The Albert Einstein College of Medicine

Of Yeshiva University

Nutrition and Preventive Medicine Handbook

Adapted with permission from the Nutrition and Preventive Medicine Handbook Marilyn S. Edwards, PhD, RD/LD, FACN

Associate Professor, Department of Internal Medicine University of Texas Medical School

Houston, Texas 77030

Funding for the Nutrition and Preventive Medicine Guidebook has been provided by the National Heart, Lung, and Blood Institute through the Nutrition Academic Award and through the Dr.

Robert C. Atkins Foundation

Table of Contents

Introduction ................................................................................................................... 1 1. Body Mass Index (BMI) Calculator and Norms................................................... 2 2. Body Fat Percent Norms ...................................................................................... 2

Methods for Determining Body Fat Percentage For Adults ............................. 3 3. Basic Nutrition Assessment for Adults: WAVE.................................................. 4 4. Physical Activity: USDA Guidelines for Americans, 2005 ................................. 6 5. Fluid Guidelines for Exercise............................................................................... 7

HEAT INDEX................................................................................................. 10 6. Carbohydrate Guides for Exercise .................................................................... 10 7. Nutrient Composition of Common Sports Supplements ................................. 11 8. Exercise chart with body weights and kcal expenditure ................................. 12 9. Recommended Dietary Allowances and Dietary Reference Intakes............... 13 10. Calculating Energy Requirements..................................................................... 21 11. Calculating Protein Requirements..................................................................... 21 12. NCEP Lipid Management Guidelines: National Heart, Lung, and Blood

Institute: Adult Treatment Panel III (ATP III)...................................................... 22 Risk Assessment........................................................................................... 23 Drugs that Affect Lipid Metabolism................................................................ 25 Dietary Guidelines......................................................................................... 26

13. Prevention and Treatment of HTN Guidelines (NHLBI).................................... 27 The JNC VII Guide To Prevention, Detection, Evaluation and Treatment of High Blood Pressure ..................................................................................... 27 Dietary Approaches to Stop Hypertension (DASH) diet ................................ 29 Sample DASH Diet Menus............................................................................ 30

14. Prevention and Treatment of Obesity Guidelines ............................................ 31 Classification of Overweight and Obesity by BMI, Waist Circumference and Associated Disease Risk............................................................................... 31 Determination of Absolute Risk Status Based on Overweight and Obesity Parameters.................................................................................................... 32 Treatment Algorithm...................................................................................... 33 Selecting The Treatment for Obesity............................................................. 34 Exercise recommendations for Obesity......................................................... 34 A Quick Primer For Health Professionals: Four Types Of Popular Weight Loss Diets.............................................................................................................. 36 Weight Loss Drugs........................................................................................ 46 Weight Loss Surgery..................................................................................... 47 Assessing Patients’ Motivation to Make Nutrition and Lifestyle Changes ..... 49

15. Criteria for the Diagnosis of Diabetes Mellitus and Impaired Glucose Tolerance ............................................................................................................. 52

Medical Nutrition Algorithm IFG/Type 2 Diabetes Prevention & Therapy...... 53 Pharmacological Algorithm for Type 2 Diabetes ........................................... 54 Lipids Algorithm IFG and Type 2 Diabetes.................................................... 55 Medications for People with Type 2 Diabetes ............................................... 57 Comparative Profiles of Various Types of Regular Human Insulin................ 58 Nutritional and Exercise Recommendations for People with Type 2 Diabetes...................................................................................................................... 59

Diabetes Diet Guidelines............................................................................... 60 Types and Limitations of Various Artificial Sweeteners................................. 61 Glycemic Index.............................................................................................. 62 Exercise Recommendations for Type 2 Diabetes ......................................... 65

16. Nutrition Assessment And Guidelines for Older Individuals .......................... 67 NHLBI Guidelines for Weight Reduction after Age 65................................... 68 Exercise for Older Adults............................................................................... 68 Borg Perceived Exertion Scale...................................................................... 71

17. ACS Recommendations for Nutrition and Physical Activity for Cancer Prevention............................................................................................................ 72

18. Osteoporosis Prevention and Treatment Guidelines....................................... 72 19. Diet and Dental Health ........................................................................................ 75 20. The New Food Pyramid....................................................................................... 78 21. U.S. Dietary Guidelines for Americans 2005..................................................... 79 22. Referral to a Dietitian .......................................................................................... 82 23. Herbal Supplements............................................................................................ 83 24. Food Sources of Common Nutrients................................................................. 85

Food Sources of Calcium.............................................................................. 87 Foods Sources of Iron................................................................................... 89 Food Sources of Fiber................................................................................... 90 Food Sources of Omega 3 Fatty Acid ........................................................... 93

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Introduction The Handbook of Nutrition and Preventive Medicine was first published in 2001 by Dr. Marilyn Edwards, Associate Professor at the University of Texas Medical School. In this new edition, we have retained the majority of the original handbook and primarily focused on updating medical and medical nutrition therapy guidelines. Our adaptation is intended to specifically complement the Albert Einstein College of Medicine curriculum. We are very indebted to Dr. Edwards for the creation of the original edition. This edition, like the original, is intended as a resource for medical students, residents, and other health care professionals. The information contained in this handbook will be useful for working with adult patients who have risk factors for chronic diseases including cardiovascular disease, hypertension, diabetes, and obesity. The handbook contains the new National Cholesterol Education Program (NCEP) Lipid Management Guidelines, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) Guide, NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, and the Texas Diabetes Council Algorithms for Prevention and Treatment of Type 2 Diabetes. For medical professionals working with patients in the area of weight management, the Handbook provides Body Mass Index (BMI) calculations, body fat percent norms, American College of Sports Medicine (ASCM) Guidelines for exercise, and information to assess patient motivation for diet and lifestyle change. When counseling patients about healthy eating, the Handbook includes the U.S. Dietary Guidelines for Americans 2000, the Food Guide Pyramid, American Cancer Society Guidelines on Diet, Nutrition, and Cancer Prevention, and a section on diet and dental health. In addition, tables for calculating protein and energy requirements, and the Recommended Dietary Allowances (RDAs) and the Dietary Reference Intakes (DRIs) for nutrients are included. For health care professionals who work with older individuals, a section is included for weight management and exercise after age 65; the National Institutes of Health Osteoporosis Prevention and Treatment Guidelines are also included. Tables of food composition include values for kilocalories, protein, fat, carbohydrate, sodium, calcium, fiber, antioxidants and omega-3 fatty acids; the Food Counter was generously provided by the Nutrition Academic Award team at Tufts University. The National Heart, Lung, and Blood Institute of the National Institutes of Health through the Nutrition Academic Award have provided funding for this Handbook. Adaptation of this handbook for Albert Einstein College of Medicine was made possible through contributions by the Dr. Robert C. Atkins Foundation.

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1. Body Mass Index (BMI) Calculator and Norms BMI = Weight (kg)

Height (m2) OR BMI = (703) x Weight (lbs) Height x Height (in x in)

Classification of Overweight and Obesity by BMI1

Obesity Class BMI (kg/m2) Underweight < 18.5 Normal 18.5-24.9 Overweight 25-29.9 Obesity I 30.0-34.9 Obesity II 35.0-39.9 Extreme Obesity III >40.0 1.Source (adapted from): Preventing and managing the Global epidemic of Obesity. Report of the World Health Organization Consultation of Obesity. WHO, Geneva, June 1997. 2. Body Fat Percent Norms

Percent Body Fat Norm Chart1 Percent body fat Category

Gender Age Low Average High Obese <29 3-10 11-17 18-23 >24

30-39 3-12 13-20 21-25 >26 40-49 3-14 15-21 22-27 >28 50-59 3-15 16-22 23-27 >28

Males

>60 3-16 17-23 24-27 >28 <29 8-18 19-24 25-30 >31

30-39 8-19 20-26 27-32 >33 40-49 8-20 21-27 28-34 >35 50-59 8-21 22-28 29-35 >35

Females

>60 8-22 22-29 30-35 >35 Males Females Essential Body fat ~ 5% ~ 8% Minimal Body fat ~ 5% ~ 10-14% Athletic Groups2 5-13% 12-22% Fitness and Health 10- 25% 16-30% Obesity >25% >30-35% 1. Source: Pat Vehrs, PhD, Brigham Young University, Utah. 2. Range of body composition varies tremendously between sports.

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Methods for Determining Body Fat Percentage For Adults 1) Caliper Measurements: Performed by a trained clinician using metal (Lange,

Harpenden, or Holtain) calipers. Equations are based on testing from 3-9 body sites. Equations are population-specific, i.e., for children, for athletes.

2) Bioelectrical Impedance Analysis (BIA)1: Performed by a trained clinician using a

hand held impedance monitor. Requires placement of electrodes on wrist and ankle. Measures body cell mass (lean tissue), adipose tissue, intracellular water and extracellular water. Quantitates adipose tissue but does not delineate where it is deposited. Estimates body fat percentage with an error of margin 3-4%; fat free mass within 2.5 to 3.5 kg2.

3) Underwater (Hydrostatic) Weighing: Performed in a research setting. In this

procedure body density is calculated from body volume according to the Archimedes principle of displacement, which states that an object submerged in water is buoyed up by the weight of water displaced. Once body density has been determined, one can then convert this value to percent body fat through some simple calculations3.

4) DEXA- dual energy x-ray absorptiometry. DEXA measures three compartments:

total body mineral (from bones), fat-free soft (lean) mass, and adipose tissue. It can measure the area of disposition of adipose as well as the total quantity.

5) BOD POD- Based on the whole-body measurement principal (as is hydrostatic

weighing), but uses air displacement technology instead of water. The subject sits inside the BOD POD while computerized pressure sensors determine the amount of air displaced by the person's body. A complete analysis can be performed in about 5 minutes4.

1. Multiple, validated prediction equations for specific populations are available for anthropometrics and

BIA. Select the appropriate equation for assessing the individual. 2. ACSM, ADA and Dietitians of Canada Position Stand: Nutrition and Athletic Performance (2000).

Nutrition and Athletic Performance Medicine & Science in Sports & Exercise 32(12)2130-2145. 3. Alan C. Utter Ph.D., M.P.H., FACSM Associate Professor of Health and Exercise Science,

http://www.nwcaonline.com/Sports%20science%20articles/underwater.cfm 4. Fields Da, Higgins Pb, Radley D. Air-Displacement Plethysmography: here to stay. Current Opinion in

Clinical Nutrition and Metabolic Care, 8(6):624-629, 2005. For further reading: Charlotte Feicht Sanborn, Fact and Fat of Body Composition, In eds. J.R. Berning, S.N. Steen: Sports Nutrition for the 90s, Maryland: Aspen Publishers, 1991.

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3. Basic Nutrition Assessment for Adults

Adult WAVE Assessment Weight

Assess patient’s Body Mass Index.*

Patient is overweight if BMI>25.

HeightBody

Weight lbs. HeightBody

Weight lbs.4'10" >119 5'8" >1644'11" >124 5'9" >1695'0" >128 5'10" >1745'1" >132 5'11" >1795'2" >136 6'0" >1845'3" >141 6'1" >1895'4" >145 6'2" >1945'5" >150 6'3" >2005'6" > 155 6'4" >2055'7" >159

* Certain pts may require assessment for underweight and/or unintentional weight loss

Activity Ask patient about any physical activity in the past week: walking briskly, jogging, gardening, swimming, biking, dancing, golf, etc. 1. Does patient do 30 minutes of moderate

activity on most days/wk.? 2. Does pt do “lifestyle” activity like taking the

stairs instead of elevators, etc.? 3. Does patient usually watch less than 2

hours of TV or videos/day? If pt answers NO to above questions, assess whether pt is willing to increase physical activity.

Variety Is patient eating a variety of foods from important sections of the food pyramid? Grains (6-11 servings) Fruits (2-4 servings) Vegetables (3-5 servings) Protein (2-3 servings) Dairy (2-3 servings) Determine Variety and Excess using one of the following methods: • Do a quick one-day recall. • Ask patient to complete a self-

administered eating pattern questionnaire.

Excess

Is patient eating too much of certain foods and nutrients?

Too much fat, saturated fat, calories • > 6 oz/day of meat • Ice cream, high fat milk, cheese, etc. • Fried foods or foods cooked with fat • High fat snacks and desserts • Eating out > 4 meals/wk Too much sugar, calories • High sugar beverages • Sugary snacks/desserts Too much salt • Processed meats, canned/frozen meals, salty

snacks, added salt • What does pt think are pros/cons of his/her eating pattern?

• If pt needs to improve eating habits, assess willingness to make changes.

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Adult WAVE Recommendations1

Weight If pt is overweight:

1. State concern for the pt, e.g., “I am concerned that your weight is affecting your health.”

2. Give the pt specific advice, i.e., a) Make 1 or 2 changes in eating habits to

reduce calorie intake as identified by diet assessment.

b) Gradually increase activity/decrease inactivity.

c) Enroll in a weight management program and/or consult a dietitian.

3. If patient is ready to make behavior changes, jointly set goals for a plan of action and arrange for follow-up.

4. Give pt education materials/ resources.

Activity Examples of moderate amounts of physical activity:

• Walking 2 miles in 30 minutes • Stair walking for 15 minutes • Washing and waxing a car for 45-60 minutes • Washing windows or floors for 45-60 minutes • Gardening for 30-45 minutes • Pushing a stroller 1 ½ miles in 30 minutes • Raking leaves for 30 minutes • Shoveling snow for 15 minutes

1. If patient is ready to increase physical activity, jointly set specific activity goals and arrange for a follow-up

2. Give pt education materials/ resources.

Variety What is a serving? Grains (6-11 servings)

1 slice bread or tortilla, ½ bagel, ½ roll, 1 oz. ready-to-eat cereal, ½ cup rice, pasta, or cooked cereal, 3-4 plain crackers Is patient eating whole grains?

Fruits (2-4 servings) 1 medium fresh fruit, ½ cup chopped or canned fruit, ¾ cup fruit juice

Vegetables (3-5 servings) 1 cup raw leafy vegetables, ½ cup cooked or chopped raw vegetables, ¾ cup vegetable juice

Protein (2-3 servings) 2-3 oz. poultry, fish, or lean meat, 1-1 ½ cup cooked dry beans, 1 egg equals 1 oz. meat, 4 oz. or ½ cup tofu

Dairy (2-3 servings) 1 cup milk or yogurt, 1½ oz. cheese See instructions 1-4 under Excess.

Excess 1. Discuss pros and cons of pt’s eating

pattern keeping in mind Variety & Excess. 2. If patient is ready, jointly set specific

dietary goals and arrange for follow-up. 3. Give pt education materials/resources. 4. Consider referral to a dietitian for more

extensive counseling and support. Suggestions for decreasing excess: • Eat chicken and fish (not fried) or meatless

meals instead of red meat • Choose leaner cuts of red meat • Choose skim or 1% milk • Eat less cheese/choose lower fat cheeses • Bake, broil, grill foods rather than fry • Choose low fat salad dressings, mayo,

spreads, etc. • Eat more whole grains, fruits & vegetables • Drink water instead of sugary drinks • Use herbs instead of salt

1. Adult and Pediatric WAVE Information at http://www.aecom.yu.edu/nutrition/instrume.htm Physician Checklist To Review During Patient Visit1

1. Number of meals away from home weekly? 2. Alcohol intake patterns? 3. Who cooks? 4. Food allergies, avoidances, intolerances? 5. Past history of nutrition or dietary advice? From whom? 6. History of eating disorders? 7. Current dietary restrictions? 8. Use of multivitamin and mineral supplements, herbs, liquid supplements, e.g., Boost, Ensure? 9. ASCVD Risk factor assessment

• Hypercholesterolemia (Total chol > 200, LDL > 130, HDL < 40) • Smoking • HTN • DM • Early family disease (CHD in male first degree relative <55 years; CHD in female first degree

relative <65 years) 1. http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter4.htm

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4. Physical Activity: USDA Dietary Guidelines for Americans, 2005 According to the US Department of Agriculture (USDA), regular physical activity has been shown to reduce the risk of certain chronic diseases including hypertension, stroke, coronary artery disease, type 2 diabetes, colon cancer and osteoporosis. To reduce the risk of chronic disease, it is recommended that adults engage in at least 30 minutes of moderate intensity physical activity on most, and preferably, all days of the week. For most people, greater health benefits can be obtained by engaging in physical activity of more vigorous intensity or of longer duration. In addition, physical activity appears to promote psychological wellbeing and reduced feelings of mild to moderate depression and anxiety. Regular physical activity is also a key factor in achieving and maintaining a healthy body weight for adults and children. Key Recommendations 1) Engage in regular physical activity and reduce sedentary activities to promote

health, psychological well-being, and a healthy body weight.

2) To reduce the risk of chronic disease in adulthood: Engage in at least 30 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week.

3) For most people, greater health benefits can be obtained by engaging in physical

activity of more vigorous intensity or longer duration.

4) To help manage body weight and prevent gradual, unhealthy body weight gain in adulthood: Engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week while not exceeding caloric intake requirements.

5) To sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily

moderate-intensity physical activity while not exceeding caloric intake requirements. Some people may need to consult with a healthcare provider before participating in this level of activity.

6) Achieve physical fitness by including cardiovascular conditioning, stretching

exercises for flexibility, and resistance exercises or calisthenics for muscle strength and endurance.

Key Recommendations for Specific Population Groups1

• Children and adolescents: Engage in at least 60 minutes of physical activity on most, preferably all, days of the week. • Pregnant women: In the absence of medical or obstetric complications, incorporate 30 minutes or more of moderate-intensity physical activity on most, if not all, days of the week. Avoid activities with a high risk of falling or abdominal trauma. • Breastfeeding women: Be aware that neither acute nor regular exercise adversely affects the mother’s ability to successfully breastfeed. • Older adults: Participate in regular physical activity to reduce functional declines associated with aging and to achieve the other benefits of physical activity identified

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for all adults. 1. US Department of Health and Human Services, US Department of Agriculture, www.healthierus.gov/dietaryguidelines

5. Fluid Guidelines for Exercise 1. Adequate hydration is essential to prevent dehydration and injury during exercise

and to speed recovery.

2. The timing and quantity of fluid replacement requires planning on the part of the exerciser.

3. Fluid intake should replace sweat loss during exercise. Overall fluid intake should be 150% of the fluid loss during and after exercise. Many athletes can sweat 2-3 liters hourly.

4. Sweat contains an average sodium concentration of 50 mEq (1 gm Na) per liter. Prolonged sweat loss with plain water replacement may produce hyponatremia.

5. Thirst is not a reliable mechanism to promote adequate fluid intake.

6. The color and volume of urine is a helpful indicator of hydrational status.

7. Flavored, sweetened beverages with some sodium encourage greater fluid intake than plain water.

8. Monitoring body weight pre and post exercise helps to evaluate fluid needs. Drink 24 oz. of fluid for each pound lost during exercise in order to rehydrate within 6 hours of an exercise session or competitive event.

9. Exercise at altitude >8,200 feet may produce extraordinary losses through respiration and diuresis. Fluid intake needs may be as high as 3-4 liters daily.1

10. The ideal sport drink should contain 6-10% CHO to deliver adequate kcal and facilitate gastric emptying.

Fluid Requirement During Prolonged Exercise and Competition1

2 hours before competition

Immediately before competition or sustained activity

During competition or exercise up to 60 minutes1

Exercise or competition lasting >60 minutes

Fluid Requirement 400-600 ml (14-21 oz.)

500 ml (17 oz.)

150-350 ml (5-12 oz.) every 15-20 minutes. More if sweat losses are excessive.

150-350 ml (5-12 oz.) every 15-20 minutes. More if sweat losses are excessive.

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Type of Fluid Water Water Water for most activities. High intensity activity performance may be enhanced with carbohydrate.

Beverage with <8% carbohydrate concentration. May need beverage with 500-700 mg Na/L for activity >3 hours.2 (or consume salt in food).

1. American College of Sports Medicine, American Dietetic Association and Dietitians of Canada Position Stand: Nutrition and Athletic Performance (2000). Nutrition and Athletic Performance Medicine & Science in Sports & Exercise 32(12)2130-2145. 2. Commercial sports beverages contain 55-110 mg Na/Liter.

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FLUIDS 2000 DEHYDRATION AND HEAT ILLNESS

Heat Index Chart

This Heat Index Chart provides general guidelines for assessing the potential severity of heat stress. Individual reactions to heat will vary. It should be remembered that heat illness can occur at lower temperatures than indicated on the chart. In addition, studies indicate that susceptibility to heat illness tends to increase with age. How To Use The Heat Index Chart:

1. Across the top of the chart, locate the ENVIRONMENTAL TEMPERATURE i.e., the air temperature.

2. Down the left side of the chart, locate the RELATIVE HUMIDTY.

3. Follow across and down to find the APPARENT TEMPERATURE. Apparent Temperature is the combined index of heat and humidity. It is an index of the body’s sensation of heat caused by the temperature and humidity (the reverse of the "wind chill factor").

Note: Exposure to full sunshine can increase Heat Index values by up to 15oF

APPARENT TEMPERATURE

HEAT STRESS RISK WITH PHYSICAL ACTVITY AND/OR PROLONGED EXPOSURE

90 o - 105 o Heat cramps or heat exhaustion possible

105 o - 130 o Heat cramps or heat exhaustion likely. Heatstroke possible

130 o and up Heatstroke highly likely

Note: This Heat Index chart is designed to provide general guidelines for assessing the potential severity of heat stress. Individual reactions to heat will vary. It should be remembered that heat illness can occur at lower temperatures than indicated on the chart. In addition, studies indicate that susceptibility to heat disorders tends to increase with age.

Permission to reprint granted by Gatorade Sports Science Institute.

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HEAT INDEX

ENVIRONMENTAL TEMPERATURE (oF) 70o 75o 80o 85o 90 o 95o 100o 105o 110o 115 o 120 o

Relative Humidity

Apparent Temperature*

0% 64 o 69 o 73 o 78 o 83 o 87 o 91 o 95 o 99 o 103 o 107 o

10% 65 o 70 o 75 o 80 o 85 o 90 o 95 o 100 o 105 o 111 o 116 o

20% 66 o 72 o 77 o 82 o 87 o 93 o 99 o 105 o 112 o 120 o 130 o

30% 67 o 73 o 78 o 84 o 90 o 96 o 104 o 113 o 123 o 135 o 148 o

40% 68 o 74 o 79 o 86 o 93 o 101 o 110 o 123 o 137 o 151 o 50% 69 o 75 o 81 o 88 o 96 o 107 o 120 o 135 o 150 o 60% 70 o 76 o 82 o 90 o 100 o 114 o 132 o 149 o 70% 70 o 77 o 85 o 93 o 106 o 124 o 144 o 80% 71 o 78 o 86 o 97 o 113 o 136 o 90% 71 o 79 o 88 o 102 o 122 o

100% 72 o 80 o 91 o 108 o *Combined index of heat and humidity… what it "feels like" to the body. Source: National Oceanic and Atmospheric Administration

6. Carbohydrate Guides for Exercise

Carbohydrate (CHO) Requirement During Prolonged Exercise and Competition

Two Hours Before

Competition

Immediately Before

Competition Or Sustained

Activity

During Competition Or Exercise Up To

60 Minutes1

Exercise Or Competition Lasting >60

Minutes

After Competition Or

Prolonged Endurance

Activity

Suggested Intake

Meal or snack, low fat, low fiber, high CHO (200-300 gm)

30-60 gm CHO/hour. Some performance improvements at as little as 20-25 gm/hour. Maximal rate of utilization = 60-75 grams/hour: no additional performance benefits from more.

If glycogen depleted (>2000 kcal exercise), eat 1.5 gm CHO/kg in first 30 minutes and again every 2-4 hours until replete.

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Consume familiar, well-tolerated foods during competition. Practice fueling strategies during training. Generally, there is little performance enhancement from carbohydrate loading for events less than one hour unless they are high intensity efforts. 7. Nutrient Composition of Common Sports Supplements

Energy Bars

Product Size (gm)

Kcal* Protein (gm)

Carb (gm)

Fat (gm)

Fiber (gm)

Na (mg)

%RDA # Nutrients Added

Cost per 200 kcal**

365 Verve Whole Foods

68 210 8 44 1.5 4 140 6-25% 4 .85

365 Everyday Whole Foods

50 200 18 18 4.5 2 109 50% 17 .89

Power Bar 65 230 10 45 2.5 3 90 20-100% 17 1.21

Power Bar Harvest

65 240 7 45 4.5 4 80 15-100% 17 1.32

Power Bar Protein Plus

78 290 24 38 5 3 105 20-100% 17 2.39

Balance Bar 50 190 14 22 6 0 200 10-100% 24 1.36

Clif Bar 66 230 10 42 3.5 6 140 15-100% 23 1.30

Luna Bar 48 180 10 26 4 2 50 35-100% 23 1.10

Zone Bar 50 200 14 22 7 1 150 15-200% 20 1.69

Genisoy Bar 61.5 220 28 32 3.5 1 120 25% 19 1.17

Gatorade Bar 65 260 8 46 5 2 160 2-30% 11 .84

Hi Pro Balance 75 300 22 33 10 1 330 8-150% 23 .66

Energy Gels

Gu 31 100 0 25 0 0 20 ** 2.00

Power Gel 35 100 0 25 0 0 ** 1.51

Clif Shot 32 110 0 28 0 0 50 ** 2.00

Fluid Replacement Beverages

Gatorade 240 50 0 14 0 0 110 0 0 1.39

Powerade 240 70 0 19 0 0 55 10% 3 1.20

Propel 240 10 0 3 0 0 35 10-25% 6 6.60

*Macronutrients vary slightly within the same product line depending on flavors of the bar. **Gels may contain caffeine.

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8. Exercise chart with body weights and kcal expenditure per minute of activity1

Body weight (lb) 120 140 180 220

Sitting 1.5 1.8 2.3 2.8

Basketball, recreational 6.0 7.0 9.0 11.0

Bicycling (6 mph) 3.2 3.8 4.9 6.0

Bicycling (12 mph) 6.9 8.1 10.4 12.8

Bicycling (20 mph) 12.8 14.9 19.2 23.5

Dancing, moderate (waltz)

3.8 4.5 5.7 7.0

Dancing vigorous (aerobic)

7.3 8.5 10.9 13.3

Golf (2-some, carry clubs)

4.4

5.1

6.6

8.0

Golf (power-cart) 2.3 2.7 3.5 4.3

Roller skating (9 mph) 5.1 5.9 7.6 9.4

Running

(mph) 5.0 6.0 9.0

(min/mile) 12:00 8:35 6:40

7.3 10.2 12.9

8.5 11.9 15.1

10.9 15.4 19.5

13.4 18.8 23.9

Skiing, cross-country (4 mph)

7.8 9.2 11.9 14.5

Skiing, downhill 7.8 9.2 11.9 14.5

Swimming (25 yds/min) 4.8 5.6 7.2 8.8

Swimming (50 yds/min) 8.5 9.9 12.8 15.6

Tennis, singles 6.0 7.0 9.0 11.1

Walking (20 min/mile) 3.3 3.8 4.9 6.0

Walking (15 min/mile) 5.1 5.9 7.6 9.4

Walking (12 min/mile) 6.5 7.7 9.8 12.0

Weight training 6.2 7.3 9.4 11.5

1. Source: Berning, JR, Steen, SN (1991) Sports Nutrition for the 90s: the Health Professionals Handbook. Maryland: ASPEN: 256-263.

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9. Recommended Dietary Allowances and Dietary Reference Intakes Since 1940, the Food and Nutrition Board of the National Academy of Sciences (NAS) has developed and periodically published recommended dietary allowances (RDAs). RDAs have been used as the scientific basis for federal nutrition and food policy in the U.S. When first developed, RDAs were intended as allowances that would meet the nutritional needs of most healthy people; they were designed for planning diets to prevent nutrient deficiencies in groups. They have come to be used for many other purposes, such as food labeling and food selection guides for healthy diets. As scientific knowledge about diet and health has increased, technology has improved to allow measurement of small changes in individual adaptation to consumption of various levels of nutrients. Chronic diseases or conditions that had been difficult to ascribe to inadequate or excess consumption of a specific nutrient have been found to be closely linked to diet or nutrient intake. To include these possible relationships in the definition of "adequacy" used to establish dietary allowances, the NAS Food and Nutrition Board (FNB) has expanded its framework for determining dietary allowances. Thus, Dietary Reference Intakes (DRIs) were established. The DRIs are a set of reference values: Recommended Dietary Allowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake Levels, (UL) that have replaced the 1989 Recommended Dietary Allowances (RDAs). The AIs and ULs were established based on the examination of data regarding increased consumption of nutrients in concentrated form, either singly or in combination with others outside of the context of food, and because of the use of fortification or enrichment of foods, the extent to which excess nutrient intakes increase the risk of adverse or toxic effects. The following table gives the DRIs for nutrients based on age and gender; adverse effects of excessive intakes are also provided. Unless one is consuming large proportions of fortified foods, it is usually not possible to reach toxic levels of nutrients from food alone; however, supplements may need to be monitored to ensure that the UL is not exceeded. Nutrient Life Stage

Group RDA/AI ULa Adverse

effects of excessive intake

Calcium

M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 1000 1000 1200 1200 1000 1000 1200 1200 1000 1000 1000 1000

(mg/day) 2500 2500 2500 2500 2500 2500 2500 2500 2500 2500 2500 2500

Kidney stones, hypercalcemia, milk alkali syndrome, renal insufficiency

Chromium M 19-30 y M 31-50 y

(mcg/day) 35 35

ND ND

Chronic renal failure

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M 50-70 y M>70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

30 30 25 25 20 20 30 30 45 45

ND ND ND ND ND ND ND ND ND ND

Copper M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mcg/day) 900 900 900 900 900 900 900 900 1000 1000 1300 1300

(mcg/day) 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000

Gastrointestinal distress, liver damage

Fluoride M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 4 4 4 4 3 3 3 3 3 3 3 3

(mg/day) 10 10 10 10 10 10 10 10 10 10 10 10

Tooth enamel and skeletal fluorosis

Biotin M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mcg/day) 30 30 30 30 30 30 30 30 30 30 35 35

(mcg/day) ND ND ND ND ND ND ND ND ND ND ND ND

ND

Choline M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y

(mg/day) 550 550 550 550 425 425 425 425 450

(mg/day) 3500 3500 3500 3500 3500 3500 3500 3500 3500

Fishy body odor, sweating, salivation, hypotension, hepatotoxicity

- 15 -

Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

450 550 550

3500 3500 3500

Folate

M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mcg/day) 400 400 400 400 400 400 400 400 600 600 500 500

(mcg/day) 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000

Masks neurological complications in people with B12 deficiency. No adverse affects have been reported with folate from food or supplements. The UL for folate applies to synthetic forms obtained from supplements and/or fortified foods.

Niacin M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 16 16 16 16 14 14 14 14 18 18 17 17

(mg/day) 35 35 35 35 35 35 35 35 35 35 35 35

No evidence of adverse effects from niacin in foods. Adverse effects from supplements include GI distress and flushing. UL applies to niacin from supplements and/or fortified foods.

Panthothenic Acid

M 19-30 y M 31-50 y M50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 5 5 5 5 5 5 5 5 6 6 7 7

(mg/day) ND ND ND ND ND ND ND ND ND ND ND ND

ND

Riboflavin M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y

(mg/day) 1.3 1.3 1.3 1.3 1.1 1.1

(mg/day) ND ND ND ND ND ND

ND

- 16 -

F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

1.1 1.1 1.4 1.4 1.6 1.6

ND ND ND ND ND ND

Iodine M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mcg/day) 150 150 150 150 150 150 150 150 220 220 290 290

(mcg/day) 1100 1100 1100 1100 1100 1100 1100 1100 1100 1100 1100 1100

Elevated thyroid stimulating hormone (TSH) concentration

Iron M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 8 8 8 8 18 18 8 8 27 27 9 9

(mg/day) 45 45 45 45 45 45 45 45 45 45 45 45

Gastrointestinal distress

Magnesium M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 400 420 420 420 310 320 320 320 350 360 310 320

(mg/day) 350 350 350 350 350 350 350 350 350 350 350 350

No known adverse effects from Mg in foods. Supplemental Mg may cause diarrhea. The UL for Mg represents intake from supplements and does not include water and food intake.

Manganese M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 2.3 2.3 2.3 2.3 1.8 1.8 1.8 1.8 2.0 2.0 2.6 2.6

(mg/day) 11 11 11 11 11 11 11 11 11 11 11 11

Elevated blood concentration and neurotoxicity

- 17 -

Molybdenum M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mcg/day) 45 45 45 45 45 45 45 45 50 50 50 50

(mcg/day) 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000

Reproductive effects as observed in animal studies

Phosphorus M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 700 700 700 700 700 700 700 700 700 700 700 700

(mg/day) 4000 4000 4000 3000 4000 4000 4000 3000 3500 3500 4000 4000

Metastatic calcification, skeletal porosity, interference with calcium absorption

Selenium M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mcg/day) 55 55 55 55 55 55 55 55 60 60 70 70

(mcg/day) 400 400 400 400 400 400 400 400 400 400 400 400

Hair and nail brittleness and loss

Zinc M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 11 11 11 11 8 8 8 8 11 11 12 12

(mg/day) 40 40 40 40 40 40 40 40 40 40 40 40

Reduced copper status

Vitamin A M 19-30 y M 31-50 y M 50-70 y M >70 y

(mcg/day) 900 900 900 900

(mcg/day) 3000 3000 3000 3000

Teratological effects, liver toxicity Note: from preformed

- 18 -

F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

700 700 700 700 770 770 1300 1300

3000 3000 3000 3000 3000 3000 3000 3000

vitamin A only

Vitamin B6

M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 1.3 1.3 1.7 1.7 1.3 1.3 1.5 1.5 1.9 1.9 2.0 2.0

(mg/day) 100 100 100 100 100 100 100 100 100 100 100 100

No known adverse effects from B6 in food. Sensory neuropathy has occurred from high intakes of supplemental forms.

Vitamin B12 M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mcg/day) 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.6 2.6 2.8 2.8

(mcg/day) ND ND ND ND ND ND ND ND ND ND ND ND

ND

Vitamin C M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 90 90 90 90 75 75 75 75 85 85 120 120

(mg/day) 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000

GI disturbances, kidney stones, excess iron absorption

Vitamin D M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y

(mcg/day) 5 5 10 15 5 5 10 15

(mcg/day) 50 50 50 50 50 50 50 50

Elevated plasma 25(OH) D concentration causing hypercalcemia

- 19 -

Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

5 5 5 5

50 50 50 50

Vitamin E M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 15 15 15 15 15 15 15 15 15 15 19 19

(mg/day) 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000

No adverse effects known from vitamin E in foods. Adverse effects from vitamin E containing supplements may include hemorrhagic toxicity. The UL for vitamin E applies to any form of tocopherol obtained from supplements and/or fortified foods.

Vitamin K M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mcg/day) 120 120 120 120 90 90 90 90 90 90 90 90

(mcg/day) ND ND ND ND ND ND ND ND ND ND ND ND ND

ND

Thiamin M 19-30 y M 31-50 y M 50-70 y M >70 y F 19-30 y F 31-50 y F 50-70 y F >70 y Pregnant 19-30 y Pregnant 31-50 y Lactation 19-30 y Lactation 31-50 y

(mg/day) 1.2 1.2 1.2 1.2 1.1 1.1 1.1 1.1 1.4 1.4 1.4 1.4

(mg/day) ND ND ND ND ND ND ND ND ND ND ND ND

ND

NOTE: The table is adapted from DRI reports. RDAs are in bold type while Adequate Intakes (AI) are in ordinary type. RDAs and AIs may be used as goals for individual intakes. RDAs are set to meet the needs of 97-98% of people in a group. aUL = The maximum amount that can be consumed safely. Includes intake from food, water and supplements. When insufficient data exists to define an UL (ND), extra caution may be warranted in consuming more than RDAs.

- 20 -

Sources: DRIs for Ca, P, Mg, Vitamin D, and Fluoride(1997); DRIs for Thiamin, Riboflavin, Niacin, B6, Folate, B12, Pantothenic acid, Biotin and Choline(1998); DRIs for Vitamin C, Vitamin E, Selenium, and Carotenoids(2000); DRIs for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc(2001). These reports may be accessed via www.nap.edu.

- 21 -

10. Calculating Energy Requirements Estimated Kilocalorie Requirements for Adults (kcal/kg)1

Activity Level Men Women Light 30 30 Moderate 40 37 Heavy 50 44 1. National Research Council. Recommended Dietary Allowances, 10th ed. Washington, DC: National

Academy Press; 1989.

• Energy requirements are influenced by age, heredity, sex, body composition, body size, ambient temperature, and the type, duration, intensity and frequency of exercise.

• It is necessary to consume an excess of 3,500 kcal to gain one pound of body

fat. Conversely, reducing cumulative dietary intake by 3,500 kcal over a period of time will produce a one-pound fat loss.

11. Calculating Protein Requirements1 Group (Adults) Protein Needs grams /kg RDA 0.8 Vegetarians Increase by 10% Endurance athletes 1.2 - 1.4 Strength athletes 1.6 - 1.7 Elderly 1.252 1. ACSM, ADA and Dietitians of Canada Position Stand: Nutrition and Athletic Performance (2000).

Nutrition and Athletic Performance Medicine & Science in Sports & Exercise 32(12)2130-2145. 2. Campbell, WW, Crim, MC, Dallal, DE, Young, VR. (1994) Increased protein requirements in the

elderly: new data and retrospective reassessments. AJCN 60:167-175.

- 22 -

12. NCEP Lipid Management Guidelines: National Heart, Lung, and Blood Institute: Adult Treatment Panel III (ATP III)

STEP 1: Determine lipoprotein levels - obtain complete lipoprotein profile after 9- to 12-hour fast.

ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL) LDL Cholesterol - Primary Target of Therapy* <100 Optimal 100-129 Near Optimal/Above Optimal 130-159 Borderline High 160-189 High >190 Very high

Total Cholesterol <200 Desirable 200-239 Borderline High >240 High

HDL Cholesterol <40 Low >60 High STEP 2: Identify presence of clinical atherosclerotic disease that confers high risk for coronary heart disease (CHD) events (CHD risk equivalent):

• Clinical CHD • Symptomatic carotid artery disease • Peripheral arterial disease • Abdominal aortic aneurysm

Note: in ATP III, diabetes is regarded as a CHD risk equivalent. STEP 3: Determine presence of major risk factors (other than LDL): Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals

• Cigarette smoking • Hypertension (BP 140/90 mm Hg or on antihypertensive medication) • Low HDL cholesterol (<40 mg/dl)* • Family history of premature CHD (CHD in male first degree relative <55 years;

CHD in female first degree relative <65 years) • Age (men 45 years; women 55 years)

- 23 -

• HDL cholesterol >60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count.

STEP 4: If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk Risk Assessment NHLBI’s Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (Myocardial Infarction and Coronary Death) can be found at: http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof Or use Risk Finder Chart:

ote: Almost all people with 0-1 major risk factors have a 10 year risk of <10%: Thus,

Three levels of 10-year risk: ivalent

STEP 5: Determine risk category:

N10 year risk assessment in people with 0-1 risk factors is not necessary.

• >20% -- CHD risk equ• 10-20% • <10%

• Establish LDL goal of therapy

- 24 -

lifestyle changes (TLC)

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)

Risk Category LDL LDL Level at Which to Initiate LDL Level at Which

• Determine need for therapeutic• Determine level for drug consideration

and Drug Therapy in Different Risk Categories

Goal Therapeutic Lifestyle Changes (TLC)

to Consider Drug Therapy

CHD or CHD Risk ar risk 100 mg/dL

130 mg Equivalents (10-ye

>20%)

<100 mg/dL

/dL (100-129mg/dL: drug optional)*

2+ Risk Factors (10-year <130 130 mg/dL

0

r risk <10%: 160 risk 20%) mg/dL

10-year risk 10-20%: 13mg/dL 10-yeamg/dL

0-1 Risk Factor** <160

160 mg/dL /dL

/dL: LDL-

mg/dL

190 mg(160-189 mglowering drug optional)

ome authorities recommend use of LDL-lowering drugs in this category if an LDL

Almost all people with 0-1 risk factor have a 10-year risk <10%, thus 10-year risk

high risk, a group that is considered a “sub-set” of the high-risk

*Scholesterol <100 mg/dL cannot be achieved by therapeutic lifestyle changes. Othersprefer use of drugs that primarily modify triglycerides and HDL, e.g., nicotinic acid or fibrate. Clinical judgment also may call for deferring drug therapy in this subcategory. **assessment in people with 0-1 risk factor is not necessary. Very High Risk For people at verycategory, the update offers a new therapeutic lifestyle change option of treating LDless than 70 mg/dL. For very high-risk patients whose LDL levels are already below 100mg/dL, there is also an option to use drug therapy to reach the less than 70 mg/dL goal. The NCEP defines very high-risk patients as those who have cardiovascular disease

L to

gh

TEP 6: Initiate therapeutic lifestyle changes (TLC) if LDL is above goal.

(see diet below)

vity

STEP 7: Consider adding drug therapy if LDL exceeds levels shown in Step 5

TLC for CHD and CHD equivalents

together with either multiple risk factors (especially diabetes), or severe and poorly controlled risk factors (e.g., continued smoking), or metabolic syndrome. Patients hospitalized for acute coronary syndromes such as heart attack are also at very hirisk. STLC Features

• TLC Diet• Weight management • Increased physical acti

table: • Consider drug simultaneously with• Consider adding drug to TLC after 3 months for other risk categories.

http://www.nhlbi.nih.gov/guidelines/cholesterol/

- 25 -

Drugs that Affect Lipid Metabolism

Drug Class Agents and Daily Doses

Lipid/ Lipoprotein

Effects Side

Effects Contraindications

HMG CoA Reductase Inhibitors (statins)

Lovastatin (20-80 mg), Pravastatin (20-40 mg), Simvastatin (20-80 mg), Fluvastatin (20-80 mg), Atorvastatin (10-80 mg), Cerivastatin (0.4-0.8 mg)

LDL-C 18-55% HDL-C 5-15% TG 7-30%

Myopathy Increased liver enzymes

Absolute: Active or chronic liver disease Relative: Concomitant use of these drugs*

Bile Acid Sequestrants

Cholestyramine (4-16 g) Colestipol (5-20 g) Colesevelam (2.6-3.8 g)

LDL-C 15-30% HDL-C 3-5% TG No change or increase

GI distress Constipation Decreased absorption of other drugs

Absolute: dysbeta-lipoproteinemia TG >400 mg/dL Relative: TG >200 mg/dL

Nicotinic Acid

Immediate release (crystalline) nicotinic acid (1.5-3 gm), extended release nicotinic acid (Niaspan ®) (1-2 g), sustained release nicotinic acid (1-2 g)

LDL-C 5-25% HDL-C 15-35% TG 20-50%

Flushing Hyperglycemia Hyperuricemia (or gout) Upper GI distress Hepatotoxicity

Absolute: Chronic liver diseaseSevere gout Relative: Diabetes Hyperuricemia Peptic ulcer disease

Fibric Acids Gemfibrozil (600 mg BID)Fenofibrate (200 mg) Clofibrate (1000 mg BID)

LDL-C 5-20% (may be increased in patients with high TG) HDL-C 10-20% TG 20-50%

Dyspepsia Gallstones Myopathy

Absolute: Severe renal disease Severe hepatic disease

*Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (fibrates and niacin should be used with appropriate caution).

- 26 -

Dietary Guidelines

American tion

y Strategies to Reduce th aHeart Associa

e Risk of Coronar1

y HeDietar rt Disease o Eat a variety of fr ose 5 or m vings per day.

o Eat a variety of grain p e 6 rvings p

o Includ e and lo fis ns), ski meats.

o C s s ines, canola oil and olive oil.

o Balance the number of calories you eat with use e er, multiply t of pound pres ries used in one day if you're mo If you1 )

o Maintain a level of physical activity that keeps you fit and matche r o r do other activities tes on most days. To lose wei enou o use up more calories than you eat every day.

o Limit your intake s or inclu candy that have a lot of sug

o Limit foods high in satu such a eats, tropical oils, partially hydro etable oils and egg yolks. Instead hoose d fat, trans fat and chol ur points above.

o Eat less than 6 grams of salt (sodium chloride illigrams of sodi

o H man re than two if you're a ma" e alcohol. Examples of one dri z. of beer, 4 oz. of wine, 1 1

uits and vegetables. Cho

roducts, including whol

w-fat milk products,

s with 2 grams or less satu

ore ser

e grains. Choos

h, legumes (bea

rated fat per table

or more se

nless poultry and lea

poon, such a

er day.

n

liquid and tub margar

e fat-fre

hoose fats and oil

the number you calories. This re get very little exercise, multiply your weight by 13

ach day. (To find that numbents the averag

s the numbe

he number

5. Less-active p

s you weigh now by 15derately active.

e number of calo instead of

f calories you eat. Walk o

eople burn fewer calories.

for at least 30 minu

of foods high in caloriers.

rated fat, trans fat and/or genated veg

esterol from the first fo

ght, do

ding foods like soft drin

s full-fat milk c

gh activity t

ks and

products, fatty m foods low in saturate

low in nutrition,

cholesterol,

a

) per day (2,400 m

you're a wo

0-proof spirits.

um).

n. nk are 12 o

ave no more than one alOne drink" mean

coholic drink per day if s it has no more than 1/2 ounce of pur/2 oz. of 80-proof spirits or 1 oz. of 10

and no mo

1. American Heart Association, April 2006 www.americanheart.org

NHLBI Total Lifestyle Change Diet to Reduce CAD Risk

Nutrient Recommendation Comment Saturated Fat Less than 7% of total kcal Trans fatty acid intake should be

minimized as they raise LDL Polyunsaturated Fat Up to 10 % of total kcal Monounsaturated Fat Up to 20% of total kcal Total fat 25-35% of total kcal Using 2g/day plant

stanols/sterols reduces LDL Carbohydrate 50-60% of total kcal Choose complex carbohydrates

such as grains, whole grains, fruits and vegetables

Fiber 20-30 g/day Increased viscous (soluble) fiber to 10-25 g/day reduces LDL

Protein Approximately 15% of total kcal

Cholesterol Less than 200 mg/day Total kcal Balance activity and energy

intake to achieve and maintain a desirable weight

Remain moderately active

- 27 -

13. Prevention and Treatment of HTN Guidelines (NHLBI) The JNC VII Guide To Prevention, Detection, of High Blood PressuEvaluation and Treatment re

- 28 -

HUhttp://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf

- 29 -

Dietary Approaches to Stop Hypertension (DASH) diet

DASH is an eating plan low in saturated fat, total fat and cholesterol, and high in fruits, vegetables and low fat dairy foods. The plan is rich in calcium, magnesium, potassium as well as protein and fiber. The diet reduced systolic pressure by an average of 6 mm Hg and diastolic by 3 mm Hg in normotensive individuals; in those with hypertension, the systolic dropped an average of 11 mm Hg and the diastolic about 6 mm Hg. Selecting the lower-end of the number of servings, the diet provides about 1900 kilocalories and 70 grams protein, while the higher-end of the number of servings offer 2550 kilocalories and 105 grams protein. Number of servings may need to be reduced for individuals if weight loss is desired. Food

Group Daily

Servings Serving Sizes Examples and Notes

Grains & grain products

7-8 1 slice bread (1oz) 1/2 muffin 1 cup dry cereal 1/2 cup rice, pasta or cereal 5 crackers 1/4 bagel or pita

Whole wheat bread, English muffin, pita bread, bagel, cereals, grits, oatmeal, crackers, unsalted pretzels and popcorn

Vegetables 4-5 1 cup raw leafy vegetable 1/2 cup cooked vegetable 6 oz. vegetable juice

Tomato, potato, carrot, green pea, squash, broccoli, turnip green, collard, kale, spinach, artichoke, green bean, lima, sweet potato

Fruits 4-5 6 oz. fruit juice 1 medium fruit 1/4 cup dried fruit 1/2 cup fresh or canned fruit

Banana, date, grape, ora orange juice, grapefruit, mango, melon, peach, pineapple, prune, raisin, strawberry, tangerine

nge,

Low fat or fat free dairy foods

2-3 8 oz milk 1 c yogurt 2.5 oz cheese 1/2 cup cottage cheese

Fat free, skim or low fat 1% milk, fat free or low fat frozen yogurt, low fat and fat free cheese

Meats, poultry & fish

2 or less 3 oz cooked meat, poultry or fish Select only lean; trim away visible fat; broil, roast or boil; remove sk om poultry

in fr

Nuts, seeds & dry beans

4-5 per week 1/3 cup or 1.5 oz nuts 2 Tbsp. or 1/2 oz seeds 1/2 cup cooked beans

Almond, mixed nuts, peanut, walnut, sunflower seed, kidney bean, lentil, peas

Fats & oils 2-3 1 tsp. soft margarine 1 Tbsp. low fat mayonnaise 2 Tbsp. light salad dressing 1 tsp. vegetable oil

Soft margarine, low fat mayonnaise, light salad dressing, vegetable oil (such as olive, corn, canola,safflower)

Sweets, fat-free

5 per week 1 Tbsp sugar, jelly 8 oz. cola 1 Tbsp syrup

Jelly beans, sugar, sherbet, gelatin, hard candy

Source: U.S. Department of Health and Human Services; NIH Publication No. 99-4082. Originally printed 1998 http://dash.bwh.harvard.edu

- 30 -

ample DASH Diet MenusS The following tw g sizes in the DASH diet.

o menus follow the lower and higher recommendations for servin

Lower End of DASH Recommendations

Higher End of DASH Recommendations

Breakfast 2 cups Cheerios 1 Tbsp sugar 12 oz. orange juice 8 oz. skim milk Coffee or tea

Breakfast 2 slices toast 1 Tbsp jelly 1 cup cantaloupe 1/2 cup cottage cheese Coffee or tea

Lunch lices wh ad, 1.5 oz. Sese, ps w

garbanzo beans bsp. light dressing

1 peach Diet soda

Lunch2 sche

cu

eat bretomato

ed salad

wiss

2

2 T

toss ith 1/2 cup

d potato

1 oz. grated ch2 Tbsp. sour c1 slice wheat b

apes Diet lemonade

Bake1/2 cup broccoli, steamed

eese ream read

30 gr

Dinner 1.5 cups spaghetti 3 oz lean ground beef 1/2 cup ghetti sauc1/2 cup steamed squa1 teas. butter

a h sweetene

ner

spa e sh

Iced te wit r

Din 6 oz. baked sa1.5 cups rice, steamed with herbs 1 cup tossed s2 teas. olive oi

s. vinega10 saltines 1 apple oz. skim milk

lmon

alad l r 1 tea

8 Snack

p pineapple cubes 1/2 cuSnack 1/3 cup mixed nuts

- 31 -

14. Prevention and Treatment of Obesity Guidelines

ication of Overweight and Obesity by BMI, Waist Circumference and

ClassifAssociated Disease Risk

Dise ormal Weight and Waist Circumference

ase Risk Relative to N

BMI (kg/m2) Obesity Men < 102 cm (< 40 iClass n.);

Women < 88 cm (<35 in.)

Men > 102 cm (>40 in.);

Women > 88 cm (>35 in.)

Underweight < 18.5

Normal 18.5-24.9

Overweight 25-29.9 High Increases

Obesity l 30.0-34.9 I Very High High

Obesity ll 35.0-39.9 II y High Very High Ver

Obesity lll >40.0 III Extremely High Extremely High

alth Risk and WaHe ist Circumference Men >102 cm >40 inches

Women >88 cm >35 inches

here To Measu rcumferance

How And W re Waist Ci

- 32 -

y Determination of Absolute Risk Status Based on Overweight and ObesitParameters

Deteoverweight, as well as the presence of exisrequires taking into account the patient's history, physical examinatresults. Of greatest urgency is the need to detecttha trigger the need k f ific is nt. Sin e the major risk e in vates hypertension, dyslipidemias, and diabetes which causmanagement of obesity should be implemented in the context of reducing thesrisk factors. Ide n of Pati ry High Absolute Risk The following disease conditions or targetde ence gh absolu risk that trifactor modification as well as disease management. For example, the presence of very hig risk ind eed for gressive cholesterol-lowering therapy. a. Established coronary heart disease (CHD)

of myois (stable nstab

of corona ry surgery• History of coronary artery procedures (angioplasty)

• Peripheral arterial dis• Abdominal aortic aneurysm • Symptomatic carotid artery disease

rmining the patient's absolute risk status requires consideration of the degree of ting diseases or risk factors. To do so

ion, and laboratory existing CVD or end-organ damage

t c

for intense riss of obesity ar

actor moddirect (obesity elic

e cardiovascular complications), the

ation as well as dits or aggra

ease manageme

e other

ntificatio ents at Ve organ damage in hypertensive patients

notes the pres of very hi te ggers the need for intense risk

h absolute icates the n ag

• History cardial infarction • History of angina pect• History

orry arte

or u

le)

b. Presence of other atherosclerotic diseases ease

c. Type 2 diabetes d. Sleep apnea

- 33 -

Treatment Algorithm

- 34 -

Selecting The Treatment for Obesity

BMI Treatment 25-26.9 27-29.9 30-34.9 35-39.9 >40.0

Diet, physical activity, and behavior therapy

With comorbidities

With comorbidities

Indicated Indicated Indicated

Pharmacotherapy Not Indicated With comorbidities Indicated Indicated Indicated

Surgery Not Indicated Not Indicated With comorbidities

Exercise recommendations for Obesity Initially, moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days per week, should be encouraged. Extremely obese persons may need to start with simple exercises that can be intensified gradually in order to avoid injury. Although it will not lead to a substantially greater weight loss than diet alone over 6 months, it is most helpful in the prevention of weight regain. Exercise is beneficial for reducing risks for cardiovascular disease and type 2 diabetes, beyond that produced by weight reduction

en should include skilled supervision and idance as well as motivational techniques, in order to reduce injury potential and hance compliance.

e need for performing exercise testing for cardiopulmonary disease is based on a tient's age, symptoms, and concomitant risk factors. For most obese patients, ysical activity should be initiated slowly, and the intensity should be increased adually. Initial activities may be increasing small tasks of daily living such as taking e stairs or walking or swimming at a slow pace. With time, depending on progress, the

st, and functional capacity, the patient may engage in more strenuous activities. Some of these include fitness walking, cycling, rowing, cross-country skiing, aerobic dancing, and jumping rope. The same amounts of activity can be obtained in longer sessions of moderately intense activities (such as brisk walking) as in shorter sessions of more strenuous activities (such as running). Caloric expenditure will vary depending on the individual's body weight and the intensity of the activity. Reducing sedentary time, i. e., time spent watching television or playing video games, is another approach to increasing activity. Patients should be encouraged to build physical activities into each day. Examples include leaving public transportation one stop before the usual one, parking farther than usual from work or shopping, and walking up stairs instead of taking elevators or escalators. New forms of physical activity should be suggested (e. g., gardening, walking a dog daily, or new athletic activities). Identifying a safe area to perform the activity (e. g., community parks, gyms, pools, and health clubs); or, a designated area in one's home can facilitate engaging in physical activity. Encourage patients to plan and schedule physical activity 1 week in advance, budget the time necessary to do it, and document their physical activity by keeping a diary and recording the duration and intensity of exercise. http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

alone. Starting a physical activity regimguen Thpaphgrthamount of weight lo

- 35 -

Haskell, et al. have suggested the use of 4kcal/kghe Surgeon General recommends a minimum of 2 kcal/kg daily (2). See section 8 of

this handbook for ideas on amount of exerci sary for a given individual. 1. Haskell, WL, Montoye, HJ, Orenstein, D (1985 ical activity and exercise to achieve health-

cal fitness co nts. Publi ep

of body weight of exercise daily (1). T

se neces) Phys

related physi mpone c Health R 100:202-212. 2. DHHS: Physical activity and Health: A Report of the Surgeon General. Atlanta:US DHHS, CDC,

r for Chronic D e Control evention, National Center for Chronic Disease .

National CentePrevention and Health Pro

iseasmotion, 1996

and Pr

- 36 -

A Quick Primer For Health Professionals: Four Types Of Popular Weight Loss Diets By Valerie Berkowitz, MS RD CDE

CJ Segal-Isaacson, EdD RD Elena Tateo, MS RD

VERY LOW FAT MODERATELY LOW

FAT VERY LOW

CARBOHYDRATE LO

CAW/CON

RBOHTROYDR

LLED ATE

"Eat More, Weigh Less" by Dean Ornish, M.D.

Therapeutic Lifestyle Changes (TLC) Diet by the

American Heart Association

"Dr. Atkins New Diet Revolution" by Robert C.

Atkins, M.D.

“Theby A

South rthur A

Beacgatso

h Diet” n, M.D.

GOALS To prevent/reverse heart disease by lowering cholesterol and blood pressure with diet and lifestyle changes. Recommended for weight loss because of the premise that a low fat diet results in weight loss. Eating a vegetarian diet that is high in fiber and carbohydrate and very low in fat will help achieve goals.

To reduce the risk and rate of heart disease through adequate individualized calories promoting weight reduction and encouraging increased physical activity. Focus is placed on decreasing saturated fat and lowering LDL cholesterol. If diet alone is ineffective another therapeutic option is used: plant stanols/sterols (2 g/day) and soluble fiber (10-25g/day).

To achieve weight loss, weight maintenance, good health, increased energy, and prevent medical conditions such as heart disease, diabetes, and other diseases associated with metabolic resistance. Controlling carbohydrate intake and correcting hormonal imbalances, such as excessive insulin levels will help achieve goals.

To achieand imprprofile todisease aassociate

ve a healtove lipid prevent nd metabd with ob

hy boand glor revolic syesity.

dy weight ucose

erse heart ndrome

NUTRIENT COMPOSITION

No caloric restriction Carbohydrate: 70-80% Fat: 10 % (~15-25g)

Calories based on individual needs, caloric distribution: Carbohydrate: 50-60% (~20-30g fiber) Protein: 15% Total Fat: 25-35% Saturated fat <7%

No caloric restriction, nutrient composition changes with each phase of the program: Phase I, Induction Carbohydrate: 5-8% carb (~20g)

Does not re xof protein, dFocus is pla crefined carb teallows som vegetables 1 alow-glycem tables.) es unsaturated fats, including3’s and monounsaturates (ie. olive oil) in place of saturated and trans

quire ficarbohyced on ohydra

e whole (Phase ic vege

ed prate ontr int

graionly

ercentage or fat. olling ake but ns, fruit and

llows Promot omega-

- 37 -

20% CholesterSodium ≤ 2400mg

e II, On-Going Weight

Polyunsaturated fat 10%

Protein: 30-35% Fat: 60-65%

Monounsaturated fat

ol <200mg PhasLoss Carbohydrate: 9- 12% (25- >45g) or (60-90g

ProF Phase III, Pre-Maintenance

with vigorous activity)

tein: 30-35% at: 53-55%

Range of CHO (individualized, slightly mocarbs than phase II, slightly less than phase IV) between12.5 and 24%, 30-35%protein (allow 3 months to lose the last few pounds) Carbohydra

re

te: 12.5-24%

individualized, slightly more

loose the last 10 pounds Phase IV, Maintenance

(than Phase II, slightly lessthan Phase IV) Protein: 30-35% Fat: 41-57% *Allow 3 months to

(25-Carbohydrate: 13-25%

>90g) or (>90g with vigorous activity) Protein: 30-35%

at: 40-45%

Phase 1

F

fat.

All carbohydrates restricted except for low-glycemic vegetables. Allleafats. ty

ows “normal” portions of n/medium fat protein and good

Sample meal plans indicate pical serving sizes.

Phase 2

The concept of glycemic index (Gis introduced and lower-GI carbohydrates, such as apples, higfiber cereals, multigrain breads, anreduced-fat milk, are gradually reintroduced into the diet.

I)

h-d

Higher-GI carbohydrates, such as refined-

rain breads and potatoes, are proscribed.

Phase 3

g

Maintenance phase when one has reached their ideal weight and no foods are specifically prohibited.

- 38 -

VERY LOW FAT HYDRATE LOW/CONTROLLED ARBOHYDRATE

MODERATELY LOW FAT VERY LOW CARBO

C "Eat More, Weigh Less"

by Dr. Dean Ornish t by the American

Dr. Atkins New Diet Revolution" he South Beach Diet” Therapeutic Lifestyle Changes (TLC) Die

Heart Association

"by Dr. Robert C. Atkins

“Tby Arthur Agatson, M.D.

FOODS CONSUMED

Allowable foods: Beans/legumes, fruits, grains, vegetables, non-fat dairy products Eliminate: All meats (including chicken/fish), all dairy except non-fat choices, all oils, olives, nuts/seeds, and avocado Avoid simple sugars, fats, and alcohol Include fish oil supplements

AAl s and portion size Meat (lean cuts only), poultry, fish, peas/beans, tofu, eggs (<

llowable foods: l foods based on calorie

2 yolks/week, unlimited egg whites) Milk/yogurt/ cheese (non-fat or low fat) Fats/oils/nuts/salad dressing (includes food preparation) Fruit Vegetables Grains, pasta, rice, cooked cereal, potatoes, bread Sweets/snacks

Allowable foods: Phase I, Induction Liberal combinations of natural, not hydrogenated, fats (oils, butter, heavy cream and mayonnaise) and

ken, shellfish,

l

j

protein (fish, chiceggs, red meat)

Measured portions of dark green eafy and non-starchy salad

vegetables, olives, avocado, lemon uice

Eliminate: fruit, bread, pasta, grains, starchy vegetables, milk, yogurt ordairy

Phase 1 First 14 days exclude bread, rice, potatoes, pasta, baked goods, fruit, candy, cake, cookies, ice cream, sugar, and alcohol. Foods allowed: lean/medium fat proteins including

ggs, meat, poultry, tofu, pork, veal, some unsaturated fats

h as

,

seafood, e

such as olive or canola oil and nuts, low-glycemic vegetables sucgreens, asparagus, broccoli, cabbage cucumbers, etc., unsweetened fat-free or low-fat dairy, and if desiredsugar-free “sweets” (limit “sweets”to 75 calories per day). Phase 2 Add fruits excluding canned fruit,

apple, raisins and elon. Add (sparingly) whole

hase 3

juice, pinewatermgrain bread, rice and pasta, sweet potatoes, popcorn. May have red orwhite wine and fat-free, sugar-free pudding. P

he most liberal stage of the diet. There are no food lists and the author suggests enjoying food without over-indulging. If any weight gain during this time, switch back to Phase 1 for a week or two to lose any weight you may have gained.

T

- 39 -

V M T L D

ERY LOW FAT ODERATELY LOW FA VERY LOW CARBOHYDRATE

OW/CONTROLLECARBOHYDRATE

"Eat More, Weigh Less" by Dr. Dean Ornish

Therapeutic Lifestyle Changes (TLC) Diet by the

can Heart AssoAmeri ciation tkins

"Dr. Atkins New Diet Revolution" by Dr. Robert

C. A

“The South Beach Diet” by Arthur Agatson, M.D.

FOODS CONSUMED

Phase II, Ongoing Weight Loss Carbohydrate-containing loglycemic response foods should be added carefully ihe following

w-

n order: Non-

sh

wine and other low-

grams a day of carbohydrate For example, the first week, starting from a base of 20 g carbs, add five grams for one week so that the total daily carbohydrate intake is 25g. If the weight loss is still satisfactory, add another five grams of daily carbohydrate. Continue adding carbohydrate back like this as long as satisfactory weight loss continues.

tstarchy salad vegetables, frecheeses, seeds/nuts, berries and other low-glycemic index fruits,carb spirits Add 5

- 40 -

VERY LOW FAT MODERATELY LOW FAT VERY LOW

CARBOHYDRATE LOW/CONTROLLED

CARBOHYDRATE "Eat More, Weigh Less"

by Dr. Dean Ornish Therapeutic Lifestyle

Changes (TLC) Diet by the American Heart Association

"Dr. Atkins New Diet Revolution" by Dr. Robert

C. Atkins

“The South Beach Diet” by Arthur Agatson, M.D.

FOODS CONSUMED

Phase III, Near Goal Weight

rease loss is

ms, if ined this is

Legumes, fruits higher in glycemic index, starchy vegetables and whole grains The goal is to lose about one pound per week. To do this, add 10 grams of carbohydrate per day for one week (add another 10g carbohydrate per day, if weight loss is > pound; dec1

carbohydrate if weight< than 1 pound). If goal weight achieved, maintain this level of carbohydrate for one month (add 10 grams of carbohydrate per day to determine effect onweight), if weight gain occurseliminate the 10 graweight is maintathe critical carbohydrate level for maintaining weight. Phase IV, Maintenance All foods selected above as art of a varied nutrition

regimen p

- 41 -

VERY LOW FAT MODERATELY LOW FAT VERY LOW CARBOHYDRATE

LOW/CONTROLLED CARBOHYDRATE

"Eat More, Weigh Less"

by Dr. Atkins by Dr. Dean Ornish

Therapeutic Lifestyle Changes (TLC) Diet by the

American Heart Association

"Dr. Atkins New Diet Revolution" Robert C.

“The South Beach Diet” by Arthur Agatson, M.D.

SAMPLE MENU Breakfast Fruit salad with nonfat cottage cheese topped with granola Lunch Fresh vegetable salad topped with tofu, raisins and mandarin orange slices and a baked potato topped with nonfat yogurt Dinner Rice and beans with steamed vegetables Snack Melon wedge

Breakfast Egg white vegetable omelet, low-fat cheese, 1/2 bagel with jam Lunch Minestrone soup, grilled turkey sandwich with lettuce and tomato, fruit cup Dinner Tossed salad, low-fat salad dressing, pasta with chicken and broccoli Snack fruit

and cado,

rlic,

Phase 1 Breakfast 6 oz. Vegetable juice cocktail, 2 vegetable quiche cups (recipe), decaf coffee or tea. Midmorning snack: 1 part-skim mozzarella cheese stick Lunch: Sliced grilled chicken breast on romaine, 2 Tbsp Balsamic Vinaigrette (recipe) or low-sugar prepared dressing Sugar-free flavored gelatin dessert Mid-afternoon snack: Celery stuffed with 1 wedge of light cheese Dinner: Grilled Salmon with Rosemary (recipe), steamed asparagus, tossed salad, oil & vinegar to taste. Dessert: Vanilla Ricotta Crème (recipe)

Breakfast Whole egg mushroom, tomato cheese omelet with sliced avonitrite-free Canadian bacon Lunch Spinach and mixed leaf salad with fresh veggies topped with parmesan cheese and sliced beef round and oil and vinegar dressing Dinner Salmon, kale topped with galemon and sesame seeds Snack

hicken salad C

- 42 -

CLAIMS "Eat more weigh less", eat an extremely low-fat vegetarian diet, reducreverse/prevent heart disease (i.e. arterial clogging, angina) This increase eneed for medication.

Consuming the appropriatpercentages of nutrients wi in an

will help to reduce cardiac risks and weight

Switch the body from carbohydrate to fat burning (lipolytic pathway) to correct m ties asso rate intak This will p h, help impr

resistance (obesity, ,

e stress, and exercise to

will promote weight loss, nergy and eliminate the

e th

individualized amount of calories etabolic abnormaliciated with excess carbohyde and insulin sensitivity

romote good healtprove energy levels and help event medical conditions affected

by insulin diabetes, heart disease, syndrome XPCOS, cancer and mood swings/energy level)

- 43 -

T LOW/CONTROLLED CARBOHYDRATE

MODERATELY LOW FAVERY LOW FAT VERY LOW

CARBOHYDRATE "Eat More, Weigh Less"

by Dr. Dean Ornish erapeutic Lifestyle

Changes (TLC) Diet by the American Heart Association

et Revolution" by Dr. Robert

“The South Beach Diet” by Arthur Agatson, M.D.

Th "Dr. Atkins New Di

C. Atkins SUPPORTING EVIDENCE FOR CLAIMS

LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280(23):2001-7.1

PMID: 9863857 Ornish D, Brown SE, Scherwitz LW, et al. Lifestyle changes and heart disease. Lancet, 1990;336(8707):129-33. 2

PMID: 1975906 Ornish, D. Avoiding revascularization with lifestyle changes: the multicenter lifestyle demonstration project. Am J Cardiol. 1998; 82(10B): 72T-76T.3 PMID: 960380

Lichtenstein AH, Ausman LM, Jalbert SM, et al. Efficacy of a Therapeutic Lifestyle Change/Step 2 diet in moderately hypercholesterolemic middle-aged and elderly female and masubjects. J Lipid Res. 2002;43(2):264-73. 7

PMID: 11861668 Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-97.8

PMID: 11368702 Katan MB. High-oil compared with low-fat, high-carbohydrate diets in the prevention of ischemic heart disease. Am J Clin Nutr. 1997; 66(4 Suppl):974S-979S. PMID: 9322576 Katan MB, Grundy SM, Willett WC. Should a low-fat, high-carbohydrate diet be recommended for everyone? Beyond low-fat diets. N Engl J Med. 1997;337(8):563-6.9 PMID: 9262504

oks;

an, NM, Jacobson MS. Low carbohydrate dieting increases weight loss but not cardiovascular risk in obese adolescents: a randomized controlled trial. J AdolHealth. 2000;26:91. 14

Sharman MJ, Kraemer WJ, Love DM. et al. A ketogenic diet favorably affects serum biomarkers for cardiovascular disease in normal-weight men. J Nutr. 2002;132(7):1879-85.15

PMID: 12097663 Westman EC, Yancy, WS, Edman JS, et al. Effect of 6-month adherence to a very low carbohydrate diet program. Am J Med. 2002; 113(1):30-6. 16 PMID: 12106620

A search of Pub Med using keywords “South Beach Diet” did not return any citations specific to this diet. No references cited in book.

Ornish D, Scherwitz

le

Atkins RC. Dr. Atkins' New Diet Revolution. NY;NY: Avon Bo2002.13 Sondike SB, Copperm

- 44 -

VERY LOW FAT MODERATELY LOW FAT VERY LOW CARBOHYDRATE

LOW/CONTROLLED CARBOHYDRATE

"Eat More, Weigh Less" Therapeutic Lifestyle by Dr. Dean Ornish Changes (TLC) Diet by the

American Heart Association

"Dr. Atkins New Diet Revolution"

by Dr. Robert C. Atkins

“The South Beach Diet” by Arthur Agatson, M.D.

REFUTING

Kasim-Karakas SE, Almario

at,

gy intake. Am J 2000; 71(6):1439-

The soft ary fat. Science.

5

ow-fat diet is not associated with improved lipoprotein profiles in men with a predominance of large, low-density lipoproteins. Am J Clin Nutr. 1999;69: 411-18.6 PMID: 10075324

a

-

87S.11

lin T, Lamendola C, et al. High

8.12 PMID: 11078235

Westma

1999;6(7):36-40. 17

None could be found. EVIDENCE FOR CLAIMS

RU, Mueller WM, Peerson J. Changes in plasma lipoproteins during low-fhigh-carbohydrate diets: effects of enerClin Nutr.47.4

PMID: 10837283

trition. Taubes G. Nucience of diets

2001; 291(5513):2536-45.PMID: 11286266 Dreon DM, Fernstrom HA,

et al. A very-Williams PT,l

Brown RC, Cox CM. Effects of high fat versus high carbohydrate diets on plasmlipids and lipoproteins in endurance athletes. Med Sci Sports Exerc. 1998;30(12):1677-83.10 PMID: 9861599 Krauss RM, Dreon DM. Lowdensity-lipoprotein subclasses and response to a low-fat diet in healthy men. Am J Clin Nutr. 1995;62:478S-4PMID: 7625363

aughAbbasi F, McL

carbohydrate diets, triglyceride-rich lipoproteins, and coronary heart disease risk. Am J Cardiol. 2000;85(1):45-

n EC. A review of very low carbohydrate diets for weight loss. J Clin Obes Med.

- 45 -

POTENTIAL ADVERSE EVENTS

Increased triglycerides,

in faa

Decreased HDL without Short term

decrease in HDL, conditions associated with a decrease

t-soluble, B vitamin stores nd essential fatty acids

change in TG or total cholesterol/HDL-C ratio

ps,

con

ele

Bad breath, muscle cramstipation, increased uric

acid levels and occasionally vated LDL

Long term Unknown, currently being studied

Phase 3 (the maintenance

th

mof how

prevent subsequent weight gain.

phase) of the diet is not well defined. The book indicates

at no foods are restricted during this phase. The overall

essage may not be clear to the consumer in terms much food they should eat to

CLINICAL BENEFITS d

ease i

t al cholesterol and triglycerides, increased HDL and improvements in glycemic control

Weight loss, may improve lipid profile and glycemic control during Phase I and II.

Weight loss, reverse/prevent heart disease, stress reduction

If portions are used appropriately, weight loss anreduced risk of heart dis

l prof lebased on persona

Weight loss, decreased ot

- 46 -

Weight Loss Drugs

t s approved by the FDA for long-term usage Indications for weigh loss drug

M• Patients with a B I >30 an

I >

d without concomitant obesity-related risk factors or

Mdiseases.

• Patients with a B 27 wit

ht manag

h concomitant obesity-related risk factors or diseases.

ig ement has begun to change from short-term to long-term

• Because of the tendency to regain weight after weight loss, the use of long-term ication to aid reatment of obesity may be indicated for carefully selected

ents. patien no e ommended 1 pound per week after at least 6 months weigh ss re includes an LCD, increased physical activity, and

avior t py, l consideration may be given to pharmacotherapy. ted ern cceptable side effects, such as regurgitant valvular hea withdrawal of dexfenfluramine and fenfluramine from r p e 7 roved Sibutramine and in April 1999 Orlistat, for r o

• These drugs are modestly effective in their ability to produce weight loss. Net weight loss attributable to drugs has generally been reported to range from 2 to 10 kilograms.

• itial responders ten inue to respond, whereas initial nonresponders are ss likely to respo ith an increase in dosage. If a patient does not lose 2 ilograms (4.4 lbs 4 weeks after initiating therapy, the likelihood of long-rm response is v is information may be used in deciding to discontinue eatment.

classes of weigh norexiants ppetite suppress

lasses of anorexiant drugs which affect neurotransmitters are:

that affect olamines, such as dopamine and norepinephrine; that affect in; that affect an one neurotransmitter.

Drug therapy for weuse.

medpati

• If a on abeh

• Reporlesionsthe ma

• In Novlong-te

in the t

t lost th recgimen that

then carefus about unart, led to thetember 1997. , the FDA appbesity.

t hast lo

heraconcthe in Seer 199se in

of ketmbm u

Inlektetr

Two1. A2. A

d to contnd, even w

) in the first ery low. Th

t loss drugs

ants.

Three c1. Those2. Those3. Those

catechserotonmore th

- 47 -

current weight loss medications are:

omments

Two commonly used Drug Dosage Mechanism Side Effects C

Sibutramine 5, 10, 15 mg Inhibits Increase in heart People with high bloo(Meridia) 10 mg p.o. the reuptake of

norepinephrine, rate and BP. pressure,

CHD, congestive hq.d. to start,

increased to 15 mg or

d

eart

of stroke

may be dopamine and serotonin

failure, arrhythmias, or history

decreased to 5 mg.

should not take sibutramine.

Orlistat 12(Xenical) t.i.d. before

meals. pancreatic lipase; decreases fat absorption by

absorption of fat-soluble vitamins. Soft stools and

supplement is recommended wtaking this drug.

0 mg p.o. Inhibits Decreases A multivitamin

hen

30% anal leakage. Follow-Up Visit Schedule and assessment of side-effects • Two to four weeks after initial visit • Monthly for three months • Every three months for the first year after initiating the medication. • After the first year, the doctor will advise the patient on appropriate return visits. Weight Loss Surgery Candidates for weight loss surgery • Patients with severe and resistant obesity • Patients in whom efforts at other therapy have failed Patients in whom complications of obesity are present

-related morbidity and mortality and motivated patients with BMI>

•• Patients at high risk for obesity• Well informed 40 • Patients with BMI>35 who have comorbid conditions (cardiovascular, sleep apnea,

uncontrolled type 2 DM, weight-induced physical problems that interfere with activities of daily living).

• Patients with acceptable operative risks

- 48 -

ption:

ctive O s: Lim nd do ith the no

A band of siliconsmall pouch and narro

rest of the stomach.

• Verti a G): Uses both a band ansmall stomach pouch. VBG is not often used today. Adv er to perform and generally safer than maoper AGB is routinely performed via laparoscopy. Disa Lo e/c ions. Risk iting is t on ris s narrow passage into the larger party of t me r risk is slippage or wearing away of the band and some patients experience infections and bleeding but this is much less common than other risks. Death

ll cases.

tive Operations: Malabsorptive operations are no longer recommended because they result in

be more

stric bypass (RGB): The most common and successful e US. The Surgeon creates a small stomach pouch

ped section of the small intestine is he lower stomach, the

ted operation, the

tritional

kly with combined procedures and continue to do so for up to 24 months after procedure. Weight maintenance is more likely than in restrictive surgery alone. RGB is often performed laparoscopically, which is less common with the BPD procedure. Disadvantages: Combined procedures are more difficult to perform than restrictive procedures. They are also more likely to result in long-term nutritional deficiencies because the food bypasses the duodenum and jejunum where many nutrients are absorbed. Most common deficiencies: Vitamin B12, iron, calcium, and Vitamins A, D, E and K. RGB and BPD may also cause “dumping syndrome” when food moves too quickly through the body without being absorbed and may cause diarrhea, nausea, pain, bloating, weakness, sweating, faintness.

Surgical Interventions geared toward reducing food consum Restri peration it food intake a not interfere w rmal digestiveprocess.

• Adjustable Gastricstomach near its upper end, creating a

Banding (AGB):

stroplasty (VB

e is placed around the w passage into the

d staples to create a

labsorptive

cal Banded G

antages: Easiations.dvantages: s: Vom

se less weight thanhe most comm

from malabsorptivk when patient eat

ombined operattoo much food or the s blocked. Anothehe stomach beco

may occur from complications in less than 1 percent of a

Combined Restrictive/Malabsorp(intestinal bypasses) alonesevere nutritional deficiencies. However, combined operations may effective in improving the health problems associated with severe obesity.

• Roux-en-Y gacombined procedure in thto restrict food intake. Next, a Y-shaattached to the pouch to allow food to bypass tduodenum, and the first portion of the jejunum.

• re complica Biliopancreatic diversion (BPD): In this mo

lower portion of the stomach is removed. The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the duodenum and jejunum. This poses a greater risk for nudeficiencies. Advantages: Most patients lose weight quic

- 49 -

s such as infections, combined procedures are more likely to lead to complications.

abdominal hernias (up to 28 percent), which require a follow-up operation to

• Co ght. • Co st period of sustained

we

• Deapp

• Sigost

Premenop ed.

• ould

•

stric bypass operation reduces

Risks: In addition to risks associated with restrictive procedure

Combined operations carry a greater risk than restrictive operations for

correct. The risk of hernia, however, is lower (about 3 percent) when laparoscopic techniques are used. Risk of death for RGB patients is less than1 percent of cases; BPD with duodenal switch has an increased risk of 2.5 to 5% of cases.

Summary Notes On Weight Loss Surgery

mbined procedures may help patient lose 60 to 80 percent of excess weimpared to other interventions, surgery produces the longeight loss.

creases mortality for each year of follow-up when compared to non-surgical roach. (2)

nificant and prompt improvement in DM, sleep apnea, hypertension, GERD, eoarthritis, and urinary incontinence.

ausal women should avoid pregnancy until weight has stabiliz•

Women wishing to conceive after weight has stabilized post bariatric surgery shbe evaluated for micronutrient deficiencies and have them corrected prior to conception.

Good bariatric treatment should include medical, behavioral and nutritional components.

1. Source: National Institute of Diabetes and Digestive & Kidney Diseases http://win.niddk.nih.gov/publications/gastric.htm

. McDonald, K.G., Long, S.D., Swanson, M.S. et al (1997) The ga2

the progression of mortality of NIDDM. Jo Gastrointestinal Surgery 1: 213-220.

sessing Patients’ Motivation to Make Nutrition and Lifestyle Changes As

tients vary in their readiness (stages of change) for making lifestyle changes that lead Pato weight loss. Before recommending a weight loss program, the following factors be evaluated:

• Reaso nt's serious e? What ibehavi

• Previo hat factorsmainte

• Family patientto such

ns and motivation for weight loss: What is the extent of the patieness and readiness to undergo a sustained period of weight loss at this tim

s the patient's current attitude about making a life-long commitment to or change?

us history of successful and unsuccessful weight loss attempts: W were responsible for previous failures and successes at weight loss or nance of normal body weight?

, friends, and work-site support: What is the social framework in which the will attempt to lose weight, and who are the possible helpers and antagonists an attempt?

- 50 -

• The pa tes to obedange

• Attitudincreas

• Time ahealth professionals in long-term weight loss therapy?

Barriers: What are the obstacles that will interfere with the patient's ability to

y

fessional counseling that is not covered by insurance.

tient's understanding of overweight and obesity and how it contribusity-associated diseases: Does the patient have an appreciation of the rs of obesity, and are these dangers of significant concern to the patient?

e toward physical activity: Is the patient motivated to enter a program of ed physical activity to assist in weight reduction?

vailability: Is the patient willing to commit the time required to interact with

•implement the suggestions for change?

• Financial considerations: Is the patient willing to pay for obesity therapy? This mainclude having to pay for travel to the medical facility, time lost from work, and paying for pro

- 51 -

ner

Assessing Patient Motivation for Diet and Lifestyle Change

Stages of Change Characteristics Techniques for Practitio

Pre-contemplation Unaware of need for or possibility of change in health

Empower patient – decision is heEncour

behavior.

rs. age self-exploration, not action.

Contemplation Aware of health issue and now Empothinking about it. Encourage analysis of pros

wer patient – decision is hers. and cons

of health behavior.

Preparation Getting ready to make change in health behavior (setting start/quit date, etc.).

Identify and assist in problem solvin(e.g. obstacles). Help patientsocial support. Enc

g identify

ourage initial small steps.

Action Changing health behavior. Reinforce decision to act. Focus on restructuring cues and social support. Bolster self-efficacy for dealing with obstacles.

Maintenance Keeping new health behavior. Plan for follow-up support. Reinforce internal rewards and health benefits. Discuss coping with relapse.

Relapse Falling back to old health behavior.

Evaluate trigger for relapse. Reassess motivation and barriers. Plan stronger coping strategies.

Prochaska JO, DiClemente CC, Norcross JC.(1992) In search of how people change. Applications to addictive behaviors. Am Psychol 47(9):1102-14

- 52 -

nd Impaired 15. Criteria for the Diagnosis of Diabetes Mellitus aGlucose Tolerance

D s and I

Criteria for the iagnosis of Diabete mpaired Glucose Tolerance1

Diabetes Mellitus (on llowing criteria): e of the fo

• A casual plasma glucose concentration of >200llitus(polyuria, poly

mof diabetes me dipsia, unintent

• A fasting plasma glucose (FPG) level of >

g/dL(11.1 mmol/L) plus symptoms ional weight loss).

126 mg/dL (7 mmol/L) on two separate ions. Fas ke

• A 2-hour plasmoccas ting is defined as no caloric inta

a glucose level of > for > 8 hours.

200 mgOGTT) employing 75

/dL (11tolerance test ( grams of glu

.1 mmol/L) during an oral glucose cose.

Impaired Glucose Tolerance:

• 2-hour post-prandial glucose > 140 mg/dL (7.8 mmon OGTT.

ol/L) but <200 mg/dL (11.1 mmol/L)

Impaired Fasting Glucose:

• Fasting plasma glucose > 100 mg/dL but < 126 mg/dL (6.1 to 7.0 mmol/L). 1. Report of the expert committee on the diagnosis and clas e 20:

-1197.

sification of DM(1997). Diabetes Car1183

ADA Treatment Guidelines for Glycemic Control in Type 2 Diabetes

Lab Value (whole blood) Normal Goal Action Suggested

Preprandial glucose < 90 mg/dL 80-120 mg/dL < 80 or > 140 mg/dL

Bedtime glucose < 120 md/dL 100-140 mg/dL < 100 mg/dL or > 160 mg/dL

HgbA1C < 6%* < 7% > 8% * depending on lab norms.

- 53 -

Medical Nutrition Algorithm IFG/Type 2 Diabetes Prevention & Therapy

http://www.dshs.state.tx.us/diabetes/PDF/algorithms/NUTRITIO.PDF

- 54 -

harmacological Algorithm for Type 2 Diabetes

Hhttp://www.dshs.state.tx.us/idcu/health/dpn/issues/DPN58N18.PDF

P

Lipids Algorithm IFG e 2 Diabetes and Typ

- 55 -

- 56 -

http://www.dshs.state.tx.us/diabetes/PDF/algorithms/LIPID.PDF

- 57 -

Medications for People with Type 2 Diabetes

Oral Antidiabetic Agents1

Generic Name Brand Name

Daily Dose (mg)

Duration of Action (hours)

Mechanism of Action

Comments

First-Generation Sulfonylureas

Tolbutamide Orinase 500-3000 6-12

Chlorpropamide Diabinese 100-500 60

Tolazamide Tolinase 100-1000 12-24

Increases insulin secretion. Contraindicated when known sensitivity to the drug, in pregnancy.

Second-Generation Sulfonylureas

Glucotrol 2.5-20.0 12-24 Glipizide

Glucotrol XL 5-20 24

Diabeta 1.25-20.0 16-24 Glyburide

Micronase Glynase Pres Tab

0.75-12.0 12-24

Glimepiride Amaryl 1-4 24

Increases insulin secretion. Contraindicated when known sensitivity to the drug, pregnancy.

Meglitinides

Repaglinide Prandin 1-16 ~1 Taken before meals to increase insulin secretion and decrease post-prandial BS.

Metabolized by the liver; not contraindicated in renal insufficiency.

Biguanides

Metformin Glucophage 1500-2550 ~5.5* Primarily reduces hepatic glucose production; also increases muscle glucose uptake.

Increases HDL rol: decreases trigly e, total cholesterol and LDL Avoid use when sCr > 1.5 mg/dl, liver failure, CHF; near surgery or contr udies.

cholestecerid

ast st

Alpha-Glucosidase Inhibitors

Acarbose Precose 25-150 8*

Miglitol Glyset 25-300 8*

Inhibits carbohydrate absorption from the gut.

Contraindicated in patients with major GI di ers, severe hepatic or renal disease.

sord

Thiazolidinediones

Rosiglitazone Avandia 4-8 12

Pioglitazone Actos 15-45 24

Enhances sensitivity to insulin in peripheral tissues.

Monitor LFTs every 2 months for first year.

*Plasma half-life

1. Adapted from: Umpierrez, G.E., Kitabchi, A.E. (2001) Managing Type 2 diabetes: Evolving srategies fotreatment. Obstetrics and Gynecology Clinics

r 28(2):401-419.

- 58 -

s of Regular Human Insulin

Comparative Profiles of Various Type

Type of Insulin Onset (hr)

Effective (hr)

Maximal Duration (hr) Peak (hr) Duration

Lispro 4 <15 min 1 3

Regular 0.5 to 1 6 2 to 3 3 to 6

NPH 2 to 4 4 to 10 10 to 16 18

Len 4 12 12 to 18 te 3 to 4 to 20

Ultralente 6 to 24 to 30 10 Varies with 18 to 20dose

Ins e 1 to 2 Flat 24 (unulin glargin der review)

- 59 -

utritional and Exercise Recommendations for People with Type 2 Diabetes

1. The Essential Elem r Evaluating DM Nu ated Outluco H

• Monitor lipids

BP.

onitor rena .

als of Medical N Th NT) Maintain blood glucose levels as near normal as possible using medications, a balanced food intake, and physical activity.

ieve opt m

a reasonable weight. Current focus is lyc ntrol ss on weigh s.

• Prevent and treat long term complications of DM.

• Improve general health through good nutrition.

3. Nutrition Therapy and Type 2 Diabetes • Pharmacologic weight loss agents may be of benefit for people with

BMI>

N

ents Fose and

trition-Rel comes • Monitor g gbA1C.

.

• Monitor

• M l status

2. Go utrition erapy (M•

• Ach imal seru lipids.

• Provide adequate calories to achieve more on g emic co and le t los

27. Gastric reduction may be considered if BMI>35.

• Spacing meals and carbohydrate intake appropriately throughout the day helps improve glycemic control.

• Include 10-20% of kcal as protein, from vegetable, grain and animal sources. Severe protein restriction to 0.8 gm/kg may help delay the progression of renal disease if overt nephropathy is present. Further restriction to 0.6 gm/kg is suggested once GFR begins to fall.

- 60 -

Item Diabetes Diet Guidelines

1

Weight If excess body weight is present, restrict daily caloric intake by 500-1000 calorieManag

s per day < ug therapy to achieve weight loss as an adjunct to lifestyle

propriate. In patients with severe/morbid obesity, surgical options, such as gastroplasty, may be appropriate. It is important to counsel patients on the

including mortality, depression, hypoglycemia, nutritional deficiencies, d weight regain over the long term.

ement usual intake. In selected patients, drchange may be apgastric bypass andrisks of surgery,osteoporosis, an

Protein present

~10% of daily kcal 0.8 gm/kg body weight if overt nephropathy 0.6 gm/kg if GFR is declining

Carboh d ion

oves glycemic control. ride l

agement of DM.

y rate 45-65% of daily kcal. Total amount of CHO may be individualized based on nutritassessment, treatment goals, lipid profile. Spacing CHO throughout day imprBoth the amount and type of CHO in food influence blood glucose level. Increased triglyceand VLDL may merit reduction CHO and increased monounsaturated kcal. Restricting totacarbohydrate to <130 g/day is not recommended in the man

Fiber aily.

Promotes bowel health and regularity. 20-35 gm total of soluble and insoluble recommended d

Alcohol May produce hypoglycemia in people treated with oral agents or insulin, especially if consumed

ecially

without food. Limit to 1 drink daily for women, 2 for men. Reduction or abstention if pancreatitis, neuropathy, dyslipidemia, esphypertriglyceridemia, or history of alcoholism.

NutritivSweetene

, and an sucrose.

hese may

e rs

No evidence that foods sweetened with corn syrup, fruit concentrates, honey, molassesmaltose promote better DM control thKcal from maltitol, mannitol, xylitol, and sorbitol should be counted in total kcal: Thave a laxative effect.

Fat 0-15% kcal

If LDL elevated- < 200 mg cholesterol.

25-35% of daily kcals. <7% kcal as saturated fat, < 10% kcal as polyunsaturates, 1as monounsaturates, <300 mg cholesterol.

Sodium General recommendations < 2300 mg daily.

Multivitamins Not recommended unless diet is of poor nutritional quality

1. Standards of Medical Care in Diabetes. 2006. American Diabetes Association http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s4#T6

- 61 -

Types and Limitations teners of Various Artificial SweeChemical

Name ProN d

duct ame

Sweetness Relative to

Sugar

Uses Limitations Types of foods Year Develope

Saccharin Swee

r foods (manufacturer

tituting it for

cancer in lab rats – not

ut risks ns.

Bitter aftertaste.

scovered in 1870s

t N Low 200 to 700 times

Can be used in both hot & cold

Avoid if pregnant Causes

All types Di

sweeter than suga

recommends sure aboto huma

subsonly half the sugar in recipes)

Aspartame NutraSEqualNatraT

baking

Desserts, soft

old preparations. NatraTaste is

Discovered in

by 1974

weet; ;

160 to 220 times

Substitute 6 (1gram) packets

Do not use ifhave PKU

aste sweeter than sugar

for each ¼ cup of sugar

Loses sweetness when heated – not good for

drinks, candy & gum, teas, breath mints, vitamins & c

1965, approved FDA in

Kosher

Ace potassium (acesulfame-K)

SweeSunetAltern

for each ¼ cup of

goods not same drinks, baked

is Kosher

1967, approved by FDA in 1988

sulfame t One; 200 times Can use for Texture of baked Hot & cold Discovered inte; aSweet

sweeter than sugar

baking & cooking: does not break down when heated.

as with sugar. Bitter aftertaste.

goods, etc. Sweet One

Use with sugar when baking – substitute 6 (1gram) packets

sugar.

Sodium and Calcium Cy yl-fam

Cycla

countries. Heat

Toothpaste, mouthwash, desserts, candy, etc. When previously used in foods, it was

ed together ther

artificial sweeteners b/c it added bulk to finished product.

Discovered in 1937. Lost FDA approval in 1970.

clohexylsate

mate Banned for food use in US in 1970. Still used in over 55 other

stable. blendwith o

- 62 -

lycemic Index The glycemic i 100 according to th Foods with a

GI ar hat diges d absor ed ood (typica cose or white bread.) Low-GI foods, by virtue of their slow digestion

and absorption, produce more gradual rises in blood sugar and insulin levels, and some dies l s m oth in peopl

with diabetes (type 1 and type 2). al onfirmed this effehowever. (2) Although the glycemic index can b fo betic patients about their diets, the concept has not be ndorsed; in part because the GI of an isolated food changes depending actors. First, meals contain other

stitu s f t the d ab of tfood. Th ric (or here it it process st ar rateglycemia as well. Using carrots as an example, note the GI variability of this food based on different conditions:

• Although boiled carrots have a low/moderate to high GI, the actual effect on blood sugar is small because portion sizes are typically much smaller than that u GI

R

Gndex (GI) is a ranking of carbohydrates on a scale from 0 to e extent to which they raise blood sugar levels after eating.

high loa

e those tlly glu

are rapidly ted an bed compar to a standard f d

stu suggest that ow-GI diet ay improve b(1) Other clinic

e a useful tool en universally eon a variety of f

glucose and lipid levels e ct, trials have not c

r educating dia

con ents such ae total caloed, and the

protein and contentyle of prep

at that affecserving size) of tation (cooking m

digestion anhe food, w

sorption rate is grown, howall affect the

he is of ethod and time)

sed to test

aw

.

• carrots ha lo

• Australian boiled carrots are reported to have a low GI (32 to anadian boiled carrots have a high G

Glycemic Index and Diabetes When working with a diabetic patie sugar or hemoglobin A1C is not well-controlled, it is most important to l he total amount of carbohydrates in the diet as

as rbo ydrate is d gh ut the day. Sec may bul to ge the patient to er glycemic foods lycem

The patient may benefit from a ref tered Dietitian (RDDiabetes Educator (CDE) who can implement a plan and evaluate their progress. Some steps the RD or CDE might take could include (4):

1. Monitor pre and post blood glucose concentration 1-2 hour a sess the effects of carbohydrate and total food intake on glycemic control (Note: Normal glucose concentration is < 140 mg/dL at two hours but goals need to be individualized based on the risk of hypoglycemia).

2. Determine if the amount of carbohydrate eaten is contributing to any post meal elevation (keeping the amount of carbohydrate consistent will make assessing the effects on postprandial glucose easier).

3. Examine the portion size, especially potential errors, in estimating how many grams of carbohydrate may be in foods with variable portion sizes (e.g., pasta, bagels, muffins) and

ve a very w GI of 16.

I (92). (3)

nt whose bloodook at t

49), while C

well usefones.

how this ca encoura

h istributed throu substitute high

erral to a Regis

o-

ondarily, it with lower-g

) or Certified

fter eating to as

e ic

- 63 -

mponents of carbohydrate such as fiber in legumes that may affect

4. Examine cothe postprandial response and the glycemic load of food intake.

Glycemic Index of Select Foods*~

Low GI (55 or less) ** Medium GI (56-69) * * High GI (70 or more) * *

BREADS BREADS BREADS 100% stone ground whole wheat Whole wheat White bread Heavy mixed grain Rye Kaiser roll Pumpernickel Pita Bagel, white

CEREAL CEREAL CEREAL All Bran™ Grapenuts™ Bran flakes Bran Buds with Psyllium™ Shredded Wheat™ Corn flakes Oatmeal Quick oats Rice Krispies™ Oat Bran™ Cheerios™

GRAINS GRAINS GRAINS Parboiled or converted rice Basmati rice Short-grain rice Barley Couscous Bulgar Sweet corn Pasta/noodles

STARCHY VEG, FRUIT, STARCHY VEG, FRUIT, LEGUMES LEGUMES LEGUMES

STARCHY VEG, FRUIT,

Sw Potato, baking (Russet) e t potato Potato, new/white eYam Cantaloupe French fries Lentils Kiwi Watermelon Chickpeas Black bean soup Kidney beans Green pea soup Split peas Apricot, raw (Italy) Soy Peach, raw (Italy) beans Baked beans Cantaloupe Apple, raw OTHER OTHER Grapes (Canada) Popcorn Pretzels Banana Stoned Wheat Thins™ Rice cakes Pineapple, raw (Philippines) Ryvita™ (rye crisps) Soda crackers Orange, raw, Sunkist Scones Gatorade (sports drink)

*Adapted from Canadian Diabetes Website www.diabetes.ca and Foster-Powell K, Holt, S, and Brand-Miller, J Am J Clin Nutr 2002;76:5-56

~Lower-starch vegetables and raw berries are not included in the list due the their negligible effect on glycemia.

**Expressed as a percentage of the value for glucose. 1. University of Sydney, Australia http://www.glycemicindex.com/aboutGI.htm

- 64 -

: etes: a statement

3. Foster-Powell K, Holt S an ic index and glycemic load values: 2002 Am J Clin Nutr

instein Co nding rev7.

2. Sheard NF, Clark NG, Brand-Miller JC, Franz, MJ, Pi-Sunyer FX, Mayer-Davis e, Kulkarni K, Geil PDietary carbohydrate (amount and type) in the prevention and management of diabof the American Diabetes Association. Diabetes Care 27:2266-2271. 2004

d Brand-Miller J: International table of glycem 2002; 76:5-56

4. Wylie-Rosett, J. Albert EDietetic Association, 200

llege of Medicine. Article pe iew, Journal of American

- 65 -

larly.

at least 1000 kcal weekly.

rols and should aim for an exercise level of 10-12 RPE (very light to somewhat hard).

• Autonomic neuropathy may affect heart rate; therefore, RPE may be easier for monitoring exercise use than heart rate.

• Low intensity exercise may enhance metabolic control but may not necessarily produce CV training effects. It may increase likelihood of adherence and less opportunity for musculoskeletal injury.

• Short-term, high-intensity exercise may increase blood sugar in obese, insulin resistant people with Type 2 DM. Hyperglycemia may persist up to 1 hour after activity.

• There is an inverse relationship between fitness level and mortality across all levels of glycemic control (1). Intra-abdominal obesity may be decreased by resistance training (2).

• Hypoglycemic reactions associated with exercise are rare, occurring mainly in clients treated with insulin or sulfonlyurea oral medication, during prolonged or intense physical exertion. Avoid exercise during the time of peak insulin activity. Discourage insulin administration in a site that will be intensely exercised.

• For fluid and carbohydrate recommendations for prolonged exercise, see sections 5 and 6.

• Self blood glucose monitoring is helpful before and after activity.

Exercise Guidelines For Diabetes

Exercise Recommendations for Type 2 Diabetes • Favorable changes in glucose tolerance and insulin sensitivity subside 72 hours

after exercise. Therefore, exercise should be performed regu

• Individuals should strive to perform

• People with Type 2 DM generally have a lower level of fitness than age and activity-matched cont

Cardiovascular Exercise: 1000 kcal/week

Resistance Exercise: 8-10 exercises involving the major muscle groups

Frequency >3 nonconsecutive days per week and up to 5 days

>2 days weekly

Intensity Low to moderate 40-70% VO2max, 10-12 RPE*. If nephropathy present, avoid activity which produces BP >180-200 mm Hg; later stages low intensity 50% VO2max

1 set of 10-15 repetitions to near fatigue.

Duration 10-15 minutes initially. >30 minute goal. 30-60 minutes for weight loss.

Mode Walking Non-weight bearing if peripheral neuropathy: swim, aquatic activity, stationary cycle.

- 66 -

*

d

RPE=Rating of Perceived Exertion 1. Kohl, H.W., Gordon, N.F., Villegas, J.A., et al (1992) Cardiorespiratory fitness, glycemic status, an

mortality risk in men. Diabetes Care 15:185-192 2. Treuth, M.S., Hunter, G.R., Keekes-Szabo, R.L., et al (1995) Reduction in intra-abdominal adipose

tissue after strength training in older women. J Appl Physiol 78:1425-1431.

Client Evaluation before Beginning an Exercise Program (ADA1, ACSM2)

Appraisal of glucose control (HgbA1C)

Analysis of joint limitations

Evaluation of medications and potential for hypoglycemia with activity

Type and severity of complications (nephropathy, retinopathy, peripheral neuropathy)

Exercise ECG to establish safe target heart rates in clients with known or suspected CA>30 years of age with Type 1 DM, Type 1 > 15 years, or Type 2 > 35 years old..

D,

1. ADA American Diabetes Association. The Health Professional's Guide to Diabetes and

rciseExercise.(1995) Ruderman, N., and Devlin, J., eds. Alexandria, VA: ADA, Inc. 2. ACSM Position Stand: Exercise and Type 2 DM(2000) Medicine & Science in Sports & Exe 32(7):1345-1360.

- 67 -

ent And Guidelines for Older Individuals16. Nutrition Assessm

- 68 -

Considerations in Prescribing Weight Reduction after 65 years of Age

NHLBI Guidelines for Weight Reduction after Age 65

• Potential ability to increase functional status.

• Ability to reduce the risk of future CV events.

• Patient motivation.

• Cardiovascular (CV) risk factors are especially increased in older persons who are overweight.

• Obesity is a major predictor of functional limitations and mobility impairments in this group.

Factors in safe weight reduction

• Include skilled nutrition counseling to minimize the adverse effects on bone health and overall nutritional status.

• Include expert instruction in moderate weight-bearing and resistance activity.

• Aim to preserve lean body mass and reduce fat mass. Exercise for Older Adults • By the year 2030, there will be >70 million people in the U.S. > 65 years; people >

85 years will be the fastest growing segment of the population.

• While increasing physical activity may not always improve markers of training, improved health and functionality may occur. Improvements in glucose metabolism may occur even before weight or body composition changes.

• VO2MAX decreases 5-15% per decade after age 25. Maintaining high levels of exercise training can diminish declines in VO2MAX.

• Older adults demonstrate similar physiologic responses (increase 10-30% VO2MAX) with prolonged endurance exercise training.

• Older adults demonstrate similar or superior strength gains with resistance training compared to younger people. Two to three fold increases in strength may be demonstrated in 3-4 months.

• Symptomatic and asymptomatic CV disease increases in prevalence with age; absolute and relative contraindications to exercise testing and exercise training should be noted (ACSM, 1995).

• Sport-specific exercise testing may be necessary, e.g., a weightlifting stress test prior to initiating a resistance activity program.(Evans, 1995)

• Muscle mass declines with age: urinary creatinine, an indirect measure of muscle mass, decreases 50% between ages 20 to 90.

• Reduction in muscle strength is typical with age. Strength decreases approximately 15% per decade in the 6th and 7th decade and 30% per decade thereafter. Most of the strength loss is due to loss of mass.

- 69 -

Adequate protein intake is necessary for successful resistance training. Protein ll, 1994) This is an amount of

f elderly people.

d and walking ability.

e individual losing balance while

l changes of the collagen fibers, increasing the fibers diameter

fasting and glucose-induced insulin levels; improved insulin sensitivity and glucose tolerance.

to moderate intensity endurance exercise

increased HDL and HDL2, decreased triglyceride and

aabdominal fat.

lin

training help improve postural stability.

l

ological changes of aging, reverse disuse

e rograms in this population are

•requirements for the elderly are 1.25 gm/kg. (Campbeprotein consumption that is typically not consumed by the majority o

• Muscle strength is directly related to gait spee

• Postural stability, implying little or no risk of thstanding or falling during a dynamic activity, decreases with age.

• Aging causes physicaand decreasing extendibility. Flexibility begins to decline in the third decade of life.

Benefits of Endurance Exercise and Strength Training in Healthy Older Adults • Lower

• Decreases in blood pressure with light training.

• Improvements in lipid profiles:Tchol: HDL ratio.

• Decreases in body fat 1-4% even without weight loss.

• Marked decreases in intr

• Improvements in CV function and improvements in some CV risk factors with moderate to intense training.

• Increased activity level and muscle mass will increase metabolic rate, which normally declines with age. Meeting the increased need for kilocalories will increasethe total nutrient load and enhance the likelihood of meeting RDIs.

• Strength training helps maintain bone density, aerobic capacity, enhances insusensitivity and nitrogen retention. Functional independence and strength are increased. Improvements in dynamic balance may decrease fall risk and osteoporotic fractures.

• Light-intensity exercise training and strength

• Physical activity increases sense of self-efficacy and control. Normally, males experience a greater sense of self-efficacy. However, with exercise training in women, the gender bias disappears.

• Exercise in the frail and very old provides physiological, metabolic, psychologicaand functional adaptations to physical activity, which contributes to quality of life. Goals in this population are to minimize bisyndromes, control chronic disease, maximize psychological well-being, and increase mobility and function.

• “Sedentariness” appears a far more dangerous condition than physical activity in thvery old.”(ACSM, 1998) Most aerobic training pconducted at 60% of maximal predicted heart rate.

- 70 -

ajor Relative Contraindications for Exercise Testing

ventricular ectopy

Major Absolute Contraindications to Exercise Testing • Recent ECG changes or MI

• Unstable angina

• Uncontrolled arrythmias

• Third degree heart block

• Acute congestive heart failure M• Elevated blood pressure

• Cardiomyopathies

• Valvular heart disease

• Complex

• Uncontrolled metabolic diseases 1. ACSM. Guidelines for Exercise Testing and Prescription, (1995) 5t

Wilkins: 1-373 h ed. Baltimore: Williams and

vity for Older Adults. Medicine & Science in Sports 2. ACSM Position Stand: Exercise and Physical Acti& Exercise 30(6): 992-1008.

3. North, T.C., McCullagh, P., Tran, Z.V. (1990) Effect of exercise on depression. Exercise Sport Science Review 18:379-415.

4. Evans, W. (1995) Exercise and Aging, in eds. Ruderman, N. and Devlin, J.T., The Health Professional’s Guide to Diabetes and Exercise. Virginia: American Diabetes Association: 223-232.

5. Campbell, WW, Crim, MC, Dallal, DE, Young, VR. (1994) Increased protein requirements in the elderly: new data and retrospective reassessments. AJCN 60:167-175.

. Recommendations for Training for Older Americans • Cardiovascular: See ACSM recommendations (section 4). Programs of less

intensity or those combining briefer periods throughout the day may elicit health, but not necessarily CV training benefits.

• Strength Training: See ACSM recommendations (section 4). Results occur at aweight 60-100% of one Repetition Max

(RM) defined as the maximal amount that can

ncy ined.

Aerobic Dance, And Stretching: Due to age-related declines in flexibility, stretching pre and post-activity is increasingly important in order to decrease the likelihood of orthopedic injury.

be lifted with one contraction. Weights should be increased every 2-3 weeks until goal is achieved.

• Postural Stability: Broad based exercise program that includes balance training, resistive exercise, walking and weight transfer to reduce risk of falling. Frequeand intensity remain to be determ

• Flexibility: Include exercises that have been shown to increase range of motion: walking,

•

- 71 -

w strength and balance training. At least 3 days inutes, 40-60% heart rate reserve, or 11-13 rating of perceived

scale.

sive resistance training of the major muscle groups of the s and the trunk: at least 2 but ideally 3 days per week, 2-3

de some standing postures with free weights.

Postural Stability: Broad based exercise program that includes balance training, risk of falling. Frequency

determined.

lude exercises that have been shown to increase range of ic dance, and stretching.

Perceived Exertion Scale

Recommendations For The Very Old And Frail • Cardiovascular: Should follo

weekly, at least 20 mexertion on the Borg

• Strength Training: Progresupper and lower extremitiesets on each training day. Inclu

•resistive exercise, walking and weight transfer, to reduceand intensity remain to be

• Flexibility: Should incmotion: walking, aerob

Borg

Rating of Perceived Exertion (RPE) Description

6 7 Very, very light

8

9 Very light

10

11 Fairly light

12

13 Somewhat hard

14

15 Hard

16

17 Very hard

18

19 Very, very hard

20 Borg, G.A. (1982) Med Sci Sports Exercise 14:377-387.

- 72 -

and Physical Activity for 17. ACS Recommendations for NutritionCancer Prevention

Eat a variety of healthful foods, with an emphasis on plant sources.

.

re erate to vigorous activity on 5 or

more days per week may further enhance reductions in the risk of breast and colon cancer.

• a utes per day of moderate-to-vigorous physical activity at least 5 days per week.

Maintain a healthful w ight throughout life

• Balance caloric intake with physical activity. • Lose weight if cu ntly overweight or o

If you drink alcoholic beverages, limit consumption. http://www.cancer.org/doc ent/PED_3_2X s.asp?sitearea=PED 18. Osteoporosis Prevention and Treatment Guidelines

• Eat five or more servings of a variety of vegetables and fruits each day.

• Choose whole grains in preference to processed (refined) grains and sugars.

• Limit consumption of red meats, especially those high in fat and processed

• Choose foods that maintain a healthful weight. Adopt a physically active lifestyle.

• Adults: engage in at least moderate activity for 30 minutes or more on 5 or modays of the week; 45 minutes or more of mod

Children and adolescents: engage in t least 60 min

e .

rre bese.

root/PED/cont _Recommendation

als for Managem t of Bone Health Go enGroup Goal Recommended

Daily Calcium Intake

Females <30 1000 mg Maximize mineral density in bone

Females 30-- menopause

1000 mg Maintain bone mineral stores

Pregnancy ntain bone mineral tores. Provide for 1000 mg Mai sfetus.

Lactation Maintain bone mineral stores. Provide for milk production.

1000 mg

Females post-menopause on HRT

Reduce mineral losses 1200 mg

- 73 -

RT

Females post-menopause, no

Reduce mineral losses 1500 mg

HMales < 65 years Maximize and maintain mineral density in 1000 m

bone g

Males 65+ years Maximize and maintain mineral density in 1500 mg bone

Dietary Reference Intake Values for Vitamin D1

Life Stage Group2 Criterion AI (ug/day) 3,4,5

19-30 years Serum 25 (OH)D 5

31-50 years Serum 25 (OH)D 5

51-70 years Serum 25 (OH)D 10

>70 years Serum 25 (OH)D 15

Pregnancy and Lactation Serum 25 (OH)D 5 1. Food and Nutrition Board Institute of Medicine. Dietary Reference Intake. Washington: National

ation.

Academy Press, 1999.

2. All groups are male and female except pregnancy and lact

d group of healthy people. AI is used if the scientific evidence is not available to derive an Estimated Average Requirement (EAR). Some seemingly healthy people may require higher vitamin D intakes to

w dietary

. In the absence of exposure to sunlight. Defining Osteoporosis • Definition (WHO)- osteoporosis is present when the T-score is at le

SDs below the mean for young, adult, white women.

numb ge bone nsity e for yo

umber of SDs above or below the average BMD for age and gender-controls.

• Measures at the hip provide the best assessment for risk of hip fracture while s at the s

3. As cholecalciferol. 1ug cholecalciferol = 40 IU vitamin D

4. AI = Adequate Intake. The experimentally determined estimate of nutrient intake by a define

minimize risk of low serum25(OH)D levels and some individuals may be at lower risk on lointakes of vitamin D.

5

ast minus 2.5

• T-score- the er of SDs above or below the avera mineral de(BMD) valu

• Z-score- n

ung, healthy, white women.

matched

measure pine predict spinal fracture risk.

- 74 -

nt Eviagn

termine the fracture risk. ee

• Adequate calcium intake is generally obtained through inclusion of dairy products ee

• Vitamin D is obtained through fortified fluid milk (not yogurt or cottage cheese) and through conversion in the skin in the presence of sunlight. Vitamin D is also known as the "sunshine vitamin" because the body manufactures the vitamin after being exposed to sunshine. Ten to 15 adequate to produce the body’s require amin D

• W intolerance limits cal er lactose-reduced, prepared milk, e.g., LactaidR. Clients may prepare lactose-reduced milk using Lactaid drops purchased in the pharmacy setablets (LactaidR) are available for concurrent consumption with high-lactose f owever, these may no fully redu products for severely intolerant individuals.

eased fiber and water intake.

w bone loss. Resistance exercise

, Tai Chi, yoga, helps to prevent falls.

• Female athletes may be at risk if kilocalorie and dairy product intake is low, and ent.

T). HRT is the most effective way to not

d as a substitute for HRT at the time of menopause (1)

The th muscle-building activity is more

effective. (1)

• Evaluate risk for osteoporosis if glucocorticoid therapy daily is used for greater than 2 months, e.g., prednisone >

Goals for Patie1. Establish the d2. De

aluation osis of osteoporosis on the basis of bone mass assessment.

3. Decide on the n d for instituting therapy.

in the diet. S section 24 for a list of calcium rich foods.

minutes of sunshine 3 times weekly is ment of vit .

hen lactose cium intake, consid

ction of most supermarkets. Lactase

oodstuffs: h t be as effective as ced

• Calcium supplements are often reported to produce constipation. This may bealleviated by incr

• Maintain a healthy body weight and muscle mass.

• Exercise helps to build strong bones and sloincreases protective tissue mass around the skeleton and strengthens the spinal area. Muscle strength and bone mineral density are directly related. Weight bearing exercise, e.g., running, walking, stair climbing, and impact sports, strengthens bones in the legs, hips, and lower spine. Furthermore, exercise, which increases balance, e.g.

amenorrhea is pres

• Smoking exacerbates bone loss, perhaps through alterations in estrogen production or intestinal absorption.

• Discourage alcohol intake in excess of 2 alcoholic beverages daily.

• Consider hormone replacement therapy (HRreduce osteoporosis risk during and after menopause. Physical activity can be recommende

• Walking programs may not prevent bone loss in postmenopausal women. addition of higher intensity activity combined wi

5mg q.d.

- 75 -

clic etidronate, alendronate and risedronate increase ile consistently reducing the risk of vertebral fractures.

k on nonvertebral fractures in women with

beneficial effects of

re

Pharmacologic Therapy 1. Biphosphonates: Prospective Randomized Clinical Trials (PRCTs) and meta-

analyses have shown that cyBMD at the spine and hip whAlendronate and risedronate reduce the risosteoporosis and adults with glucocorticoid-induced osteoporosis.

2. Selective Estrogen Receptor Modulators (SERMs): maximize estrogen on bone and minimize/antagonize deleterious effects on the breast and endometrium. Raloxifene, a SERM approved by the FDA for the treatment and prevention of osteoporosis, has been shown to reduce the risks of vertebral fractuby 36% in large clinical trials. Tamoxifen, used in the treatment and prevention of breast cancer, can maintain bone mass in postmenopausal women. However, effects on fracture are unclear (2).

1. American College of Sports Medicine (1995) ACSM Position Stand on Osteoporosis and

Exercise. Medicine & Science in Sports & Exercise 27(4):I-vii.

2. National Institutes of Health Consensus Development Conference Statement. Osteoporosis Prevention, Diagnosis and Therapy. March 27-29, 2000.

19. Diet and Dental Health 1,2 Effects of Nutrition on Dental Health3 Nutrition has a systemic effect on the development, regeneration and repair of both hard

ly by

retentive/adherent sugar is consumed

of

sions

and soft tissues. These effects include: • Topical and local effects on the maintenance of oral tissues. • Tooth enamel is influenced by systemic nutrition prior to eruption and topical

the diet after tooth eruption. Sucrose and Dental Caries • Increased sugar consumption results in increased caries incidence.

• Incidence of caries is increased when between meals, e.g., candies, raisins and cooked starches such as cookies, crackers, and potato chips.

• Amount of sugar in the diet is not as important as the frequency and formconsumption.

• Caries evolution shows wide interpersonal variation.

• Cessation of caries-promoting agents will decrease activity although, new lemay continue to develop.

- 76 -

Frequent use of sugar-free gum increases saliva production and increases the pH of

Factors in Dental Health Saliva: • Contains calcium and phosphate to remineralize early dental lesions.

• A critical pH<5.7 is necessary for this process.

• Also contains immune factors that such as lysozyme, lactoferrin and secretory IgA.

• Constant flow of saliva removes cariogenic material from the mouth.

• Diseases (Sjogren's or cancer of the neck with radiation therapy) or drugs (antihistamines, antidepressants, diuretics, ma huang, ephedra) that reduce saliva production can increase caries risk. Increased water intake may help counter the effect.

•dental plaque to > normal.

Oral Hygiene

lthough brushing and flossing remove foodstuffs and bA acteria from the mouth, the reatest benefit is the application of fluoride to the tooth surface.

rporated into the enamel especially during

many foods.

the main reason for declines in caries rates in the

etary practices

c.

. use of drinks and use of sugar free gum may reduce tooth erosion

d the frequency of eating. • Follow a sugary snack with an anticariogenic one such as sugar-free gum or a

cariostatic food such as milk to raise plaque pH.4

1. Mobley, C. (1998)Diet and Dental Health. Topics in Nutrition 7. Pennsylvania: Hershey Foods Corporation.

2. Mobley, C., Saunders, M. (1997) Oral health screening guidelines for nondental health care providers. J Am Diet Assoc

g

Fluoride: • Strengthens enamel by being inco

remineralization episodes to form fluoroapatite.

• Present in many water supplies, toothpaste, mouth rinse and

• High-concentration topical applications are available at the dental office.

• Availability of fluoride may beU.S.

• Optimum fluoride exposure will not fully protect teeth from poor dialthough, it may reduce the effects.

• Intake during both pre and post-eruptive development of teeth is cariostati Sports Drinks:

• Prolonged use of sports drinks is associated with dental erosion in athletesIntermittent and caries risk.

To Reduce Caries:

• Monitor food choices an

97(suppl 2):S123-S126.

- 77 -

ensel, C.E., Lanke, S.L., et al (1954) The Vipeholm dental caries study 3. Gustafsson, B.E., QuActa Odont Scand 11:232-364.

Higham, S.M., Edgar, W.M. (1989) Effects of parafilm and cheese chewing on human dental 4. plaque pH and metabolism. Caries Res 23:42-48.

- 78 -

20. The New Food Pyramid The USDA has recently revised the food pyramid that has been used for decades by health care professionals, nutritionists, teachers, and interventionists to yield a more interactive and individually-suited version based on the 2005 Dietary Guidelines for Americans and the Dietary Reference Intakes from the National Academy of Sciences. The new pyramid goes far beyond the old pyramid by stressing activity, moderation, personalization, proportionality, variety and gradual improvement. The symbolism of the new pyramid emphasizes many key concepts. For example, the figure climbing up the stairs represents individual motivation and the step-by-step

process to achieve greater health. From left to right, the colors in order represent: grains, vegetables, fruits, oils, milk, and meat and beans. Each colored section is roughly proportional to the amount that each of these food groups should be present in a healthy person’s diet. The wide base of each colored section stands for foods with little or no solid fats or added sugars, and the narrow top area stands for foods containing more added sugars and solid fats, emphasizing that everything is acceptable in moderation in conjunction with physical activity.

The USDA has created a highly interactive website that provides an important resource both for the general public and for professionals. By entering values for age, sex, and activity level, individuals can obtain a personalized dietary recommendation based on the values represented in the pyramid (see Table 1), as well as useful tips on: how to incorporate each of the food groups into a daily diet, what foods belong to each group and which are the most nutrient dense, how to maintain variety, and how to read food labels accurately to be able to make informed decisions. In addition, the website gives professionals a ready-made education framework that includes teaching tools, such as posters and daily food tracking charts, and more in-depth information to help guide individuals to achieve and maintain a healthy weight. For more information, visit the website at: http://www.mypyramid.gov.

Dietary recommendation for 30 year old female with average activity level (2000 kcal diet) ►Grains 6 ounces►Vegetables 2.5 cups►Fruits 2 cups►Milk 3 cups►Meat & Beans 5.5 ounces

- 79 -

r Americans 2005121. U.S. Dietary Guidelines fo

the

a balanced eating

Key Recommendations: • To maintain body weig

beverages with calorie• To prevent gradual we

beverage calories and

Physical Activity Key Recommendations:

• Engage in regular phyhealth, psychological well-bei

in adulthood: Engage in at least 30

efin

rev ight roxim inutes of modert day hile not exc

: P t 60 tonsity ph not e

ess by including cardiovascular conditioning, stretching for muscle

strength and endurance.

ood Groups To Encourage ey Recommendations: • Consume a sufficient amount of fruits and vegetables while staying within energy

needs. Two cups of fruit and 21/2 cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level.

Adequate Nutrients Within Calorie Needs Key Recommendations:

• Consume a variety of nutrient-dense foods and beverages within and among basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol.

• Meet recommended intakes within energy needs by adoptingpattern, such as the USDA Food Guide or the DASH Eating Plan.

Weight Management

ht in a healthy range, balance calories from foods and s expended. ight gain over time, make small decreases in food and increase physical activity.

sical activity and reduce sedentary activities to promote ng, and a healthy body weight.

o To reduce the risk of chronic disease minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week.

o For most people, greater health benphysical activity of more vigorous inte

o To help manage body weight and pgain in adulthood: Engage in appvigorous-intensity activity on moscaloric intake requirements.

o To sustain weight loss in adulthoodminutes of daily moderate-intecaloric intake requirements. Some people may need to consult with ahealthcare provider before participating in this level of activity.

• Achieve physical fitn

ts can be obtained by engaging in sity or longer duration. ent gradual, unhealthy body weately 60 m ate- to s of the week w eeding

articipate in at leasysical activity while

90 xceeding

exercises for flexibility, and resistance exercises or calisthenics

FK

- 80 -

particular, select from all

.

s. le grains.

Fats :

n 10 percent of calories from saturated fatty acids and less as

ng ated fatty acids, such as fish,

d preparing meat, poultry, dry beans, and milk or milk

acids, and choose

CarbohyKe

• s by practicing good oral hygiene and tly.

SodiuKey R

•

ium-

s should not be consumed by some individuals, including those who cannot restrict their alcohol intake, women of childbearing age who may become pregnant, pregnant and lactating women, children and adolescents,

• Choose a variety of fruits and vegetables each day. In five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times a week

• Consume 3 or more ounce-equivalents of whole-grain products per day, with the rest of the recommended grains coming from enriched or whole-grain productIn general, at least half the grains should come from who

• Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products.

Key Recommendations• Consume less tha

than 300 mg/day of cholesterol, and keep trans fatty acid consumption as lowpossible.

• Keep total fat intake between 20 to 35 percent of calories, with most fats comifrom sources of polyunsaturated and monounsaturnuts, and vegetable oils.

• When selecting anproducts, make choices that are lean, low-fat, or fat-free.

• Limit intake of fats and oils high in saturated and/or trans fattyproducts low in such fats and oils.

drates

y Recommendations: • Choose fiber-rich fruits, vegetables, and whole grains often.

• Choose and prepare foods and beverages with little added sugars or caloric sweeteners, such as amounts suggested by the USDA Food Guide and the DASH Eating Plan.

Reduce the incidence of dental carieconsuming sugar- and starch-containing foods and beverages less frequen

m And Potassium ecommendations: Consume less than 2,300 mg (approximately 1 tsp of salt) of sodium per day.

• Choose and prepare foods with little salt. At the same time, consume potassrich foods, such as fruits and vegetables.

Alcoholic Beverages Key Recommendations:

• Those who choose to drink alcoholic beverages should do so sensibly and in moderation—defined as the consumption of up to one drink per day for women and up to two drinks per day for men.

• Alcoholic beverage

- 81 -

individuals engaging in activities that

o Clean hands, food contact surfaces, and fruits and vegetables. Meat and ld not be washed or rinsed.

urized) milk or any products made from unpasteurized w or uts.

ocument/html/executivesummary.htm

individuals taking medications that can interact with alcohol, and those with specific medical conditions.

• Alcoholic beverages should be avoided byrequire attention, skill, or coordination, such as driving or operating machinery.

Food Safety Key Recommendations:

• To avoid microbial foodborne illness:

poultry shouo Separate raw, cooked, and ready-to-eat foods while shopping, preparing,

or storing foods. o Cook foods to a safe temperature to kill microorganisms. o Chill (refrigerate) perishable food promptly and defrost foods properly. o Avoid raw (unpaste

milk, raw or partially cooked eggs or foods containing raw eggs, raundercooked meat and poultry, unpasteurized juices, and raw spro

1. Executive Summary Issued by HHS-USDA http://www.health.gov/dietaryguidelines/dga2005/d

- 82 -

22. Referral to a Dietitian INDICATORS for REFERRAL to the REGISTERED DIETITIAN (R.D.)

for MEDICAL NUTRITIO ERAPY N TH Disease or Condition

Indicators Medical Nutrition Therapy utri N ts ed to

come

N tion Services eeded NuRDe

mb.D. sire

er Visi

d

TotaHouImp

l R.D. rs Needact Out

Hyperlipidemia

Total cholesterol > 200 mg/dl, HDL < 40 mg/dl, LDL > 130 mg/dl (or >100 if >2 risk factors or known CVD) Triglyceride >150 mg/dl

Reduced fat, trans fatty acid, saturateand cholesterol. Increased omega 3 amonounsaturated fat. May reduce ETOH and CHO if triglyceride high.

loss

y

vices

le

d fand

t Diet instruction, restaurant dining plaion

strategies, recipe mod

menuificat

nning and 2-3 >3wene

if ighteded

2.5-3 Variwith Ongprommostoutc

.0

es greatlclient.

oing serote the favorabomes.

Type 2 Diabetes Mellitus

New diagnosis, new/changed medication regimen, frequent hypoglycemic events, HgbA1C > 7%, fasting BG almost always >150 mg/dl, starting SBGM, greater than 2 years since MNT counseling,

Individual diet plan based on patient patterns, weight, activity, DM medications, lipid status and organ function. Encourage consistent exerc

raningdifils; din SB

ial

low-up east 1-2 year

w-ou

BG

ise.

Diet instrucCHO contrstrategies, lplanning, rebehavior chnutrient adveating, exer

tion ol, reabel cipeangeice, cise,

that stauread mo goacoor and

includet din, mecatiodrugatinGM

s ing nu n and -

g .

Init3-5 Folat lper

Initia3-5 Follo1-2 h

l

up rs

Hypertension >140/ 90 mm Hg for uncomplicated hypertension; lower goal for those with target organ damage or clinical CV disease; <130/ 85 mm Hg for patients with diabetes

Low sodium diet (<2,400 mg) or DAdiet. Encourage consistent exercise.

aurni

drode E H.

2 >3 if weight loss needed

es g y cli

oin vices

fav le ome

SH Diet instrucstrategies, recipe modadvice, behavioral mDecrease or

tion,menu planificat

elim

rest

ion,

inat

ant dng anug-nuificaTO

ining d trient

tion.

1-2 Variwith Ongprommostoutc

reatlent. g ser

ote the orabs.

Obesity or Overweight

BMI > 25 Waist > 35" female; > 40" male

Calorie controlled. Encourage consisexercise.

aur inini nd

dr utriod tio

>tent Diet instrucstrategies, recipe modadvice, behavioral m

tion,menu planificat

rest

ion;

ant dng aug-nifica

ng

ent n.

3 es g y cli

oin vices

fav le ome

Variwith Ongprommostoutc

reatlent. g ser

ote the orabs.

Osteoporosis Z-score below the average BMD for age and gender-matched controls.

Nutritionally dense diet with adequate calcium and vitamin D. Promote healthy body weight and muscle mass. Encourage consistent weight bearing exercise.

efication ug-

e, supplement evaluation.

Diet instruction, mand recipe nutrient advic

nu planning; dr

modi

1 1-1.5

- 83 -

23 l . Herba Supplements There has been a significant increase in the use of dietary supplements including nutraceuticals over the past two decades. Nutraceuticals include all herbal medications, me ods, a tamins heir use of herbs to their hea r and c herbs to be non-harmful supplements. Bec ial for g n physicians ould include he supplements in the medical history and should document the patient's use of these drugs. Patients who are sched ical p nee e screened f use of supp esthe ns ocomplications.

e ore ly used he in the tablth int se, possibl ations

Supplement N

Intenplic

dicinal folth carause o

nd vioviders potent

. Most patients do not reveal tofte to

e pf t

n xic

onsider or druhe ity -nutrient interactio s, sh

rbal

or the

commonended u

uled for surgr to avoid an

s are listed d contraindic

rocedures sia reactio

following .

Side Effects And Possible Com

d to br other

e along

ations

lements in orde

rbal supplemente side effects, an

ded Use/Dose

Thwi

am

m the

e Bilber T t of diarrhe

reduced platelet aggregatiregeneration of rhodopsin/240-480 mg TID.

No city or adverse reactions.

ry reatmen a; improves circuon; vision - increased

lation and know toxi

Chamomile Digestive aid in infla ator wel d se; used topically for inflammatory skin conditions such as eczema, insect bites, and poison ivy; mouthwash fo k ores/take opical of 3-10% concentration.

Avoid taking if allergic to ragweed, asters ch nthemums

mm y bo

n as tea; t

isea

creamr can er s

and . rysa

Cranb Treatment of urinary tract infections/300-400 mg e

Consume with ample fluids; not to be used as substitute for antibiotic.

erry xtract BID.

Echin Prevention and treatment of colds and flu - immune s proves of wh od cells to organ blood ; used o al yea s/900 r day for 10-14 days

Allergies to flowers of the daisy fa utoimmu rs; progressive systemic disorders such as MS and

acea timulatin attackrally for

g, im micro vagin

migrationisms in thest infection

ite blostream mg pe

mily; a ne disorde

TB.

EvPrimrose Oil

Treatme f eczem e a PMS a ycl e p 6 d

No reported side effects. ening nt oical br

a, diab tic neuropain/3- grams per

thy,ay. nd c ast

Feverfew P en iin i sp e e y

Avoid with use of other migr drugs; areg cy & lact oid if ll o daisies

revflamarth

timano

on of mtory dlide p

igrasear da

nes; may also heles such as arthrit.

p is/ 250 mg aine

nanic t

void in ation; av.

pa erg

Ga R lb ean antibiotic - stimulates body's natural defenses; antioxidant/600-900 mg per day BID/TID.

r ction n ants.

rlic educlood

espre

cholesssure

terolow

biosynthesis in liring effect; fights

ver; has mildbacteria like

Da

ugtic

interaoagul

with

Ginkgo Biloba

Potent antioxidant; improves circulation and reduces platelet aggregation; used for treatment of cerebrovascular insufficiency, intermittent

Side effects include GI dis es and headaches. turbanc

- 84 -

claudication, diabetic peripheral neuropathy/120-240 mg divided BID/TID.

Ginseng Enhance mental perform(Panaxginsen

ance; boost energy levels; Avoid with high blood pressure; oid on;

g)

stimulate the immune system/100 mg BID for 2-3 weeks followed by 1-2 week rest period.

avoid use with caffeine; avduring pregnancy & lactatimay cause menstrual abnormalities and breast tenderness; may cause GI upset.

Kava K he ug

interactions with barbiturates

ava Used as an antianxiety and "tension reducing" agent/ 200-300 mg QD.

Side effects: yellowing of tskin; allergic rash; drug-dr

and antidepressants. Milk Th

alcoholic liver disease/ 70-80% silymarin given 160 mg TID for 8 we

cause transient laxative effect .

istle Treatment for liver disease, viral hepatitis, and May

eks Saw tto Treatment of benign prostatic hyperplasia/ 320 mg Mild gas

Palme

of lipophilic extract per day. trointestinal

disturbances. Not to be usedas a treatment for prostate cancer.

St. John's Wort

Treatment for mild depression; inhibits monoamine oxidase (MAO)/extract which provides 1 mg hypericin per day.

Increases sensitivity to sunot to be used with prescantidepressants; tyramrestriction may be needed;

nlight; ription

ine

physicians' approval needed to

ives, anti-seizure

use during pregnancy & lactation; drug interactions with anticoagulants, oral contraceptmeds, drugs to treat HIV or prevent transplant rejection.

Valerian

Treatment of insomnia/300-500 mg before bedtime;treatment of mild anxiety/150 mg AM and 300-500mg PM.

Very objectionable smell.

Vitex Treatment of PMS, hot flashes, and menorrhagia. pregnancy or with hormonal Not to be used during

replacement therapy. Sources: 1.Clinical N se of Herbal Supplements", Roberta ADepartment of Pediatrics a t Sports Medicine, Baylor College o

2. Herbalgr

utrition Elective Lecture "Und Adolescen

nding, M.S., R.D., CDE, f Medicine;

am.org, Altmed.od.nih.gov, Amfoundation.org/herbmed.htm

- 85 -

24. Food Sources of Common Nutrients Nutrient Food Sources

Calcium , kaMilk & milk products, sardines, clams, oystersgreen, tofu

le, turnip greens, mustard

Phosphorous Cheese, egg yolk, milk, meat, fish, poultry, wholenuts

grain cereals, legumes,

Magnesium Whole grain cereals, tofu, nuts, meat, milk, green vegetables, legumes, chocolate

Sodium animal foods, milk, eggs (in mTable salt, seafood, ost foods except fruit)

Chloride Table salt, seafood, milk, meat, eggs

Potassium mes Fruit, milk, meat, cereals, vegetables, legu

Sulfur , Meat, fish, poultry, eggs, milk, cheese, legumes nuts

Iron Liver, meat, egg yolk, legumes, whole or enriched grainvegetables, dark molasses, shrimp, oysters

s, dark green

Zinc Oysters, shellfish, herring, liver, legumes, milk, wheat bran

Copper Liver, shellfish, whole grains, cherries, legumes, kidney, poultry, oysters, chocolate, nuts

Molybdenum y vegetab Legumes, cereal grains, dark green leaf les, organs

Iodine Iodized table salt, seafood

Manganese Beet greens, blueberries, whole grains, nuts, legumes, fruit, tea

Fluoride Drinking water (1 ppm), tea, coffee, rice, soybeanlettuce

s, spinach, gelatin, onions,

Cobalt Liver, kidney, oysters, clams, poultry, milk

Selenium Grains, onions, meats, milk, vegetables (depending on selenium content of soil in which they were grown)

Chromium me drinking water Corn oil, clams, whole grain cereals, meats, so

Vitamin A r, kidney, milk fat, fortified margarine, egg yolk, yellow and dark green s

Liveleafy vegetables, apricots, cantaloupe, peache

Vitamin D Vit D milk, irradiated foods, some in milk fat, liverfish, sardines

, egg yolk, salmon, tuna,

Vita , nuts min E Wheat germ, vegetable oils, green leafy vegetables, milk, fat, egg yolk

Vitamin K Liver, soybean oil, other vegetable oils, green leafy vegetables, wheat bran

Vitamin B1 (Thiamin)

Pork, liver, organ meats, legumes, whole grain and enriched cereals and breads, wheat germ, potatoes

Vitamin B2 (Riboflavin)

Milk, dairy foods, organ meats, green leafy vegetables, enriched cereals and breads, eggs

Niacin Fish, liver, meat, poultry, many grains, egg, peanuts, milk, legumes, enriched

- 86 -

grains and breads

Vita(Py

Pork, glandular meats, cereal b ilk, egg yolk, oatmeal, and legumes

min B6 ridoxine)

ran and germ, m

Folate Green leafy vegetables, organ meats (leafy), lean beef, wheat, eggs, fish, drbeans, lentils, cowpeas, asparagus, broccoli, collards, yeast

y

Vitamin B12 (Cobalamin)

Liver, kidney, milk and dairy foods, meat, eggs (vegans will need supplements)

Pantothenate Present in all plant and animal foods. Eggs, kidney, liver, salmon and yeare best sources.

ast

Biotin Liver, mushrooms, peanuts, yeast, milk, meat, egg yolk, most vegetables, banana, grapefruit, tomato, watermelon and strawberries

Vitamin C (Ascorbate)

cabbage, guava, Citrus fruit, tomato, melon, peppers, greens, rawstrawberries, pineapple, potato

Resources: 1998 Texas Dietetic Association (TDA) Manual for Medical Nutrition Therapy.

- 87 -

Food Sources of Calcium

Food Amount Calcium (mg) Buttermilk 1 cup 285

Chocolate milk 1 cup 284

Evaporated skim milk 1 cup 368

Whole mil 1 cup 291 k Skim or 1% milk 1 cup 300

Low fat, 2% milk 1 cup 297

Milk (dry n 4 onfat) 2 Tbsp. 10

American cheese 1 oz 174

Bleu chee 150 se 1 oz

Cheddar cheese 1 oz 204

Cheese food (American)

1 oz 174

Cheese food (Swiss) 1 oz 205

Colby cheese 1 oz 194

Cottage cheese (2% low fat)

1 cup 155

Monterrey cheese 1 oz 212

Mozzarella cheese 1 oz 207

Muenster cheese 1 oz 203

Ricotta (part skim) ½ cup 334

Swiss cheese 1 oz 272

Milkshake (vanilla) 10 oz 415

Ice cream 1 cup 176

Ice milk (soft serve) 1 cup 274

Yogurt (fruit, low fat) 1 cup 345

Yogurt (plain) 1 cup 240

Pudding (chocolate) ½ cup 133

Custard (baked) ½ cup 148

Oysters 7-9 oz 113

Salmon (with bones) 3 ½ oz 185

Sardines (with bones) 3 oz 382

Tofu (regular) 4 oz 130

- 88 -

Pizza (cheese) 332 ¼ of a 14-inch pie

Chili con with beans

carne 1 cup 82

Macaroni & cheese 1 cup 181

Mushroom soup made with milk

1 cup 191

Tomato soup made with milk

1 cup 168

Bokchoy (cooked) 1 cup 252

Broccoli (fresh, cooked)

1 cup 72

Collards (cooked) 1 cup 220

Mustard greens (fresh, cooked)

1 cup 104

Turnip greenscooked)

(fresh, 1 cup 267

Spinach (frozen, cooked)

1 cup 276

Lima beans (cooked) 1 cup 55

Navy beans (cooked) 1 cup 95

Black-eyed peas (cooked)

1 cup 43

Great northern bea(cooked)

ns 1 cup 90

Kidney beans (cooked) 1 cup 74

Almonds ½ cup 184

Sesame seeds ½ cup 83

Sunflower seeds ½ cup 87

Molasses, blackstrap 1 Tbsp. 137

Reference: 1998 TDA Manual for Medi tion Therapy cal Nutri

- 89 -

Foods Sources of Iron

Food A Iron* mountBeef (cooked regulahamburger)

r 2.1 mg 4 oz

Steak 3 oz 2.6 mg

Ham (light cured) 3 oz 0.7 mg

Lamb chop 3 oz 1.7 mg

Fish sandwich with 1 cheese

1 .8 mg

Pork (cooked, 3 oz 1.3 mg shoulder) Scallops 6 2 .0 mg

Shrimp (fried) 3 oz 1.4 mg

Veal cutlet 3 oz 0.8 mg

Black beans (dry, ½ cup 2.45 mg cooked) Pork & beans (dry, ½ cup 2.5 mg cooked) Chick peas (dry, cooked)

½ cup 2.45 mg

Chili con carne with 1 cup 4.3 mg beans Pizza (cheese) 1 slice 1.6 mg

Chicken breast (cooked)

3 oz 0.9 mg

Tuna (in oil) 3 oz 1.6 mg

Tuna (in water) 3 oz 0.6 mg

Turkey (no skin, light &dark meat)

1.4 mg 3 oz

Cash 1.7 mg ew nuts 1 oz

Egg 2 medium 1.4 mg

Peanuts 1 oz 0.5 mg

Peanut butter 1 Tbsp. 0.3 mg

Mixed nuts (dry roasted)

1oz 1.0 mg

Apple juice 1 cup 1.9 mg

- 90 -

Prune juice 1 cup 3.0 mg

Tomato ju 1.4 mg ice 1 cup

Beets (cooked) ½ cup 1.5 mg

Spinach (raw, chopped) 1 cup 1.5 mg

Spinach (cooked) 1 cup 6.4 mg

Turnip (cooked) 1 cup 0.3 mg

Greens 1 cup 1.3 mg

Peas (frozen, cooked) 1 cup 2.5 mg

Raisins 1 oz or 1½ Tbsp. 0.3 mg

Apricots (dried) ½ cup 3.0 mg

Strawberries (whole) 1 cup 0.6 mg

Molasses (blackstrap) 2 Tbsp. 10.1 mg

Instant oatmeal 1 packet 6.7 mg

Cream of wheat (fortified)

1 cup 10.7 mg

Raisin Bran ¾ cup or 1 oz 3.5 mg

Bread (enriched) 1 slice 0.9 mg

Noodles (enrichedcooked)

, 1 cup 2.6 mg

Corn chips 1 oz 0.5 mg

Tortilla 1 2.2 mg

*Consuming foods high in Vitamin C a e time will assist in absorption of iron. tp://www.rochester.edu/s srvcs/UHS/iron.htm (and ite tritive Value of Food. U.S artment of Agriculture Bulletin #72 Washington,

Food Sou of Fiber

t the samReference: htreferenced “NuD.C.”)

tudent-. Dep

this web s

rcesFood Serving Size Fib s) er (gram

High Fiber Cereals (5g er

ng)

⅓ to ½ cup 5.0 – 13.0 or more fiber pserviLentils (cooked) ½ cup 7.8

Lima beans (cooked) ½ cup 6.6

Black beans (cooked) ½ cup 6.5

Kidney beans (cooked) ½ cup 5.7

Pistachios (dry roasted) ⅓ cup 4.7

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roasted) Peanuts (dry ⅓ cup 4.6

Green peas (frozen, ½ cup cooked)

4.4

Barley (cooked) ½ cup 4.3

Raspberries (raw) ½ cup 4.2

Bran muffin 1 = 2 oz 4.0

Acorn squash (baked) ½ cup 3.4

Wheat bran 2 Tbsp. 3.2

Orange 1 medium 3.1

Apple (with skin) 1 medium 3.0

Pear (with skin) 1 medium 3.0

Broccoli (cooked) ½ cup 2.8

Spinach (cooked) ½ cup 2.7

Carrots (cooked) ½ cup 2.6

Banana 1 small 2.2

Dried fruit (mixed) 1 oz 2.2

Blueberries ½ cup 2.0

Oatmeal (cooked) ½ cup 2.0

Whole wheat bread 1 slice 2.0

Green beans (cooked) ½ cup 1.9

Brown rice ½ cup 1.8

Prunes (dried) 3 prunes 1.8

Figs (dried) 1 fig 1.7

Pumpernickel bread 1 slice 1.6

Raisins (seedless) 1.5 ¼ cup

Oat bran bagel ½ large bagel 1.4

Reference: Nutrition in Clinical Care, (1999) Vol 2(3), 187-188.

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The e recommen 35 grams of fiber dai ere is a quick method for assessing daily total dietary determined from US Department of Agriculture data or food label. Add the sum of each of the following:

ice) x 1.5 grams tables x 1.5 gram

f refined grains x 1.0 g ___ g. ins x 2.5 gra

To Ref dical Nut

National Cancer Institut ds 20 to ly. Hfiber intakes. Serving size can be

Servings of fruit (not juServings of vege

= ____g. s = ____g.

Servings o ram = Servings of whole graAdditional foods

ms = ___ g. = ___ g.

tal = ____g.

erence: 1998 TDA Manual for Me rition Therapy

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Food Sources of Omega 3 Fatty Acid

Food Item Portion Size Grams of Omega-3 (ALA + EPA + DHA)*

Can 1.4 ola oil 1 Tablespoon

Flax 6.7 seed oil 1 Tablespoon

Flax 2.63 seeds 1 Tablespoon

Wal 1 s 1.3 nut oil Table poon

Wal 3.4 nuts ¼ cup

Wheat germ oil 1 Tablespoon 0.86

Soybeans, cooked ¼ cup 1.05

Catfish 3.5 oz, raw 0.6

Cod 3.5 oz, raw 0.2

Haddock 3.5 oz, raw 0.2

Herring 3.5 oz 1.7

Sardines 3.5 oz 1.5

Salmon 3.5 oz 1.9

Scallops, sea 3.5 oz, raw 0.2

Shrimp, gulf 3.5 oz, raw 0.3

Swordfish 3.5 oz, raw 0.9

Tuna, albacore 3.5 oz, raw 2.1

Tuna, yellowfin 3.5 oz, raw 0.6

Omega-3 enriched eggs** 1 egg 0.4

*Alpha-linoleic acid (ALA) is the parent compound of the omega-3 fatty acid family. ALA is the precursor to the long-chain fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and is an essential fatty acid for humans because it cannot be synthesized from dietary precursors. The recommended daily allowance by the American Dietetic Association is 1.5-3.0 grams omega-3 fatty acids per day. Flaxseed is the richest source of ALA. ALA is also found in the oils of canola, wheat germ, soybeans, and walnuts. Fish contain only small amounts of ALA, although salmon, sardines, and herring are rich in EPA and DHA. Leafy greens contain small amounts of ALA but their overall contribution to the diet is minimal. **The increased ALA content of omega-3 fatty acids is achieved by feeding hens rations containing flaxseed.

Mediterranean countries, e.g., Crete, have a high amount of omega-3 fatty acid in the diet. This is thought to be a factor in reduced cardiovascular disease and cancer. Whereas the ratio of omega-6: omega-3 fatty acid in the diet of Crete is 4:1, the American diet is 16:1. Sources: 1. A.P. Simopoulos and J. Robinson (1999) The Omega Diet, HarperCollins Publishers. 2. Flaxseed Council of Canada. 3. www.seafoodhandbook.com