In This IssueMicrobes at the Table: The Role of the Gut Microbiome and Related Nutritional Interventions in the Treatment of Anorexia Nervosa...........89CPE Reporting Form, Instructions, and Questions...................................................100CPE Certificate...............................................101Blenderized Tube Feeding........................102News You Can Use.......................................105Members in the News................................107Member Spotlight.......................................108Resource Reviews: Nutrient Power: Heal Your Biochemistry and Heal Your Brain.....109 Nutrition Essentials for Mental Health: A Complete Guide to the Food-Mood Connection.......................110Edible Essential Oils....................................111Recipe: Chicken and Broccoli Pasta With Pesto..................................................113What Members Are Saying.......................114YourPlate Contest Winner.........................114Chair's Corner.................................................115Editor's Notes.................................................116Second Century Vision, Mission and Principles...........................................117Executive Committee List.........................119

THE INTEGRATIVERDN

Dietitians inIntegrativeand FunctionalMedicinea dietetic practice group of the

Academy of Nutritionand Dietetics

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Microbes at the Table: The Role of the Gut Microbiome and Related Nutritional Interventions in the Treatment of Anorexia Nervosa

Spring 2017Volume 19, Issue 4

Katherine Stephens-Bogard, MS, RDN/LD, CDE, RYT and Sherie L. Edenborn, MT (ASCP), PhD

Katherine Stephens-Bogard, MS, RDN, CDE, RYT is a dietitian nutritionist, Certified Diabetes Educator & Registered Yoga Teacher specializing in integrative and functional neuroendocrinology, specifically eating disorders and diabetes/glucose abnormalities at The Washington Health System in southwestern Pennsylvania. You may contact her at ksbrlb@gmail.com. Dr. Sherie Edenborn, MT (ASCP), PhD is an Associate Professor of Biology at Chatham University in Pittsburgh, PA. Her research interests are interdisciplinary and focus on how physiology and ecology of microorganisms contribute to the health of diverse ecosystems, including the human body. You may contact Dr. Edenborn at sedenborn@chatham.edu or 412-759-4857.

Introduction

Eating Disorders (EDs) are complex psycho-behavioral metabolic illnesses that arise from

epigenetic, psycho-neuroendocrine, socio-cultural, environmental, biochemical and nutritional interactions.1,2 Complications are similarly multi-systemic, affecting the neuroendocrine, gastrointestinal (GI), cardiovascular, musculoskeletal, and reproductive systems, but also psychosocial well-being and emotional health.1,2 Likewise, the treatment is increasingly multi-faceted. Novel approaches to treatment have garnered recent attention owing to a convergence of many branches of biomedical and behavioral sciences including, but not limited to: neuroscience and

its subdivisions—neuropsychiatry, psychoneuroimmunology, neuroanatomy and neuroimaging3,4—and the biological sciences— genetics and genomics,5-7 nutritional biochemistry,8–15 and microbiology, most notably, GI microbiology.16,17 This article presents an integrative and functional view of Anorexia Nervosa (AN). Specifically, it illustrates how the GI microbiome and the gut-brain axis (GBA) act as both an antecedent and mediator in the pathogenesis and treatment of AN. Relevant research is summarized and contemporary nutritional treatment modalities are highlighted, serving as a foundation for exploring how functional and integrative dietary interventions may improve metabolic and mental health via modulation of the GI microbiome and GBA. Translation of the empirical science into practical clinical nutrition treatment recommendations with suggested areas of ongoing research concludes the review.

Eating Disorder Review—Diagnosis, Epidemiology, and Genetics

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders Fifth Edition defines and distinguishes four categories of EDs: AN, Bulimia Nervosa (BN), Binge-Eating Disorder (BED), and other specified feeding or eating disorders (OSFED).18 Recent studies have revealed co-morbid and confounding diagnoses of depression and anxiety,19-22 obsessive compulsive disorder,23,24 impulse control disorders,25 attention deficit

CPE Article

ObjectivesAfter completing this CPE activity, the nutrition professional will be able to:

1) Discuss the evidence that suggests a relationship between the gut microbiome and anorexia nervosa.

2) Describe functional and integrative nutritional interventions for the treatment of anorexia nervosa.

3) Determine which integrative treatment approaches would be appropriate given different practice settings.

hyperactivity disorders26 and autism spectrum disorders (ASD), which have a very similar cognitive profile to AN.7-29 These include deficits in social cognition and emotional regulation and the inability to adapt to change, marked by such behaviors as insistence on sameness and rigid patterns in thinking and behavior.30 In fact, clinical research in those [women] with chronic enduring AN often referred to it as the "female Aspergers.”31

Establishing the exact epidemiology of EDs is difficult. Data from the National Comorbidity Survey Replication (NCS-R)32 indicates that fewer than half of individuals with EDs access care for their illness. Furthermore, it is estimated that 50% of EDs are missed in the clinical setting. Notwithstanding these variables, the lifetime prevalence of AN is estimated at 0.9% for adult females, 0.5% for adult males, and 0.3% among adolescents of either gender.32

The genetics of EDs continue to be elucidated. The heritability of AN and BN is estimated between 33% and 84%.32 To date, the genetics of EDs have been explored using linkage and association studies, candidate genes and genomic-wide association studies, gene-expression and epigenetics such as DNA methylation, and gene-by-environment interactions.5,6,7 Though no single gene has been found to be a major risk factor, independent familial studies have found variations in genes such as the opioid delta

receptor (OPRD1), which are related to specific characteristics of AN such as addictive behaviors.33,34 It seems likely that genomic and genetic factors are interdependent in shaping AN susceptibility, illness course, and outcome. Further, it is possible that nutritional genomics will enable more personalized development of nutritional, nutraceutical, and pharmacological interventions.

Microbes in the Mirror: Anorexia Nervosa Reflected in Gastrointestinal Microbiome

Over the past ten years, research has revealed that the average human is colonized by an estimated 100 to 350 trillion microorganisms.35 These microorganisms along with all their genes are collectively called the human microbiome and are considered to be as essential as our own cells in modulating physiology,36 immunity to infectious disease37 and even behavior.38,39 The microbial communities associated with the human body vary based on anatomical location, with the GI or “gut microbiome” having the greatest number and diversity of microorganisms. Research suggests that the human gut microbiome is comprised of five major bacterial phyla as well as a core microbiome comprised of 14 different genera (Figure 1).40-42 There also is evidence that many of the microorganisms in a person’s microbiome are individually unique.43 Dysbiosis has been linked to

a variety of physical and mental disorders, including AN,16 and can be characterized at different levels of the taxonomic hierarchy.

More recently, research has revealed the critical importance of diet in regulating the structure of the GI microbiome and associated effects on human health.45-48 Collectively, evidence that links diet with alterations in the microbiome and health may provide a framework for developing and monitoring nutritional interventions for the treatment of obesity, malnutrition and AN.49 In 2000, Sokol50 provided evidence that the development of AN may be related to specific microorganisms. In this groundbreaking study, prior infections with Group A streptococci were related to the development of AN and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal

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Figure 1 - Profile of the Human Gastrointestinal Microbiomes

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Important Terms

Infections (PANDAS). Although only four individuals were included in the study group, weight restoration and decreased eating disorder symptoms were observed following conventional treatment with antibiotics. Further studies have implicated specific microorganisms in the etiology of AN, as well as the clinical symptoms related to weight, functional GI complaints, and mental health. Armougom et al51 found significant differences in the number and type of bacteria in the feces of obese, lean, and anorexic subjects. Specifically, they observed higher concentrations of Lactobacillus species in obese subjects compared to anorexic subjects and much higher concentrations of the anaerobe Methanobrevibacter smithii in those with AN. The authors hypothesized that increased colonization by M. smithii may be an adaptive response to low caloric intake since this bacterium’s primary mode of metabolism creates an environment in the GI tract that improves the conversion of nutrients into calories. This hypothesis is supported by the work of Million et al,52 who reported significant correlations between body mass index (BMI) and specific bacteria, including positive correlations for Lactobacillus reuteri and negative correlations for M. smithii, Bifidobacterium animalis and Escherichia coli. Dysbiosis in individuals with anorexia may also be characterized by lower concentrations of total bacteria. Morita et al16 observed dysbiosis in anorexic subjects characterized by lower concentrations of total bacteria, especially those associated with Lactobacillus plantarum, Clostridium leptum, Clostridium coccoides, Bacteroides fragilis, and Streptococcus. In contrast, Pfleiderer et al53 and Mack et al54 reported increased levels of clostridia in patients with AN. Interestingly, an overabundance of clostridia is also found in patients with ASD and is thought to be involved in both the GI and psychiatric conditions associated with this disorder.55,56

Although these studies document a pattern of dysbiosis, there is a paucity of data that weight restoration, in fact, restores the GI microbiome. Mack et al54 examined the microbiome of AN clients

before and after weight restoration and noted no change in the gut microbiome or GI symptoms. Compared to controls, Kleiman et al57 noted that patients with AN had less taxa diversity at treatment onset and after weight restoration. Specifically, persistent perturbations in the family Ruminococceae (genus Parabacteroides) were observed. Interestingly, this family of bacteria is also associated with intestinal disorders marked by inflammation including irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).58,59

Modulation of the AN Microbiome and GBA via Nutritional Intervention

Our expanded understanding of how the structure and function of the microbiome can affect physical and mental health provides a role

for nutritional intervention in the treatment of neuropsychiatric disorders such as AN. Central to this new paradigm has been the discovery of the ways in which the gut microbiota communicates with the nervous, endocrine, immune and digestive systems. Most amazing has been the discovery of the GBA, which is a bi-directional pathway between the brain and the enteric nervous system (ENS).60 At one end of this axis lies the brain and the

blood brain barrier (BBB), which regulates the passage of oxygen, nutrients, neurotransmitters, and cytokines into the cerebrospinal fluid (CSF) and protects it from harmful microorganisms and chemicals.60 At the other end is the gut and ENS, which is similar in complexity and importance to the brain61 and is able to sense biological and chemical agents derived from the host and imported from the environment. Also present are the cells and proteins of the immune and endocrine systems that act as sentinels and deliver signals that provide information that can help protect the brain and body or direct them into a state of unbalance. Figure 260,62 summarizes the mechanisms by which the GI microbiome communicates with the brain; more detailed information can be found in associated review articles.16,20-22

From Microbes to Meals - The Role of Evidence-Based Practice

Gorwood et al63 provide an excellent overview of seven different models that, in combination, have the potential to provide a holistic model of AN as well as define connections between AN, the microbiome and diet. For example, one model proposes that the dysregulation of hunger and satiety in patients with AN may be due to

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Figure 2 - Communication Pathways in the Gut-Brain Axis

GI bacteria synthesize & regulate levels of neurotransmitters such as GABA, serotonin, dopamine, noradrenaline & histamine

Pro-inflammatory cytokines (IL-1, IL-8, TNF)can induce neuroinflammation in response to leakage of lipopolysaccharides (LPS) from gram-negative bacteria into peripheral circulation.Psychobiotics can increase anti-inflammatorycytokines, such as Il-10

Plays an important role in memory, learning & HPA axis

Regulate GI motility & pH, glucose metabolism, adiposity, heart rate, oxygen consumption, neurotransmission, microglial homeostasis, behavior & funtion of regulatory T cells

the development of autoantibodies against appetite-regulating neuropeptides (ARNP) such as ghrelin and α-melanocyte-stimulating hormone (α-MSH). This model is supported by a study by Fetissov et al,54 which showed that plasma concentrations of ghrelin have been directly related to scores on the Eating Disorder Inventory-2 (EDI-2) in patients with AN.64 The autoantibody hypothesis is of particular importance to RDNs because autoantibodies against ARNP are generated against microorganisms in the GI tract, including those that are introduced by food or supplements.65 Of particular concern are Lactococcus lactis and Bifidobacterium longum, which share similarities to known antigens that stimulate the production of ARNPs. L. lactis and B. longum are found in both supplements (Table 1) and food, especially cheeses—colby, cheddar, cottage, cream, and blue—as well as fermented milk products such as sour cream and buttermilk.65,66 More evidence is necessary to support the potential role of these bacteria in symptoms of AN, but these data may support empirical observations made by RDNs involved in the nutritional management of patients with AN. The previous example illustrates how an understanding of the microbiome provides clinicians with a new platform to integrate evidence-based practice in their treatment plans for AN.17

Because of the overlapping neurocognitive profiles of ASD and AN, studies regarding the use of nutritional interventions that help mitigate GI and cognitive symptoms in patients with ASD provide related evidence.69 Functional and integrative nutritional interventions supported by existing evidence include probiotics, prebiotics, psychobiotics, polyphenols, and omega-3 fatty acids (n-3s).

Probiotics/Psychobiotics/Prebiotics

Selecting the appropriate probiotic/psychobiotic agents for the treatment of AN should be guided by both the clinical pathology and the known abilities of the specific probiotic agent to mitigate AN symptomatology. For example, probiotic agents have been shown to modulate weight in both

humans and animals.5 Evidence also suggests that a variety of microbial agents can support GI health, which should in theory support the GBA and thus cognitive function in persons with AN. Ritchie et al70 used meta-analysis to evaluate the effects of 11 species of probiotic bacteria and probiotic mixes on eight different GI diseases. They reported significant positive effects except for Lactobacillus acidophilus, Lactobacillus plantarum, and Bifidobacterium infantis. Kennedy et al71 summarized human clinical trials that demonstrated improvement in recall and recognition and in emotional regulation, and a decrease in anxiety, depression and sad mood following targeted pre/probiotic supplementation.71 Similarly, a variety of psychotropic bacteria, including Lactobacillus rhamnosus and Bifidobacterium infantis, have been shown to modify host mental health via regulating neurotransmitter synthesis, modulating the production of pro-inflammatory cytokines, and communicating with the brain via the vagus nerve.62 Table 1 pg. 95 provides additional information about probiotic bacteria and yeast that have been shown to modulate weight, mood, and GI health. A fully integrated treatment approach will combine appropriateprobiotic/psychobiotic microorganisms with complementary prebiotics.72-74 Examples of prebiotics are galacto-oligosaccharides (GOS), fructo-oligosaccharides (FOS), inulin and lactulose,75 starch, pectin, dietary fibers, and whole grains, as well as human milk oligosaccharides.73 Prebiotic foods enhance the functional capabilities of probiotic/psychobiotic bacteria by stimulating their growth and activity75 and providing substrates that facilitate the production of metabolic end products such as short-chain fatty acids (SCFA) and neurotransmitters that can positively affect host physiology.73 Lactic acid bacteria, found in such functional foods as cheese, yogurt, fresh milk, kimchi, cabbage, fermented fish, and Chinese paocai,77 are major producers of the neurotransmitter gamma-aminobutyric acid (GABA).62 GABA deficiency increases the velocity of synaptic transmission leading to an increase in emotional dysregulation, anxiety, agitation, panic attacks and addictive behaviors.78 Likewise,

the neurotransmitters serotonin and dopamine can be synthesized by GI bacteria from the amino acid precursors tryptophan and phenylalanine,79 found in such foods as poultry, seafood, beef, pork, egg whites, legumes, nuts and seeds.8,80,81

Polyphenols

Classified by structure, polyphenols are a large class of plant-derived compounds that includes phenolic acids, flavonoids, lignans and stilbenes.9–11,71 Food sources include berries, citrus, red wine, coffee, tea, and cocoa.80,81 Epidemiological and interventional studies suggest that a diet rich in polyphenols may help maintain normal brain function and cognitive processing, improve emotional regulation and decrease anxiety and depression.71 It is hypothesized that anti-inflammatory, anti-oxidant, and enzymatic modulation of phenolic compounds accounts for their positive CNS effect.9,10,71 Polyphenolic compounds are not only metabolized by the gut microbiota but also modulate their composition. For example, green and black tea have been shown to retard the growth of dysbiotic Helicobacter pylori, Staphylococcus aureus, Salmonella typhimurium, and Listeria monocytogenes bacteria while other polyphenols have been shown to promote the growth of beneficial bacteria such as Bifidobacterium spp.11

Omega-3 Fatty Acids

Found in cold-water fatty fish, nuts and seeds (chia, hemp, flax),80,81 as well as in fortified foods, dietary omega-3s (n-3s), especially eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been studied with regard to nearly every aspect of cognitive brain function and mental health.12,71 Omega-3s play pivotal roles in synaptic plasticity, monoaminergic (i.e. dopamine and serotonin) neurotransmission,81 modulating HPA axis activity,81 and reducing central and peripheral inflammation.13-15 Via these mechanisms, preclinical and clinical trials have shown improvements in anxiety, depression, emotional reactivity and impulse control, perfectionism and cognitive behaviors.12,15,71,83 Similarly, many of

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2

Table 1. Microorganisms Shown to Modulate Weight, Gastrointestinal Symptoms, and Mood

In seeking sponsors, DIFM has established product standards for products and services of value to the integrative and functional medicine field. We consider product quality, efficacy, manufacturing, and business practices among other criteria. We encourage all professionals and individuals to choose products aligned with their own specific standards.

Dietitians inIntegrativeand FunctionalMedicinea dietetic practice group of the

Academy of Nutritionand Dietetics

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Superscript lower-case letters: % of species found in branded supplements as reported by Labdoor (https://labdoor.com) (established strains, when known) a 77% (La-14); b 55% (PR-32, GG); c 42% (LC-11); d 39%(Ls-33); e 26% (Lp-115); f 23% (Lpc-37); g 19%; h N/A; I N/A; j 10%; k 10%; l 6%; m <1%; n 50% (spp); o 31%; p 16%; q 50%; r 50%; s < 1%; t 19%; u < 1%

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these central effects are mediated through GI bacteria. For example, in vitro and animal studies suggest n-3s can promote growth of strains of Lactobacillus; conversely, lactobacilli can modulate n-3 absorption.14 Furthermore, n-3s increase growth of bifidobacteria and reduce growth of dysbiotic enteric bacteria.15

Microbes by Meal from Bench to Table: Translation and Clinical Application

Contemporary nutritional treatment paradigms include variations in exchange-based meal plans,84 staff/family measured portioning within a calorically-appropriate structured meal plan,85,86 as well as inclusion of mindfulness based intuitive eating philosophies.87-89 Nutrient requirements are determined by both the medical examination and related tests (i.e. labs, EKG, and bone density)1 as well as the nutrition-focused assessment.90 Notwithstanding the need to weight restore and pharmacologically supplement nutrients of concern as medically identified,1 the RDN integrating a functional approach to AN could include the previously highlighted components: probiotics, polyphenols, and n-3s. Inclusion criteria, importance and timing of introduction are dependent on the type of practice setting: inpatient hospitalization (IP), specialty hospital inpatient treatment, commonly referenced as residential treatment (RT), intensive outpatient (IOP), or outpatient (OP). For example, IP is primarily tasked with medical stabilization to include progressive weight restoration without iatrogenic refeeding syndrome.1 An integrative approach in this setting could include supplemental probiotics and n-3s regardless of feeding route—enteral or by mouth (PO). As PO intake improves, food sources providing prebiotics, probiotics, n-3s and phenolic compounds in tandem with other calorically nutrient dense foods should be included in the rotational menu. Transitioning to RT, IOP, and OP treatment, the integrative RDN should continue to increase the variety of functional foods. Supplemental n-3s and probiotics may also be continued, but bacterial strains may need to be changed depending on AN

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symptomatology and/or treatment priority (Table 1). Likewise, the RDN will necessarily need to address each client’s individual orthorexic8 food ideology.7,88,91,92 Tables 2 and 3 illustrate an example of a patient-centric mindfulness-based integrative and functional food nutrition prescription for a client currently receiving OP medical nutrition therapy (MNT). Concomitantly, as part of MNT and nutrition education, a food-as-medicine module could be included. The goal of this would be to expand upon the traditional treatment paradigm of nutrition education in food procurement, selection, and preparation across the spectrum of eating environments—restaurant, buffet/cafeteria, social dining, and home cooking. In this functional and integrative approach, the client is tasked with procuring supplies to cultivate a fermentable food of choice (i.e. kombucha, yogurt, or kefir). Similarly, the client is

invited to grow a mini-culinary garden. Such applications not only allow food and nutrition science education in a creative non-threatening way but also promote greater microbial diversity. Digging in the soil—cultivating a mini-garden—exposes the client to a greater number of bacterial phyla and species, promoting microbial diversity and augmenting proper immune function.95 Furthermore, farm-to-table activities are a great platform upon which to discuss energy metabolism, macronutrient utilization, functional foods and bioactive substances and their relationship in the GBA and HPA axis, and the roles these play in mood and recovery.

Conclusions

The complexity of the pathogenesis as well as the treatment96 of AN is well-established. Building upon current

scientific foundations, further studies should: 1) Analyze the microbiome of AN clients pre- and post-weight restoration following a hyper-caloric functional food and strategic supplementation protocol; 2) Further explore probiotic species and utilitarian functionality of psychobiotics; and 3) Investigate the role of nutrients in the epigenetics and genomics of AN. Because AN treatment is necessarily multi-disciplinary, by partnering with clinical researchers, RDNs can enhance research methodology by designing the nutritional protocol. Clinically, RDNs can include functional foods along with targeted supplementation as well as kinesthetic learning into MNT; this supports both restoration of physical and mental health and augments the work of the mental health providers.

Table 2. Mindfulness Based Functional Food and Nutrient Group Guided Meal Plan

Food Group

Fruit

Vegetables

Dairy or non-dairy equivalent

Lipid

Grains, beans, legumes & other plant protein

Fermentable food/beverage

Challenge item(s)

Eggs

Fish/Seafood

Minimum* Number of Servings/day

6 (5 as fruit, 1 as juice)

Unlimited

3

5

6

1

1

Aim for 3 per week

Aim for 3, 3+ oz. servings per week

Specific Guidelines

One vitamin C rich juice to be drunk with non-heme plant food; include citrus, berries, and bananas

Consider fermented veggies (i.e. sauerkraut, kimchee, kvass)

One per day is either yogurt or kefir; all must be full-fat

Two must be rich in n-3s

Choose a variety of whole grains and/or those fortified with iron, as well as those loaded with (prebiotic) fiber

In addition to yogurt/kefir—consider Kombucha, coconut water kefir

≥250 Kcalories (from client's orthorexic food list)

Include fatty fish such as salmon, tuna and trout. Begin to consider other animal protein sources

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*Client & RDN created menu based on patient preferences and current symptomatology—anxiety, modest weight restoration without noteworthy GI complaints.

Table 3. Sample One-Day Menu*

Breakfast

A.M. Snack

Lunch

P.M. Snack

Dinner

HS Snack

• Fruit-yogurt parfait: layers of homemade yogurt, fruit (berries and banana) and oatmeal/walnut/flax & chia seed granola

• Hot green tea with honey

• Challenge item: Medium decaf flavored latte prepared with coconut milk

• Mexican wrap: whole-grain or brown rice wrap filled with grilled or blackened seafood (mahi-mahi, salmon, shrimp, cod), avacado/guacamole, tomatoes/salsa, lettuce, chives & cilantro (from culinary garden), yogurt-based or full-fat salad dressing (i.e. chipotle ranch or lime vinaigrette), and grated cheese

• Apple slices dipped in almond butter

• Kombucha (ginger/peach)

• Homemade trail mix (2/3 cup): pistachios or other nuts of choice, coconut flakes, dark chocolate cocoa nibs, and non-heme iron rich food (raisins, prunes or dates)

• Quinoa tabbouleh with feta cheese on mixed bed of greens

• Sourdough bread dipped in olive oil, n-3-fortified dressing or spread with nut butter

• Grapes• Decaf coffee with vanilla coconut/

almond milk

• Hummus and either pita chips, corn tortilla chips or nut thin crackers

• 4 oz. pineapple juice with 1 TBSP psyllium husk and additional 8 oz. water

1. AED report 2016, 3rd edition, Eating Disorders: A guide to medical care. https://www.aedweb.org/images/2016MCSGV3.pdf. Accessed January 8, 2017.2. Frank GK. The perfect storm-A bio-psycho-social risk model for developing and maintaining eating disorders. Front Behav Neurosci. 2016;10. 3. Kaye WH, Wierenga CE, Bailer UF, Simmons AN, Bischoff-Grethe A. Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa. Trends Neurosci. 2013;36(2):110-120.4. Frank GK, Shott ME, Hagman JO, Mittal VA. Alterations in brain structures related to taste reward circuitry in ill and recovered anorexia nervosa and in bulimia nervosa. Am J Psychiatry. 2013;170(10):1152-1169. 5. Shih PB, Woodside DB. Contemporary views on the genetics of anorexia nervosa. Eur Neuropsychopharmacol. 2016;26(4):663-673.6. Clarke TK, Weiss ARD, Berrettini WH. The genetics of anorexia nervosa. Clin Pharmacol Ther. 2012;91(2):181-188.7. Bulik CM. Exploring the gene-environment nexus in eating disorders. J Psychiatry Neurosci JPN. 2005;30(5):335-339.8. Richard DM, Dawes MA, Mathias CW, Acheson A, Hill-Kapturczak N, Dougherty DM. L-tryptophan: basic metabolic functions, behavioral research and therapeutic indications. Int J Tryptophan Res IJTR. 2009;23(2):45-60.9. Valdés L, Cuervo A, Salazar N, Ruas-Madiedo P, Gueimonde M, González S. The relationship between phenolic compounds from diet and microbiota: impact on human health. Food Funct. 2015;6(8):2424-2439.10. Letenneur L, Proust-Lima C, Le Gouge A, Dartigues J-F, Barberger-Gateau P. Flavonoid intake and cognitive decline over a 10-year period. Am J Epidemiol. 2007;165(12):1364-1371.11. Duda-Chodak A, Tarko T, Satora P, Sroka P. Interaction of dietary compounds, especially polyphenols, with the intestinal microbiota: a review. Eur J Nutr. 2015;54(3):325-341.12. Freeman MP, Hibbeln JR, Wisner KL, et al. Omega-3 fatty acids:

evidence basis for treatment and future research in psychiatry. J Clin Psychiatry. 2006;67(12):1954-1967.13. Pusceddu MM, Kelly P, Ariffin N, Cryan JF, Clarke G, Dinan TG. n-3 PUFAs have beneficial effects on anxiety and cognition in female rats: Effects of early life stress. Psychoneuroendocrinology. 2015;58:79-90.14. Laparra JM, Sanz Y. Interactions of gut microbiota with functional food components and nutraceuticals. Pharmacol Res. 2010;61(3):219-225.15. Kaliannan K, Wang B, Li X-Y, Kim K-J, Kang JX. A host-microbiome interaction mediates the opposing effects of omega-6 and omega-3 fatty acids on metabolic endotoxemia. Sci Rep. 2015;11:11276. 16. Morita C, Tsuji H, Hata T, et al. Gut dysbiosis in patients with anorexia nervosa. PLOS ONE. 2015;10(12):e0145274. doi:10.1371/journal.pone.0145274.17. Carr J, Kleiman SC, Bulik CM, Bulik-Sullivan EC, Carroll IM. Can attention to the intestinal microbiota improve understanding and treatment of anorexia nervosa? Expert Rev Gastroenterol Hepatol. 2016;10(5):565-569.18. Association AP, others. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). American Psychiatric Pub; 2013. http://www.dsm5.org/psychiatrists/practice/dsm. Accessed January 7, 2017.19. Herzog DB, Keller MB, Sacks NR, Yeh CJ, Lavori PW. Psychiatric comorbidity in treatment-seeking anorexics and bulimics. J Am Acad Child Adolesc Psychiatry. 1992;31(5):810-818.20. Braun DL, Sunday SR, Halmi KA. Psychiatric comorbidity in patients with eating disorders. Psychol Med. 1994;24(04):859-867.21. Holderness CC, Brooks-Gunn J, Warren MP. Co-morbidity of eating disorders and substance abuse review of the literature. Int J Eat Disord. 1994;16(1):1-34.22. Godart NT, Flament MF, Curt F, et al. Anxiety disorders in subjects seeking treatment for drinking disorders: a DSM-IV controlled study. Psychiatry Res. 2003;117(3):245-258.23. Halmi KA, Sunday SR, Klump KL, et al. Obsessions and compulsions in anorexia nervosa subtypes. Int J Eat

Disord. 2003;33(3):308-319.24. Matsunaga H, Kiriike N, Iwasaki Y, Miyata A, Yamagami S, Kaye WH. Clinical characteristics in patients with anorexia nervosa and obsessive–compulsive disorder. Psychol Med. 1999;29(2):407-414.25. Fernández-Aranda F, Pinheiro AP, Thornton LM, et al. Impulse control disorders in women with eating disorders. Psychiatry Res. 2008;157(1):147-157.26. Nazar BP, Pinna CM de S, Coutinho G, et al. Review of literature of attention-deficit/hyperactivity disorder with comorbid eating disorders. Rev Bras Psiquiatr. 2008;30(4):384-389.27. Oldershaw A, Treasure J, Hambrook D, Tchanturia K, Schmidt U. Is anorexia nervosa a version of autism spectrum disorders? Eur Eat Disord Rev. 2011;19(6):462-474. 28. Westwood H, Eisler I, Mandy W, Leppanen J, Treasure J, Tchanturia K. Using the autism-spectrum quotient to measure autistic traits in anorexia nervosa: a systematic review and meta-analysis. J Autism Dev Disord. 2016;46(3):964-977.29. Huke V, Turk J, Saeidi S, Kent A, Morgan J, others. Autism spectrum disorders in eating disorder populations: a systematic review. Eur Eat Disord Rev. 2013;21(5):345-351.30. Dudova I, Kocurkova J, Koutek, J. Early onset anorexia nervosa in girls with Asperger syndrome. Neuropsych Disord Treat. 2015;11:1639-1643.31. Arnold C. The invisible link between autism and anorexia. Spectrum. February 17, 2016. https://spectrumnews.org/features/deepdive/the-invisible-link-between-autism-and-anorexia. Accessed February 9, 2017.32. Hudson JI, Hiripi E, Pope HG, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358.33. Bergen AW, Van Den Bree MBM, Yeager M, et al. Candidate genes for anorexia nervosa in the 1p33–36 linkage region: serotonin 1D and delta opioid receptor loci exhibit significant association to anorexia nervosa. Mol Psychiatry. 2003;8(4):397-406.34. Brown KM, Bujac SR, Mann ET,

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Microbes at the Table: References

Campbell DA, Stubbins MJ, Blundell JE. Further evidence of association of OPRD1 & HTR1D polymorphisms with susceptibility to anorexia nervosa. Biol Psychiatry. 2007;61(3):367-373.35. Consortium HMP, others. Structure, function and diversity of the healthy human microbiome. Nature. 2012;486(7402):207-214.36. Cho I, Blaser MJ. The human microbiome: at the interface of health and disease. Nat Rev Genet. 2012;13(4):260-270.37. Tilg H, Moschen AR. Food, immunity, and the microbiome. Gastroenterology. 2015. http://www.sciencedirect.com/science/article/pii/S0016508515000128. Accessed January 22, 2015.38. Dinan TG, Stilling RM, Stanton C, Cryan JF. Collective unconscious: How gut microbes shape human behavior. J Psychiatr Res. 2015;63:1-9.39. Luna RA, Foster JA. Gut brain axis: diet microbiota interactions and implications for modulation of anxiety and depression. Curr Opin Biotechnol. 2015;32:35-41. 40. Falony G, Joossens M, Vieira-Silva S, et al. Population-level analysis of gut microbiome variation. Science. 2016;352(6285):560-564.41. Stearns JC, Lynch MD, Senadheera DB, et al. Bacterial biogeography of the human digestive tract. Sci Rep. 2011;1:170.42. Schroeder BO, Bäckhed F. Signals from the gut microbiota to distant organs in physiology and disease. Nat Med. 2016;22(10):1079-1089.43. Meadow JF, Altrichter AE, Bateman AC, et al. Humans differ in their personal microbial cloud. PeerJ. 2015;3:e1258. doi:10.7717/peerj.1258.44. Delzenne NM, Cani PD. Interaction between obesity and the gut microbiota: relevance in nutrition. Annu Rev Nutr. 2011;31:15-31.45. Hollister EB, Gao C, Versalovic J. Compositional and functional features of the gastrointestinal microbiome and their effects on human health. Gastroenterology. 2014;146(6):1449-1458. 46. Alenberg LG, Wu GD. Diet and the intestinal microbiome: Associations, functions, and implications for health and disease. Gastroenterology. 2014;146(6):1564-1572.47. Sandhu KV, Sherwin E, Schellekens H, Stanton C, Dinan TG, Cryan JF. Feeding the microbiota-gut-brain axis: diet, microbiome, and

neuropsychiatry. Transl Res. 2017;179:223-244.48. Oriach CS, Robertson RC, Stanton C, Cryan JF, Dinan TG. Food for thought: The role of nutrition in the microbiota-gut–brain axis. Clin Nutr Exp. 2016;6:25-38.49. Al ou MT, Lagier J-C, Raoult D. Diet influence on the gut microbiota and dysbiosis related to nutritional disorders. Hum Microbiome J. 2016;1:3-11.50. Sokol MS. Infection-triggered anorexia nervosa in children: clinical description of four cases. J Child Adolesc Psychopharmacol. 2000;10(2):133-145.51. Armougom F, Henry M, Vialettes B, Raccah D, Raoult D. Monitoring bacterial community of human gut microbiota reveals an increase in Lactobacillus in obese patients and Methanogens in anorexic patients. PloS One. 2009;4(9):e7125.52. Million M, Angelakis E, Paul M, Armougom F, Leibovici L, Raoult D. Comparative meta-analysis of the effect of Lactobacillus species on weight gain in humans and animals. Microb Pathog. 2012;53(2):100-108. 53. Pfleiderer A, Lagier J-C, Armougom F, Robert C, Vialettes B, Raoult D. Culturomics identified 11 new bacterial species from a single anorexia nervosa stool sample. Eur J Clin Microbiol Infect Dis. 2013;32(11):1471-1481.54. Mack I, Cuntz U, Grämer C, et al. Weight gain in anorexia nervosa does not ameliorate the faecal microbiota, branched chain fatty acid profiles, and gastrointestinal complaints. Sci Rep. 2016;6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4882621/. Accessed July 20, 2016.55. Martirosian G. Clostridium spp. spores in pathomechanism of autism. Wiad Lek. 2009;62(2):119-122.56. Macfabe DF. Short-chain fatty acid fermentation products of the gut microbiome: implications in autism spectrum disorders. Microb Ecol Health Dis. 2012;23. doi:10.3402/mehd.v23i0.19260.57. Kleiman, SC, Bulik-Sullivan EC, Young Huh E, Tarantiino LM, Bulik CM, Carroll IM. The intestinal microbiota in acute anorexia nervosa and during renourishment: relationship to depression, anxiety, and eating disorder psychopathology. Psychosom Med. 2015;77(9):969-981.58. Berry D, Reinisch W. Intestinal microbiota: a source of novel biomarkers in inflammatory

bowel disease? Best Pract Res Clin Gastroenterol. 2013; 27(1):47-58.59. Rajiliac-Stojanovic M, Biagi E, Hei-lig HG, et al. Global and deep molec-ular analysis of microbiota signatures in fecal samples from patients with irritable bowel syndrome. Gastroenterology. 2011;141:1792-1801. doi:10.1053/j.gastro.2011.07.043.60. Bauer KC, Huus KE, Finlay BB. Microbes and the mind: emerging hallmarks of the gut microbiota-brain axis. Cell Microbiol. 2016;18(5):632-644. 61. Mayer EA. Gut feelings: the emerging biology of gut–brain communication. Nat Rev Neurosci. 2011;12(8):453-466. 62. Sherwin E, Sandhu KV, Dinan TG, Cryan JF. May the force be with you: The light and dark sides of the microbiota-gut-brain axis in neuropsychiatry. CNS Drugs. 2016;30(11):1019-1041. 63. Gorwood P, Blanchet-Collet C, Chartrel N, et al. New insights in anorexia nervosa. Front Neurosci. 2016:256. doi:10.3389/fnins.2016.00256.64. Fetissov SO, Harro J, Jaanisk M, et al. Autoantibodies against neuropeptides are associated with psychological traits in eating disorders. Proc Natl Acad Sci U S A. 2005;102(41):14865-14870.65. Fetissov SO, Dechelotte P. The putative role of neuropeptide autoantibodies in anorexia nervosa. Curr Opin Clin Nutr Metab Care. 2008;11(4):428-434.66. Online Textbook of Bacteriology. http://textbookofbacteriology.net. Accessed February 10, 2017.67. Hoek HW. New developments in the treatment of eating disorders. Curr Opin Psychiatry. 2015;28(6):445-447.68. Peterson CB, Becker CB, Treasure J, Shafran R, Bryant-Waugh R. The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives. BMC Med. 2016;14(1):1.69. van De Sande MM, van Buul VJ, Brouns FJ. Autism and nutrition: the role of the gut–brain axis. Nutr Res Rev. 2014;27(02):199-214.70. Ritchie ML, Romanuk TN. A meta-analysis of probiotic efficacy for gastrointestinal diseases. PLOS ONE. 2012;7(4):e34938. doi:10.1371/journal.pone.0034938.71. Kennedy PJ, Murphy AB, Cryan JF, Ross PR, Dinan TG, Stanton C.

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Microbiome in brain function and mental health. Trends Food Sci Technol. 2016;57(B):289-301.72. Hill C, Guarner F, Reid G, et al. Expert consensus document: The international scientific association for probiotics and prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nat Rev Gastroenterol Hepatol. 2014;11(8):506-514.73. Bindels LB, Delzenne NM, Cani PD, Walter J. Towards a more comprehensive concept for prebiotics. Nat Rev Gastroenterol Hepatol. 2015;12(5):303-310.74. Sarkar A, Lehto SM, Harty S, Dinan TG, Cryan JF, Burnet PW. Psychobiotics and the manipulation of bacteria-gut-brain signals. Trends Neurosci. 2016;39(11):763-781. 75. Gibson GR, Scott KP, Rastall RA, et al. Dietary prebiotics: current status and new definition. Food Sci Technol Bull Funct Foods. 2010;7:1-19.76. Scott KP, Antoine J-M, Midtvedt T, Hemert S van. Manipulating the gut microbiota to maintain health and treat disease. Microb Ecol Health Dis. 2015;26(0). doi:10.3402/mehd.v26.25877.77. Beena Divya J, Kulangara Varsha K, Madhavan Nampoothiri K, Ismail B, Pandey A. Probiotic fermented foods for health benefits. Eng Life Sci. 2012;12(4):377-390.78. Richard W. Olsen. GABA. In: Davis, KL Charney, D Coyle, JT, Nemeroff. C, eds. Neuropsychopharmacology - 5th Generation of Progress. Philadelphia, PA: Lippincott, Williams, & Wilkins;2002:159-163.79. Dinan TG, Stanton C, Cryan JF. Psychobiotics: a novel class of psychotropic. Biol Psychiatry. 2013;74(10):720-726.80. Pennington JAT, Spungen J. Bowe’s & Church’s Food Values of Portions Commonly Used. 19th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2010.81. United States Department of Agriculture Agricultural Research Service USDA Food Composition Databases. https://ndb.nal.usda.gov/ndb/. Accessed February 7, 2017.82. Chalon S. Omega-3 fatty acids and monoamine neurotransmission. Prostaglandins Leukot Essent Fatty Acids. 2006;75(4):259-269.83. Chen H-F, Su H-M. Exposure to a maternal n-3 fatty acid-deficient diet during brain development provokes excessive hypothalamic–pituitary–adrenal axis responses to stress and

behavioral indices of depression and anxiety in male rat offspring later in life. J Nutr Biochem. 2013;24(1):70-80.84. Tribole, E. Intuitive eating in the treatment of eating disorders; the journey of attunement. Perspectives-A Professional Journal of Renfrew Center Foundation. https://www.evelyntribole.com/uploads/Tribole.IntuitiveEating.Eating%20Disorders.2010.pdf. Accessed January 29, 2017.85. Hammons AJ, Fiese BH. Is frequency of shared family meals related to the nutritional health of children and adolescents? Pediatrics. 2011;127(6):1565-1574.86. LeGrandge D, Lock J, Loeb K, Nicholls D. Academy for eating disorders position paper: the role of the family in eating disorders. Int J Eat Disord. 2010; 43(1):1-5.87. Tribole E, Resch E. Intutive Eating, 2nd ed, New York. NY: ST. Martin's Press; 2003.88. Hong PY, Lishner DA, Han KH, Huss, EA. The positive impact of mindful eating on expectations of food liking. Mindfulness. 2011;2(2):103-113.89. Wanden-Berghe RG, Sanz-Valero J, Wanden-Berghe C. The application of mindfulness to eating disorders treatment: A systematic review. Eating Disord. 2011:19(1);34-48.90. Practice paper: nutrition intervention in the treatment of eating disorders. J Acad Nutr Diet. 2011;111(8):1261.91. Schebendach J, Mayer LES, Devlin MJ, Attia W, Walsh BT. Dietary energy density and diet variety as risk factors for relapse in anorexia nervosa: A replication. Int J Disord. 2012; 45(1):79-84.92. Steinglass, JE, Albano AM, Simpson HB, Carpenter K, Schebendach J, Attia E. Confronting fear using exposure and response prevention for anorexia nervosa: A randomized controlled pilot study. Int J Eat Disord. 2014; 47(2):174-180.93. National Eating Disorders Association Website. Orthorexia Nervosa. https://www.nationaleatingdisorders.org/orthorexia-nervosa. Accessed February 6, 2017.94. Dunn, TM, Braman S. On orthorexia nervosa: a review of the literature and proposed diagnostic criteria. Eat Behav. 2016:21;11-17.95. Zhou D, Zhang H, Bai Z, et al. Exposure to soil, house dust and decaying plants increases gut

microbial diversity and decreases serum immunoglobulin E levels in BALB/c mice. Environ Microbiol. 2016;18(5):1326-1337. 96. Stapleton P, Bannatyne A. Treatment for anorexia nervosa: are we missing the mark? Curr Res Psychol. 2014;5(2):73-76.97. Wang H, Lee I-S, Braun C, Enck P. Effect of probiotics on central nervous system functions in animals and humans: A systematic review. J Neurogastroenterol Motil. 2016;22(4):589-605.98. Williams NT. Probiotics. Am J Health Syst Pharm. 2010;67(6). 99. Bravo JA, Forsythe P, Chew MV, Escaravage E, Savignac HM, Dinan, TG, others. Ingestion of Lactobacillus strain regulates emotional behavior and central GABA receptor expression in a mouse via the vagus nerve. Proc Natl Acad Sci. 2011;108(38):16050-16055. 100. Benton D, Williams C, Brown A. Impact of consuming a milk drink containing a probiotic on mood and cognition. Eur J Clin Nutr. 2007;61(3):355-361.101. Tillisch K, Labus J, Kilpatrick L, et al. Consumption of fermented milk product with probiotic modulates brain activity. Gastroenterology. 2013;144(7):1394-1401.102. Messaoudi M, Lalonde R, Viola N, Javelot H, Desor D, Nejdi A. Assessment of psychotropic-like properties of a probiotic formulation (Lactobacillus helveticus R0052 and Bifidobacterium longum R0175) in rats and human subjects. Br J Nutr. 2011;105(05):755-764.103. Bercik P, Park AJ, Sinclair D, et al. The anxiolytic effect of Bifidobacterium longum NCC3001 involves vagal pathways for gut-brain communication. Neurogastroenterol Motil. 2011;23(12):1132-1139.104. Kristensen NB, Pedersen O. Targeting body weight regulation with probiotics: A review of randomized trials in obese and overweight people free of comorbidities. J Nutr Food Sci. 2015;5(6):422. doi:10.4172/2155-9600.1000422.105. Dufresne C, Farnworth E. Tea, Kombucha, and health: a review. Food Res Int. 2000;33(6):409-421.106. Samual BS, Gordon JI. A humanized gnotobiotic mouse model of host-archael-bacterial mutualism. Proc Natl Acad Sci USA. 2006;103:1001-1016.

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CPE Reporting Form

1) Read the Continuing Professional Education article and answer the associated quiz questions. For each question, select the one best response. Compare your answers to the answer key on this page.

2) Send your completed quiz and application for CPE credit by email or mail to: Shari Pollack, MPH, RDN, LDN 4500 Keeney Street, Skokie, IL 60076 sbethp@gmail.com.

3) Print the CPE certificate, complete a copy, and retain it for your records. You will be notified only if your application for credit is not approved.

Instructions for Completing the CPE Activity for Credit

This activity has been approved for 1.5 hours of CPE credit. You will be notified if hours are not approved. Suggested Learning Needs Codes: 2010, 5200, 5420, and 6030. Suggested Performance Indicators: 8.1.5, 9.3.2, and 10.4.4.

Questions:1. How do prebiotics work? A. They serve as precursors to gamma-aminobutyric acid (GABA) B. They stimulate the growth and activity of probiotic bacteria C. They convert tryptophan and phenylalanine into serotonin and dopamine D. They modulate the absorption of omega-3 fatty acids

2. Green and black teas have been shown to do which of the following? A. Promote the growth of Bifidobacterium spp. B. Act as a precursor to neurotransmitters C. Retard the growth of Helicobacter pylori D. Increase the production of short-chain fatty acids

3. The study by Armougom et al found which of the following? A. No difference in the number and types of fecal bacteria between obese and anorexic subjects B. Higher concentrations of Lactobacillus bacteria in anorexic subjects C. Higher concentrations of Methanobrevibacter smithii in obese subjects D. Higher concentrations of Methanobrevibacter smithii in anorexic subjects

4. Which of the following best describes the gut-brain axis? A. A bidirectional pathway between the brain and the enteric nervous system B. A barrier regulating the passage of oxygen, nutrients and neurotransmitters into the brain

C. The nervous system in the gut which senses and responds to biological and chemical agents D. The microorganisms colonizing the GI tract, along with their genes

5. Which of the following plays a role in synaptic plasticity and monoaminergic neurotransmission? A. Polyphenols B. Probiotics C. Omega-3 fatty acids D. Prebiotics

Expiration Date: May 15, 2020Please print or typeName: ____________________________________________________________________________________Address: __________________________________________________________________________________Academy Membership #: __________________________________Phone: _____________________________Email Address: _____________________________________________________________________________DIFM Member: Yes No Date Test Completed: ____/____/____

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Microbes at the Table: The Role of the Gut Microbiome and Related

Nutritional Interventions in the Treatment of Anorexia Nervosa

132837 (Expires 04/01/2020)

1.5

Microbes at the Table: The Role of the Gut Microbiome and Related

Nutritional Interventions in the Treatment of Anorexia Nervosa

132837 (Expires 04/01/2020)

1.5

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Katherine DiGeronimo, RD, LD is the Registered Dietitian for Nutritional Medicinals, LLC. Prior to this, she worked in the clinical nutrition setting, specializing in the pediatric GI population. She is a Certified Lactation Counselor and is currently working towards IFNCP certification through the Integrative and Functional Nutrition Academy. Contact Katherine at katherine@functionalformularies.com.

Introduction

Research continues to show the importance of the food we eat related to various aspects

of health including its impact on the prevention of chronic disease, immune function, and obesity, among others. The 2015-2020 Dietary Guidelines for Americans from the USDA emphasizes a diet that is rich in whole foods and there has been a growing movement towards understanding and implementing a whole foods approach to diet.1 This also extends to the community of individuals who require tube feeds as their source of nutrition. Thousands of individuals in the United States require enteral nutrition and millions worldwide, with the number of those who require long-term nutrition support continuing to rise. The global enteral nutrition market was valued at $13 million in 2016 and is expected to grow 5.8% in the next six years.2 Yet the quality of nutrition from standard formula options for those on feeding tubes has been far below the established expectations for healthy individuals who are able to eat orally.3 Over the past decade, this has started to shift due to increasing interest from those in the adult and pediatric tube-fed community to deliver whole foods through the feeding tube—or blenderized tube feeding.

Blenderized Tube Feeding: Definition and History

Blenderized tube feeding—also known as home blended formula, blended diet, or pureed by G-tube—refers to using a blend of foods and liquid that is pureed and given through a feeding tube.4-9 In practice, this can encompass various types of

blended diets including: blending table foods with some type of liquid in a powerful blender, commercial baby foods mixed together with milk or other formula as the base, or more recently, commercial food-based formula options.7-8

Though the use of conventional commercial formulas is common practice today, reliance on such formulas has only occurred for a short time relative to the history of enteral feeds.10 Using whole foods to deliver nutrition and foster health was the first method of nutritional support. This dates back to ancient Egypt with accounts of enemas using grains, milk, whey, and wine. It was not until the mid-1900s that this began to shift.6,10 This was largely in part due to the first automated pump in 1940, followed by the development of commercial formulas in the 1950s.4,10 The introduction of commercial formulas was not without debate within the medical community. Some physicians argued that providing mixtures of whole blended foods showed better gastrointestinal (GI) tolerance and were less costly. In opposition to this, commercial formulas were valued for their ease of use, decreased risk of microbial contamination, and exact nutrition information. With more manufacturing of commercial formulas and greater availability of these products in the 1960s and 1970s, the use of blenderized tube feeds steadily declined.10 Several studies suggest that requests for a blenderized diet have been increasing in the tube-fed population over the past several years.4-9 One cross-sectional study using a self-reported survey found that a significant percentage of home enteral nutrition patients reported using blenderized tube feedings in some capacity—65.9% of adult patients and 89.6% of pediatric patients.9 Another survey of pediatric registered dietitians found that 77% reported positive outcomes with blenderized tube feedings, including improved growth and oral intake. Despite these positive outcomes, the number one reason to initiate blenderized diets was still largely parent driven. Reasons cited for not using blenderized diets in clinical practice included risk of bacterial

overgrowth, inadequate time to follow-up with patients, and lack of specified nutrient composition in these diets. Twenty-eight percent of those surveyed showed interest in further information on how to implement.5 This can suggest that while interest in blenderized diets is increasing, there is a need for action in the healthcare community to gain knowledge in this area to help patients and families in their efforts.

Disadvantages

Though most research articles cite the need for further studies on blenderized diets, there is a growing body of literature that discusses its use and reviews advantages and potential barriers.4-9 It is generally recommended that individuals pursuing a blenderized diet are bolus fed via a gastrostomy tube that is size 14F or greater. Blending is typically not recommended for continuous feeds since the viscosity is often too thick and can cause clogging issues.4,6-8 A hang time of no longer than 2 hours is recommended due to the risk of microbial activity. Due to the specificity of such recommendations, this can certainly be considered a barrier as it excludes many tube-fed individuals. As later discussed, the presence of commercial food-based enteral products has helped alleviate some of these barriers. Other potential disadvantages often recognized in the literature include increased labor involved in preparing and administering recipes, especially considering that families are often caring for patients with medically complex conditions. There is also a general concern for improper food handling and subsequent food safety issues. Although for many this would be no different than preparing a family meal safely, it is important to consider the literacy of the family or caregiver in implementing a labor intensive practice that requires concentration on safe food handling. Another common concern among healthcare practitioners is uncertain nutrient levels, which leaves the potential for macronutrient and micronutrient deficiencies if a nutritionally sound recipe is not in place.4-9 For this reason, it is highly

Blenderized Tube Feeding Katherine DiGeronimo, RD, LD

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recommended that a registered dietitian skilled in blenderized tube feeding help implement these diets with close monitoring and evaluation.4,7-9 Cost can also be a barrier if families are purchasing their own ingredients out of pocket, as opposed to the potential for insurance coverage of commercial formulas.4,7

Advantages

There are several significant advantages of implementing a blenderized tube feeding. Among the first recognized in many reviews includes the psychosocial benefits. For many families and caregivers, implementing a blenderized diet can normalize feeding and allows individuals the opportunity to be a part of meal time fellowship.6 It can also foster the innate sense of nurturing that comes with preparing and providing meals to loved ones. Included in the psychosocial component of blenderized diets is the opportunity to provide foods that are in line with nutritional views as well as avoiding ingredients that they may not prefer.6-7 This can provide more comfort and confidence in the food they are providing their loved one. Improved tolerance is also noted. This includes improved GI symptoms, including decreased reflux and constipation, as well as better volume tolerance. Decreased symptoms of retching and gagging have also been shown.4-9 Possibly in part due to improved tolerance, studies have shown increased oral intake when on a blenderized diet.4,6-7

However, what has been discussed less frequently in reviews of blenderized diets are the potentially harmful ingredients in conventional commercial formulas and the improved nutritional quality when implementing feedings made from whole foods. The majority of commercial enteral formulas on the market today are largely comprised of inexpensive, highly refined ingredients—including added sugars, heavily processed corn and soy ingredients, vegetable and seed oils, as well as casein. It can be argued that while these formulas are made to meet macronutrient requirements, they do little to support health and potentially drive inflammation, create dysbiosis in the

microbiome, contribute to GI distress, and suppress immune function.3 Of equal importance are the benefits that whole foods provide. Among the most beneficial attributes of switching to a whole foods formula are (1) vegetable sources of fermentable fiber—fostering healthy gut bacteria, better glycemic control and better digestion; and (2) plant sources of phytonutrients—with health promoting properties that may be protective against disease, reduce inflammation, and strengthen the immune system.3,11-12 Another important distinction is the availability of more microbial accessible carbohydrates (MACs) in blenderized diets—carbohydrates that can be metabolically used by the microbes in the gut. These carbohydrates feed important families of microbes and promote microbial diversity that evidence suggests can play an important role in improved health outcomes.13 With more clinicians realizing the potential for this impact, more studies are being conducted to better understand the merit of whole foods formulas.

Commercial Food-Based Enteral Formulas

There are now commercial food-based formulas available for individuals, families, and caregivers looking to implement a blenderized diet. This can be especially helpful for those who seek the benefits of whole foods, while also easing the potential difficulty of preparing recipes on their own. Some use these options as their sole nutrition source, while others may use it in combination with their home blends or during special circumstances such as travel.8 While each of these products are marketed towards the blenderized diet community, there are notable differences between them. One such product has been on the market for several years and has recently been slightly reformulated. While it contains certain food ingredients in the form of powders and purees, it also includes ingredients and additives similar to those found in standard formulas.14 Another option is comprised of a line of four blends, each of a different variety made of six to eight ingredients. These are not considered nutritionally complete and are intended to be

used as a supplement to another formula.15 The third option consists of an adult formula that has been on the market for almost 4 years, and a newer pediatric formula that was released within the past year. These products are the only whole foods enteral formulas that are certified USDA organic with no chemical preservatives and no sources of added sugar, in the form of corn syrup, fruit juice concentrates, or brown rice syrup. Both are nutritionally complete in of the number of pouches recommended for different age groups, and are thin enough to be used in continuous feeds, including J-tube feeds. They can also be used as oral meal replacements.16

Conclusion

While concerns still exist among healthcare professionals and further studies are needed, blenderized tube feedings have the potential to offer tremendous benefits to those medically fragile individuals requiring enteral nutrition. While enteral nutrition support over the past 40 years has largely focused on commercial products, growing interest in blenderized tube feedings is allowing the tube-fed population the opportunity to benefit from whole food nutrition—in one of the populations who perhaps needs it most.

4,6

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Academy of Nutritionand Dietetics

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1. 2015-2020 Dietary Guidelines for Americans. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015. 8th Edition. http://health.gov/dietaryguidelines/2015/guidelines.2. Global Enteral Nutrition Market Size, Share, Development, Growth and Demand Forecast to 2022. P&S Market Research. www.psmarketresearch.com. 3. Bengmark S. Nutrition of the Critically Ill - A 21st-Century Perspective. Nutrients. 2013;5:162-207. doi:10.3390/nu5010162.4. Walia C, Van Hoorn M, Edlbeck A, Feuling MB. The registered dietitian nutritionist’s guide to homemade tube feeding. J Acad Nutr Diet. 2017;117(1):11-16. doi:10.1016/j.jand.2016.02.007.5. Johnson TW, Spurlock A, Pierce L. Survey study assessing attitudes and experiences of pediatric registered dietitians regarding blended food by gastrostomy tube feeding [published online ahead of print December 22, 2014]. Nutr Clin Pract. 2015;30(3):402-405. doi:10.1177/0884533614564996.

6. Bobo E. Reemergence of blenderized tube feedings: exploring the evidence. Nutr Clin Pract. 2016;31:730-735. doi:10.1177/0884533616669703.7. Escuro A. Blenderized tube feeding: suggested guidelines to clinicians. Pract Gastroenterol. 2014;38(12):58-66. 8. Zettle S. Deconstructing pediatric blenderized tube feeding: getting started and problem solving common concerns. Nutr Clin Pract. 2016;31(6):773-779. doi:10.1177/0884533616662993.9. Epp L, Lammert L, Vallumsetla N, Hurt R, Mundi M. Use of blenderized tube feeding in adult and pediatric home enteral nutrition patients. Nutr Clin Pract. 2016:1-5. doi:10.1177/0884533616662992.10. Harkness L. The history of enteral nutrition therapy: from raw eggs and nasal tubes to purified amino acids and early postoperative jejunal delivery. J Am Diet Assoc. 2002;102(3):399-404.11. Eswaran S, Muir J, Chey W. Fiber and Functional Gastrointestinal

Disorders. Am J Gastroenterol. 2013;108:718-727. doi:10.1038/ajg.2013.63.12. Gupta C, Prakash D. Phytonutrients as Therapeutic Agents. J Complement Integr Med. 2014;11(3):151-169. doi:10.1515/jcim-2013-0021.13. Sonnenburg E, Sonnenburg J. Starving our Microbial Self: The Deleterious Consequences of a Diet Deficient in Microbiota-Accessible Carbohydrates. Cell Metab. 2014;20(5):779-786. doi:10.1016/j.cmet.2014.07.003.14. Compleat. Nestle Health Science Website. https://www.nestlehealthscience.us/brands/compleat/compleat. Updated 2017. Accessed March 14, 2017. 15. Nutritional Data. Real Food Blends Website. http://www.realfoodblends.com. Accessed March 14, 2017.16. Products. Nutritional Medicinals, LLC Website. http://www.functionalformularies.com. Updated 2017. Accessed March 14, 2017.

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Upcoming Conferences and Educational Opportunities

June 1-3, Institute for Functional Medicine 2017 Annual Conference. Los Angeles, CA. http://www.functionalmedicine.org/

June 2-5, Medicines from the Earth Herb Symposium 2017. Black Mountain, NC. https://www.botanicalmedicine.org/medicines-earth-herb-symposium-2017/

June 7-11, Am I Hungry? Eat Mindfully, Live Vibrantly Workshop and Retreat. Ivins, UT. http://thecenterformindfuleating.org/event-2414012

June 9-11, 13th International Herb Symposium. Norton, MA. http://www.internationalherbsymposium.com

June 12-16, Applying Functional Medicine in Clinical Practice. Washington, DC. https://www.

functionalmedicine.org/afmcp/home/ This course will also be available at other dates and locations: • September 11-15, Dallas, TX. • November 12-16, Chicago, IL.

July 8-9, Simply Spicy: An Exploration of Botanical and Culinary Medicine in Integrative Practice. Taos, NM. https://www.imconsortium.org/events/upcoming-conferences/simply_spicy.cfm

July 29-30, Medical Cannabis Conference. Portland, OR. http://career-alumni.nunm.edu/event/2017-medical-cannabis-conference-registration/

Electronic Mailing List (EML) Recent Topics Review:

In a discussion regarding foods that could block estrogen, responses suggested soy, flax, garlic, onions, cruciferous vegetables, and citrus bioflavonoids from citrus fruits. In a thread on high serum ferritin levels, many members suggested Hashimoto’s disease as being a possible cause. Aside from reducing serum ferritin levels with blood transfusions, avoiding excess iron and supplementation of vitamin C was also suggested. In two separate discussions on colostomies, several members recommended banana flakes to bulk up stool and treat diarrhea. Other popular EML threads included: postpartum hair loss, good sources for nutrigenomics, candida causing celiac disease, and a treatment for MRSA during pregnancy. In our commitment to being fair and unbiased, discussions regarding individuals or organizations, as well as certificate programs, testing, and nutrient analysis programs can be found on the electronic mailing list under: https://groups.yahoo.com/neo/groups/DIFM_Listserv/info.

What’s New - Journal Reviews and Resources

Cardiovascular Mortality and High-Density Lipoproteins in Individuals Without Pre-Existing Cardiovascular Conditions The Cardiovascular Health in

Ambulatory Care Research Team (CANHEART) cohort was used to assess the relationship of mortality and high-density lipoprotein cholesterol (HDL-C) in individuals without pre-existing cardiovascular disease (CVD). The study consisted of 631,762 Ontario residents between the ages of 40 and 105 with the average age being 57.2 years old. The fasting HDL-C was measured one year before the inception date. The sample excluded nursing home residents and any individuals with CVD or comorbidities such as cancer, dementia, peripheral vascular disease, abdominal aortic aneurysm, and venous thrombosis. The outcome measures were cause-specific mortality, including CVD, cancer, and non-CVD and noncancer mortality. The HDL-C relation to each of the three causes of death was estimated using separate cause-specific hazard models for men and women while adjusting for age, income, hypertension, diabetes mellitus, smoking, cholesterol levels, previous comorbidities, and Johns Hopkins’ Aggregated Diagnosis Groups. Subgroups were stratified by association of cause-specific mortality and HDL-C in individuals with low-density lipoprotein cholesterol (LDL-C) varying from ≤ 100 mg/dl to > 100 mg/dl, those older than 66 who were eligible for or using statins one year before inception, and individuals with a body mass index higher or lower than 25 kg/m2. The Canadian Community Health Survey (CCHS) was used for participants to self-report their help status, health determinants, and utilization of healthcare. Among the 5,108 participants who completed the CCHS, there was a strong correlation between higher HDL-C levels and healthier lifestyle factors. Individuals with higher HDL-C levels showed a higher prevalence of BMIs lower than 25 kg/m2, moderate physical activity (walking 30 minutes or more a day), and daily consumption of five or more servings of fruits and vegetables. The study found a high correlation between lower HDL-C levels and lower socioeconomic status, unhealthy lifestyles, increased CVD risk factors, and increased prevalence of medical comorbidities.

News You Can Use Compiled by Racquel Praino, Resource Review/News You Can Use/Networking/Spotlight Editor

Featured Educational Opportunity

May 18-20, Plant-Based Prevention of Disease conference. Albuquerque, NM. The fourth annual P-POD Conference brings together 33 expert speakers such as researchers, clinicians, and educators to discuss the latest research on plant-based diets and their effect on prevention and treatment of chronic diseases. T. Colin Campbell, PhD and founder of T. Colin Campbell Center for Nutrition Studies and Plant-Based Nutrition Certificate program, eCornell Inc., will be the keynote speaker for P-POD’S first annual Denis Burkitt Memorial lecture. Up to 17.25 hours of continuing education credits are available for RDNs and NDTRs. For more information, please see www.preventionofdisease.org or contact info@p-pod.org.

This announcement is courtesy of an agreement between P-POD and DIFM.

www.integrativeRD.org106Spring 2017 Volume 19, Issue 4

While lower HDL-C levels were found to be associated with an increased risk of both CVD and non-CVD mortality, individuals with very high HDL-C levels were associated with an increased risk of non-CVD mortality. Due to the similarities in the association of HDL-C levels and non-CVD mortality, HDL-C is unlikely to be a determinant of CVD-specific risk factors. Ko DT, Alter DA, Guo H, et al. High-Density Lipoprotein Cholesterol and Cause-Specific Mortality in Individuals Without Previous Cardiovascular Conditions: The CANHEART Study. J Am Coll Cardiol. 2016;68:2073-2083. doi:10.1016/j.jacc.2016.08.038.

Effects of Yoga and Lifestyle Modifications on Blood Pressure Authors conducted a study comparing the effects of yoga on the average 24-hour ambulatory blood pressure (ABP) among adults with prehypertension or stage one hypertension over a 24-week period. A total of 137 participants were randomized into three intervention groups: the structured yoga program (YP), the blood pressure education program (BPEP), and the combined yoga and education intervention (COMBO). The YP consisted of 12 weeks of biweekly yoga classes and self-practice and then 12 weeks 90-minute yoga classes, as well as 90-minute at-home yoga sessions. The BPEP intervention was comprised of 12 nutrition classes, 12 motivational experiences, small-group health education classes, and a walking program which consisted of 180 minutes walking each week, ideally over six days, or approximately 10,000 steps per day. Participants in COMBO program took part in two yoga classes each week, the biweekly nutrition lecture, and the walking program. ABP was measured at baseline and weeks 12 and 24. From weeks 0-12 and 0-24, there was a significant decrease (1.1 mm Hg) in systolic blood pressure (SBP) and diastolic blood pressure in all three intervention groups. By week 12, the YP and COMBO group showed a greater decrease in SPB, however, by week 24, the BPEP was shown to have a slightly higher reduction in SBP. Based on this study, the effects of yoga on ABP were found to be similar to both the diet and exercise group and the combination intervention.

Cohen DL, Boudhar S, Bowler A, Townsend RR. Blood Pressure Effects of Yoga, Alone or in Combination with Lifestyle Measures: Results of the Lifestyle Modification and Blood Pressure Study (LIMBS) [published online ahead of print January 15, 2016]. J Clin Hypertens. 2016;18(8):809-816. doi:10.1111/jch.12772.

Reduction of Preoperative Anxiety in Breast Surgery Patients with Aromatherapy The association of anxiety and aromatherapy using lavender fleur oil (LFO) and unscented oil (UO) was observed in 93 women just prior to undergoing breast surgery. The purpose of this study was to determine if use of LFO aromatherapy would have any reduction on preoperative anxiety. The women were randomized into two groups of either the lavender fleur oil or unscented oil. Before and after aromatherapy treatment, which took place immediately before surgery, vital signs (blood pressure and heart rate) were taken and the participants completed the Speilberger State Anxiety Inventory (STAI) questionnaire. The STAI questionnaire analyzed the responses as being either positive or negative emotions. Patients received treatment by wearing a plastic oxygen face mask for 10 minutes which contained either 2 drops of 2% LFO or UO inside. Both groups scored significantly higher (P ≤ .003) for positive feelings on the STAI questionnaire after treatment. The LFO group had a stronger effect, with scores that were slightly, but significantly more positive (P ≤ .001) than those of the UO group. The LFO and UO groups both decreased feelings of jitteriness, tension, and of being frightened or worried, however, neither decreased any feelings of confusion or being upset. While the STAI scores did show a decrease in anxiety, there was no significant decrease in heart rate or blood pressure after LFO or UO treatment. Both treatment with LFO and UO demonstrated the ability to reduce pre-operative anxiety, however, this is likely due to both the aromatherapy of LFO and placebo effect of the UO. Franco L, Blanck TJJ, Dugan K, et al. Both lavender fleur oil and unscented oil aromatherapy reduce preoperative anxiety in breast

surgery patients: a randomized trial [published online ahead of print May 5, 2016]. J Clin Anesth. 2016;33:243-249. doi:10.1016/j.jclinane.2016.02.032.

Nutritional Genomics Research Publications – Feb 1, 2017 Courtesy of the International Society of Nutrigenetics and Nutrigenomics (ISNN) at www.NutritionAndGenetics.org/, and of www.Nutrigenetics.net. High-saturated-fat diet increases circulating angiotensin-converting enzyme, which is enhanced by the rs4343 polymorphism defining persons at risk of nutrient-dependent increases of blood pressure. J Am Heart Assoc. 2017;17;6(1). pii: e004465. doi:10.1161/JAHA.116.004465. (PubMed ID: 28096099) Angiotensin-converting enzyme (ACE) is involved with blood pressure regulation. When subjected to a high-saturated-fat diet, those subjects who carried two copies of the rs4343 variant (GG) allele of the ACE gene showed a significant increase in systolic blood pressure. SNP rs11185644 of RXRA gene is identified for dose-response variability to vitamin D3 supplementation: a randomized clinical trial. Sci Rep. 2017;7:40593. doi:10.1038/srep40593. (PubMed ID: 28079136) Among the postmenopausal Caucasian women studied, the rs11185644 variant near the RXRA gene was associated with dose-response for supplemental vitamin D. Also, five variants in the CYP2R1 gene, and 6 variants in the GC gene were found to be associated with baseline serum levels of 25-hydroxyvitamin D3, a metabolite of vitamin D. Bioactive nutrients and nutrigenomics in age-related diseases. Molecules. 2017;22(1). pii: E105. doi:10.3390/molecules22010105. (PubMed ID: 28075340) Aging-related disorders are discussed in relation to various “omics” technologies, including nutritional genomics. The authors suggest that personalized nutrition, together with corresponding lifestyle changes, will become increasingly important for both preventive and therapeutic strategies.

Spring 2017 Volume 19, Issue 4 www.integrativeRD.org107

Interaction between a variant of CDKN2A/B-gene with lifestyle factors in determining dyslipidemia and estimated cardiovascular risk: A step toward personalized nutrition. Clin Nutr. 2016. pii: S0261-5614(16)31359-0. doi:10.1016/j.clnu.2016.12.018. [Epub ahead of print] (PubMed ID: 28065479) Among the Iranian subjects tested, obese subjects with 2 copies of the T allele (TT) of the rs10811661 variant had a significantly less favorable, higher-risk cardiovascular profile than those with the CT or CC alleles. However, this elevation in risk profile was mitigated among those with lower body mass index (BMI). Thus, for obese subjects with the TT allele, a low-calorie diet combined with greater physical activity could be especially helpful for reducing cardiovascular risk. Nutrigenomic functions of PPARs in obesogenic environments. PPAR Res. 2016;2016:4794576. doi:10.1155/2016/4794576. Epub 2016 Nov 30. (PubMed ID: 28042289) The roles of PPARs (PPARA, PPARB and PPARG) in regulating white, brown, and beige adipose tissues are discussed. Table 3 lists various flavonoids that have been studied in relation to PPARs, and specific variants of PPARG are discussed in more detail. Genetic variations involved in vitamin E status. Int J Mol Sci. 2016;17(12). pii: E2094. (PubMed ID: 27983595) Table 1 provides a summary listing of genes and gene variants that have been associated with blood levels of

vitamin E and its bioavailability. Polymorphism of the transcription factor 7-Like 2 gene (TCF7L2) interacts with obesity on type-2 diabetes in the PREDIMED Study emphasizing the heterogeneity of genetic variants in type-2 diabetes risk prediction: Time for obesity-specific genetic risk scores. Nutrients. 2016;8(12). pii: E793. (PubMed ID: 27929407) The rs7903146 variant of the TCF7L2 gene is shown in this report to interact with obesity status with regard to their combined influence on the risk of developing type-2 diabetes. Awareness of such interactions will lead to greater accuracy of risk predictions. Recent findings in Alzheimer's disease and nutrition focusing on epigenetics. Adv Nutr. 2016;7(5):917-27. doi:10.3945/an.116.012229. Print 2016 Sep. (PubMed ID: 27633107) This review discusses the influence of epigenetics on Alzheimer-related gene expression, which includes environmental influences. DNA methylation, histone modifications, and microRNAs are discussed, along with risk-modifying factors such as heavy metals, alcohol, trace elements, vitamins, and omega-3 fatty acids. Botanical constituents such as resveratrol, oleuopein, curcumin, etc., are also described. An update on the role of nutrigenomic modulations in mediating the cardiovascular protective effect of fruit polyphenols. Food Funct. 2016;7(9):3656-76. doi:10.1039/

c6fo00596a. Epub 2016 Aug 18. (PubMed ID: 27538117) The influence of various botanical constituents on gene expression related to cardiovascular risks are reviewed. Discussion includes flavonoids (e.g., anthocyanins, flavanones, flavanols, and flavonols), phenolic acids, and stilbenes. Copyright © 2017 Nutrigenetics Unlimited, Inc. Inquiries about above references? Contact Ron L Martin, MS, President, Nutrigenetics Unlimited, Inc., ron@nutrigenetics.net. The database at http://nutrigenetics.net/ is available to the public free on weekends (U.S. Central time) by using Free as the username, and Weekends as the password, as shown on the login page at https://nutrigenetics.net/Login.aspx. Check out http://www.nutritionandgenetics.org/ to learn more about ISNN membership discounts for dietitians, which includes 24/7 database access plus a subscription to the Journal of Nutrigenetics and Nutrigenomics.

Members in the NewsDIFM Media Chair Michelle Loy, MS, MPH, RDN, CSSD was awarded “Outstanding Board Member” for the 2016-17 year by the Orange District of the California Academy of Nutri-tion and Dietetics. Michelle Loy is serving as Communication Chair and Website Coordinator of the Orange District. Michelle was recently award-ed “Outstanding Board Member” during the 50th year of the Orange District. Michelle positively trans-formed the communications and the website of Orange District. She is a dedicated and talented professional with multiple responsibilities and still able to manage those commitments in an organized way.

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DIFM Network Chair, Mary Therese Hankinson, MBA, MS, RD, EDAC, CTP, holds

the position as the Director of Office of Patient-Centered Care/Planetree Office of the Veteran Affairs New Jersey Health Care System (VANJHCS). Planetree is a non-profit organization that gives hospitals and healthcare facilities the support needed to integrate holistic approaches into various clinical settings all over the world. The Planetree organization helps transform traditional healthcare settings by sharing their philosophies on patient-centered care and helping to facilitate the development of a healing environment. In 2005, Mary Therese led the VANJHCS to become an affiliate with Planetree to bring the body, mind, and spirit approach to improve patient-centered care. A core component of the Planetree model involves implementation of integrative therapies. During the initial phases of implementation, VANJHCS was successful in the implementation of integrative therapies as providers with allopathic and integrative credentials served as clinical champions and incorporated the practice of integrative medicine into their work at the VA. For example, Mary Therese worked with Doreen Korn, RN, MA, AHN-BC, QTTP, HWNC-BC, an advanced practice holistic nurse, who taught nursing staff to incorporate holistic practices such as therapeutic touch to help patients heal faster. The new approach also brought about more opportunities to implement yoga therapy and mindfulness practices for patients with chronic pain and behavioral health diagnoses. In 2011, Mary Therese and her staff collaborated with nursing to implement a Sleep Menu, thereby building on the previous campaigns to reduce noise and promote a quieter healing environment. Similar to the previous noise reduction projects, it relied heavily on staff to be mindful of their work behavior and to internalize the importance of sleep and quiet as a necessary ingredient for patient healing. The Sleep Menu today offers the following items for sleep promotion and veteran preference:

• Aromatherapy with lavender infused essential oil aromatabs

• Ear plugs• Eye mask• Herbal chamomile tea• Soothing music and nature

scenes via the interactive patient system and cable television; 3 channels provide light jazz, classical or sonic Zen music

• Warm blanket• Warm milk upon request.

During 2011, the VA implemented a national office of Patient-Centered Care & Cultural Transformation (OPCC&CT) to build a proactive and personalized patient-centered health care system to empower veterans to achieve their greatest level of health and well-being. OPCC&CT advertised requests for patient-centered proposals and Mary Therese wrote a grant in collaboration with Rutgers University Cooperative Extension of Essex County and VANJHCS to fund the creation of one greenhouse at the East Orange Campus of the VANJHCS. This complemented a burgeoning integrative environment by giving patients the opportunity to grow various anti-inflammatory foods and incorporate them into different menus, thus enabling them to create their own healthy meals. Additionally, this grant also provided funding for veterans to take part in a compensated work therapy (CWT) program in sustainable landscaping and storm water management. Through their participation in this program, veterans created an on-site storm water management system, which uses water from runoff to produce local, sustainably-grown vegetables and herbs. This program gives veterans the opportunity to learn the therapeutic value of organic gardening, reduce stress, and enjoy their surroundings. Mary Therese collaborates with Nancy Ann Cotter, MD, CNS, FAAAPMR, FACN, Physician Lead for Integrative Medicine at the VANJHCS, to enlighten health care professionals on the scientific evidence of the benefits of anti-inflammatory foods, herbs, and spices on pain reduction and chronic inflammatory diseases. Dr. Cotter and one of the VANJHCS

dietitians educate patients on foods and herbs that have natural anti-inflammatory effects on the body. Additionally, through a grant written by Mary Therese, the East Orange Campus of the VA will be opening a culinary kitchen this year where patients can obtain cooking classes within the health care system. Food production employees received health-supportive culinary education to make the connection between healthy whole-foods and functional nutrition. VANJHCS dietitians wrote a grant to implement Healthy Teaching Kitchens within Nutrition and Food Service at the East Orange and Lyons campuses. The Healthy Teaching Kitchen program provided interactive cooking demonstrations to veterans and their families. These VA Healthy Teaching Kitchens focus on disease-specific diets and sites with their own gardens incorporate their own locally grown foods into the cuisines. One and a half years ago, the VANJHCS also developed a holistic pain management program to decrease the use of opioids by using non-pharmacological integrative approaches including acupuncture, nutrition, mindfulness and yoga. In 2005, Planetree laid the groundwork and shortly after, under the leadership of Mary Therese, the VANJHCS was able to achieve Planetree Silver Merit Recognition in Patient-Centered Care. The model implemented by the VA Office of Patient-Centered Care and Planetree provides frameworks for facilities to initiate the use of integrative practices and identify credentialed integrative practitioners. Through Mary Therese’s diligence with Planetree, the VANJHCS is continuously growing as a true patient-centered, integrative environment that touches many veterans’ lives and demonstrates increased patient and employee satisfaction as well.

Member Spotlight Written by Racquel Praino, Resource Review/News You Can Use/Networking/Spotlight Editor in collaboration with Mary Therese Hankinson, MBA, MS, RD, EDAC, CPT

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Nutrient Power: Heal Your Biochemistry and Heal Your Brain

William J. Walsh, PhDSoftcover: $13.01New York; Skyhorse Publishing. 2014. 224 pp.ISBN-13: 978-1-62636-128-7

As advances in science and technology continue to emerge in the field of nutritional genomics, a new era of disease prevention is rising in our healthcare system. In Nutrient Power: Heal Your Biochemistry and Heal Your Brain, Dr. William Walsh presents natural treatment systems for individuals diagnosed with mental disorders, including schizophrenia, depression, autism, behavioral disorders, ADHD, and Alzheimer’s disease. A valuable resource for physicians, psychiatrists, pharmacists, clinical researchers, and dietitians, this book provides an important analysis of current therapies used for mental disorders and the role that nutrient therapies can play in treating and preventing disorders. Walsh views psychiatric medications as unsustainable treatments to help individuals with mental disorders, since they often provide only partial benefits to patients and can cause unpleasant side effects. He emphasizes that medications are essentially “foreign molecules” that create abnormal conditions in the body, whereas nutrient therapy can normalize brain chemistry. Moreover, he believes that nutrient therapy will eventually replace psychiatric medications as a method of treatment. Walsh states that genetic and environmental factors can produce nutrient imbalances in the brain, which can result in a myriad of mental disorders. These nutrient imbalances can cause improper concentrations of key neurotransmitters, alter gene expression of proteins that govern neurotransmitter activity at synapses, and can lead to impaired protection against toxic metals in the brain. Using blood, urine, and tissues tests, nutrient imbalances can be identified and targeted for nutrient therapy. Nutrient therapy can stabilize nutrient concentrations required for

proper neurotransmitter synthesis, modify epigenetic regulation of neurotransmitter activity, and reduce oxidative stress caused by free radicals. As a scientist with a doctorate in chemical engineering, Walsh has spent over thirty years studying more than 30,000 patients with different mental disorders. To support his theories related to underlying nutrient imbalances and effective therapies, he uses his own quantitative data, which includes over 3 million chemical assays in a variety of patients, including serial killers, autistic children, and Alzheimer’s patients. Additionally, he uses data from other researchers and historical accounts from patients and their families. The structure of the book gives the reader a foundation of brain chemistry and how intertwined nutrients are in the functioning of the brain. Walsh provides an overview of biochemical individuality and mental health, an introduction to brain chemistry, the role of nutrients in mental health, epigenetics and mental health, individual mental disorders, and clinical application of nutrient therapies. For each mental disorder discussed, Walsh reviews background information and history of the disorder, biotypes within each disorder, symptoms and traits of each biotype, nutrient therapies for each biotype, example case studies to demonstrate the clinical application of nutrient therapies, current psychiatric medications for each disorder, and the future of nutrient therapies and medication for each disorder. Although he provides compelling arguments for the nutrient imbalances identified with each mental disorder and has demonstrated effective nutrient treatments for each imbalance, further research is required for this to be clinically applicable nationwide. Walsh does not claim that his nutrient therapy approach definitively works for every patient, but he openly discusses the reports from patients, patient family members, and physicians. For integrative RDNs taking a holistic approach to nutrition and medicine, this book can be a valuable resource

that personifies the essential role of nutrients in brain chemistry and in the treatment of mental disorders.

Reviewed by Kathleen Walters, dietetic intern at Virginia Tech University. Kathleen earned her BA in Political Science and Spanish from the University of Notre Dame in 2008 and BS in Food and Nutrition from the University of Alabama in 2015. She is passionate about nutritional genomics, food policy, and nutrition education and promotion. Kathleen can be reached via email at kwalter5@vt.edu.

Resource Review: Nutrient Power

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Nutrition Essentials for Mental Health

Leslie Korn, PhDHardcover: $42.50New York, NY; W. W. Norton & Company. 2016. 424pp.ISBN: 978-0-393-70994-0

Nutrition Essentials for Mental Health: A complete guide to the Food-Mood Connection, written by Leslie Korn, PhD, is written to be a comprehensive text for professionals in the mental health field including psychiatrists, psychologists, and medical doctors who may have received little, if any, nutrition education. Dr. Korn holds a PhD in Behavioral Medicine, an MS in Public Health from Harvard and an MS in Health Psychology. Dr. Korn conveys the philosophy that the key to mental health lies within the power of nutrition. She states, “Nutrition matters and is the most important missing link to mental health in society today.” Dr. Korn stresses the importance of scope of practice, laws, and competence among providers and includes details on how to develop that competence. She discusses potential legal issues, rules, and legislation regarding the practice of medical nutrition therapy, and encourages anyone interested in incorporating nutrition into their practice to review their own state laws prior to proceeding. In the first chapter, Dr. Korn begins by stating her case as to the importance and role of nutrition in mental health. She starts with the basics: what information to collect on a nutrition assessment and how to interpret it (complete with a sample intake form), the anatomy of a food diary, and samples of motivational interviewing dialogues. Her writing style is straight-to-the-point and she effectively translates what can be complex scientific material into easy-to-understand and digestible bits. She tackles topics such as adrenal support, genetics, food sensitivities and inflammation using analogies and simple examples. Overall, Dr. Korn thoroughly cites well-respected scientific journals to support the use of various nutrition approaches for mental health conditions such as bipolar

disorder, eating disorders, substance abuse and addiction, schizophrenia, autism, anxiety, and attention-deficit disorder. In fact, sixteen pages are dedicated to references from well-respected sources such as the Journal of Clinical Nutrition and the Journal of the American Medical Association. However, in several instances, Dr. Korn neglected to cite research to support certain areas of practice. For example, she encourages providers to utilize methods to determine a client’s “metabolic type” using niacin and vitamin C. Dr. Korn states that these supplements can be used to determine a client’s rate of oxidation, which then indicate their metabolic type. She follows with specific percentages of protein, carbohydrates, and fat that clients should aim for based on their rate of oxidation. Upon emailing Dr. Korn to request the references that show the validity of such testing, she was unable to provide any well-documented research, but did point to other doctors that use the protocol that she recommended. The advanced integrative RDN may find the majority of the material basic. As the book lends itself to more of a textbook approach, she spends considerable time defining concepts and diseases that are part of standard training for RDNs. She devotes an entire chapter to the basics of mental health diagnoses such as anxiety, substance abuse, dementia, and eating disorders. In other chapters, she covers food allergies, sensitivities and special diets, and nutrients in specific foods to treat or support various conditions. While much of the material may be familiar, Dr. Korn has successfully consolidated the information into detailed and easily-referenced protocols. This book may be a comprehensive, introductory reference manual to have on hand and could be especially relevant for RDNs new to the area of functional and integrative nutrition.

Reviewed by Amber Gourley, MS, RDN, LDN, CLT, CDE. Amber received her master’s degree in Clinical Nutrition from East Tennessee State University during her dietetic internship in 2013. She currently works full-time at the Mountain Home Veterans Affairs Hospital. Amber also operates a small

private practice, The Disobedient Dietitian, where she challenges conventional approaches to nutrition and body image and utilizes the principles of functional and integrative nutrition to change people’s health and lives. Contact Amber at www.thedisobedientdietitian.com or at ambergourleyrd@gmail.com.

Resource Review: Nutrition Essentials for Mental Health

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Throughout history, essential oils (EOs) have been cultivated from

plants and used around the world for their various properties. Today, inte-grative and functional medicine dieti-tians can use EOs as another tool to encourage a more natural approach to health and healing. This fact sheet summarizes the potential attributes of three edible EOs, each of which are FDA approved for internal consump-tion.

History of EOs For centuries, the therapeutic, antimicrobial and antiseptic proper-ties of plants have been used throughout the world. Today, with a noticeable rise in drug-resistant path-ogens, the various healing aspects of these EOs have become a prevalent topic of modern day research. EOs,

also known as volatile oils, are ex-tracted from plants and contain con-centrated amounts of various phyto-chemicals and compounds. The mech-anisms of action of EOs are depend-ent upon environmental factors and specific chemical compounds of the plant from which they were extract-ed. As the strength and concentration of these compounds is highly potent, dosage is under constant debate.¹

While most EOs are used for their aromatic properties, there are a few EOs acknowledged as Generally Rec-ognized As Safe (GRAS) by the FDA for internal consumption. To avoid toxici-ty, carefully follow the directions on purchased oil containers before con-suming.

Mikayla Cupp is a senior at the University of Kentucky with a major and interest in dietetics. She is an ex-ecutive committee member for the SSTOP Hunger (Sustainable Solutions To Overcome Poverty) student organi-zation on her university’s campus, as well as a community volunteer for various, local affiliations within Lex-ington, Kentucky. Contact Mikayla at mikayla.cupp@uky.edu.

Edible Essential Oil Description Key Constituents Holistic and Healing Functions LEMON GRASS OIL

Scientific Name: Cymbopogon citratus

Lemon grass (Stapf) is within the Graminaceae plant lineage and is

native to southern India and southeast Asia.3

Lemon grass is currently cultivated globally within tropical

and semi-tropical regions for various purposes including

culinary flavoring.4

Lemon grass EO has a citrus flavor and can be used in Asian inspired

cuisine, soups, teas, and curry dishes.4

The EO of Cymbopogon citratus is extracted from the whole aerial

leaves on the plant through distillation.3

Lemon grass EO is composed of various hydrocarbon terpenes,

alcohols, esters, ketones, and aldehyde compounds 4 as well as various phytochemicals including alkaloids, flavonoids, terpenoids

and tannins.5

Specifically, the oil contains the phytoconstituent citral (about 70%)3

as well as citronellal, geroniol, terpinolene, geranyl acetate, and

myrecene.4

Lemon grass EO has proven to contain antibacterial, anti-inflammatory, and antioxidant activities.4 These properties can be used to remedy headaches, fever,

muscle cramps, and boost overall health.4

Studies have reported evidence demonstrating lemon grass’s antidiarrheal activity,4 which can be used to treat

gastrointestinal and digestive issues by relieving abdominal cramping and flatulence, as well as

improving digestion.3

Various studies involving animal testing have shown evidence of anti-diabetic, chemopreventive, and

cytotoxicity properties,5 as well as potentially positive hypocholesterolemic, hypoglycemic and hypolipidemic

effects.4 Specifically, a study involving rats showed decreased levels of total cholesterol, fasting glucose,

triglycerides, LDLs and VLDLs using a lemon grass EO treatment.4

POTENTIAL RISKS: Based on a study involving rats, a suggested limit of 0.7 mg/kg/day of the EO has been suggested for human consumption. Those who are pregnant and/or breastfeeding should avoid usage, as the components citral and myrcene induced maternal complications in recorded rat studies.6

~ Edible Essential Oils ~

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PEPPERMINT OIL Scientific Name:

Mentha × piperita L. Peppermint is part of the

Lamiaceae plant lineage and is a hybrid of water mint and spearmint.3 Peppermint is

commercially grown throughout North America, Asia, and Europe and the EO functions mostly for

medicinal purposes.3

Peppermint EO has a strong mint flavor and aroma and is

commonly used for culinary flavoring in teas, baked goods,

desserts, and candies.

Peppermint EO is extracted from flow-ering aerial leaves on the plant

through distillation in the spring months.3

The peppermint plant contains over 40 chemical compounds.7

Key constituents of peppermint EO include mainly menthol (35-55%) and

menthone (10-40%), as well as flavonoids, phenolic acids, and

triterpenes.3

Peppermint EO has digestive and antispasmodic properties that help to relax the gut muscles and increase

the flow of digestion.3

The EO may improve gastrointestinal issues including abdominal pain, indigestion, IBS, nausea, vomiting and

bloating.3

Studies suggest peppermint EO has strong antibacterial activity, acting as an inhibitor of various strains of bacteria,

including staphylococci.2

A research study produced in 2014 provided evidence that the ingestion of 50 µl of peppermint oil improved athletic

performance regarding strength and speed.7

Other studies have concluded choleretic, carminative, antiviral, antioxidant, anti-inflammatory, analgesic, and

vasodilator effects,7 as well as anticancer activity.8

POTENTIAL RISKS: Peppermint oils containing more than 1% concentration of pulegone are considered toxic and should be avoided. 9

Those experiencing gastric ulcers or heartburn should avoid use due to the oil’s ability to decrease esophageal pressure.10 Pregnant and/or breastfeeding women as well as those with known peppermint allergies should avoid use.

BASIL OIL (SWEET) Scientific Name:

Ocimum basilicum L. Sweet basil is a culinary and

aromatic herb within the Lamiaceae plant family, cultivat-

ed within the subtropical and tropical areas of South America,

Asia, and Africa.1

Basil has a distinctive sweet, yet savory taste including hints of

mint and pepper. This EO can be used to add flavor to a multitude

of culinary dishes including soups, fish, pasta sauce, and

salad dressings.

Basil EO is extracted from the aerial flowering plant leaves through

distillation.3

The main constituents of sweet basil’s EO are found within the basil leaves3

and include estragole, linalool, methyl chavicol, citral, and thymol.1

Basil EO can be used as treatment for symptoms including coughing, cephalagia, diarrhea, constipation,

and indigestion.1 The antibacterial activity of basil EO has been correlated to the high amounts of linalool and estragole components

it contains.1 These antibacterial functions were proven specifically in one study, providing resistance to clinical

isolates of E. coli, K. pneumonia, P. aeruginosa, and A. baumannii.1

Antimicrobial properties of basil EO have been proven in studies, specifically against strains of Staphylococcus spp., Bacillus subtilis, Listeria spp., Salmonella spp., and others.1 Other studies have supported this oil’s anti-inflammatory,

antioxidant, and analgesic effects.1

POTIENTIAL RISKS: Breastfeeding women should avoid consumption of basil EO due to the high amounts of estragole present and the lack of information available regarding this component.11

Edible Essential Oil Description Key Constituents Holistic and Healing Functions

Works Cited

1. Sakkas H, Papadopoulou C. Antimicrobial activity of basil, oregano and thyme essential oils [published online ahead of print December 20, 2016]. J Microbiol Biotech-nol. 2016;26:10. doi:10.4014/jmb.1608.08024. 2. Dagli N, Dagli R, Mahmound RS, Baroudi K. Essential oils, their therapeutic properties, and implication in dentistry: A review. J Int Soc Prevent Communit Dent. 2015;5(5):335-340. doi:10.4103/2231-0762.165933. 3. Chevallier A. Encyclopedia of Herbal Medicine. 3rd ed. New York, NY: DK Penguin Random House; 2016. 4. Shah G, Shri R, Panchal V, Sharma N, Singh B, Mann AS. Scientific basis for the therapeutic use of Cymbopogon citratus, stapf (Lemon grass). J Adv Pharm Technol Res. 2011;2(1):3-8. doi:10.4103/2231-4040.79796. 5. Avoseh A, Oyedeji O, Rungqu P, Nkeh-Chungag B, Oyedeji A. Cymbopogon species; ethnopharmacology, phytochemistry and the pharmacological importance. Mole-cules. 2015;20(5):7438-7453. doi:10.3390/molecules20057438. 6. Fandohan P, Gnonlonfin B, Laleye A, Gbenou JD, Darboux R, Moudachirou M. Toxicity and gastric tolerance of essential oils from Cymbopogon citratus, Ocimum gratis-simum and Ocimum basilicum in Wistar rats [published online ahead of print April 13, 2008]. Food Chem Toxicol. 2008;46(7):2493-2497. doi:10.1016/j.fct.2008.04.006. 7. Meamarbashi A. Instant effects of peppermint essential oil on the physiological parameters and exercise performance. Avicenna J Phytomed. 2014;4(1):72-78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103722/pdf/ajp-4-072.pdf. Accessed February 4, 2017.8. Kim SH, Nam JH, Park EJ, et al. Menthol regulates TRPM8-independent processes in PC-3 prostate cancer cells [published online ahead of print October 9, 2008]. Bio-chimica et Biophysica Acta. 2009;1792(1):33-38. doi:10.1016/j.bbadis.2008.09.012. 9. Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics. New York, New York: Wiley Interscience; 1980.10. Hills JM, Aaronson PI. The mechanism of action of peppermint oil on gastrointestinal smooth muscle. An analysis using patch clamp electrophysiology and isolated tissue pharmacology in rabbit and guinea pig. Gastroenterology.1991;101(1):55-65. https://www.ncbi.nlm.nih.gov/pubmed/1646142. Accessed February 4, 2017. 11. Kopec K. Herbal medications and breastfeeding. J Hum Lact. 1999;15(2):157-61. https://www.ncbi.nlm.nih.gov/pubmed/10578793. Accessed February 4, 2017.

Photo source: Pixabay.com. https://pixabay.com/. Accessed May 14, 2017.

1. Sakkas H, Papadopoulou C. Antimicrobial activity of basil, oregano and thyme essential oils [published online ahead of print December 20, 2016]. J Microbiol Biotech-nol. 2016;26:10. doi:10.4014/jmb.1608.08024. 2. Dagli N, Dagli R, Mahmound RS, Baroudi K. Essential oils, their therapeutic properties, and implication in dentistry: A review. J Int Soc Prevent Communit Dent. 2015;5 (5):335-340. doi:10.4103/2231-0762.165933. 3. Chevallier A. Encyclopedia of Herbal Medicine. 3rd ed. New York, NY: DK Penguin Random House; 2016. 4. Shah G, Shri R, Panchal V, Sharma N, Singh B, Mann AS. Scientific basis for the therapeutic use of Cymbopogon citratus, stapf (Lemon grass). J Adv Pharm Technol Res. 2011;2(1):3-8. doi:10.4103/2231-4040.79796. 5. Avoseh A, Oyedeji O, Rungqu P, Nkeh-Chungag B, Oyedeji A. Cymbopogon species; ethnopharmacology, phytochemistry and the pharmacological importance. Molecules. 2015;20(5):7438-7453. doi:10.3390/molecules20057438. 6. Fandohan P, Gnonlonfin B, Laleye A, Gbenou JD, Darboux R, Moudachirou M. Toxicity and gastric tolerance of essential oils from Cymbopogon citratus, Ocimum gratis-si-mum and Ocimum basilicum in Wistar rats [published online ahead of print April 13, 2008]. Food Chem Toxicol. 2008;46(7):2493-2497. doi:10.1016/j.fct.2008.04.006. 7. Meamarbashi A. Instant effects of peppermint essential oil on the physiological parameters and exercise performance. Avicenna J Phytomed. 2014;4(1):72-78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103722/pdf/ajp-4-072.pdf. Accessed February 4, 2017.8. Kim SH, Nam JH, Park EJ, et al. Menthol regulates TRPM8-independent processes in PC-3 prostate cancer cells [published online ahead of print October 9, 2008]. Bio-chimica et Biophysica Acta. 2009;1792(1):33-38. doi:10.1016/j.bbadis.2008.09.012. 9. Leung AY. Encyclopedia of Common Natural Ingredients Used in Food, Drugs, and Cosmetics. New York, New York: Wiley Interscience; 1980.10. Hills JM, Aaronson PI. The mechanism of action of peppermint oil on gastrointestinal smooth muscle. An analysis using patch clamp electrophysiology and isolated tissue pharmacology in rabbit and guinea pig. Gastroenterology.1991;101(1):55-65. https://www.ncbi.nlm.nih.gov/pubmed/1646142. Accessed February 4, 2017. 11. Kopec K. Herbal medications and breastfeeding. J Hum Lact. 1999;15(2):157-61. https://www.ncbi.nlm.nih.gov/pubmed/10578793. Accessed February 4, 2017.

Photo source: Pixabay.com. https://pixabay.com/. Accessed May 14, 2017.

Kathleen Walters is a dietetic intern at Virginia Tech University. Kathleen earned her BA in Political Science and Spanish from the University of Notre Dame in 2008 and BS in Food and Nutrition from the University of Alabama in 2015. She is passionate about nutritional genomics, food policy, and nutrition education and promotion. Contact Kathleen at kwalter5@vt.edu.

Prep Time: 10 minutes Cook Time: 15 minutesTotal Time: 35 minutes

Serves: 4

Ingredients• 1 lb whole-wheat penne• 2 tbsp basil oil*• 1 lb chicken breast strips • 1 lb broccoli florets• 4 tbsp oregano• 2 tsp pepper• 8 Roma tomatoes, sliced• Pesto sauce:

o 2/3 cup basil oil*o 1/4 cup pine nutso 10 basil leaveso 1/2 cup parmesan

cheese, gratedo 2 cloves garlic, minced

Directions1. Prepare the pesto sauce by

adding the oil, nuts, basil leaves, cheese, and garlic to a food processor. Pulse until mixture is smooth and creamy. Set aside.

2. Bring 2 quarts of water to boil. Cook the penne pasta for 8-10 minutes until desired tenderness.

3. While pasta cooks, heat oil in a large skillet. Add the broccoli florets and cook (covered) for 2 minutes. Add chicken strips, oregano, and pepper. Cook for 5 minutes, stirring occasionally. Add Roma tomatoes and cook (uncovered) for 2 minutes. Remove from heat.

4. Once pasta has reached desired tenderness, rinse under cold water and drain.

5. Add pasta and pesto to the skillet. Stir until blended and serve immediately.

*“Basil oil” refers to the mixture of basil essential oil with a carrier oil, such as sunflower oil. The number of drops will depend on the oils used and flavor desired. For this recipe, start with one drop of basil essential oil and one drop of lemon essential oil added to 2/3 cup of sunflower oil. Add drops, one at a time, to taste.

Be advised that basil essential oil is very strong and should be added in small increments. Before using essential oils in recipes, verify that they are marketed as safe for internal consumption.

Recipe: Chicken and Broccoli Pasta with Pesto

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Dietitians inIntegrativeand FunctionalMedicinea dietetic practice group of the

Academy of Nutritionand Dietetics

®

www.integrativeRD.org114Spring 2017 Volume 19, Issue 4

I just completed the first module last week. I appreciated having a broad overview and insight into how

I can...and already am...providing integrative care to my patients. Thanks!!! – Michelle McQueen, RD, CD

I completed the entire course, all 5 modules. I loved it and learned so much. I would have liked a little more info on the best anti-inflammatory diet, maybe some patient handout type things as well as the dosing on some of the herbs like turmeric. Also

would be nice to have a follow up course on reading the different lab tests that are out there like ALCAT. – Amy Hansen Hammons, MS, RD, LD

I’m almost finished! So far it has been really good. Very detailed info on metabolic pathways, etc. May have to go back through it more than once. Would love to have flyers or something on all the different 5R regimens. – Lisa Upchurch Wiggins, RDN with MEd in Exercise Physiology

Most beneficial CEU program I’ve completed in 7 years as an RDN. Would love to see a second level certificate with even more in depth info and practice pearls. – Kodi Watson, MS, RDN, LD

I have completed first 2 rounds and I am really enjoying it. I would love case studies for each module that tie the information all together. – Kerry Barbera, RDN, LDN

Thank you so much! The meal was lightly sautéed salmon marinated in turmeric, sodium

free herb blend, salt and pepper. I made some oven roasted Brussels sprouts and baby squash lightly tossed in olive oil and salt for the veggie side. Salad was a broccoli and cabbage slaw with kale, pumpkin seeds, and dried cranberries with a lemon juice and olive oil dressing. Winning this membership is very exciting for me since it gives me the opportunity to learn from the best in the field. This field is definitely an area of dietetics that I’m super passionate about and I am really interested in learning more! Thank you again for this opportunity. Saghar Sefidbakht, MS, RD

What Members Are Saying About the Online Certificate of Training Program

YourPlate Contest Winner

Dietitians inIntegrativeand FunctionalMedicinea dietetic practice group of the

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®

Saghar Sefidbakht MS, RD

Check in with Facebook regularly for our next contest.

As the end of my time as chair approaches, I have been reflecting on DIFM’s key projects and the

exciting achievements we have made this year—not least of which was the launch of the Certificate of Training in Integrative and Functional Nutrition this past February! This five module, 10 CPE series is available through the Academy’s Center for Lifelong Learning and is a bargain at $24 per module for Academy members. This series provides an excellent overview of the science and philosophy behind Integrative and Functional Nutrition (IFN), including practices that are considered emerging and many that are well established. The project has been two years in the making and has been carefully vetted by the Dietetics Practice Based Research Network (DPBRN), the Center for Lifelong Learning and DIFM. Please help us spread the word about this exciting educational opportunity and consider completing the modules for yourself! They can be found at the Academy eatright.org store. We have two large and important projects underway that will help define the practice of IFN and promote greater understanding and acceptance among dietitians and other healthcare professionals.

• Our standards of practice and standards of professional performance (SOP/SOPP) are currently being updated with the help of IFN experts Diana Noland, RDN, MPH, CCN and Sudha Raj, PhD, RDN, FAND. We are grateful for their contributions and efforts. This project is being managed through the Practice Standards and Quality Assurance Team at the Academy and will be published in the Academy journal.

• The Role Delineation and Decision Making Frameworks for Integrative and Functional Medicine RDNs research project began this winter. Working with DPBRN, research fellow Emily Gooman, MS, RD, LD was hired to work with DPBRN to gather data for this study that will be published in the Academy journal next year.

DIFM has launched a speakers’ bureau/expert database and we encourage you to join! We have many requests for speakers, authors and consultants on IFN and we need to grow this database to meet the demand. You can find the link on our website, integrativerd.org in the members only section.

Last month we were given permission from the Academy to start a state ambassador program in three states—New York, Florida and California. Our hope is to increase our visibility at the state level with meet ups, outreach, and by promoting member connections. If these three states are successful we will be looking to ramp up this program to other states in the coming year. I want to give a warm welcome and congratulations to our newly elected executive committee members who will be serving you next year. Our chair-elect is Danielle Omar, MS, RDN. As DIFM’s current marketing chair, Danielle has helped to redesign our website and has worked closely with our communications team to improve our social media platforms and blog. She will be a creative and dynamic leader. Our new secretary is Denine Rogers, MS, RDN, LD, FAND. A fellow of the Academy, Denine recently completed a master’s degree in Complementary and Alternative Medicine and a graduate certificate in Herbal Medicine at American College of Health Sciences. Our incoming nominating committee chair is Susan Linke, MBA, MS, RDN, LD, CGP, CLT, an expert IFN dietitian, and well-known and respected LEAP practitioner and mentor. Our nominating committee member is Jessica Redmond, MS, RDN, CSCS, FAND. Jess is a PhD candidate in Science Education at Syracuse University, a certified yoga instructor, and our current secretary. Mary Purdy, MS, RDN is incoming DIFM chair. She is a senior

integrative dietitian and trainer at Arivale, with a wealth of knowledge, enthusiasm, and creativity; not to mention experience as a dedicated DIFM leader. I know you will be in good hands with DIFM’s incoming team! It is an exciting time to be practicing integrative and functional nutrition—interest has never been so high. Our DIFM membership has grown to over 4700 and continues to grow each month. Your membership is important to us, so please make sure to renew this May. As part of your membership you have access to monthly webinars by experts in the field, archived webinars and newsletters, monthly CPE offerings, our electronic mailing list, the Natural Medicines Database, three full text natural medicine journals, FNCE meet-ups including Mind Body Happy Hour and the opportunity to connect with like-minded peers. In closing, I want to thank our current executive committee and leadership team—you all have been a joy to work with and a true inspiration. Thank you also to our members for your support and engagement. May the bounty of spring rain upon you!

In health and wellness,

Chair, Dietitians in Integrative and Functional Medicine

Chair’s Corner Kelly Morrow, MS, RDN, CDChair, Dietitians in Integrative and Functional Medicine

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Kelly

115

As I write this column, I am spending the last few days of a seven-week journey in the Southern Hemisphere—Australia (AU) and New Zealand. Traveling by car through both countries and spending time with locals has called attention to two

things: the similarities between these countries in incidence of obesity and chronic diseases; and the extent of unregulated information regarding alternative (as opposed to complementary or integrative) care and nutrition in the public domain. According to available statistics, the rate of overweight and obesity in Australia has one of the higher in the world at 63.4% of the adult population, an increase of 12% over the past 20 years.1 The rate in the US has also increased and now 68.8% of adult Americans are overweight or obese with 36.5% obese and one in twenty, extremely obese.2 There is a plethora of advertisements for treatments for weight loss, just as in the US. Some of them are legitimate while many are not, given that consumers generally want an easy fix without changing their eating and exercise habits. Some treatments may be overseen by a dietitian/nutritionist, while a preponderance are not administered by licensed nutrition or medical professionals. While the per capita AU Accredited Practising Dietitians (APDs)—one per 3958 people—and US Registered Dietitian Nutritionists (RDNs)—one per 3646—is similar, one significant difference seems to exist; I observed little reference to APDs in public advertising. Every town or city from several thousand to several million in Australia has store-front nutrition specialists: “Suzie’s Nutrition” or “Miss Nutrition” as real-life examples. It appears that there are self-proclaimed nutritionists “practicing” in local health foods stores or in conjunction with physiotherapists, acupuncturists, or Chinese Medicine specialists. In other cases, local martial arts teachers and massage therapists advertise themselves as specialists in nutrition. In my travels of over 3400 km (over 2000 miles) by car to date, I have seen that many towns have “nutrition advice” offered on store fronts, sometimes every block, without reference to credentialed APDs. However, I have seen APDs referred to infrequently in magazines and newspapers, while not at all on medical practitioner’s placards advertising dietitian services. While America has many “alternative practitioners,” the laws in most of the US do not allow for what appears in AU to be blatant advertising, including claims seen in stores, magazines, and with “healthcare” practitioners. As RDNs we favor laws that help protect consumers from being treated and sometimes exploited by those without credentials, often unknowingly and/or out of desperation. Alternative therapies are just that—alternatives to traditional treatment, all too often administered without medical license or credentials. What sets DIFM apart from alternative nutrition providers is that we have the opportunity for certification by knowledgeable, credentialed RDNs who are providing evidence-based information and treatments with an integrative and functional approach. We do not suggest that integrative nutrition and/or medicine is an alternative treatment, rather it is offered to compliment traditional therapies. In the US we also embrace those who may not have RDN credentialing, but have advanced education and therefore evidence-based expertise to offer, for instance those associated with organizations such as the Institute of Functional Medicine. As a founding member of what is now DIFM, I remain concerned about those with little or no accredited or evidence-based education providing nutrition services to “the masses.” The availability of education with unsubstantiated nutrition information/counseling will remain, but as long as there is the option for reliable evidence-based information from credentialed RDNs, such as DIFM RDNs, the consumer choosing an RDN should be protected from maltreatment. As we approach the new year for the Academy and DIFM, I sincerely hope that you will renew your membership. We have many exciting plans for offerings in The Integrative RDN that will bring evidence-based nutrition information that you can use to help your patients/clients. As always, please feel free to contact me at peaknut70@gmail.com with any questions or if you are interested in writing or assisting with the newsletter. As is customary in Australia, I close with… See Ya!

References

1. Overweight and Obesity. Australian Government. Australian Institute of Health and Welfare. Available at http://www.aihw.gov.au/overweight-and-obesity/. Accessed May 13, 2017.2. Adult Obesity Facts. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/obesity/data/adult.html. Accessed May 13, 2017.

Editor’s Notes

Sarah

Spring 2017 Volume 19, Issue 4 www.integrativeRD.org

EditorSarah Harding Laidlaw, MS, RDN, MPA, CDEpeaknut70@gmail.comCopy EditorEmily D. Moore, MS, RDN, LD/Nemilydavismoore@hotmail.comAssociate EditorJena Savadsky Griffith, BA, BSjenas_mailbox@yahoo.comCPE EditorShari B. Pollack, MPH, RDN, LDNsbethp@gmail.comCommunications ChairMalorie Blake, MS, RDN, LDN, CNSC mblake822@gmail.comBiochemistry/Nutritional Genomics Danica Cowan, MS, RDdcowan57@gmail.comNYCU/Resource Reviews/Members In The News/SpotlightRaquel Praino, Dietetic Intern raquelpraino@yahoo.comBotanicals/Functional Foods/SupplementsDina Ranade, RDN, LDdranade@comcast.netMind/BodyDoris Piccinin, MS, RD, CDE, LDNdpicc100@gmail.comStudent Member Services ChairKathleen Schofielddifmstudentchair@gmail.comEditorsLinda Lockett Brown, ABD, M.Ag., RDN,LDN, CLCChristian Calaguas, RD

Upcoming Issues• Fall 2017, Editor’s Deadline July 1 CPE Deadline June 15 • Winter 2018, Editor's Deadline November 1, 2017 • Spring 2018, Editor's Deadline February 1, 2018 CPE Deadline January 15 • Summer 2018, Editor's Deadline April 1, 2018

The views expressed in this newsletter are those of the authors and do not necessarily reflect the policies and/or official positions of the Academy of Nutrition & Dietetics.

We invite you to submit articles, news and comments. Contact us for author guidelines.Send change-of-address notification to the Academy of Nutrition & Dietetics, 120 South Riverside Plaza, Ste. 2000, Chicago, IL 60606-6995.

Copyright © 2017 Dietitians in Integrative and Functional Medicine, a Dietetic Practice Group of the Academy of Nutrition & Dietetics. All material appearing in this newsletter is covered by copyright law and may be photocopied or otherwise reproduced for noncommercial scientific or educational purposes only, provided the source is acknowledged. For all other purposes, the written consent of the editor is required.

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116

Second Century Vision, Mission and Principles

At the Academy Board of Directors’ most recent meeting on February 24, the Board

discussed where they saw the biggest opportunities for growth as an organization and how the Academy could increase value to members while making an impact in the world. The new vision, mission and principles were informed by the Academy’s collective best thinking and reflect member and stakeholder input.

Second Century Vision

A world where all people thrive through the transformative power of food and nutrition

Second Century Mission

Accelerate improvements in global health and well-being through food and nutrition

Second Century Principles

The Academy of Nutrition and Dietetics and our members:

1. Integrate research, professional development and practice to stimulate innovation and discovery

2. Collaborate to solve the greatest food and nutrition challenges now and in the future

3. Focus on system-wide impact across the food, wellness and health care sectors

4. Have a global impact in eliminating all forms of malnutrition

5. Amplify the contribution of nutrition practitioners and expand workforce capacity and capability.

The past vision statement evolved to describe a future state that we want to help create. It acknowledges that food and nutrition are instrumental ingredients to individual health and societal well-being. Each word was carefully chosen and deliberate:

• World reflects that the Academy is striving for a global impact

• All people acknowledges a broad reach and impact on humanity

• Thrive is a positive verb synonymous with flourish, prosper, advance and succeed

• Transformative power recognizes that the Academy and its members are capable of stimulating change

• Food and nutrition are the vehicles by which this change occurs.

The Second Century mission evolved to focus directly on the outcome of why the Academy exists—to improve health. Again, each word was carefully chosen and deliberate:

• Accelerate improvements in health reflects that the Academy will enable faster or greater progress in being free from ailment

• Global acknowledges that the Academy has a role in influencing health all over the world

• Food and nutrition identifies the mechanism by which health is improved and the particular area of expertise the Academy contributes.

The vision and mission work together: Vision is the future the Academy wants to create. Mission is how we will get there. The five principles for the Second Century are extensions of the vision and mission and are both aspirational and strategic. Principles are core

commitments that clarify and help align organizational leadership on a strategic direction. You can learn more about the vision, mission and principles in the Academy’s press release. Also, check out the Academy Vision, Mission and Principles video—great for sharing on social media and in your e-newsletters!

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Chair 2016-2017Kelly Morrow, MS, RDN, CDkmorrow@bastyr.edu Past Chair 2016-2017Monique M Richard, MS, RDN, LDNmmr2v@mtmail.mtsu.edu Chair Elect 2016-2017Mary Purdy, MS, RDNMaryPurdyRD@gmail.com Treasurer 2016-2018Dana Elia, MS, RDN, LDNDIFMTreasurer@gmail.com Secretary 2015-2017Jessica G Redmond, MS, RD, CSCSjess.g.redmond@gmail.com DPG Delegate 2016-2019Mary Beth Augustine, RDN, CDN, FANDdelegatedifm@gmail.com Nominating Committee Chair 2016-2017Aarti Batavia, MS, RDN, CLT, CFSP, IFMCP aartibatavia@gmail.com

Indicates Voting Member  DIFM Leadership Team Communications Chair 2015-2017 Malorie R Blake, MS, RDN, LDN, CNSCmblake822@gmail.com Development Chair 2016-2018 Kristie Finnan, RDN LDNkristiefinnan@me.com DIFM Historian 2016-2017Kathy Moore, RDN, LD, CCNmoorenutritiondifm@gmail.com Diversity Chair 2016-2017Rita Kashi Batheja, MS, RDN, CDN, FANDkrbatheja@gmail.com Executive Asst/Website MgrAmy JarckPhone: 800-279-6880Fax: 877-862-8390info@integrativeRD.org FNCE 2017 Planning ChairMary Alice Gettings, MS, RDN, LDN, CDEdifmma@gmail.com

FNCE 2017 Planning Vice ChairAnn Sukany-Suls, M.Ed, RDN, LDann.suls@gmail.com Marketing Chair 2015-2017Danielle Omar, MS, RD2eatwell@gmail.com Member Services Chair 2016-2018Jacqueline Santora Zimmerman, MS, RDNjacq.zimmerman@gmail.com  Mentor/Coaching Chair 2015-2017Lesli Bitel-Koskela, MBA, BS, RDN, LDLeslibitelk@gmail.com Network Chair 2016-2018Mary Therese Hankinson, MBA, MS, RD, EDAC, CTPmthank@aol.com Newsletter Editor 2016-2017Sarah Harding Laidlaw, MS, RDN, MPA, CDEpeaknut70@gmail.com Newsletter Copy Editor 2016-2017Emily D. Moore, MS, RDN, LDNemilydavismoore@hotmail.com Newsletter Editor Associate 2016-2017Jena Savadsky Griffith, BA, BSJenas_mailbox@yahoo.com Newsletter Editor Associate 2016-2017Racquel Praino, Dietetic Internprainorr01@mail.buffalostate.edu Newsletter Editor Associate 2016-2017Dina Ranade, RDN, LDdranade@comcast.net Newsletter CPE Editor/CPE Item Writer 2016-2017Shari B Pollack, MPH, RDNsbethp@gmail.com Nominating Committee Chair Elect 2016-2017Stephanie Harris, PhD, MS, RDN, LDstephanie-harris@case.edu Nominating Committee Member 2016-2017Elizabeth Redmond, PhD, MS, RD, LDeredmond@gdx.net 

Policy Advocacy Leader 2015-2017Olivia Wagner, MS, RDN, LDNoliviawagner28@gmail.com Professional Advancement Chair 2016-2018Kory A DeAngelo, MS, RDkdeangelo@bastyr.edu Speakers Bureau Chair 2016-2017Therese Berry, MS, RDN, LD, CNSCtherese.austin@coramhc.com  Social Media Chair 2016-2017Michelle Loy, MPH, MS, RDN, CSSDmichelle@gowellnessco.com Student Committee Chair 2016-2017 Kathleen Schofieldschofka@gmail.com Volunteer Chair 2015-2017Ryan Whitcomb, RD, CDN, CLTwhitcomb.ryan@gmail.com Academy Practice Manager 2016-2017Carrie Kiley, MBAManager, DPG/MIG/Affiliate Relationsckiley@eatright.org DIFM Office AddressDietitians in Integrative and Functional MedicineP.O. Box 308Mount Pleasant, SC 29464Phone: 800-279-6880Fax: 877-862-8390Email: info@IntegrativeRD.orgWebsite: www.IntegrativeRD.org

Executive Committee List

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Dietitians inIntegrativeand FunctionalMedicinea dietetic practice group of the

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Executive Committee Members

Thank Youto our SPONSORS!

Chair 2016-2017Kelly Morrow, MS, RDN, CDkmorrow@bastyr.edu

Chair Elect 2016-2017Mary Purdy, MS, RDNMaryPurdyRD@gmail.com

Past Chair 2016-2017Monique Richard, MS, RDN, LDNmmr2v@mtmail.mtsu.edu

Treasurer 2016-2017Dana Elia, MS, RDN, LDNDIFMTreasurer@gmail.com

Secretary 2016-2017Jessica G. Redmond, MS, RD, CSCSjess.g.redmond@gmail.com

DPG Delegate 2016-2019Mary Beth Augustine, RDN, CDN, FANDdelegatedifm@gmail.com

Nominating Committee Chair 2016-2017Aarti Batavia, MS, RDN, CLT, CFSP, IFMCP aartibatavia@gmail.com