Written By: Sara Scheler, RDN
I attended a lecture at the Colorado Society for Parenteral and Enteral Nutrition (CSPEN) nutrition support symposium in September, where Carrie Schimmelpfenning, RDN at Denver Health’s ACUTE eating disorder center, provided information regarding severely malnourished eating disorder patients. Carrie shared an overview of ACUTE, a review of common eating disorders, and nutrition therapy recommendations for critically ill eating disorder patients. The following is a summary of Carrie’s informative presentation.
ACUTE is an inpatient medical stabilization program for eating disorder patients—the only one if its kind in the country. Admission criteria includes weighing <70% of IBW, having a BMI <15, severe medical complications from an eating disorder, and/or needing to safely detox from laxative or diuretic abuse. ACUTE accepts male and female patients 17 years of age and older. Patients are seen 5 days/week by internal medicine doctors, registered dietitians, psychologists, psychiatrist, occupational therapists, physical therapists and speech therapists. They receive customized, daily meal plans and receive 24/7 observation for their first week. The goals of ACUTE are: to nourish the body with calories (the ultimate goal is a 2-3 pound per week weight gain), correct micronutrient/macronutrient deficiencies, empower clients to choose for themselves, provide nutrition education, and reduce disordered eating behavior.
Anorexia nervosa (AN)affects 0.9% of women and 0.1% of men nationwide. It has the highest mortality rate of any psychiatric disorder. The average recovery from anorexia nervosa is seven years; about 30% of patients never fully recover. Anorexia nervosa occurs when genetic predisposition meets an environmental trigger (abuse, social, trauma, etc.). The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) defines anorexia nervosa as:
AN patients are categorized into one of two subtypes. Restricting anorexia nervosa involves severely restricted PO intake; these patients have not binged and purged in the past three months. A patient who has binged and purged in the past three months is characterized as binge-purge subtype. Patients can move back and forth between the two subtypes.
Bulimia Nervosa is characterized by recurrent episodes of binge eating (once per week or more), and recurrent compensatory behavior in order to prevent weight gain (laxatives, vomiting, diuretics and/or exercise). Bulimic patients typically present with a healthy BMI.
ARFID (avoidant-restrictive food intake disorder) is a newer ED diagnosis, in which patients chronically fail to meet appropriate nutritional and/or energy needs. Food avoidance in ARFID can be related to sensory issues (taste/texture avoidance) or a fear-based experience (Carrie shared that one of her patients choked on food when he was young and had a fear of eating related to that incident). ARFID patients typically present with significant weight loss, nutritional deficiencies, dependence on enteral nutrition and/or oral nutrition supplements, and abnormal psychosocial functioning due to their condition.
Carrie highlighted a few medical complications that are common among ED patients in detail:
Patients are at risk for refeeding syndrome if they weigh <70% of their IBW, have been NPO for 7-10 days, and/or experience >10% weight loss in the past 2-3 months. Refeeding syndrome is characterized by a metabolic shift of utilizing fat for energy to utilizing carbohydrates for energy. Hypophosphatemia, hypomagnesemia, hypokalemia and edema are classic signs of refeeding syndrome. Thiamine deficiency is also common, as carbohydrate metabolism requires thiamine.
Cardiac complications are common among eating disorder patients, as a starved body utilizes muscles in the heart for energy. Phosphorous depletion and edema exacerbate cardiac complications in AN patients.
Superior mesenteric artery syndrome occurs when the fat pad surrounding the duodenum disintegrates and compresses, causing nausea, vomiting, abdominal distention, diarrhea and abdominal pain. Nutrition therapy for this condition include an all-liquid diet (milk, ice cream, oral nutrition supplements, pudding, ice cream, etc.) until the patient can tolerate whole foods.
Fifty percent of anorexia nervosa patients have hepatitis, and it is common for AN patients to have AST and ALT values 2-3 times higher than normal. Refeeding hepatitis looks similar to fatty liver, where the liver enlarges. Nutrition therapy for refeeding hepatitis includes reducing carbohydrate intake to <45% of total calories and holding or reducing caloric intake until liver enzymes stabilize.
About 50% of AN patients experience gastroparesis. In this condition, the gastrointestinal tract slows during starvation, in order to absorb nutrients completely. Eating disorder patients may feel their disorder is reinforced by their GI symptoms, as any PO intake causes abdominal pain, bloating and discomfort. Carrie tells her patients “the only way out of this is through it.” A return to proper digestion will come in time, provided the GI tract is utilized. Nutrition therapy for gastroparesis in eating disorder patients involves small, frequent, low-fiber meals. A low-fat diet is typically recommended for gastroparesis, as fat increases gastric emptying time, however, Carrie still recommends 25% of her patients’ calories come from fat, as it is very difficult to meet energy goals with a low-fat diet. A patient would have to consume a high volume of low-fat foods in order to meet energy needs, and it is unrealistic to expect eating disorder patients to consume high-volumes of food.
Some ACUTE patients are on nutrition support, though Carrie explained that TPN is not recommended unless the case is very severe. Patients can manipulate their PICC line and harm themselves; they also need to feel their GI tract being utilized, in order to work toward a full recovery. Carrie recommends a post-pyloric NG tube if enteral nutrition is required. Some of her patients take nocturnal feeds, or are willing to accept a bedtime oral nutrition supplement instead. Hearing the machine pumping at night, Carrie explained, causes a great deal of anxiety for patients, so she is often able to bargain with them to accept a supplement and stay off nutrition support. Carrie recommends starting on a 1.2 kcal/ml formula and transitioning to a 2 kcal/ml formula, to decrease total volume.
“Almost all medical complications associated with eating disorders can be resolved with consistent nutrition and full weight restoration,” Carrie said. This is particularly exciting for dietitians, as our main goal is to provide adequate nutrition to restore patients to their full, healthy capacity.
Carrie discussed the “therapeutic relationship” dietitians have with ED patients: her job is to establish trust, establish autonomy and boundaries, provide acceptance, normalize patients’ experiences, struggles and thoughts, and remain open and curious when patients resist.
ACUTE admission line: 1-844-649-8844
Thanks to MSU Denver students, Shawn Portwood and Alicia Wildman for contributing this article
The human digestive tract is an amazing organ system, it helps us break down food, absorb nutrients, and provides over 70% of our immune functions and that’s just from the bacteria found in our intestines.1 The bacteria, or biota, located within are so unique, one might even call them our own digestive finger print. So, how can we eat this holiday season to feed these critters and optimize how they work for us?
First a background, there are two major classes of bacteria found in our gastrointestinal tract (GIT). These include Firmicutes and Bacteroidetes, trust me there’s way more but that’s a topic for another day.i, 2 These two classes play very different roles in utilizing the foods we eat, each special in their own ways. So let’s dive in!
Firmicutes get a bad rap in the gut biota. When this phylum of bacteria is in a higher proportional ratio to Bacteroidetes, it has been shown to create a dysbacteriosis of the gut. In other words, if you have too many Firmicutes and your gut colony is out of whack then you have a potentially higher risk for gaining weight. This was demonstrated in a Ukraine study in which stool samples were collected and bacterial content was sequenced. Participants were grouped into categories by BMI and tests revealed the Firmicutes colonized at a higher percentage rate as BMI increased.3 Also, a mouse study that was published in Nature took gene sequencing samples from overweight ob/ob mice and their lean +/+, ob/+ littermates. In a similar breakdown to human biota, ~90% of the bacteria were in the two mentioned phyla – Firmicutes and Bacteroidetes. In the obese mice, there was a 50% higher abundance of the Firmicutes species over Bacteroidetes and the inverse held true in the lean mice. 4
Studies show that once you have established whom the ALPHA bacterial phyla is, which is dictated through early childhood development and dietary intake, how you retain caloric density gets sorted one way or another by the Bacteroidetes or Firmicutes. 5 If Firmicutes tend to be favored in your gut fight club than you have a much higher tendency to retain and absorb broken down fats, carbs and proteins that are turned into Short Chain Fatty Acids (SCFA) to be used as energy. The mechanism at play here is the microbes suppressing the host’s fasting-induced adipocyte factor, and by suppressing this enzymatic reaction more triglycerides end up in adipocytes.6 So, if you have a ton of these overachieving bugs you will retain too much stored energy and doing that for years on end may lead to negative health outcomes such as obesity. So what foods tend to feed your colony of Firmicutes? There is some research that shows these little bugs thrive in people with a diet that is high in both fats and sugars (The Standard American Diet aka SAD!).
Foods of plant origin contain fiber, something we simply cannot get from meat, eggs, or milk. The vegetables, fruits, grains, and seeds we eat all contain a variety of fibers. Some are digestible by our own bodies and some are indigestible. For the fibers our bodies cannot break down, we rely on the bacteria in our GIT to lend us a hand. Bacteroidetes have the special ability to break down glycans or huge links of carbs that we would not otherwise be able to use. 7 The indigestible fiber we get from our diet not only feed these bacteria and keeps them in working order, but the by-products of this breakdown feed the cells in our GIT and keep our digestion in working order.ii This phyla is also known to produce SCFA but to a lesser degree than that of the Firmicutes. For this reason, Bacteroidetes are considered the “lean” biota.i, ii
Bacteroidetes also have the ability to break down yeast that we get from food most notably found in bread, wine, and beer. This is so awesome because yeast is known to have a protective layer covering its cells that makes it nearly impossible to break down without the help of our little bacterial friends. Certain sub groups of Bacteroidetes have the skills necessary to break down the side chains and backbone structure supporting the shell around these yeast cells and keep them from proliferating in the GIT. 8 Essentially, filling your plate with more fruits and veggies can keep other bugs in check.
One of the coolest things about this class of bacteria is that it can thrive in environments within and outside of the body and tends to be found on the fiber known as hemicellulose found in plants.vii This means, the more plant sources of food we consume the greater the amount of Bacteroidetes that make it into our bodies and the better we can utilize nutrients from these types of foods. These bugs contain a strong ability to adapt to a varied diet, and rely on a mix of items on your plate.
Now for the holiday cheer! If you are thinking, “Darn! I can’t drink any egg nog because it’s high in sugars AND fats,” or, “what about those cookies made with butter?” Relax! This is the time of the year to enjoy time with friends, family and loved ones. So, enjoy the cookies and egg nog. Just try to focus on nourishing the Bacteroidetes at the majority of your meals this season to ensure they are fully fed, equipped and ready to wage war on keeping a symbiotic balance with their nemesis: the Firmicutes. Then once the party begins, indulge a bit because remember we are ALL one happy family, and that includes the Firmicutes! We just don’t want too many of them hanging around into the New Year!
To feed your Firmicutes make sure to load your plate with:
For bulking your Bacteroidetes take an extra helping of:
1. Walsh, C. J., Guinane, C. M., O'Toole, P. W., Cotter, P. D. (2014), Beneficial
modulation of the gut microbiota, FEBS Letters, 588, doi:
2. Parnell, J. A., & Reimer, R. A. (2012). Prebiotic fibres dose-dependently increase satiety hormones and alter bacteroidetes and firmicutes in lean and obese JCR:LA-cp rats. The British Journal of Nutrition, 107(4), 601-13. doi:http://dx.doi.org.aurarialibrary.idm.oclc.org/10.1017/S0007114511003163
3. Koliada, A., Syzenko, G., Moseiko, V., et. al. (2017). Association between body mass index and Firmicutes/Bacteroidetes ratio in an adult Ukrainian population. BMC Microbiology, 17, 120. http://doi.org/10.1186/s12866-017-1027-1
4. Turnbaugh, P., Ley, R., Mahowald, M. et. al. (2006). An obesity-associated gut microbiomewith increased capacity for energy harvest. Nature 444, 1027–103. doi:10.1038/nature05414
5. Mariat, D., Firmesse, O., Levenez, F., et. al. (2009). The Firmicutes/Bacteroidetes ratio of the human microbiota changes with age. BMC Microbiology 2009 9:123. https://doi.org/10.1186/1471-2180-9-123
6. Million, M., Lagier, J.C., Yahav, D., Paul, M. (2013). Gut bacterial microbiota and obesity. Clin Microbiol Infect 2013; 19: 305–313. doi: 10.1111/1469-0691.12172
7. Martens, E., Koropatkin, N., Smith, T., Gordon, J. (2009). Complex Glycan Catabolism by the Human Gut Microbiota: The Bacteroidetes Sus-like Paradigm. The Journal of Biological Chemistry 284, 24673-24677. doi: 10.1074/jbc.R109.022848
8. Cuskin, F., Lowe, E., Temple, M. (2015). Human gut Bacteroidetes can utilize yeast mannan through a selfish mechanism. Nature 2015 Jan 8; 517(7533): 165-169. doi: 10.1038/nature13995
Alicia Wildman is a senior at Metropolitan State University of Denver about to complete her BSc in Human Nutrition and Dietetics. She plans to apply for a few distance internships for the Spring 2018 match and after becoming a Registered Dietitian, go on to pursue a Master’s and PhD. in biochemistry. She hopes to use her education to expand future research on the science of food. In her free time she enjoys hiking, yoga, and art as great stress relievers.
Shawn Portwood is a senior at Metro State University of Denver pursuing his BSc in Dietetics with a minor in biology and emphasis in microbiology. His long term plans are to obtain his RD credentials as well as pursue a PhD in nutritional biology to research the microbiome. He is also a certified personal trainer (NASM CPT) and corrective exercise specialist (NASM CES). In his free time, he loves reading, training for endurance races and is obsessed with Star Wars.
Written by: Sara Scheler, RDN
The alkaline, or acid-ash diet, has been gaining traction as the new, “best” way to eat. Proponents of this diet claim that high acidity causes our bodies to steal minerals from our bones and organs. They
the advocate a decreased intake of minerals that create acidic ash, namely phosphate, chloride and sulfur, to restore our body’s pH back to its normal range. Foods are rated on a scale based on their Potential Renal Acid Load (PRAL), a calculation of the acidic ash they create when consumed (Cl + Po4 + SO4 – Na – K – Ca – Mg). High PRAL foods are to be avoided. Meat, fish, eggs, dairy, alcohol, wheat and yeast are the biggest offenders. Low PRAL foods are to be consumed daily—leafy greens, sea vegetables, some fruits, most vegetables and sprouted seeds. Neutral PRAL foods (fruits, nuts, some grains and legumes) are to be used occasionally in the diet (see Supplement 1).
These concepts are not new; H.C. Sherman created the first list of acidic and basic foods in 1912 when scientists began to investigate the functional properties of food8. Popularity of this diet has grown in recent years. As with most fad diets, there are numerous blogs devoted to the alkaline eating pattern. Some alkaline diet gurus, such as the Alkaline Sisters Julie and Yvonne, describe their results as dramatic weight reduction, relief from chronic back pain and total body healing2. Others claim the diet protects from sarcopenia, improves immune function, prevents cancer, increases vitamin absorption and combats mineral deficiency1. Chiropractic and clinical nutrition celebrity Dr. Josh Axe claims that chronic disease will not occur in bodies with balanced pH levels.
pH and Mineral Balance in a Healthy Human Body
Of course, these claims rest on the assumption that our body cannot regulate pH effectively on its own. In most cases, our renal and respiratory systems are proficient at maintaining healthy pH levels. If phosphate levels rise in the blood, bone resorption occurs. Osteoclasts break down bone and release calcium, which acts as a buffer to neutralize the phosphate. Alkaline diet followers maintain that this breakdown process depletes our bones of minerals and leads to osteoporosis. However, current medical research shows that this is not the case. In a meta-analysis of the alkaline diet, researchers concluded that the pH of urine was not related to an increase in bone damage or fractures4.
The alkaline diet also maintains that phosphate intake causes calcium excretion and subsequently osteoporosis. However, in all studies reviewed, phosphate intake was found to increase levels of bone calcium and increase acid excretion4. A meta-analysis of these studies concludes, “Dietary advice that dairy products, meats and grains are detrimental to bone health due to “acidic” phosphate content needs reassessment. There is no evidence that higher phosphate intakes are detrimental to bone health.”4 Neither dietary phosphate nor supplements reduced the amount of excreted calcium, as presumed by the alkaline diet4.
Dr. Axe claims that calcium in dairy products causes acidity and calcium loss, leading to osteoporosis1. Most practitioners in the medical and nutrition worlds know that dietary calcium has a protective effect against osteoporosis, and regular calcium intake is recommended for all individuals, especially children, adults and pregnant or nursing mothers5. The body regulates calcium absorption and excretion to prevent our bones from deteriorating. When calcium levels are low, the parathyroid hormone increases calcium excretion from bones, while also increasing calcium resorption and absorption to rebuild the bone structure. A healthy human body will regulate its own calcium levels, rather than steal from our bones as Dr. Axe suggests.
Some studies indicate that an acidic diet can increase urinary calcium excretion, however, researchers note that urinary excretion is not an effective measure of the body’s calcium status4. Urinary calcium does not provide a good picture of calcium balance because this mineral is absorbed, secreted and lost in various ways throughout the body4. Many studies that support the alkaline diet consider urinary calcium excretion as the only measurable aspect of acid balance, while studies that consider whole body calcium balance do not support the diet’s hypotheses4. The biochemistry behind the alkaline diet is based on limited studies that consider urinary calcium excretion as proof that an acidic diet causes osteoporosis. A meta-analysis of calcium balance studies found no connection between acidic food intake and calcium loss or osteoporosis, further squelching this diet’s credibility4.
Practicality of the Alkaline Diet
The alkaline diet may have minor benefits during anaerobic exercise. A study of 10 participants found that a low-acid diet increased anaerobic exercise performance, as compared to a high-acid diet3. Participants who consumed 6-8 cups of vegetables, four cups of fruit, and low-acid seeds and plant fats for four days performed 21% better on an anaerobic exercise test (running on a treadmill) than those who consumed large quantities of meat, dairy and grains for four days prior3. Participants who followed the low acid diet consumed 60 grams of protein per day, while the high-acid participants consumed 110 grams per day3. Current recommendations for endurance athletes are 1.2-1.7 grams of protein per kilogram of body weight per day (70-100 grams per day for someone of my size, for example). The low-acid diet in this study would not provide enough protein to maintain athletic performance and muscle structure. It would not provide enough calcium, either; the Academy of Nutrition and Dietetics recommends 1000mg of calcium per day for adults5. The low-acid diet in this trial provided just 556mg per day.
A sample from the Alkaline for Life® 30-day meal plan provides just 1280 calories, 67 grams of protein and 610mg calcium. Alkaline for Life® meal plans focus on balancing acidic and alkaline foods at each meal, so dairy, meat and eggs are allowed in small amounts. Even with this modified alkaline diet, the meal plans do not provide enough nutrients to maintain weight in any healthy adult, much less an athlete. It would be difficult to maintain micro and macronutrient requirements while adhering to an alkaline diet, and almost impossible if adhering to a strict alkaline diet and avoiding all animal-based proteins.
A strict alkaline diet is vegan by nature. Research indicates that vegan diets can cause nutrient deficiencies6. Recently, the German Nutrition Society published a position paper stating that a vegan diet is not suitable for children, adolescents, or pregnant or nursing women7. Researchers cited vitamin B12 as the most notable deficiency but Omega-3, vitamin D, riboflavin, protein and mineral deficiencies are also commonly seen with vegan diets7. The alkaline diet recommends avoidance of meats, grains and dairy products, all of which contain bone-protecting protein, calcium and vitamin D. Strict alkaline diet followers are certainly at risk for developing nutrient deficiencies.
Clinical Significance and Implications for Practice
The principles of the alkaline diet are used clinically in two ways. Sodium bicarbonate is used to correct blood imbalances and improve growth rates in children with metabolic acidosis, and the higher pH level that results from an alkaline diet can make some chemotherapeutic agents more effective4. For healthy individuals, however, an alkaline diet does not have the benefits that its followers proclaim. Though some studies suggest that a low-acid diet can moderately increase exercise endurance, the diet is low in calories, protein and calcium, expensive, time-consuming and impractical to maintain. Furthermore, a strict alkaline diet poses serious risks of vitamin and mineral deficiencies. The limited and inconsistent research that supports this diet is certainly not enough to warrant recommendation of its use. I would not recommend an alkaline diet, as it would be difficult to maintain any level of athletic performance and avoid deficiencies with a diet devoid of animal, egg and dairy-based proteins. A minor increase in performance, based off the small cohort and very short duration found in one study does not transcend the risks this diet poses to long-term health.
As with all fad diets, it is important to investigate the biochemistry behind its claims and evaluate whether or not diet’s suggestions align with physiological fact; in the case of the alkaline diet, they do not.
Supplement 1: Alkaline Food Chart. Source: Alkaline Sister (web)
Accessed September 2016 from: Alkaline Food Chart
Celery with 1 tsp almond butter
½ baked sweet potato with butter and cinnamon
Beets and Greens
1. Alkaline diet: the key to longevity and fighting chronic disease? Dr. Axe Web site. https://draxe.com/alkaline-diet/. Accessed August 29, 2016.
2. Alkaline sister: my story. Alkaline Sister Web site. http://www.alkalinesisters.com/sisters-blog/. Published 2009. Accessed September 1, 2016.
3. Caciano C, Inman C, Gockel-Blessing E, Weiss E. Effects of dietary acid load on exercise metabolism and anaerobic exercise performance. Journ. Sports Sci and Med. 2015; 14, 364-371.
4. Fenton T, Lyon A, Eliasziw M, Tough S, Hanley D. Phosphate decreases urine calcium and increases calcium balance: a meta-analysis of the osteoporosis acid-ash diet hypothesis. Nutr Journ. 2009; 8-41.
5. Mahan L, Escott-Stump S, Raymond J. Krause’s food and the nutrition care process. 13th ed. St. Louis, MO: Elsevier; 2012.
6. Mądry E, Lisowska A, Grebowiec P, Walkowiak J. The impact of vegan diet on B-12 status in healthy omnivores: a five-year prospective study. Acta. Sci. Pol. 2012; 209-213.
7. Richter M, Boeing H, Grünewald-Funk D, Heseker H, Kroke A, Leschik-Bonnet E, Oberritter H, Strohm D, Watzl B for the German Nutrition Society (DGE) (2016) Vegan diet. Position of the German Nutrition Society (DGE). Ernahrungs Umschau 63(04): 92– 102.
8. Sherman H, Gettler A. The balance of acid-forming and base-forming elements in foods and its relation to ammonia metabolism. Columbia University; 1912; 205.
What is one of the top reasons that many moms quit breastfeeding? Returning to work or school! According to the U.S. Department of Labor, women are the fastest growing segment of the U.S. workforce. In 2014, 57.3% of new mothers were in the workforce, an increase of 80% over the past 20 years. Working outside the home negatively impacts both breastfeeding initiation and duration. It can be challenging for some moms to balance breastfeeding and working. What many do not realize however, is that there are laws in place to help them!
Laws that support breastfeeding moms
In 2010, the Fair Labor Standards Act was amended and now requires employers to accommodate breastfeeding moms who want to pump milk for their infants while at work. The law states that employers must provide reasonable time and a private space (that is not a bathroom) to express milk. In 2008, the Workplace Accommodations for Nursing Mothers Act was passed in Colorado which provides greater protections for moms. This law requires all employers to:
Moms can ease the transition of going back to work by planning ahead. They need to learn as much as they can before the baby’s birth – learn how to get off to a good start with breastfeeding, learn about their rights, research day care options and talk with their employer about their needs. Employers may not know how to support a mom and most will be happy to do so when they learn how easy it is. Moms can do much of the creative problem solving themselves like finding a place they can pump and figuring out how pumping can work in their schedule.
Starting the conversation
There are many ways a mom can start a conversation with her employer. Part of the conversation with employers and co-workers should include information about the health benefits of breastfeeding and the benefits support brings to a business. Providing support to a breastfeeding mom benefits a business’s bottom line - lower health care costs due to healthier moms and infants, less time away from work for a mom to care for a sick infant, lower turnover rates and greater productivity and loyalty.
What if a mom is not getting support from her employer?
If a mom feels like she is not being supported as required by Colorado law she needs to find an advocate to help. Moms can document what is happening in the workplace and ask their employer to go to mediation to try and resolve issues. The Colorado Breastfeeding Coalition can provide information, support and resources such as recommendations for Colorado attorneys with experience in worksite breastfeeding issues.
Going above and beyond the state law
Some employers have created broad breastfeeding policies and programs to support their employees. Some provide options like access to lactation support counseling, breastfeeding classes, breast pumps and peer support groups. Some employers have implemented family friendly policies such as paid maternity leave, on-site daycare and Infant at Work programs allowing parents to be with their young infants for a longer period of time after birth or throughout the work day.
Infant at Work program participant, Jaclyn Blitz (Tri-County Health Department Registered Dietitian Nutritionist) and her daughter Kaiah.
Many moms breastfeed successfully after going back to work. Employers and moms need to be aware of the laws in place and the resources available to create a successful comprehensive plan to make breastfeeding work at work!
Want more information? Check out these resources:
Heidi Williams, MPH, RD with Tri-County Health Department
The Denver Dietetic Association hosted their most recent monthly meeting at Rose Medical Center in Denver with a presentation by guest speaker Donna Shields, MS, RDN on how cannabis fits into the world of nutrition.
Donna Shields, MS, RDN is co-founder of Holistic Cannabis Academy, a cannabis education, training, and business-building platform for holistic-minded practitioners about medical marijuana and its integration with other healing modalities. Donna and her co-founding partner Laura Lagano, MS, RDN, CDN both have personal experiences that led them to the use of cannabis and eventually the startup of Holistic Cannabis Academy.
Here is a recap of what Donna had to say about incorporating cannabis into the world of nutrition.
With more than half of the states in the U.S. being approved to use cannabis for medicinal purposes it’s important for the nutrition community, specifically RDs, to be informed.
Cannabis is being used to treat a number of illnesses and conditions, many of which are also being treated with some form of nutritional therapy; therefore, Donna suggests by using a holistic approach and integrative system to incorporate cannabis into our nutrition therapy recommendations, we will better serve our patients/clients.
For example, chemo patients can often benefit from some sort of nutritional therapy for nausea, vomiting and/or appetite stimulation, all of which can also be treated with cannabis, so by incorporating a holistic integrative approach for treatment, cannabis and nutrition can work in synergy, to better treat the patient.
Other illnesses and conditions that are often treated with some form of nutrition therapy that can also be treated with cannabis here in Colorado are:
Post-traumatic Stress Disorder (PTSD)
Cachexia (wasting syndrome)
Persistent muscle spasms
Donna also mentioned that by using this holistic/integrative approach, we, as nutritional professionals, will have more opportunities to expand our scope of practice and gain new clients/patients. Cannabis is is being recommended by doctors and other health care professionals to treat a number of disease and conditions, so to stay relevant and valuable it's important for the nutrition professionals to understand cannabis and how to incorporate it into their area of expertise if it applies to their patients.
However, breaking into cannabis is still a scary thing for many health and nutrition professionals, and recommending it presents a number of challenges. To name a few, cannabis is not covered by insurance, it is not approved for all health conditions, accessing certain forms of cannabis may be difficult and it hasn't been approved in all states. Many also question if they will be judged for recommending cannabis. Cannabis has long been classified as a schedule one drug, which is also where heroine lies, so this classification alone makes recommending cannabis a challenge. There have also been horror stories of people who have had extremely bad experiences with cannabis, but Donna states that these fears and horrific experiences are likely due to lack of education and improper dosing.
Healthcare professionals have had next to no training on cannabis - the plant and its components (THC, CBD, CBC, THCV, CBN, terpenes - just to name a few), quality and safety, different forms and uses, dosing, the benefits of its effects, or how it interacts with human receptors.
Being educated and able to answer simple questions a client may have, such as where to buy cannabis and how to determine the quality and safety of the product, (for example, if it has been contaminated with pesticides or mold) is one of the most basic, yet overlooked questions. Although there is no required testing, or standards for cannabis, many grow operations/facilities have reports that show the quality of their product.
It is also important to understand that cannabis can be used without having the psychoactive effects and that the ratio between THC and CBD is extremely important. Donna stressed the fact that you don’t have to be “high” to receive the health benefits of cannabis. This is often how pediatric treatment is conducted.
The are many forms in which cannabis is available as well, so if a patient is opposed to smoking, for example, they have other options. Smoking, eating, vaporizing, tinctures, and topicals are among the most common forms in which cannabis is available.
Donna stated that cannabis is not a gateway drug, but an exit drug from opioids.
If you are considering furthering your education on cannabis treatment, unfortunately at this time, continuing education credits (CPE’s CPEU’s, CEU’s) for the Holistic Cannabis Network program have not been approved by the Academy of Nutrition and Dietetics, but Donna says they are working on getting it approved. There are however, a few nutrition-related organizations that do recognize their members’ continuing education in the cannabis field. Those organizations are:
Nutritional Therapy Association (NTA)
Canadian Health Coach Alliance (CHCA)
Canadian Association for Integrative Nutrition (CAIN)
Thank you, Donna for your insightful information into the synergistic world of cannabis and nutrition!
Is cannabis right for your practice? Will you be incorporating it into your field of practice? We would love to hear your thoughts in the comments below.
Donna has also contributed to Cannabis Kitchen Cookbook. You can find the book here.
Slides from last week's presentation here.
November Blog Post: DDA Updates in Policy Recap
Our last DDA meeting was a full house at Tri-County Health Department! With the topic of Public Policy fueling our minds, we also fueled our bellies with Wong Way Veg food truck’s veggie-forward offerings. Our guest speakers of the night were Tyson Marden, Colorado Academy of Dietetics (CAND) President and Terri Livermore and Gabriella Warner from LiveWell Colorado, a Denver non-profit that is committed to promoting healthy eating and active living throughout Colorado.
Tyson updated us on CAND’s goals for the 2017-2018 year. It is exciting to see the effort being made to bring Colorado dietitians and dietetic students together and elevate our profession throughout the state. Some of his updates were as follows:
These are some exciting happenings for CAND! If you are not already a member and receiving their emails, head on over to the website http://www.eatrightcolorado.org/ and sign up. To reach Tyson about any of the events listed above or other questions about CAND his email is email@example.com
Terri started off by providing a fantastic overview of the legislative process at both the state and federal level. While Terri’s overview was much more engaging and poignant you can watch School House Rock’s “I’m Just a Bill on Capitol Hill” if you missed it! https://youtu.be/FFroMQlKiag
Gabriela, LiveWell’s on-staff Registered Dietitian shared the organizations current statewide policy initiatives. They include school lunches, food access and food insecurity and lobbying for programs that support healthy food systems. This includes following the Child Nutrition Re-Authorization Act and Farm Bill to prevent cuts to programs like SNAP and school lunches. You can learn more about specific initiatives at their website: https://livewellcolorado.org/healthy-communities/
Gabriela wrapped up the evening with a call to action. She stressed the importance of registered dietitians becoming more civically engaged and using our expertise to make change with major priority ares:
There are many ways to get involved including:
The meeting wrapped up with a group discussion. The prompt was Agriculture Secretary, Sonny Perdue’s rollbacks on the Healthy, Hunger-Free Kids Act regarding requirements for reimbursable school lunches. Breaking off into small groups, it was energizing to hear the different paradigms being shared and DDA members speaking passionately about the issue. This was one of the best turn outs for a policy-related meeting and members gleaned a better understanding of why registered dietitians need to have a presence in local, state and federal policy and be true advocates for healthy eating, active living.
In 2016, the FDA rolled out a plan to update the Nutrition Facts Label, based on current science and nutrition recommendations from the 2015-2020 Dietary Guidelines for Americans. On first glance, the new label may not seem significantly different, but there are some key changes that are important for dietitians to understand.
The most noticeable change is larger-print calories and servings per container, which allows for consumers to more easily determine how many calories are in a serving. Serving sizes on products are often unrealistically small; the new guidelines require serving sizes to be updated, reflecting present-day portion sizes. For packaged foods that can (and often are) consumed in one sitting, companies are now required to provide “per package” nutrition information.
The FDA decided to remove “calories from fat” from the label, sending the message that the type of fat is more important than total grams of fat.
Added sugars are going on the label, which is pretty remarkable considering the overhead this will cause for food companies. Added sugars are often difficult to track, because companies need to record all sugars coming from any ingredient that contain added sugars. The FDA defines added sugars as anything that increases the natural sweetness of a product, including honey, concentrated fruit juices, maple syrup, table sugar and HFCS.
Total carbohydrate recommendations will be reduced from 300 grams to 270 grams for a 2000 calorie diet. Percentage daily value of added sugar will be calculated based on the recommendation from the Dietary Guidelines for Americans that it is difficult to meet nutrient needs when greater than 10% of caloric intake comes from added sugars (this amounts to 50 grams for a 2000 calorie diet).
Vitamin D and potassium are now required to be listed on the label, while vitamins A and C will become optional.
The DRV for dietary fiber has increased from 25 to 28 grams, so the percentage daily value for fiber on products will look a bit lower. Only certain fibers that have proven nutritional benefit will be counted toward total fiber on the new nutrition facts label. These fibers include: beta-glucan soluble fiber (soluble), psyllium husk (mostly soluble), cellulose (insoluble), guar gum (soluble), pectin (soluble)
locust bean gum (soluble) and hydroxypropylmethcellulose (soluble). Any fiber not on this list (for example, inulin) will now be considered part of total carbohydrates, rather than adding to the total fiber of a product.
The FDA initially planned to enforce these updates by 2018, allowing smaller companies (with <$10 million in annual sales) to comply by 2020; however, the FDA recently proposed to delay compliance until 2020 for all companies, and 2021 for small companies.
What can we do? If you agree that the new nutrition facts label will be more transparent and accurate and will help consumers make healthier food choices, fill out this call to action plan to voice your opinion.
If you are interested in learning more, Abbott offers free CPEUs for their Nutrition Facts Label courses. You can also learn more on the FDA’s website.
Written by: Sara Scheler, RDN
Photo credit: NBC News
Denver, what are you eating? We want to know! Show off your #RDapproved lunch and you could win $25.
Cooking for family and friends this holiday season? This baked quinoa is easy, delicious, healthy and free of the top 8 allergens!
2 cups quinoa, rinsed and drained
4 cups almond or soy milk
4 granny smith apples, peeled and diced
1/4 cup maple syrup (or more, depending on how sweet you like it, and whether the milk is sweetened or not)
2 t. cinnamon
2 t. pumpkin pie spice (or your favorite combination of fall spices)
2 t. vanilla extract
1 t. salt
Combine all ingredients in a mini slow cooker or saucepan. For slow cooker, cook on high for 3-4 hours, or until quinoa is very tender. For saucepan, cook on medium for 3-4 hours. Serve immediately; store leftovers in the refrigerator. To reheat, add a little more soy or almond milk and microwave or heat in a saucepan until warm. Sprinkle with cinnamon, walnuts, raisins and/or cranberries and enjoy.
What is better on a cool fall morning (or in today's case, this snowy fall morning) than the aroma of a hot pumpkin spice latte with real pumpkin puree? In my opinion, nothing really.
We are excited to announce that we will be sharing a recipe from time-to-time and modifying it to be just a tad bit healthier. With all the added sugars, and unknowns in our food and beverages these days, it's totally worth it to spend the extra time whipping up your favorite food or treat, so you know what you are actually eating. This morning we kick off the week with this delicious pumpkin spice latte.
What are your some modifications you've made to some of your favorite foods? An alternative to a sugar or fat product? Lower amounts of something? Share with us your favorites in the comments below!
1/2c whole milk (a little more, as some will steam off)
1/2c strong coffee or shot of Espresso
2 tbsps pumpkin puree
1 tbsp maple syrup
.5 tsp cinnamon (and a sprinkle for the top)
Bring milk to a rolling simmer for a few minutes, add pumpkin puree and simmer for another two minutes, stir in maple syrup, pour coffee or espresso to a coffee mug, add milk mixture and cinnamon to mug and serve.
Serving size is 8 oz.
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