Vol. 15 No.

January 2013 The Magazine for Nutrition Professionals

Gluten-Free
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Journey RDs Serve as a Guide for Patients

on a Quest to Relieve Symptoms
and Improve Health

ASPEN
Conference
Issue

Ethical Decision
Making in End-of-Life
Healthcare

Kids Frown on
New School Lunch
Standards

Embracing Meatless
Monday www.TodaysDietitian.com
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EDITORS SPOT
GRUMBLING BELLIES
Its been one year since the unveiling of
the new standards for school meals that
have resulted in healthier lunches for kids
across the country. The new meal require-
ments have raised standards for the first
time in more than 15 years, and chances
are they will improve the health and nutri-
tion of nearly 32 million kids who participate in the program
each school day.
As you know, the new standards require school cafeterias
to serve larger portions of fresh fruits, vegetables, and whole
grains; fat-free (unflavored/flavored) or 1% (unflavored) milk;
less saturated and trans fats and sodium; and proper portion
sizes and caloric intake based on age.
While the healthier meals are a key component of the
Healthy, Hunger-Free Kids Act of 2010, championed by
First Lady Michelle Obama and signed into law by President
Obama, ironically theyre leaving many kids across the
country with growling bellies by the end of the school day.
To voice an opinion of the new standards, a group of
creative high school students in Kansas posted a video on
YouTube called We Are Hungry to the tune of fun.s We Are
Young. If you feel like giggling a bit, go to YouTube and type in
the title. There are scenes of kids storing food in their lockers
to ensure they have enough to eat in between classes, kids
walking the halls snacking on food, kids collapsing on the
gym floor during basketball practice, and kids falling asleep
in class because theyre hungry and have no energy. While
the video parody will make you laugh, the kids message is
a serious one: The food may be healthful, but its not filling
them up. You can read more about this and find out what your
colleagues had to say about the kids reactions in the feature
Healthful School Lunches.
My son, a high school senior, has different complaints.
He says its not that the healthier meals leave him hungry;
the problem is that the more healthful foods just dont look
appetizing, so he buys the less healthful options from the la
carte menu. What do you think about this? Weigh in with your
feedback about this story and the issues other articles on our
Twitter and Facebook pages.
Happy New Year to all, and please enjoy the issue.
Judy
Judith Riddle
Editor
TDeditor@gvpub.com
6 todays dietitian january 2013
President & CEO
Kathleen Czermanski
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EDITORIAL
Editor Judith Riddle
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CONTENTS JANUARY 2013

34 18
FEATURES DEPARTMENTS

24 The Gluten-Free Journey RDs serve as a guide for patients 6 Editors Spot
on a lifelong quest to relieve symptoms and improve health.
10 Reader Feedback
28 Ethical Decision Making This article details the dietitians 12 Ask the Expert
role in end-of-life healthcare when considering enteral and
parenteral nutrition. 14 Nutrition Support 360

17 Personal Computing
34  ealthful School Lunches Are the New Standards
H
All Theyre Cracked up to Be? Dietitians speak out about 18 Dynamics of Diabetes
the new federal school meals program that many kids say is
22 For Your Information
leaving their stomachs growling by the end of the school day.
52 Supplement Spotlight
38 Meatless Monday This growing campaign encourages people
to increase their intake of fruits, vegetables, whole grains, and 54 Focus on Fitness
legumes, and dietitians are embracing it as a tool to promote 58 Products + Services
healthful eating patterns.
60 News Bites
42 Educating Young Palates MindStream Academy is blending
62 Get to Know
food, nutrition, and education to teach students how to live
healthfully for the rest of their lives. 64 Datebook

46 CPE Monthly: Autism Spectrum Disorder Research 66 Culinary Corner

suggests good nutrition may help manage various symptoms.

Page 46

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READER FEEDBACK

Dear Editor,
AMERICAN DIABETES MONTH
Vol. 14 No. 11

Thank you for publishing the very November 2012 The Magazine for Nutrition Professionals

Happy Thanksgiving
thorough and informative article on Veggie Style! From Our Facebook Wall
migraine headaches in the November Clients Can P
Prepare
repare SSuch
uch
Delicious, Healthful Meals
That Nobody Will Miss the Turkey
Pumpkin
Soup

2012 issue. This is probably the most

Worldwide Diabetes Cases Hit Record,
useful information Ive ever read
Half Go Undiagnosed
Reversing Type 2
Diabetes With
Natural Therapies

regarding the treatment of migraines. I

news.msn.com
Gluten-Free
Kitchen Essentials

suffered from migraines for years and Helping Clients

Linda Mooring: What will it take for people to get

With Binge
Eating Disorder www.TodaysDietitian.com

saw multiple doctors who prescribed

the message and change their diet? Sugar is evil!
some dangerous drugs. It was a dietitian who finally relieved
me of my migraines using MRT [Mediator Release Testing]. Ive
Study: Flu, Fever in Pregnancy Linked to Autism Risk
been migraine free now for more than four years!
www.usatoday.com
With the right tools, dietitians can accomplishso much.
Kristen Conner Pardue:
However, to move forward, its essential they keep open minds
Disagree with this study.
and embrace new medical technology.
Women have had fevers
during pregnancy for
Lori Langer, RD, MEd, CLT, LDN,
decades.
specializes in food allergies, sensitivities,
Kimberly Davis-Coniglio:
intolerances, and inflammatory conditions
I found this to be interest-
ing and they state to be
cautious with this information, but the results defi-
nitely indicate that the fever-autism link should be
investigated further.
From Our Twitter Page
Popular Tweets, Retweets

@AhealthEeater: Just reading Todays Dietitian while

waiting for my oil change and enjoying a cup of coffee!

October Issue

Boosting B12 Intake

@SarahKoszykRD: Salmon has B12, which can possibly
reduce depression. Add 4 oz to salads or quinoa. Theres Homework to Do on School Lunches
Great B12 tips! well.blogs.nytimes.com
Trina Astor-Stewart: I agree with the article.
The Real Scoop on Sugar Children need to be introduced to healthful foods
in order to want them above the junk foods. These
@KarmstrongKurt: Thank you, Todays Dietitian, for a days, more moms are conscious of nutrition than
great link on the debate on sugar.
before.
Bonnie Egner Johnson: I dont see much change.
Combating Clostridium Difficile School lunch is just offering more of what students
@bmlococo: Just read the Todays Dietitian article havent chosen before. I believe the quality, appear-
about C diff. Could antibiotic use in animal meat be a ance, and the way fruits and vegetables are served
cause in increased cases? Any evidence out there? is often missing in school lunches. Salad with dress-
ing on it already? No thanks! There needs to be
Breast-Feeding Success more attention [paid] to this with less attention on
@runongreen: Breast-feeding success stories from the number of items offered!
Todays Dietitian inspire us to remember breast is Cyndy Finfrock: Starts and ends with the parents
best! eating habits and what they buy/prepare for their kids.

10 todays dietitian january 2013

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ASK THE EXPERT

Fill pitchers and glasses with ice using a scoop.

Get ingredients from lower cabinets.
Shape dough for cookies.
Place toppings on pizza or salad ingredients into a bowl.
Scoop batter into muffin tins for baking.
Mash ingredients such as bananas or cooked potatoes.
Set the table with assistance from an older family member.
Help clear off dirty dishes and smaller items on the table,
such as serving utensils or small containers.

Ages 6 to 8
Help plan meals for the week.
Select fresh fruits and vegetables at the supermarket.
Get ingredients for recipes in the kitchen and at the store.
Perform tasks over the stovetop with assistance, such as
COOKING WITH KIDS mixing oatmeal or scrambling eggs.
Prepare a simple salad, including shredding the lettuce and
By Toby Amidor, MS, RD, CDN
washing and peeling vegetables, as needed.

Q: In my practice, I typically recommend parents involve

their children with cooking. Could you provide some
guidance on age-appropriate cooking-related tasks kids can
Roll dough for pizza or cookies.
Use a butter knife to spread cream cheese or peanut butter.
Set the table without assistance.
perform? Help clear the table of all items.

A: Getting kids involved in the cooking process can help

them understand the concept of farm to table and pick up
healthful eating habits from an early age.
Load the dishwasher except for sharp objects such as knives.

Ages 8 and Up
Choose tasks they can perform from the start to the end of a Plan simple meals.
meal, including those related to planning, shopping, preparing, Write out a shopping list.
cooking, serving, and even cleaning up. Place an order at the deli and butcher counter.
Use a pizza cutter and can opener.
Kid-Appropriate Tasks Skewer food.
Listed below are suggested tasks for kids aged 2 and up. Each Make smoothies with supervision.
age group builds on the age-related tasks of the previous one. Prepare easy no-cook recipes such as tuna salad or home-
made trail mix.
Ages 2 to 3 Clear the table and help rinse small dishes before placing
Help place fresh fruits and vegetables in plastic produce them in the dishwasher.
bags at the supermarket. Help place leftovers in storage
Place food items in the shopping cart. containers and put the containers
Wash fruits and vegetables. in the refrigerator.
Toss empty packages and containers in the garbage.
Peel bananas and oranges with assistance. Toby Amidor, MS, RD, CDN, is
Stir batters with assistance. founder of Toby Amidor Nutrition
Place dirty dishes and silverware in the kitchen sink after a (www.tobyamidornutrition.com), a
meal with assistance. nutrition expert for FoodNetwork.
com, and a nutrition advisor
Ages 4 to 5 for Sears FitStudio.com.
Help select recipes (use recipes with photos).
Assist with food selection at the supermarket, specifically on
lower shelves. Have questions about nutrition trends, patient care,
Place food items from the shopping cart onto checkout coun- and other dietetics issues youd like to ask our expert?
ter with assistance. Send your questions to Ask the Expert at TDeditor@gvpub.com
or send a tweet to @tobyamidor.
Stir batters without assistance
Measure ingredients.

12 todays dietitian january 2013

 presents a new
online resource for
The Magazine for Nutrition Professionals

health-conscious individuals
Whether youre a nutrition professional or a consumer
looking for trustworthy guidance, the Todays Dietitian
Health & Nutrition Center is a free online resource
packed with useful information that can benet anyone.
Centered around a diverse catalog of nutritious and tasty
recipes, the Health & Nutrition Center also presents
articles and insights from an impressive array of experts.
Our online recipe database may be helpful to RDs writing
meal plans for clients with specic nutritional or dietary
needs, such as gluten free, plant based, or diabetes.
Also, share our site as a reference guide for clients, friends, nutrition professionals
and family members in need of fresh ideas and choices
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NUTRITION SUPPORT 360
PARENTERAL NUTRITION
HOME-STARTS
Learn How RDs Can Help Patients Safely
Begin PN Care at Home
By Sandra I. Austhof, MS, RD, LD, CNSC
People unable to use their gastrointestinal (GI) tract due
to intestinal failure require parenteral nutrition (PN). PN, the
administration of IV nutrients, is a potentially lifesaving ther-
apy that, when required long-term, can be administered safely
in the home to allow people to live higher-quality lives.1
Some clinicians believe PN should always be started in a
hospital setting where patients can be closely monitored to
avoid potential complications such as refeeding syndrome,
which causes electrolyte imbalances of serum phosphorous,
potassium, and magnesium that can potentially lead to heart
failure or other life-threatening conditions.
However, many home infusion companies have safely
and successfully started PN at home in patients with mild
to moderate electrolyte abnormalities by correcting these
electrolytes before PN infusion.2 This allows the patient to
be more comfortable and avoids the risk of possible expo-
sure to hospital-acquired infections while reducing overall
healthcare costs.
One of the earliest reports on transitioning PN from the
hospital to the home was documented 40 years ago.3 Due to
technological advances in access devices, infusion pumps,
14 todays dietitian january 2013
home care agency creation, and reimburse-
ment strategies, select patients have been
starting PN in the comfort of their homes
for the past 20 years.4 In fact, data spanning
the last 10 years have estimated that 39,000
patients receive PN at home each year.1
Home-start PN can save nearly $2,000 per
day in healthcare costs compared with receiv-
ing IV feeding in the hospital.5
Whether a patient begins PN in the hospi-
tal or at home, a knowledgeable interdisciplin-
ary team must develop a care plan with the
patient that includes the indication for home
PN, the approximate length of time the therapy
is needed, the end point of therapy, and nutri-
tional goals.6
This article will take a closer look at home-
start PN and evaluate its benefits in compari-
son with hospital-start PN as well as discuss
the role dietitians can play in preparing the
patient and family for PN care in the home
setting.
Evaluating the Home Environment
Once a physician determines a patient is a good candidate
for home PN, a home infusion nurse first assesses the patients
home environment for cleanliness, sanitary water supply, elec-
tricity, refrigeration, adequate storage space for supplies,
and telephone access.7 The nurse also assesses whether the
patient or caregiver is capable of administering home PN ther-
apy and verifies insurance coverage. If the patient is in the hos-
pital, a social worker, PN nurse, and nurse case manager meet
with the patient and family at the bedside to assess the home
environment and insurance coverage for home PN care.
Home PN Education
Once its considered safe to administer home PN, quali-
fied healthcare nurses begin educating the patient and
family about what it entails. The patient or a family member
is chosen as the primary caregiver who must demonstrate
competence in preparing and administering PN, which
includes infection control, caring for the vascular access
device, connecting and disconnecting the IV tubing, safely
incorporating additives, and properly storing supplies.7
For hospital-start PN patients, the PN nurse educates the
patient and family at the bedside, and a visiting nurse contin-
ues the instruction at home.
All patients receive three consecutive days of lessons in
the home. Once the home infusion nurse determines the pri-
mary caregiver can implement PN procedures, the nurse will
make weekly visits.
Advantages of Hospital-Start PN
Most patients discharged from the hospital on PN werent
admitted specifically to start PN but for unrelated medical or
surgical reasons that resulted in the need for home PN care.
Due to safety concerns, clinicians often prefer hospital-
start PN. High-risk patients who would benefit from hospital-
start PN include infants, the elderly, IV drug users, patients
with fluid and electrolyte disorders, those with uncontrolled
diabetes or major organ dysfunction, or those at high risk of
refeeding syndrome.7,8
Replacing fluid and electrolytes before initiating PN and
then starting PN with a low carbohydrate load can prevent
refeeding syndrome. Rex Speerhas, RPh, BCNSP, a clinical
nutrition specialist at the Cleveland Clinic, says, The patient
can be treated much more promptly and effectively in the
hospital setting with frequent intravenous electrolyte supple-
mentation. The bedside nurse and primary care physician
also can closely monitor the patient.
Another concern is hyperglycemia, the most common
side effect in preparing a patient for cyclic home PN.9 When
a patient is initiated in the hospital setting, blood glucose
levels can be monitored much more frequently, thus episodes
of hyperglycemia can be immediately treated with insulin or
avoided completely, Speerhas says, adding that to achieve
the same quality of care, close monitoring in the home set-
ting would require the presence of a healthcare professional
around the clock. The testing supplies needed would quickly
become very costly to the patient.
The hospital dietitians role in preparing the patient for
home PN involves stabilizing and cycling the PN formula
by monitoring daily vital signs, electrolytes, glucose levels,
intake and output records, and weights. This usually takes
three to six days to complete. PN is started at full protein
needs with one-half of the dextrose load infused continuously
over 24 hours. Lipids usually are given separately. Shortening
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the infusion time by four hours each day over three consecu-
tive days or six hours each day for two consecutive days can
cycle PN from 24 to 12 hours. In stable, select patients, PN
can be cycled from 24 to 12 hours over one day.
Advantages of Home-Start PN
While hospital-start PN has its advantages, home-start
PN also has its benefits. Home-start PN enables patients to
learn about PN in the comfort of their home plus they have
fewer hospital expenses and dont have to worry about
hospital-acquired infections.10 The decision to initiate PN
in the home depends on patients clinical stability, whether
they have a need for PN, whether a nurse can evaluate them
in their home, and whether a caregiver can safely adminis-
ter the therapy.7
Patients who can receive home PN care are those who either
dont have a chronic illness or have a chronic illness thats well
controlled, such as cancer, HIV, hyperemesis gravidarum, or GI
disorders; those with bariatric surgery complications; or those
with failed enteral nutrition.8,10
Many home infusion companies that provide home-start
PN services have experienced dietitians, nurses, and phar-
macists working for them who can offer quality care to
patients and have a track record of successfully initiating PN
in the home, bypassing hospital admission.
Walgreens Infusion Services, the nations largest infu-
sion provider, initiates home PN with at least one patient
almost every day. According to Noreen Luszcz, RD, MBA,
CNSC, Walgreens nutrition program director, the key to the
companys success is its multidisciplinary team approach,
slow progression of starting PN, and ongoing communica-
tion with the team, patient, and physician. Slow progression
means that macronutrients, especially dextrose, are started
at a reduced concentration to prevent complications such as
hyperglycemia or electrolyte imbalances.
january 2013 www.todaysdietitian.com 15
 Once Walgreens receives a referral from a physicians
office or clinic, a dietitian and a nurse become actively
involved in the initial home visit. The dietitian completes a
comprehensive nutrition assessment and determines needs
and formula recommendations.
Choosing appropriate patients for home-start PN is
essential. Luszcz reports that high-risk patients, such as
those with uncontrolled diabetes, high GI losses, or multi-
ple organ failure, usually are referred to hospital-start PN.
When beginning PN in the home, however, Luszcz says Wal-
greens patients begin with reduced protein, dextrose, and
lipids infused over 24 hours. Daily weights, lab data, and
intake and output records are closely monitored.
Once the patient is stabilized, which can take several days,
PN is slowly increased to provide the full amount of macro-
nutrients. PN is reduced to 18 hours and eventually to eight
to 12 hours once the patient is stabilized on full PN. Some
home infusion companies, such as ThriveRx, start low-
calorie PN over 12 to 18 hours at a reduced rate for younger,
stable patients, according to Donna Kloth, RN, CRNI, CNSC, a
With the advances in standards
of care, equipment, and
specialized home infusion
services, patients can start
IV nutrition at home, allowing
for continued daily activities
and increased quality of life.
nutrition liaison with ThriveRx. By carefully monitoring the
patient, we slowly advance the PN formulation to goal, which
usually takes a week, she explains.
To prevent refeeding syndrome, home infusion companies
usually have protocols that involve administering replace-
ment fluids and electrolytes in the home before starting
PN. In one study, Walgreens showed that patients at risk of
refeeding syndrome can safely begin home PN, eliminating
the need for hospital admission.2 In this small, retrospec-
tive study, 15 high-risk patients were started on 25% of dex-
trose needs for the first three to four days. Once the patients
were stabilized, 50% of dextrose needs were given for another
three to four days. Researchers closely monitored lab results,
and patients reached their PN goal needs.
16 todays dietitian january 2013
Safe Alternative
Patients have been started safely on PN in the hospital setting
and at home for many years. The key to this success has been the
experience of knowledgeable interdisciplinary healthcare teams
consisting of physicians, dietitians, nurses, and pharmacists. With
the advances in standards of care, equipment, and specialized
home infusion services, patients can start IV nutrition at home,
allowing for continued daily activities and increased quality of life.
Sandra I. Austhof, MS, RD, LD, CNSC, is a nutrition
support dietitian at the Cleveland Clinic and has
worked in the field for more than 30 years.
Acknowledgement
The author would like to extend a special thanks to Kaylee
Adams, a PharmD candidate at Ohio Northern University, for her
assistance in the research of this article.
References
1. Ireton-Jones C, DeLegge MH, Epperson LA, Alexander
J. Management of the home parenteral nutrition patient. Nutr
Clin Pract. 2003;18(4):310-317.
2. Jansson L, Brand S, Monahan R, Knowles S. Home start
parenteral nutritionyes we can! Presented at: American
Society for Parenteral and Enteral Nutrition Clinical Nutrition
Week; January 21-24, 2012; Orlando, FL.
3. Jeejeebhoy KN, Zohrab WJ, Langer B, Phillips MJ, Kuksis
A, Anderson GH. Total parenteral nutrition at home for 23
months, without complication, and with good rehabilitation.
A study of technical and metabolic features. Gastroenterology.
1973;65(5):811-820.
4. Sanville MH. Initiating parenteral nutrition therapy in the
home. J Intraven Nurs. 1994;17(3):119-126.
5. Ireton-Jones C, Hamilton KS, DeLegge MH. Improving
clinical and financial outcomes with parenteral nutrition ther-
apy. Support Line. 2009;31(1):23-25.
6. Kirby DF, Corrigan ML, Speerhas RA, Emery DM. Home
parenteral nutrition tutorial. JPEN J Parenter Enteral Nutr.
2012;36(6):632-644.
7. Kovacevich DS, Frederick A, Kelly D, Nishikawa R, Young
L. Standards for specialized nutrition support: home care
patients. Nutr Clin Pract. 2005;20(5):579-590.
8. Crocker KS, Ricciardi C, DiLeso M. Initiating total paren-
teral nutrition at home. Nutr Clin Pract. 1999;14:124-129.
9. Suryadevara S, Celestin J, DeChicco R, et al. Type and
prevalence of adverse events during the parenteral nutrition
cycling process in patients being prepared for discharge. Nutr
Clin Pract. 2012;27(2):268-273.
10. Newton AF, DeLegge MH. Home initiation of parenteral
nutrition. Nutr Clin Pract. 2007;22(1):57-64.

EMERGENCY PREPAREDNESS
Cloud-Based Backup Simplifies
This Essential Task
By Reid Goldsborough
Hurricane Sandy, which led to so much damage in New York
and New Jersey in late October 2012, was only one of numer-
ous natural and manmade disasters that, along with destroying
life and property, destroyed data. Whether you work for a large
company, run a small business, or use a computing device in
your home or whether its corporate trade secrets or family
photos, data can be irreplaceable.
The key to disaster recovery is disaster preparation, and the
key to disaster preparation is redundancy. In a nutshell, back-
ups. If you have backup power such as a generator, you can con-
tinue to compute if the electricity goes out. If you have one or
more backup computers, you can still get things done if equip-
ment is damaged. And if you have backup data, you can pick up
any project where you left off.
Cloud Computing
For several years now a big buzzword in the computer world
has been the cloud, which is just a whimsical way of saying the
Internet. Instead of storing data or using programs on computers
at your location, with cloud computing you use data or programs
stored on other computers you connect to over the Internet.
One of the most effective uses for cloud computing is making
remote backups of data. That way, even if your computer equip-
ment is destroyed in a flood or fire, you wont lose your data.
The same cant be said for a backup stored at your location
that youve made onto an external hard drive, USB drive, opti-
cal disc, or tape, though these media still can be useful among
other ways as a backup for your backup.
Remote Backup Services
A host of free and fee-based remote backup services have
popped up in recent years. The free services typically provide
a limited but often appreciable amount of storage space, with
additional storage costs.
PERSONAL COMPUTING
Along with using such services for backing up, you often can
use them for other purposes as well, such as sending large files
in ways that are more convenient than e-mail or other older
technologies, syncing files youre working on from different
computers, and collaborating with others on the same project.
Heres a rundown of seven of the more useful or otherwise
notable file hosting services that are primarily for backing up
files or can be used for the above purposes. Each of the ser-
vices below is free for a given amount of storage space. Big
names are important, since you dont want such a service to go
away, but the smaller guys listed below appear stable.
Dropbox (www.dropbox.com): This may be the most
talked about and recommended file hosting service. Its fairly
skimpy on the free storage, offering only 2 gigabytes, but its
easy to use and versatile. You use it by either copying files you
want automatically backed up into a Dropbox folder or subfold-
ers on your computer or you ensure the files you want auto
matically backed up are stored in one of these folders.
SugarSync (www.sugarsync.com): With 5 gigabytes of
storage before you have to pay, SugarSync is more generous
than Dropbox. It also doesnt require you to create special fold-
ers but instead lets you designate which of your folders you
want automatically backed up with its own interface.
IDrive Sync (www.idrive.com): This is the most gener-
ous of the services listed here, giving you 10 gigabytes of free
storage. Unlike some other services, IDrive lets you choose
between continuous backup and scheduled backup, which is
the default.
Google Drive (http://drive.google.com): If you already use
Google Docs, a free cloud suite of word processing, presenta-
tion, spreadsheet, and other programs, this is where your files
are stored. But you also can use Google Drive with data created
using programs on your own computer. It offers 5 gigabytes of
free storage.
Amazon Cloud Drive (www.amazon.com/clouddrive): This
is Amazons cloud storage service, but its clunkier than the
other services here. Amazon Cloud Drive offers 5 gigabytes of
free storage. It makes copies of previously backed up or deleted
files in case you need to retrieve them.
iCloud (http://apple.com/icloud): From Apple, this service
is tailored to Apple products. It can work with an iPad, iPhone,
iPod touch, or Mac, and it works with Windows PCs as well.
iCloud gives you 5 gigabytes of free storage.
Skydrive (http://skydrive.live.com): This is Microsofts
offering, with 7 gigabytes of free storage. Along with Windows
PCs and Windows Phone, Skydrive also works with Macs, Apple
devices, and Android devices.
Ultimately, choosing and using a backup service is far more
important than which service you choose.
Reid Goldsborough is a syndicated columnist and author of the
book Straight Talk About the Information Superhighway. He can be
reached at reidgoldsborough@gmail.com or www.reidgold.com.
january 2013 www.todaysdietitian.com 17
DYNAMICS OF DIABETES
DIABETES AND
COMPLEMENTARY CARE
More Patients Are Following Alternative Diets
to Manage the Disease
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
As diabetes cases continue to soar worldwide, people with
the disease are turning more and more to alternative thera-
pies to help manage it. Specifically, in an analysis of data from
the 2002 National Health Interview Survey, Bell and colleagues
found that more than 72% of people with diabetes use comple-
mentary and alternative medicine (CAM) to manage their dis-
ease.1 A literature review on the use of CAM among people with
diabetes, published in 2007 in the Journal of Advanced Nursing,
reported prevalence rates as high as 78%. Moreover, people
with diabetes are 1.6 times more likely to use CAM therapies
than people without diabetes.2
What Is CAM?
The terms alternative medicine and complementary med-
icine often are used interchangeably, but according to the
National Center for Complementary and Alternative Medicine,
CAM is a group of diverse medical and healthcare systems,
practices, and products that arent generally considered to be
part of conventional medicine. Complementary medicine is
used with conventional medicine, whereas alternative medicine
is used instead of conventional medicine.3
Examples of CAM therapies include herbs, bodywork,
special diets, and dietary supplements. Most people with
diabetes who use CAM follow diet-based therapies to
manage the disease.1
The following are the six most common diet-based therapies
people use to treat diabetes more naturally and holistically.
18 todays dietitian january 2013
Alkaline Diet
This diet is based on the fact our bodies have a pH of 7.35
to 7.45, which makes them slightly alkaline.4 Proponents of
the alkaline diet believe humans evolved on a diet much more
alkali forming than diets eaten today. An excess of grains and
animal products is believed to cause an acid overload, leading
to muscle wasting, kidney stone formation, kidney damage,
and the dissolution of bone.4 But Vesanto Melina, MS, RD,
coauthor of Becoming Raw: The Essential Guide to Raw Vegan
Diets, notes that all the research has been theoretical.
The fact is that the body works hard and efficiently on its
own to keep the blood at the proper pH. Our body is capable of
adequately maintaining the perfect acid-base balance regard-
less of what we eat, says Vandana Sheth, RD, CDE, a spokes-
person for the Academy of Nutrition and Dietetics, so theres
no need to alter the diet to try to affect the pH level.
However, Sheth believes the alkaline diet can be a healthful
choice for people with diabetes. An alkaline diet is primarily a
vegetarian diet, emphasizing fresh fruits, vegetables, soy, nuts,
legumes, and olive oil, she says.
Food-Combining Diet
The theory behind the food-combining diet is that if protein
and starch are eaten simultaneously, the body will wear itself out
by producing both alkaline and acidic digestive juices, which nul-
lify both the protein and the starch and impair digestion.4 This
diet promotes eating proteins and starches at separate meals.
Vegetables can be eaten with both protein and starch, but fruits
should be eaten alone. Its proponents say this diet will encour-
age weight loss and improve digestion. Research supports that
a weight loss of 10 to 15 lbs is enough to decrease insulin resis-
tance and improve blood glucose levels in people with diabetes.
However, theres no scientific evidence stating this diet is
beneficial for weight loss or digestion. In fact, The research is
flawed, and some of the ideas are counterproductive, Melina
says. For example, vitamin C in fruit can help increase iron
absorption from iron-rich plant foods such as legumes. But
according to food-combining guidelines, this combination isnt
permissible. For people with diabetes, this diet is contrary to
the American Diabetes Associations 2012 nutrition recom-
mendations for optimal blood glucose control. Balancing a
meal with both protein and carbohydrates promotes fewer
carbs at the meal, resulting in more stable blood glucose and
insulin levels.
Macrobiotic Diet
This diet incorporates the Asian philosophy that foods are
either yin (cooler) or yang (warmer) and that certain health
conditions require food that will cool or warm the body. The
macrobiotic diet is vegetarian based, consisting mainly of
brown rice, whole grains, and vegetables. It has gained pop-
ularity among cancer patients who understand it to be an
 Today's Dietitian Ad_12-03-12 (2-2).ai 1 12/3/12 4:54 PM

effective way to treat the disease. Currently, theres no evi-

dence that a macrobiotic diet can prevent or cure cancer.
Researchers are examining whether a macrobiotic diet can
prevent and treat diabetes. A study published in the Septem-
ber 2012 issue of the Journal of Nutrition and Metabolism found
that a macrobiotic diet could be a successful therapy for type 2
diabetes. The macrobiotic diet is naturally high in fiber, which
helps to slow the conversion of starch to glucose, thus keeping
the blood glucose level more stable. In fact, participants in this
study were able to reduce their insulin by as much as 64%.

Raw Food Diet

Based on unprocessed and uncooked plant foods, the
raw food diet consists of fresh fruits and vegetables,
sprouts, seeds, nuts, grains, beans, dried fruit, and sea-
weed. Followers believe that heating a food above 118F
destroys helpful enzymes in food, but eating food raw or
carefully dehydrated increases energy, improves digestion,
promotes weight loss, and reduces the risk of chronic ill-
nesses, including diabetes.5
This diet is very restrictive and could cause nutrient defi-
ciencies in calcium, iron, vitamin B12, and protein.5 Con- C

trary to the belief of raw food diet proponents, the enzymes M

needed for digestion are produced by the pancreas and Y

small intestines.
CM
Research on the raw food diet is under way, but no studies
have looked at the diets effect on diabetes specifically. MY

CY

The Makers Diet CMY

The Makers Diet is based on eating foods that God intended

K
for us to eat, such as whole natural foods, including organic
meats, fruits, and vegetables. It also encompasses the four
pillars of healthphysical, spiritual, mental, and emotional
including increasing physical activity, reducing stress, and
finding faith.6 The diet claims to improve health and promote
weight loss, which will lower the risks of chronic illnesses,
including diabetes.
There are many benefits to adopting a lifestyle that will
increase physical activity, reduce stress, and help one find
faith. This is particularly true when it comes to diabe-
tes, which can be a challenge physically, spiritually, and
emotionally.
The diet is broken down into three phases that last a total of
40 daysthe first of which allows no carbohydrates. The next
two phases slowly reintroduce healthful foods, including whole
grains, fruits, and vegetables, and organic meats such as beef
and chicken.6
The diet recommends a large number of supplements
that Jordan Rubin, the author of the book, happens to sell on
his website. Rubin claims the diet is well researched in clini-
cal trials and studies. However, there are no significant peer-
reviewed journal articles on the Makers Diet.6

january 2013 www.todaysdietitian.com 19

Ayurvedic Diet
The Ayurvedic diet, popularized by author Deepak Chopra,
MD, is based on a system of medicine that originated in ancient
India. It attempts to balance and restore harmony in the body by
using diet, yoga, and herbs.
The diet is built on a theory that people are born with
unique characteristics based on the combination of doshas
in the gene structure. The doshas are dynamic forces within
the universe, including earth, water, fire, and wind. A per-
sons chances of developing certain types of diseases are
thought to be related to the way doshas are balanced, the
state of the physical body, and mental or lifestyle factors.7
Ayurvedic doctors determine which doshas are strongest
and which are out of balance, and give a diet prescription that
strengthens and balances them. Ayurvedic practitioners claim
this diet will bring harmony back to the body and, in doing so,
help with weight loss and decrease the likelihood of chronic ill-
nesses, including diabetes.
Ayurvedic treatments rely heavily on herbs and other plants,
such as oils and common spices. Turmeric, holy basil, Coccinia
indica, gumar, fenugreek, and jambul powder are commonly
RESOURCES
You dont need to know everything about com-
plementary and alternative medicine, but you
should know where to find credible information.
The following resources can help:
Resources for Patients
National Center for Complementary and Alterna-
tive Medicine (NCCAM) (http://nccam.nih.gov)
NCCAM Time to Talk Tips on Complementary
Health Practices (http://nccam.nih.gov/
health/tips)
MedlinePlus (www.nlm.nih.gov/medlineplus)
Federal Resources for Providers
NCCAM Resources for Health Care Providers
(http://nccam.nih.gov/health/providers)
NCCAM Clinical Digest monthly e-newsletter
(http://nccam.nih.gov/health/providers/digest)
NCCAM Complementary and Alternative Medi-
cine Online Continuing Education Series (http://
nccam.nih.gov/training/videolectures)
20 todays dietitian january 2013
used for diabetes, Sheth says. And theres evidence suggest-
ing Coccinia indica, holy basil, fenugreek, and Gymnema sylvestre
have a glucose-lowering effect.8
Most clinical trials of Ayurvedic approaches have been
small and not well done. Therefore, scientific evidence for
the effectiveness of Ayurvedic practices varies. More rig-
orous research is needed to determine which practices are
safe and effective.7
Tips for Dietitians
Its important for RDs to increase their knowledge and
awareness of alternative approaches to diabetes self-
management, Sheth says, as more people with the disease
turn to CAM to manage it. This will enable RDs to more effec-
tively counsel their clients. To ensure coordinated and safe
care, Sheth encourages RDs to communicate with their clients
alternative medicine practitioners as well.
Constance Brown-Riggs, MSEd, RD, CDE, CDN, is the
national spokesperson for the Academy of Nutrition and Dietetics,
specializing in African American nutrition, and author of the
African American Guide to Living Well With Diabetes
and Eating Soulfully and Healthfully With Diabetes.
References
1. Bell RA, Suerken CK, Grzywacz JG, Lang W, Quandt SA,
Arcury TA. Complementary and alternative medicine use
among adults with diabetes in the United States. Altern Ther
Health Med. 2006;12(5):16-22.
2. Egede LE, Ye X, Zheng D, Silverstein MD. The prevalence
and pattern of complementary and alternative medicine use in
individuals with diabetes. Diabetes Care. 2002;25(2):324-329.
3. Complementary and alternative medical therapies for dia-
betes. National Diabetes Information Clearinghouse website.
http://diabetes.niddk.nih.gov/dm/pubs/alternativetherapies.
Last updated January 24, 2012. Accessed November 18, 2012.
4. Davis B, Melina V, Berry R. Becoming Raw: The Essential
Guide to Raw Vegan Diets. Summertown, TN: Book Publishing
Co; 2010: 176-178.
5. Raw food diet. WebMD website. http://www.webmd.com/
food-recipes/guide/raw-food-diet. Reviewed February 20, 2010.
Accessed November 11, 2012.
6. Longe JL. The Gale Encyclopedia of Diets: A Guide to Health
and Nutrition. Farmington Hills, MI: Gale; 2007: 643-646.
7. Ayurvedic medicine: an introduction. National Center
for Complementary and Alternative Medicine website. http://
nccam.nih.gov/health/ayurveda/introduction.htm. Last updated
July 2009. Accessed November 11, 2012.
8. Hardy ML, Coulter I, Venuturupalli S, et al. Ayurvedic inter-
ventions for diabetes mellitus: a systematic review. Evid Rep
Technol Assess (Summ). 2001;(41):2p.
 FNCE 2012 CON
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FOR YOUR INFORMATION
RISING FOOD COSTS
How Last Years Drought May Affect
This Years Prices
By David Yeager
No one can say with certainty whether climate change is
directly responsible for the droughts that have plagued the
United States over the past couple years, but you cant deny that
2011 and 2012 brought exceptionally dry weather to significant
portions of the country.
In 2011, the most severe drought in decades hit large seg-
ments of Texas, decimating the states cattle industry. In 2012,
the Midwest and its grain crops bore the brunt of the drought.
Although fluctuations in rainfall occur every year, extended
periods without enough rain could pose a serious problem for
the United States in the future.
Jack Juvik, PhD, a professor and the graduate program
coordinator in the department of crop sciences at the University
of Illinois College of Agricultural, Consumer, and Environmental
Sciences, says water issues are affecting most countries
dramatically in some casesand the United States is no excep-
tion. He cites areas of the Central Valley in California where the
salt level of the soil already prevents the growth of a range of
valuable crops. In places like this, long-term drought could be
especially damaging. If water becomes scarcer, it could multiply
this effect and lead to disputes among regions and states vying
for use of the same major water systems.
So not only is [water scarcity] going to affect what we can
grow, its going to affect where we can grow, and its also
going to lead to huge, huge battles, legal [battles] and, prob-
ably, armed conflict [in some countries]. There are a lot of
places right now that are on the edge of conflict due to the
fact people are fighting for water rights, Juvik explains. Since
water is essential for life, it should come as no surprise that
22 todays dietitian january 2013
between 80% and 90% of freshwater con-
sumption in the United States is attributable to
agriculture.
In his research, Juvik has measured varia-
tions in phytochemical levels up to 20% in some
drought-affected fruits and vegetables, but
that effect is difficult to measure because each
nutrient, as well as each fruit or vegetable, is
affected differently. However, these variations
arent likely to have a significant effect on human
health; a much greater threat from drought is its
effect on crop yields.
In the United States, irrigated crops have
been less affected by drought than nonirrigated
crops. More efficient water management in
recent years has helped to conserve water thats
used on crops, particularly those that require
irrigation. Where farmers once flooded fields
and orchards, those who can afford it have switched to more
efficient drip irrigation systems. Most fruits and vegetables
require irrigation.
The United States also imports a significant amount of pro-
duce, such as bananas, tomatoes, melons, peppers, and pota-
toes, from other countries. For these reasons, food price
increases for produce probably have been less related to water
availability than to other factors such as transportation and
refrigeration costs. As long as farmers can maintain irrigation,
the availability of produce should remain stable.
Hidden Costs
After Hurricane Sandy pummeled the East Coast in October
2012, many Americans probably forgot about the oppressive
heat and drought that affected a large part of the country this
past summer. But with nearly two-thirds of the United States
still affected by drought, consumers could feel the effects well
into this year.
Because the drought was concentrated in the Midwest, the
crops hit hardest were grain products such as corn, soybeans,
and wheat, which arent irrigated. Aside from the obvious rise
in the cost of these staple crops, David Bitter, CEO of Cropfax,
a provider of seed selection decision-making tools, says prices
are likely to rise for nearly all food products.
Grains are just such large volume [items], and they go into
everything. Corn is in [nearly] everything that has been pro-
cessed, and youve got aisles and aisles of it, Bitter says.
Youve got one small produce section in the store, which is kind
of like the jewel in the crown; youve got strawberries, youve
got fresh fruit. But the rest of the store, unless its a bottled
fruit or a packaged fruit, is pretty much a derivative of corn or
soy or wheat: your granola bars, your cereals, your chips.
Higher grain prices also are reflected in the cost of animal
feed. This affects food costs because it increases the cost of
animal farming. Animal products already cost more to produce schedule for the next week so youre able to buy accordingly,
than vegetable products, and drought exacerbates these costs. especially produce, Sandquist says. Will you be home or
The consumption of water for the production of meatsfor are you going to be gone? If its a week when youre out a lot,
beef, poultry, hogs, etcper acre and per pound of product out- youre not going to have a chance to eat that produce unless
strips produce and grain by many, many factors, Bitter says. you take it with you for a snack.
So it [seems likely that] if you have a higher cost of grain and a
scarcity of water, meat prices will continue to escalate. David Yeager is a freelance writer and editor
Overall, the USDA forecasts that food prices will rise 3% to based in Royersford, Pennsylvania.
Half page Lea Russel_Layout 1 12/3/12 1:39 PM Page 1
4% in 2013, but prices for some meat and dairy products may
decrease in the short term. This is because
some farmers are reducing their herds in
response to the drought. Once the extra supply
has been consumed, prices for beef, pork,
poultry, and dairy are expected to rise between
2.5% and 5%. Grow your practice and improve
Stretching Food Budgets patient outcomes with the leader
Taken together, these factors suggest that
consumers will need to stretch their food budgets
in food sensitivity testing
a little further than usual. Dee Sandquist, MS, For almost 25 years, The ALCAT Test has provided physicians and their
RD, LD, CDE, a spokesperson for the Academy patients with a tool to successfully overcome a wide variety of conditions
of Nutrition and Dietetics, says small changes in resulting from food and chemical intolerances.
food buying and preparation can make a big dif-
ference. While the additional cost of meat may The ALCAT Test accurately measures immune reactions
be challenging, there are ways to work around it. to over 290 foods, additives and environmental chemicals
using just a small quantity of blood.
One way is to purchase cheaper cuts of meat for
some meals. Another is to add plant protein.
The ALCAT Test is the most effective tool I
Some people will choose to eat more plant-
use in my practice to assist my patients in
based proteins, and thats certainly a healthful the management of food sensitivity and
choice, Sandquist says. So it might be a good intolerance -Lea Russell, MBA, RD, LD/N,
time to mix some lentils in with that ground Nutrition Health Services, Tampa, Florida
beef if you want to stretch your food dollar a www.nutritionhealthservices.com
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A recent report from the Natural Resources If you see patients who suffer from migraine headaches, IBS,
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waste as much as 40% of the food they buy, simply cant lose weight, call us today!
resulting in a loss of $165 billion per year.
Cell Science Systems, Corp. 1(800) US-ALCAT (872-5228) 1-954-426-2304 www.ALCAT.com
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PRODUCT SERVICE

C NRTL US

before you go to the store. Look at your

january 2013 www.todaysdietitian.com 23

Gluten-Free
The

Journey Whether clients follow the diet

because of celiac disease or the less
understood gluten sensitivity, RDs
serve as a guide for patients on a
lifelong quest to relieve symptoms
and improve health.
BY MAURA KELLER
A
fter months of gastrointestinal discom-
fort, abdominal pain, and bloating followed
by weeks of medical testing, Susan finally
learned she has celiac disease. Frightened,
confused, and overwhelmed about the next
steps in her new restricted dietary lifestyle,
she turned to an RD her physician recommended. The RD faces
the challenge of calming her new patient, educating Susan
about the celiac disease diagnosis, and walking with her along a
journey fraught with misinformation and confusion.
Celiac Disease vs. Gluten Sensitivity
Its not surprising that many patients newly diagnosed with
celiac disease become overwhelmed at the thought of modi-
fying their lifestyle, including what they can and cannot eat in
restaurants and at parties. Fortunately, Susan and others with
celiac disease arent alone in their journey. According to Rachel
Begun, MS, RD, CDN, a food and nutrition consultant and
spokesperson for the Academy of Nutrition and Dietetics (the
Academy), approximately 1% of the population has celiac dis-
ease, and about 90% of them are undiagnosed or misdiagnosed.
A bigger portion of the population experiences gluten sen-
sitivity to varying degrees. Estimates are that as much as 6% of
the population, or 20 million Americans, may be gluten sensi-
tive, Begun says.
Celiac disease is an autoimmune disorder in which the body
triggers an attack on the intestines every time gluten is eaten,
Begun says. Inflammation and damage occur in the small intes-
tine and nutrients cant be absorbed, leading to nutrition defi-
ciencies and a wide range of symptoms.
Begun says many people with the disease are asymptomatic
and thus dont experience any negative symptoms after eating
gluten. They are, however, experiencing the same damage to the
intestines as those who do experience symptoms, she cautions.
According to the National Foundation for Celiac Awareness,
non-celiac gluten sensitivity is found in individuals who cannot
tolerate gluten and experience symptoms similar to those with
celiac disease but yet who lack the same antibodies and intes-
tinal damage as seen in celiac disease. Early research sug-
gests that non-celiac gluten sensitivity is an innate immune
response, as opposed to an adaptive immune response (such
as autoimmune) or allergic reaction.
We dont know much about gluten sensitivity just yet, but
we do know that its a unique condition from celiac disease and
involves an immune response, Begun says. While symptoms
of gluten sensitivity can be similar to those of celiac disease,
people with gluten sensitivity dont produce antibodies to gluten
or show signs of damage to the intestine.
Dietary Treatment
Laura Jeffers, MEd, RD, LD, says patients usually are eager
to embrace the gluten-free (GF) lifestyle once they realize how
it will benefit them: symptom relief, more energy, better health
status, and an improved quality of life. Jeffers, outpatient man-
ager for nutrition therapy at the Digestive Disease Institute at
the Cleveland Clinic, teaches patients the importance of adopt-
ing the changes involved in living GF for the long haul.
I stress the importance of GF for life, Jeffers says. No
small bites every now and then and no mostly GF. I also explain
that wheat free is not gluten free and that reading labels must
become a habit. While theres no cure for [celiac disease], the
GF diet can relieve symptoms of the disease, and patients can
feel healthy and full of energy while on the diet. The mucosal
damage is a result of a genetic predisposition in combination
with environmental factors and inflammation that s immune
based. Therefore its important for dietitians to clarify with
their patients that even the tiniest amount of gluten may cause
intestinal damage even if there are no overt symptoms.
Some patients are in a state of shock when they find out
they have a type of condition thats not going to go away, says
Lenore Wespetal, MS, RD, CDE, a certified diabetes educatorat
Shawano Medical Center in Wisconsin.
Gluten Buzzwords
RDs need to educate their clients with celiac dis-
ease about the buzzwords on food labels that may
indicate the presence of gluten. These buzzwords
include wheat, rye, oats, barley, malt, and brewers
yeast. (Note: If the oats are labeled as gluten free,
theyre safe to eat as part of a gluten-free diet.)
Wheat is required to be identified [on a food label],
as it is one of the top eight allergens that have to be
declared on the label, according to the Food and Drug
Administrations Food Allergy and Consumer Pro-
tection Act, explains Mary K. Sharrett, MS, RD, LD,
CNSD. Rye and oats arent hidden in any ingredients,
although oats need to be labeled gluten free to be sure
theyre uncontaminated. Barley is almost always listed
as barley or malt. Brewers yeast is likely to be con-
taminated with barley.
Sharrett says hidden wheat may be found in prod-
ucts governed by the USDA because they dont have
to follow the FDAs allergy labeling laws. Therefore
wheat may be in modified food starch, starch, or dex-
trin, Sharrett says. The good news is that 80% to
90% of these companies do identify allergens.
To identify a USDA-inspected food (eg, processed
meat, poultry, eggs, and some mixed food products,
such as soups containing meat) look for an Inspected
by the USDA stamp on the front of the package.
MK
january 2013 www.todaysdietitian.com 25
 Most of Beguns patients feel overwhelmed with the dietary
changes that are part of a GF diet. In particular, parents of
[young] celiac disease patients can feel overwhelmed knowing
theyre responsible for ensuring their kids avoid gluten. While
some are relieved knowing they finally have found the answer to
their health issues, others are in denial about having to change
their diet, Begun says. Theres also the emotional part that
comes with the social aspects of eating. People are worried they
wont be able to enjoy eating out which, for many, is an important
part of socializing with friends and family. In the end, though,
most are happy to be feeling better and doing the right thing for
their long-term health.
To Eat or Not to Eat
The key types of common foods that are safe for patients
with celiac disease include naturally GF items such as fruits,
vegetables, meats, nuts, legumes, fish, poultry, eggs, and most
dairy (eg, cheese, yogurt, cottage cheese). GF grains include rice
and corn. Some less familiar GF options include flaxseeds, nut
and bean flours, potato starch, quinoa, rice bran, teff, wild rice,
tapioca, buckwheat, arrowroot, millet, amaranth, chia seeds,
mesquite, montina, sago, and sorghum. Oats also are consid-
ered GF but only if theyre labeled as such.
Begun stresses RDs need to help their patients with celiac
disease focus their diet on naturally GF foods rather than GF
packaged alternatives. Its even more important to get this
message across with newly diagnosed patients because their
bodies have been devoid of nutrients and need to heal, she says.
Snacks Aplenty
While preparing gluten-free meals takes some effort
to evaluate ingredients and identify gluten-free recipes,
snack options are plentiful:
Gluten-free corn tortilla chips are available in white,
yellow, and blue varieties. You can enjoy some great
flavor combinations when you pair them with salsa,
hummus, cherry tomatoes, carrot sticks, or tart
apple slices.
A handful of nuts or roasted soy nuts is a protein-rich
snack and easy to store in your pantry, a desk drawer,
a gym bag, or a purse.
Enjoy a gluten-free bagel or slices of bread with
peanut butter.
Try orange slices with sugar snap peas when you
know your next meal will be delayed.
Make your own snack mix with gluten-free cereal
squares, dried fruit, and sunflower or pumpkin seeds.
MK
26 todays dietitian january 2013
Nutrient-dense foods remedy nutrition deficiencies and help
the body to heal faster.
Its also important to meet patients where they are in terms of
current lifestyle and dietary patterns. If a patient has no cook-
ing skills and is traveling for business five days a week, then its
a good idea to focus first on how to handle themselves in a res-
taurant, Begun says. For the mother whos making most of the
childs meals and snacks at home, then you want to teach them
how to make smart choices at the grocery store as well as intro-
duce them to common ingredients used in gluten-free cooking
and baking.
Avoiding cross-contamination when following a GF diet is
of utmost importance. Its very important to discuss cross-
contamination with newly diagnosed patients, Jeffers says.
Its important for patients to understand how easily foods
can become contaminated with gluten. If a gluten bun on a
sandwich is removed and replaced with the GF bread, its
too late. Or if there are croutons on the salad and [theyre]
picked off, the salad shouldnt be eaten since it was already
contaminated.
Additionally, gluten can be spread from containers of food,
such as peanut butter and jelly, when a knife that has touched
gluten-containing bread is dipped into the jar. Its also important
to use separate toasters and related small appliances as well as
cutting boards and dishes when handling both GF and non-GF
foods. If this isnt possible, the item must be thoroughly cleaned
to remove any traces of gluten to avoid cross-contamination.
Be sure to tell patients to read the food labels of their favor-
ite foods every six months, as ingredients can change at any
time and some products that didnt contain gluten in the past
may contain it now, Jeffers says.
Helping People Adapt
Mary K. Sharrett, MS, RD, LD, CNSD, a clinical dietitian in
nutritional support services at Nationwide Childrens Hospital in
Columbus, Ohio, suggests RDs schedule two 45-minute to one-
hour sessions with clients newly diagnosed with celiac disease
because theyll have numerous questions, as theres much to
learn about following a GF diet.
If you dont know the answer, dont try to guess. Tell them
youll get back to them and then find an expert to help you, says
Sharrett, whos also a member of the Academys celiac disease
expert workgroup for the Evidence-Based Analysis Library and
the founder and dietitian advisor for the Gluten-Free Gang, a
celiac disease support group. The Academys Medical Nutrition
Practice Group has a subunit called Dietitians in Gluten Intoler-
ance Disease with lots of experts.
Sharrett also recommends RDs provide a few naturally GF
recipes to help clients start their journey. Moreover, RDs should
determine some of their clients favorite meals and provide sug-
gestions for making them GF. For instance, if a client enjoys
tacos, suggesting a GF brand of taco seasoning is a good fix.
For patients having difficulty adhering to the diet, encourage
them to get involved with a support group, online or in person,
Jeffers says. Also, let patients know
there are many great online sources of
gluten-free products, and some compa-
nies will send samples.
Wespetal says its also important to
determine what research the patient
already has done regarding celiac dis-
ease and a GF diet. This will help clarify
any misconceptions the patient may have
about what celiac disease is and what
their role is in managing it, she says.
Also, RDs should explain how to review
ingredient lists on food packages. Is it
clear to them that wheat free does not
mean gluten free? Finally, use follow-up
visits to assess the nutritional adequacy
of the patients typical eating pattern,
especially fiber and B vitamins.
Your patients become very informed
and may teach you something along
the way, Jeffers says. Theres nothing
wrong with learning from your patients
especially since theyre living it on a
daily basis.
Eating Out
For many people with celiac disease,
eating at restaurants or attending par-
ties especially may cause frustration
and fear. To increase the likelihood of
getting a safe meal, call the restaurant
ahead of time to let them know about
your gluten-free needs, Begun says.
Right from the beginning youll know
if the restaurant isnt knowledgeable
about serving people with dietary restric-
tions. If you get that gut feeling that they
dont know what youre talking about, its
a red flag to make reservations some-
where else. I also recommend review-
ing the restaurants menu ahead of time
so you can narrow down your choices and
have a more focused conversation with
the server. This is easier for the server,
which makes it more likely youll get a
gluten-free meal.
When counseling patients about eating
out or attending parties, Jeffers suggests
giving them the following tips:
Before going to a restaurant, try to
view the menu online and identify pos-
sible GF items in advance.
Let the server know that you cant eat
gluten, which includes avoiding wheat,
rye, barley, and derivatives of those
sources.
Salads should never have croutons,
and confirm that salad ingredients are
GF before consumption.
Always ask before ordering. Flour
often is used to thicken soups, and
meats may contain fillers made of
gluten.
Avoid anything described as being
encrusted, breaded, marinated, or
served in an unknown broth.
Fried foods must be fried in separate
oil to be considered GF.
Consider bringing your own GF bread
or crackers.
Consider eating out at an ethnic res-
taurant, as many of the foods may be
from GF sources (eg, rice, corn).
At parties, if possible, clients with
celiac disease should speak with the host
to make him or her aware of their need
to avoid gluten, preferably with enough
advance notice so the host can adjust the
menu accordingly. Begun suggests offer-
ing to make one or two dishes if the party
is more intimate, as this ensures safe
items for the client to eat and takes pres-
sure off the host. The following are some
additional tips:
Dont attend the party hungry, as there
may be few GF items from which to
choose.
Bring your own GF bread or crackers
or a GF item to share.
Never assume something is GF. Con-
firm that its safe before eating it.
Fresh fruits, vegetables, dairy items,
and fish are safe options as long as
they didnt come in contact with any
products containing gluten.
Silver Lining
Though following a GF diet may seem
daunting at first, clients with celiac dis-
ease or gluten sensitivity, with the help
of knowledgeable RDs, easily can navi-
gate their way through daily living as well
as special events without worrying that
gluten will cross their lips and potentially
cause problems once again.
Maura Keller is a Minneapolis-based
freelance writer and editor.
january 2013 www.todaysdietitian.com 27
 The Dietitians
Role in
End-of-Life
Healthcare
When
Considering
Enteral and
Parenteral
Nutrition

ETHICAL
DECISION MAKING
By Denise Baird Schwartz, MS, RD, FADA, CNSC

28 todays dietitian january 2013

A
n 85-year-old man was admitted to an
acute care facility after suffering a
stroke. Despite his advanced age and
history of progressive dementia, his
family never prepared documents that addressed
advance care planning, which would have desig-
nated a surrogate decision maker and indicated his
wishes for his end-of-life healthcare.
Before his hospitalization, the patient was living
with the youngest of his three adult children, the
only daughter. A swallow evaluation by a speech
pathologist indicated severe dysphagia. The speech
pathologist recommended discontinuing oral
feedings and starting the patient on tube feeding.
The physician requested that an RD perform a
nutrition consultation to initiate a nasogastric
tube feeding and progress the feeding to meet the
patients nutrient needs. After the RD reviewed
the patients medical record and consulted with
the RN, the dietitian discussed plans for the tube
feeding with the patients daughter at her fathers
bedside. The RD verbally presented information
about the tube feeding and provided written infor-
mation to ensure health literacy, asking the
daughter to reiterate and demonstrate what was
discusseda communication technique called
the teach-back method.
During this exchange, the daughter indicated
that her father never wanted a feeding tube or
other medical therapies that would prevent him
from enjoying simple daily activities. The daughter
said her brothers wanted their father to receive
nutrition through tubes and all other medical
therapies needed to prolong his life. They were
adamant that everything be done to extend their
fathers life, from a feeding tube to a ventilator to
cardiopulmonary resuscitation. This potential
conflict between siblings is all too common when
dealing with end-of-life healthcare decisions,
commonly known as ethical dilemmas.
This article will discuss this common occur-
rence, the importance of discussing end-of-life
healthcare issues with patients and family mem-
bers while honoring patients wishes, strategies to
prevent conflict, and the RDs role in ethical deci-
sion making in the context of enteral and paren-
teral nutrition.
Ethical Dilemma Issues and Stakeholders
The above case study is an example of inade-
quate family communication without written
documentation about end-of-life healthcare
wishes. Without documents for advance care
planning in a patients healthcare record, the
clinical ethical dilemmaa difficult problem
involving moral conflicts for which there seems
to be no satisfactory solutionis now set in
motion. This can result in the patient receiving
medical treatments that go against his or her
wishes and family members making decisions
without the individuals input.
Yet the goal of any healthcare team is to provide
appropriate and effective patient-centered care
based on the individuals wishes. From the team
members perspective, they should deliver medi-
cally appropriate treatment using evidence-based
medicine and assess the benefits and risks/burdens
involved. And they should adhere to their institu-
tions policies and procedures for ethical decision
making regarding artificial nutrition.1 Such care is
difficult to provide in the case presented due to the
clinical ethical dilemma of family members in con-
flict with the patients wishes.
The ways in which people deal with issues of
serious illness often are shaped by their faith and
culture. Individuals with different faiths and cul-
tures have diverse perspectives on the use of
life-sustaining therapies, the communication
process for delivering health information directly
to the patient vs. through the family, and the fam-
ilys role in the decision-making process for
healthcare at the end of ones life.2
The dietitians understanding of cultural and
religious diversity is necessary to best meet the
needs of a heterogeneous patient population.
Diversity awareness gives the RD the ability to
tailor information to patients, families, and sig-
nificant others, and promote understanding of
decision making when dealing with the use of
artificial nutrition. And awareness of different
cultures and faiths furthers an RDs understanding
of diversity in clinical ethics, which promotes
making right choices and decisions in health-
care delivery.
Although the patient is the predominate stake-
holder in this process, the concerns of the family,
physician, dietitian, and other healthcare providers
are what comprise the process of providing the
most appropriate nutrition therapy intervention.
The patients best interests always should be at the
center of healthcare decisions. Patient-centered
care is defined as care thats respectful of the
individual person and responsive to his or her
preferences, needs, and values and that ensures
january 2013 www.todaysdietitian.com 29
patient values guide all decisions.3 The focus of healthcare
should be shifted away from managing just the disease and
back to patients and their families, the major stakeholders
in the process.4
Health Literacy and the Teach-Back Method
The use of evidence-based practice guidelines, such as those
from the Academy of Nutrition and Dietetics (the Academy), is
beneficial in providing appropriate patient education informa-
tion.5 As indicated in the education process with the daughter
in the aforementioned case study, the RD was concerned about
presenting the information in simple terms due to the issue of
health literacy. Health literacy is defined as the degree to which
individuals obtain, process, and understand basic health infor-
mation and services to make appropriate healthcare decisions.6
It involves a range of social, cultural, and individual factors,
such as age, education, and race.
Due to concerns for improving health literacy, the RD
used the teach-back technique with the daughter while edu-
cating her about tube feeding. This is an effective method to
ensure individuals understand what theyve been told. The
process involves asking the individual to explain or demon-
strate what he or she was taught. If the person doesnt explain
correctly what he or she learned, the assumption is that the
information wasnt presented effectively. If this is the case,
the RD would explain the information again but use an alter-
native approach.7
In addition to verbal communication, understanding the
printed information is a significant factor that affects the
impact of the message. The printed educational material the
dietitian gave the daughter was written in accordance with
the teach-back method. A fifth-grade reading level or lower
is recommended for informational material and has been
identified as a criterion for low literacy.5
Awareness of health literacy concerns and the use of the
teach-back method are aspects of patient-centered care RDs
can use to improve communication with patients and their
families. Moreover, RDs should be aware of comparative
Triggers for Cue-Based
Patient/Family Discussion
Patient/family are healthcare team members.
Patient-/person-centered healthcare is based on
patient wishes.
The family expresses what the patient would want.
Family/surrogate decision makers role is to repre-
sent the patients wishes, not their own.
30 todays dietitian january 2013
clinical effectiveness research, which determines what treat-
ment works best, for whom, and under what circumstances,
to enhance the decision makers ability to fully understand
and weigh the alternative healthcare options available.8
Preventive Ethics and the RDs Role
Another important aspect of end-of-life care for dietitians is
the practice of preventive ethics. Preventive ethics suggest
that ethical conflict between family members is largely pre-
dictable, but it can be avoided through interventions aimed
at the organization, the patient care unit, and the individuals
involved. The goals of preventive ethics are to identify common
triggers of ethical conflict, such as unrealistic expectations
that treatment will be effective, and address them before they
contribute to conflict. Preventive ethics would have provided
options for the RD and other healthcare clinicians involving
the 85-year-old father and his children to implement a pro-
active process to reduce the potential conflict among them.
Preventive ethics represents a dramatic shift from the tra-
ditional ethics approach, which involves reacting to ethically
challenging patient situations on a case-by-case basis.9
RDs maintain a unique role in the hospital setting. Theyre
in a position to develop nutrition screening parameters for all
patients and implement the nutrition care process. This process
may call for initiating enteral or parenteral nutrition. But what
if this therapy isnt congruent with the patients wishes based
on his or her quality-of-life goals? To avoid such dilemmas,
RDs can screen for quality-of-life goals before initiating the
nutrition care process. They can review the medical record
for an advance directivewritten documentation of treatment
preferences and the designation of a surrogate decision maker
and discuss their findings with other healthcare team members.1
Dietitians are in the best position to improve ethical decision
making for enteral and parenteral nutrition because they can
facilitate an interprofessional, collegial approach to whole
patient-centered care while delivering nutrition therapies.
This approach involves two or more medical professionals
working together as a team with a common purpose and
commitment, and with mutual respect. The process involves
the RD being aware of the role of nutrition as it relates to the
physical, emotional, and spiritual needs of the patient, when
applicable, and relaying this information to the other health-
care team members.
The word nutrition connotes a sense of vibrancy and life.
The hope is that nutrition, for some patients, will open the door
that leads to advance care planning and end-of-life discussions
in the hospital setting. Dietitians already have formed bridges
between themselves and other medical fields, for example,
through discussions with physicians about optimal placement
of small-bowel feeding tubes beyond the ligament of Treitz
under specific conditions, and with respiratory therapists
about the impact of nutrition substrates on blood gases and
pulmonary function. And RDs can learn to incorporate
ethics in the decision-making process by integrating clinical
ethics into their dietetic practices. They can become knowl-
edgeable about advance care planning terms and learn how
to promote conversations about nutrition with patients and
their families, which can lead to a transformation in nutri-
tion support practice.
Collaboration with the physician, nurse, social worker,
chaplain, palliative care team, and other healthcare team
members is optimal to facilitate this process. Dietitians who
learn more about advance directives, living wills, durable
power of attorney for healthcare (a legal document in which
a competent person gives another person the power to make
healthcare decisions for him or her if unable to make those
decisions personally), and physician orders for life-sustaining
treatment have an advantage in understanding documents in
the patients medical record.
Cue-Based Patient/Family Discussion
One way to promote conversations about nutrition ther-
apy with families is to learn about cue-based patient/family
discussion. This involves listening for specific key words or
trigger phrases from a patient or family member expressing
he or she doesnt want a particular therapy, such as a feeding
tube. RDs can use this response to begin cue-based discus-
sions about quality-of-life goals while educating patients
and family members about nutrition therapies.
To begin, dietitians can tell family members the goal is to
provide enteral or parenteral nutrition support based on the
patients wishes. The sidebar on page 30 presents examples
of these triggers for cue-based discussion that can lead a
patient or family to understand that the focus should be on
the patients wishes.
This process is especially useful when the patient is on a
ventilator or unable to communicate. The important concept
is that family members or surrogate decision makers must
understand that their role is to represent the patients wishes
and not their own. Based on the cues given by the patient or
family, dietitians can refer further discussions to the physi-
cian, nurse, social worker, or chaplain. Documenting these
referrals in the medical record is essential. The verbal and
written interprofessional communication is important to
facilitate a consistent healthcare team approach. The primary
care physician is the coordinator of the clinical ethics process
with the patient, family, and healthcare team. RDs and other
healthcare professionals help contribute to the clinical ethics
process regarding artificial nutrition.
Action Steps for Process Improvement
Both the American Society for Parenteral and Enteral
Nutrition (ASPEN) and the Academy provide resources for
healthcare professionals on ethical considerations regarding
nutrition therapies, including recommendations and guide-
lines.10,11 The first step for healthcare institutions is to incorporate
these recommendations when developing ethical decision
making for artificial nutrition policy and procedure. Recommen-
dations and guidelines from other societies and organizations
are important to include in these documents based on the
patient population characteristics and religious affiliation of
the healthcare facility. Its important to develop the policy and
procedure in collaboration with all healthcare professionals
involved in the process to encourage acceptance of the final
document. A sample policy and procedure for dealing with
ethical decision making for artificial nutrition has been pub-
lished in The ASPEN Adult Nutrition Support Core Curriculum.12
The second step for healthcare institutions involves imple-
menting the policies and procedures needed to improve com-
munication among patients, families, and healthcare providers
regarding clinical ethics and nutrition therapies. To sustain
improvements in practice, the facility needs to standardize a
proactive, integrated, systematic process that focuses on
patient-centered care and communication.
The third step involves designing an improvement project
dealing with clinical ethics and artificial nutrition with mea-
surable goals, along with developing a plan to remeasure
the data. An example of measurable goals can include the
number of patients receiving nutrition support that have an
advance directive in their chart, the number of patients with
family care conferences, or the reduction in the number of
bioethics consults, which involve mediation to obtain a con-
sensus among individuals in conflict concerning artificial
nutrition issues. Even incorporating an analysis involving
patient satisfaction can facilitate process improvements.1,13
The final step involves presenting information about best
practices with other facilities at national meetings and publish-
ing data. Accomplishing this step would help dietitians in private
practice improve patient-centered care by standardizing the
incorporation of clinical ethics in the field of nutrition support.1,13
Engaging the Public in End-of-Life Conversations
To engage the public in end-of-life healthcare conversations,
healthcare professionals must educate themselves about the
process and become aware of resources and tools available
(see sidebar on page 32).
End-of-life conversations dont involve just the elderly and
their adult children; they affect everyone in some capacity. In the
hospital setting, patient-centered care is best achieved when all
healthcare professionals communicate and are engaged in the
conversation to provide a consistent healthcare team approach.14
Perhaps if RDs and other healthcare team members
embrace these conversations in their professional and personal
lives, the public will become more engaged in end-of-life
healthcare discussions. Recognizing the importance of com-
munication in families and acting on these discussions is the
january 2013 www.todaysdietitian.com 31
best way to prevent clinical ethics dilemmas and provide
whole patient-centered care in the hospital. In the future,
the goal will be for everyone to have advance care planning
discussions with their family and written documentation before
an illness develops and hospitalization follows. Dietitians are
essential healthcare team members involved in clinical ethics
due to their role in the optimal use of enteral and parenteral
nutritionand they can make a difference.
Denise Baird Schwartz, MS, RD, FADA, CNSC,
is the nutrition support coordinator at Providence
Saint Joseph Medical Center in Burbank, California,
and has been recognized both nationally and
internationally as a speaker on nutrition
support topics for the critically ill.
References
1. Schwartz DB. Ethical considerations in the critically ill
patient. In: Cresci G, ed. Nutritional Therapy for the Critically
Ill Patient: A Guide to Practice. 2nd ed. Boca Raton, FL: Taylor
& Francis; 2013 (in press).
2. Preedy VR, ed. Diet and Nutrition in Palliative Care. Boca
Raton, FL: CRC Press; 2011.
3. Barry MJ, Edgman-Levitan S. Shared decision
makingthe pinnacle of patient-centered care. N Engl J
Med. 2012;366(9):780-781.
4. Reuben DB, Tinetti ME. Goal-oriented patient care
an alternative health outcomes paradigm. N Engl J Med.
2012;366(9):777-779.
Resources and Tools
National Healthcare Decisions Day (www.nhdd.org):
Held annually on April 16, the goal of this day is to inspire,
educate, and empower the public and healthcare provid-
ers regarding the importance of advance care planning.
Resources for activities to promote this day are available
on the website.
Speak Up Campaign (www.advancecareplanning.ca):
This campaign is designed to promote advance care plan-
ning in Canada. It was developed to raise awareness of
the importance of advance care planning and end-of-life
care. The website provides a kit with material to pro-
mote advance care planning.
Aging With Dignitys Five Wishes (www.agingwith
dignity.org/five-wishes.php): This guide helps start impor-
tant conversations about end-of-life care. It provides a
documentation tool for detailing an individuals wishes.
32 todays dietitian january 2013
5. Gallagher-Allred CR. Communication and education for
families dealing with end-of-life decisions. J Acad Nutr Diet.
2012;112(2):309-310.
6. Carbone ET, Zoellner JM. Nutrition and health literacy:
a systematic review to inform nutrition research and practice.
J Acad Nutr Diet. 2012;112(2):254-265.
7. Weiss BD. Health Literacy and Patient Safety: Help Patients
Understand. 2nd ed. Chicago, IL: American Medical Association
Foundation; 2007.
8. Gabriel SE, Normand SL. Getting the methods rightthe
foundation of patient-centered outcomes research. N Engl J
Med. 2012;367(9):787-790.
9. Epstein EG. Preventive ethics in the intensive care unit.
Am Assoc Crit Care Nurs. 2012;23(12):217-224.
10. Barrocas A, Geppert C, Durfee SM, et al. A.S.P.E.N.
ethics position paper. Nutr Clinc Prac. 2010;25(6):672-679.
11. OSullivan Maillet J. Position of the American Dietetic
Association: ethical and legal issues in nutrition, hydration,
and feeding. J Am Diet Assoc. 2008;108(5):873-882.
12. Geppert CMA, Barrocas A, Schwartz DB. Ethics and
law. In: Mueller C, McClave SA, Schwartz DB, Kovacevich D,
Miller SJ, eds. The A.S.P.E.N. Adult Nutrition Support Core
Curriculum. 2nd ed. Springfield, MD: American Society for
Parenteral and Enteral Nutrition; 2012: 656-676.
13. Schwartz DB. Three steps for improving end-of-life
nutrition care. Clinical Nutrition Insight. 2012;38(10):4-5.
14. Schwartz DB. Clinical ethics and nutrition support.
J Nutr Therapeutics. 2012;1(1):86-90.
Physician Orders for Life-Sustaining Treatment (www.
polst.org): This is based on effective communication of
patient wishes. It involves documenting medical orders on a
brightly colored form and includes a paradigm program to
improve the quality of care people receive at the end of life.
The Conversation Project (www.theconversation
project.org): The goal of this project is to have every
persons end-of-life preferences expressed and respected.
It includes a starter kit to help initiate conversations
with loved ones regarding end-of-life care wishes.
Breathe a True Story of Letting Go of My Parents
Gracefully, For I Will See Them Again (www.breathe-
annebland.com): This book is a healthcare professionals
personal story intended to help others begin the dialogue
with family members about end-of-life care decisions. Per-
sonal stories such as this one are intended to help individu-
als deal with family relationships, faith, and values and are
designed for both healthcare professionals and the public.
 Get a
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 Healthful
School Lunches
Are the New Standards All Theyre Cracked up to Be?

By Lori Zanteson

Dietitians speak out about the new federal school meals program that many
kids say is leaving their stomachs growling by the end of the school day.

34 todays dietitian january 2013

T
he start of the school year welcomes students
with the promise and expectation of filling their
minds with knowledge andfor the 32 million
in our nations school meal programstheir
bodies with nutritious foods. Only this year
the implementation of the new federal lunch
standards mandated by the Healthy, Hunger-Free Kids Act
of 2010 isironicallyleaving kids hungry.
And this youngest generation is speaking out. Fueled by
the pangs of their growling bellies, complaints from our
nations youths have spread across the country via blogs,
websites, boycotts, strikes and, most famously, YouTube.
One Million Hits and Counting
A video parodyviewed more than 1 million timeshas
students singing We Are Hungry to the tune of fun.s We
Are Young. The student-teacher compilation, made in the
high school of a small Kansas town, protests the lower calo-
ries and limited carbohydrates and proteins under the new
lunch standards.
The video features scenes of starving athletes collaps-
ing during after-school practice, a student who falls asleep
in class, and elementary school students crawling out of a
school building, presumably dragging due to hunger, all set
to a chorus of Tonight/We are hungry/Set the policy on fire/
It can burn brighter/Than the sun.
A call to action, the video opens with statistics on the
minimum calories necessary for high school athletes and
ends with a plea to all students to voice their opinion.
Whats Changed?
The video grabbed the medias attention, cranking up several
notches the volume of the public outcry and putting the new
school lunch standards into mainstream focus. The perception
is that the new lunch standards serve a radically changed
menu from previous years, certainly one that skimps on
calories. In reality, most of the changes have been progres-
sively introduced in schools since 2009 when the Institute of
Medicine developed recommendations that formed the basis
for these standards in direct response to the childhood obesity
epidemic. School nutrition professionals who were aware of
the pending recommendations to increase the amount of fruits,
vegetables, and whole grains served and lower sodium,
saturated fat, and calories got right to work.
Many schools embraced the imminent changes in policy
and worked hard to introduce and integrate new and colorful
fruits and vegetables into their meal programs so the eventual
adoption of new standards would be an easy and seamless
transition. Programs such as A Tasting of the Rainbow at
Anne Arundel County Public Schools in Maryland showcased
a variety of fruits and vegetablessome the children had
never seen beforeand encouraged them to taste a free
sample. The response, according to Jodi Risse, MS, RD,
LDN, division of food and nutrition services, was positive on
the lunch line where these featured fruits and veggies were
incorporated into the menu. Familiarity was the first step
toward broadening the childrens formative palates.
Out With the Old
Theres no argument that the new lunch standards are an
improvement over the old lunch standards, which had been
untouched for more than 15 years. During her 1998 dietetic
internship, Laura Cipullo, RD, CDE, CEDS, CDN, of Whole
Nutrition Services, LLC, and MomDishesItOut.com, recalls
visiting New York City schools and seeing banana bread with
whole milk served for breakfast and pizza with whole milk and
fruit for lunch. Im not a fan of school lunch in general, she
says, but I feel the new standards are a step in the right direc-
tion. Increasing whole grain specifications, providing colorful
vegetables, and offering 1% milk are great new options.
According to the USDA, a typical lunch menu under the old
standards might include pizza sticks (3.8 oz) with 14 cup of
marinara sauce, a banana, 1 oz of raisins, and 8 oz of whole
milk. Compare that with a typical menu under the new stan-
dards: one slice of whole wheat cheese pizza, 12 cup of
sweet potato fries, 14 cup of raw grape tomatoes, 12 cup of
applesauce, 8 oz of 1% milk, and 1 oz of low-fat ranch dip.
Key Word: Calories
The healthful addition of fruits and vegetables and even
whole grains isnt the problem. Students say theyre not getting
enough calories to satisfy their hunger.
Making Good of the
New Standards
Here are some suggestions from Laura Cipullo,
RD, CDE, CEDS, CDN, to help put a positive spin on
the new school menu changes:
Periodically invite chefs to your school to teach
foodservice staff new, healthful recipes.
Rotate students through the school kitchen to help
prepare meals and offer new ideas for dishes.
Have children plant gardens and eat the food they
grow.
Include cooking classes in the schools curriculum,
and teach kids how to make healthful, tasty food.
Create yearly school cookbooks featuring the
students favorite healthful recipes.
Teach students how to modify their favorite recipes
to develop more wholesome, healthful ones.
january 2013 www.todaysdietitian.com 35
 According to Deborah Beauvais, RD, CDN, SNS, district
supervisor of school nutrition services in the Gates Chili
Central and East Rochester Union Free school districts in
western New York, thats a case of perception vs. reality.
The calories a year ago were still in that same range, she
explains. The main difference is that the old standards set a
target number of calories, which could be exceeded, while
the new standards set a range of calories thats capped with
maximums. These guidelines are based on science and
are written for the center of the bell curve. Its too much for
some, too little for others, she says.
A quick glance at government calorie recommendations
confirms this. The USDA recommends that boys aged 14 to18
consume an average of 2,200 to 3,200 kcal/day and girls aged
14 to 18 take in 1,800 to 2,400 kcal/day for a healthful, balanced
diet. Assuming the average teenage boy or girl falls somewhere
in the middle of these ranges, the calories they consume at lunch
will equate to about one-third of their daily calories. Assuming
again that these teens are eating three meals as well as a snack
or two each day, there shouldnt be a calorie deficit.
However, the USDA clearly states that these ranges are
estimated amounts of calories needed to maintain calorie
balance and that individual calorie needs may be lower or
higher. According to information from the American Dietetic
Association Complete Food & Nutrition Guide by Roberta
Larson Duyff, MS, RD, FADA, CFCS, those calorie require-
ments jump to 3,500 or more for athletes and those involved
in strenuous exercise.
Table 1 Typical School Lunch Portions Based on the New Federal Standards
Food Group Previous Requirements
Fruits and vegetables 1
2 to 4 cup total
3
There are no specifications regarding
the types of vegetables to be served.
Meat/meat alternative 1.5 to 2 oz equivalent (daily minimum)
Grains Eight servings weekly; minimum of
one serving per day
Whole grains are encouraged.
Milk 1 cup; variety of fat contents allowed
and flavors not restricted
Table adapted from a comparison of previous and current regulatory requirements under the Nutrition Standards in the National School Lunch and School Breakfast Program
(http://www.fns.usda.gov/cnd/governance/legislation/comparison.pdf)
36 todays dietitian january 2013
One Size Doesnt Fit All
Clearly, every lunch wont fulfill every students caloric
needs, but according to Beauvais, even the old standards
didnt sustain all the kids. Her first question for todays stu-
dents complaining of hunger is Are you eating breakfast
before you leave home or at school? She says lunch isnt
intended to supply the entire days calories, but if students
are hungry beyond whats on their tray, schools offer extra
portions. With all the choices of fresh fruits and vegetables
at kids disposal, certainly something should be appealing,
Beauvais adds.
Perhaps that appeal is partly to blame for the perceived
calorie deficit. If kids dont eat whats offered, theyre not
getting the calories and the energy available and necessary
to sustain them throughout the afternoon. Cipullo noted the
problem back in 1998 during her school tours. Children
were forced to take a minimum of each item even if they
didnt want to eat the food, she says. This created unnec-
essary food waste. It was a huge problem then and is still a
huge problem now.
Cipullo believes the reason kids arent eating enough calo-
ries is twofold. The new offerings, she says, need to be more
visually pleasing and palatable. But keep in mind that kids
have been accustomed to eating processed foods laden with
added sugar, foods that appeal to them even if theyre not
necessarily nutritionally adequate. Rather than calories,
she says, the attention should focus on how to serve positive
change in the way students view nutrition and food.
Current Requirements
Fruits: 12 to 1 cup
Vegetables: 34 to 1 cup
There are weekly requirements for dark green, red/orange, and
starchy vegetables and beans/peas (legumes) plus other vegetables as
defined by the 2010 Dietary Guidelines.
Grades K to 5: minimum 1 oz equivalent daily; 8 to 10 oz weekly
Grades 6 to 8: minimum 1 oz equivalent daily; 9 to 10 oz weekly
Grades 9 to 12: minimum 2 oz equivalent daily; 10 to 12 oz weekly
Grades K to 5: minimum 1 oz equivalent daily; 8 to 9 oz weekly
Grades 6 to 8: minimum 1 oz equivalent daily; 8 to 10 oz weekly
Grades 9 to 12: minimum 2 oz equivalent daily; 10 to 12 oz weekly
As of July 1, 2012, at least one-half of the grains served had to be whole
grain rich. Beginning July 1, 2014, all grains must be whole.
1 cup; must be fat free (unflavored or flavored) or 1% (unflavored)
 This is especially true when it comes to athletes who have a
much higher calorie requirement compared with nonathletes
as much as 4,500 kcal/day. I think students need more whole
grains, proteins, and healthful fat options such as nuts, avoca-
dos, and olives as part of their daily lunch meal, Cipullo says.
Lets offer less-processed, wholesome foods without such
tight maximums on calories. We also should encourage some
of the kids to take just some of the food offered and then eat
again two or three hours later. More often than not, smaller
meals are easier on our endocrine systems and may help
reverse the trend of increasing diabetes.
Beauvais, whose son is a 6-foot 3-inch athlete, isnt surprised
that the lunches he eats at school arent enough calories to
carry him through his afternoon sports practice, but they
werent last year either. When this is the case, Beauvais
says these kids need another plan for the afternoon, which
might mean bringing a snack from home or money for a
healthful vending machine option.
Wheres the Beef?
While its true the number of calories in school lunches
arent that different from a year ago, theyre distributed
differentlyand this is what the kids notice. Perhaps the
most dramatic change is the cap on protein and grains. At
the high school level, its the difference between this years
burger and last years: What was once a 3-oz meat patty is now
2 oz. Beauvais says the differencethe patty gets lost in the
bunis visibly obvious to the kids. She says that our new
motto is How about some lettuce and tomato with that?
It has become a challenge on the foodservice side as well,
which Beauvais describes as kind of like a puzzle. Take that
burger, for example. To accommodate the addition of a half-
ounce slice of cheese, youd first have to make the patty a
half-ounce smaller. Well, they dont come in a 212 -oz size.
And sandwichesa staple on every lunch lineare no
longer so simple under the new standards. A cap of 9 oz of
bread, at 1 oz per slice, makes a challenging breakdown for
the five-day school week. There might be a future for an
open-faced sandwich on the menu, Beauvais says.
Changing the Food Isnt Enough
Laudable as the efforts behind the new standards are,
theyre not enough, according to two former New York City
public school teachers who have taken the issue of obesity in
school children into their own hands. Deborah Lewison-Grant,
MA, MEd, and Carolyn Cohen, MEd, started their own nonprofit
organization called FoodFight to include teachers, who they
believe are the missing link in the growing obesity epidemic.
FoodFight also involves a curriculum that teaches teens about
nutrition and how the media influences their food choices.
You cant revolutionize food without revolutionizing the
culture in the schools, Cohen says. Without buy-in from both
Table 2 Calorie Counts of Lunches Before
and After New Standards Took Effect
Previous Standards Current Standards
Grades K to 3: 633 Grades K to 5: 550 to 650
Grades 4 to 12: 785 Grades 6 to 8: 600 to 700
Grades 7 to 12: 825 (optional) Grades 9 to 12: 750 to 850
Table adapted from a comparison of previous and current regulatory requirements
under the Nutrition Standards in the National School Lunch and School Breakfast
Program (http://www.fns.usda.gov/cnd/governance/legislation/comparison.pdf)
adults and students on campus, the healthier lunches wont
change anything. Even after the dust settles and the protests
wane, negative attitudes and food waste in the cafeteria are
likely to continue.
Theres a clear disconnect when grown-ups arent included,
Lewison-Grant says. They wield a lot of influence on students
a disproportionate amount of influence.
FoodFights goal is to improve the health and life outcomes
of students by bringing teachers and personnel into the con-
versation. Their health and wellness is critical to their job.
Corporate wellness is so accepted, but we dont see that in
schools, Lewison-Grant continues.
By running wellness programs for teachers and school staffs,
Cohen and Lewison-Grant believe their graduates will bring
an empowerment and energy for healthful living and eating to
the students. If you engage the entire staff, you can ignite an
important process that can change food in schools, they say.
In addition, Cohen and Lewison-Grant believe the new lunch
standards would be more effective if they were introduced within
a context. A new set of guidelines without explanation is confus-
ing. Its missing the education component, Lewison-Grant says.
When the students dont understand the reason behind their
role in the changes, it becomes a control issue. Food is the one
area over which they exert control, she explains. They can
decide what to put in their mouths, but they dont understand the
forces shaping it. School lunch isnt exempt. This is where the
adults in the school can lead students through the changes and
together change the current food climate into a healthful one.
Embracing Change Is Tough
All change is subject to scrutiny, doubt, and sometimes protest,
and the new school lunch standards are no exception. But like any
new policy, especially one as large-scale as the US school meal
program, its being closely monitored. According to Beauvais,
the USDA is receiving information from around the country
and, she says, Im hoping there will be some minor revisions.
Lori Zanteson is a food, nutrition,
and health writer based in southern California.
january 2013 www.todaysdietitian.com 37
Meatless
Monday
This growing campaign encourages people to increase
their intake of fruits, vegetables, whole grains, and
legumes, and dietitians are embracing it as a tool
to promote healthful eating patterns.
By Sharon Palmer, RD

38 todays dietitian january 2013

W
hat do Oprah Winfrey, Michael Pollan,
and Mario Batali have in common?
Theyve all jumped on the Meatless
Monday bandwagon. Hospitals, colleges,
restaurants, magazines, foodservice
companies, workplaces, and entire communities are pledging
their support for the program, too.
Whats Meatless Monday all about? Its a nonprofit initia-
tive of The Monday Campaigns, which is developed in asso-
ciation with the Johns Hopkins Bloomberg School of Public
Health, with a simple message: By cutting out meat once per
week, you can improve your health and reduce your carbon
footprint. The initiative provides information and recipes to
help people start each week with healthful, eco-friendly,
meat-free alternatives.
Allison Righter, MSPH, RD, who coordinates the Meatless
Monday science advisory at the Center for a Livable Future
(CLF), reports that Meatless Monday began in 2003 in response
to the release of the Healthy People 2010 report, which included
goals to reduce dietary saturated fat by 15%. Since saturated
fat primarily comes from meat and animal products and since
one day a week is just under 15% of the week, Meatless Monday
was a practical method for helping people to meet those goals.
Reducing meat consumption also has many other benefits,
such as lowering the environmental burden of industrial food
animal production, which is a major focus of CLFs research,
Righter says.
Benefits Aplenty
Theres growing support for adopting a more plant-based
diet, even in the 2010 Dietary Guidelines for Americans, which
offer the general recommendation to eat a plant-based diet that
focuses on consuming vegetables, cooked dry beans and peas,
fruits, whole grains, nuts, and seeds with moderate amounts of
lean meats, poultry, eggs, and dairy.1
A position paper published by the Academy of Nutrition and
Dietetics concluded that a plant-based, vegetarian dietary pat-
tern is completely healthful and nutritionally adequate for
people throughout all stages of life and that it has several
health advantages, including lower blood cholesterol and pres-
sure levels and lower risk of heart disease, hypertension, and
type 2 diabetes.2
Semivegetarian, lacto-vegetarian, and vegan women have
a lower risk of overweight and obesity than do omnivorous
women, according to data from 55,459 healthy women partici-
pating in the Swedish Mammography Cohort, suggesting that
advice to consume more plant foods and less animal products
may help individuals control their weight.3
In a recent meta-analysis, Harvard researchers linked high
processed-meat intake to a 42% higher risk of coronary heart
disease.4 Data from the Health Professionals Follow-Up Study,
which included more than 440,000 participants, revealed that
eating a daily 100-g serving of red meat was linked with a 19%
increased risk of developing type 2 diabetes, and eating a daily
50-g serving of processed meat was associated with a 51%
greater risk.5
The NIH-AARP Diet and Health Study, which included more
than 500,000 men and women, found a significantly higher risk
of cancers of the colorectum, esophagus, lung, and liver asso-
ciated with red meat intake; an increased risk of colorectal and
lung cancer was associated with higher intake of processed
meat; and red and processed meat intake was associated with
cancer mortality.6
In addition to health, people are interested in reducing their
animal food intake for environmental benefits. Italian research-
ers performed a life cycle assessment to evaluate the cradle-
to-grave environmental impact of several dietary patterns.
They reported that an organic, vegan diet had the smallest
environmental impact, while a conventionally farmed diet that
included meat had the greatest impact on the environment
and the more meat consumed, the greater the impact. Beef was
the food with the single greatest impact on the environment.
Cattle require lots of feed, water, and fossil fuels to turn plants
into protein, the scientists said. To produce 1 kcal from beef
requires 40 kcal of fossil fuels, whereas producing 1 kcal from
grains requires only 2.2 kcal of fuel.7
In an analysis for the public advocacy organization Environ-
mental Working Group (EWG), greenhouse gas emissions gen-
erated by conventionally raising lamb, beef, pork, and farmed
salmon and producing cheese far exceed those from other food
choices, such as lentils and beans. The EWG found that eating
less meat could significantly reduce a persons carbon foot-
print. For example, if everyone in the United States ate no meat
or cheese for just one day per week, it would be like taking 7.6
million cars off the road.8
The Meatless Monday message helps people ease into
the concept of decreasing animal intake by selecting just
one day per week to go meatless. Were not asking people
to cut out meat from the diet, Righter says. This is all
about moderation; its one simple tool to help people incor-
porate healthierand also more environmentally sustain-
ablealternatives to meat into their diets just one day each
week. Its a platform to introduce new and often overlooked
foods, and ideally this will trickle over into other days of the
week and ultimately translate into healthier eating habits and
dietary patterns over time.
january 2013 www.todaysdietitian.com 39
 What I think is important to understand, especially for
dietitians, is that people are consuming too much meat
more than whats needed to achieve nutritional recommen-
dations, Righter continues. Were eating more than twice
the EAR [estimated average requirement] or about 112 times
the RDA [Recommended Dietary Allowance] for protein.
The majority of our protein is coming from meat and animal
products, which provide additional saturated fat and often
not the same nutritional benefits of other plant-based pro-
teins. This excess of meat and lack of health-protective plant
foods is a huge problem in terms of its association with an
increased risk of chronic diseases.
Indeed, Meatless Monday appears to be an effective tool
for promoting health. A nationwide survey conducted by FGI
Research for Meatless Monday found that among those who
are aware of the initiative, 36% say the campaign has influ-
enced their decision to cut back or consider cutting back on
meat. Of those influenced by Meatless Monday to reduce meat
intake, 62% say theyve tried to incorporate it in their weekly
routine; 40% incorporate more meatless meals the rest of
the week; 73% eat more vegetables; 64% eat more fruits; 42%
eat more beans; 47% eat more whole grains; 50% experiment
with new meatless recipes when they cook at home; and 42%
try more meatless dishes when eating out.
Meatless Monday Takes Off
The Meatless Monday movement has grown dramatically
in the past two years. Awareness of the campaign primarily is
due to grassroots viral dissemination and support of partici-
pating organizations rather than advertising. According to the
FGI Research survey, public awareness of Meatless Monday
increased from 26% to 43% from November 2010 to July 2012.
Meatless Monday has more than 35,000 Facebook likes and
18,000 Twitter followers as of July 2012. In addition, many
organizations, such as the Food Network (more than 3 million
Facebook likes and 1 million Twitter followers) and the Cook-
ing Channel (more than 345,000 Facebook likes and 87,000
Twitter followers), post Meatless Monday content every week.
Organizations have helped Meatless Monday become
mainstream, says Peggy Neu, president of The Monday
Campaigns. Sodexo was the first to join in 2011. Theyre
enormous, with 6,000 customers in the United States serv-
ing 10 million meals a day. As weve grown both in our
awareness and number of people who say theyre practicing
Meatless Monday, we have all of these companies and orga-
nizations offering a solution to what you can have instead of
meat. Morningstar Farms was one of the first big brands to
promote Meatless Monday, along with others, including the
Mushroom Council and Birds Eye.
High-profile chefs and restaurants have helped bring
Meatless Monday to the forefront as well. In the beginning,
40 todays dietitian january 2013
Meatless Monday was started in restaurants by pioneers
like Mario Batali. Now its gone mainstream, says Neu, who
reports growing innovation in the restaurant world. Chefs
are employing food stations, special menu features, and
tasting menus to help promote Meatless Monday.
The campaign also has been a darling in the media. The
media, bloggers, and Food Network have all become active
in Meatless Monday, Neu says. Were not saying that
people should give up meat entirely; were not saying to be
vegetarian or vegan entirely. Our press is so good because
whats there to argue?
Meatless Monday also is growing with schools, colleges,
food distributors, worksite wellness programs, and insur-
ance companies. Were even seeing Meatless Monday in
communities, such as in Raleigh-Durham [North Caro-
lina] and Aspen, Colorado, where community organizers go
around and get schools, media, and events to support a com-
munitywide gestalt.
Employing Meatless Monday in Other Settings
Dietitians are getting excited about using Meatless
Monday as a tool in various work settings. Dietitians are
involved in marketing, cooking classes, community, tele-
vision, cooking demos, and blogs. Theyre also involved in
foodservice settings, Neu says of the many ways dietitians
use Meatless Monday to provide healthful eating messages.
Meatless Monday can be used as a platform in any set-
ting for dietitians to not only talk about nutrition but to raise
awareness of larger issues related to our industrial food
system, Righter adds. Food is connected to everything. This
can help dietitians become well versed on these issues.
Righter recently conducted an informal survey of dieti-
tians regarding their knowledge and use of Meatless Monday
in their work. About half of the people I got responses from
already had heard about the campaign and were using it in
the classroom or with clients in some capacity, she says.
However, a lot of people werent aware of iteither theyd
never heard of it or they didnt realize it was a campaign with
its own website, social media, and all sorts of information,
recipes, and resources.
Its one strategy to help bring Americans in line with the
Dietary Guidelines. Everyones on the same page; were all
struggling to get people to eat more healthfully. Using Meat-
less Monday is an opportunity to introduce these plant-based
foods, like vegetables, fruits, beans, and whole grains. Thats
one of the things that came back from our survey of dieti-
tians. They believe Meatless Monday provides an opportunity
for people to try new recipes and new foods, Righter says.
Dana Dose, RD, CPT, a dietitian at Harrahs Health and Well-
ness Center in Lake Tahoe, California, uses Meatless Monday
in her one-on-one sessions with clients. Ive also started the
process of seeing if the on-site cafeteria for the employees will
start offering additional meatless options on Mondays. Once
that goes through, Ill promote Meatless Monday throughout
the property, especially in the employee cafeteria, by using sig-
nage and putting an article in the employee newsletter, Dose
says. Its great to be able to show people the positive impact
they can have on the environment and their bodies when they
go just one day without meat.
Lauren Harris-Pincus, MS, RD, and Kathy Siegel, RD,
CDN, cofounders of NutritionBabes.com, feature a meatless
recipe category with 85 recipes on their website and blog,
and they encourage their clients, readers, and listeners to
consider forgoing meat one day per week. By raising aware-
ness of the benefits of decreasing meat consumption, we can
open consumers minds to the potential positive effects on
their health, Harris-Pincus says. The path to better health
is traveled one step at a time, and removing meat from your
meal plan one day per week can be one of those steps.
Roberta Anding, MD, RD, LD, CDE, CSSD, director of
sports nutrition at Texas Childrens Hospital in Houston, uses
Meatless Monday as a tool in teaching an introductory nutri-
tion course. It dovetails with my lecture on vegetarian nutri-
tion. From a clinical perspective, I use it to reduce the high
calorie burden of my carnivore Texans. Im contemplating
writing about it for the Houston Texans Gameday magazine,
she adds.
Natalie Bates, a clinical nutrition student at the Univer-
sity of California, Davis, spent the past summer in an intern-
ship at Kaiser Permanente San Diego Medical Center, where
she created, promoted, and implemented a Meatless Monday
program for the cafeteria. To kick it off, Bates created a pre-
sentation that was shown on the TV in the hospital cafete-
ria. She tested meatless recipes and worked with the chef
to offer four different meatless entres in the cafeteria on
Meatless Monday. Bates made table tents that included
recipe pictures and environmental and nutritional informa-
tion. She also set up a table at the cafeteria entrance that
showcased a poster promoting the campaign and that pro-
vided staff to answer peoples questions.
Bates distributed a survey about Meatless Monday
to receive feedback from the cafeteria customers. The
survey indicated very mixed results. While some people
were excited about having meatless options, others were
upset that the cafeteria would try to influence their dietary
choices, she explains. Those who were interested in eating
healthfully were easy to convince to try Meatless Monday on
a regular basis, and they liked the vegetarian options offered
in the cafeteria that day. However, within the hostile audi-
ence, it was difficult to see any impact. I think the area of
opportunity for people in the public health field is among the
neutral/undecided individuals who are intrigued and open to
the idea but havent been exposed to or received guidance for
implementing Meatless Monday into their lives. Surprisingly,
I found that emphasizing the environmental impact often
can motivate people to participate in Meatless Monday who
wouldnt be interested in participating for health reasons.
Getting Started
If youd like to use Meatless Monday in your own practice,
MeatlessMonday.com offers many great resources to get you
started, such as information on nutritional and environmen-
tal benefits, articles, a recipe widget that can be placed on
any website or blog, and a tool kit with promotional materials
in a downloadable format.
So go ahead, jump on the Meatless Monday bandwagon and
encourage your clients to take the ride for better health, too.
Sharon Palmer, RD, is a contributing editor at Todays
Dietitian, a freelance food and nutrition writer in southern
California, and author of The Plant-Powered Diet.
References
1. US Department of Agriculture, US Department of Health
and Human Services. Dietary Guidelines for Americans, 2010.
7th ed. Washington, DC: US Government Printing Office; 2010.
2. Craig WJ, Mangels AR; American Dietetic Association.
Position of the American Dietetic Association: vegetarian diets.
J Am Diet Assoc. 2009;109(7):1266-1282.
3. Newby PK, Tucker KL, Wolk A. Risk of overweight and obe-
sity among semivegetarian, lactovegetarian, and vegan women.
Am J Clin Nutr. 2005;81(6):1267-1274.
4. Micha R, Wallace SK, Mozaffarian D. Red and processed
meat consumption and risk of incident coronary heart disease,
stroke, and diabetes mellitus: a systemic review and meta-
analysis. Circulation. 2010;121:2271-2283.
5. Pan A, Sun Q, Bernstein AM, et al. Red meat consump-
tion and risk of type 2 diabetes: 3 cohorts of US adults and an
updated meta-analysis. Am J Clin Nutr. 2011;94(4):1088-1096.
6. Cross A, Leitzmann MF, Gail MH, et al. A prospective study
of red and processed meat intake in relation to cancer risk.
PLoS Med. 2007;4(12):e325.
7. Baroni L, Cenci L, Tettamanti M, Berati M. Evaluating
the environmental impact of various dietary patterns com-
bined with different food production systems. Eur J Clin Nutr.
2007;61(2):279-286.
8. Hamerschlag K. Meat Eaters Guide to Climate Change
+ Health. Environmental Working Group website. http://static.
ewg.org/reports/2011/meateaters/pdf/report_ewg_meat_
eaters_guide_to_health_and_climate_2011.pdf. July 2011.
Accessed May 10, 2012.
january 2013 www.todaysdietitian.com 41
Educating
Young Palates
MindStream Academy is blending food,
nutrition, and education to teach students how
to live healthfully for the rest of their lives.
By Juliann Schaeffer

42 todays dietitian january 2013

T
he number of children suffering from childhood
obesity has more than tripled in the past 30 years,
according to the Centers for Disease Control and
Prevention, putting them at an increased risk for
much more than teasing from schoolyard bul-
lies. The US Department of Health and Human Services has
reported that being overweight during childhood and ado-
lescence increases the risk of developing high cholesterol,
hypertension, respiratory ailments, orthopedic problems,
depression, and type 2 diabetes as a youth.
These conditions are a serious public health concern facing
children today, but a new weight-loss academy based in Bluff-
ton, South Carolina, is hoping to make a dent in these troubling
statistics by looking at much more than just childrens weight.
The academy is attempting to forge an innovative partnership
with a Missouri school district to expand its reach to more kids
nationwide.
MindStream Academy: What Its About
MindStream Academy, a full-service boarding school, is in
many ways like your typical high school, fully credentialed to
offer academic coursework to students of all levels. Yet its
designed specifically for kids whose health, future, and very
lives are on the line due to obesity and its attendant physi-
cal and psychological burdens, says MindStream Academy
Founder and CEO Ray Travaglione.
In addition to their regular coursework, MindStream stu-
dents are taught the basics of nutrition, cooking, and fitness in
an attempt to get to the root of their weight issues and address
them for the long term. Their instruction ranges from neuro-
biofeedback to gardening, psychological counseling to the care
of horses, and from lengthy bike rides to the preparation of
wholesome, gourmet meals, Travaglione explains.
He says the idea for MindStream Academy came from his
work with children who are among the fittest for their age
group: athletes. My background is in passion-based learn-
ing for teens. Beginning with student athletes, I created pro-
grams that provided the opportunity to develop their skills and
test them against their peers, founding both Hank Haney Inter-
national Junior Golf Academy and the International Junior Golf
Tour, where many of the young PGA and LPGA players have
either attended or competed, he explains. To accommodate
our students training schedule, I then created a school that
views pursuing a passion as important as core academics: Her-
itage Academy.
As Travaglione became more aware of obesitys increas-
ing stranglehold on todays youths, he decided he had to get
involved. Obesity in our youth has the potential to bring this
country to its knees in a very short period of time, and I could
not stand idly by and allow this to happen, he says. I decided it
was time to do something to turn the tide on this epidemic and
founded MindStream Academy.
A Mind-Body Approach to Wellness
The biggest difference between MindStream and other
weight-loss programs is its overall focus. While its no secret
that it addresses obesity, the school takes pride in its mind-
body approach to health and wellness, impressing on children
that life is about much more than what the scale dictates.
MindStream Academy has created a school climate in which
optimal health and wellness is equally as important as high
academic standards. Ultimately what we offer is an education
for lifelong vitality and vibrancy, Travaglione says, noting that
in addition to a lower weight, students also are pursuing the far
loftier goals of optimal wellness and their fullest life potential.
MindStream staff aim to help students achieve these goals
with targeted fitness, nutrition, and culinary education as well as
counseling. Were not interested in quick fixes and dont focus
solely on weight loss, Travaglione says. Physical fitness and
proper nutrition are part of what we do but not all we do. The
weight loss and developing fitness habits is a product of self-
confidence and self-management skills. We want our students
to take the skills theyve learned here and maintain their success
for life, which is why our program is so experiential in nature.
What kinds of skills are these kids learning? Stress man-
agement, gardening prowess, and cooking basics to start. Our
boarding program for teens requires a semester minimum,
as it takes about four months for behavioral changes to stick.
In that time, our students learn to better manage stress; to be
mindful; to garden; cook fresh, delicious foods; enjoy moving
their bodiesperhaps for the first timesocial and emotional
well-being; and to appreciate the great outdoorsoverall
becoming more grounded to the earth, Travaglione says.
To address whats at the core of the teens weight issues,
MindStream staff use experiential therapies, such as equine-
assisted psychotherapy and neurobiofeedback, which are
designed to better reach children by offering counseling in a
more fun, solution-focused, and nonthreatening way than tradi-
tional one-on-one therapy.
Even students families get in on the action. Our students
families participate in our program through weekly coun-
seling sessions via Skype, nutrition education, and weekend
workshops so the changes that are made at MindStream will
continue at home, Travaglione says, adding that by support-
ing the whole childand not just focusing on weight losshe
hopes to put students on a path of lifelong health and wellness.
Nutrition Nuts and Bolts
MindStream bases its nutrition program on what it calls the
FLOW concept (Fresh, Local, Organic, Whole food style and
nutrition program), which Travaglione says gives importance
to the following principle: Meals prepared with seasonal, farm-
fresh, local and regional wholesome ingredients taste better
and, when eaten in appropriate quantities, will lead to optimum
weight and wellness.
january 2013 www.todaysdietitian.com 43
 Our nutrition program has been designed to rekindle our
natural relationship with simple healthful eating and demon-
strate the essential life skill of how to select and lightly prepare
ones own food, he says.
The importance of the farm-fresh, organic, and local part
of the program is demonstrated in MindStreams own Soul
Garden, a 1-acre garden of herbs, fruits, and vegetables that
students take care of. They participate in all aspects of the
gardens care, from planting the seeds to harvesting their crops
and bringing them into the kitchen, Travaglione says, adding
that many students love the experience so much that when they
return home they start a garden of their own.
An RD/chef team, which works to bring MindStreams nutri-
tion philosophy to life, develops all student meals. This years
offerings were expanded from a three-week to a six-week
menu cycle to give students more options.
The menus are based on a 1,500-kcal diet, which is broken
down into three meals and two 100-kcal snacks, says Tina
Steinberg, MEd, RD, LD, whos behind MindStreams nutrition
curriculum. Steinberg and MindStreams chef work hard to
make all choices healthful and kid friendly.
The majority of foods served are made from scratch,
including dressings and sauces; grains/breads are whole
wheat; fruit is served with breakfast; and salads are served
with lunch and dinner, she says. Foods are minimally pro-
cessed and contain very little sugarunder 6 g. Beverage
choices are water and milk. The kids drink water all day long
to stay hydrated.
Targeted Education
Not only are students served the healthiest and freshest foods
available, theyre also taught how to integrate various culinary
skills, nutrition tips, and fitness into their day-to-day lives.
Culinary skills: Students learn how to prepare the types of
foods they eat at MindStream by participating in culinary demos
that are conducted once or twice per week. The kids learn
hands-on how to make their own meals and healthful desserts.
The demos have been a great hit with the kids, Steinberg says.
The culinary education program begins from the ground
up, Travaglione says, noting that at the academy students learn
about food from its true beginnings: the earth. Students have
the opportunity to assist in gardening fresh plant foods grown
on site, harvesting ingredients for the kitchen, and working
hands-on side by side with our chefs.
Through this hands-on experience, MindStream aims to give
students the tools they need to prepare simple, delicious, fresh,
and healthful meals after their return home.
Nutrition: According to Steinberg, students attend two-
hour-long nutrition classes once per week, which always are
taught by a registered and licensed dietitian. The classes are
lecture type but also include student participation, classroom
discussion, and hands-on activities, she says. While the
44 todays dietitian january 2013
classes follow a 16-week syllabus, theyre also redesigned
to incorporate popular topics, which the kids may discuss
during class time.
In addition to nutrition basics, the classes hit on topics such
as the importance of portion sizes, how to make good choices
when eating out, healthful substitutes for recipes, and how
to navigate the grocery store and decipher food labelsall
intended to give students a well-rounded knowledge base of
what it will take to continue their healthful habits at home.
Fitness: Students are enrolled in a fitness program to get
them movingfor life. Staffed by certified personal trainers as
well as dance, martial arts, Zumba, and yoga instructors, the
program is designed to get students to improve overall body
movement and learn to enjoy it.
To fuel their desire toward fitness, weve created a move-
ment playground, Travaglione says. Its this same belief that
correct movement is the backbone of a lifelong commitment to
fitness that has inspired us to focus on body weight-driven exer-
cise. We believe so strongly in body weight movement that there
are no traditional exercise machines at MindStream Academy.
According to Travaglione, MindStream students define their
own fitness path, as all fitness regimens are individualized.
Our four-phase program is based on the values we gain from
initial fitness evaluations, he explains. Training is based off of
ones own baseline, and a students current fitness level helps
determine his or her program, pace, and progression. As fit-
ness level increases, so does the pace of the program and the
difficulty of the activities.
The biggest difference between MindStreams approach
compared with most weight-loss programs may not be in what
theyre doing but in what theyre not doing, which is anything too
extreme. What makes our program so unique is that theres
nothing extreme about what were doing; weve just brought stu-
dents back to the basics, Travaglione says. They have put down
 their electronics, developed a relationship
with themselves, their bodies, and the world
around them, and as a result are achieving
goals they never thought possible.
He explains that while under some
weight-loss programs, such as those pop-
ular on TV, participants might endure
severely restrictive diets of 600 kcal or
PHOTO COURTESY OF MINDSTREAM ACADEMY
fewer to achieve dramatic results. Trava-
glione says MindStream students achieve
similar results but not in such an extreme
atmosphere.
Still, while the scale tells a compelling
story, Travaglione says perhaps the most
significant change MindStream students
undergo is related to their mental health,
which can have a far more lasting effect:
They arrive feeling despondent, and they
leave feeling like a new person. The changes that are made
here arent skin-deep. There are tremendous shifts in personal
responsibility, self-esteem, healthful risk taking, and a sense of
hope through accomplishing tremendous goals.
When our students go home, theyre maintaining their
weight loss, and some have continued on their weight-loss
journey, he adds. Students report better grades, being more
socially outgoing, and embrace their role as a healthful lifestyle
ambassador.
Branching Out
While MindStream is satisfied with the success its students
are achieving, it wants to effect change in more childrens lives.
Its hoping a new partnership with Independence School District
will help it do just that.
This semester were piloting a direct relationship with a
public school district, Travaglione says. Essentially, Mind-
Stream is taking in a cohort of kids whose obesity/metabolic
and psychosocial problems are too complex for a public school
to handle. This potentially frees up resources in the public
school district while MindStream helps these kids turn their
health and lives around so they can return as ambassadors of
what theyve learned and pay it forward.
The idea for the partnership came from the collaboration
of Travaglione and two others: Jim Hinson, superintendent of
the Independence School District, and noted prevention expert
David L. Katz, MD, MPH, FACPM, FACP, director of the Yale
University Prevention Research Center. We saw this unique
opportunity to partner and help obese kids in his district, and
the rest as they say is history, Travaglione says.
Designed to provide the promise of a better quality of life and
longevity for students in need, Travaglione hopes partnerships
such as this one will eventually help turn the tide on this epi-
demic and turn our countrys future around.
If these kids drop out, if they dont realize their fullest poten-
tial, if they remain in poor health, if they die before their life
begins, we all lose, he adds. The best economic stimulus we
can do is get these kids healthy.
To ascertain which kids in the school district are best
suited for the MindStream program, the staff looks at more
than students BMI. The selection criteria is based on a vari-
ety of assessments performed by members of our counseling
team, academic program, admissions officers, the students
guidance counselors, and other relevant advocates,
Travaglione explains.
Under the current partnership, the school district can offset
a portion of the cost of tuition ($28,500 per semester, and most
students attend for one semester). Primarily, this is done
through the collection of average daily student attendance while
they attend MindStream and reporting this to the State Depart-
ment of Elementary and Secondary Education for state fund-
ing, Travaglione says. Parents, corporate partners, private
donors, and the School District Foundations all participate in
contributing money that helps offset the cost of tuition.
Rather than waiting on the world to change, MindStream
gives these kids the world as it should bea world that leads
to health and away from bullying and ridicule, Katz says. Its
as much about community and solidarity as it is about fitness,
nutrition, and academics. It is, in a word, extraordinary. The
true beauty of this better world is that it imparts a skill set the
kids take back with them to the world as it is, making them far
better able to deal with it.
MindStream also gives the kids skills they can pay forward,
he adds. They can help others with what they learn there.
MindStream isnt about giving kids a better BMI; its about giving
kids both the will and the way toward a better life.
And so far, results are promising. According to Travaglione,
13 Independence School District students attended Mind-
Stream during the first semester of its partnership. At press
time, those students had collectively lost more than 500 lbs
and gained much more. Their self-confidence is through the
roof. Theyre performing better academically, loving the cook-
ing demos, and are preparing to return home as a community
resource and motivate other kids to get healthy and fit, he says.
This is great news for these teens but also good news for
students struggling elsewhere across the country, as Mind-
Stream has more school district partnerships currently in
the works.
Were at various stages of replicating this partnership in
South Carolina, Florida, Mississippi, Ohio, New York, and Ken-
tucky, Travaglione says, and we plan to do so in every state
and school district in the country.
Juliann Schaeffer is a freelance writer and
editor based in Allentown, Pennsylvania,
and a frequent contributor to Todays Dietitian.
january 2013 www.todaysdietitian.com 45
CPE MONTHLY
AUTISM SPECTRUM
DISORDER
Research Suggests Good Nutrition
May Manage Symptoms
By Dawn Privett, RD, LD, CLT
Decades ago, autism spectrum disorder (ASD), a group of
developmental disabilities in which patients have significant
social, communication, and behavioral difficulties, was consid-
ered rare, and the prognosis of those who had it usually wasnt
good. Many individuals were committed to institutions for the
rest of their lives because of their inability to function in society.
But times have changed.
The prevalence of ASD among adults and children has sky-
rocketed over the last several years. Much more research on
the etiology of the disorder and the different ways to treat and
manage it has become available. Today theres evidence show-
ing how nutrition therapy can play a significant role in manag-
ing various symptoms that prevent ASD patients from living
productively.
This continuing professional education course will define
ASD, discuss its prevalence and possible causes based on the
latest research, and evaluate the critical role good nutrition
may play in helping individuals function optimally. Dietitians will
learn about the various nutrition therapies available and be able
to apply them to practice.
46 todays dietitian january 2013
Defining Autism
The word autism comes from the Greek word autos, mean-
ing self. Its been used for about 100 years to describe a
condition in which people cant engage in social interaction.
Originally, it was thought to be associated with schizophrenia.
In 1943, Leo Kanner, MD, known as the father of child psychia-
try for his pioneering work related to autism, first identified
the disorder at The Johns Hopkins University in Baltimore.1
Also in the early 1940s, German scientist and pediatrician Hans
Asperger, MD, identified patients with similarly withdrawn
behavior, now known as Aspergers syndrome.2
Today, autism is better defined by the term autism spectrum
disorder, which describes a grouping of various developmental
disabilities. Symptoms of ASD usually begin before the age of 3
and continue throughout a persons life. In some infants, there
are early signs of the disorder, such as not wanting to cuddle,
lack of eye contact, or abnormal responses to touching and
affection. Other early signs include the inability to follow objects
visually, not responding to his or her name being called, and
lack of facial expressions, such as smiling.3 Some children with
ASD develop normally until the age of 1 or 2, then stop learning
new skills or lose the ones they already have learned.3
There are three main classifications of ASD and understand-
ing the difference among them will help to better focus treat-
ment. The first classification of ASD is autistic disorder, which
is considered the classic form of autism. Patients usually have
significant delays in language, social skills, and the ability to
communicate. Some have unusual behaviors and interests, and
have a measurable intellectual disability.
The second form of autism is Aspergers syndrome, usu-
ally a milder form of autism. Patients still have delays in social
abilities and communication skills, and have unusual behav-
iors and interests.4 Many individuals have a specific interest
that encompasses much of their time and thought. People with
Aspergers may spend much of their time devoted to a hobby
LEARNING OBJECTIVES
After completing this continuing education activity,
nutrition professionals should be able to:
1. Define the three types of autism spectrum disorder
(ASD).
2. Assess the various problem-eating behaviors associ-
ated with ASD.
3. Develop strategies to eliminate problem-eating
behaviors.
4. Employ the various nutritional therapies to treat ASD
patients.
(eg, trains, computers). They usually dont have issues with lan-
guage skills or intellectual development. In fact, many are intel-
ligent, especially when it comes to their own special interests.
Some experts liken patients with Aspergers to little professors
in their areas of interest; they can have near genius IQs.
The third form of autism is pervasive developmental dis-
order, not otherwise specified, or atypical autism. These indi-
viduals meet only some of the criteria for classic autism or
Aspergers. They have fewer, milder symptoms and may
experience delays only in the areas of social skills and
communication.4
Current ASD Statistics
The number of children diagnosed with ASD has increased
almost tenfold in the last 40 years.5 Currently, one in every 88
children is diagnosed with ASD.5 When broken down by gender,
five times more males (one in 54) than females (one in 252) are
affected.5 These statistics indicate that ASD affects more than
2 million people in the United States and more than 10 million
worldwide.4 According to the organization Autism Speaks, ASD
affects more children than diabetes, AIDS, or cancer combined.5
The increase in diagnoses may be due in part to better diag-
nostic tools, but many believe environmental toxins and genet-
ics hold better clues to the increase in prevalence, although this
hasnt been proven.
Link Between ASD and Environmental Toxins
No specific environmental toxin has been identified as the
cause of autism, but research to determine which chemicals
may be culpable is under way. Its been proven that a fetus is
vulnerable to environmental chemicals during development.
Examples of chemicals that, in the past, have been shown to
harm fetal development include organophosphate insecti-
cides6 (eg, chlorpyrifos), mercury exposure,7 and heavy metals
(eg, lead).8
Its a widely held belief that people with ASD have diffi-
culty eliminating toxic chemicals from their body. If this is the
case, exposure to environmental contaminants could play
a significant role in poor neural development or brain func-
tion processing. Unfortunately, because of the short amount
of time research has been conducted on the link between
autism and environmental toxins, causality still remains
speculative. However, it continues to appear that genetics,
environment, and the interaction of a childs physical and
psychosocial environment play an interrelated role in the
possible causes and triggers of ASD. Such associations can
be seen in the high incidence of autism in twins and genetic
siblings who have the disorder.9
Other suspected causes of autism include advanced parental
age,10 low birth weight,11 and multiple births.12 A viral infection,
such as the flu, in the first trimester has been shown to triple
the odds of a child developing ASD, and a bacterial infection,
such as a urinary tract infection, in the second trimester has
been found to increase the risk of ASD by 40%.13 Recently,
researchers examined inflammatory disease as a possible
cause of autism and found that it could possibly contribute to
the etiology of the disorder.14
Problem-Eating Behaviors
While the medical community may not have identified the
exact causes of ASD, much has been learned about the chal-
lenges ASD patients face that often lead to poor diet qual-
ity. These include problems with sensory processing, eating
behaviors, and feeding disorders. Its estimated that 46% to
89% of patients with ASD experience some kind of problem-
eating behavior.15 Some feeding difficulties revolve around
changes in routine. For example, patients with ASD may
refuse to eat unless they sit in the same place at the table,
eat on the same dishes, use the same tablecloth, and eat the
same foods daily.15 The slightest change in routine can cause a
tantrum or result in the refusal to eat.
Other issues may occur in the area of sensory processing.
For example, if children with ASD are hypersensitive to sounds,
they may not want to eat in a noisy area or with others engaged
in conversation. If they have visual sensitivities, they may accept
foods only of certain colors. They also may not be able to eat
foods that are touching each other on their plate.
Some children are sensitive to the way foods feel in their
mouth. They may avoid crunchy foods or foods that have a slick
mouthfeel. The way food smells can cause similar reactions,
and there are instances in which children may not recognize
certain tastes but can distinguish between others.
A study by Benetto and colleagues showed that children
with ASD were less able to accurately identify sour or bitter
tastes but could recognize salty and sweet tastes.16 This study
may shed light on why patients with ASD avoid several types of
foods, such as proteins, but will usually accept foods in the car-
bohydrate group.
The best approach to solving problem-eating behaviors,
according to Elizabeth Strickland, MS, RD, LD, author of the
book Eating for Autism: The 10-Step Nutrition Plan to Help Treat
New Lower
Price! How to Earn 2 CPEUs
Read this article and select your answers for the examination.
Then visit our CE Learning Library at CE.TodaysDietitian.com
to purchase access to complete the online exam and earn your
credit certificate. For more information, call our continuing
education division toll-free at 877-925-CELL (2355) (M-F, 9 am -
5 pm ET) or visit www.TodaysDietitian.com.
Suggested CDR Learning Codes: 3000, 3010, 3100, 4000, 4150,
4160, 5000, 5070, 5080, 5180, 5390, Level 2
january 2013 www.todaysdietitian.com 47
Your Childs Autism, Aspergers, or ADHD, is to assemble a feed-
ing team, a group of healthcare professionals consisting of a
physician, speech language pathologist, occupational therapist,
behavioral therapist, and RD.17 A dietitian can evaluate the foods
the child agrees to eat for potential dietary deficiencies. He or
she can watch the child and family during meal times to assess
habits that may be hindering food intake. An RD also can screen
the medications the child takes that may have side effects that
contribute to feeding problems.
ASD and Food Additives
Just as problem-eating behaviors can prevent ASD patients
from getting the nutrients they need, so can consistently con-
suming highly refined foods. Since highly refined foods may
contain artificial dyes and preservatives that could be asso-
ciated with aggravating behavioral symptoms in those with
ASD,18,19 suggesting the family eat natural, whole foods may be
an important treatment intervention.
When discussing dietary
recommendations with ASD patients
or their parents or caregivers, also
suggest that patients be screened
for nutritional deficiencies that can
result from the medications they take.
Dietitians working with ASD patients can recommend elimi-
nating the following substances from an ASD patients diet if
they believe a sensitivity exists:
Food dyes and artificial colors: These additives have been
linked to hyperactivity, breathing disorders, skin eruptions,
and gastrointestinal symptoms in non-ASD patients.18,19 Since
many ASD patients already have these symptoms, eliminating
foods that contain these substances may be helpful to assess a
patients reaction.
High-fructose corn syrup: One of the main concerns with
high-fructose corn syrup involves the manufacturing process.
Research has found that mercury, one of the environmental
toxins that may be responsible for the increased prevalence of
ASD, is part of the refining process when making high-fructose
corn syrup.7 Removing it from the diet whenever possible may
be a helpful suggestion.
Artificial flavorings: Monosodium glutamate (MSG), for
example, has been shown to cause headaches, muscle tight-
ness, numbness or tingling, weakness, and flushing in people
who are sensitive to it.20 Because of these known potential side
effects, it may be appropriate for ASD patients to avoid MSG as
a precautionary measure.
48 todays dietitian january 2013
Artificial preservatives: Studies have indicated that
artificial preservatives may cause sensitive individuals to
experience headaches, behavioral/mood changes,21 or hyper-
activity.22 So removing foods that contain these substances
may be beneficial.
Artificial sweeteners: Aspartame, acesulfame-K,
neotame, and saccharin have been known to cause headaches,
mood changes, nausea, vomiting, and diarrhea in the general
population.23
When discussing dietary recommendations with ASD
patients or their parents or caregivers, also suggest that
patients be screened for nutritional deficiencies that can result
from the medications they take. Some medications can affect
appetite and cause nausea, vomiting, constipation, hard stools,
diarrhea, esophageal reflux, weight gain or loss, sedation,
drooling, and sometimes dysphagia, all of which can compro-
mise nutritional status. For example, if a child is constipated,
he or she may experience a decrease in appetite. If dysphagia is
an issue, he or she may decrease food intake for fear of choking
while swallowing. If medication causes sedation, the child may
not feel the need to eat even though he or she is hungry.
Supplementation
Another aspect of ASD treatment involves supplementa-
tion with multivitamins, omega-3 fatty acids, vitamins D and
B6, magnesium, and other nutrients. Beginning multiple sup-
plements at one time may impede the ability to determine
whats working or not working in ASD patients. Therefore, the
best strategy may be to start one supplement at a time for
several weeks to determine whether theres an improvement
in symptoms.
If the patient takes one supplement for several weeks and
experiences no improvements in symptoms, it means the
supplement may not be helpful for that particular patient. If
improvements are seen, stopping the supplement for a week or
so to determine whether symptoms return can be a good strat-
egy to gauge effectiveness. This process allows ASD patients
to follow the least restrictive regimen possible while identifying
improvements in symptoms.
Multivitamins
Most practitioners who work with ASD patients agree that
a good-quality multivitamin without artificial colors or flavors
can help offset limited dietary preferences and poor nutritional
intake. Finding the right multivitamin will depend on a patients
tolerance. Some will swallow a pill, while others will prefer a
liquid, gummy, or chewable form. RDs are in a perfect position
to determine whats acceptable and meets each patients needs.
Omega-3 Fatty Acids
Research has shown that adding omega-3 fatty acid sup-
plements to ASD patients diets may provide many benefits.
Omega-3s are critical for brain development and proper neural
function. Multiple studies have shown imbalances in the ratio
of omega-3 to omega-6 fatty acids in the bloodstreams of ASD
patients.24-27 Obtaining adequate amounts from food alone may
be difficult because of the limited number of foods they may
eat. For example, some children with ASD wont eat cold-water
fish (eg, salmon, tuna), and some parents wont add fish to their
childrens diet because they believe it contains mercury that
may exacerbate ASD symptoms. Still, many parents do give
their children omega-3 supplements.28
Some practitioners recommend 1.5 g/day of omega-3 fatty
acids for most pediatric patient populations.25 According to
research, children with ASD who take omega-3 supplements
have less anxiety and aggression, decreased hyperactivity and
impulsivity, longer attention spans, and improvement in lan-
guage development, reading, and spelling skills.27,29-31 Most
omega-3 supplements are made from fish oil, so its impor-
tant to ensure theyre free of mercury. (The label will indicate
mercury-free processing.) Because oils can become rancid,
its best to use supplements before their expiration date. Some
supplements contain added vitamin E as a preservative to
improve shelf life, while others are bound with dietary calcium
to preserve the oil at room temperature.
If patients complain of stomach upset or fishy burps but dont
experience this when they eat fish, question the freshness of
the supplements. Patients may need to keep the supplements
in the refrigerator so they stay fresher longer.
Vitamin D
Several studies suggest a direct link between low vitamin
D (25-hydroxyvitamin D) levels and the risk of ASD since vita-
min D regulates the immune system. Research shows that
children are at risk of ASD because of their bodys inability to
identify foreign invaders and eliminate toxic substances and
have an even higher risk of developing the disorder if theyre
vitamin D deficient.
Vitamin D protects against DNA damage and can help repair
damage once its occurred. (Its role in reducing damage in the
case of environmental toxins is being investigated.) In addi-
tion, vitamin D may reduce oxidative stress, a hallmark of ASD,
and lower the number of inflammatory cytokines present in the
brain, which have been associated with the disorder.32
According to John J. Cannell, MD, founder and execu-
tive director of the Vitamin D Council, the prevalence of ASD
increases in regions of greater cloud cover and rainfall.33
Studies have shown there are more ASD cases in children born
between October and March.34 Research suggests this may be
due to the lack of sunlight exposure.
The body produces vitamin D when the skin is exposed to
the suns ultraviolet B rays, but during the cooler months of the
year, the sun isnt out long enough for pregnant mothers to get
ample exposure. Ensuring women get adequate amounts of
vitamin D during pregnancy is imperative. In supplement form,
the Recommended Dietary Allowance (RDA) is 600 IU. How-
ever, if blood work shows a pregnant woman is deficient, a plan
for increasing her vitamin D level must be directed by her phy-
sician, who may prescribe doses much greater than the RDA.
This applies to nursing mothers and children with ASD as well.
Vitamin B6 and Magnesium
Vitamin B6 and magnesium supplementation also are used in
treating ASD patients. One way to boost intake is in the form of
a multivitamin that contains both at US Reference Daily Intake
standards. Some studies have shown improvements in behav-
iors, such as increased speech, decreased aggression/temper
issues, better eye contact, increases in IQ, and the ability to
interact socially, with vitamin B6 and magnesium supplemen-
tation.35 Other studies, however, have shown that high-dose
pyridoxine supplements can cause peripheral or sensory neu-
ropathies,36-37 and larger doses of magnesium can cause gas-
trointestinal upset and diarrhea.
Other Supplements
Glutathione, which can be used in ASD treatment, enables
the body to detoxify and protect itself against oxidative
damage.38 Moreover, dimethylglycine is touted to improve lan-
guage skills and the ability to make eye contact. However,
theres little evidence showing that either alleviates symp-
toms.39-40 More research is needed to show efficacy of some of
the current supplements being used.
Probiotics, Antifungals, and Digestive Enzymes
Probiotics and antifungals are common treatments for the
abdominal pain, bloating, gas, constipation, gastroesopha-
geal reflux disease, nausea, vomiting, and diarrhea that many
ASD patients experience. No conclusive evidence is available
to explain why these digestive symptoms are common in ASD
patients, but the use of probiotics has provided relief of these
symptoms for many of them.
The National Center for Complementary and Alternative
Medicine defines probiotics as live microorganismsusually
bacteria, but they also can include microbes such as yeast
that people can ingest to increase the population of desirable
bacteria in the gut. Antifungals inhibit the growth of a fungus
or destroy it. Theyre used in the treatment of Candida albicans,
a fungus frequently reported as the culprit when a yeast infec-
tion is present. It can cause itching and burning of the mucous
membranes, skin eruptions, and imbalances in the overall
health of the gastrointestinal tract.
Digestive enzymes are substances that help break down
large macromolecules in foods to smaller substances to
facilitate their absorption. Examples of digestive enzymes
include proteases that break down proteins or lipases
that help break down fat. If a dietitian suspects a patient
january 2013 www.todaysdietitian.com 49
is experiencing inadequate digestion, digestive enzymes
may help. In some cases, digestive enzymes may aid in the
removal of toxic compounds from the gut.17
Elimination Diet Therapy
The elimination diet is another option that has shown prom-
ise in treating ASD and involves removing certain foods from
the diet for a period of time to determine whether theyre caus-
ing symptoms of food allergies and intolerances. Research has
shown that eliminating gluten and casein from the diet of ASD
patients can alleviate symptoms such as behavior problems
and poor cognitive and social functioning.41
There are several theories as to why the elimination diet may
be beneficial. One hypothesis is that ASD patients cant digest
gluten and casein, causing the formation of the peptides gluteo-
morphin and caseomorphin and their absorption into the blood-
stream because of increased gut permeability, or leaky gut
syndrome. These two peptides, which appear to have a chemi-
cal structure similar to opiates, can cross the blood-brain bar-
rier and cause symptoms such as delayed social and language
skills, and withdrawn behavior.42
The elimination diet is another
option that has shown promise in
treating ASD and involves removing
certain foods from the diet for a
period of time to determine whether
theyre causing symptoms of food
allergies and intolerances.
There are concerns about the use of a gluten-free/casein-
free diet because its planning requires a skilled professional
who understands the complexities of elimination diets and the
restrictions of appropriate foods. The exclusion of wheat and
milk puts an ASD patient at risk of nutrient deficiencies in cal-
cium, protein, vitamin D, folic acid, and B vitamins. And studies
have found that diets lacking gluten and casein raise the risk of
decreased bone density and stunted growth.43 However, RDs can
introduce other foods into the diet as well as provide advice on
nutritional supplements to compensate for low nutrient intakes.
A more complex elimination diet that some specially trained
dietitians use is called the LEAP (Lifestyle, Eating, and Per-
formance) protocol. This involves eliminating any known foods
or chemicals suspected of triggering symptoms. These foods
and chemicals are identified by a blood test called the Medi-
ator Release Test, which shows reactions to multiple foods
and chemicals. These reactions involve the immune systems
of patients who ingest foods and chemicals to which theyre
50 todays dietitian january 2013
sensitive. Their immune system identifies these foods and
chemicals as foreign invaders, causing the immune system to
release mediators to fight off the invaders.
Some of the mediators released include histamine, prosta-
glandins, leukotreines, cytokines, and peroxides. These media-
tors have been shown to cause reactions such as inflammation,
diarrhea, pain, intestinal cramping, constipation, headache, and
pain receptor changes. Studies have shown enhanced proinflam-
matory cytokine production is present in patients with ASD.44-47
Reactions to certain foods and chemicals also can cause the
release of the brain neurotransmitters dopamine and sero-
tonin. Dopamine appeals to the sense of reward and enjoyment,
and plays a role in addictive behavior. Serotonin contributes to
feelings of well-being and happiness.
When dopamine and serotonin are released as a result of
ASD patients ingesting foods and chemicals to which theyre
sensitive, they may experience less pain, brain fog, or inabil-
ity to focus and concentrate. According to certified LEAP ther-
apists, ASD patients also may feel euphoric after ingesting
a reactive substance or stop throwing a tantrum after eating
a reactive food. Its in these instances where the Mediator
Release Test may help with identifying reactive substances that
can be eliminated to improve behavior, communication skills,
and other immune-related health issues and allow for more
variety in the diet for better nutrition.
What Lies Ahead
So what does the future hold for individuals with ASD? While
theres no concrete answer to this question, we know RDs can play
a huge role in the management and treatment of ASD symptoms.
RDs ability to analyze diets for nutritional deficiencies can
help concerned parents. Contacts with other healthcare disci-
plines that monitor patient behaviors make RDs invaluable as
they provide holistic approaches to treatment for optimal cogni-
tive and social functioning. RDs are the best source for provid-
ing accurate and up-to-date information on supplementation,
elimination diet therapy, and current research on new nutri-
tional approaches.
More and more patients will depend on dietitians as the
source of information that will enable patients to live productive
lives. Dietitians with the passion to work with this challenging
segment of the population will be a much-needed resource in
the dietetics community in the years to come.
Dawn Privett, RD, LD, CLT, is a freelance writer and owner of
Privett Nutrition Services in Kansas City, Missouri.
For references, view this article on our website
at www.TodaysDietitian.com.
 CPE Monthly Examination

1. A patient presents with significant delays in language 6. Which of the following treatments may aid in removing
and social skills, and cant clearly communicate. The toxic compounds from the gut of ASD patients?
patient may have which type of autism spectrum disorder a. Probiotics
(ASD)? b. Antifungals
a. Autistic disorder c. Digestive enzymes
b. Aspergers syndrome d. Dimethyglycine
c. Pervasive developmental disorder, not otherwise
specified 7. Research has shown that eliminating gluten and casein
d. None of the above from the ASD patients diet can alleviate which of the fol-
lowing symptoms?
2. Which of the following is not usually a challenge ASD a. Behavior problems
patients may face that often leads to poor diet quality? b. Poor cognitive functioning
a. Sensory processing c. Poor social functioning
b. Feeding disorders d. All of the above
c. Binge eating
d. Problem-eating behaviors 8. Patients with Aspergers syndrome are more likely to
have which of the following characteristics than those
3. Patients with ASD who avoid several types of foods, diagnosed with a different type of ASD?
such as proteins, usually will accept foods in the carbohy- a. Significant delays in language skills
drate group. b. Abnormal responses in balance
a. True c. Delayed reactions to pain
b. False d. A near genius IQ

4. Which of the following is one of the best approaches to 9. A viral infection such as the flu in the third trimester has
addressing problem-eating behaviors? been shown to triple the odds of a child developing ASD.
a. Introduce one new food every three weeks until the a. True
child gets accustomed to eating it. b. False
b. Eliminate a food the child doesnt want to eat for
three weeks then reintroduce it. 10. Which of the following is not an early sign of ASD in
c. Evaluate the foods the child agrees to eat for poten- infants?
tial deficiencies. a. Not wanting to cuddle
d. A and B b. Lack of eye contact
c. Abnormal responses to touch and affection
5. Which of the following supplements have been shown d. Colic
to reduce anxiety and aggression, decrease hyperactiv-
ity and impulsivity, and increase attention span in ASD
patients?
a. Multivitamins
b. Omega-3 fatty acids
c. Vitamin D
d. Glutathione

Take this exam by visiting our CE Learning Library at CE.TodaysDietitian.com.

january 2013 www.todaysdietitian.com 51

SUPPLEMENT SPOTLIGHT
ZINC AND INFLAMMATION
Age-Related Zinc Deficiency May Contribute
to Chronic Disease Risk
By Marie Spano, MS, RD, CSCS, CSSD
A recent study published in the Journal of Nutritional Bio-
chemistry found a biological explanation for age-related
reductions in zinc status that may lead to impaired immune
system functioning and systemic inflammation, which are
contributing factors to chronic diseases. The study, which
used cell cultures and a mouse model, suggests that improv-
ing zinc status through diet and supplementation may be a viable
strategy for reducing the risk of inflammatory diseases.
When the body has insufficient access to zinc, its hit on
many levels due to the many ways in which zinc typically func-
tions to protect the body, explains Ellen B. Fung, PhD, RD,
CCD, an associate research scientist at Childrens Hospital
and Research Center in Oakland, California. First, zinc plays
a significant role as an antioxidant in the body. Therefore, in a
zinc-deficient state, there will be an excess of oxidants pres-
ent, leading to increased DNA damage. In addition, zinc is
a cofactor for RNA and DNA polymerases, which aid in the
usual repair mechanisms. When these systems dont function
properly, there will be increased damage. Finally, zinc aids in
modulating DNA repair and damage proteins. ... In a deficient
state, these systems also are in a state of disarray and lead to
increased DNA damage.
Researchers from Oregon State University examined the
effects of zinc deficiency and age on inflammatory responses
in both a cell culture model and an aged mouse model. One
aspect of the study compared groups of mice fed two different
amounts of zinc in their diets. The group receiving zinc sup-
plementation showed fewer age-related increases in markers
of inflammation. Though inflammation is essential for tissue
52 todays dietitian january 2013
repair and recovery from infections and injuries,
uncontrolled systemic inflammation leads to the
excessive formation of free radicals and subse-
quent damage to body tissues, a cascade of events
that contributes to the development of autoim-
mune diseases and several chronic diseases.1,2
The link that Dr [Emily] Ho has made between
zinc deficiency and DNA damage, and now sys-
temic inflammation, explains much of what we see
on a cellular or whole-animal level, Fung says.
For example, the root cause of the link between
immune function deficitswhy you get sick more
readily as you ageand zinc deficiency may be
the increased methylation of zinc transporters,
causing them not to function properly. This
leads to decreased zinc inside an immune cell and
increased inflammationa bad situation.
If the results can be translated to humans, they
would suggest that we can override the age-related deficits
by supplementing with zinc, according to Fung.
Study Details
In the in vitro cell model, human monocytes were grown
in zinc-deficient or -adequate media for up to 14 days. Mac-
rophages were then treated with 0, 10, or 100 ng/mL of LPS,
the major structural component of the outer wall of gram-
negative bacteria that initiates inflammatory responses. Cells
grown in zinc-adequate media had a significant decline in
zinc status after exposure to LPS. However, cells grown in
zinc-deficient media had significantly lower zinc status both
pre- and post-LPS exposure compared with those grown in
zinc-adequate media. In addition, zinc deficiency was associ-
ated with an increase in age-related inflammation as mea-
sured by expression of tumor necrosis factor-alpha and
interleukin-1-beta, cytokines that are important mediators of
the inflammatory response.
In the animal model, mice aged 2 to 26 months were fed a
standard rodent diet, a zinc-adequate diet (30 mg/kg of zinc),
or a zinc-supplemented diet (300 mg/kg) for three weeks. Age-
related declines in immune cell intracellular zinc content were
associated with an increase in markers of inflammation. In
addition, age-related environmental changes in gene expres-
sion led to alterations in zinc transport mechanisms, including
an increase in DNA methylation and histone modifications.
What leads to age-related changes in zinc status? With
age, the ability to absorb and utilize zinc is compromised,
though we dont know why it isnt well absorbed, notes Emily
Ho, PhD, lead study author and a micronutrient expert at
Oregon State University.
Making matters worse, many older adults dont consume
enough zinc through their diet or supplements. According to
National Health and Nutrition Examination Survey (NHANES)
data from 2001-2002, 30% of men and 36% of women over the
age of 71 consume less than the Estimated Average Require-
ment for zinc.3 Even those who consume supplements may still
fall short. NHANES III data found that 35% to 45% of elderly
adults had inadequate dietary intakes of zinc, and even with a
combination of diet and supplement use, 20% to 25% still fell
short on their zinc intake.4
Additionally, data from NHANES III (1988-1994) found that
older adults (aged 60 or older) from food-insufficient house-
holds have significantly lower intakes of zinc (less than 50%
of the Recommended Daily Intake) compared with those from
food-sufficient households,5 suggesting that access to food
also may be a factor in zinc intake.
Sara A. Blackburn, DSc, RD, an associate professor of clini-
cal nutrition at Indiana University-Purdue University Indianapo-
lis, has observed this pattern of low zinc intake in older people.
Ive seen zinc-poor diets in many adult patients with a chronic
disease such as diabetes, she says.
How Much Zinc?
If a persons ability to absorb zinc declines with age, should
he or she consume more of this mineral? We dont have a
great biomarker for zinc deficiency in humans and therefore
just meeting the DRI [Dietary Reference Intake] is a good place
to start until more research answers this question, Ho says.
In addition to ensuring adequate intake, Blackburn sug-
gests that a thorough physical examination be conducted by the
appropriate physician, paying particular attention to nonheal-
ing wounds and the skins appearance in case there are signs
of zinc deficiency.
Fish and meat are among the top sources of zinc. The bio-
availability of zinc in some plant-based foods is lower than
FOODS HIGH IN ZINC7,8
Raw oysters (Pacific), 3 oz: 14.1 mg
Baked beans, canned with pork and tomato
sauce, 1 cup: 13.5 mg
Beef, chuck roast, lean only, fat trimmed,
braised, 3 oz: 7 mg
Crab, King Alaskan, cooked (moist heat), 3 oz: 6.5 mg
Baked beans, canned, plain or vegetarian, 1 cup:
5.8 mg
Beef patty, 95% lean, broiled, 3 oz: 5.3 mg
Lobster, cooked (moist heat), 3 oz: 3.4 mg
Pork loin, lean only, cooked, 3 oz: 2.9 mg
zinc from animal foods due to phytates that bind zinc and
remove it from the body.6
Meeting Daily Requirements
The rapid growth of the older population makes preventing
age-related diseases a paramount concern. And if the results
of this study prove any indication in humans, honing in on zinc
status may be particularly important as a measure of preven-
tion. Age-related epigenetic decline in zinc status may contrib-
ute to both impaired immune system functioning and chronic
inflammation and, subsequently, related health problems.
Ho recommends seniors take a multivitamin that contains
the Recommended Dietary Allowance (RDA) of zinc. Zinc is a
great antioxidant. It helps with repair systems within the body.
Zinc is involved in a lot of the processes that fix DNA, says Ho,
who believes future research should examine biomarkers for
zinc deficiency and help determine whether the RDA for zinc is
adequate for the elderly.
Marie Spano, MS, RD, CSCS, CSSD, is a freelance writer
and owns a sports nutrition and nutrition
communications consulting company.
References
1. Perry VH. The influence of systemic inflammation on inflam-
mation in the brain: implications for chronic neurodegenerative
disease. Brain Behav Immun. 2004;18(5):407-413.
2. Hansson GK. Inflammation, atherosclerosis, and coronary
artery disease. N Engl J Med. 2005;352(16):1685-1695.
3. Moshfegh A, Goldman J, Cleveland L. What We Eat in
America, NHANES 2001-2002: Usual Nutrient Intakes From Food
Compared to Dietary Reference Intakes. Washington, DC: US
Department of Agriculture Agricultural Research Service; 2005.
4. Ervin RB, Kennedy-Stephenson J. Mineral intakes of
elderly adult supplement and non-supplement users in the
Third National Health and Nutrition Examination Survey. J Nutr.
2002;132(11):3422-3427.
5. Dixon LB, Winkleby MA, Radimer KL. Dietary intake and
serum nutrients differ between food-insufficient and food-
sufficient families: Third National Health and Nutrition Examina-
tion Survey, 1988-1994. J Nutr. 2001;131(4):1232-1246.
6. Institute of Medicine Food and Nutrition Board. Dietary Ref-
erence Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium,
Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vana-
dium, and Zinc. Washington, DC: National Academies Press; 2001.
7. Dietary supplement fact sheet: zinc. National Institutes of
Health Office of Dietary Supplements website. http://ods.od.nih.
gov/factsheets/Zinc-HealthProfessional/#en9.
8. USDA national nutrient database for standard refer-
ence. United States Department of Agriculture Agricultural
Research Service website. http://www.ars.usda.gov/Services/
docs.htm?docid=8964. Last modified October 9, 2012.
january 2013 www.todaysdietitian.com 53
FOCUS ON FITNESS
MOBILE APP MOTIVATORS
New Tech Tools May Help Keep Clients
Exercising Well Beyond the New Year
By Jennifer Van Pelt, MA
Happy New Year! After counting down the seconds to 2013,
your clients probably started counting the calories they need
to cut and the number of pounds theyd like to lose. As is
typical every January, New Years resolutions to lose weight,
exercise more, and eat healthier are made and then soon
broken. Gym owners, fitness instructors, and personal trainers
all confirm that at the start of every new year, the gym equip-
ment and classes are mobbed, and training sessions are
booked solid. By March, the crowds thin out considerably when
busy schedules and lost motivation overshadow resolutions to
exercise regularly.
Psychology Behind Motivation
Motivation and exercise adherence involve a complex
interaction of an individuals personality, goals, and behavior
choices. Researchers have sought to better define these fac-
tors with the hope of improving promotional health messages to
increase physical activity.
54 todays dietitian january 2013
Understanding exercise moti-
vation is especially important
as the prevalence of overweight
and obesity continues to rise.
One evolving area of study is
self-determination theory, which
examines intrinsic and extrin-
sic motivation. As related to
exercise, intrinsic motivation is
defined as exercising because
its satisfying and elicits feelings
of enjoyment. Extrinsic moti-
vation is defined as exercising
for a specific reason or to elicit
a particular outcome. It may
involve the perception that exer-
cise is a means to an end, results
in a reward, or is performed
in response to an expectation.
For example, a client who plays
tennis regularly because she enjoys the sport, mastering
playing skills, and/or the competition likely is intrinsically
motivated. A client who exercises to lose weight is extrinsi-
cally motivated.
In addition to providing an explanation of self-determination
theory in relation to exercise, a systematic review published in
the June 2012 issue of the International Journal of Behavioral
Nutrition and Physical Activity found that intrinsic motivation
was more likely to result in long-term exercise adherence.
The New Years resolution to exercise is categorized as
extrinsic motivation. Therefore, clients who use a New Years
resolution to initiate an exercise routineno matter the
intended goalwill inevitably have problems maintaining moti-
vation over the long term. The principle of intrinsic motivation
can be applied to developing strategies to help clients succeed
with maintaining an exercise program. As Ive discussed in a
previous column, encouraging clients to find an exercise activ-
ity they enjoy is a good first step toward exercise adherence.
(See the September 2012 installment of Focus on Fitness,
Dance Fitness.)
Unfortunately, intrinsic motivation may be difficult to cultivate
in some clients, particularly those who have self-esteem issues,
negative attitudes about exercise, or physical limitations. For
example, even if a client enjoys dancing for exercise, feeling
self-conscious in a dance class or lack-
ing space at home may override intrin-
sic enjoyment. Is it possible then to use
extrinsic motivation to improve exercise
adherence?
The introduction of high-tech fitness
gadgets and smartphone apps for fit-
ness could provide extrinsic motivation
for the long-term. Given our obsession
with being connected via wireless net-
working, its reasonable to consider
that fitness gadgets and apps can be
more successful extrinsic motiva-
tors than, for example, tracking calo-
ries burned and pounds lost in a written
food and activity diary.
For technophobic clients, using
technology to enhance motivation to
exercise can be as simple as exchang-
ing daily text messages with a fitness
buddy who has similar exercise goals,
signing up for motivational daily e-mails
from a fitness website, or using an
online personal training service. For
clients who always have their smart-
phone in hand and love technology toys,
the following gadgets and mobile apps
may be of interest to track their fit-
ness activities, providing motivation for
daily workouts and encouraging fitness
progress over time.
Fitness Gadgets
FitBit One: This fitness tracking
device is the size of a USB flash drive
and costs $99.95. It tracks fitness data,
such as steps walked or climbed, dis-
tance, calories burned, sleep cycle, and
sleep quality, 24 hours a day, 7 days a
week. The One also has a silent alarm
that gently vibrates to wake you up in the
morning. Data can be viewed via a cus-
tomizable dashboard and mobile app,
which are both free. Progress is tracked
using charts, graphs, and other user-
friendly displays to help clients reach
their goals. Moreover, interfacing with
apps such as SparkPeople, MyFitness-
Pal, MapMyFitness, and LoseIt! is free.
The FitBit One wirelessly syncs with
PCs, Macs, iPhone 4S and 5, third gen-
eration iPads, and iPod touch.
Striiv: A combination fitness
tracker and mini gaming device cost-
ing approximately $100, the Striiv
fits into a pocket and tracks steps
walked and climbed each day. Clients
can meet a series of challenges and
score points during the day based on
the number of steps, stairs climbed,
miles walked, or time spent being
active. A walkathon feature connects
with Striiv, which will donate money on
behalf of the client.
Fitness Apps
miCoach: This training app is avail-
able for free for iPhone, iPod touch,
iPad, Android phones, and BlackBerry
devices. Clients get real-time audio
coaching throughout a customized
workout they can vary each day. The
app tracks time, distance, pace, and
calories burned.
FitnessBuilder: Available for
the iPhone, iPod touch, and Android
phones, FitnessBuilder is a subscrip-
tion personalized workout app. Clients
can choose from a large library of
instructional workout videos, design
their own workouts by selecting a range
of exercises from the library, connect
with a live personal trainer, and use
fitness-tracking tools to measure their
success weekly.
Tech Tools Galore
These are just a few of the new fit-
ness gadgets and apps available for
clients beginning an exercise program
or who require additional motivation to
continue a regular program. Many more
are available for advanced exercisers
and athletes for a range of fitness activi-
ties, from strength and muscle building
to mapping running and cycling routes.
Linking a love of technology to exercise
goals may provide the tech-savvy client
with the right motivation.
Jennifer Van Pelt, MA, is a certified
group fitness instructor and healthcare
research analyst/consultant
in the Reading, Pennsylvania, area.
january 2013 www.todaysdietitian.com 55
BOOKSHELF
The Essential Cancer Treatment Nutrition Guide & Cookbook
By Jean LaMantia, RD, with Neil Berinstein, MD
2012, Robert Rose
Softcover, 320 pages, $24.95
Cancer treatments create a spectrum of nutritional chal-
lenges for patients, their caregivers, and the dietitians who
advise them. The Essential Cancer Treatment Nutrition Guide
& Cookbook is an indispensable tool for any professional
working with such clients. This detailed and authoritative
book, written by Jean LaMantia, RD, a cancer survivor, along
with Neil Berinstein, MD, a practicing oncologist, underscores
proper food and diet as a vital complementary treatment for
cancer patients at every stage of recovery.
The first part of the book examines conventional cancer
therapies and their side effects and provides information on
managing those side effects, from anemia and fatigue to
diarrhea and heartburn, through diet. Another chapter
offers nutritional strategies for boosting the immune
system, reducing inflammation, and creating a life-long
therapeutic diet to prevent cancer recurrence.
Nondietary complementary therapies, such as homeopathy,
aromatherapy, and reiki, are outlined, with an emphasis on the
importance of physical activity in addition to nutrition. Sample
menus and advice on shopping and food safety also are provided.
Numerous charts, sidebars, and frequently asked questions
present a wealth of information in an easy-to-use format.
The 150 recipes at the back of the bookdeveloped by
LaMantia and six contributorsencompass everything from
breakfast dishes and entres to snacks and beverages.
Ingredient lists include
both standard US mea-
surements and imperial
units for Canadian read-
ers. The recipes, which
focus on comfort foods to
tempt suppressed appe-
tites, use easy-to-find
ingredients and uncom-
plicated directions.
Supplemental infor-
mation provided with
each recipe is a standout
feature of the book. Along
with a full nutritional
analysis, every dish
includes recommendations for specific side effects or con-
ditions (eg, dehydration, nausea, weight gain promotion), a
variety of practical food and cooking tips, and suggestions
for adjusting the recipe to alleviate particular symptoms.
Many of the recipes can be made ahead of time, and instruc-
tions on storage and reheating are given.
So-called survivor wisdom quotes from LaMantia are
scattered throughout the book, providing helpful insights
and adding a personal touch to this invaluable guide.
Lenora Dannelke is an independent journalist who writes
about food for numerous publications.
Healthy Eating, Healthy Weight for Kids and Teens
By Jodie Shield, MEd, RD, and Mary Catherine Mullen, MS, RD
2012, Academy of Nutrition and Dietetics
Softcover, 288 pages, $21.95
Appropriately addressing a
weight issue can confound even
the best and brightest, but its
particularly perplexing when
children are involved. Yet one
look at the statisticsan esti-
mated one in three American
children today is either over-
weight or obeseshows many
kids are struggling. This book
seeks to help.
Written by dietitians Jodie
Shield and Mary Catherine
Mullen and produced by the
Academy of Nutrition and Dietetics publishing arm, Eat
Right Press, Healthy Eating, Healthy Weight for Kids and
Teens aims to provide parents with the knowledge and tools
to wage warand winagainst whatever food issues their
children are facing.
To help parents determine whether their child has a weight
problem that requires intervention, two introductory chapters
serve as required reading and help define what actually
constitutes a healthy weight. Here, topics such as whats
normal for certain age ranges, what BMI is and what it
means, and how parents can best track a childs height and
weight are discussed. (Tip 1: Use a digital scale for accuracy.)
The eight chapters that follow dont need to be read in
order; each outlines a particular strategy that addresses a
specific problem. Parents are meant to scan the chapter titles
to see which they might benefit from most before diving into
them. For example, if Mom and Dad both work full time and,
due to work and a dozen after-school commitments, have
trouble getting a dinner routine in order, often opting for fast
food, then Chapter 3: Eat With a Plan might suit them well. In
this chapter, the authors define in concrete terms what
healthful eating actually looks like (with help from a Choose
MyPlate illustration), then break it down even further with
kid-friendly tips on how to incorporate whole grains, dairy,
fruits, and veggies into a daily meal plan. The book provides a
sample one-day menu to help parents see what theyre
shooting for in terms of foods and serving sizes.
Other chapters provide strategies, addressing several
all-too-common healthful-eating barriers that can prevent
kids from keeping their weight in check, such as watching
too much TV, drinking soda and other sugar-sweetened
beverages, portion distortion, fast-food hang-ups, and picky
eaters aversions to fruits and veggies.
Backed by scientific research, the authors say these
strategies also may help healthy-weight kids from ever
having to deal with the unwanted physical and emotional
dilemmas that come with being overweight or obese. To
finish up this book, three weeks of sample menus (with
healthful meal and snack ideas) serve as a great resource to
help parents practice their just-learned healthful strategies
with fresh (and kid-approved) dinner ideas.
Juliann Schaeffer is a freelance writer and
editor based in Allentown, Pennsylvania,
and a frequent contributor to Todays Dietitian.
Cooking Vegan
By Vesanto Melina, MS, RD, and Joseph Forest
2012, Book Publishing Company
Softcover, 224 pages, $19.95
Ill be the first to admit that when Cooking Vegan came across
my desk, I hesitated about agreeing to be a reviewer. Despite a
handful of half-hearted attempts by my husband in the past to
convince me we should become vegetarian, I remain fairly com-
mitted to my life as a carnivore. But with its underlying tone
that eating vegan (at least sometimes) is for everyone, Cooking
Vegan is just as appropriately written for people like me as it is
for those who are vegan. This collection includes recipes worth
trying for a diet with fewer animal-based foods or to add more
creative dishes to your
repertoire.
Readers of Cooking
Vegan will appreciate
the variety of cre-
ative recipes and fla-
vors, and the way the
authors have demysti-
fied vegan ingredients.
Nutrition profession-
als will appreciate the
inclusion of a detailed
and easy-to-read intro-
duction on the vegan
lifestyle, including an
abbreviated explana-
tion of vegan nutrition,
a description of ingre-
dients commonly used in vegan dishes, cooking tips, and
sample menus. Additionally, nutritional information is avail-
able for every recipe, with more than just a macronutrient
breakdown provided.
Cooking Vegan showcases a variety of dishesbreakfast
foods, sauces, dips, salads, and sweet treatsand theres
something for everyone. I sampled the Fiesta Quinoa Salad
With Lime Dressing; Avocado, Grapefruit, and Chipotle
Dressing; Thai Pasta Salad With Spicy Peanut Sauce; and
the Walnut, Olive, and Sun-Dried Tomato Tapenade. The
directions were easy to understand, clearly written and, as a
novice vegan eater, I especially enjoyed the short description
that accompanied every recipe.
Readers should take caution and note the yield, as some
recipes make quite a large amount. They also should be
prepared that while most ingredients are common and read-
ily available, I did have to purchase several oils and spices
that arent usually stocked in my pantry. These items were
available at my local grocer but were fairly costly; I suspect
that had I gone to my local specialty store, these ingredients
would have cost less.
But these minor considerations dont overshadow the
variety of unique ideas readers can find in Cooking Vegan.
Christin L. Seher, MS, RD, LD, is a dietitian, instructor,
and nutrition consultant in northeast Ohio.
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E ISSUE
2012 CONFERENC
FNCE CONFERENCE
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Vol. 13 No. 10

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Beyond Yogurt
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scientic evidence cardiovascular
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Get CE credits quickly,

anyone singing these praises anymore. 2000 to an average
this in of 152 lbs
addition to per year.
eating Peoplefoods
processed
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Lustig
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date. In April,
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though research of long-term
and total mortality. Keep in mind, a similar
a direct link, the AHA stated.2
thus farsalt hasrestriction on CVD to confirm
been insufficient
review article pub-
For decades, both consumers and health experts have among the public over the potential health fallout. Find- blood pressure of greater than or equal to 130/85 have a 1.5 to lished in [The American Journal of Clinical Nutrition in March]
Cardioprotective
been pondering the potential negative health effects
what weve heard thus far a bit of an exaggeration?
ings from the International Food Information Council Foun-
Recently, a media restorm erupted over a
health. He reported that sugar is toxic and that its to blame for Most everyone agrees that the increase in sugar intake has
2.5 times greater risk of experiencing a heart attack than those 4 last year failed to nd an association between saturated fat
the public health crisis more than any other food substance. led to a sea of unwanted calories. The Dietary Guidelines for
related to sugar consumption. The classic 1986 book Sugar dation 2012 Food & Health Survey revealed consumers with a blood pressure value of less than 120/80. intake and CVD events. Nevertheless, theres a known impact of
Effects
Blues by William Dufty exploded onto the sugar-busting attitudes about
July report in the Cochrane Database of System-
sugar
atic andalso
Reviews, health. Consumers
appearing were asked
simultaneously in the
One
So yearthe
whats
article titled
confusion,
earlier,
Is Sugar
especially
Lustig
real story? Such
whenToxic?
was featured
con
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clients catch only
in a New
icting reports
byhalf
Gary
canYork
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create
story on the
Times saturated Americans
authorrespectively,
fat and salt
amounts,
report
on LDL
resulting
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that added sugars
cholesterol
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clinical intake
trials,
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of calories
he says.
pressure, in excessive
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scene. People were shocked to read which calorie sources (sugars, carbo-

Give
Give You
ourr Job
Job Sear
Search
h
American Journal of Hypertension, which seemed of Good Calories, Bad Calories, whowith shares similar
they were consuming, on average, 100 nightly news. As patients come calling questions, saltviews
shaker with data suggest
nutritionalis the payback.
failure to However, the guidelines
nd an association in studies statethatthat foods
By Sharon Palmer, RD to callhydrates, fats,
into question theprotein,
basis foror allrestriction
salt sources)
Lustig.
at Sugar
the ready, isnt
youll need just an empty
to know how tocalorie,
respond Lustig
to their says
sodiumin the arti-
measured withtheseadded sugars are
parameters no more likely
inaccurately. The datato contribute
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lbs of sugar per year. they believe are more responsible for
cle; its In
queries. effects on us are
the following much
article, moreprofessionals
nutrition insidious. Its a poison by
evaluate importgain than anyalter
and shouldnt other source
clinical of calories in an eating pattern thats
decisions.
itself, Lustig was quoted as saying. Taubes wrote: within calorie limits.6
40 todays dietitian october 2011 october 2011 www.todaysdietitian.com 41
28 todays dietitian october 2012 october 2012 www.todaysdietitian.com 29

Call 877-394-7350 or e-mail a Stab

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Registered Dietitian
Chronic Disease Management/Transitional Care Clinic/Heart Failure Clinic

For details regarding Employment Opportunities:

Call our Recruitment Office at 1-800-726-9862 or
928-336-7121 or Email: HR@yumaregional.org
We are an equal opportunity employer and support a drug-free and tobacco-free work environment.

january 2013 www.todaysdietitian.com 59

NEWS BITES
Mindful Eating Lowers Weight, Blood Sugar in Diabetes
Eating mindfully, or consuming food in response to
physical cues of hunger and fullness, is just as effective as
adhering to nutrition-based guidelines in reducing weight
and blood sugar levels in adults with type 2 diabetes,
suggests a new study published in the November issue of
the Journal of the Academy of Nutrition and Dietetics.
In a comparison study of the effectiveness of the two
types of behavioral interventions, participants lost about
the same amount of weightan average of between 312
and 6 lbsand lowered their long-term blood sugar
levels significantly after three months.
One treatment group followed an established diabetes
self-management education program, with a strong empha-
sis on nutrition information. The other group was trained in
mindful meditation and a mindful approach to food selec-
tion and eating. Both interventions, involving weekly group
meetings, also recommended physical activity.
The more traditional education program includes
general information about diabetes but with more
emphasis on nutrition and food choice: What are differ-
ent types of carbohydrates and fats, and how many am I
supposed to have? What should I look for when I read a
food label? What are healthful options when dining out?
That was the traditional diabetes education program,
explains Carla Miller, PhD, an associate professor of
human nutrition at Ohio State University and lead study
author. We compared it to an intervention where mind-
ful meditation was applied specifically to eating and food
choices. This intervention group didnt receive specific
nutrition goals. We said we want you to really tune into
your body before you eat. Take a few minutes to assess
how hungry you are and make conscious choices about
how much youre eating. Stop eating when youre full.
We studied two very different approaches, and we
found they both worked, Miller says.
Participants were between the ages of 35 and 65 and
had been diagnosed with type 2 diabetes for at least one
year. To be eligible, participants had to have a BMI of 27
or higher, indicating they were overweight, and a hemo-
globin A1c (HbA1c) reading of at least 7%.
Study participants were randomly assigned to a treat-
ment group. Twenty-seven completed the mindful eating
program, and 25 completed the traditional diabetes self-
management program called Smart Choices. Each inter-
vention involved eight weekly and two biweekly 212 -hour
sessions with trained facilitators.
The interventions took place over three months.
60 todays dietitian january 2013
Researchers assessed participants health measures and
dietary habits immediately after the programs concluded
and then again three months later at the studys end.
Weight loss and improvements in HbA1c levels were
similar for both groups at the six-month follow-up point.
Smart Choice participants as a group lost more weight,
an average of 6 lbs, than did the mindful eating group,
which lost an average of 3.5 lbs, but the difference wasnt
significant when analyzed statistically, Miller says.
HbA1c levels dropped in both groups as well between
about 0.7% and 0.8%. That was a clinically meaningful
reduction in Hba1c, equivalent to what youd get on some
diabetes medications, Miller says. If the reduction were
sustained over time, it would mean a dramatic reduction
in complications associated with diabetes.
Both groups also similarly reduced calorie intake and low-
ered their consumption of foods with a high glycemic index.
Miller says that because nutrition education is important
to people with a new diabetes diagnosis, she sees the mind-
ful meditation and eating option as a potential supplement
to basic diabetes education. She also said that participants
adapted well to the concept of mindfulness even though its
generally considered an alternative health practice.
One of the things we were evaluating was how well this
was accepted by people who had no experience with it. It
was very well accepted by participants in that group, and
this tells us that people with diabetes have choices, Miller
says. The fact that both interventions were equally effective
suggests we should let people choose. If mindful meditation
is appealing and people think that approach is effective, then
it very well could be the best choice for them.
SOURCE: OHIO STATE UNIVERSITY
High-Carb Diet Associated With Colon Cancer Recurrence
Colon cancer survivors whose diets are heavy in complex
sugars and carbohydrate-rich foods are far more likely to have
a recurrence of the disease than are patients who eat a better
balance of foods, indicates a new study by Dana-Farber Cancer
Institute researchers.
The connection is especially strong in patients who are
overweight or obese, the authors wrote. More than 1,000
patients with advanced (stage 3) colon cancer participated in
the study, one of the first to examine how diet can affect the
chances that the disease will recur. The findings are being
published online by the Journal of the National Cancer Institute.
Although the results point to a potential hazard of a high-
carbohydrate diet for colon cancer patients, the take-home
message is not a conclusive eat less sugar, says lead author
Jeffrey Meyerhardt, MD, MPH. Our study certainly supports
the idea that diet can impact the progression of colon cancer,
and that patients and their doctors should consider this when
making posttreatment plans, but further research is needed
to confirm our findings.
Recent studies have shown that colorectal cancer survivors
whose diet and activity patterns lead to excess amounts of
insulin in the blood have a higher risk of cancer recurrence
and death from the disease.
In a previous study of advanced-stage colon cancer
patients, Meyerhardt and his colleagues found that those
with a typical Western diet, marked by high intakes of meat,
fat, refined grains, and sugary desserts, were three times
more likely to have a cancer recurrence than those whose
diets were least Western. The new study was conducted to
High Vitamin D Levels May Protect Mothers Against MS
Pregnant women who have higher levels of vitamin D in their
blood may have a lower risk of developing multiple sclerosis
(MS) than women with lower levels, while their babies may not
see the same protective effect, according to a study published
online in Neurology.
In our study, pregnant women and women in general
had a lower risk for MS with higher levels of the vitamin, as
expected. However, a mothers levels of vitamin D during
early pregnancy didnt have an effect on MS risk for her
baby, says study author Jonatan Salzer, MD, with Ume
University Hospital in Sweden.
For the study, scientists reviewed information about 291,500
blood samples from 164,000 people collected since 1975 in the
northern half of Sweden. Of those, 192 people developed MS an
average of nine years after their blood sample was drawn, and
there were 37 blood samples drawn during pregnancy from
mothers whose children went on to develop MS later in life.
explore which component of the Western diet is most respon-
sible for the increased risk of recurrence.
The study involved 1,011 stage 3 colon cancer patients
who had undergone surgery and participated in a National
Cancer Institute-sponsored Cancer and Leukemia Group B
clinical trial of follow-up chemotherapy for their disease.
Participants reported their dietary intake during and six
months after the trial.
Researchers tracked the patients total carbohydrates as
well as their glycemic index and glycemic load and looked for
a statistical connection between these measures and colon
cancer recurrence.
They found that participants with the highest dietary levels
of glycemic load and carbohydrate intake had an 80% increased
risk of colon cancer recurrence or death compared with those
who had the lowest levels. Among patients who were overweight
or obese (BMI above 25), the increase was even greater.
In light of our and others research, we theorize that factors
including a high glycemic load may stimulate the bodys produc-
tion of insulin, Meyerhardt says. That, in turn, may increase the
proliferation of cells and prevent the natural cell-death process
in cancer cells that have metastasized from their original site.
Meyerhardt adds that while the study doesnt prove that diets
high in glycemic load and carbohydrate intake cause recur-
rence of colon cancer, the results strongly suggest that such
dietary factors play a role. Our findings may offer useful guid-
ance for patients and physicians in ways of improving patient
survival after treatment, he says.
SOURCE: DANA-FARBER CANCER INSTITUTE
The research found that women who had high levels of vitamin
D in their blood had a 61% lower risk of developing MS compared
with those who had low levels of vitamin D in their blood. Over-
all, few people had high levels of vitamin D. Only seven of the
192 people (4%) who developed MS had high vitamin D levels
compared with 30 of 384 controls (8%) without the disease.
No association was found between the mothers vitamin D
level and whether her child would later develop MS.
Since we found no protective effect on the baby for women
with higher levels of vitamin D in early pregnancy, our study
suggests the protective effect may start in later pregnancy
and beyond, Salzer says. Another interesting finding in our
study was that the vitamin D levels became gradually lower
with time from 1975 and onward. Its possible that this decline
in vitamin D status is linked to the increasing numbers of MS
cases seen worldwide.
SOURCE: AMERICAN ACADEMY OF NEUROLOGY
january 2013 www.todaysdietitian.com 61
GET TO KNOW
CAT CORA
An Iron Chef With a Heart
for Combating Hunger
By Juliann Schaeffer
As one of the newest membersand the first female
inducted into the Culinary Hall of Fame, its no secret Cat Cora
knows her way around a kitchen. First employing her cook-
ing prowess in 2005 to best the brightest of culinary stars as
the firstand onlyfemale Iron Chef on Food Networks Iron
Chef America (for which she may be most recognized), now the
celebrity chef is utilizing social media technology to bring those
top-rate cooking skills to the masses with a new iPad app.
Called Cat Coras Kitchen, the app not only gives users deli-
cious recipes but also assists users in organizing their time via
a scheduler that includes step-by-step instructions and esti-
mated completion times for each dish.
62 todays dietitian january 2013
Hunger kills more people each year
than AIDS, tuberculosis, and malaria
combined. Chefs for Humanity is
a nonprofit organization I founded
to galvanize chefs, the culinary
community, and other concerned
individuals to support hunger relief.
We designed the app to serve as a tool for at-home chefs
to plan and execute stress-free meals for their family and
friends, Cora says. The meal planner is detailed with step-by-
step instructions to make cooking meals easier for everyone.
The less time you spend stressing over a meal, the more time
you can spend actually enjoying it!
In addition to penning popular cookbooks, conceptualizing
fresh and exciting concepts for restaurants, and heading a line
of specialty foods and cookware, Cora also finds time for phi-
lanthropy, fighting both hunger and obesity through her non-
profit organization, Chefs for Humanity.
But the most motivating of her endeavors? No question, its
her four boys: My kids inspire and motivate me every single day.
Todays Dietitian (TD): Iron Chef, TV host, contributing editor
for O, The Oprah Magazine: Whats next?
Cora: I just opened a new Cat Coras Kitchen restaurant at the
Salt Lake City Airport and hope to open more across the coun-
try soon. Im also putting the final touches on a shoe line, which
will be available [sometime in 2013].
TD: In 2005, you founded Chefs for Humanity. What is this
organization, and what sparked the idea for its inception?
Cora: Hunger kills more people each year than AIDS, tuber-
culosis, and malaria combined. Chefs for Humanity is a non-
profit organization I founded to galvanize chefs, the culinary
community, and other concerned individuals to support
hunger relief and improve nutrition for children and fami-
lies here in the United States as well as in places in the world
where hunger and malnutrition pose even more dire threats
to public health.
I was inspired to start Chefs for Humanity after witnessing
how chefs and people who love to cook also love to help, and
learning how valuable skills like cooking for large crowds and
safe food handling can be in times of disaster such as during
Hurricane Katrina, where I, along with other chefs, helped the
American Red Cross set up temporary kitchens to feed dis-
placed victims.
 Recognizing that chronic hunger and malnutrition is an
ongoing disaster for so many people, Chefs for Humanity is
committed to mobilizing those with needed skills and passion to
help every day as well as in times of crisis.
TD: How does Chefs for Humanity work to prevent hunger and
reduce obesitytwo causes close to the hearts of many dieti-
tiansand whats your proudest accomplishment of the orga-
nization thus far?
Cora: Chefs for Humanity works to prevent hunger and malnu-
trition, which includes obesity, by raising support and aware-
ness and developing programs to address these issues. There
are many accomplishments were proud of but, most recently,
were working to establish a Global School Gardens initiative
to help educate children about good nutrition while connecting
them to the culinary community and engaging local chefs, res-
taurants, and others to ensure that healthful eating and afford-
able access to good food is a communitywide effort.
Greek Cinnamon Stewed Chicken (Koto Kapama)
Serves 4
Ingredients
1 chicken (212 to 3 lbs), cut into eight pieces
1 tsp ground cinnamon
2 tsp kosher salt
1 tsp freshly ground black pepper
5 peeled garlic cloves, minced
2 T extra-virgin olive oil
2 peeled, coarsely chopped medium yellow onions
1
2 cup dry white wine
1 cup water
1 cup chicken stock
One 6-oz can tomato paste
1 T fresh oregano, chopped
1
2 cup grated Mizithra cheese
Instructions
1. Pat the chicken dry with paper towels. A wet chicken
will cause the oil to splatter while the chicken is sauting.
Mix the cinnamon, salt, and pepper in a small bowl. Rub the
chicken pieces on all sides with the seasoning.
2. Mince three of the garlic cloves. Heat the olive oil in
a large nonreactive deep skillet over high heat. A 12-inch
skillet with sides about 212 to 3 inches high will allow you to
brown all the chicken at once. If you dont have a skillet large
enough, brown them in two batches using one-half of the
TD: Is there one product in your specialty food line that you
couldnt live without in your own kitchen?
Cora: I cook with my award-winning Cat Coras Kitchen BY
GAEA organic olive oil almost daily. Its the first-ever bottled
olive oil to be completely carbon neutral.
TD: Whats your favorite family recipe and why?
Cora: I love my moms Greek Cinnamon Chicken recipe (see
below). It was my absolute favorite growing up; my mom would
make it on special occasions like holidays, birthdays, and anni-
versaries. I carry on that tradition today, and my kids love it!
Eating it always brings back fond memories.
Juliann Schaeffer is a freelance writer and
editor based in Allentown, Pennsylvania,
and a frequent contributor to Todays Dietitian.
oil for each batch. Whats important is that the chicken isnt
overcrowded, which would cause the pieces to steam rather
than brown.
3. Add the chicken to the oil and brown for about 4 to 5
minutes on each side. Turn the pieces using a metal spat-
ula, as they have a tendency to stick to the pan. Remove the
pieces when theyre well browned on all sides.
4. Lower the heat to medium-high and add the onions
and minced garlic. Cook for about 3 minutes, stirring con-
stantly, until the onions have softened and are a rich golden
brown. Add the wine and scrape the bottom of the pan with
a spatula or spoon to deglaze the pan, loosening any parti-
cles stuck on the bottom.
5. When the wine has evaporated, add the water, chicken
stock, tomato paste, fresh oregano, and remaining two
garlic cloves. Return the chicken to the pan. The liquid
should cover about 34 of the chicken pieces. Cover the
pot and simmer over low heat for about an hour or until
the chicken is tender and thoroughly cooked. If the sauce
becomes too thick, it can be thinned with a little more
water. Season the finished sauce with kosher salt and
pepper to taste.
6. Serve the chicken topped with the sauce and sprinkle
with Mizithra cheese.
Nutrient Analysis per serving
Calories: 560; Total fat: 18 g; Sat fat: 6 g; Trans fat: 0 g;
Cholesterol: 174 mg; Sodium: 1,113 mg; Total carbohydrate:
19 g; Dietary fiber: 3 g; Sugars: 9 g; Protein: 74 g
january 2013 www.todaysdietitian.com 63
DATEBOOK

FEBRUARY 9, 2013 MARCH 7, 2013 APRIL 2-6, 2013

AMERICAN DIABETES ASSOCIATION TENNESSEE ACADEMY OF NUTRITION NATIONAL KIDNEY FOUNDATION
DIABETES EXPO AND DIETETICS ANNUAL MEETING SPRING CLINICAL MEETINGS
Denver, Colorado www.eatright-tn.org Orlando, Florida
www.diabetes.org www.nkfclinicalmeetings.org
MARCH 14-17, 2013
FEBRUARY 9-12, 2013 HEALTHY KITCHENS, HEALTHY LIVES: APRIL 4-6, 2013
AMERICAN SOCIETY FOR PARENTERAL CARING FOR OUR PATIENTS AND MISSOURI, IOWA, NEBRASKA, AND
AND ENTERAL NUTRITION CLINICAL OURSELVES KANSAS DIETETIC ASSOCIATIONS
NUTRITION WEEK Offered by the Harvard School of Public ANNUAL CONFERENCE
Phoenix, Arizona Health and The Culinary Institute of Overland Park, Kansas
www.nutritioncare.org/cnw America www.eatrightnebraska.org
Napa Valley, California
FEBRUARY 22-26, 2013 www.healthykitchens.org APRIL 5-6, 2013
AMERICAN ACADEMY OF ALLERGY, ILLINOIS DIETETIC ASSOCIATION
ASTHMA & IMMUNOLOGY ANNUAL MARCH 19-21, 2013 SPRING ASSEMBLY
MEETING WEST VIRGINIA ACADEMY Oak Brook, Illinois
San Antonio, Texas OF NUTRITION AND DIETETICS www.eatrightillinois.org
http://annualmeeting.aaaai.org ANNUAL MEETING
Huntington, West Virginia APRIL 5-6, 2013
FEBRUARY 28 MARCH 1, 2013 www.wvda.org SOUTH CAROLINA ACADEMY
GEORGIA ACADEMY OF NUTRITION AND OF NUTRITION AND DIETETICS
DIETETICS ANNUAL CONFERENCE & MARCH 19-22, 2013 ANNUAL MEETING
EXHIBITION EPIDEMIOLOGY AND PREVENTION/ Columbia, South Carolina
Stone Mountain, Georgia NUTRITION, PHYSICAL ACTIVITY, AND www.eatrightsc.org
www.eatrightgeorgia.org METABOLISM SCIENTIFIC SESSIONS
New Orleans, Louisiana
MARCH 2, 2013 www.my.americanheart.org/ APRIL 11-13, 2013
AMERICAN DIABETES ASSOCIATION professional/index.jsp CALIFORNIA DIETETIC
DIABETES EXPO ASSOCIATION ANNUAL
Salt Lake City, Utah MEETING AND EXHIBITION
www.diabetes.org 800+ dietetic professionals,
75+ exhibits
Santa Clara Convention Center
ADVERTISER INDEX Santa Clara, California
For advertising information, please call 800-278-4400 or visit our website at www.TodaysDietitian.com.
www.dietitian.org
Bakery On Main, www.bakeryonmain.com...............................................................................................27
beBetter Health, Inc., www.theportionplate.com..................................................................................... 19
Cell Science Systems, www.alcat.com.....................................................................................................23
Cera Products, Inc., www.ceraproductsinc.com......................................................................................65
CinSulin, www.cinsulin.com......................................................................................................................68
Daisy Brand Cottage Cheese, www.daisybrand.com/cottagecheese...................................................4, 5 Datebook listings are offered to
Dietmaster Systems, www.dietmaster.com.............................................................................................65 all nonprofit organizations and
Dr. Lucys, www.drlucys.com....................................................................................................................65
associations for their meetings. Paid
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Glutenfreeda Foods, Inc., www.glutenfreedafoods.com www.glutenfreeda.com...................................54
listings are guaranteed inclusion.
Ians Natural Foods Inc., www.iansnaturalfoods.com.............................................................................. 15 All for-profit organizations are paid
Jackson PEG Tube Stands, www.jacksonpegtubestands.com.................................................................65 listings. Call for rates and availability.
Kibow Biotech, Inc., www.kibow.com.......................................................................................................55
Konsyl Pharmaceuticals, www.konsyl.com.............................................................................................. 67 Call 610.948.9500
Nestle Ocean Spray, www.oceanspray.com............................................................................................... 7 Fax 610.948.7202
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The Nutrition Company, www.nutritionco.com........................................................................................65 E-mail TDeditor@gvpub.com
Walden Farms, www.waldenfarms.com...................................................................................................... 2 Send Write with your listing two
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This index is a service to our readers. The publisher assumes no liability for errors or omissions. of issue.

64 todays dietitian january 2013

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CULINARY CORNER

Quinoa Salad With Roasted Garlic

While this recipe gives directions for cooking 1 bulb

of garlic, you can easily roast two or three at a time for
later use. This salad is great garnished with feta cheese.

Serves 6 as a side dish

Ingredients
1 garlic bulb
1 cup water
3
4 cup quinoa
4 cup red wine vinegar
GARLIC
1

3 T fresh lemon juice

One of Natures Brightest Bulbs
By Bryan Roof, RD, LDN
My mother used to tell me that the secret to her cooking
was salt, pepper, and garliclots of garlic. Shed make potent
Caesar dressings, bracingly sharp aiolis, and fragrant garlic-
rubbed roast chicken. I loved her cooking because of it.
We never understood how people could dislike garlic. (Some
people are just plain crazy, I suppose, with their fear of garlic
breath.) She added garlic for flavor and flavor alone long before
it was eaten for its health benefits. Garlic has been found to
reduce cholesterol and blood pressure, improve circulation and
immune function, and lower overall cancer risk. Not bad for
something that tastes so good.
Garlic imparts its flavor based on how its prepared before
cooking. By crushing, mincing, or pureing garlic, you release
its essential oils, the bulk of its potency. You could stick a whole
head of unpeeled garlic into a braise or stew and still not impart
as much oomph as a few finely minced cloves.
When shopping for garlic, opt for fresh bulbs over the pre-
peeled or the prechopped stuff in a jar, which bears little
resemblance to its fresh counterpart. Prepeeled garlic is inar-
guably convenient, but the blanching process that removes the
skin also robs it of some of its flavor. Look for firm, fresh bulbs
with taut papery skin. Once you get it home, store garlic in a
cool, dark place, such as a kitchen cupboard.
While Im a true garlic fan, I realize many people dont share
the same affinity for its aggressively strong flavor. So for you,
well turn to roasting. Roasted whole, the cloves develop a
pleasant sweetness that even haters seem to fancy. You can
use roasted garlic for any number of dishes, from bruschetta
to salad dressing to pasta sauce. Youll still get all the health
benefits and most of the flavor but less of the garlic breathif
youre at all concerned.
Bryan Roof, RD, LDN, is a chef, dietitian, and food writer
living in Boston. Follow him on Twitter at @bryanroof.
3 T extra-virgin olive oil
2 tsp Dijon mustard
1
2 tsp fine sea salt
3
4 tsp black pepper
1 red bell pepper, stemmed, seeded, and chopped
1 cup diced English cucumber
1 cup fresh cilantro leaves, coarsely chopped
2 scallions, sliced thin
1
4 cup sliced red onion
1
4 cup cashew pieces
Directions
1. Adjust the oven rack to the middle position and
heat the oven to 350F. Cut off the top 14-inch stem of
the garlic bulb and discard. Wrap the bulb in aluminum
foil and roast until tender and fragrant, 1 to 114 hours.
Let the foil-wrapped garlic sit at room temperature until
cool enough to handle.
2. Meanwhile, bring water to a boil in a small sauce-
pan over medium-high heat. Stir in the quinoa and return
to a boil. Remove the pot from the heat, cover, and let sit
undisturbed for 20 minutes. Fluff the quinoa with a fork
and let cool to room temperature.
3. Whisk the vinegar, lemon juice, olive oil, mus-
tard, salt, and pepper together in a large bowl. Add the
quinoa, bell pepper, cucumber, cilantro, scallions, onion,
and cashews. Squeeze the root end of the garlic bulb,
forcing the roasted garlic out of the cut end and into the
bowl. Toss the ingredients to combine. Season with salt
and pepper to taste. Serve.
Nutrient Analysis per serving
Calories: 210; Total fat: 11 g; Sat fat: 1.5 g; Trans fat:
0 g; Cholesterol: 0 mg; Sodium: 240 mg; Total carbohy-
drate: 23 g; Dietary fiber: 3 g; Sugars: 4 g; Protein: 5 g

66 todays dietitian january 2013

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