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Dietitians in
Integrative
and Functional
Medicine
THE
THE INTEGRATIVE
INTEGRATIVE
RDN
RD
a dietetic practice group of the
®
Academy of Nutrition
and Dietetics
Fall 2015
Volume 18, Issue 2
Winter 2014
Volume 16, Issue 3
CPE Article
Supporting a Patient with
Food, Water, and
the Environment:
Hashimoto’s
Thyroiditis
What’s Women’s
Health Got to Do with It?
through
Nutrition
•DIFM-HEN
• • • •FNCE
• • •Joint
• •Session
• • •Overview
• • • •By•Emily
• • Davis
• • •Moore,
• • MS,
• •RDN,
• • LDN
In This Issue
IN THIS ISSUE:
Supporting a Patient With
Food, Water, & the Environment:
Hashimoto’s.......................................29
CPE
Reporting
Form.......................38
What’s
Women’s
Health Got to Do
CPE
Instructions...............39
with Activity
It? .....................................37
CPE Questions...................................39
Editors
Corner .........................38
CPE
Certificate..................................40
Myths
of
Hypothyroidism.............41
Chair’s Corner
.........................39
Resource Review:
Leadership
List ........................40
The
Autoimmune
Solution..........44
Ginger: Symptom
Detox Presentation ..................41
Management....................................45
News
You
Can Use...........................48
Student
Spotlight
.....................43
Student Corner.................................53
Member
Review .......44
DIFMBreakfast
Student Stipend...........53
Immune
Boosters....................55
News You Can Use ..................45
Chair’s Corner....................................57
Networking
News.....................48
Editor’s
Notes....................................58
Dietary
Supplement
Reducing Environ. Toxins.........49
Safety In the News..........................59
Annual
Report
2014 - 2015..........60
Resource
Review:
Executive Committee List.............67
Numen Film Review .............50
“Cooked” Book Review .........51
Objectives
Advocating for Advocados .......52
After
completing
thisList
CPE
activity,
Extended
Leadership
........54
the nutrition professional will be
able to:
1. Recognize the prevalence of
Hashimoto’s thyroiditis
2. Understand the conventional
approach to Hashimoto’s
thyroiditis
3. Discuss the integrative
approach to Hashimoto’s
thyroiditis
N
®
Dr. Izabella Wentz, PharmD, FASCP
is a pharmacist
whodietetic
was diagnosed
utrition and
with Hashimoto’s
thyroiditis
in
professionals
must remain
2009. Over
the past
six years,
abreast
of available
evidence
she
hasthe
dedicated
careerabout
to the
amidst
growing her
concerns
helping
peopleofwith
Hashimoto’s
health impacts
pollutants
in our food
recover
their
health.
In 2015,members
she
and water
supply.
To enable
conducted
largestresponses
patient- to
in providingthe
scientific
experience
for people
with
patient/clientsurvey
questions,
the Hunger
Hashimoto’s,
collecting
responses
and Environmental
Nutrition
(HEN)
from
2232
Hashimoto’s
patients
and the
Dietitians
in Integrative
and
on
the most
helpful (DIFM)
interventions.
Functional
Medicine
Dietetic
She
is theGroups
author(DPGs)
of the New
York
Practice
partnered
Times
bestselling
guide, Hashimoto’s
in presenting
“Food,
Thyroiditis:
Lifestyle Interventions for
Water, and the
Finding
and Treating
Environment:
What’s the Root Cause,
aWomen’s
co-founder
of the
Health
Got Hashimoto’s
Institute,
a frequent speaker on
to Do withand
It?”during
thyroid
Contact Dr. Wentz at
the 2013health.
Food and
[email protected].
Nutrition Conference
and Expo (FNCE®) in
ashimoto’s
thyroiditis is an
Houston,
Texas. The
autoimmune
session
presenters, condition that
resultsPhD,
in the destruction
Kim Robien,
of
the
thyroid
RD,
CSO,
FANDgland,
and eventually
leading
hypothyroidism.
Elizabethto
Redmond,
Hashimoto’s
is the most frequently
PhD, MMSc, RDN,
occurring
autoimmune condition,
both well-regarded
with
aninestimated
prevalence
experts
their
rate
between
12% and 26% in
fields,
shared current
1,2
the
general
population,
andfor
the
research
findings
and strategies
leading
of hypothyroidism
reducingcause
exposure
to environmental in
the
United States, accounting for
pollutants.
H
90-97% of cases.1-3
“Environmental Nutrition and
Women’s Health - should we worry
Testing
for Hashimoto’s
about BPA and phthalates?”
Presented
by Kim
Robien,with
PhD, RD,
Clinicians
working
CSO,
George
Washington
University
people with Hashimoto’s should
be aware
of the primary
Environmental
nutrition tests
is an
used
to diagnose
andismonitor
emerging
concept and
defined
the
condition.
tests, thyroid
by Dr.
Robien asBlood
the intersection
ultrasound,
as well as health
a biopsy
between environmental
andof
the thyroid gland can be used to
nutrition. Although
food and water
diagnose
Hashimoto’s. Blood
tests
provide
essential
nutrients,
they can
are the most accessible option
alsomost
servecommonly
as mechanisms
toxin
and
usedformethod
delivery.
Food
rich
in
nutrients
to determine a diagnosis of can
decrease the absorption and harm of
Hashimoto’s.
toxins
aid in stimulating
their elimination. Yet
Theand
thyroid
the
most
commonly
foods—
hormone (TSH) testconsumed
is the most
especially
in
the
fast-food
laden
areas
commonly utilized screening and
Dr.
Robien
calls
“food
swamps”—often
monitoring test for thyroid disease.
lackisthe
nutrient
value
that is important
TSH
made
by the
pituitary
gland,
not
only
for
basic
health,
but thyroid
also for
which sends signals to the
harmful chemicals.
toprotection
increasefrom
production
of thyroid
hormones when levels are low.
An elevated TSH test is indicative
of hypothyroidism but is not
diagnostic of Hashimoto’s.
In recent years, the National
Academy of Clinical Biochemistry
indicated 95% of individuals
without thyroid disease have TSH
concentrations below 2.5 mU/L,
and a new normal reference
range was defined by the
American Association of Clinical
Endocrinologists to be between 0.3
and 3.0 mU/L in healthy adults
without thyroid disease. Elderly
individuals over the age of 80,
however, may have a TSH value
Unfortunately,
thismU/L
is not without
an issue that
that
is above 2.5
any
lends itselfoftoautoimmune
quick and conclusive
evidence
thyroid
answers4 through research. As it is
disease.
unethical
to conduct
randomized
Thyroid
peroxidase
(TPO)
controlled trials
potentially toxic
antibodies
and with
thyroglobulin
(Tg)
chemicals on
much antiof the
antibodies
arehumans,
the primary
research
is focused detected
on animal in
models.
thyroid
antibodies
Additionally, testing
is expensive,
Hashimoto’s
thyroiditis
and are is
subject to
plastic
present
in contamination
90% and 80%with
of those
5
collectionrespectively.
containers, and
has aantilimited
affected,
These
ability toantibodies
effectively measure
thyroid
indicatelow-dose
that
exposure.
there
is an active autoimmune
process happening in the thyroid
Continued on page 39
gland. However, it can take many
years before enough gland
damage occurs to affect the
thyroid’s ability to adequately
produce thyroid hormones and
before a change in TSH is noted
on lab testing. Thus, thyroid
antibodies can be used to
diagnose Hashimoto’s and may
be present for decades before a
change in TSH is observed.5
Thyroid antibodies
are thought to have a
positive correlation with the
aggressiveness of the condition,
indicating a greater attack on
the thyroid gland.6 Seronegative
Hashimoto’s has been recently
described as a less aggressive
version of the condition, where
thyroid specific antibodies
are not detected, however
the hypoechoic pattern of the
thyroid gland characteristic of
Hashimoto’s is found on thyroid
ultrasound.7
Thyroid hormones
can also be assessed. Most
circulating thyroxine (T4) and
triiodothyronine (T3) are proteinbound; unbound T4 and T3 are
the active forms of the hormone
available to the body. Total T4 and
total T3 levels reflect both the
bound and unbound hormones,
while free T4 and free T3 testing
measures just the active, unbound
hormone levels.
A full thyroid work-up for
people with Hashimoto’s should
include TSH, free T3, free T4 and
thyroid antibodies (inclusive of
TPO and Tg antibodies). A baseline
thyroid ultrasound should also be
utilized.
However, some individuals
with Hashimoto’s may also
experience symptoms typically
associated with hyperthyroidism,
such as irritability, palpitations
and anxiety due to a transient
hyperthyroidism that results from
a flood of thyroid hormones into
the blood stream secondary to
breakdown of thyroid tissue.
In addition to experiencing
symptoms of hypo- and
hyperthyroidism, many people
with Hashimoto’s also experience
a variety of other inflammatory
symptoms, especially
gastrointestinal distress, such as
irritable bowel syndrome (IBS),
gastroesophageal reflux disease
(GERD), diarrhea, constipation,
bloating, rashes, allergies, adrenal
fatigue, and nutrient deficiencies.
Furthermore, recent studies
point to the role of a high titer
of thyroid antibodies resulting
in symptoms such as distress,
obsessive-compulsive symptoms
and anxiety, even in euthyroid
(having thyroid hormone levels
within the normal reference
range) subjects.8,9
Pharmacotherapy
The standard of care for
Hashimoto’s hypothyroidism
is the use of thyroid hormone
medications to bring a patient
into the euthyroid state. As
thyroid hormone receptors
are present in every cell of the
body, medication optimization
is an important step in helping
a person with Hashimoto’s feel
better.
The medication levothyroxine
Symptoms
is the drug of choice per
conventional treatment
Many symptoms of
guidelines. Chemically,
Hashimoto’s result from
levothyroxine contains one
hypothyroidism and include the
tyrosine molecule with four
classical hypothyroid symptoms of attached iodine molecules and
cold intolerance, hair loss, fatigue, is often referred to as T4. T4 has
weight gain, forgetfulness, muscle been described as a pro-hormone,
aches, constipation, a loss of the
as it needs to be deiodinated
outer third of the eyebrow, and
in the body to produce
infertility.
triiodothyronine (T3), a more
Fall 2015 Volume 18, Issue 2
30
physiologically and metabolically
active thyroid hormone that
contains three molecules of
iodine.
Synthetic T3-containing
medications, liothyronine
sodium, are also available, as
well as T4/T3 combination
medications, including desiccated
thyroid extract products, and
compounded medications made
by compounding pharmacists.
While treatment guidelines
suggest that most Hashimoto’s
patients can be well-controlled
with levothyroxine,4 a new paper
on the quality of life in people
with Hashimoto’s thyroiditis
found that some people with
the disorder may continue to
experience symptoms despite
levothyroxine treatment.10
In 2014, Dr. Wilmar Wiersinga,
a Dutch endocrinologist and top
thyroid researcher, stated that
“Impaired psychological wellbeing, depression or anxiety are
observed in 5–10% of hypothyroid
patients receiving levothyroxine,
despite normal TSH levels. Such
complaints might hypothetically
be related to increased free T4
and decreased free T3 serum
concentrations, which result in
the abnormally low free T4:free T3
ratios observed in 30% of patients
on levothyroxine. Evidence is
mounting that levothyroxine
monotherapy cannot assure
a euthyroid state in all tissues
simultaneously, and that normal
serum TSH levels in patients
receiving levothyroxine reflect
pituitary euthyroidism alone.”11
New research supportive
of the role of T3 in thyroid care
is emerging, and a 2013 study
conducted by the National
Institutes of Health concluded
that: “DTE [Desiccated Thyroid
Extract] therapy did not result in a
significant improvement in quality
of life; however, DTE caused
modest weight loss and nearly
half (48.6%) of the study patients
expressed preference for DTE over
www.integrativeRD.org
L-T4. DTE therapy may be relevant
for some hypothyroid patients.”12
In a survey of 2232 people
with Hashimoto’s, the majority
reported feeling best with
a TSH under 2.0 mU/L and
showed a preference for
products that contained both
T4 and T3 hormones, such as
natural desiccated thyroid or
compounded T4/T3 medications.13
Thyroid hormone therapy
should be individualized with the
patient in mind. Each person with
Hashimoto’s should be evaluated
by a physician who specializes in
thyroid hormone optimization.
Goals of Integrative and
Complementary Methods
While conventional treatment
protocols offer many lifestyle
interventions for the treatment
of other chronic conditions, most
primary care physicians receive
very little training in lifestyle
interventions for Hashimoto’s.
A functional and integrative
approach to Hashimoto’s can
address many of the residual
symptoms experienced by
people with Hashimoto’s, reduce
thyroid antibodies, and can,
in some cases, even prevent
the progression into other
types of autoimmune disease.
Additionally, through the use
of functional medicine and
integrative approaches, this
writer has documented numerous
Hashimoto’s remission stories,
resulting in thyroid antibodies
becoming seronegative, often
along with a reduced need for
thyroid hormone replacement.14-21
Integrative Approach to
Hashimoto’s
develop: 1) genetic predisposition,
2) a trigger, and 3) intestinal
permeability. These three factors
together create “the perfect
storm” of autoimmunity, and it
has been found that eliminating
triggers or the intestinal
permeability can lead to a
remission of autoimmunity.22,23
It may take some detective
work to identify triggers, and
even the root causes of intestinal
permeability—some root causes
have not yet been identified,
and we may not have the tools
to resolve them, but helping to
support a person’s body though
nutrition should always be the
first approach to improving the
outcomes of the condition. The
integrative approach to helping
people with Hashimoto’s focuses
on addressing nutrient depletions,
food sensitivities, stress response,
detoxification, and any underlying
or chronic infections.21
Multiple nutritional
approaches have been reported to
help the prognosis of Hashimoto’s
and/or other autoimmune
conditions, including a gluten-free
diet, iodine-free diet, the Specific
Carbohydrate Diet, GAPS Diet,
paleo diet, autoimmune
paleo diet, soy-free diet,
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New research from Dr.
Alessio Fasano and colleagues
has focused on the “three-legged
stool of autoimmunity.” Dr. Fasano
has found that three primary
factors need to be present
in order for autoimmunity to
Fall 2015 Volume 18, Issue 2
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31
www.integrativeRD.org
dairy-free diet, low FODMAPs diet,
and the Body Ecology Diet.
Vegetable juicing and elemental
diets may also play a supportive
role.14-21, 24
The connecting thread
behind these diverse dietary
approaches is that they all remove
various reactive foods. Most of
the diets also include animal
proteins, are more nutrient dense
than the standard American
diet, and eliminate processed
foods. As many of these diets
limit carbohydrates, they are also
likely to be helpful for people with
Hashimoto’s due to blood sugar
balancing effects.
Reducing the intake of
goitrogenic vegetables, which
can block the intake of iodine
into the thyroid gland, has been
a common recommendation for
people with iodine deficiency
hypothyroidism, however, as
Hashimoto’s is not an iodine
deficiency-related thyroid
condition, but rather an
autoimmune condition, that
recommendation is not relevant
for most with Hashimoto’s.25-27
Fluoride, which was
historically used as a thyroidsuppressing agent due to its
antagonistic effects with iodine,
however, may be a relevant
substance to avoid for those with
Hashimoto’s. Hypothetically,
fluoride, when occupying
iodine receptors, can initiate
inflammation in the thyroid
gland, acting as a catalyst in the
autoimmune response. Using
a reverse-osmosis water filter
can be helpful in reducing one’s
exposure to fluoride.28-31
Blood Sugar Balance
According to a 2012 Polish
study, “Carbohydrate metabolism
disorders in the form of type
1 diabetes connected with an
autoimmune process, as well
as type 2 diabetes connected
with the increase of the insulin
resistance, occurred in an average
Fall 2015 Volume 18, Issue 2
of half of the patients with
Hashimoto’s thyroiditis.”32 Blood
sugar imbalances can exacerbate
the autoimmune response in
Hashimoto’s and may lead to
increased levels of anxiety and
thyroid antibodies. Balancing
blood sugar levels should be one
of the priorities for everyone with
autoimmune thyroiditis. Reducing
the intake of carbohydrates,
excess fruits and sugars, while
increasing the intake of healthy
fats can be a helpful measure for
people with Hashimoto’s.
Food Sensitivities
People with Hashimoto’s
often present with numerous food
sensitivities, and testing may show
IgG antibodies to various food
proteins. IgG antibodies are also
thought to be the same types of
antibodies that target the thyroid
gland in autoimmune disease,
thus removing IgG reactive foods
may attenuate the IgG response
to the thyroid gland.33
Gluten, the protein found in
wheat, rye and barley, is a known
trigger of intestinal permeability.
Various studies have looked
at the rates of celiac disease in
people with Hashimoto’s. All of
the studies have found celiac
disease to be more common with
Hashimoto’s, but the incidence
rates have varied.34-37 While a
2006 Brazilian study found an
incidence rate of celiac disease
at only 1.2% of people with
Hashimoto’s, a 2007 Dutch study
found that 15% of subjects
with Hashimoto’s had celiac
disease.34,37 One study, focused on
patients with co-occurring celiac
disease and Hashimoto’s, found
that most people with these
concurrent conditions were able
to regain thyroid function—as
manifested by a reduction of
TSH, normalization of thyroid
antibodies and a reduced need for
medications—after implementing
a gluten-free (GF) diet.37
In this author’s experience,
32
a small subset of clients have
been able to achieve remission of
Hashimoto’s with a GF diet as the
sole intervention. However, very
little has been published on the
topic of the effects of a GF diet in
individuals with Hashimoto’s who
do not have celiac disease.
As there is no current research
supporting the use of dietary
interventions for Hashimoto’s,
with the exception of a GF diet
for those with co-occurring celiac
disease, during May 2015, this
author conducted a survey of
2232 people with Hashimoto’s
who are readers of the www.
thyroidpharmacist.com website.
Seventy-six percent reported
that they believed that they were
gluten sensitive (another 16% of
respondents were not sure).13 Most people that reacted
to gluten reported feeling the
reaction in their gut (constipation,
diarrhea, cramping, bloating,
nausea, gas, acid reflux,
burning or burping) and in their
brain, with symptoms such as
headaches, dizziness, brain fog,
anxiety, depression, fatigue and
insomnia.13 Overall, 88% of survey
respondents with Hashimoto’s
who attempted a GF diet felt
better, with 86% reporting
an improvement in digestive
symptoms. Improvements in
mood, energy levels and weight
reduction were reported in 60%,
67%, and 52% of people with
Hashimoto’s who undertook a
GF diet, respectively.13 Notably,
only 3.5% of survey respondents
reported being diagnosed with
celiac disease,13 suggesting that
a person with Hashimoto’s does
not have to have celiac disease to
benefit from a GF diet.
Limiting sugar was reported
as “helpful” for 81% of those
surveyed. Additional common
food sensitivities reported by
survey respondents include
soy, dairy, eggs, nuts, seeds,
nightshades and grains. Survey
www.integrativeRD.org
results indicated that people with
Hashimoto’s may also be more
sensitive to the effects of caffeine,
which can exacerbate heart
palpitations and anxiety.13
It should be noted that this
sample was comprised of readers
of www.thyroidpharmacist.com,
and not the typical patients
presenting at an endocrinology
clinic. As the author advocates
nutrition as an integral approach
to Hashimoto’s, it is possible that
the respondents were biased
towards a GF diet. Nonetheless,
until more published research
becomes available, these results
can be used as a guide for
clinicians helping people with
Hashimoto’s.
Nutrient Density
In addition to GF diets, the
other most helpful dietary
interventions included sugar-free,
paleo, autoimmune paleo, grainfree, dairy-free, and low glycemic
index diets. Survey respondents
who tried these approaches
reported feeling 75-81% better.13
Incorporating nutrient-dense
“healing” foods also supported
symptom improvement.
Homemade bone-broth helped
70% of those that tried it,
while green smoothies helped
69%, and fermented foods helped
another 57%.13
While one study found that
vegans had a lower incidence
rate of hypothyroidism compared
to lacto-ovo vegetarians and
people eating the standard
American diet,38 out of 292 survey
respondents with Hashimoto’s
who attempted the vegan diet, 87
said it made them feel better, 83
said it made them feel worse, and
122 did not see a difference.13
In contrast, out of 1793 survey
respondents with Hashimoto’s
who tried a GF diet, 88% (1580
respondents) reported that it
made them feel better, less than
1% (13) reported that it made
them feel worse, and 11% (200)
Fall 2015 Volume 18, Issue 2
did not see a difference.13
This author’s clinical
experience has shown that
some individuals were able to
achieve remission of Hashimoto’s
following the transition from a
vegan diet to a paleo-like diet.
More research is needed on
the role of specialized diets in
autoimmune thyroid disease.
Until then, clinical experience has
indicated that the most helpful
approaches have been found to
be the GF diet, sugar free diet,
paleo diet, grain-free diet, dairyfree diet, autoimmune modifiedpaleo diet, and the low glycemic
index diet.13
Food sensitivity testing,
elimination diets and rotation
diets may further improve
outcomes.21
Nutrients Required for Proper
Thyroid Function
Selenium, iron, vitamin
A, vitamin E, the B vitamins,
potassium, iodine, and zinc are
all required for proper thyroid
function. Other nutrients,
although not directly involved in
thyroid function, are also essential
for proper immune, gut, liver and
adrenal function.
People who are diagnosed
with Hashimoto’s should be tested
for vitamin D, vitamin B12, and
ferritin deficiency. While iodine
deficiency is a known cause of
non-autoimmune hypothyroidism,
Hashimoto’s does not seem to
correlate with iodine deficiency.
In fact, iodine excess has been
recognized as a trigger for
Hashimoto’s, and an upper intake
limit of 400 mcg of iodine per day
has been suggested for those
with Hashimoto’s. Testing for the
remaining nutrients required for
thyroid function is not readily
accessible, and clinicians have
the option of relying on the use
of clinical assessments, advanced
functional medicine nutrient
testing as well as multivitamin
supplements. Supplements
33
containing up to 150 mcg of
iodine have been found to
be tolerated by people with
Hashimoto’s without increasing
thyroid antibodies.5,24,34-36
Vitamin D
Adequate vitamin D levels
have been associated with a
lower likelihood of developing
Hashimoto’s. Vitamin D levels
should be checked at regular
intervals, especially in the winter
months. There are two available
tests: 1,25-dihydroxyvitamin
D [1,25(OH)2D] and
25-hydroxyvitamin D [25(OH)D].
The latter is preferred. Blood levels
of 25(OH)D should be between 60
and 80 ng/L for optimal thyroid
receptor and immune system
function.39-40
Sources of vitamin D include
cod liver oil, fatty fish, fortified
dairy and orange juice, eggs,
and sunlight. Despite dietary
interventions and sunlight, many
people may still require an oral
vitamin D3 supplement to reach
their target range.
Vitamin B12
Vitamin B12 is naturally found
in animal products including fish,
meat, poultry, eggs, milk, and
other dairy products. However
this vitamin is generally not
present in plant foods, and thus
vegetarians and especially vegans
are at a greater risk for deficiency.
Low levels of B12 can
contribute to fatigue and are
often found in people with
Hashimoto’s. Normal levels of B12
are between 200-900 pg/mL, yet
levels under 350 are associated
with neurological symptoms.
If B12 levels are below 800, a
person may still benefit from
supplementation. Patients with
Hashimoto’s and low B12 levels
should be screened for parietal
cell antibodies, which may be
present in up to one-third of
patients with Hashimoto’s.41-43
www.integrativeRD.org
Options for B12 replacement
include capsules, sublingual
tablets, liquids, and injections.
The sublingual route may offer
an advantage for those with
absorption issues, and it is more
convenient than injections.
Methylcobalamin versions of
B12 are highly bioavailable, do
not require intrinsic factor for
activation, and are generally
preferred over cyanocobalamin
versions.
Selenium
Selenium deficiency has been
identified as an environmental
trigger for Hashimoto’s, and
multiple studies have been
done on the role of selenium in
autoimmune thyroid disease.
While several studies reported no
benefit and a Cochrane review
found insufficient evidence,
many other studies reported
the benefit of selenium in
autoimmune thyroid disease.5,44-50
Testing for selenium deficiency
is not routinely performed;
however a 200 mcg dose of
selenomethionine was found
to reduce thyroid peroxidase
antibodies by 50% over the
course of three months.49 Patients
who start selenium often report
feeling calmer, potentially due
to a reduction in thyroid tissue
breakdown.50
Selenium is a trace mineral
that is incorporated into proteins
to make antioxidants including
glutathione peroxidase. This
type of protein, known as a
selenoprotein, prevents damage
from the hydrogen peroxide
generated from the conversion
of iodide to iodine by breaking
down the hydrogen peroxide into
water particles. This allows for the
removal of the cells affected by
oxidative damage, leads to the
preservation of tissue integrity,
and prevents the convergence of
white blood cells in the thyroid
gland.47
The Recommended Daily
Fall 2015 Volume 18, Issue 2
Allowance (RDA) for selenium
is 55 mcg, while the Tolerable
Upper Intake Level (UL) is 400
mcg.51 A study done in South
Dakota did not find any signs of
toxicity at levels as high as 724
mcg; however, changes in nail
structure, a sign of toxicity, were
reported with selenium intakes
of 900 mcg per day in China.52
Most reported toxicity cases have
been associated with industrial
accidents and manufacturing
errors. Some symptoms of
selenium toxicity that have been
reported include GI disturbances,
hair loss, changes in hair and nails,
peripheral neuropathy, fatigue,
irritability, garlic-smelling breath,
and a jaundice-like yellow tint to
the skin.52,53
While the RDA of
selenium may usually be
found in multivitamin/
mineral combinations, that
will not be sufficient for TPO
antibody reduction. Studies have
been done to test the minimal
dose of selenium for thyroid
antibody reduction, and that dose
was established to be 200 mcg
daily; even a 100 mcg dose did not
produce a statistically significant
TPO antibody reduction.49
Hypochlorhydria/Achlorhydria
Studies have found that
people with Hashimoto’s and
hypothyroidism often have
hypochlorhydria (low stomach
acid) or achlorhydria (lack of
stomach acid).54
An inadequate amount
of stomach acid can make it
more difficult for patients to
digest proteins, making them
more fatigued and more likely
to develop food sensitivities,
especially to gluten, dairy and soy,
as these proteins are amongst the
most difficult to digest and are
also the most commonly eaten
proteins in the standard western
diet. Furthermore, low stomach
acid can contribute to small
intestinal bacterial overgrowth,
34
which can be a trigger for
intestinal permeability and was
reported to be present in 54% of
people with hypothyroidism in
one study.55
Additionally, having low
stomach acid makes individuals
more susceptible to acquiring gut
infections such as Helicobacter
pylori (H. pylori), Yersinia, other
bacteria with lipo-polysaccharide
residues, and parasites, which
may contribute to the antigenic
burden commonly found in
autoimmunity.
Nutrient depletions of
iron and B12 are sometimes
secondary to hypochlorhydria
or achlorhydria, and supporting
proper stomach acid production
may be a useful measure in
helping to address deficiencies,
restoring proper digestive
function, resolving fatigue and
preventing the development of
new food sensitivities.56, 57
Betaine hydrochloride (HCl)
with pepsin, taken at the end of
a protein-containing meal, can
be a supportive supplement for
restoring stomach acid levels.
However, root causes of low
stomach acid, such as H. pylori
infection should also be explored
and addressed.
Clinicians should be familiar
with instructing their clients on
proper dose titrations of betaine
HCl with pepsin, having the
client start with one dose per
protein-containing meal, then
watching for responses such
as a slight burning sensation in
the throat or esophagus. The
patient should be instructed
to increase the betaine by one
dose until the burning sensation
is perceived; at that point, the
target dose can be estimated to
be one dose less than the dose at
which the burning sensation was
experienced.
Intestinal permeability support
Supporting intestinal barrier
function though the use of
www.integrativeRD.org
digestive enzymes, omega-3
fatty acids, zinc, L-glutamine,
and curcumin can be helpful in
healing the intestinal barrier and
improving immune regulation.
Overall, survey respondents
reported the following
supplements as helpful:
vitamin B12 (76%), vitamin
D3 (74%), digestive enzymes
(73%), iron (63%), omega-3
fatty acids (65%), selenium 200
mcg (63%), betaine HCl with
pepsin (59%), curcumin (56%),
zinc 30 mg (52%) and L-glutamine
(51%).13 (The numbers in
parentheses represent the
percentage of people who
reported “feeling better” after
incorporating these supplements.)
Additional interventions
Supporting a person’s
nutrition status can help put
some cases of Hashimoto’s into
remission and will help most
people with the condition feel
better.
Additional integrative
methods that may be used in
conjunction with medications
and nutrition may include stress
reduction, emotional support,
adrenal support, detoxification
protocols, and addressing chronic
infections that may be present in
those who do not immediately
respond to initial nutritional
interventions.
Pathogens can contribute to
the antigenic load of Hashimoto’s
through various mechanisms,
including leading to intestinal
permeability, the “bystander
effect” (when a pathogen is inside
the target organ), as well as
molecular mimicry (when proteins
on the pathogen are similar to
proteins on the target organ).
Common pathogens that
have been identified in people
with Hashimoto’s include H.
pylori,58-59 Yersinia entercolitica,60-62
Borrelia burgdorferi (one
of the bacteria that causes
Lyme disease)62 as well as an
Fall 2015 Volume 18, Issue 2
overgrowth of bacteria in the
small intestine.55 Epstein Barr Virus
(EBV) has also been implicated
in triggering Hashimoto’s
and other autoimmune
conditions.63- 65 Reactivations of
EBV can potentially exacerbate
Hashimoto’s symptoms.65
The treatment of chronic
infections and toxins in
Hashimoto’s is beyond the scope
of this article; however any person
who has not responded to three
months of nutritional therapy
should be investigated for the
presence of infections and toxins.
Further discussion on
Hashimoto’s, infections,
detoxification and a functional
medicine root cause approach
can be found in Hashimoto’s
Thyroiditis: Lifestyle Interventions
for Finding and Treating the Root
Cause.21
••••••••••••••
Erratum to the Summer 2015 issue of
The Integrative RDN.
On page 15, it is incorrectly stated
that KU Integrative Medicine accepts
students. The KUMC Department
of Dietetics and Nutrition offers the
graduate certificate program, teaches the
graduate level classes and accepts the
Fellows. We are sorry for any confusion or
misunderstanding this may have created.
••••••••••••••
Dietitians in
Integrative
and Functional
Medicine
a dietetic practice group of the
®
Academy of Nutrition
and Dietetics
35
www.integrativeRD.org
Supporting a Patient with Hashimoto’s
Thyroiditis Through Nutrition References
•••••••••••••••••••••••••••••••••••••••••••
1. Wang C, Crapo LM. The
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17. Wentz I. Jen’s Hashimoto’s
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18. Wentz I. Lisa’s Hashimoto’s
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19. Wentz I. Liz’s root cause (a
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20. Wentz I. Dorthea’s
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www.thyroidpharmacist.com/
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Accessed July 28, 2015.
21. Wentz I, Nowosadzka M.
Hashimoto’s Thyroiditis: Lifestyle
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23. Fasano A. Zonulin and its
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28. Peckham S, Lowery D,
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29. Galletti P, Joyet G. Effect
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32. Gierach M, Gierach
J, Skowrońska A, et al. Hashimoto's
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JW. Coeliac disease in Dutch
patients with Hashimoto's
thyroiditis and vice versa. World J
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35. Farahid OH, Khawaja N,
Shennak MM, Batieha A, ElKhateeb M, Ajlouni K. Prevalence
of coeliac disease among adult
patients with autoimmune
hypothyroidism in Jordan. East
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36. Teixeira LM, Nisihara R,
Utiyama SR, et al. Screening
of celiac disease in patients
with autoimmune thyroid
disease from Southern Brazil.
Arq Bras Endocrinol Metabol.
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37. Sategna-Guidetti C, Volta
U, Ciacci C, et al. Prevalence of
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38. Tonstad S, Nathan E, Oda
K, Fraser G. Vegan diets and
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39. Wang J, Lv S, Chen G,
et al. Meta-analysis of the
association between vitamin
D and autoimmune thyroid
disease. Nutrients. 2015;7(4):24852498.
40. Mansournia N, Mansournia
MA, Saeedi S, Dehghan J. The
association between serum
25OHD levels and hypothyroid
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mechanisms in pernicious
anaemia & thyroid
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42. Rojas Hernandez CM, Oo
TH. Advances in mechanisms,
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43. Gerenova JB, Manolova IM,
Tzoneva VI. Clinical significance of
autoantibodies to parietal cells in
patients with autoimmune thyroid
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44. Balazs C, Kaczur V. Effect of
selenium on HLA-DR expression
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10.1155/2012/374635.
45. Negro R. Selenium and
thyroid autoimmunity. Biologics.
2008;2:265-273.
46. Xu J, Liu XL, Yang
XF, Guo HL, Zhao LN, Sun XF.
Supplemental selenium alleviates
the toxic effects of excessive
iodine on thyroid [published
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2, 2010]. Biol Trace Elem Res.
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s12011-010-8728-8.
47. Drutel A, Archambeaud
F, Caron P. Selenium and the
thyroid gland: more good news
for clinicians. Clin Endocrinol (Oxf).
2013;78(2):155-164.
48. van Zuuren EJ, Albusta AY,
Fedorowicz Z, CarterB, Pijl H.
Selenium supplementation for
Hashimoto's thyroiditis: summary
of a Cochrane Systematic Review.
Eur Thyroid J. 2014;3(1):25-31.
49. Gärtner R, Gasnier BC, Dietrich
JW, Krebs B, Angstwurm MW.
Selenium supplementation
in patients with autoimmune
thyroiditis decreases thyroid
peroxidase antibodies
concentrations. J Clin Endocrinol
Metab. 2002;87(4):1687-1691.
50. Toulis KA. Selenium
supplementation in the
treatment of Hashimoto's
thyroiditis: a systematic review
and a meta-analysis. Thyroid.
2010;20(10):1163-1173.
51. National Institutes of Health.
Dietary Supplement Fact Sheet:
Selenium. Office of Dietary
Supplements Website. http://ods.
od.nih.gov/factsheets/SeleniumHealthProfessional/. Published
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52. Fan AM, Kizer KW. Selenium
– nutritional , toxicologic, and
clinical aspects. West J Med.
1990;153:160-167.
53. Longnecker MP, Taylor
PR, Levander OA, et al. Selenium in
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54. Daher R, Yazbeck T, Jaoude
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55. Lauritano AC, Bilotta
AL, Gabrielli M, et
al. Association between
hypothyroidism and small
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56. Betesh AL, Santa Ana
CA, Cole JA, Fordtran JS. Is
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deficiency anemia? Am J Clin Nutr.
2015;102(1):9-19.
57. Jensen RT. Consequences of
long-term proton pump blockade:
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Pharmacol Toxicol. 2006;98(1):4-19.
58. Aghili R, Jafarzadeh F,
Bhorbani R, Khamseh ME, Salami
MA, Malek M. The association of
Helicobacter pylori infection with
Hashimoto's thyroiditis. Acta Med
Iran. 2013;51(5):293-296.
59. Franceschi F, Satta MA
Mentella MC. Helicobacter
pylori infection in patients
with Hashimoto's thyroiditis.
Helicobacter. 2004;9(4):369.
60. Shenkman L, Bottone
EJ. Antibodies to Yersinia
enterocolitica in thyroid
disease. Ann Intern
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61. Guarneri F, Carlotta D,
Saraceno G, Trimarchi F,
Benvenga S. Bioinformatics
support the possible triggering
of autoimmune thyroid diseases
by Yersinia enterocolitica
outer membrane proteins
homologous to the human
thyrotropin receptor. Thyroid.
2011;21(11):1283-1284.
62. Benvenga S, Santarpia
L, Trimarchi F, Guarneri F. Human
thyroid autoantigens and proteins
of Yersinia and Borrelia share
amino acid sequence homology
that includes binding motifs to
HLA-DR molecules and T-cell
receptor. Thyroid. 2006;16(3):22536.
63. Janegova A, Janega P, Rychly
B, Kuracinova K, Babal P. The role
of Epstein-Barr virus infection in
the development of autoimmune
thyroid diseases. Endokrynol
Pol. 2015;66(2):132-136.
64. Draborg AH, Duus K, Houen
G. Epstein-Barr virus in systemic
autoimmune diseases. Clin Dev
Immun. 2013;2013:535738. doi:
10.1155/2013/535738. Epub 2013
Aug 24.
65. Nagata, K, Nakayama Y, Higaki
K, et al. Reactivation of persistent
Epstein-Barr virus (EBV) causes
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their surface. Autoimmunity.
2015;48(5):328-335.
CPE Reporting Form
Supporting a Patient with Hashimoto’s
Thyroiditis through Nutrition
Expiration Date: September 15, 2018
Please print or type
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
Academy Membership #: __________________________________Phone: _____________________________
Email Address: _____________________________________________________________________________
DIFM Member:
Yes
No Date Test Completed: ____/____/____
The answer key for the questions: 1. a; 2. c; 3. c; 4. b; 5. d.
Fall 2015 Volume 18, Issue 2
38
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Instructions for Completing the CPE Activity for Credit
1) Read the Continuing Professional Education article and
answer the associated quiz questions. For each question, select the one best response. Compare your answers to the answer key on the previous page.
2) Send your completed quiz and application for CPE
credit by email or mail to:
Shari Pollack, MPH, RDN, LDN
4500 Keeney Street, Skokie, IL 60076
[email protected]
3) Print the CPE certificate, complete a copy, and retain it for your records. You will be notified only if your
application for credit is not approved.
This activity has been approved for one and a half hours of CPE credit. You will be notified if hours are not approved.
Possible Learning Codes: 3020, 4180, and 5420
CPE Questions:
1) Why is it important to correct blood sugar
imbalances in people with Hashimoto’s
thyroiditis?
a. They can exacerbate the autoimmune
response.
b. They can worsen the T4 to T3 ratio.
c. They can lead to intestinal permeability.
d. They can increase IgG antibodies to food.
2) What is the role of betaine HCl and pepsin in
patients with Hashimoto’s?
a. It is necessary for the conversion of T4 to
T3.
b. It can prevent hyperchlorhydria.
c. It can help restore gastric acid levels in
patients with hypochlorhydria.
d. It has been shown to reduce thyroid
antibodies.
3) What is the dose of selenium methionine shown
to reduce thyroid peroxidase antibodies?
a. 55 mcg
b. 100 mcg
c. 200 mcg
d. 724 mcg
4) The “three-legged stool” of autoimmunity
includes all of the following except:
a. Intestinal permeability
b. Vitamin D deficiency
c. A trigger
d. Genetic predisposition
5) Which of the following can support intestinal
barrier integrity?
a. Vitamin A, vitamin D, and iodine
b. Selenium, iron, and omega-3 fatty acids
c. Vitamin B12, potassium, and betaine HCl
d. L-glutamine, zinc, and curcumin
Dietitians in
Integrative
and Functional
Medicine
a dietetic practice group of the
®
Fall 2015 Volume 18, Issue 2
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Academy of Nutrition
and Dietetics
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Session Title:
Supporting a Patient with Hashimoto's Thyroiditis
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CDR Activity Number:
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CPEUs Awarded:
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Supporting a Patient with Hashimoto's Thyroiditis
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www.integrativeRD.org
Myths of Hypothyroidism
Leigh Wagner, MS, RDN, LD
•••••••••••••••••••••••••••••••••••••••••••
Leigh Wagner, MS, RDN, LD is an
Integrative and Functional RDN at
KU Integrative Medicine in Kansas
City. She loves building relationships
with clients and investigating their
histories to design personalized
nutrition and supplement
programs. Leigh teaches cooking
classes on campus and is working
toward a PhD in Medical Nutrition
Science from the KU. Please join
her on Instagram @GoodKarme for
posts on nutrition, motivation and
recipes. Contact Leigh at lwagner@
kumc.edu.
H
ypothyroidism is a common
and burdensome health
condition. Symptoms
of hypothyroidism include
constipation, dry skin, muscle
pain, brittle hair, hair loss, fatigue,
and difficulty losing weight. Since
1 in 300 people (NHANES III)1 and
nearly 10% of adult women have
hypothyroidism,2 it is important
to address some of the myths
surrounding the disease. The
following are some common
myths and a brief summary
of evidence to address the
controversy or misconception.
Myth: Everyone with
hypothyroidism needs iodine
supplementation.
Iodine is required for healthy
thyroid function, and iodine
is most highly concentrated
within the thyroid gland. Thus,
adequate iodine levels are
important for the thyroid to work
properly. One situation where
clinicians should be cautious
with iodine supplementation is
in the presence of anti-thyroid
antibodies.3 Persons with
elevated thyroid antibodies are
at increased risk of experiencing
negative effects of iodine
supplementation.3 In other words,
when a person has elevated
thyroid antibodies, he or she
should be wary of high, long-term
iodine intake. Therefore, persons
with hypothyroidism should
Fall 2015 Volume 18, Issue 2
be tested for the presence of
thyroid antibodies prior to iodine
supplementation.
Myth: People with
hypothyroidism should avoid all
goitrogenic foods.
Myth: Anyone in the U.S. eating
commercially prepared foods
or consuming dairy products
regularly gets enough iodine
from salt or dairy foods.
Goitrogens are compounds
in foods that inhibit thyroid
function. When a person has
hypothyroidism or is at risk for
thyroid dysfunction, it may be
recommended that they decrease
Although iodized salt is widely goitrogenic foods. Goitrogenic
available, salt iodization is not
foods primarily include soy,
mandated in the U.S.4 Most food
millet, and cruciferous vegetables
companies use non-iodized salt in (broccoli, cauliflower, cabbage,
their foods.5 As a result, Americans Brussels sprouts, mustard, kale,
may not consume as much iodine collard greens, kohlrabi, bok choy,
rutabaga, and turnips).7 Although
through salty, processed foods as
once thought.
a person with hypothyroidism
Like salt, dairy foods are
should be cautious of the amount
assumed to have high amounts
of goitrogenic foods, he or she
of iodine because, historically,
can continue to eat cruciferous
iodine has been supplemented
vegetables, as long as the
in dairy cattle and iodine-based
vegetables are cooked. Cooking
disinfectants were used in
generally decreases cruciferous
tanks for dairy transportation.
vegetables’ goitrogenic effects.2
Unfortunately, soy’s goitrogenic
However, cattle aren’t as widely
activity is not affected by heating
supplemented and the iodineor cooking,8 and cooking millet
based disinfectants are often
actually increases its goitrogenic
replaced with chlorine-based
antiseptics.6 As such, dairy cannot activity.9
be considered a dependable
source of iodine in the U.S. food
Myth: People with
supply.
hypothyroidism should avoid
soy completely.
Myth: Iodine deficiency is the
main cause of hypothyroidism
Soy is commonly known
in the U.S.
to affect the thyroid gland.10 Its
isoflavones (phytonutrients in soy)
Although worldwide iodine
affect Thyroid Peroxidase (TPO)11;
deficiency is to blame for
TPO is involved in the synthesis
hypothyroidism, in the United
of thyroid hormones (T3 and T4).
States, Hashimoto’s thyroiditis is
For clinicians who are concerned
the primary cause of the disease.1 about the anti-thyroid effects of
Keep in mind that one sign of
soy, it is important to know that
iodine deficiency is low thyroxine
persons with deficient iodine
(T4).6 When possible, doctors
levels are at higher risk for soy’s
should check urinary iodine
negative thyroid effect compared
levels (preferably 24-hour urinary
to iodine-replete individuals.
iodine) to determine iodine
Thus, it is important to check
status. Knowing iodine status can iodine levels in individuals with
help determine whether iodine
hypothyroidism.
supplementation is warranted.
41
www.integrativeRD.org
Myth: If Thyroid Stimulating
Hormone (TSH) is elevated
but T4 is normal, then thyroid
function is normal.
Subclinical Hypothyroidism
(SCH) is not a medical diagnosis
but is defined biochemically as
elevated Thyroid Stimulating
Hormone (TSH) with normal free
Thyroxine (fT4).12-14 Depending on
the level of TSH elevation, SCH can
be mild (4.5-9.0 mU/L) or severe
(≥10 mU/L).13 Its prevalence varies
widely, ranging between 4-10%
in the general adult population
and as high as 20% in older
women.15-17
Despite the fact that SCH
is not a medical diagnosis, SCH
increases risk for cognitive
impairment,18 cardiovascular
disease,19 and for progression to
overt hypothyroidism.1,13 Although
screening and treatment
recommendations vary,20-22 most
experts recommend treatment
with thyroid hormone (L-T4) at
TSH > 10 mU/L because higher
TSH levels make progression to
overt hypothyroidism more likely.
When TSH is between 4.5 and 10
mU/L, treatment is typically left
to clinicians’ judgment.17 Patients
with both SCH and vitamin D
deficiency also have increased
cardiovascular risk.23
Myth: Measuring TSH is the only
important test to screen the
thyroid.
Although TSH “with reflex
T4” (when TSH is out of range the
laboratory will be triggered to
test T4) is a commonly used lab
test among clinicians, integrative
medicine doctors suggest, at a
minimum, to test TSH, free T3,
free T4, TPO antibodies, minerals
or cofactors, and reverse T3. Also,
note that TSH is highest typically
between 10 pm and 4 am, and it is
lowest between 10 am and 6 pm.24
Fall 2015 Volume 18, Issue 2
Take Home Message
The thyroid is a complex
gland, and its activity influences
more than metabolism and
weight management. A
healthy thyroid can influence
cardiovascular health, cognitive
function, bone health, and keep
one feeling vibrant and energetic.
Both the public and clinicians
alike are easily overwhelmed
and sometimes confused by
conflicting information in the
media. The information provided
in this article is likely to change
as we continue to learn more
about the thyroid gland and the
foods and nutrients that affect its
function. With nutritional science
ever-evolving and growing,
clinicians must stay up-to-date on
thyroid-related clinical guidelines
and existing science to help
individualize patient and client
care and to address the recurrent
myths that circulate.
Myths of Hypothyroidism
References
1. Gaitonde DY, Rowley KD,
Sweeney LB. Hypothyroidism:
an update. Am Fam Phys.
2012;86(3):244-251.
2. Escott-Stump S, Giroux I.
Nutrition and Diagnosis-Related
Care, 7th Ed. + Applications and
Case Studies in Clinical Nutrition.
Philadelphia, PA: Lippincott
Williams & Wilkins; 2012.
3. Leung AM, Braverman
LE. Iodine-induced thyroid
dysfunction. Curr Opin Endocrinol
Diabetes Obes. 2012;19(5):414-419.
4. Leung AM, Braverman LE,
Pearce EN. History of U.S. iodine
fortification and supplementation.
Nutrients. 2012;4(11):1740-1746.
5. National Institutes of Health:
Office of Dietary Supplements.
Iodine: Fact Sheet for Health
Professionals. https://ods.
od.nih.gov/factsheets/IodineHealthProfessional/. Reviewed
June 24, 2011. Accessed July 27,
2015.
42
6. Zimmermann MB, Boelaert K.
Iodine deficiency and thyroid
disorders. Lancet Diab Endocrinol.
2015;3(4):286-295. DOI: http://
dx.doi.org/10.1016/S22138587(14)70225-6.
7. Higdon JV, Delage B, Williams
DE, Dashwood RH. Cruciferous
vegetables and human
cancer risk: epidemiologic
evidence and mechanistic
basis. Pharmacological Res.
2007;55(3):224-236.
8. Divi RL, Chang HC, Doerge DR.
Anti-Thyroid Isoflavones from
Soybeans. Biochem Pharma.
1997;54(10):1087-1096.
9. Gaitan E. Goitrogens in
food and water. Ann Rev Nutr.
1990;10:21-39.
10. Messina M, Redmond G.
Effects of Soy Protein and Soybean
Isoflavones on Thyroid Function in
Healthy Adults and Hypothyroid
Patients: A Review of the Relevant
Literature. Thyroid. 2006;16(3):249258.
11. Doerge DR, Chang HC.
Inactivation of thyroid peroxidase
by soy isoflavones, in vitro and in
vivo. J Chromatogr B Analyt Technol
Biomed Life Sci. 2002;777(1-2):269279.
12. Surks, MI Ortiz E, Daniels GH,
et al. Subclinical thyroid disease
scientific review and guidelines
for diagnosis and management.
JAMA. 2004;29(2):228-238.
13. Cooper DS, Biondi B.
Subclinical thyroid disease. Lancet.
2012. 379:1142-1154.
14. Cooper DS. Subclinical
Hypothyroidism. NEJ M.
2001;345:260-266.
15. Hollowell JG, Staehling NW,
Flanders WD, et al. Serum TSH,
T4, and Thyroid Antibodies in the
United States Population (1988
to 1994): National Health and
Nutrition Examination Survey
(NHANES III). J Clin Endocrin.
2002;87(2):489-499.
16. Canaris GJ, Manowitz NR,
Mayor G, Ridgway EC. The
Colorado Thyroid Disease
Prevalence Study. Arch Intern Med.
2000;160:526-534.
www.integrativeRD.org
17. Gharib H, Tuttle RM, Baskin HJ.
Subclinical thyroid dysfunction: a
joint statement on management
from the American Association
of Clinical Endocrinologists, the
American Thyroid Association,
and the Endocrine Society. J Clin
Endocrinol Metab. 2005;90(1):581585.
18. Resta F, Triggiani V, Barile G,
et al. Subclinical hypothyroidism
and cognitive dysfunction
in the elderly. Endocr Metab
Immune Disord Drug Targets.
2012;12(3):260-267.
19. Rodondi N den Elzen WP,
Fall 2015 Volume 18, Issue 2
Bauer DC, et al. Subclinical
hypothyroidism and the
risk of coronary heart
disease and mortality. JAMA.
2010;304(12):1365-1374.
20. Ringel MD, Mazzaferri EL
Subclinical thyroid dysfunction-can there be a consensus about
the consensus? J Clin Endocr
Metab. 2005;90(1):588-590.
21. Cooper DS. Subclinical
thyroid disease: consensus or
conundrum? Clin Endocr (Oxf ).
2004;60(4):410-412.
22. Chu JW, Crapo LM. The
treatment of subclinical
43
hypothyroidism is seldom
necessary. J Clin Endocr Metab.
2001;86(10):4591-4599.
23. Yilmaz H, Cakmak M, Darcin T,
et al. Subclinical hypothyroidism
in combination with vitamin
D deficiency increases the risk
of impaired left ventricular
diastolic function. Endocr Regul.
2015;49(2):84-90.
24. Rakel D. Integrative Medicine.
3rd ed. Philadelphia, PA: Saunders,
Elsevier Inc; 2012.
www.integrativeRD.org
Resource Review:
The Autoimmune Solution
Emily D. Moore, MS, RDN, LD/N
• • • •he•Autoimmune
• • • • • •Solution
• • • • • •reducing
• • • environmental
• • • • • • toxins,
• • • • • Reviewed
• • • •by• Emily
• • D.• Moore,
• • • MS,
•
T
Amy Myers, MD
Hardcover: $27.99
New York, NT: HarperCollins.
2015. 390 pp.
ISBN: 978-0-06-234747-3
Amy Myers, MD, is a family
practice physician and a leader
in functional medicine. Dr.
Myers explored integrative
and functional approaches
for answers after losing her
mother to cancer, watching her
father suffer with autoimmune
disease, and struggling with her
own autoimmune diagnosis.
Conventional treatments
resulted in harsh side effects
and inadequate relief, pushing
her to seek out other options.
When she learned of integrative
and functional methods through
the Integrative Healthcare
Symposium, she was inspired
to train through the Institute
of Functional Medicine, follow
her own path to better health,
and open a private practice
in functional medicine. In The
Autoimmune Solution, Dr. Myers
shares her years of education and
both personal and professional
experience with autoimmune
disease in an effort to empower
the reader on his or her own
journey towards health.
Part I of The Autoimmune
Solution engages the reader
with Dr. Myers’ story, a simplified
explanation of autoimmunity, and
a comparison of conventional and
functional treatments. Targeted
towards the patient, the language
requires no specific medical
background to be understood
and frequent lists, quizzes and
graphics help the patient identify
how the information applies to his
or her own health condition and
goals.
In Part II, Dr. Myers explains
the solution to autoimmune
disease, which she titles “The
Myers Way.” She describes in detail
the importance of healing the gut,
removing inflammatory foods,
Fall 2015 Volume 18, Issue 2
healing infections, and relieving
stress. Throughout the section and
the following, Dr. Myers includes
helpful lists of not only what to
exclude, but also what to include
in the patient’s plan for reducing
inflammation. Part III includes
a 30-day protocol, complete
with a 30-day diet plan, a 7-day
vegetarian diet plan, and “The
Myers Way Recipes.” Throughout
Part II and Part III, Dr. Myers
refers the reader to the book’s
seven appendices and additional
resources. The reader will find
more specific tips and hints for
applying “The Myers Way” and a
long list of websites organized by
category (Detoxifying, Food and
Dining, Laboratories, Research
and Treatment, Supplements, and
many more).
Part IV offers additional tips
on applying “The Myers Way” for
a lifetime—through the holidays,
when traveling, and in other
social situations. Additionally, Dr.
Myers offers the patient advice for
including a healthcare provider
in the treatment plan. Although
success stories were sprinkled
throughout the first sections
of the book, she closes with
additional stories to inspire the
patient on his or her journey.
While The Autoimmune
Solution is written for the patient,
it provides the advanced practice
integrative RDN with examples
of simple language to use with a
client, specific treatment plans,
and numerous resources to share
with the reader or to educate
oneself. The beginning integrative
RDN will find the book to be an
easy-to-digest introduction to the
subject of autoimmune disease.
Dr. Myers’ application of her
knowledge and experience into a
detailed, ready-for-execution plan
is of great value to all readers.
RDN, LD/N, Copy Editor of the
Integrative RDN and Asst. Professor
at Daytona State College. Contact
Emily at emilydavismoore@hotmail.
com.
•••••••••••••
•••••••••••••
Dietitians in
Integrative
and Functional
Medicine
a dietetic practice group of the
®
44
Academy of Nutrition
and Dietetics
www.integrativeRD.org
Ginger: Symptom Management for Chemotherapy
Elle Skinner, RDN
Induced Nausea and Vomiting
• •Elle• Skinner
• • • is• a•Registered
• • • •Dietitian
• • • • •Chemotherapy
• • • • • • Induced
• • • •Nausea
• • • • results
• • •from
• • peripheral
• • • • nerve
•••
working in the Trauma/Surgery ICU,
University of New Mexico (UNM)
Hospital and a graduate student
in the UNM Nutrition and Dietetics
Program. She completed her
Bachelor's degree at the University
of Newcastle, Australia in 2010 and
practiced as a clinical dietitian for
three years in drug and alcohol,
mental health and rehabilitation.
Contact Elle at [email protected].
N
ausea and vomiting are
some of the most commonly
experienced side effects of
chemotherapy.1 The occurrence
of chemotherapy induced nausea
and vomiting (CINV) is dependent
on the type, strength and duration
of chemotherapy treatment.
Emesis occurs in chemotherapy
patients due to the stimulation
of the brain’s “vomiting center”
(VC), the central point where the
peripheral and central nervous
system meet. The multifaceted
stimuli causing CINV make it
difficult to provide targeted
treatment.2 Neurotransmitter
receptors present in this
region include serotonin,
5-hydroxytryptamin-3 (5-HT3)
receptors, opioid receptors,
dopamine D2 receptors and
receptors for substance P.3 These
neurologic receptor pathways, in
combination with sensory stimuli
of smell, taste, psychological
response and pain are said to
define the chemoreceptor trigger
zone (CTZ).2,4 Chemotherapy acts
as gastrointestinal tract stimuli
resulting in the production of
serotonin through the 5-HT3
receptors; treatment is therefore
targeted towards these receptors.
Current research studies suggest
gingerol, derived from the ginger
plant (zingiber officinale), has
an effective role on serotonin
receptors (5-HT3) and reducing
emesis.5 The following review
aims to summarize several clinical
studies related to the efficacy of
ginger as an antiemetic for CINV.
Fall 2015 Volume 18, Issue 2
and Vomiting
Five sub-categories include:
(1) Acute CINV defined as
onset within the first 24 hours
of treatment and; (2) Delayed
CINV, where CINV occurs 24
hours after treatment initiation,
lasting up to five days; Less
common and dependent on the
type of chemotherapy agent
administered are: (3) Anticipatory
CINV, reflecting the period of
time post one significant nausea
and vomiting episode and prior
to the next cycle where CINV is
ongoing; (4) Breakthrough CINV,
when a patient has been treated
for nausea and vomiting, however
it still occurs; and (5) Refractory
CINV, when previously effective
prophylactic antiemetic therapies
are no longer successful during
subsequent treatment cycles.2
CINV is reported to occur in
approximately 60% of oncology
patients receiving chemotherapy
treatment.6,7 However, high
emetogenic agents such as
cisplatin and doxorubicin are
known to have a >90% incidence
of CINV.7
Treatment for CINV and its
effectiveness
Current medical guidelines
advocate for CINV to be treated
by antiemetics,6 with focus on
prescription of 5HT3 receptor
antagonists.7 For moderate to
high emetogenic agents, such
as cisplatin, 5HT3 receptor
antagonist-based regimens
are routinely administered.6-8
There is less consistency in the
recommendations for antiemetics
for combination regimens and
chemotherapy types such as
anthracyclines, cyclophosphamide
and carboplatin.7,9 Most
antiemetics’ primary function is
to block the neurotransmitter
receptors. For example 5-HT3,
which releases 5-HT, inhibits
the nausea and emesis that
45
stimulation.4 While research shows
antiemetics provide effective
relief, particularly during acute
CINV, their effectiveness for
delayed CINV is still yet to be
established.1,5
Ginger as an antiemetic
Known for its flavorsome
aromatic qualities, ginger is a
spice used in traditional Asian and
Indian cooking.10 It is also used
in traditional Chinese medicine
and Ayurvedic remedies, with
specific uses reported for fresh
root (Sheng Jiang) and dried root
(Gan Jiang).5,11 The biologically
active ingredients in ginger reside
predominantly in the rhizome,
which is the underground root
or stem.11 Pharmacologic activity
is related to the gingerol and
shogaol properties of the plant.12
The non-volatile compounds
in ginger such as gingerol,
shogaol, paradol and zingerone
are responsible for the chemical
warmth sensation and pungent
taste.5 These compounds, when
extracted, have been shown to
contain the biologically active
components that have the
medicinal effect. Recently, the
scientific community has begun
to study ginger and its antiemetic
effect. In Western cultures,
ginger as an herbal supplement
is predominantly used for
minimizing pregnancy induced
nausea and vomiting, motion
sickness and of recent, CINV.2
Mode of Action
The mechanism of ginger’s
antiemetic action is not known
in its entirety. Research suggests
a link between gingerol and
shogaol in inhibition of the 5-HT3
receptor pathway. It is suggested
that the phytochemical properties
act as an antiemetic by binding
to the modulatory site distinct
from the serotonin binding site.
This has the potential to indirectly
www.integrativeRD.org
affect signaling cascades that
stimulate the 5-HT3 receptor
channel complex and VC. Studies
have shown gingerol enhances
gastric motility and reduced the
occurrence of emesis; however, to
date this has only been shown in
animal models.5
Review of Literature
Panahi et al studied the
efficacy of ginger’s antiemetic
activity when combined with
standard pharmacological
antiemetics in both acute CINV,
defined as onset within the first 24
hours of treatment and delayed
CINV, defined as onset 24 hours
after treatment initiation and
lasting up to five days.6,7 They
found that at 6 to 24 hours post
chemotherapy infusion, the
addition of ginger to the standard
antiemetic regimen provided a
significant reduction in nausea.
For the delayed phase of CINV
the authors found no significant
difference in the prevalence of
nausea, vomiting and retching.13
Zick et al compared the abilities
of a low dose ginger extract, a
high dose ginger extract, and a
placebo in reducing delayed CINV
(24 hours post chemotherapy
infusion). The authors found
no significant difference in the
prevalence of acute nausea,
delayed nausea, acute vomiting
or delayed vomiting. However,
for participants who received the
high dose of ginger (2.0 g per
day) a greater severity of delayed
nausea was reported, compared
to the lower dose (1.0 g of ginger
per day) and placebo.14
Ryan et al evaluated the effect
of ginger supplementation in
reducing acute chemotherapyinduced nausea (CIN) amongst
patients receiving a standard
5-HT3 receptor antagonist
antiemetic across two cycles of
chemotherapy. The study found
all doses of ginger significantly
reduced the severity of acute
nausea for both cycles of
Fall 2015 Volume 18, Issue 2
chemotherapy treatment in
comparison to the placebo. The
most effective dosages of ginger
were 0.5 g and 1.0 g.15
Sontakke et al studied the
effects of 500 mg of ginger
against the control antiemetics
metoclopramide (20 mg
intravenous) and ondansetron
(4 mg intravenous) in
oncology patients receiving
cyclophosphamide. Sixty-two
percent of patients achieved
complete control with ginger,
in comparison to 58% with
metoclopramide and 86%
with ondansetron. Overall,
ondansetron achieved a greater
antiemetic effect than both ginger
and metoclopromide.16
Manusirivthaya et al had similar
conclusions when comparing the
effects of ginger in comparison to
metroclopromide in gynecologic
oncology patients receiving the
chemotherapy agent cisplatin.
Overall, the investigators found
that both regimens resulted in
a 58% success rate (defined as
achieving complete protection
and major control) for acute
phase and delayed phase CINV.
The study demonstrated that
ginger compares favorably with
metoclopramide.17
chemotherapy infusion did
not have a clinical effect in
combination with standard
antiemetics.14 Regarding dosage
of ginger, findings suggest 0.5 g
to 1.0 g is the most efficacious
dose.13-17 However, there are
inconsistent findings as to the
upper limit of ginger dosage
as Zick et al found 2.0 g per
day caused greater severity in
comparison to lower dosages.14
In contrast, Ryan et al found 2.0 g
per day to be as efficacious as 0.5
g and 1.0 g.15
Timing and administration/dose
Take Home Message
Evidence on most efficacious
dosage and timing of ginger
administration is varied amongst
results published in scientific
literature. With the strongest study
design and largest population
sample, Ryan et al advocates
for ginger administration three
days prior to chemotherapy
administration.15 Sontakke et al
and Manusirivthaya et al advocate
for ginger administration
20-30 minutes prior to
chemotherapy administration;
findings showed control of
delayed CINV comparable to
metoclopramide.16,17 Zick et
al found that administration
of ginger one hour after
The current studies provide
evidence that demonstrates
ginger’s comparable ability to
some of the current available
standard antiemetics, such as
metoclopramide, particularly in
the delayed phase. Ondansetron
however, when compared to
ginger, has the strongest efficacy
for reducing CINV in both
acute and delayed phases. It is
important to note that of the
current studies only one study,
Sontakke et al, trialed ginger
as a stand-alone treatment.
Of the remaining studies
reviewed, ginger was used as an
adjunctive therapy with standard
antiemetics. Due to the body
46
Side Effects of Ginger
No significant difference in
adverse events was reported
between each dose of ginger and
placebo in the Zick et al study.14
Gastrointestinal symptoms such
as grade 2 heartburn, hot flushes
and topical rash were reported
in Ryan et al as ginger-related
adverse events.15 Sontakke
et al found no side effects
related to the administration of
ginger.16 Although diarrhea and
dizziness were reported in the
Manusirivithaya et al study, they
were reported to not be statically
significant; the p value was not
disclosed.17
www.integrativeRD.org
of evidence predominantly
using ginger as an adjunctive
therapy, it can be concluded that
ginger may aid in decreasing
CINV when given prior to
chemotherapy administration and
in combination with a standard
antiemetic regimen. Further
studies need to be conducted
to show the effect of ginger as a
stand-alone antiemetic treatment
for CINV.
References
1. Navari RM. Treatment of
chemotherapy-induced nausea.
Community Oncol. 2012;9(1):20-26.
2. Navari RM. Pathogenesis-based
treatment of chemotherapyinduced nausea and vomiting:
two new agents. J Support Oncol.
2003;1(2):89-103.
3. DuPuis LL, Nathan PC.
Options for the prevention
and management of acute
chemotherapy-induced nausea
and vomiting in children. Paediatr
Drugs. 2003;5(9):597-613.
4. Haniadka R, Popouri S, Palatty
PL, Arora R, Baliga MS. Medicinal
plants as antiemetics in the
treatment of cancer: a review.
Integr Cancer Ther. 2012;11(1):1828.
5. Haniadka R, Rajeev AG, Palatty
PL, Arora R, Baliga MS. Zingiber
officinale (ginger) as an antiemetic in cancer chemotherapy:
a review. J Altern Complem Med.
2012;18(5):440-444.
6. Grunberg SM, Deuson RR,
Mavros P, et al. Incidence
of chemotherapy-induced
nausea and emesis after
modern antiemetics. Cancer.
2004;100(10):2261-68.
7. Kris MG, Hesketh PJ, Somerfield
MR, et al. American Society of
Clinical Oncology guideline
for antiemetics in oncology:
update 2006. J Clin Oncol.
2006;24(18):2932-2947.
8. Cohen L, de Moor CA,
Eisenberg, P, Ming EE, and Hu
H. Chemotherapy-induced
nausea and vomiting—
Fall 2015 Volume 18, Issue 2
incidence and impact on patient
receiving cisplatin. Int J Gynecol
quality of life at community
Cancer. 2004;14(6):1063-1069.
oncology settings. Support Care
Cancer. 2007;15(5):497-503.
9. Basch E, Prestrud A, Hesketh P,
Kris M, Feyer P, Somerfield M, et al.
Antiemetics: American Society of
Clinical Oncology clinical practice
guideline update. J Clin Oncol.
2011;29(31):4189-4198.
10. Basch E, Prestrud AA,
Hesketh PJ, et al. Antiemetics:
American Society of Clinical
Oncology clinical practice
guideline update. J Clin Oncol.
2011;29(31):4189-4198.
11. Hamilton K. Ginger and
chemotherapy: A literature
review. Shadows: The New Zealand
Journal of Medical Radiation
Technology. 2011;54(2):23-28.
12. Palatty PL, Haniadka R, Valder
B, Arora R, and Baliga M. Ginger
in the prevention of nausea and
vomiting: a review. Crit Rev Food
1896 color plate from
Sci Nutr. 2013;53(7):659-669.
Köhler's Medicinal Plants
13. Panahi Y, Saadat A, Sahebkar
Scientific classification
A, Hashemian F, Taghikhani
M and Abolhasani E. Effect of
Kingdom: Plantae
Ginger on Acute and Delayed
Clade:
Angiosperms
Chemotherapy-Induced Nausea
and Vomiting A Pilot, Randomized,
Clade:
Monocots
Open-Label Clinical Trial. Integr
Clade:
Commelinids
Cancer Ther. 2012;11(3):204-211.
Order:
Zingiberales
14. Zick SM, Ruffin MT, Lee J, et
al. Phase II trial of encapsulated
Family:
Zingiberaceae
ginger as a treatment for
Genus:
Zingiber
chemotherapy-induced nausea
and vomiting. Support Care
Species:
Z. officinale
Cancer. 2009;17(5):563-572.
Binomial name
15. Ryan JL, Heckler CE, Roscoe JA,
Zingiber officinale
et al. Ginger (Zingiber officinale)
reduces acute chemotherapyinduced nausea: a URCC CCOP
study of 576 patients. Support Care
Cancer. 2012;20(7):1479-1489.
16. Sontakke S, Thawani V and
Naik MS. Ginger as an antiemetic
in nausea and vomiting
induced by chemotherapy: a
randomized, cross-over, double
blind study. Indian J Pharmacol.
2003;35(1):32-36.
17. Manusirivithaya S, Sripramote
a dietetic practice group of the
M, Tangjitgamol S, et al.
Academy of Nutrition
Antiemetic effect of ginger in
gynecologic oncology patients
and Dietetics
Dietitians in
Integrative
and Functional
Medicine
®
47
www.integrativeRD.org
News You Can Use
Compiled by Jacqueline Santora Zimmerman, MS,
RDN, Associate Newsletter Editor,
[email protected]
•••••••••••••••••••••••••••••••••••••••••••
U
pcoming Conferences and
Educational Opportunities
September 28-October 2, Institute
for Functional Medicine, Applying
Functional Medicine in Clinical
Practice. Atlanta, GA. Sold Out Waitlist available: https://www.
functionalmedicine.org/conference.
aspx?id=2916&cid=0&section=t500
October 1-4, 13th Annual
International Restorative Medicine
Conference, Practical Clinical Skills
in Nutrition, Hormones and
Botanical Medicine. Blaine, WA.
http://restorativemedicine.org/conference/2015/
October 3-6, Food & Nutrition
Conference & Expo (FNCE®).
Nashville, TN. To see sessions
included in the Emerging
Integrative Approaches for
Nutrition and Dietetics Practice
track, see:
http://fnce.eatright.org/FNCE/
Tracks.aspx?GroupID=808
• Stop by the DIFM Booth at
Product Marketplace and
the DPG Showcase:
✴ Product Marketplace,
Booth 25, Music City
Center, Exhibit Hall C Sunday, October 4, 9a-3p.
✴ DPG Showcase, Booth 142,
Music City Center, Exhibit
Hall C - Monday, October 5,
9a-12p.
• Join DIFM for Mind Body
Happy Hour on Monday,
October 5th, 5:30p-7:30p,
Omni, 225 Legends Ballroom
F/G.
October 9-10, Integrative
Healthcare Symposium: Focus on
the Microbiome. Hollywood, FL.
http://www.ihsymposium.com/focus-event/
October 15-19, American
Herbalists Guild 26th Annual
Symposium: New Horizons
in Clinical Herbalism.
Granby, CO. http://www.
americanherbalistsguild.com/
symposium/introduction-tosymposium
Fall 2015 Volume 18, Issue 2
October 25-29, Academy of
Integrative Health & Medicine
Annual Conference: People,
Planet, Purpose - Global
Practitioners United in Health &
Healing. San Diego, CA. https://
aihm.org/aihm-conference/
testing. DIFM members also
receive 20% off International
Society of Nutrigenetics and
Nutrigenomics (ISSN)
membership. http://integrativerd.
org/members-only/learn/nutritional-genomics/
November 1-4, American
College of Lifestyle Medicine
Annual Conference (ACLM),
Lifestyle Medicine: Integrating
Evidence into Practice. Nashville,
TN. http://lifestylemedicine2015.
org/
Archived Webinars: DIFM offers
numerous webinars to our
members at no or minimal cost.
Webinars are categorized
according to the DIFM DPG
Integrative and Functional
Medicine Career Development
Helix and the educational content
provided. The categories are
Novice/Beginner, Competent/
Proficient and Advanced/Expert.
http://integrativerd.org/membersonly/learn/archived-webinars/
November 6-8, Institute for
Functional Medicine Advanced
Practice Module: Energy,
Illuminating the Energy Spectrum:
Evidence and Emerging Clinical
Solutions for Managing Pain,
Fatigue, and Cognitive
Dysfunction. Dallas, TX. https://
www.functionalmedicine.org/conference.aspx?id=2934&cid=35&section=t542
November 6-8, Institute for
Functional Medicine Advanced
Practice Module: GI, Restoring
Gastrointestinal Equilibrium:
Practical Applications for
Understanding, Assessing, and
Treating Gut Dysbiosis. Dallas,
TX. https://www.functionalmedicine.org/conference.aspx?id=2929&cid=35&section=t532
November 11-13, American
College of Nutrition 56th Annual
Conference; Translational
Nutrition: Optimizing Brain Health.
Orlando, FL. http://americancollegeofnutrition.org/conference
DIFM Member Benefits Update
Log in and visit:
Databases: Free access to both
Natural Standard database and
Natural Medicines Comprehensive
Database Professional Version.
http://integrativerd.org/membersonly/nmcd/
Nutritional Genomics: Many
resources are available including
listings of journals/references,
books, websites and genetic
48
Integrative Health Journals: DIFM
members have free digital access to
Integrative Medicine: A Clinician’s
Journal (IMCJ), Alternative
Therapies in Health and Medicine
(ATHM) and Advances in Mind-Body
Medicine (Advances). Members
may purchase print subscriptions at
$20.00/each or $50.00 for all three
journals. This option is available
on each journal’s digital issue site.
http://integrativerd.org/membersonly/learn/integrative-healthjournals/
Electronic Mailing List (EML)
• In several threads,
supplements for various
conditions and situations are
discussed: elevated Lp(a)
levels, iron for a male
adolescent, brands of
vitamin K2 for patients
allergic to soy, radiation and
chemotherapy cancer
patients.
• In the Supplements for
Cancer thread, one
practitioner recommends
the Greece Cancer Test, to
which can assess sensitivity
chemotherapy as well as
response to over 50 natural
substances.
• Memorial Sloan Kettering
Cancer Center has an herb
and integrative medicine
www.integrativeRD.org
database: https://www.
mskcc.org/cancer-care/treat
ments/symptom-manage
ment/integrative-medicine/
herbs.
• SharePractice is a
collaborative functional
medicine web tool and
iPhone app that provides
baseline clinical information
on conditions and allows
users to view other
practitioners’ protocol
recommendations. Users
must be verified clinicians to
obtain access: https://
sharepractice.com/.
Reviews, Resources & Research
Institute for Functional
Medicine’s Advanced Practice
Module: Hormone Module:
Re-establishing Hormonal
Balance in the Hypothalamic,
Pituitary, Adrenal, Thyroid, and
Gonadal Axis. July 9-11, 2015;
Chicago, IL.
Presenters: Dan Lukaczer, ND;
Bethany Hays, MD; Joel Evans, MD;
Filomena Trindade, MD, MPH; and
Mark Holthouse, MD.
Prior to the conference,
attendees received access to
pre-onsite webinars, which
provided a foundation for what was
to come. In addition, for those new
to functional medicine and those
needing a refresher, videos and
readings covered the fundamental
concepts of the functional
medicine model and explained
two of its most important tools:
the functional medicine matrix and
timeline, which were employed
throughout the onsite programs.
In the opening session, Dr. Joel
Evans introduced key concepts
and several “anchor slides” that
were referred to throughout the
two-and-a-half day conference.
He focused on the ways in which
the hypothalamic, pituitary,
adrenal, thyroid, and gonadal
(HPATG) axis affects and is affected
by imbalances in physiological
processes in other areas of the
functional medicine matrix. Dr.
Evans reviewed the biosynthetic
Fall 2015 Volume 18, Issue 2
pathways of steroid hormones and
the major factors that influence
them and introduced the PTSD
mnemonic. PTSD stands for
Production, Transport, Sensitivity
and Detoxification, and it
represents the functional
medicine approach to treating
hormone dysfunction. When
addressing imbalance in the HPATG
axis, we need to consider the
following:
• What are the building blocks
of the hormone in question
and what factors affect its
synthesis? (Production)
• Do the levels of one hormone
impact the levels of others;
does the transport of a
hormone have an impact
on its effectiveness; can we
impact the level of free
hormone and/or the
transformation of hormones
to their active forms?
(Transport)
• What are the lifestyle factors
that influence the cellular
response to hormones?
(Sensitivity)
• Can we change the
metabolism of hormones
such as estrogens or
testosterone? (Detoxification)
One of the prevailing themes
of this Advanced Practice Module
was “treat the matrix first” before
addressing hormone dysfunction.
Hormonal imbalance can be an
appropriate response to
imbalances elsewhere, and the
complex endocrine system will
often correct itself once other
imbalances are addressed. The
metaphor of the matrix as a vault
was used to illustrate this concept.
In order to get into the vault to
address hormones, all the nodes of
the matrix—assimilation, defense
and repair, energy,
biotransformation and elimination,
transport, communication, and
structural integrity—must first
be “unlocked” or treated. Once
inside, treatment must be initiated
in a specific order, like opening a
combination lock: first adrenal, then
thyroid, and finally sex hormones.
49
Other key points included:
• All hormones act in concert,
so changing one hormone
level potentially affects
levels of many others.
• Adrenals are first to unlock,
last to replace.
• Adrenal hormones are the
body’s major response to
internal or external stress or
trauma.
• Thyroid dysfunction is
influenced by stress,
inflammation, infection,
dietary factors (including
gluten and nutrient
insufficiencies), toxins, and
medications.
• Sex hormone binding
globulin is reduced by
excess body weight,
excessive visceral adipose
tissue, and insulin
resistance—so obesity and
insulin resistance influence
hormonal transport.
• To address hot flashes, first
treat endothelial
dysfunction and lower
epinephrine, which triggers
them. Hot flashes do not
always correlate with
estrogen levels, so estrogen
is not always the correct
treatment.
• Remove what causes
imbalance. Provide what
creates balance.
Whether addressing adrenal,
thyroid, or sex hormone
dysfunction, each of the
presenters framed their topic
within the functional medicine
context, identifying the most
common antecedents, triggers
and mediators of the hormonal
dysfunction and walking attendees
through the real-world clinical
application of the concepts being
taught, from discussing the key
aspects of taking a patient’s history,
physical examination and
laboratory evaluations to
populating the matrix and choosing
treatment tools focused on lifestyle,
dietary, nutraceutical, botanical,
and pharmaceutical interventions.
Each session was well-supported
www.integrativeRD.org
by evidence-based research and
brought to life with case vignettes.
Reviewed by Shari Pollack, MPH, RDN,
LDN. Shari is the Employee Wellness
Coordinator at the Jesse Brown VA
Medical Center in
Chicago and the CPE Editor of The
Integrative RDN. She can be reached
at [email protected].
Institute for Functional
Medicine’s Detox Advanced
Practice Module: Detox:
Understanding Biotransformation
and Recognizing Toxicity:
Evaluation and Treatment in the
Functional Medicine Model, July
12-14, 2015; Chicago, IL. Presenters:
Robert Roundtree, MD; T.R. Morris,
ND; Richard Mayfield, CD, CCN;
Mary Ellen Chalmers, DMD; Deanna
Minich, PhD, CNS
The eve of the onsite
sessions, Dr. Bob Roundtree’s
engaging livestream presentation,
Environmental Toxins: Paranoid
Fantasy or Legitimate Threat?,
made the case that long-term,
low-level exposures to common
environmental chemicals and heavy
metals can lead to physiologic
dysfunction.
The opening session by Dr.
Mayfield provided attendees with
the key functional medicine tools
and framework for the assessment
and treatment of patients with
toxicity-related imbalances
and introduced the PURE
mnemonic: Pattern recognition,
Undernourished, Reduce exposures,
and Ensure a safe detox program.
In the session Total Toxic Load and
the Science of Biotransformation,
Dr. Roundtree argued that
“we are what we absorb and
fail to eliminate” and reviewed
in detail phase 1 and phase 2
biotransformation, including factors
such as genetic variations that can
induce or suppress the activity of
these enzymatic systems.
Each of the remaining session
topics then delved into one of the
PURE categories:
• Pattern Recognition
• Clinical Patterns and Laboratory
Fall 2015 Volume 18, Issue 2
Assessments to Aid Decision
Making in the Toxic Patient
• Identifying Oral Health and
Dentistry Concerns in the Toxic
Patient
• Undernourished
• Key Nutritional Modulators in a
Total Toxic Load
• Nutrition-Oriented Physical
Exam
• Reduce Exposures
• Safely Identifying and Assessing
for the Presence of Heavy Metal
Contaminants
• Strategies to Reduce Exposures
and Transform Lifestyle in a
Whole-Self Detox
• Ensure a Safe Detox Program
• Phytochemicals and Nutrients
to Improve Detoxification
• Food First, Integrating Whole
Foods and a Whole Color
Approach to Support the
Detoxification Process
• Managing Complicated Cases
• Applying Oral Chelation
Therapy to Reduce an Elevated
Heavy Metal Burden
Some key messages of this module
were:
• Exposure to environmental
toxins is widespread, increasing
and lifelong.
• The total body burden of these
toxins can act synergistically
to cause physiologic
widespread dysfunction.
• This dysfunction can lead
to chronic illness in susceptible
individuals.
• Susceptibility is largely
defined by an individual’s
ability to biotransform, detoxify
and eliminate exogenous and
endogenous toxins.
• Lifestyle, diet and nutraceuticals
can enhance detoxification,
prevent disease, and restore
health.
• Poisoning is not an “all or
nothing” proposition.
• There are both naturally
occurring and humangenerated sources of
environmental toxicity.
• Naturally occurring include:
ionizing radiation; oxidation;
animal, plant and mycotoxins;
50
products of combustion; heavy
metals
• Synthetic include: industrial
chemicals, pharmaceuticals,
byproducts of food preparation,
metals/metalloids, and
electromagnetic fields.
• Persistent organic pollutants
(POPs) have been widely
produced for the last 60 years
or so; these long-lasting
chemicals were virtually nonexistent before then but are
now detectible in the tissues of
all living things on earth.
• The synergistic effects of
toxins is more than additive
or multiplicative. For example,
cigarette smoking increases the
risk of lung cancer ten-fold, and
asbestos exposure is associated
with a five-fold increase in
lung cancer risk, but the risk of
lung cancer increases by 55
times in smokers who are
exposed to asbestos.
• Toxins are ubiquitous,
and exposure and the bodily
accumulation of many toxins is
virtually unavoidable.
• Health care providers should
consider that chemical
exposures may be playing a role
in patient concerns.
• Genetic variations or single
nucleotide polymorphisms
(SNPs) in biotransformation
enzymes impact an individual’s
detoxification capability and
thus susceptibility.
• Clinical presentations related
to toxic exposures can fall into
recognizable patterns:
neurologic toxicity,
immunologic toxicity,
mitochondrial toxicity,
genotoxicity and
carcinogenesis, and endocrine
disruptions.
• A whole foods diet with a high
intake of colorful plant foods
rich in phytonutrient diversity
is an important component of
any detox program.
The presenters did a great job
of translating the evidence into a
clinically applicable framework,
populating the functional medicine
matrix with the most common
www.integrativeRD.org
symptoms, antecedents, triggers
and mediators, and using relevant
case examples to illustrate the
concepts discussed. As is the case
with other IFM trainings, attendees
of the Detox APM were given access
to an extensive toolkit of resources.
Of particular importance for the
nutrition professional is the IFM
Detox Food Plan.
Reviewed by Shari Pollack, MPH, RDN,
LDN. Shari is the Employee Wellness
Coordinator at the Jesse Brown VA
Medical Center in Chicago and the
CPE Editor of The Integrative RDN.
She can be reached at
[email protected].
Curcumin Supplement May Be
Effective as an Adjuvant
Treatment in Patients with
Psoriasis Vulgaris
This randomized, double-blind,
placebo-controlled study
examined the effectiveness of
Meriva, a bioavailable oral
curcumin as a complementary
therapy to a topical steroid in the
treatment of psoriasis.
Autoimmunity and keratinocyte
proliferation are thought to be
the underlying problems, thus,
curcumin was selected due to
its anti-inflammatory and antiproliferative effects. The treatment
group (n=31) received topical
methylprednisolone aceponate
0.1% once daily on the lesions plus
500 mg Meriva (100 mg curcumin/
tablet) twice daily for 16 weeks.
The control group (n=32) received
topical methylprednisolone
aceponate 0.1% plus a placebo.
Results indicated that while
both groups achieved significant
reduction in psoriasis lesions as
indicated by the Psoriasis Area
Severity Index, the patients using
both topical steroid and Meriva
showed a significantly greater
reduction than those using topical
steroid alone. In addition, only the
treatment with Meriva was able
to significantly downregulate the
concentrations of serum IL-22.
IL-22 is secreted from T helper
22 cells and plays a major role in
several steps of the pathogenesis
Fall 2015 Volume 18, Issue 2
of the disease, including
inflammation and the proliferation
of keratinocytes. In conclusion, this
study demonstrated that Meriva, a
highly bioavailable form of
curcumin, can be a safe and
effective adjuvant therapy in
patients with psoriasis vulgaris.
Its ability to downregulate T-cell
mediated inflammation warrants
further study as a major mechanism
by which curcumin can control
psoriasis.
Antiga E, Bonciolini V,
Volpi W, Del Bianco E, Caproni M.
Oral Curcumin (Meriva) is Effective
as an Adjuvant Treatment and Is
Able to Reduce IL-22 Serum Levels
in Patients with Psoriasis Vulgaris.
BioMed Res Int. 2015;2015:283634.
http://www.hindawi.com/journals/
bmri/2015/283634/. Accessed
August 4, 2015.
Summarized by: Julie Niewiadomski
HOT Nutritional Genomics
Research Publications –
June 24, 2015
Courtesy of the International
Society of Nutrigenetics and
Nutrigenomics (ISNN) at www.
NutritionAndGenetics.org/, and of
www.Nutrigenetics.net.
Impact of nutrition on noncoding RNA epigenetics in breast
and gynecological cancer. Front
Nutr. 2015 May 27;2:16. doi:
10.3389/fnut.2015.00016.
eCollection 2015. PubMed ID:
26075205. Table 1 lists the various
microRNAs which have been
associated with breast cancer,
ovary cancer, cervical cancer, and
uterine cancer. Table 2 lists various
phytochemicals that have been
shown to alter gene expression
for those microRNAs, including
curcumin, genistein, resveratrol,
sulforaphane, pomegranate
polyphenols, cruciferous
vegetables, and garcinol, among
others.
A combination of singlenucleotide polymorphisms is
associated with interindividual
variability in dietary β-carotene
51
bioavailability in healthy men. J
Nutr. 2015 Jun 10. pii: jn212837.
[Epub ahead of print] PubMed
ID: 26063065. 25 gene variants in
or near 12 genes listed in table 3
were found to be responsible for
69% of the substantial variability
in absorption of beta-carotene
observed between individuals
among the French subjects who
were tested. The authors suggest
that this interindividual difference
in absorption may also extend to
other carotenoids (e.g., alphacarotene and beta-cryptoxanthin).
Genetic variation in CYP2R1 and
GC genes associated with vitamin
D deficiency status. J Pharm Pract.
2015 Jun 2. pii: 0897190015585876.
[Epub ahead of print] PubMed ID:
26038244. Subjects carrying one
or two copies of the rs10741657
variant of the CYP2R1 gene were
found to have almost a 3.7-fold
increased risk of being insufficient
in vitamin D. Subjects with one or
two copies of the rs2282679 variant
of the GC gene were less likely to be
insufficient.
Selenium and chronic diseases: a
nutritional genomics perspective.
Nutrients. 2015 May 15;7(5):3621-51.
PubMed ID: 25988760.
Selenium-related genes (including
selenoproteins) are listed in Table
1, along with a listing of functional
gene variants (SNPs) in Table 2.
Selenium-related gene variants
relevant to prostate cancer are
listed in Table 3, and those
relevant to colorectal cancer are
listed in Table 4. Other health
conditions listed in Table 5 include
lung cancer, laryngeal cancer,
bladder cancer, cardiovascular
disease, Kashin-Beck disease, Crohn
disease, and type-2 diabetes.
The genomics of micronutrient
requirements. Genes Nutr. 2015
Jul;10(4):466. doi: 10.1007/s12263015-0466-2. Epub 2015 May 19.
PubMed ID: 25981693. Now that
omics technologies are available,
traditional approaches to assessing
nutritional requirements should
also include environmental, lifestyle
and socioeconomic factors.
www.integrativeRD.org
The next generation of dietitians:
Implementing dietetics education
and practice in integrative
medicine. J Am Coll Nutr. 2015
May 11:1-6. [Epub ahead of
print] PubMed ID: 25961884. The
authors describe development of a
curriculum in integrative medicine
with core courses that cover
inflammation, immune regulation,
herbal supplements, and
“Nutrigenomics and Nutrigenetics
in Health and Disease.”
Obesity: interactions of genome
and nutrients intake. Prev Nutr
Food Sci. 2015 Mar;20(1):1-7.
doi: 10.3746/pnf.2015.20.1.1.
Epub 2015 Mar 31. PubMed ID:
25866743. Discusses obesogenic
environments, including nutrition
and lifestyle, and their interaction
with specific gene variants. The text
also provides a discussion of the
distinction between nutrigenomics
and nutrigenetics.
Fall 2015 Volume 18, Issue 2
Obesity and diabetes: from
genetics to epigenetics. Mol Biol
Rep. 2015 Apr;42(4):799-818.
doi: 10.1007/s11033-014-3751-z.
PubMed ID: 25253098. Table 1 lists
examples of genes and microRNAs
which can affect obesity and type-2
diabetes.
Interindividual variability of lutein
bioavailability in healthy men:
characterization, genetic variants
involved, and relation with fasting
plasma lutein concentration. Am J
Clin Nutr. 2014 Jul;100(1):168-75.
doi: 10.3945/ajcn.114.085720. Epub
2014 May 7. PubMed ID: 24808487.
Table 3 is a listing of genes and
gene variants which were found
to be associated with variations
in postprandial lutein levels in
chylomicrons.
Martin, MS, President, Nutrigenetics
Unlimited, Inc.; ron@nutrigenetics.
net. The database at Nutrigenetics.
net is available to the public free
on weekends (U.S. Central time)
by using Free as username, and
Weekends as the password, as
shown on the login page at https://
nutrigenetics.net/Login.aspx. Check
out www.NutritionAndGenetics.
org to learn more about the ISNN
membership discount for dietitians,
which includes database access as a
benefit. Learn about the upcoming
10th ISNN Congress on May 23-26,
2016 in Tel Aviv, Israel, with optional
pre- or post-conference cultural
tours: http://www.ortra.com/
events/isnn2016/Home.aspx.
Copyright 2015 Nutrigenetics
Unlimited, Inc. Inquiries about
above references? Contact Ron L
52
www.integrativeRD.org
Student Corner
Madelaine Dickinson
•••••••••••••••••••••••••••••••••••••••••••
DIFM Student Stipend
Review - Food As Medicine
•Madelaine
• • • •Dickinson
• • • recently
•••
completed her dietetic internship
at University of Kansas Medical
Center (KUMC) in Kansas City, KS
and is currently finishing her MS in
nutrition and specialty certificate and
fellowship in dietetics and integrative
medicine at KUMC. Contact
Madelaine at [email protected].
A
ttending the Food as
Medicine (FAM) Conference,
June 11-14, 2015, was a
truly unforgettable experience.
As a student, my future practice
of nutrition has been profoundly
impacted by what I learned in
the four packed days of this
professional training program.
The conference took place this
year in Minneapolis, MN and was
sponsored by The Center for Mind
Body Medicine, an organization
whose goal is to “create healing
communities and a community of
healers by teaching scientifically
validated techniques to health
professionals, educators, and
community leaders.” The theme
of equipping providers for
community-wide impact was
woven throughout the conference
and was also evident in the
amazing diversity of the attendees,
ranging from doctors, pharmacists,
psychologists, and dietitians
to yoga instructors, chefs, and
community organizers. The goal of
FAM is to equip those in individual
or community healing positions
with the foundational principles
of whole-foods medicine and the
tools they need to build them into
practice, community, and personal
life.
FAM is making this goal a
reality. The presentations made
me feel confident and prepared
to implement the content, which
included relaxation strategies,
new cooking techniques, safe
perinatal botanical use, and more.
The conference was presented as
a single unified program that built
on itself throughout the weekend.
Although the sheer amount
of information presented was
Fall 2015 Volume 18, Issue 2
staggering, it was well-organized
and had a logical flow, so it was
much easier to digest, absorb, and
assimilate. The content struck a
great balance between research
and practical application and
between mind and body health.
The Food as Medicine faculty
teaching the sessions were also
of exceptional quality. Wellknown speakers included Dr. Mark
Hyman discussing the biology
of food addiction, Kathie Swift,
RDN, LDN, FAND, EBQ lecturing
on digestion and elimination
diets, Dr. Mark Pettus speaking on
detoxification, and Dr. Aviva Romm
talking about women’s health and
prenatal care, and John Bagnulo,
MPH, PhD discussing macro and
micronutrients. The conference
was structured for attendees to
be able to connect with and learn
from the faculty on a deeper level,
whether it was through question
and answer sessions, book signings,
or sitting and enjoying great
food and discussion with them at
lunch. Speakers made themselves
very accessible in a way that I
hadn’t experienced previously at
a conference and were incredibly
gracious and giving of their time,
energy, and perspective.
As is the theme of this DIFM
newsletter, thyroid health was also
a recurring theme throughout the
FAM weekend. In her lecture on
“Understanding Core Imbalances,”
Dr. Cynthia Geyer, medical director
of Canyon Ranch in Lenox, MA,
discussed detoxification as one of
the major areas where imbalances
can occur. Dr. Geyer discussed
endocrine-disrupting chemicals
and their potential implications
in obesity and thyroid disease.
Later, in her lecture on functional
laboratory assessment, Dr. Geyer
compared the thyroid gland to
a “canary in the coal mine” as
she discussed the assessment of
subclinical hypothyroidism, which
may be indicated in cases where
TSH is elevated but T4 is within
the reference range. Interestingly,
most people do not have a
“normal” TSH.1 She explained that
subclinical hypothyroidism is
highly significant and should not
53
be overlooked, as it is associated
with many serious health issues
including “increased LDL, metabolic
syndrome, endothelial dysfunction,
elevated CRP, altered cerebral blood
flow, impaired working memory,
atherosclerosis, and congestive
heart failure.” Later, Dr. Geyer talked
about the link between acute
illness and thyroid hormones,2 her
treatment recommendations, and
many other clinical pearls. One
of the pearls that I found most
interesting is how thyroid needs
can be impacted by changes in
sex hormones, as in pregnancy,
postpartum, menopause, with oral
contraceptive use, or with hormone
replacement therapy.
Kathie Swift discussed thyroid
and gut health connections in her
lecture titled “Digestion: A Holistic
Approach” as she humorously
shared a quote by Dr. Alessio
Fasano, “The gut is not like Las
Vegas. What happens in the
gut doesn’t stay in the gut!” She
explained how the dramatic rise in
GI disorders parallels pandemics
in autoimmune disorders, such
as those that affect the thyroid.
However, she did discuss the
encouraging news that the issue
of gut health is drawing increasing
attention within the field of
medicine.3 Kathie explained that
the link between gut health and
immunity is extremely complex,
but that one of the factors that
may be at play is the crossreaction of bacterial proteins with
human antigens. This triggers
an inappropriate reaction of the
adaptive immune system,4 which
may be linked to both gluten and
thyroid immune issues.
John Bagnulo discussed the
connection between thyroid
and dietary components in his
fascinating lectures on macro
and micronutrients. In his
macronutrient lecture, Dr. Bagnulo
reviewed research supporting
that a higher ratio of essential
versus non-essential amino acids
in the diet favors an anabolic state
that includes a hyperinsulinemic
response, depressed glucagon, and
metabolic syndrome. He explained
that “accompanying molecules
www.integrativeRD.org
in specific proteins influence
either immune system activity or
inflammation.” Examples of specific
proteins include casein and gliadin
or amino acids such as Neu5Gc
(N-Glycolylneuraminic acid). He
believes there are implications
especially for individuals with
Hashimoto’s thyroiditis or Crohn’s
disease and he advocates a more
plant-based diet, avoiding high
Neu5Gc sources such as red meat in
these populations.
In his micronutrient lecture,
Dr. Bagnulo described iodine
as one of the most frequently
seen deficiencies with common
associated effects. He explained
that individuals can be especially
susceptible to iodine deficiency
if their diet is high in brassica
(cruciferous) vegetables like kale,
cabbage, and broccoli because of
their goitrogenic effects leading
to depletion of iodine in the body.
Often this same population is at
further increased risk of iodine
deficiency due to other “healthy”
practices such as using sea salt
rather than processed, iodized salt.
This discussion was a great example
of balancing research versus clinical
application. Dr. Bagnulo explained
that it is not that clients should
cut out cruciferous vegetables,
but that it is important for health
professionals to recognize
individuals at risk for iodine
deficiency and help them balance
their intake of iodine (either wholefood sources or supplementation)
with their consumption of
goitrogenic foods.
The lectures of Dr. Geyer, Kathie
Swift, and Dr. Bagnulo are just a
few great examples of the evidence
presented throughout the FAM
conference that thyroid health is a
critical part of overall health, with
indisputable links to nutrition and
lifestyle.
I came away from Food as Medicine
having learned so much about how
to be a holistic and compassionate
care provider, rather than simply a
more knowledgeable professional.
One of my top take-aways from
this conference was vision for
how I would like to work with
Fall 2015 Volume 18, Issue 2
other healing professionals in the
future. There were individuals
of many different backgrounds
in attendance, and this led to a
rich combination of perspectives,
especially as we wrapped up the
weekend with small group work
on case studies expertly led by
Kathie Swift and Dr. Geyer that were
extremely helpful in applying our
FAM training. I was so inspired by
the considerate respect extended
to me within my group for what
I brought to our case study, even
though I was a student in a group
of experienced professionals
(a pediatrician, a dietitian, a
pharmacist, and a yoga instructor).
As we worked, I thought to myself,
“Now this is truly integrative”
because that term applied not only
to the care we were providing,
but also our team dynamic.
Throughout my future career, I
am resolved to extend the same
open-minded respect to others
that I saw modeled throughout this
conference. As promoted, Food
as Medicine was truly “a feast of
science and wisdom” and I came
away filled with vision for how I
want to practice, excitement for
lifelong learning, and even deeper
conviction that food is powerful
medicine.
Implications for the diagnosis of
subclinical hypothyroidism. J Clin
Endocrinol Metab. 2008;93(4):12241230.
2. Aytug, S. Euthyroid sick
syndrome. Medscape. http://
emedicine.medscape.com/
article/118651-overview. Accessed
April 4, 2014.
3. Bischoff S. 'Gut health': a new
objective in medicine? BMC Med.
2011;9:24. doi:10.1186/1741-70159-24.
4. Galland, L. The gut microbiome
and the brain. J Medicinal Food.
2014;17(12):1261-1272.
Note
“Food As Medicine-East Coast will
be offered at Kripalu Center for
Yoga and Health, Stockbridge,
MA, September 18-22, 2015 and
June 2016 in Portland, OR. DIFM
DPG members receive a discount
on tuition for the course and some
exciting new faculty members
will be presenting. For more
information: www.cmbm.org/
fam or contact Maureen George,
[email protected].”
DIFM Student Stipend
Review Food As Medicine
References
1. Hamilton, TE. Thyrotropin levels
in a population with no clinical,
autoantibody, or ultrasonographic
evidence of thyroid disease:
54
www.integrativeRD.org
Immune Boosters
Jessica Vierra, RN, BSN
•••••••••••••••••••••••••••••••••••••••••••
Jessica Vierra, RN, BSN, is a wellness
coach, registered nurse, concert
violinist, vocalist, and life-long
learner. While music and healthcare
are dear to her heart, Jessica
enjoys leading in community
nutrition programs, conducting
plant-based cooking schools, and
providing nutritional counseling to
clients. She graduated from Bastyr
University in June, 2015 with a
Master of Science in Nutrition. She
is currently working on a distance
internship through California State
University, Long Beach, CA. Contact
Jessica at the.violin.player@gmail.
com or [email protected].
I
ntroduction
The old adage “an ounce
of prevention is worth a pound
of cure” still holds true today.
Current research is taking a
closer look at the natural world
and how the foods we consume
protect our cells and nourish our
bodies. There are some foods
that are commonly found in the
grocery store that have clinically
confirmed health benefits for our
immune system: garlic, broccoli,
and mushrooms. Hundreds
of studies have found a wide
variety of active properties in
these vegetables that result in
strengthening the body’s immune
system.
The immune system operates
in a similar fashion to the United
States Department of Defense.
When it functions properly, it
protects against foreign invaders
and maintains national peace
and order. There are several major
branches of the Department of
Defense: Army, Navy, Air Force,
and Marines, to name a few.
Likewise, our immune system
employs several branches of
defense: the B lymphocytes, the
T lymphocytes, the phagocytes,
and the natural killer cells. The B
lymphocytes respond to various
stimuli by producing antibodies,
which help fight common
infections. T lymphocytes have
Fall 2015 Volume 18, Issue 2
four distinct subtypes involved
in controlling foreign invaders,
maintaining cellular boundaries,
and responding to allergic
reactions. The phagocytic cells,
such as macrophages, act as the
"national guard." Macrophages are
stationed in various parts of our
body tissue while other cell types
are mostly found in the blood.
Natural killer cells directly attack
abnormal cells, causing apoptosis
or programmed-cell death.
Supporting proper function of this
complex system can be achieved
by including immune-boosting
foods such as garlic, broccoli, and
mushrooms.
Garlic
Garlic belongs to the allium
plant family, which also includes
onions, leeks, and shallots. Garlic
is primarily used in the culinary
world for flavor enhancement.
Ancient writings tell of garlic
being used not only as a culinary
herb, but also as a natural
remedy. Clinical research has now
confirmed what our ancestors
have always known—garlic
possesses powerful healing
properties.
Garlic is effective in a variety
of ways, and has shown clinical
evidence for enhancing immune
function. One recent controlled
trial showed that garlic activates
macrophage properties by
stimulating tumor necrosis factor
-α (TNF- α) production.1 TNF-α
is a cytokine that, depending
on cellular context, can regulate
a number of cellular functions
including inflammation and cell
death or survival. Macrophages
are the main producers of
TNF-α.1 In another controlled
trial, researchers found that
S-allylcysteine, the most abundant
organosulfur compound in aged
garlic extract, increases human
macrophage expression.2
Benjamin Lau, MD an
immunologist, surgeon,
researcher, and former professor
55
at Loma Linda University School
of Medicine, conducted and
reviewed extensive research on
garlic and garlic extracts. Dr. Lau
found that aged garlic extract
enhanced macrophage activity
by generating an oxidative
burst while other commercial
preparations did not.3 Another
study carried out by researchers
at the University of Sydney found
that dietary garlic protected
hairless mice from UV radiation
damage, through augmentation
of T lymphocyte activity.3
The effects of raw garlic and
Kyolic garlic capsules on volunteer
subjects in a randomizedcontrolled trial were studied with
a third group that did not have
any garlic, serving as a control.
After three weeks, the researchers
tested the blood of the subjects
on tumor cells in a laboratory
culture. They found that the
natural killer cells of those who
ate raw garlic daily destroyed 139
percent more tumor cells than the
natural killer cells of those who
did not eat raw garlic. Even more
effectively, the natural killer cells
of those who took garlic capsules
daily destroyed 159 percent
more tumor cells than the natural
killer cells of those who did not
eat raw garlic.3 Dr. Lau and other
researchers recommend making
garlic a regular part a dietary
pattern with consumption of at
least one clove of raw garlic or
lightly cooked garlic per day.
Broccoli
Broccoli is a member of the
cruciferous plant family and is
incorporated into a variety of
culinary cuisines. Cruciferous
vegetables have recently gained
notoriety due to their anti-cancer,
protective properties, namely a
phytochemical compound called
sulforaphane. Animal and human
studies have demonstrated a
correlation between increased
cruciferous vegetable intake and
a reduced risk of various cancers
www.integrativeRD.org
such as lung and gastrointestinal
cancer. Sulforaphane is indirectly
involved in immune function by
eliminating reactive anti-oxidant
species (ROS) and enhancing
antioxidant cellular activity.
Sulforaphane works by other
mechanisms as well. It induces
cell cycle arrest and apoptosis
in cancer cells. Additionally,
sulforaphane has been shown to
reduce inflammatory cytokines
and inhibit the growth of
established tumors.4
What about fresh or cooked
broccoli? While high levels of
heat do not destroy sulforaphane,
it does affect the enzyme
myrosinase, which is necessary for
its conversion. Heating inactivates
myrosinase, which is necessary for
the conversion of glucoraphanin
to sulforaphane.In a study
testing fresh versus steamed
broccoli, Conaway and colleagues
indicated that sulforaphane in
broccoli was three times higher
in fresh broccoli than cooked
broccoli.4 One of the best ways
to get significant amounts of this
anti-cancer compound in the diet
is to consume broccoli sprouts.
Broccoli sprouts contain 20-100
times more glucoraphanin than
a full-grown head of broccoli.4
Significant evidence confirms
that cruciferous vegetable
consumption should be a part
of a regular balanced diet for
enhanced immune support.
Mushrooms
If cruciferous vegetables are
the king of edible plant foods
then mushrooms are the queen.
Consuming mushrooms regularly
is associated with a decreased risk
of breast cancer in both pre- and
postmenopausal women due
to the anti-aromatase activity of
mushrooms. There are several
varieties of mushrooms, which
have been ranked for their antiaromatase activity:
• High anti-aromatase activity:
white button, white stuffing,
Fall 2015 Volume 18, Issue 2
cremini, Portobello, reishi,
maitake;
• Mild anti-aromatase activity:
shitake, chanterelle, baby
button;
• Little or no anti-aromatase
activity: oyster, wood ear.5
References
1. Sung J, Harfouche Y, De La
Cruz M. Garlic (Allium sativum)
stimulates lipopolysaccharideinduced Tumor Necrosis Factoralpha production from J774A.1
In one recent study,
murine macrophages. Phytother
Korean women who ate 10
Res. 2014;29:288-294.
g of mushrooms, which is
2. Malekpour-Dehkordi Z, Javadi
the equivalent to about one
E, Doosti M, et al. S-allylcysteine,
mushroom cap per day, had
a garlic compound, increases
a 64 percent decreased risk
ABCA1 expression in human THPof breast cancer.6 Even more
1 macrophages. Phytother Res.
impressive, Chinese women who
2012;29:357-361.
consumed 10 g of mushrooms
3. Lau B. Garlic and you: the
and consumed green compounds modern medicine. Vancouver,
from green tea daily had an
Canada: Apple Publishing
89 percent decrease in risk for
Company Ltd; 1997.
premenopausal women and 82
4. Herr I, Buchler M. Dietary
percent for postmenopausal
constituents of broccoli and
women.7
other cruciferous vegetables:
Other studies show that
implications for prevention and
mushrooms have specific
therapy of cancer. Cancer Treat
compounds that enhance
Rev. 2010;36:377-383.
the immune system through
5. Fuhrman J. Super Immunity.
activation of macrophages, T
New York, NY: Harper One
lymphocytes, and natural killer
Publishers; 2011.
cells. The levels of natural killer cell 6. Hong S, Kim K, Nam S, et al. A
activity were monitored in cancer case-control study on the dietary
patients receiving D-fraction
intake of mushrooms and breast
(a polysaccharide compound
cancer risk among Korean women.
in maitake mushrooms), and
Int J Cancer. 2008;122:919-923.
increased macrophage and
7. Zhang M, Huang J, Xie X, et al.
natural killer cell activity were
Dietary intakes of mushrooms
found in patients with lung and
and green tea combine to
breast cancer.8,9
reduce the risk of breast cancer
in Chinese women. Int J Cancer.
Take Home Message
2009;124;1404-1408.
8. Kodama N, Asakawa A, Inui A,
The combination of
et al. Enhancement of cytotoxicity
mushrooms and green
of NK cells by D-fraction, a
compounds are a potent and
polysaccharide from Grifola
powerful anti-cancer and
frondosa. Oncol Rep. 2005;13:497immune-boosting concoction.
502.
Theoretically, there is even greater 9. Kodama N, Komuta K, Nanba H.
significance in the simultaneous
Effect of maitake (Grifola frondosa)
consumption of garlic, broccoli,
D-fraction on the activation of
and mushrooms. Therefore, if
NK cells in cancer patients. J Med
you are deciding on making a
Food. 2003;6:371-377.
vegetable entrée, such as a stirfry dish, then make sure that it
features plenty of garlic, broccoli,
and mushrooms.
56
www.integrativeRD.org
Chair’s
Corner
•••••••••••••••••••••••••••••••••••••••••••
Monique Richard, MS, RDN, LDN
DIFM Chair 2015-2016
D
ear DIFM members-
As we fly through summer we
are reminded of one thing that
is constant, change. In dietetics
we see the evolution of nutrition
science regularly. We adapt to new
research and educate our patients
regarding their own beliefs,
clarifying any misinformation
related to their dietary choices.
Occasionally we must adjust our
own biases and beliefs as well.
“Preconceived notions are
the locks on the door to wisdom”
(Merry Browne). That statement
could not ring more true. As
dietitians in integrative and
functional medicine and nutrition
we understand we must push the
limits and boundaries by asking
more questions, seeking more
answers, and always digging
deeper. We adapt and change,
meld and innovate. We appreciate
our evidenced-based roots, but
also know that wisdom comes
from execution of understanding
what works. Sometimes the
limitations of scientific rigor
cannot keep pace with the
outcomes we witness in our
patients and clients and we forge
ahead to prove the validity.
This is where tools like
the Academy of Nutrition and
Dietetics Health Informatics
Infrastructure (ANDHII) come
in. ANDHII is an online tool,
free for Academy members. It
is designed to collect impact
data for use in public policy and
quality improvement research
using the Nutrition Care Process.
The Academy of Nutrition and
Dietetics also states “In addition
to helping advance the dietetics
profession, ANDHII will assist
dietetics practitioners and
workplaces in demonstrating their
impact on patients and clients.”
Find more information at www.
eatrightpro.org and www.andhii.
org.
It is important we scrutinize
our expertise and look at ways to
Fall 2015 Volume 18, Issue 2
become better, more effective.
Dietitians in Integrative and
Functional Medicine (DIFM) is
doing this as well. We continue to
work on finalizing our Certificate
of Training program to provide
more tools for and depth of
understanding into the integrative
and functional medicine world.
We are expanding and enhancing
our website for better access
to toolkits, resources and
information for member use,
and we are striving to do more
to enhance our positon as the
nutrition experts, improve quality
in patient care, and allow the
value of the RDN to be recognized
and sought out. DIFM is working
to provide you with up-to-date
nutrition policy information so
that you, too, may be involved
on the forefront of some critically
important nutrition issues and use
your integrative and functional
nutrition expertise to change
minds and change lives.
We must use all the tools and
resources at our disposal and
work together to strengthen our
practices and improve patient
outcomes. There is so much to be
done, but we hope you continue
the journey with us and as the
African proverb states, “If you
want to go fast, go alone. If you
want to go far, go together.” Let’s
go far, together!
Here, in The Integrative RDN
we tackle a variety of topics and
issues. The thyroid is another
area of immense complexity
and interest and we hope you’ll
continue to add knowledge to
your skill set. We also want to
remind you that our second
annual Mind and Body Happy
Hour (MBHH) will take place in
Nashville at FNCE® and we are
so excited to once again be able
to bring this exquisite evening
to you. At the MBHH, enjoy an
evening of networking and
winding down after a busy day. Learn more about the therapeutic
effects of EFT (Emotional Freedom
Technique) Tapping, deep
57
breathing with aromatherapy, and
yoga. We look forward to enjoying
your company and comradery; we
can’t wait to meet you there!
Also, meet Ashley Koff,
RD, an award-winning
dietitian on a mission to help
everyone get Better Nutrition,
Simplified. Members will have
the opportunity to receive a
complimentary signed copy of
Ashley’s book, Mom Energy. In
addition, all members will receive
a gift.
Registration for the Mind
Body Happy Hour is available
in August on the DIFM website,
www.integrativerd.org.
Best in integrative and
functional health,
Monique
Join us on...
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pages/IntegrativeRD-Dietitiansin-Integrative-and-FunctionalMedicine/323229871046292?fref=ts
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Dietitians in
Integrative
and Functional
Medicine
a dietetic practice group of the
®
Academy of Nutrition
and Dietetics
www.integrativeRD.org
Editor
Sarah Harding Laidlaw, MS, RDN, MPA,
CDE
Associate Editor
Jacqueline Santora Zimmerman, MS,
RDN
Copy Editor
Emily D. Moore, MS, RDN, LD/N
CPE Editor
Shari B. Pollack, MPH, RDN
Communications Chair
Mary Purdy, MS, RDN
Associate Communications Chair
Malorie Blake, MS, RDN, LDN, CNSC
Resource Reviews/Networkings Editor
Dina Ranade, RDN
Editors
Linda Lockett Brown, ABD, M.Ag., RDN,
LDN, CLC
Christian Calaguas, MPH, RDN
Upcoming Issues
•Winter 2015, Editor’s Deadline November 15, 2015
•Spring 2016, Editor’s Deadline February 15, 2016
•Summer 2016, Editor’s Deadline April 15, 2016
•Fall 2016, Editor’s Deadline June 15, 2016
The views expressed in this newsletter are those
of the authors and do not necessarily reflect the
policies and/or official positions of the Academy of
Nutrition & Dietetics.
We invite you to submit articles, news and
comments. Contact us for author guidelines.
Send change-of-address notification to the
Academy of Nutrition & Dietetics, 120 South
Riverside Plaza, Ste. 2000, Chicago, IL 60606-6995.
Copyright © 2015 Dietitians in Integrative and
Functional Medicine, a Dietetic Practice Group
of the Academy of Nutrition & Dietetics. All
material appearing in this newsletter is covered
by copyright law and may be photocopied or
otherwise reproduced for noncommercial scientific
or educational purposes only, provided the source
is acknowledged. For all other purposes, the written
consent of the editor is required.
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For international orders, please add $5 shipping
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and mail to Dietitians in Integrative and Functional
Medicine, PO Box 3624, Pittsfield, MA 01202. ISSN
1524-5209
Fall 2015 Volume 18, Issue 2
Editor's Notes
Sarah Harding Laidlaw, MS, RDN, CDE
•••••••••••••••••••••••••••
W
ith Indian summer closing in on us, it is also the time to
prepare for FNCE® and all of the exciting offerings that the
Academy of Nutrition and Dietetics (the Academy) and
Dietitians in Integrative and Functional Medicine (DIFM) have in
store for members who are attending. But before the conference
and exhibitions there is much to be done ‘down on the ranch.’ Fall
is harvest time and despite the prolific weeds, I have managed
to salvage some organic produce and begun to process it. It is
hard to know what to do with everything, but one thing I would
like to explore more is fermentation. I think this is a topic that
many members are interested in, including myself. That said, I
would welcome an article for publication in the newsletter on
the topic; the benefits, whys, and hows would be so interesting.
Please contact me at [email protected] if you would like to
contribute.
I hope to have the opportunity to meet many of you at FNCE®
in Nashville. Please plan to stop by and visit with the many DIFM
Executive Committee members who will be present and take the
opportunity to ask questions, and to volunteer to help with one
or more of our many projects. For information on the Emerging
Integrative Approaches for Nutrition and Dietetics Practice
Track that is being offered once again this year, please refer to
the summer issue of the newsletter or the News You Can Use
Column in this issue. There are many topics relevant to the field
of integrative and functional medicine offered as part of the track
and several that are complimentary to the field.
This issue of the newsletter addresses an area that many
members have requested additional information on—
Hashimoto’s thyroiditis and the myths of hypothyroidism. I think
you will find the information most helpful and interesting, as
well as offering CPEU credit. In the future we are planning on
exploring the exploding area of genetics as it applies to nutrition.
We hope to be able to review single nucleotide polymorphisms
(SNPs) and methylation and what they can tell us about our
health, testing options, and relevant diet and supplementation
recommendations. This CPEU issue to be offered next year
(hopefully Spring 2016) will be an issue everyone will be looking
forward to and talking about!
Once again, I encourage you to contact me with topics you
would like to see offered in the newsletter and, if by chance, an
offer to help with the newsletter and/or author an article.
Until FNCE®…or the winter issue of The Integrative RDN.
Sarah
58
www.integrativeRD.org
Dietary Supplement Safety in the News
Kelly Morrow, MS, RD
•••••••••••••••••••••••••••••••••••••••••••
A
s an Integrative Registered
Dietitian Nutritionist
(RDN), we follow a Code
of Ethics, which states, among
other important principles
such as practicing with
integrity and honesty, that “The
dietetics practitioner practices
dietetics based on evidencebased principles and current
information.” Nutrition science
continues to evolve at a rapid
speed and the use and regulation
of dietary supplements continues
to elicit challenges when advising
our patients and clients regarding
their supplemental needs. The
complexity of interactions,
manufacturing practices and lack
of oversight can alter the intended
benefits and consequently
cause adverse reactions. DIFM
continues to support members’
needs related to this area of
practice for evidence-based
research with access to the
Natural Medicines Database,
a comprehensive research
bank of specific information
on dietary supplements,
use, recommendations,
interactions etc. and many other
accompanying resources. We also
work on continuing to educate
our clients and patients of the
unique bio-individuality they
possess and being cautious,
informed, and vigilant about the
current research is a necessary
component of any nutritional
intervention. Please continue
reading as our Chair-elect, Kelly
Morrow MS, RDN highlights some
important action items related
to a current article studying the
adverse reactions related to
dietary supplements.
Best in health,
Monique Richard MS, RDN, LDN
Chair, Dietitians in Integrative and
Functional Medicine Last week, the New England
Journal of Medicine published an
article about emergency room
visits related to adverse events
Fall 2015 Volume 18, Issue 2
from dietary supplements. Based
on a nationally representative
probability sample and using
10 years of data, they reported
that each year adverse events
from dietary supplements were
responsible for 23,000 emergency
room visits. Most common issues
were tachycardia, chest pains and
palpitations in young people,
choking, nausea and abdominal
pain in elders, and unintended
ingestion by children.
As integrative RDNs, it is
important that we help our
patients understand how to
use dietary supplements wisely. Below are some action items we
can take from the article:
1. It is important to buy
reputable brands that
do not sell adultered
products – this is hard to
identify because quality
information is not readily
available. Many obscure
brands taint their products
with drugs or banned
substances that cause
harm or don’t do adequate
testing to ensure their
products are safe. Look for
3rd party certification, buy
nationally known brands,
subscribe to consumer
labs, check the Office
of Dietary Supplements
(ODS) website for warnings
and recalls.
2. Weight loss and ergogenic
(body building and energy)
supplements pose the
biggest risk – especially
if bought off the internet
or from international or
obscure retailers. We need
to educate young people
about the risks.
3. More is not better: many
people think the serving
size is just a suggestion
and that more is better.
swallowing pills – not a
handful at a time but one
at a time with ample water.
5. Make sure children do not
have unsupervised access
to dietary supplements.
Comparatively speaking, dietary
supplements have had far fewer
adverse events reported than
pharmaceutical drugs. The FDA
reported that during 2008 – 2011
there were 2.7 million adverse
events related to pharmaceutical
drugs. RDNs need to be vigilant
in our recommendations of
safety. If people don’t use dietary
supplements wisely, there could
be more regulatory restrictions
put on them.
Geller A et al. Emergency
department visits for adverse
events related to dietary
supplements.
NEJM. 2015;373(16):1531-1540
US Food and Drug Administration.
Reports Received and Reports
Entered into FAERS by Year. Food
and Drug Administration website.
http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEffects/ucm070434.htm.
Kelly Morrow, MS, RD
Chair-Elect, Dietitians in
Integrative and Functional
Medicine
email: [email protected]
Dietitians in
Integrative
and Functional
Medicine
a dietetic practice group of the
®
Academy of Nutrition
and Dietetics
4. For elders, take care in
59
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Dietitians in Integrative and Functional Medicine
Annual Report 2014-2015
Respectfully submitted by:
Mary Beth Augustine, RDN, CDN, FAND, Past Chair (2015-2016)
VISION
Optimize health and healing with integrative and functional nutrition
MISSION
Empower members to be leaders in integrative and functional nutrition
VALUES
Innovation, Integrity, and Compassion
Website: www.IntegrativeRD.org
Fall 2015 Volume 18, Issue 2
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Key Activities and Accomplishments of DIFM DPG:
Our Internal Workings
1.
2.
3.
4.
5.
Elected Officers:
Chair, Mary Beth Augustine, RDN, CDN, FAND (from January 2014-June 2015)
Chair-Elect, Monique Richard, MS, RDN, LDN (January 2014-Present)
Past Chair, Alicia Trocker, MS, RDN
Secretary, Ann Sukany-Suls, M.Ed, RDN, LD
Treasurer, Stephanie Harris, PhD, MS, RDN, LD
Nominating Chair, Kathy Moore, RDN, LD, CCN
Reached another milestone in membership numbers, with 3818 members. Membership continues to
increase.
Status
Total
Active
3171
Associate
2
Guest
1
International
17
Life
7
Retired
91
Staff
6
Student
523
Total
3818
Maintained financial reserves for the DPG well over 100% (see Financial Report for FY 2014-2015, Item 21
below), so DIFM has maintained fiscal responsibility.
DIFM was well represented at the Public Policy Workshop in April 2014 by Policy Advocacy Leader (20142015), Anne Marie Kis, MS, RDN, LDN.
Newsletter Team continues to hold monthly team calls and communication, which reports to the EC via
the Newsletter Editor, Sarah Harding Laidlaw, MS, RDN, MPA, CDE and functions to assure quality and
expanded content to the DIFM Newsletter, “The Integrative RDN.”
Summer – 2014
Articles
Introduction to Integrative and Functional Medicine Certificate Author: Kathie Madonna Swift,
MS, RDN interviewed by Malorie Blake, MS, RDN, LDN, CNCS
Food As medicine Conference review by DeeAnna Wales VanReken, Student Educational Stipend
Award Winner
Integrative Healthcare Symposium 2014 review by Mary Purdy, MS, RDN
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Integrative Registered Dietitian Nutritionists (RDN): Who are we and what do we do? By
Monique Richard, MS, RDN, LDN
Resource Reviews
The American Herbal Products Association’s Botanical Safety Handbook, 2nd Edition reviewed by
by Dina Ranade RDN, LDN, Resource Review and Networking Editor
Botanical Medicine for Women’s Health reviewed by by Dina Ranade RDN, LDN, Resource Review
and Networking Editor
Student’s Corner
Interviews of practitioners conducted by Olivia Wagner
Professional’s Corner
Interviews of practitioners conducted by Jacqueline Santora Zimmerman, MS, RDN, Associate
Newsletter Editor
Fall – 2014
Articles
CPE article: Recognition of and Treatment Approaches for Polycystic Ovary Syndrome by Angela
Grassi, MS, RDN, LDN
Aglaée Jacob Interview by Dina Ranade RDN, LDN, Resource Review and Networking Editor
Going with Your Gut by Megan Meyer and Sarah Romotsky, RD
Mind, Food, Mood Review by Janet M. Lacey, DrPH, RD, LDN
News You Can Use compiled by Jacqueline Santora Zimmerman, MS, RDN, Associate Newsletter
Editor
Resource Reviews
PCOS: The Dietitian’s Guide reviewed by Sarah Harding Laidlaw, MS, RDN, CDE, Newsletter Editor
Missing Microbes reviewed by Jacqueline Santora Zimmerman, MS, RDN, Associate Newsletter
Editor
Winter – 2014/2015
Articles
Interview With Inflammation Module Authors Kelly Morrow and Beth McDonald – interview by
Sarah Harding Laidlaw, MS, RDN, CDE, Newsletter Editor
FNCE Educational Track Session Reviews
Environmental Pollutants and Obesity: Can Detoxing Help Patients? by Angelo Tremblay, MSc,
PhD and Mary Beth Augustine, RDN, CDN, FAND; Session reviewed by Jacqueline
Santora Zimmerman, MS, RDN, Associate Newsletter Editor
East Coast Food as Medicine Review By Natasha Eziquiel-Shriro, MS
News You Can Use Compiled by Jacqueline Santora Zimmerman, MS, RDN, Associate Newsletter
Editor
Resource Reviews
Becoming Vegan: Comprehensive Edition reviewed by Katherine Stephens-Bogard, MS, RDN/LD,
CDE, RYT
The Swift Diet reviewed by Sarah Harding Laidlaw, MS, RDN, CDE, Newsletter Editor
Spring – 2015
Articles
Green Tea & Women’s Health by Tori Hudson, ND
Interview With Dr. Sheila Dean Detoxification Module Author interviewed by Emily Davis Moore,
MS, RDN, LDN
FNCE 2014 Track Session Reviews
A Big MNT Headache: Identifying Dietary Migraine Triggers and Integrative Treatments reviewed
by Angela Wolfenberger
Dietary Nitrates and Nitrites: Prescribing Foods for Nitric Oxide Production Reviewed by Mary
Purdy, MS, RDN
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Integrative Sports Nutrition: Validity, Safety, Quality and Identity for Supplementation Reviewed
by Olivia Wagner, MS, RDN
The Truth About Acid Reflux by Jody Garlick, RDN, LDN, CLT
P-POD The Role of Plant Based Nutrition workshop review by Eliza Mellion
Resource Review
The Disease Delusion reviewed by Dina Ranade RDN, LDN, Resource Review and Networking
Editor
Functional Nutrition Cookbook reviewed by Dina Ranade RDN, LDN, Resource Review and
Networking Editor
Recipes
Roasted Garlic and Bean Dip with Crudités & Balsamic and Soy Marinated Veggies from the
Functional Nutrition Cookbook
De-Stressing Fact Sheet
6.
7.
8.
9.
Communications Chair, Marketing Chair, Social Media Chair, and Member Services Chair initiated a robust
promotions and marketing campaign with efforts focused on presence in social media, e-blasts,
contributing articles to integrative healthcare and nutrition and dietetics publications, and development
and release of the DIFM promotional video “We are Dietitians in Integrative and Functional Medicine.”
Executive Committee members met for an annual Strategic Plan planning session at FNCE in Atlanta, GA.
Monthly conference calls were held to conduct routine business of the DPG.
DIFM hosted a group of leaders for a Spring Leadership Retreat (SLR) in Chicago, IL in April. This SLR gave
rise to key amendments to the DIFM Strategic Plan 2015 Strategies, Goals and Tasks. Key amendments to
the DIFM Guiding Principles 2015 included a change in Nominations, Elections, and Vacancies with the
final slate now subject to submission to the Executive Committee for discussion and final approval by
voting members of the Executive Committee, the addition of two more voting members, Delegate and
Nominating Committee Chair (for a total of seven voting members), and the addition of several appointed
Chairs and Vice Chair positions- Mentor/Coaching Chair, FNCE Planning Chair and FNCE Planning Vice
Chair, Diversity Chair and Diversity Vice Chair, DIFM Historian, Professional Advancement Vice Chair, and
Volunteer Chair.
Member Services and Education
10. Hosted the inaugural Mind Body Happy Hour at FNCE, Sponsored by Gaia Herbs, 160 DIFM members
attended.
11. Honored members with Awards: (included financial stipend)
Excellence in Practice—awarded to Susan Linke, MBA, MS, RD, LD, CLT
Excellence in Service—awarded to Deb Ford, RDN, CCN
Lifetime Achievement Award—awarded to Diana Noland, MPH, RD, CCN, LD
Professional Development—awarded to Katherine L. Stephens-Bogard MS, RYT, RD, CDE
Professional Development Student Award—awarded to Madelaine Dickinson
12. Active EML (electronic mailing list) with 1,107 DIFM members as active EML subscribers. The EML is
reported to be a favorite membership benefit, with interactions giving opportunity for clinical expertise
sharing.
13. Offered educational webinars throughout the year, several free of charge to members. One CPEU was
awarded when attending the live presentation. Webinars are archived on the integrativerd.org website.
Fall 2015 Volume 18, Issue 2
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Registered
Date
Number
Attended
Name of Webinar
Sponsor
Introduction to
Dietetics and
Integrative Medicine
and Models for
IFMNT training
presented by Diana
Noland, MPH, RD,
CCN LD and Leigh
Wagner, MS, RD
Network
Partner
KUMC
620
05/19/15
299
Free
$0.00
Getting to Know
Herbs - Foundations
of Herbal Medicine
presented by Dr.
Mary Bove
Gaia
Herbs
590
03/25/15
244
Free
$0.00
How to use genetic
information for
nutritional guidance
presented by Martin
Kohlmeier, MD, PhD
Network
partner
ISNN
422
02/12/15
169
Free
$0.00
The Science, Art &
Practice of Dietary
Supplementation
presented by Mary
Beth Augustine, RDN,
CDN, FAND
None
480
11/20/14
225
Free
$0.00
Let me hear your
body talk: the
nutrition focused
physical exam by
Coco Newton, MPH,
RD, CCN
None
98 paid
09/18/14
65
Becoming an
Integrative Dietitian:
Aligning Perspectives
in Philosophy and
Practice by Debra A.
Boutin, MS, RDN, CD
None
586
08/21/14
283
Fall 2015 Volume 18, Issue 2
64
Fee or Free
$10 members,
$20 non
members
Free
Revenue
$980.00
$0.00
www.integrativeRD.org
Culinary Nutrition:
From Science to Plate
presented by Stefanie
Sacks, MS, CNS, CDN
None
N/A
07/30/14
69
Micronutrients:
Sources and
Environmental
Influences presented
by John Bagnulo,
MPH, PhD
Network
partner
CMBM
405
06/27/14
155
Integrative
Approaches to
Irritable Bowel
Syndrome presented
by Dr. Gerard
Mullin
Genes, Nutrition and
Weight Loss- What to
tell your clients
presented by Lisa
Andres, MS, CGC,
MBA
None
None
N/A
70
06/25/14
06/19/14
$10 members,
$20 non
members
Free
$1,167.80
$0.00
42
$10 members,
$20 non
members, 56
paid
$581.30
59 (54 + 5
free DIFM
EC)
$10 members,
$20 non
members, 75
paid
$761.30
14. Published four quarterly issues of the DIFM Newsletter, The Integrative RD. Newsletters included two
Continuing Professional Education (CPE) articles: Fall 2014 issue- Using Dietary Supplements in Practice:
What You Need to Know by authors Kelly Morrow, MS, RDN and Susan Allen, RD, CCN and Spring 2015
issue- Green Tea and Women's Health by author Tori Hudson, ND.
Collaborative Initiatives and External Efforts
15. Work continued on the Online Certificate of Online Training Program (COTP) in Integrative and Functional
Medicine initiative in collaboration with the Academy of Nutrition and Dietetics Center for Professional
Development. Five online training modules are under development by DIFM DPG subject matter expert
content developers. This 10-credit online COTP is comprised of five 2 hour CPEU modules- Module 1:
Introduction to Integrative and Functional Medicine, Module 2: Digestion, Module 3: Detoxification,
Module 4: Inflammation, and Module 5: Dietary Supplements. The COTP is subject to approval and
release by the Academy of Nutrition and Dietetics Center for Professional Development. Expected release
date is Fall/Winter 2015.
16. Work continued on the DIFM-Dietetics Practice Based Research Network survey initiative. 65,000 surveys
were emailed to members of the Academy. Results: 5,164 respondents (an 8.5% response rate), with
strong agreement that ACEND should create competencies in integrative medicine (stronger for ACEND
DPD programs than ACEND DI programs) and CDR should offer a specialty certification in integrative
medicine, and strong interest in CPE in integrative medicine (72% for integrative medicine in general and
87% for disease specific use of dietary supplements). A manuscript is under review at the Journal of the
Fall 2015 Volume 18, Issue 2
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17.
18.
19.
20.
21.
22.
Academy of Nutrition and Dietetics- Augustine, MB; Swift, KM; Harris, SR; Anderson, EJ; Hand, RK.
Integrative Medicine: Education, Perceived Knowledge, Attitudes and Practice Among Academy of
Nutrition and Dietetics Members. A poster session will be presented by above survey working
group/manuscript authors at FNCE 2015 on October 4, 2015, Session Number 101, Presentation Number
099, titled Integrative Medicine: Is there a Gap between Pre and Post Professional Education and
Registered Dietitian Nutritionists Practice Interests?
Work commenced on the Connecting Educators in Integrative and Functional Medicine initiative. This
initiative invites members of the Nutrition and Dietetic Educators and Preceptors Council (NDEP Council)
to attend webinar introductions to a variety of integrative and functional medicine (IFM) topics.
Additionally, a closed list EML was formed- the DIFM Educators in Integrative Medicine EML- to allow
NDEP members to subscribe to connect ACEND DPD, CP, DI, AND ISPP educators and preceptors with IFM
subject matter experts to discuss strategies for implementing IFM curriculum and supervised practice
experience in nutrition and dietetic programs. Two pilot webinars were held- Introduction to Integrative
and Functional Medicine on February 26, 2015, and Dietary Supplements Science, Art, & Practice on April
20, 2015, both presented by DIFM DPG Chair (2014-2015), Mary Beth Augustine, RDN, CDN, FAND. Both
webinars were moderated by DIFM DPG Professional Advancement Associate (2014-2015), Ashley Harris,
MS, RDN, CSO. Both webinars included panel discussion with integrative and functional medicine subject
matter expert panelists DIFM DPG Treasurer (2014-2016), Stephanie Harris, PhD, RDN, DIFM DPG
Delegate (2013-2016), Kathie Swift, MS, RDN, FAND, and Professional Advancement Co-Chair (2014-2015)
Kelly Morrow, MS, RDN. Webinars will resume in academic year 2015-2016. Next topic/date TBD.
Secured sponsorship from organizations who are aligned with DIFM mission, vision, and goals, and who
provided educational opportunities for members:
1. Beano (Pollock Communications)
2. Cranberry Institute
3. Dairy Council (Food Minds)
4. Gaia Herbs
5. Institute for Functional Medicine
6. Metagenics
7. Neogenis Labs
Eight members of DIFM spoke for the Emerging Integrative Approaches for Nutrition and Dietetics
Practice educational track at FNCE 2014.
Network Relationships: American Botanical Council, Arizona Center for Integrative Medicine,
International Society of Nutrigenetics and Nutrigenomics (ISNN), The Center for Mind-Body Medicine, The
Institute for Functional Medicine, University of Kansas Medical Center, Dietetics & Nutrition-Integrative
Medicine
DIFM has an updated social media presence on our Facebook, Twitter, Instagram, Pinterest, and LinkedIn.
Members and EC are encouraged to “like”/follow/post/tweet/retweet/favorite/pin and share content for
social media.
Financial Report for FY 2014-2015:
Total assets: $427,589
Net assets: $315,761
Actual expenses: $155,253
Total revenue:
$161,889
Budgeted
expenses:
$193,828
Total revenue:
$161,889
Investment
reserve
as of 05/31/15: $315,761
Investment
as of2014-2015
05/31/15:budget:
$315,761
Reserves
as reserve
% of actual
163%
Reserves as % of actual 2014-2015 budget: 163%
Fall 2015 Volume 18, Issue 2
Submitted August 18, 2015
66
www.integrativeRD.org
Submitted August
18, 2015
Executive Committee List
•••••••••••••••••••••••••••••••••••••••••••
Chair 2015-2016
Monique M Richard, MS, RDN, LDN
[email protected]
Development Associate 2015-2016
Debra A Silverman, MS, RD
[email protected]
Past Chair 2015-2016
Mary Beth Augustine, RDN, CDN,
FAND
[email protected]
DIFM Historian 2015-2016
Kathy Moore, RDN, LD, CCN
[email protected]
Chair Elect 2015-2016
Kelly Morrow, MS, RDN, CD
[email protected]
Diversity Chair 2015-2016
Denine M. Rogers, RDN, LD, FAND
[email protected]
Treasurer 2014-2016
Stephanie Harris, PhD, MS, RDN, LD
[email protected]
Diversity Vice Chair 2015-2016
Rita Kashi Batheja, MS, RDN, CDN,
FAND
[email protected]
Secretary 2015-2017
Jessica G Redmond, MS,RD, CSCS
[email protected]
Executive Asst/Website Mgr/EML
Coordinator
Amy Jarck
[email protected]
DPG Delegate 2013-2016
Kathie Madonna Swift, MS, RDN,
LDN, FAND
[email protected]
Nominating Committee Chair 20152016
Alicia Trocker, MS, RDN
[email protected]
Indicates Voting Member
Nominating Committee Chair Elect
2015-2016
Aarti Batavia, MS, RDN, CLT, CFSP,
IFMCP
[email protected]
Nominating Committee Member
2015-2016
Lisa Dorfman, MS, RD, CSSD, LMHC,
FAND
[email protected]
Communications Chair 2015-2017
Mary Purdy, MS, RDN
[email protected]
Communications Associate 20152016
Malorie R. Blake, MS, RDN, LDN,
CNSC
[email protected]
Development Chair 2014-2016
Susan Wyler, MPH, RDN, LDN
[email protected]
Fall 2015 Volume 18, Issue 2
FNCE 2015 Planning Chair
Mary Alice Gettings, MS, RDN, LDN,
CDE
[email protected]
FNCE 2015 Planning Vice Chair
Ann Sukany-Suls, M.Ed, RDN, LD
[email protected]
Fulfillment Chair 2014-2016
Jackie Glew, MS, RDN, CSO, LDN
[email protected]
Marketing Chair 2015-2017
Danielle Omar, MS, RD
[email protected]
Newsletter Editor-Associate 20152016
Jacqueline Santora Zimmerman,
MS, RDN
[email protected]
Newsletter Copy Editor 2015-2016
Emily D. Moore, MS, RDN, L/DN
[email protected]
Newsletter CPE Editor/CPE Item
Writer 2015-2016
Shari B Pollack, MPH, RD
[email protected]
Newsletter Resource Reviews Editor
2015-2016
Dina Ranade, RDN, LD
[email protected]
Nutritional Genomics Advisor 20152017
Diana Noland, MPH RD CCN LD
[email protected]
Policy Advocacy Leader 2015-2017
Olivia Wagner, MS, RDN, LDN
[email protected]
Professional Advancement Chair
2014-2016
Therese Berry, MS, RDN, LD, CNSC
[email protected]
Social Media Chair 2015-2016
Michelle Loy, MPH, MS, RDN, CSSD
[email protected]
Member Services Chair 2015-2017
Dana Elia, MS, RDN, LDN
[email protected]
Student Member Services Chair
2015-2016
Eliza Mellion
[email protected]
Mentor/Coaching Chair 2015-2017
Lesli Bitel-Koskela, MBA, BS, RDN,
LD
[email protected]
Volunteer Chair 2015-2017
Ryan Whitcomb, RD, CDN, CLT
[email protected]
Network Chair 2015-2017
Laura Tolosi, MS, RDN, CCN
[email protected]
Network Associate 2015-2016
Mary Therese Hankinson, MBA, MS,
RD, EDAC, CTP
[email protected]
Newsletter Editor 2015-2016
Sarah Harding Laidlaw, MS, RDN,
MPA, CDE
[email protected]
67
DIFM Office Address
Dietitians in Integrative and
Functional Medicine
P.O. Box 3624
Pittsfield, MA 01202
Phone: 800-279-6880
Fax: 877-862-8390
Email address:
[email protected]
Website:
www.IntegrativeRD.org
www.integrativeRD.org
Sarah Harding Laidlaw, MS, RDN, MPA, CDE
60870 Kansas Road
Montrose, CO 81403
PRSRT STD
US POSTAGE PAID
Grand Junction, CO
PERMIT NO. 34
Executive Committee
Members
Chair 2015-2016
Monique Richard, MS, RDN, LDN
[email protected]
Chair Elect 2015-2016
Kelly Morrow, MS, RDN
[email protected]
Past Chair 2015-2016
MaryBeth Augustine, RDN, CDN, FAND
[email protected]
Treasurer 2014-2016
Stephanie Harris, PhD, MS, RDN, LD
[email protected]
Thank
You
to our SPONSORS!
Secretary 2015-2017
Jessica G Redmond, MS, RD, CSCS
[email protected]
• Gaia Herbs Professional Solutions
For the full Executive Committee list and
contact information, please see the online
version of the newsletter.
Fall 2015 Volume 18, Issue 2
• Metagenics
68
www.integrativeRD.org