Today's Dietitian

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The Link Between Diet and Arterial Health Gluten-Free Pastas Enjoying Ancient Grains Lobster salad at The Café at the Ritz-Carlton, Buckhead ATLANTA DINING With Forks Held High, Taste this City’s Creative Reinventions of Southern Cuisine CONFERENCE ISSUE www.TodaysDietitian.com September 2014 Vol. 16 No. 9 The Magazine for Nutrition Professionals T h e L i nk B etw ee n D iet a nd Arte r ia l Healt h G l ute n-Fr ee P astas En j oy i n g An c i e n t G r a i n s Lobster salad at The Café at the Ritz- Carlton, Buckhead With Forks Held High, T aste this Cit y’s Creative Reinventions of Southern Cuisine www.TodaysDietitian.com September 2014 September 2014 V ol. 1 6 No. 9 T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T Th h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h he e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M Magazine f or Nutrition Prof essional s

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September 2014 Issue //leading news source for dietitians and nutritionists

Transcript of Today's Dietitian

Page 1: Today's Dietitian

The Link Between Diet and Arterial Health

Gluten-Free Pastas

Enjoying Ancient Grains

Lobster salad at The Café at the

Ritz-Carlton, Buckhead

ATLANTA DININGWith Forks Held High, Taste this City’s Creative Reinventions of Southern Cuisine

CONFERENCE ISSUE

www.TodaysDietitian.com

September 2014

Vol. 16 No. 9

The Magazine for Nutrition Professionals

The Link BetweenDiet and Arterial Health

Gluten-Free Pastas

Enjoying Ancient Grains

Lobster salad at The Café at the

Ritz-Carlton,Buckhead

With Forks Held High, Taste this City’s Creative Reinventions of Southern Cuisine

www.TodaysDietitian.com

September 2014September 2014

Vol. 16 No. 9

TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTThhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhheeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMagazine for Nutrition Professionals

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EDITOR’S SPOT

President & CEO Kathleen Czermanski

Vice President & COO Mara E. Honicker

EDITORIALEditor Judith Riddle

Editorial Director Jim Knaub Editorial Assistants Heather Hogstrom, Leesha Lentz

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

Janet Bond Brill, PhD, RD, CSSD, LDN; Marlisa Brown, MS, RD, CDE, CDN; Constance Brown-Riggs, MSEd, RD, CDE, CDN;

Carol Meerschaert, MBA, RD; Sharon Palmer, RDN; Christin L. Seher, MS, RD, LD

ARTArt Director Charles Slack

Graphic Designer Erin ProsiniJunior Graphic Designer Victoria Tuturice

ADMINISTRATIONAdministrative Manager Helen Bommarito

Administrative Assistants Pat Plumley, Susan YanulevichExecutive Assistant Matt Czermanski

Systems Manager Jeff CzermanskiSystems Consultant Mike Davey

FINANCEDirector of Finance Jeff Czermanski

CONTINUING EDUCATIONDirector of Continuing Education Jack Graham

Continuing Education Editor Kate Jackson Continuing Education Coordinator Leara Angello

Continuing Education Assistant Susan Graver

CIRCULATIONCirculation Manager Nicole Hunchar

MARKETING AND ADVERTISINGPublisher Mara E. Honicker

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

Marketing Coordinator Leara AngelloSales Manager Brian Ohl

Associate Sales Manager Peter J. BurkeSenior Account Executives Sue Aldinger, Gigi Grillot,

Diana Kempster, Beth VanOstenbridgeAccount Executives Victor Ciervo, Dan Healey, Patricia McLaughlin

Sales Coordinator Joe Reilly

© 2014 Great Valley Publishing Company, Inc.

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

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

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

All articles contained in Today’s Dietitian, including letters to the editor, reviews, and editorials, represent the opinions of the authors, not those of Great Valley Publishing Company, Inc. or any organizations

with which the authors may be affiliated. Great Valley Publishing Company, Inc., its editors, and its editorial advisors do not assume

responsibility for opinions expressed by the authors or individuals quoted in the magazine, for the accuracy of material submitted by the authors, or for any injury to persons or property resulting from reference to ideas or

products discussed in the editorial copy or the advertisements.

Judy

DIET AND ALZHEIMER’SIf you’ve been listening to the news lately, you’ve probably heard much discussion about the new study findings concerning the preven-tion, diagnosis, and treatment of Alzheimer’s disease. In July, about 4,000 leading experts and researchers from 75 countries attended the Alzheimer’s Association International

Conference in Copenhagen, Denmark, to present the latest groundbreaking research in dementia science.

An estimated 5.2 million Americans of all ages have Alzheim-er’s, of which 5 million are aged 65 and older and approximately 200,000 have younger-onset Alzheimer’s. Experts believe the number of Americans aged 65 and older with Alzheimer’s may nearly triple by 2050.

Most notable to nutrition professionals are results of a two-year clinical trial called The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER Study). The study of 1,260 older adults at risk of cognitive impairment and Alzheimer’s disease showed that physical activity, nutrition interventions, cognitive training, social activities, and manage-ment of heart health risk factors improved cognitive performance.

These findings present opportunities for dietitians who coun-sel middle-aged and elderly clients and patients concerned about their cognitive health or who may be showing early signs of memory loss and/or other neurological impairments. Dieti-tians can encourage clients to eat a variety of fresh fruits and vegetables, whole grains, and cold-water fish and use olive oil when cooking to boost omega-3 fatty acid intake. Research has found that such an eating pattern can slow cognitive decline and even prevent other chronic diseases.

You can learn more about the benefits of plant-based diets and physical activity and of fatty acids on other aspects of health at the Academy’s Food & Nutrition Conference & Expo next month in Atlanta, a metropolis brimming with historical sites and a distinct food scene rooted in Southern food tradi-tions. Today’s Dietitian gives you the lowdown on the hottest restaurants to visit in our annual dining guide on page 24. Visit award-winning restaurants where you can eat a wide variety of traditional Southern foods and soul food as well as Korean, Asian, Mexican, Thai, and Indian cuisine with and without a Southern twist—or should I say Southern twang?

Also be sure to read the other articles in this issue on arte-rial health and diet, gluten-free pastas, electronic medical records, and the gut microbiome.

Please enjoy the rest of the issue. See you in Atlanta!

Judith [email protected]

4 today’s dietitian september 2014

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FEATURES

24 Atlanta Dining If you’re headed to the Academy’s Food & Nutrition Conference & Expo next month, get ready to discover Atlanta’s intriguing dining scene. Today’s Dietitian asked some of Atlanta’s top food experts to weigh in on what’s hot in the city’s food scene.

32 The Link Between Diet and Arterial Health It isn’t just about elevated cholesterol levels.

36 Gluten-Free Pastas Here’s a review of the new options on the market plus cooking tips for delicious homemade meals.

42 Electronic Medical Records Transitioning from paper charts to EMRs can facilitate patient visits and help you run your practice more efficiently.

46 Enjoying Ancient Grains From amaranth to quinoa, they offer a wealth of nutrients and can add much-needed variety to your clients’ and patients’ diets.

52 The Frailty Syndrome Although it lacks a standardized clinical definition, the frailty of older adults demands special considerations in terms of treatment and nutritional needs.

56 CPE Monthly: Curcumin and Inflammatory Diseases This continuing education course reviews inflammation’s impact on most chronic disease states, curcumin’s potential role in preventing and treating these diseases, and evidence-based recommendations for dietary intake of curcumin.

DEPARTMENTS

4 Editor’s Spot

8 Reader Feedback

10 Ask the Expert

12 Digestive Wellness

14 Focus on Fitness

16 Get to Know…�

18 Foodservice Forum

21 Food for Thought

64 Supplement Spotlight

66 Enteral and Parenteral Nutrition

68 Bookshelf

70 Products + Services

72 News Bites

76 Conference Showcase

78 Research Briefs

80 Personal Computing

81 Datebook

82 Culinary Corner

CONTENTS SEPTEMBER 2014

Today’s Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published monthly by Great Valley Publishing Company, Inc., 3801 Schuylkill Road, Spring City, PA 19475. Periodicals postage paid at Spring City, PA, Post Office and other mailing offices. Permission to reprint may be obtained from the publisher. REPRINTS: The Reprint Outsource, Inc.: 877-394-7350 or e-mail [email protected] NOTE: For subscription changes of address, please write to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Changes of address will not be accepted over the telephone. Allow six weeks for a change of address or new subscriptions. Please provide both new and old addresses as printed on last label. POSTMASTER: Send address changes to Today’s Dietitian, 3801 Schuylkill Road, Spring City, PA 19475. Subscription Rates — Domestic: $14.99 per year; Canada: $48 per year; Foreign: $95 per year; Single issue: $5. Today’s Dietitian Volume 16, Number 9.

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READER FEEDBACK

From Our Facebook Page

“Obesity: We’re Not Overeating, We’re Under-Exercising, Study Suggests”www.latimes.com

Amy Parker: While lack of exercise is a contributing factor to the rise in obesity, you simply cannot outexercise a poor diet. I also find that people have no idea how many calories they con-sume and would be shocked if they recorded everything they ate. Unfortunately, there are too many factors that play into obesity for us to try and peg it on one thing.Tina Peebles: I really think it’s both, and we should focus on both. However, if the evidence shows that this is really the case, we should be tackling this issue as well. Many schools have drastically reduced the amount of recess and time for physi-cal activity kids get and replaced it with time sitting at a desk. Workplaces need to put more effort into programs that give their employees time and resources to exercise. This problem is especially difficult among the poor. If you work two or three jobs to get by, it’s really hard to have the time and energy to exercise, and there is sometimes no place to do it in poverty-stricken neighborhoods. We fail to realize a lot of the time that having the time to exercise and focus on fitness is a luxury.Angelique R. Gertig: I, for one, as a dietetics student, don’t see any single thing as the biggest problem. I think it’s a few factors of our society. Overeating/portion sizes is one problem, but lack of exercise is certainly another one. I think the best solution for a healthy future for anyone must include addressing both eating behavior and exercise. I know plenty of “fat” people who are

eating lots of fruits and veggies, juicing, etc, but their portions are too big, and they get no exercise.Pattie Gibbons: The study refers to one of the caveats of the data being that people were self-reporting their caloric intake. It is my experience that unless one writes down, weighs, and measures everything that is ingested, the caloric energy intake will be skewed. Unless one is trained in food measurements, the food industry packages foods in such a way that a package may seem to a layperson to be a serving. While people don’t move as much as they should, I don’t think we, as professionals, can take this latest statistical finding as a cure-all for obesity, as the title of the study suggests.Kurt Carlan: It is said that “sitting is the new smoking.” Regard-less of weight, there are many studies showing that physically active people are healthier than their sedentary counterparts. I would like to see more of an emphasis on being active (for example, gardening) than planned exercise. That’s hard for me to suggest since I love to exercise!

From Our Twitter Page Popular Tweets, Retweets

July Issue

“Diabetes and Cardiovascular Damage”

@MountSinaiRDs: We love this review from Today’s Dietitian on antioxidants and decreasing your risk of chronic disease.

“Veggies at Breakfast”

@cmeebert: Veggie browns are a good option!

@alisbaig: I love veggies at breakfast! Sometimes there’s nothing better than a salad to start the day! Great tips for getting more in.

@lizdunn: Put kale in my smoothie before I noticed the “Veggies at Breakfast” article.

@KConnaherRD: My fave is a veggie omelet!

“Understanding Facts Up Front” (Ask the Expert)

@NutritionistaRD: The Facts Up Front is another gimmick to fool consumers into thinking many hyperprocessed foods are healthy.

Substituting Palm OilTrans FatIs Palm Oil a Good Alternative for Human Health and the Environment?

forSpring SymposiumHighlights

Diabetes andCardiovascular Damage

Tips for Adding More Veggies at Breakfast

RDs Debate the FDA’s Proposed Nutrition Facts Label

July 2014

Vol. 16 No. 7

The Magazine for Nutrition Professionals

CONFERENCE ISSUE

www.TodaysDietitian.com

8 today’s dietitian september 2014

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The USDA recommends3 servings of dairy every day.

Makeyogurtone ofthem!

The American diet is more unbalanced than ever and in a state of crisis. Americans consume only about half of the USDA recommended daily servings of low fat and fat free dairy. Yogurt is a convenient, nutrient-dense food that contributes to the recommended 3 daily servings of dairy. Most yogurts contain nutrients that are lacking in the American diet, including calcium, vitamin D and potassium. Yogurt can be an excellent source of high-quality protein, which helps with satiety, and promotes muscle and bone health. Recent epidemiological studies in healthy populations also show that frequent yogurt consumption, as part of a healthy diet,is associated with less weight gain over time, healthy levels of systolic blood pressure and circulating glucose within the normal range. Eating one yogurt every day is an important first step toward creating a more balanced diet and a healthier lifestyle, and improving public health.

them!

The American diet is more unbalanced than ever and in a state of crisis. Americans consumeonly about half of the USDA recommended

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BUILD A BETTER SMOOTHIEBy Toby Amidor, MS, RD, CDN

Q:Smoothies are popular among my clients, but what tips can I provide them on how to make healthier smoothies?

A:Smoothies are a quick and easy breakfast or snack, but without careful planning, the number of calories

and the sugar content easily can get out of control. Dietetic professionals should provide clients with simple and creative ideas on how to build delicious smoothies that can be part of any healthful eating plan.

Common Smoothie TrapsClients may be convinced that they’re eating properly by

combining numerous healthful ingredients into their smoothies. However, they may be unknowingly sabotaging smoothie quality by making the following common mistakes:•Large portions: Using 16- or 20-oz glasses easily can bring

calories up to 500 or more per serving.•High-fat ingredients: Avocados and nut butters are delicious

ways to add healthful fat and protein, but oftentimes, clients feel more is better and add too much of these ingredients.•Too much sugar: Overusing fruit juices, sorbets, or sherbets

can displace healthier ingredients that are lower in sugar or more nutrient-dense ingredients.Nutrition professionals should pinpoint clients’ mistakes or

misconceptions when it comes to making smoothies and then provide tips and ideas and healthful recipes to counteract these problems.

Smoothie-Making TipsThe first step to making a healthful smoothie is deciding

what ingredient to use for the smoothie’s base to help keep the calories within reasonable limits. Milk is readily available in many homes and can help clients meet the three recommended daily servings of dairy. Selecting nonfat milk in lieu of whole milk cuts 65 kcal per cup and eliminates practically all of the saturated fat. Alternatively, light soymilk, which contains 60 kcal less than regular soymilk, can be used. If clients choose a flavored milk or milk alternative, be sure to discuss portion sizes to help them keep calories and sugar under control.

For a thick texture, silken tofu or nonfat plain Greek yogurt is a good choice. Ice also is a good option for those on a very low-calorie diet looking to cut calories wherever possible.

Next, discuss the ingredients that will be added in. Smooth-ies are a great way to consume more fruit. To be mindful of food prices, recommend using seasonal fruits. If clients select frozen fruits, show them how to read nutritional labels to avoid added sugar.

If your clients are willing to experiment, there are many creative, healthful options available for making smoothies. Vegetables such as kale, spinach, and cucumbers add

nutrients without many calories, and oats contribute whole grains. Recommend natural peanut butter for protein or ground flaxseeds for an omega-3 boost. If clients want to use protein powders, such as whey or soy, suggest they look for brands without synthetic amino acids, added vitamins, minerals, and herbal supplements because they can cause side effects and negatively interact with certain medications they may be taking.

— Toby Amidor, MS, RD, CDN, is the founder of Toby Amidor Nutrition (http://tobyamidornutrition.com) and

author of the cookbook The Greek Yogurt Kitchen. She’s also a nutrition

expert for FoodNetwork.com and contributor to US News Eat + Run.

ASK THE EXPERT

Peach Oatie SmoothieServes 1

Ingredients1⁄4 cup nonfat milk1 T old-fashioned rolled oats11⁄2 cups unsweetened frozen

peach slices1⁄2 cup peach nectar1⁄4 cup nonfat vanilla Greek yogurt1⁄8 tsp ground cinnamon

Directions1. Place a 12-oz glass in the freezer and allow it to chill for at least 30 minutes.2. Place the milk and oats in the blender jar and stir with a spoon to combine. Allow the oats to hydrate for at least 10 minutes or up to 30 minutes.3. Add the peach slices, peach nectar, yogurt, and cin-namon to the oat mixture in the blender. Cover and blend until smooth. Pour into the chilled glass and serve immediately.

Nutrient Analysis per servingCalories: 227; Total fat: 0 g; Saturated fat: 0 g; Protein:

9 g; Total carbohydrates: 49 g; Sugars: 41 g; Dietary fiber: 4 g; Cholesterol: 1 mg; Sodium: 58 mg

— RECIPE COURTESY OF TOBY AMIDOR, MS, RD, CDN, FROM THE GREEK YOGURT KITCHEN (GRAND CENTRAL PUBLISHING, 2014)

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

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

10 today’s dietitian september 2014

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MAPPING THE GUT MICROBIOMEAn Ambitious Project That Could Lead to Better Gastrointestinal HealthBy David Yeager

Many people are familiar with the Human Genome Project, which identified all the genes in human DNA and determined the sequence of the 3 billion chemical base pairs that comprise it. However, another project is under way that’s no less impor-tant and arguably more ambitious under the auspices of the National Institutes of Health: the Human Microbiome Project. And many of the largest labs in the country are participating.

The first phase of the project was conducted from 2007 to 2012 and focused on developing data sets and computational tools to describe the composition and diversity of the microbial communities that live in and on our bodies. The second phase, which began in 2013 and runs until 2015, aims to create the first integrated data sets describing the biological properties of interactions between microbes and humans.

The research still is in an early phase, but the insight it will give scientists likely will affect how we maintain health and treat disease, especially digestive disease. Justin L. Sonnenburg, PhD, an assistant professor of microbiology and immunology at Stanford University School of Medicine in California, didn’t participate in the initial phase of the Human Microbiome Project, but his lab studies how intestinal microbes affect our biology. He says one thing that’s becoming clear is that microbes play a crucial role in our lives.

“All of this [research] collectively has created a huge par-adigm shift for biomedicine in general and brought to light the realization that we’re not just collections of human cells. The individual is much more than that,” Sonnenburg says. “We’re actually composite organisms. We’ve coevolved with these microbial communities, which are integrated into virtu-ally all facets of our biology in some direct or indirect way, and

so we have to somehow incorporate these bacteria and other microbes into our conceptualization of health and determine how we should conduct medicine [going forward].”

Sonnenburg, who prefers the term “microbiota” to describe the communities of microbes in our bodies and refers to the microbiome as the collective genome of those microbes, says no two microbiota are the same. He notes, however, that while there are noticeable differences between healthy and unhealthy indi-viduals, it’s too early to draw conclusions about what constitutes an optimal microbiotic community. For example, obese people as a population tend to have different microbiota than average, healthy individuals, but some obese individuals also don’t have dysbiotic (unhealthy) microbiota. Likewise, some lean individuals have microbiota that are similar to those who are obese.

Sonnenburg says mouse studies have shown that microbiota associated with obesity can make lean mice obese, demonstrat-ing that such microbiota can transfer to lean individuals. A pre-vious human trial demonstrated a short-lived but measureable decrease in factors associated with the metabolic syndrome, such as insulin resistance and glucose tolerance, when micro-biota were transferred from a lean individual to someone who was obese, he says. Unfortunately, the processes that cause these reactions aren’t well defined. What’s needed is increased study on the basic mechanisms that connect microbial and human biology, he explains.

Tuning an Organ?Defining those mechanisms will take some time; the micro-

biome is 100 times larger than the human genome. It’s been estimated that there are 10 times as many microbial cells in and on our bodies as there are human cells, but human cells have significantly greater mass. Although microbes add only a few pounds per person to overall weight, they perform a variety of functions on which our bodies rely.

“The microbiome makes up 1% to 2% of the adult body, so it could essentially be considered a separate organ,” says Kristi L. King, MPH, RDN, CNSC, LD, a senior pediatric dietitian at Texas Children’s Hospital, clinical instructor at Baylor College of Medicine in Houston, and spokesperson for the Academy of Nutrition and Dietetics. “Previously, we thought it was just there to help us with the digestion of foods and the production of cer-tain vitamins, such as vitamin K or vitamin D, but now we’re seeing that it’s playing a much bigger role than that.”

King says certain microbes are important for intestinal health. For example, probiotics have been shown to help with certain infections, such as Clostridium difficile, and fecal trans-plants have been shown to relieve symptoms of C difficile and ulcerative colitis. Baylor University researchers, who partici-pated in the Human Microbiome Project, also have studied how microbes affect drug metabolism, which can help to measure the effectiveness of certain drug therapies.

King says each person’s microbiota is like a fingerprint, and determining how those thousands of microbes affect food

DIGESTIVE WELLNESS

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metabolism will open all sorts of possibilities. With all of the talk of personalized medicine in areas such as data analysis and medical imaging, research on the human microbiome may lead to the most personalized treatments of all: diets tailored to spe-cific individuals based on their personal microbial communities.

“We know that people with IBS [irritable bowel syndrome] have certain intolerances, and that’s where FODMAPs have become really popular,” King says. “Is it really that the patients are unable to digest those particular carbohydrates or is their microbiome contributing to that? That, I think, is probably our first inclination of how [personalized diets are] going to go.”

Sonnenburg says that as these mechanisms are better under-stood, it likely will be possible to add beneficial microbes, such as specific probiotics that are highly effective at competing with harmful microbes, to individual microbial communities. He adds that it even may be possible to add either engineered or nonengi-neered strains of microbes to improve immune function.

He says modern practices such as cesarean sections, anti-biotic use, and low-fiber diets as well as overly sanitized envi-ronments and food supplies have led to a major decrease in the diversity and function of human microbiota and may be predis-posing us to conditions ranging from allergies and asthma to Crohn’s disease and cancer. Although microbiota can quickly change in ways that aren’t always predictable, there are some steps people can take to maintain their microbial health.

Sonnenburg has studied how microbiota react to changes in diet and says certain parameters are taking shape. One recom-mendation is to eat a high-fiber diet. Many people essentially are starving certain species of beneficial fiber-eating microbes in their intestines, he says, adding that overuse of antibiotics can decimate microbiotic communities, and it’s unclear whether those communities ever recover. He adds that breast-feeding is important because it helps to properly colonize infant digestive tracts, which basically are sterile at birth.

In terms of diet, Sonnenburg says fermented foods and probi-otics may be important for regulating gut responses in microbial communities. He recommends foods such as kefir, yogurt, and kimchee and expects designer probiotics to play a larger role in treating disease and maintaining health. Ultimately, under-standing what an optimal microbiota is for any given individual will allow clinicians to implement highly targeted treatments. They just need to be aware of unintended complications.

“We need to think about how to take all of the technological and medical advances of the modern world and make sure that those are not used in ways that lead to detrimental health effects because of collateral damage to the microbiota,” Sonnenburg says.

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

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Page 14: Today's Dietitian

FOCUS ON FITNESS

QIGONGBy Jennifer Van Pelt, MAThis traditional Chinese health and wellness system provides a variety of health benefits.

In a previous column, I wrote about the benefits of tai chi. This month, I’ll be discussing qigong, a lesser known ancient and traditional Chinese health care practice.

According to the National Qigong Association, the word “qigong” (also known as chi kung) is derived from two Chinese words: qi (pronounced “chee”), which means the life force or vital energy that flows through all things in the universe, and gong (pronounced “gung”), which means accomplishment or skill that’s cultivated through steady practice. Together, qigong means cultivating energy.

Qigong is a system practiced for health maintenance, healing, and vitality, and it’s popularity as a fitness activity is increasing, though it’s often confused with, or even combined with, tai chi.

What’s the Difference? “Qigong and tai chi both use slow, gentle, rhythmic

movements and focus on cultivating internal stillness and quieting the mind through weightless, effortless movements. However, there are several important distinctions between these two traditions,” says Ashley Welikonich, an American Council on Exercise–certified mind-body exercise specialist, a certified qigong instructor, and the owner of Pagoda Wellness in Reading, Pennsylvania.

Qigong is a health or wellness system of exercise, whereas tai chi is a martial art. With tai chi, a form often is practiced where an individual will follow a fixed set of exercises. As a result, it can take longer to become adept at tai chi. In qigong, exercises can be selected individually and practiced for any duration of time. With the flexibility provided by qigong, it’s easy to modify as needed for any musculoskeletal or health restrictions.

Tai chi can require more advanced balance skills, while many qigong exercises are completed in a stationary position. Qigong does improve balance, though, through weight-bearing, core-strengthening exercises.

When qigong and tai chi are compared with other forms of therapeutic exercise, they’re the most similar to each other, and many practitioners use a mix of both. However, com-pared with yoga, there are vast differences, Welikonich says. All three have the goal of aligning body, mind, and breath, but qigong and tai chi use more continuous movements. In yoga, the same goal most often is achieved through holding a pose or a series of poses, she says.

Health BenefitsThe National Qigong Association states that qigong is prac-

ticed to maintain health, calm the mind, and reconnect with one’s spirit. According to Welikonich, her clients commonly practice qigong for stress relief and increased energy.

As qigong moves into mainstream American fitness facilities, exercisers are wondering about its purpose and benefits compared with more familiar fitness activities. Qigong especially is popular among older adults because of the many stationary stances and ease of modifying movements to accommodate physical limitations. Qigong even can be practiced while seated and therefore is a welcome addition to senior exercise program offerings. Additional health benefits for older adults include increased bone density and functional mobility, promotion of longevity, and lessening of senility, Welikonich says.

However, qigong isn’t only for the elderly. Benefits for individuals with active lifestyles include improved balance, coordination, and athletic performance, Welikonich adds. Qigong programs for athletes are available and endorsed by professional athletes to improve focus, performance, strength, energy, and pain reduction.

Qigong ResearchAmericans have a tendency to focus on only the fitness

aspect of Eastern health practices such as yoga, tai chi, and qigong. Calorie burning and muscle toning become the primary goals when considering new fitness activities, but qigong provides benefits beyond just fitness and should be viewed as a practice to improve overall health. Scientific studies support qigong’s health benefits for many conditions, including hypertension, cardiovascular disease, immune function, stroke, chronic fatigue, fibromyalgia, osteoarthritis,

14 today’s dietitian september 2014

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respiratory function, and cancer, Welikonich says.Hundreds of studies regarding qigong have been published

over the last 20 years, with the following being recent ones of note: •Twosystematicreviewsofrandomizedcontrolledtrials

on traditional Chinese exercise (qigong and tai chi) found therapeutic value associated with qigong for pulmonary rehabilitation in patients with COPD, including improvements in physical performance, lung function, dyspnea remission, and quality of life.1,2

•Hemodialysispatientswhopracticedqigongthreetimesweekly for six months significantly reduced their fatigue com-pared with usual routine care.3 •Patientswithchronicfatiguesymptomswhopracticed

qigong twice weekly for 17 weeks experienced significantly improved physical and mental fatigue and depression symptoms.4

•Asystematicreviewandmeta-analysisof13randomizedcontrolled trials on qigong/tai chi practiced by cancer patients found positive effects on cancer-specific quality of life, fatigue, immune function, and cortisol levels.5

•Ameta-analysisof26randomizedcontrolledtrialsofqigong in older patients with chronic medical conditions found qigong positively affected physiologic factors such as white blood cell and lymphocyte counts, cardiovascular and respi-ratory function, blood pressure, and cholesterol as well as depressive mood scores.6

Valuable AdditionWith the potential to improve health, reduce stress, and

increase energy, qigong can be a valuable addition to any-one’s exercise program. As with all exercise, it’s important to start slowly and make gradual lifestyle changes that will last, Welikonich says. Many participants begin with a qigong class that meets once weekly and are motivated to practice more once they experience the benefits, she says. “Ideally, qigong should be practiced daily for 15 to 60 minutes,” she adds.

For those interested in further information on qigong’s back-ground, science, and basic exercises, Welikonich recommends the book The Healer Within by Roger Jahnke.

After thousands of years of practice in China, qigong now is becoming more popular in the United States, so clients should be able to find a local class to attend at a fitness facility, com-munity center, long term care/older adult organization, or mind-body studio.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care research

analyst/consultant in the Reading, Pennsylvania, area.

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

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GET TO KNOW…�

VIRGINIA MESSINAAn RD for Work, a Vegan for LifeBy Juliann Schaeffer

Virginia Kisch Messina, MPH, RD, may have embarked on her career in nutrition as an empathetic animal lover, but she didn’t connect how those dots of compassion for the four-legged related to her diet until years later.

“I started my career as a public health nutritionist in a small rural clinic in southwest Michigan and then at a large urban health clinic in Washington, D.C.,” she says. “I also taught dietetics students at Central Michigan University.”

Yet at the age of 28, Messina happened upon the vegetar-ian cookbook Laurel’s Kitchen, which sparked something inside Messina: not just a realization of what veganism is all about, but also a passion for eating humanely and spreading awareness. “I was a vegetarian for ethical reasons for a number of years before becoming vegan,” she says. “But learning more about the effects of factory farming on animals and on the environ-ment inspired me to adopt a vegan lifestyle.”

Ever since (that was almost three decades ago), much of Messina’s work has focused on vegan advocacy. She’s written books and articles on the topic, including Vegan for Life, Vegan for Her, and Never Too Late to Go Vegan. She’s developed a CE program on vegetarian nutrition for dietitians, and she’s even coauthored the Academy of Nutrition and Dietetics’ position statement on the vegetarian diet.

But maybe the biggest sounding board for her stances on all things vegan is her blog, The Vegan RD, where she delves into diverse topics that affect those living the vegan life, including espousing the differences between Paleo and low-carb diets and touting the benefits of plant-based proteins.

While she’s always been interested in the science of nutrition and public health, Messina says veganism has shown her that the simple dietary choices she makes each day can have a huge effect on far more than human health. “They have an impact on

the environment, animal welfare, and global food security,” she explains. “So my perspective on what constitutes an optimal diet is much broader today than when I first became a dietitian.”

Today’s Dietitian (TD): If you were asked to post a job opening for “vegan RD,” what would be the top three requirements?Messina: A commitment to a vegan ethic, a commitment to scientific integrity, and good writing skills.

TD: What do you wish all RDs knew about veganism?Messina: I’d like dietitians to know that vegan diets are as safe and nutritious as any other way of eating. While certain nutrients need extra attention in vegan diets, that’s really true of any eating pattern. The difference is that vegan diets are less common, so there can be a learning curve for dietitians as well as their cli-ents. But with attention to just a few details, it’s really pretty easy.

TD: What five items are always in your kitchen and why?Messina: Chickpeas: Because they’re so versatile. I use them in hummus, vegetable soup, and vegan tuna salad. Tofu: It’s my go-to breakfast. Quinoa: It cooks up quickly and is much higher in protein than other grains. Good-quality olive oil: Because I love the flavors of Mediterranean-style cuisine. Collard greens: A lot of vegans are crazy for kale, but I’m partial to the texture and flavor of collards, especially because they’re such a great source of calcium.

TD: What would you say is your cooking style?Messina: I cook mostly from scratch but with a little conve-nience thrown in. I do bulk cooking every week, spending a few hours on the weekend stocking the refrigerator with food for the week ahead. There are always bean soups, bean burritos, scrambled tofu, roasted sweet potatoes, and a couple sauces, such as spicy peanut sauce and creamy cashew sauce, on hand.

TD: Best advice for making tasty vegan desserts?Messina: If you eat a healthy diet and limit sweets to occasional treats, it’s OK to let dessert be dessert in all its decadent glory. Baking without eggs can produce desserts that are a little bit heavier and less tender. Omitting added fats and sweeteners and using only whole grain flours can sometimes add to that problem.

TD: Is veganism an all-or-nothing proposition? In other words, for an omnivore who may be intimidated by changing his or her diet completely at once but is sympathetic to many tenets of veganism, are there ways to adopt vegan principles in a step-by-step approach? If so, what’s the single greatest change clients can make to eat more humanely?Messina: I think of veganism as being about intention and effort. The key is to keep moving forward in whatever way you can, to keep learning and experimenting with new foods and trying dif-ferent ways of eating.

16 today’s dietitian september 2014

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For those who want to make a difference right away with their choices, the single best thing to do is to stop eating chickens and other birds. Because they’re small, you end up saving many more animals when you stop eating chickens than you would by giving up beef for example. Also, birds aren’t protected by the Humane Slaughter Act.

I also recommend making the supereasy changes. Replacing cow’s milk with fortified plant milk, whichever type you like, is so easy that there’s no reason not to do it. The same goes for cooking with vegetable oils rather than animal fats. These are small changes that make the world a little bit of a better place without requiring much effort on your part.

TD: What foods do you crave?Messina: Comfort foods like Reuben sandwiches and mac and cheese. Fortunately, there are many vegan variations on these foods. I have a Pinterest board that’s devoted just to vegan macaroni and cheese recipes.

TD: How do you prefer to stay active?Messina: I prefer to sit on the couch and read, but I walk 2 to 4 miles every day and do strengthening exercises five times per week. In the summer, I work in the garden for at least an hour every day.

TD: What does the Vegan RD’s garden grow?Messina: The veggie garden is filled with all types of leafy greens plus onions, blueberries, and strawberries—and a few sad tomatoes that don’t do too well in Pacific Northwest sum-mers. The rest of my property is landscaped for wildlife, with a pond and lots of grasses and perennials.

TD: Favorite place or way to relax and unwind?Messina: A glass of wine on my front porch with my cats, the flowers, and the deer that wander in and out of the yard.

TD: What’s something most people may be surprised to learn about the vegan diet in general?Messina: People may not realize that a vegan diet can be anything you want it to be. You can choose comfort foods such as spa-ghetti, hot dogs, pot pies, and chocolate cake or easy convenience foods such as pasta sauce from a jar and canned baked beans. A vegan diet can also be gourmet fare—slow-cooked risotto or bruschetta with cashew cream and tapenade. People often think that vegan food is rice and beans, and sometimes it is, but the options for healthy and appealing vegan cuisine are endless.

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

and a frequent contributor to Today’s Dietitian.

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Page 18: Today's Dietitian

FOOD ALLERGY MANAGEMENT IN RESTAURANTSMore Resources Are Available to Keep Customers Safe By Sherry Coleman Collins, MS, RDN, LD

A study about fatalities resulting from food allergy anaphylaxis found that 25% of deaths recorded over a five-year period occurred while dining out.1 With an estimated 15 million food allergic individuals in the United States, restaurants have a greater opportunity to protect their patrons with food allergies.2

But how do these individuals stay safe while dining out when so many adverse reactions occur in these settings? Visiting restaurants during nonpeak hours is one way to stay safe, as is calling the restaurant beforehand to ensure it has a solid food allergy policy in place and the staff has a clear understanding about food allergies, says Eleanor Garrow-Holding, president and CEO of the Food Allergy and Anaphylaxis Connection Team, an organization that specializes in education, advocacy, and raising awareness about food allergies and anaphylaxis, and the parent of a food allergic child. “Never assume restaurant staff will remember your needs. Always inform restaurant staff of your needs during each visit and ask to speak to the manager and/or kitchen chef upon arrival,” she says, adding that allergic diners also should carry epinephrine with them at all times.

Nonetheless, restaurants are becoming more responsible when it comes to food allergies. For example, foodservice operators and staff members are taking advantage of various education and training opportunities to become more informed and ensure customer safety. In fact, food allergy training is mandatory in some establishments.

Regulating Food Allergy SafetyNational legislation requiring restaurants to follow standardized food

allergy management policies doesn’t exist as it does in the area of food safety, but activists have been lobbying for such requirements at state

and local levels. As a result, certain states and communities have adopted their own food allergy management policies.

Massachusetts was the first state to sign into law specific food allergy legislation with the 2009 Food Allergy Awareness Act after working closely with Food Allergy Research & Education (formerly the Food Allergy and Anaphylaxis Network), a nonprofit organization whose mission is to increase food allergy awareness, conduct research, and provide education and resources to those with food allergies, and celebrity chef Ming Tsai. This law requires food allergy management training for certified food protection managers and for restaurants to hang food allergy posters in staff areas. It also requires notices to be posted on menus asking customers to inform servers about their food allergies.3 According to the law, all food establishments (eg, grocery stores that sell prepared foods, takeout counters) that cook, prepare, or serve food intended for immediate consumption either on or off the premises are included.3

In 2013, Rhode Island joined Massachusetts with nearly identical requirements, although the law in Rhode Island still is being implemented.4 In New York City and St Paul, Minnesota, res-taurants are required to hang posters in kitchen staff areas describing food allergies and their associated adverse reactions.4 In these cities, legislation has been proposed to include food allergy training, but it hasn’t become law. Other states, such as Georgia and Illinois, have intro-duced food allergy legislation for restaurants, but it hasn’t yet been adopted.

Still, Garrow-Holding says restaurants are becoming increasingly prepared to manage food allergies, due in part to food allergy awareness provisions being added to the FDA Food Code along with allergens being classified as a hazard in the 2011 Food Safety Modernization Act. State and local health departments use the Food Code to establish food safety regulations, as it requires restaurants to have a person in charge who knows about food allergy management and can identify reactions.5 The person in charge is responsible for ensuring that employees are properly trained in food allergies and food safety management. However, the Food Code doesn’t specify what the training should entail or how to assess knowledge.

FOODSERVICE FORUM

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Taking It to the TableRestaurants that embrace the opportunity to meet their

customers’ specific dietary needs experience the benefits of returning patrons. According to Paul Antico, president of AllergyEats.com, an online peer-reviewed directory of user-friendly restaurants across the United States, and the parent of three children with food allergies, 90% of families managing food allergies eat out regularly. He also notes that Disney World is considered the gold standard of food allergy accommodations. “In fact, many families spend the exorbitant amount of money for a Disney World trip in order to have their food allergic child eat in a restaurant for the first time,” he says.

In addition to Disney World, Antico cites chain restaurants Red Robin and P.F. Chang’s as known leaders in the area of food allergy management. They successfully make accommodations for all major allergens, showing that it’s possible to safely serve both allergic and nonallergic customers simultaneously. In addition, they have a step-by-step process for identifying food allergic customers, train all staff on food allergy management, and have a “when in doubt, throw it out” attitude to ensure allergen-safe foods.

Regional restaurant chain Burtons Grill also is building a reputation for caring about customers with food allergies. According to CEO Kevin Harron, making food allergies a high priority is good business. “Our company is about trust

and integrity. The discipline involved in serving [diners with] allergies is good behavior,” he says, adding that doing a good job serving those with food allergies means positive word- of-mouth publicity, which ultimately leads to increased sales.

Getting SchooledDavid Crownover, product manager for the National Restau-

rant Association, says a 2012 survey of its members showed that while foodservice establishments were aware of the top food allergens, they didn’t understand what to do with that knowledge as it related to the restaurant environment. He reported that 78% of respondents identified food allergies as an important issue, yet less than 50% were providing training in food allergy management, and 1% reported they didn’t serve anything allergenic on their menu. Since more than 160 differ-ent foods have been implicated in causing food allergy reac-tions, Crownover concluded there was a problem.

The good news is that restaurant operators now have a variety of resources available to learn how to manage food allergies. Food Allergy Research & Education has devel-oped SafeFare.com as a resource to help connect restaurant operators with food allergy training and diners with restau-rants whose staff has completed training. Included on the site is the National Restaurant Association’s ServSafe Allergens Online Course, a comprehensive, interactive course geared

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Page 20: Today's Dietitian

to help restaurant staff better understand the safety precau-tions required when serving customers with food allergies. The training course began in July 2013, and so far more than 5,000 foodservice workers from across the country have participated.

Additionally, the AllerTrain Program, created by MenuTrinfo, a provider of nutrition analysis and allergen education, offers training in a classroom setting and via live webinars, which Antico describes as the best “deep dive” into food allergy management available.

Those who want to experience training on a larger scale among peers can attend AllergyEats’ annual Food Allergy Conference for Restaurateurs, which will be held in New York City in October. The conference covers the basics of food allergies and safe food handling practices as well as the financial reasons for implementing a food allergy management training program. According to Antico’s estimations, the food allergy and celiac disease communities represent 5% of the population, yet they may account for as much as 15% of diners when considering that an average party of three will choose to dine someplace else if a restaurant can’t accommodate a particular family member with food allergies.

To date, little has been done to measure the impact of food allergy management training programs on restaurants and their customers. Outcomes measures are needed to deter-mine what type of training works best and how frequently it

should be provided. “There’s nothing special about the tech-niques necessary [for managing food allergens], but not every restaurant can safely accommodate every allergic individual, [although] every restaurant can accommodate some allergic individuals,” Crownover says, noting that restaurants can be successful if they’re transparent about what food allergies they’re capable of managing and keep the lines of communica-tion open with patrons.

Career OpportunitiesDietitians who educate themselves about food allergy man-

agement have additional job opportunities available to them. “RDNs are food and nutrition experts who can help separate facts from fads and translate nutrition science into information restaurants can use,” Garrow-Holding says.

Foodservice establishments need ongoing training for staff, assistance with safe menu development and appropriate substitutions, and evaluation of their current operation—all opportunities for the food-savvy dietitian. “Serving the food allergy community is about demystifying the serving of an underserved community. On top of that, there’s money to be made,” Crownover says.

To learn more about food allergy management, dietitians should familiarize themselves with the resources available to help clients and patients with food allergies navigate the world of dining out. RDs who work in foodservice can complete one or more food allergy training courses to begin understanding how to manage food allergies in restaurants.

— Sherry Coleman Collins, MS, RDN, LD, is a private practitioner in Atlanta, specializing in food allergies and

sensitivities and digestive disorders. She also provides nutrition communications consulting services for the Peanut Board.

References1. Bock SA, Muñoz-Furlong A, Sampson HA. Further

fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol. 2007;119(4):1016-1018.

2. Food allergy facts and statistics for the US. Food Allergy Research & Education website. http://www.foodallergy.org/document.doc?id=194. Accessed June 25, 2014.

3. Q&As for MDPH allergen awareness regulation. Massachusetts Department of Public Health website. http://www.mass.gov/eohhs/docs/dph/environmental/foodsafety/food-allergen-3-reg-faqs.pdf. Accessed June 25, 2014.

4. Food allergies and restaurants. Food Allergy Research & Education website. http://www.foodallergy.org/advocacy/restaurants. Accessed June 25, 2014.

5. FDA food code 2009: chapter 2 — management & person-nel. FDA website. http://www.fda.gov/Food/GuidanceRegula tion/RetailFoodProtection/FoodCode/ucm181242.htm. Last updated October 29, 2013. Accessed June 25, 2014.

RESOURCES •AllergyEats.com is dedicated to connecting food

allergic individuals with food allergy–aware restaurants around the country. You can learn more about the AllergyEats Food Allergy Conference for Restaurateurs and Food Service Professionals at AllergyEats.com/conference.

•Food Allergy and Anaphylaxis Connection Team (www.foodallergyawareness.org) is an organization dedi-cated to education, advocacy, and raising awareness about food allergies and anaphylaxis.

•Food Allergy Research and Education (FARE) is the nation’s largest food allergy group. FoodAllergy.org pro-vides resources to help individuals with food allergies and their families as well as tips and tools for restaurants.

•SafeFare.org is FARE’s website dedicated to connecting restaurant operators with educators in food allergy manage-ment and with potential food allergic customers.

•MenuTrinfo AllerTrain offers in-person and virtual instruction on managing food allergies and gluten-free foods.

•National Restaurant Association’s ServSafe Allergen Training is an interactive, avatar-based virtual training program in food allergy management available on demand at ServSafe.com/allergens.

— SCC

20 today’s dietitian september 2014

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FOOD FOR THOUGHT

FISH OILS AND COGNITIVE FUNCTIONBy William S. Harris, PhDResearch suggests higher omega-3 intake leads to greater brain health.

“Fish is brain food.” The origin of this bromide is unclear, but scientific support

for this idea during both the sunrise and sunset years of life is growing.

Scientists began to link fish oils, which are rich sources of two omega-3 fatty acids—EPA and DHA—with brain health by observing that DHA is one of the two most plentiful fatty acids in the brain, and that it’s particularly enriched in the retina of the eye, an extension of the brain. If it’s there, it’s probably doing something.

Studies in animals and newborn babies have confirmed that DHA deficiency adversely affects visual function and certain learning behaviors.1,2 More recently, anecdotal stories of very high doses of fish oil being used to successfully treat traumatic brain injury and of animal experiments showing accelerated healing after spinal cord injury continue to build the evidence base for omega-3s playing a functional role in the central nervous system.3,4

When studies reporting a link between fish intake and dementia/cognitive function began to be published, and biomarker-based studies showed lower plasma/erythrocyte omega-3 levels in patients with cognitive dysfunction, the stage was set for randomized trials to prospectively test whether higher omega-3 intakes could forestall the development of dementia and Alzheimer’s disease.

This article summarizes some of the high points in this journey, discusses some recent findings in which the author was involved, and concludes with suggestions for using fish oils in the prevention (treatment?) of dementia and Alzheimer’s. (Several reviews are available regarding this information.5-9)

BackgroundBefore examining the studies themselves,

some background on how scientists study diet-disease relationships may be helpful.

There are two basic epidemiological approaches, both of which look for associations between the intake of nutrient X and disease Y and between blood levels of nutrient X (ie, biomark-ers) and disease Y. Both of these can be studied cross-sectionally, that is, at one point in time (dis-ease prevalence), or prospectively, where intake/biomarker levels are determined at one time point

and disease development (incidence) is tracked longitudinally. The strongest of these study designs typically is the pro-

spective/biomarker approach, but even this can’t show that a deficiency of nutrient X causes the disease—association never proves causation—but this is considered good evidence of possible causation.

The way to study causation is with a randomized controlled trial, where nutrient X is given to one group of randomly selected people and a placebo to an identical group, and then both groups are followed over years for disease development. However, this is a drug model, and it has limitations when studying nutrients, which, by definition, already are present in the body at some level, while drugs aren’t. Thus, in nutrition research, randomized controlled trials and prospective/biomarker-based studies both should be viewed as providing strong evidence for diet-disease relationships.

When it comes to omega-3 fatty acids and dementia, all of these research approaches have been used, and the jury is still out on their relationship.

Fish and Omega-3 Intake Conklin and colleagues conducted a cross-sectional/

intake-based study involving a group of 55 men and women with a mean age of 45; the highest tertile of EPA+DHA dietary intake was associated with larger hippocampal volume.10 (Hippocampal atrophy is commonly observed before symptomatic impairment.11)

Another example is the Cardiovascular Health Study in which, of 2,465 participants (59% women, average age of 75), the reported intake of fatty, nonfried fish (those richest in EPA+DHA) was inversely associated with the presence of subclinical brain infarcts on MRI examination (ie, defined as ischemic lesions of 3 mm or less in diameter).12

september 2014 www.todaysdietitian.com 21

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The Prospective Investigation of the Vasculature in Uppsala Seniors study exemplifies the intake/prospective approach. The investigators tested the hypothesis that higher cognitive test scores and greater brain volume are associated with a higher vs. lower omega-3 fatty acid dietary intake. The dietary intake of EPA+DHA of 252 cognitively healthy elderly subjects aged 70 was determined by a seven-day food protocol.13

Five years later, the participants’ global cognitive function was exam-ined and MRI was used to measure their brain volumes. The subjects’ intake of EPA+DHA at the age of 70 was positively associated with global gray matter volume and global cogni-tive performance score at the age of 75. However, intake wasn’t significantly associated with total brain, global white matter, or regional gray matter volumes. In other words, people who ate more fish had fewer infarcts.13

These studies suggest that more fish in the diet helps preserve brain health, but they don’t prove that fish—much less the omega-3 fatty acids in fish—provide this benefit since another component of fish could be beneficial, the foods people avoid in order to eat fish could be harmful, or people who eat fish may have other lifestyle habits that are protective.

Omega-3 Biomarkers The biomarker-based approach

also was used in the Cardiovascular Health Study, measuring both cross-sectional and prospective end points. In this study, 3,660 participants aged 65 and older had a brain MRI done and a blood sample taken at baseline. Five years later, 2,313 had another MRI done. Baseline blood DHA levels were inversely related to the presence of subclinical infarct volume and white matter grade at baseline, and they were inversely associated with worsening white matter grade over time.12

Two reports from the Framingham Heart Study have linked omega-3 bio-marker levels with brain health. The first was a prospective study looking at DHA levels in 899 participants in the original cohort in Framingham who were aged 76, on average, when their blood was drawn, and they were free of clinical dementia. They were fol-lowed over the next nine years for the development of dementia or Alzheim-er’s. Those in the highest quartile of DHA (levels associated with eating about three fish meals per week) were nearly one-half as likely to develop dementia or Alzheimer’s compared with those with lower levels.14

In the cross-sectional Framingham Offspring cohort (in which the author was involved), researchers compared red blood cell levels of EPA and DHA with MRI and cognitive markers of dementia risk in 1,575 dementia-free participants (aged 67±9).15 Participants with red blood cell DHA levels in the lowest quartile had lower total brain and greater white matter hyperinten-sity volumes.15 A lower level of red blood cell DHA and of EPA+DHA (the latter termed “the omega-3 index”16) also was associated with lower scores on tests of visual memory, executive function, and abstract thinking.15 Hence, lower red blood cell omega-3 levels were linked with smaller brain volumes and a vascular pattern of cog-nitive impairment even in those free of clinical dementia.15

Another study from our group, using the omega-3 index as a biomarker of omega-3 fatty acid status, involved data from the Women’s Health Initia-tive Memory Study. We examined the extent to which the omega-3 index had a protective association with domain-specific cognitive function. The cogni-tive domains examined were fine motor speed, verbal memory, visual memory, spatial ability, verbal knowledge, verbal fluency, and working memory. Post-menopausal women (n = 2,157, mean age of roughly 70) had blood drawn at

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baseline. Three years later, they under-went the first cognitive testing panel, which was repeated for the next six years. A higher omega-3 index was associated with better fine motor speed, verbal knowledge, and verbal fluency.17

However, after statistical adjustment for nine other factors, the independent relationships were lost. No significant differences were found between the high and low omega-3 index tertiles in the rate of cognitive change over time. Therefore, in this cohort of women free of dementia at enrollment, while there were some connections between omega-3 status and deficits in certain cognitive function domains, these relationships either were mediated by or otherwise associated with other lifestyle/physiological factors.17

Pottala and colleagues conducted another analysis from the same cohort and found a significant direct relationship between the omega-3 index measured at baseline and total brain volume measured by MRI eight years later.18 A higher omega-3 index was specifically correlated with greater hippocampal volume. We concluded that a lower omega-3 index may signal increased risk for hippocampal atrophy.

Other examples of biomarker-based studies that found significant associations between MRI metrics and omega-3 levels come from Bowman and colleagues and from Samieri and colleagues.19,20

Intervention StudiesCurrently, there are no published

studies attempting to demonstrate that omega-3 fatty acids can help reverse Alzheimer’s or dementia; pre-vention appears to be the only hope. Because of the typically slow develop-ment of Alzheimer’s and dementia and the inability to positively identify when

the process begins, performing inter-vention studies to forestall disease development requires a long period of time and large numbers of sub-jects to achieve worthwhile results. To date, several trials have been con-ducted,21-26 but only one lasted more than two years (40 months); it used very low omega-3 doses and focused on patients with a history of coronary heart disease.23

In general, beneficial effects from omega-3 fatty acids have been seen for some end points related to cogni-tive function (eg, executive function, attention, anxiety) for some subgroups (eg, noncarriers of ApoE4 allele, mild cognitive impairment; see review by Cederholm and colleagues9), so there’s reason to persevere with larger and longer trials.

RecommendationsResearch to date indicates there’s

virtually no risk associated with increasing the typically low (about 150 mg/day) EPA+DHA intake in Ameri-cans to 250, 500, or even 1,000 mg/day (see international recommendations in Flock and colleagues27). This can be accomplished by eating more fish, pref-erably oily varieties, or taking omega-3 supplements (from fish or algal oils).28

Given the “smoke” seen across a spectrum of studies linking higher omega-3 intakes/status with improved cognitive function, it seems likely that there is a “fire” behind it.

— William S. Harris, PhD, is a professor of medicine in the

University of South Dakota Sanford School of Medicine. He’s also president

of OmegaQuant Analytics in Sioux Falls, South Dakota, and a senior research

scientist at Health Diagnostic Laboratory in Richmond, Virginia.

Helping people make healthier choices is what we do.

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• Consumer sodium campaign and website

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

september 2014 www.todaysdietitian.com 23

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ATLANTA DININGA New Twist on Southern Cuisine

Butternut squash ravioli at Livingston

Restaurant + Bar

Page 25: Today's Dietitian

When you think of Atlanta’s culinary aesthetic, what comes to mind? That’s a question the city’s inhabitants have been asking for years. After all, Atlanta doesn’t have quite the same food cache

as other Southern locales, such as New Orleans, Memphis, or Charleston.

However, a new culinary identity is organically begin-ning to form in this pulsing metropolis, which boasts the sixth largest economy in the United States. This culinary vision is rooted in Southern food traditions and history—this is where the civil rights movement was born. But this seat of the New South also has a bold splash of eclectic, ethnic flavors, thanks to Atlanta’s melting pot population. Throw in a few award-winning celebrity chefs, and you’ve got an exciting food scene.

“Atlanta is always searching for an identity. In many ways, restaurants are one of Atlanta’s strongest facets,” says Krista Reese, dining editor for Georgia Trend Magazine and author of two Atlanta cookbooks.

Reese notes that while other cities may have signa-ture foods and restaurants, Atlanta is different. “Atlanta is a port city, an airport city, a crossroads,” she says. “It has an interesting mix of cultures. That is its strong point. It’s a restless commuter-driven city. There aren’t a whole lot of Atlanta-born natives here.”

“Compared to other Southern cities, Atlanta is a new city, and we don’t have a lot of the really old tra-ditional restaurant stalwarts,” says Susan Puckett, former food editor for The Atlanta Journal-Constitution,

a food writer for Atlanta Magazine, and the author of Eat Drink Delta: A Hungry Traveler’s Journey Through the Soul of the South. “Yet the restaurant scene is very alive and very exciting. The chefs have a tremen-dous amount of integrity and individuality that I think is really interesting and exciting. When you come to Atlanta, you can choose basically whatever kind of dining experience you want.”

According to Rachel Peavy, director of communica-tions for the Atlanta Convention and Visitors Bureau, “In the past five years alone, 45 Atlanta chefs have been nominated as semifinalists for the James Beard Awards. Atlanta is known for Southern hospitality, and that translates into a very approachable dining scene that’s not at all pretentious. I think that’s what makes our dining scene unique; our local chefs open restau-rants that cater to each neighborhood, providing a warm welcome and inviting ambiance that makes their food—even high-end food—very accessible.”

GETTING AROUND THE DINING NEIGHBORHOODS“What makes the Atlanta dining scene unique are the various pockets of restaurants,” says Mara Davis, cohost of Atlanta Eats TV and host of Atlanta Eats radio. “Each area has it’s own culinary personality.”

Susan Nicholson, RDN, LD, an Atlanta-based syndi-cated columnist and the author of 7-Day Menu Planner for Dummies, says there are several great places within an easy taxi ride from your conference hotel. The Atlanta Beltline Eastside Trail is a great walking and biking trail that connects Midtown Atlanta to other in-town neighbor-hoods. You also can use Uber (www.uber.com), a trans-portation network company that allows users to request a chauffeur via mobile app, or MARTA (www.itsmarta.com), Atlanta’s public transit, to get you to your dining destination for the evening. And the Atlanta Streetcar, which just opened this summer, provides easy access from downtown hotels to restaurants. Check out the Atlanta Convention and Visitors Bureau’s neighborhood map guide at www.atlanta.net/explore/neighborhoods.

To wrap your mind around the food scene of Atlanta, Peavy gives a crash course on some of the city’s neigh-borhoods, including a few restaurant highlights.

Downtown, where the Georgia World Congress Center and nearby hotels are located, offers more than 300 restaurant options within walking distance. While you can find several familiar chain restaurants right across from the convention center, you may want to try something more quintessential Atlanta. Alma Cocina (191 Peachtree Street NE, 404-968-9662, http://alma-atlanta.com) is a local favorite, offering modern Latin cuisine featuring fresh ingredients. Sundial (210 Peachtree Street NW, 404-659-1400, www.sundialres taurant.com), a gorgeous revolving restaurant with a 360-degree panoramic view of the Atlanta skyline, offers

If you’re headed to FNCE®

next month, get ready to

discover Atlanta’s intriguing

dining scene. This city has

reinvented Southern food, with

a mischievous wink to ethnic

inspiration and a reverent nod

to history. We asked some

of Atlanta’s top food experts

to weigh in on what’s hot in

Atlanta’s food scene.

BY SHARON PALMER, RDN

RIGHT: PHOTO BY JAMES CAMP PHOTOGRAPHY COURTESY OF GREEN OLIVE MEDIA september 2014 www.todaysdietitian.com 25

Page 26: Today's Dietitian

seasonal, local cuisine such as wild Gulf shrimp with house-cured bacon and warm potato salad.

Midtown is just minutes up Peachtree Street, where you can find some of the hottest restaurants in the city, such as Empire State South (999 Peachtree Street, 404-541-1105, www.empirestatesouth.com), where chef, owner, and Top Chef judge Hugh Acheson takes a modern approach to creating authentic Southern dishes, relying on regional foods. South City Kitchen (1144 Crescent Avenue, 404-873-7358, http://midtown.southcitykitchen.com) boasts authentic yet sophisticated Southern cuisine, where you may even spot a celebrity or two since this eatery tends to be a favorite for stars in town filming movies.

Buckhead, known as the “Beverly Hills of the East,” lies further up Peachtree Street. There you’ll find high-end shopping and dining, including King + Duke (3060 Peachtree Road NW, 404-447-3500, www.kingandduke atl.com), run by one of Atlanta’s hottest chefs, Ford Fry, who helms other buzzworthy restaurants throughout the city (eg, St. Cecilia, 3455 Peachtree Road NE, 404-554-9995, http://stceciliaatl.com, for Italian coastline

fare; and JCT Kitchen & Bar, 1198 Howell Mill Road, 404-355-2252, www.jctkitchen.com, for Southern farm stand cooking). King + Duke, which GQ named one of this year’s best new restaurants in America, focuses on local, seasonal fare with a nod to American traditions.

Another Buckhead must-see is Bistro Niko (3344 Peachtree Road, 404-261-6456, www.buckheadrestau rants.com/bistro-niko), which Peavy describes as “a piece of Paris in the heart of Buckhead.”

Atlanta’s Eastside is just a few minutes east of down-town by taxi, where you’ll encounter some of Atlanta’s oldest original neighborhoods. Check out Rathbun’s (112 Krog Street, 404-524-8280, www.kevinrathbun.com), one of the most popular steakhouses in the city, run by Iron Chef America contestant Kevin Rathbun.

Atlanta’s Westside, a few minutes west of Midtown, is the city’s historic meatpacking district, now trans-formed into a destination for dining and design. This is home to Bacchanalia (1198 Howell Mill Road, 404-365-0410, www.starprovisions.com/bacchanalia.php), one of Atlanta’s most celebrated restaurants, where chefs and owners Anne Quatrano and Clifford Harrison offer a seasonal five-course prix fixe menu for $85, featur-ing seasonal organic ingredients sourced from their own farm.

Beyond Atlanta proper, Decatur, located 7 miles from the convention center, awaits your discovery. “Decatur used to be considered an Atlanta suburb, but now it’s considered an in-town neighborhood. There’s a won-derful walking neighborhood feel. A lot of people talk about Decatur like it’s Atlanta’s Berkeley. It has won-derful food,” Reese says.

“Decatur is a foodie heaven. You can walk to a dozen different really great dining options, some of which are on the James Beard Award–winning chefs list. There are also more inexpensive local options—more neigh-borhood joints—that are really good,” says Puckett, who lives in Decatur.

Leon’s Full Service (131 E Ponce De Leon Avenue, 404-687-0500, www.leonsfullservice.com), which is housed in an old gas station, offers casual fare with a fresh, elegant touch, such as pan-seared trout with baby bok choi, broccoli, and jicama hash.

Nearby sits No 246 (129 E Ponce De Leon Avenue, 678-399-8246, www.no246.com), where Fry serves up local, seasonal foods with an Italian flair.

Chai Pani (406 W Ponce De Leon Avenue, 404-378-4030, www.chaipanidecatur.com) is a small restaurant serving contemporary, vibrant Indian street food, and Paper Plane (340 Church Street, 404-377-9308, www.the-paper-plane.com) offers modern classic dishes sourced locally, such as Creekstone ribeye cap flat iron steak with kale and fingerling potatoes.

Sundial Restaurant, Westin Peachtree Plaza

ATLANTA DINING

LEFT: PHOTO COURTESY OF ACVB/ATLANTAPHOTOS.COM26 today’s dietitian september 2014

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PAST MEETS PRESENTAtlanta, the home of Gone With the Wind, also has its fair share of romantic historical intrigue. While you’re there, visit the Margaret Mitchell House (www.atlanta historycenter.com/mmh).

But probably most notable is that the city’s gaining attention as the cradle of the civil rights movement. The historically black colleges in Atlanta, such as Spelman, Morris Brown, and Morehouse, helped develop black leadership during the civil rights movement. And let’s not forget that it’s the birthplace of Martin Luther King, Jr. You can visit the Martin Luther King Jr National His-toric Site (www.nps.gov/malu/index.htm) and the brand new Center for Civil and Human Rights museum (www.civilandhumanrights.org) during your trip.

Today, Atlanta’s historic past blends into its cui-sine. “Atlanta has an interesting take on preserv-ing the past; they’re bringing back the plate foods that go beyond typical fried chicken, which is always wonderful,” says Suzanne Corbett, a freelance food writer and food historian who studied Atlanta cuisine while on assignment for the St Louis Post-Dispatch. “But new restaurants are taking an updated South-ern bistro chic approach to food.”

Corbett was particularly drawn to Swan Coach House (3130 Slaton Drive NW, 404-261-0636, www.swancoach house.com), a restaurant serving lunch in the historic carriage house of the Swan House mansion, now on the grounds of The Atlanta History Center. “It’s a great retro tea room, which is something you just don’t see anymore, with a fascinating 1950s ‘ladies who lunch’ menu that’s just delightful. Their signature dessert is a meringue base with a light milk chocolate whipped mousse decorated with puff pastry shaped like a swan—it’s one of those beautiful things that used to be the norm 50 or 60 years ago.”

And the history lesson doesn’t stop there for Corbett, who raves about Livingston Restaurant and Bar (659 Peachtree Street NE, 404-897-5000, www.livingstonat lanta.com), located in The Georgian Terrace hotel, famous for its white marble columns, crystal chandeliers, and long list of glittering celebrities who have been gracing its doors since 1911, including the cast of Gone With the Wind and F. Scott Fitzgerald. With its stunning space and evocative dishes, such as sweet tea pressed crispy duck and sorghum and sea salt brick chicken, Corbett says this restaurant “just knocks it out of the park.”

NEW SOUTH CUISINE“Atlanta’s take on Southern [cuisine] raises the stan-dard with high-end creativity,” Davis says. Chef Kevin Gillespie, of the popular Atlanta restaurant Gunshow, adds that “many Atlantans aren’t from the South, so it

tends to be a mix of both popular Southern dishes as well as more modernized variants.”

“We’re seeing a lot more restaurants with an ethnic flavor that also combine Southern flavors. We have Mexican chefs incorporating turnip greens and bar-beque into their menus, and Asian chefs doing really interesting things with okra. This really is the flavor of Atlanta; we’re Southern, but we’re also international,” says Puckett, who calls this style of cuisine “ethnic Southern mashup.”

So which restaurants fully exemplify Atlanta’s distinc-tive take on Southern food? Davis nominates Gillespie’s restaurant Gunshow (924 Garrett Street, 404-380-1886, www.gunshowatl.com), with its unique Southern dim sum–style fixings, as one of the city’s brightest stars. Puckett agrees: “Kevin Gillespie was a Top Chef final-ist, and his style of dining is unique. He has a team of

TOPLivingston

Restaurant + Bar’s dining room

BOTTOMSeared Maine diver scallops at Livingston

Restaurant + Bar

RIGHT: PHOTOS BY JAMES CAMP PHOTOGRAPHY COURTESY OF GREEN OLIVE MEDIA september 2014 www.todaysdietitian.com 27

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energetic, young, talented chefs who cook something different and bring out trays of foods in tapas portions on a tray. You either take it or pass on it. It’s a really fun way to dine.”

Many of our food experts point to Sobban (1788 Clair-mont Road, 678-705-4233, www.sobban.com) for its inspired Korean Southern diner–style food, such as okara hushpuppies and shrimp and rice grits served with miso kale. “It’s a really clever Korean diner run by a couple—she’s Korean and he’s Southern. Their heir-loom barbeque is traditional Southern, but they serve it with kimchi coleslaw. They seamlessly slip in Korean flavors in a natural way because that’s how they cook as a couple,” Puckett says.

Another Southern mashup winner is Cardamom Hill (1700 Northside Drive, 404-549-7012, http://cardamom hill.net). “Asha Gomez is from India, and she’s a fasci-nating chef who’s getting a lot of media attention—and for good reason. She combines Southern and Kerala [the southwestern-most state of India] flavors in a bril-liant way,” Puckett says. Davis says you’ll find an Indian twist on Southern classics, such as fried chicken and waffles and shrimp étouffée.

Poor Calvin’s (501 Piedmont Avenue, 404-254-4051, http://poorcalvins.com) “proudly embraces its Vietnam-ese roots and serves Thai-Southern dishes,” Reese says. Chef Calvin Phan’s menu includes everything from mac and cheese and fried chicken to his popular “duck dynasty,” which features maple duck breast, tiger

shrimp, kale mashed potatoes, and seasonal greens. As an added bonus, Poor Calvin’s offers a free Uber ride to and from any downtown hotel.

SOUTHERN COMFORT If you’re craving some good ole Southern comfort food, you’ll find that in Atlanta, too. Puckett recommends Busy Bee Café (810 Martin Luther King, Jr Drive SW, 404-525-9212, www.thebusybeecafe.com) for a “mem-orable, traditional soul food experience in a historic neighborhood.” An Atlanta tradition since 1947, the menu includes classics, such as fried chicken, pork chops, collard greens, and Georgia peach cobbler.

Though it’s touristy, Mary Mac’s (224 Ponce De Leon Avenue NE, 404-876-1800, www.marymacs.com) is “the real deal—it’s a Southern institution,” Puckett says. This is where you can get your fill of comfort food, includ-ing fried green tomatoes and okra, shrimp and cheese grits, and of course, fried chicken.

The Varsity (61 North Avenue, 404-881-1706, www.thevarsity.com), a hot dog place dating back to 1928, claims the title of the world’s largest drive-in. Puckett says it’s one of “the old stalwarts that people in Atlanta go to” for chili cheese dogs, onion rings, a frosted orange, and fried pies.

Then there’s Paschals (180-B Northside Drive, 404-525-2023, www.paschalsatlanta.com), located in the Castleberry Hills Art District. “The original location [on West Hunter Street] is where Martin Luther King, Jr planned his strategy,” Reese says. Called the unofficial headquarters of the civil rights movement, it was one of the first restaurants to seat black and white patrons together during the segregation era. “The fried chicken is still the same,” she says, and the collard greens, mac and cheese, black-eyed peas, and candied yams aren’t bad either.

If you’re looking for a more refined take on Southern cuisine, try Watershed on Peachtree (1820 Peachtree Road NW, 404-809-3561, http://watershedrestaurant.com). Located in a historic neighborhood, this award-winning restaurant employs a farm-to-table philosophy to deliver Georgian flavors in dishes such as Cajun-style beignets with country ham, jambalaya with butter-poached shrimp, and hot milk cake with caramel icing—washed down with a mint julep, of course.

PURE ETHNIC INSPIRATIONWhat if you feel like authentic ethnic food with nary a Southern touch in sight? Don’t worry because Atlanta’s got that, too. “We’ve got it all, from Persian to Peru-vian,” says Carolyn O’Neil, MS, RDN, LD, author of Southern Living’s The Slim Down South Cookbook and a columnist for The Atlanta Journal-Constitution. “It’s

Pan roasted duck breast with peach, hazelnut, nasturtium and foie gras three ways at Gunshow

ATLANTA DINING

LEFT: PHOTO BY ANGIE MOSIER28 today’s dietitian september 2014

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pretty amazing to experience authentic global cuisine without a trip out of town.”

And, luckily, much of the best ethnic food is located in one thoroughfare: Buford Highway. “Buford Highway is just one ethnic hole in the wall after another,” Puckett says. “Buford Highway is endless: Chinese, Thai, Viet-namese, Malaysian, Mexican, Indian, Peruvian, and the phenomenal Buford Highway Supermarket,” Davis adds.

Gu’s Bistro (5750 Buford Highway, 770-451-8118, www.gusbistro.com) serves award-winning authentic Szechuan cuisine, such as Zhong-style pork dumplings, Chengdu cold noodles with bean sprouts and scallions, and Luo Jiang dried tofu with sweet and spicy sauce.

Co’m Vietnamese Grill (4005 Buford Highway, 404-320-0405, www.comgrillrestaurant.com) is a local fan favorite for fresh Vietnamese dishes such as rice vermicelli with grilled beef and shrimp, pho, and grape leaf rolls.

Outside of Buford Highway, Desta Ethiopian Kitchen (3086 Briarcliff Road, 404-929-0011, www.destaethio piankitchen.com) has excellent Ethiopian food within a comfortable setting. It’s a great option for vegetarian palates, with dishes such as shiro (chickpea stew) and gomen (spiced collard greens).

Taqueria del Sol (1200-B Howell Mill Road, 404-352-5811, www.taqueriadelsol.com) can help you satisfy your Mexican food cravings. Owner Eddie Hernandez throws a little Southern heat into his signature Mexi-can dishes, such as Memphis BBQ tacos, fried chicken tacos, and spicy turnip greens.

LOCAL FOOD MOVEMENTIf you’re wondering how the local food movement is coming along in Atlanta, it’s doing just fine, according to O’Neil, who says, “There’s an active farm-to-table, ranch-to-table, and coop-to-table movement. This is where all the farms are, as well as farmers’ mar-kets, Southern-made cheeses, charcuterie, and even house-canned, pickled, and preserved produce.”

Executive Chef Franck Steigerwald at The Café at the Ritz-Carlton, Buckhead (3434 Peachtree Road NE, 404-237-2700, www.ritzcarlton.com/en/Properties/Buckhead/Dining/TheCafe), which serves fresh cuisine inspired by Italian and French flavors, says, “There’s a strong farm-to-table trend in Atlanta, and restaurants have the ability to create dishes using local and farm-fresh ingredients.”

Many restaurants have local food artisans, includ-ing High Road Craft Ice Cream & Sorbet, Doux South Pickles, H&F Bread Co, Sweet Grass Dairy, Grassroots Farms (poultry), and The Spotted Trotter (meats). O’Neil suggests visitors check out the Preserving Place (1170 Howell Mill Road, 404-815-5267, www.preservingplace.

com) “where they sell house-made preserves and even do classes on home canning.”

“Local food is super important to the dining commu-nity here,” Davis says. “We have so many great purveyors and chefs who make it a point to showcase local food on their menus.” This is true of Atlanta’s most famous chefs, such as Acheson and Fry, and many more chefs join their ranks. For example, Miller Union (999 Brady Avenue NW, 678-733-8550, www.millerunion.com) does “a very plant-focused menu,” according to Puckett. “The chef puts pro-duce first and foremost and works very seasonally and closely with local farmers.” This is easy to see in dishes such as field pea hummus and farro ravioli with squash blossoms and duck egg.

Chef Billy Allin, who got his culinary start at Chez Panisse in Berkeley, California, and later Napa Valley, helms Cakes & Ale (155 Sycamore Street, 404-377-7994, www.cakesandalerestaurant.com). His appreciation for local seasonal foods shines through on his menu, which includes a rainbow of produce from fennel and pole beans to squashes and kohlrabi.

Led by Linton Hopkins, Restaurant Eugene (2277 Peachtree Road, 404-355-0321, www.restauranteu gene.com) “is a wonderful place, and the chef has won

TOPTagliatelle pasta

with sea urchin at The Café at

the Ritz-Carlton, Buckhead

BOTTOMMiller Union’s

seasonal summer vegetable plate

TOP: PHOTO COURTESY OF BEN ROSE PHOTOGRAPHY; BOTTOM: PHOTO BY CRAIG BRIMANSON september 2014 www.todaysdietitian.com 29

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many awards. It’s gorgeous and elegant, offering craft cocktails and heirloom vegetables,” says Reese of its farm-to-table fare. You can even find a vegetable tasting menu here with delectable dishes such as wild black-berry gazpacho with sorrel and clay pot Vidalia onion with parsley and cracklin.

MORE NOTEWORTHY DINING“We’ve got breadth and depth in our dining scene,” Reese says. While it’s impossible to list all of Atlan-ta’s finest restaurants in the confines of this article, a few more deserve special mention.

At the top of that list is Polaris (265 Peachtree Street NE, 404-577-1234, http://www.atlantaregency.hyatt.com), a great revolving blue restaurant perched atop the Hyatt Regency. “For someone visiting, it’s one of the most exciting things to see. It goes back to the ‘60s, but it’s just been given a huge makeover, and it’s straight out of Mad Men,” Puckett says. “It’s a great place to have small bites and cocktails, and it’s great fun,” Reese adds.

The General Muir (1540 Avenue Place B-230, 678-927-9131, www.thegeneralmuir.com) is a modern Jewish deli, with house-cured meats and two-fisted deli sandwiches that transport you back to Brooklyn. “They’re incorporating modern flavors with really classic foods, such as pastrami and house-made bagels,” Puckett says.

And the list goes on, according to O’Neil, who says, “You’ll find the millennial crowd at artisanal pizza places, such as Ammazza (591-A Edgewood Avenue SE, 494-228-1036, http://ammazza.com), and sushi fanatics and a real sexy crowd at Umi (3050 Peachtree

Road NW, 404-841-0040, http://umiatlanta.com). And no trip to Atlanta, if you’re a foodie, would be complete without checking out Holeman & Finch Public House (2277 Peachtree Road, 404-948-1175, www.holeman-finch.com), where you’ll find everything from oyster po’ boy to fried lacinato kale with blueberry preserves in this sophisticated pub.”

“For a special occasion, Aria (490 East Paces Ferry, 404-233-7673, www.aria-atl.com) never misses. It has a sleek, sexy atmosphere with excellent food from Chef Gerry Klaskala,” Davis says. Menu offerings have included herb-crusted fillet of red snapper with Tucker Farms basil emulsion and preserved lemons.

La Tavola (992 Virginia Avenue NE, 404-873-5430, http://latavolatrattoria.com) “is my favorite neighbor-hood spot for simple, fresh Italian,” Davis says. And Gillespie adds BoccaLupo (753 Edgewood Avenue NE, 404-577-2332, http://boccalupoatl.com) to the neigh-borhood Italian eatery list, “for their handmade pastas. They’re very passionate about the craft of cooking.”

Our experts also enthuse over Ecco (40 7th Street NE, 404-347-9555, www.ecco-atlanta.com), which serves award-winning, seasonally inspired European fare, such as wood-fired pizzas and cured meat and cheese plates.

Your eating choices are endless in Atlanta, so make sure to carve out time to experience at least a few of them. For additional guidance, check out our Atlanta Dining Resources.

— Sharon Palmer, RDN, is a contributing editor to Today’s Dietitian and the author of The Plant-Powered

Diet and Plant-Powered for Life.

Access Atlanta (www.accessatlanta.com)

Atlanta Downtown Improvement District Downtown Atlanta Dining (www.atlantadowntown.com/guide/dining)

Atlanta Eats (www.atlantaeats.com)

Atlanta Eater (www.atlanta.eater.com)

Atlanta Journal-Constitution (www.ajc.com)

Atlanta Magazine (www.atlantamagazine.com)

Food & Wine Atlanta Travel Guide (www.foodandwine.com/atlanta-travel)

Zagat, Atlanta (www.zagat.com/atlanta)

ATLANTA DINING RESOURCES

LEFTSpring vegetables at Restaurant Eugene

RIGHTSquash blossom, crawfish, vichyssoise, caviar at Restaurant Eugene

ABOVE: PHOTOS COURTESY OF RESTAURANT EUGENE30 today’s dietitian september 2014

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With each powerful contraction, the human heart forces a strong wave of blood into the arteries. The blood presses against the vessel walls, which stretch and flex against the force,

smoothing out the flow and moving it along. Many Americans believe that eating too much cholesterol

leads to plaque buildup in the artery walls, blocking that flow and increasing the risk of heart attack and stroke. Unfortu-nately, this is untrue. Only one-half of all heart attack and stroke victims have elevated cholesterol levels,1 as there are many other factors that contribute to the development of car-diovascular disease (CVD). The good news is a nutritious diet can help maintain a clear, flexible, healthy circulatory system.

Healthy Circulatory SystemWhen the circulatory system is functioning normally, the

heart sends blood to the lungs to collect oxygen and then cir-culates that oxygen- and nutrient-rich blood to all cells in the body. Arteries carry blood away from the heart to the lungs, brain, or the rest of the body, and veins bring it back.2

Arteries and veins are lined with endothelial cells, which keep those blood vessels flexible, supple, and strong. This vas-cular endothelium (lining of blood vessels) controls vasodilation (widening of blood vessels) and vasoconstriction (narrowing of blood vessels). It’s also in charge of mounting an immune response and repairing any damage to blood vessels.2

Unhealthy Circulatory SystemPhysicians have long been aware that arteries thicken and

harden as we age as a result of plaque buildup. Tradition-ally, this process, called atherosclerosis, was treated by plac-ing stents in blocked arteries to hold them open, removing the narrowed sections through bypass surgery, or using statins to lower LDL cholesterol to slow plaque buildup.

“There was an awakening in the cardiology world several years ago,” says David Becker, MD, a cardiologist with Chestnut Hill Temple Cardiology in Philadelphia and originator of Healthy

Change of Heart, a lifestyle intervention program for individuals who have high cholesterol or are concerned about heart health. “Plaque is not just about LDL cholesterol; it’s a multifactorial process. In fact, the presence of elevated LDL cholesterol levels only explains about half of all acute cardiovascular events.”

According to Becker, physicians used to think that plaque built up over a lifetime like rings on a tree. They now know that irritation of the vascular endothelium causes plaque to grow. When the endothelium is irritated or damaged, it mounts an immune response to fix the problem. It’s this immune response that ultimately leads to plaque development.

It’s possible for plaque to remain stable, but if an area where plaque has developed continues to be irritated, the plaque can rupture. “If the plaque becomes irritated by inflammation, a scab or clot will form,” Becker says. “That’s when you need emergency intervention.”

The clot can completely block an artery and cause a heart attack or stroke. “Inflammation is as important, or more impor-tant, than factors like cholesterol level in the development of cardiovascular disease,” Becker adds.

Inflammation and Risk FactorsAnything that damages the artery walls or otherwise causes

inflammation is a risk factor for CVD. Tobacco smoke is an example of a toxin that irritates the lining of blood vessels, trig-gering plaque formation. LDL cholesterol particles are part of the makeup of plaque, but their presence in the blood also causes inflammation. (HDL cholesterol, on the other hand, helps prevent inflammation.)

High blood pressure damages the arteries in another way: The increase in pressure overstretches the artery walls, lead-ing to small tears that scar over with plaque. Even systemic inflammation caused by stress, lack of sleep, inflammatory dis-ease, or obesity affects the arterial lining. High blood sugar and high triglyceride levels also contribute to inflammation.3,4 Con-trolling these risk factors with diet and other lifestyle changes can decrease the risk of heart attack and stroke.

Arterial HealthDiet &

It Isn’t Just About Elevated Cholesterol Levels

The Link Between

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By Judith C. Thalheimer, RD, LDN

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Dietary ImpactDiet can be a powerful tool in protecting the lining of the arter-

ies from damage. The ideal diet for healthy arteries minimizes harmful factors such as high LDL cholesterol and elevated blood sugar, blood pressure, and triglycerides, and maximizes factors that increase HDL cholesterol, support vasodilation and arte-rial elasticity, discourage clotting, and reduce oxidative stress to keep the vascular endothelium healthy.

Plenty of information is available on what not to eat, as sat-urated fat, trans fat, cholesterol, sodium, and added sugars clearly are associated with clogged arteries. Research now is focusing on what food components may positively impact arter-ies, including the following: •Unsaturated fats can help reduce LDL cholesterol levels

when eaten in moderation in place of saturated or trans fats.

They’re mainly found in fish such as salmon, trout, and herring; avocados; olives; walnuts; and liquid vegetable oils such as soy-bean, corn, safflower, canola, olive, and sunflower.5

Omega-3 fatty acids have been the focus of much research. These polyunsaturated fats are found in fish but also in plant foods such as flaxseeds, Chinese broccoli, and wheat germ and are thought to make the vascular endothelium healthier and stronger and also improve vasodilation.6-8 •Antioxidants, which are abundant in plant foods, reduce

LDL oxidation, which helps lower inflammation and prevent plaque buildup.7

Flavonoid antioxidants such as those found in cocoa and red wine decrease inflammation, boost HDL cholesterol levels, and stimulate nitric oxide production. Nitric oxide, a key trigger of vasodilation, helps lower blood pressure and reduce blood clotting.7

Vitamin C is an antioxidant that’s converted in the body to collagen and elastin that help keep blood vessel walls flexible and strong.9 Besides its powerful antioxidant action, vitamin E promotes healthy circulation by keeping platelets from sticking together and forming clots.9 •B vitamins such as B6, B12, and folic acid (folate) help break

down homocysteine in the body. According to the American Heart Association (AHA), evidence suggests that homocysteine dam-ages the vascular endothelium, promoting atherosclerosis, and that high serum levels of homocysteine have been associated with a greater risk of coronary heart disease, stroke, and periph-eral vascular disease. It should be noted, however, that a causal link hasn’t been established, and currently the AHA doesn’t rec-ognize high homocysteine levels as a risk factor for CVD.10

•Arginine is an amino acid found in plant and animal proteins. Especially abundant in nuts and legumes such as lentils, the form L-arginine is a precursor of nitric oxide, which may help keep blood vessels dilated and improve blood flow.2 However, results of studies on L-arginine supplementation have been inconsistent.11

•Fiber-rich foods (eg, whole grains, fruits, vegetables, legumes, nuts, seeds) are high in many of the beneficial compo-nents listed above, but fiber itself can help lower LDL cholesterol levels, support weight-loss efforts, and control blood sugar.

The food and beverage industries are seeking to capitalize on the possible cardiovascular benefits of individual food compo-nents by adding omega-3s, olive polyphenols, cocoa flavanols, and chitin-glucan fiber, an insoluble fiber derived from the cell walls of the mycelium of Aspergillus niger, to processed foods.1

Role of Dietary PatternsEating less saturated and trans fats, cholesterol, sugar, and

sodium and more omega-3 fatty acids, fiber, and antioxidants can be beneficial, but simply adjusting the intake of these par-ticular components isn’t the answer, says Alice H. Lichtenstein, DSc, director and senior scientist at the Cardiovascular Nutri-tion Laboratory at Tufts University and a spokesperson for the AHA. “When someone decreases their intake of one food, most people compensate by automatically increasing their intake of another. If there’s a biologic effect, we don’t know whether it’s due to the lack of the one food or the substitution of the other,” she says. “When individual nutrients have been studied to decrease CVD risk, for the most part, the results have been null, and in some cases concern has been raised when very high levels of single nutrients were used.”

While the media and food companies tend to focus on indi-vidual components of food, “there tends to be too much focus on single nutrients. We need to get away from trying to assign an effect to an individual food or nutrient and think in terms of dietary patterns,” she adds.

The 2013 AHA/American College of Cardiology (ACC) Guideline on Lifestyle Management to Reduce Cardiovascular Risk recom-mends a dietary pattern of fruits, vegetables, whole grains, low-fat dairy products, poultry, fish, and nuts with limited red meat and foods and beverages high in sugar.12 This dietary pattern sup-plies plenty of arterial health-boosting nutrients without adding any special foods or supplements. “Most people will lower their blood pressure by restricting salt and getting enough potassium,” Lichtenstein explains. “Getting adequate potassium happens automatically when we eat more fruits and vegetables.”

And the benefits of a healthful dietary pattern go beyond a single nutrient. “Sure, a fiber-rich diet may have some impact on lowering LDL cholesterol levels, but you also get other benefits when you eat fiber-rich foods like fruits, vegetables, legumes, nuts, and whole grains such as essential nutrients and healthful fats,” Lichtenstein notes.

Putting It Into PracticePatti Morris, RDN, CDE, is an independent contractor who

works with cardiology patients in Philadelphia and is the nutri-tion educator for Healthy Change of Heart. She recommends a modified Mediterranean-style eating pattern in line with the AHA/ACC guideline to her clients and avoids advocating for spe-cific food components. “People get confused when they hear they should eat more antioxidants,” she says. “I just tell them to eat more fruits and vegetables. They all have antioxidants.”

To increase fruit and vegetable intake, Morris encourages her clients to aim for 3 cups of vegetables and two pieces of

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fruit every day and to eat as many colors as possible. “I find it helps to give them good/better/best scenarios,” she explains. “It’s reassuring to them to know they don’t have to do every-thing right all the time. Any change is a good change.”

Since her patients already have heart disease, Morris rec-ommends chicken, turkey, and fish almost exclusively, elimi-nating or at least cutting back on egg yolks and focusing on the quantity and type of fat in the diet, emphasizing mono- and poly-unsaturated fats in place of saturated fat. “I also strongly rec-ommend eating beans. They’re like a magic food: high in fiber, filling, and they help stabilize blood sugar,” she adds.

Alissa Rumsey, RD, CDN, CNSC, CSCS, a dietitian, personal trainer, and spokesperson for the Academy of Nutrition and Dietetics, recommends a similar dietary pattern with more mono- and polyunsaturated fats from foods such as olive oil and avocados, nuts, seeds, omega-3 fats from fish, and plenty of fruits and veggies. “All the food components that help keep arteries healthy are in these foods,” she says.

She encourages clients to fill at least one-half of their plates with brightly colored vegetables at lunch and dinner. “I give them specific ideas for adding beneficial foods to their diets, like using avocado slices on a sandwich instead of may-onnaise, stirring walnuts into oatmeal, or sprinkling almonds over a couscous with veggies.”

However, just following a healthful dietary pattern isn’t the whole answer. “You have to look at this in the context of energy balance,” Lichtenstein cautions. “You can eat the best heart-healthy, nutrient-rich diet, but if you take in an excess of energy, you’re not likely to see the benefit.” Obesity goes hand in hand with artery-damaging conditions such as high blood pressure, high cholesterol, and diabetes, and it’s associated with a gen-eral rise in inflammation.

Morris counsels overweight clients to lose weight. “You don’t have to get back to your high school weight,” she explains. “Any loss is good.”

To encourage moderation, Morris suggests decreasing fat intake and talks to her clients about portion control using food models to demonstrate appropriate portion sizes.

Rumsey advocates watching sugar consumption. “People don’t realize all the hidden names for sugar: evaporated cane juice, fruit juice concentrate, and dextrose [for example]. Excess sugar can cause inflammation in the body, and it adds to the overall excess of calories that leads to weight gain.”

Insulin resistance makes losing weight difficult, so Morris advocates patience. “Clients with fasting blood glucose over 100 may not lose weight right away, but I reassure them that if they stick with it, the weight will start to come off. It helps them to know I’ve seen it work,” she says.

Other Lifestyle ChangesNonetheless, achieving optimal arterial health requires

more than just eating healthfully and managing weight. “It’s important for dietitians to help clients make other lifestyle changes,” Rumsey says. Quitting smoking, getting enough

sleep, reducing stress, and increasing physical activity are all essential to maintaining healthy arteries.

Rumsey offers tips for including these topics in nutrition counseling sessions: “Try to have clients pencil in at least 10 or 15 minutes of relaxation time each day, even if it’s just turn-ing off their computer monitor and taking deep breaths at their desk. I like meditation for stress release, but reading, walking, or taking a bath can all help them leave the world behind.”

Rumsey also emphasizes sleep to keep inflammation in check. “Lots of research has shown that less than six hours of sleep can result in more inflammation,” she says. “Older adults that already have high blood pressure and then don’t get enough sleep increase their risk of heart attack dramatically. I encourage clients to get seven or eight hours a night.”

Increasing physical activity is particularly important, as regular physical exercise is associated with improvements in blood pressure, decreases in LDL cholesterol levels, increases in HDL cholesterol levels, and improved glucose metabolism and body weight, and it promotes an antioxi-dant state that helps keep the vascular endothelium healthy.7 “How active you are correlates to how long you live,” Becker says. “The more active you are, the less likely you are to have a cardiac event.”

Rumsey encourages her clients to track their physical activ-ity along with food intake. “There are a lot of great apps and technologies out there now,” she says. “Some of them can even automatically share data with me.”

Bottom LineHealthy arteries are key to preventing heart attack and

stroke. Limiting irritation of the arterial lining reduces plaque buildup, keeping arteries open and flexible.

A healthful dietary pattern can have a big impact on reduc-ing inflammation. Following a diet rich in fruits, vegetables, whole grains, low-fat dairy products, poultry, fish, and nuts with limited red meat and foods and beverages high in sugar ensures an intake of several inflammation-fighting nutrients and minimizes plaque-promoting factors such as saturated fat. Other lifestyle changes go hand in hand with diet to keep inflammation in check.

According to Becker, a healthful lifestyle does prevent CVD. “Less than 3% of Americans eat a good diet, exercise regu-larly, are not overweight, and don’t smoke,” he says. “But these people have a very low risk of heart attack and stroke.” Dieti-tians can help more people make the lifestyle changes neces-sary to keep their arteries healthy for a lifetime.

— Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer, a community educator, and

the principle of JTRD Nutrition Education Services.

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

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luten is like a four-letter word for people with celiac disease or

nonceliac gluten sensitivity. Yet for many others, gluten is considered a

magic ingredient. At least that’s how Sylvia Tam, vice president of sales and

marketing for gluten-free pasta manu-facturer Maplegrove Foods, describes it.

That magic ingredient has been associated with wheat pasta for hundreds of years, creating what most people refer to as pasta’s traditional (and much-loved) taste and texture. But it seems gluten-free product manufacturers are finding their own magic and creating different but still palatable pasta options that may lack the gluten but little else.

“Any gluten-free product presents a challenge to manufacturers, but the old saying, ‘Necessity is the mother of invention’ has led to giant leaps in the qual-ity, taste, and texture [of gluten-free pasta products] over the years,” Tam says, “so much so that non-celiacs are buying and enjoying gluten-free pastas. My favorite instance was when we launched our mac & cheese cups at the celiac show in Phoenix and a little boy, who was not the celiac member of the family, turned and remarked to his mother, ‘Mommy, this doesn’t taste gluten-free.’”

With new ingredient formulations, flavor combina-tions, and shapes offered on grocery shelves, the gluten-free pasta choices available today are plentiful, and many

say these options have a more desirable taste and texture than what existed a decade ago.

Today’s Dietitian interviewed a handful of gluten-free pasta manufacturers to get a peek into how they’re creating their gluten-free magic and then asked chefs and culinary RDs for their best cooking tips to help clients and patients make gluten-free pasta dishes and create their own magic at home.

More Choices, Better Options“There has been significant growth in the number

of pasta brands on the market, and we’ve had an active role in this, as we’re primarily a contract manufacturer,” says Tam, noting that Maplegrove Foods makes several gluten-free pastas, including Pastato and Pastariso. “A lot of familiar brands have originated in one of our two plants in California. Even without counting, I feel safe in stating that there are at least 10 times the number that existed 10 years ago.”

“The gluten-free pasta category is growing significantly across all channels,” says Constance Roark, MS, RDN, director of marketing for gluten-free pasta manufacturer Ancient Harvest, noting that not all gluten-free pastas are created equal in taste and texture. “We believe the category will continue to see steady innovation, and consumers will be faced with even a greater range of choices.”

While it may go without saying, it’s worth mentioning to clients and patients that one of the most important

By JULIANN SCHAEFFER

Gluten-Free

G

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A Review of the New Options on the Market Plus Cooking Tips for Delicious

Homemade Meals

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factors in choosing the right gluten-free pasta, even ahead of preference for celiac patients, is looking for a third-party seal indicating that the product is certified as gluten-free—something all experts interviewed here affirmed.

“It’s always wise to buy certified gluten-free products for safety’s sake,” says Carol Fenster, author of 11 gluten-free cookbooks, including Gluten-Free 101: The Essential Beginner’s Guide to Easy Gluten-Free Cooking. “Look for the logo on the package. As for ingredients, it’s really a matter of taste and personal preferences. I encourage people to try various brands to find one [they] like and then stick with it.”

Aside from the particulars involved in ensuring all products are safe from any potential cross-contamination, which involves sourcing from only audited gluten-free suppliers, Tam credits Maplegrove Foods’ flavor and texture improvements over the years with the quality and variety of ingredients they use in their pastas. “We use strictly non-GMO ingredients, which range from corn, rice, teff, amaranth, millet, quinoa, hemp, chia, flax, pre- and probiotics, vitamins and minerals, peas, and beans as is required by the formulation,” she says.

According to Tam, Maplegrove Foods has been consistently improving its products since the company’s inception in 1982, letting customer feedback guide its products’ evolution, including the importance of convenience in today’s society. “Today [vs. a few decades ago], our product holds up better. We now have microwavable versions [of some products] and soon will have one that rehydrates in hot water,” she says, adding that Maplegrove Foods recently tested a new formulation for a chickpea pasta.

According to Roark, Ancient Harvest pays close attention to creating the taste and texture it believes customers are looking for, and it believes quality ingredients are the way to get there. Ancient Harvest has determined that using certified organic and non-GMO ingredients are key attributes to getting the flavor and texture profiles it seeks from its products. For example, its Supergrain Pastas line is made up of an organic quinoa and corn flour blend. “Quinoa’s rich, nutty flavor combined with the organic corn flours in our proprietary blend give Ancient Harvest gluten-free pasta the familiar taste and al dente texture of traditional pastas,” Roark says, noting that the quinoa and corn combination gives the noodles a rich, nutty flavor.

Vegetable Lasagna

Serves 8 to 12

Ingredients1 T olive oil 1 medium onion, chopped2 cloves garlic, minced8 oz button mushrooms, sliced3 (8-oz) cans tomato sauce1 (6-oz) can tomato paste1⁄2 tsp dried basil1⁄2 tsp dried rosemary1⁄2 tsp dried thyme1⁄2 tsp dried oregano100 g superfine brown rice flour90 g tapioca starch 43 g corn flour (not corn starch)42 g potato starch4 large eggsCooking spray10 oz frozen spinach, thawed and

drained16 oz cottage cheese16 oz shredded mozzarella cheese

Directions1. Preheat oven to 375˚F. 2. Heat olive oil in a large skillet over medium-high heat. Add onion and garlic to skillet and cook until onion begins to turn

translucent. Add mushrooms and cook until they soften. Stir in tomato sauce, tomato paste, and herbs, and cook until combined and heated through. Remove from heat.3. Bring a large pot of salted water to a boil. Meanwhile, combine brown rice flour, tapi-oca starch, corn flour, and potato starch in a medium bowl. Make a well and add eggs. Stir well until mixture forms a ball. Remove to a lightly tapioca-starched sur-face and knead well. Roll between two tap-ioca-starched pieces of parchment paper, stopping frequently to rub starch over pasta dough, until dough is 1⁄8-inch thick. Cut dough with a fluted-cutter (or plain old knife) into 9- X 3-inch strips. Gather left-over scraps, and reroll and cut to make a total of 9 strips. Cook 3 strips at a time for 2 minutes in the boiling water, keeping remaining uncooked strips covered with a wet paper towel. 4. Spoon a thin layer of tomato mixture onto the bottom of a 13- X 9-inch baking dish coated with cooking spray. Lay three cooked pasta strips on the tomato mix-ture. Sprinkle evenly with 1⁄2 of the spinach and 1⁄2 of the cottage cheese. Spread 1⁄3 of the tomato mixture on top. Sprinkle 1⁄3 of the shredded mozzarella on top of tomato

sauce. Repeat layer once. Top with remain-ing three pasta strips, remaining 1⁄3 tomato mixture, and remaining 1⁄3 shredded mozza-rella. Cover with foil. 5. Bake for 45 minutes. Remove foil and bake an additional 18 minutes, or until cheese is melted and begins to brown.

Nutrient Analysis per servingCalories: 343; Total fat: 6 g; Sat fat: 2 g;

Trans fat: 0 g; Sodium: 1,280 mg; Choles-terol: 0 g; Total carbohydrate: 49 g; Dietary fiber: 4 g; Sugar: 10 g; Protein: 22 g— RECIPE AND PHOTO COURTESY OF GRETCHEN BROWN, RD

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“Our Garden Pagodas are also a nice option to serve plain because of the added spinach, beet, and red bell pepper” that add a nice flavor profile, she adds.

Heidi Gordon, marketing manager for Italian pasta maker Jovial Foods, says it’s difficult to make gluten-free pasta taste like traditional wheat pasta. Jovial uses Old World artisan techniques, such as extruding the pasta dough through bronze dies to create the shapes and a slower low-temperature drying technique. “This creates a delicious al dente pasta even non–gluten-free eaters can enjoy,” Gordon says. Jovial, which uses an organic brown rice blend for many of its pastas, also recently introduced the first organic gluten-free egg noodle.

Craig Schauffel is the chef at Three Bridges, a San Fran-cisco–based company that offers a refrigerated line of chef-crafted pastas, sauces, and meals, including a gluten-free filled pasta option in five cheese ravioli and butternut squash ravioli. According to Schauffel, the process of making cut and dried pastas allows for more flexibility when attempting to avoid the typical gumminess associated with gluten-free pastas because numerous other grains can be added to the dough mix. This isn’t so easy when making gluten-free raviolis. As such, when attempting to formulate Three Bridges’ fresh ravioli, Schauffel says he encountered additional obstacles that were unique to this pasta type.

“In fresh pasta like Three Bridges’ gluten-free ravioli, there are much bigger challenges to overcome when trying to get two sheets of dough to laminate together and create a seal when the gluten protein structure is absent,” he says. “Only corn and rice flour have enough starch to help with this type of process and are usually 75% or more of the dough formulation. You can add in some of the ancient grains, but if you add more than 10%, then the dough will not function—the seal will open up and the filling will leak out—for a fresh-filled ravioli.

“For filled pasta, you need to try and create that gluten weblike structure with functional gums and starches, using egg to create that al dente bite,” he continues, noting that it took him and his team at Three Bridges more than a year and a half to find the perfect blend of the right ingredients in the right amounts to mimic a ravioli similar to a wheat pasta.

Of course, for clients and patients interested in adding some adventure to their afternoon (an evening likely won’t suffice), they’re welcome to try their hand at making their gluten-free pasta at home—if they dare. “Absolutely, gluten-free pasta can be made at home, just as any wheat-based pasta is made,”

says Gretchen F. Brown, RD, founder of the gluten-free blog Kumquat and author of Fast & Simple Gluten-Free. “The only change is that the dough may require a binder, such as an extra egg yolk or a tiny bit of xanthan gum, if it becomes too tender.”

Over the years, Fenster has made her share of gluten-free pasta from scratch. She says the trick is finding the right blend of flavors. “My recipe includes flours from sorghum, potato, corn, and tapioca and also xanthan gum and eggs to bind it all together,” she says.

However, Fenster says because of the increased quality of today’s store-bought gluten-free pasta offerings, she’s often forgone homemade pasta. “I haven’t included a recipe for homemade pasta in any of my books since 2010 because I think that manufacturers are doing such a good job—especially with penne, tubular, and spiral pasta—that the home cook can’t possibly make a product that is as good, especially the tubular or spiral types,” she says. “That said, we can still make excellent gnocchi and flat pasta such as lasagna noodles.”

For those with the time and inclination, suggest clients and patients try their hand at Brown’s gluten-free lasagna on page 38, which is made with homemade corn lasagna noodles.

Gluten-Free Cooking TipsAccording to Fenster, one of the biggest complaints of gluten-

free pasta as a whole is its tendency to fall apart if overcooked. “It also tends to clump together if not served immediately after cooking,” she says. But according to the chefs and RDs interviewed here, there are ways to get the most out of any gluten-free pasta to ensure the end product turns out as intended, both in flavor and texture.

First, Fenster says directions on the back of the box are indispensable. While clients and patients may be accustomed to how long any given wheat pasta may take to reach al dente on their stove, every gluten-free pasta will be different, as different ingredients will require different cooking times. “Use plenty of water—4 cups for each 8 oz of pasta,” Fenster says, “and salt the water liberally after it starts to boil. Most pasta is mild, and salt brings out its flavor.”

Karen Morgan, founder of Blackbird Bakery in Austin, Texas, and author of The Everyday Art of Gluten-Free, also sees the importance of salt, not just for flavor but also to keep the pasta from sticking together. “I always use heavily salted water to both flavor the pasta as it cooks and to change the weight of the water,” she says. “When people swim in the Dead Sea, they

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float because there’s so much salt in the water. When you’re boiling pastas, the same principle applies: The pasta will float apart more readily, reducing the risk of sticking together in an unsightly lump.

“You also need to stir the pasta after you have added it to the water so this will not happen, but my general rule of thumb is to toss in 1.5 T of kosher salt per pound of pasta,” she adds.

Fenster recommends cooking the pasta just until it feels slightly soft when you bite into it—sometimes called al dente or “to the tooth”—but not soft. “Remove it from the heat and drain. It will continue to cook from residual heat even after it’s out of the boiling water,” she says.

Rocco DiSpirito, chef and author of The Pound a Day Diet, suggests modifying the cooking preparation time depending on the ingredients from which a pasta is made. “Quinoa is one of my favorite gluten-free pastas, but if you cook it like a wheat pasta, you will have a broken mess,” he says. “It needs to be blanched and then steeped in the sauce it’s ultimately destined for.”

Conversely, DiSpirito says corn pasta should be rinsed after boiling but recommends saving some of the cooking water, which he says is integral to giving sauces a silky texture and shine.

Unlike regular pasta, which can be more forgiving, Fenster says gluten-free pastas should be eaten immediately. “It will get mushy and break apart if it sits

in the pot or on a buffet table for an extended period of time,” she says. “Be gentle when you stir in the sauce so you don’t tear the pasta.”

Though gluten-free pastas will clump together when chilled, Fenster says a brief rinsing in hot water will separate the pasta pieces.

Because one of the “sticking points” of gluten-free pasta is its tendency to get mushy when overcooked, not all gluten-free varieties will survive in a casserole or soup. To solve this problem, DiSpirito suggests trying corn elbow pasta for any baked dish. “Just try to cook the dish beforehand and just use the oven’s broiler to brown the top instead of cooking the whole dish through,” he says.

Moreover, DiSpirito says that because gluten-free pastas can be made with different ingredients, not only will they cook differently, but some will pair better with certain flavor combinations. “Try quinoa pasta with shellfish or a corn-based pasta with creamy sauces,” he says, noting that farro pastas work well with mushroom sauces.

One need only take his advice to see how right he is. “Try a chestnut pasta with a simple Bolognese and tell me I’m wrong,” he says.

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

contributor to Today’s Dietitian.

Pesto Caprese Quinoa Penne Pasta Salad

Serves 4 to 6

Ingredients1 (8-oz) package Ancient Harvest

Penne Quinoa Pasta, cooking water reserved

1⁄3 to 2⁄3 cup chilled pesto sauce (homemade or store-bought)

1 pint cherry or grape tomatoesFresh mini mozzarella ballsSalt and pepperFresh basil, to top

Directions1. Bring a large pot of water to a boil. 2. Add pasta, stirring occasionally, for 6 to 9 minutes until just tender. Avoid overcooking. 3. Drain the pasta and reserve 1⁄2 cup of the cooking water in bowl.4. Run pasta under cold water to halt the cooking process and chill.

5. Place the pasta back in the pot and stir in the desired amount of pesto, adding 1 T at a time of cooking water to help spread. You will most likely only need 2 to 4 T of water. 6. Slice desired amount of tomatoes and mozzarella in halves or quarters and mix into the pasta.7. Taste and add salt and pepper if needed. Top with basil. This pasta salad is best when chilled for about 1 to 2 hours in the fridge but fine to serve immediately. Store leftovers in a sealed container in the fridge for three to four days. Add a good drizzle of olive oil to remoisten before eating.

Nutrient Analysis per servingCalories: 232; Total fat: 14 g; Sat fat: 4 g;

Trans fat: 0 g; Sodium: 314 mg; Cholesterol: 0 g; Total carbohydrate: 19 g; Dietary fiber: 2 g; Sugar: 4 g; Protein: 6 g— RECIPE AND PHOTO COURTESY OF ANCIENT HARVEST

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Brown Rice Tagliatelle With Creamy Mushrooms and Chickpeas

Serves 4

Ingredients9 oz Jovial egg tagliatelle8 oz mushrooms, sliced3 scallions, sliced3 T Jovial extra-virgin olive oil1 cup chickpeas1 clove garlic3⁄4 cup water2 T fresh parsley, minced

Directions1. Sauté mushrooms, scallions, 2 T of olive oil with salt to taste in a large skillet until tender.2. In a blender, purée 1⁄2 cup of chickpeas, garlic, 1 T of olive oil, and 3⁄4 cup of water until creamy.

3. Add chickpea cream and 1⁄2 cup of whole chickpeas to the skillet, turn heat to medium low, and cook until thickened, about 5 minutes.4. Cook pasta according to package instructions.5. Toss pasta with creamy mushrooms and chickpea sauce and serve garnished with freshly minced parsley.

Nutrient Analysis per servingCalories: 395; Total fat: 13 g;

Sat fat: 2 g; Trans fat: 0 g; Sodium: 184 mg; Cholesterol: 0 g; Total carbohydrate: 59 g; Dietary fiber: 5 g; Sugar: 3 g; Protein: 13 g— RECIPE AND PHOTO COURTESY OF JOVIAL FOODS

Gluten-Free Mac and Cheese Bites

Makes 36 appetizers

IngredientsGluten-free nonstick cooking spray1⁄2 lb Pastariso Gluten Free White

Rice Pasta Elbows (2 cups uncooked)

3⁄4 cup plus 2 T milk2 tsp corn or tapioca starch2 T butter1⁄2 white onion, very finely diced3⁄4 tsp kosher or fine sea salt1⁄2 tsp black pepper1⁄4 tsp nutmeg, freshly grated1⁄4 cup plus 2 T Parmesan cheese,

grated1 cup yellow or white cheddar

cheese, grated2 T gluten-free panko style bread

crumbs

Directions1. Preheat oven to 425˚F. Spray 36 mini muffin tins with gluten-free nonstick cook-ing spray.2. Cook the pasta in heavily salted boiling water per the package directions. Drain and rinse with hot water.3. In a small bowl, stir together 2 T of milk with the corn or tapioca starch.4. In a large skillet, melt the butter over medium heat. Add the onion, salt, pepper, and nutmeg and cook until the onion is very soft but not browned, about 5 minutes. Add

the remaining 3⁄4 cup of milk and bring to a boil. Stir in the cornstarch mixture and boil until thickened, just a few seconds. Stir in 1⁄4 cup of Parmesan cheese and the ched-dar cheese. Lower heat and stir until the cheeses are melted. Add the cooked pasta and stir to coat the pasta with the cheese sauce. Taste and add some more salt and pepper if needed.5. Combine the remaining 2 T of Parmesan cheese with the bread crumbs.6. Spoon rounded tablespoons of the mac and cheese mixture into the prepared muffin tins, gently pressing down with the back of a

spoon. Sprinkle a pinch of the bread crumb mixture on top of each mac and cheese bite and bake for 11 to 12 minutes or until the bites are golden brown and sizzling. Let cool for 5 minutes, then run a knife around each bite and remove from the pans.7. Serve warm.

Nutrient Analysis per serving (1 bite)Calories: 53; Total fat: 2 g; Sat fat: 1 g;

Trans fat: 0 g; Sodium: 44 mg; Cholesterol: 0 g; Total carbohydrate: 5 g; Dietary fiber: 0 g; Sugar: 0 g; Protein: 2 g— RECIPE AND PHOTO BY CAROL KICINSKI FOR MAPLEGROVE FOODS

september 2014 www.todaysdietitian.com 41

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Transitioning from paper charts to EMRs can facilitate patient visits and help you run your practice more efficiently.

Electronic Medical Records

42 today’s dietitian september 2014

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When Angela Lemond, RDN, CSP, LD, started Lemond Nutrition, her private nutrition practice, in 2008 in Plano, Texas, she used paper charts, but it bothered her that she couldn’t send

notes to referring physicians that looked professional. “If I handwrote it, it didn’t seem like it faxed well,” she says. And typing up all her notes and records was labor intensive. “I found myself getting behind in my charting,” she says.

Then, in November 2012, on her way home from her office, Lemond stopped to run an errand and thieves broke into her car, walking off with her laptop and her briefcase in which she had five patient charts she had planned to review that evening. That was the final straw.

Lemond, who already had been investigating what it would take to go electronic with her patient records, decided it was time to make the switch. “I had already been getting pric-ing and thinking of going that route, and when that happened [the theft], it was done,” she says. Lemond now uses MNT Assis-tant, an electronic medi-cal record (EMR) program designed for dietitians in private practice that has been available since 2002.

Karen K. Patalano, MBA, RD, LDN, CDE, of Boylston, Massachusetts, who developed the KaiZenRD EMR software for dietitians, tells a similar story. When she started her private nutrition practice in 2003, she was using paper charts. As her practice grew, so did her filing cabinets. “I stuffed them full of charts,” she says. “They were so crammed, I had no more room to get anything in or out.”

By 2010, Patalano knew she had to go electronic, as her documentation was incomplete and illegible, and she had no room for more filing cabinets.

Patalano, who has an MBA in technology manage-ment from an engineering school, searched for soft-ware for RDs and couldn’t find anything that suited her needs. So she used her expertise in systems management and technology to develop KaiZenRD. The name comes from the Japanese words kai, which

means “change,” and zen, which means “for the better.” She started using the EMR program in her nutrition practice four years ago and hasn’t looked back since.

No one knows how many RDs in private practice have converted to EMRs. MNT Assistant has about 100 users, while KaiZenRD signed its 100th client on March 1, exactly two years after its release.

John Gobble, DrPH, RD, LD, CHES, of Clakamas, Oregon, who developed MNT Assistant, is certain the number of dietitians who are using EMRs is growing steadily. “Some people come and go from the profes-sion, so our current users fluctuate, but it’s a growing number,” he says.

Patalano offers free weekly webinars for dietitians interested in learning about and using her EMR program.

“I’ve had people come to the webinars from all over the world,” she says.

Like Gobble, Patalano has noticed increased interest in EMRs for pri-vate RD practices, such as through her well-attended session at the Pennsyl-vania Academy of Nutri-tion and Dietetics’ annual meeting in April. She sus-pects that as Medicare and third-party payers no longer accept paper

claims, the demand for EMRs in nutrition private practices will skyrocket.

No Going Back Now that they’ve gone paperless, Lemond and Pat-

alano can’t figure out how they ever managed without EMRs. They make housekeeping tasks easier: They can store patients’ vital stats, contact information, insurance, referring doctors, medications, and lab results in one place. EMRs also make it easier to keep notes on patients and what was discussed in sessions.

When Patalano was doing all this by hand, she’d sit down after dinner and spend hours on billing and patient chart management, trying to finish at a rea-sonable hour because she had to start all over again the next morning. “For every eight hours of seeing patients, I had four more hours of paperwork,” she

By Beth W. Orenstein

[EMRs] make housekeeping tasks easier: They can store patients’ vital stats, contact information,

insurance, referring doctors, medications, and lab results in one place. EMRs also make it easier to keep notes on patients and what

was discussed in sessions.

september 2014 www.todaysdietitian.com 43

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says, adding that charting electronically is much more effi-cient. “I got back 50% of my time. I was able to work longer hours on the days I leased an office, resulting in more income and a relaxed dinner with my family.”

One of the biggest time-savers was adding billing to the EMR program, Patalano says. “It creates the bill while you see the patient. All you have to do is upload in a batch at the end of the day, and you don’t have to pay for a biller. It’s really simple.”

Lemond doesn’t use MNT’s billing feature because she has an office manager whose job includes submitting bills, but she says having the patients’ insurance and billing infor-mation electronically stored in the charts has simplified the process. “We put all the patients’ billing and insurance infor-mation in their electronic charts, and she [the office man-ager] just goes in and pulls it from there.”

Visits More Productive RDs using EMRs say the systems also make the time they

spend with patients more productive. The programs have nutri-tion analysis tools dietitians can access while patients discuss diet and health or go over their food log. “As a pediatric dietitian, I can estimate the child’s progress and nutrition needs without having to manually go plot it on a growth chart. You really know quickly the patient’s BMI, and you can input it and track it,” Lemond says.

On Lemond’s recommendation, Gobble added growth charts from the World Health Organization for children aged 2 or younger to the MNT program. “Now you can choose one or the other chart set,” Lemond says.

Patalano designed a feature for KaiZenRD that enables dietitians to develop a relationship with their patients using the built-in nutrition assessment forms. In addition to name, address, and insurance, the forms ask for the patients’ family, medical, and nutrition histories; what medications they’re taking; and why they think they’ve gained or lost weight. “It’s a really nice way to get to know the patient,” she says.

Patalano enters information about what she discusses with her patients directly into the EMR during their visit. She created customizable drop-down lists, so it’s often only a matter of calling up recommendations for a patient note or foods for a meal plan that can be customized for diabetes, an eating disorder, or whatever health issue the patient has. Then it’s just a matter of checking boxes vs. lots of typing, she says. “Some RDs are fearful of that.”

With KaiZenRD, “When the patient gets up off the chair, you’re all done with the patient note, doctor’s note, and the bill,” Pata-lano says. “That was a huge plus for me. Before, I had to come home to a suitcase full of paper I had to deal with.”

At the end of a patient visit, Patalano can generate a report with a summary of the visit, menus, and instructions and give it to the patient. The reports she gives to her patients and the referring physicians are professional, easy to read, and even have a logo on them. “The patients and doctors are delighted with them,” she says.

If dietitians use SOAP (subjective, objective, assessment, and plan) or ADIME (assessment, diagnosis, intervention, monitoring, and evaluation) notes, they’re available with the EMR as well. Patalano leaves room at the bottom of the patient feedback form where she can type a personal note, such as “Great job on snacking this month” or “Here’s why you need to exercise more.”

Like handwritten notes, EMRs can contain errors, such as when incorrect information is copied and pasted mul-tiple times. It’s important for dietitians to check their work whether it’s on paper or the computer keyboard. Moreover, patient information that’s stored electronically is HIPAA com-pliant, so patient privacy isn’t a concern, Patalano says.

Because KaiZenRD is a cloud-based program, patient records can be accessed through desktop computers, tab-lets, and smartphones as long as there’s an Internet con-nection. Lemond believes that if her patients’ records had been kept electronically when thieves broke into her car, she wouldn’t have had the issue she did. “Some of the files that were stolen were kids’, and we had to tell the moms that some of their information was taken,” she says.

Lemond also was fearful that the break-in would damage the relationships she’d worked so hard to develop with the referring physicians. Fortunately, there weren’t any serious consequences from the theft, she says.

How to Get Started Gobble says that instituting and using EMRs in a nutrition

practice requires some organization. “You have to create tem-plates and a process and stick with it,” he says. But once you have your templates and processes down, “it doesn’t take that much time. It’s just a matter of getting used to it. Once you have it down, ‘boom,’ you do it and it’s not a big deal.”

ResourcesInterested in learning more about electronic

records for private nutrition practices? Contact Karen Patalano at [email protected]

or 508-335-2452. Visit her website at www.kaizen rd.com to learn more about her software. You also can contact John Gobble at johngobble@mntnorth west.com or 503-746-9134. Or visit his website at www.MNTAssistant.com.

—BWO

44 today’s dietitian september 2014

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Lemond believes using EMRs has increased her credibility with referring physicians and makes her practice look professional. And her name and logo are printed on the forms she sends, “so it keeps you in front of them,” she says.

The RDs interviewed here also have been able to easily search their EMRs for material for research studies. “We’re living in the information age, and we’re interested in questions such as, ‘How many people did you see with this condition?’” Gobble says. “It’s easy to do a search if your patient records are electronic.”

Gobble was one of the authors of a study published in The American Journal of Cardiology in 2012 on the effectiveness of a 30-day lifestyle modification pro-gram delivered by volunteers for reducing cardio-vascular disease risk factors. By searching patients’ EMRs, Gobble and his colleagues collected data on more than 5,000 patients. From the data, they were able to show that volunteers can be valuable social capital in the fight against cardiovascular disease. Their study concluded that “when sourced with appropriate, well-developed materials and programs, volunteers can act as powerful agents of change for health promotion within their community.”

At her presentation for the Pennsylvania Academy, Pata-lano offered outcomes data from KaiZenRD that showed sta-tistically significant weight loss and an increase in exercise frequency and duration in patients after nutrition counseling by private practice RDs.

Connectivity Issues Lemond’s only concern about using EMRs and storing

them in the cloud involves Internet outages. “If for some reason you can’t get online, that would be a detriment,” she says. Fortunately, most people aren’t without power for long or have lengthy technical glitches, she says.

Kristi King, MPH, RDN, CNSC, LD, a senior pediatric dieti-tian at Texas Children’s Hospital, which has met the federal mandate for public and private health care providers to use EMRs, sees another possible drawback: “When everything is automated and calculated for you, you could lose the ability to do it in your head if you have to. You could forget how to use certain skills if you’re not practicing them.” But it’s also good

to double-check the computer’s math. “If you do the math, and it comes out differently from the program in the elec-tronic record, it’s going to tell you something.”

Lemond says dietitians in private practice also have to consider the cost of implementing and using EMRs. “You have to justify the cost,” she says, but “I would highly recommend it. It really makes our profession look better and more con-sistent as a health care provider.”

Patalano’s program, which includes unlimited free billing and support, costs $85 per month. The fee covers the cost of hosting the program, she notes. MNT Assistant runs $49 per month for the first provider in the practice and $29 per month for each addi-tional provider. Ancillary users, such as administrative assistants or bookkeepers, may be added for $19 each per month.

If you’re considering EMRs, you’ll need a program that’s customizable. Both KaiZenRD and MNT Assistant meet this criterion. Patalano and Gobble recommend reviewing your practice’s needs and determining what forms would be most valuable to have in your program and on your website. The developers are willing to work with you to get you set up and teach you how to use their programs.

— Beth W. Orenstein is a freelance health writer living in Northampton, Pennsylvania.

“ I’m not only learning about nutrition, I’m learning about treating people with integrity and care.”Ellie Freeman, MS (2013)

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september 2014 www.todaysdietitian.com 45

Page 46: Today's Dietitian

From amaranth to quinoa,

ancient grains offer a

wealth of nutrients and

can add much-needed

variety to your clients’

and patients’ diets.

Page 47: Today's Dietitian

hen it comes to eating grains, most Americans limit themselves to only a few choices, but there’s a whole world of grains out there of which many have never heard. The so-called ancient grains, such as amaranth, spelt, and

quinoa, are referred to as such because they’ve been around, largely unchanged, for millennia.

Incorporating more grain varieties into one’s day not only makes meals more interesting but also rounds out a well-balanced and nutritious diet. The key is getting more people on board with trying these unknown foods.

“If you were told to eat more vegetables, you wouldn’t just eat carrots. You’d eat a variety of veggies,” says Cynthia Harriman, director of food and nutrition strategies for Oldways/The Whole Grains Council. “But for some reason, we do that with grains. We mostly eat wheat, corn, and rice. Even oats is a mainstream grain, but we don’t consume as much of it. Therefore, ancient grains are totally off the radar. A lot of people don’t even know what they are.”

Ruth Frechman, RDN, author of The Food Is My Friend Diet, agrees and says that getting a variety of foods—whether fruits, vegetables, or grains—always is beneficial. It’s one of the best ways to obtain a well-rounded diet with all the necessary nutri-ents. “Each ancient grain offers different amounts of nutrients,” she says. “Many of the ancient grains are consumed as whole grains, thus providing varying amounts of protein, vitamins, minerals, phytonutrients, and fiber. For example, 1 cup of teff contains 123 mg of calcium.”

With the rising popularity of gluten-free diets, ancient grains also are a nice way to add variety to what may feel like a restric-tive diet. “Because some of the ancient grains are gluten-free, they can add variety for someone who’s allergic to wheat or sensitive to gluten,” Frechman says.

Hurdles to OvercomeWhile ancient grains can pack a nutritional punch, there are

several barriers preventing some people from trying them, one of which is accessibility. “There are still many grocery stores that don’t carry a variety of ancient grains,” says Janice Newell Bissex, MS, RD, cofounder of MealMakeoverMoms.com. “While quinoa has become more available, other ancient grains like farro, kamut, or freekeh are harder to find. In addition, the cost of these grains can be higher than what some people are will-ing to spend.”

Harriman says unfamiliarity also has prevented people from trying ancient grains since people often are uncomfortable with trying something new. In fact, they may not even know what’s out there, but this is a problem dietitians can help tackle. They can introduce their clients to some of the ancient grains and suggest ways to cook with them. Harriman says that if you can get comfortable cooking rice, you can get comfortable cooking almost any grain.

But clients still may need some convincing. Maria Speck, author of Ancient Grains for Modern Meals and the forthcoming Simply Ancient Grains, says she believes people are curious about ancient grains, but there are two misperceptions about cooking them that stand in the way: People assume ancient grains are hard to cook and take too long to cook. “Nothing could be further from the truth,” Speck says. “I always say that ancient grains are as easy to cook as a pot of pasta, and many can be on the table as quickly as white rice.”

“It’s important to suggest simple recipe ideas so that people know what to do with ancient grains,” Newell Bissex says. “They’ll be much more likely to try the grains if they know how to prepare them.”

First and foremost, suggest clients begin thinking about incorporating grains into all three meals, says Vandana Sheth, RDN, CDE, a spokesperson for the Academy of Nutrition and

By Lindsey Getz

W

EnjoyingAncient Grains

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Dietetics. So often clients think of grains as a stand-alone side dish to dinner, such as a side of rice. But grains aren’t just for dinner and easily can be incorporated into a dish as opposed to just being a side.

Sheth recommends three ways to use quinoa for breakfast, lunch, and dinner: “With milk, fruit, cinnamon, and nuts as a hot breakfast; with seasonal greens, beans, herbs, and spices as a side or entrée salad; and used in place of rice within a stir fry.

“Be creative and adventurous,” she adds. “Challenge your-self and your clients to try one new grain per week and look for different recipes for each grain in order to keep it interesting.”

Liz Weiss, MS, RD, cofounder of MealMakeoverMoms.com, agrees that ancient grains make interesting toppers for salads. Their crunchy texture and sometimes nutty flavor add appeal. They also work well when added to soups. “Cooked farro, for example, can easily be incorporated into soups instead of rice or pasta for an instant flavor and nutritional boost,” Weiss says. “Replacing traditional grains with an ancient grain is another easy way to incorporate them into the diet. You can make risotto with barley or farro vs. the usual Arborio rice. And quinoa mixed with diced veggies and a simple vinaigrette can be served as a simple side dish.”

“Maybe you grew up adding oats to your meatloaf, but try using bulgur as a replacement next time,” Harriman suggests. “So often we think of grains as our side, but we can make it the main dish. I work with a lot of amazing chefs who have come up with creative ways to make grains the center of the plate. Barley tacos or black bean bulgur burgers are just two examples.”

Of course making grains the main dish may be intimidat-ing to clients and patients who view this as a big change. Harriman suggests people start slowly when introducing ancient grains into their diet. “Stick to your comfort level of having the grain as a little side dish that replaces white rice,” she says. “That’s a good place to start. But when you cook the grain, cook extra and set it aside. With that extra, you have a whole array of possibilities. Warming it up with some milk and dried fruit or nuts makes a great breakfast, or eating it cold with some vinaigrette and veggies makes a delicious salad.”

While Harriman says there’s some debate over what grains are considered ancient, she says the big-picture idea is to eat more of a variety and not split hairs over technicalities such as which are ancient and which are modern. The following are some of the grains often considered ancient that you can recommend to clients and patients:•Amaranth: This South American grain is both gluten-

and wheat-free and offers a nice boost of protein, calcium, and iron. It’s also the only grain documented as containing vitamin C. Amaranth is easy to cook (requires gentle boiling) and never fully loses its crunchy texture, making it a nice addition to salads or soups. This cooked grain even can be tossed into cookie batter to pack in some crunch and nutritional power. •Barley: This excellent source of fiber, manganese,

selenium, and thiamine does take a while to cook, but it can be used in place of rice for a variety of meals, such as stir-fry

Kamut Minestrone Soup

Serves 8 to 10

Ingredients 1 qt water2 cups beef broth1 (28-oz) can diced or crushed tomatoes1 (15-oz) can tomato sauce2 large carrots, peeled and sliced1 T dried parsley1 tsp dried oregano1⁄2 tsp dried basil1⁄4 tsp pepper1⁄4 tsp garlic powderSea salt, to taste1 (15-oz) can garbanzo beans, rinsed and drained1 (15-oz) can kidney beans, rinsed and drained2 cups frozen green beans11⁄4 cups Kamut Khorasan elbows (or whole grain pasta

of choice)Parmesan cheese, grated, for garnish

Directions1. In a large pot com-bine water, broth, tomatoes, tomato sauce, carrots, parsley, oregano, basil, pepper, garlic powder, and sea salt, to taste. Bring to a boil. Cover and simmer over low heat about 20 minutes. 2. Add garbanzo beans, kidney beans, and green beans. Return to a boil. Add Kamut pasta. Cook 10 minutes or until pasta is tender. 3. Garnish with Parmesan cheese.

Nutrient Analysis per serving Calories: 240; Fat: 1.5 g; Sat fat: 0 g; Sodium: 820 mg;

Carbohydrate: 47 g; Protein: 12 g; Dietary fiber: 9 g

— REPRINTED WITH PERMISSION FROM THE KAMUT ASSOCIATION AND THE WHOLE GRAINS COUNCIL

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dishes, soups, or casseroles. Consider cooking a large batch at once to save time. Look for hulled or hulless barley; pearl barley isn’t a whole grain.•Bulgur: Bulgur is a quick-cooking form of whole wheat.

High in manganese, 1 cup of cooked bulgur also provides about 33% of the recommended dietary allowance of fiber and 5.6 g of protein. Clients can toss it into virtually everything from soups and salads to burgers and casseroles.

• Einkorn: Thought to be the most ancient of wheat varieties, einkorn is higher in protein and key nutrients, such as beta caro-tene and lutein, than modern wheat. It also has a mild flavor.•Farro: This savory wheat variety comes in both pearled

and semipearled form. Look for whole farro; the semipearled is missing some of the bran and isn’t a whole grain. Farro is a staple in Italy and often prepared as a risotto dish or as part of a salad. It’s rich in fiber and magnesium and, like other wheat varieties, it can provide many benefits in its whole grain form, including reducing the risk of stroke, type 2 diabetes, and heart disease.•Freekeh: Freekeh is a young green wheat typically sold

toasted and cracked. It’s full of fiber and contains minerals such as selenium, potassium, and magnesium. Freekeh can be incorporated into stir-fries, risottos, and soups.•Kamut brand Khorasan wheat: Kamut has a nutty flavor

Simple Spelt Pancakes

Makes 16 (4-inch) pancakes

Ingredients2 cups (7 oz) whole spelt flour2 T (7⁄8 oz) sugar1 T baking powder3⁄4 tsp salt13⁄4 cups (14 oz) milk2 T (1 oz) unsalted butter, melted2 T vanilla (optional)

Directions1. In a medium bowl, whisk together the spelt flour, sugar, baking powder, and salt.2. Combine the milk and melted butter, and the vanilla if you’re using it.3. Form a well in the center of the dry ingredients and pour the wet ingredients into the dry. Stir the batter just until the dry ingredients are thoroughly moistened. It will seem very wet but will thicken as it sits. Let the batter sit for about

15 minutes before using it. 4. Heat a nonstick griddle or a heavy skillet, preferably cast iron. If your surface isn’t nonstick, brush it lightly with vegetable oil.5. When the surface of your pan is hot enough that a drop of water sputters across the surface, give the pan a quick swipe with a paper towel to eliminate excess oil and spoon the batter on the hot surface, 1⁄4 cupful at a time.6. Let the pancakes cook on the first side until bubbles begin to form around the edges of the cakes, about 2 to 3 min-utes. You may need to adjust your heat up or down to get the pancakes to cook through without scorching the surface or being too pale.7. When the cakes are just about to set, flip them and let them finish cooking on the second side, about 1 minute more, until they’re golden brown on both sides.

Nutrient Analysis per serving (2 pancakes)Calories: 137; Fat: 4 g; Carbohydrate: 20 g; Protein: 5 g;

Dietary fiber: 4 g

— REPRINTED WITH PERMISSION FROM THE KING ARTHUR FLOUR COMPANY AND THE WHOLE GRAINS COUNCIL

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september 2014 www.todaysdietitian.com 49

Page 50: Today's Dietitian

and packs in fiber and protein as well as several minerals, including selenium and manganese. •Millet: This small, whole grain is a staple in many Asian

and African countries but thought of mostly as bird food in the United States. While it’s the main ingredient in birdseed, millet is a heart-healthy grain rich in copper, manganese, phosphorus, and magnesium. •Sorghum: Sorghum is an ancient cereal grain that was

collected 8,000 years ago in southern Egypt and later domes-ticated in Ethiopia and Sudan. Because of its natural drought tolerance, it’s an important crop in many parts of Africa and Asia. Sorghum is easy to substitute for wheat flour in a variety of baked goods and has a neutral, slightly sweet flavor. Some specialty sorghums are high in antioxidants. •Spelt: Commonly eaten in medieval times, spelt is part of

the wheat family and is high in protein and fiber. Spelt has a dis-tinctive nutty chewiness that makes it appealing not only as a substitute for rice but also for pasta in some dishes. •Teff: This is known for being tiny in size, but it’s still a

nutritional powerhouse and leads all of the grains by a wide margin in calcium content. Just 1 cup of cooked teff offers 123 mg of calcium. It’s often ground into flour but also can be cooked to sprinkle atop vegetables or salads or mixed in with soups or casseroles. •Quinoa: Perhaps the best known ancient grain, quinoa is

a complete protein since it has all nine essential amino acids. A 1-cup serving also provides approximately 20% of the iron and phosphorous needed on a daily basis. It cooks quickly and because it has become so popular, it’s easy to find on grocery shelves. There are also a multitude of recipes out there that call for quinoa.

In addition to giving clients and patients more information about ancient grains, Today’s Dietitian has provided some recipes to share with them.

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.

Peanut Butter and Chickpea Soup With Farro

Serves 6

Ingredients 1 T canola oil1 small onion, cut into 1⁄4-inch dice (about 1 cup)1 medium red or orange bell pepper, cut into

1⁄4-inch dice (about 11⁄2 cups)2 cloves garlic, minced1 32-oz container all-natural vegetable broth1 15-oz can tomato sauce1⁄2 tsp curry powder1⁄2 tsp ground cumin1⁄4 tsp chili powder1⁄4 tsp ground cinnamon1⁄4 tsp celery seed1⁄8 tsp freshly ground black pepper1 15-oz can garbanzos (chickpeas), drained and rinsed2⁄3 cup creamy peanut butter1⁄2 cup 10-minute farroRoasted peanuts, chopped (optional)

Directions1. Heat the oil in a large Dutch oven or saucepan over medium heat. Add the onion and cook, stirring frequently, until softened (about 7 minutes). Add the bell pepper and garlic and cook, stirring frequently, until the pepper softens, an additional 5 minutes.2. Stir in the broth, tomato sauce, curry powder, cumin, chili powder, cinnamon, celery seed, and black pepper. Cover,

raise the heat, and bring to a boil. Reduce the heat and simmer, covered, until the flavors meld, about 15 minutes.3. Add the chickpeas, peanut butter, and farro and stir well until the peanut butter melts into the soup. Cover, return to a simmer, and cook until the farro is tender, about 10 min-utes. Season with kosher salt and pepper to taste. Top each serving with peanuts as desired.

Nutrient Analysis per serving Calories: 310; Fat: 15 g; Carbohydrate: 34 g; Dietary fiber:

7 g; Protein: 12 g

— REPRINTED WITH PERMISSION FROM THE MEAL MAKEOVER MOMS’ KITCHEN (WWW.MEALMAKEOVERMOMS.COM/KITCHEN)

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By Zachary J. Palace, MD, CMD, and Jennifer Flood-Sukhdeo, MS, RD, CDN

Frailty SyndromeThe

Early Diagnosis and Proper Nutrition Can Improve Patient Care

he normal aging process is characterized by a progression of physiologic events that occur throughout the life cycle. Changes associated with aging occur throughout the body and are most prominent in the later years. Changes

in the musculoskeletal system begin to occur after the third decade and continue into the eighth and ninth decades. The frailty syndrome can be described as a culmination of the effects of these changes on the human body.

As normal aging progresses, the musculoskeletal system shows declines in several different areas. The term “sarcopenia” describes the biochemical changes that occur within the muscle fibers as they relate to declining muscle mass and muscle

function. Visible atrophy of muscle fibers results in decreased strength. These changes result from fat deposition replacing lean muscle mass, a process that begins after the third decade of life and can result in up to a 40% decrease in muscle mass by the eighth decade of life. Marked losses in muscle strength and decreased endurance become more prominent over time and correlate with an increased risk of falls.1

The structural integrity of the skeleton plays a major role in maintaining optimal posture and gait. The body’s peak bone den-sity occurs during an individual’s late 20s. An ongoing process of bone formation and resorption occurs throughout life in healthy bones. After the age of 40, however, the rate of bone resorption increases, resulting in decreased bone mass and bone density.

T

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This process is exacerbated in women following menopause and can lead to osteopenia and osteoporosis.2

Independent of the development of osteoporosis, normal age-related decreases in bone density result in decreased structural bone strength, which can increase the risk of falls and fractures. Compression fractures of the anterior cervical spine result in kyphosis, a stooped posture that often is referred to as a dowa-ger’s hump. This forward shift of the center of gravity increases the risk of the loss of balance and falls.2

Recognizing FrailtyThese normal processes of aging affect both the muscular

and skeletal systems and, as a result, play a significant role in the decreased mobility that often is observed in later life. Never-theless, the frailty syndrome isn’t defined by mobility alone; mal-nourishment, as evidenced by involuntary weight loss, also is an important component. Although it’s difficult to define precisely, most clinicians will concur that frailty easily can be recognized as “you know it when you see it.” The following clinical vignettes illustrate this point:•Herbisan86-year-oldretiredattorneyresidingwithhis

wife in their home. He has a medical history significant for mild hypertension and degenerative joint disease with severe kyphosis of the thoracic spine. He underwent a right hip hemiarthroplasty at the age of 80 and continued to remain mobile and physically active postoperatively.

Recently, as a result of the progression of kyphosis, he can’t hold his head upright and walks with a severe forward-stooped posture. This posture significantly has shifted his center of gravity anteriorly, resulting in two to three falls per day while ambulating. He has difficulty in rising unassisted from a seated position and has become more sedentary.•Bettyisa78-year-oldretiredteacher.Shelivesinher

apartment in the community with a home health aide who spends several hours per day assisting her with shopping and household chores. She’s independent in her activities of daily living. Her medical history is significant for insulin-dependent diabetes mellitus, hyperlipidemia, hypertension, and cata-racts. She also suffers from chronic pain due to severe bilat-eral knee osteoarthritis, which greatly limits her mobility and keeps her sedentary much of the day. Although she has no recent fall history, she describes herself as feeling weak and fatiguing easily.•Ritaisa96-year-oldwidowwhoresidesinanursinghome.

She has a medical history of dementia and was admitted to long term care three years ago. Having outlived all of her other family members, Rita lived in an apartment in the community, where she was found to have poor hygiene and was wandering frequently, often becoming lost.

Her stay in long-term care has been unremarkable, and she receives assistance with her activities of daily living. She has a hearty appetite, attends activities, and continues to wander through the hallways of the nursing facility.

Although these three individuals present quite differently, most clinicians likely would agree that both Herb and Betty would be considered to manifest frailty. Physical limitations due to severe kyphosis and frequent daily falls would cause most clinicians to label Herb as frail. Betty’s clinical picture that includes multiple comorbidities and a limited level of physical activity also would be consistent with frailty.

However, most clinicians wouldn’t consider Rita as manifest-ing the frailty syndrome. Although she’s 96 years old, cognitively impaired, and living in long term care, her level of physical activ-ity, as indicated by her frequent wandering, would be less con-sistent with a frailty diagnosis.

As the population continues to age and the percentage of older adults over the age of 80 continues to expand, it’s now more important than ever to identify the frailty syndrome sooner. To do so, it’s necessary to codify into a working definition the common findings associated with the frailty syndrome. Several different studies have attempted to identify frailty based on rec-ognizable operational criteria or by incorporating measurable scales of disability. In a landmark study analyzing multiple com-monly observed characteristics of frailty, Fried and colleagues identified and defined frailty as a syndrome that’s distinct and independent of medical comorbidities and disability.3

The frailty syndrome requires at least three of the following five characteristics:•unintentionalweightloss,asevidencedbyalossofatleast

10 lbs or greater than 5% of body weight in the previous year;•muscleweakness,asmeasuredbyreducedgripstrength

in the lowest 20% at baseline, adjusted for gender and BMI;•physicalslowness,basedonmeasuredtimetowalka

distance of 15 ft;•poorendurance,asindicatedbyself-reportedexhaus-

tion; and•lowphysicalactivity,asscoredusingastandardized

assessment questionnaire.Among the study population of more than 5,300 participants,

researchers observed several significant findings about frailty. Subjects who met the criteria for frailty syndrome were more likely to be older and in poorer health and had higher rates of comorbid chronic disease and disability.3 Diagnoses of cardio-vascular disease, pulmonary disease, diabetes, and arthritis as well as impaired cognition and depression were found to be more prevalent in this group.3 Studies also have identified obesity as a significant risk factor for frailty in women.4

Nevertheless, 7% of the population aged 65 and older and 20% of the population aged 80 and over meet the criteria for frailty in the absence of any acute or chronic medical conditions.5

Nutritional Considerations Nutrition is an important component to consider in the eval-

uation of frailty. Physicians should assess and evaluate nutri-tional status and, with input from dietitians and other members of the health care team, discuss nutrition concerns with family

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members and other caregivers. Weight should be measured at each visit to identify unintended or unexplained weight changes.

Many factors contribute to poor nutritional status in the elderly. Weight loss often occurs secondary to an underlying con-dition that may be either physical or psychological and can affect a patient’s ability to consume adequate calories or protein on a daily basis to maintain optimal functional status. For example, poor dentition can affect the ability to chew and swallow foods of a firm consistency. Patients with diabetes may have delayed gas-tric emptying, which can result in early satiety. Depression can present with poor appetite and a malnourished state. Prescribed medications can cause dysgeusia, an alteration in the perceived taste of foods, resulting in anorexia and weight loss.

Physicians need to periodically monitor diagnostic lab tests, including blood chemistries. These tests can be used to deter-mine electrolyte imbalances, macro- or micronutrient defi-ciencies, and anemia. In particular, vitamin D levels should be checked and supplemented if they’re low because of vitamin D’s role in calcium absorption and its important aspect in the pre-vention and treatment of osteoporosis and overall bone health.

Primary care physicians, dietitians, and other health care providers should be aware of physical limitations that may impede food purchasing and preparation. In these situations, a referral to community-based programs that may provide meals at senior centers or deliver meals to homebound elders should be considered.

Frail elders are at greater risk of skin breakdown caused by protein malnutrition or unintended weight loss. Meeting specific nutrition requirements may play an integral part in preventing further deterioration in status and may in fact show positive outcomes.6

Another factor contributing to frailty may be dysphagia, the inability to adequately and safely chew and swallow.7 Nutrition interventions to ease chewing and swallowing difficulties include mechanically altering the consistency of food and/or liquids. Other nutritional recommendations that are appropri-ate for frail elders may include smaller more frequent meals, supplementation use, and referrals to speech pathologists, occupational therapists, and dietitians.

Supplementation can play a major role in positively impacting the nutritional status of a frail individual, particularly when diet alone fails to meet daily dietary needs. Specific indications for the use of supplements may include difficulty chewing or swal-lowing, unintended weight loss, protein/calorie malnutrition, or increased calorie needs secondary to a hypermetabolic state. Contraindications for supplementation may include unintended weight gain, renal conditions, and nutrient-drug interactions.

Treating FrailtyOnce the frailty syndrome is recognized, the next step is

treatment. The key in treating frailty lies in targeting the condi-tions associated with it. Developing appropriate interventions is an important multifaceted process.

As previously mentioned, frailty isn’t defined by medical diagnoses. Nevertheless, common chronic comorbidities have been noted with higher prevalence in this population. Evidence-based medication management of congestive heart failure results in better outcomes, fewer exacerbations, and an overall improvement in physical function and quality of life. Optimized management of chronic pulmonary disease as well as improved glycemic control of diabetes results in improved health status, fewer hospitalizations, and reductions in the physical declines associated with the frailty syndrome.

Consistent with the fundamentals of geriatric medicine, phy-sicians should perform a thorough medication review during periodic office visits to inventory all medications, including pre-scription and over-the-counter medications. Unrecognized drug side effects as well as drug-drug interactions can cause unex-pected adverse effects that can predispose patients to weak-ness, slowness (both physical and mental), and falls. Frequent medication review can identify opportunities for medication reduction and avoid polypharmacy.

A comprehensive exercise program and increased physi-cal activity have been shown to benefit the frailty syndrome. Muscle weakness and muscle disuse atrophy resulting from a sedentary disposition and chronic illness respond well to physi-cal therapy. Studies have demonstrated positive outcomes in increased muscle strength and muscle mass as a result of par-ticipating in a physical fitness program focused on resistance training.8 Studies also have supported the beneficial effects of tai chi on reducing frailty as well as reducing the occurrence of falls in the elderly.9

Increasing PrevalenceWith the significant growth of the over-80 population and the

increase in average life expectancy, health care practitioners no doubt will encounter a rise in the prevalence of the frailty syndrome. Many of the predisposing factors of frailty occur as a result of the aging process. Most practitioners generally identify frail elders superficially by the “you know it when you see it” test.

However, early recognition and assessment of the identified standardized criteria for the diagnosis of the frailty syndrome is an important first step that will guide the appropriate treat-ment interventions and improve outcomes. Helping older adults attain and maintain their highest level of function is the goal of optimal care.

— Zachary J. Palace, MD, CMD, is a board-certified geriatrician and the medical director, and Jennifer Flood-Sukhdeo, MS, RD,

CDN, is a clinical dietitian and the director of nutrition at The Hebrew Home at Riverdale in New York.

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

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CURCUMIN AND INFLAMMATORY DISEASESLearn about its Potential Role in Prevention and Treatment By Sharon Collison, MS, RD, LDN, CSSD

The spice turmeric has been used for centuries not only to flavor, color, and preserve foods but also as a medicinal remedy, and it has been used for thousands of years in Ayurvedic medicine for the treatment of inflammatory disorders.1,2

Turmeric is derived from the plant Curcuma longa, a member of the ginger family, and its rhizome (root) is the most useful part for culinary and medicinal purposes. Turmeric contains three naturally occurring phytochemicals called curcuminoids: curcumin, demethoxycurcumin, and bisdemethoxycurcumin, though the terms “curcumin” and “curcuminoids” frequently are used interchangeably in the research literature. Curcumin is one of the principal healthful components of turmeric, comprising 2% to 5% of most turmeric preparations2 and giving the spice its characteristic yellow color.

Increasingly, the anti-inflammatory properties of these curcuminoids have attracted the attention of researchers, who have gathered extensive evidence of curcumin’s positive impact on the prevention and treatment of proinflammatory diseases.3 Curcumin is a nontoxic and highly promising natural anti-inflammatory compound that’s currently being administered in phase 2 and 3 clinical trials.1

This continuing education course reviews inflammation’s impact on most chronic disease states, curcumin’s potential role

in preventing and treating these diseases, curcumin’s main mechanisms of action, and evidence-based recommendations for dietary intake of curcumin RDs can provide to their clients.

Inflammation and DiseaseWhen the body experiences injury,

irritation, or infection, an acute inflammatory response occurs to heal the affected tissue. However, when that acute response isn’t effective, the body elicits a chronic inflammatory response. Although acute inflammation has therapeutic potential, persistent low-level inflammation eventually can cause chronic diseases.

Chronic inflammation is associated with the alteration of cell signaling pathways, which results in increased levels of inflammatory markers, lipid peroxides, and free radicals, causing cell damage and eventually leading to the clinical symptoms of disease. Recent research

has demonstrated that chronic inflammation initiates and promotes many disease states, including obesity; diabetes; cardiovascular, neurodegenerative, and inflammatory bowel diseases; and certain types of cancers.1,4-7

Oxidative damage is a major contributor to the inflammatory response as well as the functional decline that’s characteristic of aging and diseases of aging.8 Immune system cells use free radicals such as reactive oxygen species and reactive nitro-gen species to eliminate disease-causing viruses and bacte-ria. The excess production of free radicals results in a state of

CPE MONTHLY

COURSE CREDIT: 2 CPEUs

LEARNING OBJECTIVESAfter completing this continuing education course, nutrition professionals should be better able to:

1. Identify chronic inflammation’s role in predisposition to illness, including neurodegenerative, cardio-vascular, pulmonary, metabolic, autoimmune, and neoplastic diseases.

2. Identify curcumin’s mechanisms of action on the inflammatory process and various disease states.

3. Make recommendations for curcumin consumption to benefit patients and clients.

Suggested CDR Learning Codes 2010, 2020, 4040; Level 2

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oxidative stress, which damages polyunsaturated fats in lipo-proteins and cell membranes and alters proteins such as DNA and RNA.9,10 This damage leads to impaired cell functions and an inflammatory response that contributes to cell damage, aging, and disease.

Chronic inflammation and oxidative stress result in increased serum levels of the transcription factor NF-KB.11-13 Transcription factors regulate gene expression within cells and ultimately control cell behavior. NF-KB controls DNA transcription and can be activated by factors that trigger an inflammatory response, such as viral infections, oxidants, and antigens.14

The NF-KB proinflammatory signaling pathway drives macrophages and neutrophils to respond to such pathogens as part of the immune response. Cell signaling pathways are the body’s primary means of communication, directing and regulating all cellular activities. Incorrect regulation of NF-KB has been linked to improper immune development, inflammatory and autoimmune diseases, viral infections, neurodegenerative diseases, and cancer.3,15

NF-KB increases the expression of many cytokines and enzymes that are active in these chronic inflammatory diseases. Cytokines are hormonelike proteins that act as signaling mole-cules to regulate immune responses and responses to infection, inflammation, and trauma. Some cytokines are anti-inflamma-tory and promote healing once the injury, infection, or foreign body has been destroyed. Other cytokines are proinflammatory, such as tumor necrosis factor–alpha (TNF-alpha) and interleu-kin-1 (IL-1), as well as IL-2, -6, -8, and -12, and initiate an inflam-matory response that recruits lymphocytes to fight disease.

The release of proinflammatory cytokines into the blood-stream signals the liver to produce proteins such as acute phase reactants and cell adhesion molecules that respond to trauma or infection and serve as additional biomarkers of inflamma-tion. Plasma concentrations of acute phase reactants either can increase (positive reactants) or decrease (negative reactants) during chronic inflammation. C-reactive protein (CRP), fibrino-gen, and amyloid are examples of positive acute phase reactants that increase with inflammation; transferrin and albumin are negative phase reactants that decrease with inflammation.

Cyclooxygenase-2 (COX-2), inducible nitric oxide synthase (iNOS), and lipoxygenase (LOX) are important enzymes that mediate inflammatory processes. Pathways that depend on COX and LOX enzymes synthesize lipid mediators involved in inflammation. Improper upregulation of these enzymes has been associated with the pathophysiology of inflammatory disorders and certain types of cancer.4,16 COX-2, for example, is responsible for the increased production of the prostanoids (arachidonic acid–derived prostaglandins and thromboxane) in inflammatory diseases,16 which results in inflammation and pain.

Anti-Inflammatory AgentsSynthetic drugs such as NSAIDs traditionally are the first line

of defense against acute and chronic inflammation and pain.

NSAIDs are a family of COX-1 and -2 inhibitors used to reduce prostanoid synthesis, especially prostaglandin E2, resulting in anti-inflammatory and antitumor activities.17,18 However, the side effects of long-term use of these drugs, including upper gastrointestinal complications and cardiovascular events, often outweigh the benefits.18,19 Efforts are under way to discover safer NSAIDs that inhibit the inflammatory process while reducing the side effects associated with long-term treatment.

Curcumin’s Anti-Inflammatory PropertiesResearchers have found that phytochemicals from natural

foods, including spices and herbs, are safe and effective therapies to help reduce inflammation and prevent and treat disease. Phenolic compounds derived from botanic sources such as curcumin have demonstrated anti-inflammatory activity in vitro and in vivo.17,20,21

Extensive clinical trials over the past several decades have addressed curcumin’s pharmacokinetics, safety, and efficacy against many diseases in humans. However, research on curcumin accelerated much earlier when it was found to have not only anti-inflammatory properties but also cholesterol-lowering, antidiabetic, and antioxidant properties.22-24

Curcumin’s anticancer activity was first discovered in the 1980s in both in vitro and in vivo studies.25,26 Once these studies demonstrated curcumin’s role as a therapeutic agent for disease, research increased significantly. In 1995, it was discovered that curcumin inhibits NF-KB, pointing toward curcumin’s potential as an effective and safe anti-inflammatory agent.27

Curcumin also exerts a protective role against inflammatory diseases by scavenging free radicals and suppressing COX, LOX, iNOS, and other inflammatory mediators.1,4,5

Research involving patients with various proinflammatory diseases, including neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune, and neoplastic diseases, has been encouraging.1,4,5 Curcumin also shows promise in the treatment of hepatic conditions such as liver fibrosis and cirrhosis, psoriasis, AIDS, burn pain, and wounds.4,28-31

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Obesity and Heart DiseaseExtensive research in the last two decades has shown that

obesity, a major risk factor for chronic diseases such as type 2 diabetes, atherosclerosis, and cancer, is a proinflammatory disease. Obesity and insulin resistance in patients suffering from type 2 diabetes are associated with chronic low-grade systemic inflammation, resulting in increased inflammatory markers.31 Adipose tissue is the main origin of this inflam-matory response, and it’s a major secretor of adipocytokines, especially adiponectin, an anti-inflammatory cytokine, and leptin, a proinflammatory cytokine. Either a reduced level of adiponectin or an increased level of leptin results in an elevated risk of atherosclerotic disease.32

Abdominal obesity reflects the amount of adipose tissue in the body.32 Macrophages respond to increased fat cell mass by infiltrating adipose tissue,33 secreting proinflammatory cytokines, including TNF-alpha, IL-6, and IL-1 beta. These, in turn, signal the liver to produce CRP and initiate inflammatory pathway signaling.31,34

Evidence from cellular and animal studies supports the beneficial effects of curcumin on obesity and related metabolic disorders.34-36 Weisberg and colleagues demonstrated that treating genetically obese mice fed a high-fat diet with curcumin decreased NF-KB activation in the liver and decreased macrophage accumulation in adipose tissue. The curcumin-treated mice experienced increased adiponectin production by adipose tissue and decreased development of insulin resistance and hyperglycemia. They also had a small but significant decrease in body weight and fat content despite either a maintenance or increase in total daily calories, suggesting that curcumin may have beneficial effects on body composition.36

Shao and colleagues found similar results in a mouse study where curcumin significantly attenuated the effect of a high-fat diet on glucose tolerance, body weight and body fat gain, and the development of insulin resistance.37

Although several studies have found that curcumin’s anti-oxidant and anti-inflammatory effects reduce body weight, lower triglyceride synthesis, increase basal metabolic rate and fatty acid oxidation, and improve insulin sensitivity in animal models,34-37 human clinical trials are needed to verify such antiobesity benefits.38

Few studies have been conducted to evaluate curcumin’s effect on obesity and heart disease in humans. Two small studies have been done to examine curcumin’s effect on obesity-related parameters.39,40 One study examined curcumin’s effect on HDL and LDL cholesterol. Twelve men taking 20 mg of curcumin per day for 30 days increased their HDL cholesterol and apolipoprotein A levels while decreasing their LDL cholesterol, apolipoprotein B, and apolipoprotein A/B levels. High levels of apolipoprotein B are related to heart disease, whereas apolipoprotein A is cardioprotective.39

Ramirez and colleagues completed another study in adults with atherosclerosis in which 10 mg of curcumin was

administered to 16 men and 14 women twice daily for 15 days.40 Curcumin significantly lowered the levels of plasma fibrinogen, a major plasma protein coagulation factor, in both men and women. Fibrinogen, a classical positive acute-phase reactant, independently predicts coronary heart disease events.41

In a recent six-month randomized, double-blind, placebo-controlled clinical trial to evaluate curcumin’s effects on risk factors for atherosclerosis in type 2 diabetes patients, participants were instructed to take three capsules with blinded labels containing either 250 mg of curcuminoid or a placebo twice per day (total of six capsules per day). The results showed that curcumin intervention significantly reduced pulse wave velocity (an atherosclerosis indicator), increased levels of serum adiponectin, and decreased levels of leptin, thus reducing the risk of atherosclerotic disease in patients with type 2 diabetes. At the last follow-up visit (six months after intervention), the authors noticed slight reductions in mean body weight, BMI, lipid profiles (total and LDL cholesterol), blood glucose profiles (fasting blood glucose and hemoglobin A1c [HbA1c]), and a slight increase in HDL cholesterol in the group of patients treated with curcumin but not in the placebo-treated group.32

These in vitro, in vivo, and clinical studies support curcumin’s anti-inflammatory and antioxidant effects on obesity, leading to outcomes such as weight loss, improved blood lipids, increased basal metabolic rate, increased fatty acid oxidation, increased energy expenditure, reduced risk of atherosclerosis, and improved insulin sensitivity. Thus, curcumin shows potential for addressing obesity and associated inflammation.38

Type 2 DiabetesHyperglycemia, insulin resistance, and decreased insulin

secretion characterize type 2 diabetes. Oxidative stress and inflammatory reactions have been found to play a crucial role in the occurrence and development of type 2 diabetes, resulting in insulin resistance, impaired insulin signaling, pancreatic beta cell dysfunction, and abnormal glucose and lipid metabolism, which cause elevated blood glucose.42 Hyperglycemia can lead to further oxidative stress, mainly through the increased production of mitochondrial free radicals.42 Oxidative stress associated with hyperglycemia impairs cellular function and alters vascular and neural function.4

Since antidiabetic agents alleviate, rather than cure, the disease, there’s growing interest in complementary and alternative approaches, including herbal therapies.43,44 Curcumin appears to influence diabetes by stimulating the pancreas to produce and secrete insulin, interfering with dietary glucose absorption, causing insulin-sparing action, and exerting its antioxidant and anti-inflammatory properties.4 Curcumin also directly affects pancreatic beta cells, which could contribute to the hypoglycemic/antidiabetic effects.34

Several studies have found that curcumin and curcumi-noids can help regulate glucose and lipid metabolism in

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type 2 diabetes.21,42,45 Some of these studies also demon-strated that curcumin and curcuminoids can significantly improve glycemic control while also increasing the activity levels of antioxidant enzymes and scavenging free radicals.42 Research has shown that curcumin can reduce blood glu-cose and glycosylated HbA1c levels and inhibit the activity of inflammatory cytokines.36,46,47 Jain and colleagues reported that curcumin supplementation in diabetic rats lowered the production of inflammatory cytokines and decreased blood levels of TNF-alpha, IL-6, monocyte chemoattractant pro-tein-1, glucose, and HbA1c.46

A randomized, double-blind, placebo-controlled trial involving 240 prediabetic subjects investigated curcumin’s effect on the progression of prediabetes to diabetes. Subjects were given capsules totaling 250 mg of curcuminoid or a placebo twice daily for nine months. Curcumin significantly reduced type 2 diabetes development; none of the 120 curcumin-treated subjects progressed to type 2 diabetes compared with a 16.4% progression rate in the placebo group. The curcumin-treated group showed significantly lower HbA1c levels and fasting and postprandial glucose levels, and increased levels of the anti-inflammatory cytokine adiponectin.47

Many studies have indicated that curcumin can attenuate several complications of diabetes, mainly through its antioxidant and anti-inflammatory activities.21,42,45 For instance, diabetic neuropathy, a microvascular problem that occurs mostly because of oxidative damage and inflammation, was shown to improve after curcumin administration.48

Many studies also have demonstrated that curcumin can reduce both neuropathic and inflammatory pain, most likely through its inhibitory action on inflammatory cytokines and free radicals.45 Curcumin also improved complications such as diabetic retinopathy, nephropathy, and cardiomyopathy.45,49-52

Alzheimer’s DiseaseThe pathogenesis of Alzheimer’s disease (AD) involves

neuroinflammation induced by free radical production and oxidative damage1,3,4,53 and the formation and accumulation of beta-amyloid plaques, or fibrils, in the brain. Amyloid fibrils are formed by normally soluble proteins, which assemble to form insoluble fibers. High expression of beta-amyloid plaques, along with neuroinflammation, is associated with the loss of neurons and synapses that affects neuronal function in patients with AD.54

Because current treatments for AD and other neurodegen-erative diseases, including Parkinson’s and Huntington’s, can cause severe side effects,55 there’s strong interest in alternative approaches. Because of its antioxidant and anti-inflammatory effects as well as its ability to inhibit protein aggregation, curcumin has the potential to help reduce oxidative damage, prevent mitochondrial and cellular dysfunction, and counteract neurodegeneration.53

In a large population-based study of 1,010 elderly Asians without dementia, subjects who consumed curcumin-rich curry occasionally, often, or very often scored significantly better on the Mini-Mental State Examination (MMSE), an established measure of cognitive function, than did those who never or rarely consumed curry.56

Substantial in vitro data indicate that curcumin has antioxidant, anti-inflammatory, and anti–beta-amyloid protein activity. In addition, studies in animal models of AD indicate a direct effect from curcumin in decreasing AD’s amyloid pathology.57,58 These findings suggest that curcumin may be one of the most promising compounds for the development of AD therapies.59

Several in vivo preclinical studies and cell culture and animal models also support curcumin’s neuroprotective potential and suggest a role for this compound in the prevention and reversal of degenerative diseases such as AD and Parkinson’s.60-62

Clinical trials, however, haven’t been as promising. Two independent clinical trials concluded that curcumin wasn’t effective at reducing cognitive decline.63,64 One, a six-month randomized, placebo-controlled, double-blind, clinical pilot study in Hong Kong, involved 34 participants with AD who were randomly assigned to receive curcumin at two different doses (1 or 4 g) or a placebo. MMSE scores didn’t improve in the curcumin group. However, the curcumin group showed increased plasma levels of vitamin E and increased serum beta-amyloid 40 compared with the placebo group, suggesting that curcumin could disaggregate beta-amyloid deposits in the brain and release them for circulation and disposal.63

Despite the results of these clinical trials, it’s too soon to conclude that there’s a lack of effectiveness regarding curcumin and AD.55 A recently published review of studies summarizing the effects of curcumin and curcuminoids in AD concluded that the different components of a curcuminoid mixture showed different biological activities with varied efficacy and potency, and that a curcuminoid mixture may offer better therapeutic potential in AD compared with pure curcumin.65

Two other clinical studies involving AD patients remain active55: a phase 2 study in India using 2 g/day of curcumin and an early intervention study conducted in the United States with a combination of 5.4 g of curcumin and bioperine, a natural product derived from black pepper that’s thought to increase curcumin’s bioavailability. These studies are directed to evaluate the efficacy, safety, and tolerability of curcumin in moderate AD.

Although clinical trials to date haven’t shown curcumin to be therapeutic in patients with AD, its success as part of in vitro and animal studies and the current progress with its improved bioavailability combined with the knowledge that curcumin, even at the highest doses, didn’t cause adverse effects warrant further clinical studies.

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ArthritisOsteoarthritis (OA), one of the most common types of

arthritis, results in joint degradation, including articular cartilage and subchondral bone. It’s a chronic condition in which cartilage breaks down, causing the bones to rub against each other and resulting in stiffness, pain, and loss of joint movement.

Rheumatoid arthritis (RA) is an autoimmune disease that results in a chronic, systemic inflammatory disorder that may affect many tissues and organs but principally attacks flexible (synovial) joints.

The roles of inflammatory cytokines and chemokines (special types of cytokines that direct the migration of white blood cells to infected or damaged tissues), inflammatory enzymes, and cell adhesion molecules in the pathogenesis of arthritis are well documented. NF-KB has been shown to regulate almost all of the mediators of inflammation linked with arthritis.3

NSAIDs such as celecoxib (Celebrex) are efficient anti-inflammatory agents frequently used to treat OA but, as noted previously, they can have negative side effects.3,66 Lev-Ari and colleagues conducted a study to determine whether a lower and safer concentration of celecoxib in combination with curcumin would be effective for treating OA. Curcumin augmented the inhibition of OA cell growth and enhanced celecoxib’s induction of apoptosis. This synergistic effect of curcumin and celecoxib was mediated through inhibition of COX-2 activity. The authors noted that the results of this study support the use of celecoxib at lower and safer concentrations and may pave the way for a novel combination treatment of arthritis.66

In a clinical study on curcumin’s effects on OA, 50 patients were given Meriva, a proprietary formulation of 200 mg of curcumin blended with lecithin, daily for three months. OA signs and symptoms plus mobility and inflammatory status were evaluated using the Western Ontario and McMaster Universities Arthritis Index (WOMAC), walking performance, and CRP measurement, respectively. Meriva treatment decreased the global WOMAC score by 58%, extended walking distance from 76 to 332 meters, and decreased CRP levels from 168±18 to 11.3±4.1 mg/L.67

In another study of 45 patients diagnosed with RA, 500 mg of curcumin and 50 mg of diclofenac sodium alone or in combination were administered to three groups of patients. Diclofenac, the current standard of care for patients with RA, is an NSAID used to relieve pain, tenderness, swelling, and stiffness. Study results showed that the curcumin group had the best improvement of the overall Disease Activity Score and American College of Rheumatology scores (tests used in clinical practice and clinical trials to evaluate symptoms of RA and disease progression) of all three groups.68

By inhibiting COX-2 and reducing arthritis pain and swelling, curcumin’s role in the treatment of OA and RA shows promise.

Inflammatory Bowel DiseasesInflammatory bowel diseases (IBDs), including Crohn’s

disease and ulcerative colitis, are debilitating immune disorders involving chronic inflammation of the digestive tract that results in severe abdominal cramping and diarrhea.

Two of the main treatments for mild to moderate IBD are the anti-inflammatory medications sulfasalazine (Azulfidine) and mesalamine, which work by inhibiting the COX and LOX pathways and the inflammatory process. Unfortunately, these medications frequently produce side effects such as nausea, headache, diarrhea, and abdominal pain.69

Two independent researchers have found that in rats with IBD colitis, the expression of NF-KB activation and proinflammatory cytokines in colonic mucosa was suppressed in the curcumin-treated groups.70,71 Since curcumin has shown efficacy as an anti-inflammatory without significant side effects, many studies have been conducted to evaluate its potential in patients with IBD.72,73

Holt and colleagues conducted a pilot study in people with IBD to determine whether the dosage of routine medications given to suppress disease symptoms could be reduced with curcumin coadministration. Five patients with ulcerative colitis each were given 550 mg of curcumin twice daily for one month and then 550 mg three times daily for another month. Five patients with Crohn’s disease each were given 360 mg of curcumin three times per day for one month and then four times per day for two months. Of the 10 patients, nine showed immunological and symptomatic improvement at the study’s conclusion. Curcumin reduced the inflammatory response in four of five ulcerative colitis patients and four of five Crohn’s disease patients. In fact, four of the five patients with ulcerative colitis were able to decrease or eliminate their medications. These subjects reported improvement in clinical symptoms, including more formed stools, less frequent bowel movements, and decreased abdominal pain/cramping.74

In a multicenter, double-blind, placebo-controlled clinical trial, 89 patients with ulcerative colitis were randomized to receive curcumin (1 g twice daily) or a placebo for six months. Both groups also received sulfasalazine or mesalamine. There were significant improvements in the curcumin group but not in the placebo group, showing that curcumin significantly suppressed the morbidity associated with active ulcerative colitis. Relapse rate was significantly lower in the curcumin group over the placebo group.72,75

The research results to date support further exploration of curcumin’s efficacy for treating patients with IBD. Clinical studies of curcumin for patients with active IBD are needed in large cohorts using a wide range of dosages and long follow-up times.72 Furthermore, large clinical trials on patients with active IBD are needed with curcumin not only as a monotherapy but also as an adjuvant to the commonly used medications to evaluate its beneficial effects.76 Several clinical trials currently are being conducted.

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CancerRegularly consuming turmeric has been suggested as a

possible factor contributing to lower cancer rates (colorectal, liver, pancreatic, lung, breast, uterine, ovarian, prostate, bladder, kidney, renal, brain, non-Hodgkin lymphoma, and leukemia) in India compared with those in Western countries.77,78 However, without quantitative data, a cause-and-effect relationship between turmeric consumption and cancer incidence can’t be assumed.79

Epidemiological studies have identified chronic infections and inflammation as major risk factors for various types of cancer.80 Most risk factors for cancer, including tobacco use, obesity, alcohol consumption, infections, stress, food carcinogens, and environmental pollutants, have been shown to be components of a proinflammatory lifestyle that leads to tumorigenesis.81 In fact, inflammation is involved in most stages of tumor development, including initiation, promotion, malignant conversion, invasion, and metastasis.80

The mixture of cytokines and proinflammatory mediators that are produced in tumor cells play an important role in tumor development and progression. NF-KB activation leads to the expression of inflammatory enzymes and mediators, including COX-2, LOX-2, iNOS, cell adhesion molecules, and inflammatory cytokines, especially TNF-alpha and chemokines.81

Recently, biochemical and animal studies revealed that the activation and interaction between NF-KB and STAT3, another transcription factor, are major factors linking inflammation to cancer.80,82 In fact, most carcinogens activate NF-KB and STAT3 pathways.83 Both NF-KB and STAT3 are overactivated and locked in an “on” position in human cancer.81

Since the dysregulation of multiple cell signaling pathways causes cancer, the new generation of anticancer drugs is designed to modulate multiple targets.84 Many spices have been found to target multiple cellular signaling pathways in tumorigenesis.81 By modulating multiple targets, such as transcription factors like NF-KB and STAT3, growth factor receptors, kinases, and inflammatory mediators, curcumin inhibits several processes that contribute to cancer cell survival, proliferation, invasion, and metastasis.81,84 And because of its multitargeting activities, curcumin has been found to be effective against many cancer types in human clinical trials.21

A clinical trial of 62 patients with external cancerous lesions conducted in 1987 first demonstrated curcumin’s anticancer activities in humans. Topical curcumin was found to produce substantial symptomatic relief as evidenced by reductions in smell, itching, lesion size, and pain.26

In a phase 1 dose-escalation clinical trial, 15 patients with advanced colorectal cancer took 0.45, 0.9, 1.8, or 3.6 g of curcumin once daily for up to four months. Toxic effects weren’t observed, suggesting good tolerability of curcumin. The highest daily dose (3.6 g) significantly lowered the levels of the inflammatory biomarker prostaglandin E2. The authors

recommended a daily oral dose of 3.6 g of curcumin for phase 2 evaluation in the prevention or treatment of cancers outside the gastrointestinal tract.85

In another study of patients with colorectal cancer, presurgical curcumin administration (360 mg three times daily) for 10 to 30 days increased body weight, decreased serum TNF-alpha levels, increased the number of apoptotic cells, and enhanced the expression of p53, a known tumor suppressor, in tumor tissue. The study concluded that curcumin may be therapeutic in patients with colorectal cancer.86

In a clinical trial evaluating curcumin’s effect in 29 multiple myeloma patients, the treatment group took curcumin at doses of 2, 4, 6, 8, or 12 g/day alone or in combination with bioperine (10 mg) for 12 weeks. Curcumin and bioperine were well tolerated, with no significant adverse events. Results showed that curcumin downregulated the activation of NF-KB and STAT3, and suppressed COX-2 expression.87 These observations support curcumin’s potential for treating multiple myeloma.

In another clinical trial, 25 patients with pancreatic cancer were given 8 g of curcumin per day, with restaging (the process of finding out how much cancer there is in a person’s body and where it’s located) every two months. The majority of the patients showed downregulation of NF-KB and COX-2 after treatment with curcumin, but this downregulation didn’t result in a clinical response in many patients.88

Since poor bioavailability may be a reason for the lack of a clinical response, the authors concluded that the development of liposomal curcumin for clinical trials in cancer patients is a worthwhile strategy, since this curcumin formulation may provide more consistent blood levels with better pharmacologic effect. This is the first study to show that curcumin can downregulate the expression of these inflammatory molecules in humans, and that oral curcumin is well tolerated at doses of 8 g/day for up to 18 months.88

In vitro, in vivo, animal, and human clinical studies support curcumin’s clinical therapeutic potential for cancer patients.25,26,89-92 Some of the leading clinical research centers in the United States are involved in preclinical and clinical research of the anticancer mechanism and application of curcuminoids in cancer treatment. Many clinical trials already have been completed that support curcumin’s safety and efficacy in patients with multiple myeloma, colorectal, pancreatic, breast, prostate, lung, and head and neck cancers.21 This research supports curcumin’s potential to prevent and treat various cancers.93

BioavailabilityAs discussed, one drawback to the therapeutic use of

curcumin is its poor bioavailability.3,21,80,93-95 The main limitation for using curcumin-based formulations is its poor solubility and fast metabolism, resulting in poor absorption from the gastrointestinal tract and limiting therapeutic effectiveness.95 With oral doses, most of the curcumin is excreted in feces,

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and only traces appear in the blood. Since curcumin’s limited bioavailability weakens its effectiveness in vivo, improving bioavailability is of the utmost importance.

Several strategies have been explored to improve curcumin’s bioavailability, such as modulation of the delivery system and medium of curcumin administration (nanoparticles, liposomes, micelles, and phospholipid complexes), blocking of metabolic pathways by administering curcumin with other agents (adjuvants), and conjugation and structural modifica-tions of curcumin.93,94

The roles of adjuvants, or substances added to block curcumin metabolism, resulting in increased absorption, are of great interest.94,95 Piperine is a popular adjuvant in clinical application.96 For example, in humans receiving a dose of 2 g of curcumin, serum levels either have been undetectable or very low, but using piperine as an adjuvant was associated with a 2,000% increase in curcumin’s bioavailability.96 Other adjuvants, such as quercetin, genistein and eugenol, also show promise in improving curcumin’s uptake and bioavailability.94

In addition, many scientists are focusing on structurally modifying curcumin to improve its bioavailability.94 Many patented formulas are being developed and used in clinical trials. For example, the patented curcumin formula Meriva resulted in total curcuminoid absorption 29-fold higher than an unformulated curcuminoid mixture.21,97,98 In addition, since curcumin is of low molecular weight and highly lipophilic, it’s possible that it may be absorbed more easily through a transdermal rather than an oral route.36

With the fast pace at which new synthetic curcuminoids and their delivery systems are being patented and disclosed, the development of a more bioavailable curcumin product is likely.94,95

SafetyHuman clinical trials have established curcumin’s safety,

tolerability, and nontoxicity at high doses.32,68,85,88 However, some investigators have reported undesired adverse effects at higher doses. Some human studies have shown that curcumin at doses ranging from 0.9 to 3.6 g/day for one to four months resulted in nausea and diarrhea.85 In a recent clinical trial of 240 subjects who were instructed to take three blinded-label capsules twice per day either of curcumin (1.5 g of total curcuminoids) or placebo continuously for six months, curcumin was well tolerated with few adverse effects: One subject reported a hot flash, two subjects reported constipation, and one reported nausea.32

Based on a review of clinical trials to date, curcumin is considered to be safe and well tolerated at doses up to 8 g/day.1,99 As a result of this research, the FDA has approved curcumin as a Generally Recognized as Safe compound. However, dose levels that elicit desirable vs. undesirable effects need to be determined in order for curcumin to be useful as a preventive or therapeutic drug.

Clinical RecommendationsMore than 1 billion people regularly consume curcumin

as part of their diets.4 In India, the average dietary intake of turmeric by 60-kg individuals (roughly 132 lbs) is approximately 2 to 2.5 g/day, which provides 60 to 100 mg of curcumin daily.100

According to one study, 1,500 mg of turmeric per day has biological activity.78 The University of Maryland Medical Center suggests 1 to 3 g of dried, powdered turmeric root per day is needed to gain health benefits.101 However, there’s no clear recommendation for curcumin dosage.

Until research supports more specific recommendations for therapeutic curcumin intake, RDs can educate their patients on how to include turmeric in everyday cooking to try to reap some of its related health benefits. Both whole and ground dried turmeric are readily available in the spice section of most grocery stores. However, the curcumin content of turmeric and curry powders varies considerably. Turmeric powder has the highest curcumin concentration (averaging 3.14% by weight).79

Turmeric is an important ingredient in curry mixes, chutney, and mustard pickles, but relatively small amounts of curcumin are present in curry powder samples.79 Consuming curcumin with meals increases its absorption, especially with fatty foods such as olive oil, avocado, fish oil, and seeds.102

With its earthy flavor and a hint of ginger, turmeric gives poultry and seafood a warm color and accents its natural flavor. It also goes well with rice, lentil, and vegetable dishes and can enhance the flavor of soups and stews. It can be added to vinaigrettes and to oil or butter for color and flavor; used with onion powder, garlic powder, cayenne pepper, or bouillon cubes; or included as part of a traditional Indian beverage of milk, turmeric powder, and sugar to taste.78 However, it should be added gradually since its flavor grows more pronounced during cooking and using too much at one time could ruin a dish.

In ConclusionEvidence continues to mount in support of curcumin’s role

in inhibiting the inflammatory process and, thus, inflammatory diseases. Additional research is needed to improve bioavailability and determine specific recommendations for curcumin intake. In the meantime, RDs can encourage their patients to incorporate turmeric in everyday food preparation and recipes to boost color and flavor while helping to fight inflammation.

— Sharon Collison, MS, RD, LDN, CSSD, is a dietitian in private practice and a freelance writer in Newark, Delaware.

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

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CPE Monthly Examination

1. Which of the following statements best describes the relationship between disease and NF-KB?

a. Viral infections reduce the presence of NF-KB.b. NF-KB increases the transcription of inflammatory

mediators.c. NF-KB increases the transcription of anti-

inflammatory cytokines.d. NF-KB reduces the expression of cyclooxygenase-2

(COX-2).

2. In which of the following ways does curcumin act on adipose tissue?

a. It promotes macrophage infiltration.b. It promotes NF-KB activation.c. It increases the expression of tumor necrosis factor–

alpha (TNF-alpha).d. It increases the expression of adiponectin.

3. Curcumin exerts its anti-inflammatory effects through which of the following mechanisms?

a. Increasing free radical productionb. Suppressing and activating lipoxygenase (LOX)c. Suppressing LOX, COX, and inducible nitric oxide

synthase (iNOS)d. Activating LOX and iNOS

4. Which of the following results were found as part of in vivo studies involving daily curcumin doses of 10 to 20 mg?

a. Decreased HDL cholesterolb. Increased LDL cholesterolc. Increased apolipoprotein A and decreased

apolipoprotein A/Bd. Increased plasma fibrinogen

5. Curcumin has been shown to do which of the following in clinical trials?

a. Reduce cognitive decline in patients with Alzheimer’s disease

b. Decrease morning stiffness and joint swelling in patients with rheumatoid arthritis

c. Increase inflammatory cytokines in cancer patientsd. Increase the expression of COX-2 and LOX in cancer

patients

6. Results from a clinical trial that evaluated curcumin’s effect on risk factors for atherosclerosis in patients with type 2 diabetes found which of the following to be true?

a. Decreased leptin in the curcumin group vs. the placebo group

b. Increased pulse wave velocity in the curcumin group vs. the placebo group

c. Decreased levels of adiponectin in the curcumin group vs. the placebo group

d. Normal hemoglobin A1c levels in the curcumin group vs. the placebo group

7. Based on this course, which of the following statements is true regarding curcumin absorption and bioavailability?

a. Curcumin is highly soluble in water.b. Consuming curcumin with dietary fat results in

increased absorption.c. Curcumin is metabolized slowly, resulting in reduced

absorption. d. Consuming curcumin on an empty stomach

increases its absorption.

8. In what way does curcumin affect cancer cells?a. It interferes with cell signaling mechanisms for

tumorigenesis.b. It increases tumor angiogenesis.c. It prevents cancer cell apoptosis.d. It promotes metastasis.

9. In patients with colorectal cancer, curcumin has been found to do which of the following?

a. Decrease body weightb. Increase TNF-alphac. Decrease the number of apoptotic cellsd. Enhance expression of p53

10. Which of the following is an appropriate recommendation for curcumin consumption?

a. Use curry powder to season foods since curry is the best source of curcumin.

b. Consume curcumin with a low-fat meal. c. Use curcumin supplements for disease prevention.d. Use turmeric frequently in cooking since turmeric is

the best source of curcumin.

For more information, call our continuing education division toll-free at 877-925-CELL (2355) M-F 9 am to 5 pm ET or e-mail [email protected].

Register or log in on CE.TodaysDietitian.com to purchase access to complete the online exam and earn your credit certificate for 2 CPEUs on our CE Learning Library.

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NIGELLA SATIVABy Megan Tempest, RDResearch suggests this ancient medicinal plant may have present-day uses for a variety of conditions.

If you’ve never heard of Nigella sativa (also known as black seed or black cumin), you’re not alone. Despite centuries of use as a traditional, alternative medicine, Nigella sativa is off the radar of mainstream conventional medicine. Yet this ancient plant deserves some attention from health care professionals. Several animal studies and some human studies suggest that Nigella sativa potentially could treat common diseases and conditions typically addressed with pharmaceutical drugs.

This article provides a brief history of Nigella sativa, highlights recent studies that have examined its role in health promotion and disease prevention, and discusses whether dietitians should apply the data to daily practice.

What It IsA member of the botanical family Ranunculaceae, the Nigella

sativa seed is derived from a ripe fruit that grows abundantly in Eastern Europe, the Middle East, and western Asia. These small black seeds historically have been used in food and cooking prep-arations and for more than 2,000 years as a folk medicine to treat ailments ranging from headaches to parasitic infections. Reports suggest Nigella sativa was discovered in King Tut’s tomb.1,2

Today, Nigella sativa supplements are available online and in health food stores under the name black seed and usually are sold in capsules of crushed black seed or softgels of black seed oil. The supplements are marketed to support overall health and well-being and to treat specific ailments such as asthma, allergies, flu, joint pain, and gastrointestinal problems.2

Compelling ResearchOn the heels of much animal research, published results from

human studies have emerged exploring Nigella sativa’s role as an effective complementary and alternative medicine. Here’s a review of some of the most recent research.

HypertensionNigella sativa has demonstrated antioxidant, hypotensive,

calcium channel blockade, and diuretic effects that function to lower blood pressure.3

Its vasorelaxant effect was the focus of a double-blind, ran-domized, placebo-controlled clinical trial of 70 healthy individu-als between the ages of 34 and 63 with systolic blood pressure ranging from 110 to 140 mm Hg and diastolic blood pressure from 60 to 90 mm Hg. (The American Heart Association defines the optimal range for blood pressure as below 120/80 mm Hg.)4

Published in the December 2013 issue of Phytotherapy Research, the results suggested that an oral intake of 5 mL of Nigella sativa oil for eight weeks significantly lowered systolic and diastolic blood pressures without any apparent adverse effects.4

HyperlipidemiaWhen taken as an oral supplement, Nigella sativa has shown

potential in improving dyslipidemia. Results of a four-week clinical trial suggested that supplemental Nigella sativa lowered total cholesterol by 5%, LDL cholesterol by 8%, and triglyceride levels by 17%.5

A two-month randomized trial of menopausal women with hyperlipidemia, published in the March issue of the Journal of Translational Medicine, associated the intake of a Nigella sativa supplement with a 27% reduction in LDL cholesterol, a 22% decrease in triglycerides, and a 16% decline in total cholesterol. Researchers noted a slight but statistically insignificant improve-ment in HDL cholesterol levels. Furthermore, the researchers observed that when the women stopped taking the supplement, their lipid profiles reverted to pretreatment levels.6

One theory behind the slight HDL-boosting effects of Nigella sativa is that it stimulates apolipoprotein A-I gene expression, the primary component of cardioprotective HDL cholesterol.7

An analysis of overweight sedentary women published in the February issue of the International Journal of Preventive Medicine showed that eight weeks of Nigella sativa supplementation combined with aerobic activity had a synergistic effect in improving serum lipid profiles.8 Researchers saw a 5% decrease in total cholesterol, an 8% reduction in triglycerides, a 5% drop in LDL cholesterol, and a 6% rise in HDL cholesterol.

In a 12-week study published in September 2012 in the Journal of Family Community Medicine, researchers compared the effects of three different doses of Nigella sativa supplements (1, 2, and 3 g/day) on the lipid profiles of 94 individuals with type 2 dia-betes. Patients who took 2 g/day had significantly greater reduc-tions in total cholesterol (up to 15%), LDL cholesterol (up to 17%), triglycerides (up to 22%) and increases in HDL cholesterol (up to 6%) compared with those who took 1 g/day. However, researchers didn’t see a significantly greater benefit in those who took 3 g/day.9

Margaret Wertheim, MS, RD, CD, a private practice dietitian in Madison, Wisconsin, knows about the research linking Nigella sativa to improved serum lipid profiles but isn’t yet convinced she should recommend it to clients with hyperlipidemia. “Research has shown decreases in LDL and triglycerides, but the decrease

SUPPLEMENT SPOTLIGHT

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is mild,” she says. “Since there are effective dietary strategies, I would try those first to reduce high LDL/triglycerides.”

Of course, diet and exercise modifications are widely accepted as safe and effective methods of improving lipid profiles, but the extent to which Nigella sativa may work in tandem with or in comparison to these methods still is relatively unknown.

Cancer Treatment Researchers who have studied the medicinal plant in vitro

have found that thymoquinone, the predominant bioactive con-stituent in Nigella sativa, can induce apoptosis (cell death) and slow cancer cell metastasis in breast cancer, glioblastoma, melanoma, squamous cell carcinoma, certain forms of lym-phoma, cervical cancer, osteosarcoma, and lymphoblastic leu-kemia.10-17 Thymoquinone analogs have been shown to inhibit pancreatic cancer cell proliferation in vitro and enhance cancer cell sensitivity to chemotherapy,18 and results of a recent in vitro study showed that Nigella sativa seed extract and seed oil signifi-cantly reduced human lung cancer cell viability.19 Nonetheless, because these are in vitro studies, more research is needed to determine the anticancer effects.

Diabetes One study suggested oral Nigella sativa supplementation

could improve blood glucose control among patients with type 2 diabetes.20 Results of a recent animal study suggested that Nigella sativa supplements can help lower blood glucose levels and improve serum lipid profiles, demonstrating its potential as a functional food to treat diabetes and its associated comorbidities.21

In addition, researchers investigated the hypoglycemic effects of Nigella sativa in a study of menopausal women. They reported that 1 g/day of encapsulated Nigella sativa seed powder taken for two months correlated with a significant decrease in fasting blood glucose levels and improvement in serum lipid profiles compared with placebo.22

Cognitive FunctionFollowing animal studies demonstrating a possible link

between Nigella sativa and improved brain function, human studies are further establishing this relationship. A study of 40 healthy elderly patients showed that 1 g/day of Nigella sativa enhanced memory, cognition, and attention without adverse side effects. Based on these findings, the researchers emphasized the need for further research in Nigella sativa’s role in prevent-ing or slowing the progression of Alzheimer’s disease.23

Liver Health A study published in the April 2013 issue of the World Journal of

Gastroenterology found an association between hepatoprotection and Nigella sativa in individuals with hepatitis C. Researchers concluded that 1,350 mg/day of Nigella sativa was tolerable, safe, and decreased viral load among participants. Moreover, this dose was found to improve oxidative stress, clinical condition, and glycemic control among diabetes patients with hepatitis C.24

Rheumatoid ArthritisThe beneficial, immune-modulating effects of Nigella sativa

were the focus of a recent study on individuals suffering from rheumatoid arthritis. Among a group of 40 female rheumatoid arthritis patients, a 500-mg dose of Nigella sativa oil capsules twice daily was associated with a decrease in disease activity and symptoms of swollen joints and morning stiffness, suggest-ing Nigella sativa may be an affordable potential adjuvant therapy for rheumatoid arthritis treatment.25

AllergiesA prospective, double-blind, placebo-controlled trial investi-

gated the anti-inflammatory effects of Nigella sativa on patients with allergic rhinitis. The results suggested it may reduce common symptoms such as nasal itching and congestion, runny nose, and sneezing. The researchers noted that this supplement could be considered a treatment for allergic rhinitis when the side effects of common allergy drugs must be avoided.26

Counseling PatientsThe scientific evidence behind Nigella sativa’s health-promoting

effects may pique dietitians’ interests. However, in the absence of further research and clinical trials to establish appropriate use and safe therapeutic doses, it may be premature for RDs and other health care professionals to recommend this supplement to treat specific medical conditions.

“Some of the most promising evidence for Nigella sativa appears to be for reducing allergy symptoms, and it could be a supplement recommended by RDs for this use,” Wertheim says. Acknowledging that the safety research on black seed is limited, she believes Nigella sativa does appear to be safe, “especially given that recommended supplemental doses are similar to amounts used as a culinary spice.” Research has shown that toxicity has occurred in rats that were given high doses; otherwise, adverse effects are reportedly rare.27,28 Regardless, Wertheim recommends pregnant and nursing women avoid using the supplement because of the lack of sufficient testing.

Julia Zumpano, RD, LD, a clinical dietitian in the department of preventive cardiology at the Cleveland Clinic, suggests dietitians use caution regarding Nigella sativa and all herbal supplements. “They aren’t regulated; therefore, it’s unknown if the dosage provided is accurate and effective.” Instead, she recommends all clients and patients be advised to check with their physician before taking any supplements since they can interact with current medications, other supplements, or medical conditions.

— Megan Tempest, RD, is a freelance writer based in Boulder County, Colorado.

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

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Older Adults Need Regular Nutrition Screenings

As older adults typically have one or more chronic health conditions that can affect dietary intake, malnutrition has been identified as a serious problem. This has given rise to the rec-ommendation that nutrition screenings be a mandatory part of the comprehensive geriatric assessment.

First developed in the 1930s, comprehensive geriatric assessment is a multidimensional diagnostic process that looks at a frail elderly person’s medical, psychosocial, and functional capabilities in order to develop an overall plan for treatment and follow-up. While it has been used across health settings, the assessment typically is used in a geriatric specialty unit by a team that includes physicians, nurses, dietitians, pharmacists, therapists, and social workers.

In a special review article published in Nutrition in Clinical Practice, Rose Ann DiMaria-Ghalili, PhD, RN, CNSC, an associate professor of nursing at Drexel University in Philadelphia, examined each component of the comprehensive geriatric assessment and outlined how nutrition screenings would fit into the following domains: physical/medical, mental, functional, and social.

DiMaria-Ghalili noted that health care providers should look for signs of malnu-trition, such as loss of subcutaneous fat, muscle loss, and fluid accumulation, as part of the physical examination portion of the comprehensive geriatric assessment. In regard to mental health status, she identi-fied how changes in cognition and dementia can affect nutrition.

In the examination of older adults’ functioning, DiMaria-Ghalili highlighted that malnutrition leads to a loss of muscle strength and mass, which will affect a patient’s functional status. As for older adults’ social domains (social networks and economic status), she pointed out that older adults on fixed and limited incomes often need to make decisions regarding payment for medications, housing costs, and food purchases, leading them to purchase food that’s cheaper and less nutritious. Beyond identifying potential nutrition prob-lems, DiMaria-Ghalili stressed that any problems identi-fied should be addressed and interventions implemented in a timely fashion. For this to be successful, she encour-aged the delivery and management of nutrition interventions to be undertaken using a team approach, involving all of the patient’s health care providers. — SOURCE: AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION

ENTERAL AND PARENTERAL NUTRITION

Long-Term Feeding Tubes May Increase Fistula RiskPediatric patients with intestinal failure often need

gastrostomy tubes, or feeding tubes inserted into an opening created in the stomach, for long-term nutrition. The use of such tubes can lead to persistent gastrocutaneous fistulae, or the failure of the opening to close on its own, resulting in a need for surgical closure.

The causes of gastrocutaneous fistulae in pediatric patients largely are unknown, but researchers at Boston Children’s Hospital looked at possible risk factors, including nutrition. Their findings were published online in the Journal of Parenteral and Enteral Nutrition.

Of all the risk factors studied, only prolonged use of a gastrostomy tube was identified with an increased like-lihood of gastrocutaneous fistulae. In addition, fistulas in pediatric patients that persisted for longer than seven days were unlikely to close.

The researchers recommended that early operative intervention be considered after a relatively brief trial of spontaneous gastrostomy tubes site closure, especially in children who have had indwelling tubes for longer than 18 months.— SOURCE: AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION

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Current Guidelines for IV Feeding May Require RevisionsCurrent guidelines to help prevent bloodstream infec-

tions during IV feeding may need revisions to strengthen protections for patients, a new study finds.

Researchers at the University of Southampton in the United Kingdom found that current guidelines don’t account for other independent factors that can affect the growth of potentially deadly microorganisms. The study was published online in the Journal of Parenteral and Enteral Nutrition.

Existing guidelines restrict how long a single bag of parenteral nutrition containing lipids can be used due to the lipids’ ability to encourage microorganism growth. This study looked at the growth of Escherichia coli and

Enterococcus durans in parenteral nutrition to determine whether other factors can affect microbial growth. Researchers found that additional factors, including glucose concentration, proportion of glucose to lipid, and osmolarity (concentration of a solution that can pass through the wall of a living cell through osmosis) can affect microbial growth apart from the presence of lipids.

The researchers recommended that these additional factors be considered when making clinical and policy decisions to limit the potential growth of microorganisms in parenteral nutrition. — SOURCE: AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION

Homecare Patients Should Prepare Emergency Plans

On the heels of the 2014 hurricane season, researchers are calling for home parenteral and enteral nutrition consumers and their home care providers to have a comprehensive emergency preparedness plan to ensure that special needs are met during a disaster.

In a paper published in Nutrition in Clinical Practice, researchers with Coram Specialty Infusion Services outlined the experiences of home parenteral and enteral nutrition consumers and home care providers in New Jersey who were affected by Hurricane Sandy in October 2012 and used that information to present recommenda-tions for emergency preparedness plans.

Among the key recommendations for consumers is to contact their utility company before any disaster to ensure

they’re properly identified as power-dependent customers and to have a home parenteral and enteral nutrition emergency kit as well as a basic emergency kit. They also advocate for consumers to have an emergency contact list that includes names and contact information for designated family and friends, physicians, and pharmacy and home care providers.

The researchers recommended that the home care providers’ emergency plans be focused on ensuring the safety of consumers and employees, minimizing any interruption of services, and preparing contingency plans or designating backup providers. They also recommended that providers develop an emergency preparedness plan manual for their home parenteral and enteral nutrition consumers, and that they provide their consumers with supplies to have on hand in case they require an alternate method or type of feeding.

To help these consumers and home care providers develop emergency plans, the researchers cited The Oley Foundation (www.oley.org) as a helpful resource. — SOURCE: AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION

[Researchers recommend] consumers have an emergency contact list that includes names and contact information for designated family and friends, physicians, and pharmacy and home care providers.

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Cooking Light Dinnertime Survival Guide By Sally Kuzemchak2014, Oxmoor HouseHardcover, 256 pages, $24.95

Sally Kuzemchak is a busy mom of two boys who writes the popular blog Real Mom Nutrition. Her new book, a collaboration with Cooking Light, is a great resource for any busy mom looking to get a healthful and delicious meal on the table in a flash. Her book outlines 10 tough dinnertime dilemmas and solves them with simple, delicious recipes:• I have zero time! (speedy recipes to save the day)• I can barely boil water! (meals with the no-fail feature)• I can’t afford healthy food (save bucks with thrifty dishes)•Who ate my cheese? Bread? Salad? (dinners from a stocked

pantry) • I’m not a short order cook! (feeding picky eaters)•Nobody’s around to eat it anyway (adaptable meals for

hectic schedules)• I’m on a diet, they’re not (healthy foods everyone will love)•My kids take all my attention! (one-handed recipes—almost)•Meat loaf. Again? (busting out of the dinner rut)•Frankly, I just don’t feel like it (easy meals to get it done)

After reading through the 10 different sections of this cookbook, I found multiple recipes that I was eager to try. I love slow-cooker recipes, so when I saw a recipe for Slow-Cooker Lasagna, I had to try it. While I did have to prep a bit before layering everything into the slow cooker, this recipe was definitely a nice time-saver, and it was tasty. The Pasta Primavera With Zucchini, Cherry Tomatoes, and Ricotta was equally delicious, but the preparation was even simpler.

I also made Oatmeal Pancakes, Cheesy Mini Meat Loaves, Speedy Sloppy Joe Sliders, Marbled Chocolate-Banana Bread, Popeye’s Baked Ziti, and White Chocolate, Strawberry, and Oatmeal Cookies (although I made them with dark chocolate and without the dried strawberries), and I enjoyed all of them.

However, after sampling some of these recipes, I was left with a few complaints. The prep time isn’t accounted for in the

“hands-on time” listed because the ingredient list includes items that already are chopped or ready to use. Thus, the recipes do take longer to prepare. Furthermore, in the case of the Popeye’s Baked Ziti, the ingredients called for 4 cups of hot cooked ziti. Maybe it’s just me, but I find it easiest when a recipe uses a whole box or container of something. I made the mistake of cooking the whole box and thus had a diluted baked ziti. It was still tasty but just not quite as cheesy-looking as the photo.

All in all, I do highly recommend this book as well as the Real Mom Nutrition website/blog. It’s a great resource to share with clients, friends, family, and colleagues. I know I’m always looking for new, exciting recipes to try.

— Janice H. Dada, MPH, RD, CSSD, CDE, CHES, owns SoCal Nutrition & Wellness, a private practice and consulting business

in Newport Beach, California. She’s also a freelance writer and works in education.

The Greek Yogurt Kitchen: More Than 130 Delicious, Healthy Recipes for Every Meal of the DayBy Toby Amidor, MS, RD, CDN2014, Grand Central PublishingSoftcover, 256 pages, $20

As a fan of Greek yogurt, I was thrilled to discover The Greek Yogurt Kitchen, which shows how Greek yogurt can be much more than a breakfast or snack food.

Author Toby Amidor begins with a history of Greek yogurt—which actually didn’t originate in Greece—followed by a nutritional comparison with traditional yogurt. Greek yogurt wins with lower sodium, sugar, and calories. It also offers twice as much protein as traditional yogurt and is rich in calcium.

In addition, you’ll learn why Greek yogurt is loaded with probiotics and why it’s good for heart health, lowering blood pressure, and losing weight. Included are tips on choosing the best brands as well as a recipe for making your own Greek yogurt.

BOOKSHELF

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Each recipe contains the exact measurements for one serv-ing size, so you can watch calories and purchase ingredients in appropriate quantities. A nutritional breakdown accompanies each recipe, so you can make the best choices for your needs.

The recipes call for wholesome ingredients such as fruits, vegetables, whole grains, nuts, seeds, lean proteins, and low-fat and nonfat dairy. The recipes also are free of artificial sweeteners.

You’ll be amazed at the versatility of Greek yogurt as you create smoothies, dips, and dressings as well as salads, soups, pizzas, main entrées, side dishes, desserts, and breads. Personally, I’m eager to make the Green Goddess Deviled Eggs, Grilled Flounder With Avocado Sauce, and Double Chocolate Chip Cookies.

You’ll discover that Greek yogurt is the perfect substitute for higher-fat ingredients such as cream cheese, mayonnaise, oil, butter, sour cream, and buttermilk.

While some recipes are as simple as combining a few ingre-dients, some may require an hour or more prep and cook time.

The Greek Yogurt Kitchen is a healthful, scrumptious, kid-friendly meal manual that anyone who’s health conscious should have on hand.

— Karen Appold is a freelance medical writer and editor based in Pennsylvania’s Lehigh Valley.

The Nourished Kitchen: Farm-to-Table Recipes for the Traditional Foods LifestyleBy Jennifer McGruther2014, Ten Speed PressPaperback, 320 pages, $27.99

If you’ve ever peeked at what fellow supermarket shoppers were putting in their grocery carts and been disheartened by the large number of refined and additive-filled packaged foods they were buying, The Nourished Kitchen (already in its second printing) will give you hope. Its recipes are the antithesis of the fast-food, overly processed American diet and are inspired by the food philosophy of the late Weston A. Price, a Cleveland dentist who studied the effects of diet on dental health. The book emphasizes traditional cooking techniques and organic, whole or minimally processed, seasonal, and locally harvested foods.

The Nourished Kitchen offers more than 160 recipes, which are organized into chapters based on where the ingredients come from: garden, pasture, range, waters, fields, wild,

orchard, and larder (pantry). The recipes teach cooking skills such as making your own yogurt, fermenting vegetables, simmering bone broths, sprout-ing grains, and baking bread from a sourdough starter. For the less adventurous, simpler recipes such as Cider-Braised Kale and Maple-Roasted Pears may be more appealing.

Each recipe is introduced with a short, artfully written narrative of McGruther’s experience with the recipe or highlighting the recipe’s flavors and how to pair it with other items. Surprisingly, some of the recipes are fairly simple in ingredients and required steps, although other ingredients may be difficult to purchase or simply unappetizing, such as chicken feet and goose livers. Even so, the artful, colorful photographs of the recipes help transition almost unthinkable ingredients into appetizing dishes, such as the marrow of beef bones used to make custard, prettily topped with parsley.

Moreover, the recipes include the number of servings but no nutrition information, so the reader remains blissfully uncertain of the calories and fat they provide. The author isn’t afraid to use butter, home-rendered lard, and heavy cream rich in fat-soluble vitamins, but clearly replete with saturated fat, which major health organizations recommend limiting. Certain ingredients may raise eyebrows among food safety experts, such as raw milk, which McGruther acknowledges may be difficult to obtain.

For those who already are stripping their pantry of processed foods and who aren’t afraid to invest extra time tracking down locally sourced foods and preparing foods in the kitchen, this cookbook may be a good fit. The back of the book includes a resources section to help find certain ingredients, and readers can find more information on McGruther’s website, www.nourishedkitchen.com, where this food educator and food activist also offers online cooking classes and subscription-based meal plans.

— Marsha McCulloch, MS, RD, LD, is a nutrition writer and consultant in South Dakota.

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PRODUCTS + SERVICES

Bob’s Red Mill Cuts Gluten in Baking Flour

Bob’s Red Mill Natural Foods, a provider of whole grain and gluten-free foods, has announced the availability of a new gluten-free flour that easily converts any conventional recipe to a gluten-free one. The new product, Bob’s Red Mill Gluten Free 1-to-1 Baking Flour, can be substituted for traditional flour, providing an easy way to create safe gluten-free baked goods.

The Gluten Free 1-to-1 Baking Flour is a blend consisting of a handful of gluten-free ingredients, including whole grain brown rice flour, whole grain sorghum flour, sweet white rice flour, potato starch, tapioca flour, and xanthan gum. It enables bakers to follow any baking recipe and directly replace the amount of traditional wheat flour with the new baking flour. The resulting baked goods promise to offer the same flavor and texture as the conventional counterpart.

The new flour is made from high-quality gluten-free ingre-dients in a 100% dedicated gluten-free facility. All of Bob’s Red Mill gluten-free ingredients and products are batch tested in the company’s quality control laboratory with an R5 ELISA Gluten Assay test to ensure the absence of gluten.

For more information, visit www.bobsredmill.com.

Hilary’s Eat Well Offers Allergen-Free Products

Hilary’s Eat Well is a line of convenient, common allergen–free food products, including the World’s Best Veggie Burger, the Adzuki Bean Burger, the Hemp & Greens Burger, the Root Veggie Burger, the Black Rice Burger, and Original Veggie Bites. The company also has launched a line of shelf-stable common allergen–free dressings.

Hilary’s Eat Well product lines are non-GMO verified, gluten-free certified, and vegan certified. They also are free of dairy, soy, eggs, yeast, corn, sugar, and nuts. The production facility is free of common food allergens, and all products are displayed in environmentally conscious minimal packaging.

For more information, visit www.hilaryseatwell.com.

Beanfields Adds Classic FlavorsBeanfields has released chips in classic Ranch and

Barbecue flavors. The chips, made from beans and rice, are certified gluten-free, non-GMO verified, and vegan.

Beanfield’s Ranch tortilla chips are vegan, meaning that consumers can enjoy the classic creamy taste with-out the dairy. The Barbecue chips are made without sugar and instead are made with a plant-based sweetener with no added calories.

For more information, visit www.beanfieldssnacks.com.

DeeBee’s TeaPops Hit US Shelves

Made with teas, naturally noncaffeinated rooibos, and organic fruit, DeeBee’s TeaPops are lightly sweetened with organic coconut flower blossom nectar or organic, non-GMO honey.

The TeaPops range from 25 to 50 kcal and are 100% certified organic; certified peanut- and nut-free; non-GMO; free of dairy, soy, and gluten; kosher; and almost entirely vegan. They provide the health benefits of tea and rooibos—potent in antioxidants, increasing metabolism, and reducing the risk of cancer.

For more information, visit http://frozen.deebeesorganics.com.

Rickland Orchards Debuts Strawberry Fruit Bites

B&G Foods has debuted Strawberry Fruit, the newest flavor in the Rickland Orchards Greek on the go! line. Strawberry Fruit Bites are dark chocolate–flavored, Greek yogurt–coated fruit bites made with real fruit and fruit juice. In resealable pouches, the newest flavor offers a convenient, on-the-go snack.

For more information, visit www.ricklandorchards.com.

Stouffer’s Vegetable Lasagna Made With Whole Grains

Stouffer’s authentic lasagna collection features a new take on vegetable lasagna: It now features ricotta cheese, golden breadcrumbs, sea salt, and ruffled pasta made with whole grains. For foodservice, entrées are available in four 96-oz trays that yield 48 servings per case in three additional flavors: Classic Lasagna, Lasagna With Meat & Sauce, and Chicken Lasagna.

For more information, visit www.nestle professional.com/stouffers.

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Red Jacket Orchards Introduces Juice With Antioxidants

Red Jacket Orchards, a family-owned brand crafting fresh fruits and juices for over five decades, introduces a new alter-native to traditional juicing by creating cold pressed juices. In addition to their well-known apples, Red Jacket Orchards grows seasonal fruits such as peaches, plums, strawberries, raspberries, cherries, and apricots.

Red Jacket Orchards Cold Pressed Juices are produced using a traditional rack-and-cloth method of taking fresh fruit, chopping it, and pressing the cold mash into a notice-ably cloudy juice. This cloudiness is the presence of soluble fiber, antioxidants, and flavonoids. The cold pressed juices are made naturally with whole fruit and no additives.

For more information, visit www.redjacketorchards.com.

Annie’s Snack and Meal Kits Offer Convenience

Annie’s has introduced a variety of Snack and Mini Meal Kits, combining snack and meal items in a shelf-stable, kid- and adult-friendly kit. With no artificial flavors, synthetic colors, or synthetic preservatives, these kits provide an alternative to overly processed prepacked lunches.

Available in six varieties, Annie’s Snack and Mini Meal Kits offer 6 to 10 g of protein, 3 to 6 g of fiber, and one full serving of fruit in each kit. The varieties offered include two gluten-free versions for those with gluten allergies or sensitivities.

Annie’s Snack Kits are available in the following three varieties: Almond Butter & Crackers, Hummus & Crackers, and Gluten Free. Annie’s Mini Meal Kits are available in three varieties: White Cheddar Mac & Cheese, Real Aged Cheddar Mac & Cheese, and Gluten Free Rice Pasta & Cheddar.

For more information, visit www.annies.com.

NuttZo Cuts the Sugar in Chocolate Line

In the last year, NuttZo has come out with its smooth line, chocolate line, and 2-go packs. The Chocolate line contains only 2 g of sugar per serving and is made with 70% dark Peruvian organic chocolate.

NuttZo doesn’t add any sugar or oils to its nut but-ters, and every flavor is a blend of seven healthful nuts and seeds, including almonds, cashews, hazelnuts, brazil nuts, peanuts, sunflower seeds, pumpkin seeds, chia seed, and flaxseeds. Ingredients are high quality, organic, non-GMO, and gluten-free certified.

For more information, visit https://gonuttzo.com.

Earth Balance Launches Vegan Cheddar Squares

Earth Balance has launched its Vegan Cheddar Flavor Squares, a nondairy, plant-based cracker developed with non-GMO ingredients.

In the United States, snacks represent 50% of eating occasions, and cheese-flavored crackers are an annual $1.39 billion segment of the cracker category. Earth Balance sees the non-dairy, non-GMO snacking category as an opportunity and important area for growth. Currently, only one-tenth of 1% of US cheese cracker sales are GMO-free.

For more information, visit http://earthbalancenatural.com.

PÜR Gum Releases Two New Flavors

PÜR Gum has introduced the newest members of its sugar and aspartame-free family: Cinnamon and Coolmint.

PÜR Cinnamon captures the balance of hot and sweet sensations from cinnamon bark. Infused nat-urally, it’s made with no artificial ingredients. PÜR Coolmint refreshes the breath with a clean, crisp, and chilling flavor, with natural mint revitalizing the senses.

For more information, visit http://pur-gum.com.

Grecian Delight Reveals Greek Yogurt Dips

Grecian Delight Food has released a line of Greek yogurt and feta cheese dips. The entire line of spreads is all natural and low in fat, making them healthy alternatives to mayonnaise- or sour cream–based spreads. The natural dips contain no trans fats, artificial colors, or flavors.

Opaa! Brand spreads offer the following flavors: Zesty Greek Yogurt Spread with tomatoes, green peppers, and spicy peppers; Sun-Dried Tomato Yogurt Spread with sun-dried tomatoes and roasted red peppers; Garden Yogurt Spread with green peppers and onions; and Creamy Yogurt Spread with Mediterranean spices.

For more information, visit www.greciandelight.com.

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NEWS BITES

Energy Drinks Raise New Questions About Caffeine’s SafetyCaffeine, which was extensively researched for possible

links to birth defects in animals and cardiovascular disease in humans more than 30 years ago and then exonerated, has become the focus of renewed concerns because caffeine-containing energy drinks have surged in popularity.

However, according to a panel discussion at the Institute of Food Technologists annual meeting in New Orleans, a rich database of health evidence exists confirming the safety of caffeine for consumers at current levels of exposure. What isn’t known, however, is how caffeine may interact with the myriad ingredients found in many energy drinks.

In 2013, Congress urged the FDA to look harder at caffeine’s safety. The FDA responded by sponsoring an Institute of Medicine scientific workshop in August 2013. Two areas of focus that came out of the workshop were the need to identify vulnerable populations that may be at risk from increased caffeine exposure and pinpoint research gaps that need to be filled.

“I thought we had put these safety issues to bed in the ‘80s,” said James Coughlin, PhD, president and founder of Coughlin & Associates, a consulting firm based in Aliso Viejo, California. “But today’s concerns are being raised because no one has gone back to look at this literature. There has been a lot of bad science related to caffeine that is fueling concerns.”

The FDA has begun an internal evaluation of caffeine’s safety and is expected to issue guidelines.

James C. Griffiths, PhD, vice president of scientific and international affairs at the Council for Responsible Nutrition (CRN) in Washington, D.C., and a member of the panel, said, “CRN believes that no new regulations are necessary concerning caffeine-containing products, since there’s overwhelming scientific evidence demon-strating its safety. We’re all waiting to see what the FDA is going to do.”— SOURCE: INSTITUTE OF FOOD TECHNOLOGISTS

Peanuts Don’t Panic Parents as Much as Milk and Eggs

It’s tough being the parents of a child with food allergies. Constant vigilance is needed for everything their child eats since a single food item containing a hidden ingredient can be fatal.

Although worry is a factor for anyone caring for a child with food allergies, according to a study published in the Annals of Allergy, Asthma, and Immunology, there’s increased anxiety and strain for caregivers of children allergic to milk and eggs.

The study examined 305 caregivers of children allergic to milk, eggs, peanuts, or tree nuts, which are the four most common food allergies. The caregivers were asked about details of the children’s most severe food reaction and infor-mation about the caregivers’ quality of life. Researchers found

caregivers who understood their child’s reaction to offending foods had a higher quality of life. If they knew exactly what foods could give their child an allergic reaction, they were less likely to be anxious and stressed.

The authors were surprised to learn that milk and egg aller-gies were the most worrisome for caregivers.

“It’s assumed peanut and tree allergies are the most severe, and therefore it may be presumed they would cause the most strain for caregivers,” says allergist Laura Howe, MD, lead study author and a member of the American College of Allergy, Asthma, and Immunology (ACAAI). “But because eggs and milk are everywhere and used to prepare so many dishes, caregivers with children allergic to those two ingredients feel more worried and anxious.”

Only 64% of caregivers accurately perceived the severity of their child’s reaction. More than 15% overperceived their child’s reaction severity, and 19% underperceived the reaction sever-ity. Caregivers had significant concerns regarding their ability to help in the event of a reaction and also that others wouldn’t understand the seriousness of their child’s food allergy.

“It’s important for those who care for food-allergic children to work with an allergist to determine exactly what foods their child is allergic to and how to respond in an emergency situation,” says allergist Michael Foggs, MD, ACAAI president. “Parents need to have a clear plan of action in case their child eats a food they shouldn’t. Children with a history of allergic reactions and their caregivers need to know how to administer epinephrine. Having plans in place can ease a parent’s worries.”— SOURCE: AMERICAN COLLEGE OF ALLERGY, ASTHMA, AND IMMUNOLOGY

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Healthy Lifestyle Crucial for Women of Childbearing AgeNutrition is crucial before, during, and after pregnancy to

optimize health for both mother and child, according to an updated position paper and a new practice paper from the Academy of Nutrition and Dietetics (the Academy).

The Academy’s position paper, “Nutrition and Lifestyle for a Healthy Pregnancy Outcome,” was published in the Journal of the Academy of Nutrition and Dietetics. An accompanying practice paper was published on the Academy’s website for members. The practice paper provides RDs and DTRs with an overview of current recommendations related to nutrition and healthy lifestyles during pregnancy and best practices on ways to implement those recommendations.

The Academy says, “It is the position of the Academy of Nutrition and Dietetics that women of childbearing age should adopt a lifestyle optimizing health and reducing risk of birth defects, suboptimal fetal development, and chronic health problems in both mother and child. Components leading to healthy pregnancy outcome include healthy prepregnancy weight, appropriate weight gain and physical activity during pregnancy, consumption of a wide variety of

foods, appropriate vitamin and mineral supplementation, avoidance of alcohol and other harmful substances and safe food handling.”

According to the position paper’s authors, factors that contribute to a healthy pregnancy go beyond a well-balanced diet, and RDs and DTRs can help pregnant women select an appropriate food plan and tailor advice to the woman’s needs.

The Academy offers the following advice:•Followahealthydietandbephysicallyactivebefore,

during, and after pregnancy.•Awell-balanceddietcanmeetmostofyournutrientneeds

during pregnancy. Talk with your health provider about iron and other nutrient supplements.•Askyourhealthproviderhowmuchweightgainisrightfor

you. A healthy weight gain is important for both baby and mother. •Ahealthylifestylehelpspreventexcessiveweightgain

during pregnancy.•RDsandDTRscanhelpyouselectanappropriatefoodplan

and tailor advice to your needs.— SOURCE: ACADEMY OF NUTRITION AND DIETETICS

Nutrition Program Improves Preschoolers’ At-Home DietA nutrition education program in low-

income child care centers can improve a child’s at-home consumption of vegeta-bles and low-fat/fat-free milk, according to a study by researchers from RTI Inter-national, Altarum Institute, and the USDA. The USDA’s Food and Nutrition Service supported the study.

Published in the Journal of the Academy of Nutrition and Dietetics, the study is the first to examine and find that a multicomponent nutrition education program for low-income preschool-aged children and their parents in a child care setting can affect a child’s at-home diet.

The USDA recommends that children aged 2 to 5 eat 1 to 11⁄2 cups of vegetables daily and 1 to 11⁄2 cups of fruit each day. Nearly 60% of US children aged 3 to 5 attend a center-based child care program, according to the US Department of Educa-tion, which can provide an opportunity to improve the nutrition of preschool-aged children.

Researchers found that children who participated in the nutrition education program were about 39% more likely to drink or use low-fat/fat-free milk on their cereal than children who weren’t exposed to the program. The study also found a significant increase in the number of cups of vegetables that these children consumed at home each day.

The study examined the State of New York’s Eat Well Play Hard in Child Care Settings nutrition education program administered by RDs in low-income child care settings.

Researchers sampled 24 child care centers that serve low-income families and receive reimbursement for meals and snacks served as part of the USDA’s Child and Adult Care Food Program in New York. Twelve child care centers took part in an intervention, consisting of multilevel messaging targeted to preschoolers, par-ents, and child care staff.

As part of the program, RDs provided nutrition education to both children and their parents during a six- to 10-week period. Parents were asked to complete a mail or telephone survey at the beginning and end of the program to report their child’s at-home consumption of fruits, vegetables, and milk.

At the child care centers, children participated in 30-minute nutrition education classes about trying new foods, eating a variety of vegetables and fruit, using healthier dairy products, and eating healthier snacks. Nutritionists also provided train-ing sessions to child care center staff about identifying areas of policy needed to improve nutrition at the center and how to incorporate messages about nutrition into the classroom.

While children’s vegetable and low-fat/fat-free milk con-sumption improved, the study found that the program didn’t have a significant impact on parental offerings of fruits and vegetables or fruit consumption since most children already were close to meeting the recommended amount of fruit.— SOURCE: RTI INTERNATIONAL

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Study Finds Kids Eat Whole Grains When Offered

According to a new study by researchers at the University of Florida’s Institute of Food and Agricultural Sciences, kids will eat whole grains when they’re offered, and they will eat whole and refined grain foods in equal amounts.

“We tried to choose foods we thought kids would enjoy, such as cereal bars, macaroni and cheese, and SunChips, and found that they ate the ready-to-eat snack foods the most,” says Allyson Radford, PhD, a University of Florida research study coordinator in food science and human nutrition and one of the study authors. “We were interested to see if they would eat the whole grain foods as much as the refined grain foods, and we were pleasantly surprised that they would eat the same amount whether the food was whole or refined.”

Radford cowrote the paper with assistant professor Wendy Dahl, PhD, and professor Bobbi Langkamp-Henken, PhD, both from the food science and human nutrition department. The study was published online in the Journal of the Academy of Nutrition and Dietetics.

The 2010 Dietary Guidelines for Americans call for at least one-half of the grain consumers eat to be whole grains, and they urge adolescents to consume 5 to 7 oz of grains daily, with at least one-half being whole grains. National surveys suggest adolescents consume far less: about 1 oz, or the amount of grain contained in one slice of bread.

Federal dietary guidelines for the 2012-2013 school year increased the whole grain required in school lunches. Start-ing this fall, schools must offer only whole grain–rich products. The new rules requiring more whole grains in school lunches should result in adolescents eating more of them, Dahl says, but many parents believe their kids won’t eat whole grains.

General Mills funded a broad study on the impact of whole grains on immunity. As part of the study, Radford wanted to know whether children could meet the 2010 Dietary Guide-lines for whole grains. For the study, 83 students in a Florida middle school were randomly assigned to receive either whole or refined grain foods over a six-week period in 2010. Of those, 42 students were in the refined grain group, while 41 were in the whole grain group.

Participants and their families were given refined grain or whole grain pasta, rice, bread, and other foods to eat at home and whole and refined grain snack foods to eat at school.

Researchers interviewed students weekly to see what fruits, vegetables, and grains they ate in the previous 24 hours. Before the study, participants were eating about 1 oz of whole grain per day. During the study, students in both groups reported eating more than 6 oz of grains per day, and those given whole grains reported more than one-half of their grain intake came from whole grains, meeting the 2010 Dietary Guidelines. Snacks served at school were the most popular grain foods the kids ate.

“Encouraging consumption of whole grain foods that require little to no preparation may be the most effective means of increasing whole grain intake at home,” Radford says.— SOURCE: UNIVERSITY OF FLORIDA INSTITUTE OF FOOD AND AGRICULTURAL SCIENCES

BMI Measurement May Miss Some Children Who Are Obese

Physicians using BMI to diagnose children as obese may be missing more than 25% of kids who have excess body fat despite a normal BMI, which can be a serious concern for long-term health, according to a Mayo Clinic study published in Pediatric Obesity.

The researchers found that BMI has high specificity in identifying pediatric obesity, meaning BMI accurately identifies children who are obese, but has moderate sensitivity, meaning the BMI tool misses children who actually should be considered obese, according to the percent of fat in their bodies.

“If we are using BMI to find out which children are obese, it works if the BMI is high, but what about the children who have a normal BMI but do have excess fat? Those parents may get a false sense of reassurance that they do not need to focus

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Poor Awareness of Injection Techniques Affects Glucose ControlPatients with diabetes who don’t know proper injection

techniques may administer insulin incorrectly, leading to poor glycemic control and adverse outcomes, a new study from Iraq finds. The results were presented at the joint meeting of the International Society of Endocrinology and the Endocrine Society in Chicago.

“Lack of simple education about proper injection tech-niques could be blamed for many complications and adverse outcomes,” said study author Hassan A. R. Ibrahim, MBChB, MSc, a diabetes specialist at the Layla Qasim Diabetes Center in Erbil, Kurdistan, Iraq. “I thought about conducting this study after managing two teenage patients who suffered diabetic ketoacidosis, a life-threatening acute emergency. The condition occurred due to the lump formed because they were unaware of the proper injection techniques.”

Insulin therapy injection technique among insulin-treated diabetes patients has been poorly studied, Ibrahim said. To investigate the impact of injection technique on diabetes con-trol, he administered a 12-item, oral-structured injection tech-nique knowledge questionnaire to 216 clinic patients that assessed their understanding of injection techniques and ability to administer their injections successfully.

Overall, the mean score was 47.5%, and only 31% of the patients answered more than one-half of the questions cor-rectly. Approximately one-half of the patients with poor test scores had poor glycemic control compared with roughly 28% of the participants with acceptable scores.

“I was surprised by the results of the study and at the same time disappointed. I did not expect that such a great number of patients would not be aware of the proper use of insulin. This was mainly due to inadequate education and resources for the patients using insulin,” Ibrahim said.

He found no significant association between the test scores and the patients’ residency, sex, age, or duration of diabetes, although more highly educated patients, including patients who had received previous education on injection technique, had higher scores. He did find associations between the test scores and the type of diabetes, insulin regimen, insulin devices, gly-cemic control, prior training on the correct injection technique, and previous lump formation at the site of injection.

Ibrahim says educating patients is crucial. He recommends that an educator be available to teach new patients having their first injection the correct techniques, and that no patient should be sent home unless the physicians are sure he or she has the necessary knowledge. Patients need to learn the correct insu-lin dosing for vials and syringes and know the preferred sites of injection, how to prevent lumps at the injection sites, and the negative consequences of uncontrolled blood sugar.

“We have an educator, but she cannot cope with the large number of the patients visiting the center,” he said. “Some patients are not given enough time to learn. Therefore, more educators should be allocated, and annual reassessment is recommended.”— SOURCE: ENDOCRINE SOCIETY

on a better weight for their children,” says Francisco Lopez-Jimenez, MD, senior study author and director of preventive cardiology at the Mayo Clinic in Rochester, Minnesota.

In the meta-analysis, the researchers used 37 eligible studies that evaluated 53,521 patients with mean ages rang-ing from 4 to 18. It’s the first systematic review and meta-analysis to assess BMI’s diagnostic performance to identify excess body fat compared with techniques considered refer-ence standard to measure obesity. These other techniques include skin-fold thickness measurement and dual-energy X-ray absorptiometry, which can be used to measure body composition and fat content.

It’s known that childhood obesity can lead to an increased risk of type 2 diabetes and cardiovascular disease, says Asma Javed, MD, the study’s first author and a pediatric endocrinology fellow at the Mayo Clinic Children’s Center. “Our research raises the concern that we very well may be missing a large group of children who potentially could be at

risk for these diseases as they get older,” Javed says. “We hope our results shine a light on this issue for physicians, parents, public health officials, and policymakers.”

While not part of this study, its results mirror what has been found in Lopez-Jimenez’s research of adults. Over several years of research, he and other investigators discovered what they call normal-weight obesity, wherein adults have a normal BMI but a large percentage of body fat. Normal-weight obesity shares some of the risks of obesity, which can lead to prediabetes, the metabolic syndrome, and cardiovascular death.

“The lesson is that we need additional research in children to determine the potential impact of having high fat in the set-ting of normal BMI to recognize this issue and perhaps justify the use of body composition techniques to detect obesity at an early stage,” he says.— SOURCE: MAYO CLINIC

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RESEARCH BRIEFS

Boron Tolerance Discovery for Higher Wheat Yields

Australian scientists have identified the genes in wheat that control tolerance to a significant yield-limiting soil condition found around the globe: boron toxicity.

Published in Nature, the identification of boron tolerance genes in wheat DNA is expected to help plant breeders more rapidly advance new varieties for increased wheat yields to help feed the growing world population.

The researchers, from the Australian Centre for Plant Functional Genomics at the University of Adelaide’s Waite campus within the university’s School of Agriculture, Food, and Wine, say that in soils where boron toxicity is reducing yields, genetic improvement of crops is the only effective strategy to address the problem. “About 35% of the world’s 7 billion people depend on wheat for survival,” says project leader Tim Sutton, PhD. “However, productivity is limited by many factors, such as drought, salinity, and subsoil constraints including boron toxicity.

“In southern Australia, more than 30% of soils in grain-growing regions have too-high levels of boron,” he continues. “It’s also a global problem, particularly in drier grain-growing environments. Boron-tolerant lines of wheat, however, can maintain good root growth in boron toxic soils whereas intolerant lines will have stunted roots. Our identification of the genes and their variants responsible for this adaptation to boron toxicity means that we now have molecular markers that can be used in breeding programs to select lines for boron tolerance with 100% accuracy.”

Sutton says wheat has been difficult to work with in genomics. The wheat genome is very large, with about six times the number of genes as humans. This complexity has meant that genes controlling yield and adaptation to environmental stresses have remained extremely challenging to identify. “Advances in molecular biology and genetics technologies of the past few years, coupled with the extensive collections of wheat genetic material available around the world, have paved the way for a new era in the analysis of complex genomes such as wheat,” he says.

In this study, the researchers tracked these specific boron tolerance genes from wild wheats grown by the world’s earliest farmers in the Mediterranean region, through wheat lines brought into Australia more than a century ago, to current day Australian commercial varieties. They found a distinct pattern of gene variant distribution that correlated to the levels of boron in soils from different geographical regions. “This discovery means that wheat breeders will now have precision selection tools and the knowledge to select for the right variants of the tolerance gene needed to do the job in specific environments,” Sutton says.— SOURCE: UNIVERSITY OF ADELAIDE

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Do Probiotics Help Kids With Stomach Bugs?

To better understand probiotics’ capabilities, research-ers at the Washington University School of Medicine in St Louis are leading a nationwide clinical trial to determine whether one of the most commonly used probiotics can safely and effectively treat infants and toddlers suffering from acute gastroenteritis, otherwise known as stomach virus or stomach flu.

“Probiotics are very popular,” says David Schnadower, MD, the trial’s principal investigator and an associate professor of pediatrics. “People use them for everything, especially diarrhea, yet minimal data exist showing they really help. There’s a real need to do a clear, definitive study of the use of probiotics in kids with gastroenteritis.”

While medical professionals sometimes give children with gastroenteritis medication to treat nausea and fluids to prevent dehydration, currently there are no treatments for the condition.

“We hope to provide evidence for or against the use of probiotics in children with stomach viruses,” says Schnadower, who also treats patients at St Louis Children’s Hospital. “If the probiotic we’re studying is helpful, safe, and cost-effective, then I can foresee

doctors prescribing it to children with diarrhea and other symptoms of gastroenteritis. But what we don’t want is for the use of probiotics to become a practice that isn’t supported by evidence.”

The trial will involve about 900 chil-dren aged 3 to 48 months treated at St Louis Children’s and at eight other academic medical centers. Partici-pants may be eligible if they come to the emergency department with symptoms of gastroenteritis, including watery stools, vomiting, dehydration, or other signs of acute intestinal infec-tion. They also must not have taken probiotics in the preceding two weeks and must meet other criteria.

Children will be randomly assigned to receive a probiotic or a placebo for five days. The probiotic, approved by the FDA, is Lactobacillus GG. Other-wise, children in the trial will receive standard clinical care.

Researchers will assess patients by tracking the severity of their gastroenteritis, taking into account the duration and frequency of diarrhea and vomit-ing, the duration and height of fever, and the use of health care resources such as doctor or hospital visits and the use of intravenous rehydration.

For the first five days after an emergency department visit and again at two weeks, researchers will monitor patients via symptom diaries and phone or Internet sur-veys. The researchers will follow up with parents at one, three, six, nine, and 12 months after the initial emergency department visit to check on each child’s health.

Schnadower says investigators also will examine the impact, if any, that probiotics have on household transmis-sion of diarrhea and a range of economic data involving missed work, missed day care, and even the cost of diapers.

A similar trial in Canada examining the safety and efficacy of another common probiotic (Lacidofil) will coincide with the US study. That trial, funded by the Canadian Institutes of Health Research, also will involve young children with gastroenteritis.

“Not only will we be able to know whether one probi-otic is effective vs. placebo, we also likely will be able to combine our data and learn whether one probiotic is more effective,” Schnadower says.— SOURCE: WASHINGTON UNIVERSITY IN ST LOUIS

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WI-FI HOTSPOT ETIQUETTEBy Reid Goldsborough

Using Wi-Fi in public is much like using a cellphone in public. There are dos and don’ts if you want to avoid stares, mumbles, or getting yelled at. Whether you’re in a coffee shop, bookstore, library, or airport lounge, the long and short of it is the Golden Rule: Do unto others as you would have them do unto you. The following are additional rules you should keep in mind when in a Wi-Fi hotspot:

• Keep it quiet. Just as people talking on a cellphone tend to talk loudly, the same applies to people Skyping or using their laptops or tablets to communicate orally. If you need to talk, go outside or to an isolated part of the space you’re in, or keep it short and say you’ll get back to the other person later.

A public Wi-Fi hotspot also isn’t the best place to show off your add-on speakers as you listen to iTunes music or watch a YouTube video or Netflix movie. Headphones are an inexpensive solution to nip this noise problem in the bud. A noise-cancelling headset not only lets you listen to what you want but also puts a damper on ambient sounds.

• Share outlets. Laptop batteries last longer than ever, and tablet batteries can seem like they last forever, but the urge to plug in is pretty strong. Screen brightness may be better when plugged in or maybe you just don’t want to risk running down your battery.

Many public Wi-Fi hotspots have limited electrical outlets for patrons to use, and those they have may be in out-of-the-way locations. This prompts some users to bring long extension cords, but this may violate the location’s safety policies and may risk tripping other users.

If you’re not using an outlet, don’t sit next to one; instead free up that spot for someone who needs it. Try to choose a location not too close to the door, not too far from the restroom, and not next to a vent that pumps out uncomfortably cold air.

If you use outlets regularly, consider purchasing an inexpensive portable outlet extender, which can multiply one prong from an outlet into six, enabling more people to use the same outlet. Some outlet extenders include surge suppression.

• Be courteous to the staff. Librarians aren’t your personal computer support staff. If you’re having problems, some may help you out, but most won’t know enough details about your par-ticular glitch or have the time to devote to it.

The waitstaff at coffee shops and restaurants—and increasingly at bookstores, too—depend on your buying beverages or additional items for their jobs. Don’t forget the tips. The implicit agree-ment here is they provide the Wi-Fi and you pay for the refreshments to keep them in business.

• Avoid public meetings. Though you sometimes see them happen publicly, having a meeting or conducting a job inter-view are private matters. Just because the space is free doesn’t mean you can use it as you please.

You hear anecdotal stories of interviewers asking inter-viewees to disclose personal information, lawyers discussing financial information with clients, and loud meetings involving multiple tables that disrupt the ambiance for everyone else in the coffee shop.

If you don’t have a private office or conference space avail-able, a better place for meetings is a dedicated coworking space at a local business center.

• Stay security conscious. Your laptop or tablet can disap-pear in a blink of an eye and so can your briefcase or purse. When you need to use the restroom, you should either ask someone to keep an eye on your gear, pack it all up and set up again when you return, or secure your laptop to your table with a laptop lock.

For digital security, make sure no one is looking over your shoulder if you need to type in sensitive information. Log onto the right network rather than a rogue network with a similar name set up by a crook looking to steal your information.

Finally, even with HTTPS-secured websites, it’s safest to use a virtual private network system such as Hotspot Shield (www.hotspotshield.com) if you’re using public Wi-Fi to make online purchases, conduct online banking, or engage in similar activi-ties involving financial information.

— Reid Goldsborough is a syndicated columnist and author of the book Straight Talk About the Information Superhighway. He can

be reached at [email protected] or www.reidgold.com.

PERSONAL COMPUTING

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NOVEMBER 5-6, 2014IOWA ACADEMY OF NUTRITION AND DIETETICS ANNUAL MEETINGWest Des Moines, Iowawww.eatrightiowa.org

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NOVEMBER 21, 2014CHILDREN’S HOSPITAL OF PHILADELPHIA EMERGING TOPICS IN PEDIATRIC NUTRITION: A PRACTICAL APPROACHPhiladelphia, Pennsylvaniawww.chop.edu/cme

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DECEMBER 4-6, 2014AMERICAN SOCIETY FOR NUTRITION ADVANCES AND CONTROVERSIES IN CLINICAL NUTRITIONWashington, D.C.www.nutrition.org

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FEBRUARY 14-17, 2015AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION CLINICAL NUTRITION WEEKLong Beach, Californiawww.nutritioncare.org

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MAKING PEACE WITH BEETSA Root Vegetable Messy to Prepare but Oh So FlavorfulBy Grace Dickinson

It wasn’t until last year that I decided how I felt about beets. This slow decision-making process stemmed from having two parents who held diametrically opposed opinions about this root vegetable.

Beets were my mom’s worst nightmare. The juice stained her cut-ting boards, tie-dyed her kids’ white T-shirts, and left her scrubbing the kitchen counters until her hands turned pink. On the other hand, beets were my dad’s favorite vegetable. They were one of his con-tinuously best-growing crops in the family garden. He loved nothing more than staining his hands as he pulled the beets out of the ground each year, and he had an affinity for their taste that my mom couldn’t match. And unfortunately, my mom had cleaning skills that my dad couldn’t match, so every summer there was a comical bone of con-tention that surrounded beets.

These opposing views left me baffled, and over the years I didn’t experiment with the veggie even as I developed my own interest in cooking. The flavor of beets was one I could do without as well as the mess that came with preparing them. Last year, however, I decided to throw a small beet into a bowl of summer tabbouleh. Instantly, the grain salad turned a majestic pink, and from that day forward, I officially became a beet lover.

For me, the key is to use beets in small amounts. That way, there are fewer to chop and less of a mess. But the bottom line is that beets lend a sweet, earthy flavor when added to a dish. I prefer just a hint of this flavor, and only a hint is needed to transform an entire dish into a beautiful, pink presentation. You’ll find that’s the case with the following burger recipe, where one small beet makes the whole batter pop with color and taste. The beet also adds a hint of sweetness that goes perfectly with the smoky paprika and parsley herb sauce. Serve on a whole wheat bun alongside a simple cucum-ber and onion salad for a light meal.

— Grace Dickinson is a photo enthusiast, food blogger, and recipe developer for FoodFitnessFreshAir.com.

CULINARY CORNER

Smoky Black Bean Burgers With Herb Yogurt Sauce

Beets add a touch of sweetness yet a vibrant color to these bean burgers. Feel free to use basil or cilantro instead of parsley in the yogurt sauce, as they make excellent alternatives.

Makes 6 medium-sized burgers

Ingredients3 cloves garlic, chopped1 onion, chopped1 small beet, chopped3 cups cooked black beans, 1 cup set aside2 tsp smoked paprika1 lime, juiced1 tsp salt plus a pinchPepper, to taste1 cup cooked bulgur wheat (can use short

grain brown rice instead)1 large egg1 T olive oil3⁄4 cup low-fat Greek yogurt1 T parsley, minced6 whole wheat buns

Directions1. Place garlic, onion, and beet in a food processor and process until veggies are grated. Add 2 cups of black beans, smoked paprika, half of the lime juice, salt, and pepper. Process until fairly smooth. Use a spatula to stir in remaining beans, bulgur, and egg.2. Preheat oven to 400˚F. Shape burgers into 6 circular patties. Line a baking sheet with aluminum foil and lightly grease with olive oil. Bake 30 to 40 minutes until lightly browned on the outside.3. While burgers are baking, whisk yogurt with remaining lime juice and parsley. Add a pinch of salt.4. Place burger on bun. Top with a dollop of yogurt sauce and serve.

Nutrient Analysis per servingCalories: 360; Total fat: 5 g; Sat fat: 1 g; Trans

fat: 0 g; Cholesterol: 32 mg; Sodium: 600 mg; Total carbohydrate: 58 g; Dietary Fiber: 8 g; Sugar: 2 g; Protein: 17 g

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© Silver Palate Kitchens, Inc. 2014. All rights reserved. Visit us at Silver Palate Booth #2516

How Can Grain Berry®

Slow Digestion and New PlanHelp Manage Your Weight?

Simple carbs and concentrated sugars many of us consume in cakes, candy, sodas and many cereals and snacks speed up the digestive process and create sugar “spikes” in our blood. The recent article in The New York Times, titled, “Always Hungry? Here's Why” suggests that it’s the simple carbs and added sugars that store fat in our tissues - not fats and calories per se.

In that regard, Grain Berry whole grain, sorghum bran antioxidant cereals, pasta and mixes along with fresh or frozen multi-colored vegetables and fruits digest slower in our bodies and prevent spikes in sugar content in our blood (lower glycemic index). Plus Grain Berry Cereals contain fewer added sugars than many other brands to begin with.

Follow this easy 2-2-2™ Grain Berry Eating Regimen.

2 Servings of Whole Grains; 2 Servings Whole Fruits; 2 Servings Vegetables Per Day

2 Servings Grain Berry or other whole grains each day.Grain Berry Cereals, Pasta, Baking Mixes, and other whole grains are needed each day to provide not only whole grain nutrition but a whole network of natural antioxidants and bioactive compound.

2 Servings Whole fruits and berries each day.Also add to cereal.

2 Servings Green and other color vegetables each day.

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