Summer 2019

By Aliza Becker, BA, MPS Ms. Becker is the managing editor of the The Journal of Innovations in Cardiac Rhythm Management, a freelance editor, and an instructor in the George Washington University’s MPS Publishing program. Sugar is among the oldest sweet foods known to humankind, with a historical timeline that traces its cultivation and production across the world. The most widely accepted theory suggests that sugarcane may have been first domesticated from wild cane (Saccharum robustum) in the New Guinea region approximately 8,000 years ago.1,2 From there, cultivated sugarcane (Saccharum officinarum) was transported by humans into Southeast Asia and beyond, where it encountered and hybridized with related wild Saccharum species, giving rise to new cultivated forms.1,3 Although the indigenous people of New Guinea are thought to have consumed sugarcane itself as a food, subsequent technological developments enabled the production of sugar crystals from cane juice in India during the early Common Era,4 and knowledge of sugar production subsequently spread through Asia and the Middle East before eventually reaching the Mediterranean world.5 During the Middle Ages (approximately 500–1600 CE), sugar became increasingly available in Europe by way of growing trade networks and greater contact between Europe and the eastern Mediterranean (eg, during the Crusades).6 Sugar production continued to expand thereafter, including throughout the Americas, where large-scale sugar production developed in countries such as Brazil.7 Then, during the 19th century, the industry was further transformed by technological advances, including the introduction of steam power in sugar manufacturing8 and the development of methods for producing sugar from sugar beets.9 Continued technological advances in sugar manufacturing during the 19th and 20th centuries further enabled sugar to be produced on an increasingly large and efficient scale.10 Today, sugar has permeated our diets. Although foods contain some naturally occurring sugars (eg, fructose in fruits, lactose in milk and dairy products), added sugars are also widely consumed in the United States (US) diet. According to 2017 to 2018 National Health and Nutrition Examination Survey (NHANES) data, both US adults and children/adolescents aged 2 to 19 years consumed an average of 17 teaspoons (approximately 68 g) of added sugars per day.11 In contrast, the Dietary Guidelines for Americans recommend that individuals aged 2 years and older limit added sugars to less than 10% of total daily energy intake (eg, no more than 200 calories, or 50 g, from added sugars on a 2,000-calorie diet).12 Importantly, higher dietary sugar consumption has been associated with adverse health outcomes, including excess body weight/obesity, type 2 diabetes, cardiovascular disease, and dental caries (eg, cavities).13 These concerns have contributed to growing interest in lower-sugar and sugar-free alternatives. Available Alternatives to Sugar Sugar alternatives can be broadly divided into several categories: artificial sweeteners, natural sweeteners, sugar alcohols, and alternative sugars. Artificial/synthetic sweeteners. The first widely used artificial sweetener, saccharin, was discovered accidentally in 1879 by Constantin Fahlberg while working in Ira Remsen’s laboratory at Johns Hopkins University.14 Subsequent sweeteners included cyclamate, discovered in 1937; aspartame, discovered in 1965; and acesulfame potassium and sucralose, discovered in 1967 and 1976, respectively.15 To date, the US Food and Drug Administration (FDA) has reviewed 6 artificial sweeteners commonly used in foods: aspartame, acesulfame potassium, sucralose, neotame, advantame, and saccharin.16 Broadly, artificial sweeteners are significantly sweeter than sucrose (ie, common table sugar), ranging from approximately 200-fold sweeter for acesulfame potassium to several thousand-fold sweeter for neotame, allowing them to be used in smaller quantities to achieve a similar level of sweetness without as large a caloric load.16 However, as their use expanded, questions about their safety also emerged. For example, further use of cyclamate was prohibited in the United States in 1970 after animal studies raised concerns about its potential carcinogenicity.17 Saccharin, too, became a similar subject of concern after studies linked it to bladder tumors in laboratory rats.16 Aspartame also received substantial regulatory scrutiny both before and after its approval in the US, including regarding potential carcinogenicity.18 Although some of these early fears were ultimately reconsidered in light of subsequent research—for example, the FDA states that more than 30 human studies demonstrated that the results pertaining to saccharin in rats were irrelevant to humans and that saccharin is safe for human consumption16—concerns about potential adverse health effects have persisted, including possible effects on the gut microbiome.19,20 Meanwhile, consumer interest in “natural” and clean-label ingredients has contributed to growing interest in plant-derived sweeteners and other alternatives.21 Natural/plant-derived sweeteners. Three natural/plant-derived sweeteners have been the subject of FDA GRAS notices: (1) high-purity (95% minimum purity) steviol glycosides, including rebaudioside A, stevioside, rebaudioside D, or steviol glycoside mixture preparations with rebaudioside A and/or stevioside as predominant components; (2) Siraitia grosvenorii Swingle fruit extract, also known as luo han guo or monk fruit; and (3) thaumatin, a group of basic proteins isolated from Thaumatococcus daniellii (West African Katemfe fruit).16 The FDA notes separately that whole-leaf and crude stevia extracts are subject to an Import Alert and are not permitted for use as sweeteners.16 Like sugar itself, these sweeteners have a long history of use in their countries of origin, with commercial use of their purified extracts emerging much more recently. For example, in South America, particularly in Paraguay, the stevia plant (Stevia rebaudiana) has a long history of traditional use as a sweetener,22 while monk fruit has been used in China for more than 300 years as a natural sweetener and in traditional medicine.23 Current evidence from toxicological and regulatory assessments supports the safety of these sweeteners under intended conditions of use,16 although continued research may be warranted given the relative scarcity of long-term human data. Furthermore, although these sweeteners are derived from plants, their purified extracts should not necessarily be assumed to have the same physiological effects as the whole plants from which they are derived. Aside from the aforementioned natural non-nutritive sweeteners, naturally occurring nutritive (caloric) sweeteners like honey; coconut sugar; and maple, date, and agave syrups also exist.21 Caloric-conscious consumers should be aware that their use as sweeteners may add substantial amounts of calories to the diet.21 Sugar

By Kate Turner, MA, RD, CSSD, CPT Ms. Turner is a registered dietitian, certified personal trainer, and owner of LIVE WELL with Kate. Gulcagon-like peptide-1 (GLP-1)–based medications have changed the landscape of weight management, offering an effective tool for many people who struggle with their weight. These medications can help reduce appetite, increase feelings of fullness, and lead to substantial weight loss when combined with lifestyle intervention.1,2 But there is an important misconception worth addressing in order for people to achieve success long-term: GLP-1 medications do not replace good nutrition—they can make good nutrition even more important. Weight Loss Is Not the Same as Fat Loss When appetite decreases, it can become easier to eat less. That can be beneficial for achieving the calorie deficit needed for weight loss. However, eating substantially less also means fewer opportunities to obtain adequate calories, protein, fiber, vitamins, minerals, and other essential nutrients. There is another consideration that becomes particularly important as we age: preserving lean muscle. Many times weight loss, particularly fast weight loss, generally involves some loss of lean tissue in addition to fat. Muscle weighs more than fat, so oftentimes when the scale is going down quickly it can be an indicator of muscle loss. The primary goal when wanting to lose fat and preserve muscle is to lose inches and improve how your clothes fit vs constantly watching the number on the scale. In a 2026 meta-analysis of 20 randomized trials, lean mass accounted for approximately 25% to 39% of weight lost with weight loss–support medications. The proportion was lower when resistance training, also known as weight or strength training, was incorporated.3 Preserving muscle and strength should be a priority during weight loss in general—particularly for those on a GLP-1 medication and older adults, who are already at increased risk of age-related muscle loss.4 The Goal: Lose Fat While Protecting and/or Building Muscle Rather than focusing on eating as little as possible, the goal should be to lose excess body fat while maintaining the nutritional adequacy discussed, muscle mass, strength, and function. Two strategies are especially important: adequate protein intake and resistance exercise. Expert reviews and recent clinical guidance recommend prioritizing protein-rich foods while on a GLP-1 and incorporating regular resistance training to help support lean tissue and physical function.4–6 This is especially relevant when appetite is low. When you’re eating less overall, the nutritional quality of what you do eat matters more. Meals and snacks should emphasize nutrient-dense foods that provide protein, fiber, healthy fats, vitamins, and minerals rather than relying primarily on foods that provide calories without much nutritional value. Don’t Ignore Digestive Side Effects Nausea, constipation, diarrhea, vomiting, and feeling overly full are among the gastrointestinal side effects commonly reported with GLP-1 medications. In clinical trials of semaglutide, these effects were generally mild to moderate and most common during dose increases.7 These symptoms can make it even harder to consume enough food and fluids. Consuming smaller nutrient-dense meals, eating slowly, and staying adequately hydrated can all help to manage these unwanted symptoms. Please note that significant or ongoing nausea, vomiting, constipation, or difficulty eating should be discussed with a medical professional rather than simply tolerated. Think of Your Medication as a Tool—Not the Whole Strategy GLP-1 medications can be powerful tools for weight loss and, depending on the medication and the individual, may provide important cardiometabolic benefits. For example, the SELECT trial found that semaglutide reduced major cardiovascular events in adults with established cardiovascular disease and overweight or obesity who did not have diabetes.8 But medication is only one component of a comprehensive approach to weight loss and improving your health. The goal isn’t simply to make the number on the scale smaller, which at times may primarily be muscle loss. It’s to lose excess fat while preserving muscle, strength, and nutritional status. Prioritizing adequate nutrition and regular resistance exercise can help make weight loss a healthier and more sustainable process. If you’re taking or considering a GLP-1 medication, talk with your healthcare provider and/or registered dietitian about how to meet your individual nutrition and activity needs throughout treatment. Sources Wilding JPH, Batterham RL, Calanna S, et al; STEP 1 Study Group. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989–1002. Look M, Dunn JP, Kushner RF, et al. Body composition changes during weight reduction with tirzepatide in the SURMOUNT-1 study of adults with obesity or overweight. Diabetes Obes Metab. 2025;27(5):2720–2729. Eisa N, Barood O. Lean mass changes with incretin therapy versus lifestyle intervention: a systematic review and meta-analysis of randomised controlled trials. Diabetes Obes Metab. 2026;28(6):4818–4827. Locatelli JC, Costa JG, Haynes A, et al. Incretin-based weight loss pharmacotherapy: can resistance exercise optimize changes in body composition? Diabetes Care. 2024;47(10):1718–1730 Mozaffarian D, Agarwal M, Aggarwal M, et al. Nutritional priorities to support GLP-1 therapy for obesity: a joint advisory from the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association, and the Obesity Society. Am J Lifestyle Med. 2025:15598276251344827. Arslan S. Medical nutrition in the glucagon-like peptide-1 (GLP-1) era: protein strategies, micronutrient monitoring, and lean mass preservation. Clin Nutr ESPEN. 2026;73:103305. Wharton S, Davies M, Dicker D, et al. Gastrointestinal tolerability of once-weekly semaglutide 2.4 mg in adults with overweight or obesity, and the relationship between gastrointestinal adverse events and weight loss. Diabetes Obes Metab. 2021;24(1):94–105. Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 2023;389(24):2221–2232.

By Kate Turner, MA, RD, CSSD, CPT Ms. Turner is a registered dietitian, certified personal trainer, and owner of LIVE WELL with Kate. In Part 1 of this series, we discussed why nutrition becomes even more important when taking a glucagon-like peptide-1 (GLP-1) medication. Because these medications can substantially reduce appetite and food intake, it can become challenging to stay hydrated and consume enough protein, fiber, and other essential nutrients.1,2 The goal isn’t simply to eat less—it is to make the food you do eat as nutritious as possible. Here are 4 priorities to put into practice when taking a GLP-1 medication. 1. Prioritize Protein Adequate protein intake is particularly important during weight loss because it can help support the preservation of lean mass when combined with resistance exercise.1,2 Current expert guidance for people taking GLP-1 medications commonly recommends protein intakes of at least approximately 1.2 g/kg of body weight per day, although individual needs may be higher depending on age, activity level, body composition goals, and health status.2,3 For older adults, this target is especially relevant. Experts generally recommend at least 1.0 to 1.2 g/kg per day, with higher intakes often appropriate for active individuals or those at risk of muscle loss.4 Rather than getting overwhelmed by calculations, make protein the priority at every meal. Try eggs or Greek yogurt at breakfast; chicken, fish, lean meat, tofu, or beans at lunch and dinner; and protein-rich snacks, such as cottage cheese, Greek yogurt, edamame, or a protein shake, when needed. When appetite is low, it can help to plan your protein rather than waiting until you feel hungry. 2. Gradually Increase Fiber Fiber supports digestive health and is an important component of a nutrient-dense eating pattern. However, suddenly increasing fiber intake can worsen bloating, gas, or abdominal discomfort—particularly if you’re already experiencing gastrointestinal symptoms from a GLP-1 medication.1,2 A practical goal for many women is about 25 to 30 grams of fiber per day, although individual needs may vary.2,5If your current intake is significantly lower, work toward this amount gradually rather than trying to reach it overnight. A recent systematic review of nutrition and physical activity guidelines for chronic constipation found that gradual increases in dietary fiber were consistently recommended, with several expert guidelines specifically recommending 25 to 30 grams per day for mild-to-moderate constipation.5 Build fiber gradually through foods such as berries, vegetables, beans and lentils, chia or flax seeds, nuts, avocado, and high-fiber whole grains. If constipation is an issue, increasing fluids along with fiber is also important.1,5 The goal isn’t to suddenly add a large amount of fiber, but to gradually build a fiber-rich eating pattern that your digestive system can tolerate. 3. Stay Hydrated Adequate fluid intake is another important consideration, particularly if reduced food intake or gastrointestinal side effects such as vomiting or diarrhea are occurring.1,2 There is no single amount of water that everyone needs. The National Academies’ adequate intake for total water is approximately 2.7 liters per day for women, but this includes water from beverages and food, and individual needs vary with body size, activity, climate, and health conditions.6 Electrolytes are not automatically necessary for everyone taking a GLP-1 medication. However, they may be useful in certain situations involving significant fluid or electrolyte losses, such as prolonged vomiting, diarrhea, or heavy sweating. If you are struggling to stay hydrated, talk with your healthcare provider about the best approach for you. 4. Don’t Forget Strength Training Protein provides the building blocks your body needs to maintain muscle, but resistance exercise provides an important stimulus for your muscles to adapt and remain strong.1,2 Combining adequate protein with progressive resistance training is therefore a key strategy for protecting muscle during weight loss.1,2 Aim for resistance training at least twice per week, using weights, resistance bands, machines, or your own body weight, with the specific program adapted to your fitness level and health status.7 Make Every Bite Count When appetite is significantly reduced, eating less doesn’t mean your body needs fewer essential nutrients. Instead of asking, “How little can I eat?” ask, “How can I make the food I am eating as nutritious as possible?” A small breakfast of Greek yogurt topped with berries, chia seeds, and a little granola can provide substantially more protein and nutrients than a few bites of toast. A smaller lunch built around chicken or salmon, vegetables, avocado, and beans can provide protein, fiber, healthy fats, and other nutrients without requiring a large portion. If a full meal feels overwhelming, smaller meals may be easier to tolerate. The important thing is to make sure your overall intake is adequate rather than intentionally restricting food as much as possible. Ultimately, think of your GLP-1 medication as one part of a larger health strategy: protein, fiber, hydration, and strength training. If significant appetite suppression or gastrointestinal symptoms are making it difficult to meet your nutritional needs, a registered dietitian or healthcare provider can help you create an individualized plan. Sources Mozaffarian D, Agarwal M, Aggarwal M, et al. Nutritional priorities to support GLP-1 therapy for obesity: a joint advisory from the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association, and the Obesity Society. Obesity (Silver Spring). 2025;33(8):1475–1503. Dobbie LJ, Tolvanen L, Alves D, et al. Nutritional, functional, and psychological considerations for incretin-based therapies in adults-an EASO, EFAD, and ECPO Consensus Statement. Lancet Diabetes Endocrinol. 202614(9):754–777. Arslan S. Medical nutrition in the glucagon-like peptide-1 (GLP-1) era: protein strategies, micronutrient monitoring, and lean mass preservation. Clin Nutr ESPEN. 2026;73:103305. Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013;14(8):542–559. Kamareddine S, Bhurosy T. An assessment of nutrition and physical activity guidelines for adult patients with chronic constipation: a systematic review. Clin Nutr ESPEN. 2025;68:630–637. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. National Academies Press; 2005. Fragala MS, Cadore EL, Dorgo S, et al. Resistance training

By Sarabeth Lowe, MPH Ms. Lowe is a Communication Specialist at the University of Delaware Disaster Research Center. Autumn is well underway, and there’s more to this season than cooler weather and pumpkin spice lattes. Fall ushers in its own legendary line of produce: apples, cranberries, corn, and, of course, pumpkins. With their hard, thick skin and iconic orange color, these fall fruits may bring back memories of traipsing through a pumpkin patch or carving a jack-o’-lantern. If you’ve ever done the latter, you’re familiar with its pale, stringy insides. Hidden among those fibrous strands are seeds, a nutritious morsel waiting to be plucked from the pulp. These flat, oval seeds have a slightly nutty, sweet flavor and are perfect for snacks, garnishing savory dishes, topping salads and smoothie bowls, or simply eaten whole. Here’s what to know about the health benefits of pumpkin seeds and how to safely turn what would be tossed into the trash into a tasty treat. Nutrition and Health Benefits Pumpkin seeds are a nutrition powerhouse. They provide a combination of macronutrients, fiber, and vitamins and minerals, all of which play important roles in keeping the body functioning optimally.1–9 The exact nutritional content depends on the type of pumpkin and how the seeds are prepared; below is the nutrient profile for 1 oz (about 28 g or 85 pieces) of whole, roasted, unsalted pumpkin seeds:10,11 Calories: 126 Fat: 5.5 g Sodium: 5 mg Carbohydrates: 15.2 g Fiber: 5.2 g Protein: 5.3 g Iron: 0.938 mg Magnesium: 74.3 mg Manganese: 0.141 mg Phosphorous: 26.1 mg Copper: 0.196 mg Zinc: 2.92 mg Pumpkin seeds provide the 3 main categories of macronutrients—carbohydrates, fats, and protein—which are the essential nutrients your body needs in large amounts to function.1,2,4,6–8,10,12–15 Carbohydrates are the body’s primary fuel and provide energy for your muscles and the central nervous system during movement and exercise.14–16 Fat also gives your body energy, and it protects your organs, supports cell growth, and helps your body absorb vital nutrients.12,14,15,17 Protein helps build and repair tissues, strengthens your muscles, and promotes satiety.1–3,7,10,12,15,18 Similarly, fiber can promote feelings of fullness.1,2,10,19,20 These seeds also contain several essential vitamins and minerals that help keep your body healthy.1–9,10,21,22 Zinc, for example, is an essential trace mineral that supports immune function, wound healing, and cellular metabolism; iron, which your body uses to make the red blood protein hemoglobin, helps carry oxygen from your lungs to the rest of your body.23,24 Despite their small size, pumpkin seeds are one of the best sources of magnesium, a nutrient that is important for many processes in the body, including regulating muscle and nerve function, sleep, and making protein, bone, and DNA.6,7,9,22,25 A Few Things to Keep in Mind Experts have widely lauded the nutritional qualities and benefits of pumpkin seeds. Some scientists have deemed them a nutraceutical or “functional food,” a term that loosely describes foods that provide health benefits beyond basic nutrition.4–8,22,26,27 However, that doesn’t mean these seeds are a magic bullet. Here are a few considerations to keep in mind. A little goes a long way. Pumpkin seeds are calorie-dense, especially when considering their small size. This is why you should limit your portions to the recommended serving size of 1 oz, which is a little less than a quarter-cup.1,2,9,16,28 Raw vs roasted. Pumpkin seeds can be eaten raw or cooked, but research has shown roasting can enhance their nutritional quality.1–5,29,30 Heating these seeds causes chemical changes that can break down cell walls and release more antioxidants.29,30 This process also makes them easier for your body to break down and absorb nutrients from the seeds. Digestion. Pumpkin seeds come in 2 main varieties: whole, which have a flat, oval, ivory-colored hull, and pepitas, their smaller, darker, shelless counterpart.8,31 Both can be eaten, but their texture is different. Whole seeds’ stiff shell can make them more difficult to digest, especially when roasted, and their high-fiber content can cause uncomfortable symptoms like gas, bloating, or constipation.10,19,20 Buyer beware. Pumpkin seeds that are sold in stores can contain added ingredients and seasonings, and salted varieties are especially common.2,21,32 People watching their sodium intake can search for lightly salted or unsalted alternatives. You can check the ingredient list and nutrition label for more information. Safety considerations. While uncommon, some people can be allergic to pumpkin seeds.5,33,34 If you have other food allergies, particularly to other seeds, consult your health care provider. Pumpkin seeds’ small size can also make them a choking hazard, so young children and people with swallowing disorders should not eat them.35–37 Always chew them thoroughly and in small amounts. How to Harvest Once you have selected a pumpkin, it’s time to get carving. Whether you’re designing a jack-o’-lantern or simply cutting to the core to harvest the seeds, be cautious and pay attention. Research shows that pumpkin-related knife injuries have a high incidence in fall months, particularly in the last week of October.38 A 2022 report from the United States Consumer Product Safety Commission found that an estimated 55% of Halloween-related emergency room visits are due to pumpkin carving accidents.39,40 There are several precautions you can take to reduce your risk of injury.40–43 Choose a clean, well-lit area with a flat surface, and wash the pumpkin before carving. Make sure your hands and tools are completely dry before carving to prevent slipping that could cause an injury.  Use and choose your tools wisely. Pumpkins’ hard outer shells can cause knives to wedge in the flesh. Removing them can require rough, brute force, which can lead to injury. Pumpkin carving kits are a better option than kitchen knives because they provide a variety of instruments designed to slice through the thick skin. Always cut away from your hand, and never put your hand inside the pumpkin when carving. Clean your hands as you go. Handling pumpkin pulp can leave your hands and tools slick and slimy, and using a knife with slippery hands is a recipe for disaster. Once you’re done carving your pumpkin, it’s time