Vol. 26 No.

November/December 2024 The Magazine for Nutrition Professionals

Artificial Intelligence
in Dietetics
RDs’ Value in
an AI-Powered
Health Care
Revolution

Medically
Tailored Meals

The Impact of New

Weight Loss Drugs
on Dietetics

The Rise of the Zero-

Waste Grocery Store WWW.TODAYSDIETITIAN.COM
Cont ents
VOLUME 26 • NUMBER 9 NOVEMBER/DECEMBER 2024

24 42
F E AT U R E S
D E PA R T M E N T S

14 The Impact of New Weight

Loss Drugs on Dietetics How
have advances in new weight loss
30 The Rise of the Zero-Waste
Grocery Store There are over
14 million tons of plastic packaging
6 Editor’s Spot

medications affected dietetics? To waste generated annually in America, 7 Ask the Expert
understand their impacts on nutrition with a signifi cant portion coming
care, Today’s Dietitian talked to weight- from food packaging. Read about 8 Fermented Foods
inclusive and weight-management how the grocery industry is adapt-
dietitians, and those in between. ing to counteract these statistics and
12 Holistic Nutrition
how RDs can contribute to a more
sustainable future.
18 Artificial Intelligence
in Dietetics AI technology is here
42 Focus on Fitness

but what does this mean for RDs

and nutrition practice? Discover how
and why dietitians are necessary to
34 CPE Monthly: Regulation
of Heavy Metals in the Food
Supply This continuing education
44 Get to Know …

46 News Bite
support the evolution of the tech- course will provide an overview of the
enhanced world of health care and scope of heavy metal contamination 48 Datebook
how to stay up to date on the latest of global food sources and strategies
innovations in the industry. to manage this public health hazard.
50 Culinary Corner

24 Medically Tailored Meals

Patients’ lives are being transformed
through the nutrition provided by
medically tailored meals. Learn
how dietitians have been vital in the
development and management of the
medically tailored meals movement to
ensure meal plans meet high nutrition
standards. 34
Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published nine times a year in Jan, Feb, Mar, Apr, May, Jun, Aug, Oct and Nov by Great Valley Publishing Company, PO Box 486, Valley Forge, PA 19481. Periodicals
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4 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

 ’tis
Seasoning for CALIFORNIA WALNUTS
THE

Add these Rosemary and Sea Salt Walnuts

to your holiday charcuterie board

INGREDIENTS
2 Tbsp Butter
2 Tbsp Fresh rosemary,
finely chopped or
2 tsp of dried rosemary
1 tsp Smoked black pepper
¾ tsp Sea salt
2 C California walnuts

PREPARATION
Preheat oven to 300°F.
Melt butter in a small saucepan.
Stir in rosemary, pepper and salt.

Add walnuts and stir well with

a rubber scraper until mixture
evenly coats walnuts.

Transfer to a baking sheet and cook

for 30 minutes, stirring every 10
minutes. Let cool completely before
adding to your board, storing the
extra in an airtight container.

For more walnut recipes and resources,

visit walnuts.org and follow us @CAWalnuts.
Editor’s Spot

Subject Matter Experts Are EXECUTIVE

Chief Executive Officer Mara E. Honicker
Critical for AI Development Chief Operating Officer Jack Graham

EDITORIAL

A
s nutrition experts uniquely positioned to coun- Editor Heather Davis, MS, RDN, LDN
Chief Editorial Advisor Sharon Palmer, MSFS, RDN
ter misinformation and misapplication of nutri-
Editorial Department Manager Dave Yeager
tion advice in the public, we Production Editor Heather Hogstrom
have our work cut out for us. Assistant Editor Chris Baldwin
The use of artificial intelligence (AI) in Editorial Assistant Josh Hildebrand
Editorial Advisory Board Toby Amidor, MS, RD, CDN, FAND;
health care settings is expanding, and Dina Aronson, MS, RDN; Constance Brown-Riggs, MSEd, RD, CDCES, CDN;
nutrition therapy and personalization Karen Collins, MS, RDN, CDN, FAND; Carrie Dennett, MPH, RDN, LD;
of nutrition guidance are increasingly Jill Weisenberger, MS, RDN, CDCES, CHWC, FAND
seen as areas ripe for AI applications. ART
However, many of the experts directly Art Director Charles Slack
involved in building the algorithms and software for Senior Graphic Designer Erin Faccenda

these platforms, including computer programmers and ADMINISTRATION

digital user specialists, may have little to no formal train- Administrative Manager/Human Resources Janet Renz
ing or credentials in nutrition science or MNT. Administrative Assistant Jennifer Mest
Executive Assistant Matt Czermanski
A couple of years ago, I was invited to consult with a Systems Manager Jeff Czermanski
team of researchers in Texas who were interested in build-
CONTINUING EDUCATION
ing a predictive algorithm for personalized nutrition
Director of Continuing Education Jack Graham
recommendations. They wanted to develop an AI-driven Director of Professional Development Leslie Cimei
program that could use blood glucose data alone to tell Senior Manager Education and Accreditation Susan Prentice
users how and what to eat. Continuing Education Coordinator Jennifer Kirkegaard
Customer Support Associate Jennifer Mest
I knew that basing nutrition recommendations on Program Planner Ginger Hultin, MS, RDN
raw glucose data alone was unlikely to yield appropriate
CIRCULATION
treatment conclusions. For example, I knew that
Circulation Director Susan Wood
elevations in glucose levels could be caused by many
things, including dozens of different meal patterns, MARKETING AND ADVERTISING
Publisher Mara E. Honicker
foods, or fasting (via activation of the stress response); Associate Publisher Peter J. Burke
certain types and durations of physical activity; and Director of Marketing and Digital Media Tim Rinda
even watching a scary movie. Furthermore, I knew Web Designer Jessica McGurk
Junior Digital Designer Emma Connolly
that individualized dietary recommendations needed
Email Marketing Coordinator Alexis Manduke
to appreciate far more than raw glucose data points to Social Media Associate Nicole Pratt
accomplish the goal of improving health and reducing Director of Events and Sponsorships Gigi Grillot
disease risk. I shared this feedback with the researchers Manager of Events and Sponsorships Brittany Collins
Director of Sales Brian Ohl
who told me they hadn’t considered any of these points Senior Account Executives Diana Kempster,
before our conversation. Brian Sheerin, Beth VanOstenbridge
RDs are essential for quality AI-driven nutrition
FOUNDER EMERITUS
program development. We offer valuable feedback to Kathleen Czermanski
the developer teams. Having an RD (or several) on the
development team can make the difference between
© 2024 Great Valley Publishing Company
producing a dangerous gimmick vs a legitimate health-
improvement tool. Phone: 610-948-9500
Editorial e-mail: [email protected]
In this month’s issue, Today’s Dietitian features the arti-
Sales e-mail: [email protected]
cle, “Artificial Intelligence in Dietetics.” In it, we discuss Website: www.TodaysDietitian.com
the rapidly developing world of AI and its use in health Subscription e-mail: [email protected]
care settings, including nutrition care and how RDs can Ad fax: 610-948-4202 Ad artwork e-mail: [email protected]

establish their high value in that arena. All content contained in Today’s Dietitian represents the opinions of the authors, not
those of Great Valley Publishing Company (“GVP”) or any organizations with which
Also in this issue are articles on how new-generation the authors may be affiliated. GVP and its employees and agents do not assume
weight loss drugs are impacting dietetics, medically tai- responsibility for opinions expressed by the authors or individuals quoted in the
magazine; for the accuracy of material submitted by authors or advertisers; or for
lored meals, and the rise of zero-waste retailers and the any injury to persons or property resulting from reference to ideas or products
discussed in the editorial copy or the advertisements.
challenges they face.
All content contained in Today’s Dietitian is created for informational purposes only and
I hope you enjoy this month’s edition! shall not be construed to diagnose, cure, or treat any medical, health, or other condition.
Moreover, the content in Today’s Dietitian is no substitute for individual patient/client
assessment based upon the professional’s examination of each patient/client and
— Heather Davis, MS, RDN, LDN consideration of laboratory data and other factors unique to the patient/client.
[email protected] CONTENT CONTAINED IN TODAY’S DIETITIAN SHALL NOT BE CONSTRUED TO
CONSTITUTE PROFESSIONAL MEDICAL, HEALTH, LEGAL, TAX, OR FINANCIAL ADVICE.

6 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

Ask the Expert By Toby Amidor, MS, RD, CDN, FAND

Certified Health Coaches

Understanding and Collaborating With This Key
Role on the Care Team RD and Health Coaches
Collaboration

Q I have been seeing more health

coaches promote services. Can
you explain what a certified health coach
coaching provides hands-on practice ses-
sions with personalized feedback in live
coaching labs from faculty.
The role of a certified health coach and
RD go hand-in-hand. By working together,
RDs and health coaches can enhance
does and the benefits of an RD becom- In addition, according to the NBHWC overall patient care and experience. Sev-
ing or working with a health coach? code of ethics, a certified coach must eral recommendations on how RDs can
A: Certified health coaches differ from accurately identify their coaching quali- collaborate with certified health coaches
RDs in their standards of education, cer- fications, expertise, experience, training, include the following:
tifications, and scope of practice. Certi- certifications, and NBHWC credentials.3
fied health coaches are prohibited from In addition, they must “Disclose to all cli- • becoming familiar with certified health
diagnosing and treating nutritional ents the exact nature of the coach’s role coaches and their scope of practice;
issues. However, some RDs are certified within the company or organization and • building a network of certified health
as health coaches or work alongside RDs the limitations and expectations thereof.”3 coaches with reputable credentials and
in practice. Below you will find informa- experience; and
tion defining a certified health coach, the A Health Coach vs an RD • communicating with the client’s
difference between an RD and a certified RDs must complete a bachelor’s degree coaches to discuss progress, chal-
health coach, and how RDs can utilize a in nutrition or a related field and as of lenges, and any changes in recommen-
health coach in practice. January 1, 2024, they also need a master’s dations or goals.
degree to be eligible to take the credential-
What’s a Certified Health Coach? ing exam. RDs can diagnose and/or treat According to Piper, “The RD can rely on the
“RDs and health coaches differ in their a medical condition and provide MNT, health coach to help their client meet their
education, certification, and scope of while certified health coaches cannot goals, while the health coach can refer to
practice,” explains Kathryn Piper, RDN, diagnose or treat nutritional issues. the RD for specialized nutrition educa-
LD, NBC-HWC, owner of The Age-Defying MNT is a systematic process that tion.” Piper feels that as a previous outpa-
Dietitian. Certified health coaches have consists of performing nutrition diag- tient diabetes education dietitian, it would
diverse educational backgrounds, and a nosis, therapy, and counseling services have been helpful to have a health coach
college degree isn’t required. In addition, for the purpose of disease management, work with the client after initial RD edu-
coaching certification programs vary while health coaching is advice.1 Health cation sessions. “Collaboration between
in length and rigor, and certified health coaches rely on the diagnoses of phy- RDs and health coaches enhances care by
coaches focus on minute details to help sicians and/or RDs and then use their combining clinical expertise with behavior
with behavior changes that an RD may rec- expert knowledge to advise patients change support.” I
ommend to the client. They also focus on about the best way to manage their health
overall wellness. This means that they pro- issues. In addition, health coaches don’t Toby Amidor, MS, RD,
vide general nutrition advice and lifestyle prescribe a specific course of action but CDN, FAND, is founder
recommendations. According to an article make suggestions and provide informa- of Toby Amidor Nutrition
published in the Journal of the Academy of tion and motivation. It’s up to the patient (tobyamidornutrition.
Nutrition and Dietetics, “Health coaching to decide whether they choose to adhere com) and a Wall Street
consists of providing advice to clients in to the coach’s advice. Dietetics profes- Journal bestselling
order to help them learn to develop more sionals can pursue a career in health author. She’s written 11
healthful behaviors on their own.”1 coaching or bring on a health coach but cookbooks, including
According to the National Board should be familiar with the differences. Health Shots: 50 Simple Tonics to Help Improve
for Health and Wellness Coaching Piper has worked in a telephonic health Immunity, Ease Anxiety, Boost Energy, and
(NBHWC), which merged with The coach role for about two years and her More. She’s also an award-winning media
International Sports Sciences Associa- employer offered a health coach exam dietitian, spokesperson, and nutrition expert
tion, this certificate consists of three training program as part of their initiative for FoodNetwork.com, and a contributor
months of online training and is led by to certify all their coaching staff. As an to U.S. News and other national outlets.
experienced instructors and the inter- RD, Piper took the health coach exam and
active program provides a cohort-based is a National Board Certified Health and
learning experience.2 The program Wellness Coach, explaining, “My educa- For references, view this article on our
helps develop essential communication tion and training as an RD aligned well website at www.TodaysDietitian.com.
skills, learn effective goal setting and with the role of a health coach. The certi- Send your questions to Ask the Expert at
action-planning techniques, and explore fication added another layer of coaching [email protected]
healthful lifestyle practices and behavior strategies that helped marry the RD and or send a tweet to @tobyamidor.
change strategies. The client-centered coaching role together.”

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 7

Fermented Foods By Michelle Dudash, RDN

African Fermented Food Staples

Discover the Complex and Diverse World of African Dishes

W
hen you hear the term “fer- candidate at American University School introduces beneficial components, like
mented,” foods and bever- of Communication. microorganisms that nourish the gut.
ages like pickles, sauerkraut, “African fermented foods have been a “Fermented foods are packed with ben-
kombucha, and kimchee cornerstone of our diets for centuries, serv- eficial bacteria and nutrients that support
may immediately come to mind. A lesser- ing not just as nourishment but as a vital gut health, which are increasingly recog-
known treasure that has been a staple for part of our cultural identity and commu- nized as essential for overall well-being,”
centuries across Africa is gaining attention nity practices,” Stevenson explains. Since Stevenson says.
in research and on kitchen tables in the the base ingredients of African fermented The fermentation of traditional African
United States: African fermented foods. foods are whole foods like vegetables, foods may produce strains from the gen-
If you’ve ever stepped inside an Ethio- grains, and dairy, they are inherently nutri- era of Lactobacillus, Streptococcus, Leuco-
pian restaurant and scooped up stew with tious, contributing a wide variety of nutri- nostoc, and Pediococcus, among others.
a piece of thin, bubbly flatbread with your ents, which may include B vitamins, amino Fermentation also helps remove antinu-
bare hands, you’ve tasted injera, an Afri- acids, and beta carotene.1 Beyond injera, tritional compounds, like phytates, tan-
can fermented food. discover the world of African fermented nins, lectins, saponins, and oxalate, and
“African fermented foods are still a foods, from dairy to legumes to tubers. even toxins, like hydrogen cyanide. Some
staple in Africa, as well as in the United fermented foods contain prebiotics, as well.
States for African descendants,” accord- African Fermented Foods as It’s important to note that research-
ing to Tambra Ray Stevenson, founder of Functional Foods ers use the word “probiotics” cautiously
WANDA: Women Advancing Nutrition, In addition to improving the shelf life since the microorganisms in these fer-
Dietetics, and Agriculture, and a PhD of foods, the process of fermentation mented foods don’t necessarily match the

8 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

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Fermented Foods

criteria used to define probiotics. More Additionally, according to Stevenson, fermented dairy beverages include
research needs to be done. In the mean- “In many African households, foods like mabisi (amasi), amabere amaruranu,
time, “Potential health-promoting micro- fermented maize, millet, and cassava are and fura de nono (millet and milk).4
organisms” may be a more careful way to still prepared using traditional methods Furthermore, Oldways’ African Heri-
explain these benefits. passed down through generations.” tage Diet includes buttermilk and
Stevenson points out that some major yogurt in the dairy group.5
Traditional African Fermented Foods supermarkets are beginning to stock • Fermented Tubers: In addition to gari
Stevenson, who is a fifth-generation Okla- these foods, especially in areas with a made from cassava (also known as
homan with roots in Nigeria, now lives in larger African diaspora, which is defined yuca or manioc), other commonly fer-
Washington, D.C., and shares her favorite as the voluntary and involuntary move- mented tubers include yams and sweet
fermented foods that are also important ment of Africans and their descendants to potatoes.
African food staples: various parts of the world during the mod- • Grain-Based Fermented Beverages:
ern and premodern periods.3 Bushera, shamita, munkoyo, and
• Injera: Stevenson loves this sour- mahewu.6
dough flatbread for its unique Additional African Fermented • Alcoholic Beverages: Enjoyed in South-
tangy flavor and versatility. Injera Food Mainstays ern Africa, burukutu is brewed from
is made from teff flour, an ancient the grains of Guinean corn (sorghum
grain originating from Ethiopia and • Fermented Legumes: These important biocolor) and millet. Beers include chi-
Eritrea. 2 Teff is naturally gluten-free sources of protein become more bio- buku and umqombothi.
and contains protein, fiber, iron, available after fermentation, helping
calcium, and magnesium. At res- battle malnutrition. Oftentimes these Commercial African Fermented Foods
taurants, however, Stevenson says foods are produced as condiments and in the United States
it’s important for gluten-avoiding specific varieties include iru, tempeh, In Africa, the majority of traditional fer-
guests to ask if the injera is made soumbala, ugba, ogiri, and siljo, from mented foods are made by women and
from teff or wheat. “I love the way fava bean flour. locally, since an extended shelf life of these
these foods connect me to my roots • Fermented Dairy Products: Fermenting foods can be challenging. Some entrepre-
and keep me grounded in my heri- milk produces a variety of products, neurs in the United States, however, are
tage,” Stevenson says, who loves including nunu, wara, fene, suusac, and getting creative in the African food space.
to pair injera with chickpea stew pendidam. Leben (or iben or leban) is For instance, “Pikliz is probably the
(shira). Stevenson says that she has a liquid or semisolid food made from most quintessential representation of
prepared injera at home because she curdled milk and enjoyed as a beverage any food brought to the US from Africa,”
enjoys the process and it’s a staple in in North Africa. Typically, new batches claims Alexandra Baker, cofounder of In
her household. She also appreciates of these foods are produced using a the Kitchen with Alexandra (@mypikliz).
how injera can be found prepack- starter culture from a previous batch. “Even if they don’t call it pikliz in West
aged at many international or Afri- The result is a food containing a pleth- Africa, it’s pikliz.” After Baker handed out
can markets, plus some specialty ora of nutritionally beneficial strains of jars of her homemade pikliz to colleagues
stores in the United States. “Making bacteria with a longer shelf life. Other at the Home Shopping Network, people
injera is a three-day process, where
teff flour is allowed to rise and then
poured onto a hot plate in a circular
motion,” Stevenson explains.
• Gari (fermented cassava root tuber):
“Gari reminds me of home,” Stevenson
recalls, “where you can pick it up with
a green leaf or swallow with stew or
soup.” This West African staple can be
eaten as a porridge or used as a base in
dishes like eba.
• Ogi (also called pap, from maize, sor-
ghum, or millet): This fermented cereal
pudding is common in Nigeria. “It’s
often eaten for breakfast and pairs well
with akara (bean cakes) or moi moi
(steamed, flan-like bean pudding),”
Stevenson says.
• Uji (fermented millet or sorghum): This
breakfast porridge has East African
roots and may be paired with fruits or
nuts for added nutrition.

10 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

 Get the Buzz
asked how they could buy more. That’s when she realized it
was really hard to find pikliz at stores. If they did find pikliz, on New Zealand
the taste didn’t come close to hers. Traditionally, pikliz is a
fermented and pickled slaw composed largely of sweet and hot Mānuka Honey
peppers, carrots, and cabbage. Pikliz in Haiti is a product of the
African diaspora.
A Functional Food with 2000+
Baker explains, “West African slaves were brought to Haiti Bioactive Components1
and were given the name of their owners, who were sugar cane
farmers.” Since 1713, her family has carried the name Rumain, 30+ years of research has shown
being 59% West African, of which the majority is of Nigerian ingesting mānuka honey may help
descent. Baker brought the product to market in 2022, selling it with health conditions
online and on television, and now has plans to bring it to retail including
chains. Different from traditional pikliz, Baker’s pikliz is a rel-
ish containing finely diced vegetables, rather than kraut-style
shapes, and contains no added sugar. Vinegar, lime, garlic, and
salt are added to the fresh vegetables, which are then lightly
pasteurized for one minute. “As soon as the jar is sealed, the fer-
mentation process begins,” Baker explains. “Within five days
to two to three weeks, the pikliz ferments and the microorgan- IMMUNE S O OT H I N G
SUPPORT S O R E T H R OAT S
isms appear and start to do their job.”
Other commercially available African fermented foods
include gari and fufu. According to Stevenson, gari is widely
available premade in grocery stores. While fufu (fermented
cassava or plantain mash) is available in Ghanaian restau-
rants, like in Washington, D.C., and in the freezer section in
GUT CO U G H
some grocery stores. H E A LT H RELIEF

Getting Acquainted With African Fermented Foods Look for mānuka honey labeled with the
If you or your clients are trying African fermented foods for the UMF™ mark to ensure authenticity and purity
first time, you can begin by keeping it straightforward.
“Start with a dish that’s simple yet authentic,” Stevenson sug-
gests. “For example, trying injera with a mild lentil stew is a great Register* for the Mānuka Mastery
way to ease into the flavors.” RDs or their clients can also try vis- Course to enter to Win a Mānuka
iting African restaurants and international grocery markets. Honey Discovery Box
Stevenson recommends experimenting further by
adding gari to smoothies or sprinkling it over salads as a
crunchy topping. *Enter by subscribing
Baker shares that she loves spooning her Alexandra’s to receive course modules
Pikliz onto eggs and sandwiches, using it to tenderize and at the QR code by
marinate steaks, and mixing it with olive oil and lime juice 12/31/24
for dressing salads.
Dietitians may have a range of clientele. “Think about that
grandma who enjoys eating her soup and fufu,” Stevenson
advises. “Incorporating these foods helps with patient com-
pliance and dietitians can be better equipped to help their
patients accomplish health care outcomes.”
Adding just one or two new foods to your list of favorites
may open your eyes to a whole new-to-you world of delicious
and nutritious foods to enjoy! I

Michelle Dudash, RDN, is a Cordon Bleu–certified chef; author of

Clean Eating Kitchen: The Low-Carb Mediterranean Cookbook
(Fair Winds Press, 2021), and creator of Spicekick® Seasoning Mix,
a line of gluten-free, no-added-sugar seasoning mixes. Follow her
at @michelledudash.
SCAN TO
REGISTER
For references, view this article on our 1. Wang S, Qiu Y, Zhu F. An updated review of functional ingredients of Manuka
website at www.TodaysDietitian.com. honey and their value-added innovations. Food Chem. 2024 May 15;440:138060.

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 11

Holistic Nutrition By Alexandria Hardy, RDN, LDN

coriander, which are the seeds of the same

plant. Spices and herbs may have different
smells, tastes, and flavors, though herbs
tend to have a higher or more concen-
trated dose of health-boosting benefits.2

Global Varieties
Nearly all of the recognizable herbs and
spices that are used today come from the
Middle East, Asia, and the Mediterranean;
many have been in use since ancient
times.1 Basil, oregano, and rosemary are
staples in Italian cuisine, perfect for pasta
sauces and pizzas. Thyme, mint, and
parsley are common in Mediterranean
dishes like tabbouleh and hummus.
Ginger, turmeric, and coriander are
essential in many Asian recipes, from
curries to stir-fries. Cinnamon and
cardamom are originally found in the
Indian subcontinent and can be used in
both sweet and savory preparations, from
chai to rubs and biryani.

Harvesting and Preservation

Fresh herbs can be picked from the garden
or purchased from local markets. For the
best flavor, select bunches that are vivid in
appearance with aromatic leaves. To pre-
serve freshness, it’s best to store herbs in
the refrigerator or dry them for long-term
use. Spices should be kept in a cool, dark
place to maintain potency.

Medical Impact

Herbs and Spices’ Herbs and spices aren’t just flavor enhanc-
ers; they’re also packed with phytochemi-
cals—natural compounds found in plants
Metabolic Impact that have various health benefits. These
phytochemicals have in vitro antioxi-
The Power of Culinary Doses in Everyday Cooking dant, anti-inflammatory, and antimicro-
bial properties and are increasingly being

H
erbs and spices have been used sprinkle of cinnamon in a cup of coffee or a studied for their in vivo health impact.1,3
for centuries to enhance the dash of oregano in pasta sauce, herbs and In addition to their medicinal uses, they
flavor, aroma, texture, and spices can elevate the taste of the ingredi- also have been used historically as food
overall experience of food. ents they’re combined with. In addition, preservatives.1
They can transform a simple dish into each individual herb and spice boasts a
something extraordinary, making them distinctive flavor that can vary depending What Is a Culinary Dose?
essential ingredients in every kitchen. But on whether they’re fresh or dried. When discussing using herbs and spices
did you know they can also impart health Herbs and spices are the aromatic, in cooking, it’s essential to understand
benefits? This article explores the unique fresh, dried, or processed leaves and what a culinary dose is. A culinary dose
healthful attributes herbs and spices flowers of herbaceous plants. Techni- refers to the amount of herbs or spices
bring to the plate when consumed in a cally speaking, herbs are classified as the typically used in food preparation when
culinary dose. fresh part of the plant (think leaves), while considering the average American
spices are considered the dried, aromatic eating habits. Including herbs and spices
Diversify Dishes and Beverages portion of the plant (stalk, root, seeds, in a meal can improve postprandial
Adding herbs and spices to meals can and fruits).1 This is why a grocery store metabolic responses, especially as they
enhance food and drink thanks to their might sell fresh bundles of cilantro (typi- relate to CVD, glycemic control, and
unique flavor profiles. Whether it’s a cally the leaves and stalk) but jars of dried oxidative stress.4

12 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

 In a study published in the American total cholesterol, triglycerides, and Some of the samples are also extremely
Journal of Clinical Nutrition, a low-dose LDL, with an increase in HDL levels.8 concentrated extract forms, which aren’t
diet (also defined as low spice) was defined Although it didn’t affect postprandial widely utilized in home cooking; there’s
as 0.5 g/d, a moderate dose was defined as blood sugar, ginger decreased markers also a prevalence of dried, ground herbs
3.3 g/d, and a high dose was defined as of insulin resistance and inflammation, and spices studied as opposed to fresh.
6.6 g/d; all were based on 2,100 kcal diet.4 such as C-reactive protein and prosta- Finally, the most widely studied popula-
In teaspoons, this equates to the following: glandin.9 Ginger has also been shown to tions are adults with acute or chronic ill-
reduce thyroid symptoms and improve nesses, which can make the findings more
• low dose: a pinch to ¼ tsp; various domains of well-being, including difficult to generalize and disseminate to
• medium dose: ½ to 1 tsp; and weight gain, cold intolerance, and con- a broader population.
• high dose: more than 1 tsp. centration issues.5
Meanwhile, cardamom was found to Future Research and Challenges
Culinary Dose and Disease Risk improve fatty liver grades, blood glucose Future research should explore the
Herbs and spices can positively affect sev- levels, and lipid profiles.5,10,11 However, impact of herbs and spices on the gut
eral health conditions when consumed it didn’t significantly affect BMI, total microbiota, as early studies suggest
at culinary doses, particularly metabolic cholesterol, or fasting blood glucose.5,12 that herbs and spices can influence the
syndrome (MetS). MetS is a cluster of con- The use of cardamom also resulted in gut microbiome and potentially lead to
ditions that increase the risk of heart dis- a reduction in C-reactive protein and improved health outcomes. Many results
ease, stroke, and type 2 diabetes. systolic blood pressure, along with an are also dose dependent, which indicate
A comprehensive search of the increase in serum nitric oxide. There were that more research is necessary to deter-
PubMed, Scopus, and Google Scholar no changes observed in serum ADMA mine the most efficacious dose as well as
databases was conducted to evaluate the (a potential marker of CVD) or diastolic education on how to implement that dose.
existing clinical evidence on the use of blood pressure.5 One of the main challenges dietitians
culinary doses of commonly used herbs may face when discussing culinary doses
and spices.5 The review focused on trials Incorporating Into the ‘Standard of herbs and spices with their clients is
that assessed health outcomes related to American Diet’ a lack of confidence. Clinicians may not
metabolic disorders in both healthy indi- Incorporating herbs and spices into the receive adequate culinary medicine train-
viduals and those with MetS or related standard American diet can be easy and ing in their internships or on the job,
conditions. From an initial pool of 1,738 delicious. Here are some practical tips to which could lead to feelings of not being
papers, 142 relevant studies were identi- encourage clients to boost their intake of appropriately prepared.13 They may also
fied that investigated the effects of black herbs and spices to an appropriate culi- need to coordinate care with other mem-
pepper, chili, cardamom, cinnamon, cori- nary dose, which is roughly 1 tsp dried bers of the interdisciplinary team to deter-
ander, cumin, fennel, fenugreek, garlic, herb or spice or 1 T fresh herbs. The gen- mine the potential effects of a culinary
ginger, nigella seed, rosemary, sage, and eral rule of thumb for converting or sub- dose on medications.
turmeric.5 Some of the most potent and stituting dried herbs for fresh is a 1:3 ratio.
promising herbs and spices in terms of For example, if you’re planning to use 1 Bottom Line
medicinal benefits postreview include tsp dried basil, you would need 1 T of fresh Herbs and spices are more than just flavor
cinnamon, ginger, and cardamom.5,6 basil to impart the same benefits. enhancers—they’re packed with health
In a series of studies, cinnamon benefits. By developing an understand-
didn’t significantly affect glycemic or • Breakfast: Add a teaspoon of ground ing of what culinary doses are and how to
inflammatory markers overall. However, cinnamon and ginger to oatmeal, incorporate them into meals, dietitians
it did improve menstrual cyclicality baked goods, or smoothies for a sweet, can empower their clients to diversify
to a degree similar to metformin and spicy kick. their diets and support their overall health
increased serum antioxidant capacity.5,7 • Lunch: Sprinkle 1 to 2 T of oregano and in a low-cost way that yields big results.13
In people with poorly controlled type 2 basil on salads, pasta, or sandwiches. From improving glycemic control to
diabetes, 2 g of cinnamon daily reduced • Dinner: Use a teaspoon of ground garlic, enhancing cardiometabolic health, the
HbA1c, systolic blood pressure, and rosemary, and thyme to season roasted phytochemicals in herbs and spices make
diastolic blood pressure, although fasting vegetables or meats. them a valuable addition to any kitchen.
blood glucose remained unchanged.5 • Snacks: Mix ½ to 1 tsp of turmeric Keep experimenting with different combi-
In addition, cinnamon improved lipid and black pepper into hummus or nations and enjoy the delicious results! I
profiles by reducing total cholesterol and yogurt dips.
LDL while increasing HDL levels.5 Alexandria Hardy, RDN, LDN, is a nutrition
Ginger supplementation has been Study Limitations educator and the owner of Pennsylvania
shown to offer several health benefits. While research on the health benefits of Nutrition Services, an insurance-based private
It led to significant reductions in body herbs and spices is promising, there are practice located in Lancaster, Pennsylvania.
weight, BMI, waist circumference, and some limitations. Studies often focus on
appetite. It also improved fasting blood the effects of single herbs or spices instead For references, view this article on our
glucose, insulin levels, insulin sensitiv- of examining spice blends, which many website at www.TodaysDietitian.com.
ity, and lipid profiles, including lower individuals might use when cooking.

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 13

 The
Impact of New
Weıght Loss Drugs
on Dıetetics By Carrie Dennett, MPH, RDN

It’s
diet and lifestyle habits because they’re
been less than four years since the first no longer experiencing uncontrollable
glucagonlike peptide-1 (GLP-1) recep- hunger and food noise. “The GLP-1s
remove obstacles. They’re a phenom-
tor agonist medication was approved for enal tool for the right person.”
use for weight loss. Today, these medica-
tions—which include semaglutide (Ozempic and Wegovy), Food Noise and Food
Relationships
liraglutide (Saxenda), and tirzepatide (Mounjaro and Zep- Quieting “food noise” is one commonly
bound)—are an inescapable part of public discourse. But cited benefit of GLP-1s,1,2 although
not all dietitians agree about what
how are they impacting dietetics practice? Today’s Dietitian that means. Colleen Tewksbury, PhD,
talked to weight-inclusive dietitians, weight-management RD, CSOWM, an assistant professor
of nutrition at Penn Nursing in
dietitians, and those who are somewhere in between. Philadelphia, describes it as, “They
no longer feel as though their body
Julia Lloyd, MPH, RD, LDN, CDCES, counseling sessions, and mostly dia- is screaming at them to eat or crave
senior dietitian for the Center for betes and MNT. Now my schedule is higher calorie foods, nor do they find
Weight Management and Wellness at 85% weight management.” However, themselves constantly thinking about
Brigham and Women’s Hospital in she says many of her patients are food, all of which are common reports
Boston, says the surge in GLP-1 use is referred for weight loss when the real in behavioral weight loss.”
continually changing the weight man- issue is often that they have a lack of Melissa Majumdar, MS, RD,
agement landscape. For example, she knowledge about how to manage their CSOWM, LDN, metabolic and bariat-
says many of her patients are opting to health condition. ric coordinator at Emory Healthcare
try one of the new weight loss medica- Not every person who is taking a in Atlanta, says many of her patients
tions before considering surgery, often GLP-1 medication for weight loss con- have a challenging relationship with
due to a perception that surgery will sults with a dietitian, but for those who food and their bodies, and regulating
result in complications. do, many are also open to making diet hunger can take the pressure off food
Clara Nosek, MS, RD, an outpa- and lifestyle changes. Lauren Harris- decisions. “Weight loss is one of the
tient dietitian in Modesto, California, Pincus, MS, RDN, Basking Ridge, New more challenging goals we can embark
says she began seeing an immedi- Jersey-based founder of NutritionStar- on, and using tools that can support
ate uptick in patients prescribed ringYOU.com and nutrition advisor for efforts just makes sense,” she says.
GLP-1s for weight loss when they Ro, which prescribes GLP-1s, says she Lloyd says one patient told her,
became approved for that use. “Prior finds that her clients taking a GLP-1 “‘I no longer feel like a prisoner in
to that, my days were a couple GLP-1 are more capable of adopting positive my own mind.’ Previously, food was

14 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

What’s changed
for weight-
inclusive
and weight
management
dietitians?

constantly at the forefront of their on the Brooklyn, New York-based

mind due to insatiable hunger or other side Shana Minei Spence, MS,
obsessive worry that a meal or food of stop- RDN, CDN, author of Live
would lead to weight gain.” ping. “There’s Nourished: Make Peace With
On the flip side, Abby Chan, MS, unfinished Food, Banish Body Shame,
RDN, RYT, co-owner and nutrition work with their and Reclaim Joy, says with
director of EVOLVE Flagstaff in Ari- relationship many celebrities nonchalantly tak-
zona, says food noise also decreases with food that ing GLP-1s, she’s seen more people
when dietitians help clients eat really didn’t get wanting to try the medication to
enough food, then create more per- tended to, it was just get “reunion ready” or “swimsuit
mission around these foods. She says masked by this medi- ready”—so more for vanity than for
using GLP-1s to reduce hunger and cation. Plus, not know- a health concern. “I am not shaming
appetite can give people false confi- ing if they’re going to gain anyone for wanting to use medications
dence that they’ve healed their rela- weight, and blaming themselves if they because I do believe in body autonomy.
tionship with food, even without the are gaining weight, is a lot to navigate.” I just believe that if we didn’t live in a
medication. “Once they do get off, it Nicole Patience, MS, RD, CDE, fatphobic and capitalist society, there
becomes this tidal wave back into the CEDRD, a diabetes and eating disorder wouldn’t be a strong desire to try these
out-of-control feeling around food, specialist who provides weight-inclu- medications for weight loss.”
feeling like it’s always on your mind, sive care at Joslin Diabetes Center and
and feeling hungry all the time,” CNC360, both in the Boston area, says Stigma and Shame
she says, noting that some of this is someone who uses food to manage Chan says that, as a weight-inclusive
due to the body’s response to caloric emotions then loses their appetite on dietitian, she’s found the overall influx
restriction while on the drug. a GLP-1 might not have other tools to of GLP-1s both interesting and challeng-
Kimmie Singh, MS, RD, owner of rely on. “Because eating disorders are ing, in part because of some of the rheto-
Body Honor Nutrition in New York City, oftentimes born out of a desire to feel ric around them, including co-opting of
has worked with several clients who protected and self-guard against other antiweight stigma language. For exam-
stopped, or wanted to stop, taking GLP- things, I like to make sure that other ple, taking the message that weight isn’t
1s, often because of side effects, and maladaptive coping behaviors don’t a personal choice and turning it into,
some experienced a deep fear of what’s start to emerge.” “It’s ‘not your fault’ that you exist in this

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 15

body and we have this great medication we drugs do and don’t do, the possible side ramifications of inadequate intake of
can offer you to ‘fix’ that.” Culturally, she effects, and what happens if they take the calories, protein, and other nutrients.
says it’s disappointing to see a return to drug and then later go off it.3,4 Chan says one of her biggest concerns
“the thinner you are the better” messages. As part of some research she’s doing, about GLP-1s is related to loss of muscle
“It really did seem like socially we were hav- Tewksbury is finding, anecdotally, that and bone mass,6,7 especially when they’re
ing a little bit of backlash to that. Unfortu- some patients do their own research before recommended to perimenopausal and
nately, I feel like we’re just backtracking in asking their provider about GLP-1s, while menopausal women. “We lose about 1% of
so many ways because of these drugs.” others say their doctor broached the sub- muscle mass per year, theoretically, after
Singh says witnessing celebrities, ject. “I have not come across anyone who the age of 30. That tissue is important not
friends, and coworkers “shrinking or get- has been prescribed these medications only from a metabolic rate standpoint but
ting smaller,” has made some clients start and did not have a full conversation with also from the standpoint of your longevity,
fantasizing about how their life might look their provider nor seek out the information your quality of life, your overall risk of fall-
different if they were thin, despite doing themselves.” While Lloyd says her patients ing. If we have decreased muscle mass and
significant work on body acceptance. meet with multiple clinicians and are fully also have compromised bone density, that
“Sometimes as a dietitian that’s great for us informed about these medications, other becomes a more compounding issue.”
to explore, because some of that stuff might dietitians find that the responsibility for Lloyd says when side effects cause
have already been going on under the sur- delivering education falls on them, in large chronic inadequate intake, most patients
face.” She says some clients have also felt part because of how little time most physi- reach out to her for guidance. “On the rare
conflicted about not being aligned with cians have with their patients. occasions when someone is under the
their values around rejecting diet culture, “In my experience, our health care sys- impression that minimal intake is benefi-
plus shame for being curious about weight tem does not allow physicians the time cial, I thoroughly review how all weight
loss. “That’s something we’ll talk about a necessary to educate patients appropri- loss is not ‘good’ weight loss,” she says,
lot, that shame on top of shame, and I try to ately and fully on all aspects of risks, ben- adding that her goal for her patients is
really emphasize that it’s understandable efits, and strategies for taking a GLP-1,” not just to lose fat but also to preserve or
to want thin privilege.” Harris-Pincus says. “There’s zero time, increase lean muscle mass.
Chan says the prevalence of weight potentially not full knowledge, and defi- Harris-Pincus says she works with her
stigma and antifat bias in society means nitely not the skill set when it comes to clients closely to make sure that their dose
some patients and clients in larger bodies nutrition.” Nosek says at her hospital, it’s isn’t so high that they physically can’t eat
may see the medications as an escape from left to the dietitians to explain to patients much. “The goal isn’t just to lower the num-
that oppression. “As a provider who has thin how the drug works, as well as how much ber on the scale. So that’s where we come in
privilege and who doesn’t have that lived they should be eating and exercising. “The and talk about the importance of nutrients
experience, I can’t tell someone what to do doctors don’t have time to go over all of and food. Simply eating less of nutrient-
with their body,” she says. “Outside of food, that. I think that’s a product of the system poor foods is going to result in a lower body
water, and shelter, one of the most impor- of health care in general.” weight, but it may compromise health.”
tant human needs is validation and fitting Nosek says she has some older patients
in, and I think that needs to be a conversa- Protein, Muscle, and Malnutrition who want to eat as little as possible while
tion. If someone does go on these medica- While many dietitians have long had to taking a GLP-1, so she explains metabolic
tions, as weight-inclusive dietitians, how do screen for malnutrition in their patient adaptation and how much energy it takes
we hold that nuance and understand that population, the increased use of this new to build muscle. “Then I talk about how it
people get to have a choice and our role is to generation of weight loss medications has doesn’t matter how skinny you are if you
take the harm reductionist approach and brought these concerns to the forefront can’t get up off the toilet. And what hap-
ensure that they are taking care of them- for a broader range of dietitians, includ- pens if you fall? Will you be able to get up?
selves physically, mentally, and emotionally ing those in private practice. In some Will you be able to heal properly? Do you
in the most compassionate way?” cases, patients may have gastrointestinal have enough bone density? If you’re only
side effects5 such as nausea and con- focused on the number on the scale, these
Ensuring Informed Consent stipation severe enough that adequate are the things that you’re missing.”
Part of a harm-reduction approach means food intake is impossible. Other patients Patience has seen drug-seeking behav-
ensuring that patients and clients are might lean into the drug’s appetite- ior in some clients who have lost weight
making a fully informed decision about suppressing effects and decide that less but aren’t eating enough, making contin-
whether to take a weight loss medication. food is better. Either way, dietitians are ued use of a GLP-1 inappropriate. “The
That includes understanding what the working to prevent the possible health absolute anger, resentment of not having

“It’s dangerous to glorify or villainize these medications

and to generalize them as either ‘good’ or ‘ bad,’ just like it’s
dangerous for us to classify food, weight, and BMI in this way.”
— Julia Lloyd, MPH, RD, LDN, CDCES

16 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

 access to that medication that is helping information. “It’s dangerous to glorify or Singh thinks dietitians should be open
them conform and feel safe in their body villainize these medications and to gener- to potential future benefits of GLP-1s, not
is very distressing,” she says. “Our job is alize them as either ‘good’ or ‘bad,’ just like dismiss them because they’re promoted
to help them make informed choices and it’s dangerous for us to classify food, weight, for weight loss, and to generally create
try to align with their healthy self and not and BMI in this way.” space for nuance. “When I work with a
the eating disorder self, the parts that are Nosek agrees that talking about weight client that’s being denied a very impor-
maladaptive. We want the medication to loss medications is “a sticky, messy con- tant procedure and they have explored
be a tool that we use as it’s appropriate to versation to have, specifically in the online all options, I am absolutely not going to
help support health and well-being. But space.” She says, “I think it’s forcing every- judge them for wanting to go on a GLP-1.
monitoring is the absolute pivotal piece.”8 one to have that honest conversation about I’ve never been denied a lifesaving proce-
Chan has counseled clients who are what is it that we really want,” often, she dure because of my weight. But if I was,
prescribed a GLP-1 to meet a surgical BMI says, it comes down to the desire for more who’s to say I wouldn’t pursue something
cut-off for gender-affirming care, or for a social capital. She says she’s not immune like that?” As for the long-term impact of
knee or hip replacement. “It may be a hoop to the pressure to lose weight, and while these drugs on the dietetics profession,
that someone has to jump through in order she feels supported enough emotionally she says that’s hard to predict. “I suspect
to get this very necessary treatment.” She and physically to not “pull the trigger,” more people are going to be reaching out
counsels these clients on how to structure not everyone has that support. “It’s really in the future when GLP-1s don’t work as
their lives around possible side effects. complicated, and it’s not just a ‘yes’ or ‘no.’ expected, which isn’t what I would hope.
“Unfortunately, it does feel a little bit more It’s so diabolical in the way that it has just I’d rather be proven wrong and have peo-
prescriptive and less of that intuitive, ‘I can turned everything kind of upside down.” ple just have positive experiences.” I
eat freely and I can listen to my internal She also says that as a nondiet dietitian,
cues,’ because those don’t exist anymore.” she gets “a lot of hate” from some weight- Carrie Dennett, MPH, RDN, is the nutrition
inclusive dietitians for being very open columnist for The Seattle Times, owner of
Making Room for Difficult about the fact she counsels on GLP-1s. Nutrition By Carrie, and author of Healthy for
Conversations “We’re all here, and everything is hard. So, Your Life: A Non-Diet Approach to Optimal
Social media isn’t always a place for telling someone, ‘This is the right way to Well-Being.
nuanced conversations on any topic, let live your hard life, and this is the wrong way
alone GLP-1s. Lloyd says that both social to live your hard life’ is weird to me,” she For references, view this article on our
and traditional media are barriers to receiv- says. “I think it’s reductive, which makes me website at www.TodaysDietitian.com.
ing and understanding evidence-based sad because I think we’re better than that.”

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Artificial
Intelligence
in Dietetics

A
rtificial intelligence (AI) is Six in 10 American adults are living
with chronic conditions.1 It’s estimated
here and will be a major part that 90% of the $4.3 trillion annual cost of
health care in the United States is spent
of transforming health care, on medical care for chronic diseases.2 The
which is predicted to change increasing prevalence of complex cardio-
metabolic conditions, combined with a
more in the next decade waning number of skilled care providers3
underscores the need for new approaches
than it has in the previous to chronic care management to expand
century. Why does health care need to access to care, lessen the burden of care,
improve efficiencies and reduce unsus-
change and how will AI help? Health care tainable medical costs. The RD plays a
critical role in chronic care management
needs to change because health care is not since healthful eating as part of a healthy
lifestyle is foundational to managing
healthy. This article will discuss how the chronic conditions.
role of RDs must evolve to demonstrate the It’s reported that primary care pro-
viders with a typical panel of 2,500 adult
profession’s value amid what is being called patients would need to work 26.7 hours
per day to provide all the recommended
an AI-powered health care revolution. The preventive, chronic care. While the time
RD can lead in harnessing the potential of demands are still excessive, if a team-
based care model (including RDs) is
AI to help make health care healthful. implemented, the hours needed to provide

18 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

 The Value of RDs
in an AI-Powered
Health Care
Revolution

By
Janice MacLeod, MA,
RD, CDCES, FADCES
 recommended care decrease by of Artificial Intelligence in Medi-
TABLE 1
over half.4 It’s predicted that gen- cine offers training courses and
erative AI technologies like Chat- certification on health AI (see AI-Related Definitions6
GPT will be able to help lessen the sidebar for access to these orga-
workload considerably as AI reli- nizations and other resources).
Artificial intelligence: Software that
ability and capability continue to These organizations stress the learns, simulating intelligent behavior
improve.5 This is an opportunity responsibility all clinicians have in computers.
for RDs well-versed in AI technolo- to work collaboratively with their
Rule-based artificial intelligence (AI):
gies to provide their expertise to respective workplace leadership
Predefined rules are used to process
boost the value and reach of their and colleagues to responsibly data and make decisions. This is suited
services in the primary care set- leverage AI for the tremendous for environments where rules and
ting and beyond. good it can bring to health care. outcomes are constant and clear, (eg,
RDs can join these organizations an automated insulin calculator that
Artificial Intelligence to provide their expertise and to used an insulin-to-carbohydrate ratio
Defined envision and shape a better health and correction factor to recommend
an insulin bolus dose.)
What is AI or augmented intel- care future.
ligence as the American Medical Machine learning (ML): A subset of AI
Association names it? Table 1 pro- AI-Powered Technologies that enables systems to learn from
vides definitions, and Table 2 lists Can Help Address Health data, identify patterns, and make
decisions with minimal human
ways AI is being used in health care, Care Challenges
intervention. Types of machine
including in the RD practice, and The increasing availability of learning include the following:
some potential risks to be aware of.6 connected health technologies
· Supervised learning: Algorithms
Organizations are forming to such as episodic and continuous
are trained on labeled data.
address the challenges of respon- glucose monitors, smart insulin · Unsupervised learning: Algo-
sibly bringing AI to health care. delivery tools (automated insulin rithms identify patterns in
One such organization, Coalition delivery and smart insulin pens), unlabeled data.
of Health AI, includes stakehold- blood pressure monitors, fitness · Reinforcement learning: Systems
ers from across the health care wearables, smart scales, heart rate learn through trial and error and
receiving rewards for correct
and technology landscape to har- monitors, stethoscopes and other
actions.
monize standards and reporting digital health applications enable
for health AI and to educate end- and empower individuals to mea- Deep learning (DL): A subset of ML
users on how to evaluate these sure, track, and self-manage their involving neural networks with multiple
technologies. The US National health directly using the data col- layers, enabling high-level data
Academy of Medicine is develop- lected during their daily lives. abstraction and pattern recognition.
DL could be used for pathology and
ing a Code of Conduct for AI in AI-powered digital health tools
radiology advanced image analysis,
health care and biomedical sci- can analyze the various data gen- for speech recognition and natural
ence while the American Board erated by the person using these language processing applications, and
for analysis of genomic data for
personalized medicine. Concerns
FIGURE 1 include the lack of transparency of
DL models and potential biases and
Technology-Enabled, Personalized Care ethical considerations in the decision-
for Populations at Scale making processes.

Natural language processing (NLP): A

field of AI that focuses on the
interactions between computers and
humans through natural language. NLP
Connected
could be used to extract relevant
technologies information from unstructured data like
gathering data clinical notes. Virtual health assistants
and chatbots can be used to answer
Data-informed, colleague or patient questions. NLP
personalized care for
could provide automated transcription
populations at scale
and summarization of medical records,
thus reducing administrative burden.

AI making data Clinically linked, Generative AI: A broad category of AI

meaningful and technology-enabled that can create original content.
continuous care Generative AI tools are built on
actionable
underlying AI models, such as a large
models
language model (the text-generating
part of generative AI).

20 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

connected technologies and provide
TABLE 2
personalized coaching and feedback
as people self-manage their chronic Uses and Potential Risks of AI
conditions while away from the care in Health Care and RD Practice
team. Clinicians can remotely moni-
tor population-level data to assess Uses of AI in health care and RD practice: Potential risks and considerations:
the health of the populations they
serve. They can efficiently identify • Automating routine administrative • Data privacy and security: A large
who needs human intervention tasks such as staff, patient, and facility amount of personal health data is
scheduling; sending appointment collected and processed by AI systems,
and when, whether a brief coaching
reminders; conducting screening and raising concerns about data privacy
nudge or reminder, an adjustment in triage; and automating billing and and security.
a therapy prescription, or behavioral claims processing, significantly shorten-
ing the revenue cycle. • Accuracy and reliability: AI
or social support (see Figure 1).
algorithms can make errors in
Using text messaging, patient por- • Summarizing complex medical records, predictions and recommendations.
tals, digital social networks, and video documenting clinical encounters, Incorrect or misleading results that AI
telehealth, clinical teams can interact drafting responses to client and models generate are called
remotely with their clients as needed colleague’s questions, and generating hallucinations and can be caused by a
preauthorization requests. variety of factors, including biases in
in a continuous, data-informed feed- the data or insufficient data used to
back loop.7 This better matches the • Generating culturally appropriate, train the model or incorrect
demands of living with a persistent customized meal plans; designing assumptions made by the model.
personalized educational content; and
condition like diabetes and other
summarizing research. • Quality of data: The accuracy of AI
chronic conditions. This enables a depends on the quality of data it is
pivot away from the inefficient and • AI-powered food tracking and analysis trained on; incomplete or biased data
tools and AI-powered dynamic menu can lead to inaccurate outcomes.
ineffective episodic, time-bound care
planning platforms are allowing RDs to
model to a continuous, on-demand scale their practice, expanding access • Dependency and overreliance: While
data-informed care approach that to their services. AI can provide valuable support, it’s
allows each member of the care team essential to have human oversight to
• Nutrition research can be made more interpret and validate AI-driven
to operate at the top of their license, streamlined and effective. recommendations. Overreliance on AI
making the most of valuable clinician tools may also lead to reduced patient
time. AI-powered health technolo- autonomy in managing their own
gies enable the move from mass gen- health. For example, back-up plans for
eralization to mass customization, automated insulin delivery are needed
in the event the technology fails or is
providing true person-centered care
unavailable.
for entire populations at scale.8 Edu-
cating on the benefits of connectivity • Ethical considerations: AI systems can
and building digital health literacy perpetuate existing biases if not
carefully designed and monitored,
skills among those living with chronic potentially leading to disparities in care.
conditions as well as addressing the
digital divide is critical.9,10 • Transparency: It’s essential to ensure
transparency in AI decision-making
In response to the challenges process for trust and accountability.
health care is facing, the Institute for
Health Improvement has set forth
the quintuple aim: Improving the
health of the population (aim 1) at a
lower cost (aim 2), while improving
both the patient and health care team AI-enabled geo-location capabili- opportunity to rethink and redesign
care experience (aims 3 and 4) and ties could identify, for example, local the patient customer care experience
addressing disparities in care (aim food banks for those struggling with from start to finish. As an example,
5).11 The fifth aim requires a shift from food insecurity. Natural language instead of just sending a patient the
a downstream and reactive disease processing capabilities can be used results of a recent lab draw, alterna-
management health care approach to to efficiently scan free text in medi- tively, providing the lab results with
an upstream, proactive, and preven- cal records where many risk factors an explanation of what the results
tive approach. With health inequities for disease severity and progression mean and linking to potential action
estimated to cost the US health care and SDOH are captured and thus help steps including, if indicated, provid-
system approximately $83 billion clinicians and health care systems ing an opportunity to schedule an
annually, addressing the fifth aim is identify at-risk patients. appointment with an RD to address
critical for value and sustainability.12 for example, an abnormal lipid
Finding efficient ways to assess and Why Do RDs Need to Learn profile. It’s important for RDs to be
address social determinants of health and Join the Conversation? aware of AI initiatives being explored
(SDOH) through linking to local AI experts see the true potential of and implemented to better provide
community resources is essential. AI as giving health care systems the input on how to integrate valuable

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 21

 Action Steps for Building AI Acumen
Consider following these experts in the application of AI to edu/programs/value-science-driven-health-care/
health care. RDs can add valuable perspectives and discover health-care-artificial-intelligence-code-of-conduct.
and promote opportunities for RDs to be at the table by pro-
viding thoughtful responses to posts. Consider enrolling in AI training and certification offerings
at the American Board of Artificial Intelligence in Medicine,
• Bertlan Mesko, PhD: MedicalFuturist.com; www.linkedin. available at https://abaim.org.
com/in/bertalanmesko/
• Eric Topol, MD: www.linkedin.com/in/ Consider every repetitive task you do over and over each
eric-topol-md-b83a7317/ day as you provide consultations, teach classes, and
• Harvey Castro, MD: www.linkedin.com/in/harveycastromd document your visits. How could AI help?
• Tom Lawry: www.tomlawry.com; www.linkedin.com/in/
tomlawry/ Use the Chat GPT Prompt guide to learn how to refine
• Jan Berger: www.linkedin.com/ your prompts to optimize output: CHAT GPT Cheat
newsletters/7016868239498444800/ Sheet by Harvey Castro, MD, an AI expert and medical
doctor, available at https://www.linkedin.com/posts/
Add to your reading list: harveycastromd_healthcare-gpt-cheat-sheets-activity-
7093963347984863232-BB6P.
• Lawry T. Hacking Health Care: How AI and the Intelligence
Revolution Will Reboot an Ailing System. New York: Join the RD Facebook group AI Powered Nutrition, available
Routledge; 2023. at www.facebook.com/groups/350955327768168. This is a
• The American Medical Association’s Augmented place where RDs can learn from each other about using AI
Intelligence in Medicine, available at www. in the field of nutrition. The goal is to get the RD profession
ama-assn.org/practice-management/digital/ involved in the AI revolution.
augmented-intelligence-medicine.
• The Coalition for Health AI’s Blueprint for Trustworthy Make a list of what you could do to bring value to clients if
AI Implementation Guidance and Assurance for Health freed from the rote, repetitive tasks.
Care, available at www.coalitionforhealthai.org/papers/
blueprint-for-trustworthy-ai_V1.0.pdf. Read this related LinkedIn post: www.linkedin.com/pulse/
• The National Academy of Medicine’s Code healthy-eating-diabetes-person-list-foods-avoid-janice/.
of Conduct for AI in Health, Health Care, and
Biomedical Science, available at https://nam. Lean in. Embrace the change. Be part of the solution.

RD services. Refer to the sidebar for completely differently, including rei- digital health and chronic condition
action steps to take to build your magining the role of the RD.13 management. She is past chair of
AI literacy and join the intelligent Anybody (including a chatbot) the Academy of Nutrition & Dietetics
health care revolution. can hand out a list of foods to eat and Diabetes Practice Group and is
avoid. It takes a skilled RD with exper- currently serving on the Association
In Conclusion tise in person-centered care to equip of Diabetes Care and Education
There’s a golden opportunity for and empower a client in progressively Specialists Board of Directors, 2024–
the RD to step up and lead in har- building a healthful approach to food 2027. MacLeod has authored multiple
nessing the expanding AI-powered that fits their life and promotes well- publications and developed numerous
digital health capability to build being. As technology advances, RDs programs on diabetes nutrition, digital
a continuous, data-informed, vir- have a chance to offload some of the health, and practice transformation.
tual care model linking people with rote, repetitive tasks and finally focus Her passion is developing business-
chronic conditions to expert care on the person in front of them. A truly savvy solutions leveraging technology
on-demand, 24/7, better matching transformative revolution such as this to transform care.
the reality of living with persistent brings major opportunities and major
chronic conditions like diabetes. challenges. AI is here and it’s up to Disclosure: JM is serving as a consultant
to Welldoc doing medical writing,
Specialized virtual care and educa- each one of us to harness its potential evidence strategy, and science calendar
tion clinics would need to connect to make health care healthful. I management.
to behavioral health experts and
local community resources to help Janice MacLeod, MA, RD, CDCES,
For references, view this article on our
address the SDOH. This requires FADCES, is a diabetes-cardiometabolic website at www.TodaysDietitian.com.
thinking about and delivering care consultant and key opinion leader in

22 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

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Medically
Tailored
Meals By Alyssa Saltz, MS, RD, LDN

M
edically tailored meals have been available for Peer-reviewed research has demon-
strated that for individuals with com-
more than 35 years. They started as a community plex health conditions, medically
response to the AIDS crisis as volunteers tried to tailored meals can lead to a 16% net
develop strategies to help prevent malnutrition, reduction in health care costs, 72%
fewer skilled nursing facility admis-
manage side effects, and bring dignity to the lives sions, and a 70% decrease in emergency
of people with AIDS when there were no other proven treatments.1 Once department visits.2 A focus on good
the medical community developed treatments for this population, med- nutrition also helps address malnutri-
tion, frailty, independence, and more.
ically tailored meal programs evolved to help meet the nutritional needs According to the Food Is Medicine
of those living with other chronic health conditions. Coalition, medically tailored meals are
medically appropriate meals delivered
The role of dietitians has been vital outcomes from following a medically to the homes of individuals living with
in the development and management of prescribed meal plan for many health severe, complex, and/or chronic ill-
the medically tailored meals movement conditions. However, due to various nesses who are too sick to shop or cook
to ensure meal plans are evidence-based barriers, such as socioeconomic for themselves.1 Many medically tai-
and meet high nutrition standards. status, education level, finances, lored meal programs provide frozen
Individuals living with serious lack of time, and limited cooking or shelf-stable meals designed to meet
health conditions often are prescribed skills, patients may struggle to follow the needs of specific health conditions.
evidence-based nutrition therapy specified diet recommendations. They often eliminate concerns around
to help manage side effects, slow Using dietary interventions has grocery shopping, label reading, food
disease progression, and lower the been shown to not only improve medi- preparation, or determining what to eat.
risk of comorbidities. Much research cal outcomes but also lower financial The meals are different from other pre-
has demonstrated improved health burdens and raise patient satisfaction. pared meal companies because they’re

24 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

Transforming
Patient Care
One Meal
at a Time
developed in accordance with high-
quality ingredient standards, designed
by dietitians, and tailored to meet
postdischarge needs of individuals.
Medically tailored meal programs
often accommodate multiple dietary
restrictions rather than focusing on
only calorie- or carbohydrate-con-
trolled options, and they consider
reductions in sodium and saturated
fats, as well as increases in fiber and
other nutrients. The programs also
provide one-on-one nutrition counsel-
ing or MNT with a dietitian.
After patients are referred by medi- in medically tailored meals in the satisfaction, and reduced malnutri-
cal professionals or health care plans, United States and found that there tion and improved health outcomes.
they may receive a limited number would be $14 billion in health care According to Catherine Macpher-
of meals per week or receive all three savings and 1.6 million fewer hos- son, MS, RD, senior vice president
meals for the day, depending on their pital visits in just one year’s time. 3 and chief nutrition officer at Mom’s
insurance coverage, ability to pay, and With the current state of health care Meals, a leading nationwide provider
the service they choose. If a health and a growing population of older of medically tailored, fully prepared
care plan covers meals, patients may adults needing medical care, medi- home-delivered meals, “We’ve seen
need to be assessed for eligibility. The cally tailored meals may be a solu- strong results with medically tailored
length of time patients are enrolled in tion to improve patient care, lower meals for many groups of vulner-
the program (generally a minimum of health care costs, and decrease the able people. When medically tailored
12 weeks) will depend on their nutri- burden on our country’s stressed meals are provided after discharge,
tional needs. Moreover, patients may medical systems. we’ve seen rates of readmissions cut
need to be reassessed routinely to One study conducted by Metro- in half.4 For people with an uncon-
continue receiving meals beyond the politan Area Neighborhood Nutri- trolled chronic condition like dia-
initial period. tion Alliance found that client’s betes or kidney disease, we’ve seen
health care costs were reduced by improvements in clinical status.”5,6
Research-Backed Benefits of $10,765 per month in the first three In a recent case study with a
Medically Tailored Meals months after receiving medically health plan in California for dually
Studies have shown that 5% of tailored meals.4 Its pilot program eligible (Medicare and Medicaid)
patients generate 50% of health care on medically tailored meals found members with heart failure, Mom’s
costs.1 Medically tailored meals help that receiving meals led to 37% Meals and the health plan provided
to address the needs of this popula- shorter hospital stays, 50% fewer six months of support: three medi-
tion with nutrition interventions to hospital admissions, 20% more likely cally tailored meals per day for the
improve their overall health.1 to be discharged home, 28% cost first three months, then two medi-
Tufts University Friedman School savings, decreased hospital read- cally tailored meals per day for the
of Nutrition Science and Policy con- mission rates, 50% fewer visits to next two months, then one meal per
ducted a study in 2022 looking at the the emergency department, 50% day for the last month. In the last
amount of health care savings and improved medication adherence, three months, produce and pan-
reduction in hospital admissions if decreased social isolation, improved try boxes also were delivered to the
every eligible patient participated self-management of condition and members’ homes, along with simple

Medically tailored meals may be a solution to improve

patient care, lower health care costs, and decrease the
burden on our country’s stressed medical systems.
26 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024
 recipes. Members also received up to health care costs in their service Meals often can be tailored to
seven calls from a dietitian and had areas that cover more than 65% of meet the needs for the following
access to a nurse and community the state’s Medi-Cal population. dietary interventions:
health workers from their health Chronic physical or behavioral health
plan. In this program, patients lost conditions, in patient discharges, or • cancer support;
an average of 6 lbs and reported high-risk pregnancies make Medi- • diabetes friendly;
reduced heart failure symptoms. Cal members eligible to receive a • general wellness;
The number of visits to the emer- minimum of 12 weeks of medically • gluten-free;
gency department was cut in half tailored meals. • heart healthy;
and the rate of inpatient hospitaliza- • kosher;
tion also was reduced by 50%. The Medically Tailored Meals for • low fat;
cost savings of the program were Various Health Conditions • low fiber/high fiber;
25%, which equals about $19,000 To be eligible for medically tai- • low sodium;
per patient per year. “Members lored meals, recipients with com- • pureed;
reported very high satisfaction with plex (often diet-related), severe, and • renal friendly; and
the program, and many tried a new chronic illnesses must be referred by • vegetarian/vegan.
fruit or vegetable for the first time,” a medical professional or health care
Macpherson says. plan. Often, individuals with high- Filling in the Gaps
In California, they started need, high-cost conditions that have Rene Ficek, RDN, CDCES, president and
the California Food Is Medicine a higher risk of hospital or skilled owner of Seattle Sutton’s Healthy Eat-
Coalition, a nonprofit community- nursing care admission are the best ing (SSHE), a medically tailored meals
based organization that provides candidates for a medically tailored company that provides nationwide
medically tailored meals and meals program. These chronic health delivery, says, “We are one of those few
nutrition services to individuals conditions include cancer, CVD, companies helping to fill in the gaps
living with serious medical chronic kidney disease, COPD, dia- for individuals who are between the
conditions.1 They partner with betes, end-stage renal disease, HIV, start of chronic disease and a diagno-
different health plans and health care diabetes, and other diseases/condi- sis that’s covered for medically tailored
providers and have noticed improved tions that may increase the need for meals.” An RN founded SSHE in 1985
health outcomes and reduced hospitalization.7,8 with the goal of helping individuals

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 manage, plan, and pro-
vide expertise to meal
programs. They can
help perform research
on how the Food as
Medicine movement
improves patient care,
connect individuals
with medically tai-
lored meal programs,
and help them manage
their conditions to feel
their best and main-
tain independence.
Erin Pellegrin, RD,
LDN, director of culi-
nary nutrition and
education with Unite
For HER, a nonprofit
organization focus-
ing on the health and
wellness of individu-
als diagnosed with
breast and ovarian
cancers, based in West
apply diet recommendations from doc- various health concerns before they Chester, Pennsylvania, says, “RDs’
tors and dietitians to real life by provid- become more severe. involvement in medically tailored
ing freshly prepared meals that follow “In my previous role as a clinical meals enables us to drive home the
the recommendations of the American dietitian, I frequently encountered education we provide to the patients
Heart Association, American Diabetes patients grappling with overwhelm- we serve. Whether it’s involvement
Association, and the 2020–2025 Dietary ing dietary recommendations from in recipe development or assisting
Guidelines for Americans. Today, the their physicians,” Ficek says. “Balanc- patients with selecting the foods/
company employs three RDs, a certified ing heart-healthy eating with newly meals that best support their health,
diabetes care and education specialist, diagnosed diabetes, many felt lost in the impact is great and goes far.” In
and an executive chef. “Our meals have the complexity of dual dietary require- tangible ways, RDs can do the fol-
been used for almost 40 years to help ments. I often emphasized that these lowing for patients:
customers manage health conditions dietary guidelines share similarities,
like diabetes, heart health, cancer care, and adopting a calorie-controlled, 1. Reduce the stress and confusion
kidney disease, liver disease, and more. healthful diet featuring lean proteins, patients experience when they must
We’ve seen lives transformed because of vegetables, fruits, whole grains, and make adjustments to their current
our meals, and what we take most pride low-fat dairy could effectively manage way of eating to better support their
in is helping individuals learn how to these conditions. Importantly, such a health goals.
eat healthier by demonstrating what diet not only addresses specific health 2. Introduce patients to new recipes,
variety, freshness, and portion control concerns but also serves as a preven- flavor profiles, and methods of cook-
should look like.” tative measure against other chronic ing that promote their health.
While medically tailored meals diseases. Now, in my current capac- 3. Preserve their energy. Food prepa-
must meet a set of stringent dietary ity, I take pride in contributing to the ration and cooking may feel like an
guidelines for insurance coverage, creation of meals designed to allevi- arduous task for patients dealing
there are alternatives accessible to ate stress and confusion surrounding with fatigue, neuropathy, and other
those without insurance benefits dietary choices. These meals not only types of chronic pain. Medically
or who don’t meet the disease cri- address health concerns but also serve tailored meals enable them to enjoy
teria. Choosing freshly prepared as valuable tools for educating individu- foods that support their health and
meals that align with calorie consis- als on what constitutes a healthful diet.” lighten their load.
tency and dietary recommendations Macpherson primarily works
serves as an excellent starting point. How Dietitians Are Getting with health care partners, including
This approach proves beneficial for Involved health plans, health systems, and
individuals aiming to lower choles- Like Ficek, dietitians as a whole are hospitals that want to establish
terol, reduce blood pressure, improve a critical aspect of the medically medically tailored meal programs
blood sugar levels, and address tailored meals movement. RDs can for one or more of their populations.

28 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

“I ensure the program design
will optimize outcomes for those
receiving meals and be cost-
effective for the partner. And there’s Recommendations for RDs
a way to measure the impact of the
• Review nutrient analyses of medically tailored meals. Review nutrition
program,” Macpherson says.
content to ensure the meals and overall program are suited for your
At Mom’s Meals, dietitians
patient’s needs. Find programs that follow high nutrition standards and
work in a variety of roles. The
director of research and develop- work with a variety of health conditions rather than just one condition
ment collaborates with the team or a single diet.
of chefs to ensure that medi- • Connect with RDs working with medically tailored meal programs.
cally tailored meals meet dietary Making personal connections with fellow dietitians increases confi -
guidelines and that menus are dence in the program and helps determine whether it will work for
updated to offer seasonal selec- your patients. Many programs have resources to connect patients with
tions. RDs provide support and their services. RDs also can help patients choose the correct menu
education to individuals in the type, consider food allergies, discuss food aversions, and include taste
program, and other dietitians and cultural preferences.
work directly with health plan
customers to ensure their meal • Contact insurance plans to determine whether they cover medically tai-
programs are running smoothly. lored meals. Since many patients have this benefit, and some unknow-
ingly, contact their insurance carrier to refer them to a medically tailored
Working With Patients meal program and determine how they can take advantage of this ser-
When RDs sit with patients, vice affordably.
Macpherson says they should ask
• Search for programs with sustainable practices and environmentally
them if they know whether medi-
friendly products. Look for plans that minimize food waste, use recycla-
cally tailored meals are covered
ble materials, and focus on economical food sourcing.
by their insurance plan. Most
patients won’t know, so RDs can
encourage them to call the num-
ber on the back of their insurance
card to find out. RD support. Unite For HER part- Mary Anderson, a patient with stage
“Most people with Medicare Advan- ners with Sunbasket Meals, a meal 3 kidney disease, who’s been enrolled
tage have medically tailored meal delivery service that provides meal in a heart-healthy, diabetes-friendly
benefits for two to four weeks after kits and freshly prepared meals for meals program for more than
discharge from an inpatient stay. Some a variety of dietary patterns, to offer four years, says that the meals she
have benefits for longer periods of members the choice of three dinners receives have kept her kidney values
time—12 weeks or longer to help them (six servings total) preselected by its steady. The nutrition and sodium
better manage a chronic condition. team of dietitians to be delivered to reduction in the meals “have helped
“In addition, many Medicare their homes. me so much. The meals also are con-
Advantage members have a monthly In addition, several types of medi- venient. I don’t have to plan, prepare,
allowance on a card they can use to cally tailored meals programs exist or shop for meals. I eat so much more
pay for Mom’s Meals or other medi- that offer patients fully prepared meals healthfully than I would if I were
cally tailored meals,” Macpherson says. or partially prepared meals, requiring preparing meals at home on my own,
Patients on Medicaid also may have little meal planning and preparation. especially since I’m over 80 years old
medically tailored meal benefits fol- Ficek says a program that offers fully and living alone.”I
lowing a recent hospital admission or prepared meals helps patients with
during pregnancy. limited cooking skills or who want Alyssa Saltz, MS, RD, LDN, is a registered
According to Pellegrin, patients more convenience due to limitations or dietitian nutritionist in Northern Illinois,
with chronic conditions should have a hectic schedule. It’s important to con- serving as the lead dietitian at Seattle
more insurance coverage and nutri- sider the patients’ constraints and abil- Sutton’s Healthy Eating. In her role, she
tion support, as well as additional ities when choosing a program that’s oversees nutritional standards, manages
programs and education to reduce best for them. “Programs like SSHE do the Nutrition Ambassador Program, and
the risk of disease and improve over- the shopping, planning, prep work, and provides personalized counseling to
all health. When medically tailored cooking for patients, so they can focus customers, drawing from her extensive
meals aren’t available to patients, on taking care of themselves and doing experience in various areas of dietetics.
RDs can fill that gap by connecting the things they love.”
them with companies that provide Patients’ lives are being trans- For references, view this article on our
home-delivered meals that meet formed through the nutrition pro- website at www.TodaysDietitian.com.
high nutrition standards and offer vided by medically tailored meals.

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 29

The

Rise
Zero-Waste
of
the

Grocery Store
The challenge in the
movement to make it mainstream.
BY JAMIE SANTA CRUZ

A
mericans generate over 14 million tons Zero-waste stores typically have a
warehouse or market-style setup that
of plastic packaging waste annually, avoids individual packaging and allows
customers to purchase from bulk bins.
Instead of providing disposable packag-
with a significant portion coming from ing, these stores ask customers to bring
their own reusable containers to fill.
food packaging.1 This waste not only Though the first zero-waste store
didn’t open in the United States until
contributes to environmental pollution but also poses 2012,4 the concept is now booming, with
over 1,300 zero-waste stores currently
health risks due to plastics contaminating food.2,3 operating across the country.5 From
Precycle in Brooklyn, New York, to Nude
As awareness of these issues grows, a Here’s how the grocery industry is Foods Market in Boulder, Colorado,
movement to cut packaging waste in gro- changing—and how dietitians can be to Byrd’s Filling Station in San Mateo,
cery stores is gaining momentum. One part of the movement for a more sustain- California, stores built on this model can
notable development is the “zero-waste” able future. now be found in many major metro areas
grocery stores that have started popping and in some smaller cities as well.
up around the country. Although zero- The Exploding Popularity Despite their success, zero-waste stores
waste stores are typically small specialty of Local Zero-Waste Grocers have some limitations. These are shown
stores, large grocery chains and food man- Zero-waste grocery stores are built on a below in Table 1.
ufacturing companies are also experiment- simple idea: sell food package-free as far Given these limitations, there’s a
ing with ditching disposable packaging. as possible. clear need for larger-scale solutions that

30 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

are both more convenient and more eco- disposable plastic bags to use, meaning sensor-driven bulk dispensers that auto-
nomical, in order to tackle food packag- their bulk section often aren’t reducing matically measure the amount of food
ing waste. packaging waste.7,8 dispensed, eliminating the need to weigh
That said, several companies are containers.9 Meanwhile, the Refill Coali-
Large Retailers and Reusable working to increase the convenience of tion, a partnership among multiple gro-
Packaging the bulk aisle. SmartBins, a San Fran- cery retailers in the United Kingdom, is
Large grocery chains have been slow to cisco Bay Area company, has developed working on standardized refill dispensers
address packaging waste. A 2021 Green-
peace scored 20 of the top US retailers on
TABLE 1
their efforts in reducing the use of dispos-
able plastic and gave all 20 failing scores.6 Limitations of Zero-Waste Grocers
Several large retailers, including
Availability Many people still don’t have a zero-waste store nearby.
Sprouts, Whole Foods, Kroger, and Pub-
lix, have bulk sections in their stores, Cost These stores are “generally geared toward more affluent communities
which could in theory support a culture and people who can afford to spend a little more,” says Lisa Ramsden,
of refilling. But as in boutique zero-waste BS, BA, senior plastics campaigner at Greenpeace USA.
stores, buying from bulk bins tends to
be time-consuming, and supermarket Selection Zero-waste grocers typically offer only a limited range of products
bulk sections contain only a limited that can be easily sold from bulk dispensers.
selection of products. Furthermore,
although customers can in theory bring Convenience The onus is on customers to bring their own containers, weigh each
one in store (empty), then weigh the filled container again to
their own reusable containers, super-
determine their final cost.
markets almost always offer customers

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 31

that similarly aim to automate the pro- and Bold Reuse also ended their partner- collecting, transporting, and sanitizing
cess and increase convenience.10 ship earlier this year—though Bold Reuse packaging mean that reusable packaging
Increasingly, supermarkets are experi- CEO Jocelyn Quarrell explains the move as isn’t actually better for the environment.21
menting with a completely different model “more of a pivot than a quit. We are confi- According to a 2020 report, 72% of stud-
as well—namely, prefilled reusable pack- dent that refill and reuse is the future.” ies that have looked at reusable packaging
aging. Whereas the bulk-food model relies These setbacks illustrate that a sys- have found that it has environmental ben-
on consumers to bring in their own con- tem of reuse has serious challenges. These efits over single-use packaging, but the
tainers and fill themselves, the “prefill” include the following considerations. rest were mixed or negative.22
model works differently: grocery stores or
food manufacturers acquire reusable con- Infrastructure System-Level Change:
tainers and prefill them with their prod- Setting up systems for collecting, sorting, The Oregon Model
ucts. Customers then grab and go. sanitizing and refilling reusable pack- To achieve significant reductions in
This model is very convenient at the aging is complex.8 Companies like Bold packaging waste, a systemic approach
point of purchase, but the challenge is that Reuse and Loop are attempting to address will be necessary. Single-use “is the norm
customers need to return the container this issue, but they have a “chicken and for so many of us for so long. It’s a really
after use. Depending on the program, this egg” problem, according to Crystal Dreis- ingrained part of our culture,” Dreisbach
happens in one of two ways: bach, MPH, CEO of Upstream, an agency says. “In order to change the whole econ-
advocating for the reuse movement in omy of how we package our food, you have
1. Return on the go: Customers return the the United States and Canada. “You can’t a systems-level issue.”
container to the store or another desig- grow your business to have the capacity What’s needed, then, is a system-
nated drop-off point. to wash for a Whole Foods or [some other level response, where all the actors in
2. Return from home: Containers are large company] unless you have the con- the United States’ entire grocery, food
picked up by a collection service from the tracts to do it”—but it’s also impossible to packaging, and food manufacturing
customer’s home. get contracts without having the infra-
structure to support them.
Throughout much of the 20th century,
US soda and beer companies ran on this Cost
model, selling their beverages in glass bot- Reusable packaging can be cheaper long- Plastic Substitutes
tles on a deposit-return system (a “return term: the Ellen MacArthur Foundation,
In the effort to avoid plastic,
on the go” scheme). Meanwhile, old-fash- a nonprofit that has extensively studied
retailers and consumers alike
ioned milk delivery services that drop off reuse/refill systems, estimates that compa-
often turn to glass or metal as a
full bottles of milk on customers’ porches nies could save $10 billion by replacing 20%
solution, or to plastics that are
and pick up their empty bottles at the same of their single-use plastic packaging with
biodegradable or compostable.
time are an example of “return from home.” reusable alternatives.16 But the initial invest-
However, these forms of pack-
Several US chains have recently ment in infrastructure to support reusable
aging are not automatically
experimented with prefilled reusable packaging is significant17—and customers
more environmentally friendly
packaging. Starting in 2019, New Seasons are reluctant to pay the extra cost.8,18
than single-use plastic.
Market, which operates 21 stores in the
Glass and metal are emis-
Pacific Northwest, implemented reusable Convenience and Customer Education
sions-intensive to make, meaning
packaging for certain products in its Research shows that consumers prefer
that the environmental impact
stores. To pull off the model, the grocery recycling—which is now an established
of producing a container out of
chain partnered with Bold Reuse, a norm—to reuse,19 which is seen as incon-
these materials is greater than
company that handles the logistics of venient.8 Customers don’t always under-
for a plastic container.33 Glass
collecting customers’ empty containers stand the value of reuse (compared with
and metal can be more environ-
and sanitizing them for reuse.11 recycling) and so don’t choose reusable.20
mentally friendly than plastic, but
Other large chains, including Walmart,
only if they’re reused many times.
Kroger, and Giant Food, have experi- Not Enough Reuse in Practice
Biodegradable plastics, mean-
mented with prefilled packaging as well. Reusable packaging must be used a mini-
while, don’t actually break down
These retailers have all established trial mum number of times to be more envi-
very easily. As for compostable
programs with Loop, a company that, like ronmentally friendly than single-use
plastics, there are few industrial
Bold Reuse, distributes reusable packag- alternatives. But sometimes containers
composting facilities that can
ing to brands, then collects the packaging break, or customers don’t return them.
process these plastics, and those
after use and sanitizes it.12,13 Loop offers a In addition, reusable packaging natu-
that exist often won’t accept
limited range of products from brands like rally starts to show superficial wear over
compostable plastics because
Proctor and Gamble, Nestle, and Mon- time, which can be a turnoff to customers
they can contaminate soil.34
delez in reusable packaging.14 and can potentially trigger companies to
Increasingly, therefore,
But not all the forays into this new replace the packaging too quickly.18
experts on the topic are arguing
world have gone smoothly. Several retail-
that society needs to ditch the
ers that established trial programs with Environmental Impact
idea of single-use altogether, in
Loop ended those trials without clear In some reuse programs, the energy use,
favor of reuse. 35
plans for expansion.15 New Seasons Market water use, and emissions involved in

32 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

industries move toward reuse. That TABLE 2
means “reconsidering a lot of different
parts of our food system and thought-
Four Tips for Reducing Packaging Waste
fully redesigning it from a linear model TIP 1 Shop at zero-waste stores if feasible. Caveat: This won’t be geographi-
to one that allows for more circularity of cally or financially realistic for many clients. “Helping people learn how
packaging,” Quarrell says. “It’s not going to incorporate sustainability practices can look different depending on
who we are serving. It’s up to us to meet people where they are and
to be an overnight effort.”
find ways to help best support them without shame,” says Sherene
While it might take time, Oregon’s bev- Chou, MS, RDN, cofounder and director of community engagement at
erage industry offers an example of how Food+Planet, a nonprofit that engages health professionals to be
systemic change can occur. leaders in sustainable food systems.
In 1971, Oregon passed the nation’s first
“Bottle Bill,” a law that established a refund TIP 2 Bring reusable bags every time you head to the store.
value for beverage bottles (to promote recy-
TIP 3 Choose loose or imperfect produce. “This can often be a more
cling). The law also required retailers to affordable option while also eliminating packaging,” Chou says.
participate in the collection of the bottles.23
The new law prompted Oregon beverage TIP 4 Buy from bulk bins where available—but bring your own container.
distributors to band together to form the Using single-use plastic bags provided by the store negates the
Oregon Beverage Recycling Cooperative, environmental benefits of buying bulk.
which manages bottle collection through
a statewide system of drop boxes. It also
handles the flow of deposits and refunds Oregon will be crucial. “For any scale, you “People are feeling the need for reuse.
for its members. The cooperative currently definitely need a greater infrastructure There’s definitely demand for it,” Dreis-
has a collection rate of 80% to 90%, com- and government policies that assist it or bach says.
pared with the national average beverage incentivize it,” Swihart says. “Assisting Meanwhile, dietitians are well-
container recycling rate of about 35%.24 companies in setting up infrastructure, or positioned to help guide clients on
For years, the cooperative collected having required targets for reuse, is going how to avoid food packaging waste.
beverage bottles for recycling, not reuse. to be needed. It’s very, very important.” “Dietitians are among the most trusted
But because it already had bottle collec- Quarrell agrees on the importance of voices on food information,” Chou
tion infrastructure in place, the coopera- policy. Companies really need “support says, citing a 2022 survey showing that
tive was able to go a step further. In 2018, from cities and states to support this tran- dietitians had more public trust than
it launched the nation’s first statewide sition to reusable packaging. That is likely any other information source on food.31
refillable bottle program.23 to include both sticks (bans or fees) and “It’s critical that we use our knowledge
The program has proven to have both carrots, like tax incentives or public fund- to support our communities with well-
environmental and economic benefits. ing that can support the infrastructure.” rounded evidence-based information to
Each bottle gets reused about 25 times The United States is moving in this help people make informed decisions.”
and has a 95% lower carbon footprint than direction, albeit slowly. Ten US states now See Table 2 for a list of the top tips to
nonrefillable bottles.25 And it also low- have bottle bills similar to Oregon’s,26 and reduce packaging waste dietitians can
ers packaging costs: the cost per use for a national bottle bill has been proposed as offer clients.
a reusable bottle in the program is about well.27,28 In addition to bottle bills, several Finally, given that it’s currently very
half of the cost for a new, nonreusable bot- states—Oregon, Colorado, California, and difficult to avoid packaging waste,
tle, according to Matt Swihart, cofounder Maine—have recently passed a new kind of dietitians can encourage clients to look
of Double Mountain Brewery, which par- legislation for packaging called extended beyond packaging. Tackling packaging
ticipates in the program. producer responsibility (EPR). EPR laws go waste is obviously a worthy effort, but
Significantly, Double Mountain had beyond just beverages and require compa- other aspects of our food choices make
already started using refillable bottles nies to take responsibility for other kinds of an equally large or possibly larger
before the cooperative launched its larger- packaging waste as well.29 Although none difference for the environment—such
scale program. However, the brewery strug- of these laws technically mandate reuse, all as increasing vegetable intake and
gled to get traction as long as they were of them help spur companies to collaborate reducing meat consumption, which
working alone trying to implement a sys- on the kind of infrastructure that makes has a huge impact on an individual’s
tem of reuse. “We had some marginal suc- systems of reuse possible. environmental footprint.32 In other
cess [on our own], but we really did do a lot words, even if a culture of reuse is still
better once the cooperative came in,” Swi- Tips for Reducing Packaging in the future, there are plenty of other
hart says. “It made a lot of logistical head- Waste environmentally friendly actions to take
aches go away.” This experience illustrates It’s impossible to completely avoid pack- in the meantime. I
the importance of industrywide coopera- aging waste, but Americans want to do so
tion and systemwide change over piece- as much as possible. A 2022 survey found Jamie Santa Cruz is a freelance writer based in
meal efforts from individual companies. that 86% of consumers under age 45 said Parker, Colorado.
they would pay more for sustainable pack-
Future Directions aging, and 74% of consumers said they For references, view this article on our
For broader adoption of reuse systems, would be interested in buying products website at www.TodaysDietitian.com.
legislation of the kind that was passed in that come in refillable packaging.30

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 33

CPE Monthly By Sara Chatfield, MPH, RDN, LDN

to meet food production demands.11 Irri-

gation with contaminated sources is a
major cause of heavy metals in the food
supply in low- to middle-income coun-
tries.1,12,13 In higher-income countries, air
pollution and the use of contaminated
fertilizer are more frequent causes of
heavy metals in food.12,13
Water polluted by runoff or atmo-
spheric deposition can contaminate
aquatic foods with heavy metals like
mercury.10,14 Electronic waste caused by
dumping can also lead to water pollu-
tion and increased heavy metals, partic-
ularly cadmium, in crops. Heavy metal
levels in crop samples grown in elec-
tronic-waste areas in China were found
to be three times higher than those in
control samples.4,13

Heavy Metal Contamination

of Crops
Heavy metal contamination may
impact food production through its
adverse effects on the growth and
health of crop plants. Heavy metals
may also impact the nutrient content
Regulation of Heavy Metals of crops; cadmium toxicity can reduce
plants’ mineral content.1,13,15
in the Food Supply The amount of heavy metals absorbed
by crop plants varies by metal and plant

H
eavy metal pollution is a food will further RDs’ ability to help the variety.1 Certain plants take up higher
global environmental issue public limit exposure. This continuing quantities of heavy metals from the soil,
threatening food security education course describes the scope like leafy and root vegetables.1 A study of
and public health. Urban- of heavy metal contamination of global 22 species of vegetables, including carrot,
ization and industrialization around food sources and strategies to manage radish, sweet potato, caitai (a Chinese
the world have led to greater accumula- this public health hazard. “stalk” vegetable), eggplant, red pepper,
tion and movement of waste products,
contributing to the heavy metal pollu- Sources of Heavy Metals in the
tion of air, soil, and water, particularly in Food Supply COURSE CREDIT: 2 CPEs
populated areas.1,2 Heavy metal con- Heavy metal pollution of air, water,
tamination of urban soil has increased and soil can all impact the food sup- Learning Objectives
dramatically in recent decades.1-3 Heavy ply. Although there are both natural After completing this continuing edu-
metals in the environment can contami- and anthropogenic (human-caused) cation course, nutrition professionals
nate the food supply and lead to harmful sources of heavy metals, anthropogenic should be better able to:
effects on human health and cognition. sources are the primary cause of heavy
1. Name five heavy metal contami-
Arsenic, lead, cadmium, mercury, metal pollution.7 They include emissions
nants found in food.
and chromium are among the top from factories, mines, power plants, and
environmental substances endanger- vehicles and discharge of industrial and 2. List four sources of heavy metal
ing human health, according to the US agricultural waste products.1,8,9 Natural contamination of food.
Agency for Toxic Substances and Dis- sources of heavy metals include ground-
3. Detail at least six potential health
ease Registry (ATSDR) and the US Envi- water, weathering and erosion, forest
complications of heavy metal
ronmental Protection Agency (EPA).1 fires, and volcanic ash.1,9,10
ingestion.
Heavy metals impact the health of mil- Agricultural use of pesticides, herbi-
lions worldwide.6 Populations particu- cides, fertilizers, livestock manure, sew- 4. Name eight organizations working
larly vulnerable to their effects include age sludge, and contaminated water can to limit heavy metals in food sources.
infants, young children, and pregnant also contribute heavy metals to the food
5. Describe strategies for limiting the
people. Enhancing their knowledge of supply.1 Contaminated soil and irrigation
ingestion of heavy metals.
the risks of heavy metal ingestion from sources may be used in areas struggling

34 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

tomato, pumpkin, cucumber, cabbage, older adults and neurodevelopmental miscarriage, stillbirth, premature birth,
spinach, and lettuce, grown on contami- damage in children.1,3,8,12,23 or low birth weight.3,19 Low to moderate
nated farmland in China found that the exposure in childhood has been associ-
leafy vegetables (like cabbage, lettuce, Heavy Metals and Children’s Health ated with negative effects on neurocogni-
and spinach) absorbed the greatest con- Heavy metal exposure during preg- tive development, including lower IQ.8,19
centration of heavy metals, particularly nancy can lead to adverse effects on the
cadmium, while the melon-type vegeta- fetus. Many toxic heavy metals cross Cadmium
bles (such as cucumbers and pumpkin) the placental barrier and can nega- Sources of cadmium include occupational
absorbed the least.16 tively impact fetal growth and develop- exposure (eg, metal machining, welding,
Climate, weather, soil pH, crop rotation, ment.12,24 Heavy metals can also pass to painting) and smoking, but diet accounts
and harvest and storage conditions and infants through breastmilk.24 for most exposure in nonsmokers.23 Once
practices can also impact contaminant Small children are particularly sus- absorbed, a large percentage of cadmium
levels in crops.17,18 Because rice plants are ceptible to the effects of dietary heavy accumulates in the kidneys and liver.29
grown in flooded conditions that increase metal exposure. Both their typically lower Cadmium interferes with the absorption
the amounts of contaminants absorbed by dietary variety and two- to three-fold of calcium, iron, and zinc.3,15 Cadmium
their roots, rice tends to have higher con- higher food intake for their body weight toxicity can lead to anemia and damage
centrations of heavy metals, particularly compared with adults can lead to greater to multiple organs and systems, includ-
arsenic and mercury, than other grains.13,19 exposure.8,19,25 Furthermore, their greater ing the kidneys, liver, bones, muscles, and
Some studies of crops grown on con- intestinal absorption and lower renal lungs, and the gastrointestinal, reproduc-
taminated urban and suburban soil have secretion of heavy metals can result in tive, and nervous systems.3,4,13,15,25
determined that their heavy metal levels more accumulation.8,25 Young children’s The EPA has designated cadmium as
were high enough to pose a risk to human rapidly developing brains and nervous a probable human carcinogen.30 It’s been
health, especially for children.2,16 systems are more vulnerable to damage associated with cancers of the kidney,
from toxins like heavy metals.2,19 bladder, gastrointestinal tract, lungs, pan-
Health Effects of Heavy Metals creas, breast, and prostate.3,4,20
Heavy metals can cause toxicity in liv- Heavy Metal Disease Risk Cadmium can inhibit nutrient trans-
ing organisms, including animals used The degree of heavy metal toxicity and fer across the placenta during pregnancy
for food and humans, because they bio- resulting health impacts vary in indi- and has been linked with lower infant birth
accumulate in the food chain and don’t viduals depending on their age, weight, weight and length.15,29 Exposure to cad-
easily biodegrade.8,12,14 Though humans sex, and other physiological factors mium in infancy and early childhood has
can also absorb heavy metals through and on the dose and type of metal, its been associated with lower IQ and a higher
inhalation or skin contact, ingestion bioavailability—the amount actually incidence of the neurodevelopmental disor-
through water or food is a major route absorbed—and the route and frequency der ADHD.8 A cross-sectional study found
of exposure.2,3,12,20,21 of exposure.8,12,18,26,27 Arsenic, cadmium, that school-aged children with the inatten-
Exposure to very high doses of heavy chromium, lead, and mercury have been tive subtype of ADHD had higher levels of
metals can cause acute toxicity, leading prioritized by regulatory agencies due to cadmium than children with the hyperac-
to severe gastrointestinal effects, neuro- the hazards they present to environmen- tive-impulsive subtype of ADHD or healthy
logical effects, or kidney failure, and may tal and human health. controls.31 Higher cadmium levels in the
be fatal.3,6,15,22 With chronic lower-level study were negatively correlated with IQ.31
exposure, heavy metals can build up in Arsenic
bone, muscle, fatty tissue, and organs and Contaminated water and food are the most Chromium
damage cells and enzymes throughout common sources of arsenic.10 Inorganic Chromium III, or trivalent chromium, is a
the body.1,2,6,12 arsenic is highly bioavailable and more trace element found in a variety of foods.
Heavy metal accumulation in the toxic than its organic forms.3,10,19,28 Expo- Chromium VI, or hexavalent chromium, is
body can deplete essential nutrients sure to large doses of arsenic can be fatal.19 a toxic byproduct of industrial processes.5
and may cause anemia.1,3,8,12 It can Chronic arsenic exposure has been It’s challenging to differentiate between
harm the bones, kidneys, liver, and associated with increased mortality and chromium III and chromium VI because
lungs, as well as the cardiovascular, negative health impacts on the kidneys, natural reducing agents in many foods
reproductive, and immune systems, liver, muscles, and skin, and on pulmonary, and the gastrointestinal tract can convert
and can cause macular degeneration in cardiovascular, hematological, gastroin- chromium VI to chromium III.21 Although
older adults.1,3,8,12,23 Heavy metals, nota- testinal, immunological, and neurological toxicity can occur from contaminated
bly chromium, cadmium, and arsenic, systems.3,8 It’s been strongly linked with food or water, the FDA has reported low
can cause oxidative stress and carci- ischemic heart disease, skin lesions, and levels in food samples.3,21
nogenic effects in the body.1,3,4,12 These lung and bladder cancers.19 It’s also been Exposure to elevated levels of the toxic
effects are dose-dependent and may be associated with skin and kidney cancer.20 form of chromium can damage the kid-
cumulative with exposure to multiple Arsenic crosses the placenta, and neys, skin, and gastrointestinal system.
heavy metals. 3,16 Heavy metal expo- limited research indicates that even low It’s classified as a carcinogen and has been
sure can also impact cognition and has to moderate exposure in pregnancy can linked with cancers of the lung, larynx,
been linked with cognitive decline in adversely affect the fetus, resulting in bladder, kidney, testicle, thyroid, and bone.3

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 35

CPE Monthly

Lead a cross-sectional study of Taiwanese chil- methylmercury through food, primar-

Lead can have negative effects through- dren with and without ADHD, lead levels ily aquatic foods.3,13,21,36 Methylmercury is
out the body. Once absorbed, it’s stored were positively correlated with the ADHD easily absorbed and dispersed through-
in bones and continues to circulate in symptoms of inattention, hyperactivity, out the body and crosses blood-brain and
the body for decades.32 Lead toxicity can and impulsivity and were negatively cor- placental barriers.3,21,37
impact heme synthesis, leading to iron related with IQ.31 No known level of lead is Mercury toxicity can damage the
deficiency anemia, and may interfere with safe for children’s neurodevelopment, mak- central nervous system, kidneys, liver,
vitamin D synthesis.22,33 It can damage ing it difficult for regulatory agencies to set and gastrointestinal tract. 3,6 Young
bones and kidneys and can cause hyper- exposure limits.21,26 Lead toxicity can lead to children, particularly infants, are more
tension and damage to cardiovascular, other negative effects in children, including susceptible to central nervous system
pulmonary, gastrointestinal, hepatic, and hearing damage, stunted growth, delayed damage from mercury.13 Prenatal mer-
neurological systems.3,6,15,21 puberty, and kidney damage.8,34 cury exposure has been linked with
Lead can pass through the placenta Recent research suggests that adults birth defects, lower IQ, and neurode-
during pregnancy. Lead exposure in preg- with chronic low-level lead exposure are velopmental issues in children.3,8,31,37
nancy is associated with several negative also at risk of adverse effects, including Though research is limited, some stud-
outcomes, including miscarriage, elevated decreased cognitive function and CVD.15,35 ies have found that prenatal mercury
blood pressure, preterm birth, fetal growth A prospective study of 14,289 US adults exposure was associated with poorer
restriction, and low birth weight.15,26,32,34 found that even blood lead levels below cognitive and fine motor function in
While house dust, contaminated soil, the CDC’s action level for adults (5 mcg/dL children and adolescents.13,37
and drinking water are the major routes of during the study period) were associated
lead exposure for children, contaminated with all-cause, cardiovascular, and isch- Heavy Metals in Foods
food remains a concern.10,34 Children absorb emic heart disease mortality.35 Heavy metal levels in foods vary widely
higher amounts of ingested lead than adults depending on location and sources of
and are highly sensitive to its neurological Mercury contamination. Multiple organizations
effects.26,32 These can include permanent Organic forms of mercury are more toxic worldwide regulate heavy metals in the
cognitive damage, developmental delays, than inorganic mercury. Humans are food supply to help protect human and
and attention and behavioral issues.8,15,34 In mainly exposed to the organic compound environmental health. Many have set

TABLE 1
Regulatory Agency Abbreviations

Abbreviation Organization or Program

ATSDR Agency for Toxic Substances and Disease Registry

CAC Codex Alimentarius Commission

CCFAC Codex Committee on Food Additives and Contaminants

CDC Centers for Disease Control and Prevention

CONTAM The Panel on Contaminants in the Food Chain

EFSA European Food Safety Authority

EPA Environmental Protection Agency

FAO Food and Agricultural Organization of the United Nations

FDA Food and Drug Administration

HHS Health and Human Services

IRIS Integrated Risk Information System

JECFA Joint FAO/WHO Expert Committee on Food Additives

OEHHA California Environmental Protection Agency’s Office of Environmental Health Hazard Assessment

USDA United States Department of Agriculture

WHO World Health Organization

36 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

TABLE 2
Organizations Regulating Heavy Metals1-15

Regulatory Body Affiliations Location Reference Values

JECFA, CCFAC, CAC FAO/WHO International Tolerable Intakes

EPA IRIS Program United States Reference Doses (RfDs)

ATSDR HHS, CDC United States Minimal Risk Levels (MRLs)

FDA HHS, Toxic Elements United States Interim Reference Levels (IRLs)
Working Group

EFSA CONTAM European Union Tolerable Intakes

USDAI FDA United States n/a

OEHHAII California EPA California, United States No Significant Risk Levels

(NSRLs)III and Maximum
Allowable Dose Levels (MADLs)IV

I PARTNERS WITH THE FDA TO RESEARCH AND MONITOR HEAVY METALS IN THE FOOD SUPPLY
II ADMINISTERS THE PROPOSITION 65 PROGRAM UNDER THE SAFE DRINKING WATER AND TOXIC ENFORCEMENT ACT OF 1986
III FOR CANCER-CAUSING CHEMICALS
IV FOR CHEMICALS CAUSING REPRODUCTIVE TOXICITY

limits, also known as reference values, for done in Europe, the Middle East, South several brown rice and one US white rice
human exposure to heavy metals from America, and North America, with the sample exceeded Codex Alimentarius
food and drinking water. Reference val- largest number done in Asia, found that Commission arsenic limits.20 Brown rice
ues vary by organization and are based many foods analyzed, some of which were tends to contain more arsenic and mer-
on dose-response data from studies of produced in contaminated areas, had cury than white rice due to its concentra-
humans and lab animals.21 heavy metal levels surpassing the study tion in the bran.13 According to data from
Assessing the risk of heavy metal inges- limits (adapted from international ref- the FDA’s Total Diet Study, which conducts
tion from specific foods is complicated by erence values) for lead, arsenic, or cad- biannual studies of food contaminants in
limited and varying reference values, lim- mium.12 While all food groups included popular foods and food ingredients sold
ited research, and the global food trade.4,12 samples with elevated heavy metal levels, across the United States, rice and rice
International reviews have frequently those most frequently exceeding limits products like cereals had the highest mean
found elevated levels of heavy metals in were vegetables and grains, mainly rice.12 levels of inorganic arsenic.19,21,28
aquatic foods, vegetables, and fruits.12 An analysis of US and imported rice Some imported candies made with
One review of 152 studies, including those from Thailand, India, and Italy found that tamarind or chili powder contain elevated
levels of lead.34,38 Additionally, nonprofit
groups have recently alleged that many
TABLE 3 chocolate bars available for retail sale
US Nonprofits Advocating for Stricter Heavy could result in consumers exceeding Cali-
Metal Regulation in Food fornia’s Maximum Allowable Dose Levels
(MADLs) for lead and cadmium.39 Pend-
ing resolution of a lawsuit brought by the
Organization Link nonprofit environmental and social justice
group As You Sow against members of the
confectionary industry, an expert commit-
American Academy of www.healthychildren.org/English/ages-stages/baby/
tee established interim limits for lead and
Pediatrics feeding-nutrition/Pages/Metals-in-Baby-Food.aspx
cadmium in cocoa and chocolate prod-
Consumer Reports www.consumerreports.org/issue/food-safety ucts sold in California and made recom-
mendations for manufacturers to reduce
Environmental Defense Fund www.edf.org/health/heavy-metals-food heavy metals in their products, including
changes in growing and harvesting prac-
Healthy Babies, Bright Futures https://hbbf.org
tices.40 Products with a higher percentage
Clean Label Project https://cleanlabelproject.org of cocoa have proportionally higher levels
of cadmium and lead.18 Research indicates

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 37

CPE Monthly

that cadmium is more bioavailable from and the EPA have recommended that babies may be at higher risk than babies of
cocoa products than lead.18 children and people who are pregnant or other ethnicities since they’re more likely to
Vegetables, particularly leafy greens; breastfeeding avoid large predatory fish consume rice.44 Rice cereals are a common
seeds; shellfish; organ meats; nuts; and rice like bigeye tuna, shark, swordfish, marlin, first food, and studies have found 4.5-fold
and other grains are also common sources king mackerel, tilefish, and orange roughy increases in infants’ levels of toxic inor-
of cadmium.3,4,10,29 The US-sold foods with due to the risk of elevated mercury levels.42 ganic arsenic after weaning.8 Brown rice
the highest mean cadmium levels, accord- infant cereals tend to have more arsenic
ing to recent Total Diet Study data, were Infant and Toddler Foods than those made from white rice. In 2020,
sunflower seeds and spinach.28 Some Heavy metal contamination of baby food the FDA finalized its action level for arsenic
studieshave found higher cadmium levels is an ongoing concern, particularly since in infant rice cereal in an effort to moder-
in vegetarians compared with omnivores, infants and toddlers are highly vulner- ately reduce the risk of arsenic exposure in
and researchers have suggested that this able to the adverse effects of heavy metals. children, particularly infants.19,45
may be due to higher consumption of plant Regulatory agencies and nonprofits have However, in a recent study estimating
foods containing cadmium, like spinach, reported recent tests detecting lead, arsenic, the risk of infants and toddlers’ exposure
potatoes, and sunflower seeds.4,24 cadmium, or mercury in many commer- to heavy metals from a variety of com-
Seafood is the most common food cial baby and toddler foods.8,43 Infant and mercial baby foods, both rice-based infant
source of mercury, although rice, leafy toddler foods, including baby food sweet cereals tested exceeded FDA action levels
vegetables, and other foods can also potatoes and teething biscuits, were among for arsenic.46 Arsenic was determined to
contain mercury, depending on where the foods with the highest mean lead levels, present the most significant health risk of
they’re produced.3,4,13,41 According to according to recent Total Diet Study data.28 the heavy metals, although organic and
Total Diet Study data, the US-sold foods Although arsenic levels have decreased inorganic arsenic weren’t differentiated.46
with the highest mean levels of mercury significantly in US infant cereal and juice The researchers judged that levels of cad-
were canned tuna, baked cod, and baked over the past decade, arsenic in rice and mium and mercury in the tested foods did
salmon, but none exceeded the FDA’s rice products may still pose risks to the not pose risks, while lead was assessed
action level for methylmercury.28 The FDA youngest consumers.44 Asian and Hispanic to present a small risk to young children;

TABLE 4
Current Heavy Metal Reference Values for Oral Intake (Per Day)1-12

Organization
(Reference Value) Arsenic Cadmium Chromium VI Lead Methylmercury

JECFA (PTMI, PTWI) 0.8 μg/kga 0.23 μg/kgb

FDA (IRLs) 2.2 μgc, 8.8 μgd

EPA (RfDs) 0.3 μg/kge 1 μg/kg 3 μg/kg 0.1 μg/kg

ATSDR (MRLs—for
0.3 μg/kg 0.1 μg/kg 0.9 μg/kg 0.1 μg/kg
chronic exposuref)

OEHHA (NSRLs, MADLs) 10 μgg 4.1 μgh 8.2 μgh 0.5 μgh

EFSA (TWIs) 0.36 μg/kgi 0.19 μg/kgj

a ESTIMATED FROM PROVISIONAL TOLERABLE MONTHLY INTAKE (PTMI) OF 25 ΜG/KG

b ESTIMATED FROM PROVISIONAL TOLERABLE WEEKLY INTAKE (PTWI) OF 1.6 ΜG/KG
c FOR CHILDREN
d FOR “FEMALES OF REPRODUCTIVE AGE”
e FOR INORGANIC ARSENIC
f CHRONIC EXPOSURE IS DEFINED AS ONE YEAR OR GREATER
g NSRL FOR INORGANIC ARSENIC
h MADL
i ESTIMATED FROM TOLERABLE WEEKLY INTAKE (TWI) OF 2.5 ΜG/KG
j FOR METHYLMERCURY, ESTIMATED FROM TWI OF 1.3 ΜG/KG
e FOR INORGANIC ARSENIC
f CHRONIC EXPOSURE IS DEFINED AS ONE YEAR OR GREATER
g NSRL FOR INORGANIC ARSENIC
h MADL
i ESTIMATED FROM TOLERABLE WEEKLY INTAKE (TWI) OF 2.5 ΜG/KG
j FOR METHYLMERCURY, ESTIMATED FROM TWI OF 1.3 μG/KG

38 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

TABLE 5
Highlighted Reference Values for Specific Foods1-9

Organization/Term Food Arsenic Cadmium Lead Methylmercury

FDA action level Fish and shellfish 1 ppm

FDA action level CandyI 100 ppb

FDA action level Infant rice cereal 100 ppb

FDA draft action levels Baby foodII 10 ppb

FDA draft action levels Baby foodIII 20 ppb

FDA action level Apple juice 10 ppb 10 ppb

FDA draft action level Other juices 20 ppb

EU maximum level Fruit juices 50 ppb

EU maximum level Infant formula 5–20 ppbIV 20 ppb

EU maximum level Infant food and cereal 40 ppb

EU maximum level Cocoa products 600–800 ppbV

OEHHA interim warning levels Cocoa products 400–960 ppbVI 100–225 ppbVII

I “LIKELY TO BE CONSUMED BY YOUNG CHILDREN”

II INCLUDES FRUITS, VEGETABLES OTHER THAN ROOT VEGETABLES, YOGURTS, CUSTARDS/PUDDINGS, AND SINGLE-INGREDIENT MEATS
III INCLUDES SINGLE-INGREDIENT ROOT VEGETABLES AND DRY INFANT CEREALS
IV VARIES BY TYPE OF FORMULA
V VARIES BY COCOA CONTENT UP TO 800 PPB FOR PRODUCTS WITH 50% OR MORE COCOA
VI VARIES BY COCOA CONTENT UP TO 960 PPB FOR PRODUCTS WITH OVER 95% COCOA
VII VARIES BY COCOA CONTENT UP TO 225 PPB FOR PRODUCTS WITH OVER 95% COCOA

lead levels were just over California’s was partially attributed to the children’s lead, cadmium, and mercury in the food
MADL in some products—mostly cereal frequent consumption of these foods.25 supply.48 They have drafted guidance for
grains, sweet potatoes, and carrots.46 In 2021, the US House of Representatives action levels for lead in juice and processed
A study evaluating the food intake of Subcommittee on Economic and Con- infant and toddler foods.47,49,50 In collabo-
3,103 children aged 1 to 6 years for lead sumer Policy reported that four of seven ration with the USDA, they’ve also been
and cadmium exposure, using Total Diet major baby food manufacturers’ products investigating methods to reduce heavy
Study and National Health and Nutri- contained concerning levels of arsenic, metal absorption by crops.48,51
tion Examination Survey data, found lead, cadmium, and mercury, while three As of January 2024, the FDA confirmed
that many foods commonly consumed of the companies hadn’t provided the that elevated levels of lead found in at least
by children contained detectable levels of information requested.8,47 The subcommit- 90 people across the United States, mainly
cadmium and lead. Children’s mean esti- tee recommended that manufacturers be babies and young children, were linked to
mated lead exposure was below the FDA’s required to test for and disclose the pres- three brands of now-recalled cinnamon
Interim Reference Level (IRL); however, ence of heavy metals in their products and applesauce pouches, which reportedly
at the 90th percentile, the mean estimated to replace any ingredients, such as rice or contained imported cinnamon with high
exposure exceeded the IRL.25,27 Children’s vitamin mixes, identified as sources of con- levels of lead and chromium.52 This incident
mean estimated cadmium exposure taminants. It also recommended that the demonstrates the challenges associated
exceeded ATSDR limits but not Joint FAO/ FDA set protective limits for lead, arsenic, with regulation of some imported herbs
WHO Expert Committee on Food Addi- cadmium, and mercury in baby foods.47 or spices. The FDA’s Center for Food Safety
tives limits. Grains, vegetables, and food Nonprofit groups have also advocated for and Applied Nutrition routinely monitors
mixtures, primarily entrees composed of more stringent limits for heavy metals in and prevents such products from entering
foods from various groups, contributed infant and toddler foods.43,47 In response to US commerce through sampling at import.
most to their cadmium exposure, while concerns, the FDA formed its Closer to Zero However, these surveillance approaches
grains, dairy, fruit, and food mixtures con- action plan focused on reducing infants’ only evaluate a subset of the products
tributed most to their lead exposure; this and young children’s exposure to arsenic, imported and may not catch everything. In

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 39

CPE Monthly

the “FDA Alert Concerning Certain Cinna- highly polluted areas.55 A recent analysis gluten. Researchers theorized that higher
mon Products Due to Presence of Elevated of 1,496 spice samples from the New York intakes of fish and rice-based foods by
Levels of Lead,” the FDA states that it is “the City Department of Health and Mental those following gluten-free diets may
responsibility of the manufacturers and the Hygiene’s investigations found that over also contribute to increased heavy metal
importers to ensure the safety of the prod- 50% of them had detectable lead levels, levels, although the study didn’t analyze
ucts that enter into the US market.” with over 30% exceeding their guidance specific dietary intake.56
level of two parts per million (ppm), with
Effects of Food Processing and spices purchased abroad having signifi- Recommendations for RDs:
Preparation on Heavy Metal Content cantly higher levels.54 Putting It Into Practice
Methods of processing, packaging, A North Carolina study based on Heavy metal contamination of food can
preparing, and storing foods can impact inspections of the homes of 61 children endanger public health, particularly
heavy metal content.8,14,17,18 Processing with elevated lead levels discovered during vulnerable life stages, includ-
rice can lower its arsenic content; instant Ayurvedic medicine and spices, including ing pregnancy, infancy, and childhood.
rice has significantly less arsenic than saffron and turmeric, with high levels of Exposure to toxic heavy metals can
standard rice.19 Research has also found lead.55 Research has found that up to one- lead to a host of adverse effects, such as
that rinsing rice prior to cooking it third of Ayurvedic medicinal products are essential nutrient depletion, damage to
lowered levels of heavy metals, including contaminated with lead, mercury, or arse- multiple organs and body systems, and
arsenic, in the range of 28% to 60%, while nic, particularly lead.3,10,55 impairment of neurodevelopment and
cooking it in extra water decreased cognition. As food and nutrition profes-
arsenic levels by 40% to 60%, though Nutrition Status and Heavy sionals, RDs are uniquely positioned to
using water high in arsenic can increase Metal Toxicity advocate effectively for reducing harm-
levels.19,20 Rinsing and cooking rice in People’s nutrient status can affect their ful heavy metals in the food supply in
extra water also lowers levels of enriched vulnerability to toxic heavy metals.32 collaboration with other health experts,
nutrients, including iron, folate, thiamin, Higher levels of some essential micro- nonprofit groups, and lawmakers.
and niacin, which may be problematic nutrients appear to protect against lead RDs can also help clients reduce their
in cases where rice is a critical source toxicity; zinc reduces lead absorption in risk of heavy metal toxicity by assessing
of these nutrients.19,20 Cooking may also the gastrointestinal tract.32 In pregnancy, for adequate levels of essential nutri-
lower the bioavailability of mercury in higher intakes of calcium have been associ- ents, particularly iron, calcium, and zinc,
seafood; the mercury in canned tuna ated with lower blood lead levels.26 Inad- encouraging them to consume a variety
tends to be less bioavailable than that in equate levels of calcium, iron, and zinc can of nutrient-rich foods, and avoiding or
raw tuna, likely due to heating during increase lead absorption and have been limiting products that tend to be high
the canning process.41 linked with lead toxicity, particularly in in heavy metals. RDs should encourage
Processed food ingredients like spices, children.26,32 A study of 310 Pakistani chil- caregivers of infants and toddlers to offer
enzymes, or micronutrients may be con- dren aged 1 through 10 found that lower a variety of cereal grains and limit fruit
taminated with heavy metals, which can blood levels of calcium, iron, and zinc were juices and processed foods made with
contaminate final products.8 Filtering associated with higher lead levels and that rice ingredients.44,46,57,58 They can also
beverages with processing aids that con- malnourished children had lower levels of advise clients on food preparation tech-
tain mined minerals like bentonite clay essential micronutrients and higher levels niques that may reduce heavy metals,
or diatomaceous earth can increase their of lead than well-nourished children.32 such as rinsing rice or cooking it in extra
heavy metal content. Some studies have Susceptibility to cadmium’s effects can water.8,20 Thoroughly washing produce,
found increased levels of arsenic, lead, also be influenced by nutrient status. Hav- removing the outer layers of leafy vegeta-
and cadmium in fruit juices, wine, sake, ing adequate stores of calcium, iron, and bles, and peeling root vegetables may also
or beer after filtration with bentonite or zinc can lower cadmium absorption from lower heavy metal exposure.14
diatomaceous earth.53 One observational food, and zinc protects against oxidative RDs can play a critical role in reduc-
study found higher lead levels in women stress and bone damage from cadmium.29 ing the adverse environmental and public
who drank more than two alcoholic bever- Conversely, deficiencies of protein, calcium, health effects of heavy metals by advo-
ages per week, though their levels were well and vitamin D can increase susceptibility cating for more research and regulation.
under reference values.24 Storing or con- to bone damage from cadmium.29 They can also assist individuals with opti-
suming food or beverages from containers Following a gluten-free diet may be mizing their nutrition status and intake to
contaminated with lead, such as lead-glazed a risk factor for heavy metal exposure, limit heavy metal exposure. I
ceramic, can also lead to lead exposure.14 possibly due to a lower intake of essential
minerals, including iron and zinc.56 In a Sara Chatfield, MPH, RDN, LDN, is a
Heavy Metals in Spices cross-sectional study based on National Chicago-based freelance nutrition writer
and Supplements Health and Nutrition Examination Sur- who has practiced dietetics in clinical and
A number of spices and supplements, vey data from 2009 to 2012, individuals community settings.
particularly imported herbal and tra- following gluten-free diets had signifi-
ditional remedies, have been identified cantly higher blood levels of mercury, For references, view this article on our
as potential sources of lead and cad- lead, and cadmium and urine levels website at www.TodaysDietitian.com.
mium.29,54 Many spices are imported from of arsenic than those not restricting

40 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

 Become a CPE Monthly Pass holder for access to CPE
Monthlies and their associated exams for about $8/credit!
Go to CE.TodaysDietitian.com/CPEMonthlyPass and get
your Pass to Monthly CPEs.

CPE Monthly Examination

1. The Food and Nutrition Board has set adequate intakes 6. As part of their Closer to Zero action plan, the FDA
for the following heavy metal, which also has a toxic form: has recently drafted guidance for action levels for lead
in which foods?
a. Arsenic
b. Chromium a. Chocolate and baked goods
c. Mercury b. Fish and shellfish
d. Cadmium c. Milk and infant formula
d. Juice and processed infant and toddler foods

2. What is a common anthropogenic source of heavy

metals in the environment? 7. Research has found that up to this amount of Ayurvedic
medicinal products are contaminated with heavy metals,
a. Erosion
especially lead:
b. Forest fires
c. Volcanic ash a. One-half
d. Agricultural waste b. One-third
c. One-fifth
d. One-eighth
3. In a Chinese study of 22 types of vegetables grown in
contaminated soil, which group of vegetables absorbed the
greatest concentration of heavy metals? 8. Having adequate levels of calcium, iron, and zinc has
been associated with a reduced risk of toxicity from which
a. Root vegetables like carrots and sweet potatoes
heavy metal(s)?
b. Melon-type vegetables like cucumbers and pumpkin
c. Leafy vegetables like cabbage and spinach a. Chromium III and chromium VI
d. Caitai, a “stalk” vegetable b. Methylmercury
c. Lead and cadmium
d. Arsenic
4. In 2020, the FDA reduced its action level for the follow-
ing heavy metal often found to be elevated in infant rice
cereal: 9. What strategy can cut down on arsenic ingestion
from rice?
a. Nickel
b. Chromium a. Choosing brown rice
c. Arsenic b. Purchasing fortified rice
d. Zinc c. Purchasing organic rice
d. Rinsing rice prior to cooking

5. The US Environmental Protection Agency and the FDA

have advised children and people who are pregnant or 10. What strategy is recommended to help reduce heavy
breastfeeding to avoid consuming large predatory fish due metal ingestion from produce?
to the risk of ingestion of which heavy metal?
a. Avoiding leafy vegetables
a. Mercury b. Avoiding nonorganic produce
b. Chromium VI c. Thorough washing
c. Arsenic d. Leaving the peel on root vegetables
d. Lead

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NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 41

Focus on Fitness By Dana Angelo White, MS, RDN, ATC

Sports Nutrition performance dietitian positions available

within the collegiate setting has absolutely
exploded over the last decade,” Knappen-
in Collegiate Athletics berger says. “In 2014, I can remember our
organization celebrating the creation of
The Value of the Interprofessional Team each and every full-time dietitian position
at Power 5 universities. Now, we have Col-

I
n late 2022, a project nearly 10 years included the ASPDA, the National Ath- legiate Performance Nutrition programs
in the making was finally published letic Trainers’ Association, the Sports and with over eight RDs! We also see RDs sup-
in the Journal of Athletic Training. Human Performance Nutrition (SHPN) porting DII and DIII athletes! It’s incredible
The Interassociation Consensus subgroup of the Academy of Nutrition growth and I absolutely love the countless
Statement on Sports Nutrition Models for and Dietetics, the American Medical stories that pour into ASPDA about the
the Provision of Nutrition Services From Society for Sports Medicine, and the impact that these RDs are having on ath-
Registered Dietitian Nutritionists in Col- Collegiate Strength and Conditioning lete health, performance, and experience.”
legiate Athletics1 was the brainchild of Coaches Association. With this growth comes the need for
a small group of sports dietitians that The paper established evidence-based more organization and collaboration
now aims to set the standards for care for practice models for RDs specializing in among the various clinicians who prac-
sports nutrition services for college ath- sports dietetics (sports RDs) working in tice within athletic departments. Defining
letes and support staff. all ranges of capacities.1 It’s a document to roles and knowing how other clinicians
This statement was the first of its kind share with members of the athletic medi- operate can help create more efficient pro-
and created an opportunity for all the cine team as well as coaches and admin- tocols and better care for student athletes.
important clinicians involved in college istrators to help build staffing that could
sports to collaborate, define their roles, range from a part-time consultant to a Defining Roles in College Sports
and optimize care while simultaneously department with several full-time staff. Sports RDs and credentialed board-certi-
giving athletic departments tools to help In addition, the paper demonstrates fied specialists in sports dietetics (CSSDs)
structure programs big and small. and explains the extensive training sports are the preferred nutrition providers
Victoria Lambert, MS, RD, lead author RDs have in medical nutrition therapy, at the college level due to the unique
and member of the American Sports education and behavioral counseling, food demands of the job.
and Performance Dietitians Association service management, exercise physiology, Sports RDs often work alongside ath-
(ASPDA), formerly named the Collegiate physical performance, and administration. letic trainers, strength and condition-
and Professional Sports Dietitian Associa- ing coaches, medical doctors, sports
tion (CPSDA), shares what led to the need The Growth of Sports RDs psychologists, physical therapists, and
to convene on this topic. In 1994, one Division 1 university employed other medical professionals to provide
“During the early part of my tenure as one full-time sports RD. To date, at least comprehensive and collaborative inter-
Princeton University’s sports and eating 30% of D1 programs have at least one full- professional care. While all these prac-
disorders dietitian, collegiate sports time sports RD on staff, and the numbers titioners play a crucial role in the health
nutrition was experiencing a huge wave continue to grow.2 Katie Knappenberger, and safety of student athletes, sports
of growth and it was becoming clear MS, RD, CSSD, ATC, president of ASPDA, RDs are specially trained in key areas.
that without a unified path forward, recalls the amazing growth the field has Lambert et al identify specific areas of
the specialty may not advance in ways I experienced. “The number of sports and expertise and demonstrate how they are
and others thought prioritized our roles
as health care providers, clinical sports
dietitians, and sports scientists. By 2013, I
was serving as a board member for CPSDA
and brought the idea to the leadership
who responded with unanimous support.
From there, a committee was formed that
included myself as well as Jen Ketterly, MS,
RD, CSSD, LDN, who was at Georgia at the
time, and Amy Culp, RD, CSSD, CEDS-C,
from the University of Texas at Austin. Our
first meeting took place in Texas in 2014.”
In the years that followed, the writing
team expanded to six authors. After years
of drafts, edits, feedback, and eventually
approval from partnering organizations,
the paper was submitted and approved
for publication by the Journal of Athletic
Training. The organizational review panel

42 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

 Strength & ŽŶĚŝƟŽŶŝŶŐ Coaches Certified Athletic Trainers Sports RDNs

Basic Knowledge: Identify & Refer Basic Knowledge: Identify & Refer Clinical Sports Nutrition
• Basic strategies for manipulating food • Knowledge of general nutrition concepts • Evaluation & treatment of clinical diagnoses
choices & training methods to maximize to prevent injury & illness & maintain a requiring medical nutrition therapy
performance healthy lifestyle • Evaluation & treatment of disordered eating &
• Provide guidance in nutrition and injury eating disorders
• Assess & monitor weight status & body
prevention composition • Physical examination
• Basic knowledge of risks and alternatives • Identify signs & symptoms of disordered • Medical & nutrition history
for common performance-enhancing eating & eating disorders • Assess nutrient & energy needs
substances • Assess food & nutrient intake
• Explain usage patterns & effects of
• Recognize signs and symptoms of eating common dietary supplements & • Anthropometric assessment
disorders performance-enhancing substances • Biochemical assessment
• Assess hydration status, fluid, & • Hydration assessment
electrolyte replacement
• Assess drug–nutrient interactions
• Assess nutritional status & nutrient timing • Evaluation of dietary & herbal supplements
• Assess food access & availability
commonly executed in college sports. • Communicate & coordinate plan of care with
Examples of these areas are summa- interdisciplinary team
• Monitor & evaluate progress
rized in the following1:
• Chronic disease prevention & immune system
experience away from home can be enhancement
• Clinical sports nutrition practice overwhelming. Furthermore, college • Pre- & postevent fueling & recovery
includes identification and treatment campuses present a new food uni- Nutrition Education
of nutrient deficiencies, risks to cardio- verse for athletes, and many struggle • Team & individual nutrition education
metabolic health, and eating disorders to meet their nutrient needs. These • Community education
and disordered eating in an athletic issues are often made more difficult Food-Service Administrative Management
• Management of food service operations
population. with additional information athletes
• Finance, budget, & contract negotiations
• Onsite delivery of nutrition education for access via social media. Many ath-
teams, individual athletes, and sup- letes report seeking guidance on food
port staff to help navigate the nutrition choices and dietary supplements on
needs of a college athlete in and out of social media, which can put them at
their competitive seasons. greater risk for malnutrition.3,4 tap into resources, including ASPDA and
• Food service management at the cam- The recent NCAA Name, Image, and SHPN to help build their case for more
pus cafeteria, off-campus kitchen, Likeness policy5 that allows athletes to sports nutrition services.
training tables, locker rooms, and off- monetize their personal branding has When asked what the future holds,
site events. There are various access deepened social media connections where Lambert remains hopeful. “The knowl-
points to food that benefit from sports many athletes interact and endorse spe- edge and perception of our training
RD management. cific brands. While this is a wonderful and capabilities still varies and limits
• Performance nutrition encompasses the opportunity for athletes to be compen- our effectiveness in the areas of athlete
management of dietary supplements sated for their hard work, it also makes safety and welfare, in addition to human
and banned substances and the chal- them more susceptible to scrutiny and performance. It’s always been my hope
lenges of proper hydration and avoid- exposes them to brands and products that that administrators, other sports medi-
ing heat illness. may put their health and safety at risk. cine professionals, coaches, and athletes
Having access to a qualified sports RD alike begin to value and utilize the quali-
It’s also worthwhile for sports RDs to can help educate these athletes about the fications and skill set of sports dietitians
understand how to best communicate potential risks associated with partnering to their greatest potential. All the authors,
and delegate to other members of the with and consuming some products. reviewers, and organizations who sup-
health care team when appropriate. Scope ported this work share in that hope.” I
of practice for athletic trainers, physical Looking to the Future
therapists, and strength and conditioning No matter what the size or budget of the Dana Angelo White, MS, RDN, ATC, is a dual
professionals does include some nutrition, institution, there are opportunities for registered dietitian nutritionist and certified
therefore these providers can help support sports RDs to integrate their services. athletic trainer with over 20 years of clinical
the efforts of the sports RD in their role. The consensus statement offers tangible experience. She is a media dietitian, cookbook
data for clinicians to shape their proto- author and full-time professor and sports RDN at
Unique Challenges cols and for athletic department admin- Quinnipiac University in Hamden, Connecticut.
College athletes face unique challenges. istrators to build their departments.
The demands of balancing athletic and Practicing sports RDs are encouraged For references, view this article on our
academic responsibilities, NCAA regula- to communicate and share their expe- website at www.TodaysDietitian.com.
tions, team dynamics, and for many, a first riences and aspiring sports RDs can

TABLE ABOVE REPRINTED WITH PERMISSION FROM THE JOURNAL OF ATHLETIC TRAINING NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 43
Get to Know … By Elizabeth S. Goar

a more traditional career, working as a

clinical dietitian and outpatient nutri-
tion counselor, that passion expanded
to encompass a broader definition of
communications.
“I eventually figured out I enjoy writ-
ing educational materials. When I was in
an outpatient role at a health maintenance
organization, I found I also really enjoyed
speaking to groups,” she says. “I would
create programs for doctors to educate
them about nutrition … I also did a little
television. The marketing department
approached me to write some health blurbs
for its summer television segments and I
did commercials about health and food
safety tips. I thought, ‘Oh, I like this too!’”
When her family relocated from
Pittsburgh to the small Pennsylvania
town of Meadville, Rust—who’s past
chair of the Academy of Nutrition and
Dietetics—set up shop as Rust Nutri-
tion. She freelanced for the local news-
paper, was a guest speaker at the local
college, and was an adjunct professor at
other area colleges.
Today, she’s an established nutrition
communications consultant with more
than eight books and a thriving online
and social media presence.
“The food world is always evolving.
There are always new foods and there
are always new trends and misinforma-
tion,” she says. “I’ve taken challenging
roles in terms of controversial ingredi-
ents or foods, but it always comes down to
Rosanne Rust college, her mother managed her food
choices. “But I happened to be at a state
[whether] this is something I eat, use, and
feel safe about. I’m going to just communi-
Setting the Record Straight school that had a food and nutrition cate the science in the most objective way
major and thought I might like that I can. It’s all about balance.”

G
rowing up with gastroin- because food was a big part of my child- She adds, “My focus is busting myths
testinal (GI) issues and food hood,” Rust says. and communicating the science and
sensitivities that her mother She quickly discovered that she did, information behind a food, ingredients, or
helped control through diet— in fact, like it. Just as quickly, however, a food group.”
no small task in a food-centric Italian she discovered that there was little
family—Rosanne Rust, MS, RDN, a nutri- information to help her better under- Today’s Dietitian (TD): Your tagline
tion communications consultant, was stand her GI issues. is “Food is chemistry. Nutrition is a
aware from a young age that food and “We truly didn’t know that much in the science.” What does that mean and how
health are inextricably intertwined. Yet ’80s … there was no low FODMAP diet or does it reflect your nutrition philosophy?
her health experiences weren’t an early other protocols for gastrointestinal dis- Rust: The tagline came from my favor-
factor in her decision to pursue a career eases and GI health,” Rust says, as she was ite college food science teacher. She said
in nutrition. eventually diagnosed with mild Crohn’s it and it stuck with me. Food is chemis-
In fact, nutrition wasn’t even a consid- colitis. Knowledge at the time “was very try. It’s made up of chemicals. As nutri-
eration as a freshman at Indiana Uni- rudimentary.” tion students, we study lots of chemistry
versity of Pennsylvania. “I initially went Her studies, coupled with her inter- and biochemistry. We talk about carbo-
to college with no intention of studying est in learning more about her condition, hydrates, protein, and fat, which are all
nutrition,” she says. awoke in Rust a passion for writing and made up of chemicals. Carbohydrates are
Nor did she think much about food’s research. In graduate school at the Univer- made up of carbon, hydrogen, and oxygen.
impact on her GI issues because, until sity of Pittsburgh and later while following Today, we see a fear of chemicals because

44 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

people don’t necessarily understand that will kill you.” We dietitians aren’t going what crazy thing is happening I should
all organic matter is made of chemicals. I to do that, so we try to get as creative as be aware of. Then I go through my email,
like to reinforce that food is chemistry and we can to get people’s attention. But it’s which can take hours. From there, every
that the way our body digests food natu- an uphill battle because everyone has a week looks very different. Because I’m a
rally involves lots of chemical reactions, so platform today and anyone can be veri- consultant, I mostly work on a project-
it’s nothing to fear. fied as a human, which is all you need to by-project basis doing whatever is on
be … human. No verified knowledge or the calendar that week. It’s usually some
TD: What are a few egregious credentials required. But there are more writing or editing—this week I went on
misinformation examples you’re of us out there now and we’re all saying a farm tour and need to finish a blog
pushing back against right now? it again and again with the hopes that post—or doing interviews or attending
Rust: There’s still a lot of misinformation repetition works. meetings. Some weeks it’s maintaining
about GMOs. Food labeling like the Non- my own media presence or making sure
GMO Project’s product label magnifies TD: Your latest book, Zero Waste things are going out and dealing with
the confusion in many ways. It’s frus- Cooking for Dummies, tackles the technical stuff. I’m a one-woman show
trating because companies pay to put problem of food waste. What are the and it’s controlled chaos!
that label on food and food manufactur- root causes of food waste?
ers are just slapping it on everything, Rust: The root causes, I believe, are a lack TD: What do you do in your downtime?
even if there’s no GMO alternative. of creative culinary skills, food handling Rust: I play golf. I also love to socialize; to
Ultimately, it doesn’t matter because skills, and confidence in the kitchen. We have people over and enjoy food and drink
they’re all safe. Genetic modification is have all these food shows and videos, together. I started pickleball this summer
just a plant-breeding technique, but it food and foodie blogs, and people who and I try to get some weightlifting in.
can be more precise and is often a much are very committed to recipes. They’ve
quicker way to create a new plant than grown into their adulthood using reci- TD: What are some of your favorite
traditional trial-and-error methods. I pes and they’re not able to wing it. Part of meals or foods and why?
also think that when you call anything reducing food waste is being able to see Rust: All my favorite meals involve pasta.
“free” on a label, the consumer thinks what you have and make something out I grew up in an Italian household, so
you took it out, which isn’t always the of it. An old tomato still has nutritional pasta is my comfort food. I also love rice
case. There’s also a lot of misinformation value, so eat it instead of throwing it and beans in any kind of bowl, like with
about sugar and nonnutritive sweeten- away. Our societal views add to it: We buy chicken or salmon. I love salmon. I love
ers, which are both safe in normal and food and throw food away, buy more and good bread and cheese. Eggplant, too. I
appropriate quantities. But we have a lot throw that away because we know we can love it prepared the Italian way, the Indian
of “sugar-free” or “reduced sugar” label- go back and score more. way, any way. I just love it. In fact, I love
ing that implies that sugar was reduced food, period. Including cake and pastries.
but doesn’t say what replaced it. There TD: What is a zero-waste cooking
are a lot of nuances with ingredient strategy? TD: What are your favorite hobbies
labeling that consumers don’t under- Rust: In my book, I try to get people to and why?
stand. Another trend is all the misinfor- realize they can stop throwing food Rust: I’ve been active my entire life with
mation about seed oils; there’s nothing away by being more mindful. My three tennis, running, walking, skiing, strength
wrong with soybean, corn, or sunflower key messages are “Buy less, store it training, golf, and now pickleball. But I
oil. Finally, the organic and conventional right, and use it all.” It’s about shopping also really enjoy entertaining. I love rear-
produce debate. It’s a myth that certified strategies and making sure you know ranging the furniture. I like to change
organic is superior. how you’re going to use everything things around every season. People seem
that goes into your cart. And then food to enjoy being in my home and I enjoy
TD: Misinformation can spread storage—how to store food and how long the art of decorating and staging a home,
like wildfire on social media. Can it lasts. The freezer is your friend! Zero creating cozy spaces that draw people in.
social media be equally powerful at waste is a lot of back-to-basics education That’s sort of my hobby—bringing people
combatting it? for having a good shopping plan, a good together and creating fun connections.
Rust: I do think it can and that’s why food plan, and properly storing the food.
I’m doing it. But my personal conclu- Frozen and canned fruits and vegetables TD: If we were to peek into your pantry
sion is that it’s more challenging for us are just as nutritious as fresh, and they or refrigerator, what would we find?
as health professionals, as RDs with help reduce food waste because they Rust: Yogurt and berries (most often blue-
the credentials and an ethics code, to won’t go bad in a week. berries), cheese, milk—chocolate milk for
do it as effectively as everyone who my husband after his bike rides—and prob-
doesn’t know anything about science or TD: What does your typical workweek ably carrots and celery. And a lot of con-
food or health or nutrition or physiol- look like? diments. I also always have citrus fruits,
ogy. They can say whatever they want Rust: I try to get my exercise in the apples, and leftovers (which we eat!). I
with no supporting evidence. They lie. morning for myself, then start the
They make stuff up. It’s usually negative workday checking social media for any Elizabeth S. Goar is a freelance health writer
claims like “this will be toxic” and “this comments I need to respond to and to see based in Benton, Wisconsin.

NOVEMBER/DECEMBER 2024 • WWW.TODAYSDIETITIAN.COM 45

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Culinary Corner By Kristy Del Coro, MS, RDN, LDN

White Bean, Basil, Kelp,

and Avocado Dip and
Whole Wheat Kelp Crackers
Makes 8 servings

Ingredients
Whole Wheat Cracker
1¼ cups white whole wheat flour
2 tsp kelp powder
1 tsp fine sea salt
¼ cup + 1 T extra virgin olive oil
½ cup water
Topping: sesame seeds mixed with
equal part seaweed flakes such as
kelp flakes or dulse flakes

Sea Vegetables’ Benefits Avocado Dip

1 15-oz can white cannellini beans,
Dive Into Their Nutrient Profile and Culinary Uses rinsed and drained
2 pureed kelp cubes (like Atlantic Sea

W
idely consumed for strips make a great alternative to Farms kelp cubes)
millennia in coastal bacon; ribbons of kelp can be added ½ cup fresh basil
regions all over the to a soup in place of kale; dried sea- 2 to 3 T fresh lemon juice
world, sea vegetables weed flakes or powder can be used in 2 T extra virgin olive oil
are both nutrient-rich and environ- baked goods, salad dressings, spice ¼ large ripe avocado
mentally sustainable, requiring mini- blends, and seed mixes; kombu can ½ tsp ground coriander
mal resources to grow and offering be added to soups and stocks, and ½ tsp fine sea salt
numerous benefits for the planet. added to liquid while cooking dried 1 to 2 T water if needed
Sea vegetables belong to three beans to help reduce gas formation; Ground black pepper to taste
different major categories—red wakame can be rehydrated for a
(Rhodophyta), brown (Phaeophyta), delicious seaweed salad; and pureed Directions
and green (Chlorophyta)—and can fresh kelp can be added to dips, 1. Preheat oven to 375˚ F.
be consumed in a variety of forms sauces, and even smoothies. Don’t be 2. Combine all cracker ingredients except
including dried, rehydrated, fresh, afraid to start experimenting with for topping mixture in a mixing bowl and
and gently steamed or blanched in seaweed in your kitchen in some of gently knead until the dough can be formed
rapidly boiling water. your favorite recipes to appreciate its into a smooth ball.
Each category of seaweed has its versatility first-hand! I 3. Roll out on lightly floured surface to ⅛"
unique benefits, so consuming a mix thickness.
of sea vegetables is ideal. This helps to Kristy Del Coro, MS, RDN, LDN, is a 4. Cut into desired cracker shapes and place
reduce the risk of excess iodine and culinary nutritionist, consultant, and on parchment lined sheet tray, with about
heavy metal intake; since sea veg- freelance food and health writer based ½” space between each cracker.
etables can also take up heavy metals in southern Maine. She’s cofounder of 5. Sprinkle each cracker with sesame seeds
from the environment.1 The team of the Culinary Nutrition Collaborative, and seaweed flakes, gently pressing the
RD experts from the nonprofit organi- which offers culinary-focused nutrition seeds and flakes down into the dough.
zation Food and Planet recommends education for health professionals. 6. Bake for 12 to 15 minutes until crispy. Cool
serving sizes of 3 to 7 g dried sea veg- As a professionally trained chef and on rack before serving.
etables and 9 to 21 g fresh or rehydrated dietitian, Del Coro frequently shares 7. For dip, combine all dip ingredients in
sea vegetables and suggests consum- her expertise in various media outlets food processor or high-speed blender and
ing one serving once or twice per week. and is passionate about promoting blend until smooth. Serve with crackers.
This provides the greatest health ben- foods that are good for both human and
efit while also reducing the risk of any environmental health. Follow her at on Nutrition Analysis per serving
kind of heavy metal toxicity. Instagram @kristydelcoro_rd. (2 T dip + 8 crackers)
Calories: 255; Total fat: 13.5 g; Sat fat: 2 g;
Cholesterol: 0 mg; Sodium: 430 mg; Total
Culinary Uses For references, view this article on our carbohydrate: 29 g; Total sugars: 0 g; Dietary fiber:
Sea vegetables can be incorporated website at www.TodaysDietitian.com. 6 g; Protein: 7 g
into all types of cuisines: smoked dulse

50 TODAY’S DIETITIAN • NOVEMBER/DECEMBER 2024

2025 SPRING SYMPOSIUM
SPEAKER LINEUP
MAY 4–7, 2025
San Antonio, TX

We are proud to introduce a sneak peek of our lineup of world class speakers for the 2025
Today's Dietitian Spring Symposium! Register today for a continuing education experience like
no other, taking place in San Antonio, Texas. You won't want to miss out on this exclusive learning
experience. Explore our speakers and their presentation topics below.

Carrie Dennett, MPH, RDN Jessica Setnick, MS, RDN, CEDS-C,

Intuitive Eating and Carrie Boyd Lutter, LCSW, RDN*
Is This Framework Right for Everyone? What’s Eating Your Clients?
Understanding Epigenetics and Early Childhood Feeding
Bonnie Taub-Dix, MA, RDN, CDN Experiences to Solve Eating Problems
How to Ditch Dietitian Dissatisfaction and Make
the Most of Your Career Through Media Judy Simon, MS, RDN, CD, CHES, FAND,
and Angela Thyer, MD*
Jackie Topol, MS, RDN, CDN, How to Improve Fertility Outcomes (In the Kitchen)
and Kristy Del Coro, MS, RDN, LDN
Dynamic Duo Arlayna Jackson, MDS, RDN, LDN,
How Teaming Up Can Help Your Business Thrive and Claire Daniels, CCC-SLP
Enhancing Nutrition Outcomes Through
Jaclyn London, MS, RDN, CDN Interdisciplinary Collaboration
Institutional Mistrust A Comprehensive Approach
The RD's Role in Restoring and Rebuilding Faith
in Public Health and Evidence-Based Nutrition Toby Smithson, MS, RDN, LD, CDCES, FAND,
and Jason Baker, MD*
Jill Castle, MS, RDN, LDN A Pivotal Life
Whole Child Healthy The Diabetes Management Journey From a Health Care
Helping Families Resist Dichotomies, Bias, and Stigma Professional and a Person Living With Diabetes

Britt Burton-Freeman, PhD, Su-Nui Escobar, DCN, RDN, FAND*

and Maggie Moon, MS, RDN Life After GLP-1 Agonist Therapy
The Polyphenol Effect for Weight Loss
Gut Microbiome, Inflammation, and the Brain - A Research-Based
Approach to Culinary Medicine for Cognitive Health Andie Lee Gonzalez, PhD, MPH, RDN, LD, FAND;
Kimberly Avila Edwards, MD;
Toby Amidor, MS, RDN, CDN, FAND and Erika Estrada-Ibarra, BSN, RN*
Ask the Expert Overcoming Systemic Barriers
A Year in Review and a Look Ahead Implementing the AAP's New Pediatric Obesity
Guidelines in Health Care
Rene Pearson, RDN, LDN, and Maegan Blau
Freedom in Cooking Jessica Ball, MS, RD
Empowering Nutrition and Health Through Creating Enticing Nutrition and Culinary Messaging
Accessible Home Kitchens to Increase Engagement and Participation

*Sessions with an interprofessional continuing education focus, developed by and for the health care team.
Topics and speakers are subject to change

Register today at tdsymposium.com

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