Stephen F. Austin State University

Student Blogs

Student Blogs

Dietetic Interns are required to write a blog in the graduate level advanced nutrition course about a topic that is of interest to their selected audience. These blogs are published on the website so that other people can see what interest our students have and the quality of their work.

Allergy / Intolerances

Do You Have Histamine Intolerance?
Histamine Intolerance

Do You Have Histamine Intolerance?

By Heather Gallant

Dietetic Intern at Stephen F. Austin State University

Have you ever experienced headaches, flushing of the skin, or abnormally rapid heart rate when you eat certain foods? Did you get allergy tested and receive a negative result? If so, then you might have histamine intolerance. Most people have heard of intolerances to lactose and gluten, but did you know you can be intolerant to histamine? In fact, about 1% of the population has histamine intolerance.

What is Histamine?

Histamine is a type of biogenic amine that is made from the amino acid histidine. It is produced by mast cells, white blood cells, platelets, and histamine neurons and is stored in cells6. Histamine is released when stimulated and acts as a trigger for many mechanisms in the body. It can cause muscle contraction, dilatation of blood vessels, alterations of blood pressure, and irregular heartbeat6. In addition, histamine is known to play various roles in the release of neurotransmitters and gastric acid as well as can modify the functioning of the immune system6. There are two enzymes that play a role in the metabolism of histamine-diamine oxidase (DAO) and histamine-N-methyltransferase (HNMT)6. DAO is responsible for breaking down histamine when the body releases it after histamine-rich food is consumed while HNMT inactivates histamine in cells6. For this blog post, we are going to focus on the DAO enzyme because of its role in metabolizing histamine in the body from food.

Histamine Formula

Histamine Intolerance

Histamine intolerance simply refers to an imbalance between the build up and breakdown of histamine. Histamine from food can be quickly eliminated from the body with the help of the DAO enzyme but when breakdown is impaired, the DAO enzyme activity decreases and insufficiently does its job of breaking down histamine. This causes histamine to excessively collect in the body and when this happens, a person can experience various symptoms, which we will discuss later on.

There are various possible mechanisms that can be the cause of histamine intolerance. It can develop through both increased accumulation of histamine and impaired histamine breakdown. Increased accumulation of histamine occurs by the overproduction of it caused by allergies, too many mast cells in your body, bacteria, gastrointestinal bleeding, or increased consumption of histamine by food. The main cause of histamine intolerance has to do with the breakdown of histamine. The DAO enzyme is responsible for breaking down histamine, but it can become impaired due to genetics and lack of enzyme production due to gastrointestinal diseases. Additionally, alcohol, medications and other biogenic amines can impair the breakdown of histamine by DAO.

Food Allergy and Food Intolerance

Before we get any further, I think it's important to explain the difference between food allergy and food intolerance. Food allergy causes a reaction in the immune system that affects various organs in the body. Food intolerance, also known as hypersensitivity, doesn't cause an immune response and is associated with the body's inability to digest a certain food. Food intolerance accounts for 15-20% of all reactions to food while the prevalence of a food allergy accounts for only 2-5% in adults and 5-10% in young children. Food allergies are classified as either immediate or delayed and cause an immune response. It is important to note that some food intolerances can be classified as a delayed food allergy.

Histamine intolerance is called a pseudoallergy, meaning it creates an allergic-like reaction but not because of activation of the immune system, but by impaired food digestion. Some people with symptoms of histamine intolerance might associate them to a food allergy when in fact, it's not because the immune system isn't involved. That is why people with this intolerance receive negative results from a food allergy test. It's tricky because food intolerance can cause some of the same signs and symptoms as a food allergy.

Symptoms of Histamine Intolerance

When people have reduced DAO activity, even small amounts of histamine can lead to symptoms, which can be expressed in multiple organs and systems of the body including skin, gastrointestinal tract, heart, lungs, and brain. Because of these common symptoms, the presence of histamine intolerance is frequently overlooked, or its symptoms are misinterpreted.

Common Symptoms of Histamine Intolerance

  • Hypotension
  • Wheezing
  • Headache
  • Irregular heartbeat
  • Diarrhea
  • Itchy rashes on skin
  • Nasal congestion
  • Dizziness
  • Nausea
  • Abnormally rapid heart beat

Histamine Intolerance and Food

Histamine is found in various amounts of different types of foods and their presence increases as the food ages. In addition to the amount of histamine in foods, the presence of other biogenic amines like tyramine and sulfites, the intake of alcohol, and DAO-blocking drugs are factors that increases reactions to the ingested food. Some release histamine from tissue mast cells. Listed below are foods that should be avoided if you have histamine intolerance.

Foods High in Histamine

  • Aged cheese
  • Vegetables: sauerkraut, spinach, eggplant, tomatoes
  • Fish: mackerel, herring, sardines, tuna
  • Cured and processed meats: salami, ham, sausage, hot dogs, bacon
  • Alcohol and especially fermented alcoholic drinks: red wine, champagne, fermented beers
  • Leftovers

Foods That Release Histamine When Eaten

  • Citrus fruits: papaya, strawberries, pineapple
  • Nuts and peanuts
  • Egg whites
  • Chocolate
  • Certain spices and additives

Testing and Treatment

You should first get allergy tested to rule out a food allergy. If the results come back negative, then you should test for histamine intolerance. The diagnosis is determined by the presence of at least two symptoms and an improvement of symptoms from a histamine-free diet. It is recommended to completely eliminate histamine from the diet for 4 weeks (about 30 days) and then reintroduce histamine foods one at a time to see how you react. I suggest keeping a food journal while you do this elimination diet to keep track of your symptoms as you slowly add in different foods. You may find that you tolerate some foods better than others. You can also get blood tested to determine your histamine and DAO levels.

The best thing you can do to treat histamine intolerance is to figure out the root cause of it. Talk to your doctor about the medications you are on and see if any of them are causing this intolerance. Work on healing your gut and look at other biogenic amines in the food as well that may be contributing to symptoms. Remove alcohol from your diet-most people know they have a problem with alcohol if they get a red, flushed face when consuming it. If you find that eliminating all histamine-rich foods works for you, then you can continue doing so. You can also take a DAO supplement that can help breakdown the histamine you do consume, but speak with your doctor first before taking it. Histamine intolerance is an individualized process of figuring out what foods your body can and can't tolerate.

References

1. Bieganski, T., Kusche, J., Lorenz, W., Hesterberg, R., Stahlknecht, C. D., & Feussner, K.D. (1983). Distribution and properties of human intestinal diamine oxidase and its relevance for the histamine catabolism. Biochimica et Biophysica Acta (BBA)- General Subjects, 756(2), 196-203.

2. Bodmer, S., Imark, C., & Kneubühl, M. (1999). Biogenic amines in foods: histamine and food processing. Inflammation Research, 48(6), 296-300.

3. De Martino, B. G. C., De Martino, S., & Tritto, G. (2000). Histamine plasma levels and elimination diet in chronic idiopathic urticaria. European Journal of Clinical Nutrition, 54(2), 155.

4. Krabbe, A. A., & Olesen, J. (1980). Headache provocation by continuous intravenous infusion of histamine: clinical results and receptor mechanisms. Pain, 8(2), 253-259.

5. Maintz, L., Bieber, T., & Novak, N. (2006). Histamine intolerance in clinical practice. Dtsch Arztebl, 103(51-52), 3477-83.

6. Maintz, L., & Novak, N. (2007). Histamine and histamine intolerance. The American Journal of Clinical Nutrition, 85(5), 1185-1196.

7. Mušic, E., Korošec, P., Šilar, M., Adamic, K., Košnik, M., & Rijavec, M. (2013). Serum diamine oxidase activity as a diagnostic test for histamine intolerance. Wiener klinische Wochenschrift, 125(9-10), 239-243.

8. Raithel, M., Küfner, M., Ulrich, P., & Hahn, E. G. (1999). The involvement of the histamine degradation pathway by diamine oxidase in manifest gastrointestinal allergies. Inflammation Research, 48(13), 75-76.

9. Sattler, J., Hesterberg, R., Lorenz, W., Schmidt, U., Crombach, M., & Stahlknecht, C. D. (1985). Inhibition of human and canine diamine oxidase by drugs used in an intensive care unit: relevance for clinical side effects?. Inflammation Research, 16(3), 91-94.

10. Wantke, F., Götz, M., & Jarisch, R. (1993). Histamine-free diet: treatment of choice for histamine-induced food intolerance and supporting treatment for chronical headaches. Clinical and Experimental Allergy, 23(12), 982-985.

11. Yan, L., Galinsky, R. E., Bernstein, J. A., Liggett, S. B., & Weinshilboum, R. M. (2000). Histamine N-methyltransferase pharmacogenetics: association of a common functional polymorphism with asthma. Pharmacogenetics and Genomics, 10(3), 261-266.

12. Zopf, Y., Hahn, E. G., Raithel, M., Baenkler, H. W., & Silbermann, A. (2009). The differential diagnosis of food intolerance. Deutsches Ärzteblatt International, 106(21), 359.

Beverages

Is Your Coffee Obsession Healthy? Maybe.
Coffee Blog

Is Your Coffee Obsession Healthy? Maybe.

By Author Name

Dietetic Intern at Stephen F. Austin State University

Most Americans start the day with a cup of coffee, and we aren't alone! In fact, roughly 80% of the adult population worldwide consumes coffee on a regular basis (Komes & Busic, 2014). For most of us, coffee is our major source of caffeine to help us power through the day. However, lately I have heard several of my friends on social media and in conversation mention that they are trying to stop drinking coffee. Some of my friends have even tried replacing their morning cup of joe with warm, lemon water. But, why? Any time I ask for a reason, they always just simply say, "because I've always heard coffee isn't good for you." As an avid coffee drinker, I have decided to make it a personal mission to debunk the myths and spread knowledge I have learned through my own obsessive research about the true nature of coffee and its perceived health effects.

Coffee has been recognized for its various health benefits for over 1000 years! As early as fourth century BC, coffee was used as a mood stabilizer and often even given as a prescription for various illnesses (Bizzo, Farah, Kemp, Scancetti, 2015). Coffee is a blend of many different bioactive compounds that have varying effects on the body.

What are these bioactive compounds?

First and foremost, caffeine. Caffeine is the most well-known compound found in coffee, and is also the reason most of us drink this delicious brew in the first place. Caffeine is a heat-stable alkaloid that stimulates the central nervous system, acting as an adenosine-receptor antagonist (Bae, Park, Im, Song, 2014). In simple terms, this means that caffeine binds to certain receptors in the brain, blocking the effects of adenosine. Adenosine is a compound that signals to our brain that it is time for sleep. When caffeine binds instead of adenosine, we feel energized and ready to take on the day! Caffeine also functions to enhance mood, improve exercise performance, and has even shown to decrease tremors in individuals with Parkinson's disease (Esquivel & Jimenez, 2012).

You might also be surprised to find that coffee is actually full of antioxidants! In some countries, coffee is actually the major source of antioxidants for the general population (Komes & Busic, 2014). A class of phenolic compounds called chlorogenic acids are the main bioactive components responsible for coffee's abundant antioxidant activity. Several studies have reported that chlorogenic acids found in coffee are greatly associated with a decreased risk of diabetes, Parkinson's, Alzheimer's Disease, and even liver cancer (Komes & Busic, 2014). Over the years, researchers have also found that brewed coffee demonstrates a significant oxygen scavenging ability. However, longer roasting periods can result in a total loss of chlorogenic acid, and overall antioxidant activity. Therefore, medium-roasted coffee tends to have the highest oxygen scavenging ability, or the highest concentration of antioxidants (Komes & Busic, 2014).

Trigonelline is an alkaloid compound found in coffee and is largely responsible for coffee's bitter taste. Trigonelline has been shown to regenerate dendrites and axons in the brain, which may help to improve memory (Farah, 2012). Through the brewing process, trigonelline is converted to nicotinic acid, or a B-vitamin known as Niacin. Essentially, niacin helps the body to utilize the energy in our food (Komes & Busic, 2014).

Cafestol and Kahweol are also major bioactive compounds in coffee. Both compounds are diterpenes, which have shown to be help protect against liver damage as well as prevent premature cell death resulting from neurotoxins produced from Parkinson's disease (Bae, et al. 2014; Kim & Lee, 2015)

Coffee has also shown to be neuroprotective. Researchers believe that this is due partly to caffeine and caffeic acid. Certain studies have found that caffeic acid protects against amyloid ß induced neurotoxicity and tau phosphorylation, which means that coffee can possibly decrease the risk of Alzheimer's disease and help to support cognition through old age (Kim & Lee, 2015).

All of these health benefits sound amazing, right? Does all of this prove that coffee is in fact good for everyone? Well, no. Of course not. That would be too simple. Whether or not you experience positive effects from coffee all depends on how your body processes it!

The caffeine in coffee is metabolized by an enzyme in the liver, resulting from the gene CYP1A. Variations in the CYP1A gene affect how quickly you metabolize caffeine. Do you ever wonder why some people are anxious and jittery after just one cup of coffee, while others still struggle to keep their eyes open after 3 or 4 cups? Well, the answer lies in your genetics! Variations in the CYP1A gene place each of us in one of two groups: "fast" metabolizers vs "slow" metabolizers. Individuals with the "fast" CYP1A gene metabolize coffee roughly 4 times faster than individuals with the "slow" metabolizing variant (O'Connor, 2016). So how does that affect the health benefits mentioned previously? Well, several research studies have found that for "slow" metabolizers, many of the perceived health benefits of coffee consumption seem to actually have an opposite effect. Moderate to high coffee consumption among "slow" metabolizers has been associated with a higher risk of heart attack, heart disease, hypertension, and a lack of "protective" effects against some cancers when compared to those with the "fast" metabolizing variation of CYP1A (Cornelis, et al. 2006; Kressor, 2016).

Approximately 50% of the population has the genotype to be considered "slow" metabolizers. With a country divided, this could definitely explain the immense amount of conflicting data surrounding coffee consumption related to overall health. Obviously, not all of us are able to be tested for which CYP1A genotype we have. My best advice? Listen to your body! If you think you are a "fast" metabolizer, go ahead and stumble out of bed each morning to pour yourself a big cup of warm, delicious coffee. If you aren't sure which group you fall into, just be sure to listen to your body! If you don't feel like you tolerate coffee very well, then it might be better to err on the side of caution and minimize your caffeine intake.

References:

1. Bae, J., Park, J., Im, S., & Song, D. (2014). Coffee and health. Integrative Medicine Research, 3(4), 189-191. https://doi.org/10.1016/j.imr.2014.08.002

2. Cornelis, M. C., El-Sohemy, A., Kabagambe, E. K., & Campos, H. (2006). Coffee, CYP1A2 Genotype, and Risk of Myocardial Infarction. Jama,295(10), 1135. doi:10.1001/jama.295.10.1135

3. Esquivel, P., & Jiménez, V. M. (2012). Functional properties of coffee and coffee by-products ?. FRIN, 46(2), 488-495. https://doi.org/10.1016/j.foodres.2011.05.028

4. Farah, A. (2012). Coffee: Emerging Health Effects and Disease Prevention, First Edition. Y.F. Chu (Ed.) Blackwell Publishing Ltd.

5. Kim, J., & Lee, K. W. (2015). Neuroprotective, 423-427. https://doi.org/10.1016/B978-0-12-409517-5.00046-2

6. Komes, D., & Busic, A. (2014). Antioxidants in Coffee, 25-32. https://doi.org/10.1016/B978-0-12-404738-9.00003-9

7. Kresser, C. (2016, December 15). Coffee is good for you-unless it's not! Retrieved April 21, 2017, from https://chriskresser.com/coffee-is-good-for-you-unless-its-not/

8. Letícia, M., Bizzo, G., Farah, A., & Kemp, J. A. (2015). Highlights in the History of Coffee Science Related to Health. Coffee in Health and Disease Prevention. Elsevier Inc. https://doi.org/10.1016/B978-0-12-409517-5.00002-4

9. O'Connor, A. (2016, July 12). For Coffee Drinkers, the Buzz May Be in Your Genes. Retrieved April 21, 2017, from https://well.blogs.nytimes.com/2016/07/12/for-coffee-drinkers-the-buzz-may-be-in-your-genes/?_r=0

Diabetes

Apple Cider Vinegar, Friend or Foe for Diabetes? - Lindsay Hetzel
Apple Cider Vinegar

Apple Cider Vinegar, Friend or Foe for Diabetes?

By Lindsay Hetzel
April 23, 2017

Dietetic Intern at Stephen F. Austin State University

Introduction

Apple cider vinegar has been on the forefront of discussion; everywhere we look there is chatter about how to take apple cider vinegar, what the benefits are, and who benefits from taking it. Researchers have discovered that the acetic acid in apple cider vinegar has been found to suppress body fat accumulation, leading scientists to find out what the other benefits the vinegar could provide (Kondo et al., 2009). From diving in to research to find these answers I have found that people with type II diabetes, obese individuals wanting to lose weight, and individuals with high cholesterol appear to benefit the most from ingesting apple cider vinegar. For the purpose of this article, individuals with diabetes will be the focus.


Vinegar has a long history, dating back to Babylonia 5,000 BC (Kondo et al., 2009). There are various types of vinegar consumed today, apple cider vinegar, rice wine vinegar, red and white wine vinegar, and balsamic vinegar used for seasoning and preserving food. The main component of vinegar is acetic acid derived from fermentation giving vinegar its distinctive taste and pungent smell (Budak et al., 2014).

Individuals with type II diabetes mellitus (T2DM) are growing in population due to rising obesity, diet choices, and genetics. There are an estimated 171 million people worldwide suffering with T2DM, and that number is expected to increase to 366 million by 2030 (Hlebowicz et al., 2007). Insulin resistance is a condition where the cells in our body do not accept the insulin our pancreas creates for us to utilize the glucose in our bloodstream, thus our cells become insulin resistant.


Experts conducting research have agreed on the dose on 30 ml of apple cider vinegar to be sufficient to see results (White et al., 2007) (Kondo et al., 2009) (Mitrou et al., 2015). A study of obese Japanese individuals were split in to 3 groups consuming 30 ml, 15 ml, or 0 ml of apple cider vinegar to identify if the effects of vinegar intake on the reduction of body fat (Kondo et al., 2009). After 12 weeks, both of the vinegar groups lowered their body weight, BMI, abdominal fat, waist circumference, and decreased serum triglyceride levels compared to the 0 ml group (Kondo et al., 2009). While both groups had success, the 30 ml group lost more weight than the low dose group, and maintained their weight loss better than the 15 ml group (Kondo et al., 2009).


Apple cider vinegar has positive effects on insulin sensitivity and natural honey has been shown to have positive effects on cardiovascular disease risk factors (Beheshti et al., 2012) (Derakhshandeh-Rishehri et al., 2014). Honey and vinegar are often combined to be able to tolerate the mixture. Iran has a traditional syrup composed of 1 kg honey, 1500 ml water, and 300 g of vinegar, and a few mint sprigs, known as Sekanjabin, one of the oldest Iranian drinks that was studied to evaluate the effects in healthy individuals measuring cardiovascular disease risk factors (Derakhshandeh-Rishehri et al., 2014). The group consuming the syrup had a negative result of increased fasting insulin levels, but decreased their total cholesterol (Derakhshandeh-Rishehri et al., 2014). Concluding, consuming this amount of honey and vinegar did not enhance, but did not worsen each other's effects.


Advantages for Type II Diabetes

Ingesting apple cider vinegar has been shown to raise insulin sensitivity when taken at mealtime and at bedtime (Johnston et al., 2004) (White et al., 2007). Research has shown in insulin-resistant study participants that consuming apple cider vinegar (20 grams) before a high carbohydrate meal such as a bagel with butter and orange juice, resulted in raising the whole-body insulin sensitivity after 1 hour in the participants by 34%, and increased satiety (Johnston et al., 2004) (Ostman et al., 2005).


Individuals with T2DM are aware of the "dawn-phenomenon" known as an abnormal rise in blood glucose in the early-morning hours (White, et al., 2007). Consuming 2 tablespoons (30 ml) of apple cider vinegar and 1 ounce of cheese before bedtime improved the blood glucose levels in the morning in individuals with T2DM (White et al., 2007). Acetic acid has an antiglycemic effect, reducing starch digestion and/or delaying gastric emptying (White et al., 2007).


Disadvantages for Type II Diabetes

Individuals with gastroparesis, or delayed gastric emptying resulting from type I or II diabetes typically suffer with nausea, bloating, and vomiting (Hlebowicz, 2007). Individuals with gastroparesis were found to be negatively effected after consuming vinegar, exasperating their delayed emptying even further, making it difficult to control their blood sugar (Hlebowicz, 2007).


Conclusion

Overall, apple cider vinegar is helpful and cost-effective for people with T2DM, wanting to lose weight, and decrease their cardiovascular disease risk factors. Consuming 30 ml of apple cider vinegar daily has been proven to improve health. Individuals with gastroparesis may want to skip the vinegar, due to worsening symptoms.


Disclosure: As always, consult your physician before beginning any new regimen.


Easy Apple Cider Vinegar Drink

1-2 tablespoons water
2 (30 ml) tablespoons apple cider vinegar
1/4 teaspoon honey


Combine and mix all ingredients. Optional add-ins: dash of cinnamon, few drops of lemon juice.

References

Beheshti, Z., Chan, Y., Sharif Nia, H., Hajihosseini, F., Nazari, R., Shaabani, M., & Omran, M. (2012). Influence of apple cider vinegar on blood lipids. Life Science Journal, 9(4). Retrieved from https://www.researchgate.net/profile/Hamid_Sharif_Nia/publication/260311324_Influence_of_apple_cider_vinegar_on_blood_lipids/links/00b7d530bb6f074e4b000000.pdf

Budak, N., Aykin, E., Seydim, A., Greene, A., & Guzel-Seydim, Z. (2014). Functional properties of vinegar. Journal of Food Science, 79(5). Retrieved from http://doi.org/10.1111/1750-3841.12434

Derakhshandeh-Rishehri, S., Heidari-Beni, M., Feizi, A., Askari, G., & Entezari, M. (2014). Effect of honey vinegar syrup on blood sugar and lipid profile in healthy subjects. International Journal of Preventative Medicine, 5(12), 1608-1615. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336993/?report=printable

Hlebowicz, J., Darwiche, G., Bjorgell, O., & Almer, L. (2007). Effect of apple cider vinegar on delayed gastric emptying in patients with type 1 diabetes mellitus: a pilot study. BMC Gastroenterology, 7(46). doi:10.1186/1471-230X-7-46

Johnston, C.S., Kim, C.M., Buller, A.J. (2004). Vinegar improves insulin sensitivity to a high-carbohydrate meal in subjects with insulin reistance or type 2 diabetes. Diabetes Care, 27(1), 281-282. doi:10.2337/diacare.27.1.281

Mitrou, P., Petsiou, E., Papakonstantinou, E., Maratou, E., Lambadiari, V., Dimitriadis, P., … Spanoudi, F. (2015). The role of acetic acid on glucose uptake and blood flow rates in the skeletal muscle in humans with impaired glucose tolerance. European Journal of Clinical Nutrition, (69), 734-739. doi:10.1038/ejcn.2014.289

Ondo, T. K., Ishi, M. K., Ushimi, T. F., Gajin, S. U., & Aga, T. K. (2009). Vinegar Intake Reduces Body Weight , Body Fat Mass , and Serum Triglyceride Levels in Obese Japanese Subjects, 73(8), 1837-1843. http://doi.org/10.1271/bbb.90231

Ostman, E., Granfeldt, Y., Persson, L., & Bjorck, I. (2005). Vinegar supplementation lowers glucose and insulin responses and increases satiety after a bread meal in healthy subjects. European Journal of Clinical Nutrition, (59), 983-988. doi:10.1038/sj.ejcn.1602197

White, A. M., & Johnston, C. S. (2007). Vinegar ingestion at bedtime moderates waking glucose concentrations in adults with well-controlled type 2 diabetes. Diabetes Care, 30(11). Retrieved from DOI: 10.2337/dc07-1062

Immune Health

How to Avoid Getting Sick: Food, Move, & Soothe
Immune Health

How to Avoid Getting Sick: Food, Move, & Soothe

By Alexandria Broadbent

Dietetic Intern at Stephen F. Austin State University

Big life changes can take a toll on the body: starting at a new university, a new job, moving to a new city… Sometimes when these changes happen, we don't always remember to take care of ourselves, so a lot of times, we get sick. Let's take a look at three major ways within our control that can help keep our immune system in check so this is less likely to happen! As my mama always says, "it stinks to be sick".

Diet

Diet plays a huge role in the function of the immune system. Here is a summary of a few of the vitamins that contribute greatly and why they are so important. Let's go alphabetically:

· Vitamin A makes sure that the mucosal barriers separating the outside world from our inside world stays strong. These barriers are in the digestive tract, respiratory tract, and even our eyes. Another function of Vitamin A is to produce the appropriate inflammatory response (Maggini et al., 2007). Inflammatory response is the reaction to any negative stimuli in the body. When a mosquito bites us, it gets red and swells. That's the inflammatory response on a small scale. Vitamin A keeps that process in check so the appropriate cells are taking action to clear up the issue ASAP. Vitamin A can be found in liver, eggs, and dairy products. A precursor to Vitamin A, beta-carotene, is mostly found in orange/red vegetables: carrots, tomato, sweet potato, and butternut squash, just to name a few.

· Vitamin B6 breaks down dietary proteins. These proteins break down into amino acids which are used for building antibodies and cytokines (Maggini et al., 2007). Antibodies and cytokines are created for the sole purpose of defending the body from foreign invaders! B6 is found in high amounts in fish, meats, and is in some produce like bananas, spinach, and sweet potato.

· Vitamin C seems to be a popular vitamin when we get sick. Does it really help us recover? That's a good question! Well, research has shown that Vitamin C intakes had no effect on prevention of getting sick. There is hope, though. Vitamin C did have a significant effect on decreasing the duration of common cold symptoms. There does seem to be one caveat. Athletes who perform in extreme weather have a 50% reduced chance of getting sick with consistent intake of Vitamin C (Hemila & Chalker, 2013). That is some powerful stuff! But it definitely won't keep you from getting sick unless you are an extreme athlete. And remember, don't wait until you're sick to get your C-stores up! You can find vitamin C in citrus, bell peppers, kale, and many fruits.

· On to Vitamin D. It has been shown to support antimicrobials in the respiratory system lining and increases activity in the body's defensive cells. Vitamin D is special because it has a protective factor that can influence the occurrence autoimmunity (Maggini et al., 2007). Getting enough Vitamin D is quite difficult. One solution that we always have is the sun (for at least 10 hours a day)! Our bodies can convert sunshine into vitamin D. It does take quite a bit of time for this method to happen, and you do have to be careful not to get sunburned! This process is not as reliable in those with darkly pigmented skin or those living in cold regions. Some foods with Vitamin D are fatty fish, fortified beverages like milk and OJ, and egg yolks.

· Vitamin E also plays an important role in immune health. It helps to trigger the white blood cell action when infectious agents enter the body. Vitamin E supplementation can be beneficial to counteract the effects of decreased immune response with age (Bunout et al., 2004). Some sources of Vitamin E are nuts, cooking oils, avocado, spinach, and sweet potato.

I know what you're thinking. It does seem like these vitamins all kind of do the same thing. In the grand scheme of things, that is correct. But in different ways. For example, creating a lymphocyte (defensive white blood cell) is a process. Every vitamin will play a necessary role in each step- from creating a lymphocyte to activating it into battle. We can't do it without our little vitamin friends working together to keep us safe!

So what is the overall takeaway for diet and immune support? Supplements are okay, but quality is hard to find at an affordable price. It is also difficult to know what to look for when there are so many options out there. Basically what we need to do is eat more fruits and vegetables (like we didn't see that coming). But really, many Americans are lacking in this department. The recommended amount is to reach is 9 servings per day. We also need to eat a wide variety of whole foods. These sources of vitamins and minerals are the most natural and effective way for our bodies to get what they need to keep on ticking. Whole food provides the complimentary nutrients that we need in order to fully absorb these key vitamins (Gershwin et al., 2004). Supplements just can't fake that.

Exercise

We have all been there before: spending most of our time caught up in life, and not putting physical activity at the forefront of our minds. Let's say that one day we finally have some free time and decide to play a game of 2v2 basketball. The next day we are so sore and regret ever doing it! Research shows that acute bouts of exercise like this actually lower the immune system by increasing inflammation (Walsh et al., 2011). However, regular exercise (4-7 days/week) has been shown to improve the immune system. Moderate training a few times a week promotes adaptation of the immune system, improving and increasing the function of immune cells (Fuente et al., 2005). Exercise can be a scary word for some people. Just think of it as moving more! Hitting the gym or running 10 miles isn't for everyone. Walking the dog, playing with your kids at the park, or going for a swim are some (fun) ways to reach a physical activity goal. The main thing is to move.

Stress

No matter what stage of our lives, we are all going to experience some kind of stress-whether it is physical or emotional. Both kinds can take a toll on the body. I experienced this first hand with struggles in my personal life. I was sick for about 6 weeks with an infection, migraines, and acne breakouts. All my terrible symptoms began to resolve once my emotional stress decreased, which happened when everything finally settled down. SO, needless to say, emotions can certainly have an affect on physical health.

Not everyone is affected in the same way by stress. It can depend on the person's genetics, coping mechanism, personality, and social support available (Shapiro et al., 2005). Chronic, or continuous stress, can increase a person's risk for diabetes, asthma, depression, and tumor development (Salleh, 2008). Freaky, huh? This just shows, we all need to take a breather. We usually make time to brush our teeth 2-3x a day, we can certainly set a few minutes aside each day to relax or cope however we do best. Some people say that yoga is the best kind of stress reliever, but it's really just as effective as relaxation alone (Smith et al., 2006). But, please, if you want to knock out two birds with one stone (exercise and stress reduction), go for it!

Temporary stress, however, like first date nervousness, game day anxiety, or giving a speech can be good for us! Instead of putting us in distress, these kinds create eustress. Eustress is what makes us get out of bed in the morning, gives us a competitive edge, or enthusiasm to project across the crowd. Eustress allows us to adapt. Distress holds us back (Salleh, 2008).

Now, as we age, we should expect many changes in our bodies. This includes microscopic changes in our immune system. Our body is not able to produce lymphocytes the way it used to (Linton, et al, 2004). This makes it even more important to strengthen our immunity and take care of ourselves to the best of our abilities, especially as we age.

So get out there and get the right food, move more, and soothe your tensions!

References

Bunout, D., Barrera, G., Hirsch, S., Gattas, V., de la Maza, M.P., …, & Munoz, C. (2004). Effects of a nutritional

supplement on the immune response and cytokine production in free-living Chilean elderly. Journal of Parenteral Enteral Nutrition, 28: 348 -354.

Fuente, M., Hernanz, A., & Vallejo, M.C. (2005). Forum review: The immune system in the oxidative stress conditions of

aging and hypertension: Favorable effects of antioxidants and physical exercise. Antioxidants & Redox Signaling, 7 (9&10): 1356-1366.

Gershwin, M.E., Nestel, P., & Keen, C.L. (2004). Handbook of nutrition and immunity. Totowa, NJ: Humana Press Inc.

Hemila, H., & Chalker, E. (2013). Vitamin C for preventing and treating the common cold (Review). The Cochrane Library,

2013(5): 1- 103.

Linton, P.J., & Dorshkind, K. (2004). Age-related changes in lymphocyte development and function. Nature Immunology,

5:133-139.

Maggini, S., Wintergerst, E.S., Beveridge, S., & Hornig, D.H. (2007). Selected vitamins and trace elements support

immune function by strengthening epithelial barriers and cellular humoral immune responses. British Journal of Nutrition, 98(1): S29-S35.

Salleh, M.R. (2008) Life event, stress and illness. The Malaysian Journal of Medical Sciences, 15(4): 9-18.

Shapiro, S.L., Astin, J.A., Bishop, S.R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care

professionals: Results from a randomized trial. International Journal of Stress Management, 12(2):164-176.

Smith, C., Hancock, H., Blake-Mortimer, J., & Eckert, K. (2006). A randomized comparative trial of yoga and relaxation to

reduce stress and anxiety. Complementary Therapies in Medicine, 15: 77-83.

Walsh, N.P., Gleeson, M., Shephard, R.J., Gleeson, M., Woods, J.A., …, & Simon, P. (2011). Position statement part one:

Immune function and exercise. Exercise Immunology Review, 17: 6-63.

Lifecycle Nutrition

Must-have Foods During Pregnancy
Berries

Must-have Foods During Pregnancy

By Author Name

Dietetic Intern at Stephen F. Austin State University

Expecting a baby is an exciting time. It's an overwhelming, exhausting, thrilling, draining, yet totally exciting time. Everyone you know will offer advice and suggestions on how to go through your pregnancy and what to expect. This is normal and everyone means well, yet it is easy to get lost in the long list of what to do and not do. I believe there are a few necessities that must be incorporated, specifically in your diet, as related to what that sweet bundle of joy needs to grow, thrive, and ultimately have the best start at life.

Using prenatal vitamins is typically recommended, yet does not replace a healthy diet. It is imperative that your diet include certain vitamins and minerals from whole foods, as this is the body's best bet for absorption. Ultimately, a whole foods diet, with lots of fruits and vegetables that eliminates processed foods and sugars will do a body and baby good.

In order to provide yourself and your baby with proper nutrients, include these foods in your daily diet before, during and even afterpregnancy!

  • Fiber-Rich Foods - Research has recently revealed that a high-fiber diet may beneficially alter a woman's gut bacteria during pregnancy, producing anti-inflammatory substances that suppress asthma-related genes in her baby.(1) There is also research that suggests a high-fiber diet can help reduce your risk of premature death from any cause, likely because it helps to reduce your risk of a number of chronic diseases. This can help you and your baby! Choosing vegetables, nuts, and seeds is a great way to increase fiber in your diet.

Examples:

Cauliflower Beans Peas
Root Vegetables Onions Chia seeds
Flax seeds Almonds Brussel Sprouts

Leafy Greens and Broccoli - One of the most important nutrients to make sure is abundant in your diet before and during pregnancy is folate. Folate has been proven to be particularly important for the development of the nervous system and for preventing neural tube defects (NTDs) in babies. Broccoli and dark green leafy vegetables like spinach and kale are loaded with important nutrients for pregnant women, including folate, fiber, potassium, calcium, iron, and vitamins C, K, and A. Also, note that folate is found naturally in food while folic acid is the synthetic version of folate. There is a big difference between the two-especially for certain people with genes that make it more difficult to process folic acid. For more information, read the blog post "Folic Acid vs. Folate: Part I-the link can be found in reference 2.

Wild Caught Salmon and Sardines - Eating fish is the best way to get omega-3 fats EPA and DHA, but being aware of the toxic effects of pollutants found in fish is incredibly important. Among the safest in terms of contamination, and the highest in healthy omega-3 fat, is wild-caught Alaskan or sockeye salmon. Enjoying salmon a few times a week will greatly improve your omega-3 status.(3) Omega-3 fat and its derivative, DHA, is so essential to a child's development that if a mother and infant are deficient in it, the child's nervous system and immune system may never fully develop, and it can cause a lifetime of unexplained emotional, learning, and immune system disorders. Salmon also contains an abundance of other nutrients, from vitamin B12 and selenium to protein, calcium, and choline, making them one of the best dietary sources of animal-based omega-3s. Sardines have the most amount of omega-3 fats. They are delicious on toast. You can also supplement your diet with animal-based omega-3s by taking a krill or fish oil supplement.

Organic free range eggs - Eggs are really a superfood. They are a great source of protein, fat, and other nutrients, most importantly choline. In women who are pregnant, choline plays a vital role in helping to prevent certain birth defects, such as spina bifida, as well as playing a role in brain development. Consuming higher levels of choline during pregnancy is linked to beneficial epigenetic changes in the fetus, including protection from stress-related and metabolic disorders, that likely last into adulthood.(4)

Avocados - Avocados provide close to 20 essential health-boosting nutrients, including potassium, vitamin E, vitamin K, B vitamins, and folate. They're also one of few foods that contain significant levels of both vitamins C and E and are an excellent source of healthy monounsaturated fat.(5) Avocados are absolutely a superfood. You can add avocados pretty much to anything!

Berries - Berries are magical little fruit. They are lower in sugar than many fruits and therefore less likely to destabilize your insulin levels. Berries also contain high amounts of vitamin C, which helps in the absorption of iron, and they also have fiber. Berries have been found to have disease-fighting phytochemical which are found to boost your immunity, prevent cancer, protect your heart, as well as prevent seasonal allergies. (6)

Liver - I enjoy Pate regularly in my diet. Pate is finally chopped or seasoned pureed animal liver. Currently, the Western diet rarely involves eating the organs of animals, we prefer the muscle. Eating the liver, especially, has been done by many cultures and groups of people for centuries. Choosing grass-fed beef liver or free-range chicken liver is the only way to go. Impressively abundant in organ meats from pastured animals, Vitamin A is a catalyst for multiple biochemical processes. Vitamin A is vital for prevention of birth defects, prevention of infection, hormone production, optimal thyroid function, good digestion, good vision, and healthy bones and blood. Without it, your body cannot utilize protein, minerals and water-soluble vitamins. (7) Organ meats provide plentiful Vitamin E, K, D, complex B vitamins, choline, and trace minerals. This is a must in your diet during pregnancy and even after as well. There are many great recipes available, start experimenting!

Vitamin D - Vitamin D is not a specific food, but optimizing your vitamin D during pregnancy is one the most important things you can do for yourself and your baby. When a child is born deficient in vitamin D, his or her health can be significantly affected in any number of ways. Research confirms there is a lifelong impact of vitamin D deficiency in pregnancy ranging from childhood allergies to asthma, colds and flu, dental cavities, diabetes, and even strokes and cardiovascular disease in later life of the child. (8) I believe vitamin D is as important to pregnant women as folate is. Once you become pregnant, or if you are hoping to become pregnant, visit your doctor and have your vitamin D levels checked. One study revealed that women with low levels of vitamins D and E in early pregnancy are associated with an increased risk of asthma in her child within the first 10 years of life. (9) There is also mounting evidence that vitamin D deficiency in pregnant women is linked with pre-term births. (10) Talk with your doctor and find out the best ways to maximize your consumption of vitamin D.

All of these foods deserve a place in your diet during pregnancy and really before and after as well. As the emotional, mental, and physical rollercoaster ensue, it is a good idea to try to enjoy these short or long 9 months and do what you can to help bring a healthy beautiful baby into this world. You and your baby deserve the best and deserve to great healthy start to the next chapter in life!

References

1. Thornburn, A. et al (2015). Evidence that asthma is a developmental origin disease influenced by maternal diet and bacterial metabolites. Nature Communications. doi: 10.1038/ncomms83201.

2. Vitiello, P. (n.d.). Research & Education Blog. Retrieved April 30, 2017, from http://blog.designsforhealth.com/blog/bid/115121/Folic-Acid-vs-Folate-Part-I

3. Dungan, J. (2012). The Salmon in Pregnancy Study: study design, subject characteristics, maternal fish and marine n-3 fatty acid intake, and marine n-3 fatty acid status in maternal and umbilical cord blood. Yearbook of Obstetrics, Gynecology and Women's Health,2012, 152-153. doi:10.1016/j.yobg.2012.06.1

4. Jiang, X., Yan, J., West, A. A., Perry, C. A., Malysheva, O. V., Devapatla, S., . . . Caudill, M. A. (2012). Maternal choline intake alters the epigenetic state of fetal cortisol-regulating genes in humans. The FASEB Journal,26(8), 3563-3574. doi:10.1096/fj.12-207894

5. Dreher, M. L., & Davenport, A. J. (2013). Hass Avocado Composition and Potential Health Effects. Critical Reviews in Food Science and Nutrition,53(7), 738-750. doi: 10.1080/10408398.2011.556759

6. Chen, L., Xin, X., Yuan, Q., Su, D. and Liu, W. (2014), Phytochemical properties and antioxidant capacities of various colored berries. J. Sci. Food Agric., 94: 180-188.

7. Razaitis, L. (2005, July 29). The Liver Files. Retrieved May 01, 2017, from https://www.westonaprice.org/health-topics/food-features/the-liver-files/

8. Rodda, C.P., Benson, J.E., Vincent, A.J., Whitehead, C.L., Polykov, A. and Vollenhoven, B. (2015), Maternal vitamin D supplementation during pregnancy prevents vitamin D deficiency in the newborn: an open-label randomized controlled trial. ClinEndocrinol, 83: 363-368. doi:10.1111/cen.127

9. Allan, K. M., Prabhu, N., Craig, L. C., Mcneill, G., Kirby, B., Mclay, J., . . . Devereux, G. (2014). Maternal vitamin D and E intakes during pregnancy are associated with asthma in children. European Respiratory Journal, 45(4), 1027-1036. doi:10.1183/09031936.00102214

10. Miller, D. R., Turner, S. W., Spiteri-Cornish, D., Scaife, A. R., Danielian, P. J., Devereux, G. S., & Walsh, G. M. (2015). Maternal vitamin D and E intakes during early pregnancy are associated with airway epithelial cell responses in neonates. Clinical & Experimental Allergy, 45(5), 920-927. doi:10.1111/cea.12490

Sweeteners

Should You Avoid High Fructose Corn Syrup in Your Child's Diet?
High Fructose Corn Syrup Should You Avoid High Fructose Corn Syrup in Your Child's Diet?
By Tammy Proctor
Dietetic Intern at Stephen F. Austin State University


One of the most concerning topics for a parent is what you will feed your child. According to Psychology Today, 57% of parents are concerned about unhealthy eating. The food we put in our bodies is important, which is why what your child eats and drinks is a legitimate concern. I think it's safe to say, we have all heard that we should either cut back or stop consuming sodas and processed foods.


The CDC reports that 49% of adults and 63% of youth drink at least one sugar-sweetened beverage per day. It's been estimated that 61% of the average American diet is made up of highly processed foods. One of the main ingredients in these items is high fructose corn syrup (HFCS), whichin many cases it is the first ingredient. The dangers of HFCS have been discussed in the news, social media, and many other publications but the question is whether it's really harmful or not. Let's get to the facts!


What is High Fructose Corn Syrup (HFCS)?


HFCS first began to be used in the 1970's when the cost of sugar was high and corn prices were very low and have continued to be utilized due to the low cost and functionality. It's made from corn starch in which the manufacturers use an enzymatic process where the molecules are altered changing some of the glucose into fructose.


As a comparison, the sucrose molecule (table sugar), has a 1:1 ratio of fructose to glucose. There are two main forms of HFCS which are referred to as HFCS 42 and HFCS 55. This indicates the percentage of the molecule that is made up of fructose, so HFCS 42 contains 42% fructose and HFCS 55 has 55% fructose. The remainder of the molecule contains glucose and water.


HFCS 42 is mainly used in manufacturing processed foods and HFCS 55 is predominantly used in sodas. So why do they use HFCS? The purpose of using HFCS is to provide sweetness, enhance flavors, reduce water content, reduce freezer burn, enhancetexture and moisture of baked goods, gives body and texture in beverages, and it causes the enzymatic browning of baked goods.


How is High Fructose Corn Syrup (HFCS) Metabolized?


Fructose from sugar or HFCS meets the same fate. It arrives in the gut and then is sent directly to the liver. There is a difference between the way glucose and fructose are metabolized. Once glucose reaches the liver it is then either stored as glycogen (for use as energy in the muscle), stored as fat (once glycogen stores are full), or transported to cells for use as energy. Fructose, on the other hand, can only be metabolized in the liver. It is either converted to glucose or when excess is consumed, stored as fat within the liver.


Since fructosemetabolism only occurs in the liver, lipogenesis is able to occur more efficiently than with glucose. Lipogenesis is the metabolic process in which energy is changed into fat and stored. De novo lipogenesis (DNL)is another form of lipogenesis that may occur where excess carbohydrates are stored as fat and have been shown to occur with excessive consumption of HFCS. Some of the harmful effects that are associated with DNL include elevated triglycerides and fat storage in the liver. This is a fancy way of saying that this is the process in which fatty liver disease occurs.


You may be thinking, fruit contains fructose, so should I be concerned with my child eating fruit? Absolutely not! Fruit is full of important vitamins and minerals and is a great addition to any diet. The difference between HFCS and the fructose in fruit is the concentration. Fructose that comes from HFCS is a concentrated amount of fructose causing a greater consumption of fructose in products containing HFCS compared to fruit. A large apple has approximately 23 grams of sugar and 13 grams are from fructose. While a 16 oz. bottle of Coke has 52 grams of sugar and 30 grams come from fructose. This is a considerable difference! Not to mention that the apple contains fiber which helps to slow the digestion causing the fructose to make it to the liver at a more gradual pace.


Common Myths About High Fructose Corn Syrup (HFCS)


Many of us have preconceived notions about HFCS and may have assumptions that are incorrect so let's clear up some of the myths about high fructose corn syrup.


  • HFCS causes obesity - We can't blame the obesity epidemic on HFCS. There is not one specific cause of obesity, there are many causes; genetics, lack of physical activity, food choices, portion sizes, and many more. The blame cannot be attributed to one specific ingredient in a food item or beverage.
  • HFCS is sweeter than sucrose - Many people have the misconception that HFCS is sweeter than sucrose, but it's not. In order to determine how sweet a sweetener is, whether it is artificial or natural, the standard is sucrose. When compared they are equal in sweetness. As a matter of fact, the industry produced HFCS as a replacement for sucrose. They are interchangeable, HFCS just has some added benefits such as preservation and increased moisture.
  • HFCS is higher in calories than sucrose - People often think that HFCS has a higher caloric value than sucrose, however, they have the same caloric value in which they both contain 4 kcal/g.


What is Concerning About High Fructose Corn Syrup (HFCS)?


The research on HFCS is conflicting. Some research shows that HFCS is no different than sucrose and other research that shows HFCS has specific effects on the body. The following research is concentrated on adults 18 to 70 and shows some of the negative effects of HFCS:


  • Fructose ratios may be higher in some beverages than thought - In a study by Walker, Dumke, & Goran, they found that certain beverages contained 60% fructose, which is contradictory to the 55% that they were thought to have contained. This shows that fructose consumption may be more than previously thought due to the increased percentage of fructose in the ratio of the HFCS that was used.
  • Excessive consumption of HFCS may lead to non-alcoholic fatty liver disease (NAFLD) - An animal study evaluating the effects of HFCS 55 showed that rats who consumed sugar solutions had increased total food intakes when compared to rats drinking water. When the study concluded there was no change in body weight gain but when the rats were dissected it was found they had higher liver weight, total liver and triglyceride content, than the rats who drank water. These findings are alarming because the excess weight of the liver indicates that there was lipid accumulation suggesting that de novo lipogenesis occurred. Ultimately, the study determined that the type of excess sugar does influence hepatic lipid metabolism and influences the advancement of NAFLD, therefore it is advisable to limit the consumption of HFCS and sweetened beverages containing calories.
  • Consumption of HFCS may increase the risk of cardiovascular disease (CVD) - A study published in the American Journal of Clinical Nutrition, revealed that the consumption of beverages including 10%, 17.5%, or 25% of HFCS showed to have a relation to increased risk of CVD. The results displayed that HFCS increased 6 biochemical markers which can increaseCVD mortality risk.
  • Role of HFCS in metabolic syndrome and lipogenesis - Metabolic syndrome is made up of a group of conditions including elevated blood pressure, high blood sugar, excess abdominal fat, and high cholesterol or triglyceride levels. These conditions increase the risk for heart disease, stroke, and diabetes. The intake of fructose has been linked to increased levels of triglyceride synthesis and lipogenesis in the liver and may contribute to visceral adiposity causing metabolic alterations to occur, leading toinsulin resistance. Insulin resistance is when cells no longer properly respond to insulin making it difficult for glucose to get inside the cells. The pancreas continues to try to produce insulin because blood glucose levels are elevated and can eventually lead to type 2 diabetes due to the body's inability to regulate blood glucose levels.

In a study by Stanhope et al., comparing sugar-sweetened beverages that contained glucose or fructose, showed that weight gain was similar amongst both groups, however, there was significant increases visceral adiposity (fat stored in the abdomen) in the fructose group. The evidence shows that visceral adiposity is one of the causation factors of metabolic syndrome. Furthermore, a study by Hu & Malik containing 6,000 adult subjects showed a 39% increased risk for metabolic syndrome when subjects consumed one or more soft drinks per day over a four-year period.


Suggestions to Cut Out High Fructose Corn Syrup (HFCS) and Added Sugar


Looking at all the facts, the reality about HFCS is it carries all the risks of sucrose plus potentially other risks previously mentioned that most parents would want to avoid in feeding their children. HFCS, whether it is or isn't thought of as the worst ingredient in many foods and beverages, it is still considered added sugar.The American Academy of Nutrition and Dietetics recommends no more than 10% of your daily caloric intake should come from added sugar. This equates to approximately 12 teaspoons or 48g of sugar per day. A typical breakfast for a child may include Cap N' Crunch cereal. If a child consumed ¾ of a cup, it would contain 12 grams of sugar, which is equal to 3 teaspoons of sugar in just the cereal alone. Depending on the appetite or size of the child, this could be double or triple that amount in just one meal.Being vigilant in watching how much HFCS or added sugar your child is consuming is one of the main ways you can be assured your child is not getting excessive amounts of added sugar and forming habits that will increase their risk for chronic diseases and/or obesity. Here are a few tips for parents to decrease or cut HFCS or added sugar from your child's diet:


  • Reading your food labels. HFCS and added sugar are in many of the foods we purchase at the grocery store including:
    • Beverages
    • Cereals
    • Candy
    • Chocolate
    • Yogurt
    • Baked goods
    • BBQ sauce
    • Ketchup
    • Salad dressing
    • Condiments
    • Granola
    • Instant oatmeal
    • Frozen foods
    • Protein/cereal/granola bars
    • Pasta sauce
    • Dried/canned fruit
    • Juice
    • Baby food
  • Cooking at home. This allows you to control the ingredients that are being used and decrease the amount of sugar that goes into a recipe.
  • Sweeten items with natural sources of sugar by using fruit. An example would be using unsweetened oatmeal and adding fruit to give it that sweetened flavor or adding fruit in water to improve flavor.
  • Lead by example. Children learn their eating habits from the way their parents eat. How you eat, is most likely how your child will eat.


Conclusion


Added sugars, whether sucrose or HFCS, when eaten in excess is a future ticking time bomb for our children's health. There is still not enough evidence to conclusively state that HFCS is any worse than sucrose, however, some of the research shows that HFCS could pose serious health risks when consumed in excess. I'm not trying to vilify HFCS, but rather give parents a better understanding of the risks that accompany the excessive consumption of items that may include this ingredient.


What we do know is that excess intake of any type of sugarregardless of the typehas been linked to many chronic diseases and obesity. Parents want what is best for their children, and setting them up with healthy eating habits is an important aspect of how they will eat for the rest of their lives. Limiting the amount of excess sugar should be something everyone should be aware of by focusing on limiting the amount we consume. So much of the food we purchase from the grocery store is processed with unwholesome ingredients and full of hidden sugar. I encourage you to look at food labels and pay close attention to what your child is eating because after all, their health is depending on it!

References

Top 10 Concerns Parents Have for Their Own Kids (and Others). Psychology Today. https://www.psychologytoday.com/us/blog/the-athletes-way/201708/top-10-concerns-parents-have-their-own-kids-and-others. Accessed April 16, 2018.

[1]Nutrition. Centers for Disease Control and Prevention. https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html. Published April 7, 2017. Accessed March 13, 2018.

[1]Jennifer M Poti, Michelle A Mendez, Shu Wen Ng, Barry M Popkin; Is the degree of food processing and convenience linked with the nutritional quality of foods purchased by US households?, The American Journal of Clinical Nutrition, Volume 101, Issue 6, 1 June 2015, Pages 1251-1262, https://doi.org/10.3945/ajcn.114.100925

[1]Gropper S, Smith J. Advanced Nutrition and Human Metabolism. Cengage Learning, Inc; 2013.

[1]Food Additives & Ingredients - High Fructose Corn Syrup Questions and Answers. U S Food and Drug Administration Home Page. https://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAdditivesIngredients/ucm324856.htm. Accessed March 13, 2018.

[1]Fast Facts about High-Fructose Corn Syrup. FoodInsight.org. http://www.foodinsight.org/Fast_Facts_about_High_Fructose_Corn_Syrup. Accessed March 15, 2018.

[1]Ter Horst KW, Serlie MJ. Fructose Consumption, Lipogenesis, and Non-Alcoholic Fatty Liver Disease. Nutrients. 2017;9(9):981. doi:10.3390/nu9090981.

[1]Adipose tissue de novo lipogenesis. http://www.asbmb.org/asbmbtoday/asbmbtoday_article.aspx?id=15872. Accessed March 17, 2018.

[1]Gunnars K. Is Fruit Good or Bad For Your Health? The Sweet Truth. Healthline. https://www.healthline.com/nutrition/is-fruit-good-or-bad-for-your-health. Accessed April 24, 2018.

[1]Fitch C, Keim KS. Position of the Academy of Nutrition and Dietetics: Use of Nutritive and Nonnutritive Sweeteners. Journal of the Academy of Nutrition and Dietetics. 2012;112(5):739-758. doi:10.1016/j.jand.2012.03.009.

[1]About High Fructose Corn Syrup. Go to Corn Refiners Association. https://corn.org/products/sweeteners/high-fructose-corn-syrup/. Accessed March 16, 2018.

[1]White JS. Straight talk about high-fructose corn syrup: what it is and what it ain't. The American Journal of Clinical Nutrition. 2008;88(6). doi:10.3945/ajcn.2008.25825b.

[1]Walker RW, Dumke KA, Goran MI. Fructose content in popular beverages made with and without high-fructose corn syrup. Nutrition. 2014;30(7-8):928-935. doi:10.1016/j.nut.2014.04.003.

[1]Mock K, Lateef S, Benedito VA, Tou JC. High-fructose corn syrup-55 consumption alters hepatic lipid metabolism and promotes triglyceride accumulation. The Journal of Nutritional Biochemistry. 2017;39:32-39. doi:10.1016/j.jnutbio.2016.09.010.

[1]Stanhope KL, Medici V, Bremer AA, et al. A dose-response study of consuming high-fructose corn syrup-sweetened beverages on lipid/lipoprotein risk factors for cardiovascular disease in young adults. The American Journal of Clinical Nutrition. 2015;101(6):1144-1154. doi:10.3945/ajcn.114.100461.

[1]Prediabetes & Insulin Resistance. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/prediabetes-insulin-resistance. Published August 1, 2009. Accessed April 16, 2018.

[1]Stanhope KL, Schwarz JM, Keim NL, et al. Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans. The Journal of Clinical Investigation. 2009;119(5):1322-1334. doi:10.1172/JCI37385.

[1]Wajchenberg BL. Subcutaneous and Visceral Adipose Tissue: Their Relation to the Metabolic Syndrome. Endocrine Reviews. 2000;21(6):697-738. doi:10.1210/er.21.6.697.

[1]Hu FB, Malik VS. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: Epidemiologic evidence. Physiology & behavior. 2010;100(1):47-54. doi:10.1016/j.physbeh.2010.01.036.

[1]Looking to Reduce Your Family's Intake of Added Sugars? Here's How. Eat Right. Academy of Nutrition and Dietetics. https://www.eatright.org/food/nutrition/dietary-guidelines-and-myplate/looking-to-reduce-your-familys-added-sugar-intake-heres-how. Published December 6, 2016. Accessed March 15, 2018.

[1]Quaker Oats Company. Cap'n Crunch - Reclaim Your Crunch Time! Cap'n Crunch! http://www.capncrunch.com/. Accessed April 24, 2018.

Stevia
Sugar Sub

Stevia

By Katie Shumate

Dietetic Intern at Stephen F. Austin State University

Have you heard of stevia? It's an increasingly common zero calorie sweetener that's gained popularity in recent years being praised as the "healthy" and "all-natural" sweetener. Other sweeteners have been linked to increased genotoxicity, cancer (Yilmaz & Ucar, 2014) insulin resistance, metabolic disease as well issues with gut bacteria and other negative side effects (Suez et al., 2014). You've probably seen stevia on the shelves with the yellow, blue and pink sweeteners, but is it really better than the other sweeteners?

I'd like to go over what stevia is, some of its history, how it is extracted and what research has shown about it so we can draw some conclusions about using it.

What is Stevia?


Stevia is a non-caloric sweeter that is typically sold in either a powder or liquid form that is 200-300 times sweeter than table sugar (Engber, 2014). It has become very popular with the food industry who are trying to find ways to please health conscious customers.

Stevia is made from the leaves of the SterviarebaudianBertoni which is a native shrub in South America, most commonly found in Brazil and Paraguay (Examine.com, n.d.).

Stevia_1

There are several chemical compounds that give the plant its sweetness, but the two most abundant and commonly used are stevioside and rebaudioside-A (Stevia.com, n.d). Both of these compounds are steviolglycosides- a fancy chemical word for a sugar group attached to another chemical functional group. Humans are unable to metabolize the chemical structures of stevioside and rebaudioside-A, giving it the intended sweetness everyone is looking for without the calories. Once stevia reaches the colon, gut bacteria convert steviol glycosides into steivol, which is metabolized by the liver then excreted in the urine (Nichols, 2016). I'll talk more about these two compounds later.

Stevioside Rebaudioside-A
Stevioside Rebaudioside

Brief History of Stevia

Historically it was used by the Guarani Indians in Brazil. They called it "kaa he he" which means sweet herb. They used it in medicines, in tea, or just to chew on.

In 1887, it was "re-discovered" by Dr. Moises Santiago Bertoni, an Italian college professor. He "found" the stevia plant and made it more well-known to the developed world.

Stevia was presented to the USDA by George S. Brady in 1921 as a new sweetener, but met a lot of resistance in starting up widespread use and manufacturing from the sugar cane companies (Gates, 2000)

In 1931, French scientists isolated the compound stevioside and attributed it to what made stevia taste sweet.

In the 1960s and 1970s, Japan did extensive research on stevia. There was a huge push during this time to eliminate unnatural chemicals in foods, and as a result many things like other artificial sweeteners were banned. A lot of money and research that has continued today was poured into finding a more natural product. By 1988, stevia represented 41% of Japan's non-sugar sweetener market.

In the mid-1980s, stevia became popular in manufacturing and processed goods (Gates, 2000).

Stevia was banned briefly in the United States in 1991 because some animal and cell studies found that it potentially damaged cells and caused cancer. Later studies could not replicate these outcomes and the concentration used in the earlier studies could never be consumed by a human, making the early studies not completely applicable to human health. (Goyal, Samsher, & Goyal, 2010). Other early studies indicated that it may negatively impact the endocrine system and alter hormones, especially in males. Again, later studies could not replicate this outcome and again mentioned the very high concentration of stevioside was not representative of the intake normally consumed in the average human diet (Goyal, Samsher, Goyal, 2010; Oliveira-Filho, Uehara, Minetti, & Valle, 1989).

After much disagreement in the research through the 1990s and early 2000s, finally the compound rebaudioside A gained GRAS or Generally Recognized as Safe status from the Food and Drug Administration (FDA) in 2008 (Stevia.com, 2016). GRAS status is a designation which means that this compound is considered safe by "qualified experts, as having been adequately shown to be safe under the conditions of its intended use" (U.S. Food and Drug Administration, 2017).

In 2008-2009 larger companies like Pepsi, Cargill, and Coca-Cola made their own stevia products (Stevia.com, 2016).

Today there are a ton of stevia products on the shelves!

Stevia Store

Forms of Stevia

I told you I would come back to this! So as I said above, rebaudioside-A is the chemical compound approved by the FDA (Examine.com, n.d.). This means it can be sold as a food item (sweetener powder and liquid drops in the regular sweetener isle) and as an additive in things like drinks, candies, and other processed food items. It has a less bitter aftertaste, but has not been studied as extensively as stevioside.

The other structure found in stevia, stevioside, does not yet have approval by the FDA. You can, however, find stevioside at the grocery store! Instead of being in the sweetener isle, stevioside is found in the supplement isle and sold as a medicinal product/sweetener (Examine.com, n.d.). It can be used like a sweetener for your coffee and tea, but it can also be taken like a supplement. Companies are able to do this because supplements are not considered food or drugs and therefore are not evaluated or regulated by the FDA. This can cause some concern over purity and safety. If you would like to use stevioside as a sweetener, I would recommend going with higher quality brands that list stevioside as the only ingredient, often found in drops. It is a little more bitter than rebaudioside, but several studies have found that stevioside has positive health effects.

There is also of course green leaf stevia or whole leaf stevia which is basically whole stevia leaves that have been dried and ground into a powder. It is more bitter than both of the above compounds, but is still 30-40 times sweeter than sugar (Gelski, 2010). I would consider this to be the most natural form of stevia, if that is your concern.

How is Stevia Extracted?

The extraction process performed by different companies may differ slightly, but they all generally have a multi-step chemical extraction and purification. The liquid and powder form of stevia (rebaudioside-A in the sweetener isle) is made by first drying and grinding up plant leaf cuttings. The leaves are then steeped in hot water (Stevia.com, 2016). The solution then goes through several stages of filtering, centrifuging, and extracting using solvents like acetone, methanol, ethanol, isoproponal and other chemical products (Pasquel, Meireles, Marques, &Ptenate, 2000). Many of these solvents are carcinogenic, and concerns about these harmful solvents remain as it is next to impossible to get rid of all residues (Truth in Advertising, 2014). Food grade stevia has to be at least 95% steviol glycosides to be sold (Stevia.com, 2016). The rebaudioside-A is bottled if it is to become the liquid form,or dried and cut with bulking agents like inulin, maltodextrin, dextrose, or erythritol if made into the powder form. There are also concerns about the bulking agents used. For example, erythritol is a yeast-produced no-calorie sugar alcohol, that may be fed sugars from GMO corn (Engber, 2014).Though stevia originates from a plant, the extraction process may not be as "natural" as we thought.

Current Research

Did you know that stevia isn't just for making your favorite food taste sweeter? There are actual research studies that have found that stevia may be helpful to treat certain health conditions. An animal study done on rats may show that stevia is helpful in the treatment of diabetes. Scientists took a group of rats and gave them diabetes then treated them with stevia extract in their water. They found that though stevia extract did not increase the number of insulin-making beta cells in the pancreas, it helped the rats better use the insulin available by lowering inflammatory chemicals produced by fat cells.

This study showed that steviols have the potential to be a drug treatment for humans in the future, though more research is needed (Akbarzadeh et al., 2014). A study done on humans found that supplementing with stevia in those with type 2 diabetes reduced postprandial blood glucose and glucagon response after a test meal of stevia vs placebo, though other studies have found that stevia supplementation has no significant effects on diabetes. Another study found that stevia may also help lower glucose and insulin levels in those that are not diagnosed with diabetes (Fitch, Keim, Academy of, & Dietetics, 2012).

Other studies showed that stevioside has a positive effect on health by helping to lower blood pressure. In one study, 168 men and women with mild hypertension took 500 mg of stevioside powder or a placebo 3 time a day. After 2 years, the stevioside group had significantly lowered their mean systolic and diastolic blood pressure to a normal range (Hsieh, 2003). Other studies found that stevia had no effect, though all were done for shorter periods of time.

Other studies have shown that stevia extracts alone as well as when they are incorporated into foods act as good antioxidants (Hajihashemi & Ehsanpour, 2014; Ruiz-Ruiz, Moguel-Ordonez, Matus-Basto, & Segura-Campos, 2015)

Many of these studies used stevioside alone or mixtures of stevioside and rebaudioside-A, in much higher doses than you would put in your coffee or tea. No adverse events or issues with safety were reported during these studies. Though more research about long-term use of rebaudioside-A by itself in amounts found in foods, beverages, and added sweeteners should be done, it seem that there is little risk associated with using stevia, especially if you opted to get the stevioside drops found in the supplement isle.

Future Research

There are other glycosides in stevia leaves that have the potential to be just as sweet and useful to the food industry. Companies are now researching rebaudioside-D and rebaudioside-X as possible additives in the future (Gelski, 2010).

Food companies are also researching how to genetically modify yeast to produce the desired glycoside. This would allow companies to produce stevia without the cost of maintaining plants, harvest, cutting, dissolving and heavy processing (Gelski, 2010). The concerns of GMOs will definitely still be present, however.

More research will also be done in the area of long-term use safety and how it affects gut microbiota since this is such a large concern with other artificial sweeteners.

Conclusion

While there are concerns about the chemical residues from the extraction process and added ingredients, it seems that stevia has not been shown to be dangerous, and may even have some health benefits. If you are interested in purchasing stevia for use as a sweetener, I would look for companies that are transparent about processing techniques and for products with the least amount of added ingredients.

References

Akbarzadeh, S., Eskandari, F., Tangestani, H., Bagherinejad, S. T., Bargahi, A., Bazzi, P., . . . Rahbar, A. R.

(2014). The Effect of Stevia Rebaudiana on Serum Omentin and Visfatin Level in STZ-Induced

Diabetic Rats. Journal of Dietary Supplements, 12(1), 11-22. doi:10.3109/19390211.2014.901999

Engber, D. (2014). The quest for a natural sugar substitute. The New York Times. Retrieved from:

https://www.nytimes.com/2014/01/05/magazine/the-quest-for-a-natural-sugar-

substitute.html?_r=0G\

Examine.com. Stevia. Retrieved from: https://examine.com/supplements/stevia/

Fitch, C., Keim, K. S., Academy of, N., & Dietetics. (2012). Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. J Acad Nutr Diet, 112(5), 739-758. doi:10.1016/j.jand.2012.03.009

Gates, D. (2000) History of Use. Stevia.net. Retrieved from: http://www.stevia.net/history.htm

Gelski, J. (2010). Stevia needs a baking partner. Food Business News. Retrieved from:

http://www.foodbusinessnews.net/News/News-Home/Features/2010/7/Stevia-needs-a-

partner-in-baking.aspx?cck=1
Goyal S, Samsher, Goyal R. (2010)
. Stevia (Stevia rebaudian) a bio-sweetener: a review. International

Journal Of Food Sciences And Nutrition. 61(1), 1-10.

Hajihashemi, S., & Ehsanpour, A. A. (2014). Antioxidant response of Stevia rebaudiana B. to polyethylene glycol and paclobutrazol treatments under in vitro culture. Appl Biochem Biotechnol, 172(8), 4038-4052. doi:10.1007/s12010-014-0791-8

Hsieh, M., et. al. (2003). Efficacy and tolerability of oral stevioside in patients with mild essential hypertension: A two-year, randomized, placebo-controlled study. Clinical Therapeutics, 25(11), 2797-2808

Nichols, H. Stevia: Health Benefits, Facts, Safety. Medical News Today. Retrieved from:

http://www.medicalnewstoday.com/articles/287251.php

Oliveira-Filho, R., Uehara, O., Minetti, C., & Valle, L. (1989). Chronic administration of aqueous extract of

Stevia rebaudiana (Bert.) Bertoni in rats: Endocrine effects. General pharmacology, 20(2), 187-191.

Pasquel, A., Meireles, M.A.A., Marques, M.O.M., &Petenate, A.J.. (2000). Extraction of stevia glycosides

with CO2 + water, CO2 + ethanol, and CO2 + water + ethanol. Brazilian Journal of Chemical

Engineering, 17(3), 271-282. https://dx.doi.org/10.1590/S0104-66322000000300003

Ruiz-Ruiz, J. C., Moguel-Ordonez, Y. B., Matus-Basto, A. J., & Segura-Campos, M. R. (2015). Nutritional, amylolytic enzymes inhibition and antioxidant properties of bread incorporated with Stevia rebaudiana. Int J Food Sci Nutr, 66(6), 649-656. doi:10.3109/09637486.2015.107778

Suez, J., Korem, T., Zeevi, D., Zilberman-Schapira, G., Thaiss, C. A., Maza, O., . . . Elinav, E. (2014). Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Nature, 514(7521), 181-186. doi:10.1038/nature13793

Stevia.com. (2016). How is stevia leaf extract made? Retrieved from:

https://www.stevia.com/2016/10/03/how-is-stevia-leaf-extract-made/

Truth in Advertising. (2014). What extra ingredients are in your natural stevia product? Retrieved from:https://www.truthinadvertising.org/extra-ingredients-natural-stevia-product/

U.S. Food & Drug Administration. (2017). Generally recognized as safe (GRAS). Retrieved from:

https://www.fda.gov/food/ingredientspackaginglabeling/gras/

Yilmaz, S., & Ucar, A. (2014). A review of the genotoxic and carcinogenic effects of aspartame: does it safe or not? Cytotechnology, 66(6), 875-881. doi:10.1007/s10616-013-9681-0

Traditional Foods

The Nutritional Benefits of Sourdough Bread
Sourdough Bread

The Nutritional Benefits of Sourdough Bread

By Author Name

Dietetic Intern at Stephen F. Austin State University

Sourdough breads have recently been popping up at most major grocery stores. However, sourdough breads have been around for centuries! You may be thinking- what's the difference between sourdough bread and regular bread, aren't they both made from flour? This post is here to explain the many unique nutritional benefits from sourdough bread.

What is Sourdough Bread?

Before we get into the nutritional benefits of sourdough, let's first get a clear understanding of what exactly is sourdough bread. Sourdough breads were one of the first forms of leavened breads. The lactic acid bacteria and the wild yeasts that are present in sourdough leaven the bread, which make it fluffy and light. Today, most breadis leavened with baker's yeast due to its simplicity and convenience.Sourdough can be made with refined white flour, whole-wheat flour, or a variety of different grains including barley, quinoa, and oat. It is common in the Mediterranean and Middle East, and especially popular in San Francisco. Each sourdough is unique due to the bacteria and fungi that are present in the region it is prepared. Authentic sourdough breads can be found at local farmers markets and specialty shops. It has a mildly sour flavor, hence the name, sourdough(Poutanen, Flander, & Katina, 2009).

Fermentation

Traditional sourdough breads are made with lactic acid bacteria and naturally occurring yeasts. These ingredients are then fermented; a long, slow ferment is recommended for the most health benefits. This process does produce probiotics, however, these probiotics are destroyed during the baking process. But the good news is that recent studies show that killed probiotics may have positive effects on health! Even though sourdough doesn't contain probiotics, it does contain exopolysaccharides, which acts as a prebiotic to feed the good intestinal bacteria(Poutanen, Flander, & Katina, 2009). The breads that have a longer ferment have no need for additional leavening agents, including baking soda or brewers yeast. These breads can be made with only 4 simple ingredients: flour, water, salt, and a sourdough starter. If you are making sourdough at home, a sourdough starter can be made or purchased (Marco et al., 2017).

Improved Digestibility

The long, slow fermentation process helps break down carbohydrates. It decreases the fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FOD-MAPS) that are found in breads. The reduced FOD-MAP content in sourdough bread improves the digestibility of the bread. This means that patients with IBS may be able to tolerate sourdough breads! Food trials are necessary to determine if a patient with IBS can tolerate sourdough(Poutanen, Flander, & Katina, 2009).

Sourdough breads have also been shown to have a reduced gluten content. The decreased pH during fermentation causes gluten degradation. The reduced gluten content of sourdough may improve digestion too! It is important to note that individuals with celiac disease, non-celiac wheat sensitivity, and other forms of gluten intolerance still cannot properly digest the glutenfound in sourdough breads(Poutanen, Flander, & Katina, 2009). However, sourdough breads can be made from gluten-free flours! The sourdough fermentation of gluten-free products improves the taste, texture, and can even delay the onset of staling. So you can still receive the health benefits of sourdough even on a gluten-free diet (Rizzello, Lorusso, Montemurro, &Gobbetti, 2016).

Phytic Acid

Phytic acid (PA)is a chemical compound that act as anti-nutrients in the body because it inhibits the absorption of certain minerals including calcium, magnesium, zinc, and iron (Lopez et al., 2003).The PA binds to these minerals forming phytates, which cannot be absorbed by the body. These phytates pass through the intestinal track unabsorbed and these important minerals are excreted. PA is found in high amounts in many whole-grain products including traditional breads. Even when sourdough bread is made from the same flour as conventional bread, it has a lower PA content. This is due to the lactic acid bacteria lowering the pH of the bread, which causes phytate hydrolysis that reduces the PA content of the bread (Leenhardt, Levrat-Verny, Chanliaud, &Rémésy, 2005).This means that the minerals found in sourdough bread can be absorbed and utilized in the body!

Glycemic Index

The glycemic index is a measure of the rise in blood glucose after a food is consumed. Foods that are high in carbohydrates and low infiber typically have a high glycemic index. Traditional white bread has a glycemic index of 70. Studies show that sourdough breads made from both white flour and whole-wheat flour have a lower glycemic index than the traditional counterparts. Individuals with type 1 and type 2 diabetes mellitus, should be aware of food with a high glycemic index because it can cause a rapid rise in blood glucose(De Angelis et al., 2007). In a recent study of healthy participants, sourdough's effects on postprandial glycemic and insulin responses were evaluated. This study compared sourdough bread leavened with lactobacilli and a normal bread leavened with baker's yeast. This study found that the participants who received the sourdough bread had lower plasma glucose and lower plasma insulin responses (Maioli et al., 2008). This means that patients with impaired glucose metabolism, like diabetes, may benefit from consuming sourdough bread!

Overall, sourdough breads can be a great addition to a healthy and balanced diet. Sourdough breads unique fermentation helps improve mineral bioavailability and digestibly, while lowering the phytic acid content and the glycemic index. So whether you enjoy sourdough breads for their health benefits or for it's delicious flavor, choosing to go sour can actually be a pretty sweet deal!

References

Bartkiene, E., Juodeikiene, G., Vidmantiene, D., Viskelis, P., &Urbonaviciene, D. (2011). Nutritional and quality aspects of wheat sourdough bread using L. luteus and L. angustifolius flours fermented by Pedioccocusacidilactici.International Journal of Food Science and Technology, 46(8), 1724-1733.

Bryszewska, M. A., Ambroziak, W., Diowksz, A., Baxter, M. J., Langford, N. J., & Lewis, D. J. (2005). Changes in the chemical form of selenium observed during the manufacture of a selenium-enriched sourdough bread for use in a human nutrition study. Food Additives and Contaminants, 22(2), 135-140.

De Angelis, M., Rizzello, C. G., Alfonsi, G., Arnault, P., Cappelle, S., Di Cagno, R., &Gobbetti, M. (2007).Use of sourdough lactobacilli and oat fibre to decrease the glycaemic index of white wheat bread.British Journal of Nutrition, 98(06), 1196-1205.

Leenhardt, F., Levrat-Verny, M. A., Chanliaud, E., &Rémésy, C. (2005). Moderate decrease of pH by sourdough fermentation is sufficient to reduce phytate content of whole wheat flour through endogenous phytase activity. Journal of Agricultural and Food Chemistry, 53(1), 98-102.

Lopez, H. W., Duclos, V., Coudray, C., Krespine, V., Feillet-Coudray, C., Messager, A., &Rémésy, C. (2003). Making bread with sourdough improves mineral bioavailability from reconstituted whole wheat flour in rats. Nutrition, 19(6), 524-530.

Maioli, M., Pes, G. M., Sanna, M., Cherchi, S., Dettori, M., Manca, E., & Farris, G. A. (2008). Sourdough-leavened bread improves postprandial glucose and insulin plasma levels in subjects with impaired glucose tolerance. ActaDiabetologica, 45(2), 91-96.

Marco, M. L., Heeney, D., Binda, S., Cifelli, C. J., Cotter, P. D., Foligné, B., &Smid, E. J. (2017). Health benefits of fermented foods: Microbiota and beyond. Current Opinion in Biotechnology, 44(1), 94-102.

Poutanen, K., Flander, L., & Katina, K. (2009). Sourdough and cereal fermentation in a nutritional perspective.Food Microbiology, 26(7), 693-699.

Rizzello, C. G., Lorusso, A., Montemurro, M., &Gobbetti, M. (2016). Use of sourdough made with quinoa (Chenopodium quinoa) flour and autochthonous selected lactic acid bacteria for enhancing the nutritional, textural and sensory features of white bread. Food Microbiology, 56(1), 1-13.

Scazzina, F., Del Rio, D., Pellegrini, N., &Brighenti, F. (2009). Sourdough bread: Starch digestibility and postprandial glycemic response. Journal of Cereal Science, 49(3), 419-421.

Tucker, A. J., MacKay, K. A., Robinson, L. E., Graham, T. E., Bakovic, M., & Duncan, A. M. (2010). The effect of whole grain wheat sourdough bread consumption on serum lipids in healthy normoglycemic/normoinsulinemic and hyperglycemic/hyperinsulinemic adults depends on presence of the APOE E3/E3 genotype: A randomized controlled trial. Nutrition and Metabolism, 7(1), 37-50.

Weight Regulation

A Non-Diet Approach to Weight Loss and Dieting Myths Debunked
Fruits FND Blog A Non-Diet Approach to Weight Loss and Dieting Myths Debunked
By Nathan Slinkard
Dietetic Intern at Stephen F. Austin State University


The ever elusive goal of sustained weight loss has been chased by so many Americans with varying degrees of success and failure (at least 80% fail). Weight loss frenzy has caused food producers, doctors, and "health" companies to create pills and concoctions and plans to help us tighten our belts. But why are so many Americans still obese? Why do dieters fail so often? Hasn't someone figured out the perfect weight loss diet by now? Although the weight loss industry in America has suffered some losses in recent years due to distain for diet products and weight-loss programs, it still amassed $64 billion in revenue in 2014. In fact, other weight loss avenues such as bariatric surgery and health club memberships have risen in popularity. In this blog, we'll take a look at some of the reasons why weight loss can be so challenging and some strategies that actually work for the majority of people. But here's a spoiler alert: everyone is different and there is not one approach that fits all.


The myth that cutting 3500 calories a week results in one pound of fat loss:


A widespread generalization still popular today, is that one pound of body fat is equivalent to 3500 calories. The reason why this is an inaccurate assumption, is that everyone is different and, thermodynamically speaking,the body digests and stores food at a rate unique to the individual. Furthermore, the trillions of bacteria in our guts caneven impact how many calories we absorb. A review of seven closely-controlled clinical weight loss studiestested the accuracy of the 3500 calorie rule. The participants, who were monitored at all times, restricted calories over an average of 64.8 days with an average deficit of 1,409 calories. If 3500 calories means one pound of weight loss, the participants should have lost an average of 27.6 pounds. However, they lost an average of 20.1 pounds plus or minus a huge range of 12.6 pounds. This brings up an important point which we'll discuss next: why do dieters hit plateaus during their weight loss journeys?


Cutting calories and adaptive thermogenesis


This point is one that frustrates many to no end and leads to feelings of hopelessness. I'm referring to the "wall" that calorie cutters often hit after just one or two weeks of quick weight loss. This can be attributed to how our body's metabolism slows in response to weight loss. Research has shown that energy expenditure slows by 20-25% after a 10% reduction in body weight, mostly due to a change in non-resting energy expenditure. That's an extra 10-15% less calories that we expend beyond what might have been predicted by recalculating energy expenditure. This is due to a complex, coordinated reaction by our bodies that involves many neuroendocrine and metabolic pathways.


Thrifty Genes and the Set Point Theory


The Thrifty Gene Hypothesis claims that this modern weight loss conundrum can be explained by "thrifty genes" that efficiently store food as fat in times of reduced calorie consumption. Our ancestors lacked the luxury of grocery stores and fast food restaurants and had frequent food shortages. The idea then is that our bodies have evolved to efficiently store food as body fat in times of famine. A society in which we no longer forage or hunt for food has fueled an overabundance of this storage! Another well-known ideology, the Set Point Theory, says that each individual has a fairly narrow range of weight that their body is comfortable with. Any change in weight, whether gained or lost, will result in the body fighting against this with shifts in metabolism. Perhaps those that tend to carry a little extra weight were never really meant to lose it. So, how is it possible to lose weight and keep it off when our bodies seem to be fighting against us? The resounding answer is that sustained weight loss must involve lifestyle changes.


Why lifestyle changes are more important than a diet


A large study conducted in Australia sought to determine how effective or detrimental habitual dieting is for weight loss. They adjusted the data for initial BMI (Body Mass Index) and tracked what happened over the following 12 months. Amazingly, the risk of developing obesity was 1.9, 2.9 or 3.2 times higher for those that dieted once, more than once, and always, respectively, versus non-dieters. Non-dieters had much better odds of maintaining their BMI or reducing it compared to dieters. Whoa! The researchers copied what many health professionals preach by saying that "losing weight requires a commitment to change one's lifestyleand a sustained effort to maintain a healthy diet and engage in physical activity". That's right, folks! It is nearly impossible to keep weight off without making some lasting changes. This is not to say that every diet approach is ineffective, and it is important to determine which pattern of eating is most effective for you.


No diet works for everyone


If habitual dieting has a poor track record, what has been effective? One of the hottest trends is the ketogenic diet which keeps your fats very high (around 80% of your calories), your protein pretty moderate (~10-20%), and your carbs extremely low (~20-50 grams per day).And it has shown to be very effective for some. However, low-fat vegan and vegetarian diets, at the opposite end of the scale, have also shown to promote great weight loss results. So, wait. Which diet, as you're asking right now, is better?Even more important questions to ask, though, are "why did these diets fail some participants?" and "would you fall into this group?" The answer to the first question, as you probably guessed, is that everyone is different. There is exciting new research of how personalizing diet based onan individual's genetics, also known as nutrigenomics,can help reduce the risk of developing conditions like obesity. However, personalized nutrition based on genetics has certainly experienced some growing pains. The second question, then, is harder to answer and may very well take some trial-and-error. By no means, though, should you have to do this all on your own. Nutrition counselling is ideal, especially when navigating the field of nutrigenomics, and is helpful for weight loss in both group and individual formats.


Lifestyle changes to implement and a brief conclusion


The most effective weight loss strategies center around improving sleep, reducing stress, getting off the couch and moving around more, and eatinga diet low in processed foods and loaded with vegetables. Often the reason why studies show great results for vastly different diets,(such as the Mediterranean or the vegan or the ketogenic) is that participants go from eating a standard American junk food diet to making conscious decisions about what they put into their bodies.If you go from eating McDonald's to tofu or salmon or a grass-fed avocado burger, then you have a pretty decent chance of losing belly fat! These diets often have overlapping core principles like choosing whole foods, real foods, and foodproducts with fewer ingredients. These, along with the following tips, are time-honored approaches to better health. Increase your physical activity to boost your metabolism and practice mindful eating to help avoid overeating. Drink plenty of water for itshealth benefits like helping to prevent headaches and constipation, but also for its potential impact on weight loss itself and because thirst may be misinterpreted by the body as hunger. Keep track of how your diet is impacting your lab values, and investigate underlyingproblemsif you fail to lose weightsuch as sleep apnea and hormonal imbalances. Rely on friends and family for support and seek nutritional counselling for guidance, especially with regards to optimizing diet based on genetic testing.


In conclusion, remember to not expect exactly one pound of weight loss for every 3500 calories that you cut. Know that the human body adapts to weight loss by adjusting metabolic rates, and that it may be an uphill battle because of our evolution and genetics. But take heart, because you know a secret that failing dieters are not accepting: smart,lifestyle changes trumphabitual on and off dieting for sustained weight loss results.


References


[1]Kell J. Lean times for the diet industry. Fortune. http://fortune.com/2015/05/22/lean-times-for-the-diet-industry/. Published May 22, 2015.

[1]Thomas DM, Martin CK, Lettieri S, et al. Can a weight loss of one pound a week be achieved with a 3500-kcal deficit? Commentary on a commonly accepted rule. International Journal of Obesity. 2013;37(12):1611-1613. doi:10.1038/ijo.2013.51.

[1]Rosenbaum M, Leibel RL. Adaptive thermogenesis in humans. International journal of obesity (2005). 2010;34(0 1):S47-S55. doi:10.1038/ijo.2010.184.

[1]Siahpush M, Tibbits M, Shaikh R, Singh G, Sikora Kessler A, Huang T. Dieting Increases the Likelihood of Subsequent Obesity and BMI Gain: Results from a Prospective Study of an Australian National Sample. International Journal Of Behavioral Medicine [serial online]. October 2015;22(5):662-671. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed April 14, 2018.

[1]Dashti HM, Mathew TC, Hussein T, et al. Long-term effects of a ketogenic diet in obese patients. Experimental & Clinical Cardiology. 2004;9(3):200-205.

[1]Huang R, Huang C, Hu F, Chavarro J. Vegetarian Diets and Weight Reduction: a Meta-Analysis of Randomized Controlled Trials. Journal Of General Internal Medicine [serial online]. January 2016;31(1):109-116. Available from: MEDLINE, Ipswich, MA. Accessed April 15, 2018.

[1]Luan J, Browne P, Wareham N, et al. Evidence for Gene-Nutrient Interaction at the PPAR lambda Locus. Diabetes [serial online]. March 2001;50(3):686. Available from: Academic Search Complete, Ipswich, MA. Accessed April 15, 2018.

[1]Moleres A, Ochoa M, Marti A, et al. Dietary fatty acid distribution modifies obesity risk linked to the rs9939609 polymorphism of the fat mass and obesity-associated gene in a Spanish case-control study of children. The British Journal Of Nutrition [serial online]. February 2012;107(4):533-538. Available from: MEDLINE, Ipswich, MA. Accessed April 15, 2018.

[1]Kourlaba G, Kondaki K, Grammatikaki E, et al. Interaction effects between total energy and macronutrient intakes and angiotensin-converting enzyme 1 (ACE) I/D polymorphism on adiposity-related phenotypes in toddlers and preschoolers: the Growth, Exercise and Nutrition Epidemiological Study in preSchoolers (GENESIS). British Journal Of Nutrition [serial online]. December 2008;100(6):1333-1340. Available from: Agricola, Ipswich, MA. Accessed April 15, 2018.

[1]Qi Q, Sacks F, Qi L, Bray G, Hu F. Weight-loss diets modify glucose-dependent insulinotropic polypeptide receptor rs2287019 genotype effects on changes in body weight, fasting glucose, and insulin resistance: the Preventing Overweight Using Novel Dietary Strategies trial. American Journal Of Clinical Nutrition [serial online]. February 2012;95(2):506-513. Available from: Agricola, Ipswich, MA. Accessed April 15, 2018.

[1]Phimarn W, Paktipat P, Pansiri K, Klabklang P, Duangjanchot P, Tongkul A. Effect of Weight Control Counselling in Overweight and Obese Young Adults. Indian Journal Of Pharmaceutical Sciences [serial online]. January 2017;79(1):35-41. Available from: Academic Search Complete, Ipswich, MA. Accessed April 14, 2018.

[1]Chang T, Ravi N, Plegue MA, Sonneville KR, Davis MM. Inadequate Hydration, BMI, and Obesity Among US Adults: NHANES 2009-2012. Ann Fam Med. 2016:320-324. doi:10.1370/afm.1951.Introduction.

[1]Marshall M. The big benefits of plain water. Harvard Health Blog. https://www.health.harvard.edu/blog/big-benefits-plain-water-201605269675. Published May 13, 2016. Accessed April 15, 2018.

Say Good-Bye to Eating Rules
Weight Regulation

Say Good-Bye to Eating Rules

By Tiffany Kroll

Dietetic Intern at Stephen F. Austin State University

Intuitive Eating is the non-diet approach to help individuals relearn how to eat in response to internal, rather than external cues (Bush et al, 2014). It is learning to listen to your body, rather than ignoring those inner cues - you know, that tell you when you are hungry and when you are full. It isn't restrictive eating, it is relying on your body to know when to eat, how much to eat, and when to stop. I'm sure you've heard your friends talk about diets that they've tried, or said something like, "oh my goodness, Spring Break is 4-weeks away, need to start my cleanse." When you turn on the television it seems like there's a new diet advertisement every day, or a new way to exercise, or some new "miracle pill" that'll melt the fat away. Well, intuitive eating is something that's not a diet, it's a way of life. It's time that we all say "no" to the diets, and start listening to what our bodies are trying to say.

There have been multiple studies showing that restrictive eating does not result in reduced weight in the long term but also, that the majority of individuals dieting to lose weight regain the weight they lost (Mann et al, 2007). Some researchers believe that dieting can actually lead to obesity, due to the mechanism of "yo-yo dieting". If that is the case, then why do so many people continue to do these restrictive diets? Maybe they just need to adopt intuitive eating! I am going to share with you the 10 principles that Tribole and Resch (2012) discussed in their book, Intuitive Eating: A Revolutionary Program That Works.

Reject the Diet Mentality

Rejecting the diet mentality helps people avoid feeling guilty about their meals, let go disordered eating, negative body views, stress, and overall negative relationships with food. The Eat for Life intervention study found that intuitive eating is associated with a positive body appreciation, and that people who live an intuitive eating lifestyle have a lower body mass index (BMI) and make more healthful choices (Bush et al, 2014). Also, studies have shown that post-dieting binges occur in ~50% of all people who end a diet (Tribole& Resch, 2012). You don't have time in college to have an additional stress factor, so ditch the diet mind.


Honor Your Hunger

Hunger is not the bad guy, it's a natural feeling to become hungry, but it's up to you to listen to your hunger cues. As Lauren Outland says, "weight homeostasis does not exist," and we can't fool mother nature (Outland, 2010). When we ignore our hunger cues and proceed to restricting, we may be damaging body chemicals, tissues, and organs. Going hungry causes an increase in ghrelin, an increase in brain hunger chemicals, possible leptin resistance, and metabolism to slow down. Then, once we have the opportunity to eat, we tend to consume more than we would in the first place because we are "starving" (it's an evil cycle). Next time you feel your tummy growling, allow yourself to have a snack, and try not to ignore your hunger cues.

Make Peace with Food

Do you have a favorite food? Sure you do. Now think about that food, do you allow yourself to eat it or do you restrict yourself on how often you eat it? If you tend to restrict yourself from that specific food then think again, and end that war. Stop thinking about what you can and can't have, and learn to fit it into your meals. There's no need to live the majority of your life missing out on the foods we enjoy most, just discover ways to balance your meals, eat some veggies, and maybe get a few extra steps with your friends and family that day.

Challenge the Food Police

See that picture that I first introduced this post with? Well this plays right into that. Our minds have so many things running through it including work, school, money, friend drama, family issues, you name it. Who wants to add another player into the mix? Not I. There is no more of labeling foods, "good" and "bad", because all foods are allowed in your diet. Get rid of that little voice in your head saying, "don't eat that or else this", "can't eat that it's not allowed", "oh that has too much sugar", and the commentary can continue all the way to the check-out line at the grocery store. Don't place all of these food rules in your brain, because I'm sure your brain has enough to think about as it is. Also, if you're concerned about your weight then let me ease your mind. Avalos and Tylka discovered that individuals who responded to their internal hunger and satiety cues on a regular basis tended to be at a weight that is appropriate for their body type, as well as having increased levels of psychological well-being (Avalos &Tylka, 2006). Stop giving yourself another thing to stress about, and enjoy life without the food police!

Respect Your Fullness

Your body is very intelligent, and it is capable of many things, and one thing is knowing when it is satisfied. Listen to the signals your body is sending when you are eating a meal, and understand when your body has had what it needs. Denny et al, looked at intuitive eating in young adults, and they found that women who listened to their body when they were full had lower odds of chronic dieting and binge eating (Denny et al, 2013). When take out all the external cues, and tune in to your internal cues you'd be surprised at what you'll discover while eating.

Discover the Satisfaction Factor

Eating should be a pleasant experience, and it should be a time that you are able to sit down and enjoy the meal that is in front of you. Sometimes we may not all be able to take an hour-long lunch, but for that brief time that you do have, be satisfied with the food on your plate. Augustus-Horvath and Tylka looked at the acceptance model of intuitive eating, and found that individuals who ate mindfully often chose foods that help their bodies function well in addition to being pleasing to their palate (Augustus-Horvath &Tylka, 2011). Eating mindfully doesn't have to be boring, and if you don't like celery then don't eat it. No one forces you to eat things you don't enjoy, and you shouldn't force yourself either. Next time you go to the grocery store have a plan to make a meal that is beneficial to your body along with being appealing to your taste buds. Make meal times a delightful experience, and make it colorful!

Honor Your Feelings Without Using Food

One way that people tend to cope with their feelings is by eating, or better known as "emotional eating". Yes, it's nice to "treat yourself" when you're feeling a bit down, but discover other ways to cope with your emotions other than using food as a reward. Be in-tune with your body, and realize when you are hungry versus bored or upset. Herbert et al found that those who reported practicing intuitive eating were less likely to overindulge in food in the absence of hunger (Herbert et al, 2013). When you find yourself wanting food to help you feel better, think of ways to combat your emotions by not using food as that coping mechanism.

Respect Your Body

We are each created to be special and unique, none of us will have the same body frame, none of us will have the same muscle tone, and none of our bodies will respond to food the same exact way. Learn to appreciate your body, and love the one you have because it's the only one you have. Schoenefeld and Webb discovered that young women who reported higher level of engagement in intuitive eating further reported both higher levels of body image acceptance and compassion as well as being moderate in size (Schoenefeld& Webb, 2013).Another study found similar results, that women with higher levels of intuitive eating are, "more satisfied with their bodies and perceive less pressure to be thin," (Tylka, 2006). Our society is so judgmental and cruel these days, doing way more harm than good, and we need to learn how to ignore what they say and listen to what our body says. Fuel your body with the proper nutrients, let the body do its job, and have self-compassion. Learn to love your body and be comfortable in your own skin.

Exercise - Feel the Difference

Physical activity should be FUN, not a constant misery that you feel is necessary to do 7-days out of the week in order to "maintain your figure". Gastet al, looked at undergraduate women and found that those who were internally motivated to engage in physical activity were also less likely to engage in restrictive eating, and more likely to practice self-care (Gast et al, 2013). This study also showed that increased scores on the Intuitive Eating Scale were correlated with decreases in BMI in both male and female subjects. If we eat intuitively, then our BMI will take care of itself and we won't have to constantly worry about getting those 2-hours of exercise in a day. Try to find ways to move your body that you enjoy, and learn different exercises that your body is capable of doing.

Honor Your Health - Compassion

What you put into your body should taste good, and you shouldn't feel limited to certain foods because in intuitive eating ALL foods are allowed. If you want to indulge, then allow yourself to have that item you desire, because one meal or snack isn't going to break your health. One study on the Health at Every Size program (HAES), found that once the participants listened to their hunger and satiety cues, they were able to regulate their food intake, feel better about themselves, and maintain this behavior change over the 104-week period (Bacon, 2005). They also found that the HAES group saw a decrease in LDL cholesterol and systolic blood pressure, along with sustaining these results at the 2-year follow-up whereas the diet group that was studied did not. Seeing this, it should give us joy that our body knows exactly what to do with the food we put inside of it and once we listen to it, then our overall health will improve as well. Our bodies are truly amazing.

Let's all say good-bye to eating rules, and adapt the intuitive way of eating. Listening to our hunger and satiety cues, enjoying physical activity, nurturing our body with compassion, fueling it with the nutrients it needs, and loving it for all the wonderful things it is capable of. The weight will adjust itself, just trust the process and trust your body.You are wonderfully made, and you are beautiful in your own skin.

References

Augustus-Horvath, C., &Tylka, T. (2011). The acceptance model of intuitive eating: a
comparison of women in emerging adulthood, early adulthood, and middle
adulthood. Journal of Counseling Psychology. Accessed from
http://u.osu.edu/tracyltylka/files/2015/02/Augustus-HorvathTylkaJCPArticle
2buggx0.pdf.

Avalos, L., &Tylka, T. (2006). Exploring a model of intuitive eating with college women.
Journal of Counseling Psychology. Accessed from
https://www.researchgate.net/profile/Tracy_Tylka/publication/232489009_Explor
ng_a_model_of_intuitive_eating_with_college_women/links/544954650cf2ea65
130c1c5.pdf.

Bacon, L., Stern, J., Loan, M., &Keim, N. (2005). Size acceptance and intuitive eating
improve health for obese, female chronic dieters. The American Dietetic
Association. Accessed from https://naldc.nal.usda.gov/download/8478/PDF.

Bush, H., Rossy, L., Mintz, L., &Schopp, L. (2014). Eat for life: a work site feasibility
study of novel mindfulness-based intuitive eating intervention. American Journal
of Health Promotion. Accessed from
https://www.researchgate.net/profile/Lynn_Rossy/publication/255910404_Eat_fo
_Life_A_Work_Site_Feasibility_Study_of_a_Novel_Mindfulness
Based_Intuitive_Eating_Intervention/links/577ebf8808ae01f736e1718d.pdf.

Denny, K., Loth, K., Eisenberg, M., &Neumark-Sztainer, D. (2013). Intuitive eating in
young adults: who is doing it, and how is it related to disorder eating behaviors?
Appetite. Accessed from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3511603/pdf/nihms421703.pdf.

Gast, J., Nielson, A., Hunt, A., &Leiker, J. (2013). Intuitive eating: associations with
physical activity motivation and BMI. American Journal of Health Promotion.
Accessed from
http://www.morganvanvliet.com/uploads/4/7/5/8/47583769/gast._intuitive_eating
aph.2014_-_annotated.pdf.

Herbert, B., Blechert, J., Hautzinger, M., Matthias, E., & Herbert, C. (2013). Intuitive
eating is associated with interoceptive sensitivity: effects on body mass index.
Appetite. Accessed from
http://www.morganvanvliet.com/uploads/4/7/5/8/47583769/b.intuitive_eating_int
roceptive.appetite.2013_-_annotated.pdf.

Hudnall, M. (2017). Mindful eating in nutrition counseling for eating behaviors: what
research suggests. Today's Dietitian.
Outland, L. (2010). Intuitive eating: a holistic approach to weight control. Holistic
Nurse Practice Journal. Accessed from
https://www.researchgate.net/profile/Lauren_Outland/publication/40731012_Intui
ive_Eating_A_Holistic_Approach_to_Weight_Control/links/576b304908ae5b9a6
b3a8e4.pdf.

Jennings, K. (2016). A quick guide to intuitive eating. Authority Nutrition. Accessed from
https://authoritynutrition.com/quick-guide-intuitive-eating/.

Mann, T., Tomiyama, A., Westling, E., Lew, A., Samuels, B., & Chatman, J. (2007).
Medicare's search for effective obesity treatments. American Psychologist.
Accessed from https://escholarship.org/uc/item/2811g3r3.

Outland, L. (2010). Intuitive eating: a holistic approach to weight control. Holistic
Nursing Practice. Accessed from
https://www.researchgate.net/profile/Lauren_Outland/publication/40731012_Intui
ive_Eating_A_Holistic_Approach_to_Weight_Control/links/576b304908ae5b9a6
b3a8e4.pdf.

Schoenefeld, S., & Webb, J. (2013). Self-compassion and intuitive eating in college
women: examining the contributions of distress tolerance and body image
acceptance and action. Eating Behaviors. Accessed from
https://www.researchgate.net/profile/Jennifer_Webb2/publication/258251341_Se
f
compassion_and_intuitive_eating_in_college_women_Examining_the_contributi
ns_of_distress_tolerance_and_body_image_acceptance_and_action/links/542a
5520cf29bbc126a7bdd.pdf.

Tribole, E., & Resch, E. (2012). Intuitive Eating: A Revolutionary Program That Works.
3rd ed. New York, NY: St. Martin's Griffin.

Tylka, T. (2006). Development of psychometric evaluation of a measure of intuitive
eating. Journal of Counseling Psychology. Accessed from
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.541.918&rep=rep1&ty
e=pdf.