAD+ production and slow the aging process. Both of these precursors are sold as supplements marketed to possess antiaging effects. Burgeoning Market Consumer demand for antiaging supplements is growing.5 According to Global Market Insights, the size of the NAD+ supplement market was more than $488 million in 2021 and was expected to grow 13% between 2022 and 2030.5,6 As a result, consumers can find a variety of brands that offer NAD+ supplements as NR or NMN. Below is a sample of supplement brands on the market. Ask the Expert By Toby Amidor, MS, RD, CDN, FAND 8 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

• Life Extension NAD+ Cell Regenerator (www.lifeextension.com) is an NRbased NAD+ supplement that claims to promote cellular energy production and support cellular metabolism. Recommended dosage is one 300 mg capsule per day. • TruNiagen (www.truniagen.com) claims it uses NR for cellular energy metabolism, repair, vitality, and healthy aging. Capsules are sold in 100 mg doses with recommendations to take one to three pills per day. • Renue Lipo NR (https://renuebyscience. com) claims to increase lifespan. Recommended dose is one 300 mg capsule per day. • NOVOST Boost (https://novoslabs.com) is an NMN-based supplement that claims to be a powerful longevity ingredient that boosts energy, metabolism, and DNA repair. Recommended dose is two 125 mg capsules per day. • ProHealth Longevity NMN Pro 300 (www.prohealth.com) claims to help combat aging, improve heart health, and promote muscle strength. Recommended dose is two 300 mg capsules per day. Recommendations for RDs One of the basic factors of cellular nutrition is consumption of vitamins, minerals, antioxidants, and macronutrients. This means that balanced nutrition should be the primary focus for clients with concerns about aging. In addition, Rosene says the diet shouldn’t be high in fat and added sugars, which are two metabolic stressors that decrease NAD+. After addressing diet, if clients still want to supplement with NAD+, dietetics professionals should ensure they take the recommended doses on the bottles. According to a 2020 review study, NAD+ supplements are safe for human consumption short term—up to 12 to 24 weeks.7-9 However, more long-term studies are needed to determine their safety in children, pregnant and lactating women, individuals on medications, and those with lower immunity. Currently, NAD+ supplementation is contraindicated in these populations. In addition, NMN and NR supplements have been associated with similar side effects, such as digestive discomfort, but currently, there’s no evidence of medication interactions. Nevertheless, research has suggested that NAD+ supplements may increase the prevalence of cancer and metastases and therefore aren’t recommended for patients with active cancer or cancer survivors.10 n Toby Amidor, MS, RD, CDN, FAND, is founder of Toby Amidor Nutrition (tobyamidornutrition. com) and a Wall Street Journal bestselling author. She’s written 10 cookbooks, including the upcoming Up Your Veggies: Flexitarian Recipes for the Entire Family (October 2023) and 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. Send your questions to Ask the Expert at [email protected] or send a tweet to @tobyamidor. SEPTEMBER 18 SEPTEMBER 19 SEPTEMBER 20 SEPTEMBER 21 SEPTEMBER 22 12:00 – 1:30 PM ET 12:00 – 1:30 PM ET 12:00 – 1:15 PM ET 12:00 – 1:15 PM ET 12:00 – 1:00 PM ET Malnutrition in the Patient With Obesity: How to Address the Under Recognition Is This Malnutrition? How to Approach Common Diagnostic Challenges Pediatric Malnutrition Diagnosis and Provider Engagement Addiction: The New Skeleton in the Hospital Closet Malnutrition and Transitions of Care Between Health Care Settings CE Credit: 1.5 hours CE Credit: 1.5 hours CE Credit: 1.25 hours CE Credit: 1.25 hours CE Credit: 1.0 hour Participants may be eligible to claim CE credits. ASPEN is accredited to provide medical, pharmacy, nursing, and dietetic credits. Schedule and topics subject to change. #ASPENMAW23 #LetsNourishOurPatients NUTRITION CARE IS A PATIENT RIGHT Visit nutritioncare.org/TD-MAW to register for webinars and access complimentary practice tools, videos, podcasts, and other resources addressing malnutrition. © Copyright 2023 ASPEN | American Society for Parenteral and Enteral Nutrition Malnutrition Awareness WeekTM is a trademark of the American Society for Parenteral and Enteral Nutrition.

PN and EN Product Shortages RDs can help mitigate the challenges to improve patient outcomes. H ealth care is a fundamental human right, and having access to prescription drugs is vital for optimal medical care and patient outcomes.1 At some point, almost all sectors in every hospital— from rural clinics to urban health care systems—suffer from product supply shortages. The unanticipated arrival of COVID-19 in the United States in 2020 forced clinicians to face catastrophic shortages of medical supplies that rarely had been a concern beforehand. Innumerable medical equipment necessities—from the scarcity of ventilators to the minimal supply of tube feeding sets for enteral nutrition (EN) administration—became global causes for concern throughout the pandemic. And there was a baby formula shortage due to product recalls that jeopardized the health of millions of infants. In this article, Today’s Dietitian focuses on the ongoing shortages of EN and parenteral nutrition (PN) products in the health care system and speaks with dietitians from the Cleveland Clinic about the impact these shortages have had on their daily work and patient care. History of Shortages When supply chains of PN and EN products are interrupted, health care providers face acute challenges to meet patients’ nutritional needs. These product shortages emerge due to interruptions in supply chain delivery, manufacturing issues, and regulatory concerns. The FDA states that drug product shortages occur “when the demand or projected demand for the drug within the United States exceeds the supply of the drug.”2 These periods of drug shortages often lead to serious consequences related to patient outcomes.3 Insufficient supplies of PN and EN formulas can delay nutrition therapy initiation in the hospital and home settings, interrupt nutrition therapy, or cause the administration of incorrect formulas. These issues can lead to malnutrition, overfeeding or underfeeding, fluid and electrolyte abnormalities, or EN intolerance. Drug shortages of PN ingredients and additives have been on the rise for nearly 40 years.4 A shortage of any single parenteral element can be significant since formulas are composed of 20 or more individual sterile injectable components. Many ingredients can’t be substituted for alternative products without risking patient safety and causing harm.5 In 2011, the number of national drug shortages reached a record high of 267, of which 57% were sterile injection products.3 As a result of the 2011 drug shortage crisis, the Food and Drug Administration Safety and Innovation Act of 2012 was enacted. This legislation created pathways for early identification and mitigation of potential drug shortages.4 Since nearly 40% of drugs and 80% of active drug ingredients are imported to the United States, this legislation expands the FDA’s authority to help protect the global drug supply chain and help patients maintain access to the medications they need. Many events precipitated the 2011 crisis, including the closure of several compounding sites due to quality issues.6 However, challenges other than manufacturing quality issues are causing ongoing product shortages. “The primary causes of product shortages have shifted from those historically resulting from manufacturing compliance and quality issues to now unknown causes or issues related to an imbalance between supply and demand.”4 In 2017, Hurricane Maria destroyed a PN manufacturing facility in Puerto Rico. The destruction of this factory led to a wave of sterile injectable product shortages, especially amino acids. An interruption from a significant production source causes cascading failures in the product supply chain, thus exacerbating the need for other manufacturers to ramp up production.4 A single event such as Hurricane Maria can create long-lasting negative impacts on supply chain deliveries worldwide. Data on EN product shortages are less definitive than data on PN product shortages due to inconsistent record keeping.4 According to Mulherin and colleagues, “Minimal documentation may be related to a lack of registered dietitians who are accustomed to reporting EN shortages coupled with less rigid federal oversight of medical foods compared with drugs.4 Medical foods aren’t drugs and, therefore, aren’t subject to regulatory requirements that are specific to drugs. The FDA requires all facilities involved in the manufacturing, processing, packing, or holding of medical foods for consumption in the United States to be registered with the agency. However, the FDA doesn’t retain a registry of medical foods.7 Home Health Care By Berri Burns, MEd, RD, LD, CNSC 10 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

Product Shortage Crisis Impacts of PN Shortages Although product shortages in 2011 reached a record high, they represent only a fraction of what took place in 2023. In the first quarter of 2023 alone, 301 national drug shortages were recorded— of which 55% included sterile injectable ingredients.8 The fragility of specialty compounding pharmacies, coupled with supply chain distributions during the COVID-19 pandemic, contributed to the increase in shortages. “The lack of additives at compounding pharmacies seemed to fuel parenteral nutrition shortages,” says Elizabeth Galant, RD, LD, CNSC, home nutrition support clinician at the Cleveland Clinic. “Supply chain distribution issues lead to insufficient ingredients for compounding the sterile additives. During the pandemic, this worsened, and even if the additive could be made, the delayed logistics of getting the product to the hospital caused another layer of shortage.” Kristin Izzo, MS, RD, LD, CNSC, a clinical nutrition manager at the Cleveland Clinic, says that some of the current challenges of PN shortages include logistical and supply chain disruptions as well as ongoing manufacturing and transportation staff limitations resulting from the pandemic. These delivery disruptions technically may not be considered product shortages since they were caused by supply chain limitations, but they impacted patients and caregivers just as much as standard product shortages. Despite these issues, Izzo believes a lack of compounding and administration materials poses the greatest risk to patient care during PN product shortages. “There are many creative ways to combat component shortages for parenteral nutrition, but we have an extremely limited ability to provide adequate therapy when shortages impact the physical ability to compound and administer custom total parenteral nutrition,” Izzo continues. “Fortunately, we have some great minds and resources in our home parenteral nutrition community. In recent years, we’ve had multiple IV lipid emulsions we’ve been able to learn more about and substitute in times of lipid shortages. When [possible], we have skilled clinicians that can determine if oral substitutes are an appropriate alternative for many components, such as magnesium, phosphorus, potassium, sodium bicarbonate, calcium, vitamins, and trace elements. We’ve also been able to work with our pharmacies to substitute different concentrations of sodium chloride during shortages. Recently, with our renal experts, we created a mathematical approach to replete bicarbonate deficits with oral rehydration solutions containing baking soda or other sodium bicarbonate oral medication replacements,” Izzo says. Home PN is more challenging in the home setting, as it isn’t monitored as closely as it is in the hospital setting. Less monitoring for long-term PN patients increases the risk of nutrient deficiencies if there’s a shortage of PN components. For example, omission or inadequate provision of multivitamins poses the greatest risk to patients.4 Impacts of EN Shortages Patients who require EN often are in a more dire situation than those needing PN due to the lack of monitoring and documentation of EN shortages. Partner With Us TARGETED NUTRACEUTICALS INCREASED ENERGY AND STRENGTH CARDIOVASCULAR SUPPORT COGNITIVE ENHANCEMENT BLOOD SUGAR MANAGEMENT OUR AFFILIATE PROGRAM IS OPEN FOR NEW APPLICATIONS. Learn more about how our products can improve your clients’ success and how you can earn a generous commission. SCAN THE QR CODE TO LEARN MORE about the research behind our formulas and how you can partner with us to create lasting change for your clients, or call 800-733-1658 to apply. ProHealth has been formulating research-backed third-party tested supplements of the highest possible quality for over 35 years, and we are constantly expanding our portfolio to meet the needs of you and your clients. PROHEALTH.COM/NUTRITION-PRO

The demand for EN products in hospitals exploded during the height of the COVID-19 pandemic. The surge in COVID-19 patients admitted to ICUs, who required tube feeding, placed a greater strain on EN inventory and exposed the potential for future shortages. Clinicians had to prioritize feeding administration pumps for patients with post pyloric feeding tubes. Sarah McIntyre, RD, LD, an inpatient dietitian at the Cleveland Clinic, says that product shortages have made a significant impact on her practice. “Due to volume restrictions for many of my clinical patients, standard enteral formulas—in particular, shortages of calorie-dense products—have altered my practice. This scenario impacts hospital length of stay due to product demand and unavailable inventory and/or delayed delivery of products post discharge to home,” McIntyre says. In 2022, the infant enteral formula crisis illustrated the long-lasting negative effects of a medical food shortage. On February 17, 2022, Abbott Nutrition announced a voluntary recall of powdered infant formula due to Cronobacter sakazakii contamination.9 Cronobacter sakazakii is a bacterium found naturally in very dry environments, including in dry foods such as powdered infant formula, powdered milk, herbal teas, and starches. Cronobacter illnesses are rare, but when infections occur in infancy, they can be fatal.9 Diana Schnee, MS, RD, CSP, LD, an outpatient pediatric nutrition support dietitian at the Cleveland Clinic, says that during the infant formula shortage, “Increased time was dedicated to helping patients find products, transition to appropriate alternatives, and deal with the side effects of changing formulas. Dietitians [offering a different] formula isn’t as simple as just giving an alternative product. Many of our kids are on specialized recipes, so they need recipes with new product alternatives. In addition, the creation and mixing of new recipes require substantial time above and beyond scheduled patient care.” Andrea Adler, RD, CSP, CSPCC, LD, an inpatient pediatric nutrition support dietitian at the Cleveland Clinic, says, “[The] inpatient RD team worked with Patient Food Service to obtain comparable products [that weren’t] on the hospital enteral formulary.” For example, she says, “Some patients were required to transition to a free amino acid-based formula, since the semi-elemental infant formula available contained probiotics, which was contraindicated in the pediatric transplant population.” On the other hand, when it was closer to discharge, the inpatient RD team assessed what the Home Infusion Pharmacy’s inventory could provide if the hospital tube feeding prescription couldn’t be duplicated at home because of product shortages. “Certain products aren’t yet available today. The [inpatient RD] team researched European infant formulas for alternative offerings. We were limited to infant formulas approved for import to the United States. Some of our patients transitioned from a 1 kcal/mL to a 1.2 kcal/mL product due to availability, but [they] didn’t necessarily [receive] an adjusted feed volume to account for the calorie difference.” Strategies to Deal With Shortages PN and EN product shortages can lead to many challenges for hospitals, patients, and caregivers both domestically and globally, but RDs who are part of interdisciplinary health care teams can help implement the following strategies to prepare and manage drug shortages to improve patient health outcomes. • Use a decision tree. A decision tree is a treelike diagram that represents a series of decisions and their possible consequences or outcomes. It’s a flowchart that dietitians and other clinicians can use to decide how to prepare, monitor, and manage drug shortages. According to Schnee, a decision tree is centered on a root question or root problem and involves brainstorming a variety of ideas to help develop processes that can lead to making the best clinical decisions for improved patient outcomes. It serves as a starting point for clinicians to map out a plan to prepare for and manage drug product shortages. • Standardize methods to report and manage shortages. Request a weekly email from the infusion pharmacy to update the status of the PN and EN formulary inventory and determine potential shortages. Next, collaborate with team members and leadership to develop contingencies if infusion pumps, tube feeding sets, or syringes are in short supply. • Create a database of alternative PN and EN formulas patients can use if their current formula prescriptions are out of stock. The database will help clinicians choose alternatives when there are PN and EN formula restrictions and substitutions are necessary. Moreover, a database of currently available PN and EN formulas will encourage prescribing providers to order nonshortage items. When the shortage items are back in stock again, RDs can update the database to reflect the status change. • Communicate with families and stakeholders. It’s important for RDs to discuss the status of product shortages with patients and caregivers and offer alternative formulas. Maintain open and consistent lines of communication with all supply chain personnel, manufacturers, RD teams, and those in leadership. All new prescriptions for alternative PN and EN formulas must be approved, formulated, and covered by insurance. In addition, these new prescription orders must be faxed or sent electronically to the infusion pharmacy. Final Thoughts Over the last few years, PN and EN product shortages have become more widespread. They’re unpredictable and affect many stakeholders, especially patients, their families, and consumers. The prevalence of product shortages creates growing challenges and hardships that can lead to severe health and economic consequences. Recently, temporary PN and EN product shortages have become the “new normal” in medicine, but making attempts to identify which shortages may be on the horizon and which ones could have the largest impact may be a step toward more timely mitigation. When communicating shortage updates and discussing potential solutions with all partners in the health care system, everyone will be better prepared to handle the shortages and improve patient care and health outcomes more seamlessly. n Berri Burns, MEd, RD, LD, CNSC, is an advanced practice dietitian at Infusion Pharmacy at Home at Cleveland Clinic. Home Health Care For references, view this article on our website at www.TodaysDietitian.com. 12 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 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.

Spotlight on Wheat Berries Using an Ancient Favorite in the Modern Era Wheat is the most widely grown crop in the world and one of the most-produced grains worldwide.1 Wheat is estimated to provide 20% of the total daily food calories for people in many regions and 13% of daily protein, which is higher than most other grains. Although wheat doesn’t contain all of the essential amino acids to make it a complete protein, its dominance worldwide makes it an essential source of plant protein, especially in developing countries. In recent years, there’s been a growing interest in ancient grains and new forms of grains such as einkorn, spelt, kamut, farro, and wheat berries. Wheat berries are kernels of whole wheat used in a variety of methods and recipes. To understand more about wheat berries, this article will cover the history, botany, nutrient content, and culinary uses (including two recipes), as well as how to make the most of this ancient grain. Brief History Agriculture originated in the Fertile Crescent more than 10,000 years ago with the domestication of cereal grains, including emmer and einkorn.1 The Fertile Crescent encompasses a large area of what’s now the Middle East from Iran to Israel and into Southeast Turkey. This area has been shown to be the habitat of domesticated cereal grains’ ancestors, including wild wheats, barley, and rye. Furthermore, archeological records show early human interaction with these grains.1 For example, in early Neolithic archeological sites, seeds from these wild species were found that indicated cultivation compared with later habitation of the sites where domesticated forms of the cereal grains were also discovered.1 Today, breeders have identified wheat’s genome to help distinguish valuable traits of ancient and modern wheat varieties, which results in more robust and diverse crops within our population. This means they can identify crops that can face the challenges of the warming weather and expanding population. Currently, the top global producer of wheat is mainland China, followed by India and Russia. In the US market, wheat is the third most produced food after corn and soybeans. The United States exports 50% of the wheat produced annually and makes up 16% of total wheat exports. Approximately 95% of wheat grown globally is Triticum aestivum, known as common wheat or bread wheat. The remaining 5% of global wheat production is Triticum durum, 1 also known as durum wheat or pasta wheat, which is grown in hotter and drier climates. What Are Wheat Berries? The kernel of whole wheat is called a wheat berry, and it contains the bran, germ, and edosperm of the entire wheat kernel.2 The kernel typically is processed to produce foods such as bread and pasta. Wheat berries have a nutty, sweet taste, and because the wheat kernel is still intact, the wheat berry provides a plethora of fiber, protein, and thiamin and niacin. The wheat berries seen at the market usually refer to kernels of hard red winter wheat, hard red spring wheat, or soft wheat. There also are several other ancient wheats used interchangeably with wheat berry recipes, including einkorn, farro, kamut, and spelt.3 Whole wheat variants, such as wheat berries, can take close to an hour to cook, but you can reduce the cooking time by using a rice cooker or pressure cooker. In addition, to help decrease the cooking time of wheat berries, some processors crack the wheat kernels into smaller pieces without removing the bran or germ. Some of these quick-cooking wheat pieces include bulgur and freekeh. Bulgur are wheat kernels that have been preboiled and then ground into small pieces. Because they’re precooked and dried, they need to be boiled for only 10 minutes until they’re ready. Freekeh is a hard wheat that’s harvested when the plant is young and green and then roasted and rubbed. This process gives freekeh its smoky flavor, and it also can be sold cracked for smaller, quicker cooking pieces. Powerhouse of Nutrition One-quarter cup of hard red winter wheat berries provides 148 kcal, 1 g total fat, <1 g saturated fat, 31 g total carbohydrate, 5 g total fiber, 7 g protein, and 1 mg sodium. It’s free of sugar and trans fats. A single 1/4-cup serving also provides 9% of the daily recommended amount of iron, 3% of the daily recommended amount of potassium, and 1% of the daily recommended amount of calcium.4 Ancient Grains By Toby Amidor, MS, RD, CDN, FAND 14 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

Culinary Uses Like other nutritious grains, wheat berries can be used in a variety of recipes, such as in stews, salads, bread, energy bars, and more. To prepare wheat berries, follow the steps listed below5 : Step 1: (Optional) This step can reduce cooking time. Place the wheat berries in a bowl, cover entirely with water, and soak overnight. Soak berries for at least 12 hours and drain. Step 2: (Optional) Toast the berries before cooking on a stovetop. Preheat the oven to 375˚ F, spread the berries on a parchment paper-lined baking sheet, and toast for 10 minutes. Step 3: Place 21/2 to 3 cups of water or liquid (like broth) in a saucepan and add 1 cup wheat berries. Bring the mixture to a boil over high heat, reduce the heat to low, and simmer. Check the pan occasionally to ensure there’s enough water. Typically, wheat berries take about one hour to cook, but soaking can decrease cooking time to about 35 minutes. They’re done when the berries are chewy. Step 4: Drain any excess liquid from the wheat berries. Wheat berries also can be prepared in a slow cooker using a 3:1 ratio of liquid to grain. Rinse the wheat berries, set the cooker on low, and cook, covered, for eight to 12 hours. Drain the berries and set them aside to cool before using or serving. Uncooked wheat berries can be stored in an airtight container in the pantry for up to six months and in the freezer for up to one year. What follows are two recipes for wheat berries—one for a wheat berry salad that serves eight and one for wheat berry burgers that can serve six. n 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. Wheat Berry Salad Serves 8 Ingredients 2 cups dry wheat berries 3 T honey 3 small garlic cloves, peeled and minced 2 T lime juice 2 T rice vinegar 2 T peanut oil 1/2 tsp salt 1/2 cup dried currants 1/4 cup unsalted peanuts, chopped 2 cups fresh or frozen peaches or mangos, defrosted, and chopped 1 small red bell pepper, finely chopped 2 cups fresh spinach, chopped Directions 1. Cook wheat berries according to package directions, place in a strainer, rinse, drain, and cool. 2. Whisk the honey, garlic, lime juice, rice vinegar, peanut oil, and salt in a large bowl until combined. 3. Add the wheat berries, currants, peanuts, peaches or mangos, bell peppers, and spinach in the bowl with the dressing and stir to coat. Chill. Nutrient Analysis per 1/2-cup serving Calories: 207; Total fat: 7 g; Sat fat: 1 g; Sodium: 290 mg; Total carbohydrate: 33 g; Dietary fiber: 3 g; Sugars: 18 g; Protein: 5 g SOURCE: RECIPE AND PHOTO COURTESY OF JACQUELINE LARSON, MS, RDN, HTTPS:// CONSULTANTDIETITIAN.COM Wheat Berry Burgers Serves 6 Ingredients 7 tsp olive oil, divided 1/2 small onion, chopped Kosher salt and black pepper 2 cups cooked wheat berries, cooled 4 peppadew peppers 2 T prepared hummus 1 large egg Directions 1. Heat 1 tsp of oil in a small skillet. Add onion, season with a pinch of salt, and sauté until translucent, about 4 minutes; set aside to cool. 2. Combine cooked onion, wheat berries, peppadew peppers, hummus, and egg in a food processor fitted with a steel blade. Season with 1/4 tsp each of kosher salt and black pepper. Pulse until mixture is well combined, stopping to scrape down the sides of the bowl a couple of times. Form mixture into six equal-sized patties (about 1/2 cup each). 3. Heat 2 tsp of oil in a large skillet, place two burgers in the skillet and cook for 5 minutes per side; transfer to a plate. Repeat for remaining burgers. Nutrient Analysis per serving (1 burger) Calories: 186; Total fat: 8 g; Sat fat: 1 g; Total carbohydrate: 24 g; Dietary fiber: 5 g; Sugars: 1 g; Sodium: 113 mg; Protein: 5 g SOURCE: RECIPE AND PHOTO COURTESY OF DANA ANGELO WHITE, MS, RD, ATC, OWNER OF DANA WHITE NUTRITION, HTTPS://DANAWHITENUTRITION.COM For references, view this article on our website at www.TodaysDietitian.com. AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 15

Creating Kid-Friendly Snacks Strategies for Parents and Caregivers F eeding young children is an ongoing task for parents. In addition to eating three meals per day, most kids need at least a couple of snacks in between to help keep them energized and focused. This is especially true for elementary school children, whose bodies and brains are rapidly developing. In fact, it’s estimated that children get about 27% of their daily calories from snack foods, with snacking habits only increasing over the past few decades.1 There’s no shortage of snack options, whether made at home or bought in stores. Yet not all of them are healthful choices. Unfortunately, most American children consume snacks high in calories but low in nutrients. This is concerning since data from the 2009–2010 National Health and Nutrition Examination Survey (NHANES) revealed that children don’t get enough vitamin D, calcium, and potassium but tend to consume excess calories, carbohydrates, and sodium.2 Feeding children healthful snacks is an important part of supporting their current and future health, which is why it’s important for RDs to encourage parents to provide nutritious food options and snack ideas to achieve this goal. Benefits of Snacking Children’s bodies are rapidly growing, yet their stomach size is still small. So, eating more frequently throughout the day typically works best for them. “Snacks play an important role in kids’ diets by supporting their energy needs while providing essential nutrients necessary for growth and development,” says Dani Lebovitz, MS, RDN, a children’s nutrition education expert based in Franklin, Tennessee, and founder of kidfoodexplorers.com, a website focused on children’s nutrition. Similarly, Liz Weiss, MS, RDN, founder of lizshealthytable.com and host of the podcast EAT, DRINK, LIVE LONGER, based in Boston, says, “Snacks can be the secret sauce to better nutrition for kids. They help fill in the nutrient gaps in a child’s day and also offer an opportunity to try new foods and explore new flavors.” Back to School By Joanna Foley, RD 16 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

When done right, snacking can support children’s health by offering the following benefits: • providing energy to fuel daily activities; • helping improve the ability to think clearly and focus3 ; • controlling hunger; • helping control cravings for sweets or other less nutritious foods; • supporting balanced blood sugar levels; and • contributing essential daily nutrients to support normal growth and development. Finding Healthful Snacks Since healthful snacks are beneficial to children, it’s important to note that some snack options are better than others. Many snack foods are low in substantial nutrients such as protein and fiber while high in refined carbohydrates and added sugars.4 These snacks still will provide kids with energy and calories, but they don’t offer the right nutrients a growing child needs. They’re also likely to cause a crash in blood sugar not long after consumption. This can trigger more hunger and cravings and potentially lead to eating more calories than the child needs. When creating healthful homemade snacks, here’s what parents and caregivers should keep in mind: 1 Protein: Protein supports a child’s bodily processes, including the immune system, hormones, bone development, and more.5,6 Protein also leads to better satiety than carbohydrates or fat, which may help control hunger for longer.7 2 Fiber: Fiber is a type of complex carbohydrate that comes from plants such as whole grains, nuts, seeds, fruits, vegetables, and legumes. Foods high in fiber tend to be more nutrient dense than foods low in fiber. Fiber has many health benefits for children, such as promoting a healthy digestive system, supporting heart health, and managing inflammation.8 3 Healthful fats: Fat is essential for normal brain development in children.9 It also helps their bodies absorb vitamins.10 Healthful fats such as nuts, seeds, avocados, and olive oil don’t need to be restricted for children. 4 Produce: School-aged children need 1 to 11/2 cups of fruit and 11/2 to 2 cups of vegetables each day.11 Yet, most don’t eat enough of these foods. Offering fruits and vegetables at snack times can help children meet this daily goal. Different types of produce have different nutrition profiles, so the more colors and variety, the better. Taking this into account, nutrition still is one of several important components of a snack. “The ideal snack also should be portable (if parents and kids are on the go), delicious, appealing to the individual child, affordable, in sync with the family’s culture and food preferences, and nourishing to body and soul,” Weiss says. Tips for Healthful Snacks Parents who forgo store bought snacks in favor of homemade snacks can get creative. Making homemade snacks doesn’t have to be complicated, expensive, or require many ingredients. “Keep things simple, fun, and enjoyable for parents, caregivers, and kids, and be mindful of the child’s age and stage of development,” Weiss says. Lebovitz recommends parents and caregivers consider how much time the Earn FREE CPEUs The Soy Connection health and nutrition newsletter is available online. READ NOW! www.SoyConnection.com

Back to School child will have between snacking and the next meal and where the child will be eating the snack to determine what to offer. Lebovitz also suggests keeping “a shelfstable snack readily accessible in backpacks, purses, and cars in case of hangry emergencies.” In addition, “try coaching kids to pick and pack their own snack based on their needs— it just requires a little kid-friendly kitchen prep and skill building. Creating pantry baskets and/or fridge space designed for easy grab-and-go options will make healthful snack prep a breeze!” Lebovitz says. Here are eight simple homemade snack ideas for children to share with clients: 1 Low-sugar trail mix. This snack can include endless variety, provide a great mix of nutrients, and help keep a child satiated for hours. Simply combine the desired ratio of a low-sugar cereal, popcorn, or crackers; unsweetened dried or freeze-dried fruit; and nuts, then mix together. Example recipe: Cheerios mixed with freeze-dried strawberries and peanuts. 2 Piece of fruit paired with nut butter. This is a nutritious way to give a child a serving of produce, plus the healthful fats from nuts. Caregivers can make “banana sushi” by spreading nut butter in between two thin banana slices or make “apple nachos” by drizzling sliced apples with nut butter and a sprinkle of nuts for a fun and simple snack. 3 Yogurt parfait. Yogurt doesn’t have to be served only in the morning. Greekor Icelandic-style yogurts provide a great source of protein, plus the benefits of natural probiotics. Parents can make a colorful parfait using plain yogurt, berries, or other colorful fruit slices, in addition to other desired add-ins such as low-sugar granola, chia seeds, and nut butter. 4 Piece of whole grain toast with a hardboiled egg. This classic combo provides fiber, protein, and fat. Parents can serve the toast with a pat of butter, nut butter, or even mashed avocado. They also can serve the egg whole or in slices with a pinch of salt and pepper. If toast isn’t available, whole grain crackers also make a good option. 5 Veggie sticks dipped in hummus. Kids who are resistant to vegetables may be more inclined to try them if they’re paired with a tasty dip. Parents can encourage their children to choose what vegetables they want, such as bell peppers, celery, or carrot Peanut Butter and Banana Smoothie Bowl Serves 3 Remember that when making smoothie bowls, anything goes, so this recipe can easily be tweaked. Consider using cow’s milk or almond milk instead of soymilk, add some Greek yogurt to boost protein, or swap the peanut butter for another nut butter. Cater to what’s available and what the child likes most. This recipe is best served fresh, so if fewer servings are required, simply cut the recipe in half. Ingredients 1 cup unsweetened vanilla soymilk 2 frozen bananas 3 T natural peanut butter 2 T unsweetened cocoa or cacao powder 1 T chia seeds Optional toppers: O-shaped whole grain cereal, crushed graham crackers, chopped peanuts, coconut chips, additional chia seeds, or sliced banana Directions 1. Place the milk, bananas, peanut butter, cocoa powder, and chia seeds into a blender and blend until smooth. 2. Pour into individual bowls and garnish with your choice of optional toppers. Serve immediately. Nutrient Analysis per serving Calories: 216; Total fat: 11 g; Sat fat: 2 g; Total carbohydrate: 26 g; Sugars: 11 g; Added sugars: 0 g; Dietary fiber: 7 g; Sodium: 26 mg; Protein: 8 g; SOURCE: RECIPE AND PHOTO COURTESY OF LIZ WEISS, MS, RDN, FOUNDER OF LIZSHEALTHYTABLE.COM. 18 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

sticks. Then, pour the hummus into a container and place the veggie sticks in or around it for a colorful display. If hummus isn’t available or desired, choose guacamole, tahini, or pesto sauce. Another option is to serve hummus with pita bread, pita chips, or whole grain crackers. 6 Avocado or hummus “quesadilla.” Spread mashed avocado and/or hummus onto a tortilla, fold it in half, and cut it appropriately for your child’s age for a quick, nutritious snack. 7 Tuna and whole grain crackers. Canned tuna provides a great source of healthful omega-3 fats and is an affordable fish. Pair it with whole grain crackers for a delicious and satisfying snack that’s easy to make. Caregivers can prepare the tuna however their kids like it best. 8 Smoothie bowl (see recipe). Smoothies aren’t just for mornings or to be sipped from a cup. Making a smoothie bowl is a nutritious way to get extra produce and other nutrient-dense foods into a child’s diet. Too Much Snacking? Despite all of the healthful benefits of snacking, doing too much of it can lead to problems. Allowing kids to eat snacks regularly or in excess can interfere with their appetite for mealtimes as well as their natural ability to gauge their normal hunger levels. “Think of snacks as mini meals to hold kids over until lunch or dinner,” Weiss says. Instead of allowing children to graze throughout the day, it’s best to have designated snack times. “By offering consistent and predictable snack opportunities, kids can learn how to tune in to their intrinsic hunger and fullness cues and eat what they need to satisfy themselves until the next meal or snack,” Lebovitz explains. Ideally, snacks should occur about one to three hours after the previous meal ended. Postponing snacking can help prevent kids from refusing whatever is served at mealtime. In addition, snack time should end at least one hour before the next meal. This can help prevent them from being overly full and potentially missing out on quality nutrients at mealtime. If children ask for food when it’s not a designated snack time, caregivers can remind them that they will have to wait until it’s snack time. On the other hand, if children don’t want a snack that’s offered, there’s no need for parents to force it since doing so can interfere with a child’s ability to self-regulate their own appetite. Recommendations for RDs Snacking isn’t only advantageous for children but also can offer many health benefits. RDs should encourage parents and caregivers to create and choose healthful snacks for their kids by considering their nutrition profile, desirability, and level of appropriateness for their stage of development. Because it’s easy for snacking to get out of hand, it’s a good idea for parents to set guidelines so it doesn’t interfere with mealtimes and encourage their children’s natural ability to self-regulate their appetites. n Joanna Foley, RD, is a freelance health writer and author of two cookbooks based in San Diego, California. Learn more about her writing services at joannafoleynutrition.com/press. For references, view this article on our website at www.TodaysDietitian.com. BERRY BLISS HO R NEY BUNS ol Ou Memorie the Honey Bun #09712 Net Wt. 1.76 oz Case Ct. 144 Shelf Life 120 Days Also Avail. in 4 oz AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 19

Lamb shank, caviar with champagne potato chips and creme fraiche, salmon crudo, and crispy whole 20 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023 haddock at Stoic & Genuine If you’re headed to FNCE®, peruse this dining guide for critically acclaimed, awardwinning restaurants to visit that will satisfy a diversity of palates.

Denver dietitian Anita Bancroft, RD, CC, an ACF-certified culinarian and interim manager of the Community Nutrition Programs at the University of Colorado’s Anschutz Health and Wellness Center, says, “The Denver food and dining scene is relatively new compared to some of the other larger cities across the United States. It offers a wide variety of cuisines and is continuously changing.” Bancroft’s colleague Courtney Kiang, RD, says one of the marvels of the Denver restaurant landscape is the variety and volume of meals to try. “So many flavors, types of foods, owner’s visions, ingredient sources. It feels impossible to try all the recommendations people toss around,” Kiang says. “Honestly, after having kids, a Denver night out that includes a fancy restaurant is savored, so trying something new each time we venture into the city is something special.” If you’re looking for a food experience that’s historical and unique to Denver, Bancroft suggests Buckhorn Exchange (www.buckhorn.com, 1000 Osage Street, Denver, 303-534-9505). “It’s Denver’s oldest restaurant and bar, established in 1893, and located in Denver’s oldest neighborhood,” she says. “It has a rich history and has hosted numerous celebrities. They offer wild game meats along with While Denver might once have been best known for green chiles and tacos, the city’s culinary scene is on the rise and getting noticed, with James Beard Award– winning chefs, a diverse representation of global food cultures, a growing and committed farm-to-table movement, and more sophisticated diners demanding more of the same—if not better. Despite being landlocked, Denver’s ability to quickly access fresh seafood from both coasts has become evident on many menus in delicious ways. AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 21 SAVOR LEFT: PHOTO BY JONI SCHRANTZ BEST CUISINE DENVER’S GET READY TO EXPERIENCE A BOOMING, DIVERSE FOOD SCENE BY CARRIE DENNETT, MPH, RDN

other exotic meats. You can get your Rocky Mountain Oysters here, too!” She notes that Buckhorn is brimming with taxidermy, so it may not be for everyone. Another unique Denver food experience is Casa Bonita (www.casabonita denver.com, 6715 W Colfax Avenue, Denver, 303-232-5115; reservations likely necessary). “It’s quintessentially Denver, as this historical restaurant was a part of many Coloradoans’ lives,” Bancroft says. “This was the place to go in the ’80s and ’90s for birthday parties and family fun, watching divers, playing games, and eating Mexican food.” But there was one problem, she says: “Besides the sopaipillas, the food was barely edible.” She’s excited for the next stage of Casa Bonita’s life. South Park creators Trey Parker and Matt Stone purchased the property in 2021 and hired two-time James Beard–nominated chef Dana “Loca” Rodriguez to overhaul the kitchen and the menu. Mexico City–born Rodriguez, who worked her way up the ranks at Rioja and Bistro Vendome (see “AwardWinning Chefs and Fine Dining” on page 24) before opening her own Latin American restaurants, Work & Class (workandclassdenver.com, 2500 Larimer Street, Denver, 303-292-0700), Cantina Loca (www.cantinaloca.com, 2890 Zuni Street, Denver, 303-284-6738), and Super Mega Bien (supermegabien.com, 1260 25th Street, Denver, 720-269-4695), is sticking to her preference for simple, flavorful food. The new menu includes approachable but elevated Mexican specialties, served cafeteria-style. All dishes—such as roasted bone-in chicken with nutty mole negro or smokey chipotle sauce, slow-braised carnitas with house-made tortillas, or sauteed vegetables and roasted poblanos with a red chile–enriched sauce—come with chips and freshly made salsa, and sides of beans, rice, and salad with citrusy dressing. On the dessert menu, sopaipillas are joined by flan, a chipotle-spiced chocolate mousse, and a Mexican lime icebox cake. Craft cocktails are another new addition to this classic destination. Neighborhoods of Note One can assume correctly that restaurants don’t exist in a vacuum— they live in neighborhoods. The convention center is in Denver’s walkable lower downtown (LoDo)— home to the city’s top chef-driven eateries and innovative craft breweries such as Jagged Mountain Craft Brewery (www.jaggedmountainbrewery.com, 1139 20th Street, Denver, 720-689-2337), Denver Beer Co. (denverbeerco.com, 1695 Platte Street, Denver, 303-433-2739), and Wynkoop Brewing Company (wynkoop. com, 1634 18th Street, Denver, 303-297- 2700), founded by former Colorado Governor John Hickenlooper. Taste other local brews at Tap Fourteen (www. tapfourteen.com, 1920 Blake Steet, Denver, 303-297-8279), a rooftop bar and beer garden featuring 70 Colorado beers on tap, plus more than 50 Colorado whiskeys. “One of the most notable attributes for Denver is the city’s craft beer culture, a major draw for food lovers and beer enthusiasts alike,” says Tyson Marden, RDN, nutrition core manager and senior professional research assistant at the Colorado Clinical and Translational Sciences Institute, and a former fine dining chef. He likes Wynkoop Brewing Company and recommends three other notable Denver breweries in downtown’s neighboring Five Points neighborhood: Goed Zuur (goedzuur.com, 2801 Welton Street, Denver, 720-749-2709), which specializes in sour and wild ales, cheese, and other nibbles; Great Divide Brewing Company (greatdivide.com, 2201 Arapahoe Street, Denver, 303-296-9460); and Ratio Beerworks (ratiobeerworks.com, 2920 Larimer Street, Denver, 303-997-8288). Prefer wine over beer? Attimo Wine (www.attimowine.com, 2246 Larimer Street, Denver, 720-287-4988) is a working urban winery that ages, blends, and bottles wines from Northern Italy and serves them alongside authentic Italian snacks, such as marinated olives and charcuterie, Thursday through Saturday at its tasting room near Coors Field. A few blocks away, one of Denver’s most iconic historic landmarks, Denver Union Station (www.denverunionstation.com, 1701 Wynkoop Street, Denver, 833-391- 0338), a renovated 1914 Beaux-Arts train station, is home to 10 chef-owned restaurants and bars. (Tip: Taking the train from the Denver airport to Union Station puts you one mile from the convention center for a fraction of the cost of an Uber, Lyft, or taxi.) Union Station is next to a Whole Foods (www.wholefoodsmarket.com/ stores/unionstation, 1701 Wewatta Street, 720-572-8800, Denver) and sits at the north end of the 16th Street Mall (www.the16thstreetmall.com), a milelong pedestrian-friendly corridor, full of restaurants and shopping (served by free MallRide buses), which passes through Lobster bisque at Bistro Vendome Bahn mi tacos with lemongrass tofu at Vital Root 22 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023 LEFT: PHOTO BY JONI SCHRANTZ RIGHT: PHOTO BY STEPHAN WERK

the FNCE® hotel area. Restaurants include Blue Agave Grill (blueagavegrillcolorado. com, 1201 16th Street, Denver, 720- 550-8389), featuring contemporary Southwestern cuisine with a large margarita selection, house-infused tequilas, and homemade sangria. MAD Greens (www.madgreens.com, 1600 Stout Street, Suite 101, Denver, 720- 468-4173) offers salads, grain bowls, wraps, mac and cheese bowls, and juices. Colorado-based Modern Market (modernmarket.com, 900 16th Street, Denver, 303-534-0190) serves farmto-table fare that can be ordered at the counter, including breakfast burritos, toasted sandwiches, brick-oven pizzas, fresh salads and bowls, and hearty soups. Marden says one way Denver’s dining scene continues to evolve and expand is through the “number of great food halls and markets popping up around the city, offering visitors and locals alike a vibrant and dynamic culinary experience.” He points to The Dairy Block (dairyblock.com, 1800 Wazee Street, Denver, 303-309-4847), The Denver Milk Market (www.denvermilkmarket. com, inside The Dairy Block, 303-792- 8242), and Stanley Marketplace (https:// stanleymarketplace.com, 2501 Dallas Street, Aurora, Colorado, 720-990-6743) as a few notable examples. North of downtown is one of Denver’s oldest and most diverse neighborhoods, Five Points, which was once known as the “Harlem of the West” because it was a frequent stop for Billie Holiday, Louis Armstrong (Satchmo), Miles Davis, and other jazz greats. It has stately Victorian houses and restaurants serving up amazing Caribbean, soul food, catfish, and barbecue. Welton Street Café (weltonstreetcafe.com, 2883 Welton Street, Denver, 303-296-6602) is a soul food staple, offering Southernstyle cooking with a Caribbean twist— from crispy fried chicken or catfish to smothered pork chops to smoked collard greens and black-eyed peas. On the northwest edge of Five Points (and technically part of it) along the South Platte River, River North Art District (RiNo) is a blend of urban charm and industrial revival known for its street art, restaurants, and galleries. Historic warehouses and factories now house jazz bars, restaurants, craft distillers and brewers, winemakers, smallbatch coffee roasters, art galleries, and working studios. RiNo is home to several indoor food halls and markets, including the Source Hotel & Market Hall (www. thesourcehotel.com/markethall, 3350 Brighton Boulevard, Denver, 720-443- 1135), a highly curated European-style artisan food market in an iconic 1880s ironworks building, and the Mardenrecommended Denver Central Market (www.denvercentralmarket.com, 2669 Larimer Street, Denver), showcasing some of Denver’s top chefs and food purveyors. North of RiNo, the Highland neighborhood features historic homes and buildings, lush gardens and parks, and innovative restaurants and bars. Marden and Kiang both recommend Avanti Food and Beverage (avantifandb. com, 3200 Pecos Street, Denver, 720-269- 4778), a modern-day food hall inspired by European markets and food truck roundups. It features seven different restaurant concepts—each one housed in a modified shipping container—with affordable, chef-driven cuisine, plus two bars under one roof with communal dining. “It is a fun and inclusive dining experience,” Kiang says. She also recommends Linger (www.ediblebeats.com/ linger, 2030 W 30th Avenue, Denver, 303- 993-3120), which categorizes its menu as cuisine by region, including Asia, the Americas and Europe, Africa, the Middle East, and India. “Linger has an upscale casual feel, and it used to be a mortuary,” she says. “It’s also conveniently located next to Colorado-only Little Man Ice Cream (www.littlemanicecream.com, 2620 16th Street, Denver, 303-455-3811) with vegan and classic ice cream options if you’re looking for dessert.” Also known as North Capitol Hill, Uptown Denver, just east of downtown, is home to Restaurant Row, the stretch of E 17th Avenue running from Broadway to City Park, lined with cafes, bistros, pubs, fine dining, and LGBTQ-friendly bars—most of them with outdoor patios. Steuben’s (www.steubens.com, 523 E 17th Avenue, Denver, 303-830- 1101) merges a modern diner with a classic café—with 1960s flare—serving regional American fare, including lobster rolls, green chili cheeseburgers, fried chicken, ribs, and cupcakes. It’s open for lunch, dinner, and weekend breakfast and brunch. Right next door is Ace Eat Serve (www.aceeatserve. com, 501 E 17th Avenue, Denver, 303-800- 7705), which is part Asian eatery, part ping pong hall, and part indoor-outdoor bar that serves craft cocktails, a welledited beer selection, and an extensive list of Japanese whisky. Executive chef Thach Tran’s modern and exciting style of Asian cuisine explores authentically inspired Vietnamese, Chinese, Thai, Korean, and Japanese cuisine. Plant-Forward Dining Plant-forward eating is also a trend that continues to gain steam—in Denver and elsewhere—especially as innovative chefs and restaurants keep demonstrating how delicious plant foods can be. While many restaurants include appealing vegan options on their menus, for a full plant-based experience, Kiang suggests Watercourse Foods (www.watercoursefoods.com, 837 E 17th Avenue, Denver, 303-832-7313) or—for a must-taste food experience that’s quintessentially Denver—City O’ City (cityo citydenver.com, 206 E 13th Avenue, Denver, 303-831-6443), which share the same owner. “Whether you are vegetarian or not, delicious and innovative food comes out of that kitchen,” she says. “It’s the best vegan and vegetarian food in the city, no one will argue with this.” Vital Root (www.ediblebeats.com/ vital-root, 3915 Tennyson Street, Denver, 303-474-4131) offers what the website describes as “a fast-casual approach to the Omnivore’s Dilemma” with bright, nutrient-dense, plant-based meals, such as bahn mi tacos, cashew “queso” nachos, and root vegetable Reubens that are “99% vegan, 100% gluten-free, and 101% craveable.” Marden recommends Bang Up to the Elephant! (bangupto theelephant.restaurant, 1310 N Pearl Street, Denver, 303-792-4949), which offers vegan food with a chill tropical vibe, including coconut curry, a seitan cubano, peas n’ rice, and papaya slaw. Dining Resources Eater Denver: https://denver.eater.com Denver Tourism: https://www.denver.org/ food-drink/restaurants/ must-try-restaurants 303 Magazine: https://303magazine.com/ category/food-and-booze 5280 Magazine: https://www.5280.com/ category/eat-and-drink WWW.TODAYSDIETITIAN.COM 23

Farm to Table Denver’s farm-to-table scene also is increasing, in spite of a challenging growing season, with spring snowstorms, summer hail, and unexpected frosts. Many restaurants feature dishes inspired by what’s seasonal and local, from produce to meat to grains. (If you’re lucky, you’ll get to taste Palisade peaches, grown in the town of Palisade—Colorado’s fruit and wine country—along the Colorado River. They’re known for being extra juicy and extra sweet, thanks to the long sunny days and cool summer nights.) Marden says one of the most notable aspects of the Denver restaurant landscape is its focus on farm-to-table cuisine, with many restaurants incorporating locally sourced, seasonal ingredients into their menus. “This emphasis on fresh, locally grown ingredients has helped to support Colorado’s thriving agricultural community and has led to a rich and diverse culinary landscape.” He recommends The Wolf’s Tailor (www. thewolfstailor.com, 4058 Tejon Street, Denver, 720-456-6705)—one of a handful of restaurants founded by James Beard– nominated Chef Kelly Whitaker—which offers a multicourse tasting menu showcasing the best wild, foraged, seasonal, and fermented products from its Colorado farmers and purveyors. The restaurant serves a seasonal tasting menu Tuesday through Sunday. Kiang recommends Root Down (www. ediblebeats.com/root-down, 1600 W 33rd Avenue, Denver, 303-993-4200), an employee-owned restaurant that selfidentifies the menu as “fresh from the Earth.” The menu includes entrees such as bison with smashed fried sunchokes and harissa “tofu” tagine with charred cauliflower. (It also has an outpost at the Denver International Airport in Concourse C past security.) Kiang also suggests Point Easy (pointeasydenver.com, 2000 E 28th Avenue, Denver, 303-233- 5656), noting that it’s “upscale, lovely, and comfy.” 303 Magazine calls the thoughtful menu of starters, pasta, small plates, and large plates, which includes food, wine, and spirits from 50 local purveyors, “rustic and approachable.” Coperta (www.copertadenver.com, 400 E 20th Avenue, Denver, 720-749-4666) works with Colorado’s best farmers and ranchers to gather ingredients for its authentic Southern Italian, seasonally inspired dishes, with mainstays such as cacio e pepe and eggplant parmigiana, alongside seasonal offerings and specials. Start with the housemade garlic herb focaccia while perusing the wine list dedicated exclusively to Italy’s central and southern regions. Alex Seidel, chef-owner of Mercantile Dining & Provision in Union Station (see “Award-Winning Chefs and Fine Dining” below), also founded Fruition Farms, a 10-acre plot southeast of Denver that grows vegetables and herbs for his restaurants. Global Flavors “Another key characteristic of the Denver dining scene is its eclectic mix of cuisines, with a wide range of international flavors and influences represented,” Marden says. “There are very few ‘native Denverites.’ So many people move from all over the country and world to Denver, and we benefit from this as they bring their delicious cuisines to share with us. From traditional Mexican and Italian fare to more contemporary Asian and fusion cuisine, there are great cuisines from all over the world.” Marden particularly recommends Café Brazil (cafebrazildenver.com, 4408 Lowell Boulevard, Denver, 303-480-1877), an off-thebeaten-path South American–inspired seafood restaurant. A sister restaurant to The Wolf’s Tailor (see Farm to Table above), BRUTØ (www. brutodenver.com, 1801 Blake Street, Denver, 720-325-2195), has a 15-seat chef’s counter that offers a multicourse, omakase-style dinner tasting menu (Tuesday through Sunday) inspired by traditional ingredients grown and found around Latin America, Mexico, Texas, and Colorado, and revolving around local grains, fermentation, and chiles. Bancroft likes the “delicious plates and cocktails at El Five (www.ediblebeats. com/el-five, 2930 Umatilla, fifth floor, Denver, 303-524-9193), a tapas restaurant with Mediterranean cuisine focusing on regions such as Spain, North Africa, and the Middle East. She also likes the view: “The restaurant sits high on the fifth floor and has an incredible view of the Denver skyline.” Domo Japanese Country Restaurant (domorestaurant.com, 1365 Osage Street, Denver, 303-595-3666). “This is one of my all-time favorite restaurants in Denver,” Bancroft says. Chef-owner Gaku Homma closed the restaurant in 2021 after a viral TikTok video led to long lines of people that made social distancing impossible but is reopening the restaurant with a smaller focus. “The food is amazing, and they have a beautiful Japanese garden you can sit in.” She also recommends Star Kitchen (starkitchenseafooddimsum.com, 2917 W Mississippi Avenue, Denver, 303-936-0089). “If you’re a fan of dim sum, this restaurant is worth the wait!” Bancroft says. “They have some of the best dim sum in town, and people line up around the corner to get into their first seating of the day.” Vinh Xuong Bakery (vinhxuong.square.site, 2370 W Alameda Avenue, Denver, 303-922- 0999) is Bancroft’s favorite place to get a bahn mi. The menu includes vegan and gluten-free options. Cuba Cuba Cafe & Bar (www.cuba cubacafe.com, 1173 Delaware Street, Denver, 303-605-2822) offers authentic Cuban cuisine and craft cocktails— accompanied by salsa music—in two adjacent historic turquoise bungalows with a palm tree out front. Sip a mojito and crunch on some plantain chips and dips before enjoying empanadas, ropa vieja (shredded flank steak prepared with a Creole sauce), or camarones con coco (pan-seared shrimp sautéed with a French-style sofrito, garlic, ginger, and coconut milk over creamy mash potato). No reservations; first come, first served. Award-Winning Chefs and Fine Dining Conde Nast Traveler proclaimed Denver an official food city in 2018, in part because of Tavernetta (www. tavernettadenver.com, 1889 16th Street Mall, Denver, 720-605-1889), an Italian hot spot founded by James Beard Award winners Bobby Stuckey and Lachlan Mackinnon-Patterson, in the Limelight Hotel. At Tavernetta, handmade pastas shine, but so do dishes such as 24 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023 Banana cream pie at Root Down

milk-braised rabbit with morels, lentils, and gremolata, and veggie-forward sides such as grilled rapini with smoked ricotta and garlic. Another stellar hotel restaurant—this one in the Thompson Denver hotel—is French brasserie Chez Maggy (www.chezmaggydenver.com, 1616 Market Street, Denver, 720-794- 9544), where Michelin-starred French chef Ludo Lefebvre creates a unique approach to French cuisine using elements and ingredients native to Colorado. Look for mussels frites, trout almandine, Colorado lamb chops, and French wine. Kiang likes The Capital Grille (www. thecapitalgrille.com, 1450 Larimer Street, Denver, 303-539-2500), a classic steakhouse with some twists, and Ocean Prime (www.ocean-prime.com, 1465 Larimer Street, Denver, 303-825-3663), which is like a steakhouse with a strong seafood emphasis. “Both are Denver staple restaurants in Larimer Square, which was Denver’s first block, its first commercial district, home to its first residence and first city hall, and was the city’s first designated historic district.” Bancroft suggests The Mercantile Dining and Provisions (www.mercantile denver.com, 1701 Wynkoop Street #155, Denver, 720-460-3733), located in Union Station and featuring creations from chef-owner Alex Seidel, a James Beard Foundation Award winner for Best Chef Southwest 2018. “It’s great for a nice, sit-down meal or grabbing some quick snacks from the market side.” She also likes the food and wine selection at Rioja (www.riojadenver.com, 1431 Larimer Street, Denver, 303-820-2282), which offers fine dining specializing in seasonal Mediterranean Spanish cuisine in Larimer Square, with ingredient-driven dishes featuring fresh fish, pastas, and local meats. Chef Jennifer Jasinski won the James Beard Foundation Award for Best Chef Southwest 2013 and was a semifinalist for Outstanding Chef 2016. Other Jasinski restaurants include Ultreia (ultreiadenver.com, 1701 Wynkoop Street, Denver, 303-534-1970), which offers shared plate pinxtos (pronounced peen chos), and tapas—including ham croquettes, bacon-wrapped dates, tinned fish, roasted garlic soup, and Moorish spiced ribs—inspired by Spain and Portugal, right in Union Station. Also in Union Station is Jasinski’s Stoic & Genuine (stoicandgenuine.com, 1701 Wynkoop Street, Denver, 303-640-FISH), a multicoastal seafood house and oyster bar. Chef Jasinski’s fourth offering is Bistro Vendome (bistrovendome.com, 2267 Kearney Street, Denver, 303-825-3232), a secluded bistro offering an approachable French menu—think onion tart, seafood stew, steak frites, roasted beets in tarragon vinaigrette—in a charming garden setting in Park Hill, a neighborhood east of downtown and the massive City Park. For more great French food, Marden recommends Brasserie Brixton (www.bras seriebrixton.com, 3701 N Williams Street, Denver, 720-617-7911). The tightly curated menu includes bouillabaisse, coq au vin, steak frites, and a gruyere cheeseburger. Casual but Tasty Eats Of course, fine dining isn’t the only way to find great food. If your tastes—or budget—lean toward more casual dining, right next to Brassiere Brixton is The Yacht Club (yachtclubbar.com, 3701 N Williams Street, Denver, no phone), which Marden says has great cocktails and hot dogs. He also suggests RiNo’s Mister Oso (misterosotacos.com, 3163 Larimer Street, Denver, 720-677-6454), which has made several “best of” lists for its playful menu of tacos, cebiche, and interesting salads—for example, the Brussels sprout salad with avocado, dried cantaloupe, cotija, almonds, quinoa, and creamy tomatillo dressing—and snacks, including many vegetarian options. Chef and Colorado native Blake Edmunds has worked at Michelin-starred restaurants in California, New York, and France. Other eateries making numerous “best of” lists (including Travel + Leisure’s “The Very Best Breakfast Spots in the U.S.”) is one of Kiang’s picks: Onefold (www.onefolddenver.com, 1919 19th Street, Denver, 720-788-7550). She suggests trying the Union Station location of this breakfast and lunch restaurant so you also can browse the shops inside the historic landmark after you tuck into chilaquiles, congee, crepes, duck fried rice, or a barbacoa chicken bowl. Or head to Fox Run Café (www.foxruncafe.com, 3550 E Colfax Avenue, Denver, 303-537- 4594), which also has enticing breakfast and lunch options, such as lemon ricotta pancakes, whipped feta toast, and a tahini Caesar salad. Two more earlyin-the-day Kiang picks are Rosenberg’s Bagels (rosenbergsbagels.com, 725 E 26th Avenue, Denver, 720-440-9880) in Five Points for “fresh ingredients and the best bagels in the city”—grab a bagel and coffee or go for one of the delightful bagel sandwich options—and Denver Biscuit Company (www.denbisco.com, multiple locations, including 3237 E Colfax Avenue, Denver, 303-339-3977), which she describes as “Southern comfort meets the Mile High City.” There are biscuit sandwiches, biscuits and gravy, shrimp and grits in a biscuit bowl … or a housemade granola bowl if you prefer. If dinner is what you’re after, Kiang suggests Reckless Noodle House (www. recklessnoodlesdenver.com, 800 N Sherman Street, Denver, 720-734-2518) for its “quality ingredients, fun flavor combos, and, in their words, ‘chill vibes.’” Whether you go for simple or fancy, plant based or meat and seafood forward, Denver restaurants have something for everyone. So, if you’re headed to FNCE®, plan carefully, don’t fill up on Expo hall snacks, and be ready to savor the experience. Bon appétit! n Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Non-Diet Approach to Optimal Well-Being. Churros with chile chocolate ganache and salted caramel at Ultreia LEFT: PHOTO BY STEPHAN WERK TOP: PHOTO BY JONI SCHRANTZ AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 25

26 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023 Today, a growing body of research is showing support for various types of plant-based diets in diabetes prevention and management. In fact, major health organizations, such as the American Diabetes Association, Academy of Nutrition and Dietetics, CDC, and Harvard School of Public Health, are recommending a more plant-based approach to eating for diabetes in recent recommendations. “Healthful plant-based diets, rich in vegetables, fruits, whole grains, beans, lentils, nuts, and seeds, are powerful for lowering the risk of type 2 diabetes,” says Michelle McMacken, MD, FACP, DipABLM, executive director of Nutrition & Lifestyle Medicine at NYC Health + Hospitals, an associate professor of medicine at NYU Grossman School of Medicine, and an attending physician at Adult Primary Care Center and NYC Health + Hospitals/Bellevue. “Moreover, for people who already have type 2 diabetes, a healthful plant-based diet can not only improve blood sugar and potentially reduce the need for medications but it can lower blood pressure, cholesterol, inflammation, and the risk of serious complications such as heart disease and kidney disease.” Plant-Based Diets & Diabetes P lant-based diets are lush with colorful vegetables and fruits, earthy pulses, vibrant herbs and spices, and crunchy whole grains, nuts, and seeds. It’s an eating style widely recommended for a variety of health conditions, and the list now includes both prevention and treatment of diabetes. Benefits of plant-based diets in diabetes management include better glucose control, reduced need for medication, weight management, and reduced risks of complications typically associated with diabetes. Considering that type 2 diabetes is a rapidly increasing global epidemic, with approximately 422 million cases worldwide as of 2022, a plantbased diet may hold exciting promise.1 A Guide for Prevention and Management By Sharon Palmer, MSFS, RDN

This new understanding of diabetes management isn’t a surprise for health professionals. After all, research shows that lifestyle, such as diet and physical activity, has the power to significantly prevent or delay type 2 diabetes, potentially send type 2 diabetes into remission, manage type 1 and type 2 diabetes after diagnosis, and reduce the risks of other chronic diseases and complications that tend to accompany diabetes. The landmark Diabetes Prevention Program found that lifestyle changes alone reduced the risk of type 2 diabetes in older adults by 71%.2 The Science on Plant-Based Diabetes Prevention Science has supported the role of plantbased diets in lowering the risk of type 2 diabetes for years. The Adventist Health Study-2 found that when comparing diabetes incidence among five eating patterns (nonvegetarian, semivegetarian, pescatarian, vegetarian, and vegan), the more plant-based the diet, the better the protection against type 2; vegans had a 77% lower risk, and vegetarians a 54% decreased risk compared with nonvegetarians.3 Other studies looking at various types of eating patterns have confirmed similar results. In the UK EPIC-Oxford Study, vegetarians and vegans had a lower risk of type 2 diabetes compared with those who ate regular amounts of meat, or low amounts of meat, and fish.4 In a study in India that compared different diet patterns, vegetarian diets were linked with lower diabetes risk compared with nonvegetarian diets.5 And in Taiwan, a study comparing various diet patterns found a strong protective effect for vegetarian diet patterns compared with nonvegetarian diets.6 Furthermore, a recent scientific review, with evidence from nine nutrition studies that included more than 300,000 participants, showed that people who ate a mostly plant-based diet decreased their risk of diabetes by 23%.7 Health advantages have been found for a variety of plant-based eating patterns, including vegan, vegetarian, semivegetarian, and pescatarian; however, like the Adventist Health Study2, much of the diabetes research has shown that the more plant-based, the better, in terms of benefits. But it’s not just any plant-based diet that yields the greatest effect. Research shows that if people eat a higher quality plant-based diet—less refined and focusing on whole forms of plant foods—they further improved their odds of preventing type 2 diabetes, compared with a lower-quality, more refined plant-based diet.8 Another factor behind the benefits of plant-based eating is meat reduction, in particular, red and processed meats. Research increasingly has linked these foods, especially processed meats, with increased risks of heart disease, type 2 diabetes, and certain types of cancer. A Harvard study found that eating processed meat was linked with a 42% higher risk of heart disease and a 19% higher risk of type 2 diabetes.9 Another study from China found that higher intakes of red meat significantly increased the risk of type 2 diabetes, leading the researchers to conclude that optimal diets should include more healthful alternatives to red meat, such as fish, tofu, and legumes.10 Diabetes Complications One of the foremost goals of managing type 1 and type 2 diabetes is to help prevent devastating complications that affect health, productivity, and quality of life. An estimated 63% of people with diabetes have hypertension, 56% have dyslipidemia, 18% are obese, and more than one-half die of coronary vascular disease (especially heart disease and stroke). In addition, they suffer higher risks of Alzheimer’s and certain cancers, and have the potential for damage to organs, such as kidneys, eyes, and nerves, making diabetes a major cause of blindness and lower limb amputation.11 The American Diabetes Association encourages people to practice self-dietary management through nutrition as a key to managing diabetes and preventing complications, making it a perfect opportunity for dietitians to help guide patients to healthful eating patterns. One of the benefits of plant-based diets is that they can help reduce the risks of many of these predisposed conditions, such as obesity, hypertension, dsylipidemia, coronary heart disease, and certain cancers.12 Connections Between Diet and Diabetes What are the underlying benefits of plant-based diets that aid in diabetes prevention and reduce the risk of complications? Three main threads connect diet with the onset of type 2 diabetes and other chronic conditions. • Chronic inflammation. This condition is at the root of the development of type 2 diabetes, as well as other chronic diseases that correlate with type 2 diabetes. According to the CDC, chronic inflammation has been observed as an underlying condition in type 2 diabetes, in addition to obesity, mortality, hypertension, high cholesterol and triglyceride levels, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, many types of cancer, low quality of life, mental illness, and body pain. Many of these conditions parallel the course of diabetes, and diet plays a powerful role in either promoting or reducing chronic inflammation in the body. Plant-based diets—rich in antioxidant and anti-inflammatory compounds—have a history of reducing levels of chronic inflammation. • Weight. Excess body weight has long been known to increase the risk of type 2 diabetes. Women with a BMI of 30 have a 28 times higher risk of diabetes; and women with a BMI of 35 have a 93 times greater risk compared with normal BMI levels.13 Extra body fat promotes higher levels of hormones and inflammation, 28 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

further feeding into insulin resistance and a chronic cycle in which overweight feeds into inflammation, creating damage to tissues and body organs that leads to diseases such as diabetes and heart disease. Inflammation and overweight also are linked to metabolic syndrome. Plantbased diets, which are rich in fiber and low in fat and energy, also have an established history of better weight management. • The gut. Another avenue for diabetes protection is through the gut microbiome, as increasing knowledge shows that the gut interacts with diabetes in many ways regarding energy balance and immune function. People with overweight or obesity have a different profile of gut microbes than do lean individuals, and fecal transplants from lean people to insulin-resistant individuals have resulted in metabolic improvements. The gut microbiome also impacts insulin resistance and inflammation.14 The good news is that fiber-rich, plant-based diets have been shown to be beneficial to the gut microbiome profile. Diabetes Management With Plant-Based Eating The potential for using plant-based diets in diabetes management is promising. Emerging evidence that shows plantbased diets may improve diabetes management, reduce complications, and decrease the need for medications is exciting. Research conducted by Neal Barnard, MD, FACC, found that vegan diets improved beta cell function, insulin resistance, blood glucose, and cholesterol levels and that those with type 2 diabetes were able to get off oral medications and insulin after 25 days on a program that included plant-based eating and physical activity.15 “The exciting news for people with prediabetes or type 2 diabetes is that they may be able to turn back the clock on their diabetes diagnosis if they follow a plantbased eating plan,” says Toby Smithson, MS, RDN, CDCES, diabetes lifestyle expert for DiabetesEveryDay.com and author of Diabetes Meal Planning and Nutrition for Dummies. “There are observational studies showing that those who follow a plantbased diet have a lower risk of prediabetes and type 2. And for those who are diagnosed with prediabetes or type 2 diabetes, there’s potential for remission of diabetes.” How do plants help manage diabetes? It’s clear that plant nutrients and compounds, such as fiber, vitamins, minerals, healthful fats, phytochemicals, and lowglycemic carbohydrates can work both individually and synergistically to provide health benefits for those with diabetes. These plant-rich diets promote healthier weight and waist circumference, better glucose control, reduced levels of inflammation, greater insulin sensitivity, lower levels of blood pressure and cholesterol, and decreased risks of disease development and progression. In particular, plant foods’ rich cache of fiber, phytochemicals, antioxidants, and magnesium promotes insulin sensitivity.16 In addition, plant-based diets low in animal foods, such as red and processed meat, are naturally lower in saturated fat, dietary cholesterol, sodium, and compounds associated with the cooking, curing, and processing of meats, such as N-nitroso compounds, heterocyclic amines, polycyclic aromatic hydrocarbons, glycation end products, trimethylamine N-oxide, and heme iron. Another important factor is fiber, which feeds the gut microbiome and has many positive effects on the immune system, weight, inflammation, blood glucose control, and heart health. Studies have shown that low-fiber diets are linked with the development of type 2 diabetes, and a high-fiber diet, particularly with soluble fiber, improves glucose control, decreases hyperinsulinemia, and lowers LDL cholesterol levels in people with type 2 diabetes.17 The CDC now states that fiber is important in helping manage diabetes because of its powerful blood glucose control benefits. Carbohydrate foods high in fiber produce slower rises in glucose levels, as these foods take longer to break down during digestion. In addition, the CDC recognizes fiber’s role in heart health, gut health, and weight management—all important in managing diabetes. Most Americans fall short on fiber intake, getting only about 15 g per day. The official recommendation for adults is 20 to 30 g per day; however, there are benefits in aiming for even more, in the range of 40 g per day, for diabetes management. Getting more fiber-rich foods in the diet, such as pulses, whole grains, fruits, vegetables, nuts, and seeds is an important strategy. Assembling the Plate Given this new focus on plant-based eating for diabetes prevention and management, how can dietitians help clients and patients find success? Diabetes experts Jill Weisenberger, MS, RDN, CDCES, CHWC, FAND, author of Prediabetes: A Complete Guide, Second Edition, and Smithson offer the following guidance. WWW.TODAYSDIETITIAN.COM 29

• Match strategies with patients. Are there certain patients that do better on plantbased diets? “As a registered dietitian and certified diabetes educator, I encourage plant-based eating to all my patients who have been diagnosed with diabetes, whether it’s prediabetes, type 1, or type 2 diabetes,” Smithson says. “Some patients have already begun including more plants, such as fruits, vegetables, and whole grains, into their eating plan, while others are looking for guidance on how to incorporate more plant protein sources into their eating plan.” Weisenberger agrees: “I recommend plant-focused—not vegan or vegetarian— to all the people I work with because of the important nutrients and phytonutrients in plant foods that help with inflammation, insulin sensitivity, cancer prevention, and more.” • Managing carbohydrate levels. Creating a more balanced plate with plantbased food sources that have higher carbohydrate levels is key. “When following a plant-based eating plan to manage diabetes, it’s all a matter of balancing your food selections,” says Smithson, who manages her own type 1 diabetes with a plant-based diet. “Since some of the plant-based choices are higher in carbohydrate content, adding lower-carb side dishes will help balance the amount of carbs per meal. For instance, if you’re eating a serving of black bean chili at lunch, balance your plate with side dishes of lower-carb vegetables like steamed green beans, a leafy green salad, roasted broccoli, or sliced tomatoes.” Weisenberger says, “Many [people] are hesitant because they think they need to limit their carbohydrate intake too much [in order] to replace any of their animalbased options with plant-based options. I can ease them in with tofu and edamame beans because they’re lower in carbohydrate than more plant-based proteins. And I can often ease people into pulses by suggesting they add a spoonful to a green salad or mix them into chili and tacos.” According to Smithson, “it will be trial and error” for patients taking insulin to determine “the correct dosing of insulin to carb ratio until they see a blood glucose pattern.” She says, “Personally, with managing my own diabetes, I monitor my blood glucose patterns and add two servings of vegetables with lunch and dinner to help with the carbohydrate distribution balance and help me feel satiated,” Smithson says. • Offer diet tips and strategies to help clients manage their disease through plant-based eating. “First, start off with the plantbased meals you already eat and like,” Weisenberger says. “Add them into rotation more often. Try one new recipe every week or every other week until you have a large collection of recipes you like. If they want to boost their protein without raising their carb counts so much, I recommend more tofu and edamame beans, and I recommend combining animal and plant proteins. For example, I often eat beans and lentils with a dollop of Greek yogurt.” Smithson says, “Plant food choices with fiber, such as nuts, seeds, beans, oatmeal, and other whole grains, can help slow down the absorption of carbohydrate, offering the benefit of a slower rise in blood sugar levels. These foods can help keep blood sugar levels steady and improve insulin sensitivity,” adding that some fruits and vegetables, such as leafy greens, root vegetables, blueberries, and grapes, have been shown to lower the risk of diabetes. Smithson says dietitians and clients currently use total grams of carbohydrate as their guide and don’t subtract fiber from the total grams of carbohydrate. “As dietitians and certified diabetes care and education specialists, we encourage our patients to consume a diet high in fiber. On packaged goods, the term ‘net carbs’ is often used, but the American Diabetes Association cautions that subtracting fiber or sugar alcohols is not reliable. Subtracting fiber from the total carbohydrate content should not be used when calculating grams of carbs consumed. Remember, one person may not digest food the same as the next person. We need to rely on blood glucose patterns when tweaking the insulin-to-carb ratio or consuming an amount of total carbs at a meal.” If patients measure their blood sugar levels at home, Weisenberger also recommends they do it more often before meals and two hours after meals, so they can see the effect of what they just ate. She adds, “Typically, people make more than one change at a time. They may improve their overall diet, add some exercise, and become more regular with meals or medications, so the changes add up and they can get a lot of positive feedback.” • Discuss extra bonuses. The advantages of plant-based eating for patients with diabetes can expand in different directions. “Plant-based eating can cause a positive domino effect for people with diabetes,” Smithson says. “Consuming meat and meat products increases sleep disruptions, including sleep apnea. Improving sleep is very important for all people, but also has a key role in diabetes management. When a person with diabetes has nights of poor sleep, they often will see higher fasting blood glucose levels due to an increase in cortisol and increase in stress. If a plant-based plan is consumed as part of a balanced meal plan, it will provide a variety of vitamins, minerals, antioxidants, and phytochemicals, which in turn will reduce oxidative stress and improve immunity.” n Sharon Palmer, MSFS, RDN, is The PlantPowered Dietitian, author of the new book The Plant-Powered Plan to Beat Diabetes, nutrition editor of Today’s Dietitian, and cofounder of the nonprofit organization Food + Planet. For references, view this article on our website at www.TodaysDietitian.com. 30 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

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Parkinson’s Diet’s Rolein Disease BY JAMIE SANTA CRUZ Scientists don’t yet know what causes the disease, and while there’s no known cure, diet is emerging as a modifiable risk factor that can slow disease progression and improve symptoms for people who have it. What Is PD? The hallmark of PD is the accumulation of abnormal alpha-synuclein neural proteins in the brain that damage dopamine-producing cells. Dopamine is a neurotransmitter that’s essential in movement control, and the loss of dopamine causes the distinctive motor symptoms characteristic of PD. Although PD symptoms can vary greatly from one person to the next, common motor symptoms include slowness of movement, stiffness, decreased flexibility, tremors, and trouble with balance and coordination. Patients with PD also frequently experience nonmotor symptoms, such as mood changes, cognitive impairments, sleep disturbances, constipation, and difficulties with speech and swallowing. Role of Diet There are several avenues through which diet may affect the course of PD, including the following: • Antioxidant and inflammatory effects: PD is associated with oxidative stress and inflammation, which contribute to the degeneration of dopamineproducing cells. It’s thought that a diet high in antioxidants and antiinflammatory foods may help protect against this damage to neural cells, slowing disease progression. • Drug interactions: Levodopa is the main medication used to manage PD, but diet can affect its absorption. In particular, protein-rich foods can be problematic because large neutral amino acids compete with levodopa for the same transporters to cross the gut and enter the brain. Emily Knight, MS, RD, a PhD student in the department of nutritional sciences at Auburn University in Auburn, Alabama, says, “Imagine you have a large group that’s all trying to get into a house but there’s only one door.” • Alteration of the gut microbiome: As noted above, PD is characterized by the accumulation of abnormal alphasynuclein neural proteins in the brain. Some evidence suggests these proteins may originate in the gut (as a result of gut dysbiosis) and then migrate to the brain via the vagus nerve.2 Thus, resolving dysbiosis in the gut could, in theory, impact the course of PD. In addition, certain gut microbiota are capable of producing or metabolizing dopamine, so alterations to the gut microbiome also could impact dopamine levels in the brain, influencing motor symptoms of PD via this avenue.3 According to Tracy Lister, DCN, MHS, RD, a functional nutritionist in private practice in Parksville, British Columbia, Canada, research into the gut-brain connection and how diet can impact the brain via the microbiome is currently one of the most promising areas of research on Parkinson’s disease (PD) is a progressive neurodegenerative disorder that causes unintended or uncontrollable movements. It’s the second-most common neurodegenerative disease after Alzheimer’s. Nearly 1 million people in the United States currently live with the disease, but that number is expected to grow to 1.2 million by 2030.1 What’s more, large numbers of older adults experience Parkinsonian signs (ie, motor symptoms similar to PD), although they haven’t been diagnosed with PD. 32 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

Evidence suggests key nutrients and dietary patterns may help prevent or lessen signs and symptoms.

PD. “We’re always thinking about the brain, levodopa, producing dopamine, but we’re not thinking about the gut, and we should be, because it produces dopamine. But if there’s intestinal permeability or dysbiosis, that mechanism is altered.” There’s now substantial evidence that diet in midlife significantly affects the risk of developing PD. Epidemiologic research shows that a diet high in dairy, meat, refined pastries, and fried food is linked to increased risk of developing the disease, whereas a diet high in fresh fruits and vegetables, whole grains, legumes, nuts, and seeds is associated with lower risk.4 So far, there’s less research available about how diet affects the progression of PD once the disease process is underway. However, early evidence suggests that dietary interventions indeed can have an impact. The research so far seems to suggest that an overall dietary pattern may have a more significant effect on PD progression than individual foods or nutrients. Here’s what dietitians need to know about the impact of individual nutrients and overall dietary patterns. Impact of Foods and Nutrients Caffeine A 2020 meta-analysis found that caffeine intake is linked to slower disease progression among individuals with PD.5 Another review article published the same year came to a similar conclusion, arguing that caffeine appears to protect against the degeneration of dopamine cells and that it has benefits for motor and cognitive function in PD.6 However, the evidence isn’t uniform. A large multicenter clinical trial of a caffeine intervention in patients with PD found that caffeine intake didn’t produce any clinically significant improvements in motor function.7 Although there appears to be a clear correlation between caffeine intake and PD progression, some researchers have suggested that the relationship may not be causal. It may be that people who are predisposed to PD are less likely to consume caffeine, rather than caffeine having a protective effect.8 It’s also possible that the impact of caffeine on PD is affected by genes.9 The theory, according to Lister, is that some people have a genetic mutation that impacts the metabolism of caffeine, and for them, caffeine is aversive to their health. For those who can metabolize caffeine, on the other hand, the antioxidants have health benefits. Beans Currently, the main treatment for PD is levodopa, which is the precursor to dopamine.10 Several varieties of beans contain levodopa, suggesting that consumption of beans could help improve PD symptoms. Two varieties of beans that have received attention for their potential benefits in PD are fava beans (vicia faba), which contain 0.5% levodopa, and velvet beans (mucuna pruriens), which contain the highest levodopa concentration of any bean—up to 6% levodopa when the beans are dried and roasted.8 Unfortunately, with respect to fava beans, the clinical evidence supporting a benefit for PD symptoms is limited to anecdotal reports; no rigorous studies have examined their utility for treating PD.8 On the other hand, the evidence is more promising with respect to velvet beans. In fact, a velvet bean extract preparation currently is approved for the treatment of PD in India.8 One consideration regarding the value of naturally occurring levodopa in beans is that levodopa can’t be given as a standalone medication. “In pharmaceutical preparations, levodopa has to be combined always with an enzyme-inhibitor to prevent the breakdown of levodopa in the blood,” says Michel Rijntjes, MD, a professor of neurology at the University of Freiburg in Germany. According to Rijntjes, some reports suggest that certain components in velvet beans may work similarly to the enzyme inhibitors in pharmaceutical levodopa, but additional evidence is needed. “This would be very interesting, because it may better explain the effect of [velvet beans] and also lead to new pharmaceutical products,” Rijntjes says. Coenzyme Q10, Vitamin D, and Other Antioxidants Coenzyme Q10 is a powerful antioxidant, and supplementation with this nutrient initially was thought to hold great promise for staving off damage to dopamine-producing cells in PD. In fact, animal studies and early human trials supported its benefits for PD.11 Unfortunately, larger, more recent studies tell a different story.12 A large multicenter, randomized, double-blinded, placebo-controlled clinical trial found that supplementation with coenzyme Q10 didn’t affect PD progression.13 Similarly, a meta-analysis of randomized controlled trials found no evidence that coenzyme Q10 impacts motor symptoms of PD.14 Another antioxidant that’s received attention in PD is vitamin D. Several studies have shown that low serum levels of this vitamin are linked with PD progression. However, the nature of the link is unclear. It’s possible that low vitamin D spurs PD progression, but it’s also possible that as PD progresses, individuals with the disease spend more time inside and get less exposure to sunshine, so their vitamin D levels fall.15 Two small clinical trials have examined vitamin D supplementation to determine whether it can slow disease progression, but the results of these trials were conflicting. Thus, it’s not yet clear whether vitamin D supplementation impacts PD progression—and if it does, at what dose.15 One point of note is that dietary intake of antioxidants may have different effects than supplementation. A 2022 longitudinal study of 682 participants found that intake of dietary sources of vitamin E and vitamin C are linked to slower progression of Parkinsonian signs.16 However, lead study author Puja Agarwal, PhD, an assistant professor of nutrition and nutritional epidemiology at the Rush Alzheimer’s Disease Center at Rush University in Chicago, says, “What we found was that the association of vitamin E and vitamin C with slower progression of Parkinsonian signs was significant only when these nutrients were coming from a dietary source, not from supplements.” Probiotics Multiple studies have observed that the gut microbiota of healthy adults differs from the gut microbiota of people with PD.17,18 There’s also increasing awareness that the gut microbiome appears to play a significant role in the pathology of PD. Therefore, there’s growing interest in the potential of probiotics to influence symptoms of the disease as well as the disease course. Multiple human trials have found that probiotic supplementation can help relieve constipation in PD (constipation is a very common symptom of the disease and underscores the involvement of the gut in the disease pathology).19 Thus far, there’s limited evidence about the effect of probiotics on other aspects of the disease, such as motor symptoms or cognitive function. However, several studies in animal models of PD suggest that probiotics stave off the loss of dopamine-producing 34 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

neurons and also reduce motor impairments.20 In addition, one small randomized, double-blinded, placebo-controlled human trial by Iranian researchers found that a multistrain probiotic administered over the course of 12 weeks resulted in improved motor function in patients with PD.21 A 2023 meta-analysis found that probiotics can significantly improve motor symptoms as well as gastrointestinal, anxiety, and depressive symptoms in people with PD. That said, the researchers note that the quality of the evidence was low or very low and that further research is needed in larger trials.22 Dietary Patterns and PD To date, much of the research on individual nutrients and their potential as treatments for PD has proven inconclusive. Some researchers have suggested that it’s more promising to examine the impact of holistic diets rather than individual nutrients. Here’s what research shows thus far: Protein-Restricted Diet As noted previously, protein consumption can impact absorption of levodopa, the primary treatment for PD. For this reason, individuals with PD are sometimes encouraged to follow a protein-restricted diet. In an observational study of 600 people with PD and 600 controls, Italian researchers found that people with PD who had greater adherence to a proteinrestricted diet received lower levodopa doses and had fewer fluctuations in motor symptoms than those with lower adherence to a protein-restricted diet. The same study also found that increased intake of protein (10 g per day over the RDA recommendation) was directly linked to increased levodopa usage.23 However, there’s a caveat: Any diet that restricts intake of certain foods can promote weight loss, which is already a significant concern in PD. Furthermore, only 6% of patients with PD have protein interactions with levodopa, meaning that protein consumption can hinder levodopa absorption.24 According to Knight, this means that protein restriction shouldn’t be recommended to the majority of people with PD. “If they aren’t experiencing protein interactions with levodopa, you would be putting them at risk of malnutrition,” she says. Mediterranean Diet A Mediterranean dietary pattern has been associated with reduced risk of various diseases, including neurodegenerative diseases like Alzheimer’s.25 Although the specific definition of the diet varies from study to study, the Mediterranean diet generally means a diet rich in fruits, vegetables, legumes, cereals, nuts, fish, and monounsaturated fatty acids. The diet incorporates moderate alcohol intake but low intake of dairy products and red meats.26 A range of large observational studies have looked at the impact of the Mediterranean diet on PD risk, and most—though not all—have found its link with reduced risk and/or later age of onset.27 By contrast, only a few studies have examined the impact of the Mediterranean diet on PD progression, and those appear promising. A 2017 cross-sectional study of 1,053 people with self-reported PD looked at the relationship between dietary pattern and disease severity. The study found that greater consumption of coconut oil, fish, fresh fruit, fresh vegetables, nuts, olive oil, spices, and wine were all linked to reduced PD severity. Meanwhile, consumption of beef, canned fruit, canned vegetables, cheese, yogurt, ice cream, fried food, and diet soda were all associated with increased severity. The authors note that the foods linked to lower severity largely constitute the Mediterranean diet and suggest that this diet might slow PD progression.28 Two large observational studies have found that the Mediterranean diet was associated with a slower rate of progression of Parkinsonian signs in older adults.4,29 In addition, two small randomized clinical trials of patients with PD in Iran also found a benefit of following the Mediterranean diet.30,31 The first study found that participants following the Mediterranean diet had significantly better cognitive function at the end of the intervention than those in the control group. The other study found that participants following the Mediterranean diet had lower disease severity. More research is needed to confirm these benefits, but the evidence to date is encouraging. The MIND Diet The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet is a combination of the Mediterranean and DASH diets into a single diet that’s specifically targeted to promote brain health. Like both of the diets from which it draws, the MIND diet is a plant-based eating pattern, but its uniqueness is that it places a special emphasis on consumption of green leafy vegetables and berries.32 “Both of these food groups are very rich in different antioxidant nutrients, including phytonutrients like flavonoids, which help lower oxidative stress and inflammation,” Agarwal says. To date, just two studies have examined the impact of the MIND diet on progression of Parkinsonian signs, but both have been positive. In 2018, Agarwal’s research team looked at a sample of more than 700 older adults and found that adherence to the MIND diet was associated with a reduced risk of developing Parkinsonian signs as well as a slower rate of progression of those signs.30 Separately, a 2022 observational study of 1,205 adults also found that the MIND diet was linked to a reduced likelihood of developing Parkinsonian signs and a slower rate of progression.29 (Note that in both studies, the researchers were investigating signs of Parkinson’s, not diagnosed Parkinson’s per se.) Significantly, both of these studies examining the impact of the MIND diet compared the MIND diet with the Mediterranean diet. The two diets were linked with slower progression of Parkinsonian signs, but in both studies, the benefit of the MIND diet was greater than the Mediterranean diet. There are limitations to studies of overall dietary patterns because it’s difficult to control for confounding factors; however, the existing research is promising. Takeaways for Dietitians The research on how diet impacts the progression of PD and the severity of symptoms is still early, which means dietitians should refrain from making recommendations to clients and patients. “The evidence supports that there’s a potential for a healthy dietary pattern to reduce PD severity,”27 Knight says. “But evidence isn’t strong enough to recommend a particular dietary pattern.” Lister agrees with the need for caution. For most dietary interventions, she says, the evidence is still a “mishmash” as to how they impact PD. Nevertheless, Lister’s main message to dietitians is a hopeful one because diet represents a promising strategy for managing a disease that’s currently very burdensome. “I really want dietitians to be aware that we can do something for this population of patients,” she says. n Jamie Santa Cruz is a writer based in Parker, Colorado. For references, view this article on our website at www.TodaysDietitian.com. AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 35

FRESH LOOK AT FAMILY 36 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

Few would argue against the idea that food brings people together and eating a meal together provides more than just nutrition. The multiple benefits of family meals have been well studied for more than two decades. Studies have shown that families who eat together enjoy better communication, relationships, and social outcomes.1 And breaking bread together as a family or group has been demonstrated to have benefits to overall physical and mental well-being through the lifecycle. Since loneliness is related to increased mortality, shared meals may even be linked to longevity.2 Some studies show that frequency of meals eaten together correlates with better diet quality and positive social outcomes. Studies that specifically examine the dinner meal have found positive associations between how often a family eats dinner. A 2020 systematic literature review with meta-analyses published in The Journal of Nutrition Education and Behavior confirms that eating meals together as a family has benefits for both children and adults.1 How People Come Together at the Table The term “family” can be defined in many ways. The benefits of a shared meal experience remain, whether they’re shared with friends, relatives, or community members. Sitting at a table together allows for conversations to be explored. The connectedness experienced during a meal not only MEALS Children and adults alike experience improved health and better relationships when they regularly break bread together. By Rosanne Rust, MS, RDN AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 37

helps families communicate with one another but also builds problem-solving skills. Children who eat with their families most days of the week have higher grades in school, less depression and anxiety, lower incidence of eating disorders, and less substance and alcohol abuse. And they eat more nutritious foods.3 In fact, the more meals eaten together, the more balanced the nutrition and overall diet. For instance, researchers have found a positive association between the frequency of family meals and fruit and vegetable intake. The dinner meal is consistently correlated to increased produce consumption. Studies also report less consumption of sugar-sweetened beverages as a positive trend for families eating together. Benefits for Children and Adults Like children, adults who participate in family meals experience better emotional and mental health, greater self-esteem, less depression, and better marital and family relationships.4-6 Participating in shared meals also may reduce the incidence of obesity.7,8 While the impact that family meals have on body weight in children and adults is inconclusive, it’s suggested that parents and children alike maintain a healthier body weight when more family meals are cooked at home.9 This may be due to the increased intake of fruits and vegetables and fewer calories in home cooked meals compared with restaurant meals. What’s more, shared meals benefit adults and families who don’t have children. Regardless of parental status, adults who eat with others also tend to eat more fruits and vegetables, and they eat less fast food compared with those who eat alone. Other findings, which include fathers eating less fast food and mothers engaging in fewer dieting and binge eating behaviors, were associated with family meal frequency and overall life satisfaction.10 One study asked 2,000 adults to rate how many meals they ate alone during the week and how often they’d eaten meals with different members of their extended network. Using a 10-point scale, they were asked to rate how satisfied and worthwhile they felt their life was, how happy they’d been the day before, and how engaged they felt with their local community.11 People who ate with others more often were more likely to feel happy and satisfied with their lives. And the same holds true for older adults. Longevity and Productivity Research suggests that shared meal experiences also may influence the health, well-being, and independence of older adults well after parenthood. Overall, adults who eat alone have lower diet quality than those who share meals with others.12 Eating meals with others also may promote longevity. Researchers who study the “Blue Zones” (regions of the world where people live to age 100) have found that the social aspect of one’s life, including eating together, has a positive impact on longevity. They’ve found that the world’s longest-lived people either were born into or tend to join social circles that support healthy behaviors. This includes shared meals. These groups often meet and enjoy camaraderie while preparing meals together and sharing them at the table.13 Shared meals also impact work productivity. Within home communities and workplaces, eating behavior and environment can have positive impacts beyond health. For instance, a study of firefighters found that shared meals resulted in more collaboration and productivity.14 Learning More About Shared Meals The FMI Foundation tracks the importance of family meals, designating September as Family Meals Month.15 Dietitians can learn more about the family meals movement and find other ways to educate and inspire patients to gather more often for meals, as well as provide conversation starters and recipes on their websites. RDs also can find inspiration and other ideas to share with clients and patients at the Family Dinner Project.16 What follows are recipe ideas for family meals from expert culinary dietitians that you can share with clients. n Rosanne Rust, MS, RDN, is owner of Rust Nutrition Services, where she provides communications services and strategic advice to her clients within the food and nutrition industry. She’s a freelance writer and content creator, author, blogger, and truth-seeker who focuses on helping people set realistic health goals. She’s published several consumer books, including Zero Waste Cooking for Dummies and DASH Diet for Dummies (2nd edition). Find her on social media @chewthefacts or at www.rustnutrition.com. For references, view this article on our website at www.TodaysDietitian.com. 38 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

Pizza Beans Serves 4 “Pizza beans, as we call them in our house, are a kidfriendly, family favorite that emphasizes plant protein. Made in minutes in one pot, these pizza-flavored beans are flavorful and pair perfectly with a nice crusty bread or grains of choice,” says Sarah Schlichter, MPH, RDN. Ingredients 1 T olive oil 1 onion, diced 2 cloves garlic, minced 2 cans cannellini beans, rinsed 2 cans diced tomatoes 1/2 tsp salt 1/2 tsp pepper 11/2 tsp oregano 2 tsp Italian seasoning Optional Garnish Fresh basil Shredded cheese (if not vegan) Directions 1. In a pan or skillet over medium-high heat, sauté onion in olive oil. Add garlic cloves. 2. Add in any other veggies desired. 3. To the skillet, add cannellini beans and diced tomatoes. Stir and lower heat to low to medium. 4. Add in spices and continue to stir periodically. Garnish with basil and cheese, if using. 5. Serve with garlic bread or a good crusty bread. Note: Optional ingredients and toppings include peppers, mushrooms, sundried tomatoes, red pepper flakes, cheese, or whatever you’d like to add to pizza. In step 4, top with shredded cheese and place under the broiler set to medium for 1 to 2 minutes. Nutrient Analysis per serving Calories: 205; Total fat: 4 g; Sat fat: 1 g; Cholesterol: 0 mg; Sodium: 980 mg; Total carbohydrate: 30 g; Protein: 7 g; Dietary fiber: 7 g SOURCE: RECIPE COURTESY OF SARAH SCHLICHTER, MPH, RDN, HTTPS:// WWW.BUCKETLISTTUMMY.COM/VEGAN-WHITE-BEAN-AND-TOMATO-SKILLET/ Ultimate Street Fish Tacos Serves 4 Home cooks can choose any white fish such as cod, mahi mahi, tilapia, and halibut, as they all have a firm texture that works well with tacos. For convenience and cost savings, use frozen fish and thaw it before cooking, or add five minutes to cooking time if cooking the fish frozen. “What I love about these Ultimate Street Fish Tacos is that they’re a one-dish dinner that can be customized to how each family member likes them. Not only are they swimming in taste, but they’re also a good source of immune- and energy-supporting nutrients,” says Patricia Bannan, MS, RDN, author of From Burnout to Balance. Ingredients 1 T olive oil 1 large shallot, minced 3 garlic cloves, finely minced 1 fresh jalapeño, sliced 11/2 cups baby cherry tomatoes, halved or quartered 3 T fresh lime juice 1/4 cup fresh cilantro, chopped 1 tsp sweet paprika 1/2 tsp ground cumin 1/2 tsp kosher salt 1/2 tsp ground black pepper 1 lb (or four 4-oz fillets) firm white fish, such as tilapia, cod, mahi mahi, or halibut (fresh or frozen and thawed) 12 4-inch corn tortilla “sliders” Garnish 1/2 medium avocado, sliced 1/4 cup fresh cilantro, chopped 6 lime wedges Directions 1. Heat a small skillet with the olive oil over medium heat. Add the shallot, garlic, and jalapeño and sauté until fragrant, or about 6 minutes. Stir in the cherry tomatoes and lime juice and cook until the tomatoes have wilted down slightly, and the mixture looks like a loose sauce. Remove from heat, add the fresh cilantro, and transfer to a small bowl for serving. 2. In a small bowl, combine the paprika, cumin, salt, and pepper. Season the fish with the paprika mixture. Heat a large skillet to medium-high heat and sauté the fish for 2 to 3 minutes on each side until cooked through. 3. To serve, warm 12 tortillas in a skillet or crisp lightly over an open flame, and transfer to plates. Layer a few pieces of the fish onto the tortillas and spoon over the cherry tomato sauce. Top with avocado slices and a few cilantro leaves. Serve the tacos with lime wedges and enjoy immediately. Nutrient Analysis per serving Calories: 170; Total fat: 6 g; Sat fat: 1 g; Cholesterol: 40 mg; Sodium: 250 mg; Total carbohydrate: 14 g; Fiber: 2 g; Protein: 17 g SOURCE: RECIPE COURTESY OF PATRICIA BANNAN, MS, RDN, AUTHOR OF FROM BURNOUT TO BALANCE RECIPES AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 39

Mediterranean Rice Bowls Serves 4 “Bowls are our favorites, because kids have the autonomy to choose their own toppings, and they help them navigate their own tastes without pressure,” says Wendy Jo Peterson, MS, RDN, author of the Instant Pot Cookbook for Dummies. “I often prep all the toppings ahead of time and put them on the table while chicken and rice are cooking. This way, when the smells start to make everyone hungry it gives them something to snack on while they wait.” Ingredients 11/2 cups basmati rice, rinsed well (until water runs clear) 13/4 cups water 11/2 lemons, zested, juiced, and divided 1 tsp salt 5 chicken thighs, skinless and boneless 1 tsp dried dill 2 garlic cloves, minced 2 T extra virgin olive oil 1 cup plain Greek yogurt 1 cup grated cucumber, squeezed to remove excess liquid 2 T fresh dill, chopped (or 2 tsp dried) Salt and pepper, to taste 1/4 cup fresh parsley, chopped (or 1 T dried) 1 cup grape tomatoes, halved 1 cup kalamata olives 1 small red onion, thinly sliced Salt and pepper, to taste Garden Turkey Meatballs & Spaghetti Serves 6 “Lean ground turkey, fresh vegetables, and whole grain pasta come together quickly for this nutritious weeknight dinner of Garden Turkey Meatballs & Spaghetti that your entire family will love,” says Liz Weiss, MS, RDN, owner of Liz’s Healthy Table. Ingredients 1 lb lean ground turkey 2 medium carrots (about 6 oz), peeled and grated (about 2/3 cup) 1 large egg, beaten 1/2 cup quick-cooking oats 1/2 cup grated Parmesan cheese 2 T ground flaxseed or wheat germ 1/2 cup chopped fresh basil or 1 T dried basil 1/2 tsp garlic powder 1/2 tsp kosher salt 1/8 tsp pepper 1 26-oz jar pasta sauce 12 oz whole wheat or whole wheat blend spaghetti Directions 1. Preheat oven to 400˚ F. Lightly oil or coat a large, rimmed baking sheet with nonstick cooking spray, and set aside. 2. Place the ground turkey, carrots, egg, oats, Parmesan cheese, flaxseed, basil, garlic powder, salt, and pepper in a large bowl and mix until just combined. 3. Shape the meat mixture into 24 11/2-inch balls. Place on the prepared baking sheet and cook until lightly browned, or about 10 minutes. 4. Meanwhile, place the pasta sauce in a large saucepan over medium heat. Cover and bring to a simmer. When the turkey meatballs come out of the oven, add them to the sauce, reduce the heat and simmer, covered, until the meatballs are fully cooked and have absorbed some of the sauce flavors, or about 20 minutes. 5. While the sauce and meatballs are simmering, cook the pasta according to package directions. Drain, transfer to a large bowl or platter, and serve with the sauce and meatballs on top. Nutrient Analysis per serving Calories: 276; Total fat: 12 g; Sat fat: 4 g; Cholesterol: 95 mg; Sodium: 863 mg; Total carbohydrate: 28 g; Protein: 23 g; Dietary fiber: 2.8 g SOURCE: RECIPE COURTESY OF LIZ WEISS, MS, RDN, OWNER OF LIZ’S HEALTHY TABLE Directions 1. Place rice, water, 1 tsp lemon zest, salt, chicken, dill, and garlic in the base of a multicooker. Secure lid and cook under high pressure for 5 minutes with a natural release of 10 minutes. Remove chicken and dice, and fluff rice with a fork. Stir together lemon juice and olive oil, and drizzle over the rice. 2. While rice is cooking, prepare the yogurt sauce. In a medium bowl, stir together Greek yogurt, remaining lemon zest, grated cucumber, and fresh dill. Season with salt and pepper, to taste. 3. Serve family style, place rice in one bowl, chopped chicken in one bowl, yogurt sauce in one bowl, and remaining toppings: parsley, tomatoes, olives, and red onions in their own bowls. Allow family members to choose their own toppings and create their own masterpiece dinner bowl. Note: If you don’t have an Instant Pot or a pressure cooker, the chicken and rice can be prepared on a stove top. Place the rice in the base of a stock pot, top with chicken, water, zest, salt, and garlic. Reserve dill for after. Bring to a boil, then cover with a lid and reduce heat to a low simmer and continue cooking for 25 minutes or until water is absorbed in rice and chicken is fully cooked. Stir in dill with lemon juice and olive oil. Nutrient Analysis per serving Calories: 981; Total fat: 34 g; Sat fat: 7 g; Cholesterol: 302 mg; Sodium: 1,285 mg; Total carbohydrate: 75 g; Dietary fiber: 6 g; Protein: 101 g SOURCE: RECIPE COURTESY OF WENDY JO PETERSON, MS, RDN 40 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

Peanut Butter Banana Protein Baked Oatmeal Serves 6 “Baked oatmeal is an easy way to prep a nutrient-packed family meal for busy mornings. There are endless varieties of toppings to choose from to create excitement as well as use up small portions of fruit, nuts, etc, to minimize food waste. Enjoy a wedge as is or add more protein and fiber with strawberry Greek yogurt and peanuts or some cottage cheese and blueberries,” says Lauren Harris-Pincus, MS, RDN, founder of NutritionStarringYOU. com and author of The Everything Easy Pre-Diabetes Cookbook: 200 Healthy Recipes to Help Reverse and Manage Pre-Diabetes. Ingredients 2 cups old-fashioned oats 1 tsp baking powder 1 tsp cinnamon 1/2 tsp salt 3 packets of preferred sweetener or 2 T brown sugar 1/2 cup powdered peanut butter 1 scoop (1/4 cup) vanilla plant-based protein powder 1 cup unsweetened plant-based milk or 1% milk 1/2 cup nonfat plain Greek yogurt 3 T liquid egg whites or 1 egg 1 ripe banana, mashed (4 oz) 1 tsp vanilla extract Topping 1 ripe banana, sliced in 24 slices (4 oz) Directions 1. Preheat oven to 350˚ F. 2. In a large bowl, combine the first seven dry ingredients. 3. In a separate bowl, combine the milk, yogurt, egg whites, mashed banana, and vanilla extract. 4. Add oat mixture to the wet ingredients and gently stir until fully combined. 5. Line a 9-inch brownie pan with parchment paper. Pour the mixture into the pan and spread it evenly. 6. Top with 24 banana slices (4 rows of 6 slices each). 7. Bake for 27 to 35 minutes or until golden brown and set. 8. Let cool then cut into 6 rectangles. Wrap and refrigerate the extras until ready to eat. Nutrient Analysis per serving Calories: 200; Total fat: 3.5 g; Sat fat: 0 g; Cholesterol: 0 mg; Sodium: 320 mg; Total carbohydrate: 30 g; Dietary fiber: 6 g; Protein: 13 g SOURCE: RECIPE AND PHOTO COURTESY OF LAUREN HARRIS-PINCUS, MS, RDN, FOUNDER OF NUTRITIONSTARRINGYOU.COM AND AUTHOR OF THE EVERYTHING EASY PRE-DIABETES COOKBOOK Pork Tenderloin Lettuce Wraps With Ginger Lime Dressing Serves 4 “Families that enjoy experimenting with new flavors will appreciate these pork tenderloin lettuce wraps. They’re easy to assemble and fun to eat. This recipe provides a build-your-ownadventure approach, so kids who might be cautious about trying new foods can decide for themselves what goes into their own wraps. They draw on ingredients from the Vietnamese and Thai pantry, and the gingery marinade does double duty, because it’s used to flavor the meat and dress the finished wraps. This dish is on the lighter side, so consider pairing these with steamed basmati rice tossed with a splash of toasted sesame oil, chopped scallions, and salt. Bonus: The rice can be tucked into the wraps, too,” says Katie Morford, MS, RD, a culinary dietitian and author of three cookbooks, including Prep: The Essential College Cookbook. Ingredients Marinade/Dressing 1/2 cup lime juice 1/2 cup seasoned rice vinegar 1 T nam pla or nuoc mam (fish sauce) 2 T honey 1 T avocado oil or canola oil 1/2 to 1 tsp Sriracha 1 large garlic clove, grated on a microplane or minced 2 T finely chopped fresh ginger Pork and Wrap Ingredients 1 lb pork tenderloin 1 T avocado oil or canola oil Leaves from 1 large head of butter lettuce or 1 head Romaine lettuce 11/2 cups mung bean sprouts 1 cup shredded carrots 1/2 English cucumber, cut into 1/4-inch-thick spears 1/4 cup roasted, salted peanuts 1/3 bunch fresh cilantro (chopped or in sprigs) Directions 1. In a small bowl, whisk all of the marinade/dressing ingredients until blended. Put the pork in a medium bowl and pour half the marinade over it. Marinate for 1 hour, turning the pork from time to time. Reserve the remaining marinade for serving. 2. Heat 1 T of oil in a large, heavy skillet (I use cast iron) over mediumhigh heat. Remove the pork from the marinade, allowing the juices to drip off, and lay in the skillet. Cook until the exterior is deeply browned on all sides and the center of the meat is pale pink and registers 145˚ F on an instant read thermometer, about 20 to 25 minutes. Transfer pork to a cutting board to rest for 10 minutes (the internal temperature will rise as it sits). 3. While the meat cooks, place the lettuce on a large serving platter followed by the bean sprouts, carrots, cucumbers, peanuts, and cilantro, leaving room for the pork. 4. Cut the meat in half lengthwise, then crosswise into thin slices. Transfer to the serving platter. Set the remaining dressing on the side. 5. To assemble, layer the pork on top of the vegetables. Spoon a little dressing over the top and serve. Note: Pork tenderloin, a particularly lean cut, cooks quickly and is tender. Chicken or flank steak will work equally well. Nutrient Analysis per serving Calories: 371; Total fat: 16 g; Sat fat: 3 g; Cholesterol: 83 mg; Sodium: 593 mg; Total carbohydrate: 22 g; Protein: 36 g; Dietary fiber: 2 g SOURCE: RECIPE COURTESY OF KATIE MORFORD, MS, RD, A CULINARY DIETITIAN AND AUTHOR OF THREE COOKBOOKS, INCLUDING PREP: THE ESSENTIAL COLLEGE COOKBOOK

Just moments away from monuments, shops, local eateries, and live music, the Hyatt Regency Savannah afforded the perfect venue to host and celebrate our 10th year of providing high-quality continuing education via workshops, panel discussions, and Q&As—all presented by leading RDs and other medical/health care experts in the country. The workshops explored cuttingedge research in dietetics and covered the latest nutrition trends, including food as medicine, digestive wellness, cultural foodways, social media, diabetes, cancer, recipe development, and more. “I really enjoyed all of the speakers,” said Teresa T. Graham, MPA, RD, LD, CLC, nutrition services director of the Georgia WIC program at the Georgia Department of Public Health in Albany, Georgia. “They were really informative. They knew what they were talking about, and the research was really good.” In addition to the workshops, TD offered valuable networking opportunities, fitness classes to help attendees unwind and recharge, fun special events, and an exhibit hall showcasing 48 sponsor companies that featured a variety of products and services and whose representatives discussed the latest research tailored to all things dietetics. This year, 650 nutrition professionals attended the symposium—many of whom included dietitians in private practice and clinical RDs specializing in diabetes management and education, pediatrics, retail, sports dietetics, media, meal planning, malnutrition, oncology, home health care, culinary arts, and public health. Launch Day The symposium jumped off with three extraordinary workshops hosted by leading-edge presenters: “Ethics for All in a Sometimes-Unethical World in 2023,” presented by Dianne Polly, JD, MS, RDN, LDN; “Zero to 100: Becoming a Powerhouse in Public Speaking,” presented by Wendy Bazilian, DrPH, MA, RD, ACSM-EP, and Jen Nguyen, RD, CDN, NASM-CPT; and “What Should the RDN Do for the 96 Million Americans With Prediabetes?” presented by Jill Weisenberger, MS, RDN, CDCES, CHWC, FAND. Each session Today’s Dietitian celebrates 10 years of providing symposia to nutrition professionals in the coastal city of Savannah—and what a special, memorable time for everyone! By Judith Riddle T oday’s Dietitian (TD) has reached a huge milestone! We kicked off our 10th annual Spring Symposium on May 14 to 17 at the Hyatt Regency Savannah in Savannah, Georgia, a coastal city well known for its renowned historic sites and gardens, river boat cruises, music festivals and performances, beaches and parks, and award-winning cuisine. 10th ANNUAL SPRING SYMPOSIUM SAVANNAH 2023 42 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

offered dietitians evidence-based information and practical strategies to apply to their daily work. After attending the “Ethics for All …” workshop, Mary Johnson, RD, a nutrition business owner in Eastman, Georgia, said, “This course made me think more about ethical situations in the workplace. It’s very easy to take small gifts from clients, and this was a good reminder to steer clear of that. It’s also important not to take money or bribes when dealing with clients or retailers.” Paula Livernois, RD, a clinical manager in Chesapeake, Virginia, said, “I will continue to live by our Academy of Nutrition and Dietetics Code of Ethics and report any unethical activity, even if it means losing my job. And if an ethics issue arises, I will handle it at the lowest level or with HR to resolve it before I take it further.” According to Desirae Suggs, MS, RD, a foodservice manager at Emory Healthcare in Atlanta, the public speaking workshop will help her “be more confident in pursuing speaking engagements. I will be less nervous while delivering presentations.” Kimberly Harmon, MS, RD, CDCES, BC-ADM, a certified diabetes educator at the University of Colorado Hospital, Endocrinology Clinic, in Denver, added that she plans to focus on three questions when developing presentations: “What is the topic?” “What value do you bring?” and “What will the audience gain?” Cathy Armacost, MS, RD, from Spokane, Washington, said she was “totally impressed with the [public speaking] presentation. It gave me a lot of new ideas on how to develop an engaging presentation.” Stephanie Jiaqi Yang, RD, CDCES, a clinical dietitian and diabetes care and education specialist at Sutter Health in the San Francisco Bay Area, who attended Weisenberger’s prediabetes workshop, said she “gained knowledge on how to use consumer language to better describe the ominous octet that summarizes the pathophysiology of prediabetes and its progression to diabetes,” adding that “I plan on improving my counseling skills by implementing this terminology when working with clients with prediabetes.” Cindy Cysewski, MS, RD, LDN, director of healthcare sales at Lyons Magnus, a food and beverage services company in Asheville, North Carolina, said she “enjoyed Jill’s presentation very much. She was so knowledgeable about prediabetes.” Kerry McArthur, MPH, RD, CDN, a certified intuitive eating counselor in Brooklyn, New York, said she “loved the language [Jill] used to explain the whys for addressing prediabetes. After attending Weisenberger’s presentation, Mandy Light, MS, RD, LDN, a dietitian at Novant Health Heart & Vascular Institute in Charlotte, North Carolina, plans to “focus on [establishing] small goals with patients that are achievable, such as the benefits of reaching normoglycemia.” Vandana Sheth, RDN, CDCES, FAND AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 43

Keynote and Dinner Presentation The three opening sessions prepared attendees and paved the way for the keynote and dinner presentation sponsored by General Mills. The session called “Empowerment or Shame? How Are Biases Shaping the Way RDNs Communicate About Nutrition?” was presented by Amy Cohn, RD, CDM, CFPP; JC Lippold, MAL, RYT; and Jessica Broome, PhD. The presenters discussed new survey research findings on food and fitness shaming through the eyes of consumers, RDs, and certified fitness professionals. The speakers explained the complexities of shaming and provided solutions for dietitians to help break the cycle. Jennifer Lyons, RDN, CDCES, owner of Jennifer Lyons Nutrition, a private practice specializing in diabetes care in Alexandria, Virginia, said the keynote presentation “was really good.” The speakers discussed “new information I initially wasn’t familiar with, and I learned things I can definitely apply to my practice.” Elizabeth Green, RD, from Jordan, New York, said, “This session was excellent and timely. I personally have experienced shaming due to obesity, so sessions last year and this year have helped me immensely.” According to Alexandra Toline, MS, RDN, LDN, NASM-CPT, founder and owner of The Dietitian Mom, a nutrition business in the Memphis, Tennessee, area, specializing in nutritional health before, during, and post pregnancy, “The [keynote] presentation was well presented, and it brought up a good conversation for RDs to ponder when working with clients. I appreciated their perspective and also enjoyed hearing the questions other participants asked at the end for discussion.” Courtney McCormick, RD, manager of clinical research and nutrition at Nutrisystem in Fort Washington, Pennsylvania, agreed: “This was a wonderful presentation to help RDNs rethink how we speak to our clients to ensure our messages aren’t causing shame. The use of consumer insights really helped bring the client perspective to the presentation.” Morning Workouts Following the first day of thoughtprovoking sessions and the keynote presentation, symposium attendees kick-started their mornings at 6:30 am with a cardio and yoga workout. Frisline Saintoiry, MA; Mary Medina; and Colleen Higgins from Carlson Labs led Carlson’s Vitamin D Dash Walk/Run. Attendees from all fitness levels enjoyed the scenic route around the city of Savannah. Everyone who participated received a tote bag containing a vitamin D test and a bottle of Carlson Super Daily D3. Dessie Daniell from The Hub Savannah led Hub Yoga Flow, sponsored by Lifeway Foods, a one-hour breath-based session geared toward strengthening the core and body. Participants received a complimentary yoga mat and a bottle of Lifeway Kefir. Workshop Faves Once attendees felt reenergized after their morning walk/run and yoga workout, they attended many other educational sessions of interest. Some of their favorite workshops included “TikTok Made Me Eat It: How RDNs Can Empower Consumers to Eat Better by Creating Short Videos on TikTok and Instagram,” presented by Rosanne Rust, MS, RDN, author, blogger, and owner of Rust Nutrition Services, and Liz Weiss, MS, RDN, founder of LizsHealthyTable.com and the podcast EAT, DRINK, LIVE LONGER. Rust and Weiss discussed the impact TikTok and Instagram reels have on food and nutrition education and showed RDs how to create and compose short videos, develop strategies to grow an engaged following, and begin posting frequently on these social media platforms. Many attendees were unfamiliar with TikTok but were expressing interest in sharing content on the popular app. “[I plan] to familiarize myself with the videos from dietitians on TikTok and begin creating short videos with clients in mind,” Lyons said. “As dietitians, we need to combat misinformation, which means we need to be present on social media platforms.” Suggs agreed: “I can use TikTok to promote nutrition/preventative care outside of the hospital. I have the tools to create engaging and relevant content and reach potential clients.” Another favorite session was “Starting a Side Hustle: Opportunities and First Steps,” presented by Katie Dodd, MS, RDN, CSG, LD, FAND, owner of Katie Dodd Nutrition, LLC, founder of The Geriatric Dietitian blog and High Calorie Recipes food blog, and the host of the Dietitian Side Hustle podcast. Mary Branom, RD, a clinical dietitian at Banner Health in Greeley, Colorado, said, “[This was a] wonderful thoughtprovoking presentation that will help me step out of my comfort zone and look into options for a side hustle for myself.” Mary Grainger, RD, a consulting dietitian in Columbia, South Carolina, said Dodd “was so thorough! I will use her techniques to get more gigs to help impact the health of patients.” The session “Dietitians to the Rescue: Translating Complex High-Quality Research Into Simple Messages to Combat Nutrition Quackery,” presented by Taylor C. Wallace, PhD, CFS, FACN, principal and CEO of the Think Healthy Group and a professor in the department of nutrition and food studies at George Mason University, also was highly popular among RDs. With all of the disinformation on the internet and social media about diet and nutrition, Wallace reviewed various study design elements and their utility, discussed how to interpret the strengths and limitations of research, and develop Jack Grahm, COO, and Mara Honicker, CEO, Today’s Dietitian 44 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

1. Attendee at the Carlson’s Vitamin D Dash Walk/Run event; 2. Session attendees; 3. Liz Weiss, MS, RDN; 4. Rosanne Rust, MS, RDN; 5. Session Q&A; 6. Session attendees; 7. Katie Dodd, MS, RDN, CSG, LD, FAND 1 3 2 4 6 5 7

1. David Katz, MD, MPH, FACPM, FACP, FACLM; 2. Lunch buffet sponsored by American Pistachio Growers; 3. Jessica Broome, PhD, keynote and dinner presentation; 4. Lunch buffet sponsored by the National Dairy Council; 5. Session attendees; 6. Neil Skolnik, MD, Splenda 1 3 5 2 4 6

strategies to squash nutrition quackery through truthful, straightforward messages for patients and the mainstream media. “I loved this speaker and want to know more about [how to] translate research into simple messages,” said Kelsi Evans, RD, a clinical dietitian from Bloomington, Illinois. Sarah Hester, MS, RD, community wellness manager at the Dairy Alliance in Youngsville, North Carolina, said, “This presentation was my whole graduatelevel research methods class summed up within an hour. It was a great refresher!” Emily Massi, RDN, LDN, healthy living merchandising manager at Giant Food in Rockville, Maryland, said, “Proper understanding of evidencebased research is critical to the success of our field. In a world where nutrition information can be obtained at any time, it’s imperative that dietetics professionals remain cognizant of how to identify good research and guide consumers to do the same. This session provided the tools needed to do so. Moving forward, I will use the skills identified in this session to parse good research from questionable [research] and educate consumers.” Participants also applauded the session “The 5-Flavored Case for Food as Medicine,” presented by the renowned David Katz, MD, MPH, FACPM, FACP, FACLM, founder and former director of Yale University’s Yale-Griffin Prevention Research Center, past president of the American College of Lifestyle Medicine, president and founder of the nonprofit True Health Initiative, and founder and CEO of Diet ID, Inc. In this session, Katz, an internal medicine and lifestyle medicine specialist, explained food as medicine concepts and goals, its applicability in nutrition science and potential for impacting health outcomes, how it’s measured, and the dietitians’ role. Many RDs raved about Katz’s presentation, wanting more information and more time for Q&As. Attendees said this was an “excellent presentation,” “a thorough presentation,” and that Katz “was great” and “amazing.” Ronni Julien, MS, RDN, LDN, president of Julien Nutrition Institute, a private consulting practice in Aventura, Florida, said, “Dr. Katz is one of the finest speakers. I have listened to his live lectures for about 30 years, and I’m never disappointed. He’s an extraordinary warrior for nutrition and lifestyle!” Lise Gloede, MS, RD, CDCES, founder of Nutrition Coaching, LLC, in Falls Church, Virginia, agreed, saying Katz “was an excellent speaker and esteemed evidenced-based practitioner,” urging TD to “invite other similar speakers to future symposiums.” Learning While Munching As in previous years, attendees enjoyed special breakfast and lunch presentations sponsored by several food companies. TD hosted the following five breakfast presentations: • “Affordable Nutrition: How Food Prices Impact Food Insecurity and How to Leverage Grocery Stores to Shop Healthy on a Budget,” sponsored by General Mills’ Bell Institute of Health and Nutrition and presented by Craig Gundersen, PhD, Snee Family Endowed Chair, Baylor Collaborative on Hunger and Poverty Professor in the department of economics, and Lorena Kaplen, RDN, LDN, H-E-B Wellness Nutrition Strategy; • “A Closer Look at Low- and No-Calorie Sweeteners: Safety, Efficacy, and Implementation,” sponsored by Splenda and presented by Holly Moran, MS, RD, LD, CDCES, manager of nutrition and science communications for the Heartland Food Products Group, and Neil Skolnik, MD, professor of family and community medicine at Temple University School of Medicine in Philadelphia, and associate director of the family medicine residency program at Abington Memorial Hospital, in Abington, Pennsylvania; • “Sustainable Behavior Changes for Cardiovascular Health: Navigating Client Recommendations in a Socially Influenced Society,” sponsored by Fresh Avocados–Love One Today and presented by Wendy Bazilian, DrPH, MA, RDN, ACSM-EP, owner of a private practice and consulting business, and a writer, educator, food enthusiast, and award-winning journalist; • “Building Your Ag IQ: What Farmers Wish You Knew About Healthy, Sustainable Diets,” sponsored by the National Cattleman’s Beef Association and presented by Marianne Smith Edge, MS, RD, LD, FAND, an adjunct assistant professor in the department of dietetics and human nutrition at the University of Kentucky; Lauren Twigge, MCN, RD, LD, founder of Lauren Twigge Nutrition, LLC, a private practice providing healthful eating education, weight management, mindful eating, and other services; and Jason Sawyer, PhD, chief science officer for East Foundation in San Antonio, Texas; and • “Today’s Food Conversation: What Messages Should We Be Communicating About Strawberries?” sponsored by California Strawberries and presented by Amy Myrdal Miller, MS, RDN, FAND, founder and president of Farmer’s Daughter Consulting, an agriculture, food, and culinary communications firm, in the Sacramento, California area. The four lunch presentations included the following: • “Prebiotics and Gut Microbiota: Establishing a Healthy Trajectory From Early Life to Adulthood,” sponsored by Beneo Institute and presented by Raylene Reimer, PhD, RD, a professor in the faculty of kinesiology and the Cumming School of Medicine at the University of Calgary, and a full scientist in the Alberta Children’s Hospital Research Institute; • “Not All Plant-Based Diets Are Created Equal: Practical Ways to Help Clients and Patients Replace Processed Plant Foods With Whole Plant Foods,” sponsored by American Pistachio Growers and presented by Cynthia Sass, MPH, MA, RD, CSSD, owner of a Los Angelesbased and virtual private practice, specializing in performance nutrition and plant-based diets; • “Nourishing the First 1,000 Days: Dairy and Baby’s Brain Development,” sponsored by the National Dairy Council and presented by Elizabeth Zmuda, DO, FAAP, FACOP, a pediatrician and director of medical education for Doctor’s Hospital at OhioHealth; Sun Young Lee, MD, MSc, an assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine; and Marina Chaparro, MPH, RD, CDE, founder of Nutrichicos, a bilingual nutrition practice specializing in children and family nutrition in Miami; and • “Good to the Bone: The Intersection of Inflammation, Bone Health, and a Daily Handful of California Prunes,” sponsored by California Prunes and presented by Connie Rogers, PhD, MPH, a professor and head of the department of nutritional sciences at the University of Georgia, and Lauren AUGUST/SEPTEMBER 2023 • WWW.TODAYSDIETITIAN.COM 47

Manaker, MS, RDN, LD, CLEC, CPT, owner of nutritionnowcounseling.com, a nutrition communications business in Charleston, South Carolina. Networking and Special Events Following the breakfast and lunch presentations, TD kicked off four special events that enabled dietitians to learn, network, and have some fun. “Putting the ‘Happy’ in ‘Happy Hour,’” sponsored by the National Watermelon Promotion Board and Bayer, gave dietitians a chance to relax and sip on watermelon rosemary lemonade mocktails and mingle with colleagues. The National Watermelon Promotion Board shared recent survey findings on the health benefits of eating watermelon— considered summer’s favorite fruit. Dietitians attended the “Savoring Savannah With American Pecans” event sponsored by American Pecan Council. They enjoyed pecan-inspired hors d’oeuvres and cocktails, met industry experts and members of the American Pecan Council team, and networked with colleagues. The “Bee Garden Tour” sponsored by the National Honey Board took RDs off property to the Savannah Bee Company to learn about its history, tour the bee garden, observe the honey bees, and learn the impact bees have on their everyday lives and the environment. Participants sampled different varieties of honey and enjoyed a six-flight mead tasting. To celebrate the final day of continuing education, attendees gathered along Savannah’s historic Riverwalk to attend a happy hour event, sponsored by Regular Girl and WellVine, where they sipped on cocktails and shared good conversation while taking in the spectacular views of Port of Savannah—the nation’s largest port. Exhibit Hall Excitement The infectious enthusiasm among RDs at the special events spilled over to the exhibit hall, where they walked from booth to booth, eagerly meeting and greeting the 48 sponsor companies that sampled new products and discussed the health benefits of their brands as well as nutrition research. “It was nice to talk to professionals about their products and the research done on the different products,” said Laurie Fortlage, MS, RD, an eating disorder dietitian in Ann Arbor, Michigan. Amid the deafening din of spirited conversations between attendees and sponsors were announcements of prize winners. Attendees were randomly chosen to win cash prizes. The grand prize included free registration for TD’s 2024 Spring Symposium and a threenight hotel stay. Attendees had to be in the exhibit hall when their names were called to win. The grand prize winner was Jeanette Shelley, RD, a clinical dietitian at Beltline Health, LLC, in Newnan, Georgia. Social Media Blitz To promote ongoing engagement throughout the symposium, TD encouraged all attendees, presenters, and sponsors to go on Facebook, Instagram, and Twitter and use our hashtag, #TDinGA, to tweet and post photos and video clips to let everyone know how much they were enjoying the symposium. Our staff also tweeted and posted comments on these social media channels in real time throughout the event. Facebook Posts Ruth Frechman, MA, RDN, CPT, author of The Food is My Friend Diet: The Ultimate 30-Day Weight Loss Plan, and founder of On the Weigh, a nutrition consulting business in Burbank, California, posted, “Congrats to Today’s Dietitian for a very successful 10th anniversary spring symposium in Savannah, Georgia! Wishing you continued success for future events. You provide a valuable and enriching experience for dietitians. Thank you!” Sylvia Klinger, DBA, MS, RDN, LDN, CPT, founder of Hispanic Food Communications, Inc, a nutrition communications and culinary consulting company in the greater Chicago area, posted, “Today’s Dietitian delivered lectures that [will] enhance my practice and provided unique events and an intimate networking environment that made it easier to dialog with dietitians, farmers, and vendors.” Instagram Posts and Tweets Andrea Mathis, MA, RDN, LD, founder of Beautifuleatsandthings.com, a website focused on recipes, wellness, and lifestyle, and author of The Complete Book of Healthy Smoothies, posted, “I had such a wonderful time in Savannah, attending the Today’s Dietitian symposium. I enjoyed seeing my dietitian friends and attending some amazing sessions and events!” Weiss posted: “I attended Today’s Dietitian 10th annual Spring Symposium in Savannah. If I had to give the conference a grade, it would be an A+.” Sarah Garone, MA, NDTR, a food and nutrition blogger in Mesa, Arizona, tweeted, “It was an awesome few days in Savannah, Georgia, where I attended the @Today’s Dietitian 2023 conference. I learned tons about the gut microbiome, cardiovascular health, and nutrition myth-busting, and I (of course) ate some delicious food!” Bright Future Ahead This year’s symposium was extra special because it marked our 10-year anniversary hosting continuing education symposia for dietitians across the country and abroad. All of the attendees appreciated the workshops, the exhibit hall, special networking events, and fitness classes. The TD staff thanks all of our sponsors, presenters, attendees, and volunteers who helped make the symposium a huge success. The Today’s Dietitian 11th Spring Symposium 2024 will be held in Salt Lake City (nicknamed “Salt Lake” and known for its vast salt flats and powdery ski slopes) on May 19 to 24. Don’t wait another moment to register at TodaysDietitian.com/ss24. We look forward to seeing you there! n Judith Riddle is editor of Today’s Dietitian. Toby Amidor, MS, RD, CDN, FAND (seated), and Ashley Carter, MS, RD, LDN 48 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023

1. Riverwalk Happy Hour, sponsored by Regular Girl and WellVine; 2. Joan Salge Blake, EdD, MS, RDN, LDN, FAND; Toby Amidor, MS, RD, CDN, FAND; and Vandana Sheth, RDN, CDCES, FAND; 3. Christina Mallas, brand ambassador, and Caroline Margolis, RDN, nutrition and culinary communications, Lifeway Foods; 4. Exhibit hall attendees; 5. Trici Swalina, retail trade manager, LaCroix Sparkling Water; 6. Jill Weisenberger, MS, RDN, CDCES, CHWC, FAND; 7. TD staff 1 3 6 2 4 7 5

Nutrition Needs for Aging Adults People are now living longer but not necessarily healthier lives than their predecessors.1-3 The World Health Organization (WHO) suggests this is partially due to a person’s ability to make positive or negative health-related choices throughout their lifetime.1,3,4 Variables within an individual’s control include diet quality, level of physical activity, and hydration status. Environmental and socioeconomic factors also play a role, as cigarette smoking, pollution, food deserts, community, and access to medical care influence nutrition status.1,5 Recognizing and respecting the multitude of factors that contribute to a healthful lifestyle is crucial to the interdisciplinary team as they work to serve a diverse, aging population.1 This continuing education course reviews the leading health concerns of older adults and their dietary needs, macronutrients and fluid recommendations, and plant-based and other diet solutions. Population As life expectancy continues to lengthen, the proportion of aging adults also will continue to change. In the United States, seniors are designated by Feeding America and the 2020–2025 Dietary Guidelines for Americans as adults aged 60 or older.6,7 Much of the research done on aging populations follows this metric; this is also the age at which many community-based feeding programs begin eligibility.7 According to data from the 2020 Profile of Older Americans, the number of Americans who are older than 60 is 74.6 million, which is a 34% increase in the past decade.8 This growth is expected to continue over the coming decades, with a prediction that older adults will compose 25% of the population by 2050 in most continents.2 Primary Health Concerns for Older Adults An aging population is faced with unique health considerations. Metabolic processes are altered, increasing the risk of developing noncommunicable diseases like diabetes, CVD, certain cancers, and some types of chronic respiratory disease.1,6,9 Cellular damage, including oxidative stress and inflammation, also is at risk of developing with a nutrient deficient diet.1 Moreover, food insecurity, malnutrition, and social interactions present as complications to consider. One of the primary challenges to feeding an aging population is acknowledging the multiple barriers surrounding diet and food choice. Environmental stressors that may increase emotional and mental loads, chronic disease, sleep hygiene, physical activity, and lifestyle decisions like housing and retirement age/ability all can affect nutrition status.1 Per the Hellenic Longitudinal Investigation of Aging and Diet study, elevated nutrition risk is directly correlated with marital status (unmarried older individuals carry the biggest risk), high BMI, being male, less formal education, decreased cognitive engagement, and poor dietary habits.10 Some of these factors are within the control of the individual, and some are not, and it’s the job of the interdisciplinary team to help their clients identify which factors they may be willing and able to change. By acknowledging these barriers and acting proactively, older adults may be CPE Monthly By Alexandria Hardy, RDN, LDN COURSE CREDIT: 2 CPEUs Learning Objectives After completing this continuing education course, nutrition professionals should be better able to: 1. Assess malnutrition and describe why it’s a major health risk to older adults. 2. Educate patients on three micronutrients of concern and explain how to include them in the diet. 3. Evaluate two modifiable feeding challenges older adults may face. CPE Level 2 50 TODAY’S DIETITIAN • AUGUST/SEPTEMBER 2023