However, recent research and newer guidelines, such as the National Kidney Foundation’s 2020 Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in CKD, created in partnership with the Academy, recommend focusing on total diet quality — which includes more plant foods. This approach, along with an individualized nutrition intervention, may be more effective at slowing progression of CKD than sticking to strict nutrient ranges.

Some research suggests eating patterns associated with better kidney health outcomes include the Mediterranean, DASH, Nordic and vegan and vegetarian diets, all of which place heavy emphasis on plant foods. People adhering to these eating patterns tend to have less incidence of CKD. What’s more, when individuals with CKD adopt these eating patterns, their disease progression often slows.

Plant Versus Animal Protein

The KDOQI guidelines and Academy’s Evidence Analysis Library support reduced protein consumption and close monitoring for adults with CKD stages 3 through 5 who are “metabolically stable” and not receiving dialysis. But while both state there is insufficient evidence to recommend one protein source over another — meaning animal versus plant protein — there may be reason to give this another look, since the guidelines are based upon the best information available as of April 2017 (or through August 2018 for any of the consensus opinion statements).

“While there was insufficient data to support a strong recommendation at that time, additional evidence favoring plant-based proteins has been published since,” says Annamarie Rodriguez, RDN, LD, FAND, who has been a nephrology dietitian for almost 25 years and has served on several boards of renal-related groups and held positions in Academy and affiliate groups. She works full time with an infusion company and runs a private practice.

Regardless, there is enough evidence to support the benefits of incorporating more plant foods and plant proteins for patients or clients with CKD or at risk for CKD, whether plant proteins are the basis of protein consumption or not.

Benefits of Plant Foods for CKD

Potential benefits of plant protein consumption and a plant-based diet for people with CKD may include decreased inflammation, less uremic toxins, reduced metabolic acidosis, improved gut microbiome from increased fiber intake and reduced bioavailability of certain nutrients such as phosphorus and potassium.

Inflammation

People with CKD are at higher risk of inflammation and inflammatory comorbid conditions. For instance, 40% of people with CKD also have Type 2 diabetes; 65% also have cardiovascular disease, and 50% to 75% have hypertension. Cardiovascular disease is the primary cause of death for people with CKD.

Diets higher in plant foods such as the Mediterranean, DASH and vegan and vegetarian diets have been associated with lower comorbidities and inflammation. A 2019 study found eating at least 800 grams of fruits and vegetables per day, or about five servings, showed heart-protective benefits. Furthermore, Rodriguez says there are dozens of epidemiological studies to suggest the protective and anti-inflammatory benefits of increased fruit and vegetable consumption.

“The phytochemicals and antioxidants in fruits and vegetables are so essential to what our patients need when we look at the comorbid conditions and inflammatory response mechanisms that are triggered with CKD,” Rodriguez says. “Eating an abundance of fruits and vegetables is the more natural way to combat that.”

Metabolic Acidosis

Metabolic acidosis, or the buildup of too many acids in the blood, can be both a contributor and a consequence of CKD, occurring because of the kidney’s reduced ability to filter and eliminate acids through urine. Too much acid in body fluids can lead to osteoporosis, insulin resistance and other endocrine disorders, muscle loss or protein energy wasting and worsening kidney disease.

Rodriguez explains that a diet high in animal protein favors acid production due to organic sulfur found in amino acids such as methionine and cysteine, which are oxidized to sulfate. “If we look at plant-based foods such as fruits, vegetables and legumes, they have natural alkaline precursors, such as citrate and malate, which are converted to serum bicarbonate that can act as a buffer.” While there are oral alkali medications, Rodriguez argues that eating a diet high in alkaline foods can be just as effective while providing the benefits of fiber, antioxidants and phytonutrients that are often lacking in the historic or traditional CKD diet.

Reviews in 2013 and 2015 both found a diet higher in fruits and vegetables is beneficial in treating and preventing metabolic acidosis. Randomized controlled trials published in 2012, 2013 and 2014 found eating more fruits and vegetables was as effective as oral sodium bicarbonate for people with CKD stages 2, 3 and 4 with metabolic acidosis.

Rodriguez says even if patients or clients aren’t ready to give up animal-based proteins, finding ways to incorporate more plant foods such as fruits and vegetables may help balance it out.

Bioavailability of Phosphorus and Potassium

Sweeping restrictions of foods high in phosphorus and potassium was once foundational to the CKD diet for people with CKD stages 3 through 5 and on dialysis. This generally resulted in people limiting their consumption of plant foods. However, research suggests the phosphorus and potassium in plant foods are less bioavailable, meaning the body does not absorb all the phosphorus and potassium present in plant sources. A 2018 study adds that animal proteins such as meat, poultry and fish can contain additives of phosphorus and potassium, in a more bioavailable form. The updated KDOQI guidelines suggest practitioners consider bioavailability of phosphorus sources.

“Any time I talk to dietitians about incorporating more plant-based proteins in patients with CKD, they’re more concerned about potassium and phosphorus,” Rodriguez says. She explains that the phosphorus in some plant foods comes in the form of phytic acid, which is largely indigestible in humans because they lack the enzyme phytase, which is needed to convert phytic acid into a more bioavailable form of phosphorus. She says the higher fiber in plant foods may help reduce absorption of both phosphorus and potassium. Additionally, newly introduced potassium binders can help patients and clients keep serum potassium levels within range while also eating more plant foods.

However, processing such as sprouting, fermenting and cooking can make phosphorus more bioavailable, which Rodriguez says she always discusses with her patients or clients. Rodriguez recommends registered dietitian nutritionists educate patients or clients on inorganic sources of phosphorus, which often are found in highly processed foods and beverages such as soda. Virtually all added (or inorganic) phosphorus is absorbed by the body.

RDN Takeaways

Despite the staggering amount of people who have CKD and the potential for medical nutrition therapy to slow the progression of the disease, only 10% of people with non-dialysis CKD are estimated to ever see an RDN. Barriers to MNT may include a lack of physician awareness and referrals, plus RDN availability. Whatever the cause, RDNs may want to consider advocating for the importance of nutrition for CKD whenever possible.

For some people, the cost of seeing a dietitian may be a reason they don’t receive or seek out medical nutrition therapy. To make appointments more affordable, RDNs in private practice could consider becoming Medicare providers, which cover a select number of appointments for beneficiaries with CKD who are not on dialysis or received a kidney transplant within the past 36 months and were referred by a physician.

Patients or clients may have preconceived notions or misconceptions that eating fruits, vegetables and whole grains will have a negative effect on their disease process. When counseling patients or clients, present the updated data and explain the benefits of eating more plant-based foods and create an individualized care plan. If patients or clients are not ready to make big changes, emphasize the impact of small, gradual shifts over time.

“Even small goals, even baby steps, can make a significant impact on health outcomes,” says Rodriguez. “Simple steps, such as swapping out one or two meals a week for a plant-based meal, can really add up.”

MORE TO LEARN

Watch these Academy webinars to take a deeper dive into the benefits of a plant-based diet for CKD and practical applications:

• The Emerging Benefits of a Plant-Forward Approach to the Chronic Kidney Disease Diet
• Plant-Forward with Chronic Kidney Disease
• Medical Nutrition Therapy for Chronic Kidney Disease Stages 1-5 Not on Dialysis
• Chronic Kidney Disease Nutrition Management Certificate of Training

References

Harvey K. Medical Nutrition Therapy for Chronic Kidney Disease Stages 1-5 Not on Dialysis. Academy of Nutrition and Dietetics website. https://www.eatrightstore.org/dpg-products/rpg/medical-nutrition-therapy-for-chronic-kidney-disease-stages-1-5-not-on-dialysis. Published September 21, 2021. Accessed March 25, 2022.
Ikizler TA, Burrowes JD, Byham-Gray LD, et al; KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107.
Rodriguez A. Phone interview. April 1, 2022.
Rodriguez A. Plant-Forward with Chronic Kidney Disease. Academy of Nutrition and Dietetics. https://www.eatrightstore.org/dpg-products/rpg/plant-forward-with-chronic-kidney-disease. Published January 19, 2021. Accessed March 28, 2022.
Wallace TC, Bailey RL, Blumberg JB, et al. Fruits, vegetables, and health: A comprehensive narrative, umbrella review of the science and recommendations for Enhanced Public Policy to improve intake. Crit Rev Sci Nutr 2019;60(13):2174-2211. doi:10.1080/10408398.2019.1632258
Metabolic Acidosis. National Kidney Foundation website. https://www.kidney.org/atoz/content/metabolic-acidosis. Accessed April 11, 2022.
Scialla JJ, Anderson CA. Dietary acid load: a novel nutritional target in chronic kidney disease?. Adv Chronic Kidney Dis. 2013;20(2), 141–149. https://doi.org/10.1053/j.ackd.2012.11.001
Kraut JA, Madias NE. Metabolic Acidosis of CKD: An Update. Am J Kidney Dis. 2016;67(2):307-317. doi:10.1053/j.ajkd.2015.08.028
Goraya N, Simoni J, Jo C-H, Wesson DE. A comparison of treating metabolic acidosis in CKD stage 4 hypertensive kidney disease with fruits and vegetables or sodium bicarbonate. Clin J Am Soc Nephrol. 2013;8(3):371-381. doi:10.2215/cjn.02430312
Goraya N, Simoni J, Jo C-H, Wesson DE. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate. Kidney International. 2014;86(5):1031-1038. doi:10.1038/ki.2014.83
Goraya N, Simoni J, Jo C, Wesson DE. Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney International. 2012;81(1):86-93. doi:10.1038/ki.2011.313
Chronic Kidney Disease in the United States, 2021. Centers for Disease Control and Prevention website. https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html. Reviewed March 4, 2021. Accessed April 1, 2022.
Medicare MNT. Academy of Nutrition and Dietetics website. https://www.eatrightpro.org/payment/medicare/mnt. Accessed April 11, 2022.
Picard K. Potassium additives and bioavailability: Are we missing something in hyperkalemia management? Journal of Renal Nutrition. 2019;29(4):350-353. doi:10.1053/j.jrn.2018.10.003
Kramer H, Jimenez EY, Brommage D, et al. Medical nutrition therapy for patients with non–dialysis-dependent chronic kidney disease: Barriers and solutions. J Acad Nutrition Dietetics. 2018;118(10):1958-1965. doi:10.1016/j.jand.2018.05.023
Chronic Kidney Disease. Academy of Nutrition and Dietetics Evidence Analysis Library website. https://www.andeal.org/topic.cfm?menu=5303&ref=692D90EB3962C711EAE5386E380B7620DADC270410246E10A063DE0778C4DD55A3C4472DD408D81DC4D0EB1576E99915003B3CA183A6DA99. Accessed April 15, 2022.
Parpia AS, L’Abbé M, Goldstein M, Arcand J, Magnuson B, Darling PB. The Impact of Additives on the Phosphorus, Potassium, and Sodium Content of Commonly Consumed Meat, Poultry, and Fish Products Among Patients With Chronic Kidney Disease. J Ren Nutr. 2018;28(2):83-90. doi:10.1053/j.jrn.2017.08.013

Signs and Symptoms
Common symptoms include pain, swelling or stiffness in more than one joint, usually on both sides of the body. Stiffness is typically worse in the morning, getting better as the day progresses. Joints most impacted by rheumatoid arthritis are in the hands, wrists and knees, but other joints and organs such as the lungs, heart and eyes can be affected. Other symptoms may include weight loss, fever, weakness or fatigue.

It is common for people with RA to experience flares — times when symptoms get worse — and remission, when symptoms improve.

Risk Factors
The cause of rheumatoid arthritis is unknown. Factors that may increase risk of development include aging and genetics. According to the American College of Rheumatology, about 75% of people diagnosed with RA are women. Additional risk factors include smoking, obesity, early life exposures such as children whose mothers smoked and social determinants of health. Conversely, breastfeeding has been found to decrease risk.

Diagnosis
Blood tests are one of many completed to determine if a person has rheumatoid arthritis and are an important factor in determining whether a person has seropositive or seronegative RA. Seropositive is the most common form; it means the person has antibodies called anti-cyclic citrullinated peptides or rheumatoid factors. These antibodies attack joints and cause inflammation. Usually, people with seropositive RA will experience more severe symptoms.

Nutrition for Prevention
Though evidence is limited, some research suggests diet may play a role in the prevention of rheumatoid arthritis. Using data from two cohort studies of nearly 170,000 women, researchers found a healthier overall dietary pattern (measured by the 2010 Alternative Healthy Eating Index) led to reduced risk in women 55 or younger. In this age-specific analysis of the study, women with the highest healthy eating index scores, indicating an overall healthier diet, showed a 33% reduction in RA risk compared to those with the lowest scores.

Authors of a 2018 review discussed the potential of the Mediterranean diet for prevention. Noting the prevalence of rheumatoid arthritis in Southern Europe is lower than Northern Europe and the United States, they argued the Mediterranean diet could be a factor since it is higher in antioxidants, unsaturated fats and foods with anti-inflammatory properties compared to the typical Western diet; however, more evidence is needed.

Other studies hint that reducing sodium and sugar-sweetened soda intake may reduce risk. A cross-sectional study of 18,555 people found high sodium consumption (an average of nearly 5,000 milligrams a day) was associated with self-reported rheumatoid arthritis, while a case-control study found a significant association only existed between high sodium consumption and risk for RA among smokers, and it was dose dependent, more than doubling their risk. Additionally, another study found women who drank one or more servings of sugar-sweetened soda a day may be at an increased risk of seropositive RA (but not seronegative).

Nutrition for Disease Management
Researchers are equally interested in the Mediterranean diet for rheumatoid arthritis management but, so far, findings are mixed. Results of a 2018 systematic review showed two prospective studies found no significant benefits of following a Mediterranean diet, while two clinical trials reported modest but favorable outcomes. One clinical trial reported improvement in pain and physical function after three months and reduced stiffness after six months following the Mediterranean diet. Participants in the other clinical trial saw swelling and inflammatory biomarker improvements after three months.

Of studies included in a 2020 systematic review on the effects of diet and dietary supplements on Disease Activity Score in 28 joints, or DAS28 which measures rheumatoid arthritis severity, one reported a significant improvement after 12 weeks of following the Mediterranean diet, while another reported benefits after 10 weeks, but those results were not statistically significant.

Supplements
The same systematic review looked at three small studies of various spices (administered in high doses in capsules or tablets) on DAS28. One study had participants supplement with 1.5 grams of ginger powder daily for three months; another with 2 grams of cinnamon (Cinnamomum burmannii) powder daily for two months; and another with 100 milligrams of saffron daily for three months. All three studies reported significant improvement in DAS28 when compared to placebo.

Similar results were shown in a pilot study on curcumin. Participants who supplemented 500 milligrams twice daily for eight weeks had the highest improvement in overall DAS28 scores compared to participants who supplemented with 50 milligrams diclofenac sodium (a pain medication) alone or in combination with curcumin.

Omega-3 Fatty Acids
Evidence of supplemental omega-3 fatty acid intake on RA symptoms is limited and inconsistent. Some research suggests it may help reduce the number of swollen and tender joints, and some studies suggest omega-3 fatty acid supplements may reduce the need for medication. For example, when supplementing with 10 grams of fish oil daily (containing 1.8 grams of EPA and 1.2 grams of DHA), one study found a decreased need for non-steroidal anti-inflammatory drugs.

Probiotics
A 2020 systematic review found two studies that supported benefits of supplementing with probiotics containing L. casei. One study had participants supplement with a capsule of L. casei 01 (10⁸ colony forming units) and maltodextrin daily for two months, which resulted in a lower inflammatory marker score for the intervention group compared to those who only took maltodextrin. The other had participants take capsules containing L. casei (2 × 10⁹ colony forming units), L. Acidophilus (2 × 10⁹ colony forming units) and B. Bifidum (2 × 10⁹ colony forming units) daily for two months. Among the beneficial effects reported in this randomized, double-blind, placebo-controlled trial was an improvement in DAS28 compared to placebo.

Lifestyle
The Centers for Disease Control and Prevention recommend adults with arthritis aim for at least 150 minutes of moderate physical activity each week. Research has shown physical activity can help manage pain from rheumatoid arthritis and improve quality of life for people with RA. However, for someone experiencing a flare, the American College of Rheumatology recommends prioritizing rest and opting for gentle range-of-motion exercises, such as stretching.

Several community-based, physical activity programs are recommended by the CDC; they have been proven to reduce symptoms and help participants safely increase their physical activity.

Epidemiological studies suggest smoking significantly increases risk and complications of rheumatoid arthritis; recommend to clients and patients that they quit.

RDN Takeaways
Until data is more conclusive concerning the effects of diet and dietary supplements on RA prevention and symptom management, registered dietitian nutritionists should encourage patients and clients to follow an overall balanced and healthful eating pattern consistent with the 2020-2025 Dietary Guidelines for Americans. Emphasize limiting sodium consumption and encourage patients and clients to eat foods higher in unsaturated fats and dietary fiber, as well as a variety of fruits and vegetables, whole grains, lean protein foods (especially fatty fish) and low-fat or fat-free dairy.

People with rheumatoid arthritis are at risk for malnutrition, so RDNs need to tailor nutrition interventions to address disease severity, polypharmacy and comorbidities. Referrals for occupational or physical therapy may need to be considered. Finally, educate patients and clients on the benefits of appropriate physical activity for RA management and help them find healthful ways to incorporate more movement into their daily lives.

References

Academy of Nutrition and Dietetics. Nutrition Care Manual. Rheumatoid Arthritis. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=272978&lv2=30456&ncm_toc_id=30456&ncm_heading=Nutrition%20Care. Accessed February 10, 2022
Arthritis: Key Public Health Messages. Centers for Disease Control and Prevention website. https://www.cdc.gov/arthritis/about/key-messages.htm. Reviewed August 26, 2021. Accessed January 28, 2022.
Chandran B, Goel A. A randomized, pilot study to assess the efficacy and safety of curcumin in patients with active rheumatoid arthritis. Phytother Res. 2012;26(11):1719-1725.
Chang K, Yang SM, Kim SH, Han KH, Park SJ, Shin JI. Smoking and rheumatoid arthritis. Int J Mol Sci. 2014;15(12):22279-22295. Published 2014 Dec 3. doi:10.3390/ijms151222279.
Di Giuseppe D, Wallin A, Bottai M, Askling J, Wolk A. Long-term intake of dietary long-chain n-3 polyunsaturated fatty acids and risk of rheumatoid arthritis: a prospective cohort study of women. Ann Rheum Dis. 2014;73(11):1949-1953.
Disease Activity Score (DAS)/Disease Activity Score in 28 joints (DAS28). American College of Rheumatology website. https://www.rheumatology.org/Learning-Center/Glossary/ID/451/. Accessed January 25, 2022.
Forsyth C, Kouvari M, D’Cunha NM, et al. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatol Int. 38, 737–747 (2018).
Forsyth C, Kouvari M, D’Cunha NM, et al. The effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment: a systematic review of human prospective studies. Rheumatol Int. 38, 737–747 (2018).
Hu Y, Costenbader KH, Gao X, et al. Sugar-sweetened soda consumption and risk of developing rheumatoid arthritis in women. Am J Clin Nutr. 2014;100(3):959-967. doi:10.3945/ajcn.114.086918.
Hu Y, Sparks JA, Malspeis S, et al. Long-term dietary quality and risk of developing rheumatoid arthritis in women. Ann Rheum Dis. 2017;76(8):1357-1364.
Kostoglou-Athanassiou I, Athanassiou L, Athanassiou P. The Effect of Omega-3 Fatty Acids on Rheumatoid Arthritis. Mediterr J Rheumatol. 2020;31(2):190-194. Published June 30, 2020.
Nelson J, Sjöblom H, Gjertsson I, Ulven SM, Lindqvist HM, Bärebring L. Do Interventions with Diet or Dietary Supplements Reduce the Disease Activity Score in Rheumatoid Arthritis? A Systematic Review of Randomized Controlled Trials. Nutrients. 2020;12(10):2991. Published September 29, 2020.
Omega-3 Fatty Acids. National Institutes of Health Office of Dietary Supplements website. https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/#rheumatoid. Updated August 4, 2021. Accessed February 8, 2022.
Pedersen M, Stripp C, Klarlund M, Olsen SF, Tjønneland AM, Frisch M. Diet and risk of rheumatoid arthritis in a prospective cohort. J Rheumatol. 2005;32(7):1249-1252.
Physical Activity Programs. Centers for Disease Control and Prevention website. https://www.cdc.gov/arthritis/interventions/physical-activity.html. Reviewed April 16, 2021. Accessed January 28, 2022.
Rheumatoid Arthritis (RA). Centers for Disease Control and Prevention website. https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html. Reviewed July 27, 2020. Accessed January 18, 2022.
Rheumatoid Arthritis Also called: RA. MedlinePlus website. https://medlineplus.gov/rheumatoidarthritis.html. Accessed January 18, 2022.
Rheumatoid Arthritis. American College of Rheumatology website. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Rheumatoid-Arthritis. Updated March 2019. Accessed January 18, 2022.
Salgado E, Bes-Rastrollo M, de Irala J, Carmona L, Gómez-Reino JJ. High Sodium Intake Is Associated With Self-Reported Rheumatoid Arthritis: A Cross Sectional and Case Control Analysis Within the SUN Cohort. Medicine (Baltimore). 2015;94(37):e0924.
Seropositive and seronegative. National Rheumatoid Arthritis Society website. https://nras.org.uk/resource/seropositive-and-seronegative/. Updated February 4, 2019. Accessed February 8, 2022.
Seropositive Rheumatoid Arthritis. Healthline website. https://www.healthline.com/health/seropositive-rheumatoid-arthritis. Updated January 26, 2021. Accessed February 8, 2022.
Sundström B, Johansson I, Rantapää-Dahlqvist S. Interaction between dietary sodium and smoking increases the risk for rheumatoid arthritis: results from a nested case-control study. Rheumatology (Oxford). 2015;54(3):487-493.
What Type of RA Do You Have? WebMD website. https://www.webmd.com/rheumatoid-arthritis/rheumatoid-arthritis-types. Reviewed October 19, 2021. Accessed February 8, 2022.

How It Happens
Normally, the small intestine contains very little bacteria; the concentration of microbes increases progressively down the small bowel to the colon, where approximately 38 trillion microbes live. With SIBO, bacteria are displaced from the colon, increasing the number and types of microbes in the small intestine and causing excess fermentation, malabsorption or inflammation.

SIBO is a secondary condition, meaning it occurs in response to something else, such as a disease or alteration to the small bowel. There are several reasons SIBO may develop: Post-surgical causes may include resections or anastomotic adhesions or strictures. Medications can contribute; for instance, opioids slow the bowel and anticholinergics alter gastric acid production. Structural causes may include diverticula of the small intestine or fibrous bands. Additionally, small intestine function can be altered by chronic inflammatory diseases, such as lupus, diabetes or chronic pancreatitis.

Any of these factors can disrupt the mechanisms that keep the small intestine “clean” and introduce bacteria that normally wouldn’t be there. Innate cleaning mechanisms of the small intestine include secretion of stomach acid, pancreatic excretions and the migrating motor complex, a cyclical four-stage process that occurs during fasting and includes contractions, which push residual food to the colon. Additionally, the ileocecal valve keeps out unwanted microbes by blocking the connection between the colon and the small intestine.

Symptoms
Symptoms associated with SIBO may include abdominal distention and bloating. Abdominal distention grows progressively worse throughout the day and is usually worst in the evening. Abdominal pain or discomfort also is common, though intense pain is not usually associated with SIBO. Feeling full quickly, “brain fog” or fatigue, especially after eating, are other possible signs of SIBO. While weight loss has long been a symptom associated with SIBO, weight gain is now a recognized symptom as well. People with SIBO also may experience nausea, diarrhea or constipation (which can occur depending on the type of overgrowth present).

SIBO or IBS?
RDNs may encounter SIBO in the context of irritable bowel syndrome, as many of the symptoms overlap. Although data varies on the prevalence of SIBO in people with IBS, a recent meta-analysis reviewed 25 case-controlled studies with more than 3,000 IBS patients and 3,000 controls without IBS. Researchers found the prevalence of SIBO in subjects with IBS was 31% and only 9% in the control group, meaning people with IBS are more likely to have SIBO. Another study found that SIBO was more prevalent in IBS patients with diarrhea than those with constipation.

Dietary Interventions
RDNs can guide patients and clients on how to best manage symptoms through diet modifications. Though many diet therapies have been suggested — such as the Specific Carbohydrate Diet, SIBO Bi-Phasic Diet, Gut & Psychology Syndrome Diet, low FODMAP diet and Cedars-Sinai Low Fermentation diet — evidence is lacking on whether any of these diets is best for someone with SIBO.

In February 2020, the American College of Gastroenterology released clinical guidelines for SIBO. They recommend eating fewer fermentable foods, including “alcohol sugars and other fermentable sweeteners such as sucralose.” Additionally, the guidelines suggest reducing fiber consumption and avoiding prebiotics such as inulin.

Some practitioners suggest incorporating meal spacing, which means waiting at least five hours between meals to allow as much time as possible for the migrating motor complex to occur. This gives more time for contractions to push residual food and bacteria through the small intestine to the colon.

Key nutritional concerns of SIBO include reduced fat absorption and, consequently, fat-soluble vitamin deficiencies as well as iron, thiamin and B₁₂ deficiencies. There is not enough evidence to support the use of probiotics in people with SIBO, and some studies suggest probiotics may worsen symptoms.

After a physician’s diagnosis, RDNs should first consider removing fermentable carbohydrates from the patient’s or client’s diet, then reintroducing them as tolerated to create an individualized eating plan that can be maintained over the long term. Consider trialing meal spacing and be mindful of potential nutrient deficiencies.

Additionally, practicing a multidisciplinary approach can lead to better overall care. This means working alongside a patient’s or client’s gastroenterologist, primary care physician and any other health care professionals. Working as a team can create seamless care and encourage patients and clients to follow nutrition recommendations for best management of their symptoms.

Learn more about the testing for SIBO, diagnostic criteria and the rate of recurrence, plus discover the three pillars of management — including considerations for an elemental diet — by watching the 2021 Food & Nutrition Conference & Expo™ session Diagnosis, Treatment and Dietary Interventions for Small Intestinal Bacterial Overgrowth: An Up-To-Date Practical Review.

References

Anastomotic Stenosis (Stricture) After Gastric Bypass Surgery. University of Rochester Medical Center website. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=134&contentid=155. Accessed November 22, 2021.
Anticholinergic Agents. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda(MD); 2017.
Deloose E, Janssen P, Depoortere I, Tack J. The migrating motor complex: control mechanisms and its role in health and disease. Nat Rev Gastroenterol Hepatol. 2012;9(5):271-285. Published March 27, 2012.
Fogt E, Hardy A, Rezaie A. Diagnosis, Treatment and Dietary Interventions for Small Intestinal Bacterial Overgrowth: An Up-To-Date Practical Review. Food & Nutrition Conference & Expo™ session. Presented October 18, 2021.
Pimentel M, Saad R, Long M, Rao S. Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020(115)(2);165-178.
Rao SSC, Bhagatwala J. Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management. Clin Transl Gastroenterol. 2019;10(10):e00078.
Sizar O, Genova R, Gupta M. Opioid Induced Constipation. StatPearls Publishing. Treasure Island(FL); 2021.
Takakura W, Pimentel M. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome – An Update. Front Psychiatry. 2020;11:664.

The importance of skin protection
Spending time outside might boost your mood, but without proper skin protection, time outside can have unfavorable consequences, such as sunburn, increased risk of skin cancer and premature skin aging, all caused by ultraviolet radiation from the sun.

Sunlight produces three types of UV rays: UVA, UVB and UVC. UVA rays penetrate the skin deepest and contribute to premature aging, such as sunspots, wrinkles and sagging. There are two forms of UVA: UVA1 and UVA2; UVA1 rays penetrate the skin deeper than UVA2. Of the three main types of UV rays, UVA accounts for 95% of UV exposure, of which UVA1 accounts for 75%. UVB rays produce sunburns and are largely responsible for skin cancer. The most dangerous type, UVC, is blocked by the earth’s ozone layer but also is present in some artificial light sources, such as mercury lamps or lasers.

And while many people think sun protection is only relevant on sunny days, UV rays can penetrate through clouds and be reflected off snow, sand, concrete and water, and UVA rays specifically can penetrate through glass, making sun protection essential year-round.

Unprotected skin can be damaged in as little as 15 minutes outside. Because of this, the American Academy of Dermatology recommends getting vitamin D from foods, including natural sources, such as salmon, eggs and mushrooms exposed to UV light, and those fortified with vitamin D, such as orange juice, dairy products and cereals.

Skin tone and susceptibility
The Centers for Disease Control and Prevention reported 46.3% of non-Hispanic white adults experienced a sunburn in 2015. In contrast, 22.4% of Hispanic people and 9.9% of Black people experienced a sunburn the same year. A lower incidence of sunburn among people with darker skin tones is largely due to melanin, a skin pigment that helps block harmful UV rays. The darker a person’s skin tone, the more melanin it contains, whereas lighter skin tones have less melanin.

While melanin helps protect against UV rays, protecting skin from the sun through other measures is important for people of all skin tones. Some studies have shown that despite having lower incidences of melanoma, a form of skin cancer, Black people have a lower five-year melanoma survival rate compared to white people (67% and 92%, respectively) and Black people and Hispanic people are more likely to have a late-stage melanoma diagnosis compared to white people. Some dermatologists speculate medical bias may play a role, in addition to a public misconception that only white people develop skin cancers and sun damage. People with darker skin tones may not burn as easily, but skin cancer and sun damage affect people of all races, ethnicities and skin tones.

Although research is still early and ongoing, some studies suggest certain compounds in foods and beverages may help boost the skin’s defenses against UV rays. Carotenoids, vitamin C and vitamin E, omega-3 fatty acids and some polyphenols are a few notable compounds showing potential benefits, such as delaying or preventing sunburns and redness and helping prevent or reduce signs of aging.

Carotenoids

Lycopene
Studies suggest lycopene may have photoprotective benefits, meaning it offers skin protection against UV light. Lycopene, a pigment found in red, yellow and orange fruits and vegetables, can be obtained through tomatoes, watermelon, pink guava, red oranges, pink grapefruit, rosehips, carrots, bell peppers and papaya. Lycopene is easier for the body to use when the source has been heated, meaning pasta sauce and tomato juice offer more lycopene than raw tomatoes.

Several studies have shown that consuming 10 to 16 milligrams of lycopene per day in the form of supplements or tomato paste with olive oil may offer photoprotective benefits. Compared to placebo groups, skin redness from exposure to UV light was significantly lower after consuming 10 to 16 milligrams each day for 10 to 12 weeks. Some of these studies included only participants with fair skin tones, while others did not list skin tone as an inclusion or exclusion criteria.

A delay in skin reddening after UV exposure suggests lycopene may help boost skin’s defenses against UVB rays, which are most responsible for an increased risk of skin cancer. However, one study sought to find if lycopene offered protection against UVA1 rays and discovered certain biomarkers associated with oxidative damage, collagen breakdown and inflammation from UVA1 were reduced after supplementing with 10 grams of lycopene soft gels daily for 12 weeks.

Astaxanthin
Astaxanthin is a red pigment responsible for the color of many marine animals, such as salmon, lobster and shrimp, plus some bacteria and algae. A 2019 review and a 2020 systematic review of 11 clinical trials found taking 3 to 6 milligrams of astaxanthin supplements per day for four to 16 weeks helped protect skin against UV-induced damage. Studies also showed astaxanthin minimizes effects of aging, such as wrinkles and sunspots. However, most of the studies conducted so far have had small sample sizes with primarily female Japanese participants. Therefore, more research and a more diverse study population is needed to further substantiate astaxanthin’s role in sun protection.

Beta-carotene
The pigment beta-carotene is found in yellow and orange fruits and vegetables including carrots, sweet potatoes and winter squash, and in leafy green vegetables such as spinach and lettuce.Research investigating potential sun-protective benefits of beta-carotene date back to the 1970s.

A 2020 review found that beta-carotene had sun-protective benefits at doses ranging from 12 to 180 milligrams a day. A seemingly more important factor was how long participants took the doses — not necessarily how much.

Beta-carotene may provide some sun protection at a minimum dose of 12 milligrams per day when taken for at least seven weeks. Studies show participants who followed this regimen could be exposed to UV rays longer before getting sunburned compared to those who weren’t taking beta-carotene. However, some of these studies had only participants with fair skin tones, while others did not mention if all participants had a similar skin tone.

A few animal studies found that beta-carotene reduced the risk of skin cancer, but human studies have not been able to reproduce the same results. For instance, one large human study had participants supplement with 50 milligrams daily and saw no significant reductions in skin cancer risk after five years.

Anyone considering beta-carotene supplements should take caution — when it comes to dose, more may not be better.

Two studies found that higher doses of beta-carotene (20 to 30 milligrams) taken over several years increased the risk of lung cancer in some people.

Ingesting a mixture of lycopene, beta-carotene and lutein also has shown to help protect skin against UV rays. One study found that 8 milligrams of the mixture taken daily for 12 weeks was as effective at protecting skin from UV rays as taking 24 milligrams of beta-carotene alone. Another study found that a mixture of beta-carotene (6 milligrams), lycopene (6 milligrams), vitamin E (10 milligrams) and selenium (75 micrograms) helped prevent sunburn and skin damage after seven weeks.

Lutein and Zeaxanthin
These orange and yellow pigments are found in foods such as cantaloupe, corn, carrots, peppers and eggs. Other sources include kale, spinach, broccoli and peas. Although lutein and zeaxanthin may be better known for supporting eye health, early research suggests they may help protect skin against UV rays. When supplementing with lutein and zeaxanthin, skin took longer to turn red under UV light. While results are promising, they are primarily from animal studies. Therefore, more research is needed.

Vitamins C and E

Most Americans get vitamin C from citrus fruits, tomatoes and tomato juice, but other sources include red and green bell peppers, kiwifruit, broccoli, Brussels sprouts and strawberries. Sources of vitamin E include vegetable oils, nuts and seeds, spinach, broccoli and kiwifruit.

While there is limited evidence (mostly from animal studies) suggesting topical vitamin C can help limit skin damage from UV exposure, there is not much evidence suggesting oral vitamin C supplementation can do the same. Likewise, while many studies have tested the potential photoprotective benefits of oral vitamin E supplementation, the results so far suggest it may not offer much protection. However, when vitamin C is combined with vitamin E, studies show it may reduce the rate at which skin burns and reduce the amount of DNA damage after UV exposure.

In one double-blind placebo-controlled study, participants took 2 grams of vitamin C with 1,000 international units of vitamin E. After eight days, researchers found it took longer for participants to get a sunburn than it did before they took the supplements. Another study had participants take 1 gram of vitamin C and 500 IU of vitamin E for three months and found similar results. For perspective, the current recommended daily dietary allowance of vitamin C is 90 milligrams for males 19 and older and 75 milligrams for females 19 and older (85 milligrams for pregnant women and 120 milligrams for those who are lactating). The current recommended daily dietary allowance of vitamin E is 15 milligrams for males and females 14 and older, plus those who are pregnant, and 19 milligrams for people who are lactating.

Omega-3s

Some studies suggest supplementing with omega-3 polyunsaturated fats, particularly eicosapentaenoic acid, or EPA, may help protect the skin against UV damage. Common food sources of omega-3 fatty acids include fatty fish such as salmon, mackerel, herring and sardines.

During one randomized controlled-trial, participants took 4 grams of either purified (95%) EPA supplements or oleic acid supplements (a monounsaturated omega-9 fatty acid) for three months. At the end of the trial, the EPA group saw a significant reduction in UVB-induced redness and DNA damage. Another trial involved participants taking fish oil capsules (2.8 grams of DHA and 1.2 gram of EPA) every day for four weeks and found those who supplemented could be exposed to UV light for longer before experiencing skin redness. Another trial found taking 5 grams of fish oil twice a day for six months significantly increased the amount of UV exposure participants could handle before being burned, but the benefits seemed to disappear once they stopped supplementing. Plus, the safety of this high of a dose may be a concern. Some scientists believe supplementing with omega-3s may help suppress the inflammatory response that happens after exposure to ultraviolet radiation, but more research is needed.

Research suggests omega-3s also may help reduce signs of aging. A few cross-sectional studies found people with higher intakes of omega-3 fatty acids had less skin wrinkling on sun-exposed areas and were less likely to have dry skin and skin thinning.

Polyphenols

Some studies have found sun-protective benefits in both topically applied and ingested polyphenols. Polyphenols are powerful antioxidants found in plants, such as fruits and vegetables, whole grains and flowers. Many well-known sources include black and green tea, red wine and foods such as cocoa and dark chocolate, beans, soy, berries and artichokes.

In vitro and animal studies suggest polyphenols in green tea might have photoprotective benefits when ingested or applied topically. More human studies have been done on the benefits of topical green tea extract application, but some have tested the sun-protective benefits from ingesting green tea.

One study had participants (all females) drink a liter of green tea (containing 1,402 milligrams of green tea catechins) daily for 12 weeks and found it had skin-protective benefits after six weeks. Participants who drank the tea could be exposed to UV light longer before experiencing skin reddening. After 12 weeks, the benefits were even greater and included better skin elasticity and structure, reduced water loss from the skin, increased blood flow in the skin and higher serum flavonoid concentration. However, a separate study in which participants took capsules of 1,080 milligrams of green tea catechins per day for 12 weeks found no benefit.

In one study on cocoa powder, participants (all female) drank either a high (326 milligrams) or low (27 milligrams) flavanol-containing cocoa beverage every day for 12 weeks. At the end of the study, participants who consumed the high-flavanol drink saw less skin reddening when exposed to UV and had improved skin structure and circulation. Another study found consuming 6 milliliters of high-polyphenol wine per kilogram of body weight over 40 minutes helped protect skin against UVB. However, the study size was small with only 15 male participants, and the amount of wine needed to reproduce these benefits may not be practical. For instance, a 120-pound person would need to drink 11 ounces of wine in 40 minutes. For individuals who are of legal age and choose to drink, the 2020-2025 Dietary Guidelines for Americans suggests limiting alcohol intake and, for wine, this amounts to one, five-ounce glass or less a day for women and two, five-ounce glasses a day or less for men.

Coffee also may have sun-protective benefits. Researchers of one study examined food-frequency questionnaires of 447,357 non-Hispanic white people and found those who consumed four or more cups per day had a 20% lower risk of developing malignant melanoma after a 10-year follow-up compared to those who drank one or fewer cups. Interestingly, the benefits were not applicable to decaffeinated coffee. The Food and Drug Administration has stated that 400 milligrams of caffeine a day (or about four or five cups of coffee) is not generally associated with dangerous, negative effects for healthy adults who are not pregnant or breastfeeding.

For registered dietitian nutritionists

While more research is needed — especially research including a wider range of skin tones — current findings suggest some carotenoids, polyphenols and vitamins may help protect the skin from ultraviolet radiation from the inside out. For registered dietitian nutritionists seeing patients or clients with a heightened risk of skin cancer or who have patients or clients asking questions about overall skin health, it may be worthwhile to discuss the potential benefits of these compounds and encourage greater consumption from dietary sources or possibly supplementation. If supplementation is considered, other factors will need to be taken into account, since the doses of supplements described were high in some cases and/or may interact with medications. However, it is important to reiterate that the more certain ways to protect skin are by limiting exposure to sunlight and wearing sunscreen and sun-protective clothing.

References

12 Foods That Are Very High in Omega-3. Healthline website. Accessed August 2, 2021.
Abdel-Aal el-SM, Akhtar H, Zaheer K, Ali R. Dietary sources of lutein and zeaxanthin carotenoids and their role in eye health. Nutrients. 2013;5(4):1169-1185.
About The Buzz: Lycopene Promotes Healthy Skin. Fruits and Veggies for Better Health website. Accessed August 2, 2021.
Alexis A. Ask the Expert: Is There a Skin Cancer Crisis in People of Color? Skin Cancer Foundation website. Published July 5, 2020. Accessed August 5, 2021.
Anstey A. Systemic photoprotection with α-tocopherol (vitamin E) and β-carotene. Clin Exp Dermatol. 2002;27(3):170-176.
Are Some People More Likely to Get Skin Damage from the Sun? American Cancer Society website. Updated July 29, 2019. Accessed August 5, 2021.
Astaxanthin. Therapeutic Research Center’s Natural Medicines website. Accessed August 2, 2021.
Beta-carotene. Therapeutic Research Center’s Natural Medicines website. Accessed August 2, 2021.
Coffee May Be Associated With a Lower Risk of Malignant Melanoma. JNCI: Journal of the National Cancer Institute. Volume 107, Issue 2, February 2015, djv013.
Eberlein-König B, Placzek M, Przybilla B. Protective effect against sunburn of combined systemic ascorbic acid (vitamin C) and d-alpha-tocopherol (vitamin E). J Am Acad Dermatol. 1998;38(1):45-48. doi:10.1016/s0190-9622(98)70537-7.
Essential Fatty Acids and Skin Health. Oregon State University website. Accessed August 2, 2021.
Flavonoids and Skin Health. Oregon State University website. Accessed August 2, 2021.
Grether-Beck S, Marini A, Jaenicke T, Stahl W, Krutmann J. Molecular evidence that oral supplementation with lycopene or lutein protects human skin against ultraviolet radiation: results from a double-blinded, placebo-controlled, crossover study. Br. J. Dermatol. 2017;176(5):1231-1240.
Groten K, Marini A, Grether-Beck S, et al. Tomato Phytonutrients Balance UV Response: Results from a Double-Blind, Randomized, Placebo-Controlled Study. Skin Pharmacol Physiol. 2019;32(2):101-108. doi:10.1159/000497104.
Healthy Foods High in Polyphenols. WebMD website. Accessed August 2, 2021.
Heinrich U, Moore CE, De Spirt S, Tronnier H, Stahl W. Green tea polyphenols provide photoprotection, increase microcirculation, and modulate skin properties of women. J Nutr. 2011;141(6):1202-1208.
Heinrich U, Neukam K, Tronnier H, Sies H, Stahl W. Long-term ingestion of high flavanol cocoa provides photoprotection against UV-induced erythema and improves skin condition in women. J Nutr. 2006;136(6):1565-1569.
Ito N, Seki S, Ueda F. The Protective Role of Astaxanthin for UV-Induced Skin Deterioration in Healthy People-A Randomized, Double-Blind, Placebo-Controlled Trial. Nutrients. 2018;10(7):817. Published June 25, 2018.
Köpcke W, Krutmann J. Protection from Sunburn with β-Carotene—A Meta-analysis. Photochem Photobiol. 2008;84(2):284-288. doi:10.1111/j.1751-1097.2007.00253.
Lutein and Zeaxanthin: Benefits, Dosage and Food Sources. Healthline website. Accessed August 2, 2021.
Lycopene. Medline Plus website. Accessed August 2, 2021.
Lycopene. Therapeutic Research Center’s Natural Medicines website. Updated September 12, 2018. Accessed July 26, 2021.
Farrar M, Nicolaou A, Clarke K, et al. A randomized controlled trial of green tea catechins in protection against ultraviolet radiation–induced cutaneous inflammation. Am. J. Clin. Nutr. 2015;102(3):608-615.
Moehrle M, Dietrich H, Patz CD, Häfner HM. Sun protection by red wine?. J Dtsch Dermatol Ges. 2009;7(1):29-33.
Ng QX, De Deyn MLZQ, Loke W, Foo NX, Chan HW, Yeo WS. Effects of Astaxanthin Supplementation on Skin Health: A Systematic Review of Clinical Studies. J. Diet. Suppl. 2021;18:2:169-182.
Oleic Acid. Science Direct website. Accessed August 6, 2021.
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Pilkington S, Watson R, Nicolaou A, Rhodes L. Omega-3 polyunsaturated fatty acids: photoprotective macronutrients. Exp Dermatol. 2011;20(7):537-543.
Placzek M, Gaube S, Kerkmann U, et al. Ultraviolet B-induced DNA damage in human epidermis is modified by the antioxidants ascorbic acid and D-alpha-tocopherol. J Invest Dermatol. 2005;124(2):304-307.
Rhodes LE, Shahbakhti H, Azurdia RM, et al. Effect of eicosapentaenoic acid, an omega-3 polyunsaturated fatty acid, on UVR-related cancer risk in humans. An assessment of early genotoxic markers. Carcinogenesis. 2003;24(5):919-925.
Rizwan M, Rodriguez-Blanco I, Harbottle A, et al. Tomato paste rich in lycopene protects against cutaneous photodamage in humans in vivo: a randomized controlled trial. Br. J. Dermatol. 2010;164(1):154-162.
Sharkey L. What Dark-Skinned People Need to Know About Sun Care. Healthline website. Published July 30, 2019. Accessed August 5, 2021.
Singh K, Patil S, Barkate H. Protective effects of astaxanthin on skin: Recent scientific evidence, possible mechanisms, and potential indications. J Cosmet Dermatol. 2019;19(1):22-27.
Stahl W, Heinrich U, Aust O, Tronnier H, Sies H. Lycopene-rich products and dietary photoprotection. Photochem Photobiol Sci. 2006;5(2):238-242.
Stahl W, Heinrich U, Wiseman S, Eichler O, Sies H, Tronnier H. Dietary tomato paste protects against ultraviolet light-induced erythema in humans. J Nutr. 2001;131(5):1449-1451.
Sun Safety. Centers for Disease Control and Prevention website. Accessed August 2, 2021.
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The Difference Between UVA and UVB Rays. Paula’s Choice website. Accessed July 26, 2021.
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Top Foods with Polyphenols. Healthline website. Accessed August 2, 2021.
Ultraviolet (UV) radiation. U.S. Food & Drug Administration website. Accessed August 2, 2021.
Vitamin C and Skin Health. Oregon State University website. Accessed August 2, 2021.
Vitamin C. National Institutes of Health Office of Dietary Supplements website. Accessed August 3, 2021.
Vitamin E and Skin Health. Oregon State University website. Accessed August 2, 2021.
Vitamin E. National Institutes of Health Office of Dietary Supplements website. Accessed August 3, 2021.
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Zerres S, Stahl W. Carotenoids in human skin. Biochim Biophys Acta Mol Cell Biol Lipids. 2020;1865(11):158588.

Feeding and eating disorders such as avoidant/restrictive food intake disorder, or ARFID, can have several causes with serious consequences. Registered dietitian nutritionists — especially those working with pediatric patients or clients with eating disorders — should be aware of signs and symptoms of ARFID, considerations for treatment and with which health care professionals to collaborate and refer to for comprehensive care.

What Is ARFID?
ARFID occurs when there is a change in eating or feeding that makes it impossible for the person to meet their caloric and nutritional needs. A child with ARFID may not eat or drink enough calories or nutrients to grow normally, and adults may not eat or drink enough to maintain normal body functions. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, or DSM-5, this change in eating must be accompanied by one or more of the following: “significant weight loss (or failure to achieve expected weight gain or faltering growth in children), significant nutritional deficiency, dependence on enteral feeding or oral nutrition supplements or marked interference with psychosocial functioning.”

The DSM-5 also states ARFID cannot occur simultaneously with anorexia nervosa or bulimia nervosa, nor can it be better explained by an underlying medical condition or mental disorder. Additionally, it cannot be diagnosed if the condition is better attributed to food insecurity or religious practices.

Like anorexia nervosa, ARFID results in an avoidance of food; unlike anorexia nervosa, individuals with ARFID are not concerned with body shape or size. Rather, the disorder presents in three ways: a lack of interest in food or a low appetite (the restrictive subtype); cutting out certain foods due to sensory sensitivities (the aversion subtype); or a restricted intake caused by a traumatic event or fear of a traumatic event, such as choking or vomiting (the avoidant subtype).

Making a Diagnosis
Before the addition of ARFID to the DSM-5 in 2013, children with ARFID often were described by practitioners as having “Selective Eating Disorder” or were diagnosed with “Feeding Disorder in Infancy or Early Childhood.” Only children under 6 could be diagnosed with FDIEC, whereas there is no age limit when diagnosing ARFID. This change acknowledges that, while ARFID may be more common among children and teenagers, it can persist into adulthood if left untreated.

“ARFID is a fairly new diagnosis, which was added to the eating disorders section of the DSM-5,” says Anna Lutz, MPH, RD, LDN, CEDRD-S, co-creator of Sunny Side Up Nutrition and co-owner of Lutz, Alexander and Associates Nutrition Therapy in Raleigh, N.C. “Because of this addition, more and more individuals that meet the criteria for ARFID are now being treated at higher levels of care.”

People with autism spectrum conditions, attention deficit hyperactivity disorder and intellectual disabilities, as well as children with anxiety disorders and those who do not outgrow normal picky eating, are at a higher risk of developing ARFID. People of all ages and genders are at risk of developing ARFID, though it is more common in children and young people and is thought to be more common in males.

Typically, children with picky eating will still eat foods from all food groups and their pickiness does not interfere with their growth and development. Children with ARFID, however, may avoid eating entire food groups and their extreme picky eating can stunt growth and hinder weight gain. Usually, ARFID is accompanied by anxiety and worry around eating. The disorder can disrupt family dynamics and make eating around others distressing and anxiety-provoking.

Physical signs of ARFID include stomach cramps or other gastrointestinal pain, dizziness or fainting, fatigue and sleep disturbances, difficulty concentrating, amenorrhea and the propensity to get cold easily.

How to Treat ARFID
Like other eating disorders, when treating patients or clients who are diagnosed with ARFID, collaboration with health care professionals in a team approach is preferred. RDNs, psychotherapists, speech language pathologists, occupational therapists and physicians may be involved.

Lutz says that because ARFID is a newer diagnosis, more research is needed to determine best treatments. Therefore, there is no definitive way a practitioner should treat a patient or client with ARFID. While many current therapies mimic traditional eating disorder treatments such as residential care and family-based treatment, many practitioners, including Lutz, have found responsive feeding therapy, or RFT, to be helpful and hope more research will be dedicated to the subject.

Rather than trying to change the behavior of the child with ARFID (for instance, trying to get them to eat more food), RFT puts more emphasis on the relationship between the caregiver or parent and the child. “Responsive feeding therapy is a treatment that takes into account the feeding relationship between the caregiver and the individual — the connection between them and collaboration between them,” Lutz says.

According to Lutz, this approach empowers the caregiver and the child and encourages caregivers to listen to what their child is telling them about what they are or aren’t eating. “A good first step is for parents and caregivers to notice how they feel when they’re feeding. Since many feeding issues come from anxiety, if a caregiver is also feeling worried and experiencing anxiety, that can be a communication to the child.”

Self-reflection from the caregiver or parent can help facilitate a calmer eating environment, which, Lutz says, RDNs should encourage before addressing more logistical questions, such as which foods parents are serving their children.

Additionally, RDNs should determine which ARFID subtype is present, since each subtype may require a different approach. For instance, Lutz says treatment of a child with avoidant ARFID who is afraid to eat because of a traumatic event such as choking may require more coaching of the parent. “A parent may feel scared to push their child who had a choking incident, or the opposite — a parent forcing too much may feed into the anxiety. It usually requires a lot of coaching for the parent to take charge and reassure their child that they’re going to be OK.”

While a standardized approach to treating ARFID may be far off, RDNs can help progress the field by being aware of the warning signs, learning more about responsive feeding therapy, encouraging caregivers and parents and learning together with their fellow practitioners.

Learn more about various treatments and approaches for each subtype of ARFID, warning signs that may indicate a referral to a speech language pathologist and which treatments may be more harmful than helpful by watching the FNCE® 2020 session Picky, Selective, ARFID? Assessment and Treatment of Pediatric Feeding Difficulties.

References

Avoidant Restrictive Food Intake Disorder (ARFID). National Eating Disorder Association website. Accessed May 21, 2021.
Balla Kohn J. What Is ARFID? J Acad Nutr Diet. 2016;116(11):1872.
Interview with Anna Lutz, MPH, RD, LDN, CEDRD-S.
Lesser J. More than picky eating—7 things to know about ARFID. National Eating Disorder Association website. Accessed June 15, 2021.
Manikam R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. 2000;30(1):34-46.
Picky, Selective, ARFID? Assessment and Treatment of Pediatric Feeding Difficulties. Food & Nutrition Conference & Expo^™ 2020 recorded session. Published October 21, 2020. Accessed May 21, 2021.
Responsive Feeding Therapy: Values and Practice. Responsive Feeding Therapy website. Published August 16, 2020. Accessed May 24, 2021.
Thomas J, Lawson E, Micali N, et al. Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Curr Psychiatry Rep. 2017;19(8):54.
What is ARFID? An Overview of the Often-Missed Eating Disorder. Central Coast Treatment Center website. Published October 2020. Accessed May 24, 2021.

Defining Placebo and Nocebo
The term placebo in health care dates to at least the late 1700s, when British physician William Cullen used the word to describe his administration of medications at a lower dose to patients with incurable disease. Cullen claimed he did this to please and provide comfort to his patients. Although there was no cure for their disease, he knew his patients expected a treatment and offering them medication provided satisfaction. Cullen employed what is now considered an “active placebo,” when a real drug is given at a sub-therapeutic dose.

In 1811, Hooper’s Medical Dictionary defined placebo as “any medicine adapted more to please than benefit the patient.” Today, Merriam-Webster defines placebo as “a usually pharmacologically inert preparation prescribed more for the mental relief of the patient than for its actual effect on a disorder.”

While a placebo generates positive effects, a nocebo does the contrary. According to Merriam-Webster, a nocebo is “a harmless substance or treatment that when taken by or administered to a patient is associated with harmful side effects or worsening of symptoms due to negative expectations or the psychological condition of the patient.”

Beyond a Pill
Talk of placebos may conjure images of sugar pills, but research suggests a pill isn’t the only thing inducing placebo effects. The very act of visiting a health care provider may be a form of placebo. The influence of the patient-provider relationship on health outcomes is considered “placebo-rapport,” or the placebo aspect of routine care when no therapeutic intervention is given. A therapeutic ritual or treatment, such as taking a pill at the same time each day as prescribed by a doctor, is considered “placebo-treatment.”

Many studies support the potential of placebo-treatment and placebo-rapport. One example is a randomized controlled trial of people with irritable bowel syndrome who were given acupuncture with dummy needles (placebo-treatment) and spent varied lengths of time with the practitioner (placebo-rapport). The group that spent the most time with the practitioner received a 45-minute initial consultation, during which the practitioner displayed “a warm, friendly manner” and employed “active listening (such as repeating the patient’s words, asking for clarifications); empathy (such as saying ‘I can understand how difficult IBS must be for you’); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (‘I have had much positive experience treating IBS and look forward to demonstrating that acupuncture is a valuable treatment in this trial’).” Another group received a five-minute initial consultation where interaction with the practitioner was limited, and a third group received no treatment. of confidence and positive expectation (‘I have had much positive experience treating IBS and look forward to demonstrating that acupuncture is a valuable treatment in this trial’).” Another group received a five-minute initial consultation where interaction with the practitioner was limited, and a third group received no treatment.

After six weeks, the group with the highest level of interaction with a practitioner saw significantly greater results: a higher global improvement scale, higher adequate relief of symptoms, the largest declines in symptom severity score and the greatest increase in quality of life. The group that received the five-minute consultation reported better results (with the exception of quality of life) than the group that received no treatment at all.

Not only might the length of time spent with a practitioner impact health outcomes, but some studies suggest demeanor, words and attitude of a practitioner may have influence, noting poorer outcomes or nocebo effects in people whose doctor expressed doubt in a particular treatment or who had a negative demeanor.

Placebo-rapport also may enhance the efficacy of real drugs, not only placebos. For instance, one study found that when a pain medication was administered to patients without their knowledge, it had no effect. When the medication was administered again by a clinician with the patient’s knowledge, the drug was found to be more effective than placebo.

Ethics and Deception
The deception sometimes involved in using placebos — administering fake medications or providing a fake procedure without a patient’s knowledge or consent — has some wondering how ethical placebos in practice might be.

But recent studies have shown deception may not need to be a factor. For instance, a 2016 randomized controlled study examined the impact of “open-label placebos” — knowingly taking a placebo — on lower back pain. During this study, all participants were educated on placebo effects, including how powerful placebo effects can be, the potential impact of a positive attitude on inducing placebo effects and the importance of taking the placebo pills each day. Half of the participants took placebo pills, which were in a bottle labeled “placebo pills,” and the other half continued treatment as usual without taking placebo pills.

After three weeks, the open-label placebo group saw a significant reduction in pain and disability related to pain compared to the group who did not take the placebo pills. During interviews, some participants explained they experienced increased pain on a day when they forgot to take the placebo pills and one participant even said, “it worked so well that it has to contain something.”

A 2021 systematic review identified 11 studies involving open-label placebos and found significant positive effects of open-label placebos when compared to no treatment. The conditions identified as having positive results from openlabel placebos included seasonal allergies, IBS, chronic back pain, migraine, fatigue in cancer survivors, attention deficit hyperactivity disorder, menopause hot flashes and major depressive disorder.

Placebo Conditions
Placebos target symptoms — not diseases — particularly subjective or self-perceived symptoms. For example, a placebo will not cure cancer or shrink a tumor, but it might reduce a person’s perceived pain from radiation or nausea from chemotherapy. In general, placebos are shown to be most effective for psychological conditions and there are more studies showing promise for placebos in cases such as pain management, stress-related insomnia and cancer treatment side effects.

Mechanisms of Placebo
As research continues to test the possibilities of placebos, interest on exactly how placebos work is rising. Researchers believe the answers are in the brain.

To date, research suggests placebos work by activating specific areas of the brain involving autonomic responses, or involuntary bodily functions, such as heart rate, sweating or digestion; neuroendocrine responses, or fluctuations in hormones controlled by the hypothalamus–pituitary–hormone systems; and neurotransmitters such as cannabinoids, dopamine and opioids in the brain. Awareness of the person receiving the placebo has been a key factor in studies, showing a significantly reduced response to medications and placebos when an individual is unaware of its administration.

While many specifics concerning the biological processes of the placebo effect are still uncertain, it is evident that psychological factors play a role, including the beliefs and attitude of the person taking the placebo in addition to the context in which it is given, by whom it is given and the attitudes and beliefs of the administrator.

Implications for RDNs
It may be beneficial for registered dietitian nutritionists to make note of the influence of placebo-rapport and attempt to utilize its benefits. Authors of a 2019 paper provided a framework for employing placebo-rapport, stating the phenomenon can be broken down into two key factors: the patient’s or client’s belief that a practitioner (1) “gets it” and (2) “gets me,” meaning the practitioner demonstrates knowledge and competency but also displays genuine care, empathy and engagement.

Competency is further dissected into two factors: perceived competency as it relates to the specific patient or client — showing understanding of their family history, disease and treatment — and competency in general — the practitioner’s educational background, training and ability to confidently articulate concepts. The two-factor breakdown also is true for care and empathy. One factor is patient- and client-specific — taking interest in the patient’s or client’s life outside of a health care context, listening to their stories, understanding their values, practicing active listening and using their name — and then in general, being friendly to co-workers, smiling and engaging socially.

RDNs who work with patients or clients to help manage symptoms, such as those related to IBS or cancer treatments, may particularly benefit from the concept of placebo-rapport. By emulating behaviors of practitioners in placebo effect research, such as active listening, empathy and communication of confidence — behaviors also emphasized in motivational interviewing — RDNs can serve as a positive influence for their patients and clients, which may ultimately increase the success of their nutrition therapy and health outcomes.

References

APA Dictionary of Psychology: Autonomic nervous system (ANS). American Psychological Association website. Accessed March 29, 2021.
Carvalho C, Caetano J, Cunha L, et al. Open-label placebo treatment in chronic low back pain: a randomized controlled trial. Pain. 2016;157(12):2766-2772.
Finnis D. Chapter One – Placebo Effects: Historical and Modern Evaluation. Int Rev Neurobiol. 2018;139:1-27.
Howe L, Leibowitz K, Crum A. When Your Doctor “Gets It” and “Gets You”: The Critical Role of Competence and Warmth in the Patient-Provider Interaction. Front Psychiatry. 2019;10:475.
Kaptchuk T, Miller F. Placebo Effects in Medicine. N Engl J Med. 2015;373:8-9.
Kaptchuk T, Kelley J, Conboy L, et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ. 2008;336(7651):999-1003.
Nocebo. Merriam-Webster website. Accessed March 29, 2021.
Placebo. Merriam-Webster website. Accessed March 29, 2021.
Sussex R. Describing Placebo Phenomena in Medicine: A Linguistic Approach. Int Rev Neurobiol. 2018;139:49-83.
The power of the placebo effect. Harvard Health Publishing Harvard Medical School website. Updated August 9, 2019. Accessed March 29, 2021.
von Wernsdorff M, Loef M, Tuschen-Caffier B, et al. Effects of open-label placebos in clinical trials: a systematic review and meta-analysis. Sci Rep. 2021;11(3855).
Wager TD, Atlas LY. The neuroscience of placebo effects: connecting context, learning and health. Nat Rev Neurosci. 2015;16(7):403-418.

Since their debut four decades ago, the Dietary Guidelines for Americans have experienced quite the evolution. It might seem as if the 2020-2025 Dietary Guidelines, released in December 2020, are more of the same compared to their recent predecessors, but there are some significant changes to both the ninth edition as well as the procedures behind the scenes.

Enhanced Transparency
To promote transparency, some notable changes were made to the process of developing the 2020-2025 Dietary Guidelines for Americans and selecting the Dietary Guidelines Advisory Committee. For the first time, the U.S. Departments of Agriculture and Health and Human Services were responsible for selecting topics and scientific questions to be considered by the Committee before the Committee was established.

Furthermore, the agencies allowed for public comment on the topics and scientific questions before the Committee was selected. This change not only supported transparency, but also helped ensure the most appropriate Committee members were selected — members whose expertise matched the topics.

When the USDA and HHS issued a public request for Committee nominations, they also provided an outline of specific information needed in all nomination packages — another first. To better avoid conflicts of interest, everyone under final consideration for the Committee was required to submit a Confidential Financial Disclosure Report before being selected. Previously, this report was submitted after Committee members were already selected.

For the first time, the Committee had a sixth meeting, which was added to focus solely on reviewing the draft report. According to Jackie Haven, deputy administrator of the USDA Food and Nutrition Services’ Center for Nutrition Policy and Promotion, this allowed the Committee to discuss overarching findings and the draft of their scientific report, which previous Committees had not done.

Additionally, the Committee was required to explain how it planned to answer each scientific question — by conducting a systematic review using data analyses, food pattern modeling analyses or the USDA’s Nutrition Evidence Systematic Review — and post it online for public viewing and comment.

Of the six Committee meetings (all open for public viewing and some for in-person attendance), the public had two opportunities to provide oral comments rather than just one. And for the first time in two decades, a meeting was held outside of the Washington, D.C., metro area.

According to the Dietary Guidelines website, these changes were an effort to “promote a deliberate and transparent process, better define the expertise needed on the Committee and ensure the scientific review conducted by the Committee would address Federal nutrition policy and program needs.”

Life Stages
A highly anticipated update to the 2020-2025 Dietary Guidelines for Americans is the addition, or reorganization, of information into life stages. The life stages are organized into infants and toddlers (birth through 23 months); children and adolescents (ages 2 through 18, further broken down into groups of ages 2 through 4, 5 through 8, 9 through 13 and 14 through 18); adults (ages 19 through 59); women who are pregnant or lactating; and older adults (ages 60 and older).

The structural change complements a few overarching guidelines and themes: “Follow a healthy dietary pattern at every life stage,” and, “It is never too early or too late to eat healthy.” Haven explains that organizing the Dietary Guidelines by life stage allowed for more tailored guidance specific to each stage of life and showcased how healthy dietary patterns can be carried forward into the next life stage.

New Populations
Thanks to the Agricultural Act of 2014, guidance for infants and toddlers ages 0 to age 24 months and women who are pregnant or lactating are now included in the ninth edition of the Dietary Guidelines.

Guidelines for infants and toddlers address factors such as when to introduce complementary foods and potentially allergenic foods, how to determine developmental readiness for eating solid foods, and vitamins and minerals of concern. The newly added guidance for women who are pregnant or lactating includes information such as working with a health care provider to achieve weight management goals and special nutrient needs such as increased folate, iodine and iron.

An Emphasis on Culture, Budget and Preference
In every chapter, the guidelines focus on food groups and subgroups rather than specific foods, reiterating that the Dietary Guidelines are not prescriptive, but rather an outline or framework. This links to another key recommendation or overarching guideline: “Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions and budgetary considerations.”

“As our society grows and evolves, so too does our knowledge about the importance of representation and equity,” Haven says. “In the 2020-2025 Dietary Guidelines for Americans, we wanted to be crystal clear about the importance of celebrating the rich diversity of the people who live here and respecting cultural foodways.”

A broad spectrum of food examples is included in the guidelines to fit diverse preferences. For instance, taro leaves are an example of dark green vegetables, calabaza is listed for red and orange vegetables and cassava and plantains for starchy vegetables. Haven says the USDA and HHS made a concerted effort to represent all Americans through careful consideration of the food examples and images selected, showcasing the diversity of food and people through representation in age, life stage, race, ethnicity, body size and ability.

A Change in Name

The vegetable subgroup known as “legumes” is now called, “beans, peas and lentils.” While the foods in the subgroup have not changed, the USDA and HHS say the name is a more accurate description of the foods within the group.

Nutrient Density and Dietary Patterns
A noticeable emphasis of the 2020-2025 Dietary Guidelines for Americans is their reiteration of choosing nutrient-dense foods and focusing on dietary patterns — how someone regularly eats overall, not just a single meal. These are not new concepts to the Dietary Guidelines, but their presence appears more pronounced.

The guidelines state people should strive to achieve healthy dietary patterns that focus on nutrient-dense foods — foods that provide vitamins, minerals and other health-promoting components with little or no added sugars, saturated fat and sodium — to reduce the risk of chronic disease at every life stage.

The Dietary Guidelines also make prominent the percentage of total calories that should come from nutrient-dense foods versus the percentage that might come from other sources, such as foods and beverages that include sources of added sugars and saturated fats. The Dietary Guidelines state 85 percent of total calories should come from nutrient-dense foods to healthfully meet food group recommendations.

“With the limits on added sugars and saturated fat, it is important to underscore that there is not a lot of room for extras,” Haven says. “The majority of the foods people eat should be in nutrient-dense forms to help them meet their nutrient needs without consuming excess calories. For this reason, nutrient-density is a foundational piece of this edition and emphasized throughout each chapter.”

Controversy?
The 2020 Dietary Guidelines Advisory Committee recommended the 2020-2025 Dietary Guidelines for Americans set the limit of added sugars to 6 percent of total calories — a 4-percent drop from the previous guidelines. Essentially, the Committee concluded that if 85 percent of total calories came from nutrient-dense foods and the remaining 15 percent came from solid fats and added sugars, then added sugars should be limited to 6 percent or less to stay within the recommended total calories. The Committee also recommended limiting alcoholic beverages for both men and women who choose to drink to no more than one drink per day on days when alcohol is consumed. Like its predecessor, the 2020-2025 Dietary Guidelines for Americans specify that on days when alcohol is consumed, adults of legal age who choose to drink (and it is not contraindicated, such as during pregnancy) should limit consumption to two drinks or less per day for men and one drink or less per day for women. Ultimately, the USDA and HHS did not adopt the recommendations of the Committee, stating in a report that “there was not a preponderance of evidence in the Committee’s review of studies since the 2015-2020 edition to substantiate changes to the quantitative limits for either added sugars or alcohol.” The full response is available here.

Put It Into Practice
Registered dietitian nutritionists should become familiar with the 2020-2025 Dietary Guidelines for Americans to best counsel patients or clients and adequately answer questions. For a quick overview, the USDA offers the Top 10 Things You Need to Know About the Dietary Guidelines for Americans, 2020-2025. Additionally, RDNs can recommend patients or clients visit MyPlate.gov to take advantage of newly released features such as the new MyPlate quiz and personalized plans. The Dietary Guidelines website also includes additional resources for health professionals.

References

Dietary Guidelines Advisory Committee. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. Dietary Guidelines website. Accessed January 22, 2021.
The Process to Develop the Dietary Guidelines for Americans, 2020-2025. Dietary Guidelines website. Accessed January 22, 2021.
Top 10 Things You Need to Know About the Dietary Guidelines for Americans, 2020-2025. Dietary Guidelines website. Accessed January 22, 2021.
USDA-HHS Response to the National Academies of Sciences, Engineering, and Medicine: Using the Dietary Guidelines Advisory Committee’s Report to Develop the Dietary Guidelines for Americans, 2020-2025. Dietary Guidelines website. Accessed January 22, 2021.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. Dietary Guidelines website. Published December 2020. Accessed January 22, 2021.

Understanding Imposter Syndrome
Imposter syndrome is associated with feelings of being undeserving of achievements or praise for accomplishments. A person with imposter syndrome may think of themself as a fake, phony, fraud — or imposter — and may attribute their accomplishments to luck rather than personal capabilities. In addition to feeling like a fraud, an individual with imposter syndrome also may fear detection or worry that those around them will eventually discover they are not as competent as they seem.

People who experience imposter syndrome generally lack the ability to internalize success, meaning they often seek external validation or praise from others, which paradoxically, they feel they do not deserve. This can further exacerbate feelings of imposter syndrome. Sufferers of the syndrome may believe success is solely determined by what people think of them, rather than what they think of themselves. When a person with impostor syndrome achieves success, it’s usually accompanied by feelings of relief, rather than joy or pride, and their ability to repeat success is frequently self-doubted.

Prevalence and Personality
Imposter syndrome may be more prevalent or likely to occur during major life events, such as a new position at work. It also can be induced by praise and recognition, such as an honor or award.

Women — particularly women of color — were originally thought to be more susceptible, though recent research suggests both men and women are equally vulnerable to experiencing imposter syndrome. In general, ethnic minorities experience disproportionately higher rates of imposter syndrome, which may be in part due to a lack of representation that can make people of color and other underrepresented individuals feel like outsiders. Additionally, it appears to be more common for students, people in their 20s or those early in their career, though it can be experienced by anyone of any age and experience level.

Individuals with imposter syndrome may cope by obsessively overpreparing. They may prefer to maintain a low profile or stay out of the spotlight at work to avoid scrutiny. Additionally, they may enlist charm and humor to win the approval of peers and dodge being “found out” as an imposter.

Imposter syndrome has not been extensively studied among registered dietitian nutritionists. However, existing research suggests imposter syndrome is experienced by other health care professionals such as nurses, physicians, and medical and pharmacy residents whose personality traits may be similar to those of RDNs.

Research is limited and doesn’t pinpoint exactly why RDNs could experience imposter syndrome. According to Dylan Bailey, MS, RD, chair of the Cultures of Gender and Age member interest group and moderator of the FNCE^® 2020 session, Power In Your Presence: Taming Feelings of Insecurity and Imposter Syndrome, many theories point to the fact that RDNs work in a culture that feeds self-doubt, plus psychological factors that increase susceptibility. “Dependence on approval from others, excessive worry and the drive for perfection could be partly responsible for dietitians and other health care professionals experiencing imposter syndrome,” says Bailey.

Potential Consequences
Imposter syndrome can cause great psychological distress, triggering feelings of anxiety, self-doubt and fear of failure. An individual with imposter syndrome may feel like they don’t belong or may overcompensate, which can strain relationships and may prohibit them from pursuing new opportunities, such as a new job, relationship or hobby.

Bailey notes that imposter syndrome can impair job performance, contribute to burnout and decrease job satisfaction. “Consistently going at 1,000 percent, employees may overproduce and overwork to prove they are capable, which can lead to burnout and ultimately be counterproductive,” he says. “Capable, competent employees may also miss opportunities because they feel unworthy.”

Imposter syndrome also can affect relationships. “When you have someone who’s always working and trying to prove themselves in a professional capacity to avoid feeling like a phony, a fake or a fraud, think about what that may do to interpersonal relationships and mental well-being,” says Bailey.

Fighting Feelings of Fraudulence
The first step in solving a problem is to recognize there is a problem. Evaluate if you struggle with imposter syndrome and, if you do, train yourself to recognize the thoughts and feelings associated with the syndrome as they occur. Understand that these thoughts and feelings are not rooted in fact, and start engaging in positive self-talk.

When negative thoughts occur, reframe them by acknowledging your expertise, earned accomplishments and achievements. One way to make reframing easier is to keep a list of past accomplishments, both big and small. Consider compiling a “good news folder,” filled with documents that remind you of significant career milestones, such as a letter notifying you of passing the RDN exam, a college diploma or certificate of achievement. Include recommendation letters, emails of praise and other items that remind you of earned accomplishments and abilities to succeed.

Recognize and acknowledge that everyone makes mistakes — and expect to make mistakes, especially at the beginning of a new job or experience. When a mistake occurs, identify small actions that can lead to improvement.

Confide in a trusted friend who can remind you of your successes and encourage you. Connect with a mentor who has taken a similar career path and can guide you — and consider being a mentor to someone else. “Our profession is built on the accumulation of knowledge, and having a mentor to guide you through the things we face day in, day out as dietitians can be a protective measure against imposter syndrome,” says Bailey. A mentor also can listen to your concerns and provide reassurance and guidance, helping you feel better equipped to handle tasks and less like an imposter.

For individuals who may not have access to a mentor, Bailey adds that a “good news folder” allows you to be your own mentor. “It can reinforce confidence that you are not a fraud, you are capable, you are competent, you are doing a good job and you’re supposed to be where you are,” he says.

Additionally, consider seeking professional help for personalized tips and strategies to combat feelings of imposter syndrome. Finally, be kind to yourself. Self-reflection and change is difficult work. Continue to affirm your earned success and constantly remind yourself that you are not a fraud.

References

Bravata D, Watts S, Keefer AL, et al. Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review. J Gen Intern Med. 2020;35(4):1252-1275. doi:10.1007/s11606-019-05364-1.
Imposter Syndrome. Psychology Today website. Accessed November 19, 2020.
Power in Your Presence: Taming Feelings of Insecurity and Imposter Syndrome. 2020 FNCE® Session.
Young V. The 5 Types of Imposters. ImposterSyndrome.com website. impostorsyndrome.com/5-types-of-impostors. Accessed December 4, 2020.

While factors such as muscle loss and diminished handgrip strength are considered when diagnosing malnutrition in adults, some related contributing factors may be overlooked or underestimated, such as functional mobility. This could potentially be remedied — or at least improved — if RDNs collaborate with fellow health care professionals, particularly physical therapists.

What Is Malnutrition?
The Academy of Nutrition and Dietetics defines malnutrition as the “inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle stores, including starvation-related malnutrition, chronic disease orcondition-related malnutrition and acute disease or injury-related malnutrition.” Malnutrition can occur in people who are both underweight or overweight (including obese) and is also known as “poor nutrition” or “undernutrition.”

It has been estimated that up to half of all patients entering the hospital are malnourished or at risk for malnutrition. Yet during their stay at an acute care facility, only 7 percent of patients aretypically diagnosed with malnutrition, which can lead to poorer outcomes. For instance, malnourished surgical patients are two to three times more likely to experience complications or death after a procedure, and hospital costs can be twice as much for someone with malnutrition.

Functional Mobility and Malnutrition
While the cause and remedy of malnutrition may seem as straightforward as making changes to the diet, there are several factors to consider. For example, functional mobility: the ability to move and perform everyday tasks or activities of daily living, such as standing up from a chair, getting out of bed, brushing the teeth or taking a shower — anything that involves moving to perform common daily tasks.

Impaired functional mobility can hinder a person’s access to proper nutrition and hydration. For instance, a decrease in the ability to stand for long periods may render a person unable to cook at home. A decreased ability to walk and drive may prevent someone from being able to go to the grocery store. Additionally, decreased functional mobility can impact fine motor skills such as the ability to hold utensils, pick up a pot or pan, or hold a glass of water long enough to drink.

Understanding a patient’s or client’s functional mobility is critical when making nutrition recommendations for treating or preventing malnutrition. For example, if a patient or client is sent home on enteral or parenteral nutrition, do they have the strength and ability to set it up independently? Can they walk around the house with it, or will it impede their mobility?

“If the RDN knows a patient has difficulty standing up or that they’re weaker in their dominant hand, the nutrition prescription, advice or education will be different based on the person’s ability to move,” says Patrick Berner PT, DPT, RDN, who owns Fuel Physio LLC in South Carolina and serves as adjunct faculty for doctor of physical therapy programs at Baylor University, Anderson University and South College.

Working with Physical Therapists
Berner says collaborating with PTs can help RDNs get a better grasp on a patient’s or client’s functional mobility. He likens it to getting a different perspective or deeper look, since it’s not uncommon for PTs to get more time or more frequent visits with patients and clients in therapy. PTs may be able to answer an RDN’s questions more accurately or more in-depth than the patient or client. “An RDN can get a general sense of mobility status by asking the patient questions, but the difficult component is that the RDN may get a different answer than what the PT assesses,” Berner says. For instance, a patient or client may tell the RDN they can stand, but the PT can provide more detail, such as the person can stand only with assistance and no longer than 10 minutes at a time.

Likewise, Jacob Mey, PhD, RD, a postdoctoral research fellow at Pennington Biomedical Research Center’s Integrated Physiology and Molecular Medicine Lab, at Louisiana State University, believes the benefits and importance of collaborating with PTs is reciprocal. “PTs’ goals are to support the physical recovery of the patient, and we know nutrition can help that recovery,” Mey says. “PTs can reinforce nutrition recommendations from the RDN and give additional feedback from the patient that the RDN may not get.”

Both Berner and Mey stress the need for and benefits of RDNs collaborating with PTs and the entire health care team for the treatment of malnutrition.

For More Information

View the webinar Malnutrition Across the Lifespan: Viewed Through the Lenses of Registered Dietitian Nutritionists and Physical Therapists for tips on reaching out to PTs, ways to foster collaboration between dietetic interns and PT students and more.

Learn about the Nutrition Focused Physical Exam Hands-on Training Workshops and how to attend.

Read the Journal of the Academy of Nutrition and Dietetics article “Malnutrition Care During the COVID-19 Pandemic: Considerations for Registered Dietitian Nutritionists” for guidance on nutrition care for adults with suspected or confirmed COVID-19 infections in various health care settings.

References

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for Nutrition Care. [Malnutrition (undernutrition) (NC4-1)].
Bouça-Machado R, Maetzler W, Ferreira JJ. What is Functional Mobility Applied to Parkinson’s Disease? J Parkinsons Dis. 2018;8(1):121-130.
Guenter P, Jensen G, Malone, A; et al. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.
Malnutrition Across the Lifespan: Perspectives from Registered Dietitians and Physical Therapists webinar. Accessed August 5, 2020.
Why Malnutrition Matters. MQII Malnutrition Quality Improvement Initiative website. Accessed August 12, 2020.

Lesbian refers to women who are sexually or romantically attracted to women. Although gay can be used as a general term, it typically refers to men who are sexually or romantically attracted to men. Bisexual is being attracted to two or more gender identities. Transgender or trans (but not transgendered) is a term used to describe someone who does not identify with the biological sex assigned at birth; this may be (but is not limited to) a man who was assigned female at birth or a woman who was assigned male at birth.

The term queer can be viewed as derogatory by some but is gaining positive acceptance and refers to a variety of sexual orientations and gender identities. Questioning represents someone who is unsure of their sexual orientation or gender identity. Ally is a person who provides support and serves as an advocate. Asexual is the sexual orientation of someone who identifies as having no sexual attraction to anyone, and intersex is a person born with sexual anatomy that does not fit conventional classifications of male or female.

Gay, lesbian, bisexual and asexual are terms used to describe sexual orientation, or how a person characterizes their physical, emotional and romantic attachments to other people. Other sexual orientations include pansexual (attracted to all gender identities), demisexual (attracted only to those with whom an emotional connection is formed), graysexual (occasionally or infrequently experience sexual attraction but usually at a lower intensity) and more.

Gender Concepts and Terminology
While individuals have a sex assigned at birth based on factors such as genitalia and chromosomes, a person’s gender identity refers to their inner sense of being male, female, both or possessing no gender at all. Nonbinary is a term used to describe an individual who identifies as neither male nor female. Gender-neutral describes an individual who prefers not to be defined by a gender or pronouns such as she/her/hers or he/him/his, preferring instead the pronoun “they” or “them.” Nonbinary individuals may also prefer they or them pronouns.

Gender identity may or may not match sex assigned at birth or it may change over time, which can be described as gender-fluid. When an individual’s gender identity matches sex assigned at birth, it is known as cisgender.

Gender expression is how an individual expresses their gender identity and can include aspects such as clothing choices, hair style and other physical traits or social expression through choice of pronouns or name. Gender nonconforming refers to an individual with gender expression outside the norms of traditional femininity and masculinity. Gender perception refers to the way an individual’s gender is perceived by others.

Creating a More Inclusive Practice
Registered dietitian nutritionists and other nutrition and dietetics practitioners can take simple and practical steps to be more inclusive and affirming in their practice. Becoming familiar with basic terminology and concepts is a great start; remaining interested and open to learning more to enhance cultural competence is equally important. There is always something left to learn; do not be afraid to ask clarifying questions of clients or patients, if needed.

Ask clients or patients their preferred pronouns and consider purchasing pronoun pins to wear. When in doubt, use gender-neutral pronouns. Avoid gender-specific words such as sir, ma’am, guys and girls; opt instead for words such as you, folks and you all. Practice using they/them pronouns — if a slipup occurs during a session, simply apologize and move on without making it a big deal. Additionally, keep in mind that LGBTQ+ identities are considered protected health information and covered by the Health Insurance Portability and Accountability Act of 1996, or HIPAA.

Modifying the language on client and patient intake forms is another way to be more inclusive. Consider asking an individual’s gender identity in addition to sex assigned at birth. Pediatric RDNs may consider changing “mother and father” to “parents and guardians.”

Additional steps may include designating an all-gender restroom, training staff on appropriate language and behaviors and ensuring referrals to other health care practitioners are LGBTQ+ inclusive.

References

443. Engaging LGBTQ Clients in Nutritional Counseling Through Cultural Humility webinar. FNCE® 2018. Academy of Nutrition and Dietetics.
All About Being LGBTQ. Planned Parenthood website. Accessed May 20, 2020.
Building a Foundation: LGBTQ+ Terminology, Concepts, and Affirming Communication webinar. Academy of Nutrition and Dietetics.
Gender identity & expression. Smart Sex Resource website. Accessed May 20, 2020.
GLAAD Accelerating Acceptance 2017. GLAAD website.  Accessed May 19, 2020.
Gold A. The ABCs of L.G.B.T.Q.I.A.+. The New York Times website. Updated June 7, 2019. Accessed May 19, 2020.
Intersex. Medline Plus website. Reviewed August 7, 2019. Accessed May 26, 2020.
LGBTQIA Resource Center Glossary. UC Davis website. Updated January 14, 2020. Accessed May 20, 2020.

The Importance of Diversity
As of June 2020 there were 93,320 registered dietitian nutritionists in the United States: 81.1 percent report being white, 3.9 percent Asian, 3.1 percent Hispanic or Latino, 2.6 percent Black or African American, 1.3 percent Native Hawaiian Pacific Islander and 0.3 percent American Indian or Alaskan Native. Compare that to July 2019 statistics from the U.S. Census Bureau: 60.4 percent of the population is white, 5.9 percent Asian, 18.3 percent Hispanic or Latino, 13.4 percent Black or African American, 0.2 percent Native Hawaiian Pacific Islander and 1.3 percent American Indian or Alaskan Native.

When the demographics of practitioners do not reflect those of the populations they serve, research suggests there is a higher risk for suboptimal care through compromised access, lower quality treatment and a reduced ability to build rapport. The demographics of nutrition and dietetics practitioners often do not accurately reflect the demographics of the populations they serve.

While large-scale efforts are needed to make systemic changes, RDNs and nutrition and dietetics technicians, registered, must additionally acknowledge their potential role in causing harm by addressing, recognizing and combatting biases (conscious and subconscious) and preventing microaggressions. Biases and microaggressions can impact communication, the amount of time spent with patients or clients, the ability to express empathy toward certain patients or clients and the type of treatment prescribed.

Understanding Microaggressions
Microaggressions can be defined as everyday slights, indignities, put-downs or insults directed toward an individual because of their group identity; for example, people of color, women or LGBTQ+ populations. Microaggressions are essentially an expression of biases and may be performed subconsciously or consciously, but contain a hidden insult or message directed at the target group.

Examples of racial microaggressions include a white woman clutching her purse as a Black man approaches because she believes he may be a criminal; asking a Latino person where they are from, assuming they are not American; or someone asking an Asian person for help with math, assuming all Asians are proficient at mathematics.

Microaggressions can be sorted into three categories: microassaults, microinsults and microinvalidations. Microassaults are often deliberate actions or statements meant to hurt a person, such as a white person refusing to speak to a person of color or calling that person by a derogatory name. Microinsults are subtle snubs that could take the form of sarcasm, such as assuming a person’s intelligence based on race or where they live. Microinvalidations exclude, negate or invalidate a person’s thoughts, feelings or life experience. An example may be a white person saying they “don’t see color.”

Addressing Personal Biases
To start confronting personal bias and racism, practitioners should first adopt a growth mindset and practice cultural humility, which supports learning. Rather than viewing cultural competence as an end goal, cultural humility and a growth mindset reflect the idea that learning is never complete.

As the United States becomes more diverse, practitioners should continually seek to learn more about the populations they serve. Practicing cultural humility and adopting a growth mindset could be as simple as asking a patient or client what types of foods they eat, rather than assuming based on the individual’s race or ethnicity; or it can be as in-depth as intense research and education through reading, conversation, podcasts, webinars, classes and other avenues. The main point is that this process should never end.

Start addressing and preventing microaggressions by developing appropriate language, considering the impact of what you do and do not say. For example, do you address a man with a PhD as “doctor” but address a woman with a PhD by her first name? What if the individual with a PhD is a Black person versus a white person — does that change how you address them? Does your language differ based on the race of a patient or client or the size and weight of an individual? In addition to self-reflection, itmay be beneficial to survey clients and patients to ask if your language has ever been perceived as microaggressive.

Encourage open and honest dialogue with yourself and trusted colleagues; urge them to share without ridicule. This dialogue should set in motion processes needed to create a more inclusive and equitable environment within your own practice and workplace. Write down actionable steps and goals; define what an equitable, diverse and inclusive workplace means to you and your team and revisit the conversation frequently. Eradicating discrimination, including microaggressions, cannot occur without individuals acknowledging their own role and working toward a more diverse, inclusive and equitable health care system.

References

Combatting Unconscious Bias and Preventing Microaggressions: A Professional Duty. FNCE® 2019. Academy of Nutrition and Dietetics.
Examples of Racial Microaggressions. University of Minnesota School of Public Health website. Accessed June 10, 2020.
Quick Facts United States. United States Census Bureau website. Accessed June 9, 2020.
Registered Dietitian (RD) and Registered Dietitian Nutritionist (RDN) by Demographics. Commission on Dietetic Registration website. Accessed June 10, 2020.

The Architecture of Sleep
Research suggests sleep may help remove toxins from the brain that build up during waking hours. Sleep also may help with learning new information, making memories and regulating emotions. Although sleep patterns change as we age, a full night of sleep consists of cycling through the sleep stages: stage 1, 2, 3 and rapid eye movement sleep, or REM.

A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society recommends adults get seven or more hours of sleep each night. In addition to enough sleep, quality is important. Indicators of poor sleep quality include frequently waking during the night, not feeling rested after a full night of sleep or episodes of snoring or gasping for air, which may indicate a serious sleep disorder.

Sleep and Food Choices
A lack of sleep may result in making poor food choices, eating too many calories and a higher risk of being overweight or obese. Not getting enough sleep can lead to an increase in ghrelin, a decrease in leptin or both. Leptin and ghrelin are hormones that are key in regulating appetite and food intake. In short, an increase in ghrelin means an increase in hunger and an increase in leptin means an increase insatiety or fullness.

Some research suggests not getting enough sleep may make the brain more sensitive to food stimuli, such as sights and smells, and may find food more rewarding. Not getting enough sleep also may increase the brain’s endocannabinoids, increasing hunger and appetite. Additionally, less sleep may alter resting metabolic rate — the total number of calories burned at rest and needed for basic bodily functions such as breathing. While these findings are all results of studies, most featured small sample sizes, so more research is needed.

Along with the more complicated hormonal and cerebral theories of why inadequate sleep leads to overeating comes a simpler explanation: Less sleep means more time awake, which means more time to eat.

Sleep and Health
Increases in chronic disease and deficient sleep have many scientists wondering how, or if, the two are related. So far, not enough sleep or low-quality sleep have been linked to chronic diseases such as obesity, Type 2 diabetes, cardiovascular disease, depression and other conditions including impaired immunity, social isolation, overall well-being, mortality and even suicide.

Diabetes
Lack of sleep from obstructive sleep apnea (which causes periods of stopped breathing) and other sleep disorders can lead to decreased insulin sensitivity and reduced insulin production. To compound these effects, lack of sleep also can lead to an increase of stress hormones, preventing insulin from functioning properly. Over time, increased glucose in the bloodstream (and obesity) can raise the risk of developing Type 2 diabetes.

Heart Disease
Since blood pressure decreases during sleep, a lack of sleep keeps blood pressure higher for longer periods, increasing risks for hypertension. Obstructive sleep apnea limits the amount of oxygen in the body, which can increase risk for stroke, heart attack and high blood pressure. Sleep apnea and sleep disorders may be linked to hardening of the arteries and an irregular heartbeat.

One epidemiological study found deficient sleep is connected to decreased HDL and increased LDL, suggesting that a lack of sleep can interfere with cholesterol metabolism. However, some experimental studies show mixed results.

Immunity
Some science suggests sleep deprivation can reduce the body’s ability to build up defenses against illness. One study found the immune systems of participants with healthy sleep were better at “remembering” a virus and had an enhanced ability to attack it, compared to those who did not get enough sleep.

Other studies have shown insufficient sleep can result in increased white blood cell count, indicating inflammation. Not getting enough sleep can increase inflammatory markers, stimulate immune cells and prolong recovery.

Overall Well-being
While stress can interfere with sleep, the reverse is also true: Lack of sleep can increase stress. One study found deficient sleep interfered with processing emotions, suggesting that people who do not get enough sleep may be less capable of empathy. According to the National Institutes of Health, sleep disorders may be linked to attention-deficit hyperactivity disorder, or ADHD.

People with insomnia and obstructive sleep apnea are significantly more likely to experience depression compared to individuals with healthy sleep. Not getting enough sleep and poor-quality sleep can lead to social isolation, which can lead to loneliness. Studies suggest individuals with deficient sleep also are at higher risk of suicide.

Mortality
Short sleep duration and long sleep duration are associated with an increase in all-cause mortality, meaning too much or too little sleep can increase risk of death. A meta-analysis of 57 studies found a U-shaped association between how long an individual slept and risk of death; the lowest risk was around seven hours of sleep.

Children
Growing research shows that children with deficient sleep are at higher risk of obesity, Type 2 diabetes, and mental health and behavioral problems. Children ages 6 to 12 need nine to 12 hours of sleep each night, while 13- to 18-year-olds need eight to 10 hours of sleep. Teens who do not get enough sleep may exhibit more risky behaviors, such as texting while driving or riding in the car with someone who has been drinking alcohol. The CDC estimates that 60 percent of middle schoolers and 70 percent of high schoolers do not get enough sleep.

References

1 in 3 adults don’t get enough sleep. Centers for Disease Control and Prevention website. Updated February 16, 2016. Accessed February 4, 2020.
Aho V, Ollila H, Kronholm E, et al. Prolonged sleep restriction induces changes in pathways involved in cholesterol metabolism and inflammatory responses. Sci Rep. 2016;6:24828.
Benedict C, Brooks SJ, O’Daly OG, et al. Acute sleep deprivation enhances the brain’s response to hedonic food stimuli: an fMRI study. J Clin Endocrinol Metab. 2012;97(3):E443–E447.
Besedovsky L, Lange T, Born J. Sleep and immune function. Eur J Physiol. 2012;463(1):121–137.
Brain Basics: Understanding Sleep. National Institutes of Health website. Updated August 13, 2019. Accessed February 4, 2020.
Depression and Sleep. Sleep Foundation website. Accessed February 4, 2020.
Dimitrov S, Lange T, Gouttefangeas C, Jensen A, et al; Gαs-coupled receptor signaling and sleep regulate integrin activation of human antigen-specific T cells. J Exp Med. 2019;216(3):517–526.
Ding C, Lim LL, Xu L, Kong APS. Sleep and Obesity. J Obes Metab Syndr. 2018;27(1):4–24.
Do Your Children Get Enough Sleep? Centers for Disease Control and Prevention website. Accessed February 4, 2020.
Guadagni V, Burles F, Ferrara M, Iaria G. The effects of sleep deprivation on emotional empathy. J Sleep Res. 2014;23(6):657–663.
Hanlon E, Tasali E, Leproult R, et al. Sleep Restriction Enhances the Daily Rhythm of Circulating Levels of Endocannabinoid 2-Arachidonoylglycerol. Sleep. 2016;39(3):653–664.
How Does Sleep Affect Your Heart Health? Centers for Disease Control and Prevention website. Accessed February 4, 2020.
How Much Sleep Do I Need? Centers for Disease Control and Prevention website. Accessed February 4, 2020.
Jenco M. CDC: Lack of sleep associated with risky behavior among teens. AAP news website. Accessed February 4, 2020.
Klock M, Jokobsdottir S, Drent M. The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review. Obes Rev. 2006.
Lassalin J, Rehman J, Akerstedt T, Lekander M, Axelsson J. Effect of long-term sleep restriction and subsequent recovery sleep on the diurnal rhythms of white blood cell subpopulations. Brain Behav Immun.2015;47:93-99.
Link Between a Lack of Sleep and Type 2 Diabetes. Sleep Foundation website. Accessed February 4, 2020.
McCall V. The Correlation Between Sleep Disturbance and Suicide. Psychiatric Times website. Accessed February 4, 2020.
Simon E, Walker M. Sleep loss causes social withdrawal and loneliness. Nat Commun. 2018;9:3146.
Sleep and Chronic Disease. Centers for Disease Control and Prevention website. Accessed February 4, 2020.
Sleep Deprivation and Deficiency. National Institutes of Health. Accessed February 4, 2020.
Spaeth A, Dinges D, Goel N. Effects of Experimental Sleep Restriction on Weight Gain, Caloric Intake, and Meal Timing in Healthy Adults. Sleep. 2013;36(7)981–990.
Spaeth A, Dinges D, Goel N. Resting metabolic rate varies by race and by sleep duration. Obesity (Silver Spring). 2015;23(12):2349–2356.
St-Onge M, McReynolds A, Trivedi Z, Roberts A, Sy M, Hirsch J. Sleep restriction leads to increased activation of brain regions sensitive to food stimuli. Am J Clin Nutr. 2012;95(4):818–824.
Stress and Insomnia. Sleep Foundation website. Accessed February 4, 2020.
The Connection Between Sleep and Overeating. Sleep Foundation website. Accessed February 4, 2020.
Thomas S, Calhoun D. Sleep, insomnia, and hypertension: current findings and future directions. J Am Soc Hypertens. 2017;11(2):122–129.
Why do we need sleep Sleep Foundation website. Accessed February 4, 2020.
Yin J, Jin X, Shan Z, et al. Relationship of Sleep Duration with All Cause Mortality and Cardiovascular Events: A Systematic Review and Dose Response Meta‐Analysis of Prospective Cohort Studies. J. Am. Heart Assoc.

Since the signing of the Agriculture Improvement Act of 2018 — commonly known as the 2018 Farm Bill — cannabidiol, or CBD, has flooded the marketplace. CBD seemingly is everywhere and in everything, from health and beauty products including bath salts, mascara, lotions and lipsticks to food and beverage items such as sparkling water, ice cream, restaurant menu items and candy. CBD has become so popular that Nielsen predicts the U.S. hemp-derived CBD market could become a $6 billion industry by 2025.

How It Started
Although a new farm bill is enacted approximately every five years, the 2018 Farm Bill was unlike its predecessors because it legalized the cultivation of industrial hemp with a license or permit and declassified it as a Drug Enforcement Administration, or DEA, Schedule I controlled substance. This declassification transferred supervision of hemp from the DEA to the U.S. Department of Agriculture’s Agricultural Marketing Service. Additionally, the bill expanded the possibilities for, and placed an increased emphasis on, industrial hemp research apart from standard market evaluations, which are done for business research purposes.

Defining the Substance
Hemp, marijuana, CBD and delta-9-tetrahydrocannabinol, or THC, all have had their share of the spotlight. While there is some relation between them, there are key differences.

In legislation, hemp is defined as the cannabis plant — the same cannabis plant that produces marijuana. However, it does not, and legally cannot, contain more than 0.3 percent THC. Before the 2018 Farm Bill, federal law did not differentiate hemp from other cannabis plants such as marijuana.

THC is the key psychoactive compound in marijuana that produces the sensation commonly referred to as being “high.” Marijuana plants contain higher concentrations of THC. CBD is found in both hemp and marijuana. But unlike THC, CBD is not a psychoactive compound and therefore does not provide the same “high” sensation as THC. Both CBD and THC have the same molecular structure, but one small difference in the arrangement of molecules is responsible for the big difference in their psychoactive or nonpsychoactive effects.

The human body produces its own cannabinoids, known as endocannabinoids, the endocannabinoid system (ECS) or endogenous cannabinoids. When THC is consumed, it interacts with endogenous cannabinoids to create the “high” sensations and effects. Researchers still are unsure of how CBD interacts with the ECS.

CBD Research
Early evidence suggests there may be benefits from CBD. In 2018, the U.S. Food and Drug Administration approved the first CBD drug, Epidiolex, to treat seizures associated with Lennox-Gastaut syndrome and Dravet syndrome in patients age 2 and older. Children with these serious forms of epilepsy typically do not respond to traditional therapies and anti-seizure medications, but clinical trials showed Epidiolex, along with other medications, was effective in reducing the frequency of seizures compared to placebo.

Among the general public, pain reduction is perhaps a more widely associated and touted benefit of CBD. While CBD is frequently promoted as being able to reduce chronic pain, medical research exploring and confirming the mechanisms is limited to mostly animal models, meaning more human research is needed. Other possible yet unsubstantiated benefits include a reduction in anxiety, treating inflammation and promoting sleep. Current claims on the benefits of CBD mostly are anecdotal, and more research is needed to confirm and understand these statements.

The benefits of CBD may be promising, but there are potential side effects: Some human pre-clinical and clinical trials on CBD for epilepsy and psychiatric disorders reported adverse effects such as CBD-induced drug interactions, liver problems, diarrhea, fatigue, vomiting, mood changes and extreme sleepiness.

Legal Confusion
The 2018 Farm Bill may have declassified industrial hemp as an illegal substance, but it also ushered in a lot of confusion. Is CBD legal? In short, it depends.

In a statement released by the FDA immediately following the signing of the bill, then commissioner Scott Gottlieb, MD, emphasized that despite the declassification, the FDA maintains its authority to regulate products that contain cannabis or cannabis-derived compounds under the Federal Food, Drug, and Cosmetic Act (FD&C Act) and section 351 of the Public Health Service Act. These regulations create complications for food and beverage manufacturers that wish to incorporate CBD into their products.

Under the FD&C Act, it is unlawful to use any active ingredients that are already in FDA-approved drugs, or any ingredients that were studied in substantial clinical investigations, in foods or dietary supplements. This means both food and dietary supplements containing added CBD or THC is unlawful, regardless of whether the substance is hemp-derived or not.

The FDA can issue a regulation to allow the use of CBD and THC in a food or dietary supplement. And while it held a public hearing in May 2019, allowing stakeholders to share feedback and scientific data related to CBD, the FDA has not issued any new regulations and says it will continue to uphold current guidelines until it can obtain enough research, data and public health input to warrant a change.

Numerous warning letters have been sent by the FDA and the Federal Trade Commission to companies selling CBD products such as food items and dietary supplements and products meant for therapeutic use, mainly those claiming to cure diseases such as Alzheimer’s, Parkinson’s or cancer. It should be noted that there are three hemp-derived substances that have been approved by the FDA as Generally Recognized as Safe (GRAS) and are therefore lawful: hulled hemp seeds, hemp seed protein powder and hemp seed oil.

The rules and regulations get even hazier considering various state laws; some states still consider CBD illegal despite the 2018 Farm Bill, and there are some states where all marijuana and cannabis (medical or recreational) are illegal. Laws fluctuate between states, and CBD oil may be legal recreationally or medically depending on the location. Some states have been more adamant about enforcing these laws including Texas, Ohio and Iowa, whose law enforcement has raided stores selling CBD products.

Implications for RDNs
Since CBD is gaining popularity, clients and patients likely will have questions about the compound. Because laws vary by state, registered dietitian nutritionists should stay abreast of their individual state laws as well as any progress in federal legislation. Keeping clients and patients aware of the legality of CBD in food and dietary supplements may be as important as educating them on the potential risks and benefits.

Many products containing CBD are being introduced without regard for the legal requirements that apply to dietary supplements, foods, drugs and cosmetics. The FDA sends warning letters after a product has been produced and sold — usually because it is either promoted as a cure for disease or due to an adverse reaction. This means some CBD products may have gone through little, insufficient or no testing before sale. Some products could contain more or less CBD or THC than advertised, which could have safety implications of a drug interaction, impairment or an occupational problem for those who are drug tested. Additionally, products could contain other harmful ingredients unknown to the buyer.

The Academy of Nutrition and Dietetics recommends consumers use caution when purchasing CBD products and food items and has taken a neutral stance regarding the use of CBD in food and beverage products. The Academy supports a “science-based, public health-driven approach to the regulation of products containing cannabis or cannabis-derived compounds, including THC and CBD.”

RDNs should monitor developing research, laws and regulations concerning CBD to best counsel and educate clients and patients.

References

Abernethy A, Schiller L. FDA is Committed to Sound, Science-based Policy on CBD. U.S. Food and Drug Administration website. Updated July 17, 2019. Accessed September 25, 2019.
Academy Provides Comments to FDA on Cannabis Products. Academy of Nutrition and Dietetics website. Published July 17, 2019. Accessed September 25, 2019.
Akpan N, Leventhal J. Is CBD legal? Here’s what you need to know, according to science. PBS NewsHour Website. Published July 12, 2019. Accessed September 25, 2019.
By 2025, the U.S. Hemp-based CBD Industry Will Be a $6 Billion Opportunity—Snack Industry Take Note. Nielsen website. Published June 6, 2019. Accessed September 25, 2019.
FDA approves first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy. U.S. Food and Drug Administration website. Published June 25, 2018. Accessed September 25, 2019.
FDA Clarifies Position on CBD After Passage of 2018 Farm Bill. Hall Render Law Firm website. Published January 18, 2019. Accessed September 25, 2019.
FDA Regulation of Cannabis and Cannabis-Derived Products: Q&A. U.S. Food and Drug Administration website. Updated December 31, 2019. Accessed January 2, 2020.
FDA warns company marketing unapproved cannabidiol products with unsubstantiated claims to treat cancer, Alzheimer’s disease, opioid withdrawal, pain and pet anxiety. U.S. Food and Drug Administration website. Published July 23, 2019. Accessed September 25, 2019.
Grinspoon P. Cannabidiol (CBD) — what we know and what we don’t – Harvard Health Blog website. Updated August 27, 2019. Accessed September 25, 2019.
H.R.2 – 115th Congress (2017-2018): Agriculture Improvement Act of 2018. Congress.gov website. Published December 20, 2018. Accessed September 25, 2019.
Holland K. What’s the Difference Between CBD and THC Healthline website. Reviewed May 20, 2019. Accessed September 25, 2019.
Hudak J. The Farm Bill, hemp legalization and the status of CBD: An explainer. Brookings Institution website. Published December 14, 2018. Accessed September 25, 2019.
Huestis M, Solimini R, Pichini S, Pacifici R, Carlier J, Busardò F. Cannabidiol Adverse Effects and Toxicity. Curr Neuropharmacol. 2019;17(10):974-989.
Industrial Hemp. National Institute of Food and Agriculture website. Accessed September 25, 2019.
Johnson J. CBD oil for pain management: Effects, benefits, and uses. Medical News Today website. Reviewed July 29, 2018. Accessed September 25, 2019.
Statement from FDA Commissioner Scott Gottlieb, M.D., on signing of the Agriculture Improvement Act and the agency’s regulation of products containing cannabis and cannabis-derived compounds. U.S. Food and Drug Administration website. Published December 20, 2018. Accessed September 25, 2019.
What to Know About Products Containing Cannabis and CBD. U.S. Food and Drug Administration website. Published November 25, 2019. Accessed September 25, 2019.

The State of Food Loss and Food Waste
In the United States, nearly 150,000 tons of food is wasted every day — about one pound per person. The U.S. Department of Agriculture’s Economic Research Service estimated that in 2010, 31 percent of the food supply was lost or wasted: about 133 billion pounds or $162 billion. In 2012, the National Resources Defense Council reported that up to 40 percent of U.S. food goes uneaten, an average of 400 pounds per person per year, worth $218 billion — about $1,800 per four-person household. Around the world, about 1.3 billion tons of food is wasted or lost each year.

Fruits and vegetables are the most wasted foods in the world, and the USDA estimates that fruits and vegetables account for 32.9 percent of food waste and loss in America. Yet only one in 10 U.S. adults meets the recommended intakes for fruits and vegetables.

In the U.S., most food is wasted in homes. ReFed, a multi-stakeholder nonprofit fighting food waste in America, estimates that 43 percent of all food waste and loss comes from homes; 18 percent from restaurants; 16 percent from farms; 13 percent from grocery stores and distribution centers; 8 percent from institutional and foodservice facilities; and 2 percent from manufacturers.

Why It’s Important
Reducing food waste could significantly affect the environment — it’s the single largest component of municipal landfills, which account for 20 percent of total U.S. methane emissions.

Food waste also is a misuse of resources. According to NRDC, food waste in America represents the misappropriation of 21 to 33 percent of all agricultural water use. Between 18 to 28 percent of U.S. croplands — about the size of New Mexico — produce food that ultimately goes uneaten. Uneaten food uses 19 to 27 percent of the fertilizer in the U.S. and accounts for 2.6 percent of all greenhouse gas emissions — the equivalent of more than 37 million passenger vehicles. As the population continues to grow, the demand for food will increase, as will food waste emissions.

In 2017, 15 million households were food-insecure, meaning they were unsure of having or unable to obtain enough food for all household members. Reducing food waste could help reduce hunger and food insecurity.

What the U.S. Is Doing
Businesses, organizations and government bodies have recognized the problem and are working toward solutions. The USDA, Environmental Protection Agency and U.S. Food and Drug Administration recently announced the Winning on Reducing Food Waste initiative, a combined agreement to reduce loss and waste through joint and individual action.

In 2015, the USDA and EPA spearheaded the first domestic food loss and waste goal to reduce wasted food by 50 percent by 2030. The agencies created the U.S. Food Loss and Waste 2030 Champions, a compilation of organizations and businesses making commitments to reduce waste.

The Food Recovery Challenge is the EPA’s way of encouraging businesses and organizations to improve sustainable food practices by making a pledge to follow its food hierarchy. The hierarchy ranks sustainable food practices from most to least preferred starting with a reduction in excess food and donating to food banks. Similarly, the USDA is encouraging companies, schools and organizations to sign up for its U.S. Food Waste Challenge, a one-time public pledge and disclosure of company initiatives to reduce food waste and loss.

The NRDC is working with cities through its Food Matters initiative, which strives for a 15-percent reduction in food waste and loss within five years. As of June, the organization is working with Nashville, Baltimore, New York City and Denver.

The Food Waste Reduction Alliance is comprised of the Grocery Manufacturers Association, Food Marketing Institute, or FMI, and National Restaurant Association, which represent food and beverage companies, food retailers and the foodservice sector, respectively. The alliance has three goals: to reduce food waste, increase the amount of food donated and recycle unavoidable food waste to keep it from landfills.

ReFed developed a Roadmap to Reduce U.S. Food Waste, which details the top methods for reducing food waste to make it easier to meet the 50-percent reduction goal by 2030. It’s the first national economic study and action plan driven by a group of more than 50 businesses, nonprofits, foundations and government agencies. Roadmap items include initiatives such as standardized date labeling, consumer education programs, donation programs and packaging solutions.

Retailers and manufacturers are contributing to efforts by standardizing date labeling, which is used voluntarily, except in the case of infant formulas which require a “use by” date. Terms including “best by” or “sell by” have historically caused confusion, contributing to an estimated 20 percent of food waste in homes. FMI is encouraging retailers and manufacturers to standardize date language using two phrases: “BEST If Used By,” which refers to product quality, meaning the food may not taste as expected but is safe to eat; and “USE By,” which would appear on perishable products to indicate safety and signify it should be consumed by the date listed and may not be safe afterward. However, at this time, the FDA is only supporting the industry’s standardized use of a “Best if Used By” date label as it applies to quality, not safety.

Feeding America, the largest hunger-relief organization in the U.S., and its partners saved 3.5 billion pounds of food in 2018. The organization works closely with companies to salvage food before it’s discarded. Feeding America’s MealConnect program allows local businesses to alert nearby food banks of food ready for immediate pick-up.

The Academy of Nutrition and Dietetics is fighting food waste and loss through Further with Food: Center for Food Loss and Waste Solutions, an online platform for sharing information and answers to food waste. Further with Food provides resources for parties interested in learning more about reducing waste and uses input from groups such as Feeding America, FMI, GMA, the Innovation Center for U.S. Dairy, the National Consumers League, NRA, NRDC, USDA and EPA. In 2016, the Academy’s Foundation published “The State of America’s Wasted Food & Opportunities to Make a Difference” report, detailing opportunities to reduce wasted food along the food supply chain.

Help Reduce Food Waste
Since most food waste happens at home, consumers can make a big impact. Proper food storage techniques are a simple yet effective way to reduce waste by keeping food fresh and safe for as long as possible. The Academy’s website offers useful resources on proper storage tips, as does the FDA on its website. Created by the USDA’s Food Safety and Inspection Service, Cornell University and FMI, the FoodKeeper App lists foods with instructions on proper storage and shelf life.

Planning meals in advance is another technique to reduce food waste while also saving money. Weekly meal planning with a grocery list prevents buying more food than is needed. Be observant about what foods you are discarding and change purchasing habits to prevent tossing the same foods.

Repurposing food can be a fun and creative way to prevent waste. Before buying anything new, shop your fridge and eat the foods you already have on hand. Use leftovers within three to four days (or freeze for later use) to make new recipes such as smoothies, infused water or stock for soup.

Many organizations offer tips and information about reducing food waste. The EPA’s website has a toolkit with dozens of tips to reduce waste. Further with Food offers waste reduction tips and educational resources, including meal preparation methods and local community events. The Academy’s Foundation has an initiative, Future of Food, which offers toolkits on reducing food insecurity and food waste and loss.

Registered dietitian nutritionists can educate clients and patients on food label date language. Consumers should be aware of dates on food and beverages and consume the oldest items first, implementing a “first in, first out” method. When raw produce goes bad, composting at home can keep it from landfills. Learn more about composting on the EPA’s and USDA’s websites.

RDNs in institutional foodservice can consider implementing room service to reduce waste. A study published in February 2018 in the Journal of the Academy of Nutrition and Dietetics reported an increase in nutrition, improved satisfaction, and reduced plate waste and costs when room service was used compared to a traditional foodservice model. Additionally, work with local food banks to create a plan to donate surplus food, implement a composting program or donate appropriate food to animal farms.

Food waste and food loss affect us all. Fixing it must be an individual and global effort.

References

Are You Storing Food Safely? U.S. Food and Drug Administration website. Published 2019. Accessed May 30, 2019.
By the Numbers: Reducing Food Loss and Waste. World Resources Institute website. Published 2019. Accessed May 30, 2019.
CDC Press Releases. Centers for Disease Control and Prevention website. Published November 16, 2017. Accessed May 30, 2019.
Confused by Date Labels on Packaged Foods? FDA website. Accessed June 19, 2019.
Conrad Z, Niles M, Neher D, Roy E, Tichenor N, Jahns L. Relationship between food waste, diet quality, and environmental sustainability. PLoS ONE. 2018;13(4):e0195405.
Estimates of Food Loss at the Retail and Consumer Level. USDA Economic Research Service website. Published 2019. Accessed May 30, 2019.
Food Loss and Food Waste. Food and Agriculture Organization of the United Nations website. Published 2019. Accessed May 30, 2019.
Food Loss and Waste. USDA website. Published 2019. Accessed May 30, 2019.
Food Matters: Empowering Cities to Tackle Food Waste. NRDC website. Published 2019. Accessed May 30, 2019.
Food Recovery Hierarchy. United States Environmental Protection Agency website. https://www.epa.gov/sustainable-management-food/food-recovery-hierarchy. Published 2019. Accessed May 30, 2019.
Food: Too Good to Waste. EPA website. Published 2019. Accessed May 30, 2019.
Food Waste Reduction Alliance. Food Waste Reduction Alliance website. Published 2019. Accessed May 30, 2019.
Food Waste Solutions. ReFED website. Published 2019. Accessed May 30, 2019.
Further with Food: Academy of Nutrition and Dietetics Joins Public-Private Partnership to Reduce Food Waste. Academy of Nutrition and Dietetics website. Published 2019. Accessed May 30, 2019.
Further with Food: Center for Food Loss and Waste Solutions. Further with Food website. Published 2019. Accessed May 30, 2019.
Key facts on food loss and waste you should know! Food and Agriculture Organization of the United Nations website. Published 2019. Accessed May 30, 2019.
McCray S, Maunder K, Barsha L, Mackenzie-Shalders K. Room service in a public hospital improves nutritional intake and increases patient satisfaction while decreasing food waste and cost. J Hum Nutr Diet. 2018;31(6):734-741.
Our Approach to Food Waste and Rescue. Feeding America website. Published 2019. Accessed May 30, 2019.
Reducing Wasted Food At Home. EPA website. Published 2019. Accessed May 30, 2019.
Refrigerate – The Basics. Academy of Nutrition and Dietetics website. Published 2019. Accessed May 30, 2019.
Resources – Further With Food. Further With Food website. Published 2019. Accessed May 30, 2019.
The State of America’s Wasted Food and Opportunities to Make a Difference. Academy Foundation website. Published 2016. Accessed May 30, 2019.
United States 2030 Food Loss and Waste Reduction Goal. United States Environmental Protection Agency website. Published 2019. Accessed May 30, 2019.
USDA ERS – Key Statistics & Graphics. Economic Research Service website. Published 2019. Accessed May 30, 2019.
U.S. Food Loss and Waste Challenge Participants Listing Activities. USDA website. Published 2019. Accessed May 30, 2019.
U.S. Food Waste Challenge FAQs. USDA website. Published 2019. Accessed May 30, 2019.
Wasted: How America Is Losing Up to 40 Percent of Its Food from Farm to Fork to Landfill. NRDC website. Published 2019. Accessed May 30, 2019.
Working with the Food Industry to Reduce Confusion Over Date Labels. U.S. Food and Drug Administration website. Published 2019. Accessed May 30, 2019.
World Population Clock: 7.7 Billion People (2019) – Worldometers. Worldometers.info website. Published 2019. Accessed May 30, 2019.

Who recalls food, and why?
Several organizations oversee and issue food recalls and remove products from the market. The Food Safety and Inspection Service, or FSIS, a branch of the U.S. Department of Agriculture, is responsible for the safety of meat, poultry and some egg products, which accounts for roughly 20 percent of the nation’s food supply. The U.S. Food and Drug Administration is responsible for the safety of the remaining food supply, including domestic and imported foods and pet foods. When a foodborne illness occurs, state departments contact the Centers for Disease Control and Prevention, which then contacts the FDA or FSIS. Additionally, manufacturers play a significant role in overseeing and issuing recalls for their own products.

The cause of a food recall typically fits into one of three categories: pathogen contamination, physical contamination or misbranding. Pathogen contamination happens when a disease-causing microorganism such as E. Coli or Salmonella infiltrates a food item. Physical contaminants are foreign objects such as plastic, glass or metal. Misbranding can refer to undeclared allergens such as nuts or milk, undeclared substances, such as food additives or colorings, or putting the wrong label on a product. Undeclared allergens and foodborne illness were the top reasons for food recalls in 2017.

Manufacturers discover food safety threats through in-house inspections and safety checks. Additionally, customers may alert companies of a food safety issue. Aside from manufacturer inspections, the FDA and FSIS perform their own safety checks by inspecting manufacturing facilities and food samples. High-risk facilities are inspected once every three years. When foodborne illness occurs, state health departments and the CDC inform the FDA or FSIS, which then contact the manufacturer.

Most recalls are done voluntarily by the manufacturer. If a company needs to issue a recall, it is required to inform the FDA or FSIS immediately with a plan of action that includes how the company intends to handle the recall, a press release and who is affected. It is the responsibility of the manufacturer to remove the product from market as soon as the problem has been found, even while the FDA or FSIS is reviewing the submitted plan. It is rare for the FDA or FSIS to issue a recall instead of the manufacturer, but this can occur when the source of the contaminant has yet to be determined.

How food gets contaminated
As access to food becomes more convenient, the food supply becomes more convoluted. Food travels longer distances, goes through more processing and is touched by more hands — all of which can contribute to contamination. Fruits and vegetables can be contaminated by birds or other animals. Fields can flood with contaminated water that is then used to feed plants. Produce can become contaminated by manure or farm workers who may not practice proper hand-washing.

While some foods once had seasons of availability, most now are accessible year-round, meaning the food can travel thousands of miles before reaching a supermarket. This can increase opportunity for contamination from handling and temperature changes. Additionally, convenience foods such as pre-chopped and washed salads are handled by more people and machines. The same can be true for packaged foods.

Healthy animals used for food often contain foodborne microbes, and contamination can occur during slaughter if small amounts of intestinal contents are exposed to meat. Grinding meat exposes the processing equipment to contaminants that were present in the intestines, exposing the ground meat to contaminants.

Raw milk and fruit juices are pasteurized to kill pathogens, but there have been recalls on these items due to human error where the liquid was either not pasteurized or not pasteurized to the proper temperature. A common concern with eggs is Salmonella, which can get on the outer shell from exposure to manure or can be found inside the egg if it’s transferred from the hen’s ovaries.

Why we’re seeing more recalls
Approximately one in six Americans gets sick each year from foodborne illness. According to the reputation management company Stericycle, recalls for all products (including nonfood) increased 33 percent from 2012 to 2017. The U.S. Public Interest Research Group Education Fund found food recalls increased 10 percent between 2013 and 2017. However, yearly data from the FDA shows recalls declined significantly from 2017 (3,609 cases) to 2018 (1,935 cases), which is promising for the future.

The FDA could be discovering problems that may have previously gone undetected. The Food Safety Modernization Act, enacted in 2011, gave the FDA more power in preventing food safety problems. Among the law’s many results, all food facilities are required to have a preventive controls plan; produce safety rules are enhanced; FDA facility inspections are more frequent and mandated; the FDA has access to food safety records of all companies and greater authority over imported foods; and the FDA has the power to issue a mandatory recall and discontinue registration of any company it deems unsafe.

The FDA, USDA and CDC now use a technology called whole genome sequencing, which enables them to discover the source of foodborne illness faster and more efficiently. This method works by using a database of samples collected from food, production facilities and people who become ill.

When a person contracts a foodborne illness, scientists can compare a sample of the pathogen with those in the database to find its exact or closest genetic match and determine which food or facility caused the illness. The ability to compare pathogens at the genetic level significantly increases the accuracy and speed at which a food can be recalled.

Product labeling also may be responsible for the rise in recalls. For instance, a lack of place-of-origin labeling on produce makes it more difficult to track the source of an outbreak and could increase the amount of product recalled, as seen in the December 2018 romaine lettuce recall. In the wake of the romaine recall, all lettuce will display place of origin and harvest date, and the FDA is advocating for place-of-origin labeling on all produce packaging. This could make recall responses more effective and allow consumers to be more informed.

Foodborne illness recalls also can easily be caused by human error, which may explain food companies’ increased use of robotics. According to the Robotic Industry Association, orders for robots among the food and beverage industry increased 32 percent in 2016. Although better technology can help decrease the amount of recalls, it also may be a contributing factor to the increase in recalls. For instance, automated packaging has led to an increase in product mislabeling and manufacturing equipment has led to an increase in foreign materials found in foods.

Easier access to information may contribute to a public perception that there are more recalls. Typically, the FDA and FSIS do not directly alert the media about a food recall. Social media may contribute to more awareness and the belief that recalls are increasing.

How RDNs can help
Registered dietitian nutritionists can play an important role in protecting clients from foodborne illness by providing education about proper food handling techniques. Cleanliness is imperative in safe food preparation, yet a recent USDA study found 97 percent of consumers fail to wash their hands properly.

In addition to personal hygiene, RDNs can educate patients and clients on cleanliness in the kitchen and food preparation areas. Consumers should understand the importance of avoiding crosscontamination, thawing food appropriately and cooking to proper temperatures.

RDNs can inform patients and clients of any pertinent recalls and make them aware of resources available. Many grocery stores have social media profiles that are updated with relevant recalls. Foodsafety.gov is regularly updated with recalls and has Facebook, Twitter and Pinterest profiles and an RSS feed that users can sign up to receive automatic alerts. FSIS also keeps a running record of recalls at fsis.usda.gov and allows users to sign up for automatic alerts.

References

206 million eggs recalled: What you need to know about salmonella. CBS News website. Updated April 16, 2018. Accessed January 8, 2019.
Background on the FDA Food Safety Modernization Act (FSMA). FDA website. Updated January 30, 2018. Accessed January 26, 2019.
Dewey C. Why E. coli keeps getting into our lettuce. Washington Post website. Published April 26, 2018. Accessed January 6, 2019.
Don’t ignore food recalls. UMN Extension website. Updated 2018. Accessed January 5, 2019.
FDA 101: Product Recalls. FDA website. Updated September 10, 2018. Accessed January 6, 2019.
FDA Food Safety Modernization Act (FSMA). FDA website. Updated November 15, 2018. Accessed January 20, 2019.
Food Contamination and Foodborne Illness Prevention. Minnesota Department of Health website. Accessed January 6, 2019.
Food Safety Consumer Research Project: Meal Preparation Experiment Related to Thermometer Use. Executive Summary 2018. USDA website. Accessed February 12, 2019.
Foreign Food Facility Inspection Program Questions & Answers. FDA website. Updated September 19, 2018. Accessed February 6, 2019.
Good M. Automation: Stemming the Recall Tide. Food Quality & Safety website. Published October 17, 2017. Accessed January 30, 2019.
Henne B. How far did your food travel to get to you? MSU Extension website. Published September 20, 2012. Accessed January 6, 2019.
Hirsch J. Why Is Ground Beef Making People Sick? Consumer Reports website. Updated December 12, 2018. Accessed January 8, 2019.
Karthekiyan V, Garber, A. How Safe Is Our Food? U.S. PIRG Education Fund website. Accessed January 19, 2019.
Maberry T. A Look Back at 2017 Food Recalls. Food Safety Magazine website. Published February 6, 2018. Accessed January 31, 2019.
Mackin K. Stericycle report shows ‘foreign material’ top cause of recalls. Food Safety News website. Published May 8, 2018. Accessed January 23, 2019.
Organic milk recalled when improper pasteurization discovered. Food Safety News website. Published April 6, 2018. Accessed January 9, 2019.
Page ET. Trends in Food Recalls: 2004-13. USDA website. Published April 2018. Accessed February 11, 2019.
Pasteurization. IDFA website. Accessed January 9, 2019.
Recalls. FDA website. Accessed January 29, 2019.
Sanitary Transportation of Human and Animal Food. Federal Register website. Published April 6, 2018. Accessed February 6, 2019.
Shropshire C. Food recalls explained: Why it seems like food contamination is on the rise. Chicago Tribune website. Published June 19, 2018. Accessed January 9, 2019.
Statement from FDA Commissioner Scott Gottlieb, M.D. and FDA Deputy Commissioner Frank Yiannas on new findings and updated consumer recommendations related to the romaine lettuce E.coli O157:H7 outbreak investigation. FDA website. Published December 13, 2018. Accessed February 12, 2019.
Summary of Recall Cases in Calendar Year 2018. USDA website. Accessed January 31, 2019.
US: Pathogen contamination a leading reason for food recalls. Fresh Plaza website. Published July 16, 2018. Accessed January 6, 2019.
White-Cason J. Understanding Food Recalls: The Recall Process Explained. Food Safety News website. Published August 12, 2013. Accessed January 5, 2019.
Whole Genome Sequencing (WGS) Program. FDA website. Updated February 15, 2018. Accessed January 27, 2019.

Alzheimer’s, which has no known cure, accounts for 60 to 80 percent of all cases of dementia and is the sixth-leading cause of death in the United States. Nearly 6 million Americans are living with Alzheimer’s, and the number is estimated to rise to almost 14 million by 2050.

While there are many signs and symptoms of Alzheimer’s disease, the initial indicator usually is difficulty remembering newly learned information. Other symptoms that may develop include confusion about events, times and places; significant mood and behavior changes; and difficulty speaking. Additionally, Alzheimer’s may have nutrition-related symptoms such as forgetting how to use cutlery, loss of appetite or forgetting about previous meals. Other symptoms may include unintentional weight loss, difficulty swallowing or swallowing without chewing, forgetting how to eat or drink and attempting to eat inedible items.

Although Alzheimer’s disease is not a normal part of the aging process, the biggest risk factor is increasing age. Most people with Alzheimer’s are older than 65. The risk of developing Alzheimer’s doubles after 65 and nearly one-third of people over 85 will develop the disease. “Early onset” Alzheimer’s occurs in people younger than 65 — about 5 percent of all diagnosed cases; however, the number of people who suffer from early onset could be higher since it is not commonly recognized and therefore more difficult to diagnose.

Anyone with a parent or sibling with Alzheimer’s disease has a greater risk of developing the condition; risk increases if multiple family members have Alzheimer’s. Genetics and other factors, such as head injury, also can increase risk; in addition, Hispanics and African-Americans are at greater risk. Poor heart health or poor overall vascular health, as well as lifestyle factors such as tobacco use and excessive alcohol consumption, can increase chances of developing Alzheimer’s. On the other hand, staying socially active, exercising and following a healthy diet may decrease risk.

Based on the latest research, the Alzheimer’s Association recommends the Mediterranean diet and the Dietary Approaches to Stop Hypertension, or DASH, diet, both of which may decrease risks of developing heart disease and dementia.

Mediterranean Diet
This diet is highly focused on plant foods such as fruits, vegetables and whole grains; foods containing heart-healthy fats including olive oil; spices and occasional fish, poultry and dairy. Red meat and salt are limited.

Studies have shown the Mediterranean diet may help prevent or delay the onset of Alzheimer’s disease by 1½ to 3½ years. Participants in a 2018 study were 30 to 60 years old with no dementia; they received brain imaging scans at the start and end of a two-year period. About half the group reported practicing a high adherence to the diet, while the other half reported following a Western diet. Follow-up scans revealed the Western diet group had higher betaamyloid protein deposits and lower energy use, both signs of early dementia.

Meta-analyses and systematic reviews have found a large body of research that suggests the Mediterranean diet may help decrease risks for several brain-related diseases including depression, stroke, Alzheimer’s disease and mild cognitive impairment, which can progress to Alzheimer’s.

It’s not exactly known how the Mediterranean diet may help delay or prevent dementia. Some theories suggest high amounts of antioxidants from foods in the diet may play a role, while others speculate the high amount of beneficial fats may contribute to vascular health, which can contribute to better brain health.

Most studies are observational and many use dietary recalls, which can be unreliable. To further strengthen the recommendation of the Mediterranean diet for Alzheimer’s disease, more randomized controlled studies with longer follow-up periods are needed.

DASH Diet
Although there is less research on the DASH diet as it relates specifically to the delay, prevention or treatment of Alzheimer’s disease, this eating pattern is recommended by the Alzheimer’s Association. The DASH diet involve consuming lots of fruits, vegetables and whole grains, limiting saturated fats, salt and added sugars, and aiming to be high in potassium. DASH is very similar to the Mediterranean diet, but puts less emphasis on olive oil as the primary fat source and does not promote regular alcohol consumption.

In the limited pool of research, there is a correlation between adherence to the DASH diet and lower incidence of cognitive decline. A greater amount of research suggests following the DASH diet can help prevent other conditions, including hypertension and cardiovascular disease. Several studies have found the DASH diet improves cardiovascular and vascular health by reducing blood lipid levels and blood pressure. Cardiovascular and vascular health have been directly correlated with brain health and Alzheimer’s risk, which may explain the association’s endorsement of the diet, but more research is needed on the DASH diet and its impact on Alzheimer’s disease.

MIND Diet
The Mediterranean-DASH Intervention for Neurodegenerative Delay, or MIND, diet was created by researchers as an eating pattern specifically targeted to brain health. The diet is a combination of aspects from the Mediterranean and DASH diets, with more specific recommendations: 10 foods to incorporate and five foods to avoid.

On the MIND diet, people should eat six or more servings of green, leafy vegetables each week and one additional serving of vegetables daily. The only fruits mentioned in this eating pattern are berries, which are recommended twice a week because of their high antioxidant content. The MIND diet recommends five or more servings of nuts per week and using only olive oil as an added fat. Three servings of whole grains should be eaten daily; fish at least once a week; beans at least four times a week; poultry twice a week; and no more than one glass of wine per day. Foods to avoid or limit include butter and margarine, cheese, red meat, fried foods, pastries and sweets.

Created in 2015, the MIND diet is relatively new and more research is needed to support it. The most notable research study comes from Rush University Medical Center, which followed more than 900 participants for an average of 4½ years. Researchers found the MIND diet may reduce the risk of developing Alzheimer’s by as much as 53 percent.

More Research Needed
Alzheimer’s disease is an increasing problem and current research hints that diet may be able to help. However, more research is needed on the role of nutrition, including these three diets, on the ability to prevent or delay Alzheimer’s and dementia. Because research shows overall positive health outcomes from both the Mediterranean and DASH diets, registered dietitian nutritionists may feel most comfortable recommending them to patients and clients who are concerned about brain and overall health.

TREATING ALZHEIMER’S WITH FOOD

Research on diet for treating Alzheimer’s disease is limited and there is no specific nutrition prescription. However, good nutrition is imperative and there are several recommendations and modifications that can help people who have Alzheimer’s:

• Follow an overall healthy diet.
• Limit distractions that can interfere with food intake, such as television.
• Avoid having too many items on the table to prevent confusion.
• Only serve one or two food items at a time.
• Avoid patterned plates.
• Modify food textures as needed.
• Allow plenty of time to complete a meal.
• Consider liberalizing diets to incorporate favorite foods.
• If weight loss is a concern, consider fortified foods and supplements.

References

Adopt a Healthy Diet. Alzheimer’s Association website. Published 2018. Accessed October 6, 2018.
Alzheimer’s. Published 2018. Accessed October 6, 2018.
Alzheimer’s: Nutrition Prescription. Nutrition Care Manual website. Published 2018. Accessed October 7, 2018.
Berti V, Walters M, Sterling J et al. Mediterranean diet and 3-year Alzheimer brain biomarker changes in middle-aged adults. Neurology. 2018;90(20):e1789-e1798.
DASH Eating Plan. National Heart, Lung, and Blood Institute website. Published 2018. Accessed October 7, 2018.
Diet May Help Prevent Alzheimer’s. Rush University Medical Center website. Published 2018. Accessed October 7, 2018.
Early Onset Dementia: A National Challenge, A Future Crisis. Alzheimer’s Association website. Published 2018. Accessed October 6, 2018.
Facts and Figures. Alzheimer’s Association website. alz.org/alzheimers-dementia/facts-figures. Published 2018. Accessed October 6, 2018.
Food and Eating. Alzheimer’s Association website. Published 2018. Accessed October 7, 2018.
Graff-Radford J. Alzheimer’s: Can a Mediterranean diet lower my risk? Mayo Clinic website. Published 2018. Accessed October 6, 2018.
Meal Times. Alzheimer Society of Canada website. Published September 2012. Accessed October 6, 2018.
Mediterranean diet and dementia. Alzheimer’s Society website. Accessed October 7, 2018.
Morris MC, Tangney CC, Wang Y, Sacks FM, Bennett DA, Aggarwal NT. MIND Diet Associated with Reduced Incidence of Alzheimer’s Disease. Alzheimers Dement. 2015;11(9):1007-1014.
Pearson K. The MIND Diet: A Detailed Guide for Beginners. Healthline website. Published 2018. Accessed October 6, 2018.
Psaltopoulou T, Sergentanis T, Panagiotakos D, Sergentanis I, Kosti R, Scarmeas N. Mediterranean diet, stroke, cognitive impairment, and depression: A meta-analysis. Ann Neurol. 2013;74(4):580-591.
Reynolds S. Mediterranean diet may slow development of Alzheimer’s disease. National Institutes of Health website. Published May 15, 2018. Accessed October 6, 2018.
Risk Factors. Alzheimer’s Association website. Published 2018. Accessed October 6, 2018.
Singh B, Parsaik AK, Mielke MM, et al. Association of Mediterranean diet with Mild Cognitive Impairment and Alzheimer’s disease: A Systematic Review and Meta-Analysis. J Alz Dis. 2014;39(2):271-282.
Tangney CC. DASH and Mediterranean-type Dietary Patterns to Maintain Cognitive Health. Curr Nutr Rep. 2014;3(1):51-61.
The MIND Diet — Fighting Dementia With Food. Today’s Geriatric Medicine website. Published 2018. Accessed October 7, 2018.
What Is Alzheimer’s? Alzheimer’s Association website. Published 2018. Accessed October 6, 2018.

Private Label Products

Private label products display the retailer’s logo instead of the manufacturer’s emblem. In 2017, sales of private-label products tripled the sales of branded products. Data show this category grows in sales by about 3 percent each year.

Private label products are becoming brands in their own right; about 46 percent of consumers say these items influence where they shop. Retailers recognize this and are increasing their private label offerings. Generation X is the largest driver in sales of private label products, followed by older millennials and younger baby boomers.

This age range typically includes families, who may be more likely to gravitate toward less-expensive private label items, especially since nearly one-third of U.S. families struggles to pay for groceries. An increase in available private label products also gives customers a larger selection of items from which to choose, increasing their buying power.

Meal Kits

Meal kits are groupings of pre-packaged ingredients, sold together and used to make a featured recipe. While they originated from notable online companies featuring home delivery, grocery stores are jumping on the trend. In 2017, meal kits generated nearly $155 million in retail sales. Of the 25 percent of Americans who say they purchased meal kits last year, 17 percent purchased one at a supermarket.

This trend is driven largely by millennial men and families with children. Most meal kit consumers believe they are healthier than prepared food options in the supermarket and that they save time shopping, planning and preparing meals.

Meal kits may persuade shoppers to try new recipes and they allow for easier recipe modification compared to restaurant foods or other prepared foods. Although consumers believe meal kits are healthier, that may not always be true: Many can be high in calories, sodium or saturated fat and often include sauces high in added sugars. RDNs can encourage clients to review the package labels before purchasing a meal kit. If nutrition facts aren’t available, review the ingredients or ask store personnel for help in obtaining such information.

Online Ordering, Home Delivery and Store Pickup

While online companies have changed the competition for brick-and-mortar retailers, most online purchases are health, beauty and pet products. By 2024, it is estimated that more than 70 percent of consumers will be purchasing some form of food and beverage online. This means grocery stores still have an advantage when it comes to providing food (especially fresh items), but it doesn’t minimize the need to evolve to accommodate shopper trends related to convenience.

To compete with online sales, many retailers offer home delivery and curbside pickup through in-house services or by partnering with third-party businesses. One survey found a 67-percent increase in the use of curbside, a service where consumers purchase items online and collect it later at the store. This trend is most popular among consumers 25 to 44 years old. Fresh foods such as produce and milk are the most common purchases.

Home delivery and store pickup may offer a timesaving convenience and help shoppers save money by reducing the opportunity for impulse buys. However, many home delivery services come with additional fees and they can reduce customers’ ability to choose their own items.

Local

Sales of local foods are expected to reach $20 billion by 2019, up from $5 billion in 2008.

Shopping local is trending overall, but fresh items — especially produce — are driving the trend. Local produce sold twice as much compared to overall produce, with a 10-percent lift in sales in 2017. Shoppers who purchase local items say they believe these goods are of higher quality, fresher and better for the environment.

Buying local may reduce foods’ processing and travel time, which could equate to a fresher product with more nutrients. Purchasing local products also may mean more money goes back into the local economy. Reduced distances may lessen fuel and emissions, contributing to increased sustainability. Caution clients that the term “local” is defined in many ways, which could be misleading. The USDA’s vague definition of local — “the direct or intermediated marketing of food to consumers that is produced and distributed in a limited geographic area” — does not provide a specific distance or radius. Shoppers should investigate their store’s definition of local.

Take note as supermarket trends come and go to better educate clients and patients on how to make smart, healthful purchases.

Probiotics are live, active microorganisms ingested to alter the gastrointestinal flora for health benefits. They often are referred to as “good” bacteria in the gut and compete with “bad” bacteria for adhesion sites to either rid the body of pathogens or increase the host’s immune system. Their benefits were first noticed centuries ago, when people started eating fermented foods. Today, those foods include fermented vegetables, sauerkraut, miso, fermented cheese, kefir, yogurt, tempeh, pickles, kimchi, green olives, wine, natto and sourdough bread. In addition to fermented foods, probiotic supplements are available in pill, powder and chew forms, and some manufacturers have begun adding probiotics to non-fermented grocery items such as water, chips and juice.

The potential benefits of probiotics are widespread, but there is no one-size-fits-all application. Under the umbrella of probiotic genera are hundreds of species with even more strains, each performing a separate function or producing a different benefit in the body when used alone or in conjunction with others. The most widely researched bacterial genera include Lactobacillus, Bifidobacterium and Streptococcus, while yeast varieties include Saccharomyces boulardii.

Lactobacillus

Lactobacillus bacteria are found in the GI and urinary tracts and are the most abundant bacteria in the vagina. These aerobic, lactic-acid-forming bacteria are the most widely used probiotic in foods such as yogurt. Their ability to form biofilms allows them to survive in harsh conditions, such as the low pH of stomach acid, and maintain colonies in their host.

Lactobacillus acidophilus

L. acidophilus is the most common species of Lactobacillus. Research suggests it may help certain vaginal conditions, treat diarrhea and boost immunity.

Suppositories of L. acidophilus have been successful in treating bacterial vaginosis, and some research shows the ingestion or application of yogurt to the vagina can help prevent yeast infections. In combination with other forms of Lactobacillus, research suggests it may prevent traveler’s diarrhea; antibiotic-associated diarrhea, or AAD; and Clostridium difficile when taken with antibiotics. In some instances, L. acidophilus reduced the incidence of eczema in infants when it was taken orally by their pregnant or breast-feeding mothers.

Dietary sources of L. acidophilus include certain brands of yogurt and milk, miso and tempeh. It also is available as pills, freeze-dried granules, powders and vaginal suppositories. Probiotic supplements should be refrigerated to maintain quality. Recommended doses vary but range from 1 billion to 15 billion colony forming units, or CFU, per day.

Lactobacillus helveticus with Bifidobacterium longum

Together, L. helveticus and B. longum may have immune-boosting properties and the ability to treat psychological conditions, improve overall health and skin conditions, such as atopic dermatitis. Individuals given a daily probiotic blend reported lowered feelings of anxiety and depression. When used alone, L. helveticus was associated with improved quality of sleep and increased serum calcium levels in elderly individuals.

L. helveticus is most commonly used in the fermentation of milk for producing Italian and Swiss cheeses. In addition, both species can be found in kefir, certain yogurts and in supplement form. Currently, there is no recommended dosage, but an intake of 3 billion CFU per day showed improvements in anxiety and depression in studies.

Lactobacillus delbrueckii subsp. bulgaricus with Streptococcus thermophilus

The probiotic combination of L. delbrueckii subsp. bulgaricus and S. thermophilus is most commonly found in yogurt and may be used to increase immunity. One pilot study found that patients in the ICU for traumatic brain injury showed a significant reduction in length of stay and a reduced risk of infection after taking a daily blend of 100 billion CFU of B. longum, L. bulgaricus and S. thermophilus. Another study saw a significant improvement in a marker of non-alcoholic fatty liver disease after taking 500 million CFU of L. bulgaricus and S. thermophilus daily.

All yogurt containing live and active cultures will have L. delbrueckii subsp. bulgaricus (or L. bulgaricus) and S. thermophilus; the two work synergistically to create yogurt by feeding off the other’s byproducts. In addition, the combination can be found in supplements.

Lactobacillus plantarum

L. plantarum may have a significant impact on its host by improving psychological health, increasing immunity and improving metabolic conditions. Several studies have shown a daily intake of L. plantarum can reduce anxiety and depression and may improve symptoms of autism.

Intake of L. plantarum might be beneficial in certain metabolic disorders by reducing BMI, improving blood pressure, decreasing cholesterol and reducing fat oxidation. It also may decrease the development of cardiovascular disease in smokers. Other studies have found supplementation may decrease allergy symptoms in children.

L. plantarum can be found in fermented vegetables such as kimchi, fermented beets, pickled cucumbers, pickled beans and sauerkraut. Other sources include fermented juice drinks and green olives. Although no exact dose is recommended, many over-the-counter supplements contain anywhere from 3 billion to 10 billion CFU.

Lactobacillus reuteri

L. reuteri may reduce inflammation and allergies and serve as a potential treatment for pro-inflammatory diseases. Several studies have shown a reduction of infection and inflammatory markers in diseases such as rheumatoid arthritis, cystic fibrosis and general allergies and inflammation of the airways. In addition, research suggests this probiotic may lessen eczema in children, and oral supplementation may decrease dental carries.

L. reuteri can be found in certain fermented vegetables and dairy products, and also is available in supplement form. Doses used in studies ranged from 100 million to 10 billion CFU per day.

Lactobacillus rhamnosus GG

L. rhamnosus GG, or LGG, is more likely to survive in the gut compared to other species of the Lactobacillus genus. It is one of the most effective probiotics for treating infectious diarrhea and may be used to promote vaginal health (with L. reuteri) and treat certain pediatric conditions.

In addition to treating acute diarrhea in children, LGG also may prevent dental caries and improve infant neurological health, reducing the risk of developing ADD or ADHD. Supplementation of LGG and L. reuteri together may decrease the risk of bacterial vaginosis and promote growth of beneficial bacteria. In studies using a vaginal suppository, the risk of yeast infection declined.

LGG can be found in kefir and certain brands of kombucha drinks and yogurt, as well as supplements and powders. The American Academy of Pediatrics states that LGG is the most effective probiotic for acute infectious diarrhea in children and is dose-dependent past 10 billion CFU. However, the American Academy of Pediatrics does not recommend the use of probiotics in children with compromised immune systems.

Lactobacillus casei

Studies on L. casei suggest it may play an important role in the gut-brain axis by improving mental and neurological health. Supplementation of L. casei resulted in significant decreases in anxiety and depression in individuals with chronic fatigue syndrome and improved mood and cognition in people with autism. Supplementation also has been associated with improved symptoms of multiple sclerosis and improved cognition.

L. casei is available as pill supplements and some chewable forms for children. It also is used in certain dairy and non-dairy yogurts, kefir and kvass, a fermented beverage. Study doses ranged from 100 million to 8 billion CFU per day.

Bifidobacterium

Bifidobacterium inhabits the gut, mouth and vagina. As one of the first bacteria to inhabit the gut, this microorganism aids in the digestion of foods, producing short-chain fatty acids and reducing inflammation through the stimulation of immune cells.

Bifidobacterium bifidum

Research suggests B. bifidum may boost immunity and improve eczema in infants. It also is a hopeful treatment for certain GI conditions, such as constipation, traveler’s diarrhea, IBS, ulcerative colitis and H. pylori.

Food sources of B. bifidum include yogurt, kefir, buttermilk, miso, tempeh, pickles, kimchi, cured meats, some wines and vinegars, sauerkraut and sourdough bread. Supplements also are available. Although there is no recommended dosage, many studies saw benefits at around 1 billion CFU per day.

Bifidobacterium infantis

B. infantis may be beneficial to mental health and possess anti-inflammatory properties. Early research showed that a blend of probiotic strains that included B. infantis improved symptoms of anxiety, depression and autism spectrum disorder. Although B. infantis may be found in certain dairy products, such as yogurt, it is more common as a supplement.

Saccharomyces boulardii

In contrast to bacterial probiotics, S. boulardii is a yeast that has been used for nearly 30 years to treat several gastrointestinal conditions. This probiotic has been used in the treatment and prevention of diarrhea in children and infants. It often is used to prevent diarrhea in patients with feeding tubes and may be effective in adults for AAD, traveler’s diarrhea and diarrhea from C. diff.

This yeast is used to make kombucha and also is available as a supplement. Doses ranging from 250 to 1,000 milligrams of S. boulardii daily for two to four weeks have been used in adults with diarrhea and 250 to 750 milligrams daily for children with diarrhea, not exceeding more than five days.

Putting it Into Practice

While certain strains and species may work together to provide health benefits, there is not enough scientific evidence to justify recommending probiotics in large combinations at high doses. Robin Foroutan, MS, RDN, HHC, spokesperson for the Academy of Nutrition and Dietetics, says she has more success starting patients on low doses, such as 3 billion to 5 billion CFU rather than 100 billion CFU. She explains that too much at one time can result in symptoms such as gas, bloating, constipation or diarrhea.

When deciding on probiotic supplements versus food, dietitians have differing preferences. Emily Parker, MS, RDN, at California State University–Long Beach, and co-author of several comprehensive probiotic summaries, prefers recommending food before supplements. “I suspect that there are benefits to fermented foods that may go beyond the strains of bacteria — the bioavailability of some vitamins and minerals is elevated by the fermentation process of vegetables,” Parker says.

Conversely, Heather Finley, MS, RD, LD, CEDRD, CLT, doctoral student and one of several co-authors with Parker, prefers recommending supplements in addition to food at the start. “The fastest way to change the microbiome is through diet, but a probiotic supplement can be a great option for clients because they provide bacterial diversity and most provide high amounts of CFU,” Finley says. “In some cases, fermented foods can exacerbate GI conditions and a probiotic supplement may be better tolerated.”

When it comes to supplements, Parker trusts products labeled “Good Manufacturing Practices” (GMP) by NSF International, a third-party organization that tests and audits nutritional supplements for quality standards.

Whether from food, drink or pill, the potential benefits of probiotics are promising. As the National Institutes of Health continues its extensive research through the Human Microbiome Project, more findings are guaranteed, and registered dietitian nutritionists have a large part to play in reviewing research and finding what works best for patients.

Do Your Research

Before you do anything, make sure the company you want to work for doesn’t already have a dietitian. A quick Google search of the company’s name plus the word dietitian would have prevented a recent snafu at my own workplace. An RDN used the “contact us” page to suggest it hire a dietitian, specifically her.

Once you know the company doesn’t have an RDN, note similar or competing companies that do. I compiled a list of major retailers with dietitians, especially local competitors. I also included articles from publications that discussed benefits retailers receive from hiring dietitians and included statistics such as, “95% of American grocery stores have at least one dietitian on staff.” No business wants to feel behind on a trend. If what you’re proposing is ahead of trend, use that for leverage as well.

Explain specifically what you can do for your target company. Contact dietitians in similar positions, see how their job descriptions differ and tailor your pitch by combining the best ideas. Include a complete job description with your proposal — the kind you see when job-searching online.

Consider adding an emotional aspect by discussing the benefit as it relates to the community, its employees, its image, etc.

Don’t Forget About Yourself

It’s one thing to persuade a company to hire a dietitian; explain why you are the best person for the job. Add this section after the reasons to hire an RDN.

Take Your Time and Organize

Be diligent and patient when researching, writing and compiling all aspects of your proposal and have trusted individuals proof your work. My proposal consisted of a formal letter, a PowerPoint presentation to coincide with the letter, a separate form of my proposed job description, my resume, as well as a CD of all the documents submitted. Deliver your proposal in person if you can. I was states away so I mailed it off in a nice portfolio and immediately left a voicemail with the owner explaining who I was and what was coming his way. Either way, always offer to present the proposal in person.

Who Do You Know?

After asking several people, I discovered I knew a friend of the owner. He didn’t do much — just mentioned my name and gave a good word on my work ethic — and I did the rest. It is not necessary, but it’s a great bonus if you can find it!

Be Persistent and Take Risks

Brace yourself for silence and practice persistence. After I was hired, someone asked my boss why, to which he responded, “She bugged me enough that I finally said yes,” and that’s fine by me! It was months of back and forth, but I didn’t let him forget about me and the experience showed me the importance of persistence and taking risks. It worked for me and who knows, maybe it’ll work for you, too!

How did bottled water begin, anyway? While it seems like a recent trend, bottling water in the United States started as far back as 1760 in a Boston spa, where it was believed the mineral water could heal ailments. The trend grew and was viewed as a safer alternative to tap water, but when the chlorination of water began at the turn of the 20^th century, most people lost interest. In 1977 bottled water’s popularity saw a rebirth following a successful marketing campaign and nearly four decades later in 2015, Americans spent an average of $11.8 billion on bottled water, buying 30 billion bottles, according to the Statistic Brain Research Institute.

According to the Beverage Marketing Corporation, bottled water recently hit a milestone, officially becoming the largest beverage category by volume, surpassing carbonated soft drinks.

Water may seem straight forward but there are different varieties.  Artesian water originates in a confined, underground aquifer and is naturally filtered and free from contact with the air. Mineral water is ground water and contains at least 250 parts per million of dissolved solids at the source. Spring water comes from an underground source and flows naturally to the Earth’s surface. If you see the letters P.W.S. on a bottle, it stands for “public water source,” or tap water. These are just a few examples.

New and improved twists on bottled water are all over the grocery aisles. One popular trend is alkaline water, which has a pH higher than regular drinking water or a pH higher than seven. Health claims include reduced acid reflux, better sports recovery after exercise and even an increase in bone, muscle and kidney health. One study found that drinking alkaline water helped deactivate pepsin, reducing symptoms of acid reflux. The claims are broad, but the research is slim and there is not sufficient evidence to support any claims.

Research on the potential benefits of probiotics has led to many new products, and bottled water is no exception. There are two widely produced brands — one with a probiotic powder in the cap and another with probiotics already mixed in the water. The two most studied probiotics are Lactobacillus and Bifidobacterium but both water brands use Bacillus coagulans, of which benefits are even less known. Kombucha is another popular probiotic drink, though it’s considered a tea more than a bottled water.

Higher energy is the goal of caffeinated waters and oxygenated waters. One brand touts 1,000 parts per million, or PPM, of oxygen, whereas tap water tends to have 40 PPM. A study published in Journal of the International Society of Sports Medicine found that lactate clearance after exercise was improved in those who drank oxygenated water, but there is not enough research to fully support their energy-boosting claims. Many caffeinated waters have less caffeine than a cup of coffee or tea, so it may not be worth swapping for your morning joe.

According to Food Marketing Institute, consumers are increasingly interested in getting more nutrition from their products. Bottled water trends have followed suit as vendors attempt to make the simplest product into something bigger and better. Who knows what they’ll think up next?