Mercury is a naturally occurring metal which has several forms. The most common organic form is methylmercury, which occurs naturally in the environment and is produced mainly by microscopic organisms in soil and water.1Agency for Toxic Substances & Disease Registry (ATSDR). ToxFAQsTM for Mercury. https://www.atsdr.cdc.gov/toxfaqs/tf.asp?id=113&tid=24. Accessed February 28, 2017.Google Scholar Traces of methylmercury are found in most fish, but levels are typically elevated in older, larger predatory fish. High exposure to methylmercury, a neurotoxin, is tied to brain and nervous system problems, especially in fetuses, infants, and young children. The nutritional value of seafood is particularly important during fetal growth and development, as well as in early infancy and childhood. Intake of n-3 fatty acids, particularly docosahexaenoic acid, from at least 8 oz of seafood per week for pregnant women is associated with improved infant visual and cognitive development.2Procter S.B. Campbell C.G. Position of the Academy of Nutrition and Dietetics: Nutrition and lifestyle for a healthy pregnancy outcome.J Acad Nutr Diet. 2014; 114: 1099-1103Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar A federal analysis of fish consumption data found that 50% of pregnant women surveyed ate fewer than 2 oz a week, far less than the amount recommended. Because the nutritional benefits of eating fish are important for growth and development during pregnancy and early childhood, two federal agencies are advising and promoting a minimum level of fish consumption for these groups, according to a statement from the US Food and Drug Administration (FDA) and the US Environmental Protection Agency (EPA).3US Food and Drug Administration. FDA News Release. FDA and EPA issue final fish consumption advice. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm537362.htm. Accessed February 28, 2017.Google Scholar On January 18, 2017, the FDA, in coordination with the EPA, issued final advice regarding fish consumption, which refers to fish and shell fish collectively as “fish.” The revised fish advice is designed to encourage women who are pregnant and breastfeeding to consume 8 to 12 oz of a variety of fish per week, and it includes further modified wording and organization to enhance the likelihood that recommendations will be followed by the target audience. The updated advice cautions against seven types of fish that typically have higher mercury levels: tilefish from the Gulf of Mexico, shark, swordfish, orange roughy, bigeye tuna, marlin, and king mackerel. The revised fish advice includes a chart and supplemental questions and answers to make it easier to choose dozens of healthy and safe options.4US Environmental Protection Agency. 2017 EPA-FDA Advice about Eating Fish and Shellfish. https://www.epa.gov/fish-tech/2017-epa-fda-advice-about-eating-fish-and-shellfish. Accessed March 1, 2017.Google Scholar The chart provides recommendations for how often the target audience (pregnant women, women who might become pregnant, breastfeeding women, and young children) should eat more than 60 different fish, based on mercury concentrations. For women of childbearing age (about 16 to 49 years old), especially pregnant and breastfeeding women, and for parents and caregivers of young children, the recommendations are:•Eat 2 to 3 servings of fish from the “Best Choices” list OR 1 serving from the “Good Choices” list.•Eat a variety of fish.•Serve 1 to 2 servings of fish to children, starting at age 2 years.•If you eat fish caught by family or friends, check for fish advisories with their regional advisories. If there is no advisory, eat only one serving and no other that week. (Access regional advisories at: http://fishadvisoryonline.epa.gov/General.aspx). The supplemental questions and answers also assist in making choosing fish to eat easier.4US Environmental Protection Agency. 2017 EPA-FDA Advice about Eating Fish and Shellfish. https://www.epa.gov/fish-tech/2017-epa-fda-advice-about-eating-fish-and-shellfish. Accessed March 1, 2017.Google Scholar For example the questions below regarding tuna are answered.1. What is the difference between albacore (white) tuna and canned light tuna?Albacore, or white tuna, is larger and lives longer than the fish generally used in canned light tuna. Meanwhile, canned light tuna can be a mix of a variety of generally smaller tuna species, most often skipjack.2. I eat a lot of tuna, especially canned light tuna because it is particularly affordable. Is this okay?Yes. Canned light tuna is in the “Best Choices” category and it is fine to eat 2 to 3 servings per week. We recommend that you eat a variety of fish. You may wish to try other affordable fish in the “Best Choices” category such as canned salmon or sardines, frozen fish, or fresh fish that are at a reduced price.3. I eat a lot of tuna, but prefer to eat albacore tuna. Is this okay?Albacore tuna, also known as white tuna, typically contains three times more mercury than canned light tuna. You can eat albacore or any of the other fish from the “Good Choices” category once a week. These resources will help registered dietitian nutritionists and nutrition and dietetics technicians, registered, balance the benefits of eating fish while avoiding high-mercury content seafood.

There is no established recommended intake for nickel. The nutritional importance or biochemical function of nickel in humans has not been clearly established. Data were insufficient to set estimated average requirements, recommended daily allowances, or adequate intakes. The upper tolerable intake level for nickel is based on animal data. However, the data review indicated a need for continued study of this element to determine specific metabolic roles, identify sensitive indicators, and more fully characterize nickel's functions in human health.

In addition to consuming a healthy eating pattern, regular physical activity is one of the most important things all Americans, including children and adolescents, can do to improve their health. The 2008 Physical Activity Guidelines for Americans, published by the US Department of Health and Human Services, describe the types and amounts of physical activity that offer substantial health benefits.1Office of Disease Prevention and Health Promotion. Physical Activity Guidelines. Washington, DC: US Department of Health and Human Services. https://health.gov/paguidelines/. Accessed July 12, 2017.Google Scholar Children and adolescents should do 60 minutes or more of physical activity daily. Most of that time should be spent doing either moderate- or vigorous-intensity aerobic activity. In addition, they should participate in muscle-strengthening and bone-strengthening activities at least 3 days a week. The “Be Active Your Way” blog is the official blog of the Physical Activity Guidelines for Americans, and it provides updates about the development of the second edition of the guidelines and insights from health and physical activity professionals about translating the guidelines into practice.2Office of Disease Prevention and Health Promotion. Be Active Your Way. Washington, DC: US Department of Health and Human Services. https://health.gov/news/category/blog-bayw/. Accessed May 30, 2017.Google Scholar A 2012 mid-course Physical Activity Guidelines report on “Strategies to Increase Physical Activity Among Youth” further emphasized the importance of physical activity for health in children and youth and outlined methods for achieving the recommended 60 minutes of physical activity per day, while noting that fewer than half of children meet the recommendations.3Office of Disease Prevention and Health Promotion. PAG Midcourse Report: Strategies to Increase Physical Activity Among Youth. Washington, DC: US Department of Health and Human Services. https://health.gov/paguidelines/midcourse/. Accessed July 12, 2017.Google Scholar Additional statistics and information about physical activity and health are available on the Centers for Disease Control and Prevention’s physical activity webpage.4National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. Facts about Physical Activity. Atlanta, GA: Centers for Disease Control and Prevention. https://www.cdc.gov/physicalactivity/data/facts.htm. Accessed May 30, 2017.Google Scholar Proper nutrition is a major factor that can help make participation in physical activity a positive experience for children and adolescents. Registered dietitian nutritionists may be called upon to talk with coaches, make presentations to players and their parents, or provide personalized nutrition counseling. An excellent resource for sports-related nutrition information is the Pediatric Nutrition Care Manual (PNCM).5Pediatric Nutrition Care Manual. Child athletes. Chicago, IL: Academy of Nutrition and Dietetics. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=12&lv1=144615&ncm_toc_id=144615&ncm_heading=&. Accessed May 30, 2017.Google Scholar According to the PNCM, nutrient needs are similar for boys and girls prior to puberty. When a variety of foods are consumed, a child’s diet can meet nutrient needs by following the 2015-2020 Dietary Guidelines for Americans in conjunction with guidelines specified in ChooseMyPlate.gov. The PNCM states that for activities lasting less than 60 minutes, water is all that is needed for hydration. For activities longer than 60 minutes, other beverages, such as fluid-replacement drinks that contain additional carbohydrate and electrolytes, are recommended. Some studies suggest that the presence of flavoring, sodium, and carbohydrate in a beverage enhances thirst and is effective in reducing or preventing voluntary dehydration. Puberty, which occurs during adolescence, is characterized by increases in height and weight, completion of skeletal growth, increases in bone mass, changes in body composition, and sexual maturation. Children enter adolescence and begin puberty at varying ages. These changes result in increased nutrition needs, and optimal nutrition is key. In addition to physical growth, adolescents experience an increase in the ability to assess and address more complex situations and a significant increase in the desire for autonomy. The increased nutrient needs—along with more independence in decision-making regarding food choices and other influences such as peer pressure or the media—may put some adolescents at nutritional risk. Understanding the physical and cognitive changes occurring throughout adolescence can help nutrition and dietetics practitioners working with adolescents. The PNCM provides guidance and resources to assist with meeting the needs of the active child. It also addresses the unique nutritional needs of the child athlete in relation to growth and development and within the context of the Nutrition Care Process. A registered dietitian nutritionist, especially one that specializes in sports nutrition, can be an asset to the child who is becoming more active and to the child athlete who is already participating in sporting events that can vary greatly in skill levels.

The discovery of vitamin K has its origin in the 1930s, when vitamin K was identified as playing an essential role as a coenzyme in the biological reactions involved in normal blood coagulation.1Dam H. The antihaemorrhagic vitamin of the chick.Biochem J. 1935; 29: 1273-1285Crossref PubMed Google Scholar Vitamin K is a generic name for a group of compounds with a common chemical structure: phylloquinone (vitamin K1) is the predominant dietary form found in vegetables; menaquinones (vitamin K2) are synthesized by bacteria, and exist in various forms with side chains of different lengths; and there is also a synthetic form, menadione (vitamin K3). Phylloquinones are present in vegetables, especially green leafy vegetables and vegetable oils, and some fruit, according to the Vitamin K Fact Sheet for Professionals by the National Institutes of Health Office of Dietary Supplements.2National Institutes of Health. Office of Dietary Supplements. Vitamin K: Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/VitaminK-HealthProfessional/. Accessed February 26, 2016.Google Scholar Meat, dairy foods, and eggs contain low levels of phylloquionones but modest amounts of menaquinones. The fact sheet includes a list of food sources of vitamin K, primarily based on the phylloquinone content, except when menaquinone content is known. Much of what we know about the vitamin K content of foods in the US food supply comes from research conducted in Tufts University’s Human Nutrition Research Center on Aging Vitamin K Laboratory.3Tufts University Health & Nutrition Letter. Finding New Health Benefits for Vitamin K.February 2015:4-5.Google Scholar The lab assesses vitamin K dietary factors while also addressing the roles and mechanisms of action for vitamin K beyond coagulation. Clinically significant vitamin K deficiency is extremely rare but can occur in individuals with malabsorption syndromes, or those treated with drugs known to interfere with vitamin K metabolism, such as warfarin. Vitamin K is essential to the series of chemical reactions through which blood clots are formed; warfarin decreases the activity of vitamin K, lengthening the time it takes for a clot to form. Vitamin K nutrition therapy recommendations include eating a normal, balanced diet, and keeping the intake of vitamin K–rich foods consistent so the effect on coagulation time is as constant and predictable as possible. A recent study published in the Journal of the Academy of Nutrition and Dietetics suggests that avoidance of vitamin K−rich foods, particularly green vegetables, is common among warfarin users and translates into lower usual vitamin K intakes.4Leblanc C, Dubé M-P, Presse N, et al. Avoidance of vitamin K−rich foods is common among warfarin users and translates into lower usual vitamin K intakes [published online ahead of print February 25, 2016]. J Acad Nutr Diet. http://dx.doi.org/10.1016/j.jand.2015.12.023.Google Scholar The researchers recommended that future research address the need for health care professionals to incorporate evidence-based vitamin K−related recommendations for warfarin users. As vitamin K research has evolved it has led to the discovery of vitamin K−dependent proteins beyond coagulation, including proteins involved in bone metabolism. Vitamin K plays a role as a coenzyme during the synthesis of osteocalcin, a protein derived from osteoblasts involved in bone formation. One of the richest food sources of menaquinone is natto, a traditional Japanese food made from steamed, fermented, and mashed soybeans. An interesting study involving natto, conducted in Japan, found that regional variation in the consumption of natto was found to be a major determinant of large geographic difference in circulating levels of vitamin K2. These findings suggested possible implications for hip-fracture risk.5Kaneki M. Hodges S.J. Hosoi T. et al.Japanese fermented soybean food as the major determinant of the large geographic difference in circulating levels of vitamin K2: Possible implications for hip-fracture risk.Nutrition. 2001; 17: 315-321Crossref PubMed Scopus (183) Google Scholar Cautious interpretation of positive associations between vitamin K intakes and markers of bone health is warranted. There have been reports that in response to vitamin K supplementation, total osteocalcin has increased, decreased, or remained unchanged.6Gundberg C.M. Lian J.B. Booth S.L. Vitamin K-dependent carboxylation of osteocalcin: Friend or foe?.Adv Nutr. 2012; 3: 149-157Crossref PubMed Scopus (135) Google Scholar The research on vitamin K–dependent osteocalcin and bone health remains conflicting. The National Osteoporosis Foundation (NOF) does not support the practice of taking a vitamin K supplement to prevent osteoporosis and broken bones. The NOF cites concerns that vitamin K supplementation may decrease the effectiveness of medications like warfarin.3Tufts University Health & Nutrition Letter. Finding New Health Benefits for Vitamin K.February 2015:4-5.Google Scholar More research will decide the amount and form of vitamin K needed for optimal bone health, and yield more discoveries about the diverse roles of this essential nutrient.

Anthropometric measurements include various measures of body weight, size, and composition to evaluate nutritional status. They are useful in monitoring the need for, and effects of, nutrition intervention. Body mass index (BMI), a measure of a ratio of weight in relation to height, does not provide information on the distribution of body fat. Body fat distribution is also an important risk factor for obesity-related disorders. Subcutaneous fat is found just below the skin. The more consequential, visceral body fat surrounds the internal organs such as the liver, pancreas, and intestines within the abdominal cavity. Individuals who have a primarily upper-body fat distribution (characterized by an android or apple shape) are at increased risk of type 2 diabetes, cardiovascular disease (CVD), and death, even after controlling for BMI.1Zhang C. Rexrode K.M. van Dam R.M. Li T.Y. Hu F.B. Abdominal obesity and the risk of all-cause, cardiovascular, and cancer mortality: Sixteen years of follow-up in US women.Circulation. 2008; 117: 1658-1667Crossref PubMed Scopus (597) Google Scholar, 2Zhang M, Hu T, Zhang S, Zhou L. Associations of different adipose tissue depots with insulin resistance: A systematic review and meta-analysis of observational studies. Sci Rep. http://dx.doi.org/10.1038/srep18495. http://www.nature.com/articles/srep18495. Published December 21, 2015. Accessed December 23, 2015.Google Scholar The first set of clinical guidelines for the treatment of overweight and obesity in adults was published in 1998 and identified BMI and waist circumference as primary metrics when assessing a patient for risk status and as a candidate for weight loss therapy.3National institutes of HealthClinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—The evidence report.Obes Res. 1998; : S51-S209Google Scholar In 2008, the National Heart, Lung, and Blood Institute of the National Institutes of Health began extensive review of the guidelines utilizing a series of expert panels. In 2013 the Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society was published.4Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and The Obesity Society.Circulation. 2014; 129: S102-S138Crossref PubMed Scopus (1769) Google Scholar, 5Millen B.E. Wolongevicz D.M. Nonas C.A. Lichtenstein A.H. 2013 American Heart Association/American College of Cardiology/The Obesity Society guideline for the management of overweight and obesity in adults: Implications and new opportunities for registered dietitian nutritionists.J Acad Nutr Diet. 2014; 114: 1730-1735Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar It was determined that there were insufficient data to recommend a change to BMI, and the cut points for overweight (BMI 25 to 29.9) and obesity (BMI ≥30) still stand. The available evidence for waist circumference measurements of >102 cm (>40 in) in men and >88 cm (>35 in) in women was inadequate to address the relationship between current cut points and CVD outcomes. Adequate evidence was available on the relationship between waist circumference as a continuous variable and CVD outcomes. Therefore, expert opinion was used to recommend the measurement of waist circumference at annual visits or more frequently in overweight and obese adults. Registered dietitian nutritionists can advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. Alternative cut points for waist circumference currently in common use are from either National Institutes of Health/National Heart, Lung, and Blood Institute: >102 cm (>40 in) in men or >88 cm (>35 in) in women; or World Health Organization/International Diabetes Foundation: >94 cm (>37 in) in men and >80 cm (>31.5 in) in women. These may continue to be used to identify patients who may be at increased risk until further evidence becomes available. The Academy of Nutrition and Dietetics’ position paper on adult weight management has recently been updated and incorporated the revised Academy evidence-based adult weight management guidelines from the Evidence Analysis Library and the 2013 American College of Cardiology/American Heart Association/Task Force on Practice Guidelines and The Obesity Society guideline for obesity. The following recommendation was made specific to anthropometric measurements that are obtained as part of the initial assessment and used to monitor effectiveness of medical nutrition therapy in the reassessment:EAL Recommendation: “The [registered dietitian nutritionist], in collaboration with other health care professionals, administrators, and/or public policy decision-makers, should ensure that all adult patients have the following measurements at least annually: height and weight to calculate BMI; and waist circumference to determine risk of CVD, type 2 diabetes, and all-cause mortality.”6Raynor H.A. Champagne C.M. Position of the Academy of Nutrition and Dietetics: Interventions for the treatment of overweight and obesity in Adults.J Acad Nutr Diet. 2016; 116: 129-147Abstract Full Text PDF PubMed Scopus (198) Google Scholar

Hemoglobin, the molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs, is made of two protein chains: alpha globin and beta globin. When genes controlling hemoglobin production are missing or altered, thalassemia occurs and is classified as alpha thalassemia or beta thalassemia. Hundreds of alpha globin and beta globin mutations have been identified in thalassemia, and the severity of the disease depends on which mutation or combination of mutations is present.1National Heart Lung, and Blood Institute: Explore thalassemias. http://www.nhlbi.nih.gov/health/health-topics/topics/thalassemia/. Accessed May 27, 2016.Google Scholar Mild forms of the disease may not need any treatment, but those with moderate to severe thalassemia may be treated with life-sustaining blood transfusions. Regular blood transfusions greatly contribute to the quality and length of life of thalassemia patients, but leave patients with progressive iron deposition in body tissues that can result in organ injury due to iron overload. Despite receiving no or only occasional blood transfusions, patients with non–transfusion-dependent thalassemia can also develop iron overload due to increased intestinal absorption of dietary iron, which can accumulate iron to levels comparable with transfusion-dependent patients.2Taher A.T. Viprakasit V. Musallam K.M. Cappellini M.D. Treating iron overload in patients with non-transfusion-dependent thalassemia.Am J Hematol. 2013; 88: 409-415Crossref PubMed Scopus (59) Google Scholar Iron overload can be successfully managed with chelation therapy to remove excess iron from the body.1National Heart Lung, and Blood Institute: Explore thalassemias. http://www.nhlbi.nih.gov/health/health-topics/topics/thalassemia/. Accessed May 27, 2016.Google Scholar, 2Taher A.T. Viprakasit V. Musallam K.M. Cappellini M.D. Treating iron overload in patients with non-transfusion-dependent thalassemia.Am J Hematol. 2013; 88: 409-415Crossref PubMed Scopus (59) Google Scholar Considering the relationship between iron overload and organ dysfunction in thalassemia, it is not surprising that dietary iron reduction has for decades been the focus of nutrition intervention in patients with thalassemia. However, the Standard of Care Guidelines for Thalassemia published by the Children’s Hospital & Research Center Oakland makes the following recommendations specific to iron:•Non-transfused patients are encouraged to consume a moderately low-iron diet—that is, avoiding iron-fortified foods and excessive consumption of red meat.•For transfused patients on chelation therapy, a low-iron diet is unnecessary and may decrease quality of life for some patients.3Standards of Care Guidelines for Thalassemia. Northern California Comprehensive Thalassemia Center. UCSF Benioff Children's Hospital Oakland. http://thalassemia.com/treatment-guidelines-1.aspx#gsc.tab=0. Accessed May 27, 2016.Google Scholar In addition to iron-related issues, patients with thalassemia commonly exhibit morbidities linked with poor nutritional status: inadequate growth, poor immune function, and decreased bone mineralization. As part of the Thalassemia Clinical Research Network’s Longitudinal Cohort Study, research investigating dietary intake of thalassemia patients was published in the Journal in 2012.4Fung E.B. Xu Y. Trachtenberg F. et al.Inadequate dietary intake in patients with thalassemia.J Acad Nutr Diet. 2012; 112: 980-990Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Fung and colleagues studied patients with thalassemia across 10 hematology outpatient clinics in the United States and Canada, comparing their food frequency data with the US Dietary Reference Intakes and correlations with serum 25-OH vitamin D and total body iron stores. Results showed surprising levels of nutrient inadequacy in this population. Recommendations based on this preliminary data suggested that registered dietitian nutritionists shift the focus away from avoiding iron-rich diets and toward concentrating on a more well-balanced diet rich in antioxidants and minerals. When iron is avoided in the diet, zinc intake is frequently reduced; zinc is an essential nutrient that has been shown to be particularly beneficial to immune status, bone health, and growth in thalassemia. The intake of dairy foods is also low, which might, in part, be related to lactose intolerance. Therefore, strategies for increasing dietary calcium and magnesium should emphasize lactose-free dairy and calcium-fortified foods. Shifting the focus toward more fruits, vegetables, and whole grains will not only enhance antioxidant and fiber intake, but also enhance folate intake, which is critically important to red blood cell metabolism. In 2016, a study reviewed the relationship between nutritional status and three commonly experienced comorbidities in patients with transfusion-dependent thalassemia: low bone mass/osteoporosis, growth-deficiency and/or delayed puberty, and diabetes.5Fung E.B. The importance of nutrition for health in patients with transfusion-dependent thalassemia.Ann N Y Acad Sci. 2016; 1368: 40-48Crossref PubMed Scopus (9) Google Scholar The researcher concluded that on the whole, there are few well-designed, adequately powered studies on the role of general dietary or specific micronutrients in the cause, treatment, or prevention of these commonly observed morbidities in thalassemia. Until these data are gathered, it is suggested that patients with thalassemia be monitored frequently and that their nutritional deficiencies be corrected when observed in order to advance their overall health and quality of life. Until that time, optimizing dietary intake through nutrient-dense foods and appropriate use of supplements, where necessary, can improve overall health in these subjects.5Fung E.B. The importance of nutrition for health in patients with transfusion-dependent thalassemia.Ann N Y Acad Sci. 2016; 1368: 40-48Crossref PubMed Scopus (9) Google Scholar

Behavior change theories and models are integral to the nutrition care process, guiding nutrition assessment, intervention, and outcome evaluation. These theories provide an evidence-based approach for changing energy-balance behaviors that are important for obesity treatment.1Spahn J.M. Reeves R.S. Keim K.S. et al.State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change.J Am Diet Assoc. 2010; 110: 879-891Abstract Full Text Full Text PDF PubMed Scopus (242) Google Scholar According to the Academy’s position paper on weight management, the best combination of behavior-change strategies and techniques to apply in treating obesity is not known at this time. Instead, it is believed that a variety of strategies from different behavior change theories can be applied to assist with changing behaviors.2Raynor H.A. Champagne C.M. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults.J Acad Nutr Diet. 2016; 116: 129-147Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar The Academy’s Evidence Analysis Library recommends “The registered dietitian nutritionist (RDN) should assess motivation, readiness, and self-efficacy for weight management, based on behavior change theories and models (such as cognitive-behavioral therapy, transtheoretical model and social cognitive theory/social learning theory). While research supports cognitive-behavioral therapy as an effective method of overweight and obesity treatment, there is limited research in the areas of the transtheoretical model and social cognitive theory and social learning theory.” The recommendation is rated “Fair, Imperative.”3Academy of Nutrition and Dietetics Evidence Analysis Library. AWM: Assess Motivation for Weight Management 2014. http://www.andeal.org/template.cfm?template=guide_summary&key=3503&cms_preview=true&project_id=1171. Accessed September 28, 2016.Google Scholar The concept of self-efficacy (or confidence) attempts to predict and explain human behavior that is fundamental to behavior change interventions.2Raynor H.A. Champagne C.M. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults.J Acad Nutr Diet. 2016; 116: 129-147Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar Self-efficacy is not a general belief about oneself, but a specific belief tied to a specific task. Self-efficacy has been shown to be a strong predictor of health behavior, including weight-control behavior, sometimes explaining more than 50% of variability.4AbuSabha R. Achterberg C. Review of self-efficacy and locus of control for nutrition- and health-related behavior.J Am Diet Assoc. 1997; 97: 1122-1132Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Patient motivation is a key component of success in a weight loss program and a prerequisite for weight loss therapy. Although it is difficult to quantify, research suggests that patients who have high pretreatment motivation and self-efficacy may lose more weight than patients with lower motivation and self-efficacy.5Kushner R.F. Kushner N. Blatner D.J. Counseling Overweight Adults: The Lifestyle Patterns Approach and Toolkit. American Dietetic Association, Chicago, IL2009Google Scholar A sense of motivation can be determined by asking the following questions:•“How ready are you to commit time, energy, and resources to weight loss therapy?”•“How confident are you in your ability to lose weight and keep it off?” Motivational Interviewing (MI) is a collaborative, goal-oriented method of communication between a practitioner and a client with a focus on drawing out a client’s personal motives by allowing a person to find answers on his or her own. MI is believed to enhance motivation and self-efficacy, which are both considered to be key for changing behavior and sustaining behavior changes.2Raynor H.A. Champagne C.M. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults.J Acad Nutr Diet. 2016; 116: 129-147Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar The Academy publication, “Counseling Overweight Adults: The Lifestyle Patterns Approach and Toolkit,” includes a simple and rapid method to assess readiness by anchoring the patient’s interest and confidence to a numerical scale.5Kushner R.F. Kushner N. Blatner D.J. Counseling Overweight Adults: The Lifestyle Patterns Approach and Toolkit. American Dietetic Association, Chicago, IL2009Google Scholar Readiness is viewed as the balance of two opposing forces: motivation (the patient’s desire to change) and resistance (the patient’s struggle against changing). Simply ask the patient, “On a scale of from 0 to 10, with 0 being not important and 10 being very important, how ‘important’ is it for you to lose weight at this time?” and “Also on a scale from 0 to 10, with 0 being not confident and 10 being very confident, how ‘confident’ are you that you can lose weight at this time?” This is a very useful exercise to initiate further discussion. The Weight Control Importance and Patient Confidence Scales can help to identify areas for behavior change and to focus behavior change counseling. If patients are motivated and confident, they should be ready to successfully initiate heath changes with the support and guidance of the RDN. It is important that RDNs empower individuals and provide them with the most effective behavior change strategies.

The hospital medical record constitutes the only permanent record of a patient’s illness and treatment. At one time, dietitians routinely kept patient progress notes in dietary department files.1American Dietetic AssociationGuidelines for the therapeutic dietitian in making notations in the medical record.J Am Diet Assoc. 1966; 49: 215-216PubMed Google Scholar In December of 1965, it was recommended that the progress notes of the patient’s medical record was the most appropriate place within the medical record for reporting on dietary consultation, and guidelines were released in 1966.1American Dietetic AssociationGuidelines for the therapeutic dietitian in making notations in the medical record.J Am Diet Assoc. 1966; 49: 215-216PubMed Google Scholar The guidelines were later revised and included information on how narrative entries could be structured in the SOAP (subjective, objective, assessment, plan) format of medical record documentation.2American Dietetic AssociationGuidelines for Recording Nutritional Information in Medical Records.in: Handbook of Clinical Dietetics. American Dietetic Association, Chicago, IL1981: 113-118Google Scholar However, the guideline stated, “Regardless of format used, entries in the patient’s medical record should contain sufficient information to support the dietary assessment, to justify dietetic care, and to document the results accurately.”2American Dietetic AssociationGuidelines for Recording Nutritional Information in Medical Records.in: Handbook of Clinical Dietetics. American Dietetic Association, Chicago, IL1981: 113-118Google Scholar Medical record documentation over the years has included a variety of strategies in response to various influences. Ultimately, however, as noted from the beginning, the documentation method selected is determined by the institution where the dietitian practices. In 2003, the Academy announced the adoption of the Nutrition Care Process and Model in an article describing the complete Nutrition Care Process (NCP).3Lacey K. Pritchett E. Nutrition care process and model: ADA adopts road map to quality care and outcomes management.J Am Diet Assoc. 2003; 103: 1061-1072Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar The NCP is intended to provide nutrition and dietetics practitioners with a framework for critical thinking and decision-making. The NCP is not intended to standardize nutrition care for each patient/client, but to establish a standardized process for providing individualized care. Key to identifying the unique contributions of registered dietitian nutritionists (RDNs) is the use of standardized terminology. Using standardized terminology in the context of medical record documentation allows RDNs in all settings to use the same words to describe things, which results in more precise and effective communication. The NCP consists of four steps: (a) Nutrition Assessment, (b) Nutrition Diagnosis, (c) Nutrition Intervention, and (d) Nutrition Monitoring and Evaluation. Some RDNs also use ADIME (A=Assessment, D=Diagnosis, I=Intervention, M=Monitoring, E=Evaluation). Regardless of format, quality documentation should include:•nutrition-related assessment data;•a clear concise statement of nutrition diagnosis(es);•a description of the nutrition intervention; and•a description of nutrition monitoring and evaluation to identify patient/client outcomes.4Writing Group of the Nutrition Care Process/Standardized Language CommitteeNutrition care process part II: Using the International Dietetics and Nutrition Terminology to document the nutrition care process.J Am Diet Assoc. 2008; 108: 1287-1293Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar An update of the NCP focusing on documentation includes examples incorporating standardized terminology into documentation.4Writing Group of the Nutrition Care Process/Standardized Language CommitteeNutrition care process part II: Using the International Dietetics and Nutrition Terminology to document the nutrition care process.J Am Diet Assoc. 2008; 108: 1287-1293Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Additional case studies, “Inpatient Critical Illness—Diabetes” and “Outpatient Weight Management,” are used in examples showing documentation for the same case study in a Narrative Format, a SOAP Format, and ADIME, reiterating the importance of content over documentation format. These examples can be found in the NCP 101 information on the Academy’s website at: http://www.eatrightpro.org/resource/practice/nutrition-care-process/ncp-101/nutrition-care-process-the-next-level. Use of a standardized terminology enables RDNs to move from documentation in paper medical records to an integral component of electronic health records. The profession is currently transitioning toward RDNs working in a team environment, providing interventions, and measuring improved outcomes via electronic health records.5Grim J. Roberts S. The Clinical Nutrition Manager's Handbook: Solutions for the Busy Professional. Academy of Nutrition and Dietetics, Chicago, IL2014: 192-193Google Scholar The tools below can assist the RDN in utilizing the Nutrition Care Process and helping ensure that critical data are captured and nutrition care documentation is included in databases and collected in a consistent way.

Dietary fatty acids are often characterized by their saturation status. Of all the fatty acid categories, monounsaturated fatty acids (MUFAs) are consumed the most, comprising 36% of total fat intake, and the majority of MUFA consumption is oleic acid at 27 g/day. Second to oleic acid is palmitoleic acid at 1.2 g/day. Palmitoleic acid is an n-7 fatty acid, which is a small family of unsaturated fatty acids in which the site of unsaturation is seven carbon atoms from the end of the carbon chain. Palmitoleic acid is not commonly found in food but is a product of palmitic acid metabolism in the body.

When one thinks of the term "edible portion" or the part of the food commonly eaten, flowers of ornamental plants may not automatically come to mind. Historically, however, flower cookery has been traced back to civilizations of antiquity. The culinary use of flowers has varied from culture to culture. The Chinese incorporated flowers as ingredients in a wide variety of recipes, and flower usage can be traced back as far as 3000 BCE. Early reports indicate that in Ancient Rome, the edible flowers of violets and roses were used in dishes, and lavender was used in sauces.

A person's skin constantly sheds dead cells and produces new ones in a process called cell turnover. Normally, it takes about a month for new cells that grow deep in the skin to rise to the surface, but in psoriasis this process is accelerated and new cells rise from below the skin surface in a matter of days.1MedlinePlus. Psoriasis. http://www.nlm.nih.gov/medlineplus/psoriasis.html. Accessed December 23, 2013.Google Scholar Overgrowths of cells accumulate on the skin surface resulting in red, flaky, crusty patches covered with silvery lesions. Despite the fact that it is not a contagious disorder and the patches are not infectious, people with the condition can suffer from social exclusion. According to the National Psoriasis Foundation (NPF), psoriasis is the most prevalent autoimmune disease in the United States, and studies indicate as many as 7.5 million Americans suffer from it.2National Psoriasis Foundation. Frequently Asked Questions. http://www.psoriasis.org/page.aspx?pid=375. Accessed December 23, 2013.Google Scholar As is often the case in patients with chronic diseases, people with psoriasis turn to diet in hopes of a positive impact on their condition. A poster session presented at the 2011 Food & Nutrition Conference & Expo in San Diego, CA, summarized a literature search on Medline (1950 to January 2011) for studies testing the effectiveness of any diets or dietary supplements in reducing psoriasis symptoms.3Brown A.C. Shankar P. Psoriasis, diet, and dietary supplements—A review [abstract].J Am Diet Assoc. 2011; 111: A33Abstract Full Text Full Text PDF Google Scholar Approximately 228 articles were found, including articles on the impact of obesity on psoriasis and the effectiveness of a gluten-free diet on psoriasis, among other factors. The meeting abstract for the poster session noted some evidence supportive of a low-calorie/low-energy diet. In 2013, a small clinical trial based in Denmark reported what they believed to be the first results of a study on the effects of weight loss using the severity of psoriasis as a primary endpoint. The researchers found that obese patients with psoriasis who lost weight through a low-calorie diet experienced a significant improvement in their quality of life compared with obese psoriasis patients who didn't lose weight. In the randomized clinical trial, 27 patients were assigned to an intervention group that followed a low-calorie diet, and 26 patients were assigned to a control group that continued to eat ordinary healthy foods. The participants met every 2 weeks for a total of eight group sessions led by the study dietitian. The patients on a low-calorie diet ended up losing nearly 34 lb in 16 weeks, and reported improvements in both their psoriasis symptoms and their overall quality of life.3Brown A.C. Shankar P. Psoriasis, diet, and dietary supplements—A review [abstract].J Am Diet Assoc. 2011; 111: A33Abstract Full Text Full Text PDF Google Scholar There are data that suggest that following a gluten-free diet may ameliorate symptoms in individuals with chronic autoimmune disease conditions such as psoriasis.4Jensen P. Zachariae C. Christensen R. et al.Effect of weight loss on the severity of psoriasis: A randomized clinical study.JAMA Dermatol. 2013; 149: 795-801Crossref PubMed Scopus (143) Google Scholar However, the NPF states that the jury is still out on this topic. In some cases, eliminating gluten does seem to help reduce psoriasis. In a smaller number of cases, eliminating gluten can lead to dramatic improvements.5Gaesser G.A. Angadi S.S. Gluten-free diet: Imprudent dietary advice for the general population?.J Acad Nutr Diet. 2012; 112: 1330-1333Abstract Full Text PDF PubMed Scopus (69) Google Scholar If celiac disease or gluten sensitivity is suspected, a registered dietitian nutritionist should coordinate care with a physician to evaluate the patient for either of these conditions in order to determine the appropriateness of a gluten-free diet. For the client with psoriasis who does not also have celiac disease or gluten sensitivity, it is not advised to follow a gluten-free diet. The Incident Health Outcomes and Psoriasis Events (iHOPE) Study, which examined the prevalence of major medical comorbidity in patients with mild, moderate, or severe psoriasis classified objectively based on body surface area involvement compared with that in patients without psoriasis, found a definite link between the severity of a person's psoriasis and the odds that person may develop several other diseases,6Yeung H. Takeshita J. Mehta N.N. et al.Psoriasis severity and the prevalence of major medical comorbidity: A population-based study.JAMA Dermatol. 2013; 149: 1173-1179Crossref PubMed Scopus (324) Google Scholar including:•chronic pulmonary disease;•diabetes;•mild liver disease;•myocardial infarction and peripheral vascular disease (cardiovascular disease);•peptic ulcer disease;•renal disease; and•other rheumatological diseases.6Yeung H. Takeshita J. Mehta N.N. et al.Psoriasis severity and the prevalence of major medical comorbidity: A population-based study.JAMA Dermatol. 2013; 149: 1173-1179Crossref PubMed Scopus (324) Google Scholar, 7National Psoriasis Foundation. Study: Risk of serious medical events increases with psoriasis severity. http://www.psoriasis.org/news/stories/2013/08/08/risk-of-serious-medical-events-increases-with-psoriasis-severity. Accessed December 23, 2013.Google Scholar According to Mark Lebwohl, MD, a dermatologist commenting on the iHOPE study, “Many of the other diseases linked to psoriasis are linked to obesity, and several of the diseases indicated in the study are already linked to obesity, too, like diabetes and hypertension. Exercising, eating right, quitting smoking, and treating psoriasis can help prevent comorbidities.”7National Psoriasis Foundation. Study: Risk of serious medical events increases with psoriasis severity. http://www.psoriasis.org/news/stories/2013/08/08/risk-of-serious-medical-events-increases-with-psoriasis-severity. Accessed December 23, 2013.Google Scholar

Obesity concerns have proven to be a thriving ground for companies advertising weight-loss products. In January of 2014, the Federal Trade Commission (FTC), in its ongoing effort to protect consumers from false or misleading advertising for products, announced “Operation Failed Resolution.” This is the latest in ongoing efforts by the federal agency to crack down on companies' advertising weight-loss products using unsubstantiated claims targeting consumers desperate for results. The FTC has compiled a list of seven statements in ads that simply can't be true to assist the media in spotting false weight loss claims (Figure).FigureThe Federal Trade Commission's Seven “Gut Check” Claims.Adapted from reference 1.The Seven Gut Check Claims1Gut Check: A Reference Guide for Media on Spotting False Weight Loss Claims. Federal Trade Commission website. http://www.business.ftc.gov/documents/0492-gut-check-reference-guide-media-spotting-false-weight-loss-claims#claims. Accessed March 31, 2014.Google Scholar1.Causes weight loss of 2 lb or more a week for a month or more without dieting or exercise.Gut check: Meaningful weight loss requires taking in fewer calories than you use. It's that simple. But it's also that difficult for people trying to shed pounds. That means ads promising substantial weight loss without diet or exercise are false. And ads suggesting that users can lose weight fast without changing their lifestyles—even without mentioning a specific amount of weight or length of time—are false, too. Some ads might try a subtler approach, say, by referring to change in dress size or lost inches, but the effect is the same.2.Causes substantial weight loss no matter what or how much the consumer eats.Gut check: It's impossible to eat unlimited amounts of food—any kind of food—and still lose weight. It's a matter of science: To lose weight, you have to burn more calories than you take in. To achieve success, dieters have to put the brakes on at the dinner table. If an ad says users can eat any amount of any kind of food they want and still lose weight, the claim is false.3.Causes permanent weight loss even after the consumer stops using product.Gut check: Without long-term lifestyle changes—like continuing to make sensible food choices and upping the activity level—weight loss won't last once consumers stop using the product. Even if dieters succeed in dropping pounds, maintaining weight loss requires lifelong effort.4.Blocks the absorption of fat or calories to enable consumers to lose substantial weight.Gut check: Without lifestyle changes, no over-the-counter product can block enough fat or calories to cause the loss of lots of weight. To work, even legitimate “fat blockers” must be used with a reduced-calorie diet.5.Safely enables consumers to lose more than 3 lb per week for more than 4 weeks.Gut check: Medical experts agree: Losing more than 3 lb a week over multiple weeks can result in gallstones and other health complications. So if an ad says dieters can safely and quickly lose a dramatic amount of weight on their own, it's false.6.Causes substantial weight loss for all users.Gut check: People's metabolisms and lifestyles are different. So is how they'll respond to any particular weight-loss product. The upshot: No product will cause every user to drop a substantial amount of weight. Any ad that makes a universal promise of success is false.7.Causes substantial weight loss by wearing a product on the body or rubbing it into the skin.Gut check: Weight loss is an internal metabolic process. Nothing you wear or apply to the skin can cause substantial weight loss. So weight-loss claims for patches, creams, lotions, wraps, body belts, earrings, and the like are false. There's simply no way products like that can live up to what the ads say. Open table in a new tab The seven “gut check” claims apply to dietary supplements, over-the-counter drugs, and products rubbed into the skin or worn on the body. The FTC's rules in their Guide Concerning the Use of Endorsements and Testimonials in Advertising apply across the board, including all weight-loss products.2Guide Concerning the Use of Endorsements and Testimonials in Advertising. Federal Trade Commission website. http://www.ftc.gov/sites/default/files/documents/one-stops/advertisement-endorsements/091005revisedendorsementguides.pdf. Accessed March 31, 2014.Google Scholar The two documents demonstrate the FTC's interest in weight-loss claims and its expectation that the media will do its part to prevent the dissemination of deceptive diet ads.

January 1st is the perennial start date for many clients/patients to resolve to improve their diets, most notably, in order to lose weight. Unrealistic and overly aggressive weight-loss goals may undermine the efforts of the success of weight-loss attempts, according to a 2009 study published in the Journal.1Wamsteker E.W. Geenen R. Zelissen P.M. van Furth E.F. Iestra J. Unrealistic weight-loss goals among obese patients are associated with age and causal attributions.J Am Diet Assoc. 2009; 109 (1903–1903)Abstract Full Text Full Text PDF Scopus (25) Google Scholar This Dutch study investigated the frequency of unrealistic personal goals at the start of a dietary treatment and the association with other patient characteristics at the start of a weight-loss program. An unrealistic goal was arbitrarily defined as exceeding the medically advised goals by more than 50%. Unrealistic goals were observed in 49% of the patients. Significantly more younger patients than older patients had unrealistic personal weight loss goals. The frequency of unrealistic goals did not vary by body mass index subgroups or by sex in this study. A realistic initial weight loss goal according to the 1998 National Institutes of Health Guidelines is to reduce body weight by approximately 10% from baseline for the first 6 months of treatment.2National Institutes of Health/National Heart Lung and Blood Institute. Clinical Guidelines on the identification, evaluation and treatment of overweight and obesity in adults: The Evidence Report. http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf. Accessed October 25, 2013.Google Scholar Goal setting was one of the strategies the Nutrition Counseling Evidence Analysis Team included in a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Good evidence supports the use of goal setting as a strategy, but additional research is needed to assess effectiveness in a broader range of populations over a broader range of nutrition goals.3Spahn J.M. Reeves R.S. Keim K.S. et al.State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change.J Am Diet Assoc. 2010; 110: 879-891Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar Every client has his or her own weight gain story to tell. Careful listening and the use of effective open-ended questions facilitates client participation and can assist in moving clients toward the behavior changes needed to successfully implement an individualized reduced-calorie diet, the basis of the dietary component of weight loss interventions.4Abusabha R. Interviewing clients and patients: Improving the skill of asking open-ended questions.J Acad Nutr Diet. 2013; 113: 624-633Abstract Full Text PDF PubMed Scopus (6) Google Scholar A model for setting very specific goals self-determined by the patient is the WHAT System recommended by the authors of the Academy publication, Inspiring and Supporting Behavior Change: A Food and Nutrition Professional's Counseling Guide.5Constance A. Sauter C. Inspiring and Supporting Behavior Change: A Food and Nutrition Professional's Counseling Guide. American Dietetic Association, Chicago, IL2011Google Scholar•W stands for what the patient will do, when he or she will do it, and where he or she will do it.•H is for how much or how many, and how often.•A stands for achievable (and believable).•T represents the time frame for accomplishing the goal. Behavior change is a process that, for the most part, is measured through self-monitoring. SuperTracker, the US Department of Agriculture’s online diet and activity tool, available at www.SuperTracker.usda.gov, is a free resource that assists clients in tracking diet (Food Tracker) and physical activity (Physical Activity Tracker). In addition, the My Weight Manager feature is a visual reminder of personal weight management goals and progress. The My Top 5 Goals feature allows consumers to choose and track up to five personal goals. There are currently 19 different goals that can be set related to weight management, physical activity, calories, food groups, and nutrients. Consumers can easily measure progress toward their goals on the My Top 5 Goals page with both daily graphs and weekly trend analyses.6Post R.C. Herrup M. Chang S. Leone A. Getting plates in shape using SuperTracker.J Acad Nutr Diet. 2012; 112: 354-358Abstract Full Text PDF PubMed Scopus (6) Google Scholar Articles related to MyPlate and associated tools like SuperTracker are housed on the Journal website under the collections tab as “The MyPlate Message Chronicles,” available at http://www.adajournal.org/content/myplate. Realistic goal setting is just one component of effective nutrition counseling and should be preceded by an assessment of the client’s readiness to change, both of which are addressed in the resources cited earlier.3Spahn J.M. Reeves R.S. Keim K.S. et al.State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change.J Am Diet Assoc. 2010; 110: 879-891Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar, 5Constance A. Sauter C. Inspiring and Supporting Behavior Change: A Food and Nutrition Professional's Counseling Guide. American Dietetic Association, Chicago, IL2011Google Scholar Routine use and documentation of evidence-based interventions will enable registered dietitian nutritionists to better understand the intricacies of nutrition-related behavior change and strategies that are effective in aiding clients in achieving behavior change goals.

Water is truly the beverage for life. It serves as the medium of transport within the body by supplying nutrients and removing waste. Since data were insufficient to calculate a Recommended Daily Allowance (RDA), an Adequate Intake (AI) was developed by the Institute of Medicine (IOM) instead. The AIs are based on median total water intake from US survey data. The AI for generally healthy people living in temperate climates is 125 oz per day for males aged 19 years and over, and 91 oz for females 19 years and over.1Institute of Medicine, Food and Nutrition BoardDietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. National Academies Press, Washington, DC2004Google Scholar Sources include drinking water, other beverages, and water in food.1Institute of Medicine, Food and Nutrition BoardDietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. National Academies Press, Washington, DC2004Google Scholar Clearly, hydration is important for health, but in the ongoing quest for evidence-based strategies to address weight loss and weight loss maintenance, where does water consumption fit in? It is commonly recommended that individuals attempting weight loss ramp up their water intake, but there is a lack of research that directly addresses the efficacy of water consumption to facilitate weight loss. Virginia Tech researchers studied 48 adults aged 55 to 75 years to test the effect of premeal water consumption on energy intake.2Dennis E.A. Dengo A.L. Comber D.L. et al.Water consumption increases weight loss during a hypocaloric diet intervention in middle-aged and older adults.Obesity. 2010; 18: 300-307Crossref PubMed Scopus (155) Google Scholar The study participants were divided into two groups. One group drank approximately 500 mL of water before their meals and the other group did not. All of the subjects consumed a hypocaloric diet during the study. Over the course of 12 weeks, water drinkers lost about 2 kg more than non–water drinkers, demonstrating that when combined with a hypocaloric diet, consuming 500 mL water before each main meal leads to greater weight loss than a hypocaloric diet alone in middle-aged and older adults. It was hypothesized that this may be due in part to an acute reduction in meal energy intake following water ingestion. A recent article published in the Journal looked at the impact of daily self-monitoring of increased water as a long-term weight-loss management strategy—a strategy not previously examined. The Virginia Tech research group examined the same dieters who had previously participated in the 12-week randomized controlled weight-loss intervention trial described previously to determine the effects of premeal water on weight loss maintenance for 12 months.3Akers J.D. Cornett R.A. Savla J.S. Davy K.P. Davy B.M. Daily self-monitoring of body weight, step count, fruit/vegetable intake, and water consumption: A feasible and effective long-term weight loss maintenance approach.J Acad Nutr Diet. 2012; 112: 685-692.e2Abstract Full Text PDF PubMed Scopus (49) Google Scholar Both groups self-monitored behaviors, but the experimental group participants were also instructed to consume 16 fl oz of water before each main meal and to record daily water intake. There was significant improvement in weight-loss maintenance in the pre-meal water group, indicating self-monitoring of increased water consumption may provide additional weight loss maintenance benefits. In an article published online in Critical Reviews in Food Science and Nutrition, a research team presented nine obesity myths and 10 commonly held presumptions about obesity.4Casazza K. Brown A. Astrup A. et al.Weighing the evidence of common beliefs in obesity research.Crit Rev Food Sci Nutr. 2014; https://doi.org/10.1080/10408398.2014.922044Crossref Scopus (94) Google Scholar Obesity myths were defined as beliefs that persist despite contradicting evidence and presumptions as beliefs that persist in the absence of supporting scientific evidence. The statement, “Drinking more water will reduce energy intake and will lead to weight loss or less weight gain, regardless of whether one intentionally makes any other changes to one's behavior or environment” was classified as a presumption. According to the authors, the research on satiety is variable. They also note that the hunger and thirst mechanisms are quite separate and it is unlikely that thirst would be interpreted as hunger. It is possible however, that drinking water could fill people up and reduce hunger resulting in reduced energy intake.4Casazza K. Brown A. Astrup A. et al.Weighing the evidence of common beliefs in obesity research.Crit Rev Food Sci Nutr. 2014; https://doi.org/10.1080/10408398.2014.922044Crossref Scopus (94) Google Scholar The exact mechanisms of the effect water consumption has on body weight changes are still unclear. However, what is clear is that questions about water and its connection to body weight warrant further study.

A perennial holiday question received by registered dietitian nutritionists is: What is the average holiday weight gain between Thanksgiving and New Year's Day? General belief and self-reports of winter holiday weight gain range from 5 to 10 pounds, but no clinical research study supported this belief. A classic study published in the New England Journal of Medicine suggested that Americans gain, on average, about 1 pound during the winter holiday, contrary to popular belief. 1 Yanovski J.A. Yanovski S.Z. Sovik K.N. Nguyen T.T. O'Neil P.M. Sebring N.G. A prospective study of holiday weight gain. N Engl J Med. 2000; 342: 861-867 Crossref PubMed Scopus (248) Google Scholar One hundred and ninety-five study participants who were primarily National Institutes of Health (NIH) employees were weighed at 6-week intervals before, during, and after the winter holiday season. Compared to their initial weight, the volunteers gained just over 1 pound by late February, and most of that weight gain occurred during the 6-week interval between Thanksgiving and New Year's Day. The researchers also found that study volunteers who engaged in more physical activity had less holiday weight gain, suggesting that increasing physical activity may be an effective method for preventing weight gain during this “high-risk” time. In addition, study volunteers believed they had gained much more weight than they actually had over the holidays, overestimating their weight gain by slightly more than 3 pounds. Fewer than 10% of subjects gained more than 5 pounds over the holiday season. However, the overweight and obese volunteers were more likely to gain 5 pounds than those who were not overweight, which suggests that the holiday season may present special risks for those who are already overweight.

THERE ARE OVER 20 SPECIES OF Candida that can cause a fungal infection or candidiasis in humans.1Centers for Disease Control and PreventionCandidiasis.http://www.cdc.gov/fungal/candidiasis/Google Scholar The most common species, Candida albicans commonly resides on the skin, mouth, intestinal tract, vagina, and other moist, warm, and dark areas of the body. Candida is often called yeast, but it is a dimorphic fungus, meaning that it grows as a yeast form in a carbohydrate media and forms hyphae (strands) when the medium is low in nutrients. For this reason, Candida is also referred to as a psuedoyeast.2Joneja J.V. The Health Professionals Guide to Food Allergies and Intolerances. Academy of Nutrition and Dietetics, Chicago, IL2012Google Scholar Candida is a typical inhabitant of the body's resident microflora, but under certain circumstances it can become infective.Those at risk for infection include individuals with a weakened immune system due to certain medications (such as antibiotics) and diseases that compromise the immune system. The presence of oral candidiasis (thrush) is a common condition in human immunodeficiency virus–infected individuals and is associated with poor nutrition because it may result in painful mucosal lesions, impairing the ability to consume food.3Hendricks K.M. Dongs K.R. Gerriot J.L. Nutrition Management of HIV and AIDS. Academy of Nutrition and Dietetics, Chicago, IL2009Google Scholar Candida albicans can also be a cause of Candida vulvovaginitis, commonly termed “yeast infection.” Consuming cultured dairy products may offer some protection against the infection, but the evidence is not conclusive.4Pirotta M. Gunn J. Chondros P. et al.Effect of lactobacillus in preventing post-antibiotic vulvovaginal candidiasis: A randomized control trial.BMJ. 2004; 329: 548Crossref PubMed Scopus (96) Google Scholar Women with Candida vulvovaginitis may wish to try cultured dairy products not only for their potential ability to improve the infection, but also because of the nutrient density of these products.It has long been proposed that Candida might be an allergen associated with a variety of symptoms.5Barrett S. Dubious “yeast allergies”.http://www.quackwatch.com/01QuackeryRelatedTopics/candida.htmlGoogle Scholar The concept of “candidiasis hypersensitivity” was popularized in the book, The Yeast Connection, originally published in 1983. Promoters also referred to this condition as chronic candidiasis, candidiasis hypersensitivity, Candida-related complex, the yeast syndrome, yeast allergy, yeast overgrowth, or simply “Candida” or “yeast problem.” The American Academy of Allergy, Asthma, and Immunology issued a position statement that the concept of candidiasis hypersensitivity should be regarded as “speculative and unproven” unless supported by competent research.6Position statement: Executive Committee of the American Academy of Allergy and Immunology Candidiasis sensitivity syndrome.J Allergy Clin Immunol. 1986; 78: 271-273Abstract Full Text PDF PubMed Scopus (92) Google ScholarAnother member of the fungi family is mold. The Academy publication, The Health Professionals Guide to Food Allergies and Intolerances, includes a chapter titled “Yeast and Mold Allergy.” According to the publication,2Joneja J.V. The Health Professionals Guide to Food Allergies and Intolerances. Academy of Nutrition and Dietetics, Chicago, IL2012Google Scholar individuals sensitized to fungi and fungal spores produce immunoglobulin E (IgE) against the fungal allergenic proteins. These IgE antibodies can be detected in blood tests such as allergen-specific IgE. In addition, skin tests for the fungal allergen are usually positive. There is no scientifically proven connection between Candida and this allergy discussed in the Academy publication.The management of a yeast and mold allergy requires the elimination of all food that might contain yeast or mold. A yeast and mold allergy handout will be available as part of a set of patient education materials available in 2013 with detailed recommendations for this allergy. Some of the yeast-related dietary exclusions include: •Baked goods. Yeast (Saccharomyces species) are used in leavened baked products.•Alcoholic beverages. Yeast fermentation of a substrate (sugar) is the basis of production of alcoholic beverages. Distilled beverages such as spirits, are usually tolerated.•Savory spreads. Some use yeast extracts. In Britain the product is marketed as Marmite (Unilever), in Australia as Vegemite (Kraft Foods, Inc), and in Switzerland a similar product is Cenovis (Cenovis AG).•Sourdough breads. Sourdough starter is a form of yeast.•Certain multivitamin preparations. Yeast is a source of B vitamins and is present in many multivitamin preparations containing B vitamins.Food allergies are a growing concern. Registered dietitians will likely encounter patients seeking dietary counseling for suspected or diagnosed food allergies including requests such as a “yeast allergy diet.” Maintaining current information and resources to communicate evidence-based guidelines is critical. Working with a board-certified allergist can support the individual's understanding of this topic and help determine whether a dietary intervention is warranted or not. THERE ARE OVER 20 SPECIES OF Candida that can cause a fungal infection or candidiasis in humans.1Centers for Disease Control and PreventionCandidiasis.http://www.cdc.gov/fungal/candidiasis/Google Scholar The most common species, Candida albicans commonly resides on the skin, mouth, intestinal tract, vagina, and other moist, warm, and dark areas of the body. Candida is often called yeast, but it is a dimorphic fungus, meaning that it grows as a yeast form in a carbohydrate media and forms hyphae (strands) when the medium is low in nutrients. For this reason, Candida is also referred to as a psuedoyeast.2Joneja J.V. The Health Professionals Guide to Food Allergies and Intolerances. Academy of Nutrition and Dietetics, Chicago, IL2012Google Scholar Candida is a typical inhabitant of the body's resident microflora, but under certain circumstances it can become infective. Those at risk for infection include individuals with a weakened immune system due to certain medications (such as antibiotics) and diseases that compromise the immune system. The presence of oral candidiasis (thrush) is a common condition in human immunodeficiency virus–infected individuals and is associated with poor nutrition because it may result in painful mucosal lesions, impairing the ability to consume food.3Hendricks K.M. Dongs K.R. Gerriot J.L. Nutrition Management of HIV and AIDS. Academy of Nutrition and Dietetics, Chicago, IL2009Google Scholar Candida albicans can also be a cause of Candida vulvovaginitis, commonly termed “yeast infection.” Consuming cultured dairy products may offer some protection against the infection, but the evidence is not conclusive.4Pirotta M. Gunn J. Chondros P. et al.Effect of lactobacillus in preventing post-antibiotic vulvovaginal candidiasis: A randomized control trial.BMJ. 2004; 329: 548Crossref PubMed Scopus (96) Google Scholar Women with Candida vulvovaginitis may wish to try cultured dairy products not only for their potential ability to improve the infection, but also because of the nutrient density of these products. It has long been proposed that Candida might be an allergen associated with a variety of symptoms.5Barrett S. Dubious “yeast allergies”.http://www.quackwatch.com/01QuackeryRelatedTopics/candida.htmlGoogle Scholar The concept of “candidiasis hypersensitivity” was popularized in the book, The Yeast Connection, originally published in 1983. Promoters also referred to this condition as chronic candidiasis, candidiasis hypersensitivity, Candida-related complex, the yeast syndrome, yeast allergy, yeast overgrowth, or simply “Candida” or “yeast problem.” The American Academy of Allergy, Asthma, and Immunology issued a position statement that the concept of candidiasis hypersensitivity should be regarded as “speculative and unproven” unless supported by competent research.6Position statement: Executive Committee of the American Academy of Allergy and Immunology Candidiasis sensitivity syndrome.J Allergy Clin Immunol. 1986; 78: 271-273Abstract Full Text PDF PubMed Scopus (92) Google Scholar Another member of the fungi family is mold. The Academy publication, The Health Professionals Guide to Food Allergies and Intolerances, includes a chapter titled “Yeast and Mold Allergy.” According to the publication,2Joneja J.V. The Health Professionals Guide to Food Allergies and Intolerances. Academy of Nutrition and Dietetics, Chicago, IL2012Google Scholar individuals sensitized to fungi and fungal spores produce immunoglobulin E (IgE) against the fungal allergenic proteins. These IgE antibodies can be detected in blood tests such as allergen-specific IgE. In addition, skin tests for the fungal allergen are usually positive. There is no scientifically proven connection between Candida and this allergy discussed in the Academy publication. The management of a yeast and mold allergy requires the elimination of all food that might contain yeast or mold. A yeast and mold allergy handout will be available as part of a set of patient education materials available in 2013 with detailed recommendations for this allergy. Some of the yeast-related dietary exclusions include: •Baked goods. Yeast (Saccharomyces species) are used in leavened baked products.•Alcoholic beverages. Yeast fermentation of a substrate (sugar) is the basis of production of alcoholic beverages. Distilled beverages such as spirits, are usually tolerated.•Savory spreads. Some use yeast extracts. In Britain the product is marketed as Marmite (Unilever), in Australia as Vegemite (Kraft Foods, Inc), and in Switzerland a similar product is Cenovis (Cenovis AG).•Sourdough breads. Sourdough starter is a form of yeast.•Certain multivitamin preparations. Yeast is a source of B vitamins and is present in many multivitamin preparations containing B vitamins. Food allergies are a growing concern. Registered dietitians will likely encounter patients seeking dietary counseling for suspected or diagnosed food allergies including requests such as a “yeast allergy diet.” Maintaining current information and resources to communicate evidence-based guidelines is critical. Working with a board-certified allergist can support the individual's understanding of this topic and help determine whether a dietary intervention is warranted or not.

Nitrate (NO3) and nitrite (NO2) have a long history as an effective way to preserve meat. Nitrate alone is not effective in the curing process until it has been chemically reduced to nitrite.1Igoe R.S. Hui Y.H. Dictionary of Food Ingredients.4th ed. Aspen Publishers, Gaithersburg, MD2001: 98Google Scholar Nitrite converts to nitric oxide (NO) in the curing process when it reacts with the pigment in meat. This reaction stabilizes the color associated with processed meat products like hot dogs, bacon, and ham. As food additives, these compounds also provide protection against the deadly bacteria Clostridium botulinum.1Igoe R.S. Hui Y.H. Dictionary of Food Ingredients.4th ed. Aspen Publishers, Gaithersburg, MD2001: 98Google Scholar Estimates indicate that meat, on average, contributes 5% to 20% of dietary nitrate and nitrite intake, with drinking water providing about 10% to 25%. Vegetables, as a source of ingested nitrates, account for approximately 80% of dietary intake in the average population.2Hord N.G. Tang Y. Bryan N.S. Food sources of nitrates and nitrites: The physiologic context for potential health benefits.Am J Clin Nutr. 2009; 90: 1-10Crossref PubMed Scopus (624) Google ScholarDietary nitrate and nitrite are substrates for a diverse group of metabolites. Ingested nitrate reduced to nitrite can also bind with hemoglobin to form methemoglobin. In methemoglobinemia, the hemoglobin is unable to release oxygen effectively to body tissues. According to the American Academy of Pediatrics (AAP), infants fed formula prepared with well water contaminated with nitrates are at the greatest risk of methemoglobinemia or “blue baby syndrome.”3Greer F.R. Shannon M. the American Academy of Pediatrics Committee on Nutrition, the American Academy of Pediatrics Committee on Environmental HealthInfant methemoglobinemia: The role of dietary nitrate in food and water.Pediatrics. 2005; 116 (Statement reaffirmed April 2009): 784-786Crossref PubMed Scopus (222) Google Scholar A safe source of water should be found for preparing infant formula. Nitrates are inorganic and cannot be destroyed by boiling. Reports of nitrate poisoning from home-prepared vegetable foods for infants are rare. A preventive strategy recommended by AAP is that home-prepared infant foods from vegetables (eg, spinach, beets, green beans, squash, carrots) should be avoided until infants are 3 months or older, although there is no nutritional indication to add complementary foods to the diet of the term infant before 4 to 6 months of age. Breastfeeding infants are not at risk of methemoglobinemia even when mothers ingest water with very high concentrations of nitrate nitrogen (100 ppm).Dietary intake of nitrates and nitrites can increase the endogenous formation of N-nitroso compounds. Results from animal studies and mechanisms describing DNA damage suggest that these compounds are carcinogenic in humans. However, a lack of compiled data on N-nitroso compounds in foods has hampered efforts to accurately measure intake. The development of a database to quantify N-nitroso compounds accurately has been reported by Stuff and colleagues.4Stuff J.E. Goh E.T. Barrera S.L. Bondy M.L. Forman M.R. N-nitroso compounds: Assessing agreement between food frequency questionnaires and 7-day food records.J Am Diet Assoc. 2009; 109: 1179-1183Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Cancer prevention guidelines recommend limiting intake of processed meat, but researchers have not yet been able to determine the key factor linking processed meat and cancer.5Wiseman M. The second World Cancer Research Fund/American Institute for Cancer Research expert report. Food, nutrition, physical activity, and the prevention of cancer: A global perspective.Proc Nutr Soc. 2008; 67: 253-256Crossref PubMed Scopus (619) Google Scholar Nitrates and nitrates and their resulting N-nitroso compounds may be key, but the research continues to be monitored.There is emerging evidence that conversion of dietary nitrate and nitrite to nitric oxide has beneficial effects in cardiovascular disease, with promising results in the lowering of blood pressure.6Lundberg J.O. Carlstrom M. Larsen F.J. Weitzbert E. Roles of dietary inorganic nitrate in cardiovascular disease and health.Cardiovasc Res. 2011; 89: 525-532Crossref PubMed Scopus (228) Google Scholar The positive research challenges the traditional view of nitrates, but is still in its infancy. A study by Murphy and colleagues shows that eating cooked beets “acutely improves running performance.”7Murphy M. Eliot K. Heuertz R.M. PhD Weiss E. Whole beetroot consumption acutely improves running performance.J Acad Nutr Diet. 2012; 112: 548-552Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar The key, according to the study, is nitrate. However, the authors make clear that the “apparent paradox” of nitrates being both harmful and healthful needs more research. For those wishing to increase their nitrate intake for health benefits it is best to obtain it from nitrate-rich vegetables like leafy greens or the roots of plants with leafy greens, such as beets. The research on this topic continues to evolve and ranges from the earliest reports indicating harm to more recent research that indicates a role as a substrate for in vivo generation of nitric oxide.2Hord N.G. Tang Y. Bryan N.S. Food sources of nitrates and nitrites: The physiologic context for potential health benefits.Am J Clin Nutr. 2009; 90: 1-10Crossref PubMed Scopus (624) Google Scholar Implications of emerging research aside, the recommendation to eat more vegetables is one of the tried and true recommendations for a healthy diet. Nitrate (NO3) and nitrite (NO2) have a long history as an effective way to preserve meat. Nitrate alone is not effective in the curing process until it has been chemically reduced to nitrite.1Igoe R.S. Hui Y.H. Dictionary of Food Ingredients.4th ed. Aspen Publishers, Gaithersburg, MD2001: 98Google Scholar Nitrite converts to nitric oxide (NO) in the curing process when it reacts with the pigment in meat. This reaction stabilizes the color associated with processed meat products like hot dogs, bacon, and ham. As food additives, these compounds also provide protection against the deadly bacteria Clostridium botulinum.1Igoe R.S. Hui Y.H. Dictionary of Food Ingredients.4th ed. Aspen Publishers, Gaithersburg, MD2001: 98Google Scholar Estimates indicate that meat, on average, contributes 5% to 20% of dietary nitrate and nitrite intake, with drinking water providing about 10% to 25%. Vegetables, as a source of ingested nitrates, account for approximately 80% of dietary intake in the average population.2Hord N.G. Tang Y. Bryan N.S. Food sources of nitrates and nitrites: The physiologic context for potential health benefits.Am J Clin Nutr. 2009; 90: 1-10Crossref PubMed Scopus (624) Google Scholar Dietary nitrate and nitrite are substrates for a diverse group of metabolites. Ingested nitrate reduced to nitrite can also bind with hemoglobin to form methemoglobin. In methemoglobinemia, the hemoglobin is unable to release oxygen effectively to body tissues. According to the American Academy of Pediatrics (AAP), infants fed formula prepared with well water contaminated with nitrates are at the greatest risk of methemoglobinemia or “blue baby syndrome.”3Greer F.R. Shannon M. the American Academy of Pediatrics Committee on Nutrition, the American Academy of Pediatrics Committee on Environmental HealthInfant methemoglobinemia: The role of dietary nitrate in food and water.Pediatrics. 2005; 116 (Statement reaffirmed April 2009): 784-786Crossref PubMed Scopus (222) Google Scholar A safe source of water should be found for preparing infant formula. Nitrates are inorganic and cannot be destroyed by boiling. Reports of nitrate poisoning from home-prepared vegetable foods for infants are rare. A preventive strategy recommended by AAP is that home-prepared infant foods from vegetables (eg, spinach, beets, green beans, squash, carrots) should be avoided until infants are 3 months or older, although there is no nutritional indication to add complementary foods to the diet of the term infant before 4 to 6 months of age. Breastfeeding infants are not at risk of methemoglobinemia even when mothers ingest water with very high concentrations of nitrate nitrogen (100 ppm). Dietary intake of nitrates and nitrites can increase the endogenous formation of N-nitroso compounds. Results from animal studies and mechanisms describing DNA damage suggest that these compounds are carcinogenic in humans. However, a lack of compiled data on N-nitroso compounds in foods has hampered efforts to accurately measure intake. The development of a database to quantify N-nitroso compounds accurately has been reported by Stuff and colleagues.4Stuff J.E. Goh E.T. Barrera S.L. Bondy M.L. Forman M.R. N-nitroso compounds: Assessing agreement between food frequency questionnaires and 7-day food records.J Am Diet Assoc. 2009; 109: 1179-1183Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Cancer prevention guidelines recommend limiting intake of processed meat, but researchers have not yet been able to determine the key factor linking processed meat and cancer.5Wiseman M. The second World Cancer Research Fund/American Institute for Cancer Research expert report. Food, nutrition, physical activity, and the prevention of cancer: A global perspective.Proc Nutr Soc. 2008; 67: 253-256Crossref PubMed Scopus (619) Google Scholar Nitrates and nitrates and their resulting N-nitroso compounds may be key, but the research continues to be monitored. There is emerging evidence that conversion of dietary nitrate and nitrite to nitric oxide has beneficial effects in cardiovascular disease, with promising results in the lowering of blood pressure.6Lundberg J.O. Carlstrom M. Larsen F.J. Weitzbert E. Roles of dietary inorganic nitrate in cardiovascular disease and health.Cardiovasc Res. 2011; 89: 525-532Crossref PubMed Scopus (228) Google Scholar The positive research challenges the traditional view of nitrates, but is still in its infancy. A study by Murphy and colleagues shows that eating cooked beets “acutely improves running performance.”7Murphy M. Eliot K. Heuertz R.M. PhD Weiss E. Whole beetroot consumption acutely improves running performance.J Acad Nutr Diet. 2012; 112: 548-552Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar The key, according to the study, is nitrate. However, the authors make clear that the “apparent paradox” of nitrates being both harmful and healthful needs more research. For those wishing to increase their nitrate intake for health benefits it is best to obtain it from nitrate-rich vegetables like leafy greens or the roots of plants with leafy greens, such as beets. The research on this topic continues to evolve and ranges from the earliest reports indicating harm to more recent research that indicates a role as a substrate for in vivo generation of nitric oxide.2Hord N.G. Tang Y. Bryan N.S. Food sources of nitrates and nitrites: The physiologic context for potential health benefits.Am J Clin Nutr. 2009; 90: 1-10Crossref PubMed Scopus (624) Google Scholar Implications of emerging research aside, the recommendation to eat more vegetables is one of the tried and true recommendations for a healthy diet.

THE INSTITUTE OF MEDICINE report Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids includes the following definition of a dietary antioxidant: "A dietary antioxidant is a substance in foods that significantly decreases the adverse effects of reactive species, such as reactive oxygen and nitrogen species, on normal physiological function in humans".1

Multiple sclerosis (MS) is a disease whose precise origin is unknown, although it is generally accepted that MS involves an immune-mediated process. The disease is characterized by the destruction of myelin sheath, the protective material that surrounds and protects nerve cells in the brain and spinal cord. The progressive loss and thinning of myelin leads to the formation of scar tissue or plaques. This interferes with the transmission of nerve signals producing symptoms which vary depending on where damage has occurred. Common symptoms of MS include fatigue, pain, numbness, blurred vision, cognitive impairment, and bladder and bowel dysfunction, but the course of MS is unpredictable and varies individually, with some patients experiencing minimal impairment. There is no cure for MS. Medications are used to help control symptoms and slow the progression of the disease.1National Multiple Sclerosis SocietyAbout MS.http://www.nationalmssociety.org/about-multiple-sclerosis/index.aspxGoogle Scholar A review of complementary and alternative medicine (CAM) use among MS patients indicates that up to 70% of patients with MS try one or more CAM therapies.2Yadav V. Shinto L. Bourdette D. Complementary and alternative medicine for the treatment of multiple sclerosis.Expert Rev Clin Immunol. 2010; 6: 381-395Crossref PubMed Scopus (69) Google Scholar The researchers found most MS patients use both conventional and complementary therapies and perceive both to be beneficial. Dietary supplements commonly used include n-3 fatty acids, lipoic acid, ginkgo biloba, ginseng, green tea polyphenols, and vitamin D. Of these, the supplements identified as warranting further investigation were n-3, lipoic acid, and vitamin D supplementation. A low-fat diet was also identified as a therapy used by many MS patients, with the most popular diet approach being a diet introduced by neurologist Roy Swank over 50 years ago. The Swank diet is characterized by a low amount of saturated fat not to exceed 15 g and supplementation with cod liver oil. Follow-up by Swank reported positive outcomes, but research related to the Swank diet has been criticized for the lack of a control group for comparison for scientific validation. A 2012 Cochrane review attempted to answer MS patients' questions about safety of dietary regimen and whether these changes could favorably impact the prognosis for people with MS.3Farinotti M. Vacchi L. Simi S. Di Pietrantonj C. Brait L. Filippini G. Dietary interventions for multiple sclerosis.Cochrane Database Syst Rev. 2012; 12 (Published December 12, 2012. Accessed April 30, 2013)http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004192.pub3/abstractPubMed Google Scholar Selection criteria limited participants to adult patients with clinically definitive MS in controlled clinical trials. All controlled trials with advice or instructions on a specific dietary intervention, diet plan, or dietary supplementation (except vitamin D) that were compared to no dietary modification or placebo were eligible. Many dietary interventions have been recommended or studied for managing MS such as allergen-free, gluten-free, and raw food diets, but none were found that met inclusion criteria. The resulting six studies used in the review were all related to polyunsaturated fatty acids. The Swank diet and some of the other dietary intervention studies for MS patients were not included in the review. At the time some of them were published, methodological aspects were not as stringent as they are today, or they were not randomized or had an outcome other than disease progression. The lead researcher of the Cochrane study was quoted as saying that patients with MS should not focus on any particular supplement or dietary approach but adopt healthy eating habits, and also noted a high incidence of malnutrition in patients with MS.4Anderson P. Jury still out on dietary interventions in MS. Medscape.December 27, 2012http://www.medscape.com/viewarticle/776775Google Scholar A second 2012 review of nutritional factors impacting MS found that patients with low blood levels of vitamin D have more brain lesions and signs of a more active disease state. This research suggests a potential link between higher vitamin D levels and lower subsequent disability, but according to the study authors, these observations did not prove a cause-and-effect relationship.5von Geldern G. Mowry E.M. The influence of nutritional factors on the prognosis of multiple sclerosis.Nat Rev Neurol. 2012; 8: 678-689Crossref PubMed Scopus (78) Google Scholar Considering the wide range in disease course severity and the risk of malnutrition among MS patients, registered dietitians working with MS patients should review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems based on these signs and symptoms. Weight and weight history is the first parameter for consideration when malnutrition is suspected. Common problems that may be modified by nutrition care include conditions addressed in the Nutrition Care Manual, such as dysphagia and constipation. Particular attention should be paid to the MS patient's appetite and ability to eat with or without assistance, as well as arrangements regarding food shopping and cooking. RDs need to ascertain the use of dietary supplements given their prevalent use among MS patients. Details on special diets used by MS patients should be reviewed for efficacy and safety. RDs can help consumers critically assess their supplement practices and help them make informed choices. Supportive nutrition education tailored to the individual can help a person with MS meet nutritional needs and regain some feeling of control in his or her life.