Today's Dietitian

The Link Between
Diet and Arterial

Health
Gluten-Free Pastas
Enjoying
Ancient Grains
Lobster
salad at The
Caf at the
Ritz-Carlton,
Buckhead
ATLANTA
DINING
With Forks Held High,
Taste this Citys
Creative Reinventions
of Southern Cuisine
CONFERENCE ISSUE
www.TodaysDietitian.com
September 2014
Vol. 16 No. 9
The Magazine for Nutrition Professionals
The Link Between
Diet and Arterial
Health
Gluten-Free Pastas
Enjoying
Ancient Grains
Lobster
salad at The
Caf at the
Ritz-Carlton,
Buckhead
With Forks Held High,
Taste this Citys
Creative Reinventions
of Southern Cuisine
September 2014 September 2014
Vol. 16 No. 9
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EDITORS SPOT
President & CEO
Kathleen Czermanski
Vice President & COO
Mara E. Honicker
EDITORIAL
Editor Judith Riddle
Editorial Director Jim Knaub
Editorial Assistants Heather Hogstrom, Leesha Lentz
Contributing Editor Sharon Palmer, RDN
Editorial 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
ART
Art Director Charles Slack
Graphic Designer Erin Prosini
Junior Graphic Designer Victoria Tuturice
ADMINISTRATION
Administrative Manager Helen Bommarito
Administrative Assistants Pat Plumley, Susan Yanulevich
Executive Assistant Matt Czermanski
Systems Manager Jeff Czermanski
Systems Consultant Mike Davey
FINANCE
Director of Finance Jeff Czermanski
CONTINUING EDUCATION
Director of Continuing Education Jack Graham
Continuing Education Editor Kate Jackson
Continuing Education Coordinator Leara Angello
Continuing Education Assistant Susan Graver
CIRCULATION
Circulation Manager Nicole Hunchar
MARKETING AND ADVERTISING
Publisher Mara E. Honicker
Director of Marketing and Digital Media Jason Frenchman
Web Designer/Marketing Assistant Jessica McGurk
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Sales Manager Brian Ohl
Associate Sales Manager Peter J. Burke
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Diana Kempster, Beth VanOstenbridge
Account Executives Victor Ciervo, Dan Healey, Patricia McLaughlin
Sales Coordinator Joe Reilly
2014 Great Valley Publishing Company, Inc.
Phone: 610-948-9500 Fax: 610-948-7202
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All articles contained in Todays Dietitian, including letters to
the editor, reviews, and editorials, represent the opinions of the authors,
not those of Great Valley Publishing Company, Inc. or any organizations
with which the authors may be afliated. 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 ALZHEIMERS
If youve been listening to the news lately,
youve probably heard much discussion about
the new study ndings concerning the preven-
tion, diagnosis, and treatment of Alzheimers
disease. In July, about 4,000 leading experts
and researchers from 75 countries attended
the Alzheimers 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-
ers, of which 5 million are aged 65 and older and approximately
200,000 have younger-onset Alzheimers. Experts believe the
number of Americans aged 65 and older with Alzheimers 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 Alzheimers disease showed that physical activity, nutrition
interventions, cognitive training, social activities, and manage-
ment of heart health risk factors improved cognitive performance.
These ndings 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 sh 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 benets of plant-based diets
and physical activity and of fatty acids on other aspects of
health at the Academys 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. Todays 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 twistor 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 Riddle
Editor
TDeditor@gvpub.com
4 todays dietitian september 2014
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Todays Dietitian Aug ad_03.indd 1 23.06.14 09:41
SPONSORED CONTENT
FEATURES
24 Atlanta Dining If youre headed to the Academys Food &
Nutrition Conference & Expo next month, get ready to discover
Atlantas intriguing dining scene. Todays Dietitian asked some
of Atlantas top food experts to weigh in on whats hot in the
citys food scene.
32 The Link Between Diet and Arterial Health It isnt just
about elevated cholesterol levels.
36 Gluten-Free Pastas Heres 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 efciently.
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 denition, 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 inammations impact
on most chronic disease states, curcumins potential role in
preventing and treating these diseases, and evidence-based
recommendations for dietary intake of curcumin.
DEPARTMENTS
4 Editors 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
Todays Dietitian (Print ISSN: 1540-4269, Online ISSN: 2169-7906) is published monthly by Great Valley Publishing Company, Inc., 3801 Schuylkill Road, Spring City, PA 19475. Periodicals
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$95 per year; Single issue: $5. Todays Dietitian Volume 16, Number 9.
Page 56
18 46
READER FEEDBACK

From Our Facebook Page
Obesity: Were Not Overeating, Were
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 nd 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 its 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 difcult among the poor. If you work two or three
jobs to get by, its 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 tness is a luxury.
Angelique R. Gertig: I, for one, as a dietetics student, dont see
any single thing as the biggest problem. I think its 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 dont
move as much as they should, I dont think we, as professionals,
can take this latest statistical nding 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. Thats 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 Todays
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
theres 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 Oil
Trans Fat Is Palm Oil a Good Alternative for Human Health
and the Environment?
for
Spring Symposium Highlights
Diabetes and
Tips for Adding More
RDs Debate the FDAs
Proposed Nutrition
Facts Label
July 2014
Vol. 16 No. 7
CONFERENCE ISSUE
The USDA recommends
3
servings of dairy every day.
Make
yogurt
one of
them!
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.
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2014 The Dannon Company, Inc. All rights reserved.
BUILD A BETTER SMOOTHIE
By 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 Traps
Clients may be convinced that theyre 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 Tips
The rst step to making a healthful smoothie is deciding
what ingredient to use for the smoothies 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 avored 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 axseeds 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. Shes also a nutrition
expert for FoodNetwork.com and
contributor to US News Eat + Run.
ASK THE EXPERT
Peach Oatie Smoothie
Serves 1
Ingredients
1
4 cup nonfat milk
1 T old-fashioned rolled oats
1
1
2 cups unsweetened frozen
peach slices
1
2 cup peach nectar
1
4 cup nonfat vanilla Greek yogurt
1
8 tsp ground cinnamon
Directions
1. 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 serving
Calories: 227; Total fat: 0 g; Saturated fat: 0 g; Protein:
9 g; Total carbohydrates: 49 g; Sugars: 41 g; Dietary ber:
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 youd like to ask our expert?
Send your questions to Ask the Expert at TDeditor@gvpub.com
or send a tweet to @tobyamidor.
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MAPPING THE GUT
MICROBIOME
An Ambitious Project That Could Lead
to Better Gastrointestinal Health
By David Yeager
Many people are familiar with the Human Genome Project,
which identied 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 thats 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 rst 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 rst
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, didnt participate in the initial phase of the
Human Microbiome Project, but his lab studies how intestinal
microbes affect our biology. He says one thing thats 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 were not just collections of human cells.
The individual is much more than that, Sonnenburg says.
Were actually composite organisms. Weve 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, its 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 dont 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 arent well dened. Whats needed is increased
study on the basic mechanisms that connect microbial and
human biology, he explains.
Tuning an Organ?
Dening those mechanisms will take some time; the micro-
biome is 100 times larger than the human genome. Its 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 signicantly 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 Childrens 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 were
seeing that its 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 difcile, and fecal trans-
plants have been shown to relieve symptoms of C difcile 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 persons microbiota is like a ngerprint, and
determining how those thousands of microbes affect food
DIGESTIVE WELLNESS
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-
cic individuals based on their personal microbial communities.
We know that people with IBS [irritable bowel syndrome]
have certain intolerances, and thats 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
rst 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 benecial microbes, such
as specic 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-ber 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
Crohns disease and cancer. Although microbiota can quickly
change in ways that arent 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-ber diet. Many people essentially
are starving certain species of benecial ber-eating microbes
in their intestines, he says, adding that overuse of antibiotics
can decimate microbiotic communities, and its 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 ker, 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.
More ways to enjoy eating less
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FOCUS ON FITNESS
QIGONG
By Jennifer Van Pelt, MA
This traditional Chinese health and wellness
system provides a variety of health benets.
In a previous column, I wrote about the benets of tai chi.
This month, Ill 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 ows through all things in the universe, and
gong (pronounced gung), which means accomplishment or
skill thats cultivated through steady practice. Together, qigong
means cultivating energy.
Qigong is a system practiced for health maintenance,
healing, and vitality, and its popularity as a tness activity is
increasing, though its often confused with, or even combined
with, tai chi.
Whats 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 Exercisecertied mind-body exercise specialist, a
certied 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 xed 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 exibility provided by
qigong, its 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, theyre 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 Benets
The National Qigong Association states that qigong is prac-
ticed to maintain health, calm the mind, and reconnect with
ones spirit. According to Welikonich, her clients commonly
practice qigong for stress relief and increased energy.
As qigong moves into mainstream American tness facilities,
exercisers are wondering about its purpose and benets
compared with more familiar tness 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 benets for older adults include
increased bone density and functional mobility, promotion of
longevity, and lessening of senility, Welikonich says.
However, qigong isnt only for the elderly. Benets 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 Research
Americans have a tendency to focus on only the tness
aspect of Eastern health practices such as yoga, tai chi,
and qigong. Calorie burning and muscle toning become the
primary goals when considering new tness activities, but
qigong provides benets beyond just tness and should be
viewed as a practice to improve overall health. Scientic
studies support qigongs health benets for many conditions,
including hypertension, cardiovascular disease, immune
function, stroke, chronic fatigue, bromyalgia, osteoarthritis,
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:
Two systematic reviews of randomized controlled trials
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
Hemodialysis patients who practiced qigong three times
weekly for six months signicantly reduced their fatigue com-
pared with usual routine care.
3

Patients with chronic fatigue symptoms who practiced
qigong twice weekly for 17 weeks experienced signicantly
improved physical and mental fatigue and depression symptoms.
4
A systematic review and meta-analysis of 13 randomized
controlled trials on qigong/tai chi practiced by cancer patients
found positive effects on cancer-specic quality of life, fatigue,
immune function, and cortisol levels.
5
A meta-analysis of 26 randomized controlled trials of
qigong 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 Addition
With the potential to improve health, reduce stress, and
increase energy, qigong can be a valuable addition to any-
ones exercise program. As with all exercise, its 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 benets, she says. Ideally, qigong
should be practiced daily for 15 to 60 minutes, she adds.
For those interested in further information on qigongs 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 nd a local class to attend at a tness facility, com-
munity center, long term care/older adult organization, or
mind-body studio.
Jennifer Van Pelt, MA, is a certied group
tness instructor and health care research
analyst/consultant in the Reading, Pennsylvania, area.
For references, view this article on
our website at www.TodaysDietitian.com.
More ways to be good
to your heart
For nutrition data and client coupons (while supplies
last), visit www.ConAgraFoodsScienceInstitute.com*
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95% of us consume
less potassium than
recommended
Calorie for calorie,
tomatoes provide more
potassium than other
foods that clients often
turn to, like bananas,
orange juice and milk
GET TO KNOW
VIRGINIA MESSINA
An RD for Work, a Vegan for Life
By Juliann Schaeffer
Virginia Kisch Messina, MPH, RD, may have embarked on her
career in nutrition as an empathetic animal lover, but she didnt
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 Laurels 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
Messinas work has focused on vegan advocacy. Shes written
books and articles on the topic, including Vegan for Life, Vegan
for Her, and Never Too Late to Go Vegan. Shes developed a CE
program on vegetarian nutrition for dietitians, and shes 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 benets of plant-based proteins.
While shes 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 rst became a dietitian.
Todays 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
scientic integrity, and good writing skills.
TD: What do you wish all RDs knew about veganism?
Messina: Id 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, thats 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, its really pretty easy.
TD: What ve items are always in your kitchen and why?
Messina: Chickpeas: Because theyre so versatile. I use them
in hummus, vegetable soup, and vegan tuna salad. Tofu: Its 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 avors of Mediterranean-style cuisine. Collard greens:
A lot of vegans are crazy for kale, but Im partial to the texture
and avor of collards, especially because theyre 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, its 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 ours 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, whats 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.
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 theyre small, you end up
saving many more animals when you stop eating chickens
than you would by giving up beef for example. Also, birds arent
protected by the Humane Slaughter Act.
I also recommend making the supereasy changes. Replacing
cows milk with fortied plant milk, whichever type you like, is
so easy that theres 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 thats 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 ve times per
week. In the summer, I work in the garden for at least an hour
every day.
TD: What does the Vegan RDs garden grow?
Messina: The veggie garden is lled with all types of leafy
greens plus onions, blueberries, and strawberriesand a few
sad tomatoes that dont do too well in Pacic 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
owers, and the deer that wander in and out of the yard.
TD: Whats 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 fareslow-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 Todays Dietitian.
100-
calorie
option
More smart, satisfying
snack choices.
All popcorn is whole grain. Just a serving of Orville Redenbachers

SmartPOP!
popcorn delivers 2 complete servings of whole grains.

Source: Bowes & Churchs, Food Values of Portions Commonly Used, 19th edition 2010.
Orville Redenbachers SmartPOP! butter-avor popcorn data, July 2014.
A serving of popcorn provides more volume
and more satisfaction than other snacks.
1 serving (1 ounce)
Calories
Fiber (grams)
6 cups
120
4
2/3 cup
119
1.1
About 15
153
1.2
FOOD ALLERGY MANAGEMENT
IN RESTAURANTS
More 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 ve-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 Safety
National legislation requiring restaurants to follow standardized food
allergy management policies doesnt 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 rst state to sign
into law specic 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 nonprot 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 certied 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 hasnt become law. Other
states, such as Georgia and Illinois, have intro-
duced food allergy legislation for restaurants,
but it hasnt 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 classied 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
doesnt specify what the training should entail
or how to assess knowledge.
FOODSERVICE FORUM
Taking It to the Table
Restaurants that embrace the opportunity to meet their
customers specic dietary needs experience the benets
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 rst time, he says.
In addition to Disney World, Antico cites chain restaurants
Red Robin and P.F. Changs as known leaders in the area of food
allergy management. They successfully make accommodations
for all major allergens, showing that its 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 Schooled
David 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 didnt understand what to do with that
knowledge as it related to the restaurant environment. He
reported that 78% of respondents identied food allergies as
an important issue, yet less than 50% were providing training
in food allergy management, and 1% reported they didnt 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 Associations ServSafe Allergens
Online Course, a comprehensive, interactive course geared
More eggs, fewer calories.
Made of real
eggs, no fat
or cholesterol
Low in
calories, dense
in nutrients
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
nancial reasons for implementing a food allergy management
training program. According to Anticos 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 cant 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. Theres 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 theyre transparent about what food allergies
theyre capable of managing and keep the lines of communica-
tion open with patrons.
Career Opportunities
Dietitians 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 operationall
opportunities for the food-savvy dietitian. Serving the food
allergy community is about demystifying the serving of an
underserved community. On top of that, theres 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.
References
1. Bock SA, Muoz-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 allergyaware 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
nations 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 FAREs 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 Associations ServSafe Allergen
Training is an interactive, avatar-based virtual training
program in food allergy management available on demand
at ServSafe.com/allergens.
SCC
FOOD FOR THOUGHT
FISH OILS AND
COGNITIVE FUNCTION
By William S. Harris, PhD
Research suggests higher omega-3 intake
leads to greater brain health.
Fish is brain food.
The origin of this bromide is unclear, but scientic support
for this idea during both the sunrise and sunset years of life
is growing.
Scientists began to link sh oils, which are rich sources of
two omega-3 fatty acidsEPA and DHAwith brain health by
observing that DHA is one of the two most plentiful fatty acids
in the brain, and that its particularly enriched in the retina
of the eye, an extension of the brain. If its there, its probably
doing something.
Studies in animals and newborn babies have conrmed
that DHA deciency adversely affects visual function and
certain learning behaviors.
1,2
More recently, anecdotal stories
of very high doses of sh 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 sh 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 Alzheimers disease.
This article summarizes some of the high
points in this journey, discusses some recent
ndings in which the author was involved, and
concludes with suggestions for using sh oils
in the prevention (treatment?) of dementia and
Alzheimers. (Several reviews are available
regarding this information.
5-9
)
Background
Before 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 cant show that a
deciency of nutrient X causes the diseaseassociation never
proves causationbut 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 denition, already are present in
the body at some level, while drugs arent. 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 sh (those richest in EPA+DHA)
was inversely associated with the presence of subclinical brain
infarcts on MRI examination (ie, dened as ischemic lesions of
3 mm or less in diameter).
12

september 2014 www.todaysdietitian.com 21
The Prospective Investigation of the
Vasculature in Uppsala Seniors study
exemplies 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 wasnt signicantly
associated with total brain, global
white matter, or regional gray matter
volumes. In other words, people who
ate more sh had fewer infarcts.
13
These studies suggest that more
sh in the diet helps preserve brain
health, but they dont prove that sh
much less the omega-3 fatty acids in
shprovide this benet since another
component of sh could be benecial,
the foods people avoid in order to eat
sh could be harmful, or people who
eat sh 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
rst 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-
ers. Those in the highest quartile of
DHA (levels associated with eating
about three sh meals per week) were
nearly one-half as likely to develop
dementia or Alzheimers 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 679).
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 Womens Health Initia-
tive Memory Study. We examined the
extent to which the omega-3 index had
a protective association with domain-
specic cognitive function. The cogni-
tive domains examined were ne motor
speed, verbal memory, visual memory,
spatial ability, verbal knowledge, verbal
uency, 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 rst cognitive testing panel,
which was repeated for the next six
years. A higher omega-3 index was
associated with better ne motor speed,
verbal knowledge, and verbal uency.
17
However, after statistical adjustment
for nine other factors, the independent
relationships were lost. No signicant
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 decits 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 signicant 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 specically 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 signicant
associations between MRI metrics and
omega-3 levels come from Bowman
and colleagues and from Samieri and
colleagues.
19,20
Intervention Studies
Currently, there are no published
studies attempting to demonstrate
that omega-3 fatty acids can help
reverse Alzheimers or dementia; pre-
vention appears to be the only hope.
Because of the typically slow develop-
ment of Alzheimers 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, benecial 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 colleagues
9
), so
theres reason to persevere with
larger and longer trials.
Recommendations
Research to date indicates theres
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 colleagues
27
). This can be
accomplished by eating more sh, pref-
erably oily varieties, or taking omega-3
supplements (from sh 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 re behind it.
William S. Harris, PhD,
is a professor of medicine in the
University of South Dakota Sanford
School of Medicine. Hes 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
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ATLANTA
DINING
A New Twist on Southern Cuisine
Butternut squash
ravioli at Livingston
Restaurant + Bar
When you think of Atlantas culinary
aesthetic, what comes to mind? Thats
a question the citys inhabitants have
been asking for years. After all, Atlanta
doesnt 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
historythis is where the civil rights movement was
born. But this seat of the New South also has a bold
splash of eclectic, ethnic avors, thanks to Atlantas
melting pot population. Throw in a few award-winning
celebrity chefs, and youve got an exciting food scene.
Atlanta is always searching for an identity. In many
ways, restaurants are one of Atlantas 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. Its a restless commuter-driven city. There arent
a whole lot of Atlanta-born natives here.
Compared to other Southern cities, Atlanta is a
new city, and we dont 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 Travelers 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 seminalists for the James Beard
Awards. Atlanta is known for Southern hospitality, and
that translates into a very approachable dining scene
thats not at all pretentious. I think thats 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 foodvery 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 its 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), Atlantas 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 Bureaus 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 citys 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 nd 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 youre headed to FNCE

next month, get ready to
discover Atlantas 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 Atlantas top food experts
to weigh in on whats hot in
Atlantas food scene.
BY SHARON PALMER, RDN
RIGHT: PHOTO BY JAMES CAMP PHOTOGRAPHY COURTESY OF GREEN OLIVE MEDIA september 2014 www.todaysdietitian.com 25
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 nd 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 lming movies.
Buckhead, known as the Beverly Hills of the East,
lies further up Peachtree Street. There youll nd high-
end shopping and dining, including King + Duke (3060
Peachtree Road NW, 404-447-3500, www.kingandduke
atl.com), run by one of Atlantas 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 years 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.
Atlantas Eastside is just a few minutes east of down-
town by taxi, where youll encounter some of Atlantas
oldest original neighborhoods. Check out Rathbuns
(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.
Atlantas Westside, a few minutes west of Midtown,
is the citys 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 Atlantas most celebrated restaurants, where chefs
and owners Anne Quatrano and Clifford Harrison offer
a seasonal ve-course prix xe 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 its
considered an in-town neighborhood. Theres a won-
derful walking neighborhood feel. A lot of people talk
about Decatur like its Atlantas 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 Awardwinning chefs list. There
are also more inexpensive local optionsmore neigh-
borhood jointsthat are really good, says Puckett,
who lives in Decatur.
Leons 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 air.
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 at iron
steak with kale and ngerling potatoes.
Sundial
Restaurant,
Westin
Peachtree
Plaza
ATLANTA
DINING
LEFT: PHOTO COURTESY OF ACVB/ATLANTAPHOTOS.COM 26 todays dietitian september 2014
PAST MEETS PRESENT
Atlanta, the home of Gone With the Wind, also has its
fair share of romantic historical intrigue. While youre
there, visit the Margaret Mitchell House (www.atlanta
historycenter.com/mmh).
But probably most notable is that the citys 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 lets
not forget that its 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, Atlantas historic past blends into its cui-
sine. Atlanta has an interesting take on preserv-
ing the past; theyre 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. Its a great
retro tea room, which is something you just dont see
anymore, with a fascinating 1950s ladies who lunch
menu thats just delightful. Their signature dessert is
a meringue base with a light milk chocolate whipped
mousse decorated with puff pastry shaped like a swan
its one of those beautiful things that used to be the norm
50 or 60 years ago.
And the history lesson doesnt 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
Atlantas 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 arent from the South, so it
tends to be a mix of both popular Southern dishes as
well as more modernized variants.
Were seeing a lot more restaurants with an ethnic
avor that also combine Southern avors. 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 avor of
Atlanta; were Southern, but were also international,
says Puckett, who calls this style of cuisine ethnic
Southern mashup.
So which restaurants fully exemplify Atlantas distinc-
tive take on Southern food? Davis nominates Gillespies
restaurant Gunshow (924 Garrett Street, 404-380-1886,
www.gunshowatl.com), with its unique Southern dim
sumstyle xings, as one of the citys brightest stars.
Puckett agrees: Kevin Gillespie was a Top Chef nal-
ist, and his style of dining is unique. He has a team of
TOP
Livingston
Restaurant +
Bars dining room
BOTTOM
Seared Maine
diver scallops
at Livingston
Restaurant + Bar
RIGHT: PHOTOS BY JAMES CAMP PHOTOGRAPHY COURTESY OF GREEN OLIVE MEDIA september 2014 www.todaysdietitian.com 27
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. Its 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 dinerstyle food, such as
okara hushpuppies and shrimp and rice grits served
with miso kale. Its a really clever Korean diner run by
a coupleshes Korean and hes Southern. Their heir-
loom barbeque is traditional Southern, but they serve
it with kimchi coleslaw. They seamlessly slip in Korean
avors in a natural way because thats 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 shes a fasci-
nating chef whos getting a lot of media attentionand
for good reason. She combines Southern and Kerala
[the southwestern-most state of India] avors in a bril-
liant way, Puckett says. Davis says youll nd an Indian
twist on Southern classics, such as fried chicken and
wafes and shrimp touffe.
Poor Calvins (501 Piedmont Avenue, 404-254-4051,
http://poorcalvins.com) proudly embraces its Vietnam-
ese roots and serves Thai-Southern dishes, Reese
says. Chef Calvin Phans 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 Calvins offers a free Uber
ride to and from any downtown hotel.
SOUTHERN COMFORT
If youre craving some good ole Southern comfort food,
youll nd that in Atlanta, too. Puckett recommends
Busy Bee Caf (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 its touristy, Mary Macs (224 Ponce De Leon
Avenue NE, 404-876-1800, www.marymacs.com) is the
real dealits a Southern institution, Puckett says. This
is where you can get your ll 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 worlds largest drive-in. Puckett
says its one of the old stalwarts that people in Atlanta
go to for chili cheese dogs, onion rings, a frosted orange,
and fried pies.
Then theres 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 unofcial
headquarters of the civil rights movement, it was one
of the rst 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
arent bad either.
If youre looking for a more rened 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 avors 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 INSPIRATION
What if you feel like authentic ethnic food with nary a
Southern touch in sight? Dont worry because Atlantas
got that, too. Weve got it all, from Persian to Peru-
vian, says Carolyn ONeil, MS, RDN, LD, author of
Southern Livings The Slim Down South Cookbook and
a columnist for The Atlanta Journal-Constitution. Its
Pan roasted
duck breast with
peach, hazelnut,
nasturtium and
foie gras three
ways at Gunshow
ATLANTA
DINING
LEFT: PHOTO BY ANGIE MOSIER 28 todays dietitian september 2014
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.
Gus 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.
Com 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. Its 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 MOVEMENT
If youre wondering how the local food movement is
coming along in Atlanta, its doing just ne, according
to ONeil, who says, Theres 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 Caf 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 avors, says, Theres 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). ONeil
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 Atlantas 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 rst and foremost and works very seasonally and
closely with local farmers. This is easy to see in dishes
such as eld 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
TOP
Tagliatelle pasta
with sea urchin
at The Caf at
the Ritz-Carlton,
Buckhead
BOTTOM
Miller Unions
seasonal summer
vegetable plate
TOP: PHOTO COURTESY OF BEN ROSE PHOTOGRAPHY; BOTTOM: PHOTO BY CRAIG BRIMANSON september 2014 www.todaysdietitian.com 29
many awards. Its gorgeous and elegant, offering craft
cocktails and heirloom vegetables, says Reese of its
farm-to-table fare. You can even nd 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
Weve got breadth and depth in our dining scene,
Reese says. While its impossible to list all of Atlan-
tas nest restaurants in the connes 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, its one of the
most exciting things to see. It goes back to the 60s, but
its just been given a huge makeover, and its straight
out of Mad Men, Puckett says. Its a great place to have
small bites and cocktails, and its 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-sted
deli sandwiches that transport you back to Brooklyn.
Theyre incorporating modern avors with really
classic foods, such as pastrami and house-made
bagels, Puckett says.
And the list goes on, according to ONeil, who says,
Youll 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 youre a foodie, would be complete
without checking out Holeman & Finch Public House
(2277 Peachtree Road, 404-948-1175, www.holeman-
nch.com), where youll nd 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 llet 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.
Theyre 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-red 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
Todays 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
LEFT
Spring
vegetables at
Restaurant
Eugene
RIGHT
Squash blossom,
crawsh,
vichyssoise,
caviar at
Restaurant
Eugene
ABOVE: PHOTOS COURTESY OF RESTAURANT EUGENE 30 todays dietitian september 2014
Visit Us at FNCE at Booth #2233!
California Walnuts are a heart-healthy whole food and the only nut rich in the essential omega-3 fatty
acid ALA. A one ounce serving of walnuts is also a source of antioxidants and contains protein and ber.*
Help your clients defend their bodies naturally with the nutrient-dense goodness of California Walnuts.
For complete nutritional information, educational resources and more, visit walnuts.org.
Natural Defenders of the Human Body
TM
,,
,
'
Scan the QR code to view
our nutritional information.
WALNUTS
*A one ounce serving of walnuts contains 18g of total fat - 2.5g of monounsaturated fat, 13g of polyunsaturated fat, including 2.5g of plant-based omega-3 ALA. It also provides 4g of protein, 2g of ber,
and 3.721 mmol antioxidants. Supportive but not conclusive research shows that eating 1.5 ounces of walnuts per day, as part of a low saturated fat and low cholesterol diet and not resulting in increased
caloric intake, may reduce the risk of coronary heart disease. U.S. Food and Drug Administration, March 2004.
CWC F0435 Bowl_Snipe_8x10.5.indd 1 8/14/14 10:27 AM
W
ith 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 ex against the force,
smoothing out the ow and moving it along.
Many Americans believe that eating too much cholesterol
leads to plaque buildup in the artery walls, blocking that ow
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, exible, healthy circulatory system.
Healthy Circulatory System
When 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 exible, supple, and strong. This vas-
cular endothelium (lining of blood vessels) controls vasodilation
(widening of blood vessels) and vasoconstriction (narrowing
of blood vessels). Its also in charge of mounting an immune
response and repairing any damage to blood vessels.
2

Unhealthy Circulatory System
Physicians 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; its 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 x the problem. Its this immune response
that ultimately leads to plaque development.
Its 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 inammation, a
scab or clot will form, Becker says. Thats when you need
emergency intervention.
The clot can completely block an artery and cause a heart
attack or stroke. Inammation is as important, or more impor-
tant, than factors like cholesterol level in the development of
cardiovascular disease, Becker adds.
Inammation and Risk Factors
Anything that damages the artery walls or otherwise causes
inammation 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 inammation. (HDL cholesterol, on the other hand,
helps prevent inammation.)
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
inammation caused by stress, lack of sleep, inammatory dis-
ease, or obesity affects the arterial lining. High blood sugar and
high triglyceride levels also contribute to inammation.
3,4
Con-
trolling these risk factors with diet and other lifestyle changes
can decrease the risk of heart attack and stroke.
Arterial Health
Diet &
It Isnt Just About Elevated Cholesterol Levels
The Link Between
By Judith C. Thalheimer, RD, LDN
Dietary Impact
Diet 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.

Theyre mainly found in sh such as salmon, trout, and herring;
avocados; olives; walnuts; and liquid vegetable oils such as soy-
bean, corn, safower, canola, olive, and sunower.
5

Omega-3 fatty acids have been the focus of much research.
These polyunsaturated fats are found in sh but also in plant
foods such as axseeds, 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 inammation and prevent
plaque buildup.
7

Flavonoid antioxidants such as those found in cocoa and
red wine decrease inammation, 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 thats converted in the body to
collagen and elastin that help keep blood vessel walls exible
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 B
6
, B
12
, 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 hasnt been established, and currently the AHA doesnt 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 ow.
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 benecial compo-
nents listed above, but ber 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 benets of individual food compo-
nents by adding omega-3s, olive polyphenols, cocoa avanols,
and chitin-glucan ber, an insoluble ber derived from the cell
walls of the mycelium of Aspergillus niger, to processed foods.
1
Role of Dietary Patterns
Eating less saturated and trans fats, cholesterol, sugar, and
sodium and more omega-3 fatty acids, ber, and antioxidants
can be benecial, but simply adjusting the intake of these par-
ticular components isnt 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 theres a biologic effect, we dont know whether
its 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, sh, 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 benets of a healthful dietary pattern go beyond a
single nutrient. Sure, a ber-rich diet may have some impact
on lowering LDL cholesterol levels, but you also get other
benets when you eat ber-rich foods like fruits, vegetables,
legumes, nuts, and whole grains such as essential nutrients
and healthful fats, Lichtenstein notes.
Putting It Into Practice
Patti 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 modied Mediterranean-style eating pattern in line with the
AHA/ACC guideline to her clients and avoids advocating for spe-
cic 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
fruit every day and to eat as many colors as possible. I nd it
helps to give them good/better/best scenarios, she explains.
Its reassuring to them to know they dont 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 sh 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. Theyre like a magic food: high in ber,
lling, 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 sh, 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 ll at least one-half of their
plates with brightly colored vegetables at lunch and dinner.
I give them specic ideas for adding benecial 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 isnt 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,
youre not likely to see the benet. Obesity goes hand in hand
with artery-damaging conditions such as high blood pressure,
high cholesterol, and diabetes, and its associated with a gen-
eral rise in inammation.
Morris counsels overweight clients to lose weight. You
dont 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
dont realize all the hidden names for sugar: evaporated cane
juice, fruit juice concentrate, and dextrose [for example]. Excess
sugar can cause inammation in the body, and it adds to the
overall excess of calories that leads to weight gain.
Insulin resistance makes losing weight difcult, 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 Ive seen it work, she says.
Other Lifestyle Changes
Nonetheless, achieving optimal arterial health requires
more than just eating healthfully and managing weight. Its
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 its 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 inammation in
check. Lots of research has shown that less than six hours
of sleep can result in more inammation, she says. Older
adults that already have high blood pressure and then dont 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 Line
Healthy arteries are key to preventing heart attack and
stroke. Limiting irritation of the arterial lining reduces plaque
buildup, keeping arteries open and exible.
A healthful dietary pattern can have a big impact on reduc-
ing inammation. Following a diet rich in fruits, vegetables,
whole grains, low-fat dairy products, poultry, sh, and nuts
with limited red meat and foods and beverages high in sugar
ensures an intake of several inammation-ghting nutrients
and minimizes plaque-promoting factors such as saturated
fat. Other lifestyle changes go hand in hand with diet to keep
inammation 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 dont 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.
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 thats 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 pastas traditional (and much-loved)
taste and texture. But it seems gluten-free product
manufacturers are nding 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
doesnt taste gluten-free.
With new ingredient formulations, avor 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.
Todays Dietitian interviewed a handful of gluten-
free pasta manufacturers to get a peek into how theyre
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 signicant growth in the number
of pasta brands on the market, and weve had an active
role in this, as were 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
signicantly 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, its worth mentioning
to clients and patients that one of the most important
By JULIANN SCHAEFFER
Gluten-Free
G
A Review of the
New Options on
the Market Plus
Cooking Tips
for Delicious
Homemade Meals
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 certied as gluten-free
something all experts interviewed here afrmed.
Its always wise to buy certied gluten-free products for
safetys sake, says Carol Fenster, author of 11 gluten-free
cookbooks, including Gluten-Free 101: The Essential Beginners
Guide to Easy Gluten-Free Cooking. Look for the logo on the
package. As for ingredients, its really a matter of taste and
personal preferences. I encourage people to try various brands
to nd 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 avor 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, ax, 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 companys inception in 1982,
letting customer feedback guide its products evolution,
including the importance of convenience in todays 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 certied organic
and non-GMO ingredients are key attributes to getting the avor
and texture proles it seeks from its products. For example,
its Supergrain Pastas line is made up of an organic quinoa and
corn our blend. Quinoas rich, nutty avor combined with
the organic corn ours 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 avor.
Vegetable Lasagna
Serves 8 to 12
Ingredients
1 T olive oil
1 medium onion, chopped
2 cloves garlic, minced
8 oz button mushrooms, sliced
3 (8-oz) cans tomato sauce
1 (6-oz) can tomato paste
1
2 tsp dried basil
1
2 tsp dried rosemary
1
2 tsp dried thyme
1
2 tsp dried oregano
100 g superne brown rice our
90 g tapioca starch
43 g corn our (not corn starch)
42 g potato starch
4 large eggs
Cooking spray
10 oz frozen spinach, thawed and
drained
16 oz cottage cheese
16 oz shredded mozzarella cheese
Directions
1. Preheat oven to 375F.
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 our, tapi-
oca starch, corn our, 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 uted-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.
Calories: 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
ber: 4 g; Sugar: 10 g; Protein: 22 g
RECIPE AND PHOTO COURTESY OF GRETCHEN BROWN, RD
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 avor prole, she adds.
Heidi Gordon, marketing manager for Italian pasta maker
Jovial Foods, says its difcult 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 rst organic gluten-free egg noodle.
Craig Schauffel is the chef at Three Bridges, a San Fran-
ciscobased company that offers a refrigerated line of chef-
crafted pastas, sauces, and meals, including a gluten-free
lled pasta option in ve cheese ravioli and butternut squash
ravioli. According to Schauffel, the process of making cut
and dried pastas allows for more exibility when attempting
to avoid the typical gumminess associated with gluten-free
pastas because numerous other grains can be added to the
dough mix. This isnt 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 our 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 functionthe seal will open up and the
lling will leak outfor a fresh-lled ravioli.
For lled 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 nd 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 wont sufce),
theyre welcome to try their hand at making their gluten-free
pasta at homeif 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 nding the right blend
of avors. My recipe includes ours 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
todays store-bought gluten-free pasta offerings, shes often
forgone homemade pasta. I havent included a recipe for
homemade pasta in any of my books since 2010 because I think
that manufacturers are doing such a good jobespecially
with penne, tubular, and spiral pastathat the home cook
cant 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 at pasta such as lasagna noodles.
For those with the time and inclination, suggest clients and
patients try their hand at Browns gluten-free lasagna on page
38, which is made with homemade corn lasagna noodles.
Gluten-Free Cooking Tips
According 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 avor 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
water4 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 avor.
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 avor but also to keep the
pasta from sticking together. I always use heavily salted water
to both avor the pasta as it cooks and to change the weight of
the water, she says. When people swim in the Dead Sea, they
oat because theres so much salt in the water. When
youre boiling pastas, the same principle applies: The
pasta will oat 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 itsometimes called
al dente or to the toothbut not soft. Remove it from
the heat and drain. It will continue to cook from residual
heat even after its 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 its 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 dont 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 ovens 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 avor combinations. Try quinoa pasta with
shellsh 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 Im wrong, he says.
Juliann Schaeffer is a freelance writer and
editor based in Alburtis, Pennsylvania, and a frequent
contributor to Todays Dietitian.
Pesto Caprese Quinoa Penne Pasta Salad
Serves 4 to 6
Ingredients
1 (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 tomatoes
Fresh mini mozzarella balls
Salt and pepper
Fresh basil, to top
Directions
1. 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 ne 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.
Trans fat: 0 g; Sodium: 314 mg; Cholesterol:
0 g; Total carbohydrate: 19 g; Dietary ber:
2 g; Sugar: 4 g; Protein: 6 g
RECIPE AND PHOTO COURTESY OF ANCIENT HARVEST
Brown Rice Tagliatelle With Creamy Mushrooms and Chickpeas
Serves 4
Ingredients
9 oz Jovial egg tagliatelle
8 oz mushrooms, sliced
3 scallions, sliced
3 T Jovial extra-virgin olive oil
1 cup chickpeas
1 clove garlic
3
4 cup water
2 T fresh parsley, minced
Directions
1. Saut mushrooms, scallions, 2 T of olive
oil with salt to taste in a large skillet until
tender.
2. In a blender, pure
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.
Calories: 395; Total fat: 13 g;
Sat fat: 2 g; Trans fat: 0 g; Sodium:
184 mg; Cholesterol: 0 g; Total
carbohydrate: 59 g; Dietary ber: 5 g;
Sugar: 3 g; Protein: 13 g
RECIPE AND PHOTO COURTESY OF JOVIAL FOODS
Gluten-Free Mac and Cheese Bites
Makes 36 appetizers
Ingredients
Gluten-free nonstick cooking spray
1
2 lb Pastariso Gluten Free White
Rice Pasta Elbows (2 cups
uncooked)
3
4 cup plus 2 T milk
2 tsp corn or tapioca starch
2 T butter
1
2 white onion, very nely diced
3
4 tsp kosher or ne sea salt
1
2 tsp black pepper
1
4 tsp nutmeg, freshly grated
1
4 cup plus 2 T Parmesan cheese,
grated
1 cup yellow or white cheddar
cheese, grated
2 T gluten-free panko style bread
crumbs
Directions
1. Preheat oven to 425F. Spray 36 mini
mufn 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 mufn
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)
Trans fat: 0 g; Sodium: 44 mg; Cholesterol:
0 g; Total carbohydrate: 5 g; Dietary ber:
0 g; Sugar: 0 g; Protein: 2 g
RECIPE AND PHOTO BY CAROL KICINSKI FOR MAPLEGROVE FOODS
Transitioning from paper charts to EMRs can facilitate
patient visits and help you run your practice more efciently.
Electronic
Medical Records
W
hen 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 couldnt send
notes to referring physicians that looked professional.
If I handwrote it, it didnt 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
ofce, Lemond stopped to run an errand and thieves
broke into her car, walking off with her laptop and her
briefcase in which she had ve patient charts she had
planned to review that evening. That was the nal 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
ling 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 ling cabinets.
Patalano, who has an MBA in technology manage-
ment from an engineering school, searched for soft-
ware for RDs and couldnt nd 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 hasnt 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 uctuate, but its a growing
number, he says.
Patalano offers free weekly webinars for dietitians
interested in learning about and using her EMR program.
Ive 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 theyve gone paperless, Lemond and Pat-
alano cant gure 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, shed
sit down after dinner and spend hours on billing and
patient chart management, trying to nish 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.
says, adding that charting electronically is much more ef-
cient. I got back 50% of my time. I was able to work longer
hours on the days I leased an ofce, 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 dont have to pay for a biller. Its really simple.
Lemond doesnt use MNTs billing feature because she
has an ofce manager whose job includes submitting bills,
but she says having the patients insurance and billing infor-
mation electronically stored in the charts has simplied the
process. We put all the patients billing and insurance infor-
mation in their electronic charts, and she [the ofce 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 childs progress and nutrition needs without having
to manually go plot it on a growth chart. You really know quickly
the patients BMI, and you can input it and track it, Lemond says.
On Lemonds 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 theyre
taking; and why they think theyve gained or lost weight. Its 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 its 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 its 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, youre
all done with the patient note, doctors 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, theyre 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 Heres 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. Its important for dietitians to check their work
whether its on paper or the computer keyboard. Moreover,
patient information thats stored electronically is HIPAA com-
pliant, so patient privacy isnt 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 theres an Internet con-
nection. Lemond believes that if her patients records had
been kept electronically when thieves broke into her car,
she wouldnt have had the issue she did. Some of the les
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 shed worked so hard to develop with the
referring physicians. Fortunately, there werent 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 doesnt take that much
time. Its just a matter of getting used to it. Once you have it down,
boom, you do it and its not a big deal.
Resources
Interested in learning more about electronic
records for private nutrition practices?
Contact Karen Patalano at kpatalano@kaizenrd.com
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
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. Were living in the information age, and were
interested in questions such as, How many people did
you see with this condition? Gobble says. Its 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 modication 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
ght 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 signicant weight loss and an increase in exercise
frequency and duration in patients after nutrition counseling
by private practice RDs.
Connectivity Issues
Lemonds only concern about using EMRs and storing
them in the cloud involves Internet outages. If for some
reason you cant get online, that would be a detriment, she
says. Fortunately, most people arent without power for long
or have lengthy technical glitches, she says.
Kristi King, MPH, RDN, CNSC, LD, a senior pediatric dieti-
tian at Texas Childrens 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 youre not practicing them. But its also good
to double-check the computers math. If you do the math,
and it comes out differently from the program in the elec-
tronic record, its 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.
Patalanos 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 rst 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 youre considering EMRs, youll need a program thats
customizable. Both KaiZenRD and MNT Assistant meet this
criterion. Patalano and Gobble recommend reviewing your
practices 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.
Im not only learning about nutrition,

Im learning about treating people
with integrity and care.
Ellie Freeman, MS (2013)

NURTURE

YOUR

CALLING
Learn more:
Nutrition.Bastyr.edu
855-4-BASTYR
Seattle San Diego
Create a
Healthier World
Create a
Healthier World
Create a
Healthier World
From amaranth to quinoa,
ancient grains offer a
wealth of nutrients and
can add much-needed
variety to your clients
and patients diets.
hen it comes to eating grains, most
Americans limit themselves to only a
few choices, but theres 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 theyve been around,
largely unchanged, for millennia.
Incorporating more grain varieties into ones 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 wouldnt just eat
carrots. Youd 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 dont consume as much of it. Therefore, ancient
grains are totally off the radar. A lot of people dont even know
what they are.
Ruth Frechman, RDN, author of The Food Is My Friend Diet,
agrees and says that getting a variety of foodswhether fruits,
vegetables, or grainsalways is benecial. Its 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 ber. 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 whos allergic to wheat or
sensitive to gluten, Frechman says.
Hurdles to Overcome
While 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 dont 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 nd. 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 whats
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.
Its important to suggest simple recipe ideas so that people
know what to do with ancient grains, Newell Bissex says.
Theyll 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
Enjoying
Ancient Grains
Dietetics. So often clients think of grains as a stand-alone side
dish to dinner, such as a side of rice. But grains arent 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 entre 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 avor 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 avor 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. Thats 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 theres 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. Its 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 ber, 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 water
2 cups beef broth
1 (28-oz) can diced or crushed tomatoes
1 (15-oz) can tomato sauce
2 large carrots, peeled and sliced
1 T dried parsley
1 tsp dried oregano
1
2 tsp dried basil
1
4 tsp pepper
1
4 tsp garlic powder
Sea salt, to taste
1 (15-oz) can garbanzo beans, rinsed and drained
1 (15-oz) can kidney beans, rinsed and drained
2 cups frozen green beans
1
1
4 cups Kamut Khorasan elbows (or whole grain pasta
of choice)
Parmesan cheese, grated, for garnish
Directions
1. 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.
Calories: 240; Fat: 1.5 g; Sat fat: 0 g; Sodium: 820 mg;
Carbohydrate: 47 g; Protein: 12 g; Dietary ber: 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 isnt 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 ber 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 avor.
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 isnt a whole grain. Farro is a
staple in Italy and often prepared as a risotto dish or as part of
a salad. Its rich in ber and magnesium and, like other wheat
varieties, it can provide many benets 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. Its full of ber 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 avor
Simple Spelt Pancakes
Makes 16 (4-inch) pancakes
Ingredients
2 cups (7 oz) whole spelt our
2 T (
7
8 oz) sugar
1 T baking powder
3
4 tsp salt
1
3
4 cups (14 oz) milk
2 T (1 oz) unsalted butter, melted
2 T vanilla (optional)
Directions
1. In a medium bowl, whisk together the spelt our, sugar,
baking powder, and salt.
2. Combine the milk and melted butter, and the vanilla if
youre 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 isnt 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 rst 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, ip them and let
them nish cooking on the second side, about 1 minute
more, until theyre golden brown on both sides.
Nutrient Analysis per serving (2 pancakes)
Calories: 137; Fat: 4 g; Carbohydrate: 20 g; Protein: 5 g;
Dietary ber: 4 g
REPRINTED WITH PERMISSION FROM THE KING ARTHUR FLOUR COMPANY
AND THE WHOLE GRAINS COUNCIL
NO NEED TO COMPROMISE!
TO TRY IT FOR YOURSELF, CALL:
Purity Foods, Inc. Hudson, MI 49247
1-800-99-SPELT (1-800-997-7358)
TO TRY IT FOR YOURSELF, CALL:
Purity Foods, Inc. Hudson, MI 49247
1-800-99-SPELT (1-800-997-7358)
As natural as it gets!
100% Whole grain goodness
100% Delectable taste
100% Silky smooth texture
and packs in ber 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 its 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, its an important crop in many parts of Africa and
Asia. Sorghum is easy to substitute for wheat our in a variety
of baked goods and has a neutral, slightly sweet avor. 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 ber. 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 its 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. Its often ground into our 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, its easy to nd 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, Todays 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 oil
1 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 1
1
2 cups)
2 cloves garlic, minced
1 32-oz container all-natural vegetable broth
1 15-oz can tomato sauce
1
2 tsp curry powder
1
2 tsp ground cumin
1
4 tsp chili powder
1
4 tsp ground cinnamon
1
4 tsp celery seed
1
8 tsp freshly ground black pepper
1 15-oz can garbanzos (chickpeas), drained and rinsed
2
3 cup creamy peanut butter
1
2 cup 10-minute farro
Roasted peanuts, chopped (optional)
Directions
1. 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 avors 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.
Calories: 310; Fat: 15 g; Carbohydrate: 34 g; Dietary ber:
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 Syndrome
The
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
bers as they relate to declining muscle mass and muscle
function. Visible atrophy of muscle bers 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 bodys peak bone den-
sity occurs during an individuals 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
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-
gers hump. This forward shift of the center of gravity increases
the risk of the loss of balance and falls.
2
Recognizing Frailty
These normal processes of aging affect both the muscular
and skeletal systems and, as a result, play a signicant role in
the decreased mobility that often is observed in later life. Never-
theless, the frailty syndrome isnt dened by mobility alone; mal-
nourishment, as evidenced by involuntary weight loss, also is an
important component. Although its difcult to dene 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:
Herb is an 86-year-old retired attorney residing with his
wife in their home. He has a medical history signicant 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 cant
hold his head upright and walks with a severe forward-stooped
posture. This posture signicantly has shifted his center of
gravity anteriorly, resulting in two to three falls per day while
ambulating. He has difculty in rising unassisted from a seated
position and has become more sedentary.
Betty is a 78-year-old retired teacher. She lives in her
apartment in the community with a home health aide who
spends several hours per day assisting her with shopping and
household chores. Shes independent in her activities of daily
living. Her medical history is signicant 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.
Rita is a 96-year-old widow who resides in a nursing home.
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. Bettys clinical picture
that includes multiple comorbidities and a limited level of
physical activity also would be consistent with frailty.
However, most clinicians wouldnt consider Rita as manifest-
ing the frailty syndrome. Although shes 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, its now
more important than ever to identify the frailty syndrome sooner.
To do so, its necessary to codify into a working denition the
common ndings 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
identied and dened frailty as a syndrome thats distinct and
independent of medical comorbidities and disability.
3
The frailty syndrome requires at least three of the following
ve characteristics:
unintentional weight loss, as evidenced by a loss of at least
10 lbs or greater than 5% of body weight in the previous year;
muscle weakness, as measured by reduced grip strength
in the lowest 20% at baseline, adjusted for gender and BMI;
physical slowness, based on measured time to walk a
distance of 15 ft;
poor endurance, as indicated by self-reported exhaus-
tion; and
low physical activity, as scored using a standardized
assessment questionnaire.
Among the study population of more than 5,300 participants,
researchers observed several signicant ndings 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 identied
obesity as a signicant 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
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 patients 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 rm 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 de-
ciencies, and anemia. In particular, vitamin D levels should be
checked and supplemented if theyre low because of vitamin Ds
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 specic
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 difculties
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. Specic indications for
the use of supplements may include difculty 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 Frailty
Once 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 isnt dened 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 ofce 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 benet 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 tness program focused on resistance
training.
8
Studies also have supported the benecial effects of
tai chi on reducing frailty as well as reducing the occurrence of
falls in the elderly.
9
Increasing Prevalence
With the signicant 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 supercially by the you know it when you see it test.
However, early recognition and assessment of the identied
standardized criteria for the diagnosis of the frailty syndrome
is an important rst 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-certied 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.
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CURCUMIN AND
INFLAMMATORY DISEASES
Learn 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
avor, 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 inammatory 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 preparations
2
and giving
the spice its characteristic yellow color.
Increasingly, the anti-inammatory properties of these
curcuminoids have attracted the attention of researchers, who
have gathered extensive evidence of curcumins positive impact
on the prevention and treatment of proinammatory diseases.
3

Curcumin is a nontoxic and highly promising natural anti-
inammatory compound thats currently being administered in
phase 2 and 3 clinical trials.
1

This continuing education course reviews inammations
impact on most chronic disease states, curcumins potential role
in preventing and treating these diseases,
curcumins main mechanisms of action,
and evidence-based recommendations for
dietary intake of curcumin RDs can provide
to their clients.
Inammation and Disease
When the body experiences injury,
irritation, or infection, an acute inammatory
response occurs to heal the affected
tissue. However, when that acute response
isnt effective, the body elicits a chronic
inammatory response. Although acute
inammation has therapeutic potential,
persistent low-level inammation eventually
can cause chronic diseases.
Chronic inammation is associated with
the alteration of cell signaling pathways,
which results in increased levels of
inammatory markers, lipid peroxides,
and free radicals, causing cell damage
and eventually leading to the clinical
symptoms of disease. Recent research
has demonstrated that chronic inammation initiates and
promotes many disease states, including obesity; diabetes;
cardiovascular, neurodegenerative, and inammatory bowel
diseases; and certain types of cancers.
1,4-7
Oxidative damage is a major contributor to the inammatory
response as well as the functional decline thats 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 OBJECTIVES
After completing this continuing education course,
nutrition professionals should be better able to:
1. Identify chronic inammations role in predisposition
to illness, including neurodegenerative, cardio-
vascular, pulmonary, metabolic, autoimmune, and
neoplastic diseases.
2. Identify curcumins mechanisms of action on the
inammatory process and various disease states.
3. Make recommendations for curcumin consumption to
benet patients and clients.
Suggested CDR Learning Codes
2010, 2020, 4040; Level 2
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 inammatory response that contributes to cell damage,
aging, and disease.
Chronic inammation 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 inammatory response,
such as viral infections, oxidants, and antigens.
14

The NF-KB proinammatory signaling pathway drives
macrophages and neutrophils to respond to such pathogens
as part of the immune response. Cell signaling pathways
are the bodys primary means of communication, directing
and regulating all cellular activities. Incorrect regulation of
NF-KB has been linked to improper immune development,
inammatory 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 inammatory diseases.
Cytokines are hormonelike proteins that act as signaling mole-
cules to regulate immune responses and responses to infection,
inammation, and trauma. Some cytokines are anti-inamma-
tory and promote healing once the injury, infection, or foreign
body has been destroyed. Other cytokines are proinammatory,
such as tumor necrosis factoralpha (TNF-alpha) and interleu-
kin-1 (IL-1), as well as IL-2, -6, -8, and -12, and initiate an inam-
matory response that recruits lymphocytes to ght disease.
The release of proinammatory 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 inamma-
tion. Plasma concentrations of acute phase reactants either can
increase (positive reactants) or decrease (negative reactants)
during chronic inammation. C-reactive protein (CRP), brino-
gen, and amyloid are examples of positive acute phase reactants
that increase with inammation; transferrin and albumin are
negative phase reactants that decrease with inammation.
Cyclooxygenase-2 (COX-2), inducible nitric oxide synthase
(iNOS), and lipoxygenase (LOX) are important enzymes that
mediate inammatory processes. Pathways that depend on
COX and LOX enzymes synthesize lipid mediators involved in
inammation. Improper upregulation of these enzymes has been
associated with the pathophysiology of inammatory disorders
and certain types of cancer.
4,16
COX-2, for example, is responsible
for the increased production of the prostanoids (arachidonic
acidderived prostaglandins and thromboxane) in inammatory
diseases,
16
which results in inammation and pain.
Anti-Inammatory Agents
Synthetic drugs such as NSAIDs traditionally are the rst line
of defense against acute and chronic inammation and pain.
NSAIDs are a family of COX-1 and -2 inhibitors used to reduce
prostanoid synthesis, especially prostaglandin E2, resulting
in anti-inammatory 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 benets.
18,19
Efforts are under way to discover
safer NSAIDs that inhibit the inammatory process while
reducing the side effects associated with long-term treatment.
Curcumins Anti-Inammatory Properties
Researchers have found that phytochemicals from natural
foods, including spices and herbs, are safe and effective
therapies to help reduce inammation and prevent and treat
disease. Phenolic compounds derived from botanic sources
such as curcumin have demonstrated anti-inammatory
activity in vitro and in vivo.
17,20,21
Extensive clinical trials over the past several decades have
addressed curcumins pharmacokinetics, safety, and efcacy
against many diseases in humans. However, research on
curcumin accelerated much earlier when it was found to have
not only anti-inammatory properties but also cholesterol-
lowering, antidiabetic, and antioxidant properties.
22-24

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

Curcumin also exerts a protective role against inammatory
diseases by scavenging free radicals and suppressing COX,
LOX, iNOS, and other inammatory mediators.
1,4,5
Research involving patients with various proinammatory
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 brosis and
cirrhosis, psoriasis, AIDS, burn pain, and wounds.
4,28-31
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Obesity and Heart Disease
Extensive 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 proinammatory
disease. Obesity and insulin resistance in patients suffering
from type 2 diabetes are associated with chronic low-grade
systemic inammation, resulting in increased inammatory
markers.
31
Adipose tissue is the main origin of this inam-
matory response, and its a major secretor of adipocytokines,
especially adiponectin, an anti-inammatory cytokine, and
leptin, a proinammatory cytokine. Either a reduced level of
adiponectin or an increased level of leptin results in an elevated
risk of atherosclerotic disease.
32
Abdominal obesity reects the amount of adipose tissue in
the body.
32
Macrophages respond to increased fat cell mass
by inltrating adipose tissue,
33
secreting proinammatory
cytokines, including TNF-alpha, IL-6, and IL-1 beta. These, in
turn, signal the liver to produce CRP and initiate inammatory
pathway signaling.
31,34
Evidence from cellular and animal studies supports the
benecial 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 signicant
decrease in body weight and fat content despite either a
maintenance or increase in total daily calories, suggesting that
curcumin may have benecial effects on body composition.
36

Shao and colleagues found similar results in a mouse study
where curcumin signicantly 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 curcumins anti-
oxidant and anti-inammatory 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 benets.
38
Few studies have been conducted to evaluate curcumins
effect on obesity and heart disease in humans. Two small
studies have been done to examine curcumins effect
on obesity-related parameters.
39,40
One study examined
curcumins 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 signicantly lowered the levels of plasma brinogen,
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 curcumins 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 signicantly
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 proles (total
and LDL cholesterol), blood glucose proles (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 curcumins
anti-inammatory 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 inammation.
38
Type 2 Diabetes
Hyperglycemia, insulin resistance, and decreased insulin
secretion characterize type 2 diabetes. Oxidative stress and
inammatory 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, theres growing interest in complementary and
alternative approaches, including herbal therapies.
43,44

Curcumin appears to inuence 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-inammatory 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
type 2 diabetes.
21,42,45
Some of these studies also demon-
strated that curcumin and curcuminoids can signicantly
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
inammatory cytokines.
36,46,47
Jain and colleagues reported
that curcumin supplementation in diabetic rats lowered the
production of inammatory 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 curcumins
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 signicantly
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 signicantly
lower HbA1c levels and fasting and postprandial glucose
levels, and increased levels of the anti-inammatory
cytokine adiponectin.
47

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

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

Alzheimers Disease
The pathogenesis of Alzheimers disease (AD) involves
neuroinammation induced by free radical production and
oxidative damage
1,3,4,53
and the formation and accumulation of
beta-amyloid plaques, or brils, in the brain. Amyloid brils
are formed by normally soluble proteins, which assemble to
form insoluble bers. High expression of beta-amyloid plaques,
along with neuroinammation, 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 Parkinsons and Huntingtons, can
cause severe side effects,
55
theres strong interest in alternative
approaches. Because of its antioxidant and anti-inammatory
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 signicantly 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-inammatory, and antibeta-amyloid protein
activity. In addition, studies in animal models of AD indicate
a direct effect from curcumin in decreasing ADs amyloid
pathology.
57,58
These ndings 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 curcumins neuroprotective potential and
suggest a role for this compound in the prevention and reversal
of degenerative diseases such as AD and Parkinsons.
60-62
Clinical trials, however, havent been as promising. Two
independent clinical trials concluded that curcumin wasnt
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 didnt
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, its too soon
to conclude that theres 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 efcacy 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
active
55
: 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 thats thought
to increase curcumins bioavailability. These studies are
directed to evaluate the efcacy, safety, and tolerability of
curcumin in moderate AD.
Although clinical trials to date havent 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, didnt cause adverse effects warrant
further clinical studies.
Arthritis
Osteoarthritis (OA), one of the most common types of
arthritis, results in joint degradation, including articular
cartilage and subchondral bone. Its 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 inammatory disorder that may
affect many tissues and organs but principally attacks exible
(synovial) joints.
The roles of inammatory cytokines and chemokines
(special types of cytokines that direct the migration of white
blood cells to infected or damaged tissues), inammatory
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 inammation linked
with arthritis.
3

NSAIDs such as celecoxib (Celebrex) are efcient anti-
inammatory 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 celecoxibs 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 curcumins 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 inammatory 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 16818 to
11.34.1 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,
curcumins role in the treatment of OA and RA shows promise.
Inammatory Bowel Diseases
Inammatory bowel diseases (IBDs), including Crohns
disease and ulcerative colitis, are debilitating immune
disorders involving chronic inammation 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-inammatory medications sulfasalazine (Azuldine)
and mesalamine, which work by inhibiting the COX and LOX
pathways and the inammatory 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
proinammatory cytokines in colonic mucosa was suppressed
in the curcumin-treated groups.
70,71
Since curcumin has shown
efcacy as an anti-inammatory without signicant 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 Crohns 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 studys
conclusion. Curcumin reduced the inammatory response in
four of ve ulcerative colitis patients and four of ve Crohns
disease patients. In fact, four of the ve 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 signicant improvements in the curcumin group but
not in the placebo group, showing that curcumin signicantly
suppressed the morbidity associated with active ulcerative
colitis. Relapse rate was signicantly lower in the curcumin
group over the placebo group.
72,75

The research results to date support further exploration
of curcumins efcacy 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 benecial effects.
76
Several clinical trials currently
are being conducted.
Cancer
Regularly 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 cant be assumed.
79
Epidemiological studies have identied chronic infections
and inammation 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 proinammatory lifestyle that leads
to tumorigenesis.
81
In fact, inammation is involved in most
stages of tumor development, including initiation, promotion,
malignant conversion, invasion, and metastasis.
80

The mixture of cytokines and proinammatory mediators
that are produced in tumor cells play an important role in tumor
development and progression. NF-KB activation leads to the
expression of inammatory enzymes and mediators, including
COX-2, LOX-2, iNOS, cell adhesion molecules, and inammatory
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 inammation 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 inammatory 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 rst demonstrated curcumins 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
werent observed, suggesting good tolerability of curcumin.
The highest daily dose (3.6 g) signicantly lowered the levels
of the inammatory 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 curcumins 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 signicant adverse events. Results showed
that curcumin downregulated the activation of NF-KB and
STAT3, and suppressed COX-2 expression.
87
These observations
support curcumins 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 nding out how much cancer there is in a persons body
and where its located) every two months. The majority of the
patients showed downregulation of NF-KB and COX-2 after
treatment with curcumin, but this downregulation didnt 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 rst study to show that curcumin can
downregulate the expression of these inammatory 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 curcumins 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 curcumins safety
and efcacy in patients with multiple myeloma, colorectal,
pancreatic, breast, prostate, lung, and head and neck
cancers.
21
This research supports curcumins potential to
prevent and treat various cancers.
93

Bioavailability
As 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,
and only traces appear in the blood. Since curcumins limited
bioavailability weakens its effectiveness in vivo, improving
bioavailability is of the utmost importance.
Several strategies have been explored to improve curcumins
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 modica-
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 curcumins bioavailability.
96
Other adjuvants,
such as quercetin, genistein and eugenol, also show promise in
improving curcumins 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,
its 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
Safety
Human clinical trials have established curcumins 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 ash, 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 Recommendations
More 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 benets.
101
However, theres no clear
recommendation for curcumin dosage.
Until research supports more specic 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 benets. 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, sh oil, and seeds.
102

With its earthy avor and a hint of ginger, turmeric gives
poultry and seafood a warm color and accents its natural avor.
It also goes well with rice, lentil, and vegetable dishes and
can enhance the avor of soups and stews. It can be added to
vinaigrettes and to oil or butter for color and avor; 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 avor grows more pronounced during
cooking and using too much at one time could ruin a dish.
In Conclusion
Evidence continues to mount in support of curcumins role
in inhibiting the inammatory process and, thus, inammatory
diseases. Additional research is needed to improve bioavailability
and determine specic 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 avor while helping to ght inammation.
Sharon Collison, MS, RD, LDN, CSSD, is a dietitian in private
practice and a freelance writer in Newark, Delaware.
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 inammatory
mediators.
c. NF-KB increases the transcription of anti-
inammatory 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 inltration.
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-inammatory effects through
which of the following mechanisms?
a. Increasing free radical production
b. 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 cholesterol
b. Increased LDL cholesterol
c. Increased apolipoprotein A and decreased
apolipoprotein A/B
d. Increased plasma brinogen
5. Curcumin has been shown to do which of the following in
clinical trials?
a. Reduce cognitive decline in patients with Alzheimers
disease
b. Decrease morning stiffness and joint swelling in
patients with rheumatoid arthritis
c. Increase inammatory cytokines in cancer patients
d. Increase the expression of COX-2 and LOX in cancer
patients
6. Results from a clinical trial that evaluated curcumins
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 weight
b. Increase TNF-alpha
c. Decrease the number of apoptotic cells
d. 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 CE@gvpub.com.
Register or log in on CE.TodaysDietitian.com
to purchase access to complete the online
exam and earn your credit certicate for
2 CPEUs on our CE Learning Library.
NIGELLA SATIVA
By Megan Tempest, RD
Research suggests this ancient medicinal
plant may have present-day uses
for a variety of conditions.
If youve never heard of Nigella sativa (also known as black
seed or black cumin), youre 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 Is
A 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 Tuts 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 specic ailments such as asthma,
allergies, u, joint pain, and gastrointestinal problems.
2

Compelling Research
On the heels of much animal research, published results from
human studies have emerged exploring Nigella sativas role as
an effective complementary and alternative medicine. Heres a
review of some of the most recent research.
Hypertension
Nigella 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 denes
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 signicantly lowered systolic and
diastolic blood pressures without any apparent adverse effects.
4
Hyperlipidemia
When 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 insignicant improve-
ment in HDL cholesterol levels. Furthermore, the researchers
observed that when the women stopped taking the supplement,
their lipid proles 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 proles.
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 proles of 94 individuals with type 2 dia-
betes. Patients who took 2 g/day had signicantly 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
didnt see a signicantly greater benet 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 proles but isnt yet convinced she
should recommend it to clients with hyperlipidemia. Research
has shown decreases in LDL and triglycerides, but the decrease
SUPPLEMENT SPOTLIGHT
is mild, she says. Since there are effective dietary strategies,
I would try those rst to reduce high LDL/triglycerides.
Of course, diet and exercise modications are widely accepted
as safe and effective methods of improving lipid proles, 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 signi-
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 proles, 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 signicant decrease in
fasting blood glucose levels and improvement in serum lipid
proles compared with placebo.
22
Cognitive Function
Following 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 ndings, the researchers emphasized
the need for further research in Nigella sativas role in prevent-
ing or slowing the progression of Alzheimers 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 Arthritis
The benecial, 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
Allergies
A prospective, double-blind, placebo-controlled trial investi-
gated the anti-inammatory 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 Patients
The scientic evidence behind Nigella sativas 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 specic 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
sufcient 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 arent regulated; therefore, its 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.
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
identied 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 persons 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 t 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 uid accumulation, as
part of the physical examination portion of
the comprehensive geriatric assessment. In
regard to mental health status, she identi-
ed 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 patients functional
status. As for older adults social domains (social networks
and economic status), she pointed out that older adults on
xed and limited incomes often need to make decisions
regarding payment for medications, housing costs, and food
purchases, leading them to purchase food thats cheaper and
less nutritious. Beyond identifying potential nutrition prob-
lems, DiMaria-Ghalili stressed that any problems identi-
ed 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
patients health care providers.
SOURCE: AMERICAN SOCIETY FOR PARENTERAL AND ENTERAL NUTRITION
ENTERAL AND PARENTERAL NUTRITION
Long-Term Feeding Tubes May Increase Fistula Risk
Pediatric 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 stulae, or the failure of the opening to
close on its own, resulting in a need for surgical closure.
The causes of gastrocutaneous stulae in pediatric
patients largely are unknown, but researchers at Boston
Childrens Hospital looked at possible risk factors, including
nutrition. Their ndings 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 identied with an increased like-
lihood of gastrocutaneous stulae. In addition, stulas
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.
Current Guidelines for IV Feeding May Require Revisions
Current guidelines to help prevent bloodstream infec-
tions during IV feeding may need revisions to strengthen
protections for patients, a new study nds.
Researchers at the University of Southampton in the
United Kingdom found that current guidelines dont 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.
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
theyre properly identied 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.
[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.
Cooking Light Dinnertime Survival Guide
By Sally Kuzemchak
2014, Oxmoor House
Hardcover, 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 ash. 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 cant afford healthy food (save bucks with thrifty dishes)
Who ate my cheese? Bread? Salad? (dinners from a stocked
pantry)
Im not a short order cook! (feeding picky eaters)
Nobodys around to eat it anyway (adaptable meals for
hectic schedules)
Im on a diet, theyre not (healthy foods everyone will love)
My kids take all my attention! (one-handed recipesalmost)
Meat loaf. Again? (busting out of the dinner rut)
Frankly, I just dont 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 denitely 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,
Popeyes 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 isnt 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 Popeyes Baked Ziti, the ingredients called for 4 cups
of hot cooked ziti. Maybe its just me, but I nd 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. Its a great resource to share
with clients, friends, family, and colleagues. I know Im 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. Shes also a freelance
writer and works in education.
The Greek Yogurt Kitchen: More Than 130 Delicious,
Healthy Recipes for Every Meal of the Day
By Toby Amidor, MS, RD, CDN
2014, Grand Central Publishing
Softcover, 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
yogurtwhich actually didnt originate in Greecefollowed
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, youll
learn why Greek
yogurt is loaded with
probiotics and why
its 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
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 articial
sweeteners.
Youll be amazed at the versatility of Greek yogurt as you
create smoothies, dips, and dressings as well as salads,
soups, pizzas, main entres, side dishes, desserts, and
breads. Personally, Im eager to make the Green Goddess
Deviled Eggs, Grilled Flounder With Avocado Sauce, and
Double Chocolate Chip Cookies.
Youll 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 whos health conscious
should have on hand.
Karen Appold is a freelance medical writer and editor based
in Pennsylvanias Lehigh Valley.
The Nourished Kitchen: Farm-to-Table Recipes for
the Traditional Foods Lifestyle
By Jennifer McGruther
2014, Ten Speed Press
Paperback, 320 pages, $27.99
If youve ever peeked at what fellow supermarket shoppers
were putting in their grocery carts and been disheartened
by the large number of rened and additive-lled 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, elds, 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 McGruthers experience with the recipe or
highlighting the recipes avors 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 difcult 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 isnt
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 difcult to obtain.
For those who already are stripping their pantry of
processed foods and who arent afraid to invest extra time
tracking down locally sourced foods and preparing foods
in the kitchen, this cookbook may be a good t. The back of
the book includes a resources section to help nd certain
ingredients, and readers can nd more information on
McGruthers 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.
PRODUCTS + SERVICES
Bobs Red Mill Cuts
Gluten in Baking Flour
Bobs Red Mill Natural Foods, a provider of whole grain
and gluten-free foods, has announced the availability of a new
gluten-free our that easily converts any conventional recipe to
a gluten-free one. The new product, Bobs Red Mill Gluten Free
1-to-1 Baking Flour, can be substituted for traditional our,
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 our, whole grain sorghum our, sweet white rice
our, potato starch, tapioca our, and xanthan gum. It enables
bakers to follow any baking recipe and directly replace the
amount of traditional wheat our with the new baking our.
The resulting baked goods promise to offer the same avor
and texture as the conventional counterpart.
The new our is made from high-quality gluten-free ingre-
dients in a 100% dedicated gluten-free facility. All of Bobs Red
Mill gluten-free ingredients and products are batch tested
in the companys quality control laboratory with an R5 ELISA
Gluten Assay test to ensure the absence of gluten.
For more information, visit www.bobsredmill.com.
Hilarys Eat Well Offers
Allergen-Free Products
Hilarys Eat Well is a line of convenient, common
allergenfree food products, including the Worlds 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
allergenfree dressings.
Hilarys Eat Well product lines
are non-GMO veried, gluten-
free certied, and vegan certied.
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.
Beanelds Adds Classic Flavors
Beanelds has released chips in classic Ranch and
Barbecue avors. The chips, made from beans and rice, are
certied gluten-free, non-GMO veried, and vegan.
Beanelds 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.beaneldssnacks.com.
DeeBees TeaPops
Hit US Shelves
Made with teas, naturally noncaffeinated rooibos, and
organic fruit, DeeBees TeaPops are lightly sweetened
with organic coconut ower blossom nectar or organic,
non-GMO honey.
The TeaPops range from 25 to 50 kcal and are
100% certied organic; certied peanut- and nut-
free; non-GMO; free of dairy, soy, and gluten;
kosher; and almost entirely vegan. They provide
the health benets of tea and rooibospotent 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 avor in the Rickland Orchards Greek on the
go! line. Strawberry Fruit Bites are dark chocolate
avored, Greek yogurtcoated fruit bites made with
real fruit and fruit juice. In resealable pouches, the
newest avor offers a convenient, on-the-go snack.
For more information, visit www.ricklandorchards.com.
Stouffers Vegetable Lasagna
Made With Whole Grains
Stouffers authentic lasagna collection features a
new take on vegetable lasagna: It now features ricotta
cheese, golden breadcrumbs, sea salt, and rufed
pasta made with whole grains. For foodservice, entres
are available in four 96-oz trays that yield 48 servings
per case in three additional avors: Classic Lasagna,
Lasagna With Meat & Sauce, and Chicken Lasagna.
For more information, visit www.nestle
professional.com/stouffers.
Red Jacket Orchards Introduces
Juice With Antioxidants
Red Jacket Orchards, a family-owned brand crafting fresh
fruits and juices for over ve 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
ber, antioxidants, and avonoids. The cold pressed juices are
made naturally with whole fruit and no additives.
For more information, visit www.redjacketorchards.com.
Annies Snack and Meal Kits
Offer Convenience
Annies 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 articial avors, synthetic
colors, or synthetic preservatives, these kits provide an
alternative to overly processed prepacked lunches.
Available in six varieties, Annies Snack and Mini Meal Kits
offer 6 to 10 g of protein, 3 to 6 g of ber, and one full serving of
fruit in each kit. The varieties offered include two gluten-free
versions for those with gluten allergies or sensitivities.
Annies Snack Kits are available in the following three
varieties: Almond Butter & Crackers, Hummus & Crackers,
and Gluten Free. Annies 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 doesnt add any sugar or oils to its nut but-
ters, and every avor is a blend of seven healthful nuts
and seeds, including almonds, cashews, hazelnuts,
brazil nuts, peanuts, sunower seeds, pumpkin seeds,
chia seed, and axseeds. Ingredients are high quality,
organic, non-GMO, and gluten-free certied.
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-
avored 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.
PR Gum Releases
Two New Flavors
PR Gum has introduced the newest members
of its sugar and aspartame-free family: Cinnamon
and Coolmint.
PR Cinnamon captures the balance of hot and
sweet sensations from cinnamon bark. Infused nat-
urally, its made with no articial ingredients. PR
Coolmint refreshes the breath with a clean, crisp, and
chilling avor, 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,
articial colors, or avors.
Opaa! Brand spreads offer the following avors: 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.
NEWS BITES
Energy Drinks Raise New Questions About Caffeines Safety
Caffeine, 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 conrming the safety of
caffeine for consumers at current levels of exposure. What
isnt 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
caffeines safety. The FDA responded by sponsoring an
Institute of Medicine scientic 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 lled.
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 rm based in Aliso
Viejo, California. But todays 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 caffeines
safety and is expected to issue guidelines.
James C. Grifths, PhD, vice president of scientic
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 theres overwhelming scientic evidence demon-
strating its safety. Were all waiting to see what the FDA
is going to do.
SOURCE: INSTITUTE OF FOOD TECHNOLOGISTS
Peanuts Dont Panic Parents
as Much as Milk and Eggs
Its 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, theres 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 childrens most severe food reaction and infor-
mation about the caregivers quality of life. Researchers found
caregivers who understood their childs 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.
Its 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 childs reaction. More than 15% overperceived their childs
reaction severity, and 19% underperceived the reaction sever-
ity. Caregivers had signicant concerns regarding their ability
to help in the event of a reaction and also that others wouldnt
understand the seriousness of their childs food allergy.
Its 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 shouldnt. Children with
a history of allergic reactions and their caregivers need to
know how to administer epinephrine. Having plans in place
can ease a parents worries.
SOURCE: AMERICAN COLLEGE OF ALLERGY, ASTHMA, AND IMMUNOLOGY
Healthy Lifestyle Crucial for Women of Childbearing Age
Nutrition 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 Academys 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 Academys 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 papers 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 womans needs.
The Academy offers the following advice:
Follow a healthy diet and be physically active before,
during, and after pregnancy.
A well-balanced diet can meet most of your nutrient needs
during pregnancy. Talk with your health provider about iron and
other nutrient supplements.
Ask your health provider how much weight gain is right for
you. A healthy weight gain is important for both baby and mother.
A healthy lifestyle helps prevent excessive weight gain
during pregnancy.
RDs and DTRs can help you select an appropriate food plan
and tailor advice to your needs.
SOURCE: ACADEMY OF NUTRITION AND DIETETICS
Nutrition Program Improves Preschoolers At-Home Diet
A nutrition education program in low-
income child care centers can improve a
childs 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 USDAs Food and Nutrition Service
supported the study.
Published in the Journal of the Academy of
Nutrition and Dietetics, the study is the rst
to examine and nd that a multicomponent nutrition education
program for low-income preschool-aged children and their
parents in a child care setting can affect a childs at-home diet.
The USDA recommends that children aged 2 to 5 eat 1 to
1
1
2 cups of vegetables daily and 1 to 1
1
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 werent exposed to the program. The study also found a
signicant increase in the number of cups of vegetables that
these children consumed at home each day.
The study examined the State of New Yorks 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 USDAs 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 childs 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 childrens vegetable and low-fat/fat-free milk con-
sumption improved, the study found that the program didnt
have a signicant 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
Study Finds Kids Eat Whole
Grains When Offered
According to a new study by researchers at the University of
Floridas Institute of Food and Agricultural Sciences, kids will
eat whole grains when theyre offered, and they will eat whole
and rened 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 rened grain foods, and we
were pleasantly surprised that they would eat the same amount
whether the food was whole or rened.
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 grainrich 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 wont 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 rened grain foods over a six-week period in 2010. Of those,
42 students were in the rened grain group, while 41 were in
the whole grain group.
Participants and their families were given rened grain or
whole grain pasta, rice, bread, and other foods to eat at home
and whole and rened 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 specicity
in identifying pediatric obesity, meaning BMI accurately
identies 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 nd 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
Poor Awareness of Injection Techniques Affects Glucose Control
Patients with diabetes who dont know proper injection
techniques may administer insulin incorrectly, leading to poor
glycemic control and adverse outcomes, a new study from
Iraq nds. 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 signicant 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 nd 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
rst 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. Its the rst systematic review and meta-
analysis to assess BMIs 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.
Its known that childhood obesity can lead to an increased
risk of type 2 diabetes and cardiovascular disease, says
Asma Javed, MD, the studys rst author and a pediatric
endocrinology fellow at the Mayo Clinic Childrens 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 ofcials, and policymakers.
While not part of this study, its results mirror what has
been found in Lopez-Jimenezs 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 identied the genes in wheat
that control tolerance to a signicant yield-limiting soil
condition found around the globe: boron toxicity.
Published in Nature, the identication 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 Adelaides Waite
campus within the universitys 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 worlds
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. Its 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
identication 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 difcult 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 specic
boron tolerance genes from wild wheats grown by the
worlds 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
specic 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 u.
Probiotics are very popular, says David Schnadower,
MD, the trials principal investigator and an associate
professor of pediatrics. People use them for everything,
especially diarrhea, yet minimal data exist showing they
really help. Theres a real need to do a clear, denitive
study of the use of probiotics in kids with gastroenteritis.
While medical professionals sometimes give children
with gastroenteritis medication to treat nausea and uids
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
Childrens Hospital. If the probiotic were 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 dont
want is for the use of probiotics to
become a practice that isnt supported
by evidence.
The trial will involve about 900 chil-
dren aged 3 to 48 months treated at
St Louis Childrens 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
ve 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 rst ve 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 childs 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
efcacy of another common probiotic (Lacidol) 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
WI-FI HOTSPOT ETIQUETTE
By Reid Goldsborough
Using Wi-Fi in public is much like using a cellphone in public.
There are dos and donts if you want to avoid stares, mumbles,
or getting yelled at. Whether youre 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 youre in, or keep it
short and say youll get back to the other person later.
A public Wi-Fi hotspot also isnt the best place to show off
your add-on speakers as you listen to iTunes music or watch a
YouTube video or Netix 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 dont 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 locations safety policies and may
risk tripping other users.
If youre not using an outlet, dont 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 arent
your personal computer support staff. If youre
having problems, some may help you out, but
most wont 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, toodepend on
your buying beverages or additional items for
their jobs. Dont 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 doesnt
mean you can use it as you please.
You hear anecdotal stories of interviewers asking inter-
viewees to disclose personal information, lawyers discussing
nancial information with clients, and loud meetings involving
multiple tables that disrupt the ambiance for everyone else in
the coffee shop.
If you dont have a private ofce 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, its safest to use
a virtual private network system such as Hotspot Shield (www.
hotspotshield.com) if youre using public Wi-Fi to make online
purchases, conduct online banking, or engage in similar activi-
ties involving nancial information.
Reid Goldsborough is a syndicated columnist and author of
the book Straight Talk About the Information Superhighway. He can
be reached at reidgoldsborough@gmail.com or www.reidgold.com.
PERSONAL COMPUTING
OCTOBER 11, 2014
AMERICAN DIABETES
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NOVEMBER 5-6, 2014
IOWA ACADEMY OF NUTRITION AND
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CHILDRENS HOSPITAL OF
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AMERICAN SOCIETY FOR NUTRITION
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www.nutrition.org
JANUARY 11-13, 2015
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www.schoolnutrition.org
FEBRUARY 14-17, 2015
AMERICAN SOCIETY FOR PARENTERAL
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NUTRITION WEEK
Long Beach, California
www.nutritioncare.org
AMERICAN ACADEMY OF ALLERGY,
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Houston, Texas
www.aaaai.org
NATIONAL EATING DISORDERS
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DATEBOOK
SEPTEMBER 26, 2014
ENHANCING HEALTH WITH
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MARKETPLACE
MAKING PEACE WITH BEETS
A Root Vegetable Messy to Prepare
but Oh So Flavorful
By Grace Dickinson
It wasnt 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 moms 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 dads 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 afnity for their taste that my mom couldnt
match. And unfortunately, my mom had cleaning skills that my dad
couldnt match, so every summer there was a comical bone of con-
tention that surrounded beets.
These opposing views left me bafed, and over the years I didnt
experiment with the veggie even as I developed my own interest
in cooking. The avor 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 ofcially 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 avor when added to a dish. I prefer just
a hint of this avor, and only a hint is needed to transform an entire
dish into a beautiful, pink presentation. Youll nd thats 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
Ingredients
3 cloves garlic, chopped
1 onion, chopped
1 small beet, chopped
3 cups cooked black beans, 1 cup set aside
2 tsp smoked paprika
1 lime, juiced
1 tsp salt plus a pinch
Pepper, to taste
1 cup cooked bulgur wheat (can use short
grain brown rice instead)
1 large egg
1 T olive oil
3
4 cup low-fat Greek yogurt
1 T parsley, minced
6 whole wheat buns
Directions
1. 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 400F. 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.
Calories: 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
Silver Palate Kitchens, Inc. 2014. All rights reserved. Visit us at Silver Palate Booth #2516
How Can Grain Berry
Slow Digestion and New Plan

Help 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 its 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.
C
M
Y
CM
MY
CY
CMY
K
TodayDietician222-COPDlogo_x1a.pdf 1 8/21/14 10:43 AM
Mondelez0914.indd 1 8/12/14 10:06 AM

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is 100% real milk, just without the lactose.

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offers more than 160 single-serve, portion-

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