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Winter 2013 Chesapeake Dietetic Lines

Chesapeake Dietetic Lines

The Patient Protection and Affordable Care Act has been law since 2010. In May 2012, Maryland Governor O’Malley signed the Maryland Health Benefit Exchange Act into law. On September 30, 2012, the Health Care Reform Coordinating Council selected the Essential Health Benefits benchmark plan. Maryland is one of eleven states participating in the optional Medicaid expansion, one of the fastest moving states in imple-menting health care reform overall, and registered dietitians are not included. If Maryland RDs do not get involved and included now, we will miss the opportunity similarly to Medicare in 1965. Berit Christen-sen, RD, LD, attended a colloquium and public hearing to find out more of how Maryland is implementing health reform. Maryland Health Benefit Exchange timeline: March 2010 – ACA becomes law June 2011 – Exchange Board holds first meeting September-November 2011 – Phase 1 of Advisory Committee meetings May 2012 – Maryland Health Benefit Exchange Act 2012 signed into law June 2012 – December 2012 – Phase 2 of Advisory Committee meetings October 2012 – Qualified Plan Cer-tification Interim Policies adopted by MHBE Board January 1, 2013 – MHBE must be certified for operation as a state-based Exchange by federal government October 1, 2013 – Open enrollment begins January 1, 2014 – Coverage is effective January 1, 2016 – Exchange must be self-sustaining

Table 1: Consider the impact of ACA in Maryland and the number (in thou-sands) of uninsured: Future of Maryland Exchange: When the health exchange is ready, patients will visit Marylandhealth-connection.gov. The eligibility in the Exchange requires citizenship. Basic Health Program has an option to include non-citizens, but Mary-land does not have enough data at this point to implement that program as there is unknown cost to the state. It will be reexamined in 2015.

Table 2: Maryland population insurance coverage status (in thousands)

Things for the Maryland RD to consider: 1. What will be the impact to the health community of 147,000 new patients in 2014 in the system? Not much is being done to promote the need of health providers that will be necessary to match the thousands of new enrollees. The current solution: expand the scope of prac-tice. For example, nurse practitioners will be taking on more of the role of primary care physicians. RDs already have competi-tion and fear of scope creep from other health providers (which is why reporting these instances to the licensure board is so important). Only half of new graduates are being matched to a dietetic internship. Entry level RDs are struggling to find work.

Continued on page 5

RD Dilemma: Fitting into Maryland Health Reform Berit Christensen, RD, LD - MPP-Health Policy Graduate Student,

MAND Public Policy Coordinator

2014 2020

Total uninsured without ACA 746 724

Total uninsured with ACA 599 390

# of new individuals insured with ACA law 147 333

“If Maryland RDs

do not get in-

volved and in-

cluded now, we

will miss the op-

portunity simi-

larly to Medicare

in 1965.”

2014 2020

Total Maryland population 5,924 6,216

Medicaid 1,088 1,244

Medicare 833 1,024

CHAMPUS/Tricare 188 183

Commercial insurance coverage 3,248 3,285

Maryland Health Benefit Exchange 147 284

Total uninsured 599 390

Adjusted for dual coverage -178 -193

Total coverage including dual coverage 6,103 6,409

From the President 2

Letter to the Editor 3

HOD Report 4

Let’s Move 6

Board Spotlight 8

Clinically Speaking 9

Inside this issue:

Christensen (right) meets with speaker asking how RDs fit into the new health exchanges.

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PO Box 642 • Buckeystown , MD 21717

410.591.9865

Chesapeake Dietetic Lines

Chesapeake Dietetic Lines

STAFF

Melissa Bosslet Majumdar, RD, LDN

Editor

Jennifer Schmiel, RD, LDN Layout & Design

Articles or ads for the next publication must be received no later than

February 19. 2013

Estimated date of distribution is March 19, 2013

The Maryland Dietetic Association makes no war-ranty of any kind, express or implied, concerning the products that are advertised in its newsletter. The Maryland Dietetic Association has not done any type of testing whatsoever on the products advertised in this newsletter. The fact that the products are advertised in this newsletter should in no way be deemed as a seal of approval by the Maryland Dietetic Association.

Advertising Rates

1/4 page: $25 1/2 page: $50 3/4 page: $75 Full page: $100 The Newsletter Editor reserves the right to charge current advertising rates for articles submitted by individuals promoting a product or service within their article or by-line.

We reserve the right to edit for length, style or clarity.

Information submitted for publication MUST be submitted electronically and received by the DEADLINE. Send publication information and PAYMENT to melissa.majumdar@gmail.com. Mailing address is Chesapeake Dietetic Lines/MDA PO Box 642, Buckeystown, MD 21717

To request a hard copy of this publication, e-mail execdirector@eatwellmd.org or call 410-591-9865

President’s Message

Jessica Kiel, RD, LDN, CPT

As we say our goodbyes to 2012 and anxiously await the arrival of 2013, we naturally reflect on the year’s accomplishments, both personally and profes-sionally. Over the last few months the Maryland Academy of Nutrition and Dietetics has accomplished a great deal; our volunteers have accomplished some great work! Updates to the Strategic Plan were finalized and passed by the Board of Directors in the earlier part of this year. For more information on specific changes, login to the Members Only portion of the website and click on the “About Us” section. In September, the first round of bylaw changes was completed, allowing us to officially change our name from the Maryland Dietetic Association to the Maryland Academy of Nutrition and Dietetics (October 1, 2012). Thanks to our Communications and PR Chairs (Anders Grant and Kelly O’Con-nor) we were able to share this exciting change with you on a real-time basis. This year’s annual member reception at FNCE was an incredible success! Over 90 individuals were in attendance, marking one of the highest turnouts on record for this affair. I, personally, would like to extend a very special thank you to Linda Paren, our President-elect, for organizing and hosting this phenomenal networking event. For those who were not able to attend, we look forward to seeing you next year in Houston. With the election (finally) over and initiatives related to healthcare reform already underway, I am pleased to announce our State Policy Representative, Barbara Hoffstein, has selected February 13th as the new date for this year’s annual Legislative Day. The best way for each of us to prepare is to get to know our own legislators; understand who is representing you, what committees they sit on and how they affect our profession (even if indirectly). For help or more information on this topic, please feel free to contact either myself or Barbara (jkiel@choosemedifast.com or bhoff-steinRD@gmail.com). Also be sure to check out the latest updates from our Public Policy Coordi-nator, Berit Christensen and our House of Delegates delegate, Karen Bellesky; these are located on pages 1 and 4, respectively. Like the years before it, 2013 will certainly prove to be another busy and exciting time for the Maryland Academy of Nutrition and Dietetics. If you’re interested in getting involved, please let us know by contacting our Executive Director, Jennifer Schmiel, at execdirector@eatwellmd.org. On behalf of the Board of Directors, have a very happy holiday season and a prosperous new year!

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The Maryland Dietetic Association seeks to empower its members to be Maryland’s food and nutrition experts.

Upcoming Dates 1/15/2013 MAND Board Meeting (info) 2/12/2013 MAND Board Meeting (info) 2/26/2013 MAND Legislative Day (registration details coming soon!) 3/5/2013 Nominations for MAND Annual Awards due (info) 3/10-3/12/2013 Public Policy Workshop (info) 4/26/2013 MAND Annual Meeting (registration details coming soon!)

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Dear Editor, I always read the Clinically Speaking section of the MDA newsletter with interest. However, the recent summary entitled “Docosahexaenoic acid (DHA) Fortification of Infant Formula: Exploring the Claims and Controversies” by Elizabeth Metz causes me concern. I am an employee of DSM Nutritional Lipids (formerly Martek Biosciences) with experience in research, teaching, and industry efforts regarding long chain essential fatty acids. Therefore, I welcome independent assessments of this literature, particularly from students. However, this review exemplifies a common but significant error that prevents an objective scientific examination of the subject. That error is the use of secondary Internet sources in place of pri-mary scientific information. Sole use of information from lobbyist organizations such as Cornicopia Institute and commercially-endorsed consumer blog sites such as Safe Baby often results in the presentation of data in a distorted manner. They may use secondary sources themselves, or present old or biased information through the Internet. As your readers know, repeated statements on the Internet often enter mainstream publications whether or not they are based on valid documentation. The Cornicopia web site fails to reveal the final FDA response in 2011 confirming the safety of DHA and ARA in infant formula. The FDA made it clear that claims regarding harmful effects of DHA and ARA in infant formula made by Cornicopia had been reviewed thoroughly by Agency ex-perts and were found to be without scientific merit. The FDA review from 2011 is available at the following Internet link: http://www.elsevierbi.com/~/media/Images/Publications/Archive/The%20Tan%20Sheet/19/40/05111003013/111003_fda_dha_warning_petn_response.pdf. Similarly, the National Organic Standards Board made final comment to USDA in 2011 recommending the use of Martek’s DHA as a non-synthetic in organic products. They also recommended that DHA be sourced from non-hexane extraction when used in organic foods. The Board’s debate and final recommendation regarding Martek DHA can be found at the following link: http://www.ams.usda.gov/AMSv1.0/getfile?dDocName=STELPRDC5097102 By relying on secondary sources, the author heavily cites older literature. Select clinical trials from the 1990s do not accurately reflect the totality of evidence regarding the safety and benefits of DHA and ARA as published through 2012. The trial design, outcome measures, and even the source of DHA and ARA are now often different from those in the studies by Ryan et al. 1990 or Scott et al. 1998 as cited in the article. In fact, these se-lected studies used a fish oil source of DHA. Their findings confirm the need for the addition of ARA in any DHA-supplemented formula. Finally, the most important reason for including DHA and ARA in infant formula was not made clear in the review. While breast milk from a well-nourished mother is the best source of nutrition for newborns, there are many instances when an infant cannot or will not receive breast milk, or when a mother chooses not to breastfeed. Breast milk always contains DHA and ARA, and since infant blood levels of these fatty acids decline fol-lowing birth, infants receiving formula maintain similar nutritional status to breast fed infants only if DHA and ARA are in the formula. This is, and should be, the goal for all nutrients added to infant formula. I enjoy and learn from the articles published in the newsletter and I sincerely hope that Elizabeth Metz will continue writing about nutrition. I know of the time, skill, and dedication needed to complete such articles. However, I hope that all of your readers will closely scrutinize the use of secon-dary sources for nutrition information and seek well-balanced presentations of complete scientific evidence for decision making purposes. Sincerely, Connye Kuratko, PhD, RD Columbia, MD

Letter to the Editor

What Can You Get For a Dollar? Jane Libby, MA, RD - Foundation Liaison

Here’s what your donations to the Academy of Nutrition and Dietetics Foundation did just this past year:

Awarded $488,650 to 211 dietetic students

Expanded the Energy Balance for Kids program to California

Announced a third $35,000 research grant for members, funded by member donations like yours Launched Kids Eat Right campaign, a joint effort with the Academy to support prevention of childhood obesity and created two new websites to support the campaign. If each member makes a donation of just $1.00, these initiatives will continue to grow. Imagine what could be accomplished with a gift of $5.00!…of $10.00!…of $25.00! Please take a moment to go online to make your donation; or send your check to The Academy of Nutrition and Die-tetics Foundation, 120 South Riverside Plaza, Suite 2000, Chicago, IL 60606-6995. Thank you for continuing to make our organization the leader that it is today.

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The Fall 2012 HOD meeting took place October 5 and 6. Delegates and an additional150 invited and interested members, including members of the Academy Board of Directors, convened in Philadelphia, Pennsyl-vania, to discuss two mega issue topics: Moving Forward-A Vision for Education, Credentialing and Practice and Public Health Nutrition: It’s Every Members’ Business. The Council on Future Practice Visioning Report and the Public Health Nutrition Backgrounder are available on the Academy website (www.eatright.org/hod). Prior to the meeting, delegates conducted discussions with members regarding these issues and members had the opportunity to share comments directly with the Council on Future Practice regarding the Visioning Report. These fact sheets provide a summary of the outcomes of activities. Thank you to those who contrib-uted comments and congratulations to the winner of the $50 gift card, Elizabeth. The HOD conducted a dialogue on the Visioning Report: Moving For-ward-A Vision for Education, Credentialing and Practice on October 5. Over 210 participants attended this dialogue session. The purpose of the dialogue session was for delegates and members to provide reaction to the Visioning Report and create suggestions for implementation of at least some of the Visioning Report recommendations. There was a great deal of discussion, and some of the recommendations were sent to ACEND for revision. On September 6 the Visioning Report was re-leased to HOD and the membership and members were asked to submit their reactions on the report to the Council on Future Practice’s elec-tronic mailbox. The reactions received were posted to the HOD Com-munications Platform throughout the month of September. The reac-tions were also shared with CFP for their review. The comments from September 6-28 can be accessed at www.eatright.org/hod > Fall 2012 MEETING > Meeting Materials. A separate HOD Fact Sheet “Council on Future Practice Visioning Re-port Outcomes Fact Sheet” was released on October 10, 2012. This fact sheet provides key responses to delegate questions along with next steps and can also be accessed at www.eatright.org/hod > Fall 2012 MEET-ING > Meeting Materials. On October 6, 2012, the HOD conducted a dialogue on for Public Health Nutrition: It’s Every Members’ Business. The purpose of the dialogue session was for delegates and members to1) recognize, prepare for, and SEIZE opportunities in public health nutrition and community nutrition, 2) be leaders in public health nutrition and community nutri-tion by actively working in policy development, advocacy, assessment, assurance, environmental change, education, and programs and services and 3) provide input on how to prepare members to meet the needs in public health nutrition and community nutrition. As a result of the dialogue session, the HOD will establish a Public Health Nutrition/Community Nutrition Task Force, comprised of members from the previous Board appointed Public Health Task Force and related DPGs. The task force will be charged to develop a plan for members and the Academy based on the HOD dialogue session, along with identifying gaps to be filled. The plan will provide direction on how members can prepare to become active in public health nutri-tion/community nutrition and the role the Academy can play to assist members in this effort. The task force will be requested to submit a plan by April 1, 2013, for approval. During the Fall 2012 HOD meeting, the Quality Management Commit-tee presented the Comprehensive Scope of Practice Resources. In col-laboration with the Scope of Practice Sub-committee, QMC revised the 2008 Standards of Practice in Nutrition Care for the Registered Dietitian

and the Dietetic Technician, Registered, the Standards of Professional Performance for the RD and DTR, and the Scope of Dietetics Practice Framework during the 2011-2012 program year. The result of this revi-sion was the Comprehensive Scope of Practice Resource for the Regis-tered Dietitian and the Comprehensive Scope of Practice Resource for the Dietetic Technician, Registered. These new resources and tools are an all-inclusive set of documents that answer what the RD and DTR need to acquire to provide quality nutri-tion and dietetics care. The resources describe the tasks and services RDs and DTRs perform to meet employer, government, customer/client/patient and other stakeholder requirements and opportunities. The re-sources are anticipated to be available to members in early Spring 2013. Amendments to the Academy Bylaws were brought to HOD in August and a 45 day member comment period on the proposed amendments occurred from August 9, 2012, through September 24, 2012. Motions to approve the proposed amendments were made and voting occurred after the HOD meeting. The Revised Academy Bylaws can be accessed at www.eatright.org/hod > Fall 2012 MEETING > Meeting Materials. Delegates received updates from the Academy President Ethan Bergman, Academy Treasurer Mary Russell, and the Academy Foundation Chair Diane Heller. Members can view their slides by visiting www.eatright.org/hod > Fall 2012 MEETING > Meeting Materials. All HOD committees have also submitted their Fall 2012 reports. These are also available on the Fall 2012 HOD Meeting site. To learn more about the House visit www.eatright.org/hod or contact your delegate. Delegate Contact Information: kbellesky@gmail.com or 443-794-0388. Public Health Nutrition and Community Health Nutrition Motion 1: 103 support/1 opposed – motion carried. Next Steps: A Public Health Nutrition/Community Nutrition Task Force comprised of members from the previous Board appointed Public Health Task Force and related DPGs will be established. The task force will develop a plan based on the HOD dialogue session which will include providing direction on how members can prepare to become active in public health nutrition/community nutrition and the role the Academy can play to assist members in this effort. The HLT will request that the task force submit a plan by April 1, 2013, for approval. Academy’s Comprehensive Scope of Practice Resources Motion 2: 103 support/1 opposed – motion carried. Next Steps: The 2012 Comprehensive Scope of Practice Resources which includes the Scope of Practice Overview for the RD and DTR, RD Scope/Standards of Practice/Standards of Professional Performance, DTR Scope/Standards of Practice/Standards of Professional Perform-ance and Practice Tools (on-line interactive Scope of Practice Decision Tool and Definition of Terms) will be included into all Academy docu-ments and publications and available to Academy members and creden-tialed practitioners as of June 1, 2013. Academy Bylaws Amendment-ACEND Functions Motion 3: 104 support/0 opposed – motion carried. Next Steps: Implementation of the amended Academy Bylaws will be effective December 3, 2012. Academy Bylaws Amendment-CDR Functions Motion 4: 102 support/1 opposed – motion carried. Next Steps: Implementation of the amended Academy Bylaws will be effective December 3, 2012.

Summary of the Fall 2012 Meeting of the House of Delegates Karen Bellesky, RD, LDN - Maryland Affiliate Delegate

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Experienced RDs are competing for higher salaries and faced with reim-bursement issues 2. Is the debate over uninsured or access to care? Maryland has approximately 2,000 RDs which mean there is one RD for every 3,000 people in Maryland. Everyone with health insurance does not guarantee everyone with access to an RD or even a physician of their choice for that matter. Originally, RDs were not included in the lan-guage of Medicare. After years of advocacy, only a couple disease states were included in medical nutrition therapy (MNT) reimbursement. The fight continues. Inclusion in the Maryland Exchange language or a state mandate is necessary to reach over one million Marylanders in the ex-pansion. 3. Where is the opportunity for the RD/LDN? In the Maryland EHB Draft “nutritional therapy” is included under medi-cal foods coverage, but does not specify the provider. The EHB Draft includes Bariatric Surgery, “Specialist Visit,” Acupuncture, and Hair Prosthesis to name a few specialty services covered. The Draft (as of November) does not mention registered dietitian or clarify where the RD could fit into certain prevention and treatment services that are in-cluded. It was thought RDs could fit into substitution rules by replacing acupuncture, for example. Unfortunately this is not the case. The next best option for inclusion is either totally separate legislation asking for a state mandate, or for pushing the Essential Health Benefits cover RD services and MNT.

Next Steps: On November 16, 2012, members of MAND attended and testified at the Maryland Health Insurance Commission public hearing. The hearing was intended as the second step in the substitution process to document testimonies of potential Health Insurance Benchmark Plan Substitutions. Several RDs/LDNs in Maryland sent written testimony that was col-lected in a binder and submitted. MAND president, Jessica Kiel RD, LDN, CPT, also attended a public hearing Dec. 12 to further clarify the need for MNT inclusion. Final Countdown: Moving forward, the MAND Public Policy Panel will continue to attend public hearings as they arise and push for MNT coverage. The key rela-tionships made with decision makers will benefit MAND members if our grassroots efforts pay off. Even if included in draft format, things can change. YOU are needed to continue the momentum if RDs are to be included before implementation. Stay tuned for more health care re-form updates! For questions and feedback contact Berit Christensen RD, LD at bmchrist@cord.edu. References: 1. UMBC Fall Colloquium Health Reform: Implementing Insurance Coverage

Expansion; Attended Friday, October 26, 2012; http://www.hilltopinstitute.org/Symposiu m/Colloquium2012.cfm

2. Draft Maryland Essential Health Benefits 3. Maryland Health Insurance Commission Public Hearing Attended Friday, November

16, 2012

Maryland Health Reform (continued from page 1)

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Let’s Move! In Rockville Sara Mason – Student, Salisbury University

Obesity affects about one-third of our children. In an effort to combat this epidemic, First Lady Michelle Obama launched the Let’s Move! initiative. By providing healthier foods in our schools, ensuring that families have access to healthy, affordable food, and helping kids become more physically active, the campaign hopes to solve childhood obesity within a generation. Let’s Move! encourages mayors and local officials to take a leadership role in their communities by signing up to adopt long-term, sustainable approaches to fighting childhood obesity. Nearly 500 communities across America signed up for Let’s Move Cities and Towns and Rockville, Md., was one of them. In the summer of 2011, the City of Rockville held their first Let’s Move Celebration of Health in which over 500 children took part in games, races, healthy snacks and more. A group of MAND RDs from Rockville, the Let’s Move Rock-ville RDs, were on hand to teach kids about healthy eating, sugar in beverages, and growing their own food.

With the help of student interns, the Let’s Move Rockville RDs got involved again this past summer – this time with the City of Rockville summer camps programs. For kids 5 to 7 and up to teenagers, nutrition activities became a part of the curriculum. The first step was to gauge how much the kids knew about nutrition and healthy eating – some kids could recite the food groups and read labels, others knew less. We started with the USDA’s MyPlate; subsequent lessons built upon the food groups and serving sizes. Kids being kids, we had to make it fun and engaging, or we would lose their interest. We made use of the National Heart, Lung, and Blood Institute’s “Go Slow Whoa” and turned it into a relay game – they learned about which foods to eat more frequently and less frequently in a fun and physically active way. Later sessions introduced more challenging topics like the role of different vitamins and minerals in our bodies. In “Nutrition Boot Camp,” teams had to answer nutrition trivia questions and run through obstacle courses. Probably the most “nutrition challenging” game was “Nutrition Jeopardy,” which brought out the competitive nature of many of the campers. Surprisingly, the kids showed incredible interest and enthu-siasm. In fact, the consensus from the kids was that the activities taught them about nutrition and physical activity and motivated them to maintain a healthy lifestyle. Cynthia

Bangali, Community Service Program Coordinator for the City of Rockville, commented, “The kids re-ceived practical and engaging instruction on healthy food choices. The game format in which the material was presented really helped the kids to be receptive to the information and learn ways to apply it.” Cynthia went on to say, inviting the MAND RDs to participate in the program “added even more depth” to the programs.

The most recent event, the City of Rockville’s Healthy Living Expo, occurred this past September and included fitness demos, health screenings, and fun activities. The Let’s Move Rockville RDs were on hand again. They engaged kids with carrot cutting, adults with raffles, and all age groups with nutrition education. Rockville is committed to making their community healthier. By partnering up with Rockville RDs, the community learns about nutrition and healthy eating from the ex-perts. As a nutrition student, the Let’s Move! Initiative has given me the oppor-tunity to get involved in my community and learn more about the topic I love, nutrition. *Special thanks to Sasha Nunes and the Let’s Move Rockville RDs – Rhonda Brandes, Berit Christensen, Andrea Troutner, Elaine Trujillo, and Christine Williams.

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Welcome new Let’s Move Cities & Towns State Coordinator for the Maryland Academy of Nutrition and Dietetics! Berit Christensen, RD, LD - MAND Public Policy Coordinator & Former Let’s Move Coordinator Since the fall of 2010, Maryland has been involved in the Let’s Move Cities & Towns campaign as called upon by the White House and the Academy of Nutrition and Dietetics Washington, D.C., office. The Maryland cities include: Aberdeen, Annapolis, Baltimore, Bladensburg, Brentwood, Cecil-ton, Centreville, Charlestown, College Park, Colmar Manor, Crisfield, District Heights, Elkton, Forest Heights, Frederick, Gaithersburg, Green-belt, Greensboro, Laurel, Mount Rainier, Myersville, North Brentwood, Rockville, Seat Pleasant, Somerset, and Westminster. Cities are always welcome to join the initiative with hopes the Maryland involvement continues to grow. Berit Christensen, RD, LD, has coordinated Maryland RD/LDN volunteers in this program for the last couple of years and is very pleased to an-nounce the new Let’s Move Coordinator in Maryland: Jackie Monahan, RD, LDN, BSN, RN, CNOR. Jackie has been a registered dietitian since 1986 and a Registered Nurse since 2003. Originally from Ohio, Jackie holds a bachelor’s degree in Nu-trition and Dietetics from The University of Dayton in Dayton, Ohio, and completed her dietetic internship at the Augusta Area Dietetic Internship program in Augusta, Ga. Subsequently she worked as a clinical dietitian in hospitals and clinics in Georgia, West Virginia, Delaware, and North Carolina. Jackie’s clinical nutrition experience runs the gamut of assessment and monitoring for therapeutic diets, tube feedings, TPN, and also teaching weight control programs. While working as a research dietitian at the General Clinical Research Center at UNC Chapel Hill, Jackie was accepted into the nursing program at UNC Chapel Hill and returned to school to pursue a BSN. Since then, she has been working full time as an operating room nurse and occasionally does private nutrition counseling and public speaking on nutrition topics. When not working or encouraging others to engage in healthy lifestyle habits, her other interests include staying active with outdoor activities such as walking, hiking, and gardening. Jackie also enjoys writing for pleasure and for publication and has had the honor of publication in a professional nursing journal. Jackie has two adult daughters who are completing their college educations and provide a constant source of inspiration. Jackie recently relocated from N.C. to Calvert County, Md., and is excited to assume the role of Maryland State Coordinator for the Let’s Move program. Her contact info is: 919-423-4319; stewartjee@msn.com Some updates to Let’s Move include but are not limited to: a remodeled website, partnership with Kids Eat Right; and new staff Marissa Duswalt, RD, Associate Director of Policy & Events/Let’s Move within the Office of the First Lady at the White House. Several volunteer opportunities are available in Maryland through Let’s Move Cities & Towns and its sub-initiatives. Please reach out to Jackie if you would like to become involved in the Let’s Move initiative in Maryland!

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Samantha Mollica, MS, RD, LDN, is serving as the CPI Chair-Elect for the Maryland Academy of Nutrition and Dietetics’ Board. She moved to Mary-land from Central Pennsylvania in 2009 after completing her dietetic internship and Master’s in Nutrition degree from Indiana University of Pennsylvania. Currently, she works for United Healthcare as a clinical dietitian where she provides telephonic nutrition coun-seling and education to members across the U.S. Her areas of focus include treatment of morbid obesity, malnutri-tion, and management of chronic dis-eases. She is also the IT authority for her dietetic team. In her free time, Samantha enjoys staying active, cooking, catching up on reality TV shows, and is a long time fan of the New York Yankees.

Community Nu-trition Chair Catherine Brown, MS, RD, LDN, CDE, works as a Senior Account Supervisor at Hager Sharp, a health communi-cations firm in Washington, D.C. Her work is focused on the

National Diabetes Education Program, which is a partnership be-tween the National Institutes of Health and the Centers for Disease Control and Prevention. Previously, Catherine worked as the Dia-betes Education Coordinator at the University of Maryland Center for Diabetes and Endocrinology and as a nutritionist for the Medstar Diabetes Institute at Good Samaritan Hospital in Baltimore. She obtained her bachelor's degree in Dietetics from the University of Dayton in Ohio, and her master's degree in Community Health Education from Towson University.

Karen Bellesky, RD, LDN, is the Affiliate Delegate to the Academy House of Delegates (HOD). As delegate, it her job to get your opin-ions on the mega issues being brought to the HOD during its two meetings a year: fall, just before FNCE and spring, a virtual meeting. About a month prior to each HOD meeting, Karen receives informa-tion about the mega issues, reads them, summarizes them and sends them out to the membership for comment. A gift certificate is awarded to one respondent for each meeting as a way to entice the members to comment. Without member comments, Karen can only share her personal opinions. In addition, Karen serves on the Public Policy Panel of the Maryland Academy. In order to pay the bills, Karen works at a Federally Qualified Health Center as a part time RD and a part time grants coordinator, working on grants to provide HIV care and Medical Nutrition Therapy to pa-tients who have limited or no insurance. Besides nutrition, Karen is passionate about baseball. While she can no longer play, the Orioles are her team.

Consultation and Business Practice Chair Sarah Ganginis is a registered dietitian with a master's degree in Nutrition Edu-cation, a graduate certificate in Food and Nutrition, and a bachelor's degree in Dietetics. Sarah's previous experience includes working in a hospital setting and counseling individuals with eating disor-ders. She is currently self-employed in private practice, S-GANGINIS, LLC, where she has offices in both Washing-ton, D.C., and in Columbia, Md. With so much attention on weight and food in the media, Sarah aspires to teach children

and adults the true meaning of healthy eating.

Berit Christensen, RD, LD, is in her third year as Public Policy Coordinator (PPC) for MAND. Originally from the Minneapolis area, Berit received her Bachelor of Arts in Food/Nutrition & Dietetics and Exercise Science from Con-cordia College in Moorhead, Minn. Her dietetic internship was completed in Prescott, Ariz., at the Yavapai County Community Health Services. Berit always had an interest in nutrition policy and advocacy for the dietetics profession, and was looking to move closer to Washington, D.C., to influence Congress. Her first job as a clinical dietitian was for Morrison at the MedStar National Rehabilitation Hospital in Washington, D.C. Living in downtown Silver Spring, Md., her proximity to Washington, D.C., was conveniently paired with her passion in policy to represent MAND as PPC. Some of the highlights as PPC have included inviting and introducing Maryland U.S. Senator Cardin to speak at the MDA 2012 Annual Meeting, working with state Delegate Costa on a Childhood Obesity Workgroup in Annapolis, involvement as State Coordinator for the Let’s Move Cities and Towns initiative, coordinating a new Grassroots Team, and leading RDs to Capitol Hill a few times annually to meet with congressmen or their staff including during the Academy’s annual Public Policy Workshop. The roll as PPC led to her pursuit in a degree in this area. In January 2012 Berit started a master’s degree in public policy with health policy emphasis at the University of Maryland Baltimore County. At the MDA 2012 annual meeting, Berit received a Returning Graduate Student award from MDAF and Rec-ognized Young Dietitian of the Year award from MDA. Currently Berit is working for Abbott Nutrition as a Pediatric

Sales Representative in Washington, D.C., and Maryland. Her hobbies include music, traveling, spending time with her two dogs, and playing poker. “Thank you MAND members for your involvement over the years. RDs are faced with challenges in the public policy arena and your voice needs to be heard now more than ever!”

Spotlight on the Board of Directors

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Clinically Speaking

Infants are born made of human cells (1), yet in adults bacteria outnumber human cells by a factor of 10 (2). Bacterial colonization begins immedi-ately after birth and is established steadily throughout the first year of life at which point it is considered to be of an ‘adult-like’ pattern (3). Com-mensal bacteria in the infant gut helps to establish, maintain, and mature the gut mucosal barrier, which is critical to protect infants who are par-ticularly susceptible to infectious disease (3). The composition of bacteria that can colonize the infant gut has been shown to affect health outcomes, and there are specific changes in the bacterial colonization process that may predispose an infant to disease later in life (4). Since bacterial composi-tion is determined early in life and bacterial composition affects health outcomes, it is an important public health issue to determine how the infant gut flora develops and what role it plays once there. From a nutritional standpoint, one way to affect early change in the gut bacteria composition in infants is through breast milk. Exclusive breastfeed-ing is the best known way to promote an infant’s immune system; among the many remarkable factors about human milk, one standout is that breast milk contains both bacteria and products that support the growth of bacteria (5,6).

The physiology of the infant gut plays a role in making it more susceptible to adherence of non-pathogenic bacteria. Factors that promote coloniza-tion change with age, and it is easier to colonize the infant gut than the more stabile adult gut because the higher pH and slower emptying time make the infant gut more conducive to colonization (2,8,9). Though humans are constantly exposed to bacteria throughout all life stages, the criti-cal period in which colonization occurs – and health outcomes determined – may be immediately after birth through the breastfeeding process (10).

The major roles of gut bacteria can be subdivided into three main categories: metabolic, trophic and protective (10,11). Nutritionally, gut bacteria can synthesize vitamins (Vitamin K and B complex) and short-chain fatty acids. The short-chain fatty acids that are produced by bacteria in the gut can aid in epithelial cell growth and differentiation, and notably maintain GI mucosal integrity. From a protective standpoint, the bacteria guard the gut from pathogens. There are several mechanisms by which the commensal bacteria can protect from pathogens. Bacteria compete for attachment to epithelial cells, and the presence of healthy flora can prevent attachment of pathogenic bacteria. Also bacteria compete for nutrients, and a symbiotic relationship between the commensal bacteria and the host ensure the proper amount of nutrient is present, not overproduction of nutrients which would then be available for pathogens. Finally bacteria can produce antimicrobial substances called bacteriocins (9).

Patterns of bacterial colonization tend to correspond to specific physiological outcomes and health consequences. Recognizing that one cannot de-fine an “optimal” microbiome, the composition of bacteria in a full-term breastfed infant to have a “healthy” gut microbiome is noted to be diverse with predominance of Bifidobacteria (12). Bifidobacteria is thought to have positive health benefits and a decreased proportion of it is associated with atopy and incidence of diarrheal disease. The mechanism by which Bifidobacteria is thought to work is by promoting the growth of butyric acid which lowers pH to a range that harmful bacteria cannot sustain (13). Deviations from a Bifidobacteria dominant breastfed bacterial composition have also been associated with obesity and inflammatory bowel disease in later life (14).

Breastfeeding makes significant contribution to the infant gut flora, both in its capacity to deliver bacteria itself, and its ability to promote the growth of other healthy flora. Early introduction of, and exclusive feeding with breast milk promotes a “healthy” microbiome characterized by pre-dominance of diverse Bifidobacteria that is associated with reduced incidence of atopy, obesity, and inflammatory bowel disease. Initial colonization of the microflora plays a crucial role in establishing a composition that stays relatively stable through adulthood. Thus understanding the beneficial contribution of breast milk, and potentially finding ways to incorporate these benefits into formula, should be critical public health goals. References:

1. Hooper LV. Bacterial contributions to mammalian gut development. Trends Microbiol 2004;12(3):129–34.

2. Mackie RI, Sghir a, Gaskins HR. Developmental microbial ecology of the neonatal gastrointestinal tract. Am J Clin Nutr 1999;69(5):1035S-1045S.

3. Penders J, Thijs C, Vink C, et al. Factors influencing the composition of the intestinal microbiota in early infancy. Pediatrics 2006;118(2):511–21. 4. Kalliomäki M, Kirjavainen P, Eerola E, Kero P, Salminen S, Isolauri E. Distinct patterns of neonatal gut microflora in infants in whom atopy was and was not developing. J

Allergy Clin Immunol 2001;107(1):129–34.

5. Adlerberth I. Establishment of a normal intestinal microflora in the newborn infant. In: Probiotics, other nutritional factors, and intestinal microflora. Nestle Nutrition Workshop Series. Philadelphia: Lippincott-Raven; 1999.

6. Zivkovic AM, German JB, Lebrilla CB, Mills D a. Human milk glycobiome and its impact on the infant gastrointestinal microbiota. Proc Natl Acad Sci U S A 2011;108 Suppl :4653–8.

7. Black RE, Allen LH, Bhutta Z a, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008;371(9608):243–60.

8. Martín V, Maldonado-Barragán A, Moles L, et al. Sharing of bacterial strains between breast milk and infant feces. J Hum Lact 2012;28(1):36–44.

9. Berg RD. The indigenous gastrointestinal microflora. Trends Microbiol 1996;4(11):430–5.

10. Guarner F, Malagelada J-R. Gut flora in health and disease. Lancet 2003;361(9356):512–9.

11. Vael C, Desager K. The importance of the development of the intestinal microbiota in infancy. Curr Opin Pediatr 2009;21(6):794–800.

12. Hanson L a. Session 1: Feeding and infant development breast-feeding and immune function. Proc Nutr Soc 2007;66(3):384–96.

13. Hosea Blewett HJ, Cicalo MC, Holland CD, Field CJ. The immunological components of human milk. Adv Food Nutr Res 2008;54:45–80. 14. Kalliomäki M, Collado MC, Salminen S, Isolauri E. Early differences in fecal microbiota composition in children may predict overweight. Am J Clin Nutr 2008;87(3):534–

8.

Breastfeeding Benefits Infant Gut Microbiota Danielle Flug - MSPH/RD Student, Johns Hopkins Bayview Medical Center

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Chesapeake Dietetic Lines

As dietetic practitioners, it is beneficial to be aware of the common supplements that patients and clients are taking for various health reasons. One such supplement, Coenzyme Q10 (CoQ10), is gaining popularity amongst people with many different disease states. In fact, this compound is one of the most commonly consumed dietary supplements. For a bit of metabolism review, CoQ10 is a naturally occurring vitamin-like compound that is produced by our bodies and found in almost all human cells (1,2). Within our cells, it serves as a component of the electron transport chain for ATP synthesis. A lipid-soluble antioxidant, CoQ10 protects the mitochondria against free radical damage. It also protects the phospholipids within our cell membranes. Tissues that use large amounts of energy (ATP) contain larger amounts of this compound; these include the liver, kidney, skeletal muscle, and heart (3). As we age, our bodies synthesize less CoQ10; decreased levels have been observed in numerous acute and chronic diseases (2). In light of this, CoQ10 supplementation has been used and studied for numerous medical conditions – acute MI, Alzheimer’s disease, diabetes mellitus, congestive heart failure, and periodontal disease are only a few to name (1). Circulating concentrations will increase after taking supplements, but the impact depends on dosage and type of formulation. The literature supports doses of 100-200 mg/day for treating cardiovascular diseases. One major ad-vantage to supplementation is that side effects are typically either nonexistent or very transient and mild (headache, abdominal discomfort). How-ever, there are a number of potential interactions; for example, supplementation may lower blood sugar levels, lower blood pressure, and may also decrease response to Warfarin (2,4). Though the evidence is rapidly growing for its therapeutic use, CoQ10 still remains controversial as a treatment for many of these conditions. The most evidence of benefit from supplementation has been found in treatment of CVD because CoQ10 deficiency in the myocardium is consistently found in CVD patients. So what is the evidence that CoQ10 is an effective therapy for certain cardiovascular diseases? Let's take a look at three dif-ferent cardiovascular conditions: heart failure, hypertension, and statin-induced cardiomyopathy. Heart failure Heart failure is the “end stage” of all CVD and involves a progressive impairment in the ventricles ability to pump blood. Patients with HF are often classified using the New York Heart Association Functional Classification (classes I-IV) according to severity of symptoms and limitation in physical activity. Many studies and reviews support the use of CoQ10 as an additional therapy for patients with HF. Specifically, it has been found in some studies to improve ejection fraction, improve symptom class, and improve cardiac output (4,5,6). Patients who start CoQ10 supplementation sooner after being diagnosed with heart failure tend to see the most improvement in heart function. One recent 2008 study also found that plasma CoQ10 levels are an independent predictor of survival in chronic heart failure (7). For now, the evidence appears promising for using CoQ10 as an adjunctive therapy for HF; however, there is still some debate within the literature over its routine clinical use. Researchers are calling for more well designed, large-scale trials before it can be included in the therapeutic guidelines for HF. Hypertension Some studies have found that CoQ10 supplementation can reduce both systolic and diastolic blood pressure (8,9,10). Researchers have hypothe-sized that it may have anti-atherogenic effects, or that it could act directly on the blood vessels to lower peripheral resistance (8). Most studies have been smaller in nature, and anti-hypertensive effects are usually seen over time (1-3 months). One 2007 meta-analysis reviewed 12 clinical trials and found significant decreases in both systolic and diastolic blood pressure after supplementation. Doses in these studies ranged from 34 mg/day to 225 mg/day (9). The authors concluded that CoQ10 can effectively lower blood pressure in patients with hypertension without significant adverse effects. A Cochrane review done in 2009 found similar results; the authors looked at three double-blind, randomized, placebo controlled trials. However, although statistically significant mean decreases of 11 mmHg systolic and 7 mmHg diastolic blood pressure were found, the authors de-termined that there were potential issues with randomization, blinding, and selective reporting in some of these studies (8). They concluded that CoQ10 could potentially be an effective treatment for HTN, however more reliable research and larger, longer-term trials are needed. In sum, it appears that several studies have consistently found that CoQ10 can reduce blood pressure. However, more large-scale, reliable studies are needed before it can be used for therapeutic management of HTN. CoQ10 and Statin-Induced Myopathy Statin use in patients with high cholesterol is often associated with muscle complaints. Since studies consistently show that statins lower serum CoQ10 levels, many have hypothesized that statin-associated myopathy may be related to the inhibition of CoQ10 synthesis. Very few randomized trials have evaluated CoQ10 as a treatment for this myopathy, and the results have been mixed. One 2007 double blind, randomized study com-pared patients treated with 100 mg/day of CoQ10 to patients treated with 400 IU/day of vitamin E (12). They assessed muscle pain before and after supplementation, and after 30 days they found that pain interference with daily activities decreased by 38% and pain severity decreased by 40% in the CoQ10 group. On the other hand, two recent systematic reviews that examined CoQ10 and statin-induced myopathy concluded that although supplementation can raise plasma levels, it is still unclear if this relieves myopathic symptoms (13,14). Considering the conflicting results of recent trials, it seems that there is currently not enough evidence to conclude that CoQ10 supplementation alleviates symptoms of statin-induced myopathy. So what can we conclude from all of this? We know that CoQ10 is a potent antioxidant and that it plays an important role in energy metabolism within all cells. Levels decline with age, certain medications, and in various disease states including diabetes, myocardial infarction, and CHF. Sup-plementation can raise serum CoQ10 levels and there are fortunately little to no side effects associated with taking supplements. In light of the cur-rent research, CoQ10 shows some promising benefits for use in patients with cardiovascular disease, particularly with heart failure. However, as with many nutrition topics, more research is needed before it can become widely used in clinical practice.

Continued on page 11

Spotlight on Supplements: CoQ10 and Cardiovascular Disease Elizabeth Kellis - Dietetic Intern, Johns Hopkins Bayview Medical Center

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Winter 2013

References: 1. Lexicomp, Inc. Coenzyme Q10: Natural drug information. UpToDate. 2012.

Accessed September 6, 2012. 2. Micromedex 2.0. Coenzyme Q10: Drug Details. http://

www.thomsonhc.com/micromedex2/librarian/PFDefaultActionId/CoenzymeQ10. Accessed September 6, 2012.

3. Singh U, Devaraj S, Jialal I. Coenzyme Q10 supplementation and heart failure. Nutr Rev. June 2007;65(6 Part 1):286-293. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 6, 2012.

4. Hiebert JB, Shen Q, Pierce JD. Application of Coenzyme Q10 in Clinical Practice. Internet J Intern Med. 2012;9(2). DOI: 10.5580/2b24.

5. Bramwell, B. Coenzyme Q10 supplementation in the treatment of heart disease. Int J Pharm Comp. 2010;14(2):108-111. Accessed September 19, 2012.

6. Kumar A, Kaur H, Devi P, Mohan V. Role of coenzyme Q10 (CoQ10) in cardiac disease, hypertension, and Meniere-like syndrome. Pharmacol Ther. 2009;124:259-268. Doi: 10.1016/j.pharmthera.2009.07.003.

7. Molyneux S, Florkowski C, George P, Pilbrow A, Frampton C, Lever M, Richards A. Coenzyme Q10: An independent predictor of mortality in chronic heart failure. J Am Coll Cardiol. 2008;52(18):1435-1441. doi:10.1016/j.jacc.2008.07.044.

8. Ho MJ, Bellusci A, Wright JM. Blood pressure lowering efficacy of coenzyme

9. Q10 for primary hypertension. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD007435. DOI: 10.1002/14651858.CD007435.pub2.

10. Rosenfeldt F, Haas S, Krum H, Hadj A, Ng K, Leong J-Y, Watts G. Coen-zyme Q10 in the treatment of hypertension: a meta-analysis of the clinical trials. J Hum Hypertens. 2007:21:297-306. Accessed September 17, 2012.

11. Rasmussen, C. B., Glisson, J. K. and Minor, D. S. (2012), Dietary Supple-ments and Hypertension: Potential Benefits and Precautions. J Clin Hypertens, 14:467–471. doi: 10.1111/j.1751-7176.2012.00642.x

12. Caso G, Kelly P, McNurlan M, Lawson W. Effect of coenzyme Q10 on myopathic symptoms in patients treated with statins. Am J Cardiol. 2007;99:1409-1412. Accessed September 17, 2012.

13. Marcoff L, Thompson P. The role of coenzyme Q10 in statin-associated myopathy: a systematic review. J Am Coll Cardiol. 2007;49(23):2231-2237. doi: 10.1016/j.jacc.2007.02.049.

14. Mas E, Mori T. Coenzyme Q10 and statin myalgia: what is the evidence? Curr Atheroscler Rep. 2010;12:407-413. doi: 10.1007/s11883-010-0134-3.

15. Schaars C, Stalenhoef A. Effects of ubiquinone (coenzyme Q10) on myopathy in statin users. Curr Opin Lipidol. 2008;19:553-557. doi:10.1097/MOL.0b013e3283168ecd.

Spotlight on Supplements: CoQ10 and Cardiovascular Disease (continued from page 10)

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