Despite its importance, choline is seriously overlooked. Data from the National Health and Nutrition Examination Survey suggest only 8 percent of American adults meet the adequate intake for choline; in the 2010 Dietary Guidelines for Americans, it was identified as a shortfall nutrient; and the 2015-2020 Dietary Guidelines for Americans estimate most Americans consume less than the adequate intake level.

Roles in Health

Choline is essential throughout the life cycle and is critical for brain and spinal cord development. Beginning in utero and continuing throughout childhood, choline is crucial for brain development and cognitive learning. Some research shows choline can improve memory by slowing cognitive decline in older adults.

Beyond the brain, choline is part of acetylcholine, a neurotransmitter important in muscle control, memory, mood and nervous system functions. Choline also plays a role in the stabilization of DNA, transportation of fats and (with folate) possibly the prevention of neural tube defects.

Choline’s role as a neurotransmitter signaling muscle cell activity may enhance athletic performance, according to preliminary research.

Some research shows choline may be cardioprotective, yet other studies have found conflicting results. Further research is needed to investigate the link between choline and cardiovascular disease risk.

Current Recommendations

In 1998, the Food and Nutrition Board established adequate and tolerable upper intake levels for choline. Requirements begin at 125 milligrams per day in the first six months of life and advance to 550 milligrams per day for males 14 and older and 425 milligrams per day for females 19 and older. Pregnant and lactating women require 450 milligrams per day and 550 milligrams per day, respectively.

Food Sources

The U.S. Food and Drug Administration recently set the daily value for choline at 550 milligrams per day for adults and children 4 and older based on the updated Reference Daily Intake values. Foods containing 55 to 104.5 milligrams (10 to 19 percent of the DV) of choline per serving can be declared a good source and foods containing 110 milligrams or more of choline per serving (20 percent or more of the DV) are an excellent source.

Supplements are usually necessary for pregnant and lactating women. Choline supplements are available as a single nutrient, with B vitamins and in some multivitamin mineral products in amounts ranging from 10 to 250 milligrams.

Signs of Deficiency

While most Americans fall short of meeting choline requirements, deficiency is rare in healthy, non-pregnant people. A choline deficiency can cause muscle damage and nonalcoholic fatty liver disease from abnormal deposits of fat in the liver.

Toxicity

Exceeding the tolerable upper intake level of 3,500 milligrams per day of choline for adults has been associated with vomiting, increased sweating, low blood pressure and fishy body odor. Further, the FNB warns that individuals with liver or kidney disease, Parkinson’s disease, depression or inherited trimethylaminuria may be at increased risk for severe side effects when exceeding the tolerable upper intake level.

Populations at Risk

Choline’s role in brain and spinal cord development makes its consumption vital for pregnant and lactating women. However, many prenatal supplements contain little choline. In June 2017, the American Medical Association recommended that prenatal vitamins increase the amount of choline from 0 to 55 milligrams to the adequate intake of 450 milligrams daily.

Individuals with genetic alterations also may be at higher risk of deficiency.

Bottom Line

The mounting evidence of choline’s importance makes it essential that registered dietitian nutritionists remain up to date on this critical nutrient. Throughout the life cycle, RDNs can help clients meet choline requirements for good health. Food manufacturers also may take note and start fortifying choline in foods to help consumers meet requirements more easily.

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Emulsifiers made from plant, animal and synthetic sources commonly are added to processed foods such as mayonnaise, ice cream and baked goods to create a smooth texture, prevent separation and extend shelf life. However, in this era of “clean labels,” consumers question the necessity of additives in food.

Definition

A food emulsifier, also called an emulgent, is a surface-active agent that acts as a border between two immiscible liquids such as oil and water, allowing them to be blended into stable emulsions. Emulsifiers also reduce stickiness, control crystallization and prevent separation.

Functions, Names and Labeling

Emulsifiers create two types of emulsions: either droplets of oil dispersed in water or droplets of water dispersed in oil. Within the emulsion, there is a continuous and dispersed phase. In an oil-in-water emulsion, the continuous phase is the water and the dispersed phase is the oil; conversely, in a water-in-oil emulsion, the oil is the continuous phase.

Emulsions also can be made by applying mechanical force from a blender or homogenizer, which breaks down the dispersed phase into tiny droplets that become suspended in the continuous phase.

Low-fat spreads, ice cream, margarine, salad dressings and many other creamy sauces are kept in stable emulsions with the addition of emulsifiers. These additives also are widely used in other foods such as peanut butter and chocolate.

“Emulsifiers enhance the structure of baked goods by increasing whip-ability of batters, conditioning of dough and helping foods like pasta be more resistant to overcooking,” says food scientist Kantha Shelke, PhD, CFS.

Commonly used emulsifiers in modern food production include mustard, soy and egg lecithin, mono- and diglycerides, polysorbates, carrageenan, guar gum and canola oil.

Lecithin in egg yolks is one of the most powerful and oldest forms of an animal-derived emulsifier used to stabilize oil in water emulsions, for example, in mayonnaise and hollandaise sauce.

Emulsifiers are required by law to be included on a food’s ingredient list.

Oversight

Safety of emulsifiers is carefully regulated and tested by the U.S. Food and Drug Administration. Emulsifiers can be found on the Generally Recognized As Safe, or GRAS, list and are allowed in specific types of food and beverages at precise levels.

However, “FDA processes do not take into consideration individual diets of people who rely heavily on packaged foods,” Shelke says.

Although GRAS substances technically must meet the same safety standards as approved food additives, the GRAS process has evolved into a voluntary notification program and many GRAS additives have not been tested.

Congress defines safe as “reasonable certainty that no harm will result from use” of an additive. Additives are never given permanent approval. The FDA continually reviews the safety of approved additives, based on the best scientific knowledge, to determine if approvals should be modified or withdrawn.

Earlier in 2017, the FDA reviewed and confirmed the safety of carrageenan, an emulsifier whose safety has been questioned.

Safety

Most concerns about food additives target synthetic ingredients that are added to foods.
Published peer-reviewed intervention studies involving emulsifiers are limited to animals. A 2015 mouse study published in Nature found that two common synthetic emulsifiers, carboxymethylcellulose (CMC) or polysorbate 80 (P80), triggered weight gain and low-grade symptoms of inflammation and metabolic syndrome after 12 weeks.

“We suspect some emulsifiers act like detergents, upsetting the friendly bacteria in the microbiota, which triggers low-grade inflammation and causes excess eating,” says co-author Andrew Gewirtz, PhD.

A follow-up study by Gewirtz, a professor of biomedical sciences at Georgia State University, and his colleagues, published in Cancer Research, suggested the changes in gut bacteria from emulsifiers could trigger bowel cancer. A small clinical trial currently is underway to evaluate the role of CMC in humans.

In response to questions about the safety of some emulsifiers, a team of FDA scientists conducted a review of seven emulsifiers commonly used in food, including CMC and P80, to determine whether these ingredients pose any risk to human health. Their findings, published in 2017, confirmed that emulsifiers remained safe at the estimated exposure levels.

Final Thoughts

Food additives, including emulsifiers, play an important role in our food supply. Consumers who are concerned about these ingredients are encouraged to read labels and consume more minimally processed foods.

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Definition

Color additives, including food dyes and pigments, are substances derived from both synthetic and plant, animal or mineral sources that add color to food. The objective is to enhance natural colors, add color to otherwise colorless foods, compensate for natural color variations and help identify flavors (such as yellow for lemon).

Functions, Names and Labeling

Synthetic color additives were developed to maintain hue and depth of color regardless of pH, temperature or presence of other ingredients. Synthetic colors are classified as “certifiable colors,” as they require U.S. Food and Drug Administration testing and certification each time a new color batch is used. Certifiable color additives are man-made and derived primarily from petroleum.

The nine FDA-approved “certifiable colors” include:

FD&C (FDA approved for Food, Drugs & Cosmetics) Blue No. 1, Blue No. 2, Green No. 3, Red No. 3, Red No. 40, Yellow No. 5 and Yellow No. 6; Orange B (only for use in hot dog and sausage casings) and Citrus Red No. 2 (only for use to color orange peels).

Other color additives derived from sources such as fruits, vegetables, insects and minerals are “exempt” from batch testing and certification, but they still must adhere to safety standards and regulatory requirements. Examples include grape skin extract, saffron, and fruit and vegetable juices. Some people may call these color additives “natural.” However, the term “natural” is not regulated or defined by the FDA, and the FDA objects to the term’s use in products containing added color, whether from certifiable or plant- or mineral-derived colorants.

Certifiable colors must be declared on food labels by the name of the additive, with at least the color and number (such as “Blue 2”). Other color additives may be declared as “Artificial Color,” “Artificial Color Added” or “Color Added,” or by an equally informative term such as “Colored with Fruit Juice” or “Vegetable Juice Color.” Carmine and cochineal extract color additives must be declared on labels because some people are allergic to these substances.

The ability to replace synthetic with plant- or mineral-derived colorant compounds depends on and varies with the pH and temperature of the food or beverage. Certifiable colorants may be preferable when the color needs to be vibrant, stable for long periods of time or when a specific color cannot be achieved with plant- or mineral-derived options.

Oversight

The FDA oversees all color additives, which must be approved for use in food, dietary supplements, drugs and cosmetics, and includes ongoing review of scientific evidence on the safety of their use. In addition, the FDA sets specifications and limitations for types of foods to which each color additive may be added, maximum amounts allowed in foods and how they must be identified on labels.

Color additives are regulated a little differently than other additives. “Because of the potential to deceive consumers about quality or safety of food, color additives require proof of safety during the authorization procedure and cannot be registered as ‘generally recognized as safe,’ exempt from FDA approval,” says Kantha Shelke, PhD, CFS, principal at Corvus Blue, LLC, and adjunct faculty in food safety regulations at Johns Hopkins University.

Safety

Despite additional layers of oversight, some consumers are concerned about the safety of food dyes. The FDA asserts color additives are thoroughly evaluated prior to approval and safe when used in accordance with regulations. However, over the years, many colors — including yellows 1, 2, 3 and 4 — have been banned due to adverse health effects. Color additives that have been found to cause cancer in animals or humans may not be used in FDA-regulated products marketed in the U.S.

Scientists have examined the relationship between food coloring and hyperactive behavior in children with mixed results.

“The FDA has reviewed and will continue to examine the effects of food dyes on children’s behavior,” says Andrew Zajac, PhD, director of the Division of Petition Review in FDA’s Office of Food Additive Safety. “The totality of scientific evidence indicates that most children have no adverse effects when consuming color additives, but some evidence suggests that certain children may be sensitive to them.”

Adverse reactions to color additives are estimated to be quite rare overall, even among people with allergies. Research is limited in this area, and there is no scientific evidence to support a link between exposure to artificial coloring and allergies.

That said, some experts think color additives are completely unnecessary. “It’s better to color food with colorants from food sources or add no color at all than to use synthetic color additives without the benefit of long-term safety studies,” says Virginia Tech food science professor Sean F. O’Keefe, PhD.

Whether in response to mounting evidence or ongoing consumer concern, many companies around the world have begun eliminating food dyes from some or all of their products. The British government now requires warning labels on most foods containing color additives, which has led to the reformulation of many products.

Final Thoughts

There is a growing trend to replace synthetic colors with plant- or mineral-derived compounds. These are assumed to be safer, but without regulation of the term “natural” and without being batch tested or certified, plant- and mineral-derived color additives are not a panacea.

“It is essential that all colorants be tested with the same rigor, something not always done with ingredients such as fruit extracts that bestow a false sense of safety because they are derived from familiar plants and foods,” Shelke says.

Color additives, which confer no health or nutritional benefit, are unlikely to be dangerous for most people. For those wishing to avoid color additives, helpful strategies include reading food labels and eating more foods that are minimally processed.

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Definition

Anticaking agents stop powders and granulated ingredients from clumping, and humectants stabilize foods through moisture control. Both food additives can be derived from natural sources or manufactured from chemical or artificial ingredients. They also are used in nonfood applications, such as cosmetics, detergents, pharmaceuticals and tobacco.

It is important to note that many food additives serve more than one role. Mannitol, for example, is an additive that functions as a humectant, nutritive sweetener and texturizer.

Functions, Names and Labeling

Anticaking agents function by absorbing excess moisture or by coating particles to make them more water repellant, which helps inhibit clumping. Added in very small amounts, these compounds prevent dry foods from sticking together, ensuring a product remains dry and free-flowing.

Humectants control water activity in foods, thus enhancing stability and viscosity, maintaining texture and reducing microbial activity. If processed foods were consumed within a few days, food additives would not be necessary; since many food products sit on shelves in stores and homes for some time, additives aid in reducing water activity while keeping foods moist and safe for a longer shelf life.

Humectants

Foods that need to be kept moist risk potential bacterial growth. Moisture in food affects microbial activity, physical and sensory properties and possible chemical changes. Moisture in food can be controlled by removing it through dehydration or chemically binding it with humectants. Humectants control moisture changes caused by humidity fluctuations in processing, transit and storage on the shelf.

Dry cereal with raisins, candy with liquid centers, cheese, coconut, marshmallows and baked goods are a few examples of foods that rely on humectants. Humectants also are used in military and space technology to allow foods such as meat to be stored without refrigeration for longer periods of time.

Sugar and salt are the oldest and most widely used humectants. Examples of other commonly used humectants include glycerin, honey, sugar alcohols, glucose syrup, egg yolk, egg white, molasses and alpha hydroxy acids such as lactic acid.

Anticaking Agents

Fine-particle solids such as dry milk powder, flour, baking powder, cake mixes and powdered sugar are a few foods that benefit from anticaking agents, which prevent the formation of lumps and keep the products flowing freely. Without them, coffee powders in vending machines would not function properly and foods like grated cheese could form clumps and become sticky.

Most anticaking agents are made from synthetic substances such as silicon dioxide, magnesium carbonate and iron ammonium citrate. Calcium silicate, commonly added to table salt, absorbs both oil and water. Natural anticaking agents include magnesium silicate and corn starch.

Oversight

Humectants and anticaking agents are direct food additives that must be approved before use by the U.S. Food and Drug Administration. Assessment of a food substance includes an evaluation of its safety and functionality, including all studies on its stability, purity, potency, performance and usefulness.

Additive standards are defined with strict criteria, including safety, lack of adverse odors and flavors, and documented need of use before approval is granted. Maximum usage levels vary depending on the additive and food in which it is used. For example, silicon dioxide used in shredded cheese and powdered mixes has a limit of 2 percent by weight of the food.

Recently, a few government rulings have changed the status of anticaking agents and humectants. The new ruling removes partially hydrogenated oils, used as an anticaking agent, from the “Generally Recognized as Safe” list and gives manufacturers until the summer of 2018 to remove it from their products.

Safety

People sensitive to humectants, especially when ingested in large amounts, may suffer from nausea or diarrhea. Sugar alcohols in large doses may have a laxative effect.

Humectants and anticaking agents continue to be active areas of research and development in an effort to discover safe, natural alternatives and emerging technologies that can offer additional benefits to our food supply and the planet.

Final Thought

Humectants and anticaking agents are used in very small amounts to safeguard the food supply and maintain quality during shelf life. Extensive research and testing have deemed these additives safe in approved amounts. However, anyone with questions about food additives can consult a registered dietitian nutritionist.

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Definition

Extracted primarily from natural substances, stabilizers, thickeners and gelling agents are approved direct additives incorporated into foods to provide structure, viscosity, stability and other qualities, such as maintaining existing color.

Functions, Names and Labeling

Thickeners, stabilizers and gelling agents are classified separately but overlap in functionality. When dissolved or added to foods, they create stiffness, stabilize emulsions or form gels.

Thickeners range from flavorless powders to gums and are chosen for their ability to work in a variety of chemical and physical conditions. Variables affecting choice of thickener include pH, frozen state, clarity and taste. Starches, pectin and gums are the most common commercial thickeners used in soups, sauces and puddings.

Stabilizers are substances that increase stability and thickness by helping foods remain in an emulsion and retain physical characteristics. Ingredients that normally do not mix, such as oil and water, need stabilizers. Many low-fat foods are dependent on stabilizers. Lecithin, agar-agar, carrageenan and pectin are common in ice cream, margarine, dairy products, salad dressings and mayonnaise.

Gelling agents also function as stabilizers and thickeners to provide thickening without stiffness through the formation of gel in jellies, jams, desserts, yogurts and candies. Gums, starches, pectin, agar-agar and gelatin are common gelling agents.

Home cooking achieves the same structural changes with the addition of familiar starches, grains, egg yolks, yogurt, gelatin, mustard and vegetable purees.

Thickening agents also are used in treating medical conditions, such as dysphagia, to make swallowing easier and reduce the risk of aspiration.

To help consumers understand the function of the food additive, a classification is indicated on food labels — for example, “pectin (gelling agent).” Most direct additives are identified on the ingredient label of foods.

Thickeners, stabilizers and gelling agents are largely polysaccharides or derived from protein sources, for example:

Polysaccharides

• Starches: arrowroot, cornstarch, potato starch, sago, tapioca
• Vegetable gums: guar gum (extracted from guar bean), xanthan gum (from microbial fermentation used in gluten-free baked goods), locust bean gum (from carob tree)
• Pectin (from apples or citrus fruit)

Protein

• Collagen, egg whites, gelatin (from animal collagen), whey

Others

• Sugars: agar (from algae), carrageenan (from seaweeds and used to prevent separation in dairy products and ice cream)
• Sodium pyrophosphate (used in common foods such as canned fish and instant pudding)
• Lecithin (found in egg yolk, legumes and corn)
• Mono- and diglycerides (stabilizers naturally present in many seed oils)

Sources are primarily natural (arrowroot, gelatin, starches) but also can be synthetic (carboxymethyl cellulose, methyl cellulose).

Oversight

Thickeners, stabilizers and gelling agents must be authorized by the Food and Drug Administration before use. Standards for food additives are clearly defined with strict criteria, and there must be a documented need for their use before approval is granted. Maximum usage levels vary depending on the additive and the food in which it is used.

For example, stabilizers in frozen dairy desserts, fruit and water ices and in confections and frostings cannot exceed 0.5 percent by weight of the final product. Emulsifier, flavoring adjuvant, stabilizer or thickener in baked goods have the same 0.5 percent by weight limit.

Safety

Today, food additives are scrutinized, regulated and monitored more closely than at any other time. All new food additives undergo a rigorous testing and safety assessment to minimize potential adverse effects to human health. However, side effects and nutrient-drug interactions may result from large doses. For example, consuming more than 15 grams of xanthan gum may cause nausea, flatulence and bloating. Food-drug interactions are possible with certain medications; carrageenan may cause adverse side effects in people taking anticoagulants and antihypertensive drugs, and pectin may interact with antibiotics and cholesterol-lowering drugs.

Final Thought

Registered dietitian nutritionists can help consumers feel more comfortable about food additives by communicating their similar role in home kitchens.

“While the name of the ingredient may be unfamiliar, the mode of action in the food matrix is similar,” says Heather Dover, RDN, research assistant at the Center for Research on Ingredient Safety at Michigan State University.

“Most concerns about food additives are related to synthetic ingredients added to foods, yet 99 percent of these additives are derived from natural sources and meet all of the FDA standards for safety, intended use and populations,” says Roger Clemens, DrPH, and former president of the Institute of Food Technologists. “For over 100 years of usage, these direct additives have posed no adverse effect for any population.”

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Definition

Food preservatives play a vital role in preventing deterioration of food, protecting against spoilage from mold, yeast, life-threatening botulism and other organisms that can cause food poisoning. By extension, preservatives reduce food cost, improve convenience, lengthen shelf life and reduce food waste.

Functions, Names and Labeling

There are two modes of preservation: physical and chemical. Physical preservation refers to processes such as refrigeration or drying. Chemical preservation is adding ingredients to a food for the purpose of preventing potential damage from oxidation, rancidity, microbial growth or other undesirable changes — and is considered a “direct additive.”

The U.S. Food and Drug Administration classifies both natural preservatives (for example, from lemon juice, salt and sugar) and artificial preservatives as “chemical preservatives.” While many common preservatives occur naturally, manufacturers often use synthetic versions of these chemicals. Artificial preservatives can be divided into three major groups:

Antimicrobial agents destroy bacteria or inhibit the growth of mold on foods:

• Benzoates – the salts of benzoic acid
• Sorbates – sorbic acid and its three mineral salts, potassium sorbate, calcium sorbate and sodium sorbate
• Propionates – the salts of propionic acid
• Nitrites – the salts of nitrous acid

Antioxidants inhibit oxidation:

• Sulfites – a group of compounds containing charged molecules of sulfur compounded with oxygen, including sodium sulfite, sodium bisulfite, sodium metabisulfite, potassium bisulfite and potassium metabisulfite
• Vitamin E (tocopherol) – a fat-soluble vitamin
• Vitamin C (ascorbic acid) – a water-soluble vitamin and its salts, sodium ascorbate, calcium ascorbate and potassium ascorbate
• Butylated hydroxyanisole (BHA) – a waxy solid used to preserve butter, lard, meats and other foods
• Butylated hydroxytoluene (BHT) – similar in structure and function to BHA, but in powder form

Chelating agents bind metal ions in certain foods to prevent oxidation:

• Disodium ethylenediaminetetraacetic acid (EDTA) – used in food processing to bind manganese, cobalt, iron or copper ions
• Polyphosphates – used as anti-browning agents in dips and washes for peeled fruits and vegetables
• Citric acid – found naturally in citrus fruits

All preservatives added to food products must be declared on the ingredient list on the food label using common names of ingredients. When no such name exists, synthetic forms can be listed. For example, synthetic vitamin B9 can be listed as “folic acid.” Preservative ingredients must either be identified as a preservative or the specific function must be given, such as “sorbic acid (to retain freshness).”

Oversight

The FDA has jurisdiction over all preservatives, with the Food Safety and Inspection Service sharing responsibility for the safety of food additives used in meat, poultry and egg products. The FDA mandates that preservatives not be used in such a way as to conceal damage or inferiority, make the food appear better than it is or adversely affect the nutritive value of the food. Food additives approved for use as preservatives are listed in the U.S. Code of Federal Regulations.

Safety

According to the regulatory authorities, preservatives are generally recognized as safe, or GRAS, in the quantities in which they are allowed in individual food products. “Safe” for food additives is defined to mean “a reasonable certainty in the minds of competent scientists that the substance is not harmful under the intended conditions of use.” Still, there are some preservatives of concern.

Sodium nitrite/nitrate used in processed meats is an example of compounds that may increase the potential of these foods to cause cancer. Studies have linked eating large amounts of processed meats with an increased risk of colorectal cancer. 

Sodium benzoate and sulfites appear to be safe for most people, but may cause adverse reactions in others. A 2007 study published in The Lancet suggests sodium benzoate and artificial food colorings may exacerbate hyperactivity in young children.

Although butylated hydroxyanisole, or BHA, is listed by the National Toxicology Program as “reasonably anticipated to be a human carcinogen,” the FDA considers it a GRAS substance in minute quantities. Meanwhile, butylated hydroxytoulene, or BHT, has been banned in some countries but has not been shown conclusively to be carcinogenic.

Final Thought

To be clear, a diet awash with processed foods may contain excessive preservatives — both artificial and natural (think salt and sugar) — and should be limited. But preservatives within the context of an overall healthful diet help safeguard food and protect consumer health, neither of which are reasonable tradeoffs.

“Removing preservatives compromises food safety, and there is no good scientific reason to avoid them,” says Robert Brackett, PhD, director of the Institute for Food Safety and Health. He used nitrates as an example: “The
risk of getting botulism from processed meats far outweighs the risk of the preservative especially when consumed in moderation.”

Nonetheless, emerging technological innovations aimed at replacing traditional preservatives are in the works. Development of technologies such as high-pressure processing and ultrasonic preprocessing with pulsed light are promising — and may yield additional benefits such as reduced water usage, energy efficiency and improved food quality.

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Definition 

A food additive is a natural or synthetic (“artificial”) substance that is added to, or comes into contact with, a food during production or processing. There are direct additives — ingredients that help to preserve flavor, enhance nutrition, extend shelf-life or enhance taste, texture or appearance — and indirect additives — typically trace amounts of residues from packaging, storage or handling. 

Basic Functions 

Direct food additives may serve single or multiple functions, including preservatives used to prevent spoilage; emulsifiers and stabilizers that help keep blended ingredients from separating; anticaking agents that reduce the formation of lumps in granulated foods; humectants that help foods stay moist; thickeners that improve the texture of certain foods; and color additives used for visual appeal. Food additives also include vitamins and minerals added to replace those lost in processing (called “enrichment”) or that might not be present in the food but are lacking in most diets (called “fortification”). 

Chemical Names 

Scary-sounding names is a frequently mentioned factor in anti-additive conversations, often coupled with the suggestion that the longer the name, the less “safe” the ingredient — or that using chemical names serves to obscure transparency. In fact, chemical nomenclature is designed to prevent ambiguity. When an ingredient does not have a common name, such as “sugar,” a chemical name may be used — but that doesn’t mean the ingredient is less safe. 

Labeling 

As a rule, food labels should list the common names of ingredients. However, not all additives have succinct aliases — for example, whereas synthetic forms of vitamin B9 can be listed on a food label as “folic acid,” a synthetic vitamin B1 additive may appear as “thiamin mononitrate.” In addition, certain additives, namely preservatives, require their specific function to appear after their name, such as “sorbic acid (to retain freshness).” Furthermore, when an ingredient itself contains two or more sub-ingredients, the food label must reflect those sub-ingredients. On the other hand, some additive ingredients may be listed collectively without further specification (think “artificial flavors”) as long as they are used in quantities and purposes for which they are approved, helping manufacturers safeguard trade secrets.

Oversight

The Federal Food, Drug and Cosmetic Act, first passed in 1938, gives authority to the U.S. Food and Drug Administration to oversee food product ingredients and how they must be listed on food labels. As food technology evolved and new additives were developed, Congress passed an amendment requiring premarket approval of all new additives, or Food Additive Safety Determination. Exempt from this requirement are grandfathered substances that were already in use (called Prior Sanctioned Substances) and those that have been designated by experts in the scientific community as Generally Recognized As Safe (GRAS). Although technically GRAS substances must meet the same safety standards as approved food additives, over the decades, the GRAS process has evolved into a voluntary notification program. So if a company wants to use a new substance in its food, it can either submit it to the FDA for premarket approval as an additive or, with review from scientific experts, determine it is GRAS. The company may then move forward with using the substance in its products, and it may (but is not required to) notify the FDA of the new GRAS substance. As a result, although the FDA maintains a registry of more than 10,000 food additives — of which roughly half are direct additives and more than 600 are on the GRAS list — there is an indeterminate number (one study reported approximately 1,000) of GRAS substances about which the FDA may not have been notified. 

In 2010, a U.S. Government Accountability Office report concluded that greater oversight is needed to help ensure the safety of all new GRAS determinations, citing gaps in information about substances currently in the food supply, and address challenges to existing GRAS substances. A 2013 Pew Charitable Trusts report echoed these findings, adding criticism over conflicts of interest arising from conclusions developed by company employees and consultants, and legislative ambiguity surrounding the FDA’s actual ability to enforce compliance. The FDA responded through the issuance of a final rule in August 2016 designed to demonstrate more stringent GRAS standards — namely clarifying criteria for and documentation of all GRAS conclusions, strongly encouraging companies to work with the FDA when considering new substances.

Final Thought 

“Countless studies and hours of scientific evaluation go into the process of food substance safety review,” says Hilary Thesmar, PHD, RD, Food Marketing Institute Chief Food and Product Safety Officer. “However, practitioners with concerns about an additive should use the evidence-based analysis process to evaluate the literature in peer-reviewed journals and conduct their own risk analyses.”  

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Many individuals who are unable to eat by mouth rely on commercial formulas and may not be aware of other options. But with proper guidance, gastrostomy-fed people (who have a tube inserted into their abdomen that connects to their stomach) can have the option of making their own formula using whole foods — called blenderized feedings.

Potential Benefits

Vegetables, fruits, grains and legumes are packed with fiber and phytonutrients that are ideal for gut health. Many people who use blended feedings see a substantial improvement in their gastrointestinal function. "When people switch from commercial formulas to blended feedings, we see less abdominal bloating, nausea, reflux and retching, improved stools, better GI tolerance and, in general, they feel better and have more energy," says Atlanta pediatric gastroenterologist Stanley Cohen, MD.

In the past 10 years, Houston pediatric dietitian Kristi King, MPH, RDN, LD, CNSC, says she has observed marked improvement in her patients' GI symptoms (and quality of life) when switching to whole-food feedings. "Blended whole foods are trending in hospitals, either by using the hospital's own recipes or commercial whole-food formulas, because patients prefer it and usually tolerate it better than some other formulas," says King.

At home, eating the same meals as the family and "enjoying a variety of foods, the aromas and even burps of familiar food gives tube-fed patients satisfaction and a feeling of normalcy," says Alissa Rumsey, MS, RD, CDN, CSCS, a nutrition and wellness consultant in New York City. Most feedings are done just like meals, three to six times per day, and are administered through the gastrostomy tube using a syringe.

Another advantage of whole-food feeding is that ingredients can be customized to meet an individual's nutritional needs. This is especially important for anyone with intolerances or allergies to ingredients in commercial formulas.

While a considerable time commitment is required to prepare the feedings, there also are economic savings over most commercial formulas, especially if they are not covered by health insurance.

Possible Limitations

Risk factors associated with preparing homemade formulas include nutritional adequacy, safe food handling, tube clogging and improper administration.

Meeting nutritional needs with blended whole foods takes meticulous planning and the oversight of an expert. "One of the greatest concerns is that home feedings won't meet nutritional requirements," King says. "Careful attention to food selection, safety and handling are essential because many tube-fed people have compromised immunity."

Patients with jejunal tubes (which direct feedings into the small intestine without being digested in the stomach), fluid restrictions or on pumped overnight feedings are not good candidates for blended feedings. "Assess the caregivers and patients to make sure they have the time, knowledge and skills to manage the challenges of preparing safe and nutritionally adequate [homemade formula]," Cohen says.

DIY Formula 101

Making tube-feeding formula can be relatively easy with the right equipment. Almost any food can be liquefied with a commercial blender, and some companies offer medical and RDN discounts.

Certain foods, such as cheese, seeds, corn, nuts and stringy foods, are more difficult to blend. "Warm and cooked foods blend easiest," Rumsey says. Choose nutrient-rich foods to prepare different flavors of formulas: fruit, vegetables, grains and yogurt, or meats, grains and oils. Another option is combining homemade and whole-food commercial formulas.

Add liquids to the mixture to achieve the necessary consistency to flow through the particular size of gastrostomy tube. And flush tubes with water before and after feedings to prevent clogging.

7 Formula Blending Tips for RDNs

An ideal candidate for blended feedings is a patient who is medically stable and has a family with the ability, motivation, time and commitment to appropriately prepare the feeding. These individuals should be able to follow instructions and food safety guidelines.

RDNs must monitor patients and provide support and supervision to ensure the right materials and resources are used. While blended whole-food feedings is an emerging practice with little research and few professional standards guiding preparation and use, these tips can help promote safe preparation:

• Wear gloves, wash hands often, use separate cutting boards and wash produce thoroughly.
• Keep formulas refrigerated and discard after 24 hours.
• Jars of pureed baby food are good options to add to the blender to help meet nutritional goals.
• Raw seafood, undercooked foods and unpasteurized juice or milk are not recommended.
• Feedings are ideally administered several times a day but also can be used with a pump if the feeding is completed within two hours.
• Use healthy fats and oils, such as avocados or vegetable oils, to add calories and essential fatty acids.
• Avoid highly processed foods, such as potato chips and cookies. Vary the fruits, vegetables, grains and protein foods to provide adequate nutrition.

The post The Risks and Benefits of DIY Blended Tube Feedings appeared first on HealthStylz.

Vitamin D has two forms that are relevant to human health: vitamin D2 (produced by some plants) and vitamin D3 (synthesized when skin is exposed to ultraviolet rays). Its primary role is in the regulation and absorption of calcium and phosphorus. Rickets in children and osteomalacia, osteopenia and osteoporosis in adults are the most well-established consequences of vitamin D deficiency.

In addition, hundreds of studies over the past 15 years underscore interest in vitamin D's potential role in risk reduction of other diseases, including some cancers, heart disease, stroke, diabetes, autoimmune diseases, infectious diseases, neurocognitive disorders and mortality. While much of this research is ongoing and may provide more definitive answers in the future, the current general consensus is that — with the exception of bone health — the relationship between vitamin D and other health conditions is still unclear.

However, there is little consensus as to what constitutes vitamin D deficiency and optimal intake.

What Is the Recommended Intake of Vitamin D?

Vitamin D status is assessed through a simple blood test and measured as nanograms of 25-hydroxy vitamin D per milliliter of blood, or ng/ml. Depending on who you ask, sufficient levels range between 20-50 ng/ml and 40-80 ng/ml, while recommended intakes for adults are as low as 600 IU per day and as high as 5,000 IU per day.

Where experts do agree is that most American adults fall short in the vitamin D department. At particular risk are overweight or obese individuals or those who have undergone gastric bypass surgery, older adults, people with limited sun exposure and people with inflammatory bowel disease or other conditions causing fat malabsorption. Identified as “an underconsumed nutrient” in the 2015-2020 Dietary Guidelines for Americans, achieving adequate vitamin D intake from food alone may be challenging. There is a relatively limited number of foods rich in vitamin D — the best sources being fatty fish such as salmon, sardines, trout, mackerel and tuna, in addition to fish liver oils. In fact, most dietary vitamin D comes from fortified foods such as milks, juices and breakfast cereals.

While some sources advocate sensible sun exposure for vitamin D production, exposure without sunscreen to block UV rays poses an increased risk of skin cancer — although this potentially could change pending the release of vitamin D-friendly sunscreen products.

In the meantime, supplemental vitamin D may be necessary to fill nutrient gaps. Vitamin D3, which is made in part from sheep's wool, is the preferred form because it is more efficiently converted in the liver to the form the body uses than vitamin D2 (which is commonly found in medical prescriptions but is harder to measure in blood). When counseling vegan clients, however, RDNs should recommend vitamin D2 supplements. Supplements can be taken daily, weekly or monthly, and many health-care providers recommend starting with a higher dose, then reducing after a month or two and continuing with a maintenance dose. Multivitamins also may provide some vitamin D — typically 400 IU, but with a range between 200 IUs and 10,000 IUs.

Vitamin D Toxicity

Whereas safety concerns often abound with high levels of fat-soluble vitamins, vitamin D appears to be the exception. Vitamin D toxicity, one of the rarest medical conditions, is typically due to extremely high doses of 50,000 IU daily but can occur at as low as 10,000 IU per day. The tolerable upper intake level is 4,000 IU for adults. “Too much vitamin D can increase calcium levels, which can lead to calcification of kidneys and blood vessels, high blood levels of calcium and phosphorus usually occurring when serum levels reach 200-250 ng/ml,” says Michael Holick, PhD, MD. “When toxic levels are reached, consequences disappear once the supplement is discontinued unless the toxicity has persisted for long periods of time.”

The post What Is the Optimal Intake of Vitamin D? appeared first on HealthStylz.

The answers may not be so clear-cut. Historically, gluten was thought to pose problems only for the 1 percent to 2 percent of the population who suffer from autoimmune celiac disease, for which the cornerstone of treatment is a strict gluten-free diet. But emerging research suggests there is a spectrum of non-celiac gluten-related disorders that improve when gluten is removed from the diet.

"Celiac-Lite"

For years, gastroenterologists and researchers have been trying to understand the role of gluten in non-celiac conditions. In 2012, celiac researchers coined the term "non-celiac gluten sensitivity," or NCGS, for individuals who present with symptoms similar to celiac disease and say they feel better on a gluten-free diet. "Roughly 6 percent of the population suffers from NCGS, which pre NCGS, which presents as a trigger to gluten with a possible presence of gluten immune-reaction," says Alessio Fassano, MD, director of the Center for Celiac Research at MassGeneral Hospital for Children in Boston.

Sometimes referred to as "celiac-lite," NCGS is a form of gluten intolerance that does not meet diagnostic criteria for celiac disease or other related conditions, such as wheat allergy, and does not cause inflammation or damage to the small intestine. NCGS is a rapidly growing diagnosis, despite not having an established definition and being a controversial topic that is not well-understood.

"Gluten sensitivity is an understudied area that appears to be a gluten-induced activation of an innate, rather than adaptive, immune-mediated reaction to gluten that does not always occur in the same way when eating gluten," Fassano says.

Variability among patients, the lack of definitive biomarkers and inconclusive studies have hindered progress in identifying NCGS. However, a few studies have offered some insight into the condition. A small Australian study published in 2011 was among the first to show gluten could induce symptoms in non-celiac patients. A well-conducted study using a double-blind, placebo-controlled design found NCGS exists in specific clinical conditions, including 5 percent to 20 percent due to irritable bowel syndrome.

Researchers at the National Institutes of Health recently published a study corroborating these findings. The study population consisted of a group of 59 participants who believed they suffered from NCGS. They were given less than 5 grams of gluten or a placebo in pill form for one week. Participants taking the gluten pills reported a significant difference in symptoms compared to those taking placebo pills after just one week.

However, research published in 2013 suggests that gluten alone may not be responsible for the symptoms. The same Australian researchers conducted a follow-up study that challenged the findings of their earlier study. Only 8 percent of the participants improved on gluten-free diets, yet all of the participants had significant improvements on a low fermentable oligosaccharides, disaccharides, monosaccharides and polyols, or FODMAP, diet. These results indicate the possibility that the positive effect was due to removing FODMAPs — not gluten.

Detecting Gluten Sensitivity

Sensitivity to gluten appears to occur at any age and to people who have previously tolerated gluten. "Gluten triggers a biological response in everyone, yet not everyone gets sick when eating gluten," Fassano says. Without biomarkers to confirm NCGS, it is considered a diagnosis of exclusion. The only way to identify NCGS is to rule out other related conditions and demonstrate both improvement when gluten is removed and recurrence of symptoms when gluten is reintroduced.

Celiac disease is a serious condition that must be ruled out first, after which other potential causes within the spectrum of gluten-related disorders should be considered. A diagnosis of NCGS can only be made when celiac disease and other related conditions are adequately excluded. Testing for celiac disease requires a celiac blood test and biopsy samples from multiple areas of the intestine, including the duodenal bulb. Consumption of gluten is essential for accurate results. Going on a gluten-free diet beforehand can mask the results of the tests and result in an inaccurate diagnosis, which many experts suspect is why celiac disease is dramatically underdiagnosed.

NCGS is a condition typically characterized by gastrointestinal symptoms (diarrhea, abdominal discomfort, pain, bloating and flatulence) or extraintestinal symptoms (fatigue, headache, brain fog and lethargy) that occur after gluten ingestion and improve after gluten is removed from the diet. Undigested gluten can act like a foreign invader, irritating the gut and the microvilli within the intestine, leading to decreased absorption of nutrients.

“Celiac disease can be a challenge to diagnose, with up to 50 percent of people presenting without any gastroenterology symptoms,” says Shelley Case, RD, author of Gluten-Free Diet: A Comprehensive Resource Guide (9th edition due in fall 2015, self-published). Many patients present with anemia due to reduced iron absorption.”

Non-Celiac Gluten-Related Disorders

Only a fraction of the patients who report NCGS have a gluten-related condition. When it is not celiac disease or NCGS, experts consider FODMAP intolerance. Fermentable sugars may be poorly digested in some people, causing discomfort, gas and bloating — symptoms similar to those of NCGS and other gastrointestinal conditions. Food intolerance occurs either when the body lacks a particular enzyme needed to digest nutrients, nutrients are too abundant to be completely digested or a particular nutrient cannot be properly digested.

Following a low-FODMAP diet can be more challenging than a gluten-free diet and requires the guidance of a registered dietitian nutritionist. The elimination diet limits fructose (fruits and vegetables), lactose (dairy), fructans (wheat, rye barley, onions, garlic and leeks, for example), galactans (some legumes, broccoli and cabbage) and polyols (types of sugars). Most people with a FODMAP intolerance are able to identify which foods are problematic and gradually add back the ones that are well-tolerated.

Since fructans include the gluten-containing grains wheat, rye and barley, people intolerant to FODMAPs show some signs of improvement on a gluten-free diet, but it may only be temporary. A hydrogen breath test is an effective diagnostic tool used to help distinguish food intolerances from NCGS.

A wheat allergy, which affects less than 1 percent of adults in the U.S., is another cause of these problematic symptoms. Food allergies are very specific immune system responses involving either the immunoglobulin E, or IgE, antibody or T-cells reacting to a particular food protein. Wheat allergy differs from celiac disease and NCGS, and therefore the body reacts differently.

An allergic immune response to wheat can lead to a variety of symptoms, including swelling, itching, skin rash, nasal congestion and tingling or burning of the mouth. People with wheat allergies are allergic to a wheat protein, not necessarily gluten, and can tolerate gluten-containing barley and rye.

Many people feel better when they remove gluten, but it may not be due to a specific food allergy or intolerance. "The number of people going gluten-free vastly outnumbers the number of people who truly have a biological problem tolerating gluten,” says Mayo Clinic gastroenterologist Joseph Murray, MD. “Some people feel better when gluten is eliminated for many reasons — including the placebo effect, they eat less, their diet is healthier, they believe it is better for them — and when they return to their old diets, they start feeling bad.”

Potential Causes for Gluten Sensitivity

There is no evidence indicating an increase in gluten sensitivity over the last 35 years, but rather a lot of media attention, Murray says. The prevalence of NCGS in the general population is unknown, largely because many people are self-diagnosing and adopting a gluten-free diet without medical advice or consultation. NCGS does not appear to be genetically based, unlike celiac disease, which has a fairly well-established pathogenesis. The cause of NCGS is not well-understood and may be different for individual patients. It has been hypothesized that symptoms may be a result of impaired intestinal mucosa barrier function or related to an innate immune response to gluten. Whether it is actually the gluten or a component in the grain that is responsible for the symptoms remains under scrutiny.

“New varieties of wheat, wheat hybridization and quality of grains that have been introduced over the past 40 years have been ruled out as causing an increase in the condition,” Fassano says. “Individuals may be predisposed to NCGS. It does not appear to be related to the timing of introduction of grains, nor does breastfeeding appear to be protective.”

In an attempt to unscramble the gluten puzzle, emerging research takes a closer look at how the microbiome may be affected by genetics, the environment and the immune system. The microbiome, a community of microorganisms in the human digestive tract housing good and bad bacteria, has been of particular interest in recent research. (Even Hippocrates believed that all diseases begin in the gut.) The microbiome is inherited from the mother, is extremely dynamic, varies among individuals and changes in the same individual over time.

Beyond genetics, nutrition is one of the most influential factors in the microbiome that may offer protection. “Babies born vaginally, consuming balanced diets and with minimal infections and antibiotics in the first few years of life establish a healthy gut and microbiome that is protective and likely lowers risk for developing diseases,” Fassano says. “On the other hand, when the microbiome is trained inappropriately, the risk for disease is greater and may be a secondary factor explaining NCGS.”

Why RDNs Are Fundamental to Success

NCGS is a growing problem encountered in clinical practice, yet is difficult to diagnosis and a challenge to manage in the absence of diagnostic markers. Whether gluten removal, wheat exclusion or a low-FODMAP diet, a carefully executed process of trial and error is required with elimination diet plans. Food diaries, in which clients record everything they eat and drink and any symptoms that follow, are especially helpful.

However, relying on what people report or anecdotal observations are subjective and open to misinterpretation. “Double-blind food challenges are the most accurate way to determine NCGS,” Murray says. No evidence-based guidelines exist for reintroduction of gluten-containing foods; it is dependent upon the level of sensitivity. Reintroducing gluten is best done when the patient feels better and with simple foods, such as matzo or soda crackers, which are pure wheat.

Gluten reintroduction is a risk-versus-benefit decision and should be highly individualized to the patient. “Unlike celiac disease, there is no damage to the small intestine, so consuming small amounts of gluten goes without incident,” Murray says. When removing gluten is effective, there could be a threshold of tolerance that allows some gluten in the diet. When it is ineffective, Case recommends trying a low-FODMAP diet.

RDNs may have been skeptical about NCGS initially, but it has proven to be an excellent opportunity to assume a leadership role in the diagnosis and care of patients. “Asking the right questions, doing a detailed diet history and overseeing gluten elimination and challenges are where dietitians can play an essential role,” Case says. “Dietitians are having great success treating NCGS patients, and unless we embrace and treat these conditions, patients will seek alternative practitioners.”

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