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Vol. 15 No.

January 2013 The Magazine for Nutrition Professionals


Journey RDs Serve as a Guide for Patients

on a Quest to Relieve Symptoms
and Improve Health


Ethical Decision
Making in End-of-Life

Kids Frown on
New School Lunch

Embracing Meatless
New Years Resolutions
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Its been one year since the unveiling of Kathleen Czermanski
the new standards for school meals that
Vice President & COO
have resulted in healthier lunches for kids Mara E. Honicker
across the country. The new meal require-
ments have raised standards for the first EDITORIAL
Editor Judith Riddle
time in more than 15 years, and chances Editorial Director Jim Knaub
are they will improve the health and nutri- Senior Production Editor Tracy Denninger
tion of nearly 32 million kids who participate in the program Assistant Editor Brandi Redding
Editorial Assistant Heather Hogstrom
each school day. Contributing Editor Sharon Palmer, RD
As you know, the new standards require school cafeterias Editorial Advisory Board Dina Aronson, MS, RD; Jenna A. Bell, PhD, RD;
to serve larger portions of fresh fruits, vegetables, and whole Carol M. Meerschaert, MBA, RD; Sharon Palmer, RD; Kyle Shadix, MS, RD

grains; fat-free (unflavored/flavored) or 1% (unflavored) milk;

less saturated and trans fats and sodium; and proper portion Senior Graphic Designer Charles Slack
sizes and caloric intake based on age. Graphic Designer Erin Prosini
Junior Graphic Designer Emily Avedissian
While the healthier meals are a key component of the
Healthy, Hunger-Free Kids Act of 2010, championed by ADMINISTRATION
First Lady Michelle Obama and signed into law by President Administrative Manager Helen Bommarito
Administrative Assistants Kim Mayfield, Pat Plumley
Obama, ironically theyre leaving many kids across the
Executive Assistant Matt Czermanski
country with growling bellies by the end of the school day. Systems Manager Jeff Czermanski
To voice an opinion of the new standards, a group of Systems Consultant Mike Davey
creative high school students in Kansas posted a video on
YouTube called We Are Hungry to the tune of fun.s We Are Director of Finance Jeff Czermanski
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 Director of Continuing Education & New Business Development
Jack Graham
to ensure they have enough to eat in between classes, kids
walking the halls snacking on food, kids collapsing on the CIRCULATION
gym floor during basketball practice, and kids falling asleep Circulation Manager Nicole Hunchar

in class because theyre hungry and have no energy. While MARKETING AND ADVERTISING
the video parody will make you laugh, the kids message is Publisher Mara E. Honicker
a serious one: The food may be healthful, but its not filling Director of Marketing and Digital Media Jason Frenchman
Web Designer/Marketing Assistant Jessica McGurk
them up. You can read more about this and find out what your Marketing Assistant Leara Angello
colleagues had to say about the kids reactions in the feature Director of Sales Stephanie Mitchell
Healthful School Lunches. Senior Account Executives Sue Aldinger, Seth Bass,
Peter J. Burke, Gigi Grillot, Brian Ohl
My son, a high school senior, has different complaints. Account Executives Diana Kempster,
He says its not that the healthier meals leave him hungry; Beth VanOstenbridge, Josh Yohnke
the problem is that the more healthful foods just dont look Sales Coordinators Joe Reilly, Dani Kriest-Reifsneider

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 2013 Great Valley Publishing Company, Inc.
Twitter and Facebook pages.
Phone: 610-948-9500 Fax: 610-948-7202
Happy New Year to all, and please enjoy the issue. Editorial e-mail: Sales e-mail:
Judy Subscription e-mail:
Ad fax: 610-948-4202 Ad artwork e-mail:

Judith Riddle All articles contained in Todays Dietitian, including letters to

Editor the editor, reviews, and editorials, represent the opinions of the authors,
not those of Great Valley Publishing Company, Inc. or any organizations with which the authors may be affiliated. Great Valley Publishing Company,
Inc., its editors, and its editorial advisors do not assume responsibility for
opinions expressed by the authors or individuals quoted in the magazine,
for the accuracy of material submitted by the authors, or for any injury to
persons or property resulting from reference to ideas or products
discussed in the editorial copy or the advertisements.

6 todays dietitian january 2013

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34 18

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
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

Todays Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published monthly by Great Valley Publishing Company, Inc., 3801 Schuylkill Road, Spring City, PA 19475. Periodicals
postage paid at Spring City, PA, Post Office and other mailing offices. Permission to reprint may be obtained from the publisher. REPRINTS: The Reprint Outsource, Inc.: 877-394-7350
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$95 per year; Single issue: $5

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Dear Editor,
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
repare SSuch
Delicious, Healthful Meals
That Nobody Will Miss the Turkey

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
Kitchen Essentials

suffered from migraines for years and Helping Clients

Linda Mooring: What will it take for people to get

With Binge
Eating Disorder

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!
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,
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!
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.
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

Natures Sweet Solution








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 (, a
meal with assistance. nutrition expert for FoodNetwork.
com, and a nutrition advisor
Ages 4 to 5 for Sears
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
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
to help them stay t or develop a healthier lifestyle.

Content from a trusted source

Advice and insight from respected health,

tness, and healthy living experts

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Healthy, categorized recipes

Professional guidance on
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Visit and share the link!


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

PARENTERAL NUTRITION Evaluating the Home Environment

Once a physician determines a patient is a good candidate
HOME-STARTS for home PN, a home infusion nurse first assesses the patients
Learn How RDs Can Help Patients Safely home environment for cleanliness, sanitary water supply, elec-
Begin PN Care at Home tricity, refrigeration, adequate storage space for supplies,
and telephone access.7 The nurse also assesses whether the
By Sandra I. Austhof, MS, RD, LD, CNSC
patient or caregiver is capable of administering home PN ther-
People unable to use their gastrointestinal (GI) tract due apy and verifies insurance coverage. If the patient is in the hos-
to intestinal failure require parenteral nutrition (PN). PN, the pital, a social worker, PN nurse, and nurse case manager meet
administration of IV nutrients, is a potentially lifesaving ther- with the patient and family at the bedside to assess the home
apy that, when required long-term, can be administered safely environment and insurance coverage for home PN care.
in the home to allow people to live higher-quality lives.1
Some clinicians believe PN should always be started in a Home PN Education
hospital setting where patients can be closely monitored to Once its considered safe to administer home PN, quali-
avoid potential complications such as refeeding syndrome, fied healthcare nurses begin educating the patient and
which causes electrolyte imbalances of serum phosphorous, family about what it entails. The patient or a family member
potassium, and magnesium that can potentially lead to heart is chosen as the primary caregiver who must demonstrate
failure or other life-threatening conditions. competence in preparing and administering PN, which
However, many home infusion companies have safely includes infection control, caring for the vascular access
and successfully started PN at home in patients with mild device, connecting and disconnecting the IV tubing, safely
to moderate electrolyte abnormalities by correcting these incorporating additives, and properly storing supplies.7
electrolytes before PN infusion.2 This allows the patient to For hospital-start PN patients, the PN nurse educates the
be more comfortable and avoids the risk of possible expo- patient and family at the bedside, and a visiting nurse contin-
sure to hospital-acquired infections while reducing overall ues the instruction at home.
healthcare costs. All patients receive three consecutive days of lessons in
One of the earliest reports on transitioning PN from the the home. Once the home infusion nurse determines the pri-
hospital to the home was documented 40 years ago.3 Due to mary caregiver can implement PN procedures, the nurse will
technological advances in access devices, infusion pumps, make weekly visits.

14 todays dietitian january 2013

Advantages of Hospital-Start PN the infusion time by four hours each day over three consecu-
Most patients discharged from the hospital on PN werent tive days or six hours each day for two consecutive days can
admitted specifically to start PN but for unrelated medical or cycle PN from 24 to 12 hours. In stable, select patients, PN
surgical reasons that resulted in the need for home PN care. can be cycled from 24 to 12 hours over one day.
Due to safety concerns, clinicians often prefer hospital-
start PN. High-risk patients who would benefit from hospital- Advantages of Home-Start PN
start PN include infants, the elderly, IV drug users, patients While hospital-start PN has its advantages, home-start
with fluid and electrolyte disorders, those with uncontrolled PN also has its benefits. Home-start PN enables patients to
diabetes or major organ dysfunction, or those at high risk of learn about PN in the comfort of their home plus they have
refeeding syndrome.7,8 fewer hospital expenses and dont have to worry about
Replacing fluid and electrolytes before initiating PN and hospital-acquired infections.10 The decision to initiate PN
then starting PN with a low carbohydrate load can prevent in the home depends on patients clinical stability, whether
refeeding syndrome. Rex Speerhas, RPh, BCNSP, a clinical they have a need for PN, whether a nurse can evaluate them
nutrition specialist at the Cleveland Clinic, says, The patient in their home, and whether a caregiver can safely adminis-
can be treated much more promptly and effectively in the ter the therapy.7
hospital setting with frequent intravenous electrolyte supple- Patients who can receive home PN care are those who either
mentation. The bedside nurse and primary care physician dont have a chronic illness or have a chronic illness thats well
also can closely monitor the patient. controlled, such as cancer, HIV, hyperemesis gravidarum, or GI
Another concern is hyperglycemia, the most common disorders; those with bariatric surgery complications; or those
side effect in preparing a patient for cyclic home PN.9 When with failed enteral nutrition.8,10
a patient is initiated in the hospital setting, blood glucose Many home infusion companies that provide home-start
levels can be monitored much more frequently, thus episodes PN services have experienced dietitians, nurses, and phar-
of hyperglycemia can be immediately treated with insulin or macists working for them who can offer quality care to
avoided completely, Speerhas says, adding that to achieve patients and have a track record of successfully initiating PN
the same quality of care, close monitoring in the home set- in the home, bypassing hospital admission.
ting would require the presence of a healthcare professional Walgreens Infusion Services, the nations largest infu-
around the clock. The testing supplies needed would quickly sion provider, initiates home PN with at least one patient
become very costly to the patient. almost every day. According to Noreen Luszcz, RD, MBA,
The hospital dietitians role in preparing the patient for CNSC, Walgreens nutrition program director, the key to the
home PN involves stabilizing and cycling the PN formula companys success is its multidisciplinary team approach,
by monitoring daily vital signs, electrolytes, glucose levels, slow progression of starting PN, and ongoing communica-
intake and output records, and weights. This usually takes tion with the team, patient, and physician. Slow progression
three to six days to complete. PN is started at full protein means that macronutrients, especially dextrose, are started
needs with one-half of the dextrose load infused continuously at a reduced concentration to prevent complications such as
over 24 hours. Lipids usually are given separately. Shortening hyperglycemia or electrolyte imbalances.

Providing All-Natural, Allergy-Friendly Foods Consumers Can Trust!

Gluten Free
w w

january 2013 15

Once Walgreens receives a referral from a physicians Safe Alternative
office or clinic, a dietitian and a nurse become actively Patients have been started safely on PN in the hospital setting
involved in the initial home visit. The dietitian completes a and at home for many years. The key to this success has been the
comprehensive nutrition assessment and determines needs experience of knowledgeable interdisciplinary healthcare teams
and formula recommendations. consisting of physicians, dietitians, nurses, and pharmacists. With
Choosing appropriate patients for home-start PN is the advances in standards of care, equipment, and specialized
essential. Luszcz reports that high-risk patients, such as home infusion services, patients can start IV nutrition at home,
those with uncontrolled diabetes, high GI losses, or multi- allowing for continued daily activities and increased quality of life.
ple organ failure, usually are referred to hospital-start PN.
When beginning PN in the home, however, Luszcz says Wal- Sandra I. Austhof, MS, RD, LD, CNSC, is a nutrition
greens patients begin with reduced protein, dextrose, and support dietitian at the Cleveland Clinic and has
lipids infused over 24 hours. Daily weights, lab data, and worked in the field for more than 30 years.
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- Acknowledgement
nutrients. PN is reduced to 18 hours and eventually to eight The author would like to extend a special thanks to Kaylee
to 12 hours once the patient is stabilized on full PN. Some Adams, a PharmD candidate at Ohio Northern University, for her
home infusion companies, such as ThriveRx, start low- assistance in the research of this article.
calorie PN over 12 to 18 hours at a reduced rate for younger,
stable patients, according to Donna Kloth, RN, CRNI, CNSC, a
1. Ireton-Jones C, DeLegge MH, Epperson LA, Alexander
J. Management of the home parenteral nutrition patient. Nutr
With the advances in standards Clin Pract. 2003;18(4):310-317.
2. Jansson L, Brand S, Monahan R, Knowles S. Home start
of care, equipment, and parenteral nutritionyes we can! Presented at: American
Society for Parenteral and Enteral Nutrition Clinical Nutrition
specialized home infusion Week; January 21-24, 2012; Orlando, FL.

services, patients can start 3. Jeejeebhoy KN, Zohrab WJ, Langer B, Phillips MJ, Kuksis
A, Anderson GH. Total parenteral nutrition at home for 23
IV nutrition at home, allowing months, without complication, and with good rehabilitation.
A study of technical and metabolic features. Gastroenterology.
for continued daily activities 1973;65(5):811-820.
4. Sanville MH. Initiating parenteral nutrition therapy in the
and increased quality of life. 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.
nutrition liaison with ThriveRx. By carefully monitoring the 6. Kirby DF, Corrigan ML, Speerhas RA, Emery DM. Home
patient, we slowly advance the PN formulation to goal, which parenteral nutrition tutorial. JPEN J Parenter Enteral Nutr.
usually takes a week, she explains. 2012;36(6):632-644.
To prevent refeeding syndrome, home infusion companies 7. Kovacevich DS, Frederick A, Kelly D, Nishikawa R, Young
usually have protocols that involve administering replace- L. Standards for specialized nutrition support: home care
ment fluids and electrolytes in the home before starting patients. Nutr Clin Pract. 2005;20(5):579-590.
PN. In one study, Walgreens showed that patients at risk of 8. Crocker KS, Ricciardi C, DiLeso M. Initiating total paren-
refeeding syndrome can safely begin home PN, eliminating teral nutrition at home. Nutr Clin Pract. 1999;14:124-129.
the need for hospital admission.2 In this small, retrospec- 9. Suryadevara S, Celestin J, DeChicco R, et al. Type and
tive study, 15 high-risk patients were started on 25% of dex- prevalence of adverse events during the parenteral nutrition
trose needs for the first three to four days. Once the patients cycling process in patients being prepared for discharge. Nutr
were stabilized, 50% of dextrose needs were given for another Clin Pract. 2012;27(2):268-273.
three to four days. Researchers closely monitored lab results, 10. Newton AF, DeLegge MH. Home initiation of parenteral
and patients reached their PN goal needs. nutrition. Nutr Clin Pract. 2007;22(1):57-64.

16 todays dietitian january 2013


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 ( 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
EMERGENCY PREPAREDNESS easy to use and versatile. You use it by either copying files you
Cloud-Based Backup Simplifies want automatically backed up into a Dropbox folder or subfold-
This Essential Task ers on your computer or you ensure the files you want auto
matically backed up are stored in one of these folders.
By Reid Goldsborough
SugarSync ( With 5 gigabytes of
Hurricane Sandy, which led to so much damage in New York storage before you have to pay, SugarSync is more generous
and New Jersey in late October 2012, was only one of numer- than Dropbox. It also doesnt require you to create special fold-
ous natural and manmade disasters that, along with destroying ers but instead lets you designate which of your folders you
life and property, destroyed data. Whether you work for a large want automatically backed up with its own interface.
company, run a small business, or use a computing device in IDrive Sync ( This is the most gener-
your home or whether its corporate trade secrets or family ous of the services listed here, giving you 10 gigabytes of free
photos, data can be irreplaceable. storage. Unlike some other services, IDrive lets you choose
The key to disaster recovery is disaster preparation, and the between continuous backup and scheduled backup, which is
key to disaster preparation is redundancy. In a nutshell, back- the default.
ups. If you have backup power such as a generator, you can con- Google Drive ( If you already use
tinue to compute if the electricity goes out. If you have one or Google Docs, a free cloud suite of word processing, presenta-
more backup computers, you can still get things done if equip- tion, spreadsheet, and other programs, this is where your files
ment is damaged. And if you have backup data, you can pick up are stored. But you also can use Google Drive with data created
any project where you left off. using programs on your own computer. It offers 5 gigabytes of
free storage.
Cloud Computing Amazon Cloud Drive ( This
For several years now a big buzzword in the computer world is Amazons cloud storage service, but its clunkier than the
has been the cloud, which is just a whimsical way of saying the other services here. Amazon Cloud Drive offers 5 gigabytes of
Internet. Instead of storing data or using programs on computers free storage. It makes copies of previously backed up or deleted
at your location, with cloud computing you use data or programs files in case you need to retrieve them.
stored on other computers you connect to over the Internet. iCloud ( From Apple, this service
One of the most effective uses for cloud computing is making is tailored to Apple products. It can work with an iPad, iPhone,
remote backups of data. That way, even if your computer equip- iPod touch, or Mac, and it works with Windows PCs as well.
ment is destroyed in a flood or fire, you wont lose your data. iCloud gives you 5 gigabytes of free storage.
The same cant be said for a backup stored at your location Skydrive ( This is Microsofts
that youve made onto an external hard drive, USB drive, opti- offering, with 7 gigabytes of free storage. Along with Windows
cal disc, or tape, though these media still can be useful among PCs and Windows Phone, Skydrive also works with Macs, Apple
other ways as a backup for your backup. devices, and Android devices.
Ultimately, choosing and using a backup service is far more
Remote Backup Services important than which service you choose.
A host of free and fee-based remote backup services have
popped up in recent years. The free services typically provide Reid Goldsborough is a syndicated columnist and author of the
a limited but often appreciable amount of storage space, with book Straight Talk About the Information Superhighway. He can be
additional storage costs. reached at or

january 2013 17


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

DIABETES AND vegetarian diet, emphasizing fresh fruits, vegetables, soy, nuts,
legumes, and olive oil, she says.
More Patients Are Following Alternative Diets Food-Combining Diet
to Manage the Disease The theory behind the food-combining diet is that if protein
and starch are eaten simultaneously, the body will wear itself out
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
by producing both alkaline and acidic digestive juices, which nul-
As diabetes cases continue to soar worldwide, people with lify both the protein and the starch and impair digestion.4 This
the disease are turning more and more to alternative thera- diet promotes eating proteins and starches at separate meals.
pies to help manage it. Specifically, in an analysis of data from Vegetables can be eaten with both protein and starch, but fruits
the 2002 National Health Interview Survey, Bell and colleagues should be eaten alone. Its proponents say this diet will encour-
found that more than 72% of people with diabetes use comple- age weight loss and improve digestion. Research supports that
mentary and alternative medicine (CAM) to manage their dis- a weight loss of 10 to 15 lbs is enough to decrease insulin resis-
ease.1 A literature review on the use of CAM among people with tance and improve blood glucose levels in people with diabetes.
diabetes, published in 2007 in the Journal of Advanced Nursing, However, theres no scientific evidence stating this diet is
reported prevalence rates as high as 78%. Moreover, people beneficial for weight loss or digestion. In fact, The research is
with diabetes are 1.6 times more likely to use CAM therapies flawed, and some of the ideas are counterproductive, Melina
than people without diabetes.2 says. For example, vitamin C in fruit can help increase iron
absorption from iron-rich plant foods such as legumes. But
What Is CAM? according to food-combining guidelines, this combination isnt
The terms alternative medicine and complementary med- permissible. For people with diabetes, this diet is contrary to
icine often are used interchangeably, but according to the the American Diabetes Associations 2012 nutrition recom-
National Center for Complementary and Alternative Medicine, mendations for optimal blood glucose control. Balancing a
CAM is a group of diverse medical and healthcare systems, meal with both protein and carbohydrates promotes fewer
practices, and products that arent generally considered to be carbs at the meal, resulting in more stable blood glucose and
part of conventional medicine. Complementary medicine is insulin levels.
used with conventional medicine, whereas alternative medicine
is used instead of conventional medicine.3 Macrobiotic Diet
Examples of CAM therapies include herbs, bodywork, This diet incorporates the Asian philosophy that foods are
special diets, and dietary supplements. Most people with either yin (cooler) or yang (warmer) and that certain health
diabetes who use CAM follow diet-based therapies to conditions require food that will cool or warm the body. The
manage the disease.1 macrobiotic diet is vegetarian based, consisting mainly of
The following are the six most common diet-based therapies brown rice, whole grains, and vegetables. It has gained pop-
people use to treat diabetes more naturally and holistically. ularity among cancer patients who understand it to be an

18 todays dietitian january 2013

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


The Makers Diet CMY

The Makers Diet is based on eating foods that God intended

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
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 19

Ayurvedic Diet used for diabetes, Sheth says. And theres evidence suggest-
The Ayurvedic diet, popularized by author Deepak Chopra, ing Coccinia indica, holy basil, fenugreek, and Gymnema sylvestre
MD, is based on a system of medicine that originated in ancient have a glucose-lowering effect.8
India. It attempts to balance and restore harmony in the body by Most clinical trials of Ayurvedic approaches have been
using diet, yoga, and herbs. small and not well done. Therefore, scientific evidence for
The diet is built on a theory that people are born with the effectiveness of Ayurvedic practices varies. More rig-
unique characteristics based on the combination of doshas orous research is needed to determine which practices are
in the gene structure. The doshas are dynamic forces within safe and effective.7
the universe, including earth, water, fire, and wind. A per-
sons chances of developing certain types of diseases are Tips for Dietitians
thought to be related to the way doshas are balanced, the Its important for RDs to increase their knowledge and
state of the physical body, and mental or lifestyle factors.7 awareness of alternative approaches to diabetes self-
Ayurvedic doctors determine which doshas are strongest management, Sheth says, as more people with the disease
and which are out of balance, and give a diet prescription that turn to CAM to manage it. This will enable RDs to more effec-
strengthens and balances them. Ayurvedic practitioners claim tively counsel their clients. To ensure coordinated and safe
this diet will bring harmony back to the body and, in doing so, care, Sheth encourages RDs to communicate with their clients
help with weight loss and decrease the likelihood of chronic ill- alternative medicine practitioners as well.
nesses, including diabetes.
Ayurvedic treatments rely heavily on herbs and other plants, Constance Brown-Riggs, MSEd, RD, CDE, CDN, is the
such as oils and common spices. Turmeric, holy basil, Coccinia national spokesperson for the Academy of Nutrition and Dietetics,
indica, gumar, fenugreek, and jambul powder are commonly specializing in African American nutrition, and author of the
African American Guide to Living Well With Diabetes
and Eating Soulfully and Healthfully With Diabetes.

You dont need to know everything about com- References
plementary and alternative medicine, but you 1. Bell RA, Suerken CK, Grzywacz JG, Lang W, Quandt SA,
should know where to find credible information. Arcury TA. Complementary and alternative medicine use
The following resources can help: 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
Resources for Patients
and pattern of complementary and alternative medicine use in
National Center for Complementary and Alterna- individuals with diabetes. Diabetes Care. 2002;25(2):324-329.
tive Medicine (NCCAM) ( 3. Complementary and alternative medical therapies for dia-
betes. National Diabetes Information Clearinghouse website.
NCCAM Time to Talk Tips on Complementary
Health Practices (
Last updated January 24, 2012. Accessed November 18, 2012.
4. Davis B, Melina V, Berry R. Becoming Raw: The Essential
MedlinePlus ( Guide to Raw Vegan Diets. Summertown, TN: Book Publishing
Co; 2010: 176-178.
Federal Resources for Providers 5. Raw food diet. WebMD website.
food-recipes/guide/raw-food-diet. Reviewed February 20, 2010.
NCCAM Resources for Health Care Providers Accessed November 11, 2012.
( 6. Longe JL. The Gale Encyclopedia of Diets: A Guide to Health
NCCAM Clinical Digest monthly e-newsletter and Nutrition. Farmington Hills, MI: Gale; 2007: 643-646.
( 7. Ayurvedic medicine: an introduction. National Center
for Complementary and Alternative Medicine website. http://
NCCAM Complementary and Alternative Medi- Last updated
cine Online Continuing Education Series (http:// 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.

20 todays dietitian january 2013

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between 80% and 90% of freshwater con-

sumption in the United States is attributable to
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
RISING FOOD COSTS and orchards, those who can afford it have switched to more
How Last Years Drought May Affect efficient drip irrigation systems. Most fruits and vegetables
This Years Prices require irrigation.
The United States also imports a significant amount of pro-
By David Yeager
duce, such as bananas, tomatoes, melons, peppers, and pota-
No one can say with certainty whether climate change is toes, from other countries. For these reasons, food price
directly responsible for the droughts that have plagued the increases for produce probably have been less related to water
United States over the past couple years, but you cant deny that availability than to other factors such as transportation and
2011 and 2012 brought exceptionally dry weather to significant refrigeration costs. As long as farmers can maintain irrigation,
portions of the country. the availability of produce should remain stable.
In 2011, the most severe drought in decades hit large seg-
ments of Texas, decimating the states cattle industry. In 2012, Hidden Costs
the Midwest and its grain crops bore the brunt of the drought. After Hurricane Sandy pummeled the East Coast in October
Although fluctuations in rainfall occur every year, extended 2012, many Americans probably forgot about the oppressive
periods without enough rain could pose a serious problem for heat and drought that affected a large part of the country this
the United States in the future. past summer. But with nearly two-thirds of the United States
Jack Juvik, PhD, a professor and the graduate program still affected by drought, consumers could feel the effects well
coordinator in the department of crop sciences at the University into this year.
of Illinois College of Agricultural, Consumer, and Environmental Because the drought was concentrated in the Midwest, the
Sciences, says water issues are affecting most countries crops hit hardest were grain products such as corn, soybeans,
dramatically in some casesand the United States is no excep- and wheat, which arent irrigated. Aside from the obvious rise
tion. He cites areas of the Central Valley in California where the in the cost of these staple crops, David Bitter, CEO of Cropfax,
salt level of the soil already prevents the growth of a range of a provider of seed selection decision-making tools, says prices
valuable crops. In places like this, long-term drought could be are likely to rise for nearly all food products.
especially damaging. If water becomes scarcer, it could multiply Grains are just such large volume [items], and they go into
this effect and lead to disputes among regions and states vying everything. Corn is in [nearly] everything that has been pro-
for use of the same major water systems. cessed, and youve got aisles and aisles of it, Bitter says.
So not only is [water scarcity] going to affect what we can Youve got one small produce section in the store, which is kind
grow, its going to affect where we can grow, and its also of like the jewel in the crown; youve got strawberries, youve
going to lead to huge, huge battles, legal [battles] and, prob- got fresh fruit. But the rest of the store, unless its a bottled
ably, armed conflict [in some countries]. There are a lot of fruit or a packaged fruit, is pretty much a derivative of corn or
places right now that are on the edge of conflict due to the soy or wheat: your granola bars, your cereals, your chips.
fact people are fighting for water rights, Juvik explains. Since Higher grain prices also are reflected in the cost of animal
water is essential for life, it should come as no surprise that feed. This affects food costs because it increases the cost of

22 todays dietitian january 2013

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
little bit more.
Cooking at home rather than eating out No cost to get started CLIA licensed and inspected
also can save a significant amount of money. Participate in Nationwide Available in over 20
This requires more of a time investment, but it Physician Referral Network countries worldwide
doesnt have to become a burden. Clients can
Results are available online 98% success in body
cook a large batch of food and freeze a portion
within 5 business days composition improvement
for later use to save time in the kitchen.
of testing and/or weight loss (Baylor
Buying raw ingredients can cut costs, too.
A 5-lb bag of potatoes costs much less per Mobile blood draw service Med. College)
pound than a 1-lb bag of potato chips, and it available in US and Canada Awarded 3 US patents
will go much further toward meeting nutri- FDA inspected, registered Supported by European Union
tional needs. Beware of overbuying, though.
A recent report from the Natural Resources If you see patients who suffer from migraine headaches, IBS,
Defense Council estimated that Americans asthma, chronic inflammation, ADD, fatigue, eczema or
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.
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meals and eat whats already in the house.
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january 2013 23


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.
fter months of gastrointestinal discom- status, and an improved quality of life. Jeffers, outpatient man-
fort, abdominal pain, and bloating followed ager for nutrition therapy at the Digestive Disease Institute at
by weeks of medical testing, Susan finally the Cleveland Clinic, teaches patients the importance of adopt-
learned she has celiac disease. Frightened, ing the changes involved in living GF for the long haul.
confused, and overwhelmed about the next I stress the importance of GF for life, Jeffers says. No
steps in her new restricted dietary lifestyle, small bites every now and then and no mostly GF. I also explain
she turned to an RD her physician recommended. The RD faces that wheat free is not gluten free and that reading labels must
the challenge of calming her new patient, educating Susan become a habit. While theres no cure for [celiac disease], the
about the celiac disease diagnosis, and walking with her along a GF diet can relieve symptoms of the disease, and patients can
journey fraught with misinformation and confusion. feel healthy and full of energy while on the diet. The mucosal
damage is a result of a genetic predisposition in combination
Celiac Disease vs. Gluten Sensitivity with environmental factors and inflammation that s immune
Its not surprising that many patients newly diagnosed with based. Therefore its important for dietitians to clarify with
celiac disease become overwhelmed at the thought of modi- their patients that even the tiniest amount of gluten may cause
fying their lifestyle, including what they can and cannot eat in intestinal damage even if there are no overt symptoms.
restaurants and at parties. Fortunately, Susan and others with Some patients are in a state of shock when they find out
celiac disease arent alone in their journey. According to Rachel they have a type of condition thats not going to go away, says
Begun, MS, RD, CDN, a food and nutrition consultant and Lenore Wespetal, MS, RD, CDE, a certified diabetes educatorat
spokesperson for the Academy of Nutrition and Dietetics (the Shawano Medical Center in Wisconsin.
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-
Gluten Buzzwords
tive, Begun says. RDs need to educate their clients with celiac dis-
Celiac disease is an autoimmune disorder in which the body ease about the buzzwords on food labels that may
triggers an attack on the intestines every time gluten is eaten, indicate the presence of gluten. These buzzwords
Begun says. Inflammation and damage occur in the small intes- include wheat, rye, oats, barley, malt, and brewers
tine and nutrients cant be absorbed, leading to nutrition defi- yeast. (Note: If the oats are labeled as gluten free,
ciencies and a wide range of symptoms. theyre safe to eat as part of a gluten-free diet.)
Begun says many people with the disease are asymptomatic Wheat is required to be identified [on a food label],
and thus dont experience any negative symptoms after eating as it is one of the top eight allergens that have to be
gluten. They are, however, experiencing the same damage to the declared on the label, according to the Food and Drug
intestines as those who do experience symptoms, she cautions. Administrations Food Allergy and Consumer Pro-
According to the National Foundation for Celiac Awareness, tection Act, explains Mary K. Sharrett, MS, RD, LD,
non-celiac gluten sensitivity is found in individuals who cannot CNSD. Rye and oats arent hidden in any ingredients,
tolerate gluten and experience symptoms similar to those with although oats need to be labeled gluten free to be sure
celiac disease but yet who lack the same antibodies and intes- theyre uncontaminated. Barley is almost always listed
tinal damage as seen in celiac disease. Early research sug- as barley or malt. Brewers yeast is likely to be con-
gests that non-celiac gluten sensitivity is an innate immune taminated with barley.
response, as opposed to an adaptive immune response (such Sharrett says hidden wheat may be found in prod-
as autoimmune) or allergic reaction. ucts governed by the USDA because they dont have
We dont know much about gluten sensitivity just yet, but to follow the FDAs allergy labeling laws. Therefore
we do know that its a unique condition from celiac disease and wheat may be in modified food starch, starch, or dex-
involves an immune response, Begun says. While symptoms trin, Sharrett says. The good news is that 80% to
of gluten sensitivity can be similar to those of celiac disease, 90% of these companies do identify allergens.
people with gluten sensitivity dont produce antibodies to gluten To identify a USDA-inspected food (eg, processed
or show signs of damage to the intestine. meat, poultry, eggs, and some mixed food products,
such as soups containing meat) look for an Inspected
Dietary Treatment by the USDA stamp on the front of the package.
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

january 2013 25

Most of Beguns patients feel overwhelmed with the dietary Nutrient-dense foods remedy nutrition deficiencies and help
changes that are part of a GF diet. In particular, parents of the body to heal faster.
[young] celiac disease patients can feel overwhelmed knowing Its also important to meet patients where they are in terms of
theyre responsible for ensuring their kids avoid gluten. While current lifestyle and dietary patterns. If a patient has no cook-
some are relieved knowing they finally have found the answer to ing skills and is traveling for business five days a week, then its
their health issues, others are in denial about having to change a good idea to focus first on how to handle themselves in a res-
their diet, Begun says. Theres also the emotional part that taurant, Begun says. For the mother whos making most of the
comes with the social aspects of eating. People are worried they childs meals and snacks at home, then you want to teach them
wont be able to enjoy eating out which, for many, is an important how to make smart choices at the grocery store as well as intro-
part of socializing with friends and family. In the end, though, duce them to common ingredients used in gluten-free cooking
most are happy to be feeling better and doing the right thing for and baking.
their long-term health. Avoiding cross-contamination when following a GF diet is
of utmost importance. Its very important to discuss cross-
To Eat or Not to Eat contamination with newly diagnosed patients, Jeffers says.
The key types of common foods that are safe for patients Its important for patients to understand how easily foods
with celiac disease include naturally GF items such as fruits, can become contaminated with gluten. If a gluten bun on a
vegetables, meats, nuts, legumes, fish, poultry, eggs, and most sandwich is removed and replaced with the GF bread, its
dairy (eg, cheese, yogurt, cottage cheese). GF grains include rice too late. Or if there are croutons on the salad and [theyre]
and corn. Some less familiar GF options include flaxseeds, nut picked off, the salad shouldnt be eaten since it was already
and bean flours, potato starch, quinoa, rice bran, teff, wild rice, contaminated.
tapioca, buckwheat, arrowroot, millet, amaranth, chia seeds, Additionally, gluten can be spread from containers of food,
mesquite, montina, sago, and sorghum. Oats also are consid- such as peanut butter and jelly, when a knife that has touched
ered GF but only if theyre labeled as such. gluten-containing bread is dipped into the jar. Its also important
Begun stresses RDs need to help their patients with celiac to use separate toasters and related small appliances as well as
disease focus their diet on naturally GF foods rather than GF cutting boards and dishes when handling both GF and non-GF
packaged alternatives. Its even more important to get this foods. If this isnt possible, the item must be thoroughly cleaned
message across with newly diagnosed patients because their to remove any traces of gluten to avoid cross-contamination.
bodies have been devoid of nutrients and need to heal, she says. 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.
Snacks Aplenty Helping People Adapt
While preparing gluten-free meals takes some effort Mary K. Sharrett, MS, RD, LD, CNSD, a clinical dietitian in
to evaluate ingredients and identify gluten-free recipes, nutritional support services at Nationwide Childrens Hospital in
snack options are plentiful: Columbus, Ohio, suggests RDs schedule two 45-minute to one-
Gluten-free corn tortilla chips are available in white, hour sessions with clients newly diagnosed with celiac disease
yellow, and blue varieties. You can enjoy some great because theyll have numerous questions, as theres much to
flavor combinations when you pair them with salsa, learn about following a GF diet.
hummus, cherry tomatoes, carrot sticks, or tart If you dont know the answer, dont try to guess. Tell them
apple slices. youll get back to them and then find an expert to help you, says
A handful of nuts or roasted soy nuts is a protein-rich Sharrett, whos also a member of the Academys celiac disease
snack and easy to store in your pantry, a desk drawer, expert workgroup for the Evidence-Based Analysis Library and
a gym bag, or a purse. the founder and dietitian advisor for the Gluten-Free Gang, a
Enjoy a gluten-free bagel or slices of bread with celiac disease support group. The Academys Medical Nutrition
peanut butter. Practice Group has a subunit called Dietitians in Gluten Intoler-
ance Disease with lots of experts.
Try orange slices with sugar snap peas when you
Sharrett also recommends RDs provide a few naturally GF
know your next meal will be delayed.
recipes to help clients start their journey. Moreover, RDs should
Make your own snack mix with gluten-free cereal determine some of their clients favorite meals and provide sug-
squares, dried fruit, and sunflower or pumpkin seeds. gestions for making them GF. For instance, if a client enjoys
MK 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,

26 todays dietitian january 2013

Jeffers says. Also, let patients know rye, barley, and derivatives of those
there are many great online sources of sources.
gluten-free products, and some compa- Salads should never have croutons,
nies will send samples. and confirm that salad ingredients are
Wespetal says its also important to GF before consumption.
determine what research the patient Always ask before ordering. Flour
already has done regarding celiac dis- often is used to thicken soups, and
ease and a GF diet. This will help clarify meats may contain fillers made of
any misconceptions the patient may have gluten.
about what celiac disease is and what Avoid anything described as being
their role is in managing it, she says. encrusted, breaded, marinated, or
Also, RDs should explain how to review served in an unknown broth.
ingredient lists on food packages. Is it Fried foods must be fried in separate
clear to them that wheat free does not oil to be considered GF.
mean gluten free? Finally, use follow-up Consider bringing your own GF bread
visits to assess the nutritional adequacy or crackers.
of the patients typical eating pattern, Consider eating out at an ethnic res-
especially fiber and B vitamins. taurant, as many of the foods may be
Your patients become very informed from GF sources (eg, rice, corn).
and may teach you something along At parties, if possible, clients with
the way, Jeffers says. Theres nothing celiac disease should speak with the host
wrong with learning from your patients to make him or her aware of their need
especially since theyre living it on a to avoid gluten, preferably with enough
daily basis. advance notice so the host can adjust the
menu accordingly. Begun suggests offer-
Eating Out ing to make one or two dishes if the party
For many people with celiac disease, is more intimate, as this ensures safe
eating at restaurants or attending par- items for the client to eat and takes pres-
ties especially may cause frustration sure off the host. The following are some
and fear. To increase the likelihood of additional tips:
getting a safe meal, call the restaurant Dont attend the party hungry, as there
ahead of time to let them know about may be few GF items from which to
your gluten-free needs, Begun says. choose.
Right from the beginning youll know Bring your own GF bread or crackers
if the restaurant isnt knowledgeable or a GF item to share.
about serving people with dietary restric- Never assume something is GF. Con-
tions. If you get that gut feeling that they firm that its safe before eating it.
dont know what youre talking about, its Fresh fruits, vegetables, dairy items,
a red flag to make reservations some- and fish are safe options as long as
where else. I also recommend review- they didnt come in contact with any
ing the restaurants menu ahead of time products containing gluten.
so you can narrow down your choices and
have a more focused conversation with Silver Lining
the server. This is easier for the server, Though following a GF diet may seem
which makes it more likely youll get a daunting at first, clients with celiac dis-
gluten-free meal. ease or gluten sensitivity, with the help
When counseling patients about eating of knowledgeable RDs, easily can navi-
out or attending parties, Jeffers suggests gate their way through daily living as well
giving them the following tips: as special events without worrying that
Before going to a restaurant, try to gluten will cross their lips and potentially
view the menu online and identify pos- cause problems once again.
sible GF items in advance.
Let the server know that you cant eat Maura Keller is a Minneapolis-based
gluten, which includes avoiding wheat, freelance writer and editor.

january 2013 27

The Dietitians
Role in
Enteral and

By Denise Baird Schwartz, MS, RD, FADA, CNSC

28 todays dietitian january 2013

n 85-year-old man was admitted to an wishes. Without documents for advance care
acute care facility after suffering a planning in a patients healthcare record, the
stroke. Despite his advanced age and clinical ethical dilemmaa difficult problem
history of progressive dementia, his involving moral conflicts for which there seems
family never prepared documents that addressed to be no satisfactory solutionis now set in
advance care planning, which would have desig- motion. This can result in the patient receiving
nated a surrogate decision maker and indicated his medical treatments that go against his or her
wishes for his end-of-life healthcare. wishes and family members making decisions
Before his hospitalization, the patient was living without the individuals input.
with the youngest of his three adult children, the Yet the goal of any healthcare team is to provide
only daughter. A swallow evaluation by a speech appropriate and effective patient-centered care
pathologist indicated severe dysphagia. The speech based on the individuals wishes. From the team
pathologist recommended discontinuing oral members perspective, they should deliver medi-
feedings and starting the patient on tube feeding. cally appropriate treatment using evidence-based
The physician requested that an RD perform a medicine and assess the benefits and risks/burdens
nutrition consultation to initiate a nasogastric involved. And they should adhere to their institu-
tube feeding and progress the feeding to meet the tions policies and procedures for ethical decision
patients nutrient needs. After the RD reviewed making regarding artificial nutrition.1 Such care is
the patients medical record and consulted with difficult to provide in the case presented due to the
the RN, the dietitian discussed plans for the tube clinical ethical dilemma of family members in con-
feeding with the patients daughter at her fathers flict with the patients wishes.
bedside. The RD verbally presented information The ways in which people deal with issues of
about the tube feeding and provided written infor- serious illness often are shaped by their faith and
mation to ensure health literacy, asking the culture. Individuals with different faiths and cul-
daughter to reiterate and demonstrate what was tures have diverse perspectives on the use of
discusseda communication technique called life-sustaining therapies, the communication
the teach-back method. process for delivering health information directly
During this exchange, the daughter indicated to the patient vs. through the family, and the fam-
that her father never wanted a feeding tube or ilys role in the decision-making process for
other medical therapies that would prevent him healthcare at the end of ones life.2
from enjoying simple daily activities. The daughter The dietitians understanding of cultural and
said her brothers wanted their father to receive religious diversity is necessary to best meet the
nutrition through tubes and all other medical needs of a heterogeneous patient population.
therapies needed to prolong his life. They were Diversity awareness gives the RD the ability to
adamant that everything be done to extend their tailor information to patients, families, and sig-
fathers life, from a feeding tube to a ventilator to nificant others, and promote understanding of
cardiopulmonary resuscitation. This potential decision making when dealing with the use of
conflict between siblings is all too common when artificial nutrition. And awareness of different
dealing with end-of-life healthcare decisions, cultures and faiths furthers an RDs understanding
commonly known as ethical dilemmas. of diversity in clinical ethics, which promotes
This article will discuss this common occur- making right choices and decisions in health-
rence, the importance of discussing end-of-life care delivery.
healthcare issues with patients and family mem- Although the patient is the predominate stake-
bers while honoring patients wishes, strategies to holder in this process, the concerns of the family,
prevent conflict, and the RDs role in ethical deci- physician, dietitian, and other healthcare providers
sion making in the context of enteral and paren- are what comprise the process of providing the
teral nutrition. most appropriate nutrition therapy intervention.
The patients best interests always should be at the
Ethical Dilemma Issues and Stakeholders center of healthcare decisions. Patient-centered
The above case study is an example of inade- care is defined as care thats respectful of the
quate family communication without written individual person and responsive to his or her
documentation about end-of-life healthcare preferences, needs, and values and that ensures

january 2013 29

patient values guide all decisions.3 The focus of healthcare clinical effectiveness research, which determines what treat-
should be shifted away from managing just the disease and ment works best, for whom, and under what circumstances,
back to patients and their families, the major stakeholders to enhance the decision makers ability to fully understand
in the process.4 and weigh the alternative healthcare options available.8

Health Literacy and the Teach-Back Method Preventive Ethics and the RDs Role
The use of evidence-based practice guidelines, such as those Another important aspect of end-of-life care for dietitians is
from the Academy of Nutrition and Dietetics (the Academy), is the practice of preventive ethics. Preventive ethics suggest
beneficial in providing appropriate patient education informa- that ethical conflict between family members is largely pre-
tion.5 As indicated in the education process with the daughter dictable, but it can be avoided through interventions aimed
in the aforementioned case study, the RD was concerned about at the organization, the patient care unit, and the individuals
presenting the information in simple terms due to the issue of involved. The goals of preventive ethics are to identify common
health literacy. Health literacy is defined as the degree to which triggers of ethical conflict, such as unrealistic expectations
individuals obtain, process, and understand basic health infor- that treatment will be effective, and address them before they
mation and services to make appropriate healthcare decisions.6 contribute to conflict. Preventive ethics would have provided
It involves a range of social, cultural, and individual factors, options for the RD and other healthcare clinicians involving
such as age, education, and race. the 85-year-old father and his children to implement a pro-
Due to concerns for improving health literacy, the RD active process to reduce the potential conflict among them.
used the teach-back technique with the daughter while edu- Preventive ethics represents a dramatic shift from the tra-
cating her about tube feeding. This is an effective method to ditional ethics approach, which involves reacting to ethically
ensure individuals understand what theyve been told. The challenging patient situations on a case-by-case basis.9
process involves asking the individual to explain or demon- RDs maintain a unique role in the hospital setting. Theyre
strate what he or she was taught. If the person doesnt explain in a position to develop nutrition screening parameters for all
correctly what he or she learned, the assumption is that the patients and implement the nutrition care process. This process
information wasnt presented effectively. If this is the case, may call for initiating enteral or parenteral nutrition. But what
the RD would explain the information again but use an alter- if this therapy isnt congruent with the patients wishes based
native approach.7 on his or her quality-of-life goals? To avoid such dilemmas,
In addition to verbal communication, understanding the RDs can screen for quality-of-life goals before initiating the
printed information is a significant factor that affects the nutrition care process. They can review the medical record
impact of the message. The printed educational material the for an advance directivewritten documentation of treatment
dietitian gave the daughter was written in accordance with preferences and the designation of a surrogate decision maker
the teach-back method. A fifth-grade reading level or lower and discuss their findings with other healthcare team members.1
is recommended for informational material and has been Dietitians are in the best position to improve ethical decision
identified as a criterion for low literacy.5 making for enteral and parenteral nutrition because they can
Awareness of health literacy concerns and the use of the facilitate an interprofessional, collegial approach to whole
teach-back method are aspects of patient-centered care RDs patient-centered care while delivering nutrition therapies.
can use to improve communication with patients and their This approach involves two or more medical professionals
families. Moreover, RDs should be aware of comparative 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
Triggers for Cue-Based applicable, and relaying this information to the other health-
Patient/Family Discussion care team members.
The word nutrition connotes a sense of vibrancy and life.
Patient/family are healthcare team members. The hope is that nutrition, for some patients, will open the door
Patient-/person-centered healthcare is based on that leads to advance care planning and end-of-life discussions
patient wishes. in the hospital setting. Dietitians already have formed bridges
The family expresses what the patient would want. between themselves and other medical fields, for example,
Family/surrogate decision makers role is to repre- through discussions with physicians about optimal placement
sent the patients wishes, not their own. 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

30 todays dietitian january 2013

pulmonary function. And RDs can learn to incorporate nutrition therapies, including recommendations and guide-
ethics in the decision-making process by integrating clinical lines.10,11 The first step for healthcare institutions is to incorporate
ethics into their dietetic practices. They can become knowl- these recommendations when developing ethical decision
edgeable about advance care planning terms and learn how making for artificial nutrition policy and procedure. Recommen-
to promote conversations about nutrition with patients and dations and guidelines from other societies and organizations
their families, which can lead to a transformation in nutri- are important to include in these documents based on the
tion support practice. patient population characteristics and religious affiliation of
Collaboration with the physician, nurse, social worker, the healthcare facility. Its important to develop the policy and
chaplain, palliative care team, and other healthcare team procedure in collaboration with all healthcare professionals
members is optimal to facilitate this process. Dietitians who involved in the process to encourage acceptance of the final
learn more about advance directives, living wills, durable document. A sample policy and procedure for dealing with
power of attorney for healthcare (a legal document in which ethical decision making for artificial nutrition has been pub-
a competent person gives another person the power to make lished in The ASPEN Adult Nutrition Support Core Curriculum.12
healthcare decisions for him or her if unable to make those The second step for healthcare institutions involves imple-
decisions personally), and physician orders for life-sustaining menting the policies and procedures needed to improve com-
treatment have an advantage in understanding documents in munication among patients, families, and healthcare providers
the patients medical record. regarding clinical ethics and nutrition therapies. To sustain
improvements in practice, the facility needs to standardize a
Cue-Based Patient/Family Discussion proactive, integrated, systematic process that focuses on
One way to promote conversations about nutrition ther- patient-centered care and communication.
apy with families is to learn about cue-based patient/family The third step involves designing an improvement project
discussion. This involves listening for specific key words or dealing with clinical ethics and artificial nutrition with mea-
trigger phrases from a patient or family member expressing surable goals, along with developing a plan to remeasure
he or she doesnt want a particular therapy, such as a feeding the data. An example of measurable goals can include the
tube. RDs can use this response to begin cue-based discus- number of patients receiving nutrition support that have an
sions about quality-of-life goals while educating patients advance directive in their chart, the number of patients with
and family members about nutrition therapies. family care conferences, or the reduction in the number of
To begin, dietitians can tell family members the goal is to bioethics consults, which involve mediation to obtain a con-
provide enteral or parenteral nutrition support based on the sensus among individuals in conflict concerning artificial
patients wishes. The sidebar on page 30 presents examples nutrition issues. Even incorporating an analysis involving
of these triggers for cue-based discussion that can lead a patient satisfaction can facilitate process improvements.1,13
patient or family to understand that the focus should be on The final step involves presenting information about best
the patients wishes. practices with other facilities at national meetings and publish-
This process is especially useful when the patient is on a ing data. Accomplishing this step would help dietitians in private
ventilator or unable to communicate. The important concept practice improve patient-centered care by standardizing the
is that family members or surrogate decision makers must incorporation of clinical ethics in the field of nutrition support.1,13
understand that their role is to represent the patients wishes
and not their own. Based on the cues given by the patient or Engaging the Public in End-of-Life Conversations
family, dietitians can refer further discussions to the physi- To engage the public in end-of-life healthcare conversations,
cian, nurse, social worker, or chaplain. Documenting these healthcare professionals must educate themselves about the
referrals in the medical record is essential. The verbal and process and become aware of resources and tools available
written interprofessional communication is important to (see sidebar on page 32).
facilitate a consistent healthcare team approach. The primary End-of-life conversations dont involve just the elderly and
care physician is the coordinator of the clinical ethics process their adult children; they affect everyone in some capacity. In the
with the patient, family, and healthcare team. RDs and other hospital setting, patient-centered care is best achieved when all
healthcare professionals help contribute to the clinical ethics healthcare professionals communicate and are engaged in the
process regarding artificial nutrition. conversation to provide a consistent healthcare team approach.14
Perhaps if RDs and other healthcare team members
Action Steps for Process Improvement embrace these conversations in their professional and personal
Both the American Society for Parenteral and Enteral lives, the public will become more engaged in end-of-life
Nutrition (ASPEN) and the Academy provide resources for healthcare discussions. Recognizing the importance of com-
healthcare professionals on ethical considerations regarding munication in families and acting on these discussions is the

january 2013 31

best way to prevent clinical ethics dilemmas and provide 5. Gallagher-Allred CR. Communication and education for
whole patient-centered care in the hospital. In the future, families dealing with end-of-life decisions. J Acad Nutr Diet.
the goal will be for everyone to have advance care planning 2012;112(2):309-310.
discussions with their family and written documentation before 6. Carbone ET, Zoellner JM. Nutrition and health literacy:
an illness develops and hospitalization follows. Dietitians are a systematic review to inform nutrition research and practice.
essential healthcare team members involved in clinical ethics J Acad Nutr Diet. 2012;112(2):254-265.
due to their role in the optimal use of enteral and parenteral 7. Weiss BD. Health Literacy and Patient Safety: Help Patients
nutritionand they can make a difference. Understand. 2nd ed. Chicago, IL: American Medical Association
Foundation; 2007.
Denise Baird Schwartz, MS, RD, FADA, CNSC, 8. Gabriel SE, Normand SL. Getting the methods rightthe
is the nutrition support coordinator at Providence foundation of patient-centered outcomes research. N Engl J
Saint Joseph Medical Center in Burbank, California, Med. 2012;367(9):787-790.
and has been recognized both nationally and 9. Epstein EG. Preventive ethics in the intensive care unit.
internationally as a speaker on nutrition Am Assoc Crit Care Nurs. 2012;23(12):217-224.
support topics for the critically ill. 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.
References 11. OSullivan Maillet J. Position of the American Dietetic
1. Schwartz DB. Ethical considerations in the critically ill Association: ethical and legal issues in nutrition, hydration,
patient. In: Cresci G, ed. Nutritional Therapy for the Critically and feeding. J Am Diet Assoc. 2008;108(5):873-882.
Ill Patient: A Guide to Practice. 2nd ed. Boca Raton, FL: Taylor 12. Geppert CMA, Barrocas A, Schwartz DB. Ethics and
& Francis; 2013 (in press). law. In: Mueller C, McClave SA, Schwartz DB, Kovacevich D,
2. Preedy VR, ed. Diet and Nutrition in Palliative Care. Boca Miller SJ, eds. The A.S.P.E.N. Adult Nutrition Support Core
Raton, FL: CRC Press; 2011. Curriculum. 2nd ed. Springfield, MD: American Society for
3. Barry MJ, Edgman-Levitan S. Shared decision Parenteral and Enteral Nutrition; 2012: 656-676.
makingthe pinnacle of patient-centered care. N Engl J 13. Schwartz DB. Three steps for improving end-of-life
Med. 2012;366(9):780-781. nutrition care. Clinical Nutrition Insight. 2012;38(10):4-5.
4. Reuben DB, Tinetti ME. Goal-oriented patient care 14. Schwartz DB. Clinical ethics and nutrition support.
an alternative health outcomes paradigm. N Engl J Med. J Nutr Therapeutics. 2012;1(1):86-90.

Resources and Tools Physician Orders for Life-Sustaining Treatment (www. This is based on effective communication of
National Healthcare Decisions Day ( patient wishes. It involves documenting medical orders on a
Held annually on April 16, the goal of this day is to inspire, brightly colored form and includes a paradigm program to
educate, and empower the public and healthcare provid- improve the quality of care people receive at the end of life.
ers regarding the importance of advance care planning. The Conversation Project (www.theconversation
Resources for activities to promote this day are available The goal of this project is to have every
on the website. persons end-of-life preferences expressed and respected.
Speak Up Campaign ( It includes a starter kit to help initiate conversations
This campaign is designed to promote advance care plan- with loved ones regarding end-of-life care wishes.
ning in Canada. It was developed to raise awareness of Breathe a True Story of Letting Go of My Parents
the importance of advance care planning and end-of-life Gracefully, For I Will See Them Again (www.breathe-
care. The website provides a kit with material to pro- This book is a healthcare professionals
mote advance care planning. personal story intended to help others begin the dialogue
Aging With Dignitys Five Wishes (www.agingwith with family members about end-of-life care decisions. Per- This guide helps start impor- sonal stories such as this one are intended to help individu-
tant conversations about end-of-life care. It provides a als deal with family relationships, faith, and values and are
documentation tool for detailing an individuals wishes. designed for both healthcare professionals and the public.

32 todays dietitian january 2013

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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

he start of the school year welcomes students sample. The response, according to Jodi Risse, MS, RD,
with the promise and expectation of filling their LDN, division of food and nutrition services, was positive on
minds with knowledge andfor the 32 million the lunch line where these featured fruits and veggies were
in our nations school meal programstheir incorporated into the menu. Familiarity was the first step
bodies with nutritious foods. Only this year toward broadening the childrens formative palates.
the implementation of the new federal lunch
standards mandated by the Healthy, Hunger-Free Kids Act Out With the Old
of 2010 isironicallyleaving kids hungry. Theres no argument that the new lunch standards are an
And this youngest generation is speaking out. Fueled by improvement over the old lunch standards, which had been
the pangs of their growling bellies, complaints from our untouched for more than 15 years. During her 1998 dietetic
nations youths have spread across the country via blogs, internship, Laura Cipullo, RD, CDE, CEDS, CDN, of Whole
websites, boycotts, strikes and, most famously, YouTube. Nutrition Services, LLC, and, recalls
visiting New York City schools and seeing banana bread with
One Million Hits and Counting whole milk served for breakfast and pizza with whole milk and
A video parodyviewed more than 1 million timeshas fruit for lunch. Im not a fan of school lunch in general, she
students singing We Are Hungry to the tune of fun.s We says, but I feel the new standards are a step in the right direc-
Are Young. The student-teacher compilation, made in the tion. Increasing whole grain specifications, providing colorful
high school of a small Kansas town, protests the lower calo- vegetables, and offering 1% milk are great new options.
ries and limited carbohydrates and proteins under the new According to the USDA, a typical lunch menu under the old
lunch standards. standards might include pizza sticks (3.8 oz) with 14 cup of
The video features scenes of starving athletes collaps- marinara sauce, a banana, 1 oz of raisins, and 8 oz of whole
ing during after-school practice, a student who falls asleep milk. Compare that with a typical menu under the new stan-
in class, and elementary school students crawling out of a dards: one slice of whole wheat cheese pizza, 12 cup of
school building, presumably dragging due to hunger, all set sweet potato fries, 14 cup of raw grape tomatoes, 12 cup of
to a chorus of Tonight/We are hungry/Set the policy on fire/ applesauce, 8 oz of 1% milk, and 1 oz of low-fat ranch dip.
It can burn brighter/Than the sun.
A call to action, the video opens with statistics on the Key Word: Calories
minimum calories necessary for high school athletes and The healthful addition of fruits and vegetables and even
ends with a plea to all students to voice their opinion. whole grains isnt the problem. Students say theyre not getting
enough calories to satisfy their hunger.
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 Making Good of the
is that the new lunch standards serve a radically changed New Standards
menu from previous years, certainly one that skimps on
Here are some suggestions from Laura Cipullo,
calories. In reality, most of the changes have been progres-
RD, CDE, CEDS, CDN, to help put a positive spin on
sively introduced in schools since 2009 when the Institute of
the new school menu changes:
Medicine developed recommendations that formed the basis
Periodically invite chefs to your school to teach
for these standards in direct response to the childhood obesity
foodservice staff new, healthful recipes.
epidemic. School nutrition professionals who were aware of
Rotate students through the school kitchen to help
the pending recommendations to increase the amount of fruits,
prepare meals and offer new ideas for dishes.
vegetables, and whole grains served and lower sodium,
Have children plant gardens and eat the food they
saturated fat, and calories got right to work.
Many schools embraced the imminent changes in policy
Include cooking classes in the schools curriculum,
and worked hard to introduce and integrate new and colorful
and teach kids how to make healthful, tasty food.
fruits and vegetables into their meal programs so the eventual
Create yearly school cookbooks featuring the
adoption of new standards would be an easy and seamless
students favorite healthful recipes.
transition. Programs such as A Tasting of the Rainbow at
Teach students how to modify their favorite recipes
Anne Arundel County Public Schools in Maryland showcased
to develop more wholesome, healthful ones.
a variety of fruits and vegetablessome the children had
never seen beforeand encouraged them to taste a free

january 2013 35

According to Deborah Beauvais, RD, CDN, SNS, district One Size Doesnt Fit All
supervisor of school nutrition services in the Gates Chili Clearly, every lunch wont fulfill every students caloric
Central and East Rochester Union Free school districts in needs, but according to Beauvais, even the old standards
western New York, thats a case of perception vs. reality. didnt sustain all the kids. Her first question for todays stu-
The calories a year ago were still in that same range, she dents complaining of hunger is Are you eating breakfast
explains. The main difference is that the old standards set a before you leave home or at school? She says lunch isnt
target number of calories, which could be exceeded, while intended to supply the entire days calories, but if students
the new standards set a range of calories thats capped with are hungry beyond whats on their tray, schools offer extra
maximums. These guidelines are based on science and portions. With all the choices of fresh fruits and vegetables
are written for the center of the bell curve. Its too much for at kids disposal, certainly something should be appealing,
some, too little for others, she says. Beauvais adds.
A quick glance at government calorie recommendations Perhaps that appeal is partly to blame for the perceived
confirms this. The USDA recommends that boys aged 14 to18 calorie deficit. If kids dont eat whats offered, theyre not
consume an average of 2,200 to 3,200 kcal/day and girls aged getting the calories and the energy available and necessary
14 to 18 take in 1,800 to 2,400 kcal/day for a healthful, balanced to sustain them throughout the afternoon. Cipullo noted the
diet. Assuming the average teenage boy or girl falls somewhere problem back in 1998 during her school tours. Children
in the middle of these ranges, the calories they consume at lunch were forced to take a minimum of each item even if they
will equate to about one-third of their daily calories. Assuming didnt want to eat the food, she says. This created unnec-
again that these teens are eating three meals as well as a snack essary food waste. It was a huge problem then and is still a
or two each day, there shouldnt be a calorie deficit. huge problem now.
However, the USDA clearly states that these ranges are Cipullo believes the reason kids arent eating enough calo-
estimated amounts of calories needed to maintain calorie ries is twofold. The new offerings, she says, need to be more
balance and that individual calorie needs may be lower or visually pleasing and palatable. But keep in mind that kids
higher. According to information from the American Dietetic have been accustomed to eating processed foods laden with
Association Complete Food & Nutrition Guide by Roberta added sugar, foods that appeal to them even if theyre not
Larson Duyff, MS, RD, FADA, CFCS, those calorie require- necessarily nutritionally adequate. Rather than calories,
ments jump to 3,500 or more for athletes and those involved she says, the attention should focus on how to serve positive
in strenuous exercise. change in the way students view nutrition and food.

Table 1 Typical School Lunch Portions Based on the New Federal Standards
Food Group Previous Requirements Current Requirements
Fruits and vegetables 1
2 to 4 cup total
Fruits: 12 to 1 cup
There are no specifications regarding Vegetables: 34 to 1 cup
the types of vegetables to be served.
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.
Meat/meat alternative 1.5 to 2 oz equivalent (daily minimum) 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
Grains Eight servings weekly; minimum of Grades K to 5: minimum 1 oz equivalent daily; 8 to 9 oz weekly
one serving per day
Grades 6 to 8: minimum 1 oz equivalent daily; 8 to 10 oz weekly
Whole grains are encouraged.
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.
Milk 1 cup; variety of fat contents allowed 1 cup; must be fat free (unflavored or flavored) or 1% (unflavored)
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

36 todays dietitian january 2013

This is especially true when it comes to athletes who have a Table 2 Calorie Counts of Lunches Before
much higher calorie requirement compared with nonathletes and After New Standards Took Effect
as much as 4,500 kcal/day. I think students need more whole Previous Standards Current Standards
grains, proteins, and healthful fat options such as nuts, avoca-
Grades K to 3: 633 Grades K to 5: 550 to 650
dos, and olives as part of their daily lunch meal, Cipullo says.
Lets offer less-processed, wholesome foods without such Grades 4 to 12: 785 Grades 6 to 8: 600 to 700
tight maximums on calories. We also should encourage some
Grades 7 to 12: 825 (optional) Grades 9 to 12: 750 to 850
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 Table adapted from a comparison of previous and current regulatory requirements
under the Nutrition Standards in the National School Lunch and School Breakfast
meals are easier on our endocrine systems and may help Program (
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 adults and students on campus, the healthier lunches wont
carry him through his afternoon sports practice, but they change anything. Even after the dust settles and the protests
werent last year either. When this is the case, Beauvais wane, negative attitudes and food waste in the cafeteria are
says these kids need another plan for the afternoon, which likely to continue.
might mean bringing a snack from home or money for a Theres a clear disconnect when grown-ups arent included,
healthful vending machine option. Lewison-Grant says. They wield a lot of influence on students
a disproportionate amount of influence.
Wheres the Beef? FoodFights goal is to improve the health and life outcomes
While its true the number of calories in school lunches of students by bringing teachers and personnel into the con-
arent that different from a year ago, theyre distributed versation. Their health and wellness is critical to their job.
differentlyand this is what the kids notice. Perhaps the Corporate wellness is so accepted, but we dont see that in
most dramatic change is the cap on protein and grains. At schools, Lewison-Grant continues.
the high school level, its the difference between this years By running wellness programs for teachers and school staffs,
burger and last years: What was once a 3-oz meat patty is now Cohen and Lewison-Grant believe their graduates will bring
2 oz. Beauvais says the differencethe patty gets lost in the an empowerment and energy for healthful living and eating to
bunis visibly obvious to the kids. She says that our new the students. If you engage the entire staff, you can ignite an
motto is How about some lettuce and tomato with that? important process that can change food in schools, they say.
It has become a challenge on the foodservice side as well, In addition, Cohen and Lewison-Grant believe the new lunch
which Beauvais describes as kind of like a puzzle. Take that standards would be more effective if they were introduced within
burger, for example. To accommodate the addition of a half- a context. A new set of guidelines without explanation is confus-
ounce slice of cheese, youd first have to make the patty a ing. Its missing the education component, Lewison-Grant says.
half-ounce smaller. Well, they dont come in a 212 -oz size. When the students dont understand the reason behind their
And sandwichesa staple on every lunch lineare no role in the changes, it becomes a control issue. Food is the one
longer so simple under the new standards. A cap of 9 oz of area over which they exert control, she explains. They can
bread, at 1 oz per slice, makes a challenging breakdown for decide what to put in their mouths, but they dont understand the
the five-day school week. There might be a future for an forces shaping it. School lunch isnt exempt. This is where the
open-faced sandwich on the menu, Beauvais says. adults in the school can lead students through the changes and
together change the current food climate into a healthful one.
Changing the Food Isnt Enough
Laudable as the efforts behind the new standards are, Embracing Change Is Tough
theyre not enough, according to two former New York City All change is subject to scrutiny, doubt, and sometimes protest,
public school teachers who have taken the issue of obesity in and the new school lunch standards are no exception. But like any
school children into their own hands. Deborah Lewison-Grant, new policy, especially one as large-scale as the US school meal
MA, MEd, and Carolyn Cohen, MEd, started their own nonprofit program, its being closely monitored. According to Beauvais,
organization called FoodFight to include teachers, who they the USDA is receiving information from around the country
believe are the missing link in the growing obesity epidemic. and, she says, Im hoping there will be some minor revisions.
FoodFight also involves a curriculum that teaches teens about
nutrition and how the media influences their food choices. Lori Zanteson is a food, nutrition,
You cant revolutionize food without revolutionizing the and health writer based in southern California.
culture in the schools, Cohen says. Without buy-in from both

january 2013 37

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

hat do Oprah Winfrey, Michael Pollan, In a recent meta-analysis, Harvard researchers linked high
and Mario Batali have in common? processed-meat intake to a 42% higher risk of coronary heart
Theyve all jumped on the Meatless disease.4 Data from the Health Professionals Follow-Up Study,
Monday bandwagon. Hospitals, colleges, which included more than 440,000 participants, revealed that
restaurants, magazines, foodservice eating a daily 100-g serving of red meat was linked with a 19%
companies, workplaces, and entire communities are pledging increased risk of developing type 2 diabetes, and eating a daily
their support for the program, too. 50-g serving of processed meat was associated with a 51%
Whats Meatless Monday all about? Its a nonprofit initia- greater risk.5
tive of The Monday Campaigns, which is developed in asso- The NIH-AARP Diet and Health Study, which included more
ciation with the Johns Hopkins Bloomberg School of Public than 500,000 men and women, found a significantly higher risk
Health, with a simple message: By cutting out meat once per of cancers of the colorectum, esophagus, lung, and liver asso-
week, you can improve your health and reduce your carbon ciated with red meat intake; an increased risk of colorectal and
footprint. The initiative provides information and recipes to lung cancer was associated with higher intake of processed
help people start each week with healthful, eco-friendly, meat; and red and processed meat intake was associated with
meat-free alternatives. cancer mortality.6
Allison Righter, MSPH, RD, who coordinates the Meatless In addition to health, people are interested in reducing their
Monday science advisory at the Center for a Livable Future animal food intake for environmental benefits. Italian research-
(CLF), reports that Meatless Monday began in 2003 in response ers performed a life cycle assessment to evaluate the cradle-
to the release of the Healthy People 2010 report, which included to-grave environmental impact of several dietary patterns.
goals to reduce dietary saturated fat by 15%. Since saturated They reported that an organic, vegan diet had the smallest
fat primarily comes from meat and animal products and since environmental impact, while a conventionally farmed diet that
one day a week is just under 15% of the week, Meatless Monday included meat had the greatest impact on the environment
was a practical method for helping people to meet those goals. and the more meat consumed, the greater the impact. Beef was
Reducing meat consumption also has many other benefits, the food with the single greatest impact on the environment.
such as lowering the environmental burden of industrial food Cattle require lots of feed, water, and fossil fuels to turn plants
animal production, which is a major focus of CLFs research, into protein, the scientists said. To produce 1 kcal from beef
Righter says. requires 40 kcal of fossil fuels, whereas producing 1 kcal from
grains requires only 2.2 kcal of fuel.7
Benefits Aplenty In an analysis for the public advocacy organization Environ-
Theres growing support for adopting a more plant-based mental Working Group (EWG), greenhouse gas emissions gen-
diet, even in the 2010 Dietary Guidelines for Americans, which erated by conventionally raising lamb, beef, pork, and farmed
offer the general recommendation to eat a plant-based diet that salmon and producing cheese far exceed those from other food
focuses on consuming vegetables, cooked dry beans and peas, choices, such as lentils and beans. The EWG found that eating
fruits, whole grains, nuts, and seeds with moderate amounts of less meat could significantly reduce a persons carbon foot-
lean meats, poultry, eggs, and dairy.1 print. For example, if everyone in the United States ate no meat
A position paper published by the Academy of Nutrition and or cheese for just one day per week, it would be like taking 7.6
Dietetics concluded that a plant-based, vegetarian dietary pat- million cars off the road.8
tern is completely healthful and nutritionally adequate for The Meatless Monday message helps people ease into
people throughout all stages of life and that it has several the concept of decreasing animal intake by selecting just
health advantages, including lower blood cholesterol and pres- one day per week to go meatless. Were not asking people
sure levels and lower risk of heart disease, hypertension, and to cut out meat from the diet, Righter says. This is all
type 2 diabetes.2 about moderation; its one simple tool to help people incor-
Semivegetarian, lacto-vegetarian, and vegan women have porate healthierand also more environmentally sustain-
a lower risk of overweight and obesity than do omnivorous ablealternatives to meat into their diets just one day each
women, according to data from 55,459 healthy women partici- week. Its a platform to introduce new and often overlooked
pating in the Swedish Mammography Cohort, suggesting that foods, and ideally this will trickle over into other days of the
advice to consume more plant foods and less animal products week and ultimately translate into healthier eating habits and
may help individuals control their weight.3 dietary patterns over time.

january 2013 39

What I think is important to understand, especially for Meatless Monday was started in restaurants by pioneers
dietitians, is that people are consuming too much meat like Mario Batali. Now its gone mainstream, says Neu, who
more than whats needed to achieve nutritional recommen- reports growing innovation in the restaurant world. Chefs
dations, Righter continues. Were eating more than twice are employing food stations, special menu features, and
the EAR [estimated average requirement] or about 112 times tasting menus to help promote Meatless Monday.
the RDA [Recommended Dietary Allowance] for protein. The campaign also has been a darling in the media. The
The majority of our protein is coming from meat and animal media, bloggers, and Food Network have all become active
products, which provide additional saturated fat and often in Meatless Monday, Neu says. Were not saying that
not the same nutritional benefits of other plant-based pro- people should give up meat entirely; were not saying to be
teins. This excess of meat and lack of health-protective plant vegetarian or vegan entirely. Our press is so good because
foods is a huge problem in terms of its association with an whats there to argue?
increased risk of chronic diseases. Meatless Monday also is growing with schools, colleges,
Indeed, Meatless Monday appears to be an effective tool food distributors, worksite wellness programs, and insur-
for promoting health. A nationwide survey conducted by FGI ance companies. Were even seeing Meatless Monday in
Research for Meatless Monday found that among those who communities, such as in Raleigh-Durham [North Caro-
are aware of the initiative, 36% say the campaign has influ- lina] and Aspen, Colorado, where community organizers go
enced their decision to cut back or consider cutting back on around and get schools, media, and events to support a com-
meat. Of those influenced by Meatless Monday to reduce meat munitywide gestalt.
intake, 62% say theyve tried to incorporate it in their weekly
routine; 40% incorporate more meatless meals the rest of Employing Meatless Monday in Other Settings
the week; 73% eat more vegetables; 64% eat more fruits; 42% Dietitians are getting excited about using Meatless
eat more beans; 47% eat more whole grains; 50% experiment Monday as a tool in various work settings. Dietitians are
with new meatless recipes when they cook at home; and 42% involved in marketing, cooking classes, community, tele-
try more meatless dishes when eating out. vision, cooking demos, and blogs. Theyre also involved in
foodservice settings, Neu says of the many ways dietitians
Meatless Monday Takes Off use Meatless Monday to provide healthful eating messages.
The Meatless Monday movement has grown dramatically Meatless Monday can be used as a platform in any set-
in the past two years. Awareness of the campaign primarily is ting for dietitians to not only talk about nutrition but to raise
due to grassroots viral dissemination and support of partici- awareness of larger issues related to our industrial food
pating organizations rather than advertising. According to the system, Righter adds. Food is connected to everything. This
FGI Research survey, public awareness of Meatless Monday can help dietitians become well versed on these issues.
increased from 26% to 43% from November 2010 to July 2012. Righter recently conducted an informal survey of dieti-
Meatless Monday has more than 35,000 Facebook likes and tians regarding their knowledge and use of Meatless Monday
18,000 Twitter followers as of July 2012. In addition, many in their work. About half of the people I got responses from
organizations, such as the Food Network (more than 3 million already had heard about the campaign and were using it in
Facebook likes and 1 million Twitter followers) and the Cook- the classroom or with clients in some capacity, she says.
ing Channel (more than 345,000 Facebook likes and 87,000 However, a lot of people werent aware of iteither theyd
Twitter followers), post Meatless Monday content every week. never heard of it or they didnt realize it was a campaign with
Organizations have helped Meatless Monday become its own website, social media, and all sorts of information,
mainstream, says Peggy Neu, president of The Monday recipes, and resources.
Campaigns. Sodexo was the first to join in 2011. Theyre Its one strategy to help bring Americans in line with the
enormous, with 6,000 customers in the United States serv- Dietary Guidelines. Everyones on the same page; were all
ing 10 million meals a day. As weve grown both in our struggling to get people to eat more healthfully. Using Meat-
awareness and number of people who say theyre practicing less Monday is an opportunity to introduce these plant-based
Meatless Monday, we have all of these companies and orga- foods, like vegetables, fruits, beans, and whole grains. Thats
nizations offering a solution to what you can have instead of one of the things that came back from our survey of dieti-
meat. Morningstar Farms was one of the first big brands to tians. They believe Meatless Monday provides an opportunity
promote Meatless Monday, along with others, including the for people to try new recipes and new foods, Righter says.
Mushroom Council and Birds Eye. Dana Dose, RD, CPT, a dietitian at Harrahs Health and Well-
High-profile chefs and restaurants have helped bring ness Center in Lake Tahoe, California, uses Meatless Monday
Meatless Monday to the forefront as well. In the beginning, in her one-on-one sessions with clients. Ive also started the

40 todays dietitian january 2013

process of seeing if the on-site cafeteria for the employees will the idea but havent been exposed to or received guidance for
start offering additional meatless options on Mondays. Once implementing Meatless Monday into their lives. Surprisingly,
that goes through, Ill promote Meatless Monday throughout I found that emphasizing the environmental impact often
the property, especially in the employee cafeteria, by using sig- can motivate people to participate in Meatless Monday who
nage and putting an article in the employee newsletter, Dose wouldnt be interested in participating for health reasons.
says. Its great to be able to show people the positive impact
they can have on the environment and their bodies when they Getting Started
go just one day without meat. If youd like to use Meatless Monday in your own practice,
Lauren Harris-Pincus, MS, RD, and Kathy Siegel, RD, offers many great resources to get you
CDN, cofounders of, feature a meatless started, such as information on nutritional and environmen-
recipe category with 85 recipes on their website and blog, tal benefits, articles, a recipe widget that can be placed on
and they encourage their clients, readers, and listeners to any website or blog, and a tool kit with promotional materials
consider forgoing meat one day per week. By raising aware- in a downloadable format.
ness of the benefits of decreasing meat consumption, we can So go ahead, jump on the Meatless Monday bandwagon and
open consumers minds to the potential positive effects on encourage your clients to take the ride for better health, too.
their health, Harris-Pincus says. The path to better health
is traveled one step at a time, and removing meat from your Sharon Palmer, RD, is a contributing editor at Todays
meal plan one day per week can be one of those steps. Dietitian, a freelance food and nutrition writer in southern
Roberta Anding, MD, RD, LD, CDE, CSSD, director of California, and author of The Plant-Powered Diet.
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 References
calorie burden of my carnivore Texans. Im contemplating 1. US Department of Agriculture, US Department of Health
writing about it for the Houston Texans Gameday magazine, and Human Services. Dietary Guidelines for Americans, 2010.
she adds. 7th ed. Washington, DC: US Government Printing Office; 2010.
Natalie Bates, a clinical nutrition student at the Univer- 2. Craig WJ, Mangels AR; American Dietetic Association.
sity of California, Davis, spent the past summer in an intern- Position of the American Dietetic Association: vegetarian diets.
ship at Kaiser Permanente San Diego Medical Center, where J Am Diet Assoc. 2009;109(7):1266-1282.
she created, promoted, and implemented a Meatless Monday 3. Newby PK, Tucker KL, Wolk A. Risk of overweight and obe-
program for the cafeteria. To kick it off, Bates created a pre- sity among semivegetarian, lactovegetarian, and vegan women.
sentation that was shown on the TV in the hospital cafete- Am J Clin Nutr. 2005;81(6):1267-1274.
ria. She tested meatless recipes and worked with the chef 4. Micha R, Wallace SK, Mozaffarian D. Red and processed
to offer four different meatless entres in the cafeteria on meat consumption and risk of incident coronary heart disease,
Meatless Monday. Bates made table tents that included stroke, and diabetes mellitus: a systemic review and meta-
recipe pictures and environmental and nutritional informa- analysis. Circulation. 2010;121:2271-2283.
tion. She also set up a table at the cafeteria entrance that 5. Pan A, Sun Q, Bernstein AM, et al. Red meat consump-
showcased a poster promoting the campaign and that pro- tion and risk of type 2 diabetes: 3 cohorts of US adults and an
vided staff to answer peoples questions. updated meta-analysis. Am J Clin Nutr. 2011;94(4):1088-1096.
Bates distributed a survey about Meatless Monday 6. Cross A, Leitzmann MF, Gail MH, et al. A prospective study
to receive feedback from the cafeteria customers. The of red and processed meat intake in relation to cancer risk.
survey indicated very mixed results. While some people PLoS Med. 2007;4(12):e325.
were excited about having meatless options, others were 7. Baroni L, Cenci L, Tettamanti M, Berati M. Evaluating
upset that the cafeteria would try to influence their dietary the environmental impact of various dietary patterns com-
choices, she explains. Those who were interested in eating bined with different food production systems. Eur J Clin Nutr.
healthfully were easy to convince to try Meatless Monday on 2007;61(2):279-286.
a regular basis, and they liked the vegetarian options offered 8. Hamerschlag K. Meat Eaters Guide to Climate Change
in the cafeteria that day. However, within the hostile audi- + Health. Environmental Working Group website. http://static.
ence, it was difficult to see any impact. I think the area of
opportunity for people in the public health field is among the eaters_guide_to_health_and_climate_2011.pdf. July 2011.
neutral/undecided individuals who are intrigued and open to Accessed May 10, 2012.

january 2013 41

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

he number of children suffering from childhood A Mind-Body Approach to Wellness
obesity has more than tripled in the past 30 years, The biggest difference between MindStream and other
according to the Centers for Disease Control and weight-loss programs is its overall focus. While its no secret
Prevention, putting them at an increased risk for that it addresses obesity, the school takes pride in its mind-
much more than teasing from schoolyard bul- body approach to health and wellness, impressing on children
lies. The US Department of Health and Human Services has that life is about much more than what the scale dictates.
reported that being overweight during childhood and ado- MindStream Academy has created a school climate in which
lescence increases the risk of developing high cholesterol, optimal health and wellness is equally as important as high
hypertension, respiratory ailments, orthopedic problems, academic standards. Ultimately what we offer is an education
depression, and type 2 diabetes as a youth. for lifelong vitality and vibrancy, Travaglione says, noting that
These conditions are a serious public health concern facing in addition to a lower weight, students also are pursuing the far
children today, but a new weight-loss academy based in Bluff- loftier goals of optimal wellness and their fullest life potential.
ton, South Carolina, is hoping to make a dent in these troubling MindStream staff aim to help students achieve these goals
statistics by looking at much more than just childrens weight. with targeted fitness, nutrition, and culinary education as well as
The academy is attempting to forge an innovative partnership counseling. Were not interested in quick fixes and dont focus
with a Missouri school district to expand its reach to more kids solely on weight loss, Travaglione says. Physical fitness and
nationwide. 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-
MindStream Academy: What Its About confidence and self-management skills. We want our students
MindStream Academy, a full-service boarding school, is in to take the skills theyve learned here and maintain their success
many ways like your typical high school, fully credentialed to for life, which is why our program is so experiential in nature.
offer academic coursework to students of all levels. Yet its What kinds of skills are these kids learning? Stress man-
designed specifically for kids whose health, future, and very agement, gardening prowess, and cooking basics to start. Our
lives are on the line due to obesity and its attendant physi- boarding program for teens requires a semester minimum,
cal and psychological burdens, says MindStream Academy as it takes about four months for behavioral changes to stick.
Founder and CEO Ray Travaglione. In that time, our students learn to better manage stress; to be
In addition to their regular coursework, MindStream stu- mindful; to garden; cook fresh, delicious foods; enjoy moving
dents are taught the basics of nutrition, cooking, and fitness in their bodiesperhaps for the first timesocial and emotional
an attempt to get to the root of their weight issues and address well-being; and to appreciate the great outdoorsoverall
them for the long term. Their instruction ranges from neuro- becoming more grounded to the earth, Travaglione says.
biofeedback to gardening, psychological counseling to the care To address whats at the core of the teens weight issues,
of horses, and from lengthy bike rides to the preparation of MindStream staff use experiential therapies, such as equine-
wholesome, gourmet meals, Travaglione explains. assisted psychotherapy and neurobiofeedback, which are
He says the idea for MindStream Academy came from his designed to better reach children by offering counseling in a
work with children who are among the fittest for their age more fun, solution-focused, and nonthreatening way than tradi-
group: athletes. My background is in passion-based learn- tional one-on-one therapy.
ing for teens. Beginning with student athletes, I created pro- Even students families get in on the action. Our students
grams that provided the opportunity to develop their skills and families participate in our program through weekly coun-
test them against their peers, founding both Hank Haney Inter- seling sessions via Skype, nutrition education, and weekend
national Junior Golf Academy and the International Junior Golf workshops so the changes that are made at MindStream will
Tour, where many of the young PGA and LPGA players have continue at home, Travaglione says, adding that by support-
either attended or competed, he explains. To accommodate ing the whole childand not just focusing on weight losshe
our students training schedule, I then created a school that hopes to put students on a path of lifelong health and wellness.
views pursuing a passion as important as core academics: Her-
itage Academy. Nutrition Nuts and Bolts
As Travaglione became more aware of obesitys increas- MindStream bases its nutrition program on what it calls the
ing stranglehold on todays youths, he decided he had to get FLOW concept (Fresh, Local, Organic, Whole food style and
involved. Obesity in our youth has the potential to bring this nutrition program), which Travaglione says gives importance
country to its knees in a very short period of time, and I could to the following principle: Meals prepared with seasonal, farm-
not stand idly by and allow this to happen, he says. I decided it fresh, local and regional wholesome ingredients taste better
was time to do something to turn the tide on this epidemic and and, when eaten in appropriate quantities, will lead to optimum
founded MindStream Academy. weight and wellness.

january 2013 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 classes follow a 16-week syllabus, theyre also redesigned
curriculum. Steinberg and MindStreams chef work hard to to incorporate popular topics, which the kids may discuss
make all choices healthful and kid friendly. during class time.
The majority of foods served are made from scratch, In addition to nutrition basics, the classes hit on topics such
including dressings and sauces; grains/breads are whole as the importance of portion sizes, how to make good choices
wheat; fruit is served with breakfast; and salads are served when eating out, healthful substitutes for recipes, and how
with lunch and dinner, she says. Foods are minimally pro- to navigate the grocery store and decipher food labelsall
cessed and contain very little sugarunder 6 g. Beverage intended to give students a well-rounded knowledge base of
choices are water and milk. The kids drink water all day long what it will take to continue their healthful habits at home.
to stay hydrated. Fitness: Students are enrolled in a fitness program to get
them movingfor life. Staffed by certified personal trainers as
Targeted Education well as dance, martial arts, Zumba, and yoga instructors, the
Not only are students served the healthiest and freshest foods program is designed to get students to improve overall body
available, theyre also taught how to integrate various culinary movement and learn to enjoy it.
skills, nutrition tips, and fitness into their day-to-day lives. To fuel their desire toward fitness, weve created a move-
Culinary skills: Students learn how to prepare the types of ment playground, Travaglione says. Its this same belief that
foods they eat at MindStream by participating in culinary demos correct movement is the backbone of a lifelong commitment to
that are conducted once or twice per week. The kids learn fitness that has inspired us to focus on body weight-driven exer-
hands-on how to make their own meals and healthful desserts. cise. We believe so strongly in body weight movement that there
The demos have been a great hit with the kids, Steinberg says. are no traditional exercise machines at MindStream Academy.
The culinary education program begins from the ground According to Travaglione, MindStream students define their
up, Travaglione says, noting that at the academy students learn own fitness path, as all fitness regimens are individualized.
about food from its true beginnings: the earth. Students have Our four-phase program is based on the values we gain from
the opportunity to assist in gardening fresh plant foods grown initial fitness evaluations, he explains. Training is based off of
on site, harvesting ingredients for the kitchen, and working ones own baseline, and a students current fitness level helps
hands-on side by side with our chefs. determine his or her program, pace, and progression. As fit-
Through this hands-on experience, MindStream aims to give ness level increases, so does the pace of the program and the
students the tools they need to prepare simple, delicious, fresh, difficulty of the activities.
and healthful meals after their return home. The biggest difference between MindStreams approach
Nutrition: According to Steinberg, students attend two- compared with most weight-loss programs may not be in what
hour-long nutrition classes once per week, which always are theyre doing but in what theyre not doing, which is anything too
taught by a registered and licensed dietitian. The classes are extreme. What makes our program so unique is that theres
lecture type but also include student participation, classroom nothing extreme about what were doing; weve just brought stu-
discussion, and hands-on activities, she says. While the dents back to the basics, Travaglione says. They have put down

44 todays dietitian january 2013

their electronics, developed a relationship If these kids drop out, if they dont realize their fullest poten-
with themselves, their bodies, and the world tial, if they remain in poor health, if they die before their life
around them, and as a result are achieving begins, we all lose, he adds. The best economic stimulus we
goals they never thought possible. can do is get these kids healthy.
He explains that while under some To ascertain which kids in the school district are best
weight-loss programs, such as those pop- suited for the MindStream program, the staff looks at more
ular on TV, participants might endure than students BMI. The selection criteria is based on a vari-
severely restrictive diets of 600 kcal or ety of assessments performed by members of our counseling

fewer to achieve dramatic results. Trava- team, academic program, admissions officers, the students
glione says MindStream students achieve guidance counselors, and other relevant advocates,
similar results but not in such an extreme Travaglione explains.
atmosphere. Under the current partnership, the school district can offset
Still, while the scale tells a compelling a portion of the cost of tuition ($28,500 per semester, and most
story, Travaglione says perhaps the most students attend for one semester). Primarily, this is done
significant change MindStream students through the collection of average daily student attendance while
undergo is related to their mental health, they attend MindStream and reporting this to the State Depart-
which can have a far more lasting effect: ment of Elementary and Secondary Education for state fund-
They arrive feeling despondent, and they ing, Travaglione says. Parents, corporate partners, private
leave feeling like a new person. The changes that are made donors, and the School District Foundations all participate in
here arent skin-deep. There are tremendous shifts in personal contributing money that helps offset the cost of tuition.
responsibility, self-esteem, healthful risk taking, and a sense of Rather than waiting on the world to change, MindStream
hope through accomplishing tremendous goals. gives these kids the world as it should bea world that leads
When our students go home, theyre maintaining their to health and away from bullying and ridicule, Katz says. Its
weight loss, and some have continued on their weight-loss as much about community and solidarity as it is about fitness,
journey, he adds. Students report better grades, being more nutrition, and academics. It is, in a word, extraordinary. The
socially outgoing, and embrace their role as a healthful lifestyle true beauty of this better world is that it imparts a skill set the
ambassador. kids take back with them to the world as it is, making them far
better able to deal with it.
Branching Out MindStream also gives the kids skills they can pay forward,
While MindStream is satisfied with the success its students he adds. They can help others with what they learn there.
are achieving, it wants to effect change in more childrens lives. MindStream isnt about giving kids a better BMI; its about giving
Its hoping a new partnership with Independence School District kids both the will and the way toward a better life.
will help it do just that. And so far, results are promising. According to Travaglione,
This semester were piloting a direct relationship with a 13 Independence School District students attended Mind-
public school district, Travaglione says. Essentially, Mind- Stream during the first semester of its partnership. At press
Stream is taking in a cohort of kids whose obesity/metabolic time, those students had collectively lost more than 500 lbs
and psychosocial problems are too complex for a public school and gained much more. Their self-confidence is through the
to handle. This potentially frees up resources in the public roof. Theyre performing better academically, loving the cook-
school district while MindStream helps these kids turn their ing demos, and are preparing to return home as a community
health and lives around so they can return as ambassadors of resource and motivate other kids to get healthy and fit, he says.
what theyve learned and pay it forward. This is great news for these teens but also good news for
The idea for the partnership came from the collaboration students struggling elsewhere across the country, as Mind-
of Travaglione and two others: Jim Hinson, superintendent of Stream has more school district partnerships currently in
the Independence School District, and noted prevention expert the works.
David L. Katz, MD, MPH, FACPM, FACP, director of the Yale Were at various stages of replicating this partnership in
University Prevention Research Center. We saw this unique South Carolina, Florida, Mississippi, Ohio, New York, and Ken-
opportunity to partner and help obese kids in his district, and tucky, Travaglione says, and we plan to do so in every state
the rest as they say is history, Travaglione says. and school district in the country.
Designed to provide the promise of a better quality of life and
longevity for students in need, Travaglione hopes partnerships Juliann Schaeffer is a freelance writer and
such as this one will eventually help turn the tide on this epi- editor based in Allentown, Pennsylvania,
demic and turn our countrys future around. and a frequent contributor to Todays Dietitian.

january 2013 45


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

AUTISM SPECTRUM is considered the classic form of autism. Patients usually have
significant delays in language, social skills, and the ability to
DISORDER communicate. Some have unusual behaviors and interests, and
Research Suggests Good Nutrition have a measurable intellectual disability.
May Manage Symptoms The second form of autism is Aspergers syndrome, usu-
ally a milder form of autism. Patients still have delays in social
By Dawn Privett, RD, LD, CLT
abilities and communication skills, and have unusual behav-
Decades ago, autism spectrum disorder (ASD), a group of iors and interests.4 Many individuals have a specific interest
developmental disabilities in which patients have significant that encompasses much of their time and thought. People with
social, communication, and behavioral difficulties, was consid- Aspergers may spend much of their time devoted to a hobby
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. LEARNING OBJECTIVES
The prevalence of ASD among adults and children has sky- After completing this continuing education activity,
rocketed over the last several years. Much more research on nutrition professionals should be able to:
the etiology of the disorder and the different ways to treat and 1. Define the three types of autism spectrum disorder
manage it has become available. Today theres evidence show- (ASD).
ing how nutrition therapy can play a significant role in manag-
ing various symptoms that prevent ASD patients from living 2. Assess the various problem-eating behaviors associ-
productively. ated with ASD.
This continuing professional education course will define 3. Develop strategies to eliminate problem-eating
ASD, discuss its prevalence and possible causes based on the behaviors.
latest research, and evaluate the critical role good nutrition
may play in helping individuals function optimally. Dietitians will 4. Employ the various nutritional therapies to treat ASD
learn about the various nutrition therapies available and be able patients.
to apply them to practice.

46 todays dietitian january 2013

(eg, trains, computers). They usually dont have issues with lan- such as a urinary tract infection, in the second trimester has
guage skills or intellectual development. In fact, many are intel- been found to increase the risk of ASD by 40%.13 Recently,
ligent, especially when it comes to their own special interests. researchers examined inflammatory disease as a possible
Some experts liken patients with Aspergers to little professors cause of autism and found that it could possibly contribute to
in their areas of interest; they can have near genius IQs. the etiology of the disorder.14
The third form of autism is pervasive developmental dis-
order, not otherwise specified, or atypical autism. These indi- Problem-Eating Behaviors
viduals meet only some of the criteria for classic autism or While the medical community may not have identified the
Aspergers. They have fewer, milder symptoms and may exact causes of ASD, much has been learned about the chal-
experience delays only in the areas of social skills and lenges ASD patients face that often lead to poor diet qual-
communication.4 ity. These include problems with sensory processing, eating
behaviors, and feeding disorders. Its estimated that 46% to
Current ASD Statistics 89% of patients with ASD experience some kind of problem-
The number of children diagnosed with ASD has increased eating behavior.15 Some feeding difficulties revolve around
almost tenfold in the last 40 years.5 Currently, one in every 88 changes in routine. For example, patients with ASD may
children is diagnosed with ASD.5 When broken down by gender, refuse to eat unless they sit in the same place at the table,
five times more males (one in 54) than females (one in 252) are eat on the same dishes, use the same tablecloth, and eat the
affected.5 These statistics indicate that ASD affects more than same foods daily.15 The slightest change in routine can cause a
2 million people in the United States and more than 10 million tantrum or result in the refusal to eat.
worldwide.4 According to the organization Autism Speaks, ASD Other issues may occur in the area of sensory processing.
affects more children than diabetes, AIDS, or cancer combined.5 For example, if children with ASD are hypersensitive to sounds,
The increase in diagnoses may be due in part to better diag- they may not want to eat in a noisy area or with others engaged
nostic tools, but many believe environmental toxins and genet- in conversation. If they have visual sensitivities, they may accept
ics hold better clues to the increase in prevalence, although this foods only of certain colors. They also may not be able to eat
hasnt been proven. foods that are touching each other on their plate.
Some children are sensitive to the way foods feel in their
Link Between ASD and Environmental Toxins mouth. They may avoid crunchy foods or foods that have a slick
No specific environmental toxin has been identified as the mouthfeel. The way food smells can cause similar reactions,
cause of autism, but research to determine which chemicals and there are instances in which children may not recognize
may be culpable is under way. Its been proven that a fetus is certain tastes but can distinguish between others.
vulnerable to environmental chemicals during development. A study by Benetto and colleagues showed that children
Examples of chemicals that, in the past, have been shown to with ASD were less able to accurately identify sour or bitter
harm fetal development include organophosphate insecti- tastes but could recognize salty and sweet tastes.16 This study
cides6 (eg, chlorpyrifos), mercury exposure,7 and heavy metals may shed light on why patients with ASD avoid several types of
(eg, lead).8 foods, such as proteins, but will usually accept foods in the car-
Its a widely held belief that people with ASD have diffi- bohydrate group.
culty eliminating toxic chemicals from their body. If this is the The best approach to solving problem-eating behaviors,
case, exposure to environmental contaminants could play according to Elizabeth Strickland, MS, RD, LD, author of the
a significant role in poor neural development or brain func- book Eating for Autism: The 10-Step Nutrition Plan to Help Treat
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 New Lower
Price! How to Earn 2 CPEUs
speculative. However, it continues to appear that genetics,
environment, and the interaction of a childs physical and
Read this article and select your answers for the examination.
psychosocial environment play an interrelated role in the Then visit our CE Learning Library at
possible causes and triggers of ASD. Such associations can to purchase access to complete the online exam and earn your
be seen in the high incidence of autism in twins and genetic credit certificate. For more information, call our continuing
siblings who have the disorder.9 education division toll-free at 877-925-CELL (2355) (M-F, 9 am -
Other suspected causes of autism include advanced parental 5 pm ET) or visit
age,10 low birth weight,11 and multiple births.12 A viral infection, Suggested CDR Learning Codes: 3000, 3010, 3100, 4000, 4150,
such as the flu, in the first trimester has been shown to triple 4160, 5000, 5070, 5080, 5180, 5390, Level 2
the odds of a child developing ASD, and a bacterial infection,

january 2013 47

Your Childs Autism, Aspergers, or ADHD, is to assemble a feed- Artificial preservatives: Studies have indicated that
ing team, a group of healthcare professionals consisting of a artificial preservatives may cause sensitive individuals to
physician, speech language pathologist, occupational therapist, experience headaches, behavioral/mood changes,21 or hyper-
behavioral therapist, and RD.17 A dietitian can evaluate the foods activity.22 So removing foods that contain these substances
the child agrees to eat for potential dietary deficiencies. He or may be beneficial.
she can watch the child and family during meal times to assess Artificial sweeteners: Aspartame, acesulfame-K,
habits that may be hindering food intake. An RD also can screen neotame, and saccharin have been known to cause headaches,
the medications the child takes that may have side effects that mood changes, nausea, vomiting, and diarrhea in the general
contribute to feeding problems. population.23
When discussing dietary recommendations with ASD
ASD and Food Additives patients or their parents or caregivers, also suggest that
Just as problem-eating behaviors can prevent ASD patients patients be screened for nutritional deficiencies that can result
from getting the nutrients they need, so can consistently con- from the medications they take. Some medications can affect
suming highly refined foods. Since highly refined foods may appetite and cause nausea, vomiting, constipation, hard stools,
contain artificial dyes and preservatives that could be asso- diarrhea, esophageal reflux, weight gain or loss, sedation,
ciated with aggravating behavioral symptoms in those with drooling, and sometimes dysphagia, all of which can compro-
ASD,18,19 suggesting the family eat natural, whole foods may be mise nutritional status. For example, if a child is constipated,
an important treatment intervention. 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
When discussing dietary not feel the need to eat even though he or she is hungry.

recommendations with ASD patients Supplementation

or their parents or caregivers, also Another aspect of ASD treatment involves supplementa-
suggest that patients be screened tion with multivitamins, omega-3 fatty acids, vitamins D and
B6, magnesium, and other nutrients. Beginning multiple sup-
for nutritional deficiencies that can plements at one time may impede the ability to determine
result from the medications they take. 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
Dietitians working with ASD patients can recommend elimi- in symptoms.
nating the following substances from an ASD patients diet if If the patient takes one supplement for several weeks and
they believe a sensitivity exists: experiences no improvements in symptoms, it means the
Food dyes and artificial colors: These additives have been supplement may not be helpful for that particular patient. If
linked to hyperactivity, breathing disorders, skin eruptions, improvements are seen, stopping the supplement for a week or
and gastrointestinal symptoms in non-ASD patients.18,19 Since so to determine whether symptoms return can be a good strat-
many ASD patients already have these symptoms, eliminating egy to gauge effectiveness. This process allows ASD patients
foods that contain these substances may be helpful to assess a to follow the least restrictive regimen possible while identifying
patients reaction. improvements in symptoms.
High-fructose corn syrup: One of the main concerns with
high-fructose corn syrup involves the manufacturing process. Multivitamins
Research has found that mercury, one of the environmental Most practitioners who work with ASD patients agree that
toxins that may be responsible for the increased prevalence of a good-quality multivitamin without artificial colors or flavors
ASD, is part of the refining process when making high-fructose can help offset limited dietary preferences and poor nutritional
corn syrup.7 Removing it from the diet whenever possible may intake. Finding the right multivitamin will depend on a patients
be a helpful suggestion. tolerance. Some will swallow a pill, while others will prefer a
Artificial flavorings: Monosodium glutamate (MSG), for liquid, gummy, or chewable form. RDs are in a perfect position
example, has been shown to cause headaches, muscle tight- to determine whats acceptable and meets each patients needs.
ness, numbness or tingling, weakness, and flushing in people
who are sensitive to it.20 Because of these known potential side Omega-3 Fatty Acids
effects, it may be appropriate for ASD patients to avoid MSG as Research has shown that adding omega-3 fatty acid sup-
a precautionary measure. plements to ASD patients diets may provide many benefits.

48 todays dietitian january 2013

Omega-3s are critical for brain development and proper neural vitamin D during pregnancy is imperative. In supplement form,
function. Multiple studies have shown imbalances in the ratio the Recommended Dietary Allowance (RDA) is 600 IU. How-
of omega-3 to omega-6 fatty acids in the bloodstreams of ASD ever, if blood work shows a pregnant woman is deficient, a plan
patients.24-27 Obtaining adequate amounts from food alone may for increasing her vitamin D level must be directed by her phy-
be difficult because of the limited number of foods they may sician, who may prescribe doses much greater than the RDA.
eat. For example, some children with ASD wont eat cold-water This applies to nursing mothers and children with ASD as well.
fish (eg, salmon, tuna), and some parents wont add fish to their
childrens diet because they believe it contains mercury that Vitamin B6 and Magnesium
may exacerbate ASD symptoms. Still, many parents do give Vitamin B6 and magnesium supplementation also are used in
their children omega-3 supplements.28 treating ASD patients. One way to boost intake is in the form of
Some practitioners recommend 1.5 g/day of omega-3 fatty a multivitamin that contains both at US Reference Daily Intake
acids for most pediatric patient populations.25 According to standards. Some studies have shown improvements in behav-
research, children with ASD who take omega-3 supplements iors, such as increased speech, decreased aggression/temper
have less anxiety and aggression, decreased hyperactivity and issues, better eye contact, increases in IQ, and the ability to
impulsivity, longer attention spans, and improvement in lan- interact socially, with vitamin B6 and magnesium supplemen-
guage development, reading, and spelling skills.27,29-31 Most tation.35 Other studies, however, have shown that high-dose
omega-3 supplements are made from fish oil, so its impor- pyridoxine supplements can cause peripheral or sensory neu-
tant to ensure theyre free of mercury. (The label will indicate ropathies,36-37 and larger doses of magnesium can cause gas-
mercury-free processing.) Because oils can become rancid, trointestinal upset and diarrhea.
its best to use supplements before their expiration date. Some
supplements contain added vitamin E as a preservative to Other Supplements
improve shelf life, while others are bound with dietary calcium Glutathione, which can be used in ASD treatment, enables
to preserve the oil at room temperature. the body to detoxify and protect itself against oxidative
If patients complain of stomach upset or fishy burps but dont damage.38 Moreover, dimethylglycine is touted to improve lan-
experience this when they eat fish, question the freshness of guage skills and the ability to make eye contact. However,
the supplements. Patients may need to keep the supplements theres little evidence showing that either alleviates symp-
in the refrigerator so they stay fresher longer. toms.39-40 More research is needed to show efficacy of some of
the current supplements being used.
Vitamin D
Several studies suggest a direct link between low vitamin Probiotics, Antifungals, and Digestive Enzymes
D (25-hydroxyvitamin D) levels and the risk of ASD since vita- Probiotics and antifungals are common treatments for the
min D regulates the immune system. Research shows that abdominal pain, bloating, gas, constipation, gastroesopha-
children are at risk of ASD because of their bodys inability to geal reflux disease, nausea, vomiting, and diarrhea that many
identify foreign invaders and eliminate toxic substances and ASD patients experience. No conclusive evidence is available
have an even higher risk of developing the disorder if theyre to explain why these digestive symptoms are common in ASD
vitamin D deficient. patients, but the use of probiotics has provided relief of these
Vitamin D protects against DNA damage and can help repair symptoms for many of them.
damage once its occurred. (Its role in reducing damage in the The National Center for Complementary and Alternative
case of environmental toxins is being investigated.) In addi- Medicine defines probiotics as live microorganismsusually
tion, vitamin D may reduce oxidative stress, a hallmark of ASD, bacteria, but they also can include microbes such as yeast
and lower the number of inflammatory cytokines present in the that people can ingest to increase the population of desirable
brain, which have been associated with the disorder.32 bacteria in the gut. Antifungals inhibit the growth of a fungus
According to John J. Cannell, MD, founder and execu- or destroy it. Theyre used in the treatment of Candida albicans,
tive director of the Vitamin D Council, the prevalence of ASD a fungus frequently reported as the culprit when a yeast infec-
increases in regions of greater cloud cover and rainfall.33 tion is present. It can cause itching and burning of the mucous
Studies have shown there are more ASD cases in children born membranes, skin eruptions, and imbalances in the overall
between October and March.34 Research suggests this may be health of the gastrointestinal tract.
due to the lack of sunlight exposure. Digestive enzymes are substances that help break down
The body produces vitamin D when the skin is exposed to large macromolecules in foods to smaller substances to
the suns ultraviolet B rays, but during the cooler months of the facilitate their absorption. Examples of digestive enzymes
year, the sun isnt out long enough for pregnant mothers to get include proteases that break down proteins or lipases
ample exposure. Ensuring women get adequate amounts of that help break down fat. If a dietitian suspects a patient

january 2013 49

is experiencing inadequate digestion, digestive enzymes sensitive. Their immune system identifies these foods and
may help. In some cases, digestive enzymes may aid in the chemicals as foreign invaders, causing the immune system to
removal of toxic compounds from the gut.17 release mediators to fight off the invaders.
Some of the mediators released include histamine, prosta-
Elimination Diet Therapy glandins, leukotreines, cytokines, and peroxides. These media-
The elimination diet is another option that has shown prom- tors have been shown to cause reactions such as inflammation,
ise in treating ASD and involves removing certain foods from diarrhea, pain, intestinal cramping, constipation, headache, and
the diet for a period of time to determine whether theyre caus- pain receptor changes. Studies have shown enhanced proinflam-
ing symptoms of food allergies and intolerances. Research has matory cytokine production is present in patients with ASD.44-47
shown that eliminating gluten and casein from the diet of ASD Reactions to certain foods and chemicals also can cause the
patients can alleviate symptoms such as behavior problems release of the brain neurotransmitters dopamine and sero-
and poor cognitive and social functioning.41 tonin. Dopamine appeals to the sense of reward and enjoyment,
There are several theories as to why the elimination diet may and plays a role in addictive behavior. Serotonin contributes to
be beneficial. One hypothesis is that ASD patients cant digest feelings of well-being and happiness.
gluten and casein, causing the formation of the peptides gluteo- When dopamine and serotonin are released as a result of
morphin and caseomorphin and their absorption into the blood- ASD patients ingesting foods and chemicals to which theyre
stream because of increased gut permeability, or leaky gut sensitive, they may experience less pain, brain fog, or inabil-
syndrome. These two peptides, which appear to have a chemi- ity to focus and concentrate. According to certified LEAP ther-
cal structure similar to opiates, can cross the blood-brain bar- apists, ASD patients also may feel euphoric after ingesting
rier and cause symptoms such as delayed social and language a reactive substance or stop throwing a tantrum after eating
skills, and withdrawn behavior.42 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,
The elimination diet is another and other immune-related health issues and allow for more
variety in the diet for better nutrition.
option that has shown promise in
treating ASD and involves removing What Lies Ahead
certain foods from the diet for a So what does the future hold for individuals with ASD? While
theres no concrete answer to this question, we know RDs can play
period of time to determine whether
a huge role in the management and treatment of ASD symptoms.
theyre causing symptoms of food RDs ability to analyze diets for nutritional deficiencies can
allergies and intolerances. 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-
There are concerns about the use of a gluten-free/casein- tive and social functioning. RDs are the best source for provid-
free diet because its planning requires a skilled professional ing accurate and up-to-date information on supplementation,
who understands the complexities of elimination diets and the elimination diet therapy, and current research on new nutri-
restrictions of appropriate foods. The exclusion of wheat and tional approaches.
milk puts an ASD patient at risk of nutrient deficiencies in cal- More and more patients will depend on dietitians as the
cium, protein, vitamin D, folic acid, and B vitamins. And studies source of information that will enable patients to live productive
have found that diets lacking gluten and casein raise the risk of lives. Dietitians with the passion to work with this challenging
decreased bone density and stunted growth.43 However, RDs can segment of the population will be a much-needed resource in
introduce other foods into the diet as well as provide advice on the dietetics community in the years to come.
nutritional supplements to compensate for low nutrient intakes.
A more complex elimination diet that some specially trained Dawn Privett, RD, LD, CLT, is a freelance writer and owner of
dietitians use is called the LEAP (Lifestyle, Eating, and Per- Privett Nutrition Services in Kansas City, Missouri.
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- For references, view this article on our website
ator Release Test, which shows reactions to multiple foods at
and chemicals. These reactions involve the immune systems
of patients who ingest foods and chemicals to which theyre

50 todays dietitian january 2013

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
a. Multivitamins
b. Omega-3 fatty acids
c. Vitamin D
d. Glutathione

Take this exam by visiting our CE Learning Library at

january 2013 51


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
ZINC AND INFLAMMATION would suggest that we can override the age-related deficits
Age-Related Zinc Deficiency May Contribute by supplementing with zinc, according to Fung.
to Chronic Disease Risk
Study Details
By Marie Spano, MS, RD, CSCS, CSSD
In the in vitro cell model, human monocytes were grown
A recent study published in the Journal of Nutritional Bio- in zinc-deficient or -adequate media for up to 14 days. Mac-
chemistry found a biological explanation for age-related rophages were then treated with 0, 10, or 100 ng/mL of LPS,
reductions in zinc status that may lead to impaired immune the major structural component of the outer wall of gram-
system functioning and systemic inflammation, which are negative bacteria that initiates inflammatory responses. Cells
contributing factors to chronic diseases. The study, which grown in zinc-adequate media had a significant decline in
used cell cultures and a mouse model, suggests that improv- zinc status after exposure to LPS. However, cells grown in
ing zinc status through diet and supplementation may be a viable zinc-deficient media had significantly lower zinc status both
strategy for reducing the risk of inflammatory diseases. pre- and post-LPS exposure compared with those grown in
When the body has insufficient access to zinc, its hit on zinc-adequate media. In addition, zinc deficiency was associ-
many levels due to the many ways in which zinc typically func- ated with an increase in age-related inflammation as mea-
tions to protect the body, explains Ellen B. Fung, PhD, RD, sured by expression of tumor necrosis factor-alpha and
CCD, an associate research scientist at Childrens Hospital interleukin-1-beta, cytokines that are important mediators of
and Research Center in Oakland, California. First, zinc plays the inflammatory response.
a significant role as an antioxidant in the body. Therefore, in a In the animal model, mice aged 2 to 26 months were fed a
zinc-deficient state, there will be an excess of oxidants pres- standard rodent diet, a zinc-adequate diet (30 mg/kg of zinc),
ent, leading to increased DNA damage. In addition, zinc is or a zinc-supplemented diet (300 mg/kg) for three weeks. Age-
a cofactor for RNA and DNA polymerases, which aid in the related declines in immune cell intracellular zinc content were
usual repair mechanisms. When these systems dont function associated with an increase in markers of inflammation. In
properly, there will be increased damage. Finally, zinc aids in addition, age-related environmental changes in gene expres-
modulating DNA repair and damage proteins. ... In a deficient sion led to alterations in zinc transport mechanisms, including
state, these systems also are in a state of disarray and lead to an increase in DNA methylation and histone modifications.
increased DNA damage. What leads to age-related changes in zinc status? With
Researchers from Oregon State University examined the age, the ability to absorb and utilize zinc is compromised,
effects of zinc deficiency and age on inflammatory responses though we dont know why it isnt well absorbed, notes Emily
in both a cell culture model and an aged mouse model. One Ho, PhD, lead study author and a micronutrient expert at
aspect of the study compared groups of mice fed two different Oregon State University.
amounts of zinc in their diets. The group receiving zinc sup- Making matters worse, many older adults dont consume
plementation showed fewer age-related increases in markers enough zinc through their diet or supplements. According to
of inflammation. Though inflammation is essential for tissue National Health and Nutrition Examination Survey (NHANES)

52 todays dietitian january 2013

data from 2001-2002, 30% of men and 36% of women over the zinc from animal foods due to phytates that bind zinc and
age of 71 consume less than the Estimated Average Require- remove it from the body.6
ment for zinc.3 Even those who consume supplements may still
fall short. NHANES III data found that 35% to 45% of elderly Meeting Daily Requirements
adults had inadequate dietary intakes of zinc, and even with a The rapid growth of the older population makes preventing
combination of diet and supplement use, 20% to 25% still fell age-related diseases a paramount concern. And if the results
short on their zinc intake.4 of this study prove any indication in humans, honing in on zinc
Additionally, data from NHANES III (1988-1994) found that status may be particularly important as a measure of preven-
older adults (aged 60 or older) from food-insufficient house- tion. Age-related epigenetic decline in zinc status may contrib-
holds have significantly lower intakes of zinc (less than 50% ute to both impaired immune system functioning and chronic
of the Recommended Daily Intake) compared with those from inflammation and, subsequently, related health problems.
food-sufficient households,5 suggesting that access to food Ho recommends seniors take a multivitamin that contains
also may be a factor in zinc intake. the Recommended Dietary Allowance (RDA) of zinc. Zinc is a
Sara A. Blackburn, DSc, RD, an associate professor of clini- great antioxidant. It helps with repair systems within the body.
cal nutrition at Indiana University-Purdue University Indianapo- Zinc is involved in a lot of the processes that fix DNA, says Ho,
lis, has observed this pattern of low zinc intake in older people. who believes future research should examine biomarkers for
Ive seen zinc-poor diets in many adult patients with a chronic zinc deficiency and help determine whether the RDA for zinc is
disease such as diabetes, she says. adequate for the elderly.

How Much Zinc? Marie Spano, MS, RD, CSCS, CSSD, is a freelance writer
If a persons ability to absorb zinc declines with age, should and owns a sports nutrition and nutrition
he or she consume more of this mineral? We dont have a communications consulting company.
great biomarker for zinc deficiency in humans and therefore
just meeting the DRI [Dietary Reference Intake] is a good place References
to start until more research answers this question, Ho says. 1. Perry VH. The influence of systemic inflammation on inflam-
In addition to ensuring adequate intake, Blackburn sug- mation in the brain: implications for chronic neurodegenerative
gests that a thorough physical examination be conducted by the disease. Brain Behav Immun. 2004;18(5):407-413.
appropriate physician, paying particular attention to nonheal- 2. Hansson GK. Inflammation, atherosclerosis, and coronary
ing wounds and the skins appearance in case there are signs artery disease. N Engl J Med. 2005;352(16):1685-1695.
of zinc deficiency. 3. Moshfegh A, Goldman J, Cleveland L. What We Eat in
Fish and meat are among the top sources of zinc. The bio- America, NHANES 2001-2002: Usual Nutrient Intakes From Food
availability of zinc in some plant-based foods is lower than 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
FOODS HIGH IN ZINC7,8 Third National Health and Nutrition Examination Survey. J Nutr.
Raw oysters (Pacific), 3 oz: 14.1 mg 5. Dixon LB, Winkleby MA, Radimer KL. Dietary intake and
Baked beans, canned with pork and tomato serum nutrients differ between food-insufficient and food-
sauce, 1 cup: 13.5 mg sufficient families: Third National Health and Nutrition Examina-
tion Survey, 1988-1994. J Nutr. 2001;131(4):1232-1246.
Beef, chuck roast, lean only, fat trimmed,
6. Institute of Medicine Food and Nutrition Board. Dietary Ref-
braised, 3 oz: 7 mg
erence Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium,
Crab, King Alaskan, cooked (moist heat), 3 oz: 6.5 mg Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vana-
Baked beans, canned, plain or vegetarian, 1 cup: dium, and Zinc. Washington, DC: National Academies Press; 2001.
5.8 mg 7. Dietary supplement fact sheet: zinc. National Institutes of
Health Office of Dietary Supplements website. http://ods.od.nih.
Beef patty, 95% lean, broiled, 3 oz: 5.3 mg
Lobster, cooked (moist heat), 3 oz: 3.4 mg 8. USDA national nutrient database for standard refer-
Pork loin, lean only, cooked, 3 oz: 2.9 mg ence. United States Department of Agriculture Agricultural
Research Service website.
docs.htm?docid=8964. Last modified October 9, 2012.

january 2013 53


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
MOBILE APP MOTIVATORS playing skills, and/or the competition likely is intrinsically
New Tech Tools May Help Keep Clients motivated. A client who exercises to lose weight is extrinsi-
Exercising Well Beyond the New Year cally motivated.
In addition to providing an explanation of self-determination
By Jennifer Van Pelt, MA
theory in relation to exercise, a systematic review published in
Happy New Year! After counting down the seconds to 2013, the June 2012 issue of the International Journal of Behavioral
your clients probably started counting the calories they need Nutrition and Physical Activity found that intrinsic motivation
to cut and the number of pounds theyd like to lose. As is was more likely to result in long-term exercise adherence.
typical every January, New Years resolutions to lose weight, The New Years resolution to exercise is categorized as
exercise more, and eat healthier are made and then soon extrinsic motivation. Therefore, clients who use a New Years
broken. Gym owners, fitness instructors, and personal trainers resolution to initiate an exercise routineno matter the
all confirm that at the start of every new year, the gym equip- intended goalwill inevitably have problems maintaining moti-
ment and classes are mobbed, and training sessions are vation over the long term. The principle of intrinsic motivation
booked solid. By March, the crowds thin out considerably when can be applied to developing strategies to help clients succeed
busy schedules and lost motivation overshadow resolutions to with maintaining an exercise program. As Ive discussed in a
exercise regularly. previous column, encouraging clients to find an exercise activ-
ity they enjoy is a good first step toward exercise adherence.
Psychology Behind Motivation (See the September 2012 installment of Focus on Fitness,
Motivation and exercise adherence involve a complex Dance Fitness.)
interaction of an individuals personality, goals, and behavior Unfortunately, intrinsic motivation may be difficult to cultivate
choices. Researchers have sought to better define these fac- in some clients, particularly those who have self-esteem issues,
tors with the hope of improving promotional health messages to negative attitudes about exercise, or physical limitations. For
increase physical activity. example, even if a client enjoys dancing for exercise, feeling

54 todays dietitian january 2013

self-conscious in a dance class or lack- Striiv: A combination fitness
ing space at home may override intrin- tracker and mini gaming device cost-
sic enjoyment. Is it possible then to use ing approximately $100, the Striiv
extrinsic motivation to improve exercise fits into a pocket and tracks steps
adherence? walked and climbed each day. Clients
The introduction of high-tech fitness can meet a series of challenges and
gadgets and smartphone apps for fit- score points during the day based on
ness could provide extrinsic motivation the number of steps, stairs climbed,
for the long-term. Given our obsession miles walked, or time spent being
with being connected via wireless net- active. A walkathon feature connects
working, its reasonable to consider with Striiv, which will donate money on
that fitness gadgets and apps can be behalf of the client.
more successful extrinsic motiva-
tors than, for example, tracking calo- Fitness Apps
ries burned and pounds lost in a written miCoach: This training app is avail-
food and activity diary. able for free for iPhone, iPod touch,
For technophobic clients, using iPad, Android phones, and BlackBerry
technology to enhance motivation to devices. Clients get real-time audio
exercise can be as simple as exchang- coaching throughout a customized
ing daily text messages with a fitness workout they can vary each day. The
buddy who has similar exercise goals, app tracks time, distance, pace, and
signing up for motivational daily e-mails calories burned.
from a fitness website, or using an FitnessBuilder: Available for
online personal training service. For the iPhone, iPod touch, and Android
clients who always have their smart- phones, FitnessBuilder is a subscrip-
phone in hand and love technology toys, tion personalized workout app. Clients
the following gadgets and mobile apps can choose from a large library of
may be of interest to track their fit- instructional workout videos, design
ness activities, providing motivation for their own workouts by selecting a range
daily workouts and encouraging fitness of exercises from the library, connect
progress over time. with a live personal trainer, and use
fitness-tracking tools to measure their
Fitness Gadgets success weekly.
FitBit One: This fitness tracking
device is the size of a USB flash drive Tech Tools Galore
and costs $99.95. It tracks fitness data, These are just a few of the new fit-
such as steps walked or climbed, dis- ness gadgets and apps available for
tance, calories burned, sleep cycle, and clients beginning an exercise program
sleep quality, 24 hours a day, 7 days a or who require additional motivation to
week. The One also has a silent alarm continue a regular program. Many more
that gently vibrates to wake you up in the are available for advanced exercisers
morning. Data can be viewed via a cus- and athletes for a range of fitness activi-
tomizable dashboard and mobile app, ties, from strength and muscle building
which are both free. Progress is tracked to mapping running and cycling routes.
using charts, graphs, and other user- Linking a love of technology to exercise
friendly displays to help clients reach goals may provide the tech-savvy client
their goals. Moreover, interfacing with with the right motivation.
apps such as SparkPeople, MyFitness-
Pal, MapMyFitness, and LoseIt! is free. Jennifer Van Pelt, MA, is a certified
The FitBit One wirelessly syncs with group fitness instructor and healthcare
PCs, Macs, iPhone 4S and 5, third gen- research analyst/consultant
eration iPads, and iPod touch. in the Reading, Pennsylvania, area.

january 2013 55


The Essential Cancer Treatment Nutrition Guide & Cookbook includes recommendations for specific side effects or con-
By Jean LaMantia, RD, with Neil Berinstein, MD ditions (eg, dehydration, nausea, weight gain promotion), a
2012, Robert Rose variety of practical food and cooking tips, and suggestions
Softcover, 320 pages, $24.95 for adjusting the recipe to alleviate particular symptoms.
Many of the recipes can be made ahead of time, and instruc-
Cancer treatments create a spectrum of nutritional chal- tions on storage and reheating are given.
lenges for patients, their caregivers, and the dietitians who So-called survivor wisdom quotes from LaMantia are
advise them. The Essential Cancer Treatment Nutrition Guide scattered throughout the book, providing helpful insights
& Cookbook is an indispensable tool for any professional and adding a personal touch to this invaluable guide.
working with such clients. This detailed and authoritative
book, written by Jean LaMantia, RD, a cancer survivor, along Lenora Dannelke is an independent journalist who writes
with Neil Berinstein, MD, a practicing oncologist, underscores about food for numerous publications.
proper food and diet as a vital complementary treatment for
cancer patients at every stage of recovery. Healthy Eating, Healthy Weight for Kids and Teens
The first part of the book examines conventional cancer By Jodie Shield, MEd, RD, and Mary Catherine Mullen, MS, RD
therapies and their side effects and provides information on 2012, Academy of Nutrition and Dietetics
managing those side effects, from anemia and fatigue to Softcover, 288 pages, $21.95
diarrhea and heartburn, through diet. Another chapter
offers nutritional strategies for boosting the immune Appropriately addressing a
system, reducing inflammation, and creating a life-long weight issue can confound even
therapeutic diet to prevent cancer recurrence. the best and brightest, but its
Nondietary complementary therapies, such as homeopathy, particularly perplexing when
aromatherapy, and reiki, are outlined, with an emphasis on the children are involved. Yet one
importance of physical activity in addition to nutrition. Sample look at the statisticsan esti-
menus and advice on shopping and food safety also are provided. mated one in three American
Numerous charts, sidebars, and frequently asked questions children today is either over-
present a wealth of information in an easy-to-use format. weight or obeseshows many
The 150 recipes at the back of the bookdeveloped by kids are struggling. This book
LaMantia and six contributorsencompass everything from seeks to help.
breakfast dishes and entres to snacks and beverages. Written by dietitians Jodie
Ingredient lists include Shield and Mary Catherine
both standard US mea- Mullen and produced by the
surements and imperial Academy of Nutrition and Dietetics publishing arm, Eat
units for Canadian read- Right Press, Healthy Eating, Healthy Weight for Kids and
ers. The recipes, which Teens aims to provide parents with the knowledge and tools
focus on comfort foods to to wage warand winagainst whatever food issues their
tempt suppressed appe- children are facing.
tites, use easy-to-find To help parents determine whether their child has a weight
ingredients and uncom- problem that requires intervention, two introductory chapters
plicated directions. serve as required reading and help define what actually
Supplemental infor- constitutes a healthy weight. Here, topics such as whats
mation provided with normal for certain age ranges, what BMI is and what it
each recipe is a standout means, and how parents can best track a childs height and
feature of the book. Along weight are discussed. (Tip 1: Use a digital scale for accuracy.)
with a full nutritional The eight chapters that follow dont need to be read in
analysis, every dish order; each outlines a particular strategy that addresses a
specific problem. Parents are meant to scan the chapter titles creative dishes to your
to see which they might benefit from most before diving into repertoire.
them. For example, if Mom and Dad both work full time and, Readers of Cooking
due to work and a dozen after-school commitments, have Vegan will appreciate
trouble getting a dinner routine in order, often opting for fast the variety of cre-
food, then Chapter 3: Eat With a Plan might suit them well. In ative recipes and fla-
this chapter, the authors define in concrete terms what vors, and the way the
healthful eating actually looks like (with help from a Choose authors have demysti-
MyPlate illustration), then break it down even further with fied vegan ingredients.
kid-friendly tips on how to incorporate whole grains, dairy, Nutrition profession-
fruits, and veggies into a daily meal plan. The book provides a als will appreciate the
sample one-day menu to help parents see what theyre inclusion of a detailed
shooting for in terms of foods and serving sizes. and easy-to-read intro-
Other chapters provide strategies, addressing several duction on the vegan
all-too-common healthful-eating barriers that can prevent lifestyle, including an
kids from keeping their weight in check, such as watching abbreviated explana-
too much TV, drinking soda and other sugar-sweetened tion of vegan nutrition,
beverages, portion distortion, fast-food hang-ups, and picky a description of ingre-
eaters aversions to fruits and veggies. dients commonly used in vegan dishes, cooking tips, and
Backed by scientific research, the authors say these sample menus. Additionally, nutritional information is avail-
strategies also may help healthy-weight kids from ever able for every recipe, with more than just a macronutrient
having to deal with the unwanted physical and emotional breakdown provided.
dilemmas that come with being overweight or obese. To Cooking Vegan showcases a variety of dishesbreakfast
finish up this book, three weeks of sample menus (with foods, sauces, dips, salads, and sweet treatsand theres
healthful meal and snack ideas) serve as a great resource to something for everyone. I sampled the Fiesta Quinoa Salad
help parents practice their just-learned healthful strategies With Lime Dressing; Avocado, Grapefruit, and Chipotle
with fresh (and kid-approved) dinner ideas. Dressing; Thai Pasta Salad With Spicy Peanut Sauce; and
the Walnut, Olive, and Sun-Dried Tomato Tapenade. The
Juliann Schaeffer is a freelance writer and directions were easy to understand, clearly written and, as a
editor based in Allentown, Pennsylvania, novice vegan eater, I especially enjoyed the short description
and a frequent contributor to Todays Dietitian. that accompanied every recipe.
Readers should take caution and note the yield, as some
Cooking Vegan recipes make quite a large amount. They also should be
By Vesanto Melina, MS, RD, and Joseph Forest prepared that while most ingredients are common and read-
2012, Book Publishing Company ily available, I did have to purchase several oils and spices
Softcover, 224 pages, $19.95 that arent usually stocked in my pantry. These items were
available at my local grocer but were fairly costly; I suspect
Ill be the first to admit that when Cooking Vegan came across that had I gone to my local specialty store, these ingredients
my desk, I hesitated about agreeing to be a reviewer. Despite a would have cost less.
handful of half-hearted attempts by my husband in the past to But these minor considerations dont overshadow the
convince me we should become vegetarian, I remain fairly com- variety of unique ideas readers can find in Cooking Vegan.
mitted to my life as a carnivore. But with its underlying tone
that eating vegan (at least sometimes) is for everyone, Cooking Christin L. Seher, MS, RD, LD, is a dietitian, instructor,
Vegan is just as appropriately written for people like me as it is and nutrition consultant in northeast Ohio.
for those who are vegan. This collection includes recipes worth
trying for a diet with fewer animal-based foods or to add more

RD Clinic Allows RDs Lilys Sweets Debuts

to Streamline Their Practice Stevia-Sweetened Chocolate
A successful weight-loss program requires a nutrition pro- Lilys Sweets has introduced the
fessional to assess, diagnose, intervene, monitor, and evaluate first fair trade-certified stevia-sweet-
clients. Unfortunately, these tasks require a professional ened chocolate bars made with 55%
to spend a large percentage of their time doing data entry, cocoa. Lilys bars naturally contain
which takes away from working directly with clients. 25% fewer calories than other 55% dark
RD Clinic aims to change that. Designed for RDs who work chocolates sweetened with sugar. The
in hospitals and other healthcare facilities, private practice, 3-oz chocolate bars contain no added
or with HMOs to streamline their day-to-day work and client sugar, artificial ingredients, or GMOs
interactions, it includes health assessments, questionnaires, and have just 160 to 170 kcal per half-
medical records, detailed nutritional tools, physical activity bar serving.
analysis, documentation, webinars, video, communication The bars come in four flavors:
with clients, and medical billing. Original, Crispy Rice, Coconut, and
Its available for any device connected to the Internet. Almond.
In addition, it allows clients to track their information. They In addition, Lilys Sweets donates a
can search, write, e-mail, photograph, or even call a toll-free percentage of its profits to organiza-
number and the information will be saved in their journals. tions that support childhood cancer
Clients also can follow plans online and communicate with survivors and fighters.
their nutrition professional. For more information, visit
When clients initially call for an appointment, if they use
e-mail, an account is automatically created for them. They
receive instructions to use the applications and can start
tracking their information. The more information they enter,
the better. By the time theyre seen by the professional, all
the reports are already done. If the client doesnt use the In The Raw Expands With
Internet, the RD can enter their intake directly to do the
analysis and still save time.
Monk Fruit Sugar Substitute
All features are HIPAA compliant, and all data can be The In The Raw family of all-natural sweeteners has
printed and made available on cell phones and tablets, and expanded with the launch of Monk Fruit In The Raw, a
are delivered in multiple languages. The database of foods, zero-calorie sugar substitute with a natural taste. Monk
meals, and fitness plans is updated daily. It also interfaces Fruit In The Raw is ideal for individuals looking to cut
with existing electronic medical record systems to offer added sugars and also is recommended for those with
one location for all patient records. diabetes seeking sugar substitutes.
Theres no cost for patients to use the program, only for Monk Fruit In The Raw is made from monk fruit,
healthcare professionals. a vine-ripened fruit native to Asia. The product is
For more information, visit different from other monk fruit-based sweeteners
because it doesnt contain added table sugar, sugar
alcohols, or molasses.

Foods Alive Introduces Monk Fruit In The Raw

can be used in any recipe
Certified Organic Chia Oil that calls for sugar, used to
sweeten beverages, blended
Foods Alive brings chia right to your kitchen for a simple in yogurt and smoothies,
new way of introducing omega-3s to the diet. and put on cereal or oat-
Chia oil is derived from the seeds of the chia plant. It contains meal. Its available in sin-
more than 60% omega-3 fatty acids, one of natures richest plant gle-serve packets.
sources of essential fatty acids, and cell-protecting antioxidants. For more information,
The oil has no odor and a very mild flavor, so its easy to add to visit
smoothies, soups, or sauces or use to create salad dressings.
For more information, visit

58 todays dietitian january 2013

Manager Nutrition
Scottsdale Healthcare
Dietitian - Diabetes Education
Education and Experience
Scottsdale Healthcare, located in
Bachelors degree in Nutrition or Food
Science with completion of clinical dietitian sunny Arizona, is composed of
internship program or equivalent is required. two medical centers and a Connect
Certificates, Licenses, and Registrations community hospital, complete TO A CAREER THAT
Current State of Wyoming Licensed Dietitian with IP/OP and home health NOURISHES YOUR HEART

(LD) is required. services and more. This position Passion. Dedication. Knowledge. Motivation.
Experience. These are the impressive qualities
Registered Dietitian (registered by the
Commission on Dietetic Registration) is
manages the system-wide youll find in the Fresenius Leadership Team. We
Nutrition and Patient Service
provide our employees with the best of both worlds
required. the friendliness of a local organization and the
Current American Heart Association (AHA) department including Clinical stability of a worldwide organization. This creates
diverse experiences and challenging career
Basic Life Support (BLS) for Health Care
Providers is required. Nutrition, patient, staff and opportunities. When you join the Fresenius Medical
community education; enteral-
Care team, youll be welcomed into a company that
Certied Pump Trainer is preferred. is built on the philosophy that our employees are

parenteral nutrition delivery. our most important asset.
To apply, visit our website at
Registered Dietitians
Bring your multi-location, Positions Available Nationwide
healthcare system RD experience We offer a generous compensation and benefits

to Scottsdale2/9 V and enjoy package that includes medical and dental, 401(k)
Generate new business. Healthcare match, profit sharing, short and long term disability,
a career where World-Class
TD_WY_WyoMed.indd 1 1/2/13 1:21 PM tuition reimbursement, and a generous paid time
Vitalize existing client off program.
relationships. Patient Care puts the individual To discover the difference between a job and
Promote a greater first. We care for our patients as real job satisfaction, go to:
understanding of your industry. well as the people who work here

by providing a culture of respect

and compassion plus fantastic
ORDER REPRINTS! quality-of- life features like on-site Fresenius Medical Care North America is an Equal Opportunity Employer.

Reprints connect you with clients, students, child care.

and colleagues in an exciting, informative
way. Theyre the ideal tools for sales teams,
and they make great trade show handouts.
Learn more and apply online:
FNCE ISSUE Vol. 14 No. 10
Vol. 13 No. 10

Maga or N
zine ffor
Magazine trition
ufor Nutrition
he The
October 2011
October 2012

The Real
California Style!
Todays Dietitian
The Real weight gain. Twenty percent said that calories from sugars are Lustigs argument, however, is not about the consumption

The onSugar
most responsible. While 62% believed a moderate amount can of empty caloriesand biochemists have made the same
Investigates the Teeming
Fragrant, Flavorful,

Grea Salt
be part of a healthful diet and 61% said its not necessary to case previously, though not so publicly. It is that sugar has
completely eliminate Aftersugar to loselooked
weight, onlydata28% of believed unique characteristics, specifically in the way the human body
Health Benets
Sugar Debate recommendations. researchers at the 6,500 the historical evidence on the link between sodium, hypertension,

With all sugars (including

they concluded
and honey)
restriction couldnt
provenand based
corn syrup [HFCS],
that the cardioprotective
used by the body
on current
benetstable of
in the same
evidence. you can use
and cardiovascular
to answer
diseasethe fructose
if consumed
(CVD) riskinand
your clients in tough
it, that
some make
it singularly

Scoop way. Fifty-one

Shortly percent
after this of Americans
controversial are trying
meta-analysis to limit
hit the air- or avoid
waves, whenU.K.choosing
preventivefoods and beverages,
medicine experts quickly while 35% pay no
countered Is SugarTake
Professionals Really Dangerous?
these claims.
attention They reanalyzed
to sugar content.3 the same data and concluded in Probably to the dismay
Lustigs views of onconsumers,
sugar andmany health dietitians
bring toand light the crux of
a comment in the July 30 issue of The Lancet that the results of doctorsthe overwhelmingly
sugar argument, agreed with the
raising thefollow-up
question, conclusions to
is there proof that the

Todays Dietitian investigates our
Hits thecontrary to the claims by Taylor and colleagues,
support current public-health recommendations to reduce salt
Whats fueling the publics sugar fears? Consumers have
the controversial
negative impact Cochrane of review
sugar extends
ndings and
plans to change their sodium recommendations anytime soon.
say they
beyond its have no of empty

the sugar debate. intake in the whole population.

been hearing for years the stories linking sugar to hyperactiv-
Many in the medical community as well as the RDs inter-
Clearly these ndings are far out in left eld and do not
The concept that sugar is toxic simply has no credibility,
reect the overwhelming amount of strong scientic evidence
ity, diabetes, obesity, and other chronic diseases, says Jean-gathered says David M. Klurfeld, PhD, national program leader for the
The Great Salt Debate
viewed by Todays Dietitian agree with the U.K. researchers over decades that supports the fact that reducing
nie Gazzaniga-Moloo, PhD, RD, a national spokesperson for sodiumHuman
assessment. Nutrition
intake reduces bloodUSDA Agricultural
pressure, therebyResearch
reducing risk Service, who

Experts Support the Academy

also heard
is a vitalofnutrient
and Dietetics
required for the body
Bond Brill,connections
function Theyve
between sugar
in Prevent a andBrill
all says
edited a June
of cardiovascular
of the
of the Science
disease, Journal
on Dietary
nations of leading
Nutrition supplement
report. Sweeteners Containing Fructose.
of death,The State

Salt Restrictions
Cardioprotective Effects Healthier Frozen these conditions.
Second Heart Attack:I 8think Foods, many consumers
8 Weeks to Reverse are confused
Heart Disease. about She Theres
refers to one little doubt
such piecethat Americans
of evidence consume
to back up hertoo much sugar,

Yet while role
sugars essential in small
in disease amounts, consuming
development too much
and management. stance butin Prevent
we have a Second
no data Heart Attack.
to tell A recent
us how muchstudy is toopub- much for any
ByFoods Schaeffer saltThe
has led manyon
volume Americans to associate
the sugar-health the nutrient
debate turnedwith up aannotch lished in the April
health 2007 issue
endpoint we ask of BMJ concerning a group of
Center Stage unfortunately
when a recent
leading risk
wave of media
for heart
high blood
called onpressure,
the opinions a ofindividualsWalter
cutting back
with borderline
Willett, DrPH,
their salt
to highMD,
of thefound
risk of
of nutri-
9 Probiotic-Rich
Robert H. Lustig, MD, a professor of pediatrics in the division tion at the Harvard School of Public Health, says, There are
High blood pressure is extraordinarily common in the United heart disease by 25% and of dying of the disease by up to 20%.
of endocrinology at the University of California, San Francisco, problems with sugar due to adverse metabolic effects, but the
Beyond Yogurt
States, affecting approximately one-third of the adult popula- The researchers surmised that sodium acts directly on blood
whos a leader in the antisugar movement. Lustig has spoken idea that fructose is dangerousthe science doesnt support
tion, Brill says. Hypertension is a powerful and unequivocal vessel walls, stiffening them and making them more suscepti-
Dairys Role out at several recent nutrition conferences on the adverse ble to atherosclerosis.
independent risk factor for cardiovascular and renal diseases,
this. To only focus on sugar as the problem, the science isnt

in Improving
health effects
including coronary of sugar, including
heart disease, the Annual
stroke, and renal Nutrition
failure. & Health Another there. There
study, may beinsubtle
published metabolic
the February 2010differences
issue of The in the body
Despite majorand the Experimental
advances Biologyand
in the understanding meeting.
treatment with fructose.
New England Journal ofCutting
Medicine, back on sugar
concluded thatisifan important
everyone cut part of a
New Research Pressure School Nutrition Lustig reported
of hypertension over the at the
decades, the & Health
diseaseConfer- salt intake healthful
by justdiet, along with
a 12 tsp/day, therecutting
would be backcloseon to refined
100,000 starches and
Soy Lowers Blood ence in the
in theand
is a major
that fructose
health concern,
has doubled
an egregious
over theshe
in the United
30 years from CVD
fruit juice,
fewer heart
all wouldThe
by up
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to 92,000Heart
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Brill says (AHA)
of another
as sugar.
Scientific State-
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www.TodaysDietit itsAccording
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sucrose, and (WHO) estimates,
juice. The fructosi- piece ofmentevidence in her arsenal
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to Tell Clients About Combating

fication of our causes
million increases
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palatability. In light of suchthat
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excessiveBrill says shes siding
consumption ofwith
sugars the has been linked
quality foods Andhave
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added on thatpurpose.American withHeartseveralAssociation,
metabolic which recommends
abnormalities and alladverse
Americans health condi-

about 62% of strokes and 49% of heart attacks are caused by aim for consuming less than 1,500 mg of sodium per day.
Its used as a browning agent, Lustig said. tions. Though the mechanisms are unclear, relative to other car-
hypertension, according to Brill. Nutrition research scientist James J. Kenney, PhD, RD,
an you pass the salt? is a common He reported that our growing dependence on fructose has bohydrate sources, sugar intake appears to be associated with

Its an issue dietitians and doctors know well. Also well FACN, says he isnt surprised by the studys controversial nd-
question we hear at the breakfast, fueledisthe obesity and type 2 diabetes epidemics and has led ings,
to considering
increasedwhat triglyceride
ccording to the 1964 Walt Disney musical Fast forward to today, when Americans are consuming known part of the popular lifestyle prescription to help he callslevels, a known
the limited quality risk
of thefactor
datafor coronary
lunch, and dinner table each day. increased
Mary Poppins, just a spoonful of sugar helps even more of the sweet stuff.We According to the USDA, per patients ghtenergy
or preventintake, decreased
hypertension resting
and energy expenditure,
heart disease: hearthad
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to workand with.someGiven studies
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long termwith and increased the medicine go down. But while sugar may capita consumption of caloric sweeteners, mainly sucrose sodium of peoples intake

Experts Stand
there to get our food to taste just
Irrefutable hyperglycemia,
scientic evidence cardiovascular
supports the fact disease, and meta-
that reduc- how hard inflammation
it is for people and tooxidative
really restrictstress,
salt intake, to the
the AHA.
help the medicine go down, you dont hear and corn sugars, increased 39% right between
before wethe dig 1950s
in. Andand
we do
ing syndrome
sodium intake,in [ashumans.
well as] increasing potassium intake, failure of theWhile acknowledging
Cochrane review to that obesitydiets
nd low-salt is a multifactorial
reduce CVD con-

Get CE credits quickly,

anyone singing these praises anymore. 2000 to an average
this in of 152 lbs
addition to per year.
eating Peoplefoods
are nowand res-
Behind Salt
Instead, many Americans and those in the healthcare com- taurant
eating an average fare on30
of about a regular basis,per
tsp of sugar which experts
day, whichsay
his YouTube havelecture
a hit among
Sugar:the The
Bitter ts of
and total
which He says must
isnt surprising,
its likely
that Americans
he explains.
recent history of weight gain
actually re
in part to increased ect theofneed
intake added forsugars,
munity claim Sugar is toxic. Sugar causes obesity. contributes a is where most
whopping 476ofkcal
our per
2 comeswith
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Sugar makes you fat. Restrictions Butintake
the rise in sugar is all ofhas
sodium were eating
a growing really
aging our long-term cardiovascular health? Or is
of dam-
has received
for blood
utes aired a individuals,
than 2.6control
segment featuring
Brill says.
in hits
She says
as an
date. In April,
expert withonasugar and
better data
and60 Min- evenon the impact
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]
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
Blues by William Dufty exploded onto the sugar-busting attitudes about
July report in the Cochrane Database of System-
atic andalso
Reviews, health. Consumers
appearing were asked
simultaneously in the
So yearthe
article titled
Is Sugar
real story? Such
was featured
clients catch only
in a New
icting reports
story on the
Times saturated Americans
fat and salt
on LDL
in controlled
that added sugars
in a high
clinical intake
are consumed
and blood
of calories
he says.
pressure, in excessive
What these that offer little
scene. People were shocked to read which calorie sources (sugars, carbo-

Give You
ourr Job
Job Sear
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,
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basis foror allrestriction
salt sources)
at Sugar
the ready, isnt
youll need just an empty
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cle; its In
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the following much
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evaluate importgain than anyalter
and shouldnt other source
clinical of calories in an eating pattern thats
itself, Lustig was quoted as saying. Taubes wrote: within calorie limits.6
40 todays dietitian october 2011 october 2011 41
28 todays dietitian october 2012 october 2012 29

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january 2013 59


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 Researchers assessed participants health measures and
meetings, also recommended physical activity. dietary habits immediately after the programs concluded
The more traditional education program includes and then again three months later at the studys end.
general information about diabetes but with more Weight loss and improvements in HbA1c levels were
emphasis on nutrition and food choice: What are differ- similar for both groups at the six-month follow-up point.
ent types of carbohydrates and fats, and how many am I Smart Choice participants as a group lost more weight,
supposed to have? What should I look for when I read a an average of 6 lbs, than did the mindful eating group,
food label? What are healthful options when dining out? which lost an average of 3.5 lbs, but the difference wasnt
That was the traditional diabetes education program, significant when analyzed statistically, Miller says.
explains Carla Miller, PhD, an associate professor of HbA1c levels dropped in both groups as well between
human nutrition at Ohio State University and lead study about 0.7% and 0.8%. That was a clinically meaningful
author. We compared it to an intervention where mind- reduction in Hba1c, equivalent to what youd get on some
ful meditation was applied specifically to eating and food diabetes medications, Miller says. If the reduction were
choices. This intervention group didnt receive specific sustained over time, it would mean a dramatic reduction
nutrition goals. We said we want you to really tune into in complications associated with diabetes.
your body before you eat. Take a few minutes to assess Both groups also similarly reduced calorie intake and low-
how hungry you are and make conscious choices about ered their consumption of foods with a high glycemic index.
how much youre eating. Stop eating when youre full. Miller says that because nutrition education is important
We studied two very different approaches, and we to people with a new diabetes diagnosis, she sees the mind-
found they both worked, Miller says. ful meditation and eating option as a potential supplement
Participants were between the ages of 35 and 65 and to basic diabetes education. She also said that participants
had been diagnosed with type 2 diabetes for at least one adapted well to the concept of mindfulness even though its
year. To be eligible, participants had to have a BMI of 27 generally considered an alternative health practice.
or higher, indicating they were overweight, and a hemo- One of the things we were evaluating was how well this
globin A1c (HbA1c) reading of at least 7%. was accepted by people who had no experience with it. It
Study participants were randomly assigned to a treat- was very well accepted by participants in that group, and
ment group. Twenty-seven completed the mindful eating this tells us that people with diabetes have choices, Miller
program, and 25 completed the traditional diabetes self- says. The fact that both interventions were equally effective
management program called Smart Choices. Each inter- suggests we should let people choose. If mindful meditation
vention involved eight weekly and two biweekly 212 -hour is appealing and people think that approach is effective, then
sessions with trained facilitators. it very well could be the best choice for them.
The interventions took place over three months. SOURCE: OHIO STATE UNIVERSITY

60 todays dietitian january 2013

High-Carb Diet Associated With Colon Cancer Recurrence
Colon cancer survivors whose diets are heavy in complex explore which component of the Western diet is most respon-
sugars and carbohydrate-rich foods are far more likely to have sible for the increased risk of recurrence.
a recurrence of the disease than are patients who eat a better The study involved 1,011 stage 3 colon cancer patients
balance of foods, indicates a new study by Dana-Farber Cancer who had undergone surgery and participated in a National
Institute researchers. Cancer Institute-sponsored Cancer and Leukemia Group B
The connection is especially strong in patients who are clinical trial of follow-up chemotherapy for their disease.
overweight or obese, the authors wrote. More than 1,000 Participants reported their dietary intake during and six
patients with advanced (stage 3) colon cancer participated in months after the trial.
the study, one of the first to examine how diet can affect the Researchers tracked the patients total carbohydrates as
chances that the disease will recur. The findings are being well as their glycemic index and glycemic load and looked for
published online by the Journal of the National Cancer Institute. a statistical connection between these measures and colon
Although the results point to a potential hazard of a high- cancer recurrence.
carbohydrate diet for colon cancer patients, the take-home They found that participants with the highest dietary levels
message is not a conclusive eat less sugar, says lead author of glycemic load and carbohydrate intake had an 80% increased
Jeffrey Meyerhardt, MD, MPH. Our study certainly supports risk of colon cancer recurrence or death compared with those
the idea that diet can impact the progression of colon cancer, who had the lowest levels. Among patients who were overweight
and that patients and their doctors should consider this when or obese (BMI above 25), the increase was even greater.
making posttreatment plans, but further research is needed In light of our and others research, we theorize that factors
to confirm our findings. including a high glycemic load may stimulate the bodys produc-
Recent studies have shown that colorectal cancer survivors tion of insulin, Meyerhardt says. That, in turn, may increase the
whose diet and activity patterns lead to excess amounts of proliferation of cells and prevent the natural cell-death process
insulin in the blood have a higher risk of cancer recurrence in cancer cells that have metastasized from their original site.
and death from the disease. Meyerhardt adds that while the study doesnt prove that diets
In a previous study of advanced-stage colon cancer high in glycemic load and carbohydrate intake cause recur-
patients, Meyerhardt and his colleagues found that those rence of colon cancer, the results strongly suggest that such
with a typical Western diet, marked by high intakes of meat, dietary factors play a role. Our findings may offer useful guid-
fat, refined grains, and sugary desserts, were three times ance for patients and physicians in ways of improving patient
more likely to have a cancer recurrence than those whose survival after treatment, he says.
diets were least Western. The new study was conducted to SOURCE: DANA-FARBER CANCER INSTITUTE

High Vitamin D Levels May Protect Mothers Against MS

Pregnant women who have higher levels of vitamin D in their The research found that women who had high levels of vitamin
blood may have a lower risk of developing multiple sclerosis D in their blood had a 61% lower risk of developing MS compared
(MS) than women with lower levels, while their babies may not with those who had low levels of vitamin D in their blood. Over-
see the same protective effect, according to a study published all, few people had high levels of vitamin D. Only seven of the
online in Neurology. 192 people (4%) who developed MS had high vitamin D levels
In our study, pregnant women and women in general compared with 30 of 384 controls (8%) without the disease.
had a lower risk for MS with higher levels of the vitamin, as No association was found between the mothers vitamin D
expected. However, a mothers levels of vitamin D during level and whether her child would later develop MS.
early pregnancy didnt have an effect on MS risk for her Since we found no protective effect on the baby for women
baby, says study author Jonatan Salzer, MD, with Ume with higher levels of vitamin D in early pregnancy, our study
University Hospital in Sweden. suggests the protective effect may start in later pregnancy
For the study, scientists reviewed information about 291,500 and beyond, Salzer says. Another interesting finding in our
blood samples from 164,000 people collected since 1975 in the study was that the vitamin D levels became gradually lower
northern half of Sweden. Of those, 192 people developed MS an with time from 1975 and onward. Its possible that this decline
average of nine years after their blood sample was drawn, and in vitamin D status is linked to the increasing numbers of MS
there were 37 blood samples drawn during pregnancy from cases seen worldwide.
mothers whose children went on to develop MS later in life. SOURCE: AMERICAN ACADEMY OF NEUROLOGY

january 2013 61


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].

CAT CORA TD: In 2005, you founded Chefs for Humanity. What is this
An Iron Chef With a Heart organization, and what sparked the idea for its inception?
for Combating Hunger Cora: Hunger kills more people each year than AIDS, tuber-
culosis, and malaria combined. Chefs for Humanity is a non-
By Juliann Schaeffer
profit organization I founded to galvanize chefs, the culinary
As one of the newest membersand the first female community, and other concerned individuals to support
inducted into the Culinary Hall of Fame, its no secret Cat Cora hunger relief and improve nutrition for children and fami-
knows her way around a kitchen. First employing her cook- lies here in the United States as well as in places in the world
ing prowess in 2005 to best the brightest of culinary stars as where hunger and malnutrition pose even more dire threats
the firstand onlyfemale Iron Chef on Food Networks Iron to public health.
Chef America (for which she may be most recognized), now the I was inspired to start Chefs for Humanity after witnessing
celebrity chef is utilizing social media technology to bring those how chefs and people who love to cook also love to help, and
top-rate cooking skills to the masses with a new iPad app. learning how valuable skills like cooking for large crowds and
Called Cat Coras Kitchen, the app not only gives users deli- safe food handling can be in times of disaster such as during
cious recipes but also assists users in organizing their time via Hurricane Katrina, where I, along with other chefs, helped the
a scheduler that includes step-by-step instructions and esti- American Red Cross set up temporary kitchens to feed dis-
mated completion times for each dish. placed victims.

62 todays dietitian january 2013

Recognizing that chronic hunger and malnutrition is an TD: Is there one product in your specialty food line that you
ongoing disaster for so many people, Chefs for Humanity is couldnt live without in your own kitchen?
committed to mobilizing those with needed skills and passion to Cora: I cook with my award-winning Cat Coras Kitchen BY
help every day as well as in times of crisis. GAEA organic olive oil almost daily. Its the first-ever bottled
olive oil to be completely carbon neutral.
TD: How does Chefs for Humanity work to prevent hunger and
reduce obesitytwo causes close to the hearts of many dieti- TD: Whats your favorite family recipe and why?
tiansand whats your proudest accomplishment of the orga- Cora: I love my moms Greek Cinnamon Chicken recipe (see
nization thus far? below). It was my absolute favorite growing up; my mom would
Cora: Chefs for Humanity works to prevent hunger and malnu- make it on special occasions like holidays, birthdays, and anni-
trition, which includes obesity, by raising support and aware- versaries. I carry on that tradition today, and my kids love it!
ness and developing programs to address these issues. There Eating it always brings back fond memories.
are many accomplishments were proud of but, most recently,
were working to establish a Global School Gardens initiative Juliann Schaeffer is a freelance writer and
to help educate children about good nutrition while connecting editor based in Allentown, Pennsylvania,
them to the culinary community and engaging local chefs, res- and a frequent contributor to Todays Dietitian.
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) oil for each batch. Whats important is that the chicken isnt
overcrowded, which would cause the pieces to steam rather
Serves 4 than brown.
3. Add the chicken to the oil and brown for about 4 to 5
Ingredients minutes on each side. Turn the pieces using a metal spat-
1 chicken (212 to 3 lbs), cut into eight pieces ula, as they have a tendency to stick to the pan. Remove the
1 tsp ground cinnamon pieces when theyre well browned on all sides.
2 tsp kosher salt 4. Lower the heat to medium-high and add the onions
1 tsp freshly ground black pepper and minced garlic. Cook for about 3 minutes, stirring con-
5 peeled garlic cloves, minced stantly, until the onions have softened and are a rich golden
2 T extra-virgin olive oil brown. Add the wine and scrape the bottom of the pan with
2 peeled, coarsely chopped medium yellow onions a spatula or spoon to deglaze the pan, loosening any parti-
2 cup dry white wine cles stuck on the bottom.
1 cup water 5. When the wine has evaporated, add the water, chicken
1 cup chicken stock stock, tomato paste, fresh oregano, and remaining two
One 6-oz can tomato paste garlic cloves. Return the chicken to the pan. The liquid
1 T fresh oregano, chopped should cover about 34 of the chicken pieces. Cover the
2 cup grated Mizithra cheese pot and simmer over low heat for about an hour or until
the chicken is tender and thoroughly cooked. If the sauce
Instructions becomes too thick, it can be thinned with a little more
1. Pat the chicken dry with paper towels. A wet chicken water. Season the finished sauce with kosher salt and
will cause the oil to splatter while the chicken is sauting. pepper to taste.
Mix the cinnamon, salt, and pepper in a small bowl. Rub the 6. Serve the chicken topped with the sauce and sprinkle
chicken pieces on all sides with the seasoning. with Mizithra cheese.
2. Mince three of the garlic cloves. Heat the olive oil in
a large nonreactive deep skillet over high heat. A 12-inch Nutrient Analysis per serving
skillet with sides about 212 to 3 inches high will allow you to Calories: 560; Total fat: 18 g; Sat fat: 6 g; Trans fat: 0 g;
brown all the chicken at once. If you dont have a skillet large Cholesterol: 174 mg; Sodium: 1,113 mg; Total carbohydrate:
enough, brown them in two batches using one-half of the 19 g; Dietary fiber: 3 g; Sugars: 9 g; Protein: 74 g

january 2013 63


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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

1 garlic bulb
1 cup water
4 cup quinoa
4 cup red wine vinegar

3 T fresh lemon juice

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

66 todays dietitian january 2013

0.25g 0.44g 0.49g 0.90g 0.67g 1.09g 0.94g

Which serving has the

most sol
soluble fiber?
0.99g 1.38g


0.58g 1.25g

0.58g 1.12g

0.77g 1.17g

Konsyl O
r i g i n a l Formula

yllium Fib
Psyllium Fiber
0.61g 1.45g
Just one teaspoon of sugar-free Konsyl Original Formula has 6 grams of
psyllium fiber, equivalent to 3 grams of soluble fiber thats 75% more
psyllium fiber than leading brands!

As part of a healthy lifestyle, the all-natural psyllium contained in Konsyl

products can help your patients lose weight and help reduce their risk
1.36g of heart disease by lowering their cholesterol. Psyllium fiber also helps 1.02g
stabilize blood sugar levels and regulate digestion by treating constipation,
preventing hemorrhoids and easing the symptoms of IBS.*

Konsyl fiber supplements have been recommended by health care

professionals for over 50 years. Have you told your patients about
Konsyl Psyllium Fiber?
1.31g 0.44g

For free professional samples, visit Like us on Facebook
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0.44g 0.67g

*These statements have not been evaluated by the FDA. This product
is not intended to diagnose, treat, cure, or prevent any disease.
0.47g 1.51g 0.92g 0.15g
Betty W. Li, Karen W. Andrews, Pamela R. Pehrsson, Individual Sugars, Soluble, and Insoluble Dietary Fiber Contents of 70 High Consumption Foods,
Journal of Food Composition and Analysis, Volume 15, Issue 6, December 2002, Pages 715-723, ISSN 0889-1575, 10.1006/jfca.2002.1096.
Now theres a natural and clinically proven
ingredient for managing blood sugar levels *
CinSulin Water Extract of Cinnamon contains high quality concentrated
cinnamon extract. Unlike common cinnamon products on the market, CinSulin uses a
proprietary water extraction process that gently separates and concentrates
the health-supporting water-soluble components in the cinnamon.
The result CinSulin, a cinnamon concentrate that is 10:1 stronger than common
cinnamon! Youd have to take at least 10 common cinnamon capsules to
just 2 CinSulin capsules! **

Available in three formulas that target

the of individuals wanting to
manage their blood sugar levels*

For more information and a complete list of retailers carrying CinSulin,

call 1-855-844-4370 or visit
Within the normal range ** Refers to Advanced Strength and Healthy Weight CinSulin Clinical study available upon request
*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.