Dietitians in Integrative and Functional Medicine

THE INTEGRATIVERDN

In This IssueSupporting a Patient With Hashimoto’s.......................................29CPE Reporting Form.......................38CPE Activity Instructions...............39CPE Questions...................................39CPE Certificate..................................40Myths of Hypothyroidism.............41Resource Review: The Autoimmune Solution..........44Ginger: Symptom Management....................................45News You Can Use...........................48Student Corner.................................53 DIFM Student Stipend...........53 Immune Boosters....................55Chair’s Corner....................................57Editor’s Notes....................................58Dietary Supplement Safety In the News..........................59Annual Report 2014 - 2015..........60Executive Committee List.............67

Supporting a Patient with Hashimoto’s Thyroiditis through Nutrition

Nutrition and dietetic professionals must remain abreast of available evidence

amidst the growing concerns about the health impacts of pollutants in our food and water supply. To enable members in providing scientific responses to patient/client questions, the Hunger and Environmental Nutrition (HEN) and the Dietitians in Integrative and Functional Medicine (DIFM) Dietetic Practice Groups (DPGs) partnered in presenting “Food, Water, and the Environment: What’s Women’s Health Got to Do with It?”during the 2013 Food and Nutrition Conference and Expo (FNCE®) in Houston, Texas. The session presenters, Kim Robien, PhD, RD, CSO, FAND and Elizabeth Redmond, PhD, MMSc, RDN, both well-regarded experts in their fields, shared current research findings and strategies for reducing exposure to environmental pollutants.“Environmental Nutrition and Women’s Health - should we worry about BPA and phthalates?”Presented by Kim Robien, PhD, RD, CSO, George Washington University Environmental nutrition is an emerging concept and is defined by Dr. Robien as the intersection between environmental health and

nutrition. Although food and water provide essential nutrients, they can also serve as mechanisms for toxin delivery. Food rich in nutrients can decrease the absorption and harm of toxins and aid in their elimination. Yet the most commonly consumed foods—especially in the fast-food laden areas Dr. Robien calls “food swamps”—often lack the nutrient value that is important not only for basic health, but also for protection from harmful chemicals.

Unfortunately, this is not an issue that lends itself to quick and conclusive answers through research. As it is unethical to conduct randomized controlled trials with potentially toxic chemicals on humans, much of the research is focused on animal models. Additionally, testing is expensive, is subject to contamination with plastic collection containers, and has a limited ability to effectively measure low-dose exposure.

THE INTEGRATIVERDWinter 2014

Volume 16, Issue 3

IN THIS ISSUE: Food, Water, & the Environment: What’s Women’s Health Got to Do with It? .....................................37

Editors Corner .........................38

Chair’s Corner .........................39

Leadership List ........................40

Detox Presentation ..................41

Student Spotlight .....................43

Member Breakfast Review .......44

News You Can Use ..................45

Networking News .....................48

Reducing Environ. Toxins .........49

Resource Review:

Numen Film Review .............50

“Cooked” Book Review .........51

Advocating for Advocados .......52

Extended Leadership List ........54

Food, Water, and the Environment: What’s Women’s Health Got to Do with It? DIFM-HEN FNCE® Joint Session Overview By Emily Davis Moore, MS, RDN, LDN

Continued on page 39

Fall 2015Volume 18, Issue 2

Objectives

After completing this CPE activity, 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

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • Dr. Izabella Wentz, PharmD, FASCP is a pharmacist who was diagnosed with Hashimoto’s thyroiditis in 2009. Over the past six years, she has dedicated her career to helping people with Hashimoto’s recover their health. In 2015, she conducted the largest patient-experience survey for people with Hashimoto’s, collecting responses from 2232 Hashimoto’s patients on the most helpful interventions. She is the author of the New York Times bestselling guide, Hashimoto’s Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause, a co-founder of the Hashimoto’s Institute, and a frequent speaker on thyroid health. Contact Dr. Wentz at [email protected].

Hashimoto’s thyroiditis is an autoimmune condition that results in the destruction

of the thyroid gland, eventually leading to hypothyroidism. Hashimoto’s is the most frequently occurring autoimmune condition, with an estimated prevalence rate between 12% and 26% in the general population,1,2 and the leading cause of hypothyroidism in the United States, accounting for 90-97% of cases.1-3

Testing for Hashimoto’s

Clinicians working with people with Hashimoto’s should be aware of the primary tests used to diagnose and monitor the condition. Blood tests, thyroid ultrasound, as well as a biopsy of

the thyroid gland can be used to diagnose Hashimoto’s. Blood tests are the most accessible option and most commonly used method to determine a diagnosis of Hashimoto’s. The thyroid stimulating hormone (TSH) test is the most commonly utilized screening and monitoring test for thyroid disease. TSH is made by the pituitary gland, which sends signals to the thyroid to increase 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 that is above 2.5 mU/L without any evidence of autoimmune thyroid disease.4

Thyroid peroxidase (TPO) antibodies and thyroglobulin (Tg) antibodies are the primary anti-thyroid antibodies detected in Hashimoto’s thyroiditis and are present in 90% and 80% of those affected, respectively.5 These anti-thyroid antibodies indicate thatthere is an active autoimmune process happening in the thyroid

CPE Article

Dietitians inIntegrativeand FunctionalMedicinea dietetic practice group of the

Academy of Nutritionand Dietetics

®

Fall 2015 Volume 18, Issue 2 www.integrativeRD.org

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 protein-bound; 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.

Symptoms

Many symptoms of Hashimoto’s result from hypothyroidism and include the classical hypothyroid symptoms of cold intolerance, hair loss, fatigue, weight gain, forgetfulness, muscle aches, constipation, a loss of the outer third of the eyebrow, and infertility.

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 is the drug of choice per conventional treatment guidelines. Chemically, levothyroxine contains one tyrosine molecule with four attached iodine molecules and is often referred to as T4. T4 has been described as a pro-hormone, as it needs to be deiodinated in the body to produce triiodothyronine (T3), a more

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 well-being, 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

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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

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

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

Nutrition Support

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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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 thyroid-suppressing 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

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,

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

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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, grain-free, 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)

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, dairy-free diet, autoimmune modified-paleo 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

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

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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

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,

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

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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

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.



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Supporting a Patient with Hashimoto’s Thyroiditis Through Nutrition References• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

1. Wang C, Crapo LM. The epidemiology of thyroid disease and implications for screening. Endocrinol Metab Clin North Am. 1997;26:189-218. 2. Prummel MF, Wiersinga WM. Thyroid peroxidase autoantibodies in euthyroid subjects. Best Pract Res Clin Endocrinol Metab. 2005;19:1-15.3. Baldini M, Colasanti A, Orsatti A, Airaghi L, Mauri MC, Cappellini MD. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf). 1995;43(1):55-68.4. Garber J, Cobin R, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):e1-e45. 5. Davies TF. Pathogenesis of Hashimoto's thyroiditis (chronic autoimmune thyroiditis). UpToDate. http://www.uptodate.com/contents/pathogenesis-of-hashimotos-thyroiditis-chronic-autoimmune-thyroiditis. Published August 2014. Accessed July 19, 2015.6. Strieder TG. Prediction of progression to overt hypothyroidism or hyperthyroidism in female relatives of patients with autoimmune thyroid disease using the Thyroid Events Amsterdam (THEA) score. Arch Intern Med. 2008;168(15):1657-1663.7. Rotondi M, de Martinis L, Coperchini F, et al. Serum negative autoimmune thyroiditis displays a milder clinical picture compared with classic Hashimoto's thyroiditis. Eur J Endocrinol. 2014;171(1):31-36.8. Carta MG, Loviselli A, Hardoy MC, et al. The link between thyroid autoimmunity (antithyroid peroxidase autoantibodies) with anxiety and mood disorders in the community: a field of interest for

public health in the future. BMC Psychiatry. 2004;4:25.9. Müssig K, Künle A, Säuberlich AL, et al. Thyroid peroxidase antibody positivity is associated with symptomatic distress in patients with Hashimoto's thyroiditis. Brain Behav Immun. 2012;26(4):559-563. 10. Nexø MA, Watt T, Cleal B, et al. Exploring the experiences of people with hypo- and hyperthyroidism. Qual Health Res. 2015;25(7):945-953.11. Wiersinga WM. Paradigm shifts in thyroid hormone replacement therapies for hypothyroidism. Nat Rev Endocrinol. 2014;10(3):164-174.12. Hoang TD, Olsen CH, Mai VQ, Clyde PW, Shakir MK. Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study. J Clin Endocrinol Metab. 2013;98(5):1982-1990.13. Wentz I. Results of survey of 2232 people with Hashimoto's. Your Thyroid Pharmacist Website. http://www.thyroidpharmacist.com/blog/top-10-takeaways-from-2232-people-with-hashimotos. Accessed June 26, 2015.14. Wentz I. Stephanie’s medication free Hashimoto’s remission. Your Thyroid Pharmacist Website. http://www.thyroidpharmacist.com/blog/stephanies-medication-free-hashimotos-remission. Accessed July 28, 2015.15. Wentz I. Rebecca’s Hashimoto’s success story. Your Thyroid Pharmacist Website. http://www.thyroidpharmacist.com/blog/rebeccas-hashimotos-success-story. Accessed July 28, 2015.16. Wentz I. Crystal’s story: Hashimoto’s remission. Your Thyroid Pharmacist Website. http://www.thyroidpharmacist.com/blog/crystals-story-hashimotos-remission. Accessed July 28, 2015.17. Wentz I. Jen’s Hashimoto’s

remission story. Your Thyroid Pharmacist Website. http://www.thyroidpharmacist.com/blog/jens-hashimotos-remission-story. Accessed July 28, 2015.18. Wentz I. Lisa’s Hashimoto’s remission story. Your Thyroid Pharmacist. http://www.thyroidpharmacist.com/blog/lisas-hashimotos-remission-story. Accessed July 28, 2015.19. Wentz I. Liz’s root cause (a story about remission). Your Thyroid Pharmacist Website. http://www.thyroidpharmacist.com/blog/lizs-root-cause-a-story-about-remission. Accessed July 28, 2015.20. Wentz I. Dorthea’s healing journey. Your Thyroid Pharmacist Website. http://www.thyroidpharmacist.com/blog/dortheas-healing-journey. Accessed July 28, 2015.21. Wentz I, Nowosadzka M. Hashimoto’s Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause. Wentz LLC; 2013.22. Fasano A. Leaky gut and autoimmune disease. Clin Rev Allergy Immunol. 2012;42(1):71-78.23. Fasano A. Zonulin and its regulation of intestinal barrier function: the biological door to inflammation, autoimmunity, and cancer. Physiol Rev. 2011;91:151-175.24. Joung JY, Young CY, Sun-Mi P, et al. Effect of iodine restriction on thyroid function in subclinical hypothyroid patients in an iodine-replete area: a long period observation in a large-scale cohort. Thyroid. 2014;24(9):1361-1368.25. Zaletel K, Gaberšček S, Pirnat E, Krhin B, Hojker S. Ten-year follow-up of thyroid epidemiology in Slovenia after increase in salt iodization. Croat Med J. 2011;52:615-621. 26. Zhao H, Tian Y, Liu Z, Li X, Feng M, Huang T. Correlation between iodine intake and thyroid disorders: a cross sectional study from the south of China. Biol Trace

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Elem Res. 2014;162:87-94.27. Rink T, Schroth HG, Holle LH, Garth H. Effect of iodine and thyroid hormones in the induction and therapy of Hashimoto's thyroiditis. Nuklearmedizin. 1999;38(5):144-149.28. Peckham S, Lowery D, Spencer S. Are fluoride levels in drinking water associated with hypothyroidism prevalence in England? A large observational study of GP practice data and fluoride levels in drinking water. J Epidemiol Community Health. 2015;69(7):619-24. 29. Galletti P, Joyet G. Effect of fluorine on thyroidal iodine metabolism in hyperthyroidism. J Clin Endocrinol Metab. 1958;18:1102-1110.30. Department of Health and Human Services. Review of Fluoride: Benefits and Risks. Public Health Service Website. http://health.gov/environment/ReviewofFluoride/. Published 1991. Accessed July 8, 2014.31. Scientific Committee on Health and Environmental Risks. Critical review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridating agents of drinking water. European Union: European Commission, Scientific Committee on Health and Environmental Risks; 2010. 32. Gierach M, Gierach J, Skowrońska A, et al. Hashimoto's thyroiditis and carbohydrate metabolism disorders in patients hospitalised in the Department of Endocrinology and Diabetology of Ludwik Rydygier Collegium Medicum in Bydgoszcz between 2001 and 2010. Endokrynol Pol. 2012;63(1):14-17.33. Luiz HV. IgG4-related Hashimoto's thyroiditis – a new variant of a well known disease. Arq Bras Endocrinol Metabol. 2014;58(8):862-868.34. Hadithi, M, de Boer H, Meijer JW. Coeliac disease in Dutch patients with Hashimoto's thyroiditis and vice versa. World J

Gastroenterol. 2007;13(11):1715-1722.35. Farahid OH, Khawaja N, Shennak MM, Batieha A, El-Khateeb M, Ajlouni K. Prevalence of coeliac disease among adult patients with autoimmune hypothyroidism in Jordan. East Mediterr Health J. 2014;20(1):51-55.36. 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. 2014;58(6):625-629.37. Sategna-Guidetti C, Volta U, Ciacci C, et al. Prevalence of thyroid disorders in untreated adult celiac disease patients and effect of gluten withdrawal: an Italian multicenter study. Am J Gastroenterol. 2001;96(3):751-757.38. Tonstad S, Nathan E, Oda K, Fraser G. Vegan diets and hypothyroidism. Nutrients. 2013;5(11):4642-4652.39. Wang J, Lv S, Chen G, et al. Meta-analysis of the association between vitamin D and autoimmune thyroid disease. Nutrients. 2015;7(4):2485-2498. 40. Mansournia N, Mansournia MA, Saeedi S, Dehghan J. The association between serum 25OHD levels and hypothyroid Hashimoto's thyroiditis. J Endocrinol Invest. 2014;37(5):473-476.41. Osborne D, Sobczyńska-Malefora A. Autoimmune mechanisms in pernicious anaemia & thyroid disease. Autoimmun Rev. 2015;14(9):763-768.42. Rojas Hernandez CM, Oo TH. Advances in mechanisms, diagnosis, and treatment of pernicious anemia. Discov Med. 2015;19(104):159-168.43. Gerenova JB, Manolova IM, Tzoneva VI. Clinical significance of autoantibodies to parietal cells in patients with autoimmune thyroid diseases. Folia Med (Plovdiv). 2013;55(2):26-32.

44. Balazs C, Kaczur V. Effect of selenium on HLA-DR expression of thyrocytes. Autoimmune Dis. 2012; 2012:374635. doi: 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 online ahead of print June 2, 2010]. Biol Trace Elem Res. 2011;141(1-3):110-8. doi: 10.1007/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/Selenium-HealthProfessional/. Published July 2013; accessed July 19, 2015.52. 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 diet, blood, and toenails in relation to human health in a

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seleniferous area. Am J Clin Nutr. 1991;53(5):1288-1294.54. Daher R, Yazbeck T, Jaoude JB, Abboud B. Consequences of dysthyroidism on the digestive tract and viscera. World J Gastroenterol. 2009;15(23):2834-2838. 55. Lauritano AC, Bilotta AL, Gabrielli M, et al. Association between hypothyroidism and small intestinal bacterial overgrowth. J Clin Endocrinol Metab.2007;92(11):4180-4184.56. Betesh AL, Santa Ana CA, Cole JA, Fordtran JS. Is achlorhydria a cause of iron deficiency anemia? Am J Clin Nutr. 2015;102(1):9-19.57. Jensen RT. Consequences of long-term proton pump blockade: insights from studies of patients with gastrinomas. Basic Clin 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 Med. 1976;85(6):735-739.61. 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):225-36.63. 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 secretion of thyrotropin receptor antibodies (TRAbs) in EBV-infected B lymphocytes with TRAbs on their surface. Autoimmunity. 2015;48(5):328-335.

Expiration Date: September 15, 2018

Please print or typeName: ____________________________________________________________________________________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.


CPE Reporting FormSupporting a Patient with Hashimoto’s Thyroiditis through Nutrition

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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

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.

Instructions for Completing the CPE Activity for Credit

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




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Continuing Professional Education Certificate of Attendance -Attendee Copy-

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Supporting a Patient with Hashimoto's Thyroiditis

through Nutrition

121375 (Expires 9/15/2018)

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Supporting a Patient with Hashimoto's Thyroiditis

through Nutrition

121375 (Expires 9/15/2018)

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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 [email protected].

Hypothyroidism 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

be tested for the presence of thyroid antibodies prior to iodine supplementation.

Myth: Anyone in the U.S. eating commercially prepared foods or consuming dairy products regularly gets enough iodine from salt or dairy foods.

Although iodized salt is widely available, salt iodization is not mandated in the U.S.4 Most food companies use non-iodized salt in their foods.5 As a result, Americans may not consume as much iodine through salty, processed foods as once thought. Like salt, dairy foods are assumed to have high amounts of iodine because, historically, iodine has been supplemented in dairy cattle and iodine-based disinfectants were used in tanks for dairy transportation. However, cattle aren’t as widely supplemented and the iodine-based disinfectants are often replaced with chlorine-based antiseptics.6 As such, dairy cannot be considered a dependable source of iodine in the U.S. food supply.

Myth: Iodine deficiency is the main cause of hypothyroidism in the U.S.

Although worldwide iodine deficiency is to blame for hypothyroidism, in the United States, Hashimoto’s thyroiditis is the primary cause of the disease.1 Keep in mind that one sign of iodine deficiency is low thyroxine (T4).6 When possible, doctors should check urinary iodine levels (preferably 24-hour urinary iodine) to determine iodine status. Knowing iodine status can help determine whether iodine supplementation is warranted.

Myth: People with hypothyroidism should avoid all goitrogenic 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 goitrogenic foods. Goitrogenic foods primarily include soy, millet, and cruciferous vegetables (broccoli, cauliflower, cabbage, Brussels sprouts, mustard, kale, collard greens, kohlrabi, bok choy, rutabaga, and turnips).7 Although a person with hypothyroidism should be cautious of the amount of goitrogenic foods, he or she can continue to eat cruciferous vegetables, as long as the vegetables are cooked. Cooking generally decreases cruciferous vegetables’ goitrogenic effects.2 Unfortunately, soy’s goitrogenic activity is not affected by heating or cooking,8 and cooking millet actually increases its goitrogenic activity.9 Myth: People with hypothyroidism should avoid soy completely.

Soy is commonly known to affect the thyroid gland.10 Its isoflavones (phytonutrients in soy) affect Thyroid Peroxidase (TPO)11; TPO is involved in the synthesis of thyroid hormones (T3 and T4). For clinicians who are concerned about the anti-thyroid effects of soy, it is important to know that persons with deficient iodine levels are at higher risk for soy’s negative thyroid effect compared to iodine-replete individuals. Thus, it is important to check iodine levels in individuals with hypothyroidism.

Myths of Hypothyroidism • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

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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

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/Iodine-HealthProfessional/. Reviewed June 24, 2011. Accessed July 27, 2015.

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/S2213-8587(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):249-258.11. 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):269-279.12. 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.

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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):581-585.18. 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,

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

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.


Resource Review: The Autoimmune Solution Emily D. Moore, MS, RDN, LD/N

The Autoimmune SolutionAmy Myers, MDHardcover: $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,

reducing environmental toxins, 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.

Reviewed by Emily D. Moore, MS, RDN, LD/N, Copy Editor of the Integrative RDN and Asst. Professor at Daytona State College. Contact Emily at [email protected].

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Elle Skinner is a Registered Dietitian 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].

Nausea 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.

Chemotherapy Induced Nausea 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

results from peripheral nerve 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

Ginger: Symptom Management for Chemotherapy Induced Nausea and Vomiting

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Elle Skinner, RDN

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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 chemotherapy-induced 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

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

Timing and administration/dose

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

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

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

Take Home Message

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


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 chemotherapy-induced 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):18-28.5. Haniadka R, Rajeev AG, Palatty PL, Arora R, Baliga MS. Zingiber officinale (ginger) as an anti-emetic 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—

incidence and impact on patient quality of life at community 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 Sci Nutr. 2013;53(7):659-669.13. Panahi Y, Saadat A, Sahebkar A, Hashemian F, Taghikhani M and Abolhasani E. Effect of Ginger on Acute and Delayed Chemotherapy-Induced Nausea and Vomiting A Pilot, Randomized, Open-Label Clinical Trial. Integr Cancer Ther. 2012;11(3):204-211.14. Zick SM, Ruffin MT, Lee J, et al. Phase II trial of encapsulated ginger as a treatment for chemotherapy-induced nausea and vomiting. Support Care Cancer. 2009;17(5):563-572.15. Ryan JL, Heckler CE, Roscoe JA, et al. Ginger (Zingiber officinale) reduces acute chemotherapy-induced 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 M, Tangjitgamol S, et al. Antiemetic effect of ginger in gynecologic oncology patients

receiving cisplatin. Int J Gynecol Cancer. 2004;14(6):1063-1069.


1896 color plate from

Köhler's Medicinal Plants

Scientific classification Kingdom: Plantae

Clade: Angiosperms

Clade: Monocots

Clade: Commelinids

Order: Zingiberales

Family: Zingiberaceae

Genus: Zingiber

Species: Z. officinale Binomial name

Zingiber officinale



®

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News You Can Use • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Upcoming 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 AnnualInternational Restorative Medicine Conference, Practical Clinical Skills in Nutrition, Hormones and Botanical Medicine. Blaine, WA. http://restorativemedicine.org/con-ference/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/fo-cus-event/

October 15-19, American Herbalists Guild 26th Annual Symposium: New Horizons in Clinical Herbalism. Granby, CO. http://www.americanherbalistsguild.com/symposium/introduction-to-symposium

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/

November 1-4, American College of Lifestyle Medicine Annual Conference (ACLM), Lifestyle Medicine: Integrating Evidence into Practice. Nashville, TN. http://lifestylemedicine2015.org/

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/con-ference.aspx?id=2934&cid=35&sec-tion=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.functional-medicine.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://americancol-legeofnutrition.org/conference

DIFM Member Benefits UpdateLog in and visit:

Databases: Free access to both Natural Standard database and Natural Medicines Comprehensive Database Professional Version. http://integrativerd.org/members-only/nmcd/

Nutritional Genomics: Many resources are available including listings of journals/references, books, websites and genetic

testing. DIFM members also receive 20% off International Society of Nutrigenetics and Nutrigenomics (ISSN) membership. http://integrativerd.org/members-only/learn/nutrition-al-genomics/

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/members-only/learn/archived-webinars/

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/members-only/learn/integrative-health-journals/

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

Compiled by Jacqueline Santora Zimmerman, MS, RDN, Associate Newsletter Editor, [email protected]

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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

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.

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

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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

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 human- generated sources of environmental toxicity. • Naturally occurring include: ionizing radiation; oxidation; animal, plant and mycotoxins;

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 non- existent 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

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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 anti-proliferative 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

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 non-coding 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 single-nucleotide polymorphisms is associated with interindividual variability in dietary β-carotene

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., alpha-carotene 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/s12263-015-0466-2. 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.

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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.

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. Copyright 2015 Nutrigenetics Unlimited, Inc. Inquiries about above references? Contact Ron L

Martin, MS, President, Nutrigenetics Unlimited, Inc.; [email protected]. 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.


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].

Attending 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

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. Well-known 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

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 cross-reaction 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

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Madelaine Dickinson

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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 whole-food 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

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.

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:

Implications for the diagnosis of subclinical hypothyroidism. J Clin Endocrinol Metab. 2008;93(4):1224-1230.2. 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:10.1186/1741-7015-9-24.4. Galland, L. The gut microbiome and the brain. J Medicinal Food. 2014;17(12):1261-1272.


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 [email protected] or [email protected].

Introduction

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

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

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 randomized-controlled 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

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Jessica Vierra, RN, BSN

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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 anti-aromatase activity: • High anti-aromatase activity: white button, white stuffing,

cremini, Portobello, reishi, maitake;

• Mild anti-aromatase activity: shitake, chanterelle, baby button; • Little or no anti-aromatase activity: oyster, wood ear.5

In one recent study, Korean women who ate 10 g of mushrooms, which is the equivalent to about one mushroom cap per day, had a 64 percent decreased risk of breast cancer.6 Even more impressive, Chinese women who consumed 10 g of mushrooms and consumed green compounds from green tea daily had an 89 percent decrease in risk for premenopausal women and 82 percent for postmenopausal women.7 Other studies show that mushrooms have specific compounds that enhance the immune system through activation of macrophages, T lymphocytes, and natural killer cells. The levels of natural killer cell activity were monitored in cancer patients receiving D-fraction (a polysaccharide compound in maitake mushrooms), and increased macrophage and natural killer cell activity were found in patients with lung and breast cancer.8,9

Take Home Message

The combination of mushrooms and green compounds are a potent and powerful anti-cancer and immune-boosting concoction. Theoretically, there is even greater significance in the simultaneous consumption of garlic, broccoli, and mushrooms. Therefore, if you are deciding on making a vegetable entrée, such as a stir-fry dish, then make sure that it features plenty of garlic, broccoli, and mushrooms.

References

1. Sung J, Harfouche Y, De La Cruz M. Garlic (Allium sativum) stimulates lipopolysaccharide-induced Tumor Necrosis Factor-alpha production from J774A.1 murine macrophages. Phytother Res. 2014;29:288-294. 2. Malekpour-Dehkordi Z, Javadi E, Doosti M, et al. S-allylcysteine, a garlic compound, increases ABCA1 expression in human THP-1 macrophages. Phytother Res. 2012;29:357-361. 3. Lau B. Garlic and you: the modern medicine. Vancouver, Canada: Apple Publishing Company Ltd; 1997. 4. Herr I, Buchler M. Dietary constituents of broccoli and other cruciferous vegetables: implications for prevention and therapy of cancer. Cancer Treat Rev. 2010;36:377-383. 5. Fuhrman J. Super Immunity. New York, NY: Harper One Publishers; 2011. 6. Hong S, Kim K, Nam S, et al. A case-control study on the dietary intake of mushrooms and breast cancer risk among Korean women. Int J Cancer. 2008;122:919-923.7. Zhang M, Huang J, Xie X, et al. Dietary intakes of mushrooms and green tea combine to reduce the risk of breast cancer in Chinese women. Int J Cancer. 2009;124;1404-1408. 8. Kodama N, Asakawa A, Inui A, et al. Enhancement of cytotoxicity of NK cells by D-fraction, a polysaccharide from Grifola frondosa. Oncol Rep. 2005;13:497-502. 9. Kodama N, Komuta K, Nanba H. Effect of maitake (Grifola frondosa) D-fraction on the activation of NK cells in cancer patients. J Med Food. 2003;6:371-377.



Dear 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

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

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

Monique Richard, MS, RDN, LDNDIFM Chair 2015-2016Chair’s Corner

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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.

Annual Subscription Rates (payable in U.S. funds):Non-members .......................................................$60/yearAcademy members ..............................................$40/yearStudent members ................................................$20/year

For international orders, please add $5 shipping and handling for each printed issue. Make checks payable to The Academy of Nutrition and Dietetics and mail to Dietitians in Integrative and Functional Medicine, PO Box 3624, Pittsfield, MA 01202. ISSN 1524-5209


With 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.

Editor's Notes

Sarah

Sarah Harding Laidlaw, MS, RDN, CDE

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Dietary Supplement Safety in the News• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

As 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 evidence-based 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

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.

4. For elders, take care in

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/Guid-anceComplianceRegulatoryInfor-mation/Surveillance/AdverseDru-gEffects/ucm070434.htm. Kelly Morrow, MS, RD Chair-Elect, Dietitians in Integrative and Functional Medicine email: [email protected]

Kelly Morrow, MS, RD



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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


Key Activities and Accomplishments of DIFM DPG:

Our Internal Workings

1. 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

2. 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

3. 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.

4. DIFM was well represented at the Public Policy Workshop in April 2014 by Policy Advocacy Leader (2014-2015), Anne Marie Kis, MS, RDN, LDN.

5. 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


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


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. 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.”

7. Executive Committee members met for an annual Strategic Plan planning session at FNCE in Atlanta, GA. 8. Monthly conference calls were held to conduct routine business of the DPG. 9. 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.


Name of Webinar Sponsor Registered Date Number Attended Fee or Free Revenue

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

$10 members, $20 non members $980.00

Becoming an Integrative Dietitian: Aligning Perspectives in Philosophy and Practice by Debra A. Boutin, MS, RDN, CD None 586 08/21/14 283 Free $0.00


Culinary Nutrition: From Science to Plate presented by Stefanie Sacks, MS, CNS, CDN None N/A 07/30/14 69

$10 members, $20 non members $1,167.80

Micronutrients: Sources and Environmental Influences presented by John Bagnulo, MPH, PhD

Network partner CMBM 405 06/27/14 155 Free $0.00

Integrative Approaches to Irritable Bowel Syndrome presented by Dr. Gerard Mullin None N/A 06/25/14 42

$10 members, $20 non members, 56 paid $581.30

Genes, Nutrition and Weight Loss- What to tell your clients presented by Lisa Andres, MS, CGC, MBA None 70 06/19/14

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


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?

17. 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.

18. 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

19. Eight members of DIFM spoke for the Emerging Integrative Approaches for Nutrition and Dietetics Practice educational track at FNCE 2014.

20. 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

21. 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.

22. Financial Report for FY 2014-2015:

Total assets: $427,589

Net assets: $315,761

Actual expenses: $155,253

Budgeted expenses: $193,828

Total revenue: $161,889

Investment reserve as of 05/31/15: $315,761

Reserves as % of actual 2014-2015 budget: 163%

Submitted August 18, 2015

Total revenue: $161,889

Investment reserve as of 05/31/15: $315,761

Reserves as % of actual 2014-2015 budget: 163%

Submitted August 18, 2015

Chair 2015-2016 Monique M Richard, MS, RDN, [email protected]

Past Chair 2015-2016Mary Beth Augustine, RDN, CDN, [email protected]

Chair Elect 2015-2016Kelly Morrow, MS, RDN, [email protected]

Treasurer 2014-2016Stephanie Harris, PhD, MS, RDN, [email protected]

Secretary 2015-2017Jessica G Redmond, MS,RD, [email protected]

DPG Delegate 2013-2016Kathie Madonna Swift, MS, RDN, LDN, [email protected]

Nominating Committee Chair 2015-2016Alicia Trocker, MS, [email protected]

Indicates Voting Member

Nominating Committee Chair Elect 2015-2016Aarti Batavia, MS, RDN, CLT, CFSP, IFMCP [email protected]

Nominating Committee Member 2015-2016Lisa Dorfman, MS, RD, CSSD, LMHC, FAND [email protected]

Communications Chair 2015-2017Mary Purdy, MS, [email protected]

Communications Associate 2015-2016Malorie R. Blake, MS, RDN, LDN, [email protected]

Development Chair 2014-2016Susan Wyler, MPH, RDN, [email protected]

Development Associate 2015-2016Debra A Silverman, MS, [email protected]

DIFM Historian 2015-2016Kathy Moore, RDN, LD, [email protected]

Diversity Chair 2015-2016Denine M. Rogers, RDN, LD, [email protected]

Diversity Vice Chair 2015-2016Rita Kashi Batheja, MS, RDN, CDN, [email protected]

Executive Asst/Website Mgr/EML CoordinatorAmy [email protected]

FNCE 2015 Planning ChairMary Alice Gettings, MS, RDN, LDN, [email protected]

FNCE 2015 Planning Vice ChairAnn Sukany-Suls, M.Ed, RDN, [email protected]

Fulfillment Chair 2014-2016Jackie Glew, MS, RDN, CSO, [email protected]

Marketing Chair 2015-2017Danielle Omar, MS, [email protected]

Member Services Chair 2015-2017Dana Elia, MS, RDN, [email protected]

Mentor/Coaching Chair 2015-2017Lesli Bitel-Koskela, MBA, BS, RDN, [email protected]

Network Chair 2015-2017Laura Tolosi, MS, RDN, [email protected]

Network Associate 2015-2016Mary Therese Hankinson, MBA, MS, RD, EDAC, [email protected]

Newsletter Editor 2015-2016Sarah Harding Laidlaw, MS, RDN, MPA, [email protected]

Newsletter Editor-Associate 2015-2016Jacqueline Santora Zimmerman, MS, [email protected]

Newsletter Copy Editor 2015-2016Emily D. Moore, MS, RDN, L/[email protected]

Newsletter CPE Editor/CPE Item Writer 2015-2016Shari B Pollack, MPH, [email protected]

Newsletter Resource Reviews Editor 2015-2016Dina Ranade, RDN, [email protected]

Nutritional Genomics Advisor 2015-2017Diana Noland, MPH RD CCN [email protected]

Policy Advocacy Leader 2015-2017Olivia Wagner, MS, RDN, [email protected]

Professional Advancement Chair 2014-2016Therese Berry, MS, RDN, LD, [email protected]

Social Media Chair 2015-2016Michelle Loy, MPH, MS, RDN, [email protected]

Student Member Services Chair 2015-2016Eliza [email protected]

Volunteer Chair 2015-2017Ryan Whitcomb, RD, CDN, [email protected]

DIFM Office AddressDietitians in Integrative and Functional MedicineP.O. Box 3624Pittsfield, MA 01202Phone: 800-279-6880Fax: 877-862-8390Email address: [email protected]: www.IntegrativeRD.org

Executive Committee List • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •


Executive CommitteeMembers

Chair 2015-2016Monique Richard, MS, RDN, LDN [email protected]

Chair Elect 2015-2016Kelly Morrow, MS, [email protected]

Past Chair 2015-2016MaryBeth Augustine, RDN, CDN, [email protected]

Treasurer 2014-2016Stephanie Harris, PhD, MS, RDN, [email protected]

Secretary 2015-2017Jessica G Redmond, MS, RD, [email protected]

For the full Executive Committee list and contact information, please see the online

version of the newsletter.

Thank Youto our SPONSORS!

• Gaia Herbs Professional Solutions

• Metagenics

Sarah Harding Laidlaw, MS, RDN, MPA, CDE60870 Kansas RoadMontrose, CO 81403

PRSRT STDUS POSTAGE PAIDGrand Junction, CO

PERMIT NO. 34


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Dietitians in Integrative and Functional Medicine

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