Test Drive: Manual of Medical Nutrition Therapy

Florida Dietetic Association
Manual of Medical Nutrition Therapy

2011 Edition
Editor: Catherine Christie, PhD, RD, LD/N, FADA
Assistant Editors: Nancy Correa-Matos, PhD, RD Judy Perkin, DrPH, RD Judith C. Rodriguez, PhD, RD, LD/N, FADA Claudia Sealey-Potts, PhD, RD Jackie Shank, MS, LD/N, RD Delores Truesdell, PhD, RD Lauri Wright, PhD, RD Kate N. Chang, UNF Nutrition Student
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All rights reserved. No part of this manual, other than those specifically designed for patient education, may be reproduced, stored in a retrieval system, or transmitted, in
Manual of Medical Nutrition Therapy 2011 Edition
iiii Preface
The Manual of Medical Nutrition Therapy was written to serve as a nutrition care guide for dietetics professionals and other health care professionals. Each section of the Manual was researched, written, and reviewed by Registered Dietitians, Dietetic Technicians Registered or nutrition/dietetic students in accredited programs. However, the field of nutrition and its application to individual needs is constantly changing with continuous research. Therefore, this Manual should always be used with consultation from a Registered Dietitian. The specific purpose of the Manual of Medical Nutrition Therapy is to provide general practice information in the course of normal dietetics practice and to alert practitioners to general areas of concern for which you may seek additional medical, technical, or professional assistance. Many sections of the FDA Manual of Medical Nutrition Therapy contain Practitioner Points for the Registered Dietitian (RD) and Dietetic Technician Registered (DTR) and when appropriate Nutrition Education for the public. To be effective, medical nutrition therapy must be individualized for each person. This requires a collaborative effort between the patient or client and the dietitian. Handing out diet sheets to those with nutrition-related medical problems completely overlooks the unique qualities of that person and limits the rate of adherence. The development and maintenance of new eating behaviors requires commitment, time, and support from qualified professionals. The Practitioner Points of each diet contain a brief description of rationale, use, related physiology, nutrients modified, nutritional adequacy and references. The Nutrition Education contains an introduction, purpose, nutrients modified, dietary guidelines, food lists, sample menus or handouts, and approximate nutritional analysis. All diets analyzed for this manual contain adequacy statements based on the 1989 Recommended Dietary Allowances and Dietary Reference Intakes (DRIs) for adult males and females. No warranty, explicit or implied, as to the appropriateness of application of the contents of this manual to specific individuals is made by the Florida Dietetic Association, the authors and reviewers, nor by their employers.
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Acknowledgements
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Special thanks to the Florida Dietetic Association members who served on the Board of Directors during the time of the 2011 manual revision for their vision and support of this manual. FDA Board Members Holly Adams RD, LD/N Stephanie Norris RD, LD/N Heather Fisher RD, LD/N Mandy Layman RD, LD/N Molly Gladding RD, LD/N Michelle Pugsley RD, LD/N Joey Quinlan RD, LD/N FDA Executive Director
Christine Stapell MS, RD, LD/N, Authors and Reviewers
The following pages list the Authors and Reviewers who donated their valuable time and expertise to write or review sections of the Manual of Medical Nutrition Therapy. Without their exceptional work and dedication to the Dietetics and Nutrition profession, this Manual would not be possible.
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Manual of Medical Nutrition Therapy Authors

Michelle Albers, PhD, RD, LD/N Linda Ammon, MS, RD, LD/N, CDE Linda Attkisson, MS, RD, LD/N Sharon M. Bartfield, MS, RD, LD/N Mindy Benedict, RD, LD/N Donnie Berger, MS Lucille Beseler, MS, RD, LD/N, CSP Linda B. Bobroff, PhD, RD, LD/N Bernice Boivin, RD, LD/N Ellen K. Bowser, MS, RD, LD/N, CSP Ann Braun, RD Susan Burke, MS, RD, LD/N, CDE Mary Lu Carpenter, MS, RD, LD/N Catherine Christie, PhD, RD, LD/N Cathy Clark-Reyes, RD, LD/N Dana Cohen, RD, LD/N Suzanne Cole, MS, RD, LD/N Peggy Cooper, MS, RD, LD/N Nancy Correa-Matos, PhD, RD Avernelle Cromer, RD Ruth M. DeBusk, PhD, RD Donna DeCunzo-Taddeo, RD, LD/N Carolyn S. DeVries, RD, LD/N Jamie Diamond, MS, RD, LD/N, CNSD Marianne Duda, MS, RD, LD/N, CNSD Evelyn B. Enrione, PhD, RD, LD/N John R. Ferrante, MS, RD, LD/N Joan Marn Franklin, MS, RD, LD/N Patricia J. Funk, MS, RD, LD/N, CNSD Maureen Gardner, MA, RD, LD/N Molly Gladding, RD, LD/N Dawn Goodholm, RD, LD/N Leslene Gordon, PhD, RD, LD/N Denise M. Hall, MS, RD, LD/N Sarah Hall, RD, LD/N, CNSD Lenore S. Hodges, PhD, RD, LD/N Stephanie Holmes, MS, RD, LD/N, CNSD Geanne Hudson, RD, LD/N Rita Jackson, PhD, RD, LD/N Delores C.S. James, PhD, RD, LD/N Elaine Jansak, MS, RD, LD/N, CDE Donna T. Jones, MSH, RD, LD/N Gail P. A. Kauwell, PhD, RD, LD/N Brenda Keen, RD, LD/N Karen Kratina, PhD, MPE, RD, LD/N Beverly J. Kraus, RD, LD/N Susan Latham, MS, RD, LD/N Grace Lau, RD, LD/N, CDE Jennifer Lefton, RD, LD/N, CNSD Kristen Leonburg, RD, LD/N Sherry Mahoney, RD, LD/N, CDE Connie Malik, RD, LD/N, CDE Christina S. McClernan, MS, RD, LD/N, CNSD Carol Mellen, MS, RD, LD/N Susan Moyers, PhD, MPH, LD/N Misty Murray, MS, RD, LD/N Annette Owen, DTR Nadine Pazder, MS, RD, LD/N, CDE Judy E. Perkin, DrPH, RD, LD, CHES Erin Petrey, MS Elsa Pinto-Lopez, MS, RD Stephanie Quirantes, MS, RD, CNSD Glenna Raidt, RD, LD/N, CDE Sheah Rarback, MS, RD Mirta Rios, RD, LD/N Tania Rivera, MS, RD, LD/N Judith C. Rodriguez, PhD, RD Michelle Romano, RD, LD/N, CNSD Michelle Schmitz, MS, RD, LD/N Claudia Sealey-Potts, PhD, RD Mindy Seltzer, RD, LD/N Jackie Shank, MS, RD Nancy Spaulding-Albright, MMS, RD, LD/N, CNSD Barbara Sperrazza, MS, RD, LD/N, CDE Nancy T. Smith, MS, RD, CDE Deanna Stanz, MS, RD Rheba Summerlin, MSH, RD Vilia B. Tarrosa, MS, RD, LD/N Susan J. Tassinari, MS, RD, LD/N Cathy Trcalek, RD, LD/N Joanna Uptagraft, RD, LDN Catherine Wallace, MSH, RD, LD/N Julia A. Watkins, PhD, MPH Sally E. Weerts, PhD, RD Vilma Willard, MS, RD, CSR, LD/N Lauren Willis, RD, LD/N Merrie M. Wilner, RD, LD/N Debra Wilson-Case, DTR Lauri Wright, PhD, RD
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Manual of Medical Nutrition Therapy Reviewers

Lori Alexander, MSHS, RD, LD/N, CCRC Melissa A. Baron, MS, RD, LD/N Luce Bernard, MS, RD, LD/N, CDE Amy E. Bowersock, PhD, FACSM Gayle Brazzi Smith, MS, RD, LD/N June Carder, MS, RD, LD/N Mary Lu Carpenter, MS, RD, LD/N Joy Chambers, MA, RD, LD/N Catherine Christie, PhD, RD, LD/N Michelle Ciccazzo, PhD, RD, LD/N Laura Cook, PhD, RD, LD/N Judith Cooper, MS, MBA, RD, LD/N Sondra Cornett, MS, RD, LD/N Helen L. Curtis, RD, LD/N, CDE Sheila G. Dean, MS, RD, LD/N, CDE Jamie Diamond, MS, RD, LD/N, CNSD Evelyn B. Enrione, PhD, RD, LD/N Jennifer Eshelman, MS, RD, LD/N, CSNC Kristen M. Farnham, MSH, RD, LD/N Jorge R. Franceschi, MSH, RD, LD/N Mary C. Friesz, PhD, RD, LD/N, CDE Donna Greenwood, PhD, RD, LD/N Sarah Hall, RD, LD/N, CNSD Pat Hare, RD, CPS Cristen Harris, MS, RD, LD/N Rebecca Helquist, RD, LD/N, CDE Jennifer Hillan, MSH, RD, LD/N Starr Horn, MS, RD, LD/N Heather Huffman, MS, RD, LD/N Alice Jaglowski, MSH Kristi Jesionek-Brewton, RD, LD/N, CNSD Elaine M. Jansak, MA, MS, RD, DCE, LD/N Carol Francis Jubert, MS, RD Stephanie Kahn, MS, RD, LD/N Kristen Kenny-Keller, RD Myerly Kertis, MS, RD, LD/N Samantha Knight, MS, RD, LD/N Cynthia Kupper, RD, CD Grace Lee, MS, RD, LD/N Jennifer Lefton, RD, LD/N, CNSD Emily Marcus, RD, CDN Victoria Martinez, RD, LD/N Janet S. McKee, MS, RD, LD/N Janis Mena, MPH, RD, LD/N Christine Miller, MS, RD, LD/N, CDE Susan Mitchell, PhD, RD, LD/N Jen Moccia, MS, RD, LD/N Kathy Nelson, RD, LD/N Pamela Ofstein, MS, RD, LD/N Peggy ONeil, MS, RD Stephanie Perry, MSH, RD, LD/N Theresa Perry, RD, LD/N Denise Pickett-Bernard, PhD, RD, LD/N Tania Rivera, MS, RD, LD/N Judy Rodriguez, PhD, RD, LD/N Ellen Rovinsky, MS, RD Pam Schmidt, MS, RD, LD/N, CDE Evelyn P. Schumacher, MS, RD, LD/N, CDE Cecelia Sheridan, RD, LDN, CSP Eunshil Shim, MS, RD, LD/N Andrea Skowronek, RD Nancy Spyker, RD, LD/N Isabel Suarez-Blandino, RD, LD/N Vicki Sullivan, PhD, RD, LD/N Leslie Taylor, Graduate Student Aurea Thompson, MSH, RD, LD/N R. Elaine Turner, PhD, RD Lois J. Waltz, RD, LD/N Julia Watkins, PhD, MPH Sally E. Weerts, PhD, RD Lauri Wright, PhD, RD Regan Zayas, MBA, RD, LD/N Kim Zeller, MSH, RD
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Table of Contents
C A. The Nutrition Care Process
Nutrition Assessment Nutrition Education and Counseling Nutrition for Culturally Diverse Populations Calorimetry Equations Current Recommendations Nutrition Care Process B. Medical Nutrition Therapy for Overweight and Obesity Adult Obesity Prevention Adult Nutrition for Weight Loss Childhood Obesity Prevention Treating the Overweight Child Children and Physical Activity Health at Every Size (HAES) Physical Fitness and Athletic Performance Vegetarian Nutrition Bariatric Surgery B1.1 B2.1 B3.1 A1.1 A2.1 A3.1 A4.1 A5.1
C. Medical Nutrition Therapy for Contemporary Nutrition Issues
Metabolic Syndrome Food Labeling
Nutrition Resources Online
Dietary Reference Intake (DRI) Functional Foods
Complementary and Alternative Medicine Nutritional Care for Dental Health
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B4.1 B5.1 B6.1 C1.1 C2.1 C3.1 C4.1 C5.1 C6.1 C7.1 C8.1 C9.1 C10.1 C11.1 C12.1 C13.1
Up to Date: Folate, Food Folate, Folic Acid and Folacin Up to Date: Iron in Health Promotion and Disease Prevention Up to Date: Caffeine and Health D. Life Cycle Medical Nutrition Therapy Nutrition Guidelines and Recommended Eating Patterns Under Revision Nutrition and Wellness: Balance of Body, Mind & Spirit Nutrition in Pregnancy Nutrition in Lactation
D1.1 D2.1 D3.1 D4.1
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Geriatric Nutrition Liberal Geriatric Diet No Concentrated Sweets Diet No Added Salt Diet Long Term Care Nutrition Nutrition Education for High Calorie/High Protein Diet Nutrition for Osteoporosis Nutrition for Anemia Nutrition for Wound Healing E. Pediatric Medical Nutrition Therapy Infant Nutrition 0-12 Months Nutrition for Children 1-10 yrs Adolescent Nutrition Nutrition for Children with Diarrhea Preterm and Low Birth Weight Nutrition Pediatric Enteral Nutrition Support Cystic Fibrosis Nutrition Pediatric Parenteral Nutrition Support D5.1 D6.1 D7.1 D8.1 D9.1 D10.1 D11.1 D12.1 D13.1
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Pediatric/Adolescent Inflammatory Bowel Disease Nutrition Pediatric Insulin Dependant Diabetes Mellitus Nutrition Pediatric HIV/AIDS Nutrition Inborn Errors of Metabolism- Phenylketonuria Inborn Errors of Metabolism- Galactosemia Inborn Errors of Metabolism- Maple Syrup Urine Disease Ketogenic Diet Growth Charts for Children F. Medical Nutrition Therapy for Textural Changes Clear Liquid Diet Full Liquid Diet Pureed Diet Mechanical Soft Diet Soft Diet Dysphagia Diet Tonsellectomy Diet
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E1.1 E2.1 E3.1 E4.1 E5.1 E6.1 E7.1 E8.1 E9.1 E10.1 E11.1 E12.1 E13.1 E14.1 E15.1 E16.1
F1.1 F2.1 F3.1 F4.1 F5.1 F6.1 F7.1

Table of Contents
G. Medical Nutrition Therapy for Eating Disorders, Substance Abuse and Brain/Central Nervous System Disorders Nutrition for Eating Disorders Nutrition for Substance Abuse Treatment Nutrition for Neurological and Mental Disorders Primary Headaches (Migraine, Tension-Type, and Cluster Headaches) Nutrition for Depression Nutrition for AD/HD Nutrition for Autism H. Medical Nutrition Therapy for Cardiovascular Disease Coronary Heart Disease and Hyperlipidemia Congestive Heart Failure Sodium Controlled Diets Heart Transplant I. Medical Nutrition Therapy for Hypertension Nutrition for Hypertension DASH Diet G1.1 G2.1 G3.1 G4.1 G5.1 G6.1 G7.1
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J. Medical Nutrition Therapy for Diabetes Nutrition for Diabetes Diabetes Self-Management Training
Nutrition for Hypoglycemia Secondary to Diabetes Nutrition for Functional Reactive Hypoglycemia Nutrition for Gestational Diabetes Nutrition for Diabetes Related Amputations K. Medical Nutrition Therapy for GI Disorders Nutrition for Esophageal Reflux (GERD) High Fiber Diet Low Residue Diet Bland Diet Nutrition for Post-Gastrectomy Short Bowel Syndrome
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H1.1 H2.1 H3.1 H4.1 I1.1 I2.1 J1.1 J2.1 J3.1 J4.1 J5.1 J6.1 K1.1 K2.1 K3.1 K4.1 K5.1 K6.1
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L. Medical Nutrition Therapy for Liver and Biliary Disorders Protein Restricted Diet Fat Restricted Diet Nutrition for Liver Disease Updated Section! Nutrition for Cirrhosis M. Medical Nutrition Therapy for Kidney Disorders Nutrition for Chronic Kidney Disease Stages 1-4 Nutrition for Chronic Kidney Disease Stage 5 N. Medical Nutrition Therapy for Hypermetabolic Conditions Nutrition for Adult Burns Nutrition for Cancer Nutrition for Solid Organ Transplantation Nutrition for Chronic Obstructive Pulmonary Disease Nutrition for HIV/AIDS O. Enteral and Parenteral Nutrition Support Enteral Nutrition Support M1.1 M2.1 N1.1 N2.1 N3.1 N4.1 N5.1 L1.1 L2.1 L3.1 L4.1
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Parenteral Nutrition Support
P. Medical Nutrition Therapy for Food Allergies/Intolerances/Restrictions Nutrition for Food Allergies Egg Free Diet Gluten Free Diet Milk Free Diet Wheat, Egg & Milk Free Diet Purine Controlled Diet Tyramine Restricted Diet Latex Sensitivity/Allergy Diet Oxalate Restricted Diet Q. Medical Nutrition Therapy for Medical Tests Nutrition for Glucose Tolerance Test Nutrition for Vanillylmandelic Acid (VMA) Test Nutrition for 100 Gram Fat Fecal Fat Test Nutrition for Serotonin (5-HIAA) Test
Lactose Restricted Diet
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O1.1 O2.1 P1.1 P2.1 P3.1 P4.1 P5.1 P6.1 P7.1 P8.1 P9.1 P10.1 Q1.1 Q2.1 Q3.1 Q4.1
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R. Spanish Nutrition Education Materials Adult Weight Loss Adult Obesity Overweight Child CHD/Hyperlipidemia Sodium Controlled Diets Type 1 and Type 2 Diabetes Diabetes Self Management Training Gestational Diabetes Hypoglycemia Secondary to Diabetes Mellitus Functional Reactive Hypoglycemia GERD Bland Diet High Fiber Diet Low Residue Diet Dental Health Index R1.1 R2.1 R3.1 R4.1 R5.1 R6.1 R7.1 R8.1 R9.1
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R10.1 R11.1 R12-1 R13.1 R14.1 R15.1 S1.1
Nutrition Assessment
Written by: Patricia J. Funk, MS, RD, LD/N, CNSD, Shands at AGH, Gainesville, Florida Reviewed by: Eunshil Shim, MS,RD,LD/N, Consulting Dietitian, Gainesville, Florida addition to usual or actual food intake, information is obtained regarding physical activity, ethnic, religious, and cultural influences, economics, appetite, allergies and food intolerances, home life, dental health, gastrointestinal health, medications, chronic diseases, weight changes and nutrition problems as perceived by the patient. See Information obtained from a nutrition history and patient/caregiver interview in this section. Methods for obtaining nutritional history (2, 3) The nutrition history is obtained by interviewing the patient/caregiver/family. It is important to establish rapport and convey empathy and acceptance in order to establish a relationship with the patient. Pace the interview to complete it within an appropriate amount of time. It is helpful to avoid complicated technical and medical terminology. Techniques of communication are encouraged such as acceptance, recognition, restating or paraphrasing. Avoid judging comments. 1. Twenty-four (24) hour recall provides information on food intake of the previous 24 hours. 2. Food frequency questionnaires or checklists of foods with patient/client, or caregiver indicating the frequency with which foods are eaten. 3. Food records or diaries provide three to five day records of actual food consumption. 4. Direct observation of patient's intake. Information obtained from a nutrition history and patient/caregiver interview (4) Economics income frequency and steadiness of employment amount of money budgeted for food each week or month and individual's
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PRACTITIONER POINTS
RATIONALE The purpose of a nutritional assessment is to evaluate a patient's nutritional adequacy to identify nutritionrelated problems, existing nutritional deficits and degree of nutritional risk for developing nutritional deficits. A nutritional assessment is a comprehensive evaluation of a patients nutritional status, which establishes baseline data to evaluate the effectiveness of medical nutritional therapies and to develop a nutritional care plan. A comprehensive nutritional assessment utilizes both objective data and subjective data from the patient and/or significant other to determine past and present nutritional state of health. The recommendations made are dependent on the skill and experience of the clinician in interpreting available information and the significance and limitations of the data. Elements of a comprehensive nutritional assessment include: a thorough history (nutritional, medical, surgical, and social), psychological, medical record review, physical examination, patient and/or caregiver interview, anthropometric measurements, laboratory data and assessment of nutrient requirements (1). NUTRITION HISTORY The value of accurate dietary data is well known. The act of obtaining accurate information is a challenging part of a complete nutritional assessment. It is difficult to obtain dietary data without influencing food intake. Individuals may or may not be able to recall foods eaten, others may agree to record foods eaten. Few people can accurately judge or report the size of portions eaten. In
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perception of its adequacy for meeting food needs eligibility for food stamps, cost and amount of stamps received Physical Activity occupation type, hours per week, shift, estimated energy expenditure exercise type, amount, frequency, seasonal changes Sleep hours per day, continuous, or interrupted handicaps Ethnic, Religious, or Cultural Background influence on eating habits educational level Home Life and Meal Patterns number in household who eat meals together person who does the shopping person who does the cooking food storage and cooking facilities type of housing, e.g. home, apartment, adult congregate living facility ability to shop and prepare food, or dependence on others for this activity Appetite good, poor, changes in amount and types of foods eaten, including textures factors that affect appetite including changes in taste and smell Allergies, Food Intolerances, Food Avoidances foods avoided and reasons length of time of avoidance description of problem caused by eating avoided foods Dental and Oral Health condition of teeth, dentures, and/or gums problems with eating and/or drinking due to sore mouth/tongue, thrush foods that cannot be eaten problems with swallowing, salivation, chewing, jaw pain, food sticking in mouth or throat Gastrointestinal Health problems with heartburn, bloating, gas, diarrhea, vomiting, constipation, distention frequency and severity of problems home remedies antacid, laxative, or other drug use Chronic Disease treatment length of time of treatment dietary modification physician prescription, date of modification, education received, comprehension and compliance with nutrition prescription
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Medication vitamin and/or mineral supplements frequency, type, amount herbal products type, frequency, amount, reason for taking, or expected outcome medications type, amount, frequency, length of time taking medication, taken with or without food. Recent Weight Changes loss or gain how many pounds, over what length of time intentional or non-intentional Nutritional problems as perceived by the patient CLINICAL EVALUATION Physical Examination Thorough physical assessment is a key component of the patients nutritional health history. Observations in the general physical exam are usually indicative of long-term nutrition depletion (13, 21). Ideally, the physical exam should include assessment of muscle mass and
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subcutaneous fat stores, inspection and palpation for edema and ascites (indicators of diminished visceral protein levels and hepatic dysfunction), inspection and evaluation for signs and symptoms of vitamin and mineral deficits (13, 21, 26). Various clinical findings are associated with specific nutrient deficiencies (5-8). Physical signs are usually non-specific and nonapparent until the patient is severely malnourished. Specific nutrient deficiencies should be confirmed by appropriate laboratory data before therapy is instituted. Nutritional Physical Examination The exam proceeds from head to toe to assess patients nutritional health. Equipment for assessment includes stethoscope, reflex hammer, tape measure, calipers, thermometer, tongue blade, and penlight. Nutrition-focused-physical examination concentrates on 4 techniques: (21, 34) 1. 2. 3. 4. Inspection Palpation Percussion Auscultation distal portion is placed firmly against the clients skin. The middle finger of the dominant hand strikes the pleximeter with the fingertip, not the finger pad. It should hit at a right angle to the stationary finger. The finger strikes twice and is withdrawn immediately to avoid interfering with vibrations. Different sounds are produced by different tissues (21). Auscultation: Uses the stethoscope to listen to sounds produced by organs and viscera including lungs, heart, blood vessels, stomach and intestines. Auscultation is used last in physical assessment except in the abdomen. Since bowel sounds may be disrupted by palpation, auscultation is used second in the abdomen after inspection.
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Inspection: Good lighting is essential. Focus on observation of color, texture, size and shape. Palpation: Exam by touching body structures, pulsations and vibrations. Light palpation: gently press in to a depth of 1 cm. Deep palpation: press in to a depth of approximately 4 cm. Light palpation is adequate for nutrition examination. Percussion: Produce sounds to locate organ borders and assess organ shape and position. Direct percussion: Tap fingertips or hand directly against the body structure. Indirect percussion: Use the nondominant hand as the stationary hand. The middle finger or pleximeter is hyperextended and the
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ANTHROPOMETRY Frame size
Signs and symptoms that often indicate nutritional deficiencies are described in references 13 and 21. Details on physical assessment skills can be viewed in The American Dietetic Associations video: Nutrition-Focused Physical Assessment Skills for Dietitians (34).
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Determination of frame size is important in interpreting weight and weight for height tables. In many instances weight tables are published only for "medium" framed individuals. Of several methods available, one of the easiest is to have patients gauge their frame size by wrapping the nondominant wrist with the thumb and index finger of the dominant hand at the level of the radius and ulnar styloid process. If the fingertip and thumb meet, the frame is medium; if the fingertip and thumb over lap, the frame is small; if the fingertip and thumb do not meet, the frame is large (9). Frame size can also be determined by measuring the smallest part of the right wrist circumference, distal to the styloid process of
the ulna three times and then averaging the measurements and recording the mean (10, pg.10).
Frame size (r) = height in centimeters (cm) wrist circumference (cm) Classification of frame size: small frame medium frame men <9.9 9.9 - 10.9 <9.6 women 9.6 - 10.4 large frame >10.9 >10.4
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indicate a larger frame. Height Measurement of height forms the basis for calculation of ideal body weight (IBW), caloric need, and adequacy of caloric intake. Unfortunately, it is often missing from the medical record. When documenting height, the person should be barefoot, or wearing only socks or stockings. The feet should be together with the heels against the wall or measuring board. The person should be standing erect, neither slumped nor stretching, looking straight ahead. The top of the ear and outer corner of the eye should be in a line parallel to the floor, called the Frankfort plane. A horizontal bar, a rectangular block of wood, or the top of the statiometer then should be lowered to rest flat on the top of the head. The height should be read to the nearest 1/4 inch or 0.5 centimeters (4). Height can be estimated in bed-ridden patients using knee-length prediction equations. Using a broad blade caliper, with the patient lying supine, and the knee bent at a 90-degree angle. One blade of the caliper is placed over the anterior surface of the left thigh, above the condyles of the femur and just proximal to the patella. The caliper shaft is held parallel to the shaft of the tibia. Pressure is applied, and two readings should agree within +/- 0.5 cm. Height is then calculated from the following two equations (11): Men: Height (cm) = 64.19 - (0.4 x age) + (2.02 x knee height) Women: Height (cm) = 84.88 - (0.24 x age) + (1.83 x knee height) Weight Measurement of weight is a key assessment parameter. It is often missing from the medical record. Avoid relying on
A third method for determining frame size is based on a measurement of elbow width. Have the patient extend the arm and bend the forearm upward at a 90-degree angle. Keeping fingers straight, turn the inside of the wrist toward the body. Place the thumb and index finger of the other hand on the two prominent bones on either side of the elbow. Measure the space between the thumb and index finger against a ruler or tape measure. Compare it with the Table 1 below that lists elbow measurements for medium framed men and women.
Table 1. ELBOW BREADTH MEASUREMENTS FOR A MEDIUM FRAME (11) Men Height 5'2" - 5'3" 5'5" - 5'7" 5'8" - 5'11" 6'0" - 6'3" 6'4" + Women Height 4'10" - 4'11" 5'0" - 5'3" 5'4" - 5'7" 5'8" - 5'11" 6'0" + Elbow Breadth 2 1/2" - 2 7/8" 2 5/8" - 2 7/8" 2 3/4" - 3" 2 3/4" - 3 1/8" 2 7/8" - 3 1/4" Elbow Breadth 2 1/4" - 2 1/2" 2 1/4" - 2 1/2" 2 3/8" - 2 5/8" 2 3/8" - 2 5/8" 2 1/2" - 2 3/4"
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Measurements lower than those listed indicate a small frame. Higher measurements
patients self-reports of weight or height. Weights can easily be measured inaccurately, or complicated by the patient's medical condition, such as edema, ascites, or tumors, or treatments, such as casts, traction or life-support equipment. Accuracy in measurement is essential as it is often the foundation of important clinical decisions. Use a beam balance scale, rather than a spring scale, whenever possible. Periodically calibrate the scale for accuracy, especially if it is moved from place to place. Use known weights for calibration. Weigh the individual in light clothing without shoes and heavy objects in their pockets, such as keys. Record weight to the nearest 1/2 pound or 0.2 kilogram for adults. Use bed scales or wheelchair scales for patients unable to stand unassisted (4). The type of scale used should be noted along with the weight, especially with bed and wheelchair scales. Fluctuations in weight may be due to improper weighing techniques, such as: weighing bedding or leaning on the bed when weighing the patient, weighing orthopedic appliances such as braces, or switching from one scale to another without checking calibration. When amputees are weighed it should be noted whether or not they are wearing any prosthetic devices during the weighing. Estimation of Desirable Body Weight Using the Hamwi Formula (2) For women: Allow 100 pounds for the first five feet of their height. Multiply each inch over five feet by 5 and add it to 100. For a small frame subtract 10% For a large frame add 10% For men: Allow 106 pounds for the first five feet of their height Multiply each inch over five feet by 6 and

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add it to 106 For a small frame subtract 10% For a large frame add 10%
For example: a medium frame woman who is 5'6" tall: 100 + (5 x 6 = 30) = 130 pounds A large frame man who is 5'6": 106 + (6 x 6 = 36) + 10% = 156 pounds Estimation of Ideal Body Weight Adjusted for Obesity For obese patients, it is assumed that fat has less metabolically active lean body tissue than fat-free lean body tissue. It has been reported that men have obese tissue composed of 62% fat and 36% to 38% lean body mass. Womens obese tissue is reported to have up to 70% fat and 22% to 32% lean body mass. Based on this information, an adjusted ideal body weight (AIBW) equation may be used. Men: AIBW = [(actual weight - IBW) x 0.38] + IBW Women: AIBW = [(actual weight - IBW) x 0.32] + IBW
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Many practitioners choose to use a weight estimate called adjusted body weight (Adj BW/ABW) AdjBW= 0.25(actualBW-IdealBW) + IBW The ABW equation assumes that obese people possess an average of about 25% metabolically active lean body tissue in their weight in excess of their IBW. Limitations of ABW: It does not take into consideration the wide variability in body composition among obese people. Estimation of Desirable Body Weight for Amputees Determine ideal body weight using
Hamwi formula or AIBW. Use the last known height prior to amputation. Subtract the percent listed below from ideal or adjusted body weight for body part amputated to determine desirable body weight (12). Method #1 (based on cadaveric studies) Hand subtract 1% Forearm with hand subtract 3% Entire arm subtract 6.5% Foot subtract 1.8% Lower leg with foot subtract 5.9% Entire leg subtract 18.5% Above the knee subtract 13% Below the knee subtract 6% Method #2 (gross estimation) Foot amputation subtract 5 lbs Below knee subtract 10 lbs Above knee subtract 15 lbs Entire leg subtract 20 lbs Estimation of Desirable Body Weight for Paraplegics and Quadriplegics A person with injury to the spinal cord is at risk for obesity due to immobilization and decreased energy expenditure. Maintenance of an ideal body weight slightly below the average for a healthy adult is recommended to facilitate transfers and enhance self-care activities (13). Paraplegics: commonly to determine nutritional status based on weight. Both a weight loss and a weight gain need to be compared to the usual or pre-illness weight, as well as comparing the current weight to a reference standard. Usual body weight is a more useful parameter than healthy or ideal body weight when evaluating the status of an ill patient. The percentage of recent weight change with respect to the UBW correlates best with acute morbidity and mortality. The disadvantage is that it is dependent on patient or caregiver memory. A past medical record may be available to give weight history. Percent usual body weight (% UBW) = (actual weight)__ X 100 (usual body weight)
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Clinical significance of %UBW (2): 85-90% mild malnutrition 75-84% moderate malnutrition <74% severe malnutrition Percent Ideal (Healthy) Body Weight
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Due to inaccuracies associated with some patient's ability to recall their previous weight, it may be advisable to use the ideal weight based on an average weight for height obtained from a standard formula, such as the Hamwi Formula.
For both men and women, subtract 5 10% from the desirable weight figured using the Hamwi Formula. Quadriplegics: For both men and women, subtract 10 15% from the desirable weight figured using the Hamwi Formula. Interpretation of Weight Percent Usual Body Weight Usual Body Weight (UBW) is used most
Percent ideal body weight (% IBW) = (actual weight)_ X 100 (ideal body weight) Clinical significance (%IBW) (2): morbidly obese > 200% obese > 150% overweight > 120% 80 - 90% mild malnutrition 70 - 79% moderate malnutrition <69% severe malnutrition Percent Weight Loss Changes in the patient's percent of usual weight are considered to be a more
accurate indicator of recent or chronic nutritional deprivation than weight expressed as a percent of ideal body weight. Current body weight needs to be dry weight or nonedematous weight. % weight loss = UBW-current weight UBW Clinical Significance (1):
Time 1 week 1 month 3 months 6 months Significant Severe weight weight loss (%) loss (%) 1-2 % 5% 7.5% 10% > 2% >5% > 7.5% > 10%
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TSF is most commonly used in clinical settings to estimate energy reserves because it is an easily accessible and indirect measure of subcutaneous fat. Measurements of Mid-Arm Circumference (MAC), Mid-Arm Muscle Circumference (MAMC) and Arm Muscle Area (AMA) are indirect methods of measuring somatic protein (skeletal muscle mass). Nutritional risk based on these measurements utilizes reference data which are not available for elderly people or ethnic minorities. Assessment of short-term changes in body composition especially for ICU patients or acutely stressed patients is not reliable (13, 17, 21). Mid-Arm Circumference (MAC), Arm Muscle Circumference (AMC), and Arm Muscle Area (AMA) These are indirect methods of measuring somatic protein (skeletal protein mass). AMC is derived from TSF and MAC and provides a quick and easy approximation of skeletal muscle mass and degree of depletion (11). They are estimated from the following equations:
AMC (cm) = MAC (cm) - 0.314 TSF (mm)
X 100
Body Composition As with other anthropometric measurements, care must be taken in the measurement technique and in the interpretation of results. Single measurements are not particularly useful and should not be used in conjunction with other indices. Changes need to be followed periodically over time to provide meaningful data and assessments. Skinfold Measurements
Skinfold measurements using calipers are a non-invasive measure of subcutaneous fat for an indirect estimate of fat stores. Estimate of fat stores provides an index of the body's energy reserves. Skinfold measurements are non-invasive, but technique is critical for accuracy and affected by intraobserver variability (measurements taken by different people). Intraobserver error (all measurements taken by one person) can be reduced by extensive training and practice. Intraobserver error depends on what site is being measured and what procedure is followed to take the measurements. Triceps Skinfold (TSF)
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AMA (cm2) = [MAC (cm) - 3.14 TSF (cm)] 2 4 (pi) (Tables for percentile ranking of TSF, MAC, AMC, AMA are listed in reference 14)
There is decreased accuracy of using these measurements in the clinical setting due to fluid shifts, changes in hydration status, and fluid resuscitation. Standards for these measurements were developed from non-hospitalized populations and may correlate poorly with hospitalized patients nutritional status. The above measurements are most appropriate for assessing change over time in individual patients (13, 17, 21). For healthy persons, measure at the same time of day
over time. Commonly used sites are as follows: Men: Chest, Abdomen, Thigh Women: Triceps, Suprailium, Thigh For percent fat estimate for the above sites, see Sports Nutrition: A Guide for the Professional Working with Active People, Tables 11.8 and 11.9 on pages 209, 210 (18). Limitations of Skinfold Measurements Both healthy and diseased persons have short-term hydration-related body tissue variations. People with CHF, liver and kidney disease show pronounced fluid shifts. Equations used to predict fat mass (or percentage body fat) and fat-free mass are from skinfold measurements in healthy populations and are not valid for diseased populations. Technique is critical to accuracy and affected by observer error. Differences in calipers and their calibration can contribute to errors. Some calipers consistently exert more jaw force resulting in greater compression and smaller values than other calipers. Calipers should be calibrated and re-calibrated routinely to reduce errors. and thumb. Palpation of biceps and triceps skinfolds between the finger and thumb is also useful in assessing protein status in the ill (13, 21). Body Mass Index (BMI) (11, 13, 15, 17, 21) More frequently being used as the method of determining obesity due to its higher correlation with body fat rather than body weight.
Body Mass Index = Weight (kg) Height (m)2 Body Mass Index = pounds x 705 (inches)2
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Assessment of Muscle Mass and Subcutaneous Fat Stores in Critical Care Patients This is best done by inspection of muscle groups. Temporalis muscles, deltoids, suprascapular and infrascapular muscles, bellies of biceps, triceps and interossei of hands should be observed and palpated. Long muscle tendons that are prominent to palpation are indicative of profound protein depletion or 30% loss of total body protein stores. This can be observed by appearance and by palpating skinfolds between the finger
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Clinical Significance:
Men Acceptable weight 20.7 - 27.8 Intervention indicated > 26.4 Obesity > 27.8 Severe Obesity > 31.1 Morbid Obesity > 45.4
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Women 19.1 - 27.3 > 25.8 > 27.3 > 32.3 > 44.8
A nomogram may be used to determine body mass index (11, 13, 21). Survival in a person with a BMI below 14 is very unusual (13). ASSESSMENT OF CALORIE AND FLUID NEEDS Determination of caloric requirements Definitions Basal Energy Expenditure (BEE) is represented by the Mifflin St. Jeor Equation and used to predict basal metabolic rate: BEE = BMR Basal Metabolic Rate (BMR) is a subject's energy expenditure measured in the postabsorptive state (no food consumed during the previous 12 hours) after resting quietly for 30 minutes in a thermally neutral environment (room temperature is perceived as neither hot nor cold.)
Resting Metabolic Rate (RMR) also known as Resting Energy Expenditure (REE), is the term used for metabolic rate or energy expenditure in the awake, resting, postabsorptive (2 hours post meal) subject. It is often measured by indirect calorimetry and is approximately 10% higher than the BEE or BMR (9). Harris-Benedict Equation (15) To calculate the BEE and subsequent caloric requirement for men and women follow the equation listed below, either using the metric system or pounds and inches.
For men: BEE = 66.5 + 13.7(wt in kg) + 5.0 (ht in cm) 6.8 (age in years) For women: BEE = 665 + 9.6 (wt in kg) + 1.8 (ht in cm) - 4.7(age in years) For men: BEE = 66 + 6.3 (wt in lbs) + 12.9 (ht in inches) - 6.8 (age in years)
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Mifflin St. Jeor Equation (16) To calculate the BEE and subsequent caloric requirement for men and women follow the equation listed below, either using the metric system or pounds and inches.
Males: 9.99 X weight (kg) + 6.25 X height (cm) 4.92 X age + 5. Females: 9.99 X weight (kg) + 6.25 X height (cm) 4.92 X age 161.
For women: BEE = 655 + 4.3(wt in lbs) + 4.7(ht in inches) - 4.7 (age in years)
To determine caloric requirements using the BEE, multiply BEE by the appropriate activity factor and injury factor. Weight used may be adjusted ideal body weight due to obesity as well.
Activity Factors Confined to Bed
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Injury Factors 1.2 Surgery Minor Major Skeletal or Blunt Trauma Head Trauma Infection Mild Moderate Severe 1.3 1.5
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1.0-1.2 1.1-1.3 1.1-1.6 1.6-1.8 1.0-1.2 1.2-1.4 1.4-1.8
For individuals who need to gain weight: add 500 calories to their daily requirement For individuals who need to lose weight: subtract 500 calories from their daily requirement. For additional calorie needs to provide adequate calories with a fever, add 7% of the BEE for every 1-degree over normal using the Fahrenheit scale, or add 13% of the BEE for every 1 degree over normal using the Centigrade scale. Calorie requirements = BEE (activity factor + injury factor) + (calories for desired loss or gain) + fever factor (16) For paraplegics or quadriplegics, calculate the BEE and use either 1.2 or 1.3 for activity factor, and injury factor as appropriate. For amputees, figure desirable body weight as above, and either calculate BEE with current height, if appropriate; or multiplying desirable body weight using the Hamwi formula described below.
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Out of Bed Normal ADLs
Hamwi Formula To determine calorie need in nonmetabolically stressed individuals, this formula is easy to use. Figure the individual's weight from the height (see section B3b) (17). Determine basal calories by multiplying desirable body weight (DBW) in pounds by 10. Add activity calories based on level of activity: For sedentary activity multiply DBW by 3 For moderate activity multiply DBW by 5
Burns (% body surface area) <20% BSA 1.2-1.5 20-40% BSA 1.5-1.8 >40% BSA 1.8-2.0
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Light: Mostly seated or standing, with arm movements Moderate: Frequent movements involving arms and legs, walking briskly Strenuous: Walking uphill, activities involving intermittent but frequent spurts of energy (18). For pediatric/adolescents Pediatric Section of this manual. DETERMINATION OF PROTEIN REQUIREMENTS refer to
For strenuous activity multiply DBW by 10
Add additional calories as described above for weight gain, or subtract for weight loss. For a small framed woman who is 5'8" and sedentary and her current weight is 110 lbs.
5 feet = 100 lbs 8 inches = +40 lbs 140 lbs (- 10%) (x 10) 14 for small frame 126 x 10 for basal calories 1260
(3 x 126) + 378 for sedentary activity 1638 (+ 1000) 1000 for gain of 2 lbs per wk 2638 calories daily
Kilocalorie per kilogram method
Used in non-metabolically stressed persons, often when current weight is not known. Convert ideal body weight based on individual's height to kilograms. Multiply kilograms by factor representing weight status and level of activity:
Activity Sedentary factor: Over20 weight Normal 25 weight Under 30 weight
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Light 25 30 35 30 35 40 35 40
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Estimation of protein needs can be determined in several ways: Predictive factors based on Recommended Dietary Allowances per kilogram of body weight The requirements for healthy adults (other than pregnant or lactating) are 0.8 grams of protein per kilogram per day (19). This requirement changes with specific disease states and states of metabolic stress. In general, patients who are starved but not stressed require protein intakes of 1.0 gram of protein per kilogram per day, while patients who are highly stressed require a range of 1.5 - 2.0 grams of protein per kilogram per day. Suggested guidelines are available to assist the clinician in determining protein requirements in specific disease states (13, 20, 21, 22). Non-protein kilocalories to nitrogen ratio Protein requirements can also be determined by figuring appropriate nonprotein kilocalorie to nitrogen ratio. Generally, for the non-stressed patient, the non-protein calorie to nitrogen ratio should be 150:1. This figure changes with specific diseases. Stressed patients require a non-protein calorie to nitrogen ratio of 80-100:1 (Note: 1
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Moderate Strenuous
45-50
Activity levels should be determined according to the type of activity that comprises the major portion of the individual's hours: Sedentary: Confined to chair or bed rest. Convalescing from debilitating disease.
gram of nitrogen = 6.25 grams of protein) (21). Nitrogen balance studies Protein requirements should be routinely monitored via nitrogen balance studies in stressed patients because prediction of requirements is difficult in septic, trauma, post-surgical or critically ill patients. Note that nitrogen loss after injury and infection is less than expected in the elderly and in already depleted individuals (23). Appropriate candidates for nitrogen balance studies are catheterized patients on reasonably well-defined nutrition support regimens where energy intake and urinary output is well controlled. Careful monitoring of nitrogen intake is necessary for patients receiving transitional or supplemental feedings (13, 20, 21). Determination of Fluid Requirements Multiple methods can be employed to determine baseline daily fluid requirements (20). Patients should have normal renal and cardiac function to apply these predictive factors. Use reference weight standards or desirable body weight for obese patients and actual body weight for others. RDA for water in the normal, unstressed adult is 1 ml per calorie of daily diet (18). Adult requirements by age:

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1000 ml for the first 10 kg of body weight 50 ml for the next 10 kg for persons < 50 years: add 20 ml for each additional kg for persons > 50 years: add 15 ml for each additional kg
Factors that include fever, third surgery or trauma, suctioning, fistula diarrhea, vomiting, respirator (22).
increase fluid needs space losses following nasogastric tube for and wound drains, hyperventilation, and
Factors that decrease fluid needs include cardiac or renal disease, and dilutional hyponatremia (13, 20, 21). MEDICAL RECORDS REVIEW
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Medical History Medications
The purpose is to provide detailed information about past and present medical problems. Some areas that affect nutritional status are: 1. acute and chronic illnesses with nutritional implications 2. hypermetabolic conditions 3. diagnostic procedures, therapies, or treatments that increase nutrient needs or induce malabsorption 4. surgical resections or diseases of the GI tract, liver, gallbladder, or pancreas 5. alcohol or drug addiction 6. medications affecting appetite, digestion, utilization, or excretion of nutrients
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Method #1 (23, 32) young active 16-30 years old: 40 ml/kg average adult 25-55 years old: 35 ml/kg older patients 56-65 years old: 30-35 ml/kg elderly > 65 years old: 30 ml/kg Method #2 (22, 32) young adults vigorous with large muscle mass: 40 ml/kg adults 18-55 years old: 35 ml/kg older adults >55 years old, with no cardiac or renal disease: 30-35 ml/kg Requirements based on body weight (22, 32)
A thorough review of all medications an individual is taking is necessary to determine whether a drug-nutrient interaction could impact their nutritional or medical status. JCAHO continues to insist the RDs assume responsibility for counseling on drug-nutrient interaction. Use of over-the-counter medications, e.g. laxative, analgesics, self-
prescribed vitamins, herbal products, or experimental medications, should also be identified. Biochemical Assessment While laboratory tests are used to provide worthwhile information for evaluating and managing nutritional status, they are often influenced by non-nutritional factors. Lab results can be altered by medications, hydration status, or other changes in metabolic processes during illness or stress. Interpretation must include these confounding factors (26). Values should be interpreted using the laboratory standards because assay methods may vary among labs. The major biochemical parameters for assessing nutritional status can be divided into those that measure lean body mass and those that measure transport proteins that are synthesized by the liver. Standard measurements of protein status include serum levels of albumin, transferrin, and prealbumin (transthyretin). Because of their different half-lives, these transport proteins can be used to assess an individual's long-term (albumin with a half life of 20 days), intermediate (transferrin with a half-life of 8 days), and short-term (prealbumin with a half life of 2 days) protein status. Most readily available in lab reports is albumin, with transferrin and prealbumin usually a costly, and frequently unseen test. Both transferrin and prealbumin are most helpful when fine-tuning a protein prescription for a nutritionally depleted patient (1).
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overload is detected. Serum osmolality can be estimated from serum sodium, blood urea nitrogen, and glucose. All three are usually available in even the most limited serum chemistries. mOsm/L = 2(Na + K) + BUN + Glu 2.8 18 Adult normal range is 280 - 295 mOsm/kg Values may be increased with dehydration, fever, insensible water losses, burns, artificial ventilation, hyperglycemia, glucosuria, high protein diets, IV sodium, Addison's disease, and excessive losses as in persistent vomiting or diarrhea.
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Values may be decreased in diabetes insipidus, cerebral injuries with decreased ADH, compulsive water drinking, aldosteronism, IV D5W, and fluid overload (20). Other biochemical and urinary indications of hydration status include BUN/ creatinine ratio, urine specific gravity, serum sodium, and hematocrit. Table 2 lists these tests with values for dehydration, normal and overhydration. Hematologic Assessment (2, 3, 28) Hematologic indices are used to differentiate nutritional anemias from other anemias. Nutritional anemias such as irondeficiency anemia and megaloblastic anemia of B12 and folic acid deficiency are corrected by replacement of the specific nutrient. In non-nutritional anemias, such as the anemia of chronic disease (seen in inflammatory bowel disease and cancer), the mechanism for the deficit may not be clear. Even though routine laboratory studies may suggest iron deficiency anemia, iron therapy may be ineffective and even harmful. Iron deficiency is the most common single nutrient deficiency in the United States
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Hydration status is a common factor that can falsely elevate or depress laboratory parameters due to serum concentration or third space losses (loss into interstitial spaces). Estimated serum osmolality has been suggested as a reliable measure of body hydration status (20, 23, 26, 27). Significant lab values should be interpreted with caution if either dehydration or fluid
and the most common cause of anemia. Anemia refers to a hemoglobin level below expected reference ranges and results from infection, chronic disease, and deficiencies of folate and vitamin B12. Medical management for iron deficiency anemia includes investigation of underlying causes including inadequate nutrient intake, impaired utilization or absorption, altered hematopoietic activity, or blood loss. Just as no single test is indicative of malnutrition, no single laboratory test is diagnostic of impaired iron status and several different tests are used to assess iron status. They may include hemoglobin, serum iron, serum plasma ferritin, percent transferrin saturation, red blood cell counts, red blood cell protoporphyrin, or mean corpuscular volume depending on the model requested. Additional non-specific studies of inflammatory response such as RBC sed-rate (red blood count sedimentation rate or ESR), zeta-sedimentation rate (SR), and C-reactive protein (CRP), allow for discrimination between iron deficiency anemia and the anemia caused by infection, inflammation, and chronic disease. Red blood cell indices typically include information on the following: MCV (mean corpuscular volume): volume of the red blood cell; increased values result in macrocytosis (MCV > 100) MCH (mean corpuscular hemoglobin): the amount of hemoglobin in the red blood cells; cells with low values are described as hypochromic (MCH < 27) MCHC (mean corpuscular hemoglobin concentration): average concentration of hemoglobin in the average red blood cell; hypochromic at <320 gm of hemoglobin per liter. Typically cells in iron deficiency anemia are hypochromic and microcytic while those in B12 and folic acid deficiency show evidence of macrocytosis. See Table 3 for summary of types of anemias.
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Table 2. Assessment of Hydration Status (19)
Test Est. serum Osmolality Urine Specific gravity BUN: creatinine ratio
Dehydration >300
Norms 280-295 mOsm/kg 1.035 1.003 g/ml
Overhydration <280
>1.035
<1.003
>25:1
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Serum Na Hct
>148
>52% men
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10:1 135-145 mEq/l 44-52% men 39-47% women
<10:1
<135
<44%
>47 women
<39%
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TABLE 3- SUMMARY OF TYPE OF ANEMIAS Serum Iron Transferrin Saturation , or Normal , or Normal Normal
Hb Hct
MCV or Normal Normal or Normal
TIBC or Normal or Normal
Ferritin Normal Normal
RBC
Retic or Normal or Normal
Iron Deficiency Vitamin B12 Folic Acid Vitamin E Chronic Disease Chronic Infection
Normal
Normal Normal
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or or Normal Normal
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Nutrition Education and Counseling

Written by: Judy E. Perkin, DrPH, RD, CHES, Professor, Department of Public Health, University of North Florida, Jacksonville and Susan R. Mella, MS, RD, LD/N, Instructor, Department of Biology and Health and Wellness, Miami Dade College, North Campus, Miami Reviewed by: Michelle Ciccazzo, PhD, RD, Associate Dean, College of Health and Urban Affairs, Florida Atlantic University, Miami and Judy Rodriguez, PhD, RD, LD/N, Professor, Department of Public Health, University of North Florida, Jacksonville study modules, written articles, posters, visual models, games, theatrical performances, puppet shows, audiocassette tapes, grocery store tours, food or cooking demonstrations, food tasting events, magazines, newspapers, television, videotapes, digital recordings, CDROMs, computer software, and the Internet (7, 31-33). Examples of nutrition education activities, as cited by Holli, Calabrese, and OSullivan Maillet (7, pg.258), might include the following: lectures, directed discussion, debate, individual or group problem solving, case studies, role playing and simulation, demonstrations, and completion of projects. Nutrition education may also be delivered through messages on food product packaging, in product advertising, in food product brochures, or via other promotional items designed to influence food or beverage consumption (11, 34). Frequently other creative means are used to convey nutrition education messages (10). As an example, the United States Department of Agriculture has recently initiated use of a Food Safety Mobile which is an automotive van designed to deliver food safety messages by touring across the country (35).
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PRACTITIONER POINTS
RATIONALE AND USE It has been stated that the health promotion challenge confronting dietitians is to connect peoples nutrition knowledge with action and change.(1, pg.1,2). A large body of dietetics and health education literature notes that nutrition education and nutrition counseling are health promoting methods used by dietitians to increase knowledge, alter attitudes, build skills, and to ultimately help develop and maintain appropriate health-related behaviors (1-15). The literature recognizes that both nutrition education and counseling need to have as a foundation evidence-based information from the sciences of food, dietetics, nutrition, and health care (1-2, 4-18). Equally important is that consideration needs to be given to client or patient expectations, as well as characteristics such as culture, age, gender, educational and literacy levels, occupation, religion, language, and lifestyle (5-15, 1926).
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Vaandrager and Koelen (36) have advocated and described a collaborative, community-based nutrition education approach which simultaneously involves a wide spectrum of institutions (schools, retail food outlets, restaurants, health organizations, and consumers). Dietitians may want to consider this model or other collaborative models of nutrition education program design that can effectively and efficiently accomplish nutrition education objectives (2, 14, 37). Nutrition counseling, as typically described in the literature, involves the establishment of a relationship of trust and respect which addresses a clients nutritional concerns through a goal-directed interchange between the client, or group, and the dietitian (4-8, 38). Nutrition counseling is generally accomplished in a dietitians pri-
Nutrition education may be accomplished at the individual, group, and community levels (7,10,22) or may involve coordinated efforts targeting county, state, national, or international populations (2, 10, 15, 27-30). Vehicles frequently used to deliver nutrition education include the following: classes, brochures, newsletters, self-

vate practice office and/or in an institutional setting such as a hospital or clinic (5-7). It most frequently involves a one-to-one interaction between dietitian and patient/ client, but can also occur in small groups (57, 22). Curry and Jaffe (5) emphasize the problem-solving aspects of nutrition counseling in Chapter 3 of their text and the importance of culturally competent counseling in Chapter 7. Holli, Calabrese, and OSullivan Maillet (7) devote Chapter 8 of their text to a discussion on the relationship between nutrition counseling and cultural/life cycle issues. Readers are directed to these references for a thorough discussion of above -stated topics. THEORETICAL BASES OF NUTRTION EDUCATION AND COUNSELING Many practitioners and researchers acknowledge that behavioral change theories may help dietitians develop effective nutrition education and counseling strategies. It has been said that such theories may help dietitians understand how and why individuals establish and alter dietary behaviors (5-8, 1012, 14). There are instances where more than one theoretical framework may be used in counseling and/or education (8, 9, 39) and it has been advocated that dietitians may be more effective as nutrition educators if this is the case (7, 40). Laquatra and Danish (26, pg. 1318) perceptively state that No model, strategy, or technique works effectively with everyone. Table 1 summarizes some of the more common behavioral change theories and models used in nutrition education and counseling, provides example literature citations, and gives examples of how the theories or models may be used by the dietitian (5-12, 14, 40). effectiveness. The report defined the following as contributing to nutrition education program success 1) use of a behavioral theory or theories; 2) use of techniques to motivate program participants; 3) incorporation of strategies to increase social support and participant empowerment; 4) use of environmental strategies to make appropriate foods and beverages more accessible; and /or 5) involvement of multiple organizational partners in the delivery of nutrition education messages. The American Dietetic Association has provided guidance for dietitians regarding nutrition education for the public in a Position Paper which advocates the use of a total diet approach nutrition education message (11). This guidance encourages the dietitian to focus on messages related to moderation, appropriate portion size, balance and adequacy of the total diet over time, the importance of obtaining nutrients from foods, and physical activity (11, pg.100). In another Position Paper, the American Dietetic Association encourages dietitians to collaborate with others and take leading roles in disease prevention and health promotion efforts which encompass the provision of nutrition education, especially consumer education (60).
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NUTRITION EDUCATION IN DIETETIC PRACTICE Contento et al. (14) reviewed over 200 studies of nutrition education programs and focused on factors that contributed to their
Texts and articles emphasize that the process of nutrition education involves the dietitian in multiple roles as an instructor, a facilitator, a mentor, and a role model (2, 7). Steps in the instruction process include the following: 1) assessment of learning needs; 2) development of learning objectives; 3) selection of educational content based on audience needs and desires, as well as the knowledge, skills, and motivations needed to achieve objectives; 4) design and creation of an appropriate learning environment; 5) development or selection of appropriate learning materials; 6) planning and implementation of learning activities; and 7) evaluation of the individual or group educational experience (7).

TABLE 1. BEHAVIORAL THEORIES AND MODELS USED IN NUTRITION EDUCATION AND COUNSELING Behavioral Theory or Model Name Description Example Citations of Nutrition Articles Using Theory/ Models Examples of How Theory/ Model May Be Used by Dietitians
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Behavioral Modification or Behavioral SelfManagement
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This popular and widely referenced approach seeks to condition behavior, a term which denotes linking a desired dietary behavior to an environmental observation (5, 6, 7). Those describing how to use this approach note that emphasis is given to creating behavioral change through awareness of cues or environmental factors that trigger or initiate dietary behavior (5-8). Major strategies described in the literature to implement this approach are: selfmonitoring to identify and modify behavioral triggers (cues), establishment of nutrition behavior goals, use of rewards for appropriate eating behaviors, seeing or hearing about how others handle a situation, and cognitive restructuring to control inappropriate thinking about food (5-7, 41, 42).
Poston WSc 2nd, Foreyt JP. Successful management of the obese patient. Am Fam Physician. 2000; 61: 3615-3622. Mossavar-Rahmani Y, Henry H, Rodabough, Bragg et al. Additional self-monitoring tools in the dietary modification component of the womens health initiative. J Am Diet Assoc. 2004; 104: 7686.
Nutrition EducationThe dietitian may facilitate a group nutrition education session on a dietary topic to encourage client dialog about factors that facilitate or cue desirable and undesirable dietary behaviors (6, 7). Nutrition Counseling- In order to create an awareness of environmental cues, several texts suggest that the dietitian ask a patient or client to keep a log of consumption behavior and also record related environmental factors that influence intake behaviors (5, 6, 7). Bauer and Sokolik (6, pg.266) provide an Eating Journal Behavior form that may be used for this purpose. Holli, Calabrese, and OSullivan Maillet (7, pgs. 117 -119) provide an extensive listing of behavior change strategies that can be used in nutrition counseling and also on page 124 provide an example for keeping a behavioral management food record.
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TABLE 1. BEHAVIORAL THEORIES AND MODELS USED IN NUTRITION EDUCATION AND COUNSELING Behavioral Theory or Model Name Description Example Citations of Nutrition Articles Using Theory/ Models Examples of How Theory/ Model May Be Used by Dietitians
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Consumer Information Processing Theory
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This theory, described by Rudd and Glanz (43) and Rosal (8), highlights the need to present dietary information when persons are receptive to receiving the message, and also stresses the importance of nutrition information being presented in a manner that the client or audience can understand.
Rosal MC, Ebberling CB, Ockene JK, Ockene IS, Hebert JR. Facilitating dietary change: the patientcentered counseling model. J Am Diet Assoc. 2001; 101: 332 - 338, 341.
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Nutrition EducationA dietitian may initiate a nutrition education program when he/she becomes aware of community interest in, and receptiveness to, learning about a nutrition topic. The resultant nutrition education program messages could be pretested to ensure that the messages are interpreted correctly by the intended recipients of the nutrition education (8, 43). Nutrition CounselingThe dietitian could ask questions to ascertain client readiness to receive a nutrition message and could also use communication techniques and informal tests of understanding to ensure that information shared with the client was interpreted properly (8, 43).
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TABLE 1. BEHAVIORAL THEORIES AND MODELS USED IN NUTRITION EDUCATION AND COUNSELING Behavioral Theory or Model Name Description Example Citations of Nutrition Articles Using Theory/ Models 1) Sigman-Grant M. Can you have your low fat cake and eat it too? The role of fat-modified products. J Am Diet Assoc. 1997; 97 (7 Supple): S 76-81. Examples of How Theory/ Model May Be Used by Dietitians
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Diffusion of Innovations
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This model postulates that a new food behavior could be adopted in five stage which have been outlined as: 1) knowledge of the new behavior; 2) development of a positive attitude toward the new behavior; 3) a decision to adopt the behavior; 4) adoption of new behavior; and 5) reinforcement of the decision to adopt the new behavior (7, 10, 44). This model speaks not only to individual dietary change but has been used to classify members of a group in terms of diffusion behavior stages labeled in a continuum from early to late adopters of a dietary change behavior (10).
Nutrition Education- The dietitian could use the Diffusion of Innovations approach to ascertain the nutrition message most appropriate for and attractive to the target population or population subgroups. A 2) Pollard C, Lewis J, nutrition education message, Miller M. Start right-eat for example, may be designed right scheme: to develop a positive attitude implementing food and about a food by showing the nutrition policy in child food consumed by an care centers. Health attractive person with a Educ Behav. 2001: 28- healthy appearance (7). 320-330. Nutrition Counseling- The dietitian in counseling can use this model to establish counseling goals that are appropriate to the clients innovation stage. An example might be to help the client devise a goal and strategies related to maintaining a new behavior, such as increased vegetable consumption (7, 10).
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TABLE 1. BEHAVIORAL THEORIES AND MODELS USED IN NUTRITION EDUCATION AND COUNSELING Behavioral Theory or Model Name Social Cognitive (Social Learning) Theory and the Concept of SelfEfficacy Description Example Citations of Nutrition Articles Using Theory/ Models 1) Hindin TJ, Contento IR, Gussow JD. A media literacy nutrition education curriculum for Head Start parents about the effects of television advertising on their childrens food requests. J Am Diet Assoc. 2004; 104: 192198. 2) Resnicow K, Wallace DC, Jackson A, Digirolamo A, Odom E, Wang T et al. Dietary change through African American churches: baseline results and program description of the Eat for Life Trial. J Cancer Educ. 2000 Fall; 15: 153-163. Examples of How Theory/ Model May Be Used by Dietitians Nutrition EducationEmploying the notion of learning through observation, the dietitian could design a nutrition education program using target population peers to design, deliver, and role model the relevant nutrition education messages (5-8, 10, 12, 14). Nutrition CounselingBauer and Sokolik (6, pg.6) point out that nutrition counseling methods such as reinforcement, behavioral contracting and tracking aid in the development or strengthening of client selfefficacy. Numerous other texts on counseling (5-8, 10) also suggest strategies for dietitians that are based on the social cognitive theory.
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This theory, frequently referenced in works describing nutrition education and counseling efforts, focuses on interactions between humans and their environment and stresses the concept of self-efficacy, acquisition of knowledge and skills, and learning through doing the behavior ones self or observing the action or behavior of others (5-8, 10, 14, 50).
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TABLE 1. BEHAVIORAL THEORIES AND MODELS USED IN NUTRITION EDUCATION AND COUNSELING Behavioral Theory or Model Name Theory of Reasoned Action and Planned Behavior Description Example Citations of Nutrition Articles Using Theory/ Models Examples of How Theory/ Model May Be Used by Dietitians
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This theory has been used in nutrition education studies to link dietary and other health behavior to the concept of behavioral intent that is believed to be determined by 1) attitude, 2) subjective norms, and 3) the perception of how difficult behavioral performance will be. Subjective norms, in the literature discussing the Theory of Reasoned Action and Planned Behavior, have been defined as reflections of social pressure related to engaging or not engaging in a dietary behavior (10, 51-53).
1) Kim K, Reicks M, Sjoberg S. Applying the theory of planned behavior to predict dairy product consumption by older adults. J Nutr Educ Behav. 2003: 35: 294301.
Nutrition EducationThe dietitian could use this theory to do the following: 1) design nutrition education programs that would develop positive social norms about a nutrition topic; and 2) highlight behavioral strategies to change diet that would be 2) Robinson R, Smith C. perceived as realistic and Psychosocial and achievable by members of demographic variables the educational target group associated with (10, 51-53). consumer intention to purchase sustainably Nutrition Counselingproduced foods as In counseling, the dietitian defined by the Midwest could reinforce clientFood Alliance. J Nutr perceived norms supporting Educ Behav. 2002; 34: desirable nutrition behavior 316-325. change. The dietitian could also work with the client to 3) Chase K, Reicks M, develop skills, attitudes, and Jones JM. Applying the social circumstances that theory of planned would support the relative behavior to promoting ease of desired dietary whole-grain foods by behavioral change dietitians. J Am Diet (10, 51-53). Assoc. 2003; 103: 1639-1642.
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TABLE 1. BEHAVIORAL THEORIES AND MODELS USED IN NUTRITION EDUCATION AND COUNSELING
Behavioral Theory or Model Name Description Example Citations of Nutrition Articles Using Theory/ Models 1) Steptoe A, PerkinsPorras L, Mc Kay C, Rink E, Hilton S, Cappuccio FP. Behavioral counseling to increase consumption of fruits and vegetables in low income adults: a randomized trial. Brit J Med. 2003; 326:855. Examples of How Theory/ Model May Be Used by Dietitians
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Transtheoretical or This model has been Stages of Change widely adapted for use by Model dietitians and postulates that behavioral change occurs in stages related to thought and action ranging from precontemplation (stage 1) where there is no thought about a change in behavior to maintenance (final stage 5) where behavior is displayed for six months or more. Most texts place the following stages between the first and fifth stages of the model contemplation (stage 2), preparation (stage 3), action (stage 4) (5-8, 10). At least one text (7) also adds a stage of termination after the maintenance stage. This model envisions individuals moving through changes or stages in a non -linear manner, with return to an earlier stage possible (5- 8, 10, 54-56).
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Nutrition EducationAs discussed in the literature, dietitians have used this theory to formulate nutrition education content and strategies to match the behavior state or stages of the population or populations desiring of or in need of dietary behavior change (56-59). For example, for an audience in the 2) Bass M, Turner L, Hunt pre-contemplation stage, the S. Counseling female nutrition education message athletes: application of could be aimed at sparking the stages of change awareness of a topic (10, 54model to avoid disordered 59). Alternatively if the eating, amenorrhea, and audience is in the preparation osteoporosis. Psychol stage, the nutrition education Rep. 2001; 88 ( 3 Pt 2): program content might include 1153-1160. and focus on specific tips to enable the start of change (10, 3) Finckenor M, Byrd54-59). Bredbenner C. Nutrition intervention group program based on stage- Nutrition CounselingBauer and Sokolik (6, pg.60) oriented change provide a visual approach to processes of the assessment of nutrition-related Transtheoretical Model stage of change and also promotes long-term reduction in fat intake. J outline three categories of counseling strategies based on Am Diet Assoc. 2000; client stage ( 6, pg.70). 100: 335-342. Kristal, Glanz, Curry, and 4) Greene GW, Rossi SR, Patterson (59) also provide very Rossi JS, Velicer WF, Fava specific guidance with regard to JL, Prochaska JO. Dietary using the transtheoretical applications of the stages model to counsel patients. of change model. J Am Curry and Jaffe (5, pg.132) link Diet Assoc. 1999; 99: problem-solving aspects of 673-678. counseling to the five behavioral stages described in 5) Nitzke S, Auld G, Mc Nulty J, Bock M, Bruhn C, the Transtheoretical model.
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Gabel K et al. Stages of change for reducing fat and increasing fiber among dietitians and adults with diet-related chronic disease. J Am Diet Assoc. 1999: 99: 728731.

Holli, Calabrese, and OSullivan Maillet (7, pg.212) discuss extensively how cognitive, social, and behavioral theories have been modified to deal with the issue of learning in the context of nutrition education. These authors note that the cognitive approach emphasizes asking questions, using repetition, establishing goals, and bringing new information into the persons memory. They characterize social learning theory as stressing the importance of positive role modeling, as well as observation and practice. And finally, these authors state that behavioral theories, as applied to the learning environment, focus on giving positive reinforcement for acquisition of new knowledge and skills. In addition to behavioral change theories, nutrition education efforts may draw on age-related theories specific to education and learning (7). Important in this regard for dietitians is the distinction made between pedagogy (that deals with children as learners) and andragogy (that deals with adult learners) (7, 10). Pedagogy, based on characteristics and needs of children, may emphasize acquisition of knowledge and development of healthy eating habits (10). Strategies of pedagogy often focus on making learning fun and hands on activities, as well as the use of rewards and incentives (7, 10). Descriptions of many excellent nutrition education programs for children can regularly be found in nutrition education and dietetics journals. Examples are: The Food Friends: Making New Foods Fun for Kids (61), a program designed to teach children nutrition through drawing and coloring (62), using a nutrition calendar to promote childrens consumption of fruits and vegetables (63), and incorporation of garden activities to positively influence childrens views of vegetables (6465). andragogy , articulated by Knowles (66) and summarized by nutrition education and counseling texts, emphasize that adult learners have unique characteristics that include: focusing on learning self-defined as relevant and important, engaging in learning more of their own free will, and bringing life experiences and the need to solve problems into the learning environment (6, 7, 10). Examples of nutrition education programs targeted to adults include: a curriculum designed to teach dietary control principles to persons with Type 2 diabetes mellitus (67), development of brochures to teach weight management principles (68), use of cooking classes to promote low fat dining (69), implementation of a workshop to teach food money management and government dietary advice (70), development of manuals and uses of classes to aid in development of positive body images (71), and use of the Internet and newsletters to deliver nutrition education messages to the elderly (72-73). Learning needs related to nutrition may be assessed through testing, surveys, interviewing, focus groups, observation, or through inference via an analysis of nutritional problems (3, 7). As learning needs are assessed, the dietitian can also ask questions to ascertain receptiveness and ability to change dietary behaviors (6, 7, 8). Differences in learning style have also been noted as being important in nutrition education (6, 7). The dietitian, as an educator, needs to be aware of the ways that individuals learn most readily. For example, some learners may be more visual, some more auditory and others may learn most effectively through techniques that emphasize practice or hands on activity (7). Once learning styles have been assessed, specific learning objectives for the nutrition education effort should be written in order to clarify the intended learner outcome or outcomes of the nutrition education
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In many hospital, clinic, and community settings, dietitians may be dealing with adult learners (6, 7, 10). The principles of

program or session (7, 10). Objectives can be written using verbs describing anticipated knowledge or skill gains, and should be measurable so that learner evaluation can assess the extent to which the objectives were attained (7, 10, 74). Learning objectives can be placed in categories called domains which address major outcomes of nutrition education such as knowledge (the cognitive domain), skills (the psychomotor domain), or beliefs and/or values (the affective domain) (7, 74). Shown in Table 2 are example learner objectives and learner evaluation strategies for each domain (7). It may be helpful, or in some cases mandatory, to develop specific lesson plans for a nutrition education session or program (7, 10). Components of a nutrition education lesson plan may include a description or listing of the following: 1) the name or title of the nutrition lesson; 2) audience characteristics and expected numbers of participants; 3) learning objectives; 4) time or duration of lesson; 5) a learner assessment method related to determination of existing knowledge level, skill level, or attitudes; 6) main points to be covered in the lesson; 7) learning activities and/ or discussion points; 8) educational materials to be used ( including handouts); 9) equipment needed; 10) supplies needed and 11) post-lesson evaluation methods related to the learning of the individual or of the group (7, 10). Readers are referred to Holli, Calabrese, and OSullivan Maillet (7, pgs.282 and 283) for examples of nutrition education lesson plans.
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appropriate interaction (7). The room should be a comfortable temperature with appropriate types and numbers of seats (7, 10). If needed, the room should contain the appropriate technological equipment in working order and additional teaching materials, including handouts, that could be used if needed (7). In some instances, the physical environment may be under less control and therefore be potentially more variable. For example, learners participating via a computer or video connection at a distant site may have multiple distractions not amenable to instructor control (7). In terms of an ideal psychological and social environment for nutrition education, it has been noted that the environment should be respectful, interactive, and perceived as accessible, understanding, and equitable (7, 10). The literature describes the process of social marketing as employing concepts related to marketing of commercial products and services, and applying these to health and nutrition with the goals of changing attitudes and behaviors (10-12, 76, 77). Social marketing is used in nutrition education to develop nutrition education programs that reflect the priorities and culture of the defined audience (10, 12). The programs content, format, strategies and materials can be developed and assessed by obtaining input from those who are to be the recipients of the education (10, 12). Examples of nutritional education programs using the social marketing approach are Project LEAN (Low Fat Eating for America Now) (12, 78), the U.S. Department of Agriculture Team Nutrition Initiative (79), and the 5-A-Day campaign (11, 12). Social marketing has also been used to develop nutrition education messages for specific cultural groups at the local level (80). Additional information on the use of social marketing to promote health can be found on the American Public Health Association website (81). The Boyle text (10, pg.557) also provides an extensive list of resources on
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The environment in which nutrition education takes place is important and may influence educational outcomes as well (7, 10). Design and creation of a learning environment should address the physical, psychological, social, and cultural aspects (7, 10). Nutrition education sessions should be located in venues or facilities that are easy for the target group to locate and reach (10). A physical environment conducive to learning is one that allows hearing, seeing, and
Nutrition for Culturally Diverse Populations

Written by: Leslene Gordon, PhD, RD, LD/N, Community Health Director, Hillsborough County Health Department Reviewed by: Victoria Martinez, RD, LD/N, Public Health Nutrition Consultant, Lois J. Waltz, RD, LD/N, Senior Public Health Nutritionist, Cindy Hardy, RN, Assistant Community Health Nursing Director and Barbara Roberts, MS, RD, LD/N, Nutrition Consultant
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PRACTITIONER POINTS INTRODUCTION AND BACKGROUND The term diverse refers to differences. The many ways that Americans differ from each other cannot be addressed within the scope of this section. The focus then is on cultural and religious diversity relevant to the practice of dietetics. Over recent years, demographic data, including the United States Census reports, have indicated a continuing increase in the number of minority and ethnic populations. It has been noted; however, that though these increases are significant, they may underestimate the actual numbers. Data may not accurately categorize or count those of mixed ethnicity or ancestry or whites from other ethnic groups. Additionally, the categories used can be confusing to respondents. For example, some citizens who have been historically referred to as black but born outside of the United States may not select African American as the category to define themselves.
disproportionately higher morbidity and mortality rates for many chronic diseases (2). Efforts to reduce these disparities have become a major public health focus. Ethnicity, and more broadly culture, has a significant impact on disease development, disease prevention, and treatment. The nutritional status of an individual and the steps that need to be taken to bring about diet-related behavior change are greatly impacted by culture. A variety of definitions exist for the term culture. Culture is a social identity and can be broadly described as the learned patterns of beliefs, attitudes, values, customs and habits that are accepted by an individual or a population. Culture is dynamic and always changing. Religious food habits are also a consideration for many groups and an important part of their identity (3). The diet related requirements and regulations associated with Jewish, Muslim, and Seventh Day Adventist religions, to name just a few, can sometimes be very specific and cannot be ignored.
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Further, the census does not record many who reside in the U.S. but are not citizens (1). Regardless of the actual numbers and percentages, America continues to be one of the most racially and ethnically diverse populations in the world. This is a fact that cannot be ignored by health professionals, including those in the dietetics or nutrition profession. There is significant evidence that minority groups in America have
Varied ethnic groups have their own culturally derived foods and food habits. These habits are not always the same even within similar ethnic groups and change as individuals and groups become assimilated and acculturated. Some ethnic foods and food habits may even become integrated into the food ways of the mainstream population. For example, tofu lasagna is an American dish obviously born of Italian and Chinese influences. The previously mentioned factors help to complicate matters and increase the need for a culturally competent approach when providing nutrition-related services. APPLICATION The culturally competent approach involves having knowledge of the ethnic groups one routinely works with, recognizing personal

biases, understanding the cultural differences, and being able to communicate effectively across cultural lines (4). Utilizing effective listening, facilitating feedback, encouraging client involvement, facilitating behavior change and shared goal setting are aspects of nutrition counseling that should be employed especially when counseling in a multicultural setting. Gaining detailed information on the client or patient from another culture is essential to facilitate appropriate counseling and increase the potential for diet-related behavior change. Information can be gained from a variety of books and electronic sources but the nutrition professional should not exclude information gained from interviewing the client and others in the ethnic group. Visiting food markets or ethnic grocery stores and restaurants are also good ways to become more informed. As information is gained, it is important to avoid stereotyping as we apply or use the information. Individuals identified within a specific group may not share all the same values, beliefs, attitudes or behaviors of their cultural group. Asking questions becomes even more important so that patients are seen and treated as individuals, rather than as total representation of a selected group. The following approach may be taken to provide medical nutrition therapy or preventive nutrition services to a culturally diverse audience. A. Understanding Your Own Worldview The information needed to achieve success in a multicultural setting actually begins with the nutrition professional. Our attitudes, values, opinions and how they impact our behavior, decisions and how we see life are based on our culture and would be considered our worldview. For example, we may have a worldview that is in line with germ theory, i.e. microorganisms cause disease. This may be very different from the
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worldview of others who believe that diseases are often caused by spiritual or supernatural forces or an imbalance in nature. Another example would be a provider who believes that the patient has the ability or power to change his or her health status and is faced with an individual who feels that the progress of his disease is not his to control or beyond his power to control. It is therefore necessary that the provider understand the potential for cultural bias and how it may affect the interaction with the patient, client, or group. Understanding one's own cultural perspective and recognizing that while different they are not inferior or superior will assist the practitioner in communicating effectively. It further reduces the potential for imposing one's worldview on others. Actions: 1. Consider your own cultural values and biases. 2. Accept cultural differences without being judgmental or discarding your own values. 3. Consider potential inherent biases in measurement and assessment tools. Are they appropriate for measuring or evaluating the population with whom you are working? 4. Be flexible and open to adapting your counseling approach or procedure to where practical, meet the needs of the patient, client, or group (5). B. Gaining General Background Information It is necessary to gain information from the client that may not directly relate to the disease or specific nutrition concerns. The information may be more demographic in nature, but is relevant for assessment and intervention. Actions: Determine specifically what the cultural background is, as identified by the individual. The broad term Hispanic, for example, includes individuals of varied
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races and ethnicities. Gain health statistic data for the target group. What are disease incidence rates and what health conditions are most prevalent in that group? Determine if the individual is a recent immigrant. If not, are traditional cultural values maintained? Determine the level of education and level of fluency or language skills. Religious affiliation, if relevant, including level of orthodoxy or specific sect or group, needs to be determined. When relevant, specifics related to religious dietary guidelines, holy days, holidays and periods of fasting also need to be recognized. Are there barriers or limitations that may affect dietary intake? These need to be explored. For example, socioeconomic or financial limitations, availability of traditional foods, and knowledge of foods available in U.S. supermarkets. Determine family structure and the role of family members as it relates to responding to provider recommendations or making health-related decisions. Are there beliefs or values associated with hierarchy, power and respect based on age, sex, and place in the family or titles? These factors must also be given some consideration. C. Communication
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and cooperation. Customs related to eye contact, personal space, gestures, touching, and the format used to verbally present information varies greatly among cultures. Gaining basic knowledge of the cultural values, beliefs and practices for the specific population you are working with is essential for good cross-cultural communication. The following actions, though limited, will assist in communicating across culture lines. Actions: Establish rapport with the client. A courteous, respectful verbal greeting is appropriate in almost all cultures. Initial formality is often acceptable until you have gained information on how the patient prefers to be addressed. Arrange for a trained interpreter if needed. Speak directly to the client even when using an interpreter. Avoid body language or touching that may be misunderstood. Speak clearly and choose a speech rate and style that promotes understanding and demonstrates respect. Avoid slang, technical jargon, and complex sentences. Ask questions, listen carefully, and do not assume anything. As much as practical, use open-ended questions phrased in several ways when necessary to obtain information. Do not hesitate to explain to clients why the information is necessary. Encourage patients to ask questions and make it clear that you are comfortable with their questions. Determine the patient's or client's reading level or ability before using written materials. As you consider presenting recommendations, build on cultural practices, reinforcing those that are positive and promoting change only in those that are harmful. Though the practitioner is often seen as the expert, it is important to base the format of your presentation on your knowledge of the individual and cultural group. For example,
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To a great degree our success as dietetic professionals depends on how effectively we are able to communicate. It is our professional responsibility to take steps that will facilitate good communication with the client, our patient. Ineffective communication results in confusion, noncompliance, poor outcomes and dissatisfied or angry clients. To change deeply rooted food habits or behaviors, we must develop rapport with the client, establish a trusting relationship, show respect and empathy, deliver a clear message, and gain the client's involvement

choosing a participative or authoritative style, or being very direct versus being less explicit should depend on your knowledge of the individual. Evaluate the client's understanding and acceptance of your discussions and recommendations. D. Health Beliefs The beliefs the client or patient may have related to health in general or their specific condition are culture-bound. The individual's perceptions, beliefs and explanations for what causes or cures disease or maintains good health may be very different from those of the provider. We have, as providers, been trained in the context of the biomedical paradigm. For the most part, nature, fate, divine intervention or other similar factors are not essential considerations when providing treatment. We assume that our scientific perception of disease conditions and the steps that need to be taken to prevent them or cure them are congruent with those of the patient's. This may not be the case. The dietitian must gain specific information on the health beliefs and values of the individual or group. Actions: Helpful information to have includes What does the individual call the sickness or illness, what does he or she think caused it, and what are its effects? Does the client believe the condition can be cured? What does the client believe the cure for the condition involves? Does treatment include culturally traditional treatment, folk or home remedies, or the involvement of a cultural or folk healer? Are alternative therapies being utilized? Does the client have certain specific beliefs related to food and health? Are specific foods required to achieve and maintain health (6)? Are specific foods selected or avoided based on the type of illness or life condition, such as pregnancy?
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Are there spiritual or supernatural dimensions associated with health, illness, or diet? How is health defined? Are there differing views related to the body, body image, and size and how do these reflect health or illness? Is being very lean, for example, a sign of illness? E. Food Ways, Beliefs and Practices Food and what is considered edible or inedible largely depends on culture. Corn, which is enjoyed by most Americans, for example may be considered fit only for farm animals by the French. Eating and what is eaten is often associated with religious beliefs, ethnic behaviors and is reflective of cultural heritage and identity. Culture-based food habits are often the last things to change even in individuals who adopt new cultural norms. Core foods (staples regularly included in the diet in unmodified from), such as rice, are often the last things to be eliminated from the diet. However, assumptions cannot be made about an individual's consumption based only on general information related to their ethnic or cultural group. For example, many African Americans do not regularly consume a more southern cuisine, "Soul Foods", as is sometimes assumed. Individuals may hold to traditional dietary practices or may adopt mainstream food habits in varying degrees. The following should be included in assessment and planning when working with different cultural groups.
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Information that may need to be gained includesAre there specific religious guidelines or restrictions related to intake? Are traditional foods available, are they consumed, how often? Are there traditional core foods that are consumed or required for meals? Are there unusual foods that are consumed

that have not been included in the standardized tool for assessing intake? Are foods given any beneficial or detrimental value related to specific health conditions? Are there foods that are routinely restricted from the diet because of taboos or other cultural restrictions? Who traditionally controls food purchase and preparation? What are the traditional food preparation methods used? What non-traditional foods are eaten and how often? What is the typical meal pattern or how many meals are eaten per day? What is considered healthy eating? Does it relate to specific food groups and/or the amount of food or serving size eaten? What beliefs and symbolisms are associated with food and eating? Is eating a social event with associated rituals? Does offering abundant foods indicate hospitality, generosity, and wealth? What food related celebrations, holidays and holy days are relevant? Is the individual open to making changes in traditional foods that may be detrimental to the individual? Are there appropriate foods within the traditional diet that may be used to substitute for foods that need to be avoided? We do not live in a cultural vacuum. For most individuals, culture and ethnic identity are a source of pride. The associated norms provide stability and direction in our lives. All of us are affected by beliefs, attitudes and values that shape our perceptions that are related to health in general and food, specifically. These perceptions are learned over time and are not easily changed. Specific efforts must be made by the nutrition professional to facilitate behavior change in a culturally diverse environment. Positive national health outcomes cannot be achieved without these efforts. Further, the Code of Ethics for the Profession of Dietetics challenges dietetic practitioners
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under one of its principles to "provide professional services in a manner that is sensitive to cultural differences and does not discriminate against others on the basis of race, ethnicity, creed, religion, disability, sex, age, sexual orientation, or national origin"(7). REFERENCES 1. Kittler PG, Sucher KP. Food and Culture in America. A Nutrition Handbook, 2nd Edition. Belmont, CA: Wadsworth Publishing Co: 1998. 2. U.S. Department of Health and Services. Health People Washington DC: U.S. Printing 2000. 3. Bronner, Y. Cultural Sensitivity and Nutrition Counseling. Top. Clin. Nutr. 1994;9(2): 13-19. 4. Curry KR, Jaffe, A. Nutrition Counseling and Communication Skills. Philadelphia, Pennsylvania: W.B. Saunders Co: 1998. 5. Ponterotto JG, Casas JM, Suzuki LA, Alexander CM Handbook of Multicultural Counseling. Thousand Oaks, California; SAGE Publications Inc:1995. 6. American Dietetic Association Dietitians of Canada. Manual of Clinical Dietetic. 6th Edition, 2000. 7. The American Dietetic Association. http://www.eatright.org/ Accessed January 15, 2009.
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Adult Obesity Prevention and Treatment

Written by: Susan Moyers, PhD, MPH, LD/N, Department of Exercise Science and Sports Studies, University of Tampa, Tampa Reviewed by: Amy E. Bowersock, PhD, FACSM
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Obesity Synopsis Nearly two-thirds of adults in the United States have crossed the BMI thresholds and are now classified as either overweight (BMI=25.0-29.9), or obese (BMI =30) (1). Rates of obesity have doubled since 1980, and the World Health Organization now labels obesity a global epidemic (2). In Florida, since 1986 when monitoring began, obesity among adults has has almost tripled increasing from 9.8 percent to 26.5 percent in year 2009 (3). In 2009, 36.9 percent of Florida adults were overweight, or approximately 7,341,036 individuals living in our state. Much of what we know about rates of overweight and obesity comes from the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is an ongoing, statebased random-digit dialing survey organized and produced by the US Centers for Disease Control and Prevention. Overall, in the United States, obesity has been estimated to account for up to nine percent of national health expenditures, up to $147 billion in 2006. Health care spending is 42 percent higher for obese individuals compared with individuals of normal weight(4); and, most notably, medication costs are 77 higher among the obese (5). We now know that obesity is a predictor of many adverse health conditions. Indeed, a growing number of factors suggest that obesity is a gateway - that is, a gate that once passed through, dramatically increases the likelihood of impaired quality of life and chronic disease. Some analysts have
projected that obesity has about the same association with chronic health conditions as does twenty years of aging, and greatly exceeds the associations of smoking or problem drinking (5). Life-table analysis has estimated that 5.8 to 7 years of life may be lost due to obesity among non-smokers, and approximately 13 years of life may be lost among obese smokers (6). If we can decrease or prevent obesity, we can ameliorate many of these conditions, which would substantially impact quality of life as well as health care costs. Being obese carries an increased risk of illness from hypertension, lipid disorders, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and respiratory problems. Several forms of cancer are highly correlated with body fatness, including cancers of the colon, endometrium, prostate, kidney, and breast. A recent study from the American Cancer Society concluded that 14 percent of all cancer deaths among men, and 20 percent among women are attributable to overweight and obesity (7). Recent evidence also associates obesity with rising rates of non-alcoholic liver disease, and death from cirrhosis among non-drinkers (8). In addition to health consequences and costs, there are other economic repercussions from obesity, as higher BMI predicts increased job absenteeism and work-hours foregone (9).
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A trend of particular concern is the rise in morbid obesity (class 3 obesity, BMI > 40), which has grown faster than obesity itself. Data from the Behavioral Risk Factor Surveillance System survey indicate that in the year 2009, 2.2 percent of adult Americans were classified as morbidly obese. The rates were highest among African-American women (6 percent) (10). From 2001 to 2005, the percentage of adults with a BMI >40 rose from 8.9 percent to 52.0 percent, and those with a BMI >50 rose from 12.5 percent to 75 percent.(11). These extreme BMI levels are associated with the most

severe health complications. A once-accepted belief is that obesity represents a self-induced state of overnutrition due to lack of willpower or weakness. This paradigm is now replaced by the understanding that obesity is very complex and involves social, cultural, genetic, biological, environmental and developmental factors. Scientists are especially interested in identifying and understanding molecular components that contribute to obesity, as well as genetic determinants. Studies so far have shown that, in humans, obesity is seldom caused by a single gene, but is due more to the interaction of a genetic proclivity to obesity coupled with many other factors. A great deal of study is focused on various molecules believed to help regulate body weight, adiposity, and energy expenditures. Recent discoveries of leptin, ghrelin, and several dozen other components of weight and appetite regulation help clarify our knowledge of obesity. But despite the fascinating results of studies, it remains that we are still somewhat in the dark and there is no scientific consensus about the neurochemical and endocrine pathways leading to obesity. While scientific opinion varies about causes and contributors to obesity, almost always the equation energy inputs vs. energy outputs forms the basis for understanding the trends. The dietary trends are clear when we compare changes in eating patterns over the past 30 to 40 years. Major shifts are seen, including an increase in total daily kcal intake, larger portion sizes; large increases in consumption of snacks, soft drinks and pizza (12, 13, 14). To cite one example, Nielson and Popkin (15) report that between 1977 and 1998, average portions for hamburgers and salty snacks increased by about 100 kcal, French fries by 68 kcal, and soft drinks by 49 kcal. Some experts suggest that the rise in overweight and obesity can be traced, at least in part, to the increase in habitual sodadrinking and snacking, and the widespread
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use of high fructose corn syrup as a sweetener by the snack and beverage industries (16). Fructose does not promote insulin secretion and is preferentially metabolized to lipid in the liver, thus contributing to weight gain. USDA disappearance data indicate that per capita intake of fructose from combined sources was 62.4 pounds per year, or approximately 77 grams (306 kcal) per day in 1997. Almost three-quarters of this fructose intake came from soft drinks (12). Other experts note Americans are eating much more high-fat cheese in snacks and elsewhere, cheese is now the most widelymentioned protein food in chain restaurants, with menu selections that top meats with cheese, add cheese to breading, and serve foods with cheese sauces adding to the calories that already exist in the basic recipes for these items. There is good news amidst the disturbing trends, mounting body of data shows that even modest weight loss can yield substantial health benefits. A 5-10 percent reduction in initial weight is associated with significant improvements in systolic and diastolic blood pressure, cholesterol and plasma lipids, blood glucose, and can improve risk factor clustering for vascular diseases (17, 18), particularly in obese individuals with type 2 diabetes (19). In addition, recent intervention studies have shown that a weight reduction of 5-10 percent is effective in preventing or at least delaying the appearance of type 2 diabetes and hypertension in high-risk individuals (20, 21). However, the practical problem remains, how do we translate results from these studies into the daily practice of dietetics? Combined Approaches - Diet, Physical Activity, Counseling We know that a consistent course of counseling and contact is important to weight
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loss success. In its December 2003 recommendations to practitioners, the US Preventive Services Task Force specified that the most effective strategies for weight loss are combination approaches using nutrition, diet and exercise counseling, and behavioral modification. In their review of evidence, the Task Force stated that there is fair to good evidence that high-intensity counseling, defined as a minimum of 3 monthly one-onone visits, combined with behavioral interventions, produces sustained weight loss of typically 3 to 5 kg for 1 year in obese adults (22). Two major intervention trials, as well as several smaller trials, have demonstrated that diet and exercise programs, coupled with individualized nutrition counseling, provide effective long-term weight management. A randomized, prospective study in Finland (23) employed a physician, study nurse, nutritionist, and exercise physiologist. A total of 522 middle-aged, overweight patients were followed for three years. Goals included 5 percent weight reduction, moderate-intensity physical activity of 30 min/day, dietary fat of 30 percent or less of total daily energy intake, saturated fat of 10 percent or less of daily intake, and fiber intake of 15 g/1,000 kcal or more. Intervention group subjects received 7 individualized face-to-face, 30-minute sessions with the study nutritionist in year 1, and 4 sessions per year thereafter. All subjects regularly measured and recorded weight and physical activity. Control group subjects were given the same general goals and information in a single group session with no individualized counseling. Physical activity and weight loss maintenance was significantly higher after three years for the counseling group (3.5 kg compared with 0.9 kg). In the United States Diabetes Prevention Program (DPP), 24 out of 1,000 individuals participated in a lifestyle intervention that included diet and physical activity goals facilitated by case managers or "lifestyle coaches." Participants were targeted to lose 7 percent of baseline body weight and
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engage in 150 minutes per week of physical activity, such as brisk walking. Hallmarks of the intervention included frequent contact throughout the trial, a "toolbox" tailored to the individual participant, and a network that provided training, feedback, and clinical support for the lifestyle coaches. Participants followed a 16-session core curriculum, then were seen face-to-face at least once every 2 months and contacted by phone at least once between visits. Those in the lifestyle intervention group lost an average of 7 kg after 6 months; some of the weight was regained, and net weight loss averaged about 4 kg at 4 years of follow-up. There are many approaches to weight loss counseling that have been published, including the approach employed in the DPP (24). A growing number of practitioners favor a technique known as motivational interviewing, which centers on the use of open-ended questions, reflective listening, and patient-generated answers and solutions. Some practitioners also follow a model called the "stages of change," or transtheoretical model, that strives to identify motivation and readiness to change behaviors. A list of references for motivational interviewing and other counseling strategies is found in the Nutrition Education and Counseling section of this manual. Meanwhile, some practical tips for clinical practice are adapted from the work of psychologist Gary Foster, Director of the Weight and Eating Disorders Program at the University of Pennsylvania (25). 1. Set realistic expectations. 2. Be clear about what treatments can and cannot do. 3. Have patient specifically identify goals. For example, ask the person, "Eat less of what?" 4. Have patient express when behaviors will occur. 5. Have patient express how behaviors will occur.
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6. Do not ask why. 7. Have patient identify their most difficult times for compliance. 8. Have patient maintain a record of behavior (activity log, food diary). 9. Follow up on progress. 10. Congratulate successes without chastising failures. From a practical standpoint, it is important to recognize that most interventions result in a substantial, but not dramatic, loss of weight, 5-10 percent of body weight. The only treatment shown consistently to result in sustained losses greater than 40 to 50 pounds is bariatric surgery (22, 26). It is also important for patients to note that whatever diet and lifestyle changes are made to lose weight, there must be a strategy to maintain the loss after the initial period if the weight loss is to be sustained. The following information may be helpful for dietetics professionals when considering a weight loss program for their patients. Advertising Claims
B1.4
analysis. In December 2003, the FTC announced an educational campaign for the media that identifies seven common weightloss claims that are cautionary flags about a product or service. These claims include:
About one in every three adult Americans reports having tried one or more weight loss plans, and most of the individuals are not using the recommended combination of reducing food intake and increasing physical activity (27). Many turn to products and services that are advertised to help drop unwanted pounds. The US market for diet and weight loss products was estimated to be 58.6 billion dollars in 2007 (28). In September 2002, the Federal Trade Commission (FTC) issued an advisory on weight-loss advertising, concluding that, despite vigorous law enforcement and consumer education efforts, fraudulent and misleading weight-loss advertising is widespread. Over half of advertising for weight loss products and services contained false or unsupported claims in the FTC
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Causes weight loss of two pounds or more a week for a month or more without dieting or exercise. Causes substantial weight loss, no matter what or how much the consumer eats. Causes permanent weight loss (even when the consumer stops using the product). Blocks the absorption of fat or calories to enable consumers to lose substantial weight. Safely enables consumers to lose more than three pounds per week for more than four weeks. Causes substantial weight loss for all users. Causes substantial weight loss by wearing it on the body or rubbing it into the skin.
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All of the above claims are scientifically infeasible at the current time and advertising that uses one or more of these claims is subject to action by the FTC. Internal Revenue Service and Reimbursement Considerations The US Internal Revenue Service has determined that certain expenses associated with weight loss are deductible medical expenses under some conditions (29). Patients cannot include the cost of a weightloss program if the purpose of the weight loss is improvement of appearance or general health. However, patients can deduct these expenses if weight loss is a treatment for a specific disease diagnosed by a physician (such as obesity, hypertension, or heart disease). The new ICD-9-CM codes for obesity include:
obesity unspecified - 278.00

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morbid obesity -278.01 dysmetabolic syndrome - 277.7
Codes for primary and/or associated disease manifestations include athersclerosis (414.01), diabetes (250.00), and others. Deductible items include fees for membership in a weight reduction group, and attendance at periodic meetings. Memberships in a gym, health club, or spa are not deductible, nor is the cost of diet food or beverages, unless all three of the following requirements are met:
energy balance using food records or diet recalls, and assess resting energy expenditures using standard equations, such as Mifflin St. Jeor: Males: 9.99 X weight (kg) + 6.25 X height (cm) 4.92 X age + 5. Females: 9.99 X weight (kg) + 6.25 X height (cm) 4.92 X age 161. There are also newer portable office devices for measuring resting energy expenditure (RMR). Two such devices are BodyGem and MedGem (HealtheTech, Inc, Golden, Colorado). The hand-held units use indirect calorimetry by inhaled and exhaled air with a fixed respiratory quotient of 0.85, and a modified Weir equation to derive kcal expended. (RMR= 6.931xVO2); VO2 = oxygen uptake (ml/min)). Weight Loss Strategies
The food does not satisfy normal nutritional needs. The food alleviates or treats an illness. The need for the food is substantiated by a physician. The deductible amount for these foods is limited to the amount by which the cost of the special food exceeds the cost of a normal diet. Nutrition Assessment
Before any diet and physical activity program can be personalized and implemented, a nutrition assessment is needed, along with an understanding of the individual's readiness to change and motivation. It is important to determine factors associated with weight gain, such as past history of exercise, pregnancy, and health conditions, which may influence weight loss, and sedentary and non-sedentary work patterns. It is important to understand the patient's dieting history, the types of diets attempted and their relative success, along with usual body weight, desired, highest, lowest, and preferred body weights. Properly measure height (using a wallmounted height board or stadiometer); measure weight using a calibrated balance-beam scale, calculate BMI, waist circumference; and body composition (% body fat). Assess
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Portion Control
Recommendations should promote weight loss of 0.5 to 1 lb/wk through diet and exercise. For example, to attain a deficit of 500 kcal daily, recommend a diet with 250 fewer kcal combined with 250 additional kcal in physical activity. (See the physical activity table provided in the exercise section of this section for specific energy expenditure in activity). If a person is not able to adhere to an exercise program, then achieve the kcal deficit through diet alone, while encouraging a more gradual introduction to exercise. Remember that the most effective approaches involve both diet and physical activity, along with consistent counseling (22).
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Portion control is essential for weight loss and for long term success in weight maintenance (30). The US Department of Agriculture (USDA) is responsible for defining standard serving sizes for dietary guidance

and the Food and Drug Administration (FDA) is responsible for defining standard serving sizes for food labels. Standard serving sizes are important in nutrition counseling, since many products available in the marketplace are sometimes as much as 2 to 8 times the recommended standard serving sizes. This inconsistency between the recommended standard serving sizes and the marketplace serving sizes is an opportunity for nutritionists to educate the relationship between portion sizes and energy intake for weight loss or weight maintenance (I, II). Pharmacotherapy for Weight Loss In the State of Florida, the use of pharmaceutical agents for weight loss is subject to the Administrative Code (F.A.C. Rule 64B8-9.012, Standards for the Prescription of Obesity Drugs). The code addresses prescription medications, as well as OTC diet aids, herbs and other dietary supplements. To justify the use of any weight loss enhancer the patient must have either: 1) a BMI > 30 or above; 2) a BMI > 27 with at least one co-morbidity factor (such as type 2 diabetes, lipid abnormalities, or sleep apnea); or 3) a measurable body fat content equal to or greater than 25 percent of body weight for males, or 30 percent of body weight for females. Each practitioner who prescribes, orders, or provides a weight loss enhancer must assure that affected patients undergo an in-person re-evaluation within 2 to 4 weeks of receiving the regimen, and additional evaluation at least every three months while continuing the regimen. The consumer protection aspects of the code specify, among other things, that practitioners may not promise specific results, may not claim rapid, dramatic, or safe weight loss, and may not suggest that diets or exercise are not required. Prescription Medications
B1.6
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A number of prescription medications are available to help promote weight loss that is substantial, but not dramatic. Most studies report a loss of about 5 percent to 10 percent of initial body weight in patients undergoing therapy with these agents. Medications that have been approved by the US Food and Drug Administration (FDA) for the induction and maintenance of weight loss in adults include: Sibutramine (Meridia) Orlistat (Xenical) Anorectics (appetite suppressants) Phentermine and phentermine resin (Medeva, Fastin, Ionamin(r)) Diethylpropion (Tenuate, Tenuate Despan) Mazindol (Mazanor, Sanorex) Phendimetrazine Tartrate (Prelu-2, Bontril) Phenmetrazine (Preludin) Orlistat has also received FDA approval for use in adolescent populations (ages 12 through 16). Among the above-referenced agents, sibutramine and orlistat are the most commonly prescribed. The others are indicated for short term use (a few weeks to <3 months).
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Case reports and clinical trial data have demonstrated that several other medications may have anti-obesity properties, as weight loss was an unexpected spin-off during treatments for other health conditions. Some practitioners prescribe these agents in "off label" indications for obesity. The medications include: Topiramate (Topamax) Metformin (Glucophage) Bupropion (Wellbutrin) Acarbose (Precose) Miglotol (Glyset) Zonisamide (Zonegran) It should be noted that several barriers limit the use of any weight loss medication, including findings that most health insurance providers do not cover their cost. Patients must pay out-of-pocket for charges that typically exceed $100 per month.

Sibutramine Sibutramine acts on the central nervous system to increase satiety, reduce hunger, and lessen the drop in metabolic rate that often occurs with weight loss (31). It is a combined serotonin-norepinephrine reuptake inhibitor, with features that resemble actions of antidepressants and stimulants. Sibutramine does not seem to inhibit individuals from starting to eat a meal, but rather stimulates the feeling of fullness to promote earlier termination of a meal and inhibit between-meal snacking. Research suggests that persons taking sibutramine eat less, approximately 300 to 350 fewer kilocalories per day compared to control subjects (31). Weight reductions of 5 percent to 10 percent have been observed with use of sibutramine (32). In patients with type 2 diabetes, the weight losses have been accompanied by improved glycemic control and blood lipid profiles (33). Sibutramine dosages range from 5 mg to 15 mg/day. Typically, a patient begins at 10 mg, and the dose is adjusted according to results and patient tolerance. The FDA has indicated a use of sibutramine for up to one year. Since its pharmacological action involves stimulation of the sympathetic nervous system, patients taking sibutramine may experience cardiovascular side effects. In a study of individuals with type 2 diabetes, sibutramine was associated with a heart rate increase of >10 beats per minute in 42 percent of subjects (33). Among individuals with uncomplicated obesity, sibutramine produced a dose-dependent increase in heart rate averaging 3-7 beats per minute (34). Sibutramine is therefore not recommended for patients with a history of coronary artery disease, arrhythmias, congestive heart failure, or stroke.
B1.7
hypertension. However, many patients who lose 5 percent or more of initial body weight experience an overall reduction in blood pressure, which correlates with the amount of lost weight, so the clinical relevance of a short term slight increase in blood pressure is unclear (33, 34). Data from studies indicate the average increase in systolic blood pressure with sibutramine at the 15 mg daily dose is 1 mmHg, although substantial number of patients experience increases of 5mmHg (33). Sibutramine is also not recommended in combination with certain antidepressant agents, such as monoamine oxidase inhibitors or selective serotonin reuptake inhibitors. Augmentation of adverse reactions associated with sibutramine (tachycardia, increased blood pressure) may occur with concurrent use of other central acting agents such as pseudoephedrine or ephedra.(35) Sibutramine was removed from the US market in 2010. Orlistat
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Sibutramine can also produce dosedependent increases in blood pressure, especially during initial treatment, and is not recommended for persons with uncontrolled
Orlistat is an agent that inhibits gastric lipase, causing lower gut enzyme activity to reduce by approximately one-third the amount of dietary fat that is absorbed. Typical dosing of orlistat is 120 mg three times per day. Depending on the fat content of an individual's diet, this lowered absorption can represent 150-200 kcal/day. The effects of orlistat on diet are often self-limiting because meals containing more than 20 g of fat tend to generate side effects in the lower intestine. This includes oily stools, flatus with discharge, and fecal urgency; thus creating a feedback mechanism that tends to decrease the amount of fat patients consume. Additionally, the reduction in lipid absorption with orlistat is associated with a reduction in the absorption of fat-soluble vitamins. Supplements of these vitamins are typically indicated, with care to separate the dosing of orlistat and the supplement by >2 hours. In adults, the effects of orlistat on

serum concentrations of vitamins A, E, and D have been minimal (36). Among adolescent patients, absorption of retinol is not significantly altered, but absorption of tocopherol is impaired, and plasma vitamin D is significantly reduced, despite multivitamin supplementation (37). Most, but not all studies have shown significant weight loss with orlistat (38). In randomized trials of patients with diabetes, participants who received orlistat plus diet restriction lost 4 to 5 percent of their baseline weight within 1 year, compared with 1 to 2 percent for those assigned to placebo plus diet (39, 40, 41). Even in the absence of weight loss, orlistat treatment resulted in improved cholesterol profile and better glycemic control (38). Most clinical trials of weight loss medications report results for one year or less. However, in a four-year double-blind, prospective European study among 3,305 patients, weight loss was significantly greater in the orlistat group than in the placebo group (5.8 vs. 3.0 kg) (42). One quarter of the orlistat patients who stayed with the medication kept off 10 percent of their initial body weight after four years, compared to 16 percent of placebo patients. Both groups were assigned to a dietary restriction of 700 to 800 fewer kcal per day than their baseline diets.
B1.8
recommended dosage should not be exceeded in an attempt to increase the effect, but instead the drug should be discontinued (43). In addition, medications of this type are stimulants that may produce nervousness, insomnia, elevated heart rate, anxiety, and related effects. Common symptoms include palpitations, tachycardia, arrhythmias, hypertension, nervousness, restlessness, dizziness, insomnia, tremors and headaches. Patients also report dry mouth, unpleasant taste, nausea, vomiting, diarrhea and constipation (44). The effects of these agents typically last approximately 4-6 hours, but mazindol lasts between 8 and 15 hours.
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All of these drugs, except for mazindol, are derivatives of -phenylethylamine, which forms the backbone for the neurotransmitters dopamine, norepinephrine, and epinephrine all of which are synthesized from the amino acid tyrosine. Mazindol is a tricyclic drug similar in structure to some of the older antidepressants such as imipramine. The agents are indicated only for monotherapy and should not be combined with selective serotonin-reuptake inhibitor antidepressants (e.g. fluoxetine, fluvoxamine, paroxetine, sertraline) or monoamine oxidase (MAO) inhibitors. The following medications: phentermine, diethylpropion, benzphetamine, and phendimetrazine are thought to stimulate the release of norepinephrine, but they may also stimulate dopamine release, particularly phentermine. Phentermine appears to both suppress appetite and increase energy expenditure. Mazindol blocks reuptake of norepinephrine, and is thought also to stimulate thermogenesis and possibly delay gastric emptying (44). For mazindol, the dose is 1 to 3 mg per day. The usual adult dosage of phentermine hydrochloride is 8 mg 3 times daily, given 30 minutes before meals. Alternatively, 15 or 30 mg of phentermine as the resin complex, or
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Anorectics Medications of this type act principally on the satiety center of the hypothalamic and limbic regions of the brain. The anorexic effect is temporary, seldom lasting more than a few weeks. The development of tolerance and "wearing-off" of effects form the main drawbacks of these medications. The appetite suppressants have been associated with abuse, particularly in connection with long-term therapy, as they are pharmacologically related to amphetamines. When tolerance to these agents develops, the

15-37.5 mg of phentermine hydrochloride, may be given as a single daily dose in the morning. Phentermine has not been studied as a monotherapy for longer than 36 weeks or approved for administration longer than a few weeks (45). The usual adult dosage of diethylpropion hydrochloride is 25 mg 3 times daily 1 hour before meals, an additional 25 mg may be given in mid-evening. The extendedrelease tablet containing 75 mg of the drug may be given once daily, in midmorning. The dosages of benzphetamine vary from 25 to 150 mg per day. For phendimetrazine tartrate the dosage range is 17.5 to 35 mg and for phenmetrazine it is 25 to 50 mg. Metformin Metformin (Glucophage) is a commonly prescribed medication for Type 2 diabetes. It is an "insulin sensitizer," that enhances glucose uptake without promoting insulin secretion. Metformin is not approved by the FDA as a weight loss agent, but has been used in "off label" indications for obesity. In several studies, diabetic patients assigned to metformin therapy experienced modest weight loss (46). For example, the US Diabetes Prevention Program was a large randomized clinical trial with participants in one arm of the trial receiving metformin therapy (20). These subjects lost around 2 kg after 6 months; weight loss was about 1 kg at the end of 4 years of follow-up. This type of observation led researchers to investigate whether metformin might enhance weight loss in non-diabetic individuals. Thus far, studies to address this question suggest that weight loss may indeed occur (47, 48). However, most of the subjects in research to date had features of insulin resistance syndrome, so it is unclear whether weight loss is due to an improvement in glucose tolerance or an effect of the drug. Acarbose & Miglitol
B1.9
Like metformin, acarbose and miglitol are medications designed to improve glycemic control in diabetes. Neither agent has FDA approval for weight loss. However, a side effect of weight loss has been reported in diabetic persons taking these agents for glycemic control, and some practitioners may include these agents in a weight loss plan (49). The two drugs are inhibitors of the glucosidase enzyme in the small intestine. The resulting effect is a dose-dependent reduction in the digestion and absorption of carbohydrates. It is suggested that weight loss associated with these drugs occurs due to lower net kcal intake resulting from lowered absorption of nutrients. However, there is some evidence that these agents promote satiety by modulating production of glucagon-like peptide 1 (GLP-1), a gut hormone that contributes to the feeling of fullness (50). So far, research has been limited in connection with using these medications for weight loss in non-diabetic individuals. Two studies report that weight loss was not significantly different between those taking acarbose and placebo patients (51, 52).
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It should be noted that acarbose and miglitol promote the passage of undigested carbohydrates to the large intestine, where they are acted upon by intestinal flora and can produce bloating, abdominal discomfort and flatulence. These are the most widely reported side effects in both drugs, although fewer side effects are reported with miglitol than acarbose. Topiramate Topiramate was developed and FDAapproved as an anti-seizure medication. Topiramate has not been approved as a weightloss agent. Shortly after its introduction as an anti-convulsant, case reports began to

emerge indicating that patients taking topiramate experienced substantial weight loss (53). Subsequently, several small trials have been published showing successful weight loss and reduced frequency of pathologic eating patterns in persons with eating disorders, such as binge eating disorder and nocturnal eating syndrome (54, 55, 56). Dosages have been titrated from 96 to 218 mg daily. In one study of uncomplicated obesity, after six-months of treatment at varying and sliding doses, topiramate was associated with an average loss of about 6 percent of baseline body weight (57). Subjects also participated in a lifestyle program consisting of a 600 kcal/day deficit diet, nutrition and exercise education, and behavioral therapy. However, a high rate of side effects was noted in the trial, including paresthesia and dizziness, as well as difficulty with memory, concentration, and attention. The mechanism of weight loss associated with topiramate is not known, however, animal studies indicate that topiramate affects the regulation of energy balance as well as influences metabolic variables such as glucose and leptin (58). Zonisamide Bupropion
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Zonisamide, like topiramate, is an anticonvulsant medication that has also been associated with weight loss in limited study. It has not been approved as an anti-obesity treatment. It is reported that zonisamide might help to regulate appetite by effects on serotonin and dopamine. But thus far, there is scant clinical evidence for zonisamide and obesity. A single-blind study of 60 obese patients at the Duke University Medical Center reported an average weight loss of 14 pounds after 16-weeks of zonisamide therapy, which was combined with dietary restriction of 500 fewer than usual kcal per day (59). In comparison, patients in a placebo group lost an average of about 2 pounds.
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Bupropion (Wellbutrin) is a drug approved for the treatment of depression and smoking cessation. On the basis of the clinical observations that a large percentage of patients taking bupropion lost weight, several research trials have been conducted to determine its efficacy in facilitating weight loss, with promising results (60, 61). Jain and colleagues (62) report a randomized, doubleblind, placebo-controlled study among 394 adults who were obese but also diagnosed with depressive symptoms. All subjects were asked to follow a diet for 26 weeks with 500 fewer than usual kcal daily; half of patients were assigned to sustained-release bupropion at 300 mg/day. The group receiving bupropion lost an average of 4.6 percent of base weight, compared to 1.7 percent of base weight loss for the control group. Bupropion used in connection with weight loss does not appear to depend on the presence of underlying depression. In another study involving 192 obese subjects who did not report depressive symptoms, those patients who completed 48 weeks of bupropion therapy maintained losses of initial body weight of 10 percent at 24 weeks, and about 8 percent at 48 weeks (63). The precise mechanism of action of bupropion is unclear, but it is thought to inhibit uptake of norepinephrine and dopamine, and may help regulate food intake (64). As a treatment for depression, the recommended maximum daily dosage is 400 mg as extended-release tablets or 450 mg as conventional tablets (45). Common adverse effects of the drug include agitation, dry mouth, insomnia, headache/migraine, nausea/vomiting, constipation, and tremor (45). Bupropion also carries a seizure risk of four in 1,000 people at the maximum dose (64). It is not recommended for patients with a history of bulimia, anorexia or seizures because the seizure risk may be even higher
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Adult Nutrition for Weight Loss

Written by: Donna DeCunzo-Taddeo, RD, LD/ N, Weight Management Specialist, Lighthouse Point, FL Reviewed by: Mary C. Friesz, PhD, RD, LD/N, CDE entertainment. The average American adult spends half of his or her leisure time watching television. Combine this with jobs that involve very little physical activity, video games, movies, computing, gambling, etc., and it becomes apparent why daily caloric expenditure has declined precipitously since the 1950's and 60's. Dietary patterns contribute substantially to the development of obesity. Despite an increased focus on nutrition, a heightened awareness of the energy and fat content of foods, and the availability of various reduced-fat, fat-free, and sugar-free foods and beverages, obesity continues to increase. Todays society facilitates excessive consumption in the following ways: its abundance of inexpensive, energydense foods. the multitude of eating establishments that reflect the increased prevalence of dining out, particularly at fast food restaurants, which serve super-sized portions. the ubiquitousness of food in places ranging from gasoline stations to vending machines, as well as in discount and department stores.
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PRACTITIONER POINTS
ETIOLOGY Obesity is a complex, multifactorial, chronic disease. The factors likely to predispose some individuals to obesity include genetic, metabolic, and hormonal influences. Other factors, such as: behavioral, environmental, physiological, social, and cultural factors may also result in energy imbalance and promote excessive fat deposition. Bodyweight depends upon the balance between calories consumed and calories expended. This balance depends largely on genetic make-up, level of physical activity, body composition and resting energy expenditure. If more calories are consumed than expended, the excess calories are stored as fat in the form of adipocytes (fat cells). The relative contribution of each of these factors has been studied extensively, and although genetics plays an important role in the regulation of body weight. The World Health Organization Consultation on Obesity concluded that behavioral and environmental factors (sedentary lifestyles combined with excess energy intake) are the primary variables responsible for the dramatic increase in obesity during the past two decades. American society has evolved into an environment that facilitates weight gain. Studies show that approximately only 20 percent of Americans achieve the minimum public health goal, established by the Centers for Disease Control (CDC), of 30 minutes of moderate intensity physical activity on most days of the week. The US is also a leading innovator of passive
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RATIONALE
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In addition, behavioral changes common during holidays contribute to seasonal weight gain during the winter months, which although less than 0.5 kg (1.1 pounds) on average, is greater among individuals who are overweight or obese and it is responsible for at least half of annual weight gain (1).
Overweight and obesity have reached epidemic proportions in the United States and worldwide with more than 64 percent of the US adult population being classified as either overweight or obese (2, 3). The rationale for treating obesity lies in its adverse medical conditions. These conditions substantially increase the risk of
Manual of Medical Nutrition Therapy Manual 2011 Edition

morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary artery disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems and cancers of the endometrium, breast, prostate and colon (4-15). The prevalence of overweight and obesity has steadily increased over the years among genders of all ages, from all racial and ethnic groups and all educational levels (16). From 1960 to 2000, the prevalence of overweight (BMI > 25 to < 30) increased from 31.5 to 33.6 percent in U.S. adults aged 20 to 74 (17). The prevalence of obesity (BMI > 30) during this same time period more than doubled, from 13.3 to 30.9 percent, with most of this rise occurring in the past 20 years (18). From 1988 to 2000, the prevalence of extreme obesity (BMI > 40) increased from 2.9 to 4.7 percent, up from 0.8 percent in 1960 (18,19). The prevalence of overweight and obesity is also increasing for children and adolescents in the United States. Approximately 15.3 percent of children (ages 611) and 15.5 percent of adolescents (ages 1219) were overweight in 2000. An additional 15 percent of children and 14.9 percent of adolescents were at risk for overweight (BMI for age between the 85th and 95th percentile) (20). The economic costs of overweight and obesity are estimated to be $99.2 billion according to The National Institute of Diabetes & Digestive & Kidney Diseases. Americans spend $33 billion annually on weight-loss products and services (described as all efforts at weight loss or weight maintenance including low-calorie foods, nutritional supplements, over-the-counter appetite suppressants, artificially sweetened products such as diet sodas, and memberships to commercial weight-loss centers) (21). Obesity is a complex chronic disease requiring a lifelong effort for successful treatment. Treatment of an overweight or obese individual involves two steps, assessment and management. Assessment determines the degree of overweight or obesity and overall health status; management involves weight loss and maintenance of the reduced body weight and control over risk factors. ASSESSMENT Assessment of an individual should include the evaluation of body mass index (BMI), waist circumference, and overall medical risk. 1. Body Mass Index (BMI): To determine an individuals BMI, use the following formula or refer to Table 1, Body Mass Index Table: BMI= weight (in pounds) x 703 height (in inches) 2
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Classification Underweight Normal Weight Overweight Obesity (class1) Obesity (class 2) Extreme Obesity
Classifications for BMI (adopted by the Expert Panel on Identification, Evaluation, and Treatment of Overweight and Obesity in Adults):
BMI___________ <18.5 18.5-24.9 25-29.9 30-34.9 35-39.9 >40
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*Please note: BMI may overestimate the degree of fatness in muscular individuals. It may also underestimate ones degree of fatness in osteoporotic individuals. Also, the adult BMI charts are not accurate for estimating BMI in children and in adolescents.
2. Waist Circumference: Excess abdominal fat is an important independent risk factor for disease. Waist circumference is particularly useful in those who are categorized as normal or overweight. Males with a waist circumference >40 inches and females with a
Adult Nutrition for Weight

Table 1 Body Mass Index Table BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
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Height (inches) 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 94 97 100 104 107 110 114 118 121 125 128 132 136 140 144 148 99 102 106 109 113 116 120 124 127 131 135 139 143 147 151 155 104 107 111 115 118 122 126 130 134 138 142 146 150 154 159 163 109 112 116 120 124 128 132 136 140 144 149 153 157 162 166 171 114 118 122 126 130 134 138 142 146 151 155 160 165 169 174 179 119 123 127 131 135 140 144 148 153 158 162 167 172 177 182 186 124 128 132 136 141 145 150 155 159 164 169 174 179 184 189 194
Body Weight (pounds)
128 133 137 142 146 151 156 161 166 171 176 181 186 191 197 202
133 138 143 147 152 157 162 167 172 177 182 188 193 199 204 210
138 143 148 153 158 163 168 173 178 184 189 195 200 206 212 218
143 148 153 158 163 169 174 179 185 190 196 202 208 213 219 225
148 153 158 164 169 174 180 186 191 197 203 209 215 221 227 233
153 158 164 169 175 180 186 192 198 203 209 216 222 228 235 241
158 163 169 175 180 186 192 198 204 210 216 222 229 235 242 249
163 168 174 180 186 192 198 204 211 216 223 229 236 242 250 256
168 174 180 186 191 197 204 210 217 223 230 236 243 250 257 264
173 179 185 191 197 204 210 216 223 230 236 243 250 258 265 272
T
160 164
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176 184 192 200
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75
152
168
208
216
224
232
240
248
256
264
272
279
76
156
172
180
189
197
205
213
221
230
238
246
254
263
271
279
287

BMI 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54
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Height (inches) 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76
Body Weight (pounds)
172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443
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waist circumference >35 inches are at higher risk for diabetes, dyslipidemia, hypertension and cardiovascular disease. Individuals with at risk waist circumferences should be considered one risk category above that defined by their BMI. 3. Risk factors or Comorbidities: Overall risk factors must take into account the potential presence of other risk factors. Conditions denoting high absolute risk include: established coronary heart disease, other atherosclerotic diseases, type 2 diabetes and sleep apnea. Three or more of the following risk factors indicate high absolute risk: hypertension, cigarette smoking, high lowdensity lipoprotein (LDL) cholesterol, low highdensity lipoprotein (HDL) cholesterol, impaired fasting glucose, family history of early cardiovascular disease and age (male> 45 and female> 55). The following conditions increase risk, but are not life threatening: Osteoarthritis, gallstones, stress incontinence and gynecological abnormalities such as amenorrhea and menorrhagia. The individuals readiness to make necessary lifestyle changes should also be considered before beginning a weight loss treatment. Evaluation of readiness should include: Reasons and motivation for weight loss Previous attempts at weight loss Support expected from family/friends Understanding of risks and benefits Attitudes toward physical activity Time availability Financial limitations linked to the individuals adoption of change CLASSIFICATION OF OVERWEIGHT AND OBESITY The primary classification of overweight and obesity is based on the assessment of BMI, waist circumference and associated disease risk. It should be noted that the relationship between BMI and disease risk varies among individuals and among different populations. Table 2 lists disease risk relative to normal weight and waist circumference. TREATMENT/MANAGEMENT The goals of therapy for those with a BMI>30,those with a BMI between 25 to 29.9, or a high risk waist circumference and two or more risk factors are to reduce body weight and to maintain a lower body weight long term. An initial weight loss of 10 percent of body weight over 6 months is a recommended target. One to two pounds of weight loss per week is desirable. After the first 6 months of weight loss therapy, the goal should be changed to weight maintenance for a period of time before further weight loss is recommended. Preventing further weight gain is an appropriate goal for individuals with a BMI of 25 to 29.9 who are not otherwise at high risk. NUTRITION THERAPY Nutrition therapy includes instructing patients in the modification of their diets to achieve a decrease in caloric intake. A diet that is planned to create a deficit of 500 to 1000 kcal/day is integral in achieving a 1 to 2 pound weight loss per week. The composition of the diet should also be modified to minimize other risk factors. Very Low Calorie Diets (VLCD) are those diets consisting of less than 800 kcal/day. VLCDs should not be used routinely for weight loss and require special medical monitoring and nutrient supplementation. Low calorie diets (LCD) contain between 1000-1200 kcal/day for females and between 12001600 kcal/day for males or females who weigh more than 165 pounds, or by those
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Table 2 Disease Risk* Relative to Normal Weight and Waist Circumference
BMI (kg/m2) Obesity Class Men 102 cm (40 in) or less Women 88 cm (35 in) or less Increased I II III High Very High Men > 102 cm (40 in) Women > 88 cm (35 in) High
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Underweight Normal Overweight Obesity
< 18.5 18.5 - 24.9 25.0 - 29.9 30.0 - 34.9 35.0 - 39.9
Extreme Obesity
40.0 +
*Disease risk for type 2 diabetes, hypertension, and CVD. +Increased waist circumference can be a marker for increased risk, even in persons of normal weight. Adapted from Preventing and Managing the Global Epidemic of Obesity. Report of the World Health Organization Consultation of Obesity. WHO, Geneva, June 1997.
Calories Total Fat
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< 30% total calories 8-10 total calories up to 10% total calories up to 15% total calories <300 mg/day >55% total calories ~15% total calories 1000-1500 mg/day 20-30g/day
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Extremely High
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Very High Extremely High
Very High
Table 3 Step 1 Diet
Approximate reduction of 500-1000 kcal/day from usual intake
Saturated fat Polyunsaturated fat Monounsaturated fat Cholesterol Carbohydrates Protein Sodium Chloride Calcium Fiber
No more than 100 mmol/day (approximately 2.4g of sodium or 6 g sodium chloride)

who exercise regularly. The recommended LCD is known as the Step 1 Diet and also contains the nutrient composition that will decrease other risk factors, such as high blood cholesterol and hypertension. The composition of the Step 1 Diet is listed in Table 3. Educational efforts should focus on: The energy values of different foods Food composition: fats, carbohydrates, fiber, sodium and protein Evaluation of nutrition labels to determine caloric content and food composition New habits of purchasing lower calorie foods Food preparation techniques Portion control and avoiding overconsumption of high calorie foods Adequate water/fluid intake Limiting alcohol consumption PHYSICAL ACTIVITY Behavior therapy provides methods for overcoming barriers to compliance with diet therapy and/or increased physical activity. It also assesses the individuals readiness to begin a weight loss program. Proven behavior modification techniques are used to assist the individual in weight loss. It is important in any weight loss program to set reasonable and achievable short- and long-term goals. To assist in modifying ones behaviors, any or a combination of the following may be implemented: self-monitoring; rewards, and/ or stimulus control. PHARMACOTHERAPY Weight loss drugs approved by the FDA for long-term use may be useful as an adjunct to diet and physical activity for patients with a BMI> 30 and without concomitant obesityrelated risk factors or diseases, or for those with a BMI> 27 with concomitant obesityrelated risk factors or diseases. Drugs should only be used as part of a comprehensive program that includes diet, behavior modification therapy and physical activity. Physicians must monitor weight, blood pressure, pulse and evaluate side effects while individuals take such medications. WEIGHT LOSS SURGERY Weight loss surgery is an option for weight reduction for those who are clinically severely obese (BMI>40 or BMI>35 with comorbid conditions) and only for those in which other methods have failed. An integrated program that provides guidance on diet, physical activity and psychosocial concerns before and after surgery is necessary. WEIGHT LOSS PLATEAU A weight loss plateau is common to individuals following any weight loss program lasting more than 6 months. Although the cause is unclear, combinations of biological and behavioral factors are responsible. It is at
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An increase in physical activity should be an integral part of weight loss therapy and maintenance. Moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days per week should be encouraged as a starting point. Although it will not lead to a substantially greater weight loss than diet alone over 6 months, sustained physical activity is most helpful in the prevention of weight regain (22-24). In addition to helping to control weight, physical activity decreases the risk of dying from coronary heart disease and reduces the risk of developing diabetes, hypertension, or colon cancer. (25) For most obese patients, physical activity should be initiated slowly and the intensity should be increased gradually. A regimen of daily walking or water exercise is suggested, particularly for those who are obese. BEHAVIOR
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this point that weight maintenance should be implemented for a period of time before weight loss efforts are reinstated. WEIGHT MAINTENANCE Some individuals will not be able to accomplish a significant amount of weight loss. The goal for these patients should be guidance in preventing further weight gain and for reducing risk factors, when present. Key findings from the National Weight Control Registry (NWCR), an ongoing study of individuals who have been successful at longterm weight maintenance include: consumption of a low calorie, low fat diet; high levels of physical activity; and remaining vigilant about ones weight. Similar findings concur that weight loss maintenance improves by maximizing contact with individuals, encouraging moderate to high levels of exercise, providing structured approaches to modifying dietary intake, increasing social support and problem solving techniques and increasing initial weight-loss success. Key Recommendations (From the Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults)

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Weight loss to lower elevated blood pressure in overweight and obese persons with high blood pressure. Weight loss to lower elevated levels of total cholesterol, LDL-cholesterol, and triglycerides, and to raise low levels of HDL-cholesterol in overweight and obese persons with dyslipidemia. Weight loss to lower elevated blood glucose levels in overweight and obese persons with type 2 diabetes. Use the BMI to assess overweight and obesity. Body weight alone can be used to follow weight loss, and to determine the effectiveness of therapy. The BMI to classify overweight and obesity and to estimate relative risk of
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disease compared to normal weight. The waist circumference should be used to assess abdominal fat content. The initial goal of weight loss therapy should be to reduce body weight by about 10 percent from baseline. With success, and if warranted, further weight loss may be attempted. Weight loss should be about 1 to 2 pounds per week for a period of 6 months, with the subsequent strategy based on the amount of weight lost. Low calorie diets (LCD) such as the Step 1 Diet are indicated for weight loss in overweight and obese persons. Reducing fat as part of an LCD is a practical way to reduce calories. Reducing dietary fat alone without reducing calories is not sufficient for weight loss. However, reducing dietary fat, along with reducing dietary carbohydrates, can help reduce calories. A diet that is individually planned to help create a deficit of 500 to 1,000 kcal/day should be an integral part of any program aimed at achieving a weight loss of 1 to 2 pounds per week. Physical activity should be part of a comprehensive weight loss therapy and weight control program because it: 1) modestly contributes to weight loss in overweight and obese adults, 2) may decrease abdominal fat, 3) increases cardiorespiratory fitness, and 4) may help with maintenance of weight loss. Physical activity should be an integral part of weight loss therapy and weight maintenance. Initially, moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days a week, should be encouraged. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most and preferably all days of the week. The combination of a reduced calorie diet and increased physical activity is recommended since it produces weight loss that may also result in decreases in abdominal fat and increases in
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cardiorespiratory fitness. Behavior therapy is a useful adjunct when incorporated into treatment for weight loss and weight maintenance. Weight loss and weight maintenance therapy should employ the combination of LCDs, increased physical activity, and behavior therapy. After successful weight loss, the likelihood of weight loss maintenance is enhanced by a program consisting of dietary therapy, physical activity, and behavior modification therapy which should continue indefinitely. Drug therapy may also be used. However, drug safety and efficacy beyond 1 year of total treatment have not been established. A weight maintenance program should be a priority after the initial 6 months.
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REFERENCES 1. Yanovski JA, Yanovski SZ, Sovik KN, et al. A prospective study of holiday weight gain. N Engl J Med. 2000;342:861-867. 2. World Health Organization, (1998) Obesity: Preventing and managing the global epidemic, Report of WHO Consultation on Obesity, Geneva, 3-5 June, 1997, WHO, 1998. 3. National Center for Health Statistics (1999) (2000) Prevalence of overweight and obesity among adults. 4. Dyer AR, Elliot P. The INTERSALT study; relations of body mass index to blood pressure. INTERSALT Co-operative Research Group. J Hum Hypertens. N1989;3:299-308. 5. Tchernof A, Lamarche B, PrudHomme D, et al. The dense LDL phenotype: association with plasma lipoprotein levels, visceral obesity, and hyperinsulinemia in men. Diabetes Care. 1996;19(6):629-637. 6. Lew EA, Garfinkel L. Variations in mortality by weight among 750,000 men and women. J Chronic Dis.1979;32:563576.
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7. Larsson B, Bjorntorp P, Tibblin G. The health consequences of moderate obesity. Int J Obes. 1981;5:97-116. 8. Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of U.S. adults. Am J Epidemiol. 1997;146:214-222. 9. Lipton RB, Liao Y, Cao G, Cooper RS, McGee D. Determinants of incident noninsulin-dependent diabetes mellitus among blacks and whites in a national sample. The NHANES I Epidemiologic Follow-up Study. Am J Epidemiol. 1993;138:826-839. 10. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation. 1983;67:968-977. 11. Rexrode KM, Hennekens CH, Willett WC, et al. A prospective study of body mass index, weight change, and risk of stroke in women. JAMA. 1997;277:1539-1545. 12. Stampfer MJ, Maclure KM, Colditz GA, Manson JE, Willett WC. Risk of symptomatic gallstones in women with severe obesity. Am J Clin Nutr. 1992;55:652-658. 13. Hochberg MC, Lethbridge-Cejku M, Scott WW Jr, Reichle R, Plato CC, Tobin JD. The association of body weight, body fatness and body fat distribution with osteoarthritis of the knee: data from the Baltimore Longitudinal Study of Aging. J Rheumatol. 1995;22:488-493. 14. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleepdisordered breathing among middle-aged adults. N Engl J Med.1993;328:12301235. 15. Chute CG, Willett WC, Colditz GA, et al. A prospective study of body mass, height, and smoking on the risk of colorectal cancer in women. Cancer Causes Control. 1991;2:117-124. 16. Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS. Prevalence of obesity, diabetes, and
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obesity-related health risk factors, 2001. JAMA. 2003;289(1):76-79. 17. Pastor PN, Makuc DM, Reuben C, Xia H. Chartbook on Trends in the Health of Americans. Health, United States, 2002. Hyattsville, MD: National Center for Health Statistics. 2002. 18. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1723-1727. 19. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: Prevalence and trends, 19601994. International Journal of Obesity. 1998;22:3947. 20. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288:17281732. 21. Colditz GA. Economic costs of obesity. Am J Clin Nutr. 1992;55:503-507s. 22. Katzel LI, Bleecker ER, Colman EG, Rogus EM, Sorkin JD, Goldberg AP. Effects of weight loss vs aerobic exercise training on risk factors for coronary disease in healthy, obese, middle-aged and older men. A random-ized controlled trial. JAMA. 1995;274:1915-1921. 23. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273:402-407. 24. NIH Consensus Conference. Physical activity and cardiovascular health. JAMA. 1996;276:241-246. 25. U.S. Department of Health and Humans Services. Physical Activity and Health: A Report of the Surgeon General. Centers for Disease Control and Prevention. 1996. RESOURCES American Dietetic Association 216 West Jackson Boulevard Chicago, IL 60606-6995 (312) 899-0040 1-800-877-1600 fax http://www.eatright.org National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Building 31, Room 9A52 31 Center Drive Bethesda, MD 20892-1818 (301) 496-5877 (301) 402-2125 fax http://www.niddk.nih.go/index.htm
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The Weight-Control Information Network National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health 1 Win Way Bethesda, MD 20892-0001 (301) 570-2177 (301) 570-2186 fax 1-800-WIN-8098 National Diabetes Information Clearinghouse (NIDDK) 1 Information Way Bethesda, MD 20892-3560 (301) 654-3327 (301) 907-8906 fax American Society for Bariatric Surgery (ASBS) 140 Northwest 75th Drive, Suite C Gainesville, FL 32607 (352) 331-4900 (352) 331-4975 fax http://www.asbs.org/
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American College of Sports Medicine P.O. Box 1441 Indianapolis, IN 46206-1440 (317) 637-9200 (317) 634-7817 fax http://www.acsm.org American Diabetes Association 1660 Duke Street Alexandria, VA 22314 1-800-DIABETES http://www.diabetes.org American Society of Bariatric Physicians (ASBP) 5600 South Quebec Street, Suite 109A Englewood, CO 80111 (303) 770-2526, ext. 17 (membership information only) (303) 779-4833 (303) 7794834 fax http://www.asbp.org American Heart Association 7272 Greenville Avenue Dallas, TX 75231-4596 (214) 706-1220 (214) 706-1341 fax 1-800-AHA-USA1 (1-800-242-8721) http://www.americanheart.org National Institute of Neurological Disorders and Stroke National Institutes of Health P.O. Box 1350 Silver Spring, MD 20911 (800) 352-9424 http://www.ninds.nih.gov
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American Obesity Association 1250 24th Street, NW, Suite 300 Washington, DC 20037 202-776-7711 202-776-7712 fax http://www.obesity.org American Cancer Society Atlanta, GA 1-800-ACS-2345 http://www.cancer.org
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Office of Cancer Communications National Cancer Institute National Institutes of Health Building 31, Room 10A-24 31 Center Drive, MSC 2580 Bethesda, MD 20892-2580 1-800-4-CANCER (1-800-422-6237) http://www.nci.nih.gov
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Nutrition Education Adult Weight Loss

Written by: Donna DeCunzo-Taddeo, RD,LD, Weight Management Specialist, Lighthouse Point, FL Reviewed by: Mary C. Friesz, PhD, RD, CDE, LD/N
NUTRITION EDUCATION FOR ADULT WEIGHT LOSS

Understanding portion sizes and calorie levels of food groups are important skills for weight loss and weight maintenance. Within each food group, foods can be exchanged for each other. You can use this list to give yourself more choices.
FOOD EXCHANGE LIST

Vegetables contain 25 calories and 5 grams of carbohydrate. One serving equals: 1/2 cup 1 cup 1/2 cup
Cooked vegetables (carrots, broccoli, zucchini, cabbage, etc.) Raw vegetables or salad greens Vegetable juice
Fat-Free and Very Low fat Milk contain 90 calories per serving. One serving equals: 1 cup 3/4 cup 1 cup
Very Lean Protein choices have 35 calories and 1 gram of fat per serving. One serving equals: 1 ounce 1 ounce 1 ounce 1 ounce 3/4 cup 2 each 1/4 cup 1 ounce 1/2 cup Turkey breast or chicken breast, skin removed Canned tuna in water Shellfish (clams, lobster, scallop, shrimp) Cottage cheese, non fat or low fat Egg whites Egg substitute Fat-free cheese Beans- cooked (black beans, kidney, chick peas or lentils): count as 1 starch/bread and 1 very lean protein Fish fillet (flounder, sole, scrod, cod, etc.)
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If youre hungry, eat more fresh or steamed vegetables
Milk, fat-free or 1% fat
Yogurt, plain non fat or low fat
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Yogurt, artificially sweetened
Florida Dietetic Association Website: www.eatrightflorida.org For a referral to a nutrition professional in your area, visit: www.eatright.org . 2011 FDA. Reproduction of this medical nutrition therapy tool is permitted for educational purposes only. It does not substitute for meeting with a Registered Dietitian to develop a personalized plan that is right for you.
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Fruits contain 15 grams of carbohydrate and 60 calories. One serving equals: 1 small 1 medium 1 1/2 1/2 1 cup 1 cup 1/8 4 ounces 4 teaspoons Apple, banana, orange, nectarine Fresh peach Kiwi Grapefruit Mango Fresh berries (strawberries, raspberries or blueberries) Fresh melon cubes Honeydew melon Unsweetened Juice Jelly or Jam
Lean Protein choices have 55 calories and 2-3 grams of fat per serving. One serving equals: 1 ounce 1 ounce 1 ounce 1 ounce 1 ounce 1 ounce 1 ounce 1 ounce 1 ounce 1/4 cup 2 medium
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Sardines
Chicken- dark meat, skin removed Turkey- dark meat, skin removed Salmon, Swordfish, herring
Lean beef (flank steak, London broil, tenderloin, roast beef)* Lamb, roast or lean chop* Pork, tenderloin or fresh ham*
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Veal, roast or lean chop*
Low fat cheese (3 grams or less of fat per ounce) 4.5% cottage cheese
Low fat luncheon meats (with 3 grams or less of fat per ounce)
* Limit to 1-2 times per week
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Medium Fat Proteins have 75 calories and 5 grams of fat per serving. One serving equals: 1 ounce 1 ounce 1 each 1 ounce 1/4 cup 4 ounces Beef (any prime cut), corned beef, ground beef ** Pork chop Whole egg (medium) ** Mozzarella cheese Ricotta cheese Tofu (note this is a Heart Healthy choice) ** choose these very infrequently
Starches contain 15 grams of carbohydrate and 80 calories per serving. One serving equals: 1 slice 2 slice 1/4 (1 Ounce) 1/2 1/2 3/4 cup 1/3 cup 1/3 cup 1/3 cup 1/2 cup 1/2 cup 1/2 cup 3 ounce 3/4 ounce 3 cups Bread (white, pumpernickel, whole wheat, rye) Reduced calorie or "lite" Bread Bagel (varies)
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English muffin Cold cereal Hamburger bun Pasta- cooked Bulgur- cooked Pretzels
Rice, brown or white- cooked
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Barley or couscous- cooked
Legumes (dried beans, peas or lentils)- cooked
Corn, sweet potato or green peas Baked sweet or white potato Popcorn, hot air popped or microwave (80% light)
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Fats contain 45 calories and 5 grams of fat per serving. One serving equals: 1 teaspoon 1 teaspoon 1 teaspoon 1 teaspoon 1 Tablespoon 1 Tablespoon 1 Tablespoon 2 Tablespoons 1/8 8 large 10 large 1 slice Oil (vegetable, corn, canola, olive, etc.) Butter Stick margarine Mayonnaise Reduced fat margarine or mayonnaise Salad dressing Cream cheese Lite cream cheese Avocado Black olives Stuffed green olives Bacon
Source: Based on American Dietetic Association Exchange List
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Tips for a Healthier You!
Use
vegetables and whole grains as the focus of your meals.
Keep
healthy snacks visible and within reach such as fresh fruit, vegetables, whole grain cereal, unsalted nuts, and low fat yogurt; you will be more likely to snack on them! nuts and fruit to your salads, oatmeal, or cereal. fruit as dessert; fruit and yogurt make a great parfait!
Add Use If
lunch is on the run, choose healthier options/restaurants and bring your own sides (fruit, vegetables, trail mix). out your local grocery store for healthy convenience items that require little or no preparation. convenient stores and gas stations sell fresh fruit, low fat milk, and yogurt.
Check
Most
Choose Bake, READ
FOOD LABELS and ingredients; limit food items with hydrogenated and partially hydrogenated oils. your whole grain consumption; choose items that have whole grains listed as the first ingredient. your portion sizes; use your measuring cups for a few weeks until you can eye the amounts.
Handout created by: Catherine Wallace, MSH, RD, Baptist Medical Center
healthy oils such as olive and vegetable.
broil, and grill instead of frying; steam veggies to preserve nutrients.
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Increase
Watch
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Instead of: 1/2 cup oil 1 cup heavy cream 1 cup shortening/lard 1 egg 1 cup all-purpose flour Oil for sauting
Try: 1/2 cup unsweetened applesauce 1 cup evaporated fat free milk 3/4 cup oil or soft (tub) margarine 1 egg white + 2 tsp vegetable oil or egg substitute
Salt
American processed cheese
Canned vegetables and beans
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1/2 cup all-purpose flour and 1/2 cup whole wheat flour
Wine, sherry, vinegar, low-sodium broth, tomato juice, lemon juice, skim milk, water Garlic, onions, herbs, spices, lemon, pepper, Mrs. Dash
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Try a variety of cheeses, some are lower in fat: part skim mozzarella; provolone; Swiss; Cabot reduced fat cheddar, soy cheese (veggie cheese); watch portion sizes Look for No Added Salt on the label or rinse before heating to decrease the amount of sodium. Remember fresh and frozen are best! Look for the cuts loin or round when selecting beef or pork; a round cut of beef has less fat then dark chicken meat
Meat, Poultry
Handout created by: Catherine Wallace, MSH, RD, Baptist Medical Center
Exercise? Yes You Can!

Chewing gum at about 100 chews per minute uses about 11 calories each hour. This was reported by the Mayo Clinic in a publication no less prestigious than the New England Journal of Medicine. If a person chewed sugar-free gum during all waking hours and did not change eating habits or other activities, there could be a loss of more than 10 pounds of body fat per year - just from the calories burned in chewing sugar-free gum! Of course, sugared chewing gums don't have the same effect because of the calories in the sugar.
The Energy Expended in Chewing Gum. New England Journal of Medicine, December 30, 1999
Did You Know?
Moving Experiences
Physical activity is a powerful weapon to help ensure a long and healthy life. The studies tell us that people who exercise do improve their health and live longer. How much exercise we need to achieve this is not yet clear. So far, the statistics tell us that regular exercise, using 1,000 calories a week, reduces risk of death from any cause by 20 to 30 percent and exercising more than that may offer additional risk reduction. It does not have to be organized sport activity being physically active onthe-job, with household tasks, or recreations all of these activities count. We also know that not exercising can increase our risks for many diseases, including heart disease and the three most common cancers colon, breast and prostate. And we know that exercising even just a little can provide a protective effect, perhaps by helping us to keep our body weight in a healthy range.
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Exercise pumps more blood through the veins. This increases the size of arteries, prevents fat from clogging them, and helps prevent blood clots. Regular exercise also increases the HDL (good) cholesterol and helps lower total cholesterol, and lower blood pressure. The lungs also benefit from exercise as they become better conditioned so that activities such as climbing stairs will not make us out of breath. Muscles that are not used become small and inelastic, but aerobic exercise or anaerobic strength training will help tone the body by increasing muscle size, strength and flexibility while burning fat. Exercise is also a great stress-buster, so we can feel more relaxed at the end of a day. Stress from major life events or just the hassles of daily living can affect anyone. Chronic stress, when we get no relief, leads to exhaustion or burnout, a state that can cause physical changes. The sinking feeling in the pit of the stomach, the cold, clammy hands, the tightness of the neck -- these are often triggered by two stress hormones -- called adrenalin and cortisol. Exercise helps to burn up these stress hormones, so people feel more physically at ease after an exercise session.
Coping With Lifes Stresses
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You Are Never Too Old
Physical activity over the course of a lifetime seems to confer the greatest benefit, but even people who begin exercise in their later years derive a benefit. A study of 7,500 women over age
65 from Baltimore, Minneapolis, Pittsburgh and Portland, Oregon reported that those who began to increase physical activity 10 to 12 years earlier (to about one mile a day of walking) experienced lower death from all causes, including 40 percent fewer deaths from cardiovascular disease and cancer, compared to inactive women. This study and others also show that beneficial activity is not limited to vigorous exercise. Even moderate activity, such as walking one mile per day, can result in gains for health. Let's face it. Not everyone will spend an hour or two each day at the gym. Many of us just don't want to sweat. More often, it just seems that there are not enough hours in the day to make room for fitness. Mental as well as physical fatigue couple with time demands and even with the best of intentions, exercise just falls off the daily schedule too often for many of us. It's important to remember that we don't have to spend hours at the gym to benefit from exercise. Just about any form of physical activity provides health benefit and helps us to relax. Burning as few as 150 additional calories a day by means of exercise reduces risks of high blood pressure, coronary artery disease, diabetes, and cancer. We can burn 150 calories in a surprising variety of activities, some of which we might not consider to be "real" exercise. For instance, one-half hour of brisk walking, or bicycling does the job.
What Is Aerobic Exercise?
The term aerobic means "using oxygen." During aerobic exercise we use oxygen to burn a mixture of fat and carbohydrates for energy. It takes a while for the bodys metabolic engine to rev up to aerobic mode. That is why aerobic exercise burns the most calories if done for 30 minutes, at least three times a week.
Fitting-In Fitness
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The term anaerobic means "without oxygen." During anaerobic exercise we use mostly our bodys stored carbohydrates for fuel. We use the anaerobic mode during short bouts of activity, like lifting a heavy box or free-weight for example, or running from home plate to first or second base on a baseball diamond. Strength training to build muscles and improve physique is typically an anaerobic exercise.
What Is Anaerobic Exercise?
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Which Is Better?
Both types of exercise provide benefit. Studies tell us that we get the greatest benefit if we perform both aerobic and anaerobic workouts. Generally speaking, many experts now believe that, of the two, aerobic exercise provides more overall boost to health. Aerobic exercise strengthens the heart and lungs, and has a favorable effect on cholesterol and blood pressure, among other things. Anaerobic strength training improves muscle tone and body composition, resulting in a greater amount of lean body mass and lower body fat, and may provide similar benefits for the heart, and blood pressure.
It is also been shown that strenuous activity alters several hormones that play Target Heart Rate is what the pulse a role in health and disease. Physical rate should be to exercise safely and activity lowers blood insulin, glucose, receive the maximum cardiovascular triglycerides, and raises HDL cholesterol benefits. Your age and how well condiall of which may help decrease disease tioned you are determine your target risk. heart rate. Exercise also seems to favorably The simplest way to calculate your own target heart rate is to subtract your affect sex hormones such as testosterone age from 220. This number is the maxiand estrogen. Both these hormones promum times your heart can beat in one mote cancer growth. Men with prostate minute. If you are just beginning, your cancer have higher levels of testosterone target heart rate should be than healthy men, and between 60% to 75% of your women with breast maximum heart rate but cancer have more exposure to estrogen than after six months you can Age is not the healthy women. Male safely go up to 85%. issue. Even endurance athletes, The easiest way to people who such as triathletes, have check your heart rate is to begin exercise less testosterone than place the tips of your middle in their 50s and non-athletes, and and index fingers in the 60s and later in groove of your throat just to women who engage in intensive physical the side of the Adam's apple. life derive a activity have less Count the heart beats for six benefit from estrogen than nonseconds and multiply the exercise. athletes. So, some of the number of beats by 10. If benefits of exercise may you are not within target come from effects on sex range, adjust the workout. hormones. After cooling down, check your pulse Fitness and Healthy Aging rate again. It should be less than 100 Besides offering protection from major beats per minute before you stop moving. diseases such as heart disease and canIf it takes more than 5 minutes to recover, cer, exercise can help us to be more vital lower your workout intensity. later in life. As we age, the body has a tendency to Keeping Off the Unwanted Weight change composition, losing muscle mass We don't really know why exercise and skeleton, and gaining fat. Medically, reduces disease risk. Exercise produces a the condition is known as sarcopenia. positive effect on weight, which may Our body strength tends to go down, as explain some of the benefits, because does our activity level. Experts used to obese people have higher risk for chronic think that sarcopenia was inevitable in old diseases, compared to non-obese people. age, but it is not inevitable. Keeping active Keeping weight in the healthy range helps fend off the loss of energy, strength, is important. And exercise is one way to and muscle. Even among the so-called help keep off those pounds. We see time frail elderly people 90 or so years of and time again among people who diet age strength training that involves to lose weight, those who exercise tend to resistance training can improve movement keep off the pounds more than dieters and muscle function. who do not exercise, regardless of the type of diet they have followed.
What Is a Target Heart Rate?
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It is important to select some activity that you can enjoy and stick with at least three times a week for 30 minutes on each day that you exercise. Make sure you are dressed in clothing that is comfortable and loose fitting. If the activity takes you outdoors, wear light-weight clothes that allow body heat to escape. On cold days, dress in layers so you can remove one layer if exercise gets you uncomfortably hot. If it is really cold, wear a hat and gloves. An exercise regime should always include five minutes of warm-up -- a slow-pace version of your activity -- a slow walk for example. This gradually increases heart rate and blood flow to prepare the heart and muscles for exercise. Follow this with a little stretching for another five minutes. This helps to prevent injuries, since warm, stretched muscles are less prone to injury than cold, tight ones. Stretch your major muscle groups, the muscles you plan to use during exercise. Stretch in a relaxed, controlled way. Extend the muscle only as far as comfortable. If it hurts, you are doing too much. Hold each stretch for 10 seconds. Do NOT bounce. Do NOT hold your breath. Breathe normally.
What Is the Right Exercise for Me?
Cooling down allows your heart rate, breathing and blood pressure to return to normal. It also prevents blood from pooling in your working muscles, returns it to your heart and brain, and prepares your body for stretching. To cool down, decrease your activity to a slower pace for about five minutes. Then S T R E T C H, holding each stretch 20 to 30 seconds. Stretching after a workout improves flexibility, lessens muscle soreness and helps you relax. Stretch your major muscle groups, the ones you used during exercise. Stretch and breathe in the same relaxed manner that you used before the workout.
Cool-Down
Warm-Up
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The time we exercise is also important. Avoid strenuous activity if it is hot and humid and also wait at least two hours after eating. Digesting food increases blood flow to the stomach and intestines, but exercise sends the blood to working muscles. This causes food to stay in the GI tract longer, which produces bloating, indigestion, and other discomfort.
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Time of Day
Work-Out
After the warm up, start with 5 to 10 minutes of exercise, slowly increasing until you reach target heart rate. Gradually over a period of weeks or months increase exercise time to 40 or 45 minutes at target heart rate. This maximizes aerobic benefits. Dont try to overdo it, especially at first.
Sedentary people who do little or no regular exercise can lose up to 30% of their muscle mass due to inactivity during adulthood, averaging several pounds of lost muscle per decade. Losing muscle mass means the metabolism slows down, because muscle needs a lot of calories to maintain itself. Slower metabolism results in the body burning fewer calories, and that can cause weight gain. Muscle is an active tissue. Each pound of muscle requires about 30 to 50
All About Muscles and Fat
calories per day for maintenance. What does this mean in practical terms? Add just one pound of muscle and burn 210 to 350 extra calories per week. In contrast, each pound of fat only burns 3 calories per day. So, it is easy to see that, for two people who have the same weight, the person whose body has more muscle will use more calories by far than the person whose body has more fat.
Strength & Resistance Training

Strength and resistance training, or working out with weights, is a great way to improve muscle mass and tone, plus improve balance and coordination and helps smooth out the body curves. Before you begin a program to work out with weights, it is a good idea to consult with an expert -someone who can show you proper body alignment, form and technique. This will help maximize results, and minimize risk of injury and strain that can occur when we dont use proper form. Here are some things to remember about strength training:
the weight again due to fatigue. Start with a low weight of perhaps one to five pounds on muscles of the upper body, and ten pounds on muscles of the lower body. Target doing the workout 2 to 3 times per week, resting your muscles for 48 hours between workouts to give the muscles time to repair and rebuild. Shoot for gradually increasing the amount of weight you lift. When you can do 10 to 15 reps at one weight with ease, it is time to increase the weight by three to five pounds on the upper body, and up to ten pounds on the lower body. Stop exercising a muscle when you feel you may be losing control of the muscle, or if the muscle is too fatigued or strained to keep the the correct form. Dont add more stress to muscles that are already tired. Take it slow when you perform the reps. Many exercise experts advise to count to 2 as you lift the weight, and count to 4 as you lower it. Exhale when you lift a weight. Never hold your breath while lifting a weight. Rest 30 to 90 seconds between each exercise. Count on having some muscle soreness, especially in the beginning days of your program. This is normal. The soreness eventually goes away as you continue to workout. Remember that a little soreness is fine, but P A I N is not good. Stop if you feel pain.
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Work the biggest muscles first (chest, back, legs), then the smaller muscles (shoulders, biceps, triceps) Balance the weights on right and left sides, front and back. Try to do 10 to 15 repetitions with each exercise. A repetition (or rep) is the number of times you lift the weight. Lift a weight that is just heavy enough to tire your muscles after 10 to 15 reps (where you cannot lift
If you are over age 35 or have a history of medical problems, it is important to see your doctor before beginning an exercise program. Most doctors will perform a medical evaluation to assess your health and fitness. They will check blood pressure, cholesterol, and weight, and identify any problems that could affect your circulation, muscles or bones. Depending on your health background, a doctor may recommend an EKG (electrocardiogram to monitor the heart rate and function), or a treadmill test. A fitness evaluation may also be recommended to determine your current fitness level and to set fitness goals. The evaluation may involve a muscle strength test, including push-ups and sit-ups; a flexibility test to check your range to stretch the various muscle groups; a back assessment to determine strength and flexibility to help avoid spinal injury; and an assessment of body fat to determine your fat to lean body mass ratio. After examining the test results, your doctor will be able to help you design an exercise routine that will set you on your way to better fitness.
When To See The Doctor First
Small Moves
Here are some little exercise activities that, done regularly, can add up: Leave the car behind and walk to the store for that short trip to buy a quart of milk or lotto ticket. In public buildings, and in apartment complexes, take the stairs rather than elevators. Spend time window shopping by walking around shopping streets. If you play golf, carry your own club bag around the course.
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At the movies, at church or temple, or at the mall, park far away from the entrance, and walk to the entrance.
Take the kids or grandkids out to the park for a game of frisbee. Make the dogs daily outing an excuse for your getting some exercise as well. Take a long walk with the pooch. Stand rather than sit when you talk on the phone, entertain friends, or engage in any type of conversation. Standing uses up 40 percent more calories than sitting. Go dancing with your spouse or with friends modern dancing, ballroom dancing, ethnic dancing, square dancing any kind of dancing will do -- even taking a ballet or tap dancing class at the local YMCA or school.
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Activities and Calories Spent
You can use this table* to determine how many calories you may burn in a given activity. Just find the column that that corresponds to your weight, and then move down the column to see the activity. Multiply the number of calories per minute by the number of minutes spent in the activity to find out how many calories are being used.
Activity Intensity 110lbs
Cycling Cycling Cycling Cycling Stretches Stretches Dancing Dancing Dancing Dancing Fishing Home Home Home Home Home Home Inactivity Inactivity Lawn Lawn Lawn Music Music Work Work Work Work Work Running Running Running Running Running Sports Sports Sports Sports Sports Sports Sports Slow, for pleasure 10-11.9 mph, leisure, slow 12-13.9 mph, moderate 14-15.9 mph, vigorous Stretching, hatha yoga Water calisthenics General Aerobic, low impact Aerobic, general Aerobic, high impact Fishing from boat Sitting, knitting, sewing Carpet or floor sweeping Cleaning house Washing the car Painting, outside house Carpentry, sawing hardwood Watch TV, Listen to music Sleeping Mowing , riding mower Mowing walk, power mower Shoveling snow, by hand Piano or organ Drums Sitting-light office work Standing, light Construction Masonry Carrying heavy loads Running, 5 mph Running, 5.2 mph Running, 6 mph Running, 7 mph Running up stairs Basketball, baskets Basketball, game Boxing, punching bag Frisbee, ultimate Golf, using power cart Golf, pulling clubs Handball
130lbs 4.14 6.20 8.27 10.34 4.14 6.20 4.65 5.17 6.20 7.24 2.59 1.55 2.59 3.62 4.65 5.17 7.76 1.03 0.93 2.59 4.65 6.20 2.59 4.14 1.55 2.59 5.69 7.24 8.27 8.27 9.31 10.34 11.89 15.51 4.65 8.27 6.20 3.62 3.62 5.17 12.41
Calories per Minute 150lbs 170 lbs 190lbs 210lbs 4.77 7.16 9.55 11.93 4.77 7.16 5.37 5.97 7.16 8.35 2.98 1.79 2.98 4.18 5.37 5.97 8.95 1.19 1.07 2.98 5.37 7.16 2.98 4.77 1.79 2.98 6.56 8.35 9.55 9.55 10.74 11.93 13.72 17.90 5.37 9.55 7.16 4.18 4.18 5.97 14.32 5.09 7.64 10.18 12.73 5.09 7.64 5.73 6.36 7.64 8.91 3.18 1.91 3.18 4.45 5.73 6.36 9.55 1.27 1.15 3.18 5.73 7.64 3.18 5.09 1.91 3.18 7.00 8.91 10.18 10.18 11.45 12.73 14.64 19.09 5.73 10.18 7.64 4.45 4.45 6.36 15.27 6.05 9.07 12.09 15.11 6.05 9.07 6.80 7.56 9.07 10.58 3.78 2.27 3.78 5.29 6.80 7.56 11.34 1.51 1.36 3.78 6.80 9.07 3.78 6.05 2.27 3.78 8.31 10.58 12.09 12.09 13.60 15.11 17.38 22.67 6.80 12.09 9.07 5.29 5.29 7.56 18.14 6.68 10.02 13.36 16.70 6.68 10.02 7.52 8.35 10.02 11.69 4.18 2.51 4.18 5.85 7.52 8.35 12.53 1.67 1.50 4.18 7.52 10.02 4.18 6.68 2.51 4.18 9.19 11.69 13.36 13.36 15.03 16.70 19.21 25.06 7.52 13.36 10.02 5.85 5.85 8.35 20.05
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3.50 5.25 7.00 8.75 3.50 5.25 3.94 4.38 5.25 6.13 2.19 1.31 2.19 3.06 3.94 4.38 6.56 0.88 0.79 2.19 3.94 5.25 2.19 3.50 1.31 2.19 4.81 6.13 7.00 7.00 7.88 8.75 10.06 13.13 3.94 7.00 5.25 3.06 3.06 4.38 10.50
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Activity
Intensity 110lbs 130lbs
Calories per Minute 150lbs 170 lbs 190lbs 210lbs 9.55 10.18 4.77 5.09 11.93 12.73 11.93 12.73 13.12 14.00 9.55 10.18 5.97 6.36 4.77 5.09 4.77 5.09 7.16 7.64 9.55 10.18 3.58 3.82 7.16 7.64 2.98 3.18 7.76 8.27 9.55 10.18 2.39 2.55 3.58 3.82 4.18 4.45 4.77 5.09 5.37 5.73 5.97 6.36 3.58 3.82 7.16 7.64 11.93 12.73 5.97 6.36 9.55 10.18 9.55 10.18 4.18 4.45 12.09 6.05 15.11 15.11 16.62 12.09 7.56 6.05 6.05 9.07 12.09 4.53 9.07 3.78 9.82 12.09 3.02 4.53 5.29 6.05 6.80 7.56 4.53 9.07 15.11 7.56 12.09 12.09 5.29 13.36 6.68 16.70 16.70 18.37 13.36 8.35 6.68 6.68 10.02 13.36 5.01 10.02 4.18 10.86 13.36 3.34 5.01 5.85 6.68 7.52 8.35 5.01 10.02 16.70 8.35 13.36 13.36 5.85
Sports Sports Sports Sports Sports Sports Sports Sports Sports Sports Sports Walking Walking Walking Walking Walking Walking Walking Walking Walking Walking Water Water Water Water Winter Winter Winter Winter
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Hockey, ice or field Horseback riding Judo, karate, kick boxing Racquetball, competitive Rock climbing Rope jumping, slow Softball or baseball Table tennis Tai chi Tennis, doubles Tennis, singles Downstairs Hiking, cross country Pushing stroller Race walking Up stairs Walking, very slow 2.5 mph, level 3.0 mph, level, moderate 3.5 to 4.0 mph, level, brisk 4.5 mph, level, very brisk Snorkeling Surfing, body or board Swimming, leisurely Swimming laps, freestyle Skiing, downhill, light Skiing, downhill, racing Snow shoeing Snowmobiling
7.00 3.50 8.75 8.75 9.63 7.00 4.38 3.50 3.50 5.25 7.00 2.63 5.25 2.19 5.69 7.00 1.75 2.63 3.06 3.50 3.94 4.38 2.63 5.25 8.75 4.38 7.00 7.00 3.06
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8.27 4.14 10.34 10.34 11.37 8.27 5.17 4.14 4.14 6.20 8.27 3.10 6.20 2.59 6.72 8.27 2.07 3.10 3.62 4.14 4.65 5.17 3.10 6.20 10.34 5.17 8.27 8.27 3.62
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Data compiled from Ainsworth, et al. Compendium of Physical Activities: Classification of Energy Cost of Human Physical Activities. Medicine and Science in Sports and Activities, 1993;25:71-80
Susan Moyers, PhD, MPH, LD/N Manual of Medical Nutrition Therapy 2011 Edition
Nutrition for Childhood Obesity Prevention

Written by: Erin Petrey, MSH Dietetic Intern, University of North Florida, Jacksonville Reviewed by: Catherine Christie, PhD, RD, LD/N, FADA. Chair, Department of Nutrition & Dietetics, University of North Florida, Jacksonville (4). The latter study also found that if overweight begins before 8 years of age, obesity in adulthood is likely to be more severe. Obese children and adolescents are at risk for health problems during their youth and as adults. Some negative health outcomes that may be more obvious to children and their parents are asthma, sleep apnea, skin infection, and complaints of joint pain (4,6). There are also more serious health risks associated with obesity that may be less obvious to the child or parent, such as high blood pressure (hypertension), high cholesterol, and Type 2 diabetes (4,6). These conditions can have serious long-term health effects and may require ongoing medical treatment and management. The bottom line is obesity can cause immediate health problems as well as a number of very serious chronic health conditions. In addition, research indicates that obese children have lower self esteem and self confidence than their thinner peers (6). Low self esteem and self confidence have been linked to poor academic performance, fewer friends, and depression (6). For all of these reasons it is important to try and prevent childhood obesity and identify overweight and obese children quickly so they can begin treatment and attain and maintain a healthy weight.
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PRACTITIONER POINTS
RATIONALE The prevalence of childhood obesity has increased greatly during the past three decades (1). The prevalence of obesity among children aged 6 to 11 years increased from 6.5 percent in 1980 to 19.6 percent in 2008. The prevalence of obesity among adolescents aged 12 to 19 years increased from 5.0 percent to 18.1 percent (2). Results from the 2007-2008 National Health and Nutrition Examination Survey (NHANES), using measured heights and weights, indicate that an estimated 17 percent of children and adolescents ages 219 years are obese (2). Obesity may lead to psychological, social, physical, and medical problems for a child (3). BMI percentile on the sex-specific BMI for age growth charts which follow this section (CDC 2000) are currently the best readily available measure for determination of pediatric overweight and prediction of risk for adult obesity. Underweight: BMI below the 5th percentile Normal weight: BMI at the 5th and less than the 85th percentile Overweight: BMI at the 85th and below the 95th percentile Obese: BMI at or above the 95th percentile (need for in-depth medical assessment) Obese children and adolescents are more likely to become obese as adults (5). One study found that approximately 80 percent of children who were overweight at ages 1015 years were obese adults at age 25 years. Another study found that 25 percent of obese adults were overweight as children
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Some examples of the problems associated with obesity are (6):
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Glucose intolerance and insulin resistance

Type 2 Diabetes High blood pressure High cholesterol
Low self esteem Negative body image Depression
Stigma Teasing and bullying Negative stereotyping Discrimination Social marginalization
Hepatic steatosis (fatty liver disease (FLD) Cholelithiasis (gallstones) Sleep apnea Asthma Skin conditions Menstrual abnormalities Impaired balance Orthopedic problems
Adapted from the National Alliance for Nutrition and Activity Obesity Fact Sheet
Preventative measures are most important, especially if there is a genetic propensity toward obesity. At times, despite prudent measures, genetic and environmental influences prevail and a child becomes obese (7, 8). It is generally agreed that the longer and the more obese a child is, the more likely it is that the condition will continue to adulthood leading, in many cases, to depression and chronic disease (3, 9, 10). In childhood specifically, body weights should not be the goal and weight loss may not always be appropriate. Instead, healthy lifestyles including exercise and proper eating habits should be encouraged, as well as improving our childrens self esteem. If a child falls into one or more categories outlined below, consider further assessment, counseling,
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and medical nutrition therapy: If > 95% for weight- for- length for kids less than age 2 If > 95% BMI for age/sex for kids greater than age 2 If child increases a percentile (or more) above his/her established weight for age pattern If weight exceeds height by more than two percentiles These guidelines are for healthy children over 2 years of age through puberty. RELATED PHYSIOLOGY Childhood obesity can result from the influences and interactions of a number of factors, including genetic, behavioral, and environmental factors (11).

Genetic Factors Studies suggest that specific genetic characteristics may increase an individuals predisposition to excess body weight (12, 13). However, this genetic susceptibility may need to exist within a combination of contributing behavioral and environmental factors in order to have a significant effect on weight. Twin and adoption studies show that genetics play a role in obesity (1). Twins who were adopted by different families were found to be closer in weight to their biological parents than to their adoptive parents (7). Prenatal factors such as maternal obesity, excess pregnancy weight gain, and diabetes, may also predispose a child to obesity (14, 15). Mothers with diabetes, either gestational or insulin dependent diabetes prior to pregnancy, have a higher percentage of babies of elevated birth weight and children with a greater risk of overweight and obesity. The cause of this obesity risk from maternal factors is still unknown, yet many hypothesize a link to increased insulin secretion, excess glucose, and/or increased fat transfer. Behavioral Factors
B3.3
light approach or by eliminating one or two high-calorie foods and excessive fruit juice from the diet may be beneficial (19). Educating children on the use of MyPyramid to establish a proper plan for eating and calorie counting should not be approached. Obese children generally have higher total resting metabolic rates (RMR) when compared to non-obese peers, but the rate relative to body size may be low and when adjusted for body composition is not different. Researchers have determined that RMR is determined more by fat free mass than any other factor with age (RMR decreases with increasing age), and gender (males have higher RMRs than females) also playing a smaller but significant role (20).
It is not possible to identify one specific behavior as the cause of childhood obesity, but certain behaviors can contribute to an energy imbalance, therefore leading to obesity.
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Energy Intake: Dietary fat intake, portion control and increased energy expenditure are among the important components of weight control (16). Eating meals away from home, frequent snacking on energy-dense foods, and consuming beverages with added sugar are often attributed to the consumption of excess calories in children and teens (17). Excluding inappropriate snacks and overeating by utilizing the stop
Physical Activity: Physical activity, an integral part of weight loss for children and teens, may also have beneficial effects on blood pressure and bone strength (21). Families must establish a family routine (including parents and siblings) to include physical activity to help metabolize fat, expend excess calories as well as to increase fat free mass (18). Children are encouraged to have at least 60 minutes of moderate intensity activity each day (1). At least 30 minutes of that should be from physical activity at school (1). Team sports, dance and martial arts are examples of aerobic activities that may benefit an obese child. Physically active children are more likely to remain physically active throughout adolescence and possibly adulthood (22).
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Sedentary Behavior: Parents should be encouraged to get their children involved in activities where they will play and not sit the bench and ones that are for recreation not just competition. Limiting

television, video games and other sedentary after-school activities is imperative. Several studies have found a positive association between time spent watching television and prevalence of obesity in children (23, 24). The American Academy of Pediatrics recommends no more than 2 hours of sedentary behavior each day. In regard to screen time (time spent watching television or playing video games), children aged 0-2, should have zero hours of screen time per day (1). Children aged 2-18 should not exceed 12 hours of screen time per day (1). Listed in Table 1 are recommended weight goals for children according to age and BMI percentile.
Age 2-7years BMI 85-94% BMI > 95% Weight maintenance If no complications, weight maintenance If medical complications, weight loss If no complications, weight maintenance If medical complications, weight loss
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child care or at school. This can be a setting in which healthy eating and physical activity habits are established. A childs community can play a big role in influencing physical activity and access to affordable and healthy food. A lack of sidewalks, safe bike paths, and parks can discourage children from walking or biking to school as well as from participating in outdoor physical activities (17). Nutrients Modified Nutrition guidelines for children include all foods but recommend limited use of high calorie, high fat and refined carbohydrate foods. Fats should be limited to 20-30 percent of calories with < 10 percent coming from saturated fat and < 300 mg of cholesterol per day (26). Fat should not be restricted in children younger than 2 years of age. MyPyramid should be utilized to promote a healthy mixture of carbohydrate, fat, and protein to maintain adequate growth without inappropriate weight gain.
Age >7 years BMI 85-94%
Table 1- Recommendations for Weight Goals (18):
Environmental Factors
BMI > 95%
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Nutritional Adequacy Diets should be evaluated using the Recommended Dietary Allowances (RDA) and the Dietary Reference Intakes (DRI) (27, 28). RDAs can be used to assess the adequate intake of nutrients that prevents a deficiency. To assure intake of nutrients in levels that may reduce the risk of diet-related diseases, the DRIs are used. When a variety of foods are consumed, this diet is adequate for all nutrients specified by the Dietary Reference Intakes (DRIs) for children over the age of two. MNT for Childhood Overweight and Obesity (30) The following are suggested pediatric weight management protocols adapted from the American Academy of Pediatrics: 1st RD Visit
A childs behavior related to food intake and physical activity can be influenced within the home, child care, school, and community (17). Within the home, parental obesity (of undetermined cause) has been shown to play the biggest role in the development of childhood obesity in children 5 years of age, making genetics a probable cause (25). Until the reasons for obesity are identified and addressed, and obese parents successfully improve their eating and activity habits, permanent weight loss attempts may fail. The majority of childrens time is spent in
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Medical and nutrition evaluation (blood pressure, height, weight, BMI, growth chart, review labs). See ADA Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines. Review PCP comments and goals as available Nutrition assessment (including readiness to change assessment ) See ADA Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines. Determine nutrition diagnosis Prioritize needs and goals based on child and family interests and issues (refer to Nutrition Topic List) Begin intervention/counseling/education (for example: food pyramid food choices, review portion sizes or other nutrition topic from list) See ADA Pediatric Weight Management Nutrition Intervention Algorithm. Recommend food and activity records and/or self-monitoring activity to support goals Document Discuss/share plan with PCP
(s) at last visit). See ADA Pediatric Weight Management Nutrition Intervention Algorithm. Recommend food and activity records and/ or self-monitoring activity to support goals Document Discuss/share plan with PCP Nutrition Diagnoses In regard to childhood overweight and obesity, some possible PES statements and nutrition diagnoses might be:
Excessive energy intake related to lack of knowledge as evidenced by 3 sugary drinks/ day and BMI of 34. Excessive energy intake related to lack of access to healthy food choices (fast food) as evidenced by diet history and BMI of 35.
RD Visits 2-4 Review medical record/chart notes and Pediatric Weight Management Ongoing Care Coordination and Information Sharing form from PCP as available; acknowledge PCP feedback on goals/revised goals & medical status, review reports from other consultants, as applicable Review labs from PCP, as applicable. Medical and nutrition re-evaluation. Recheck weight, etc. See ADA Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines. Update/modify nutrition diagnosis, as needed Review goals from prior session Reinforce progress Counseling on nutrition topic for the session (Items identified from Nutrition Topic List) Establish new goals (or maintenance goal
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Obesity related to lack of physical activity and poor food choices as evidenced by diet history and charting above 95th percentile on growth chart. REFERENCES
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1. Barlow, et al. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics. 2007;120;S164-S192. 2. Han JC, Lawlor DA, Kimm SYS. Childhood obesity. The Lancet . 2010;375: 1737-48. 3. Childhood Overweight and Obesity. Center for Disease Control and Prevention Web site. Accessed April 10, 2010. Available at: http:// w w w . c d c .go v / o b e s i t y / c h i l d h o o d / index.html. 4. Hill JO, Trowbridge FL. Childhood the United States, 19861990." Arch Pediatr Adolesc Med 1996;150(4):356 62.
Treating the Overweight Child

Written by: Nadine Pazder, MS, RD, LD/N, CDE, Outpatient Dietitian, Morton Plant Hospital, Clearwater Reviewed by: Pat Hare, RD, CPS, All Childrens Hospital, St. Petersburg less than age 2 If > 95% BMI for age/sex for kids greater than age 2 If child increases a percentile (or more) above his/her established weight for age pattern If weight exceeds height by more than two percentiles
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PRACTITIONER POINTS
RATIONALE Overweight and obesity are increasing in prevalence among all age groups but especially fast in children and adolescents (1). Research indicates that up to 25 percent of the nations youth can be considered overweight or obese (1). Obesity may lead to psychological, social, physical, and medical problems for a child (2). BMI percentile on the sex-specific BMI for age growth charts which follow this section (CDC 2000) are currently the best readily available measure for determination of pediatric overweight and prediction of risk for adult obesity.

USE These guidelines are for healthy children over 2 years of age through puberty. RELATED PHYSIOLOGY Twin and adoption studies show that genetics play a role in obesity. Twins who were adopted by different families were found to be closer in weight to their biological parents than to their adoptive parents (4). Prenatal factors: maternal obesity, excess pregnancy weight gain, and diabetes, may also predispose a child to obesity (8, 9). Mothers with diabetes, either gestational or insulin dependent diabetes prior to pregnancy, have a higher percentage of babies of elevated birth weight and children with a greater risk of overweight and obesity. The cause of this obesity risk from maternal factors is still unknown, yet many hypothesize a link to increased insulin secretion, excess glucose, and/or increased fat transfer. Dietary fat intake, portion control and increased energy expenditure are among the important components of weight control (10). Excluding inappropriate snacks and overeating by utilizing the stop light approach or by eliminating one or two highcalorie foods and excessive fruit juice (no more than 12 oz per day) from the diet may be beneficial (12). Educating children on the use of MyPyramid to establish a proper plan for eating and calorie counting should not be approached. Obese children generally have higher
BMI 85-94% indicates risk of overweight BMI > 95% indicates overweight and need for in depth medical assessment
Preventative measures are most important, especially if there is a genetic propensity toward obesity. At times, despite prudent measures, genetic and environmental influences prevail and a child becomes obese (3, 4, 5). It is generally agreed that the longer and the more obese a child is, the more likely it is that the condition will continue to adulthood leading, in many cases, to depression and chronic disease (2, 6, 7). In childhood specifically, body weights should not be the goal and weight loss may not always be appropriate. Instead, healthy lifestyles including exercise and proper eating habits should be encouraged, as well as improving our childrens self esteem. If a child falls into one or more categories outlined below, consider further assessment, counseling, and medical nutrition therapy:
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If > 95% for weight- for- length for kids

total resting metabolic rates (RMR) when compared to non-obese peers, but the rate relative to body size may be low and when adjusted for body composition is not different. Researchers have determined that RMR is determined more by fat free mass than any other factor with age (RMR decreases with increasing age), and gender (males have higher RMRs than females) also playing a smaller but significant role (13). Exercise is an integral part of weight loss. Families must establish a family routine (including parents and siblings) to include physical activity to help metabolize fat, expend excess calories as well as to increase fat free mass (11). At least 30 minutes of activity should be a goal for all families. Team sports, dance and martial arts are examples of aerobic activities that may benefit an obese child. Parents should be encouraged to get their children involved in activities where they will play and not sit the bench and ones that are for recreation not just competition. Limiting television, video games and other sedentary after-school activities is imperative. Listed in Table 1 are recommended weight goals for children according to age and BMI percentile.
Table 1- Recommendations for Weight Goals (11): Age BMI 85-94% 2-7years BMI > 95% Weight maintenance
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However, parental obesity (of undetermined cause) has been shown to play the biggest role in the development of childhood obesity in children 5 years of age, making genetics a probable cause (14). Until the reasons for obesity are identified and addressed, and obese parents successfully improve their eating and activity habits, permanent weight loss attempts may fail. NUTRIENTS MODIFIED This meal pattern includes all foods but recommends limited use of high calorie, high fat and refined carbohydrate foods. Fats should be limited to 20-30 percent of calories with <10 percent coming from saturated fat and < 300mg of cholesterol per day (15). Fat should not be restricted in children younger than 2. MyPyramid should be utilized to promote a healthy mixture of carbohydrate, fat, and protein to maintain adequate growth without inappropriate weight gain. NUTRITIONAL ADEQUACY
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If no complications, weight maintenance If medical complications, weight loss If no complications, weight maintenance If medical complications, weight loss Weight loss
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REFERENCES 1.
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Diets should be evaluated using the Recommended Dietary Allowances (RDA) and the Dietary Reference Intakes (DRI) (16, 17). RDAs can be used to assess the adequate intake of nutrients that prevents a deficiency. To assure intake of nutrients in levels that may reduce the risk of diet-related diseases, the DRIs are used. When a variety of foods are consumed, this diet is adequate for all nutrients specified by the Dietary Reference Intakes (DRIs) for children over the age of two.
Age BMI 85-94% >7 years
BMI > 95%
A variety of factors: appetite, cultural preferences and patterns, and psychological needs drive and influence eating behavior.
2.
Troiano RP, Flegal KW. Overweight children: description, epidemiology and demographics. Pediatrics. 1998;101:497-504. Hill JO, Trowbridge FL. Childhood obesity: future directions and research priorities.

Pediatrics. 1998;101:570-574. Garn SM, Sullivan TV, Hawthorne VM. Fatness and obesity of parents of obese individuals. Am J Clin Nutr . 1989;50:1308-1313. 4. Stunkard AJ, Sorennsen IA, Hanis C, Teasdale TW, Chakraborty R, Schull WJ, Schulsinger F. An adoption study of human obesity. NEJM. 1986;314:193198. 5. Bouchard C, Tremblay A, Despres J, Nadeau A, Lupien P, Therault G, Dussault J, Moorjani S, Pinault S, Fournier G. The response to long term overfeeding in identical twins. NEJM. 1990;322:1477-1488. 6. Casey VA, Dwyer JT, Coleman KA, Valedian I. Body mass index from childhood to middle age: a 50 year follow up. Am J Clin Nutr. 1992;56:1418. 7. Guo S, Roche A, Cameron Chumlea W, Gardner J, Siervogel R. The predictive value of childhood body mass index values for overweight at age 35 years. Am J Clin Nutr. 1994;59:815-816. 8. Whitaker RC, Dietz WH. Role of the prenatal environment in the development of obesity. J Pediatr. 1998;132:768-776. 9. Plagemann A, Harder T, Kohlkoff R, Rhode W, Dorner G. Overweight and obesity in infants of mothers with long term insulin-dependant diabetes or gestational diabetes. International Journal of Obesity. 1997;21:451-456. 10. Williams Cl, Bollella M, Boccia L, Spark A. Nutrition and the life cycle. Dietary fat and childrens health. Nutrition Today.1998;33:144-155. 11. Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. Pediatrics. 102;e2948. (Electronic pages). 12. Dennison BA, Rockwell HL, Baker SL. Excess fruit juice consumption by preschool-aged children with short stature and obesity. Pediatrics. 1997;99:15-22. 3. 13. Molnar D, Schultz Y. The effect of obesity, age, puberty and gender on resting metabolic rate in children and adolescents. Eur J Pediatr. 1997;156:376-381. 14. OCallaghan MJ, Williams GM, Anderson MJ, Bor W, Najman JM. Prediction of obesity in children at 5 years: a cohort study. J Paediatr Child Health. 1997;33: 311-316. 15. American Academy of Pediatrics, Committee on Nutrition, Statement on Cholesterol Pediatrics. 90: 469, 1992. 16. National Research Council. Recommended Dietary Allowance, 10th Edition. National Academy Press.1989. 17. Dietary Reference Intakes. Food and Nutrition Information Center web site. 2003. Available at: http:// www.nal.usda.gov/fnic/ etext/000105.html. Accessed October 2003.
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Physical Fitness and Athletic Performance

Written by: Delores C.S. James, PhD, RD, LD/N, Associate Professor, Department of Health Science Education, University of Florida Reviewed by: Jennifer Hutchison, RD, LD/N, CSCS, Sports Dietitian, Private Practice force that is exerted by a muscle or muscle group in a single contraction. Muscular strength is developed by progressive resistance by weight training with free weights (dumbbells and barbells), exercise machines, strength training equipment, Nautilus machines, and other resistance equipment. Calisthenic exercises, such as sit-ups and push-ups, can strengthen muscles but are not as effective as weight training because overloading of the muscles is difficult to achieve; they are best suited for developing muscular endurance (4-7). Muscular Endurance refers to repeated muscular force. It involves repetitions against resistance that are less than maximal. Muscular endurance exercises include calisthenics (push-ups, sit-ups), and repeated lifting of weights (4-7). Flexibility refers to the ability of a joint to go through a range of motion. Flexibility exercises include yoga and stretching activities. Flexibility exercises should be part of the warm-up and cool-down routines (4-7). Body Composition refers to the proportion of lean body weight to fat tissues. Lean body weight is composed of muscles, bones, and organs. Health risks for some chronic diseases such as obesity, heart disease, some cancers, diabetes, and hypertension increase as proportion of body fat increases. Body weight is influenced by genetics, age, gender, body type, physical activity, and individual variation. The average American has 16 to 24 percent body fat (8). Acceptable figures for the general population are 15-18 percent for males and 20 to 25 percent for females. Males having more than 25 percent body fat and females having more than 30 percent body fat are considered obese and are at high risk for certain chronic diseases (3). Percent body fat for athletes usually ranges from 5 to 12 percent in males and 10 to 20 percent in females, depending on the sport (8).
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RATIONALE Physical fitness is as important to health as proper nutrition. Physical fitness is beneficial to everyone, regardless of the initial level of fitness. The goal of a physical fitness program is to reduce body fat and increase lean muscle mass (1, 2). For optimal health and prevention of weight gain, approximately 2000 kcal/week should be expended in physical activity (2-5). These guidelines are designed to provide adequate calories and nutrients for adequate performance. RELATED PHYSIOLOGY
The components of a physical fitness program are cardiovascular endurance, flexibility, muscular strength, muscular endurance, and body composition (4-7). Cardiovascular Endurance refers to the body's ability to use oxygen for muscular work. A continuous supply of oxygen is needed to burn carbohydrates and fats for energy in aerobic activities. Cardiovascular endurance improves with regular aerobic activities such as jogging, aerobic dancing, walking, and cycling. Aerobic activities involve continuous rhythmic activities of large muscle groups for at least 20 minutes. Short-term, high-intensity activities such as diving, high jumping, and discus throwing use anaerobic fuel sources. Activities such as tennis, volleyball, basketball, and soccer generally requires both aerobic and anaerobic fuel sources (4-7). Muscular Strength refers to the maximal
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Body mass index (BMI) is an indicator of body composition. Desirable BMI ranges are 21.9 to 22.4 for men and 21.3 to 22.1 for women. BMI has limited usefulness for elite and professional athletes as many of these athletes have a higher portion of lean body mass compared to fat mass. The National Center for Health Statistics defines overweight as BMI over 27. However, the Dietary Guidelines for Americans, the National Heart Lung and Blood Institute, and the World Health Organization define overweight as BMI over 25 (9). Individuals with a BMI between 25 and 26.9 should be encouraged to become physically active and to avoid further weight gain (9).

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lung function Lowered LDL-cholesterol and increased HDL-cholesterol Decreased blood pressure and slower resting pulse rates Increased basal metabolic rate (BMR) Increased lean muscle mass and decrease in body fat Increased bone density Improved glucose tolerance Increased self-esteem and a sense of well -being
NUTRIENT REQUIREMENTS Proper nutrition is essential for recreational, amateur, and professional athletes. To date, no specific diet has been formulated for athletes, but there are general guidelines and recommendations for those engaged in regular strenuous exercise. Energy
Table 1. Calculating BMI

BMI = Weight (kilograms) Height (meters)2 OR
BMI =
For example, the BMI for a person 5'7" (170 centimeters) weighing 153 pounds (69.5 kilograms) is 24. BMI = 703x 153 = 23.9 (1.7 meters) 2 or BMI = 69.5 kg = 24.0 (67 inches) 2
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703 x Weight (pounds) Height (in inches)2
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BENEFITS OF PHYSICAL ACTIVITY Regular physical activity has several health benefits. Most of these benefits can be gained by performing moderate-intensity activities. However, physical activity must be performed regularly to maintain these effects (1-6): Reduced risk of coronary heart disease Improved circulation, heart capacity, and
Energy needs will vary depending on the individual, gender, age, the particular event or sport, and the intensity, frequency and the duration of the event or sport (3, 4, 12, 13). Energy needs can be determined by an exercise physiologist who can administer an oxygen consumption test at the competing heart rate (13). A person's true caloric requirement results from a combination of basal energy expenditure (BEE), daily activity needs, and energy expended during exercise (8). If there is no access to physiological testing, energy needs can be calculated by hand. Mahan and Arlin (14) provide a quick method for estimating daily energy requirement:
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Table 2. Estimating Energy Needs
1. Estimate desirable weight in kg 2. Determine basal needs: male = 1 kcal/kg/hr x 24 hr female = 0.95/kcal/kg/hr x 24 hr 3. Subtract 0.1 kcal/kg/hr of sleep 4. Add activity increment 30% sedentary 50% for moderately active 75% for active 100% strenuous work 5. Add the thermic effect of food (10% of BEE plus activity increment) energy needs is approximately 3330 calories: 150 x 15 + (0.08 x 90 x 150) = 2250+ 1080 = 3330 kcalories Carbohydrate Carbohydrates are an indispensable fuel for essentially all types of athletic performance. Glycogen depletion during exercise leads to reduced performance and decreased endurance (3, 8, 13). To provide adequate substrate for glycogen synthesis and to meet other nutritional needs, 60 to 65 percent of total energy should come from carbohydrates. Ultraendurance and ultradistance athletes (those who participate in triathlons, and other events lasting 6 to 24+ hours) may require a diet of as high as 70 percent carbohydrates (3,13). 500 to 800 grams of carbohydrates (2,000 to 3,200 kcal) per day may be needed to maintain maximal glycogen stores in athletes (16, 17). Protein
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For example, the energy needs for a sedentary female who is 5' 10, weighs 150 pounds, and sleeps 8 hours/day: 1. 150 2.2 = 68.18 kg 2. 68.18 x 0.95 x 24 (BMR factor for females) = 1554.5 3. 1554.5 - (68.18 x .1 x 8 = 54.54) = 1499.96 4. (1499.96 x .30%) + (1499.96 x .10) = 449.98 + 149 = 598.98 5. 1499.96 + 598.98 = 2098.94 6. Energy needs are approximately 2100 kcals per day The energy needs of athletes may be calculated as follows (13). Adult athlete: ideal body weight (lbs) x 15 + (training expenditure (kcal/min/lb x minutes x weight in lb) = total daily energy needs (kcal)
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Fat
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Growing athlete: ideal body weight (lbs) x 30 + training expenditure (kcal/min/lb X minutes x weight in lb) = total daily energy needs (kcal)
The Recommended Dietary Allowance (RDA) for protein (0.8 gm/kg body weight) may be inadequate for many athletes, such as endurance athletes, body builders, and football players. Endurance athletes should consume 1.2 to 1.4 g/kg body weight, whereas strength and power athletes may need protein as high as 1.6 to 1.7 g/kg body weight (18). Calculating protein needs on a per kilogram body weight basis may be more appropriate than calculating needs as a percentage of total protein, as the latter may result in excessive protein intake for athletes with extremely high caloric intakes (3).
For example, the energy needs of a 150 lb (68 kg) athlete who does cross-country running for 90 minutes, expends 0.08 kcal/ min/lb body weight would be: total daily
Fat is an important part of an athletes diet as it provides energy, fat soluble vitamins, and essential fatty acids. Fat should not exceed 30 percent of total calories. Saturated fat and trans fatty acids should be limited, while emphasis on monounsaturated
Vegetarian Nutrition
Written by: Catherine A. Wallace, MSH, RD, LD/N, Baptist Medical Center, Jacksonville Reviewed by: Catherine Christie, PhD, RD, LD/N, FADA, Nutrition Programs Director, University of North Florida, Jacksonville disease, hypertension, type 2 diabetes, cancer, and diverticular disease and are at a lower risk of mortality from chronic diseases (2-12). NUTRIENTS MODIFIED Vegetarian diets can be healthful and nutritionally adequate if properly planned and a variety of foods are consumed. Vegetarian diets tend to be higher in fiber, vitamins A and C, and phytochemicals and lower in calories, cholesterol, saturated fat, and sodium than non-vegetarian diets (2, 11, 12). Groups at risk for inadequate caloric and nutrient intake include: infants, children, adolescents, and pregnant and lactating women (3, 11, 12). However, with proper planning a vegetarian diet can meet nutrient needs throughout the life cycle (3).
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PRACTITIONER POINTS
RATIONALE Vegetarianism is defined as the practice and philosophy of eating a plant based diet including grains, nuts, seeds, legumes, vegetables, and fruit (1, 2). However, vegetarian diets vary according to ethical, economic, environmental, humanitarian or religious concerns. Most exclude meat, fowl, and fish and some exclude eggs and dairy products. There are different variations of the vegetarian diet, but the three main types are: vegan (strict vegetarian); lactovegetarian, which includes milk in the diet; and lacto-ovo-vegetarian, which includes milk and eggs. Another variation of the vegetarian diet, though not considered true vegetarianism, is called pesco-vegetarian. This variation of the vegetarian diet includes fish and is sometimes referred to as macrobiotic. Refer to Table 1 for a listing of the different classifications of the vegetarian diet. USE
The vegetarian diet is composed predominantly of plant foods and may or may not include eggs and dairy products. The 2003 Position Statement of the American Dietetic Association and Dietitians of Canada states that an appropriately planned vegetarian diet is healthful, nutritionally adequate, and provides health benefits in the prevention and treatment of certain diseases (3). RELATED PHYSIOLOGY Research has shown that vegetarians are at a lower risk for many diseases and conditions, including obesity, cardiovascular
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Nutrient deficiencies are possible if adequate energy intake and a variety of foods are not consumed (2-4). In planning a vegetarian diet, one should choose a variety of foods in accordance with the Dietary Guidelines for Americans, and a modified MyPyramid. In 2000, Oldways Preservation and Exchange Trust developed The Traditional Healthy Vegetarian Diet Pyramid and the Traditional Healthy Vegetarian Diet Pyramid for Children as seen in Figures 1 and 2 (13). This pyramid is a useful tool to help professionals and their clients design vegetarian meals appropriately. Another tool that can be utilized for planning an appropriate vegetarian diet is the New Food Guide for North American Vegetarians which was developed by dietitians and published in the June 2003, Journal of The American Dietetic Association (14). Individuals following a vegetarian diet need to plan meals accordingly to ensure adequate intake of iron, zinc, vitamin D, vitamin B12, omega-3 fatty acids, and overall energy. Vegans should have a reliable source
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Vegetarian Nutrition
Table 1. VEGETARIAN DIET CLASSIFICATIONS Diet Classification Vegan Foods Included Grains, legumes, vegetables, seavegetables, fruits, seeds, nuts, nutritional yeast, vegetable oils, may include soy products and/or meat analogs Grains, legumes, vegetables, seavegetables, fruits, seeds, nuts, nutritional yeast, vegetable oils, dairy products, may include soy products and/or meat analogs Foods Excluded Eggs, meat, fowl, fish, shellfish, all dairy products, honey, products containing animal byproducts Nutritional Concerns Low calorie, protein, riboflavin, vitamin B12, iron, zinc, calcium, vitamin D, omega-3 fatty acids
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LactoVegetarian
Eggs, meat, fowl, fish, shellfish
Iron, zinc, omega-3 fatty acids
Lacto-OvoVegetarian
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Grains, legumes, vegetables, seavegetables, fruits, seeds, nuts, nutritional yeast, vegetable oils, dairy products, eggs, may include soy products and/or meat analogs Grains, legumes, vegetables, seavegetables, fruits, seeds, nuts, fish, vegetable oils, nutritional yeast
Meat, fowl, fish, shellfish
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Zinc
PescoVegetarian (Macrobiotic)
Meat, fowl, eggs, dairy
Zinc, calcium, vitamin B12, vitamin D
Bariatric Surgery
Written by: Cathy Clark-Reyes, RD, LD/N, Nutrition Concepts, Inc., Miami Reviewed by: Emily Marcus, RD, CDN, Bariatric Nutrition Coordinator, Center for Weight Management, North Shore-Long Island Jewish Health System following recommendations for the treatment of morbid obesity: 1) the individual being considered for surgery be motivated to lose weight and have attempted and failed at medically-supervised dietary and behavioral weight loss programs in the past, 2) either gastric restrictive or gastric bypass are acceptable weight loss surgical procedures for the treatment of morbid obesity, 3) the surgery should be performed only by a surgeon skilled in Bariatric surgery, 4) the surgical program should have a multidisciplinary team, and 5) the program should provide the surgical patient life-long medical surveillance. There are several types of Bariatric surgery. Some are purely restrictive such as the Vertical Banded Gastroplasty (VBG) and Laparoscopic Adjustable Gastric Banding (LAGB); other procedures are primarily malabsorptive such as the Biliopancreatic Diversion/Switch (BPD); and the most well known procedure is a combination of restrictive and malabsorptive the Roux-N-Y Gastric Bypass (RYGBP), which can be standard, long-limb, or distal. Both malabsorptive procedures are of greater nutritional concern due to the fact that the lower portion of the stomach and the duodenum are bypassed. Other types include: Silastic Ring Gastroplasty, Sleeve Gastrectomy, and BPD with Duodenal Switch. The dietary concerns following these procedures are control of food consistency and volume, provision of adequate protein, and maintenance of nutrient density. Minimizing symptoms of dumping syndrome, and the prevention of anemia and other vitamin/mineral deficiencies are important dietary factors with this surgery. Each procedure has its own form of treatment and diet therapy. Ultimately, the success of this procedure hinges on lifestyle change and the patients comprehension of their role in creating an optimal outcome. Nutrition education should ideally be provided within the context of a comprehensive, interdisciplinary
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PRACTITIONER POINTS
RATIONALE Obesity has reached epidemic proportions in this country. It is a progressive disease of multi-factorial origin. According to the findings of NHANES survey (1999-2008), 33.8 percent of all American adults are now obese and 68 percent are overweight. And, nearly 12.4 percent of children age 2 to 5 and 17 percent of children age 6 to 11 were overweight and 17.6 percent of adolescents were overweight in the NHANES survey (2003-2006). The prevalence of overweight and obese adults from 1960-2 to 2005-6 has increased from 13.4 to 35.1 percent in U.S. adults age 20 to 75 (1). Surgical weight loss is reserved for morbidly obese patients who have been unsuccessful at less invasive, supervised attempts at weight loss. To be a candidate for the surgery, one must have one or more of the following criteria set forth by the 1991 National Institute of Health Consensus Statement: One must be morbidly obese, defined as anyone who is >100 lbs. over Ideal Body Weight (IBW), Body Mass Index (BMI) >40 kg/m2, or BMI >35 kg/m2 with comorbidities. Children and adolescents have not been sufficiently studied to allow a recommendation for surgery for them even in the face of obesity associated with BMI >40kg/m2 .
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The National Institute of Health Consensus Report in 1991 concluded, Surgery is the only effective therapy for long -term weight loss of individuals with morbid obesity. The Consensus further provided the
Bariatric Surgery
behavioral weight management program. loss tool as RYGBP because patients can still tolerate sweets and high calorie liquids, while patients with RYGBP experience dumping syndrome with those same foods (4). Studies show that patients typically will lose 50 percent of excess body weight. This surgery is not without potential risk, primarily staple line breakdown, which can lead to weight regain over time. Laparoscopic Adjustable Gastric Band LAGB restricts the size of the stomach by placing an adjustable silicone gastric band around the upper stomach, creating a small pouch. The new stomach pouch holds only a small amount of food, restricting the amount of food that can be eaten and making the individual feel full sooner and for a longer period of time. A hollow expandable band is connected to a saline reservoir by a thin tube that sits below the skin on the abdominal wall. The band can then be tightened by injecting additional saline or loosened by removing saline. If an individual fails to lose enough weight, additional saline can be added by syringe and needle to the access port site, located beneath the skin on the left side of the body. If an individual becomes ill and needs additional nutrition, loses too much weight, or becomes pregnant, saline can be removed from the ring, making the opening between the stomach pouch and the remainder of the stomach larger and allowing for increased food intake. The digestive process then continues normally without any malabsorption therefore decreasing the risk of vitamin deficiencies or anemia. This surgery is less invasive and reversible but does not promise the same results as RYGBP. The potential problems associated with this surgery are band slippage and band erosion. As with VBG, there is a learning curve associated with this surgery and more emphasis needs to be placed on behavior modification and the development of good nutrition practices (4).
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USE These dietary guidelines are for patients who will or have undergone VBG, LAGB, RYGBP or BPD for the treatment of clinically severe morbid obesity. RELATED PHYSIOLOGY Purely Restrictive Procedures Vertical Banded Gastroplasty VBG creates a small pouch (capacity of about 50 ml) by placing vertical rows of staples in the upper end of the stomach. The lower end of the vertical pouch created by the staple rows becomes the outlet of the new stomach and is encircled by a fine solid silicone ring which effectively prevents the 1.0 cm opening from ever enlarging.
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Ethicon Endo-Surgery, Inc. 2004 Food empties from the small food pouch into the stomach. Digestion and absorption are normal from that point (2, 3). The VBG has less risk of complications than the RYGBP because there is no malabsorption. Therefore the risk of vitamin deficiencies and anemia is almost unheard of. However, VBG is not as effective a weight
Bariatric Surgery
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Ethicon Endo-Surgery, Inc. 2004
Biliopancreatic Diversion (BPD) The stomach pouch created with this surgery is much smaller than with other procedures. The goal is to restrict the amount of food consumed and alter the normal digestive process, but to a much greater degree. The anatomy of the small intestine is changed to divert the bile and pancreatic juices so they meet the ingested food closer to the middle or the end of the small intestine. BPD removes approximately 3/4 of the stomach to produce both restriction of food intake and reduction of acid output. Leaving enough upper stomach is important to maintain proper nutrition. The small intestine is then divided with one end attached to the stomach pouch to create what is called an "alimentary limb." All the food moves through this segment though not much is absorbed. The bile and pancreatic juices move through the "biliopancreatic limb," which is connected to the side of the intestine close to the end. This supplies digestive juice in the section of the intestine now called the "common limb." The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat and fat-soluble vitamins.
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Biliopancreatic Diversion with "Duodenal Switch" (BPD/DS) This procedure is a variation of BPD in which a larger pouch is created. The pylorus between the stomach and small intestine is left unchanged. The duodenum is divided so that pancreatic and bile drainage is bypassed. After division of the duodenum, one end is anastomosed to the distal end of the ileum creating the common limb. The other part is anastomosed to the distal ileum proximal to the ileocecal valve creating a proximal enteric limb. The individual who has the BPD/DS can eat more and weight loss is attributed to malabsorption.
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permitting the digestion of the food (2, 3).
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Ethicon Endo-Surgery, Inc. 2004 Roux-N-Y Gastric Bypass Surgery According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass (RYGBP) is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States. The Roux-N-Y procedure divides the stomach with horizontal rows of staples to create a small food pouch (measured capacity of <50 ml at the upper end of the stomach). A new opening of about 1.0 cm diameter is made in the small portion of the stomach. The proximal small intestine is then divided close to its commencement and the lower divided end brought up and joined to the new stomach opening creating a gastroenterostomy. The upper divided end is connected into the jejunum 40-100 cm below the gastroenterostomy.
Roux-N-Y Gastric Bypass
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Food entering the new small stomach causes a sensation of fullness, and then slowly empties into the intestine through the new small outlet. This re-routing causes food to bypass the lower part of the stomach. Digestive juices from the lower stomach and duodenum flow to mix with food through the new jejunal hook-up lower down, thus
With the arrangement of the new hookup between the stomach pouch and intestine, gastric contents enter the jejunum directly after leaving the stomach pouch. When concentrated sweets are ingested the result is hypertonicity of the jejunal contents, which in turn, produces a rapid influx of fluids drawn from the plasma and extracellular fluid. This causes intestinal distention, a drop in circulating blood volume with a subsequent decrease in cardiac output and a release of vasoactive peptides. This produces symptoms known as Dumping Syndrome. This syndrome is characterized by gastrointestinal symptoms of epigastric fullness, nausea, abdominal cramping, diarrhea and vasomotor symptoms of flushing, sweating, weakness, tachycardia and postural hypotension (2, 5). These symptoms are considered an advantage not a disadvantage of the RYGBP because they discourage the patient from eating high calorie, low nutrient sweet foods. There is a learning curve associated with this surgery and more emphasis needs to be placed on behavior modification and the development of good nutrition practices.
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Metabolic Syndrome
Written by: Elaine M. Jansak, MS, RD, LD/N, CDE, Consultant Dietitian Reviewed by: Sarah Hall, RD, LD/N, CNSD, Clinical Nutrition Manager at Shands at AGH the success of these lifestyle changes and the addition of a few specific recommendations. ICD-9-CM code 277.7 is the classification code given for treatment of "Metabolic Syndrome X" (4). Medical Nutrition Therapy (MNT) goals for Metabolic Syndrome depend on the presenting criteria. Specifically, they are to achieve euglycemia, weight loss and a healthy body weight, optimal lipid levels, and normal blood pressure through diet, exercise and healthy lifestyle changes. USE Metabolic Syndrome is diagnosed when three out of five qualifying criteria are present (see Table 1) (1). Prevention and treatment of Metabolic Syndrome significantly decreases the onset of obesity-related illnesses, Type 2 Diabetes Mellitus (Type 2 diabetes) and Cardiovascular diseases (1). Major causes for Metabolic Syndrome include poor nutrition, excess weight, and lack of exercise. Dietary alterations and other lifestyle changes reduce the incidence of this syndrome and corresponding disease states. METABOLIC SYNDROME Metabolic Syndrome is so named because of the complexity of the contributing criteria. General features include abdominal and intra-abdominal fat leading to large waist circumference and sometimes obesity, hyperlipidemia, blood pressure (BP) of at least 130/80 mm Hg, and insulin resistance measured as impaired fasting glucose or impaired glucose tolerance (see Figure 1). Often an inflammatory state is also present, which can accelerate artery degeneration and the onset of cardiovascular diseases (1). More specific than overall obesity, Metabolic Syndrome is related to the central distribution of fat, including abdominal and intra-abdominal fat, especially if insulin resis-
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RATIONALE The Metabolic Syndrome criteria was recently defined by the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of Blood Cholesterol in Adults (Adult Treatment Panel III or ATP III) (1). Prevalence of Metabolic Syndrome is quite high. The Centers for Disease Control (CDC) estimate that 40 - 50 percent of Americans over the age of 50 have Metabolic Syndrome (2). Prevalence increases with age, but the syndrome in adults is documented as young as 20 years old (24 percent of Americans over the age of 20. Potentially 47 million Americans have Metabolic Syndrome (2). Metabolic Syndrome needs to be diagnosed and treated in order to decrease mortality related to chronic disease. Despite the knowledge that there are some genetic factors in insulin resistance, treatment of Metabolic Syndrome should not be deferred. Triglyceride-rich lipoprotein cholesterol is especially athrogenic (called non-HDL cholesterol), and ideally should be treated prior to Metabolic Syndrome risk factors (1). In studies around the world, intensive individual counseling on weight reduction, food intake, and physical activity has been found to decrease the incidence of further metabolic disease by 58 percent (3). Weight reduction and physical activity will be the main therapeutic goals for persons with Metabolic Syndrome. Other risk factors will most commonly decrease with
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tance is a factor. The general features of this syndrome have been reviewed extensively. Names used include "Syndrome X", "Dysmetabolic Syndrome", MetSyn, or "Dysmetabolic Syndrome X" (4-7). Persons with Metabolic Syndrome are identified as candidates for intensified Therapeutic Lifestyle Changes (TLC) (1). Exercise and good stress management techniques are required for TLC, but an overall review of food choices, including a medical nutrition therapy assessment of food and behaviors is the foundation of treatment. Untreated, Metabolic Syndrome progresses to hypertension, cardiovascular disease, Type 2 diabetes, and the chronic complications leading from these illnesses. For additional information on these diseases, see the appropriate sections of this manual. Table 1Risk Factors / Criteria Metabolic Syndrome 1. Abdominal circumference: >than 35 inches (88 cm) for women >than 40 inches (102 cm) for men 2. Glucose (serum) of at least: 110 mg/dL (fasting or oral glucose tolerance) 3. Triglycerides (serum) of at least 150 mg/dL RELATED PHYSIOLOGY Metabolic Syndrome develops with metabolic slowing of the body (for instance from increased calories and decreased exercise) or metabolic disorder for other reasons (smoking, alcohol, hormonal). Overall, less glucose is used for fuel, free fatty acids are created and glucose is stored as triglycerides. A decrease of high density lipoproteins (HDLs) occurs as lipids shift from glucose metabolism to lipogenesis. Increased fat storage expands fat cells, which in turn, increases body fat. The increase of body fat heightens blood pressure and insulin resistance. Insulin resistance creates a greater storage of fats by triglycerides, increasing circulating free fatty acids and vascular pressure. Although complex, this is essentially the metabolic criteria for the syndrome. Although excess body fat and physical inactivity promote the development of insulin resistance, some individuals are at higher genetic risk (1). Other metabolic changes also occur. Coagulation factors and cytokines change the vasculature and release inflammatory markers. These also relate to a higher risk of hypertension, stroke, and cardiovascular disease (8). However, even without apparent cardiovascular disease, treatment of Metabolic Syndrome will decrease the risk of diabetes. Weight gain and increased hunger (a sign of insulin resistance) is one of the precursors that may be observed by the individual at risk for obesity, pre-diabetes, and Metabolic Syndrome. Complaints of increased weight, hunger and abdominal girth should be taken seriously and the individual should be screened for additional risk factors. If biochemical laboratory data determine three out of five risk factors or criteria is met, treatment regimens for Metabolic Syndrome will be initiated. In absence of Metabolic Syndrome, individuals should still be encouraged to make TLC changes towards optimal health.
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(HDL)
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4. High Density Lipoprotein Cholesterol: <50 mg/dL for women <40 mg/dL for men 5. Blood pressure (BP) of at least 130/85 mm Hg.
A combination of three or more risk factors must be present for diagnosis and treatment (1). Although any risk factor alone may increase the risk of chronic illness.
Nutrition Resources Online

Written by: Susan Burke MS, RD, LD/N, CDE VP Nutrition Services, eDiets.com Reviewed by: Pamela Ofstein, MS, RD, LD/N, Manager of Nutrition Product Development, eDiets.com the data they are reading. Guidelines for Evaluating Health Information on the Internet
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PRACTITIONER POINTS
Guide to Online Resources for Nutrition Professional According to the National Center for Health Statistics, 51% of adults aged 18-64 had used the Internet to look up health information between January June 2009. The Internet provides valuable information for users seeking health information, and can be a tool for educators to easily access the most current standards of care and professional policies. Sifting through the large number of websites to access credible information can be daunting. There are no uniform guidelines for online quality assessment of Web-based health information for consumers. However, online resources are available to help guide you to reliable and reputable Websites. Finding information on the Web is easy, finding credible and reliable information is not always guaranteed. The Health on the Net Foundation and The American Dietetic Association www.eatright.org are just two of many nonprofit organizations that publish guidelines for use in evaluating the quality of health information provided on the Internet. Look for websites that subscribe to The Health on the Net Foundation http:// www.hon.ch/Global. These companies promise to adhere to a Code of Conduct to help standardize the reliability of medical and health information available on the World-Wide Web. The HON code defines a set of rules to: hold Web site developers to basic ethical standards in the presentation of information, and help make sure readers always know the source and the purpose of
Web sites that end in .edu (defines an educational institution) or .gov (defines government agencies) are credible Web sites, containing current and accurate information. Web sites ending in .org (defines organizations, often nonprofit) also can be a good source of information. Commercial websites ending in .com (defines commercial sites) can be a good source of information. Websites requiring personal information should have a privacy policy posted. Is information about the security of the site clearly stated? This is especially important if the site asks you to fill in forms with personal health information such as your age, medical condition, or medications for which you would like information. There should be a clear statement that personal health information you share with the site is not made available to other organizations or companies. Authors and contributors should post their credentials, and affiliations. Qualified nutrition experts include Registered Dietitians (RD) or Medical or Osteopathic Physicians (MD or DO) and affiliations with nationally known health organizations such as the American Dietetic Association (ADA), the American Medical Association (AMA), or the American Heart Association (AHA). Information should be factual, with references cited. Scientific studies should have publication, year, page and author included.
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Food Labeling
Written by: Molly Gladding, RD, LD/N, West Palm Beach Reviewed by: Judith Cooper, MS, MBA, RD, LD/N. Senior Nutritionist, Palm Beach County Health Department nutrients or carried nutrition claims. Other than adding sodium as a mandatory listing and potassium as a voluntary listing, the nutrition label remained the same for almost 20 years. Efforts to overhaul the program came from consumers, regulators, professional groups and Congress. As consumers became more interested in nutrition, the efforts increased. The industry argued, Nutrition doesnt sell food. Price, taste and convenience sell food. During the 1980s it was clear that Nutrition does sell food and health claims were becoming widespread. In the late 1980s the Surgeon General released two reports (1998 Surgeon Generals Report on Nutrition and Health; 1989 National Research Councils Diet and Health: Implications for Reducing Chronic Disease Risk) that lent strong support to the development of a new labeling system. These reports put forth evidence of a direct relationship between diet and chronic disease. This evidence combined with questionable health claims led to the first serious effort to revamp the food label. In 1990 the Nutrition Labeling and Education Act (NLEA) became law. The law makes the United States the first country in the world to have mandatory food labeling and to allow labels to carry health claims. Exemptions Under NLEA, foods exempt from the law include: Foods available for immediate consumption (hospital cafeterias, airline food, and vendors such as vending machines, sidewalk vendors, and all cookie counters) Food prepared primarily on site and readyto-eat food that is not for immediate consumption (bakery, deli, candy store,
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PRACTITIONER POINTS
RATIONALE The Food and Drug Administration is responsible for the implementation and enforcement of the Nutrition Labeling and Education Act of 1990. The regulations, implemented in 1994, were intended to insure that: Most foods contain nutrition information labeling Labels will provide guidance on how a food fits into a daily diet Information will be presented on nutrients of health concern to todays consumers Government definitions are established for terms used to describe a foods nutrient content Health claims that relate to nutrient content will be supported by scientific evidence Serving sizes are more consistent across product lines, are expressed in household and metric measures and better reflect the amounts that people eat Provide a declaration of total percentage of juice in juice drinks Food labeling is mandatory for most processed foods and is voluntary for raw produce and fish
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History The 1990 law represented the first extensive change to the food labeling laws since the voluntary nutrition labeling laws enacted in 1974. The original act only addressed products that contained added
Dietary Reference Intakes

Written by: Sally E. Weerts, PhD, RD, Jacksonville Reviewed by: Helen L. Curtis, RD, LD/N, CDE, Nutrition Consultant and Independent Contractor, Interlachen and policy using EARs.
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Goal #3: Establish upper-limit safety guidelines as ULs. Goal #4: Prevent chronic diseases by linking newer research about nutrient and non-nutrient levels that prevent disease and promote health.
PRACTITIONER POINTS
OVERVIEW The Dietary Reference Intakes (DRIs) represent four separate tables, each of which is designed to estimate quantities of nutrients needed in the average daily diet by normal, healthy populations living in the U.S. and Canada. The most well known of the four tables is the Recommended Dietary Allowances (RDAs), joined by the Estimated Average Requirement (EAR), Adequate Intakes (AIs), and the Tolerable Upper Intake Levels (ULs) (1-3). The DRIs have three general purposes. First, they provide sets of values used by professionals to plan policy and assess daily diets of individuals and populations. Values are for males and females from infancy to >70 years of age and for conditions of pregnancy and lactation. Second, the DRIs are used to set standards for diet planning tools like the U.S. food labels and MyPyramid (4). Third, these help to interpret data gathered from population studies and clinical research to learn about nutritional inadequacies and excesses that may be of interest or concern (5).
THE RDAs, EAR, AIs, and ULs The RDAs are the levels of essential nutrients that are judged to be adequate to meet the known nutrient needs of practically all healthy persons (1). These are calculated from scientific data to meet the needs of nearly all healthy people as they are adjusted upward to allow for individual differences and bioavailability of nutrients. The EAR is the level of a nutrient that is estimated to meet the nutrient requirement of one-half of the healthy individuals in each grouping. The RDA can be set only for those nutrients with an EAR. When there is insufficient scientific evidence to calculate an EAR, an AI is set, rather than an RDA, and used as a goal. The AIs are set through observations or scientific estimates at levels needed to maintain health and/or growth. For example, the AIs in early infancy are based on the daily mean nutrient intake supplied by human breast milk. The ULs, on the other hand, are the highest level of nutrients on a daily basis that pose no risk of adverse health effects. These values are not recommendations but are used to provide guidance for fortification and other uses beyond the RDAs. UPDATE Sets of DRIs are a work in progress. In September 2002, new DRIs were released for energy, including Estimated Energy
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GOALS The DRI committee, made up of experts from the U.S. and Canada, established four goals toward setting the appropriate nutrient intake levels (6, 7). These are:
Goal #1: Set adequate recommended intake values as an RDA and/or AI. Goal #2: Facilitate nutrition research
Manual of Florida Medical Nutrition Therapy 2011 Edition

Requirements for four different activity levels; and for the Acceptable Macronutrient Distribution Ranges of 45 to 65% for carbohydrate, 10 to 35% for protein, and 20 to 35% for fat. These join DRIs for the antioxidants (carotenoids, selenium, and vitamins A and E), bones (calcium, phosphorus, magnesium, vitamin D, and fluoride); for the B vitamins, choline, vitamins A, and K, and the trace elements. New RDAs for carbohydrate and protein have also been established as have new AIs for total water and the electrolytes sodium, potassium and chloride (on an equi-molar basis to sodium); fiber and essential fatty acids. Last, new ULs have been established for sodium and chloride. Current DRIs by nutrient are shown on the following tables. (8) REFERENCES 1. National Research Council, Food and Nutrition Board. Recommended Dietary Allowances, 10th Edition. Washington, D.C. National Academy Press, 1989. 2. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, D.C. National Academy Press, 1997. 3. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B-6, Folate, Vitamin B-12, Pantothenic Acid, Biotin, and Choline. Washington, D.C. National Academy Press, 1998. 4. U.S. Department of Agriculture. The Food Guide Pyramid revised 2000. http:// www.mypyramid.gov/pyramid/index.html. Accessed January 19, 2011.. 5. Smolin, L.A. and Grosvenor. M.B. Nutrition: Science and Applications, 4th Edition. John Wiley & Sons, Inc, 2003. 6. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine, Dietary Reference Intakes: Applications in Dietary Assessment Washington, D.C.: National Academy Press, 2000. 7. Sizer, F. and Whitney, E. Nutrition Concepts and Controversies, 9th Edition. Thomson Wadsworth, 2003. 8. Food and Nutrition Information Center. Dietary Reference Intakes. http:// fnic.nal.usda.gov/nal_display/index.php? info_center=4&tax_level=3&tax_subject= 256&topic_id=1342&level3_id=5140&le vel4_id=0&level5_id=0&placement_defa ult=0. Accessed: January 19, 2011.
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DIETARY REFERENCE INTAKES: MACRONUTRIENTS
Nutrient Function Life Stage Group Infant 0-6 mo 7-12 mo Children 1-3 y 4-8 y Males 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Females 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Pregnancy < 18 y 19-30 y 31-50 y Lactation < 18 y 19-30 y 31-50 y Infant 0-6 mo 7-12 mo Children 1-3 y 4-8 y Males 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Females 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Pregnancy < 18 y 19-30 y 31-50 y Lactation < 18 y 19-30 y 31-50 y RDA/AI * (g/d) 60* 95* 130 130 130 130 130 130 130 130 130 130 130 130 130 130 175 175 175 210 210 210 ND ND AMDRa Selected Food Sources Adverse Effects of Excessive Consumption While no defined intake level at which potential adverse effects of total digestible carbohydrate was identified, the upper end of the adequate macronutrient distribution range (AMDR) was based on decreasing risk of chronic disease and providing adequate intake of other nutrients. It is suggested that the maximal intake of added sugars be limited to providing no more than 25% of energy.
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Cabohydrate Total digestible
RDA based on its role as the primary energy source for the brain: AMDR based on its role as a source of kilocalories to maintain body weight
NDb ND 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65
Starch and sugar are the major types of carbohydrates. Grains and vegetables (corn, pasta, rice, potatoes, breads) are sources of starch. Natural sugars are found in fruits and juices. Sources of added sugars are soft drinks, candy, fruit drinks, and desserts.
Total Fiber
Improves laxation, reduces risk of CHD, assists in maintaining normal blood glucose levels.
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19* 25* 31* 38* 38* 38* 30* 30* 26* 26* 25* 25* 21* 21* 28* 28* 28* 29* 29* 29*
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Includes dietary fiber naturally present in grains (such as found in oats, wheat, or unmilled rice) and functional fiber synthesized or isolated from plants or animals and shown to be of benefit to health.
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Dietary fiber can have variable compositions and therefore it is difficult to link a specific source of fiber with a particular adverse effect, especially when phytates is also present in the natural fiber source. It is concluded that as part of an overall healthy diet, a high intake of dietary fiber will not produce deleterious effects in healthy individuals. While occasional adverse GI symptoms are observed when consuming isolated or synthetic fibers, serious chronic adverse effects have not been observed. Due to bulky the nature of fibers, excess consumption is likely to be self-limiting. Therefore, a UL was not set for individual functional fibers.
Note: The table is adapted from the DRI reports, see www.nap.edu. It represents Recommended Dietary Allowances (RDAs) in bold type, Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). RDAs and AIs can both be used as goals for individual intake. RDAs are set to meet the needs of almost all (97-98%) individuals in a group. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover the needs of all individuals in the group, but lack of data prevent being able to specify with confidence the percentage of individuals covered by this intake. A Acceptable Macronutrient Distribution Range (AMDR)A is the range of intake for a particular energy source that is associated with reduced risk of chronic disease while providing intakes of essential nutrients. If an individual consumes excess of the AMDR, there is potential of increasing risk of chronic disease and/or insufficient intakes of essential nutrients. BND= Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake. SOURCES: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005). This report may be accessed via www.nap.edu

Nutrient Function Life Stage Group Infant 0-6 mo 7-12 mo Children 1-3 y 4-8 y Males 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Females 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Pregnancy < 18 y 19-30 y 31-50 y Lactation < 18 y 19-30 y 31-50 y Infant 0-6 mo 7-12 mo Children 1-3 y 4-8 y Males 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Females 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Pregnancy < 18 y 19-30 y 31-50 y Lactation < 18 y 19-30 y 31-50 y RDA/AI * (g/d) 31* 30* 30-40 25-35 25-35 25-35 20-35 20-35 20-35 20-35 25-35 25-35 20-35 20-35 20-35 20-35 20-35 20-35 20-35 20-35 20-35 20-35 NDb ND AMDRa Selected Food Sources Adverse Effects of Excessive Consumption While no defined intake level at which potential adverse effects of total fat was identified, the upper end of AMDR is based on decreasing risk of chronic disease and providing adequate intake of other nutrients. The lower end of the AMDR is based on concerns related to the increase in plasma triacyglycerol concentrations and decreased HDL cholesterol concentrations seen with very low fat (and thus high carbohydrate) diets.
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Total Fat
Energy source and when found in foods, is a source of n-6 and n-3 polyunsaturated fatty acids. Its presence in the diet increases absorption of fat soluble vitamins and precursors such as vitamin A and pro-vitamin A carotenoids.
Butter, margarine, vegetable oils, whole milk, visible fat on meat and poultry products, invisible fat in fish, shellfish, some plant products such as seeds and nuts, and bakery products.
n-6 polyunsaturated fatty acids (linoleic acid)
Essential component of structural membrane lipids, involved in cell signaling and precursor of eicosanoids. Required for normal skin function.
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4.4* 4.6* 7* 10* 12* 16* 17* 17* 14* 14* 10* 11* 12* 12* 11* 11* 13* 13* 13* 13* 13* 13*
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5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10
Nuts, seeds, and vegetable oils such as soybean, safflower, and corn oil.
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While no defined intake level at which potential adverse effects of n-6 polyunsaturated fatty acids was identified, the upper end of the AMDR is based on the lack of evidence that demonstrates longterm safety and human in vitro studies which show increased free-radical formation and lipid peroxidation is thought to be a component in the development of atherosclerotic plaques.

Nutrient Function Life Stage Group Infant 0-6 mo 7-12 mo Children 1-3 y 4-8 y Males 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Females 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Pregnancy < 18 y 19-30 y 31-50 y Lactation < 18 y 19-30 y 31-50 y Infant 0-6 mo 7-12 mo Children 1-3 y 4-8 y Males 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Females 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Pregnancy < 18 y 19-30 y 31-50 y Lactation < 18 y 19-30 y 31-50 y RDA/AI * (g/d) 0.5* 0.5* 0.7* 0.9* 1.2* 1.6* 1.6* 1.6* 1.6* 1.6* 1.0* 1.1* 1.1* 1.1* 1.1* 1.1* 1.4* 1.4* 1.4* 1.3* 1.3* 1.3* ND ND AMDRa Selected Food Sources Adverse Effects of Excessive Consumption While no defined intake level at which potential adverse effects of n-3 polyunsaturated fatty acids was identified, the upper end of AMDR is based on maintaining appropriate balance with n-6 fatty acids and on the lack of evidence that demonstrates longterm safety, along with human in vitro studies which show increased freeradical formation and lipid peroxidation with higher amounts of polyunsaturated fatty acids. Lipid peroxidation is thought to be a component in the development of atherosclerotic plaques.
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n-3 Polyunsaturated fatty acids (-linolenic acid)
Involved with neurological development and growth. Precursor of eicosanoids.
NDb ND 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2
Vegetable oils such as soybean, canola, and flax seed oil, fish oils, fatty fish, with smaller amounts in meats and eggs.
Saturated and trans fatty acids, and cholesterol
No required role for these nutrients other than as energy sources was identified; the body can synthesize its needs for saturated fatty acids and cholesterol from other sources.
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Saturated fatty acids are present in animal fats (meat fats and butter fat) and coconut and palm kernel oils. Sources of cholesterol include liver, eggs, and foods that contain eggs such as cheesecake and custard pies. Sources of trans fatty acids include stick margarines and foods containing hydrogenated or partially-hydrogenated vegetable shortenings.
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There is an incremental increase in plasma total and low-density lipoprotein cholesterol concentrations with increased intake of saturated or trans fatty acids or with cholesterol at even very low levels in the diet. Therefore, the intakes of each should be minimized while consuming a nutritionally adequate diet.

Nutrient Function Serves as the major structural component of all cells in the body and functions as enzymes in membranes, transport carriers, and as some hormones. During digestion and absorption dietary proteins are broken down to amino acids which becomes the building blocks of these structural and functional compounds. Nine of the amino acids are must be provided in the diet; these are indispensable amino acids. The body canmakethe other amino acids needed to synthesize specific structures from other amino acids. Life Stage Group Infant 0-6 mo 7-12 mo Children 1-3 y 4-8 y Males 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Females 9-13 y 14-18 y 19-30 y 31-50 y 50-70 y > 70 y Pregnancy < 18 y 19-30 y 31-50 y Lactation < 18 y 19-30 y 31-50 y RDA/AI * (g/d)a 9.1* 11.0 13 19 34 52 56 56 56 56 34 46 46 46 46 46 71 71 71 71 71 71 AMDRb Selected Food Sources Adverse Effects of Excessive Consumption
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Protein and amino acids
NDc ND 5-20 10-30 10-30 10-30 10-35 10-35 10-35 10-35 10-30 10-30 10-35 10-35 10-35 10-35 10-35 10-35 10-35 10-35 10-35 10-35
Note: The table is adapted from the DRI reports, see www.nap.edu. It represents Recommended Dietary Allowances (RDAs) in bold type, Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). RDAs and AIs can both be used as goals for individual intake. RDAs are set to meet the needs of almost all (97-98%) individuals in a group. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover the needs of all individuals in the group, but lack of data prevent being able to specify with confidence the percentage of individuals covered by this intake.
A Based on 1.5g/kg/day for infants, 1.1g/kg/day for 1-3 y, 0.95 g/kg/day for 4-13 y, 0.85 g/kg/day for 14-18, 0.8 g/kg/day for adults, and 1.1 g/kg/day for pregnant (using pregnancy weight) and lactating women. B Acceptable Macronutrient Distribution Range (AMDR)A is the range of intake for a particular energy source that is associated with reduced risk of chronic disease while providing intakes of essential nutrients. If an individual consumes excess of the AMDR, there is potential of increasing risk of chronic disease and/or insufficient intakes of essential nutrients.
NDc= Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source
of intake should be from food only to prevent high levels of intake.
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Proteins from animal sources such as meat, poultry, fish, eggs, milk, cheese, and yogurt provide all nine indispensable amino acids in adequate amounts and for this reason are considered complete proteins. Proteins from plants, legumes, grains, nuts, seeds, and vegetables tend to be deficient in one or more of the indispensable amino acids area are called incomplete proteins. Vegan diets are adequate in total protein content can be complete by combining sources of incomplete proteins which lack different indispensable amino acids.
While no defined intake level at which potential adverse effects of protein was identified, the upper end of AMDR based on complementing the AMDR for carbohydrate and fat for the various age groups. The lower end of the AMDR is set at approximately the RDA.
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SOURCES: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005). This report may be accessed via www.nap.edu

Nutrient Function IOM/FNB 2002 Scoring Patterna Histidine Isoleucine Lysine Leucine Methionine & Cysteine Phenylalanine & Tyrosine Threonine Tryptophan Threonine Tryptophan Valine Valine Mg/g protein 18 25 55 51 25 47 27 7 32 Adverse effects of excessive consumption
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Indispensable amino acids: Histidine Isoleucine Lysine Leucine Methionine & Cysteine Phenylalanine & Tyrosine
The building blocks of all proteins in the body and some hormones. These nine amino acids must be provided in the diet and thus are termed indispensable amino acids. The body can make the other amino acids needed to synthesize specific structures from other amino acids and carbohydrate precursors.
Since there is no evidence that amino acids found in usual or even high intakes of protein from food present any risk, attention was focused on intakes of the L-form of these and other amino acids found in dietary protein and amino acid supplements. Even from well-studied amino acids, adequate dose-response data from human or animal studies on which to base an UL were not available. While no defined intake level at which potential adverse effects of protein was identified for any amino acid, this does not mean that there is no potential for adverse effects resulting from high intakes of amino acids from dietary supplements. Since data on the adverse effects of high levels of amino acid intakes from dietary supplements is limited, caution may be warranted.
Note: The table is adapted from the DRI reports, see www.nap.edu.
A Based on the amino acid requirements derived for Preschool Children (1-3 y): (EAR for amino acid EAR for protein); for 1-3 y group where EAR for protein= 0.88 g/kg/day.
SOURCES: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005). This report may be accessed via www.nap.edu
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Nutrition Guidelines and Recommended Eating Patterns

Written by: Linda Benjamin Bobroff, PhD, RD, LD/N, Professor, Department of Family, Youth and Community Sciences, Institute of Food and Agricultural Sciences, University of Florida. Reviewed by: Jennifer Hillan, MSH, RD, LD/ N, Clinical Dietitian, Pediatric Pulmonary Center, University of Florida Health Science Center, and R. Elaine Turner, PhD, RD, Associate Professor, Food Science and Human Nutrition Department, Institute of Food and Agricultural Sciences, University of Florida. future developments in response to the new food guidance system, MyPyramid. Our discussion of the Dietary Guidelines for Americans includes a brief history of Dietary Guidelines and a discussion of the current (sixth) edition. Finally, we include suggestions for how dietitians can help consumers use food guides to select foods for a healthful diet, and provide links to reliable on-line nutrition education resources. BRIEF HISTORY OF FOOD GUIDES The federal government has been involved in advising Americans about their diets since the late 1800s (1). Dietary recommendations for the healthy American population take the form of food guides, which are based on dietary standards such as the Dietary Reference Intakes (DRIs) and recommendations for healthful diets such as the Dietary Guidelines for Americans, generally referred to simply as the Dietary Guidelines (2-3).
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PRACTITIONER POINTS
INTRODUCTION This chapter focuses on dietary recommendations for persons who have no special dietary needs related to a medical condition or illness. Currently, the primary foundations of nutrition education for government agencies and dietetics professionals who work with healthy consumers are the Dietary Guidelines for Americans 2005 and the new food guidance system developed and recently released by the U.S. Department of Agriculture (USDA), which is called MyPyramid. In this chapter we begin with a brief history of food guides, leading to a discussion about the current food guidance system, MyPyramid. This latest food guide was included in table format in the Dietary Guidelines for Americans 2005, and formally introduced to the public with the now familiar graphic on April 19, 2005. We include information about MyPyramid for Kids, a graphic that is targeted to children six to eleven years old. We also review several of the food pyramids that have been developed over the past few years by various individuals, groups, and organizations. Since several of these food pyramids were developed to reflect different approaches to a healthful diet in response to USDA's Food Guide Pyramid, it will be of interest to follow
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In each food guide developed by the USDA since 1916, foods have been grouped according to their nutrient content, with foods having similar amounts of critical nutrients appearing in the same food group. Food guides suggest the amount of food from various food groups that will provide a healthful diet for people without special dietary needs. Over the past century, our definition of what constitutes a healthful diet evolved as scientific advances provided more information about human nutrient requirements and relationships between diet and health. USDA food guides changed significantly during this time to reflect these changes in knowledge as well as changes in nutrition and health concerns of the healthy population (1, 4). Early food guides were designed to help the population meet basic nutrient needs such as calories, protein, and fat. The emphasis was on getting enough to eat, and

in times of want such as the Depression in the 1930s and during World War II, USDAs food economists included strategies for using scarce resources efficiently (1, 4). To this day, USDA provides food plans at various cost levels, including the Thrifty Food Plan to meet the needs of limited resource families (5). When the first edition of the Recommended Dietary Allowances (RDAs) was published in 1941, the National Research Council committee included a food guide, developed in cooperation with USDA, which showed how to meet the new RDAs and prevent nutrient deficiencies (1, 4). One of the most enduring of USDAs food guides was The Basic Four, introduced in 1956. This food guide provided a foundation diet, and it was the basis of nutrition education for more than 20 years (1). As the relationship between diet and the risk of the major chronic diseases began to emerge in the 1970s, USDA added a fifth food group, fats, sweets, and alcohol, to emphasize that certain foods were to be consumed only in moderation (1). After publication of the first edition of the Dietary Guidelines for Americans, a new food guide called A Pattern for Daily Food Choices was introduced in 1986 (6). This food guide was intended to help people select a total diet that was consistent with the Dietary Guidelines (7-8). A Pattern for Daily Food Choices introduced an eating plan that was moderate in nutrients of concern, fats, sodium, and sugars, and that could reduce the risk of obesity, cardiovascular disease, and some forms of cancer. The new food guide was designed to promote overall health of Americans two years of age and older, and to be usable by consumers with varying eating styles and lifestyles (7). The food guide emphasizes foods of plant origin, including grain products (especially whole grains), fruits, and vegetables, by recommending the largest number of servings from these three food groups. Fewer servings of dairy products and protein-rich foods are included, while fats, sweets, and alcoholic beverages are to be consumed only in moderation (8). A Pattern for Daily Food Choices appeared in USDA publications beginning in the mid 1980s, but was not widely recognized until the Food Guide Pyramid was released in 1992 (9, 10). THE FOOD GUIDE PYRAMID The Pattern for Daily Food Choices food guide was represented graphically as the Food Guide Pyramid, which was released in 1992, and used until USDA introduced its new food guidance system in 2005 (9-10). The Food Guide Pyramid was designed to help people select foods to obtain the nutrients they need while controlling their intake of fat, saturated fat, cholesterol, sugars, and sodium, in accordance with the Dietary Guidelines. The number of servings recommended within each food group was given as a range, to reflect different calorie needs among persons based on age, gender, size, and activity levels. The intent was for people to select the number of servings from each food group that would allow them to meet their calorie needs.
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Many consumers did not understand this recommendation and were confused by the range of servings given for each food group, and even by the concept of serving. USDA addressed this confusion with publications such as How Much Are You Eating? which examined servings, "a standard amount used to help give advice about how much to eat, or to identify how many calories and nutrients are in a food versus portions, "the amount of food you choose to eat. There is no standard portion size and no single right or wrong portion size." (11). Nutrition educators spent much time and effort helping consumers sort out servings and portions, and it became clear that servings needed to be omitted from the food guidance system, and that is exactly what USDA did in MyPyramid.

MYPYRAMID Since the Food Guide Pyramid was developed, the Dietary Guidelines have been evaluated and updated twice, and new nutritional standards (DRIs) have been established. USDA spent several years working on revisions to its food guidance system to ensure that it continues to be based on current and sound science and that it is relevant to todays consumers. To that end, the revision of the food guidance system was coordinated with development of the Dietary Guidelines for Americans 2005 (12). On April 19, 2005, USDA unveiled MyPyramid, not only a new symbol, but also a more personalized and interactive food guidance system that is designed to help people make healthier food and physical activity choices for healthy lifestyles that are consistent with the Dietary Guidelines (1213). As with the Dietary Guidelines, the recommendations of MyPyramid are designed to be used together, and as a whole they would result in the following changes from a "typical" diet:
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The new food guide has three key messages: 1. Make smart choices within and among the food groups. 2. Keep a balance between food intake and physical activity. 3. Get the most nutrients from your calories. Although the first key message is not new, there is a stronger focus on variety within the food groups in MyPyramid, compared with the Food Guide Pyramid. The emphasis on physical activity is clear from the change in the graphic, with the steps and the person walking up the steps demonstrating the importance of physical fitness as well as calorie balance for weight control. The third key message focuses on nutrient density, getting the most nutrients from calories eaten (13). This is particularly important with our aging population, since calorie needs decrease with age, while the need for most nutrients either stays the same or increases. To avoid weight gain with age, baby boomers and older persons need to eat a nutrient dense diet and include up to 60 minutes of moderate to vigorous physical activity most days of the week (3, 13).
Increased intake of vitamins, minerals, dietary fiber, and other essential nutrients, especially those that are often low in "typical" diets. Lowered intake of saturated fats, trans fats, and cholesterol and increased intake of fruits, vegetables, and whole grains to decrease risk for some chronic diseases. Calorie intake balanced with energy needs to prevent weight gain and/or promote a healthy weight. USDA provides extensive background information for nutrition and health professionals in the "For Professionals" link on the website MyPyramid.gov. The following is a brief overview of the MyPyramid food guidance system, which can be supplemented with materials from the website.
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The six colored bands of MyPyramid represent the need for variety in food choices. In order from left to right, the bands represent the Grains, Vegetables, Fruits, (Oils, not a major food group), Milk, and Meat and Beans food groups. By selecting recommended amounts of foods from each food group based on calorie needs, consumers will get a wide variety of nutrients, phytochemicals, and an appropriate calorie intake to attain or maintain a healthy body weight (13). MyPyramid looks as though the Food Guide Pyramid was pushed over, and that is essentially what USDA did to create the new graphic. You can see this transformation demonstrated in a short animated feature on the website. The vertical bands of the food

groups that get narrower from the bottom to the top symbolize that in each food group there are foods that should be chosen more often than others, based on nutrient content. The healthier choices are those with little or no solid fats or added sugars, and they should form the base of our diets. Foods from various food groups that contain solid fat and/or added sugars can be eaten, but less often to enjoy a diet that promotes good health. We visualize these foods at the tip of the appropriate food group bands. Persons who are more active can fit more foods from the upper part of the pyramid into their diets. This concept of moderation can be applied to sodium content of foods, with high sodium foods visualized toward the top of the food bands. This may be a hard concept for consumers to grasp, and a challenging one for nutrition educators to teach. The different widths of the food group bands represents proportionality, or the relative amounts of food recommended from each food group. The widest bands are those representing the Grains, Milk, and Vegetable groups, with Fruit a close fourth. Consuming recommended intakes from these food groups will provide a variety of nutrients and dietary fiber and help reduce risk of chronic diseases and conditions, including hypertension, osteoporosis, and coronary heart disease (13). The Educational Framework provided on the MyPyramid.gov website section designated "For Professionals," organizes key concepts of the food guide into twelve topic areas, with each describing what actions should be taken for a healthy diet, how these actions can be implemented by consumers, and why each action is important for health. These are not meant to be consumer messages, but rather background information that health professionals can use to develop targeted messages and educational materials for clients and consumers. MyPyramid emphasizes that "one size does not fit all." According to USDA, MyPyramid "symbolizes a personalized approach to healthy eating and physical activity." This personalized approach is demonstrated by three components of the MyPyramid graphic, the person climbing the stairs, the slogan "Steps to a Healthier You," and the website address MyPyramid.gov, where consumers can obtain a personalized food guide representing their calorie needs. Since people have different calorie needs, USDA developed a food guidance system that includes 12 different calorie levels, from 1,000 to 3,200 calories/day. Consumers can estimate their calorie needs by entering their age, gender, and activity level into MyPyramid Plan at the MyPyramid.gov website. They then obtain a food guide customized to their calorie level that indicates how much to eat from each of the food groups. As mentioned above, this food guidance system does not mention servings; rather, the recommendations are given in total amount of food to eat for the day from each food group, in household measures such as cups and ounces (13). Calorie values generated in MyPyramid Plan are based on persons of average height at a healthy weight, so consumers may need assistance adjusting their food intake to be more realistic for them. Also, they can adjust their food intake if they would like to lose or gain weight. Food guides at the 12 different calorie levels may be downloaded from the MyPyramid.gov website. The slogan, Steps to a Healthier You, encourages consumers to make gradual changes to improve their diets and lifestyles. The slogan emphasizes that taking small steps can lead to significant changes in lifestyle and health. This is a very positive message to present to clients and consumers, as they dont have to feel overwhelmed and under pressure to change overnight. When using the MyPyramid symbol,
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dietitians should be aware that USDA has provided standards that should be carefully followed in order to provide consistent messages and appearance of the symbol, and to avoid consumer confusion. The MyPyramid Graphic Standards relate to size, color, maintaining integrity of the food bands widths and colors, and avoiding product, program or other types of promotions associated with MyPyramid. MYPYRAMID FOR KIDS MyPyramid for Kids also was released in 2005. It presents simplified nutrition messages that are geared toward the food preferences and nutrient needs of children aged six to eleven. The basic format of MyPyramid for Kids is the same as for MyPyramid, with vertical bands representing the five food groups, plus oils, and the stairs symbolizing physical activity. Rather than the slogan "Steps to a Healthier You," MyPyramid for Kids has "Eat Right. Exercise. Have Fun." A variety of kid-friendly foods are pictured on the graphic, and diverse children are pictured in active play, emphasizing the importance of daily physical activity for young children. Two messages are included, "Find your balance between food and fun" and "Fats and sugars, know your limits." These are positive messages that communicate that physical activity is fun, and that fats and sugars are not off limits, but that intake should be limited for good health. vegetarians, and various ethnic groups have been developed by individuals, agencies, and organizations, although most of these lack the type of extensive research and development process that was used to prepare USDA's Food Guide Pyramid, and subsequently, MyPyramid. In addition, a Mediterranean food guide has received quite a bit of media attention. This section provides brief descriptions of some of the pyramids that are readily available for use in educating consumers about healthy approaches to their daily diet. (Note: USDA's Food Guide Pyramid for Young Children (14) has been replaced by MyPyramid for Kids and will not be addressed in this review.) As stated in the Introduction, it will be of interest to see if any of these "alternative" food pyramids are adapted in response to the release of MyPyramid by USDA. Older Adults. Researchers at the Tufts University Center on Nutrition and Aging developed a prototype of a pyramid for persons over age seventy, which they published in the Journal of Nutrition in 1999, to stimulate discussion and further research in this area (15). The need for a pyramid targeted to older adults was clear when nutrition educators began using the Modified Food Guide Pyramid for People Over Seventy Years of Age, or modified versions, in their work with older adults (16). Special features of this pyramid include, a.) slimmer size to represent lower calorie needs, b.) addition of water at the base of the pyramid due to concerns about hydration status, c.) symbols representing fiber in several food groups to encourage consumption of high fiber foods, and d.) notation that calcium, vitamin D and vitamin B12 supplements may be needed. A pyramid adapted at the University of Florida in 2000, for a statewide Extension program, Elder Nutrition and Food Safety (ENAFS), which is targeted to older persons participating at congregate nutrition sites, includes many of the adaptations described by the researchers at Tufts University, along
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The back of the mini poster, which is downloadable from the MyPyramid website, includes fourteen "Tips for Families," divided into two categories: Eat Right and Exercise. VARIATIONS ON THE FOOD GUIDE PYRAMID Although USDA's Food Guide Pyramid was adaptable for use with a variety of target groups, a number of variations to the Pyramid have been developed since it was introduced. Pyramids for young children, older adults,

with several key differences. The ENAFS Daily Food Guide Pyramid for Elders features fluids rather than water at the base of the pyramid, omits the word "supplements" from the graphic, and uses words (e.g. two or more) rather than symbols (e.g. >) to describe the number of servings for each food group. In addition, the graphic includes canned and frozen foods to emphasize food choices, such as canned fruit, often used by older persons. An updated Tufts pyramid, currently available for use with consumers, features many of the same changes from their original prototype as appear in the ENAFS pyramid. University of Florida IFAS Extension faculty are currently evaluating whether or not to adapt the ENAFS pyramid to be consistent with MyPyramid, while still addressing the unique nutritional needs of older persons. Vegetarians. USDA's Food Guide Pyramid had some flexibility to help vegetarians plan healthful diets. However, special nutrient concerns for vegetarians may not have been satisfactorily addressed since the Pyramid was designed for those consuming an omnivorous diet. Over the years, various vegetarian pyramids were developed to meet the special needs of vegetarians. A Vegetarian Food Pyramid developed with input from individuals who participated in the Third International Congress on Vegetarian Nutrition was published in the Journal of Nutrition (17). The conceptual framework for this pyramid was described previously (18). Important principles included: variety and abundance of plant foods; emphasis on unrefined and minimally processed foods; optional use of dairy products and/or eggs; wide range of fat intake; generous fluid intake; and other lifestyle factors such as regular exercise and daily exposure to sunlight (for vitamin D) and fresh air (18). This vegetarian pyramid was designed to meet the needs of both lactovegetarians and vegans, and addresses nutrient concerns such as lower digestibility of protein in plant-based diets, limited availability of vitamin B12, vitamin D and calcium, and lower bioavailability of zinc and iron. A second vegetarian pyramid was published as part of a companion paper to the joint position paper on vegetarian diets published by the American Dietetic Association and Dietitians of Canada in 2003 (19-20). The Food Guide for Vegetarians actually is presented in two formats in the paper, a rainbow and a pyramid (19). Canada currently represents its food guide as a rainbow. The food guide was designed to assist persons following various types of vegetarian diets in selecting diets that meet Dietary Reference Intakes (DRI) for protein, iron, zinc, calcium, vitamin D, riboflavin, vitamin B12, vitamin A, omega-3 fatty acids, and iodine (20). Food groups include: grains, vegetables, fruits, legumes, nuts and other protein-rich foods, fats, and calcium-rich foods. The calcium-rich foods group includes foods from each of the other food groups. Mediterranean Diet. Considerable media attention has been focused on the potential health benefits of the diet typically consumed by people in the Mediterranean basin, particularly in the olive growing areas of the region. Epidemiological studies first reported in the 1960s have been interpreted to support consumption of a relatively high-fat diet to reduce heart disease risk, as long as the primary source of fat in the diet is olive oil, which is rich in monounsaturated fatty acids (MUFA) (21,22). The Mediterranean Diet has been associated with overall mortality in several cohort studies, indicating that this style of eating style may increase longevity (23,24). Data from a 44-month case -control study supported the protective effects of the Mediterranean diet against death from coronary heart disease and cancer, as well as total mortality (24). Supporters of the Mediterranean Diet Pyramid proposed that the Food Guide Pyramid be changed to reflect the
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Mediterranean eating pattern. Even though dietary fat is primarily in the form of olive oil in the Mediterranean diet, concerns have been raised about the high fat level of the Greek diet in some regions, in light of increasing incidence of obesity and associated health problems in the Greek population (25). This trend also is a major concern in the U.S., with overweight and obesity reaching "epidemic" proportions in recent years. The traditional Mediterranean diet is largely plant-based, with high intake of vegetables, legumes, fruits, nuts, cereals, and olive oil, a moderately high intake of fish, depending on location, low-to-moderate intake of dairy products, primarily in the form of yogurt and cheese, and low intake of meats and poultry. Wine is regularly, but moderately consumed, mostly with meals. The level of fat in the diet varies among countries and regions within countries in the Mediterranean basin (22). Ethnic Groups. Numerous food guides have been developed to address the eating patterns of various ethnic groups. None has been as widely tested and validated as USDA's Food Guide Pyramid, but they provide tools that may be useful for working with specific audiences. USDA provides links to a number of these pyramids on their website (see Resources section). of the pyramid, labeled as "Monthly". The Asian Diet Pyramid also includes symbols outside of the pyramid to represent physical activity, along with alcoholic beverages. The USDA's Center for Nutrition Policy and Promotion website includes links to the Asian Diet Pyramid, Bilingual Food Guide Pyramids in over 30 different languages, and the Native American Food Guide. The Native American Food Guide uses the same food groups as USDA's Food Guide Pyramid, but includes "Low or Non-fat" in the descriptor for the dairy products group to emphasize the importance of these choices for this population. The base of the pyramid indicates two sections: Bread, Cereal Group and Rice, Pasta Group, each of which suggests 6-11 servings; unless this is not meant to represent two separate food groups (and there is no line to separate the two sections), it is an unusual recommendation for a people at such high risk for obesity, diabetes and heart disease (26). Faculty at the University of Connecticut Family Nutrition Program and experts at the Hispanic Health Council developed the Puerto Rican Food Guide Pyramid (Figure 11). They based the Pyramid on quantitative and focus group research. It includes pictures of traditional foods in the familiar five food groups. Another pyramid targeted to the Puerto Rican population is the Food Pyramid for Puerto Rico, developed by a subcommittee of the Nutrition Committee of Puerto Rico and released in 1994, just two years after the Food Guide Pyramid was published (27). Both of these pyramids targeted to Puerto Ricans are very similar to USDA's Food Guide Pyramid. The pyramid developed in Puerto Rico includes water as part of the food guide due to concerns about hydration in a tropical climate and viandas (e.g., plaintains, white and sweet potatoes, yucca, celery root, and malanga) as part of the pyramid's grain food base (27). DIETARY GUIDELINES FOR AMERICANS
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Some of the pyramid variations, such as the Soul Food Pyramid, adhere closely to the food group design of the Food Guide Pyramid, and appeal to a particular group by including familiar foods and having an appealing design. Others, such as the Asian Diet Pyramid, address significant differences in food preferences through the use of different number and placement of food groups within the pyramid structure. For example, since many Asian Americans do not consume dairy products, one level of the pyramid, labeled "Optional Daily" is identified as "Fish & Shellfish or Dairy," and Meat is at the very tip

The Dietary Guidelines for Americans are recommendations about how to eat to stay healthy based on current knowledge about diet-disease relationships. The Dietary Guidelines are targeted to Americans over age two years since the dietary needs of infants and toddlers are different from those of older children and adults. The Dietary Guidelines are the cornerstone of Federal nutrition policy, influencing programs such as USDA's Food Stamp Program, Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and the School Lunch Program (3,7). In 1980, USDA and the U.S. Department of Health, Education, and Welfare (currently the Department of Health and Human Services, USDHHS) published the first edition of the Dietary Guidelines, called Nutrition and Your Health: Dietary Guidelines for Americans (6). The seven guidelines recommended a diet that included a variety of foods to provide essential nutrients and adequate starch and fiber, that maintained "ideal" body weight, and that was moderate in fat, saturated fat, cholesterol, sugars, sodium, and alcohol. Every five years, the Dietary Guidelines are reviewed by a committee of nongovernment nutrition and health experts and are re-issued by the USDA and USDHHS (see box, Dietary Guidelines, A Brief History). The Dietary Guidelines Advisory Committee for the 2005 edition conducted an extensive search of the research literature, reviewed existing reports and analyses conducted especially for the Committee, and obtained input from invited experts as well as from the public. The current (sixth) edition of the Dietary Guidelines was issued in February 2005, and is a 70-page document targeted to policymakers, nutrition educators, dietitians, and healthcare providers, rather than to the general public as in previous editions (3). A separate consumer-oriented brochure, Dietary Guidelines, A Brief History The Dietary Guidelines were first published in 1980 (6), and the first revision, in 1985 (28), included only minor changes in wording. After this second edition of the Guidelines was released, two major reports were published, the Surgeon General's Report on Nutrition and Health (29) and the National Academy of Science's Diet and Health: Implications for Reducing Chronic Disease Risk (30). These publications summarized current knowledge in diet-disease relationships, and were used by the Dietary Guidelines Advisory Committee as scientific resources for the third edition, published in 1990 (31). That edition took a more positive approach, using wording such as "choose ..." rather than "avoid too much ..." It focused more on the total diet, and included more specific, practical advice for each Guideline. This trend was continued in the fourth edition, which was published in 1995 (32). There was an increased emphasis on physical activity, and instructions on using the Food Guide Pyramid and the Nutrition Facts label to plan a healthful diet. Vegetarian diets were discussed for the first time in the fourth edition. The fifth edition took a new approach by dividing the Guidelines into three components Aim, Build and Choose and described ten guidelines. For the first time, food safety was included as a guideline, and the Variety guideline was changed to "Let the Pyramid guide your food choices," to emphasize food choices based on this familiar educational tool (33). The current edition encourages most Americans "to eat fewer calories, be more active, and make wiser food choices" (3). This edition is described more fully in this chapter.
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Finding Your Way to a Healthier You, provides tips for implementing the key recommendations of the Dietary Guidelines (see Resources for Education and Counseling).

The Dietary Guidelines for Americans 2005 is organized into nine inter-related focus areas, each with key recommendations for the general public and key recommendations for specific population groups. The intent is for the recommendations to be implemented as a whole to plan a healthful diet. The nine chapters of the Dietary Guidelines for Americans 2005 publication are: 1. 2. 3. 4. 5. 6. 7. 8. 9. Adequate Nutrients within Calorie Needs Weight Management Physical Activity Food Groups to Encourage Fats Carbohydrates Sodium and Potassium Alcoholic Beverages Food Safety health: "Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol." "Reduce the incidence of dental caries by practicing good oral hygiene and consuming sugar-and starch-containing foods and beverages less frequently." Although the intake of most essential nutrients is adequate in the U.S., the Dietary Guidelines identified several nutrients as potential concerns. These include vitamin E, calcium, magnesium, potassium, and fiber for children and adults, and vitamins A and C among adults. The report also addresses special micronutrient concerns for population subgroups, as follows.
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The 2005 Dietary Guidelines reflect current concerns about overweight and obesity, as well as attention to critical nutrients that may be of concern through the lifecycle. Calorie intake and/or energy balance are addressed in six of the nine chapters. The focus is on calorie intake rather than the proportion of calories consumed from protein, carbohydrate, or fat. It is suggested that the healthiest way to decrease energy consumption is to reduce intake of added sugars, solid fats, and alcohol in the diet since they provide "empty" calories. Even small changes in energy balance can make a difference in body weight over time, for both children and adults. As in the previous edition, physical activity is included as a key message.
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In a departure from previous editions of the Dietary Guidelines, the current edition addresses sugar intake as part of the Carbohydrates chapter, rather than including a key message targeted specifically to sugar intake. Consumption of sugars is addressed in the context of calorie control and dental
Women of childbearing age who may become pregnant: Eat foods high in heme iron and/or consume iron-rich plant foods or iron-fortified foods with an enhancer of iron absorption, such as vitamin C-rich foods. Women of childbearing age who may become pregnant and those in the first trimester of pregnancy: Consume adequate synthetic folic acid daily (from fortified foods or supplements) in addition to food forms of folate from a varied diet. People over age 50: Consume vitamin B12 in its crystalline form (i.e. fortified foods or supplements). Older adults, people with dark skin, and people exposed to insufficient ultraviolet band radiation (i.e., sunlight): Consume extra vitamin D from vitamin D-fortified foods and/or supplements. The 2005 Dietary Guidelines indicate that the greatest health benefits will be obtained by following all of the recommendations, although health benefits can be reaped from following only some of
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them. To help consumers make food selections for a healthful diet, the Dietary Guidelines includes two eating patterns that "exemplify" the guidelines. One is the DASH eating plan, which was developed for the Dietary Approaches to Stop Hypertension (DASH) study, and the second is the new USDA Food Guide, which was developed by USDA specifically to help Americans implement the Dietary Guidelines 2005. The USDA Food Guide is rich in fruits, vegetables, whole grains, and nonfat or low-fat milk products; provides nutrients in amounts that meet nutrient needs and reduce risk of chronic disease; and is low in saturated fat, cholesterol, and added sugars. The eating pattern also can be low in trans fat, although this is not included in USDA's model, and sodium, with appropriate food choices, such as limiting intake of foods containing partially hydrogenated fat and selecting low or reduced sodium products, respectively. The family and larger community environments can play critical roles in influencing lifestyle choices, such as whether or not an individual consumes excess calories, eats a healthful diet, and is physically active, all of which contribute to positive health outcomes. This is a critical issue as we deal with increasing incidences of obesity and type 2 diabetes among adults and young people in our country. Dietitians can help to influence community environments that currently promote overeating, consumption of foods of low nutrient density (and often high calorie density), and physical inactivity, through involvement in community coalitions, schools, and other local venues.
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development. It is generally recommended that beginning at the age of two years, children be gradually introduced to a lower fat diet, although this recommendation is not without controversy among health professionals (34). Dietitians can help parents and caregivers understand young childrens special nutrient needs, including the need for a calorie-dense diet to avoid inadequate food and nutrient intake in these young people. HELPING CONSUMERS USE FOOD GUIDES Food guides were designed to help people select foods for a healthful diet. Grouping foods based on nutrient content is helpful to people faced with tens of thousands of choices at the supermarket and in restaurants. However, consumers need assistance in understanding and using food guides in their daily lives. MyPyramid is no exception, and dietitians can help consumers interpret the messages, identify an appropriate calorie level for their weight management goals, and use the eating plan to meet their calorie and nutrient needs within the context of their ethnic background, cultural preferences, and budgets.
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Dietary Guidelines and Young Children. The Dietary Guidelines have always been designed for adults and children over two years of age and should not be applied to the diets of children under two years of age. Infants and toddlers require a more energydense diet containing adequate calories, fat, and cholesterol to support growth and
Variations in Nutrient Content. Although specific foods within each food group contain similar amounts of key nutrients, there are large variations in the levels of some micronutrients, such as beta-carotene and folate in fruits and vegetables, and zinc in meat and meat alternates. Dietitians can help consumers make healthful choices within the food groups to improve nutrient density of the diet in general, and also to help individuals make choices appropriate to their eating styles and/or special nutrient needs. MyPyramid provides more specific advice regarding consumption of specific foods within the food groups to enhance variety and nutrient density. For example, within the Vegetables Group, MyPyramid includes weekly recommendations for five

subgroups, based on their nutrient content: Dark Green Vegetables, Orange Vegetables, Dry Beans and Peas, Starchy Vegetables, and Other Vegetables. Specific food choices are included in the "Inside The Pyramid" sections of MyPyramid.gov. Dietitians are encouraged to use the tools provided on the website in working with clients to build a healthy diet. Lifestyle. It has now been many years since the "typical" American family, with dad in the work force, mom at home, and children in school has actually been typical. Women's labor force participation rose from 46 percent to almost 59 percent between 1975 and 1996. Among women with children under the age of six, labor force participation changed from 38.8 to 62.3 percent during this same period (35) and in 2004, was 61.8 percent, a slight decrease (36). In 2004, 70.4 percent of women with children under the age of 18 were in the labor force (36). These women have less time available than stay-at-home mothers to prepare dinners "from scratch" and to teach their children how to cook. Single mothers, who are likely to work full-time, often have little time to prepare family meals. Seventy-two percent of single mothers were in the labor force in 2004 (36). Many young people, including young parents, have few if any food preparation skills, and depend on pre-prepared foods including frozen entrees, restaurant or supermarket take out, and fast food. School age children have limited access to food preparation skill building through the school system. In many homes the family dinner occurs on a weekly basis if at all. Older people, especially women, often live alone and may have difficulty shopping, preparing, and/or eating meals. All of these situations can have negative impacts on the diets of people of all ages in this country, and point to the need for nutrition education to help people select and/ or prepare healthful foods that fit their lifestyles.
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a significant factor in their food choices. In 2003, 11.2 percent of households in the U.S. (12.6 million) were food insecure, meaning that at some time during the year they did not have access to enough food for all household members due to a lack of resources (37). Persons living in food insecure households are more likely to experience hunger, poor nutritional status, and health problems. Dietitians can assist low-income individuals in selecting healthful diets within a limited budget by teaching them to comparison shop, plan healthful low-cost meals, and store and use leftovers. These skills can help persons with limited resources make their food dollar and/or food stamps last all month and decrease food insecurity. Dietitians who work with limited resource families can also help them obtain assistance, such as Food Stamps or WIC, to reduce reliance on emergency food programs. Cooperative Extension supports two nutrition education programs targeted to persons with limited resources, the Expanded Food and Nutrition Education Program (EFNEP) and the Food Stamp Nutrition Education Program, called the Family Nutrition Program (FNP) in many states, including Florida. Dietitians in Florida can contact their local county Extension office to see which program might be available in their counties. There may be opportunities to share resources, refer clients to free nutrition education classes, and collaborate to address community nutrition and health issues. SOURCES FOR EDUCATION AND COUNSELING Note: All of the Federal government publications may be reproduced for educational purposes. For the latest updates of USDA publications related to MyPyramid, MyPyramid for Kids, and the Dietary Guidelines, check the Center for Nutrition
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Food Costs. For many people food costs are

Policy and Promotion website: http:// www.usda.gov/cnpp. Resources are being developed in both English and Spanish. Accessed January 15, 2009. Dietary Guidelines for Americans, 6th Edition. The booklet may be purchased from the Federal Consumer Information Center, tollfree at (888) 878-3256. Download a PDF file at: http://www.cnpp.usda.gov/Publications/ DietaryGuidelines/2005/2005DGPolicyDocu ment.pdf. Accessed January 15, 2009. Finding Your Way to a Healthier You. Consumer brochure based on the Dietary Guidelines for Americans 2005. Download a PDF file at: http://www.health.gov/ dietaryguidelines/dga2005/document/pdf/ brochure.pdf. Accessed January 15, 2009. MyPyramid. Download a PDF file of the graphic and other resources, find information for professionals, and use the interactive features at: http://mypyramid.gov. MyPyramid food guides at 12 calorie levels (1000 to 3200). Downloaded PDF files at: http://mypyramid.gov/professionals/ results_downld.html. Accessed January 15, 2009. MyPyramid Graphic Standards, Guidelines for using the MyPyramid graphic. Source: http:// mypyramid.gov/downloads/resource/ MyPyramidGraphicStandards.pdf. Accessed January 15, 2009. MyPyramid for Kids. Download a PDF file of the graphic and tips for healthy eating and physical activity at http:// www.mypyramid.gov/kids/index.html. Accessed January 15, 2009. An interactive game for children (ages six to eleven) is accessible through the website. Modified Food Guide Pyramid for People Over Seventy Years of Age. Available at: http:// n u tr i ti o n . t u f ts . ed u / 1 19 79 72 03 13 85/ Nutrition-Page-nl2w_1198058402614.html. Accessed January 15, 2009.
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ENAFS Daily Food Guide Pyramid for Elders. Order ENAFS educational CDs from the "Education" section of the IFAS bookstore: http://www.ifasbooks.ufl.edu/merchant2/. Accessed January 15, 2009.(The pyramid is included in Module 1 in black and white and in full color.) This pyramid is being reviewed as we go to press. Asian Food Pyramid: Available at http:// www.oldwayspt.org/asian_pyramid.html. Accessed January 15, 2009. Mediterranean Diet Pyramid. Available at http://www.oldwayspt.org/ med_pyramid.html. Accessed January 15, 2009. Native American Food Pyramid. Download the image at: http://www.nal.usda.gov/fnic/Fpyr/ NAmFGP.html. Accessed January 15, 2009. Puerto Rican Food Guide Pyramid. Download the image at: http:/www.hispanichealth.com/ pyramid.htm. To order print copies, contact: the University of Connecticut Family Nutrition Program at (860) 486-3635, fax (860) 4863674, or email:[email protected]. FIGURES My Pyramid Graphics, developed by the U.S. Department of Agriculture, 2008. Source: http://www.mypyramid.gov/global_nav/ media_resources.html. Accessed on January 15, 2009. Modified Food Guide Pyramid for People Over Seventy Years of Age, developed at the Tufts University Center on Nutrition and Aging. Source: http://nutrition.tufts.edu/pdf/pyramid.pdf. Accessed January 15, 2009. Vegetarian Food Pyramid, developed at Arizona State University East, Mesa AZ. Source: http://www.oldwayspt.org/
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vegetarian_pyramid.html. Accessed January 15, 2009. Vegetarian Food Guide, developed by the American Dietetic Association and Dietitians of Canada. Source: Can J Diet Pract Res. 2003;64(2):82-86. The Traditional Healthy Mediterranean Diet Pyramid, developed by Oldways Preservation and Exchange Trust, 2000. Source: http://www.oldwayspt.org/ med_pyramid.html. Accessed January 15, 2009. Asian Diet Pyramid, developed by researchers at Cornell and Harvard Universities, with other experts. Source: http://www.news.cornell.edu/ Chronicle/96/1.18.96/AsianDiet.html. Accessed January 15, 2009. Native American Food Pyramid, California Adolescent Nutrition and Fitness Program, Source: http://www.nal.usda.gov/fnic/Fpyr/ NAmFGP.html. Accessed January 15, 2009. REFERENCES
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1. Welsh S, Davis C, Shaw A. A brief history of food guides in the United States. Nutr Today. 1992;27 6-11. 2. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. 1999. Food and Nutrition Board, Institute of Medicine. Washington, DC. National Academy Press. 3. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, Fifth Edition. 2005. Available at: http:// w w w . c n p p . u s d a . g o v / DGAs2005Guidelines.htm. Accessed January 15, 2009. 4. Davis CA, Britten P, Myers EF. Past,
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present, and future of the Food Guide Pyramid. J Am Diet Assoc. 2001;101:881 -885. 5. Economic Research Service. USDA. Appendix C. USDAs Thrifty Food Plan. In: Household Food Security in the United States. FANRR-35. Washington DC: USDA, 2002. Available at: http:// www.ers.usda.gov/publications/fanrr35/ fanrr35appc.pdf . Accessed January 15, 2009. 6. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. 1980. USDA Home and Garden Bulletin No. 232. 7. Cronin FJ, Shaw AM, Krebs-Smith SM, Marsland PM, Light L. Developing a food guidance system to implement the Dietary Guidelines. J Nutr Ed . 1987;19:281-302. 8. Welsh S, Davis C, and Shaw A. Development of the Food Guide Pyramid. Nutr Today. 1992;27:12-23. 9. Dixon LB, Cronin FJ, Krebs-Smith SM. Let the Pyramid guide your food choices: capturing the total diet concept. J Nutr. 2001;131:461S-472S. 10. U.S. Department of Agriculture, Human Nutrition Information Service. The Food Guide Pyramid, 1992. USDA Home and Garden Bulletin No. 252. 11. Center for Nutrition Policy and Promotion, U.S. Department of Agriculture. How Much Are You Eating? 2002. USDA Home and Garden Bulletin No. 267-1. Available at: http://www.cnpp.usda.gov/ P u b l i c a t i o n s / DietaryGuidelines/2000/2000DGBrochur eHowMuch.pdf. Accessed January 15, 2009 12. U.S. Department of Agriculture press release April 15, 2005. Johanns Reveals USDA's Steps to a Healthier You. Available at: http://mypyramid.gov/ global_nav/media_press_release.html. Accessed on January 15, 2009. 13. U.S. Department of Agriculture.
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MyPyramid. 2005. Available at: http:// mypyramid.gov. Accessed January 15, 2009. 14. Davis CA, Escobar A, Marcoe KL, Tarone C, Shaw A, Saltos E, Powell R. Food Guide Pyramid for Young Children 2 to 6 Years Old: Technical Report on Background and Development . U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. 1999. CNPP-10. 15. Russell RM, Rasmussen H, Lichtenstein AH. Modified Food Guide Pyramid for people over seventy years of age. J Nutr. 1999;129 (3):751-753. 16. Martin, L.A., & Bobroff, L.B. Florida partnership funds nutrition education for Florida's elders. Gerontological Nutritionists Newsletter, Spring 2000. 17. Venti CA and Johnston CS. Modified food guide pyramid for lactovegetarians and vegans. J Nutr. 2002;132:1050-1054. 18. Haddad EH, SabatJ J, Whitten CG. Vegetarian food guide pyramid: a conceptual framework. Am J Clin Nutr. 1999;70:615S-619S. 19. Messina V, Melina V, Mangels AR. A new food guide for North American vegetarians. Can J Diet Pract Res. 2003;64(2):82-86. 20. American Dietetic Association; Dietitians of Canada. Position of the American Dietetic Association and Dietitians of Canada: Vegetarian Diets. J Am Diet Assoc 2003;103 (6):748-65. 21. Keys A. Coronary heart disease in seven countries. Circulation. 1970; 41-42 (Suppl 1):1-211. 22. Kok FJ, Kromhout D. Atherosclerosis Epidemiological studies on the health effects of a Mediterranean diet. Eur J Nutr. 2004; (Suppl 1):43:1/2-1/5. 23. Knoops KTB, de Groot LCPGM, Kromhout D, Perrin A-E, Moreiras-Varela O., Menotti A., van Staveren WA. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women. The HALE Project. JAMA. 2004;292:1433-1439. 24. Trichopoulou A, Costacou T, Barnia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 2003;348:25992608. 25. Ferro-Luzzi A, James WPT, Kafatos A. The high -fat Greek diet: a recipe for all? Eur J Clin Nutr.
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2002;56:796-809. 26. National Heart, Lung, and Blood Institute, National Institutes of Health. Building Healthy Hearts for American Indians and Alaska Natives: A Background Report. 1998. Available at: http://www.nhlbi.nih.gov/health/ prof/heart/other/na_bkgd.pdf Accessed on January 15, 2009. 27. MacPherson-Sanchez A. A food guide pyramid for Puerto Rico. Nutr Today. 1998;33:198209. 28. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 2nd Edition. 1985. USDA Home and Garden Bulletin No. 232. 29. U.S. Department of Health and Human Services. The Surgeon General's Report on Nutrition and Health. 1988. DHHS (PHS) Publication No. 88-50210. 30. Committee on Diet and Health, Food and Nutrition Board, National Research Council. Diet and Health. Implications for Reducing Chronic Disease Risk. 1989. Washington, DC, National Academy Press. 31. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 3rd ed. 1990. USDA Home and Garden Bulletin No. 232. 32. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 4th ed. 1995. USDA Home and Garden Bulletin No. 232. 33. Harper, AE. Dietary guidelines in perspective. J Nutr. 1996; 126:1042S-1048S. 34. Bureau of Labor Statistics. U.S. Department of Labor. Employment characteristics of families in 2007. News Release, July 9, 2003. Available at: http://stats.bls.gov/ news.release/pdf/famee.pdf. Accessed January 15,2009. 35. Bureau of Labor Statistics. U.S. Department of Labor. Employment characteristics of families in 2004. News Release, June 9, 2005. Available at: http://stats.bls.gov/ news.release/pdf/famee.pdf. Accessed on 10/25/05. 36. Nord M, Andrews M, Carlson S. Household Food security in the United States, 2003. Food Assistance and Nutrition Research
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MyPyramid. 2005. Available at: http:// mypyramid.gov. Accessed January 15, 2009. 14. Davis CA, Escobar A, Marcoe KL, Tarone C, Shaw A, Saltos E, Powell R. Food Guide Pyramid for Young Children 2 to 6 Years Old: Technical Report on Background and Development. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. 1999. CNPP-10. 15. Russell RM, Rasmussen H, Lichtenstein AH. Modified Food Guide Pyramid for people over seventy years of age. J Nutr. 1999;129(3):751753. 16. Martin, L.A., & Bobroff, L.B. Florida partnership funds nutrition education for Florida's elders. Gerontological Nutritionists Newsletter, Spring 2000. 17. Venti CA and Johnston CS. Modified food guide pyramid for lactovegetarians and vegans. J Nutr. 2002;132:1050-1054. 18. Haddad EH, SabatJ J, Whitten CG. Vegetarian food guide pyramid: a conceptual framework. Am J Clin Nutr. 1999;70:615S-619S. 19. Messina V, Melina V, Mangels AR. A new food guide for North American vegetarians. Can J Diet Pract Res. 2003;64(2):82-86. 20. American Dietetic Association; Dietitians of Canada. Position of the American Dietetic Association and Dietitians of Canada: Vegetarian Diets. J Am Diet Assoc 2003;103(6):748-65. 21. Keys A. Coronary heart disease in seven countries. Circulation. 1970; 41-42 (Suppl 1):1211. 22. Kok FJ, Kromhout D. Atherosclerosis Epidemiological studies on the health effects of a Mediterranean diet. Eur J Nutr. 2004;(Suppl 1):43:1/2-1/5. 23. Knoops KTB, de Groot LCPGM, Kromhout D, Perrin A-E, Moreiras-Varela O., Menotti A., van Staveren WA. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women. The HALE Project. JAMA. 2004;292:1433-1439. 24. Trichopoulou A, Costacou T, Barnia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 2003;348:2599-2608. 25. Ferro-Luzzi A, James WPT, Kafatos A. The high-fat Greek diet: a recipe for all? Eur J Clin Nutr. 2002;56:796-809. 26. National Heart, Lung, and Blood Institute, National Institutes of Health. Building Healthy
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Hearts for American Indians and Alaska Natives: A Background Report. 1998. Available at: http:// www.nhlbi.nih.gov/health/prof/heart/other/ na_bkgd.pdf Accessed on January 15, 2009. 27. MacPherson-Sanchez A. A food guide pyramid for Puerto Rico. Nutr Today. 1998;33:198-209. 28. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 2nd Edition. 1985. USDA Home and Garden Bulletin No. 232. 29. U.S. Department of Health and Human Services. The Surgeon General's Report on Nutrition and Health. 1988. DHHS (PHS) Publication No. 8850210. 30. Committee on Diet and Health, Food and Nutrition Board, National Research Council. Diet and Health. Implications for Reducing Chronic Disease Risk. 1989. Washington, DC, National Academy Press. 31. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 3rd ed. 1990. USDA Home and Garden Bulletin No. 232. 32. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, 4th ed. 1995. USDA Home and Garden Bulletin No. 232. 33. Harper, AE. Dietary guidelines in perspective. J Nutr. 1996; 126:1042S-1048S. 34. Bureau of Labor Statistics. U.S. Department of Labor. Employment characteristics of families in 2007. News Release, July 9, 2003. Available at: http://stats.bls.gov/news.release/pdf/famee.pdf. Accessed January 15,2009. 35. Bureau of Labor Statistics. U.S. Department of Labor. Employment characteristics of families in 2004. News Release, June 9, 2005. Available at: http://stats.bls.gov/news.release/pdf/famee.pdf. Accessed on 10/25/05. 36. Nord M, Andrews M, Carlson S. Household Food security in the United States, 2003. Food Assistance and Nutrition Research Report No. (FANRR42), October 2004. Available at: http:// w w w . e r s . u s d a . g o v / p u b l i c a t i o n s /f a n r r 4 2 / fanrr42.pdf. Accessed on January 15, 2009..
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The Florida Medical Nutrition Therapy Manual 2009 Edition
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FCS8559-Eng.
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Facts About the ENAFS Daily Food Guide Pyramid for Elders
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The ENAFS Daily Food Guide Pyramid for Elders was adapted from the Modified Food Guide Pyramid for People over Seventy Years of Age developed at the U.S. Department of Agriculture (USDA) Human Nutrition Research Center on Aging at Tufts University. The Tufts pyramid is an adaptation of The Food Guide Pyramid that was developed by USDA for the general population. Compare the ENAFS Pyramid with USDAs Food Pyramid for the general population: The ENAFS pyramid is slimmer: As we age, most of us need fewer calories from food. When eating less food, it becomes especially important to choose nutrient-rich foods. Fluids make up the base of the ENAFS pyramid: There is an increased concern about adequate fluid intake in elders. Fluid needs may not be higher in elders, but dehydration and constipation are common problems. These problems can be reduced by drinking appropriate fluids. The number of servings is different: A minimum numberinstead of a rangeof servings from each food group is recommended. The number of recommended servings from the Milk, Yogurt, and Cheese group is higher because elders have increased calcium and vitamin D needs. A need for fiber is indicated: It is important for elders to get enough fiber, in order to stay regular and avoid constipation. Food groups in which you can select high fiber foods have the symbol. Diverse food choices are included: Ethnic food examples are included in the ENAFS pyramid, to allow for diverse food preferences and customs. The Meat, Poultry, Fish, Dry Beans, Eggs, Nuts and Tofu group is divided into two parts, to point out plant sources of protein. Vitamin and mineral needs may be higher: Elders may need more calcium, vitamin D, and vitamin B12, as indicated by the flag at the top of the ENAFS pyramid. Ask your physician or a registered dietitian if a supplement is appropriate for you. It is best to get advice regarding supplement usage from health professionals who are NOT selling these products.
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TUFTS
FOOD Guide Pyramid for Older Adults
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Vegetarian Food Guides
Developed by the American Dietetic Association and Dietitians of Canada. Source: Can J Diet Pract Res. 2003;64(2): 82-86.
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Native American Food Pyramid

California Adolescent Nutrition and Fitness Program Source: http://www.nal.usda.gov/fnic/Fpyr/NAmFGP.html
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Infant Nutrition (0-12 Months)

Written by: Deanna Stanz, MS, RD Pediatric Clinical Dietitian, Arnold Palmer Women & Childrens Hospital, Orlando Reviewed by: Dona Greenwood, PhD, RD, LD/N, Director of Nutritional Care, Tallahassee Memorial Regional Medical Center the infants rate of maturation of the nervous system, intestinal tract, and kidneys. The nursing period occurs when human milk or an appropriate formula is the sole source of nutrition. During the transitional period, age appropriate foods are introduced in addition to human milk or formula. The modified adult period occurs when the infant is receiving the primary source of nutrition from table foods (2). Specifics on infant feeding as well as infant development and feeding skills will be addressed in subsequent paragraphs. Table 2 states the Recommended Dietary Allowance (RDA) for calories, protein and fluids.
Table 1. Average Expected Weight Gain for Infants (1)
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PRACTITIONER POINTS
RATIONALE The diet for infants is designed to provide adequate nutrients for optimal growth and development. The primary method of evaluating the nutritional status of infants is growth. USE These guidelines are appropriate for healthy term infants from birth to twelve months of age. RELATED PHYSIOLOGY
The newborns birth weight is determined by various factors such as length of gestation, mothers pre-pregnancy weight, as well as weight gain during pregnancy. The average full-term birth weight in this country is approximately 3500 grams (1). Weight loss averaging 6% after birth is expected in all full-term healthy infants due to fluid losses and some catabolism of tissue. Most infants regain this weight within the first two weeks of life. Thereafter, infants gain weight at a rapid but decelerating rate (1). See Table 1. By four months of age, most infants will double their birth weight. Likewise, height increases at a rapid but decelerating rate. Average length at birth is approximately 50-53cm. Infants usually increase their length 50% by one year of age (1).
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Age (months) 0 - 4 months 5 - 12 Age 0-6 months 6-12 months 108 98
Average Weight Gain (gm/day) 20-25 gm/ day
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Protein gm/kg BW 2.2 1.6 Fluids ml/kg BW
Expectation Double birth weight by 4-5 months
15 gm/day
Triple birth weight by 12 months
Table 2. Dietary Recommendations for Infants Calories/ kg BW
140-160 125-155
Infant feeding tends to occur in three overlapping periods. It should be noted that the rate at which an infant progresses through these stages will vary depending on
Breast milk and/or iron-fortified commercial formula provide the nutrients needed by the healthy term infant (see Table 3). The Committee on Nutrition of the American Academy of Pediatrics recommends ironfortified formula for all formula-fed infants

(4). Iron stores in the newborn infant preclude the need for other iron sources during the first early months of life. Between 4-6 months of age iron stores begin to deplete, erythropoiesis begins and there is a rapid rise in total body hemoglobin (2). This increases the need for dietary iron. Ironfortified cereals are the first semi-solid foods to be incorporated into the infants diet (1,5,6). Infant cereals are fortified with, ferrous sulfate, reduced iron, and ferrous fumarate, well absorbed forms of iron (6). Between 3-4 months of age, the infant is developmentally able to take solids from a spoon and has lost the tongue thrust reaction present from birth (1) (see Table 4). Physical readiness for solids is further demonstrated by ability to swallow non-liquid foods, sitting independently and maintaining balance (5). Breast milk or formula should be added to thin cereal to the desired consistency. The consistency should gradually become thicker as the infant is able to master swallowing and spoon feeding (1). The use of whole cows milk during infancy is discouraged and has been associated with iron-deficiency anemia, possibly due to gastrointestinal blood loss (4, 5, 7). The composition of whole cows milk (high in calcium, phosphorus, protein; low in vitamin C) may affect the bioavailability of iron from other dietary sources such as infant cereal (7). The American Academy of Pediatrics, Committee on Nutrition does not recommend the use of whole cows milk or low-iron commercial formulas during the first year of life (3, 7). breast milk or formula are sufficient to meet an infants needs. Healthy infants usually require little or no supplemental water, except in hot weather and when solid foods are introduced. The introduction of solids increases renal load (4). In places where the weather is very hot, a 4oz-bottle of water may be appropriate for infants over 6 months. At approximately 6-7 months, fruits and vegetables may be added to the diet. The exact order is not important, but only one new food should be added at a time. Wait for 5-7 days and observe the infant for signs of allergies or intolerance, such as diarrhea, vomiting, or rash, before adding another new food.
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Foods should be as simple as possible, with minimal added sugar, sodium, or other ingredients. The use of fruit or junior desserts should be discouraged because of the high content of simple carbohydrates (up to 30% of calories as sucrose) and calories, with few other nutrients (1, 5). Fruit juices may be used when the infant is able to drink from a cup (1, 4). When the infant is comfortable with the texture of strained foods at 9-10 months, simple mashed, soft and well-cooked table foods can be added. Yogurt, mashed potatoes, plain vegetables, grits, oatmeal and other similar foods provide the infant with a variety of textures (1). In preparation for the transition from breast milk or iron-fortified commercial formulas to whole cows milk, additional iron sources such as meat are added to the diet at 9-10 months of age. Strained meats can be purchased, or lean, well-cooked meat can be finely chopped and mixed with other foods. Meat dinners or combination dinners are not recommended because they provide less than half as much protein as pure meat (1). Plain meats provide 220-250% more protein and up to 200% more iron than meat dinners.
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Overdilution of infant formula reduces the caloric and nutrient content of feedings. Functionally immature kidneys in newborns make them vulnerable to water imbalances (1). If fed water instead of formula, or provided with large quantities of water between feedings, water intoxication with resultant hyponatremia, irritability, or coma may occur (1, 8). The fluids provided by

Follow-up formulas for infants over six months of age can provide additional iron for those receiving inadequate amounts in their solid feedings. These formulas are nutritionally adequate, but are not necessary for infants receiving appropriate amounts of iron and vitamins in their diet (2). Foods that are common allergens are not added to the diet until close to or after one year of age (5). These foods include eggs, shellfish, citrus fruit, corn products and nuts. Foods that are easily aspirated or that may cause choking, like raisins, small candies (M&Ms, etc.), nuts, hot dogs, peanut butter, grapes, popcorn, and whole kernel corn, are not appropriate for infants (1, 5). Honey has been found to contain spores of Clostridium botulinum, which can be fatal when consumed by infants with immature gastrointestinal and immune systems (1, 9). At one time, honey was used to treat constipation, but it is no longer recommended for infants. Training with a cup during the second half of the first year is important. It will facilitate weaning from the bottle and should be accomplished as close to one year as possible in order to prevent the development of nursing bottle caries or baby bottle tooth decay (1, 5). The leading cause of baby bottle tooth decay is provision of concentrated mono and disaccharides (milk/juices) in the bottle, especially at bedtime (5). chooses not to breastfeed or stops before the infants first birthday, an iron-fortified commercial formula is the best feeding alternative (5, 7). The Committee on Nutrition of the American Academy of Pediatrics has issued a policy statement on standard commercial formulas. The composition of breast milk from a healthy mother is used as the standard for commercial formulas. The goal is to approximate the minimum nutrient content of breast milk; the maximum amount is intended for infants with special needs (e.g. low birth weight infants) (1).
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NUTRIENTS MODIFIED This diet does not involve nutrient modification. Rather, food varieties and textures advance based on developmental skills of the infant. NUTRITIONAL ADEQUACY Breast milk is the recommended source of nutrition for the first six months of life (5). The American Academy of Pediatrics and the American Dietetic Association have published papers supporting breastfeeding. If a woman

Table 3 COMMONLY USED INFANT FORMULAS AND INDICATIONS FOR USE
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Formula * Similac{*}, Enfamil[*], Good Start(*)
Description
Indication
Modified skim cows milk: For healthy, term infants; to be reduced protein and mineral used as an alternative when content with blended fats added. breastfeeding is not possible (5) Taurine is added Soy isolate protein fortified with methionine, corn syrup or sucrose, soy, coconut, or oleo, and vitamins and minerals Milk-based, lactose-free, iron-fortified For infants recovering from diarrhea, with galactosemia or bovine protein intolerance (5)
Isomil{*}, ProSobee[*], Alsoy(*)
Lactofree[*]
Nutramigen[*]
Pregestmil[*]
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Casein hydrolysate, soy and corn oil
Casein hydrolysate and mediumchain triglycerides (MCT)
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For infants, with lactose intolerance, lactase deficiency, chronic diarrhea, galactosemia and that are allergic to soy products For infants, with intact protein intolerance, galactosemia, recovery from mild/moderate diarrhea, food allergies
For infants with severe malabsorption disorders (cystic fibrosis, intractable diarrhea, severe protein-energy malnutrition, steatorrhea, short gut syndrome) For infants with protein sensitivity or allergy, protein maldigestion, fat malabsorption
Alimentum{*}
Casein hydrolysate, free amino acids, MCT, safflower and soy oils
* Registered Trademark [*]Mead Johnson Nutritionals Pediatric Products Handbook {*}Ross Laboratories Product Handbook (*)Nestle Professional Handbook

Table 4. INFANT DEVELOPMENT AND FEEDING SKILLS (10) Development Skills Mouth, Hand and Body Patterns Sucking/swallowing reflex Tongue thrust reflex Poor lip closure Poor control of head, neck, trunk Draws in lower lip as spoon is removed from mouth Up and down movement Transfers food from front to back of tongue to swallow Sits with support Good head control Uses whole hand to grasp objects Up and down munching movement Positions food between jaws for chewing Begins to sit alone without support Begins to use thumb and index finger to pick up objects
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Babys Age Birth through 5 months
Baby is able to.... Swallow liquids but pushes most solid foods from the mouth
4 through 6 months
Take spoonful of pureed or strained food and swallow it without choking Control position of food in mouth
5 through 9 months
8 through 11 months
10 through 11 months
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Complete side-to-side tongue movement Begins to curve lips around rim of cup Sits alone easily Rotary chewing (grinding) Begins to put spoon in mouth Begins to hold cup
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Eat mashed foods Eat from spoon easily
Eat ground or finely chopped food Feed self with hands Drink from a cup Eat chopped food and small pieces of soft, cooked table food

REFERENCES 1. Pipes PL, Trahms CM. Nutrition in Infancy and Childhood, 6th Edition. St. Louis, MO: Mosby Year Book, Inc. 1997. 2. Kleinman RE. American Academy of Pediatrics, Committee on Nutrition. Pediatric Nutrition Handbook, 6th Edition. 2008. 3. Grummer-Strawn LM, Scanlon KS, Fein SB. Infant feeding and feeding transition during the first year of life. Pediatrics 2008;122:S36-S42. 4. h t t p : / / b r i g h t f u t u r e s . a a p . o r g / p d f s / G u i d e l i n e s _ P D F / 6 Promoting_Healthy_Nutrition.pdf Accessed January 14, 2011. 5. Samour PQ, Helm KK, Lang CE. Handbook of Pediatric Nutrition. 3rd Edition. Sudbury, MA: Jones and Bartlett; 2005. 6. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115:496506. 7. American Academy of Pediatrics, Committee on Nutrition. The use of whole cows milk in infancy. Pediatrics. 1992;89:1105. 8. Keating JP, Schears GJ, Dodge PR. Oral water intoxication in infants: an American epidemic. AJDC. 1991;45:985-990. 9. Aaron SS, Midura TF, Damus K, Thompson B, Wood RM, Chin J. Honey and other environmental risk factors for infant botulism. J Ped. 1979;94:331-336. 10. Feeding Infants: A Guide for Use in the Child Care Food Program. USDA-Food and Nutrition Service, FNS-258. 11. Department of Dietetics, Childrens Hospital. Infant Formulas and Selected Nutritional Supplements. Columbus, OH: Childrens Hospital Print Shop; 1993. Feeding Infants and Toddler Study. 2004;104:S22-S30. 3. US Department of Agriculture, Agricultural Research Service. Food and Nutrient by Region, 1994-1996. Table set 14. 1999. 4. Ryan C, Dwyer J, Ziegler P, Yang E, Moore L, Song WO. What should infants eat and what do infants really eat? Nutrition Today. 2002;37:50-56. 5. Greer FR, Sicherer SH, Burks W. Effects of early nutritional interventions on the development of atopic disease in infants and children; the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods and hydrolyzed formulas. Pediatrics 2008;121 (1);183-191.
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Suggested References on Breastfeeding for the Health Care Provider 1. Position of the American Dietetic Association: Promoting and Supporting Breastfeeding. Journal of the American Dietetic Association 2009;109:19261942. 2. American Academy of Pediatrics, Breastfeeding and the Use of Human Milk . Pediatrics. 2005;115(2):496-506. 3. Worthington-Roberts, B., & Williams, S.R. Nutrition in Pregnancy and Lactation. 6th Edition. Missouri, Mosby-Yearbook. 1997. 4. The Womanly Art of Breastfeeding Illinois: La Leche League International, 2005. 5. Neifert, M. Dr. Moms Guide to Breastfeeding. New York: Penguin, 1998. 6. Mohrbacher, N., & Stock, J., The Breastfeeding Answer Book. Illinois: La Leche League International, 2003.
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ADDITIONAL REFERENCES 1. Devaney B, Zielger P, Pac S, Karwe V, Barr S. Nutrient Intakes of Infant and Toddlers. JADA. 2004;104:S14-S21. 2. Fox MK, Pac S, Devaney B, Jankowski L.
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Nutrition Education for Feeding Infants (0-12 Months)

Written by: Deanna Stanz, MS, RD, Pediatric Clinical Dietitian, Arnold Palmer Women & Childrens Hospital, Orlando Reviewed by: Dona Greenwood, PhD, RD, LD/N, Director of Nutritional Care, Tallahassee Memorial Regional Medical Center
NUTRITION EDUCATION FOR FEEDING INFANTS (0-12 MONTHS)

INTRODUCTION Feeding practices and skills vary from infant to infant. However, some guidelines and recommendations have been established to facilitate this process and ensure that your infant will receive the maximum benefits of good nutrition. Your pediatrician and registered dietitian (RD) will answer questions about your infants nutrition and will help you establish feeding goals. PURPOSE
This diet is designed to provide adequate calories and nutrients to support healthy growth and to prevent nutrition-related deficiencies during the first six months of life. From 6 to 12 months the diet is designed to increase food variety and provide about 35-50% of calories from sources other than breast milk or iron-fortified commercial formula. NUTRIENTS MODIFIED
This diet does not involve nutrient modification. Rather, food varieties and textures advance based on development skills of the infant. DIETARY GUIDELINES
In the first year, your baby will experience rapid growth and development. Adequate nutrition is needed to support healthy growth. This section will present information that will help you provide adequate nutrition for your baby. These guidelines are intended for full-term, healthy babies. Although adequate feeding practices have been identified you must remember that your baby is very unique. His/her growth, development, and needs may differ from those of other babies. 1. The American Academy of Pediatrics recommends infants receive human milk exclusively for the first 6 months of life. Thereafter, breastfeeding should be continued, with the addition of solid foods, at least through the infants first year. Human milk provides nutritional, immunological and psychosocial benefits to your baby. If you want to know more about breastfeeding, read the lactation section of this manual, Why should I nurse my baby? and other questions mothers ask about breastfeeding, by Pamela K. Wiggins, IBCLC, or ask your registered
Florida Dietetic Association Website: www.eatrightflorida.org For a referral to a nutrition professional in your area, visit: www.eatright.org 2011 FDA. Reproduction of this medical nutrition therapy tool is permitted for educational purposes only. It does not substitute for meeting with a Registered Dietitian to develop a personalized plan that is right for you.
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reading materials about breastfeeding. Benefits of Breastfeeding Provides your baby with the nutrients needed for optimal growth Provides immunological protection, especially in the first weeks of life when babys immune system is immature and more susceptible Decreases incidence of respiratory and gastrointestinal infections Makes you feel closer to your baby Provides health benefits for mothers that breastfeed 2. If you cannot or do not want to breastfeed, the acceptable alternative is iron-fortified commercial formula. Iron-fortified commercial formula is nutritionally similar (not equal) to breast milk and has been shown to prevent iron-deficiency anemia. 3. For the first four months of life, your infants diet should be only breast milk and/or iron-fortified commercial formula. 4. When bottle feeding, hold the baby in a semi-upright position. Do not prop the bottle and do not feed him/her when they are lying down because this increases the risk of choking. In addition, the formula can flow into the middle ear increasing the chance of ear infection. Enjoy holding your baby close to you. 5. Breastfeed or bottle feed on demand; do not put your infant on a rigid feeding schedule. 6. Healthy infants may spit up a small amount of formula at each feeding. This does not affect growth. Make sure the baby is not drinking too much at a time, that the nipple hole is not too big, that the baby is not sucking air and that the feeding time is not too noisy. If the baby is bringing up large amounts of formula, if he seems sick or is not growing well, contact your pediatrician. 7. Start feeding iron-fortified baby cereal at approximately 4-6 months of age. Start with rice cereal because it is less allergenic. Mix 1-2 tablespoons of dry cereal with breast milk or ironfortified commercial formula and thin the consistency to desired texture. Feed with an infant spoon. Do not try to feed cereal from the infants bottle. This can result in overfeeding and excessive weight gain. Introduce other single-grain fortified infant cereals to add variety. Introduce only one new food at a time for 3-4 days before trying another. Look for signs of allergies or intolerance, such as diarrhea or rash. 8. Vegetables and fruits can be introduced at 6 months of age. Begin with small amounts of plain, strained vegetables or fruits, adding one new food item at a time. Gradually increase the texture to mashed. When preparing strained vegetables at home, use fresh, high-quality vegetables rather than canned vegetables that may be high in salt. Do not add salt, butter or
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margarine, sugar or honey. 9. When your baby is comfortable with strained foods (the age depends on babys individual development), try simple mashed or well-cooked, soft table foods. Yogurt, mashed potatoes, plain vegetables, grits or oatmeal can be used. Foods should be as simple as possible, with no added sugar, salt, butter, margarine or honey. 10. In the beginning, your baby may refuse new flavors and textures. Try another food and reintroduce the refused food later. 11. As your baby gets closer to one year of age, there is a need to provide iron-rich foods to replace breast milk or iron-fortified formula. Start feeding meats at around 9-10 months of age. Use strained meats first and gradually increase texture. Use lean cuts of well-cooked and finely chopped meat. 12. Foods that may cause allergies (eggs, shellfish, citrus fruits and chocolate) should not be fed until close to or after 1 year of age. 13. Do not give infants raisins, nuts, peanut butter, hot dogs, grapes, popcorn, or whole kernel corn because they may cause choking. FORMULA PREPARATION: Aseptic Method:

Wash bottles, nipples, and caps in hot soapy water. Rinse well. Place bottles, nipples, and caps and any other utensil to be used in a large pan. Add approximately 5 inches of water and boil for 5-10 minutes. Remove from the pan and place on clean cloth or paper towel. Boil the water to be used for mixing the formula for 2 minutes. Cool. Mix formula with the boiled and cooled water following the instructions on the label of the can. Add 1 ounce of water to 1 ounce concentrated liquid formula. Add 2 ounces of water to 1 scoop of powdered formula. Fill bottles with prepared formula and store in refrigerator for up to 48 hours. Terminal Method: The American Academy of Pediatrics recommends this method if you use well water or nonchlorinated water.

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Wash bottles, nipples, and caps in hot soapy water. Rinse well. Mix formula with water following the instructions on the label of the can. Add 1 ounce of water to 1 ounce concentrated liquid formula. Add 2 ounces of water to 1 scoop of powdered formula. Prepare enough bottles for 24 hours.
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Put nipples in bottles, upside down, with disc seals covering the top. Screw top loosely. Put bottles in a rack or on towel in a big pot. Add 2-3 inches water and cover. Boil for 25 minutes. Let bottles cool and refrigerate for up to 48 hours. FOOD SAFETY AND THE INFANT

Do not buy baby food in damaged packages. Check the expiration dates printed on the cans or jars of baby food. Do not use if the expiration date has passed. Always wash your hands and utensils before preparing you babys formula or food. Store unopened formula or jars of food in a dry, cool area. After mixing formula, label and keep it in a covered jug or pitcher in the refrigerator. If you do not use it within 2 days, throw it away. When feeding your baby, place small amounts of food in a bowl. Do not feed directly from the jar. Food left in the jar needs to be labeled. Use within the next 2 days. Throw away food left over on the bowl or plate after each meal. Honey and raw eggs can have bacteria that may make your baby very sick or possibly die. Never feed these foods to your baby.
PARENT RESOURCES
1. Position of the American Dietetic Association: Promoting and Supporting Breastfeeding. Journal of the American Dietetic Association 2009;109:1926-1942. 2. American Academy of Pediatrics, Breastfeeding and the Use of Human Milk . Pediatrics. 2005;115(2):496-506. 3. Worthington-Roberts, B., & Williams, S.R. Nutrition in Pregnancy and Lactation. 6th Edition. Missouri, Mosby-Yearbook. 1997. 4. The Womanly Art of Breastfeeding Illinois: La Leche League International, 2005. 5. Neifert, M. Dr. Moms Guide to Breastfeeding. New York: Penguin, 1998. 6. Mohrbacher, N., & Stock, J., The Breastfeeding Answer Book. Illinois: La Leche League International, 2003.
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Clear Liquid Diet

Written by: Nancy Correa-Matos, PhD, RD, Assistant Professor, Department of Nutrition & Dietetics, University of North Florida Reviewed by: Catherine Christie, PhD, RD, LD/N, FADA, Chair, Department of Nutrition & Dietetics, University of North Florida popsicles, red gelatin and other red clear liquids should not be included. Several commercially available products can be added to increase kilocalories, protein, and other nutrients. Additional modifications such as omission of gas-forming carbonated beverages and fruit juices may be necessary following gastrointestinal surgery for some patients. NUTRITIONAL ADEQUACY This diet is inadequate in all nutrients and kilocalories specified by the 1989 Recommended Dietary Allowances and the 2001 Dietary Reference Intakes (DRIs) for adult males and females. It is also inadequate in fluid for most patients and fluid and electrolytes may be replaced intravenously until the diet is advanced. It should be used only for brief periods of time, generally no more than 3 days. Beyond 3 days, appropriate oral supplementation is suggested to meet nutrient needs (1). Noncaloric (sugar-free) liquid diets are not appropriate for individuals with diabetes. Individuals on clear liquid diets should receive approximately 130-200 grams of carbohydrate throughout the day, divided in equal amounts at meals and snack times (2). Advancing from clear liquids to full liquids to solid foods should be done as soon as a patient can tolerate the progression (2). Emerging research is focusing in the use of low residue soft diets instead of clear liquids as early as during the first PO day following laparotomy (3), or even before a colonoscopy procedure (4). Until more research is done, clear liquid diets are still in use in the clinical setting.
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PRACTITIONER POINTS
RATIONALE The Clear Liquid Diet offers the simplest form of food with regard to digestion and absorption. USE This diet is used prior to some diagnostic tests, pre- and post-operatively, and when other liquids and solid foods are not tolerated. It may be indicated as a short term diet during acute inflammatory conditions of the gastrointestinal tract or in the acute stages of illness. The Clear Liquid Diet helps prevent dehydration and relieve thirst. RELATED PHYSIOLOGY
This diet provides fluids which do not stimulate digestive processes. Clear liquids are provided which leave no residue. NUTRIENTS MODIFIED
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The Clear Liquid Diet provides foods that are liquid at room temperature. These foods contain electrolytes and small amounts of calories, mainly in the form of carbohydrates. Milk and juices with pulp must be avoided. Addition of strained fruit juices such as grape, apple and cranberry add to the nutritive value of this diet. While many diagnostic tests require the patient to be NPO past midnight, occasionally a clear liquid diet may be ordered on the morning of a procedure such as an endoscopy. Because the presence of red liquids in the gut or colon can be mistaken for blood, red juices,
Clear Liquid Diet

REFERENCES 1. Mahan, LK & S Escott-Stump. Krauses Food, Nutrition and Diet Therapy, 12th Edition Philadelphia, PA: W.B. Saunders Co.; 2008. 2. American Diabetes Association, Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, Hoogwerf BJ, Lichtenstein AH, Mayer-Davis E, Mooradian AD, Wheeler ML. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2008 Jan;31 Suppl 1:S61-78. 3. Park DI, Park SH, Lee SK, Baek YH, Han DS, Eun CS, Kim WH, Byeon JS, Yang SK.Efficacy of prepackaged, low residual test meals with 4L polyethylene glycol versus a clear liquid diet with 4L polyethylene glycol bowel preparation: a randomized trial. J Gastroenterol Hepatol. 2009 Jun; 24(6):988-91. 4. Toulson Davisson Correia MI, Costa Fonseca P, Machado Cruz GA. Perioperative nutritional management of patients undergoing laparotomy. Nutr Hosp. 2009 Jul-Aug;24(4):479-84.
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Nutrition Education Adult Weight Loss (Spanish Version)

EDUCACIN NUTRICIONAL PARA LA REDUCCIN DE PESO EN ADULTOS
Escrito por: Donna DeCunzo-Taddeo, RD,LD, Especialista en mantenimiento de peso, Lighthouse Point, FL Revisado by: Mary C. Friesz, PhD, RD, CDE, LD/N Versin en Espaol escrito por: Daniel Santibanez, MPH, LD/N, Universidad del Norte de la Florida, Jacksonville, Florida EDUCACIN NUTRICIONAL PARA LA REDUCCION DE PESO EN ADULTOS Entender las porciones y el contenido de caloras en los grupos de alimentos son habilidades importantes para la perdida y el mantenimiento del peso. Usted puede intercambiar las comidas dentro de cada uno de los grupos de alimentos. Use la lista de sustitutos para una mayor variedad en la seleccin de alimentos.
LISTA DE SUSTITUTOS
1/2 taza 1 taza 1/2 taza
Verduras contienen 25 caloras y 5 gramos de carbohidratos. Una porcin equivale a: Verduras crudas lechuga
Verduras cocidos (zanahoria, brcol, calabacn, col, etctera)
Leche Desnatada muy Baja en Grasa contiene 90 calaras por racin. Una racin equivale: 1 taza Leche, desnatada o al 1% 3/4 taza 1 taza
Protenas muy magras tienen 35 caloras y 1 gramo de grasa por racin. Una racin equivale: 1 onza Pechuga de pavo pollo sin piel 1 onza 1 onza 1 onza 3/4 taza 2 cantidades 1/4 taza 1 onza 1/2 taza Filete de pescado (platija, lenguado, abadejo, bacalao, etctera) Atn enlatado en agua Mariscos (almeja, langosta, camarones) Requesn, sin grasa bajo en grasa Claras de huevos Sustituto de huevo Queso sin grasa Frijoles cocidos: cuntalos como un almidn/pan y una protena magra
Asociacin Diettica de Florida
Pgina de Internet: www.eatrightflorida.org Para referidos a la nutricionista en su rea, favor de visitar la pgina: www.eatright.org 2011 FDA. La reproduccin de este documento es permitido slo para propsitos educativos. Este documento no sustituye la visita con su dietista para desarrollar un plan adaptado a su condicin.
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Jugo de verduras
Si tiene hambre, coma ms verduras frescas o al vapor
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Yogur, natural sin grasa bajo en grasa
Yogur con edulcorante artificial
Manual of Medical Nutrition Therapy 2011 Edition Spanish Version
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Frutas contienen 15 gramos de carbohidratos y 60 caloras. Una porcin equivale a: 1 pequeo 1 mediano 1 1/2 1/2 1 taza 1 taza 1/8 4 onzas 4 cuchaditas Manzana, bananos, naranja, nectarines Melocotn fresca Kiwi Toronja Mango Moras frescas (fresas, frambuesas o arndanos) Cubitos de meln frescos Meln dulce Jugo natural Jalea mermelada
Protenas Magras tienen 55 caloras y 2-3 gramos de grasa por racin. Una racin equivale: 1 onza 1 onza 1 onza 1 onza 1 onza 1 onza 1 onza 1 onza 1 onza 1/4 taza 2 mediano
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Requesn Sardinas
Pollo parte oscura, sin piel Salmn, espada, arenque
Pavo parte oscura, sin piel
Res magra (falda, asado a la Londinense, lomo, rosbif)*
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Ternera, asada chuleta magra* Cordero, asada chuleta magra* Cerdo, lomo jamn fresco*
Queso bajos en grasa (3 gramos menos de grasa por onza) Embutidos bajos en grasa (con 3 gramos menos de grasa por onza)
* Limite a 1-2 veces por semana

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Protenas de Grasa Moderada contienen 75 caloras y 5 gramos de grasa por porcin. Una porcin equivale a: 1 onza 1 onza 1 cantidad 1 onza 1/4 taza 4 onzas Res (cualquier corte de primera calidad), cecina de vaca, res molida** Chuleta de cerdo Huevo entero (mediano) ** Queso mozzarella Requesn Tofu /Queso de soya (Note que esta es una seleccin saludable para el corazn) ** Seleccione estos alimentos menos frecuentemente
Almidones contienen 15 gramos de carbohidratos y 80 caloras por porcin. Una racin equivale a: 1 rebanada 2 rebanadas 1/4 (1 onza) 1/2 1/2 3/4 taza Pan (blanco, integral de centeno, integral, centeno)
1/3 taza 1/3 taza 1/3 taza 1/2 taza 1/2 taza 1/2 taza 3 onza
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Tortita (Inglesa) Panecillo Cereal Pasta- cocida Trigo cocido Pretzels
Pan de caloras reducida liviano
Rosquillas (varias)
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Arroz, integral blanco, cocido
Cebada cuscus - cocido Legumbres (frijoles secos, guisantes lentejas)- cocidos
Maz, batata guisante verde Papa batata horneada Palomitas de maz, cocidos en aire caliente o en microonda (80% bajo en caloras)
3/4 onza 3 taza

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Grasas contienen 45 caloras y 5 gramos de grasa por porcin. Una porcin equivale a: 1 cucharadita 1 cucharadita 1 cucharadita 1 cucharadita 1 cucharada 1 cucharada 1 cucharada 2 cucharadas 1/8 8 grande 10 grandes 1 rebanada Aceite (vegetal, maz, canola, oliva, etctera) Mantequilla Margarina en barra Mayonesa Mayonesa margarina baja en grasa Aderezo Queso crema Queso crema baja en grasa Aguacate Aceitunas negras Aceitunas verdes rellenas
Referencia: Basado en la lista de sustitutos provisto por la Asociacin Diettica Americana
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Consejos para Estar Ms Saludable!

Use
verduras y granos integrales como el foco principal de sus comidas.
Mantenga
meriendas saludables visibles y a la mano tales como frutas frescas, verduras, cereales integrales, nueces sin sal, y yogur bajo en grasa; Ser ms fcil consumirlos! nueces y frutas por encima de sus ensaladas, avena, cereal.
Aada Use Si
fruta como postre; las frutas y el yogur hacen un postre magnifico!
come almuerzo sobre la marcha, seleccione restaurantes con opciones saludables y traiga sus propios acompaantes (frutas, verduras, cctel de frutas secos). en su mercado local comidas saludables fciles de preparar que requieran poca ninguna preparacin. mayoras de las tiendas de conveniencia y gasolineras venden frutas frescas, leche baja de grasa, y yogur.
Busque
La
Seleccione Cocine
al horno, en la estufa, a la parrilla en vez de frer; cocine verduras al vapor para conservar los nutrientes. LA ETIQUETA DE LOS ALIMENTOS y los ingredientes; limite las comidas con grasas hidrogenadas y aceites parcialmente hidrogenados. el consumo de granos integrales; seleccione productos que incluyen tienen los granos integrales enlistado como el primer ingrediente. el tamao de las porciones. Use sus tazas de medir por varias semanas hasta que puede fijar las cantidades por usted mismo.
aceites saludables tales como de oliva y vegetal.
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LEA
Aumente
Controle

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En Vez de: 1/2 taza aceite 1 taza crema de leche 1 taza manteca vegetal/manteca 1 huevo 1 taza harina de todo uso Aceite para frer
Sustituya por 1/2 taza pur de manzana sin edulcorante 1 taza leche evaporada sin grasa 3/4 taza aceite margarina para untar (tarrina) 1 clara de huevo + 2 cucharadita de aceite vegetal sustituto de huevo
Sal
Queso americano procesado
Verduras y frijoles enlatadas
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1/2 taza harina de todo uso y 1/2 taza harina integral Vino, jerez, vinagre, caldo bajo en sodio, jugo de tomate, jugo de lima/limn, leche sin grasa, agua Ajo, cebollas, hierbas, especias, lima, pimienta, Mrs. Dash Pruebe una variedad de quesos, algunos son ms bajo en grasa: mozzarella hecho con leche sin grasa; provolone; queso suizo; cheddar marca Cabot bajo en grasa, queso soya (queso vegetariano); controle sus porciones Busque en las etiquetas por la frase Sin Sal Aadido o escurra ante de cocinar para disminuir la cantidad de sodio. Recuerde que las frescas y congeladas con las mejores! Busque por los cortes lomo redondo para seleccionar res cerdo; un corte redondo de res tiene menos grasa de la carne oscura de pollo
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Escrito por: Catherine Cashman, MSH, RD, LD/N, Universidad del Norte de la Florida 2004
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Nutrition Education for Adult Obesity (Spanish Version)

EDUCACIN NUTRICIONAL PARA EL ADULTO OBESO
Nombre: Peso Actual: Peso Meta: Caloras Total:es Prdida de Peso Por Semana: Dietista: # de Telfono
Control de Caloras y Raciones para Perder Peso/Mantener el Peso

CONSEJOS: Tome 8 tazas de agua cada da (1 taza
= 8 oz.). Evite comida tales como bizcochos, pasteles, papitas fritas, y refrescos. Consuma porciones pequeas. Seleccione alimentos nutritivos tales como granos integrales
Grasas, Aceites, Dulces

Queso Crema, Mayonesa, Mantequilla, Aderezo
_____# de Porciones
Leche, Yogur, Queso
_____# de Porciones
Grupo de Verduras
_____# de Porciones
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taza cocido crudo 1 taza hojas crudas taza jugo
1 taza de leche desnatada de 1% grasa 1 taza de yogur bajo de grasa 1 oz. queso bajo en grasa
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Carne, Mantequilla de man, Huevos, Frijoles Secos _____# de Porciones Grupo de Frutas _____# de Porciones
1 taza fresca, enlatada en sirope liviana, jugo 3/4 taza 100% jugo
Pan, cereal, arroz, pasta, galletas, panqueques, molletes 1 rebanada de pan integral 1/2 taza de cereales integrales 1/3 taza de arroz integral 1/2 taza de pasta integral 4 galletas de granos integrales _____# de Porciones
Escrito por: Heather Huffman, MS, RD, LD/N

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LISTA DE COMPRAS SALUDABLE

Bebidas: Frutas: Te sin edulcorante Consejo: Seleccione fresca. Refresco de dieta Si es enlatada, escoge fruta en 100% jugo de fruta sirope liviana o en su propio jugo. Pan integral Manzanas 100% jugo de verdura Tortillas integrales Naranjas Agua embotellada Arroz integral Bananos Pasta integral Melocotones Otros Productos Enlatados/en Fresas Jarros: Arndanos Mantequilla de man baja Peras en grasa Uvas Salsa de tomate Sanda Frijoles Cereal: Meln Pur de manzanas Consejo: Seleccione cereales con Pia Atn en agua >5g de fibra por racin Toronja Concentrado de tomate Cereal integral Pan/Granos: Consejo: Seleccione productos 100% integrales Avena Trigo molido
Productos Lcteos: Consejo: Seleccione productos bajos en grasa sin grasa. Leche desnatada baja en grasa Yogur bajo en grasa Queso bajo en grasa Helado bajo en grasa
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Carne: Consejo: Seleccione trozos de carnes magras. Quite la grasa visible antes de cocinar. Pechuga de pollo Pechuga de pavo Pescado
Consejos de Compras: Use una lista de compras le ayudar a planificar comidas saludables. Nunca vaya al mercado con hambre. Trate de planear sus comidas dndole nfasis a las verduras, frutas, y granos integrales, en vez de carne. Trate de llenar su carrito de compras con frutas y verduras frescas. PLANIFIQUE! Sepa lo que quiere comprar antes de ir y compre solamente lo que esta en su lista de compras. Escrito por: Dr. Susan Moyers
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Seleccione comidas que son preparadas de esta manera: Ahumado a la Parrilla Horneado Asado Hervido
Incluye una ensalada pequea con aderezo bajo en grasa para aumentar la ingestin de verduras.
Comparta su Comida! Divida la comida en mitad. Mitad de las caloras. Mitad de la grasa. Pregunte por una caja cuando pida su comida y guarde mitad de la comida para el prximo da.
PREGUNTA: Pregntele al mesero como la comida va a ser preparada. Pregunte por alternativas bajas en grasa sin grasa. Pida que pongan los condimentos al lado del plato. EVITE: Comidas fritas. Salsas de crema. Los refrescos! (Son altos en azcar.) Los postres altos en caloras.
Escrito por: Dra. Susan Moyers
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Nutrition Education for (Spanish Version) Dental Health

Escrito por: Judith C. Rodrguez, PhD, RD, LD/N, FADA, Catedrtica de la Universidad del Norte de la Florida Revisado por: Brittney Berling, Pamela Gregory, Kate Strubbe, Programa Graduado de Nutricin de la Universidad del Norte de la Florida, Jacksonville, Franklin M. Ros, DMD, Cypress Point Family Dentistry, Jacksonville, Florida Versin al espaol escrito por: Nancy J. Correa-Matos RD. PhD, de la Universidad del Norte de la Florida
EDUCACIN NUTRICIONAL PARA LA SALUD DENTAL Y ORAL

INTRODUCCIN
Durante todas las etapas de la vida, la salud dental/oral esta influenciada por el estado de salud en general. Es importante promover la prctica saludable de la higiene oral desde la infancia y durante toda la vida. Esto ayudara a prevenir las caries dentales y las enfermedades periodontales. Usted debe establecer una rutina simple, efectiva y llevadera para promover la salud dental y oral. PROPSITO
El propsito de la promocin de una buena salud dental es para mantener la salud y prevenir caries dentales, enfermedades periodontales y dolores asociados a enfermedades orales. Ms aun, la salud puede afectar y a la vez, ser afectada por enfermedades en las cuales la dieta y la intervencin nutricional es importante, como lo son la diabetes y las enfermedades cardiovasculares. La gingivitis o inflamacin de las encas (gingiva), es la etapa primaria de la enfermedad de las encas. La enfermedad periodontal es una infeccin bacteriana que destruye la enca y los tejidos que rodean y que proveen soporte a los dientes, causando la perdida de los mismos, pero existen cosas que tu puedes hacer como parte de tu rutina diaria que ayudan a promover la salud dental, prevenir la gingivitis y la enfermedad periodontal. Las enfermedades periodontales ocurren debido a: Higiene oral diaria inadecuada Falta de limpieza dental profesional Dietas inadecuadas no-balanceadas Dentaduras u otros equipos dentales que no se ajustan adecuadamente Dientes rellenos rotos cados Dientes apiados mal acomodados Factores sistmicos (desbalances nutricionales, diabetes, SIDA y cncer) Medicamentos, especialmente si causa resequedad en la boca
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Estas recomendaciones le ayudaran a tener una buena salud dental y oral
Considere
La cantidad y tipo de carbohidratos
Pregntese
Tendr un contenido alto de azcar, especialmente de azcar aadida?
Por qu?
Las azcares, especialmente la sacarosa (sucrosa), otras azcares aadidas y otros carbohidratos fermentables, pueden convertirse en cidos en la boca. Este acido puede destruir el esmalte de los dientes y causar caries dentales. Cuando las azucares se consumen solas, se convierten ms rpidamente en cidos. Muchos alimentos ofrecen alguna proteccin reduciendo la produccin de cidos. Mientras ms usted mastique los alimentos, ms saliva va a producir, y esto ayuda a remover las comidas de los dientes. Mientras ms veces haya comida en la boca, ms oportunidad existe para que se produzcan cidos.
La combinacin de los alimentos
Esta usted tomando refrescos con su comida o esta tomado solo el refresco?
La frecuencia de las comidas
Adherencia y consistencia
Tiempo en que la comida esta en la boca
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Esta usted comiendo picando frecuentemente durante el da? Se adhiere se pega la comida a los dientes? Esta usted comiendo rpidamente, permite que la comida este en su boca por mucho tiempo? Es esta una comida saludable o es un alimento alto en caloras vacas?
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Mientras ms se adhiera se pegue la comida en los dientes, mayor es la oportunidad para que se produzcan cidos. Mientras ms tiempo este la comida en la boca, mayor es el tiempo en que el acido esta expuesto a los dientes.
Tipo de comidas
Los alimentos saludables como las frutas y las verduras, contienen una combinacin de nutrientes tales como vitaminas, fibra y agua, los cuales estimulan la masticacin y la produccin de saliva y estos ayudan a mantener las encas y los dientes saludables.

R15.3S

GUAS ALIMENTARIAS Existe evidencia que el consumo frecuente de azucares y otros carbohidratos fermentables esta asociado con el desarrollo de caries dentales y enfermedades periodontales. Existen guas generales para las personas de todas las edades y etapas de la vida, y tambin, para diferentes enfermedades y condiciones de salud. El consumir una dieta saludable, moderada en azucares simples, como lo recomiendan Las Guas Dietarias para los Americanos, publicada por el Departamento de Agricultura de los Estados Unidos y el Departamento de Salud y Servicios Humanos, ayuda a promover la salud total y adems la salud dental y oral. EMBARAZO
Los cambios hormonales que ocurren en esta etapa, pueden aumentar los riesgos padecer de caries dentales, gingivitis, o enfermedades periodontales.

Utilice una pasta de dientes suave que contenga fluoruro si usted padece de nauseas en la maana Utilice el hilo dental, cepille y enjuague su boca con agua para remover el exceso de partculas en la boca al consumir meriendas frecuentes, para nauseas en las maanas Enjuague su boca frecuentemente con agua si esta vomitando Hgase una limpieza dental profesional durante el segundo trimestre Mastique goma de mascar con xylitol Evite exponerse a rayos X
INFANCIA Y NIEZ
Esta es una etapa muy importante para establecer comportamientos saludables para el cuidado de su salud dental y oral y que estos duren para toda la vida.

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Lacte a su beb Evite poner a dormir a su beb con la botella en la boca Evite compartir utensilios de comer, vasos y chupetes Evite las bebidas dulces y carbonatadas Limpie los dientes del beb con una toalla limpia despus de tomar la leche Limpie los dientes del beb con un cepillo de dientes especial una vez los dientes hayan salido Enjuague su boca despus de comer
R15.4S

Use hilo dental una vez el nio tenga dientes que se puedan tocar Haga un examen dental regular a partir de seis meses luego de que le salgan los dientes y no ms tarde de 12 meses de edad El nio debe tomar de un vaso desde el primer ao de edad Evite el consumo prolongado de lquidos con azcar Ensee a su nio a cepillarse los dientes por dos minutos, por lo menos, dos veces al da Utilice por lo menos, la cantidad de pasta de dientes con fluoruro equivalente al tamao de un guisante Asegrese que su nio escupa toda la pasta cuando se cepille los dientes Use un cepillo de dientes de cerdas suaves Introduzca el uso del cepillo de dientes en la etapa andante (toddler) y reemplace el cepillo cada tres a cuatro meses Supervise al nio mientras se cepilla los dientes y use el hilo dental para asegurarse de que lo esta haciendo correctamente Evite enjuagadores bucales con fluoruro en nios menores de seis anos de edad Estimule a su nio a que aprenda a lavarse los dientes correctamente y que pueda hacerlo por si solo a partir de los siete aos de edad
ADOLESCENCIA
Las bebidas carbonatadas y otras bebidas, muchas veces conocidas como lquidos dulces son la mayor fuente de azucares aadidas en la dieta de los nios y adolescentes.

Estimule le consumo de meriendas saludables Estimule las visitas regulares al profesional de la salud dental para limpiezas y revisiones rutinarias
ADULTEZ
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Esta etapa es muy importante para mantener la salud oral, para prevenir problemas dentales en los aos futuros, y para mantener la salud de los dientes permanentes, ya que dientes desgastados, rallados, con aberturas prtesis dentales poco ajustadas, pueden contribuir al deterioro de la salud dental al mantener atrapados depsitos de comidas en los dientes.

Cepille sus dientes por lo menos dos veces al da por dos minutos en cada cepillado Use el hilo dental diariamente Use pasta de dientes con fluoruro y enjuagador bucal con agente antimicrobiales Consuma una dieta balanceada y limite el numero de meriendas entre las comidas
R15.5S
Seleccione meriendas nutritivas como las manzanas, zanahorias, quesos, nueces, yogur sin azcar aadida. Limite las comidas azucaradas como las sodas, caramelos y galletas Cepille los dientes despus de la comidas, y si no se puede cepillar, entonces enjuague su boca con agua Visite a su dentista con regularidad para limpiezas profesionales y revisiones dentales
GUAS GENERALES SI USA DENTADURAS

Use limpiadores especiales para dentaduras diariamente Utilice un cepillo especial para limpiar dentaduras Busque limpiadores para dentaduras que lleven el sello de aprobacin de la Asociacin Americana de Dentistas (ADA Seal of Acceptance) Coloque sus dentaduras en una solucin limpiadora o en agua cuando no lo este usando de manera que no pierdan su forma Visite a su dentista con regularidad para mantener el ajuste correcto en su dentadura para reemplazar dentaduras defectuosas Consuma comidas saludables y nutritivas para mantener su salud oral y dental OTRAS CONSIDERACIONES
Si sus destrezas manuales estn limitadas debido a una enfermedad o incapacidad, usted puede beneficiarse con el uso de un cepillo de dientes elctrico. Una mordedura pobre puede causar inestabilidad en la boca, limitar el disfrute de ciertos alimentos y puede aumentar el deterioro dental El deterioro dental se puede prevenir con la deteccin temprana y la consulta con el dentista durante sus visitas regulares. Las pastas de dientes que contienen fluoruro y enjuagadores bucales con agentes antimicrobiales deben tener el sello de aceptacin de la Asociacin Americana de Dentistas (ADA Seal of Acceptance) afirmando que estos productos han probados ser efectivos en la reduccin de placas dentales y gingivitis. Los procedimientos para blanquear los dientes deben ser llevados a cabo en las oficinas dentales o en el hogar. El sello de aceptacin de la Asociacin Americana de Dentistas (ADA Seal of Acceptance) indica que este producto ha cumplido con los requisitos de seguridad y efectividad. REFERENCIAS 1. American Academy of Pediatric Dentistry. Public and Professional Education
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R15.6S

http://www.aapd.org/foundation/education.asp 2. American Dental Association. Manage Your Oral Health. http://www.ada.org/public/media/videos/minute/index.asp 3. American Dietetic Association. Oral Health and Nutrition http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/advocacy_1743_ENU_HTML.htm 4. American Dietetic Association. The impact of fluoride on health http://www.eatright.org/cps/de/xchg/ada/hs.xsl/home_3795_ENU_HTML.htm
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Index
A
Activity factor, A1.9-A1.10, C1.3 Acute kidney failure, M2.1 ADHD, G6.1 Adolescent nutrition , E3.1 Adequacy in, E3.4 Athletes, E3.4 Dietary guidelines, E3.6 Eating disorders, E3.4 Food choices, E3.1 Obesity, E3.3, B3.1 Pregnancy, E3.3 Sample menu for, E3.10 Adult nutrition assessment, A1.1 Amputations, A1.6 Anemias, A1.12 Anthropometric data, A1.3 Activity Factor, A1.9, A1.10 Biochemical data, A1.11 BMI, A1.8, B2.3 Calorie needs, A1.9 Clinical evaluation, A1.2 Diet history and intake data, A1.1 Elbow breadth, A1,4 Energy needs, A1.8 Fluid requirements, A1.11 Frame size, A1.4 Height, A1.4 Hamwi formula, A1.5, A1.9 Harris-Benedict, A1.9 Hematological, A1.12 Injury factors, A1.9 Immunological, A1.17 Lab values, A1.11 Malnutrition, A1.17 Medical history, A1.11 Midarm muscle circumference, A1.7 Nitrogen balance, A1.10 Paraplegic, A1.6 Percent IBW, A1.6 Percent weight loss, A1.6 Protein needs, A1.10 Quadriplegic, A1.6 Skinfold thickness, A1.7 Weight, A1.4 Adult nutrition for weight loss, B2.1 Assessment, B2.2 BMI Tables, B2.3
S1.1
Exchange lists, B2.12 Nutrition education materials, B2.12 Nutrition therapy, B2.5 Physical activity, B2.7 Step 1 diet, B2.6 Weight maintenance, B2.8 AIDS, N5.1 Alcohol and drug abuse, G3.1 Nutrition education materials, G3.4 Allergies to food, P1.1 Alternative medicine, C8.1 Clinical centers, C8.16 Commonly used herbs, C8.14 Commonly used supplements, C8.13 Commonly used therapies, C8.12 Definitions, C8.1 Dietary supplements, C8.2 Resources, C8.5 Supplement labels, C8.3 Alzheimers disease, D5.4, D9.2 Amino acids, C2.7 Amputees, ideal body weight, A1.5 Anemia, A1.12, D12.1 Anorexia nervosa, G1.1 Description of, G1.2 Diagnostic criteria, G1.2 Nutrition therapy for, G1.6, G1.9, G1.12 Signs and symptoms, G1.5 Anthropometric measurements, A1.3 Asian diet pyramid, D1.5, D1.22 Athletic performance, C1.1 Autism, G7.1
T S E
R D
B
E IV
Bariatric surgery, C3.1 Anemia, C3.6 Nutrition education materials, C3.10 BEE (Basal Energy Expenditure), A1.9 B vitamins, D2.12 Behavior modification and weight, B2.7 Biliopancreatic diversion (BPD), C3.3 Biochemical assessment, A1.11 Bland Diet, K4.1 Nutrition education materials, K4.3 Blenderized liquid diets, see pureed diet Blood pressure, see hypertension
Index
Body fat, A1.7 Body mass index (BMI), A1.8, B2.3 Bread, low protein, L1.8 Breast feeding, D4.1 Advantages of, D4.6 Guidelines for, D4.3 Resources, D4.6 Bulimia nervosa, G1.1 Description of, G1.2 Diagnostic criteria, G1.2 Nutrition therapy for, G1.6, G1.9, G1.12 Signs and symptoms, G1.5 Burns, adult, N1.1 Calorie requirements, N1.2 Curreri formula, N1.2 Ireton-Jones formula, N1.2 Parenteral nutrition, N1.3 Monitoring nutrition, N1.4 Radiotherapy, N2.3 Resources, N2.15 Taste alterations, N2.9 Carbohydrates, J1.4 Celiac disease, P3.1 Children 1-10 years, E2.1 Dental health, E2.2 Feeding skill development, E2.1 Food choices, E2.8 Nutrition education materials, E2.4 Childrens weight control, B3.1 Adequacy, B3.2 BMI Tables, B3.4 Educations materials, B3.6 Guidelines for meal planning, B3.6 Recommended weight goals, B3.2 Chemical dependency treatment, G3.1 Vitamin-mineral deficiencies associated with substance abuse, G3.2 Cholesterol, H1.3 Congestive heart failure, H2.1 Nutrient drug considerations, H2.2 Coronary heart disease and hyperlipidemia, H1.1 ATP III lipid classifications, H1.2 CHD risk factors, H1.1 Therapeutic Lifestyle Changes (TLC diet) H1.3 Nutrition education materials, H1.8 Chronic obstructive pulmonary disease, N4.1 Chronic peptic ulcer disease diet, K4.1 Chronic kidney disease stage 5, M2.1 Body weight calculations, M2.10 Diabetic modifications, M2.6 Enteral supplements, M2.15 Hemodialysis, M2.1 Hyperlipidemia management, M2.6 Intradialytic parenteral nutrition (IDPN), M2.2 Meal planning, M2.25 Modification in, M2.25 National Renal Diet food choices, M2.12 Nutrient needs calculations, M2.10 Nutrition recommendations, M2.3 Nutrition supplements, M2.15-2.16 Peritoneal dialysis, M2.2 Resources, M2.18 Standard body weights, M2.11
S1.2
C Caffeine, C13.1
Calcium, D11.4, B2.12 In chronic kidney disease stages 1-4, M1.2 In chronic kidney disease stage 5, M2.5 In osteoporosis, D11.3 In vegetarian diet, C2.3 Calorimetry, A 4.1 Calories, A1.9 Burns, N1.2 Cancer, N2.2 COPD, N4.1 Elderly, D5.3 HIV/AIDS, N5.7 Lactation, D4.2 Pregnancy, D3.2 Weight loss, B2.5 Cancer, N2.1 Cachexia, N2.1 Calorie needs, N2.2 Chemotherapy, N2.3 Dietary guidelines, N2.8 Low bacteria diet, N2.5 Neutropenic diet, N2.3 Nutrition education materials, N2.8 Prevention, N2.2
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Index
Chronic kidney disease stages 1-4, M1.1 Daily nutrient and fluid recommendations, M1.3 Dietary guidelines, M1.6 Food lists for, M1.7 Meal patterns, M1.7 Modifications in, M1.6 Nutrient recommendations, M1.1 Purpose of, M1.1 Sample menu for, M1.9, M1.10 Stages of chronic kidney disease, M1.1 Chronic kidney failure, see chronic kidney disease stage 5 Cirrhosis, L3.1, L1.1 Nutrition therapy, L1.4 Clear liquid diet, F1.1 Recommended foods in, F1.2 Sample menu for, F1.2 Complementary and alternative medicine, C8.1 Clinical centers, C8.16 Commonly used herbs, C8.14 Commonly used supplements, C8.13 Commonly used therapies, C8.12 Definitions, C8.1 Dietary supplements, C8.2 Resources, C8.5 Supplement labels, C8.3 Complementary proteins, C2.7 Congestive heart failure, H2.1 Drug / nutrient considerations, H2.2 Nutrients modified, H2.1 Use of, E1.1 Continuous administration of tube feedings, O1.2 Creatinine height index, A1.16 Crohns disease, pediatrics, E9.1 Crohns disease, adults, K3.1 Cultural Diversity, A3.1 Curreri formula, N1.2 Cystic fibrosis, E8.1 Life cycle, E8.3 Nutritional assessment and monitoring, E8.2 Nutrition education materials, E8. 7 Sample menu, E8.8 Special circumstances, E8.4
S1.3
D
Danish dessert, recipe for, L1.7 DASH diet, I1.5, I2.1 Nutrition education materials, I2.3 Decubitus Ulcers, D9.10, D13.1 Dental health, C10.1 Depression, G5.1 Diarrhea in children, E4.1 Commonly used rehydration solutions, E4.3 Oral rehydration solutions, E4.1 Nutrition education materials, E4.4 Diabetes mellitus, J1.1 Alternate sweeteners, J1.4, J2.3 Amputations, J6.1 Carbohydrate counting, J1.7 Children and adolescents, J1.8 Classification, J1.5 Diagnostic criteria, J1.6 Definition and description, J1.2 Enteral nutrition, J1.10 Exchange lists, B2.12, J1.22 Exercise and stress, J1.8 Gastropathy, J1.9 Gastroparesis, J1.9 Goals of MNT, J1.1 Insulins and actions, J1.15 Meal planning, J1.17, J1.22 Oral hypoglycemic agents, J1.12 Prediabetes, J1.7 Nutrition education materials, J1.20 Nutrition intervention, J1.7 Sick days, J1.31, J2.3 Snack bars, J1.21 Diabetes self-management, J2.1 Alcohol management, J2.3 Alternate sweeteners, J1.4, J2.3 Exercise, J2.3 Hypoglycemia, J2.4 Meal planning, J2.4 Sick days, J1.31, J2.3 Dietary fiber, K2.1 Dietary, recommended allowances (RDA), C7.1 Dietary Reference Intakes (DRI), C7.1 Diverse populations, A3.1 Diverticulitis, K3.1 Dopamine and tyramine restricted diet, P8.1
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E IV
Index
Drugs Over-the-counter, sodium content, H3.1 Dumping syndrome, K5.1 Dysphagia diet, F6.1 Dysphagia Outcome and Severity Scale, F6.1 Liquids, F6.14 National Dysphagia Diet, F6.1 Nutrition education materials, F6.11 Recommended foods, F6.13 Ethnic food guides, D1.4, D1.21-1.24 Exogenous hypoglycemia, J4.1 Exchange lists, B2.12
S1.4
F
Fasting hypoglycemia, J4.1 Fat restricted diet, L2.1 Fat soluble vitamins, D2.12 Fever factor, A1.9 Fiber, high, K2.1 Fiber content, H1.10, K2.3 Nutrition education materials, K2.4 Fitness, C1.1 Fluid replacement drinks, C1.4 Food allergies, P1.1 Classification system, P1.1 Diagnosis, P1.2 Elimination diet, P1.2 Immune reactions, P1.1 Food guide pyramids, D1.14-1.24 Food labeling, C6.1 Nutrition education materials, C6.8 Folate, folic acid and folacin, C11.1 Frame size, formula for determining, A1.4 Full liquid diet, F2.1 Nutrition education materials, F2.2 Recommended foods, F2.3 Sample menu, F2.4 Functional foods, C9.1
E
Eating disorders, G1.1 Approaches to health enhancement, G1.13 Food guide, G1.19 Diagnostic criteria, G1.2 Exercise, G1.7 Nutrition assessment, G1.9 Nutrition education materials, G Nutrition therapy, G1.6, G1.9 Pharmacotherapy, G1.8 Signs and symptoms, G1.5 Special considerations, G1.14 Treatment overview, G1.6 Eating disorders not otherwise specified (EDNOS), G1.3 Diagnostic criteria, G1.3 Education and counseling, A2.1 Behavioral theories, A2.3 Learning objectives, A2.12 Egg free diet, P2.1 Elimination diet, P1.2 End stage renal failure, see Chronic Kidney Disease stage 5 Enteral nutrition support, O1.1 Access, O1.1 Contraindications, O1.1 Formula selection, O1.1 Gastrointestinal complications, O1.4 Indications, O1.1 Mechanical complications, O1.4 Metabolic complications, O1.5 Monitoring guidelines, O1.2 Route of administration, O1.2 Esophageal reflux diet, K1.1 Esophagitis, K1.1
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G
E IV
Galactosemia, E13.1 Gall bladder disease, L2.1 Gastric bypass, see Bariatric surgery Anemia, C3.6 Vertical banded gastroplasty, C3.2 Nutrition education materials, C3.10 Gastroparesis, J1.9 Geriatric nutrition, D5.1 Fluid requirements, D5.4 Malnutrition and weight loss, D5.4 Nutrient requirements, D5.3 Pressure sore development, D5.5 Side effects of medication, D5.2 Swallowing problems, D5.3
Index
GERD, K1.1 Gestational diabetes, J5.1 Insulin requirements, J5.2 Nutrition education materials, J5.5 GI Disorders, Section K Bland diet, K4.1 GERD, K1.1 High Fiber, K2.1 Low residue diet, K3.1 Post-gastrectomy, K5.1 Glucose self-monitoring, J2.2 Chart for self-monitoring, J1.28 Glucose tolerance test, Q1.1 Gluten Gliaden free diet, P3.1 Nutrition education materials, P3.3 Growth charts infants and children, E16.1 Hypoglycemia, functional reactive, J4.1 Nutrition education materials, J4.3 Hypoglycemia secondary to diabetes, J3.1 Nutrition education materials, J3.3 Treatment, J3.5
S1.5
I
Inborn errors of metabolism, E12.1-E14.1 Galactosemia, E13.1 Maple syrup urine disease, E14.1 Phenylketonuria, E12.1 Infant nutrition (0-12 months), E1.1 Infant development and feeding skills, E1.5 Infant expected weight gain, E1.1 Infant food safety, E1.10 Infant formula preparation, E1.9 Infant nutrition, E1.1 Infant nutrition education materials, E1.7 Inflammatory bowel disease, adult,K3.1, P3.1 Inflammatory bowel disease, pediatric/ adolescent, E9.1 Ulcerative colitis, E9.1 Crohns disease, E9.1 Nutrients of concerns, E9.2 Nutrition support, E9.3 Nutrition education materials, E9. 5 Injury factor, A1.9 Insulin, J1.15 Iron in health promotion and disease prevention, C12.1
H
Hamwi formula, A1.5, A1.9 Harris-Benedict formula, A1.9 Headaches, G4.1 Health at every size, B5.1 Nutrition education materials, B5.20 Heart transplant, H4.1 Helicobacter pylori infection, K4.1 Hemigastrectomy, K5.1 Hemodialysis, M2.1 Hepatitis, L3.1, L1.1 Nutrition therapy, L1.4 Hepatic encephalopathy, L1.1 Nutrition therapy, L1.4 Hiatal hernia, K1.1 High biologic value protein, M1.1 High calorie high protein diet, D10.1 HIV / AIDS, N5.1 Classification system, N5.2 Drug / nutrient interaction, N5.5 Enteral / parenteral nutrition, N5.7 Medications, N5.3 Nutrient goals, N5.7 Unproven therapies, N5.7 Hyperlipidemias, H1.1 Hypertension, I1.1 Classification of blood pressure, I1.2 Nutrition therapy, I1.2 DASH diet, I1.5
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J K
E IV
Jejunostomy tube, E6.3, O1.1
Ketogenic diet, E15.1 Treatment centers in Florida, E15.2 Kwashiorkor, A1.17
Index
L
Label at a glance, C6.8 Laboratory values, A1.11 Lactation, D4.1 Recommended nutrient intakes, D4.2 Nutrition education materials, D4.3 Lactose restricted diet, P4.1 Nutrition education materials, P4.3 Laproscopic adjustable gastric band, C3.2 Latex sensitivity / allergy, P9.1 Liberal geriatric diet, D.6.1 Nutrition interventions, D6.2 Liver disorders, L1.1 L4.1 Cirrhosis, L4.1 Hepatitis, L3.1 Long term care nutrition, D9.1 Decubitus ulcer stages and nutrition needs, D9.10 Low bacteria diet, NG.5 Low density lipoproteins (LDL), H1.1 Low residue diet, K3.1 Nutrition education materials, K3.3
S1.6
N
National Cholesterol Education Program Guidelines, H1.1 Neurological and mental disorders, G3.1 Neutropenic diet, G2.5 Nitrogen balance studies, A1.15 No added salt diet, D8.1 Nutrition education materials, D8.3 No Concentrated sweets diet, D7.1 Nutrition education materials, D7.2 Nutrition assessment, A1.1 Nutrition care process, A5.1 Nutrition guidelines and recommended food patterns, D1.1 Dietary Guidelines for Americans, D1.5 Food guides, D1.1 Food guide pyramid, D1.2, D1.14 Food guide pyramids, D1.14-1.24 Resources for education and counseling, D1.10
Maple syrup urine disease, E14.1 Malabsorption syndromes, L2.1 Marasmus, A1.17 MCT oil, L2.1 Mechanical soft diet, F4.1 Nutrition education materials, F4.2 Recommended foods, F4.3 Sample menu, F4.4 Medical foods (PKU), E12. 4 Mediterranean Diet, D1.4, D1.21 Metabolic syndrome, C4.1 Diagnostic criteria, C4.2 Nutrition education materials, C4.13 Mifflin-St Jeor, A5.1 Milk-free diet, P5.1 Nutrition education materials, P5.4 Minerals, D2.12, C7.1 Monoamine oxidase inhibitors (MAOI) drugs, diet for, P8.1
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O
Obesity Treatment in Adults, B1.1 Nutrition assessment, B1.5 Pharmacotherapy, B1.6 Physical activity, B1.13 Maintenance, B1.14 Patient education materials, B1.22 Obesity in Children, B3.1 Omega-3 fatty acids, C2.4, H1.4 Online nutrition resources, C5.1 Oral hydration solutions, E4.3 Oral hydration therapy, E4.1 Organ transplant, N3.1 Osteoporosis, D11.1 Calcium content of common foods, D11.4 Classification, D11.1 Nutrition education materials, D11.7 Prevention, D11.2 Treatment, D11.5
E IV
Index
Pancreatic enzyme replacement therapy, E8.3 Pancreatitis, N3.2, L2.1 Paraplegic assessment, A1.6 Parenteral nutrition support, O2.1 Access, O2.1 Amino acid solutions, O2.2 Contraindications, O2.1 Complications, O2.6, O2.8 Electrolyte requirements, O2.4 Indications, O2.1 Macronutrients, O2.1 Micronutrients, O2.5 Mineral requirements, O2.3 Monitoring guidelines, O2.5 Transitioning, O2.7 Vitamin requirements, O2.3 Writing solution orders, O2.9 Parkinsons disease, D10.1 Pediatric enteral nutrition, E6.1 Complications, E6.4 Initiation of feeding, E6.1 Routes of intubation, E6.2 Special concerns, E6.5 Tolerance, E6.3 Pediatric HIV / AIDS, E11.1 Classification, E11.2 Clinical manifestations, E11.3 Definition of, E11.2 Infection-immunity-nutrition-interaction, E11.3 Nutrition assessment, E11.4 Nutrition education materials, E11.8 Nutrition management, E11.5 Transmission, E11.1 Pediatric insulin-dependent diabetes mellitus (IDDM), E10.1 Hypoglycemia, E10. 2 Meal planning guidelines, E10.2 Pediatric nutrition, See E1.1E15.1 Pediatric parenteral nutrition, E7.1 Access routes, E7. 2 Complications and monitoring, E7.7 Initiation, E7.1 Nutrient recommendations, E7.3 Peptic ulcer disease, K4.1 Peritoneal dialysis, M2.2 Pharmacological ergogenic aids, C1.6 Phenylketonuria, E12.1 Medical foods, E12.4 Recommended daily intakes, E12.4 Sample menu, E12.8 Physical Activity, Adults, B1.13, B2.7 Physical Activity Children, B4.1 Physical activity pyramid for children, B4.3 Physical fitness and athletic performance, C1.1 Fluid requirements, C1.4 Glycogen loading, C1.5 Nutrient needs, C1.3 Ergogenic aids, C1.6 Plant stanols and sterols, H1.5 Post-gastrectomy diet, K5.1 Nutrition education materials, K5.3 Pregnancy, D3.1 Preconception nutrients, D3.2 Prenatal nutrients, D3.4 Required nutrients, D3.2 Weight status, D3.3 Nutrition education materials, D3.6 Pressure sore development, D9.10, D13.1 Preterm and low birth weight infants, E5.1 Commercial formulas, E5.5 Discharge summaries, E5.9 Human milk fortifiers, E5.6 Nutrient needs, E5.1 Nutrition support, E5.5 Poor growth, E5.9 Specialized formulasE5.7 Pro Mod, M2.16 Propofol, O2.2 Protein/calorie malnutrition, A1.17 Protein content of food groups, M2.12, B2.12 Protein restricted diet, L1.1 Protein controlled dietary supplement suppliers, L1.3 Protein controlled meal pattern, L1.9 Pureed diet, F3.1 Nutrition education materials, F3.3 Recommended foods, F3.4 Sample menu, F3.6 Purine controlled diet, P7.1 Pyloroplasty, K5.1
S1.7
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E IV
Q
Quadriplegic assessment, A1.6
Index
R
Reactive hypoglycemia, J4.1 Recipes Danish dessert, L1.8 High carbohydrate beverage, L1.8 Low protein bread, L1.8 Recommended dietary allowances, C7.1 Roux-N-Y, C3.4
S1.8
U
Ulcerative colitis, K3.1 Pediatric ulcerative colitis, E9.1 Usual body weight, A1.6
V
Vagotomy, K5.1 Vanillylmandelic acid (VMA) test diet, Q2.1 Vegetarian diet, C2.1 Classification, C2.2 Complementary proteins, C2.7 Daily food guide, C2.7, D1.19, D1.20 Key nutrients, C2.3 Recommended patterns for vegan, C2.11 Infants/children, C2.1 Very low calorie diets, B2.5 Vitamins, D2.12 Fat soluble. D2.12 Water soluble, D2.12
S
Saturated fats, H1.3 Semi-thick liquids, F6.14 Serving sizes, D1.9 Short bowel syndrome, K6.1 Sodium controlled diet, H3.1 3000-4000 mg Sodium diet, H3.6 Label terms, H3.2 Sodium free seasonings, H3.5 Sources of sodium, H3.2 Soft diet, F5.1 Nutrition education materials, F5.3 Recommended foods, F5.4 Sample menu, F5.6 Spanish nutrition education materials, R1.1R15.1 Standard body weight, M2.11 Step 1 diet, B2.6 Substance abuse nutrition, G3.1 Nutrition education materials, G3.4 Sweeteners, J1.4, J2.3
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W
E IV
Test diets, Q1.1-Q4.1 Glucose tolerance, Q1.1 100 gram fecal fat, Q3.1 Serotonin (5-HIAA) , Q4.1 VMA, Q2.1 Textural changes, F1.1-F6.1 Thick liquids, F6.14 Thin liquids, F6.14 Total gastrectomy, K5.1 Trans fatty acids, C6.2, H1.3 Tyramine and dopamine restricted diet, P8.1
Weight control diet, B2.6 Weight loss, adult, B2.1 Assessment, B2.2 BMI Tables, B2.3 Exchange lists, B2.12 Nutrition education materials, B2.12 Nutrition therapy, B2.5 Step 1 diet, B2.6 Weight maintenance, B2.8 Wellness, D2.1 Health continuum, D2.2 Nutrition education materials, D2.4 Wellness contract, D2.10 Wheat, egg and milk allergy diet, P6.1 Nutrition education materials, P6.3 Wheat flour equivalents, P6.3 Whipples procedure, K5.1 Wound Healing, D13.1
Z
Zinc, D2.12, D9.10

Test Drive: Manual of Medical Nutrition Therapy

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Florida Dietetic Association

Manual of Medical Nutrition Therapy

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Christine Stapell MS, RD, LD/N, Authors and Reviewers

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy Authors

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy Reviewers

Manual of Medical Nutrition Therapy 2011 Edition

C. Medical Nutrition Therapy for Contemporary Nutrition Issues

Metabolic Syndrome Food Labeling

Nutrition Resources Online

Dietary Reference Intake (DRI) Functional Foods

Complementary and Alternative Medicine Nutritional Care for Dental Health

D1.1 D2.1 D3.1 D4.1

Manual of Medical Nutrition Therapy 2011 Edition

F1.1 F2.1 F3.1 F4.1 F5.1 F6.1 F7.1

Manual of Medical Nutrition Therapy 2011 Edition

Parenteral Nutrition Support

Lactose Restricted Diet

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

1.0-1.2 1.1-1.3 1.1-1.6 1.6-1.8 1.0-1.2 1.2-1.4 1.4-1.8

Out of Bed Normal ADLs

Manual of Medical Nutrition Therapy 2011 Edition

For strenuous activity multiply DBW by 10

Kilocalorie per kilogram method

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy 2011 Edition

Table 2. Assessment of Hydration Status (19)

Norms 280-295 mOsm/kg 1.035 1.003 g/ml

Manual of Medical Nutrition Therapy 2011 Edition

MCV or Normal Normal or Normal

TIBC or Normal or Normal

Ferritin Normal Normal

Retic or Normal or Normal

Manual of Medical Nutrition Therapy 2011 Edition

Nutrition Education and Counseling

Manual of Medical Nutrition Therapy 2011 Edition

Nutrition Education and Counseling

Manual of Medical Nutrition Therapy 2011 Edition

Nutrition Education and Counseling

Behavioral Modification or Behavioral SelfManagement

Manual of Medical Nutrition Therapy 2011 Edition

Nutrition Education and Counseling

Consumer Information Processing Theory

Manual of Medical Nutrition Therapy 2011 Edition

Nutrition Education and Counseling

Manual of Medical Nutrition Therapy 2011 Edition

Nutrition Education and Counseling