Todays Dietitian January 2013 US

Ethical Decision Making in End-of-Life Healthcare

Kids Frown on New School Lunch Standards

Embracing Meatless Monday

Gluten-FreeJourney RDs Serve as a Guide for Patients

on a Quest to Relieve Symptoms and Improve Health

The

ASPEN Conference

Issue

January 2013

Vol. 15 No. 1

The Magazine for Nutrition Professionals

www.TodaysDietitian.com

-Great Taste and Calorie Free. How does Walden Farms do it?

© 2013 Walden Farms, Inc100% GUARANTEED 800.229.1706 USee What’s New at WALDENFARMS.COM

No Calories, No Fat, No Carbs, No Gluten, No Sugars of any kind!Great Taste & Calorie Free. How does Walden Farms do it? Rich Natural Flavors...

Switch & Save Hundreds of Calories Every Day The Walden Way””

Chocolate Dip • Caramel Dip • Marshmallow Dip • Chocolate Syrup • Caramel Syrup • Pancake Syrup • Fruit Syrups • Fruit Spreads • Peanut Spread • Chocolate Peanut Spread Cinnamon Raisin Peanut Spread • Pasta Sauces • Mayo • Flavored Mayo’s • Salad Dressings • Coleslaw Dressing • BBQ Sauces • Ketchup • Seafood Sauce • Single Serve Packets

Help Patients Comply with your Prescribed Health Management Plan

Walden Farms Calorie Free Caramel Syrup is made from Rich Caramel and Pure Vanilla. Rich natural fl avors make all Walden Farms Syrups and Dips taste incredibly delicious including Real Chocolate from Premium Natural Cocoa Beans, delicious Fresh Fruit Extract from Strawberries, Blueberries, Raspberries, Apples, Apricots, Oranges and Grapes, Real Maple and so much more.Great on ice cream, fresh fruit, in smoothies, coffee, milk and more. Best of all, you can use all the Walden Farms you want, it’s Calorie Free.

Find us onFacebook

New Year’s Resolutions“The Walden Way”“The Walden Way”

Heavenly Caramel Sundae “The Walden Way”

Switch & Save 432 Calories

-

FREE Caramel Syrup ($4.99 Value) Visit waldenfarms.com/TDJ13 for detailsHealthcare Providers visit waldenfarms.com/HCP for Free Single Serve Packets for Your Patients

With The Food Processor®

Nutrition and Fitness Software,

you know you’re getting the best availableproduct on the market.

No other software offers such a wide variety of features.

No other software boasts the mostextensive and accurate database outthere.

No other software gives you accessto our in-house nutrition and technicalexperts.

And this has been true since the 1980s.

The

“world’s Greatest”

diet changes

every week.

The

world’s greatest

diet software

Doesn’t.

with FoodProdigy® online companionood Processor®

1-800-659-3742 | [email protected] | www.esha.com

FThe

worldsgreatest:Layout 1 11/5/2012 12:27 PM Page 1

DaisyBrandHealth.com

Only 4 Ingredients

DaisyBrandHealth.comDaisyBrandHealth.com

No preservatives, thickeners, or added growth hormones.

14 grams of protein per ½ cup.

Good source of calcium.

Low in cholesterol.

to the healthy foods you already recommend.

Add Daisy

Increased protein consumption can

help stimulate fat loss and preserve

lean body mass.

of

[1] http://www.usdairy.com/Public%20Communication%20Tools/Scientifi cStatusReportProtein.pdf

EDITOR’S SPOT

GRUMBLING BELLIESIt’s been one year since the unveiling of the new standards for school meals that have resulted in healthier lunches for kids across the country. The new meal require-ments have raised standards for the first time in more than 15 years, and chances are they will improve the health and nutri-

tion of nearly 32 million kids who participate in the program each school day.

As you know, the new standards require school cafeterias to serve larger portions of fresh fruits, vegetables, and whole grains; fat-free (unflavored/flavored) or 1% (unflavored) milk; less saturated and trans fats and sodium; and proper portion sizes and caloric intake based on age.

While the healthier meals are a key component of the Healthy, Hunger-Free Kids Act of 2010, championed by First Lady Michelle Obama and signed into law by President Obama, ironically they’re leaving many kids across the country with growling bellies by the end of the school day.

To voice an opinion of the new standards, a group of creative high school students in Kansas posted a video on YouTube called “We Are Hungry” to the tune of fun.’s “We Are Young.” If you feel like giggling a bit, go to YouTube and type in the title. There are scenes of kids storing food in their lockers to ensure they have enough to eat in between classes, kids walking the halls snacking on food, kids collapsing on the gym floor during basketball practice, and kids falling asleep in class because they’re hungry and have no energy. While the video parody will make you laugh, the kids’ message is a serious one: The food may be healthful, but it’s not filling them up. You can read more about this and find out what your colleagues had to say about the kids’ reactions in the feature “Healthful School Lunches.”

My son, a high school senior, has different complaints. He says it’s not that the healthier meals leave him hungry; the problem is that the more healthful foods just don’t look appetizing, so he buys the less healthful options from the à la carte menu. What do you think about this? Weigh in with your feedback about this story and the issue’s other articles on our Twitter and Facebook pages.

Happy New Year to all, and please enjoy the issue.

Judith [email protected]

President & CEO Kathleen Czermanski

Vice President & COO Mara E. Honicker

EDITORIALEditor Judith Riddle

Editorial Director Jim Knaub Senior Production Editor Tracy Denninger

Assistant Editor Brandi Redding Editorial Assistant Heather Hogstrom

Contributing Editor Sharon Palmer, RDEditorial Advisory Board Dina Aronson, MS, RD; Jenna A. Bell, PhD, RD;

Carol M. Meerschaert, MBA, RD; Sharon Palmer, RD; Kyle Shadix, MS, RD

ARTSenior Graphic Designer Charles Slack

Graphic Designer Erin ProsiniJunior Graphic Designer Emily Avedissian

ADMINISTRATIONAdministrative Manager Helen Bommarito

Administrative Assistants Kim Mayfield, Pat PlumleyExecutive Assistant Matt Czermanski

Systems Manager Jeff CzermanskiSystems Consultant Mike Davey

FINANCEDirector of Finance Jeff Czermanski

Director of Continuing Education & New Business Development Jack Graham

CIRCULATIONCirculation Manager Nicole Hunchar

MARKETING AND ADVERTISINGPublisher Mara E. Honicker

Director of Marketing and Digital Media Jason Frenchman Web Designer/Marketing Assistant Jessica McGurk

Marketing Assistant Leara AngelloDirector of Sales Stephanie Mitchell

Senior Account Executives Sue Aldinger, Seth Bass, Peter J. Burke, Gigi Grillot, Brian OhlAccount Executives Diana Kempster,

Beth VanOstenbridge, Josh YohnkeSales Coordinators Joe Reilly, Dani Kriest-Reifsneider

© 2013 Great Valley Publishing Company, Inc.

Phone: 610-948-9500 Fax: 610-948-7202Editorial e-mail: [email protected] Sales e-mail: [email protected]

Website: www.TodaysDietitian.com Subscription e-mail: [email protected]

Ad fax: 610-948-4202 Ad artwork e-mail: [email protected]

All articles contained in Today’s Dietitian, including letters to 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.

Judy

6 today’s dietitian january 2013

OCSCPP2144_Exceptional_Cranberry_V1b 8.5" x 11"8" x 10.5"

7.25" x 10"

Scooter/NN

4CP

Exceptional Cranberry Corporate

Janeen SaraJulie

OCSCPP2144 Date: 7/5/12 Version: 1 Page: 1

The Cranberry. So much goodness for such a tiny berry.

When promoting nutrition as part of a healthy lifestyle, remember the cranberry. Popular for their effectiveness in supporting urinary tract health, cranberries are loaded with polyphenol antioxidants and dense in powerful nutrients. So if you’re looking to help others make big strides toward whole body health through balanced nutrition, look no further than the tiny, yet powerful, cranberry.

Brought to you by

©2012 Ocean Spray Cranberries, Inc.

OCSCPP2144_Exceptional_Cranberry_V1b.indd 1 7/5/12 10:53 AM

CONTENTS

FEATURES

24 The Gluten-Free Journey RDs serve as a guide for patients on a lifelong quest to relieve symptoms and improve health.

28 Ethical Decision Making This article details the dietitian’s role in end-of-life healthcare when considering enteral and parenteral nutrition.

34 Healthful School Lunches — Are the New Standards All They’re Cracked up to Be?� 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.

38 Meatless Monday This growing campaign encourages people to increase their intake of fruits, vegetables, whole grains, and legumes, and dietitians are embracing it as a tool to promote healthful eating patterns.

42 Educating Young Palates MindStream Academy is blending food, nutrition, and education to teach students how to live healthfully for the rest of their lives.

46 CPE Monthly: Autism Spectrum Disorder Research suggests good nutrition may help manage various symptoms.

DEPARTMENTS

6 Editor’s Spot

10 Reader Feedback

12 Ask the Expert

14 Nutrition Support 360

17 Personal Computing

18 Dynamics of Diabetes

22 For Your Information

52 Supplement Spotlight

54 Focus on Fitness

58 Products + Services

60 News Bites

62 Get to Know…�

64 Datebook

66 Culinary Corner

34 18

JANUARY 2013

Today’s 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 or e-mail [email protected] NOTE: For subscription changes of address, please write to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on last label. POSTMASTER: Send address changes to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Subscription Rates — Domestic: $14.99 per year; Canada: $48 per year; Foreign: $95 per year; Single issue: $5

Page 46

Glut

en-Fr

ee Go

urme

t Bar

s...Pe

an

ut Butter & Chocolate, Chocolate Mint, Chocolate Cara

mel Bl

iss, C

hoco

late

Pean

ut Bu

tter Caramel Crisp, Nuts About Tropical Fruit, Marshmall

ow R

ice C

risp..

.

NoGii.com

GluteN-free solutioNsfor healthy families

•ALL NATURAL •NO GLUTEN •NO TRANS FAT •NO HYDROGENATED OILS •NO HIGH FRUCTOSE CORN SYRUP

Available at retailers nationwide

From Elisabeth Hasselbeck, Co-Host of ABC’s The View

Dear Editor,Thank you for publishing the very

thorough and informative article on migraine headaches in the November 2012 issue. This is probably the most useful information I’ve ever read regarding the treatment of migraines. I suffered from migraines for years and saw multiple doctors who prescribed some dangerous drugs. It was a dietitian who finally relieved me of my migraines using MRT [Mediator Release Testing]. I’ve been migraine free now for more than four years!

With the right tools, dietitians can accomplish so much. However, to move forward, it’s essential they keep open minds and embrace new medical technology.

Lori Langer, RD, MEd, CLT, LDN, specializes in food allergies, sensitivities,

intolerances, and inflammatory conditions

READER FEEDBACK

From Our Facebook Wall

“Worldwide Diabetes Cases Hit Record, Half Go Undiagnosed” news.msn.comLinda Mooring: What will it take for people to get the message and change their diet? Sugar is evil!

“Study: Flu, Fever in Pregnancy Linked to Autism Risk” www.usatoday.comKristen Conner Pardue: Disagree with this study. Women have had fevers during pregnancy for decades.Kimberly Davis-Coniglio: 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.

“There’s Homework to Do on School Lunches” well.blogs.nytimes.comTrina Astor-Stewart: I agree with the article. Children need to be introduced to healthful foods in order to want them above the junk foods. These days, more moms are conscious of nutrition than before.Bonnie Egner Johnson: I don’t see much change. School lunch is just offering more of what students haven’t chosen before. I believe the quality, appear-ance, and the way fruits and vegetables are served is often missing in school lunches. Salad with dress-ing on it already? No thanks! There needs to be more attention [paid] to this with less attention on the number of items offered! Cyndy Finfrock: Starts and ends with the parents’ eating habits and what they buy/prepare for their kids.

From Our Twitter Page Popular Tweets, Retweets

@AhealthEeater: Just reading Today’s 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. Great B12 tips!

“The Real Scoop on Sugar”

@KarmstrongKurt: Thank you, Today’s Dietitian, for a great link on the debate on sugar.

“Combating Clostridium Difficile”

@bmlococo: Just read the Today’s Dietitian article about C diff. Could antibiotic use in animal meat be a cause in increased cases? Any evidence out there?

“Breast-Feeding Success”

@runongreen: Breast-feeding success stories from Today’s Dietitian inspire us to remember “breast is best”!

Clients Can Prepare Such Delicious, Healthful Meals That Nobody Will Miss the Turkey

November 2012

Vol. 14 No. 11



Clients Can PPrepare SSuch

Veggie Style!Happy Thanksgiving

Reversing Type 2 Diabetes WithNatural Therapies

Gluten-Free Kitchen Essentials

Helping Clients With Binge Eating Disorder

Pumpkin Soup

AMERICAN DIABETES MONTH


Nature’s Sweet Solution

SWEETLEAF.COM BUY ONLINE:LOOK FOR US IN YOUR GROCERY AND NATURAL FOODS STORES.

SWEETLEAF STEVIA® SWEETENER IS THE KEY TO ACHIEVING A

NEW YEAR’S RESOLUTION TO LOSE WEIGHT AND STAY FIT. MADE WITH

ORGANIC STEVIA LEAF EXTRACT AND NATURAL FLAVORS, YOU CAN

ENJOY GREAT TASTE WITHOUT THE GUILT.

ZERO CALORIES ZERO CARBS

ALL NATURAL GREAT VALUE

AWARD-WINNING TASTE

COOKING WITH KIDSBy Toby Amidor, MS, RD, CDN

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 perform?

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. Choose tasks they can perform from the start to the end of a

meal, including those related to planning, shopping, preparing, cooking, serving, and even cleaning up.

Kid-Appropriate TasksListed below are suggested tasks for kids aged 2 and up. Each

age group builds on the age-related tasks of the previous one.

Ages 2 to 3•Help place fresh fruits and vegetables in plastic produce

bags at the supermarket. •Place food items in the shopping cart.•Wash fruits and vegetables.•Toss empty packages and containers in the garbage.•Peel bananas and oranges with assistance.•Stir batters with assistance.•Place dirty dishes and silverware in the kitchen sink after a

meal with assistance.

Ages 4 to 5•Help select recipes (use recipes with photos).•Assist with food selection at the supermarket, specifically on

lower shelves.•Place food items from the shopping cart onto checkout coun-

ter with assistance.•Stir batters without assistance•Measure ingredients.

•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

mixing oatmeal or scrambling eggs.•Prepare a simple salad, including shredding the lettuce and

washing and peeling vegetables, as needed. •Roll dough for pizza or cookies.•Use a butter knife to spread cream cheese or peanut butter.•Set the table without assistance.•Help clear the table of all items.•Load the dishwasher except for sharp objects such as knives.

Ages 8 and Up•Plan simple meals.•Write out a shopping list.•Place an order at the deli and butcher counter.•Use a pizza cutter and can opener.•Skewer food.•Make smoothies with supervision.•Prepare easy no-cook recipes such as tuna salad or home-

made trail mix.•Clear the table and help rinse small dishes before placing

them in the dishwasher.•Help place leftovers in storage

containers and put the containers in the refrigerator.

— Toby Amidor, MS, RD, CDN, is founder of Toby Amidor Nutrition

(www.tobyamidornutrition.com), a nutrition expert for FoodNetwork.

com, and a nutrition advisor for Sears FitStudio.com.

ASK THE EXPERT

Have questions about nutrition trends, patient care, and other dietetics issues you’d like to ask our expert?

Send your questions to Ask the Expert at [email protected] or send a tweet to @tobyamidor.


presents a new online resource for…


Whether you’re a nutrition professional or a consumer looking for trustworthy guidance, the Today’s Dietitian Health & Nutrition Center is a free online resource packed with useful information that can benefi t 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 specifi c nutritional or dietary needs, such as gluten free, plant based, or diabetes.

Also, share our site as a reference guide for clients, friends, and family members in need of fresh ideas and choices to help them stay fi t or develop a healthier lifestyle.

Healthy, categorized recipesProfessional guidance on

diet and weight loss

Content from a trusted source

Advice and insight from respected health, fi tness, and healthy living experts

…health-conscious individuals

…nutrition professionals

…and their clients!

Visit www.TodaysDietitian.com/healthandnutrition and share the link!

Health_Nutrition_FP.indd 1 12/19/12 9:38 AM

PARENTERAL NUTRITION HOME-STARTS Learn How RDs Can Help Patients Safely Begin PN Care at HomeBy Sandra I. Austhof, MS, RD, LD, CNSC

People unable to use their gastrointestinal (GI) tract due to intestinal failure require parenteral nutrition (PN). PN, the administration of IV nutrients, is a potentially lifesaving ther-apy that, when required long-term, can be administered safely in the home to allow people to live higher-quality lives.1

Some clinicians believe PN should always be started in a hospital setting where patients can be closely monitored to avoid potential complications such as refeeding syndrome, which causes electrolyte imbalances of serum phosphorous, potassium, and magnesium that can potentially lead to heart failure or other life-threatening conditions.

However, many home infusion companies have safely and successfully started PN at home in patients with mild to moderate electrolyte abnormalities by correcting these electrolytes before PN infusion.2 This allows the patient to be more comfortable and avoids the risk of possible expo-sure to hospital-acquired infections while reducing overall healthcare costs.

One of the earliest reports on transitioning PN from the hospital to the home was documented 40 years ago.3 Due to technological advances in access devices, infusion pumps,

home care agency creation, and reimburse-ment strategies, select patients have been starting PN in the comfort of their homes for the past 20 years.4 In fact, data spanning the last 10 years have estimated that 39,000 patients receive PN at home each year.1

Home-start PN can save nearly $2,000 per day in healthcare costs compared with receiv-ing IV feeding in the hospital.5

Whether a patient begins PN in the hospi-tal or at home, a knowledgeable interdisciplin-ary team must develop a care plan with the patient that includes the indication for home PN, the approximate length of time the therapy is needed, the end point of therapy, and nutri-tional goals.6

This article will take a closer look at home-start PN and evaluate its benefits in compari-son with hospital-start PN as well as discuss the role dietitians can play in preparing the patient and family for PN care in the home setting.

Evaluating the Home EnvironmentOnce a physician determines a patient is a good candidate

for home PN, a home infusion nurse first assesses the patient’s home environment for cleanliness, sanitary water supply, elec-tricity, refrigeration, adequate storage space for supplies, and telephone access.7 The nurse also assesses whether the patient or caregiver is capable of administering home PN ther-apy and verifies insurance coverage. If the patient is in the hos-pital, a social worker, PN nurse, and nurse case manager meet with the patient and family at the bedside to assess the home environment and insurance coverage for home PN care.

Home PN EducationOnce it’s considered safe to administer home PN, quali-

fied healthcare nurses begin educating the patient and family about what it entails. The patient or a family member is chosen as the primary caregiver who must demonstrate competence in preparing and administering PN, which includes infection control, caring for the vascular access device, connecting and disconnecting the IV tubing, safely incorporating additives, and properly storing supplies.7 For hospital-start PN patients, the PN nurse educates the patient and family at the bedside, and a visiting nurse contin-ues the instruction at home.

All patients receive three consecutive days of lessons in the home. Once the home infusion nurse determines the pri-mary caregiver can implement PN procedures, the nurse will make weekly visits.

NUTRITION SUPPORT 360


Advantages of Hospital-Start PNMost patients discharged from the hospital on PN weren’t

admitted specifically to start PN but for unrelated medical or surgical reasons that resulted in the need for home PN care.

Due to safety concerns, clinicians often prefer hospital-start PN. High-risk patients who would benefit from hospital-start PN include infants, the elderly, IV drug users, patients with fluid and electrolyte disorders, those with uncontrolled diabetes or major organ dysfunction, or those at high risk of refeeding syndrome.7,8

Replacing fluid and electrolytes before initiating PN and then starting PN with a low carbohydrate load can prevent refeeding syndrome. Rex Speerhas, RPh, BCNSP, a clinical nutrition specialist at the Cleveland Clinic, says, “The patient can be treated much more promptly and effectively in the hospital setting with frequent intravenous electrolyte supple-mentation.” The bedside nurse and primary care physician also can closely monitor the patient.

Another concern is hyperglycemia, the most common side effect in preparing a patient for cyclic home PN.9 “When a patient is initiated in the hospital setting, blood glucose levels can be monitored much more frequently, thus episodes of hyperglycemia can be immediately treated with insulin or avoided completely,” Speerhas says, adding that to achieve the same quality of care, close monitoring in the home set-ting would require the presence of a healthcare professional around the clock. The testing supplies needed would quickly become very costly to the patient.

The hospital dietitian’s role in preparing the patient for home PN involves stabilizing and cycling the PN formula by monitoring daily vital signs, electrolytes, glucose levels, intake and output records, and weights. This usually takes three to six days to complete. PN is started at full protein needs with one-half of the dextrose load infused continuously over 24 hours. Lipids usually are given separately. Shortening

the infusion time by four hours each day over three consecu-tive days or six hours each day for two consecutive days can cycle PN from 24 to 12 hours. In stable, select patients, PN can be cycled from 24 to 12 hours over one day.

Advantages of Home-Start PNWhile hospital-start PN has its advantages, home-start

PN also has its benefits. Home-start PN enables patients to learn about PN in the comfort of their home plus they have fewer hospital expenses and don’t have to worry about hospital-acquired infections.10 The decision to initiate PN in the home depends on patients’ clinical stability, whether they have a need for PN, whether a nurse can evaluate them in their home, and whether a caregiver can safely adminis-ter the therapy.7

Patients who can receive home PN care are those who either don’t have a chronic illness or have a chronic illness that’s well controlled, such as cancer, HIV, hyperemesis gravidarum, or GI disorders; those with bariatric surgery complications; or those with failed enteral nutrition.8,10

Many home infusion companies that provide home-start PN services have experienced dietitians, nurses, and phar-macists working for them who can offer quality care to patients and have a track record of successfully initiating PN in the home, bypassing hospital admission.

Walgreens Infusion Services, the nation’s largest infu-sion provider, initiates home PN with at least one patient almost every day. According to Noreen Luszcz, RD, MBA, CNSC, Walgreens’ nutrition program director, the key to the company’s success is its multidisciplinary team approach, slow progression of starting PN, and ongoing communica-tion with the team, patient, and physician. Slow progression means that macronutrients, especially dextrose, are started at a reduced concentration to prevent complications such as hyperglycemia or electrolyte imbalances.

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

NEWGluten Free

Panko Breadcrumbs!

www.iansnaturalfoods.com

january 2013 www.todaysdietitian.com 15

Once Walgreens receives a referral from a physician’s office or clinic, a dietitian and a nurse become actively involved in the initial home visit. The dietitian completes a comprehensive nutrition assessment and determines needs and formula recommendations.

Choosing appropriate patients for home-start PN is essential. Luszcz reports that high-risk patients, such as those with uncontrolled diabetes, high GI losses, or multi-ple organ failure, usually are referred to hospital-start PN. When beginning PN in the home, however, Luszcz says Wal-greens’ patients begin with reduced protein, dextrose, and lipids infused over 24 hours. Daily weights, lab data, and intake and output records are closely monitored.

Once the patient is stabilized, which can take several days, PN is slowly increased to provide the full amount of macro-nutrients. PN is reduced to 18 hours and eventually to eight to 12 hours once the patient is stabilized on full PN. Some home infusion companies, such as ThriveRx, start low- calorie PN over 12 to 18 hours at a reduced rate for younger, stable patients, according to Donna Kloth, RN, CRNI, CNSC, a

nutrition liaison with ThriveRx. “By carefully monitoring the patient, we slowly advance the PN formulation to goal, which usually takes a week,” she explains.

To prevent refeeding syndrome, home infusion companies usually have protocols that involve administering replace-ment fluids and electrolytes in the home before starting PN. In one study, Walgreens showed that patients at risk of refeeding syndrome can safely begin home PN, eliminating the need for hospital admission.2 In this small, retrospec-tive study, 15 high-risk patients were started on 25% of dex-trose needs for the first three to four days. Once the patients were stabilized, 50% of dextrose needs were given for another three to four days. Researchers closely monitored lab results, and patients reached their PN goal needs.

Safe AlternativePatients have been started safely on PN in the hospital setting

and at home for many years. The key to this success has been the experience of knowledgeable interdisciplinary healthcare teams consisting of physicians, dietitians, nurses, and pharmacists. With the advances in standards of care, equipment, and specialized home infusion services, patients can start IV nutrition at home, allowing for continued daily activities and increased quality of life.

— Sandra I. Austhof, MS, RD, LD, CNSC, is a nutrition support dietitian at the Cleveland Clinic and has

worked in the field for more than 30 years.

AcknowledgementThe author would like to extend a special thanks to Kaylee

Adams, a PharmD candidate at Ohio Northern University, for her assistance in the research of this article.

References1. Ireton-Jones C, DeLegge MH, Epperson LA, Alexander

J. Management of the home parenteral nutrition patient. Nutr Clin Pract. 2003;18(4):310-317.

2. Jansson L, Brand S, Monahan R, Knowles S. Home start parenteral nutrition—yes we can! Presented at: American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week; January 21-24, 2012; Orlando, FL.

3. Jeejeebhoy KN, Zohrab WJ, Langer B, Phillips MJ, Kuksis A, Anderson GH. Total parenteral nutrition at home for 23 months, without complication, and with good rehabilitation. A study of technical and metabolic features. Gastroenterology. 1973;65(5):811-820.

4. Sanville MH. Initiating parenteral nutrition therapy in the home. J Intraven Nurs. 1994;17(3):119-126.

5. Ireton-Jones C, Hamilton KS, DeLegge MH. Improving clinical and financial outcomes with parenteral nutrition ther-apy. Support Line. 2009;31(1):23-25.

6. Kirby DF, Corrigan ML, Speerhas RA, Emery DM. Home parenteral nutrition tutorial. JPEN J Parenter Enteral Nutr. 2012;36(6):632-644.

7. Kovacevich DS, Frederick A, Kelly D, Nishikawa R, Young L. Standards for specialized nutrition support: home care patients. Nutr Clin Pract. 2005;20(5):579-590.

8. Crocker KS, Ricciardi C, DiLeso M. Initiating total paren-teral nutrition at home. Nutr Clin Pract. 1999;14:124-129.

9. Suryadevara S, Celestin J, DeChicco R, et al. Type and prevalence of adverse events during the parenteral nutrition cycling process in patients being prepared for discharge. Nutr Clin Pract. 2012;27(2):268-273.

10. Newton AF, DeLegge MH. Home initiation of parenteral nutrition. Nutr Clin Pract. 2007;22(1):57-64.

With the advances in standards of care, equipment, and specialized home infusion services, patients can start IV nutrition at home, allowing for continued daily activities and increased quality of life.


EMERGENCY PREPAREDNESSCloud-Based Backup Simplifies This Essential TaskBy Reid Goldsborough

Hurricane Sandy, which led to so much damage in New York and New Jersey in late October 2012, was only one of numer-ous natural and manmade disasters that, along with destroying life and property, destroyed data. Whether you work for a large company, run a small business, or use a computing device in your home or whether it’s corporate trade secrets or family photos, data can be irreplaceable.

The key to disaster recovery is disaster preparation, and the key to disaster preparation is redundancy. In a nutshell, back-ups. If you have backup power such as a generator, you can con-tinue to compute if the electricity goes out. If you have one or more backup computers, you can still get things done if equip-ment is damaged. And if you have backup data, you can pick up any project where you left off.

Cloud ComputingFor several years now a big buzzword in the computer world

has been the “cloud,” which is just a whimsical way of saying the Internet. Instead of storing data or using programs on computers at your location, with cloud computing you use data or programs stored on other computers you connect to over the Internet.

One of the most effective uses for cloud computing is making remote backups of data. That way, even if your computer equip-ment is destroyed in a flood or fire, you won’t lose your data. The same can’t be said for a backup stored at your location that you’ve made onto an external hard drive, USB drive, opti-cal disc, or tape, though these media still can be useful among other ways as a backup for your backup.

Remote Backup ServicesA host of free and fee-based remote backup services have

popped up in recent years. The free services typically provide a limited but often appreciable amount of storage space, with additional storage costs.

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 you’re working on from different computers, and collaborating with others on the same project.

Here’s 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 don’t want such a service to go away, but the smaller guys listed below appear stable.•Dropbox (www.dropbox.com): This may be the most

talked about and recommended file hosting service. It’s fairly skimpy on the free storage, offering only 2 gigabytes, but it’s easy to use and versatile. You use it by either copying files you want automatically backed up into a Dropbox folder or subfold-ers on your computer or you ensure the files you want auto-matically backed up are stored in one of these folders.•SugarSync (www.sugarsync.com): With 5 gigabytes of

storage before you have to pay, SugarSync is more generous than Dropbox. It also doesn’t require you to create special fold-ers but instead lets you designate which of your folders you want automatically backed up with its own interface. •IDrive Sync (www.idrive.com): This is the most gener-

ous of the services listed here, giving you 10 gigabytes of free storage. Unlike some other services, IDrive lets you choose between continuous backup and scheduled backup, which is the default.•Google Drive (http://drive.google.com): If you already use

Google Docs, a free cloud suite of word processing, presenta-tion, spreadsheet, and other programs, this is where your files are stored. But you also can use Google Drive with data created using programs on your own computer. It offers 5 gigabytes of free storage. •Amazon Cloud Drive (www.amazon.com/clouddrive): This

is Amazon’s cloud storage service, but it’s clunkier than the other services here. Amazon Cloud Drive offers 5 gigabytes of free storage. It makes copies of previously backed up or deleted files in case you need to retrieve them.•iCloud (http://apple.com/icloud): From Apple, this service

is tailored to Apple products. It can work with an iPad, iPhone, iPod touch, or Mac, and it works with Windows PCs as well. iCloud gives you 5 gigabytes of free storage. •Skydrive (http://skydrive.live.com): This is Microsoft’s

offering, with 7 gigabytes of free storage. Along with Windows PCs and Windows Phone, Skydrive also works with Macs, Apple devices, and Android devices.

Ultimately, choosing and using a backup service is far more important than which service you choose.

— Reid Goldsborough is a syndicated columnist and author of the book Straight Talk About the Information Superhighway. He can be reached at [email protected] or www.reidgold.com.

PERSONAL COMPUTING


DIABETES AND COMPLEMENTARY CAREMore Patients Are Following Alternative Diets to Manage the DiseaseBy Constance Brown-Riggs, MSEd, RD, CDE, CDN

As diabetes cases continue to soar worldwide, people with the disease are turning more and more to alternative thera-pies to help manage it. Specifically, in an analysis of data from the 2002 National Health Interview Survey, Bell and colleagues found that more than 72% of people with diabetes use comple-mentary and alternative medicine (CAM) to manage their dis-ease.1 A literature review on the use of CAM among people with diabetes, published in 2007 in the Journal of Advanced Nursing, reported prevalence rates as high as 78%. Moreover, people with diabetes are 1.6 times more likely to use CAM therapies than people without diabetes.2

What Is CAM?�The terms “alternative medicine” and “complementary med-

icine” often are used interchangeably, but according to the National Center for Complementary and Alternative Medicine, “CAM is a group of diverse medical and healthcare systems, practices, and products that aren’t generally considered to be part of conventional medicine.” Complementary medicine is used with conventional medicine, whereas alternative medicine is used instead of conventional medicine.3

Examples of CAM therapies include herbs, bodywork, special diets, and dietary supplements. Most people with diabetes who use CAM follow diet-based therapies to manage the disease.1

The following are the six most common diet-based therapies people use to treat diabetes more naturally and holistically.

Alkaline DietThis 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 there’s no need to alter the diet to try to affect the pH level.

However, Sheth believes the alkaline diet can be a healthful choice for people with diabetes. “An alkaline diet is primarily a

vegetarian diet, emphasizing fresh fruits, vegetables, soy, nuts, legumes, and olive oil,” she says.

Food-Combining DietThe theory behind the food-combining diet is that if protein

and starch are eaten simultaneously, the body will wear itself out by producing both alkaline and acidic digestive juices, which nul-lify both the protein and the starch and impair digestion.4 This diet promotes eating proteins and starches at separate meals. Vegetables can be eaten with both protein and starch, but fruits should be eaten alone. Its proponents say this diet will encour-age weight loss and improve digestion. Research supports that a weight loss of 10 to 15 lbs is enough to decrease insulin resis-tance and improve blood glucose levels in people with diabetes.

However, there’s no scientific evidence stating this diet is beneficial for weight loss or digestion. In fact, “The research is flawed, and some of the ideas are counterproductive,” Melina says. For example, vitamin C in fruit can help increase iron absorption from iron-rich plant foods such as legumes. But according to food-combining guidelines, this combination isn’t permissible. For people with diabetes, this diet is contrary to the American Diabetes Association’s 2012 nutrition recom-mendations for optimal blood glucose control. Balancing a meal with both protein and carbohydrates promotes fewer carbs at the meal, resulting in more stable blood glucose and insulin levels.

Macrobiotic DietThis diet incorporates the Asian philosophy that foods are

either yin (cooler) or yang (warmer) and that certain health conditions require food that will cool or warm the body. The macrobiotic diet is vegetarian based, consisting mainly of brown rice, whole grains, and vegetables. It has gained pop-ularity among cancer patients who understand it to be an

DYNAMICS OF DIABETES


effective way to treat the disease. Currently, there’s 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 DietBased 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 118˚F 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-trary to the belief of raw food diet proponents, the enzymes needed for digestion are produced by the pancreas and small intestines.

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

The Maker’s DietThe Maker’s 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 health—physical, spiritual, mental, and emotional—including increasing physical activity, reducing stress, and finding faith.6 The diet claims to improve health and promote weight loss, which will lower the risks of chronic illnesses, including diabetes.

There are many benefits to adopting a lifestyle that will increase physical activity, reduce stress, and help one find faith. This is particularly true when it comes to diabe-tes, which can be a challenge physically, spiritually, and emotionally.

The diet is broken down into three phases that last a total of 40 days—the 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 Maker’s Diet.6

C

M

Y

CM

MY

CY

CMY

K

Today's Dietitian Ad_12-03-12 (2-2).ai 1 12/3/12 4:54 PM


Ayurvedic DietThe Ayurvedic diet, popularized by author Deepak Chopra,

MD, is based on a system of medicine that originated in ancient India. It attempts to balance and restore harmony in the body by using diet, yoga, and herbs.

The diet is built on a theory that people are born with unique characteristics based on the combination of “doshas” in the gene structure. The doshas are dynamic forces within the universe, including earth, water, fire, and wind. A per-son’s chances of developing certain types of diseases are thought to be related to the way doshas are balanced, the state of the physical body, and mental or lifestyle factors.7

Ayurvedic doctors determine which doshas are strongest and which are out of balance, and give a diet prescription that strengthens and balances them. Ayurvedic practitioners claim this diet will bring harmony back to the body and, in doing so, help with weight loss and decrease the likelihood of chronic ill-nesses, including diabetes.

Ayurvedic treatments rely heavily on herbs and other plants, such as oils and common spices. “Turmeric, holy basil, Coccinia indica, gumar, fenugreek, and jambul powder are commonly

used for diabetes,” Sheth says. And there’s evidence suggest-ing Coccinia indica, holy basil, fenugreek, and Gymnema sylvestre have a glucose-lowering effect.8

Most clinical trials of Ayurvedic approaches have been small and not well done. Therefore, scientific evidence for the effectiveness of Ayurvedic practices varies. More rig-orous research is needed to determine which practices are safe and effective.7

Tips for Dietitians“It’s important for RDs to increase their knowledge and

awareness of alternative approaches to diabetes self- management,” Sheth says, as more people with the disease turn to CAM to manage it. This will enable RDs to more effec-tively counsel their clients. To ensure coordinated and safe care, Sheth encourages RDs to communicate with their clients’ alternative medicine practitioners as well.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is the national spokesperson for the Academy of Nutrition and Dietetics,

specializing in African American nutrition, and author of the African American Guide to Living Well With Diabetes

and Eating Soulfully and Healthfully With Diabetes.

References1. Bell RA, Suerken CK, Grzywacz JG, Lang W, Quandt SA,

Arcury TA. Complementary and alternative medicine use among adults with diabetes in the United States. Altern Ther Health Med. 2006;12(5):16-22.

2. Egede LE, Ye X, Zheng D, Silverstein MD. The prevalence and pattern of complementary and alternative medicine use in individuals with diabetes. Diabetes Care. 2002;25(2):324-329.

3. Complementary and alternative medical therapies for dia-betes. National Diabetes Information Clearinghouse website. http://diabetes.niddk.nih.gov/dm/pubs/alternativetherapies. Last updated January 24, 2012. Accessed November 18, 2012.

4. Davis B, Melina V, Berry R. Becoming Raw: The Essential Guide to Raw Vegan Diets. Summertown, TN: Book Publishing Co; 2010: 176-178.

5. Raw food diet. WebMD website. http://www.webmd.com/food-recipes/guide/raw-food-diet. Reviewed February 20, 2010. Accessed November 11, 2012.

6. Longe JL. The Gale Encyclopedia of Diets: A Guide to Health and Nutrition. Farmington Hills, MI: Gale; 2007: 643-646.

7. Ayurvedic medicine: an introduction. National Center for Complementary and Alternative Medicine website. http://nccam.nih.gov/health/ayurveda/introduction.htm. Last updated July 2009. Accessed November 11, 2012.

8. Hardy ML, Coulter I, Venuturupalli S, et al. Ayurvedic inter-ventions for diabetes mellitus: a systematic review. Evid Rep Technol Assess (Summ). 2001;(41):2p.

RESOURCESYou don’t need to know everything about com-

plementary and alternative medicine, but you should know where to find credible information. The following resources can help:

Resources for Patients

•National Center for Complementary and Alterna-tive Medicine (NCCAM) (http://nccam.nih.gov)

•NCCAM Time to Talk Tips on Complementary Health Practices (http://nccam.nih.gov/ health/tips)

•MedlinePlus (www.nlm.nih.gov/medlineplus)

Federal Resources for Providers

•NCCAM Resources for Health Care Providers (http://nccam.nih.gov/health/providers)

•NCCAM Clinical Digest monthly e-newsletter (http://nccam.nih.gov/health/providers/digest)

•NCCAM Complementary and Alternative Medi-cine Online Continuing Education Series (http://nccam.nih.gov/training/videolectures)


Do you wish to begin or renew your subscription to Today’s Dietitian?❑ YES, please begin/renew my subscription. ❑ No thanks.

Signature______________________________________________________________________ Date________________Signature and date required for processing. Incomplete forms will not be processed.

Name_____________________________________________________________________________________________

Phone_____________________________________________________________________________________________

Facility_____________________________________________________________________________________________

Address_____________________________________________________________________________________________

City____________________________________________________ State__________________ Zip_________________

E-mail*____________________________________________________________________________________________

*E-mail address will primarily be used for renewals, e-newsletters, and digital editions.

❑ 1 Year - $14.99 (12 issues) ❑ 2 Years - $28.50 (24 issues) ❑ 3 Years - $39.99 (36 issues)For print subscriptions in Canada or other locations outside the U.S., please e-mail or call for pricing. Subscriptions are nonrefundable.

Payment Options (select one): ❑ Check made out to Today’s Dietitian ❑ Money Order ❑ Visa ❑ MasterCard ❑ AMEX

Credit Card No.____________________________________ Security Code_______________ Exp.Date___________________

SUBSCRIBE or RENEW Now and SAVE!

Today’s Dietitian contains practical articles loaded with

information that every nutrition professional needs to know

PLUS the opportunity to earn 2 CE credits by reading the

CPE Monthly article and taking a short online exam.

CHOOSE THE DESIGNATION THAT BEST DESCRIBES YOUR CREDENTIALS:

❑ RD❑ RDE❑ DTR❑ LD❑ CDM❑ CDE❑ Other____________________

CHOOSE THE TITLE THAT BEST DESCRIBES YOU:

❑ Foodservice Manager❑ Clinical Nutrition Manager❑ Consultant Dietitian❑ Dietetic Technician❑ Educator❑ Dietitian in Private Practice❑ Clinical Dietitian❑ Food and Culinary Professional❑ Director❑ Student❑ Other____________________

CHOOSE YOUR WORK SETTING:

❑ Hospital❑ Nursing Home/Long-Term Care Facility❑ State Dept. of Public Health❑ HMO❑ College/University/School District❑ Government Agency❑ Food Company❑ Pharmaceutical Company❑ Nutrition-Related Company❑ Hotel❑ Correctional Facility❑ Other____________________

INCOMPLETE FORMS WILL NOT BE PROCESSED. CODE: 010713

THREE EASY WAYS TO SUBSCRIBE OR RENEW:Online at www.TodaysDietitian.com • Fax this form to 610-819-1214 • Mail form and payment to

Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475

Clients Can Prepare Such

Delicious, Healthful Meals

That Nobody Will Miss the Turkey

November 2012

Vol. 14 No. 11



Clients Can PPrepare SSuchVeggie Style!Happy Thanksgiving

Reversing Type 2

Diabetes With

Natural Therapies

Gluten-Free

Kitchen Essentials

Helping Clients

With Binge Eating Disorder

Pumpkin

Soup

AMERICAN DIABETES MONTH

hh h als the T

hhh

enks

N DIA

Healthier Frozen Foods Take

Center Stage

Dairy’s Role in Improving School Nutrition

Combating Clostridium

Diffi cile

FNCE 2012 CONFERENCE ISSUE

on The Real

Today’s Dietitian Investigates the Sugar Debate


October 2012

Vol. 14 No. 10


wwww.TodaysDietitian.com


Center Stage

Dairy’s Rolein Improving School Nutrition


Difficilefifi

December 2012

Vol. 14 No. 12



TraditionalHoliday FoodsClients Can Enjoy the

Foods They Love and Keep

Their Meals Nutritious

2013Buyers’GuidePreventing Vitamin D Defi ciency in ChildrenFiber Facts About Cereal

Do Food DesertsReally Exist?

TD1212.indd 1Phone: 800-278-4400 • E-mail: [email protected]

www.TodaysDietitian.comwww.TodaysDietitian.com

TD_2013_Subform.indd 1 1/2/13 11:52 AM

RISING FOOD COSTSHow Last Year’s Drought May Affect This Year’s Prices By David Yeager

No one can say with certainty whether climate change is directly responsible for the droughts that have plagued the United States over the past couple years, but you can’t deny that 2011 and 2012 brought exceptionally dry weather to significant portions of the country.

In 2011, the most severe drought in decades hit large seg-ments of Texas, decimating the state’s cattle industry. In 2012, the Midwest and its grain crops bore the brunt of the drought. Although fluctuations in rainfall occur every year, extended periods without enough rain could pose a serious problem for the United States in the future.

Jack Juvik, PhD, a professor and the graduate program coordinator in the department of crop sciences at the University of Illinois College of Agricultural, Consumer, and Environmental Sciences, says water issues are affecting most countries— dramatically in some cases—and the United States is no excep-tion. He cites areas of the Central Valley in California where the salt level of the soil already prevents the growth of a range of valuable crops. In places like this, long-term drought could be especially damaging. If water becomes scarcer, it could multiply this effect and lead to disputes among regions and states vying for use of the same major water systems.

“So not only is [water scarcity] going to affect what we can grow, it’s going to affect where we can grow, and it’s also going to lead to huge, huge battles, legal [battles] and, prob-ably, armed conflict [in some countries]. There are a lot of places right now that are on the edge of conflict due to the fact people are fighting for water rights,” Juvik explains. Since water is essential for life, it should come as no surprise that

between 80% and 90% of freshwater con-sumption in the United States is attributable to agriculture.

In his research, Juvik has measured varia-tions in phytochemical levels up to 20% in some drought-affected fruits and vegetables, but that effect is difficult to measure because each nutrient, as well as each fruit or vegetable, is affected differently. However, these variations aren’t 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 that’s used on crops, particularly those that require irrigation. Where farmers once flooded fields

and orchards, those who can afford it have switched to more efficient drip irrigation systems. Most fruits and vegetables require irrigation.

The United States also imports a significant amount of pro-duce, such as bananas, tomatoes, melons, peppers, and pota-toes, from other countries. For these reasons, food price increases for produce probably have been less related to water availability than to other factors such as transportation and refrigeration costs. As long as farmers can maintain irrigation, the availability of produce should remain stable.

Hidden CostsAfter Hurricane Sandy pummeled the East Coast in October

2012, many Americans probably forgot about the oppressive heat and drought that affected a large part of the country this past summer. But with nearly two-thirds of the United States still affected by drought, consumers could feel the effects well into this year.

Because the drought was concentrated in the Midwest, the crops hit hardest were grain products such as corn, soybeans, and wheat, which aren’t irrigated. Aside from the obvious rise in the cost of these staple crops, David Bitter, CEO of Cropfax, a provider of seed selection decision-making tools, says prices are likely to rise for nearly all food products.

“Grains are just such large volume [items], and they go into everything. Corn is in [nearly] everything that has been pro-cessed, and you’ve got aisles and aisles of it,” Bitter says. “You’ve got one small produce section in the store, which is kind of like the jewel in the crown; you’ve got strawberries, you’ve got fresh fruit. But the rest of the store, unless it’s a bottled fruit or a packaged fruit, is pretty much a derivative of corn or soy or wheat: your granola bars, your cereals, your chips.”

Higher grain prices also are reflected in the cost of animal feed. This affects food costs because it increases the cost of

FOR YOUR INFORMATION


animal farming. Animal products already cost more to produce than vegetable products, and drought exacerbates these costs.

“The consumption of water for the production of meats—for beef, poultry, hogs, etc—per acre and per pound of product out-strips produce and grain by many, many factors,” Bitter says. “So it [seems likely that] if you have a higher cost of grain and a scarcity of water, meat prices will continue to escalate.”

Overall, the USDA forecasts that food prices will rise 3% to 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%.

Stretching Food BudgetsTaken together, these factors suggest that

consumers will need to stretch their food budgets a little further than usual. Dee Sandquist, MS, RD, LD, CDE, a spokesperson for the Academy of Nutrition and Dietetics, says small changes in food buying and preparation can make a big dif-ference. While the additional cost of meat may be challenging, there are ways to work around it. One way is to purchase cheaper cuts of meat for some meals. Another is to add plant protein.

“Some people will choose to eat more plant-based proteins, and that’s certainly a healthful choice,” Sandquist says. “So it might be a good time to mix some lentils in with that ground beef if you want to stretch your food dollar a little bit more.”

Cooking at home rather than eating out also can save a significant amount of money. This requires more of a time investment, but it doesn’t have to become a burden. Clients can cook a large batch of food and freeze a portion for later use to save time in the kitchen.

Buying raw ingredients can cut costs, too. A 5-lb bag of potatoes costs much less per pound than a 1-lb bag of potato chips, and it will go much further toward meeting nutri-tional needs. Beware of overbuying, though. A recent report from the Natural Resources Defense Council estimated that Americans waste as much as 40% of the food they buy, resulting in a loss of $165 billion per year. The best way to save money on food is to plan meals and eat what’s already in the house.

“All it takes is five minutes of planning before you go to the store. Look at your

schedule for the next week so you’re able to buy accordingly, especially produce,” Sandquist says. “Will you be home or are you going to be gone? If it’s a week when you’re out a lot, you’re not going to have a chance to eat that produce unless you take it with you for a snack.”

— David Yeager is a freelance writer and editor based in Royersford, Pennsylvania.

• No cost to get started

• Participate in Nationwide

Physician Referral Network

• Results are available online

within 5 business days

of testing

• Mobile blood draw service

available in US and Canada

• FDA inspected, registered

“The ALCAT Test is the most effective tool Iuse in my practice to assist my patients inthe management of food sensitivity andintolerance” -Lea Russell, MBA, RD, LD/N, Nutrition Health Services, Tampa, Florida www.nutritionhealthservices.com

Grow your practice and improvepatient outcomes with the leader

in food sensitivity testingFor almost 25 years, The ALCAT Test has provided physicians and theirpatients with a tool to successfully overcome a wide variety of conditions

resulting from food and chemical intolerances.

The ALCAT Test accurately measures immune reactionsto over 290 foods, additives and environmental chemicals using just a small quantity of blood.

• CLIA licensed and inspected

• Available in over 20

countries worldwide

• 98% success in body

composition improvement

and/or weight loss (Baylor

Med. College)

• Awarded 3 US patents

• Supported by European Union

If you see patients who suffer from migraine headaches, IBS,asthma, chronic inflammation, ADD, fatigue, eczema or

simply can’t lose weight, call us today!

USC

Safety

tested

Production

monitored

PRODUCT SERVICE

NRTL

Cell Science Systems, Corp. 1(800) US-ALCAT (872-5228) 1-954-426-2304 www.ALCAT.com ALCAT Europe GmbH August-Bebel Str. 68, 14482 Potsdam

t. +49 (0)331 74 00 88-0 f. +49 (0)331 74 00 88-29 www.ALCAT-Europe.com

Half page Lea Russel_Layout 1 12/3/12 1:39 PM Page 1


Whether clients follow the diet because of celiac disease or the less understood gluten sensitivity, RDs serve as a guide for patients on a lifelong quest to relieve symptoms and improve health.

BY MAURA KELLER

Gluten-FreeJourneyThe

A fter months of gastrointestinal discom-fort, abdominal pain, and bloating followed by weeks of medical testing, Susan finally learned she has celiac disease. Frightened, confused, and overwhelmed about the next steps in her new restricted dietary lifestyle,

she turned to an RD her physician recommended. The RD faces the challenge of calming her new patient, educating Susan about the celiac disease diagnosis, and walking with her along a journey fraught with misinformation and confusion.

Celiac Disease vs. Gluten SensitivityIt’s not surprising that many patients newly diagnosed with

celiac disease become overwhelmed at the thought of modi-fying their lifestyle, including what they can and cannot eat in restaurants and at parties. Fortunately, Susan and others with celiac disease aren’t alone in their journey. According to Rachel Begun, MS, RD, CDN, a food and nutrition consultant and spokesperson for the Academy of Nutrition and Dietetics (the Academy), approximately 1% of the population has celiac dis-ease, and about 90% of them are undiagnosed or misdiagnosed.

“A bigger portion of the population experiences gluten sen-sitivity to varying degrees. Estimates are that as much as 6% of the population, or 20 million Americans, may be gluten sensi-tive,” Begun says.

Celiac disease is an autoimmune disorder in which the body triggers an attack on the intestines every time gluten is eaten, Begun says. Inflammation and damage occur in the small intes-tine and nutrients can’t be absorbed, leading to nutrition defi-ciencies and a wide range of symptoms.

Begun says many people with the disease are asymptomatic and thus don’t experience any negative symptoms after eating gluten. “They are, however, experiencing the same damage to the intestines as those who do experience symptoms,” she cautions.

According to the National Foundation for Celiac Awareness, non-celiac gluten sensitivity is found in “individuals who cannot tolerate gluten and experience symptoms similar to those with celiac disease but yet who lack the same antibodies and intes-tinal damage as seen in celiac disease. Early research sug-gests that non-celiac gluten sensitivity is an innate immune response, as opposed to an adaptive immune response (such as autoimmune) or allergic reaction.”

“We don’t know much about gluten sensitivity just yet, but we do know that it’s a unique condition from celiac disease and involves an immune response,” Begun says. “While symptoms of gluten sensitivity can be similar to those of celiac disease, people with gluten sensitivity don’t produce antibodies to gluten or show signs of damage to the intestine.”

Dietary TreatmentLaura Jeffers, MEd, RD, LD, says patients usually are eager

to embrace the gluten-free (GF) lifestyle once they realize how it will benefit them: symptom relief, more energy, better health

status, and an improved quality of life. Jeffers, outpatient man-ager for nutrition therapy at the Digestive Disease Institute at the Cleveland Clinic, teaches patients the importance of adopt-ing the changes involved in living GF for the long haul.

“I stress the importance of GF for life,” Jeffers says. “No small bites every now and then and no ‘mostly GF.’ I also explain that wheat free is not gluten free and that reading labels must become a habit. While there’s no cure for [celiac disease], the GF diet can relieve symptoms of the disease, and patients can feel healthy and full of energy while on the diet. The mucosal damage is a result of a genetic predisposition in combination with environmental factors and inflammation that ‘s immune based.” Therefore it’s important for dietitians to clarify with their patients that even the tiniest amount of gluten may cause intestinal damage even if there are no overt symptoms.

“Some patients are in a state of shock when they find out they have a type of condition that’s not going to go away,” says Lenore Wespetal, MS, RD, CDE, a certified diabetes educator at Shawano Medical Center in Wisconsin.

Gluten BuzzwordsRDs need to educate their clients with celiac dis-

ease about the “buzzwords” on food labels that may indicate the presence of gluten. These buzzwords include wheat, rye, oats, barley, malt, and brewer’s yeast. (Note: If the oats are labeled as gluten free, they’re safe to eat as part of a gluten-free diet.)

“Wheat is required to be identified [on a food label], as it is one of the top eight allergens that have to be declared on the label, according to the Food and Drug Administration’s Food Allergy and Consumer Pro-tection Act,” explains Mary K. Sharrett, MS, RD, LD, CNSD. “Rye and oats aren’t hidden in any ingredients, although oats need to be labeled gluten free to be sure they’re uncontaminated. Barley is almost always listed as barley or malt. Brewer’s yeast is likely to be con-taminated with barley.”

Sharrett says hidden wheat may be found in prod-ucts governed by the USDA because they don’t have to follow the FDA’s allergy labeling laws. “Therefore wheat may be in modified food starch, starch, or dex-trin,” Sharrett says. “The good news is that 80% to 90% of these companies do identify allergens.”

To identify a USDA-inspected food (eg, processed meat, poultry, eggs, and some mixed food products, such as soups containing meat) look for an “Inspected by the USDA” stamp on the front of the package.

— MK


Most of Begun’s patients feel overwhelmed with the dietary changes that are part of a GF diet. “In particular, parents of [young] celiac disease patients can feel overwhelmed knowing they’re responsible for ensuring their kids avoid gluten. While some are relieved knowing they finally have found the answer to their health issues, others are in denial about having to change their diet,” Begun says. “There’s also the emotional part that comes with the social aspects of eating. People are worried they won’t be able to enjoy eating out which, for many, is an important part of socializing with friends and family. In the end, though, most are happy to be feeling better and doing the right thing for their long-term health.”

To Eat or Not to EatThe key types of “common” foods that are safe for patients

with celiac disease include naturally GF items such as fruits, vegetables, meats, nuts, legumes, fish, poultry, eggs, and most dairy (eg, cheese, yogurt, cottage cheese). GF grains include rice and corn. Some less familiar GF options include flaxseeds, nut and bean flours, potato starch, quinoa, rice bran, teff, wild rice, tapioca, buckwheat, arrowroot, millet, amaranth, chia seeds, mesquite, montina, sago, and sorghum. Oats also are consid-ered GF but only if they’re labeled as such.

Begun stresses RDs need to help their patients with celiac disease focus their diet on naturally GF foods rather than GF packaged alternatives. “It’s even more important to get this message across with newly diagnosed patients because their bodies have been devoid of nutrients and need to heal,” she says.

“Nutrient-dense foods remedy nutrition deficiencies and help the body to heal faster.”

It’s also important to meet patients where they are in terms of current lifestyle and dietary patterns. “If a patient has no cook-ing skills and is traveling for business five days a week, then it’s a good idea to focus first on how to handle themselves in a res-taurant,” Begun says. “For the mother who’s making most of the child’s meals and snacks at home, then you want to teach them how to make smart choices at the grocery store as well as intro-duce them to common ingredients used in gluten-free cooking and baking.”

Avoiding cross-contamination when following a GF diet is of utmost importance. “It’s very important to discuss cross-contamination with newly diagnosed patients,” Jeffers says. “It’s important for patients to understand how easily foods can become contaminated with gluten. If a gluten bun on a sandwich is removed and replaced with the GF bread, it’s too late. Or if there are croutons on the salad and [they’re] picked off, the salad shouldn’t be eaten since it was already contaminated.”

Additionally, gluten can be spread from containers of food, such as peanut butter and jelly, when a knife that has touched gluten-containing bread is dipped into the jar. It’s also important to use separate toasters and related small appliances as well as cutting boards and dishes when handling both GF and non-GF foods. If this isn’t possible, the item must be thoroughly cleaned to remove any traces of gluten to avoid cross-contamination.

“Be sure to tell patients to read the food labels of their favor-ite foods every six months, as ingredients can change at any time and some products that didn’t contain gluten in the past may contain it now,” Jeffers says.

Helping People AdaptMary K. Sharrett, MS, RD, LD, CNSD, a clinical dietitian in

nutritional support services at Nationwide Children’s Hospital in Columbus, Ohio, suggests RDs schedule two 45-minute to one-hour sessions with clients newly diagnosed with celiac disease because they’ll have numerous questions, as there’s much to learn about following a GF diet.

“If you don’t know the answer, don’t try to guess. Tell them you’ll get back to them and then find an expert to help you,” says Sharrett, who’s also a member of the Academy’s celiac disease expert workgroup for the Evidence-Based Analysis Library and the founder and dietitian advisor for the Gluten-Free Gang, a celiac disease support group. “The Academy’s Medical Nutrition Practice Group has a subunit called Dietitians in Gluten Intoler-ance Disease with lots of experts.”

Sharrett also recommends RDs provide a few naturally GF recipes to help clients start their journey. Moreover, RDs should determine some of their client’s favorite meals and provide sug-gestions for making them GF. For instance, if a client enjoys tacos, suggesting a GF brand of taco seasoning is a good fix.

“For patients having difficulty adhering to the diet, encourage them to get involved with a support group, online or in person,”

Snacks AplentyWhile preparing gluten-free meals takes some effort

to evaluate ingredients and identify gluten-free recipes, snack options are plentiful:

•Gluten-free corn tortilla chips are available in white, yellow, and blue varieties. You can enjoy some great flavor combinations when you pair them with salsa, hummus, cherry tomatoes, carrot sticks, or tart apple slices.

•A handful of nuts or roasted soy nuts is a protein-rich snack and easy to store in your pantry, a desk drawer, a gym bag, or a purse.

•Enjoy a gluten-free bagel or slices of bread with peanut butter.

•Try orange slices with sugar snap peas when you know your next meal will be delayed.

•Make your own snack mix with gluten-free cereal squares, dried fruit, and sunflower or pumpkin seeds.

— MK


Jeffers says. “Also, let patients know there are many great online sources of gluten-free products, and some compa-nies will send samples.”

Wespetal says it’s also important to determine what research the patient already has done regarding celiac dis-ease and a GF diet. “This will help clarify any misconceptions the patient may have about what celiac disease is and what their role is in managing it,” she says. “Also, RDs should explain how to review ingredient lists on food packages. Is it clear to them that ‘wheat free’ does not mean ‘gluten free’? Finally, use follow-up visits to assess the nutritional adequacy of the patient’s typical eating pattern, especially fiber and B vitamins.”

“Your patients become very informed and may teach you something along the way,” Jeffers says. “There’s nothing wrong with learning from your patients especially since they’re living it on a daily basis.”

Eating OutFor many people with celiac disease,

eating at restaurants or attending par-ties especially may cause frustration and fear. “To increase the likelihood of getting a safe meal, call the restaurant ahead of time to let them know about your gluten-free needs,” Begun says. “Right from the beginning you’ll know if the restaurant isn’t knowledgeable about serving people with dietary restric-tions. If you get that gut feeling that they don’t know what you’re talking about, it’s a red flag to make reservations some-where else. I also recommend review-ing the restaurant’s menu ahead of time so you can narrow down your choices and have a more focused conversation with the server. This is easier for the server, which makes it more likely you’ll get a gluten-free meal.”

When counseling patients about eating out or attending parties, Jeffers suggests giving them the following tips:•Before going to a restaurant, try to

view the menu online and identify pos-sible GF items in advance. •Let the server know that you can’t eat

gluten, which includes avoiding wheat,

rye, barley, and derivatives of those sources.•Salads should never have croutons,

and confirm that salad ingredients are GF before consumption.•Always ask before ordering. Flour

often is used to thicken soups, and meats may contain fillers made of gluten. •Avoid anything described as being

encrusted, breaded, marinated, or served in an unknown broth.•Fried foods must be fried in separate

oil to be considered GF.•Consider bringing your own GF bread

or crackers.•Consider eating out at an ethnic res-

taurant, as many of the foods may be from GF sources (eg, rice, corn).At parties, if possible, clients with

celiac disease should speak with the host to make him or her aware of their need to avoid gluten, preferably with enough advance notice so the host can adjust the menu accordingly. Begun suggests offer-ing to make one or two dishes if the party is more intimate, as this ensures “safe” items for the client to eat and takes pres-sure off the host. The following are some additional tips:•Don’t attend the party hungry, as there

may be few GF items from which to choose.•Bring your own GF bread or crackers

or a GF item to share. •Never assume something is GF. Con-

firm that it’s safe before eating it. •Fresh fruits, vegetables, dairy items,

and fish are safe options as long as they didn’t come in contact with any products containing gluten.

Silver Lining Though following a GF diet may seem

daunting at first, clients with celiac dis-ease or gluten sensitivity, with the help of knowledgeable RDs, easily can navi-gate their way through daily living as well as special events without worrying that gluten will cross their lips and potentially cause problems once again.

— Maura Keller is a Minneapolis-based freelance writer and editor.


ETHICALDECISION MAKING

The Dietitian’s Role in

End-of-Life Healthcare

When Considering Enteral and Parenteral Nutrition

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


A n 85-year-old man was admitted to an acute care facility after suffering a stroke. Despite his advanced age and history of progressive dementia, his

family never prepared documents that addressed advance care planning, which would have desig-nated a surrogate decision maker and indicated his wishes for his end-of-life healthcare.

Before his hospitalization, the patient was living with the youngest of his three adult children, the only daughter. A swallow evaluation by a speech pathologist indicated severe dysphagia. The speech pathologist recommended discontinuing oral feedings and starting the patient on tube feeding.

The physician requested that an RD perform a nutrition consultation to initiate a nasogastric tube feeding and progress the feeding to meet the patient’s nutrient needs. After the RD reviewed the patient’s medical record and consulted with the RN, the dietitian discussed plans for the tube feeding with the patient’s daughter at her father’s bedside. The RD verbally presented information about the tube feeding and provided written infor-mation to ensure health literacy, asking the daughter to reiterate and demonstrate what was discussed—a communication technique called the teach-back method.

During this exchange, the daughter indicated that her father never wanted a feeding tube or other medical therapies that would prevent him from enjoying simple daily activities. The daughter said her brothers wanted their father to receive nutrition through tubes and all other medical therapies needed to prolong his life. They were adamant that “everything be done” to extend their father’s life, from a feeding tube to a ventilator to cardiopulmonary resuscitation. This potential conflict between siblings is all too common when dealing with end-of-life healthcare decisions, commonly known as ethical dilemmas.

This article will discuss this common occur-rence, the importance of discussing end-of-life healthcare issues with patients and family mem-bers while honoring patients’ wishes, strategies to prevent conflict, and the RD’s role in ethical deci-sion making in the context of enteral and paren-teral nutrition.

Ethical Dilemma Issues and StakeholdersThe above case study is an example of inade-

quate family communication without written documentation about end-of-life healthcare

wishes. Without documents for advance care planning in a patient’s healthcare record, the clinical ethical dilemma—a difficult problem involving moral conflicts for which there seems to be no satisfactory solution—is now set in motion. This can result in the patient receiving medical treatments that go against his or her wishes and family members making decisions without the individual’s input.

Yet the goal of any healthcare team is to provide appropriate and effective patient-centered care based on the individual’s wishes. From the team members’ perspective, they should deliver medi-cally appropriate treatment using evidence-based medicine and assess the benefits and risks/burdens involved. And they should adhere to their institu-tion’s policies and procedures for ethical decision making regarding artificial nutrition.1 Such care is difficult to provide in the case presented due to the clinical ethical dilemma of family members in con-flict with the patient’s wishes.

The ways in which people deal with issues of serious illness often are shaped by their faith and culture. Individuals with different faiths and cul-tures have diverse perspectives on the use of life-sustaining therapies, the communication process for delivering health information directly to the patient vs. through the family, and the fam-ily’s role in the decision-making process for healthcare at the end of one’s life.2

The dietitian’s understanding of cultural and religious diversity is necessary to best meet the needs of a heterogeneous patient population. Diversity awareness gives the RD the ability to tailor information to patients, families, and sig-nificant others, and promote understanding of decision making when dealing with the use of artificial nutrition. And awareness of different cultures and faiths furthers an RD’s understanding of diversity in clinical ethics, which promotes making right choices and decisions in health-care delivery.

Although the patient is the predominate stake-holder in this process, the concerns of the family, physician, dietitian, and other healthcare providers are what comprise the process of providing the most appropriate nutrition therapy intervention. The patient’s best interests always should be at the center of healthcare decisions. Patient-centered care is defined as care that’s respectful of the individual person and responsive to his or her preferences, needs, and values and that ensures


patient values guide all decisions.3 The focus of healthcare should be shifted away from managing just the disease and back to patients and their families, the major stakeholders in the process.4

Health Literacy and the Teach-Back MethodThe use of evidence-based practice guidelines, such as those

from the Academy of Nutrition and Dietetics (the Academy), is beneficial in providing appropriate patient education informa-tion.5 As indicated in the education process with the daughter in the aforementioned case study, the RD was concerned about presenting the information in simple terms due to the issue of health literacy. Health literacy is defined as the degree to which individuals obtain, process, and understand basic health infor-mation and services to make appropriate healthcare decisions.6 It involves a range of social, cultural, and individual factors, such as age, education, and race.

Due to concerns for improving health literacy, the RD used the teach-back technique with the daughter while edu-cating her about tube feeding. This is an effective method to ensure individuals understand what they’ve been told. The process involves asking the individual to explain or demon-strate what he or she was taught. If the person doesn’t explain correctly what he or she learned, the assumption is that the information wasn’t presented effectively. If this is the case, the RD would explain the information again but use an alter-native approach.7

In addition to verbal communication, understanding the printed information is a significant factor that affects the impact of the message. The printed educational material the dietitian gave the daughter was written in accordance with the teach-back method. A fifth-grade reading level or lower is recommended for informational material and has been identified as a criterion for low literacy.5

Awareness of health literacy concerns and the use of the teach-back method are aspects of patient-centered care RDs can use to improve communication with patients and their families. Moreover, RDs should be aware of comparative

clinical effectiveness research, which determines what treat-ment works best, for whom, and under what circumstances, to enhance the decision maker’s ability to fully understand and weigh the alternative healthcare options available.8

Preventive Ethics and the RD’s RoleAnother important aspect of end-of-life care for dietitians is

the practice of preventive ethics. Preventive ethics suggest that ethical conflict between family members is largely pre-dictable, but it can be avoided through interventions aimed at the organization, the patient care unit, and the individuals involved. The goals of preventive ethics are to identify common triggers of ethical conflict, such as unrealistic expectations that treatment will be effective, and address them before they contribute to conflict. Preventive ethics would have provided options for the RD and other healthcare clinicians involving the 85-year-old father and his children to implement a pro-active process to reduce the potential conflict among them. Preventive ethics represents a dramatic shift from the tra-ditional ethics approach, which involves reacting to ethically challenging patient situations on a case-by-case basis.9

RDs maintain a unique role in the hospital setting. They’re in a position to develop nutrition screening parameters for all patients and implement the nutrition care process. This process may call for initiating enteral or parenteral nutrition. But what if this therapy isn’t congruent with the patient’s wishes based on his or her quality-of-life goals? To avoid such dilemmas, RDs can screen for quality-of-life goals before initiating the nutrition care process. They can review the medical record for an advance directive—written documentation of treatment preferences and the designation of a surrogate decision maker—and discuss their findings with other healthcare team members.1

Dietitians are in the best position to improve ethical decision making for enteral and parenteral nutrition because they can facilitate an interprofessional, collegial approach to whole patient-centered care while delivering nutrition therapies. This approach involves two or more medical professionals working together as a team with a common purpose and commitment, and with mutual respect. The process involves the RD being aware of the role of nutrition as it relates to the physical, emotional, and spiritual needs of the patient, when applicable, and relaying this information to the other health-care team members.

The word “nutrition” connotes a sense of vibrancy and life. The hope is that nutrition, for some patients, will open the door that leads to advance care planning and end-of-life discussions in the hospital setting. Dietitians already have formed bridges between themselves and other medical fields, for example, through discussions with physicians about optimal placement of small-bowel feeding tubes beyond the ligament of Treitz under specific conditions, and with respiratory therapists about the impact of nutrition substrates on blood gases and

Triggers for Cue-Based Patient/Family Discussion• Patient/family are healthcare team members.• Patient-/person-centered healthcare is based on

patient wishes.• The family expresses what the patient would want.• Family/surrogate decision maker’s role is to repre-

sent the patient’s wishes, not their own.


pulmonary function. And RDs can learn to incorporate ethics in the decision-making process by integrating clinical ethics into their dietetic practices. They can become knowl-edgeable about advance care planning terms and learn how to promote conversations about nutrition with patients and their families, which can lead to a transformation in nutri-tion support practice.

Collaboration with the physician, nurse, social worker, chaplain, palliative care team, and other healthcare team members is optimal to facilitate this process. Dietitians who learn more about advance directives, living wills, durable power of attorney for healthcare (a legal document in which a competent person gives another person the power to make healthcare decisions for him or her if unable to make those decisions personally), and physician orders for life-sustaining treatment have an advantage in understanding documents in the patient’s medical record.

Cue-Based Patient/Family DiscussionOne way to promote conversations about nutrition ther-

apy with families is to learn about cue-based patient/family discussion. This involves listening for specific key words or trigger phrases from a patient or family member expressing he or she doesn’t want a particular therapy, such as a feeding tube. RDs can use this response to begin cue-based discus-sions about quality-of-life goals while educating patients and family members about nutrition therapies.

To begin, dietitians can tell family members the goal is to provide enteral or parenteral nutrition support based on the patient’s wishes. The sidebar on page 30 presents examples of these triggers for cue-based discussion that can lead a patient or family to understand that the focus should be on the patient’s wishes.

This process is especially useful when the patient is on a ventilator or unable to communicate. The important concept is that family members or surrogate decision makers must understand that their role is to represent the patient’s wishes and not their own. Based on the cues given by the patient or family, dietitians can refer further discussions to the physi-cian, nurse, social worker, or chaplain. Documenting these referrals in the medical record is essential. The verbal and written interprofessional communication is important to facilitate a consistent healthcare team approach. The primary care physician is the coordinator of the clinical ethics process with the patient, family, and healthcare team. RDs and other healthcare professionals help contribute to the clinical ethics process regarding artificial nutrition.

Action Steps for Process Improvement Both the American Society for Parenteral and Enteral

Nutrition (ASPEN) and the Academy provide resources for healthcare professionals on ethical considerations regarding

nutrition therapies, including recommendations and guide-lines.10,11 The first step for healthcare institutions is to incorporate these recommendations when developing ethical decision making for artificial nutrition policy and procedure. Recommen-dations and guidelines from other societies and organizations are important to include in these documents based on the patient population characteristics and religious affiliation of the healthcare facility. It’s important to develop the policy and procedure in collaboration with all healthcare professionals involved in the process to encourage acceptance of the final document. A sample policy and procedure for dealing with ethical decision making for artificial nutrition has been pub-lished in The ASPEN Adult Nutrition Support Core Curriculum.12

The second step for healthcare institutions involves imple-menting the policies and procedures needed to improve com-munication among patients, families, and healthcare providers regarding clinical ethics and nutrition therapies. To sustain improvements in practice, the facility needs to standardize a proactive, integrated, systematic process that focuses on patient-centered care and communication.

The third step involves designing an improvement project dealing with clinical ethics and artificial nutrition with mea-surable goals, along with developing a plan to remeasure the data. An example of measurable goals can include the number of patients receiving nutrition support that have an advance directive in their chart, the number of patients with family care conferences, or the reduction in the number of bioethics consults, which involve mediation to obtain a con-sensus among individuals in conflict concerning artificial nutrition issues. Even incorporating an analysis involving patient satisfaction can facilitate process improvements.1,13

The final step involves presenting information about best practices with other facilities at national meetings and publish-ing data. Accomplishing this step would help dietitians in private practice improve patient-centered care by standardizing the incorporation of clinical ethics in the field of nutrition support.1,13

Engaging the Public in End-of-Life ConversationsTo engage the public in end-of-life healthcare conversations,

healthcare professionals must educate themselves about the process and become aware of resources and tools available (see sidebar on page 32).

End-of-life conversations don’t involve just the elderly and their adult children; they affect everyone in some capacity. In the hospital setting, patient-centered care is best achieved when all healthcare professionals communicate and are engaged in the conversation to provide a consistent healthcare team approach.14

Perhaps if RDs and other healthcare team members embrace these conversations in their professional and personal lives, the public will become more engaged in end-of-life healthcare discussions. Recognizing the importance of com-munication in families and acting on these discussions is the


best way to prevent clinical ethics dilemmas and provide whole patient-centered care in the hospital. In the future, the goal will be for everyone to have advance care planning discussions with their family and written documentation before an illness develops and hospitalization follows. Dietitians are essential healthcare team members involved in clinical ethics due to their role in the optimal use of enteral and parenteral nutrition—and they can make a difference.

— Denise Baird Schwartz, MS, RD, FADA, CNSC, is the nutrition support coordinator at Providence

Saint Joseph Medical Center in Burbank, California, and has been recognized both nationally and

internationally as a speaker on nutrition support topics for the critically ill.

References1. Schwartz DB. Ethical considerations in the critically ill

patient. In: Cresci G, ed. Nutritional Therapy for the Critically Ill Patient: A Guide to Practice. 2nd ed. Boca Raton, FL: Taylor & Francis; 2013 (in press).

2. Preedy VR, ed. Diet and Nutrition in Palliative Care. Boca Raton, FL: CRC Press; 2011.

3. Barry MJ, Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780-781.

4. Reuben DB, Tinetti ME. Goal-oriented patient care—an alternative health outcomes paradigm. N Engl J Med. 2012;366(9):777-779.

5. Gallagher-Allred CR. Communication and education for families dealing with end-of-life decisions. J Acad Nutr Diet. 2012;112(2):309-310.

6. Carbone ET, Zoellner JM. Nutrition and health literacy: a systematic review to inform nutrition research and practice. J Acad Nutr Diet. 2012;112(2):254-265.

7. Weiss BD. Health Literacy and Patient Safety: Help Patients Understand. 2nd ed. Chicago, IL: American Medical Association Foundation; 2007.

8. Gabriel SE, Normand SL. Getting the methods right—the foundation of patient-centered outcomes research. N Engl J Med. 2012;367(9):787-790.

9. Epstein EG. Preventive ethics in the intensive care unit. Am Assoc Crit Care Nurs. 2012;23(12):217-224.

10. Barrocas A, Geppert C, Durfee SM, et al. A.S.P.E.N. ethics position paper. Nutr Clinc Prac. 2010;25(6):672-679.

11. O’Sullivan Maillet J. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2008;108(5):873-882.

12. Geppert CMA, Barrocas A, Schwartz DB. Ethics and law. In: Mueller C, McClave SA, Schwartz DB, Kovacevich D, Miller SJ, eds. The A.S.P.E.N. Adult Nutrition Support Core Curriculum. 2nd ed. Springfield, MD: American Society for Parenteral and Enteral Nutrition; 2012: 656-676.

13. Schwartz DB. Three steps for improving end-of-life nutrition care. Clinical Nutrition Insight. 2012;38(10):4-5.

14. Schwartz DB. Clinical ethics and nutrition support. J Nutr Therapeutics. 2012;1(1):86-90.

Resources and Tools•National Healthcare Decisions Day (www.nhdd.org):

Held annually on April 16, the goal of this day is to inspire, educate, and empower the public and healthcare provid-ers regarding the importance of advance care planning. Resources for activities to promote this day are available on the website.•Speak Up Campaign (www.advancecareplanning.ca):

This campaign is designed to promote advance care plan-ning in Canada. It was developed to raise awareness of the importance of advance care planning and end-of-life care. The website provides a kit with material to pro-mote advance care planning.•Aging With Dignity’s Five Wishes (www.agingwith

dignity.org/five-wishes.php): This guide helps start impor-tant conversations about end-of-life care. It provides a documentation tool for detailing an individual’s wishes.

•Physician Orders for Life-Sustaining Treatment (www.polst.org): This is based on effective communication of patient wishes. It involves documenting medical orders on a brightly colored form and includes a paradigm program to improve the quality of care people receive at the end of life.•The Conversation Project (www.theconversation

project.org): The goal of this project is to have every person’s end-of-life preferences expressed and respected. It includes a starter kit to help initiate conversations with loved ones regarding end-of-life care wishes.•Breathe — a True Story of Letting Go of My Parents

Gracefully, For I Will See Them Again (www.breathe-annebland.com): This book is a healthcare professional’s personal story intended to help others begin the dialogue with family members about end-of-life care decisions. Per-sonal stories such as this one are intended to help individu-als deal with family relationships, faith, and values and are designed for both healthcare professionals and the public.


http://www.nhdd.org

http://www.advancecareplanning.ca

http://www.agingwithdignity.org/five-wishes.php

http://www.agingwithdignity.org/five-wishes.php

http://www.polst.org

http://www.polst.org

http://www.theconversationproject.org

http://www.theconversationproject.org

Get a

for your career!

Whether you’re actively seeking employment or browsing

for a better opportunity, AlliedHealthCareers.com is the

fresh start you need to plan your next career move. With

a job seeker account, you can manage your résumé,

view job offers, and even create personal job alerts

so that you can stay up-to-date on the most recent

positions that match your search criteria!

Give your résumé a few touch-ups and log on to

AlliedHealthCareers.com

set up a jobseeker account and

start searching for your next position!

FreshStart_FP.indd 1 10/24/12 4:35 PM

HealthfulSchool Lunches

Are the New Standards All They’re Cracked up to Be?

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.

By Lori Zanteson


The start of the school year welcomes students with the promise and expectation of filling their minds with knowledge and—for the 32 million in our nation’s school meal programs—their bodies with nutritious foods. Only this year the implementation of the new federal lunch

standards mandated by the Healthy, Hunger-Free Kids Act of 2010 is—ironically—leaving kids hungry.

And this youngest generation is speaking out. Fueled by the pangs of their growling bellies, complaints from our nation’s youths have spread across the country via blogs, websites, boycotts, strikes and, most famously, YouTube.

One Million Hits and CountingA video parody—viewed more than 1 million times—has

students singing “We Are Hungry” to the tune of fun.’s “We Are Young.” The student-teacher compilation, made in the high school of a small Kansas town, protests the lower calo-ries and limited carbohydrates and proteins under the new lunch standards.

The video features scenes of “starving” athletes collaps-ing during after-school practice, a student who falls asleep in class, and elementary school students crawling out of a school building, presumably dragging due to hunger, all set to a chorus of “Tonight/We are hungry/Set the policy on fire/It can burn brighter/Than the sun.”

A call to action, the video opens with statistics on the minimum calories necessary for high school athletes and ends with a plea to all students to voice their opinion.

What’s Changed?�The video grabbed the media’s attention, cranking up several

notches the volume of the public outcry and putting the new school lunch standards into mainstream focus. The perception is that the new lunch standards serve a radically changed menu from previous years, certainly one that skimps on calories. In reality, most of the changes have been progres-sively introduced in schools since 2009 when the Institute of Medicine developed recommendations that formed the basis for these standards in direct response to the childhood obesity epidemic. School nutrition professionals who were aware of the pending recommendations to increase the amount of fruits, vegetables, and whole grains served and lower sodium, saturated fat, and calories got right to work.

Many schools embraced the imminent changes in policy and worked hard to introduce and integrate new and colorful fruits and vegetables into their meal programs so the eventual adoption of new standards would be an easy and seamless transition. Programs such as “A Tasting of the Rainbow” at Anne Arundel County Public Schools in Maryland showcased a variety of fruits and vegetables—some the children had never seen before—and encouraged them to taste a free

sample. The response, according to Jodi Risse, MS, RD, LDN, division of food and nutrition services, was positive on the lunch line where these featured fruits and veggies were incorporated into the menu. Familiarity was the first step toward broadening the children’s formative palates.

Out With the OldThere’s no argument that the new lunch standards are an

improvement over the old lunch standards, which had been untouched for more than 15 years. During her 1998 dietetic internship, Laura Cipullo, RD, CDE, CEDS, CDN, of Whole Nutrition Services, LLC, and MomDishesItOut.com, recalls visiting New York City schools and seeing banana bread with whole milk served for breakfast and pizza with whole milk and fruit for lunch. “I’m not a fan of school lunch in general,” she says, “but I feel the new standards are a step in the right direc-tion. Increasing whole grain specifications, providing colorful vegetables, and offering 1% milk are great new options.”

According to the USDA, a typical lunch menu under the old standards might include pizza sticks (3.8 oz) with 1⁄4 cup of marinara sauce, a banana, 1 oz of raisins, and 8 oz of whole milk. Compare that with a typical menu under the new stan-dards: one slice of whole wheat cheese pizza, 1⁄2 cup of sweet potato fries, 1⁄4 cup of raw grape tomatoes, 1⁄2 cup of applesauce, 8 oz of 1% milk, and 1 oz of low-fat ranch dip.

Key Word: CaloriesThe healthful addition of fruits and vegetables and even

whole grains isn’t the problem. Students say they’re not getting enough calories to satisfy their hunger.

Making Good of the New Standards

Here are some suggestions from Laura Cipullo, RD, CDE, CEDS, CDN, to help put a positive spin on the new school menu changes:• Periodically invite chefs to your school to teach

foodservice staff new, healthful recipes.• Rotate students through the school kitchen to help

prepare meals and offer new ideas for dishes.• Have children plant gardens and eat the food they

grow.• Include cooking classes in the school’s curriculum,

and teach kids how to make healthful, tasty food.• Create yearly school cookbooks featuring the

students’ favorite healthful recipes.• Teach students how to modify their favorite recipes

to develop more wholesome, healthful ones.


According to Deborah Beauvais, RD, CDN, SNS, district supervisor of school nutrition services in the Gates Chili Central and East Rochester Union Free school districts in western New York, that’s a case of perception vs. reality. “The calories a year ago were still in that same range,” she explains. The main difference is that the old standards set a target number of calories, which could be exceeded, while the new standards set a range of calories that’s capped with maximums. These guidelines are “based on science and are written for the center of the bell curve. It’s too much for some, too little for others,” she says.

A quick glance at government calorie recommendations confirms this. The USDA recommends that boys aged 14 to18 consume an average of 2,200 to 3,200 kcal/day and girls aged 14 to 18 take in 1,800 to 2,400 kcal/day for a healthful, balanced diet. Assuming the average teenage boy or girl falls somewhere in the middle of these ranges, the calories they consume at lunch will equate to about one-third of their daily calories. Assuming again that these teens are eating three meals as well as a snack or two each day, there shouldn’t be a calorie deficit.

However, the USDA clearly states that these ranges are estimated amounts of calories needed to maintain calorie balance and that individual calorie needs may be lower or higher. According to information from the American Dietetic Association Complete Food & Nutrition Guide by Roberta Larson Duyff, MS, RD, FADA, CFCS, those calorie require-ments jump to 3,500 or more for athletes and those involved in strenuous exercise.

One Size Doesn’t Fit AllClearly, every lunch won’t fulfill every student’s caloric

needs, but according to Beauvais, even the old standards didn’t sustain all the kids. Her first question for today’s stu-dents complaining of hunger is “Are you eating breakfast before you leave home or at school?” She says lunch isn’t intended to supply the entire day’s calories, but if students are hungry beyond what’s on their tray, schools offer extra portions. With all the choices of fresh fruits and vegetables at kids’ disposal, certainly something should be appealing, Beauvais adds.

Perhaps that appeal is partly to blame for the perceived calorie deficit. If kids don’t eat what’s offered, they’re not getting the calories and the energy available and necessary to sustain them throughout the afternoon. Cipullo noted the problem back in 1998 during her school tours. “Children were forced to take a minimum of each item even if they didn’t want to eat the food,” she says. “This created unnec-essary food waste. It was a huge problem then and is still a huge problem now.”

Cipullo believes the reason kids aren’t eating enough calo-ries is twofold. The new offerings, she says, need to be more visually pleasing and palatable. But “keep in mind that kids have been accustomed to eating processed foods laden with added sugar, foods that appeal to them even if they’re not necessarily nutritionally adequate.” Rather than calories, she says, the attention should focus on how to serve positive change in the way students view nutrition and food.

Table 1 Typical School Lunch Portions Based on the New Federal StandardsFood Group Previous Requirements Current Requirements

Fruits and vegetables 1⁄2 to 3⁄4 cup total

There are no specifications regarding the types of vegetables to be served.

Fruits: 1⁄2 to 1 cup

Vegetables: 3⁄4 to 1 cup

There are weekly requirements for dark green, red/orange, and starchy vegetables and beans/peas (legumes) plus other vegetables as defined by the 2010 Dietary Guidelines.

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


Grains Eight servings weekly; minimum of one serving per day

Whole grains are encouraged.

Grades K to 5: minimum 1 oz equivalent daily; 8 to 9 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 and flavors not restricted

1 cup; must be fat free (unflavored or flavored) or 1% (unflavored)

— Table adapted from a comparison of previous and current regulatory requirements under the Nutrition Standards in the National School Lunch and School Breakfast Program (http://www.fns.usda.gov/cnd/governance/legislation/comparison.pdf)


http://www.fns.usda.gov/cnd/governance/legislation/comparison.pdf

This is especially true when it comes to athletes who have a much higher calorie requirement compared with nonathletes—as much as 4,500 kcal/day. “I think students need more whole grains, proteins, and healthful fat options such as nuts, avoca-dos, and olives as part of their daily lunch meal,” Cipullo says. “Let’s offer less-processed, wholesome foods without such tight maximums on calories. We also should encourage some of the kids to take just some of the food offered and then eat again two or three hours later. More often than not, smaller meals are easier on our endocrine systems and may help reverse the trend of increasing diabetes.”

Beauvais, whose son is a 6-foot 3-inch athlete, isn’t surprised that the lunches he eats at school aren’t enough calories to carry him through his afternoon sports practice, but they weren’t last year either. When this is the case, Beauvais says these kids need another plan for the afternoon, which might mean bringing a snack from home or money for a healthful vending machine option.

Where’s the Beef?�While it’s true the number of calories in school lunches

aren’t that different from a year ago, they’re distributed differently—and this is what the kids notice. Perhaps the most dramatic change is the cap on protein and grains. At the high school level, it’s the difference between this year’s burger and last year’s: What was once a 3-oz meat patty is now 2 oz. Beauvais says the difference—the patty gets lost in the bun—is visibly obvious to the kids. She says that “our new motto is ‘How about some lettuce and tomato with that?’”

It has become a challenge on the foodservice side as well, which Beauvais describes as “kind of like a puzzle.” Take that burger, for example. To accommodate the addition of a half-ounce slice of cheese, you’d first have to make the patty a half-ounce smaller. Well, they don’t come in a 21⁄2-oz size. And sandwiches—a staple on every lunch line—are no longer so simple under the new standards. A cap of 9 oz of bread, at 1 oz per slice, makes a challenging breakdown for the five-day school week. There might be a future for an open-faced sandwich on the menu, Beauvais says.

Changing the Food Isn’t EnoughLaudable as the efforts behind the new standards are,

they’re not enough, according to two former New York City public school teachers who have taken the issue of obesity in school children into their own hands. Deborah Lewison-Grant, MA, MEd, and Carolyn Cohen, MEd, started their own nonprofit organization called FoodFight to include teachers, who they believe are the missing link in the growing obesity epidemic. FoodFight also involves a curriculum that teaches teens about nutrition and how the media influences their food choices.

“You can’t revolutionize food without revolutionizing the culture in the schools,” Cohen says. Without buy-in from both

adults and students on campus, the healthier lunches won’t change anything. Even after the dust settles and the protests wane, negative attitudes and food waste in the cafeteria are likely to continue.

“There’s a clear disconnect when grown-ups aren’t included,” Lewison-Grant says. “They wield a lot of influence on students—a disproportionate amount of influence.”

FoodFight’s goal is to improve the health and life outcomes of students by bringing teachers and personnel into the con-versation. “Their health and wellness is critical to their job. Corporate wellness is so accepted, but we don’t see that in schools,” Lewison-Grant continues.

By running wellness programs for teachers and school staffs, Cohen and Lewison-Grant believe their graduates will bring an empowerment and energy for healthful living and eating to the students. “If you engage the entire staff, you can ignite an important process that can change food in schools,” they say.

In addition, Cohen and Lewison-Grant believe the new lunch standards would be more effective if they were introduced within a context. “A new set of guidelines without explanation is confus-ing. It’s missing the education component,” Lewison-Grant says.

When the students don’t understand the reason behind their role in the changes, it becomes a control issue. “Food is the one area over which they exert control,” she explains. “They can decide what to put in their mouths, but they don’t understand the forces shaping it. School lunch isn’t exempt.” This is where the adults in the school can lead students through the changes and together change the current food climate into a healthful one.

Embracing Change Is ToughAll change is subject to scrutiny, doubt, and sometimes protest,

and the new school lunch standards are no exception. But like any new policy, especially one as large-scale as the US school meal program, it’s being closely monitored. According to Beauvais, the USDA is receiving information from around the country and, she says, “I’m hoping there will be some minor revisions.”

— Lori Zanteson is a food, nutrition, and health writer based in southern California.

Table 2 Calorie Counts of Lunches Before and After New Standards Took Effect

Previous Standards Current Standards

Grades K to 3: 633 Grades K to 5: 550 to 650

Grades 4 to 12: 785 Grades 6 to 8: 600 to 700

Grades 7 to 12: 825 (optional) Grades 9 to 12: 750 to 850

— Table adapted from a comparison of previous and current regulatory requirements under the Nutrition Standards in the National School Lunch and School Breakfast Program (http://www.fns.usda.gov/cnd/governance/legislation/comparison.pdf)


http://www.fns.usda.gov/cnd/governance/legislation/comparison.pdf

MondayMeatlessThis 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


What do Oprah Winfrey, Michael Pollan, and Mario Batali have in common? They’ve all jumped on the Meatless Monday bandwagon. Hospitals, colleges, restaurants, magazines, foodservice

companies, workplaces, and entire communities are pledging their support for the program, too.

What’s Meatless Monday all about? It’s a nonprofit initia-tive of The Monday Campaigns, which is developed in asso-ciation with the Johns Hopkins’ Bloomberg School of Public Health, with a simple message: By cutting out meat once per week, you can improve your health and reduce your carbon footprint. The initiative provides information and recipes to help people start each week with healthful, eco-friendly, meat-free alternatives.

Allison Righter, MSPH, RD, who coordinates the Meatless Monday science advisory at the Center for a Livable Future (CLF), reports that Meatless Monday began in 2003 in response to the release of the Healthy People 2010 report, which included goals to reduce dietary saturated fat by 15%. “Since saturated fat primarily comes from meat and animal products and since one day a week is just under 15% of the week, Meatless Monday was a practical method for helping people to meet those goals. Reducing meat consumption also has many other benefits, such as lowering the environmental burden of industrial food animal production, which is a major focus of CLF’s research,” Righter says.

Benefits AplentyThere’s growing support for adopting a more plant-based

diet, even in the 2010 Dietary Guidelines for Americans, which offer the general recommendation to eat a plant-based diet that focuses on consuming vegetables, cooked dry beans and peas, fruits, whole grains, nuts, and seeds with moderate amounts of lean meats, poultry, eggs, and dairy.1

A position paper published by the Academy of Nutrition and Dietetics concluded that a plant-based, vegetarian dietary pat-tern is completely healthful and nutritionally adequate for people throughout all stages of life and that it has several health advantages, including lower blood cholesterol and pres-sure levels and lower risk of heart disease, hypertension, and type 2 diabetes.2

Semivegetarian, lacto-vegetarian, and vegan women have a lower risk of overweight and obesity than do omnivorous women, according to data from 55,459 healthy women partici-pating in the Swedish Mammography Cohort, suggesting that advice to consume more plant foods and less animal products may help individuals control their weight.3

In a recent meta-analysis, Harvard researchers linked high processed-meat intake to a 42% higher risk of coronary heart disease.4 Data from the Health Professionals Follow-Up Study, which included more than 440,000 participants, revealed that eating a daily 100-g serving of red meat was linked with a 19% increased risk of developing type 2 diabetes, and eating a daily 50-g serving of processed meat was associated with a 51% greater risk.5

The NIH-AARP Diet and Health Study, which included more than 500,000 men and women, found a significantly higher risk of cancers of the colorectum, esophagus, lung, and liver asso-ciated with red meat intake; an increased risk of colorectal and lung cancer was associated with higher intake of processed meat; and red and processed meat intake was associated with cancer mortality.6

In addition to health, people are interested in reducing their animal food intake for environmental benefits. Italian research-ers performed a life cycle assessment to evaluate the “cradle-to-grave” environmental impact of several dietary patterns. They reported that an organic, vegan diet had the smallest environmental impact, while a conventionally farmed diet that included meat had the greatest impact on the environment—and the more meat consumed, the greater the impact. Beef was the food with the single greatest impact on the environment. Cattle require lots of feed, water, and fossil fuels to turn plants into protein, the scientists said. To produce 1 kcal from beef requires 40 kcal of fossil fuels, whereas producing 1 kcal from grains requires only 2.2 kcal of fuel.7

In an analysis for the public advocacy organization Environ-mental Working Group (EWG), greenhouse gas emissions gen-erated by conventionally raising lamb, beef, pork, and farmed salmon and producing cheese far exceed those from other food choices, such as lentils and beans. The EWG found that eating less meat could significantly reduce a person’s carbon foot-print. For example, if everyone in the United States ate no meat or cheese for just one day per week, it would be like taking 7.6 million cars off the road.8

The Meatless Monday message helps people ease into the concept of decreasing animal intake by selecting just one day per week to go meatless. “We’re not asking people to cut out meat from the diet,” Righter says. “This is all about moderation; it’s one simple tool to help people incor-porate healthier—and also more environmentally sustain-able—alternatives to meat into their diets just one day each week. It’s a platform to introduce new and often overlooked foods, and ideally this will trickle over into other days of the week and ultimately translate into healthier eating habits and dietary patterns over time.


“What I think is important to understand, especially for dietitians, is that people are consuming too much meat—more than what’s needed to achieve nutritional recommen-dations,” Righter continues. “We’re eating more than twice the EAR [estimated average requirement] or about 11⁄2 times the RDA [Recommended Dietary Allowance] for protein. The majority of our protein is coming from meat and animal products, which provide additional saturated fat and often not the same nutritional benefits of other plant-based pro-teins. This excess of meat and lack of health-protective plant foods is a huge problem in terms of its association with an increased risk of chronic diseases.”

Indeed, Meatless Monday appears to be an effective tool for promoting health. A nationwide survey conducted by FGI Research for Meatless Monday found that among those who are aware of the initiative, 36% say the campaign has influ-enced their decision to cut back or consider cutting back on meat. Of those influenced by Meatless Monday to reduce meat intake, 62% say they’ve tried to incorporate it in their weekly routine; 40% incorporate more meatless meals the rest of the week; 73% eat more vegetables; 64% eat more fruits; 42% eat more beans; 47% eat more whole grains; 50% experiment with new meatless recipes when they cook at home; and 42% try more meatless dishes when eating out.

Meatless Monday Takes OffThe Meatless Monday movement has grown dramatically

in the past two years. Awareness of the campaign primarily is due to grassroots viral dissemination and support of partici-pating organizations rather than advertising. According to the FGI Research survey, public awareness of Meatless Monday increased from 26% to 43% from November 2010 to July 2012. Meatless Monday has more than 35,000 Facebook likes and 18,000 Twitter followers as of July 2012. In addition, many organizations, such as the Food Network (more than 3 million Facebook likes and 1 million Twitter followers) and the Cook-ing Channel (more than 345,000 Facebook likes and 87,000 Twitter followers), post Meatless Monday content every week.

“Organizations have helped Meatless Monday become mainstream,” says Peggy Neu, president of The Monday Campaigns. “Sodexo was the first to join in 2011. They’re enormous, with 6,000 customers in the United States serv-ing 10 million meals a day. As we’ve grown both in our awareness and number of people who say they’re practicing Meatless Monday, we have all of these companies and orga-nizations offering a solution to what you can have instead of meat. Morningstar Farms was one of the first big brands to promote Meatless Monday, along with others, including the Mushroom Council and Birds Eye.”

High-profile chefs and restaurants have helped bring Meatless Monday to the forefront as well. “In the beginning,

Meatless Monday was started in restaurants by pioneers like Mario Batali. Now it’s gone mainstream,” says Neu, who reports growing innovation in the restaurant world. Chefs are employing food stations, special menu features, and tasting menus to help promote Meatless Monday.

The campaign also has been a darling in the media. “The media, bloggers, and Food Network have all become active in Meatless Monday,” Neu says. “We’re not saying that people should give up meat entirely; we’re not saying to be vegetarian or vegan entirely. Our press is so good because what’s there to argue?”

Meatless Monday also is growing with schools, colleges, food distributors, worksite wellness programs, and insur-ance companies. “We’re even seeing Meatless Monday in communities, such as in Raleigh-Durham [North Caro-lina] and Aspen, Colorado, where community organizers go around and get schools, media, and events to support a com-munitywide gestalt.”

Employing Meatless Monday in Other SettingsDietitians are getting excited about using Meatless

Monday as a tool in various work settings. “Dietitians are involved in marketing, cooking classes, community, tele-vision, cooking demos, and blogs. They’re also involved in foodservice settings,” Neu says of the many ways dietitians use Meatless Monday to provide healthful eating messages.

“Meatless Monday can be used as a platform in any set-ting for dietitians to not only talk about nutrition but to raise awareness of larger issues related to our industrial food system,” Righter adds. “Food is connected to everything. This can help dietitians become well versed on these issues.”

Righter recently conducted an informal survey of dieti-tians regarding their knowledge and use of Meatless Monday in their work. “About half of the people I got responses from already had heard about the campaign and were using it in the classroom or with clients in some capacity,” she says. “However, a lot of people weren’t aware of it—either they’d never heard of it or they didn’t realize it was a campaign with its own website, social media, and all sorts of information, recipes, and resources.”

“It’s one strategy to help bring Americans in line with the Dietary Guidelines. Everyone’s on the same page; we’re all struggling to get people to eat more healthfully. Using Meat-less Monday is an opportunity to introduce these plant-based foods, like vegetables, fruits, beans, and whole grains. That’s one of the things that came back from our survey of dieti-tians. They believe Meatless Monday provides an opportunity for people to try new recipes and new foods,” Righter says.

Dana Dose, RD, CPT, a dietitian at Harrah’s Health and Well-ness Center in Lake Tahoe, California, uses Meatless Monday in her one-on-one sessions with clients. “I’ve also started the


process of seeing if the on-site cafeteria for the employees will start offering additional meatless options on Mondays. Once that goes through, I’ll promote Meatless Monday throughout the property, especially in the employee cafeteria, by using sig-nage and putting an article in the employee newsletter,” Dose says. “It’s great to be able to show people the positive impact they can have on the environment and their bodies when they go just one day without meat.”

Lauren Harris-Pincus, MS, RD, and Kathy Siegel, RD, CDN, cofounders of NutritionBabes.com, feature a meatless recipe category with 85 recipes on their website and blog, and they encourage their clients, readers, and listeners to consider forgoing meat one day per week. “By raising aware-ness of the benefits of decreasing meat consumption, we can open consumer’s minds to the potential positive effects on their health,” Harris-Pincus says. “The path to better health is traveled one step at a time, and removing meat from your meal plan one day per week can be one of those steps.”

Roberta Anding, MD, RD, LD, CDE, CSSD, director of sports nutrition at Texas Children’s Hospital in Houston, uses Meatless Monday as a tool in teaching an introductory nutri-tion course. “It dovetails with my lecture on vegetarian nutri-tion. From a clinical perspective, I use it to reduce the high calorie burden of my carnivore Texans. I’m contemplating writing about it for the Houston Texans Gameday magazine,” she adds.

Natalie Bates, a clinical nutrition student at the Univer-sity of California, Davis, spent the past summer in an intern-ship at Kaiser Permanente San Diego Medical Center, where she created, promoted, and implemented a Meatless Monday program for the cafeteria. To kick it off, Bates created a pre-sentation that was shown on the TV in the hospital cafete-ria. She tested meatless recipes and worked with the chef to offer four different meatless entrées in the cafeteria on Meatless Monday. Bates made table tents that included recipe pictures and environmental and nutritional informa-tion. She also set up a table at the cafeteria entrance that showcased a poster promoting the campaign and that pro-vided staff to answer people’s questions.

Bates distributed a survey about Meatless Monday to receive feedback from the cafeteria customers. “The survey indicated very mixed results. While some people were excited about having meatless options, others were upset that the cafeteria would try to influence their dietary choices,” she explains. “Those who were interested in eating healthfully were easy to convince to try Meatless Monday on a regular basis, and they liked the vegetarian options offered in the cafeteria that day. However, within the hostile audi-ence, it was difficult to see any impact. I think the area of opportunity for people in the public health field is among the neutral/undecided individuals who are intrigued and open to

the idea but haven’t been exposed to or received guidance for implementing Meatless Monday into their lives. Surprisingly, I found that emphasizing the environmental impact often can motivate people to participate in Meatless Monday who wouldn’t be interested in participating for health reasons.”

Getting StartedIf you’d like to use Meatless Monday in your own practice,

MeatlessMonday.com offers many great resources to get you started, such as information on nutritional and environmen-tal benefits, articles, a recipe widget that can be placed on any website or blog, and a tool kit with promotional materials in a downloadable format.

So go ahead, jump on the Meatless Monday bandwagon and encourage your clients to take the ride for better health, too.

— Sharon Palmer, RD, is a contributing editor at Today’s Dietitian, a freelance food and nutrition writer in southern

California, and author of The Plant-Powered Diet.

References1. US Department of Agriculture, US Department of Health

and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office; 2010.

2. Craig WJ, Mangels AR; American Dietetic Association. Position of the American Dietetic Association: vegetarian diets. J Am Diet Assoc. 2009;109(7):1266-1282.

3. Newby PK, Tucker KL, Wolk A. Risk of overweight and obe-sity among semivegetarian, lactovegetarian, and vegan women. Am J Clin Nutr. 2005;81(6):1267-1274.

4. Micha R, Wallace SK, Mozaffarian D. Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: a systemic review and meta-analysis. Circulation. 2010;121:2271-2283.

5. Pan A, Sun Q, Bernstein AM, et al. Red meat consump-tion and risk of type 2 diabetes: 3 cohorts of US adults and an updated meta-analysis. Am J Clin Nutr. 2011;94(4):1088-1096.

6. Cross A, Leitzmann MF, Gail MH, et al. A prospective study of red and processed meat intake in relation to cancer risk. PLoS Med. 2007;4(12):e325.

7. Baroni L, Cenci L, Tettamanti M, Berati M. Evaluating the environmental impact of various dietary patterns com-bined with different food production systems. Eur J Clin Nutr. 2007;61(2):279-286.

8. Hamerschlag K. Meat Eater’s Guide to Climate Change + Health. Environmental Working Group website. http://static.ewg.org/reports/2011/meateaters/pdf/report_ewg_meat_eaters_guide_to_health_and_climate_2011.pdf. July 2011. Accessed May 10, 2012.


EducatingYoung 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


The number of children suffering from childhood obesity has more than tripled in the past 30 years, according to the Centers for Disease Control and Prevention, putting them at an increased risk for much more than teasing from schoolyard bul-

lies. The US Department of Health and Human Services has reported that “being overweight during childhood and ado-lescence increases the risk of developing high cholesterol, hypertension, respiratory ailments, orthopedic problems, depression, and type 2 diabetes as a youth.”

These conditions are a serious public health concern facing children today, but a new weight-loss academy based in Bluff-ton, South Carolina, is hoping to make a dent in these troubling statistics by looking at much more than just children’s weight. The academy is attempting to forge an innovative partnership with a Missouri school district to expand its reach to more kids nationwide.

MindStream Academy: What It’s AboutMindStream Academy, a full-service boarding school, is in

many ways like your typical high school, fully credentialed to offer academic coursework to students of all levels. Yet it’s designed specifically for “kids whose health, future, and very lives are on the line due to obesity and its attendant physi-cal and psychological burdens,” says MindStream Academy Founder and CEO Ray Travaglione.

In addition to their regular coursework, MindStream stu-dents are taught the basics of nutrition, cooking, and fitness in an attempt to get to the root of their weight issues and address them for the long term. “Their instruction ranges from neuro-biofeedback to gardening, psychological counseling to the care of horses, and from lengthy bike rides to the preparation of wholesome, gourmet meals,” Travaglione explains.

He says the idea for MindStream Academy came from his work with children who are among the fittest for their age group: athletes. “My background is in passion-based learn-ing for teens. Beginning with student athletes, I created pro-grams that provided the opportunity to develop their skills and test them against their peers, founding both Hank Haney Inter-national Junior Golf Academy and the International Junior Golf Tour, where many of the young PGA and LPGA players have either attended or competed,” he explains. “To accommodate our students’ training schedule, I then created a school that views pursuing a passion as important as core academics: Her-itage Academy.”

As Travaglione became more aware of obesity’s increas-ing stranglehold on today’s youths, he decided he had to get involved. “Obesity in our youth has the potential to bring this country to its knees in a very short period of time, and I could not stand idly by and allow this to happen,” he says. “I decided it was time to do something to turn the tide on this epidemic and founded MindStream Academy.”

A Mind-Body Approach to Wellness The biggest difference between MindStream and other

weight-loss programs is its overall focus. While it’s no secret that it addresses obesity, the school takes pride in its mind-body approach to health and wellness, impressing on children that life is about much more than what the scale dictates.

“MindStream Academy has created a school climate in which optimal health and wellness is equally as important as high academic standards. Ultimately what we offer is an education for lifelong vitality and vibrancy,” Travaglione says, noting that in addition to a lower weight, students also are pursuing the far loftier goals of optimal wellness and their fullest life potential.

MindStream staff aim to help students achieve these goals with targeted fitness, nutrition, and culinary education as well as counseling. “We’re not interested in quick fixes and don’t focus solely on weight loss,” Travaglione says. “Physical fitness and proper nutrition are part of what we do but not all we do. The weight loss and developing fitness habits is a product of self-confidence and self-management skills. We want our students to take the skills they’ve learned here and maintain their success for life, which is why our program is so experiential in nature.”

What kinds of skills are these kids learning? Stress man-agement, gardening prowess, and cooking basics to start. “Our boarding program for teens requires a semester minimum, as it takes about four months for behavioral changes to stick. In that time, our students learn to better manage stress; to be mindful; to garden; cook fresh, delicious foods; enjoy moving their bodies—perhaps for the first time—social and emotional well-being; and to appreciate the great outdoors—overall becoming more grounded to the earth,” Travaglione says.

To address what’s at the core of the teens’ weight issues, MindStream staff use experiential therapies, such as equine-assisted psychotherapy and neurobiofeedback, which are designed to better reach children by offering counseling in a more fun, solution-focused, and nonthreatening way than tradi-tional one-on-one therapy.

Even students’ families get in on the action. “Our students’ families participate in our program through weekly coun-seling sessions via Skype, nutrition education, and weekend workshops so the changes that are made at MindStream will continue at home,” Travaglione says, adding that by support-ing the whole child—and not just focusing on weight loss—he hopes to put students on a path of lifelong health and wellness.

Nutrition Nuts and BoltsMindStream bases its nutrition program on what it calls the

FLOW concept (Fresh, Local, Organic, Whole food style and nutrition program), which Travaglione says gives importance to the following principle: Meals prepared with seasonal, farm-fresh, local and regional wholesome ingredients taste better and, when eaten in appropriate quantities, will lead to optimum weight and wellness.


“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 one’s own food,” he says.

The importance of the “farm-fresh, organic, and local” part of the program is demonstrated in MindStream’s own Soul Garden, a 1-acre garden of herbs, fruits, and vegetables that students take care of. “They participate in all aspects of the garden’s 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 MindStream’s nutri-tion philosophy to life, develops all student meals. This year’s 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, who’s behind MindStream’s nutrition curriculum. Steinberg and MindStream’s chef work hard to make all choices healthful and kid friendly.

“The majority of foods served are made from scratch, including dressings and sauces; grains/breads are whole wheat; fruit is served with breakfast; and salads are served with lunch and dinner,” she says. “Foods are minimally pro-cessed and contain very little sugar—under 6 g. Beverage choices are water and milk. The kids drink water all day long to stay hydrated.”

Targeted EducationNot only are students served the healthiest and freshest foods

available, they’re also taught how to integrate various culinary skills, nutrition tips, and fitness into their day-to-day lives.

• Culinary skills: Students learn how to prepare the types of foods they eat at MindStream by participating in culinary demos that are conducted once or twice per week. The kids learn hands-on how to make their own meals and healthful desserts. “The demos have been a great hit with the kids,” Steinberg says.

“The culinary education program begins from the ground up,” Travaglione says, noting that at the academy students learn about food from its true beginnings: the earth. “Students have the opportunity to assist in gardening fresh plant foods grown on site, harvesting ingredients for the kitchen, and working hands-on side by side with our chefs.”

Through this hands-on experience, MindStream aims to give students the tools they need to prepare simple, delicious, fresh, and healthful meals after their return home.

• Nutrition: According to Steinberg, students attend two-hour-long nutrition classes once per week, which always are taught by a registered and licensed dietitian. “The classes are lecture type but also include student participation, classroom discussion, and hands-on activities,” she says. “While the

classes follow a 16-week syllabus, they’re also redesigned to incorporate popular topics, which the kids may discuss during class time.”

In addition to nutrition basics, the classes hit on topics such as the importance of portion sizes, how to make good choices when eating out, healthful substitutes for recipes, and how to navigate the grocery store and decipher food labels—all intended to give students a well-rounded knowledge base of what it will take to continue their healthful habits at home.

• Fitness: Students are enrolled in a fitness program to get them moving—for life. Staffed by certified personal trainers as well as dance, martial arts, Zumba, and yoga instructors, the program is designed to get students to improve overall body movement and learn to enjoy it.

“To fuel their desire toward fitness, we’ve created a move-ment playground,” Travaglione says. “It’s this same belief that correct movement is the backbone of a lifelong commitment to fitness that has inspired us to focus on body weight-driven exer-cise. We believe so strongly in body weight movement that there are no traditional exercise machines at MindStream Academy.”

According to Travaglione, MindStream students define their own fitness path, as all fitness regimens are individualized. “Our four-phase program is based on the values we gain from initial fitness evaluations,” he explains. “Training is based off of one’s own baseline, and a student’s current fitness level helps determine his or her program, pace, and progression. As fit-ness level increases, so does the pace of the program and the difficulty of the activities.”

The biggest difference between MindStream’s approach compared with most weight-loss programs may not be in what they’re doing but in what they’re not doing, which is anything too extreme. “What makes our program so unique is that there’s nothing extreme about what we’re doing; we’ve just brought stu-dents back to the basics,” Travaglione says. “They have put down


their electronics, developed a relationship with themselves, their bodies, and the world around them, and as a result are achieving goals they never thought possible.”

He explains that while under some weight-loss programs, such as those pop-ular on TV, participants might endure severely restrictive diets of 600 kcal or fewer to achieve dramatic results. Trava-glione says MindStream students achieve similar results but not in such an extreme atmosphere.

Still, while the scale tells a compelling story, Travaglione says perhaps the most significant change MindStream students undergo is related to their mental health, which can have a far more lasting effect: “They arrive feeling despondent, and they

leave feeling like a new person. The changes that are made here aren’t skin-deep. There are tremendous shifts in personal responsibility, self-esteem, healthful risk taking, and a sense of hope through accomplishing tremendous goals.

“When our students go home, they’re maintaining their weight loss, and some have continued on their weight-loss journey,” he adds. “Students report better grades, being more socially outgoing, and embrace their role as a healthful lifestyle ambassador.”

Branching OutWhile MindStream is satisfied with the success its students

are achieving, it wants to effect change in more children’s lives. It’s hoping a new partnership with Independence School District will help it do just that.

“This semester we’re piloting a direct relationship with a public school district,” Travaglione says. “Essentially, Mind-Stream is taking in a cohort of kids whose obesity/metabolic and psychosocial problems are too complex for a public school to handle. This potentially frees up resources in the public school district while MindStream helps these kids turn their health and lives around so they can return as ‘ambassadors’ of what they’ve learned and pay it forward.”

The idea for the partnership came from the collaboration of Travaglione and two others: Jim Hinson, superintendent of the Independence School District, and noted prevention expert David L. Katz, MD, MPH, FACPM, FACP, director of the Yale University Prevention Research Center. “We saw this unique opportunity to partner and help obese kids in his district, and the rest as they say is history,” Travaglione says.

Designed to provide the promise of a better quality of life and longevity for students in need, Travaglione hopes partnerships such as this one will eventually help “turn the tide on this epi-demic and turn our country’s future around.

“If these kids drop out, if they don’t realize their fullest poten-tial, if they remain in poor health, if they die before their life begins, we all lose,” he adds. “The best economic stimulus we can do is get these kids healthy.”

To ascertain which kids in the school district are best suited for the MindStream program, the staff looks at more than students’ BMI. “The selection criteria is based on a vari-ety of assessments performed by members of our counseling team, academic program, admissions officers, the students’ guidance counselors, and other relevant advocates,” Travaglione explains.

Under the current partnership, the school district can offset a portion of the cost of tuition ($28,500 per semester, and most students attend for one semester). “Primarily, this is done through the collection of average daily student attendance while they attend MindStream and reporting this to the State Depart-ment of Elementary and Secondary Education for state fund-ing,” Travaglione says. “Parents, corporate partners, private donors, and the School District Foundations all participate in contributing money that helps offset the cost of tuition.”

“Rather than waiting on the world to change, MindStream gives these kids the world as it should be—a world that leads to health and away from bullying and ridicule,” Katz says. “It’s as much about community and solidarity as it is about fitness, nutrition, and academics. It is, in a word, extraordinary. The true beauty of this ‘better world’ is that it imparts a skill set the kids take back with them to the world as it is, making them far better able to deal with it.

“MindStream also gives the kids skills they can pay forward,” he adds. “They can help others with what they learn there. MindStream isn’t about giving kids a better BMI; it’s about giving kids both the will and the way toward a better life.”

And so far, results are promising. According to Travaglione, 13 Independence School District students attended Mind-Stream during the first semester of its partnership. At press time, those students had collectively lost more than 500 lbs—and gained much more. “Their self-confidence is through the roof. They’re performing better academically, loving the cook-ing demos, and are preparing to return home as a community resource and motivate other kids to get healthy and fit,” he says.

This is great news for these teens but also good news for students struggling elsewhere across the country, as Mind-Stream has more school district partnerships currently in the works.

“We’re at various stages of replicating this partnership in South Carolina, Florida, Mississippi, Ohio, New York, and Ken-tucky,” Travaglione says, “and we plan to do so in every state and school district in the country.”

— Juliann Schaeffer is a freelance writer and editor based in Allentown, Pennsylvania,

and a frequent contributor to Today’s Dietitian.

— P

HO

TO C

OU

RTE

SY

OF

MIN

DS

TRE

AM

AC

AD

EM

Y


AUTISM SPECTRUM DISORDERResearch Suggests Good Nutrition May Manage SymptomsBy Dawn Privett, RD, LD, CLT

Decades ago, autism spectrum disorder (ASD), a group of developmental disabilities in which patients have significant social, communication, and behavioral difficulties, was consid-ered rare, and the prognosis of those who had it usually wasn’t good. Many individuals were committed to institutions for the rest of their lives because of their inability to function in society. But times have changed.

The prevalence of ASD among adults and children has sky-rocketed over the last several years. Much more research on the etiology of the disorder and the different ways to treat and manage it has become available. Today there’s evidence show-ing how nutrition therapy can play a significant role in manag-ing various symptoms that prevent ASD patients from living productively.

This continuing professional education course will define ASD, discuss its prevalence and possible causes based on the latest research, and evaluate the critical role good nutrition may play in helping individuals function optimally. Dietitians will learn about the various nutrition therapies available and be able to apply them to practice.

Defining AutismThe word “autism” comes from the Greek word autos, mean-

ing “self.” It’s been used for about 100 years to describe a condition in which people can’t 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 Asperger’s 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 person’s life. In some infants, there are early signs of the disorder, such as not wanting to cuddle, lack of eye contact, or abnormal responses to touching and affection. Other early signs include the inability to follow objects visually, not responding to his or her name being called, and lack of facial expressions, such as smiling.3 Some children with ASD develop normally until the age of 1 or 2, then stop learning new skills or lose the ones they already have learned.3

There are three main classifications of ASD and understand-ing the difference among them will help to better focus treat-ment. The first classification of ASD is autistic disorder, which is considered the classic form of autism. Patients usually have significant delays in language, social skills, and the ability to communicate. Some have unusual behaviors and interests, and have a measurable intellectual disability.

The second form of autism is Asperger’s syndrome, usu-ally a milder form of autism. Patients still have delays in social abilities and communication skills, and have unusual behav-iors and interests.4 Many individuals have a specific interest that encompasses much of their time and thought. People with Asperger’s may spend much of their time devoted to a hobby

CPE MONTHLY

LEARNING OBJECTIVESAfter completing this continuing education activity,

nutrition professionals should be able to:

1. Define the three types of autism spectrum disorder (ASD).

2. Assess the various problem-eating behaviors associ-ated with ASD.

3. Develop strategies to eliminate problem-eating behaviors.

4. Employ the various nutritional therapies to treat ASD patients.


(eg, trains, computers). They usually don’t have issues with lan-guage skills or intellectual development. In fact, many are intel-ligent, especially when it comes to their own special interests. Some experts liken patients with Asperger’s to little professors in their areas of interest; they can have near genius IQs.

The third form of autism is pervasive developmental dis-order, not otherwise specified, or atypical autism. These indi-viduals meet only some of the criteria for classic autism or Asperger’s. They have fewer, milder symptoms and may experience delays only in the areas of social skills and communication.4

Current ASD StatisticsThe number of children diagnosed with ASD has increased

almost tenfold in the last 40 years.5 Currently, one in every 88 children is diagnosed with ASD.5 When broken down by gender, five times more males (one in 54) than females (one in 252) are affected.5 These statistics indicate that ASD affects more than 2 million people in the United States and more than 10 million worldwide.4 According to the organization Autism Speaks, ASD affects more children than diabetes, AIDS, or cancer combined.5

The increase in diagnoses may be due in part to better diag-nostic tools, but many believe environmental toxins and genet-ics hold better clues to the increase in prevalence, although this hasn’t been proven.

Link Between ASD and Environmental ToxinsNo specific environmental toxin has been identified as the

cause of autism, but research to determine which chemicals may be culpable is under way. It’s been proven that a fetus is vulnerable to environmental chemicals during development. Examples of chemicals that, in the past, have been shown to harm fetal development include organophosphate insecti-cides6 (eg, chlorpyrifos), mercury exposure,7 and heavy metals (eg, lead).8

It’s a widely held belief that people with ASD have diffi-culty eliminating toxic chemicals from their body. If this is the case, exposure to environmental contaminants could play a significant role in poor neural development or brain func-tion processing. Unfortunately, because of the short amount of time research has been conducted on the link between autism and environmental toxins, causality still remains speculative. However, it continues to appear that genetics, environment, and the interaction of a child’s physical and psychosocial environment play an interrelated role in the possible causes and triggers of ASD. Such associations can be seen in the high incidence of autism in twins and genetic siblings who have the disorder.9

Other suspected causes of autism include advanced parental age,10 low birth weight,11 and multiple births.12 A viral infection, such as the flu, in the first trimester has been shown to triple the odds of a child developing ASD, and a bacterial infection,

such as a urinary tract infection, in the second trimester has been found to increase the risk of ASD by 40%.13 Recently, researchers examined inflammatory disease as a possible cause of autism and found that it could possibly contribute to the etiology of the disorder.14

Problem-Eating BehaviorsWhile the medical community may not have identified the

exact causes of ASD, much has been learned about the chal-lenges ASD patients face that often lead to poor diet qual-ity. These include problems with sensory processing, eating behaviors, and feeding disorders. It’s estimated that 46% to 89% of patients with ASD experience some kind of problem-eating behavior.15 Some feeding difficulties revolve around changes in routine. For example, patients with ASD may refuse to eat unless they sit in the same place at the table, eat on the same dishes, use the same tablecloth, and eat the same foods daily.15 The slightest change in routine can cause a tantrum or result in the refusal to eat.

Other issues may occur in the area of sensory processing. For example, if children with ASD are hypersensitive to sounds, they may not want to eat in a noisy area or with others engaged in conversation. If they have visual sensitivities, they may accept foods only of certain colors. They also may not be able to eat foods that are touching each other on their plate.

Some children are sensitive to the way foods feel in their mouth. They may avoid crunchy foods or foods that have a slick mouthfeel. The way food smells can cause similar reactions, and there are instances in which children may not recognize certain tastes but can distinguish between others.

A study by Benetto and colleagues showed that children with ASD were less able to accurately identify sour or bitter tastes but could recognize salty and sweet tastes.16 This study may shed light on why patients with ASD avoid several types of foods, such as proteins, but will usually accept foods in the car-bohydrate group.

The best approach to solving problem-eating behaviors, according to Elizabeth Strickland, MS, RD, LD, author of the book Eating for Autism: The 10-Step Nutrition Plan to Help Treat

Read this article and select your answers for the examination. Then visit our CE Learning Library at CE.TodaysDietitian.com to purchase access to complete the online exam and earn your credit certificate. For more information, call our continuing education division toll-free at 877-925-CELL (2355) (M-F, 9 am - 5 pm ET) or visit www.TodaysDietitian.com.

Suggested CDR Learning Codes: 3000, 3010, 3100, 4000, 4150, 4160, 5000, 5070, 5080, 5180, 5390, Level 2

How to Earn 2 CPEUsNew Lower Price!


Your Child’s Autism, Asperger’s, or ADHD, is to assemble a “feed-ing team,” a group of healthcare professionals consisting of a physician, speech language pathologist, occupational therapist, behavioral therapist, and RD.17 A dietitian can evaluate the foods the child agrees to eat for potential dietary deficiencies. He or she can watch the child and family during meal times to assess habits that may be hindering food intake. An RD also can screen the medications the child takes that may have side effects that contribute to feeding problems.

ASD and Food AdditivesJust as problem-eating behaviors can prevent ASD patients

from getting the nutrients they need, so can consistently con-suming highly refined foods. Since highly refined foods may contain artificial dyes and preservatives that could be asso-ciated with aggravating behavioral symptoms in those with ASD,18,19 suggesting the family eat natural, whole foods may be an important treatment intervention.

Dietitians working with ASD patients can recommend elimi-nating the following substances from an ASD patient’s diet if they believe a sensitivity exists:•Food dyes and artificial colors: These additives have been

linked to hyperactivity, breathing disorders, skin eruptions, and gastrointestinal symptoms in non-ASD patients.18,19 Since many ASD patients already have these symptoms, eliminating foods that contain these substances may be helpful to assess a patient’s reaction.•High-fructose corn syrup: One of the main concerns with

high-fructose corn syrup involves the manufacturing process. Research has found that mercury, one of the environmental toxins that may be responsible for the increased prevalence of ASD, is part of the refining process when making high-fructose corn syrup.7 Removing it from the diet whenever possible may be a helpful suggestion.•Artificial flavorings: Monosodium glutamate (MSG), for

example, has been shown to cause headaches, muscle tight-ness, numbness or tingling, weakness, and flushing in people who are sensitive to it.20 Because of these known potential side effects, it may be appropriate for ASD patients to avoid MSG as a precautionary measure.

•Artificial preservatives: Studies have indicated that artificial preservatives may cause sensitive individuals to experience headaches, behavioral/mood changes,21 or hyper-activity.22 So removing foods that contain these substances may be beneficial.•Artificial sweeteners: Aspartame, acesulfame-K,

neotame, and saccharin have been known to cause headaches, mood changes, nausea, vomiting, and diarrhea in the general population.23

When discussing dietary recommendations with ASD patients or their parents or caregivers, also suggest that patients be screened for nutritional deficiencies that can result from the medications they take. Some medications can affect appetite and cause nausea, vomiting, constipation, hard stools, diarrhea, esophageal reflux, weight gain or loss, sedation, drooling, and sometimes dysphagia, all of which can compro-mise nutritional status. For example, if a child is constipated, he or she may experience a decrease in appetite. If dysphagia is an issue, he or she may decrease food intake for fear of choking while swallowing. If medication causes sedation, the child may not feel the need to eat even though he or she is hungry.

SupplementationAnother aspect of ASD treatment involves supplementa-

tion with multivitamins, omega-3 fatty acids, vitamins D and B6, magnesium, and other nutrients. Beginning multiple sup-plements at one time may impede the ability to determine what’s 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 there’s an improvement in symptoms.

If the patient takes one supplement for several weeks and experiences no improvements in symptoms, it means the supplement may not be helpful for that particular patient. If improvements are seen, stopping the supplement for a week or so to determine whether symptoms return can be a good strat-egy to gauge effectiveness. This process allows ASD patients to follow the least restrictive regimen possible while identifying improvements in symptoms.

MultivitaminsMost practitioners who work with ASD patients agree that

a good-quality multivitamin without artificial colors or flavors can help offset limited dietary preferences and poor nutritional intake. Finding the right multivitamin will depend on a patient’s tolerance. Some will swallow a pill, while others will prefer a liquid, gummy, or chewable form. RDs are in a perfect position to determine what’s acceptable and meets each patient’s needs.

Omega-3 Fatty AcidsResearch has shown that adding omega-3 fatty acid sup-

plements to ASD patients’ diets may provide many benefits.

When discussing dietary recommendations with ASD patients or their parents or caregivers, also suggest that patients be screened for nutritional deficiencies that can result from the medications they take.


Omega-3s are critical for brain development and proper neural function. Multiple studies have shown imbalances in the ratio of omega-3 to omega-6 fatty acids in the bloodstreams of ASD patients.24-27 Obtaining adequate amounts from food alone may be difficult because of the limited number of foods they may eat. For example, some children with ASD won’t eat cold-water fish (eg, salmon, tuna), and some parents won’t add fish to their children’s diet because they believe it contains mercury that may exacerbate ASD symptoms. Still, many parents do give their children omega-3 supplements.28

Some practitioners recommend 1.5 g/day of omega-3 fatty acids for most pediatric patient populations.25 According to research, children with ASD who take omega-3 supplements have less anxiety and aggression, decreased hyperactivity and impulsivity, longer attention spans, and improvement in lan-guage development, reading, and spelling skills.27,29-31 Most omega-3 supplements are made from fish oil, so it’s impor-tant to ensure they’re free of mercury. (The label will indicate mercury-free processing.) Because oils can become rancid, it’s best to use supplements before their expiration date. Some supplements contain added vitamin E as a preservative to improve shelf life, while others are bound with dietary calcium to preserve the oil at room temperature.

If patients complain of stomach upset or fishy burps but don’t experience this when they eat fish, question the freshness of the supplements. Patients may need to keep the supplements in the refrigerator so they stay fresher longer.

Vitamin DSeveral studies suggest a direct link between low vitamin

D (25-hydroxyvitamin D) levels and the risk of ASD since vita-min D regulates the immune system. Research shows that children are at risk of ASD because of their body’s inability to identify foreign invaders and eliminate toxic substances and have an even higher risk of developing the disorder if they’re vitamin D deficient.

Vitamin D protects against DNA damage and can help repair damage once it’s occurred. (Its role in reducing damage in the case of environmental toxins is being investigated.) In addi-tion, vitamin D may reduce oxidative stress, a hallmark of ASD, and lower the number of inflammatory cytokines present in the brain, which have been associated with the disorder.32

According to John J. Cannell, MD, founder and execu-tive director of the Vitamin D Council, the prevalence of ASD increases in “regions of greater cloud cover and rainfall.”33 Studies have shown there are more ASD cases in children born between October and March.34 Research suggests this may be due to the lack of sunlight exposure.

The body produces vitamin D when the skin is exposed to the sun’s ultraviolet B rays, but during the cooler months of the year, the sun isn’t out long enough for pregnant mothers to get ample exposure. Ensuring women get adequate amounts of

vitamin D during pregnancy is imperative. In supplement form, the Recommended Dietary Allowance (RDA) is 600 IU. How-ever, if blood work shows a pregnant woman is deficient, a plan for increasing her vitamin D level must be directed by her phy-sician, who may prescribe doses much greater than the RDA. This applies to nursing mothers and children with ASD as well.

Vitamin B6 and MagnesiumVitamin B6 and magnesium supplementation also are used in

treating ASD patients. One way to boost intake is in the form of a multivitamin that contains both at US Reference Daily Intake standards. Some studies have shown improvements in behav-iors, such as increased speech, decreased aggression/temper issues, better eye contact, increases in IQ, and the ability to interact socially, with vitamin B6 and magnesium supplemen-tation.35 Other studies, however, have shown that high-dose pyridoxine supplements can cause peripheral or sensory neu-ropathies,36-37 and larger doses of magnesium can cause gas-trointestinal upset and diarrhea.

Other SupplementsGlutathione, which can be used in ASD treatment, enables

the body to detoxify and protect itself against oxidative damage.38 Moreover, dimethylglycine is touted to improve lan-guage skills and the ability to make eye contact. However, there’s little evidence showing that either alleviates symp-toms.39-40 More research is needed to show efficacy of some of the current supplements being used.

Probiotics, Antifungals, and Digestive EnzymesProbiotics and antifungals are common treatments for the

abdominal pain, bloating, gas, constipation, gastroesopha-geal reflux disease, nausea, vomiting, and diarrhea that many ASD patients experience. No conclusive evidence is available to explain why these digestive symptoms are common in ASD patients, but the use of probiotics has provided relief of these symptoms for many of them.

The National Center for Complementary and Alternative Medicine defines probiotics as live microorganisms—usually bacteria, but they also can include microbes such as yeast—that people can ingest to increase the population of desirable bacteria in the gut. Antifungals inhibit the growth of a fungus or destroy it. They’re used in the treatment of Candida albicans, a fungus frequently reported as the culprit when a yeast infec-tion is present. It can cause itching and burning of the mucous membranes, skin eruptions, and imbalances in the overall health of the gastrointestinal tract.

Digestive enzymes are substances that help break down large macromolecules in foods to smaller substances to facilitate their absorption. Examples of digestive enzymes include proteases that break down proteins or lipases that help break down fat. If a dietitian suspects a patient


is experiencing inadequate digestion, digestive enzymes may help. In some cases, digestive enzymes may aid in the removal of toxic compounds from the gut.17

Elimination Diet TherapyThe elimination diet is another option that has shown prom-

ise in treating ASD and involves removing certain foods from the diet for a period of time to determine whether they’re caus-ing symptoms of food allergies and intolerances. Research has shown that eliminating gluten and casein from the diet of ASD patients can alleviate symptoms such as behavior problems and poor cognitive and social functioning.41

There are several theories as to why the elimination diet may be beneficial. One hypothesis is that ASD patients can’t digest gluten and casein, causing the formation of the peptides gluteo-morphin and caseomorphin and their absorption into the blood-stream because of increased gut permeability, or leaky gut syndrome. These two peptides, which appear to have a chemi-cal structure similar to opiates, can cross the blood-brain bar-rier and cause symptoms such as delayed social and language skills, and withdrawn behavior.42

There are concerns about the use of a gluten-free/casein-free diet because its planning requires a skilled professional who understands the complexities of elimination diets and the restrictions of appropriate foods. The exclusion of wheat and milk puts an ASD patient at risk of nutrient deficiencies in cal-cium, protein, vitamin D, folic acid, and B vitamins. And studies have found that diets lacking gluten and casein raise the risk of decreased bone density and stunted growth.43 However, RDs can introduce other foods into the diet as well as provide advice on nutritional supplements to compensate for low nutrient intakes.

A more complex elimination diet that some specially trained dietitians use is called the LEAP (Lifestyle, Eating, and Per-formance) protocol. This involves eliminating any known foods or chemicals suspected of triggering symptoms. These foods and chemicals are identified by a blood test called the Medi-ator Release Test, which shows reactions to multiple foods and chemicals. These reactions involve the immune systems of patients who ingest foods and chemicals to which they’re

sensitive. Their immune system identifies these foods and chemicals as foreign invaders, causing the immune system to release mediators to fight off the “invaders.”

Some of the mediators released include histamine, prosta-glandins, leukotreines, cytokines, and peroxides. These media-tors have been shown to cause reactions such as inflammation, diarrhea, pain, intestinal cramping, constipation, headache, and pain receptor changes. Studies have shown enhanced proinflam-matory cytokine production is present in patients with ASD.44-47

Reactions to certain foods and chemicals also can cause the release of the brain neurotransmitters dopamine and sero-tonin. Dopamine appeals to the sense of reward and enjoyment, and plays a role in addictive behavior. Serotonin contributes to feelings of well-being and happiness.

When dopamine and serotonin are released as a result of ASD patients ingesting foods and chemicals to which they’re sensitive, they may experience less pain, brain fog, or inabil-ity to focus and concentrate. According to certified LEAP ther-apists, ASD patients also may feel euphoric after ingesting a reactive substance or stop throwing a tantrum after eating a reactive food. It’s in these instances where the Mediator Release Test may help with identifying reactive substances that can be eliminated to improve behavior, communication skills, and other immune-related health issues and allow for more variety in the diet for better nutrition.

What Lies AheadSo what does the future hold for individuals with ASD? While

there’s no concrete answer to this question, we know RDs can play a huge role in the management and treatment of ASD symptoms.

RDs’ ability to analyze diets for nutritional deficiencies can help concerned parents. Contacts with other healthcare disci-plines that monitor patient behaviors make RDs invaluable as they provide holistic approaches to treatment for optimal cogni-tive and social functioning. RDs are the best source for provid-ing accurate and up-to-date information on supplementation, elimination diet therapy, and current research on new nutri-tional approaches.

More and more patients will depend on dietitians as the source of information that will enable patients to live productive lives. Dietitians with the passion to work with this challenging segment of the population will be a much-needed resource in the dietetics community in the years to come.

— Dawn Privett, RD, LD, CLT, is a freelance writer and owner of Privett Nutrition Services in Kansas City, Missouri.

For references, view this article on our website at www.TodaysDietitian.com.

The elimination diet is another option that has shown promise in treating ASD and involves removing certain foods from the diet for a period of time to determine whether they’re causing symptoms of food allergies and intolerances.


CPE Monthly Examination

1. A patient presents with significant delays in language and social skills, and can’t clearly communicate. The patient may have which type of autism spectrum disorder (ASD)?

a. Autistic disorderb. Asperger’s syndromec. Pervasive developmental disorder, not otherwise

specifiedd. None of the above

2. Which of the following is not usually a challenge ASD patients may face that often leads to poor diet quality?

a. Sensory processingb. Feeding disordersc. Binge eatingd. Problem-eating behaviors

3. Patients with ASD who avoid several types of foods, such as proteins, usually will accept foods in the carbohy-drate group.

a. Trueb. False

4. Which of the following is one of the best approaches to addressing problem-eating behaviors?

a. Introduce one new food every three weeks until the child gets accustomed to eating it.

b. Eliminate a food the child doesn’t want to eat for three weeks then reintroduce it.

c. Evaluate the foods the child agrees to eat for poten-tial deficiencies.

d. A and B

5. Which of the following supplements have been shown to reduce anxiety and aggression, decrease hyperactiv-ity and impulsivity, and increase attention span in ASD patients?

a. Multivitaminsb. Omega-3 fatty acidsc. Vitamin Dd. Glutathione

6. Which of the following treatments may aid in removing toxic compounds from the gut of ASD patients?

a. Probioticsb. Antifungalsc. Digestive enzymesd. Dimethyglycine

7. Research has shown that eliminating gluten and casein from the ASD patient’s diet can alleviate which of the fol-lowing symptoms?

a. Behavior problemsb. Poor cognitive functioning c. Poor social functioningd. All of the above

8. Patients with Asperger’s syndrome are more likely to have which of the following characteristics than those diagnosed with a different type of ASD?

a. Significant delays in language skillsb. Abnormal responses in balancec. Delayed reactions to paind. A near genius IQ

9. A viral infection such as the flu in the third trimester has been shown to triple the odds of a child developing ASD.

a. Trueb. False

10. Which of the following is not an early sign of ASD in infants?

a. Not wanting to cuddleb. Lack of eye contact c. Abnormal responses to touch and affectiond. Colic

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


ZINC AND INFLAMMATIONAge-Related Zinc Deficiency May Contribute to Chronic Disease Risk By Marie Spano, MS, RD, CSCS, CSSD

A recent study published in the Journal of Nutritional Bio-chemistry found a biological explanation for age-related reductions in zinc status that may lead to impaired immune system functioning and systemic inflammation, which are contributing factors to chronic diseases. The study, which used cell cultures and a mouse model, suggests that improv-ing zinc status through diet and supplementation may be a viable strategy for reducing the risk of inflammatory diseases.

“When the body has insufficient access to zinc, it’s hit on many levels due to the many ways in which zinc typically func-tions to protect the body,” explains Ellen B. Fung, PhD, RD, CCD, an associate research scientist at Children’s Hospital and Research Center in Oakland, California. “First, zinc plays a significant role as an antioxidant in the body. Therefore, in a zinc-deficient state, there will be an excess of oxidants pres-ent, leading to increased DNA damage. In addition, zinc is a cofactor for RNA and DNA polymerases, which aid in the usual repair mechanisms. When these systems don’t function properly, there will be increased damage. Finally, zinc aids in modulating DNA repair and damage proteins. ... In a deficient state, these systems also are in a state of disarray and lead to increased DNA damage.”

Researchers from Oregon State University examined the effects of zinc deficiency and age on inflammatory responses in both a cell culture model and an aged mouse model. One aspect of the study compared groups of mice fed two different amounts of zinc in their diets. The group receiving zinc sup-plementation showed fewer age-related increases in markers of inflammation. Though inflammation is essential for tissue

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 deficits—why you get sick more readily as you age—and 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 inflammation—a bad situation.

If the results can be translated to humans, they would suggest that “we can override the age-related deficits by supplementing with zinc,” according to Fung.

Study DetailsIn the in vitro cell model, human monocytes were grown

in zinc-deficient or -adequate media for up to 14 days. Mac-rophages were then treated with 0, 10, or 100 ng/mL of LPS, the major structural component of the outer wall of gram-negative bacteria that initiates inflammatory responses. Cells grown in zinc-adequate media had a significant decline in zinc status after exposure to LPS. However, cells grown in zinc-deficient media had significantly lower zinc status both pre- and post-LPS exposure compared with those grown in zinc-adequate media. In addition, zinc deficiency was associ-ated with an increase in age-related inflammation as mea-sured by expression of tumor necrosis factor-alpha and interleukin-1-beta, cytokines that are important mediators of the inflammatory response.

In the animal model, mice aged 2 to 26 months were fed a standard rodent diet, a zinc-adequate diet (30 mg/kg of zinc), or a zinc-supplemented diet (300 mg/kg) for three weeks. Age-related declines in immune cell intracellular zinc content were associated with an increase in markers of inflammation. In addition, age-related environmental changes in gene expres-sion led to alterations in zinc transport mechanisms, including an increase in DNA methylation and histone modifications.

What leads to age-related changes in zinc status? “With age, the ability to absorb and utilize zinc is compromised, though we don’t know why it isn’t well absorbed,” notes Emily Ho, PhD, lead study author and a micronutrient expert at Oregon State University.

Making matters worse, many older adults don’t consume enough zinc through their diet or supplements. According to National Health and Nutrition Examination Survey (NHANES)

SUPPLEMENT SPOTLIGHT


data from 2001-2002, 30% of men and 36% of women over the age of 71 consume less than the Estimated Average Require-ment for zinc.3 Even those who consume supplements may still fall short. NHANES III data found that 35% to 45% of elderly adults had inadequate dietary intakes of zinc, and even with a combination of diet and supplement use, 20% to 25% still fell short on their zinc intake.4

Additionally, data from NHANES III (1988-1994) found that older adults (aged 60 or older) from food-insufficient house-holds have significantly lower intakes of zinc (less than 50% of the Recommended Daily Intake) compared with those from food-sufficient households,5 suggesting that access to food also may be a factor in zinc intake.

Sara A. Blackburn, DSc, RD, an associate professor of clini-cal nutrition at Indiana University-Purdue University Indianapo-lis, has observed this pattern of low zinc intake in older people. “I’ve seen zinc-poor diets in many adult patients with a chronic disease such as diabetes,” she says.

How Much Zinc?� If a person’s ability to absorb zinc declines with age, should

he or she consume more of this mineral? “We don’t have a great biomarker for zinc deficiency in humans and therefore just meeting the DRI [Dietary Reference Intake] is a good place to start until more research answers this question,” Ho says.

In addition to ensuring adequate intake, Blackburn sug-gests that a thorough physical examination be conducted by the appropriate physician, paying particular attention to nonheal-ing wounds and the skin’s appearance in case there are signs of zinc deficiency.

Fish and meat are among the top sources of zinc. The bio-availability of zinc in some plant-based foods is lower than

zinc from animal foods due to phytates that bind zinc and remove it from the body.6

Meeting Daily RequirementsThe rapid growth of the older population makes preventing

age-related diseases a paramount concern. And if the results of this study prove any indication in humans, honing in on zinc status may be particularly important as a measure of preven-tion. Age-related epigenetic decline in zinc status may contrib-ute to both impaired immune system functioning and chronic inflammation and, subsequently, related health problems.

Ho recommends seniors take a multivitamin that contains the Recommended Dietary Allowance (RDA) of zinc. “Zinc is a great antioxidant. It helps with repair systems within the body. Zinc is involved in a lot of the processes that fix DNA,” says Ho, who believes future research should examine biomarkers for zinc deficiency and help determine whether the RDA for zinc is adequate for the elderly.

— Marie Spano, MS, RD, CSCS, CSSD, is a freelance writer and owns a sports nutrition and nutrition

communications consulting company.

References1. Perry VH. The influence of systemic inflammation on inflam-

mation in the brain: implications for chronic neurodegenerative disease. Brain Behav Immun. 2004;18(5):407-413.

2. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med. 2005;352(16):1685-1695.

3. Moshfegh A, Goldman J, Cleveland L. What We Eat in America, NHANES 2001-2002: Usual Nutrient Intakes From Food Compared to Dietary Reference Intakes. Washington, DC: US Department of Agriculture Agricultural Research Service; 2005.

4. Ervin RB, Kennedy-Stephenson J. Mineral intakes of elderly adult supplement and non-supplement users in the Third National Health and Nutrition Examination Survey. J Nutr. 2002;132(11):3422-3427.

5. Dixon LB, Winkleby MA, Radimer KL. Dietary intake and serum nutrients differ between food-insufficient and food- sufficient families: Third National Health and Nutrition Examina-tion Survey, 1988-1994. J Nutr. 2001;131(4):1232-1246.

6. Institute of Medicine Food and Nutrition Board. Dietary Ref-erence Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vana-dium, and Zinc. Washington, DC: National Academies Press; 2001.

7. Dietary supplement fact sheet: zinc. National Institutes of Health Office of Dietary Supplements website. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/#en9.

8. USDA national nutrient database for standard refer-ence. United States Department of Agriculture Agricultural Research Service website. http://www.ars.usda.gov/Services/docs.htm?docid=8964. Last modified October 9, 2012.

FOODS HIGH IN ZINC7,8

•Raw oysters (Pacific), 3 oz: 14.1 mg

•Baked beans, canned with pork and tomato sauce, 1 cup: 13.5 mg

•Beef, chuck roast, lean only, fat trimmed, braised, 3 oz: 7 mg

•Crab, King Alaskan, cooked (moist heat), 3 oz: 6.5 mg

•Baked beans, canned, plain or vegetarian, 1 cup: 5.8 mg

•Beef patty, 95% lean, broiled, 3 oz: 5.3 mg

•Lobster, cooked (moist heat), 3 oz: 3.4 mg

•Pork loin, lean only, cooked, 3 oz: 2.9 mg


MOBILE APP MOTIVATORS New Tech Tools May Help Keep Clients Exercising Well Beyond the New Year By Jennifer Van Pelt, MA

Happy New Year! After counting down the seconds to 2013, your clients probably started counting the calories they need to cut and the number of pounds they’d like to lose. As is typical every January, New Year’s resolutions to lose weight, exercise more, and eat healthier are made and then soon broken. Gym owners, fitness instructors, and personal trainers all confirm that at the start of every new year, the gym equip-ment and classes are mobbed, and training sessions are booked solid. By March, the crowds thin out considerably when busy schedules and lost motivation overshadow resolutions to exercise regularly.

Psychology Behind MotivationMotivation and exercise adherence involve a complex

interaction of an individual’s personality, goals, and behavior choices. Researchers have sought to better define these fac-tors with the hope of improving promotional health messages to increase physical activity.

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 it’s satisfying and elicits feelings of enjoyment. Extrinsic moti-vation is defined as exercising for a specific reason or to elicit a particular outcome. It may involve the perception that exer-cise is a means to an end, results in a reward, or is performed in response to an expectation. For example, a client who plays

tennis regularly because she enjoys the sport, mastering playing skills, and/or the competition likely is intrinsically motivated. A client who exercises to lose weight is extrinsi-cally motivated.

In addition to providing an explanation of self-determination theory in relation to exercise, a systematic review published in the June 2012 issue of the International Journal of Behavioral Nutrition and Physical Activity found that intrinsic motivation was more likely to result in long-term exercise adherence.

The New Year’s resolution to exercise is categorized as extrinsic motivation. Therefore, clients who use a New Year’s resolution to initiate an exercise routine—no matter the intended goal—will inevitably have problems maintaining moti-vation over the long term. The principle of intrinsic motivation can be applied to developing strategies to help clients succeed with maintaining an exercise program. As I’ve discussed in a previous column, encouraging clients to find an exercise activ-ity they enjoy is a good first step toward exercise adherence. (See the September 2012 installment of Focus on Fitness, “Dance Fitness.”)

Unfortunately, intrinsic motivation may be difficult to cultivate in some clients, particularly those who have self-esteem issues, negative attitudes about exercise, or physical limitations. For example, even if a client enjoys dancing for exercise, feeling

FOCUS ON FITNESS


self-conscious in a dance class or lack-ing space at home may override intrin-sic enjoyment. Is it possible then to use extrinsic motivation to improve exercise adherence?

The introduction of high-tech fitness gadgets and smartphone apps for fit-ness could provide extrinsic motivation for the long-term. Given our obsession with being connected via wireless net-working, it’s reasonable to consider that fitness gadgets and apps can be more successful extrinsic motiva-tors than, for example, tracking calo-ries burned and pounds lost in a written food and activity diary.

For technophobic clients, using technology to enhance motivation to exercise can be as simple as exchang-ing daily text messages with a fitness buddy who has similar exercise goals, signing up for motivational daily e-mails from a fitness website, or using an online personal training service. For clients who always have their smart-phone in hand and love technology toys, the following gadgets and mobile apps may be of interest to track their fit-ness activities, providing motivation for daily workouts and encouraging fitness progress over time.

Fitness Gadgets• FitBit One: This fitness tracking

device is the size of a USB flash drive and costs $99.95. It tracks fitness data, such as steps walked or climbed, dis-tance, calories burned, sleep cycle, and sleep quality, 24 hours a day, 7 days a week. The One also has a silent alarm that gently vibrates to wake you up in the morning. Data can be viewed via a cus-tomizable dashboard and mobile app, which are both free. Progress is tracked using charts, graphs, and other user-friendly displays to help clients reach their goals. Moreover, interfacing with apps such as SparkPeople, MyFitness-Pal, MapMyFitness, and LoseIt! is free. The FitBit One wirelessly syncs with PCs, Macs, iPhone 4S and 5, third gen-eration iPads, and iPod touch.

• Striiv: A combination fitness tracker and mini gaming device cost-ing approximately $100, the Striiv fits into a pocket and tracks steps walked and climbed each day. Clients can meet a series of challenges and score points during the day based on the number of steps, stairs climbed, miles walked, or time spent being active. A walkathon feature connects with Striiv, which will donate money on behalf of the client.

Fitness Apps• miCoach: This training app is avail-

able for free for iPhone, iPod touch, iPad, Android phones, and BlackBerry devices. Clients get real-time audio coaching throughout a customized workout they can vary each day. The app tracks time, distance, pace, and calories burned.

• FitnessBuilder: Available for the iPhone, iPod touch, and Android phones, FitnessBuilder is a subscrip-tion personalized workout app. Clients can choose from a large library of instructional workout videos, design their own workouts by selecting a range of exercises from the library, connect with a live personal trainer, and use fitness-tracking tools to measure their success weekly.

Tech Tools GaloreThese are just a few of the new fit-

ness gadgets and apps available for clients beginning an exercise program or who require additional motivation to continue a regular program. Many more are available for advanced exercisers and athletes for a range of fitness activi-ties, from strength and muscle building to mapping running and cycling routes. Linking a love of technology to exercise goals may provide the tech-savvy client with the right motivation.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and healthcare

research analyst/consultant in the Reading, Pennsylvania, area.


The Essential Cancer Treatment Nutrition Guide & CookbookBy Jean LaMantia, RD, with Neil Berinstein, MD2012, Robert RoseSoftcover, 320 pages, $24.95

Cancer treatments create a spectrum of nutritional chal-lenges for patients, their caregivers, and the dietitians who advise them. The Essential Cancer Treatment Nutrition Guide & Cookbook is an indispensable tool for any professional working with such clients. This detailed and authoritative book, written by Jean LaMantia, RD, a cancer survivor, along with Neil Berinstein, MD, a practicing oncologist, underscores proper food and diet as a vital complementary treatment for cancer patients at every stage of recovery.

The first part of the book examines conventional cancer therapies and their side effects and provides information on managing those side effects, from anemia and fatigue to diarrhea and heartburn, through diet. Another chapter offers nutritional strategies for boosting the immune system, reducing inflammation, and creating a life-long therapeutic diet to prevent cancer recurrence.

Nondietary complementary therapies, such as homeopathy, aromatherapy, and reiki, are outlined, with an emphasis on the importance of physical activity in addition to nutrition. Sample menus and advice on shopping and food safety also are provided. Numerous charts, sidebars, and frequently asked questions present a wealth of information in an easy-to-use format.

The 150 recipes at the back of the book—developed by LaMantia and six contributors—encompass everything from breakfast dishes and entrées to snacks and beverages.

Ingredient lists include both standard US mea-surements and imperial units for Canadian read-ers. The recipes, which focus on comfort foods to tempt suppressed appe-tites, use easy-to-find ingredients and uncom-plicated directions.

Supplemental infor-mation provided with each recipe is a standout feature of the book. Along with a full nutritional analysis, every dish

includes recommendations for specific side effects or con-ditions (eg, dehydration, nausea, weight gain promotion), a variety of practical food and cooking tips, and suggestions for adjusting the recipe to alleviate particular symptoms. Many of the recipes can be made ahead of time, and instruc-tions on storage and reheating are given.

So-called survivor wisdom quotes from LaMantia are scattered throughout the book, providing helpful insights and adding a personal touch to this invaluable guide.

— Lenora Dannelke is an independent journalist who writes about food for numerous publications.

Healthy Eating, Healthy Weight for Kids and TeensBy Jodie Shield, MEd, RD, and Mary Catherine Mullen, MS, RD2012, Academy of Nutrition and DieteticsSoftcover, 288 pages, $21.95

Appropriately addressing a weight issue can confound even the best and brightest, but it’s particularly perplexing when children are involved. Yet one look at the statistics—an esti-mated one in three American children today is either over-weight or obese—shows many kids are struggling. This book seeks to help.

Written by dietitians Jodie Shield and Mary Catherine Mullen and produced by the Academy of Nutrition and Dietetics’ publishing arm, Eat Right Press, Healthy Eating, Healthy Weight for Kids and Teens aims to provide parents with the knowledge and tools to wage war—and win—against whatever food issues their children are facing.

To help parents determine whether their child has a weight problem that requires intervention, two introductory chapters serve as required reading and help define what actually constitutes a “healthy weight.” Here, topics such as what’s normal for certain age ranges, what BMI is and what it means, and how parents can best track a child’s height and weight are discussed. (Tip 1: Use a digital scale for accuracy.)

The eight chapters that follow don’t need to be read in order; each outlines a particular strategy that addresses a

BOOKSHELF

specific problem. Parents are meant to scan the chapter titles to see which they might benefit from most before diving into them. For example, if Mom and Dad both work full time and, due to work and a dozen after-school commitments, have trouble getting a dinner routine in order, often opting for fast food, then Chapter 3: Eat With a Plan might suit them well. In this chapter, the authors define in concrete terms what healthful eating actually looks like (with help from a Choose MyPlate illustration), then break it down even further with kid-friendly tips on how to incorporate whole grains, dairy, fruits, and veggies into a daily meal plan. The book provides a sample one-day menu to help parents see what they’re shooting for in terms of foods and serving sizes.

Other chapters provide strategies, addressing several all-too-common healthful-eating barriers that can prevent kids from keeping their weight in check, such as watching too much TV, drinking soda and other sugar-sweetened beverages, portion distortion, fast-food hang-ups, and picky eaters’ aversions to fruits and veggies.

Backed by scientific research, the authors say these strategies also may help healthy-weight kids from ever having to deal with the unwanted physical and emotional dilemmas that come with being overweight or obese. To finish up this book, three weeks of sample menus (with healthful meal and snack ideas) serve as a great resource to help parents practice their just-learned healthful strategies with fresh (and kid-approved) dinner ideas.



Cooking VeganBy Vesanto Melina, MS, RD, and Joseph Forest2012, Book Publishing Company Softcover, 224 pages, $19.95

I’ll be the first to admit that when Cooking Vegan came across my desk, I hesitated about agreeing to be a reviewer. Despite a handful of half-hearted attempts by my husband in the past to convince me we should become vegetarian, I remain fairly com-mitted to my life as a carnivore. But with its underlying tone that eating vegan (at least sometimes) is for everyone, Cooking Vegan is just as appropriately written for people like me as it is for those who are vegan. This collection includes recipes worth trying for a diet with fewer animal-based foods or to add more

creative dishes to your repertoire.

Readers of Cooking Vegan will appreciate the variety of cre-ative recipes and fla-vors, and the way the authors have demysti-fied vegan ingredients. Nutrition profession-als will appreciate the inclusion of a detailed and easy-to-read intro-duction on the vegan lifestyle, including an abbreviated explana-tion of vegan nutrition, a description of ingre-dients commonly used in vegan dishes, cooking tips, and sample menus. Additionally, nutritional information is avail-able for every recipe, with more than just a macronutrient breakdown provided.

Cooking Vegan showcases a variety of dishes—breakfast foods, sauces, dips, salads, and sweet treats—and there’s something for everyone. I sampled the Fiesta Quinoa Salad With Lime Dressing; Avocado, Grapefruit, and Chipotle Dressing; Thai Pasta Salad With Spicy Peanut Sauce; and the Walnut, Olive, and Sun-Dried Tomato Tapenade. The directions were easy to understand, clearly written and, as a novice vegan eater, I especially enjoyed the short description that accompanied every recipe.

Readers should take caution and note the yield, as some recipes make quite a large amount. They also should be prepared that while most ingredients are common and read-ily available, I did have to purchase several oils and spices that aren’t usually stocked in my pantry. These items were available at my local grocer but were fairly costly; I suspect that had I gone to my local specialty store, these ingredients would have cost less.

But these minor considerations don’t overshadow the variety of unique ideas readers can find in Cooking Vegan.

— Christin L. Seher, MS, RD, LD, is a dietitian, instructor, and nutrition consultant in northeast Ohio.

Lily’s Sweets Debuts Stevia-Sweetened Chocolate

Lily’s Sweets has introduced the first fair trade-certified stevia-sweet-ened chocolate bars made with 55% cocoa. Lily’s bars naturally contain 25% fewer calories than other 55% dark chocolates sweetened with sugar. The 3-oz chocolate bars contain no added sugar, artificial ingredients, or GMOs and have just 160 to 170 kcal per half-bar serving.

The bars come in four flavors: Original, Crispy Rice, Coconut, and Almond.

In addition, Lily’s Sweets donates a percentage of its profits to organiza-tions that support childhood cancer survivors and fighters.

For more information, visit www.lilyssweets.com.

RD Clinic Allows RDs to Streamline Their Practice

A successful weight-loss program requires a nutrition pro-fessional to assess, diagnose, intervene, monitor, and evaluate clients. Unfortunately, these tasks require a professional to spend a large percentage of their time doing data entry, which takes away from working directly with clients.

RD Clinic aims to change that. Designed for RDs who work in hospitals and other healthcare facilities, private practice, or with HMOs to streamline their day-to-day work and client interactions, it includes health assessments, questionnaires, medical records, detailed nutritional tools, physical activity analysis, documentation, webinars, video, communication with clients, and medical billing.

It’s available for any device connected to the Internet. In addition, it allows clients to track their information. They can search, write, e-mail, photograph, or even call a toll-free number and the information will be saved in their journals. Clients also can follow plans online and communicate with their nutrition professional.

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 they’re seen by the professional, all the reports are already done. If the client doesn’t use the Internet, the RD can enter their intake directly to do the analysis and still save time.

All features are HIPAA compliant, and all data can be printed and made available on cell phones and tablets, and are delivered in multiple languages. The database of foods, meals, and fitness plans is updated daily. It also interfaces with existing electronic medical record systems to offer one location for all patient records.

There’s no cost for patients to use the program, only for healthcare professionals.

For more information, visit www.nutrihand.com.

PRODUCTS + SERVICES

Foods Alive Introduces Certified Organic Chia Oil

Foods Alive brings chia right to your kitchen for a simple new way of introducing omega-3s to the diet.

Chia oil is derived from the seeds of the chia plant. It contains more than 60% omega-3 fatty acids, one of nature’s richest plant sources of essential fatty acids, and cell-protecting antioxidants. The oil has no odor and a very mild flavor, so it’s easy to add to smoothies, soups, or sauces or use to create salad dressings.

For more information, visit www.foodsalive.com.

In The Raw Expands With Monk Fruit Sugar Substitute

The In The Raw family of all-natural sweeteners has expanded with the launch of Monk Fruit In The Raw, a zero-calorie sugar substitute with a natural taste. Monk Fruit In The Raw is ideal for individuals looking to cut added sugars and also is recommended for those with diabetes seeking sugar substitutes.

Monk Fruit In The Raw is made from monk fruit, a vine-ripened fruit native to Asia. The product is different from other monk fruit-based sweeteners because it doesn’t contain added table sugar, sugar alcohols, or molasses.

Monk Fruit In The Raw can be used in any recipe that calls for sugar, used to sweeten beverages, blended in yogurt and smoothies, and put on cereal or oat-meal. It’s available in sin-gle-serve packets.

For more information, visit www.intheraw.com.


GREAT VALLEY PUBLISHING BOS024523B

MWEIR

baf/baf/gl/jb/gl

FRES0001

dietitian

4

2.292 x 4.78” (4c process)

2013

Fresenius Medical Care North America is an Equal Opportunity Employer.

Passion. Dedication. Knowledge. Motivation.Experience. These are the impressive qualitiesyou’ll find in the Fresenius Leadership Team. We provide our employees with the best of both worlds– the friendliness of a local organization and the stability of a worldwide organization. This createsdiverse experiences and challenging careeropportunities. When you join the Fresenius MedicalCare team, you’ll be welcomed into a company thatis built on the philosophy that our employees areour most important asset.

Registered DietitiansPositions Available Nationwide

We offer a generous compensation and benefitspackage that includes medical and dental, 401(k)match, profit sharing, short and long term disability,tuition reimbursement, and a generous paid timeoff program.

To discover the difference between a job and real job satisfaction, go to: fmsjobs.fmcna.com/TD

ConnectTO A CAREER THAT NOURISHES YOUR HEART

Dietitian - Diabetes EducationEducation and Experience

• Bachelor’s degree in Nutrition or Food Science with completion of clinical dietitian internship program or equivalent is required.

Certifi cates, Licenses, and Registrations

• Current State of Wyoming Licensed Dietitian (LD) is required.

• Registered Dietitian (registered by the Commission on Dietetic Registration) is required.

• Current American Heart Association (AHA) Basic Life Support (BLS) for Health Care Providers is required.

• Certifi ed Pump Trainer is preferred.

To apply, visit our website atwww.wyomingmedicalcenter.org.

TD_WY_WyoMed.indd 1 1/2/13 1:21 PM

YumaAZ

2/9 V

An amazing opportunity awaits you in Southwestern Arizona…

Yuma Regional Medical Center offers an ideal combination of professional opportunities and quality lifestyle offering amenities of a large city without a stressful commute or high cost of living. We’re proud of the caring

culture we’ve created for our patients and employees.

Registered DietitianChronic Disease Management/Transitional Care Clinic/Heart Failure Clinic

For details regarding Employment Opportunities:Call our Recruitment Office at 1-800-726-9862 or 928-336-7121 or Email: [email protected]

We are an equal opportunity employer and support a drug-free and tobacco-free work environment.

Manager – Nutrition Services

Scottsdale Healthcare

Scottsdale Healthcare, located in sunny Arizona, is composed of two medical centers and a community hospital, complete with IP/OP and home health services and more. This position manages the system-wide Nutrition and Patient Service department including Clinical Nutrition, patient, staff and community education; enteral-parenteral nutrition delivery.

Bring your multi-location, healthcare system RD experience to Scottsdale Healthcare and enjoy a career where World-Class Patient Care puts the individual first. We care for our patients as well as the people who work here by providing a culture of respect and compassion – plus fantastic quality-of- life features like on-site child care.

Learn more and apply online: Jobs.SHC.org

Generate new business. Vitalize existing client

relationships. Promote a greater

understanding of your industry.

ORDER REPRINTS!Reprints connect you with clients, students, and colleagues in an exciting, informative way. They’re the ideal tools for sales teams, and they make great trade show handouts.

Call 877-394-7350 or e-mail [email protected].

Can you pass the salt?” is a common question we hear at the breakfast, lunch, and dinner table each day. We shake a little here, a little extra there to get our food to taste just right before we dig in. And we do

this in addition to eating processed foods and res-taurant fare on a regular basis, which experts say is where most of our sodium intake comes from. But is all of this sodium we’re eating really dam-aging our long-term cardiovascular health? Or is what we’ve heard thus far a bit of an exaggeration?

Recently, a media fi restorm erupted over a July report in the Cochrane Database of System-atic Reviews, also appearing simultaneously in the American Journal of Hypertension, which seemed to call into question the basis for salt restriction

recommendations. After researchers looked at the data of 6,500 participants, they concluded that the cardioprotective benefi ts of salt restriction couldn’t be proven based on current evidence.

Shortly after this controversial meta-analysis hit the air-waves, two U.K. preventive medicine experts quickly countered these claims. They reanalyzed the same data and concluded in a comment in the July 30 issue of The Lancet that “the results of our reanalysis, contrary to the claims by Taylor and colleagues, support current public-health recommendations to reduce salt intake in the whole population.”

Many in the medical community as well as the RDs inter-viewed by Today’s Dietitian agree with the U.K. researchers’ assessment.

“Salt is a vital nutrient required for the body to function properly,” wrote Janet Bond Brill, PhD, RD, CSSD, in Prevent a Second Heart Attack: 8 Foods, 8 Weeks to Reverse Heart Disease. Yet while essential in small amounts, consuming too much salt has led many Americans to associate the nutrient with an unfortunately all-too-common ailment: high blood pressure, a leading risk factor for heart disease.

High blood pressure is extraordinarily common in the United States, affecting approximately one-third of the adult popula-tion, Brill says. “Hypertension is a powerful and unequivocal independent risk factor for cardiovascular and renal diseases, including coronary heart disease, stroke, and renal failure. Despite major advances in the understanding and treatment of hypertension over the past several decades, the disease remains the most common primary diagnosis in the United States and is a major public health concern,” she adds.

According to World Health Organization (WHO) estimates, hypertension causes 5 million premature deaths per year worldwide. And across WHO regions, research indicates that about 62% of strokes and 49% of heart attacks are caused by hypertension, according to Brill.

It’s an issue dietitians and doctors know well. Also well known is part of the popular lifestyle prescription to help patients fi ght or prevent hypertension and heart disease: sodium restriction.

“Irrefutable scientifi c evidence supports the fact that reduc-ing sodium intake, [as well as] increasing potassium intake, lowers blood pressure. Myriad randomized controlled clini-cal trials collectively have demonstrated the benefi ts of sodium reduction for blood pressure control in both normotensive and hypertensive individuals,” Brill says. She says people with a blood pressure of greater than or equal to 130/85 have a 1.5 to 2.5 times greater risk of experiencing a heart attack than those with a blood pressure value of less than 120/80.

So what’s the real story? Such confl icting reports can create confusion, especially when clients catch only half the story on the nightly news. As patients come calling with questions, salt shaker at the ready, you’ll need to know how to respond to their sodium queries. In the following article, nutrition professionals evaluate

the historical evidence on the link between sodium, hypertension, and cardiovascular disease (CVD) risk and offer some strategies you can use to answer your clients’ tough questions.

Professionals’ TakeProbably to the dismay of consumers, many dietitians and

doctors overwhelmingly agreed with the follow-up conclusions to the controversial Cochrane review fi ndings and say they have no plans to change their sodium recommendations anytime soon.

“Clearly these fi ndings are far out in left fi eld and do not refl ect the overwhelming amount of strong scientifi c evidence gathered over decades that supports the fact that reducing sodium intake reduces blood pressure, thereby reducing risk of cardiovascular disease, our nation’s leading cause of death,” Brill says of the Cochrane report.

She refers to one such piece of evidence to back up her stance in Prevent a Second Heart Attack. “A recent study pub-lished in the April 2007 issue of BMJ concerning a group of individuals with borderline to high blood pressure found that cutting back on their salt intake slashed their risk of developing heart disease by 25% and of dying of the disease by up to 20%. The researchers surmised that sodium acts directly on blood vessel walls, stiffening them and making them more suscepti-ble to atherosclerosis.”

Another study, published in the February 2010 issue of The New England Journal of Medicine, concluded that if everyone cut salt intake by just a 1⁄2 tsp/day, there would be close to 100,000 fewer heart attacks each year and the number of deaths from CVD would drop by up to 92,000 annually, Brill says of another piece of evidence in her arsenal for salt restriction.

In light of such fi ndings, Brill says she’s siding with the American Heart Association, which recommends all Americans aim for consuming less than 1,500 mg of sodium per day.

Nutrition research scientist James J. Kenney, PhD, RD, FACN, says he isn’t surprised by the study’s controversial fi nd-ings, considering what he calls the limited quality of the data the authors had to work with. “Given how hard it is to get an accurate measure of people’s salt intake over the long term and how hard it is for people to really restrict their salt intake, the failure of the Cochrane review to fi nd low-salt diets reduce CVD and total mortality isn’t surprising,” he explains.

He says the authors’ conclusions actually refl ect the need for better data on the impact of long-term salt restriction on CVD and total mortality. “Keep in mind, a similar review article pub-lished in [The American Journal of Clinical Nutrition in March] last year failed to fi nd an association between saturated fat intake and CVD events. Nevertheless, there’s a known impact of saturated fat and salt on LDL cholesterol and blood pressure, respectively, in controlled clinical trials,” he says. “What these data suggest is the failure to fi nd an association in studies that measured these parameters inaccurately. The data is of little import and shouldn’t alter clinical decisions.”

Great SaltDebate

Experts Stand Behind Salt

Restriction’s Cardioprotective

Effects

The

By Juliann Schaeffer

40 today’s dietitian october 2011 october 2011 www.todaysdietitian.com 41

GGGrGrrrrreeaDDDeeeeeebbba

ExperBeh

TheTheGGBy Juliann Schaeffer

The Great Salt Debate

Experts Support

Salt Restriction’s

Cardioprotective Effects

9 Probiotic-Rich Foods

Beyond Yogurt

New ResearchSoy Lowers Blood Pressure

Plus 25 Soy Foods

to Tell Clients About

California Style!

FNCE CONFERENCE ISSUE

Fragrant, Flavorful, Teeming

With Health Benefi ts


October 2011

Vol. 13 No. 10


Vol. 13 No. 10

he Magaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaazzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzziiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiinnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnneeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee fffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffoooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooorrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuttttttttttttttttttttttttrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrriiiiiiiiiiiiiittttttttion Professionals

According to the 1964 Walt Disney musical Mary Poppins, just a spoonful of sugar helps the medicine go down. But while sugar may help the medicine go down, you don’t hear anyone singing these praises anymore.

Instead, many Americans and those in the healthcare com-munity claim “Sugar is toxic.” “Sugar causes obesity.” “Sugar makes you fat.”

For decades, both consumers and health experts have been pondering the potential negative health effects related to sugar consumption. The classic 1986 book Sugar Blues by William Dufty exploded onto the sugar-busting scene. People were shocked to read they were consuming, on average, 100 lbs of sugar per year.

Fast forward to today, when Americans are consuming even more of the sweet stuff. According to the USDA, per capita consumption of caloric sweeteners, mainly sucrose and corn sugars, increased 39% between the 1950s and 2000 to an average of 152 lbs per year.1 People are now eating an average of about 30 tsp of sugar per day, which contributes a whopping 476 kcal per day.2 And along with the rise in sugar intake has come a growing sense of dread among the public over the potential health fallout. Find-ings from the International Food Information Council Foun-dation 2012 Food & Health Survey revealed consumers’ attitudes about sugar and health. Consumers were asked

which calorie sources (sugars, carbo-hydrates, fats, protein, or all sources) they believe are more responsible for

weight gain. Twenty percent said that calories from sugars are most responsible. While 62% believed a moderate amount can be part of a healthful diet and 61% said it’s not necessary to completely eliminate sugar to lose weight, only 28% believed all sugars (including high-fructose corn syrup [HFCS], table sugar, and honey) are similar and used by the body in the same way. Fifty-one percent of Americans are trying to limit or avoid sugars when choosing foods and beverages, while 35% pay no attention to sugar content.3

Sugar Hits the AirwavesWhat’s fueling the public’s sugar fears? “Consumers have

been hearing for years the stories linking sugar to hyperactiv-ity, diabetes, obesity, and other chronic diseases,” says Jean-nie Gazzaniga-Moloo, PhD, RD, a national spokesperson for the Academy of Nutrition and Dietetics (the Academy). “They’ve also heard reports disputing connections between sugar and all these conditions. I think many consumers are confused about sugar’s role in disease development and management.”

The volume on the sugar-health debate turned up a notch when a recent wave of media reports called on the opinions of Robert H. Lustig, MD, a professor of pediatrics in the division of endocrinology at the University of California, San Francisco, who’s a leader in the antisugar movement. Lustig has spoken out at several recent nutrition conferences on the adverse health effects of sugar, including the Annual Nutrition & Health Conference and the Experimental Biology meeting.

Lustig reported at the Annual Nutrition & Health Confer-ence in May 2011 that fructose intake, an egregious component in the Western diet, has doubled over the past 30 years from all its sources, including HFCS, sucrose, and juice. “The ‘fructosi-fication’ of our food supply increases its palatability. Low- quality foods have high-fructose corn syrup added on purpose. It’s used as a browning agent,” Lustig said.

He reported that our growing dependence on fructose has fueled the obesity and type 2 diabetes epidemics and has led to increased energy intake, decreased resting energy expenditure, excess fat deposition, nonalcoholic fatty liver disease, insulin resistance, hyperglycemia, cardiovascular disease, and meta-bolic syndrome in humans.

Lustig has become a hit among mainstream audiences, thanks to his YouTube lecture “Sugar: The Bitter Truth,” which has received more than 2.6 million hits to date. In April, 60 Min-utes aired a segment featuring Lustig as an expert on sugar and health. He reported that sugar is toxic and that it’s to blame for the public health crisis more than any other food substance.4

One year earlier, Lustig was featured in a New York Times article titled “Is Sugar Toxic?” written by Gary Taubes, author of Good Calories, Bad Calories, who shares similar views with Lustig. Sugar isn’t just an empty calorie, Lustig says in the arti-cle; its effects on us are much more insidious. “It’s a poison by itself,” Lustig was quoted as saying. Taubes wrote:

Lustig’s argument, however, is not about the consumption of empty calories—and biochemists have made the same case previously, though not so publicly. It is that sugar has unique characteristics, specifically in the way the human body metabolizes the fructose in it, that may make it singularly harmful if consumed in sufficient quantities.5

Is Sugar Really Dangerous?Lustig’s views on sugar and health bring to light the crux of

the sugar argument, raising the question, is there proof that the negative impact of sugar extends beyond its provision of empty calories?

“The concept that sugar is toxic simply has no credibility,” says David M. Klurfeld, PhD, national program leader for the Human Nutrition USDA Agricultural Research Service, who edited a June 2009 Journal of Nutrition supplement “The State of the Science on Dietary Sweeteners Containing Fructose.” “There’s little doubt that Americans consume too much sugar, but we have no data to tell us how much is too much for any health endpoint we ask about.”

Walter Willett, DrPH, MD, chair of the department of nutri-tion at the Harvard School of Public Health, says, “There are problems with sugar due to adverse metabolic effects, but the idea that fructose is dangerous—the science doesn’t support this. To only focus on sugar as the problem, the science isn’t there. There may be subtle metabolic differences in the body with fructose. Cutting back on sugar is an important part of a healthful diet, along with cutting back on refined starches and fruit juice, which have the same glycemic load as sugar.”

The 2009 American Heart Association (AHA) Scientific State-ment on Dietary Sugars Intake and Cardiovascular Health reported that excessive consumption of sugars has been linked with several metabolic abnormalities and adverse health condi-tions. Though the mechanisms are unclear, relative to other car-bohydrate sources, sugar intake appears to be associated with increased triglyceride levels, a known risk factor for coronary heart disease, and some studies show that a higher consumption of high-sugar beverages and foods is associated with increased inflammation and oxidative stress, according to the AHA.

While acknowledging that obesity is a multifactorial con-dition, it’s likely that Americans’ recent history of weight gain must be related in part to increased intake of added sugars, even though research thus far has been insufficient to confirm a direct link, the AHA stated.2

Most everyone agrees that the increase in sugar intake has led to a sea of unwanted calories. The Dietary Guidelines for Americans report that added sugars are consumed in excessive amounts, resulting in a high intake of calories that offer little nutritional payback. However, the guidelines state that foods with added sugars are no more likely to contribute to weight gain than any other source of calories in an eating pattern that’s within calorie limits.6

By Sharon Palmer, RD

Scoop

on Sugar

The Real

Today’s Dietitian investigates the sugar debate.

28 today’s dietitian october 2012 october 2012 www.todaysdietitian.com 29


Center Stage

Dairy’s Role in Improving

School Nutrition


Diffi cile

FNCE 2012 CONFERENCE ISSUE

on The Real

Today’s Dietitian

Investigates the

Sugar Debate


October 2012

Vol. 14 No. 10


Get CE credits quickly, from a name you trust.

CE.TodaysDietitian.com

GiGiGiveve YYYouourr JJoJobbb SSeSearar hchch aa StStSt bababllele CCCorore.e.


NATIO

NWIDE•WY•AZ

NEWS BITES

‘Mindful Eating’ Lowers Weight, Blood Sugar in DiabetesEating 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 weight—an average of between 31⁄2 and 6 lbs—and lowered their long-term blood sugar levels significantly after three months.

One treatment group followed an established diabetes self-management education program, with a strong empha-sis on nutrition information. The other group was trained in mindful meditation and a mindful approach to food selec-tion and eating. Both interventions, involving weekly group meetings, also recommended physical activity.

“The more traditional education program includes general information about diabetes but with more emphasis on nutrition and food choice: What are differ-ent types of carbohydrates and fats, and how many am I supposed to have? What should I look for when I read a food label? What are healthful options when dining out? That was the traditional diabetes education program,” explains Carla Miller, PhD, an associate professor of human nutrition at Ohio State University and lead study author. “We compared it to an intervention where mind-ful meditation was applied specifically to eating and food choices. This intervention group didn’t receive specific nutrition goals. We said ‘we want you to really tune into your body before you eat. Take a few minutes to assess how hungry you are and make conscious choices about how much you’re eating. Stop eating when you’re full.’

“We studied two very different approaches, and we found they both worked,” Miller says.

Participants were between the ages of 35 and 65 and had been diagnosed with type 2 diabetes for at least one year. To be eligible, participants had to have a BMI of 27 or higher, indicating they were overweight, and a hemo-globin A1c (HbA1c) reading of at least 7%.

Study participants were randomly assigned to a treat-ment group. Twenty-seven completed the mindful eating program, and 25 completed the traditional diabetes self-management program called Smart Choices. Each inter-vention involved eight weekly and two biweekly 21⁄2-hour sessions with trained facilitators.

The interventions took place over three months.

Researchers assessed participants’ health measures and dietary habits immediately after the programs concluded and then again three months later at the study’s end.

Weight loss and improvements in HbA1c levels were similar for both groups at the six-month follow-up point. Smart Choice participants as a group lost more weight, an average of 6 lbs, than did the mindful eating group, which lost an average of 3.5 lbs, but the difference wasn’t significant when analyzed statistically, Miller says.

HbA1c levels dropped in both groups as well between about 0.7% and 0.8%. “That was a clinically meaningful reduction in Hba1c, equivalent to what you’d get on some diabetes medications,” Miller says. “If the reduction were sustained over time, it would mean a dramatic reduction in complications associated with diabetes.”

Both groups also similarly reduced calorie intake and low-ered their consumption of foods with a high glycemic index.

Miller says that because nutrition education is important to people with a new diabetes diagnosis, she sees the mind-ful meditation and eating option as a potential supplement to basic diabetes education. She also said that participants adapted well to the concept of mindfulness even though it’s generally considered an alternative health practice.

“One of the things we were evaluating was how well this was accepted by people who had no experience with it. It was very well accepted by participants in that group, and this tells us that people with diabetes have choices,” Miller says. “The fact that both interventions were equally effective suggests we should let people choose. If mindful meditation is appealing and people think that approach is effective, then it very well could be the best choice for them.”— SOURCE: OHIO STATE UNIVERSITY


High Vitamin D Levels May Protect Mothers Against MSPregnant women who have higher levels of vitamin D in their

blood may have a lower risk of developing multiple sclerosis (MS) than women with lower levels, while their babies may not see the same protective effect, according to a study published online in Neurology.

“In our study, pregnant women and women in general had a lower risk for MS with higher levels of the vitamin, as expected. However, a mother’s levels of vitamin D during early pregnancy didn’t have an effect on MS risk for her baby,” says study author Jonatan Salzer, MD, with Umeå University Hospital in Sweden.

For the study, scientists reviewed information about 291,500 blood samples from 164,000 people collected since 1975 in the northern half of Sweden. Of those, 192 people developed MS an average of nine years after their blood sample was drawn, and there were 37 blood samples drawn during pregnancy from mothers whose children went on to develop MS later in life.

The research found that women who had high levels of vitamin D in their blood had a 61% lower risk of developing MS compared with those who had low levels of vitamin D in their blood. Over-all, few people had high levels of vitamin D. Only seven of the 192 people (4%) who developed MS had high vitamin D levels compared with 30 of 384 controls (8%) without the disease.

No association was found between the mother’s vitamin D level and whether her child would later develop MS.

“Since we found no protective effect on the baby for women with higher levels of vitamin D in early pregnancy, our study suggests the protective effect may start in later pregnancy and beyond,” Salzer says. “Another interesting finding in our study was that the vitamin D levels became gradually lower with time from 1975 and onward. It’s possible that this decline in vitamin D status is linked to the increasing numbers of MS cases seen worldwide.”— SOURCE: AMERICAN ACADEMY OF NEUROLOGY

High-Carb Diet Associated With Colon Cancer RecurrenceColon cancer survivors whose diets are heavy in complex

sugars and carbohydrate-rich foods are far more likely to have a recurrence of the disease than are patients who eat a better balance of foods, indicates a new study by Dana-Farber Cancer Institute researchers.

The connection is especially strong in patients who are overweight or obese, the authors wrote. More than 1,000 patients with advanced (stage 3) colon cancer participated in the study, one of the first to examine how diet can affect the chances that the disease will recur. The findings are being published online by the Journal of the National Cancer Institute.

Although the results point to a potential hazard of a high-carbohydrate diet for colon cancer patients, the take-home message is not a conclusive “eat less sugar,” says lead author Jeffrey Meyerhardt, MD, MPH. “Our study certainly supports the idea that diet can impact the progression of colon cancer, and that patients and their doctors should consider this when making posttreatment plans, but further research is needed to confirm our findings.”

Recent studies have shown that colorectal cancer survivors whose diet and activity patterns lead to excess amounts of insulin in the blood have a higher risk of cancer recurrence and death from the disease.

In a previous study of advanced-stage colon cancer patients, Meyerhardt and his colleagues found that those with a typical Western diet, marked by high intakes of meat, fat, refined grains, and sugary desserts, were three times more likely to have a cancer recurrence than those whose diets were least Western. The new study was conducted to

explore which component of the Western diet is most respon-sible for the increased risk of recurrence.

The study involved 1,011 stage 3 colon cancer patients who had undergone surgery and participated in a National Cancer Institute-sponsored Cancer and Leukemia Group B clinical trial of follow-up chemotherapy for their disease. Participants reported their dietary intake during and six months after the trial.

Researchers tracked the patients’ total carbohydrates as well as their glycemic index and glycemic load and looked for a statistical connection between these measures and colon cancer recurrence.

They found that participants with the highest dietary levels of glycemic load and carbohydrate intake had an 80% increased risk of colon cancer recurrence or death compared with those who had the lowest levels. Among patients who were overweight or obese (BMI above 25), the increase was even greater.

“In light of our and others’ research, we theorize that factors including a high glycemic load may stimulate the body’s produc-tion of insulin,” Meyerhardt says. “That, in turn, may increase the proliferation of cells and prevent the natural cell-death process in cancer cells that have metastasized from their original site.”

Meyerhardt adds that while the study doesn’t prove that diets high in glycemic load and carbohydrate intake cause recur-rence of colon cancer, the results strongly suggest that such dietary factors play a role. “Our findings may offer useful guid-ance for patients and physicians in ways of improving patient survival after treatment,” he says.— SOURCE: DANA-FARBER CANCER INSTITUTE


CAT CORAAn Iron Chef With a Heart for Combating HungerBy Juliann Schaeffer

As one of the newest members—and the first female—inducted into the Culinary Hall of Fame, it’s no secret Cat Cora knows her way around a kitchen. First employing her cook-ing prowess in 2005 to best the brightest of culinary stars as the first—and only—female Iron Chef on Food Network’s Iron Chef America (for which she may be most recognized), now the celebrity chef is utilizing social media technology to bring those top-rate cooking skills to the masses with a new iPad app. Called Cat Cora’s Kitchen, the app not only gives users deli-cious recipes but also assists users in organizing their time via a scheduler that includes step-by-step instructions and esti-mated completion times for each dish.

“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, it’s her four boys: “My kids inspire and motivate me every single day.”

Today’s Dietitian (TD): Iron Chef, TV host, contributing editor for O, The Oprah Magazine: What’s next?�Cora: I just opened a new Cat Cora’s Kitchen restaurant at the Salt Lake City Airport and hope to open more across the coun-try soon. I’m also putting the final touches on a shoe line, which will be available [sometime in 2013].

TD: In 2005, you founded Chefs for Humanity. What is this organization, and what sparked the idea for its inception?� Cora: Hunger kills more people each year than AIDS, tuber-culosis, and malaria combined. Chefs for Humanity is a non-profit organization I founded to galvanize chefs, the culinary community, and other concerned individuals to support hunger relief and improve nutrition for children and fami-lies here in the United States as well as in places in the world where hunger and malnutrition pose even more dire threats to public health.

I was inspired to start Chefs for Humanity after witnessing how chefs and people who love to cook also love to help, and learning how valuable skills like cooking for large crowds and safe food handling can be in times of disaster such as during Hurricane Katrina, where I, along with other chefs, helped the American Red Cross set up temporary kitchens to feed dis-placed victims.

GET TO KNOW…�

“ 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.”


Recognizing that chronic hunger and malnutrition is an ongoing disaster for so many people, Chefs for Humanity is committed to mobilizing those with needed skills and passion to help every day as well as in times of crisis.

TD: How does Chefs for Humanity work to prevent hunger and reduce obesity—two causes close to the hearts of many dieti-tians—and what’s your proudest accomplishment of the orga-nization thus far?�Cora: Chefs for Humanity works to prevent hunger and malnu-trition, which includes obesity, by raising support and aware-ness and developing programs to address these issues. There are many accomplishments we’re proud of but, most recently, we’re working to establish a Global School Gardens initiative to help educate children about good nutrition while connecting them to the culinary community and engaging local chefs, res-taurants, and others to ensure that healthful eating and afford-able access to good food is a communitywide effort.

TD: Is there one product in your specialty food line that you couldn’t live without in your own kitchen?�Cora: I cook with my award-winning Cat Cora’s Kitchen BY GAEA organic olive oil almost daily. It’s the first-ever bottled olive oil to be completely carbon neutral.

TD: What’s your favorite family recipe and why?�Cora: I love my mom’s Greek Cinnamon Chicken recipe (see below). It was my absolute favorite growing up; my mom would make it on special occasions like holidays, birthdays, and anni-versaries. I carry on that tradition today, and my kids love it! Eating it always brings back fond memories.



Greek Cinnamon Stewed Chicken (Koto Kapama)

Serves 4

Ingredients1 chicken (21⁄2 to 3 lbs), cut into eight pieces1 tsp ground cinnamon2 tsp kosher salt1 tsp freshly ground black pepper5 peeled garlic cloves, minced2 T extra-virgin olive oil2 peeled, coarsely chopped medium yellow onions1⁄2 cup dry white wine1 cup water1 cup chicken stockOne 6-oz can tomato paste1 T fresh oregano, chopped1⁄2 cup grated Mizithra cheese

Instructions1. Pat the chicken dry with paper towels. A wet chicken

will cause the oil to splatter while the chicken is sautéing. Mix the cinnamon, salt, and pepper in a small bowl. Rub the chicken pieces on all sides with the seasoning.

2. Mince three of the garlic cloves. Heat the olive oil in a large nonreactive deep skillet over high heat. A 12-inch skillet with sides about 21⁄2 to 3 inches high will allow you to brown all the chicken at once. If you don’t have a skillet large enough, brown them in two batches using one-half of the

oil for each batch. What’s important is that the chicken isn’t overcrowded, which would cause the pieces to steam rather than brown.

3. Add the chicken to the oil and brown for about 4 to 5 minutes on each side. Turn the pieces using a metal spat-ula, as they have a tendency to stick to the pan. Remove the pieces when they’re well browned on all sides.

4. Lower the heat to medium-high and add the onions and minced garlic. Cook for about 3 minutes, stirring con-stantly, until the onions have softened and are a rich golden brown. Add the wine and scrape the bottom of the pan with a spatula or spoon to deglaze the pan, loosening any parti-cles stuck on the bottom.

5. When the wine has evaporated, add the water, chicken stock, tomato paste, fresh oregano, and remaining two garlic cloves. Return the chicken to the pan. The liquid should cover about 3⁄4 of the chicken pieces. Cover the pot and simmer over low heat for about an hour or until the chicken is tender and thoroughly cooked. If the sauce becomes too thick, it can be thinned with a little more water. Season the finished sauce with kosher salt and pepper to taste.

6. Serve the chicken topped with the sauce and sprinkle with Mizithra cheese.

Nutrient Analysis per serving Calories: 560; Total fat: 18 g; Sat fat: 6 g; Trans fat: 0 g;

Cholesterol: 174 mg; Sodium: 1,113 mg; Total carbohydrate: 19 g; Dietary fiber: 3 g; Sugars: 9 g; Protein: 74 g


FEBRUARY 9, 2013AMERICAN DIABETES ASSOCIATION DIABETES EXPODenver, Coloradowww.diabetes.org

FEBRUARY 9-12, 2013AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION CLINICAL NUTRITION WEEKPhoenix, Arizonawww.nutritioncare.org/cnw

FEBRUARY 22-26, 2013AMERICAN ACADEMY OF ALLERGY, ASTHMA & IMMUNOLOGY ANNUAL MEETINGSan Antonio, Texashttp://annualmeeting.aaaai.org

FEBRUARY 28 – MARCH 1, 2013GEORGIA ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE & EXHIBITIONStone Mountain, Georgiawww.eatrightgeorgia.org

MARCH 2, 2013AMERICAN DIABETES ASSOCIATION DIABETES EXPOSalt Lake City, Utahwww.diabetes.org

MARCH 7, 2013TENNESSEE ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETINGwww.eatright-tn.org

MARCH 14-17, 2013HEALTHY KITCHENS, HEALTHY LIVES: CARING FOR OUR PATIENTS AND OURSELVESOffered by the Harvard School of Public

Health and The Culinary Institute of America

Napa Valley, Californiawww.healthykitchens.org

MARCH 19-21, 2013WEST VIRGINIA ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETINGHuntington, West Virginiawww.wvda.org

MARCH 19-22, 2013EPIDEMIOLOGY AND PREVENTION/NUTRITION, PHYSICAL ACTIVITY, AND METABOLISM SCIENTIFIC SESSIONSNew Orleans, Louisianawww.my.americanheart.org/

professional/index.jsp

APRIL 2-6, 2013NATIONAL KIDNEY FOUNDATION SPRING CLINICAL MEETINGSOrlando, Floridawww.nkfclinicalmeetings.org

APRIL 4-6, 2013MISSOURI, IOWA, NEBRASKA, AND KANSAS DIETETIC ASSOCIATIONS ANNUAL CONFERENCEOverland Park, Kansaswww.eatrightnebraska.org

APRIL 5-6, 2013ILLINOIS DIETETIC ASSOCIATION SPRING ASSEMBLYOak Brook, Illinoiswww.eatrightillinois.org

APRIL 5-6, 2013SOUTH CAROLINA ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETINGColumbia, South Carolinawww.eatrightsc.org

DATEBOOK

Datebook listings are offered to all nonprofit organizations and associations for their meetings. Paid listings are guaranteed inclusion. All for-profit organizations are paid listings. Call for rates and availability.

Call 610.948.9500

Fax 610.948.7202

E-mail [email protected]

Send Write with your listing two months before publication of issue.

ADVERTISER INDEXFor advertising information, please call 800-278-4400 or visit our website at www.TodaysDietitian.com.

Bakery On Main, www.bakeryonmain.com ..............................................................................................27beBetter Health, Inc., www.theportionplate.com .................................................................................... 19Cell Science Systems, www.alcat.com ....................................................................................................23Cera Products, Inc., www.ceraproductsinc.com .....................................................................................65CinSulin, www.cinsulin.com .....................................................................................................................68Daisy Brand Cottage Cheese, www.daisybrand.com/cottagecheese ..................................................4, 5Dietmaster Systems, www.dietmaster.com ............................................................................................65Dr. Lucy’s, www.drlucys.com ...................................................................................................................65ESHA Research, www.esha.com ................................................................................................................3Glutenfreeda Foods, Inc., www.glutenfreedafoods.com www.glutenfreeda.com ..................................54Ian’s Natural Foods Inc., www.iansnaturalfoods.com ............................................................................. 15Jackson PEG Tube Stands, www.jacksonpegtubestands.com ................................................................65Kibow Biotech, Inc., www.kibow.com ......................................................................................................55Konsyl Pharmaceuticals, www.konsyl.com ............................................................................................. 67Nestle Ocean Spray, www.oceanspray.com ..............................................................................................7NoGii, www.nogii.com ................................................................................................................................9The Nutrition Company, www.nutritionco.com .......................................................................................65Walden Farms, www.waldenfarms.com .....................................................................................................2Wisdom Natural Brands, www.sweetleaf.com ......................................................................................... 11

This index is a service to our readers. The publisher assumes no liability for errors or omissions.

APRIL 11-13, 2013CALIFORNIA DIETETIC ASSOCIATION ANNUAL MEETING AND EXHIBITION800+ dietetic professionals,

75+ exhibitsSanta Clara Convention CenterSanta Clara, Californiawww.dietitian.org


For delicious recipe ideas, be sure

to check outCulinary Corner!

HUNGRY?

MARKETPLACE

Sponsored Content

Product Preview

Cera Products’ scientifically developed and physician- recommended rice-based oral rehydration products include CeraSport®, a high-performance hydration drink series for sweat replacement, and CeraLyte®, a medical rehydration product for correcting severe dehydration. All Cera’s products are all natu-ral, certified gluten free, a blend

of patented rice syrup solids, essential electrolytes, and flavors, and are sweetened naturally with Stevia (RebA).

Visit www.ceraproductsinc.com or call Cera Products at 843-842-2600. See us at ASPEN booth #513

Jackson PEG Tube StandThe Jackson PEG Tube Stand is designed to support a PEG tube used to deliver food products and oral medica-tions to a PEG patient.

For more information, call 606-638-3234 or e-mail [email protected].

Order and see a video at www.jacksonpegtubestands.com.

SPRING-LOADED CLIPS SECURELY HOLD SYRINGE

CLIPS ALLOW FOR SIMPLE ONE-HANDED USE

EASY-TO-USE HEIGHT ADJUSTMENT

SOLID BASE FOR STABILITY

ANGLE ADJUSTMENT

Gluten FreeAll Natural

NO PEANUTS, TREE NUTS, MILK, EGGS

0mg cholesterol

0g trans fat

Allergy friendly

Dedicated bakery

Ingredients tested

Non-GMO

Glute

drlucys.com

Non-GMO

drlucys.com


GARLICOne of Nature’s Brightest BulbsBy Bryan Roof, RD, LDN

My mother used to tell me that the secret to her cooking was salt, pepper, and garlic—lots of garlic. She’d make potent Caesar dressings, bracingly sharp aiolis, and fragrant garlic-rubbed roast chicken. I loved her cooking because of it.

We never understood how people could dislike garlic. (Some people are just plain crazy, I suppose, with their fear of garlic breath.) She added garlic for flavor and flavor alone long before it was eaten for its health benefits. Garlic has been found to reduce cholesterol and blood pressure, improve circulation and immune function, and lower overall cancer risk. Not bad for something that tastes so good.

Garlic imparts its flavor based on how it’s prepared before cooking. By crushing, mincing, or puréeing garlic, you release its essential oils, the bulk of its potency. You could stick a whole head of unpeeled garlic into a braise or stew and still not impart as much oomph as a few finely minced cloves.

When shopping for garlic, opt for fresh bulbs over the pre-peeled or the prechopped stuff in a jar, which bears little resemblance to its fresh counterpart. Prepeeled garlic is inar-guably convenient, but the blanching process that removes the skin also robs it of some of its flavor. Look for firm, fresh bulbs with taut papery skin. Once you get it home, store garlic in a cool, dark place, such as a kitchen cupboard.

While I’m a true garlic fan, I realize many people don’t share the same affinity for its aggressively strong flavor. So for you, we’ll turn to roasting. Roasted whole, the cloves develop a pleasant sweetness that even haters seem to fancy. You can use roasted garlic for any number of dishes, from bruschetta to salad dressing to pasta sauce. You’ll still get all the health benefits and most of the flavor but less of the garlic breath—if you’re at all concerned.

— Bryan Roof, RD, LDN, is a chef, dietitian, and food writer living in Boston. Follow him on Twitter at @bryanroof.

CULINARY CORNER

Quinoa Salad With Roasted Garlic

While this recipe gives directions for cooking 1 bulb of garlic, you can easily roast two or three at a time for later use. This salad is great garnished with feta cheese.

Serves 6 as a side dish

Ingredients1 garlic bulb1 cup water3⁄4 cup quinoa1⁄4 cup red wine vinegar3 T fresh lemon juice3 T extra-virgin olive oil2 tsp Dijon mustard1⁄2 tsp fine sea salt3⁄4 tsp black pepper 1 red bell pepper, stemmed, seeded, and chopped1 cup diced English cucumber1 cup fresh cilantro leaves, coarsely chopped2 scallions, sliced thin1⁄4 cup sliced red onion1⁄4 cup cashew pieces

Directions1. Adjust the oven rack to the middle position and

heat the oven to 350˚F. Cut off the top 1⁄4-inch stem of the garlic bulb and discard. Wrap the bulb in aluminum foil and roast until tender and fragrant, 1 to 11⁄4 hours. Let the foil-wrapped garlic sit at room temperature until cool enough to handle.

2. Meanwhile, bring water to a boil in a small sauce-pan over medium-high heat. Stir in the quinoa and return to a boil. Remove the pot from the heat, cover, and let sit undisturbed for 20 minutes. Fluff the quinoa with a fork and let cool to room temperature.

3. Whisk the vinegar, lemon juice, olive oil, mus-tard, salt, and pepper together in a large bowl. Add the quinoa, bell pepper, cucumber, cilantro, scallions, onion, and cashews. Squeeze the root end of the garlic bulb, forcing the roasted garlic out of the cut end and into the bowl. Toss the ingredients to combine. Season with salt and pepper to taste. Serve.

Nutrient Analysis per serving Calories: 210; Total fat: 11 g; Sat fat: 1.5 g; Trans fat:

0 g; Cholesterol: 0 mg; Sodium: 240 mg; Total carbohy-drate: 23 g; Dietary fiber: 3 g; Sugars: 4 g; Protein: 5 g


Just one teaspoon of sugar-free Konsyl Original Formula has 6 grams of psyllium fi ber, equivalent to 3 grams of soluble fi ber – that’s 75% more psyllium fi ber 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 of heart disease by lowering their cholesterol. Psyllium fi ber also helps stabilize blood sugar levels and regulate digestion by treating constipation, preventing hemorrhoids and easing the symptoms of IBS.*

Konsyl fi ber supplements have been recommended by health care professionals for over 50 years. Have you told your patients about Konsyl Psyllium Fiber?

Which serving has themost soluble fiber?

Like us on Facebookfacebook.com/konsyl

Konsyl® Original Formula

Psyllium Fiber

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.

OOOOOOrrrriiiiiigggggggiiiiiiiiinnnnnaaaallll yllium Fib

*These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.

3.0g

For free professional samples, visit

www.konsyl.comor scan this code

most sol

3.0g

1.45g

1.17g

1.51g

1.09g0.44g 0.49g

1.12g

1.25g

0.92g

0.94g

0.67g

1.38g

0.15g

0.61g

0.58g

0.77g

0.58g

0.25g

0.99g

0.67g

0.47g

1.36g

1.31g 0.44g

0.90g

0.44g

1.02g

Today's Dietitian Ad 01-13.indd 1 12/19/2012 11:42:50 AM

Now there’s a natural and clinically proven ingredient for managing blood sugar levels *†∆

CinSulin® Water Extract of Cinnamon contains high quality concentratedcinnamon extract. Unlike common cinnamon products on the market, CinSulin uses a

proprietary water extraction process that gently separates and concentratesthe health-supporting water-soluble components in the cinnamon.

The result – CinSulin®, a cinnamon concentrate that is 10:1 stronger than common cinnamon! You’d 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*†

*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.

† Within the normal range **Refers to Advanced Strength and Healthy Weight CinSulin ∆Clinical study available upon request

For more information and a complete list of retailers carrying CinSulin,call 1-855-844-4370 or visit www.cinsulin.com

Documents

Todays Dietitian January 2013 US