Vol. 24 No.

January 2022 The Magazine for Nutrition Professionals

POPULAR
WEIGHT
LOSS
APPS
Shedding excess
pounds in the new
year may be just
a tap away for clients.

Review of Specialty
Certifications to Boost
Your Career

The Link Between a Healthy

Gut and Healthy Lungs

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Canned Beans:
Nutritious Solutions for
Delicious, Convenient Meals
Registered Dietitian Nutritionists (RDNs)
know canned beans are:

Nutrient Rich Consumers have

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Recommend canned beans as a

tasty, nutritious and convenient
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for downloadable tools, resources and recipes to help
you educate about the benefits of canned beans.
Cont ents
VOLUME 24 • NUMBER 1 JANUARY 2022

12
D E PA R T M E N T S

6 E ditor’s Spot

28
8 Reader Feedback
9 A sk the Expert
10 B everages
F E AT U R E S 12 B oosting Immunity
16 H erbs + Spices

20  opular Weight Loss

P
AppsToday’s Dietitian
highlights some of the more
34 Meal Planning Software
Experts reveal how these
innovative tools can boost income,
18 L egumes
52 Focus on Fitness
trendy smartphone apps that save time, and relieve stress for RDs
may help clients shed unwanted who create meal plans for clients. 54 G et to Know …
pounds in the new year. 56 H ealth Matters

24 Specialty Certifications
Looking to take your career to the
40 Psychoactive Plant
CompoundsThese
substances have a variety of
58 N ews Bites
60 Products + Services
next level? Certifications from a effects on the human nervous 62 Research Briefs
variety of organizations can be a system, ranging from possibly
boon for your professional growth dangerous to potentially healing. 64 Datebook
(and wallet) and the well-being of 65 Fresh Ideas Showcase

46
the clients you serve.
CPE Monthly: The 66 Culinary Corner
Science on Interstitial

28 The Gut-Lung Axis

Research continues to emerge
about the connection between
Cystitis and Bladder Pain
SyndromeThis continuing
education course reviews the
the gut microbiota and lung challenges of diagnosing,
health and the role diet plays classifying, and treating interstitial
in the equation. cystitis, also known as bladder
pain syndrome, and provides
counseling strategies for clinicians
to use when working with patients. 46
Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published nine times a year in Jan, Feb, Mar, Apr, May, Jun, Aug, Oct and Nov by Great Valley Publishing Company, 3801 Schuylkill Road, Spring City, PA 19475.
Periodicals postage paid at Spring City, PA, Post Office and other mailing offices. Permission to reprint may be obtained from the publisher. Reprints: Wright’s Media: 877-652-5295 Note: For subscription changes of address, please
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Single issue: $5. Today’s Dietitian Volume 24, Number 1.

4  TODAY’S DIETITIAN • JANUARY 2022

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Editor’s Spot
Looking Forward
to 2022
A
s dietitians, are you looking forward to the new
year ahead? A year of new possibilities to explore
and new milestones to reach? If so, you’re not alone.
We’ve been in the throes of a
deadly pandemic for almost
two years now, which has turned everyone’s
life upside down—both personally and
professionally. But there are times in life
when some good can result from a crisis.
The pandemic enabled dietitians to learn
about a new, complex disease (granted, an
illness you and millions of others wish they never had to deal
with) and venture into uncharted, though daunting, territory.
COVID-19 has compelled RDs to delve deeper into research
to help clients boost their immunity via healthful foods and
supplements to avoid infection and use MNT to help nurse
clients back to health who may have contracted the virus and
now have lingering symptoms. And most importantly, RDs
have developed creative ways in which to work to carry out
these duties in the face of quarantines and social distancing
mandates. Whether you owned a private practice, worked in
media relations/communications or in clinical health care
settings, or provided nutrition services in your community, you
continued to make a living.
Dietitians in private practice quickly transitioned from
in-person to virtual nutrition counseling; others working in
doctor’s offices, academia, and various health care companies
did so from home or significantly decreased in-person office
hours to participate in video conferencing and perform other
duties. RDs employed at hospitals and long term care facilities
also worked from home and performed nutrition assessments
with patients virtually or over the phone. And these trends
will remain well into the future, providing greater career
opportunities for nutrition professionals.
Now that it’s the beginning of a new year, dietitians may be
thinking about different ways to acquire continuing education
credits and/or certifications. Many already know the value of
obtaining certifications. They enable RDs to specialize in other
areas of health care, and boost their credibility, marketability,
and annual salaries within the medical field.
In this month’s issue, Today’s Dietitian discusses the value
of certifications, including examples of those RDs can pursue
through the Commission on Dietetic Registration and outside
organizations, and tips for getting started, in the article
“Specialty Certifications” on page 24.
Also in this issue are articles on popular weight loss apps,
meal planning software for RDs, the gut-lung axis, and
psychoactive plants. Please enjoy the issue!
— Judith Riddle, Editor
TDeditor@gvpub.com
6  TODAY’S DIETITIAN • JANUARY 2022
EXECUTIVE
Chief Executive Officer Mara E. Honicker
Chief Operating Officer Jack Graham
EDITORIAL
Editor Judith Riddle
Nutrition Editor Sharon Palmer, MSFS, RDN
Editorial Director Lee DeOrio
Production Editor Kevin O’Brien
Associate Editor Hadley Turner
Editorial Assistant Heather Hogstrom
Editorial Advisory Board Toby Amidor, MS, RD, CDN, FAND;
Dina Aronson, MS, RDN; Constance Brown-Riggs, MSEd, RD, CDCES, CDN;
Karen Collins, MS, RDN, CDN, FAND; Carrie Dennett, MPH, RDN, LD;
Jill Weisenberger, MS, RDN, CDCES, CHWC, FAND
ART
Art Director Charles Slack
Senior Graphic Designer Erin Faccenda
ADMINISTRATION
Administrative Manager/Human Resources Janet Renz
Administrative Assistant Jennifer Mest
Executive Assistant Matt Czermanski
Systems Manager Jeff Czermanski
CONTINUING EDUCATION
Director of Continuing Education Jack Graham
Associate Director of Continuing Education Leslie Cimei
Education and Event Coordinator Neil Schwarz
Customer Support Associate Jennifer Mest
Program Planners Ginger Hultin, MS, RDN; Ann Lokuta, MPH, RD
MARKETING AND ADVERTISING
Publisher Mara E. Honicker
Associate Publisher Peter J. Burke
Director of Marketing and Digital Media Tim Rinda
Web Designer Jessica McGurk
Digital Marketing Coordinator David Pirozzi
Director of Events and Sponsorships Gigi Grillot
Director of Sales Brian Ohl
Senior Account Executives Diana Kempster,
Beth VanOstenbridge
Account Executives Drew Murdock, Brian Sheerin
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Phone: 610-948-9500 Fax: 610-948-7202
Editorial e-mail: TDeditor@gvpub.com
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All content contained in Today’s Dietitian represents the opinions of the authors, not
those of Great Valley Publishing Company (“GVP”) or any organizations with which
the authors may be affiliated. GVP and its employees and agents do not assume
responsibility for opinions expressed by the authors or individuals quoted in the
magazine; for the accuracy of material submitted by authors or advertisers; or for
any injury to persons or property resulting from reference to ideas or products
discussed in the editorial copy or the advertisements.
All content contained in Today’s Dietitian is created for informational purposes only and
shall not be construed to diagnose, cure, or treat any medical, health, or other condition.
Moreover, the content in Today’s Dietitian is no substitute for individual patient/client
assessment based upon the professional’s examination of each patient/client and
consideration of laboratory data and other factors unique to the patient/client.
CONTENT CONTAINED IN TODAY’S DIETITIAN SHALL NOT BE CONSTRUED TO
CONSTITUTE PROFESSIONAL MEDICAL, HEALTH, LEGAL, TAX, OR FINANCIAL ADVICE.
IT’S THE START OF SOMETHING GOOD!
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Reader Feedback
From Our
Facebook Page
NOVEMBER/DECEMBER ISSUE
Digestive Enzymes and Nutrition
(CPE Monthly)
Jan Patenaude: Thank you for this! One
interesting thing I learned many years ago
regarding lactose intolerance is that some-
times it can be triggered by parasites, more
specifically Giardia. (Happened with a now
65+ year-old Scottish dependent friend that
had new-onset lactose intolerance after
drinking creek water [that flowed through
a horse pasture] by mistake! He went from
easily consuming four glasses of milk per
day to not tolerating any lactose in a two-
week period.) After a parasite cleanse and
a few months, his tolerance fully returned.
Remains lactose tolerant 23 years later.
OCTOBER ISSUE
Helping SNAP Shoppers
Make Healthful Choices
Wendy S Chatham: Great article! When I
was young and poor, I remember receiving
$354 per month in food stamps to feed my
family of five. As a dietitian, I now look back
on the experience with gratitude as it has
enabled me to help community members
make the most of their SNAP benefit.
8  TODAY’S DIETITIAN • JANUARY 2022
From Our Twitter Feed
NOVEMBER/
DECEMBER ISSUE
Holiday Foods From Around
the World
@LizWeiss: “Holiday Foods From
Around the World” is the topic of
my latest story in Today’s Dietitian
magazine with recipes from
dietitians with roots in India,
Syria, Mexico, Cuba, Korea, and
more. Come explore their favorite
culinary creations.
Expanded Roles in Diabetes Care
@ADCESdiabetes: Today’s
Dietitian and Hope Warshaw, MMSc,
RD, CDCES, BC-ADM, FADCES,
profile seven RDs with the CDCES
credential. Read on to learn how
they’ve expanded their roles and
how they’re embracing the new
specialty name and vision.
@HopeWarshaw: Hey RDN, want to
expand your role in #diabetes care
and management? Read my article
in Today’s Dietitian’s November/
December issue that profiles seven
success stories. Thanks to Sandra
Arevalo Valencia, MPH, RDN, CDN,
CDCES, CLC, FADA; Donna Butler
Ryan, MPH, RN, RDN, CDCES, FADCES;
and others with Cecelia Health,
Omnipod, and ADCES #CDCES.
Nutrition’s Impact
on Mental Health
@tobyamidor: Evidence suggests
certain dietary patterns containing
specific nutrients can reduce
symptoms of some of the most
common mental health disorders.
Here’s my latest from Today’s
Dietitian. #mentalhealth
Nutrition for Headaches and
Migraines (Integrative Nutrition)
@nutrigirl: Headaches on the
horizon? Head them off at the pass!
Thank you, Today’s Dietitian, for
publishing my article. #migraines
#headaches #triggers #prevention
OCTOBER ISSUE
Sports Nutrition
for Bariatric Athletes
@eatfit: When sports nutrition
and bariatric surgery collide! If
you had weight loss surgery or
if you’re a registered dietitian,
check out “Sports Nutrition for
Bariatric Athletes in the latest
Today’s Dietitian to hear from me;
Nancy Clark, MS, RD, CSSD; Laurie
Schubert, PhD, RDN, CSSD, LDN;
and Carrie Dennett, MPH, RDN.
Ask the Expert By Toby Amidor, MS, RD, CDN, FAND
Responding to
Media Queries
Q I’ve received nutrition-related
media queries, but the idea of
responding seems daunting. What are
the best practices for responding to
them appropriately?
A: As awareness of RDs’ expertise has
evolved, local and national media out-
lets have been turning to RDs for quotes
and information for food- and nutrition-
related articles. According to the Inter-
national Food Information Council
Foundation’s 2018 Food & Health Survey,
70% of consumers trust RDs, so quot-
ing RDs make the information from that
media outlet more credible.
As a writer for numerous national
media outlets, I often send queries to RDs
and have found some responses to be
much better than others. RDs who under-
stand how to formulate good responses—
and do so in a way that makes reporters’
lives easier—have a better chance of being
included in media and getting their names
and science-based messages into the pub-
lic eye. This article covers some of the dos
and don’ts of responding to media queries.
Best Practices
RDs may find a media query in a private
Facebook group run by RDs or nutrition
professionals, on the website HARO
(helpareporter.com), or on other such online
services for journalists looking for experts,
or RDs may be contacted directly by
writers. Responding to media queries may
seem intimidating, but it becomes easier
with practice. Amy Gorin, MS, RDN, New
York City–based co-owner of the Master the
Media Coaching Program (masterthemedia.
co/course), shares the following tips for
responding to media queries:
• Know your audience. Is the media out-
let geared toward consumers? Health
care practitioners? Industry profes-
sionals? Respond to each query as if
you’re speaking to them. Regardless
of the audience, formulate a concise,
evidence-based response in appropri-
ate language.
• Respond right away. Whenever a
reporter reaches out to you for an
interview, reply immediately and say
that you can take the interview. The
worst thing would be for
you to delay your response,
do the work of answering
the media interview, and
the reporter not include
your quotes because they
thought you were unable to
participate.
• Reply within the body of an
e-mail. Never send a PDF
reply to a media interview.
The writer wants to cut and
paste your response into
their story, not retype your answer.
Word documents are OK, but any-
thing that requires an extra step on the
reporter’s side is seen as inconsiderate.
• Provide study links. Although this
sounds like a lot of work, provid-
ing everything the reporter needs—
including a study that supports your
tip—makes it more likely that you’ll
be included in a story. Most publica-
tions asking for quotes require that the
research is human based, published in
peer-reviewed journals, and no older
than five or six years.
• Include a credit line. A proper credit
line comprises your name, credentials,
and job title with a URL link to your
website or business. For example, I
tend to use “Toby Amidor, MS, RD,
CDN, FAND, award-winning nutrition
expert and Wall Street Journal best-
selling cookbook author.” Don’t
provide a full bio or lengthy credit line,
as the writer likely will edit it down
and the most important part of your
job title may not be included.
• Answer the specific media query. When
seeking RD input for her freelance writ-
ing on HARO, Gorin says the major-
ity of the responses she receives ask
whether she wants to interview a
certain expert, which doesn’t answer
the specific questions she posted. The
experts who respond and answer all of
her questions in the body of an e-mail
are the ones she most often uses.
• Speak in sound bites. According to
Gorin, this means “giving concise,
quotable answers that are neither
too short nor too long. Write out
your answers as you’d explain them
to a patient, replacing complicated
words with easier-to-understand
explanations.”
• Link to your website. Reporters don’t
always link to your website when
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  9
crediting you, but you should provide
one in case they do. Gorin says always
link either your name or your business
name to your website in your credit line
to drive potential clients there.
Want to Learn More?
Several available courses train RDs on
how to respond to media queries. These
include a free seven-day media boot camp
with Gorin and Erin Palinski-Wade, RD,
CDCES, LDN, CPT (masterthemedia.
co/bootcamp); Sue Mah, MHSc, RD,
PHEc, FDC’s Media Training Boot Camp
(mediatrainingbootcamp.com); and
Sharper Edge Media Training from Abbey
Sharp, RD (abbeyskitchen.com). There
also are experienced media RDs, such
as Bonnie Taub-Dix, MA, RDN, CDN
(bonnietaubdix.com), who provide one-on-
one consulting services to RDs for media
training. In addition, the Academy of
Nutrition and Dietetics has a spokesperson
program that provides media training. n
Toby Amidor, MS,
RD, CDN, FAND, is
the founder of Toby
Amidor Nutrition
(tobyamidornutrition.
com) and a Wall Street
Journal bestselling
author. She’s written
several cookbooks, including The Best
Rotisserie Chicken Cookbook and The Family
Immunity Cookbook: 101 Easy Recipes to
Boost Health. She’s also a nutrition expert for
FoodNetwork.com and a contributor to U.S.
News Eat + Run and other national outlets.
For reference, view this article on our
website at www.TodaysDietitian.com.
Send your questions to Ask the Expert
at TDeditor@gvpub.com
or send a tweet to @tobyamidor.
Beverages
Study Highlights Possible
Improvements to
Sugary Drink Taxes
Several US cities have instituted taxes on
drinks with added sugars to reduce con-
sumption, but new research suggests these
policies currently have one fatal flaw.
The study found that sugary drink
taxes only reduce purchasing if price tags
at stores mention that consumers are pay-
ing that tax when they buy the drink.
“If cities want these policies to be effec-
tive, they need to regulate how these sug-
ary drinks are labeled at the stores where
they’re sold—and they currently don’t
do that,” says Grant Donnelly, DBA, lead
study author and an assistant professor of
marketing and logistics at The Ohio State
University’s Fisher College of Business.
The findings suggest that price tags
should mention the tax, but not the
amount, because consumers tend to over-
estimate how much the tax is, Donnelly
says. If they know the true size of the tax,
they’re more willing to pay it.
Among the cities that currently have a
tax on sugary drinks are Philadelphia, San
10  TODAY’S DIETITIAN • JANUARY 2022
Francisco, Seattle, and Boulder, Colorado.
The study was published online
recently in the journal Psychological
Science.
The research included a field study
at two convenience stores in San Fran-
cisco, which currently has a tax on sugary
drinks of one cent per ounce—an added
12 cents to a 12-ounce drink.
Researchers varied the price tags
placed on the sugary drinks over the eight-
week study. There were three price tags
that were rotated: one that simply said
the price for the 12-ounce drink ($1.52),
one that had the price and the message
“Includes SF Sugary Drink Tax,” and one
that included the same message and
added that the proceeds of the tax would
support local university student programs.
All nonsugary drinks, which aren’t sub-
ject to the tax, simply had the price of the
drink, which was $1.40.
The researchers compared sales of the
drinks during the study period with the
two immediately preceding weeks. Dur-
ing this time, the sugary drink tax was in
effect, but there were no price tags on any
drinks. They also compared sales with the
two years preceding the tax.
Results showed that sales of sug-
ary drinks weren’t lower during the two
weeks before the study began, compared
with sales in the two years before the tax.
In other words, the tax itself didn’t reduce
purchases of sugary drinks.
The researchers then looked at the
effects of the three different price tags
during the course of the study. Results
showed that the share of sugary drinks
bought when the tags simply showed the
price (47%) wasn’t significantly differ-
ent from the two-week period before the
study. But the share of sugary drinks pur-
chased did decline slightly (45%) when
the tags mentioned the price included the
added tax. Results showed that most con-
sumers who chose to avoid sugary drinks
with the added tax chose a drink that
wasn’t subject to the tax.
“Consumers are averse to taxes, so when
they learn that their favorite drink has this
sugary beverage tax, some are less inter-
ested in buying it,” Donnelly says. “They
generally substitute for healthier beverages,
like bottled water. So the taxes don’t seem
to hurt the stores that sell drinks.”
Tags that noted where the taxes would
be spent had no significant effect beyond
the tags that simply noted the added tax.
In a separate online study, the
researchers asked participants who
drank sugary beverages to estimate what
the tax would be on a 12-ounce can of
their favorite beverage that cost $1.52.
The average estimate was 40 cents—
much higher than the 12 cents actually
levied in San Francisco. Another study
found that when consumers were told
the tax was only 12 cents, they reported
they were much more likely to still
purchase the drink.
“People don’t like taxes, but they think
this tax is much higher than it actually is,”
Donnelly says. “If you tell consumers the
true cost of the tax, it’s no longer effective
in reducing purchases.”
The bottom line, he says, is that if
cities want these policies to be effective
at reducing consumption of unhealthful
beverages, they must mandate that tags
mention the added tax—but not reveal
how much it is.
SOURCE: THE OHIO STATE UNIVERSITY
Warning Labels on Sugar-Sweetened “However, both policy effects tend to
diminish after the first two years of
Beverages Could Improve Health implementation.
“The diminishing returns of the poli-
Warning labels on sugar-sweetened bev- law or calorie count law, were finalized by cies shouldn’t be surprising, as weight
erages (SSB) and menu labeling require- the FDA and took effect in 2018. loss and energy restriction interventions
ments for chain restaurants could be a An and his coauthors used microsimu- often result in a number of metabolic
cost-effective policy leverage to pre- lation modeling to estimate the effects of adaptations, such as decreasing energy
vent weight gain and reduce medical nationwide implementation of SSB warn- expenditure, improving metabolic effi-
expenses, but their impact is expected ing labels and menu labeling regulations ciency and increasing cues for energy
to fade over time, finds a new study from on daily energy intake, body weight, BMI intake, which compromise the interven-
the Brown School at Washington Univer- and health care expenditures. Microsimu- tion effect,” An says.
sity in St. Louis. lation is a systems science approach that In addition, the study found larger
“Accurate, readily accessible and examines behaviors and outcomes result- policy effects in men, African Americans,
easy-to-understand nutrition labeling is ing from interactions among multiple and younger adults. “The differential
a promising policy strategy to address system components over time. effects reflect the fact that they on aver-
poor diet quality and prevent obe- “The reduced per capita health care age consumed more calories from SSBs
sity,” says Ruopeng An, PhD, an associ- expenditures translate into an annual and chain restaurant food, so if the policy
ate professor at the Brown School and total health care cost savings of $720 effects are proportional to people’s daily
lead author of the study “Projecting the million for SSB warning labels and $1.11 energy consumption, the reduction in
Influence of Sugar-Sweetened Beverage billion for the menu labeling regula- caloric intake would be larger,” An says.
Warning Labels and Restaurant Menu tions over a 10-year period,” An says. SOURCE: WASHINGTON UNIVERSITY IN ST. LOUIS
Labeling Regulations on Energy Intake,
Weight Status, and Health Care Expendi-
tures in US Adults: A Microsimulation.”
“Our policy simulation shows that SSB
warning labels and the FDA’s menu label-
ing law could discourage overconsump-
tion, prevent obesity, and save medical
costs down the road,” An says. The study
was published online in the Journal of the
Academy of Nutrition and Dietetics.
About one-half of American adults
drink SSBs on a given day, with an aver-
age consumption of 145 kcal from SSBs
daily. During the past decade, vari-
ous types of warning labels have been
developed and tested that aimed to
inform consumers about the health
impact or nutritional implications of SSB
consumption.
Some SSB warning labels conveyed
messages in text form, some adopted
symbols or graphics, and others used a
combination of different means to com-
municate with consumers. However,
to date, no law mandating SSB warn-
ing labels has been implemented in the
United States.
American adults consume one-third
of daily calories away from home. The
Affordable Care Act required chain res-
taurants with 20 or more locations in the
United States to offer calorie and other
nutrition information for menu items. The
regulations, known as the menu labeling

JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  11

Boosting Immunity By Toby Amidor, MS, RD, CDN, FAND
Optimal Nutrition for a Healthy
Immune System
EDITOR’S NOTE: The following excerpt
from dietitian Toby Amidor’s book
The Family Immunity Cookbook: 101
Easy Recipes to Boost Health can be
used as a patient education resource
to encourage clients and their fami-
lies to try a plethora of recipes so
they eat a variety of healthful foods
that will improve the health of their
immune system.
The excerpt is from the introduction
and first chapter of The Family
Immunity Cookbook, “Healthy Habits
to Strengthen Your Immune System,”
which discusses how to keep the
immune system in tip-top shape so
A
healthy immune system is
vital to good health. The
immune system helps fight
off any foreign invaders to the
body. If our immune systems
are healthy, it’s easier to fight bacteria,
viruses, or anything else trying to make
us sick. A global pandemic has shaken the
way we view our health and that of our
families, and it’s easy to feel like the odds
are stacked against us. Research has even
started to reveal that unhealthful eat-
ing potentially can impair the immune
system’s response to vaccines, including
12  TODAY’S DIETITIAN • JANUARY 2022
if a foreign invader attacks, the body
is ready. This means living the most
healthful lifestyle possible, which
includes six habits described on the
following pages.
The excerpt is written specifically
for clients and patients and therefore
serves as a patient education resource
nutrition professionals can use dur-
ing counseling sessions. Feel free to cut
out the article along the dotted line or
visit TodaysDietitian.com and print
out a copy of the PDF from the digital
edition of the January issue so you can
give it to clients and patients at the end
of their visit.
COVID-19. Keeping your family’s immune
systems strong and resilient is your first
line of defense for safeguarding their
health. It’s more important now than at
any other point in our lives to make sure
our immune systems are operating at
peak efficiency.
A healthful diet keeps your immune
system in optimum shape. If you have a
subpar diet, improving what you eat also
can help improve your immunity. Unfor-
tunately, during times of high stress, it’s
easy to forget how much we benefit from
eating well.
To make healthful eating a little easier,
I break down the concept of healthful eat-
ing well so it’s easy to understand and do.
Our bodies get different nutrients from
different foods, so when we don’t eat a bal-
anced and varied diet inclusive of fruits,
vegetables, proteins, starches (including
whole grains), milk and dairy products,
and healthful fats, we can miss out on
some (or even many) of the things that
keep our immune systems healthy and
working properly. In chapter 2, I identify
25 of the top immune-boosting foods and
incorporate them into the 101 recipes in
this book. These are ingredients that pro-
vide immune-essential nutrients to keep
your body’s defenses in tip-top shape, or
they’re foods that help decrease inflam-
mation and boost antioxidant activity,
which help your body defend itself from
illness and also can promote healing.
Adding these 25 foods to your family’s
well-balanced diet is an important part of
maintaining and helping enhance their
healthy immune systems.
When you combine healthful eating
with staying hydrated, getting plenty of
sleep, exercising regularly, consuming
alcohol in moderation, and finding good
ways to deal with stress, you set up your
family’s immune systems to be at their
best—and hopefully set them up to be sick
less often or prepare their bodies to fight
off an illness when they do get sick.
Healthy Habits to Strengthen Your
Immune System
6 Habits to Energize Your
Immune System
1 Keeping Hydrated
Approximately 60% of your body
is made of water. Keeping hydrated is
important for your overall health because
water plays an essential role in keeping
your body’s systems working efficiently—
including your immune system. Mild dehy-
dration doesn’t lead to illness, but it can
wreak havoc on your body, causing head-
aches, dizziness, or digestive problems.
It also can affect your mood, memory,
and how well you can process informa-
tion. Once you’re properly hydrated, these
milder symptoms go away. To prevent
dehydration, drink plenty of fluids daily.
Water is the top fluid recommendation
because it doesn’t contain calories. Seltzer,
sparkling water, and calorie-free flavored
 seltzers or waters also are good choices.
Other beverages that count towards hydra-
tion include 100% fruit juice and milk. If
you choose to drink juice, choose 100%
fruit or vegetable juice, and keep portions
at 1/2 cup to 1 cup since juices do contain
calories. If you drink milk, opt for low- or
nonfat milk whenever possible to help
minimize calories, added sugars, and satu-
rated fat. Coffee and tea also count toward
hydration, but minimize the amount of
sugar and cream you add, and avoid pre-
packaged sweetened coffee and tea bev-
erages to help minimize the calories and
saturated fat you’re consuming. Sweet-
ened drinks such as sodas, lemonade,
and sports drinks certainly help you stay
hydrated, but they should be minimally
consumed because of the added sugars.
Fruits and vegetables also contribute to
fluid needs, which is one reason it’s so
important to eat plenty of them.
2 Getting Plenty of Sleep
Not getting enough shut-eye has been
linked to poor dietary choices, increased
risk of chronic diseases like heart disease
and type 2 diabetes, reduced psychologi-
cal well-being, and a decreased lifespan.
There’s scientific evidence that not get-
ting enough sleep can reduce the capabili-
ties of the body’s immune system.1 Some
research shows that a lack of sleep can
result in an increase in white blood cells,
which indicates inflammation.2 It also
can make you more susceptible to getting
sick if you’re exposed to a disease-causing
microorganism and cause illness recovery
to take longer.3 Overall, getting plenty of
sleep enables your immune system to stay
healthy and better fight off illness. Adults
should aim to get at least seven hours of
sleep every night, teenagers need eight to
10 hours every night, and younger chil-
dren and infants should get up to 14 hours
(including naps).
3 Exercising Regularly
Regular physical activity helps
strengthen your immune system.
Moderate physical activity may help
reduce inflammation and help immune
#
cells regenerate regularly. Moderate
CUT ALONG DOTTED LINE
exercise includes activities such as
jogging, swimming, bicycling, playing
tennis doubles, heavy cleaning (such as
vacuuming and mopping), and mowing
the lawn. Choose activities that you enjoy
doing or exercise with a friend. Aim for at
least 150 minutes of moderate physical
activity every week. It’s always a good
idea to speak with your physician before
beginning an exercise program.
4 Consuming Alcohol in Moderation
Drinking too much alcohol can
compromise your immune system,
making it harder for it to defend your
body against foreign invaders. In addition,
alcohol can trigger inflammation in the
gut and have a negative impact on the
good bacteria living there that keep your
immune system healthy.
If you choose to drink alcohol, it’s
important to drink in moderation, which
is defined as no more than one drink per
day for a woman and two drinks per day
for a man. One drink is defined as 12 fl
oz of regular beer, 5 fl oz of wine, or 11/2 fl
oz of 80 proof liquor like rum or vodka.
Unfortunately, you can’t “save” your
drinks for Saturday night. This is the max-
imum consumption per day.
5 Healthy Eating
A healthful diet is an important part
of building a healthy immune system.
Although there’s no one food that will
magically make your immune system
perfect, including a variety of immune-
boosting foods that play various roles in
building and maintaining your immune
system certainly can help.
6 Finding Good Ways to Deal With
Stress
Scientific evidence suggests there’s a
mind-body interaction, and being stressed
can weaken the body’s ability to fight
infection. Fortunately, when we find good
ways to deal with stress, such as exercise,
meditation, yoga, or talking to a friend, it
helps our bodies stay more healthful. You
also can look for ways to minimize stress.
When it comes to healthful cooking and
eating, tactics like meal prepping, freez-
ing foods, cooking one-pot meals, and
cooking meals that take 30 minutes or less
from start to finish are great ways to make
things less stressful in the kitchen.
Foods to Build
Your Immune System
This is a list of 10 of the 25 foods that pro-
vide nutrients to keep your immune sys-
tem healthy. A full list of the 25 foods can
be found in chapter 2 starting on page 28
in The Family Immunity Cookbook.
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  13
Yogurt
WHY THIS FOOD?
It provides live, active cultures that may
act as probiotics, which can help boost the
immune system.
Whether you choose traditional or
Greek yogurt, this fermented dairy prod-
uct contains live, active cultures. These
probiotics act as “good” bacteria in your
digestive system, which means they pro-
vide health benefits and help protect the
digestive tract. Research has shown that
some strains of probiotics can help boost
your immune system and promote a
healthy digestive system.
Lentils
WHY THIS FOOD?
They’re good plant-based sources of zinc
and vitamin B6, both of which play a role
in your immune system’s defense.
Lentils are a good plant-based source
of zinc, with 1 cup of cooked lentils pro-
viding 17% of the recommended daily
dose of the mineral. This legume also is
an excellent source of iron, providing 37%
of the recommended daily amount, and a
good source of vitamin B6, providing 18%
of the recommended daily amount. Zinc,
iron, and vitamin B6 all help create infec-
tion-fighting white blood cells.
Red Bell Peppers
WHY THIS FOOD?
They’re excellent sources of the anti-
oxidant vitamin C, which plays a role in
immune function.
Just 1/2 cup of sweet red bell pepper
provides more than 100% of the daily
recommended amount of vitamin C. In
addition to its function as an antioxidant,
several cells of the immune system need
vitamin C to perform their task. Research
shows that vitamin C slightly may reduce
the duration of an illness in a healthy
person.4 Red bell peppers provide the
antioxidant vitamins A and E, which also
help fight free radicals that can damage
your body’s cells.
Almonds
WHY THIS FOOD?
They’re brimming with the antioxidant
vitamin E, which helps keep your immune
system healthy.
Boosting Immunity
Just 1 oz or 23 unsalted dry roasted
almonds provides 169 calories, 6 g plant
protein, 3 g fiber, “good” unsaturated
fats, magnesium, and vitamin E. The
antioxidant vitamin E is fat soluble
and found in high concentrations in
immune cells compared with other cells
in the blood. It’s one of the most effective
nutrients that helps keep your immune
system working properly.4 Plus, almonds
add a delicious crunch to dishes.
Oranges
WHY THIS FOOD?
They contain a plethora of vitamin C in
both the flesh and zest, which helps the
immune system work properly.
One medium orange provides 78% the
recommended daily amount of vitamin
C. This antioxidant vitamin can increase
the production of white blood cells,
which help fight infection. Vitamin C also
helps absorb the mineral iron from plant
sources (like spinach and black beans)
and helps the immune system work prop-
erly to help protect the body from disease.
The zest (or peel) of an orange also pro-
vides vitamin C, plus it adds great flavor
to recipes. Other citrus fruits like lemons,
limes, grapefruit, and more also pro-
vide vitamin C and certainly should be
included in an immune-boosting diet.
Ginger
WHY THIS FOOD?
It contains a variety of powerful antioxi-
dants that may help reduce inflammation.
The ginger we commonly eat is the root
of the ginger plant. It has a peppery flavor
with a slight sweetness and a pungent,
spicy aroma. Ginger contains a variety
of powerful antioxidants, including
gingerols, shogaols, and zingerones
that may help reduce inflammation. In
addition, initial research has shown that
ginger may be beneficial for combating
bacterial infections.5
Grapes
WHY THIS FOOD?
They contain numerous antioxidants and
polyphenols that protect the body’s cells,
as well as resveratrol, which helps with
healthy immune function.
One of the most critical components
to immune health is proper hydration.
14  TODAY’S DIETITIAN • JANUARY 2022
Grapes are 82% water and can help keep
you hydrated. They contain more than
1,600 plant compounds that may help
fight and prevent disease. Some of the
compounds in grapes include antioxi-
dants and polyphenols, which protect
the health and function of the body’s
cells. Grapes also contain resveratrol,
which helps regulate immunity and
fight inflammation. Resveratrol also
may play a beneficial role in the preven-
tion and progression of chronic diseases
related to inflammation including
diabetes, obesity, cardiovascular
disease, and cancers.6
Spinach
WHY THIS FOOD?
It includes numerous antioxidants and
iron—all of which are involved in keeping
your immune system healthy.
All antioxidants are involved in the
immune system. They help fight free
radicals that can cause damage to your
cells, and spinach provides antioxidant
vitamins A, C, and E. In addition to those
and other numerous nutrients found
in spinach, it’s also a source of iron. It’s
important to note that iron is an under-
consumed nutrient by most people
around the world, and iron deficiency
anemia can impair your immune func-
tion. When consuming iron from a plant
source, like spinach, pair it with a source
of vitamin C (like orange juice or oranges)
to aid iron absorption.
Walnuts
WHY THIS FOOD?
They’re brimming with omega-3 ALA,
vitamin B6, and polyphenols that can help
your immune system.
This tree nut is an excellent source
of omega-3 alpha linolenic acid and
a good source of vitamin B 6 , both of
which are part of a functioning immune
system. Walnuts also have the highest
amount of the natural plant compound
called polyphenols compared with
other tree nuts and peanuts, which
may play a role in supporting heart
health and cognitive health. It also
helps fight inflammation and combat
some diseases like cancer. In addition,
good gut health has been linked to
numerous health benefits for digestion,
metabolism, and the immune system.
Walnuts have been shown to have
prebiotic properties that have been
shown to be a good choice for gut health.
Oats
WHY THIS FOOD?
They provide beta-glucan, selenium, zinc,
arginine, and the natural plant compound
avenanthramides, all of which help boost
immune function.
Beta-glucan is a type of fiber found in
oats that helps boost white blood cells,
which help fight infection. The minerals
selenium and zinc also help fight off
infection and keep your immune system
healthy. In addition, beta-glucan can
help trigger a series of chemical activities
in the body that help the immune
system function more efficiently. Oats
also are brimming with the amino
acid arginine that helps heal injuries,
regulate blood flow, and boost the
immune system. Selenium is a mineral
that also helps regulate the immune
response and acts as an antioxidant
protecting your cells from oxidative
damage and infection. Oats also provide
a natural plant compound called
avenanthramides, which has antioxidant
properties and can potentially minimize
inflammatory responses and stimulate
the immune system.
When you combine healthful eating
habits with the healthful habits men-
tioned above, you set up your family’s
immune system to be at its best—and
hopefully set them up to be sick less often
or prepare their bodies to fight off an ill-
ness when they do get sick. If these habits
are established in childhood and sus-
tained throughout adulthood, the impact
on health can be profound. We all want
lifelong wellness for our families, so set
them up for success. Starting now. n
Toby Amidor, MS, RD, CDN, FAND, is
the founder of Toby Amidor Nutrition
(tobyamidornutrition.com) and a Wall Street
Journal bestselling author. She’s written
several cookbooks, including The Best
Rotisserie Chicken Cookbook. She’s also a
nutrition expert for FoodNetwork.com and a
contributor to U.S. News Eat + Run and other
national outlets.
For references, view this article on our
website at www.TodaysDietitian.com.
 Chicken Stir-Fry With Red Peppers,
Broccoli, and Walnuts
Give your immune system a boost with this colorful stir-fry.
Everyone in the family will enjoy this go-to dish.
Serves 4
Immune-Boosting Foods: 3
Ingredients
1 cup long-grain brown
rice
21/4 cups low-sodium
chicken broth, divided
2 T reduced-sodium soy
sauce
1 T unseasoned rice
vinegar
2 tsp cornstarch
1 tsp honey
1 tsp fresh lime juice
1/4 tsp ground ginger
1 lb boneless skinless
chicken breasts, cut
into 1-inch cubes
1/4 tsp salt
1/8 tsp ground black
pepper
3 T olive oil, divided
2 red bell peppers, cut
into 1/2 inch–thick slices
4 cups broccoli florets
1/4 cup raw walnuts,
coarsely chopped
Directions
1. In a medium saucepan, bring
the rice and two cups of the
broth to a boil over high heat.
Reduce the heat to low and
simmer, covered, until the
broth is absorbed, 35 to
40 minutes. Fluff the rice
with a fork.
2. In a small bowl, whisk
together the remaining 1/4 cup
broth, soy sauce, rice vinegar,
cornstarch, honey, lime juice,
and ground ginger.
#
CUT ALONG DOTTED LINE
3. Sprinkle both sides of the
chicken with the salt and black
pepper. In a large skillet or
wok, heat 2 T of the oil over
medium heat. When the oil is
shimmering, add the chicken
and cook on all sides until an
instant-read thermometer reg-
isters 165˚ F, about 8 minutes.
Transfer the chicken to a clean
plate.
4. Heat the remaining 1 T of
oil in the same skillet or wok.
When the oil is shimmer-
ing, add the bell peppers and
broccoli and cook until slightly
softened, about 5 minutes.
Add the broth mixture and
increase the heat to high and
bring to a boil, then reduce the
heat to medium and cook until
the sauce is slightly thickened,
1 minute. Add the chicken back
into the skillet or wok and toss
to evenly coat with the sauce.
Sprinkle with the walnuts.
5. To serve, divide the rice
among four plates and top
with the chicken stir-fry.
Serve warm.
SOURCE: RECIPE FROM THE FAMILY
IMMUNITY COOKBOOK BY TOBY AMIDOR,
MS, RD, CDN, FAND. PUBLISHED BY
ROBERT ROSE BOOKS. PHOTO COURTESY
OF ASHLEY LIMA. ALL RIGHTS RESERVED.
Nutrient Analysis per
serving (2 cups stir-fry
plus 1/2 cup rice)
Calories: 472; Total fat: 17 g; Sat
fat: 2 g; Sodium: 595 mg; Total
carbohydrate: 50 g; Dietary fiber:
5 g; Sugars: 5 g; Protein: 33 g
Nut and Seed Breakfast Cookies
These breakfast cookies are brimming with immune-boosting
ingredients: almonds, walnuts, and sunflower seeds. Meal prep
these cookies on Sunday and enjoy them throughout your busy
work week. Pair with a glass of milk, yogurt, or fresh fruit.
Serves 15
Immune-Boosting Foods: 3
Ingredients
2 baking sheets lined
with parchment paper
11/2 cups unbleached all-
purpose flour
1 cup large flake (old-
fashioned) rolled oats
1 tsp ground cinnamon
1 tsp baking soda
1/2 tsp salt
1 cup almond butter
1/2 cup unsweetened
applesauce
6 T pure maple syrup
2 eggs, beaten
1 tsp vanilla extract
1/4 cup raw walnuts,
coarsely chopped
1/4 cup raw almonds,
coarsely chopped
1/4 cup unsalted sunflower
seeds
1/2 cup raisins
Directions
1. Preheat oven to 350˚ F. In a
medium bowl, using a wooden
spoon, mix together the all-
purpose flour, oats, cinnamon,
baking soda, and salt.
2. In a large bowl, whisk
together the almond butter,
applesauce, and maple syrup
until well combined. Add the
eggs and vanilla extract and
whisk until smooth.
3. Gently fold the dry ingredi-
ents into the wet ingredients
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  15
and stir until just combined.
Fold in the walnuts, almonds,
sunflower seeds, and raisins,
evenly distributing through-
out the dough.
4. Scoop out 1/4 cup of the
dough and, using clean hands,
roll into a ball. Place onto a
prepared baking sheet and
gently press down on the top
to flatten slightly. Repeat with
the rest of the batter, leav-
ing about 1 inch between the
cookies.
5. Bake for 18 minutes, until
the cookies are golden brown
but soft and a tester inserted
into the center of two cookies
comes out clean. Transfer the
cookies to a wire rack and let
cool for about 10 minutes.
6. Serve warm or, once the
cookies have completely
cooled, store, covered, at
room temperature for up to
five days. Cookies also can be
placed in a sealable bag and
stored in the freezer for up to
two months.
SOURCE: RECIPE FROM THE FAMILY
IMMUNITY COOKBOOK BY TOBY AMIDOR,
MS, RD, CDN, FAND. PUBLISHED BY
ROBERT ROSE BOOKS. PHOTO COURTESY
OF ASHLEY LIMA. ALL RIGHTS RESERVED.
Nutrient Analysis per
serving (1 cookie)
Calories: 251; Total fat: 13 g; Sat
fat: 1 g; Sodium: 174 mg; Total
carbohydrate: 28 g; Dietary fiber:
3 g; Sugars: 11 g; Protein: 8 g
Herbs + Spices By Carrie Dennett, MPH, RDN, CD
Improving Taste and Smell
After COVID-19 Recovery
O
ne of the more bizarre symp-
toms of COVID-19 is loss
of taste and smell, and for
many people this sensory
deprivation lasts for several
months—or longer. What’s behind this
phenomenon, and how does it impact not
just food pleasure but also food choices
and nutrition status?
Smell, or olfaction, is the ability to
sense trillions of odors via the nose. Taste,
or gustation, is the capacity to perceive
the five taste qualities—sweet, salty,
sour, bitter, and umami—on the tongue.
Chemesthesis is the ability to discern sen-
sations in the mouth, as from eating chili
peppers, chewing mint gum, or drinking
carbonated water.1,2 Finally, flavor is the
combination of all these senses.2
Our sense of smell begins through the
nostrils, but as we chew and swallow food,
we sense odors and aromatic compounds
via the nasal cavity, which lies above the
bone that forms the roof of the mouth and
16  TODAY’S DIETITIAN • JANUARY 2022
curves down at the back to join the throat.
In both of these phases, tissues and nerves
send neurological signals to the olfactory
bulb in the brain. This plays a dominant
role in food enjoyment, quality of life, and
nutrition-related health outcomes.
Research suggests that COVID-19
infects cells that support sensory neu-
rons in the nose, known as sustentacular
cells.3 Inflammation also may play a role
in both olfactory and gustatory impair-
ment, although it’s less clear what causes
other chemosensory distortions, such
as impaired chemesthesis.4 Smell loss
has become particularly prominent as a
COVID-19 symptom. This includes hypos-
mia (reduced sense of smell), parosmia
(smell distortion—things don’t smell like
you remember them), and anosmia (com-
plete loss of smell).
“Smell loss can happen in the presence
or absence of other symptoms. For some
people, smell loss is the only symptom
they have,” says Stephanie Hunter, PhD,
a postdoctoral fellow at Monell Chemi-
cal Senses Center in Philadelphia. “Since
loss of smell, especially in the absence of
nasal congestion, is a unique symptom
of COVID—as opposed to fever or cough,
which could occur for many other rea-
sons—it’s a better predictor of COVID-19
than other symptoms.”
Hunter says a recent Monell study
found that about 77% of people with
COVID-19 experience smell loss when
measured by an actual smell test. But
when asked if they have smell loss, only
44% of people report smell loss from
COVID-19. “Actually measuring people’s
sense of smell can identify a lot more peo-
ple with smell loss from COVID, because a
lot of people just aren’t aware of changes
in their taste and smell sometimes.”
Hunter says the trajectory and
duration of smell disruptions depend
on how the person lost their sense of
smell. For example, those with postviral
smell loss from COVID-19 or a cold
typically recover quicker—within about
a month—than someone who lost their
sense of smell from head trauma, which
can be more permanent. “Postviral
parosmia typically resolves within a year
for most people,” Hunter says. “Recovery
also can differ depending on whether
someone did any interventions to get
their sense of smell back, such as smell
training, which could improve recovery
from postviral smell loss.”
Results of an ongoing Virginia Com-
monwealth University study published
online in September found that sense of
smell or taste returns within six months
for about 80% of COVID-19 survivors who
reported losing these senses, with patients
younger than 40 more likely to recover
their sense of smell than older patients.5
Impact on Nutrition
and Quality of Life
Hunter says that while many people
quickly recover from COVID-19–related
smell loss, what’s troubling is that about
10% to 15% of people will suffer long-term
smell loss from the disease. “This can
really alter their life in terms of qual-
ity of life, diet and nutrition, and safety
from toxins.” She says many people report
compensating for lack of flavor by adding
sugar, salt, or spices to their foods—and
excess sugar and salt could have adverse
effects on nutrition status and health. “On
the other hand, others may find food just
not very enjoyable, or even unpleasant to However, if a client is unfamiliar with Ginger Hultin, MS, RDN, owner of
eat, and don’t have much of an appetite, using herbs and spices, Redmond sug- Champagne Nutrition in Seattle and
and don’t eat as much as they used to.” gests listing foods, beverages, and ingre- author of Anti-Inflammatory Diet Meal
In early 2020, Chef Michele Redmond, dients they previously enjoyed. “Make Prep, suggests clients start by using lemon
MS, RDN, who provides culinary nutrition a note of those that also evoke positive as a flavor. “It’s not an herb or spice, but it
and gastronomy education and consulting memories and experiences since the can be an effective way to stimulate the
services at The Taste Workshop in Scott- olfactory bulb connects to the brain’s lim- taste buds,” she says. “Next, I might sug-
sdale, Arizona, contracted COVID-19. She bic system involved in processing mem- gest strong flavors from foods like onion
experienced reduced flavor perception but ory, mood and emotions, and learning,” and garlic. Finally, try fresh herbs, which
also increased taste sensitivity, or hyper- she says. “Then identify any herbs, spices, are often a little more potent-flavored, and
geusia, to bitter foods for more than four and flavorful ingredients fitting these cri- start with more familiar options like basil,
months. She says she easily could taste teria and individually incorporate them oregano, mint, and cilantro.”
salt and sweet and, for the first time, fre- into a food at varying quantities.” For Of course, loss of taste and smell is one
quently desired ice cream. “Despite these patients who are frustrated with loss of thing; distorted taste and smell is another.
treats, I experienced long-term appetite smell, Redmond suggests trying a smell Hunter says people will experience paros-
loss for the first time. Foods I normally training kit (see sidebar) from a repu- mia when their olfactory sensory neurons
loved tasted flat, and I lost interest in eat- table sensory organization and consider- are recovering. She says this can be a very
ing them,” she says. “However, it was a ing repeated exposure to aromas they’re troubling time and has profound negative
good professional experience for me to most familiar with, especially ones that impacts on their quality of life. “This is
consider how the impact of loss of appetite are pungent and connect to positive when people experience foods tasting like
can affect mood and mealtimes.” memories and emotions. sewage or spoiled even though they aren’t,
When flavor perception is compro- and this can especially disrupt someone’s
Use of Herbs and Spices mised or illusive, Redmond says spicy diet,” she says. “It’s hard to have an appe-
Depending on the level and type of che- ingredients can stimulate the eating expe- tite or want to eat if everything tastes bad,
mosensory impairment, using herbs and rience. “That’s because we feel ingredients and constantly smelling sewage all day
spices may help increase interest in eat- like chili flakes, chili powder, or pepper- can be very troubling.”
ing, although which herbs and spices do corns as a physical sensation,” she says. Hultin says fruity and salty flavors may
so will vary from person to person. Redmond also says dry or liquid flavor be better tolerated in this case and that
“Our lifetime eating experiences, extracts have been shown to help improve patients may find they’re averse to protein
genetic makeup, and exposure to herbs flavor and taste perception by adding foods such as meat. “Aim for plant-based
and spices uniquely shape how the brain aroma or flavor, increasing salivary out- proteins such as tofu, tempeh, beans,
interprets them,” Redmond says, adding put, heightening appetite, and masking and lentils, or use a marinade on meat to
that when a client frequently has been bad or “off” flavors. “Flavor extracts are change the flavor,” she says. “It’s impor-
exposed to herbs and spices, such as by available for a variety of flavorful plants, tant to keep trying—not to give up—and
cooking with them, this increases their including basil, garlic, thyme, anise, berga- to try a food more than once. People with
odds of enjoying and recognizing individ- mot, mint, and peppermint.” Many of these food aversions or distorted smell or taste
ual ones when they’re struggling to make extracts are available in grocery stores, may find that they can’t tolerate a food
food smell or taste good. while others may be available only online. one day, but on another, it’s better.”
However, if distorted taste and odor
perception continues to create feelings
of disgust for and aversion to previously
enjoyed foods, affecting appetite, nutri-
Resources ent and calorie intake, and mental health,
Redmond says, “It’s important to seek sup-
• Abscent.org: AbScent is a United Kingdom–registered charity that port from health professionals skilled in
funds research to end smell disorders and supports individuals experiencing sensory diagnosis and assessment.” Rhi-
the effects of smell loss. This organization sells smell training kits and nologists and otolaryngologists (ear, nose,
provides instructions for creating your own kit. It also offers other and throat doctors) who specialize in nose
information on smell loss. and sinus problems, are the specialists for
clients to contact. n
• Thestana.org: The Smell and Taste Association of North America is a patient
advocacy group that seeks to improve the quality of life for people with smell
Carrie Dennett, MPH, RDN, CD, is the nutrition
and taste disorders.
columnist for The Seattle Times, owner of
• Monell.org: The Monell Center website offers information on the Monell Nutrition by Carrie, and author of Healthy for
Chemical Senses Center’s research, including research on smell loss. Your Life: A Holistic Guide to Optimal Wellness.
• American-rhinologic.org: The American Rhinologic Society serves,
represents, and advances the science of rhinology. The website includes a For references, view this article on our
“find a rhinologist” feature and other information in the rhinology field. website at www.TodaysDietitian.com.

JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  17

Legumes By Kathryn Atkinson
Pigeon Peas
An Unusually Named Legume and
a Popular Crop Around the World
I
f dietitians are reading this article
on National Bean Day (January
6), they may want to celebrate the
pigeon pea. It has an intriguing
history and can be used in a wide
variety of recipes.
Pigeon peas are one of nearly 16,000
types of legumes grown across the world,
from chickpeas to soybeans to lentils.
Scientifically known as Cajanus cajan, the
pigeon pea is referred to by several names
across different cultures and has a fas-
cinating background. The origin of the
name “pigeon pea” is unclear, and other
names for this legume include no-eye pea,
gungo pea, guandules, and red gram.1 The
Latin name originates from the Sanskrit
word kaand, or “stem,” which became
the Telegu kandi, the Malay cachang, and
eventually, the Latin Cajanus cajan.2
Pigeon peas are grown on a massive
scale across the world. Among pulses,
their cultivation is second only to
chickpeas.3 Similar to other legumes,
pigeon peas have a high protein content
and as such have been referred to as the
“poor people’s meat.”4 What’s more, the
pigeon pea was the first legume to have its
complete genome sequenced.5
History and Current Growth
Likely originating in India, pigeon peas
have been cultivated for at least 3,700
years. The earliest archaeobotanical
evidence comes from the southern
peninsula of India, though evidence of
noncultivated, wild varieties also has been
discovered in more northern regions.4 It’s
thought that the pigeon pea spread from
India to East and West Africa, where it
was encountered by Europeans. In the
17th century, pigeon peas were brought to
the New World through the transatlantic
slave trade, and quickly spread across
Central and South America.6 Today,
this legume is widely cultivated for both
human and livestock consumption, with
much of this production centered in the
semiarid tropics.1 India and Myanmar top
the list, contributing 83% of the world’s
pigeon pea production.7 Other major
contributors include Malawi, Tanzania,
Kenya, and Uganda, and they’re also a
18  TODAY’S DIETITIAN • JANUARY 2022
popular crop in the Caribbean.4,7 Pigeon
peas are highly drought resistant, and
as such are being considered for use as a
forage crop, or a crop grown specifically
for livestock consumption, in the
southern United States.4,7,8
Botany
Pigeon peas are members of the Fabaceae
family, which is commonly referred to as
the “bean family,” from the Latin faba, or
“bean.” The genus Cajanus encompasses
32 species, most of which are found in
India.4 Unfortunately, many of these spe-
cies aren’t widely studied.
Usually grown as small, leafy shrubs
about 1 to 2 meters in height, pigeon pea
plants may grow into small trees up to 4
meters tall.1 Often, the pigeon pea plant is
used as a windbreak or as shade cover for
smaller, immature plants. When grown
with other cereal crops, pigeon peas have
a positive effect on crop yield, influencing
both the water-holding capacity of the soil
and the overall soil structure.7
Along with being drought resistant,
pigeon pea plants can grow in nutrient-
poor environments and at a range of alti-
tudes.1,4,7 However, while the pigeon pea
has been able to spread out from where it
originated in India, it hasn’t crossed the
Himalayas.4 This is likely because most
varieties aren’t frost resistant; the peak
season for pigeon peas is the late sum-
mer and early fall.1 The crop can be either
perennial, lasting around three to five
years, or annual; the latter variety is more
commonly used for seed production.
When grown alongside other crops, such
as maize, soybean, cotton, or sorghum, the
pigeon pea plants reportedly have aided in
weed control.3,7 Interestingly, they also may
reduce stormwater runoff, though this
depends on the type of pigeon pea grown.8
Arroz Con Gandules
This recipe is a popular way to
consume pigeon peas on the island
of Puerto Rico.
Serves 5
Ingredients
2 T annatto oil or vegetable oil
1/2 cup sofrito
2 T tomato paste
1/4 cup cilantro, chopped
2 cups white rice, uncooked
1 cup tomato sauce
3 cups water
1 tsp salt
1 can green pigeon peas
(gandules verdes) or 2 cups
fresh pigeon peas, cooked
Directions
1. In a medium saucepan, add oil,
sofrito, tomato paste, and cilantro
and cook at medium heat for 2 to
3 minutes.
2. Stir in rice, tomato sauce, water,
salt, and pigeon peas. Boil for
10 to 15 minutes or until water is
absorbed. Cover and cook at a
lower temperature for 15 to 20
minutes or until rice is tender. Stir
2 or 3 times during cooking to allow
for uniform doneness.
Nutrient Analysis per serving
Calories: 278; Total fat: 10 g; Sat fat: 0 g;
Sodium: 510 mg; Total carbohydrate: 38 g;
Dietary fiber: 6 g; Protein: 10 g
SOURCE: RECIPE COURTESY OF SYLVIA KLINGER,
DBA, MS, RDN, FOUNDER AND PRESIDENT OF
HISPANIC FOOD COMMUNICATIONS
 The pigeon pea grows inside long,
thin pods similar in appearance to those
of sugar snap peas or edamame. When
young, the pods are green and lighter
in color and tend to darken as the plant
ages, though they can range in color from
gray to purple or even black. Each pod
holds about two to nine seeds, which are
small and slightly flattened, and exhibit a
variety of colors, including red, black, or
brown.4 The plants also produce small red,
orange, or yellow flowers. At harvest time,
pigeon pea pods simply can be picked
straight from the plant, though further
processing often is required to dehull the
seeds. One such method involves thresh-
ing of the harvested pods with sticks.7
Another method involves soaking and sun
drying the pods before manual dehulling.
Nutrient Content
Similar to other legumes, pigeon peas are
a significant source of protein and cer-
tain amino acids. A 100-g uncooked por-
tion of pigeon peas contains 343 kcal, 22 g
protein, 63 g carbohydrates, and 1.5 g fat.
There are high levels of the amino acids
methionine, tryptophan, and lysine in a
serving of pigeon peas. In addition, these
legumes are a valuable source of B vita-
mins, such as folate; a 100-g uncooked
portion of pigeon peas contains 456 mcg
folate, which is 114% of the DV.9
Pigeon Peas in World Cuisines
Across the world, pigeon peas are con-
sumed in a variety of ways. The peas can
be eaten while immature and green or
may be consumed as a mature seed. In
India, pigeon peas—known as toor dal or
arhar dal—are considered a staple food
and are commonly used in dal or sambar.
Before use, the brown outer covering of
the legume is removed, leaving a yellow
seed that’s then split into two. This pro-
cess enables the pigeon peas to become
tender and break down during cooking,
creating a thick, soupy mixture.4
In Southeast Asia, pigeon peas are used
to make tofu, while in Central and South
America, they’re commonly eaten with rice.
Other parts of the pigeon pea plant apart
from the seeds can be eaten or used as ani-
mal feed. In Ethiopia, people eat the young
shoots and leaves. The dry stems and trunk
of the pigeon pea shrub can be used as
fuel, and the leaves often are fed to cattle.4
What’s more, the pigeon pea plant can be
used as a host for insects that produce lac, a
red substance that can be used as a dye.1
Using Pigeon Peas in Cooking
Dietitians can surmise that the pigeon pea
is a phenom in its own right. Its rich his-
tory, nutrient content, and versatility in
recipes makes it a good talking point with
clients looking to expand their palates.
Encourage clients to look for these small
but mighty legumes the next time they’re
in the grocery store. Not only will they add
a great source of protein and amino acids
to their diet but they also will enjoy one
of the world’s most popular pulses. And
whether clients consume them in a stew,
in dal, or with rice, pigeon peas are sure to
add dimension and flavor to any dish. n
Kathryn Atkinson is a junior at the University
of Connecticut double majoring in nutrition
sciences and food studies, with a minor in
classics and ancient Mediterranean studies.
In the future, she hopes to become an RD and
earn her PhD in gastronomy.
For references, view this article on our
website at www.TodaysDietitian.com.

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JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  19

 POPULAR
WEIGHT
LOSS
APPS Shedding excess pounds in the new year
may be just a tap away for clients.
By Densie Webb, PhD, RD
D
o you have clients who want
to overhaul their diets and
lose weight as they monitor
their physical activity, but
they need more assistance
than you can provide or they can afford?
Regular tracking of water, food, and
activity; dietary guidance and tips;
sharing of recipes, and more may be
just a few taps away with one of several
dieting and fitness apps.
While advice from a dietitian is invaluable, espe-
cially in the beginning, some clients may want to
go it alone after a counseling session or two but still
need some virtual handholding. There are several
dieting/fitness/weight loss apps available that vary
greatly in how they work and what they cost. And
because not every app will work for all clients, it’s up
to dietitians and their clients to choose the one that
best fits their needs and budget.
21
“Food and exercise tracking apps are one tool of
many that clients who are working toward certain
nutrition or exercise goals can utilize to help them
reach their goals,” says Caroline Susie, RDN, LD, a
national spokesperson for the Academy of Nutrition
and Dietetics in Dallas. But, she says, these apps can
be harmful for people with a history of disordered
eating because of the daily focus on food intake.
Today’s Dietitian evaluates five popular weight
loss apps and speaks with experts to find out what
they can and can’t do for users and which ones can
possibly fit into clients’ budgets. Some apps are free
to download and use, while others require a sub-
scription, and still others pose additional charges
for certain premium features. All are available for
iOS and Android devices, but it’s suggested that
clients check whether their device has the required
software version.
Baritastic
As you may have guessed by the name, Baritastic is
an app designed for patients who have had bariatric
surgery for weight loss. Claiming to be the No. 1 app
for bariatric patients, Baritastic is different from all
other weight loss apps in that it’s provided only by
doctors and clinics who pay for the service
and offer it to their patients free of charge.
Dan Abeling, the founder of BariApps,
says his company makes custom smart-
phone apps, including Baritastic, which is
used exclusively by bariatric facilities and
bariatric surgery practices and accessible
to clients via a code from a clinic or health
care facility. According to Abeling, Bari-
tastic has had about 1 million downloads
and more than 200,000 patients in the
United States use the app each month.
Baritastic tracks a wide range of
parameters that help clients stay on their
postop program, including the following:
• inches lost;
• daily reminders for water, protein
shakes, vitamins, and supplements;
• taking photos and creating a timeline;
• tracking hunger, moods, and bowel
movements;
• integration with major wearable
devices to track steps;
• a timer that separates food and water
intake; and
• a bite timer that helps users slow down
while eating.
Educational modules and videos also
are available. The patient’s provider speci-
fies the diet, and once patients are con-
nected to their providers on the app, all of
their providers’ diet guidelines are dis-
played within Baritastic.
There’s no need for clients and patients
to worry about providing their personal
health information, as the app is HIPAA
compliant. Providers have access to a
HIPAA-compliant dashboard to monitor
patients, set up checklists, review nutri-
tion, send messages and reminders, and
update content. Providers are alerted to
events such as weight gained or when
patients stop logging food, etc, enabling
patients to reach out for support. Commu-
nity support and accountability groups are
available both on and offline. The reviews
from users are overwhelmingly positive.1
For more information, visit baritastic.com.
Fitbit
Fitbit is not a single app or a single device.
Rather, Fitbit, which is owned by Google
and is the most robust and most expensive
of wearable trackers, offers entire lines of
smartwatches and fitness trackers for a
range of prices, anywhere from about $70
to $330. Which device bests suits your cli-
ents’ needs depends on their budget and
just how deeply they want to delve into
22  TODAY’S DIETITIAN • JANUARY 2022
self-monitoring of not only their diet but
also their heart rate, blood pressure, stress
level, and more. The Fitbit device comes
preloaded with a variety of apps, including
Alarms, Weather, and Exercise, and there’s
a basic food tracker included. But users
can download third-party food-tracking
apps, along with more than 3,000 partner
apps that can sync with their data.
If clients want more detailed informa-
tion about fitness and health metrics,
including workout and yoga videos and
training plans, along with reminders,
tips, and recipes, and programs to help
them reach nutrition goals, Fitbit offers a
Premium option that costs $10/month—
less if they sign up for a year—and there’s
a free 90-day trial. Fitbit also offers chal-
lenges and games to bring people together
to compete. The more expensive Fitbit
devices offer six months of the Premium
with purchase. Today’s Dietitian reached
out to Fitbit, but the company declined to
comment on their devices and apps.
Researchers have conducted a wide
range of studies to determine Fitbit’s effi-
cacy to monitor and improve physical
fitness, sleep, chronic pain, and mental
health.2 Based on customer reviews, Fit-
bit devices can sometimes be glitchy, but
CNET ranks two of Fitbit’s devices as being
among the best trackers on the market.3
There are far too many options for
devices and plans and downloadable apps
to discuss in this article, but dietitians can
learn more about Fitbit and all the options
and functions at fitbit.com.
MyNetDiary
This singular app with more than 11
million registered users has a staff of
RDs experienced in weight manage-
ment, diabetes, cardiovascular health,
food allergies, and pulmonary medicine.
MyNetDiary boasts the largest validated
food-nutrient database for English speak-
ers. Like most apps, it offers a free and a
Premium option, which costs either $9/
month or $60/year. The Premium option
offers a way to track body measurements,
blood glucose levels, A1c, LDL and HDL
cholesterol, and more than 50 nutrients.
Users also can set up custom trackers to
record anything they choose, such as hun-
ger, mood, and emotions.
While there’s no published research to
evaluate the efficacy of the app for weight
loss, according to Sue Heikkinen, MS,
RDN, CDCES, BC-ADM, ACE-PT, a con-
sultant for MyNetDiary, internal assess-
ments found that subscribers who sign
up for Premium stick with it longer and
lose more weight than free subscribers.
Premium users can choose from eight
customized diet plans: Calorie Counting,
Low-Carb, Keto, High-Protein, Low-Fat,
Mediterranean, Vegetarian, and Vegan.
All subscribers, both free and Pre-
mium, have access to daily coaching
messages that encourage reflection on
goals and obstacles and use a commu-
nity forum for support. Users may form
subgroups within the community forum
and can “friend” each other and share
data. There’s an “Ask a Registered Dieti-
tian” forum, where all subscribers can ask
a nutrition expert for guidance on their
diets and wellness plans.
MyNetDiary uses Dietary Reference
Intake equations from the National Acad-
emy of Medicine to predict subscribers’
energy needs for maintenance, and the
“AutoPilot” feature adjusts users’ energy
needs as they get closer to their target weight.
The company offers free Premium
memberships to RDs, as well as free
trial subscriptions and discounted
subscriptions for RDs to share with their
clients. The app enables users to share
their reports with dietitians or other
health care professionals. There are
plenty of positive reviews posted on the
company’s website, and the company
claims to have the highest user ratings
of all popular diet apps.4 For more
information, visit mynetdiary.com.
Noom
Noom is an exceptionally popular app
that’s widely advertised. According to the

website, “Noom uses science and person-
alization to help you lose weight and keep
it off for good. We’ll help you better under-
stand your relationship with food, how to
be more mindful of your habits, and give
you the knowledge and support you need
for long-lasting change.” Noom boasts 50
million users. Users start with a quiz to
determine calorie requirements for weight
loss. The app then offers calorie counting,
activity tracking, group support, personal
coaching, and daily “bite-sized lessons.”
The focus of Noom is on making per-
manent lifestyle changes, including diet
and physical activity. It has offered a dia-
betes prevention program since 2013, and
the program was recognized by the Cen-
ters for Disease Control and Prevention in
2017.5 The diabetes prevention program is
a year-long, evidence-based lifestyle man-
agement intervention for those meeting
clinical criteria for prediabetes.
One study found that Noom’s
diabetes prevention program had
weight loss outcomes similar to those
seen in the Centers for Disease Control
and Prevention’s National Diabetes
Prevention Program.6 The website also
cites 30 research studies that have found
Noom’s tracking tools to be effective for
weight loss and diabetes prevention.7
Today’s Dietitian reached out to Noom,
but the company declined to comment on
its program.
Noom has a range of pricing options.
A monthly autorenewal is $60. The price
per month drops the longer the renewal
period, with an annual auto-renewing
plan costing $199. Promotion codes often
can be found online, and there’s a 14-day
free trial to test the waters before commit-
ting to a monthly subscription.
One review site found that among tens
of thousands of reviewers, 84% gave Noom
four or five stars. However, other review-
ers have commented that some of the
coaching tips didn’t feel individualized.8
For more information, visit noom.com.
WW
As a weight loss program, Weight
Watchers has been around since 1963.
It became known as WW in 2018 and
now, of course, there’s the WW app.
As of mid-2021, there were 5 million
subscribers to the app. The weight loss
and weight maintenance programs
WW offers change frequently, often on a
yearly basis, but the philosophy remains
the same—to offer an adaptable, livable
weight loss program that’s a lifestyle,
not a diet, and provide sustainable food
plans, activities, behavior modification,
and group support. WW still uses the
points system, called SmartPoints,
to tally users’ intake and offers a
SmartPoints Calculator.
According to Michelle Cardel, PhD,
MS, RD, WW’s director of global clinical
research and nutrition, WW has a science
team of 12 experts specializing in behavior
change, implementation science, clinical
research, nutrition, and exercise science,
who ensure all the weight management
solutions are rooted in the research. She
adds that, according to a survey of 14,000
physicians, WW is the No. 1 doctor-
recommended weight loss program.
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  23
The app offers a barcode scanner that
enables users to scan barcodes of pack-
aged food products in the supermarket
and see how many points it contributes to
the user’s daily total. It also enables users
to create and save recipes and provides a
Connect feature, a members-only social
network where people can share their
weight loss journeys through photos and
videos. While none of the apps discussed
here are paired with delivery of foods
for the weight loss programs, WW offers
Smart Ones frozen entrées and desserts in
the supermarket that fit within the WW
point system.
Users can choose a free trial for 30 days.
Afterward, if they want to use the app,
they can select from the following pay-
ment levels:
• Digital includes app access with food
plans, tracking, workouts, progress
reports, and a 24/7 chat service for
$21.95/month.
• Digital 360 is a new membership option
that offers group coaching, commu-
nity, and live and on-demand experi-
ences for $29.95/month.
• Unlimited Workshops + Digital includes
unlimited in-person and virtual work-
shops. Price varies by ZIP code.
• 1-on-1 Coaching includes one-on-one
support with a coach and access to
digital tools for $59.95/month.
The WW app has close to 2 million
reviews on the Apple App Store with an
average 4.8-star rating. For more infor-
mation on what the WW app offers, visit
weightwatchers.com/us.
Susie says that, for the most part, “digi-
tal cognitive behavioral therapy programs
and components in conjunction with
nutrition education can be effective in
long-term successful adult weight man-
agement. Weight loss apps can work best
with clients who have no history of dis-
ordered eating and who have a need for
accountability and data collection.” But,
she says, because there’s so much inac-
curate weight loss information on social
media, “I think it’s imperative for patients
to work with an RDN.” n
Densie Webb, PhD, RD, is a freelance writer,
editor, and industry consultant based in
Austin, Texas.
For references, view this article on our
website at www.TodaysDietitian.com.
Specialty
Certifications
By Kim Crudele, RDN

D
ietitians know the value of specialized education
and the credentials that come along with it. After
all, they’ve put in countless hours of schooling,
interning, studying, and passing a board-certified
exam to earn the RD/RDN credential.
But why stop there? According to data virtual nutrition practice specializing
from the market research firm Meticu- in health empowerment and sustainable
lous Research, the human nutrition mar- wellness solutions, acquiring additional
ket will grow to a $465.4 billion industry certifications is necessary continu-
by 2025.1 Dietitians are the connectors ing education for dietitians. “Nutri-
between the food and nutrition indus- tion is based on science, and science
try and the consumer, so this predicted is always evolving,” Arnold says. “Con-
growth inherently means greater oppor- tinuing your education through certi-
tunity. The ongoing boom in the health fications helps you to stay on top of the
and wellness industry signifies a mean- latest research and specialize in areas
ingful change in consumer wants and that are most relevant to your work.”
needs (not to mention changes in nutri- In Arnold’s specialty, certifications are
tion and food science). Dietitians keep valuable because “prospective clients are
abreast of these new advances by reading interested in specialized training and
articles and staying current with indus- certifications when they’re researching
try news and research, but nutrition is prospective coaches.”
changing so quickly that sometimes this And because dietitians work in a wide
effort doesn’t seem to be enough. And variety of specialties, certifications will
that’s where certifications come into play. only help the dietetics profession grow.
Certifications give RDs greater visibil-
Why Obtain Additional ity and respect and, in many cases, an
Certifications? increased scope of practice, leading to
According to Kim Arnold, RDN, CSOWM, opportunities beyond traditional RD
founder and owner of Enlitened Nutri- roles. In addition, the process of obtain-
tion, LLC, a Ringoes, New Jersey–based ing additional certifications can help
build complementary skills, be a cost-
effective way to obtain CPEs (some
programs allow you to meet the 75-CPE
requirement in one shot, minus the
required ethics credit), and help give
dietitians the boost they need to meet a
wide variety of career goals.
Importantly, obtaining additional cer-
tifications can boost dietitians’ salaries
as they become more specialized medi-
cal experts. According to the Academy of
Nutrition and Dietetics 2021 Compensa-
tion & Benefits Survey, 24% of RDs/RDNs
have one or more specialty certifications.
The median wage reported for dietitians
holding any type of specialty certification
was $35 per hour compared with $33.17 per
hour for those without a specialty certifica-
tion. Although this was the average, dieti-
tians with a specialty certification have
reported earning up to 19% more than their
colleagues without specialty certifications.
Of the dietitians surveyed, those with a Cer-
tified Specialist in Sports Dietetics (CSSD)
credential reported the highest earnings
at an average of $39.04 per hour, followed
by $37.45 per hour for Certified Diabetes
Care and Education Specialists (CDCESs),
and $37.25 per hour for RDs with a Certified
Specialist in Obesity and Weight Manage-
ment (CSOWM) certification.2
Dietitians have two general routes to
obtaining additional certifications. The
first is through the Academy of Nutri-
tion and Dietetics, which offers several

24  TODAY’S DIETITIAN • JANUARY 2022

Obtaining them
is a strategy
to boost your
career in a
variety of health
care professions.
certification and specialization options
via the Commission on Dietetic Registra-
tion (CDR). Second, dietitians can seek
outside certification programs through
other professional organizations.
CDR Certifications
The CDR offers seven specialty certifica-
tions and an advanced practice certifica-
tion. Each certification requires dietitians to
obtain 2,000 specialty practice hours within
the past five years and then pass a board-
certified exam to obtain the certification.
For most of them, the CDR allows certain
educational and professional experiences
to count toward the required hours, up to a
maximum of 800 hours. Dietitians can earn
75 CPEs for acquiring a specialty certifica-
tion through the CDR. Each certification
requires applicants to have an RD/RDN cre-
dential that has been maintained with the
CDR for at least two years, unless otherwise
noted below. The exam fee is between $350
and $500 for each certification. The certifi-
cations include the following:
• Board Certified Specialist in Pediatric
Nutrition (CSP);
• Board Certified Specialist in Pediatric
Critical Care Nutrition (CSPCC);
• Board Certified Specialist in Renal
Nutrition (CSR);
• Board Certified Specialist in Geronto-
logical Nutrition (CSG);
• Board Certified Specialist in Oncology
Nutrition (CSO);
• Board Certified Specialist in Sports
Dietetics (CSSD);
• Board Certified Specialist in Obesity
and Weight Management (CSOWM),
which is open to credentialed health
professionals other than RDs, as long as
they have been credentialed for at least
two years; and
• Advanced Practitioner Certification in
Clinical Nutrition (RD-AP or RDN-AP),
which requires the RD credential to have
been maintained for at least four years
before certification.
Certifications Through
Outside Organizations
If none of the CDR certifications fit your
niche, there still are ways to pursue con-
tinuing education and obtain additional
credentials. Many professional organi-
zations offer certification options com-
plementary to the dietetics profession.
Acquiring certifications outside of the
CDR presents more options but doesn’t
come with some of the same assurances of
CDR certifications; the CDR is a nationally
26  TODAY’S DIETITIAN • JANUARY 2022
accredited organization recognized as
evidence based, but the same may not hold
true for all organizations offering certifi-
cations, so it’s important for dietitians to
do their research. In addition, credential-
ing and certification programs through
organizations outside of the CDR may be
more expensive and not earn RDs CPEs. (If
dietitians are relying on certifications to
give them credits toward their professional
learning plan requirements, it’s important
to check first with the CDR to make sure
they qualify.)
There are many credentialing options
outside of the CDR, but here are a few that
are popular among dietitians.
If your niche is working with children,
options include the following:
• School Nutrition Specialist (SNS).
Offered through the School Nutrition
Association for professionals working
in school nutrition, this certification
focuses on the skills and knowledge
required to manage school nutrition
programs. The certification is open to
all school nutrition professionals, not
just those who are RDs/RDNs.
• International Board Certified Lactation
Consultant (IBCLC). Calling all mem-
bers of the maternal-child care team,
this certification is offered through
the International Board of Lactation
Consultant Examiners. It focuses on
the skills needed to provide lactation
and breast-feeding care in a variety of
settings. Pediatric nutrition and lacta-
tion consultant Lauren Sams, MS, RD,
CSP, CBS, LD, is the owner of Grow Baby
Nutrition + Lactation and an IBCLC can-
didate based in Waco, Texas. For Sams,
working toward the IBCLC certifica-
tion was a no-brainer. “My specialty is
in neonatology and general infant care.
Because so many babies grow via breast-
feeding, it just made so much sense to
marry the profession of dietetics with
the profession of lactation. I can sup-
port the moms in the process of growing
their babies,” Sams says.
Dietitians who specialize in clinical
nutrition have the following options:
• Certified Nutrition Support Clinician
(CNSC). RDs who like working with
enteral and parenteral nutrition
patients may find the CNSC certification
beneficial. Offered through the National
Board of Nutrition Support Certification
(an independent credentialing board
established by the American Society
for Parenteral and Enteral Nutrition),
this credential encompasses the skills
and knowledge needed to provide
nutrition support care. “The main
benefits I’ve gained through obtaining
my CNSC were increased knowledge and
confidence when speaking with doctors
and nurses,” says Atlanta-based dietitian
Bethany Clement, MS, RDN, LD, CNSC.
Clement also notes that although
dietitians need to pass an exam, there
are no practice hours required for this
certification, which makes it perfect for
those at all levels of experience.
• Certified Diabetes Care and Education
Specialist (CDCES). A CDCES certifica-
tion can be beneficial for any dietitian
interested in diabetes management.
Offered through the Certification
Board for Diabetes Care and Education,
this multidisciplinary certification
focuses on the skills and experiences
necessary to provide comprehensive
diabetes care and education.
RDs focused on sports and fitness have
the following credentialing options out-
side of the CDR:
• National Academy of Sports Medicine
Certified Personal Trainer (NASM-CPT).
There are many routes to becoming a
Certified Personal Trainer, but the cer-
tification offered through the National
Academy of Sports Medicine is worth
exploring. This certification is accred-
ited by the National Commission for
Certifying Agencies, an independent cre-
dentialing agency established in coop-
eration with the federal government and
reflects that the practitioner has been
educated on the scientific principles
behind fitness training. Even if RDs don’t
work directly with clients on fitness
training, this certification will enable
them to make fitness recommendations
to clients with whom they do work.
• Certified Strength and Conditioning
Specialist (CSCS). Offered through the
National Strength and Conditioning
Association, this certification is for
professionals who want to use scien-
tific knowledge to help improve per-
formance in athletes. Danielle Beck,
MS, RD, LD, CSCS, a California-based
dietitian working in private school
nutrition, obtained this certification
because neither her education in nutri-
tion nor her daily duties focused largely
on sports and fitness, an area of dietet-
ics in which she’s interested. “[The CSCS
certification] has helped me establish
 side gigs coaching recreational ath-
letes, as many people want to hire
someone who has both nutrition and
fitness knowledge,” she says.
Dietitians interested in other health
care and food-related certifications can
pursue the following credentials.
• Certified Health Education Specialist
(CHES). If RDs want to provide more
comprehensive health and wellness
education than they can as a dietitian,
this certification will give them the
education they need. Offered through
the National Commission for Health
Education Credentialing, the CHES
certification establishes a national stan-
dard of practice for health education
specialists. The advanced-practice level
for this certification is Master Certified
Health Education Specialist, which has
more stringent eligibility requirements.
• Certified Food Service Professional
(CFSP). Dietitians who work in the food-
service industry may be interested in
the CFSP certification. Offered through
the North American Association of
Food Equipment Manufacturers, this
certification focuses on the skills nec-
essary to run a successful foodservice
operation and raises industry stan-
dards for foodservice professionals by
offering opportunities for continuing
development and advancement. This
certification can give dietitians more
confidence in their knowledge of food-
service, even if they don’t hold the title
of foodservice director.
Take the Leap
Dietitians interested in pursuing addi-
tional credentials but aren’t sure which
to choose due to the wide variety avail-
able at several organizations can begin
by jotting down what area in the dietetics
field interests them most and what type
of continuing education might help them
reach their career goals.
They should ask themselves, “What do I
want my career to look like in the future?”
According to Arnold, “Once you have
decided on that, you can evaluate whether
or not your current training or experience
is adequate in that area. If not, you may
want to pursue additional credentialing.”
RDs can reach out to colleagues they
admire to find out what types of continu-
ing education or certifications have or
haven’t been helpful for them. If fellow
colleagues are working in their area of
nutrition and have one or more additional
Resources
• Commission on Dietetic Registration Certifications: cdrnet.org/certifications/
board-certified-specialist
• Certified Strength and Conditioning Specialist: nsca.com/certification/cscs
• School Nutrition Specialist: schoolnutrition.org/certificate-and-credentialing/
credentialing-program
• International Board Certified Lactation Consultant: iblce.org
• National Academy of Sports Medicine Certified Personal Trainer: nasm.org
• Certified Nutrition Support Clinician: nutritioncare.org/NBNSC/Certification/
Certification_Main_Page
• Certified Diabetes Care and Education Specialist: cbdce.org/become-certified
• Certified Health Education Specialist: nchec.org/health-education-credentialing
•C
 ertified Food Service Professional: nafem.org/cfsp
certifications, chances are obtaining After dietitians get their certifications,
them will increase their credibility and they’ll need to maintain them. Julie Stefanski,
help attract more clients. MEd, RDN, CSSD, LDN, CDCES, FAND,
Nutrition professionals who want owner of Stefanski Nutrition Services in
to pursue an additional certification York, Pennsylvania, says “it’s important
through the CDR should visit its website to look at how the credentialing is main-
to learn how to get started. Most of the tained” before getting a certification. For
CDR certifications have similar require- example, Stefanski says her CSSD certifi-
ments in terms of obtaining and main- cation requires her to take the full exam
taining the certification, and the process every five years for maintenance, while she
of acquiring specialty practice hours maintains her CDCES certification through
followed by an exam is fairly straightfor- continuing education. This is an important
ward. The CDR provides detailed infor- consideration when getting an additional
mation for each certification, including certification because after dietitians put in
content outlines for each exam. the hard work, they’ll want to ensure they
Dietitians in pursuit of certifica- can maintain it long term.
tions outside of the CDR should do some Lastly, before taking steps to earn a
research. Beck says because there are specialty certification, RDs should check
many competing certifications, it’s impor- whether their employers offer education
tant to make sure the certification is well days or stipends to help offset out-of-pocket
established and well regarded before get- costs, especially if the certification is rel-
ting started. “I wanted a certification that evant to their current position. Even if an
was considered the gold standard, or the employer can’t offer assistance, inquir-
best of the best,” she says. “That’s difficult ing at least invites a conversation about
to determine, as different certifications career goals and how dietitians can work
are better suited for certain jobs. However, with the employer to achieve them mov-
the CSCS credential is widely recognized ing forward. Obtaining a specialty certi-
and many athletic organizations regard it fication is a great way to open the door to
as a high-standing credential.” new opportunities, increase one’s nego-
Once RDs have determined the caliber tiating power, and boost visibility of the
and value of the certifications they want dietetics profession, so the sooner dieti-
to pursue, they should contact the issu- tians determine what interests them the
ing organization or visit its website to sooner they can start mapping out their
learn about the eligibility requirements. path to improve the future of dietetics. n
This will give them a roadmap for their
next moves. Typically, dietitians need to Kim Crudele, RDN, is a New Jersey–based
meet certain education and/or experience dietitian specializing in school nutrition and
requirements, obtain and record special- nutrition communications. She’s the owner of
ized practice hours, and then apply to sit Well Balanced RD, where she does school and
for the certifying exam—though some corporate wellness consulting, and a freelance
organizations may do things differently. writer concentrating on food, nutrition, health,
The next step for RDs is to study. Many and agriculture.
organizations offer certification exams
only at certain intervals throughout the For references, view this article on our
year, so jot down the dates and use time website at www.TodaysDietitian.com.
wisely to prepare.
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  27
The Gut-Lung Axis

Today’s Dietitian explores foods
that promote a healthy gut to
maintain healthy lungs.
S ay that the human gut microbiota plays
a role in gastrointestinal (GI) disease,
and that likely wouldn’t come as a
surprise. But what about lung disease?
A growing body of research suggests
that the gut microbiota impacts
pulmonary health and disease through
cross-talk between the gut microbiota and the lungs.
Perhaps Hippocrates was right more than 2,000 years
ago when he said “all disease begins in the gut.”
The American Lung Association estimates that asthma affects
24.8 million Americans and COPD affects 16.4 million, each
accounting for millions of emergency department visits and bil-
lions of dollars in health care costs each year. Lung cancer has
been the leading cause of cancer deaths among men since the
1950s, and for women since 1987—the year it surpassed breast
cancer deaths.1
Long-term impairment (dysbiosis) of the gut microbiota can
aggravate or increase susceptibility to a diverse array of inflam-
matory diseases.2 This includes both acute and chronic lung dis-
eases, such as pneumonia, asthma, tuberculosis, and lung cancer.
It appears that the precise composition of the gut microbiota
may be associated with different lung diseases.3 This is because
the GI tract and the respiratory tract, while composed of sepa-
rate organs, are both parts of a shared mucosal immune system
known as the gut-lung axis, which may serve as a new target for
lung disease treatment.3-5
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  29
By Carrie Dennett, MPH, RDN, CD
Pathophysiology
The gut microbiota plays a key role in
the development and maturation of
the mucosal and systemic immune
systems, as well as in the maintenance
of epithelial barrier function.6 It’s also
an important moderator of immune
responses, including inflammation. While
the exact mechanisms by which the gut
microbiota affects lung health aren’t
fully understood, researchers do know
that immune cells travel from gut to lung
through the mucosal immune system,
so disturbances to immune function at
the gut level due to dysbiosis may affect
immune responses at the lung level.5
More specifically, it appears that com-
mensal bacteria—bacteria that trigger
protective responses from the immune
system that prevent colonization and
invasion by pathogens—can activate a
signaling pathway that modulates mem-
ory B cells in the lungs.3 Memory B cells
are part of the adaptive immune system,
remembering infectious agents encoun-
tered by their parent B cells. If antibod-
ies to a pathogen aren’t present or are at
insufficient levels to block infection by
the pathogen, memory cells help mount
an immune response that’s quicker than
the first time the pathogen was encoun-
tered.7 This plays a role in responses to

COVID-19, but it also affects the response
to lung autoimmune diseases.3,7 More-
over, metabolites of gut bacteria fermen-
tation, including short-chain fatty acids
(SCFAs), can stimulate and promote dif-
ferentiation of T cells, which support anti-
inflammatory and immune-modulating
activity in the lungs.3
Although the gut microbiota gets the
most attention, microbes are present in all
mucosal sites in the body. While the lungs
were long considered to be a sterile envi-
ronment, research in the last several years
has discovered a range of diverse microbial
species in lung samples.8 The gut micro-
biota and the lung microbiota are similar
at the higher phylum level—Bacteroidetes
and Firmicutes predominate in the gut, and
Bacteroidetes, Firmicutes, and Proteobacte-
ria predominate in the lungs—but differ at
the species level.2 The composition of the
gut and lung microbiotas is closely cor-
related across the lifespan, further sug-
gesting a hostwide network. Modifying a
newborn’s diet influences the composition
of its lung microbiota, and rat studies have
found that fecal transplantation leads to
changes in the lung microbiota.9
Researchers now know that the micro-
biotas of the upper and lower respiratory
tracts—with the vocal cords being the
dividing line between the two—act as
gatekeepers to respiratory health, even
though more research is needed to fully
30  TODAY’S DIETITIAN • JANUARY 2022
understand how these micro-
biotas are shaped and how they
function.8 The GI and respira-
tory mucosal tracts share the
same developmental origins and
both have direct contact with
the mouth and pharynx (the part
of the throat behind the mouth
and nasal cavity). And both have
projections—microvilli in the
gut and cilia in the respiratory
tract—that play a role in local
immune function.10
The epithelial surfaces of the
GI tract and the lungs also are
exposed to a variety of microor-
ganisms. Not only can the micro-
organisms that humans ingest
access both the gut and lungs,
but microorganisms from the
oral cavity and GI tract can enter
the lungs through inhalation and
microaspiration, the aspiration
of small droplets of gastric con-
tents into the lungs.4,11
The gut-lung axis is a two-way street, and the lung microbiota
similarly can influence the immune system and gut homeosta-
sis.3 Inflammation in the lungs also can cause changes in gut
microbiota via migrating lymphocytes (a type of white blood cell)
and inflammatory cytokines.5,10
Alterations in both the gut and lung microbiotas have been
observed in many respiratory diseases.2 For example, chronic
lung diseases, including asthma and COPD, often co-occur with
chronic GI diseases, such as inflammatory bowel disease (IBD)
and irritable bowel syndrome.4 In addition, animal studies have
found that pneumonia caused by multidrug-resistant bacteria
can induce intestinal injury, such as lower-than-normal growth
of epithelial cells.12
Linking the Gut to Lung Function
Despite these inroads, understanding of the gut-lung axis is still
somewhat limited, and research on the lung microbiota itself is
in its infancy. But here’s an overview of what’s understood about
some of the major lung diseases.
• Asthma. Asthma is the most common chronic lower respira-
tory tract condition in childhood. Animal studies and clinical
trials have suggested that the gut microbiota plays a cru-
cial role in the development of asthma. The initial infant gut
microbiota comes from the mother and is influenced by the
mode of childbirth, breast-feeding, and antibiotic use, eventu-
ally developing long-term stability around age 2 or 3.3 While
the overall composition of the gut microbiota isn’t altered in
infants who are at high risk of developing asthma, research-
ers have detected subtle temporary changes in certain types
of bacteria in the first few months of life in high-risk infants.4
Intestinal colonization with Clostridium difficile at 1 month of
age has been linked to wheezing and eczema throughout the
first six to seven years of life as well as childhood asthma.13
 NU-ENG-0420-096 Aviso Revista Today's Dietitian Glutapak R.pdf 1

• COPD. Recent evidence suggests the composition of the

gut microbiota changes with age and may affect the
lungs’ immune response. 3 Patients with COPD are two
to three times more likely to be diagnosed with IBD
and typically have increased intestinal permeability,
which promotes chronic inflammation. Smoking is
also the primary risk factor for COPD and increases
the risk of developing Crohn’s disease (one type of IBD)
three-fold.9 However, it’s unclear whether observed
changes in the gut and respiratory microbiota cause, or
are caused by, COPD.4
• COVID-19. Infection with the SARS-CoV-2 virus responsi-
ble for COVID-19 has been shown to disrupt the homeosta-
sis of the gut-lung axis, and COVID-19 patients presenting
with GI symptoms were more likely to also have acute
respiratory distress syndrome.14 PROBIOTIC
• Cystic fibrosis (CF). While CF is different from other lung
diseases in that it has direct manifestations in multiple
organs, research has demonstrated that children who
have had a respiratory exacerbation of CF have a signifi-
cantly different gut microbiota than children with CF who
haven’t had an exacerbation in the first six to 12 months
of life. Research also suggests that the gut microbiota may C

play a larger role in predicting lung health outcomes in CF

Clinically Proven
M
than do airway microbes, especially in early life.15
• Lung cancer. Several studies have found that the composi- Y

tion of the gut microbiota in patients with lung cancer is

significantly different from that of healthy control sub-
CM

MY
to Reduce Diarrhea
jects. Lung cancer patients also have been found to have a
less functional gut microbiota with lower levels of various CY
L-Glutamine
metabolites. However, the direction of causality between CMY • Nutrient that nourishes intestinal cells.
lung cancer and gut microbiota dysbiosis is unclear.3
• Tuberculosis. Chronic infections by the bacterium K
• Helps repair intestinal damage caused
Mycobacterium tuberculosis can be asymptomatic for by illness, infection and stress.
years or even for a lifetime without causing disease.
But this latent tuberculosis infection can progress to • Clinically proven to reduce gastrointestinal
active tuberculosis disease, especially in people with a distress and improve bowel function.
weakened immune system.16 Research has observed that
gut microbiota diversity is altered in tuberculosis patients Lactobacillus reuteri
and that this may correlate with disease progression.2
Patients with type 2 diabetes are more susceptible to • Beneficial SUPERIOR PROBIOTIC
tuberculosis infection and have a three-fold increased that effectively restores intestinal flora.
risk of developing active tuberculosis compared with
people without diabetes. They also tend to have altered gut • Fights off microbes that cause
microbiota composition and altered SCFA levels, which gastrointestinal infections.
research suggests result in alterations of pro- and anti-
inflammatory cytokines that may impair the immune
• Clinically proven to reduce diarrhea
system’s ability to mount a defense against M tuberculosis.17
and restores intestinal balance.
www.victus.com www.Glutapak-R.com
Dietary Interventions
Therapies focused on the gut microbiota for prevention and Follow us on
treatment of GI disorders are far more established than Available at
therapies targeting the gut-lung axis.4 However, improving
the health of the gut microbiota through dietary interven-
tions does have the potential to help protect against lung dis-
eases.3 The assimilation of dietary nutrients by gut microbes
produces metabolites that play significant roles in human
health, influencing the health of other organs through the
lymphatic and circulatory systems.12

JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  31

 For example, a fiber-rich diet can
modify the composition of the gut micro-
biota and increase circulating levels of
SCFAs and has specifically been observed
to reduce airway inflammation in asthma
and COPD.10 Results published in 2020
from a 10-year prospective cohort study
of 35,339 Swedish women found that high
fiber intake from grains and fruit (but not
vegetable sources) was associated with a
30% lower risk of COPD.18
Mary Purdy, MS, RDN, a Seattle-based
adjunct faculty member at Bastyr Univer-
sity and author of The Microbiome Diet
Reset, says dietary fiber is a critical food
source for the gut microbiota, primarily
because the resulting SCFAs play a key
role in protecting the intestinal lining
as well as supporting metabolic health,
immune function, and mental well-being.
“With close to 7 g of fiber per 1/2 cup, intro-
ducing clients to a wide range of beans
and lentils and how to prepare those foods
in creative and tantalizing ways can be an
easy way to up the fiber intake without a
huge change.” She also calls out inulin and
fructooligosaccharides, two types of pre-
biotic fiber found in foods such as onions,
garlic, leeks, maple syrup, bananas, and
asparagus for their demonstrated benefits
in supporting a healthy gut microbiota.
Andrea Hardy, RD, owner of Ignite
Nutrition in Calgary, Alberta, Canada,
says her top food recommendation is
simply to eat more plants, including
fruits and vegetables, pulses, nuts, seeds,
whole grains, and plant proteins such as
tofu and edamame. “There are so many
gut-healthy benefits to including more
plants in your diet, including increasing
your fiber and phytochemical intake
and increasing the diversity of fibers you
have in your diet,” she says, adding that
consuming more plants often displaces
less nutritious and less gut-healthy
foods in the diet.
Purdy says phytochemicals, carot-
enoids, and anthocyanins in particular—
which are found in bright-colored fruits
and vegetables—are good for the gut.
“Higher intake of these has been shown to
both stimulate beneficial bacteria while
inhibiting the growth of more pathogenic
bacteria,” she says.19,20
Hardy recommends including fer-
mented foods, especially because of
recent research suggesting that increas-
ing intake of fermented foods not
only improves the diversity of the gut
32  TODAY’S DIETITIAN • JANUARY 2022
microbiota but also is associated with a reduction in inflamma-
tory markers.21,22 “I like to tell my patients to ‘eat something living
every day,’ including foods like yogurt, kefir, kimchi, and sauer-
kraut, to name a few.”
It’s one thing for patients who are already eating a balanced,
nutritious diet to make a few tweaks, but what about dietitians
working with clients who have been eating a gut-unfriendly diet?
Hardy and Purdy suggest a few strategies for moving the needle
in a more healthful direction.
“It’s really all about getting back to basics,” Hardy says. “Swap-
ping out your refined carbohydrates for whole grains, cooking with
pulses (beans, peas, lentils) at least once a week—for example doing
a ‘meatless Monday,’ and ensuring your main meals are including
lots of vegetables—aiming for that half a plate is a simple target.”
Purdy says many patients don’t fully understand or appreciate
the significant role their gut microbiome has in influencing many
aspects of their health, so education can be a great first step.
“As always, it’s important to meet patients where they’re at,” she
says. “It’s usually easier to begin with adding in some of the gut-
supportive foods before advising around foods to take out. Most
individuals are low in fiber and fruits and vegetables, so even just
adding in an extra serving each day (or whatever that patient is
able to take on) can be a great starting point.”
Dietary changes have been shown to alter the gut microbiota
at the species and family level within 24 to 48 hours,23 but Purdy
says this doesn’t mean larger systemic imbalances in the body
will be resolved in that amount of time. “Dietary changes that are
sustainable are essential,” she says. “It’s about a consistent intake
of microbiome-supportive foods that’s going to make a long-last-
ing difference in gut health.”
When suggesting gut-friendly dietary changes to clients,
Hardy suggests choosing a “Goldilocks” habit change—one that’s
not too hard, but not too easy. “Start with one thing your patient
can work towards building into their everyday lives. From there,
you can build on more and more habits over time,” she says. “It’s
all about small, meaningful changes and ensuring what we’re
suggesting to patients is doable and can fit into their lives, other-
wise we know it won’t be sustainable.”
Of course, diet isn’t the only lifestyle factor that can affect gut
health and possibly our lung health. Purdy says stress is a big factor
when considering gut health. “Chronically high levels of cortisol can
negatively affect the makeup of the gut microbiome by reducing the
production of short-chain fatty acids and negatively affecting the
tight junctions, leading to a higher risk of intestinal permeability,
which can have numerous health implications.” She also says that
getting enough quality sleep is associated with a more diverse gut
population, and that physical activity has been shown to favorably
alter the gut microbial composition independent of dietary habits.
“Diving into stress management, sleep hygiene, and exercise with a
patient is a key part of the gut microbiome conversation. In fact, this
may be a super realistic place to start.” n
Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle
Times, owner of Nutrition by Carrie, and author of Healthy for Your Life:
A Holistic Guide to Optimal Wellness.
For references, view this article on our
website at www.TodaysDietitian.com.
 C O N F E RE N C E
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MEAL
PLANNING
SOFTWARE
Learn about the latest time-saving,
revenue-generating teaching tools for RDs.
By Laura Ali, MS, RDN, LDN

W
hen it comes to meal planning, most While a static meal plan may give
someone an idea of where to start, it
dietitians cringe when a client says, rarely works long term and often just
“Just give me a meal plan, and I’ll be leads to frustration and nonadherence.
They’re rarely customized and don’t teach
fine.” As food and nutrition educators,
patients the skills they need to success-
dietitians know the importance of fully plan their meals.
teaching clients the skills they need to Research has shown that meal planning
not only facilitates weight loss but also
manage their health. Most RDs consider meal planning one improves overall diet quality. A large
of those essential skills. This article reviews the importance study involving the general population in
France found that meal planning resulted
of meal planning as well as challenges associated with in both weight loss and better adherence
it, and provides an overview of some of the online tools to French dietary guidelines. Participants
who planned their meals also reported an
available for RDs to assist clients with meal planning. increased consumption of a variety of foods.1
In addition, a recent study by Jacqueline
Why Is Meal Planning Important? exercise program, and adopt a new way Hayes, PhD, and her team at the Weight
Clients easily can become overwhelmed of eating. While physicians are becoming Control and Diabetes Research Center at
when facing a new diagnosis of a serious much more in tune with the role nutrition The Miriam Hospital in Providence, Rhode
health condition. Suddenly they’re faced plays in disease management, many doc- Island, found that individuals who planned
with learning about their illness and jug- tor’s offices still hand out preprinted meal meals more frequently throughout their
gling a new routine. They may have to plans as part of the treatment package but program experienced greater weight loss.
take a variety of medications, begin an with no patient education. And those who were taught meal planning

34  TODAY’S DIETITIAN • JANUARY 2022

skills early in the program planned more
often and lost more weight.2
Whether clients want to lose weight,
manage a serious health condition, or eat
more healthfully, learning how to plan
meals is a beneficial life skill.
Challenges and Available Solutions
for Meal Planning
For RDs working with a variety of clients,
developing individualized meal plans is
a time-consuming part of their practice.
Selecting recipes, helping clients create
shopping lists, and teaching them basic culi-
nary skills adds to the process, cutting into
RDs’ time and ultimately their bottom line.
Understanding the needs of dietitians,
several companies have developed digital
software programs that either have stan-
dard meal plans for purchase or individu-
alized planning options RDs and clients
can use to create menus and download
recipes, shopping lists, and nutrition edu-
cation materials. Many programs offer
interactive apps to help clients with goal
setting, food logging, digital shopping
lists, and messaging. These programs save
RDs time and increase patient compli-
ance. The software companies report that
professionals who use their programs save
anywhere from 70% to 90% of the time it
would take to create a meal plan.
Research supports the benefits of using
a digital meal planning system. An obser-
vational study in the Journal of Medical
Internet Research followed approximately
9,000 people with obesity using a digital
food planning program. The program pro-
vided personalized nutrition recommen-
dations, recipe and meal suggestions, the
ability to order groceries online, and meal
kits. The study found that when used for
at least 24 months, one-third achieved at
least a 5% weight loss.3
Many RDs who use these programs
say that no matter which one they chose,
they not only save time but also add a
greater level of professionalism to their
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  35
service. While many of the programs
include the same features, the format,
services available, and options vary
(see table on page 37). What follows is a
summary of some of the meal planning
software programs on the market, their
general features, and costs.
Living Plate Rx
Living Plate Rx is a meal planning and
nutrition education company developed
by Jeanne Petrucci, MS, RDN. It focuses on
combining meal planning with culinary
and nutrition education to support long-
term behavior change.
The company offers RDs two member-
ship options for its meal planning pro-
grams. The free version, Living Plate Rx,
gives professionals access to the basic
meal planning platform. Clients then pay
a monthly subscription fee for access and
the health care professional receives a 30%
commission. The free version is a good
way for RDs to begin using the system if
they have only a few clients or don’t focus
on one-on-one nutrition counseling.
While using the free version also is a good
way to try the program, RDs miss out on
the more dynamic features.
Living Plate Rx Prime is the paid mem-
bership that costs $499 per year or $49
per month. The Prime membership gives
dietitians more functionality, the ability to
add an unlimited number of clients, and
in addition to having access to the preset
meal plans, they can develop their own or
“signature” meal plans they can store and
use again. Prime membership also enables
RDs to include a branded landing page for
their websites and provides access to a full
library of nutrition education resources.
Some unique features of this program
are the customizable blog posts, e-books,
courses with lesson plans and slide decks,
handouts, social media calendars, and
cooking videos RDs can use on their plat-
forms. The company currently is develop-
ing an interactive app.
The free version of Living Plate Rx
offers 21 base meal plans. It also part-
ners with a variety of companies to offer
recipes and includes 11 additional part-
ner-generated meal plans from those
companies. Chefs and dietitians develop
all of the recipes in the Living Plate sys-
tem, which are tied to specific meal plans.
All recipes come with complete nutrition
analyses that use the USDA database. In
addition, RDs can adjust the recipes for
portion size, and because the program
works in real time, nutrition analyses
automatically adjust to the changes.
Once an RD completes a meal plan,
they send the client a link to the plan that
includes recipes and a shopping list. Dieti-
tians can add notes and make suggestions
within the plan. What’s more, RDs and cli-
ents can swap meals with a drag and drop
feature. Dietitians also can set up a “favor-
ites” list of recipes for themselves and cli-
ents to facilitate the search function.
Lisa Mitchell, RDN, LD, from Style Your
Diet, a nutrition and health coaching
business in Danbury, Texas, says, “You get
so many networking opportunities, and
you get information on various resources
for dietitians that I wouldn’t necessarily
know about without being a member of
Living Plate Rx Prime.”
The masterclass video tutorials help
maximize RDs’ free or paid memberships,
enabling them to use all the features and
join in on the weekly programs and ses-
sions offered in the Facebook group. All
36  TODAY’S DIETITIAN • JANUARY 2022
members, including RDs who have a free
membership, can join the affiliate pro-
gram, which provides a monetary reward
for referring others to the program.
EatLove PRO
EatLove PRO is a San Francisco–based
digital technology group that offers an
online meal planning system specifi-
cally designed for dietitians. The system
enables RDs to provide personalized meal
plans for clients based on their individual
nutritional needs, preferences, cooking
skills, and the number of meals per day.
RDs can track clients’ progress and com-
municate directly with them in between
appointments through the system. The
group has two RDs on staff; more than
6,000 recipes sourced from cookbook
authors, chefs, and dietitians; and an in-
house recipe development team.
A limited free trial of EatLove PRO is
available. However, to access all the fea-
tures, the cost is $54 per month for the
starter package, which is billed annually.
Plans also are available for group practices.
Some standout features include the
ability to add restaurant meals as part
of meal planning. Restaurants that offer
more healthful choices have menu items
included. EatLove PRO also works with
a couple of grocery delivery services,
including Instacart, so clients can upload
grocery lists and arrange to have their
groceries delivered. Mary-Catherine
LaBossiere, MPH, RD, LDN, owner of Defy
Nutrition in Clarksville, Tennessee, says,
that along with the user-friendliness of
the program, the ability to synchronize
with grocery delivery services is a bonus
for busy clients. This is a unique service,
and research has shown that delivery of
healthful foods may be a good strategy for
improving health outcomes.3
To generate meal plans, RDs enter
nutrition data and their clients’ health
and personal information. In addition,
RDs can adjust the meal plans based on
cooking skills and desired meal prep time.
EatLove PRO also has a secure HIPAA-
compliant messaging platform that
enables dietitians to engage with clients in
between appointments and monitor their
progress on the plan.
Clients can download a free app on
their smartphones to gain access to their
personal meal plans, grocery lists, and a
food logging feature on the go. The app
contains a barcode scanner, making it
easy for clients to add foods to their log.
Ashley Larsen, RDN, owner of Ashley
Larsen Nutrition Consulting, in Fresno,
California, uses the EatLove program and
says she enjoys the flexibility it provides
and the interaction she has with clients in
between counseling sessions.
“The program also provides me a
deeper look into my client’s nutrition
habits with access to their food, exercise,
and weight logs. When we come together
for our sessions, I like to provide encour-
agement and constructive feedback on
what I’m seeing in their logs to help them
develop future goals.”
That Clean Life
Abigail Keeso Hopkins, RN, an Ontario,
Canada–based nurse, and her husband,
started the meal planning software sys-
tem That Clean Life in 2014. Her goal was
to make healthful eating simple. They
began publishing e-books of meal plans,
which evolved into the meal planning
system it is today. Membership costs for
the program is $60 per month or $600 per
year. The annual membership fee gives
RDs access to a three-week “Business
Accelerator Course” that reviews how to
best use the program to grow their busi-
nesses and includes many ideas to create
services and passive income streams,
such as creating brandable content they
can sell on their personal platforms for
additional income.
The meal planning database offers
more than 70 different customizable meal
plans that are diet and health condition
specific. Some of the diets include low-
FODMAP, diabetes, allergen-free, and a
variety of plant-based and popular weight
loss plans, such as the ketogenic diet. All
meal plans include daily nutrition totals
and nutrient breakdowns, such as macro
percentages and key nutrient totals (eg,
sodium, fiber).
The program isn’t interactive like
many of the others. Its purpose is to
enable RDs and other health care provid-
ers to create branded, customized meal
plans along with recipe books, meal prep
guides, and shopping lists to e-mail to
clients. The company currently is work-
ing on a more interactive version to be
released soon.
The database includes more than 2,000
recipes that in-house recipe develop-
ers and RDs created. Currently, the staff
is focusing on adding more culturally
diverse recipes to the database, enabling
RDs to adjust recipes by adding and
MEAL PLANNING SOFTWARE PROGRAMS FOR RDs
LIVING PLATE RX EATLOVE PRO THAT CLEAN LIFE MEAL GARDEN

Company Website livingplaterx.com eatlove.is/pro thatcleanlife.com mealgarden.com

Number 32 Automatically generated 70+ 600

of Meal Plans based on nutrition data,
Prime members can create cooking skill level, and
additional “signature” plans cooking time

Number Figure not available 6,000+ 2,000+ 7,000+ (2,500 have been
of Recipes reviewed by health
professionals)

Recipe Sources Staff RDs, chefs, and partner Cookbook authors, chefs, In-house recipe developers Community of users
programs RDs, and an in-house team and RDs
Some recipes have been
tested and reviewed by the
creative team.

Recipe Search Recipes are easy to search but
are tied to specific meal plans, so
not all are accessible for every
meal plan.
Search recipes by meal
type, cook time, nutrition
targets, and ingredient.
Search recipes by ingredient,
prep time and cook time, tags,
and nutrients.
Search recipes by ingredient
and nutrient. Curate recipe
collections to share with
clients, so they see only what
you want them to.

Ability to Add With Prime membership Yes Yes Yes

Recipes

Shopping List Yes Yes Yes Yes

Ability to Show/ Yes Yes Yes Yes

Hide Nutrition Data

Client Interaction Yes Yes No Yes

Encouraged
Company is working on a mobile
app that will give clients access
to meal plans and shopping lists.
Program has food logging
functionality. Clients can
swap recipes, access a
messaging system, and use
a mobile app.
RDs assemble a PDF including
recipes, shopping lists, and
prep guides, and e-mail it to
clients. Company is working on
an interactive component.
Clients can use a secure app
with an encrypted messaging
system, and access meal plans,
recipes, and shopping lists.

Ability to Yes Yes Yes Yes

Customize and
Brand Materials

Additional Yes No Yes Yes

Education
Available with Prime member-
Materials ship: complete lesson plans and
courses, handouts, customiz-
able blog posts, e-books,
business tools, social media
posts, and videos.
Program is based on meal
plans and recipes. RDs can
add additional recommen-
dations, and the messaging
system allows for
interactive coaching.
Recipe driven; RDs can
print recipe books and meal
plans, import their own
recipes, and create handouts.
Program includes a
document hub to add
additional education
materials for use and
embed videos and articles.

Price Free membership gives RDs
access to the basic meal
planning platform and can pay
as they go to use added
features. Clients pay subscrip-
tions starting at $9/month, and
RDs make a 30% commission.
Various packages are $60/month or $600/year $30 per month, unlimited
available. Free membership clients, and can cancel
(limited functionality). For at any time.
the starter package, paid
membership up to $54/
month billed annually.

Prime membership is $499/year

or $49/month.

Customer Support • Facebook group with frequent • FAQ section • Advanced training available • Online support available
live sessions • Business strategy calls • Coaching sessions • 24-hour response time
• Responsive e-mail and web • Facebook group • Online support available • FAQ section is limited
support • Responsive customer • Response time is a few hours • Facebook group
• Masterclass with thorough support • Facebook group
video lessons

SOURCE: THIS CHART REPRESENTS ONLY A SAMPLE OF THE MANY MEAL PLANNING PROGRAMS DESIGNED FOR RDS.

JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  37

deleting ingredients and save them as new
recipes to their personal recipe box for
future use. Dietitians also can add their
own recipes to their personal recipe box.
Mandy Enright, MS, RDN, RYT, the
FOOD + MOVEMENT Dietitian and author
of 30-Minute Weight Loss Cookbook: 100+
Quick and Easy Recipes for Sustainable
Weight Loss, says she likes “the flexibility
around creating daily meal plans, the abil-
ity to edit preexisting recipes, create a gro-
cery list, and add my own recipes. I [can]
easily import my own recipes from my blog
into That Clean Life to add to meal plans,
which [is] a huge timesaver and win. Plus,
I love how easy That Clean Life makes it
to create professional-looking meal plans,
recipe books, and handouts.”
Moreover, there are other ways to use
this program beyond developing person-
alized meal plans. RDs can customize
and brand meal plans, recipe books, and
all the handouts they create. And with
the abundant recipe database, it’s easy to
assemble recipe books and create hand-
outs for your practice, group classes, semi-
nars, and health fairs.
Other perks: RDs can apply to become a
“partner” through its affiliate program and
receive a 30% commission on meal plan-
ning program sales to other RDs. They also
can attend webinars and CE events, and, as
mentioned, sign up for the business accel-
erator course with annual membership.
Meal Garden
Meal Garden is a meal planning program
designed for health care practitioners and
consumers so they, too, can develop meal
plans and use them when needed. The cost
of the program is $30 per month. RDs can
work with an unlimited number of clients
and aren’t locked into an annual contract.
The database includes more than 7,000
recipes and 600 premade, customizable
meal plans. The recipes include those devel-
oped by the company and those submit-
ted by the community of users. Similar to
other programs, RDs can search recipes by
type of meal, cooking time, ingredients to
include or exclude, and specific nutrients.
The program has a drag and drop
function to add and delete menu items to
and from meal plans and automatically
generates shopping lists. RDs can add
prep instructions to the meal plans and
include or hide nutrient analyses and diet
goals for clients.
Clients also have a fair amount of con-
trol over their meal plans. Once signed
38  TODAY’S DIETITIAN • JANUARY 2022
in to the system, clients can access their
meal plans, recommendations, notes, and
recipe collections. They can alter the reci-
pes and make ingredient or menu item
swaps dietitians can see on their end. RDs
can embed video tutorials into the meal
plan as well as articles and other mate-
rials that can enhance the plan or help
explain their health condition.
A unique feature of the Meal Garden
program is its “health rating” system.
Using a red, yellow, or green leaf, recipes
are rated according to their healthful-
ness. It uses a proprietary system that
evaluates a food or ingredient based on
how it may contribute to chronic ill-
nesses such as heart disease and diabe-
tes. The more fruits, vegetables, whole
grains, and healthful fats a recipe con-
tains, the “greener” the recipe. However,
dietitians can modify meals and recipes
to adjust the rating.
Moreover, RDs can personalize and
brand meal plans and recipes by adding
the logos, fonts, and colors associated with
their nutrition business. They can share
meal plans over social media or in their
e-newsletters to promote their services
and build their audience and client base.
Other features include access to a blog,
a weekly e-newsletter with tips on how to
use the program to enhance their busi-
ness, and a recently launched affiliate
program that enables dietitians to earn
additional income through referrals.
Considerations When
Choosing a System
As with any business investment, there
are several things to consider when
evaluating meal planning programs.
RDs should think about how they’ll use
the program and how often. They should
find out whether there are other features
available beyond one-on-one meal plan-
ning, what their clients need, how much
interaction the program offers, and most
importantly, how accessible customer
support is. It’s a good idea to speak with
other RDs about their experiences using
these programs to get a feel for what may
be best for their business.
In addition to customer support,
LaBossiere says cost is a huge factor to
consider. And dietitians should review the
terms and conditions of each program
before signing up so they fully under-
stand what program information they can
share publicly and how long they retain
the rights to share that information. For
example, a paid membership with Liv-
ing Plate Rx Prime will enable dietitians
to share its blog posts, social media posts,
handouts, and programs with their audi-
ence. If dietitians end their membership,
however, they’re expected to remove all
Living Plate Rx material from their web-
sites and social media accounts. Other
programs may have additional rules and
requirements regarding their information,
so it’s important to read the fine print.
Jen Hernandez, RDN, CSR, LDN,
founder of Plant-Powered Kidneys, a renal
nutrition services company, suggests giv-
ing the program a test run before signing
up and discussing it with clients. “If it’s
not something you’re familiar with, it will
be incredibly hard to discuss it or even
encourage it for your clients.”
Bottom Line
Meal planning software programs can
save much time and energy, as dieti-
tians can spend less time developing
individual meal plans, see more clients,
and offer professional, branded con-
tent. Many of the systems are interac-
tive and encourage client engagement
and education. All the programs provide
more static, predesigned meal plans for
clients who want something simple to
follow and start them on their health-
ful diet and nutrition journeys. Most
systems offer opportunities to generate
additional revenue and passive income
and use tools to attract more clients and
e-mail signups. Many features these pro-
grams offer are similar, though some are
unique, possibly making one plan bet-
ter for some dietitians over others. Like
many digital platforms, meal planning
software programs are continually being
revised and updated. RDs should use
this article as a guide to choose among
the many programs available and inves-
tigate the options that may work best for
their practice. n
Laura Ali, MS, RDN, LDN, is a culinary
nutritionist and food and nutrition
communications consultant. She works with
consumers and health-focused companies to
develop simple, delicious ways to incorporate
healthful foods into everyday meals. Follow
her on Instagram and Twitter @LauraAli_RD
and her blog at lauramali.com.
For references, view this article on our
website at www.TodaysDietitian.com.
WATCH
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Continuing education is no exception and webinars have become one of the most popular platforms today
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INTERACTIVE
Our platform allows attendees of our live webinars to ask
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and which recorded webinars you’d like to watch and learn from.
BY KC WRIGHT, MS, RDN

B
eyond the human and environmental health merits of the broad spectrum of psychoactive
plant chemicals—opium, a sedative; caf-
of plant-based eating, certain plants also contain feine, a stimulant; and mescaline, a hal-
lucinogen—and links their composition
psychoactive compounds that, when consumed, fit to human consciousness. In the book, he
precisely into receptors in the brain and can alter reflects on how plant compounds can help
people identify their deepest human needs
our consciousness. Some of these plant chemicals and aspirations, the operations of their
have made a significant revival, such as psychedelic minds, and their entanglement with the
natural world.
agents, once considered illicit mind-expanding drugs of the 1960s Pollan began his illustrious career as a
garden writer, based on his practices as a
counterculture. This article considers the historical use and botany of home gardener learning about the sym-
psychoactive plants, recent research initiatives, the risks and benefits biotic relationship between plants and
people. He considers plants to be tools of
associated with their increased mainstream use, and what this may nature that, when crossed with intellec-
tual curiosity and human ingenuity, give
mean in the context of dietetics practice and when counseling clients. us the opportunity to change our con-
sciousness. But why do plants have these
In his latest book, This Is Your Mind on self-experimentation. The book title is a molecules that can change the minds of
Plants, Michael Pollan, a notable author; riff on the 1980s war on drugs campaign animals? According to Pollan, “You have
professor at the University of California, commercial called “This Is Your Brain on to wonder: what’s in it for the plants to
Berkeley’s Graduate School of Journalism; Drugs,” showing someone cracking open a devise and manufacture molecules that
and professor of the practice of nonfic- fresh egg and dropping it into an extremely can pass for human neurotransmitters
tion at Harvard, details his inquisition of hot frying pan to sizzle and burn. and affect us in such profound ways?”
drugs, plants, and humans through his Pollan bases his book on three of the Psychoactive compounds within plants
passion for gardening and engagement in compounds that comprise each category have evolved by deterring both pathogens

40  TODAY’S DIETITIAN • JANUARY 2022

What RDs Need
to Know About
Their Effects on
Human Health
and Behavior
and predators, while these same chemi-
cals can affect the brains and mental
states of humans who ingest them. Defen-
sive secondary metabolites of plants
include some well-known psychoactive
compounds such as caffeine, nicotine,
cocaine, and morphine. Psychoactive sub-
stances act on the nervous system, affect-
ing mental processes and behavior; for
example, hallucinogens can distort reality,
sedatives can induce calm or sleep, and
stimulants can wake the mind.1 Pollan
suggests that once humans realized the
effect some plants can have, they began to
expand their habitat and exploit them.
It’s well understood that most drugs
come from plants. Plants produce alka-
loids, bitter-tasting compounds meant to
discourage pests from eating them, and
if pests persist, the molecules can poison
them. Plant alkaloids include potent phar-
macologic drugs such as caffeine, mor-
phine, and mescaline. These molecules offer
humans the capability to boost alertness
and attention, relieve pain, and stimulate
the imagination, and perhaps much more
will be determined as research progresses.
RDs will need to have insight on these com-
pounds and their impact on human health,
especially since easing legal restrictions
for some of them may make their use more
commonplace among clients and patients.
Background
Fifty years ago, the United States took a
harsh approach to drug use and addiction
by implementing the most severe policies
and penalties. Yet in 2011, the Global Com-
mission on Drug Policy released a critical
report stating that “the war on drugs has
failed, with devastating consequences
for individuals and societies around the
world.”2 Pollan asserts that society has
taken a simplistic account of drugs, lump-
ing them all together, which has barred
people from objective consideration for
potential physical and mental health uses
of different substances.
Ironically, two of the most addictive
plant psychoactive compounds—etha-
nol in alcoholic beverages and nicotine in
tobacco—are legal drugs, with the latter
being the leading cause of preventable
death.3 When a person smokes a cigarette,
nicotine reaches the brain within seven
seconds, activating several neurotrans-
mitters, some of which initiate pleasure,
suppress appetite, or reduce tension and
anxiety. While nicotine plays the addictive
role in tobacco, it’s the complex mixture of
chemicals produced by burning tobacco
42  TODAY’S DIETITIAN • JANUARY 2022
and its additives that lead to cancer, heart been used as a painkiller for thousands of
disease, and other illnesses. years. It’s composed of elaborate mole-
The fermentation of plant sugars or cules nearly identical to the molecules the
starches produce ethanol, a central ner- human brain produces to confront pain
vous system (CNS) depressant that reduces and compensate itself with pleasure. It’s
overall brain activity. Drinking alcohol extracted from the common poppy flow-
stimulates the release of dopamine and ering plant, Papaver somniferum, and is
endorphins that produce feelings of plea- the key source for many narcotics, includ-
sure and satisfaction. Alcohol abuse can ing morphine, codeine, and heroin.
negatively affect the brain, heart, liver, P somniferum plants make poppy
pancreas, and immune system, while seeds that are legal and widely available
increasing the risk of certain cancers. from many seed catalogues. Poppies are
thought to be native to the Mediterra-
Opium nean, as the Greeks and Romans have
As mentioned, opium is one of the com- cultivated them for thousands of years.
pounds within the broad spectrum of Poppies thrive in temperate climates but
psychoactive plant chemicals. Opium has also can be grown in tropical regions.
PRACTICE PEARLS
In today’s global society, diverse populations from a wide range of genetic and cultural
backgrounds integrate throughout the world and into the practices of dietitians.
The following tips may be helpful when consulting with clients and patients who may
be using psychoactive compounds—with or without medical supervision.
• Treat clients and patients as whole beings, emphasizing the benefits of nutrition for
mind and body.
• Avoid stigmatizing addiction. It’s an illness that requires therapeutic treatment.
• Plant psychoactives can be both allies and poisons. As Michael Pollan, author of
This Is Your Mind on Plants, suggests, it’s up to humans to have a healthy
relationship with them.
• Practice cutting out caffeine for a week or month to understand what it’s like to
experience caffeine withdrawal.
• Share knowledge of sources of caffeine in food and beverages.
• The FDA considers 400 mg caffeine, equivalent to about four or five measured cups
of brewed coffee, to be a safe amount for healthy adults to consume daily. Pregnant
women should limit their caffeine intake to less than 300 mg daily, or about two to
three cups of coffee, according to the 2020–2025 Dietary Guidelines for Americans.
• The American Academy of Pediatrics recommends that children under age 12 not
consume any food or beverage containing caffeine. In children aged 12 and up,
caffeine should be limited to no more than 100 mg daily, the amount in two 12-oz
cans of cola soda.
• Caffeine also may be added to analgesics to provide faster and more effective relief.
Consider also that caffeine can interact with various medications.
• Evaluate new, opportunistic products on the market, such as Psychedelic Water, for
purity, safety, and efficacy.
— KCW
 In 1996, there were about 4,700 deaths
from overdose on any drug. That same
year, Purdue Pharma launched and
marketed OxyContin (a synthetic opioid
drug derived from the poppy plant) to
physicians as safer and less addictive
than other opiates, stating that it could
benefit cancer and surgery patients as
well as those suffering from arthritis,
back pain, and workplace injuries.
Through OxyContin prescriptions,
thousands of people became addicted
to opioids, eventually turning to the
underground when they could no longer
get or afford a prescription.4 As a result,
the number of opioid overdose deaths
has quadrupled since 1999; there were
around 50,000 deaths in 2019 alone.5
Pollan claims that during his formative
years, the war on drugs made him fearful
of engaging with any illicit plants, but he
reveals he eventually experimented with
growing opium poppy in his Connecticut
garden 25 years ago. He notes that it’s legal
to buy poppy seeds and grow the flowers,
but if you tried to extract opium from it,
that would be illegal.
According to Pollan, whether poppy
seed pods are grown or purchased,
fresh or dried, they contain significant
quantities of morphine, codeine, and
thebaine, three of the principal alkaloids
found in opium. Back then, he had
written an essay for Harper’s Magazine
called “Opium Made Easy,” but deleted
the recipe he used to make opium as
well as his experience after ingesting
it. This self-censorship resulted from
consultation with lawyers and facing
both the risk of arrest and confiscation
of his house, something he wasn’t
willing to gamble as a young husband
and father. This Is Your Mind on Plants
includes the omitted sections of this
essay due to less risk with transitioning
legal and societal views on drugs.
To that point, in February 2021, Oregon
passed a law to reflect a measure its citi-
zens overwhelmingly voted on to make
possession of small amounts of cocaine,
opioids, LSD, and methamphetamine,
among other drugs, punishable by a civil
citation, similar to a parking ticket, and a
$100 fine (waived with a health screening
by an addiction recovery center).6 As the
war on drugs is now widely recognized as
a failure, Pollan notes that the opioid crisis
has stamped a stigma on the opium flower
and its medicinal properties. “What is
true for the opium poppy is true for all
medicines that plants have given us: they
are both allies and poisons at once, which
means it’s up to us to devise a healthy rela-
tionship with them,” he says.
Caffeine
Most dietitians reading this article regu-
larly ingest the psychoactive plant com-
pound 1,3,7-trimethylxanthine—that is,
caffeine. Worldwide, it’s the most widely
consumed stimulant, and it acts on the
CNS to increase alertness and energy
levels.7 People consume caffeine in many
forms, most often as species within the
genus Coffea (predominantly Coffea ara-
bica) and as the Camellia sinensis plant,
commonly known as coffee and tea, respec-
tively. Pollan traces coffee consumption
back to 15th-century Africa, followed by
the population of coffeehouses in the Arab
world before its introduction into Europe
during the 17th century that appeared to
foster the Age of Enlightenment.
Coffea species are woody shrubs in
the Rubiaceae family, native to the for-
est understory of the East African high-
lands. Although it’s grown in many rainy,
warm climates of the world, the majority
of coffee now is cultivated in South and
Central America, with Brazil being the
largest producer.
Tea was first cultivated in China
thousands of years ago by monks who
believed it was an important aid to
meditation. C sinensis is a species of
evergreen shrubs or small trees in the
flowering plant family Theaceae, whose
leaves and buds are used to produce
white, yellow, green, oolong, or black
tea. Tea is cultivated mainly in tropical
climates with significant annual rainfall
such as in India, Nepal, and China, as
well as in parts of the United Kingdom
mainland as clonal plants.
Pollan explains how caffeine serves
plants as a pesticide, designed to keep
other plants from growing around cof-
fee and tea bushes. Meanwhile, bees are
attracted to a plant’s nectar where they
procure a small dose of caffeine that
reminds them which plant to return to for
more food. In essence, the plant trains the
bees to pollinate them.
Pollan analogizes that, like bees,
humans become trained to consume
caffeine, which helps improve memory
and makes them work harder and more
attentively. He says caffeine mainly func-
tions as a “tiny molecule that happens to
fit snugly into an important receptor in
the CNS,” blocking the neuromodulator
adenosine, a psychoactive compound that
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  43
has a depressive and sleep-inducing effect
on the brain when bound to its receptor.
Caffeine inhabits adenosine’s receptor
sites, increasing levels of adenosine in the
brain. After the liver removes the caffeine
from circulation (as long as 10 hours post
absorption), the concentrate of adenosine
rebounds with its chemical action on the
brain, leaving one feeling tired and per-
haps sluggish. In response, most people
consume more caffeine, demonstrating
the common human dependence on this
plant psychoactive.
Caffeine withdrawal and caffeine use
disorder are recognized in the Diagnostic
and Statistical Manual of Mental
Disorders, 5th Edition, as conditions for
which further research is encouraged.8
As an adenosine receptor antagonist,
caffeine activates the release of mainly
excitatory transmitters, including
dopamine, commonly seen in drugs of
abuse. Caffeine also is a vasodilator and
can be mildly diuretic. It temporarily
raises blood pressure and relaxes the
body’s smooth muscles, which may
account for its laxative effect.4
On average, US adults consume 11/2
8-oz cups of coffee daily, which contains
135 mg caffeine. Many sodas contain caf-
feine, as do energy drinks, some of which
have 200 mg or more of caffeine per serv-
ing. Chocolate contains caffeine, with the
highest percentage of cocoa having the
greatest amount of caffeine (eg, 25 mg/oz
for dark chocolate with 70% cocoa solids).
Caffeine is quickly absorbed into the
bloodstream, peaking within 15 min-
utes to two hours after ingestion. Food
and nutrients consumed simultaneously
can delay caffeine absorption. Heredity
explains some of the differences in the
effect caffeine can have among different
people, while regular consumption can
promote tolerance. A 1-g dose of caffeine
can cause restlessness, irritability, ner-
vousness, rapid heart rate, and tremors.9
Consuming 1.2 g or more of caffeine in
one dose can be toxic, causing vomiting
and convulsions, while a 10 to 14 g dose
can be fatal. It would take about 100 cups
of brewed coffee to equal 10 g of caffeine;
toxic levels more often are due to caffeine
pills or tablets.10
Over the decades, research has demon-
strated both the health benefits and haz-
ards of consuming caffeine. More recently,
an umbrella review of the evidence across
meta-analyses of observational studies
and randomized controlled trials showed
that coffee (when not consumed in excess)
was associated with a probable decreased
risk of breast, colorectal, colon, endo-
metrial, and prostate cancers; CVD and
mortality; Parkinson’s disease; and type 2
diabetes, while caffeine itself was associ-
ated with probable decreased risk of Par-
kinson’s disease and type 2 diabetes, but
an increased risk of pregnancy loss.11 Sleep
experts Pollan consulted (each of whom
stated they avoid caffeine) explained how
caffeine compromises quantity and qual-
ity of sleep. RDs can assess patients’ level
of caffeine consumption to determine
whether it may affect their health status.
Psychedelics
In 1938, while investigating new phar-
maceutical medications, a Swiss chemist
synthesized lysergic acid diethylamide,
more commonly known as LSD (or “acid”
in slang). Lysergic acid is derived from
ergot alkaloids caused by the fungus
Claviceps purpurea, which grows on rye
and other grains. It’s usually prepared by
chemical synthesis in a laboratory and
formed into a crystal.
In the 1950s, a group of pioneering
psychiatrists used LSD as treatment for
alcoholism and various mental disorders.
London psychiatrist Humphry Osmond,
MD, coined the term psychedelic, mean-
ing “mind manifesting” and demon-
strated that hallucinogenic drugs had
therapeutic potential.12 Psychedelics act
on receptors for serotonin, a neurotrans-
mitter that affects mood. The premise of
psychedelic therapy is that the drug con-
fers a receptive state where a patient has
the potential to consider both the past
and future, which the therapist can guide
for positive outcomes.13
The 1990s brought a rejuvenation of
psychedelic medical research with the
potential to meet treatment needs for
depression and other diseases.14 Research
on psychedelics has continued to flourish
as evidenced by gifts totaling $17 million
in 2019 to fund the launch of the Johns
Hopkins University Center for Psychedelic
& Consciousness Research. Along with
research on brain activity, anxiety, and
PTSD, current projects at Johns Hopkins
include smoking cessation, Alzheimer’s
disease, and anorexia nervosa.
What may be interesting to note is
that most psychedelics are neither habit
forming nor toxic, and there’s no lethal
dose. However, they can be psychologically
risky for people with schizophrenia
and a family history of psychosis. The
stimulant and psychedelic MDMA
44  TODAY’S DIETITIAN • JANUARY 2022
(3,4-methylenedioxymethamphetamine)
commonly known as the drugs ecstasy
or Molly (researched to treat PTSD) are
derived from amphetamines and thus may
present some risk of abuse.13,15
Psilocybin is a compound found in what
are commonly referred to as “magic mush-
rooms,” which can alter consciousness and
produce visual and auditory hallucina-
tions. Mushrooms containing psilocybin
include the genera Copelandia, Gymnopi-
lus, Inocybe, Panaeolus, Pholiotina, Pluteus,
and Psilocybe. They’ve been depicted in
Stone Age rock in Africa and Europe, most
notably represented in the pre-Columbian
sculptures and glyphs throughout North,
Central, and South America. Many spe-
cies are found in Mexico, Canada, and the
United States that grow in meadows and
woods in tropical and temperate regions.
Magic mushrooms can be eaten in fresh
or dried form, though gastrointestinal
side effects are expected. They also can be
steeped in tea or cooked into foods. Pow-
dered psilocybin can be snorted or injected.
It’s advised that individuals use extreme
caution about the identity and safety of any
mushroom they want to consume.
Researchers from Johns Hopkins Uni-
versity School of Medicine gave adult
subjects with major depression two doses
of psilocybin under clinical guidance and
monitoring. Results showed that psilocy-
bin along with psychotherapy dramati-
cally reduced symptoms for a month, with
one-half of the subjects in remission from
the depression at follow-up. The degree to
which the effect on depression persisted
was about four times greater compared
with clinical trials of traditional antide-
pressant medications.16
Some in the psychedelic research field
anticipate that psilocybin with psycholog-
ical support will become an early option
in the treatment of depression, while oth-
ers suggest its use requires medical jus-
tification, and still others think it should
be available for recreational use as in the
case of alcohol and, increasingly, can-
nabis.14 In fact, several cities and states
across the United States are in the process
of legalizing or decriminalizing psilocybin
for therapeutic or recreational purposes.13
In This Is Your Mind on Plants, Pollan
details his relatively recent interest in the
psychedelic mescaline found in peyote
cactus and San Pedro cactus. The peyote
cactus is found only in limestone soils of
the Chihuahuan desert of southern Texas
and northern Mexico, while the San Pedro
cactus is native to the Andes but now is
also cultivated in other parts of the world,
including California. Indigenous popula-
tions have used both cacti for more than
6,000 years for sacramental healing, often
to treat alcoholism or other illnesses. San
Pedro cultivation—but not extraction of
its psychedelic compound, mescaline—
is legal, whereas peyote is entirely illicit,
except for the some 250,000 members of
the Native American Church, who have the
constitutional right to use peyote per the
American Indian Religious Freedom Act
Amendments of 1994.
Pollan strongly cautions that individu-
als should use psychedelics only under
certain conditions: with intention, rev-
erence for the drug and experience, and
the assistance of a trained guide. He also
advises that the closer the drug dose is to
the whole plant, the milder and safer the
compound will be.
Pollan suggests psychedelic drugs can
benefit us “and occasionally our culture
by stimulating the imagination and nour-
ishing our creativity.”
Consider New Perspectives
Humans have a longstanding, symbiotic
relationship with plants that can
provide nourishment, beauty, and the
ability to alter consciousness. Renewed
and promising medical research in
plant psychoactive compounds to
treat addiction, depression, and other
diseases, along with Pollan’s latest book,
offer RDs the opportunity to consider
a new or different perspective on the
benefits of plants. According to Pollan,
similar to food, a psychoactive drug is
inert and ineffective without a human
brain. In sharing his research, he hopes
to enlighten others on beliefs about drug
abuse and addiction. Pollan believes
there’s much people can learn from the
traditions of certain Native American
tribes, and that there’s a way to have a
safe and healthy relationship with plant
psychoactives. In 2020, Pollan cofounded
the UC Berkeley Center for the Science of
Psychedelics to conduct research, using
psychedelics to investigate cognition,
perception, and emotion and their
biological bases in the human brain. n
KC Wright, MS, RDN, is a research dietitian
advocating for sustainable foods and planetary
health at wildberrycommunications.com.
For references, view this article on our
website at www.TodaysDietitian.com.
Claim Your Spot!
Then join your colleagues and our stellar lineup of
presenters for the 2022 Today’s Dietitian Spring
Symposium at the Hyatt Regency Coconut Point
Resort and Spa in Bonita Springs, FL, May 22-25.

Enjoy some fun in the sun, earn at least 15 CEUs, find

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PRESENTERS AND TOPICS INCLUDE:

Ask the Expert: A Year in Review Nutrition and Oral Health:
and a Look Ahead A Primer for RDs
Toby Amidor, MS, RD, CDN, FAND Ellen Karlin, MMSc, RDN, LDN, FADA

Cannabis and CBD for Gut Health Dietary Supplement Labeling

Janice Bissex, MS, RDN, FAND
Feed the Need to Succeed:
Addressing Nutrition Insecurity
and Underfueling in Athletes
Through Adequacy, Availability,
Affordability, and Practicality
Leslie Bonci, MPH, RDN, CSSD, LDN
Artificial Intelligence for
Nutrition Entrepreneurs
Chrissy Carroll, MPH, RD, USAT Level I
Triathlon Coach
Culinary Medicine: How the
Registered Dietitian Can Take a
Leading Role Interprofessional
Education
Wesley McWhorter, DrPH, MS, RDN,
LD, CSCS
and the RD
Lauren Swann,MS, RD, LDN
Where Health Meets Food:
The Intersection of Food as
Medicine in 2022
Kathleen Zelman, MPH, RDN, LD
Our Foods Are Healthy:
Culture-Focused Nutrition
Ashley Carter, RD, LDN & Jasmine
Westbrooks, MS, RD, LDN
Trauma-Informed Nutrition:
The Principles and Application
of Trauma-Informed Care to
the Field of Dietetics
Kristi Mollner, MS, RDN, CCTS-I &
Adrienne Markworth
Beyond the Textbook: Putting the
AWE in Awesome Diabetes Care
Toby Smithson, MS, RDN, LD, CDCES &
Beverly Adler, PhD, CDCES
Plant-Based Juniors: Strategies
for Meeting the Needs of Vegan,
Vegetarian, and Plant-Forward
Children
Alexandra Caspero, MA, RD & Whitney
English, MS, RD
The Continuum of Care for
the Cancer Patient: How to
“Prescribe” Nutrition and Exercise
Shayna Komar, RD, LD & Joel Hardwick,
ACSM EP-CET, EIM2
Just Do It: Finding the Right
Doctorate Program and Being
Successful Doing It
Kristen Hicks-Roof, PhD, RDN, LDN,
CLC, FAND & Catherine Coccia, PhD, RD
From Sunrise to Sunset: Practical
Culinary and Tech Solutions for
Better Sleep
Dana White, MS, RD, ATC & Karman
Meyer, RDN

T H A N K YO U TO O U R 202 2 S P RI N G S Y M P O S I U M S P O N S O R S
CPE Monthly By Tony Pipkin, MS, RDN
The Science on Interstitial Cystitis
and Bladder Pain Syndrome
F
ew conditions remain as elusive
in medical care as interstitial
cystitis (IC). Multiple attempts at
classifying the enigmatic con-
dition have been made since
Alexander Skene initially identified the
condition in 1887. Subsequent work in 1915
by Guy Leroy Hunner, a Johns Hopkins
gynecologist, identified IC as erythema-
tous patches of ulceration, and further
nomenclature evolved to describe the
condition as “Hunner” (less common and
usually more painful) or “non-Hunner”
lesions. In 1949, research by John Hand
described IC as the hemorrhagic dam-
age to the bladder’s submucosal layers. He
graded the lesions into three sequential
disease stages with a progressive diminu-
tion in bladder storage capacity.1
Other names for IC include bladder
pain syndrome (BPS), painful bladder
syndrome, hypersensitive bladder, and
ulcerative bladder (Hunner and non-
Hunner). Unfortunately, the condition is
a diagnosis of exclusion, and no definitive
straightforward treatment protocol
exists. The number of global guidelines
46  TODAY’S DIETITIAN • JANUARY 2022
developed in recent years attest to the
challenges in adequately describing the
disease, including accepted definitions,
pathology, diagnostic tools, and evidence-
based therapies.2-4
The American Urological Association
(AUA) and the Society of Urodynamics,
Female Pelvic Medicine and Urogenital
Reconstruction define IC/BPS as a col-
lection of varied symptoms that aren’t
exclusive of one another. Symptoms may
include urgent and frequent need to uri-
nate, recurrent nocturia, and pelvic pain
in the absence of proven genitourinary
infection or other pathology (eg, cancer)
with a minimum six weeks’ duration.
Some patients describe the associated
pain as being moderate to excruciating,
with symptoms often having an ebb and
flow, while some experience no pain at all.
The bladder urothelium is a highly sensi-
tive sensory tissue, and inflammation and
hypersensitivity are suspected to be the
underlying causes of IC/BPS.5-8
This continuing education course
reviews the challenges of diagnosing,
classifying, and treating IC, also
known as BPS, and provides counseling
strategies for clinicians to use when
working with patients.
Etiology
The etiology of IC/BPS is multifactorial
and includes a variety of malfunctions
including pelvic floor dysfunction, aber-
rant immune or inflammatory signals,
nerve hypersensitivity, and alteration of
the protective proteoglycan/glycosamino-
glycan (GAG) lining of the bladder.5,6 The
distinction between visceral and somatic
nerve conduction also may be used to
describe IC/BPS as a visceral pain condi-
tion. Visceral nerve conduction is slower
than that of somatic nerves, and multiple
nerves of the pelvic organs have overlap-
ping innervation. Pelvic pain due to non-
bladder conditions, such as irritable bowel
syndrome (IBS), may result in neural and
visceral sensitization, which, over time,
can result in the inability to discern the
exact location of symptoms and pain.9
Research connecting diet and IC/BPS is
limited, yet studies exist that show certain
foods can trigger or worsen symptoms.10
The 2019 Global International Cystitis,
Bladder Pain Society (GIBS) meeting fea-
tured research on the etiology of IC/BPS,
results of which suggested C-fiber neuro-
plasticity changes, neurogenic inflamma-
tion, urothelial defect, and hypersensitive
neurons as potential causes of IC/BPS.11
COURSE CREDIT: 2 CPEUs
Learning Objectives
After completing this continuing edu-
cation course, nutrition professionals
should be better able to:
1. Employ the current body of evidence
on the prevalence and diagnosis
of interstitial cystitis/bladder pain
syndrome (IC/BPS) to aid in the
recognition of the disorder.
2. Counsel clients on the relationship
between certain foods and IC/BPS
symptoms.
3. Provide recommendations for
evidence-based nutrition counseling
for management of IC/BPS.
Suggested CDR Performance Indicators
8.2.3, 8.2.4, 10.2.14, 10.5.3
CPE Level 1
Pathophysiology
The pathophysiology of IC/BPS is poorly
understood, but researchers have devel-
oped several theories. Genetics haven’t
been adequately researched, but in one
of the few studies, conducted by Warren
and colleagues, adult female first-degree
relatives of IC/BPS patients had 17 times
the risk of prevalence compared with the
general population. They also reported a
greater frequency of IC/BPS among mono-
zygotic vs dizygotic twins. Another theory
is inflammation contributes to mast cell
activation with subsequent sensory neu-
ral stimulation and suprapubic pain and
urination problems.12,13
Deficient GAG urothelium lining of the
bladder that results in permeability and
irritation is a third theory of IC/BPS.12 The
GAG lining normally contains heparin,
and its unexplained absence is suspected
as the cause of enhanced permeability.
An interruption of the protective lining
enables diffusion of urinary solutes across
the suburothelium, irritating nerves and
generating pain and hypersensitivity. The
damage may yield incorrect mastocyte
stimulation in bladder suburothelial layers.
A fourth concept by Davis and col-
leagues is associated with the Tamm-
Horsfall protein, which is of renal origin
and known to protect the urothelium lin-
ing of the bladder. Defects in this protein
are suspected to result in inflammation
and pain.12 Finally, chronic bacterial infec-
tions, malfunctioning autonomic nervous
system, and autoimmune disorders are
other suspected causes.1
Evidence continues to mount on the
gut microbiome’s health significance and
interaction with various organs. Recent
microbiota research has alluded to a
relationship between the gut and IC/BPS.
Magistro and colleagues posit that a dys-
balanced gut microbiome has an essential
role in the pathogenesis and management
of IC/BPS.14,15 And urinalysis studies have
shown that the urinary tract has its own
unique microbiota; samples from healthy
controls have shown stark differences
compared with samples from those with
urge urinary incontinence, neurogenic
bladder dysfunction, IC/BPS, and nonbac-
terial prostatitis.16,17
Prevalence and Diagnosis
International disparities in nomencla-
ture, diagnostic definitions, and treatment
guidelines for IC/BPS continue. A 2018
Visit www.TodaysDietitian.com/SS22
to register for our Spring Symposium!
review of guidelines by Malde and col-
leagues included unique and varying defi-
nitions of IC/BPS. Numerous organizations,
including the AUA, Canadian Urological
Association, European Association of Urol-
ogy, International Society for Study of BPS,
International Association for the Study of
Pain, International Consultation on Incon-
tinence, International Continence Society,
East Asian guideline, and Royal College of
Obstetricians and Gynecologists/British
Society of Urogynecology, all provide varied
information and recommendations.4
A 2009 study determined that the US
incidence of IC/BPS is 2.7% to 6.5% among
adult women (3.3 million to 7.9 million).18
The incidence is five-fold greater in women
than in men. However, Suskin and col-
leagues enhanced the existing definition
and added the NIH-Chronic Prostatitis
Symptom Index criteria to determine that
the prevalence and overlap between IC/
BPS and chronic pelvic pain syndrome/
chronic prostatitis in men is 2.9% to 4.2%
for IC/BPS and 1.8% for chronic pelvic pain
syndrome/chronic prostatitis, equating to
a much higher incidence in men than pre-
viously believed.19,20
The presence of recurrent symptoms of
urinary tract infections accompanied by
negative bacterial cultures suggests IC/
BPS. In addition, patients presenting with
subacute or chronic pelvic pain who are
otherwise undiagnosed should be consid-
ered as having IC/BPS. The validated Pel-
vic Pain and Urgency/Frequency Index is
a useful screening tool. The O’Leary-Sant
Interstitial Cystitis Symptom and Problem
Index, as well as the Interstitial Cystitis
Symptom Index, can be completed by the
patient and are useful tools in diagno-
sis; all are available from the Interstitial
Cystitis Association (ICA). The O’Leary-
Sant index includes four domains—pain,
urgency, nocturia, frequency—that assist
in determining the severity of symptoms
and guide the treatment plan.1,9,11,21,22 Rec-
ommendations stemming from the GIBS
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  47
meeting stated that, in addition to a thor-
ough history and physical examination,
a cystoscopy is required for a definitive
diagnosis of IC/BPS.11,22
Comorbid Conditions
The frequency of comorbid conditions
with IC/BPS is of interest to dietitians, as
medical care often overlaps and clinicians
must integrate the multiple conditions
into the nutrition care plan. The overlap of
conditions can generate additional pain
separate from IC/BPS yet indistinguish-
able to the patient.23
Comorbid conditions include fibro-
myalgia, migraine headache, vulvar/
vaginal pain, sexual dysfunction, chronic
fatigue syndrome, pelvic floor dysfunc-
tion, constipation, and IBS, which is the
most common (~39% of IC/BPS patients).
IBS symptoms include abdominal pain/
distension, sensation of incomplete def-
ecation, bowel straining/urgency, and
changes in gastrointestinal motility.7,8,24-26
Management and Treatment
Global guidelines for management and
treatment vary, and divergence in rec-
ommendations is common. For example,
some diagnostic steps recommend hydro-
distension (filling the bladder with water)
and bladder biopsy, while others consider
it discretionary and some even dissuade
the procedure.4
For the purposes of this course, the
guidelines and recommendations follow
the 2015 AUA-amended clinical frame-
work for the diagnosis and treatment of
IC/BPS. The treatment plan is designed
initially to be the most conservative and
progress to the least conservative over the
following six stages18:
• First-line: diet education, stress/behav-
ioral management, bladder training,
and pain control;
• Second-line: first-line treatments in
addition to physiotherapies and oral
CPE Monthly
medications (amitriptyline, cimetidine,
hydroxyzine, pentosan polysulfate);
• Third-line: cystoscopy with hydrodis-
tension, pain control, fulguration of
Hunner’s lesions if present, intravesical
therapies;
• Fourth-line: intradetrusor botu-
linum toxin A injections, sacral
neuromodulation;
• Fifth-line: cyclosporine A; and
• Sixth-line: surgical diversion with
or without cystectomy, substitution
cystoplasty.
Several other organizations have
developed approaches to the management
and treatment of IC/BPS, using various
guidelines and algorithms. Consensus
among the recommendations includes an
initial baseline approach to conservative
therapies including dietary intervention,
behavioral therapy, physical therapy, and
stress relief.27,28
The AUA recognizes that frontline
therapies are noninvasive, conservative,
and behaviorally focused, citing treat-
ments such as cognitive behavioral ther-
apy and stress reduction, physical therapy,
and dietary modifications.11,14 GIBS meet-
ing experts recognized that a compilation
of individually varied treatments
typically is needed for each patient
depending on symptomology, age, and
comorbid conditions.11
First-Line Therapies
Nutrition Education
The relationship between diet and
IC/BPS symptoms has been investigated
for many years, with some success in
identifying foods that may trigger or
aggravate symptoms.
The ICA has identified four concepts
hypothesized to explain the relationship
between foods and IC/BPS symptoms.
The damaged bladder wall is susceptible
to toxic substances in the urine, which
exacerbate the inflammation and
irritation upon contact, causing increased
pain. Secondly, some researchers propose
that sensitive terminal nerve fibers in
the bladder are irritated upon contact
with urine. Thirdly, some researchers
have found an increased number of pain
receptors in the bladder, which, when
in contact with certain compounds (eg,
capsaicin), result in increased pain. Lastly,
there’s the concept of organ cross-talk,
48  TODAY’S DIETITIAN • JANUARY 2022
which is based on the hypothesis that
foods irritating the gastrointestinal tract
use similar nerve pathways and send
pain signals to the bladder with resultant
inflammation of the bladder.1,7,10,29
Although offending compounds in
foods are thought to communicate with
the sensitized bladder neurons in IC/
BPS and result in exacerbation of IC/
BPS symptoms, successful nutrition
intervention is thought to positively affect
IC/BPS through this same concept of
“neural cross-talk” between the pelvic
organs and the intestines.7,23
There also may be a connection
between IC/BPS and food allergies; some
clinicians are discovering that 35% to
40% of their IC/BPS patients have food
allergies.30 The ICA conducted a survey of
more than 1,000 IC/BPS patients inquiring
about gluten sensitivity and celiac disease.
Of those responding, 12% reported having
celiac disease and another 15% stated
their IC/BPS flare-ups were exacerbated
by gluten-containing foods. In addition,
studies at Baylor College of Medicine
identified a link between gluten sensitivity
and IC symptoms.10,30,31
The role of diet in treating symptoms
of IC/BPS is based on limited evidence,
primarily anecdotal reports. A validated
2007 survey of 104 female patients
identified numerous offending foods,
including coffee, tea, carbonated
beverages, alcohol, hot peppers, citrus
fruits and their juices, and tomatoes.7
Urinary pH levels can be manipulated
by eliminating foods that result in more
acidic urine (eg, chocolates, carbonated
beverages, specific citrus fruits, coffee).
Some foods inflame the sensitized
bladder neurons (eg, caffeine, alcohol,
carbonated beverages, certain spices) and
should be excluded. Known allergenic
foods (eg, those with soy, gluten) may
need to be eliminated, too. The kidneys
control potassium excretion based on
dietary potassium intake. Rapid urinary
excretion occurs after potassium intake,
so restricting high-potassium foods (eg,
tomatoes) will decrease bladder wall
irritation and reduce pain.7,11,32
Most IC/BPS patients benefit from
some type of dietary modification.
While some patients suffice with minor
dietary changes, others require extensive,
ongoing adjustments to keep the painful
symptoms under control. Bladder
flare-ups are caused by not only the
foods themselves but also the quantity
and frequency of their consumption.
While most IC/BPS patients are female,
male patients with chronic pelvic pain
syndrome and persistent prostatitis can
be counseled to adopt dietary changes
that help alleviate symptoms.33
In December 2020, the American
College of Gastroenterology published
its first-ever clinical guideline on the
management of IBS. Clinicians are
advised to approach IBS with a positive
diagnosis strategy vs a diagnostic strategy
of exclusion. Recommended tests and
nutritional modifications, including a
low-FODMAP (fermentable oligo-, di-,
and monosaccharides and polyols) diet,
are included.34 Additional nutrition
interventions for IBS must be integrated
with the IC/BPS care plan. Suggested low-
FODMAP modifications include limiting
fat to between 20% and 35% of calories
and restricting gas-forming foods (eg,
beans, garlic, onions, Brussels sprouts),
sugars (especially fructose), alcohol,
sugar alcohols, caffeine, and lactose, even
when these foods would otherwise be
acceptable on an IC/BPS diet.23
Experts at the AUA and GIBS meetings
recognize that diet is a first-line treatment
for IC/BPS, with many resources
available to patients and clinicians.6,10,28
In a 2017 study by Oh-oka, participants
were randomized to follow a control
diet (nonintensive) or an IC/BPS diet
(intensive) that omitted tomatoes, tomato
products, soybean, tofu, spices, excessive
potassium, citrus, and high–acidity-
inducing substances for 30 days. After
follow-up at three months and one year,
the intensive group reported significant
improvement in IC/BPS flares vs baseline
compared with the nonintensive group.6,35
Oh-oka reported at the International
Continence Society annual meeting in
2018 that a follow-up study extended
the parameters to include a 1.5-year
follow-up. The intensive diet group
showed significant improvement in IC/
BPS symptomology compared with the
control group, and some patients were
able to decrease oral medications (eg,
amitriptyline).36
A comprehensive nutrition assess-
ment that addresses foods that trig-
ger or worsen symptoms and other
comorbid conditions is appropriate. An
effective tool for determining food sen-
sitivity and patient comprehension is
the Shorter-Moldwin Food Sensitivity
Questionnaire.37
Of additional importance in dietary
management is adequate hydration.
IC/BPS patients may elect to limit fluid
intake to avoid urinary urgency, but this
may result in increased urine concen-
tration and irritation/inflammation of
the bladder urothelium. Constipation is
common in IC/BPS due to decreased fluid
intake, use of certain medications (eg,
antidepressants, NSAIDs, opioids), and
decreased physical activity, which may
further exacerbate the pain associated
with the condition.7
The first component in dietary man-
agement of IC/BPS begins with an elimi-
nation diet. Friedlander identified that
more than 80% of IC/BPS patients exhibit
sensitivity to particular foods.14 The elimi-
nation diet removes foods that may trigger
or aggravate symptoms for a minimum of
one month before reintroduction.
Foods and beverages that have been
most strongly associated with IC/BPS
symptoms include coffee (regular and
decaffeinated), carbonated beverages
(regular and diet), caffeinated tea,
alcohol (eg, wine, beer, champagne,
spirits), certain fruits (eg, grapefruit,
lemon, orange, pineapple), fruit juices
(eg, grapefruit, cranberry, orange,
pineapple), tomato and tomato products,
hot peppers, pickles, sauerkraut, spicy
foods, chili, horseradish, vinegar, MSG,
artificial sweeteners (eg, aspartame,
saccharin), salad dressings, and pizza.
Notably, Mexican, Indian, and Thai foods
commonly include peppers, which are rich
in capsaicin and can be proinflammatory
to the bladder lining.
Foods and beverages less likely to
aggravate or trigger symptoms include
milk, plain water, certain fruits and dried
fruits (eg, bananas, blueberries, honey-
dew melon, pears, raisins, watermelon),
vegetables (eg, asparagus, broccoli, Brus-
sels sprouts, cabbage, carrots, cauliflower,
celery, cucumber, mushrooms, peas, rad-
ishes, squash, zucchini, white and sweet
potatoes), proteins (eg, chicken, eggs,
turkey, beef, pork, lamb, shrimp, tuna,
salmon, mild cheeses), oats, rice, popcorn,
and pretzels.7,10,36,38
Reintroducing foods that may trig-
ger symptoms requires meticulous effort
and often takes several months. It’s also
important for clients to continue previ-
ous routines of exercise and healthful
mindfulness during the reintroduction
period. During the reintroduction phase,
clients should record symptoms, which
can appear as soon as 20 minutes or as
late as four hours after ingesting a food.
It’s helpful to reintroduce foods in three
stages: very small portions followed by
half-size portions the next day, and, if no
flare-ups occur, then a full-size portion
on the third day. Patients may find certain
foods need to be eliminated long term to
prevent painful symptoms.7,10
An integrative medicine approach
to IC/BPS should aim to enrich the gut
microbiome with anti-inflammatory and
antioxidant foods containing flavonoids
(eg, parsley, bananas, buckwheat, blue-
berries, peanut) and omega-3 fatty acids
(eg, salmon, mackerel, lingonberry, eggs).
Nondigestible comestibles (prebiotics)
and appropriate foods, eg, low-fat yogurt
and buttermilk, mozzarella cheese, mild
cheddar cheese, and low-fat cottage cheese
(probiotics) will help bolster a healthy gut.
Medications and Supplements
In addition to dietary interventions, the
use of over-the-counter medications
and supplements may provide some
benefit to IC/BPS patients. Before a meal,
the use of calcium glycerophosphate
(Prelief) and sodium bicarbonate
together or independently has been
reported to ameliorate IC/BPS symptoms.
Other research has shown that aloe
vera concentrate, glucosamine, and
chondroitin also may minimize bladder
flare-ups. Oral preparations of the aloe
vera plant purportedly work to replenish
the deficient GAG bladder lining, which
minimizes urine irritation. Use of these
products may provide presymptomatic
relief when consumed before a meal.39
A 2011 study by the ICA included 598
completed surveys from IC/BPS patients
with 96% of respondents confirming that
specific beverages and foods exacerbated
their symptoms. The study identified over-
the-counter products such as calcium
glycerophosphate and sodium bicarbon-
ate as providing some relief when taken
with these foods.7,23,38,40
Pain relief is another area where
first-line medications can help. Progres-
sive oral medications for pain should be
incorporated into the care plan, with
proper precautions taken to address any
food-drug interactions (eg, opioids’ side
effect of constipation).
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  49
Stress and Behavioral Management
Due to the pain associated with IC/BPS,
mental and physical distress are com-
mon among patients, and the social
impact is significant.41 In a small study
(n=15), patients with IC/BPS collectively
expressed that the condition is chroni-
cally disabling, the flare-ups and pain
are unpredictable and endless, and, most
notably, suicidal ideation was verbalized
in each cohort.42
Flare-ups occur frequently, often
around menstruation and after coitus.
Urination averages 16 times per day but
may be as high as 40 to 60 times per day.
Such symptom patterns aren’t only physi-
cally and mentally taxing but also can be
embarrassing when they occur in profes-
sional, social, or intimate situations.11,27,40,41
Cognitive behavioral therapy, which is
meant to help individuals challenge their
thinking patterns and gain coping skills,
can help IC/BPS patients understand and
acknowledge the role the painful syn-
drome plays in their lives and develop
cognitive resilience as they work through
their treatment plan.11,14
Stress management exercises also
can help patients cope with their condi-
tion. Mindfulness-based stress reduction,
a paradigm that incorporates yoga and
meditation, has been successful in man-
aging psychosocial stressors associated
with IC/BPS. An ICA-conducted internet
survey revealed IC/BPS patients (n=1,967)
reported symptom reduction after yoga
(61%), meditation (67%), and stress reduc-
tion (81%) therapies.39,43-45
Bladder Training
Training to increase the time between uri-
nation has been successful with many IC/
BPS patients when combined with other
behavioral therapies. The patient focuses on
suppressing the urge to urinate with a goal
of extending the time between voids.39,46
Second-Line Therapies
Physical Therapy
Physical therapy is an important treat-
ment for IC/BPS. The muscles of the
pelvic region support the bladder, rec-
tum, uterus, and prostate and attach to
the sacrum, pelvis, and the terminal of
the spine. Contraction of these muscles
helps control bladder and bowel activity,
but spasms and muscular knots (trigger
points) generate varying degrees of pain
CPE Monthly
for IC/BPS patients. Returning the sacrum
and ilium to a natural muscular pressure
confers stability to the pelvic muscles.47,48
Manual physical therapy, includ-
ing pelvic floor massage, teaches pelvic
floor relaxation and has been reported
to be beneficial. However, exercises to
strengthen the pelvic floor (eg, Kegel exer-
cises) are contraindicated.1,48
Acupuncture
Acupuncture has been studied with
some success in relieving pain in refrac-
tory IC/BPS patients. Sönmez and
colleagues conducted acupuncture
research over a five-week period with
amelioration of symptoms at the first
and third month post acupuncture.
Unfortunately, the results diminished to
baseline at 12 months.49
Oral Medications
In addition to drugs used for pain relief,
other oral pharmacologic agents may help
mitigate some IC/BPS symptoms. Pen-
tosan polysulfate, a weak anticoagulant,
is believed to strengthen the GAG lin-
ing of the bladder wall, but the medica-
tion is associated with diarrhea, nausea,
upset stomach, and pain. The antihis-
tamine and antacid cimetidine reduces
gastric secretions and subsequently
may decrease bladder pain. Amitripty-
line, an antidepressant, blocks the reup-
take of neurotransmitters serotonin and
noradrenaline, therefore blocking pain
neurotransmission. Side effects include
constipation and abdominal weight gain.50
The antihistamine hydroxyzine affects
mast cell degranulation of the blad-
der wall and reduces urinary frequency,
nocturia, and pain; constipation and dry
mouth are potential side effects.18,51
Third-Line Therapies
More aggressive therapy is an inva-
sive cystoscopy with hydrodistension
under anesthesia, which is used to con-
firm bladder wall pathology with ful-
guration of ulcerative Hunner’s lesions
if present, although less than 10% of
patients have been documented with
these lesions.1 Intravesical therapies
involve the instillation of various phar-
macologic agents directly into the blad-
der via catheter. Agents infused have
varying grades of recommendation and
require close medical management.
Examples of agents include dimethyl
50  TODAY’S DIETITIAN • JANUARY 2022
sulfoxide, onabotulinumtoxinA, pento-
san polysuflate, hyaluronic acid, chon-
droitin sulfate, heparin, lignocaine, and
oxybutynin.4,52
Fourth-Line Therapies
The fourth-line therapies include injec-
tions, which aren’t without risk of devel-
oping acute inflammatory reaction,
hematuria, and urinary tract infection.
Neurogenic bladder can be treated with
injections of onabotulinumtoxinA, vs
bladder infusions, into the intradetru-
sor (smooth muscle) wall of the bladder.
The sensory nerves are blocked, resulting
in reduced incontinence, nocturia, and
urgency. Sacral neuromodulation, a pro-
cess in which mild electrical impulses are
sent to sacral nerves to disrupt pain signals
from the bladder, can be accomplished
with external or implanted stimulators.53,54
Fifth-Line Therapies
Continued medical approaches include
immunosuppressants. Wang and col-
leagues conducted a systematic review that
determined the oral drug cyclosporine A
can be a successful adjunct in IC/BPS treat-
ment. Close medical monitoring is required
and complications such as abdominal pain,
diarrhea, nausea, elevated serum creati-
nine, and hypertension can occur.55
Sixth-Line Therapies
Surgical options are limited to patients
with disabling IC/BPS for whom previ-
ous therapies have failed; they should be
considered as a last resort. These treat-
ment options include: 1) urinary diver-
sion with or without bladder removal; 2)
orthotopic diversion in which a bladder is
constructed from bowel tissue; 3) aug-
mentation cystoplasty, which uses bowel
tissue and reconstructs the bladder in a
combination of existing bladder wall and
bowel. A final option is cystectomy with
urinary diversion to an ostomy.1,5,14
Research Gaps
The lack of comprehensive treatment pro-
tocols and definitive diagnostic criteria
or biomarkers has resulted in extensive
ongoing research to help provide relief
to the millions of IC/BPS patients. The
Multidisciplinary Approach to the Study
of Chronic Pelvic Pain research network,
which was developed by the National
Institute of Diabetes and Digestive and
Kidney Diseases in 2008, features diverse
researchers, including clinicians and
epidemiologists, working collectively to
develop consistent diagnostic guidelines
and treatment protocols.4,56 Of inter-
est to dietitians are investigations into
the microbiome and studies to elucidate
organ cross-talk and identify IC/BPS
potential biomarkers to determine sub-
types of the disease and streamline treat-
ment algorithms.11,14
The Shorter-Moldwin Food Sensitivity
Questionnaire has potential to be aggre-
gated and analyzed for clinical studies to
assess the impact foods may have on pain
and IC/BPS symptoms. Herbal and supple-
mental products are other treatments that
have been only minimally researched.7
However, complementary and alterna-
tive medicine approaches to IC/BPS are
encouraging and further research into
this field of study is warranted.6 Pharma-
cological research with messenger RNA
into intravesical therapies also is prom-
ising and may provide yet another treat-
ment option for IC/BPS patients.52
Putting It Into Practice
RDs are essential in developing a conser-
vative approach to minimize symptoms,
integrating restrictions for comorbid con-
ditions, and ensuring a nutritious diet for
those with IC/BPS. A comprehensive nutri-
tion assessment should involve patients
recording food and beverage intake, void-
ing occasions, and symptoms. An indi-
vidualized plan is paramount, and IC/BPS
patients benefit from education on how to
read labels for offending ingredients.
Dietitians should work with patients
to set achievable goals for a nutrient-rich
diet and IC/BPS symptom relief. As mem-
bers of a multidisciplinary health care
team, RDs should engage with practitio-
ners such as behavioral/mental health
professionals and physical therapists to
encourage a holistic approach to IC/BPS
management. Further interest in IC/BPS
management on the part of clinicians,
researchers, and patients will help with a
better epidemiological understanding and
improved therapeutic interventions. n
Tony Pipkin, MS, RDN, is a Little Rock,
Arkansas–based freelance writer focused
on MNT topics.
For references, view this article on our
website at www.TodaysDietitian.com.
 Register or log in on CE.TodaysDietitian.com
to complete the online exam and earn your credit
certificate for 2 CPEUs in our CE Learning Library.

CPE Monthly Examination

1. What’s the most common comorbid condition 6. What percentage of IC/BPS patients also
associated with interstitial cystitis/bladder pain reported having celiac disease?
syndrome (IC/BPS)?
a. 3%
a. Fibromyalgia b. 9%
b. Irritable bowel syndrome c. 12%
c. Constipation d. 15%
d. Pelvic floor dysfunction
7. Which of the following foods has been shown
2. The Interstitial Cystitis Association hypothesized to aggravate or trigger symptoms in IC/BPS
four concepts that might explain the relationship patients?
between food and IC/BPS symptoms. Which of
a. Watermelon
the following is one of these concepts?
b. Asparagus
a. Hematuria c. Broccoli
b. Acid reflux d. Soy
c. Organ cross-talk
d. Pancreatic insufficiency 8. The elimination diet phase of the IC/BPS
nutrition care plan is recommended to last for a
3. An IC/BPS nutrition assessment should include minimum of how many days?
a food sensitivity questionnaire. Which of the
a. Seven
following is a recommended survey instrument?
b. 21
a. Shorter-Moldwin c. 30
b. USDA What We Eat in America d. 60
c. National Health and Nutrition Examination
Survey Food Frequency 9. Which of the following is an example of a
d. Malde-Palmisani flavonoid-rich food that can be used to enrich the
gut microbiome?
4. What is the prevalence of IC/BPS in men?
a. Buckwheat
a. 2.9% to 4.2% b. Chocolate milk
b. 3.5% to 5.5% c. Golden delicious apple
c. 5.5% to 7% d. Avocado
d. 7.5% to 9.5%
10. The American Urological Association’s 2015
5. Which of the following theories is believed to guidelines for IC/BPS treatment include how
play a role in the pathophysiology of IC/BPS? many stages?

a. Deficient Horrs-Whitsfeld protein from a. Two

the kidney b. Six
b. D eficient GAG urothelium lining of c. Eight
the bladder d. 10
c. Alkaline diet
d. Inflammatory bowel disease

For more information, call our continuing education division toll-free at

877-925-CELL (2355) M-F 9 am to 5 pm ET or e-mail CE@gvpub.com.

JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  51

Focus on Fitness By Kelly Pritchett, PhD, RD, CSSD
Exercising With Spinal Cord Injury
A Review of the Guidelines and How Physical Activity
Can Improve Quality of Life
A
pproximately 296,000 indi-
viduals in the United States
live with a spinal cord injury.
Based on data from the
National Spinal Cord Injury
Statistical Center, 17,700 new cases of
spinal cord injury occur in the United
States every year, with motor vehicle acci-
dents the leading cause of injury and an
average rehabilitation time of 34 days.
Since the 1970s, the average age of injury
has increased from 29 to 43. Spinal cord
injuries can lead to lifelong impairment,
disability, and handicap, which can sig-
nificantly impact quality of life.1
RDs who encounter clients and
patients with spinal cord injury but
don’t specialize in this area can gain an
understanding of the types of spinal cord
52  TODAY’S DIETITIAN • JANUARY 2022
injuries, the causes, and the physical
activity guidelines for this population that
can help improve their lives.
What Is a Spinal Cord Injury?
The spine consists of 33 vertebrae that are
divided into five types: cervical, thoracic,
lumbar, sacral, and coccygeal. Injury to the
thoracic or lumbar vertebrae leads to loss
of function in the legs, trunk, muscles, and
organs, which are innervated below the level
of injury on the spinal cord, and is referred
to as paraplegia. Quadriplegia refers to
injury to the cervical vertebrae resulting in
functional loss in all four extremities, with
damage to the nerves leading to the head,
neck, diaphragm, arms, and hands.
Furthermore, depending on the degree
of motor and sensory loss, spinal cord
injuries can be classified as complete or
incomplete. Although highly variable
among individuals, an incomplete spinal
cord injury denotes neurological func-
tion below the level of injury in the spinal
cord where there may be complete loss in
motor function, or the function of a body
part, but incomplete sensory loss (eg,
touch), or vice versa. A complete spinal
cord injury refers to loss of both motor and
sensory function below the level of injury
on the spinal cord.2
Benefits of Physical Activity
Physical deconditioning is a common
consequence of spinal cord injuries given
the physical, psychosocial, and environ-
mental barriers to exercise.3 As aforemen-
tioned, the level and completeness of the
injury to the spinal cord is unique to the
individual and predicts mobility.4
Compared with the general popula-
tion, individuals with spinal cord injury
are two to four times more likely to
develop obesity, diabetes, and CVD due
in part to low physical activity levels and
physiological changes that occur after
injury.5 Therefore, physical activity is key
for improving their quality of life and
health. Regular physical activity can help
improve energy levels, sleep, mood, blood
sugar, and cholesterol; help maintain a
healthy body weight; and decrease pain
and risk of heart disease. However, exer-
cise guidelines for able-bodied individuals
aren’t necessarily appropriate for a spinal
cord injury population.4
Exercise Guidelines
The American Congress of Rehabilitation
Medicine recommends people with spinal
cord injury engage in 20 to 30 minutes of
moderate to vigorous aerobic activity at
least two days per week for cardiorespi-
ratory fitness benefits.5 However, more
recent guidelines suggest engaging in at
least 30 minutes of moderate to vigorous
aerobic activity three times per week for
improvements in factors that affect car-
diometabolic health, such as body com-
position, blood lipid profiles, and vascular
function.3 Activities such as arm ergom-
eter (cranking), wheeling, aquatics, and
cycling are most appropriate.5
Muscular strength and endurance are
important for maintaining or improving
bone density, lean body mass, resting
metabolic rate, and glucose metabolism
in individuals with spinal cord injury. It’s
recommended to perform three sets of
eight to 10 reps at a moderate to vigorous
intensity, with one to two minutes of rest
using free weights, weight machines,
and/or resistance bands two times per
week. Recommended exercises target
the major functioning muscle groups
and include bicep curls, tricep press,
seated row, and chest fly latissimus dorsi.
Furthermore, a lumbar roll or chest strap
may be used for posture support and to
decrease the risk of injury.3,5
Flexibility is important for maintain-
ing range of motion and mobility. Daily
stretching is recommended but with cau-
tion not to overstretch limbs where there’s
impaired sensation. Special attention
should be paid to the chest, shoulders, and
biceps, as they may tighten after injury.5
Barriers to Exercise
Limited access, financial barriers, fear of
stigma, or health-related concerns (eg,
pressure ulcers, autonomic dysreflexia,
or bladder management) are noted as
some barriers to exercise in the spinal
cord injury population. Furthermore,
failure to provide an appropriate exercise
routine based on an individual’s injury
level can lead to decreased adherence.6
However, physical activity can provide
a positive outlet. Adaptive sports pro-
grams are a fun and competitive option
for individuals with spinal cord injury
to become active. Check whether there
are adaptive sports programs in your
client’s area at challengedathletes.org/
adaptive-sport-organizations.
The following strategies can help
address barriers to physical activity and
psychological issues that may impact the
motivation to exercise3,6:
• Emphasize the importance and thera-
peutic benefits of exercise.
• Engage in fun activities.
• Keep track of progress.
• Schedule exercise sessions.
Considerations
Before clients with spinal cord injury begin
an exercise program, they’ll need to take
some precautions regarding their health.
Blood Pressure
People with spinal cord injury have less
sympathetic nervous system activity dur-
ing exercise, which results in reduced
physiological responses compared with
their able-bodied counterparts.7 Those
with injury levels at or above the sixth
thoracic vertebrae (T6) are at risk of auto-
nomic dysreflexia, which is a spike in
blood pressure. It’s recommended they
stop exercise immediately if this occurs.
Moreover, individuals may have a
blunted heart rate response to exercise,
so using rating of perceived exertion—a
method for measuring perceived exercise
intensity using an anchored scale of 6,
or “no exertion,” to 20, or “maximum
effort”—may be helpful for prescribing
and monitoring exercise intensity.
After exercise, it’s common for these
individuals to experience a drop in
blood pressure (or hypotension) due to
decreased active musculature in the
lower extremities, which can reduce
circulation. Proper warm up and cool
down exercises can help with circulation
and blood pressure.3,5
Impaired Thermoregulation
Thermoregulation is another concern
among individuals with spinal cord
injury. Sweating is a normal physiological
response to an increase in core tempera-
ture to help keep the body cool.8 How-
ever, reduced sweat responses below the
level of injury and an impaired ability to
thermoregulate during exercise has been
documented in individuals with spinal
cord injuries.9 To help manage core tem-
perature and provide perceptual benefits
(eg, feeling cooler), clients can combine
adequate hydration (with careful atten-
tion not to overconsume fluids) and cool-
ing strategies, such as spraying water with
fans, using ice cold towels, and drinking
ice slurries or cold fluids.8
Pressure Ulcers
Another issue common among individu-
als with spinal cord injury is skin break-
down, or pressure ulcers, due to reduced
sensation. Monitoring skin and using pad-
ding with equipment can help prevent or
improve skin ulcers.3,4
Low Bone Mineral Density
Those with spinal cord injury also face a
risk of developing low bone mineral den-
sity (BMD), making them more prone to
fractures.10,11 Because bone is strength-
ened by skeletal loading, individuals who
become wheelchair bound due to their
injury subsequently decrease weight-
bearing activities. Loss of BMD after
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  53
injury is most rapid within the first few
months and reaches a steady state after
two years.12
While exercise has been shown to
increase BMD in the able-bodied popu-
lation, more research is needed to deter-
mine the effects of exercise on BMD in
individuals with spinal cord injury. Stud-
ies conducted in para-athletes and active
individuals with spinal cord injury have
shown higher BMD scores in the upper
extremities compared with their able-
bodied counterparts.13,14 Furthermore,
researchers have observed higher BMD
values in body areas above the level of
injury in basketball players with spinal
cord injury than in sedentary individuals
with spinal cord injury.13 Finally, clear-
ance from a physician before standing or
performing weight-bearing exercise is rec-
ommended if individuals haven’t stood for
one year or more.5
Final Thoughts
In general, individuals with spinal cord
injury should first obtain clearance
from their physicians before beginning
an exercise program. Exercise ideally
is performed under the supervision of
an exercise professional specializing
in spinal cord injury management.5
Physical activity combined with lifestyle
and dietary modifications should be
appropriately prescribed based on the
person’s level of function to improve
safety, adherence, and quality of life.6
The United Spinal Association offers
great resources for active individuals
(adolescents and adults) with spinal cord
injury at unitedspinal.org/exercise-and-
spinal-cord-injury. n
Kelly Pritchett, PhD, RD, CSSD, is an associate
professor in nutrition and exercise science at
Central Washington University. As a board-
certified specialist in sports dietetics, she
has consulted with both elite and collegiate
athletes as well as with active individuals.
She has authored research articles for
scientific journals and presented at regional
and national conferences with her current
research interests, including vitamin D and
energy availability in athletes with spinal cord
injury. In her spare time, she enjoys running
and spending time with her three active boys.
For references, view this article on our
website at www.TodaysDietitian.com.
Get to Know … By Lori Zanteson
Wendy Reinhardt Kapsak
A Produce Advocate Making Her Own Way
A
s president and CEO of the Pro-
duce for Better Health Founda-
tion (PBH)—the only national
nonprofit organization dedi-
cated to helping Americans
consume more fruits and vegetables—
Wendy Reinhardt Kapsak, MS, RDN, of
St. Louis, certainly has culled a singular
career for an RD.
Reinhardt Kapsak’s position at PBH is
the culmination of her constant learning
and growth, as well as rich experiences in
her previous positions, including a contro-
versial role at Monsanto (now Bayer) at the
time of many state-by-state GMO labeling
initiatives. She says she wouldn’t have pre-
dicted such a unique trajectory for herself,
but her business savvy and kind, passion-
ate personality that shine through when
speaking with her make her prestigious
path no surprise. Reinhardt Kapsak knows
that speaking her mind is powerful and
vital to effect change and that, as a dieti-
tian, she has a unique perspective, knowl-
edge, and skillset that need to be shared.
54  TODAY’S DIETITIAN • JANUARY 2022
primed for her position as president and
CEO of PBH in 2017.
Reinhardt Kapsak’s days are filled with
the responsibilities of a president and CEO,
but she doesn’t follow an “all business” per-
sonality or lifestyle. She’ll accept credit for
her hard work but is quick to express her
gratitude for the support she’s had from
the many role models and mentors along
the way. And while she’s an inspiring,
influential, and dynamic leader, she’s won-
derfully down to Earth, shuttling her kids
around and fitting in workouts to destress,
embracing the challenge of balancing it all.
Today’s Dietitian (TD): Describe your
nutrition and dietetics journey and how
it has led to your current position.
Reinhardt Kapsak: Originally, I wanted to
be a physician. As I was studying biology
as an undergraduate at the University of
Missouri-Columbia, my mom was diag-
nosed with cancer. It was at that moment
I thought I would rather help people stay
well than treat people who were really
sick. As a result, I did an extra year to
satisfy the requirements to become a
dietitian. I went on to get my master’s in
nutrition and exercise science at James
Madison University in Virginia, and then
did my dietetics internship at Yale New
Haven Hospital in Connecticut. I knew I
didn’t want to pursue clinical dietetics or
work in a hospital, given, by that time, my
It was precisely that perspective that
mom had passed away. I chose that intern-
Monsanto was seeking when Reinhardt
ship because it was the longest internship
Kapsak was brought aboard as in-house
and I knew it would be important to have
dietitian in 2012. With her RD expertise,
a clinical base. In addition, at the time,
she successfully convinced Monsanto to
it also was one of the only programs that
engage and dialog with the food and nutri-
allowed for a special interest rotation [in
tion community, as food and agriculture
a setting of my choice]. I did this rotation
always would be connected. Fruit and
in Washington, D.C., with the USDA at the
vegetable agriculture became her world.
time of the 2000 Dietary Guidelines for
Upon meeting with the president of Mon-
Americans, so I was able to see the launch
santo, Reinhardt Kapsak expressed her
of those guidelines and how the federal
view that people need to understand the
government executed food and nutrition
breeding technology that supports fruit
policy objectives. I also did part of my spe-
and vegetable agriculture because it’s the
cial interest rotation with a small orga-
foundation of all agricultural innovation.
nization called the International Food
That candid response led to her being
Information Council (IFIC). I ended up
named global corporate engagement lead
getting my first real job at IFIC and spent
for Monsanto Vegetable Seed Company. In
12 years there.
this role, she persuaded Monsanto to fund
From IFIC, I went onto a somewhat
a million-dollar effort focused on con-
controversial position at Monsanto. At
necting the food, nutrition, and culinary
the time, there were several state GMO-
communities with the agricultural com-
labeling initiatives that called into
munity to advance the dialogue regard-
question the safety of this agricultural
ing innovation to solve complex global
innovation, among other [technologies].
food system challenges. And thus, she was
They wanted a dietitian in house to help
them understand the food and nutri-
tion perspective. During that time, I was
exposed to fruit and vegetable agriculture
and Monsanto was the largest vegetable
and melon company by sales globally.
I became the global corporate engage-
ment lead for Monsanto Vegetable Seed
Company. That’s what brought me here
to become the president and CEO of PBH;
I could have never understood the chal-
lenges of fruit and vegetable growers with-
out having had the exposure and freedom
to learn as I did at Monsanto.
TD: One of the main attributes that makes
you stand out as an RD is that you’re an
inspiring leader with strong management
and marketing skills. Can you explain how
you acquired these skills?
Reinhardt Kapsak: I’ve had some really
strong and amazing leaders and mentors
throughout my career. My education gave
me a foundation, but it’s been my experi-
ences and my mentors that have made
me the leader I am today. Specifically, Sue
Borra, RD, one of the Academy Medallion
[Award] winners, is one of my very first
mentors; she had quite a nontraditional
dietetics career herself, as she was one of
the very first supermarket dietitians. Syl-
via Rowe, IFIC’s president and CEO while I
was there, also was very encouraging and
still serves as a key confidant today. When
I was at Monsanto, I had great access to
many of the executives who I learned from
and who were very supportive of me. At
PBH, my board chairs have been instru-
mental in helping me further refine my
leadership style; I’m still a work in progress
and have so much I’d like to improve upon.
My experience in Washington, D.C.,
particularly at IFIC, provided one of the
best educations in engaging multiple
stakeholders on a particular issue or topic
and trying to unite them around a pro-
gram or project that would benefit all of
them while still providing them individual
value. That’s a skill that has carried me
through every job I’ve had.
TD: What is PBH, and what’s your role in
helping the organization reach its goals?
Reinhardt Kapsak: PBH is the only national
nonprofit charitable organization that’s
100% dedicated to helping consumers live
happier, healthier lives by encouraging
them to eat fruits and vegetables every
single day. We seek to understand how to
make fruit and vegetable consumption
easier through research and consumer
insights. Those findings inform our con-
sumer and influencer outreach programs,
including the Have A Plant movement,
which is geared toward millennials and
Gen Z and [focuses on] the idea that fruits
and vegetables are really the “OG” of
plants. They’re the plants no one’s eating
enough of! Ultimately, our goal is to ele-
vate fruit and vegetable consumption as a
national priority here in the United States.
TD: What is the most influential
medium for your message?
Reinhardt Kapsak: When it comes to our
PBH audience of millennials and Gen Zs,
our most influential mode to amplify the
Have A Plant movement is social media
(#haveaplant). Since we launched the Have
A Plant movement in April 2019, we’ve
reached hundreds of millions of consum-
ers. We want everyone to use the hashtag;
we have to band together to elevate fruits
and vegetables! My role doesn’t always
allow me the time that’s necessary to
engage on social media. I’m in awe of our
social media ambassadors and the work
they do, and I rely on them heavily.
TD: As a mom of three, how do you
balance your roles as parent and CEO?
What are the biggest challenges and
rewards?
Reinhardt Kapsak: I have an excellent
partner in my husband, Dan. I wouldn’t
want to do life without him. He makes me
a better person, and he makes me laugh.
What helps me balance the stress of try-
ing to raise money for a charity, which
is what PBH is, is physical exercise and
focusing on others. Both are important
for my physical and mental health. Being
a parent is so fun. Now that I have teenag-
ers, humor plays a big role in my ability
to balance my professional and personal
responsibilities. At home, I’m probably not
the “CEO”; I think my 10-year-old daugh-
ter thinks she is.
I’ve always recognized that as a profes-
sional who has had a lot of great jobs that
have taken me many great places, I have, at
times, missed out on things with my fam-
ily. That’s a downside. The rewards are I’ve
been able to provide great opportunities for
my family and others because I’ve had these
roles. I also try to be a role model to my kids
by showing them that if you’re open to new
experiences and you work hard, there’s
really great growth that happens.
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  55
TD: Please share a glimpse of what is in
your pantry, fridge, and freezer.
Reinhardt Kapsak: I have a ton of all forms
of fruits and vegetables in my pantry,
fridge, and freezer. I also have a lot of
fresh, prepared meals because I’m so
busy, but also because I have teenage
boys, and they literally eat all the time.
These meals are easy to pop into the
microwave. I have a ton of nuts also and
whole grains and pasta. I’m not com-
pletely plant based. I love cheeseburg-
ers—and queso and chips.
Regardless, I try to live out what my
current role is promoting, which is, let’s
add more fruits and vegetables, incor-
porate them into more of your favor-
ite foods, whether pizza, tacos, burgers,
cereals, waffles, or yogurt. The research
shows that the people who consume the
most fruits and vegetables are really eat-
ing them at every meal or snack occa-
sion. But that doesn’t mean it’s the only
thing they’re eating. The most successful
fruit and vegetable eaters are those who
pair fruits and vegetables with all of their
favorite foods.
TD: When you’re not working, how do
you enjoy spending your time?
Reinhardt Kapsak: I enjoy physical work—
exercise, cleaning. Yes, cleaning; it’s weird!
I really love spending time with my fam-
ily, and I love being outside. When I’m not
working, I may be teaching a group fitness
class, or more often, I will be doing some-
thing for my family, whether it’s shopping
for them, driving them somewhere, going
to their activities and events. That’s the
phase of life I’m in right now. It’s really
serving them and recognizing that they’re
going to leave me someday. My oldest son
is a sophomore. Once he starts driving,
he’s gone. The other two … they may stay
with us forever!
TD: What’s next for you?
Reinhardt Kapsak: I don’t think I can pre-
dict. The more I move through life and
career, especially having experienced a
pandemic, I realize that while it’s impor-
tant to have a sense of what you might like
to do next, it’s also very important to be in
the moment right now. Be open to all the
possibilities; what’s next for you might be
better than you originally expected. n
Lori Zanteson is a food, nutrition, and health
writer based in Southern California.
Health Matters
Therapeutic Foods May Improve
Cognition in Malnourished Children
A nutritional supplement that’s popular in
the United States and is added to some
types of yogurt, milk, and infant formula
can significantly improve cognition in
severely malnourished children, according
to a study led by researchers at Washington
University School of Medicine in St. Louis.
The researchers found that when the
omega-3 fatty acid DHA was added to an
internationally prescribed, nutrient-dense
ready-to-use therapeutic food similar to
peanut butter, the children’s overall cogni-
tion improved. The kids who ate the DHA-
fortified food surpassed those who didn’t
in gross and fine motor abilities, language
proficiencies, and social skills—all related
to brain health.
In addition, reducing the amount of
linoleic acid—a polyunsaturated omega-6
fatty acid—in the food aided the children’s
neurological abilities. This is because the
chemical composition of the omega-6
fatty acid thwarts production of the
brain-boosting DHA, the latter of which
is essential for brain development dur-
ing pregnancy and early childhood and
is associated with improved vision, heart
health, and immune system function.
“This is the first evidence of the cogni-
tive effects of ready-to-use therapeutic
56  TODAY’S DIETITIAN • JANUARY 2022
food showing DHA and reduced omega-6
are needed to increase the brain power
of children with severe acute malnutri-
tion,” says the study’s senior author, Mark
J. Manary, MD, the Helene B. Roberson
Professor of Pediatrics at Washington
University in St. Louis. “We think the ther-
apeutic food should be reformulated and
standardized to include DHA and reduced
omega-6. All children are entitled to our
best efforts to reach their neurocognitive
potential.”
The findings were published online in
The American Journal of Clinical Nutrition.
Globally, more than 16 million children
younger than 5 suffer from severe acute
malnutrition. The condition is a form of
starvation that primarily affects kids from
impoverished areas of Africa and Asia and
causes excessive thinness or swelling of
the body while also compromising organ
systems, including the brain. Severe acute
malnutrition kills about 1 million chil-
dren each year.
Nearly two decades ago, Manary
launched an effort in Africa to fight severe
malnutrition using a peanut butter–based
therapeutic food fortified with micronu-
trients known to restore body and muscle
mass. The energy-dense, low-moisture
food comprises peanuts, milk, vegetable
oils, and sugar, and, like peanut butter, it
requires no cooking and doesn’t spoil in
ambient conditions. Such characteristics
make the food ideal for people living in
extreme poverty or in areas struck by a
natural disaster, political unrest, or other
situations causing food scarcity.
Outpatient feeding programs serving
this ready-to-use therapeutic food have
saved the lives of hundreds of thousands
of malnourished children. Earlier data
have shown that children with severe
acute malnutrition who were treated with
the food recovered at rates of 85% to 90%.
But Manary and others who care for mal-
nourished children have faced challenges
in effectively treating the cognitive prob-
lems associated with severe malnutri-
tion, such as difficulty speaking, mobility
issues, and behavioral problems.
The malnourished brain requires addi-
tional special nutrients to restore normal
function, namely omega-3 polyunsatu-
rated fatty acids most commonly found
in fish and breastmilk, Manary says. DHA
constitutes 10% of the brain matter and is
the most important nutrient for the brain.
“Adding it to the therapeutic food along
with reducing omega-6, which is antago-
nistic with omega-3, boosted cognition in
starving children,” Manary says.
The clinical feeding trial was con-
ducted from October 2017 through
December 2020 at 28 clinics in rural
Malawi in sub-Saharan Africa. It involved
2,565 children aged 6 months to 5 years
with uncomplicated severe malnutrition,
meaning they were diagnosed as severely
malnourished but still had good appetites,
weren’t hospitalized, and didn’t show
signs of severe infection.
Children were randomly assigned to
receive one of three ready-to-use thera-
peutic foods: the original standard version
with higher levels of omega-6, a version
with reduced amounts of omega-6 and
increased omega-3, and a version that
included DHA with reduced omega-6. The
trial investigators, families, and research-
ers analyzing the data didn’t know to
which groups the children were assigned.
The treatments lasted about eight
weeks. Six months after treatment ended,
the researchers compared cognition in the
malnourished children. They measured
cognition using the Malawi Development
Assessment tool, a standardized, scientifi-
cally validated battery of exercises testing
language proficiency, social interaction,
and gross and fine motor skills.
“Cognition was superior in the chil-
dren who received the therapeutic food
with additional omega-3 and DHA when
compared with the other two groups,”
Manary says. “Their scores were higher
across the board. We noted an improve-
ment that was 22% greater than in those
who received the standard ready-to-use
therapeutic food.
“For half of the children, cognition
is completely restored, but without low
omega-6 plus DHA, severely malnour-
ished children would be 10 IQ points
below average,” he adds.
Researchers also measured DHA
levels in the children’s blood immedi-
ately after completing the ready-to-use
therapeutic food intervention. After four
weeks, DHA levels decreased by 25% in
children receiving the standard food,
most likely because of the high amount
of omega-6 fatty acids. (Manary notes
that those DHA levels would decrease by
significantly larger margins if the chil-
dren were given no ready-to-use thera-
peutic food at all.) Meanwhile, after four
weeks, DHA levels increased by 49%
among children who received the DHA-
enhanced food.
“This suggests that the lack of DHA
was limiting cognitive improvement,”
Manary says. “It’s fantastic news in the
sense that the DHA-enhanced therapeutic
food could restore malnourished brains
better than before, and those benefits can
stick for six months to a year or more.”
In November, the researchers pre-
sented their findings to the World Health
Organization, which establishes inter-
national guidelines for the treatment of
malnutrition and other diseases. Addi-
tionally, in early December, they shared
their research to advocate for improve-
ments in the formulation of ready-to-use
therapeutic food distributed worldwide,
during a meeting of the Codex Alimenta-
rius Commission, an international food
safety organization that sets standards
followed by most of the world’s nations.
Manary and his colleagues are calling for
all ready-to-use therapeutic food to be
made with reduced amounts of omega-6
fatty acids and enhanced with DHA.
“Our goal is to change global policy,”
Manary says. “These children deserve
nothing less.”
SOURCE: WASHINGTON UNIVERSITY IN ST. LOUIS
SNAP Can Reduce Hospital Visits,
Health Care Costs for Older Adults
Food insecurity among older adults
takes a toll on the nutrition and health
of those affected. According to data
from 2019, 5.2 million people aged 60
and older in the United States were food
insecure—equaling 7.1% of that popula-
tion—and that number has likely grown
during the COVID-19 pandemic.
Older adults facing food insecurity
are more likely to have chronic health
conditions such as depression, asthma,
diabetes, congestive heart failure, and
heart attack. Only 48% of older adults
who qualify for the Supplemental Nutri-
tion Assistance Program (SNAP), which
provides benefits to supplement bud-
gets to purchase healthful and nutritious
foods, are enrolled in the program.
A study published in the Annals of
Internal Medicine shows the impor-
tance of older adults taking advantage
of this nutrition benefit, as it’s asso-
ciated with fewer hospital visits and
lower health care costs.
“Providing income support for
older adults is incredibly important for
health,” says study lead author Seth A.
Berkowitz, MD, MPH, an assistant pro-
fessor of general medicine and clinical
epidemiology at the University of North
Carolina School of Medicine. “Along
with affecting the foods they have
access to, food insecurity can force
people to choose between food and
medications or other basic needs, and
worsen mental health. All of this takes
a toll on what is already a group at high
risk for poor health outcomes.”
The study used a unique circum-
stance to better evaluate the association
between SNAP participation and health
care use and cost. In 2017, Benefits Data
Trust (BDT)—a national nonprofit dedi-
cated to helping people access essential
public benefits and services—was con-
tracted by the North Carolina Depart-
ment of Health and Human Services to
help people aged 65 and older who were
dually eligible for Medicare and Medic-
aid enroll in SNAP. BDT provided out-
reach to these individuals by mail and a
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  57
telephone-based screening, and—if the
person chose to enroll in SNAP—the non-
profit would aid in filing an application.
This circumstance allowed for previously
unavailable linkages among data sets
related to SNAP outreach, SNAP partici-
pation, and health care use and cost.
Researchers used data from BDT’s
outreach to more than 115,000 people
age 65 and older in North Carolina
between 2016 and 2020 who were dually
eligible for Medicare and Medicaid, and
were eligible for SNAP but not enrolled.
Almost 5,100 of those who received out-
reach about SNAP benefits enrolled in
the program. SNAP enrollment was asso-
ciated with a decrease in inpatient hospi-
talizations, emergency department visits,
and long term care admissions, as well as
fewer dollars in Medicaid payments per
person per year.
“Billions of dollars in food and health
care assistance go untapped every year,
often because people aren’t aware they
are eligible or they are not sure how
to access them,” says Pauline Aberna-
thy, chief strategy officer at BDT. “These
research findings show that data-driven
outreach and application assistance sig-
nificantly increase SNAP participation,
which in turn markedly improves health
and lowers Medicaid costs. With mil-
lions of people 65 and older eligible but
not participating in SNAP, this research
underscores the urgent need to increase
outreach and streamline enrollment.”
SOURCE: UNIVERSITY OF NORTH CAROLINA SCHOOL
OF MEDICINE
News Bites
Fast Food Availability Linked
to Higher Rates of Type 2 Diabetes
An increasing number of studies suggest
a link between a neighborhood’s built
environment and the likelihood that its
residents will develop chronic diseases
such as heart disease, type 2 diabetes,
and certain types of cancers. A new
nationwide study led by researchers from
New York University (NYU) Grossman
School of Medicine published online in
JAMA Network Open suggests that living
in neighborhoods with higher availabil-
ity of fast-food outlets across all regions
of the United States is associated with
higher subsequent risk of developing
type 2 diabetes.
Findings also indicated that the avail-
ability of more supermarkets could be
protective against developing type 2 dia-
betes, particularly in suburban and rural
neighborhoods.
The study—notable for its large geo-
graphic breadth—uses data from a
cohort of more than 4 million veterans
living in 98% of US census tracts across
the country. It counted fast-food restau-
rants and supermarkets relative to other
food outlets, and is the first, according to
the researchers, to examine this relation-
ship in four distinct types of neighbor-
hoods (high-density urban, low-density
urban, suburban, and rural) at the
hyperlocal level nationwide.
58  TODAY’S DIETITIAN • JANUARY 2022
“Most studies that examine the built
food environment and its relationship to
chronic diseases have been much smaller
or conducted in localized areas,” says
Rania Kanchi, MPH, a researcher in the
department of population health at NYU
Langone Health and lead author of the
study. “Our study design is national in
scope and allowed us to identify the types
of communities that people are living
in, characterize their food environment,
and observe what happens to them over
time. The size of our cohort allows for
geographic generalizability in a way that
other studies do not.”
The research team used data from the
US Veterans Health Administration (the
largest single-payer health care system
in the country) that captures more than
9 million veterans seen at more than
1,200 health facilities around the country.
Using these data, the researchers then
constructed a national cohort of more
than 4 million veterans without diabe-
tes from the VA electronic health records
between 2008 and 2016. Each veteran’s
health status was followed through 2018
or until the individual either developed
diabetes, died, or had no appointments
for more than two years.
Within each of four distinct neighbor-
hood types, the proportion of restaurants
that were fast food, and the proportion of
food outlets that were supermarkets were
tabulated within a one-mile walk in high-
density urban neighborhoods, a two-mile
drive in low-density urban neighborhoods,
a six-mile drive in suburban communities,
and a 10-mile drive in rural communities.
Veterans were followed for a median
of five and a half years. During that time,
13.2% of the cohort were newly diagnosed
with type 2 diabetes. Males developed
type 2 diabetes more frequently than
females (13.6% vs 8.2%). Non-Hispanic
Black adults had the highest incidence
(16.9%), compared with non-Hispanic
whites (12.9%), non-White Asian and
Hispanics (12.8%), Native Hawaiian and
Pacific Islanders (15%), and Native Ameri-
can and Alaskan Indians (14.2%).
When stratifying by community types,
14.3% of veterans living in high-density
urban communities developed type 2
diabetes, while the lowest incidence was
among those living in suburban and small
town communities (12.6%).
Overall, the team concluded that the
effect of the food environment on type 2
diabetes incidence varied by how urban
the community was but didn’t vary fur-
ther by region of the country.
“The more we learn about the relation-
ship between the food environment and
chronic diseases like type 2 diabetes, the
more policymakers can act by improving
the mix of healthy food options sold in res-
taurants and food outlets, or by creating
better zoning laws that promote optimal
food options for residents,” says Lorna
Thorpe, PhD, MPH, a professor in the
department of population health at NYU
Langone and senior author of the study.
One limitation of the study, according
to the authors, is that it may not be fully
generalizable to nonveteran populations,
as US veterans tend to be predominantly
male and have substantially greater
health burdens and financial instability
than the civilian population. They are also
at greater risk of disability, obesity, and
other chronic conditions.
The next phase of the research, Thorpe
and Kanchi say, will be to better under-
stand the impacts of the built environ-
ment on diabetes risk by subgroups. They
plan to examine whether the relationships
between fast-food restaurants, supermar-
kets, and community types vary by gender,
race/ethnicity, and socioeconomic status.
SOURCE: NEW YORK UNIVERSITY LANGONE HEALTH
How US Consumers May Reduce Their Food-Related Carbon Footprint
Most consumers want to make food
purchases that are smart for their wallets,
their health, and the environment.
And while switching to a vegetarian or
vegan diet can lower one’s impact on
greenhouse gas emissions, it may not
be realistic or healthful for everyone.
Now, researchers in the American
Chemical Society’s Environmental
Science & Technology report three ways
that Americans can reduce the carbon
footprint of their food purchases, without
requiring drastic dietary changes.
Getting food from farms to
people’s plates contributes a sizeable
portion of global greenhouse gas
emissions. And animals are inefficient
at converting the plants they eat into
energy, so meat and dairy products
result in higher emissions than fruit,
vegetables, and grains. Based on that
knowledge, previous researchers have
provided suggestions for changes that
individuals or households can make
to reduce the emissions generated
by food production. However, most
of these recommendations have been
based on an “average American diet.”
Of course, not everyone eats the same
types or quantities of foods, so to
account for this diversity, researchers
wanted to assess the actual groceries
purchased by US households and
identify the hotspots of carbon
emissions in these purchases.
The researchers analyzed detailed
grocery purchase records of more
than 57,000 US households in 2010,
and for each home, summed the
greenhouse gas emissions for grow-
ing and harvesting the food items.
Data for packaging and transportation
weren’t included because that infor-
mation was unavailable. Then, they
compared the emissions calculation
with that which would be generated
from buying foods for a benchmark
healthful and sustainable diet.
The team’s analysis revealed that 71%
of homes surveyed could decrease their
food carbon footprint, identifying the fol-
lowing main ways for consumers to do so:
JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  59
• Small households of one or two
people should buy less food in bulk
quantities, which is often more than
will be eaten, and manufacturers
should offer cost-effective pack-
age sizes.
• Cutting out foods with high caloric
content and low nutritional value
would result in a 29% reduction
of the total potential emissions,
while also possibly improving
health outcomes.
• People should buy less savory
bakery products and ready-
made foods. Though those foods
are responsible for relatively
low carbon emissions, the large
amounts of these items that
are purchased adds up to signifi-
cant emissions.
In summary, the researchers say
these strategies are initial ways people
can reduce their at-home food-based
carbon footprint.
SOURCE: AMERICAN CHEMICAL SOCIETY
Products + Services
Seed and Nut
Flour Snacks
Simple Mills, a maker of gluten-free foods including
baking mixes and snacks, rolls out a line of Organic
Seed Flour Crackers in Original, Everything, and Garlic
& Herb varieties. Made from a seed and seed flour
blend plus cassava flour, the crackers are Non-GMO
Project Verified, Certified Gluten-Free, vegan,
and USDA Organic.
The company also unveils a line of Sweet Thins made
with a seed and nut flour blend. Available varieties
include Honey Cinnamon, Mint Chocolate,
and Chocolate Brownie.
simplemills.com
Nondairy Mochi
Ice Cream Released
Bubbies Ice Cream, a maker of mochi ice cream
and ice cream bites, unveils three new nondairy
varieties of its Mochi Frozen Dessert: Vegan
Strawberry, Vegan Chocolate, and Vegan Mango.
The mochi comprises a coconut-based frozen
dessert wrapped in sweet rice dough.
bubbiesicecream.com
60  TODAY’S DIETITIAN • JANUARY 2022
New Instant Oatmeal,
Granola Variety
Bob’s Red Mill, a maker of a wide variety of pantry staples,
baking ingredients, and snacks, rolls out a line of Instant
Oatmeal in Classic, Brown Sugar & Maple, and Apple Pieces
& Cinnamon varieties. All are a good source of fiber and
are Non-GMO Project Verified, Certified Gluten-Free, and
kosher. The company also adds a new variety, Peanut
Butter, to its Homestyle Granola line. It’s Certified Gluten-
Free and Non-GMO Project Verified.
bobsredmill.com
Innovative
Protein Gummies
Global Health Products, maker of the liquid
protein supplement LiquaCel, introduces
Protein Gummies in Peach Mango and
Watermelon varieties. Each serving contains
13 g protein, 6 g fiber, and 4 g sugar.
globalhp.com
Veggie Chips Debut
Real Food From the Ground Up, a maker of vegetable-
based snacks, reveals a line of Cauliflower Potato Chips
available in Sea Salt, Salt & Vinegar, Sour Cream & Onion,
and Buffalo varieties. Made with cauliflower, spinach,
broccoli, carrot, tomato, beet, and shiitake mushrooms,
the chips are Non-GMO Project Verified, Certified Gluten-
Free, Certified Vegan, and kosher.
fromthegroundupsnacks.com
 Plant-Based Meat
Alternatives
Future Farm, a Brazilian maker of plant-based
meat alternatives made with soy, pea, and chick-
pea proteins, launches its products in the United
States. The vegan meat alternatives include
Future Burger, Future Beef (mimicking ground
beef), Future Meatballs, Future Chick’n,
and Future Sausage.
All products are non-GMO and gluten-free.
The Burgers, Beef, and Meatballs are an excellent
source of fiber, protein, and iron and a good source Quinoa Snacks
of potassium. The Chick’n is an excellent source of
protein and iron and a good source of potassium,
while the sausage is a good source of protein.
Introduced
futurefarm.io Undercover Snacks is a new line of crispy quinoa snacks made
with chocolate, dried fruits, and spices. Varieties include
Dark Chocolate + Pomegranate, Dark Chocolate + Blueberries,
Dark Chocolate + Sea Salt, Milk Chocolate, Milk Chocolate
+ Currants, Dark Chocolate + Peppermint, Milk Chocolate +
Peppermint, and Dark Chocolate + Pumpkin Spice. All are
nut-free, gluten-free, and kosher.
undercoversnacks.com

Mini Flatbreads Smoothie Pops Launch

Unveiled
Atoria’s Family Bakery, a maker of several lines
of flatbreads, debuts Cauliflower & Coconut Mini
Lavash Flatbread. Made with cauliflower and coconut
flours, the breads are a good source of protein
and fiber, vegan, and Non-GMO Project Verified.
The company also releases Roasted Red Pepper
Mini Lavash Flatbread, which is vegan, non-GMO,
and an excellent source of vitamin A.
atoriasfamilybakery.com
reBLEND Frozen Superfood Smoothie Shots is a new line
of frozen pops made with fruits, vegetables, as well as various
seeds, spices, and botanicals. The pops are available in Your
Daily Detox (green apple, pineapple, and mango), Very Berry
Glow (strawberry, cherry, and blueberry), Frosé All Day
Chill (strawberry, raspberry, and rose water), and Tropical
Bliss Recover (pineapple, peach, and mango). All varieties
are vegan and gluten-free.
reblend.co

JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  61

Research Briefs
Blood Metabolites Associated With Coffee
Consumption May Affect Kidney Disease Risk
Food and beverages may have important
effects on kidney health, but the poten-
tial biological mechanisms involved
are often unclear. New research in the
Clinical Journal of the American Society
of Nephrology identifies several metab-
olites in the blood whose levels are
altered by coffee consumption and may
affect the risk of developing chronic
kidney disease (CKD).
When Casey M. Rebholz, PhD, MS,
MNSP, MPH, of Johns Hopkins Bloom-
berg School of Public Health, and her col-
leagues examined 372 blood metabolites
in 3,811 participants in the Atherosclero-
sis Risk in Communities study, a prospec-
tive community-based cohort, they found
that 41 metabolites were associated with
coffee consumption. When the team ana-
lyzed these metabolites in an additional
1,043 adults in the Bogalusa Heart Study,
a community-based long-term epide-
miological study, 20 of the 41 metabolites
62  TODAY’S DIETITIAN • JANUARY 2022
were also associated with coffee con-
sumption in this group.
Higher levels of three of these coffee-
related metabolites were significantly asso-
ciated with higher risks of developing CKD:
glycochenodeoxycholate, O-methylcate-
chol sulfate, and 3-methylcatechol sulfate.
Glycochenodeoxycholate, a lipid
involved in primary bile acid metabo-
lism, may contribute to potentially ben-
eficial effects of coffee consumption on
kidney health. O-methylcatechol sulfate
and 3-methylcatechol sulfate, which are
involved in metabolism of the preservative
benzoate, may represent harmful aspects
of coffee on the kidneys.
“A large body of scientific evidence
has suggested that consuming a moder-
ate amount of coffee is consistent with
a healthy diet. We were able to identify
one metabolite that supports this the-
ory,” Rebholz says. “There were two other
metabolites associated with coffee that
surprisingly were associated with a higher
risk of incident chronic kidney disease.
These compounds were also associated
with cigarette smoking, which may in part
explain why these compounds were asso-
ciated with higher risk of kidney disease.”
With more research on the metabolic
underpinnings of the coffee-kidney rela-
tionship, these metabolites may point
to processes that are relevant for pre-
venting kidney disease through dietary
modifications.
An accompanying editorial notes
that it would have been interesting to
see how the study’s results on metabo-
lites associated with kidney disease after
accounting for participants’ self-reported
consumption of coffee. “Integrating these
data types should provide a better under-
standing of the role coffee and other diet
factors play in the development of CKD or
other diseases,” the authors wrote.
SOURCE: AMERICAN SOCIETY OF NEPHROLOGY
Gut Microbiome Linked to Aggressive Prostate Cancer
Cleveland Clinic researchers have In addition to PAGln, researchers also risk of cardiac events,” Hazen says. “This
shown for the first time that diet- discovered that elevated levels of two suggests that part of beta blockers’
associated molecules in the gut are nutrients abundant in animal products, potent efficacy may be due to blocking
associated with aggressive prostate including red meat, egg yolks, and high- the metabolite’s activity.”
cancer, suggesting dietary interventions fat dairy products, called choline and “New insights are emerging from
may help reduce risk. Findings from betaine, also were linked with increased large-scale clinical datasets that show
the study were published in Cancer risk of aggressive prostate cancer. While use of beta blockers is also associ-
Epidemiology, Biomarkers & Prevention. these nutrients and gut metabolites ated with lower mortality due to pros-
While more research will be necessary, have been studied previously in heart tate cancer,” says Sharifi, who’s a staff
the study’s lead author, Nima Sharifi, disease and stroke, this is the first time physician in Lerner Research Insti-
MD, says findings from the team’s gut microbiome metabolites have been tute’s Department of Cancer Biology.
analysis of nearly 700 patients may have studied clinically in relation to prostate “We will continue to work together to
clinical implications for diagnosing and cancer outcomes. investigate the possible mechanisms
preventing lethal prostate cancer. Hazen, director of Cleveland Clinic’s linking PAGln activity and prostate
“We found that men with higher Center for Microbiome & Human Health cancer disease processes in hopes of
levels of certain diet-related molecules and chair of Lerner Research Institute’s identifying new therapeutic targets
are more likely to develop aggressive Department of Cardiovascular & Meta- for our patients.”
prostate cancer,” says Sharifi, director bolic Sciences, was the first to identify The research team also will continue
of Cleveland Clinic’s Center for Genito- PAGln’s association with increased car- to explore the reliability of using cho-
urinary Malignancies. “As we continue diovascular disease risk. The findings line, betaine, and PAGln as biomark-
our research in this area, our hope is that were published in 2020 in Cell. “Interest- ers of aggressive prostate cancer and
one day these molecules can be used as ingly, we found that PAGln binds to the how dietary interventions can be used
early biomarkers of prostate cancer and same receptors as beta blockers, which to modulate their levels and reduce
help identify patients who can modify are drugs commonly prescribed to help patients’ subsequent disease risk.
their disease risk by making dietary and lower blood pressure and subsequent SOURCE: CLEVELAND CLINIC
lifestyle changes.”
In this study, Sharifi and his collabo-
rators—including Stanley Hazen, MD,
PhD, and Eric Klein, MD—analyzed data
from patients previously enrolled in the
National Cancer Institute’s Prostate,
Lung, Colorectal, and Ovarian Cancer
Screening Trial. They studied base-
line levels of certain dietary nutrients
and metabolites (byproducts produced
when a substance is broken down in
the gut) found in patients’ blood serum
before prostate cancer diagnosis. They
compared serum levels between healthy
patients and those who later received a
prostate cancer diagnosis and died from
the disease.
The researchers found that men
with elevated levels of a metabolite
called phenylacetylglutamine (PAGln)
were approximately two or three times
more likely to be diagnosed with lethal
prostate cancer. This metabolite is
produced when microbes in the gut
break down phenylalanine, an amino
acid found in many plant- and animal-
based protein sources such as meat,
beans, and soy.

JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  63

Datebook
JANUARY 16-18, 2022
School Nutrition Association School
Nutrition Industry Conference
San Antonio, Texas
http://schoolnutrition.org
FEBRUARY 25-28, 2022
American Academy of Allergy, Asthma
& Immunology Annual Meeting
Phoenix, Arizona
www.aaaai.org
MARCH 4, 2022
North Carolina Academy of Nutrition
and Dietetics Regional Meeting
Gastonia, North Carolina
www.eatrightnc.org
MARCH 7-11, 2022
National School Breakfast Week
http://schoolnutrition.org
MARCH 8-9, 2022
North Dakota Academy of Nutrition
and Dietetics “Nourishing Health”
Symposium & Expo: Virtual
https://eatrightnd.com
MARCH 11 & 18, 2022
Illinois Academy of Nutrition and
Dietetics Virtual Spring Assembly
www.eatrightillinois.org
APRIL 1, 2022
South Carolina Academy of Nutrition
and Dietetics Annual Meeting
Columbia, South Carolina
www.eatrightsc.org
APRIL 7-8, 2022
Oklahoma Academy of Nutrition
and Dietetics Spring Convention
Oklahoma City, Oklahoma
www.oknutrition.org
APRIL 21-22, 2022
Idaho Academy of Nutrition
and Dietetics Annual Meeting
Boise, Idaho
www.eatrightidaho.org
APRIL 21-23, 2022
California Academy of Nutrition
and Dietetics Conference and Expo
Oakland, California
https://dietitian.org
64  TODAY’S DIETITIAN • JANUARY 2022
The following information reflects the original dates and locations of
these events. Please check with each organization for the most up-to-date
information. Note that some events may feature virtual components.
APRIL 24-26, 2022 AUGUST 14-19, 2022
Oregon Academy of Nutrition and FASEB Science Research Conference:
Dietetics/Washington Academy of The Folate, Vitamin B12 , and One-
Nutrition and Dietetics Conference Carbon Metabolism Conference
Vancouver, Washington Asheville, North Carolina
www.eatrightoregon.org www.faseb.org
APRIL 28-30, 2022 OCTOBER 10-14, 2022
School Nutrition Association National School Lunch Week
National Leadership Conference http://schoolnutrition.org
West Palm Beach, Florida
http://schoolnutrition.org OCTOBER 31 – NOVEMBER 4, 2022
The Obesity Society
MAY 14-18, 2022 ObesityWeek® 2022
FASEB Science Research Conference: San Diego, California
The Second Acute Kidney Injury https://obesityweek.org
Conference: From Bench to Bedside
Banff, Canada JANUARY 15-17, 2023
www.faseb.org School Nutrition Association School
Nutrition Industry Conference
San Diego, California
MAY 22-25, 2022 http://schoolnutrition.org
Today’s Dietitian
2022 Spring Symposium FEBRUARY 24-27, 2023
Bonita Springs, Florida American Academy of Allergy, Asthma
www.TodaysDietitian.com/SS22 & Immunology Annual Meeting
San Antonio, Texas
www.aaaai.org
MAY 31 – JUNE 4, 2022
MARCH 6-10, 2023
American College of Sports Medicine
National School
69th Annual Meeting
Breakfast Week
San Diego, California
http://schoolnutrition.org
www.acsmannualmeeting.org
APRIL 27-29, 2023
JUNE 3-7, 2022
School Nutrition Association
American Diabetes Association
National Leadership Conference
82nd Scientific Sessions
Louisville, Kentucky
New Orleans, Louisiana
http://schoolnutrition.org
https://professional.diabetes.org
MAY 30 – JUNE 3, 2023
JULY 10-12, 2022
American College of Sports Medicine
School Nutrition Association
70th Annual Meeting
Annual National Conference
Denver, Colorado
Orlando, Florida
www.acsmannualmeeting.org
http://schoolnutrition.org
JULY 29 – AUGUST 1, 2022
Datebook listings are offered to all nonprofit
Society for Nutrition Education organizations and associations for their meetings.
and Behavior Annual Conference Paid listings are guaranteed inclusion.
Atlanta, Georgia All for-profit organizations are paid listings.
www.sneb.org Call for rates and availability.
Call 610-948-9500
AUGUST 12-15, 2022
Association of Diabetes Care Fax 610-948-7202
& Education Specialists E-mail TDeditor@gvpub.com
Annual Conference
Send Write with your listing two months
Baltimore, Maryland
before publication of issue.
www.diabeteseducator.org
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JANUARY 2022 • WWW.TODAYSDIETITIAN.COM  65

Culinary Corner By Liz Weiss, MS, RDN
Honeynut Squash
Clients will love this sweet mini winter delicacy.
B
ack in the early ’90s, my husband and I bought a
house in Lexington, Massachusetts, a suburb of
Boston. Lucky for us, our new home was just a short
walk from Wilson Farm, a family-owned farm estab-
lished in 1884. As a dietitian, cookbook author, and
mom of two, I made more trips to “the farm” than I could ever
even try to remember. I always came home with fresh, seasonal
produce—asparagus in spring, corn and tomatoes in summer,
and squash in the fall and winter—and sometimes a new pro-
duce variety would catch my eye.
Say hello to honeynut squash. I spotted it at Wilson’s about
five years ago, and I’ve been blown away by its beauty, natural
sweetness, and ease of preparation ever since.
Honeynut squash is ador-
able. It looks like a mini but-
ternut squash—it’s only five
to six inches tall—but it’s
sweeter, easier to handle, and
more nutritious (it has more
than double the beta-caro-
tene of butternut). Honeynut
is perfect for roasting and
stuffing; it cooks quickly,
too. Once these pint-sized
squashes are halved and
seeded, they take 20 to 30 minutes to roast in a 425˚ F oven.
And similar to delicata, the skin is thin, so it doesn’t need to be
peeled before cooking … and it’s edible. However, because of its
thin skin, it won’t store as long as butternut and other heartier
winter squash varieties. The flavor of honeynut is intensely
sweet with hints of caramel, and the flesh is pleasingly smooth,
tender, and a beautiful bright orange color.
Through traditional plant breeding, honeynut squash was
first introduced to the market about a decade ago. It was devel-
oped by Michael Mazourek, PhD, an associate professor in the
department of plant breeding and genetics at Cornell Univer-
sity, with help from Chef Dan Barber of the restaurants Blue
Hill and Blue Hill at Stone Barns, both based in New York. Hon-
eynut is harvested late September through early October, and
clients now can find it in grocery stores and farmers’ markets
across the United States.
For dietitians who counsel patients about adding more pro-
duce to their plates, there are multiple reasons to include hon-
eynut in their recommendations. It’s rich in beta-carotene and
a good source of vitamin C, folate, iron, potassium, and fiber;
kids will enjoy its candylike flavor and cuteness; and adults
will appreciate how easy it is to slice in half (you don’t need a
machete), seed, and roast. n
Liz Weiss, MS, RDN, is a mom of two grown boys with a specialty in
family nutrition. She’s the voice behind the family food podcast and
blog Liz’s Healthy Table, and her website is filled with easy, flavorful,
and nourishing recipes that appeal to both kids and adults. She appears
regularly on Boston’s NBC lifestyle show the Hub Today, and she’s a
Have a Plant Ambassador for the Produce for Better Health Foundation.
66  TODAY’S DIETITIAN • JANUARY 2022
Honeynut Squash Stuffed With
Mushrooms, Chickpeas, Pistachios,
& Cranberries
Serves 4
If you’re looking for a hearty and flavorful vegetable side
dish to celebrate the bounty of autumn produce, look no
further than this recipe. Every bite is a little sweet and a
little savory.
Ingredients
2 honeynut squash
4 tsp extra-virgin olive oil, divided
Kosher salt and freshly ground black pepper, to taste
1 small clove garlic, minced
8 oz sliced mushrooms, roughly chopped
4 to 5 green onions, trimmed and cut into thin rounds
(1/2 cup chopped)
3 sprigs fresh thyme, leaves removed and roughly
chopped
1/2 cup canned chickpeas, drained and rinsed
1/4 cup shelled pistachios, roughly chopped
2 T dried cranberries
Pinch red pepper flakes, optional
Directions
1. Preheat oven to 425˚ F and adjust rack to center of oven.
2. Cover a large, rimmed baking sheet with aluminum foil
and set aside. Wash and dry squash, and then cut in half,
lengthwise. Remove seeds and any stringy membranes with
a spoon, and place squash, cut side up, on the foil.
3. Use a pastry brush to brush 1 tsp of olive oil evenly over
squash. Sprinkle lightly with kosher salt and pepper. Turn
squash halves over, cut side down. Roast until thickest
portion of squash is very tender, 20 to 30 minutes. (A fork
should slide in and out very easily.)*
4. While squash is roasting, heat remaining 3 tsp of oil in
a large nonstick skillet over medium-low heat. Add garlic
and cook, stirring frequently, until fragrant, 30 seconds to
1 minute. Raise heat to medium-high and add mushrooms,
green onions, and thyme. Cook, stirring frequently, until
vegetables are tender, 6 to 8 minutes.
5. Stir in chickpeas, pistachios, dried cranberries, and red
pepper flakes, if desired, and heat through, about 2 minutes.
Season with kosher salt and pepper to taste.
6. Remove cooked squash from oven. Turn halves over so
cut sides are facing up. Place mushroom mixture (you’ll
have a total of 11/2 cups) evenly into each of the squash half
cavities. Garnish with a few thyme leaves.
* After Step 3, squash could be served, unstuffed, as a
simple side dish.
Nutrient Analysis per serving
Calories: 226; Total fat: 9 g; Sat fat: 2 g; Sodium: 58 mg; Total
carbohydrate: 36 g; Dietary fiber: 7 g; Sugars: 11 g; Protein: 8 g