SCAN Winter 2013

Winter 2013, Vol. 32, No. 1

■ CONTENTS

1Working with Dietary RestrictionsRelated to Allergies in the Treatmentof Eating Disorders

3From the Editor

5CPE article:Endothelial Dysfunction and the Female Athlete Triad: Research Updates and Management Recommendations

8High-Sodium Diets in Spaceflight: Health Consequences and Methodsto Reduce Intake

11Dietary Nitrates and Nitrites from Vegetables and Fruits: How CanSomething So Bad Be So Good? (Part 2)

15From the Chair

16Conference Highlights

17Reviews

18Sports Dietetics-USA Research Digest

20SCAN Notables

20Of Further Interest

24Upcoming Events

The signs and symptoms of food al-lergy vary, ranging from mild skin re-actions such as itching, rash, andfacial or tongue swelling to serious,life-threatening reactions that can re-sult in anaphylaxis or death. Theprevalence of documented food al-lergies in the general population isapproximately 6% to 8% in childrenand 2% in adults.1 However, 30% to40% of individuals in the generalpopulation report a prior adverse re-action to food. 2 The discrepancy be-tween documented cases of truefood allergy versus perception islinked to misinformation among thegeneral population, possible misdiag-nosis, or incorrect classification offood intolerance as allergy. The diag-nosis of food allergy can have a sig-nificant psychological impact on thepatient, including increased anxietyand a lower quality of life.3 Further-more, the need to eliminate certainfoods from the diet may exacerbateor lead to the development of an eat-ing disorder. 3,4

With the reported prevalence of foodallergy rising and the use of alterna-tive diagnostic methods for food al-lergy gaining popularity, practitionersneed to understand the differences

S C A N ’ SPu lseWorking with Dietary RestrictionsRelated to Allergies in the Treatmentof Eating Disorders by Nancy M. Lea, MS, RD

between documented food allergiesand non-immunoglobulin E (IgE)-me-diated food intolerance and must beable to identify unsupported food al-lergy claims. It is especially importantfor dietitians working in the field ofeating disorders to be knowledge-able in the proper documentationand diagnosis of food allergy. The eat-ing disorder patient population isprone to over-restricting food intakeand may use a misdiagnosis or self-reported diagnosis as a means to fur-ther restrict their food intake.

Is It Food Allergy orIntolerance?

According to the National Institute ofAllergy and Infectious Disease, foodallergy is defined as an adverse reac-tion that results from an immune(IgE-mediated) response that occursas the result of exposure to a specificfood or allergen.5 In food allergy, thebody mounts an immune reactionagainst an otherwise harmless foodprotein. While an individual may per-ceive an allergic response to severalfoods, in reality an allergy to morethan three foods is rare.1

There are eight common foods thatcomprise the majority of food aller-

dioactively labeled IgE. RAST is usedto identify antibodies with increasedlevels as predictors of clinical symp-toms. RAST is considered less sensi-tive than other tests, but itsadvantage is that it can be usedwhile a patient is on antihistamines.The double-blind placebo-controlledfood challenge (DBPCFC) is consid-ered the gold standard for the diag-nosis of food allergy. Although it ismost often used in research, it maybe necessary when the patient’s per-ceptions may bias symptom assess-ment (as in the case of a subjectivesymptom such as abdominal pain).1,6

Oral challenges are more definitive intheir results than other diagnostictests. PST has been shown to be apoor predictor with a positive resultand it merely suggests the presenceof an allergy. However, a negative re-sult in PST almost always excludesIgE reactions; therefore, a negative re-sult can be used confidently to ruleout immunologic involvement. Giventhe complexity of proper diagnosis, itis important that proven clinical tech-niques are used to determine food al-lergy and that the results of thesetests are carefully interpreted by askilled clinician.

Alternative testing for food allergy isnot well accepted. Unproven diag-nostic techniques include IgA andIgG4 measurement, electrodermalskin testing, ALCAT testing, and ap-plied kinesiology.7 Clinicians workingwith eating disorder patients shouldrecognize the differences betweenevidence-based, accepted diagnostictechniques and those that do nothave scientific backing or remaincontroversial.

It is not uncommon for patients witheating disorders to perceive that theydo not tolerate or are allergic to vari-ous foods. Sometimes these percep-tions are the result of inaccurate orinconclusive testing for allergies.Sometimes they are the result of irri-table bowel syndrome or a conse-quence of a healthcare provider’ssuggestion to cut out certain foods.8

The first step in working with eatingdisorder patients who have pur-ported food allergy symptoms is to

2 | SCAN’S PULSEWinter 2013, Vol. 32, No. 1

gens: wheat, milk, soy, eggs, peanuts,tree nuts (e.g., almonds, cashews),fish, and shellfish. These foods ac-count for up to 90% of all verified al-lergic reactions.1 Allergy to certainitems, such as wheat or milk, maypose a higher risk to patients be-cause these foods can be difficult toavoid and their elimination from thediet may lead to nutrient deficiency ifreplacement foods are not intro-duced.

Food intolerance (i.e, non-IgE-medi-ated responses) are adverse reactionsto food caused by toxic, pharmaco-logic, metabolic, idiosyncratic, orother non-IgE-mediated reactions tofood or chemicals found in the food.They are more difficult to diagnosethan food allergy. However, mostnon-IgE-mediated gastrointestinalfood intolerances occur at infancyand are outgrown within the first 2 to3 years of life. 6

Diagnosis of Food Allergy

Due to the risk and possible severityassociated with food allergy, dieti-tians who work with eating disorderspatients must be aware of methodsfor accurately and conclusively diag-nosing food allergy. No single testcan conclusively diagnose all food al-lergies. Instead, diagnosis typicallyhappens as a series of steps. The firststep is to identify the suspected foodor food group. Next, some evidencesuch as a detailed food history is re-quired to show that the food is caus-ing an adverse reaction. In the laststep, proof of immunologic involve-ment is obtained via diagnostic test-ing. Three common modes of testingmay be used: 1) the prick skin test; 2)radioallergosorbent testing; and 3)the oral food challenge (open, single-or double blind placebo test).

The prick skin test (PST) is the mostcommon and least expensivemethod of testing for food allergy.Food extracts and histamine/salinecontrols are applied to a skin prick orpuncture. Tests are considered posi-tive when a wheal of 3 mm or largerappears on the skin.1 In radioaller-gosorbent (RAST) testing, serum ismixed with food and washed with ra-

Academy of Nutrition and Dietetics Dietetic Practice Group of Sports,

Cardiovascular, and Wellness Nutrition (SCAN)

SCAN Web site: www.scandpg.org

SCAN OfficeAthan Barkoukis, Executive Director6450 Manchester Rd.Cleveland, OH 44129Phone: 440/481-3560; 800/[email protected]

ChairIngrid Skoog, MS, RD, CSSD

Chair-ElectJenna Bell, PhD, RD

Past ChairD. Enette Larson-Meyer, PhD, RD, CSSD, FACSM

TreasurerTo be appointed

SecretaryKarla M. Wright, RD, CSSD

Communications DirectorKimberly K. Schwabenbauer, RD

Continuing Education DirectorKelly White, MS, RD, CSSD

Development DirectorHope Barkoukis, PhD, RD

Member Services DirectorCheryl Toner, MS, RD

Symposium Committee ChairSharon Smalling, MPH, RD

Director, Disordered Eating & Eating Therese Waterhous, PhD, RD

Director, Sports Dietetics—USA SubunitMichele Macedonio, MS, RD, CSSD

Co-Directors, Wellness/CV RDs SubunitKaren Collins, MS, RD, CDNRosie Gonzalez, MS, RD

External Relations DirectorTo be appointed

Public Policy DirectorAlisa Krizan, MS, RD

Volunteer Coordination DirectorKatilyn L. Davis, MS, RD, CSSD

Web EditorCarla Addison, RD

Editor-in-Chief, SCAN’s PULSEMark Kern, PhD, RD, CSSD

SCAN Delegate to House of DelegatesRoberta Anding, MS, RD, CSSD, CDE

DPG Relations ManagerMya Wilson, MPH, MBA

To contact an individual listed above, go towww.scandpg.org/executive-committee/

It’s Not Debatable

by Mark Kern, PhD, RD, CSSD, Editor-in-Chief

As I write this letter, we’re in the midst of a presidential election and a season filled with debate. One issue at this moment thatisn’t debatable, however, is the fact that this issue of PULSE is extremely informative.

The article featured on the cover was written by Nancy Lea, MS, RD. In it she discusses the implications of dietary allergies inthe treatment of individuals suffering from eating disorders. Our free CPE article for this issue was provided by Kate Temme,MD, and Anne Hoch, DO, who describe for us the link between disordered eating in female athletes and endothelial dysfunc-tion. Barbara Rice, MS, RD, Helen Lane, PhD, RD, and Vickie Kloeris have contributed a fascinating article about the impact ofsodium consumption during spaceflight and the efforts made to reduce the sodium content of foods provided to astronauts.We’ve also included Part 2 of the article about nitrate and nitrite sources and metabolism written by Norman Hord, PhD, MPH,RD, to conclude the article started in our previous issue.

Be sure to also enjoy the highlights of a recent conference, the review we’ve provided of a book, notable accomplishments ofSCAN members, research summaries from Sports Dietetics-USA, and news items from SCAN. While the research described inthese pages may be filled with debatable results, I hope you’ll concur that the quality of the information provided is not a mat-

ter of debate.

SCAN’S PULSEWinter 2013, Vol. 32, No. 1 | 3

determine whether they have a legit-imate allergy to a food or have elimi-nated a food based on fear ormisperception.

Dietitians can assist patients by refer-ring them to a board-certified aller-gist for follow-up testing when theybelieve proper documentation for al-lergy is lacking. In addition, dietitianscan assist the allergist by helping pa-tients fill out a food diary and, if nec-essary, giving them guidance inpreparing for or adhering to foodelimination diets.

Working with Patients withMore Than One Allergy

When entire food groups are elimi-nated based on a diagnosed food al-lergy, it can be especially difficult toensure that the patient is consumingan adequate diet. For individuals whohave more than one allergy, knowingwhich foods are the best substitu-tions can make a big difference. Milkand wheat are particularly difficult toavoid because they are present in somany different foods. Dietitiansshould determine which nutrientsare most likely to be limited due to

the exclusion of a specific food. Forexample, with wheat allergy, dieti-tians should carefully consider howmuch thiamin, niacin, riboflavin, sele-nium, iron, and fiber the patient is re-ceiving through alternative foods,because wheat is a major source ofthese nutrients. With milk allergy, di-etitians should consider intake of cal-cium, vitamins A, D, riboflavin,pantothenic acid, and phosphorous.Providing alternative sources of thesevitamins and minerals becomes es-sential, especially in the case of an al-ready nutrient-depleted eatingdisorder patient.

Eating disorder patients with milk al-lergy should receive adequateamounts of calcium-enriched foodsand beverages. Milk substitutes suchas fortified soy, rice, and almond milkcan be used. However, it is importantto note that many of these substi-tutes are less calorically dense thanregular milk products and they oftenlack many nutrients. Milk is also agood source of protein for many pa-tients. Meats, poultry, legumes, nuts,fish, and eggs can easily make up fora lack of protein from the restrictionof dairy, and they are good sources of

riboflavin and pantothenic acid. Pro-tein supplementation is often used inthe treatment of eating disorder pa-tients to provide needed calories;however, the majority of supple-ments available contain either caseinor whey as the primary protein. Forpatients with milk allergy, dietitiansshould recommend a hypoallergenicsupplement.

While it can be difficult to avoidwheat, the popularity of gluten-freediets has risen over the past severalyears, making it easy for patients tosubstitute wheat-free breads, cereals,and other products for wheat-con-taining foods.9 Alternative grainssuch as oats, rye, barley, rice, corn,buckwheat, and quinoa are also goodsources of fiber, thiamin, riboflavin,niacin, iron, selenium, and chromium.A distinction, however, should bemade between wheat allergy andceliac disease, which is not exploredin this article. For those with celiacdisease, rye, barley, and gluten-con-taining oats are not recommended.

FromThe Editor


Keeping Food Allergy Patients Safe

When patients with documentedfood allergies begin treatment, it isessential for dietitians to educate pa-tients on avoidance of the offendingallergens. This can pose an extra chal-lenge when working with eating dis-order patients, because dietitians donot want to encourage most of theseindividuals to focus on food labels orbecome obsessed with ingredients infood. However, in the case of seriousadverse reactions, it is crucial for pa-tients to understand how to locateand eliminate offending allergens infood. For those receivinginpatient/residential treatment, thedietary staff must take special pre-cautions to ensure that patients arenot exposed to food allergens. Theseprecautions may include highlightingallergies on food labels or patientmenus and using a separate kitchenfor preparing and handling food forallergic patients. In addition, an epi-nephrine auto-injector should bereadily available, and staff should beproperly trained in its use for patientswith known anaphylactic reactions.

Additional information on food al-lergy can be found at the followingWeb sites: Asthma and Allergy Foun-dation of America (www.aafa.org);American Academy of Allergy,Asthma and Immunology(www.aaaai.org); and Food Allergyand Anaphylaxis Network(www.foodallergy.org).

Conclusion

Proper documentation of food aller-gies, provided by the patient, is re-quired for individuals with eatingdisorders who are entering inpatient,residential, or outpatient treatment.Careful review of this documentationshould reveal that the patient was di-agnosed by a board-certified allergistor that accepted diagnostic testing,including an oral food challenge, wasperformed. PST and RAST tests bythemselves are not conclusive andshould not be used alone to diagno-sis food allergy, except in the case ofa severe reaction.1

Over time, both children and adultsmay exhibit reduced reactivity tofood allergens, with the exception ofpeanuts, tree nuts, and shellfish. Di-agnostic tests should be repeated forindividuals who are allergic to foodscontaining major nutrients such asdairy, because many of these allergiesare outgrown after age 2. 4 Safe rein-troduction of eliminated foodsshould be attempted when exclusionof the food leads to restriction of amajor nutrient or food group (e.g,dairy or grains) or when exclusion

may make it more difficult for a pa-tient to restore weight.

Despite the added challenge of work-ing with eating disorder patients whohave dietary restrictions due to foodallergy, dietitians must honor anydocumented allergies and protectpatients from adverse allergic reac-tions. Dietitians will need to workwith patients on selecting alternativesources of nutrients, planning well-balanced meals, and identifying andavoiding sources of food allergens.When appropriate, eliminated foodsshould be reintroduced, if possible,while the patient is in treatment.

Nancy Lea, RD, works with eating disor-der patients at the Eating RecoveryCenter in Denver, CO.

References

1. Sampson H. Food allergy. Part 2: Diagnosis and management. J AllergyClin Immunol. 1999; 103:981-988.

2. Roberston D, Ayers R, Smith C, et al.Adverse consequences arising from

misdiagnosis of food allergy. Br Med J. 1988; 297:719-720.

3. Cummings A, Knibb R, King R, et al.The psychosocial impact of food al-lergy and food hypersensitivity inchildren, adolescents and their families: a review. Allergy. 2010;65:933-945.

4. Teufel M, Bidermann T, Rapps N, etal. Psychological burden of food al-lergy. World J Gastroenterol. 2007;13-3456-365.

5. Skypala I. Adverse food reactions –an emerging issue for adults. J AmDiet Assoc. 2011; 111:1877-1891.

6. Sicherer S. Food allergy: When andhow to perform oral food challenges.Pediatr Allergy Immunol. 1999; 10-266-234.

7. Ko J, Lee J, Munoz-Furlong A, et al.Use of complementary and alterna-tive medicine by food-allergic pa-tients. Ann Allergy Asthma Immunol. 2006; 97:365-369.

8. Atkinson W, Sheldon T, Shaath N, etal. Food elimination based on IgG an-tibodies in irritable bowel syndrome:a randomised controlled trial. Gut.2004;53:1459-1464.

9. Gaesser G, Angadi S, Gluten-freediet: imprudent dietary advice for thegeneral population? J Am Diet Assoc.2012;112:1330-1333.


This article is approved by the Academyof Nutrition and Dietetics, an accred-ited Provider with the Commission onDietetic Registration (CDR), for 1 con-tinuing professional education unit(CPEU), level 1. The PULSE CPEUprocess is now automated! To apply forfree CPE credit, take the quiz on SCAN’sWeb site (www.scandpg.org/nutrition-info/pulse-newsletters/). Upon success-ful completion of the quiz, a Certificateof Completion will appear in your MyProfile (under the heading, My History).The certificate may be downloaded orprinted for your records. You may alsoobtain the quiz by requesting it fromthe SCAN Office via phone: 800/249-2875, fax: 440/526-9422, or email: [email protected]. However, we hopeyou will enjoy the convenience of theonline quizzes.

Learning ObjectivesAfter you have read this article, youwill be able to:

■ Describe how endothelial dysfunc-tion is assessed through the meas-urement of brachial artery flow-mediated vasodilation.■ Summarize the literature demon-strating the relationship betweenathletic amenorrhea and endothelialdysfunction.■ Discuss the effects, proposedmechanism of action, and safety offolic acid supplementation in thetreatment of endothelial dysfunctionin athletes.

Since the enactment in 1972 of TitleIX—the landmark legislation pro-hibiting sex discrimination in all fed-erally funded programs—femalesports participation has increased ex-ponentially. The benefits of sportsparticipation for female athletes arenumerous in relation to self-esteem,

academic performance, mentalhealth, and prevention of high-riskbehaviors.1 However, certain meta-bolic and endocrine concerns havealso been identified in female ath-letes during this interval, includingthe female athlete triad (triad).

Endothelial Dysfunction:Should the Triad Be a Tetrad?

The American College of Sports Med-icine (ACSM) defines the female ath-lete triad as a spectrum ofinterrelationships between energyavailability, menstrual function, andbone mineral density2 (Fig. 1). At theideal end of the spectrum is optimalhealth (eumenorrhea, optimal energyavailability, and optimal bone health)contrasted by the pathological ex-treme of the spectrum (functional hy-pothalamic amenorrhea, low energyavailability with or without disor-dered eating, and osteoporosis).Functional hypothalamic amenor-rhea and the associated hypo-estro-genic state may increase the risk ofendothelial dysfunction, suggestingthat the triad may be more accuratelydescribed as a tetrad.

Endothelial dysfunction is defined asan imbalance between vasodilatingand vasoconstricting substances pro-duced by or acting upon the innerlining of blood vessels. Endothelialdysfunction is a sentinel event in thedevelopment of cardiovascular dis-ease, the leading cause of deathamong women in the United States.Cardiovascular risk increases sharplyafter menopause, and 25% of womenwill ultimately die from a cardiovas-cular event. Estrogen receptors arefound in both coronary and periph-eral vasculature, enabling estrogen toserve a regulatory role in vascularfunction. Estrogen increases the pro-duction of endothelial-derived nitricoxide, promoting vasodilatation.3 Re-duced endothelial-dependent va-sodilation is noted as early as 3months after menopause, as estro-gen levels decline, and it is a knownpredictor of future cardiovascularevents.4

Measurement of EndothelialDysfunction

Coronary endothelial dysfunctionpredicts long-term atherosclerotic

CPE article

Endothelial Dysfunction and the Female Athlete Triad:Research Updates and Management Recommendationsby Kate E. Temme, MD, and Anne Z. Hoch, DO

Figure 1. The female athlete triad is a spectrum of interrelationships between healthand disease involving energy availability, menstrual function, and bone mineral density(BMD). (Reprinted with permission from Nattiv A, et al. Med Sci Sports Exerc.2007;39:1867-1882)

Low Energy Availability with or without an

Eating Disorder

Functional Hypothalamic Amenorrhea Osteoporosis

Optimal Bone Health

Optimal Energy Availability

Reduced Energy Availability with or without

Disordered Eating

SubclinicalMenstrualDisorders Low

BMD

Eumenorrhea


disease progression and cardiovascu-lar events.5 Direct measurement of in-tracoronary arterial response toacetylcholine demonstrates paradox-ical vasoconstriction in subjects withendothelial dysfunction. However, di-rect measurements of coronary en-dothelial function are invasive,expensive, and time-consuming.Measurement of brachial artery flow-mediated vasodilation (FMD) corre-lates highly with coronaryendothelium-dependent dilation andis considered the gold standard ofnoninvasive endothelial assessment.6

Abnormal brachial artery FMD has a95% positive predictive value forcoronary endothelial dysfunction.Brachial artery FMD is assessed usinga high-resolution ultrasound tomeasure brachial artery diameter be-fore and after forearm ischemia is in-duced by inflating a blood pressurecuff to suprasystolic levels. After cuffdeflation in normal subjects, reactivehyperemia and shear stress stimulusleads to nitric oxide release and va-sodilation, with subsequent increasesin brachial artery diameter. FMD iscalculated as the percentage increasein diameter of the brachial artery; anormal response in athletes is typi-cally ≥5%.3 Those with endothelialdysfunction do not demonstrate theexpected increase in FMD.

Endothelial Dysfunction andthe Female Athlete

Several studies have demonstrated arelationship between athletic amen-orrhea and endothelial dysfunction.Hoch and colleagues observed ab-normal endothelium-dependentbrachial artery FMD responses in col-legiate amenorrheic runners com-pared with eumenorrheic runners,while both groups demonstratedsimilar endothelium-independent va-sodilation responses to sublingual ni-troglycerin.7 Rickenlund andassociates found a correlation be-tween menstrual status and brachialartery FMD in female endurance ath-letes, with amenorrheic athletesdemonstrating significantly lowerFMD compared with eumenorrheicathletes, while oligomenorrehic ath-

letes had intermediate FMD re-sponses.8 A relationship betweenamenorrhea and abnormal FMD hasalso been reported in professionalballet dancers.9 This study also foundthat the lowest FMD responses corre-lated with the lowest serum estrogenlevels as well as the lowest bone min-eral density results (Z-scores).

In addition to the potential health ef-fects of endothelial dysfunction (i.e.,progressive atherosclerotic diseaseand increased risk of cardiovascularevents), there may also be implica-tions for athletic performance. De-creased FMD in peripheralvasculature may impair exercise-in-duced vasodilation and decreaseblood flow available to exercisingmuscle. Decreased perfusion maylimit maximal exercise tolerance withsecondary effects on athletic per-formance. Thus, in athletes, treatmentof endothelial dysfunction may havegeneral health as well as athletic per-formance benefits.

Treatment of EndothelialDysfunction in Athletes

According to ACSM guidelines, thefirst priority in the treatment of thetriad is correction of energy availabil-ity through modification of dietaryintake and/or exercise energy expen-diture. Menstrual function has beenshown to improve with correction of

energy deficits in female athletes, anddata suggest this approach improvesendothelial dysfunction.4,10

Other investigators have studied theeffects of oral contraceptive pill (OCP)use on endothelial dysfunction inathletes. Rickenlund and colleaguesreported significant improvement inbrachial artery FMD among young,amenorrheic endurance athletestreated with a low-dose combinedOCP (30 ug ethinyl estradiol and 150ug levonorgestrel) for 9 months.11

These improvements were thoughtto be secondary to estrogen’s protec-tive effect on the endotheliumthrough increased nitric oxidebioavailability. However, studies ofpostmenopausal women by theWomen’s Health Initiative found in-creased rates of cardiovascularevents and breast cancer inci-dence/mortality in women treatedwith combined estrogen and prog-estin hormonal replacement.12,13 Al-though safety studies in premeno-pausal women have not been con-ducted, it is known that young amen-orrheic athletes have similar hormo-nal profiles to postmenopausalwomen. Therefore, because hormonalreplacement therapy may potentiallyincrease cardiovascular risk in thesepatients, alternative options for thetreatment of endothelial dysfunctionin young female athletes should beconsidered.

Figure 2. Production of nitric oxide (NO) by endothelial cells. Folates have been suggested to participate in the regeneration of tetrahydrobiopterin (BH4), an essential

cofactor in the production of NO.

Ach=acetylcholine; ecSOD=extracellular superoxide dismutase; eNOS=endothelial nitric oxide synthase; L-Arg=L-arginine; ROS=reactive oxygen species. (Reprinted withpermission from Gielen S, Hembrecht R. Cardiol Clin. 2001;19:361. ).

Folic Acid

L-Arg.

L-Arg.

Agonists (Ach) Shear Stress VascularLumen

CitrullineEndothelialCell

ExtracellularSpace

Vascular Smooth Muscle Cell

Peroxynitrite

ROSecSOD

eNOS

BH4

+ +

+

NO

NO


One alternative therapy that is gain-ing support is folic acid supplemen-tation. Folic acid has many potentialcardiovascular benefits including im-proved endothelial function, de-creased arterial stiffness, decreasedblood pressure, and decreasedthrombotic activity. Folic acid is theo-rized to participate in the productionof nitric oxide through its role in theregeneration of tetrahydrobiopterin,an essential cofactor in nitric oxideproduction (Fig. 2). Daily folic acidsupplementation may increase nitricoxide production and folic acid mayalso have direct antioxidant effects.Additionally, folic acid supplementa-tion has been shown to improve en-dothelium-dependent FMD in otherpopulations, including those with hy-pertension, coronary artery disease,congestive heart failure, and dia-betes.1

Several small studies have evaluatedthe effects of folic acid supplementa-tion in athletes with endothelial dys-function. Amenorrheic runners withabnormal brachial artery FMDs hadsignificant improvements in FMD re-sponses after supplementation withfolic acid (10 mg/day) for 4 weeks.14

Similar results were reported foramenorrheic ballet dancers supple-mented with 10 mg folic acid per dayfor 4 weeks.15 In addition, improvedFMDs were noted after 4 to 6 weeksof folic acid supplementation in eu-menorrheic runners with low-normalFMD when compared with a placebo-controlled group.16

Folic acid supplementation is gener-ally well tolerated, and no adverse ef-fects have been noted at doseseffective in improving endothelialdysfunction (i.e., 10 mg/day). At muchhigher doses (>15 mg/day) dyspep-sia, sleep disturbances, and dermato-logic complaints have been reported,and seizures may be provoked inthose taking anticonvulsants.1 In ad-dition, folic acid supplementationmay mask vitamin B12 deficiency, al-lowing the condition to progress un-recognized. This phenomenon shouldbe considered when prescribing folicacid for the vegan athlete or for indi-viduals with malabsorption syn-

dromes. Given the promising resultsof folic acid supplementation in thesetting of endothelial dysfunction, fu-ture large-scale studies should ad-dress optimal dosing and treatmentlength.

Conclusions

The ACSM recommends regular phys-ical activity for all girls and women, asthe benefits of maintaining an activelifestyle are numerous and outweighany potential risks. However, atten-tion must be paid to the prevention,identification, and treatment of med-ical issues relevant to female athletes,most notably menstrual dysfunctionand its comorbidities including en-dothelial dysfunction. Athletic amen-orrhea has been shown to predictendothelial dysfunction, a sentinel

event in the development of cardio-vascular disease. In postmenopausalwomen, endothelial dysfunction ispredictive of cardiovascular events,and improvements in endothelialfunction have been associated with asignificant decrease in coronary riskfactors.4

Further studies are needed to con-firm whether endothelial dysfunctionin young female athletes carries thesame long-term cardiac risks as thoseseen in older women. However, thesimilar hormonal profiles shared bythese two groups of women suggeststhat early identification and treat-ment of menstrual and endothelialdysfunction in young amenorrheicathletes may help to prevent the ac-celerated development of atheroscle-rotic disease and cardiovascularconsequences already well describedin postmenopausal women. Whilenormalization of energy availabilityshould be a priority in the manage-ment of amenorrheic athletes and as-

sociated endothelial dysfunction,folic acid supplementation showspromise as a safe, effective treatmentfor endothelial dysfunction in youngamenorrheic athletes. Further, large-scale studies are needed to refine theoptimal dosage and duration recom-mendations for folic acid in the treat-ment of endothelial dysfunction.

Kate E. Temme, MD, is an assistant pro-fessor specializing in women’s sportsmedicine in the Department of PhysicalMedicine and Rehabilitation at the Uni-versity of Pennsylvania in Philadelphia,PA. Anne Z. Hoch, DO, is a professor anddirector of the Women’s Sports Medi-cine Program in the Department of Or-thopaedic Surgery at the MedicalCollege of Wisconsin in Milwaukee, WI.

References

1. Zach KN, Smith Machin AL, HochAZ. Advances in management of thefemale athlete triad and eating disor-ders. Clin Sports Med. 2011;30:551-573.

2. Nattiv A, Loucks AB, Manore MM, etal; American College of Sports Medi-cine. American College of SportsMedicine position stand. The femaleathlete triad. Med Sci Sports Exerc.2007;39:1867-1882.

3. Lanser EM, Zach KN, Hoch AZ. Thefemale athlete triad and endothelialdysfunction. PM R. 2011;3:458-465.Review.

4. Hoch AZ, Jurva JW, Staton MA, et al.Athletic amenorrhea and endothelialdysfunction. WMJ. 2007;106:301-306.

5. Schächinger V, Britten MB, ZeiherAM. Prognostic impact of coronaryvasodilator dysfunction on adverse


long-term outcome of coronary heartdisease. Circulation. 2000; 25;101:1899-1906.

6. Anderson TJ, Uehata A, GerhardMD, et al. Close relation of endothelialfunction in the human coronary andperipheral circulations. J Am Coll Car-diol. 1995;26:1235-1241.

7. Zeni Hoch A, Dempsey RL, CarreraGF, et al. Is there an association be-tween athletic amenorrhea and en-dothelial cell dysfunction? Med SciSports Exerc. 2003;35:377-383.

8. Rickenlund A, Eriksson MJ, Schenck-Gustafsson K,et al. Amenorrhea in fe-male athletes is associated withendothelial dysfunction and unfavor-able lipid profile. J Clin EndocrinolMetab. 2005;90:1354-1359.

9. Hoch AZ, Papanek P, Szabo A, et al.Association between the female ath-

lete triad and endothelial dysfunc-tion in dancers. Clin J Sport Med.2011;21:119-125.

10. Yoshida N, Ikeda H, Sugi, K et al.Impaired endothelium-dependentand -independent vasodilation inyoung female athletes with exercise-associated amenorrhea. ArteriosclerThrombVasc Biol. 2006;26:231-232.

11. Rickenlund A, Eriksson MJ,Schenck-Gustafsson K, et al. Oral con-traceptives improve endothelial func-tion in amenorrheic athletes. J ClinEndocrinol Metab. 2005;90:3162-3167.

12. Chlebowski RT, Anderson GL, GassM, et al; WHI Investigators. Estrogenplus progestin and breast cancer inci-dence and mortality in postmeno-pausal women. JAMA. 2010;304:1684-1692.

13. Rossouw JE, Anderson GL, PrenticeRL, et al; Writing Group for the

Women’s Health Initiative Investiga-tors. Risks and benefits of estrogenplus progestin in healthy post-menopausal women: principal resultsFrom the Women’s Health Initiativerandomized controlled trial. JAMA.2002;288:321-333.

14. Hoch AZ, Lynch SL, Jurva JW, et al.Folic acid supplementation improvesvascular function in amenorrheic run-ners. Clin J Sport Med. 2010;20:205-210.

15.Hoch AZ, Papanek P, Szabo A, et al.Folic acid supplementation improvesvascular function in professionaldancers with endothelial dysfunc-tion. PM R. 2011;3:1005-1012.

16. Hoch AZ, Pajewski NM, HoffmannRG, et al. Possible relationship of folicacid supplementation and improvedflow-mediated dilation in premeno-pausal, eumenorrheic athletic wo-men. J Sports Sci Med. 2009;8:123-129.

Barbara Rice, MS, RD; Helen W. Lane, PhD, RD; and Vickie Kloeris, MS

For some 50 years, the dietitians, re-searchers, and food scientists of theNational Aeronautics and Space Ad-ministration (NASA) have providedthe nutritional and safety standards,developed the food systems, and pro-duced the food provisions for all U.S.human spaceflights. In the past 12years, the challenge to provide foodhas become more pronounced withthe continuous operation of the In-ternational Space Station (ISS).1,2 Alldiets must meet the health andsafety guidelines for crewmembersliving and working in space for up to6 months.3,4 NASA researchers spentabout 20 years studying the effects ofdietary sodium on the health andsafety of crewmembers, resulting inconclusions that the dietary sodiumshould be lowered.

The ISS standard menu containsmore than 5,600 mg/day of sodium

and 2,900 kcal/day. Dietary sodiumintake averaged about 4,600 mg/dayover the first 18 ISS expeditions (anexpedition is an ISS increment thathas a set of crewmembers and gener-ally lasts 6 months). At the same time,energy intake was generally less than2,500 kcal/day.1

The physiologic changes that occurin crewmembers in spaceflight in-clude weight loss that may result inlean and adipose tissue loss, boneloss, hematologic changes, fluidshifts, gastrointestinal changes, in-creased risk of renal stone formation,and radiation exposure, along withthe recently documented increase inintracranial pressure that has led tovision changes in some crewmem-bers.5 The ISS high-sodium diets aredirectly linked to the bone loss andincreased risk of renal stones, and po-tentially to the increased intracranial

pressure due to the impact of sodiumon blood pressure.

U.S. Food System for the ISS

The current U.S. food system for theISS is based on the Space Shuttlefood system that has been in usesince the beginning of the SpaceShuttle program in 1981. Due to thelonger duration of the ISS missions,the ISS food system was expandedfrom the more limited Space Shuttlefood list to a current inventory ofabout 200 foods and beverages. Astandard menu of foods for an 8-dayrotation is packed pantry style (i.e., allmeats are packed together, all veg-etables are packed together, etc).Crewmembers assemble meals fromthe various food categories, so theyare eating from a standard menu butnot eating in the exact meal combi-nations on the menu. In addition,


crewmembers are allowed a smallquantity of bonus food items to aug-ment the standard menu. This bonusfood equates to about 10% of thefood supply available to a crewmem-ber on orbit and can consist of moreU.S. space food or even some com-mercial shelf-stable food items.

The NASA food system menus arehigh in sodium because only ambi-ent-stored processed foods are used.The lack of refrigerators and freezersfor food, both on the Space Shuttlesand the ISS, mandate an all shelf-sta-ble food system. Shelf-stable foodshistorically tend to be high insodium, because sodium aids in thepreservation of these foods.1 Further-more, the Space Shuttle food systemwas designed with the premise ofusing as many commercial off-the-shelf (COTS) foods as possible to savemoney. The NASA food systems thatpreceded Space Shuttle consisted ofcustom-produced foods that wereextremely costly. The use of COTSfoods automatically led to a highlevel of sodium l in the diet, becausecommercially processed foods tendto be high in sodium; sodium is inex-pensive way to make foods tastegood. In addition, crews in spaceflighthave very limited, if any, access tofresh fruits and vegetables, which arenaturally low in sodium. With so fewfresh foods available to astronauts,the sodium content of the diet is in-creased even further over the typicalground-based diet.

The Process to Reduce Dietary Sodium

In March 2010, the Space Food Sys-tems Laboratory (SFSL) at NASA’sJohnson Space Center began a proj-ect to reformulate existing productsto reduce sodium levels. The projectteam in the SFSL consisted of severalfood scientists and a dietitian. Thisteam reviewed the sodium content ofthe some 200 different foods andbeverages on NASA’s food list andidentified 90 different thermostabi-lized and rehydratable food productsto be reformulated. These 90 were se-lected on the basis of sodium con-tent.

The team developed a schedule forreformulation that would have re-quired about 4 years to completewith in-house resources. NASA man-agement wanted the project com-pleted in less time, so to augment theSFSL reformulation efforts, two out-side firms, one with expertise infreeze-dried foods and one with ex-pertise in thermostabilized foods,were hired to expedite the project.The 90 products were reformulatedin about 2 years, with 30 foods each

for the two consultant firms and forthe SFSL. The approach taken, to theextent possible, was to reformulateexisting foods rather than replacefoods with totally different products.This was the goal because the exist-ing food list was balanced amongfood types, providing good varietythat is important to ISS crewmem-bers during their lengthy stays onorbit.

The primary approach was to removesodium by either using low-sodiumversions of ingredients or by remov-ing salt altogether and using otheringredients, such as spices and herbs,to compensate for the sodium in thereformulated products. Some of thespices included disodium inosinateand disodium guanylate to increasethe umami flavor in savory foodsalong with lemon juice, basil,oregano, sugar, Mrs. Dash Fiesta LimeSeasoning, and Mrs. Dash Garlic &Herb Seasoning.

Because of the low volumes of foodrequired for spaceflight, NASA has anadvantage over the commercial foodindustry in being able to use thesetypically much more expensive ingre-dients in formulations without signifi-

cant economic impact. For freeze-dried food products, NASA had, inmany instances, used COTS frozenfoods and further processed theminto freeze-dried foods. The reformu-lation of these products producedfoods made from individual ingredi-ents rather than further processedfrom commercial products with theexpected increased labor costs. Incontrast, NASA’s thermostabilizedproducts were already predominatelymade from individual ingredients, so

this project had little effect on laborcosts to produce these items.

Evaluating New Formulations

When a new formulation was identi-fied for a product, a small test batchwas made in the SFSL for evaluationby the project team. This often re-sulted in rejection and rework ofmany of the formulations. When theteam found a new formulation to beacceptable, the next step was toprocess enough of the product toallow for large-scale sensory evalua-tion using a group of untrained vol-unteer panelists. These evaluationswere publicized to the astronautcorps and some participation by cur-rent astronauts did occur.

During sensory evaluation, the prod-uct was rated for appearance, color,odor, flavor, and texture, and given anoverall rating. A 9-point hedonic scalewas used for these rankings and anoverall score of 6.0 or higher was re-quired before the product wasdeemed acceptable for use. Occa-sionally a reformulated product didnot pass this evaluation. In that case,the comments made by the panelists


light of the continuous operation ofthe ISS, NASA decided to reduce as-tronauts’ dietary sodium intake.Within a couple of years, NASA hopesthat astronauts will consume dietscloser to 3,500 mg/day, and if theyconsume only items from the U.S.menu, they will easily meet this rec-ommendation.

Barbara Rice, MS, RD, is with EnterpriseAdvisory Services, NASA, and Helen W.Lane, PhD, RD, and Vickie Kloeris, MS,are with NASA Johnson Space Center,Human Health and Performance Di-rectorate, in Houston, TX

References

1. Smith SM, Zwart SR, Kloeris V, et al.Nutritional Biochemistry of SpaceFlight. New York, NY: NOVA SciencePublishers, Inc.; 2009.

2. NASA website, www.nasa.gov/mis-sion_pages/station/main/index.html.

3. Nutritional Requirements for Inter-national Space Station (ISS) Missionsup to 360 days. Houston, TX: NationalAeronautics and Space Administra-tion, Report No. JSC-28028, 1996.

4. Smith S, Zwart SR, Block G, et al. Thenutritional status of astronauts al-tered after long-term space flightaboard the International Space Sta-tion. J Nutr. 2005;135:437.

5. Mader TH, Gibson CR, Pass AF, et al.Optic disk edema, globe flattening,choroidal folds, and hyperopic shiftsobserved in astronauts after long-du-ration space flight. Ophthalmology.2011;118:2058-2069.

6. Smith SM, Davis-Street JE, Rice BL,et al. Nutritional status assessment insemi-closed environments: ground-based and space flight studies in hu-mans. J Nutr. 2001;131:2053-2061.

7. Smith, SM, Block, G, Davis-Street, etal. Nutritional status assessment dur-ing Phases IIa and II of the Lunar-Mars life support test project. In: LaneHW, Sauer RD, Feeback DL, eds. Isola-tion NASA Experiments in Close-Envi-ronment Living. San Diego, CA.American Astronautical Society,2002;104:293-314.

agencies—and NASA obviously hasno control over the sodium contentof these foods.

Measuring Dietary Intakes: Food FrequencyQuestionnaire

With the advent of the ISS, the nutri-tion researchers needed an easy-to-use valid method to determinedietary intakes. This led to testing afood frequency questionnaire (FFQ)originally developed by GladysBlock.6 The questionnaire was vali-dated against 24-hour dietaryrecords during studies of crewmem-bers who lived in a closed chamberfor 60 and/or 91 days.6,7

This semi-quantitative FFQ is self-ad-ministered each week.4 The FFQ is de-signed to include the foods that areavailable for a specific expedition andrequires about 5 to10 minutes tocomplete. The FFQ assesses intake ofseven nutrients including sodiumalong with energy, protein, potas-sium, iron, fluids, and calcium. Datafrom the completed questionnaireare routinely provided to the med-ical-nutrition teams for assessmentsof the astronauts’ diets. These teamsthen make recommendations to theastronauts about their diets within 48hours of completion of the FFQ,thereby allowing for self-correctionsin their diets. With a sodium recom-mendation for spaceflight of 3,500mg/day, the sodium reformulationproject will enable astronauts tomeet this level.

Summary

The level of sodium in astronauts’diets has always been high and, in

were evaluated and revisions weremade to the formulation and testedagain. In the case of the reformula-tions done by the two consultantcompanies, those reformulationswent directly to large-scale sensoryevaluation.

Sensory evaluations of the final re-duced-sodium formulations showedacceptance scores that were not sig-nificantly lower than the scores oftheir higher-sodium predecessorsand in a few cases were higher. Thenet result of the reformulation taskwas a 40% reduction in the sodiumcontent of the current ISS standardmenu of 5,600 mg/day.

These reduced-sodium productswere manufactured and are now be-ginning to be shipped (launched) tothe ISS. The project team is anxious tohave feedback from crewmemberson orbit regarding the acceptabilityof these items; the crews will con-sume significant quantities of thesereformulated foods in 2013.

It is interesting to note that salt, in liq-uid form, has always been availablefor crewmembers to use on orbit.One of the assumptions of this proj-ect was that the liquid salt wouldcontinue to be made available to thecrewmembers. NASA decided thatthe reduced-sodium diet would notbe mandated to all crewmembers,but reduced-sodium products wouldbe available for those crewmemberswho desired them or had symptomsof increased intracranial pressure. Asanother variable, Russian foods are al-ways available on the ISS along withsome foods provided by the Cana-dian, European, and Japanese space


Part 2 of this article resumes a discus-sion of the potential positive health effects of dietary nitrate and nitriteconsumption. For more information onthe metabolites derived from nitrate,nitrite, and nitric oxide (NO), which arecollectively termed NOx, see Part 1 ofthis article published in the Fall 2012issue of SCAN’S PULSE.

Nitrate, Nitrite and Cardiovascular Effects of NOx

The cardiovascular benefits of dietarynitrate and nitrate in animal modelsand humans were examined in a re-cent review of the extensive literatureon this topic.1 The demonstrated car-dioprotective effects of dietary ni-trate and nitrite include reduction inblood pressure, reduced ischemia/reperfusion injury in heart and kid-ney, reduced platelet aggregation,and enhanced endothelial function.2

Indeed, plasma levels of nitrite andnitrate are strongly correlated withbrachial flow-mediated dilation re-sponses in young men and women.3

It is now clear that nitrates infoods/beverages and sodium nitritein beverages or intravenous infusionscan, in a dose-dependent fashion,predictably and acutely lower bloodpressure in humans and animals.Subjects consuming a variety of tra-ditional Japanese foods high in ni-trate (18.8 mg nitrate/kg bodyweight/day) experienced a drop in di-astolic blood pressure (DBP) of about4.5 mm Hg.4 In elegant randomizedcrossover studies in humans, Kapiland associates reported that eitherbeetroot juice (500 mL containing~341 mg nitrate) or inorganic potas-sium nitrate (KNO3) capsules (4, 12 or24 mmol containing 248, 744 or 1488mg of nitrate) produced dose-

dependent increases in plasma ni-trate and nitrite.5 The highest dose ofKNO3 caused reductions in both sys-tolic blood pressure (SBP) and DBPover 24 hours compared with thepotassium chloride control of 9.4 ±1.6 mm Hg (at 6 h) and 6.0±1.1 mmHg (at 2.75 h) for SBP and DBP, re-spectively.

Interestingly, post-hoc analyses haverevealed sex differences in process-

ing of dietary nitrate through the en-terosalivary circulation and itsconsequences on blood pressure.5 Ina subset analyses from this study, fe-males had significantly higher base-line plasma nitrite than males andalso had higher salivary (nitrite)(0.39±0.05 vs. 0.26±0.03 µM, P<.05),lower clinic SBP (SBP: 105.5±1.1 vs.113.9±0.9 mmHg, P<.01), home SBP(SBP: 109.7±1.0 vs. 119.3±1.4, P<.01)and ambulatory BP (SBP: 115.1±0.7vs. 122.0±0.8, P<.01). Females exhib-

ited 2-fold higher oral nitrite produc-tion compared with males afterbeing given capsules containingKNO3, P<.01) (Kapil V et al, unpub-lished observation: Nitric Oxide2011;24:S16–S42). These results sug-gest that females produce more ni-trite derived from enterosalivarycirculation derived from enterosali-vary circulation than men, and thatthis may contribute to the reducedBP and may partially explain the re-duced risk of cardiovascular disease(CVD) in women.

Physical activity lowers CVD risk, andone of the earliest clinical signs ofCVD is decreased endothelial reactiv-ity after ischemic reperfusion.6 It hasbeen shown that age-dependent en-dothelial dysfunction is associatedwith failure to increase plasma nitritein response to exercise. Exercise en-hances endothelial nitric oxide syn-thase (eNOS)-dependent NOproduction via shear stress.1 In a fas-cinating series of recent studies, it hasbeen demonstrated that dietary ni-trate lowers the oxygen cost of exer-cise7 and enhances endurance byabout 15%,8 ostensibly by increasingmitochondrial efficiency in humans.9

The increase in mitochondrial effi-ciency due to nitrate feeding isthought to be mediated by improve-ment in oxidative phosphorylationefficiency (P/O ratio) leading to a re-duction in oxygen cost for energyproduction during exercise.9 Thesefindings suggest that nitrate and ni-trite are efficacious as cardioprotec-tive dietary factors and also improvephysical performance.

Dietary Nitrates and Nitrites from Vegetables and Fruits: How Can Something So Bad Be So Good?(Part 2)by Norman G. Hord, PhD, MPH, RD


Dietary Intakes and Recommendations to Limit Nitrate Consumption

Intake exposure recommendationsfrom the World Health Organization(WHO) provide a basis for insightsbased on current knowledge. Factsregarding human exposures to ni-trate and nitrite casts concern overcurrent regulatory limits on nitrateand nitrite consumption. First, it ispossible to approach or exceedWorld Health Organization Accept-able Daily Intake (WHO ADI) limitswith usual intake levels of singlefoods, such as colostrum (at 100 mLintake in a newborn infant, delivering

42% of the WHO ADI intake limit),soya milk (750 mL intake for a hypo-thetical 6.8 kg-infant yields 104% ofthe WHO ADI intake limit), spinach,10

or a dessicated vegetable supple-ment.11 Second, recommended di-etary intakes of vegetables and fruits,such as a Dietary Approaches to StopHypertension (DASH) pattern withhigh-nitrate food choices, exceed theWorld Health Organization’s Accept-able Daily Intake for nitrate by 550%for a 60-kg adult.11 Third, for adultsconsuming the recommended in-takes of vegetables and fruits (thesource of over 80% of dietary nitrateand nitrite), the concentration of ni-trate in saliva can be up to threetimes the concentration allowed bymost global regulatory limits fordrinking water. Fourth, provision ofdietary nitrate, as beetroot juice (orsingle servings of spinach or veg-etable juices such as V8 juice),1 di-etary nitrate,5 or in a traditionalJapanese dietary pattern,4 are effec-tive in lowering blood pressure in hu-mans. Fifth, human infants

consuming breast milk are exposedto nitrate and nitrite in human milkfrom birth.12

These facts indicate that WHO guide-lines may limit nitrate and nitrite in-takes from foods to levels belowthose that could confer health bene-fits. As such, the intake estimates pre-viously noted may represent, at apopulation level, dietary deficiency. Ifnitrates and nitrites act as nutrients, itis likely that they do so to bolster thereserve of nitrite-derived NOxmetabolites required for optimalfunctioning through periods of phys-iologic stress (e.g., hypoxia and acido-sis) and diseases characterized by

endothelial dysfunction.13 Optimalconsumption levels of nitrates and ni-trites from vegetable and fruitsources await the consensus of ex-perts based on a systematic review ofavailable evidence.

Potential Health Benefits ofDietary Nitrates and Nitrites

Data from the laboratories of Lund-berg, Gladwin, Zweier, Bryan, and oth-ers support the modern hypothesisthat dietary nitrates and nitrites havehealth benefits.13,14 The nitrate-nitrite-NO pathway has been demonstratedto serve as a backup system to en-sure NO supply in situations whenthe endogenous L-arginine/NO syn-thase pathway is dysfunctional.1 Thisredundant system of NO productionin tissues has important implicationsfor cardiovascular, gastrointestinal,and immune function related to theprovision of dietary nitrate and ni-trite. Because nitrite-dependent NOgeneration has been shown to playcritical physiologic and pathologic

roles, and is modulated by oxygentension, pH, reducing substrates, andnitrite levels, it is necessary to bal-ance these factors in a modern regu-latory framework that acknowledgesa potential physiologic requirementfor dietary nitrate and nitrite.

Determinants of RegulatoryParadigm Change

Based on the demonstrated physio-logic functions of NOx derived fromdietary nitrates and nitrites from vegetables and fruits, it has been proposed that these dietary constitu-ents, based on their demonstratedphysiologic functions, should be con-sidered as nutrients.11 Analogous toall essential or indispensable nutri-ents, intake of excess nitrate and ni-trite exposure is, in specific contexts,associated with an increased risk ofnegative health outcomes. A set ofDietary Reference Intake (DRI) cate-gories are set by the Food and Nutri-tion Board of the National Academyof Sciences for essential nutrients toclearly define, where possible, thecontexts in which intakes are defi-cient, safe, or potentially excessive.These DRI categories include the Rec-ommended Dietary Allowance (RDA),Adequate Intake (AI), Tolerable UpperLevel Intake (TUL), and Estimated Av-erage Intake (EAI), as discussed byHord et al.11

The process of setting DRIs for nutri-ents considers a broad range of phys-iologic factors, including nutritionalstatus and potential toxicities. Ra-tional methodologies such as these,including the consideration of nor-mal dietary consumption patterns ofnitrate and nitrite-containing foods,have not been applied in setting ex-posure limits or in considering thepotential health benefits of dietarynitrates and nitrites. The determina-tion of those concentrations of ni-trate and nitrite that should bedefined as low, sufficient, or excessivein healthy populations will require aconsensus among researchers, healthprofessionals, and regulators.


Recommendation for Comprehensive Review ofHealth Effects of Nitrate and Nitrite

While there are compelling indica-tions that dietary nitrate or nitritemay reduce CVD risk, it must be ac-knowledged that the lack of aware-ness of the potential health benefitsof nitrates and nitrites is prevalent.Hence, in clinical trials such as thosetesting the efficacy of the DASH diet,nitrate and nitrite concentrations infoods were not considered. Becausethese unmeasured factors likely con-tributed to the hypotensive effects ofthe DASH dietary pattern,11 dietarynitrate and nitrite would be consid-ered confounding factors. This char-acterization is apropos for thenumerous studies attributing cardio-vascular benefits to vegetable intake,plant-based diets, and Mediterraneandiet interventions for the secondary

prevention of CVD. It is hoped that di-etary concentrations of these effectmodifiers will be measured or esti-mated and reported in future epi-demiologic and clinical studies ofcardiovascular risk.

Lack of inclusion of food nitrate andnitrite concentrations in standardfood databases (e.g., USDA NationalNutrient Database for Standard Refer-ence) is another obstacle to the de-velopment of a solid epidemiologicbasis for quantifying cardiovascularand other health benefits of dietarynitrates and nitrites in human popu-lations. As such, the developmentand availability of a database of food

nitrate/nitrite concentrations wouldencourage more thorough investiga-tions of hypotheses associating di-etary nitrate/nitrite and specifichealth outcomes.

The compelling results of clinicalstudies demonstrate great potentialfor the treatment and prevention ofcardiovascular diseases, including is-chemia-reperfusion (IR) injury andhypertension, by dietary means.4,15 Itis incumbent upon regulators tocarry out a comprehensive, system-atic, and independent review of allavailable evidence of health effects ofdietary nitrate and nitrite. A reviewprocess from an independent institu-tion such as that implemented by theInstitute of Medicine would be opti-mal. After decades of being subjectedto regulatory limits on dietary nitrateand nitrite based on the poor prac-tice of causal inference, the public de-serves cohesive regulations that

reflect the physiologic necessity ofnitrate and nitrite while accountingfor contexts in which these dietarysubstances may produce health risks.The necessary work of bringing to-gether experts from disparate scien-tific disciplines to craft meaningfuldietary recommendations for nitrateand nitrite intakes could be a boonfor public health.

Conclusions

The demonstrated hypotensive andcytoprotective effects (particularlyunder ischemic conditions) of dietarynitrate and nitrite have led to theproposal that these compounds be

considered nutrients.11 Balancedagainst the observed toxic effects athigh concentrations and in specificphysiologic contexts, as exists amongall nutrients, the promotion of con-sumption of plant sources of nitrateand nitrite has great potential to ben-efit public health. These health bene-fits may be seen in the reduction ofmorbidity and mortality due to en-hanced endothelial dilatation, mito-chondrial efficiency, and attenuationof oxidative stress.9,16-18

Norman G. Hord, PhD, MPH, RD, is asso-ciate professor in the School of Biologi-cal and Population Health Sciences,College of Public Health and HumanSciences, at Oregon State University inCorvallis, OR.

References

1. Lundberg JO, Carlstrom M, LarsenFJ, et al. Roles of dietary inorganic ni-trate in cardiovascular health and dis-ease. Cardiovasc Res. 2011;89:525-532.

2. Lundberg JO, Weitzberg E, GladwinMT. The nitrate-nitrite-nitric oxidepathway in physiology and therapeu-tics. Nature Rev. 2008;7:156-167.

3. Casey DP, Beck DT, Braith RW. Sys-temic plasma levels of nitrite/nitrate(NOx) reflect brachial flow-mediateddilation responses in young men andwomen. Clin Exper Pharmacol Physiol.2007;34:1291-1293.

4. Sobko T, Marcus C, Govoni M, et al.Dietary nitrate in Japanese traditionalfoods lowers diastolic blood pressurein healthy volunteers. Nitric Oxide.2010;22:136-140.

5. Kapil V, Milsom AB, Okorie M, et al.Inorganic nitrate supplementationlowers blood pressure in humans:role for nitrite-derived NO. Hyperten-sion. 2010;56:274-281.

6. Lauer T, Heiss C, Balzer J, et al. Age-dependent endothelial dysfunction isassociated with failure to increaseplasma nitrite in response to exercise.Bas Res Cardiol. 2008;103:291-297.

7. Larsen FJ, Weitzberg E, Lundberg


JO, et al. Dietary nitrate reduces maxi-mal oxygen consumption whilemaintaining work performance inmaximal exercise. Free Rad Biol Med.2010;48:342-347.

8. Vanhatalo A, Bailey SJ, Blackwell JR,et al. Acute and chronic effects of di-etary nitrate supplementation onblood pressure and the physiologicalresponses to moderate-intensity andincremental exercise. Am J PhysiolRegul Integr Comp Physiol.2010;299:R1121-1131.

9. Larsen FJ, Schiffer TA, Borniquel S,et al. Dietary inorganic nitrate im-proves mitochondrial efficiency inhumans. Cell Metab. 2011;13:149-159.

10. Lundberg JO, Feelisch M, Bjorne H,et al. Cardioprotective effects of veg-etables: is nitrate the answer? NitricOxide. 2006; 15::359-362.

11. Hord NG, Tang Y, Bryan NS. Food

sources of nitrates and nitrites: thephysiologic context for potentialhealth benefits. Am J Clin Nutr.2009;90:1-10.

12. Hord NG, Ghannam JS, Garg HK, etal. Nitrate and nitrite content ofhuman, formula, bovine, and soymilks: implications for dietary nitriteand nitrate recommendations. Breast-feed Med. 2010; 6:393-399.

13. van Faassen EE, Bahrami S, Feel-isch M, et al. Nitrite as regulator ofhypoxic signaling in mammalianphysiology. Med Res Rev. 2009;29:683-741.

14. Lundberg JO, Gladwin MT,Ahluwalia A, et al. Nitrate and nitritein biology, nutrition and therapeutics.Nature Chem Biol. 2009;5:865-869.

15. Dezfulian C, Shiva S, AlekseyenkoA, et al. Nitrite therapy after cardiacarrest reduces reactive oxygen

species generation, improves cardiacand neurological function, and en-hances survival via reversible inhibi-tion of mitochondrial complex I.Circulation. 2009;120::897-905.

16. Carlstrom M, Persson AE, LarssonE, et al. Dietary nitrate attenuates ox-idative stress, prevents cardiac andrenal injuries, and reduces bloodpressure in salt-induced hyperten-sion. Cardiovasc Res. 2011; 89:574-585.

17. Borniquel S, Jansson EA, Cole MP,et al. Nitrated oleic acid up-regulatesPPARgamma and attenuates experi-mental inflammatory bowel disease.Free Rad Biol Med. 2010;48::499-505

18. Rocha BS, Gago B, Pereira C, et al.Dietary nitrite in nitric oxide biology:a redox interplay with implicationsfor pathophysiology and therapeu-tics. Curr Drug Targets. 2011;12:1351-1363.

29th Annual SCAN Symposium

Tools and Techniques for Peak Professional PerformanceApril 26-28, 2013

Westin Hotel, Chicago, IL

Don’t miss an exceptional opportunity to enhance your skills at the 2013 SCAN Symposium. Choose from 30 ses-

sions and 36 speakers, including Dr. Richard Deming, Dr. Steven Heymsfield, Dr. Penny Kris-Etherton, Jessica Set-

nick, Dr. Carol Ireton-Jones, and many more!

Among many other take-home skills that you’ll acquire, Symposium 2013 will enable you to:

■ Improve your professional competency in managing advanced dyslipidemia using 2013 guidelines

■ Forget the 3,500 kcal/pound rule—learn an alternative validated approach to predict client’s weight loss

■ Become proficient in RMR data measurement, interpretation, and application

■ Use imagery exercises, body language decoding, identity issue exercises, thought translation, and

behavioral abstinence for improved treatment therapy of binge eating disorder patients

■ Practice effectively on camera, online, and in-public traditional and social media skills

■ Calculate urine specific gravity for client hydration status and intervention strategies

■ Discover sport- and individual-specific fueling strategies

■ Learn techniques for overcoming reimbursement challenges

■ Translate nutrition education information into culturally appropriate messaging

■ Enhance your proficiency in athlete dietary assessment

■ Create a treatment contract useful in the treatment of eating disorder and disordered eating populations

■ Update and apply new self-tracking technologies and data visualization skills

■ Recognize and use visual cues to develop a mindful eating strategy for your clients

25 CPEUs is requested from the Commission on Dietetic Registration

From

by Ingrid Skoog, MS, RD, CSSD

The Chair

make the desired impact. I worry about these changes andwonder if we are simply going to “confuse the public” evenmore with a name change, a new credential, and a new defi-nition of the entry-level practitioner.

This is where our proactive, articulate SCAN members enterthe picture. It is unclear whether these recommendations willbecome accepted mandates and be implemented withoutfurther discussion. However, the Academy has stated that itwants to hear from its members. So, I encourage you all to re-view this document as well as the HOD Fact Sheet: Council onFuture Practice Visionary Report: Moving Forward — A Vision forEducation, Credentialing and Practice Outcomes Report.

SCAN Symposium 2013

Moving on, we now set our sights on our spring SCAN Sym-posium in Chicago, IL. This unique event marks a turn inSCAN’s approach to supporting members’ needs for special-ized continuing education and networking. Our new ap-proach is characterized in Symposium 2013’s title: Tools andTechniques for Peak Professional Performance.

This hands-on, experiential-based learning approach to Sym-posium sessions means you will leave this event with skillsyou can immediately apply to your practice. The program willfeature integrated topics related to sports nutrition, cardio-vascular health, wellness, obesity, weight management, anddisordered eating and eating disorders. Presentations will re-flect cutting-edge research and practical applications, with aspecial emphasis on skill-building and interactive sessions.

SCAN’s Executive Committee works hard to make sure our ef-forts align with your goals and the realities of your career. Torespond to your needs we are looking at more efficient andeffective ways to communicate with and provide resources toour members. Toward those goals we are actively working onthe following: ■More webinars for close-to-home continuing education ■More efforts to promote the SCAN RD and our areas of spe-cialization ■ Stronger and more productive connections with our part-nering organizations ■ An improved Web site and online SCAN experience

So, the work, dedication, and commitment never end, and wehope you can attend SCAN Symposium 2013 and participatein this truly unique event.

Happy New Year, SCAN Members!

I’d like to discuss two topics in this issue: the Council on Fu-ture Practice’s Visionary Report presented at the 2012 Food& Nutrition Conference & Expo in October, and our 2013SCAN Symposium coming up in April.

Visionary Report of the Council on Future Practice

At the House of Delegates (HOD) meeting held duringFNCE 2012, the Council on Future Practice (CFP) presentedits report of nine recommendations. Because the HOD willbe meeting in January 2013 to continue discussions on thisreport, I want to remind our members of these recommen-dations so they can be prepared for the outcomes and de-cisions that the Academy, the Accreditation Council forEducation in Nutrition and Dietetics (ACEND), and the Com-mission on Dietetic Registration (CDR) will be making. Toreview the CFP initial report and the HOD outcomes report,visit www.eatright.org/Media/content.aspx?id=6442471758#.UHwe3VE1b8s.

In short, the following recommendations were suggestedand discussed: 1. Elevate the educational preparation requirement for anentry level RD to a minimum of a graduate degree2. Work toward the promotion of more coordinated masterof science/dietetic internship (MS/DI) programs3. Develop a new credential for those graduating with a 4-year undergraduate degree from a didactic program in di-etetics (DPD)4. Phase out the dietetic technician, registered (DTR) cre-dential5. Include practicum and outside of classroom learningcompetencies to ACEND-accredited DPD programs6. Continue work on expanding Board-Certified Specialistcredential offerings7. Continue support for developing an advanced practicecredential for nutrition and dietetics professionals 8. Conduct a well-funded, comprehensive marketing,branding, and strategic communications campaign target-ing external stakeholders 9. Support an RD credential name change

As SCAN Chair and a long-time RD, it has become clear tome that what our profession needs is reflected in #8. Untilthe public considers our discipline and expertise as a partof its regular language in the conversations about healthcare, I am not sure if these other recommendations will

SCAN’S PULSE Fall 2012, Vol. 31, No. 4 | 15


Conference Highlights

FitBloggin’ 2012Baltimore, MD September 20-22, 2012

The third annual FitBloggin’ Confer-ence carried the tagline “For bloggersinterested in fitness, wellness, goodfood, and a healthy lifestyle: Two daysof education, networking, friendship,and fun.” More than 300 attendeesfrom all over the United States con-vened to learn from each other andfrom sponsored food and fitness pro-fessionals. The participants were pri-marily women aged 25 to 40 yearswho write blogs about their personalfitness journey. Many are successfulbusinesswomen with full-time ca-reers, others are full-time moms, andall have either lost or are in theprocess of losing weight and are ex-ercising to keep it off. Some partici-pants were just starting their journeyand finding support from an onlinecommunity of followers. The newbloggers had only a few followers,while the more established bloggersreported having some 15,000 peopleread their blogs each day.

The conference offered various typesof learning opportunities, including:■ Nutrition sessions (sponsored byfood companies such as Got Choco-late Milk’s Refuel Campaign, the BeefCouncil, and Unilever)■ Exercise breaks that included yoga,CrossFit, Zumba, and fitness trampo-lines■ Sessions about blogging as a busi-ness■ Personal growth sessions on self-acceptance, weight loss, and “whenyou have a lot to lose”■ Discussions in which participantscould share their experiences aboutblogging, weight, and self-accept-ance

The titles of the “Get Down to Busi-ness” sessions offer a clear idea of thetopics discussed:■ Harness the Power of YouTube■ Transition from Blog to Book

■ Using Social Media to Drive BlogTraffic■ Attract Local Media & Find Successas a Freelance Writer■ Build Your Brand■ Tips to Leave Your Job and FollowYour Dreams■ Turn Your Post Into an Article■ Take Your Online Community Of-fline■ Drive More Traffic Through SEO■ Design a Better Blog on a Budget■ Monetizing Through the Pitch

The Business of BloggingA session of particular interest to RDswho are bloggers or contemplatingbecoming a blogger was a discussionon the business of blogging. Severalof the experienced bloggers sharedhow they have generated incomefrom their blogs. For them, bloggingis a full-time job, with some peopleblogging one to three times a day,and other three times a week.

The organizer of the conference, RoniNoone, has represented and con-sulted for a wide variety of clients inthe health and fitness industry, in-cluding Weight Watchers, Kraft, Vitali-cious, Subway, Johns HopkinsUniversity, Quaker, NutraLite, andPOM.

Here are the highlights from this dis-cussion:■ Sponsors seek out bloggers be-cause they are “real people” who offerauthentic experiences and opinions.Sponsors might secretly follow ablogger for several months and thenapproach him or her for a sponsor-ship opportunity. For example ahealth insurance company followedseveral fitness bloggers and then se-lected six, asking if they would writea paid weekly blog about their healthjourney for a year for the company’sWeb site. One blogger is a workingmother who is training for her firstmarathon. The others include a 70-year-old woman, a divorced dad, anda veteran—all of whom represent

“real people” with challenging healthjourneys.■ A company approached an experi-enced blogger (@yumyucky), want-ing to pay to put an ad on her blogpage as well as pay her to write a spe-cific number of blogs and tweetswithin a specified timeframe Al-though she did not agree to have thead on her site, the company still paidher to write some sponsored blogs. ■ A protein supplement companyapproached a former participant-turned-blogger from The BiggestLoser TV show, expressing interest insponsoring his blog and having himserve as a paid spokesperson atexpos for some bodybuilding events,including Mr. Universe. The companyhad previously used celebrity spokes-people, but they now prefer to hire“real people” because they offer morecredibility. ■ Unpaid blogging for specificbrands can be acceptable if it helps anovice blogger enhance his or her re-sume, build a portfolio, become morevisible, and create a relationship thatopens doors. These experiences cansometimes help bloggers sell them-selves and their experience to an-other sponsor.■ If you want to find a sponsor foryour blog, seek contacts for brandsthat you love. For example, if you loveapples, contact the public relationsdepartment of an apple grower, learnthe latest nutrition news regardingapples, and write a query letter let-ting the company know how you canhelp them. An important note: Whenwriting any paid articles or blogs, thewriter must disclose the sponsor ispaying them. ■ Become an affiliate withamazon.com. Any sales that come toAmazon through your Web site gen-erate an income stream. These salesinclude not just the item you men-tioned but also any other sales forother items (e.g., toys, clothing) thatgot linked to your site.


An Opportunity for RDs

There was a clear lack of RDs at theFitBloggin’ Conference. The majorityof participants were self-taughtweight loss experts who were strug-gling with self-reported food addic-tions, sugar cravings, compulsiveexercise, emotional eating, and disor-dered eating. With a few exceptions,the handful of RDs in attendancewere invited as spokespeople forfood companies. SCAN RDs and Fit-Bloggers could mutually benefit byforming partnerships!

To connect with fitness bloggers,check out the supportive online com-munity called BlogToLose(http://blogtolose.com), where morethan 5,000 dieters are bloggingabout their weight loss journey. An-other way to connect with fitnessbloggers is to follow a few of the Fit-Bloggers; a list of participants can beaccessed at www.fitblogging.com/whos-comin-2. Once you find some-one who matches your interests, youcan send them an e-mail asking ifthey might like some “food help” on

their journey. As you know, RDs areone of the best-kept secrets, so thesebloggers might be able to help us be-come more visible.

Summarized by “Conference High-lights” editor Nancy Clark, MS, RD,CSSD, who has a private practice in theBoston area, is author of the bestsellingNancy Clark’s Sports Nutrition Guide-book, and can be reached viawww.nancyclarkrd.com.

Reviews

Nutrient Timing for PeakPerformance: The RightFood, the Right Time, theRight ResultsHeidi Skolnik, MS, CDN, FACSM, andAndrea Chernus, MS, RD, CDEHuman Kinetics, Champaign, IL800/747-4457;www.humankinetics.com2010, softcover, 237 pp, $17.95ISBN-10:0-7360-8764-8

Renowned sports nutritionists HeidiSkolnik and Andrea Chernus havewritten this practical guide to helpathletes gain maximum performance,recover quickly, reduce the risk of in-jury, diminish muscle breakdown, andenhance immune function. Based ontheir years of experience workingwith professional athletes as sportsnutritionists and recent research,Skolnik and Chernus offer the lateston nutrient timing to maximize re-sults, performance, recovery, and suc-cess inNutrient Timing for PeakPerformance.

The book has three sections: “ThePrinciples,” “The Nutrients,” and “Fuel-ing Strategies, Plans and Menus.” Thefirst section emphasizes the impor-tance of nutrient timing for energy,muscle recovery, muscle breakdownand rebuilding, and immunity. Thissection also simplifies the science be-

hind the processes of digestion andmetabolism and the way our bodiesuse nutrients for fuel. The authorsprovide detailed yet easy-to-under-stand information about the effectsof training and nutrient timing onhormones including testosterone, in-sulin, insulin-like growth factor-1(IGF-1), growth hormone, glucagon,

cortisol, and adrenaline. A “timing tip”is included on each page, with a keytake-away point on the topic dis-cussed.

The books’ second section examinesthe role of macronutrients, micronu-trients, fluids, and supplements intraining, recovery, and immunity.While other books have discussedthe role of carbohydrates, protein,and fat, Nutrient Timing for Peak Per-

formance delves a little deeper. Forexample, the authors highlight sec-tions that discuss carbohydrate’s rolein overreaching, overtraining, and re-siliency. As another example, the au-thors demystify ideas of usingcarnitine, getting into the fat burningzone, and following dietary peri-odization to enhance fat burning.

The third section, “Fueling Strategies,Plan and Menus,” helps readers for-mulate a plan based on their activity:endurance, strength and power, orstop and go. There are well-definedsubsections and tables that lay out aplan for the timing of nutrients. Car-bohydrate, protein, and fat need arecalculated based on age, height, gen-der, and activity level and then trans-lated into a blueprint. The blueprintbecomes the basis for a meal plan.Within this section are chapters de-voted to addressing endurance,strength and power, and stop-and-goathletes, providing detailed mealplans and suggestions.

Nutrient Timing for Peak Performancelays down the nutritional foundationto help endurance, strength andpower, and stop-and-go athletes suc-ceed. This book would benefit noviceand elite athletes alike. It would alsomake a nice addition to the sportsnutritionist’s bookshelf to be used


when creating individualized mealplans with athletes.

Heidi Skolnik, MS, CDN, FACSM, is thepresident of Nutrition Conditioning,Inc., a nutrition consulting practice.She has master’s degrees in exercisescience and human nutrition. She isalso a New York State-certified nutri-

practice in New York City, where shesees many athletes and performers.

Reviewed by Nichole Dandrea, MS, RDpart-time women’s health nutritionistand owner of Nicobella Organics, ahealthy organic chocolate companybased in Los Angeles, CA.

tionist, a fellow of the American Col-lege of Sports Medicine (ACSM), anda certified ACSM health fitness in-structor. Andrea Chernus, MS, RD,CDE, is a registered dietitian and NewYork State-certified dietitian and nu-tritionist. She holds a master’s degreein nutrition and exercise physiology.She maintains a full-time private

Sports Dietetics-USA Research Digest

Bananas as Effective as SportDrink in Cycling PerformanceNieman DC, Gillitt ND, Henson DA, etal. Bananas as an energy source dur-ing exercise: a metabolomics ap-proach. PLoS ONE. 2012;7:e37479

Research comparing sport nutritionproducts to whole foods is lacking.This randomized, cross-over studyutilized a metabolomics approach to

compare the acute effects of bananas(BAN) versus Gatorade (GAT) on 75-km cycling performance as well aspost-exercise inflammation, oxidativestress, and changes in immune func-tion. After consuming a moderatecarbohydrate (CHO) diet 3 days priorto and Boost Plus (10 kcal/kg) 3 hoursprior to a 75-km time trial (TT), 14trained male cyclists (ages 18-45)consumed either 0.4g/kg CHO fromBAN or GAT 10 minutes prior to TT.Every 15 minutes during the TT, thecyclists ingested 0.2 g/kg CHO fromeither GAT or BAN (with equal water

to GAT). Symptom logs as well as pre-, during, post-, and 1-hour post-exer-cise blood samples were obtainedand analyzed for 103 metabolites.Mean CHO intake during both trialswas 150 ±19.5g. There were no signif-icant differences in mean power,heart rate, rate of perceived exertion,blood glucose levels, or total time be-tween GAT and BAN (P>.05). Of the103 metabolites analyzed, 56 had ex-ercise time effects suggesting in-

creased production of glutathioneand fuel-substrate utilization duringboth trials. Dopamine levels signifi-cantly increased in BAN versus GAT(P<.001), possibly contributing to thehigher antioxidant capacity (as meas-ured through ferric reducing abilityof plasma, FRAP, P=.012) in BAN. Inter-leukin (IL)-10 and IL-8 levels were sig-nificantly higher in BAN comparedwith GAT (P=.003 and .004), suggest-ing a slightly higher overall inflam-matory response. Study participantsreported feeling significantly morefull (P=.003) and bloated (P=.014)with BAN compared with GAT, likely

related to the almost 15 g of fiberconsumed during the exercise trial.These results suggest that ingestingbananas before and during pro-longed intense exercise can supportathletic performance as effectively asingesting a commercially availablesport beverage. Regardless of promis-ing data and the appeal of “food-first”in providing unique benefits overcommercial products, practicality andindividual tolerance must be consid-ered; consumers should be sure to“try before you buy.” This study wasfunded by a grant through DoleFoods.

Summarized by Jenna Becker, MS, RD,PES, CES, sports, community, and clini-cal dietitian, Athletes’ Performance, St.Jude Medical Center and the AmericanAcademy of Pediatrics, in Los Angelesand Orange County, CA.

HMB Supplementation andMuscle Mass, Strength, andAnaerobic Capacity in EliteAthletesPortal S, Zadik Z, Rabinowitz J, et al.The effect of HMB supplementationon body composition, fitness, hor-monal and inflammatory mediatorsin elite adolescent volleyball players:a prospective, double-blind, placebo-controlled study. Eur J Appl Physiol.2011;111:2261-2269.

Beta-hydroxy-�-methylbutyric acid(HMB) has purported ergogenic ef-fects relating to reduced catabolic incidence and increased training- as-sociated anabolic gains. Few studies

Soy vs. Whey in Protein Synthesis After ResistanceExercise in the Elderly Yang Y, Churchward-Venne YA, BurdNA, et al. Myofibrillar protein synthe-sis following ingestion of soy proteinisolate at rest and after resistance ex-ercise in elderly men. Nutr Metab.2012;9:57.

The ability to enhance myofibrillarprotein synthesis (MPS) at rest andafter resistance exercise (RE) follow-

ing consumption of soy or whey pro-tein appears to be markedly differentin the young and elderly. The purposeof this study was to determine the efficacy of soy protein versus wheyon MPS in the elderly. In this random-ized, counterbalanced study, threegroups of 30 male participants (meanage 71 ± 5 y) consumed water, 20 g,or 40 g of soy protein isolate follow-ing a bout of unilateral knee-extensorRE (3 sets x 10 RM). Results were thencompared with the results reportedpreviously by the same authors usingthe same protocol for 20 g and 40 gof whey protein. Whole body leucineoxidation and MPS were measuredusing a constant infusion of leucineand phenylalanine and vastus later-alis muscle biopsies from both exer-cised and non-exercised legs. Resultsindicated increased whole-bodyleucine oxidation for 20 g of soy com-pared with 20 g of whey (P=.002).There were no differences betweenthe 40 g soy and 40 g whey doses. Nochanges occurred in the myofibrillarfractional synthetic rate (MFSR) of therested leg for soy at 20 g or 40 g. Incontrast, MFSR significantly increased


at rest for both 20 g and 40 g ofwhey. Consequently, MPS was greaterfor whey versus both doses of soy(P<.005). For the exercised condition,an increase in MFSR was reported for40 g of soy following an acute bout ofRE, but not for 20 g of soy. The in-crease in MPS in the exercised legwas greater for both whey conditionscompared with soy (P<.001). Theseresults suggest that soy protein maynot be effective as whey protein instimulating MPS in the elderly. Pro-

tein sources should be consideredwhen the intention is to enhanceMPS in clinical and active elderlypopulations.

Summarized by Erica R. Goldstein, MS,CSCS, CISSN, undergraduate nutrition &dietetics student, University of NorthFlorida, Jacksonville, FL.

Raisins vs. CommercialSports Chews in EndurancePerformanceToo BW, Cicai S, Hockett KR, et al. Nat-ural versus commercial carbohydrate supplementation and endurance run-ning performance. J Int Soc SportsNutr. 2012,9:27.

Carbohydrate is a research-validatedergogenic aid for endurance per-formance. Consequently, many com-mercial carbohydrate sport foods areavailable. However, whole foods sup-plying carbohydrate may be just aseffective. The purpose of this studywas to compare the gastrointestinaltolerance, metabolic, and runningperformance responses to the inges-

have investigated the effects of HMBin younger athletes, in whom supple-mentation is becoming increasinglymore commonplace This prospective,double-blind, placebo-controlledstudy examined the effect of HMBsupplementation on body composi-tion, anabolic/catabolic hormone re-sponse, inflammatory mediatorresponse, muscle strength, andanaerobic/aerobic capacity duringthe initial training stages of elite ado-lescent male and female volleyballplayers. In this study, 28 elite Israelijunior national team volleyball play-ers were randomly assigned a 3g/daydose of HMB or placebo over theirinitial 7 weeks of training. Bothgroups were exposed to equal train-ing, sleep, and nutrition regimensover the course of the study. Baselineand post-supplementation measure-ments were taken for all participants1 week prior to and 1 week followingsupplementation. Assessments in-cluded vertical jump, upper andlower limb 6RM, isokinetic dy-namometer tests, Wingate AnaerobicTest, and a 20-minute shuttle run.Blood sampling and analyses in-cluded growth hormone, insulin-likegrowth factor (IGF)-1, IGF bindingprotein-3, lactate, cortisol, testos-terone, inflammatory mediators, in-terlukin-6, and interleukin-1 receptorantagonist. The HMB group had sig-nificant gains in anaerobic peak andmean power (P<.01), a significantlygreater increase in fat-free mass(FFM) (56.4 ± 10.2 to 56.3 ± 8.6 vs.59.3 ± 11.3 to 61.6 ± 11.3 kg; P<.001),and significant strength gains in kneeflexion isokinetic force/FFM com-pared with placebo. There were nosignificant changes in aerobic meas-ures or hormonal responses. As indi-cated by this study, HMBsupplementation may be beneficialin improving anaerobic qualities,overall strength, and body composi-tion during initial stages of training inelite adolescent athletes. Longer-term studies that also evaluate thepotential for negative side effectsshould be conducted.

Summarized by Sarah Cook, MS, di-etetic intern, Winthrop University, RockHill, SC.


by Sumner Brooks, MPH, RD, CSSD

■ The United States Olympic Com-mittee (USOC) Sports Nutrition teamis composed of five dietitians, each ofwhom supported various teams andathletes over the past four yearspreparing for the 2012 LondonOlympic Games. The USOC sent allfive nutrition team members to Lon-don, where they each helped supportthe athletes in unique ways: Alicia Kendig, MS, RD, CSSD, workedwith Paralympic sport athletes andwas the USOC winter sports dietitian;Shawn Dolan, PhD, RD, CSSD, servedas the USOC team sport dietitian andworked primarily with water poloand volleyball team athletes; AndreaBraakhuis, PhD, APD, fueled thestrength and power sports athletesand supported track and field ath-

letes with their pre- and post-nutri-tion fueling needs; Jennifer Gibson,MSc, RD, supported the acrobat andcombat sports athletes, and assistedthe Olympic wrestlers on a daily basisto ensure they made weigh-ins; andNanna Meyer, PhD, RD, CSSD,worked closely with other sport dieti-tians to organize Olympic Village din-ing options and set up numerousstations so proper recovery nutritioncould be made available to all TeamUSA competitors regardless ofwhether they had a sport dietitian.

■ SCAN’s director of communica-tions Kim Schwabenbauer, RD,earned an amazing 4th place finish inthe Women’s Pro division at the Revo-lution 3 Triathlon in Sandusky, OH, inSeptember 2012. With a completiontime of 9 hours 41 minutes, kudos go

NotablesSCAN

to Kim for her impressive perform-ance. The race required a 2.4-mileopen water swim, 112-mile bike ride,and a full marathon.

■ In August 2012, six SCAN memberspresented at the Human Perform-ance and Dietary Supplements Sum-mit for the National Institutes ofHealth – Office of Dietary Supple-ments: Carmen Caraballo, MS, RD,CSSD; Amanda Carlson-Phillips,MS, RD, CSSD; Ellen Coleman MPH,MA, RD, CSSD; Dave Ellis, RD, CSCS;Rob Skinner, RD, CSSD; and MarieSpano, MS, RD, CSSD.

If you have an accomplishment thatyou would like to be considered for anupcoming issue of PULSE, please con-tact Sumner Brooks, MPH, RD, CSSD, [email protected].

tion of a whole food (raisins) and acommercial carbohydrate product(sports chews). Eleven endurancetrained runners (mean age 29.3 ± 7.8years) ran 80 minutes on a treadmillat 75% VO2max, followed by a 5-kmtime trial (TT) during three separateexercise trials separated by 7 to 14days. Blood lactate, heart rate (HR),respiratory exchange ratio (RER),serum free fatty acids, glycerol, in-sulin, plasma glucose, creatine kinase(CK), and rating of perceived exertion(RPE) were recorded every 20 min-utes. Gastrointestinal (GI) discomfort,whole body muscle soreness, and fa-tigue were monitored by pre- andpost-questionnaires. Participants in-gested 0 .5 g CHO/kg/body weight(BW) pre-exercise and 0.2 g

CHO/kg/BW or water every 20 min-utes of exercise in the form of eitherraisins (31 g: 100-kcal, 24 g CHO) orsports chews (3 pieces of Clif blocks,30 g: 100-kcal, 24 g CHO) or waterduring the 80-minute exercise pe-riod. Fluid intake was kept constantfor all treatments. No differences be-tween CHO sources were observedfor VO2, HR, lactate, glycerol, bloodglucose, RPE, muscle soreness, fatigueratings, or GI symptoms. TT runningtime was decreased by 1 minute forboth carbohydrate sources in thetime trial compared with water(P<.05). However, sports chews re-sulted in slightly higher insulin levelsand carbohydrate oxidation ratesduring exercise compared withraisins (P<.05). Additionally, raisins

had a greater increase in CK duringexercise compared with sports chewsand water only (P<.05). The results ofthis study indicate that a whole foodcarbohydrate source (raisins) was as-sociated with similar blood glucoseresponses and running performanceas a carbohydrate sport food. Fund-ing was supported by a grant fromthe California Raisin Marketing Board.

Summarized by Stephanie R. De Leon,MS, RD, CSSD, CDE, nutritional consult-ant in San Antonio, TX.


■ Be Sure to Vote for SCANLeadersTake an active role in how SCAN isgoverned by participating in the up-coming election for SCAN leadership.Once again, SCAN will use an elec-tronic ballot. To vote online, go to thehome page of SCAN’s Web site(www.scandpg.org) and click on thelink that says “2013 Election Ballot.”Online voting polls open February 1,2013; the final date to vote is March3, 2013.

■ Apply Now for SCAN Graduate Student Research Grant Here’s a great opportunity for gradu-ate students: SCAN will award a$2,000 grant to support the researchof a SCAN student member who iscurrently a graduate student (an RDor completing RD academic require-ments) and pursuing research in oneof SCAN’s practice areas: sports andperformance nutrition, cardiovascularhealth, wellness, and disordered eat-ing/eating disorders. The applicationdeadline is February 1, 2013 (5:00pm Central Time). For an applicationand further information, look underthe “Career & Students” tab atwww.scandpg.org.

■ SCAN’s Annual ReportAvailable OnlineYou can find SCAN’s Annual Reportfor fiscal year 2011-2012 posted onSCAN’s Web site. The report givesmembers and corporate sponsors aninside look at SCAN’s programs, initia-tives, current volunteers, budget, andmore. To access the publication, go towww.scandpg.org/about-us/annual-reports/.

■ For Your Convenience: Past PULSE Articles IndexedOnlineSCAN members are frequently refer-ring to information that appeared inpast issues of SCAN’S PULSE. If you’re

Of Further Interest

doing research or simply want to lo-cate content that appeared in anarchived issue, check out the annual“Index of Topics” posted for each yearon SCAN’s Web site. You’ll find theissue and page number for each fea-ture article (conveniently listed bypractice area), and each item in Con-ference Highlights, Reviews, andSports USA-Research Digest. You canthen instantly access the archivedissue online. As a member benefit, allPULSE issues and annual indexes areavailable to you for free at www.scan-dpg.org/nutrition-info/pulse-newsletters/.

■ SCAN’s Web Site: Your Go-To ResourceBe sure to visit SCAN’s Web site(www.scandpg.org) often and dis-cover how being a member of SCANcan enhance your career. Here’s asampling of what you’ll find:

• Ways to Stay Connected via ourMember Forums. Take advantage ofthe Members Only discussion forumsthat let you network, share, and learn.Current discussions include SportsNutrition Mentoring, and House of Del-egates Issues, as well as forums withspecific questions regarding aboutSports Nutrition, CardiovascularHealth, Wellness and Weight Manage-ment, andDisordered Eating and Eat-ing Disorders. Join the discussion atwww.scandpg.org/forum/.

• It’s Good to Know SCAN. The SCANWeb site can help you get to knowfellow members better. Send us asummary about a member on theWeb, TV, radio, or at a conference byemailing [email protected].

• New! SCAN Member Spotlight.Here’s a great way to find out whatour volunteers are up to.

• Online Continuing ProfessionalEducation (CPE). SCAN works hard

to provide interesting and valuabletopics for obtaining CPEs. Go towww.scandpg.org/cpe/ to getstarted.

• Now Available: 2012 SCAN Sym-posium Recordings. All 2012 Sym-posium workshops and presentationsare now available in the SCAN OnlineStore. If you missed this event orwant to revisit some of the talks,check out the store to obtain theserecordings.

• Natural Medicines Comprehen-sive Database. You can tap into thiscomprehensive database, availablefor free to SCAN members, and takeadvantage of a great resource for in-formation and education.

• A Handy, Updated Guide. SCAN isoffering a free updated version of 10Simple Steps to Make Good HabitsMore Delicious: The Dietitian-ApprovedGuide to Applying the 2010 DietaryGuidelines for Americans and MyPlatein 10 Simple Steps! You’ll find it in theSCAN Online Store.

■ News from Wellness/CVRDs SubunitHere’s an update on developmentsfrom the Wellness/CV RDs:

• New Fact Sheet. Be on the lookoutfor the latest Wellness/CV fact sheetabout spices. To access a research up-date specifically for RDs, as well as atraditional fact sheet to give toclients, go to www.scandpg.org/car-diovascular/cardiovascular-health-fact-sheets/. If you have an idea for afact sheet topic, please contact KarenCollins at [email protected] or Rosie Gonzalez [email protected].

• Wellness/CV at Symposium 2013.Register today for the skills-focusedSCAN Symposium, April 26-28, in


SCAN’S PULSE 2012 CPE Reviewers

The SCAN’S PULSE Editorial Board would like to acknowledge those who

served as reviewers of our continuing professional education (CPE) articles

during the 2012. Their review made it possible to offer SCAN members the

opportunity to earn a total of four free CPE units from PULSE during this

period. Our appreciation goes to:

• Michele Macedonio, MS, RD, CSSD

• Mayumi Petrisko, MS, RD, CSSD

• William Proulx, PhD, RD

• Sarah Schutzberger, RD, CSO

the new edition you’ve been waitingfor and will refer to often for specificevidenced-based sports nutrition in-formation.

• New! CSSD Online Application.The application for the Board Certi-fied Specialist in Sports Dietetics(CSSD) is now available at www.cdr-net.org/certifications/spec/newonli-neeligibilityapplication.cfm.

• 13 CSSD Exam Windows. The nextexam dates are February 4-25 (ex-cept February 18; application dead-line has passed) and July 8-26(application postmark deadline: April26, 2013). For details, go to www.cdrnet.org/.

• CSSD Recertification: Five-year re-certification is due for CSSDs certifiedin 2008. Check your certification yearand be prepared to recertify. Eligibil-ity includes documentation of 1,000hours of specialty practice experi-ence as an RD within the past 5 yearsby the application due date (effectiveuntil 2014).

• The CSSD: Qualification Matters.We now have 549 CSSDs. Accordingto the 2011 Compensation and Bene-fits Survey (J Acad Nutr Diet, January2012), CSSDs earn the highest hourlywage per patient/client responsibilityamong all those holding a CDR spe-cialist credential. Overall, RDs withCDR specialty credentials earn highercompensation than RDs without spe-cialist certification. Apply now for theCSSD credential!

• IOC Diploma in Sports Nutrition:SCAN members now qualify for a10% discount off tuition and fees. Forinformation, go to www.sportsora-cle.com/ioc/.

• Tout Your Expertise. Let athletesand clients tout your expertise by

Chicago. Some of the offerings re-lated to Wellness/CV include: 1.) Anintensive 6-hour program co-pre-sented with the National Lipid Asso-ciation, explaining how to put intopractice the soon-to-be-released ATP(Adult Treatment Panel) IV guidelineson lipid management and preparefor the lipid specialist certification. 2.)A session on nutrition counselingwith cultural sensitivity, demonstrat-ing how to talk about obesity and di-etary changes while showing respectfor the client’s cultural heritage; and3.) A presentation on reimbursementchallenges and how to successfullyhandle them. Visit www.scandpg.orgfor the latest Symposium informa-tion.

• Updated List of Foods Recom-mended by SCAN Members. Checkout the list at www.scandpg.org/nu-trition-info/nutrition-info-for-con-sumers/foods-scan-rds-reommend/.Compiled by SCAN members, this listcan save you time as you navigatenew heart-healthy products at thegrocery store. To share your latest“finds,” contact Georgia Kostas at

[email protected].

• Wellness/CV Connection. If you’retrying to find an article in the Well-ness/CV Connection e-newsletter butyou can’t remember when it waspublished, visit www.scandpg.org/cardiovascular/newsletters/.

• Advanced Cardiovascular Certifi-cations. Interested in learning moreabout advanced cardiovascular certi-fications? In conjunction with SCAN’snew agreement with the NationalLipid Association, we have addedthat information to the SCAN’s Website (www.scandpg.org) under the“Nutrition Info” tab, CardiovascularHealth Professional Resources.

■ News from Sports DieteticsUSA (SD-USA)Below are some highlights from theSD-USA subunit:

• Sport Nutrition Practice Manual—New Edition. The Academy’s SportsNutrition: A Practice Manual for Profes-sionals, 5th ed., can now be pur-chased at the Academy Shop. This is


adding the Sports Nutrition—Who Delivers? YouTube link (www.youtube.com/watch?v=Ocz7P3A2rgU) to youre-mail signature. Be sure to also up-load this video to your Web site, Facebook page, and Twitter page, andshow it before or after your presenta-tions. It’s an amazing marketing tool.

• New! SD-USA Mentoring Forum.Look for this new feature on SCAN’sWeb site that allows SCAN membersto post questions and seek resourcesand opportunities in sports nutrition.You’ll find “Sports Nutrition Mentor-ing” at www.scandpg.org/forum/.

• Follow SD-USA on Twitter @Sportsdiet USA. The goal of Sports-diet USA is to market the Sports RDto the public. If you have facts or ac-complishments and would like to beincluded in one of our Tweets, con-tact us at [email protected] volunteer for this project, contactKelly Devine Rickert [email protected].

• Be Business-Savvy—Use SportsNutrition Fact Sheets. Let these factsheets serve as your “business card”and keep you front and center. VisitSCAN’s NRG to customize SCAN’sSports Nutrition Fact Sheets withyour own business information andmessage. Go to www.scandpg.org/sports-nutrition/sports-nutrition-fact-sheets/.

• SCAN Student Corner. View the lat-est sports nutrition interview atwww.scandpg.org/careers-and-stu-dents/students-and-scan/.

• SCAN’s E-Library Offerings. Ex-plore a host of e-learning opportuni-ties available to you atwww.scandpg.org/e-library/.

• Sports Nutrition Care Manual®(SNCM). The Academy’s onlineSNCM contains research-based nutri-tion information written by authorswho are CSSDs. The price is $75 forAcademy members. Preview themanual and selected pages athttp://sports.nutritioncaremanual.org/.

• Sports Nutrition Mentor Program.Three ways to gain mentoring insports nutrition: 1) Via the Sports Nu-trition Mentoring Forum. Post yourquestions on this new forum atwww.scandpg.org/forum/, and anSD-USA mentor will answer; 2) SignUp for One-on-One Mentoring. Ifyou’re an experienced sports dieti-tian, apply to become an SD-USAmentor. The mentor/mentee applica-tion appears can be accessed on theSports Nutrition Mentor page ofSCAN’s Web site. Applications are cur-rently closed to mentees, but look forthem to reopen soon; 3) Volunteerwith SD-USA.Work alongside sea-soned RDs, help your professional or-ganization, and develop leadershipskills and contacts. Complete the vol-unteer form at www.scandpg.org/volunteer-scan/.

On the Web . . .

Go to www.scandpg.org andreap the rewards of SCAN’sinteractive, updated Web site.You’ll find many features there,including:

■ SCAN’s Blogs. Read interestingposts from various RDs on a widearray of topics.

■ Event Calendar. Check outupcoming webinars and events—fantastic opportunities for you tolearn and grow.

■ Expert Nutrition Information.Get authoritative information onthe topics of interest to you:sports nutrition, wellness andcardiovascular health, anddisordered eating and eatingdisorders.

■ Free Fact Sheets andPresentations. Enjoy free accessto materials that will inform andequip you well professionally.

■ Forums. These enlighteningdiscussions and networkingopportunities will expand yourmind and your network.

For More About SCAN’s Web Site:Find out more aboutwww.scandpg.org in this issue’s“Of Further Information” (page 21)

Find SCAN Elsewhere on the Web:

■ Follow us on Twittertwitter.com/scanutritiondpg

■ Like us on Facebookhttp://www.facebook.com/scandpg?ref=ts

■ Connect with us on LinkedIn,SCAN group

Call for AbstractorsYou can contribute to the pages of PULSE by volunteering to abstract a

recently published study on sports nutrition for PULSE’s “Sports Dietetics-USA

Research Digest.” For details on this opportunity, contact Stacie Wing-Gaia,

PhD, RD,CSSD, co-editor of “Sports Dietetics-USA Research Digest,” at

[email protected].


February 8-9, 2013Sport Nutrition Workshop: From Sci-ence to Practice, Indianapolis, IN. Forinformation: Nancy Clark, www.sport-snutritionworksop.com

March 21-24, 2013IAEDP Symposium 2013, Henderson(Las Vegas area), NV. For information:International Association of EatingDisorders Professional,www.iaedp.com

April 26-28, 2013Be sure to join your colleagues at the29th Annual SCAN Symposium,Tools and Techniques for Peak Profes-sional Performance, Chicago, IL. Formore information: www.scandpg.org

May 18, 2013Intuitive Eating 2.0 Workshop, SaltLake City, UT. For information:www.IntuitiveEatingWorkshop.org

May 28-June 1, 2013ACSM’s 59th Annual Meeting and 3rd

World Congress on Exercise is Medi-cine, Indianapolis, IN. For information:American College of Sports Medicine,www.acsmannualreport.org

July 8-26, 2013CDR Sports Dietetics Specialty Exami-nation (at various U.S. sites). Postmarkdeadline for applications is April 26,2013. For information: Commissionon Dietetic Registration: www.cdrnet.org

UpcomingEvents

PRESORT STANDARD

U.S. POSTAGE

PAID

Rockford, IL

Permit No. 2495

[email protected] viewpoints and statements hereindo not necessarily reflect policiesand/or official positions of the Academy of Nutrition and Dietetics. Opinions expressed are those of theindividual authors. Publication of anadvertisement in SCAN’S PULSE shouldnot be construed as an endorsementof the advertiser or the product by theAcademy of Nutrition and Dieteticsand/or Sports, Cardiovascular, andWellness Nutrition.

Appropriate announcements are welcome. Deadline for the Summer2013 issue: March 1, 2013. Deadlinefor the Fall 2013 issue: June 1, 2013.

Manuscripts (original research, reviewarticles, etc.) will be considered forpublication. Guidelines for authors areavailable at www.scandpg.org. E-mailmanuscript to the Editor-in-Chief;allow up to 6 weeks for a response.

Send change of address to: Academyof Nutrition and Dietetics, 120 S. River-side Plaza, Suite 2000, Chicago, IL60606-6995.

Subscriptions: For individuals not eligible for Academy of Nutrition and Dietetics membership: $50. For institu-tions: $100. To subscribe: SCAN Office,800/249-2875.

Copyright © 2013 by the Academy ofNutrition and Dietetics. All rights reserved. No part of this publicationmay be reproduced, stored in a retrieval system, or transmitted in anyform by any means, electronic, mechanical, photocopying, recording,or otherwise, without prior writtenpermission of the publisher.

SCAN’S PULSE

To contact an editor listed above, visit www.scandpg.org(click Nutrition Info tab, then “SCAN’s PULSE”)

Thrift-Remsen Printers

3918 South Central Ave.

Rockford, IL 61102-4290

Publication of the Sports, Cardiovascular, and Wellness Nutrition(SCAN) dietetic practice group of the Academy of Nutrition and Dietetics.ISSN: 1528-5707.

Editor-in-ChiefMark Kern, PhD, RD, CSSDExercise and Nutritional SciencesSan Diego State University5500 Campanile Dr.San Diego, CA 92182-7251619/594-1834 619/594-6553 - [email protected]

Sports EditorKathie Beals, PhD, RD, CSSDKristine Spence, MS, RD, CSSD

Cardiovascular EditorSatya Jonnalagadda, MBA, PhD, RD

Wellness EditorsRobert Wildman, PhD, RD, FISSNJennifer Koslo, PhD, RD, CSSD, CPT

Disordered Eating EditorsKaren Wetherall, MS, RDMichelle Barrack, PhD

Conference Highlights EditorNancy Clark, MS, RD

Reviews EditorNichole Dandrea, MS, RD

Sports Dietetics-USA Research Digest Editors

Stacie Wing-Gaia, PhD, RD, CSSDJames Stevens, MS, RD

SCAN Notables EditorSumner Brooks, MPH, RD

Managing EditorAnnette Lenzi Martin312/587-3781 312/751-0313 - fax

SCAN Winter 2013

Documents

Transcript of SCAN Winter 2013