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Nutrition, Exercise and Renal Disease

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MFLN Intro

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Today’s Presenter

Kenneth Wilund, Ph.D.

Kenneth Wilund received his Ph.D. in Kinesiology from the University of Maryland.

His area of interest is exercise science.

The focus of the research in his lab is to investigate the efficacy of lifestyle modifications (exercise and dietary factors) on co-morbidities associated with chronic kidney disease (CKD).

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Exercise and Nutrition in CKD

Ken Wilund

Associate Professor

Department of Kinesiology and Community Health

University of Illinois at Urbana-Champaign

TK Cureton Physical Fitness Research Laboratory

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Overview of Presentation

• Overview of renal diet recommendations: Rationale and Concerns

• Proposed revisions to the renal diet

• Exercise Training in HD patients: Rationale and Concerns

• Revised exercise prescription for HD patients

• How to implement these changes in the clinic?

• *Note: My focus is on dialysis patients, but the main points are relevant to all CKD patients

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Webinar Goals:

After this presentation, you should be able to:

1.Critically evaluate the scientific rationale regarding dietary Na+, P, K+, and fluid restrictions in HD patients, and why these restrictions may be misguided.

2.Better communicate with HD patients and clinic staff the nuances of these dietary restrictions.

3.Promote efficacious physical activity programs for hemodialysis patients.

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Advanced CKD: A vicious cycle of disease and disability

Muscle Wasting/Functional Declines

Malnutrition, Inflammation, oxidative Stress, “Uremic-toxins”

RenalOsteodystrophy

CVD

LVH/CHF

VascularCalcification

↓ Quality of Life, ↑ Mortality

Arterial Stiffness

Can Dietary Changes and Exercise Inhibit This Cycle?7

Overview of the Renal Diet: What is left to eat??

• Protein:– Restrictions in pre-dialysis patients– Increased requirement in dialysis

• P restriction (to prevent hyper-PTH/renal osteodystrophy)

• K+ restriction (to prevent cardiac arrhythmias/sudden death)

• Fluid restriction (to prevent IDWG/volume overload)

• Na+ restriction (to prevent thirst)

• Limited fruits, veggies, nuts, legumes, dairy…

• Where’s the Fiber? Micronutrients? 8

Does it work? Or is it just a bad idea…

• Compliance is horrible

• Patients don’t understand it

• Would need TEAMS of dietitians to implement

• “Patients who follow the renal diet die…”

• Promotes malnutrition… and/or confusion…

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P restrictions and rationale

• To prevent hyperphosphatemia (serum P > 5.5mg/dL)

• Recommended P intake: < 800 to 1000mg/day (KDOQI)

• Efficacy has NOT been established.

• In HEMO study, P restriction was associated with HIGHER mortality; liberalized prescription REDUCED mortality.

– Lynch et al. Clin J Am Soc Nephrol. 2011;6(3):620-629.

• May lead to a lower intake of kcal, fiber and other nutrients.

• Restriction does not distinguish between types of dietary phosphorus (organic vs inorganic)– 20-80% absorption vs 100% 10

K+ Recs and Rationale• To prevent hyperkalemia (sudden death)

– predialysis K+ ≥ 5.5 mmol/L, prevalence = 4.5%-6.3%

• KDOQI guideline: no specific recommendation for dietary K+ for HD patients

• Joint Standards Task Force of the Academy of Nutrition and Dietetics and the NKF Council on Renal Nutrition recommend intake of 2-4g/day.

• Little evidence to support these recs– association between dietary K+ and serum K+ is weak (r = 0.14)

• Noori et al Am J Kidney Dis. 2010;56(2):338-347.

– No association b/w dietary K+ intake and serum K+ • St-Jules et al J Ren Nutr. 2016 (In press).

– Dietary K+ intake positively associated with energy and protein intake• Suggests restricting dietary K+ may be deleterious

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Fluid Restrictions… are a waste of time

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Nephrol Dial Transplant (2001) 16: 1538-1542

Advising dialysis patients to restrict fluid intake without restricting sodium intake is not based on evidence and is a waste of time

Charles R. V. Tomson

Department of Renal Medicine, Southmead Hospital, Bristol, UK

Na+ Recs and Rationale• To reduce thirst… and chronic volume overload

– Hypertension, LVH, heart failure,

• KDOQI recs: limit dietary sodium, but no specific level provided

• Previous guidelines: < 2000mg/day, but little data to support – Intake ~ 2,300 mg/day, with positive assoc b/w dietary sodium intake

and mortality

• 2 short term RCTs examining outcomes from sodium restriction– Data inconclusive

• Several studies cite “concerns” with sodium restriction:

– Loss of residual renal function– Reduced kcal intake

• Sodium restriction as a component of comprehensive volume control strategy has yielded VERY impressive results 13

Questions?

What is YOUR biggest concern with the Renal diet?

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Chronic Volume Overload

• Why a problem?

– Increases BP, LVH, cardiac

dysfunction, intradialytic symptoms,

mortality….

• How Prevalent is it?

- Prevalence in U.S. may be > 90%?

- “If on BP med, or hypertensive, they most likely have chronic volume overload. “ (Ercan Ok, MD, Izmir, Turkey)

• What to do about it?

– Can be nearly eliminated using intensive volume control strategy practiced in Izmir (including sodium restriction)

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Izmir’s Remarkable

Data

• ** ~ 90-95% of Hemodialysis patients in Izmir have NORMAL BP (~ 120/80) in the absence of B.P. Medications!

• Interdialytic weight gain (IDWG) averages < 2.0L

• Systolic and diastolic function are normalized, and LVH and heart failure are rare

• Mortality rate is ~ half of what it is in the U.S.

• Dialysis Prescription is standard: 3 days per week, for 4 hours/session.

• How do they accomplish this… and why is nobody else doing it?16

Izmir’s Volume Reduction Protocol (~1993) - 3 primary components:

1.Discontinue BP meds (w/ no change in BP)

2.Persistent ultrafiltration to decrease dry weight until reaching normal BP

— Accomplished by reducing postdialysis weight 200 – 300 g/session

— May initially require a few extended or extra HD sessions

3.Dietary salt intake reduced from ~150 mmol/day to 50 mmol/day

— continuous counseling via clinic STAFF (nurses/techs….)

— I.V. saline is rarely provided

How does Izmir do this? *

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Initial Results from Volume Control Strategy in Izmir

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Ozkahya M et al. Am J Kidney Dis 1999; 34: 218-21

• 67 hypertensive HD patients on BP meds; avg age 42y

• Improved IDWG, body mass, BP and CTi (above)

• Increase in hemoglobin and serum albumin levels

• Only 4% need anti-HT medication

• Zero patients with edema and heart failure

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Intradialytic hypotension is reduced with Izmir volume control policy

NO increase in frequency of IDH with volume control strategy (even decrease) in two different studies. Why?

1) strict dietary salt restriction to limit IDWG

2) cessation of anti-hypertensive medications

1) Ozkahya M et al. Am J Kidney Dis 1999; 34: 218-21

2) Ozkahya M et al. J Nephrol 2002; 15: 655-60

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Intradialytic Hypertension also eliminated

• 7 patients with intradialytic hypertension who were not responsive to meds

• Over 3 weeks, reduced postdialysis weight by 6.7 ±3.0 kg

• Paradoxical hypertension no longer seen

• CTi decreased

• EF increased

• valvular regurgitations disappeared/ regressed

• serum albumin increased

Cirit M et al. Nephrol Dial Transplant 1995; 10: 1417-20

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Izmir Volume Control Strategy Also Associated with Low hospitalization & Mortality

Survival of 218 patients, avg. follow-up =47 months after VC implemented

IDWG ↓ from 1.44kg/day to 0.9 kg/day

Mean BP ↓ from 150/89 to 121/76 mmHg

Only 9 patients on BP medications

1 of 210 prevalent patients hospitalized with hypervolemia in 1 year

Annual Mortality rate = 6.8% (contrast with U.S. = 20%)

Lowest Mortality with SBP= 101-110 mmHg (contrast w/ DOPPS = 130-159)

Ozkahya et al. NDT2006; 21: 3506-13

SBP = 81-90 91-100 101-110 111-120 121-130 131-140 141-150

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Summary of data from Izmir• Volume control strategy consisting of persistent reduction in post-dialysis

weight, along with persistent dietary Na+ restriction yields:

– Normalized BP in absence of BP meds– Low IDWG– Improved cardiac structure and function– Improved body composition and markers of nutritional status– Reduced intradialytic hypotension– Reduced P binders and Epo (unpublished)– Reduced hospitalization and mortality

• Works in patients with:– LOW BP – HIGH BP – intradialytic hypotension – intradialytic hypertension

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Can This Be done elsewhere?

• Tassin, France– similar results with long, slow dialysis (6-8 hours)

• Fresenius clinics in Maine and NYC (Raimann, 2015 – abstract at ASN)

• Important difference: Na+ restriction was implemented by Research Dietitian.

• My lab: Developing pilot project to implement a SUSTAINABLE, long term volume control strategy in U.S. Dialysis Clinics:– “Optimizing Cardiovascular Health and Physical Function Through

Volume Control and Exercise” (VC&E)

• Goal: “mimic” volume control protocol of Dr. Ok (Izmir), then optimize benefits with comprehensive exercise program– Izmir patients do NOT exercise… 23

– R.D.– Doctors– Nurses– Techs– Patient groups– Family members– …and even the bus driver

“Telling them once is not enough” (Ercan Ok, MD)

Convince Nephrologists 1st, Staff 2nd, and Patients will follow!

The Key to Izmir’s success:getting the whole clinic involved

The problem (and solution) concerns the whole dialysis community:

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To make this work, we need to simplify the diet(Biruete et al. JRN, in press)

Guiding principle: liberalize restrictions, throw away lists of foods, focus on processed food

Specifics:

1.K+ and P from non-processed/whole foods should be largely eliminated. Specifically, few restrictions placed on fresh fruit, veges, nuts, legumes, and dairy

– health benefits from these foods outweigh the unsubstantiated risks– added benefits of antioxidants, vitamins, and fiber. – Hyperkalemia is possible exception

1.Primary focus should be on reduction/elimination of processed, restaurant, and convenience foods that are almost universally high in:

– Na+– inorganic P– added K+

•Benefits: A far simplified message compared to current HD diet recommendations– Will help with implementation (this is NOT Medical Nutrition Therapy) – May improve patient compliance– Cost-savings may be realized through increased food consumption within the home.

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Our Working Implementation Protocol• “Immerse clinics in a culture of Na+ restriction”

– Mediated by clinic staff

• Rationale: – Na+ is a proxy for processed food

• Approach: Research dietitian is developing protocols for teaching staff (nurses/techs…) to help deliver the low Na+ message

– Modeled after Izmir protocol– Staff training/in services– Fresenius Tech Talking points will be utilized

• Ok’s (Turkish) approach relies on CONSTANT communication with the patients

– EVERYTIME a patient comes in with elevated BP or IDWG… they get counseled by the staff

– “Its not enough to tell them once!”

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Main Messages for clinic staff training:Its about the Na+ (not the fluid!)

Salt in diet IT STARTS HERE! Thirst

Strain on heart/arteries Fluid overload

↑BP and plasma volume

cramps

↑ UF

***

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Steps For Reducing Sodium Intake (guidelines we reinforce with staff & patients)

1. Shop for “whole foods”

liberalize dietary restrictions

Flavor with pepper and other herbs/spices

1. If it is in a package… read the label (processed food)

The “1mg/kcal” rule

Phosphorus additives

1. Limit eating out 29

> 1 mg/kcal < 1 mg/kcal

“The 1mg/Kcal Rule”

Na/kcal = 440/250 > 1 (BAD) Na/kcal = 130/300 < 1 (GOOD)

“Is the sodium # bigger than the calorie #?”30

I taught 75% of these guys to shop using the 1mg/kcal rule

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Questions?

Thoughts on Turkish data?

Thoughts on “liberalized renal diet”?

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Exercise for Dialysis Patients…and how to implement

• INTRA-dialytic exercise– Benefits: Captive audience

– Concerns: Limited mobility• Cycling is most feasible• Resistance training VERY difficult

• NOT during dialysis– Benefits: in theory, unlimited options

– Concerns: Compliance• Access, motivation, supervision

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If we all believe it is so important… why are there so few programs?

Tentori et al. Nephrol. Dial. Transplant. 2010;25:3050-3062

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Commonly Cited Barriers to Implementation

1) Patient-related– Co-morbidities/fatigue– Time, knowledge/self efficacy

– Access to equipment/facilities

2) Clinic Staff-related– Staff burden, expertise– Nephrologist support

3) Financial barriers– Who will pay for it?– When research grants end…programs often end

References:•Delgado et al (2012). Nephrol Dial Transplant 27: 1152–1157. •Delgado et al (2010). Nephron Clin Pract 116(4):c330-6. •Heiwe et al (2012). Implementation Science 7:68. •Young et al (2015). PLoS ONE 10(6): e0128995.

•Bossolo et al (2014). Blood Purif 2014;38:24–29. 35

The Barrier Nobody Wants to Talk About:• MANY Nephrologists are “skeptical” about exercise in dialysis patients

– Concerns over efficacy, cost, safety, staff burden, etc.

• Evidence: In clinics where Nephrologists really want it… they figure out how to do it…

and MANDATE IT

– Europe – many good programs

– Almost nothing in the U.S.

• Recent quotes from prominent U.S. Nephrologists:

– “All dialysis patients should SLEEP, instead of exercise, during their treatments.”

– “HD patients should complete a stress-echo prior to engaging in an exercise

program”

• A quote I have heard from MANY Nephrologists:

– “We bought some bikes back in the mid- 90’s… but couldn’t get anyone to use

them…”

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Why all the doubt about exercise? Don’t we have tons of evidence…?

Sort of: See recent reviews by:

1) Heiwe et al. Am J Kidney Dis. 2014 Sep;64(3):383-93

2) Barcellos et al. Clin Kidney J. 2015 Dec;8(6):753-65

• Demonstrated benefits:–Body comp/muscle strength/physical function

–Cardiovascular structure and function

–Dialysis Efficiency

–QOL

• Problem: studies are small, uncontrolled, short intervention periods –These problems are widely acknowledged… but often dismissed

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The dirty secret not many discuss: Some of the data is just NOT THAT GOOD

• Inconsistent effects of exercise on physical function/body comp/CVD risk

• Johansen et al JASN 17:2307-14 – ↑ quad CSA, strength; no Δ: phys fx, lean mass

• Dong et al. JRN 21(2): 149-59– no Δ: body comp, strength

• Kopple et al JRN 16(4): 312-24 D– no Δ: body comp

• Cheema et al JASN 18(5): 1594-1601 – no Δ: body comp; mixed results: strength/phys fx

• Kirkman et al J Cach Sarc Musc 5(3): 199-207– ↑ muscle volume, strength; no Δ: phys fx

• Koh et al. AJKD 55(1):88-99– no Δ: TUG, 6 minute walk, arterial stiffness; ↓ self-reported physical function

• Wilund et al (manuscript in prep)– Modest/no changes in physical function/strength/body comp or cardiovascular structure/function

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Why all the “uninspiring/equivocal” data?

• Has exercise volume and intensity been too low? – ~ 35- 70 kcal/session in several studies

• Are the patients too sick?– Are arteries too calcified?– Do metabolic disturbances (e.g., acidosis, anemia) inhibit muscle

and/or cardiovascular adaptations?

• Is inhibiting progression of co-morbidities all we can hope for?– May need longer trials

• When designing your own exercise program, these factors MUST be considered

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Think about what we are asking exercise to do:

Muscle Wasting/Functional Declines

Malnutrition, Inflammation, oxidative Stress, “Uremic-toxins”

RenalOsteodystrophy

CVD

LVH/CHF

VascularCalcification

↓ Quality of Life, ↑ Mortality

Arterial Stiffness

YOU CANT STOP THIS BY STICKINGA BIKE IN FRONT OF YOUR PATIENTS 40

Despite equivocal data from some RCTs… we still know exercise CAN work (and really well):

• See story of Shad Ireland (www.ironshad.com):– Age 11 – kidney failure, starts dialysis

– Age 20 - 2 failed transplants, weighed 85 pounds, is captivated watching triathlon

– Age 31 - completed 1st Ironman Triathlon

• Take home message: this stuff works… but we must do more41

Successful Anecdotes from my lab

• Patient #1: 35 year old A.A. male, Sedentary, obese, HTN, diabetes, IDWG ~ 5Kg

• Randomized to exercise group in our clinical trial, but Horrible exercise compliance

• Frequent cramping… increased Na+ in dialysate… got thirsty and started drinking

10L of Soda/day. IDWG increased to 15 kilos

• Finished study… Saw zero benefits…

• We took away bike… After 2 weeks, he asked for it back, started

cycling 1-2 hours/session, convinced him to change his diet

• He lost 40 lbs and got transplant

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Anecdote #2 • 60 year old Caucasian male

• Severe depression, randomized to Protein + Exercise group in IHOPE

• Exercise compliance was technically good, but intensity was extremely low

• Small improvements in physical function at 1 year, but arterial measures did not change

• However…Depression and QOL indices significantly improved:– “I wanted to commit suicide…. This bike saved my life.”

• Primary outcomes in IHOPE related to physical function and strength did not improve

• Take home lesson: there are so many different benefits of exercise… its hard to capture them all in a clinical trial.

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Our failures are more common than our successes. How do we change this?

• Comprehensive behavior change is needed:

1) Ex-Rx should be more than a bike in front of a chair

2) Nutritional Concerns MUST be addressed for the exercise to be effective:

- chronic volume overload

- malnutrition

• The approach needs to be cost-effective to be sustainable (or clinics wont pay for it)

• For clinics to pay, we must demonstrate we can reduce medications and hospitalizations. Where is low hanging fruit?–Cardiovascular complications (volume overload)–Falls 44

Guiding Principles for a ROBUST Exercise Program for Dialysis Patients

• RULE #1: Get buy-in from the clinic staff– **NEPHROLOGISTS– Nurses, techs, social workers…

• RULE #2: Utilize the intradialytic period… but don’t soley rely on it

– Intradialytic cycling is a great COMPONENT of a well rounded exercise program

• Up to 30-45 minutes, 3 days per week

– Standard exercise recs apply! (strength, balance, flexibility training…)

– Use the intradialytic period for counseling patients/families/staff 45

In an ideal world: Components of an Intradialytic Program

Resources will determine which components are feasible:

1) Intradialytic cycling, AND 2) intradialytic resistance training with balls/bands/dumbbells

http://kidney.org.au/ (resource packs to facilitate exercise on dialysis)

http://lifeoptions.org/ (materials for patients, staff, nephrologists…)

2) Exercise in waiting room.

See Matsufiji et al (2015). JRN Jan;25(1):17-24.

3) Education/wellness program for the patient’s family

Vital component, normally overlooked

4) Wellness program for the staff

We are developing

5) Promote “simple” nutritional advice

NOT medical nutrition therapy

Fresenius Technical talking points is a model 46

Resources• Life Options:

– Program founded in 1993 to help people live long and live well with kidney disease.

– National panel of researchers, clinicians, and ESRD Network directors.– Materials at http://lifeoptions.org/

• Exercise: A Guide for People on Dialysis• Exercise for the Dialysis Patient: A Guide for the Nephrologist• Evaluation: Unit Self-Assessment Manual for Renal Rehabilitation• Building Quality of Life: A Practical Guide to Renal Rehabilitation• Exercise for the Dialysis Patient: A Prescribing Guide

• Resource packs to facilitate exercise on dialysis. From Kidney Health Australia. – Detailed instructions on how to conduct intradialytic cycling and resistance

training: – http://kidney.org.au/ – http://www.ncbi.nlm.nih.gov/pubmed/26863718

• ACSM guide on how to start a walking program:– http://www.acsm.org/docs/brochures/starting-a-walking-program.pdf

• Falls prevention programs: CDC compendium on falls prevention: – http://www.cdc.gov/homeandrecreationalsafety/Falls/compendium.html

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Out of clinic exercise program

• Starts AT dialysis (use dialysis period for counseling)

• Walking programhttp://www.acsm.org/docs/brochures/starting-a-walking-program.pdf

• At home strength and balance (focus on falls!)–CDC compendium on falls: http://www.cdc.gov/homeandrecreationalsafety/Falls/compendium.html

• Identify exercise/PA opportunities in the community–Develop community partnerships if/where possible

• Get family involved!

• Be creative/give them choices! –How do YOU exercise?

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How are we getting staff involved?

• Training/In-services– Primarily sodium related

• Incentive programs– 3 day sodium challenge– Fitbit challenge

• Staff Wellness Program– “WOW Fresenius”

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What about the patient’s families?

• Focus groups/education

• Sodium and Fit-bit Challenges

• Family challenges?

• Family wellness program?

• Physiotherapist is available to the family at the clinic for counseling…

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If this sounds unrealistic… it’s NOT

*

*

*

*

Mexico City (grit)

Leicester(research $)

Izmir (desire)

Bichofswerda (insurance $)

Common Theme: Nephrologists and Staff Mandating Patient’s Behavior Change

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QUESTIONS?

Renal and Cardiovascular Disease

Research Laboratory

U of Illinois at Urbana-ChampaignCollaborators

• NIDDK (RO1 DK084016)

• Renal Research Institute

• AHA Pre-doctoral research fellowships

• Emily Tomayko, Brandon Kistler

• Bo Fernhall, PhD (UIC)

• Shane Phillips, PhD (UIC)

• Mohamed Ali, M.D. (UIC)

• Eddie McAuley, PhD (UIUC)

• Jake Sosnoff, PhD (UIUC)

Funding Sources

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Nutrition and Wellness Upcoming Event

• Mobile Apps for RDNs in Patient Care, What’s the Evidence Say?• Date: Wed Sept 21• Time: 11:00 am Eastern• Location:

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For more information on MFLN Nutrition and Wellness go to: https://blogs.extension.org/militaryfamilies/nutrition-and-wellness/

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