SCAN Winter 2013

Winter 2013,Vol.32,No.1
I CONTENTS
1
Working with Dietary Restrictions
Related to Allergies in the Treatment
of Eating Disorders
3
From the Editor
5
CPE article:
Endothelial Dysfunction and the
Female Athlete Triad:Research
Updates and Management
Recommendations
8
High-Sodium Diets in Spaceflight:
Health Consequences and Methods
to Reduce Intake
11
Dietary Nitrates and Nitrites from
Vegetables and Fruits:How Can
Something So Bad Be So Good?
(Part 2)
15
From the Chair
16
Conference Highlights
17
Reviews
18
Sports Dietetics-USA Research
Digest
20
SCAN Notables
20
Of Further Interest
24
Upcoming Events
The signs and symptoms of food al-
lergy vary,ranging from mild skin re-
actions such as itching,rash,and
facial or tongue swelling to serious,
life-threatening reactions that can re-
sult in anaphylaxis or death.The
prevalence of documented food al-
lergies in the general population is
approximately 6% to 8% in children
and 2% in adults.1
However,30% to
40% of individuals in the general
population report a prior adverse re-
action to food.2
The discrepancy be-
tween documented cases of true
food allergy versus perception is
linked to misinformation among the
general population,possible misdiag-
nosis,or incorrect classification of
food intolerance as allergy.The diag-
nosis of food allergy can have a sig-
nificant psychological impact on the
patient,including increased anxiety
and a lower quality of life.3
Further-
more,the need to eliminate certain
foods from the diet may exacerbate
or lead to the development of an eat-
ing disorder.3,4
With the reported prevalence of food
allergy rising and the use of alterna-
tive diagnostic methods for food al-
lergy gaining popularity,practitioners
need to understand the differences
S C A N ’ S
Pu l s e
Working with Dietary Restrictions
Related to Allergies in the Treatment
of Eating Disorders
by Nancy M.Lea,MS,RD
between documented food allergies
and non-immunoglobulin E (IgE)-me-
diated food intolerance and must be
able to identify unsupported food al-
lergy claims.It is especially important
for dietitians working in the field of
eating disorders to be knowledge-
able in the proper documentation
and diagnosis of food allergy.The eat-
ing disorder patient population is
prone to over-restricting food intake
and may use a misdiagnosis or self-
reported diagnosis as a means to fur-
ther restrict their food intake.
Is It Food Allergy or
Intolerance?
According to the National Institute of
Allergy and Infectious Disease,food
allergy is defined as an adverse reac-
tion that results from an immune
(IgE-mediated) response that occurs
as the result of exposure to a specific
food or allergen.5
In food allergy,the
body mounts an immune reaction
against an otherwise harmless food
protein.While an individual may per-
ceive an allergic response to several
foods,in reality an allergy to more
than three foods is rare.1
There are eight common foods that
comprise the majority of food aller-

dioactively labeled IgE.RAST is used
to identify antibodies with increased
levels as predictors of clinical symp-
toms.RAST is considered less sensi-
tive than other tests,but its
advantage is that it can be used
while a patient is on antihistamines.
The double-blind placebo-controlled
food challenge (DBPCFC) is consid-
ered the gold standard for the diag-
nosis of food allergy.Although it is
most often used in research,it may
be necessary when the patient’s per-
ceptions may bias symptom assess-
ment (as in the case of a subjective
symptom such as abdominal pain).1,6
Oral challenges are more definitive in
their results than other diagnostic
tests.PST has been shown to be a
poor predictor with a positive result
and it merely suggests the presence
of an allergy.However,a negative re-
sult in PST almost always excludes
IgE reactions; therefore,a negative re-
sult can be used confidently to rule
out immunologic involvement.Given
the complexity of proper diagnosis,it
is important that proven clinical tech-
niques are used to determine food al-
lergy and that the results of these
tests are carefully interpreted by a
skilled clinician.
Alternative testing for food allergy is
not well accepted.Unproven diag-
nostic techniques include IgA and
IgG4 measurement,electrodermal
skin testing,ALCAT testing,and ap-
plied kinesiology.7
Clinicians working
with eating disorder patients should
recognize the differences between
evidence-based,accepted diagnostic
techniques and those that do not
have scientific backing or remain
controversial.
It is not uncommon for patients with
eating disorders to perceive that they
do not tolerate or are allergic to vari-
ous foods.Sometimes these percep-
tions are the result of inaccurate or
inconclusive testing for allergies.
Sometimes they are the result of irri-
table bowel syndrome or a conse-
quence of a healthcare provider’s
suggestion to cut out certain foods.8
The first step in working with eating
disorder patients who have pur-
ported food allergy symptoms is to
2 | SCAN’S PULSE Winter 2013,Vol.32,No.1
gens:wheat,milk,soy,eggs,peanuts,
tree nuts (e.g.,almonds,cashews),
fish,and shellfish.These foods ac-
count for up to 90% of all verified al-
lergic reactions.1
Allergy to certain
items,such as wheat or milk,may
pose a higher risk to patients be-
cause these foods can be difficult to
avoid and their elimination from the
diet may lead to nutrient deficiency if
replacement foods are not intro-
duced.
Food intolerance (i.e,non-IgE-medi-
ated responses) are adverse reactions
to food caused by toxic,pharmaco-
logic,metabolic,idiosyncratic,or
other non-IgE-mediated reactions to
food or chemicals found in the food.
They are more difficult to diagnose
than food allergy.However,most
non-IgE-mediated gastrointestinal
food intolerances occur at infancy
and are outgrown within the first 2 to
3 years of life.6
Diagnosis of Food Allergy
Due to the risk and possible severity
associated with food allergy,dieti-
tians who work with eating disorders
patients must be aware of methods
for accurately and conclusively diag-
nosing food allergy.No single test
can conclusively diagnose all food al-
lergies. Instead,diagnosis typically
happens as a series of steps.The first
step is to identify the suspected food
or food group.Next,some evidence
such as a detailed food history is re-
quired to show that the food is caus-
ing an adverse reaction.In the last
step,proof of immunologic involve-
ment is obtained via diagnostic test-
ing.Three common modes of testing
may be used:1) the prick skin test; 2)
radioallergosorbent testing; and 3)
the oral food challenge (open,single-
or double blind placebo test).
The prick skin test (PST) is the most
common and least expensive
method of testing for food allergy.
Food extracts and histamine/saline
controls are applied to a skin prick or
puncture.Tests are considered posi-
tive when a wheal of 3 mm or larger
appears on the skin.1
In radioaller-
gosorbent (RAST) testing,serum is
mixed with food and washed with ra-
Academy of Nutrition and Dietetics
Dietetic Practice Group of Sports,
Cardiovascular,and Wellness Nutrition (SCAN)
SCAN Web site:www.scandpg.org
SCAN Office
Athan Barkoukis,Executive Director
6450 Manchester Rd.
Cleveland,OH 44129
Phone:440/481-3560; 800/249-2875
scandpg@gmail.com
Chair
Ingrid Skoog,MS,RD,CSSD
Chair-Elect
Jenna Bell,PhD,RD
Past Chair
D.Enette Larson-Meyer,PhD,RD,CSSD,FACSM
Treasurer
To be appointed
Secretary
Karla M.Wright,RD,CSSD
Communications Director
Kimberly K.Schwabenbauer,RD
Continuing Education Director
Kelly White,MS,RD,CSSD
Development Director
Hope Barkoukis,PhD,RD
Member Services Director
Cheryl Toner,MS,RD
Symposium Committee Chair
Sharon Smalling,MPH,RD
Director,Disordered Eating & Eating
Therese Waterhous,PhD,RD
Director,Sports Dietetics—USA Subunit
Michele Macedonio,MS,RD,CSSD
Co-Directors,Wellness/CV RDs Subunit
Karen Collins,MS,RD,CDN
Rosie Gonzalez,MS,RD
External Relations Director
To be appointed
Public Policy Director
Alisa Krizan,MS,RD
Volunteer Coordination Director
Katilyn L.Davis,MS,RD,CSSD
Web Editor
Carla Addison,RD
Editor-in-Chief, SCAN’s PULSE
Mark Kern,PhD,RD,CSSD
SCAN Delegate to House of Delegates
Roberta Anding,MS,RD,CSSD,CDE
DPG Relations Manager
Mya Wilson,MPH,MBA
To contact an individual listed above,go to
www.scandpg.org/executive-committee/

It’s Not Debatable
by Mark Kern,PhD,RD,CSSD,Editor-in-Chief
As I write this letter,we’re in the midst of a presidential election and a season filled with debate.One issue at this moment that
isn’t debatable,however,is the fact that this issue of PULSE is extremely informative.
The article featured on the cover was written by Nancy Lea,MS,RD.In it she discusses the implications of dietary allergies in
the treatment of individuals suffering from eating disorders.Our free CPE article for this issue was provided by Kate Temme,
MD,and Anne Hoch,DO,who describe for us the link between disordered eating in female athletes and endothelial dysfunc-
tion.Barbara Rice,MS,RD,Helen Lane,PhD,RD,and Vickie Kloeris have contributed a fascinating article about the impact of
sodium consumption during spaceflight and the efforts made to reduce the sodium content of foods provided to astronauts.
We’ve also included Part 2 of the article about nitrate and nitrite sources and metabolism written by Norman Hord,PhD,MPH,
RD,to conclude the article started in our previous issue.
Be sure to also enjoy the highlights of a recent conference,the review we’ve provided of a book,notable accomplishments of
SCAN members,research summaries from Sports Dietetics-USA, and news items from SCAN.While the research described in
these pages may be filled with debatable results,I hope you’ll concur that the quality of the information provided is not a mat-
ter of debate.
SCAN’S PULSE Winter 2013,Vol.32,No.1 | 3
determine whether they have a legit-
imate allergy to a food or have elimi-
nated a food based on fear or
misperception.
Dietitians can assist patients by refer-
ring them to a board-certified aller-
gist for follow-up testing when they
believe proper documentation for al-
lergy is lacking.In addition,dietitians
can assist the allergist by helping pa-
tients fill out a food diary and,if nec-
essary,giving them guidance in
preparing for or adhering to food
elimination diets.
Working with Patients with
More Than One Allergy
When entire food groups are elimi-
nated based on a diagnosed food al-
lergy,it can be especially difficult to
ensure that the patient is consuming
an adequate diet.For individuals who
have more than one allergy,knowing
which foods are the best substitu-
tions can make a big difference. Milk
and wheat are particularly difficult to
avoid because they are present in so
many different foods.Dietitians
should determine which nutrients
are most likely to be limited due to
the exclusion of a specific food.For
example,with wheat allergy,dieti-
tians should carefully consider how
much thiamin,niacin,riboflavin,sele-
nium,iron,and fiber the patient is re-
ceiving through alternative foods,
because wheat is a major source of
these nutrients.With milk allergy,di-
etitians should consider intake of cal-
cium,vitamins A,D,riboflavin,
pantothenic acid,and phosphorous.
Providing alternative sources of these
vitamins and minerals becomes es-
sential,especially in the case of an al-
ready nutrient-depleted eating
disorder patient.
Eating disorder patients with milk al-
lergy should receive adequate
amounts of calcium-enriched foods
and beverages.Milk substitutes such
as fortified soy,rice,and almond milk
can be used.However,it is important
to note that many of these substi-
tutes are less calorically dense than
regular milk products and they often
lack many nutrients.Milk is also a
good source of protein for many pa-
tients.Meats,poultry,legumes,nuts,
fish,and eggs can easily make up for
a lack of protein from the restriction
of dairy,and they are good sources of
riboflavin and pantothenic acid.Pro-
tein supplementation is often used in
the treatment of eating disorder pa-
tients to provide needed calories;
however,the majority of supple-
ments available contain either casein
or whey as the primary protein.For
patients with milk allergy,dietitians
should recommend a hypoallergenic
supplement.
While it can be difficult to avoid
wheat,the popularity of gluten-free
diets has risen over the past several
years,making it easy for patients to
substitute wheat-free breads,cereals,
and other products for wheat-con-
taining foods.9
Alternative grains
such as oats,rye,barley,rice,corn,
buckwheat,and quinoa are also good
sources of fiber,thiamin,riboflavin,
niacin,iron,selenium,and chromium.
A distinction,however,should be
made between wheat allergy and
celiac disease,which is not explored
in this article.For those with celiac
disease,rye,barley,and gluten-con-
taining oats are not recommended.
FromThe Editor

Keeping Food Allergy
Patients Safe
When patients with documented
food allergies begin treatment,it is
essential for dietitians to educate pa-
tients on avoidance of the offending
allergens.This can pose an extra chal-
lenge when working with eating dis-
order patients,because dietitians do
not want to encourage most of these
individuals to focus on food labels or
become obsessed with ingredients in
food.However,in the case of serious
adverse reactions,it is crucial for pa-
tients to understand how to locate
and eliminate offending allergens in
food.For those receiving
inpatient/residential treatment,the
dietary staff must take special pre-
cautions to ensure that patients are
not exposed to food allergens.These
precautions may include highlighting
allergies on food labels or patient
menus and using a separate kitchen
for preparing and handling food for
allergic patients.In addition,an epi-
nephrine auto-injector should be
readily available,and staff should be
properly trained in its use for patients
with known anaphylactic reactions.
Additional information on food al-
lergy can be found at the following
Web sites:Asthma and Allergy Foun-
dation of America (www.aafa.org);
American Academy of Allergy,
Asthma and Immunology
(www.aaaai.org); and Food Allergy
and Anaphylaxis Network
(www.foodallergy.org).
Conclusion
Proper documentation of food aller-
gies,provided by the patient,is re-
quired for individuals with eating
disorders who are entering inpatient,
residential,or outpatient treatment.
Careful review of this documentation
should reveal that the patient was di-
agnosed by a board-certified allergist
or that accepted diagnostic testing,
including an oral food challenge,was
performed.PST and RAST tests by
themselves are not conclusive and
should not be used alone to diagno-
sis food allergy,except in the case of
a severe reaction.1
Over time,both children and adults
may exhibit reduced reactivity to
food allergens,with the exception of
peanuts,tree nuts,and shellfish. Di-
agnostic tests should be repeated for
individuals who are allergic to foods
containing major nutrients such as
dairy,because many of these allergies
are outgrown after age 2.4
Safe rein-
troduction of eliminated foods
should be attempted when exclusion
of the food leads to restriction of a
major nutrient or food group (e.g,
dairy or grains) or when exclusion
may make it more difficult for a pa-
tient to restore weight.
Despite the added challenge of work-
ing with eating disorder patients who
have dietary restrictions due to food
allergy,dietitians must honor any
documented allergies and protect
patients from adverse allergic reac-
tions.Dietitians will need to work
with patients on selecting alternative
sources of nutrients,planning well-
balanced meals,and identifying and
avoiding sources of food allergens.
When appropriate,eliminated foods
should be reintroduced,if possible,
while the patient is in treatment.
Nancy Lea,RD,works with eating disor-
der patients at the Eating Recovery
Center in Denver,CO.
References
1.Sampson H.Food allergy.Part 2:
Diagnosis and management.J Allergy
Clin Immunol.1999; 103:981-988.
2.Roberston D,Ayers R,Smith C,et al.
Adverse consequences arising from
misdiagnosis of food allergy.Br Med
J.1988; 297:719-720.
3.Cummings A,Knibb R,King R,et al.
The psychosocial impact of food al-
lergy and food hypersensitivity in
children,adolescents and their
families:a review.Allergy.2010;
65:933-945.
4.Teufel M,Bidermann T,Rapps N,et
al.Psychological burden of food al-
lergy.World J Gastroenterol.2007;13-
3456-365.
5.Skypala I.Adverse food reactions –
an emerging issue for adults.J Am
Diet Assoc. 2011; 111:1877-1891.
6.Sicherer S.Food allergy:When and
how to perform oral food challenges.
Pediatr Allergy Immunol.1999; 10-266-
234.
7.Ko J,Lee J,Munoz-Furlong A,et al.
Use of complementary and alterna-
tive medicine by food-allergic pa-
tients.Ann Allergy Asthma
Immunol.2006; 97:365-369.
8.Atkinson W,Sheldon T,Shaath N,et
al.Food elimination based on IgG an-
tibodies in irritable bowel syndrome:
a randomised controlled trial.Gut.
2004;53:1459-1464.
9.Gaesser G,Angadi S,Gluten-free
diet:imprudent dietary advice for the
general population? J Am Diet Assoc.
2012;112:1330-1333.

This article is approved by the Academy
of Nutrition and Dietetics,an accred-
ited Provider with the Commission on
Dietetic Registration (CDR),for 1 con-
tinuing professional education unit
(CPEU),level 1. The PULSE CPEU
process is now automated! To apply for
free CPE credit,take the quiz on SCAN’s
Web site (www.scandpg.org/nutrition-
info/pulse-newsletters/).Upon success-
ful completion of the quiz,a Certificate
of Completion will appear in your My
Profile (under the heading,My History).
The certificate may be downloaded or
printed for your records. You may also
obtain the quiz by requesting it from
the SCAN Office via phone:800/249-
2875,fax:440/526-9422,or email:scan-
dpg@gmail.com. However,we hope
you will enjoy the convenience of the
online quizzes.
Learning Objectives
After you have read this article,you
will be able to:
I Describe how endothelial dysfunc-
tion is assessed through the meas-
urement of brachial artery flow-
mediated vasodilation.
I Summarize the literature demon-
strating the relationship between
athletic amenorrhea and endothelial
dysfunction.
I Discuss the effects,proposed
mechanism of action,and safety of
folic acid supplementation in the
treatment of endothelial dysfunction
in athletes.
Since the enactment in 1972 of Title
IX—the landmark legislation pro-
hibiting sex discrimination in all fed-
erally funded programs—female
sports participation has increased ex-
ponentially.The benefits of sports
participation for female athletes are
numerous in relation to self-esteem,
academic performance,mental
health,and prevention of high-risk
behaviors.1
However,certain meta-
bolic and endocrine concerns have
also been identified in female ath-
letes during this interval,including
the female athlete triad (triad).
Endothelial Dysfunction:
Should the Triad Be a Tetrad?
The American College of Sports Med-
icine (ACSM) defines the female ath-
lete triad as a spectrum of
interrelationships between energy
availability,menstrual function,and
bone mineral density2
(Fig.1).At the
ideal end of the spectrum is optimal
health (eumenorrhea,optimal energy
availability,and optimal bone health)
contrasted by the pathological ex-
treme of the spectrum (functional hy-
pothalamic amenorrhea,low energy
availability with or without disor-
dered eating,and osteoporosis).
Functional hypothalamic amenor-
rhea and the associated hypo-estro-
genic state may increase the risk of
endothelial dysfunction,suggesting
that the triad may be more accurately
described as a tetrad.
Endothelial dysfunction is defined as
an imbalance between vasodilating
and vasoconstricting substances pro-
duced by or acting upon the inner
lining of blood vessels.Endothelial
dysfunction is a sentinel event in the
development of cardiovascular dis-
ease,the leading cause of death
among women in the United States.
Cardiovascular risk increases sharply
after menopause,and 25% of women
will ultimately die from a cardiovas-
cular event.Estrogen receptors are
found in both coronary and periph-
eral vasculature,enabling estrogen to
serve a regulatory role in vascular
function.Estrogen increases the pro-
duction of endothelial-derived nitric
oxide,promoting vasodilatation.3
Re-
duced endothelial-dependent va-
sodilation is noted as early as 3
months after menopause,as estro-
gen levels decline,and it is a known
predictor of future cardiovascular
events.4
Measurement of Endothelial
Dysfunction
Coronary endothelial dysfunction
predicts long-term atherosclerotic
CPE article
Endothelial Dysfunction and the Female Athlete Triad:
Research Updates and Management Recommendations
by Kate E.Temme,MD,and Anne Z.Hoch,DO
Figure 1.The female athlete triad is a spectrum of interrelationships between health
and disease involving energy availability,menstrual function,and bone mineral density
(BMD).(Reprinted with permission from Nattiv A,et al.Med Sci Sports Exerc.
2007;39:1867-1882)
Low Energy Availability
with or without an
Eating Disorder
Functional
Hypothalamic
Amenorrhea Osteoporosis
Optimal Bone
Health
Optimal Energy
Availability
Reduced Energy Availability
with or without
Disordered Eating
Subclinical
Menstrual
Disorders Low
BMD
Eumenorrhea

disease progression and cardiovascu-
lar events.5
Direct measurement of in-
tracoronary arterial response to
acetylcholine demonstrates paradox-
ical vasoconstriction in subjects with
endothelial dysfunction.However,di-
rect measurements of coronary en-
dothelial function are invasive,
expensive,and time-consuming.
Measurement of brachial artery flow-
mediated vasodilation (FMD) corre-
lates highly with coronary
endothelium-dependent dilation and
is considered the gold standard of
noninvasive endothelial assessment.6
Abnormal brachial artery FMD has a
95% positive predictive value for
coronary endothelial dysfunction.
Brachial artery FMD is assessed using
a high-resolution ultrasound to
measure brachial artery diameter be-
fore and after forearm ischemia is in-
duced by inflating a blood pressure
cuff to suprasystolic levels.After cuff
deflation in normal subjects,reactive
hyperemia and shear stress stimulus
leads to nitric oxide release and va-
sodilation,with subsequent increases
in brachial artery diameter.FMD is
calculated as the percentage increase
in diameter of the brachial artery; a
normal response in athletes is typi-
cally ≥5%.3
Those with endothelial
dysfunction do not demonstrate the
expected increase in FMD.
Endothelial Dysfunction and
the Female Athlete
Several studies have demonstrated a
relationship between athletic amen-
orrhea and endothelial dysfunction.
Hoch and colleagues observed ab-
normal endothelium-dependent
brachial artery FMD responses in col-
legiate amenorrheic runners com-
pared with eumenorrheic runners,
while both groups demonstrated
similar endothelium-independent va-
sodilation responses to sublingual ni-
troglycerin.7
Rickenlund and
associates found a correlation be-
tween menstrual status and brachial
artery FMD in female endurance ath-
letes,with amenorrheic athletes
demonstrating significantly lower
FMD compared with eumenorrheic
athletes,while oligomenorrehic ath-
letes had intermediate FMD re-
sponses.8
A relationship between
amenorrhea and abnormal FMD has
also been reported in professional
ballet dancers.9
This study also found
that the lowest FMD responses corre-
lated with the lowest serum estrogen
levels as well as the lowest bone min-
eral density results (Z-scores).
In addition to the potential health ef-
fects of endothelial dysfunction (i.e.,
progressive atherosclerotic disease
and increased risk of cardiovascular
events),there may also be implica-
tions for athletic performance. De-
creased FMD in peripheral
vasculature may impair exercise-in-
duced vasodilation and decrease
blood flow available to exercising
muscle.Decreased perfusion may
limit maximal exercise tolerance with
secondary effects on athletic per-
formance.Thus,in athletes,treatment
of endothelial dysfunction may have
general health as well as athletic per-
formance benefits.
Treatment of Endothelial
Dysfunction in Athletes
According to ACSM guidelines,the
first priority in the treatment of the
triad is correction of energy availabil-
ity through modification of dietary
intake and/or exercise energy expen-
diture.Menstrual function has been
shown to improve with correction of
energy deficits in female athletes,and
data suggest this approach improves
endothelial dysfunction.4,10
Other investigators have studied the
effects of oral contraceptive pill (OCP)
use on endothelial dysfunction in
athletes.Rickenlund and colleagues
reported significant improvement in
brachial artery FMD among young,
amenorrheic endurance athletes
treated with a low-dose combined
OCP (30 ug ethinyl estradiol and 150
ug levonorgestrel) for 9 months.11
These improvements were thought
to be secondary to estrogen’s protec-
tive effect on the endothelium
through increased nitric oxide
bioavailability.However,studies of
postmenopausal women by the
Women’s Health Initiative found in-
creased rates of cardiovascular
events and breast cancer inci-
dence/mortality in women treated
with combined estrogen and prog-
estin hormonal replacement.12,13
Al-
though safety studies in premeno-
pausal women have not been con-
ducted,it is known that young amen-
orrheic athletes have similar hormo-
nal profiles to postmenopausal
women.Therefore,because hormonal
replacement therapy may potentially
increase cardiovascular risk in these
patients,alternative options for the
treatment of endothelial dysfunction
in young female athletes should be
considered.
Figure 2. Production of nitric oxide (NO) by endothelial cells.Folates have been
suggested to participate in the regeneration of tetrahydrobiopterin (BH4),an essential
cofactor in the production of NO.
Ach=acetylcholine; ecSOD=extracellular superoxide dismutase; eNOS=endothelial
nitric oxide synthase; L-Arg=L-arginine; ROS=reactive oxygen species.(Reprinted with
permission from Gielen S,Hembrecht R.Cardiol Clin. 2001;19:361.).
Folic Acid
L-Arg.
L-Arg.
Agonists (Ach) Shear Stress Vascular
Lumen
Citrulline
Endothelial
Cell
Extracellular
Space
Vascular Smooth Muscle Cell
Peroxynitrite
ROS
ecSOD
eNOS
BH4
+ +
+
NO
NO

One alternative therapy that is gain-
ing support is folic acid supplemen-
tation.Folic acid has many potential
cardiovascular benefits including im-
proved endothelial function,de-
creased arterial stiffness,decreased
blood pressure,and decreased
thrombotic activity.Folic acid is theo-
rized to participate in the production
of nitric oxide through its role in the
regeneration of tetrahydrobiopterin,
an essential cofactor in nitric oxide
production (Fig.2).Daily folic acid
supplementation may increase nitric
oxide production and folic acid may
also have direct antioxidant effects.
Additionally,folic acid supplementa-
tion has been shown to improve en-
dothelium-dependent FMD in other
populations,including those with hy-
pertension,coronary artery disease,
congestive heart failure,and dia-
betes.1
Several small studies have evaluated
the effects of folic acid supplementa-
tion in athletes with endothelial dys-
function.Amenorrheic runners with
abnormal brachial artery FMDs had
significant improvements in FMD re-
sponses after supplementation with
folic acid (10 mg/day) for 4 weeks.14
Similar results were reported for
amenorrheic ballet dancers supple-
mented with 10 mg folic acid per day
for 4 weeks.15
In addition,improved
FMDs were noted after 4 to 6 weeks
of folic acid supplementation in eu-
menorrheic runners with low-normal
FMD when compared with a placebo-
controlled group.16
Folic acid supplementation is gener-
ally well tolerated,and no adverse ef-
fects have been noted at doses
effective in improving endothelial
dysfunction (i.e.,10 mg/day).At much
higher doses (>15 mg/day) dyspep-
sia,sleep disturbances,and dermato-
logic complaints have been reported,
and seizures may be provoked in
those taking anticonvulsants.1
In ad-
dition,folic acid supplementation
may mask vitamin B12 deficiency,al-
lowing the condition to progress un-
recognized.This phenomenon should
be considered when prescribing folic
acid for the vegan athlete or for indi-
viduals with malabsorption syn-
dromes.Given the promising results
of folic acid supplementation in the
setting of endothelial dysfunction,fu-
ture large-scale studies should ad-
dress optimal dosing and treatment
length.
Conclusions
The ACSM recommends regular phys-
ical activity for all girls and women,as
the benefits of maintaining an active
lifestyle are numerous and outweigh
any potential risks.However,atten-
tion must be paid to the prevention,
identification,and treatment of med-
ical issues relevant to female athletes,
most notably menstrual dysfunction
and its comorbidities including en-
dothelial dysfunction.Athletic amen-
orrhea has been shown to predict
endothelial dysfunction,a sentinel
event in the development of cardio-
vascular disease.In postmenopausal
women,endothelial dysfunction is
predictive of cardiovascular events,
and improvements in endothelial
function have been associated with a
significant decrease in coronary risk
factors.4
Further studies are needed to con-
firm whether endothelial dysfunction
in young female athletes carries the
same long-term cardiac risks as those
seen in older women.However,the
similar hormonal profiles shared by
these two groups of women suggests
that early identification and treat-
ment of menstrual and endothelial
dysfunction in young amenorrheic
athletes may help to prevent the ac-
celerated development of atheroscle-
rotic disease and cardiovascular
consequences already well described
in postmenopausal women.While
normalization of energy availability
should be a priority in the manage-
ment of amenorrheic athletes and as-
sociated endothelial dysfunction,
folic acid supplementation shows
promise as a safe,effective treatment
for endothelial dysfunction in young
amenorrheic athletes.Further,large-
scale studies are needed to refine the
optimal dosage and duration recom-
mendations for folic acid in the treat-
ment of endothelial dysfunction.
Kate E.Temme,MD,is an assistant pro-
fessor specializing in women’s sports
medicine in the Department of Physical
Medicine and Rehabilitation at the Uni-
versity of Pennsylvania in Philadelphia,
PA.Anne Z.Hoch,DO,is a professor and
director of the Women’s Sports Medi-
cine Program in the Department of Or-
thopaedic Surgery at the Medical
College of Wisconsin in Milwaukee,WI.
References
1.Zach KN,Smith Machin AL,Hoch
AZ.Advances in management of the
female athlete triad and eating disor-
ders.Clin Sports Med.2011;30:551-
573.
2.Nattiv A,Loucks AB,Manore MM,et
al; American College of Sports Medi-
cine.American College of Sports
Medicine position stand.The female
athlete triad.Med Sci Sports Exerc.
2007;39:1867-1882.
3.Lanser EM,Zach KN,Hoch AZ.The
female athlete triad and endothelial
dysfunction.PM R. 2011;3:458-465.
Review.
4.Hoch AZ,Jurva JW,Staton MA,et al.
Athletic amenorrhea and endothelial
dysfunction.WMJ. 2007;106:301-306.
5.Schächinger V,Britten MB,Zeiher
AM.Prognostic impact of coronary
vasodilator dysfunction on adverse

long-term outcome of coronary heart
disease.Circulation.2000; 25;101:
1899-1906.
6.Anderson TJ,Uehata A,Gerhard
MD,et al.Close relation of endothelial
function in the human coronary and
peripheral circulations.J Am Coll Car-
diol.1995;26:1235-1241.
7.Zeni Hoch A,Dempsey RL,Carrera
GF,et al.Is there an association be-
tween athletic amenorrhea and en-
dothelial cell dysfunction? Med Sci
Sports Exerc.2003;35:377-383.
8.Rickenlund A,Eriksson MJ,Schenck-
Gustafsson K,et al. Amenorrhea in fe-
male athletes is associated with
endothelial dysfunction and unfavor-
able lipid profile.J Clin Endocrinol
Metab. 2005;90:1354-1359.
9.Hoch AZ,Papanek P,Szabo A,et al.
Association between the female ath-
lete triad and endothelial dysfunc-
tion in dancers.Clin J Sport Med.
2011;21:119-125.
10.Yoshida N,Ikeda H,Sugi,K et al.
Impaired endothelium-dependent
and -independent vasodilation in
young female athletes with exercise-
associated amenorrhea.Arterioscler
ThrombVasc Biol.2006;26:231-232.
11.Rickenlund A,Eriksson MJ,
Schenck-Gustafsson K,et al.Oral con-
traceptives improve endothelial func-
tion in amenorrheic athletes.J Clin
Endocrinol Metab.2005;90:3162-3167.
12.Chlebowski RT,Anderson GL,Gass
M,et al;WHI Investigators.Estrogen
plus progestin and breast cancer inci-
dence and mortality in postmeno-
pausal women. JAMA.2010;304:
1684-1692.
13.Rossouw JE,Anderson GL,Prentice
RL,et al;Writing Group for the
Women’s Health Initiative Investiga-
tors.Risks and benefits of estrogen
plus progestin in healthy post-
menopausal women:principal results
From the Women’s Health Initiative
randomized controlled trial.JAMA.
2002;288:321-333.
14.Hoch AZ,Lynch SL,Jurva JW,et al.
Folic acid supplementation improves
vascular function in amenorrheic run-
ners.Clin J Sport Med. 2010;20:205-
210.
15.Hoch AZ,Papanek P,Szabo A,et al.
Folic acid supplementation improves
vascular function in professional
dancers with endothelial dysfunc-
tion.PM R.2011;3:1005-1012.
16.Hoch AZ,Pajewski NM,Hoffmann
RG,et al.Possible relationship of folic
acid supplementation and improved
flow-mediated dilation in premeno-
pausal,eumenorrheic athletic wo-
men.J Sports Sci Med. 2009;8:123-129.
Barbara Rice,MS,RD; Helen W.Lane,PhD,RD; and Vickie Kloeris,MS
For some 50 years,the dietitians,re-
searchers,and food scientists of the
National Aeronautics and Space Ad-
ministration (NASA) have provided
the nutritional and safety standards,
developed the food systems,and pro-
duced the food provisions for all U.S.
human spaceflights.In the past 12
years,the challenge to provide food
has become more pronounced with
the continuous operation of the In-
ternational Space Station (ISS).1,2
All
diets must meet the health and
safety guidelines for crewmembers
living and working in space for up to
6 months.3,4
NASA researchers spent
about 20 years studying the effects of
dietary sodium on the health and
safety of crewmembers,resulting in
conclusions that the dietary sodium
should be lowered.
The ISS standard menu contains
more than 5,600 mg/day of sodium
and 2,900 kcal/day.Dietary sodium
intake averaged about 4,600 mg/day
over the first 18 ISS expeditions (an
expedition is an ISS increment that
has a set of crewmembers and gener-
ally lasts 6 months).At the same time,
energy intake was generally less than
2,500 kcal/day.1
The physiologic changes that occur
in crewmembers in spaceflight in-
clude weight loss that may result in
lean and adipose tissue loss,bone
loss,hematologic changes,fluid
shifts,gastrointestinal changes,in-
creased risk of renal stone formation,
and radiation exposure,along with
the recently documented increase in
intracranial pressure that has led to
vision changes in some crewmem-
bers.5
The ISS high-sodium diets are
directly linked to the bone loss and
increased risk of renal stones,and po-
tentially to the increased intracranial
pressure due to the impact of sodium
on blood pressure.
U.S.Food System for the ISS
The current U.S.food system for the
ISS is based on the Space Shuttle
food system that has been in use
since the beginning of the Space
Shuttle program in 1981.Due to the
longer duration of the ISS missions,
the ISS food system was expanded
from the more limited Space Shuttle
food list to a current inventory of
about 200 foods and beverages.A
standard menu of foods for an 8-day
rotation is packed pantry style (i.e.,all
meats are packed together,all veg-
etables are packed together,etc).
Crewmembers assemble meals from
the various food categories,so they
are eating from a standard menu but
not eating in the exact meal combi-
nations on the menu.In addition,

crewmembers are allowed a small
quantity of bonus food items to aug-
ment the standard menu.This bonus
food equates to about 10% of the
food supply available to a crewmem-
ber on orbit and can consist of more
U.S.space food or even some com-
mercial shelf-stable food items.
The NASA food system menus are
high in sodium because only ambi-
ent-stored processed foods are used.
The lack of refrigerators and freezers
for food,both on the Space Shuttles
and the ISS,mandate an all shelf-sta-
ble food system.Shelf-stable foods
historically tend to be high in
sodium,because sodium aids in the
preservation of these foods.1
Further-
more,the Space Shuttle food system
was designed with the premise of
using as many commercial off-the-
shelf (COTS) foods as possible to save
money.The NASA food systems that
preceded Space Shuttle consisted of
custom-produced foods that were
extremely costly.The use of COTS
foods automatically led to a high
level of sodium l
in the diet,because
commercially processed foods tend
to be high in sodium; sodium is inex-
pensive way to make foods taste
good.In addition,crews in spaceflight
have very limited,if any,access to
fresh fruits and vegetables,which are
naturally low in sodium.With so few
fresh foods available to astronauts,
the sodium content of the diet is in-
creased even further over the typical
ground-based diet.
The Process to Reduce
Dietary Sodium
In March 2010,the Space Food Sys-
tems Laboratory (SFSL) at NASA’s
Johnson Space Center began a proj-
ect to reformulate existing products
to reduce sodium levels.The project
team in the SFSL consisted of several
food scientists and a dietitian.This
team reviewed the sodium content of
the some 200 different foods and
beverages on NASA’s food list and
identified 90 different thermostabi-
lized and rehydratable food products
to be reformulated.These 90 were se-
lected on the basis of sodium con-
tent.
The team developed a schedule for
reformulation that would have re-
quired about 4 years to complete
with in-house resources.NASA man-
agement wanted the project com-
pleted in less time,so to augment the
SFSL reformulation efforts,two out-
side firms,one with expertise in
freeze-dried foods and one with ex-
pertise in thermostabilized foods,
were hired to expedite the project.
The 90 products were reformulated
in about 2 years,with 30 foods each
for the two consultant firms and for
the SFSL.The approach taken,to the
extent possible,was to reformulate
existing foods rather than replace
foods with totally different products.
This was the goal because the exist-
ing food list was balanced among
food types,providing good variety
that is important to ISS crewmem-
bers during their lengthy stays on
orbit.
The primary approach was to remove
sodium by either using low-sodium
versions of ingredients or by remov-
ing salt altogether and using other
ingredients,such as spices and herbs,
to compensate for the sodium in the
reformulated products.Some of the
spices included disodium inosinate
and disodium guanylate to increase
the umami flavor in savory foods
along with lemon juice,basil,
oregano,sugar,Mrs.Dash Fiesta Lime
Seasoning,and Mrs.Dash Garlic &
Herb Seasoning.
Because of the low volumes of food
required for spaceflight,NASA has an
advantage over the commercial food
industry in being able to use these
typically much more expensive ingre-
dients in formulations without signifi-
cant economic impact.For freeze-
dried food products,NASA had,in
many instances,used COTS frozen
foods and further processed them
into freeze-dried foods.The reformu-
lation of these products produced
foods made from individual ingredi-
ents rather than further processed
from commercial products with the
expected increased labor costs.In
contrast,NASA’s thermostabilized
products were already predominately
made from individual ingredients,so
this project had little effect on labor
costs to produce these items.
Evaluating New
Formulations
When a new formulation was identi-
fied for a product,a small test batch
was made in the SFSL for evaluation
by the project team.This often re-
sulted in rejection and rework of
many of the formulations.When the
team found a new formulation to be
acceptable,the next step was to
process enough of the product to
allow for large-scale sensory evalua-
tion using a group of untrained vol-
unteer panelists.These evaluations
were publicized to the astronaut
corps and some participation by cur-
rent astronauts did occur.
During sensory evaluation,the prod-
uct was rated for appearance,color,
odor,flavor,and texture,and given an
overall rating.A 9-point hedonic scale
was used for these rankings and an
overall score of 6.0 or higher was re-
quired before the product was
deemed acceptable for use.Occa-
sionally a reformulated product did
not pass this evaluation.In that case,
the comments made by the panelists

light of the continuous operation of
the ISS,NASA decided to reduce as-
tronauts’dietary sodium intake.
Within a couple of years,NASA hopes
that astronauts will consume diets
closer to 3,500 mg/day,and if they
consume only items from the U.S.
menu,they will easily meet this rec-
ommendation.
Barbara Rice,MS,RD,is with Enterprise
Advisory Services,NASA,and Helen W.
Lane,PhD,RD, and Vickie Kloeris,MS,
are with NASA Johnson Space Center,
Human Health and Performance Di-
rectorate,in Houston,TX
References
1.Smith SM,Zwart SR,Kloeris V,et al.
Nutritional Biochemistry of Space
Flight. New York,NY:NOVA Science
Publishers,Inc.; 2009.
2.NASA website,www.nasa.gov/mis-
sion_pages/station/main/index.html.
3.Nutritional Requirements for Inter-
national Space Station (ISS) Missions
up to 360 days.Houston,TX:National
Aeronautics and Space Administra-
tion,Report No.JSC-28028,1996.
4.Smith S,Zwart SR,Block G,et al.The
nutritional status of astronauts al-
tered after long-term space flight
aboard the International Space Sta-
tion.J Nutr. 2005;135:437.
5.Mader TH,Gibson CR,Pass AF,et al.
Optic disk edema,globe flattening,
choroidal folds,and hyperopic shifts
observed in astronauts after long-du-
ration space flight.Ophthalmology.
2011;118:2058-2069.
6.Smith SM,Davis-Street JE,Rice BL,
et al.Nutritional status assessment in
semi-closed environments:ground-
based and space flight studies in hu-
mans.J Nutr.2001;131:2053-2061.
7.Smith,SM,Block,G,Davis-Street,et
al. Nutritional status assessment dur-
ing Phases IIa and II of the Lunar-
Mars life support test project.In:Lane
HW,Sauer RD,Feeback DL,eds. Isola-
tion NASA Experiments in Close-Envi-
ronment Living.San Diego,CA.
American Astronautical Society,
2002;104:293-314.
agencies—and NASA obviously has
no control over the sodium content
of these foods.
Measuring Dietary
Intakes: Food Frequency
Questionnaire
With the advent of the ISS,the nutri-
tion researchers needed an easy-to-
use valid method to determine
dietary intakes.This led to testing a
food frequency questionnaire (FFQ)
originally developed by Gladys
Block.6
The questionnaire was vali-
dated against 24-hour dietary
records during studies of crewmem-
bers who lived in a closed chamber
for 60 and/or 91 days.6,7
This semi-quantitative FFQ is self-ad-
ministered each week.4
The FFQ is de-
signed to include the foods that are
available for a specific expedition and
requires about 5 to10 minutes to
complete.The FFQ assesses intake of
seven nutrients including sodium
along with energy,protein,potas-
sium,iron,fluids,and calcium.Data
from the completed questionnaire
are routinely provided to the med-
ical-nutrition teams for assessments
of the astronauts’diets.These teams
then make recommendations to the
astronauts about their diets within 48
hours of completion of the FFQ,
thereby allowing for self-corrections
in their diets.With a sodium recom-
mendation for spaceflight of 3,500
mg/day,the sodium reformulation
project will enable astronauts to
meet this level.
Summary
The level of sodium in astronauts’
diets has always been high and,in
were evaluated and revisions were
made to the formulation and tested
again.In the case of the reformula-
tions done by the two consultant
companies,those reformulations
went directly to large-scale sensory
evaluation.
Sensory evaluations of the final re-
duced-sodium formulations showed
acceptance scores that were not sig-
nificantly lower than the scores of
their higher-sodium predecessors
and in a few cases were higher.The
net result of the reformulation task
was a 40% reduction in the sodium
content of the current ISS standard
menu of 5,600 mg/day.
These reduced-sodium products
were manufactured and are now be-
ginning to be shipped (launched) to
the ISS.The project team is anxious to
have feedback from crewmembers
on orbit regarding the acceptability
of these items; the crews will con-
sume significant quantities of these
reformulated foods in 2013.
It is interesting to note that salt,in liq-
uid form,has always been available
for crewmembers to use on orbit.
One of the assumptions of this proj-
ect was that the liquid salt would
continue to be made available to the
crewmembers.NASA decided that
the reduced-sodium diet would not
be mandated to all crewmembers,
but reduced-sodium products would
be available for those crewmembers
who desired them or had symptoms
of increased intracranial pressure.As
another variable,Russian foods are al-
ways available on the ISS along with
some foods provided by the Cana-
dian,European,and Japanese space

Part 2 of this article resumes a discus-
sion of the potential positive health
effects of dietary nitrate and nitrite
consumption.For more information on
the metabolites derived from nitrate,
nitrite,and nitric oxide (NO),which are
collectively termed NOx,see Part 1 of
this article published in the Fall 2012
issue of SCAN’S PULSE.
Nitrate,Nitrite and
Cardiovascular Effects
of NOx
The cardiovascular benefits of dietary
nitrate and nitrate in animal models
and humans were examined in a re-
cent review of the extensive literature
on this topic.1
The demonstrated car-
dioprotective effects of dietary ni-
trate and nitrite include reduction in
blood pressure,reduced ischemia/
reperfusion injury in heart and kid-
ney,reduced platelet aggregation,
and enhanced endothelial function.2
Indeed,plasma levels of nitrite and
nitrate are strongly correlated with
brachial flow-mediated dilation re-
sponses in young men and women.3
It is now clear that nitrates in
foods/beverages and sodium nitrite
in beverages or intravenous infusions
can,in a dose-dependent fashion,
predictably and acutely lower blood
pressure in humans and animals.
Subjects consuming a variety of tra-
ditional Japanese foods high in ni-
trate (18.8 mg nitrate/kg body
weight/day) experienced a drop in di-
astolic blood pressure (DBP) of about
4.5 mm Hg.4
In elegant randomized
crossover studies in humans,Kapil
and associates reported that either
beetroot juice (500 mL containing
~341 mg nitrate) or inorganic potas-
sium nitrate (KNO3) capsules (4,12 or
24 mmol containing 248,744 or 1488
mg of nitrate) produced dose-
dependent increases in plasma ni-
trate and nitrite.5
The highest dose of
KNO3 caused reductions in both sys-
tolic blood pressure (SBP) and DBP
over 24 hours compared with the
potassium chloride control of 9.4 ±
1.6 mm Hg (at 6 h) and 6.0±1.1 mm
Hg (at 2.75 h) for SBP and DBP,re-
spectively.
Interestingly,post-hoc analyses have
revealed sex differences in process-
ing of dietary nitrate through the en-
terosalivary circulation and its
consequences on blood pressure.5
In
a subset analyses from this study,fe-
males had significantly higher base-
line plasma nitrite than males and
also had higher salivary (nitrite)
(0.39±0.05 vs.0.26±0.03 µM,P<.05),
lower clinic SBP (SBP:105.5±1.1 vs.
113.9±0.9 mmHg,P<.01),home SBP
(SBP:109.7±1.0 vs.119.3±1.4,P<.01)
and ambulatory BP (SBP:115.1±0.7
vs.122.0±0.8,P<.01).Females exhib-
ited 2-fold higher oral nitrite produc-
tion compared with males after
being given capsules containing
KNO3,P<.01) (Kapil V et al,unpub-
lished observation:Nitric Oxide
2011;24:S16–S42).These results sug-
gest that females produce more ni-
trite derived from enterosalivary
circulation derived from enterosali-
vary circulation than men,and that
this may contribute to the reduced
BP and may partially explain the re-
duced risk of cardiovascular disease
(CVD) in women.
Physical activity lowers CVD risk,and
one of the earliest clinical signs of
CVD is decreased endothelial reactiv-
ity after ischemic reperfusion.6
It has
been shown that age-dependent en-
dothelial dysfunction is associated
with failure to increase plasma nitrite
in response to exercise.Exercise en-
hances endothelial nitric oxide syn-
thase (eNOS)-dependent NO
production via shear stress.1
In a fas-
cinating series of recent studies,it has
been demonstrated that dietary ni-
trate lowers the oxygen cost of exer-
cise7
and enhances endurance by
about 15%,8
ostensibly by increasing
mitochondrial efficiency in humans.9
The increase in mitochondrial effi-
ciency due to nitrate feeding is
thought to be mediated by improve-
ment in oxidative phosphorylation
efficiency (P/O ratio) leading to a re-
duction in oxygen cost for energy
production during exercise.9
These
findings suggest that nitrate and ni-
trite are efficacious as cardioprotec-
tive dietary factors and also improve
physical performance.
Dietary Nitrates and Nitrites from Vegetables
and Fruits:How Can Something So Bad Be So Good?
(Part 2)
by Norman G.Hord,PhD,MPH,RD

Dietary Intakes and
Recommendations to
Limit Nitrate Consumption
Intake exposure recommendations
from the World Health Organization
(WHO) provide a basis for insights
based on current knowledge.Facts
regarding human exposures to ni-
trate and nitrite casts concern over
current regulatory limits on nitrate
and nitrite consumption.First,it is
possible to approach or exceed
World Health Organization Accept-
able Daily Intake (WHO ADI) limits
with usual intake levels of single
foods,such as colostrum (at 100 mL
intake in a newborn infant,delivering
42% of the WHO ADI intake limit),
soya milk (750 mL intake for a hypo-
thetical 6.8 kg-infant yields 104% of
the WHO ADI intake limit),spinach,10
or a dessicated vegetable supple-
ment.11
Second,recommended di-
etary intakes of vegetables and fruits,
such as a Dietary Approaches to Stop
Hypertension (DASH) pattern with
high-nitrate food choices,exceed the
World Health Organization’s Accept-
able Daily Intake for nitrate by 550%
for a 60-kg adult.11
Third,for adults
consuming the recommended in-
takes of vegetables and fruits (the
source of over 80% of dietary nitrate
and nitrite),the concentration of ni-
trate in saliva can be up to three
times the concentration allowed by
most global regulatory limits for
drinking water.Fourth,provision of
dietary nitrate,as beetroot juice (or
single servings of spinach or veg-
etable juices such as V8 juice),1
di-
etary nitrate,5
or in a traditional
Japanese dietary pattern,4
are effec-
tive in lowering blood pressure in hu-
mans. Fifth,human infants
consuming breast milk are exposed
to nitrate and nitrite in human milk
from birth.12
These facts indicate that WHO guide-
lines may limit nitrate and nitrite in-
takes from foods to levels below
those that could confer health bene-
fits.As such,the intake estimates pre-
viously noted may represent,at a
population level,dietary deficiency.If
nitrates and nitrites act as nutrients,it
is likely that they do so to bolster the
reserve of nitrite-derived NOx
metabolites required for optimal
functioning through periods of phys-
iologic stress (e.g.,hypoxia and acido-
sis) and diseases characterized by
endothelial dysfunction.13
Optimal
consumption levels of nitrates and ni-
trites from vegetable and fruit
sources await the consensus of ex-
perts based on a systematic review of
available evidence.
Potential Health Benefits of
Dietary Nitrates and Nitrites
Data from the laboratories of Lund-
berg,Gladwin,Zweier,Bryan,and oth-
ers support the modern hypothesis
that dietary nitrates and nitrites have
health benefits.13,14
The nitrate-nitrite-
NO pathway has been demonstrated
to serve as a backup system to en-
sure NO supply in situations when
the endogenous L-arginine/NO syn-
thase pathway is dysfunctional.1
This
redundant system of NO production
in tissues has important implications
for cardiovascular,gastrointestinal,
and immune function related to the
provision of dietary nitrate and ni-
trite.Because nitrite-dependent NO
generation has been shown to play
critical physiologic and pathologic
roles,and is modulated by oxygen
tension,pH,reducing substrates,and
nitrite levels,it is necessary to bal-
ance these factors in a modern regu-
latory framework that acknowledges
a potential physiologic requirement
for dietary nitrate and nitrite.
Determinants of Regulatory
Paradigm Change
Based on the demonstrated physio-
logic functions of NOx derived from
dietary nitrates and nitrites from
vegetables and fruits,it has been
proposed that these dietary constitu-
ents,based on their demonstrated
physiologic functions,should be con-
sidered as nutrients.11
Analogous to
all essential or indispensable nutri-
ents,intake of excess nitrate and ni-
trite exposure is,in specific contexts,
associated with an increased risk of
negative health outcomes.A set of
Dietary Reference Intake (DRI) cate-
gories are set by the Food and Nutri-
tion Board of the National Academy
of Sciences for essential nutrients to
clearly define,where possible,the
contexts in which intakes are defi-
cient,safe,or potentially excessive.
These DRI categories include the Rec-
ommended Dietary Allowance (RDA),
Adequate Intake (AI),Tolerable Upper
Level Intake (TUL),and Estimated Av-
erage Intake (EAI),as discussed by
Hord et al.11
The process of setting DRIs for nutri-
ents considers a broad range of phys-
iologic factors,including nutritional
status and potential toxicities.Ra-
tional methodologies such as these,
including the consideration of nor-
mal dietary consumption patterns of
nitrate and nitrite-containing foods,
have not been applied in setting ex-
posure limits or in considering the
potential health benefits of dietary
nitrates and nitrites.The determina-
tion of those concentrations of ni-
trate and nitrite that should be
defined as low,sufficient,or excessive
in healthy populations will require a
consensus among researchers,health
professionals,and regulators.

Recommendation for
Comprehensive Review of
Health Effects of Nitrate
and Nitrite
While there are compelling indica-
tions that dietary nitrate or nitrite
may reduce CVD risk,it must be ac-
knowledged that the lack of aware-
ness of the potential health benefits
of nitrates and nitrites is prevalent.
Hence,in clinical trials such as those
testing the efficacy of the DASH diet,
nitrate and nitrite concentrations in
foods were not considered.Because
these unmeasured factors likely con-
tributed to the hypotensive effects of
the DASH dietary pattern,11
dietary
nitrate and nitrite would be consid-
ered confounding factors.This char-
acterization is apropos for the
numerous studies attributing cardio-
vascular benefits to vegetable intake,
plant-based diets,and Mediterranean
diet interventions for the secondary
prevention of CVD.It is hoped that di-
etary concentrations of these effect
modifiers will be measured or esti-
mated and reported in future epi-
demiologic and clinical studies of
cardiovascular risk.
Lack of inclusion of food nitrate and
nitrite concentrations in standard
food databases (e.g.,USDA National
Nutrient Database for Standard Refer-
ence) is another obstacle to the de-
velopment of a solid epidemiologic
basis for quantifying cardiovascular
and other health benefits of dietary
nitrates and nitrites in human popu-
lations.As such,the development
and availability of a database of food
nitrate/nitrite concentrations would
encourage more thorough investiga-
tions of hypotheses associating di-
etary nitrate/nitrite and specific
health outcomes.
The compelling results of clinical
studies demonstrate great potential
for the treatment and prevention of
cardiovascular diseases,including is-
chemia-reperfusion (IR) injury and
hypertension,by dietary means.4,15
It
is incumbent upon regulators to
carry out a comprehensive,system-
atic,and independent review of all
available evidence of health effects of
dietary nitrate and nitrite.A review
process from an independent institu-
tion such as that implemented by the
Institute of Medicine would be opti-
mal.After decades of being subjected
to regulatory limits on dietary nitrate
and nitrite based on the poor prac-
tice of causal inference,the public de-
serves cohesive regulations that
reflect the physiologic necessity of
nitrate and nitrite while accounting
for contexts in which these dietary
substances may produce health risks.
The necessary work of bringing to-
gether experts from disparate scien-
tific disciplines to craft meaningful
dietary recommendations for nitrate
and nitrite intakes could be a boon
for public health.
Conclusions
The demonstrated hypotensive and
cytoprotective effects (particularly
under ischemic conditions) of dietary
nitrate and nitrite have led to the
proposal that these compounds be
considered nutrients.11
Balanced
against the observed toxic effects at
high concentrations and in specific
physiologic contexts,as exists among
all nutrients,the promotion of con-
sumption of plant sources of nitrate
and nitrite has great potential to ben-
efit public health.These health bene-
fits may be seen in the reduction of
morbidity and mortality due to en-
hanced endothelial dilatation,mito-
chondrial efficiency,and attenuation
of oxidative stress.9,16-18
Norman G.Hord,PhD,MPH,RD,is asso-
ciate professor in the School of Biologi-
cal and Population Health Sciences,
College of Public Health and Human
Sciences,at Oregon State University in
Corvallis,OR.
References
1.Lundberg JO,Carlstrom M,Larsen
FJ,et al. Roles of dietary inorganic ni-
trate in cardiovascular health and dis-
ease.Cardiovasc Res.2011;89:525-532.
2.Lundberg JO,Weitzberg E,Gladwin
MT.The nitrate-nitrite-nitric oxide
pathway in physiology and therapeu-
tics.Nature Rev. 2008;7:156-167.
3.Casey DP,Beck DT,Braith RW.Sys-
temic plasma levels of nitrite/nitrate
(NOx) reflect brachial flow-mediated
dilation responses in young men and
women.Clin Exper Pharmacol Physiol.
2007;34:1291-1293.
4.Sobko T,Marcus C,Govoni M,et al.
Dietary nitrate in Japanese traditional
foods lowers diastolic blood pressure
in healthy volunteers.Nitric Oxide.
2010;22:136-140.
5.Kapil V,Milsom AB,Okorie M,et al.
Inorganic nitrate supplementation
lowers blood pressure in humans:
role for nitrite-derived NO.Hyperten-
sion.2010;56:274-281.
6.Lauer T,Heiss C,Balzer J,et al.Age-
dependent endothelial dysfunction is
associated with failure to increase
plasma nitrite in response to exercise.
Bas Res Cardiol. 2008;103:291-297.
7.Larsen FJ,Weitzberg E,Lundberg

JO,et al.Dietary nitrate reduces maxi-
mal oxygen consumption while
maintaining work performance in
maximal exercise.Free Rad Biol Med.
2010;48:342-347.
8.Vanhatalo A,Bailey SJ,Blackwell JR,
et al.Acute and chronic effects of di-
etary nitrate supplementation on
blood pressure and the physiological
responses to moderate-intensity and
incremental exercise.Am J Physiol
Regul Integr Comp Physiol.
2010;299:R1121-1131.
9.Larsen FJ,Schiffer TA,Borniquel S,
et al.Dietary inorganic nitrate im-
proves mitochondrial efficiency in
humans.Cell Metab. 2011;13:149-159.
10.Lundberg JO,Feelisch M,Bjorne H,
et al. Cardioprotective effects of veg-
etables:is nitrate the answer? Nitric
Oxide.2006; 15::359-362.
11.Hord NG,Tang Y,Bryan NS.Food
sources of nitrates and nitrites:the
physiologic context for potential
health benefits.Am J Clin Nutr.
2009;90:1-10.
12.Hord NG,Ghannam JS,Garg HK,et
al. Nitrate and nitrite content of
human,formula,bovine,and soy
milks:implications for dietary nitrite
and nitrate recommendations.Breast-
feed Med. 2010; 6:393-399.
13.van Faassen EE,Bahrami S,Feel-
isch M,et al. Nitrite as regulator of
hypoxic signaling in mammalian
physiology.Med Res Rev.2009;29:683-
741.
14.Lundberg JO,Gladwin MT,
Ahluwalia A,et al. Nitrate and nitrite
in biology,nutrition and therapeutics.
Nature Chem Biol.2009;5:865-869.
15.Dezfulian C,Shiva S,Alekseyenko
A,et al. Nitrite therapy after cardiac
arrest reduces reactive oxygen
species generation,improves cardiac
and neurological function,and en-
hances survival via reversible inhibi-
tion of mitochondrial complex I.
Circulation. 2009;120::897-905.
16.Carlstrom M,Persson AE,Larsson
E,et al. Dietary nitrate attenuates ox-
idative stress,prevents cardiac and
renal injuries,and reduces blood
pressure in salt-induced hyperten-
sion.Cardiovasc Res.2011; 89:574-585.
17.Borniquel S,Jansson EA,Cole MP,
et al. Nitrated oleic acid up-regulates
PPARgamma and attenuates experi-
mental inflammatory bowel disease.
Free Rad Biol Med.2010;48::499-505
18.Rocha BS,Gago B,Pereira C,et al.
Dietary nitrite in nitric oxide biology:
a redox interplay with implications
for pathophysiology and therapeu-
tics.Curr DrugTargets.2011;12:1351-
1363.
29th Annual SCAN Symposium
Tools and Techniques for Peak Professional Performance
April 26-28, 2013
Westin Hotel, Chicago, IL
Don’t miss an exceptional opportunity to enhance your skills at the 2013 SCAN Symposium. Choose from 30 ses-
sions and 36 speakers, including Dr. Richard Deming, Dr. Steven Heymsfield, Dr. Penny Kris-Etherton, Jessica Set-
nick, Dr. Carol Ireton-Jones, and many more!
Among many other take-home skills that you’ll acquire, Symposium 2013 will enable you to:
I Improve your professional competency in managing advanced dyslipidemia using 2013 guidelines
I Forget the 3,500 kcal/pound rule—learn an alternative validated approach to predict client’s weight loss
I Become proficient in RMR data measurement, interpretation, and application
I Use imagery exercises, body language decoding, identity issue exercises, thought translation, and
behavioral abstinence for improved treatment therapy of binge eating disorder patients
I Practice effectively on camera, online, and in-public traditional and social media skills
I Calculate urine specific gravity for client hydration status and intervention strategies
I Discover sport- and individual-specific fueling strategies
I Learn techniques for overcoming reimbursement challenges
I Translate nutrition education information into culturally appropriate messaging
I Enhance your proficiency in athlete dietary assessment
I Create a treatment contract useful in the treatment of eating disorder and disordered eating populations
I Update and apply new self-tracking technologies and data visualization skills
I Recognize and use visual cues to develop a mindful eating strategy for your clients
25 CPEUs is requested from the Commission on Dietetic Registration

From
by Ingrid Skoog,MS,RD,CSSD
The Chair
make the desired impact. I worry about these changes and
wonder if we are simply going to“confuse the public”even
more with a name change,a new credential,and a new defi-
nition of the entry-level practitioner.
This is where our proactive,articulate SCAN members enter
the picture.It is unclear whether these recommendations will
become accepted mandates and be implemented without
further discussion. However,the Academy has stated that it
wants to hear from its members.So,I encourage you all to re-
view this document as well as the HOD Fact Sheet:Council on
Future Practice Visionary Report:Moving Forward — A Vision for
Education,Credentialing and Practice Outcomes Report.
SCAN Symposium 2013
Moving on,we now set our sights on our spring SCAN Sym-
posium in Chicago,IL. This unique event marks a turn in
SCAN’s approach to supporting members’needs for special-
ized continuing education and networking.Our new ap-
proach is characterized in Symposium 2013’s title:Tools and
Techniques for Peak Professional Performance.
This hands-on,experiential-based learning approach to Sym-
posium sessions means you will leave this event with skills
you can immediately apply to your practice.The program will
feature integrated topics related to sports nutrition,cardio-
vascular health,wellness,obesity,weight management,and
disordered eating and eating disorders.Presentations will re-
flect cutting-edge research and practical applications,with a
special emphasis on skill-building and interactive sessions.
SCAN’s Executive Committee works hard to make sure our ef-
forts align with your goals and the realities of your career.To
respond to your needs we are looking at more efficient and
effective ways to communicate with and provide resources to
our members. Toward those goals we are actively working on
the following:
I More webinars for close-to-home continuing education
I More efforts to promote the SCAN RD and our areas of spe-
cialization
I Stronger and more productive connections with our part-
nering organizations
I An improved Web site and online SCAN experience
So,the work,dedication,and commitment never end,and we
hope you can attend SCAN Symposium 2013 and participate
in this truly unique event.
Happy New Year,SCAN Members!
I’d like to discuss two topics in this issue:the Council on Fu-
ture Practice’s Visionary Report presented at the 2012 Food
& Nutrition Conference & Expo in October, and our 2013
SCAN Symposium coming up in April.
Visionary Report of the Council on Future Practice
At the House of Delegates (HOD) meeting held during
FNCE 2012,the Council on Future Practice (CFP) presented
its report of nine recommendations.Because the HOD will
be meeting in January 2013 to continue discussions on this
report,I want to remind our members of these recommen-
dations so they can be prepared for the outcomes and de-
cisions that the Academy,the Accreditation Council for
Education in Nutrition and Dietetics (ACEND),and the Com-
mission on Dietetic Registration (CDR) will be making.To
review the CFP initial report and the HOD outcomes report,
visit www.eatright.org/Media/content.aspx?id=
6442471758#.UHwe3VE1b8s.
In short,the following recommendations were suggested
and discussed:
1. Elevate the educational preparation requirement for an
entry level RD to a minimum of a graduate degree
2. Work toward the promotion of more coordinated master
of science/dietetic internship (MS/DI) programs
3. Develop a new credential for those graduating with a 4-
year undergraduate degree from a didactic program in di-
etetics (DPD)
4. Phase out the dietetic technician,registered (DTR) cre-
dential
5. Include practicum and outside of classroom learning
competencies to ACEND-accredited DPD programs
6. Continue work on expanding Board-Certified Specialist
credential offerings
7. Continue support for developing an advanced practice
credential for nutrition and dietetics professionals
8. Conduct a well-funded,comprehensive marketing,
branding,and strategic communications campaign target-
ing external stakeholders
9. Support an RD credential name change
As SCAN Chair and a long-time RD,it has become clear to
me that what our profession needs is reflected in #8. Until
the public considers our discipline and expertise as a part
of its regular language in the conversations about health
care,I am not sure if these other recommendations will
SCAN’S PULSE Fall 2012,Vol.31,No.4 | 15

Conference Highlights
FitBloggin’2012
Baltimore,MD
September 20-22,2012
The third annual FitBloggin’Confer-
ence carried the tagline“For bloggers
interested in fitness,wellness,good
food,and a healthy lifestyle:Two days
of education,networking,friendship,
and fun.”More than 300 attendees
from all over the United States con-
vened to learn from each other and
from sponsored food and fitness pro-
fessionals.The participants were pri-
marily women aged 25 to 40 years
who write blogs about their personal
fitness journey.Many are successful
businesswomen with full-time ca-
reers,others are full-time moms,and
all have either lost or are in the
process of losing weight and are ex-
ercising to keep it off.Some partici-
pants were just starting their journey
and finding support from an online
community of followers.The new
bloggers had only a few followers,
while the more established bloggers
reported having some 15,000 people
read their blogs each day.
The conference offered various types
of learning opportunities,including:
I Nutrition sessions (sponsored by
food companies such as Got Choco-
late Milk’s Refuel Campaign,the Beef
Council,and Unilever)
I Exercise breaks that included yoga,
CrossFit,Zumba,and fitness trampo-
lines
I Sessions about blogging as a busi-
ness
I Personal growth sessions on self-
acceptance,weight loss,and“when
you have a lot to lose”
I Discussions in which participants
could share their experiences about
blogging,weight,and self-accept-
ance
The titles of the“Get Down to Busi-
ness”sessions offer a clear idea of the
topics discussed:
I Harness the Power of YouTube
I Transition from Blog to Book
I Using Social Media to Drive Blog
Traffic
I Attract Local Media & Find Success
as a Freelance Writer
I Build Your Brand
I Tips to Leave Your Job and Follow
Your Dreams
I Turn Your Post Into an Article
I Take Your Online Community Of-
fline
I Drive More Traffic Through SEO
I Design a Better Blog on a Budget
I Monetizing Through the Pitch
The Business of Blogging
A session of particular interest to RDs
who are bloggers or contemplating
becoming a blogger was a discussion
on the business of blogging.Several
of the experienced bloggers shared
how they have generated income
from their blogs.For them,blogging
is a full-time job,with some people
blogging one to three times a day,
and other three times a week.
The organizer of the conference,Roni
Noone,has represented and con-
sulted for a wide variety of clients in
the health and fitness industry,in-
cluding Weight Watchers,Kraft,Vitali-
cious,Subway,Johns Hopkins
University,Quaker,NutraLite,and
POM.
Here are the highlights from this dis-
cussion:
I Sponsors seek out bloggers be-
cause they are“real people”who offer
authentic experiences and opinions.
Sponsors might secretly follow a
blogger for several months and then
approach him or her for a sponsor-
ship opportunity.For example a
health insurance company followed
several fitness bloggers and then se-
lected six,asking if they would write
a paid weekly blog about their health
journey for a year for the company’s
Web site.One blogger is a working
mother who is training for her first
marathon.The others include a 70-
year-old woman,a divorced dad,and
a veteran—all of whom represent
“real people”with challenging health
journeys.
I A company approached an experi-
enced blogger (@yumyucky),want-
ing to pay to put an ad on her blog
page as well as pay her to write a spe-
cific number of blogs and tweets
within a specified timeframe Al-
though she did not agree to have the
ad on her site,the company still paid
her to write some sponsored blogs.
I A protein supplement company
approached a former participant-
turned-blogger from The Biggest
Loser TV show,expressing interest in
sponsoring his blog and having him
serve as a paid spokesperson at
expos for some bodybuilding events,
including Mr.Universe.The company
had previously used celebrity spokes-
people,but they now prefer to hire
“real people”because they offer more
credibility.
I Unpaid blogging for specific
brands can be acceptable if it helps a
novice blogger enhance his or her re-
sume,build a portfolio,become more
visible,and create a relationship that
opens doors.These experiences can
sometimes help bloggers sell them-
selves and their experience to an-
other sponsor.
I If you want to find a sponsor for
your blog,seek contacts for brands
that you love.For example,if you love
apples,contact the public relations
department of an apple grower,learn
the latest nutrition news regarding
apples,and write a query letter let-
ting the company know how you can
help them.An important note:When
writing any paid articles or blogs,the
writer must disclose the sponsor is
paying them.
I Become an affiliate with
amazon.com.Any sales that come to
Amazon through your Web site gen-
erate an income stream.These sales
include not just the item you men-
tioned but also any other sales for
other items (e.g.,toys,clothing) that
got linked to your site.

An Opportunity for RDs
There was a clear lack of RDs at the
FitBloggin’Conference.The majority
of participants were self-taught
weight loss experts who were strug-
gling with self-reported food addic-
tions,sugar cravings,compulsive
exercise,emotional eating,and disor-
dered eating.With a few exceptions,
the handful of RDs in attendance
were invited as spokespeople for
food companies.SCAN RDs and Fit-
Bloggers could mutually benefit by
forming partnerships!
To connect with fitness bloggers,
check out the supportive online com-
munity called BlogToLose
(http://blogtolose.com),where more
than 5,000 dieters are blogging
about their weight loss journey.An-
other way to connect with fitness
bloggers is to follow a few of the Fit-
Bloggers; a list of participants can be
accessed at www.fitblogging.com/
whos-comin-2.Once you find some-
one who matches your interests,you
can send them an e-mail asking if
they might like some“food help”on
their journey.As you know,RDs are
one of the best-kept secrets,so these
bloggers might be able to help us be-
come more visible.
Summarized by“Conference High-
lights”editor Nancy Clark,MS,RD,
CSSD,who has a private practice in the
Boston area,is author of the bestselling
Nancy Clark’s Sports Nutrition Guide-
book,and can be reached via
www.nancyclarkrd.com.
Reviews
Nutrient Timing for Peak
Performance:The Right
Food,the Right Time,the
Right Results
Heidi Skolnik,MS,CDN,FACSM,and
Andrea Chernus,MS,RD,CDE
Human Kinetics,Champaign,IL
800/747-4457;
www.humankinetics.com
2010,softcover,237 pp,$17.95
ISBN-10:0-7360-8764-8
Renowned sports nutritionists Heidi
Skolnik and Andrea Chernus have
written this practical guide to help
athletes gain maximum performance,
recover quickly,reduce the risk of in-
jury,diminish muscle breakdown,and
enhance immune function.Based on
their years of experience working
with professional athletes as sports
nutritionists and recent research,
Skolnik and Chernus offer the latest
on nutrient timing to maximize re-
sults,performance,recovery,and suc-
cess in NutrientTiming for Peak
Performance.
The book has three sections:“The
Principles,”“The Nutrients,”and“Fuel-
ing Strategies,Plans and Menus.”The
first section emphasizes the impor-
tance of nutrient timing for energy,
muscle recovery,muscle breakdown
and rebuilding,and immunity.This
section also simplifies the science be-
hind the processes of digestion and
metabolism and the way our bodies
use nutrients for fuel.The authors
provide detailed yet easy-to-under-
stand information about the effects
of training and nutrient timing on
hormones including testosterone,in-
sulin,insulin-like growth factor-1
(IGF-1),growth hormone,glucagon,
cortisol,and adrenaline.A“timing tip”
is included on each page,with a key
take-away point on the topic dis-
cussed.
The books’second section examines
the role of macronutrients,micronu-
trients,fluids,and supplements in
training,recovery,and immunity.
While other books have discussed
the role of carbohydrates,protein,
and fat,NutrientTiming for Peak Per-
formance delves a little deeper.For
example,the authors highlight sec-
tions that discuss carbohydrate’s role
in overreaching,overtraining,and re-
siliency.As another example,the au-
thors demystify ideas of using
carnitine,getting into the fat burning
zone,and following dietary peri-
odization to enhance fat burning.
The third section,“Fueling Strategies,
Plan and Menus,”helps readers for-
mulate a plan based on their activity:
endurance,strength and power,or
stop and go.There are well-defined
subsections and tables that lay out a
plan for the timing of nutrients.Car-
bohydrate,protein,and fat need are
calculated based on age,height,gen-
der,and activity level and then trans-
lated into a blueprint.The blueprint
becomes the basis for a meal plan.
Within this section are chapters de-
voted to addressing endurance,
strength and power,and stop-and-go
athletes,providing detailed meal
plans and suggestions.
NutrientTiming for Peak Performance
lays down the nutritional foundation
to help endurance,strength and
power,and stop-and-go athletes suc-
ceed.This book would benefit novice
and elite athletes alike.It would also
make a nice addition to the sports
nutritionist’s bookshelf to be used

when creating individualized meal
plans with athletes.
Heidi Skolnik,MS,CDN,FACSM,is the
president of Nutrition Conditioning,
Inc.,a nutrition consulting practice.
She has master’s degrees in exercise
science and human nutrition.She is
also a New York State-certified nutri-
practice in New York City,where she
sees many athletes and performers.
Reviewed by Nichole Dandrea,MS,RD
part-time women’s health nutritionist
and owner of Nicobella Organics,a
healthy organic chocolate company
based in Los Angeles,CA.
tionist,a fellow of the American Col-
lege of Sports Medicine (ACSM),and
a certified ACSM health fitness in-
structor.Andrea Chernus,MS,RD,
CDE,is a registered dietitian and New
York State-certified dietitian and nu-
tritionist.She holds a master’s degree
in nutrition and exercise physiology.
She maintains a full-time private
Sports Dietetics-USA Research Digest
Bananas as Effective as Sport
Drink in Cycling Performance
Nieman DC,Gillitt ND,Henson DA,et
al.Bananas as an energy source dur-
ing exercise:a metabolomics ap-
proach.PLoS ONE. 2012;7:e37479
Research comparing sport nutrition
products to whole foods is lacking.
This randomized,cross-over study
utilized a metabolomics approach to
compare the acute effects of bananas
(BAN) versus Gatorade (GAT) on 75-
km cycling performance as well as
post-exercise inflammation,oxidative
stress,and changes in immune func-
tion.After consuming a moderate
carbohydrate (CHO) diet 3 days prior
to and Boost Plus (10 kcal/kg) 3 hours
prior to a 75-km time trial (TT),14
trained male cyclists (ages 18-45)
consumed either 0.4g/kg CHO from
BAN or GAT 10 minutes prior to TT.
Every 15 minutes during the TT,the
cyclists ingested 0.2 g/kg CHO from
either GAT or BAN (with equal water
to GAT).Symptom logs as well as pre-
,during,post-,and 1-hour post-exer-
cise blood samples were obtained
and analyzed for 103 metabolites.
Mean CHO intake during both trials
was 150 ±19.5g.There were no signif-
icant differences in mean power,
heart rate,rate of perceived exertion,
blood glucose levels,or total time be-
tween GAT and BAN (P>.05).Of the
103 metabolites analyzed,56 had ex-
ercise time effects suggesting in-
creased production of glutathione
and fuel-substrate utilization during
both trials.Dopamine levels signifi-
cantly increased in BAN versus GAT
(P<.001),possibly contributing to the
higher antioxidant capacity (as meas-
ured through ferric reducing ability
of plasma,FRAP,P=.012) in BAN.Inter-
leukin (IL)-10 and IL-8 levels were sig-
nificantly higher in BAN compared
with GAT (P=.003 and .004),suggest-
ing a slightly higher overall inflam-
matory response.Study participants
reported feeling significantly more
full (P=.003) and bloated (P=.014)
with BAN compared with GAT,likely
related to the almost 15 g of fiber
consumed during the exercise trial.
These results suggest that ingesting
bananas before and during pro-
longed intense exercise can support
athletic performance as effectively as
ingesting a commercially available
sport beverage.Regardless of promis-
ing data and the appeal of“food-first”
in providing unique benefits over
commercial products,practicality and
individual tolerance must be consid-
ered; consumers should be sure to
“try before you buy.”This study was
funded by a grant through Dole
Foods.
Summarized by Jenna Becker,MS,RD,
PES,CES,sports,community,and clini-
cal dietitian,Athletes’Performance,St.
Jude Medical Center and the American
Academy of Pediatrics,in Los Angeles
and Orange County,CA.
HMB Supplementation and
Muscle Mass,Strength,and
Anaerobic Capacity in Elite
Athletes
Portal S,Zadik Z,Rabinowitz J,et al.
The effect of HMB supplementation
on body composition,fitness,hor-
monal and inflammatory mediators
in elite adolescent volleyball players:
a prospective,double-blind,placebo-
controlled study.Eur J Appl Physiol.
2011;111:2261-2269.
Beta-hydroxy-␤-methylbutyric acid
(HMB) has purported ergogenic ef-
fects relating to reduced catabolic
incidence and increased training- as-
sociated anabolic gains.Few studies

Soy vs.Whey in Protein
Synthesis After Resistance
Exercise in the Elderly
Yang Y,Churchward-Venne YA,Burd
NA,et al.Myofibrillar protein synthe-
sis following ingestion of soy protein
isolate at rest and after resistance ex-
ercise in elderly men.Nutr Metab.
2012;9:57.
The ability to enhance myofibrillar
protein synthesis (MPS) at rest and
after resistance exercise (RE) follow-
ing consumption of soy or whey pro-
tein appears to be markedly different
in the young and elderly.The purpose
of this study was to determine the
efficacy of soy protein versus whey
on MPS in the elderly.In this random-
ized,counterbalanced study,three
groups of 30 male participants (mean
age 71 ± 5 y) consumed water,20 g,
or 40 g of soy protein isolate follow-
ing a bout of unilateral knee-extensor
RE (3 sets x 10 RM).Results were then
compared with the results reported
previously by the same authors using
the same protocol for 20 g and 40 g
of whey protein.Whole body leucine
oxidation and MPS were measured
using a constant infusion of leucine
and phenylalanine and vastus later-
alis muscle biopsies from both exer-
cised and non-exercised legs.Results
indicated increased whole-body
leucine oxidation for 20 g of soy com-
pared with 20 g of whey (P=.002).
There were no differences between
the 40 g soy and 40 g whey doses.No
changes occurred in the myofibrillar
fractional synthetic rate (MFSR) of the
rested leg for soy at 20 g or 40 g.In
contrast,MFSR significantly increased
at rest for both 20 g and 40 g of
whey.Consequently,MPS was greater
for whey versus both doses of soy
(P<.005).For the exercised condition,
an increase in MFSR was reported for
40 g of soy following an acute bout of
RE,but not for 20 g of soy.The in-
crease in MPS in the exercised leg
was greater for both whey conditions
compared with soy (P<.001).These
results suggest that soy protein may
not be effective as whey protein in
stimulating MPS in the elderly.Pro-
tein sources should be considered
when the intention is to enhance
MPS in clinical and active elderly
populations.
Summarized by Erica R.Goldstein,MS,
CSCS,CISSN,undergraduate nutrition &
dietetics student,University of North
Florida,Jacksonville,FL.
Raisins vs.Commercial
Sports Chews in Endurance
Performance
Too BW,Cicai S,Hockett KR,et al.Nat-
ural versus commercial carbohydrate
supplementation and endurance run-
ning performance. J Int Soc Sports
Nutr.2012,9:27.
Carbohydrate is a research-validated
ergogenic aid for endurance per-
formance.Consequently,many com-
mercial carbohydrate sport foods are
available.However,whole foods sup-
plying carbohydrate may be just as
effective.The purpose of this study
was to compare the gastrointestinal
tolerance,metabolic,and running
performance responses to the inges-
have investigated the effects of HMB
in younger athletes,in whom supple-
mentation is becoming increasingly
more commonplace This prospective,
double-blind,placebo-controlled
study examined the effect of HMB
supplementation on body composi-
tion,anabolic/catabolic hormone re-
sponse,inflammatory mediator
response,muscle strength,and
anaerobic/aerobic capacity during
the initial training stages of elite ado-
lescent male and female volleyball
players.In this study,28 elite Israeli
junior national team volleyball play-
ers were randomly assigned a 3g/day
dose of HMB or placebo over their
initial 7 weeks of training.Both
groups were exposed to equal train-
ing,sleep,and nutrition regimens
over the course of the study.Baseline
and post-supplementation measure-
ments were taken for all participants
1 week prior to and 1 week following
supplementation.Assessments in-
cluded vertical jump,upper and
lower limb 6RM,isokinetic dy-
namometer tests,Wingate Anaerobic
Test,and a 20-minute shuttle run.
Blood sampling and analyses in-
cluded growth hormone,insulin-like
growth factor (IGF)-1,IGF binding
protein-3,lactate,cortisol,testos-
terone,inflammatory mediators,in-
terlukin-6,and interleukin-1 receptor
antagonist.The HMB group had sig-
nificant gains in anaerobic peak and
mean power (P<.01),a significantly
greater increase in fat-free mass
(FFM) (56.4 ± 10.2 to 56.3 ± 8.6 vs.
59.3 ± 11.3 to 61.6 ± 11.3 kg; P<.001),
and significant strength gains in knee
flexion isokinetic force/FFM com-
pared with placebo.There were no
significant changes in aerobic meas-
ures or hormonal responses.As indi-
cated by this study,HMB
supplementation may be beneficial
in improving anaerobic qualities,
overall strength,and body composi-
tion during initial stages of training in
elite adolescent athletes.Longer-
term studies that also evaluate the
potential for negative side effects
should be conducted.
Summarized by Sarah Cook,MS,di-
etetic intern,Winthrop University,Rock
Hill,SC.

by Sumner Brooks,MPH,RD,CSSD
I The United States Olympic Com-
mittee (USOC) Sports Nutrition team
is composed of five dietitians,each of
whom supported various teams and
athletes over the past four years
preparing for the 2012 London
Olympic Games.The USOC sent all
five nutrition team members to Lon-
don,where they each helped support
the athletes in unique ways:
Alicia Kendig,MS,RD,CSSD, worked
with Paralympic sport athletes and
was the USOC winter sports dietitian;
Shawn Dolan,PhD,RD,CSSD,served
as the USOC team sport dietitian and
worked primarily with water polo
and volleyball team athletes; Andrea
Braakhuis,PhD,APD,fueled the
strength and power sports athletes
and supported track and field ath-
letes with their pre- and post-nutri-
tion fueling needs; Jennifer Gibson,
MSc,RD,supported the acrobat and
combat sports athletes,and assisted
the Olympic wrestlers on a daily basis
to ensure they made weigh-ins; and
Nanna Meyer,PhD,RD,CSSD,
worked closely with other sport dieti-
tians to organize Olympic Village din-
ing options and set up numerous
stations so proper recovery nutrition
could be made available to all Team
USA competitors regardless of
whether they had a sport dietitian.
I SCAN’s director of communica-
tions Kim Schwabenbauer,RD,
earned an amazing 4th place finish in
the Women’s Pro division at the Revo-
lution 3 Triathlon in Sandusky,OH,in
September 2012.With a completion
time of 9 hours 41 minutes,kudos go
NotablesSCAN
to Kim for her impressive perform-
ance.The race required a 2.4-mile
open water swim,112-mile bike ride,
and a full marathon.
I In August 2012,six SCAN members
presented at the Human Perform-
ance and Dietary Supplements Sum-
mit for the National Institutes of
Health – Office of Dietary Supple-
ments:Carmen Caraballo,MS,RD,
CSSD; Amanda Carlson-Phillips,
MS,RD,CSSD; Ellen Coleman MPH,
MA,RD,CSSD; Dave Ellis,RD,CSCS;
Rob Skinner,RD,CSSD; and Marie
Spano,MS,RD,CSSD.
If you have an accomplishment that
you would like to be considered for an
upcoming issue of PULSE,please con-
tact Sumner Brooks,MPH,RD,CSSD,at
sumner_brooks@yahoo.com.
tion of a whole food (raisins) and a
commercial carbohydrate product
(sports chews). Eleven endurance
trained runners (mean age 29.3 ± 7.8
years) ran 80 minutes on a treadmill
at 75% VO2max,followed by a 5-km
time trial (TT) during three separate
exercise trials separated by 7 to 14
days.Blood lactate,heart rate (HR),
respiratory exchange ratio (RER),
serum free fatty acids,glycerol,in-
sulin,plasma glucose,creatine kinase
(CK),and rating of perceived exertion
(RPE) were recorded every 20 min-
utes.Gastrointestinal (GI) discomfort,
whole body muscle soreness,and fa-
tigue were monitored by pre- and
post-questionnaires.Participants in-
gested 0 .5 g CHO/kg/body weight
(BW) pre-exercise and 0.2 g
CHO/kg/BW or water every 20 min-
utes of exercise in the form of either
raisins (31 g:100-kcal,24 g CHO) or
sports chews (3 pieces of Clif blocks,
30 g:100-kcal,24 g CHO) or water
during the 80-minute exercise pe-
riod.Fluid intake was kept constant
for all treatments.No differences be-
tween CHO sources were observed
for VO2,HR,lactate,glycerol,blood
glucose,RPE,muscle soreness,fatigue
ratings,or GI symptoms.TT running
time was decreased by 1 minute for
both carbohydrate sources in the
time trial compared with water
(P<.05).However,sports chews re-
sulted in slightly higher insulin levels
and carbohydrate oxidation rates
during exercise compared with
raisins (P<.05). Additionally,raisins
had a greater increase in CK during
exercise compared with sports chews
and water only (P<.05).The results of
this study indicate that a whole food
carbohydrate source (raisins) was as-
sociated with similar blood glucose
responses and running performance
as a carbohydrate sport food.Fund-
ing was supported by a grant from
the California Raisin Marketing Board.
Summarized by Stephanie R.De Leon,
MS,RD,CSSD,CDE,nutritional consult-
ant in San Antonio,TX.

I Be Sure to Vote for SCAN
Leaders
Take an active role in how SCAN is
governed by participating in the up-
coming election for SCAN leadership.
Once again,SCAN will use an elec-
tronic ballot.To vote online,go to the
home page of SCAN’s Web site
(www.scandpg.org) and click on the
link that says“2013 Election Ballot.”
Online voting polls open February 1,
2013; the final date to vote is March
3,2013.
I Apply Now for SCAN
Graduate Student
Research Grant
Here’s a great opportunity for gradu-
ate students:SCAN will award a
$2,000 grant to support the research
of a SCAN student member who is
currently a graduate student (an RD
or completing RD academic require-
ments) and pursuing research in one
of SCAN’s practice areas:sports and
performance nutrition,cardiovascular
health,wellness,and disordered eat-
ing/eating disorders.The application
deadline is February 1,2013 (5:00
pm Central Time).For an application
and further information,look under
the“Career & Students”tab at
www.scandpg.org.
I SCAN’s Annual Report
Available Online
You can find SCAN’s Annual Report
for fiscal year 2011-2012 posted on
SCAN’s Web site.The report gives
members and corporate sponsors an
inside look at SCAN’s programs,initia-
tives,current volunteers,budget,and
more.To access the publication,go to
www.scandpg.org/about-us/annual-
reports/.
I For Your Convenience:
Past PULSE Articles Indexed
Online
SCAN members are frequently refer-
ring to information that appeared in
past issues of SCAN’S PULSE. If you’re
Of Further Interest
doing research or simply want to lo-
cate content that appeared in an
archived issue,check out the annual
“Index of Topics”posted for each year
on SCAN’s Web site. You’ll find the
issue and page number for each fea-
ture article (conveniently listed by
practice area),and each item in Con-
ference Highlights,Reviews,and
Sports USA-Research Digest.You can
then instantly access the archived
issue online.As a member benefit,all
PULSE issues and annual indexes are
available to you for free at www.scan-
dpg.org/nutrition-info/pulse-
newsletters/.
I SCAN’s Web Site:Your
Go-To Resource
Be sure to visit SCAN’s Web site
(www.scandpg.org) often and dis-
cover how being a member of SCAN
can enhance your career.Here’s a
sampling of what you’ll find:
• Ways to Stay Connected via our
Member Forums. Take advantage of
the Members Only discussion forums
that let you network,share,and learn.
Current discussions include Sports
Nutrition Mentoring,and House of Del-
egates Issues, as well as forums with
specific questions regarding about
Sports Nutrition,Cardiovascular
Health,Wellness and Weight Manage-
ment, and Disordered Eating and Eat-
ing Disorders. Join the discussion at
www.scandpg.org/forum/.
• It’s Good to Know SCAN.The SCAN
Web site can help you get to know
fellow members better.Send us a
summary about a member on the
Web,TV,radio,or at a conference by
emailing scannews@gmail.com.
• New! SCAN Member Spotlight.
Here’s a great way to find out what
our volunteers are up to.
• Online Continuing Professional
Education (CPE). SCAN works hard
to provide interesting and valuable
topics for obtaining CPEs.Go to
www.scandpg.org/cpe/ to get
started.
• Now Available: 2012 SCAN Sym-
posium Recordings. All 2012 Sym-
posium workshops and presentations
are now available in the SCAN Online
Store.If you missed this event or
want to revisit some of the talks,
check out the store to obtain these
recordings.
• Natural Medicines Comprehen-
sive Database.You can tap into this
comprehensive database,available
for free to SCAN members,and take
advantage of a great resource for in-
formation and education.
• A Handy,Updated Guide.SCAN is
offering a free updated version of 10
Simple Steps to Make Good Habits
More Delicious:The Dietitian-Approved
Guide to Applying the 2010 Dietary
Guidelines for Americans and MyPlate
in 10 Simple Steps! You’ll find it in the
SCAN Online Store.
I News from Wellness/CV
RDs Subunit
Here’s an update on developments
from the Wellness/CV RDs:
• New Fact Sheet. Be on the lookout
for the latest Wellness/CV fact sheet
about spices.To access a research up-
date specifically for RDs,as well as a
traditional fact sheet to give to
clients,go to www.scandpg.org/car-
diovascular/cardiovascular-health-
fact-sheets/.If you have an idea for a
fact sheet topic,please contact Karen
Collins at karen@karencollinsnutri-
tion.com or Rosie Gonzalez at
Rosie.Gonzalez@hfit.com.
• Wellness/CV at Symposium 2013.
Register today for the skills-focused
SCAN Symposium,April 26-28,in

SCAN’S PULSE 2012 CPE Reviewers
The SCAN’S PULSE Editorial Board would like to acknowledge those who
served as reviewers of our continuing professional education (CPE) articles
during the 2012.Their review made it possible to offer SCAN members the
opportunity to earn a total of four free CPE units from PULSE during this
period.Our appreciation goes to:
• Michele Macedonio,MS,RD,CSSD
• Mayumi Petrisko,MS,RD,CSSD
• William Proulx,PhD,RD
• Sarah Schutzberger,RD,CSO
the new edition you’ve been waiting
for and will refer to often for specific
evidenced-based sports nutrition in-
formation.
• New! CSSD Online Application.
The application for the Board Certi-
fied Specialist in Sports Dietetics
(CSSD) is now available at www.cdr-
net.org/certifications/spec/newonli-
neeligibilityapplication.cfm.
• 13 CSSD Exam Windows.The next
exam dates are February 4-25 (ex-
cept February 18; application dead-
line has passed) and July 8-26
(application postmark deadline:April
26,2013).For details,go to www.
cdrnet.org/.
• CSSD Recertification: Five-year re-
certification is due for CSSDs certified
in 2008.Check your certification year
and be prepared to recertify.Eligibil-
ity includes documentation of 1,000
hours of specialty practice experi-
ence as an RD within the past 5 years
by the application due date (effective
until 2014).
• The CSSD: Qualification Matters.
We now have 549 CSSDs.According
to the 2011 Compensation and Bene-
fits Survey (J Acad Nutr Diet, January
2012),CSSDs earn the highest hourly
wage per patient/client responsibility
among all those holding a CDR spe-
cialist credential.Overall,RDs with
CDR specialty credentials earn higher
compensation than RDs without spe-
cialist certification.Apply now for the
CSSD credential!
• IOC Diploma in Sports Nutrition:
SCAN members now qualify for a
10% discount off tuition and fees.For
information,go to www.sportsora-
cle.com/ioc/.
• Tout Your Expertise. Let athletes
and clients tout your expertise by
Chicago.Some of the offerings re-
lated to Wellness/CV include:1.) An
intensive 6-hour program co-pre-
sented with the National Lipid Asso-
ciation,explaining how to put into
practice the soon-to-be-released ATP
(Adult Treatment Panel) IV guidelines
on lipid management and prepare
for the lipid specialist certification.2.)
A session on nutrition counseling
with cultural sensitivity,demonstrat-
ing how to talk about obesity and di-
etary changes while showing respect
for the client’s cultural heritage; and
3.) A presentation on reimbursement
challenges and how to successfully
handle them.Visit www.scandpg.org
for the latest Symposium informa-
tion.
• Updated List of Foods Recom-
mended by SCAN Members. Check
out the list at www.scandpg.org/nu-
trition-info/nutrition-info-for-con-
sumers/foods-scan-rds-reommend/.
Compiled by SCAN members,this list
can save you time as you navigate
new heart-healthy products at the
grocery store.To share your latest
“finds,”contact Georgia Kostas at
georgia@georgiakostas.com.
• Wellness/CV Connection. If you’re
trying to find an article in the Well-
ness/CV Connection e-newsletter but
you can’t remember when it was
published,visit www.scandpg.org/
cardiovascular/newsletters/.
• Advanced Cardiovascular Certifi-
cations. Interested in learning more
about advanced cardiovascular certi-
fications? In conjunction with SCAN’s
new agreement with the National
Lipid Association,we have added
that information to the SCAN’s Web
site (www.scandpg.org) under the
“Nutrition Info”tab,Cardiovascular
Health Professional Resources.
I News from Sports Dietetics
USA (SD-USA)
Below are some highlights from the
SD-USA subunit:
• Sport Nutrition Practice Manual—
New Edition. The Academy’s Sports
Nutrition:A Practice Manual for Profes-
sionals, 5th ed.,can now be pur-
chased at the Academy Shop.This is

SCAN Winter 2013

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (19)

Ähnlich wie SCAN Winter 2013

Ähnlich wie SCAN Winter 2013 (20)

SCAN Winter 2013