Dietitians in
Integrative
THE INTEGRATIVE
Summer 2020
RDN
Volume 23, Issue 1
CPE Article
Integrative Nutrition After
Cancer Treatment
Vivianne Swart, MPH,
RD, CLT, is a graduate of
University of Michigan
School of Public
Health. She serves as
Integrative Nutrition the Wellness Dietitian
After Cancer Treatment in the Integrative
Oncology Clinic for Banner MD Anderson
CPE Objectives in Gilbert, AZ. Vivianne works with
high-risk patients on preventative care,
After completing this CPE activity, the patients undergoing cancer treatment
nutrition professional will understand:
• Transcription factor Nrf2 and its
who want integrative interventions for
role in cancer prevention through
side effects, and is the dietitian for the
detoxification cancer survivorship program. She may be
• How specific foods and compounds contacted at vivimswa@gmail.com.
M
can potentially help prevent cancer or
cancer recurrence through the Nrf2 ore than 11 million residents
pathway in the United States have a
• Practical clinical applications to history of cancer. Advances
mitigate potential post-treatment side in treatment have greatly increased
effects (even up to 5-10 years later) chances of survival for many cancers
and reduced mortality. From 1991 to
2015, the overall cancer death rate fell
26% in the United States.1 In 2016, there
were an estimated 15.5 million cancer
survivors in the United States, and the
number of cancer survivors is expected
In This Issue to increase to 20.3 million by 2026.1
Integrative Nutrition After Cancer After treatment, one of the top
Treatment ...............................................................1 priorities expressed by survivors
Editor’s Notes.........................................................2 is preventing cancer recurrence.
Chair’s Corner.........................................................3 Registered dietitian nutritionists (RDN)
Supplementing Zinc for the Prevention can play a key role in this prevention.
of COVID-19 & Other Infections....................11 According to the World Health
Immune-Friendly Recipes ..............................13 Organization, 30% to 50% of cancer
Befriending Cancer Through Nutrition cases can be prevented through
and Yoga Therapy: A Collaborative adopting healthy lifestyle choices and
Approach..............................................................15 reducing risk factors like smoking, lack
Resource Review.................................................18 of physical activity, dietary factors,
News You Can Use..............................................20 obesity, and alcohol use.2 A healthy
My First Integrative Healthcare detoxification system plays a critical
Symposium..........................................................22
role as well, which can be enhanced
through dietary changes.
and Functional
Medicine
a dietetic practice group of the
®
Academy of Nutrition
and Dietetics
Vivianne Swart, MPH, RD, CLT
One significant piece of this
detoxification pathway is Nuclear
factor-erythroid 2-related factor-2
(Nrf2), a transcription factor, and
its upregulation, which may have
anti-cancer implications.3 Emerging
evidence has demonstrated that
genetic polymorphisms in the
Nrf2 gene may be associated with
cancer development, indicating that
there is a potential link between
carcinogenesis and the Nrf2 pathway.4
Not only is Nrf2 a promising target
for preventing carcinogenesis,
but also other chronic diseases,
including cardiovascular diseases,
neurodegenerative diseases, and
pulmonary injury.5 So far, the
beneficial role of Nrf2 induction has
been widely explored at multiple
organ sites including skin, lungs,
bladder, breast, colon, pancreas,
stomach, and oral cancer.6 Through
significant Nrf2 inducer capacity,
sulforaphane compounds induce
Nrf2 capacity, aiding the body’s
detoxification system.7 Sulforaphane
is a naturally occurring isothiocyanate
with high bioavailability found
predominantly in cruciferous
vegetables.
Supporting this natural system
immediately following treatment
and in the years after is important.
However, other common concerns,
even 5 to 10 years after cancer
treatment, are the side effects that
survivors can experience. RDNs can
recommend lifestyle changes and
dietary interventions to mitigate
these symptoms or lessen their
severity.
Continued on pg. 4
Editor’s Notes
T
hank you for your patience as it’s been more than a few months since we’ve brought you
an edition of the newsletter. Like several other DPGs, we needed time to readjust, get our
content in order, and refocus amidst a radically changed backdrop. We remain incredibly
grateful for your support and membership.
No doubt you have been affected by all that you’ve experienced these past months, in
varying degrees, both personally and professionally. As nurturers, caregivers, and those
who practice in service to the better health of our communities, I dare say we feel the effects of these times
greatly. One thing that has become clear is that the pandemic has highlighted and magnified the inherent
social problems of chronic disease, racial disparity, and a broken health care system. One revelatory outcome,
reflected in this JAMA observational study of 5700 COVID-19 patients in New York, is that 88% of those hos-
pitalized had at least two chronic conditions. It is no coincidence that 88% of the US population is currently
metabolically unhealthy. We have several pandemics within a pandemic, but lifestyle medicine—the essence
and core philosophy of our profession—can and should be leading the way. For some guidance, please take
a look at the Resource Review section for a sampling of the integrative and functional medicine literature
that has recently come out regarding diet, lifestyle, and immune health. At the very least, correcting baseline
inflammation is one key actionable step to optimizing health and building resilience. Additionally, please
check out my article focusing on COVID-19 and infection prevention with supplementation, highlighting the
trace mineral zinc.
Before the pandemic, our original theme for this newsletter was oncology, and we’re grateful to present
Vivianne Swart’s continuing education article on integrative nutrition strategies after cancer treatment. We
are working diligently behind the scenes to get all CPE quizzes and materials transacted digitally. Thank you
also to RDN Anu Kaur and yoga therapist Maryam Ovissi for giving us insight into their integrative and col-
laborative approach to successfully working with cancer patients.
To reiterate, we are always looking for article suggestions, writers, and feedback. Please email me anytime
at jenas_mailbox@yahoo.com or find me on Instagram @jenagee.rd. Thank you so much for taking the time
to read. We wish you good health and strength as we muster through these stressful times!
Jena
Editor News You Can Use Editors The views expressed in this newsletter are those
Jena S. Griffith, RDN, IHC Julia Shuff, RDN, LD of the authors and do not necessarily reflect the
policies and/or official positions of the Academy
jenas_mailbox@yahoo.com jwhelan928@gmail.com of Nutrition & Dietetics.
Geanna Revell, MS, RDN We invite you to submit articles, news, and com-
geanna.revell@gmail.com ments. Contact us for author guidelines.
Send change-of-address notification to the Acad-
Copy Editor emy of Nutrition & Dietetics, 120 South Riverside
Holly A Van Poots, RDN, CSP, FAND Plaza, Ste 2000, Chicago, IL 60606-6995.
hollypnpg@gmail.com Botanicals/Functional Foods/
Supplements Copyright © 2020 Dietitians in Integrative and
Dina Ranade, RDN, LD Functional Medicine, a Dietetic Practice Group of
the Academy of Nutrition & Dietetics. All material
CPE Editor dranade@comcast.net appearing in this newsletter is covered by copy-
Staci Belcher, MS, RDN right law and may be photocopied or otherwise
reproduced for noncommercial scientific or
stacibelcher5@gmail.com
Mind-Body Editor educational purposes only, provided the source is
Chrissy Barth, MS, RDN, RYT acknowledged. For all other purposes, the written
consent of the editor is required.
Biochemistry/Nutritional chrissy@nutritionlifestyleeducation.com
Genomics Editor Annual Subscription Rates (payable in US funds):
Non-members......................................................$60/year
Janie Jacoby, MS, RDN, LDN Academy members............................................$40/year
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Summer 2020 Volume 23, Issue 1 2 www.integrativeRD.org

Chair’s Corner Spring 2020 Dana Elia, DCN, MS, RDN, LDN, FAND

I
hope this issue
finds you well and
staying healthy.
Much has hap-
pened since our last
newsletter and the
entire world has
been struggling with unprecedented
hardship and strife. While we mourn
the immeasurable loss of life, liveli-
hoods, milestone celebrations, hopes,
and dreams, I sincerely hope that
during these most challenging of
times each of you have been able to
identify some silver linings amongst
all of the chaos. I am grateful for the
opportunities that have arisen from
these crises—being able to spend
more time with my family, tackle
day, but I am most grateful for the
respite our planet had been granted
while we all have been staying home.
I sincerely pray that the environmen-
tal impact as a result of our shifting
lifestyles does not get overlooked
and forgotten. Let us try to learn as
much as we can and take the steps
necessary to honor those lessons.
Maybe you have been doing
more telehealth, catching up on
some book club selections, or have
been inspired to focus energy into
advocacy projects. I’m not sure what
things will be looking like in your city
or state by the time this issue lands
in your inbox, but I hope it finds you
asking some critical thinking ques-
tions about our practice area, roles as
It’s hard to believe that my term
as Chair has come to a close but as
I pass the torch to Kory DeAngelo, I
know that her vision for this coming
year continues to resonate in her
own way with this past year’s theme
of Enlighten, Energize, Empower.
May each of you know that DIFM
holds each of you dear to our hearts
and we wish to hear how your lives
have been impacted and what can
we do to support you—our valued
members!
Please keep in touch and let me
and Kory know what DIFM can do for
you!
In health & wellness,

some of those home and business
improvement projects that kept
getting pushed to the backburner,
still finding joy and blessings each
Dana
IFN providers, and obligations to so-
ciety in the face of pandemics, social
injustices, and planetary health.

Chair’s Corner Summer 2020 Kory DeAngelo, MS, RDN

A
s I enter my into the DEI Committee and have of us, and I am hopeful that this time
Chair year plans to partner with other DPGs will allow us to dig deep, address
this summer, and MIGs to provide educational and root causes, and cultivate a stronger
I am reminded networking opportunities to foster and more inclusive profession. I so
why I love being personal and professional growth. appreciate working with such a kind
part of our DIFM We will continue to strive to create and compassionate group of RDNs,
community and a more inclusive profession, which and I look forward to hearing from
the positive and transformative may involve some uncomfortable you on how we can best support you
work that integrative and functional but rewarding practices. this year!
dietitians are doing. I want to
especially recognize the efforts This year, we will continually
Warmly,

of our Diversity Committee, who
have taken the lead in supporting
our DIFM community during this
historically challenging time. The
message is clear: we are here for
you. How can we be the change
we wish to see in our profession?
Our leadership team is prioritizing
how DIFM’s offerings this year can
further support Diversity, Equity,
and Inclusion (DEI) principles. We
expanded our Diversity Committee
Kory
ask what our members need in
order to provide the most support,
community, and connection. To
achieve this, we will be setting goals
quarterly to be able to adapt to what
is happening in the present moment
to support our members best.
FNCE® will be a virtual experience
this year and the DIFM leadership
team is busy brainstorming our
online offerings. It has been an
extraordinarily difficult year for many

Summer 2020 Volume 23, Issue 1 3 www.integrativeRD.org

Continued from pg. 1
Nrf2 and Detoxification
Exposure to intrinsic/extrinsic
factors, including various toxic
chemicals, oncogenes, viruses
(eg, hepatitis B virus or HBV),
reactive oxygen species/reactive
nitrogen species (ROS/RNS), and
inflammation, can result in genetic
mutations and/or epigenetic
alterations that cause the initiation
of carcinogenesis in healthy cells.
Several dietary phytochemicals in
fruits and vegetables have been
shown to possess cancer-preventing
effects in both preclinical animal
models and human epidemiological
studies.8 These phytochemicals are
theorized to prevent the initiation
of carcinogenesis via either direct
scavenging of reactive metabolites
or, more importantly, the induction
of cellular defense detoxifying/
antioxidant enzymes, like Nrf2. These
defense enzymes mediated by Nrf2
contribute to cellular protection
against ROS/RNS and reactive
metabolites of carcinogens.
Considering that Nrf2 signaling
pathway can regulate at least
600 genes, 200 of which encode
cell-protective proteins that are
involved in diseases and the dynamic
connections between diseases and
drugs, modulating Nrf2 activity is a
promising approach in inflammatory
and painful diseases.9 Through
focusing on raising the transcription
factor Nrf2, survivors can begin to
build a cancer-fighting diet.3
Nrf2 and Phytochemicals
In experimental studies, the
chemopreventive role of Nrf2
inducers was mainly addressed
by using the naturally occurring
isothiocyanate, sulforaphane.
Sulforaphane has received
attention because of its ability to
simultaneously modulate early
stages of carcinogenetic events
(initiation) or hamper steps
involved in cancer development.
Mechanistically, sulforaphane, via
Nrf2, promotes DNA protection by
inducing phase II enzymes.10 Phase
II detoxifying/antioxidant enzymes
provide a cytoprotective mechanism
by reducing the toxicity of reactive
intermediates, which results in
cellular defense against oxidative
or electrophilic challenges, and
maintaining chemical homeostasis in
cells.11
Summer 2020 Volume 23, Issue 1
Prevention trials using whole
foods or simple extracts offer
additional prospects for reducing
this expanding burden of cancer
effectively and frugally in contrast to
promising isolated phytochemicals
or pharmaceuticals. Combined
modification of diet and behavior
constitute one of the only available
tools for widespread change in
many populations in the developing
world.12 Besides sulforaphane
there are other molecules with
distinct mechanisms that have
therapeutic effects in cancer by
targeting Nrf2, including phenethyl
isothiocyanate (also found in
cruciferous vegetables), oltipraz,
curcumin (found in turmeric),
resveratrol (found in grapes), fumaric
acid and its esters, and synthetic
oleanane triterpenoids.13 However,
interestingly, compared with
widely used phytochemical-based
supplements like curcumin, silymarin,
and resveratrol, sulforaphane
more potently activates Nrf2 to
induce the expression of a battery
of cytoprotective genes.7 Rather
than drinking a glass of red wine
nightly for resveratrol, eating a
cup of cruciferous vegetables daily
would be a more prudent dietary
phytochemical goal.
Because they are low-cost,
practical, tolerable, safe, and
effective, foods containing bioactive
phytochemicals are gaining
significant attention as components
of chemoprevention strategies
against cancer. RDNs play a key
role, translating this research and
evidence into action-based steps
survivors can take to reduce their risk
of cancer recurrence.
Other specific phytochemicals
that can be part of a cancer-fighting
diet include:
• anacardic acid (cashew nuts)14,15
• caffeic acid and chlorogenic acid
(coffee)16,17
• genistein (soy)18-22
• EGCG (green tea)23-25
• indole-3-carbinol (cruciferous
vegetables)26,27
• 6-gingerol (ginger)28,29
• lycopene (tomato)30,31
• quercetin (citrus)32,33
Applying dietary phytochemicals
at the early stage of carcinogenesis
may block further development
of carcinogenesis.11 Treatment
with dietary phytochemicals and/
4 www.integrativeRD.org
or relatively non-toxic therapeutic
drugs on cancer cells may induce
cellular indices of stunted cancer
progression, including autophagy,
cell cycle arrest, apoptosis, and
differentiation, and may block tumor
development.11
A recent review published in
2018 from Frontiers in Pharmacology
stated, “Enhancing Nrf2 is essential
for the prevention of cancer.”3
However, the research surrounding
the activation of Nrf2 through
dietary approaches is still in its
infancy; this is a promising area of
research to watch in the oncology
field. A well-balanced diet rich in
dietary phytochemicals may have
chemopreventive effects through
Nrf2,8 but the magnitude of an effect
on cancer survivorship outcomes is
still under study.
Sulforaphane: Dietary Sources
The liver has many detoxification
and anti-oxidative stress
functions.34 Research into human
biotransformation and elimination
systems continues to evolve.
Various clinical and in vivo studies
have been undertaken to evaluate
the effects of foods and food-
derived components like dietary
phytochemicals on the activity of
detoxification pathways, including
phase I cytochrome P450 enzymes,
phase II conjugation enzymes, Nrf2
signaling as discussed previously, and
metallothionein.35 Cancer survivors
should not do a liver cleanse after
treatment; instead, practitioners can
work with patients to enhance their
natural biotransformation system
through supporting liver function,
in particular by incorporating the
intake of sulforaphane-containing
cruciferous vegetables such as
broccoli, cauliflower, kale, and more.
High intake of cruciferous
vegetables has been associated
with lower risk of various cancers,
and the cancer preventive effect of
these vegetables has been linked to
their high levels of glucosinolates.
The hydrolysis of glucosinolates
results in the generation of bioactive
compounds, including allyl nitrile,
an active inducer of some phase
II detoxification enzymes.36 The
glucosinolate hydrolysis products
and selenium derived from crucifers
protect against cancer through
altered estrogen metabolism,
protection against ROS, altered
detoxification by induction of phase
II enzymes, decreased carcinogen
activation by inhibition of phase I
enzymes, and slowed tumor growth
and induction of apoptosis.37 Results
from animal experiments show
that cruciferous vegetable intake
reduces chemically induced tumor
formation.38,39
For reasons of experimental
necessity, pre-clinical studies have
focused principally on sulforaphane
itself, while clinical studies have
relied on broccoli sprout preparations
rich in either sulforaphane or its
biogenic precursor, glucoraphanin.12
A 2015 mouse study looked at the
ability of broccoli sprout extract to
protect against acute liver injury. The
researchers were able to demonstrate
that broccoli sprout extract protected
the liver from various types of
xenobiotic substances through
induction of detoxification enzymes
and glutathione synthesis.40 The
concentration of glucoraphanin in
the broccoli sprout extract diet was
adjusted to 340 mg/100 g diet. If
calculated by the daily food intake
(approximately 15 g) by a rat, and the
body weight of a rat (approximately
200 g), researchers estimated that
rats consumed about 200-300 mg/
kg of glucoraphanin every day. While
specific intake of glucoraphanin
in humans through a cruciferous
vegetable-rich diet is not available, a
study analyzed a total of 73 samples
comprising nine types of cruciferous
vegetables for their isothiocyanate
content. Researchers observed a
wide range of isothiocyanate content
across the individual vegetables with
an average level of 16.2 μmol/100g
wet weight, ranging from 1.5 μmol in
raw cauliflower to 61.3 μmol/100g in
raw mustard greens.41
In a similar vein, a series of
studies have been undertaken in
Qidong, China, a region known
as a “hot-spot” for hepatocellular
carcinoma because of co-
exposures to HBV and aflatoxins.
In a recently completed 12-week
placebo-controlled, randomized
clinical trial, 291 participants from
Qidong were provided a broccoli
sprout beverage containing both
40 μmol sulforaphane and 600
μmol glucoraphanin. The urinary
levels of the mercapturic acids of
the air pollutants benzene and
Summer 2020 Volume 23, Issue 1
acrolein were measured and
used as biomarkers of health risk.
The levels of excretion of the
glutathione-derived conjugates
of benzene (61%) and acrolein
(23%) were significantly higher in
the participants who received the
broccoli sprout beverage compared
with placebo. This increase in
pollutant-mercapturic acid excretion
was rapid and sustained throughout
the broccoli sprout beverage
intervention. Researchers concluded
that the detoxification of these
airborne pollutants was enhanced by
the broccoli sprouts beverage.12  quality of life and may last up to ten
Despite the growing evidence
for the importance of cruciferous
vegetable intake in cancer
prevention, the American Institute
of Cancer Research estimates that if
the only dietary change made was
to increase the daily intake of fruits
and vegetables to 5 servings per
day, cancer rates could decline by as
much as 20%.37 As such, encouraging
patients to eat more cruciferous
vegetables will likely yield a net
benefit regardless of the potential
positive factors on detoxification or
Nrf2.
To illustrate this point, a study
done by Thomson et al. sought to
evaluate the association between
breast cancer recurrence and
vegetable intake including analyses
stratified on tamoxifen use. To assess
the association between vegetable
intake and breast cancer recurrence,
vegetable intake from repeat 24-
hr dietary recalls were examined
as a secondary analysis of 3,080
breast cancer survivors enrolled in
the Women’s Healthy Eating and
Living (WHEL) Study. At the time
of enrollment women were, on
average, 23.5 months post-diagnosis.
The hazard of recurrence with
vegetable intake was assessed overall
and separately for women taking
tamoxifen. Researchers found that
women with the highest reported
intakes of total vegetable intake
at their baseline measure had an
overall lower hazard for breast cancer
recurrence or new primary breast
cancer. The reduction in hazard risk
for recurrence attributed to higher
vegetable intake was most significant
in women taking the selective
estrogen receptor modulating drug,
tamoxifen.42
5 www.integrativeRD.org
Addressing Side Effects in
Survivorship
Although the cycles of
chemotherapy or radiation sessions
may be finished, patients can
experience side effects of cancer
treatment for years. Some of the
most common side effects are
fatigue, weight gain, gastrointestinal
symptoms, “chemo brain,” and/or
hair and skin problems. For example,
women diagnosed with breast cancer
report that post-chemotherapy
cognitive deficits negatively impact
years after treatment.43
Fatigue. Fatigue has many
etiologies. The patient may not be
sleeping enough, and it might be
helpful to recommend the following
interventions: no electronics 60 to
90 minutes prior to bed, keeping a
consistent bedtime, not eating within
2 hours of bedtime, and aiming
for 7 to 8 hours of sleep per night.
Lack of physical activity can also
increase fatigue; patients can start
by adding walking throughout the
day, and working toward the goal of
150 minutes of moderate physical
activity weekly as recommended
by the American Cancer Society.44
Initial evidence indicates that
interventions with cancer patients
including physical activity, cognitive
behavioral therapy, and mind-
body interventions have moderate
effectiveness in improving sleep
measures and quality of life.45
As part of their assessment, RDNs
can ask about fluid intake to assess
hydration status; adequate hydration
and electrolyte balance are essential
in preventing and treating fatigue
according to the clinical practice
guidelines in oncology.45 Additionally,
a diet high in simple sugars and
low in antioxidant-containing
foods like fruit and vegetables may
contribute to fatigue. Adjusting
to a Mediterranean-style dietary
pattern may help alleviate fatigue.47
In one population of breast cancer
survivors, higher soy and cruciferous
vegetable intake was associated with
less treatment-related menopausal
symptoms and fatigue.48 Patients may
not be meeting their protein needs
resulting in a feeling of low-energy;
in a 2013 review, after evaluating the
evidence, an international expert
panel recommended an average
daily intake of 1 to 1.2 g/kg protein
per day for those aged 65+ years and
even higher intakes for those who are
exercising and otherwise active.49
If a patient continues to
struggle with fatigue despite these
interventions, it may be helpful
to work with a physician to get
blood tests ordered or refer out to a
psychologist if the patients is having
trouble with stress management. The
following lab tests may be helpful:
iron panel, thyroid panel, vitamin
D status, and vitamin B12 status.
Supplementation may be indicated
depending on results.
For B12 supplementation, it
may be prudent to recommend
methylated forms over non-
methylated B12 because of
possible MTHFR mutations. Two
polymorphic variants in this
gene (C677T and A1298C) have
been implicated in a mild form of
MTHFR deficiency associated with
hyperhomocysteinemia. Mild to
moderate hyperhomocysteinemia
has been previously implicated as a
risk factor for cardiovascular disease.
Furthermore, the presence of these
variants, with and without mildly
elevated levels of homocysteine, has
been studied in relation to several
multifactorial disorders including
cancer.50-52
Weight Gain/Loss. Although it is
common for patients to lose weight
during chemotherapy due to side
effects like taste changes and loss of
appetite, many patients regain lost
weight post-treatment. This pattern
is more common in cancers with
higher survival rates. One study of
993 obese women with stage I-II-
III breast cancer looked at weight
changes during treatment (including
modalities like chemotherapy and
surgery). Researchers found that
14.1% women gained weight, 67.3%
remained stable, and 18.6% lost
weight.53 With 39.8% of US adults
classified as obese, weight loss is a
subject on many patients’ minds.54
Obesity has also been linked with
up to six different cancers, with
inflammation a likely modulating
factor.55 Thus although many
patients may be weight-stable
during treatment, those who are
carrying excess weight may be more
motivated to pursue a normal weight
to decrease risk cancer recurrence or
development of a new cancer.
Summer 2020 Volume 23, Issue 1
Rather than focus on a simple
calories in/calories out approach,
increasing plant foods and
decreasing inflammatory foods
may be a more prudent lifestyle
intervention. This allows the
patient to be less focused on the
number on the scale, and more
focused on a nutrient-rich, balanced
diet.56 Nutrition interventions that
emphasize healthy behaviors (eg,
eating more home-cooked meals,
increased intake of nutrient-dense
foods, and regular physical activity),
provide practical skills (eg, cooking
for one or two, adding more plant-
based foods to menu), and foster a
sense of confidence and self-efficacy
about lifestyle choices, may result in
weight loss for some individuals, but
for most will improve overall health
and well-being.57
Age contributes to weight gain for
multiple reasons. First is the natural
loss of muscle tissue that occurs with
aging, known as sarcopenia, that
can contribute to obesity through
negative impacts on metabolic
health.56 Muscle loss associated with
sarcopenia is gradual and appears
to be less than 10% up to the fifth
decade of life, whereas 30% to 40%
of muscle is lost between 50 and 80
years of age.58 Sarcopenia is a process
that occurs in both men and women
and is associated with decreased
mobility, reduced muscle strength,
increased fat mass, decreases in
resting energy expenditure,56 and
insulin resistance.58 Additionally,
previous research has demonstrated
that adults generally underestimate
their calorie intake and overestimate
energy expenditure.60 Many survivors
may not realize this effect and do not
adjust their caloric intake as they age,
resulting in unwanted weight gain.
It is common for patients to look
toward fad diets after treatment
like the alkaline diet or ketogenic
diet to address their concerns of
cancer recurrence and weight
loss. It is important to avoid being
dismissive of patients, and instead
try to find middle ground, taking
healthful pieces of what they bring
to the table, and addressing larger
misconceptions. For example, many
patients may want to start the
ketogenic diet because they have
heard that “sugar feeds cancer.”
The clinician can then explain how
excess intake of simple sugars can
6 www.integrativeRD.org
increase inflammation, which is
linked to cancer, and discuss ways
to moderate sugar in the diet, rather
than cutting out all carbohydrates.
This is also an education opportunity
to explain the importance of fiber
in cancer prevention, and reference
higher carbohydrate cancer-fighting
foods.61 The World Cancer Research
Fund/American Institute for Cancer
Research recommends eating a diet
rich in whole grains, vegetables,
fruit, and beans, while limiting
consumption of fast food, red and
processed meats, sugar-sweetened
drinks, and alcohol to reduce cancer
risk.62
Gastrointestinal Issues. Patients
frequently experience diarrhea/
constipation while receiving
treatment, but it usually resolves,
if due to a medication side effect,
after treatment. Some patients may
continue to struggle with these
symptoms, however, even years
after treatment. Patients concerned
about bloating, gas, and other IBS
symptoms could try the low-FODMAP
elimination diet (under guidance
of an RDN) to identify trigger foods.
Patients may be consuming too
little water, resulting in constipation,
or may not be consuming enough
fiber, resulting in diarrhea. National
consumption surveys indicate that
only about 5% of the population
meets recommendations for daily
fiber intake, despite its critical
importance for digestive health and
reduced risk for heart disease, stroke,
hypertension, certain gastrointestinal
disorders, obesity, type 2 diabetes,
and certain cancers.63 Evidence
is still preliminary for probiotics;
however, one group of researchers
state, “There is a general agreement
that individual probiotic strains can
beneficially affect metabolic activities
that occur in the gastrointestinal
tract and enhance the host’s immune
response.”64 During their literature
review, the authors also found,
“A tumor-suppressive molecule
has been identified from culture
supernatants of Lactobacillus gasseri
ATCC334, a well-characterized
probiotic. The molecule ferrichrome
(a hydrophilic metal chelating
agent or siderophore generated
by ATCC334) exhibited its tumor-
suppressive effect through the
induction of apoptosis in colon
cancer cells via activation of the c-jun
N-terminal kinase (JNK) pathway.”64
Incorporating probiotic-rich foods
(sauerkraut, kimchi, etc) may be
helpful to some patients, but a
customized approach must be taken
for each person. RDNs play a pivotal
role in addressing GI issues post-
treatment and can employ a number
of individualized interventions in
addition to those already discussed.
“Chemo Brain.” In the past two
decades, neuropsychological studies
have accumulated evidence of
corresponding cognitive deficits
that have mostly been attributed to
neurotoxic effects of chemotherapy.
The use of neuroimaging techniques,
such as magnetic resonance imaging
(MRI) and functional MRI (fMRI),
allow the identification of structural
and functional differences within
the brain. Several imaging studies
demonstrate that chemotherapy
can induce changes in the brain,
including volume reductions and
changes in activity patterns.43
However, observations of impaired
cognitive functioning occurring
before the start of adjuvant or
neoadjuvant chemotherapy question
the singular role of chemotherapy
for the causation of these deficits.65
There is very little evidence using
dietary interventions to address
“chemo brain,” particularly because
the symptom itself is still not well
understood. There is better evidence
for what dietary approaches support
cognitive function generally, and
these are the interventions within
the RDN scope that may be useful
for patients, such as focusing on
omega-3 fatty acids.66 Another option
would be the recently developed
MIND diet, which has been shown
to slow cognitive decline associated
with aging. The difference in decline
rates for being in the top tertile of
MIND diet scores in this study versus
the lowest was equivalent to being
7.5 years younger in age.67
One group of researchers
proposed that a diet rich in marine
omega-3 fatty acids may even be
neuroprotective during doxorubicin
chemotherapy as demonstrated
by a mouse study,43 and another
group of researchers stated that
consuming diets with an adequate
ratio (5:1) of omega-6: omega-3
fatty acids (Mediterranean diet) is
recommended given that they are
associated with better memory
capacity and lower risk of cognitive
Summer 2020 Volume 23, Issue 1
deterioration.68 For reference,
Americans consume in a ratio as high
as 30:1 of omega-6:omega-3 fatty
acids.69 Alternatively, survivors may
be consuming adequate amounts of
omega-3 fatty acids but too many
polyunsaturated omega-6 vegetable
oils, so reducing omega-6 intake is
another target for intervention.
Consistent carbohydrates
throughout the day are also
important; low glycemic index foods
seem to improve attention, memory,
and functional capacity, while those
rich in simple sugars are associated
with difficulty in concentration and
attention.68 Furthermore, a high
intake of antioxidant-rich fruits and
vegetables can help decrease chronic
inflammation.70
Hair/Skin/Nail Problems. Hair,
skin, and nail problems are frequent
complaints after cancer treatment.
This can also be an issue of aging;
however, RDNs should assess for any
potential micronutrient deficiencies
that may be contributing to these
issues. Although there exists a
substantial amount of market
advertising and social media
publicity regarding the efficacy of
biotin therapy for the improvement
of hair quality, in reality the only
human health condition for which
there is strong evidence of biotin’s
therapeutic utility is for the treatment
of biotin deficiency.71 In industrialized
countries such as the United States,
true biotin deficiencies remain rare
because the production of biotin
from intestinal bacteria remain
sufficient to meet the body’s daily
requirements.71
The exception to this would be
in cases of acquired and inherited
causes of biotin deficiency as well
as pathologies, such as brittle nail
syndrome or uncombable hair, where
biotin supplementation may be
of benefit.72 Because of this, biotin
supplementation is not usually
recommended for hair/skin/nail
health in the cancer survivorship
population, although if patients are
persistent, foods high in biotin may
be recommended such as egg yolks,
organ meats, fish, meat, dairy, nuts,
seeds, spinach, broccoli, cauliflower,
sweet potatoes, yeast, whole grains,
and bananas.73 An anti-inflammatory
diet as previously discussed would be
the first-line approach, incorporating
adequate protein and omega-3 fatty
7 www.integrativeRD.org
acids, as well as assessing for any
potential micronutrient deficiencies
such as iron or zinc.
Conclusion
Integrative dietary approaches
in cancer survivorship can vary and
should be based on the individuality
of each patient. It is critical to
support patients as they focus on
sustainable lifestyle changes. This
may mean supporting their natural
detoxification system by increasing
their cruciferous vegetable/
sulforaphane intake (inducing
the Nrf2 pathway and phase II
detoxification), increasing physical
activity to combat fatigue, guiding
them through an elimination diet,
increasing their marine omega-3
fatty acid intake or decreasing
omega-6 fatty acid intake for
cognitive support, and/or assessing
for micronutrient deficiencies that
may be impacting hair/skin/nail
health.
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We Harness
Vitality in
Whole Foods
From soil to
supplement. And every
step along the way.
Learn more at standardprocess.com
We focus on achieving wholistic health through nutrition. From our organic,
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Summer 2020 Volume 23, Issue 1
56. Tuso P.J., Ismail M.H., Ha B.P., Bartolotto C.
Nutritional update for physicians: Plant-based
diets. Perm. J. 2013;17:61–66.
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For more than 90 years, we have
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9 www.integrativeRD.org
National Cancer Institute. Monographs.
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Supplementing Zinc for the Prevention of COVID-19
& Other Infections Jena S Griffith, RDN, IHC
Jena S. Griffith, RDN, IHC
is director of nutrition for
the Culpeper Wellness
Foundation and Powell
Wellness Center,
the top ranking medical
wellness center in
Virginia. She has been
the lead nutrition
instructor for Charlottesville’s community
education program for the last decade and
maintains a private practice specializing in
digestive health and chronic pain. Jena teaches,
writes, and presents on IFN topics and is the
current editor of The Integrative RDN.
“Dietary supplements, including
vitamins, minerals, essential fatty
acids, amino acids, flavonoids,
herbs, and accessory food factors,
are among the most valuable and
safe substances for prevention
and treatment of serious chronic
and acute diseases associated
with mortality, as well as everyday
health problems that cause
discomfort and disability. It is
important to take adequate doses
for their full benefits. Because
they prevent deficiency diseases
at low doses, they have acquired
a reputation for being necessary
only at these low levels. As a result,
many physicians ignore the value
of much higher doses that are
useful for therapeutic purposes
and protection from age-related
degeneration.”1
F
rom the start of the pandemic
there has been an obvious uptick
in integrative and functional
medicine research articles, letters,
and literature focusing on diet
and lifestyle strategies to support
immune health. For as we know, if
we increase the overall health of the
human host, we increase immunity
and resilience. What has also been
made clear is that individuals with
chronic health conditions, especially
metabolic dysfunction, are more
severely affected by COVID-19. For
clarity, SARS-CoV-2 is the virus that
causes the disease COVID-19. You can
test positive for SARS-CoV-2 and not
have COVID-19.
At the same time, demand for
vitamin and mineral supplements
has increased, with many products
backordered or sold out, clearly
indicating consumers—and
practitioners—are stocking up.
Summer 2020 Volume 23, Issue 1
Historically, and often to our
detriment, nutrition research focuses
on the effects of one nutrient on
one condition. There is less research
highlighting the synergistic and
more powerful combined effect of
these nutrients and supplementing a
specific vitamin or mineral at higher
doses. However, not only is there
is definite evidence, but there are
a few nutrients that stand out, not
just for COVID-19, but for all immune
health. RDNs need to be able to
understand, personalize, and guide
supplementation as a potential
therapeutic prevention and possibly,
as an intervention. Please refer to the
COVID IFM studies in the Resource
Reviews section of this issue for
additional guidance and research.
Zinc is an essential mineral with
many biological functions, playing
critical roles in immune health,
wound healing, DNA, and protein
synthesis.2 In fact, the constant supply
of zinc is crucial to the functioning
and maintenance of the immune
system, with even mild deficiency
negatively affecting many systemic
processes and gene expression.3
While the Recommended Dietary
Allowance (RDA) is 11 mg and 8 mg/
day for men and women respectively,4
these recommendations often reflect
the minimum amount needed to
avoid deficiency rather than for
the pursuit of maximum health.5
Additionally, the definition of RDA
refers to the “needs of practically all
healthy persons.”5 With 88% of the US
population metabolically unhealthy,
the current definition must be
reconsidered and amounts adjusted
Figure 1.
Figure
Figure 1. 1.
COVID-19 Symptoms
COVID-19 Symptoms
• Loss of taste & smell
•• Loss Loss of
of taste & smell
appetite
•• Loss of appetite
Diarrhea/GI issues
•• Diarrhea/GI issues
Fatigue
•• Fatigue
Dry cough
•• Dry cough
Fever
•• Fever
Decreased immunity, white blood cell count
•• Decreased
Pneumoniaimmunity, white blood cell count
•• Pneumonia
Lower platelets (clotting factor)
•• Lower platelets
Increased (clotting(inflammation)
interleukin-6
•• Increased interleukin-6 (inflammation)
Elevated iron storage (ferritin)
•• Elevated
Elevated iron storage
C-reactive (ferritin)
protein
• Elevated C-reactive protein
11
to fit the individual and their present
environment.6
Those at risk for zinc deficiency
include the elderly, those with
autoimmune and inflammatory
conditions, vegans or vegetarians,
those taking zinc-depleting
medications (ACE inhibitors,
histamine blockers, proton pump
inhibitors, cortisone, diuretics,
etc) and those with digestive
disorders often resulting in reduced
capacity for mineral absorption.
Risk factors appear to mirror the
health conditions of the majority of
those more severely afflicted with
COVID: diabetes, kidney, liver and
gastrointestinal diseases, inadequate
diet, and alcohol dependency.7
Additionally, zinc deficiency may
be a primary factor in the majority
of infectious disease and is
responsible for 16% of respiratory
illnesses worldwide. The use of zinc
supplementation as prevention and
treatment is widely practiced and
approved for many disease states.7,8
Viruses like SARS-CoV-2 are highly
dependent upon the metabolism
of the host cell. Ample evidence
suggests zinc not only prevents
viral entry into the cell, but directly
reduces its virulence once inside.7,9
Early on in the pandemic it seemed
apparent that symptoms of zinc
deficiency and symptoms of COVID
were not only intersectional but
identical. (See Figure 1.) Whether
cause or effect, it’s impossible
to discount zinc’s integral role
in prevention and/or potential
intervention.10
Zinc Deficiency Symptoms
Zinc Deficiency Symptoms
• Loss of taste & smell
•• Loss Loss of
of taste & smell
appetite (anorexia)
•• Loss
Looseofstool
appetite (anorexia)
•• Loose
Apathystool
•• Apathy
Chronic cough
•• Chronic
Fever cough
•• Fever
Decreased immunity
•• Decreased immunity
Susceptibility to pneumonia
•• Susceptibility
Low platelets to pneumonia
factor) •• Low platelets
Increased interleukin-6
•• Increased
Increased interleukin-6
iron storage/transport
•• Increased
Increased iron storage/transport
C-reactive protein
• Increased C-reactive protein
www.integrativeRD.org
 Zinc is a positively charged ion
and needs a transporter to enter a
cell. Researchers in 2010 established
that a combination of zinc plus a zinc
transport molecule, or ionophore,
facilitates its entry into cells and can
specifically inhibit the replication of
RNA coronaviruses, and potentially
SARS-CoV-2. The combination
of zinc + ionophore was found
to be effective against the SARS
coronavirus of 2003-2004, influenza,
coxsackie virus, rhinoviruses, and
more.11 In 2014, when studying
its potential anticancer activity,
researchers demonstrated
that the antimalarial agent
hydroxychloroquine was as effective
as a zinc ionophore.12 Thus, it follows,
with zinc preventing viral replication
and conventional medicine’s track
record of ushering in zinc over the
membrane, logic directed its use with
SARS-CoV-2. While still politically
controversial, many physicians
are using this combination as
prevention and at the first sign of
infection, with much underreported
success.13-15 What about natural zinc
ionophores? Studies suggest the
flavonoid quercetin, found in apples,
onions, etc, and epigallocatechin-
gallate (EGCG), found in green tea
and in supplement form, are also
ionophores.16 Quercetin, a known
anti-inflammatory and antiviral
polyphenol, was also found to be
effective in preventing the docking of
the spike protein of SARS-CoV-2.17
Zinc can be obtained from foods,
lozenges, and pills. Lozenges are
best for releasing zinc in the mouth,
allowing it to travel into the nose and
throat while pills are able to circulate
through all tissues including lungs.
Zinc is available in animal form from
meat, eggs, and milk with the highest
amount found in oysters. One to two
oysters contain 7 to 10 mg of zinc.
Top plant-based sources are pumpkin
seeds, legumes, and wheat germ; but
overall absorption is lower due to the
inhibition of phytates. While this puts
vegans at risk, as mentioned, meat
eaters with compromised gut health
or higher alcohol intake may also be
at risk. Although serum zinc status is
most often used, assessment of true
zinc status is complex due to its daily
fluctuations, widespread presence
and tight homeostatic control, all
affected by the individual’s state
of inflammation, hormone, and
stress levels. A review identified 32
Summer 2020 Volume 23, Issue 1
different biomarkers of zinc status
and concluded that serum, urinary
excretion, and hair responded most
to zinc level fluctuations.4,18 However,
while a low serum zinc level may
accurately detect a deficiency, it
is not likely adequate to detect
sufficiency. Symptoms are often the
best indicator.19
Nutrient Interactions
The upper limit of 40 mg/day is
due to zinc’s relationship with copper
as long-term supplementation can
cause copper deficiency. Ideally
the zinc to copper ratio would
be 15:1.20 Food is the best source
of copper; and sources includes
oysters, pumpkins seeds, shiitake
mushrooms, sesame seeds, whole-
food vitamin C, dark chocolate, and
liver. Importantly, copper is toxic to
coronaviruses.20 Additionally, since
1941 foods have been fortified with
iron, possibly to our detriment,
and a potential cause of mineral
imbalance. As zinc and iron compete,
this may be an undervalued and
hidden cause of zinc deficiency.
Further, the metabolism of vitamin
A—its absorption, utilization, and
transport—is intricately linked with
zinc status.21 Vitamin A, originally
called the “anti-infective vitamin”
in 1928, has integral roles in
immune function. Thus, lowered
zinc translates to less bioavailability
of vitamin A.22 Going further, less
vitamin A has downstream effects
on the status of vitamin D, also a
well-known player in immunity
and inflammation and in a very
controlled, reciprocal dance with
A. When a vitamin or mineral
influences hundreds of enzymes and
transcription factors, it’s important
to take all of these potential
nutrient interactions into account.
Supplementation should not be
feared; however, it is not a matter of
striving for an arbitrary data point
but of achieving a certain degree
of optimal health in the individual
patient.
Supplementation
When concerned with exposure,
eating one to two oysters (or
approximately 10 mg of zinc) a few
times a day will provide the most
absorbable form of zinc, as the body
can only absorb a small amount at a
time. If eating oysters is not possible,
supplementing 15 to 30 mg per day
12
can be safely consumed by adults.23
There are limited studies evaluating
the bioavailability of the various
forms; however, zinc methionine,
glycine, gluconate, sulfate, picolinate,
and acetate are used most often
with success. Due to phytates,
supplements should not be taken
with grains, nuts, seeds, legumes,
or coffee. When less concerned
about exposure, 15 mg per day may
be sufficient. Known for “curing”
the common cold, studies actually
show that a minimum of 75 mg of
zinc acetate per day significantly
cut cold duration.24 Risk is generally
low with high amounts of zinc for
short periods of time; however,
acute and chronic zinc toxicity does
occur. Effects of larger doses include
nausea, vomiting, cramps, diarrhea,
and headaches.4 Further, long-term
supplementation of 150 mg twice
daily for 6 weeks impaired immune
function by reducing activation of
lymphocytes.25
Although data is pending in
specific regard to COVID, there is
ample evidence to strongly suggest
benefits of zinc supplementation.
With zinc’s ability to balance the
immune and redox system, its
previous history of inhibiting
coronaviruses, the symptomatic
similarities with COVID, and
importantly its effectivity with
an ionophore such as quercetin,
it may be as close as we can get
to a preventive silver bullet. With
one-third of the world deficient,
including the most severely affected
populations, together with its
antiviral properties, it seems a
disservice not to supplement with
zinc, as it is a cost-efficient, widely
available, and easy-to-use option
with little to no risk of negative side
effects.7
www.integrativeRD.org
References
1. Janson M. Orthomolecular medicine: the
therapeutic use of dietary supplements for
anti-aging. Clin Interv Aging. 2006;1(3):261-265.
doi:10.2147/ciia.2006.1.3.261
2. Prasad AS. Zinc deficiency. BMJ.
2003;326(7386):409-410. doi:10.1136/
bmj.326.7386.409
3. Haase H, Rink L. The immune system and
the impact of zinc during aging. Immun
Ageing. 2009;6:9. doi:10.1186/1742-4933-6-9
4. Zinc: fact sheet for health professionals.
National Institutes of Health Office of Dietary
Supplements. Updated July 15, 2020.
Accessed July 28, 2020. https://ods.od.nih.gov/
factsheets/Zinc-HealthProfessional/
5. National Research Council (US)
Subcommittee on the Tenth Edition of the
Recommended Dietary Allowances. Definition
and applications. In: Recommended Dietary
Allowances. 10th ed. National Academies Press;
1989:chap 2. Accessed July 29, 2020. https://
www.ncbi.nlm.nih.gov/books/NBK234926/
6. Araújo J, Cai J, Stevens J. Prevalence of
optimal metabolic health in American adults:
National Health and Nutrition Examination
Survey 2009-2016. Metab Syndr Relat Disord.
2019;17(1):46-52. doi:10.1089/met.2018.0105
7. Wessels I, Rolles B, Rink L. The potential
impact of zinc supplementation on COVID-19
pathogenesis. Front Immunol. Published online
July 10, 2020. doi:10.3389/fimmu.2020.01712
8. Wessels I, Maywald M, Rink L. Zinc as a
gatekeeper of immune function. Nutrients.
2017;9(12):1286. doi:10.3390/nu9121286
9. Phillips JM, Gallagher T, Weiss, SR.
Neurovirulent murine coronavirus JHM.SD uses
cellular zinc metalloproteases for virus entry
and cell-cell fusion. J Virol. 2017;91(8):e01564-
16. doi:10.1128/JVI.01564-16
10. Yanuck SF, Pizzorno J, Messier H, Fitzgerald
KN. Evidence supporting a phased immuno-
physiological approach to COVID-19 from
prevention through recovery. Integr Med
(Encinitas). 2020;19(suppl 1):8-35.
11. te Velthuis AJ, van den Worm SH, Sims
AC, Baric RS, Snijder EJ, van Hemert MJ.
Zn(2+) inhibits coronavirus and arterivirus
RNA polymerase activity in vitro and
zinc ionophores block the replication of
these viruses in cell culture. PLoS Pathog.
2010;6(11):e1001176. doi:10.1371/journal.
ppat.1001176
12. Xue J, Moyer A, Peng B, Wu J, Hannafon
BN, Ding WQ. Chloroquine is a zinc
ionophore. PLoS One. 2014;9(10):e109180.
doi:10.1371/journal.pone.0109180
13. Risch HA. Early outpatient treatment of
symptomatic, high-risk COVID-19 patients that
should be ramped-up immediately as key to
the pandemic crisis. Am J Epidemiol. Published
online May 27, 2020. doi:10.1093/aje/kwaa093
14. Zelenko V, Risch HA, Fareed GC. Medical Studies
Support MDs Prescribing Hydroxychloroquine for
Early Stage COVID-19 and for Prophylaxis. JRC
Publishing LLC; 2020. Accessed July 29, 2020.
https://americasfrontlinedocs.com/wp-content/uploads/
2020/07/AAA-ebook-Medical-Studies-Support-MDs-
Prescribing-Hydroxychloroquine-for-Early-Stage-COVID.
pdf
15. Scholz M, Derwand R, Zelenko V. COVID-19
Outpatients – Early risk-stratified treatment
with znc plus low dose hydroxychloroquine
and azithromycin: a retrospective case series
study. Preprints 2020, 2020070025. doi:
10.20944/preprints202007.0025.v1
16. Dabbagh-Bazarbachi H, Clergeaud G,
Quesada IM, Ortiz M, O’Sullivan CK, Fernández-
Larrea JB. Zinc ionophore activity of quercetin
and epigallocatechin-gallate: from Hepa 1-6
cells to a liposome model. J Agric Food Chem.
2014;62(32):8085-8093. doi:10.1021/jf5014633
17. Chen L, Li J, Luo C, et al. Binding interaction
of quercetin-3-beta-galactoside and its
synthetic derivatives with SARS-CoV 3CL(pro):
structure-activity relationship studies reveal
salient pharmacophore features. Bioorg Med
Chem. 2006;14(24):8295-8306. doi:10.1016/j.
bmc.2006.09.014
18. Lowe NM, Fekete K, Decsi T. Methods
of assessment of zinc status in humans:
a systematic review.  Amer J Clin Nutr.
2009;89(6):2040S–2051S. doi:10.3945/
ajcn.2009.27230G
19. Hess SY, Peerson JM, King JC, Brown
KH. Use of serum zinc concentration as an
indicator of population zinc status. Food
Nutr Bull. 2007;28(3 suppl):S403-S429.
doi:10.1177/15648265070283S303
20. Fischer PW, Giroux A, L’Abbé MR. Effect
of zinc supplementation on copper status in
adult man. Am J Clin Nutr. 1984;40(4):743-746.
doi:10.1093/ajcn/40.4.743
21. Han J, Chen L, Duan SM, et al. Efficient
and quick inactivation of SARS coronavirus
and other microbes exposed to the surfaces
of some metal catalysts. Biomed Environ Sci.
2005;18(3):176-180.
22. Christian P, West KP Jr. Interactions
between zinc and vitamin A: an update. Am
J Clin Nutr. 1998;68(2 suppl):435S-441S.
doi:10.1093/ajcn/68.2.435S
23. Alschuler L, Weil A, Horwitz R, et al.
Integrative considerations during the
COVID-19 pandemic. Explore (NY). Published
online March 26, 2020. doi:10.1016/j.
explore.2020.03.007
24. Hemilä H. Zinc lozenges may shorten
the duration of colds: a systematic
review. Open Respir Med J. 2011;5:51-58.
doi:10.2174/1874306401105010051
25. Chandra RK. Excessive intake of
zinc impairs immune responses. JAMA.
1984;252(11):1443-1446.

Immune-Friendly Recipes Holly Van Poots, RDN, CSP, FAND

Polyphenols found in tea have been linked with diverse health benefits for mood and cognition as well as the prevention of
chronic disease. Green tea varieties contain catechins, such as EGCG, and flavonoids, such as quercetin. Consuming matcha green
tea results in higher intakes of these phytochemicals compared to steeped varieties. In addition to matcha beverages, try these
recipes to give your immune system a helping hand!
Cherry Matcha Chia Pudding Ginger Green Tea
1 tsp matcha green tea powder
Serves 2 1 cup coconut milk 1 cup almond or other Smoothie
1 cup unsweetened coconut yogurt non-dairy milk
1 Tbsp maple syrup 2 Tbsp fresh ginger, grated or
¾ cup frozen cherries chopped (OR ¼ to ½ tsp
2 tsp matcha green tea powder ground ginger)
¼ cup chia seeds Lime juice, squeezed fresh
from ½ lime
Combine ½ cup coconut milk, ½ cup Handful of kale or other dark
coconut yogurt, ½ Tbsp maple syrup,
leafy green
cherries, and 2 Tbsp chia seeds in blender
and blend until smooth. Pour into a 1 small banana (or apple or pear)
container and refrigerate. Rinse blender, ¼ avocado
then combine ½ cup coconut milk, ½ Honey as needed to sweeten
cup coconut yogurt, ½ Tbsp maple syrup,
matcha powder, and 2 Tbsp chia seeds Blend all ingredients until smooth. If you
in blender and blend until smooth. Pour don’t have a high-powered blender, try Recipe adapted from
Recipe adapted from into separate container. Refrigerate both blending the leafy greens with a small
What’s Cooking
overnight and layer cherry and matcha amount of liquid first. Use a frozen banana
Le Petit Eats puddings into two jars before serving. and avocado for a creamier texture. Good Looking

Summer 2020 Volume 23, Issue 1 13 www.integrativeRD.org

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PJ180806-01_SpryLiving_F.indd 1 9/10/18 6:42 P
Befriending Cancer Through Nutrition and Yoga Therapy:
A Collaborative Approach Anu Kaur, MS, RDN, RYT-500 / Maryam Ovissi, C-IAYT
Anu Kaur, MS, RDN,
RYT-500, is a registered
dietitian nutritionist
who is dedicated to
translating nutritional
science into daily
life strategies for
cancer survivors and
individuals interested in
an integrative approach to wellness. Anu is the
current DIFM Mind-Body chair.
Maryam Ovissi, C-IAYT,
is the founder of Beloved
Yoga in Northern Virginia
(www.BelovedYoga.
com) and offers a
unique Befriending
Yoga Therapy Program,
combining polyvagal
science with yoga therapy. Maryam trains
teachers and utilizes a blend of evidence-based
tools with yoga therapy for a modern approach
to befriending the whole self.
O
ften after completing
allopathic treatments such as
surgery, chemotherapy, and
radiation, cancer patients are looking
to play an active role in their wellness,
partly by fully understanding their
choices in nutrition to prevent
cancer recurrence. Research shows
that nutrition can make a difference
in outcomes with cancer patients.1
However, currently in the outpatient
cancer care setting, the average ratio
of registered dietitian nutritionists
(RDNs) to cancer patients is 1 to
2308.2 Thus, patients often resort
to their own means to make sense
of nutrition and cancer prevention.
Additionally, a cancer diagnosis
often evokes feelings of vulnerability,
loss, anxiety, and stress, which
activates the sympathetic nervous
system (SNS), the “fight-flight-freeze”
branch of the autonomic nervous
system (ANS).3 Both the SNS and the
hypothalamic-pituitary-adrenal (HPA)
axis are stress-response systems that
elicit a release of stress (and other)
hormones that may promote tumor
growth and increase inflammation.4-6
Yoga research is showing us
that breathwork, movement, and
mind-centering practices can help
manage the ANS and hence be
therapeutic tools.7 We, the authors—
Anu Kaur, an RDN, and Maryam
Ovissi, a C-IAYT—recently chatted
about our work together as allied
health professionals. Listen in as we
Summer 2020 Volume 23, Issue 1
discuss how the combination of yoga
therapy and nutrition therapy can
fill a gap in whole-person wellness
strategies and deepen the healing on
the cancer journey.
Experiences That Brought Us to
This Point
MO: My yoga therapy experience
has come through my field work
(over 10,000 private yoga therapy
hours) and studying with teachers
like Nischala Joy Devi, Dr Ganesh
Mohan, and the Mohan family. Most
importantly, through my client work,
I am learning how cancer is a journey
unlike other imbalances and can
carry a lot of unspoken trauma. Yoga
is an amazing companion through
the entire continuum of cancer.
AK: Over the last two decades, I
have worked as an RDN with patients
on the cancer continuum from
postsurgery to those undergoing
allopathic treatments, such as
chemotherapy, as they journey
forward into survivorship. Hearing
clients repeatedly speak of the
stress of a diagnosis and the fear of
recurrence has brought me to this
place of discussing nourishment,
rather than just offering prescriptive
nutrition guidelines. My work has
given me an appreciation for patients
seeking an integrative approach
that encompasses complementary
modalities like yoga to improve
quality of life through their cancer
journeys. My own experience with
yoga and the yoga research has
sparked my collaboration with yoga
therapists to teach cancer patients
self-care through a mind-body-spirit
approach.
Roles in Allied Health Care
MO: I see a yoga therapist as
an allied health provider. We work
to support rehabilitation and
management of the body, mind, and
breath. The rigor of the training yoga
therapists go through develops their
understanding of disease and makes
them great collaborators alongside
other medical providers. I also believe
that the increase in yoga research has
brought about a growing awareness
15
from a medical perspective of how
important it is to involve mind-
centering practices, breathwork, and
appropriate levels of yoga-based
movement. Across a spectrum of
diseases, especially cancer, we need
to cultivate integrative approaches
and support lifestyle/habit changes
that can be impactful to the healing
journey.
AK: My role is to support each
person in finding their optimal
nutrition through a personalized
lifestyle medicine approach. Medical
nutrition therapy (MNT) starts with
a nutrition assessment that is shared
with doctors and other healthcare
providers. Equally important is
the translation of that nutrition
information in terms of culinary
medicine, which provides clients and
their caregivers practical guidance
on how to nourish themselves with
healthy food. As an RDN, my goal
is to help boost clients’ immune
systems via nutrition and to monitor
for biochemical effects of treatment.
Often cancer patients’ appearance
or weight does not reflect the
sarcopenia (muscle loss) that can
occur because of the accompanying
metabolic changes brought on
with cancer, which makes nutrition
management all the more important.
My goal is to help individuals make
behavioral and lifestyle changes that
are long-lasting; this is where I often
feel allopathic approaches alone miss
the mark.
Philosophy in Cancer Care: Our
Approach
MO: My approach is client-
centered and trauma-informed. On
the journey with cancer, the cancer
itself becomes the focal point and
causes trauma, which yoga teaches
us can be managed with some key
elements. When cancer alone is the
focus, often the client develops an
attitude of war with cancer, rather
than one of befriending cancer.
Understandably, it initially seems
very hard to imagine “befriending”
something you want to eradicate. A
trauma-sensitive approach embodies
a few key principles: (1) the power of
choice; (2) commitment to present-
www.integrativeRD.org
moment awareness through body
orientation, breath, and sensation
awareness; (3) use of rhythmic,
repetitive, and hold methods; and
(4) activating awe and wonder. In
this way, a yogic trauma-sensitive
approach supports us to cultivate
an attitude of befriending ourselves.
This is the gift cancer can offer us.
AK: Often, I am privy to a person’s
“new normal” and how they take care movement given their recent surgery, me maintain a balanced approach.
of themselves. The physical changes
and
momentpsychosocial
awarenessstress, which
through can orientation,
body
play
hold havoc on the
methods; andimmune system,
(4) activating awe and inwonder.
are factors that decrease our immune
cultivate an attitude of befriending ourselves. This is the gift cancer can offer us.
response and lead to inflammation. I
start with food as medicine and focus yoga,” but they may be apprehensive Anu refers clients who are outside
on what to eat, along with when and or think of yoga only as a form of
how to eat (mindfully), especially
given the current research on the
importance of dietary patterns,
mindfulness, and metabolic therapies energetically (breathwork)—and do
such as fasting. Helping individuals
recognize their stress response, be
it long-term or from short bouts of
stress, often creates an opening in
the conversation to discuss self-care
tools. I find if people can connect
with their breath, they feel more
grounded and calmer, and in many
cases they have a deeper experience
in connecting with feelings of satiety addressed, the therapy cannot
and mindfulness when eating. Our
Befriending Cancer collaboration is
done in a group setting with cancer
patients, caregivers, and even allied
health professionals coming together
to create a sangha (community),
which offers a connectedness that
further supports healing.
Expanding Support for Clients
MO: The first question I ask
clients on the journey with cancer is
whether they have addressed their
nutrition. If they haven’t, I always
make a referral to Anu. From a yogic
perspective, I work with clients to
acknowledge the presence of the
abnormal growth and appreciate
its impact on the body. At the
same time, we acknowledge the
uncertainty the disease brings
because we are still discovering what
turns on and off the cancer markers
in the body. Cancer affects us at the
cellular level, and instead of working
with cancer from a symptom-
management perspective only,
there is great value when we also
consider the body and its building
blocks. Nutrition needs much more
attention here. This is why Anu and
I created the Befriending Cancer
Summer 2020 Volume 23, Issue 1
Program, which combines yoga and are becoming yoga teachers who
nutrition therapy and offers a felt can use mind-body modalities such
experience of breathing, yoga asana, as yoga to offer more sustainability
and mindfully eating healthy foods, in maintaining a healthy weight,
together. managing a chronic disease like
cancer, and improving quality of life.
AK: I refer people to a yoga
therapist if their medical situation is Using Yoga and Nutrition to Inform
complex and they have never been Each Other’s Practices
to a group yoga class. I want them
to really understand their range of MO: Working with Anu has helped
treatment, or symptoms before Sometimes, yoga therapists can
jumping into aand
breath, group class. Often
sensation falluse
awareness; (3) intoofwhat I call the
rhythmic, “bubbleand
repetitive,
the allopathic
In this medicine
way, a yogicsetting, syndrome”: we live
trauma-sensitive approach supportsin a bubble
us to where
people have heard from their doctor
all our choices are received with
that they should consider “doing enthusiasm from the yoga clients.
the bubble and that allows me to
exercise. A yoga therapist has the skill look again at ways to present yoga
set and ability to delve in deeper with as accessible and approachable. She
emotions—viscerally, mentally, and supports me to become a wiser and
more compassionate yoga therapist.
embodied work.
AK: Working with Maryam has
Understanding Integration in offered me greater insight into my
Health Care clients’ bigger picture of wellness.
I have found people are calmer
MO: I believe nutrition is essential and often allow themselves more
while we are working on the mind, grace and compassion when yoga
breath, and movement, because therapy is part of that picture. For
until the layer of nourishment is example, one cancer survivor had
been interested in exploring yoga
fully integrate with the person. A but, like many others I have met,
person can meditate, exercise, and she had limited experience with
even have an extensive breathwork yoga and concern about going to a
practice, but if they never address studio. We had already incorporated
the layer of food, the effects of yoga some pranayama techniques to
tools can be limited. For example, I assist with sleep and fatigue, so
had a client consuming a diet that there was an openness to meet
was mostly starchy carbohydrates with Maryam. After the patient
and high in refined sugar, with some signed a release-of-information
protein and very little vegetables consent form, Maryam and I were
and water. She always felt a form of able to speak. Although my focus is
congestion and sluggishness often nutrition, I encouraged the patient to
recognized as “brain fog.” When the do her yoga practice, as it came up
client began to work with Anu and in our lifestyle and behavior goals.
address her diet, I saw a significant Maryam simultaneously was able
shift in wellness that I know I couldn’t to gently remind her of some of the
have helped her accomplish on my mindfulness nutrition goals we had
own. It was amazing to see how there set by incorporating breathwork
was a clarity of focus and a greater and specific movement practices
ability to connect to a peaceful, calm before meals. This informed my
center. work and reinforced the value of
an interdisciplinary approach with
AK: I think yoga is essential a yoga therapist for lifestyle and
because, by educating cancer behavior changes in particular.
patients as to how stress activates
the SNS, they become motivated to Moving Forward in Cancer Care
pay attention to their breath. From
my perspective, elements of MNT More National Cancer Institute
can be enhanced if patients have the (NCI)–Designated Cancer Centers
opportunity to learn firsthand how are starting to provide information
to manage inflammation, not only on modalities such as yoga (69%);
with diet, but by managing their however, fewer actually offer
stress. A growing number of RDNs services themselves.8 The growth of
16 www.integrativeRD.org
this field is dependent on using an
integrative medical model of cancer
care in which the entire person
is seen, heard, and respected.
An integrative medical model of
cancer would develop plans for
cancer patients that include the
medical treatment plan, movement,
nutrition, breathwork, meditation,
and social engagement activities.
The emotional stress of cancer care
has been shown by many studies to
be managed by yoga, breathwork,
meditation, and movement.
Collaborations between yoga
therapists and other allied health
professionals like RDNs can create
a synergy for wellness and cultivate
long-term lifestyle and culinary
changes to support cancer patients’
journeys into survivorship. Moving
forward, finding cancer centers that
hire integrative health navigators
and coordinators will be a key
aspect to mobilizing yoga therapy
and RDN support for clients with
cancer. Based on our experience of
the Befriending Cancer Program,
we have seen the efficacy of the
inclusion of yoga and nutrition
therapy together.
Approved for 21.5 CPEs
Enroll Today!
www.InnovativeHealingAcademy.com
Summer 2020 Volume 23, Issue 1
References McCall T, Telles S, eds. The Principles and
Practice of Yoga in Health Care. Handspring
1. World Cancer Research Fund/American
Publishing; 2016: 339-372.
Institute for Cancer Research. Diet, nutrition,
8. Yun H, Sun L, Mao JJ. Growth of integrative
physical activity and cancer: a global
medicine at leading cancer centers between
perspective—the third expert report.
2009 and 2016: a systematic analysis of NCI-
Published 2018. Accessed April 26, 2020.
Designated Comprehensive Cancer Center
www.wcrf.org/dietandcancer
websites. J Natl Cancer Inst Monogr. 2017
2. Trujillo EB, Claghorn K, Dixon SW, et al.
Nov;2017(52). doi:10.1093/jncimonographs/
Inadequate nutrition coverage in outpatient
cancer centers: results of a national survey. lgx004
J Oncol. 2019 Nov 22;2019:7462940.
doi:10.1155/2019/7462940
3. Uebelacker L, Lavrertsky H, Tremont G. Yoga
therapy for depression. In: Khalsa S, Cohen
L, McCall T, Telles S, eds. The Principles and
Practice of Yoga in Health Care. Handspring
Publishing; 2016: 73-93.
4. Armaiz-Pena GN, Cole SW, Lutgendorf
SK, Sood AK. Neuroendocrine influences
on cancer progression. Brain Behav Immun.
2013 Mar;30 Suppl:S19-S25. doi:10.1016/j.
bbi.2012.06.005
5. Lutgendorf SK, Sood AK. Biobehavioral
factors and cancer progression: physiological
pathways and mechanisms. Psychosom
Med. 2011;73(9):724-730. doi:10.1097/
PSY.0b013e318235be76
6. Thayer JF, Sternberg E. Beyond heart rate
variability: vagal regulation of allostatic
systems. Ann N Y Acad Sci. 2006;1088:361-372.
doi:10.1196/annals.1366.014
7. Danhauer SC, Sohl SJ, Addington EL,
Chaoul A, Cohen L. Yoga therapy during
cancer treatment. In: Khalsa S, Cohen L,
Figure 1. A mindful dark chocolate meditation
starting with smell.
Figure 2. Plant-based food shared in community.
17 www.integrativeRD.org
Resource Review
Integrative & Functional
Recommendations for
COVID-19
A
s a human and RDN, you
have, no doubt, been
paying attention to the clear
correlation between the severity of
this virus and state of chronic disease
in our nation. Emerging research is
showing what we already know to
be true: that diet and lifestyle can
either increase our susceptibility
or increase our resilience to any
disease. I sense a potential shift
in communicating the benefits of
nutrition that has not been seen
in some time. This provides an
unprecedented opportunity for us,
as nutrition experts, to significantly
contribute to the better health of
our clients, patients, families, and
communities. While there have
been several research papers and
integrative and functional medicine
organizations that have come forth
with recommendations, summaries
of a few are highlighted below.
1. From Integrative Medicine: A
Clinician’s Journal: Evidence
Supporting a Phased Immuno-
Physiological Approach to
COVID-19 From Prevention
Through Recovery. SF Yanuck , J
Pizzorno , H Messier , KN
Fitzgerald. http://imjournal.com/
oa/evidence_supporting-a_phased_
immuno-physiological_approach_
to_covid-19_from_prevention_
through_recovery/
Interventions depend on the stage
of illness; therefore this paper
presents a comprehensive four-
phased approach to COVID that
includes prevention, infection,
inflammation, and recovery.
Different aspects of the immune
system are activated depending
on the course of infection. During
early stages, we naturally have
upregulation of the inflammatory
response; however, if the infection
persists, then this upregulation or
cytokine storm is the exact process
that needs to be down regulated,
and where risk of fatality is greater.
Our most impactful role as IFN
RDNs is certainly in the prevention
phase, as outlined in the “Target
1: Foundational Support” section
Summer 2020 Volume 23, Issue 1
of the paper. Addressing diet,
inflammation, stress, glycemic
control, microbiome balance
(connected to lung health), and
movement is key in lowering
risk factors and increasing
resilience to all pathogens.
Further support targets assessing
and supplementing vitamins,
minerals, and herbs with known
immunological roles including
recommendations (at each stage)
for vitamin C, D, A, zinc, n-acetyl
cysteine, glutathione, quercetin,
melatonin, echinacea, astragalus,
Boswellia, and more, with
accompanying research for each.
Figure 2 in the paper includes a
proposed approach to populating
the five Targets of Support across
the four phases of COVID-19
disease.
2. The Institute for Functional
Medicine: COVID-19:
Functional Medicine Resources
https://info.ifm.org/covid-
19?utm_campaign=covid-
19&utm_source=website&utm_
medium=popup&utm_
content=resources_learn_more
The Institute for Functional
Medicine currently has four
sections at this link which include
resources under Nutraceuticals and
Botanicals (includes parts 1 and
2 for prevention, virus-specific),
Resilience and Lifestyle (nutrition,
sleep & stress recommendations),
Practice Considerations (tools for
reinvigorating and maintaining
your practice during the pandemic),
and Testing. The following is an
example of information found in
the Nutraceuticals and Botanicals
section: The SARS-CoV-2 virus is
said to stimulate part of the innate
immune system called the NLRP3
inflammasome. There are several
known natural compounds that
inhibit inflammasome activity and
the additional hyperinflammation
associated with the virus, notably
curcumin, EGCG (epigallocatechin
gallate commonly found in
green tea), and quercetin.
Recommendations, strength of
evidence, and reasoning for all
possible interventions are listed.
3. The American Nutrition
Association: Personalized
18
Jena S. Griffith, RDN, IHC, Editor
Nutrition & the COVID-19 Era:
A Rapid Review for Health
Professionals. VY Behm, J
Blumberg, C Bush, et al. https://
theana.org/COVID-19?fbclid=IwAR
1PUadYLKAdasrsoSavCYQZPByIctc
P2pDh9G4fIWom0t11d0uappqBw
NY
The aim of the ANA task force
completing this review was to
share collective expertise towards
the potential supportive role
of personalized nutrition. Their
summary has an understandable
explanation of the virus’ replication,
its entry via the cell’s ACE2
receptor, and potential targets
for intervention. Interventions
are divided into two categories:
those that act on the immune
system and/or human cells and
those that act on the virus itself.
A current review of the science is
discussed for nutrients that have
immune-modulating and anti-
viral properties including oil of
oregano; quercetin; vitamins A, C,
D, E; selenium, potassium, and zinc.
Also included is a chart illustrating
potential viral enzyme inhibitors
that highlights the natural
compounds andrographis, skullcap,
hesperidin, and others.
4. From Journal of Ayurveda and
Integrative Medicine: COVID-19
Pandemic: A Pragmatic Plan for
Ayurveda Intervention. S Rastogi,
DN Pandey, RH Singh. doi:10.1016/j.
jaim.2020.04.002
https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC7177084/
This proposal for intervention
provides suggested Ayurvedic
interventions at each stage of
COVID and complements India’s
Ministry of Ayurveda, Yoga, and
Naturopathy (AYUSH) guidelines
for improving immunity released
on March 31st, 2020. There are
various herbal/natural compounds
containing antiviral properties
or protease-inhibition capability
suggested for each category:
unexposed, exposed with no
symptoms, mild symptoms, and
moderate to severe symptoms. As
this will be a crucial opportunity
for learning and creating credible
evidence, the authors insist
on proper documentation of
www.integrativeRD.org
 all variables, outcomes, etc, and
referrals if necessary. Importantly,
while nothing is proven in the
case of COVID, Ayurveda, similar
to Traditional Chinese Medicine
(successfully used in China for this
virus), is to be used by identifying
syndromes and suggesting
remedies.
5. From Journal of the American
Medical Association: Presenting
Characteristics, Comorbidities,
and Outcomes Among 5700
Patients Hospitalized With
COVID-19 in the New York City
Area. doi:10.1001/jama.2020.6775
https://jamanetwork.com/
journals/jama/fullarticle/2765184
6. The M.A.T.H. Protocol
This observational study included
5700 COVID-19 patients in 12
hospitals between March 1,
2020, and April 4, 2020, in NYC
and the metropolitan area. It
Summer 2020 Volume 23, Issue 1
is included here to highlight
the comorbidities associated
with some of the more severe
manifestations of coronavirus.
Over 94% of patients had at least
one chronic condition, and 88% of
the participants had at least two.
The top three conditions were as
follows: 60% had hypertension,
40% had obesity, and 33% had
diabetes. This clearly illustrates
that focusing on improving
metabolic health, lowering
baseline inflammation, and easing
the burden of chronic disease
in this country could positively
impact risk from this and other
viruses.
www.covid19criticalcare.com
This may be considered more of
a public service announcement
and review, and is an example
19
of true integrative medicine:
using the best of conventional
and natural therapies to achieve
the best outcome. The M.A.T.H.
protocol was developed by five
physicians across the country
now called the Front Line
COVID-19 Critical Care Working
Group (FLCCCW). It stands for
methylprednisolone, ascorbic
acid, thiamine, and heparin, with
optional use of zinc and vitamin
D. It has had a very high success
rate and addresses all the central
characteristics of the severest
form of this disease including
inflammation, hypercoagulation,
and hypoxia. Visit their site for
more investigation into the
history, protocol specifics, and
outcomes.
www.integrativeRD.org
News You Can Use
What’s New - Journal Reviews and
Resources
Association of the Functional
Medicine Model of Care with
Patient-Reported Health-Related
Quality-of-Life Outcomes
This retrospective cohort study
followed 7,252 eligible patients
(aged 18 and older; average age
was 54.1 years old) to determine
whether treating them with a
functional medicine model of care
was associated with an improvement
in health-related quality of life.
The studied patients visited either
the Cleveland Clinic Center for
Functional Medicine (1,595 patients)
or Cleveland Clinic Twinsburg Family
Health Center (5,657 patients)
between April 1, 2015 and March
1, 2017. To be included in the
study, patients needed to have a
baseline Patient-Reported Outcome
Measurement Information System
(PROMIS) score as well as either
a 6-month or 1-year follow-up
score. The PROMIS questionnaire
assessed different aspects of health
(such as physical, social, emotional,
and mental factors) and overall
health, with a higher score equating
to a higher health-related quality
of life. Scores were divided into
two categories: Global Physical
Health (GPH) and Global Mental
Health (GMH). Patients completed
the questionnaire by themselves,
either via the patient portal or on
a tablet in the waiting room before
appointments. Family Health Center
patients had a higher median
income ($72,874 vs $59,286), higher
incidences of hypertension (50.9%
vs 19.2%) and diabetes (34.1%
vs 17.9%), and a higher baseline
mean PROMIS score (48.75 vs 44.81)
compared to the patients seen at
the Functional Medicine Clinic.
However, at the 6-month follow-up,
patients at the Functional Medicine
Clinic had significantly improved
PROMIS GPH scores (from 46.18
to 47.77) and PROMIS GMH scores
(from 46.53 at baseline to 47.84). A
greater proportion of patients seen
at the Functional Medicine Clinic had
PROMIS GPH and GMH scores that
increased by 5 or more compared
to the patients at the Family Health
Center. The results are not statistically
significant between the 6- and
Summer 2020 Volume 23, Issue 1
12-month follow-ups for either clinic;
however, the PROMIS GPH scores did
continue to go up for the Functional
Medicine Clinic at 12 months. This
study provides insight into how
effective functional medicine can
be for patients’ health and well-
being and is a good indication for
continued studies on this subject
and research into making this
model more prominent in the
healthcare sector.
Beidelschies M, Alejandro-
Rodriguez M, Ji X, Lapin B, Hanaway
P, Rothberg MB. Association of
the functional medicine model
of care with patient-reported
health-related quality-of-life
outcomes. JAMA Netw Open.
2019;2(10):e1914017. doi:10.1001/
jamanetworkopen.2019.14017
The Potential Link Between Long-
term Coffee Consumption and Risk
of Cardiovascular Disease
This prospective analysis looked
at people who have a genetic variant
at cytochrome P450 1A2 (CYP1A2),
which can cause them to be less
effective at metabolizing caffeine.
The study looked at whether people
with this variant had a higher
risk for myocardial infarction and
hypertension after consuming
caffeine-containing coffee. Data for
almost 350,000 people in the United
Kingdom was used that included
genetic information and coffee habits
as well as 8,368 cases of cardiovascular
disease. Logistic regression was used
to create an association between risk
of hypertension and/or myocardial
infarction and coffee intake, with
the additional inquiry regarding
genetic variant of CYP1A2. The
authors determined that there was a
moderate association between heavy
coffee drinkers (defined as consuming
more than 6 cups a day) and a risk for
cardiovascular disease, but this risk
was not increased in those with the
CYP1A2 genotype. 
Zhou A, Hyppönen E. Long-term
coffee consumption, caffeine
metabolism genetics, and risk
of cardiovascular disease: a
prospective analysis of up to
347,077 individuals and 8368
cases. Am J Clin Nutr. 2019
March;109(3):509-516. doi:10.1093/
ajcn/nqy297
20
Compiled by
Julia Shuff and Geanna Revell
The Association Between Organic
Food Consumption and Breast
Cancer Risk
This study sought to define the
association between breast cancer
risk and organic food consumption
secondary to the reduced intake
of pesticides. Organic food
consumption data came from almost
40,000 Sister Study participants
(ages 35-74). Between 2003 and
2009, these participants noted their
consumption of organic foods over
the past year. A score was assigned
to each answer (never=0, less than
half the time=1, about half the
time=2, and more than half the
time=3). For statistical analysis of
the data, adjusted hazard ratios
and 95% confidence intervals were
created using Cox proportional
hazards model, and the statistics
were adjusted for confounding
factors, such as known risk factors
for breast cancer. The study found
that breast cancer incidences
were inversely associated with
consumption of organic foods,
especially when the organic foods in
question were produce (there was
no such trend with organic dairy
or meat). Although there are likely
more causative factors that weren’t
exposed by this study, there is at
least some evidence that eating
organic produce may be beneficial
for preventing breast cancer.
Park YMM, White A, Niehoff N,
O’Brien K, Sandler D. Association
between organic food
consumption and breast cancer
risk: findings from the Sister Study
(P18-038-19). Curr Dev Nutr. 2019
June; 3(Supplement 1): nzz039.
P18-038-19. doi:10.1093/cdn/
nzz039.P18-038-19
Nutritional Genomics Research
Publications – January 15, 2020
Courtesy of the International
Society of Nutrigenetics and
Nutrigenomics (ISNN) at www.
NutritionAndGenetics.org/, and of
www.Nutrigenetics.net.
Beta-3-adrenergic receptor
rs4994 polymorphism is a
potential biomarker for the
development of nonalcoholic
fatty liver disease in overweight/
obese individuals. Dis Markers.
www.integrativeRD.org
2019 Dec 17;2019:4065327.
doi:10.1155/2019/4065327
eCollection 2019. (PubMed ID:
31929840)
The rs4994 variant of the ADRB3
gene (also known as ADRB3
Trp64Arg) was found to be associated
with the non-alcoholic fatty liver
disease among overweight/obese
subjects.
The American Nutrition
Association®: Championing
the science and practice of
personalized nutrition. J Am Coll
Nutr. 2019 Dec 27:1-4. doi:10.1080/0
7315724.2020.1699380 [Epub ahead
of print] (PubMed ID: 31880503)
This article describes the American
Nutrition Association and outlines
their vision of personalized nutrition,
plus five particular challenges:
(1) education of professionals,(2)
dissemination of information to
the public,(3) public policies which
need to be more favorable to
nutrition,(4) nutrition stakeholders
are not strongly connected and
collaborating,and (5) population
nutrition advice is not addressing
more individualized needs.
Toward the definition of
personalized nutrition: A proposal
by The American Nutrition
Association. J Am Coll Nutr. 2019
Dec 19:1-11. doi:10.1080/07315724.
2019.1685332 [Epub ahead of print]
(PubMed ID: 31855126)
Summer 2020 Volume 23, Issue 1
The vision of the American
Nutrition Association for personalized
nutrition is described, which includes:
(1) science and data,(2) education
and training, and (3) clinical guidance
and therapeutics.
Personalized nutrition: Are we
there yet? J Pediatr Gastroenterol
Nutr. 2019 Dec;69(6):633-638.
doi:10.1097/MPG.0000000000002491
(PubMed ID: 31765333)
Some of the challenges of
personalized nutrition are discussed,
including the proper consideration of
intestinal microbiota.
Nutritional psychiatry: Towards
improving mental health by what
you eat. Eur Neuropsychopharmacol.
2019 Dec;29(12):1321-1332.
doi:10.1016/j.euroneuro.2019.10.011
Epub 2019 Nov 14. (PubMed ID:
31735529)
The importance of nutrition and
intestinal microbiota on mental
health and relevant conditions like
ADHD, autism, and cognition are
discussed.
Advances in research on diabetes
by human nutriomics. Int J Mol
Sci. 2019 Oct 29;20(21):5375.
doi:10.3390/ijms20215375 (PubMed
ID: 31671732)
Table 1 lists some advances in
human nutrition with regard to
diabetes mellitus in the following
areas: nutritional genomics,
transcriptomics/gene expression,
21
proteomics, metabolomics,
lipidomics, microbiomics, and
foodomics.
Clinical genetic testing in medical
education. Proc (Bayl Univ Med
Cent). 2019 Jan 11;32(1):165-166. do
i:10.1080/08998280.2018.1528937
eCollection 2019 Jan. (PubMed ID:
30956620)
This editorial recommends early
introduction of clinical genetics into
medical education, with the goal of
being able to assess the following:
genetic risks, consideration of
genetic testing, and/or referral to a
genetic counselor.
Copyright 2020 Nutrigenetics
Unlimited, Inc. Inquiries about above
references? Contact Ron L Martin, MS,
President, Nutrigenetics Unlimited, Inc,
ron@nutrigenetics.net. The database
at Nutrigenetics.net is available to the
public free on weekends (US Pacific
time) by using “Free” as the username
and “Weekends” as the password, as
also shown on the login page at
https://nutrigenetics.net/Login.aspx.
Check out https://nutritionandgenetics.org
to learn more about ISNN and the
Lifestyle Genomics journal (formerly
named the Journal of Nutrigenetics and
Nutrigenomics).
www.integrativeRD.org
My First Integrative Healthcare Symposium
The Dietitians in
Integrative and
Functional Medicine
(DIFM) Dietetic
Practice Group offers
financial assistance
to its members to
take part in health
and nutrition-related
conferences. There are many renowned
integrative and functional medicine
conferences in the United States; however the
Integrative Healthcare Symposium (IHS), held
annually in New York City, openly recognizes
and supports RDN’s valuable contributions
in this specialized area. I didn’t want to miss
out on a valuable opportunity to learn and
network with experts, vendors, and my peers;
so I applied and was awarded a scholarship
from DIFM securing my travel and attendance
to the conference in February 2020.  processing emotions—especially
 
My private nutrition practice in Atlanta
specializes in assisting clients with health
problems associated with food sensitivities. I
knew going to the sessions and networking
events would connect me with other people
active in alternative approaches to health
care in addition to exposing me to the latest
scientific information. This conference was
the next step in learning and connecting with
integrative practitioners as I work towards
positioning myself as an expert in integrative
and functional nutrition.
What is the Integrative Healthcare
Symposium?
It’s a jam-packed, three-day event
for integrative practitioners such as
medical doctors, RDNs, osteopaths,
naturopathic doctors, chiropractors,
and research scientists. I was
blown away by the well-researched
information presented at the sessions
I attended. The attendees are a part
of a supportive community gathered
to explore new techniques in this
area of health care.
One particular session changed
my mindset towards helping my
clients make better decisions about
their health. “The Role of Lifestyle
Choices in Decision-Making:
Becoming a Conscious Architect
of Your Brain,” co-presented by
Drs David Perlmutter and Austin
Perlmutter (father and son), was
a shift in identifying factors that
contribute to successful lifestyle
changes. We’re aware poor long-
term adherence to health behavior
change is widespread. This presents
a significant challenge to the
effectiveness of lifestyle-based health
interventions. The speakers discussed
simple and doable ways to become
Summer 2020 Volume 23, Issue 1
Jerlyn Jones, MS, MPA, RDN, LD, CLT
conscious of our thoughts to lead to The presenters recommended
better decisions. Here are my three talking to our patients/clients
takeaways from their enlightened about the following simple
presentation: methods to reconnect:
• It’s all in our head. There’s a • Meditate for 12 minutes
disconnect between two areas • Decrease internet usage
of our brains: the prefrontal
cortex (located at the front of • Exercise
the brain) and the amygdala • Spend 20 minutes in nature
(located deep in the middle
(putting plants in homes
of the brain). The prefrontal and offices also offers the
cortex has many functions such same benefits)
as planning complex behaviors,
decision making, and compassion.
Healthcare practitioners can also
The amygdala plays a role in teach their patients mindfulness
(meditation styles) during nutrition
those linked to fear and pleasure. or medical sessions to reduce chronic
The idea is to connect these two stress. Studies show stress reduction
regions of the brain to lead to
correlates with structural changes in
effective decision making. the amygdala. Science supports the
following benefits associated with
• The disconnection syndrome. meditation:
Many studies show greater
exposure to stressful life events • Higher level of BDNF (brain
decreases the connection derived neurotrophic factor)
between the prefrontal cortex and
the amygdala. Inadequate sleep, • Improved memory
poor food choices, inflammation, • Reduction in inflammation
and inappropriate internet/
• Reduced cortisol
social media usage increases
the disconnection syndrome. • Improved creativity
Disconnection syndrome • Improved cardiovascular health
excites the amygdala leading
to aggressive behavior and • Improved blood sugar
attention problems, especially • Improved sleep
in children, according to a 2018
• Greater concern for
study in Social Cognitive and
environmental issues
Affective Neuroscience Journal. Our
patients/clients may understand
At the end of their presentation, I
the why and how to live healthier
felt empowered with the necessary
lives, but other factors such as
tools to help my clients incorporate
nonrestorative sleep, a sedentary one or two of these techniques to get
lifestyle, inflammation, and lots
started with making better long-term
of screen time are associated
lifestyle choices.
with a prefrontal cortex/
amygdala disconnect. Therefore,
the disconnection syndrome
eventually makes it difficult to
follow healthy lifestyle choices.
• How to reconnect. The good
news is the brain has the ability to
rewire itself. The key is to increase
the connection of the prefrontal
cortex and amygdala. Increasing
the connection involves activating
the prefrontal cortex and calming
down the amygdala. In turn, these
areas of the brain become alert,
safe, and interested in receiving
health and nutrition information.
22 www.integrativeRD.org
Jena Savadsky Griffith, RDN, IHC PRSRT STD
534 Briarwood Lane US POSTAGE PAID
Aroda, VA 22709 Charlottesville, VA
PERMIT NO. 186

2020-2021 Executive Committee Members

& Leadership Team
EXECUTIVE COMMITTEE (7 voting members)
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CHAIR 2020-2021 KORY DEANGELO, MS, RDN
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CHAIR-ELECT 2020-2021 MELISSA GROVES AZZARO, RDN, LD
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SECRETARY 2019-2021 MIHO HATANAKA, RD
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TREASURER 2020-2022
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PAST CHAIR 2020-2021 DANA ELIA, DCN, MS, RDN, LDN, FAND
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DPG DELEGATE 2019-2022 MARY BETH AUGUSTINE, RDN, CDN, FAND
NOMINATING CHAIR 2020-2021 TERYN COOK BUCHANAN, RD

LEADERSHIP TEAM
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CONNECTING EDUCATORS CHAIR 2019-2021
............. AARTI BATAVIA, MS, RDN, CLT, CFSP, IFMCP

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DIVERSITY, EQUITY and INCLUSION CHAIR 2019-2021

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DIVERSITY, EQUITY and INCLUSION ASSOCIATE 2020-2021
FATIMA BAHARY, RDN
LORA SILVER, MS, RD, LD

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DIVERSITY, EQUITY and INCLUSION ASSOCIATE 2020-2021

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DIVERSITY, EQUITY and INCLUSION ASSOCIATE 2020-2021
MANJU KARKARE, MS, RDN, LDN, CLT, FAND
ELISE HARRISON, RDN

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ENVIRONMENT & NUTRITION CHAIR 2020-2022

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FNCE PLANNING CHAIR 2020-2021
MARY PURDY, MS, RDN
SARAH HARDING LAIDLAW, MS, RDN, MPA, CDE

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MARKETING CHAIR 2019-2021 CHRISTA BIEGLER, RDN, LN, CLT

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MEMBERSHIP CHAIR, 2019-2021 ANITA DAVILA, NDTR

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MENTORING AND COACHING CHAIR 2019-2021

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MIND BODY THERAPY CO-CHAIR 2020-2022 SANDEEP (ANU) KAUR, MS, RDN, RYT-500

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MIND BODY THERAPY CO-CHAIR 2020-2022

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STACY K. LEUNG, RYT, RDN, CDN
NETWORK CHAIR 2019-2021 KATHIE MADONNA SWIFT, MS RDN LDN FAND EBQ, MBCP

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NETWORK ASSOCIATE 2020-2021 JOE ZASTAWNY, RDN, LD

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NEWSLETTER EDITOR 2020-2021 JENA SAVADSKY GRIFFITH, RDN, IHC

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NEWSLETTER COPY EDITOR 2020-2021
NEWSLETTER CPE EDITOR 2020-2021
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HOLLY VAN POOTS, RDN, CSP, FAND
STACI BELCHER, MS, RDN, LDN
NEWSLETTER BOTANICALS EDITOR 2020-2021
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NEWSLETTER NEWS YOU CAN USE EDITOR 2020-2021
DINA RANADE, RDN, LD
GEANNA REVELL, MS, RDN

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NEWSLETTER ASSOCIATE EDITOR 2020-2021

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NEWSLETTER MIND-BODY EDITOR 2020-2021
JANIE JACOBY, MS, RDN, LDN
CHRISSY BARTH, MS, RDN, RYT

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POLICY ADVOCACY LEADER 2019-2021
NOMINATING CHAIR-ELECT 2020-2021
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LISA SHKODA RDN, CSP, CNSC, FAND
ERIN SKINNER, MS, RD, IFNCP

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NOMINATING COMMITTEE MEMBER 2020-2021

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PROFESSIONAL ADVANCEMENT CHAIR 2019-2021
BONNIE BROCK, MPH, RD, LDN, ND
THERESE BERRY, MS, RDN, LD, CNSC

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PROFESSIONAL ADVANCEMENT ASSOCIATE 2020-2021

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OLIVIA WAGNER, MS, RDN
RESEARCH CHAIR 2019-2021 STEPHANIE HARRIS, PHD, MS, RDN, LD

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SOCIAL MEDIA CHAIR 2020-2021

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SOCIAL MEDIA ASSOCIATE 2020-2021
TAMARA LUCK
ALORA FREDERICK, RDN

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SPONSORSHIP CHAIR 2020-2022 BRIDGITTE CARROLL, MS, RDN, LDN

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SPONSORSHIP ASSOCIATE 2020-2021 DANIELLE OMAR, MS, RDN

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STATE COORDINATOR, CA 2019-2021

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STATE COORDINATOR, FL 2019-2021
SANGEETA SHRIVASTAVA PHD, MS, RDN
MARILYN GORDON EDD, RDN, CSSD, LDN
STUDENT MEMBERSHIP CHAIR, 2019-2021
.....
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EXECUTIVE ADMINISTRATOR/WEBSITE MGR/ EML COORDINATOR
SARAH ELSTER
AMY JARCK
ACADEMY DPG MANAGER KATIE GUSTAFSON

Summer 2020 Volume 23, Issue 1 23 www.integrativeRD.org