by Divya kakaiya, PhD

Almost everyone wants to lose weight and drop thatextra 5 or 10 pounds. But some people take that desire to extreme measures and will literally starve themselves to be thinner. While we usually associate eating disorders with sedentary clients, the truth is that more and more elite athletes are falling prey to unhealthy eating and exercise behaviors. Society admiresthe willpower, dedication and perseverance that athletes demonstratein perfecting their sports. We tend to place elite athletes on the highest pedestal of celebrity, showering them with praise and respect. Yet, it is very easy for these athletes to get disconnected from the body in the extreme pursuit of perfection and athleticism.

Considerable evidence exists that competitive athletes in certain sports are at greater risk for developing disordered eating and eating disorders than the general population. For a good majority of the population, sports participation provides a healthy, enjoyable experience that helps build self-esteem and a feeling of mastery (Fulkerson et al. 1999) and can lead to a strong body image. However, some people who participate in sports—especially sports that equate leanness with enhanced performance—are more likely to start a pattern of disordered eating behaviors, which can ultimately progress to a dangerous eating disorder.

PREVALENCE OF EATING DISORDERSIN ATHLETES
So how prevalent are eating disorders among athletes? In a largescale study of 1,445 Division I NCAA student athletes (Johnson, Powers & Dick 1999), many of the female athletes reported attitudes and symptoms that placed them at risk for anorexia nervosa or bulimia nervosa. Although no females met the American Psychiatric Association's (APA) criteria for anorexia and only 1.1% met the criteria for bulimia, 2.85% were identified as having a clinically significant problem with anorexia and 9.2% as having a clinically significant problem with bulimia. There may have been others whose symptoms were not serious enough to be considered"clinically significant." Also, more than 10% of the females reported binge eating on at least a weekly basis. There was little to no evidence of clinically significant problems with anorexia or bulimia in males, but 13.02% of males reported binge eating at least once a week.

The researchers theorized that the rates of eating disorder thoughts and behaviors would be even higher among less elite, Division II athletes and also thought that some athletes in the study might have minimized their symptoms to protect their schools' athletic departments.

Although most athletes with eating disorders tend to be female, males are at growing risk—especially those who compete in sports that place a high emphasis on diet, appearance, size and weight requirements. Examples of these sports for men include wrestling, bodybuilding, crew, running (cross-country and track), football and horse racing.

Another group of researchers conducted a meta-analysis of 34 studies involving the relationship between sports participation and eating problems (Smolak, Murnen & Ruble 2000). They found that while sports can be a positive experience for some athletes, the same activities can constitute a risk factor for others. The implication of these findings is that it is not the sport per se that creates the risk for the athlete, but rather certain aspects of the sport and/or the sport environment. Put simply, there are particular personality variables that predispose an athlete to developing an eating disorder, and specific sport environments seem to create additional risk.

TYPES OF EATING DISORDERS
Eating disorders are severe medical conditions that tend to become chronic if left untreated. These illnesses can be triggered or exacerbated by a number of factors, such as genetics, the environment and life events. Anorexia, bulimia and, particularly, exercise addiction can go undetected and undiagnosed for years.

Eating disorders typically begin with disordered eating and a disordered relationship to the body. Think of the behavior as a continuum, with disordered eating at one end and full-blown eating disorders at the other (riskier) end. The most common eating disorders include anorexia nervosa, bulimia nervosa and a third category called"eating disorders not otherwise specified." Also, the APA's Diagnostic and Statistical Manual of Mental Disorders IV-TR now includes criteria for binge eating disorder, a condition that is finally receiving appropriate recognition. The next sections will describe the different types of eating disorders, their prevalence rates and how fitness professionals can recognize the emergence of an eating disorder.

ANOREXIA NERVOSA
Anorexia nervosa typically begins in adolescence and often persists into adulthood. A popular myth is that a diagnosis of anorexia is made only if a person has stopped eating completely. The truth is that patients with anorexia lose weight by restricting their food intake and exercising excessively; a subgroup of anorexics will also induce vomiting after meals. Some of these patients will go on to abuse laxatives and/or take diet pills.

Approximately 90%–95% of patients with anorexia are female (Bulik et al. 2006). Even though the prevalence rates for men are much lower, males exhibit the symptoms of anorexia in the same way as women do. There are two critical time periods when anorexia tends to manifest: at age 13–14 or at age 17–18 (Yager & Powers 2007). Puberty and menopause are also periods that can pose a very high risk for developing anorexia.

The personality characteristics associated with anorexia include emotional restraint, rigidity, perfectionism and obsessiveness. People who develop anorexia usually take comfort in routines and do not like change. When one compares the traits of a "good athlete" with those of an anorexic client, there are a number of similarities (Thompson & Sherman 1999). A"good athlete" manifests mental toughness, a commitment to training, pursuit of excellence,"coachability," unselfishness and performance despite pain. People with anorexia are likewise given to excessive exercise, perfectionism, overcompliance, selflessness and a denial of discomfort. Since these traits are so similar, it is easy to see why a "good athlete" becomes an ideal candidate for developing anorexia. (For more information on signs of anorexia, see “Symptoms of Common Eating Disorders” sidebar.)

Anorexia tends to be most prevalent in nations where food is abundant and society places importance on a thin body ideal. The condition cuts across all socioeconomic lines and most ethnicities. Anorexia is slightly less common among African Americans, as compared with Caucasians, Hispanics and Asian Americans (Yager & Powers 2007).

The medical complications of anorexia are severe and can negatively affect the heart, endocrine system, skeleton, reproductive system, gastrointestinal system, kidneys and even the grey matter mass in the brain. According to the American Psychiatric Association, people with anorexia tend to feel cold all the time; suffer from severe constipation; fail to have regular periods; develop extremely dry skin, sometimes with a yellowish cast; and have brittle skin and nails (APA 2008).

BINGE EATING DISORDER
Binge eating disorder (BED) is characterized by recurrent binge eating. An episode of BED is defined as having two main characteristics: (1) eating more food within a 2-hour period than the average person within the same time period; and (2) feeling a lack of selfcontrol during the episode. People who suffer from BED often exhibit a tremendous amount of distress about overeating. To compensate, they eat more rapidly than normal; continue to eat until they feel uncomfortably full; eat large amounts in the absence of hunger; eat in secret out of embarrassment; and feel disgusted, depressed and guilty after eating. (For more information on signs of BED, see "Symptoms of Common Eating Disorders" on page 48.)

People with BED can be of normal weight, but most tend to be overweight and have repeatedly failed at dieting attempts in the past. As with anorexia and bulimia, BED is more common among women than among men. Interestingly, the prevalence of BED among people involved in weight loss programs is as high as 20%–30% (Spitzer et al. 1992). BED is present in all ethnic groups, with no one sub group showing a higher density (Yager & Powers 2007).

The medical complications of BED are similar to the complications associated with being overweight and obese. These include hypertension, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and cancer (Bulik et al. 2003). In one large study of twins, researchers reported that obese subjects with BED tended to have more health problems and were also significantly more likely to demonstrate dissatisfaction with their health than obese subjects without BED (Bulik et al. 2003).

For athletes with suspected BED, it can be helpful to isolate the specific factors that appear to trigger the eating binges. Fitness professionals who are aware that a client's excessive exercise is due to the shame of binge eating should aim to make the client comfortable in the fitness setting and—while always staying within scope of practice—should initiate a discussion about positive body image. Keep in mind that a history of failed dieting attempts tends to make individuals with BED very resistant to committing to a fitness goal. So an initial goal could be to learn more about nondieting approaches to weight loss or to slowly start out walking for just 10 minutes a day.

EXERCISE ADDICTION
As fitness professionals, we often encourage clients to eliminate their stress by exercising regularly. The problem is that for some people, exercise becomes their only means of releasing tension. The addiction to exercise creeps in very insidiously, and one can quickly become dependent on the natural "high" that follows a workout.

Exercise addiction is one of the most difficult conditions to reverse, since people experience so many positive gains from exercising. Most athletes and regular exercisers will report an increase in symptoms of depression when they haven't exercised for a few days. The withdrawal from exercise can be especially challenging because of the resultant depression. It is no wonder that most people who are addicted to exercise often report that they feel like "jumping out of their skin" when exercise is taken away from them.

If a client is suspected of having an exercise addiction, the best course is to slowly wean him off his fitness program, since it is often his only outlet for stress release. It is helpful to find opportunities for the client to learn how to develop better coping mechanisms that are less destructive. Depending on the individual, a referral to an allied health professional may be appropriate.

WHICH ATHLETES ARE AT RISK?
A number of factors predispose an athlete to developing an eating disorder. Risk factors include the following:
• pressure from influential people (coaches or parents) to lose weight to improve sports performance
• overinvolvement in sports, with limited other social and recreational activities
• training even when sick or injured
• training outside of scheduled practice times or more than other athletes on the team
• a traumatic event
• injury
• poor performance
• a change in coaching personnel (Sundgot-Borden 1994; Williamson et al. 1995)

The type of sport can also pose a risk to athletes. For example, involvement in any of the following activities can increase the risk:
• sports that emphasize body appearance (e.g., gymnastics, cheerleading, synchronized swimming, ballet)
• sports that focus on leanness, endurance and "weight class"
• sports that involve judging rather than refereeing (e.g., diving, figure skating, synchronized swimming, gymnastics)

Men are at highest risk for eating disorders when they participate in sports with a huge subculture of "weight cutting" (i.e., dropping weight quickly to qualify for a meet) to achieve a competitive edge; two examples are track and field and wrestling. Lightweight rowing also puts boys and men at high risk of developing disordered eating, extreme weight loss behaviors or eating disorders. Finally, sports such as swimming that require male or female athletes to wear revealing clothing can create an unhealthy body focus.

Some athletes tend to engage in competitive thinness and compare themselves with rivals who are thinner than them. This is especially true if the thin competitors are better performers, since this can provide the rationale for losing weight in harmful ways. Revealing uniforms tend to increase the likelihood of competitive thinness, because such attire encourages and facilitates unhealthy body comparisons.

HELPING ATHLETES WITH EATING DISORDERS
So how can you apply this research on athletes and eating disorders to your own clients who engage in sports? Within the fitness environment, some clubs are hot breeding grounds for competitive thinness, whereas other facilities value diversity of size. How can you ensure that your club is the latter and not the former?

Often, fitness instructors and personal fitness trainers proudly display their hard-earned bodies by wearing revealing attire. The trouble is, many clients may be using your body type as the ultimate model to which they aspire. So make it a policy to wear neat, professional, but not overly revealing clothes.

For many individuals with eating disorders, the fitness center is the place that motivates them to maintain their rigorous, demanding exercise regimens. Onsite staff—and other fitness professionals—should know how to recognize when a client has crossed the line from healthy exercise to exercise addiction.

Of course, it is not within fitness professionals' scope of practice to diagnose or treat eating disorders. However, you do have many opportunities to interact with people suffering from these disorders and you can provide education or resources if clients approach you. (See "Resources" sidebar for useful websites and books by experts.) Individuals with eating disorders use fitness facilities to further their aim of weight loss. Their compulsion can be evidenced by the rigidity with which they train and the fact that they keep going beyond the fitness goals they have set. Since athletes tend to have the same drive to excel as compulsive exercisers have, it can be difficult to differentiate between the two. By not fully recognizing what's behind a client's drive to constantly work out and strive to lose weight, you might actually expedite the pace of an eating disorder without even realizing it. But by remaining vigilant, you can become part of the solution, even if you cannot directly intervene to assist a client whom you suspect of having a disorder.

NEW GUIDELINES FOR FITNESS PROFESSIONALS
Very few studies have assessed how fitness professionals view eating disorders, be it their own disordered relationship with food and exercise or that of their clients.

However, all that may change with a study that is scheduled for publication in the March–April 2008 issue of Eating Disorders: The Journal of Treatment and Prevention (Manley, O'Brien & Samuels, in press). The goal of this new study was to determine what fitness professionals do when they suspect a client has an eating disorder and to assess the ethical and liability issues of such a situation.

The researchers surveyed fitness instructors and pediatricians as to how they would handle a described case involving a client with suspected anorexia. The researchers found that 32% of fitness instructors suspected that the client had anorexia, compared with 88% of the pediatricians, a statistically significant difference. Of the fitness instructors, 60% recognized that there wereethical and liability issues to consider, and 37% considered these issues to be serious in nature. Tellingly, all of the fitness instructors suggested that guidelines in this area would be most helpful. One specific issue the instructors wanted clarification on was whether it was okay to refuse to allow a client with a suspected eating disorder to attend their class.

The implications of this latest piece of research are profound for fitness professionals. Although it can be argued that diagnosing and treating eating disorders is not the role of trainers or instructors, it is certainly within their capacity to recognize warning signs of what are potentially severe medical conditions. One option that is highly effective is to create a "sport management" team in which a group of professionals (consisting of the fitness pro, a physician, a psychologist and a registered dietitian) work in collaboration to help clients. In this scenario, fitness professionals could receive some specialized training from other team members on working with clients with eating disorders and exercise addiction.

DRAWING CONCLUSIONS
A fitness professional can and should learn to work effectively with eating disordered or exercise-dependent athletes. But in order to succeed in this venture, it is imperative that you first honestly examine your own issues in regard to exercise, diet and the role that both play in your life. Understanding what motivates people with eating disorders and exercise addiction can help you facilitate a healthy, balanced lifestyle for these special clients.

Divya Kakaiya, PhD, CEDS, is the clinical director and owner of Health Within Inc., an outpatient program for individuals with eating disorders and body image concerns, based in San Diego. She is a nationally recognized clinician, author and presenter in the field of eating disorders and has developed specialized programs for athletes with eating disorders. She can be reached at www.healthywithin.com.

References
American Psychiatric Association. 2008. Let's talk facts about: Eating disorders. www.healthyminds.org; retrieved Jan. 14, 2008.
Bulik, C.M., et al. 2003. Twin studies of eating disorders: A review. International Journal of Eating Disorders, 27 (1), 1–20.
Bulik, C.M., et al. 2006. Prevalence, heritability and prospective risk factors for anorexia nervosa. Archives of General Psychiatry, 63 (3), 305–12.
Fulkerson, J.A., et al. 1999. Eating-disordered behaviors and personality characteristics of high school athletes and nonathletes. International Journal of Eating Disorders, 26 (1), 73–79.
Hudson, J.I., et al. 2007. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61 (3), 348–58.
Johnson, C., Powers, P.S., & Dick, R. 1999. Athletes and eating disorders: The national collegiate association study. International Journal of Eating Disorders, 26 (2), 179–88.
Manley, R.S., O'Brien, K.M., & Samuels, S. (in press). Fitness instructors' recognition of eating disorders and attendant ethical/liability issues. Eating Disorders: The Journal of Treatment & Prevention, 16, slated for publication in Mar.-Apr. 2008.
Smolak, L., Murnen, S.K., & Ruble, A.E. 2000. Female athletes and eating disorders: A meta-analysis. International Journal of Eating Disorders, 27 (4), 371–80.
Spitzer, R.L., et al. 1992. Binge eating disorder: A multisite field trial of the diagnostic criteria. International Journal of Eating Disorders, 11 (3), 191–203.
Sundgot-Borgen, J. 1994. Risk and trigger factors for the development of eating disorders in female elite athletes. Medicine & Science in Sports & Exercise, 26 (4), 414–19.
Thompson, R.A., & Sherman, R.T. 1993. Helping Athletes With Eating Disorders. Champaign, IL: Human Kinetics.
Williamson, D.A., et al. 1995. Structured equation modeling of risk factors for the development of eating disorder symptoms in female athletes. International Journal of Eating Disorders, 17 (4), 387–93.
Yager, J., & Powers, P.S. (Eds.) 2007. Clinical Manual of Eating Disorders.Washington, DC: American Psychiatric Publishing Inc.

© 2008 by IDEA Health & Fitness Inc. All rights reserved. Reproduction without permission is strictly prohibited.

Resources
Websites
www.edreferral.com (website for eating disorder professionals)
www.gurzebooks.com (eating disorder resource catalog for books)
www.healthywithin.com (eating disorder treatment center in San Diego)
www.nationaleatingdisorders.org (information for professionals, as well as prevention ideas)
www.somethingfishy.org (resources and testimonials of recovery)

Books
Life Without ED by Jenni Shaefer (McGraw-Hill 2004).
Body Wars: Making Peace With Women's Bodies by Margo Maine (Gurze Books 2000).

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By Natalie Digate Muth, MPH, RD

There seems to be a new food scare every day. Headlines blare: Multistate outbreaks of Salmonella associated with raw tomatoes! Chili sauce linked to botulism cases! Local stores recall beef patties in fast-food restaurants!

Food-borne pathogens cause about 76 million illnesses among unsuspecting Americans each year, leading to 325,000 hospitalizations and 5,000 deaths (Mead et al. 1999). Extensive outbreaks are exposing huge flaws in theU.S. food safety check-and-balance system. Recent high-profile cases illustrate the nation's vulnerabilities in areas ranging from how our produce becomes infested with E. coli and other contaminants to the risk posed by foods imported from other countries or tainted by terrorists.

A combination of outdated laws, questionable oversight and potentially deadly consequences has made food safety a hot-button issue. Even one of the agencies responsible for food safety recently issued a report saying it could no longer perform its mandate owing to woefully inadequate resources.

So what is a consumer to do to avoid food-borne illness when purchasing, preparing or eating food at restaurants or at home? One way is to stay informed about the dangers and know how to minimize the risks for you and your family.

America's Food Safety Risk
In the United States, the weighty job of food safety oversight is split mostly among three agencies: the U.S.Department of Agriculture (USDA), which regulates meat products; the Food and Drug Administration (FDA), which oversees produce and seafood; and the Centers for Disease Control and Prevention (CDC), which monitors and controls outbreaks of food-borne illnesses.

However, many other agencies play some role in food safety: according to the National Academy of Sciences, “at least a dozen federal agencies implementing more than 35 statutes make up the federal part of the food safety system” (Institute of Medicine and National Research Council 1998). Food safety threats stem from abroad and from home, further straining the government's regulatory and oversight capabilities.

The Import Safety Net
The U.S. imports $2 trillion worth of goods each year (Merle 2007). The FDA, tasked with overseeing the importation of seafood, fruits and vegetables, inspects only about 1% of incoming shipments (Merle 2007). Total imports from China, a country well known for its toxic food products, were expected to reach $341 billion in 2007, up almost 25% from 2006 (Merle 2007). That means a lot of potentially tainted food is now entering the U.S. food supply.

When the FDA perceives a risk to be particularly high, it issues an "import alert," meaning every food shipment is supposed to be held until it passes a laboratory test. For example, the FDA issued such an alert about Chinese seafood because of the high risk of contamination from banned drugs and chemicals. Unfortunately, the associated Press discovered that 1 in 4 shipments of the suspect seafood got to grocery store shelves and dinner plates without having been tested (Pritchard 2007). This shows that even when the risk is high, gaping holes exist in the nation's safety net.

Consider the vulnerability of produce imports. Consumer demand for year-round access to fruits and vegetables has contributed to increased importation of these items. Research from the Center for Science in the Public Interest (CSPI) indicates that about 13% of food-borne illness outbreaks and 21% of foodborne illnesses result from contaminated produce, such as lettuce, salads, melons, sprouts and tomatoes (DeWaal 2007b). While some of the contamination comes from domestic produce, fruit and vegetable imports from areas with substandard hygiene practices have sickened thousands of Americans—notably, those who ate Cyclospora-contaminated raspberries grown in Guatemala or strawberries infested with hepatitis A from Mexico.

The Risk at Home
Not all food safety risks stemfromforeign countries. Last year, a Consumer Reports study found that 83% of fresh, whole broiler chickens purchased throughout the U.S. were contaminated with Campylobacter or Salmonella (Consumer Reports 2007). That was up from 49% in 2003. It didn't matter if the chickens were organic or raised without antibiotics; in fact, those chickens were actually more likely to harbor Salmonella.

USDA inspectors are supposed to check animal carcasses at each plant and reject those with visible fecal matter, defects or any signs of illness. Meat and poultry are supposed to be inspected daily. But still, too much infected meat gets through these safety checks (Consumer Reports 2007).

Despite numerous recent domestic-produce “outbreaks,” the industry is still mostly unregulated. In the wake of 14 outbreaks linked to lettuce and tomatoes in 2004, the FDA sent a letter to firms that grow, pack or ship the implicated products and asked them to “review their current operations.” After yet another lettuce outbreak, the FDA targeted its letters to California lettuce growers “recommending” actions to ensure safety (DeWaal 2007b). Clearly, the FDA lacks the authority (and nowadmits it lacks the resources) to mandate changes.Thus, as long as recalls are voluntary, companies are allowed to continue selling suspect produce.

The CSPI has urged the FDA to adopt mandatory restrictions to improve produce safety. Suggested restrictions include the following:
• manure control to prevent contamination of crops
• regular assessment of water quality at food-processing plants
• strict hygiene practices
• mandatory sanitation procedures
• clear marking of packaging so the sources of fruits and vegetables can be easily traced in an outbreak (DeWaal 2007b)

A sparse budget limits the FDA's ability to enforce such suggestions. Inspections by the agency have declined 81% since 1972; the number of field staff has decreased 12% since 2003; and inspections are down 47% since 2003 (DeWaal 2007a). Processed-food facilities may see an FDA inspector only once every 5–10 years. And it's really no wonder considering the agency's scant resources.

In 2006 the FDA experienced a funding shortfall of $135 million, equivalent to about a 24% budget cut (DeWaal 2007a). While the agency oversees about 80% of the food supply, it gets about 20% of the funding for food safety. And it's not projected to get better: the 2008 budget allows for only $10.6 million in new food safety dollars for the FDA, whereas the USDA, which oversees about 20% of the food supply, is allocated $104 million for food safety (DeWaal 2007a). Drastic changes in FDA food surveillance in 2008 seem highly unlikely.

The Risk of Terrorism
Beyond the threat of unintentional contamination, the U.S. faces the risk of food terrorism. According to theWorld Health Organization (WHO), “the malicious contamination of food for terrorist purposes is a real and current threat” (WHO 2002). Acknowledging that risk, in 2003 the FDA evaluated the nation's vulnerability to a terrorist act against our food supply.According to the agency's report, U.S. troops had discovered hundreds of pages of U.S. agricultural documents translated into Arabic when searching caves in Afghanistan. The FDA concluded that there was a high likelihood the U.S.would face an act of agroterrorism (FDA 2003).

A separate study by the RAND National Defense Research Institute noted the following U.S. vulnerabilities:
• highly crowded breeding and rearing conditions for livestock, which heightens the potential that an epidemic could spread and which limits ability to recognize unusual behavior in an individual animal
• overuse and misuse of antibiotics, which increases livestock susceptibility to disease
• insufficient farm and food-related security and surveillance
• inefficient reporting of disease by livestock producers
• lack of veterinarians trained to recognize and treat unusual livestock diseases (RAND 2003)

The RAND study authors recommended severalmeasures to decrease the impact of an agroterrorism attack, including modification of vulnerable food and agriculture practices; education and training; monitoring programs to track disease; intelligence measures; public awareness and outreach programs; stockpiling of vaccines and pharmaceuticals; and early-containment procedures (RAND 2003).

No matter whether the risk comes from outside or inside the United States, theWHO suggests that measures for managing both intentional and unintentional outbreaks of food-borne illness be the same: sensible precautions and strong surveillance and response capacities (WHO 2002).

Current Food Safety Laws
The U.S government recognizes that changes are necessary to improve food safety. It recently created a panel to review import safety and called for federal agencies to do a better job of coordinating oversight and sharing information.Although the government recommended an increased focus on identifying risky imports, it fell short of suggesting any of the sweeping changes currently under debate in Congress.

Looking forward, the pending Safe Food Act of 2007 is a House initiative that would establish a Food Safety Administrationto administer and enforce food safety laws. The Act would require the administration to take these steps:
• Implement a national food safety programwith particular focus on the hazards associated with inherent risks and processing of particular foods.
• Establish standards for food processing and food establishments.
• Establish a certification system for foreign governments.
• Create requirements for tracing animals frompoint of origin to retail sale.
• Maintain an active surveillance system.
• Establish a system to monitor contaminants in food.
• Rank and analyze hazards in the food supply.
• Establish a national food safety public education campaign.
• Conduct research pertaining to food safety (GovTrack.us 2007a).

Unfortunately, the Safe Food Act has been held up in the Committee on Agriculture, Nutrition and Forestry since February 15, 2007. The Senate introduced a somewhat similar bill in September 2007, in an effort to ensure produce safety. At press time, the Senate's bill has been referred to the Committee on Agriculture, Nutrition and Forestry (GovTrack.us 2007b).

According to Marion Nestle, PhD,MPH, professor of nutrition, public health and food studies at New York University and author of Safe Food (University of California Press 2003), it is unlikely that any of the recommended changes will be passed anytime soon. “Government safety rules aremired in laws passed in 1906 long before current hazards came into existence. Every time some government agency tries to update the laws, the industry screams bloody murder and nothing much gets done,” Nestle told Slow Food USA (Slow Food LA 2004).

Meanwhile, in just 2 months last year (early September to the end of October), the federal government issued more than 20 food recalls. Several products contained unlabeled ingredients such as nuts,milk and eggs—potentially fatal mistakes for the millions of Americans with food allergies. The other recalls resulted from random testing that revealed a list of common foods harboring contaminants, such as baking-chocolate squares with Salmonella; with tofu and raw cream infected with Listeria; Mexican cheese high in Salmonella and Staphylococcus; salad and ground beef laced with E. coli 0157; and canned meat infected with the botulism toxin (www.recalls.gov). For a look at some of the “riskiest” foods, see “Most Commonly Contaminated Foods” sidebar).

Consequences of Contamination
The health consequences from exposure to contaminated food range from pesky inconveniences like indigestion to serious injury or death. Special populations most at risk include pregnant women; infants and young children; older adults; and people with compromised immune systems.

Salmonella, Campylobacter and Shigella are the most likely contaminants, according to the FoodNet surveillance system, which tracks food-borne illness in 10 states (CDC 2007). Most infections are self-limiting and resolve without need for antibiotics or treatment other than aggressive replacement of fluids lost through vomiting and diarrhea. However, E. coli 0157 poses a particularly severe risk to children, who may contract a serious condition called hemolytic uremic syndrome (HUS) following exposure to the pathogen .When HUS develops, red blood cells are destroyed, kidney function worsens and platelet count drops substantially. Blood transfusions and kidney dialysis are often required. HUS can be life-threatening and is usually treated in an intensive care unit. With intensive care, the death rate for HUS is 3%–5% (CDC 2007).

For more information on food contaminants, their symptoms and how they are usually treated, see “Common Food-Borne Illnesses” sidebar.

Alternative Methods to Keep Food Safe
While it is tempting to blame the government for its failure to protect the food supply, there are other deserving targets. Time after time, bureaucracy, turf wars, politics and funding prove to bemajor barriers to timely food safety reform. Alternative safety methods, such as food irradiation, are promising but have been slow to gain public acceptance.

Food irradiation is the process of using high-energy rays to destroy organisms with the intent to preserve the nutritional value, taste and texture of the food product (it should be noted that these characteristics are altered to varying degrees depending on the amount of irradiation and the type of food). Importantly, no radioactivity is involved during food irradiation, and all the evidence suggests that the process is entirely safe. In fact, the CDC predicts that if irradiation were used on half of the meat and poultry consumed in the U.S., there would be 900,000 fewer cases of food-borne illness and 352 fewer deaths (Osterholm & Norgan 2004).

Numerous government agencies, scientific and health-related organizations (national and international) and food-processing groups support the safety of irradiated food. Researchers who have studied consumers' reasons for being wary of irradiated food theorize that the reluctance to embrace the technology is caused by the dubious terminology (i.e., it sounds scary, as if it's linked to radiation), a lack of understanding and a lack of knowledge (Osterholm & Norgan 2004).

Opportunities for large-scale implementation of food irradiation are emerging, but until the average consumer feels comfortable with the technology, experts say that few irradiated foods will be available on store shelves.

How to Keep Your Food Safe
While no consumer can fully protect his or her family from exposure to food-borne illness, several simple precautions can reduce the risk. Fromchoosing wisely at the grocery store to safely preparing and storing your food, there are ways to exert some control in safeguarding against food-borne contamination.

Here are some tips for you and your clients to keep in mind when selecting foods:
• Check produce for bruises, and feel and smell for ripeness. Sometimes bruises and other imperfections are signs of a brewing infection.

• Look for a “sell-by date” for breads and baked goods, a “use-by date” on some packaged foods, an “expiration date”on yeast and baking powder or a “pack date” on canned and some packaged foods. Most foods that have passed the sell-by date can be safely consumed up to a few days after the marked date. However, foods with a marked expiration or use-by date should be consumed by the stamped date to minimize risk of food-borne illness and to ensure optimumquality. Play it safe by choosing products with the latest dates.The pack date is useful only if you know how long a particular food remains fresh. Generally, canned foods are good for a year after the pack date, whereas frozen foods are best used within a few months of the pack date.

• Ensure that packaged goods are not torn and cans are not dented, cracked or bulging. Dented cans provide a breeding ground for botulism. Bulging cans indicate the food is probably already fully infected with the organism.

• Keep fish and poultry apart from other purchases by wrapping them separately in plastic bags.While fish, poultry and meat products will later be cooked to a safe temperature to kill bacteria, other uncooked contaminated purchases can
harbor the infection.

• Choose refrigerated and frozen foods last, right before checking out.Make sure all perishable items are refrigerated within 2 hours of purchase. Freezing or cold temperatures stop or greatly reduce the growth rate of micro-organisms. However, once products start to warm, bacteria rapidly multiply.

Consumers may also want to pay special note to where products were processed and packaged. Generally, foods from countries with lenient food safety requirements—such as China and many developing countries—pose increased risk. The 2002 Farm Bill would have required that all beef, lamb, pork, fish, shellfish, perishable agricultural commodities and peanuts show country of origin on their labels. Unfortunately, President Bush has delayed implementation of this requirement for all these commodities except for fish and shellfish until at least September 2008 (USDA 2007).

Proper Food Preparation & Storage
In a section devoted to food safety, Dietary Guidelines for Americans 2005 (USDHHS and USDA 2005) offers several simple tips on handling, preparing and storing food safely to reduce exposure to food-borne illnesses. Although it is possible that a contaminated food can enter the marketplace, adhering to these recommendations makes it less likely that microbes will have the opportunity to cause an infection.

• Wash hands often with warm water and soap for at least 20 seconds. This is the singlemost important defense againstmicrobial infection.

• Clean hands and food contact surfaces thoroughly.

• Wash fruits and vegetables before eating or cooking them. Do not wash meat or poultry, as washing can spread infection.

• Separate raw, cooked and ready-to-eat foods while shopping, preparing and/or storing foods.

• Cook foods to a safe temperature to kill micro-organisms (bacteria grow most rapidly between 40 and 140 degrees Fahrenheit, or between 4.4 and 60 degrees Celsius).

• If you are pregnant, do not eat deli meats and frankfurters unless they have been reheated to steaming hot, to avoid the risk of listeria.

• Refrigerate perishable food within 2 hours of purchase and defrost foods properly (i.e., in the refrigerator, not on the table counter). Eat refrigerated leftovers within 3–4 days.

• Avoid raw (unpasteurized) milk or any products made from unpasteurized milk; raw or partially cooked eggs or foods containing raw eggs; raw or undercooked meat and poultry; unpasteurized juice; and raw sprouts. This is especially important for infants and young children, pregnant women, older adults and those with compromised immune systems. These groups are also advised to avoid raw or undercooked fish or shellfish.

Wrapping It All Up
Food safety in the United States appears to be mired in a web of politics and a battle for federal funding. Despite a growing number of food-borne illness outbreaks, few large-scale policy changes have been implemented to reduce the risks to our food supply.

As a consumer, you ultimately have the responsibility to minimize your own food safety risk at home and to demand that the federal government do everything it can to ensure food safety within and across our borders.

Natalie DigateMuth,MPH, RD, is a registered dietitian and an ACE-, ACSM-, and NSCA-certified fitness professional. She is currently pursuing a medical doctor degree at the University of North Carolina at Chapel Hill. She is also an ACE master trainer.

References
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As more people approach their 65th birthdays, healthy aging has emerged as a public health priority. Thanks to Baby Boomers and longer life spans, by 2030 there will be an estimated 71million older adults in the U.S., accounting for roughly 20% of the country's population (He et al. 2005). Improved longevity is associated with an increase in chronic conditions and related disabilities, which may have a significant impact on our healthcare system. According to “The State of Aging and Health in America 2007,” a report released by the Centers for Disease Control and Prevention (CDC) and The Merck Company Foundation, about 80% of older Americans are living with at least one chronic condition, and 50% have at least two (CDC & Merck 2007). The cost of providing health care for one person aged 65 or older is three to five times more than it is for a younger person. As a result, by 2030 the nation's healthcare spending is projected to increase by 25% (CDC& Merck 2007).

But as the CDC emphasizes, poor health is not an inevitable consequence of aging. To maintain health over these additional “golden” years, it's important to pay attention to nutrition and physical activity patterns early and at all stages of aging. (See “DETERMINE Nutritional Health” sidebar for a checklist that clients can use to gauge their nutritional status.) Since a healthy lifestyle is key to preventing and managing disease—as well as maintaining quality of life—the growth of the older-adult demographic offers great opportunities for health promotion and preventive services. This article focuses on the special nutrition needs of the aging body and addresses specific concerns that can impact the nutritional well-being of seniors.

Healthy Aging
Aging is a normal, gradual process of physical change over time. However, the inevitable consequences of aging are far more pronounced in some individuals than others. Although some health problems are an unavoidable aspect of aging, many more are preventable and can be influenced by three major behaviors: eating a healthy diet, staying physically active and avoiding tobacco. In fact, there is evidence that these three behaviors alone are more influential than genetic factors in fighting age-associated decline (CDC & Merck 2007). Nutrition in particular is a major determinant of healthy, successful aging, which is defined as the ability to maintain a low risk of disease and related disability; good cognitive function; and an active social life (Rowe & Kahn 1998).

So what exactly happens in the aging body? Aging is generally associated with a slower metabolism, which leads to accumulation of extra body fat, particularly around the middle. Digestion slows, and the body becomes less efficient at managing the rise in blood sugar after eating. One of the first signs of aging is loss of muscular strength, giving way to stiff joints (Ritz 2001). Muscle strength remains similar up to age 45 and decreases by 50% between the ages of 50 and 80.

Preserving bone health also becomes a concern as the body naturally loses bone density. The kidneys work harder to remove waste and keep the body hydrated, while the circulatory system becomes less efficient. Blood vessels may become clogged and constricted. In addition, maintaining cognitive health becomes increasingly important. Even in the absence of disease, normal functional declines can impact the health and well-being of older adults (Brownie 2006).

While prevention is often the focus of younger and middle-aged adults, maintaining current levels of health and managing disease or conditions becomes the focus of older adults, explains Valentina M. Remig, PhD, RD, FADA, nutrition professor at Kansas State University in Manhattan, Kansas. Remig adds that nutrient needs among older adults differ only slightly from those of younger people.

Special Nutrition Needs of the Aging Body
It is the physiological changes that occur with aging that affect nutrient needs. Gradual loss of lean body mass and reduced energy expenditure lower caloric needs. However ,nutrient needs do not drop, and in some cases they increase. As a result, packing more nutrition into fewer calories becomes a challenge for older adults (see the sidebar “Modified MyPyramid for Older Adults” sidebar formore details). For this reason, focusing on quality food choices becomes paramount. National surveys show a decline in energy intake with age, accompanied by a similar decline in protein and key vitamin and mineral intake after the age of 50. This decline reaches a low point in people 80 and older (Wakimoto & Block 2001).

While adults are not easily categorized, certain nutrients require greater attention as people age. Which vitamins andminerals are critical depends on the health status of the individual, Remig explains. “Most often, vitamin D and vitamin B are marginalized in older adults . . . followed by calcium and iron,” she adds. Studies confirm this. Inadequate dietary intakes of energy, folate, vitamin D, vitamin B6, calcium and zinc have been reported in community- dwelling adults over 60 years old (Marshall 2001).

Specific dietary recommendations are set for two age groups: adults 51–70 years old and those 70 and older (see “Dietary Reference Intakes for Key Nutrients” chart). Adult Dietary Reference Intakes (DRIs) increase with age for vitamins C, D, K and B6, as well as calcium. Additionally, Dietary Guidelines for Americans 2005, published jointly by the U.S. Department of Health & Human Services (USDHHS) and the U.S. Department of Agriculture (USDA), highlights special key issues for older adults. “Nutrients are interactive; many nutrients are needed within each system of the body for that system to run efficiently,” says Adele Huls, PhD, RD, LMNT, chair elect of the American Dietetic Association's (ADA) Healthy Aging Dietetic Practice Group. ”Those needs continue as we age. So, in essence, all nutrients have benefits in aging. “ Let's review some of the most important.

Calcium. As it ages, the body does not absorb calciumas easily as it used to. Increased calcium excretion accompanies decreased absorption. Age-associated loss of bone density increases risk for fractures and osteoporosis. Losses of skeletal calcium in postmenopausal women can reach more than 40% (Tucker 2003). Because bone fractures are a significant contributor to morbidity and mortality in older people, achieving daily calcium needs is critical; yet only 5% of older women and 10% of older men consume the DRI recommendation (Tucker 2003).

Vitamin D. Evidence suggests that vitamin D, best known for its role in bone health, may have a function in preventing a number of diseases.A recentmeta-analysis concluded that adequate vitamin D intake is associated with lower death rates fromall causes (Autier&Gandini 2007).According to the Dietary Guidelines, the need for the “sunshine vitamin” increases from 10 to 15 micrograms (mcg) after age 50 as blood levels of vitamin D decline. For the elderly, higher amounts (25 mcg, or 1,000 IU) from both fortified foods and supplements have been recommended. (Note: These amounts are greater than those recommended by the Institute ofMedicine and shown in the “Dietary Reference Intakes for Key Nutrition” chart.)

Even with supplementation, however, older adults are not consuming these higher amounts (Johnson & Kimlin 2006). Deficiency is common in the elderly and associated with many age related conditions, including high blood pressure, cancer, fractures and falls (Holick 2004). The major causes of vitamin D deficiency are decreased exposure to sunlight, a decline in synthesis of vitamin D in the skin, poor nutrition and decreased renal function (Gennari 2001). Because of this vitamin's role in calcium absorption and mineralization, chronic deficiency leads to osteomalacia, or softening-bone disease. In addition to calcium and vitamin D, magnesium and vitamin K have been shown to affect bone health, particularly with regard to risk of hip fractures (Gennari 2001).

Vitamin B12 and Folate. Most individuals over age 50 have a reduced ability to absorb naturally occurring vitamin B12 and must therefore consume it in its crystalline form (fortified foods or supplements). The major causes of vitamin B12 deficiency are atrophic gastritis and pernicious anemia. Atrophic gastritis affects nutrient bioavailability and is a problemthat increases with age; research indicates that 40%–50% of individuals over age 80 have the condition (Chernoff 2005). Consequently, a significant portion of older people are at risk of impaired absorption of vitamin B12, folic acid and other vitamins and minerals. Pernicious anemia results from an age-related loss of gastric intrinsic factor. Vitamin B12 deficiency can cause cognitive dysfunction and neurological problems in older people (Carmel 1997).

There is concern that high intakes of folate might mask the macrocytic anemia of vitamin B12 deficiency, exacerbating cognitive dysfunction (Morris et al. 2007). In seniors with normal vitamin B12 status, on the other hand, higher folate is associated with protection from anemia and cognitive impairment. Nevertheless, 90% of women and 95% of men do not meet the DRI for this vitamin (Wakimoto & Block 2001).

Sodium. Since many people will develop hypertension at some point during their lifetime—and typically the higher their salt intake, the higher their blood pressure will be—older adults should aim to consume no more than 1,500 milligrams (mg) of sodium per day (about 3/4 teaspoon of salt). Older adults as a group tend to be more salt sensitive. To manage sodium intake, individuals should read labels, aim for foods with 5% or less of the Daily Value (DV) forsodium and avoid foods with more than 20% of the DV.

Furthermore, because potassium can counter balance the harmful effects of sodium on blood pressure, older people should strive to meet the potassium recommendation (4.7 grams per day) with food. Consuming more potassium-rich foods may also help prevent the bone loss that occurs with aging. Potassium needs can be achieved by consuming the recommended daily servings of vegetables, fruits and low-fat or fat-free milk products.

Fiber. Since constipation may affect up to 20% of people overage 65, foods rich in dietary fiber become increasingly important for older adults (USDHHS 2005). Additional causes of constipation among this age group may include side effects of medications and lack of appropriate hydration. Low fiber intake may also contribute to other gastrointestinal diseases common among older adults, including diverticulosis. Although older people, especially women, are more likely to eat fruits and vegetables than younger people (Wakimoto & Block 2001), a large majority still fall short in meeting their daily needs (CDC &Merck 2007).

Adequate fluid intake not only eases constipation; it also helps avert dehydration, a serious threat to the elderly. Causes of impaired fluid and electrolyte balance include physiologic impairments in renal function and thirst perception, reduced body fluid and blunted medication effects (Ritz 2001). Severe dehydration in the elderly can lead to cognitive impairment and functional decline.

Other Nutrients.The role of antioxidants in the aging process is worth mentioning. Zinc, along with vitamins C and E, and the phytochemicals lutein, zeaxanthin and beta carotene from food sources, may help prevent or slow the onset of age-related macular degeneration, the leading cause of blindness in people over age 55. Evidence suggests that low dietary intake of these nutrients may also increase cataract risk (ADA 2005).

Tufts University researchers have updated the Food Guide Pyramid for Older Adults to correspond with changes to the USDA food pyramid, now known as MyPyramid. The Tufts version, published in the January 2008 issue of the Journal of Nutrition, is specifically designed for older adults and continues to emphasize nutrient-dense food choices and the importance of fluid balance, but it offers additional guidance about the forms of foods that could best meet the unique needs of older adults. Physical activity is also highlighted. The Modified MyPyramid for Older Adults represents foods in the following categories, as well as fluids and physical activity: • whole, enriched and fortified grains and cereals, such as brown rice and 100% whole-wheat bread • bright-colored vegetables, such as carrots and broccoli • deep-colored fruits, such as berries and melon • low-fat and nonfat dairy products, such as yogurt and low-lactose milk • dried beans, nuts, fish, poultry, lean meat and eggs • liquid vegetable oils and soft spreads low in saturated and trans fat A new pyramid foundation depicts physical activities characteristic of older adults; for example, walking, yard work and swimming. Icons representing packaged fruits and vegetables in addition to fresh varieties may be more appropriate for older adults for a number of reasons. Fiber-rich foods are also emphasized, as is the importance of consuming fluids (there is a row of glasses at the pyramid's foundation). Another integral part of the modified pyramid is a flag at the top suggesting that older adults may need certain supplemental nutrients, such as calcium, vitamin D and vitamin B12.

Concerns That Impact Seniors' Nutritional Status
Sensory Underload. Age-related changes in sensory input can impact nutritional status and quality of life. Fewer taste buds and a loss of smell can make food seem bland, impacting appetite, nutrient intake and overall enjoyment of food (Amarantos, Martinez & Dwyer 2001). More than 50%of adults between the ages of 65 and 80 have problems with their senses of smell and taste, increasing to 75% in those over 80 (Brownie 2006). Age-related sensory declines can be exacerbated by disease andmedication. These alterations in taste and smell often cause older adults to reach automatically for the salt shaker to enhance the flavor of food, a practice that can negatively influence blood pressure.

Dental Issues. Poor oral health can also affect food intake and nutritional status.Whether the issue is ill-fitting dentures or tooth loss due to gum or periodontal disease associated with diabetes or a heart condition, chewing and swallowing can be problematic for older adults (Brownie 2006). Intake of proteins and other nutrients may be compromised as meats, fresh fruits and vegetables become difficult to chew. Careful meal planning and preparation become important to ensure the right consistency and variety of softer foods. It is recommended that older adults with dental problems chop, steam, stew, grind or grate hard or tough foods to minimize the need to chew. Soft, fresh fruits and vegetables (like bananas and avocados) or juices are good choices. If raw fruits and vegetables are too hard, low sodium canned varieties can be substituted.

Food Safety. Older adults are a high-risk population and need to take extra precautions to protect themselves from food-borne illness. It is recommended that seniors avoid eating or drinking raw (unpasteurized) milk or any products made from unpasteurized milk; raw or partially cooked eggs; raw or undercooked meat, poultry, fish and shellfish; unpasteurized juices; and raw sprouts. In addition, to reduce the risk of developing listeriosis, a potentially life-threatening illness caused by a bacterium, older adults should only eat certain deli meats and frankfurters that have been reheated to steaming hot (USDHHS & USDA 2005). As a protective measure, it is imperative that seniors practice good home food-safety practices, including proper hand washing.

Malnutrition.Older people are at increased risk for nutrient deficiency and malnutrition. The prevalence of malnutrition among older adults living independently is 5%–10%, and it increases to 60% for those institutionalized or hospitalized (Brownie 2006). Regardless of whether an individual is underweight or overweight, malnutrition exacerbates disease and decreases functionality, which affects quality of life. Protein-energy malnutrition and nutrient deficiencies can compromise the elderly immune system. Furthermore, malnourished individuals are at higher risk for disability, and disabled individuals are more likely to be malnourished (ADA 2005). “Good nutritional status affects the body's ability to attain and maintain healthy organs,” says Huls. “When organs are healthy, systems work well. When systems work well, decline is slowed.”

Food Insecurity. Financial constraints and poverty can be a can be a determinant of nutritional status. Food insecurity (lack of food resources) is a problem among the elderly, affecting 1.4 million households (ADA 2005). Not surprisingly, older people who don't have enough food have consistently lower intakes of key nutrients, including protein, iron and vitamin B12, compared with those who have access to enough food. These older adults are more likely to be underweight, which compromises health and quality of life (ADA 2005).

Social Isolation. Social determinants can impact food quantity and quality for older adults. Living alone, being socially isolated and having decreased independence to shop and cook may lead to depression and can cause a person to eat less and make poor food choices. The impact of these social changes appears to affect the nutrient intake of men more than women (Brownie 2006).

Federal meal programs can increase access to nutrient-dense foods and meals and influence overall nutrient intake. These programs even have the potential to improve functional independence and quality of life (ADA 2005). Also, studies show that more food is consumed when meals are eaten with others (de Castro & Stroebele 2002). Social interaction lengthens meal duration and can make eating a more pleasurable experience.

Many programs exist that strive to serve the nutrition requirements of seniors in need. The Older Americans Nutrition Program offers nutritious meals that meet the DRIs and special nutrition needs of older people. Food is served at congregate sites, and delivery is available for the vulnerable homebound.

In addition to serving meals, the Congregate Nutrition Program provides nutrition education and opportunities for physical activity. USDA offers the Food Stamp Program and the Senior Farmers' Market Nutrition Program as additional services to older adults who meet eligibility requirements.

It Is Never Too Late
While early attention to healthy eating and physical activity patterns are most effective for prevention, the positive effects of a healthy lifestyle can be realized at any age. As Remig explains, “Older adults who achieve healthy aging are better prepared to live more years disease and/or illness free.” Regular physical activity can reduce functional declines associated with aging. In addition, wise nutrition choices are crucial for enabling older adults to live a long, healthy, active life. Aging is inevitable, but a healthy lifestyle can improve how we age.

Jennie McCary, MS, RD, LD, is the wellness coordinator for the Albuquerque Public School District and a part-time nutrition instructor at the University of New Mexico.

References
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