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NutritionforPhysiciansAssistants
PAST556:PreventativeMedicine& HealthPromotionC.BettyCrocker,MPH,[email protected]
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MyBIO
RegisteredDietitian MPH,Nutrition
LeCordonBleutrainedchef Doctoratestudent Professor:Nutrition,PublicHealth,andCulinary
Arts
ChefInstructor/Consultant PublicHealthWriter:LATimes [email protected]
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TrueNutri)onExperts
AmericanDiete)cAssocia)on(ADA www.eatright.org NowAcademyofNutri)onandDiete)cs(AND Registereddie))an(RD Cer)fieddiabeteseducator Publichealthnutri)onist Diete)ctechnician
Diete)ctechnicianregistered AmericanSocietyofNutri)on(ASN
www.nutri)on.org
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Nutritional
Assessment
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DietaryAssessment
24hourrecall 72hourrecall
Eatingpatterns Mealplans Lookingfordeficiencies Barriers:
Limitedrecalldueto______ OlderpatientsWomenvs.Men
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AnthropometricAssessment
BMI: Limitations Overestimate
bodyfatinathletes Highmuscularbuild
Underestimate Olderpersons Significantmuscleloss
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Biochemical
AssessmentofNutrition
MostsensitiveisPrealbumin:half-lifeis2days albumin:halflife~20days PABimprovednutritionincrease10mg/L/d
Inadequatenutritionalsupport Poorresponse Poorprognosis
LowPABindicates Proteinenergymalnutrition Inflammation+malnutrition
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Biochemical
AssessmentofNutrition Insulinlifegrowthfactor1(IGF1)
VerysensitivemarkerAssociatedwithincreasedmorbidityAssociatedwithproteinintake
Nosinglemarkerisevidenceofoverallnutritionalstatus
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OlderAdults
NutritionalScreening NutritionScreeningInitiative Projectof
AmericanAcademyofFamilyPhysiciansAcademyofDieteticsandNutritionNationalCouncilofAging
DetermineYourNutritionHealthchecklist
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D-E-T-E-R-M-I-N-EChecklisttohelpolderadultsIDsymptomsofNutritionalProblems
Table7.21. Disease:confusion,memoryloss,depression2. Eatingpoorly:toolittle/much,samepattern,
skipmeals
3. Toothloss/mouthpain4. EconomicHardship5. ReducedSocialContact:livingalone
6. MultipleMedicines:nausea,diarrhea7. InvoluntaryWeightLoss/Gain
8. Needsassistanceinself-care:eat,cooking,shopping
9. Above80years
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DoesNOTutilizeobjectivemeasurements BiochemicalAnthropometrics
DOESprovideScreeningtoolRequiresclinicaljudgment
InterpretinformationCollectedbyinterviews&observationsCorrelatedwellwithobjectivemeasurements
SubjectiveGlobalAssessmentTable7.3
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Table7.3
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NutritionCounseling
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DIET:foodsyouNORMALLYeatanddrink Cho0sewholefoods 3MacronutrientStrategies
Putfiberbehindyourcarbohydrates(CHO) LeanProtein(PRO) ChooseHealthyFat(Lipids)
MyPlateStrategiesplatefruits/veggrainswholegrainsLeanprotein
NutritionalCounselingHealthyMealPlanObjective
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MyPyramidisnow
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MyPlate
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ChooseMyPlateMenu
Balancingcalories
Enjoyyourfood,buteatless
Avoidoversizedpor)ons
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Another
namefor
nutrient-
densefoodsis
nutrient-
richfoods
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Nutrient-densevs.
notnutrient-dense
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Nutrient-densevs.
notnutrient-dense
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Nutrient-densevs.
notnutrient-dense
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Whole 2% 1% Fat-free
165calories
125calories
100calories
85calories
Calories
saved40 65 80
Switchingtofat-freeorlow-fat(1%
milkmakesadifference!
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MeettheNutrients
Energy-yieldingnutrients Carbohydrates4cal/g Fats9cal/g Proteins4cal/g Alcohol7cal/g
Vitaminsandminerals Providenoenergy Someareessen)al
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CalculateDAILY
CaloricNeeds
SexandAge NotPhysicallyAc8ve
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HowMuchDoINeedFromEach
FoodGroup?
Calorie
Level1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200
Grains 5 ounces6 ounces 6 ounces 7 ounces 8 ounces 9 ounces 10 ounces10 ounces10 ounces
Vegetables2 cups 2.5 cups 2.5 cups 3 cups 3 cups 3.5 cups 3.5 cups 4 cups 4cups
Fruits 1.5 cups1.5 cups 2 cups 2 cups 2 cups 2 cups 2.5 cups 2.5 cups 2.5 cups
Dairy 3 cups 3 cups 3 cups 3 cups 3 cups 3 cups 3 cups 3 cups 3 cups
Protein
Foods5 ounces5 ounces 5.5 ounces6 ounces 6.5 ounces6.5 ounces7 ounces 7 ounces 7 ounces
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CO
UNTINGBY
HAND
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MACRONUTRIENTSCARBOHYDRATES(CHOFAT(LIPIDSPROTEIN(PRO
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CARBOHYDRATES
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AMDRAcceptable Macronutrient Distribution Range
AMDR Recommendations*:CHO: 45-65%Protein: 10-35%Lipids: 20-35%
*Authored by the DRI Committee
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Basically FiberStructuralformofglucoseinplantleaves,stems,andseeds.
Cellwall=95%fiberHumandiges)veenzymescannotbreakthechemicalbondsholdingthesugar
unitstogether,i.e.indiges)bleinhuman
beings.
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Basically FiberPolysaccharideManysugarunits
Heldtogetherbyindiges)blebondsPassesthroughtheGIUndigestedUnabsorbedEXCEPTION:Somefiberisusedasanenergysourceforcolonicbacteria
causesgas
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Types of FiberDietaryFiber:Nondiges)bleintactplantcomponentsTwotype:SolubleFiberInsolubleFiber
Func8onalFiber:Nondiges)bleCHOthathavebeenextractedormanufacturedfromplants
Bothhavebeneficialphysiologicfunc)ons
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Doesntdissolveinwater
InsolublefiberpassesthroughtheGIalmostintact
Addsbulktostool
Actsasaspongetoabsorbwater
Aidsindiges8on&elimina8on
Reducescons8pa8on
IncreasesGItransit8me
Tough,fibrouspartofplants
Calledroughage Example=cellulose
StringsofceleryKernelsofcornBranlayerofwholewheatkernel
Insoluble Fiber
Sources:wheatbran,wholegrains,manyvegetablesandskinsoffruit
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Dissolvesinwater AZractswater&formsgelinGI(viscous) Slowsdiges8on
Slowsgastricemptying(stomach)PromotesfullnessSlowsbloodglucoseabsorp8on
Givesagummyorgel-likecharacteris8ctofood
Bindstocholesterolforelimina8on(lowersLDL)
Soluble Fiber
Sources:oats,soy,legumes,nuts,bananas,apples,orangescelery,cucumbers
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Addedtofood Extracted,isolatedor
manufacturedfromplants
Containbothsoluble&insolublefiber
Takesonsamephysiologicalbenefitsassolubleinsoluble
PassesthroughGI,nondigestable
Functional Fiber
Sources:availablethroughoutthefoodsupplyandincludedinthelistofingredientsandfibercontent.Nolabelingrequiredfunc8onalfiber.
hZp://www.aaccnet.org/
news/pdfs/DFreport.pdf
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Wherethereis
SOLUBLE.thereisalso
INSOLUBLE.Theygohandinhandinnature
Fig. 4-5, p. 115
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39s
Calorie values generally reflect industry practices
of calculating calories from 4-4-9 kcal/g for protein,
carbohydrate, and fat, respectively or from 4-4-9
kcal/g for protein, carbohydrate minus fiber, andfat. The latter method is frequently used for high-fiber foods.!
Notice that this presents an opportunity for
inconsistency in labeling among different food
products and companies. Some food items mayinclude the dietary fiber in the calculation of total
calories; others may not."
NLEANational Labeling & Education Act 1990
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ReducesCalorieconsump8onThinknutrientdenseDisplacesCalorie-densefats&sweets
PromotesafeelingoffullnessSlowsmovementoffoodfromthestomachtothesmallintes8neReducebloodglucosePostprandial(aerea8ng)
ContributesnoCalories
Benefits of Fiber
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PREVENTS:Cons8pa8onImpactedStool:hard,drybowelmovements
CanbepainfulPREVENTS:Straining
Difficulttopassimpactedstool
Mayresultinvaricoseveinsinrectum&hemorrhoids
Prevents:Hemorrhoidspainful,swollenveinsinthelowerpor8onofthe
rectumoranusPromotes:RegularityKeepsintes8nalcontents
moist
Easeselimina8onBulktriggersurgeto
defecate
Colonic Benefits of Fiber
HappyColon=HealthyColon:
Chroniccons3pa3onisassociatedwitha2xincreaseintherisk
ofcoloncancer.
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Happy Colon = Healthy ColonYes, these are GI cookies
PATIENT READY
FANTASTIC STOOL:If LOVING you is WRONG, I dont want to be RIGHT!
8 glasses water daily
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Preventsbacterial
infec)onofthe
appendix
Colonic Benefits of Fiber
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KeepsGImuscleshealthy&toned
PreventsDiver3culosisOncediagnosed,highfiberdiet
paramounttoensurethesmooth
passageoffecalmaterial
Abnormalpocketsinthecolonwall
Causedbyweakeningofmusclessurroundingthecolon
PreventboutsofDiver3culi3sInflamma)onofdiver)culum
Lowfiberdietrequiredduringinflamma)on
Colonic Benefits of Fiber
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Slowsdiges)on/absorp)onofotherCHOSlowstheflowofglucoseintoblood Especiallygoodfordiabe)cs
Reducesriskofcardiovasculardisease(CVD
LowersbloodcholesterolFiberbindscholesterolinbilethatisexcretedfromtheliver
Overall Health Benefits of Fiber
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DRI:DietaryReferenceIntakeMen19-50:38g/dayWomen19-50:25g/day
Fiberintakeshouldbeincreasedgraduallybecauseitmaycausebloa)ngorgas
Thesesideeffectsdisappearwithin2-3weeks
FiberintakerecommendedfromFOODAdequatefluidintakewithhighfiberdiet:
8-8ozglasseswater/day
Fiber Recommendations
RecallDVonlabelis
usedasareference.
Labelbasedon25g/d
Fib S l t b
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MineraldeficienciesCanbindminerals&PreventAbsorp8oniron,zinc,andcalcium
Dehydra8onMalnutri8on Canreduceenergyintake
Bowelimpac8ons
Fiber Supplements can be
HARMFUL
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Examples of Fiber in
Foods
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51Fig. 4-15a, p. 126
PUNCHLINE:FIBERFOUNDINPLANTS
ONLY
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Fats
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TheBadFats
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SaturatedFats
Maximumnumberofhydrogenatoms
Nopointofsaturation(doublebondsbetweencarbon)
Triglyceridesthatcontain3saturatedfattyacids
Morestableathightemperature
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SaturatedFatsFoundsinAnimalProductssuchas:
Butter Cheese WholeMilk IceCream FattyMeats Coconut,Palm&KernelOil
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SaturatedFats
Whyaretheybad?
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SaturatedFats
HeartAttacks Strokes Atherosclerosisthenarrowingofarteries
Obesity HeartDisease CancerBreast&Colon
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SaturatedFats
CardiovascularBenefits BoneHealth OptimalLiverFunction StrongLungs HealthyBrain NerveCommunication ImmuneSystemFunction
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Transfatisanothernameforanunsaturatedfat Carriesatransisomerinthefattyacidchain. Ithasadoublecarbonbond Theyaresometimesmonounsaturatedand
polyunsaturatedbutneversaturated.
TheyareknownforraisingyourLDLlevels loweringyourHDLlevelscausingcoronaryheartdisease
TransFats
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LowFatandnonfatdietsmaynotbethehealthiestforyourbody
Takingthefatoutofyourdietoftenremovestheflavorsofthefoodyouconsume Somefoodsremovefatandaddsugarforflavor
FadDiets
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TheGoodFats
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GoodFats
Goodfatshelpfighttheverydiseasesthatconsumingexcessfatwassaidtocause.
goodfatsarebeneficialtocholesterol. Monounsaturatedfathelpstolowercholesterol. theyareagoodsourceofomega-3fattyacids(coldwater
fish,nuts,oils,seeds,darkleafygreens).
hp://www.med.umich.edu/umim/food-pyramid/fats.htm
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GoodFats
Omega-3fattyacidsisanessentialfattyacidwhichisNOTmanufacturedbyourbodies,soeatingthosefoodsistheonlywaytogetthem.
Omega-3fattyacidsarealsothoughttolowerbloodpressure,combatLDL(bad)cholesterol,fightinflammationandprotectthebrainandthenervoussystem.
hp://www.med.umich.edu/umim/food-pyramid/fats.htm
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GoodFats
Eatingmonosaturatedfatsimprovesbloodcholesterollevelswhichcandecreaseyourriskofheartdisease.
ResearchshowsalsoshowsthatMUFASmaybenefitinsulinlevelsandbloodsugarcontrolwhichishelpfultopeoplewhohavetypetwodiabetes.
Omega-3fattyacidsfoundinsometypesoffattyfish,appeartodecreaseriskofcoronaryarterydisease.
hp://www.med.umich.edu/umim/food-pyramid/fats.htm
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FLAXMEAL
NUTRITIONINFORMATIONTheGoodFat 1 Tablespoon of flax meal:
3 grams fiber 2 grams omega-3 (good fat)
Recipe: 1-2 Tablespoon/cup flour
http://www.youtube.com/watch?v=_1EbDdAeq7A
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CHIASEEDS
NUTRITIONINFORMATIONTheGoodFat 1 Tablespoon of CHIA SEED:
4 grams fiber 2.4 grams omega-3 (good fat)
Recipe: Gel: 1 cup water: 2T 2t chia seeds, mix,
store in refrigerator up to a week
http://www.youtube.com/watch?v=_L4wJ1vadUg
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Walnuts Soymilk Tofu Fattyfish(salmon,tuna,
mackerel,herring,trout,sardines)
PolyunsaturatedTheGoodFat
CornOil SoybeanOil Safflower Sunflower,Sesame,
pumpkinseedsandflaxseed
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Fat&You
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Cholesterol
bloodlevelindicatesincreasedriskofatherosclerosis
Reduceyourtotalbloodcholesterolby:1. Consuminglesssaturatedand transfat2. Consumingmorefiber3. Exercising
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LowDensityLipoproteins(LDL)
Badcholesterol Delivercholesterolfromthelivertoarteries bloodlevelsindicateincreasedriskofatherosclerosis
ReduceyourLDLby:Consuminglesssaturatedandtransfat
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HighDensityLipoproteins(HDL)
Goodcholesterol Scavengeexcesscholesterolfrom)ssuesfordisposal
bloodlevelsindicatedecreasedriskofatherosclerosis
IncreaseyourHDLby:Exercisingregularly
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RECIPESTOPROMOTEHEART
HEALTH1.REDUCESATURATEDFAT2.USEGOODFAT(OMEGA3)3. INCREASEFIBER:fruits,vegetables,and
wholegrains
4. REDUCECALORIES
GOOD/BAD EICOSINOIDS
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GOOD/BADEICOSINOIDS
PhysiologicalEvent GOODEICOSANOIDS
n-DRIVEN
BADEICOSANOIDS
n-6DRIVEN
BloodVessels Open Constrict
BloodClong Decrease Promote
HeartDisease Prevent Promote
HeartArrhythmia Decreased Increased
Pain Decreased Increased
Inflamma)on Decreased Increased
SmoothMuscle Relaxa)on Contrac)on
ImmuneFunc)on Increase Decreased
MenstrualCramps Decreased Increased
TumorCells Kill Promote
Gesta)on(Pregnancy Preventpretermbirth Promotepretermbirth
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AMDR
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AMDRAcceptable Macronutrient Distribution Range
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PROTEIN
I f PROTEIN
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AAmustbecon8nuouslyavailabletobuildPROofnew8ssuesforGROWTH&MAINTENANCE Embryo,athle8cmuscles,growingchild,newbloodcellslostinmenstrua8on,
scar8ssuetohealwounds,newhair&nails
ProteinTurnover Constantlymake&breakdownPRO
RecyclingAA Daily:25%AAareirretrievablydivertedtoother8ssuestobeusedforfuel
ImportanceofPROTEIN
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TheImportanceofPRO
2 ProvidingStructure/Movement:Muscle MUSCLEScontain40%bodyPRO MusclescanreleaseEMERGENCYAAforenergy
BuildingCompounds:enzymes&hormones ENYMES:1000sresideineverycell
Recall:enzyme=catalysttospeedupreac8ons HORMONES:messengermoleculesmadefromAA
Recall:Insulin&Glucagonforglucoseregula8on
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TheImportanceofPRO
3 BUILDINGANTIBODIES
An8bodiesarePROmadebyPRO Dis8nguishforeignPROfromtheirbodyPRO Whenintruderispresent,theyaZacktodestroy
Bacterium,virus,toxin,orpresentinfoodthatcausesallergicreac8on
Recallceliacdisease(autoimmuneresponsetogluten)Eachan8bodydesignedtodestroyspecificinvader
IMMUNITY:an8bodybuiltandsuccessful,availablefornextaZack
Differentstrainsofflurequiredifferentan8bodiesbuilt
Th I t f PRO
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TheImportanceofPRO
4 MAINTAININGFLUIDBALANCE PROregulatequalityoffluidsincompartmentsofbody Lifedependsoncellsmaintainingconstantamountoffluid
TOOMUCHrupture TOOLITTLEunabletofunc8on Recall:Watercandiffusefreelyin/outcells,PRO
Homeostasis:maintainingstoresofinternalPRO&minerals BLOODVESSELSmechanism
FluidkeptinsidebloodvesselsbyPROtoolargetomoveacrosscapillarywall
PROaZractwater&holditwithinvessels,preven8ngitfromflowingintothespacesbetweencells
WhenbloodPRO(albumin)islow:TOOmuchfluidwillbetweencellswillcollectEDEMA
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TheImportanceofPRO
5 EMERGENCYENERGYSOURCE PROwillbesurrenderedtoprovideenergyifneeded
Undercondi)onsofinadequateenergy:Starva)on,prolongedfas)ng,andseverecalorierestric)onNostorageofPROaswithCHO/LipidsPROonlypresentasac)veworkingmolecular&structural
componentofbody)ssue
OrderPROdismantledforenergy blood,musclePRO,liver&otherorgans
Goal:maintainsteadybloodglucoselevelforbrainAAbreakdown:
CarbonHydrogenOxygenusedforenergyneedsNitrogenexcretedorusedelsewhere
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PROTransportSummary WhendietsuppliesanoverabundanceofPRO:bodycannotstoreAA
ExcreteAA(aminegroupsanduseresiduefor1. Immediateenergyneeds2. Makeglucoseforstorageasglycogen3. Ormakefatforenergystorage
RECALL:
CHO=energy Lipids=concentratedenergy PRO=energy+N
W ) AA S
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Was)ngAASummary
WASTING:WhenAAnotusedtobuildPROormakeotherNitrogen-containingcompounds Whenwas8ngoccurs1. BodylacksenergyfromCHO/Lipids2. DietsuppliesMOREPROthanneeded3. BodyhasTOOmuchofanysingleAA(supplements)4. DietsuppliesPROofLOWquality(toofewessen8al
AA)
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PRO Labeling Must Include:PRO grams in bold printIncomplete PRO:
When food is for adults/children over 1 year of age :label should state "0%" in % DV columnor state "Not a significant source of protein.
Voluntary Labeling:%DV Protein
% Daily Value is not required when the food is foradults or children over 4 years of age unless a proteinclaim is made
Recall NLEANational Labeling & Education Act 1990
http://www.fda.gov/ICECI/Inspections/InspectionGuides/ucm074948.htm
RECALL: AMDR
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RECALL:AMDRAcceptable Macronutrient Distribution Range
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QUALITYAA
1. LIMITINGAA Anessen8alAAthatispresentindietaryPROinINUSUFFICIENT
amount,therebylimi8ngthebodysabilitytobuildprotein
Acuteshortage:inconsequen8alascellsresumenormalproteinac8vi8eswhenlimi8ngAAisprovidedinnextmeal(~24hours)
Chronicshortage:lackvarietyofplantbasedfoods Proteinsynthesisslows Cellsbegintobreakdownprotein-makingmachinery WastedAA:Aminegroupsexcreted,C,H,Ousedelsewhere Severecases:breakdownorgansforAA
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QUALITYAA
2 COMPLIMENTARYPRO Plant-baseddiet 2ormorePROwhoseAAassortmentscomplimenteachotherin
suchaawaythattheessen8alAAmissingformonearesuppliedby
another
AAlowinsomefoodsaresuppliedbyother Goal:toconsumeessen8alAAinsufficientamounttosupport
health
MUTUALSUPPLEMENTATION:strategyofcombing2incompletePROsourcessothattheAAinonefoodmakeupforthoselackinginthe
otherfood Example:Beans&Rice
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QUALITYAA
3 PRODiges8bility Methodtoevaluate:ProteinDiges8bilityCorrectedAminoAcidScore
(PDCAAS)
ReferenceAA=eggwhite(highbiologicalvalue) Animalbaseddietshavehighestdiges8bility
Milk(100%),Beef(92%) Plantbaseddietshaveless
Soyprotein(100%)Legumes(90-70%),Fruits(75%),vegetables(73%),cereals(59%),peanuts(52%),Grains(90-70%0
Cookingwithmoistheatimprovesdiges8bilityhttp://jn.nutrition.org/content/
130/7/1865S.full
Remember
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Remember
A variety of foods,
in moderation, canfit into a healthy
eating pattern if
nutrient needs
have been met
without exceedingcalorie limits.
Regular physical
activity helpsmaintain caloriebalance.
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Thankyou