April/May 2022 Issue

CPE Monthly: Working With Clients Who Follow a Kosher Diet
By Yaffi Lvova, RD
Today’s Dietitian
Vol. 24, No. 4, P. 48

Suggested CDR Performance Indicators: 1.7.4, 2.1.3, 2.3.2, 9.4.5
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

Judaism can be defined simultaneously as a faith, a culture, a religion, and a heritage, encompassing a variety of geographical locations, multiple languages, and different cuisine styles. It can be challenging to fully grasp the needs of Jewish clients if RDs have only a basic understanding of the most common backgrounds and traditions.

Recently, there has been a notable push to recognize underserved populations in the United States and shift counseling techniques to create space for—and representation of—many of them living in the country.1 Five million to 6 million Jews live in the United States, comprising about 2% of the US population.2

Jewish observance often can seem to come into conflict with medical advice. It’s essential that health care workers understand the basics of the intersection of medicine, faith, and culture. With this knowledge, they can approach clients or patients with curiosity and compassion to help them meet their health goals and needs. By creating awareness and pursuing regular cultural education, RDs can best prepare themselves to work with clients of differing religions and cultural backgrounds.

Furthermore, it’s essential to use interviewing techniques that enable patients to lead the conversation. By listening to patients and encouraging them to participate in the process, dietitians can best learn the needs of individuals and encourage them to adopt more healthful behaviors while honoring their religious and cultural connections.

This continuing education course examines how Jewish religious dietary practices impact food choices, relationships with food, connections within the community, and nutrition status. It also considers cultural and social aspects of these dietary practices and the role of dietitians in making recommendations while honoring the culture and faith of clients.

Ancient Rules in a Modern World
Around the globe, people maintain rules initially established in ancient times, many having to do with religion and religious practice. Individuals may have their own reasons for following rules that are thousands of years old. H.L. Mencken, a journalist and cultural critic, explains that religious devotion is a major reason ancient rules remain culturally relevant.3 According to Jewish tradition, the Torah with its 613 commandments was given to Moses at Mt. Sinai 3,333 years ago in the year 1312 BCE (The designations BCE, or “before common era,” and CE, or “common era” are preferable to the designations BC—“before Christ” and AD—anno domini, or “in the year of our lord,” which operate from a decidedly Christian perspective).4 While these rules seem outdated or lacking relevance to some, there are reasons for holding them close. Some postulate that people of faith simply take on the faith of the surrounding culture, while more recent research into the cognitive science of religion supports the idea that humans are born with innate cognitive faculties that leave people prone to believe in the unbelievable.5

People may choose faith due to cultural context and upbringing, for reasons of societal or ancestral connection, or to instill more meaning in everyday objects and actions. Faith is central to the lives of the 84% of people worldwide who profess to believe in one form of spirituality or another.6 According to Mercier and colleagues, the reasons someone might choose faith include cognitive-related factors such as intelligence, loneliness, mortality, and control; socialization factors such as the religious behavior of the surrounding community; and more complex factors, including evolved cognitive biases such as perception of the divine, mind-body dualism, and cultural evolution.7

Variations of Kosher Observance in Jewish Culture
Observant Jewish clients seeking nutrition services will have many considerations related to kashrus or kashrut, the act of and specifics pertaining to keeping kosher. The difference between the two words indicates Ashkenazic vs Sephardic pronunciation, respectively. Ashkenazic Jews honor heritage from Eastern European countries whereas Sephardic Jews celebrate Western European heritage. The word “Sephard” comes from the Hebrew for Spain, but when Jews and Muslims were forcibly evicted from Spain and Spanish-controlled geographical areas, they moved across the globe, from Turkey to Israel and North Africa, and all the way to Cuba, Mexico, and South America.8 In this article, kashrus will be used for clarity, but both pronunciations are equally correct.

Working with kosher-keeping clients, or with clients observing other religion-related dietary restrictions, can be compared with working with someone following unconventional dietary preferences. For example, when working with a vegetarian, a dietitian may inquire whether they include eggs, milk, or fish to better assess the type of vegetarian diet they follow. When a client reports keeping kosher observance, an appropriate response may be, “Can you tell me about what that means to you?” or “How can I help support you?” For some people, that might mean they go out to secular restaurants and order foods that aren’t obviously in contrast with religious law. For others, it means eating exclusively at kosher restaurants and checking all packaged food for any of the hundreds of kosher labeling certification symbols, called hekschers, included on the packaging.

The Basics
Kosher, in its strictest definition, applies only to food. Colloquially, people use the same word to describe nonfood items, or even a person’s actions, but kosher laws formally apply to food. There are exceptions to the rules of kashrus, particularly concerning medications, baby formulas, tube-feeding formulas, or any instances when human life is potentially at risk.

The basic laws of kashrus include the following:
• Meat and dairy are neither cooked nor consumed together.
• Land mammals must have cloven hoofs and chew their own cud (ruminate).
• Birds must be vegetarian rather than predatory.
• Both birds and other kosher land animals must be slaughtered according to religious prescription.
• Fish must have fins and scales (for example, catfish and mature swordfish are not kosher).
• Packaged products must have appropriate certification.

The laws of kashrus are complex, but Jews are commanded to live by the rules, not die by them, with some notable exceptions. Exceptions to that concept is threefold: If someone were to try to force a Jew to commit adultery, worship an idol, or commit murder, that person is instructed to choose death instead. While Leviticus 18:5 instructs the Jewish people to live by the commandments, an expanded explanation can be found in the Babylonian Talmud, a record of rabbinical discussions pertaining to Jewish law that was written over hundreds of years and compiled around 500 CE. This is one of the primary religious texts used by Rabbinic Judaism. Tractate (section) Yoma 85b reads: “a person shall live by the commandments and not die by them.”9 The commandments exist for the living, and with very few exceptions, should not be followed when it may cause death. For example, if a medication isn’t kosher, but it’s the best for the patient, it’s not only acceptable but also necessary for that patient to have that medication. Avoiding the medication wouldn’t be kosher. Personal exemptions often are made by a rabbi (primary Jewish religious leader) for the elderly, pregnant and nursing, and those with other medical needs.

The American Academy of Pediatrics recommends hydrolyzed baby formula for atopic dermatitis, asthma, and food allergies, which may affect up to one-third of children.10,11 Specialty baby formula and tube feeding formulas may not always be kosher certified, but they’re considered kosher and acceptable if that’s the only or best option.

Before assuming that something is forbidden, clients should confer with their rabbi, who can determine whether a particular product, food, or action is appropriate in their specific circumstances. As with any medical conversation, this counseling requires input from various professionals due to the intricate nature of the human body. In the case of the kosher client, this team comprises the client, physician, and a dietitian familiar with the Jewish community. The client may place several calls to their rabbi for clarification on the finer points of kashrus as it relates to their medical status and needs.

The Torah is the primary Jewish religious text. The five books comprising the Torah were given to Moses at Mt. Sinai after the Jewish exodus from Egyptian slavery. While all Jewish sects around the world honor the Torah in its original Hebrew, there may be distinct differences regarding how the details of kashrus are understood and practiced. In each sect, and even within sects, there are differences in how kashrus is observed. For example, milk and meat aren’t mixed due to a prohibition in Leviticus, the third book of the Torah. Many Jews wait six hours after consuming meat to consume dairy, while others wait five hours, four hours, or even less time. While eating foods labeled with certain hekschers is acceptable for one person, it may not be appropriate for another. Much of this comes down to different traditions in various geographical locations, family customs, local community practices, or personal choices.

Many Orthodox communities are stringent with their observance of kashrus. Due to the prohibition of consumption of most insects, produce must be washed and inspected carefully. While many simply wash or soak and look over their produce, other communities eliminate entire groups of food for fear of hidden insects. One family may soak fresh broccoli in salt water for 30 minutes before cooking or eating raw, but others eliminate fresh broccoli entirely from the diet unless it’s grown hydroponically and is certified kosher. Eating a forbidden insect could transgress up to six Torah prohibitions, so it’s carefully avoided.12

Is Kosher Food More Healthful?
There’s a common perception that kosher food has a better nutrient profile and follows stricter sanitary precautions. In fact, according to a 2019 study by Jeong and Jang, a kosher indication on a restaurant menu positively affects consumers’ impression of the nutritional value of that meal.13 Lunch in a kosher home may be shakshuka (eggs poached in a rich tomato-bell pepper sauce), pita, and hummus, or it may be soda, Biseli (a packaged chip-type snack), and an ice cream bar. Both are representative of common kosher choices, but each represents a much different nutritional profile.

The most common reason Americans buy kosher-certified products is the impression that the kosher certification represents a higher quality of food, a thought held by 62% of those interviewed, according to the Mintel Global New Products Database.14 That study found that 51% of people who choose to buy kosher do so because of the idea that it’s more healthful. Only 14% select kosher foods due to Jewish dietary laws, and another 10% purchase them because of similar dietary restrictions in other religions.15

Just as people following any dietary pattern can adhere to a more balanced or unbalanced pattern, keeping kosher has a variety of dietary options. Someone keeping kosher may choose to consume all processed foods or all whole foods or follow a dietary pattern somewhere in the middle. Therefore, it’s impossible to make a blanket statement about the healthfulness of kosher food in general. The kosher diet helps adherents manage food choices as well as combinations of food, but it’s possible to simultaneously follow another common eating style, such as vegan, Paleo, or Mediterranean. People living in an area with a large Jewish community will have access to a greater range of certified kosher products, while others living in a smaller community setting likely will use more fresh ingredients, as they have less access to restaurants and certain packaged products. If individuals are traveling and have no access to a kitchen, they likely will rely more on packaged foods than unpackaged foods since they’re unable to prepare their own meals.

Many clients may need access to convenient meal options, but dietitians may be hesitant to encourage them to order all of their food from restaurants due to the increased calories, fat, saturated fat, and sugar along with decreased milk consumption for children.16 Furthermore, studies show that only 35% to 40% of packaged foods found in the average American supermarket are certified kosher.17 By keeping simple recipes on hand while being familiar with some common staple ingredients, RDs can be prepared to make suggestions for clients who require easier-to-prepare meals. Kosher.com offers modern and trendy kosher recipes. A much-loved cookbook in the Chabad community is Spice and Spirit, which has many of the standard Ashkenazi favorites. Cookbooks and blogs from those representing the Mizrahi and Sephardic communities offer flavorful and vibrant dishes; Candice Walker @proportionalplate and Sharon Gomperts and Rachel Emquies Sheff @sephardicspicegirls display simple and beautiful recipes. Nutrition professionals also may want to consider doing supermarket tours or cooking demos with clients.

Kosher Symbols
A company meets kosher regulatory goals by using only kosher-certified ingredients and by using equipment that doesn’t pose a cross-contamination issue for either spiritual or physical reasons. Food is broken into three categories: meat, dairy, and parve (neither meat nor dairy, but this category includes eggs and fish). Meat can’t be processed on dairy equipment (and the reverse), and food coloring can’t come from nonkosher ingredients such as carmine, a food coloring derived from a type of red beetle.18

When companies want to pursue kosher certification, they choose a certifying agency, their facility is inspected, and any changes to the equipment or recipes must be made before they can display the trademarked kosher symbol. A specially trained rabbi, called a mashgiach, inspects the food and premises on a regular basis to ensure the kosher status of the food.

The “Big Five” kosher certification agencies certify 80% of kosher food sold in the United States.19 These agencies are Orthodox Union, OK Kosher Certification, KOF-K, Star-K, and Chicago Rabbinical Council. The accompanying sidebar also includes Kosher Supervision of America.

The Chicago Rabbinical Council (crcweb.org/agencies.pdf) is one of the most reputable hekschers in the United States, out of more than 1,400. When perusing this list, note that the symbol that certifies a certain famous hot dog isn’t present. The symbol displayed on that hot dog package isn’t respected in many religiously observant households. This is one example of how some people may respect one hekscher and not others. This happens due to differing styles of religious observance, who funds and staffs the kosher certification agency, and any past noncompliance or health and safety issues a company has had.

A food item doesn’t become kosher by a rabbi’s blessing. In truth, kosher certification is complex. Many of the kosher symbols found on a package aren’t at a standard the average Orthodox Jew will accept, but this can differ from one community to the next. To serve clients and patients best, when suggesting specific products or nutritional supplements, dietitians should engage in a conversation about acceptable hekschers specific to that client’s religious observance.

The presence of a trademarked kosher symbol means the food has been inspected and certified by a third party. However, many products display a simple letter “K.” Since letters of the alphabet can’t be trademarked, this indication doesn’t mean anything to much of the Jewish community. In this instance, the company has decided the product is kosher but has elected to not hire a third party to certify its products. A certain gelatin dessert company hires OU to certify its pudding, while many of that company’s other products are marked with a simple K, which is unacceptable for much of the kosher-keeping community.

There are products with “kosher” or “Jewish” in the name that aren’t certified kosher. One bread company’s “Jewish rye” is now recently kosher after many years of bearing the word Jewish while being inaccessible to kosher-keeping Jews. “Kosher dill” pickles aren’t always kosher; they must have a hekscher to be deemed acceptable. Pure salt is always kosher, but salt with additives or flavorings requires a hekscher. Kosher salt gets its name from its role in the kashering process; a grain of kosher salt has a pyramid structure, helping to draw out the blood from raw meat, an essential step in kosher meat production.

Nutritional Concerns for Clients Who Follow a Kosher Diet
There are limited broad health effects associated with Judaism in general or engagement with a kosher diet specifically. This is likely because kashrus eliminates specific foods rather than entire food groups. A person following a kosher diet won’t eat pork but can have beef, chicken, fish, and other sources of animal protein. Dairy isn’t consumed immediately after meat but isn’t forbidden outright. All food groups are permitted, and therefore establishing a variety of nutrient intake isn’t as challenging as in other more restrictive eating styles.

Eating Disorders
It’s essential to be able to recognize the symptoms of an eating disorder while working with nearly any population. Clients can use the pursuit of purity to cover up disordered eating patterns or an outright eating disorder. Some dietitians familiar with the kosher community and its respective needs have expressed concern that an eating disorder, or disordered food-related thoughts, can be hidden under an effort to attain spiritual purity. What appears on the surface as someone who’s careful about checking produce for insects or has a very high standard regarding acceptable hekschers may be using religious rules to justify a disordered relationship with food. A person also can devote much time and energy following the many dietary rules outlined by Maimonides, a 12th- and 13th-century Sephardic doctor and philosopher also known as Rambam. Although Maimonides practiced in the Middle Ages, his works in both medicine and the Torah remain highly regarded. He promised that anyone who follows all of his medical and nutritional directives will lead a long, healthful life.20

While some modern research has found that many of these ancient guidelines instructed by Maimonides hold true with current nutrition advice, it’s also possible that given the complex and comprehensive nature of the dietary rules Maimonides endorses, individuals seeking to follow them strictly also may find themselves at nutritional risk, both from nutrition obsession and a lack of certain micronutrients and/or overall inadequate caloric intake.21

Chronic Disease
There’s a favorable link between a religious lifestyle in general and CVD risk. This has been attributed to the many ways a religious lifestyle can provide social support and connection. Support and connection can enhance the qualities of humility, gratitude, and other factors that may lead to improved self-perspective and result in positive life choices, ultimately impacting physical health.22 If the support that a religious community provides can increase positive health outcomes, the reverse also can be true.

Incidence of celiac disease in the United States is about 0.6% to 0.8%, with an additional 1.7% of the population avoiding gluten for undiagnosed reasons.23 Five percent of Americans follow a vegetarian diet, with an additional 1.4% to 2% being strictly vegan.24 Both challah (ritually important braided bread) and meat are required to be part of a festive meal in order for the meal to be considered a celebration. There certainly are many Jews who are vegetarian or vegan or eat gluten-free foods. But it’s important to note that these eating styles may be associated with feelings of separation for some people in the community, which would potentially offset the positive health effects this particular connection offers religious participants.

According to the Centers for Disease Control and Prevention, 34.2 million Americans—10.5% of the population—have diabetes.25 Because diabetes is a metabolic disease involving multiple organs, it can impact a person’s ability to fast for religious reasons. Dehydration, altered blood glucose levels, and diabetic ketoacidosis all are concerns for the fasting individual with diabetes. In addition, fasting can impact the microbiome; cause hormonal shifts, such as in adiponectin, leptin, and testosterone; and alter the circadian rhythm.26 This may mean that someone with diabetes who’s observing a fasting day, such as Yom Kippur or Tisha B’Av, may find themselves in the position of taking a break from lengthy synagogue services to find a private spot to nourish themselves. This calls into question how the act of isolating to eat while also missing out on religious services may impact a person’s relationship with food, their community, and religion in general, and how that breach of connection may impact their physical health. The dietitian’s job may include helping clients navigate these practical obstacles and associated emotions. RDs can do this by using the same gentle, curious, and compassionate approach they use with all clients as a way to establish rapport and present themselves as a safe space.

Religious Holidays
Jews associate holidays with food, either eating it in celebration or avoiding it on fasting days, and every holiday involves traditional dishes for the celebration. Whether it’s the cheesecake on Shavuot (the celebration of receiving the Torah), the intense dietary restrictions associated with Pesach (Passover), or the festival of Chanukah, complete with its fried sufganiyot (jelly-filled donuts) and latkes (fried potato pancakes), food is part of the tradition. Those operating kosher kitchens at home often find themselves preparing large festive meals days in advance—a plan that includes two meals per day for the length of the holiday, often two or three days in a row. Even on Yom Kippur, a 25-hour fast with no water or food, the Break-Fast at the end of the day is a main attraction. While all this preparation and focus on food can be overwhelming to the average person, if someone has a medical status that requires nutritional management, these traditions may present an insurmountable challenge. By helping clients with meal planning techniques while accounting for their kosher and holiday-specific needs, medical needs, and cooking interest and ability, dietitians can help these clients prepare for the upcoming holiday.

Genetic Risk Factors
While common chronic diseases aren’t necessarily more prevalent in the Jewish community, inborn errors of metabolism make an appearance more often than in the general public, many with nutritional implications. The Ashkenazi Panel is a group of blood tests that isolates inborn errors of metabolism common to Eastern European Jews. The increased genetic risk factors seen in this population appear to be associated with a history of migrations, repeated catastrophic population reductions, and repopulation from a small number of survivors over many centuries.27 While the Ashkenazi Panel is better known, in recent years, Jewish genetic screening companies such as Dor Yeshorim have begun to offer Sephardic/Mizrahi genetic screening panels aimed specifically at North African, Persian, and Middle Eastern Jews, among whom there has been an uptick in incidences of Jewish genetic diseases.28

Gaining Cultural Knowledge
Ethnic inequities are present in access to health care and thus health outcomes between underrepresented communities and majority individuals. Dietitians can seek opportunities for expanding their cultural knowledge through webinars and articles, by participating in community events, and by allowing those who live a specific culture to provide education based on their own experiences. Commission on Dietetic Registration Performance Indicators to consider include the following:

• “1.4 Respects client autonomy to make decisions about proposed services;
• 2.1 Adapts communication methods and skills to meet the needs of audiences;
• 9.2 Establishes, develops, and implements program outlines and learning plans to meet the needs of various individuals, groups, and populations;
• 9.3 Designs, selects, and implements education strategies to meet the learning needs of the individual, group, community, and population;
• 9.4 Provides nutrition and dietetic education to a variety of individuals, groups, and populations; and
• 12.3 Designs and develops community and population health programs, interventions, or initiatives to meet the needs of communities and/or populations.”

There has been an increasing concern about whitewashing in health access and information concerning nutrition and other allied health professions. Whitewashing is the act of altering information in a way that favors, highlights, or addresses only those who are racially white.29 This can manifest as a lack of professional attention to personal and cultural experiences, ignoring historical inequities and their impact on medical status, typically involving limited access to health care and resulting in poor health outcomes for underserved groups.30,31

The comment “You have too many holidays to have health goals,” is from a real-life conversation between a health care professional and a Jewish client, illustrating how a health care professional might introduce guilt into a conversation on religion and health. This statement is in opposition to the collaborative, empathetic, and understanding route that a practitioner educated in motivational interviewing—taking a humble perspective while asking the client open-ended questions—might take.31

Cultural humility is a lifelong journey. It requires a commitment to self-evaluation and critique, attempting to address cultural power imbalances and encourage more positive partnerships between patient and physician while developing relationships with communities and defined populations.32 Due to efforts in health care reform, the National Academy of Medicine is pushing toward a health care path that’s high quality, efficient, patient centered, and equitable, using evidence-based approaches to address the ethnic and racial inequities present in the US health care system. By seeing and addressing these inequities, quality, ethical, and comprehensive health care can be achieved.33

It’s essential that clients see themselves represented in the medical advice given. While professionals may not be able to create handouts and other educational materials specific to each person, having a variety of culinary traditions and cultural preferences represented will put RDs in a position to relate more effectively to clients.

Motivational Interviewing Techniques
The lifestyle associated with observant Judaism can be intricate. The number of Jewish sects and different cultural traditions within Judaism, when combined with the various individual relationships with religious observance, can be challenging for non-Jewish professionals, or those who didn’t grow up with these beliefs and traditions, to fully understand. To best support their clients, dietitians should establish a basic working knowledge of the client’s culture and address the client from a place of curiosity and compassion. Due to the nuanced nature of religious practices, it may be difficult to determine whether an attitude or behavior stems from religious vs disordered eating thinking. In these instances, it’s best to consult with a dietitian who has expertise working within the Jewish community. One might seek out names in the religion-focused member interest groups of the Academy of Nutrition and Dietetics or in dietitian-focused groups on social media.

By using open-ended questions common to motivational interviewing, dietitians can support clients in their health goals while honoring their culture and faith. True motivational interviewing is a gentle path whereby the practitioner gingerly directs the client toward change. Here, the goal is to use a few open-ended words to kindly draw personal experience and values out of the client. Then, counseling can be based on, and tailored to, the individual.

By using responsive interviewing techniques such as motivational interviewing, dietitians can position themselves to learn from their clients and use that information to cater nutrition education to clients’ specific health concerns and cultural requirements. By stepping back and asking guiding questions, then listening and responding appropriately, both nutrition professionals and clients can experience positive communication, increased confidence and motivation, better health outcomes, and more efficient disease prevention.

Putting It Into Practice
Clients and patients may be connected to any one of the multitude of cultures and faiths living in the United States. They may be following ancient traditions that tie them to a greater whole, both past and present. The lifestyles associated with many faiths may put some clients in a position of being misunderstood or misrepresented in greater American culture. Trauma-informed care guides nutrition professionals to consider the individual’s background to ask what happened to this person rather than what’s wrong with this person.36

By honoring an individual’s expertise and autonomy, as well as using empowerment and strength-based approaches, dietitians can best serve their clients’ physical, mental, and emotional needs. In promoting nutritional and spiritual community, as well as mental health, dietitians are uniquely positioned to enhance the well-being of clients who follow a kosher diet—both in the office and beyond.

— Yaffi Lvova, RD, is a dietitian and mom of twins plus one. Lvova provides family nutrition education through Nap Time Nutrition—her weekly live video blog and podcast (naptimenutrition.com)—and Toddler Test Kitchen, a unique cooking class for kids aged 2 to 6. She has written numerous books on infant feeding and feeding the neurodiverse child. Lvova also holds a degree in comparative religions.

Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Distinguish what kosher means and assess how it can impact health and food choices.
2. Provide nutrition advice to religious clients while honoring their faith and culture.
3. Describe why religious dietary restrictions are valuable to clients and how to support them while remaining culturally sensitive.

CPE Monthly Examination

1. Why is cultural humility essential for RDs?
a. It better prepares RDs for counseling sessions with clients of a certain background.
b. It helps streamline the assessment process so the most information can be provided to patients.
c. Insurance companies require it for payment and reimbursement.
d. It helps RDs to advise clients while respecting cultural differences.

2. Which of the following is not a reason people maintain ties to religion, according to Mercier and colleagues?
a. Intelligence
b. Analytical thinking
c. Culinary appreciation
d. Socialization

3. Which of the following is true about a kosher diet?
a. It’s more healthful than a nonkosher diet.
b. Public perception is that it’s more healthful than a nonkosher diet.
c. It’s less healthful than a nonkosher diet.
d. Public perception is that it’s not as healthful as a nonkosher diet.

4. Who determines whether a packaged food is kosher?
a. The consumer
b. A third-party company or organization employing rabbis
c. The supermarket selling the item
d. The FDA

5. To avoid whitewashing, health professionals should do which of the following?
a. Have a set of standard handouts to give to every client.
b. Examine research for inclusivity.
c. Be sure to have coping strategies.
d. Confer with a local rabbi while preparing for a new Jewish client.

6. If a medically necessary specialty baby formula doesn’t carry a reliable hekscher (kosher symbol), is it approved for use in a kosher family?
a. Yes, it’s considered medication and is acceptable for use.
b. No, it’s food and must be appropriately certified.
c. Yes, but not during Passover.
d. Only if it comes from Israel.

7. Which of the following is not a benefit of motivational interviewing?
a. Clients and patients may be more receptive moving forward.
b. The dietitian can get to know the patient on a more personal level.
c. The dietitian can get their questions answered quickly and efficiently.
d. The way is paved for internal change on the client’s part.

8. Why might a kosher-keeping client avoid strawberries?
a. They could contain insects and are too difficult to clean properly.
b. Red foods are forbidden.
c. They aren’t naturally grown in Israel.
d. They just ate a sandwich, and there must be a space of two hours between bread and fruit.

9. What should RDs do if they suspect their client is compromising their health and nutrition by following religious restrictions?
a. Advise the client to change their habits.
b. Describe their concerns to the client in detail.
c. Refer the client to a dietitian with a similar background.
d. Seek guidance from a local rabbi.

10. Which of the following questions could be classified as Motivational Interviewing?
a. “Can you tell me what kosher means to you?”
b. “Do you plan to raise children who keep kosher?”
c. “Do you really think keeping kosher is necessary?”
d. “Why is it important to you to keep kosher?”

References
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3. Everitt N. The Believing Primate: Scientific, Philosophical, and Theological Reflections on the Origin of Religion, edited by Jeffrey Schloss and Michael Murray. Mind. 2010;119(475):849-852.

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9. Yoma 85b:3. Sefaria website. https://www.sefaria.org/Yoma.85b.3?lang=bi. Accessed May 5, 2021.

10. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183-191.

11. Martinez JA, Ballew MP. Infant formulas. Pediatr Rev. 2011;32(5):179-189.

12. Why does some produce require special cleaning to be fit for kosher consumption? COR website. https://cor.ca/view/682/why_does_some_produce_require_special_cleaning_to_be_fit_for_kosher_consumption.html. Accessed May 7, 2021.

13. Jeong E, Jang S. Kosher labelling in restaurants: examining the healthy halo effect. J Foodserv Bus Res. 2019;23(1):46-56.

14. 3 in 5 kosher food buyers purchase for food quality, not religion. Mintel website. https://www.mintel.com/press-centre/food-and-drink/3-in-5-kosher-food-buyers-purchase-for-food-quality-not-religion. Published February 17, 2009.

15. Della Corte V, Del Gaudio G, Sepe F. Ethical food and the kosher certification: a literature review. Br Food J. 2018;120(10):2270-2288.

16. Powell LM, Nguyen BT. Fast-food and full-service restaurant consumption among children and adolescents. JAMA Pediatr. 2013;167(1):14-20.

17. Al-Mazeedi HM, Regenstein JM, Riaz MN. The issue of undeclared ingredients in halal and kosher food production: a focus on processing aids. Compr Rev Food Sci Food Saf. 2013;12(2):228-233.

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