Nutrition and Diet Therapy

FIFTH EDITION Nutrition and Diet Therapy Self-Instructional Approaches Peggy S. Stanfield, MS, RD/LD, CNS Dietetic Resources Twin Falls, Idaho Y. H. Hui, PhD West Sacramento, California

World Headquarters Jones and Bartlett Publishers Canada Jones and Bartlett Publishers Jones and Bartlett Publishers 6339 Ormindale Way International 40 Tall Pine Drive Mississauga, Ontario L5V 1J2 Sudbury, MA 01776 Canada Barb House, Barb Mews 978-443-5000 London W6 7PA [email protected] United Kingdom www.jbpub.com Jones and Bartlett’s books and products are available through most bookstores and online booksellers. To con- tact Jones and Bartlett Publishers directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jbpub.com. Substantial discounts on bulk quantities of Jones and Bartlett’s publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones and Bartlett via the above contact information or send an email to [email protected]. Copyright © 2010 by Jones and Bartlett Publishers, LLC All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval sys- tem, without written permission from the copyright owner. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to- date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits Publisher: Kevin Sullivan Acquisitions Editor: Amy Sibley Acquisitions Editor: Emily Ekle Associate Editor: Patricia Donnelly Editorial Assistant: Rachel Shuster Senior Production Editor: Tracey Chapman Marketing Manager: Rebecca Wasley V.P., Manufacturing and Inventory Control: Therese Connell Composition: Auburn Associates, Inc. Cover Design: Timothy Dziewit Cover Image: © inacio pires/ShutterStock, Inc. Printing and Binding: Malloy, Inc. Cover Printing: Malloy, Inc. Library of Congress Cataloging-in-Publication Data Stanfield, Peggy. Nutrition and diet therapy : self-instructional approaches / Peggy Stanfield, Y.H. Hui.—5th ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7637-6137-0 (pbk.) ISBN-10: 0-7637-6137-0 (pbk.) 1. Diet therapy—Programmed instruction. 2. Dietetics—Programmed instruction. I. Hui, Y. H. (Yiu H.) II. Title. [DNLM: 1. Nutritional Physiological Phenomena—Programmed Instruction. 2. Diet Therapy—Programmed Instruction. QU 18.2 S785n 2009] RM218.S73 2009 615.8'54—dc22 2008051158 6048 Printed in the United States of America 13 12 11 10 09 10 9 8 7 6 5 4 3 2 1

This fifth edition of Nutrition and Diet Therapy is dedicated with appreciation to our dear friend and first editor, James Keating, who many years ago started our writing careers. His unfailing support and encouragement enhances our endeavors and his friendship gives us great pleasure. Much love to you, Jim. Peggy and Y. H.



Contents About the Authors xix Preface xxi Acknowledgments xxiii PART I Nutrition Basics and Applications 1 CHAPTER 1 Introduction to Nutrition 3 Outline 3 Objectives 3 Glossary 3 Background Information 4 Activity 1: Dietary Allowances, Eating Guides, and the Food Guidance System 5 Dietary Standards 5 Dietary Guidelines 6 Food Guidance System 9 Food Exchange Lists 15 Responsibilities of Health Personnel 15 Progress Check on Activity 1 16 Activity 2: Legislation and Health Promotion 17 21 Food Labeling 17 Dietary Supplement Law 21 National Cholesterol Education Program (NCEP) Functional Foods and Nutraceuticals 21 Responsibilities of Health Personnel 22 Progress Check on Activity 2 22 References 23 CHAPTER 2 Food Habits 25 Outline 25 Objectives 25 Glossary 25 Background Information 26 Activity 1: Factors Affecting Food Consumption 26 Food and Symbols 26 Examples of Food Behaviors 27 Poverty, Appetite, and Biological Food Needs 28 Summary 28 Progress Check on Activity 1 28 Activity 2: Some Effects of Culture, Religion, and Geography on Food Behaviors 29 Basic Considerations 29 Reference Tables on Food Patterns 29 Responsibilities of Health Personnel 32 v

vi CONTENTS Progress Check on Activity 2 32 References 33 CHAPTER 3 Proteins and Health 35 Outline 35 Objectives 35 Glossary 35 Background Information 36 Activity 1: Protein as a Nutrient 36 Definitions, Essentiality, and Requirement 36 Protein Sparing 37 Functions, Storage, Sources, and Utilization 37 Amino Acid Supplements 38 Progress Check on Activity 1 38 Activity 2: Meeting Protein Needs and Vegetarianism 39 Requirements for Protein and Amino Acids 39 Vegetarianism: Rationale and Classification 40 Vegetarianism: Diet Evaluation 40 Vegetarianism: Diet Planning 41 Excessive and Deficient Protein Intake 42 Responsibilities of Health Personnel 43 Progress Check on Activity 2 44 References 45 CHAPTER 4 Carbohydrates and Fats: Implications for Health 47 Outline 47 Objectives 47 Glossary 48 Background Information 48 Activity 1: Carbohydrates: Characteristics and Effects on Health 49 Definitions, Classification, and Requirements 49 Functions 49 Sources, Storage, Sweeteners, and Intake 51 Athletic Activities 52 Health Implications 52 Progress Check on Activity 1 53 Activity 2: Fats: Characteristics and Effects on Health 54 Definitions and Food Sources 54 Functions and Storage 55 Diet, Fats, and Health 55 Progress Check on Activity 2 58 References 59 CHAPTER 5 Vitamins and Health 61 Outline 81 Objectives 61 Glossary 62 Background Information 62 Activity 1: The Water-Soluble Vitamins 63 Reference Tables 63 Progress Check on Activity 1 64 Activity 2: The Fat-Soluble Vitamins 67 Reference Tables 67 Antioxidants 67

CONTENTS vii Vitamins and the Preparation and Processing of Food 69 Progress Check on Activity 2 73 Responsibilities of Health Personnel 75 Summary 76 Progress Check on Chapter 5 76 References 77 CHAPTER 6 Minerals, Water, and Body Processes 79 Outline 79 Objectives 79 Glossary 80 Background Information 80 Water: A Primer 81 Activity 1: The Essential Minerals: Functions, Sources, and Characteristics 81 Reference Tables 81 Calcium 81 Potassium 84 Sodium 85 Iron 85 Implications for Health Personnel 88 Activity 2: Water and the Internal Environment 92 Functions and Distribution of Body Water 92 Body Water Balance 92 Water Requirements for Athletes 93 Responsibilities of Health Personnel 93 Summary 93 Progress Check on Chapter 6 94 References 97 CHAPTER 7 Meeting Energy Needs 99 Outline 99 Objectives 99 Glossary 99 Background Information 100 Activity 1: Energy Balance 100 Energy Measurement 100 Basal Metabolic Rate 101 Energy and Physical Activity 101 Thermic Effect of Food 101 Energy Intake and Output 101 Body Energy Need 102 Calculating Energy Intake 102 Progress Check on Activity 1 104 Activity 2: The Effects of Energy Imbalance 105 Definitions 105 How to Determine Your Weight 105 Body Composition 106 Estimate Energy or Caloric Requirements 106 Undernutrition 107 Obesity 107 Progress Check on Activity 2 109 Activity 3: Weight Control and Dieting 110 Calories, Eating Habits, and Exercise 110 Guidelines for Dieting 112

viii CONTENTS The Business of Dieting 113 114 Summary 114 Responsibilities of Health Personnel Progress Check on Activity 3 115 References 115 PART II Public Health Nutrition 117 CHAPTER 8 Nutritional Assessment 119 Outline 119 Objectives 119 Glossary 119 Background Information 120 Activity 1: Assessment of Nutritional Status 120 Physical Findings 120 Anthropometric Measurements 120 Laboratory Data 120 Diet History and Methods of Evaluating Data 120 Responsibilities of Health Personnel 123 Summary 126 Progress Check on Activity 1 126 References 127 CHAPTER 9 Nutrition and the Life Cycle 129 Outline 129 Objectives 129 Glossary 130 Background Information 130 Activity 1: Maternal and Infant Nutrition 131 Pregnancy: Determining Factors 131 Pregnancy: Nutritional Needs and Weight Gain 131 Pregnancy: Health Concerns 133 Lactation and Early Infancy: An Overview 133 Breastfeeding 134 Bottle-feeding 135 Health Concerns of Infancy 136 Introduction of Solid Foods 136 Responsibilities of Health Personnel 136 Progress Check on Activity 1 137 Activity 2: Childhood and Adolescent Nutrition 139 Toddler: Ages One to Three 139 Preschooler: Ages Three to Five 140 Early Childhood: Health Concerns 140 Early Childhood: Nutritional Requirements 142 Middle Childhood: General Considerations 142 Adolescence: Nutrition and Diet 143 Adolescence: Health Concerns 143 Responsibilities of Health Personnel 146 Progress Check on Activity 2 146 Activity 3: Adulthood and Nutrition 147 148 Early and Middle Adulthood 147 The Elderly: Factors Affecting Nutrition and Diet The Elderly: Health Problems 149 Nutrition Quackery 149 Progress Check on Activity 3 151

CONTENTS ix Activity 4: Exercise, Fitness, and Stress-Reduction Principles 153 Physical Fitness 154 Exercise and Nutritional Factors 154 An Ideal Program 154 Caloric Costs and Running 154 A Good Sports Beverage 154 Stress and Special Populations 155 Progress Check on Activity 4 155 Summary 156 Responsibilities of Health Personnel 157 References 158 CHAPTER 10 Drugs and Nutrition 159 167 Outline 159 Objectives 159 Glossary 159 Background Information 160 Progress Check on Background Information 161 Activity 1: Food and Drug Interactions 162 Effects of Food on Drugs 162 Effects of Drugs on Food 162 Food and Drug Incompatibilities 163 Clinical Implications 163 Progress Check on Activity 1 164 Activity 2: Drugs and the Life Cycle 165 Effects on Pregnancy and Lactation 165 Effects on Adults 166 Effects on the Elderly 166 An Example of Side Effects from Medications for Hyperactivity Progress Check on Activity 2 167 Nursing Responsibilities 168 References 168 CHAPTER 11 Dietary Supplements 171 Outline 171 Objectives 171 Glossary 172 Background Information 172 Progress Check on Background Information 173 Activity 1: DSHE Act of 1994 173 174 Definition of Dietary Supplement 173 Nutritional Support Statements 174 Ingredient and Nutrition Information Labeling New Dietary Ingredients 174 Monitoring for Safety 175 Understanding Claims 175 Progress Check on Activity 1 176 Activity 2: Folate or Folic Acid 177 178 Need for Extra Folic Acid 177 Vitamin B12 and Folic Acid 177 Folic Acid, Heart Disease, and Cancer 178 Folic Acid and Methotrexate for Cancer 178 Folic Acid and Methotrexate for Noncancerous Diseases Health Risk 178 Progress Check on Activity 2 178

x CONTENTS Activity 3: Kava Kava, Ginkgo Biloba, Goldenseal, Echinacea, Comfrey, and Pulegone 179 Kava Kava 179 Ginkgo Biloba 180 Goldenseal 181 Echinacea 181 Comfrey 181 Pulegone 182 Progress Check on Activity 3 182 Activity 4: An Example of Side Effects from Medications for Hyperactivity 182 More Tips and To-Do’s 184 Nursing Implications 184 FDA Enforcement 187 Progress Check on Activity 4 189 References 190 CHAPTER 12 Alternative Medicine 191 193 Outline 191 Objectives 191 Glossary 191 Background Information 192 Progress Check on Background Information 193 Activity 1: Categories or Domains of Complementary and Alternative Medicine Alternative Medical Systems 193 Mind-Body Interventions 194 Biological-Based Therapies 194 Manipulative and Body-Based Methods 194 Energy Therapies 194 Progress Check on Activity 1 194 Activity 2: Products, Devices, and Services Related to Complementary and Alternative Medicine 195 Acupuncture 196 Laetrile 197 St.-John’s-Wort 198 Nursing Implications 199 Progress Check on Activity 2 200 References 201 CHAPTER 13 Food Ecology 203 Outline 203 Objectives 203 Glossary 203 Background Information 204 Activity 1: Food Safety 204 209 Causes of Food-Borne Illness 204 Bacteria and Food Temperature 204 Safe Food-Preparation Practices 208 Case Histories of Food Poisoning in the United States Responsibilities of Health Personnel 210 Progress Check on Activity 1 210 Activity 2: Nutrient Conservation 211 Storage 211 Preparation 212 Cooking 212

CONTENTS xi Food Additives as Nutrients 212 213 Summary 212 Responsibilities of Health Personnel Progress Check on Activity 2 213 References 213 PART III Nutrition and Diet Therapy for Adults 215 CHAPTER 14 Overview of Therapeutic Nutrition 217 Outline 217 Objectives 217 Glossary 217 Background Information 218 Progress Check on Background Information 219 Activity 1: Principles and Objectives of Diet Therapy 220 Progress Check on Activity 1 220 Activity 2: Routine Hospital Diets 220 220 Regular Diets 220 Mechanically Altered or Fiber-Restricted Diets Liquid Diets 221 Diet for Dysphagia 223 Progress Check on Activity 2 223 Activity 3: Diet Modifications for Therapeutic Care 225 Modifying Basic Nutrients 225 Modifying Energy Value 225 Modifying Texture or Consistency 225 Modifying Seasonings 226 Nursing Implications 226 Progress Check on Activity 3 226 Activity 4: Alterations in Feeding Methods 226 227 Special Enteral Feedings (Tube Feedings) 226 Parenteral Feedings via Peripheral Vein 227 Parenteral Feeding via Central Vein (Total Parenteral Nutrition [TPN]) Nursing Implications 229 Progress Check on Activity 4 229 References 230 CHAPTER 15 Diet Therapy for Surgical Conditions 233 Outline 233 Objectives 233 Glossary 233 Background Information 234 Progress Check on Background Information 235 Activity 1: Pre- and Postoperative Nutrition 236 Preoperative Nutrition 236 Postoperative Nutrition 236 Rationale for Diet Therapy 236 Progress Check on Activity 1 237 Activity 2: The Postoperative Diet Regime 238 239 Goals of Dietary Management 238 Feeding the Patient Immediately After the Operation Dietary Management for Recovery 239 Gastrointestinal Surgery: An Illustration 240

xii CONTENTS Nursing Implications 241 Progress Check on Activity 2 241 References 242 CHAPTER 16 Diet Therapy for Cardiovascular Disorders 245 Outline 245 Objectives 245 Glossary 245 Background Information 246 Activity 1: The Lipid Disorders 247 250 Definitions 247 Cholesterol and Lipid Disorders 248 Dietary Management 249 NCEP Recommendations 249 Third Edition of NCEP (ATP 3) 249 Metabolic Syndrome 249 Special Consideration for Different Population Groups Racial and Ethnic Groups 252 The Role of Fish Oils 252 Drug Management 252 Nursing Implications 252 Progress Check on Activity 1 254 Activity 2: Heart Disease and Sodium Restriction 254 Diet and Hypertension 255 Diet and Congestive Heart Failure 255 The Sodium-Restricted Diet 255 Nursing Implications 257 Progress Check on Activity 2 257 Activity 3: Dietary Care After Heart Attack and Stroke 258 Myocardial Infarction (MI): Heart Attack 258 Cerebrovascular Accident (CVA): Stroke 258 Nursing Implications 259 Progress Check on Nursing Implications 259 Progress Check on Activity 3 259 References 260 CHAPTER 17 Diet and Disorders of Ingestion, Digestion, and Absorption 261 Outline 261 Objectives 261 Glossary 261 Background Information 262 Activity 1: Disorders of the Mouth, Esophagus, and Stomach 262 Mouth 262 Esophagus: Hiatal Hernia 263 Stomach: Peptic Ulcer 263 Gastric Surgery for Ulcer Diseases 266 Nursing Implications 266 Progress Check on Activity 1 268 Activity 2 : Disorders of the Intestines 268 Dietary Fiber Intake 268 Constipation 269 Diarrhea 270 Diverticular Disease 270

CONTENTS xiii Inflammatory Bowel Disease 271 272 Nursing Implications 272 Gastric Surgery for Severe Obesity Colostomy and Ileostomy 273 Nursing Implications 274 Progress Check on Activity 2 274 References 275 CHAPTER 18 Diet Therapy for Diabetes Mellitus 277 Outline 277 Objectives 277 Glossary 277 Background Information 278 Activity 1: Diet Therapy and Diabetes Mellitus 279 Treatment and Diet Therapy 279 Basic Nutrition Requirements 280 Caloric Requirements 280 Nutrient Distribution 282 Food Exchange Lists 282 Caring for a Diabetic Child 283 Insulin Preparations, Oral Hypoglycemic Agents (OHAs or Diabetic Pills), and New Drug Therapy 283 Nursing Implications 285 Progress Check on Activity 1 287 References 290 CHAPTER 19 Diet and Disorders of the Liver, Gallbladder, and Pancreas 291 292 Outline 291 Objectives 291 Glossary 292 Background Information Activity 1: Diet Therapy for Diseases of the Liver 293 Diet Therapy for Hepatitis 293 Diet Therapy for Cirrhosis 293 Hepatic Encephalopathy (Coma) 294 Cancer of the Liver 295 Liver Transplants 295 Nursing Implications 296 Progress Check on Activity 1 296 Activity 2: Diet Therapy for Diseases of the Gallbladder and Pancreas 298 Major Disorders of the Gallbladder 298 Diet Therapy for Gallbladder Disease 298 Obesity, Dieting, and Gallstones 300 Diet Therapy for Acute Pancreatitis 301 Diet Therapy for Chronic Pancreatitis 302 Nursing Implications for Patients with Gallbladder Disorders 302 Nursing Implications for Patients with Pancreatitis 302 Progress Check on Activity 2 302 References 303 CHAPTER 20 Diet Therapy for Renal Disorders 305 Outline 305 Objectives 305 Glossary 305 Background Information 306

xiv CONTENTS Activity 1: Kidney Function and Diseases 306 307 Acute Nephrotic Syndrome 307 Nephrotic Syndrome 307 Acute Renal Failure 307 Chronic Renal Failure 307 Progress Check on Background Information and Activity 1 Activity 2: Kidney Disorders and General Dietary Management 308 Description and General Considerations 308 Dietary Management 309 National Kidney Foundations 309 Nursing Implications for Activities 1 and 2 310 Progress Check on Activity 2 311 Activity 3: Kidney Dialysis 311 Definitions and Descriptions 311 Nursing Implications for Activity 3 312 Patient Education and Counseling 312 Major Resources 312 Teamwork 313 Progress Check on Activity 3 313 Activity 4: Diet Therapy for Renal Calculi 314 Causes of Kidney Stones 314 Dietary Management 314 Nursing Implications 315 Progress Check on Activity 4 316 References 316 CHAPTER 21 Nutrition and Diet Therapy for Cancer Patients and Patients with HIV Infection 319 Outline 319 Objectives 319 Glossary 320 Background Information 320 Progress Check on Background Information 321 Activity 1: Nutrition Therapy in Cancer 321 The Body’s Response to Cancer 322 The Body’s Response to Medical Therapy 322 Planning Diet Therapy 323 Nursing Implications 235 Progress Check on Activity 1 325 Activity 2: Nutrition and HIV Infections 327 328 Background 327 Basic Role of Nutrition in HIV Infections 328 General Guidelines for Nutrition Therapy in HIV Infections Nutrition in Terminal Illness 328 Alternative Nutrition Therapies 330 Special Nutritional Care for Children with AIDS 330 Food Service and Sanitary Practices 330 Nursing Implications 331 Progress Check on Activity 2 331 References 333 CHAPTER 22 Diet Therapy for Burns, Immobilized Patients, Mental Patients, and Eating Disorders 335 Outline 335 Objectives 335

CONTENTS xv Glossary 336 Background Information 336 Activity 1: Diet and the Burn Patient 336 Background Information 336 Nutritional and Dietary Care 336 Calculating Nutrient Needs 337 Enteral and Parenteral Feedings 337 Teamwork 338 Nursing Implications 338 Progress Check on Activity 1 338 Activity 2: Diet and Immobilized Patients 339 Introduction 339 Nitrogen Balance 339 Calories 340 Calcium 340 Urinary and Bowel Functions 340 Progress Check on Activity 2 340 Activity 3: Diet and Mental Patients 341 Introduction 341 Confusion About Food and Eating 342 Mealtime Misbehavior 342 Food Rejection 342 Nursing Implications 343 Progress Check on Activity 3 344 Activity 4: Part I—Eating Disorders: Anorexia Nervosa 345 Background Information 345 347 Clinical Manifestations 345 Hospital Feeding 345 Nursing Implications 346 Progress Check on Activity 4, Part I 346 Activity 4: Part II—Other Eating Disorders 347 Background Information 347 Bulimia Nervosa 347 Chronic Dieting Syndrome 347 Management of Bulimia and Compulsive Overeating Progress Check on Activity 4, Part II 348 References 348 PART IV Diet Therapy and Childhood Diseases 351 CHAPTER 23 Principles of Feeding a Sick Child 353 Outline 353 Objectives 353 Glossary 354 Background Information 354 Progress Check on Background Information 355 Activity 1: The Child, the Parents, and the Health Team 355 Behavioral Patterns of the Hospitalized Child 355 Teamwork 355 Nursing Implications 356 Progress Check on Activity 1 356 Activity 2: Special Considerations and Diet Therapy 357 Special Considerations 357 Diet Therapy and Dietetic Products 358

xvi CONTENTS Discharge and Home Nutritional Support 358 Nursing Implications 359 Progress Check on Activity 2 359 References 359 CHAPTER 24 Diet Therapy and Cystic Fibrosis 361 Outline 361 Objectives 361 Glossary 362 Background Information 362 Occurrence and Type of Disorders 362 Clinical Symptoms and Diagnosis 362 Progress Check on Background Information 362 Activity 1: Dietary Management of Cystic Fibrosis 363 365 Nutritional Needs and Goals of Diet Therapy 363 Use of Pancreatic Enzymes 363 General Feeding 363 Family Involvement and Follow-Up 364 Nutritional and Dietary Management at Different Stages of Childhood Nursing Implications 365 Progress Check on Activity 1 366 References 366 CHAPTER 25 Diet Therapy and Celiac Disease 369 Outline 369 Objectives 369 Glossary 369 Background Information 370 Activity 1: Dietary Management of Celiac Disease 370 Symptoms 370 Principles of Diet Therapy 370 Patient Education 371 Nursing Implications 371 Progress Check on Activity 1 373 Activity 2: Screening, Occurrence, and Complications 374 Screening 374 Complications 374 Nursing Implications 374 Progress Check on Activity 2 375 References 375 CHAPTER 26 Diet Therapy and Congenital Heart Disease 377 Outline 377 Objectives 377 Glossary 378 Background Information 378 Activity 1: Dietary Management of Congenital Heart Disease 379 Major Considerations in Dietary Care 379 Formulas and Regular Foods 379 Managing Feeding Problems 380 Discharge Procedures 380 Nursing Implications 380 Progress Check on Activity 1 381 References 382

CONTENTS xvii CHAPTER 27 Diet Therapy and Food Allergy 383 Outline 383 Objectives 383 Glossary 383 Background Information 384 Activity 1: Food Allergy and Children 384 387 Symptoms and Management 384 Milk Allergy 385 Diagnosis and Treatment 385 Nursing Implications 386 Progress Check on Background Information and Activity 1 Activity 2: Common Offenders 387 Common Allergens 387 Other Food Allergens 388 Peanut Allergy and Deaths 388 Progress Check on Activity 2 389 Activity 3: Inspecting Foods to Avoid Allergic Reactions 389 Progress Check on Activity 3 390 References 391 CHAPTER 28 Diet Therapy and Phenylketonuria 393 Outline 393 Objectives 393 Glossary 394 Background Information 394 Progress Check on Background Information 394 Activity 1: Phenylketonuria and Dietary Management 395 Treatment and Requirement 395 Lofenalac and Phenylalanine Food Exchange Lists 395 Special Considerations 396 Follow-up Care 397 Drug Therapy 398 Nursing Implications 398 Progress Check on Activity 1 398 References 399 CHAPTER 29 Diet Therapy for Constipation, Diarrhea, and High-Risk Infants 401 Outline 401 Objectives 401 Glossary 402 Background Information 402 Activity 1: Constipation 402 Background Information 402 Infants 402 Young Children 403 Nursing Implications 403 Progress Check on Activity 1 403 Activity 2: Diarrhea 404 404 Fecal Characteristics and Causes of Diarrhea Treatment and Caution 404 Nursing Implications 405 Progress Check on Activity 2 405

xviii CONTENTS Activity 3: High-Risk Infants 406 Background Information 406 Nutrient Needs 406 Initial Feedings 407 Use of Breastmilk or Formulas 407 Premature Babies: An Illustration 407 Nursing Implications 409 Progress Check on Activity 3 409 References 409 Appendices 411 Appendix A: Weights for Adults 413 Appendix B: Menus for a Healthy Diet 417 Appendix C: Drugs and Nutrition 425 Appendix D: CDC Growth Charts 431 Appendix E: Weights and Measures 449 Appendix F: Food Exchange Lists 451 Answers to Progress Checks 463 Posttests 483 Answers to Posttests 547 Index 557

About the Authors Peggy Stanfield is a Registered Dietitian and Professor Emeritus from the College of Southern Idaho, Twin Falls. She is a Certified Nutrition Specialist, a professional mem- ber of the Institute of Food Technology (IFT), and has recently completed a second term as president of Text and Academic Authors (TAA), an organization devoted to advancing quality education materials for students and advocating for authors’ rights. Following her retirement from CSI, she taught at the University of Hawaii, Manoa, Honolulu. While at CSI, she helped develop and implement the nutrition component of the nurs- ing curriculum, taught nutrition theory, and supervised nursing students during their clinical experience in teaching diet therapy to selected patients. She transferred from the Nursing Department into the Allied Health division, and while continuing to teach nurs- ing students also taught students with majors in other health professions. During the years that she taught at CSI, she wrote Nutrition and Diet Therapy with Self-Instructional Modules, Introduction to the Health Professions, Mastering Medical Terminology, and Essentials of Medical Terminology (Jones and Bartlett Publishers). These books continue to be revised, and most are in their third and fourth editions. She is one of the editors in Food Borne Diseases, vol. 1 (Marcel Dekker, New York, 2000) and has also contributed chapters on food safety, food regulations, and good man- ufacturing practices in books written or edited by her coauthor, Dr. Y. H. Hui. She remains active in all aspects of nutrition education. Y. H. Hui received his doctoral degree in nutrition biochemistry from the University of California at Berkeley in 1970. Dr. Hui taught nutrition and food science at Humboldt State University from 1971 to 1987. Since 1987, he has devoted himself to writing full time, also serving as a publish- ing consultant. From 1992–1995 he was Editor-in-Chief for the United States Association for Food and Drug Officials. Dr. Hui has authored or edited more than 30 books in nutrition, food science, health sciences, medicine, and law. In 2000, he published his first book as a publisher; currently, he acts as both an author and publisher. His current areas of interest are: health science, nutrition, food science, food technology, food engineering, and food laws. xix



Preface Many thanks to students and instructors for their continued support of our book, Nutrition and Diet Therapy: Self-Instructional Modules. Your insight and information have been very helpful to us in preparing this fifth edition. This book has been in print for over 20 years, and it is gratifying to know that it has benefited thousands of students entering the health professions over these years. Sweeping changes have occurred in the field of nutrition since this book first went to print, and they continue to occur with great rapidity as increasing knowledge of the sub- ject and its effects on our health and longevity are scientifically established. There is no doubt that every new edition will contain even more changes. Upon suggestions from instructors and reviewers, we have made three changes on the overall format of the book: 1. The title of the book has changed slightly to: Nutrition and Diet Therapy: Self- Instructional Approaches. 2. Each module in the book has been changed to a chapter. 3. The suggestion in previous editions at the beginning of each chapter on credits has been eliminated. The technical contents of the following chapters received major changes: 1. Chapter 1, Introduction to Nutrition, has been completely rewritten to reflect current thinking on Dietary Reference Intakes, MyPyramid, Dietary Guidelines, Food Exchanges, and Food Labeling 2. Chapter 4, Carbohydrates and Fats: Implications for Health 3. Chapter 11, Dietary Supplements 4. Chapter 13, Food Ecology 5. Chapter 14, Overview of Therapeutic Nutrition New references have been provided for all chapters in the book. Small or minor—but significant—changes have been made to all other chapters. Appendix F provides the 2007 Food Exchange Lists from the American Dietetic Association and the American Diabetes Association. We hope that the revised contents will expand your knowledge and make the basics of nutrition and diet therapy a little easier to understand. Please continue to give us feed- back; your constructive suggestions enable us to improve each succeeding edition. Peggy Stanfield Y. H. Hui xxi



Acknowledgments We all know how hard it is to prepare the manuscript for a technical book. Actually, the production of a book poses equal difficulty, though the challenges are of a different type. Many people are involved in the production of a book, and we have been fortunate to have had a number of committed people who gave their support and lent their expertise to the finished product. You are the best judge of the quality of their work. We also thank the students who helped research and compile new information that ap- pears in this edition. We are especially appreciative of the invaluable assistance of Dr. Wai-Kit Nip (Professor Emeritus, University of Hawaii) for his participation in preparing this manuscript. And last, may we again extend thanks to the students and their instructors for contin- ued use of Nutrition and Diet Therapy and valuable feedback through the last four edi- tions. We have tried in this fifth edition to again provide you with the kinds of learning activities and new information that you have asked for, and hope that our mutual relation- ship continues for another 20 years!! xxiii

Comprehensive Online Resources Available! http://nursing.jbpub.com/ A companion Web site where students and instructors will find complete, current material to support the text! For Instructors For Students PowerPoint Slides Chapter Objectives Download our slides and use them in your course! Students can download objectives to help study or prepare for lectures. Instructor’s Manual Interactive Glossary A comprehensive tool for instructors that includes classroom discussion questions, classroom activities, Allows students to search key terms and definitions and lecture ideas. alphabetically or by chapter. TestBank Animated Flash Cards A TestBank for instructors to pull questions from and These study tools provide a definition and ask for the assist in preparing tests for their students. Includes key term; the student types in the answer. critical-thinking short-answer questions as well. Crossword Puzzles Sample Syllabi These function as real crossword puzzles made up of A handful of sample syllabi for instructors to get new nursing research terms. ideas for presenting the information in their classes. Student Posttest Questions Multiple-choice questions for students that further enhance their knowledge of the material. Additional Material Web Links Applicable evidence-based nursing Web resources for easy clicking and linking! Related Titles Additional Jones and Bartlett titles in related areas that might be of interest to the student and the instructor. Additional Reading Suggestions A list of chapters from other Jones and Bartlett titles in related areas—great for further study or research projects. Instructors can ask their Jones and Bartlett sales rep to package these, or other, chapters with this textbook for required reading on a particular topic.

IP A R T Nutrition Basics and Applications Chapter 1 Introduction to Nutrition Chapter 2 Food Habits Chapter 3 Proteins and Health Chapter 4 Carbohydrates and Fats: Implications for Health Chapter 5 Vitamins and Health Chapter 6 Minerals, Water, and Body Processes Chapter 7 Meeting Energy Needs 1



OUTLINE CHAPTER 1 Objectives Introduction to Nutrition Glossary Background information Time for completion ACTIVITY 1: Dietary Activities: 11⁄2 hours Allowances, Eating Guides, Optional examination: 1⁄2 hour and Food Guidance System Dietary Standards Dietary Guidelines Food Guidance System Food Exchange Lists Responsibilities of Health Personnel Progress Check on Activity 1 ACTIVITY 2: Legislation and Health Promotion Food Labeling Dietary Supplement Law National Cholesterol Education Program (NCEP) Functional Foods and Nutraceuticals Responsibilities of Health Personnel Progress Check on Activity 2 References OBJECTIVES Upon completion of this chapter, the student should be able to do the following: 1. Define major concepts and terms used in nutritional science. 2. Identify guidelines and rationale used for planning and evaluating food intake. 3. Describe some major concerns about the American diet. 4. Use appropriate sources and services to obtain reliable nutrition information. GLOSSARY Adequate diet: one that provides all the essential nutrients and calories needed to maintain good health and acceptable body weight. Adequate Intake (AI): an estimate of average requirements when evidence is not available to establish an RDA. Calorie (Cal): unit of energy, often used for the term kilocalorie (see also kilo- calorie). Common usage indicating the release of energy from food. Culture: the beliefs, arts, and customs that make up a way of life for a group of people. 3

4 PART I NUTRITION BASICS AND APPLICATIONS Nutrition: the sum of the processes by which food is se- lected and becomes part of the body. Daily Reference Values (DRVs): a set of values that cov- ers nutrients, such as fat and fiber, that do not appear Nutritional status: state of the body resulting from the in- in the RDA tables. Expressed as % Daily Value (%DV). take and use of nutrients. Diet: (a) the foods that a person eats most frequently; (b) Optimum nutrition: the state of receiving and utilizing food considered in terms of its qualities and effects essential nutrients to maintain health and well-being on health; (c) a particular selection of food, usually at the highest possible level. It provides a reserve for prescribed to cure a disease or to gain or lose weight. the body. Dietary Guidelines for Americans: dietary recommenda- Overnutrition: an excessive intake of one or more nutri- tions to promote health and to prevent or delay the ents, frequently referring to nutrients providing en- onset of chronic diseases. ergy (kcalories). Dietary Reference Intakes (DRIs): a set of dietary refer- Poor nutritional status: an inadequate intake (or utiliza- ence values including but not limited Adequate Intake tion) of nutrients to meet the body’s requirements for (AI), Estimated Average Requirement (EAR), Rec- energy, maintenance, and growth. ommended Dietary Allowance (RDA), and Tolerable Upper Intake Level (UL) used for planning and assess- Recommended Dietary Allowances (RDAs): levels of nu- ing diets of individuals and groups. trients recommended by the Food and Nutrition Board of the National Academy of Sciences for daily Energy: capacity to do work; also refers to calories, that consumption by healthy individuals, scaled according is, the “fuel” provided by certain nutrients (carbohy- to sex and age. drates, fats, proteins). Tolerable Upper Intake Level (UL): maximum intake by Estimated Average Requirement (EAR): intake that an individual that is unlikely to pose risks of adverse meets the estimated nutrient needs of one half of the health effects in a healthy individual in a specified individuals in a specific group. Used as a basis for de- group. There is no established standard for individu- veloping the RDA. als to consume nutrients at levels above the RDA or AI. Food: any substance taken into the body that will help to Undernutrition: a deficiency of one or more nutrients, in- meet the body’s needs for energy, maintenance, and cluding nutrients providing energy (calories). growth. BACKGROUND INFORMATION Good nutritional status: the intake of a balanced diet con- taining all the essential nutrients to meet the body’s re- The subject of nutrition is both exciting and confusing to quirements for energy, maintenance, and growth. the beginning student. Nutrition has become a major topic of conversation at places of work, at social gather- Gram (g): a unit of weight in the metric system. 1 g = ings, and in the media. We are living at a time when the .036 oz. There are 28.385 grams to an ounce. This focus is on prevention of disease and responsibility for conversion is usually rounded to 30 g for ease in cal- one’s own health. The newest trends in health care em- culation, or rounded down to 28 g. phasize the importance of nutrition education. Health: the state of complete physical, mental, and social Throughout history, food and its effects on the body well-being; not merely the absence of disease and have been studied and written about, but most of the in- infirmity. formation gathered was based on trial and error. Many su- perstitions regarding the magical powers and healing Kilocalorie (kcalorie, kcal): technically correct term for capabilities of food also evolved. unit of energy in nutrition, equal to the amount of heat required to raise the temperature of 1 kg of water 1°C. The study of nutrition as a science is relatively new, developing only after chemistry and physiology became Malnutrition: state of impaired health due to undernutri- established disciplines. Its growth begins with the end tion, overnutrition, an imbalance of nutrients, or the of World War II. Nutrition science is now a highly re- body’s inability to utilize the nutrients ingested. garded discipline. The progressive advances in the sci- ence and technology of this discipline offer us hope in Microgram: a unit of weight in the metric system equal controlling our destiny by preventing or delaying the to 1/1,000,000 of a gram. onset of a number of chronic diseases related to nutri- tion, food, and lifestyle. Milligram: a unit of weight in the metric system equal to 1/1,000 of a gram. Every specialized field has its own language. A begin- ning student in nutrition needs to comprehend the lan- Monitor: to watch over or observe something for a period guage used in this discipline and to understand some of time. basic concepts upon which the science is based. The ac- tivities in this chapter should assist you in gaining the National Cholesterol Education Program (NCEP): pro- knowledge and vocabulary necessary to understand the gram designed to educate the public and healthcare science of nutrition. providers about the risks of an elevated cholesterol level and methods to lower it. Nutrient: a chemical substance obtained from food and needed by the body for growth, maintenance, or repair of tissues. Many nutrients are considered essential. The body cannot make them; they must be obtained from food.

CHAPTER 1 INTRODUCTION TO NUTRITION 5 ACTIVITY 1: dation, requirement, dietary allowances, adequate in- take, upper limits, tolerance, estimation, average re- Dietary Allowances, Eating Guides, and quirements, and so on. In general, there are four sets of Food Guidance System reference data, collectively called Dietary Reference Intakes or DRIs: Estimated Average Requirement (EAR), The appropriate diet at any stage of life is one that sup- Recommended Dietary Allowance (RDA), Adequate Intake plies sufficient energy and all the essential nutrients in (AI), and Tolerable Upper Intake Level (UL). They are de- adequate amounts for health. For more than 50 years, fined as follows: professionals from the government and academics have made recommendations on such basic needs. • Estimated Average Requirement (EAR): The intake that meets the estimated nutrient needs of half of the For more than two decades there has been increasing individuals in a specific group. This figure is to be concern about the eating patterns of American people. used as the basis for developing the RDA and is to National health policy makers have linked several spe- be used by nutrition policy makers in evaluating the cific dietary factors to chronic diseases among the pop- adequacy of nutrient intakes of the group and for plan- ulation. This connection between diet and disease has, in ning how much the group should consume. turn, led to publication of guidelines to promote health- ier eating habits. Most of these publications have been is- • Recommended Dietary Allowance (RDA): The intake sued by relevant units within the following national that meets the nutrient needs of almost all of the agencies: healthy individuals in a specific age and gender group. The RDA should be used in guiding individuals to 1. U.S. National Academy of Sciences (NAS) achieve adequate nutrient intake aimed at decreasing 2. U.S. Department of Agriculture the risk of chronic disease. It is based on estimating 3. U.S. Department of Health and Human Services an average requirement plus an increase to account 4. U.S. National Institute of Health for the variation within a particular group. 5. U.S. Surgeon General • Adequate Intake (AI): When sufficient scientific evi- According to these agencies, the major chronic dis- dence is not available to estimate an average require- eases in the United States are coronary heart disease, ment, Adequate Intakes (AIs) have been set. strokes, hypertension, atherosclerosis, some cancers, Individuals should use the AI as a goal for intake obesity, and diabetes. Several high-risk factors for these where no RDAs exist. The AI is derived through ex- diseases are linked to the American diet. A discussion of perimental or observational data that show a mean these health factors and a proper diet presented in such intake that appears to sustain a desired indicator of national publications as Healthy People 2000, American health, such as calcium retention in bone for most Dietary Guidelines, and MyPyramid will be presented in members of a population group. For example, AIs have this chapter. We will first look into the concept of dietary been set for infants through 1 year of age using the av- standards in the United States. erage observed nutrient intake of populations of breastfed infants as the standard. The committee set DIETARY STANDARDS AIs for calcium, vitamin D, and fluoride. There are two basic questions regarding dietary standards: • Tolerable Upper Intake Level (UL): The maximum in- What are the nutrients in food? How much of each nutri- take by an individual that is unlikely to pose risks of ent do we need everyday to be healthy? Collectively, this in- adverse health effects in almost all healthy individu- formation is the core of the U.S. Dietary Standards. Each als in a specified group. This figure is not intended to country has its own dietary standard, and no two countries be a recommended level of intake, and there is no es- have the same standards, for a variety of reasons. tablished benefit for individuals to consume nutrients at levels above the RDA or AI. For most nutrients, this For more than half a century the U.S. National figure refers to total intakes from food, fortified food, Academy of Sciences (NAS) has been the major scientific and nutrient supplements. arm of the federal government to provide answers to these questions. The NAS in turn depends on one of its There are nine tables of DRIs that are of interest to this institutes, the Institute of Medicine (IOM), to review sci- book. They are all issued and distributed by the National entific literature to arrive at the appropriate conclusions. Academy Press, the publishing arm of NAS. The data are IOM has developed many boards of experts to perform prepared by the FNB of the NAS. The tables are described such scientific investigations. One such board is the Food below: and Nutrition Board (FNB) which is the actual scientific body that develops most of the U.S. dietary standards. Presented inside the front cover of this book: At present the FNB is using the concept of dietary ref- 1. Table F-1: Dietary Reference Intakes (DRIs): Rec- erence standards to define the terms describing the ommended Intakes for Individuals, Vitamins. amount of nutrients we consume, such as recommen- 2. Table F-2: Dietary Reference Intakes (DRIs): Rec- ommended Intakes for Individuals, Elements.

6 PART I NUTRITION BASICS AND APPLICATIONS this section has been modified from this document, 2005 edition. Accessible at the National Academies of Science Web site (www.nas.edu): Major causes of morbidity and mortality in the United States are related to poor diet and a sedentary lifestyle. 1. Dietary Reference Intakes (DRIs): Tolerable Upper Some specific diseases linked to poor diet and physical in- Intake Levels (UL), Vitamins activity include cardiovascular disease, type 2 diabetes, hypertension, osteoporosis, and certain cancers. Further- 2. Dietary Reference Intakes (DRIs): Tolerable Upper more, poor diet and physical inactivity, resulting in an en- Intake Levels (UL), Elements ergy imbalance (more calories consumed than expended), are the most important factors contributing to the in- 3. Dietary Reference Intakes (DRIs): Estimated Energy crease in overweight and obesity in this country. Requirements (EER) for Men and Women Combined with physical activity, following a diet that does not provide excess calories according to the recom- 4. Dietary Reference Intakes (DRIs): Acceptable Macro- mendations in this document should enhance the health nutrient Distribution Ranges of most individuals. 5. Dietary Reference Intakes (DRIs): Recommended The intent of the Dietary Guidelines is to summarize Intakes for Individuals, Macronutrients and synthesize knowledge regarding individual nutrients and food components into recommendations for a pat- 6. Dietary Reference Intakes (DRIs): Additional Macro- tern of eating that can be adopted by the public. In this nutrient Recommendations publication, key recommendations are grouped under nine interrelated focus areas. It is important to remem- 7. Dietary Reference Intakes (DRIs): Estimated Average ber that these are integrated messages that should be Requirements for Groups implemented as a whole. Taken together, they encour- age most Americans to eat fewer calories, be more ac- Because nutritional requirements differ with age, sex, tive, and make wiser food choices. body size, and physiological state, all data are presented for males and females in different age and weight groups. A basic premise of the Dietary Guidelines is that nu- Nutrition-related health problems such as premature trient needs should be met primarily through consum- birth, metabolic disorders, infections, chronic diseases, ing foods. Foods provide an array of nutrients and other and the use of medications require special dietary and compounds that may have beneficial effects on health. therapeutic measures. The amount of nutrients in each In certain cases, fortified foods and dietary supplements table is determined through scientific research and varies may be useful sources of one or more nutrients that oth- from nutrient to nutrient. erwise might be consumed in less than recommended amounts. However, dietary supplements, while recom- To be valuable from a practical standpoint, the tech- mended in some cases, cannot replace a healthful diet. nical information supplied by the dietary standards must be interpreted in terms of a selection of foods to be eaten Key recommendations of the Dietary Guidelines are daily. The RDAs and other standards should be met by presented below. consuming a wide variety of acceptable, tasty, and afford- able foods and not solely through supplementation or Adequate Nutrients Within Calorie Needs the use of fortified foods. Various basic diet patterns may be devised to serve as guides in food selection. Key recommendations for the general public: There are many applications of the DRIs, some of • Consume a variety of nutrient-dense foods and bever- which will be discussed in various chapters in this book. ages within and among the basic food groups while choosing foods that limit the intake of saturated and DIETARY GUIDELINES trans fats, cholesterol, added sugars, salt, and alcohol. The Dietary Guidelines for Americans (Dietary • Meet recommended intakes within energy needs by Guidelines), first published in 1980, provides science- adopting a balanced eating pattern, such as the USDA based advice to promote health and to reduce risk for Food Guide or the DASH Eating Plan. chronic diseases through diet and physical activity. The recommendations contained within the Dietary Key recommendations for specific population groups: Guidelines are targeted to the general public over 2 years of age who are living in the United States. Because of its • People over age 50—Consume vitamin B12 in its crys- focus on health promotion and risk reduction, the talline form (i.e., fortified foods or supplements). Dietary Guidelines form the basis of federal food, nutri- tion education, and information programs. • Women of childbearing age who may become preg- nant—Eat foods high in heme-iron and/or consume By law (Public Law 101445, Title III, 7 U.S.C. 5301 iron-rich plant foods or iron-fortified foods with an et seq.), the Dietary Guidelines is reviewed, updated enhancer of iron absorption, such as foods rich in if necessary, and published every 5 years. The content of vitamin C. the Dietary Guidelines is a joint effort of the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Agriculture (USDA). Visit www. healthierus.gov/dietaryguidelines. The information in

CHAPTER 1 INTRODUCTION TO NUTRITION 7 • Women of childbearing age who may become preg- approximately 60 minutes of moderate- to vigorous- nant and those in the first trimester of pregnancy— intensity activity on most days of the week while not Consume adequate synthetic folic acid daily (from exceeding caloric intake requirements. fortified foods or supplements) in addition to food • To sustain weight loss in adulthood, participate in at forms of folate from a varied diet. least 60 to 90 minutes of daily moderate-intensity physical activity while not exceeding caloric intake • Older adults, people with dark skin, and people ex- requirements. Some people may need to consult with posed to insufficient ultraviolet band radiation (i.e., a healthcare provider before participating in this level sunlight)—Consume extra vitamin D from vitamin of activity. D-fortified foods and/or supplements. • Achieve physical fitness by including cardiovascular conditioning, stretching exercises for flexibility, and Weight Management resistance exercises or calisthenics for muscle strength and endurance. Key recommendations for the general public: Key recommendations for specific population groups: • To maintain body weight in a healthy range, balance calories from foods and beverages with calories • Children and adolescents—Engage in at least 60 min- expended. utes of physical activity on most, preferably all, days of the week. • To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase • Pregnant women—In the absence of medical or ob- physical activity. stetric complications, incorporate 30 minutes or more of moderate-intensity physical activity on most, if not Key recommendations for specific population groups: all, days of the week. Avoid activities with a high risk of falling or abdominal trauma. • Those who need to lose weight—Aim for a slow, steady weight loss by decreasing calorie intake while main- • Breastfeeding women—Be aware that neither acute taining an adequate nutrient intake and increasing nor regular exercise adversely affects the mother’s physical activity. ability to successfully breastfeed. • Overweight children—Reduce the rate of body weight • Older adults—Participate in regular physical activity gain while allowing growth and development. Consult to reduce functional declines associated with aging a healthcare provider before placing a child on a and to achieve the other benefits of physical activity weight-reduction diet. identified for all adults. • Pregnant women—Ensure appropriate weight gain as Food Groups to Encourage specified by a healthcare provider. Key recommendations for the general public: • Breastfeeding women—Moderate weight reduction is safe and does not compromise weight gain of the nurs- • Consume a sufficient amount of fruits and vegetables ing infant. while staying within energy needs. Two c of fruit and 2-1⁄2 c of vegetables per day are recommended for a • Overweight adults and overweight children with reference 2000-calorie intake, with higher or lower chronic diseases and/or on medication—Consult a amounts depending on the calorie level. healthcare provider about weight loss strategies prior to starting a weight-reduction program to ensure ap- • Choose a variety of fruits and vegetables each day. In propriate management of other health conditions. particular, select from all five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and Physical Activity other vegetables) several times a week. Key recommendations for the general public: • Consume 3 or more ounce-equivalents of whole-grain products per day, with the rest of the recommended • Engage in regular physical activity, and reduce seden- grains coming from enriched or whole-grain prod- tary activities to promote health, psychological well- ucts. In general, at least half the grains should come being, and a healthy body weight. from whole grains. • To reduce the risk of chronic disease in adulthood, • Consume 3 c per day of fat-free or low-fat milk or engage in at least 30 minutes of moderate-intensity equivalent milk products. physical activity, above usual activity, at work or home on most days of the week. Key recommendations for specific population groups: • For most people, greater health benefits can be ob- • Children and adolescents—Consume whole-grain tained by engaging in physical activity of more vigor- products often; at least half the grains should be whole ous intensity or longer duration. grains. Children 2 to 8 years should consume 2 c per • To help manage body weight and prevent gradual, un- healthy body weight gain in adulthood, engage in

8 PART I NUTRITION BASICS AND APPLICATIONS Key recommendations for specific population groups: day of fat-free or low-fat milk or equivalent milk prod- • Individuals with hypertension, blacks, and middle- ucts. Children 9 years of age and older should con- aged and older adults—Aim to consume no more than sume 3 c per day of fat-free or low-fat milk or 1500 mg of sodium per day, and meet the potassium equivalent milk products. recommendation (4700 mg/day) with food. Fats Alcoholic Beverages Key recommendations for the general public: Key recommendations for the general public: • Consume less than 10% of calories from saturated • Those who choose to drink alcoholic beverages should fatty acids and less than 300 mg/day of cholesterol, do so sensibly and in moderation—defined as the con- and keep consumption of trans-fatty acids as low as sumption of up to one drink per day for women and up possible. to two drinks per day for men. • Keep total fat intake between 20% to 35% of calories, • Alcoholic beverages should not be consumed by some with most fats coming from sources of polyunsatu- individuals, including those who cannot restrict their rated and monounsaturated fatty acids, such as fish, alcohol intake, women of childbearing age who may nuts, and vegetable oils. become pregnant, pregnant and lactating women, children and adolescents, individuals taking medica- • When selecting and preparing meat, poultry, dry tions that can interact with alcohol, and those with beans, and milk or milk products, make choices that specific medical conditions. are lean, low fat, or fat free. • Alcoholic beverages should be avoided by individuals • Limit intake of fats and oils high in saturated and/or engaging in activities that require attention, skill, or trans-fatty acids, and choose products low in such fats coordination, such as driving or operating machinery. and oils. Food Safety Key recommendations for specific population groups: Key recommendations for the general public (also see • Children and adolescents—Keep total fat intake be- Chapter 13): tween 30% to 35% of calories for children 2 to 3 years of age and between 25% to 35% of calories for children To avoid microbial food-borne illness: and adolescents 4 to 18 years of age, with most fats coming from sources of polyunsaturated and mo- • Clean hands, food contact surfaces, and fruits and veg- nounsaturated fatty acids, such as fish, nuts, and veg- etables. Meat and poultry should not be washed or etable oils. rinsed. Carbohydrates • Separate raw, cooked, and ready-to-eat foods while shopping, preparing, or storing foods. Key recommendations for the general public: • Cook foods to a safe temperature to kill micro- • Choose fiber-rich fruits, vegetables, and whole grains organisms. often. • Chill (refrigerate) perishable food promptly, and de- • Choose and prepare foods and beverages with little frost foods properly. added sugars or caloric sweeteners, such as amounts suggested by the USDA Food Guide and the DASH • Avoid raw (unpasteurized) milk or any products made Eating Plan. from unpasteurized milk, raw or partially cooked eggs or foods containing raw eggs, raw or undercooked meat • Reduce the incidence of dental caries by practicing and poultry, unpasteurized juices, and raw sprouts. good oral hygiene and consuming sugar- and starch- containing foods and beverages less frequently. Key recommendations for specific population groups: Sodium and Potassium • Infants and young children, pregnant women, older adults, and those who are immunocompromised—Do Key Recommendations for the general public: not eat or drink raw (unpasteurized) milk or any prod- ucts made from unpasteurized milk, raw or partially • Consume less than 2300 mg (approximately 1 tsp of cooked eggs or foods containing raw eggs, raw or un- salt) of sodium per day. dercooked meat and poultry, raw or undercooked fish or shellfish, unpasteurized juices, and raw sprouts. • Choose and prepare foods with little salt. At the same time, consume potassium-rich foods, such as fruits • Pregnant women, older adults, and those who are im- and vegetables. munocompromised: Only eat certain deli meats and frankfurters that have been reheated to steaming hot.

CHAPTER 1 INTRODUCTION TO NUTRITION 9 FOOD GUIDANCE SYSTEM FIGURE 1-2 MyPyramid: The Food Groups Source: Courtesy of the USDA. The USDA has released the MyPyramid Food Guidance System (www.mypyramid.gov). Along with the new • An education framework explains what changes most MyPyramid symbol, the system provides many options Americans need to make in their eating and activity to help Americans make healthy food choices and to be choices, how they can make these changes, and why active every day. Figures 1-1 and 1-2 provide visual pre- these changes are important for health. sentations of the general goals and food groups or system of MyPyramid. Consult these two figures as you follow the • A glossary defines key terms used in the Food discussion in this section. Guidance System documents. The general messages in the MyPyramid symbol are: The education framework provides specific recom- physical activity, variety, proportionality, moderation, mendations for making food choices that will improve gradual improvement, and personalization. The specific the quality of an average American diet. These recom- messages are about healthy eating and physical activity, mendations are interrelated and should be used together. which apply to everyone. MyPyramid helps consumers Taken together, they would result in the following find the kinds and amounts of foods they should eat each changes from a typical diet: day. The Food Guidance System is the core of MyPyramid. • Increased intake of vitamins, minerals, dietary fiber, The 2005 Dietary Guidelines for Americans are the and other essential nutrients, especially of those that basis for federal nutrition policy. The Food Guidance are often low in typical diets System provides food-based guidance to help implement the recommendations of the Dietary Guidelines. The sys- • Lowered intake of saturated fats, trans fats, and cho- tem was based on both the Dietary Guidelines and the lesterol, and increased intake of fruits, vegetables, and Dietary Reference Intakes from the National Academy of whole grains to decrease risk for some chronic Sciences, while taking into account current consump- diseases tion patterns of Americans. The system translates the Dietary Guidelines into a total diet that meets nutrient • Calorie intake balanced with energy needs to prevent needs from food sources and aims to moderate or limit weight gain and/or promote a healthy weight dietary components often consumed in excess. An im- portant complementary tool to the system is the nutri- The recommendations in the framework fall under tion data displayed on the labels of food products. four overarching themes: The Food Guidance System provides Web-based in- • Variety—Eat foods from all food groups and sub- teractive and print materials for all citizens: consumers, groups. news media, and professionals. They include the following: • Proportionality—Eat more of some foods (fruits, veg- • Food intake patterns identify what and how much food etables, whole grains, fat-free or low-fat milk prod- ucts), and less of others (foods high in saturated or an individual should eat for health. The amounts to eat trans fats, added sugars, cholesterol salt, and alcohol). are based on a person’s age, sex, and activity level. These patterns have been published in the 2005 • Moderation—Choose forms of foods that limit intake Dietary Guidelines. of saturated or trans fats, added sugars, cholesterol, salt, and alcohol. FIGURE 1-1 MyPyramid: Steps to a Healthier You Source: Courtesy of the USDA. • Activity—Be physically active every day.

10 PART I NUTRITION BASICS AND APPLICATIONS Eat recommended amounts of fruit, and choose a va- riety of fruits each day. For example, people who need The framework’s recommendations are presented as 2000 calories per day need 2 c of fruit per day. See food key concepts for educators. The key concepts are organized intake patterns in the next section for other calorie levels. by topic area: calories; physical activity; grains; vegetables; fruits; milk, yogurt, and cheese; meat, poultry, fish, dry Milk, Yogurt, and Cheese beans, eggs, and nuts; fats and oils; sugars and sweets; salt; alcohol; and food safety. Under each topic area, informa- The milk group includes all fluid milk products and foods tion is presented on the following: made from milk that retain their calcium content, such as yogurt and cheese. Foods made from milk that have little • What actions should be taken for a healthy diet to no calcium, such as cream cheese, cream, and butter, • How these actions can be implemented are not part of the group. Most milk group choices should • Why this action is important for health (the key benefits) be fat free or low fat. In general, 1 c of milk or yogurt, 1-1⁄2 ounces of natural cheese, or 2 ounces of processed Food Groups cheese can be considered as 1 c from the milk group. The core of MyPramid is the Food Guidance System as in- Consume 3 c of fat-free or low-fat (1%) milk, or an dicated in Figure 1-2. A brief discussion of the food equivalent amount of yogurt or cheese, per day. Children groups follows. 2 to 8 years old should consume 2 c of fat-free or low-fat milk, or an equivalent amount of yogurt or cheese, per Calories and Physical Activity day. Consume other calcium-rich foods if milk and milk products are not consumed. One must balance calorie intake from foods and bever- ages with calories expended and engage in regular phys- Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts ical activity and reduce sedentary activities. For the meat and beans group in general, 1 ounce of lean Grains meat, poultry, or fish; 1 egg; 1 tbsp peanut butter; 1⁄4 c cooked dry beans; or 1⁄2 ounce of nuts or seeds can be The grains group includes all foods made from wheat, considered as 1 ounce-equivalent from the meat and rice, oats, cornmeal, barley, such as bread, pasta, oat- beans group. meal, breakfast cereals, tortillas, and grits. In general, 1 slice of bread, 1 c of ready-to-eat cereal, or 1⁄2 c of cooked One should make choices that are low fat or lean when rice, pasta, or cooked cereal can be considered as 1 ounce- selecting meats and poultry. Choose a variety of different equivalent from the grains group. At least half of all types of foods from this group each week. Include fish, grains consumed should be whole grains. dry beans, peas, nuts, and seeds, as well as meats, poul- try, and eggs. Consider dry beans and peas as an alterna- Consume 3 or more ounce-equivalents of whole-grain tive to meat or poultry as well as a vegetable choice. Keep products per day. Since the recommended 3 ounce- the overall amounts of foods eaten from this group within equivalents may be difficult for young children to the amount needed each day. For example, people who achieve, they should gradually increase the amount of need 2000 calories per day need 5-1⁄2 ounce-equivalents whole grains in their diets. An ounce-equivalent of per day. See food intake patterns in the next section for grains is about 1 slice of bread, 1 c of ready-to-eat cereal other calorie levels. flakes, or 1⁄2 c of cooked pasta or rice, or cooked cereal. Fats and Oils Vegetables Oils include fats from many different plants and from The vegetable group includes all fresh, frozen, canned, fish that are liquid at room temperature, such as canola, and dried vegetables and vegetable juices. In general, 1 c corn, olive, soybean, and sunflower oil. Some foods are of raw or cooked vegetables or vegetable juice, or 2 c of naturally high in oils, such as nuts, olives, some fish, and raw leafy greens can be considered as 1 c from the veg- avocados. Foods that are mainly oil include mayonnaise, etable group. certain salad dressings, and soft margarine. Eat the recommended amounts of vegetables, and Choose most fats from sources of monounsaturated choose a variety of vegetables each day. For example, and polyunsaturated fatty acids, such as fish, nuts, seeds, those needing 2000 calories per day need about 2-1⁄2 c of and vegetable oils. Keep the amount of oils consumed vegetables per day. See food intake patterns in the next within the total allowed for caloric needs. For example, section for other calorie levels. people who need 2000 calories per day can consume 27 grams of oils (about 7 tsp). See food intake patterns for Fruits amounts for other calorie levels. Choose fat-free, low-fat, or lean meat, poultry, dry beans, milk, and milk prod- The fruit group includes all fresh, frozen, canned, and ucts. Choose grain products and prepared foods that are dried fruits and fruit juices. In general, 1 c of fruit or low in saturated and trans fat. 100% fruit juice, or 1⁄2 c of dried fruit, can be considered as 1 c from the fruit group.

CHAPTER 1 INTRODUCTION TO NUTRITION 11 Limit the amount of solid fats consumed to the Food Intake Patterns amount within the discretionary calorie allowance, after taking into account other discretionary calories that have The suggested amounts of food to consume from the been consumed. For example, people who need 2000 basic food groups, subgroups, and oils to meet recom- calories per day have a total discretionary calorie al- mended nutrient intakes at 12 different calorie levels are lowance of 267 calories. provided in Table 1-1. Nutrient and energy contributions from each group are calculated according to the nutrient- Sugars and Sweets dense forms of foods in each group (e.g., lean meats and fat-free milk). The table also shows the discretionary calo- Choose and prepare foods and beverages with little added rie allowance that can be accommodated within each sugars or caloric sweeteners. Keep the amount of sug- calorie level, in addition to the suggested amounts of nu- ars and sweets consumed within the discretionary trient-dense forms of foods in each group. Table 1-2 calorie allowance, after taking into account other discre- shows the vegetable subgroup amounts per week. Table tionary calories that have been consumed. For example, 1-3 shows the calorie levels for males and females by age people who need 2000 calories per day1 have a total dis- and activity level. Calorie levels are set across a wide cretionary calorie allowance of 267 calories. See food in- range to accommodate the needs of different individuals. take patterns in the next section for amounts for other Table 1-3 can be used to help assign individuals to the calorie levels. Practice good oral hygiene and consume food intake pattern at a particular calorie level. sugar- and starch-containing foods and beverages less frequently. Discretionary calorie allowance is the remaining amount of calories in a food intake pattern after account- Salt ing for the calories needed for all food groups—using forms of foods that are fat free or low fat and with no Choose and prepare foods with little salt. Keep sodium in- added sugars. take less than 2300 mg per day. At the same time, con- sume potassium-rich foods, such as fruits and vegetables. Table 1-4 shows some weekly sample menus for a daily 2000 calorie intake diet. Table 1-5 describes the nutri- Alcohol ent contribution from these weekly menus. If one chooses to drink alcohol, consume it in modera- The original MyPyramid contains many more details tion. Some people, or people in certain situations, should about the Food Guidance System. The best sources are not drink. Keep consumption of alcoholic beverages your instructors and the Web site MyPyramid.gov. within daily discretionary calorie allowance. For example, people who need 2000 calories per day1 have a total dis- At this Web site, consumers can enter their age, gen- cretionary calorie allowance of 267 calories. der, and activity level, and they are given their own plan at an appropriate calorie level. The food plan includes TABLE 1-1 Daily Amount of Food from Each Group Calorie Level 1000 1200 1400 1600 1800 2000 Fruits 1 cup 1 cup 1.5 cups 1.5 cups 1.5 cups 2 cups 1.5 cups 1.5 cups 2 cups 2.5 cups 2.5 cups Vegetables 1 cup 4 oz–eq 5 oz–eq 5 oz–eq 6 oz–eq 6 oz–eq 3 oz–eq 4 oz–eq 5 oz–eq 5 oz–eq 5.5 oz–eq Grains 3 oz–eq 2 cups 2 cups 3 cups 3 cups 3 cups 4 tsp 4 tsp 5 tsp 5 tsp 6 tsp Meat and Beans 2 oz–eq 171 171 132 195 267 Milk 2 cups 2600 2800 3000 3200 Oils 3 tsp 2 cups 2.5 cups 2.5 cups 2.5 cups 3.5 cups 3.5 cups 4 cups 4 cups Discretionary calorie allowance 165 9 oz–eq 10 oz–eq 10 oz–eq 10 oz–eq 6.5 oz–eq 7 oz–eq 7 oz–eq 7 oz–eq Calorie Level 2200 2400 3 cups 3 cups 3 cups 3 cups 8 tsp 8 tsp 10 tsp 11 tsp Fruits 2 cups 2 cups 410 426 512 648 3 cups Vegetables 3 cups 8 oz–eq 6.5 oz–eq Grains 7 oz–eq 3 cups 7 tsp Meat and Beans 6 oz–eq 362 Milk 3 cups Oils 6 tsp Discretionary calorie allowance 290 Source: Courtesy of the USDA.

12 PART I NUTRITION BASICS AND APPLICATIONS TABLE 1-2 Vegetable Subgroup Amounts per Week Calorie Level 1000 1200 1400 1600 1800 2000 Dark green veg. 1 c/wk 1.5 c/wk 1.5 c/wk 2 c/wk 3 c/wk 3 c/wk Orange veg. .5 c/wk 1 c/wk 1 c/wk 1.5 c/wk 2 c/wk 2 c/wk Legumes .5 c/wk 1 c/wk 1 c/wk 2.5 c/wk 3 c/wk 3 c/wk Starchy veg. 1.5 c/wk 2.5 c/wk 2.5 c/wk 2.5 c/wk 3 c/wk 3 c/wk Other veg. 3.5 c/wk 4.5 c/wk 4.5 c/wk 5.5 c/wk 6.5 c/wk 6.5 c/wk Calorie Level 2200 2400 2600 2800 3000 3200 Dark green veg. 3 c/wk 3 c/wk 3 c/wk 3 c/wk 3 c/wk 3 c/wk Orange veg. 2 c/wk 2 c/wk 2.5 c/wk 2.5 c/wk 2.5 c/wk 2.5 c/wk Legumes 3 c/wk 3 c/wk 3.5 c/wk 3.5 c/wk 3.5 c/wk 3.5 c/wk Starchy veg. 6 c/wk 6 c/wk 7 c/wk 7 c/wk 9 c/wk 9 c/wk Other veg. 7 c/wk 7 c/wk 8.5 c/wk 8.5 c/wk 10 c/wk 10 c/wk Source: Courtesy of the USDA. TABLE 1-3 The Calorie Levels for Males and Females by Age and Activity Level Males Females Activity level Sedentary* Mod. active* Active* Activity level Sedentary* Mod. active* Active* Age Age 1000 1000 2 1000 1000 1000 2 1000 1200 1400 3 1000 1400 1400 3 1000 1400 1400 4 1200 1400 1600 4 1200 1400 1600 5 1200 1400 1600 5 1200 1400 1600 6 1400 1600 1800 6 1200 1600 1800 7 1400 1600 1800 7 1200 1600 1800 8 1400 1600 2000 8 1400 1600 1800 9 1600 1800 2000 9 1400 1800 2000 10 1600 1800 2200 10 1400 1800 2000 11 1800 2000 2200 11 1600 2000 2200 12 1800 2200 2400 12 1600 2000 2200 13 2000 2200 2600 13 1600 2000 2400 14 2000 2400 2800 14 1800 2000 2400 15 2200 2600 3000 15 1800 2000 2400 16 2400 2800 3200 16 1800 2000 2400 17 2400 2800 3200 17 1800 2000 2400 18 2400 2800 3200 18 1800 2200 2400 19–20 2600 2800 3000 19–20 2000 2200 2400 21–25 2400 2800 3000 21–25 2000 2000 2400 26–30 2400 2600 3000 26–30 1800 2000 2200 31–35 2400 2600 3000 31–35 1800 2000 2200 36–40 2400 2600 2800 36–40 1800 2000 2200 41–45 2200 2600 2800 41–45 1800 2000 2200 46–50 2200 2400 2800 46–50 1800 1800 2200 51–55 2200 2400 2800 51–55 1600 1800 2200 56–60 2200 2400 2600 56–60 1600 1800 2000 61–65 2000 2400 2600 61–65 1600 1800 2000 66–70 2000 2200 2600 66–70 1600 1800 2000 71–75 2000 2200 2600 71–75 1600 1800 2000 76 and up 2000 2000 2400 76 and up 1600 *Calorie levels are based on the Estimated Energy Requirements (EER) and activity levels from the Institute of Medicine’s Report on Dietary Reference Intakes—Macro Nutrients, 2002. Sedentary = less than 30 minutes a day of moderate physical activity in addition to daily activities. Mod. active = at least 30 minutes up to 60 minutes a day of moderate physical activity in addition to daily activities. Active = 60 or more minutes a day of moderate physical activity in addition to daily activities. Source: Courtesy of the USDA.

CHAPTER 1 INTRODUCTION TO NUTRITION 13 TABLE 1-4 Sample Weekly Sample Menus for a Daily 2000 Calorie Intake Diet Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 BREAKFAST BREAKFAST BREAKFAST BREAKFAST BREAKFAST BREAKFAST BREAKFAST Breakfast burrito Hot cereal Cold cereal 1 whole wheat Cold cereal French toast Pancakes 1 flour tortilla 1⁄2 cup cooked 1 cup bran flakes English muffin 1 cup shredded 2 slices whole 3 buckwheat 1 cup fat-free (7” diameter) oatmeal 2 tsp soft wheat cereal wheat French pancakes 1 scrambled egg 2 tbsp raisins milk margarine 1 tbsp raisins toast 2 tsp soft 1 tsp soft 1 small banana 1 cup fat-free milk 2 tsp soft (in 1 tsp soft 1 slice whole 1 tbsp jam or 1 small banana margarine margarine margarine) margarine preserves 1 slice whole 2 tbsp maple 3 tbsp maple 1⁄3 cup black 1⁄2 cup fat-free wheat toast syrup beans* 1 tsp soft 1 medium wheat toast 1⁄2 medium grape- syrup 2 tbsp salsa milk grapefruit 1 tsp soft fruit 1⁄2 cup 1 cup orange 1 cup orange juice margarine 1 cup fat-free juice 1 cup prune juice 1 hard-cooked margarine milk strawberries 1 cup fat-free egg 1 tsp jelly 3⁄4 cup honey- milk LUNCH LUNCH 1 unsweetened LUNCH dew melon LUNCH LUNCH Tuna fish beverage Vegetarian chili 1⁄2 cup fat-free sandwich Smoked turkey on baked Roast beef Taco salad LUNCH sandwich potato milk sandwich 2 ounces tortilla 2 slices rye bread 3 ounces tuna White bean- 2 ounces whole 1 cup kidney LUNCH 1 whole grain chips vegetable soup wheat pita beans* sandwich bun 2 ounces ground (packed in bread Manhattan water, drained) 1 1⁄4 cup chunky 1⁄2 cup tomato clam 3 ounces lean roast turkey, sauteed 2 tsp mayonnaise vegetable soup 1⁄4 cup romaine sauce w/ chowder beef in 2 tsp sun- 1 tbsp diced lettuce tomato tidbits* flower oil celery 1⁄2 cup white 3 ounces 2 slices tomato 1⁄2 cup black 1⁄4 cup shredded beans* 2 slices tomato 3 tbsp chopped canned 1⁄4 cup shredded ro- beans* romaine 3 ounces sliced onions clams 1⁄2 cup iceberg lettuce 2 ounce (drained) maine lettuce lettuce 2 slices tomato breadstick smoked turkey 1 ounce lowfat 1⁄8 cup sauteed 2 slices tomato 1 medium pear breast* cheddar cheese 3⁄4 cup mixed 1 ounce low-fat 1 cup fat-free 8 baby carrots 1 tbsp mayo-type vegetables mushrooms (in cheddar cheese milk 1 cup fat-free salad dressing 1 tsp vegetable oil 1 tsp oil) 2 tbsp salsa 1 tsp yellow 1 medium baked 1 cup canned 1 1⁄2 ounce part- 1⁄2 cup avocado DINNER milk mustard tomatoes* skim mozzarella 1 tsp lime juice 1⁄2 cup apple slices potato cheese 1 unsweetened Roasted chicken DINNER 1 cup tomato 1⁄2 cup cantaloupe 10 whole wheat 1 tsp yellow beverage breast Rigatoni with juice* 3⁄4 cup lemonade crackers* mustard 3⁄4 cup baked potato 3 ounces boneless meat sauce DINNER DINNER 1 medium wedges* skinless 1 cup rigatoni orange 1 tbsp ketchup chicken breast* Grilled top loin Hawaiian pizza 1 unsweetened pasta (2 ounces steak 2 slices cheese 1 cup fat-free beverage 1 large baked dry) milk sweet potato 1⁄2 cup tomato 5 ounces grilled pizza DINNER DINNER sauce tomato top loin steak 1 ounce canadian DINNER 1⁄2 cup peas and bits* Stuffed broiled Spinach lasagna onions 2 ounces extra 3⁄4 cup mashed po- bacon Vegetable stir- salmon 1 cup lasagna lean cooked tatoes 1⁄4 cup pineapple fry 1 tsp soft ground beef 2 tbsp 5 ounce salmon noodles, cooked margarine (sauteed in 2 2 tsp soft 4 ounces tofu filet (2 oz dry) tsp vegetable margarine mushrooms (firm) 2⁄3 cup cooked 1 ounce whole oil) 2 tbsp chopped 1 ounce bread spinach wheat dinner 3 tbsp grated 1⁄2 cup steamed 1⁄4 cup green stuffing mix 1⁄2 cup ricotta roll Parmesan carrots onions and red bell cheese cheese Green salad peppers 1 tbsp chopped 1⁄2 cup tomato 1 tsp soft Spinach salad 1 tbsp honey 1 cup leafy greens onions sauce tomato margarine 1 cup baby 2 ounces whole 3 tsp sunflower 1⁄2 cup bok bits* spinach leaves choy 1 tbsp diced 1 ounce part-skim 1 cup leafy greens 1⁄2 cup tangerine wheat dinner oil and vinegar celery mozzarella salad slices roll dressing 2 tbsp vegetable cheese 1 tsp soft 1 cup fat-free oil 2 tsp canola oil 1 ounce whole 3 tsp sunflower margarine milk 1⁄2 cup saffron wheat dinner oil and vinegar 1 cup fat-free milk 1 cup brown roll dressing rice (white) rice 1 cup fat-free milk 1 ounce slivered 1 cup lemon- flavored iced almonds tea 1⁄2 cup steamed (continues) broccoli 1 tsp soft margarine 1 cup fat-free milk

14 PART I NUTRITION BASICS AND APPLICATIONS TABLE 1-4 (continued) Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 SNACKS SNACKS SNACKS 1⁄2 ounce chopped SNACKS SNACKS SNACKS walnuts 1 cup can- 1⁄2 ounce dry- 1⁄4 cup dried 1 cup low-fat 5 whole wheat 1 ounce sun- taloupe roasted apricots 3 tsp sunflower fruited yogurt crackers* flower seeds* almonds* oil and vinegar 1 cup low-fat dressing 1⁄8 cup hummus 1 large banana 1⁄4 cup pineapple fruited yogurt 1⁄2 cup fruit cock- 1 cup low-fat 2 tbsp raisins 1 cup fat-free milk tail (in water or fruited yogurt juice) SNACKS 1 cup low-fat fruited yogurt *Starred items are foods that are labeled as no-salt-added, low-sodium, or low-salt versions of the foods. They can also be prepared from scratch with little or no added salt. All other foods are regular commercial products that contain variable levels of sodium. Average sodium level of the 7 day menu assumes no-salt-added in cooking or at the table. Source: Courtesy of the USDA. TABLE 1-5 Nutrient Contribution from Weekly Menus in Table 1-4 Food Group Daily Average Nutrient Daily Average Over One Week Over One Week Grains Calories Vegetables* Total Grains (oz–eq) 6.0 Protein, g 1994 Fruits Whole Grains 3.4 Protein, % kcal 98 Milk Refined Grains 2.6 Carbohydrate, g 20 Meat & Beans Total Veg* (cups) 2.6 Carbohydrate, % kcal 264 Oils Fruits (cups) 2.1 Total fat, g 53 Milk (cups) 3.1 Total fat, % kcal 67 Meat/Beans (oz–eq) 5.6 Saturated fat, g 30 Oils (tsp/grams) 7.2 tsp/32.4 g Saturated fat, % kcal 16 Monounsaturated fat, g 7.0 Polyunsaturated fat, g 23 Linoleic Acid, g 23 Alpha-linolenic Acid, g 21 Cholesterol, mg 1.1 Total dietary fiber, g 207 Potassium, mg 31 Sodium, mg* Calcium, mg 4715 Magnesium, mg 1948 Copper, mg 1389 Iron, mg 432 Phosphorus, mg Zinc, mg 1.9 Thiamin, mg 21 Riboflavin, mg 1830 Niacin Equivalents, mg 14 Vitamin B6, mg 1.9 Vitamin B12, mcg 2.5 Vitamin C, mg 24 Vitamin E, mg (AT) 2.9 Vitamin A, mcg (RAE) 18.4 Dietary Folate Equivalents, mcg 190 18.9 1430 558 *Vegetable subgroups (weekly totals) Dk-Green Veg (cups) 3.3 Orange Veg (cups) 2.3 Beans/Peas (cups) 3.0 Starchy Veg (cups) 3.4 Other Veg (cups) 6.6 Source: Courtesy of USDA.

CHAPTER 1 INTRODUCTION TO NUTRITION 15 specific daily amounts from each food group and a limit Frozen bars, frozen desserts, frozen yogurt, and for discretionary calories (fats, added sugars, alcohol). ice cream Their food plan is one of the 12 calorie levels of the food intake patterns from the Dietary Guidelines. Visitors to Granola bars, meal replacement bars/shakes, the Web site can print out a personalized miniposter of and trail mix their plan and a worksheet to help them track their progress and choose goals for tomorrow and the future. Fruit list Fruits FOOD EXCHANGE LISTS Fruit juices The Food Exchange Lists are the basis of a meal plan- Vegetables (nonstarchy) list ning system designed by the American Dietetic Meat and meat substitutes list Association and the American Diabetes Association. They are based upon principles of good nutrition for everyone. Lean meat There are 11 lists, of which the last one is alcohol. For Medium-fat meat some lists, each contributes an approximate level of nu- High-fat meat trients for each food: calories, carbohydrates, proteins, Plant-based proteins (for beans, peas, and lentils, and fats. For others, the contribution of nutrients varies within or between lists. Every time you replace one food see starch list) item with another item in the same or different list, you Milk list know approximately the change in levels of nutrients you will be consuming. Fat-free and low-fat milk Reduced fat Choices from each group balance the meal. Health Whole milk practitioners use the exchange system because it is an Dairy-like foods easy tool to work with and teaches food selection in a Fat list practical way. It also meets the guidelines for limiting Monounsaturated fats list saturated fat and cholesterol intake. Polyunsaturated fats list Saturated fats list The associations revise and update the exchange sys- Fast-foods list tem regularly to reflect current nutrition research and Breakfast sandwiches the national dietary guidelines for health promotion and Main dishes/entrees reduction of chronic disease risk factors as new informa- Oriental tion becomes available. Pizzas Sandwiches The 2007 edition of the Food Exchange Lists contin- Salads ues the basic principles of 2003 edition, arranging the Sides/appetizers food groups into 11 broad categories or listed based on Desserts their nutrient content. Subcategories that appear within Combination foods list these categories provide additional information to assist Entrées clients in choosing more healthful foods, as well as more Frozen entrées/meals choices. They reflect today’s consumers’ changing di- Salads (deli-style) etary habits and lifestyles. The 11 lists in this document Soups are described below, with alcohol as the last category: Free foods list Low-carbohydrate foods Starch list Modified-fat foods with carbohydrate Bread Condiments Cereals and grains Free snacks Crackers and snacks Drinks/mixes Starchy vegetables Alcohol list Beans, peas, and lentils Chapter 18 and Appendix F provide more details Sweets, desserts, and other carbohydrates list on these lists concerning food, nutrient data, and Beverages, sodas, and energy/sports drinks; applications. brownies, cake, cookies, gelatin, pie, and pudding RESPONSIBILITIES OF HEALTH PERSONNEL Candy, spreads, sweets, sweeteners, syrups, and toppings 1. Assume responsibility for one’s own health through Condiments and sauces changes in eating habits and lifestyle patterns. Doughnuts, muffins, pastries, and sweet breads 2. Select, prepare, and consume an adequate diet. 3. Promote good eating habits for all age groups.

16 PART I NUTRITION BASICS AND APPLICATIONS a. the capacity to do work. b. food that provides calories. 4. Use appropriate guidelines when teaching clients re- c. chemical substances in the body. garding food selection. d. heat required to raise body temperature. e. a and b 5. Facilitate healthy lifestyles by encouraging clients to f. a, b, c, and d expand their knowledge of nutrition. 19. There are grams in one ounce. 6. Use approved food guides when assessing, planning, and evaluating a client’s intake. a. 2.285 b. 28.385 PROGRESS CHECK ON ACTIVITY 1 c. 1000 d. 36 SHORT ANSWER Define the following terms: 20. Malnutrition is defined as: 1. Calorie a. impaired health due to undernutrition. 2. Health b. imbalance of nutrients. 3. Nutrient c. excessive nutrients. 4. Optimum nutrition d. the inability of the body to use ingested 5. Appropriate diet nutrients. FILL-IN e. all of the above. 6. Dietary recommendations to promote health and prevent or delay the onset of diseases are known 21. Nutritional requirements vary from nutrient to as . nutrient because of which of these factors? 7. The recommended dietary allowances (RDAs) are . a. age 8. Tolerable Upper Intake Levels (ULs) are b. gender . c. physiological state 9. Dietary Reference Intakes (DRIs) are d. size . e. a, b, and d 10. An adequate intake is defined as what? f. a, b, c, and d DEFINE THESE ACRONYMS GENERAL QUESTIONS 11. FNB 22. What is MyPyramid? 12. ADA 23. How does MyPyramid help the consumers? 13. EAR 14. USDA 24. Define the milk, yogurt, and cheese group accord- 15. AHA ing to MyPyramid. 16. NCEP 17. UL 25. The Food Guidance System is based on two im- portant food guides. They are: MULTIPLE CHOICE Circle the letter of the correct answer. . 18. Energy is: 26. Name the seven chronic diseases in the United States that are linked to risk factors associated with diet. 27. List four nutrition health problems that require special dietary measures. 28. Explain the difference(s) between the Dietary Guidelines for Americans and MyPyramid Food Guidance System.

CHAPTER 1 INTRODUCTION TO NUTRITION 17 29. List the 11 primary lists in the 2007 Food Ex- People look at food labels for different reasons. But change Lists. whatever the reason, many consumers would like to know how to use this information more effectively and easily. 30. Name three approved food guides you would use The food label is headed with the title, “Nutrition when assessing, planning, or evaluating a client’s Facts.” It describes the nutrients, among other data, in- cluding the following: diet: (a) (b) Total calories (c) Calories from fat Calories from saturated fat SELF-STUDY Total fat Saturated fat Use Table 1-3 to determine your approximate daily Polyunsaturated fat caloric need. Write down everything you ate or drank Monounsaturated fat in the last 24 hours for meals and snacks. Then do the Cholesterol following: Sodium Potassium 1. Did you have the number of servings from the five Total carbohydrate major food groups that are right for you according Dietary fiber to MyPramid.gov? Soluble fiber Insoluble fiber 2. At approximately which of the three calorie levels was Sugars your 24-hour intake? Was the number of servings you Sugar alcohol (for example, the sugar substitutes ate greater, less, or about right for your age, gender, and activity? xylitol, mannitol, and sorbitol) Other carbohydrate (the difference between total 3. Using the Dietary Guidelines, look at your diet to see if you should make any substitutions regarding your carbohydrate and the sum of dietary fiber, sugars, salt, sugar, or fiber content (clue: visit the Web site and sugar alcohol if declared) given for the Dietary Guidelines). Protein Vitamin A 4. Write a short summary of things you could do to im- Vitamin C prove your present diet if improvement is needed. Calcium Iron Self-Study: Your individual answers will provide in- Other essential vitamins and minerals formation for your personal health status. Listing of most of the above nutrients is mandatory. ACTIVITY 2: Some are voluntary listings, and others require special consideration. Let us look at a sample label of macaroni Legislation and Health Promotion and cheese. Refer to Figure 1-3. At present, there are national policies and recommenda- The information in the main or top section (see Step 1 tion on nutrition labeling, dietary supplements, and ed- through Step 4 and Step 6 on the sample nutrition label ucational programs on cholesterol and our health. In the that follows), can vary with each food product; it con- last decade, a new concept of bioactive food ingredients tains product-specific information (serving size, calories, (nutraceuticals) and functional foods has developed and and nutrient information). The bottom part (see Step 5 will be discussed with other national policies in this on the sample label that follows) contains a footnote with activity. Daily Values (DVs) for 2000 and 2500 calorie diets. This footnote provides recommended dietary information for FOOD LABELING important nutrients, including fats, sodium, and fiber. The footnote is found only on larger packages and does In general, food and nutrition labeling is now manda- not change from product to product. tory for many foods excluding meat and poultry, with special considerations for seafood and other fresh foods. The Contents of a Food Label The information in this section has been modified Only selected information is included. Refer to Figure 1-3. from the document issued by the U.S. Food and Drug Administration, How to Understand and Use the Step 1. Start here. Nutrition Facts Label. This document was published in The first place to start when you look at the June 2000 and updated twice, July 2003 and November Nutrition Facts label is the serving size and the 2004. See www.cfsan.fda.gov/label.html for the latest updates and other legal announcements related to food labeling.

18 PART I NUTRITION BASICS AND APPLICATIONS In the example, there are 250 calories in one serving of this macaroni and cheese. How many FIGURE 1-3 Sample Label of Macaroni and Cheese calories from fat are there in one serving? Source: Courtesy of the FDA. Answer: 110 calories, which means almost half the calories in a single serving come from fat. number of servings in the package. Serving sizes What if you ate the whole package content? are standardized to make it easier to compare Then, you would consume two servings, or 500 similar foods; they are provided in familiar units, calories, and 220 would come from fat. such as cups or pieces, followed by the metric amount (the number of grams). Box 1-1, General Guide to Calories, provides a general reference for calories when you look at The size of the serving on the food package in- a Nutrition Facts label. This guide is based on a fluences the number of calories and all the nu- 2000-calorie diet. trient amounts listed on the top part of the label. Pay attention to the serving size, especially how Eating too many calories per day is linked to many servings there are in the food package. overweight and obesity. Then ask yourself, “How many servings am I consuming”? (e.g., 1⁄2 serving, 1 serving, or Look at the top of the nutrient section in the more). In the sample label, one serving of mac- sample label (Figure 1-3). It shows you some aroni and cheese equals 1 c. If you ate the whole key nutrients that affect your health and sepa- package, you would eat 2 c. That doubles the rates them into two main groups. calories and other nutrient numbers, including Step 3. Limit these nutrients. the %DVs as shown in the sample label. Table The nutrients listed first are the ones Americans 1-6 compares the nutritional contributions for generally eat in adequate amounts, or even too a single or double serving. much. Eating too much fat, saturated fat, trans Step 2. Check calories. fat, cholesterol, or sodium may increase your Calories provide a measure of how much energy risk of certain chronic diseases, such as heart you get from a serving of this food. Many disease, some cancers, or high blood pressure. Americans consume more calories than they need without meeting recommended intakes for Important: Health experts recommend that a number of nutrients. The calorie section of you keep your intake of saturated fat, trans fats, the label can help you manage your weight (i.e., and cholesterol as low as possible as part of a gain, lose, or maintain). Remember: The num- nutritionally balanced diet. ber of servings you consume determines the Step 4. Get enough of these nutrients. number of calories you actually eat (your por- Most Americans don’t get enough dietary fiber, tion amount). vitamin A, vitamin C, calcium, and iron in their TABLE 1-6 Single vs. Double Serving Single Example Serving Double 1 cup %DV Serving %DV Serving Size 2 cups (228 g) (456 g) 500 Calories 250 220 Calories from 110 Fat Total Fat 12 g 18 24 g 36 3g Trans Fat 1.5 g 15 6 g 30 Saturated Fat 3 g 10 60 mg 20 20 940 mg 40 Cholesterol 30 mg 10 62 g 20 0 0g 0 Sodium 470 mg 10 g Total Carbohydrate 31 g 10 g 48 Dietary Fiber 0 g 24 20 40 Sugars 5g 48 Protein 5g Vitamin A Vitamin C Calcium Iron Source: Courtesy of the FDA.

CHAPTER 1 INTRODUCTION TO NUTRITION 19 BOX 1-1 General Guide to Calories the example. Upper limits means it is recom- mended that you stay below—eat less than— 40 calories is low the Daily Value nutrient amounts listed per day. For example, the DV for saturated fat is 20 g. 100 calories is moderate This amount is 100%DV for this nutrient. What is the goal or dietary advice? To eat less than 20 400 calories or more is high g or 100%DV for the day. Source: Courtesy of the FDA. Now look at the entry where dietary fiber is listed. The DV for dietary fiber is 25 g, which is diets. Eating enough of these nutrients can im- 100%DV. This means it is recommended that prove your health and help reduce the risk of you eat at least this amount of dietary fiber per some diseases and conditions. For example, get- day. ting enough calcium may reduce the risk of os- teoporosis, a condition that results in brittle The DV for the entry Total Carbohydrate is bones as one ages. Eating a diet high in dietary 300 g or 100%DV. This amount is recommended fiber promotes healthy bowel function. Addi- for a balanced daily diet that is based on 2000 tionally, a diet rich in fruits, vegetables, and grain calories, but can vary, depending on your daily products that contain dietary fiber, particularly intake of fat and protein. soluble fiber, and low in saturated fat and choles- terol, may reduce the risk of heart disease. Now let’s look at the %DVs. Step 6. The percent daily value (%DV). Remember: You can use the Nutrition Facts label not only to help limit those nutrients you The % Daily Values (%DVs) are based on the want to cut back on but also to increase those Daily Value recommendations for key nutrients nutrients you need to consume in greater but only for a 2000 calorie daily diet—not 2500 amounts. calories. You, like most people, may not know Step 5. Footnote. how many calories you consume in a day. But Note the asterisk ( * ) used after the heading “% you can still use the %DV as a frame of reference Daily Value” on the Nutrition Facts label. It whether or not you consume more or less than refers to the footnote in the lower part of the 2000 calories. nutrition label, which tells you “Percent Daily Values are based on a 2,000 calorie diet.” This The %DV helps you determine if a serving of statement must be on all food labels. But the food is high or low in a nutrient. Note: A few remaining information in the full footnote may nutrients, like trans fat, do not have a %DV— not be on the package if the size of the label is they will be discussed later. too small. When the full footnote does appear, it will always be the same. It doesn’t change from You don’t need to know how to calculate per- product to product, because it shows recom- centages to use the %DV? The label (the %DV) mended dietary advice for all Americans—it is does the math for you. It helps you interpret the not about a specific food product. numbers (grams and milligrams) by putting them all on the same scale for the day Look at the amounts or the Daily Values (DV) (0–100%DV). The %DV column doesn’t add up for each nutrient listed. These are based on pub- vertically to 100%. Instead each nutrient is lic health experts’ advice. DVs are recommended based on 100% of the daily requirements for levels of intakes. DVs in the footnote are based that nutrient (for a 2000 calorie diet). This way on a 2000 or 2500 calorie diet. Note how the you can tell high from low and know which DVs for some nutrients change, while others nutrients contribute a lot, or a little, to your (for cholesterol and sodium) remain the same daily recommended allowance (upper or lower). for both calorie amounts. TABLE 1-7 Examples of DVs vs. %DVs, Look at Table 1-7 for another way to see how Based on a 2000 Calorie Diet the DVs relate to the %DVs and dietary guid- ance. For each nutrient listed there is a DV, a Nutrient DV %DV Goal %DV, and dietary advice or a goal. If you follow this dietary advice, you will stay within public Total Fat 65 g ϭ 100%DV Less than health experts’ recommended upper or lower Sat Fat 20 g ϭ 100%DV Less than limits for the nutrients listed, based on a 2000 Cholesterol 300 mg ϭ 100%DV Less than calorie daily diet. Sodium 2400 mg ϭ 100%DV Less than Total The nutrients that have upper daily limits are Carbohydrate 300 g ϭ 100%DV At least listed first on the footnote of larger labels and on Dietary Fiber 25 g ϭ 100%DV At least

20 PART I NUTRITION BASICS AND APPLICATIONS Refer to Step 6 in Figure 1-3, as shown below: Nutrient Content Claims: Use the %DV to help you Quick Guide to %DV: quickly distinguish one claim from another, such • 5% or less is low as “reduced fat” vs. “light” or “nonfat.” Just com- • 20% or more is high pare the %DVs for total fat in each food product to see which one is higher or lower in that nutrient— This guide tells you that 5%DV or less is low there is no need to memorize definitions. This for all nutrients, those you want to limit (e.g., works when comparing all nutrient content claims, fat, saturated fat, cholesterol, and sodium), or such as less, light, low, free, more, or high. for those that you want to consume in greater amounts (fiber, calcium, etc.). As the Quick Dietary Trade-Offs: You can use the %DV to help you Guide shows, 20%DV or more is high for all nu- make dietary trade-offs with other foods through- trients. out the day. You don’t have to give up a favorite food to eat a healthy diet. When a food you like is Example: Look at the amount of total fat in one high in fat, balance it with foods that are low in fat serving listed on the sample nutrition label. Is at other times of the day. Also, pay attention to how 18%DV contributing a lot or a little to your fat limit much you eat so that the total amount of fat for of 100%DV? Check the Quick Guide to %DV, and the day stays below 100%DV. you’ll see that 18%DV, which is below 20%DV, is not yet high, but what if you ate the whole package Health Claims (two servings)? You would double that amount, eat- ing 36% of your daily allowance for total fat. You may have noticed that some labels have health claims Coming from just one food, that amount leaves and some do not. At present, the FDA permits six groups you with 64% of your fat allowance (100% Ϫ 36% of qualified health claims subject to enforcement discre- ϭ 64%) for all of the other foods you eat that day, tion. They include the following. snacks and drinks included. See Figure 1-4. 1. Qualified Claims About Cancer Risk The %DV can be used for: a. Tomatoes and/or tomato sauce and prostate, ovar- ian, gastric, and pancreatic cancers Comparisons: The %DV also makes it easy for you to b. Calcium and colon/rectal cancer and calcium and make comparisons. You can compare one product recurrent colon/rectal polyps or brand to a similar product. Just make sure the c. Green tea and cancer serving sizes are similar, especially the weight (e.g., d. Selenium and cancer gram, milligram, ounces) of each product. It’s easy e. Antioxidant vitamins and cancer to see which foods are higher or lower in nutrients because the serving sizes are generally consistent 2. Qualified claims about cardiovascular disease risk for similar types of foods, except in a few cases such a. Nuts and heart disease as cereals. b. Walnuts and heart disease c. Omega-3 fatty acids and coronary heart disease FIGURE 1-4 Fat Allowance and %DV: Low vs. High Consumption Source: Courtesy of the FDA.

CHAPTER 1 INTRODUCTION TO NUTRITION 21 d. B vitamins and vascular disease lipoprotein (LDL) (Ͼ 160 mg/dl) or borderline LDL of e. Monounsaturated fatty acids from olive oil and 130–159 mg/dl. ATP 2 affirmed this approach and added a new feature: the intensive management of LDL choles- coronary heart disease terol in persons with CHD. It set a new goal of Ͻ 100 mg/dl f. Unsaturated fatty acids from canola oil and coro- of LDL. nary heart disease The third ATP report (May 2001) updates the existing g. Corn oil and heart disease recommendations for clinical management of high blood 3. Qualified claims about cognitive function cholesterol as warranted by advances in the science of a. Phosphatidylserine and cognitive dysfunction and cholesterol management. ATP 3 maintains the core of ATP 1 and 2, but its major new feature is a focus on pri- dementia mary prevention in persons with multiple risk factors. It 4. Qualified claims about diabetes calls for more intensive LDL lowering therapy in certain groups of people and recommends support for imple- a. Chromium picolinate and diabetes mentation. This approach includes a complete lipopro- 5. Qualified claims about hypertension tein profile, high density lipoprotein (HDL) cholesterol and triglycerides, as the preferred initial test. It en- a. Calcium and hypertension, pregnancy-induced hy- courages the use of plants containing soluble fiber as a pertension, and preeclampsia therapeutic dietary option to enhance lowering LDL cholesterol and presents strategies for promoting adher- 6. Qualified claims about neural tube birth defects ence. It recommends treatment beyond LDL lowering in a. 0.8 mg folic acid and neural tube birth defects people with high triglycerides. Space limitation does not permit a detailed discus- Chapter 16, “Diet Therapy for Cardiovascular Dis- sion of different aspects of food and nutrition labeling. orders,” discusses the diet therapy associated with ATP You may obtain more details in two ways: guidelines in detail. 1. The instructors will provide more information where FUNCTIONAL FOODS AND NUTRACEUTICALS applicable. In the last 15–25 years, two new concepts, functional 2. Visit the Web site www.cfsan.fda.gov/label.html for foods and nutraceuticals, have been slowly developing reference. with important ramifications to our health. To under- stand their origins and meanings, we must be familiar DIETARY SUPPLEMENT LAW with “bioactive ingredients” found in traditional foods and other edible or nonedible items. What are bioactive The Dietary Supplement Health and Education Act active ingredients? Examples include some of most pop- (DSHEA) was signed into law in October 1994. While it ular items in the news media, printed or electronic: is a compromise between the supplement industry and the FDA position, it still preserves the standards set by the 1. Omega-6 polyunsaturated fatty acids (PUFA) come from FDA in the Nutrition and Labeling Act of 1990. It provides liquid vegetable oils, including soybean oil, corn oil, consistency between food regulations and regulation of and safflower oil. Fish that naturally contain the same dietary supplements. Chapter 11, “Dietary Supplements,” ingredient, including salmon, trout, and herring, are provides a detailed discussion of this law. higher in EPA and DHA than are lean fish (e.g., cod, haddock, catfish). According to scientists, limited evi- NATIONAL CHOLESTEROL EDUCATION dence suggests an association between consumption of PROGRAM (NCEP) fatty acids in fish and reduced risks of mortality from cardiovascular disease for the general population. Such The NCEP is one of three principal programs adminis- acids form a group of bioactive ingredients. tered by the Office of Prevention, Education, and Control of the National Heart, Lung, and Blood Institute (NHLBI) 2. Folic acid is a water-soluble vitamin found in green of the National Institutes of Health (NIH). The program vegetables. Its benefit for pregnant women is getting came about after years of trials and scientific evidence increasing attention from the government, academic, that linked blood-cholesterol levels to coronary heart dis- and industrial scientists, not to mention the general ease. The trials showed that levels could be lowered safely public. There are other claims about their positive ef- by both diet and drugs. Hence, the National Cholesterol fects on clinical disorders such as birth defects. This Education Program, today known as the NCEP, came into vitamin is a bioactive ingredient. being. This became known as Adult Treatment Panel 1 (ATP 1). In 1989 the first guidelines were issued for the 3. Green tea contains three chemicals: epicatechin adult population. In 1991 the NCEP drafted an additional (EC), epicatechin gallate (ECG), eigallocatechin report that included children and adolescents. Three ATP reports have been issued. ATP 1 outlined a major strategy for primary prevention of coronary heart disease (CHD) in persons with high levels of low density

22 PART I NUTRITION BASICS AND APPLICATIONS RESPONSIBILITIES OF HEALTH PERSONNEL gallate (EGCG). The claims are that they can neu- 1. Become an informed consumer. Use the new regula- tralize free radicals (responsible for aging) and may tions to promote better health for yourself and family. reduce risk of cancer. Some consider them as bioac- tive ingredients. 2. Become an informed educator. Teach others to make 4. The botanical ginkgo contains chemicals known as healthy choices for a healthier lifestyle. flavone glycosides. The claims are that they can im- prove memory and blood flow to the brain and may PROGRESS CHECK ON ACTIVITY 2 help cure Alzheimer’s disease. Thus, these chemicals are considered by some to be bioactive ingredients FOOD AND NUTRITION LABEL: from a nonfood substance. 1. One serving of macaroni and cheese equals The printed and electronic media have listed hundreds of these bioactive ingredients found in foods (plant and . animal), spices, herbs, and so on. Industries engaged in food products, dietary supplements, and over-the-counter 2. The number of calories you actually eat is deter- (OTC) drugs have expressed tremendous interests in these bioactive ingredients because of their potential mined by . ramifications in manufacturing products that have appeal to the consumers because of health implications. 3. Americans should limit the intake of these nutri- ents if they wish to reduce the risk of certain Most popular bioactive ingredients are already sold in chromic diseases: , , traditional foods, dietary supplements, and OTC drugs. We will exclude prescription drugs. All three categories , , or . are strictly controlled by the FDA. The industry must comply with all requirements governing labeling. At pres- 4. Most Americans do not get enough of the follow- ent, there are many items in food labeling regulated under federal and state agencies. Most of them are not fa- ing nutrients: , , miliar to consumers. The three most important items in food labeling regulated by the FDA and directly related to , , and . the consumers are the following: 5. The meaning of upper limits is 1. Name of the food, supplement, and drug 2. Health claims . 3. Ingredients added 6. The %DV helps you to determine . This brings us back to the two concepts mentioned Functional foods and nutraceuticals: earlier: functional foods and nutraceuticals. Scientifically, they have been used to mean the following, among many 7. One meaning for functional foods is other definitions: . 1. Functional foods refer to “legal” conventional foods (natural or manufactured) that contain bioactive in- 8. One meaning for nutraceuticals is gredients. One example is adding PUFA to a tradi- tional TV dinner of roast beefs. Another example is . adding EC, ECG, or EGCG to any instant tea. What is the potential health benefit offered by each of 2. Nutraceuticals refer to adding a bioactive ingredi- the following bioactive ingredient: ent, especially one with nutritional value, to a di- etary or an OTC drug, such as adding ginkgo or 9. Omega-6 PUFA: . ginseng extracts. Such a product is claimed as a 10. Folic acid: . nutraceutical. 11. Green tea: . Assuming the new product complies with all require- ments of the FDA, the logical question is: Can the prod- 12. Ginkgo: uct be marketed as a functional food or nutraceutical? The FDA is now undergoing the legal process to settle Cholesterol education: this issue. At the time of printing this book, the FDA is soliciting comments from the public. The FDA hopes 13. What was the major thrust of ATP 1? that a dialogue among government, academia, industry, and the general public will facilitate the process to reach 14. What was the new added feature in ATP 2? a final legal decision. 15. In addition to retaining the core of ATP 1 and ATP 2, ATP 3 focused on yet another new feature. Name the new feature in ATP 3 and the three approaches used to implement it.

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OUTLINE CHAPTER 2 Objectives Food Habits Glossary Background Information Time for completion ACTIVITY 1: Factors Affecting Activities: 1 hour Food Consumption Optional examination: 1⁄2 hour Food and Symbols Examples of Food Behaviors Poverty, Appetite, and Biological Food Needs Summary Progress Check on Activity 1 ACTIVITY 2: Some Effects of Culture, Religion, and Geography on Food Behaviors Basic Considerations Reference Tables on Food Patterns Responsibilities of Health Personnel Progress Check on Activity 2 References OBJECTIVES Upon completion of this chapter, the student should be able to do the following: 1. Describe the cultural, social, and psychological factors that influence food behavior. a. Distinguish between biological necessity and cultural patterning. b. Identify the use of food in a culture. c. Explain the symbolism of food in a culture. d. Identify the social influences of food in a culture. e. Evaluate the psychological influence of food. 2. Determine the economic considerations that affect food intake. 3. Identify some common problems in the nutritional status of individuals in the United States. 4. Explain the ways that illness affects food acceptance. 5. Identify the dietary patterns of some ethnic, cultural, and religious groups in the United States. GLOSSARY Culture (or acculturation): traditions, values, or religions that make up a way of life. 25