Today's Dietician

Vol. 15 No.
January 2013
The Magazine for Nutrition Professionals
Gluten-Free
The
Journey
RDs Serve as a Guide for Patients on a Quest to Relieve Symptoms and Improve Health
Conference Issue
ASPEN
Ethical Decision Making in End-of-Life Healthcare Kids Frown on New School Lunch Standards Embracing Meatless Monday
www.TodaysDietitian.com
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EDITORS SPOT
GRUMBLING BELLIES
Its been one year since the unveiling of the new standards for school meals that have resulted in healthier lunches for kids across the country. The new meal requirements have raised standards for the first time in more than 15 years, and chances are they will improve the health and nutrition of nearly 32 million kids who participate in the program each school day. As you know, the new standards require school cafeterias to serve larger portions of fresh fruits, vegetables, and whole grains; fat-free (unflavored/flavored) or 1% (unflavored) milk; less saturated and trans fats and sodium; and proper portion sizes and caloric intake based on age. While the healthier meals are a key component of the Healthy, Hunger-Free Kids Act of 2010, championed by First Lady Michelle Obama and signed into law by President Obama, ironically theyre leaving many kids across the country with growling bellies by the end of the school day. To voice an opinion of the new standards, a group of creative high school students in Kansas posted a video on YouTube called We Are Hungry to the tune of fun.s We Are Young. If you feel like giggling a bit, go to YouTube and type in the title. There are scenes of kids storing food in their lockers to ensure they have enough to eat in between classes, kids walking the halls snacking on food, kids collapsing on the gym floor during basketball practice, and kids falling asleep in class because theyre hungry and have no energy. While the video parody will make you laugh, the kids message is a serious one: The food may be healthful, but its not filling them up. You can read more about this and find out what your colleagues had to say about the kids reactions in the feature Healthful School Lunches. My son, a high school senior, has different complaints. He says its not that the healthier meals leave him hungry; the problem is that the more healthful foods just dont look appetizing, so he buys the less healthful options from the la carte menu. What do you think about this? Weigh in with your feedback about this story and the issues other articles on our Twitter and Facebook pages. Happy New Year to all, and please enjoy the issue.
President & CEO Kathleen Czermanski Vice President & COO Mara E. Honicker
EDITORIAL Editor Judith Riddle Editorial Director Jim Knaub Senior Production Editor Tracy Denninger Assistant Editor Brandi Redding Editorial Assistant Heather Hogstrom Contributing Editor Sharon Palmer, RD Editorial Advisory Board Dina Aronson, MS, RD; Jenna A. Bell, PhD, RD; Carol M. Meerschaert, MBA, RD; Sharon Palmer, RD; Kyle Shadix, MS, RD ART Senior Graphic Designer Charles Slack Graphic Designer Erin Prosini Junior Graphic Designer Emily Avedissian ADMINISTRATION Administrative Manager Helen Bommarito Administrative Assistants Kim Mayfield, Pat Plumley Executive Assistant Matt Czermanski Systems Manager Jeff Czermanski Systems Consultant Mike Davey FINANCE Director of Finance Jeff Czermanski
Director of Continuing Education & New Business Development Jack Graham

CIRCULATION Circulation Manager Nicole Hunchar MARKETING AND ADVERTISING Publisher Mara E. Honicker Director of Marketing and Digital Media Jason Frenchman Web Designer/Marketing Assistant Jessica McGurk Marketing Assistant Leara Angello Director of Sales Stephanie Mitchell Senior Account Executives Sue Aldinger, Seth Bass, Peter J. Burke, Gigi Grillot, Brian Ohl Account Executives Diana Kempster, Beth VanOstenbridge, Josh Yohnke Sales Coordinators Joe Reilly, Dani Kriest-Reifsneider
2013 Great Valley Publishing Company, Inc. Phone: 610-948-9500 Fax: 610-948-7202 Editorial e-mail: TDeditor@gvpub.com Sales e-mail: sales@gvpub.com Website: www.TodaysDietitian.com Subscription e-mail: subscriptions@gvpub.com Ad fax: 610-948-4202 Ad artwork e-mail: TDads@gvpub.com All articles contained in Todays 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
Judith Riddle Editor TDeditor @gvpub.com
6 todays dietitian january 2013
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CONTENTS
JANUARY 2013
34
FEATURES 24 28
18
DEPARTMENTS
6 Editors Spot 10 Reader Feedback 12 Ask the Expert 14 Nutrition Support 360 17 Personal Computing
The Gluten-Free Journey RDs serve as a guide for patients

on a lifelong quest to relieve symptoms and improve health.
Ethical Decision Making This article details the dietitians

role in end-of-life healthcare when considering enteral and parenteral nutrition.
34
ealthful School Lunches Are the New Standards H All Theyre 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.
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
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.
Page 46
Todays Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published monthly by Great Valley Publishing Company, Inc., 3801 Schuylkill Road, Spring City, PA 19475. Periodicals postage paid at Spring City, PA, Post Office and other mailing offices. Permission to reprint may be obtained from the publisher. REPRINTS: The Reprint Outsource, Inc.: 877-394-7350 or e-mail bwhite @reprintoutsource.com NOTE: For subscription changes of address, please write to Todays 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 Todays 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
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READER FEEDBACK
Dear Editor, Thank you for publishing the very Happy Thanksgiving thorough and informative article on Veggie Style! migraine headaches in the November 2012 issue. This is probably the most useful information Ive 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]. Ive been migraine free now for more than four years! With the right tools, dietitians can accomplishso much. However, to move forward, its essential they keep open minds and embrace new medical technology.
AMERICAN DIABETES MONTH
Vol. 14 No. 11 November 2012
From Our Facebook Wall

Worldwide Diabetes Cases Hit Record, Half Go Undiagnosed news.msn.com Linda 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.com Kristen Conner Pardue: Disagree with this study. Women have had fevers during pregnancy for decades. Kimberly Davis-Coniglio: I found this to be interesting and they state to be cautious with this information, but the results definitely indicate that the fever-autism link should be investigated further.
Clients Can P Prepare repare S Such uch Delicious, Healthful Meals That Nobody Will Miss the Turkey
Pumpkin Soup
Reversing Type 2 Diabetes With Natural Therapies
Gluten-Free Kitchen Essentials Helping Clients With Binge Eating Disorder
Lori Langer, RD, MEd, CLT, LDN, specializes in food allergies, sensitivities, intolerances, and inflammatory conditions
From Our Twitter Page

Popular Tweets, Retweets
@AhealthEeater: Just reading Todays Dietitian while waiting for my oil change and enjoying a cup of coffee!
October Issue
Boosting B12 Intake
@SarahKoszykRD: Salmon has B12, which can possibly reduce depression. Add 4 oz to salads or quinoa. Great B12 tips!
The Real Scoop on Sugar

@KarmstrongKurt: Thank you, Todays Dietitian, for a great link on the debate on sugar.
Combating Clostridium Difficile

@bmlococo: Just read the Todays 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 Todays Dietitian inspire us to remember breast is best!
Theres Homework to Do on School Lunches well.blogs.nytimes.com Trina 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 dont see much change. School lunch is just offering more of what students havent chosen before. I believe the quality, appearance, and the way fruits and vegetables are served is often missing in school lunches. Salad with dressing 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.
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ASK THE EXPERT
Fill pitchers and glasses with ice using a scoop. Get ingredients from lower cabinets. Shape dough for cookies. Place toppings on pizza or salad ingredients into a bowl. Scoop batter into muffin tins for baking. Mash ingredients such as bananas or cooked potatoes. Set the table with assistance from an older family member. Help clear off dirty dishes and smaller items on the table, such as serving utensils or small containers.
Ages 6 to 8
Help plan meals for the week. Select fresh fruits and vegetables at the supermarket. Get ingredients for recipes in the kitchen and at the store. Perform tasks over the stovetop with assistance, such as 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.
COOKING WITH KIDS

By Toby Amidor, MS, RD, CDN
Q: A:
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? 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.
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 homemade 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.
Kid-Appropriate Tasks
Listed 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 counter with assistance. Stir batters without assistance Measure ingredients.
Have questions about nutrition trends, patient care, and other dietetics issues youd like to ask our expert? Send your questions to Ask the Expert at TDeditor@gvpub.com or send a tweet to @tobyamidor.
presents a new online resource for
health-conscious individuals
Whether youre a nutrition professional or a consumer looking for trustworthy guidance, the Todays Dietitian Health & Nutrition Center is a free online resource packed with useful information that can benet anyone. Centered around a diverse catalog of nutritious and tasty recipes, the Health & Nutrition Center also presents articles and insights from an impressive array of experts. Our online recipe database may be helpful to RDs writing meal plans for clients with specic nutritional or dietary needs, such as gluten free, plant based, or diabetes. Also, share our site as a reference guide for clients, friends, and family members in need of fresh ideas and choices to help them stay t or develop a healthier lifestyle.
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NUTRITION SUPPORT 360
home care agency creation, and reimbursement 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 receiving IV feeding in the hospital.5 Whether a patient begins PN in the hospital or at home, a knowledgeable interdisciplinary 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 nutritional goals.6 This article will take a closer look at homestart PN and evaluate its benefits in comparison 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.
PARENTERAL NUTRITION HOME-STARTS

Learn How RDs Can Help Patients Safely Begin PN Care at Home
By Sandra I. Austhof, MS, RD, LD, CNSC
People unable to use their gastrointestinal (GI) tract due to intestinal failure require parenteral nutrition (PN). PN, the administration of IV nutrients, is a potentially lifesaving therapy 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 exposure 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,
Evaluating the Home Environment

Once a physician determines a patient is a good candidate for home PN, a home infusion nurse first assesses the patients home environment for cleanliness, sanitary water supply, electricity, 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 therapy and verifies insurance coverage. If the patient is in the hospital, a social worker, PN nurse, and nurse case manager meet with the patient and family at the bedside to assess the home environment and insurance coverage for home PN care.
Home PN Education
Once its considered safe to administer home PN, qualified 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 continues the instruction at home. All patients receive three consecutive days of lessons in the home. Once the home infusion nurse determines the primary caregiver can implement PN procedures, the nurse will make weekly visits.
Advantages of Hospital-Start PN
Most patients discharged from the hospital on PN werent admitted specifically to start PN but for unrelated medical or surgical reasons that resulted in the need for home PN care. Due to safety concerns, clinicians often prefer hospitalstart PN. High-risk patients who would benefit from hospitalstart 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 supplementation. 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 setting would require the presence of a healthcare professional around the clock. The testing supplies needed would quickly become very costly to the patient. The hospital dietitians role in preparing the patient for home PN involves stabilizing and cycling the PN formula by monitoring daily vital signs, electrolytes, glucose levels, intake and output records, and weights. This usually takes three to six days to complete. PN is started at full protein needs with one-half of the dextrose load infused continuously over 24 hours. Lipids usually are given separately. Shortening
the infusion time by four hours each day over three consecutive days or six hours each day for two consecutive days can cycle PN from 24 to 12 hours. In stable, select patients, PN can be cycled from 24 to 12 hours over one day.
Advantages of Home-Start PN
While hospital-start PN has its advantages, home-start PN also has its benefits. Home-start PN enables patients to learn about PN in the comfort of their home plus they have fewer hospital expenses and dont have to worry about hospital-acquired infections.10 The decision to initiate PN in the home depends on patients clinical stability, whether they have a need for PN, whether a nurse can evaluate them in their home, and whether a caregiver can safely administer the therapy.7 Patients who can receive home PN care are those who either dont have a chronic illness or have a chronic illness thats well controlled, such as cancer, HIV, hyperemesis gravidarum, or GI disorders; those with bariatric surgery complications; or those with failed enteral nutrition.8,10 Many home infusion companies that provide home-start PN services have experienced dietitians, nurses, and pharmacists working for them who can offer quality care to patients and have a track record of successfully initiating PN in the home, bypassing hospital admission. Walgreens Infusion Services, the nations largest infusion provider, initiates home PN with at least one patient almost every day. According to Noreen Luszcz, RD, MBA, CNSC, Walgreens nutrition program director, the key to the companys success is its multidisciplinary team approach, slow progression of starting PN, and ongoing communication 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.
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Once Walgreens receives a referral from a physicians office or clinic, a dietitian and a nurse become actively involved in the initial home visit. The dietitian completes a comprehensive nutrition assessment and determines needs and formula recommendations. Choosing appropriate patients for home-start PN is essential. Luszcz reports that high-risk patients, such as those with uncontrolled diabetes, high GI losses, or multiple organ failure, usually are referred to hospital-start PN. When beginning PN in the home, however, Luszcz says Walgreens 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 macronutrients. 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 lowcalorie PN over 12 to 18 hours at a reduced rate for younger, stable patients, according to Donna Kloth, RN, CRNI, CNSC, a
Safe Alternative
Patients have been started safely on PN in the hospital setting and at home for many years. The key to this success has been the experience of knowledgeable interdisciplinary healthcare teams consisting of physicians, dietitians, nurses, and pharmacists. With the advances in standards of care, equipment, and specialized home infusion services, patients can start IV nutrition at home, allowing for continued daily activities and increased quality of life.
Sandra I. Austhof, MS, RD, LD, CNSC, is a nutrition support dietitian at the Cleveland Clinic and has worked in the field for more than 30 years.
Acknowledgement
The author would like to extend a special thanks to Kaylee Adams, a PharmD candidate at Ohio Northern University, for her assistance in the research of this article.
References
1. Ireton-Jones C, DeLegge MH, Epperson LA, Alexander J. Management of the home parenteral nutrition patient. Nutr Clin Pract. 2003;18(4):310-317. 2. Jansson L, Brand S, Monahan R, Knowles S. Home start parenteral nutritionyes we can! Presented at: American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week; January 21-24, 2012; Orlando, FL. 3. Jeejeebhoy KN, Zohrab WJ, Langer B, Phillips MJ, Kuksis A, Anderson GH. Total parenteral nutrition at home for 23 months, without complication, and with good rehabilitation. A study of technical and metabolic features. Gastroenterology. 1973;65(5):811-820. 4. Sanville MH. Initiating parenteral nutrition therapy in the home. J Intraven Nurs. 1994;17(3):119-126. 5. Ireton-Jones C, Hamilton KS, DeLegge MH. Improving clinical and financial outcomes with parenteral nutrition therapy. 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 parenteral 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.
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 replacement 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, retrospective study, 15 high-risk patients were started on 25% of dextrose 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.
PERSONAL COMPUTING
Along with using such services for backing up, you often can use them for other purposes as well, such as sending large files in ways that are more convenient than e-mail or other older technologies, syncing files youre working on from different computers, and collaborating with others on the same project. Heres a rundown of seven of the more useful or otherwise notable file hosting services that are primarily for backing up files or can be used for the above purposes. Each of the services below is free for a given amount of storage space. Big names are important, since you dont want such a service to go away, but the smaller guys listed below appear stable. Dropbox (www.dropbox.com): This may be the most talked about and recommended file hosting service. Its fairly skimpy on the free storage, offering only 2 gigabytes, but its easy to use and versatile. You use it by either copying files you want automatically backed up into a Dropbox folder or subfolders on your computer or you ensure the files you want auto matically backed up are stored in one of these folders. SugarSync (www.sugarsync.com): With 5 gigabytes of storage before you have to pay, SugarSync is more generous than Dropbox. It also doesnt require you to create special folders 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 generous 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, presentation, spreadsheet, and other programs, this is where your files are stored. But you also can use Google Drive with data created using programs on your own computer. It offers 5 gigabytes of free storage. Amazon Cloud Drive (www.amazon.com/clouddrive): This is Amazons cloud storage service, but its clunkier than the other services here. Amazon Cloud Drive offers 5 gigabytes of free storage. It makes copies of previously backed up or deleted files in case you need to retrieve them. iCloud (http://apple.com/icloud): From Apple, this service is tailored to Apple products. It can work with an iPad, iPhone, iPod touch, or Mac, and it works with Windows PCs as well. iCloud gives you 5 gigabytes of free storage. Skydrive (http://skydrive.live.com): This is Microsofts offering, with 7 gigabytes of free storage. Along with Windows PCs and Windows Phone, Skydrive also works with Macs, Apple devices, and Android devices. Ultimately, choosing and using a backup service is far more important than which service you choose.
Reid Goldsborough is a syndicated columnist and author of the book Straight Talk About the Information Superhighway. He can be reached at reidgoldsborough@gmail.com or www.reidgold.com.
EMERGENCY PREPAREDNESS
Cloud-Based Backup Simplifies This Essential Task
By Reid Goldsborough
Hurricane Sandy, which led to so much damage in New York and New Jersey in late October 2012, was only one of numerous natural and manmade disasters that, along with destroying life and property, destroyed data. Whether you work for a large company, run a small business, or use a computing device in your home or whether its corporate trade secrets or family photos, data can be irreplaceable. The key to disaster recovery is disaster preparation, and the key to disaster preparation is redundancy. In a nutshell, backups. If you have backup power such as a generator, you can continue to compute if the electricity goes out. If you have one or more backup computers, you can still get things done if equipment is damaged. And if you have backup data, you can pick up any project where you left off.
Cloud Computing
For several years now a big buzzword in the computer world has been the cloud, which is just a whimsical way of saying the Internet. Instead of storing data or using programs on computers at your location, with cloud computing you use data or programs stored on other computers you connect to over the Internet. One of the most effective uses for cloud computing is making remote backups of data. That way, even if your computer equipment is destroyed in a flood or fire, you wont lose your data. The same cant be said for a backup stored at your location that youve made onto an external hard drive, USB drive, optical disc, or tape, though these media still can be useful among other ways as a backup for your backup.
Remote Backup Services

A host of free and fee-based remote backup services have popped up in recent years. The free services typically provide a limited but often appreciable amount of storage space, with additional storage costs.
DYNAMICS OF DIABETES
Alkaline Diet
This diet is based on the fact our bodies have a pH of 7.35 to 7.45, which makes them slightly alkaline.4 Proponents of the alkaline diet believe humans evolved on a diet much more alkali forming than diets eaten today. An excess of grains and animal products is believed to cause an acid overload, leading to muscle wasting, kidney stone formation, kidney damage, and the dissolution of bone.4 But Vesanto Melina, MS, RD, coauthor of Becoming Raw: The Essential Guide to Raw Vegan Diets, notes that all the research has been theoretical. The fact is that the body works hard and efficiently on its own to keep the blood at the proper pH. Our body is capable of adequately maintaining the perfect acid-base balance regardless of what we eat, says Vandana Sheth, RD, CDE, a spokesperson for the Academy of Nutrition and Dietetics, so theres no need to alter the diet to try to affect the pH level. However, Sheth believes the alkaline diet can be a healthful choice for people with diabetes. An alkaline diet is primarily a vegetarian diet, emphasizing fresh fruits, vegetables, soy, nuts, legumes, and olive oil, she says.
DIABETES AND COMPLEMENTARY CARE
More Patients Are Following Alternative Diets to Manage the Disease

By Constance Brown-Riggs, MSEd, RD, CDE, CDN
As diabetes cases continue to soar worldwide, people with the disease are turning more and more to alternative therapies 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 complementary and alternative medicine (CAM) to manage their disease.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
Food-Combining Diet
The theory behind the food-combining diet is that if protein and starch are eaten simultaneously, the body will wear itself out by producing both alkaline and acidic digestive juices, which nullify 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 encourage weight loss and improve digestion. Research supports that a weight loss of 10 to 15 lbs is enough to decrease insulin resistance and improve blood glucose levels in people with diabetes. However, theres no scientific evidence stating this diet is beneficial for weight loss or digestion. In fact, The research is flawed, and some of the ideas are counterproductive, Melina says. For example, vitamin C in fruit can help increase iron absorption from iron-rich plant foods such as legumes. But according to food-combining guidelines, this combination isnt permissible. For people with diabetes, this diet is contrary to the American Diabetes Associations 2012 nutrition recommendations 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.
What Is CAM?
The terms alternative medicine and complementary medicine often are used interchangeably, but according to the National Center for Complementary and Alternative Medicine, CAM is a group of diverse medical and healthcare systems, practices, and products that arent generally considered to be part of conventional medicine. Complementary medicine is used with conventional medicine, whereas alternative medicine is used instead of conventional medicine.3 Examples of CAM therapies include herbs, bodywork, special diets, and dietary supplements. Most people with diabetes who use CAM follow diet-based therapies to manage the disease.1 The following are the six most common diet-based therapies people use to treat diabetes more naturally and holistically.
Macrobiotic Diet
This diet incorporates the Asian philosophy that foods are either yin (cooler) or yang (warmer) and that certain health conditions require food that will cool or warm the body. The macrobiotic diet is vegetarian based, consisting mainly of brown rice, whole grains, and vegetables. It has gained popularity among cancer patients who understand it to be an
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effective way to treat the disease. Currently, theres no evidence 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 September 2012 issue of the Journal of Nutrition and Metabolism found that a macrobiotic diet could be a successful therapy for type 2 diabetes. The macrobiotic diet is naturally high in fiber, which helps to slow the conversion of starch to glucose, thus keeping the blood glucose level more stable. In fact, participants in this study were able to reduce their insulin by as much as 64%.
Raw Food Diet

Based on unprocessed and uncooked plant foods, the raw food diet consists of fresh fruits and vegetables, sprouts, seeds, nuts, grains, beans, dried fruit, and seaweed. Followers believe that heating a food above 118F destroys helpful enzymes in food, but eating food raw or carefully dehydrated increases energy, improves digestion, promotes weight loss, and reduces the risk of chronic illnesses, including diabetes.5 This diet is very restrictive and could cause nutrient deficiencies in calcium, iron, vitamin B12, and protein.5 Contrary 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 diets effect on diabetes specifically.
C M Y CM MY CY
The Makers Diet
The Makers Diet is based on eating foods that God intended for us to eat, such as whole natural foods, including organic meats, fruits, and vegetables. It also encompasses the four pillars of healthphysical, spiritual, mental, and emotional including increasing physical activity, reducing stress, and finding faith.6 The diet claims to improve health and promote weight loss, which will lower the risks of chronic illnesses, including diabetes. There are many benefits to adopting a lifestyle that will increase physical activity, reduce stress, and help one find faith. This is particularly true when it comes to diabetes, which can be a challenge physically, spiritually, and emotionally. The diet is broken down into three phases that last a total of 40 daysthe first of which allows no carbohydrates. The next two phases slowly reintroduce healthful foods, including whole grains, fruits, and vegetables, and organic meats such as beef and chicken.6 The diet recommends a large number of supplements that Jordan Rubin, the author of the book, happens to sell on his website. Rubin claims the diet is well researched in clinical trials and studies. However, there are no significant peerreviewed journal articles on the Makers Diet.6
K
CMY
Ayurvedic Diet
The Ayurvedic diet, popularized by author Deepak Chopra, MD, is based on a system of medicine that originated in ancient India. It attempts to balance and restore harmony in the body by using diet, yoga, and herbs. The diet is built on a theory that people are born with unique characteristics based on the combination of doshas in the gene structure. The doshas are dynamic forces within the universe, including earth, water, fire, and wind. A persons 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 illnesses, 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 theres evidence suggesting 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 rigorous research is needed to determine which practices are safe and effective.7
Tips for Dietitians

Its important for RDs to increase their knowledge and awareness of alternative approaches to diabetes selfmanagement, Sheth says, as more people with the disease turn to CAM to manage it. This will enable RDs to more effectively 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.
RESOURCES
You dont need to know everything about complementary 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 Alternative 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 Medicine Online Continuing Education Series (http:// nccam.nih.gov/training/videolectures)
References
1. Bell RA, Suerken CK, Grzywacz JG, Lang W, Quandt SA, Arcury TA. Complementary and alternative medicine use among adults with diabetes in the United States. Altern Ther Health Med. 2006;12(5):16-22. 2. Egede LE, Ye X, Zheng D, Silverstein MD. The prevalence and pattern of complementary and alternative medicine use in individuals with diabetes. Diabetes Care. 2002;25(2):324-329. 3. Complementary and alternative medical therapies for diabetes. 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 interventions for diabetes mellitus: a systematic review. Evid Rep Technol Assess (Summ). 2001;(41):2p.
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RISING FOOD COSTS

By David Yeager
How Last Years Drought May Affect This Years Prices

No one can say with certainty whether climate change is directly responsible for the droughts that have plagued the United States over the past couple years, but you cant deny that 2011 and 2012 brought exceptionally dry weather to significant portions of the country. In 2011, the most severe drought in decades hit large segments of Texas, decimating the states cattle industry. In 2012, the Midwest and its grain crops bore the brunt of the drought. Although fluctuations in rainfall occur every year, extended periods without enough rain could pose a serious problem for the United States in the future. Jack Juvik, PhD, a professor and the graduate program coordinator in the department of crop sciences at the University of Illinois College of Agricultural, Consumer, and Environmental Sciences, says water issues are affecting most countries dramatically in some casesand the United States is no exception. He cites areas of the Central Valley in California where the salt level of the soil already prevents the growth of a range of valuable crops. In places like this, long-term drought could be especially damaging. If water becomes scarcer, it could multiply this effect and lead to disputes among regions and states vying for use of the same major water systems. So not only is [water scarcity] going to affect what we can grow, its going to affect where we can grow, and its also going to lead to huge, huge battles, legal [battles] and, probably, 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 consumption in the United States is attributable to agriculture. In his research, Juvik has measured variations in phytochemical levels up to 20% in some drought-affected fruits and vegetables, but that effect is difficult to measure because each nutrient, as well as each fruit or vegetable, is affected differently. However, these variations arent likely to have a significant effect on human health; a much greater threat from drought is its effect on crop yields. In the United States, irrigated crops have been less affected by drought than nonirrigated crops. More efficient water management in recent years has helped to conserve water thats used on crops, particularly those that require irrigation. Where farmers once flooded fields and orchards, those who can afford it have switched to more efficient drip irrigation systems. Most fruits and vegetables require irrigation. The United States also imports a significant amount of produce, such as bananas, tomatoes, melons, peppers, and potatoes, from other countries. For these reasons, food price increases for produce probably have been less related to water availability than to other factors such as transportation and refrigeration costs. As long as farmers can maintain irrigation, the availability of produce should remain stable.
Hidden Costs
After Hurricane Sandy pummeled the East Coast in October 2012, many Americans probably forgot about the oppressive heat and drought that affected a large part of the country this past summer. But with nearly two-thirds of the United States still affected by drought, consumers could feel the effects well into this year. Because the drought was concentrated in the Midwest, the crops hit hardest were grain products such as corn, soybeans, and wheat, which arent irrigated. Aside from the obvious rise in the cost of these staple crops, David Bitter, CEO of Cropfax, a provider of seed selection decision-making tools, says prices are likely to rise for nearly all food products. Grains are just such large volume [items], and they go into everything. Corn is in [nearly] everything that has been processed, and youve got aisles and aisles of it, Bitter says. Youve got one small produce section in the store, which is kind of like the jewel in the crown; youve got strawberries, youve got fresh fruit. But the rest of the store, unless its a bottled fruit or a packaged fruit, is pretty much a derivative of corn or soy or wheat: your granola bars, your cereals, your chips. Higher grain prices also are reflected in the cost of animal feed. This affects food costs because it increases the cost of
animal farming. Animal products already cost more to produce schedule for the next week so youre able to buy accordingly, than vegetable products, and drought exacerbates these costs. especially produce, Sandquist says. Will you be home or The consumption of water for the production of meatsfor are you going to be gone? If its a week when youre out a lot, beef, poultry, hogs, etcper acre and per pound of product out- youre not going to have a chance to eat that produce unless strips produce and grain by many, many factors, Bitter says. you take it with you for a snack. So it [seems likely that] if you have a higher cost of grain and a scarcity of water, meat prices will continue to escalate. David Yeager is a freelance writer and editor Overall, the USDA forecasts that food prices will rise 3% to based in Royersford, Pennsylvania. Half page Lea Russel_Layout 1 12/3/12 1:39 PM Page 1 4% in 2013, but prices for some meat and dairy products may decrease in the short term. This is because some farmers are reducing their herds in response to the drought. Once the extra supply has been consumed, prices for beef, pork, poultry, and dairy are expected to rise between 2.5% and 5%.
Stretching Food Budgets

Taken 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 difference. 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 plantbased proteins, and thats 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 doesnt 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 nutritional 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 whats already in the house. All it takes is five minutes of planning before you go to the store. Look at your
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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
fter months of gastrointestinal discomfort, abdominal pain, and bloating followed by weeks of medical testing, Susan finally learned she has celiac disease. Frightened, confused, and overwhelmed about the next steps in her new restricted dietary lifestyle, she turned to an RD her physician recommended. The RD faces the challenge of calming her new patient, educating Susan about the celiac disease diagnosis, and walking with her along a journey fraught with misinformation and confusion.
Celiac Disease vs. Gluten Sensitivity

Its not surprising that many patients newly diagnosed with celiac disease become overwhelmed at the thought of modifying their lifestyle, including what they can and cannot eat in restaurants and at parties. Fortunately, Susan and others with celiac disease arent alone in their journey. According to Rachel Begun, MS, RD, CDN, a food and nutrition consultant and spokesperson for the Academy of Nutrition and Dietetics (the Academy), approximately 1% of the population has celiac disease, and about 90% of them are undiagnosed or misdiagnosed. A bigger portion of the population experiences gluten sensitivity to varying degrees. Estimates are that as much as 6% of the population, or 20 million Americans, may be gluten sensitive, 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 intestine and nutrients cant be absorbed, leading to nutrition deficiencies and a wide range of symptoms. Begun says many people with the disease are asymptomatic and thus dont experience any negative symptoms after eating gluten. They are, however, experiencing the same damage to the intestines as those who do experience symptoms, she cautions. According to the National Foundation for Celiac Awareness, non-celiac gluten sensitivity is found in individuals who cannot tolerate gluten and experience symptoms similar to those with celiac disease but yet who lack the same antibodies and intestinal damage as seen in celiac disease. Early research suggests that non-celiac gluten sensitivity is an innate immune response, as opposed to an adaptive immune response (such as autoimmune) or allergic reaction. We dont know much about gluten sensitivity just yet, but we do know that its a unique condition from celiac disease and involves an immune response, Begun says. While symptoms of gluten sensitivity can be similar to those of celiac disease, people with gluten sensitivity dont produce antibodies to gluten or show signs of damage to the intestine.
status, and an improved quality of life. Jeffers, outpatient manager for nutrition therapy at the Digestive Disease Institute at the Cleveland Clinic, teaches patients the importance of adopting the changes involved in living GF for the long haul. I stress the importance of GF for life, Jeffers says. No small bites every now and then and no mostly GF. I also explain that wheat free is not gluten free and that reading labels must become a habit. While theres no cure for [celiac disease], the GF diet can relieve symptoms of the disease, and patients can feel healthy and full of energy while on the diet. The mucosal damage is a result of a genetic predisposition in combination with environmental factors and inflammation that s immune based. Therefore its important for dietitians to clarify with their patients that even the tiniest amount of gluten may cause intestinal damage even if there are no overt symptoms. Some patients are in a state of shock when they find out they have a type of condition thats not going to go away, says Lenore Wespetal, MS, RD, CDE, a certified diabetes educatorat Shawano Medical Center in Wisconsin.
Gluten Buzzwords
RDs need to educate their clients with celiac disease about the buzzwords on food labels that may indicate the presence of gluten. These buzzwords include wheat, rye, oats, barley, malt, and brewers yeast. (Note: If the oats are labeled as gluten free, theyre safe to eat as part of a gluten-free diet.) Wheat is required to be identified [on a food label], as it is one of the top eight allergens that have to be declared on the label, according to the Food and Drug Administrations Food Allergy and Consumer Protection Act, explains Mary K. Sharrett, MS, RD, LD, CNSD. Rye and oats arent hidden in any ingredients, although oats need to be labeled gluten free to be sure theyre uncontaminated. Barley is almost always listed as barley or malt. Brewers yeast is likely to be contaminated with barley. Sharrett says hidden wheat may be found in products governed by the USDA because they dont have to follow the FDAs allergy labeling laws. Therefore wheat may be in modified food starch, starch, or dextrin, 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
Dietary Treatment
Laura Jeffers, MEd, RD, LD, says patients usually are eager to embrace the gluten-free (GF) lifestyle once they realize how it will benefit them: symptom relief, more energy, better health
Most of Beguns patients feel overwhelmed with the dietary changes that are part of a GF diet. In particular, parents of [young] celiac disease patients can feel overwhelmed knowing theyre responsible for ensuring their kids avoid gluten. While some are relieved knowing they finally have found the answer to their health issues, others are in denial about having to change their diet, Begun says. Theres also the emotional part that comes with the social aspects of eating. People are worried they wont be able to enjoy eating out which, for many, is an important part of socializing with friends and family. In the end, though, most are happy to be feeling better and doing the right thing for their long-term health.
To Eat or Not to Eat

The key types of common foods that are safe for patients with celiac disease include naturally GF items such as fruits, vegetables, meats, nuts, legumes, fish, poultry, eggs, and most dairy (eg, cheese, yogurt, cottage cheese). GF grains include rice and corn. Some less familiar GF options include flaxseeds, nut and bean flours, potato starch, quinoa, rice bran, teff, wild rice, tapioca, buckwheat, arrowroot, millet, amaranth, chia seeds, mesquite, montina, sago, and sorghum. Oats also are considered GF but only if theyre labeled as such. Begun stresses RDs need to help their patients with celiac disease focus their diet on naturally GF foods rather than GF packaged alternatives. Its even more important to get this message across with newly diagnosed patients because their bodies have been devoid of nutrients and need to heal, she says.
Snacks Aplenty
While preparing gluten-free meals takes some effort to evaluate ingredients and identify gluten-free recipes, snack options are plentiful: Gluten-free corn tortilla chips are available in white, yellow, and blue varieties. You can enjoy some great flavor combinations when you pair them with salsa, hummus, cherry tomatoes, carrot sticks, or tart apple slices. A handful of nuts or roasted soy nuts is a protein-rich snack and easy to store in your pantry, a desk drawer, a gym bag, or a purse. Enjoy a gluten-free bagel or slices of bread with peanut butter. Try orange slices with sugar snap peas when you know your next meal will be delayed. Make your own snack mix with gluten-free cereal squares, dried fruit, and sunflower or pumpkin seeds.
MK
Nutrient-dense foods remedy nutrition deficiencies and help the body to heal faster. Its also important to meet patients where they are in terms of current lifestyle and dietary patterns. If a patient has no cooking skills and is traveling for business five days a week, then its a good idea to focus first on how to handle themselves in a restaurant, Begun says. For the mother whos making most of the childs meals and snacks at home, then you want to teach them how to make smart choices at the grocery store as well as introduce them to common ingredients used in gluten-free cooking and baking. Avoiding cross-contamination when following a GF diet is of utmost importance. Its very important to discuss crosscontamination with newly diagnosed patients, Jeffers says. Its important for patients to understand how easily foods can become contaminated with gluten. If a gluten bun on a sandwich is removed and replaced with the GF bread, its too late. Or if there are croutons on the salad and [theyre] picked off, the salad shouldnt be eaten since it was already contaminated. Additionally, gluten can be spread from containers of food, such as peanut butter and jelly, when a knife that has touched gluten-containing bread is dipped into the jar. Its also important to use separate toasters and related small appliances as well as cutting boards and dishes when handling both GF and non-GF foods. If this isnt possible, the item must be thoroughly cleaned to remove any traces of gluten to avoid cross-contamination. Be sure to tell patients to read the food labels of their favorite foods every six months, as ingredients can change at any time and some products that didnt contain gluten in the past may contain it now, Jeffers says.
Helping People Adapt

Mary K. Sharrett, MS, RD, LD, CNSD, a clinical dietitian in nutritional support services at Nationwide Childrens Hospital in Columbus, Ohio, suggests RDs schedule two 45-minute to onehour sessions with clients newly diagnosed with celiac disease because theyll have numerous questions, as theres much to learn about following a GF diet. If you dont know the answer, dont try to guess. Tell them youll get back to them and then find an expert to help you, says Sharrett, whos also a member of the Academys celiac disease expert workgroup for the Evidence-Based Analysis Library and the founder and dietitian advisor for the Gluten-Free Gang, a celiac disease support group. The Academys Medical Nutrition Practice Group has a subunit called Dietitians in Gluten Intolerance Disease with lots of experts. Sharrett also recommends RDs provide a few naturally GF recipes to help clients start their journey. Moreover, RDs should determine some of their clients favorite meals and provide suggestions for making them GF. For instance, if a client enjoys tacos, suggesting a GF brand of taco seasoning is a good fix. For patients having difficulty adhering to the diet, encourage them to get involved with a support group, online or in person,
Jeffers says. Also, let patients know there are many great online sources of gluten-free products, and some companies will send samples. Wespetal says its also important to determine what research the patient already has done regarding celiac disease and a GF diet. This will help clarify any misconceptions the patient may have about what celiac disease is and what their role is in managing it, she says. Also, RDs should explain how to review ingredient lists on food packages. Is it clear to them that wheat free does not mean gluten free? Finally, use follow-up visits to assess the nutritional adequacy of the patients typical eating pattern, especially fiber and B vitamins. Your patients become very informed and may teach you something along the way, Jeffers says. Theres nothing wrong with learning from your patients especially since theyre living it on a daily basis.
Eating Out
For many people with celiac disease, eating at restaurants or attending parties especially may cause frustration and fear. To increase the likelihood of getting a safe meal, call the restaurant ahead of time to let them know about your gluten-free needs, Begun says. Right from the beginning youll know if the restaurant isnt knowledgeable about serving people with dietary restrictions. If you get that gut feeling that they dont know what youre talking about, its a red flag to make reservations somewhere else. I also recommend reviewing the restaurants menu ahead of time so you can narrow down your choices and have a more focused conversation with the server. This is easier for the server, which makes it more likely youll get a gluten-free meal. When counseling patients about eating out or attending parties, Jeffers suggests giving them the following tips: Before going to a restaurant, try to view the menu online and identify possible GF items in advance. Let the server know that you cant eat gluten, which includes avoiding wheat,
rye, barley, and derivatives of those sources. Salads should never have croutons, and confirm that salad ingredients are GF before consumption. Always ask before ordering. Flour often is used to thicken soups, and meats may contain fillers made of gluten. Avoid anything described as being encrusted, breaded, marinated, or served in an unknown broth. Fried foods must be fried in separate oil to be considered GF. Consider bringing your own GF bread or crackers. Consider eating out at an ethnic restaurant, 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 offering to make one or two dishes if the party is more intimate, as this ensures safe items for the client to eat and takes pressure off the host. The following are some additional tips: Dont attend the party hungry, as there may be few GF items from which to choose. Bring your own GF bread or crackers or a GF item to share. Never assume something is GF. Confirm that its safe before eating it. Fresh fruits, vegetables, dairy items, and fish are safe options as long as they didnt come in contact with any products containing gluten.
Silver Lining
Though following a GF diet may seem daunting at first, clients with celiac disease or gluten sensitivity, with the help of knowledgeable RDs, easily can navigate 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.
The Dietitians Role in End-of-Life Healthcare When Considering Enteral and Parenteral Nutrition
ETHICAL DECISION MAKING

By Denise Baird Schwartz, MS, RD, FADA, CNSC
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 designated a surrogate decision maker and indicated his wishes for his end-of-life healthcare. Before his hospitalization, the patient was living with the youngest of his three adult children, the only daughter. A swallow evaluation by a speech pathologist indicated severe dysphagia. The speech pathologist recommended discontinuing oral feedings and starting the patient on tube feeding. The physician requested that an RD perform a nutrition consultation to initiate a nasogastric tube feeding and progress the feeding to meet the patients nutrient needs. After the RD reviewed the patients medical record and consulted with the RN, the dietitian discussed plans for the tube feeding with the patients daughter at her fathers bedside. The RD verbally presented information about the tube feeding and provided written information to ensure health literacy, asking the daughter to reiterate and demonstrate what was discusseda communication technique called the teach-back method. During this exchange, the daughter indicated that her father never wanted a feeding tube or other medical therapies that would prevent him from enjoying simple daily activities. The daughter said her brothers wanted their father to receive nutrition through tubes and all other medical therapies needed to prolong his life. They were adamant that everything be done to extend their fathers life, from a feeding tube to a ventilator to cardiopulmonary resuscitation. This potential conflict between siblings is all too common when dealing with end-of-life healthcare decisions, commonly known as ethical dilemmas. This article will discuss this common occurrence, the importance of discussing end-of-life healthcare issues with patients and family members while honoring patients wishes, strategies to prevent conflict, and the RDs role in ethical decision making in the context of enteral and parenteral nutrition.
Ethical Dilemma Issues and Stakeholders

The above case study is an example of inadequate family communication without written documentation about end-of-life healthcare
wishes. Without documents for advance care planning in a patients healthcare record, the clinical ethical dilemmaa difficult problem involving moral conflicts for which there seems to be no satisfactory solutionis now set in motion. This can result in the patient receiving medical treatments that go against his or her wishes and family members making decisions without the individuals input. Yet the goal of any healthcare team is to provide appropriate and effective patient-centered care based on the individuals wishes. From the team members perspective, they should deliver medically appropriate treatment using evidence-based medicine and assess the benefits and risks/burdens involved. And they should adhere to their institutions 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 conflict with the patients wishes. The ways in which people deal with issues of serious illness often are shaped by their faith and culture. Individuals with different faiths and cultures 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 familys role in the decision-making process for healthcare at the end of ones life.2 The dietitians understanding of cultural and religious diversity is necessary to best meet the needs of a heterogeneous patient population. Diversity awareness gives the RD the ability to tailor information to patients, families, and significant others, and promote understanding of decision making when dealing with the use of artificial nutrition. And awareness of different cultures and faiths furthers an RDs understanding of diversity in clinical ethics, which promotes making right choices and decisions in healthcare delivery. Although the patient is the predominate stakeholder in this process, the concerns of the family, physician, dietitian, and other healthcare providers are what comprise the process of providing the most appropriate nutrition therapy intervention. The patients best interests always should be at the center of healthcare decisions. Patient-centered care is defined as care thats respectful of the individual person and responsive to his or her preferences, needs, and values and that ensures
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
clinical effectiveness research, which determines what treatment works best, for whom, and under what circumstances, to enhance the decision makers ability to fully understand and weigh the alternative healthcare options available.8
Health Literacy and the Teach-Back Method

The use of evidence-based practice guidelines, such as those from the Academy of Nutrition and Dietetics (the Academy), is beneficial in providing appropriate patient education information.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 information 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 educating her about tube feeding. This is an effective method to ensure individuals understand what theyve been told. The process involves asking the individual to explain or demonstrate what he or she was taught. If the person doesnt explain correctly what he or she learned, the assumption is that the information wasnt presented effectively. If this is the case, the RD would explain the information again but use an alternative 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
Preventive Ethics and the RDs Role

Another important aspect of end-of-life care for dietitians is the practice of preventive ethics. Preventive ethics suggest that ethical conflict between family members is largely predictable, 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 proactive process to reduce the potential conflict among them. Preventive ethics represents a dramatic shift from the traditional ethics approach, which involves reacting to ethically challenging patient situations on a case-by-case basis.9 RDs maintain a unique role in the hospital setting. Theyre in a position to develop nutrition screening parameters for all patients and implement the nutrition care process. This process may call for initiating enteral or parenteral nutrition. But what if this therapy isnt congruent with the patients wishes based on his or her quality-of-life goals? To avoid such dilemmas, RDs can screen for quality-of-life goals before initiating the nutrition care process. They can review the medical record for an advance directivewritten documentation of treatment preferences and the designation of a surrogate decision maker and discuss their findings with other healthcare team members.1 Dietitians are in the best position to improve ethical decision making for enteral and parenteral nutrition because they can facilitate an interprofessional, collegial approach to whole patient-centered care while delivering nutrition therapies. This approach involves two or more medical professionals working together as a team with a common purpose and commitment, and with mutual respect. The process involves the RD being aware of the role of nutrition as it relates to the physical, emotional, and spiritual needs of the patient, when applicable, and relaying this information to the other healthcare 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 makers role is to represent the patients 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 knowledgeable 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 nutrition support practice. Collaboration with the physician, nurse, social worker, chaplain, palliative care team, and other healthcare team members is optimal to facilitate this process. Dietitians who learn more about advance directives, living wills, durable power of attorney for healthcare (a legal document in which a competent person gives another person the power to make healthcare decisions for him or her if unable to make those decisions personally), and physician orders for life-sustaining treatment have an advantage in understanding documents in the patients medical record.
Cue-Based Patient/Family Discussion

One way to promote conversations about nutrition therapy with families is to learn about cue-based patient/family discussion. This involves listening for specific key words or trigger phrases from a patient or family member expressing he or she doesnt want a particular therapy, such as a feeding tube. RDs can use this response to begin cue-based discussions about quality-of-life goals while educating patients and family members about nutrition therapies. To begin, dietitians can tell family members the goal is to provide enteral or parenteral nutrition support based on the patients wishes. The sidebar on page 30 presents examples of these triggers for cue-based discussion that can lead a patient or family to understand that the focus should be on the patients wishes. This process is especially useful when the patient is on a ventilator or unable to communicate. The important concept is that family members or surrogate decision makers must understand that their role is to represent the patients wishes and not their own. Based on the cues given by the patient or family, dietitians can refer further discussions to the physician, 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.
nutrition therapies, including recommendations and guidelines.10,11 The first step for healthcare institutions is to incorporate these recommendations when developing ethical decision making for artificial nutrition policy and procedure. Recommendations and guidelines from other societies and organizations are important to include in these documents based on the patient population characteristics and religious affiliation of the healthcare facility. Its important to develop the policy and procedure in collaboration with all healthcare professionals involved in the process to encourage acceptance of the final document. A sample policy and procedure for dealing with ethical decision making for artificial nutrition has been published in The ASPEN Adult Nutrition Support Core Curriculum.12 The second step for healthcare institutions involves implementing the policies and procedures needed to improve communication 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 measurable 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 consensus 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 publishing data. Accomplishing this step would help dietitians in private practice improve patient-centered care by standardizing the incorporation of clinical ethics in the field of nutrition support.1,13
Engaging the Public in End-of-Life Conversations

To engage the public in end-of-life healthcare conversations, healthcare professionals must educate themselves about the process and become aware of resources and tools available (see sidebar on page 32). End-of-life conversations dont involve just the elderly and their adult children; they affect everyone in some capacity. In the hospital setting, patient-centered care is best achieved when all healthcare professionals communicate and are engaged in the conversation to provide a consistent healthcare team approach.14 Perhaps if RDs and other healthcare team members embrace these conversations in their professional and personal lives, the public will become more engaged in end-of-life healthcare discussions. Recognizing the importance of communication in families and acting on these discussions is the
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
best way to prevent clinical ethics dilemmas and provide whole patient-centered care in the hospital. In the future, the goal will be for everyone to have advance care planning discussions with their family and written documentation before an illness develops and hospitalization follows. Dietitians are essential healthcare team members involved in clinical ethics due to their role in the optimal use of enteral and parenteral nutritionand they can make a difference.
Denise Baird Schwartz, MS, RD, FADA, CNSC, is the nutrition support coordinator at Providence Saint Joseph Medical Center in Burbank, California, and has been recognized both nationally and internationally as a speaker on nutrition support topics for the critically ill.
References
1. Schwartz DB. Ethical considerations in the critically ill patient. In: Cresci G, ed. Nutritional Therapy for the Critically Ill Patient: A Guide to Practice. 2nd ed. Boca Raton, FL: Taylor & Francis; 2013 (in press). 2. Preedy VR, ed. Diet and Nutrition in Palliative Care. Boca Raton, FL: CRC Press; 2011. 3. Barry MJ, Edgman-Levitan S. Shared decision makingthe pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780-781. 4. Reuben DB, Tinetti ME. Goal-oriented patient care an alternative health outcomes paradigm. N Engl J Med. 2012;366(9):777-779.
5. Gallagher-Allred CR. Communication and education for families dealing with end-of-life decisions. J Acad Nutr Diet. 2012;112(2):309-310. 6. Carbone ET, Zoellner JM. Nutrition and health literacy: a systematic review to inform nutrition research and practice. J Acad Nutr Diet. 2012;112(2):254-265. 7. Weiss BD. Health Literacy and Patient Safety: Help Patients Understand. 2nd ed. Chicago, IL: American Medical Association Foundation; 2007. 8. Gabriel SE, Normand SL. Getting the methods rightthe foundation of patient-centered outcomes research. N Engl J Med. 2012;367(9):787-790. 9. Epstein EG. Preventive ethics in the intensive care unit. Am Assoc Crit Care Nurs. 2012;23(12):217-224. 10. Barrocas A, Geppert C, Durfee SM, et al. A.S.P.E.N. ethics position paper. Nutr Clinc Prac. 2010;25(6):672-679. 11. OSullivan Maillet J. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2008;108(5):873-882. 12. Geppert CMA, Barrocas A, Schwartz DB. Ethics and law. In: Mueller C, McClave SA, Schwartz DB, Kovacevich D, Miller SJ, eds. The A.S.P.E.N. Adult Nutrition Support Core Curriculum. 2nd ed. Springfield, MD: American Society for Parenteral and Enteral Nutrition; 2012: 656-676. 13. Schwartz DB. Three steps for improving end-of-life nutrition care. Clinical Nutrition Insight. 2012;38(10):4-5. 14. Schwartz DB. Clinical ethics and nutrition support. J Nutr Therapeutics. 2012;1(1):86-90.
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 providers 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 planning 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 promote advance care planning. Aging With Dignitys Five Wishes (www.agingwith dignity.org/five-wishes.php): This guide helps start important conversations about end-of-life care. It provides a documentation tool for detailing an individuals 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 persons end-of-life preferences expressed and respected. It includes a starter kit to help initiate conversations with loved ones regarding end-of-life care wishes. Breathe a True Story of Letting Go of My Parents Gracefully, For I Will See Them Again (www.breatheannebland.com): This book is a healthcare professionals personal story intended to help others begin the dialogue with family members about end-of-life care decisions. Personal stories such as this one are intended to help individuals deal with family relationships, faith, and values and are designed for both healthcare professionals and the public.
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School Lunches
Are the New Standards All Theyre Cracked up to Be?
By Lori Zanteson
Healthful
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.
he start of the school year welcomes students with the promise and expectation of filling their minds with knowledge andfor the 32 million in our nations school meal programstheir bodies with nutritious foods. Only this year the implementation of the new federal lunch standards mandated by the Healthy, Hunger-Free Kids Act of 2010 isironicallyleaving kids hungry. And this youngest generation is speaking out. Fueled by the pangs of their growling bellies, complaints from our nations youths have spread across the country via blogs, websites, boycotts, strikes and, most famously, YouTube.
sample. The response, according to Jodi Risse, MS, RD, LDN, division of food and nutrition services, was positive on the lunch line where these featured fruits and veggies were incorporated into the menu. Familiarity was the first step toward broadening the childrens formative palates.
Out With the Old

Theres no argument that the new lunch standards are an improvement over the old lunch standards, which had been untouched for more than 15 years. During her 1998 dietetic internship, Laura Cipullo, RD, CDE, CEDS, CDN, of Whole Nutrition Services, LLC, and MomDishesItOut.com, recalls visiting New York City schools and seeing banana bread with whole milk served for breakfast and pizza with whole milk and fruit for lunch. Im not a fan of school lunch in general, she says, but I feel the new standards are a step in the right direction. Increasing whole grain specifications, providing colorful vegetables, and offering 1% milk are great new options. According to the USDA, a typical lunch menu under the old standards might include pizza sticks (3.8 oz) with 14 cup of marinara sauce, a banana, 1 oz of raisins, and 8 oz of whole milk. Compare that with a typical menu under the new standards: one slice of whole wheat cheese pizza, 12 cup of sweet potato fries, 14 cup of raw grape tomatoes, 12 cup of applesauce, 8 oz of 1% milk, and 1 oz of low-fat ranch dip.
One Million Hits and Counting

A video parodyviewed more than 1 million timeshas students singing We Are Hungry to the tune of fun.s We Are Young. The student-teacher compilation, made in the high school of a small Kansas town, protests the lower calories and limited carbohydrates and proteins under the new lunch standards. The video features scenes of starving athletes collapsing 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.
Key Word: Calories

The healthful addition of fruits and vegetables and even whole grains isnt the problem. Students say theyre not getting enough calories to satisfy their hunger.
Whats Changed?
The video grabbed the medias attention, cranking up several notches the volume of the public outcry and putting the new school lunch standards into mainstream focus. The perception is that the new lunch standards serve a radically changed menu from previous years, certainly one that skimps on calories. In reality, most of the changes have been progressively introduced in schools since 2009 when the Institute of Medicine developed recommendations that formed the basis for these standards in direct response to the childhood obesity epidemic. School nutrition professionals who were aware of the pending recommendations to increase the amount of fruits, vegetables, and whole grains served and lower sodium, saturated fat, and calories got right to work. Many schools embraced the imminent changes in policy and worked hard to introduce and integrate new and colorful fruits and vegetables into their meal programs so the eventual adoption of new standards would be an easy and seamless transition. Programs such as A Tasting of the Rainbow at Anne Arundel County Public Schools in Maryland showcased a variety of fruits and vegetablessome the children had never seen beforeand encouraged them to taste a free
Making Good of the New Standards

Here are some suggestions from Laura Cipullo, RD, CDE, CEDS, CDN, to help put a positive spin on the new school menu changes: Periodically invite chefs to your school to teach foodservice staff new, healthful recipes. Rotate students through the school kitchen to help prepare meals and offer new ideas for dishes. Have children plant gardens and eat the food they grow. Include cooking classes in the schools curriculum, and teach kids how to make healthful, tasty food. Create yearly school cookbooks featuring the students favorite healthful recipes. Teach students how to modify their favorite recipes to develop more wholesome, healthful ones.
According to Deborah Beauvais, RD, CDN, SNS, district supervisor of school nutrition services in the Gates Chili Central and East Rochester Union Free school districts in western New York, thats a case of perception vs. reality. The calories a year ago were still in that same range, she explains. The main difference is that the old standards set a target number of calories, which could be exceeded, while the new standards set a range of calories thats capped with maximums. These guidelines are based on science and are written for the center of the bell curve. Its too much for some, too little for others, she says. A quick glance at government calorie recommendations confirms this. The USDA recommends that boys aged 14 to18 consume an average of 2,200 to 3,200 kcal/day and girls aged 14 to 18 take in 1,800 to 2,400 kcal/day for a healthful, balanced diet. Assuming the average teenage boy or girl falls somewhere in the middle of these ranges, the calories they consume at lunch will equate to about one-third of their daily calories. Assuming again that these teens are eating three meals as well as a snack or two each day, there shouldnt be a calorie deficit. However, the USDA clearly states that these ranges are estimated amounts of calories needed to maintain calorie balance and that individual calorie needs may be lower or higher. According to information from the American Dietetic Association Complete Food & Nutrition Guide by Roberta Larson Duyff, MS, RD, FADA, CFCS, those calorie requirements jump to 3,500 or more for athletes and those involved in strenuous exercise.
One Size Doesnt Fit All

Clearly, every lunch wont fulfill every students caloric needs, but according to Beauvais, even the old standards didnt sustain all the kids. Her first question for todays students complaining of hunger is Are you eating breakfast before you leave home or at school? She says lunch isnt intended to supply the entire days calories, but if students are hungry beyond whats on their tray, schools offer extra portions. With all the choices of fresh fruits and vegetables at kids disposal, certainly something should be appealing, Beauvais adds. Perhaps that appeal is partly to blame for the perceived calorie deficit. If kids dont eat whats offered, theyre not getting the calories and the energy available and necessary to sustain them throughout the afternoon. Cipullo noted the problem back in 1998 during her school tours. Children were forced to take a minimum of each item even if they didnt want to eat the food, she says. This created unnecessary food waste. It was a huge problem then and is still a huge problem now. Cipullo believes the reason kids arent eating enough calories is twofold. The new offerings, she says, need to be more visually pleasing and palatable. But keep in mind that kids have been accustomed to eating processed foods laden with added sugar, foods that appeal to them even if theyre not necessarily nutritionally adequate. Rather than calories, she says, the attention should focus on how to serve positive change in the way students view nutrition and food.
Table 1 Typical School Lunch Portions Based on the New Federal Standards
Food Group Fruits and vegetables Previous Requirements
1
Current Requirements Fruits: 12 to 1 cup Vegetables: 34 to 1 cup There are weekly requirements for dark green, red/orange, and starchy vegetables and beans/peas (legumes) plus other vegetables as defined by the 2010 Dietary Guidelines. Grades K to 5: minimum 1 oz equivalent daily; 8 to 10 oz weekly Grades 6 to 8: minimum 1 oz equivalent daily; 9 to 10 oz weekly Grades 9 to 12: minimum 2 oz equivalent daily; 10 to 12 oz weekly
2 to 4 cup total
3
There are no specifications regarding the types of vegetables to be served.
Meat/meat alternative
1.5 to 2 oz equivalent (daily minimum)
Grains
Eight servings weekly; minimum of one serving per day Whole grains are encouraged.
Grades K to 5: minimum 1 oz equivalent daily; 8 to 9 oz weekly Grades 6 to 8: minimum 1 oz equivalent daily; 8 to 10 oz weekly Grades 9 to 12: minimum 2 oz equivalent daily; 10 to 12 oz weekly As of July 1, 2012, at least one-half of the grains served had to be whole grain rich. Beginning July 1, 2014, all grains must be whole.
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)
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, avocados, and olives as part of their daily lunch meal, Cipullo says. Lets offer less-processed, wholesome foods without such tight maximums on calories. We also should encourage some of the kids to take just some of the food offered and then eat again two or three hours later. More often than not, smaller meals are easier on our endocrine systems and may help reverse the trend of increasing diabetes. Beauvais, whose son is a 6-foot 3-inch athlete, isnt surprised that the lunches he eats at school arent enough calories to carry him through his afternoon sports practice, but they werent last year either. When this is the case, Beauvais says these kids need another plan for the afternoon, which might mean bringing a snack from home or money for a healthful vending machine option.
Table 2 Calorie Counts of Lunches Before and After New Standards Took Effect
Previous Standards Grades K to 3: 633 Grades 4 to 12: 785 Grades 7 to 12: 825 (optional) Current Standards Grades K to 5: 550 to 650 Grades 6 to 8: 600 to 700 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)
Wheres the Beef?

While its true the number of calories in school lunches arent that different from a year ago, theyre distributed differentlyand this is what the kids notice. Perhaps the most dramatic change is the cap on protein and grains. At the high school level, its the difference between this years burger and last years: What was once a 3-oz meat patty is now 2 oz. Beauvais says the differencethe patty gets lost in the bunis visibly obvious to the kids. She says that our new motto is How about some lettuce and tomato with that? It has become a challenge on the foodservice side as well, which Beauvais describes as kind of like a puzzle. Take that burger, for example. To accommodate the addition of a halfounce slice of cheese, youd first have to make the patty a half-ounce smaller. Well, they dont come in a 212 -oz size. And sandwichesa staple on every lunch lineare no longer so simple under the new standards. A cap of 9 oz of bread, at 1 oz per slice, makes a challenging breakdown for the five-day school week. There might be a future for an open-faced sandwich on the menu, Beauvais says.
Changing the Food Isnt Enough

Laudable as the efforts behind the new standards are, theyre not enough, according to two former New York City public school teachers who have taken the issue of obesity in school children into their own hands. Deborah Lewison-Grant, MA, MEd, and Carolyn Cohen, MEd, started their own nonprofit organization called FoodFight to include teachers, who they believe are the missing link in the growing obesity epidemic. FoodFight also involves a curriculum that teaches teens about nutrition and how the media influences their food choices. You cant revolutionize food without revolutionizing the culture in the schools, Cohen says. Without buy-in from both
adults and students on campus, the healthier lunches wont change anything. Even after the dust settles and the protests wane, negative attitudes and food waste in the cafeteria are likely to continue. Theres a clear disconnect when grown-ups arent included, Lewison-Grant says. They wield a lot of influence on students a disproportionate amount of influence. FoodFights goal is to improve the health and life outcomes of students by bringing teachers and personnel into the conversation. Their health and wellness is critical to their job. Corporate wellness is so accepted, but we dont see that in schools, Lewison-Grant continues. By running wellness programs for teachers and school staffs, Cohen and Lewison-Grant believe their graduates will bring an empowerment and energy for healthful living and eating to the students. If you engage the entire staff, you can ignite an important process that can change food in schools, they say. In addition, Cohen and Lewison-Grant believe the new lunch standards would be more effective if they were introduced within a context. A new set of guidelines without explanation is confusing. Its missing the education component, Lewison-Grant says. When the students dont understand the reason behind their role in the changes, it becomes a control issue. Food is the one area over which they exert control, she explains. They can decide what to put in their mouths, but they dont understand the forces shaping it. School lunch isnt exempt. This is where the adults in the school can lead students through the changes and together change the current food climate into a healthful one.
Embracing Change Is Tough

All change is subject to scrutiny, doubt, and sometimes protest, and the new school lunch standards are no exception. But like any new policy, especially one as large-scale as the US school meal program, its being closely monitored. According to Beauvais, the USDA is receiving information from around the country and, she says, Im hoping there will be some minor revisions.
Lori Zanteson is a food, nutrition, and health writer based in southern California.
Meatless
Monday
By Sharon Palmer, RD
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.
hat do Oprah Winfrey, Michael Pollan, and Mario Batali have in common? Theyve all jumped on the Meatless Monday bandwagon. Hospitals, colleges, restaurants, magazines, foodservice companies, workplaces, and entire communities are pledging their support for the program, too. Whats Meatless Monday all about? Its a nonprofit initiative of The Monday Campaigns, which is developed in association with the Johns Hopkins Bloomberg School of Public Health, with a simple message: By cutting out meat once per week, you can improve your health and reduce your carbon footprint. The initiative provides information and recipes to help people start each week with healthful, eco-friendly, meat-free alternatives. Allison Righter, MSPH, RD, who coordinates the Meatless Monday science advisory at the Center for a Livable Future (CLF), reports that Meatless Monday began in 2003 in response to the release of the Healthy People 2010 report, which included goals to reduce dietary saturated fat by 15%. Since saturated fat primarily comes from meat and animal products and since one day a week is just under 15% of the week, Meatless Monday was a practical method for helping people to meet those goals. Reducing meat consumption also has many other benefits, such as lowering the environmental burden of industrial food animal production, which is a major focus of CLFs research, Righter says.
Benefits Aplenty
Theres growing support for adopting a more plant-based diet, even in the 2010 Dietary Guidelines for Americans, which offer the general recommendation to eat a plant-based diet that focuses on consuming vegetables, cooked dry beans and peas, fruits, whole grains, nuts, and seeds with moderate amounts of lean meats, poultry, eggs, and dairy.1 A position paper published by the Academy of Nutrition and Dietetics concluded that a plant-based, vegetarian dietary pattern 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 pressure 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 participating 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 associated 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 researchers performed a life cycle assessment to evaluate the cradleto-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 Environmental Working Group (EWG), greenhouse gas emissions generated by conventionally raising lamb, beef, pork, and farmed salmon and producing cheese far exceed those from other food choices, such as lentils and beans. The EWG found that eating less meat could significantly reduce a persons carbon footprint. For example, if everyone in the United States ate no meat or cheese for just one day per week, it would be like taking 7.6 million cars off the road.8 The Meatless Monday message helps people ease into the concept of decreasing animal intake by selecting just one day per week to go meatless. Were not asking people to cut out meat from the diet, Righter says. This is all about moderation; its one simple tool to help people incorporate healthierand also more environmentally sustainablealternatives to meat into their diets just one day each week. Its a platform to introduce new and often overlooked foods, and ideally this will trickle over into other days of the week and ultimately translate into healthier eating habits and dietary patterns over time.
What I think is important to understand, especially for dietitians, is that people are consuming too much meat more than whats needed to achieve nutritional recommendations, Righter continues. Were eating more than twice the EAR [estimated average requirement] or about 112 times the RDA [Recommended Dietary Allowance] for protein. The majority of our protein is coming from meat and animal products, which provide additional saturated fat and often not the same nutritional benefits of other plant-based proteins. 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 influenced their decision to cut back or consider cutting back on meat. Of those influenced by Meatless Monday to reduce meat intake, 62% say theyve tried to incorporate it in their weekly routine; 40% incorporate more meatless meals the rest of the week; 73% eat more vegetables; 64% eat more fruits; 42% eat more beans; 47% eat more whole grains; 50% experiment with new meatless recipes when they cook at home; and 42% try more meatless dishes when eating out.
Meatless Monday was started in restaurants by pioneers like Mario Batali. Now its gone mainstream, says Neu, who reports growing innovation in the restaurant world. Chefs are employing food stations, special menu features, and tasting menus to help promote Meatless Monday. The campaign also has been a darling in the media. The media, bloggers, and Food Network have all become active in Meatless Monday, Neu says. Were not saying that people should give up meat entirely; were not saying to be vegetarian or vegan entirely. Our press is so good because whats there to argue? Meatless Monday also is growing with schools, colleges, food distributors, worksite wellness programs, and insurance companies. Were even seeing Meatless Monday in communities, such as in Raleigh-Durham [North Carolina] and Aspen, Colorado, where community organizers go around and get schools, media, and events to support a communitywide gestalt.
Employing Meatless Monday in Other Settings

Dietitians are getting excited about using Meatless Monday as a tool in various work settings. Dietitians are involved in marketing, cooking classes, community, television, cooking demos, and blogs. Theyre also involved in foodservice settings, Neu says of the many ways dietitians use Meatless Monday to provide healthful eating messages. Meatless Monday can be used as a platform in any setting 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 dietitians regarding their knowledge and use of Meatless Monday in their work. About half of the people I got responses from already had heard about the campaign and were using it in the classroom or with clients in some capacity, she says. However, a lot of people werent aware of iteither theyd never heard of it or they didnt realize it was a campaign with its own website, social media, and all sorts of information, recipes, and resources. Its one strategy to help bring Americans in line with the Dietary Guidelines. Everyones on the same page; were all struggling to get people to eat more healthfully. Using Meatless Monday is an opportunity to introduce these plant-based foods, like vegetables, fruits, beans, and whole grains. Thats one of the things that came back from our survey of dietitians. They believe Meatless Monday provides an opportunity for people to try new recipes and new foods, Righter says. Dana Dose, RD, CPT, a dietitian at Harrahs Health and Wellness Center in Lake Tahoe, California, uses Meatless Monday in her one-on-one sessions with clients. Ive also started the
Meatless Monday Takes Off

The Meatless Monday movement has grown dramatically in the past two years. Awareness of the campaign primarily is due to grassroots viral dissemination and support of participating 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 Cooking Channel (more than 345,000 Facebook likes and 87,000 Twitter followers), post Meatless Monday content every week. Organizations have helped Meatless Monday become mainstream, says Peggy Neu, president of The Monday Campaigns. Sodexo was the first to join in 2011. Theyre enormous, with 6,000 customers in the United States serving 10 million meals a day. As weve grown both in our awareness and number of people who say theyre practicing Meatless Monday, we have all of these companies and organizations 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,
process of seeing if the on-site cafeteria for the employees will start offering additional meatless options on Mondays. Once that goes through, Ill promote Meatless Monday throughout the property, especially in the employee cafeteria, by using signage and putting an article in the employee newsletter, Dose says. Its great to be able to show people the positive impact they can have on the environment and their bodies when they go just one day without meat. Lauren Harris-Pincus, MS, RD, and Kathy Siegel, RD, CDN, cofounders of NutritionBabes.com, feature a meatless recipe category with 85 recipes on their website and blog, and they encourage their clients, readers, and listeners to consider forgoing meat one day per week. By raising awareness of the benefits of decreasing meat consumption, we can open consumers minds to the potential positive effects on their health, Harris-Pincus says. The path to better health is traveled one step at a time, and removing meat from your meal plan one day per week can be one of those steps. Roberta Anding, MD, RD, LD, CDE, CSSD, director of sports nutrition at Texas Childrens Hospital in Houston, uses Meatless Monday as a tool in teaching an introductory nutrition course. It dovetails with my lecture on vegetarian nutrition. From a clinical perspective, I use it to reduce the high calorie burden of my carnivore Texans. Im contemplating writing about it for the Houston Texans Gameday magazine, she adds. Natalie Bates, a clinical nutrition student at the University of California, Davis, spent the past summer in an internship 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 presentation that was shown on the TV in the hospital cafeteria. She tested meatless recipes and worked with the chef to offer four different meatless entres in the cafeteria on Meatless Monday. Bates made table tents that included recipe pictures and environmental and nutritional information. She also set up a table at the cafeteria entrance that showcased a poster promoting the campaign and that provided staff to answer peoples questions. Bates distributed a survey about Meatless Monday to receive feedback from the cafeteria customers. The survey indicated very mixed results. While some people were excited about having meatless options, others were upset that the cafeteria would try to influence their dietary choices, she explains. Those who were interested in eating healthfully were easy to convince to try Meatless Monday on a regular basis, and they liked the vegetarian options offered in the cafeteria that day. However, within the hostile audience, it was difficult to see any impact. I think the area of opportunity for people in the public health field is among the neutral/undecided individuals who are intrigued and open to
the idea but havent been exposed to or received guidance for implementing Meatless Monday into their lives. Surprisingly, I found that emphasizing the environmental impact often can motivate people to participate in Meatless Monday who wouldnt be interested in participating for health reasons.
Getting Started
If youd like to use Meatless Monday in your own practice, MeatlessMonday.com offers many great resources to get you started, such as information on nutritional and environmental benefits, articles, a recipe widget that can be placed on any website or blog, and a tool kit with promotional materials in a downloadable format. So go ahead, jump on the Meatless Monday bandwagon and encourage your clients to take the ride for better health, too.
Sharon Palmer, RD, is a contributing editor at Todays Dietitian, a freelance food and nutrition writer in southern California, and author of The Plant-Powered Diet.
References
1. US Department of Agriculture, US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office; 2010. 2. Craig WJ, Mangels AR; American Dietetic Association. Position of the American Dietetic Association: vegetarian diets. J Am Diet Assoc. 2009;109(7):1266-1282. 3. Newby PK, Tucker KL, Wolk A. Risk of overweight and obesity 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 metaanalysis. Circulation. 2010;121:2271-2283. 5. Pan A, Sun Q, Bernstein AM, et al. Red meat consumption 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 combined with different food production systems. Eur J Clin Nutr. 2007;61(2):279-286. 8. Hamerschlag K. Meat Eaters Guide to Climate Change + Health. Environmental Working Group website. http://static. ewg.org/reports/2011/meateaters/pdf/report_ewg_meat_ eaters_guide_to_health_and_climate_2011.pdf. July 2011. Accessed May 10, 2012.
Educating Young Palates

MindStream Academy is blending food, nutrition, and education to teach students how to live healthfully for the rest of their lives.
By Juliann Schaeffer
he number of children suffering from childhood obesity has more than tripled in the past 30 years, according to the Centers for Disease Control and Prevention, putting them at an increased risk for much more than teasing from schoolyard bullies. The US Department of Health and Human Services has reported that being overweight during childhood and adolescence 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 Bluffton, South Carolina, is hoping to make a dent in these troubling statistics by looking at much more than just childrens weight. The academy is attempting to forge an innovative partnership with a Missouri school district to expand its reach to more kids nationwide.
A Mind-Body Approach to Wellness

The biggest difference between MindStream and other weight-loss programs is its overall focus. While its no secret that it addresses obesity, the school takes pride in its mindbody approach to health and wellness, impressing on children that life is about much more than what the scale dictates. MindStream Academy has created a school climate in which optimal health and wellness is equally as important as high academic standards. Ultimately what we offer is an education for lifelong vitality and vibrancy, Travaglione says, noting that in addition to a lower weight, students also are pursuing the far loftier goals of optimal wellness and their fullest life potential. MindStream staff aim to help students achieve these goals with targeted fitness, nutrition, and culinary education as well as counseling. Were not interested in quick fixes and dont focus solely on weight loss, Travaglione says. Physical fitness and proper nutrition are part of what we do but not all we do. The weight loss and developing fitness habits is a product of selfconfidence and self-management skills. We want our students to take the skills theyve learned here and maintain their success for life, which is why our program is so experiential in nature. What kinds of skills are these kids learning? Stress management, gardening prowess, and cooking basics to start. Our boarding program for teens requires a semester minimum, as it takes about four months for behavioral changes to stick. In that time, our students learn to better manage stress; to be mindful; to garden; cook fresh, delicious foods; enjoy moving their bodiesperhaps for the first timesocial and emotional well-being; and to appreciate the great outdoorsoverall becoming more grounded to the earth, Travaglione says. To address whats at the core of the teens weight issues, MindStream staff use experiential therapies, such as equineassisted psychotherapy and neurobiofeedback, which are designed to better reach children by offering counseling in a more fun, solution-focused, and nonthreatening way than traditional one-on-one therapy. Even students families get in on the action. Our students families participate in our program through weekly counseling 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 supporting the whole childand not just focusing on weight losshe hopes to put students on a path of lifelong health and wellness.
MindStream Academy: What Its About

MindStream Academy, a full-service boarding school, is in many ways like your typical high school, fully credentialed to offer academic coursework to students of all levels. Yet its designed specifically for kids whose health, future, and very lives are on the line due to obesity and its attendant physical and psychological burdens, says MindStream Academy Founder and CEO Ray Travaglione. In addition to their regular coursework, MindStream students 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 neurobiofeedback 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 learning for teens. Beginning with student athletes, I created programs that provided the opportunity to develop their skills and test them against their peers, founding both Hank Haney International 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: Heritage Academy. As Travaglione became more aware of obesitys increasing stranglehold on todays youths, he decided he had to get involved. Obesity in our youth has the potential to bring this country to its knees in a very short period of time, and I could not stand idly by and allow this to happen, he says. I decided it was time to do something to turn the tide on this epidemic and founded MindStream Academy.
Nutrition Nuts and Bolts

MindStream bases its nutrition program on what it calls the FLOW concept (Fresh, Local, Organic, Whole food style and nutrition program), which Travaglione says gives importance to the following principle: Meals prepared with seasonal, farmfresh, 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 demonstrate the essential life skill of how to select and lightly prepare ones own food, he says. The importance of the farm-fresh, organic, and local part of the program is demonstrated in MindStreams own Soul Garden, a 1-acre garden of herbs, fruits, and vegetables that students take care of. They participate in all aspects of the gardens care, from planting the seeds to harvesting their crops and bringing them into the kitchen, Travaglione says, adding that many students love the experience so much that when they return home they start a garden of their own. An RD/chef team, which works to bring MindStreams nutrition philosophy to life, develops all student meals. This years offerings were expanded from a three-week to a six-week menu cycle to give students more options. The menus are based on a 1,500-kcal diet, which is broken down into three meals and two 100-kcal snacks, says Tina Steinberg, MEd, RD, LD, whos behind MindStreams nutrition curriculum. Steinberg and MindStreams chef work hard to make all choices healthful and kid friendly. The majority of foods served are made from scratch, including dressings and sauces; grains/breads are whole wheat; fruit is served with breakfast; and salads are served with lunch and dinner, she says. Foods are minimally processed and contain very little sugarunder 6 g. Beverage choices are water and milk. The kids drink water all day long to stay hydrated.
Targeted Education
Not only are students served the healthiest and freshest foods available, theyre also taught how to integrate various culinary skills, nutrition tips, and fitness into their day-to-day lives. Culinary skills: Students learn how to prepare the types of foods they eat at MindStream by participating in culinary demos that are conducted once or twice per week. The kids learn hands-on how to make their own meals and healthful desserts. The demos have been a great hit with the kids, Steinberg says. The culinary education program begins from the ground up, Travaglione says, noting that at the academy students learn about food from its true beginnings: the earth. Students have the opportunity to assist in gardening fresh plant foods grown on site, harvesting ingredients for the kitchen, and working hands-on side by side with our chefs. Through this hands-on experience, MindStream aims to give students the tools they need to prepare simple, delicious, fresh, and healthful meals after their return home. Nutrition: According to Steinberg, students attend twohour-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, theyre also redesigned to incorporate popular topics, which the kids may discuss during class time. In addition to nutrition basics, the classes hit on topics such as the importance of portion sizes, how to make good choices when eating out, healthful substitutes for recipes, and how to navigate the grocery store and decipher food labelsall intended to give students a well-rounded knowledge base of what it will take to continue their healthful habits at home. Fitness: Students are enrolled in a fitness program to get them movingfor life. Staffed by certified personal trainers as well as dance, martial arts, Zumba, and yoga instructors, the program is designed to get students to improve overall body movement and learn to enjoy it. To fuel their desire toward fitness, weve created a movement playground, Travaglione says. Its this same belief that correct movement is the backbone of a lifelong commitment to fitness that has inspired us to focus on body weight-driven exercise. We believe so strongly in body weight movement that there are no traditional exercise machines at MindStream Academy. According to Travaglione, MindStream students define their own fitness path, as all fitness regimens are individualized. Our four-phase program is based on the values we gain from initial fitness evaluations, he explains. Training is based off of ones own baseline, and a students current fitness level helps determine his or her program, pace, and progression. As fitness level increases, so does the pace of the program and the difficulty of the activities. The biggest difference between MindStreams approach compared with most weight-loss programs may not be in what theyre doing but in what theyre not doing, which is anything too extreme. What makes our program so unique is that theres nothing extreme about what were doing; weve just brought students 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 popular on TV, participants might endure severely restrictive diets of 600 kcal or fewer to achieve dramatic results. Travaglione says MindStream students achieve similar results but not in such an extreme atmosphere. Still, while the scale tells a compelling story, Travaglione says perhaps the most significant change MindStream students undergo is related to their mental health, which can have a far more lasting effect: They arrive feeling despondent, and they leave feeling like a new person. The changes that are made here arent skin-deep. There are tremendous shifts in personal responsibility, self-esteem, healthful risk taking, and a sense of hope through accomplishing tremendous goals. When our students go home, theyre maintaining their weight loss, and some have continued on their weight-loss journey, he adds. Students report better grades, being more socially outgoing, and embrace their role as a healthful lifestyle ambassador.
Branching Out
While MindStream is satisfied with the success its students are achieving, it wants to effect change in more childrens lives. Its hoping a new partnership with Independence School District will help it do just that. This semester were piloting a direct relationship with a public school district, Travaglione says. Essentially, MindStream is taking in a cohort of kids whose obesity/metabolic and psychosocial problems are too complex for a public school to handle. This potentially frees up resources in the public school district while MindStream helps these kids turn their health and lives around so they can return as ambassadors of what theyve learned and pay it forward. The idea for the partnership came from the collaboration of Travaglione and two others: Jim Hinson, superintendent of the Independence School District, and noted prevention expert David L. Katz, MD, MPH, FACPM, FACP, director of the Yale University Prevention Research Center. We saw this unique opportunity to partner and help obese kids in his district, and the rest as they say is history, Travaglione says. Designed to provide the promise of a better quality of life and longevity for students in need, Travaglione hopes partnerships such as this one will eventually help turn the tide on this epidemic and turn our countrys future around.
If these kids drop out, if they dont realize their fullest potential, 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 variety 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 Department of Elementary and Secondary Education for state funding, Travaglione says. Parents, corporate partners, private donors, and the School District Foundations all participate in contributing money that helps offset the cost of tuition. Rather than waiting on the world to change, MindStream gives these kids the world as it should bea world that leads to health and away from bullying and ridicule, Katz says. Its as much about community and solidarity as it is about fitness, nutrition, and academics. It is, in a word, extraordinary. The true beauty of this better world is that it imparts a skill set the kids take back with them to the world as it is, making them far better able to deal with it. MindStream also gives the kids skills they can pay forward, he adds. They can help others with what they learn there. MindStream isnt about giving kids a better BMI; its about giving kids both the will and the way toward a better life. And so far, results are promising. According to Travaglione, 13 Independence School District students attended MindStream during the first semester of its partnership. At press time, those students had collectively lost more than 500 lbs and gained much more. Their self-confidence is through the roof. Theyre performing better academically, loving the cooking 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 MindStream has more school district partnerships currently in the works. Were at various stages of replicating this partnership in South Carolina, Florida, Mississippi, Ohio, New York, and Kentucky, Travaglione says, and we plan to do so in every state and school district in the country.
Juliann Schaeffer is a freelance writer and editor based in Allentown, Pennsylvania, and a frequent contributor to Todays Dietitian.
PHOTO COURTESY OF MINDSTREAM ACADEMY
CPE MONTHLY
Defining Autism
The word autism comes from the Greek word autos, meaning self. Its been used for about 100 years to describe a condition in which people cant engage in social interaction. Originally, it was thought to be associated with schizophrenia. In 1943, Leo Kanner, MD, known as the father of child psychiatry for his pioneering work related to autism, first identified the disorder at The Johns Hopkins University in Baltimore.1 Also in the early 1940s, German scientist and pediatrician Hans Asperger, MD, identified patients with similarly withdrawn behavior, now known as Aspergers syndrome.2 Today, autism is better defined by the term autism spectrum disorder, which describes a grouping of various developmental disabilities. Symptoms of ASD usually begin before the age of 3 and continue throughout a persons life. In some infants, there are early signs of the disorder, such as not wanting to cuddle, lack of eye contact, or abnormal responses to touching and affection. Other early signs include the inability to follow objects visually, not responding to his or her name being called, and lack of facial expressions, such as smiling.3 Some children with ASD develop normally until the age of 1 or 2, then stop learning new skills or lose the ones they already have learned.3 There are three main classifications of ASD and understanding the difference among them will help to better focus treatment. The first classification of ASD is autistic disorder, which is considered the classic form of autism. Patients usually have significant delays in language, social skills, and the ability to communicate. Some have unusual behaviors and interests, and have a measurable intellectual disability. The second form of autism is Aspergers syndrome, usually a milder form of autism. Patients still have delays in social abilities and communication skills, and have unusual behaviors and interests.4 Many individuals have a specific interest that encompasses much of their time and thought. People with Aspergers may spend much of their time devoted to a hobby
AUTISM SPECTRUM DISORDER

By Dawn Privett, RD, LD, CLT
Research Suggests Good Nutrition May Manage Symptoms

Decades ago, autism spectrum disorder (ASD), a group of developmental disabilities in which patients have significant social, communication, and behavioral difficulties, was considered rare, and the prognosis of those who had it usually wasnt good. Many individuals were committed to institutions for the rest of their lives because of their inability to function in society. But times have changed. The prevalence of ASD among adults and children has skyrocketed over the last several years. Much more research on the etiology of the disorder and the different ways to treat and manage it has become available. Today theres evidence showing how nutrition therapy can play a significant role in managing 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.
LEARNING OBJECTIVES
After completing this continuing education activity, nutrition professionals should be able to:
1. Define the three types of autism spectrum disorder
(ASD).
2. Assess the various problem-eating behaviors associ-
ated with ASD.

3. Develop strategies to eliminate problem-eating
behaviors.
4. Employ the various nutritional therapies to treat ASD
patients.
(eg, trains, computers). They usually dont have issues with language skills or intellectual development. In fact, many are intelligent, especially when it comes to their own special interests. Some experts liken patients with Aspergers to little professors in their areas of interest; they can have near genius IQs. The third form of autism is pervasive developmental disorder, not otherwise specified, or atypical autism. These individuals meet only some of the criteria for classic autism or Aspergers. They have fewer, milder symptoms and may experience delays only in the areas of social skills and communication.4
such as a urinary tract infection, in the second trimester has been found to increase the risk of ASD by 40%.13 Recently, researchers examined inflammatory disease as a possible cause of autism and found that it could possibly contribute to the etiology of the disorder.14
Problem-Eating Behaviors
While the medical community may not have identified the exact causes of ASD, much has been learned about the challenges ASD patients face that often lead to poor diet quality. These include problems with sensory processing, eating behaviors, and feeding disorders. Its estimated that 46% to 89% of patients with ASD experience some kind of problemeating 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 carbohydrate 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
Current ASD Statistics

The number of children diagnosed with ASD has increased almost tenfold in the last 40 years.5 Currently, one in every 88 children is diagnosed with ASD.5 When broken down by gender, five times more males (one in 54) than females (one in 252) are affected.5 These statistics indicate that ASD affects more than 2 million people in the United States and more than 10 million worldwide.4 According to the organization Autism Speaks, ASD affects more children than diabetes, AIDS, or cancer combined.5 The increase in diagnoses may be due in part to better diagnostic tools, but many believe environmental toxins and genetics hold better clues to the increase in prevalence, although this hasnt been proven.
Link Between ASD and Environmental Toxins

No specific environmental toxin has been identified as the cause of autism, but research to determine which chemicals may be culpable is under way. Its been proven that a fetus is vulnerable to environmental chemicals during development. Examples of chemicals that, in the past, have been shown to harm fetal development include organophosphate insecticides6 (eg, chlorpyrifos), mercury exposure,7 and heavy metals (eg, lead).8 Its a widely held belief that people with ASD have difficulty 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 function processing. Unfortunately, because of the short amount of time research has been conducted on the link between autism and environmental toxins, causality still remains speculative. However, it continues to appear that genetics, environment, and the interaction of a childs physical and psychosocial environment play an interrelated role in the possible causes and triggers of ASD. Such associations can be seen in the high incidence of autism in twins and genetic siblings who have the disorder.9 Other suspected causes of autism include advanced parental age,10 low birth weight,11 and multiple births.12 A viral infection, such as the flu, in the first trimester has been shown to triple the odds of a child developing ASD, and a bacterial infection,
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How to Earn 2 CPEUs
Read this article and select your answers for the examination. Then visit our CE Learning Library at CE.TodaysDietitian.com to purchase access to complete the online exam and earn your credit certificate. For more information, call our continuing education division toll-free at 877-925-CELL (2355) (M-F, 9 am 5 pm ET) or visit www.TodaysDietitian.com. Suggested CDR Learning Codes: 3000, 3010, 3100, 4000, 4150, 4160, 5000, 5070, 5080, 5180, 5390, Level 2
Your Childs Autism, Aspergers, or ADHD, is to assemble a feeding team, a group of healthcare professionals consisting of a physician, speech language pathologist, occupational therapist, behavioral therapist, and RD.17 A dietitian can evaluate the foods the child agrees to eat for potential dietary deficiencies. He or she can watch the child and family during meal times to assess habits that may be hindering food intake. An RD also can screen the medications the child takes that may have side effects that contribute to feeding problems.
ASD and Food Additives

Just as problem-eating behaviors can prevent ASD patients from getting the nutrients they need, so can consistently consuming highly refined foods. Since highly refined foods may contain artificial dyes and preservatives that could be associated with aggravating behavioral symptoms in those with ASD,18,19 suggesting the family eat natural, whole foods may be an important treatment intervention.
When discussing dietary recommendations with ASD patients or their parents or caregivers, also suggest that patients be screened for nutritional deficiencies that can result from the medications they take.
Dietitians working with ASD patients can recommend eliminating the following substances from an ASD patients diet if they believe a sensitivity exists: Food dyes and artificial colors: These additives have been linked to hyperactivity, breathing disorders, skin eruptions, and gastrointestinal symptoms in non-ASD patients.18,19 Since many ASD patients already have these symptoms, eliminating foods that contain these substances may be helpful to assess a patients reaction. High-fructose corn syrup: One of the main concerns with high-fructose corn syrup involves the manufacturing process. Research has found that mercury, one of the environmental toxins that may be responsible for the increased prevalence of ASD, is part of the refining process when making high-fructose corn syrup.7 Removing it from the diet whenever possible may be a helpful suggestion. Artificial flavorings: Monosodium glutamate (MSG), for example, has been shown to cause headaches, muscle tightness, 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 hyperactivity.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 compromise nutritional status. For example, if a child is constipated, he or she may experience a decrease in appetite. If dysphagia is an issue, he or she may decrease food intake for fear of choking while swallowing. If medication causes sedation, the child may not feel the need to eat even though he or she is hungry.
Supplementation
Another aspect of ASD treatment involves supplementation with multivitamins, omega-3 fatty acids, vitamins D and B6, magnesium, and other nutrients. Beginning multiple supplements at one time may impede the ability to determine whats working or not working in ASD patients. Therefore, the best strategy may be to start one supplement at a time for several weeks to determine whether theres an improvement in symptoms. If the patient takes one supplement for several weeks and experiences no improvements in symptoms, it means the supplement may not be helpful for that particular patient. If improvements are seen, stopping the supplement for a week or so to determine whether symptoms return can be a good strategy to gauge effectiveness. This process allows ASD patients to follow the least restrictive regimen possible while identifying improvements in symptoms.
Multivitamins
Most practitioners who work with ASD patients agree that a good-quality multivitamin without artificial colors or flavors can help offset limited dietary preferences and poor nutritional intake. Finding the right multivitamin will depend on a patients tolerance. Some will swallow a pill, while others will prefer a liquid, gummy, or chewable form. RDs are in a perfect position to determine whats acceptable and meets each patients needs.
Omega-3 Fatty Acids

Research has shown that adding omega-3 fatty acid supplements to ASD patients diets may provide many benefits.
Omega-3s are critical for brain development and proper neural function. Multiple studies have shown imbalances in the ratio of omega-3 to omega-6 fatty acids in the bloodstreams of ASD patients.24-27 Obtaining adequate amounts from food alone may be difficult because of the limited number of foods they may eat. For example, some children with ASD wont eat cold-water fish (eg, salmon, tuna), and some parents wont add fish to their childrens diet because they believe it contains mercury that may exacerbate ASD symptoms. Still, many parents do give their children omega-3 supplements.28 Some practitioners recommend 1.5 g/day of omega-3 fatty acids for most pediatric patient populations.25 According to research, children with ASD who take omega-3 supplements have less anxiety and aggression, decreased hyperactivity and impulsivity, longer attention spans, and improvement in language development, reading, and spelling skills.27,29-31 Most omega-3 supplements are made from fish oil, so its important to ensure theyre free of mercury. (The label will indicate mercury-free processing.) Because oils can become rancid, its best to use supplements before their expiration date. Some supplements contain added vitamin E as a preservative to improve shelf life, while others are bound with dietary calcium to preserve the oil at room temperature. If patients complain of stomach upset or fishy burps but dont experience this when they eat fish, question the freshness of the supplements. Patients may need to keep the supplements in the refrigerator so they stay fresher longer.
vitamin D during pregnancy is imperative. In supplement form, the Recommended Dietary Allowance (RDA) is 600 IU. However, if blood work shows a pregnant woman is deficient, a plan for increasing her vitamin D level must be directed by her physician, who may prescribe doses much greater than the RDA. This applies to nursing mothers and children with ASD as well.
Vitamin B6 and Magnesium

Vitamin B6 and magnesium supplementation also are used in treating ASD patients. One way to boost intake is in the form of a multivitamin that contains both at US Reference Daily Intake standards. Some studies have shown improvements in behaviors, 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 supplementation.35 Other studies, however, have shown that high-dose pyridoxine supplements can cause peripheral or sensory neuropathies,36-37 and larger doses of magnesium can cause gastrointestinal upset and diarrhea.
Other Supplements
Glutathione, which can be used in ASD treatment, enables the body to detoxify and protect itself against oxidative damage.38 Moreover, dimethylglycine is touted to improve language skills and the ability to make eye contact. However, theres little evidence showing that either alleviates symptoms.39-40 More research is needed to show efficacy of some of the current supplements being used.
Vitamin D
Several studies suggest a direct link between low vitamin D (25-hydroxyvitamin D) levels and the risk of ASD since vitamin D regulates the immune system. Research shows that children are at risk of ASD because of their bodys inability to identify foreign invaders and eliminate toxic substances and have an even higher risk of developing the disorder if theyre vitamin D deficient. Vitamin D protects against DNA damage and can help repair damage once its occurred. (Its role in reducing damage in the case of environmental toxins is being investigated.) In addition, 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 executive director of the Vitamin D Council, the prevalence of ASD increases in regions of greater cloud cover and rainfall.33 Studies have shown there are more ASD cases in children born between October and March.34 Research suggests this may be due to the lack of sunlight exposure. The body produces vitamin D when the skin is exposed to the suns ultraviolet B rays, but during the cooler months of the year, the sun isnt out long enough for pregnant mothers to get ample exposure. Ensuring women get adequate amounts of
Probiotics, Antifungals, and Digestive Enzymes

Probiotics and antifungals are common treatments for the abdominal pain, bloating, gas, constipation, gastroesophageal reflux disease, nausea, vomiting, and diarrhea that many ASD patients experience. No conclusive evidence is available to explain why these digestive symptoms are common in ASD patients, but the use of probiotics has provided relief of these symptoms for many of them. The National Center for Complementary and Alternative Medicine defines probiotics as live microorganismsusually bacteria, but they also can include microbes such as yeast that people can ingest to increase the population of desirable bacteria in the gut. Antifungals inhibit the growth of a fungus or destroy it. Theyre used in the treatment of Candida albicans, a fungus frequently reported as the culprit when a yeast infection 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 Therapy

The elimination diet is another option that has shown promise in treating ASD and involves removing certain foods from the diet for a period of time to determine whether theyre causing symptoms of food allergies and intolerances. Research has shown that eliminating gluten and casein from the diet of ASD patients can alleviate symptoms such as behavior problems and poor cognitive and social functioning.41 There are several theories as to why the elimination diet may be beneficial. One hypothesis is that ASD patients cant digest gluten and casein, causing the formation of the peptides gluteomorphin and caseomorphin and their absorption into the bloodstream because of increased gut permeability, or leaky gut syndrome. These two peptides, which appear to have a chemical structure similar to opiates, can cross the blood-brain barrier and cause symptoms such as delayed social and language skills, and withdrawn behavior.42
The elimination diet is another option that has shown promise in treating ASD and involves removing certain foods from the diet for a period of time to determine whether theyre causing symptoms of food allergies and intolerances.
There are concerns about the use of a gluten-free/caseinfree 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 calcium, 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 Performance) 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 Mediator Release Test, which shows reactions to multiple foods and chemicals. These reactions involve the immune systems of patients who ingest foods and chemicals to which theyre
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, prostaglandins, leukotreines, cytokines, and peroxides. These mediators have been shown to cause reactions such as inflammation, diarrhea, pain, intestinal cramping, constipation, headache, and pain receptor changes. Studies have shown enhanced proinflammatory 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 serotonin. Dopamine appeals to the sense of reward and enjoyment, and plays a role in addictive behavior. Serotonin contributes to feelings of well-being and happiness. When dopamine and serotonin are released as a result of ASD patients ingesting foods and chemicals to which theyre sensitive, they may experience less pain, brain fog, or inability to focus and concentrate. According to certified LEAP therapists, ASD patients also may feel euphoric after ingesting a reactive substance or stop throwing a tantrum after eating a reactive food. Its in these instances where the Mediator Release Test may help with identifying reactive substances that can be eliminated to improve behavior, communication skills, and other immune-related health issues and allow for more variety in the diet for better nutrition.
What Lies Ahead

So what does the future hold for individuals with ASD? While theres no concrete answer to this question, we know RDs can play a huge role in the management and treatment of ASD symptoms. RDs ability to analyze diets for nutritional deficiencies can help concerned parents. Contacts with other healthcare disciplines that monitor patient behaviors make RDs invaluable as they provide holistic approaches to treatment for optimal cognitive and social functioning. RDs are the best source for providing accurate and up-to-date information on supplementation, elimination diet therapy, and current research on new nutritional approaches. More and more patients will depend on dietitians as the source of information that will enable patients to live productive lives. Dietitians with the passion to work with this challenging segment of the population will be a much-needed resource in the dietetics community in the years to come.
Dawn Privett, RD, LD, CLT, is a freelance writer and owner of Privett Nutrition Services in Kansas City, Missouri.
For references, view this article on our website at www.TodaysDietitian.com.
CPE Monthly Examination

1. A patient presents with significant delays in language and social skills, and cant clearly communicate. The patient may have which type of autism spectrum disorder (ASD)? a. Autistic disorder b. Aspergers syndrome c. Pervasive developmental disorder, not otherwise specified d. 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 processing b. Feeding disorders c. Binge eating d. Problem-eating behaviors 3. Patients with ASD who avoid several types of foods, such as proteins, usually will accept foods in the carbohydrate group. a. True b. 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 doesnt want to eat for three weeks then reintroduce it. c. Evaluate the foods the child agrees to eat for potential deficiencies. d. A and B 5. Which of the following supplements have been shown to reduce anxiety and aggression, decrease hyperactivity and impulsivity, and increase attention span in ASD patients? a. Multivitamins b. Omega-3 fatty acids c. Vitamin D d. Glutathione 6. Which of the following treatments may aid in removing toxic compounds from the gut of ASD patients? a. Probiotics b. Antifungals c. Digestive enzymes d. Dimethyglycine 7. Research has shown that eliminating gluten and casein from the ASD patients diet can alleviate which of the following symptoms? a. Behavior problems b. Poor cognitive functioning c. Poor social functioning d. All of the above 8. Patients with Aspergers 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 skills b. Abnormal responses in balance c. Delayed reactions to pain d. 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. True b. False 10. Which of the following is not an early sign of ASD in infants? a. Not wanting to cuddle b. Lack of eye contact c. Abnormal responses to touch and affection d. Colic
Take this exam by visiting our CE Learning Library at CE.TodaysDietitian.com.
SUPPLEMENT SPOTLIGHT
ZINC AND INFLAMMATION

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

A recent study published in the Journal of Nutritional Biochemistry 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 improving zinc status through diet and supplementation may be a viable strategy for reducing the risk of inflammatory diseases. When the body has insufficient access to zinc, its hit on many levels due to the many ways in which zinc typically functions to protect the body, explains Ellen B. Fung, PhD, RD, CCD, an associate research scientist at Childrens Hospital and Research Center in Oakland, California. First, zinc plays a significant role as an antioxidant in the body. Therefore, in a zinc-deficient state, there will be an excess of oxidants present, leading to increased DNA damage. In addition, zinc is a cofactor for RNA and DNA polymerases, which aid in the usual repair mechanisms. When these systems dont function properly, there will be increased damage. Finally, zinc aids in modulating DNA repair and damage proteins. ... In a deficient state, these systems also are in a state of disarray and lead to increased DNA damage. Researchers from Oregon State University examined the effects of zinc deficiency and age on inflammatory responses in both a cell culture model and an aged mouse model. One aspect of the study compared groups of mice fed two different amounts of zinc in their diets. The group receiving zinc supplementation 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 subsequent damage to body tissues, a cascade of events that contributes to the development of autoimmune diseases and several chronic diseases.1,2 The link that Dr [Emily] Ho has made between zinc deficiency and DNA damage, and now systemic inflammation, explains much of what we see on a cellular or whole-animal level, Fung says. For example, the root cause of the link between immune function deficitswhy you get sick more readily as you ageand zinc deficiency may be the increased methylation of zinc transporters, causing them not to function properly. This leads to decreased zinc inside an immune cell and increased inflammationa bad situation. If the results can be translated to humans, they would suggest that we can override the age-related deficits by supplementing with zinc, according to Fung.
Study Details
In the in vitro cell model, human monocytes were grown in zinc-deficient or -adequate media for up to 14 days. Macrophages were then treated with 0, 10, or 100 ng/mL of LPS, the major structural component of the outer wall of gramnegative 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 associated with an increase in age-related inflammation as measured 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. Agerelated declines in immune cell intracellular zinc content were associated with an increase in markers of inflammation. In addition, age-related environmental changes in gene expression led to alterations in zinc transport mechanisms, including an increase in DNA methylation and histone modifications. What leads to age-related changes in zinc status? With age, the ability to absorb and utilize zinc is compromised, though we dont know why it isnt well absorbed, notes Emily Ho, PhD, lead study author and a micronutrient expert at Oregon State University. Making matters worse, many older adults dont consume enough zinc through their diet or supplements. According to National Health and Nutrition Examination Survey (NHANES)
data from 2001-2002, 30% of men and 36% of women over the age of 71 consume less than the Estimated Average Requirement 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 households 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 clinical nutrition at Indiana University-Purdue University Indianapolis, has observed this pattern of low zinc intake in older people. Ive seen zinc-poor diets in many adult patients with a chronic disease such as diabetes, she says.
zinc from animal foods due to phytates that bind zinc and remove it from the body.6
Meeting Daily Requirements

The rapid growth of the older population makes preventing age-related diseases a paramount concern. And if the results of this study prove any indication in humans, honing in on zinc status may be particularly important as a measure of prevention. Age-related epigenetic decline in zinc status may contribute 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.
How Much Zinc?

If a persons ability to absorb zinc declines with age, should he or she consume more of this mineral? We dont have a great biomarker for zinc deficiency in humans and therefore just meeting the DRI [Dietary Reference Intake] is a good place to start until more research answers this question, Ho says. In addition to ensuring adequate intake, Blackburn suggests that a thorough physical examination be conducted by the appropriate physician, paying particular attention to nonhealing wounds and the skins appearance in case there are signs of zinc deficiency. Fish and meat are among the top sources of zinc. The bioavailability of zinc in some plant-based foods is lower than
References
1. Perry VH. The influence of systemic inflammation on inflammation 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 Examination Survey, 1988-1994. J Nutr. 2001;131(4):1232-1246. 6. Institute of Medicine Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, 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 reference. 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
FOCUS ON FITNESS
MOBILE APP MOTIVATORS

New Tech Tools May Help Keep Clients Exercising Well Beyond the New Year
By Jennifer Van Pelt, MA
Happy New Year! After counting down the seconds to 2013, your clients probably started counting the calories they need to cut and the number of pounds theyd like to lose. As is typical every January, New Years resolutions to lose weight, exercise more, and eat healthier are made and then soon broken. Gym owners, fitness instructors, and personal trainers all confirm that at the start of every new year, the gym equipment and classes are mobbed, and training sessions are booked solid. By March, the crowds thin out considerably when busy schedules and lost motivation overshadow resolutions to exercise regularly.
Psychology Behind Motivation

Motivation and exercise adherence involve a complex interaction of an individuals personality, goals, and behavior choices. Researchers have sought to better define these factors with the hope of improving promotional health messages to increase physical activity.
Understanding exercise motivation 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 extrinsic motivation. As related to exercise, intrinsic motivation is defined as exercising because its satisfying and elicits feelings of enjoyment. Extrinsic motivation is defined as exercising for a specific reason or to elicit a particular outcome. It may involve the perception that exercise 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 extrinsically motivated. In addition to providing an explanation of self-determination theory in relation to exercise, a systematic review published in the June 2012 issue of the International Journal of Behavioral Nutrition and Physical Activity found that intrinsic motivation was more likely to result in long-term exercise adherence. The New Years resolution to exercise is categorized as extrinsic motivation. Therefore, clients who use a New Years resolution to initiate an exercise routineno matter the intended goalwill inevitably have problems maintaining motivation over the long term. The principle of intrinsic motivation can be applied to developing strategies to help clients succeed with maintaining an exercise program. As Ive discussed in a previous column, encouraging clients to find an exercise activity they enjoy is a good first step toward exercise adherence. (See the September 2012 installment of Focus on Fitness, Dance Fitness.) Unfortunately, intrinsic motivation may be difficult to cultivate in some clients, particularly those who have self-esteem issues, negative attitudes about exercise, or physical limitations. For example, even if a client enjoys dancing for exercise, feeling
self-conscious in a dance class or lacking space at home may override intrinsic enjoyment. Is it possible then to use extrinsic motivation to improve exercise adherence? The introduction of high-tech fitness gadgets and smartphone apps for fitness could provide extrinsic motivation for the long-term. Given our obsession with being connected via wireless networking, its reasonable to consider that fitness gadgets and apps can be more successful extrinsic motivators than, for example, tracking calories 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 exchanging 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 smartphone in hand and love technology toys, the following gadgets and mobile apps may be of interest to track their fitness activities, providing motivation for daily workouts and encouraging fitness progress over time.
Striiv: A combination fitness tracker and mini gaming device costing 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 available 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 subscription 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.
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, distance, 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 customizable dashboard and mobile app, which are both free. Progress is tracked using charts, graphs, and other userfriendly displays to help clients reach their goals. Moreover, interfacing with apps such as SparkPeople, MyFitnessPal, MapMyFitness, and LoseIt! is free. The FitBit One wirelessly syncs with PCs, Macs, iPhone 4S and 5, third generation iPads, and iPod touch.
Tech Tools Galore

These are just a few of the new fitness 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 activities, 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.
BOOKSHELF
The Essential Cancer Treatment Nutrition Guide & Cookbook

By Jean LaMantia, RD, with Neil Berinstein, MD 2012, Robert Rose Softcover, 320 pages, $24.95 Cancer treatments create a spectrum of nutritional challenges for patients, their caregivers, and the dietitians who advise them. The Essential Cancer Treatment Nutrition Guide & Cookbook is an indispensable tool for any professional working with such clients. This detailed and authoritative book, written by Jean LaMantia, RD, a cancer survivor, along with Neil Berinstein, MD, a practicing oncologist, underscores proper food and diet as a vital complementary treatment for cancer patients at every stage of recovery. The first part of the book examines conventional cancer therapies and their side effects and provides information on managing those side effects, from anemia and fatigue to diarrhea and heartburn, through diet. Another chapter offers nutritional strategies for boosting the immune system, reducing inflammation, and creating a life-long therapeutic diet to prevent cancer recurrence. Nondietary complementary therapies, such as homeopathy, aromatherapy, and reiki, are outlined, with an emphasis on the importance of physical activity in addition to nutrition. Sample menus and advice on shopping and food safety also are provided. Numerous charts, sidebars, and frequently asked questions present a wealth of information in an easy-to-use format. The 150 recipes at the back of the bookdeveloped by LaMantia and six contributorsencompass everything from breakfast dishes and entres to snacks and beverages. Ingredient lists include both standard US measurements and imperial units for Canadian readers. The recipes, which focus on comfort foods to tempt suppressed appetites, use easy-to-find ingredients and uncomplicated directions. Supplemental information 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 conditions (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 instructions on storage and reheating are given. So-called survivor wisdom quotes from LaMantia are scattered throughout the book, providing helpful insights and adding a personal touch to this invaluable guide.
Lenora Dannelke is an independent journalist who writes about food for numerous publications.
Healthy Eating, Healthy Weight for Kids and Teens

By Jodie Shield, MEd, RD, and Mary Catherine Mullen, MS, RD 2012, Academy of Nutrition and Dietetics Softcover, 288 pages, $21.95 Appropriately addressing a weight issue can confound even the best and brightest, but its particularly perplexing when children are involved. Yet one look at the statisticsan estimated one in three American children today is either overweight or obeseshows many kids are struggling. This book seeks to help. Written by dietitians Jodie Shield and Mary Catherine Mullen and produced by the Academy of Nutrition and Dietetics publishing arm, Eat Right Press, Healthy Eating, Healthy Weight for Kids and Teens aims to provide parents with the knowledge and tools to wage warand winagainst whatever food issues their children are facing. To help parents determine whether their child has a weight problem that requires intervention, two introductory chapters serve as required reading and help define what actually constitutes a healthy weight. Here, topics such as whats normal for certain age ranges, what BMI is and what it means, and how parents can best track a childs height and weight are discussed. (Tip 1: Use a digital scale for accuracy.) The eight chapters that follow dont need to be read in order; each outlines a particular strategy that addresses a
specific problem. Parents are meant to scan the chapter titles to see which they might benefit from most before diving into them. For example, if Mom and Dad both work full time and, due to work and a dozen after-school commitments, have trouble getting a dinner routine in order, often opting for fast food, then Chapter 3: Eat With a Plan might suit them well. In this chapter, the authors define in concrete terms what healthful eating actually looks like (with help from a Choose MyPlate illustration), then break it down even further with kid-friendly tips on how to incorporate whole grains, dairy, fruits, and veggies into a daily meal plan. The book provides a sample one-day menu to help parents see what theyre shooting for in terms of foods and serving sizes. Other chapters provide strategies, addressing several all-too-common healthful-eating barriers that can prevent kids from keeping their weight in check, such as watching too much TV, drinking soda and other sugar-sweetened beverages, portion distortion, fast-food hang-ups, and picky eaters aversions to fruits and veggies. Backed by scientific research, the authors say these strategies also may help healthy-weight kids from ever having to deal with the unwanted physical and emotional dilemmas that come with being overweight or obese. To finish up this book, three weeks of sample menus (with healthful meal and snack ideas) serve as a great resource to help parents practice their just-learned healthful strategies with fresh (and kid-approved) dinner ideas.
Cooking Vegan
By Vesanto Melina, MS, RD, and Joseph Forest 2012, Book Publishing Company Softcover, 224 pages, $19.95 Ill be the first to admit that when Cooking Vegan came across my desk, I hesitated about agreeing to be a reviewer. Despite a handful of half-hearted attempts by my husband in the past to convince me we should become vegetarian, I remain fairly committed 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 creative recipes and flavors, and the way the authors have demystified vegan ingredients. Nutrition professionals will appreciate the inclusion of a detailed and easy-to-read introduction on the vegan lifestyle, including an abbreviated explanation of vegan nutrition, a description of ingredients commonly used in vegan dishes, cooking tips, and sample menus. Additionally, nutritional information is available for every recipe, with more than just a macronutrient breakdown provided. Cooking Vegan showcases a variety of dishesbreakfast foods, sauces, dips, salads, and sweet treatsand theres something for everyone. I sampled the Fiesta Quinoa Salad With Lime Dressing; Avocado, Grapefruit, and Chipotle Dressing; Thai Pasta Salad With Spicy Peanut Sauce; and the Walnut, Olive, and Sun-Dried Tomato Tapenade. The directions were easy to understand, clearly written and, as a novice vegan eater, I especially enjoyed the short description that accompanied every recipe. Readers should take caution and note the yield, as some recipes make quite a large amount. They also should be prepared that while most ingredients are common and readily available, I did have to purchase several oils and spices that arent usually stocked in my pantry. These items were available at my local grocer but were fairly costly; I suspect that had I gone to my local specialty store, these ingredients would have cost less. But these minor considerations dont overshadow the variety of unique ideas readers can find in Cooking Vegan.
Christin L. Seher, MS, RD, LD, is a dietitian, instructor, and nutrition consultant in northeast Ohio.
PRODUCTS + SERVICES
RD Clinic Allows RDs to Streamline Their Practice

A successful weight-loss program requires a nutrition professional 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. Its 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 theyre seen by the professional, all the reports are already done. If the client doesnt 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. Theres no cost for patients to use the program, only for healthcare professionals. For more information, visit www.nutrihand.com.
Lilys Sweets Debuts Stevia-Sweetened Chocolate

Lilys Sweets has introduced the first fair trade-certified stevia-sweetened chocolate bars made with 55% cocoa. Lilys 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 halfbar serving. The bars come in four flavors: Original, Crispy Rice, Coconut, and Almond. In addition, Lilys Sweets donates a percentage of its profits to organizations that support childhood cancer survivors and fighters. For more information, visit www.lilyssweets.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 doesnt 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 oatmeal. Its available in single-serve packets. For more information, visit www.intheraw.com.
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 natures richest plant sources of essential fatty acids, and cell-protecting antioxidants. The oil has no odor and a very mild flavor, so its easy to add to smoothies, soups, or sauces or use to create salad dressings. For more information, visit www.foodsalive.com.
NATIONWIDEWYAZ
Dietitian - Diabetes Education

Education and Experience Bachelors degree in Nutrition or Food Science with completion of clinical dietitian internship program or equivalent is required. Certicates, 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. Certied Pump Trainer is preferred.
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; enteralparenteral nutrition delivery.
Connect
TO A CAREER THAT NOURISHES YOUR HEART

Passion. Dedication. Knowledge. Motivation. Experience. These are the impressive qualities youll 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 creates diverse experiences and challenging career opportunities. When you join the Fresenius Medical Care team, youll be welcomed into a company that is built on the philosophy that our employees are our most important asset.
To apply, visit our website at www.wyomingmedicalcenter.org.
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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.
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Vol. 14 No. 10
October 2012
October 2011
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Todays Dietitian Teeming Investigates the Fragrant, Flavorful, Sugar Debate Health Benets
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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 its not necessary to
Lustigs argument, however, is not about the consumption of empty caloriesand biochemists have made the same case previously, though not so publicly. It is that sugar has
The Great Salt Debate

Experts Support Salt Restrictions Cardioprotective Effects
Todays Dietitian investigates the sugar debate.
9 Probiotic-Rich
Beyond Yogurt
Foods
Healthier Frozen Take By Juliann Schaeffer Foods Center Stage Dairys Role in Improving School Nutrition
ian.com www.TodaysDietit
New Research Pressure Soy Lowers Blood

Plus 25 Soy Foods to Tell Clients About
ccording to the 1964 Walt Disney musical Fast forward to today, when Americans are consuming lunch, and dinner table each day. Mary Poppins, just a spoonful of sugar helps even more of the sweet stuff. According to the USDA, per We shake a little here, a little extra the medicine go down. But while sugar may capita consumption of caloric sweeteners, mainly sucrose there to get our food to taste just help the medicine go down, you dont hear and corn sugars, increased 39% right between before wethe dig 1950s in. Andand we do 1 this in of addition to per eating processed and resPeoplefoods are now anyone singing these praises anymore. 2000 to an average 152 lbs year. taurant fare on a regular basis,per which experts eating an average of about 30 tsp of sugar day, whichsay Instead, many Americans and those in the healthcare com2 where most our per sodium comeswith from. And along contributes a is whopping 476of kcal day.intake munity claim Sugar is toxic. Sugar causes obesity. Butintake is all ofhas thiscome sodium were eating really the rise in sugar a growing sense of damdread Sugar makes you fat. aging our long-term cardiovascular health? Or is among the public over the potential health fallout. FindFor decades, both consumers and health experts have what weve heard thus far a bit of an exaggeration? ings from the International Food Information Council Founbeen pondering the potential negative health effects Recently, a media restorm erupted over a dation 2012 Food & Health Survey revealed consumers related to sugar consumption. The classic 1986 book Sugar July report in the Cochrane Database of Systemattitudes about sugar and health. Consumers were asked Blues by William Dufty exploded onto the sugar-busting atic Reviews , also appearing simultaneously in the which calorie sources (sugars, carboscene. People were shocked to read American Journal of Hypertension, which seemed fats, protein, or allrestriction sources) they were consuming, on average, 100 into question the basis for salt By Sharon Palmer, RD to callhydrates, they believe are more responsible for lbs of sugar per year.
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Experts Stand Exper Beh Behind Salt Restrictions Cardioprotective Effects
an you pass the salt? is a common question we hear at the breakfast,
unique characteristics, specifically in the way the human body completely eliminate to lose weight, only 28% recommendations. Aftersugar researchers looked at the data of believed 6,500 the historical evidence on the link between sodium, hypertension, metabolizes the fructose in it, that make it singularly all sugars (including high-fructose corn syrup [HFCS], table participants, they concluded that the cardioprotective benets of and cardiovascular disease (CVD) risk and offermay some strategies harmful if consumed in tough sufficient quantities.5 sugar, and honey) are similar used by the body in the same salt restriction couldnt be provenand based on current evidence. you can use to answer your clients questions. way. Fifty-one percent of Americans are trying to limit Shortly after this controversial meta-analysis hit the air- or avoid Professionals waves, two U.K. preventive medicine experts quickly countered Is SugarTake Really Dangerous? sugars when choosing foods and beverages, while 35% pay no Probably to the dismay consumers, dietitians and these claims. They reanalyzed Lustigs views of on sugar andmany health bring to light the crux of attention to sugar content.3 the same data and concluded in doctors overwhelmingly agreed with the follow-up conclusions to a comment in the July 30 issue of The Lancet that the results of the sugar argument, raising the question, is there proof that the the controversial Cochrane ndings and say they no of empty our reanalysis, contrary to the claims by Taylor and colleagues, Sugar Hits the Airwaves negative impact of review sugar extends beyond its have provision plans to change their sodium recommendations anytime soon. support current public-health recommendations to reduce salt Whats fueling the publics sugar fears? Consumers have calories? Clearly these ndings are far out in left eld and do not intake in the whole population. been hearing for years the stories linking sugar to hyperactivThe concept that sugar is toxic simply has no credibility, reect the overwhelming amount of strong scientic evidence Many in the medical community as well as the RDs interity, diabetes, obesity, and other chronic diseases, says Jean-gathered says David M. Klurfeld, PhD, national program leader for the over decades that supports the fact that reducing viewed by Todays Dietitian agree with the U.K. researchers nie Gazzaniga-Moloo, PhD, RD, a national spokesperson for sodium Human Nutrition USDA Agricultural Research Service, who intake reduces blood pressure, thereby reducing risk assessment. the Academy of Nutrition and Dietetics (the Academy). edited a June 2009 Journal of leading Nutrition supplement of cardiovascular disease, our nations cause of death,The State Salt is a vital nutrient required for the body to function Theyve also heard reports disputing connections between sugar all says of the Science on Dietary of the Cochrane report. Sweeteners Containing Fructose. properly, wrote Janet Bond Brill, PhD, RD, CSSD, in Prevent a andBrill these conditions. I8 think many consumers are confused about She Theres little doubt that Americans consume refers to one such piece of evidence to back up hertoo much sugar, Second Heart Attack: Foods, 8 Weeks to Reverse Heart Disease. stance but in Prevent a Second Heart Attack. A recent study pubYet while role essential in small amounts, consuming too much sugars in disease development and management. we have no data to tell us how much is too much for any the April 2007 issue of BMJ concerning a group of saltThe has led manyon Americans to associate the nutrient with an volume the sugar-health debate turned up a notch lished in health endpoint we ask about. individuals with borderline to highMD, blood pressure that unfortunately all-too-common ailment: high blood pressure, a when a recent wave of media reports called on the opinions of Walter Willett, DrPH, chair of thefound department of nutricutting back on their salt intake slashed their risk of developing leading risk factor for heart disease. Robert H. Lustig, MD, a professor of pediatrics in the division tion at the Harvard School of Public Health, says, There are heart disease by 25% and of dying of the disease by up to 20%. High blood pressure is extraordinarily common in the United of endocrinology at the University of California, San Francisco, problems with sugar due to adverse metabolic effects, but the The researchers surmised that sodium acts directly on blood States, affecting approximately one-third of the adult populawhos a leader in the antisugar movement. Lustig has spoken idea that fructose is dangerousthe science doesnt support vessel walls, stiffening them and making them more susceptition, Brill says. Hypertension is a powerful and unequivocal out at several recent nutrition conferences on the adverse ble to atherosclerosis. this. To only focus on sugar as the problem, the science isnt independent risk factor for cardiovascular and renal diseases, health effects of sugar, including the Annual Nutrition there. There may be subtle metabolic differences study, published in the February 2010 issue of The in the body including coronary heart disease, stroke, and renal failure. & Health Another Conference the Experimental Biologyand meeting. with fructose. Cutting back on sugar isifan important New England Journal of Medicine , concluded that everyone cut part of a Despite majorand advances in the understanding treatment Lustig reported at the Annual & Health Confer- salt intake healthful along with cutting back on to refined starches and there would be close 100,000 by justdiet, a 12 tsp/day, of hypertension over the past severalNutrition decades, the disease ence in the May 2011 that fructose intake, an egregious component fruit juice, which thethe same glycemic loadfrom as sugar. fewer heart attacks each have year and number of deaths remains most common primary diagnosis in the United drop by up to 92,000Heart annually, Brill says (AHA) of another States is a major public health concern, she adds. in theand Western diet, has doubled over the past 30 years from CVD all would The 2009 American Association Scientific Statepiece of evidence in her arsenal salt restriction. According World Health Organization (WHO) estimates, its sources,to including HFCS, sucrose, and juice. The fructosiment on Dietary Sugarsfor Intake and Cardiovascular Health In light of suchthat ndings, Brill says shes siding the has been linked hypertension causes million increases premature its deaths per year Lowfication of our food5supply palatability. reported excessive consumption ofwith sugars American Heart Association, which recommends alladverse Americans worldwide. Andhave across WHO regions,corn research indicates that quality foods high-fructose syrup added on purpose. with several metabolic abnormalities and health condiaim for consuming less than 1,500 mg of sodium per day. about 62% of strokes and 49% of heart attacks are caused by Its used as a browning agent, Lustig said. tions. Though the mechanisms are unclear, relative to other carNutrition research scientist James J. Kenney, PhD, RD, hypertension, according to Brill. He reported that our growing dependence on fructose has bohydrate sources, sugar intake appears to be associated with FACN, says he isnt surprised by the studys controversial ndIts an issue dietitians and doctors know well. Also well fueledis the obesity and type 2 diabetes epidemics and has led ings, to considering increasedwhat triglyceride a known risk factor for coronary he callslevels, the limited quality of the data known part of the popular lifestyle prescription to help increased energy intake, decreased resting energy expenditure, heart disease, and some studies show that a higher the authors had to work with. Given how hard it is to get an consumption patients ght or prevent hypertension and heart disease: excessrestriction. fat deposition, nonalcoholic fatty liver disease, insulinaccurate of measure high-sugar beverages foods is associated of peoples saltand intake over the long termwith and increased sodium resistance, hyperglycemia, cardiovascular disease, and metainflammation and stress, according to the the AHA. how hard it is for people tooxidative really restrict their salt intake, Irrefutable scientic evidence supports the fact that reducfailure of the Cochrane review to nd low-salt reduce CVD coning sodium intake,in [as well as] increasing potassium intake, bolic syndrome humans. While acknowledging that obesitydiets is a multifactorial and total mortality isnt surprising, he explains. lowers blood pressure. Myriad randomized controlled cliniLustig has become a hit among mainstream audiences, dition, its likely that Americans recent history of weight gain the authors conclusions actually re ect the forsugars, cal trialsto collectively have demonstrated bene ts of sodium thanks his YouTube lecture Sugar:the The Bitter Truth, which He says must be related in part to increased intake ofneed added better data on the impact of long-term salt restriction on CVD to confirm reduction for blood pressure control in hits bothto normotensive and has received more than 2.6 million date. In April, 60 Mineven though research thus far has been insufficient and total mortality. Keep in mind, a similar review article pubhypertensive Brill says. She says people with asugar and utes aired a individuals, segment featuring Lustig as an expert on a direct link, the AHA stated.2 lished in [The American Journal of Clinical Nutrition in March] blood pressure of greater than or equal to 130/85 have a 1.5 to Most everyone agrees that the increase in sugar intake has health. He reported that sugar is toxic and that its to blame for 2.5 times greater risk of experiencing a heart attack than those 4 last year failed to nd an association between saturated fat led to a sea of unwanted calories. The Dietary Guidelines for the public health crisis more than any other food substance. intake and CVD events. Nevertheless, theres a known impact of with a blood pressure value of less than 120/80. One year earlier, Lustig was featured in a New Times saturated Americans report that added sugars are consumed fat and salt on LDL cholesterol and blood pressure, in excessive So whats the real story? Such con icting reports canYork create article titled Is Sugar Toxic? written by Gary authorrespectively, amounts, resulting in a high intake of calories that offer little in controlled clinical trials, he says. What these confusion, especially when clients catch only half theTaubes, story on the of Good Calories, Bad Calories , who shares similar views with data suggest nutritional However, the guidelines state is the payback. failure to nd an association in studies thatthat foods nightly news. As patients come calling with questions, salt shaker Lustig. Sugar isnt just an empty calorie, Lustig says in the artiwith added sugars are no more likely to contribute measured these parameters inaccurately. The data is of little to weight at the ready, youll need to know how to respond to their sodium importgain and shouldnt clinical decisions. queries. the following article, nutrition evaluate cle; its In effects on us are much moreprofessionals insidious. Its a poison by than anyalter other source of calories in an eating pattern thats itself, Lustig was quoted as saying. Taubes wrote: within calorie limits.6
todays dietitian october 2011
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uma 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. Were proud of the caring culture weve created for our patients and employees.
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NEWS BITES
Mindful Eating Lowers Weight, Blood Sugar in Diabetes

Eating mindfully, or consuming food in response to physical cues of hunger and fullness, is just as effective as adhering to nutrition-based guidelines in reducing weight and blood sugar levels in adults with type 2 diabetes, suggests a new study published in the November issue of the Journal of the Academy of Nutrition and Dietetics. In a comparison study of the effectiveness of the two types of behavioral interventions, participants lost about the same amount of weightan average of between 312 and 6 lbsand lowered their long-term blood sugar levels significantly after three months. One treatment group followed an established diabetes self-management education program, with a strong emphasis on nutrition information. The other group was trained in mindful meditation and a mindful approach to food selection 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 different 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 mindful meditation was applied specifically to eating and food choices. This intervention group didnt receive specific nutrition goals. We said we want you to really tune into your body before you eat. Take a few minutes to assess how hungry you are and make conscious choices about how much youre eating. Stop eating when youre full. We studied two very different approaches, and we found they both worked, Miller says. Participants were between the ages of 35 and 65 and had been diagnosed with type 2 diabetes for at least one year. To be eligible, participants had to have a BMI of 27 or higher, indicating they were overweight, and a hemoglobin A1c (HbA1c) reading of at least 7%. Study participants were randomly assigned to a treatment group. Twenty-seven completed the mindful eating program, and 25 completed the traditional diabetes selfmanagement program called Smart Choices. Each intervention involved eight weekly and two biweekly 212 -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 studys end. Weight loss and improvements in HbA1c levels were similar for both groups at the six-month follow-up point. Smart Choice participants as a group lost more weight, an average of 6 lbs, than did the mindful eating group, which lost an average of 3.5 lbs, but the difference wasnt significant when analyzed statistically, Miller says. HbA1c levels dropped in both groups as well between about 0.7% and 0.8%. That was a clinically meaningful reduction in Hba1c, equivalent to what youd get on some diabetes medications, Miller says. If the reduction were sustained over time, it would mean a dramatic reduction in complications associated with diabetes. Both groups also similarly reduced calorie intake and lowered 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 mindful meditation and eating option as a potential supplement to basic diabetes education. She also said that participants adapted well to the concept of mindfulness even though its generally considered an alternative health practice. One of the things we were evaluating was how well this was accepted by people who had no experience with it. It was very well accepted by participants in that group, and this tells us that people with diabetes have choices, Miller says. The fact that both interventions were equally effective suggests we should let people choose. If mindful meditation is appealing and people think that approach is effective, then it very well could be the best choice for them.
SOURCE: OHIO STATE UNIVERSITY
High-Carb Diet Associated With Colon Cancer Recurrence

Colon cancer survivors whose diets are heavy in complex sugars and carbohydrate-rich foods are far more likely to have a recurrence of the disease than are patients who eat a better balance of foods, indicates a new study by Dana-Farber Cancer Institute researchers. The connection is especially strong in patients who are overweight or obese, the authors wrote. More than 1,000 patients with advanced (stage 3) colon cancer participated in the study, one of the first to examine how diet can affect the chances that the disease will recur. The findings are being published online by the Journal of the National Cancer Institute. Although the results point to a potential hazard of a highcarbohydrate 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 responsible for the increased risk of recurrence. The study involved 1,011 stage 3 colon cancer patients who had undergone surgery and participated in a National Cancer Institute-sponsored Cancer and Leukemia Group B clinical trial of follow-up chemotherapy for their disease. Participants reported their dietary intake during and six months after the trial. Researchers tracked the patients total carbohydrates as well as their glycemic index and glycemic load and looked for a statistical connection between these measures and colon cancer recurrence. They found that participants with the highest dietary levels of glycemic load and carbohydrate intake had an 80% increased risk of colon cancer recurrence or death compared with those who had the lowest levels. Among patients who were overweight or obese (BMI above 25), the increase was even greater. In light of our and others research, we theorize that factors including a high glycemic load may stimulate the bodys production of insulin, Meyerhardt says. That, in turn, may increase the proliferation of cells and prevent the natural cell-death process in cancer cells that have metastasized from their original site. Meyerhardt adds that while the study doesnt prove that diets high in glycemic load and carbohydrate intake cause recurrence of colon cancer, the results strongly suggest that such dietary factors play a role. Our findings may offer useful guidance for patients and physicians in ways of improving patient survival after treatment, he says.
SOURCE: DANA-FARBER CANCER INSTITUTE
High Vitamin D Levels May Protect Mothers Against MS

Pregnant women who have higher levels of vitamin D in their blood may have a lower risk of developing multiple sclerosis (MS) than women with lower levels, while their babies may not see the same protective effect, according to a study published online in Neurology. In our study, pregnant women and women in general had a lower risk for MS with higher levels of the vitamin, as expected. However, a mothers levels of vitamin D during early pregnancy didnt have an effect on MS risk for her baby, says study author Jonatan Salzer, MD, with Ume University Hospital in Sweden. For the study, scientists reviewed information about 291,500 blood samples from 164,000 people collected since 1975 in the northern half of Sweden. Of those, 192 people developed MS an average of nine years after their blood sample was drawn, and there were 37 blood samples drawn during pregnancy from mothers whose children went on to develop MS later in life. 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. Overall, few people had high levels of vitamin D. Only seven of the 192 people (4%) who developed MS had high vitamin D levels compared with 30 of 384 controls (8%) without the disease. No association was found between the mothers vitamin D level and whether her child would later develop MS. Since we found no protective effect on the baby for women with higher levels of vitamin D in early pregnancy, our study suggests the protective effect may start in later pregnancy and beyond, Salzer says. Another interesting finding in our study was that the vitamin D levels became gradually lower with time from 1975 and onward. Its possible that this decline in vitamin D status is linked to the increasing numbers of MS cases seen worldwide.
SOURCE: AMERICAN ACADEMY OF NEUROLOGY
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.
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-bystep 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 philanthropy, fighting both hunger and obesity through her nonprofit organization, Chefs for Humanity. But the most motivating of her endeavors? No question, its her four boys: My kids inspire and motivate me every single day. Todays Dietitian (TD): Iron Chef, TV host, contributing editor for O, The Oprah Magazine: Whats next? Cora: I just opened a new Cat Coras Kitchen restaurant at the Salt Lake City Airport and hope to open more across the country soon. Im also putting the final touches on a shoe line, which will be available [sometime in 2013].
CAT CORA
An Iron Chef With a Heart for Combating Hunger

By Juliann Schaeffer
As one of the newest membersand the first female inducted into the Culinary Hall of Fame, its no secret Cat Cora knows her way around a kitchen. First employing her cooking prowess in 2005 to best the brightest of culinary stars as the firstand onlyfemale Iron Chef on Food Networks Iron Chef America (for which she may be most recognized), now the celebrity chef is utilizing social media technology to bring those top-rate cooking skills to the masses with a new iPad app. Called Cat Coras Kitchen, the app not only gives users delicious recipes but also assists users in organizing their time via a scheduler that includes step-by-step instructions and estimated completion times for each dish.
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, 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 and improve nutrition for children and families 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 displaced victims.
Recognizing that chronic hunger and malnutrition is an ongoing disaster for so many people, Chefs for Humanity is committed to mobilizing those with needed skills and passion to help every day as well as in times of crisis. TD: How does Chefs for Humanity work to prevent hunger and reduce obesitytwo causes close to the hearts of many dietitiansand whats your proudest accomplishment of the organization thus far? Cora: Chefs for Humanity works to prevent hunger and malnutrition, which includes obesity, by raising support and awareness and developing programs to address these issues. There are many accomplishments were proud of but, most recently, were working to establish a Global School Gardens initiative to help educate children about good nutrition while connecting them to the culinary community and engaging local chefs, restaurants, and others to ensure that healthful eating and affordable access to good food is a communitywide effort.
TD: Is there one product in your specialty food line that you couldnt live without in your own kitchen? Cora: I cook with my award-winning Cat Coras Kitchen BY GAEA organic olive oil almost daily. Its the first-ever bottled olive oil to be completely carbon neutral. TD: Whats your favorite family recipe and why? Cora: I love my moms Greek Cinnamon Chicken recipe (see below). It was my absolute favorite growing up; my mom would make it on special occasions like holidays, birthdays, and anniversaries. 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
Ingredients
1 chicken (212 to 3 lbs), cut into eight pieces 1 tsp ground cinnamon 2 tsp kosher salt 1 tsp freshly ground black pepper 5 peeled garlic cloves, minced 2 T extra-virgin olive oil 2 peeled, coarsely chopped medium yellow onions 1 2 cup dry white wine 1 cup water 1 cup chicken stock One 6-oz can tomato paste 1 T fresh oregano, chopped 1 2 cup grated Mizithra cheese
Instructions
1. Pat the chicken dry with paper towels. A wet chicken will cause the oil to splatter while the chicken is sauting. Mix the cinnamon, salt, and pepper in a small bowl. Rub the chicken pieces on all sides with the seasoning. 2. Mince three of the garlic cloves. Heat the olive oil in a large nonreactive deep skillet over high heat. A 12-inch skillet with sides about 212 to 3 inches high will allow you to brown all the chicken at once. If you dont have a skillet large enough, brown them in two batches using one-half of the
oil for each batch. Whats important is that the chicken isnt overcrowded, which would cause the pieces to steam rather than brown. 3. Add the chicken to the oil and brown for about 4 to 5 minutes on each side. Turn the pieces using a metal spatula, as they have a tendency to stick to the pan. Remove the pieces when theyre well browned on all sides. 4. Lower the heat to medium-high and add the onions and minced garlic. Cook for about 3 minutes, stirring constantly, 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 particles stuck on the bottom. 5. When the wine has evaporated, add the water, chicken stock, tomato paste, fresh oregano, and remaining two garlic cloves. Return the chicken to the pan. The liquid should cover about 34 of the chicken pieces. Cover the pot and simmer over low heat for about an hour or until the chicken is tender and thoroughly cooked. If the sauce becomes too thick, it can be thinned with a little more water. Season the finished sauce with kosher salt and pepper to taste. 6. Serve the chicken topped with the sauce and sprinkle with Mizithra cheese.
Nutrient Analysis per serving

Calories: 560; Total fat: 18 g; Sat fat: 6 g; Trans fat: 0 g; Cholesterol: 174 mg; Sodium: 1,113 mg; Total carbohydrate: 19 g; Dietary fiber: 3 g; Sugars: 9 g; Protein: 74 g
DATEBOOK
FEBRUARY 9, 2013
MARCH 7, 2013
APRIL 2-6, 2013
AMERICAN DIABETES ASSOCIATION DIABETES EXPO Denver, Colorado www.diabetes.org

FEBRUARY 9-12, 2013
TENNESSEE ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETING www.eatright-tn.org

MARCH 14-17, 2013
NATIONAL KIDNEY FOUNDATION SPRING CLINICAL MEETINGS Orlando, Florida www.nkfclinicalmeetings.org

APRIL 4-6, 2013
AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION CLINICAL NUTRITION WEEK Phoenix, Arizona www.nutritioncare.org/cnw
FEBRUARY 22-26, 2013
HEALTHY KITCHENS, HEALTHY LIVES: CARING FOR OUR PATIENTS AND OURSELVES Offered by the Harvard School of Public Health and The Culinary Institute of America Napa Valley, California www.healthykitchens.org
MARCH 19-21, 2013
MISSOURI, IOWA, NEBRASKA, AND KANSAS DIETETIC ASSOCIATIONS ANNUAL CONFERENCE Overland Park, Kansas www.eatrightnebraska.org
APRIL 5-6, 2013
AMERICAN ACADEMY OF ALLERGY, ASTHMA & IMMUNOLOGY ANNUAL MEETING San Antonio, Texas http://annualmeeting.aaaai.org
FEBRUARY 28 MARCH 1, 2013
WEST VIRGINIA ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETING Huntington, West Virginia www.wvda.org
MARCH 19-22, 2013
ILLINOIS DIETETIC ASSOCIATION SPRING ASSEMBLY Oak Brook, Illinois www.eatrightillinois.org

APRIL 5-6, 2013
GEORGIA ACADEMY OF NUTRITION AND DIETETICS ANNUAL CONFERENCE & EXHIBITION Stone Mountain, Georgia www.eatrightgeorgia.org
MARCH 2, 2013
AMERICAN DIABETES ASSOCIATION DIABETES EXPO Salt Lake City, Utah www.diabetes.org
EPIDEMIOLOGY AND PREVENTION/ NUTRITION, PHYSICAL ACTIVITY, AND METABOLISM SCIENTIFIC SESSIONS New Orleans, Louisiana www.my.americanheart.org/ professional/index.jsp
SOUTH CAROLINA ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETING Columbia, South Carolina www.eatrightsc.org
APRIL 11-13, 2013
ADVERTISER INDEX
For advertising information, please call 800-278-4400 or visit our website at www.TodaysDietitian.com.
CALIFORNIA DIETETIC ASSOCIATION ANNUAL MEETING AND EXHIBITION 800+ dietetic professionals, 75+ exhibits Santa Clara Convention Center Santa Clara, California www.dietitian.org
Bakery On Main, www.bakeryonmain.com...............................................................................................27 beBetter Health, Inc., www.theportionplate.com. .................................................................................... 19 Cell Science Systems, www.alcat.com. ....................................................................................................23 Cera Products, Inc., www.ceraproductsinc.com......................................................................................65 CinSulin, www.cinsulin.com. .....................................................................................................................68 Daisy Brand Cottage Cheese, www.daisybrand.com/cottagecheese...................................................4, 5 Dietmaster Systems, www.dietmaster.com.............................................................................................65 Dr. Lucys, www.drlucys.com....................................................................................................................65 ESHA Research, www.esha.com. ................................................................................................................ 3 Glutenfreeda Foods, Inc., www.glutenfreedafoods.com www.glutenfreeda.com...................................54 Ians Natural Foods Inc., www.iansnaturalfoods.com.............................................................................. 15 Jackson PEG Tube Stands, www.jacksonpegtubestands.com.................................................................65 Kibow Biotech, Inc., www.kibow.com.......................................................................................................55 Konsyl Pharmaceuticals, www.konsyl.com.............................................................................................. 67 Nestle Ocean Spray, www.oceanspray.com............................................................................................... 7 NoGii, www.nogii.com. ................................................................................................................................ 9 The Nutrition Company, www.nutritionco.com........................................................................................65 Walden Farms, www.waldenfarms.com. ..................................................................................................... 2 Wisdom Natural Brands, www.sweetleaf.com. ......................................................................................... 11
This index is a service to our readers. The publisher assumes no liability for errors or omissions.
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 TDeditor@gvpub.com Send Write with your listing two months before publication of issue.
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SOLID BASE FOR STABILITY
CULINARY CORNER
Quinoa Salad With Roasted Garlic

While this recipe gives directions for cooking 1 bulb of garlic, you can easily roast two or three at a time for later use. This salad is great garnished with feta cheese. Serves 6 as a side dish
Ingredients
1 garlic bulb 1 cup water 3 4 cup quinoa 1 4 cup red wine vinegar 3 T fresh lemon juice 3 T extra-virgin olive oil 2 tsp Dijon mustard 1 2 tsp fine sea salt 3 4 tsp black pepper 1 red bell pepper, stemmed, seeded, and chopped 1 cup diced English cucumber 1 cup fresh cilantro leaves, coarsely chopped 2 scallions, sliced thin 1 4 cup sliced red onion 1 4 cup cashew pieces
GARLIC
One of Natures Brightest Bulbs

By Bryan Roof, RD, LDN
My mother used to tell me that the secret to her cooking was salt, pepper, and garliclots of garlic. Shed make potent Caesar dressings, bracingly sharp aiolis, and fragrant garlicrubbed roast chicken. I loved her cooking because of it. We never understood how people could dislike garlic. (Some people are just plain crazy, I suppose, with their fear of garlic breath.) She added garlic for flavor and flavor alone long before it was eaten for its health benefits. Garlic has been found to reduce cholesterol and blood pressure, improve circulation and immune function, and lower overall cancer risk. Not bad for something that tastes so good. Garlic imparts its flavor based on how its prepared before cooking. By crushing, mincing, or pureing garlic, you release its essential oils, the bulk of its potency. You could stick a whole head of unpeeled garlic into a braise or stew and still not impart as much oomph as a few finely minced cloves. When shopping for garlic, opt for fresh bulbs over the prepeeled or the prechopped stuff in a jar, which bears little resemblance to its fresh counterpart. Prepeeled garlic is inarguably convenient, but the blanching process that removes the skin also robs it of some of its flavor. Look for firm, fresh bulbs with taut papery skin. Once you get it home, store garlic in a cool, dark place, such as a kitchen cupboard. While Im a true garlic fan, I realize many people dont share the same affinity for its aggressively strong flavor. So for you, well turn to roasting. Roasted whole, the cloves develop a pleasant sweetness that even haters seem to fancy. You can use roasted garlic for any number of dishes, from bruschetta to salad dressing to pasta sauce. Youll still get all the health benefits and most of the flavor but less of the garlic breathif youre at all concerned.
Bryan Roof, RD, LDN, is a chef, dietitian, and food writer living in Boston. Follow him on Twitter at @bryanroof.
Directions
1. Adjust the oven rack to the middle position and heat the oven to 350F. Cut off the top 14-inch stem of the garlic bulb and discard. Wrap the bulb in aluminum foil and roast until tender and fragrant, 1 to 114 hours. Let the foil-wrapped garlic sit at room temperature until cool enough to handle. 2. Meanwhile, bring water to a boil in a small saucepan 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, mustard, 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 carbohydrate: 23 g; Dietary fiber: 3 g; Sugars: 4 g; Protein: 5 g
0.25g
0.44g
0.49g
0.90g
0.67g
1.09g
0.94g
Which serving has the most sol soluble fiber ?

0.99g 1.38g
3.0g
0.58g 1.25g
0.58g
1.12g
0.77g
1.17g
Konsyl O Original r i g i n a l Formula
yllium Fib Psyllium Fiber

0.61g
Just one teaspoon of sugar-free Konsyl Original Formula has 6 grams of psyllium fiber, equivalent to 3 grams of soluble ber thats 75% more psyllium 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 fiber also helps stabilize blood sugar levels and regulate digestion by treating constipation, preventing hemorrhoids and easing the symptoms of IBS.*
1.45g
1.36g
1.02g
1.31g
Konsyl fiber supplements have been recommended by health care professionals for over 50 years. Have you told your patients about Konsyl Psyllium Fiber?
For free professional samples, visit
0.44g
www.konsyl.com
or scan this code 0.44g
Like us on Facebook facebook.com/konsyl
0.67g
0.47g
1.51g
*These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.
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.
0.92g
0.15g
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cinnamon extract. Unlike common cinnamon products on the market, CinSulin uses a proprietary water extraction process that gently separates and concentrates the health-supporting water-soluble components in the cinnamon. The result CinSulin , a cinnamon concentrate that is 10:1 stronger than common cinnamon! Youd have to take at least 10 common cinnamon capsules to
CinSulin Water Extract of Cinnamon contains high quality concentrated
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Within the normal range ** Refers to Advanced Strength and Healthy Weight CinSulin Clinical study available upon request *These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

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Vol. 15 No.

The Magazine for Nutrition Professionals

New Years Resolutions

Help Patients Comply with your Prescribed Health Management Plan

No Calories, No Fat, No Carbs, No Gluten, No Sugars of any kind! -

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

FREE Caramel Syrup ($4.99 Value) Visit waldenfarms.com/TDJ13 for details

See Whats New at WALDENFARMS.COM

with FoodProdigy online companion

1-800-659-3742 | sales@esha.com | www.esha.com

to the healthy foods you already recommend.

Director of Continuing Education & New Business Development Jack Graham

6 todays dietitian january 2013

So much goodness for such a tiny berry.

2012 Ocean Spray Cranberries, Inc.

The Gluten-Free Journey RDs serve as a guide for patients 

Ethical Decision Making This article details the dietitians 

Meatless Monday This growing campaign encourages people

Educating Young Palates MindStream Academy is blending 

CPE Monthly: Autism Spectrum Disorder Research

solutioNs for healthy families

utter & ut B er Cara C

late Mint, C e, Choco h

out Tropical F Nuts Ab

G Chocolat e e -Fr Bliss, isp...

From Elisabeth Hasselbeck, Co-Host of ABCs The View

Available at retailers nationwide

The Magazine for Nutrition Professionals

From Our Facebook Wall

Reversing Type 2 Diabetes With Natural Therapies

Gluten-Free Kitchen Essentials Helping Clients With Binge Eating Disorder

From Our Twitter Page

The Real Scoop on Sugar

Combating Clostridium Difficile

10 todays dietitian january 2013

Natures Sweet Solution

ZERO CALORIES ALL NATURAL

ZERO CARBS GREAT VALUE

LOOK FOR US IN YOUR GROCERY AND NATURAL FOODS STORES.

BUY ONLINE: SWEETLEAF.COM

ASK THE EXPERT

COOKING WITH KIDS

12 todays dietitian january 2013

The Magazine for Nutrition Professionals

presents a new online resource for

and their clients!

Healthy, categorized recipes

Professional guidance on diet and weight loss

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

NUTRITION SUPPORT 360

PARENTERAL NUTRITION HOME-STARTS

Evaluating the Home Environment

14 todays dietitian january 2013

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

Gluten Free Panko Breadcrumbs!

16 todays dietitian january 2013

Remote Backup Services

january 2013 www.todaysdietitian.com 17

DIABETES AND COMPLEMENTARY CARE

More Patients Are Following Alternative Diets to Manage the Disease

18 todays dietitian january 2013

Today's Dietitian Ad_12-03-12 (2-2).ai

Raw Food Diet

The Gluten-Free Journey RDs serve as a guide for patients

Ethical Decision Making This article details the dietitians

Meatless Monday This growing campaign encourages people

Educating Young Palates MindStream Academy is blending

CPE Monthly: Autism Spectrum Disorder Research