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Nutritional Deficiency Disease Secondary to ARFID Symptoms Associated with Autism and the Broad Autism Phenotype: A Qualitative Systematic Review of Case Reports and Case Series

Published:November 19, 2020DOI:https://doi.org/10.1016/j.jand.2020.10.017

      Abstract

      Background

      The demographics, weight statuses, and dietary patterns of people with autism or the broad autism phenotype who experience a severe nutrient deficiency disease due to symptoms of avoidant/restrictive food intake disorder have not been well established.

      Objective

      The primary objective of this review was to examine the relationship between the demographics, weight statuses, dietary patterns, and nutrient deficiency diseases that characterize the most severe manifestations of avoidant/restrictive food intake disorder symptomology associated with autism or the broad autism phenotype.

      Methods

      A systematic review of English and non-English articles published up to August 29, 2019, on the Scopus, PubMed, and Cumulative Index to Nursing and Allied Health Literature Plus electronic databases was conducted. Additional cases were identified through the reference list of all included articles. The search terms used were “autis AND (deficiency OR scurvy)”. Only case reports or case series in which a person of any age who had been identified as having a formal diagnosis of autism or autism symptoms and a disease of nutritional deficiency due to self-imposed dietary restrictions were included. Data were independently extracted by 8 authors using predefined data fields.

      Results

      A total of 76 cases (patients were aged 2.5 to 17 years) from 63 articles that were published from 1993 through 2019 were found. More than 85% cases (65 of 76 patients) were from articles published in the past 10 years. The largest percentage of published cases (69.7% [53 of 76]) involved scurvy, a vitamin C deficiency. The second-largest percentage of published cases (17.1% [13 of 76]) involved eye disorders secondary to vitamin A deficiency. Other primary nutrient deficiencies reported were thiamin, vitamin B-12, and vitamin D. In 62.9% (22 of 35) of the patients for which a body mass index or a weight percentile for age was provided, the patient was within normal weight parameters, per Centers for Disease Control weight status categories.

      Conclusions

      Based on the 63 articles extracted for this systematic review, nutritional deficiency diseases related to inadequate intakes of vitamin A, thiamin, vitamin B-12, vitamin C, and vitamin D were found in individuals with autism and the broad autism phenotype who had severe self-imposed dietary restrictions. When weight information was provided, most of the youth in these cases were not reported to be underweight. Individuals of any weight who present with symptoms of avoidant/restrictive food intake disorder can benefit from early and frequent screening for adequacy of micronutrient intake, regardless of whether they have a clinical diagnosis of autism.

      Keywords

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      References

        • American Psychiatric Association
        Highlights of changes from DSM-IV to DSM-5: Feeding and eating disorders.
        in: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association, Arlington, VA2013: 813
        • Chatoor I.
        Feeding disorders in infants and toddlers: Diagnosis and treatment.
        Child Adolesc Psychiatr Clin N Am. 2002; 11: 163-183
        • Fisher M.M.
        • Rosen D.S.
        • Ornstein R.M.
        • et al.
        Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A “new disorder” in DSM-5.
        J Adolesc Health. 2014; 55: 49-52
        • American Psychiatric Association
        Feeding and eating disorders: Avoidant/restrictive food intake disorder.
        in: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association, Arlington, VA2013: 334-338
        • Hatfield T.R.
        • Brown R.F.
        • Giummarra M.J.
        • Lenggenhager B.
        Autism spectrum disorder and interoception: Abnormalities in global integration?.
        Autism. 2019; 23: 212-222
        • Coglan L.
        • Otasowie J.
        Avoidant/restrictive food intake disorder: What do we know so far?.
        BJPsych Adv. 2019; 25: 90-98
        • Thomas J.J.
        • Wons O.B.
        • Eddy K.T.
        Cognitive-behavioral treatment of avoidant/restrictive food intake disorder.
        Curr Opin Psychiatry. 2018; 31: 425-430
        • American Dietetic Association (ADA)
        Position of the American Dietetic Association: Nutrition intervention in the treatment of eating disorders.
        J Am Diet Assoc. 2011; 111: 1236-1241
        • American Psychiatric Association
        Neurodevelopmental disorders: Autism spectrum disorder.
        in: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association, Arlington, VA2013: 50-59
        • Ledford J.R.
        • Gast D.L.
        Feeding problems in children with autism spectrum disorders: A review.
        Focus Autism Other Dev Disabil. 2006; 21: 153-166
        • Leung A.K.
        • Marchand V.
        • Sauve R.S.
        Canadian Paediatric Society, Nutrition and Gastroenterology Committee. The “picky eater”: The toddler or preschooler who does not eat.
        Paediatr Child Health. 2012; 17: 455-457
        • Emond A.
        • Emmett P.
        • Steer C.
        • Golding J.
        Feeding symptoms, dietary patterns, and growth in young children with autism spectrum disorders.
        Pediatrics. 2010; 126: e337-e342
        • Christensen S.S.
        • Bentz M.
        • Clemmensen L.
        • Strandberg-Larsen K.
        • Olsen E.M.
        Disordered eating behaviours and autistic traits—Are there any associations in nonclinical populations? A systematic review.
        Eur Eating Disord Rev. 2019; 27: 8-23
        • Brigham K.S.
        • Manzo L.D.
        • Eddy K.T.
        • Thomas J.J.
        Evaluation and treatment of avoidant/restrictive food intake disorder (ARFID) in adolescents.
        Curr Pediatr Rep. 2018; 6: 107-113
        • Marrs I.
        “Picky eaters” will not starve themselves but problem or resistant eaters might.
        (Updated 2017. Accessed April 11, 2019)
        • American Dietetic Association
        Practice paper of the American Dietetic Association: Nutrition intervention in the treatment of eating disorders.
        J Am Diet Assoc. 2011; 111: 1261
        • Malhi P.
        • Venkatesh L.
        • Bharti B.
        • Singhi P.
        Feeding problems and nutrient intake in children with and without autism: A comparative study.
        Indian J Pediatr. 2017; 84: 283-288
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Donaldson C.K.
        • Stauder J.E.A.
        • Donkers F.C.L.
        Increased sensory processing atypicalities in parents of multiplex ASD families versus typically developing and simplex ASD families.
        J Autism Dev Disord. 2017; 47: 535-548
      1. Micronutrient deficiencies: Iron deficiency anemia. World Health Organization.
        (Updated 2019. Accessed September 7, 2019)
        • Cole J.A.
        • Warthan M.M.
        • Hirano S.A.
        • Gowen Jr., C.W.
        • Williams J.V.
        Scurvy in a 10-year-old boy.
        Pediatr Dermatol. 2011; 28: 444-446
        • Belur J.
        • Tompson L.
        • Thornton A.
        • Simon M.
        Interrater reliability in systematic review methodology: Exploring variation in coder decision-making.
        Sociol Methods Res. Published online September. 2018; 24https://doi.org/10.1177/0049124118799372
        • Gagnier J.J.
        • Kienle G.
        • Altman D.G.
        • et al.
        The CARE guidelines: Consensus-based clinical case reporting guideline development.
        Glob Adv Health Med. 2013; 2: 38-43
        • Murad M.H.
        • Sultan S.
        • Haffar S.
        • Bazerbachi F.
        Methodological quality and synthesis of case series and case reports.
        BMJ Evid Based Med. 2018; 23: 60-63
        • Clark J.H.
        • Rhoden D.K.
        • Turner D.S.
        Symptomatic vitamin A and D deficiencies in an eight-year-old with autism.
        JPEN J Parenter Enteral Nutr. 1993; 17: 284-286
        • Berube M.
        • Hubbard C.
        • Mallory L.
        • Larsen E.
        • Morrison P.
        • Augustyn M.
        Historic condition in a modern child with autism.
        J Dev Behav Pediatr. 2013; 34: 288-290
        • Kinlin L.M.
        • Friedman J.N.
        • Vresk L.
        Vision loss in a child with autism spectrum disorder.
        Paediatr Child Health. 2019; 24: 148-150
        • Rafee Y.
        • Burrell K.
        • Cederna-Meko C.
        Lessons in early identification and treatment from a case of disabling vitamin C deficiency in a child with autism spectrum disorder.
        Int J Psychiatry Med. 2019; 54: 64-73
      2. Stalnaker LD, Prasher P, Flesher S. Rickets treatment improves more than bone health in toddler with autism spectrum disorder: A brief report. SAGE Open Med Case Rep. Published online August 14, 2019. https://doi.org/10.1177/2050313X19870026.

        • Swed-Tobia R.
        • Haj A.
        • Militianu D.
        • et al.
        Highly selective eating in autism spectrum disorder leading to scurvy: A series of three patients.
        Pediatr Neurol. 2019; 94: 61-63
        • Yu J.C.
        • Shliakhtsitsava K.
        • Wang Y.M.
        • et al.
        Hematologic manifestations of nutritional deficiencies: Early recognition is essential to prevent serious complications.
        J Pediatr Hematol Oncol. 2019; 41: E182-E185
        • Andrews S.L.
        • Iyer S.
        • Rodda C.
        • Fitzgerald J.
        Scurvy: A rare cause for limp in a child with autism spectrum disorder.
        J Paediatr Child Health. 2018; 54: 1375-1377
        • Burhop J.
        • Gibson J.
        • de Boer J.
        • Heydarian C.
        Do you C what I C, Emergency department evaluation and diagnosis of pediatric scurvy in an autistic child with a restricted diet.
        Pediatr Emerg Care. 2020; 36: e1-e3
        • Caldwell K.J.
        • Creedon J.K.
        • Miller A.F.
        Child with autism and a limp.
        Ann Emerg Med. 2018; 72: 493-495
        • Coppini J.
        • Borg C.
        • Vella C.
        Scurvy in children with autistic spectrum disorder: Not such a rarity.
        Malta Med J. 2018; 30: 60-63
        • Dubois M.
        • Cousin E.
        • Chouklati K.
        • Bruneau B.
        • Proisy M.
        Scurvy in a 3-year-old autistic girl: Whole-body magnetic resonance imaging findings.
        Diagn Interv Imaging. 2018; 99: 49-50
        • Harikrishnan B.
        • Balan S.
        Scurvy mimicking juvenile idiopathic arthritis in two pediatric patients.
        Indian J Rheumatol. 2018; 13: 273-276
        • Kinlin L.M.
        • Blanchard A.C.
        • Silver S.
        • Morris S.K.
        Scurvy as a mimicker of osteomyelitis in a child with autism spectrum disorder.
        Int J Infect Dis. 2018; 69: 99-102
        • Saavedra M.J.
        • Aziz J.
        • Cacchiarelli San Roman N.
        Scurvy due to restrictive diet in a child with autism spectrum disorder: Case report.
        Arch Argent Pediatr. 2018; 116: e684-e687
        • Tripathi N.
        • Shankar R.K.
        • Baghdassarian A.
        Nutritional rickets presenting as chronic episodic extremity pain in a 9-year-old with autism.
        Clin Pract Cases Emerg Med. 2018; 2: 251-254
        • Erdle S.
        • Conway M.
        • Weinstein M.
        A six-year-old boy with autism and left hip pain.
        CMAJ. 2017; 189: E275-E278
        • Golriz F.
        • Donnelly L.F.
        • Devaraj S.
        • Krishnamurthy R.
        Modern American scurvy—Experience with vitamin C deficiency at a large children's hospital.
        Pediatr Radiol. 2017; 47: 214-220
        • Jacobsen A.
        • DeNiro K.
        Rash and arthralgias in a teenager with autism.
        JAMA Pediatr. 2017; 171: 89-90
        • Metz J.
        • Holjar-Erlic I.
        • Kelly A.
        • Ramanan A.V.
        Think about the C' (in custard and crackers).
        Arch Dis Child Educ Pract Ed. 2018; 103: 304-306
        • Planerova A.
        • Philip S.
        • Elad S.
        Gingival bleeding in a patient with autism spectrum disorder: A key finding leading to a diagnosis of scurvy.
        Quintessence Int. 2017; 48: 407-411
        • Schultz K.
        • Schorr B.
        • Zaheer S.
        • Fantasia J.
        Clinicopathologic features of scurvy in an autistic child with a vitamin C deficient diet.
        Oral Surg Oral Med Oral Pathol Oral Radiol. 2017; 124 (e201-e201)
        • Amos L.E.
        • Carpenter S.L.
        • Hoeltzel M.F.
        Lost at sea in search of a diagnosis: A case of unexplained bleeding.
        Pediatr Blood Cancer. 2016; 63: 1305-1306
        • Hafez D.
        • Saint S.
        • Griauzde J.
        • Mody R.
        • Meddings J.
        Clinical problem-solving. A deficient diagnosis.
        N Engl J Med. 2016; 374: 1369-1374
        • Ma N.S.
        • Thompson C.
        • Weston S.
        Brief report: Scurvy as a manifestation of food selectivity in children with autism.
        J Autism Dev Disord. 2016; 46: 1464-1470
        • Seya M.
        • Handa A.
        • Hasegawa D.
        • Matsui T.
        • Nozaki T.
        Scurvy: From a selective diet in children with developmental delay.
        J Pediatr. 2016; 177: 331
        • Baird J.S.
        • Ravindranath T.M.
        Vitamin B deficiencies in a critically ill autistic child with a restricted diet.
        Nutr Clin Pract. 2015; 30: 100-103
        • Chandran J.J.
        • Anderson G.
        • Kennedy A.
        • Kohn M.
        • Clarke S.
        Subacute combined degeneration of the spinal cord in an adolescent male with avoidant/restrictive food intake disorder: A clinical case report.
        Int J Eating Disord. 2015; 48: 1176-1179
      3. Chiu M, Watson S. Xerophthalmia and vitamin A deficiency in an autistic child with a restricted diet. BMJ Case Rep. 2015;2015:bcr2015209413.

        • Duignan E.
        • Kenna P.
        • Watson R.
        • Fitzsimon S.
        • Brosnahan D.
        Ophthalmic manifestations of vitamin A and D deficiency in two autistic teenagers: Case reports and a review of the literature.
        Case Rep Ophthalmol. 2015; 6: 24-29
        • Gulko E.
        • Collins L.K.
        • Murphy R.C.
        • Thornhill B.A.
        • Taragin B.H.
        MRI findings in pediatric patients with scurvy.
        Skeletal Radiol. 2015; 44: 291-297
        • Inokawa S.
        • Nakashima C.
        • Shigeyasu C.
        • Yamada M.
        A case of xerophthalmia associated with vitamin A deficiency by unbalanced diet in autism spectrum disorder.
        Folia Jpn Opthalmol Clin. 2015; 8: 905-909
        • Khan N.
        • Furlong-Dillard J.M.
        • Buchman R.F.
        Scurvy in an autistic child: Early disease on MRI and bone scintigraphy can mimic an infiltrative process.
        BJR Case Rep. 2015; 1: 20150148
        • Meisel K.
        • Daggubati S.
        • Josephson S.A.
        Scurvy in the 21st century?: Vitamin C deficiency presenting to the neurologist.
        Neurol Clin Pract. 2015; 5: 491-493
        • Barbera S.E.
        • Hogue J.S.
        • Hsieh D.T.
        • et al.
        Index of suspicion. Case 1: Global developmental delay and seizures in a 34-month-old boy. Case 2: Ecchymoses on legs and refusal to walk in a 16-year-old autistic boy. Case 3: Progressive breathing difficulty in a 5-year-old girl.
        Pediatr Rev. 2014; 35: 350-355
        • Harknett K.M.
        • Hussain S.K.
        • Rogers M.K.
        • Patel N.C.
        Scurvy mimicking osteomyelitis: Case report and review of the literature.
        Clin Pediatr (Phila). 2014; 53: 995-999
        • Kitcharoensakkul M.
        • Schulz C.G.
        • Kassel R.
        • et al.
        Scurvy revealed by difficulty walking: Three cases in young children.
        J Clin Rheumatol. 2014; 20: 224-228
        • Sobotka S.A.
        • Deal S.B.
        • Casper T.J.
        • Booth K.V.
        • Listernick R.H.
        Petechial rash in a child with autism and trisomy 21.
        Pediatr Ann. 2014; 43: 224-226
        • Duvall M.G.
        • Pikman Y.
        • Kantor D.B.
        • et al.
        Pulmonary hypertension associated with scurvy and vitamin deficiencies in an autistic child.
        Pediatrics. 2013; 132: e1699-e1703
        • Gongidi P.
        • Johnson C.
        • Dinan D.
        Scurvy in an autistic child: MRI findings.
        Pediatr Radiol. 2013; 43: 1396-1399
        • Rumsey D.G.
        • Rosenberg A.M.
        Childhood scurvy: A pediatric rheumatology perspective.
        J Rheumatol. 2013; 40: 201-202
        • Brennan C.M.
        • Atkins K.A.
        • Druzgal C.H.
        • Gaskin C.M.
        Magnetic resonance imaging appearance of scurvy with gelatinous bone marrow transformation.
        Skeletal Radiol. 2012; 41: 357-360
        • De Cock J.
        • Renard M.
        • Smet M.
        • Breysem L.
        Scurvy in a 3-year-old boy: MRI features.
        JBR-BRT. 2012; 95: 377
        • Dey F.
        • Moller A.
        • Kemkes-Matthes B.
        • et al.
        Reduced platelet aggregation in a boy with scurvy.
        Klin Padiatr. 2012; 224: 448-452
        • Niwa T.
        • Aida N.
        • Tanaka Y.
        • Tanaka M.
        • Shiomi M.
        • Machida J.
        Scurvy in a child with autism: Magnetic resonance imaging and pathological findings.
        J Pediatr Hematol Oncol. 2012; 34: 484-487
        • Rana J.
        • Alterkait A.
        • Weinstein M.
        Picture of the month. Scurvy.
        Arch Pediatr Adolesc Med. 2012; 166: 479-480
        • Tanoue K.
        • Matsui K.
        • Takamasu T.
        Fried-potato diet causes vitamin A deficiency in an autistic child.
        JPEN J Parenter Enteral Nutr. 2012; 36: 753-755
        • Estienne M.
        • Bugiani M.
        • Bizzi A.
        • Granata T.
        Scurvy hidden behind neuropsychiatric symptoms.
        Neurol Sci. 2011; 32: 1091-1093
        • Bruins B.
        • Fine H.F.
        • Moorthy L.N.
        • et al.
        Index of suspicion. Case 1: Recurrent oral ulcers in an adolescent. Case 2: visual impairment in an autistic child. Case 3: Fever and hepatosplenomegaly in an infant.
        Pediatr Rev. 2011; 32: 35-40
        • Lewis C.D.
        • Traboulsi E.I.
        • Rothner A.D.
        • Jeng B.H.
        Xerophthalmia and intracranial hypertension in an autistic child with vitamin A deficiency.
        J Pediatr Ophthalmol Strabismus. 2011; 48 Online: e1-e3
        • Lin P.
        • Fintelmann R.E.
        • Khalifa Y.M.
        • Bailony M.R.
        • Jeng B.H.
        Ocular surface disease secondary to vitamin A deficiency in the developed world: It still exists.
        Arch Ophthalmol. 2011; 129: 798-799
        • Pineles S.L.
        • Avery R.A.
        • Liu G.T.
        Vitamin B12 optic neuropathy in autism.
        Pediatrics. 2010; 126: e967-e970
        • McAbee G.N.
        • Prieto D.M.
        • Kirby J.
        • Santilli A.M.
        • Setty R.
        Permanent visual loss due to dietary vitamin A deficiency in an autistic adolescent.
        J Child Neurol. 2009; 24: 1288-1289
        • Watanabe S.
        • Yamakura S.
        • Hirano K.
        • Okumura Y.
        • Aiba H.
        A case of infantile autism with pediatric Wernicke's encephalopathy due to severe eating disorder.
        No To Hattatsu. 2009; 41: 43-46
        • Basti S.
        • Schmidt C.
        Vitamin A deficiency.
        Cornea. 2008; 27 (author reply 973): 973
        • Stewart C.
        • Latif A.
        Symptomatic nutritional rickets in a teenager with autistic spectrum disorder.
        Child Care Health Dev. 2008; 34: 276-278
        • Duggan C.P.
        • Westra S.J.
        • Rosenberg A.E.
        Case records of the Massachusetts General Hospital. Case 23-2007. A 9-year-old boy with bone pain, rash, and gingival hypertrophy.
        N Engl J Med. 2007; 357: 392-400
        • Noble J.M.
        • Mandel A.
        • Patterson M.C.
        Scurvy and rickets masked by chronic neurologic illness: Revisiting “psychologic malnutrition.
        Pediatrics. 2007; 119: e783-e790
        • Uyanik O.
        • Dogangun B.
        • Kayaalp L.
        • Korkmaz B.
        • Dervent A.
        Food faddism causing vision loss in an autistic child.
        Child Care Health Dev. 2006; 32: 601-602
        • Monks G.
        • Juracek L.
        • Weigand D.
        • Magro C.
        • Cornelison R.
        • Crowson A.N.
        A case of scurvy in an autistic boy.
        J Drugs Dermatol. 2002; 1: 67-69
        • Shetty A.K.
        • Steele R.W.
        • Silas V.
        • Dehne R.
        A boy with a limp.
        Lancet. 1998; 351: 182
        • Steinemann T.L.
        • Christiansen S.P.
        Vitamin A deficiency and xerophthalmia in an autistic child.
        Arch Ophthalmol. 1998; 116: 392-393
        • Tomchek S.D.
        • Dunn W.
        Sensory processing in children with and without autism: A comparative study using the short sensory profile.
        Am J Occup Ther. 2007; 61: 190-200
      4. Data & statistics on autism spectrum disorder. Centers for Disease Control.
        (Updated September 25, 2020. Accessed May 12, 2020)
        • Loomes R.
        • Hull L.
        • Mandy W.P.L.
        What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis.
        J Am Acad Child Adolesc Psychiatry. 2017; 56: 466-474
        • Vitamin C.
        Fact sheet for health professionals. National Institutes of Health.
        (Updated 2020. Accessed May 12, 2020)
        • Clifford J.
        • Kozil A.
        Fat-soluble vitamins: A, D, E, and K – 9.315. Colorado State University Extension.
        (Published September 2017. Accessed May 12, 2020)
        • Bryant-Waugh R.
        • Lask B.
        Eating disorders in children.
        J Child Psychol Psychiatry. 1995; 36: 191-202
        • Keown K.
        • Bothwell J.
        • Jain S.
        Nutritional implications of selective eating in a child with autism spectrum disorder.
        BMJ Case Rep. 2014; bcr2013202581
        • Shmaya Y.
        • Eilat-Adar S.
        • Leitner Y.
        • Reif S.
        • Gabis L.
        Nutritional deficiencies and overweight prevalence among children with autism spectrum disorder.
        Res Dev Disabil. 2015; 38: 1-6
        • Secker D.J.
        • Jeejeebhoy K.N.
        How to perform subjective global nutritional assessment in children.
        J Acad Nutr Diet. 2012; 112: 424-431.e6
        • Pierce K.
        • Gazestani V.H.
        • Bacon E.
        • et al.
        Evaluation of the diagnostic stability of the early autism spectrum disorder phenotype in the general population starting at 12 months.
        JAMA Pediatr. 2019; 173: 578-587
      5. Data & statistics on autism spectrum disorder. Centers for Disease Control and Prevention.
        (Updated April 5, 2019. Accessed April 29, 2019)
        • Sharp W.G.
        • Volkert V.M.
        • Scahill L.
        • McCracken C.E.
        • McElhanon B.
        A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: How standard is the standard of care?.
        J Pediatr. 2017; 181: 116-124.e4

      Biography

      S. Yule is an independent researcher, Summer Yule Nutrition, Avon, CT.

      Biography

      J. Wanik is an assistant professor in residence, dietetics program, University of Connecticut, Storrs, CT.

      Biography

      E. M. Holm is a registered dietitian and nutritionist, Holm Nutrition Counseling, Alexandria, VA.

      Biography

      M. B. Bruder is a professor, pediatrics, child and family studies, University of Connecticut Health Center, Farmington, CT.

      Biography

      E. Shanley is a dietetics director, Department of Allied Health Sciences, University of Connecticut, Storrs, CT.

      Biography

      C. Q. Sherman is an educator, and therapist (licensed graduate professional counselor), St Coletta of Greater Washington Public Charter School, Washington, DC.

      Biography

      M. Fitterman is a dietetics intern, Department of Allied Health Sciences, University of Connecticut, Storrs, CT.

      Biography

      J. Lerner is a dietetics intern, Department of Allied Health Sciences, University of Connecticut, Storrs, CT.

      Biography

      M. Marcello is a dietetics intern, Department of Allied Health Sciences, University of Connecticut, Storrs, CT.

      Biography

      N. Parenchuck is a dietetics intern, Department of Allied Health Sciences, University of Connecticut, Storrs, CT.

      Biography

      C. Roman-White is a dietetics intern, Department of Allied Health Sciences, University of Connecticut, Storrs, CT.

      Biography

      M. Ziff is a dietetics intern, Department of Allied Health Sciences, University of Connecticut, Storrs, CT.