DIFM Symposium
Dietary Supplements: An Integrative and Functional Approach- Recording Available

FNCE Boston 2016 – Session Reviews

Session Title: Ethical dilemmas on Recommending Supplements and Over the Counter Medications

Session Date: October 16, 2016

Session Presenters: Dana Buelsing, Kathryn Hamilton, MA, RDN, CSO, CDN, FAND, and Kelly Leonard, MS, RDN

Session Description: Often patients will ask a registered dietitian nutritionist (RDN) for advice or recommendations regarding dietary supplements and over the counter (OTC) medications. It is within the RDN’s scope of practice and area of expertise to help the client or patient navigate the broad and often confusing chasm of information, marketing and promotion related to dietary supplements, but this does require some specific guidelines and consideration. The speakers addressed some common scenarios and ethical questions relating to suggesting, selling and analyzing supplements.

Key takeaway points included:

1. It is not within the RDN and NDTR’s scope of practice to recommend dosages and use of OTC and prescription medication, but is within the scope to recommend use and dosage of dietary supplements using evidence-based guidelines.

2. Familiarity with dietary supplements, medications and nutrient interactions should be considered and discussed with the healthcare team and documented as necessary.

3. A supplement recommendation should be:
• Evidence-based
• Compliant with State and Federal regulations
• Allowed within the employer’s or organization’s guidelines and regulations
• Provided with competency and within the Code of Ethics standards

4. RDNs have the opportunity to educate and recommend supplement brands based on their knowledge, quality, integrity and efficacy, especially related to helping consumers identify reputable sources. Pointing out a third party-verification such as NSF, USP and highlighting reliable resources such as the NIH’s Office of Dietary Supplements and ConsumerLabs.com for independent testing information is encouraged.

5. Additional considerations regarding recommendations are ensuring that they are made without personal bias and comply with State and Federal regulations.

6. If selling supplements in the office, considerations must be made related to:
• Complying with the same principles set forth in “Responsibilities to the Public”
• Practicing using current and evidence-based information
• Understanding the legal issues related to the sale
• Providing full disclosure regarding any financial relationship with the supplier as well as any perceived conflict of interest

It was also noted that when recommending a supplement, the RDN is responsible for conducting him or herself with professionalism, honesty and integrity, communicating with the healthcare team and providers, and documenting thoroughly. Additionally, keeping the following questions in mind may be helpful in guiding recommendations:
a.) Are you competent in making the supplement recommendation? Is it evidence-based?
b.) Are you complying with State and Federal regulations as well as with your employer/organization?
c.) Are you acting within the Code of Ethics, without bias or conflict of interest?

The following resources related to these key points were directly extracted from the resources handout provided by the speakers.

1. Academy Definition of Terms List. Academy of Nutrition and Dietetics Web site. www.eatrightpro.org/scope. Published July 2016. Accessed September 9, 2016.
2. Advising Patients on Use of Dietary Supplements. Dietitians in Integrative and Functional Medicine Web site. http://integrativerd.org/advising-patients-on-use-of-dietary-supplements/. Published November 18, 2015. Accessed September 9, 2016.
3. Dickinson A, Bonci L, Boyon N, Franco JC. Dietitians use and recommend dietary supplements: report of a survey. Nutrition Journal. 2012;11:14. doi:10.1186/1475-2891-11-14.
4. FDA 101: Dietary Supplements. FDA Web Site. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm050803.htm. Accessed September 9, 2016.
5. Key Points for Physicians and other Healthcare Licensees to Consider When Selling Dietary Supplements to Patients. Michael Cohen Web site. http://www.michaelhcohen.com/2014/12/key-points-for-physicians-and-other-healthcare-licensees-to-consider-when-selling-dietary-supplements-to-patients/. Accessed September 9, 2016.
6. Mehrotra A, Beelman RB, Levy E, Siuty J, Kalaras MD, Uribarn J. Bioavailability of vitamin D2 from enriched mushrooms in prediabetic adults: a randomized controlled trial. European Journal of Clinical Nutrition. 2014;68:1154-1160.
7. Scope of Practice Decision Tool. Academy of Nutrition and Dietetics Store Web site. http://www.eatrightstore.org/product/051ECA8D-389E-478D-BD29-D259DB3AB295. Accessed September 9, 2016.
8. Steinmuller PL, Kruskall LJ, Karpinski CA, Manore MM, Macedonio MA, Meyer NL. Academy of Nutrition and Dietetics: Revised 2014 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sports Nutrition and Dietetics. JAND. 2014;114(4):631-641.e43.
9. The Academy Quality Management Committee, and Scope of Practice Subcommittee of the Quality Management Committee. Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitians. JAND. 2013;113(6):S29-S45. doi:10.1016/j.jand.2012.12.007.
10. Thomson C, Diekman C, Sarubin Fragakis A, Meerschaert C, Holler H, Devlin C. Guidelines Regarding the Recommendation and Sale of Dietary Supplements. American Dietetic Association Journal. 2002;102(8):1158-1164. doi:10.1016/S0002-8223(02)90257-9.
11. 2015 CRN Consumer Survey on Dietary Supplements. CRN Web site. http://www.crnusa.org/CRNconsumersurvey/2015/. Accessed September 15, 2016.

Reviewed by: Monique Richard is a registered dietitian nutritionist (RDN) and licensed dietitian nutritionist (LDN) with a Master of Science degree in Clinical Nutrition. She is an integrative outpatient dietitian and owner of Nutrition-In-Sight specializing in counseling, consulting and nutrition communication services. Monique is the Immediate Past Chair of the Dietitians in Integrative and Functional Medicine Dietetic Practice Group and former board member of the American Overseas Dietetic Association. Monique is part of the Academy’s Food and Nutrition Security Task Force.

Session Title: Complexities of Lyme Disease and Other Stealth Pathogens

Session Date: October 18, 2016

Presenters: Lori Enriquez, MPH, RDN, LDN, CHES, FAND; Andre Garabedian, MD, FAAFP, ABIHM

Session Description:

The goal of this session is to educate RDNs on diagnosis and testing for Lyme disease and stealth pathogens, identifying patients at risk, and the integrative nutrition therapies that might best support these populations.

Diagnosis of Lyme disease is complex. Many symptoms of Lyme can be mistaken for other comorbid conditions, specifically inflammatory disorders. The popular bulls eye rash is unreliable as the sole indicator for diagnosis. Not all experience the rash and 20-25% who do, present with it in their hairline. Lyme can frequently go undiagnosed, as symptoms within the first 3-30 day’s present often like the common flu.

Symptoms of chronic Lyme vary and are primarily inflammatory in nature. Migratory arthritic pain, neuropathies, chronic pain, sleep disturbances, personality disorders, recurrent flu-like symptoms, and increased sensitivity to foods, smells, light and noises are common chronic symptoms. Red flags for Lyme include a combination of autoimmune disease(s), brain fog, and patients who have seen many health care professionals looking for answers where traditional treatments do not seem to help. Family history is additionally important as Lyme can be transmitted through breastfeeding and in utero.

An adequate immune system can overwhelm Lyme and suppress the disease into a dormant state. With Lyme spirochetes in dormancy, an effective diagnosis may be difficult with lab testing, thus a negative Western Blot could be misleading. Additionally, co-infections including Babesia, Candida, Bartonella, Ehrlichia/Anaplasma often present with Lyme and complicate treatment strategies. Antibiotics are the primary treatment for Lyme and co-infections, but herbal antimicrobials may be additionally incorporated. Treating the domain in which the Lyme and co-infections live through individualized care and providing support to the various affected body systems is advised.

Dietitians have an influential role in the treatment. Key points include:

• Team with Lyme literate medical doctor as needed.
• Address nutrient deficiencies, immune support, digestive health, detoxification, and reducing inflammation via diet and lifestyle.
• Monitor possible drug nutrient interactions, as well as appropriate timing in regard to supplements and medications being used.

Herxheimer Reaction
• The Herxheimer reaction or “die-off” is common during Lyme treatment—binders and detox support can help lessen symptoms.
• Activated charcoal is an effective binder—500-550 mg taken 4 hours away from other supplements is advised—patients can take doses in the middle of the night.
• Alka seltzer gold has been found to be very effective for easing unexpected symptoms, 2-4 tablets/day is an appropriate dose.

• Combined complimentary and traditional therapy to support detoxification and regular bowel movements is advised.
• Dry brushing of the skin prior to showering can help detox the skin, a large organ of the body.
• Increased fluid intake, magnesium citrate, and herbs like burbur-pinella support detoxification.
• N-acetyl cysteine and glutamine combined help to increase glutathione production.
• Bentonite clay and chlorella are other binding options for heavy metal detox support.
• Water with lemon is an inexpensive and effective means of detox support.
• Rebounding (i.e. jumping on a trampoline) helps support the lymphatic system.

Diet-Specific Support
• Anti-inflammatory, low sugar, high fiber, and antioxidant-rich diet.
• Whole foods focus.
• Blood sugar regulation.
• Patients must be assessed for co-existing GI conditions including SIBO, candida, histamine intolerance, and provided with the appropriate therapeutic diets.
• Allicin (derived from garlic) and monolaurin (derived from coconut), are effective herbal antimicrobials to support healthy yeast.

Lori Enriquez’s website provides a wealth of resources related to Lyme disease and biotoxins for patients and practitioners.

Reviewed by Olivia Wagner, MS, RDN, LDN, DIFM Policy Advocacy Leader. Contact Olivia at oliviawagner28@gmail.com.

Session Title: Review of Lessons learned in Research and Patient Care in a Multidisciplinary Allergy, Gastroenterology, and Nutrition Clinic

Session Date: October 18, 2016

Session Presenters: Heather Rasmussen, PhD, RD, Hannah Roosevelt, MS, RD, CNSC and introduction by Sherry Coleman Collins, MS, RDN, LD.

Session Description
Sherry Coleman Collins, MS, RDN, LD is the author of the practice paper of the Academy of Nutrition and Dietetics: Role of the Registered Dietitian Nutritionist in the Diagnosis and Management of Food Allergies.

The session’s main presenters then went on to describe the basic mechanisms behind the four types of food hypersensitivity with a focus on food allergies. Various food allergy diagnostic tools were also discussed, including IgE antibody tests and skin prick tests and how to determine the best nutrition intervention based on test results. Both dietitians work at Rush University Medical Center which has a multidisciplinary center that includes gastrointestinal doctors, RDNs and general medical doctors. This type of center allows for patients to have a ”one stop shop,” in that the patient can see the dietitian and doctors all in the same day, allowing practitioners to easily work together and thereby improve patient care.

There are several different types of food hypersensitivities:

• Food allergy: Immune-mediated reaction;
• Food intolerance: Non-immune mediated reaction;
• Food sensitivity: Adverse immune reaction without physical signs/symptoms.

A peanut allergy is an example of an IgE-mediated response and has many risk factors. Genetic factors include being female, a history of rhinitis, eczema, asthma, and a history of IgE aeroallergen sensitization. Suspected environmental factors include microbiome alterations (as theorized by the hygiene hypothesis), alterations in food composition, and cross-reactive food allergies. There are also Non-IgE mediated mechanisms mediated by a T-cell response like T helper 2 cells without IgE mediators, T helper 1 cells, T regulatory cells, and IgG antibodies, which release inflammatory cytokines.

As the gastrointestinal tract is a key location for immune stimulation by food, dietitians can play an obvious role. Hypersensitivity to food stimulates the immune system and may impact the gut barrier, causing symptoms that manifest as allergies. The RDN can help to manage these symptoms.

A large portion of the patients seen at the Rush clinic have irritable bowel syndrome (IBS) which can often be related to a histamine reaction. In a trial conducted at the Rush Clinic, some IBS patients were given a placebo and some were given a histamine antagonist. Those that took the antagonist blocked the histamine from reacting in the GI tract and decreased pain. However, along with this medication, food is a huge factor in histamine control. Here again, RDNs can have an impact by guiding patients away from histamine rich foods.

There are several diagnostic tools that help detect food hypersensitivities such as the skin prick test, blood test, oral food challenge, and the food elimination diet. Out of these tools, the gold standard is the oral food challenge. Although it is very specific, an individual food challenge can be expensive and has a potential for severe allergic reaction.

The Rush clinic initially started to work with patients with atopic IBS. The clinic looked at the prevalence of IBS in relation to allergic reactions like eczema and rhinitis. The use of diet history, a food elimination diet and a food frequency questionnaire are tools used to help the staff at the clinic narrow down what might be causing the digestive and allergy issues.

RDNs can be an integral part of treatment for those dealing with gastrointestinal issues. A multidisciplinary clinic benefits the patient and makes communication easier for medical professionals.

Sources: Collins SC. Practice Paper of the Academy of Nutrition and Dietetics: Role of the Registered Dietitian Nutritionist in the Diagnosis and Management of Food Allergies. J Acad Nutr Diet. 2016;116(10):1621-31. doi:10.1016/j.jand.2016.07.018.

Reviewer: Leah Negrin graduated from Long Island University with her B.S. in Nutrition and is currently working at Noom Inc. as a health and nutrition coach. She will be applying for her M.S. in Nutrition.

Session Title: The Emerging Field of Yoga Therapy in Dietetics

Session Date: October 16, 2016

Presenters: Anu (Sandeep) Kaur, MS, RDN, RYT; Sat Bir Khalsa, PhD; and Annie B. Kay, MS, RDN, E-RYT 500

Yoga therapy—the application of yoga practices for therapeutic purposes or healing—is a growing field, and dietitians are successfully using yoga therapy in nutrition practice settings. During this session, Anu Kaur, MS, RDN, RYT, provided an overview of yoga as a mind-body intervention and outlined its rise in popularity among the general public. Dr. Sat Bir Khalsa discussed the psychophysiological mechanisms by which yoga helps manage stress and supports healthful behavior change. Annie B. Kay, MS, RDN, E-RYT 500, concluded the session with a summary of credentialing for yoga teachers and yoga therapists, discussion of application for RDNs and practitioners of integrative and functional medicine, and a group practice of breathing techniques done while standing.

Kaur began by defining mind-body interventions as therapies that utilize the mind’s capacity to affect bodily function and symptoms. Yoga is one example of a mind-body intervention gaining popularity in the mainstream as a holistic approach to health and well-being. According to the 2016 Yoga in America Study, there are currently 36.7 million yoga practitioners in the United States, up from 20.4 million in 2012, with 74% having practiced for five years or less. Kaur stressed that yoga is not just about exercise and touched on yoga philosophy including the eight limbs of yoga. She described several of these components including postures (asanas), hand gestures (mudras), sound (mantras), breathing (pranayama), focus (drishti), and concentration (dharana). She then outlined some main principles of yoga therapy, emphasizing that teachings are individualized to the client, just as RDNs customize their recommendations to individual needs.

Dr. Khalsa, a prominent yoga researcher, provided an overview of research outcomes pertaining to yoga practices, including postures, breathing, relaxation, and meditation. Studies demonstrating efficacy of yoga practices on fitness, self-regulation, and awareness were reviewed. Dr. Khalsa noted a sharp increase in the body of yoga therapy research since 1999, mostly pertaining to mental health, cardiovascular conditions, and respiratory conditions. Positive impacts on insulin sensitivity, diabetes management, and eating disorder prevention and treatment were noted. Regarding quality of life, results from a national survey of yoga practitioners published in 2013 found that 86.5% of survey respondents agreed or strongly agreed that “I am happier because of yoga.”

Kay proceeded with examples of nutrition practice settings in which qualified RDNs are integrating yoga skills with chronic disease prevention and management as well as among patients with eating disorders. She reviewed the scope and standards of practice for RDNs in integrative and functional medicine as well as for yoga teachers, yoga therapists, and Ayurveda practitioners. She emphasized the need to be aware of evolving certification standards and of being adequately trained. Currently available credentials for yoga teachers, yoga therapists, and Ayurvedic practitioners are listed in Table 1. Next, she gave examples of yoga therapy techniques for digestive health including self-massage, getting upside down safely, abdominal lift (uddiyana bandha), and belly-pump breathing, which may be integrated with dietary changes. Potential contraindications were also presented including pregnancy, menstruation, stomach ulcer, hiatal hernia, gastroesophageal reflux, cardiovascular disease, and hypertension. Kay then led the group in a practice of breathing techniques before describing preliminary results of a survey she is conducting on use of therapeutic yoga by RDNs. Out of 17 respondents, 69% were using yoga therapeutically within their practices; and 100% were either in the process of or had obtained an RYT credential while only two had obtained the C-IAYT credential.

RDNs seeking continuing professional education programs on yoga, meditation, and mindful eating will find additional information at www.innerdoorcenter.com (Mindfulness-Based Yoga Certification in Eating Disorders approved for 50 CPEUs by the CDR), www.mindfuleatingtraining.com (Mindful Eating Training approved for 28 CPEUs by the CDR), and www.wolfrinke.com/CEFILES/C221CPEcourse.htm (Yoga & Meditation: Tools for Weight Management, 2nd edition, approved for 14 CPEUs by the CDR).

Organization Website Designations Available
Yoga Alliance (YA)

Credentialing body for yoga teachers and schools

www.yogaalliance.org Registered Yoga Teacher (RYT):

·         RYT 200

·         RYT 500

·         E-RYT 200 (Experienced Registered Yoga Teacher)

·         E-RYT 500

·         RCYT (Registered Children’s Yoga Teacher)

·         RPYT (Registered Prenatal Yoga Teacher)

International Association of Yoga Therapists (IAYT)

Credentialing body for yoga therapists and schools

www.iayt.org IAYT-Certified Yoga Therapist (C-IAYT)

Note: Grandparenting available through June 2017

National Ayurveda Medical Association (NAMA)

National membership organization of Ayurvedic professionals who meet established qualifying criteria

www.ayurvedanama.org Professional practice categories:

·         Ayurvedic Health Counselor (AHC)

·         Ayurvedic Practitioner (AP)

·         Ayurvedic Doctor (AD)

·         Ayurvedic Yoga Therapist (AYT) currently under                        development

Reviewed by Holly A. Van Poots, RDN, CSP, FAND. Holly has more than 15 years of experience working with acutely ill children in several large health systems and is the immediate past chair of the Pediatric Nutrition Practice Group (PNPG). She has also been a certified group fitness instructor since 1998. Contact Holly at hollypnpg@gmail.com.