SCAN’S Pulse€¦ · 2013 issue of SCAN’S PULSE. The cardiovascular benefits associ-ated with the consumption of veg - etables and fruit have been attributed to their constituents,

Fall 2012, Vol. 31, No. 4

■ CONTENTS

1Dietary Nitrates and Nitrites fromVegetables and Fruits: How CanSomething So Bad Be So Good? (Part 1)

3From the Editor

7CPE article:Nitrate Supplementation for Cardiovascular Health and Exercise Performance

12Cheese and Cardiometabolic Health:New Findings for a New Canvas

15Providing a Focus on Eating Disorders: The University of Minnesota – The Emily Program Dietetic Internship Program

18From the Chair

19Conference Highlights

22Sports Dietetics-USA Research Digest

23Reviews

25SCAN Notables

26Of Further Interest

28Upcoming Events

by Norman G. Hord, PhD, MPH, RD

This is the first part of a two-part arti-cle. Part II will appear in the Winter2013 issue of SCAN’S PULSE.

The cardiovascular benefits associ-ated with the consumption of veg-etables and fruit have beenattributed to their constituents, in-cluding vitamins, minerals, fiber, andplant secondary metabolites such asphenols, polyphenols, and tannins.1

There is a consensus that the largeamounts of vegetables and fruits incertain healthful diet patterns (e.g.,Mediterranean-type diet2) explaintheir cardioprotective effects. Indeed,prospective epidemiologic studieshave identified green leafy vegeta-bles as especially associated withprotection against coronary heartdisease and ischemic stroke.3 The Di-etary Approaches to Stop Hyperten-sion (DASH) studies found that dietsrich in vegetables (i.e., 8-10 servings)and low-fat dairy products lowerblood pressure to a similar extent asthat achieved with single hypoten-sive medications.4 It has been

S C A N ’ SPu lseDietary Nitrates and Nitrites from Vegetables and Fruits: How Can Something So Bad Be So Good? (Part 1)

proposed that the blood pressurelowering effect of this diet is most di-rectly attributable to the inorganic ni-trate content.5

Even though the cardiovascular ben-efits associated with vegetable andfruit consumption have been attrib-uted to various constituents,1 the po-tential role of the inorganic nitratesfound in these foods has received rel-atively little attention. It has beendemonstrated that inorganic nitrate(NO3) in certain vegetables and fruitcan provide a physiologic substratefor reduction to nitrite (NO2), andsubsequently to metabolites, includ-ing nitric oxide (NO), nitrosothiols,and nitrated fatty acids or ni-troalkenes (collectively termed NOx).

This review provides a physiologiccontext for the potential cardiovascu-lar benefits of dietary nitrite and ni-trate from plant foods, supporting agrowing consensus for a comprehen-sive reevaluation of the health bene-fits and risks associated with dietarynitrates and nitrates.

Depending on physiologic condi-tions, generation of up to about 70%of systemic NO may be accomplishedby endothelial nitric oxide synthase(eNOS), one of three members of theNOS family of enzymes, in the vascu-lar endothelium.10 These enzymessynthesize NO from the amino acid L-arginine and molecular oxygen tohelp regulate vasodilation, bloodpressure, inflammatory cell recruit-ment, and platelet aggregation.11 Asa result, the normal production of NOand nitrite and the ability of the en-dothelium to respond to thesespecies may prevent various types ofcardiovascular disease, including hy-pertension, atherosclerosis, andstroke.12

In the vascular wall, NO binds to andactivates guanylyl cyclase. This en-zyme catalyzes the dephosphoryla-tion of GTP to cyclic GMP, whichserves as a second messenger for im-portant cellular functions, includingsmooth muscle relaxation associatedwith vasodilation.13 Two other mem-bers of the NOS family have neuronalfunctions (nNOS) and inflammatoryimmune functions (inducible NOS oriNOS).8 The function of iNOS is togenerate essential signaling mole-cules in the innate immune response.In tissues experiencing chronic in-flammation (e.g., inflamed bowel tis-sue in ulcerative colitis), iNOS cangenerate high concentrations of NOthat can promote carcinogenesis byinhibiting apoptosis, enhancingprostaglandin formation, and pro-moting angiogenesis in the earlystage of carcinogenesis.14 In athero-sclerosis, hypoxic conditions com-bined with an oxidative environmentcan limit eNOS-derived NO produc-tion, whereas nitrite can directly in-duce vasodilation in hypoxicendothelium.8 Remarkably, a lowconcentration of sodium nitrite indrinking water (50 mg/L) can substi-tute for loss of eNOS-derived NO ineNOS deficient mice.15

Unlike the provision of eNOS-derivedNO from arginine in the endothe-lium, nitric oxide production from ni-trite occurs primarily in somatictissues.11 There are two systems of re-

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

Dietary Sources of NOx

Nitrate is available to plants via theaction of lightning and nitrogen-fix-ing bacteria in the soil. Lightning oxi-dizes atmospheric nitrogen andcombines with water to form nitrousacid, which is deposited into the soilby rainfall and then converted to ni-trate by bacteria.Nitrate is a requirednutrient for plants and an approvedfood additive.6 Vegetables are theprincipal source of nitrate in theAmerican diet (providing ~80% ofthe total), with smaller amounts pro-vided by surface and ground water.

Nitrate intake from vegetables is de-termined by the type of vegetableconsumed, the levels of nitrate in thevegetables (partly determined by thenitrate content of fertilizer and watersupply), and the amount of vegeta-bles consumed.7 Sources of nitritesinclude vegetables, fruit, andprocessed meats. The array ofmetabolites derived from the metab-olism of nitrate, nitrite, and NO aretermed NOx (including nitric oxide[NO], nitrosothiols, and nitroalkenes).

Physiologic Resilience: Redundant Systems of NOxProduction in Vasculatureand Tissues

Normal functioning of human vascu-lature requires the presence of nitriteand nitric oxide as well as the enzy-matic machinery to generate theseimportant signaling molecules andthe ability to respond to them.8 In-deed, oxidative stress and reducedNO bioavailability, including de-creased ability of the vasculature torespond to the vasodilatory effects ofNO, are critically linked to develop-ment of hypertension and other car-diovascular diseases. Mechanistically,the physiologic target for themetabolites of dietary nitrate is mito-chondria, where nitrite exerts cyto-protective actions via post-translational modification of complexI of the electron transport chain, lead-ing to decreased mitochondrial reac-tive oxygen species generation afterinsults such as ischemia/reperfusioninjury.9

Academy of Nutrition and Dietetics Dietetic Practice Group of Sports,

Cardiovascular, and Wellness Nutrition (SCAN)

SCAN Web site: www.scandpg.org

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

ChairIngrid Skoog, MS, RD, CSSD

Chair-ElectJenna Bell, PhD, RD

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

TreasurerMaureen Ganley, MBA, MA, RD, CSCS, CPT

SecretaryKarla M. Wright, RD, CSSD

Director of Communications Kimberly K. Schwabenbauer, RD

Director of Continuing Education Kelly White, MS, RD, CSSD

Director of Development Hope Barkoukis, PhD, RD

Director of Member Services Cheryl Toner, MS, RD

Symposium Committee ChairSharon Smalling, MPH, RD

Director, Disordered Eating & Eating Disorders SubunitTherese Waterhous, PhD, RD

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

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

Director of External Relations David H. Holben, PhD, RD

Director of Public Relations (to be appointed)

Director of Public Policy Alisa Krizan, MS, RD

Director of Volunteer Coordination Katilyn L. Davis, MS, RD, CSSD

Web EditorCarla Addison, RD

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

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

DPG Relations ManagerSusan DuPraw, MPH, RD

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

No “Beeting” Around the Bush

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

I’m not going to beat around the bush to describe this issue of PULSE. Nope, I’m just going to come out and say it ... it’s flat outgood. As always, we have four terrific feature articles and our ever-informative book reviews, highlights from the recent Ameri-can College of Sports Medicine conference, notable accomplishments of our members, the research digest from our Sports Di-etetics-USA subunit, as well as plenty of other SCAN news.

To kick things off in this issue, on the cover you’ll find Part I of an excellent article written by Norman Hord, PhD, MPH, RD. Manyof you are probably familiar with some of the recent research on nitrates and beets as a key nitrate source. This article high-lights the nutritive properties of nitrates and nitrites and their regulation in our food supply. Part II will appear in our upcom-ing Winter issue. Continuing with that theme, our free CPE article by Steven Hertzler, PhD, RD, discusses the implications ofbeets on exercise performance and cardiovascular health. You’ll also find a superb article on the available evidence on cheeseconsumption and cardiovascular health contributed by Christopher Cifelli, PhD, and Keigan Park, PhD. Finally, a revolutionarynew educational program for dietetic interns, The Emily Program, is described by its creators.

All-in-all, I don’t think you can beat this issue as a source of up-to-date information on interesting and important topics. I hopeyou agree.

SCAN’S PULSE Fall 2012, Vol. 31, No. 4 | 3

ducing nitrate to nitrite in mammals.The first is via the action of commen-sal gram negative bacteria on thetongue acting on salivary nitrate.16

The second includes several mam-malian enzymes and heme-contain-ing proteins that accomplish nitrateand nitrite reduction.9,17 Therefore, in-organic nitrate derived either fromNO oxidation or dietary sources canserve as a storage form of nitratethat can be reduced back to nitriteand NO when physiologically re-quired or in pathologic conditions.12

Nitrate is concentrated in saliva fromplasma in the saliva as part of en-terosalivary circulation of dietary ni-trate.18 Approximately 25% of nitratein circulation is concentrated in thesaliva, where some 20% of nitrate de-livered to the tongue is reduced tonitrite by commensal bacteria. Theseanaerobic bacteria (e.g., sp. Vionella)on the tongue’s dorsal surface use ni-trate as an alternative electron accep-tor to produce energy. Indeed, use ofan antibacterial mouthwash afterconsumption of nitrate (10 mg/kg inwater) attenuates the expected post-prandial rise in plasma nitrite.19 Thenitrite supplied to the gastrointesti-nal tract (whether preformed in the

diet or converted from nitrates bytongue bacteria) enhances gastricmucin production and can serve as asubstrate for generation of NOx forantimicrobial actions and supportsgastric homeostasis.20

Contribution of Dietary Constituents to NO Production

Endogenous reduction of nitrate tonitrite is the source of NO and NOx intissues and, during hypoxia, in thevasculature.12,17 As such, dietary ni-trates and nitrites, via successive re-duction by mammalian nitrate andnitrite reductases, serve as the sourcefor more than 50% of NO produced inthe human body, resulting in about 1 mmol NO per day in those consum-ing Western-type diets.21 Dietary pro-tein intakes of about 90 g/day(contributing ~14.5 g nitrogen) pro-vides arginine, which serves as an or-ganic substrate for NOS enzymes thatproduce about another 1 mmolNO/day.5 It has been estimated thatone serving of a high-nitrate veg-etable (e.g., spinach) results in moreNO production from the reduction ofnitrate to nitrite and nitrite to NOthan what is endogenously formed

by the all three NOS isoforms com-bined during a day.11 Dietary com-pounds such as vitamin C andpolyphenols can enhance the for-mation of NO from nitrite and pro-long the half-life of NO in thestomach, respectively.22.

Biologic Actions of NOx

The metabolic disposition ofplasma and tissue nitrates is de-pendent on local conditions, in-cluding tissue oxygenation,inflammatory state, and, in the skin,exposure to ultraviolet (UV) light.23

The physiologic reduction of di-etary nitrates to nitrite and subse-quently to NO can lead, in atissue-specific fashion, to the post-translational modification of pro-teins by nitration andS-nitrosylation (e.g., nitrosothiols)and nitration of fatty acids.11 Di-etary nitrate increases plasma andtissue levels of S-nitrosothiols andnitrosylation products; these bioac-tive compounds act as donors ofthe nitrosonium ion NO+ and NO,which along with NO productionfrom nitrite reduction, may mediatethe vasodilatory and cytoprotectiveeffects.24

FromThe Editor


Liberation of NOx from Nitrate in Skin by UV Light

Dietary nitrate and nitrite as well asall three NOS isoforms contribute to ahigh concentration of NOx com-pounds in the skin.25 Nitrite, nitrate,and S-nitrosothiols in the skin, so-called “dermal stores” of NOx nitrateconcentrations in skin, are about 1- to2-fold higher than plasma, whereasnitrite is approximately 10-foldhigher than nitrite in blood.26 Expo-sure of skin to whole body UVA irradi-ation (20 J/cm2) causes photo-decomposition of nitrite and S-nitrosothiols in skin, leading to NOproduction. Whole body UVA expo-sure has been shown to cause arapid, significant decrease (11% after30 min of exposure) in systolic anddiastolic blood pressure in healthyvolunteers, which can last up to 60minutes after UVA exposure.23 Thus,sun exposure not only serves an im-portant role in the activation of vita-min D3 but also in the production ofNOx sufficient to transiently lowerblood pressure.

Metabolism and regulation of NOand nitrite at the cellular and tissuelevels is dependent on oxygen ten-sion, cellular redox status, redox ac-tive metal, and thiol availability.27 Theproduction of these NOx species isassociated with vasodilation, de-creased blood pressure, and cytopro-tective functions.28,29 Despite thedemonstrated vasodilatory and cyto-protective roles for nitrate and nitritein the vasculature, consideration ofthe health consequences of foods assources of nitrates and nitrites has re-ceived little attention. This lack of at-tention is likely due to the perceivednegative health effects from drinkingwater containing nitrate and the useof nitrate and nitrite in processedmeats.28

Regulatory Limits on Nitratein Drinking Water

There are no intake recommenda-tions for dietary nitrates and nitritesexcept for regulatory limits in waterand processed meats. The permissi-ble concentration of nitrate in drink-

ing water is 50 mg nitrate/L in the Eu-ropean Union and 44 mg/L in theUnited States in accordance withWorld Health Organization (WHO)recommendations established in1970 and reaffirmed in 2004. The wis-dom of these regulations is chal-lenged by growing evidence thatascribes essential functions of thesedietary constituents to vascular andtissue homeostasis and immunefunction. Several accidental toxic ex-

posures of nitrates and nitrites havebeen described,30 yet the health risksof excessive nitrate and nitrite con-sumption such as methemoglobine-mia appear only in specificpopulation subgroups. The excessiveconcentration of nitrate in drinkingwater must be considered a serioushealth concern, particularly for in-fants.31

It is noteworthy that the few humannitrate and nitrite exposure studies,involving children and adults, havenot produced methemoglobinemia.Infants exposed to 175 to 700 mg ni-trate per day did not experiencemethemoglobin levels above 7.5%,suggesting that nitrate alone is notcausative for methemoglobinemia.32

A more recent randomized, three-way crossover study exposed healthyvolunteer adults to single doses of

sodium nitrite ranging from 150 to190 mg per volunteer to 290 to 380mg per volunteer.33 Observed methe-moglobin concentrations were 12.2%and 4.5% for volunteers receiving thehigher dose and the lower dose of ni-trite ion, respectively. Recent nitriteinfusion studies of up to 110µg/kg/minute for 5 minutes inducedmethemoglobin concentrations ofonly 3.2%.34

These data have led scientists to pro-pose alternative explanations for theobserved methemoglobinemia in in-fants, including gastroenteritis andassociated iNOS-mediated produc-tion of NO induced by bacteria-con-taminated water.35 The studies callinto question the mechanistic basisfor exposure regulations for nitrateand nitrite. At best, these findingshighlight a serious but context-spe-cific risk associated with nitrite over-exposure in infants. Thus, although itis biologically plausible that methe-moglobinemia is the result of dietarynitrite txicity, current evidence sug-gests that enteric bacterial infectionis the most likely culprit.30,31

Environmental Concerns: Eutrophication

The growing appreciation of themany mechanisms by which nitratesand nitrite may benefit health mustbe balanced with environmental con-cerns. Environmental contaminationwith excess nitrate from fertilizer useis a growing problem. Nitrate and ni-trite are naturally occurring ions thatserve as nutrients for plants via fixa-tion by soil bacteria. Enhancement ofnitrogen fixation via nitrate-contain-ing fertilizers has surpassed theamount that occurs naturally.36 Theresulting contamination of groundand surface water is a global concern.This type of pollution—eutrophica-tion—is characterized by excessivedevelopment of certain types ofalgae in aquatic ecosystems and be-comes a health risk for animals andhumans. The possible cardiovascularhealth benefits that could be pro-vided by drinking water “contami-nated” with nitrates needs to beconsidered in any risk-benefit discus-sion.

constituents to affect cancer risk. (Editor’s note: Part II will resume witha discussion of the potential positivehealth effects of dietary nitrate and nitrite consumption.)

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

References1. Couto E, Boffetta P, Lagiou P, et al.Mediterranean dietary pattern andcancer risk in the EPIC cohort. Br JCancer. 2011;104:1493-1499.2. Trichopoulou A, Bamia C, Tri-chopoulos D. Mediterranean diet andsurvival among patients with coro-nary heart disease in Greece. Arch IntMed. 2005;165:929-935.3. Joshipura KJ, Hu FB, Manson JE, etal. The effect of fruit and vegetable in-take on risk for coronary heart dis-ease. Ann Int Med.2001;134:1106-1114.4. Appel LJ, Brands MW, Daniels SR, etal. Dietary approaches to prevent andtreat hypertension: a scientific state-ment from the American Heart Asso-ciation. Hypertension. 2006;47:296-308.5. Hord NG, Tang Y, Bryan NS. Foodsources of nitrates and nitrites: thephysiologic context for potentialhealth benefits. Am J Clin Nutr.2009;90:1-10.6. Authority EFS. Nitrate in vegeta-bles: scientific opinion of the panelon contaminants in the food chain.EFSA J. 2008;689:1-79.


Dietary Nitrate and Nitrite Intakes: Estimates and Regulatory Limits

Human exposure to nitrates is sub-ject to regulatory limits. The U.S. Envi-ronmental Protection Agency limitshuman exposure to inorganic nitratesto 0.10 mg/L (or 10 ppm nitrate nitro-gen) and nitrites to 1 ppm nitrite ni-trogen. The Joint Food andAgricultural Organization/WHO hasset the Acceptable Daily Intake (ADI)for the nitrate ion at 3.7 mg/kg bodyweight and for the nitrite ion at 0.06mg/kg body weight,6 translating intoabout 222 and 3.6 mg/day, respec-tively, for a 60-kg person. These rec-ommendations are higher thancurrent intake estimates for nitrateand nitrite from food in the UnitedStates and Europe, which vary fromabout 40 to 100 mg/day and 31to185 mg/day for nitrate, respec-tively, and 0 to 20 mg/day, for nitrite.5

Nitrate intakes from sources otherthan vegetables, including drinkingwater and cured meats, has been esti-mated to average 35 to 44 mg/per-son per day for a 60-kg individual.6

On the basis of a conservative recom-mendation to consume 400 g of dif-ferent fruits and vegetables daily atmedian nitrate concentrations, the di-etary provision of nitrate would beabout 157 mg/day.6

Vegetable and fruit consumption forone day was modeled using theDASH pattern to illustrate potentialnitrate and nitrite exposure fromfood choices emphasizing high andlow nitrate vegetable and fruitchoices.5 These estimates showedthat nitrate intake when choosinghigh-nitrate vegetables and fruitscould result in about 1.2 g nitrate andexceed the WHO intake limit by550%.These data demonstrate that adietary pattern widely recommendedby federal agencies appears to be notonly safe but also associated withblood pressure lowering in adults.5

The authors conclude by ascribing atleast a portion of the blood pressurelowering effect of the DASH diet tothe nitrate and nitrite content offoods.

Potential Negative Health Effects

Epidemiologic and clinical studieshave reported that excessive nitrateand nitrite consumption in cured andprocessed meats is associated withincreased risk of gastrointestinal can-cers, thyroid dysfunction, and thyroidcancer,37 chronic obstructive pul-monary disease in women,38 andother conditions.39,40 A recent meta-analysis challenged this association

by concluding that available epi-demiologic evidence is not sufficientto support a clear and unequivocalindependent positive association be-tween processed meat consumptionand colorectal cancer risk.41

Nitrates added to meats serve as an-tioxidants, help develop flavor, andstabilize the red color, but they mustbe converted to nitrite to exert theseactions. Sodium nitrite is used as acolorant, flavor enhancer, and antimi-crobial agent in cured and processedmeats. Nitrate and nitrite use in meatproducts, including bacon, bologna,corned beef, hot dogs, luncheonmeats, sausages, and canned andcured meat and hams, is subject tolimits set by Food and Drug Adminis-tration (FDA) and U.S. Department ofAgriculture (USDA) regulations. Theuse of nitrites in bacon must be ac-companied by the either sodium ery-thorbate or sodium ascorbate(vitamin C), antioxidants that inhibitthe nitrosation effect of nitrites onsecondary amines.42 Clearly, more re-search is needed to address the po-tential interactions among food


7. Pennington J. Dietary exposuremodels for nitrates and nitrites. FoodControl. 1998; 9:385-395.8. Weitzberg E, Hezel M, Lundberg JO.Nitrate-nitrite-nitric oxide pathway:implications for anesthesiology andintensive care. Anesthesiology.2010;113:1460-1475.9. Larsen FJ, Schiffer TA, Borniquel S,et al. Dietary inorganic nitrate im-proves mitochondrial efficiency inhumans. Cell Metab. 2011;13:149-159.10. Zweier JL, Samouilov A, Kup-pusamy P. Non-enzymatic nitric oxidesynthesis in biological systems. BiochBiophys Acta. 1999;1411:250-262.11. Lundberg JO, Gladwin MT,Ahluwalia A, et al. Nitrate and nitritein biology, nutrition and therapeutics.Nature Chem Biol. 2009;5:865-869.12. van Faassen EE, Bahrami S, Feel-isch M, et al. Nitrite as regulator of hy-poxic signaling in mammalianphysiology. Med Res Rev. 2009;29:683-741.13. Lundberg JO, Weitzberg E. NO-synthase independent NO genera-tion in mammals. Biochem BiophysRes Comm. 2010;396:39-45.14. Ambs S, Merriam WG, Bennett WP,et al. Frequent nitric oxide synthase-2expression in human colon adeno-mas: implication for tumor angiogen-esis and colon cancer progression.Canc Res. 1998;58:334-341.15. Bryan NS, Calvert JW, Gundewar S,et al. Dietary nitrite restores NOhomeostasis and is cardioprotectivein endothelial nitric oxide synthase-deficient mice. Free Radic Biol Med.2008;45:468-474.16. Spiegelhalder B, Eisenbrand G,Preussmann R. Influence of dietary ni-trate on nitrite content of humansaliva: possible relevance to in vivoformation of N-nitroso compounds.Food Cosmet Toxicol. 1976;14:545-548.17. Jansson EA, Huang L, Malkey R, etal. A mammalian functional nitrate re-ductase that regulates nitrite and ni-tric oxide homeostasis. Nature ChemBiol. 2008;4:411-417.18. Duncan C, Dougall H, Johnston P,et al. Chemical generation of nitricoxide in the mouth from the enteros-alivary circulation of dietary nitrate.Nature Med. 1995;1:546-551.19. Govoni M, Jansson EA, Weitzberg

E, et al. The increase in plasma nitriteafter a dietary nitrate load ismarkedly attenuated by an antibac-terial mouthwash. Nitric Oxide.2008;19:333-337.20. Petersson J, Phillipson M, JanssonEA, et al. Dietary nitrate increases gas-tric mucosal blood flow and mucosaldefense. Am J Physiol. 2007;292:G718-724.21. Bryan NS: Cardioprotective ac-tions of nitrite therapy and dietaryconsiderations. Front Biosci.2009;14:4793-4808.22. Sobko T, Huang L, Midtvedt T, et al.Generation of NO by probiotic bacte-ria in the gastrointestinal tract. FreeRadic Biol Med. 2006;41:985-991.23. Oplander C, Volkmar CM, Paunel-Gorgulu A, et al. Whole body UVA irra-diation lowers systemic bloodpressure by release of nitric oxidefrom intracutaneous photolabile ni-tric oxide derivates. Circ Res.2009;105:1031-1040.24. Carlstrom M, Persson AE, LarssonE, et al. Dietary nitrate attenuates ox-idative stress, prevents cardiac andrenal injuries, and reduces bloodpressure in salt-induced hyperten-sion. Cardiov Res. 2011;89:574-585.25. Feelisch M, Kolb-Bachofen V, Liu D,et al. Is sunlight good for our heart?Eur Heart J. 2010;31:1041-1045.26. Mowbray M, McLintock S, Weer-akoon R, et al. Enzyme-independentNO stores in human skin: quantifica-tion and influence of UV radiation. J Invest Derm. 2009;129:834-842.27. Bryan NS, Rassaf T, Maloney RE, etal. Cellular targets and mechanisms ofnitros(yl)ation: an insight into theirnature and kinetics in vivo. Proc NatAcad Sci USA. 2004;101:4308-4313.28. Lundberg JO, Feelisch M, Bjorne H,et al. Nitric Oxide. 2006;15:359-362.29. Borniquel S, Jansson EA, Cole MP,et al. Nitrated oleic acid up-regulatesPPARgamma and attenuates experi-mental inflammatory bowel disease.Free Radic Biol Med. 2010;48:499-505.30. Butler AR, Feelisch M. Therapeuticuses of inorganic nitrite and nitrate:from the past to the future. Circula-tion. 2008;117:2151-2159.31. Greer FR, Shannon M. Infantmethemoglobinemia: the role of di-etary nitrate in food and water. Pedi-atrics. 2005;116:784-786.

32. Cornblath M, Hartmann AF:Methemoglobinemia in young in-fants. J Pediatrics.1948;33:421-425.33. Kortboyer JM, Olling M, ZeilmakerM J. The Oral Bioavailability of SodiumNitrite Investigated in Healthy AdultVolunteers. Bilthoven, Netherlands:National Institute of Public Healthand the Environment;1997.34. Dejam A, Hunter CJ, Tremonti C,etal. Nitrite infusion in humans andnonhuman primates: endocrine ef-fects, pharmacokinetics, and toler-ance formation. Circulation,2007;116:1821-1831.35. Powlson DS, Addiscott TM, Ben-jamin N, et al. When does nitrate be-come a risk for humans? J EnvironQual. 2008; 37:291-295.36. Camargo JA, Alonso A. Ecologicaland toxicological effects of inorganicnitrogen pollution in aquatic ecosys-tems: a global assessment. EnvironInter. 2006;32:831-849.37. Ward MH, Kilfoy BA, Weyer PJ, et al.Nitrate intake and the risk of thyroidcancer and thyroid disease. Epidemi-ology. 2010;21:389-395.38. Jiang R, Camargo CA, Jr, Varraso R,et al. Consumption of cured meatsand prospective risk of chronic ob-structive pulmonary disease inwomen. Am J Clin Nutr. 2008:87:1002-1008.39. Panesar NS. Downsides to the ni-trate-nitrite-nitric oxide pathway inphysiology and therapeutics? NatureRev. 2008;7:710.40. Norat T, Bingham S, Ferrari P, et al.Meat, fish, and colorectal cancer risk:the European Prospective Investiga-tion into cancer and nutrition. J NatCancer Inst. 2005;97:906-916.41. Alexander DD, Miller AJ, CushingCA, et al. Processed meat and colorec-tal cancer: a quantitative review ofprospective epidemiologic studies.Eur J Cancer Prev. 2010; 19:328-341.42. Rao GS, Osborn JC, Adatia MR.Drug-nitrite interactions in humansaliva: effects of food constituents oncarcinogenic N-nitrosamine forma-tion. J Dent Res.1982;61:768-771.43. Lundberg JO, Carlstrom M, LarsenFJ, et al. Roles of dietary inorganic ni-trate in cardiovascular health and dis-ease. Cardio Res. 2011;89:525-532.


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

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

■ Discuss the effects of nitric oxideon cellular metabolism.■ Summarize the evidence on theimpact of nitrate supplementation onperformance.■ Provide recommendations to ath-letes regarding nitrate supplementa-tion.

When most dietitians hear the wordnitrate, they probably think “enemy.”The term may conjure up fears ofcyanotic infants or maybe carcino-genic nitrosamines that could arisefrom eating diets high in processedmeats containing nitrates or nitritesas preservatives. However, there is arapidly expanding body of scientificliterature on the potential benefits ofnitrate consumption on cardiovascu-lar health and sports performance.Further, much of the evidence sug-

gesting that nitrates are potentiallyharmful is being seriously ques-tioned. This article addresses the con-fusion regarding dietary nitrates anddiscusses research linking nitrates tocardiovascular health and sport per-formance.

Nitrate Metabolism and theLink to Nitric Oxide

Nitric oxide (NO) has long been rec-ognized as a potent vasodilator, but itnow appears to have several otherimportant effects on cellular metabo-lism. A key site of NO production isthe endothelial cells that line the in-terior surface of blood vessels. There,the enzyme nitric oxide synthaseuses the amino acid arginine to pro-duce NO in an oxygen-dependent re-action.1 Under conditions of normaloxygen tension in the blood, the ni-tric oxide synthase reaction (oftencalled the endogenous NO pathway)is the major source of NO production.Previously, circulating levels of nitrate(NO3) and nitrite (NO2) were thoughtto simply represent inert waste prod-ucts resulting from the oxidation ofNO. However, it is now known that ni-trate and nitrite are not onlyNO metabolites, but theyalso contribute to its forma-tion via an alternative “ex-ogenous” pathway that isoxygen-independent.1,2

Some of the richest dietarysources of nitrate are darkleafy green vegetables andbeets (see Table). When in-gested, nitrate is rapidly ab-sorbed from thegastrointestinal tract toenter the bloodstream.While the vast majority(75%) of absorbed nitrate isexcreted in the urine, the

blood carries a portion of the nitrateto the salivary glands, which storeand concentrate nitrate before re-leasing it into the oral cavity.1,2 Anaer-obic bacteria in the mouth convertnitrate to nitrite,2 which is then swal-lowed. Absorbed nitrite can be re-duced to NO by various compoundsin blood and muscle, such as deoxy-hemoglobin and deoxymyoglobin,2

and is active at low oxygen tension inthe blood. The NO produced can thencontribute to vasodilation and exertother metabolic effects.

Nitrate and CardiovascularHealth

In theory, food-based sources of ni-trate boost NO in the bloodstream,resulting in vasodilation and lowerblood pressure. Naturally occurringsources of nitrate (e.g., juice madefrom the root portion of the beetplant) have been studied in regard toeffects on blood pressure and othercardiovascular parameters.

In one randomized crossover study,14 young, normotensive subjectswere fed a single dose of 500 mL

CPE article

Nitrate Supplementation for Cardiovascular Healthand Exercise Performanceby Steve Hertzler, PhD, RD

Table. Nitrate content of selected foods30

Source Nitrate (mg/kg)

Rucola (rocket) or Arugula 4677

Rhubarb 2943

Butterhead lettuce 2026

Red beetroot 1379

Celery 1103

Spinach 1066

Iceberg lettuce 875

Turnip 663Carrots 296

Broccoli 279

Potatoes 168


beetroot juice (~325 mg nitrate ion)or an equivalent volume of water 3hours before measurement of variouscardiovascular endpoints includingblood pressure, flow mediated dila-tion in the brachial artery, andplatelet aggregation.2 To further eval-uate the cardiovascular impact of oralbacterial conversion of nitrate to ni-trite, the study included an additionaltreatment arm in which subjects ei-ther swallowed or spit out all saliva inthe 3 hours post-treatment ingestionperiod. Compared with control, ni-trate supplementation significantlyelevated both plasma nitrate and ni-trite concentrations for at least 6hours after ingestion. The spitting outof saliva did not affect plasma nitratebut did reduce plasma nitrite,demonstrating the importance oforal bacteria in this conversion. At 2.5to 3 hours post-nitrate ingestion,peak reductions of 10.4 and 8.1 mmHg (P <.01 for both) occurred in sys-tolic and diastolic blood pressure, re-spectively. Even at 24 hourspost-ingestion, systolic blood pres-sure was 4 mm Hg lower for nitrateversus control, although the differ-ence was no longer statistically sig-nificant. Nitrate supplementation alsosignificantly improved flow-mediateddilatation in the brachial artery (e.g.,increase in brachial artery diameterafter temporary occlusion of bloodflow) and in vitro measurements ofplatelet aggregation.

As indicated in this study, the “spit-ting” condition greatly reduced thebacterial conversion of nitrate to ni-trite, which diluted the effects ofbeetroot juice ingestion on bloodpressure. Thus, it appears that oralbacteria play a critical role in the me-tabolism of nitrates and potentialsubsequent cardiovascular benefits.Related to this, it should be notedthat antibacterial mouthwashes vir-tually eliminate bacterial conversionof nitrate to nitrite.3

In another recent study, doses of 0 g,100 g, 250 g, and 500 g beetroot juicewere fed to 18 normotensive volun-teers, and blood pressure was moni-tored for 24 hours post-dosing viacontinuous ambulatory blood pres-

sure monitoring (all doses were ad-justed to 500 g with low nitratewater).4 These doses contained <31,143, 353, and 707 mg nitrate ion, re-spectively. The 500 g dose signifi-cantly reduced the 24-hour areaunder the curve (AUC) for systolic(P<.01) and diastolic (P<.001) bloodpressure. The 100 g and 250 g dosesalso significantly lowered the 24-hourdiastolic blood pressure AUC, but notquite as much as the 500 g dose. Theauthors also performed a separatestudy in 14 normotensive volunteerswith bread enriched with 100 g of either red or white beetroot. The ni-

trate ion concentrations of thebreads were <31, 99, and 112 mg forthe control bread, white beetroot,and red beetroot breads, respectively.Both beetroot breads caused similarbut nonsignificant reductions in 24-hour AUC for systolic blood pressure.Similarly, both breads also tended todecrease 24-hour AUC for diastolicblood pressure, but only the reduc-tion from the red beetroot bread wassignificant (P<.05). The authors con-cluded that it was the nitrate contentand not the red pigmentation (i.e.,betalain content) that was mainly re-sponsible for blood pressure lower-ing effects.

Nitrate Supplementation andPerformance Benefits

Since 2007, two major researchgroups have published several pa-pers demonstrating that nitrate sup-plementation, using either sodiumnitrate (Karolinska Institute group) orbeetroot juice (Exeter Universitygroup), can lower the oxygen cost ofphysical activity. Nitrate ingestionmay lower oxygen cost by increasingmetabolic efficiency, which reducesenergy wastage and lowers the de-mand on the cardiorespiratory sys-

tem to sustain a given level of physi-cal activity. This is potentially signifi-cant for athletes because delivery ofadequate oxygen to exercising mus-cle tissue represents a key limitingfactor in exercise performance.

In a randomized, double-blind,placebo-controlled crossover study,investigators supplemented 9healthy, young, well-trained men witheither 0.1 mmol/kg/day sodium ni-trate or a similar dose of sodium chlo-ride for 3 days prior to exercisetesting on a cycle ergometer at varying work rates from 45% to

VO2max.5 This dose would corre-

spond to 434 mg nitrate/day for a 70-kg subject. Nitrate supplementationsignificantly increased both restingplasma nitrate and nitrite levels(P<.01). At work outputs correspon-ding to 45%, 60%, 70%, and 80% ofVO2max, the oxygen consumption(VO2) was reduced on average by0.16 L/minute in the nitrate-supple-mented subjects (P<.02 for main ef-fect) versus control. Gross efficiencyincreased from 19.7% during controlto 21.1% during nitrate supplementa-tion over the four lowest work rates(P<.01). Nitrate supplementation alsodecreased resting systolic blood pres-sure by about 8 mm Hg (P<.01) andresting diastolic blood pressure byabout 6 mm Hg versus control(P<.01). There were no treatment-re-lated differences in heart rate, serumlactate, or hemoglobin concentra-tions. No improvement occurred atthe highest work rates (85% andmax), when the subjects were in amore anaerobic state.

In a similar study of 8 healthy menthat employed beetroot juice (500mL/day for 6 days before exercise) asthe source of nitrate (341 mg nitrateion/day), beetroot juice supplemen-


tation versus control significantly re-duced the amplitudes of fractionaloxygen extraction (13%, P<.05) andpulmonary VO2 (19%, P<.01) duringmoderate intensity cycling exercise.6

Systolic blood pressure was loweredby about 8 mm Hg in the beetrootcompared with control treatment,and beetroot juice supplementationprolonged time to exhaustion in a cy-cling test by 16% versus placebo. Inthis study, the control beverage was ablackcurrant cordial with negligiblenitrate content. In later studies, thisresearch group improved the controlbeverage by developing a “de-ni-trated” beetroot juice to further re-duce placebo bias.7,8

Several other studies, including onefrom the Netherlands, have shownsimilar effects of either sodium ni-trate or beetroot juice supplementa-tion in improving overall efficiency ofoxygen usage during mainly submax-imal exercise at comparable nitratedoses.7-13 These studies typically in-volved short duration of nitrate sup-plementation, primarily male cyclists,and fewer than 15 subjects. No stud-ies have been conducted to deter-mine whether nitrate supplemen-tation has a dose-response effect onoxygen consumption or exercise per-formance.

Investigators have reported that asingle dose of nitrate (384 mg nitrate)given as beetroot juice to male cy-clists nearly 3 hours before either a 4-km or 16.1 km cycling time trialsignificantly improved times by 2.8(P<.05) and 2.7% (P<.01), respec-tively.7 Similarly, supplementing malecyclists with 140 mL/day of concen-trated beetroot juice (496 mg nitrate)for 6 days shaved 12 seconds off a 10-km time trial (P<.005) compared withplacebo and increased poweroutput.9

Given the positive performance ef-fects of beetroot juice feeding ob-served in short-distance time trials,7

researchers sought to replicate theseresults in a longer time trial with bet-ter-trained cyclists. The study in-volved 8 well-trained cyclists whocycled at least 1 hour for a minimum

of 4 days per week and had com-peted in at least one organized cyclerace during the preceding 12months.14 Subjects completed two50-mile cycling time trials on sepa-rate occasions. In one trial, they werefed 0.5 L beetroot juice 2.5 hours be-fore the time trial; in the other, theyreceived an equivalent amount of de-nitrated beetroot juice 2.5 hours be-fore the time trial. The beetroot juicesupplement significantly improvedthe power output/VO2 ratio versusplacebo (67.4 ± 5.5 vs. 65.2 ± 4.8 W Lmin-1, P<.05). However, the 0.8% im-proved completion time with thebeetroot juice versus placebo wasnot statistically significant (P>.05). Itis unclear whether the failure of beet-root juice to improve performancewas due to the higher training statusof the subjects, the greater length ofthe time trial (>2 h), or some otherfactor. However, there was a signifi-cant inverse correlation (r = -0.83) between post-beverageplasma nitrite concentration andcompletion time.

One study not involving cycling wasof runners who consumed 200 gbaked beetroot (at least 500 mg ni-trate) or cranberry relish placebo 45minutes before a 5-km running timetrial.15 Average running velocity wasnot significantly faster for beetrootsupplementation (12.3 km/h) versusplacebo (11.9 km/h) (P=.06). However,running velocity during the last 1.8km of the trial was 5% faster (P=.016)for beetroot compared with placebo.Similarly, 6 days of beetroot juice sup-plementation (500-mL/d) improved500-m rowing performance versusplacebo in well-trained rowers.16

At present, it is unclear whether sup-plementation with arginine, a precur-sor in the synthesis of NO, or nitratehas the potential to improve athleticperformance. One study reportedthat arginine supplementation, likenitrate, can reduce the oxygen cost ofmoderate-intensity exercise and im-prove tolerance to high-intensity ex-ercise.17 Arginine-based “NOboosters” have been widely marketedto strength and physique athletes forpre-workout use, promising benefits

such as increased muscle blood flowand pump, as well as elevatedstrength and muscle mass gains. Nu-merous recent studies, however, havedisputed the efficacy of arginine sup-plementation for these purposes.18-22

It is likely that bodybuilders may re-sort to nitrate supplementation as analternative to arginine, but there areno studies on the efficacy of nitratesupplementation for these types ofoutcomes in this population.

Nitrate Supplementation andImpaired Tissue OxygenAvailability

Improved oxygen economy could beof particular benefit to those withcardiovascular disease and reducedexercise tolerance. In patients withperipheral artery disease, a singlefeeding of 500 mL beetroot juice (564mg nitrate) significantly increasedwalking time to onset of claudicationpain by 18% (P<.01) and time to ex-haustion by 17% (P<05) versusplacebo.23

Those who exercise at altitude (re-duced oxygen tension) may also beaided by nitrate supplementation. Inone study, beetroot juice supplemen-tation (750 mL beetroot juice, or 577mg nitrate) in subjects exposed to14% oxygen in their inhaled air re-sulted in exercise performance (kneeextensions) that was comparable tothat observed under normal oxygenconcentration (~20%), but without ni-trate supplementation.24 Such find-ings may have relevance for themilitary and other populations ex-posed to some degree of environ-mental hypoxia.

Proposed Mechanisms

While NO-induced vasodilation rep-resents one potential mechanism ofaction for nitrate, additional meta-bolic effects could potentially explainits cardiovascular effects. Mitochon-dria from nitrate- or placebo-supple-mented individuals obtained viamuscle biopsies were examined in arespiratory chamber, revealing thatnitrate-supplemented muscle exhibited more efficient coupling of


supplementing with high-nitratefoods such as beetroot juice andleafy green vegetables.

Summary and Recommendations

Short-term supplementation of 300mg to 500 mg nitrate per day (0.5 Lbeetroot juice) reduces the oxygencost of physical activity and has beenshown to enhance endurance per-formance (cycling and running) insome studies. There are currently nodata to indicate additional perform-ance benefits with doses above 300to 600 mg nitrate per day. The dura-tion of supplementation before exer-cise ranges from a single dose about3 hours before exercise to daily dosesgiven for up to 15 days prior to exer-cise.

Supplementation with natural formsof nitrate, such as beetroot juice orgreen leafy vegetables, is safe formost athletes and avoids potentialproblems associated with athletes ac-cidentally ingesting nitrite salts whennitrate salts were the intended sup-plement. Athletes taking nitrate-con-taining medications should be awareof potential additive cardiovasculareffects (e.g., hypotension) that mightoccur with additional food-based ni-trate supplementation. Finally, ath-letes with active gastroenteritisshould avoid nitrate supplementa-tion due to potentially excessive bac-terial conversion of nitrate to nitriteand greater risk for methemoglo-binemia.

Steve Hertzler, PhD, RD, is a senior re-search scientist at Abbott Nutrition,where he works with the EAS SportsNutrition division for the EAS Academy.

References1. Bescós R, Sureda A, Tur JA, et al. Theeffect of nitric-oxide-related supple-ments on human performance. SportsMed. 2012;42:99-117.2. Webb AJ, Patel N, LoukogeorgakisS, et al. Acute blood pressure lower-ing, vasoprotective, and antiplateletproperties of dietary nitrate via bio-conversion to nitrite. Hypertension.2008;51:784-790.

Safety of Nitrate Supplementation

Historically, dietary nitrates havebeen viewed primarily as detrimentalto health, mainly due to the potentialrelationships of dietary nitrate tomethemoglobinemia and increasedrisk of gastrointestinal cancers. In thecase of methemoglobinemia, theconcern is that conversion of nitrateto nitrite leads to the subsequent ni-trite-induced oxidation of the ferrousform of iron in hemoglobin to the fer-ric form, thus impairing the ability ofhemoglobin to bind oxygen. Somecases of cyanosis (“blue baby syn-drome”) due to methemoglobinemiawere reported in the 1940s in infantsconsuming formula made from wellwater with a high concentration ofnitrate.

Several recent reviews of these caseshave determined that nitrate expo-sure alone27-29 does not cause methe-moglobinemia but, rather, must beaccompanied by bacterial contami-nation of water or infection that dra-matically increases the conversion ofnitrate to nitrite. It is conceivable thatan athlete experimenting withsodium nitrate supplementationcould inadvertently consume sodiumnitrite instead, which would increaserisk of methemoglobinemia. How-ever, there is minimal risk when natu-rally-occurring sources of nitrate infood are used.

The potential concern regarding in-creased risk of gastrointestinal cancercenters on the reaction of nitrite inthe stomach with secondary aminesto form carcinogenic nitrosamines.However, numerous scientific expertpanels have reviewed both the epi-demiologic data on nitrate intakeand cancer incidence as well as thelaboratory evidence on nitrosamineformation, concluding that there isno convincing evidence of an associ-ation of nitrate intake with gastroin-testinal or other cancers.30,31 Giventhat diets high in fruits and vegeta-bles, which also tend to be high in ni-trate, generally decrease rather thanincrease cancer risk, there seems tobe little cause for concern for athletes

mitochondrial respiration and adeno-sine triphosphate (ATP) synthesis(e.g., more ATP production per unit ofoxygen consumed).25 The expressionof one mitochondrial protein, theadenosine nucleotide translocator(ANT), was significantly reduced bynitrate supplementation (P=.009). TheANT site is a commonly identified lo-cation for proton leakage throughthe mitochondrial membrane. Protonleakage would reduce the ATP pro-duction per unit of oxygen con-sumed, so reducing proton leakagevia nitrate supplementation may beone explanation for the exercise ben-efits observed.

The authors also measured the ex-pression of uncoupling protein 3(UCP-3), another potential site of pro-ton leakage. The change was non-significant (P=.17). However, 6 of the8 samples measured showed a de-crease in UCP-3 expression from ni-trate supplementation, while oneshowed no change and one had alarge (2-fold) increase. It is possiblethat this outlier inordinately influ-enced the data. A reduced level ofUCP-3 expression by nitrate supple-mentation would have also indicatedmore efficient coupling of oxidationand phosphorylation (i.e, ATP synthe-sis).25

Beetroot juice supplementation wasreported to reduce ATP turnover dur-ing both low- and high-intensityknee extension exercise by 35% and28%, respectively.10 That same studyalso found that phosphocreatine de-pletion during high-intensity exercisewas decreased 59% by beetroot juicesupplementation. These findings sug-gest that nitrate, via conversion toNO, may lower the actual ATP cost ofmuscle force production, thus in-creasing an athlete’s metabolic effi-ciency and requiring fewer resourcesfor the same amount of work. In sup-port of this, Hernández and col-leagues26 recently reported thatnitrate supplementation in mice for 7days increased myoplasmic free cal-cium ion concentration and contrac-tile force in fast twitch muscle.


3. Govoni M, Jansson EA, Weitzberg E,et al. The increase in plasma nitriteafter a dietary nitrate load ismarkedly attenuated by an antibac-terial mouthwash. Nitric Oxide.2008;19:333-337.4. Hobbs DA, Kaffa N, George TW, etal. Blood pressure-lowering effects ofbeetroot juice and novel beetroot-enriched bread products in nor-motensive male subjects. Br J Nutr.2012; doi: 10.1017/S0007114512000190.5. Larsen FJ, Weitzberg E, LundbergJO, et al. Effects of dietary nitrate onoxygen cost during exercise. ActaPhysiol. 2007;191:59-66.6. Bailey SJ, Winyard PG, Vanhatalo A,et al. Dietary nitrate supplementa-tion reduces the O2 cost of low-in-tensity exercise and enhancestolerance to high-intensity exercise inhumans. J Appl Physiol. 2009;107:1144-1155.7. Lansley KE, Winyard PG, Bailey SJ, etal. Acute dietary nitrate supplemen-tation improves cycling time trial per-formance. Med Sci Sports Exerc.2011;43:1125-1131. 8. Lansely KE, Winyard PG, Fulford J, etal. Dietary nitrate supplementationreduces the O2 cost of walking andrunning: a placebo-controlled study. J Appl Physiol. 2011;110:591-600. 9. Cermak NM, Gibala MJ, van LoonLJC. Nitrate supplementation’s im-provement of 10-km time-trial per-formance in trained cyclists. Int JSport Nutr Exerc Metab. 2012;22:64-71.10. Bailey SJ, Fulford J, Vanhatalo A, etal. Dietary nitrate supplementationenhances muscle contractile effi-ciency during knee-extensor exercisein humans. J Appl Physiol. 2010;109:135-148.11. Bescós R, Rodríguez FA, Iglesias X,et al. Acute administration of inor-ganic nitrate reduces VO2peak in en-durance athletes. Med Sci Sports Exerc.2011;43:1979-1986.12. Vanhatalo A, Bailey SJ, BlackwellJR, et al. Acute and chronic effects ofdietary nitrate supplementation onblood pressure and the physiologicalresponses to moderate-intensity andincremental exercise. Am J PhysiolRegul Integr Comp Physiol. 2010;299:R1121-R1131.

13. Larsen FJ, Weitzberg E, LundbergJO, et al. Dietary nitrate reduces maxi-mal oxygen consumption whilemaintaining work performance inmaximal exercise. Free Rad Biol Med.2010;48:342-347.14. Wilkerson DP, Hayward GM, BaileySJ, et al. Influence of acute dietary ni-trate supplementation on 50 miletime trial performance in well-trainedcyclists. Eur J Appl Physiol. 2012: doi:10.1007/s00421-021-2397-6.15. Murphy MC, Eliot K, Heuertz RWeiss EP. Whole beetroot consump-tion acutely improves running per-formance. J Am Diet Assoc. 2012;112:548-552.16. Bond H, Morton L, Braakhuis AJ.Dietary nitrate supplementation im-proves rowing performance in well-trained rowers. Int J Sport Nutr ExercMetab. 2012 (published ahead ofpress). Available at: http://journals.humankinetics.com/ijsnem-in-press/ijsnem-in-press/dietary-nitrate-supplementation-improves-rowing-performance-in-well-trained-rowers.Accessed July 9, 2012.17. Bailey SJ, Winyard PG, Vanhatalo A,et al. Acute L-arginine supplementa-tion reduces the O2 cost of moderateintensity exercise and enhances highintensity exercise tolerance. J ApplPhysiol. 2010;109:1394-1403.18. Bloomer RJ, Farney TM,Trepanowski JF, et al. Comparison ofpre-workout nitric oxide stimulatingdietary supplements on skeletal mus-cle oxygen saturation, bloodnitrate/nitrite, lipid peroxidation, andupper body exercise performance inresistance-trained men. J Inter SocSports Nutr. 2010;7:16.19. Forbes SC, Bell GJ. The acute ef-fects of a low and high dose of oral L-arginine supplementation in youngactive males at rest. Appl Physiol NutrMetab. 2011;36:405-411.20. Liu T-H, Wu C-L, Chiang C-W, et al.No effect of short-term arginine sup-plementation on nitric oxide produc-tion, metabolism, and performance inintermittent exercise in athletes. J Nutr Biochem. 2009;20:462-468.21. Tang JE, Lysecki PJ, Manolakos JJ,et al. Bolus arginine supplementa-tion affects neither muscle bloodflow nor muscle protein synthesis in

young men at rest or after resistanceexercise. J Nutr. 2011;141:195-200.22. Willoughby DS, Boucher T, Reid Jet al. Effects of 7 days of arginine-alpha-ketoglutarate supplementa-tion on blood flow, plasma L-arginine,nitric oxide metabolites, and asym-metric dimethyl arginine after resist-ance exercise. Int J Sport Nutr ExercMetab. 2011;21:291-299.23. Kenjale AA, Ham KL, Stabler T, et al.Dietary nitrate supplementation en-hances exercise performance in pe-ripheral artery disease. J Appl Physiol.2011;110:1582-1591.24. Vanhatalo A, Fulford J, Bailey SJ, etal. Dietary nitrate reduces musclemetabolic perturbation and improvesexercise tolerance in hypoxia. J Phy-siol. 2011;589.22:5517-5528.25. Larsen FJ, Schiffer TA, Borniquel S,et al. Dietary inorganic nitrate im-proves mitochondrial efficiency inhumans. Cell Metab. 2011;13:149-159.26. Hernández A, Schiffer TA, IvarssonN, et al. Dietary nitrate increasestetanic [Ca2+]i and contractile forcein mouse fast-twitch muscle. J Phys-iol. 2012 (published ahead of press);doi: 10.1113/jphysiol.2012.232777.27. Hord NG, Tang Y, Bryan NS. Foodsources of nitrates and nitrites: thephysiologic context for health bene-fits. Am J Clin Nutr. 2009;90:1-10.28. McKnight GM, Duncan CW, LeifertC, et al. Dietary nitrate in man: friendor foe? Br J Nutr. 1999;81:349-358.29. Powlson DS, Addiscott TM, Ben-jamin N, et al. When does nitrate be-come a risk for humans? J EnvironQual. 2008;37:291-295.30. European Food Safety Authority.Nitrate in vegetables: scientific opin-ion of the panel on contaminants inthe food chain (question No EFSA-Q-2006-071). EFSA J. 2008;689:1-79.31. Joint FAO/WHO Expert Commit-tee on Food Additives (Spiers GJA,van den Brandt PA). WHO Food Addi-tives Series: 50: Nitrate (and potentialendogenous formation of N-nitrosocompounds). Available at:http://www.inchem.org/documents/jecfa/jecmono/v50je06.htm. Ac-cessed March 16, 2012.


Cheese and Cardiometabolic Health: New Findings for a New Canvasby Christopher J. Cifelli, PhD, and Keigan M. Park, PhD

Cardiovascular disease (CVD) is aforemost public health concern in theUnited States, resulting in more than2,200 deaths each day.1 The total fis-cal costs associated with CVD in theU.S. were estimated to be $286 billionin 2007.1 It is hypothesized that thehealth and economic burden im-parted by CVD will continue to risebecause of the growing obesity epi-demic, which is not only increasingthe number of overweight olderadults but also is beginning to seri-ously affect children, adolescents, andyoung adults. Therefore, it is impor-tant to identify and implementachievable behavioral and lifestylemodifications that can ultimately re-duce the incidence of CVD.

Nutrition research and the dietaryrecommendations from key healthprofessional and government organi-zations have tended to take a reduc-tionist approach to preventing andmitigating CVD. The 2010 DietaryGuidelines for Americans,2 the Ameri-can Heart Association,3 and theAmerican Dietetic Association (nowthe Academy of Nutrition and Dietet-ics) and the Dietitians of Canada4 allrecommend reducing saturated andtrans fat intake, albeit to different de-grees, to improve cardiometabolichealth. Similar recommendationshave been made for sodium, namelyto reduce dietary sodium intakeacross the lifespan to reduce the riskof developing hypertension.2,3

Because we consume foods and notnutrients, broad recommendations toreduce sodium and saturated fat in-take can result in unintended conse-quences. For example, a reductionistapproach can lead to confusion andpoor dietary choices among con-sumers, especially when recommen-dations limit the intake of nutrient-rich foods that also contain apprecia-ble levels of sodium and saturated

fat. The complex etiology of CVD re-quires adoption of holistic ap-proaches, both at the food and dietlevel, to reduce CVD risk. Accordingly,this review describes the relationshipbetween cheese consumption andCVD risk, highlighting the importantrole of cheese in a healthful diet.

Nutrient Contribution of Cheese

Cheese, a dairy food that is typically(but not always) fermented, is a con-venient, well-liked, nutrient-rich food.While several factors influence thenutrient content of cheese (e.g., thetype of milk used, the variety of

cheese produced, and the length ofaging), cheeses contribute importantnutrients to the American diet. In ad-dition, the aging or ripening of vari-ous cheeses can beneficiallyinfluence the nutritional value ofcheese through the synthesis of sev-eral B vitamins via the cheese mi-croflora, such as vitamin B12, folic acid,biotin, and riboflavin.5 In particular,because most of the lactose found inmilk is lost during the separation ofthe milk curds from whey, cheese canbe a source of important nutrients forpeople with lactose maldiges.

Data from the 2003-2004 and 2005-2006 National Health and NutritionExamination Survey (NHANES)showed that while cheese con-tributed 5% of the calories, 8% of thesodium, and 16% of the saturated fatin the diets of Americans for 2 yearsor longer, it also contributed 21% of

the calcium, 11% of the phosphorus,9% of the protein, 9% of the vitamin A,8% of the zinc, and 3% of the magne-sium in their diets.6 Food researchhas demonstrated that among mid-dle school children, the ready avail-ability (i.e. visibility) of cheese canencourage and increase the con-sumption of other food groups (e.g.,fruits and whole grains) that maylead to an improvement in overalldiet quality.7

The Cheese Matrix

One of the reasons cheese should beincorporated into the diet, despite itshigh saturated fat content, is the

unique form of fat that it contains.Milk fat is secreted from the mam-mary gland of cows through a bud-ding process and is thereforesurrounded by a phospholipid barrierthat contains a multitude of bioactiveproteins and signaling moieties.8

Nearly all of the milk fat is packagedin triacylglycerol molecules and lo-cated within the core of the phos-pholipid layer. The triacylglycerolmolecules contain many differenttypes of fatty acids, which vary intheir length and degree of saturationas well as their binding site on theglycerol backbone.9

Each of these fatty acids may havesignificant positive or negative ef-fects on public health; however, dueto both the number and complexityof the fatty acids found in milk fat,only a few have been studied in suffi-cient detail. In addition, as already


noted, cheese contains a variety ofnutrients that are packed within itsunique matrix. Both of these distinc-tive properties—the fatty acid com-position and the variety of nutrients—may result in the fat component ofcheese being absorbed differentlythan the fat in various other foods.10

Furthermore, there is evidence tosuggest that the fat absorbed may af-fect serum lipids differently than sim-ilar fats found in other foods, possiblyresulting in a more favorable effecton cardiovascular health.11 Addi-tional evidence is needed on thistopic as it proves to be an importantpiece in the understanding of cheeseand cardiometabolic health.

Evidence on Cheese and Cardiovascular Health

Cheese and Cardiovascular Risk: Results from Prospective Trials

Prospective epidemiologic evidencehas tracked the association betweencheese consumption and coronaryheart disease (CHD) and stroke. Theseresults have suggested mostly a neu-tral association between cheese andCHD and stroke, indicating neither anegative nor a positive effect ofcheese on cardiovascular health.12-14

This is intriguing because some stud-ies have reported that total dairyproduct intake has an inverse to neu-tral association with CHD andstroke.15,16 However, the number ofstudies specifically examining cheeseconsumption as a primary variableare sparse, perhaps suggesting thatas more evidence is collected cheeseconsumption may be shown to havea similar inverse to neutral associa-tion with CHD as that observed withtotal dairy intake.

It is also unclear from these studieswhether different cheeses exert di-vergent effects. A close monitoring ofspecific cheeses is needed beforeconclusions on the heart health ef-fects of cheese can be made.

Cheese and Blood Pressure: Results from the DASH Trial

High blood pressure is a strong de-terminant of CVD and stroke. Obser-

vational and clinical studies havedemonstrated that dairy foods arebeneficially related to blood pressure,especially in those with prehyperten-sion or stage 1 hypertension.17 Whilefew clinical studies have examinedthe effects of cheese on blood pres-sure, cheese was consumed regularlyin the Dietary Approaches to StopHypertension (DASH) trial.18

In the DASH trial, subjects with high-normal blood pressure were random-ized to one of three diets: a controldiet that represented a typical Ameri-can diet, a diet rich in fruits and veg-etables, or a diet rich in fruits andvegetables that also contained low-fat dairy products (i.e., DASH diet).

Subjects in the DASH diet were al-lowed to consume approximately 2servings/day of low-fat or fat-freemilk or yogurt as well as about 1 serv-ing/day of full-fat or reduced fatcheese. A significant reduction in sys-tolic and diastolic blood pressure wasobserved with the DASH diet com-pared with the control diet. Further-more, the reduction in bloodpressure observed with the DASHdiet was nearly twice as great as thereductions observed in the diet richin fruits in vegetables only.18

Subsequent studies using the DASHdietary pattern have confirmed andextended these findings.19 These re-sults have led various health profes-sional and government organiza-tions, including federal entities that

developed the 2010 Dietary Guide-lines for Americans,2 to recognize theDASH diet as an important way to im-prove heart health. Together, the sci-ence around the DASH diet and therecommendations stemming fromthat science indicate that regularcheese consumption can be incorpo-rated into a diet that promotes car-diovascular health.

Cheese and Serum Lipids: Results fromClinical Trials

The preponderance of clinical studieshas compared cheese versus butterin their effects on total cholesterol,low-density lipoprotein (LDL) choles-terol, and high-density lipoprotein(HDL) cholesterol. These studies haveindicated that in most but not allcases cheese consumption has lessof an impact on serum lipids thanbutter, with no significant changesfrom the baseline diet.19 A likelymechanism of this neutrality is in-creased fecal fat excretion due to thecalcium content of cheese; however,additional mechanisms are likely con-tributing to the observed out-comes.10

It is important to note that thesestudies fail to examine how cheeseaffects cardiovascular health com-pared with other commonly con-sumed foods, especially foods withsimilar saturated fat content. Theseresults will be pivotal to understand-ing the cardiovascular effects ofcheese consumption. It should alsobe noted that in the process of mak-ing cheese, additional complexity isobtained through the fermentationprocess in which bacteria utilize thefat, carbohydrate, and protein com-ponents of milk to synthesize severalunique end products that may havesignificant effects on heart health.20

These end products, as well as thematrix effects previously mentioned,may be beneficial for cardiovascularhealth by simultaneously decreasingthe circulating amounts of small,dense LDL cholesterol particles andincreasing the amounts of large,buoyant LDL cholesterol particles.11

Future clinical studies that examine


the effects of cheese intake on theentire spectrum of lipid biomarkersassociated with CVD will allow for amore complete understanding of themolecular mechanisms by whichcheese affects cardiovascular health.

Conclusion

Cheese is a nutritious food that canbe easily incorporated into a health-ful eating pattern to improve overalldiet quality. As illustrated in this re-view, there is evidence to indicatethat cheese consumption may not bethe cardiovascular villain it was oncesuggested to be. In recognition ofthese recent findings, the 2010 Di-etary Guideline for Americans Advi-sory Committee stated that the“consumption of milk products maynot have predictable effects onserum lipids, weight control andmetabolic syndrome,” possibly due tothe bioactive components that maybe contained in milk fat.21

To more fully understand the impactthat cheese consumption can haveon health, additional research needsto be done on the individual fattyacids that a cheese contains, thecheese’s unique matrix and how thataffects nutrient bioactivity, and theability of cheese to effect novel bio-markers for cardiovascular diseaserisk. With this knowledge, a clearerpicture of the role that cheese playsin a healthful diet can be painted forfuture generations.

Christopher J. Cifelli, PhD, and KeiganM. Park, PhD, are directors of nutritionresearch at the Dairy Research Insti-tute, in Rosemont, IL.

References1. Roger VL, Go AS, Lloyd-Jones DM, etal on behalf of the American HeartAssociation Statistics Committee andStroke Statistics Subcommittee. Heartdisease and stroke statistics—2011update: a report from the AmericanHeart Association. Circulation.2011;123:e18–e209.2. U.S. Department of Agriculture andU.S. Department of Health andHuman Services. Dietary Guidelines forAmericans, 2010. 7thedition, Washing-

ton, DC: U.S. Government Printing Of-fice, December 2010.3. Lichtenstein AH, Appel LJ, BrandsM, et al. Diet and lifestyle recommen-dations revision 2006: a scientificstatement from the American HeartAssociation Nutrition Committee. Circulation. 2006;114:82-96. 4. Kris-Etherton PM, Innis S, AmericanDietetic Association, Dietitians ofCanada. Position of the American Di-etetic Association and Dietitians ofCanada: Dietary fatty acids. J Am DietAssoc. 2007;107:1599-1611. 5. Renner E. Nutrition aspects ofcheese. In: Milk. The Vital Force. Pro-ceedings of the XXII InternationalDairy Congress, the Hague, Septem-ber 29 – October 3, 1986. Edited bythe Organizing Committee to the XXIIInternational Dairy Congress. Boston:D. Reidel Publishing. Co.; 1987: 179-186.6. Dairy Research Institute. NHANES2003 – 2006. Data Source: Centers forDisease Control and Prevention, Na-tional Center for Health Statistics, Na-tional Health and NutritionExamination Survey Data. Hyattsville,MD: U.S. Department of Health andHuman Services, Centers for DiseaseControl and Prevention [2003-2004;2005-2006]. Available atwww.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm.7. Donnelly JE, Sullivan DK, Smith BK,et al. The effects of visible cheese onthe selection and consumption offood groups to encourage in middleschool students. J Child Nutr Manag.2010;34:Spring 2010. Available at:www.schoolnutrition.org/Content.aspx?id=14040 8. Cavaletto M, Giuffrida MG, Conti A.The proteomic approach to analysisof human milk fat globule mem-brane. Clin Chim Acta. 2004;347:41-48.9. Mather IH, Keenan TW. Origin andsecretion of milk lipids. J MammaryGland Biol Neoplasia. 1998;3:259-273. 10. Hjerpsted J, Leedo E, Tholstrup T.Cheese intake in large amounts low-ers LDL-cholesterol concentrationscompared with butter intake of equalfat content. Am J Clin Nutr. 2011;94:1479-184. 11. Sjogren P, Rosell M, Skoglund-An-dersson C, et al. Milk-derived fattyacids are associated with a more fa-

vorable LDL particle size distributionin healthy men. J Nutr. 2004;134:1729-1735.12. Goldbohm RA, Chorus AM,Galindo Garre F, et al. Dairy consump-tion and 10-y total and cardiovascularmortality: a prospective cohort studyin the Netherlands. Am J Clin Nutr.2011;93:615-627. 13. Bonthuis M, Hughes MC, IbiebeleTI, et al. Dairy consumption and pat-terns of mortality of Australianadults. Eur J Clin Nutr. 2010;64:569-577. 14. Larsson SC, Männistö S, VirtanenMJ, et al. Dairy foods and risk ofstroke. Epidemiology. 2009;20:355-360.15. Elwood PC, Pickering JE, Givens DI,et al. The consumption of milk anddairy foods and the incidence of vas-cular disease and diabetes: anoverview of the evidence. Lipids.2010;45:925-939. 16. Soedamah-Muthu SS, Ding EL, Al-Delaimy WK, et al. Milk and dairy con-sumption and incidence ofcardiovascular diseases and all-causemortality: dose-response meta-analy-sis of prospective cohort studies. Am JClin Nutr. 2011;93:158-171.17. Kris-Etherton PM, Grieger JA,Hilpert KF, et al. Milk products, dietarypatterns and blood pressure man-agement. J Am Coll Nutr. 2009;28(suppl 1):103S-119S18. Appel L J, Moore TJ, Obarzanek E,et al. A clinical trial of the effects of di-etary patterns on blood pressure.DASH Collaborative Research Group.N Engl J Med. 1997; 336: 1117-1124.19. Tholstrup T, Høy CE, Andersen LN,et al. Does fat in milk, butter andcheese affect blood lipids and choles-terol differently? J Am Coll Nutr.2004;23:169-176.20. Phelan M, Kerins D. The potentialrole of milk-derived peptides in car-diovascular disease. Food Funct.2011;2:153-167.21. Dietary Guidelines Advisory Com-mittee. 2010. Report of the DietaryGuidelines Advisory Committee onthe Dietary Guidelines for Americans,2010, to the Secretary of Agricultureand the Secretary of Health andHuman Services. U.S. Department ofAgriculture, Agricultural ResearchService, Washington, DC.

recently completed their first year ina partnership program with an em-phasis in EDs. This article describesthis program and our experiencewith its first year in operation.

Why the Partnership?

According to ACEND’s guidelines, im-plemented in 2009, all DIs are re-quired to provide: 1) at least 1,200hours of supervised practice, 2) a con-centration area, and 3) a full-time di-rector. To meet these guidelines, theUniversity of Minnesota’s DIGS pro-gram needed to be revised, present-ing the perfect opportunity forcreative thinking that ultimately ledto the involvement of The Emily Pro-gram, whose headquarters is locatedabout one-quarter mile from the Uni-versity of Minnesota St. Paul campusand the Department of Food Scienceand Nutrition. After brainstormingand arriving at some innovativestrategies, Jillian Lampert, PhD, MPH,RD, FAED, director of communica-tions, outreach and research, and Car-rie Peterson, MS, RD, CSSD, director ofthe DIGS program, decided to moveahead with creating the University ofMinnesota – The Emily Program (U ofM-TEP) dietetic internship.

The Academy of Nutrition and Dietet-ics supports the essential role of RDsin providing nutrition therapy for pa-tients with EDs. However, becauseEDs are a complex bio-psychosocialdisorder, the Academy recommendsthat RDs collaborate effectively withan interdisciplinary team, includingmedical and mental health person-nel.4 Patients with EDs are often influ-enced by other psychologicalconditions such as depression, anxi-ety, substance abuse, borderline per-sonality disorder, and obsessivecompulsive disorder.5 Therefore, theroles and responsibilities of the RD


How does one become a registereddietitian (RD) specializing in eatingdisorders (EDs)? According to the Ac-creditation Council for Education inNutrition and Dietetics (ACEND), toearn the RD credential, students mustcomplete a minimum of a bachelor’sdegree and an accredited didacticprogram, complete required compe-tencies while enrolled in an accred-ited supervised practice program,and pass a national exam adminis-tered by the Commission on DieteticRegistration (CDR). However, whilesupervised practice programs in-clude clinical, foodservice, and com-munity requirements, they may notincorporate experiences in inpatientor outpatient ED facilities.1

Because nearly 15 million people inthe United States struggle withanorexia nervosa (AN) or bulimia ner-vosa (BN), and/or compulsiveovereating (COE)/ binge eating disor-der (BED),2,3 it is likely that most indi-viduals know someone strugglingwith an ED. Often it is for this reasonor due to one’s personal experienceand recovery that an individual mightfind a passion for working as an RD inthe field of EDs. However, the lack ofrequired experience with ED patientsduring training may not adequatelyprepare RDs for work with this spe-cialized population, particularly inlight of the many challenges pre-sented with this demanding andoften fragile clientele. To effectivelywork with ED patients, RDs find thatthey need additional skills, special-ized training, and an increased aware-ness about themselves as a provider.Therefore, the opportunity to acquireprofessional experience with ED pa-tients at the dietetic internship (DI)level may significantly benefit di-etetic interns who wish to work withthis patient population. Increasingopportunities for dietetic interns at

facilities that treat EDs may also pro-vide great value for treatment cen-ters seeking trained and specializedRDs for hire.

To allow for this specialized trainingfor dietetic interns, the University ofMinnesota (U of M) Dietetic Intern-ship for Graduate Students (DIGS) re-cently transformed into a

collaborative DI with The Emily Pro-gram’s eating disorders treatmentprogram. The U of M DI, an accreditedprogram established in 1990, offersnon-credit, non-degree, supervisedpractice experiences for individualswith a nutrition/dietetics degree andprepares them to become eligible forthe RD board exam. The Emily Pro-gram is a Minnesota-based agencythat provides comprehensive psy-chological, nutritional, medical, andpsychiatric care for eating disorders.The Emily Program and the U of M DI

Providing a Focus on Eating Disorders: The University of Minnesota – The Emily Program Dietetic Internship Programby Val Schonberg MS, RD; Carrie Peterson, MS, RD, CSSD; and Doreen Lindblom, RD


include components of the nutritioncare process, while also consideringany psychological factors that mayaffect treatment.6

The Academy recommends thatentry-level RDs know the essentialsthat pertain to assessing clients, ana-lyzing anthropometric data, and un-derstanding when to recommendtreatment. However, RDs who aremost effective in working with pa-tients with EDs also need to havestrong counseling skills and, depend-ing on a patient’s cognition, need tounderstand various behavioral strate-gies, motivational interviewing, andmindfulness-based strategies. Thus,advanced training is recommendedfor individuals interested in workingin this field.6 By providing specializedexperience at the internship level, theU of M TEP DI program provides anexcellent opportunity for introducingskills and education that can providea framework for further advance-ment.

Components of the Internship Program

The U of M TEP DI accepts 15 internsfor a 35-week program extendingfrom August to April. This full-time,competency-based program pro-vides more than 1,300 hours of su-pervised learning. The clinical,community, and foodservice experi-ences entail more than 15 rotationsat 35 sites under the supervision ofhighly qualified preceptors. The pro-gram provides a variety of supervisedexperiences, training opportunities,and affiliations involving 9 medicalcenters, 4 long-term care facilities, 11foodservice management sites, and 7community nutrition locations. Addi-tional internship classes enhance theintern’s knowledge in other specialtyareas such as pediatrics, dysphagia,and sports nutrition. Interns also havean opportunity to research or furtherexplore a nutrition-oriented area ofparticular interest.

Each intern is scheduled for a 9-weekrotation through The Emily Programin various locations in the Twin Citiesmetropolitan area. During this time,

interns learn to provide recovery-minded support to clients in bothoutpatient and intensive treatmentprograms who struggle with any ofthe DE/EDdiagnoses, including AN,BN, COE/BED. After orientation andtraining are completed, an intern’stypical day begins with observationof and participation in therapeuticclient meals, goal setting, and ED be-havior identification, in either one-to-one appointments or any one of theintensive treatment programs. Eachweek, rotation sites may vary fromthe Intensive Day Program to the COEIntensive Outpatient Program (IOP).

Interns then may spend 2 weeks in anAN/BN IOP, where they have opportu-nities to lead meals, provide groupnutrition education, and assist ingroup outings. An important part ofthe training process has been the useof motivational interviewing and nu-trition counseling at an individualand group level. To provide supportin this area for interns, the programutilizes “Step-by-Step,” a program de-veloped by Molly Kellogg, RD, LCSW,that offers online podcasts for re-viewing basic nutrition counselingskills.7 Interns are also offered oppor-tunities to role play with each otherin such areas as nutrition assessment.

Two weeks of the interns’ experience

is spent at the Anna Westin House,The Emily Program’s 16-bed, 24/7adult residential treatment program.During this time, interns participatein therapeutic meals and activitieswith residents. Part of this rotationalso offers a foodservice componentthat includes such experiences asfood portioning, menu planning,catering, temperature control, foodinventory, recipe development andexecution, and preparation and serv-ice of meals. In addition, interns areable to get firsthand experience withfamily-based treatment and servicesprovided at The Emily Program’s 10-bed Anna Westin House-Adolescentresidential program and the adoles-cent outpatient program.

Interns are expected to model nor-mal eating, which includes being flex-ible and willing to eat a variety offoods. In the process, interns learn tocoach clients through challenging sit-uations that arise during therapeuticmeals. Modeling balanced eating iskey to the client’s recovery, providinga safe place for the client to challengeED thoughts and beliefs.

During the final week of the intern-ship, interns come together to de-velop and present a special finalproject for The Emily Program. Thisfinal project involves collaboratingand working creatively in teams,using their skills and talents. In theprogram’s first year of operation, in-terns worked together on projectssupporting The Emily Program Foun-dation (TEPF) and also developed re-sources for use with clients. The firsttwo teams collaborated with theCommunity Outreach Coordinatorfrom TEPF to develop an adolescent-focused curriculum and toolkit thatcould be accessed online by middleschool and high school teachers. Thethird team researched and developednutrition fact sheets for use by TheEmily Program in individual andgroup sessions. The projects werepresented to The Emily Program’steam of RDs, the community out-reach coordinator, and DI team. Over-all, the feedback from the RDs andTEPF indicated that the material cre-ated by the interns would be veryuseful for The Emily Program.


In addition to these activities, internsattend state-wide nutrition meetings,conferences, and symposiums, andparticipate in projects that includepublic relations/fundraising/massmedia, legislative, and public policyinitiatives.

Feedback from the First Year

The U of M-TEP dietetic interns hadan opportunity at the end of the in-ternship to evaluate the ED rotationorientation and training, supervisedpractice experiences, supplementarylearning experiences (e.g., case stud-ies and the final project), programevaluation, and RD preceptors. Also,interns offered suggestions for pro-gram improvements.

Overall, the feedback showed that100% of the interns either “agreed” or“strongly agreed” that they felt com-petent to begin work as an ED dieti-tian. Among the aspects reported byinterns to be the most valuable partof the internship were the following:“participating in therapeutic meals,”“each RD has a different style, whichenabled me to learn so much,” and“being immersed in the ED world for9 weeks and the exposure to so manyclients and so many ED profession-als.” One intern related the internshipexperience to learning a new lan-guage, noting that she found the im-mersion in the ED environmentprovided significantly more informa-tion than reading about EDs in a text.

Interns worked on the final projectthroughout the internship, enablingthem to develop skills related toteamwork and collaboration, timemanagement, creative thinking, andorganizing a professional presenta-tion. The project was presented tothe DI team, TEP RDs, and TEPF staff.From the interns’ self-evaluations,peer evaluations, and feedback form,it was clear that the final project al-lowed for a high degree of creativity,independence, and problem solving,as well as a chance to craft profes-sional tools for “real life” use. We planto use this feedback to create moreopportunities for interns to “give

back” as well as to develop skills theycan apply in their professional prac-tice and overall understanding ofEDs.

Interns also expressed that the mosthelpful opportunities were those thatallowed them to work with individualclients or groups. Although specifictime was allotted for this in their rota-tion, interns commented that addi-tional opportunities to coach clientswould enable them to further prac-tice their skills and, in turn, receivefeedback from clients. Interns also

expressed that role-play opportuni-ties were helpful and they desiredmore built-in time for role-play sce-narios (i.e., during meals and mealoutings). Other suggested areas forimprovement included additional ed-ucation about EDs and comorbidpsychiatric issues, such as personalitydisorders, anxiety, and depression.

Program Development

The U of M-TEP dietetic internship isaddressing the areas mentioned inthe dietetic intern evaluations by de-veloping a summer reading list,adding a mid-year ED class, enhanc-ing projects and assignments, and as-sessing the quality of our trainingand staff relief. In addition, we areworking with the staff at each site toensure we are meeting intern compe-tencies while respecting the integrityof our program. We are also review-ing the Standards of Practice (SOP)and Standards of Professional Per-formance (SOPP) for Registered

Dietitians in Disordered Eating andEating Disorders, published in August2011 by the Academy of Nutritionand Dietetics.8 This document mayprovide additional support for plan-ning and preparing skill develop-ment experiences for the dieteticinterns. In turn, it is useful readingmaterial for individuals entering thefield of EDs, as it allows them to bet-ter understand: 1) what to expect asthey begin their work in this field, and2) the amount of time it takes to de-velop the skills to become a “profi-cient” ED dietitian.

The dietetic internship program ofthe University of Minnesota and TheEmily Program strives to continuetraining interns to graduate as capa-ble RDs who are confident in theirprofessional skills and their ability tocontribute to the profession. Al-though the U of M-TEP dietetic in-ternship has an emphasis in EDs, theinterns graduate with a solid, diverse,and well-rounded knowledge andskill foundation that equips them tohandle ED-related issues no matterwhere their career takes them.

Val Schonberg, MS, RD, is the coordina-tor of the dietetic internship programat The Emily Program. Carrie PetersonMS, RD, CSSD, is the director andDoreen Lindblom RD, is the assistantdirector of the dietetic internship at theUniversity of Minnesota.

References1. Registered Dietitian (RD): Educa-tional and Professional Require-ments. Academy of Nutrition and


by Ingrid Skoog, MS, RD, CSSD

FromThe Chair

Blazing New Trails and Making a Difference

■ We also have many great events planned for the 2012Food & Nutrition Conference & Expo (FNCE) in Philadelphia,where we hope many of you will join us for some great pro-gramming and our annual SCAN Reception brought to youvia our tireless development director, Hope Barkoukis, PhD,RD, and our many amazing sponsors.

In June, I mentioned that SCAN is committed not only to pro-viding members with the best DPG deal for their dollars butalso to amplifying our member services through an increasedfocus on promoting the SCAN RD. To this end, we are in thefinal stages of recruiting a director of public relations andhave been pleased to appoint Alisa Krisan, MS, RD, as our di-rector of public policy. I believe that SCAN is the only DPGwith these two positions, and we are already putting these togood use.

There is always more to write here, especially as it relates toour SCAN subunits. I hope you will make use of the new factsheets, gain insights from the Wellness/CV Connection andScore e-newsletters, and learn more about our new Disor-dered Eating and Eating Disorders (DEED) subunit director,Therese Waterhous, PhD, RD.

Rest assured that SCAN will continue trailblazing. SCAN iscommitted to helping each of you achieve your professionalgoals, and showing the world that working with a SCAN RDwill make all the difference.

See you at FNCE!

“…Two roads diverged in a wood, and I took the one less traveled by, and that has made all the difference.”

These are the last three lines from my favorite poet RobertFrost in The Road Not Taken, written in 1920. I love thispoem and it is how I have tried to live my life. It is also thephilosophy that I associate with SCAN. SCAN as a dieteticpractice group (DPG) is filled with trailblazers: We are opento and embrace new ideas, and we are always looking to-ward the future—and, as Robert Frost said, this has madeall the difference.

What are the most recent “differences” for SCAN?

■ During the past 3 months we hired our new executive di-rector, Athan Barkoukis, who has hit the ground runningwith new ways to keep the leadership and infrastructure ofSCAN on the cutting edge.

■ We have taken on a new webinar company that enablesSCAN to produce and offer more educational opportunitiesto our busy and talented members.

■ We are well along the way in planning our new approachto Symposium 2013. Imagine attending a conferencewhere you leave with skills, tools, and techniques that youcan immediately apply to your practice. Well, mark yourcalendars for April 26-28, 2013, when SCAN will be back inChicago for Tools &Techniques for Peak Professional Perform-ance. Just a few highlights include sessions on corporatewellness, media and social media, cultural literacy andcounseling skills, and National Lipid Association training.

Dietetics Web site. Available at:http://www. eatright.org/Becomean-RDorDTR/content.aspx?id=8143. Ac-cessed April 23, 2012.2. Hudson JI, Hiripi E, Pope HG Jr, et al.The prevalence and correlates of eat-ing disorders in the National Comor-bidity Survey Replication. BiolPsychiatry. 2007;61:348-358. 3. Sonja A, Swanson ScM, Scott J, et al.Prevalence and correlates of eatingdisorders in adolescents: results fromthe National Comorbidity SurveyReplication Adolescent Supplement.Arch Gen Psychiatry. 2011;68:714-723.

4. Waterhous T, Jacob W. PracticePaper of the American Dietetic Asso-ciation: Nutrition Intervention in theTreatment of Eating Disorders. Avail-able at: http://bhndpg.org/docu-ments/Practice_Paper_Nutrition_Intervention.pdf. Accessed April 23, 2012.5. Klump KL, Bulik C, Kaye W, et al.Academy for Eating Disorders posi-tion paper: eating disorders are seri-ous mental illnesses. Int J Eat Dis.2009;42:97-103.6. Ozier AD, Henry BW. Position of theAmerican Dietetic Association: Nutri-tion intervention in the treatment of

eating disorders. J Am Diet Assoc.2011;111:1236-1241.7. Step-by-Step: A Program for Di-etetic Interns Web Site. Available at:http://www.mollykellogg.com/step-bystep.html. Accessed May 16, 2012.8. Tholking MM, Mellowspring AC,Eberle SG, et al. American Dietetic As-sociation: standards of practice andstandards of professional perform-ance for registered dietitians (compe-tent, proficient, and expert) indisordered eating and eating disor-ders (DE and ED). J Am Diet Assoc.2011;111:1242-1249.


American College ofSports Medicine Annual MeetingMay 33- June 3, 2012Sam Francisco, CA

With more than 45,000 members andcertified professionals, the AmericanCollege of Sports Medicine (ACSM) isthe world’s largest sports medicineand exercise science organization. AtACSM’s 59th Annual Meeting, morethan 6,600 exercise scientists, sportsdietitians, physicians, and otherhealth professionals gathered toshare the latest research. Shown hereare a few of the nutrition-relatedhighlights. The number in parenthe-ses indicates the number of the ab-stract, which can be found in thesupplement to the May 2012 issue ofMedicine and Science in Sports and Ex-ercise. (Additional highlights are avail-able at www.acsm.org; click on “newsreleases.”)

Foods and Phytochemicals for Performance

■ During a 75-km time trial, cyclistsperformed just as well by fuelingwith a banana versus a sports drink.The cyclists consumed 0.2-gm/kg car-bohydrate (CHO) from banana orsports drink every 15 minutes duringthe 2.3-hour event. That equates toabout 14 g CHO/15 min for a 70 kg-cyclist—about 8 oz of sports drink orhalf of a medium banana. (Abstract1333)

■ Tart cherry juice contains numer-ous antioxidant and anti-inflamma-tory agents that can reduce pain andinflammation. When 20 women (ages40-70) with osteoarthritis consumed10.5 oz of tart cherry juice or aplacebo twice daily for 3 weeks, theirserum inflammatory biomarkers(TNF-alpha, C-reactive protein) de-creased. This was particularly notice-able in the 12 women with thehighest amount of inflammation. (Ab-stract 1389)

■ Tart cherries contain the phyto-chemical melatonin, which is associ-ated with better quality of sleep. Astudy with 20 volunteers indicatedtotal sleep time and sleep efficiencyimproved after 7 days of tart cherryjuice consumption. Perhaps tartcherry juice could be helpful for trav-eling athletes? (Abstract 1390)

■ Pomegranate juice is a rich sourceof polyphenols, which can reduce de-layed onset muscle soreness (DOMS).Healthy men who drank pomegran-ate juice for 8 days before muscle-damaging exercise experienced less

DOMS. A once-daily dose of POMWonderful was as effective as atwice-daily dose. (Abstract 1391)

■ A proprietary blend of botanicalconcentrates that contains bluegreen algae, D-ribose, antioxidants,and enzymes showed no significantimprovement in recovery from exer-cise-induced muscle soreness. (Ab-stract 1392)

■ Quercetin can enhance voluntaryactivity and endurance performancein mice. Healthy older people (ages61 to 89) who received 1 g ofquercetin for 14 days significantly in-creased their step counts by about17% (compared with the controlgroup). Quercetin might be a newway to promote physical activity inolder adults. (Abstract 1386)

Conference Highlights

■ Nitrates in foods such as spinach(and beets) reduce the oxygen costof exercise and enhance efficiency.Healthy young men (age 25) whoconsumed 0.5 L of spinach juice for 6days enhanced their anaerobic per-formance. This was due to reductionof adenosine triphosphate (ATP) costand increased ATP oxidative produc-tion. (Abstract 1823)

■ Dietary nitrate supplementationimproved 4-km and 16-km time trialperformance by about 2.7% in sub-elite cyclists. During a longer, 50-miletime trial, trained cyclists who con-sumed 0.5 L of beetroot juice (~6.2mmol nitrate) 2.5 hours pre-ride rode0.8% faster. This small improvementwas not statistically significant, but toa cyclist the improvement wouldlikely be meaningful. (Abstract 1824)

■ Among elite rowers, 6 days of consuming 5.5 mmol/day of dietarynitrates from beetroot juice con-tributed to improved erg tests, partic-ularly in the later stages of exercise.(Abstract 1829)

■ Older men (ages 60-70) who con-sumed two 70-mL doses of concen-trate beetroot juice/day (~600 mgnitrate) for 3 days reduced theirblood pressure and the oxygen costof moderate-intensity treadmill exer-cise. Dietary nitrates are an effectiveway to improve performance of olderadults. (Abstract 1826)

■ Both beta-alanine and sodium bi-carbonate can limit metabolic acido-sis and enhance high-intensityexercise performance. In a 5-minutecycling test and a Wingate test, beta-alanine enhanced performance. Com-bining beta-alanine loading withsodium bicarbonate presented thehighest improvements in perform-ance. (Abstracts 1836, 1837)

Caffeine

■ Most caffeine research is per-


■ College-age dancers (n=11) hadgreater spine bone mineral densitycompared with runners (n=13) andcontrols, despite low energy availabil-ity. The loading nature of dancingmight have greater positive impacton bone than running. (Abstract2741)

■ Female cyclists (age 26) whotrained about 10 hours a week hadspine Z scores in the osteopenicrange. Cyclists should cross train withweight-bearing exercise to improvetheir bone health. (Abstract 2733).

Dehydration

■ Jockeys have a strict weight limitthat commonly leads to poor dietarypractices, compromised bone health,mood disorders, cigarette smoking,and extreme dehydration on bothrace and nonrace days. Analysis ofthe urine of 875 jockeys indicatesthat 48% were significantly dehy-drated and another 27% were highlydehydrated on race day. (Abstract1407)

■ A study with trained runners fromthe Southeastern U.S. showed theylost twice as much sweat during a 1-hour summer race than they pre-dicted. As a group, they predictedlosing about 750 mL of sweat in hot,humid conditions but they actuallylost about 1,500 mL. Pre/post-exer-cise weights can be a helpful way toteach athletes about their need tohydrate. (Abstract 2288)

■ Researchers found that 13-year-oldsoccer players (n=107) in summercamps need to be educated aboutthe symptoms of dehydration, giventhat 89% showed up dehydratedprior to practice and 96% ended updehydrated at the end of the day. Ad-vice to “drink to thirst” is inadequatefor this population! (Abstract 2289)

■ The National Athletic Trainers’ As-sociation recommends that athletesconsume 300 to 700 mg of sodiumduring the 2 to 3 hours of pre-exer-cise to help prevent sodium

■ In a cycling time trial, Red Bull en-hanced performance similarly to caf-feine. Red Bull’s “added ingredients”offered no additional benefits. (Ab-stract 2789)

Supplements

■ Of 390 soldiers in the 101st Air-borne Division, 58% took a multivita-min supplement, 32% took whey,16% consumed energy drinks, and10% took creatine in the hopes ofachieving optimal military readiness.They could more appropriately betaught to use foods and nutrient tim-ing as a safer and more effective al-ternative to dietary supplements.(Abstract 3231)

■ In an online survey sent totriathlon clubs, 126 triathletes re-ported the most common reasons fortaking supplements were to preventinjury and illness. Accordingly, 80%consumed a multivitamin supple-ment, 65% consumed whey, and 66%took fish oil. (Abstract 3234)

Female Athlete Triad

■ Cognitive restraint is a risk factorfor the female athlete triad. Womenwho tested high as restrained eaterswere more likely to limit their energyintake and experience amenorrheadue to low energy availability. (Ab-stract 931)

formed using pure caffeine supple-ments. Does coffee offer the same er-gogenic effect? Yes. In research withcyclists and triathletes, time trial re-sults were as follows: 39.4 minuteswith caffeine; 39.5 minutes with cof-fee; 41.4 minutes with instant decaf-feinated coffee; and 40.3 minuteswith the placebo. There was no differ-ence in fat metabolism, so the re-searchers suggest the approximate4% improvement was related to thecentral nervous system stimulus thatmakes exercise seem easier with caf-feine. (Abstract 2781)

■ An extensive literature review indi-cates that caffeine has little physio-logical effect on hydration status andheat tolerance. Hence, athletes neednot worry about using 3 to 9 mg caf-feine/kg body weight when exercis-ing in the heat. (Abstract 1584)

■ While low levels of caffeine do nothave a diuretic effect over the courseof the 24-hour day, what happens inthe short term? In 3 hours, habitualcoffee drinkers who consumed 200mL of coffee (with 250 mg caffeine)voided 316 mL of urine 3 hours later,a nonsignificant difference from thegroup that consumed plain waterand voided 290 mL of urine. However,the high caffeine group (550 mg caf-feine) produced 630 mL of urine. Thedata suggest that high caffeine in-take can induce an acute diuretic ef-fect. (Abstract 2791)

■ When cyclists were given either 3or 6 mg caffeine/kg body weight 1hour prior to a 40-km time trial, theyperformed equally well regardless ofthe dose. However, the athletes whoresponded best to pre-exercise caf-feine during a time trial had a specificpolymorphism that was missing inthe nonresponders. When the datawere analyzed by genotype, the AAhomozygote group was 4.6% fasterat 6 mg/kg compared with the 2.6%improvement that occurred in the Callele group. Genetic polymorphismsinfluence the ergogenic effect of caf-feine. (Abstract 2778)


depletion. Athletes need to be edu-cated that standard sports drinks—and even sodium-enhanced sportsdrinks—do not provide this level ofsodium intake. (Abstract 3026)

■ Among 207 finishers of the West-ern States 100-mile Endurance Run,12 (6%) experienced hyponatremia.The only measurable difference be-tween those 12 runners and the restof the finishers was higher creatinekinase (CK) levels. Hyponatremia wasnot associated with sodium supple-mentation (or lack thereof ) duringthe race, number of urinations, norpost-event sodium cravings andthirst ratings. (Abstract1188)

■ Among 10- to 14-year-old boys ata summer soccer camp, cold fat-freechocolate milk was chosen moreoften than cold water or cold fat-freeplain milk during exercise in the heat.The boys gave chocolate milk favor-able palatability scores and reportedinsignificant gastrointestinal (GI)complaints. (Abstract 2291)

■ During a 100-mile trail run consist-ing of 6.5 loops, runners reported GIsymptoms and food intake at the endof each loop. Nine of the 15 partici-pants in the study had GI complaints;of these, 4 finished the event and 5did not. Regardless of finishing statusthe GI complaints were similar, mostcommonly nausea (89%), cramps(44%), diarrhea (44%), and vomiting(22%). Those with GI problems con-sumed less fluid (6 vs. 11 mL/kg/h)and had a lower dietary fat intake(11% vs. 17% of energy consumed asfat). (Abstract 1191)

■ For every 1% loss of body weightpre-to-post exercise, body tempera-ture increases 0.22° C. This informa-tion can be used to predict the rise inbody temperature during exercise inthe heat. (Abstract 3019)

Body Composition

■ When using the Bod Pod, the in-structions to not eat, drink, or exer-cise for 2 hours before the

measurement are imperative. Ath-letes who did 30 minutes of treadmillexercise prior to Bod Pod testingmeasured 21.3% body fat pre-exer-cise and 19.6% post-exercise; the 2%drop was not due to a loss of bodyfat, but rather to inaccuracy related toan elevated body-temperature. (Ab-stract 3036)

■ How much variation occurs amongmethods of body fat measurement?A lot! The following results for colle-giate gymnasts were obtaining using

different methods: Tanita BF-350,21.7%; Tanita BF-522, 21.7%; OmronHBF-510W, 26.1%; Omron HBF-306C,18.4%; skinfolds, 19.5%; and DXA,21.06%. When using DXA as the goldstandard, Omron was the least accu-rate! (Abstract 3040)

■ It’s unlikely that aerobic exerciseprior to resistance exercise compro-mises muscle size and strength gains.In a 5-week study, no interferencefrom aerobic exercise was notedwhen athletes did exhaustive aero-bic exercise using one leg in themorning, rested for 6 hours, and thendid strength training using both legs.In the resistance-only leg, the quadri-ceps muscle volume increased by

only 8% compared with 11% in theleg that did both resistance and aero-bic exercise. The combined approachoffered a more robust increase inmuscle size. (Abstract 597)

Weight

■ Of 101 obese participants in aweight management program for anunderserved rural population, 60%chose to meet face to face ratherthan join an Internet group. (No oneselected the DVD option.) Self-effi-cacy was higher in the face-to-facegroup. The researchers suggest as-sessing a dieter’s self-efficacy prior toenrollment to aid in tailoring an inter-vention that meets the participant’sneeds. (Abstract 583)

■ Should we treat workplace inactiv-ity like an occupational hazard suchas chemical exposure? After all, inac-tivity reduces fitness and contributesto obesity, sleep apnea, heart disease,diabetes, and osteoporosis. Employ-ers who enable brief, periodic work-day physical activity will help sparetheir employees from the health haz-ard of inactivity—a far more preva-lent hazard than chemical exposure.Also, physically active workers aremore productive, use less sick time,have fewer injuries, and lower med-ical costs. (Abstract 3241)

■ A health care model in the Nether-lands predicts that if all Dutch work-ers did 30 minutes of moderatephysical activity 5 days a week, thehealth care savings would be $1.28billion per year. More realistically, ifonly 20% to 25% of Dutch workersbecame more active, annual savingswould be a substantial $330 million.(Abstract 3243)

Summarized by “Conference High-lights” editor Nancy Clark, MS, RD,CSSD, who has a private practice in theBoston area and is author of NancyClark’s Sports Nutrition Guidebook. She can be reached via www. nancyclarkrd.com.

Nutritional and Gastrointestinal Problems in Endurance AthletesPfeirffer B, Stellingwerff T, HodgsonAB, et al. Nutritional intake and gas-trointestinal problems during com-petitive endurance events. Med SciSports Exerc. 2012;44:344-351.

Current carbohydrate recommenda-tions for endurance athletes promotethe consumption of high amounts ofcarbohydrate during exercise. How-ever, the potential gastrointestinal(GI) distress and performance impli-cations of these recommendationsshould be considered. Thus, the aimof this study was to investigate thefood and fluid intake and GI symp-toms of 221 endurance athletes fromtwo Ironman (IM) triathlons, a half-Ironman, a 100/150-km cycle race,and a marathon. Study participantscompleted a pre-race questionnaireto determine training, nutrition, andGI symptom history and a post-racequestionnaire to determine fluid andfood intake and GI symptoms duringcompetition using a 10-point scalefor various GI complaints. Carbohy-drate intake varied greatly betweenevents and between individual ath-letes (6-136 g/h). Marathon runnershad the lowest CHO intake comparedwith IM athletes (P<.001) and cyclists(P<.034). The highest CHO intakeswere reported in the IM races (62 ±26, 71 ± 25, and 65 ± 25 g/h, respec-tively). Higher carbohydrate intakeswere not associated with higherscores for GI symptoms. However,nausea and flatulence were positivelycorrelated with CHO intake in the IMraces. Gastrointestinal symptomswere positively correlated with a his-tory of GI symptoms, indicating apossible individual predisposition toGI distress. Despite potential GI con-cerns, high carbohydrate intakeswere correlated with faster finishtimes (P<.01). Based on these find-ings, carbohydrate recommendationsfor endurance athletes should be in-dividually tailored according to toler-ance, but should generally encourage


Sports Dietetics-USA Research Digestrelatively high CHO intakes to sup-port performance. This study wassupported by a grant of Nestec Ltd.

Summarized by Jamie Saunders, MS,Division of Nutrition, University ofUtah, Salt Lake City, UT.

Effects of Dilute Carbohydrate Beverages on PerformanceWatson P, Shirreffs SM, Maughan RJ.Effect of dilute carbohydrate bever-ages on performance in cool andwarm environments. Med Sci SportsExerc. 2012;44: 336–343.

In temperate environments, commer-cially available sports drinks (6-8%carbohydrate [CHO] concentration)

have been shown to enhance per-formance. However, low concentra-tion (0-6%) CHO solutions found infitness waters may also be beneficialvia enhanced water absorption, par-ticularly when fluid intake as op-posed to CHO intake is of primaryimportance. The objective of thisstudy was to examine the influenceof diluted CHO-electrolyte sportsbeverages on physical performancein cool and warm conditions. Twoparallel experiments involving fixed-intensity exercise to volitional ex-haustion were conducted. Twelvehealthy males participated in eachexperiment, consuming 0%, 2%, 4%,and 6% CHO solutions pre-exerciseand every 10 minutes of exercise.One group completed the exercise ata work rate of 70% VO2 peak in 10

ºCwhile the other completed the exer-

cise at a work rate of 60% VO2 peak in30ºC. Expired gas samples were col-lected at 15-minute intervals to de-termine rates of substrate oxidationand energy expenditure. In the coolenvironment compared with the 0%trial, time to exhaustion (TTE) wassignificantly longer in the 4% and 6%trials. In addition, TTE was signifi-cantly longer in the 6% trial than inthe 2% trial (13.0 ± 12.5 min; P =.025).In the warm environment, there wasno significant difference between the0%, 2%, or 4% trials. However, com-pared with the 0% trial, TTE was sig-nificantly longer in the 6% trial(P=.045). In conclusion, this studydemonstrates that a lower solution of4% CHO may be beneficial in cool en-vironments, whereas a 6% CHO

solution is more beneficial in a warmenvironment. Athletes should experi-ment with differing CHO solutionsunder a variety of environmentalconditions.

Summarized by Ema Thake , graduatestudent, Coordinated Master’s Pro-gram, Sports Nutrition Emphasis, Divi-sion of Nutrition, University of Utah,Salt Lake City, UT.

Fluid Consumption PracticesDuring Marathons Beis LY, Wright-Whyte M, Fudge B, etal. Drinking behaviors of elite malerunners during marathon competi-tion. Clin J Sport Med. 2012;22:254-261.

It is widely believed that adequatefluid consumption during competi-


tion is a key determinant of athleticsuccess. Current American College ofSports Medicine (ACSM) guidelinesrecommend ad libitum fluid intakefrom 0.4 L to 0.8 L per hour during exercise to minimize body mass (BM)losses to no more than 2%. However,data on the fluid practices of elite dis-tance runners during marathon com-petition are limited. Thus, theobjective of this study was to deter-mine and assess the fluid intake ofelite marathon runners in retrospec-tive fashion. Video footage of 13major marathons was thoroughly re-viewed and total time spent consum-ing fluid calculated for 10 differentmale athletes. A separate simulationexperiment determined an averageflow rate of 45.2 mL/sec from a typi-cal sports drink bottle. Total fluid in-take was estimated by multiplying

total time spent consuming fluid bythis average flow rate. Mean durationof fluid consumption was 25.5 ± 15.0sec resulting in a mean fluid con-sumption of 0.55 ± 0.34 L/h consis-tent with ACSM guidelines. There

Call for Abstractors

You can contribute to the pages

of PULSE by volunteering to ab-

stract a recently published study

on sports nutrition. For details on

this opportunity, contact Stacie

Wing-Gaia, PhD, RD, CSSD,

co-editor of “Sports Dietetics-

USA Research Digest” at

[email protected].

were no correlations between fluidintake and running speed, nor wasambient temperature correlated withtotal time spent consuming fluid (P =.77). Adequate fluid consumption byathletes did not appear to prevent reduction in BM. For example, thewinner of the 2009 Dubai marathonconsumed 0.83 L/h of fluid but expe-rienced a 9.8% reduction in BM, trans-lating into an estimated sweat rate of3.6L/h. Based on the results of thisstudy, elite athletes should be en-couraged to practice ad libitumdrinking during the marathon eventrather than attempt to replace all flu-ids lost through sweat.

Summarized by James Stevens, MS, RD,affiliate faculty, Front Range Commu-nity College, Westminster, CO.

Reviews

The Plant-Powered Diet:The Lifelong Eating Plan forAchieving Optimal HealthSharon Palmer, RDThe Experimentwww.theexperimentpublishing.com2012, softcover, 432 pp, $15.95ISBN: 978-1-61519-058-4

Susan Palmer should be able tochange any carnivore into a plant-based foodie by her inspiring and en-ticing publication, The Plant-PoweredDiet. This is an easy-to-follow guidefor anyone interested in improvingtheir health by incorporating moreplant-based whole foods. Palmerpresents research-based evidence onthe health benefits of a plant-baseddiet and describes a simple approachto incorporating these wholesomefoods into almost any lifestyle ormeal plan. Rather than offering oneplant-based approach, which mayseem extreme and overwhelming,she presents meal plans for three dif-ferent dietary preferences: vegan,vegetarian, and omnivore.

Palmer divides the book into sevenplant-powered food categories: plant

proteins; whole grains; vegetables;fruits; healthful fats; spices, herbs, andchocolate; and coffee, tea, and wine.Within each chapter, she provides de-tailed and research-based evidencebehind the compounds found ineach plant food. This is what differen-tiates this book from others of itskind.

For example, Palmer suggests eatingmore green leafy vegetables but alsodescribes the powerful nutrientsfound in these vegetables that de-liver disease-fighting capabilities. Thereader quickly gets to know unfamil-iar terms such as betalains, chloro-phyll, kaempferol, lutein, quercetin,

and zeaxanthin through Palmer’s de-tailed descriptions and accompaniedglossary.

For each plant-powered food cate-gory, Palmer presents a comprehen-sive table that lists the food item withits description, star nutrients, andculinary suggestions. For example,the plant protein chapter describessuch foods as soy, seitan, chia, andhemp, then lists the benefits of eachand suggests how they can be incor-porated into various diets andlifestyles.

Palmer also spends time discussingthe positive environmental impact


will also find this book a nice additionto their library and a useful resourcewhen talking about the benefits of aplant-based diet with their clients.

Sharon Palmer, RD, is a registered die-titian, editor of the award-winninghealth newsletter Environmental Nutrition, and a nationally recognizednutrition expert who has reachedthousands of people through herwriting and clinical work.

Reviewed by Nichole Dandrea, MS, RD,a women’s health nutritionist andfounder of Nicobella Organics, ahealthful organic dark chocolate com-pany based in Los Angeles, CA.

8 Ways to Lose Your Blubber:Through Hormone Balancingand Lifestyle ChangesValerie A. Early, RDCreateSpacewww.createspace.com2010, softcover, 106 pp, $13.99ISBN: I-451-53669-0

Weight loss books encompass morethan just diet when they providereaders with weight managementtips. In 8 Ways to Lose Your Blubber, theauthor not only gives readers aunique, eye-catching title, but alsoprovides alternative tips on issuessurrounding weight loss. Througheasy-to-read descriptions, ValerieEarly, RD, breaks down each of hereight areas that range from diet andnutrition analysis to supplementsand “vibrational alignment.” Thisbook approaches weight manage-ment from a nutritional perspectiveand also introduces other factors thatmay influence weight and a healthfullifestyle.

when following a plant-based diet.She uses colorful analogies such as “ifyou eat one less burger a week it’slike driving 320 miles less.” Palmerdiscusses how choosing local and or-ganic foods may positively impactone’s health, the environment, andthe farmer, but he also notes thatmore research is needed in the areaof eating local and organic foods.

Readers will especially appreciate thelast two categories in The Plant Pow-ered Diet: spices, herbs, and chocolateand coffee, tea, and wine. Palmer ex-plains the immune-enhancing com-pounds found in spices and herbs,and discusses how they offer an

abundance of health benefits whileadding flavor and variety to any veg-etable-based meal. She includes re-cent research on chocolate, coffee,tea, and wine and what portion sizesprovide the greatest health benefit.

The final chapter, “14 Days of Power-ful Plants,” offers a simple, realistic 14-day meal plan for vegan, vegetarian,and omnivore diets. Each day in-cludes three creative meals and threeenergizing snacks with more than 75original recipes. Pumpkin Spice PecanPancakes and Spiced Banana Avo-cado Bread are two examples ofPalmer’s unique recipes that will cer-tainly change the perspective thatvegetable-based diets are bland.

The Plant Powered Diet is a great readand resource for vegans, vegetarians,and omnivores who are looking for asimple, effective, and creative guideto incorporating more plant-basedfoods into their lifestyle. Dietitians

The first and second chapters focuson calorie monitoring and determin-ing a meal plan using appropriate ra-tios for carbohydrates, fats, andprotein. Included are calculationsused to design menus and daily in-takes. A helpful resource in Chapter 2is a 3-day detailed meal plan, whichincludes three meals and threesnacks that contain the recom-mended ratios of macronutrients.Chapter 3 is devoted to exercise andphysical activity. It promotes the im-portance of exercise in a lifestyle andweight management program, andfurther motivates the reader by out-lining the health benefits of exerciseand explaining how to time mealswithin an exercise program.

Hormonal imbalances and effects onweight are addressed well in Chap-ters 4, 5, and 6. The points made arenot nutrition-related but are never-theless relevant, because many peo-ple experience plateaus in theirweight loss efforts and may want toexplore issues with hormones. Thesewell-written chapters do a good jobin explaining complicated conceptsregarding the thyroid gland, insulin,estrogen, and testosterone and theirpotential impact on weight gain.Early gives suggestions on laboratorytests to pursue, and also recom-mends that each individual reviewhis or her needs with a primary carephysician or endocrinologist.

The remaining Chapters 7 and 8 re-view nutrition supplementation andvibrational alignment. While thesetopics are not usually included inweight loss programs, Early offers asignificant explanation regarding thepurpose and role of these in weightmanagement. Alternative ap-proaches to managing stress and re-focusing energy may, for someindividuals, offer a valuable new ap-proach to a healthful lifestyle change.For some of these issues, the authorprovides scant scientific bases for herrecommendations.

In summary, 8 Ways to Lose Your Blub-ber suggests other factors to considerand manage in a weight loss pro-


and a Reiki Master. She currentlycounsels clients about the impor-tance of nutrition and hormonal bal-ance in her private practice(Nutrition, Connection, Balance, LLC).

Reviewed by Heather Cunningham, RD,CNSC, a clinical nutrition manager andwellness consultant in Milltown, NJ.

by Sumner Brooks, MPH, RD, CSSD

■ Erin Macdonald, RD, and her busi-

ness partner, also an RD, contributemonthly articles for two popularmagazine columns, putting regis-tered dietitians in the spotlight inmainstream nutrition media. “EasyDoes It” appears in Oxygenmagazineand “Ask the Dietitian” is beinglaunched in Clean Eating magazine.Each article features a nutrition topicand corresponding recipe. Along withthese magazine columns, the duo’sWeb site U Rock Girl.com provideshealth and wellness information forwomen. Erin runs a private practiceand consulting business in OrangeCounty, CA.

■ Susan B. Dopart, MS, RD, CDE,recently authored her second book,Healthy You, Healthy Baby: A Mother’sGuide to Gestational Diabetes. Thebook was released in June 2012. Herfirst book, A Recipe for Life by the Doc-tor’s Dietitian, published in 2009, is

available digitally at www.Susan-Dopart. com. Susan has a privatepractice in Santa Monica, CA, whereshe specializes in weight manage-ment and medical nutrition therapy.

■ Christine M. Palumbo, MBA, RD,was awarded the 2012 AlumnaeAward from St. Catherine Universityin St. Paul, MN. The award is bestowedbased on the criteria of demonstrat-ing leadership, service, professionalexcellence, and the ideals of the uni-versity. In addition, Christine wasnamed the 2011 Outstanding Dietet-ics Educator by the Illinois DieteticAssociation. Among her current rolesas a dietitian, she is an adjunct facultymember at Benedictine University,columnist for Chicago Parent, and acontributing editor for EnvironmentalNutrition. Christine runs her privatepractice in the Chicago, IL area.

NotablesSCAN

On the Web . . .

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

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

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

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

■ Free Fact Sheets andWebinars. Enjoy free access tomaterials that will inform andequip you well professionally.

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

For More About SCAN’s WebSite:Find out more aboutwww.scandpg.org in this issue’s“Of Further Information” (page 26)

Find SCAN Elsewhere on theWeb:

■ Follow us on Twittertwitter.com/scanutritiondpg

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

■ Connect with us on LinkedIn,SCAN group

gram, where other diet books gener-ally do not include this information.Early presents a concise descriptionof terms that readers can compre-hend and potentially use in theirquest to manage their weight andadopt a more healthful lifestyle.

Valerie Early, RD, is a dietitian as wellas a registered pharmacy technician,certified health and fitness specialist,

If you have an accomplishment that you would like to be considered for an

upcoming issue of PULSE, please contact Sumner Brooks, MPH, RD, CSSD, at

[email protected].


■ Save the Dates for Symposium 2013!

Invigorate your practice by attendingthe 29th Annual SCAN Symposium,Tools & Techniques for Peak Profes-sional Performance, on April 26-28, inChicago, IL. Exciting learning oppor-tunities addressing all four of SCAN’spractice areas are planned, including:• Skills-oriented tactics for improvingyour knowledge base and expandingyour practice• Take-home tools to use and sharewith clients, patients, colleagues, andstudents• New research exploration, network-ing, and fun in The Windy City

The Academy is adopting a career de-velopment guide to provide dieteticsprofessionals with a roadmap for ex-cellence in practice. The skills-ori-ented sessions planned forSymposium will help SCAN memberswork on proficiency in practice. Asthe leader in sports, cardiovascular,wellness, and disordered eating prac-tice, SCAN will equip members at-tending Symposium 2013 withcutting-edge strategies for gainingthe clinical and professional expertiseneeded to advance their careers.Mark your calendars!

■ SCAN’s Web Site: Your Go-To Resource

Be sure to go to SCAN’s Web site(www.scandpg.org) whenever youhave a few free moments, or whenyou’ve got a specific need. Here’s asampling of what you’ll find:

• Ways to Stay Connected via ourMember Forums. Take advantage ofthe Members Only discussion forumsthat let you network, share, and learn.Current discussions include SportsNutrition Mentoring and House of Del-egates Issues, as well as forums withspecific questions regarding aboutSports Nutrition, Cardiovascular

Health, Wellness and Weight Manage-ment, andDisordered Eating and Eat-ing Disorders. Join in on thediscussion at www.scandpg.org/forum/.

• Online Continuing ProfessionalEducation (CPE). SCAN works hardto provide interesting and valuabletopics for obtaining CPEs. Currentlyavailable online CPE opportunities in-clude “Forks and Fate of Our FamiliesWebinar,” “Present Like a Pro in aHealthy Cooking Demo,” and as al-ways free CPE quizzes on selectedPULSE articles. Go to www.scandpg.org/cpe/ to get started.

• Now Available: 2012 SCAN Symposium Recordings. All Sympo-sium 2012 workshops and presenta-tions are now available in the SCANOnline Store. If you missed this eventor want to revisit some of the talks,check out the store to obtain theserecordings.

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

• Foods Recommended by Mem-bers. This list of food products, sub-mitted by SCAN colleagues, isintended to complement an overallhealthful, balanced diet of wholefoods, including fruit, vegetables,whole grains, legumes, lean proteinsources, nonfat dairy items, andheart-healthy fats. Access the list atwww.scandpg.org/nutrition-info/nu-trition-info-for-consumers/foods-scan-rds-recommend/.

• Tools at Your Fingertips. SCAN hasan outstanding list of Web sites, pre-sentations, and downloadable files tohelp you in your profession. Go towww.scandpg.org/nutrition-info/pro-fessional-links-and-resources/ to viewthe various options.

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

■ News from Wellness/CV RDs Subunit

Here’s an update on developmentsfrom the Wellness/CV RDs:• Share Your Favorite Foods. Be sureto check out the list of newly up-dated Favorite Foods Recommendedby SCAN Members on SCAN’s Web site(see “Foods Recommended by Mem-bers” in the previous column.) This listsaves you time as you navigate newheart-healthy products at the grocerystore. Please send your “latest finds”to Georgia Kostas at [email protected]. The update list isposted annually. The next list will bereleased in early 2013. Please send inyour suggestions by November 30,2012.

• Wellness/CV Offerings at Sympo-sium 2013. Program planning forSymposium 2013, April 26-28, inChicago, IL, is well on its way! Amongthe highlights: Advanced level lipidtraining that will include discussionson diet and pharmacologic parame-ters by renowned speakers as well asmore wellness topics than ever be-fore. Plan to attend!

• Wellness/CV Connectione-Newsletter. Trying to find a specificarticle that was in the Wellness/CVConnection but can’t rememberwhich issue it appeared in? You cancheck out all issues at www.scan-dpg.org/cardiovascular/newsletters/.

• Advanced Cardiovascular Certifi-cations. Interested in finding outmore about advanced certificationsin cardiovascular health? With SCAN’s

Of Further Interest


new agreement with the NationalLipid Association, we have added cer-tification information to our Web siteat www.scandpg.org/nutrition-info/cardiovascular-health-profes-sional-resources/.

• Calling for Fact Sheet Topics. Doyou have an have an idea for a factsheet you would like to see SCAN de-velop in the area of wellness or car-diovascular health? If so, pleasecontact Karen Collins ([email protected]) or Rosie Gonza-lez ([email protected]) withyour ideas.

■ News from Sports DieteticsUSA (SD-USA)

Below are some highlights from theSD-USA subunit:• New Edition of Sport NutritionPractice Manual. The Academy’sSports Nutrition: A Practice Manual forProfessionals, 5th ed., can now be pur-chased at the Academy Shop. This isthe new edition you’ve been waitingfor—an indispensable source for spe-cific evidenced-based sports nutri-tion information.

• Revised CSSD Eligibility. The Com-mission on Dietetic Registration(CDR) has revised the applicationform for CSSD certification, allowingcontinuing education (CE) to substi-tute for up to 75 hours of the re-quired specialty practice hours. SCANsports nutrition offerings will counttoward the 75 CE hours. For eligibilityinformation and applications fromCDR, go to www.cdrnet.org.

• CSSD Recertification. Five-year re-certification is due for CSSDs certifiedin 2007. Check your certification yearand be prepared to recertify. Eligibil-ity includes documentation of 1,000hours of specialty practice experi-ence as an RD within the past 5 yearsby the application due date (effectiveuntil 2014).

• The CSSD: Qualification Matters.According to the 2011 Compensationand Benefits Survey (J Acad Nutr Diet -

January 2012), CSSDs earn the high-est hourly wage per patient/client re-sponsibility among all those whohold a CDR specialist credential.Overall, RDs with CDR specialty cre-dentials earn higher compensationthan RDs without specialist certifica-tion. Apply now for the CSSD creden-tial!

• IOC Diploma in Sports Nutrition.SCAN member now qualify for a 10%discount off tuition and fees. Formore information, visit www.sportso-racle.com/ioc/.

• Tout Your Expertise. Let athletesand clients tout your expertise byadding the Sports Nutrition—Who De-livers? YouTube link (www.youtube.com/watch?v=Ocz7P3A2rgU) to youre-mail signature. Be sure to also up-load this video to your Web site, Face-book page, and Twitter page, andshow it before or after your presenta-tions. It’s an amazing marketing tool.

• Follow SD-USA on Twitter @Sportsdiet_USA. The goal of Sports-diet_USA is to market the Sports RDto the public. If you have facts or ac-complishments and would like to beincluded in one of our Tweets, con-tact us at [email protected]. Ifyou are interested in volunteering forthis project, contact Kelly DevineRickert at [email protected].

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

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

• SCAN’s e-Library Additions. Visitwww.scandpg.org/e-library/ and ex-plore the e-learning opportunities: 1.) In the CSSD-Level Advanced Prac-

tice Series – Session 2: Analyze This!Evaluating Literature with a Critical Eyeand an Open Mind; and Session 1: CSSD-Level Sports Nutrition Practiceand the Diabetic Athlete; 2.) The webi-nar Peak Professional Performance:Growing a Successful Sports Dietet-ics Practice; 3.) the flash video BeSupplement Smart—Increase YourValue to Clients, offering 2 continu-ing professional education (CPE)units; 4.) presentations from pastSCAN Symposiums and Sports Di-etetics Workshops: Nutrition & Ath-letic Performance, The Cascade ofConcussion, and 5.) the webinar BeSupplement Smart—Increase YourValue to Clients - Educators version($39), for those showing this webinarto students or other groups (multipleviewing); CPE credit not available. Toorder, go to http://www.scandpg.org/store/products/10085/.

• Sports Nutrition Care Manual®(SNCM). The Academy’s online SNCMcontains research-based nutrition in-formation written by authors who areCSSDs. The price is $75 for Academymembers. Preview the manual andselected pages at http://sports.nutri-tioncaremanual.org/.

Call for Posters

2013 SCAN Symposium

“Tools and Techniques for Peak

Professional Performance”

April 26-28, 2013

Student and professional SCAN

members are invited to submit

research and practical posters for

presentation during the 2013

SCAN Symposium in Chicago, IL.

The deadline for submission is

February 1, 2013. For more infor-

mation, visit www.scandpg.org.

November 1-2, 2012Annual AICR Research Conference onFood, Nutrition, Physical Activity andCancer, Washington, DC. For informa-tion: American Institute for CancerResearch, www. aicr.org

November 9-11, 2012Annual Renfrew Center FoundationConference, Philadelphia, PA. For in-formation: www.renfrew.org

December 13-15, 2012International Sports & Exercise Nutrition Conference, Newcastleupon Tyne, UK. For information:www.isenc.org

February 8-9, 2013Sport Nutrition Workshop: From Science to Practice, Indianapolis, IN.For information: Nancy Clark,www.sportsnutritionworksop.com

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

April 26-28, 2013Join your colleagues at the 29th An-nual SCAN Symposium, Tools andTechniques for Peak Professional Per-formance, Chicago, IL. For more infor-mation: www.scandpg.org

UpcomingEvents

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

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

Sports EditorKathie Beals, PhD, RD, CSSD

Cardiovascular EditorSatya Jonnalagadda, MBA, PhD, RD

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

Disordered Eating EditorsKaren Wetherall, MS, RDMichelle Barrack, PhD

Conference Highlights EditorNancy Clark, MS, RD

Reviews EditorNichole Dandrea, MS, RD

Sports Dietetics-USA Research Digest Editors

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Documents

SCAN’S Pulse€¦ · 2013 issue of SCAN’S PULSE. The cardiovascular benefits associ-ated with the consumption of veg - etables and fruit have been attributed to their constituents,