SCAN’S Pulsescan-dpg.s3.amazonaws.com/media/files/2f7d55de-b166...SCAN’S Pulse Physical Activity in the Treatment of Eating Disorders by Valerie Carpenter, MS, RD and Natalie Bessinger,

Winter 2018, Vol. 37, No. 1

■ CONTENTS

1Physical Activity in the Treatmentof Eating Disorders

3From the Editor

4CPE article:Impact of Dietary Counseling on Useof Dietary Supplements and SportNutrition Products

8Dietary Fat Recommendations:Registered Dietitian Nutritionists’Practices and Guidance Vary

16Influence of Hydration on Cognitionand Skill Performance in Female Basketball Players

20From the Chair

20Conference Highlights

22Reviews

23Research Digest

25SCAN Notables

25Of Further Interest

28Upcoming Events

Exercise in the treatment of eatingdisorders (ED) remains a controver-sial issue. For the general population,physical activity is an important wayto reduce risk factors for conditionssuch as heart attack and stroke, aswell as to improve mood and mentalhealth.1 For overall cardiovascularhealth in the general population, theAmerican Heart Association recom-mends 30 minutes of moderate-in-tensity exercise or 25 minutes ofvigorous exercise 5 days per week,along with 2 days of strength train-ing.2 However, in the ED population,exercise can become a means of per-petuating the illness. Introducing ac-tivity back into an individual’s lifewhile in ED treatment can be benefi-cial in the long term for overall well-being, focusing more on theenjoyable activity or pleasurablemovement and less on the drive toburn calories. It is imperative that ac-tivity is reintroduced appropriatelyand under the guidance of a compre-hensive treatment team, which canhelp the patient reframe his or heridea of exercise and its purpose.

Benefits of Physical Activityin Eating Disorders

At certain stages of an individual’sED, exercise can become a rigid and

S C A N ’ SPu lsePhysical Activity in the Treatmentof Eating Disordersby Valerie Carpenter, MS, RD and Natalie Bessinger, MS, RD

time-consuming behavior, under-taken with the intention and drive tomanipulate one’s body shape, size,and weight. The National Eating Dis-order Association defines compulsiveexercise as “exercise that significantlyinterferes with important activities,occurs at inappropriate times or in in-appropriate settings, or when the in-dividual continues to exercise despiteinjury or other medical complica-tions.”3 Exercise then becomes a be-havior of the illness in the form ofpurging. Despite general assump-tions, purging does not refer only tophysically vomiting as a means to getrid of caloric intake; rather, purging isdefined as “behavior to influenceweight or shape,”4 including laxativeabuse, misuse of diuretics, and com-pulsive exercise.

Physical Benefits

Physical activity can be beneficial inthe physical rehabilitation of thebody during ED treatment, despitethe controversy that surrounds its in-clusion in various treatment modes.Physical activity can assist in both thephysical and psychological rehabilita-tion of a patient, as well as provideconstructive social reintegration.Physically, movement can be used asphysical therapy to help rebuild bone

termine if movement and physicalactivity can help patients who sufferfrom body image dysmorphia, or thealtered perception of their physicalselves, generate realistic perceptionof their bodies and improve bodyimage dissatisfaction.

Social Benefits

Socially, persons with EDs tend to iso-late themselves. Be it due to shame oftheir behaviors, discomfort with theirphysical appearance, or general so-cial anxiety, people who suffer fromEDs may withdraw from social set-tings. Physical activity, especially ifdone in a group setting, can be a wayto foster reintegration into society ina controlled, social, and safe environ-ment.

How to Begin Physical Activity in Treatment

Nutritional Status

Physical activity must not be in-cluded in ED treatment without med-ical authorization and guidance. Dueto the potential severity of physicalcomplications that often occur withmalnutrition, activity can be verydangerous if not reintroduced appro-priately. Laboratory values should bechecked often to monitor physicaland nutritional status; these studiesinclude measurement of glucose,electrolytes, and protein status. Also,physical activity should not be in-cluded if the patient is already strug-gling to restore weight at anappropriate rate. In addition, it is im-portant to keep in mind that a pa-tient’s nutritional intake will need tochange to reflect the increase inmovement to ensure continued nu-tritional rehabilitation.

Before introducing any type of physi-cal activity, it is crucial to have inter-disciplinary input regarding thepatient’s physical and mental status.Ideally, decisions concerning exerciseneed to represent a comprehensiveteam recommendation. The dietit-ian’s role is to assess caloric intakeand output as well as balance ofmacronutrient and micronutrient in-

2 | SCAN’S PULSEWinter 2018, Vol. 37, No. 1

density lost due to prolonged malnu-trition. Osteopenia and osteoporo-sis—the loss of bone mass—arecommon coexisting health problemsin the ED population. A diet rich incalcium and vitamin D as well asweight-bearing activity are used inthe management of osteoporosis.5

Bone is living tissue in which old cellscontinually break down and new tis-sue is formed. Weight-bearing exer-cise performed on a regular basishelps rebuild more bone cells andstrengthen bone as a result of thebone adapting to the impact ofweight and pull of muscle.6

In addition to favorably impactingbone health, physical exercise mightaid in restoring gastric motility dur-ing the physical rehabilitation of apatient’s gastrointestinal (GI) tract, asystem that is often damaged as a re-sult of eating disorder behaviors. Typ-ically, patients spend the majority oftheir time during a treatment daybeing sedentary in group and indi-vidual therapy sessions; therefore, theaddition of movement could be ben-eficial. Incorporation of physical activ-ity in an inpatient psychiatric settinghas been shown to improve GI motil-ity in patients.7

Psychological Benefits

Psychologically, physical activity isoften used as an anxiety and stressmanagement tool. Biochemicalchanges can occur as consequencesof the ED, including alterations inserotonin and norepinephrine levels.8

Activity may help regulate brainchemistry via release of endorphinsand other neurochemicals in patientswith disordered eating.9 Physical ac-tivity is also frequently used to helppatients make progress on bodyawareness and acceptance. A patientcan also start to have positive associ-ations between his or her physicalbody and its capabilities beyondmere physical appearance. Patientswho begin an activity program whilein treatment may become less rigidin attitudes and beliefs around exer-cise, which may also allow for im-proved weight restoration.10 Futureresearch should be conducted to de-

Academy of Nutrition and DieteticsDietetic Practice Group of Sports,

Cardiovascular, and Wellness Nutrition (SCAN)SCAN Website: www.scandpg.org

SCAN Office230 Washington Ave. Ext., Suite 101Albany, NY 12203Phone: 518/254-6730; 800/[email protected] Director: Thomas J. Coté, MBA, CAE

SCAN Executive CommitteeChairCheryl Toner, MS, RDN

Chair-ElectLindzi Sara Torres, MPH, MS, RDN, CSSD

Past ChairKaren Collins, MS, RDN, CDN, FAND

TreasurerJon Vredenburg, RDN, CSSD, CDE

SecretarySherri Stastny, PhD, RD, CSSD

Director, Sports Dietetics—USA SubunitElizabeth Abbey, PhD, RDN, CDN

Co-Directors, Wellness and CardiovascularNutrition SubunitAmanda Clark, MA, RD, CHESJudith Hinderliter, MPH, RD, CPT

Director, Disordered Eating & EatingDisorders SubunitSarah Gleason, RD, CEDRD

Director of EventsEnette Larson-Meyer, PhD, RD, CSSD, FACSM

Director of CommunicationsHeather Mangieri, MS, RD, CSSD

Director of Member ServicesKaren Reznik Dolins, EdD, RD, CSSD, CDN

Director of Volunteer CoordinationNoaa Bujanover, MS, RD, CSSD

SCAN Delegate to House of DelegatesJean Storlie, MS, RD

____________________________

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

DPG Relations ManagerRita Brummett

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

https://www.scandpg.org/executive-committee/

SCAN’S PULSEWinter 2018, Vol. 37, No. 1 | 3

take to support each new activity in-corporated. Therapists can work toensure the patient is not viewinghis/her movement through an ED fil-ter. Processing the activity each timesomething new is added can help theindividual better understand theemotions, thoughts, and physical re-sponse to that activity. Physiciansand/or nurses monitor medical statusthrough laboratory results and thepatient’s vital signs. Incorporating allmembers of the treatment team en-sures that all areas of well-being areevaluated and addressed.11

Types of Recommended Physical Activities

The types of activity introduced intreatment can have profound effectson the well-being of the patient. It isimportant to start with minimal im-pact movements. This helps the bodyadapt to the increase in exertion. Ac-tivities such as gentle stretchingyoga, progressive muscle relaxation,and Tai Chi are examples of low-im-pact movement modalities. Startingwith gentle movement can help thepatient work on layering on eachnew activity as a way to control expo-sure to different stressors. These gen-

tle types of movement are a goodway to work on starting to learn con-trol around breathing and beingpresent in the activity, instead of fo-cusing on burning calories. Oncemedically appropriate, the patientcan begin to look at adding otherforms of physical movement.

Team sports are a highly recom-mended way to move forward inreintegration of physical activity for anumber of reasons. First, there is al-ways a coach or other team memberspresent to assist in monitoring thepatient for appropriate movement.This type of accountability can bevery helpful for patients, especiallythose who have a history of hidingexercise and movement. Team sportsare also time-limited and often havea set schedule of practices andgames, which might help to ensureavoiding extra movement. Further-more, team sports will address socialreintegration and can build a senseof self within a group setting. Team-mates can provide positive social in-fluences with healthy attitudestowards different body shapes andsizes. Examples of other recom-mended activities would be rockclimbing, volleyball, and softball;

these are all sports that do not em-phasize appearance, weight require-ments, or endurance.12

Conclusions

Physical activity can be a beneficialtherapeutic intervention in the treat-ment of ED. Often the use of exerciseas an unhealthy coping skill or purg-ing mechanism in EDs can be difficultto address due to societal beliefsabout the value of exercise. It is im-portant to focus on reframing physi-cal activity as a therapeuticintervention instead of as a means formanipulating the body. Physical ac-tivity can be a way to challenge bodydistortions, improve physical health,and confront psychological beliefs,but only if done under the supervi-sion of an experienced interdiscipli-nary treatment team. Learning toincorporate activity while in treat-ment can be a beneficial tool, and itcan serve as motivation for recoveryas an outpatient.

Valerie Carpenter, MS, RD is the adoles-cent dietitian for the inpatient unit withthe Laureate Eating Disorders Programin Tulsa, OK. Natalie Bessinger, MS, RD isa clinical dietitian for the adult pro-

If It Ain’t Broke…

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

Even if “it ain’t broke,” it doesn’t mean that a little routine maintenance isn’t in order. Our hope at PULSE is that by reading thisissue, you’ll be able to tinker around the edges with maintaining your knowledge in nutrition and dietetics.

On the cover you’ll find a compelling article by Valerie Carpenter, MS, RD and Natalie Bessinger, MS, RD about the potentialbenefits that physical activity can provide during eating disorder treatment. You can also explore, in this issue’s free CPE articleprovided by Floris Wardenaar, PhD and Corrie Whisner, PhD, the possible role that nutrition professionals may have in influenc-ing clients choosing to use or not use dietary supplements. If you would like to learn how your perceptions and practices re-garding various dietary fats compare with those of registered dietitians, you’ll want to see what Sherri Stastny, PhD, RD, CSSD,Jill Fabricius Keith, PhD, RD, Nicole Vasichek, MS, RDN, and Julie Garden-Robinson, PhD, RD discovered in their research. In ourfinal feature article, Lindsay Howard, MS and Angela Hillman, PhD provide a study investigating the impact of hydration oncognition and skill during basketball simulation.

Another great way to maintain your knowledge about SCAN activities and other happenings in the field is by reading aboutnews from our subunits and other notices in our “Of Further Interest” section, taking a look at the notable accomplishments ofour members, and perusing PULSE’s “Conference Highlights,” “Research Digest,” and “Reviews” sections.

FromThe Editor


CPE article

Impact of Dietary Counseling on Use of Dietary Supplements and Sport Nutrition Productsby Floris Wardenaar, PhD and Corrie Whisner, PhD

This article is approved by the Academyof Nutrition and Dietetics, an accredi-ted Provider with the Commission onDietetic Registration (CDR), for 1 con-tinuing professional education unit(CPEU), level 1. To apply for free CPEcredit, take the quiz on SCAN’s Web site(www.scandpg.org/quiz/?id=91).Uponsuccessful completion of the quiz, aCertificate of Completion will appear inyour My Profile (under the heading, MyHistory). The certificate may be down-loaded or printed for your records.

Learning ObjectivesAfter you have read this article, you willbe able to:■ Name the types of supplements

that were more likely to be used byathletes after dietary counseling, ac-cording to a recent Dutch study.■ Discuss the results of this Dutchstudy regarding which type of supple-ments were inversely related to diet-ary counseling. ■ Describe the challenges that athle-tes face in selecting nutritional supple-ments.

The use of nutritional supplementsamong the general populationworldwide has grown steadily in re-cent years, largely due to interest inimproving health.1,2 From the ath-

Reference to the Diagnostic Criteriafrom DSM-5. Washington, DC: Ameri-can Psychiatric Publishing; 2013:176.

5. NIH Osteoporosis and RelatedBone Diseases National ResourceCenter. What People with AnorexiaNervosa Need to Know About Osteo-porosis. Available at: www.niams.nih.gov/ Health_Info/ Bone/Osteoporosis/Conditions_ Behaviors/anorexia_nervosa.asp. Accessed July 19, 2017.

6. American Academy of OrthopedicSurgeons. Weight-bearing Exercisefor Women and Girls. Available at:http://orthoinfo.aaos.org/topic.cfm?topic=A00263

7. Kim YS, Song BK, Oh JS, et al. Aero-bic exercise improves gastrointestinalmotility in psychiatric inpatients.World J of Gastroenterol. 2014;20:10577-10584.

8. Fava M, Copeland BM, Schweiger U,et al. Neurochemical abnormalities ofanorexia nervosa and bulimia ner-

gram of the Laureate Eating DisordersProgram in Tulsa, OK.

References1. Mayo Clinic. Exercise: 7 benefits ofregular physical activity. Available at:www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/exercise/art-20048389. Accessed July 19, 2017.

2. American Heart Association. Rec-ommendations for Physical Activityin Adults. Available at: www.heart.org/HEARTORG/HealthyLiving/Physi-calActivity/FitnessBasics/American-Heart-Association-Recommendations-for-Physical-Activity-in-Adults_UCM_307976_Article.jsp#.WPy2xoWWQy4. Accessed April 20, 2017.

3. National Eating Disorder Associa-tion. Compulsive Exercise. Availableat: www.nationaleatingdisorders.org/compulsive-exercise. AccessedApril 20, 2017.

4. American Psychiatric Association.Feeding and Eating Disorders. In:American Psychiatric Association Desk

vosa. Am J Psychiatry. 1989;146:963-971.

9. Wolff E, Gaudlitz K, von Linden-berger BL, et al. Exercise and physicalactivity in mental disorders. Eur ArchPsychiatry Clin Neurosci. 2011;261(suppl2):186S-191S.

10. Calogero RM, Pedrotty KN. Thepractice and process of healthy exer-cise: an investigation of the treatmentof exercise abuse in women with eat-ing disorders. Eat Disord. 2004;12:273-291.

11. Cook BJ, Wonderlich SA, MitchellJE, et al. Exercise in Eating DisordersTreatment: Systematic Review andProposal of Guidelines. Med Sci SportsExerc. 2016;48:1408-1414.

12. National Eating Disorder Associa-tion. Athletes and Eating Disorders.Available at: https://www.nationaleatingdisorders.org/athletes-and-eat-ing-disorders. Accessed April 19,2017.

lete’s perspective, the belief thatthese products will help to improveexercise performance is consideredthe main driver for supplement use.3

This article discusses recent researchon the topic of nutrition counselingand supplement use among athletesand provides practical commentaryfor the practitioner.

Supplement Use Among AthletesNutritional supplement use is nearlytwice as common among athletescompared with the general popula-tion. According to self-reported data,the prevalence for nutritional supple-ment use is as high as 100% among


elite athletes and 87% amongnonelite athletes.4,5

Despite the popularity of nutritionalsupplements among athletes, profes-sional organizations that are focusedon sports nutrition advocate a “food-first” approach to meeting the nutri-tional demands of training andcompetition.6 Therefore, athletesshould strive to optimize their gen-eral dietary intake before incorporat-ing nutrition supplements.

Classification of NutritionalSupplements

Nutritional supplements are productsfor oral consumption that add to thenutritional value of the habitual diet.7

Different classifications are used tocharacterize these products, but gen-erally nutritional supplements can beorganized into three overarchinggroups. The largest of these cate-gories comprises dietary supple-ments—products containing one ormore vitamins, minerals, or bioactives(e.g., essential fatty acids, carotenoids,and other nutritional extracts) in-tended to improve general healththrough the prevention and treat-ment of nutrient deficiencies. A sec-ond category of nutritionalsupplements frequently used by ath-letes entails sport nutrition productsthat deliver energy, electrolytes, orbuilding blocks for training adapta-tion and recovery (e.g. sports drinks,recovery drinks, and energy and pro-tein bars).7 These products often con-tain carbohydrates and protein, andprovide a practical and/or convenientalternative to regular food. The thirdcategory is ergogenic aids, which is aconstantly evolving group of supple-ments that have performance-en-hancing claims. Examples of these arecaffeine and creatine.7

Dietary Counseling and Supplement Use by Athletes

Results from an unpublished part of asurvey of Dutch elite and subeliteathletes (n=778) and athletics staffmembers (e.g., coaches andmedical/training staff, n=278) identifysports dietitians or nutritionists as

the main experts in the field of sportsnutrition. However, previous studiesreport that only a small proportion ofathletes (10%-14%) consider a dieti-tian or nutritionist as their primarysource of nutrition information.8,9

Even though dietary counseling hasbeen shown to have a beneficial ef-fect on the food intake of athletes,10,11

many athletes decide to use nutri-tional supplements without consult-ing a health professional, such as adietitian.8,12

Despite the growing interest in di-etary supplements by athletes, no in-vestigations prior to 2017 havefocused on evaluating whether nutri-tional supplement use among ath-letes is associated with dietarycounseling. More recently, however, astudy involving elite and subeliteDutch athletes examined this topic.4

In this study, 778 athletes (407 malesand 371 females, ages 24.7 ± 9.6years) completed a Web-based ques-tionnaire (The Qualtrics ResearchSuite, 2013. Provo, UT) regarding theiruse of nutritional supplements. Thequestionnaire was designed usingprevious athlete-focused surveys13,14

and was expanded to include ques-

tions about dietary counseling.Among the athletes surveyed, 97.2%had used nutritional supplements atsome time during their sports career,and 84.7% indicated having usedsupplements during the preceding 4weeks. A total of 43% of the respon-dents were currently receiving di-etary counseling. The products withthe highest reported prevalence ofuse in the dietary supplement, sportsnutrition products, and ergogenicaids categories were multi-vitaminand/or mineral preparations (42.9%),isotonic sports drinks (34.1%) andcaffeine (13.0%), respectively.

The study found that the number ofsupplements consumed over the pre-vious 4 weeks by athletes receivingdietary counseling (5.0 ± 4.4 supple-ments) did not significantly differfrom those consumed by athletes notreceiving dietary counselling (4.4 ±4.8 supplements). Interestingly, afteradjustment for elite status, age, andweekly exercise duration, dietarycounseling was significantly associ-ated with a higher prevalence of useof vitamin D (27.2% vs. 15.0%), recov-ery drinks (43.7% vs. 26.0%), energybars (29.8% vs. 22.4%), isotonic sportdrinks with protein (15.7% vs. 7.4%)and dextrose (12.0% vs. 7.6%), beta-alanine (7.2% vs. 2.7%), and sodiumbicarbonate (1.8% vs. 0.0%). In con-trast, dietary counseling was inverselyassociated with the use of energydrinks (27.4% vs. 21.4%), multivita-mins and/or minerals (10.5% vs.14.6%), branched-chain amino acids(BCAA) and other amino acids (10.8%vs.6.9%), calcium (3.3 vs. 7.8%), vita-min E (4.0 vs. 6.0%) vitamin B2 (1.2 vs.2.5%), and retinol (0.9 vs. 2.0%).

Better Informed Decision-Making

In looking at the study results, the in-vestigators observed a different pat-tern of nutritional supplement useamong athletes receiving dietarycounseling compared with athletesnot receiving dietary counseling.Supplements that could be listed asuseful for enhancing performance15

such as vitamin D, recovery drinks, b-alanine, and sodium bicarbonate


were more frequently reported byathletes receiving dietary counseling,suggesting that dietary advice mayimprove the dietary behaviors ofcompetitive athletes and therebybenefit their performance.

Although the study corrected forcompetition level (e.g., being anOlympian athlete or not), it might bespeculated that use of nutritionalsupplements by elite status holdersare influenced by the organization ofthe athletes’ team staff and financialand sponsor resources, rather than bytraining characteristics. Whether ornot this is completely beneficialneeds to be considered further, but atleast there seems to be more atten-tion for these type of products on thehigher level.

Evidence-Based Use of Supplements

The higher use of specific supple-ments by those Dutch athletes whoreceived nutritional counseling mayhave been driven by broader supple-ment trends and recent scientificcontributions. Vitamin D, for example,has recently regained interest in thesports community,16 as many athletesappear to be vitamin D-deficient.17

Other examples are the use ofsodium bicarbonate and beta-ala-nine, which have gained increasingsupport following recent meta-analy-ses.18,19

Because nutrition professionals arerequired to stay abreast of currentand emerging evidence, the findingsof the Dutch study may reflect evi-

dence-based recommendationsgiven to athletes who seek regular di-etary counseling. Few studies haverelated athlete supplement use tospecific advice given during nutri-tional counseling; therefore, furtherinvestigation is recommended toprovide clarity on the potential effectof this advice on actual behavior.

Habitual Versus Actual Daily Use

While the Dutch study provides an in-dication of frequently used nutri-tional supplements among athletes,it does not yield insight regardingdaily supplement use. In contrast, aprior study from the Netherlands pro-vides more specific information onathletes’ daily use.20 Findings from

that study indicate that, based onmultiple 24-hour recalls, specific dailyuse of nutritional supplements wasapproximately one-third lower thanhabitual use of supplement intakeover the past 12 months, as assessedutilizing a general survey.

Although the combining of informa-tion gathered from a food-frequencyquestionnaire with that from a multi-ple-day food diary gives a better per-spective on daily and habitual use,estimations of day-to-day use ofthese nutritional supplement prod-ucts are limited. This makes it ex-tremely important for practitioners toprobe and ask additional questionsregarding this subject in daily prac-tice, and to be aware of the large vari-ation in supplement intake bothamong athlete groups and within in-dividual athletes.

Supplement Versus Food Intake

Research suggests that athletes havea largely positive attitude towardsnutrition but only limited knowledgeof the subject.21,22 Furthermore, nutri-tion knowledge, beliefs, and practicesare extremely diverse in the field ofsports, which emphasize the impor-tance of involving a sports dietitian.21

While self-reported use of nutritionalsupplements by athletes may be as-sociated with dietary counseling,other factors also play a role in sup-plement use. Supplements can becostly, making dietary and wholefood approaches more cost-effectivemethods of improving intakes of spe-cific nutrients.4 Therefore, it is impor-tant that athletes make good foodchoices to avoid dependence on sup-plements when they are not trulynecessary.

Equally important is the fact that suc-cessful selection of a high-qualitydiet depends on a wide variety of fac-tors. For this reason, dietitians needto check in regularly with their clientsto make sure that athletes are contin-uing to achieve adequate nutrient in-takes from food and dietitians arerecommending supplementationonly when needed.

Periodization and Dose Differ by Supplement Type

Supplementation regimens requireoversight by nutrition professionals,because in some cases supplementsprovide either far more than the rec-ommended daily amounts or no ad-ditional benefit when consumedoutside of the competition season ortraining periodization. When recom-mending ergogenic or rehydrationaids, sports dietitians may advise lim-iting their intake so that a whole foodapproach can be implemented toprovide a wide variety of requiredmacro- and micronutrients. In thecase of high-dose supplements (serv-ings that provide more than recom-mended daily intakes), dietitians canrecommend intermittent (e.g., weeklyor biweekly) supplementation. Onthe other hand, when athletes use


multivitamin instead of incidentaluse; competition use vs. habitual use).Therefore, it is suggested to combinemultiple strategies in daily practice toobtain a complete view of actual di-etary supplement use in individuals.

Floris Wardenaar, PhD is an assistantprofessor of sports nutrition at theSchool of Nutrition and Health Promo-tion and the Sun Devil Athletics De-partment, Arizona State University,Phoenix and Tempe, AZ. Corrie Whisner,PhD is an assistant professor of vitaminand mineral metabolism at the Schoolof Nutrition and Health Promotion, Ari-zona State University, Phoenix.

References1. Gahche J, Bailey R, Burt V, et al .Sempos, C. Dietary supplement useamong U.S. adults has increased sinceNHANES III (1988-1994). NCHS DataBrief. 2011;April(61):1-8.

2. Kim HJ, Giovannucci E, Rosner B, etal. Longitudinal and secular trends indietary supplement use: Nurses’Health Study and Health Profession-als Follow-Up Study, 1986-2006. J Acad Nutr Diet. 2014:114;436-443.

3. Maughan RJ, Depiesse F, Geyer H, etal.(2007). The use of dietary supple-ments by athletes. J Sports Sci.2007;25 (Suppl 1):S103-113.

4. Wardenaar F, Ceelen I, Dijk JW, et al.Nutritional supplement use by Dutchelite and sub-elite athletes: does re-ceiving dietary counseling make adifference? Int J Sport Nutr ExercMetab. 2017;27, 32-42.

5. Knapik JJ, Steelman RA, Hoe-debecke SS, et al. Prevalence of di-etary supplement use by athletes:systematic review and meta-analysis.Sports Med. 2016;46:103-123.

6. Maughan RJ, Greenhaff PL, HespelP. Dietary supplements for athletes:emerging trends and recurringthemes. J Sports Sci. 2011;29 (Suppl1):S57-66.

7. Burke LM, Castell LM, Stear SJ.BJSM reviews: A-Z of supplements: di-etary supplements, sports nutrition

of training and competition. Imple-mentation of such a strategy requiresan interdisciplinary approach withinprofessional or intercollegiate sportsteams.

Generally, athletes and their coachesare most likely to be willing to partici-pate when they are assured that they

will receive feedback quickly. There-fore, it is important to prioritize effi-cient evaluation and reporting ofsurvey or other data that can be pro-vided to athletes.

Conclusion

Current findings confirm the wide-spread use of nutritional supple-ments by competitive athletes, andalso underline that dietary counsel-ing plays an important role in thechoice and use of specific nutritionalsupplements. More specifically, ath-letes receiving dietary counselingseem to make better choices regard-ing nutritional supplement use whencompared with athletes not receivingdietary counseling. Although thereexists a relation between the intakeof specific nutritional supplementsand dietary counseling, current evi-dence does not provide a clear un-derstanding of how and when theseproducts are used (e.g., daily use of a

low-dose multivitamins, daily use canbe recommended for optimizing nu-tritional status and athletic perform-ance.20

Interestingly, supplement use maynot always correct nutritional inade-quacies, particularly for nutrientssuch as vitamin D and iron.20,23 There-fore, dietitians should advise comple-menting supplement intake with theathlete’s dietary intake of key nutri-ents, promoting higher dietary in-takes or increased supplementationwhen necessary to meet recom-mended needs.

Challenges with Supplement Selection

When maintaining a food-first ap-proach, supplements may be neces-sary for some athletes to achieverecommended intakes of certainmicro- and macronutrients to facili-tate optimal health and performance.As the supplement market continuesto grow, it may become difficult forathletes to identify the most appro-priate, effective, and safe supple-ments for their individualized needs.Supplements have been found tolack ingredients listed on the label orcontain contaminants or bannedsubstances; these shortcoming cannegatively affect the athlete.24,25

In light of such problems, sports dieti-tians are a critical resource for ath-letes in selecting products. Theseprofessionals can be helpful in identi-fying brands, specific formulations,and supplementation regimens thatare cost-effective and meet the ath-letes’ needs while limiting the risks ofover- or under-consumption of nutri-ents and adverse events.

Connecting Research andDaily Practice

Implementing research tools as apart of an athlete’s daily routinewould enable sports dietitians tocontinuously monitor processes.Moreover, these tools would facilitatelongitudinal research in this area andevaluation of nutritional supplementintake over time at different phases


foods and ergogenic aids for healthand performance. Part 1. Br J SportsMed. 2009;43:728-729.

8. Burns RD, Schiller MR, Merrick MA,et al. Intercollegiate student athleteuse of nutritional supplements andthe role of athletic trainers and dieti-tians in nutrition counselling. J AmDiet Assoc. 2004;104:246-249.

9. Jacobson BH, Sobonya C, RansoneJ. Nutrition practices and knowledgeof college varsity athletes: a follow-up. J Strength Cond Res. 2001;15:63-68.

10. Anderson DE. The impact of feed-back on dietary intake and bodycomposition of college women vol-leyball players over a competitiveseason. J Strength Cond Res.2010;24:2220-2226.

11.Valliant MW, Emplaincourt HP,Wenzel RK, et al. Nutrition educationby a registered dietitian improves di-etary intake and nutrition knowledgeof a NCAA female volleyball team. Nutrients. 2012;4:506-516.

12. Erdman KA, Fung TS, Reimer RA, etal. Influence of performance level ondietary supplementation in eliteCanadian athletes. Med Sci SportsExerc. 2006;38:349-356.

13. Braun H, Koehler K, Geyer H, et al.Dietary supplement use among eliteyoung German athletes. Int J SportNutr Exerc Metab. 2009;19:97-109.

14. Kristiansen M, Levy-Milne R, Barr S,et al. Dietary supplement use by var-sity athletes at a Canadian university.Int J Sport Nutr Exerc Meta. 2005:15:195-210.

15. Castell LM, Stear SJ, Burke L, eds.Nutritional Supplements in Sport, Exer-cise and Health: An A-Z Guide. London,England: Routledge; 2015.

16. Larson-Meyer DE, Willis KS. Vita-min D and athletes. Curr Sports MedRep. 2010;9:220-226.

17. Farrokhyar F, Tabasinejad R, DaoD, et al. Prevalence of vitamin D inad-equacy in athletes: a systematic-re-view and meta-analysis. Sports Med.2015; 45:365-378.

18. Bellinger PM, Minahan CL. The ef-fect of beta-alanine supplementationon cycling time trials of differentlength. Eur J Sport Sci. 2015;16:829-836.

19. Carr AJ, Hopkins WG, Gore CJ. Ef-fects of acute alkalosis and acidosison performance: a meta-analysis.Sports Med. 2011;41:801-814.

20. Wardenaar F, Brinkmans N, CeelenI, et al. Micronutrient intakes in 553Dutch elite and sub-elite athletes:prevalence of low and high intakes inusers and non-users of nutritionalsupplements. Nutrients. 2017;Feb;9(2).

21. Walsh M, Cartwright L, Corish C, etal. The body composition, nutritionalknowledge, attitudes, behaviors, andfuture education needs of seniorschoolboy rugby players in Ireland.Int J Sport Nutr Exerc Metab. 2011;21:365-376.

22. Danaher K, Curley T. Nutritionknowledge and practices of varsitycoaches at a Canadian university. CanJ Diet Pract Res. 2014;75:210-213.

23.Van Erp-Baart AM; Saris WM; Bink-horst RA; et al. Nationwide survey onnutritional habits in elite athletes.Part II. Mineral and vitamin intake. IntJ Sports Med.1989;10(Suppl. 1):S11–S16

24. Judkins C, Prock P. Supplementsand inadvertent doping – how big isthe risk to athletes. Med Sport Sci.2012;59:143-152.

25. Eichner A,Tygart T. Adulterated di-etary supplements threaten the heath and sporting career of up-and-coming young athletes. Drug TestAnal. 2016;8:304-306.

Dietary Fat Recommendations:

Registered Dietitian Nutritionists’ Practices and Guidance Vary

by Sherri N. Stastny, PhD, RD, CSSD; Jill Fabricius Keith, PhD, RD; Nicole Vasichek, MS, RDN; and Julie Garden-Robinson, PhD, RD

Introduction

In the 1940s, when coronary heartdisease (CHD) first became the lead-ing cause of death in the UnitedStates, scientists began to search forcauses.1 Low-fat diets became cus-tomary in the U.S. as obesity rates in-creased and a national focus onweight loss emerged.1 The desiredoutcome of low-fat diets was to aid inweight reduction and reduce coro-nary heart disease (CHD) risk. The

“diet-heart” hypothesis was formed,stating that diets high in saturatedfatty acids (SFAs) and cholesterolwere a major cause of CHD.1

In 1980, when the first Dietary Guide-lines for Americans (DGA) were re-leased, avoidance of too much fat,SFAs, and cholesterol was suggested.2

The 1980 DGA indicated that con-sumption of excess SFA and choles-terol would increase serumcholesterol levels in most people.

However, this reaction was expectedto vary due to heredity and individualresponse to cholesterol.2 These rec-ommendations were proposed be-cause CHD was the leading cause ofdeath in the U.S. at the time.3 How-ever, conclusive nutritional data tojustify these recommendations werelacking when the 1980 DGA were re-leased.4

In 1960, U.S. individuals consumedapproximately 45% of their caloric in-


take from fat. By 1995, dietary fatconsumption had dropped to about35% of caloric intake.5-7 Despite de-creased fat intake, CHD remained theleading cause of death in the U.S. forboth men and women. About 13% ofadults were obese and less than 1%had type 2 diabetes related to obe-sity in 1960; in contrast, more recently35% of adults are obese and 9% havetype 2 diabetes.8

Subsequent DGA releases continuedwith an emphasis on either “low fat”or “fat in moderation” recommenda-tions.6 The 2000 DGA stated to “usefats sparingly.” 9 The 2005 and 2010

versions of the DGA shifted fat rec-ommendations to 20% to 35% oftotal kcal from fat kcal. 9 Other na-tional health organizations have var-ied guidance for dietary fat, and todate, recommendations are not con-sistent (as shown in Table 1). Sincethe study reported here was con-ducted, the DGA 2015-2020 were re-leased and emphasize a healthyeating pattern, which includes oilsand limits SFA and trans fats.10 Fur-thermore, the new DGA states, “…evi-dence shows that replacing SFA withpolyunsaturated fats is associatedwith a reduced risk of CVD...”

Registered dietitian nutritionists(RDNs) are expected to stay currenton changing nutrition science and di-etary recommendations. However,staying current has been a challengeas some evidence points to a lack ofnutritional science backing up formerdietary fat guidelines and subse-quent consumer confusion.4 Onestudy indicated that consumer confu-sion is associated with exposure toconflicting information regarding thehealth benefits and risks of foods andtheir belief that nutrition scientistskeep changing their minds.11

Table 1. Various Professional Recommendations for Total Fat and Different Fatty Acids as of December 2016

Total Fat PUFA MUFA SFA TFA

Group 25%-35% of Majority of Majority of <7% or 5%-6% <1%American Heart total kcal fat kcal fat kcal of kcal for thoseAssociation, 2015 trying to lower LDL

cholesterol

National Lipid Low-fat diet Partially Partially Reduce trans fattyAssociation, 2014 recommended replace refined replace refined dietary intake acid

for individuals CHO intake CHO intake due to high consumptionwith high with with SFA diet’striglycerides unsaturated unsaturated association

fats to fats to withtriglyceride triglyceride increasedlevels and levels and � LDL levelsHDL HDLcholesterol cholesterol

Dietary Guidelines Emphasis on Replace SFA Limited Retain AvoidCommittee, 2015 adequate fat with evidence upper limit partially

consumption unsaturated supporting of 10% of hydrogenatedfat diets are fat, especially reduced CVD kcal oils

not related to PUFAs risk withreduced CVD replacement ofrisk. SFA with

MUFAs

Academy Evidence 20%-35 % of PUFA Moderate <7%-10% of Intake as lowAnalysis Library total kcal consumption intake of kcal as possible position paper, with a focus MUFA2014 on n-3 intake (15%-20%)

while strivingto consume ≥2servings of fatty fish perweek

Academy=Academy of Dietetics and Nutrition; CVD=cardiovascular disease; CHO=carbohydrate; HDL=high-density lipoprotein; LDL=low-density

lipoprotein; MUFA=monounsaturated fatty acids; PUFA=polyunsaturated fatty acids; SFA=saturated fatty acids; TFA=trans-unsaturated fatty acids.


Survey Design

The Fat Facts survey, which was in-spired by the Social EcologicalModel14 used for this cross-sectionalstudy, was designed to establish abaseline of knowledge and aware-ness as well as estimate current prac-tice of dietary fat recommendationsamong a random sample of RDNs.The survey addressed dietary pat-terns and nutrition knowledge forfats and types of fats consumedusing a five-point Likert-type scale(ranging from “never” to “always”;“very important” to “not important atall”; “strongly agree” to “strongly dis-agree”) that were converted numeri-cally to assess strength of responses.Respondents were asked to rate theirlevel of agreement that olive oil,canola oil, vegetable oil, vegetable oilspray, butter, margarine, coconut oilor other fats should be regularly usedin food preparation. Demographicdata were also collected. Measures ofperceived confidence in making rec-ommendations regarding dietary fat(e.g., trans fat, SFA, PUFA) were as-sessed using a Likert-type scale(5=very confident, 4=confident,3=somewhat confident, 2=unsure,1=very unsure). For example, partici-pants were asked, “Indicate your levelof confidence in choosing foods thatcontain fats that are associated withhealth benefits.” Participants werealso surveyed on their personal useof fish oil and coconut oil and theirlikelihood to recommend the oils tothe general public.

The survey was pilot-tested with 12RDNs in a variety of practice settingsincluding clinical, education, andcommunity to test for face validity.For feedback regarding ease of use,ease of time to completion, and sug-gestions for improved understand-ability and readability, thepilot-testing contributed to changedsurvey questions before the Fat Factssurvey was delivered to the CDR sam-ple. After pilot-testing, five questionswere modified, one question wasdeleted, and two questions wereadded to the finalized survey.

As recently as 2010, when the DGAincluded 20% to 35% of kcal from fat,Jakobsen12 and Hu13 found that mostpeople restrict fats as a whole regard-less of classification as “good” or“bad.” In addition, when fat is re-stricted, processed carbohydrate-richfoods such as bread, sugary drinks, orfat-free products often are the re-placements.13

While SFA and trans-unsaturatedfatty acids are targets for reduction oravoidance, monounsaturated fattyacids (MUFAs) and polyunsaturatedfatty acids (PUFAs) should be in-cluded as part of a balanced diet.10

RDNs are key to spearheadingneeded shifts in dietary fat consump-tion among healthy consumers, andconsumer trust in their efforts will bemore effective with consistency inrecommendations. Consumer confu-sion may be partially influenced bymixed messaging from health educa-tors (e.g., RDNs). The purpose of thisstudy was to assess perceptions, nu-trition knowledge, and personal di-etary practices regarding fatrecommendations among a randomsample of RDNs.

Methods

SubjectsIn July 2015 (prior to the release ofthe DGA 2015-2020), RDNs were re-cruited to participate in an electronicFat Facts survey via the Commissionon Dietetic Registration (CDR). A re-quest was made to CDR to providethe maximum number of participantsallowed by the CDR complimentarysample list to students who are com-pleting a research project. The sam-ple of RDNs was randomly chosen byCDR from the pool of RDNs regis-tered to receive the CDR listserv. Afterthe participants received the URL,they were directed to the informedconsent form where instructions onsurvey completion were provided.The North Dakota State University In-stitutional Review Board approvedthe study protocol before recruit-ment began. A $20 Amazon gift cardwas randomly awarded to one of thefirst 150 survey completers.

Statistical Analysis

Descriptive statistics were utilized todetail RDN recommendations regard-ing total and other fats. Influence ofRDNs’ personal dietary habits on pro-fessional practice recommendationswere determined using logistic re-gression analysis. Analysis of variance(ANOVA) statistics for comparison byarea of dietetic practice was com-pleted to detail RDN level of confi-dence when making dietary fatrecommendations. The Bonferronicorrection for multiple testing wasutilized. Duncan’s multiple compar-isons were done to determine spe-cific mean differences between RDNpersonal level of confidence in ex-plaining fat’s effects on health amongdifferent areas of practice. The alphavalue was set at 0.05. All statisticswere performed using SAS InstituteInc. 9.3, 2011 (Cary, NC).

Results

The Fat Facts survey was initiallyemailed to 2,500 randomly selectedRDNs enlisted in the CDR listserv(possible 94,473 members in 2015).Of those emails sent, 29 emailsbounced back, bringing the finalsample to 2,471 potential candidates.The survey was re-sent three times tomaximize exposure. Potential partici-pants were allowed to complete thesurvey only one time using the ballot-box-stuffing-prevention fea-ture in Qualtrics. A total of 281 com-pleted surveys were returned (11%response rate). Demographic infor-mation shows that the majority ofthe participants were females, similarto overall CDR membership (96% arefemale),15 and between the ages of25 and 60 years (Table 2).

Responses regarding agreement thatspecific fats should or should not beused regularly in food preparationare shown in Table 3. Overall, of theseven dietary fats listed on the sur-vey, olive oil received the highest rat-ing, with an average weighted mean(WM) score of 4.62 (highest possible:5.00). Margarine was rated the leastacceptable to be used in food prepa-


Table 2. Study Participants: Sex, Age, and Practice Areas of RDNs Responding to the Fat Facts Questionnaire*

% nSex (n=280)

Female 97 271Male 3 9

Age (n=281)Under 18 0 018-24 3 825-39 49 13740-60 36 10261 or older 12 34

Primary area of practice (n=281)Clinical nutrition-acute care/inpatient 22 61Other 19 53Clinical nutrition ambulatory care 16 45Community 10 28Education and research 10 28Consultation and business 10 27Clinical nutrition-long-term care 9 26Food and nutrition management 4 13

Highest level of education (any major) (n=280)Master’s degree 48 133Bachelor’s degree 46 129Doctorate degree 6 18

Years of Practice as an RDN (n=281)Less than 5 y 21 585-10 y 22 6311-15 y 15 4216-20 y 14 4021-25 y 6 1626-30 y 8 21More than 30 y 15 41

Results also showed that 72% and31% of respondents consider mack-erel and lake trout, respectively, to begood sources of n-3 fatty acids, eventhough both are considered to begood sources of n-3 fatty acids.16 Inaddition, 9.25% and 8.90% indicatedthat tilapia and shrimp, respectively,were good sources of n-3 fatty acids,which is untrue.16

There were significant mean differ-ences in personal confidence and nu-tritional knowledge between RDNareas of practice when specificallyasked about n-3 fatty acids, n-6 fattyacids, and essential fatty acids. Dun-

ration, with a WM score of 2.09. Fur-ther inquiries were posed regardinguse of fat-reduced foods (Table 4). Ac-cording to cumulative frequency (CF)statistics, 53% of the sample reporteduse of processed low-fat productstwo or more times each week. How-ever, 65% indicated they never usefat-free or reduced-fat dairy substi-tutes, such as creamers.

Nearly 99% of the 280 RDN respon-dents agreed that n-3 fatty acidshave potential health benefits. In ad-dition, 93% and 90% agreed thatMUFAs and essential fatty acids, re-spectively, have potential health ben-

efits. Furthermore, 77%, 60%, and18% indicated that PUFAs, n-6 fattyacids, and SFAs, respectively, have po-tential health benefits. Only 1%agreed that trans-unsaturated fattyacids have potential health benefits.When asked which fats should beavoided or limited in the general diet,99% and 76% indicated trans-unsatu-rated fatty acids and SFAs, respec-tively. In contrast, few respondersagreed that n-3 fatty acids (1.43%),essential fatty acids (0.36%), PUFAs(12.14%), and MUFAs (2.73%) shouldbe avoided or limited in a generaldiet.

*Sample sizes vary slightly due to missing data


Table 3. Agreement That Selected Fats Should Be Used Regularly in Food Preparation Among a Random Sample ofRDNs*

Strongly Agree Neither Disagree Stronglyagree agree nor disagree

disagree(5) (4) (3) (2) (1)

n n n n n Weighted Mean**

Olive oil (n=281) 179 97 5 0 0 4.62

Canola oil 92 122 39 16 9 3.98(n=278)

Vegetable oil 20 78 91 63 24 3.03(soybean, corn,etc. (n=276)

Vegetable oil 30 109 78 31 19 3.26spray (e.g., PAM)(n=276)

Butter (n=280) 24 103 75 77 1 3.26

Margarine 1 26 54 113 84 2.09(n=278)

Coconut oil 25 74 82 75 23 3.01(n=279)

Other fat (n=207) 17 25 139 13 13 3.10

*Sample sizes vary slightly due to missing data** Mean in which each item being averaged is multiplied by a number based on the item’s relative importance ranging 1-5. The result is summed and the

total is divided by the sum of the responses.

can’s multiple comparisons wereused to determine specific mean dif-ferences. The mean (M) response forthose practicing in Education and Re-search (M=4.44) was higher (P<.05)than for those practicing in ClinicalNutrition-Acute Care/Inpatient(M=4.13). RDNs practicing in Consul-tation & Business (M=4.67) were sig-nificantly more confident than RDNsin Food and Nutrition Management(M=4.23) in choosing foods that con-tain fats associated with health bene-fits. Regardless of these differences,all RDN areas of practice reportedhigh levels of confidence; all meanswere greater than 4.0. In addition,only 19% of respondents were neu-tral or unsure of PUFAs’ effects onhealth.

Another question probed for “level ofconfidence in explaining each fat’s ef-fects on health.” No significant indica-tors were noted regarding personallevel of confidence in explaining fat’seffects on health among the differentareas of RDN practice. There were nosignificant differences in practicegroups for this question; most RDNs(92%) reported high levels of confi-dence (mean of 4 or higher). Regard-ing confidence in fat’s effect onhealth, 19% were “neutral”/“unsure”of PUFAs.

When asked about the impact of thethen-proposed 2015 Dietary Guide-lines from the DGA advisory commit-tee, 22% of respondents agreed theirconfidence level for making dietary

fat recommendations was decreasedby publication of the committee re-port. However, 18% of RDNs dis-agreed that the proposed guidelinesdecreased their confidence levelwhile making fat recommendations.In addition, 52% neither agreed nordisagreed that their confidence levelhas been affected. No significant dif-ferences in knowledge or confidencedue to the proposed 2015 DGA wereobserved based on RDNs age group,level of education, and years of expe-rience. Also, no significant differenceswere noted among dietetic practicegroups in level of confidence in ex-plaining attributes of n-6 fatty acidsin the 2015 DGA.

Of 281 responses regarding personal


use of a fish oil supplement, 37% indi-cated they use the supplement and63% indicated they do not; 40% ofRDNs “rarely”/“never” recommendfish oil supplements. Despite thatcontrast, logistic regression analysisindicated that personal use of a fishoil supplement was a significant pre-dictor of fish oil recommendations(P<.0001). The likelihood of a respon-dent personally using a fish oil sup-plement increased 3 times for everyunit (“never” to “rarely” is 1-unit) in-crease in his/her recommendation offish oil. For example, a respondentwho “most of the time” recommendsfish oil was 9 times more likely to takea fish oil supplement than a respon-dent who “never” recommends a fishoil supplement.

Response to the statement “RDN rec-ommendation of increased fish con-sumption for a heart- healthy diet”was a significant predictor (P=.027) ofhow often RDNs recommend a fishoil supplement. This was also a cate-gorical dependent variable, so thepredictors are compared with thebase levels from 1 (never) to 5 (al-ways). The reference level was 5. RDNswho reported “always” recommend-ing a fish oil supplement would bemore likely to respond “yes” to rec-ommending increased fish consump-tion.

Discussion

A key outcome of this study is thatthere is a relatively widespread lackof confidence in making suggestions

to clients regarding consumption ofdietary fats. Our results suggest thatvarying dietary fat guidelines amongthe professional organizations maybe at least partially responsible. Manyof the responding RDNs indicatedthat the advisory committee reportfor the 2015 DGA17 decreased theirconfidence level when making di-etary fat recommendations. That re-port recommended that rather thanfocusing on reduction of sodium, SFA,and added sugars, emphasis shouldbe placed on eating a healthy andbalanced dietary pattern that in-cludes oils but limits SFA and trans-unsaturated fatty acids. The currentstudy also revealed that many RDNsmake varying recommendations re-garding potential health benefits offatty acids, good sources of foods

Table 4. Weekly Self-Purchasing of Low-Fat Products Among a Random Sample of RDNs*

Cumulative % n Frequency

(CF)

Use of processed low-fat products (n=280)Always (>5 days per week) 6.79 6.79 19Most of the time (3-4 days per week) 30.00 23.21 65Sometimes (2 days per week) 53.93 23.93 67Rarely (1 day per week) 83.22 29.29 82Never 100.00 16.78 47

Use of fat-free or reduced fat salad dressing (n=277)Always (>5 days per week) 4.69 4.69 13Most of the time (3-4 days per week) 18.41 13.72 38Sometimes (2 days per week) 30.32 11.91 33Rarely (1 day per week) 54.15 23.83 66Never 100.00 45.85 127

Use of fat-free or reduced fat dairy substitutes, such ascreamers (n=277)

Always (>5 days per week) 6.14 6.14 17Most of the time (3-4 days per week) 13.00 6.86 19Sometimes (2 days per week) 21.30 8.30 23Rarely (1 day per week) 34.66 13.36 37Never 100.00 65.34 184

Use of fat-free or reduced fat dairy products (n=281)Never 14.23 14.23 40Rarely (1 day per week) 24.28 9.96 28Sometimes (2 days per week) 40.65 16.37 46Most of the time (3-4 days per week) 69.12 28.47 80Always (>5 days per week) 100.00 30.88 87

*Sample sizes vary slightly due to missing data


high in n-3 fatty acids, and avoidanceof different fatty acids. While the DGA advisory committeeand most RDNs in the current studyrecommended that trans fat shouldbe avoided, some of the RDNs in thecurrent study recommended SFAavoidance, which is contrary to DGA2015-2020.10 Fat-containing foodspossess a variety of fatty acids ratherthan one single type; therefore, com-plete avoidance of SFA is not possi-ble. The key is to limit excessconsumption of SFA. Jakobsen et al18

noted a positive direct associationbetween substituting MUFAs for SFAsand risk of coronary events, but notcoronary-related deaths. As science-based nutrition information is re-leased, many RDNs strive to changemedical nutrition therapy advice ac-cordingly.19 The American Heart Asso-ciation (AHA) recommends at least 2servings of n-3 fatty acid (PUFAs) perweek.20 A significant inverse relation-ship between substituting PUFAs forSFAs and coronary event risk andoverall coronary death has been re-ported in the literature.18 In addition,a direct negative association hasbeen observed between carbohy-drate substitution and risk of coro-nary events.18 The DGA 2015-2020clearly state that SFA should be lim-ited10 and replaced with PUFAs andMUFAs.10

When RDNs in the current study wereasked which fats provide potentialhealth benefits, most respondentsagreed that n-3 fatty acids have po-tential health benefits. In addition,most agreed that MUFAS and PUFAShave potential health benefits. How-ever, while 98% of responding RDNsagreed that olive oil should be regu-larly utilized in food preparation, only77% agreed that canola oil should beregularly utilized, even though theyare both good sources of MUFAs. Oneexplanation is that olive oil is oftenconsumed in a less refined form.

As the 2015-2020 DGA state, fattyacids are needed for overall healthand should not be avoided or iso-lated.10 The 2015-2020 DGA embodythe idea that a healthy eating patternis not a rigid prescription, but rather,

an adaptable set of guidelines tohelp people enjoy foods that meettheir personal, cultural, and tradi-tional preferences and fit within theirbudget. The DGA 2015-2020 arebased on the Social EcologicalModel.14 Responding RDNs may havebeen considering this recommenda-tion when justifying which fatty acidshave potential health benefits. More-over, some respondents may havebeen considering specific patientpopulations that may or may nothave been at higher risk for disease atthat time, and this may have influ-enced their responses.

Some discrepancies were notedamong RDNs’ nutritional knowledgeregarding good sources of n-3 fattyacids in fish. Low-fat seafood such asshrimp and tilapia are widely con-sumed. However, an average adultwould need to consume approxi-mately 104 oz of tilapia each week tomeet weekly recommendations for n-3 fatty acid intake.16 Supplementsrich in n-3 fatty acids such as fish oilmay be needed—especially by thosewho do not eat fish or otherseafood—to ensure adequate intakeof n-3 fatty acids, particularly thelonger, more unsaturated n-3 fattyacids. Fish oil supplementation maydecrease the risk of death from car-diac causes and from all causes, and italso may reduce the risk of suddencardiac death.21 In a study by Dickin-son et al, 47% of RDN respondents in-dicated they personally used fish oilor omega-3 supplements.22 Similarly,63% respondents in the Fat Facts sur-vey indicated they did not use thesupplement. How often RDNs per-sonally use a fish oil supplement wasa significant predictor of fish oil rec-ommendations in our study.

The 2010 DGA recommendations al-lowed for 20% to 35% of kcal to comefrom dietary fat.9 Individual factorssuch as knowledge and skill are es-sential for making consumptionchoices. If consumer eating patternsshift to include more of the recom-mended PUFA, greater than 35% ofkcal consumption may be needed ifthose shifts include “healthy” fats in-stead of processed carbohydrate.

Further research is needed to im-prove the understanding of RDN con-cerns and level of confidenceregarding the tremendous variationand changing dietary fat guidelines.No studies were identified that haveexamined the relationship of nutri-tional knowledge, perceptions, andhabits of RDNs regarding dietary fatrecommendations.

Several limitations are associatedwith this research. As in any self-re-ported survey, individual factors suchas mood, lack of time, social commit-ments, and lack of validity of ques-tions as worded may have influencedhow questions were answered, affect-ing the overall study results. Second,this study included personal ques-tions such as dietary fat intake, whichmay not have been reported accu-rately or truthfully. A third limitation,lack of gender variation, existed inthe sample with nearly 97% of theparticipants reported as female, butthis is not dissimilar from CDR mem-bership. Fourth, this study was per-formed nationally; therefore, regionalvariation in available foods (e.g., freshfish) may have influenced the results.A fifth limitation was that the elec-tronic survey was first released inJuly; the response rate might havebeen higher during a month less fre-quently associated with vacations.

Conclusions

Overall, the current study revealedthat perceived confidence levels varyamong RDNs regarding specific di-etary fat recommendations for SFA,MUFA, and PUFA. In addition, nutri-tional knowledge related to specificdietary fatty acids and food sourcesalso varied among the RDNs sur-veyed. Lack of consensus among or-ganizations developing dietary fatguidelines for consumers andproviders have challenged not onlythe consumer but also the healthprofessional to know which guide-lines to follow. This study also showedthat RDNs may have varying per-ceived confidence levels when mak-ing dietary fat recommendations.Clear and consistent science-baseddietary fat recommendations may


tute of Health Publication.1995.Available at www.niddk.nih.gov/about-niddk/strategic-plans-reports/Pages/diabetes-america-2nd-edition.aspx. Ac-cessed March 16, 2015.

6. Flegal KM, Carroll MD, Ogden CL,Curtin LR. Prevalence and trends inobesity among us adults, 1999-2008.2010;303:235-41.

7. Centers for Disease Control andPrevention (CDC). Long-termtrends in diabetes. 2014. Availableat www.cdc.gov/diabetes/statis-tics/slides/long_term_trends.pdf .Accessed March 28, 2015.

8. U.S. Department of America andU.S Department of Health andHuman Services. History of the Di-etary Guidelines for Americans.Available at http://health.gov/di-etaryguidelines/history.htm. Ac-cessed December 2015.

9. U.S. Department of Agricul-ture and U.S. Department ofHealth and Human Services.2015 – 2020 Dietary Guidelinesfor Americans, 8th ed; 2015.http://health.gov/dietaryguide-lines/2015/guidelines/. AccessedDecember 2015.

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11. Jakobsen MU, Dethlefsen C,Joensen AM, et al. Intake of carbohy-drates compared with intake of satu-rated fatty acids and risk ofmyocardial infarction: importance ofthe glycemic index. Am J Clin Nutr.2010;91:1764-1768.

12. Hu FB. Are refined carbohydratesworse than saturated fat? Am J ClinNutr. 2010;91:1541-1542.

13. Centers for Disease Control andPrevention. The Social-EcologicalModel: A Framework for Prevention.March 25, 2015. Available atwww.cdc.gov/violenceprevention/ov

erview/social-ecologicalmodel.htmlAccessed October, 2017.

14. Commission on Dietetic Registra-tion (CDR). Registry statistics. 2014.https://www.cdrnet.org/registry-sta-tistics. Accessed March 9, 2016.

15. DeWitt Mireles C. Seafood Net-work Information Center. 2011. Avail-able at http://seafood.oregonstate.edu/. Accessed March 9, 2016.

16. Dietary Guidelines Advisory Com-mittee. Scientific Report of the 2015Dietary Guidelines Advisory Commit-tee. 2015. Available at www.health.gov/dietaryguidelines/2015-scien-tific-report/. Accessed May 2, 2015.

17. Jakobsen MU, O’Reilly EJ, Heit-mann BL, et al. Major types of dietaryfat and risk of coronary heart disease:a pooled analysis of 11 cohort stud-ies. Am J Clin Nutr. 2009;89:1425-1432.

18. Academy of Nutrition and Dietet-ics (AND). Academy Comments re TheDGAC Scientific Report. (2015a). Avail-able at www.eatrightpro.org/re-source/news-center/on-the-pulse-of-public- policy/regulatory-com-ments/dgac-scientific-report. Pub-lished May 8, 2015. Accessed March17, 2016.

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21. Dickinson A, Bonci L, Boyon N,Franco JC. Dietitians use and recom-mend dietary supplements: report ofa survey. Nutr J. 2012;11:14.

not be currently provided by practic-ing RDNs. RDNs need to use the mostrelevant recommendations for theirpractice depending on client health,risk of heart disease, or an otherwiseindividual need for a specific diet pre-scription for fats.

Sherri N. Stastny, PhD, RD, CSSD is as-sociate professor, Health, Nutritionand Exercise Sciences, at North DakotaState University, in Fargo. Jill FabriciusKeith, PhD, RD is assistant professor,Human Nutrition & Food/Dietetics, atthe University of Wyoming, in Laramie.Nichole Vasichek, MS, RDN is directorof nutrition and culinary services forEventide Senior Living Communities, inJamestown, ND. Julie Garden-Robin-son, PhD, RD is professor and exten-sion specialist, Health, Nutrition andExercise Sciences, at North DakotaState University, in Fargo.

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3. Harcombe Z, Baker JS, Cooper SM,et al. Evidence from randomisedcontrolled trials did not support theintroduction of dietary fat guide-lines in 1977 and 1983: a systematicreview and meta-analysis. OpenHeart. 2015;2.

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Introduction

Although water composes the major-ity of the body’s cells, organs, and tis-sues, hydration recommendations areoften omitted from nutrition pre-scription. It is well documented thatphysical performance of sport skills,cognition (short-term memory, reac-tion time), and metabolism are all ad-versely impacted by dehydration.1

However, the current body of re-search lacks sport-specific analysis ofthe effects of hydration on athleticperformance and often generalizesrecommendations for activities con-sidered to be either anaerobic or aer-obic, which is simplistic.

A reduction in body weight due todehydration greater than 2% is com-monly accepted as a threshold fordeclines in performance.2 Specifically,in an assessment of basketball, dehy-dration beyond a 2% loss of bodymass is associated with decreasedperformance of basketball-relatedskills.3 Perceived exertion during bas-ketball was decreased when partici-pants were properly hydrated,suggesting that hydration could im-pact the mental aspect of athleticsuccess.4 It is clear that dehydrationaffects multiple aspects of athleticperformance; however, the recom-mendations for proper maintenanceof hydration during a basketballgame have not been clearly estab-lished.

In addition, much of the research sur-rounding the effects of hydration onexercise performance involves inter-ventions of increased ambient tem-perature, voluntary dehydration, orboth. This research generally indi-cates reductions in muscular strengthand endurance, anaerobic power, andaerobic capacity after a loss greaterthan 2% of one’s body mass.5,6 How-ever, there has been little analysis of

dehydration during team sports thatinclude both aerobic and anaerobiccomponents, specifically in the sportof basketball, and little analysis ofhow this might affect athletic per-formance.

Much of the published hydration re-search has been conducted on recre-ational exercisers and athletes,although studies do not always in-volve team sports and are not alwaysdesigned to replicate real-life gamescenarios. More sport-specific re-search involving athletes is needed inorder to apply the findings to thatparticular population. One under-studied population is women basket-ball players. Therefore, the purpose ofthis study was to complete a realisticsimulation of National Collegiate Ath-letic Association (NCAA) basketballplay to obtain an accurate and thor-ough understanding of the effect ofhydration status on various factorsthat contribute to the performanceof a basketball player.

Methods

Participants

Eight female collegiate basketballplayers (age: 20 ± 2 y; height: 166.7 ±4.1 cm; weight: 76.9 ± 10.7 kg) wererecruited to participate in this studyvia email with an attached flyer. Inclu-sion criteria required that partici-pants were current members of thewomen’s basketball team, betweenthe ages of 18 and 22, and free of in-jury for the past 6 months. Partici-pants were excluded if they had anycardiovascular, renal, or metabolicdisorders, or had been diagnosedwith phenylketonuria. All participantsprovided written informed consentprior to engaging in any of the test-ing procedures. All procedures wereapproved by the Marywood Univer-sity Institutional Review Board.

Testing Procedures

Participation consisted of one famil-iarization day as well as two testingdays. On the familiarization day, eachparticipant received an explanationof the protocol, provided a fingerstick blood sample, and completed abioelectrical impedance analysis fortotal body water and water distribu-tion (BIA InBody 520; GE Healthcare,Madison, Wisconsin). Participantsthen completed two online cognitiveassessments on HumanBenchMark.com to ensure acquaintance withthe format and rules of the tests.7 Thefirst test was a memory test in whichthey were presented with tiles thatwere highlighted and only seen for afew seconds. Once the tiles were hid-den, participants clicked the tiles thatwere previously highlighted. Theycontinued this process until theyclicked incorrectly three times.Thesecond test was a reaction time testwhere the screen starts as red andthe participant is asked to click assoon as the screen turns green. Theycompleted a total of five trials, whichwere averaged to give a final score.Participants proceeded into the gym-nasium for full explanations anddemonstrations of each of the on-court assessments including maximalvertical jump, a T-test,8 lay-up shoot-ing, jump shooting,3 and a 300-yardshuttle run.8 Participants were giventhe opportunity to ask any questionsabout any of the testing protocolsprior to leaving.

Two experimental trials separated by2 days were completed by the partici-pants. On testing days 1 and 2, partic-ipants were assigned to twoexperimental groups (which alsoserved as their teams for simulatedbasketball competition). One groupreceived a carbohydrate-electrolytesolution (CES) treatment (GatoradeG2, Gatorade, USA) providing 18 gcarbohydrate, 411 mg sodium, and

Influence of Hydration on Cognition and Skill Performance in Female Basketball Players

by Lindsay Howard, MS and Angela Hillman, PhD


114 mg potassium per 900 ml; theother group received a placebo bev-erage (sugar-free, calorie-free CrystalLight) providing 0 mg of sodium and0 mg of potassium per liter. On bothtesting days, the participants arrivedat the laboratory dressed for exerciseand a finger stick blood sample wascollected followed by BIA analysis.Each participant was assigned anAdidas Speed Cell foot pod (AdidasAG, Germany), and fastened it to theshoelaces of one of their shoes to as-sess the distance covered during thegame simulation. The foot pod wassynced to online MiCoach profiles(Adidas, USA) for wireless data collec-tion.

Participants and researchers pro-ceeded into the gymnasium to con-tinue with testing. The participantswere given 900 ml of fluid (half of thegroup received the placebo beverageand the remaining participants re-ceived CES in bottles labeled withtheir participant number). AdditionalCES and placebo beverage were pro-

vided to participants who consumedthe entire contents of their bottles,and total volume consumed wasrecorded at the end of a basketballgame simulation. Both teams com-pleted a brief 5-minute warm-up andreturned to their benches before thestart of a 20-minute NCAA regulationfirst half of basketball. During these20 minutes, two 60-second timeoutswere called. At the conclusion of thefirst half, there was a 15-minute half-time period during which finger stickblood samples were collected. Partici-pants were free to stay near theirbenches with access to their bottlesfor the duration of the on-court as-sessments.

The participants then proceeded tothe first of the on-court assessments,the Vertec vertical jump protocol.Three trials were completed using acountermovement, and the highestjump height was used for analysis.Following this, the T-test was com-pleted, which required participants tosprint and slide between a set of

cones to assess agility. Participantsthen proceeded to the two basket-ball specific assessments; the lay-updrill and the jump-shooting drillwhich were both adopted from previ-ous research. Lastly, participants com-pleted the 300-yard shuttle run,which consisted of running six fulltrips between a set of cones placed50 yards apart. Immediately uponcompletion of the full test, partici-pants provided their rating of per-ceived exertion (Borg RPE).9

At the completion of these on-courtassessments, participants returned tothe laboratory and immediately pro-vided a finger stick blood sample,which was assessed for blood lactate(Lactate Pro, NOVA Biomedical, USA)as well as hematocrit (Micro Hemat-ocrit Reader, Hawksley, UK) and he-moglobin (Hemocue 201, Hemocue,Ltd, Sheffield, UK) in duplicate for cal-culation of plasma volume changes.10

Table 1. Mean Values for Measured Physiological and Performance Variables

CES Placebo P-value

Plasma volume change (%) -1.28 ± 3.99 -3.17 ± 5.00 .49

Total fluid intake (ml) 402 ± 344 313 ± 214 .47

Blood lactate post-game (mmol/L) 2.3 ± .9 3.1 ± 2.8 .51

Blood lactate post-drill (mmol/L) 5.8 ± 2.0 5.81= ± 3.0 .95

Vertical jump height (inches) 18.1 ± 3.3 18.1 ± 3.0 .99

Jump shots made 8.6 ± 2.7 9.1 ± 2.8 .62

Layups made 12.0 ± 1.4 11.5 ± 1.5 .41

Shuttle run time (sec) 77.0 ± 8.0 78.1 ± 6.4 .28

Shuttle run RPE 13.4 ± 2.1 14.3 ± 2.2 .11

T-Test time (sec) 11.4 ± .9 11.2 ± .7 .35

Reaction time (ms) 293.1 ± 33.7 299.6 ± 63.6* .62

Memory score 7375 ± 3480** 7122 ± 2312 .79

Distance covered (km) 1.78 ± 0.10 1.78 ± 0.22 1.00

Body mass change (%) 0.9 ± 0.8 0.5 ± 1.3 .22

Total body water change pre/post (%) 1.36 ± 1.16 0.43 ± 0.92 .12

Intracellular water change pre/post-test (%) 0.28 ± 0.64 0.90 ± 0.83 .13

Extracellular water change pre/post-test (%) 0.14 ± 0.34 0.48 ± 0.38 .13

*Significant correlation between reaction time and volume of fluid consumed during placebo trial only (r = -0.71, P = .048).

**Significant correlation between memory score and plasma volume change during CES ingestion only (r = 0.90, P = .005).


Participants then completed a post-test BIA assessment, following thetwo online cognitive assessments.

Analysis of Data

All statistical analyses were con-ducted using IBM SPSS version 23.Pearson’s product-moment correla-tions were used to determine rela-tionships between all variablesbetween testing conditions. Analysesof plasma volume, blood lactate, andbody water changes were completedusing linear mixed models for re-peated measures. A significance levelof P <.05 was used for all analyses.Descriptive statistics are presented asmean ± standard deviation.

Results

All eight participants were includedin all statistical analyses, and resultsare provided in Table 1. Plasma vol-ume was decreased by -1.3 ± 4.0%versus -3.2% ± 5.0% and body masswas reduced by 0.2 ± 0.1 kg versus0.4 ± 0.2 kg in the CES versus placebotrials, respectively. These reductionswere not significantly different be-tween trials and corresponded withno significant difference in volumesof fluid consumed (402 ± 344 ml vs.313 ± 214 ml in CES vs. placebo). Like-wise, the distances covered duringthe game (1.78 ± 0.10 vs. 1.78 ± 0.22km) were not different. There was anegative correlation between reac-tion time and total fluid (placebo)consumed (r = -0.71, P = .048). Simi-larly, lower plasma volume change re-sulted in higher scores on thememory test when consuming CES (r = -0.90, P <.01). Increased CES in-gestion resulted in lower blood lac-tate concentrations both post-gameand post-drill (F = 19.83, P <.01).There were no further statistically sig-nificant differences in outcome vari-ables.

Discussion

Although participants in this particu-lar study experienced only modestdehydration (<2% body mass reduc-tion) during exercise, it is evident that

consumption of a fluid regardless ofmacro- or micronutrient content wasbeneficial in maintaining fluid bal-ance as indicated by no significantchange in plasma volume or bodymass (Table 1).

Lower plasma volume was concur-rent with higher memory scores onthe online memory test; however, thisresult was only significant when par-ticipants consumed CES (r = -0.90, P =.005). This finding suggests that fluidintake is important to cognitive per-

formance, and also indicates carbohy-drate may have had an impact onscores. Indeed, short-term memory11

and attention12 have been found tobe enhanced after the consumptionof fluids,11 whereas overall vigilance isimpaired with dehydration.2

The CES product used in this particu-lar study contained 2 g of carbohy-drate/100 ml (2% carbohydratesolution). A full bottle of CES pro-vided 18.3 g of carbohydrate; how-ever participants only consumedapproximately half this volume (400

± 344 ml). It is currently recom-mended that athletes consume asports beverage with a 6% to 8% car-bohydrate concentration during ex-ercise to maintain performance whilesimultaneously preventing any gas-trointestinal distress.13 Total time forthe current study lasted longer than1 hour, but not longer than 2 hours,indicating that consumption of bev-erages containing concentrations ofcarbohydrate less than 6% to 8% maystill benefit a basketball player, whichis in agreement with some recom-mendations,2,13,14 but in opposition toothers.15

Body mass reductions are generallyused as an indicator of degree of de-hydration in research studies and incurrent hydration recommenda-tions.1,16 In these protocols, athletesare typically brought to a level of de-hydration reaching a 2% to 4% reduc-tion in body mass prior to testing.Brandenburg and Gaetz17 found thatdespite large sweat losses only 4 of12 female basketball players reacheda body mass reduction of <1%. This isconsistent with our findings (Table 1)and others,18 demonstrating that per-haps basketball players do not reacha level of >2% body mass reductionthroughout a regulation basketballgame, or at least throughout a firsthalf, that would likely independentlycause performance deficits.16

In 2015, the NCAA instituted multiplerule changes in the game play of Di-vision I, II, and III women’s basketball,including a switch to four 10-minutequarters as opposed to the tradi-tional two 20-minute halftimes. Withthis rule change, players are given anextra 1-minute break at the end ofthe first and third quarters, givingthem another opportunity to con-sume fluids. Body mass reductionswere 2% maximally among partici-pants in the current study, but per-haps when basketball players enterthe last 25% of the game, body massreductions would be higher andmore detrimental effects could beseen. In future protocols, perform-ance declines may be able to be de-tected during the last few minutes of


the game rather than during the be-ginning of the second half; therefore,studies of longer game simulationare needed.

The statistical results of this study in-dicate that fluid intake, as well as typeof fluid consumed (CES vs. placebo),have significant impact on cognitiveperformance (reaction time andmemory). Given our limitations insample size, assessments in a largerpopulation need to be completed torule out the possibility that dehydra-tion might affect cognitive perform-ance during game play.

In future studies, a research designthat allows ad libitum fluid intake yetalso controls for hydration statusupon beginning the research proto-col would be ideal. In the currentstudy, measures were taken so thatparticipants were unaware of the truepurpose of the research, ensuring noconscious changes in hydrationhabits occurred. This caused variabil-ity in fluid consumption, which mayhave influenced the outcome. In ad-dition, because basketball drills wereperformed in a controlled setting,participants were able to concentrateon each task independently. Duringactual game play, shooting, jumping,sprinting, and decision-making hap-pen sporadically and simultaneously.Finally, in the current study, the eightparticipants came to each of the test-ing days well hydrated; however, it isunknown whether this is consistentamong Division III women’s basket-ball players before actual games. Itcannot be assumed that all share thesame hydration habits prior to prac-tices and games. With emphasis onsports nutrition for collegiate ath-letes, more attention and focus needsto be paid on hydration require-ments, recommendations, and moni-toring, which might includepre-game measurements of urinaryspecific gravity.

Lindsay Howard, MS is a full-time in-structor in the Exercise Science depart-ment at Marywood University and is aCertified Strength and ConditioningSpecialist with the National Strengthand Conditioning Association. Angela

Hillman, PhD is an assistant professorof Exercise Physiology at Ohio Univer-sity.

References1. Jequier E, Constant F. Water as anessential nutrient: the physiologicalbasis of hydration. Eur J Clin Nutr.2010;64:115-123.

2. Sawka MN, Burke LM, Eichner ER, etal. American College of Sports Medi-cine position stand. Exercise and fluidreplacement. Med Sci Sports Exerc.2007;39:377-390.

3. Baker LB, Dougherty KA, Chow M, etal. Progressive dehydration causes aprogressive decline in basketball skillperformance. Med Sci Sports Exerc.2007;39:1114-1123.

4. Carvalho P, Oliveira B, Barros R, et al.Impact of fluid restriction and ad libi-tum water intake or an 8% carbohy-drate-electrolyte beverage on skillperformance of elite adolescent bas-ketball players. Int J Sport Nutr ExercMetab. 2011;21:214-221.

5. Kavouras SA, Armstrong LE, MareshCM, et al. Rehydration with glycerol:endocrine, cardiovascular, and ther-moregulatory responses during exer-cise in the heat. J Appl Physiol (1985).2006;100:442-450.

6. Savoie FA, Kenefick RW, Ely BR, et al.Effect of hypohydration on muscleendurance, strength, anaerobicpower and capacity and verticaljumping ability: a meta-analysis.Sports Med. 2015;45:1207-1227.

7. Available at www.humanbench-mark.com. Accessed January 1, 2015.

8. Baechle TR and Earle RW, eds. Essen-tials of Strength Training and Condi-tioning, 3rd edition. National Strength& Conditioning Association. Cham-paign, IL: Human Kinetics; 2008.

9. Borg GA. Psychophysical bases ofperceived exertion. Med Sci SportsExerc.1982;14:377-381.

10. Dill DB, Costill DL. Calculation ofpercentage changes in volumes of

blood, plasma, and red cells in dehy-dration. J Appl Physiol.1974;37:247-248.

11. Fadda R, Rapinett G, Grathwohl D,et al. Effects of drinking supplemen-tary water at school on cognitive per-formance in children. Appetite.2012;59:730-737.

12. Baker LB, Conroy DE, Kenney WL.Dehydration impairs vigilance-re-lated attention in male basketballplayers. Med Sci Sports Exerc.2007;39:976-983.

13. Fink HH, Mikesky AE, Burgoon LA.Practical Applications in Sports Nutri-tion. Sudbury, Mass: Jones & BartlettLearning; 2012.

14. Coyle EF. Fluid and fuel intakeduring exercise. J Sports Sci.2004;22:39-55.

15. Dunford M, Doyle JA. Nutrition forSport and Exercise. Belmont, CA:Wadsworth, Cengage Learning; 2012.

16. Dougherty KA, Baker LB, Chow M,et al. Two percent dehydration im-pairs and six percent carbohydratedrink improves boys basketball skills.Med Sci Sports Exerc. 2006;38:1650-1658.

17. Brandenburg JP, Gaetz M. Fluidbalance of elite female basketballplayers before and during game play.Int J Sport Nutr Exerc Metab.2012;22:347-352.

18. Thigpen LK, Green JM, O’Neal EK.Hydration profile and sweat loss per-ception of male and female division IIbasketball players during practice.J Strength Cond Res. 2014;28:3425-3431.


Conference Highlights

about SCAN opportunities that may be a good fit for you.

Speaking of volunteers, I want to take a moment to thankeach and every SCAN volunteer, staff, speaker, moderator, and

sponsor for your incredible support of our presence at the2017 Food & Nutrition Conference & Expo™ (FNCE®) .Through your efforts we are able to complement the excel-lent FNCE® program with educational sessions specific to ourpractice areas. We are able to listen to and engage existingand new members. And we are able to meet face-to-facewith each other, Academy staff, and our partners to build mo-mentum for future efforts. Kudos and thanks!

One final thought: I write this letter with deep gratitude tomy SCAN colleagues. I was sidelined with unexpected healthissues just a couple of weeks before FNCE®. In the midst ofthe last-minute preparations, they all carried on while I tooktime to heal. Thanks to you all!

FromThe Chair

SCAN Volunteers: Moving Us Forward, Building Leadership Skills

by Cheryl Toner, MS, RDN

The halfway mark in our fiscal year is upon us. As you readthis issue of PULSE, the SCAN Executive Committee is initi-ating the planning process for the coming year, when I’llpass the baton to the capable hands of Lindzi Torres. Truly,any volunteer’s elected or appointed time of service toSCAN is but one leg in a much longer race. My goal was,and remains, to faithfully shepherd SCAN’s strategic planforward, according to the work of leaders who came beforeme, and in preparation for those to come.

Also at this time, the ballot for the coming year is beingformed by our Nominating Committee. It is exciting to hearabout the volunteers who have given their time and ex-pertise in so many ways already, and who are now ready totake the next step to serve on the Executive Committee.

Beyond next year’s leaders, who are the leaders of the next5, 10, or 20 years? Whether you are a new or experiencedSCAN volunteer, I encourage you to think about what youwant out of the experience. Are you enjoying the projectsyou are working on? Are you making new connections orexploring new skills? Have you given thought to how yourvolunteerism will translate into job opportunities or profes-sional advancement? If you would like to build your leader-ship experience with SCAN, talk to one or more membersof the SCAN Executive Committee about their own volun-teer paths. I would welcome an email or call from you, tohear your thoughts and answer any questions you have

American College ofSports Medicine AnnualMeetingDenver, COMay 30 – June 3, 2017

The 64th Annual Meeting of theAmerican College of Sports Medicinewas enjoyed by more than 6,000 ex-ercise scientists, sport dietitians,sports medicine physicians, and otherhealth professionals from across theglobe. It is an excellent conference forsports dietitians who want to be onthe cutting edge. Following are just a

few highlights of some presentationsthat might be of interest to SCANmembers:

■ Does bone mineral density (BMD)in the legs differ in female athleteswho participate in weightbearingversus non-weightbearing exercise,such as ice hockey versus synchro-nized swimming? Yes! Hockey playershave higher BMD. To help optimizeswimmers’ bone health, coaches andtrainers should be encouraged to in-clude training programs that focuson bone-loading exercisers. Given

that women’s BMD peaks betweenages 16 to 20, this is particularly im-portant for young swimmers.

■ Could a carbohydrate mouth rinsebe beneficial for Muslim sprint-ath-letes during Ramadan, when they donot eat during the daylight hours?Perhaps not. Active, healthy males(n=15) performed three trials of anintensive repeated sprint protocol(two sets of 5×5-second maximalsprints interspersed with 25-sec restperiods and 3-min recovery betweensets). In each trial, they swished andspat out either 1) a carbohydrate-


containing pre-sprint mouth rinse; 2)a no-calorie placebo mouth rinse; or3) they had no mouth rinse. The ath-letes’ performance was similar in alltrials. Carbohydrate mouth rinsingseems to be more beneficial duringendurance exercise than sprints.

■ A survey of 150 runners who com-pleted a prospective running journalindicates that the participants experi-enced substantial gastrointestinal(GI) distress during 44% of their runs.While food may contribute to someof the problem, stress and anxiety (asoccurs at races) plays a role as well.Perhaps runners need to practicestress management techniques—aswell as pay attention to their food in-take.

■ For athletes in weight-categorysports (light-weight rowing,wrestling, etc.), water loading (con-suming large volumes of fluid for sev-eral days, prior to withholding intake)is a means to increase body waterlosses following fluid restriction. Todetermine the effectiveness of thisstrategy, male combat sport athletesconsumed for 3 days either 40 mlfluid/kg body weight/day (~3 L) forthe control group or 100 ml/kg (~7.6liters) for the experimental group.Both groups then restricted their in-take to 15 ml/kg (~1.1 L) on thefourth day. The water-loaded grouplost about 0.6% more body mass.Water loading did not create hypona-tremia and appeared to be a safe andeffective method to achieve short-term weight loss under the condi-tions utilized.

■ Muscle dysmorphia (MD) is a psy-chological disorder characterized bythe self-perception that one is insuffi-ciently muscular, despite often hav-ing large and strong muscles. MDoften gets entangled with eating dis-orders. An online survey of 60 com-petitive bodybuilders suggests thattheir Eating Attitudes Test scoreswere low, on average, but their BodyDysmorphic Disorder Inventoryscores were mid-range. The body-builders with high scores for MDwere more likely to have eating disor-der pathology, compared with the

bodybuilders without MD. The mostexperienced competitive body-builders had the fewest symptoms ofMD. This suggests (but needs to beconfirmed by more research) thatbodybuilders with MD may be at-tracted to the sport, but their symp-toms may hinder long-termengagement in the sport.

■ Does nutrition knowledge trans-late into enhanced dietary practicesthat could improve performance?Generally not, according to most re-search studies. This held true for ateam of Division 2 collegiate femalecross-country runners (n=11). Theycompleted nutrition questionnairesand 3-day food records before andafter four 1-hour nutrition educationsessions. While they gained knowl-edge, they reported not changingwhat they ate.

■ Do elite Ironman triathletes fueldifferently from “average” Ironmanparticipants during the event? Yes! Astudy compared the calorie, fluid, andcaffeine intake of triathletes in theHawaii Ironman World Champi-onships to the intake of the less-eliteparticipants in Ironman Wisconsin. Inthe championship event, the triath-letes consumed more calories perhour (330 vs 240), fluid (3.8 L vs 3.3 L),and caffeine (110 mg vs 65 mg) whileon the bike. These heftier fuelingpractices likely enhanced their abilityto perform better (and may helpedthem get to the Championship eventin the first place).

■ Hyponatremia (<135 mmol Na/L) ismost commonly caused by over-hy-dration, but losses of sodium viasweat and lack of sodium intake dur-ing exercise can also play a role. In a3-hour study in 93-degree F, 10 cy-clists consumed a sports drink witheither 480 mg or 1,380 mg sodiumper liter in amounts that matchedtheir sweat losses. With the lowsodium trial, four cyclists experiencedhyponatremia by the end of the ride,compared with only one cyclist whoconsumed the higher sodium bever-age. Not everyone could completethe 3-hour test. Consuming moresodium than is in most sports drinks

can be beneficial for athletes who ex-ercise extensively in the heat.

■ Aspiring Navy SEALs have to com-plete SEAL Qualification Training. Asurvey of 264 of these serious “mili-tary athletes” indicates their dietsranked only 56 out of 100 on theHealthy Eating Index. This is slightlyworse than the general U.S. popula-tion, with a score of 59. To the disad-vantage of these trainees, theirdietary patterns were low in health-protective fruits, vegetables, wholegrains, and fish, but high in health-eroding refined foods with addedsugar, fat, and alcohol. This type ofeating pattern promotes inflamma-tion and hinders optimal recoveryfrom injuries.

■ Marines in training for acceptanceinto Special Operation Forces exer-cise extremely hard during theirtraining program. One might thinkthey would suffer from long-term un-desired weight loss, but this is not thecase. After each period of intentionalsevere food deprivation, the traineesmanaged to restore the significantamount of weight they lost. For ex-ample, in the toughest part of the261-day training program (days 115-123), the men burned about 6,400kcal per day. They had access to only2,400 kcal of food—about 4,000kcal/day less than they needed. Theylost, on average, 11 lb (4.9 kg) yet in-tuitively returned to their baselineweights before their next intensivetraining mission.

■ Would taking a high dose of vita-min D, which has been shown to im-prove immune function, offerprotection from upper respiratorytract infections (URTIs) such as colds?To answer that question, Marines inbasic training received daily for 12weeks either 1,000 IUs of vitamin D ora placebo. The majority (72%) of re-cruits reported getting a URTI duringthe 12 weeks. The high dose of vita-min D did not offer a protective effectin this highly stressful environment.Perhaps they should be taught to re-duce URTIs by having cleaner handsand getting adequate sleep?


derstandably, tended to have lessbody fat—except when comparedwith the best performing women.The amount of the male or femalemarines’ muscle-mass determinedathletic performance more so thantheir body fatness. The best-perform-ing men and women in Groups 1 and2 had significantly more muscle thanthe men and women in Group 3. Theresearchers concluded that musclemass may have a stronger associationwith performance during strength,aerobic, and anaerobic tests thandoes percent body fat. This is a goodexample of how the leanest athlete is

not inherently the best athlete. Forsome athletes, adding muscle massmight be more important than losingbody fat.

Summarized by Nancy Clark, MS, RD,CSSD, who has a private practice in theBoston area, where she counsels bothfitness exercisers and competitive ath-letes, offers online workshops(www.NutritionSportsExerciseCEUs.com), and is author of the best-sellingNancy Clark’s Sports Nutrition Guide-book (www.nancyclarkrd.com).

Reviews

■ Now that women get assigned tocombat duty, the question arises:How well can the women performphysically compared with the men?To find the answer, 302 marines un-derwent comprehensive testing in-cluding strength, flexibility, balance,power, agility, and physical fitnesstests (pull-ups, push-ups, sit-ups,bench press, 2-mile run, etc.). Theythen were stratified into three groupsaccording to the test results, regard-less of sex or body fat: Group 1: Best(all men), Group 2: Middle (mostlymen), Group 3: Worst (mostly female).When compared by sex, the men, un-

The Complete DASH Diet forBeginnersJennifer Koslo, PhD, RDN, CSSDRockridge Press, 918 Parker St, Berkeley, CA 94710866/744-26652017, softcover, 168 pp, $14.99ISBN 978-1-62315-959-7

The DASH diet, also known as the Di-etary Approaches to Stop Hyperten-sion, is an eating plan that limitshigh-fat foods and focuses on pro-moting fruits, vegetables, wholegrains, lean protein, beans, nuts, andlow-fat foods. It helps lower bloodpressure and aids in weight loss. Highblood pressure can lead to a multi-tude of complications such as a heartattack, stroke, or heart failure. It is im-portant for individuals to understandways to lower blood pressure andhow simple lifestyle changes can im-prove their overall health. The Com-plete DASH Diet for Beginners providesa simple and straightforward guideon how to successfully implementthe DASH diet.

The book begins with an easy-to-read explanation of what the DASHdiet is and its proven effectiveness.The guide is then separated into twoparts. Part One goes through expla-nations of hypertension basics,guidelines for the DASH diet, steps onhow to implement the DASH diet,

meal plans, and how to get started.Part Two shifts gears by providing thereader with DASH diet recipes. Kosloshares recipes for breakfast andsmoothies, vegetarian and vegandishes, poultry and seafood, beef and

pork, snack, sides, and desserts,broths, condiments, and sauces. Theguide contains tables, graphs, and

pictures to help the reader better un-derstand how to accurately followthe instructions given.

In all, The Complete DASH Diet for Be-ginners is a simple, well-organized,and an easy-to-follow guide. It edu-cates readers on background infor-mation regarding the benefits of theDASH diet, provides example mealplans to follow, and offers samplerecipes to try at home. This book canbe a beneficial tool for those who arelooking to implement a healthier wayof living through their diet.

Jennifer Koslo is a registered dietitianand a cardiovascular dietitian. Sheprovides patients with nutritional as-sessments, education, and cardiac re-habilitation education. She is also theauthor of The Heart Healthy Cookbookfor Two, Diabetic Cookbook for Two, Al-kaline Diet for Beginners, and The In-sulin Resistance Diet for PCOS. She alsocompetes in marathons, triathlons,and other athletic events.

Reviewed by Kristina Morales, RD, clini-cal dietitian, Orange County, CA, and“Reviews” editor for PULSE.


Research Digest

Effect of Exercise Intensity onPost-Exercise Gastric EmptyingEvans HG, Watson P, Shirreffs MS, et al.Effect of exercise intensity on subse-quent gastric emptying rate in hu-mans. Int J Sport Nutr Exerc Metab.2016;26:128-134.

Previous studies have shown thatgastric emptying decreases duringhigher intensity (>70% VO2max) ex-ercise. However, the effects of exer-cise intensity on gastric emptyingpost-exercise are unclear. Therefore,the purpose of this study was to de-termine whether exercise intensityinfluences the rate of gastric empty-ing following ingestion of a carbohy-drate solution post-exercise. In thisrandomized, crossover study, fivemen and three women completedthree experimental trials—rest, low-intensity exercise (33% VO2max), andhigh-intensity exercise (1 min at peakpower followed by 2 min of rest x10)—on three separate occasions,each separated by 7 days. Thirty min-utes after completion of the trials,participants drank 595 ml of 5% glu-cose solution. The rate of gastricemptying was measured for 60 min-utes post-exercise with the double-sampling gastric aspiration method.Volume of the test solution in thestomach was significantly reduced inall groups after 10 minutes (P <.05).Total volume of the glucose solutionemptied from the stomach after 1hour did not vary significantly be-tween trials (P=.172). In summary, therate of gastric emptying and carbo-hydrate absorption post-exercise isnot affected by exercise intensity. Theresults of this study support the no-tion that carbohydrates should beconsumed soon after exercise forglycogen resynthesis regardless ofexercise intensity.

Summarized by Kelsey Pearson, MS, RD,dietitian with Retrofit, CottonwoodHeights, UT.

Post-Exercise High-Fat Feeding and Muscle Protein SynthesisHammond KM, Impey SG, Currell K, etal. Postexercise high-fat feeding sup-presses p70S6K1 activity in humanskeletal muscle. Med Sci Sports Exerc.2016;48:2108-2117.

Current sports nutrition recommen-dations include high-carbohydrate(CHO) consumption before, during,and after exercise training sessions.However, recent investigations sug-

gest that CHO restriction may en-hance adaptation to endurancetraining. Therefore, the purpose ofthis randomized, crossover designstudy was to compare the effects of arestricted-carbohydrate diet plushigh-fat post-workout meal (HFAT: 2.5g/kg CHO, 2.5 g/kg protein, and 3.5g/kg fat) to an energy and proteinmatched high-carbohydrate diet(HCHO:10 g/kg CHO, 2.5 g/kg protein,and 0.8 g/kg fat) on key cell signalingand gene expression markers in 10trained male runners. Following astandardized HCHO breakfast, partici-pants completed a twice-daily exer-cise session consisting of high-intensity training (HIT) (8 x 5 min run-ning bouts at 85% VO2peak) fol-lowed by steady-state running (SS)(60 min at 70% VO2peak) 3.5 hourspost-HIT. Participants consumed ei-ther HCHO or HFAT snacks and meals2 hours post-HIT and immediately, 2.5hours, and 6.5 hours post-SS. Trialswere separated by 7 days. Muscle

biopsies were taken from the vastuslateralis muscle immediately pre-HITand immediately, 3 hours, and 15hours post-SS to evaluate key cell sig-naling kinases and expression ofgenes related to mitochondrial bio-genesis, lipid metabolism, and muscleprotein synthesis (MPS). Glycogencontent was significantly lower at 3and 15 hours post-HFAT SS than post-HCHO SS (P<.01). P70S6K1, a markerof MPS, was significantly increasedfrom pre-HIT for both diets 3 hourspost-SS (30 minutes post-feeding)

(P<.01), but was suppressed in HFATcompared with HCHO (P=.08). Geneexpression for lipid transport and oxi-dation were greater in HFAT thanHCHO (P<.05). In conclusion, a low-CHO diet with a high-fat meal follow-ing aerobic endurance trainingsuppresses the intracellular signalingresponse associated with MPS de-spite adequate protein intake. Al-though a low-CHO, high-fat diet mayincrease fat transport and oxidation,these results suggest that a high-CHO diet including post-exerciseCHO should still be recommendedfor athletes seeking to maximizetraining adaptation. This study re-ceived funding from the English Insti-tute of Sport and Science in Sport.

Summarized by Angela Smith, gradu-ate student, Coordinated Master’s Pro-gram Sport Nutrition Concentration,Department of Nutrition and Integra-tive Physiology, University of Utah, SaltLake City, UT.

Whey Protein and BloodPressure, Endothelial Function, and Lipid BiomarkersFekete AA, Carlotta Giromini C, YiannaChatzidiakou Y, et al. Whey proteinlowers blood pressure and improvesendothelial function and lipid bio-markers in adults with prehyperten-sion and mild hypertension: resultsfrom the chronic Whey2Go random-ized controlled trial. Am J Clin Nutr.2016;104:1534-1544.

Cardiovascular disease (CVD) is aleading cause of death in many West-ern countries. A primary objective inreducing CVD risk is reducing bloodpressure, a risk factor shown to be in-fluenced by diet. Previous studieshave linked reduced blood pressure(BP) with milk consumption. How-ever, the exact compound in milk re-sponsible for this reduction waspreviously unidentified. The purposeof this study was to test the effect oftwo specific bioactive compoundsfound within milk—whey proteinand calcium caseinate—on vascularfunction and 24-hour ambulatoryblood pressure (24-h AMBP). In thisrandomized, controlled, double-blinded three-way crossover study, 38prehypertensive men and womenwere randomly assigned to ingestthree isoenergetic supplements (2 ×28 g whey protein/day, 2 × 28 g cal-cium caseinate/day, or 2 × 27 g mal-todextrin (control)/day) mixed with250 ml water and noncaloric flavorconcentrate for 8 weeks with a 4-week washout between interven-tions. Participants maintained anisocaloric diet during the study underthe supervision of a dietitian. 24-h

AMBP, flow-mediated dilation (FMD)(a marker of endothelial function),and lipid profile were measured pre-and post-intervention. Followingwhey-protein consumption, therewas a significant reduction in 24-hsystolic blood pressure (SBP) and di-astolic blood pressure (DBP) (-2.9 ±1.1 mmHg and -2.0 ± 0.7 mmHg)compared with calcium caseinate (0.6± 1.7 and 0.3 ± 1.0 mmHg) and con-trol (1.0 ± 1.1 and 0.5 ± 0.6 mmHg)(P≤.05). While both whey protein and

calcium caseinate increased FMD(P<.001) and decreased total choles-terol (P≤ .05), whey protein also de-creased triacylglycerol (P=.025)compared with control. Based onthese results, dietitians may considerrecommending whey protein supple-mentation to patients with highblood pressure. This study was sup-ported by the Biotechnology and Bi-ological Sciences Research Council(United Kingdom) with collaborationfrom Volac International Ltd.

Summarized by Claire Sorensen, gradu-ate student, Department of Nutritionand Integrative Physiology, Coordi-nated Master’s Program, Nutrition, Edu-cation, and Research Concentration,University of Utah, Salt Lake City, UT.

Nitrate Oxide Consumed inthe Diet May Improve Vascular Function Velmurugan S, Ming Gan J, RathodKS, et al. Dietary nitrate improves vas-cular function in patients with hyper-cholesterolemia: a randomized,double-blind, placebo-controlledstudy. Am J Clin Nutr. 2016;103:25-38.Vascular dysfunction is a significant

contributor to cardiovascular diseaseand is related to decreased bioavail-ability of nitric oxide (NO). NO mayimprove vascular dysfunctionthrough its vasodilator, antiplatelet,anti-inflammatory, and antiprolifera-tive effects. This study examined theeffect of dietary nitrate on vascularand platelet function in hypercholes-terolemic patients. In this random-ized, double-blind, placebo-controlled trial, 65 men and womenaged 18 to 80 with total serum cho-lesterol >6 mmol/L, or elevated low-density lipoprotein (LDL) cholesterolor triglyceride levels (QRISK score>15%), consumed 250 mL of nitrate-rich beetroot juice or a nitrate-de-pleted control daily for 6 weeks.Flow-mediated dilation (FMD) of thebrachial artery, aortic pulse waveanalysis, a clinic blood pressure meas-urement, methemoglobin concentra-tions, and blood, urine and salivawere collected at baseline and at 6weeks. Dietary nitrate treatment ele-vated circulating concentrations ofboth nitrate (~7.5-fold) and nitrite(~2.5-fold), which was associatedwith a 24% improvement in FMD re-sponse (P=.0003). Improvementswere also observed in measures of ar-terial stiffness and vascular response.While the exact mechanisms are un-certain, improvement in NO activitymay be related to reductions in in-flammation-induced oxidative stressand NO scavenging that triggers sys-temic inflammation. These findingssuggest that dietary nitrate may beuseful in improving vascular andplatelet functions in hypercholes-terolemic patients and supports rec-ommendations to increase fruit andvegetable consumption among thispopulation.

Summarized by Christine Altamirano,graduate student, Department of Nutri-tion and Integrative Physiology, Coordi-nated Master’s Program, NutritionEducation and Research Concentra-tion, University of Utah, Salt Lake City,UT.


■Cast Your Vote for SCAN LeadersYour vote counts! Take an active rolein how SCAN is governed by partici-pating in the upcoming election forSCAN leaders. Once again, SCAN willuse an electronic ballot. To vote on-line, go to the home page of SCAN’swebsite (www.scandpg.org) and clickon the link that says “2018 ElectionBallot.” Online voting polls open Feb-ruary 1, 2018; the final date to vote isFebruary 15, 2018.

■ View SCAN’s Latest AnnualReport OnlineMembers can find SCAN’s Annual Re-port for fiscal year 2016-2017 postedat www.scandpg.org/about-us/annual-reports/. To access the annualreport, a member must be signedinto the website, so the link will firstprompt for credentials. The report

provides an inside look at SCAN’sprograms, services, initiatives, andmore—giving you important high-lights on what SCAN has to offer, andhow it is continually working for you.

■ Looking for PastPULSE Articles?If you’re doing research or simplywant to locate content that appearedin an archived issue of SCAN’S PULSE,check out the annual “Index of Top-ics” posted for each year on SCAN’sWebsite. You’ll find the issue andpage number for each feature article(conveniently listed by practice area),and each item in the “ConferenceHighlights,” “Reviews,” and “ResearchDigest” departments. You can then in-stantly access the archived issue on-line. As a member benefit, all PULSEissues and annual indexes are avail-able to you for free at

www.scandpg.org/nutrition-info/pulse-newsletters.

■ Call for Abstractors for “Research Digest”The “Research Digest,” which appearsin each issue of SCAN’S PULSE, pro-vides summaries of published papersrelating to all of SCAN’s practiceareas: nutrition for sports and physi-cal activity, cardiovascular health,wellness, and disordered eating andeating disorders.

You can contribute to the “ResearchDigest” by volunteering to abstract arecently published study on any ofthe above practice areas. For detailson this opportunity, contact KaryWoodruff, MS, RD, CSSD, co-editor of“Research Digest,” at [email protected]. Become a contribu-tor to PULSE!

Of Further Interest

NotablesSCAN

by Traci Roberts


■ Christine Karpinski, PhD, RD,CSSDwas named chair of the De-partment of Nutrition at West ChesterUniversity (WCU). In addition to herteaching responsibilities, she workswith athletes at WCU and mentorsundergraduate nutrition majors whoare interested in sports nutrition.Chris served on the SCAN ExecutiveCommittee as the director of theSports Dietetics-USA subunit fromJune 2013 through May 2016.

■ Kathryn Fink Martinez, MS, RDN,CEDRD recently had her article,“There’s Always Room for Ice Creamand Chocolate!” published in ObesitySurgery, a journal for bariatric/meta-bolic surgeons. Kathryn is a certifiedeating disorder registered dietitianand supervisor, a certified intuitiveeating counselor, and a certified spe-

cialist in weight management. A pastchair of the Nutrition Entrepreneurdietetic practice group, she currentlyserves on the board of directors ofthe International Federation of EatingDisorder Dietitians and is public rela-tions director of the BehavioralHealth Nutrition dietetic practicegroup.

■ Kristen Andrews, MS, RDN,CSCS, previously the sports dietitianfor the Los Angeles Galaxy of MajorLeague Soccer and the U.S. Men’s Na-tional Soccer Team, was recentlyhired as the first full-time RDN towork for the Los Angeles Lakers. Asthe manager of nutrition and well-ness, she oversees the club-wide nutrition support program with thegoal of maximizing player perform-ance, recovery, sleep, and overall well-

ness. This effort includes an emphasison both individualized nutrition rec-ommendations and education, withthe aim of developing well-fueledand nutritionally literate players.

■ Liz Fusco, MS, RDNwas high-lighted on the Suncoast NetworkNews for her work as the perform-ance dietitian for the United StatesRowing Association during the WorldRowing Championships at Sarasota-Bradenton, FL from September 23-October 1, 2017. Liz is the wellnessco-editor of SCAN’S PULSE.

If you have an accomplishment thatyou would like to be considered for anupcoming issue of PULSE, please con-tact Traci Roberts at:[email protected]

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■ News from Wellness andCardiovascular Nutrition(Wellness/CV) SubunitHere’s an update on developmentsfrom the Wellness/CV subunit:

• Wellness Task Force Updates. TheWellness Task Force is developing a 3-year plan with the objective of creat-ing materials and programming tobest support SCAN members work-ing in the wellness arena. Stay tunedfor more details.• Wellness/CV at the 2018 SCANSymposium. It’s no secret that timein the great outdoors can be benefi-cial to our overall health and well-ness. So what better location than theRocky Mountains to advance ourknowledge and network with SCANcolleagues? Join us at the 2018 SCANSymposium (see box on page 27) inMay at the Keystone Resort. SomeWellness/CV-focused sessions will in-clude: “Nutrition Guidelines for Treat-ing Patients with FamilialChylomicronemia Syndrome”; “TheBenefits of a Wellness Program on theLong-term Health and Performanceof Fire Fighters”; and “The Art and Sci-ence of the Non-Diet Approach.”• Resources. Looking for trusted re-sources to use in your wellness-and/or cardiovascular-focused prac-tice? Visit SCAN’s website to down-load the latest fact sheets and findlinks to evidence-based positionstands and partner organization sites.You’ll find these atwww.scandpg.org/cardiovascular. Allof the Wellness/CV fact sheets wereupdated in the past several months. Ifyou have one you’ve been using for awhile, check the SCAN website todownload the most up-to-date ver-sion. You can also find new webinarson the SCAN website in the e-library(www.scandpg.org/e-library/). Re-member, webinars are free to mem-bers for the first month.• Volunteers Needed. SCAN is cur-rently seeking a member with experi-ence and interest in championingreimbursement for dietitian services.Contact Amanda Clark at [email protected] if you’re inter-ested in this position.

■ News from DEED SubunitFollowing are announcements fromthe Disordered Eating & Eating Disor-ders (DEED) subunit:

• Professional Development. DEEDcontinues to provide our memberswith eating disorder education. Assuch, we are working on another se-ries of four fact sheets and a new we-binar for this year. If you need EDreferences now, check out the SCANwebsite at www.scandpg.org/e-li-brary/ to see the most current factsheets available.• Let’s Hear from You!We are alwayslooking for new ideas for educationalmaterials to produce. To share yourthoughts and ideas, contact theDEED Director, Sarah Gleason, RDN,CEDRD, at [email protected].

■ News from Sports Dietetics—USA (SD-USA)SubunitBelow are some highlights from theSD-USA subunit:

• Expanding the Arena Initiative:Optimizing Performance on EveryStage. Through this new initiative,SCAN will be working to promote un-tapped opportunities to our mem-bers and other professionals. In thesports arena, we know that the tradi-tional view of the sports RDN work-ing strictly with athletes in organizedsports does not reflect our diversework settings and client popula-tions—in reality, sports RDNs maywork with first responders, militarypersonnel, adventure racers, musi-cians, and more! Be on the lookoutfor new resources from this initiativeas well as professional developmentopportunities and inspirational mem-ber profiles. Also, consider volunteer-ing to be involved in this initiative oron other SCAN projects. Sign up atwww.scandpg.org/volunteer-oppor-tunities/ and indicate your area of in-terest.• SCAN Speaking Opportunity. TheSCAN-NATA Committee has devel-oped a PowerPoint presentation thathighlights the collaborative working

relationship of sports RDNs and ATCs.Any SCAN member can apply to offerthis presentation at a NATA-approvedprovider program. SCAN benefitsfrom increased exposure, NATA mem-bers benefit by connecting with alocal nutrition expert, and you canbenefit from potential referrals andan honorarium. Contact JenniferDoane at [email protected] more information.• External Relations. Did you knowthat SCAN also has official partner-ships with the National Athletic Train-ers’ Association (NATA), the NationalStrength and Conditioning Associa-tion (NSCA), and Professionals in Nu-trition for Exercise and Sport (PINES)?If you are interested in growing theserelationships, please contact theSCAN Office at [email protected]. • New Webinars. Check out our twonewest webinars: What Should Dieti-tians, Coaches, and Athletes KnowAbout Glycogen Metabolism and Di-etary Interventions for Athletes withGERD. These webinars are available atwww.scandpg.org/store/default.aspx?search=Webinars. As always, they arefree with your SCAN membership!

■Manuscripts for PULSE WelcomeSCAN’s PULSE welcomes the submis-sion of manuscripts to be consideredfor publication. In particular, PULSE isinterested in receiving original re-search reports and review articles.Manuscripts presenting practicalguidelines, case studies, and other in-formation relative to SCAN will alsobe considered.

Manuscripts must be prepared andsubmitted in accordance with PULSE’sGuidelines for Authors; only manu-scripts that follow these guidelineswill be considered. The Guidelines forAuthors can be accessed atwww.scandpg.org/nutrition-info/pulse/.

■ Step Up Your Sports andFitness Nutrition GameSports dietitians are welcoming thelatest version of the renowned sportsmanual, Sports Nutrition: A Handbookfor Professionals, sixth edition. This


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long-standing, authoritative refer-ence covers timely research and evi-dence-based advice for healthprofessionals working with athletesat all levels. Written and reviewed byesteemed sports RDNs and other ex-ercise experts, this comprehensivemanual incorporates theoretical andpractical information with key take-aways designed for easy implemen-tation in daily practice.

Now in full color, the latest Sports Nu-trition explores all areas of sports andfitness nutrition for both the sea-soned and novice dietitian. Includedin this edition is a new chapter dis-cussing emerging opportunities insports nutrition, a completely revisedoverview of exercise physiology,strategies for sports nutrition assess-ment, updated population- andsport-specific recommendations, andmore. It also serves as an excellenttext for sports nutrition courses and astudy aid for the CSSD specialtyexam. The price is $65 for Academymembers. To order, go to www.eatright.org. Desk copies for educa-tors are available at www.surveymon-key.com/r/KGQ2XRF.

■ Academy Offers Book onEating Right and ExercisingAfter 50It’s never too late to make healthfulimprovements, as demonstrated in anew resource from the Academy:Food & Fitness After 50: Eat Well, MoveWell, Be Well. This useful book trans-lates the latest science on aging, nu-trition, and exercise into simple,actionable steps. Packed with real-lifestories, practical advice, and success-ful tips, Food & Fitness After 50 helpsreaders create a personalized roadmap for getting healthy and stayinghealthy.

The coauthors, one of whom is aSCAN member, share years of nutri-tion and exercise knowledge to offera common-sense approach thathelps readers control their foodchoices and fitness strategies whilenavigating their 50s, 60s, 70s, and be-

yond. The goal is to learn to embraceaging, accept the challenges, andgain the confidence to eat well, movewell, and be well. The book sells for$17.99 at www.eatrightstore.com.

■ Strategies for Opening—and Growing—Your PracticeNow available from the Academy isthe second edition of Making Nutri-tion Your Business: Building a Success-ful Private Practice. This insightfulresource provides detailed advice onmarketing and growing your busi-ness, billing and reimbursement, get-ting clients to return, and much more.Written by two experienced and suc-cessful private practitioners, this edi-tion also includes a new chapter ofsuccess stories from private practi-tioners and a comprehensive re-sources section. Making Nutrition YourBusiness is a must-read for all dietet-ics professionals who aspire to go outon their own. The price is $49.99 forAcademy members. The book is avail-able at www.eatrightstore.org.

■ Link Between WorksiteWellness and Chronic Disease PreventionAccording to the Bureau of Labor Sta-tistics of 2016, Americans spent 41%of every food dollar on food pur-chased away from home. The Acad-emy encourages the Centers forDisease Control and Prevention(CDC) to recognize worksite foodconsumption for its expected sub-stantial contribution to overall nutri-tion and calorie intake and thus itseffect on health status, including pre-vention of cancer, cardiovascular dis-ease, and other chronic diseases. InOctober 2017, the Academy releasedcomments on the CDC’s Draft Na-tional Occupational Research Agendafor Cancer, Reproductive, Cardiovas-cular and Other Chronic Disease Pre-vention, which focuses on thepreventive nature of effective work-site wellness measures. In these com-ments, the Academy emphasized itssupport for the continuation of fund-ing, research vetting of relevant re-sources, and the sharing of best

practices and strategies from suc-cessful evidence-based workplacewellness programs.

■ FDA’s Proposed Delay of Nutrition Facts Label Compliance The Academy is in the process of re-viewing the rationale from the Foodand Drug Administration for its pro-posed delay of the compliance dead-line by up to 1.5 years for final rulesassociated with the updated Nutri-tion Facts Label. As stated by the FDAin its proposal, manufacturers with$10 million or more in annual foodsales would have until January 1,2020 to implement the new label,and manufacturers with less than $10million in annual food sales wouldhave until January 1, 2021. The Acad-emy plans to comment to the FDA regarding its proposal and its consis-tency with the Academy’s Principlesfor Nutrition Labeling.

Symposium 2018

No Limits Nutrition: Extreme andUnique Practices

May 4-6, 2018Keystone Resort

Keystone, Colorado

Come to the beautiful RockyMountains for the exciting 34thAnnual SCAN Symposium. We’llgather at the Keystone Resort, theperfect place to up your game inyour dietetics practice. Plan nowto attend the scores of stimulat-ing sessions, networking oppor-tunities, and rejuvenatingactivities.

For more information and up-dates, watch for eblasts and visitwww.scandpg.org/sympo-sium2018/

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

Editor-in-ChiefMark Kern, PhD, RD, CSSDExercise and Nutrition SciencesSan Diego State University5500 Campanile Dr.San Diego, CA 92182-7251619/594-1834619/594-6553 - [email protected]

Sports EditorsKristine Spence, MS, RD, CSSDMichelle Barrack, PhD, RDN, CSSD

Cardiovascular EditorTo be appointed

Wellness EditorsZachary Clayton, MSLiz Fusco, MS, RD

Disordered Eating EditorsGena Wollenberg, PhD, RD, CSSDJulie Cooper, MS, RD

Conference Highlights EditorNancy Clark, MS, RD

Reviews EditorKristina Morales, RD

Research Digest EditorsStacie Wing-Gaia, PhD, RD, CSSDKary Woodruff, MS, RD, CSSD

SCAN Notables EditorTraci Roberts

Managing EditorAnnette Lenzi Martin708/[email protected]

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

Appropriate announcements arewelcome. Deadline for the Summer2018 issue: April 1, 2018. Deadline forthe Fall 2018 issue: July 1, 2018.Manuscripts (original research, reviewarticles, etc.) willl be considered forpublication. Guidelines for authors areavailable at www.scandpg.org. E-mailmanuscript to the Editor-in-Chief;allow up to 6 weeks for a response.

Subscriptions: For individuals noteligible for Academy of Nutrition andDietetic membership: $50. Forinstitutions: $100, To subscribe: SCANOffice, 800/249-2875

Copyright © 2018 by the Academy ofNutriton and Dietetics. All rightsreserved. No part of this publicationmay be reproduced, stored in aretrieval system, or transmitted in anyform by any means, electronic,mechanical, photocopying, recording,or otherwise, without prior writtenpermission of the publisher.

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EventsUpcoming

April 5-8, 2018ACSM’s Health & Fitness Summit &Exposition, San Diego, CA. For infor-mation: acsmsummit.org

April 21-25, 2018Experimental Biology (EB) 2018, SanDiego, CA. For information: experi-mentalbiology.org/2018/Home.aspx

May 4-6, 2018Join your colleagues at the 34th An-nual SCAN Symposium, No Limits Nu-trition: Extreme & Unique Practices,Keystone, CO. For more information:www.scandpg.org/symposium2018/

May 30-June 3, 2018ACSM Annual Meeting, World Con-gress on Exercise is Medicine®, andWorld Congress on the Basic Sciencesof Exercise and the Brain, Denver, CO.For information: www.acsmannualmeeting.org

June 9-12, 2018The American Society for Nutritionwill host its annual meeting (Nutri-tion 2018) separately from Experi-mental Biology for the first time thisyear in Boston, MA. For information:https://meeting.nutrition.org/

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Documents

SCAN’S Pulsescan-dpg.s3.amazonaws.com/media/files/2f7d55de-b166...SCAN’S Pulse Physical Activity in the Treatment of Eating Disorders by Valerie Carpenter, MS, RD and Natalie Bessinger,