Edwards ('XX) - Nutrition and Preventive Medicine Handbook PDF

The Albert Einstein
College of Medicine
Of Yeshiva University
Nutrition and Preventive

Medicine Handbook
Adapted with permission from the Nutrition and Preventive Medicine Handbook
Marilyn S. Edwards, PhD, RD/LD, FACN
Associate Professor, Department of Internal Medicine
University of Texas Medical School
Houston, Texas 77030
Funding for the Nutrition and Preventive Medicine Guidebook has been provided by the National
Heart, Lung, and Blood Institute through the Nutrition Academic Award and through the Dr.
Robert C. Atkins Foundation
Table of Contents
Introduction ................................................................................................................... 1
1. Body Mass Index (BMI) Calculator and Norms................................................... 2
2. Body Fat Percent Norms ...................................................................................... 2
Methods for Determining Body Fat Percentage For Adults ............................. 3
3. Basic Nutrition Assessment for Adults: WAVE .................................................. 4
4. Physical Activity: USDA Guidelines for Americans, 2005 ................................. 6
5. Fluid Guidelines for Exercise............................................................................... 7
HEAT INDEX................................................................................................. 10
6. Carbohydrate Guides for Exercise .................................................................... 10
7. Nutrient Composition of Common Sports Supplements ................................. 11
8. Exercise chart with body weights and kcal expenditure ................................. 12
9. Recommended Dietary Allowances and Dietary Reference Intakes............... 13
10. Calculating Energy Requirements ..................................................................... 21
11. Calculating Protein Requirements..................................................................... 21
12. NCEP Lipid Management Guidelines: National Heart, Lung, and Blood
Institute: Adult Treatment Panel III (ATP III)...................................................... 22
Risk Assessment........................................................................................... 23
Drugs that Affect Lipid Metabolism................................................................ 25
Dietary Guidelines......................................................................................... 26
13. Prevention and Treatment of HTN Guidelines (NHLBI).................................... 27
The JNC VII Guide To Prevention, Detection, Evaluation and Treatment of
High Blood Pressure ..................................................................................... 27
Dietary Approaches to Stop Hypertension (DASH) diet ................................ 29
Sample DASH Diet Menus ............................................................................ 30
14. Prevention and Treatment of Obesity Guidelines ............................................ 31
Classification of Overweight and Obesity by BMI, Waist Circumference and
Associated Disease Risk............................................................................... 31
Determination of Absolute Risk Status Based on Overweight and Obesity
Parameters.................................................................................................... 32
Treatment Algorithm...................................................................................... 33
Selecting The Treatment for Obesity............................................................. 34
Exercise recommendations for Obesity......................................................... 34
A Quick Primer For Health Professionals: Four Types Of Popular Weight Loss
Diets .............................................................................................................. 36
Weight Loss Drugs........................................................................................ 46
Weight Loss Surgery..................................................................................... 47
Assessing Patients’ Motivation to Make Nutrition and Lifestyle Changes ..... 49
15. Criteria for the Diagnosis of Diabetes Mellitus and Impaired Glucose
Tolerance ............................................................................................................. 52
Medical Nutrition Algorithm IFG/Type 2 Diabetes Prevention & Therapy ...... 53
Pharmacological Algorithm for Type 2 Diabetes ........................................... 54
Lipids Algorithm IFG and Type 2 Diabetes.................................................... 55
Medications for People with Type 2 Diabetes ............................................... 57
Comparative Profiles of Various Types of Regular Human Insulin................ 58
Nutritional and Exercise Recommendations for People with Type 2 Diabetes
...................................................................................................................... 59
Diabetes Diet Guidelines............................................................................... 60
Types and Limitations of Various Artificial Sweeteners................................. 61
Glycemic Index.............................................................................................. 62
Exercise Recommendations for Type 2 Diabetes ......................................... 65
16. Nutrition Assessment And Guidelines for Older Individuals .......................... 67
NHLBI Guidelines for Weight Reduction after Age 65................................... 68
Exercise for Older Adults............................................................................... 68
Borg Perceived Exertion Scale...................................................................... 71
17. ACS Recommendations for Nutrition and Physical Activity for Cancer
Prevention............................................................................................................ 72
18. Osteoporosis Prevention and Treatment Guidelines....................................... 72
19. Diet and Dental Health ........................................................................................ 75
20. The New Food Pyramid....................................................................................... 78
21. U.S. Dietary Guidelines for Americans 2005..................................................... 79
22. Referral to a Dietitian .......................................................................................... 82
23. Herbal Supplements............................................................................................ 83
24. Food Sources of Common Nutrients................................................................. 85
Food Sources of Calcium .............................................................................. 87
Foods Sources of Iron ................................................................................... 89
Food Sources of Fiber................................................................................... 90
Food Sources of Omega 3 Fatty Acid ........................................................... 93
Introduction
The Handbook of Nutrition and Preventive Medicine was first published in 2001 by Dr.
Marilyn Edwards, Associate Professor at the University of Texas Medical School. In this
new edition, we have retained the majority of the original handbook and primarily
focused on updating medical and medical nutrition therapy guidelines. Our adaptation is
intended to specifically complement the Albert Einstein College of Medicine curriculum.
We are very indebted to Dr. Edwards for the creation of the original edition.
This edition, like the original, is intended as a resource for medical students, residents,
and other health care professionals. The information contained in this handbook will be
useful for working with adult patients who have risk factors for chronic diseases
including cardiovascular disease, hypertension, diabetes, and obesity. The handbook
contains the new National Cholesterol Education Program (NCEP) Lipid Management
Guidelines, the Joint National Committee on Detection, Evaluation, and Treatment of
High Blood Pressure (JNC-VI) Guide, NHLBI Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and Obesity in Adults, and the Texas
Diabetes Council Algorithms for Prevention and Treatment of Type 2 Diabetes. For
medical professionals working with patients in the area of weight management, the
Handbook provides Body Mass Index (BMI) calculations, body fat percent norms,
American College of Sports Medicine (ASCM) Guidelines for exercise, and information
to assess patient motivation for diet and lifestyle change. When counseling patients
about healthy eating, the Handbook includes the U.S. Dietary Guidelines for Americans
2000, the Food Guide Pyramid, American Cancer Society Guidelines on Diet, Nutrition,
and Cancer Prevention, and a section on diet and dental health. In addition, tables for
calculating protein and energy requirements, and the Recommended Dietary
Allowances (RDAs) and the Dietary Reference Intakes (DRIs) for nutrients are included.
For health care professionals who work with older individuals, a section is included for
weight management and exercise after age 65; the National Institutes of Health
Osteoporosis Prevention and Treatment Guidelines are also included. Tables of food
composition include values for kilocalories, protein, fat, carbohydrate, sodium, calcium,
fiber, antioxidants and omega-3 fatty acids; the Food Counter was generously provided
by the Nutrition Academic Award team at Tufts University. The National Heart, Lung,
and Blood Institute of the National Institutes of Health through the Nutrition Academic
Award have provided funding for this Handbook. Adaptation of this handbook for Albert
Einstein College of Medicine was made possible through contributions by the Dr. Robert
C. Atkins Foundation.
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1. Body Mass Index (BMI) Calculator and Norms
BMI = Weight (kg)
Height (m2)
OR
BMI = (703) x Weight (lbs)

Height x Height (in x in)
Classification of Overweight and Obesity by BMI 1

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

Percent Body Fat Norm Chart1
Percent body fat Category
Gender Age Low Average High Obese
Males <29 3-10 11-17 18-23 >24
30-39 3-12 13-20 21-25 >26
40-49 3-14 15-21 22-27 >28
50-59 3-15 16-22 23-27 >28
>60 3-16 17-23 24-27 >28
Females <29 8-18 19-24 25-30 >31
30-39 8-19 20-26 27-32 >33
40-49 8-20 21-27 28-34 >35
50-59 8-21 22-28 29-35 >35
>60 8-22 22-29 30-35 >35
Males Females
Essential Body fat ~ 5% ~ 8%
Minimal Body fat ~ 5% ~ 10-14%
Athletic Groups2 5-13% 12-22%
Fitness and Health 10- 25% 16-30%
Obesity >25% >30-35%
1. Source: Pat Vehrs, PhD, Brigham Young University, Utah.
2. Range of body composition varies tremendously between sports.
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Methods for Determining Body Fat Percentage For Adults
1) Caliper Measurements: Performed by a trained clinician using metal (Lange,
Harpenden, or Holtain) calipers. Equations are based on testing from 3-9 body
sites. Equations are population-specific, i.e., for children, for athletes.
2) Bioelectrical Impedance Analysis (BIA)1: Performed by a trained clinician using a

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

procedure body density is calculated from body volume according to the Archimedes
principle of displacement, which states that an object submerged in water is buoyed
up by the weight of water displaced. Once body density has been determined, one
can then convert this value to percent body fat through some simple calculations3.
4) DEXA- dual energy x-ray absorptiometry. DEXA measures three compartments:

total body mineral (from bones), fat-free soft (lean) mass, and adipose tissue. It can
measure the area of disposition of adipose as well as the total quantity.
5) BOD POD- Based on the whole-body measurement principal (as is hydrostatic

weighing), but uses air displacement technology instead of water. The subject sits
inside the BOD POD while computerized pressure sensors determine the amount of
air displaced by the person's body. A complete analysis can be performed in about 5
minutes4.
1. Multiple, validated prediction equations for specific populations are available for anthropometrics and
BIA. Select the appropriate equation for assessing the individual.
2. ACSM, ADA and Dietitians of Canada Position Stand: Nutrition and Athletic Performance (2000).
Nutrition and Athletic Performance Medicine & Science in Sports & Exercise 32(12)2130-2145.
3. Alan C. Utter Ph.D., M.P.H., FACSM Associate Professor of Health and Exercise Science,
http://www.nwcaonline.com/Sports%20science%20articles/underwater.cfm
4. Fields Da, Higgins Pb, Radley D. Air-Displacement Plethysmography: here to stay. Current Opinion in
Clinical Nutrition and Metabolic Care, 8(6):624-629, 2005.
For further reading: Charlotte Feicht Sanborn, Fact and Fat of Body Composition, In eds. J.R. Berning,
S.N. Steen: Sports Nutrition for the 90s, Maryland: Aspen Publishers, 1991.
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3. Basic Nutrition Assessment for Adults
Adult WAVE Assessment

Weight Activity
Assess patient’s Body Mass Index.* Ask patient about any physical activity in the
Patient is overweight if BMI>25. past week: walking briskly, jogging, gardening,
swimming, biking, dancing, golf, etc.
Body Body
Height Weight lbs. Height Weight lbs. 1. Does patient do 30 minutes of moderate
4'10" >119 5'8" >164 activity on most days/wk.?
4'11" >124 5'9" >169 2. Does pt do “lifestyle” activity like taking the
5'0" >128 5'10" >174 stairs instead of elevators, etc.?
5'1" >132 5'11" >179
5'2" >136 6'0" >184 3. Does patient usually watch less than 2
hours of TV or videos/day?
5'3" >141 6'1" >189
5'4" >145 6'2" >194 If pt answers NO to above questions, assess
5'5" >150 6'3" >200 whether pt is willing to increase physical activity.
5'6" > 155 6'4" >205
5'7" >159
*Certain pts may require assessment for underweight

and/or unintentional weight loss
Variety Excess
Is patient eating a variety of foods from
important sections of the food pyramid? Is patient eating too much of certain foods and
nutrients?
Grains (6-11 servings)
Fruits (2-4 servings)
Too much fat, saturated fat, calories
Vegetables (3-5 servings)
• > 6 oz/day of meat
Protein (2-3 servings)
• Ice cream, high fat milk, cheese, etc.
Dairy (2-3 servings)
• Fried foods or foods cooked with fat
• High fat snacks and desserts
Determine Variety and Excess using one
of the following methods: • Eating out > 4 meals/wk
• Do a quick one-day recall. Too much sugar, calories
• High sugar beverages
• Ask patient to complete a self- • Sugary snacks/desserts
administered eating pattern questionnaire.
Too much salt
• Processed meats, canned/frozen meals, salty
snacks, added salt
• What does pt think are pros/cons of his/her eating pattern?
• If pt needs to improve eating habits, assess willingness to make
changes.
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Adult WAVE Recommendations1
Weight Activity
If pt is overweight: Examples of moderate amounts of physical
activity:
1. State concern for the pt, e.g., “I am
concerned that your weight is affecting your • Walking 2 miles in 30 minutes
health.” • Stair walking for 15 minutes
2. Give the pt specific advice, i.e., • Washing and waxing a car for 45-60 minutes
a) Make 1 or 2 changes in eating habits to • Washing windows or floors for 45-60 minutes
reduce calorie intake as identified by diet
• Gardening for 30-45 minutes
assessment.
b) Gradually increase activity/decrease • Pushing a stroller 1 ½ miles in 30 minutes
inactivity. • Raking leaves for 30 minutes
c) Enroll in a weight management program • Shoveling snow for 15 minutes
and/or consult a dietitian. 1. If patient is ready to increase physical activity,
3. If patient is ready to make behavior jointly set specific activity goals and arrange for
changes, jointly set goals for a plan of action a follow-up
and arrange for follow-up. 2. Give pt education materials/ resources.
4. Give pt education materials/ resources.
Variety Excess
What is a serving? 1. Discuss pros and cons of pt’s eating
Grains (6-11 servings) pattern keeping in mind Variety & Excess.
1 slice bread or tortilla, ½ bagel, ½ roll, 2. If patient is ready, jointly set specific
1 oz. ready-to-eat cereal, ½ cup rice, pasta, or
dietary goals and arrange for follow-up.
cooked cereal, 3-4 plain crackers
Is patient eating whole grains? 3. Give pt education materials/resources.
Fruits (2-4 servings) 4. Consider referral to a dietitian for more
1 medium fresh fruit, ½ cup chopped or extensive counseling and support.
canned fruit, ¾ cup fruit juice Suggestions for decreasing excess:
Vegetables (3-5 servings) • Eat chicken and fish (not fried) or meatless
1 cup raw leafy vegetables, ½ cup cooked or meals instead of red meat
chopped raw vegetables, • Choose leaner cuts of red meat
¾ cup vegetable juice
• Choose skim or 1% milk
Protein (2-3 servings)
2-3 oz. poultry, fish, or lean meat, 1-1 ½ • Eat less cheese/choose lower fat cheeses
cup cooked dry beans, 1 egg equals • Bake, broil, grill foods rather than fry
1 oz. meat, 4 oz. or ½ cup tofu • Choose low fat salad dressings, mayo,
Dairy (2-3 servings) spreads, etc.
1 cup milk or yogurt, 1½ oz. cheese • Eat more whole grains, fruits & vegetables
• Drink water instead of sugary drinks
See instructions 1-4 under Excess.
• Use herbs instead of salt
1. Adult and Pediatric WAVE Information at http://www.aecom.yu.edu/nutrition/instrume.htm

Physician Checklist To Review During Patient Visit1
1. Number of meals away from home weekly?
2. Alcohol intake patterns?
3. Who cooks?
4. Food allergies, avoidances, intolerances?
5. Past history of nutrition or dietary advice? From whom?
6. History of eating disorders?
7. Current dietary restrictions?
8. Use of multivitamin and mineral supplements, herbs, liquid supplements, e.g., Boost, Ensure?
9. ASCVD Risk factor assessment
• Hypercholesterolemia (Total chol > 200, LDL > 130, HDL < 40)
• Smoking
• HTN
• DM
• Early family disease (CHD in male first degree relative <55 years; CHD in female first degree
relative <65 years)
1. http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter4.htm
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4. Physical Activity: USDA Dietary Guidelines for Americans, 2005
According to the US Department of Agriculture (USDA), regular physical activity has
been shown to reduce the risk of certain chronic diseases including hypertension,
stroke, coronary artery disease, type 2 diabetes, colon cancer and osteoporosis. To
reduce the risk of chronic disease, it is recommended that adults engage in at least 30
minutes of moderate intensity physical activity on most, and preferably, all days of the
week. For most people, greater health benefits can be obtained by engaging in physical
activity of more vigorous intensity or of longer duration. In addition, physical activity
appears to promote psychological wellbeing and reduced feelings of mild to moderate
depression and anxiety. Regular physical activity is also a key factor in achieving and
maintaining a healthy body weight for adults and children.
Key Recommendations
1) Engage in regular physical activity and reduce sedentary activities to promote
health, psychological well-being, and a healthy body weight.
2) To reduce the risk of chronic disease in adulthood: Engage in at least 30 minutes of

moderate-intensity physical activity, above usual activity, at work or home on most
days of the week.
3) For most people, greater health benefits can be obtained by engaging in physical
activity of more vigorous intensity or longer duration.
4) To help manage body weight and prevent gradual, unhealthy body weight gain in
adulthood: Engage in approximately 60 minutes of moderate- to vigorous-intensity
activity on most days of the week while not exceeding caloric intake requirements.
5) To sustain weight loss in adulthood: Participate in at least 60 to 90 minutes of daily

moderate-intensity physical activity while not exceeding caloric intake requirements.
Some people may need to consult with a healthcare provider before participating in
this level of activity.
6) Achieve physical fitness by including cardiovascular conditioning, stretching

exercises for flexibility, and resistance exercises or calisthenics for muscle strength
and endurance.
Key Recommendations for Specific Population Groups1

• Children and adolescents: Engage in at least 60 minutes of physical activity on most,
preferably all, days of the week.
• Pregnant women: In the absence of medical or obstetric complications, incorporate 30

minutes or more of moderate-intensity physical activity on most, if not all,
days of the week. Avoid activities with a high risk of falling or abdominal trauma.
• Breastfeeding women: Be aware that neither acute nor regular exercise adversely
affects the mother’s ability to successfully breastfeed.
• Older adults: Participate in regular physical activity to reduce functional declines

associated with aging and to achieve the other benefits of physical activity identified
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for all adults.
1. US Department of Health and Human Services, US Department of Agriculture,

www.healthierus.gov/dietaryguidelines
5. Fluid Guidelines for Exercise
1. Adequate hydration is essential to prevent dehydration and injury during exercise

and to speed recovery.
2. The timing and quantity of fluid replacement requires planning on the part of the
exerciser.
3. Fluid intake should replace sweat loss during exercise. Overall fluid intake should
be 150% of the fluid loss during and after exercise. Many athletes can sweat 2-3
liters hourly.
4. Sweat contains an average sodium concentration of 50 mEq (1 gm Na) per liter.
Prolonged sweat loss with plain water replacement may produce hyponatremia.
5. Thirst is not a reliable mechanism to promote adequate fluid intake.
6. The color and volume of urine is a helpful indicator of hydrational status.
7. Flavored, sweetened beverages with some sodium encourage greater fluid intake
than plain water.
8. Monitoring body weight pre and post exercise helps to evaluate fluid needs. Drink
24 oz. of fluid for each pound lost during exercise in order to rehydrate within 6
hours of an exercise session or competitive event.
9. Exercise at altitude >8,200 feet may produce extraordinary losses through
respiration and diuresis. Fluid intake needs may be as high as 3-4 liters daily.1
10. The ideal sport drink should contain 6-10% CHO to deliver adequate kcal and
facilitate gastric emptying.
Fluid Requirement During Prolonged Exercise and Competition1

2 hours before Immediately before During competition Exercise or
competition competition or or exercise up to 60 competition
sustained activity minutes1 lasting >60
minutes
Fluid Requirement 400-600 ml 500 ml 150-350 ml 150-350 ml

(14-21 oz.) (17 oz.) (5-12 oz.) every 15- (5-12 oz.) every
20 minutes. More if 15-20 minutes.
sweat losses are More if sweat
excessive. losses are
excessive.
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Type of Fluid Water Water Water for most Beverage with
activities. High <8% carbohydrate
intensity activity concentration.
performance may be May need
enhanced with beverage with
carbohydrate. 500-700 mg Na/L
for activity >3
hours.2 (or
consume salt in
food).
1. American College of Sports Medicine, American Dietetic Association and Dietitians

of Canada Position Stand: Nutrition and Athletic Performance (2000). Nutrition and Athletic Performance
Medicine & Science in Sports & Exercise 32(12)2130-2145.
2. Commercial sports beverages contain 55-110 mg Na/Liter.
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FLUIDS 2000
DEHYDRATION AND HEAT ILLNESS
Heat Index Chart
This Heat Index Chart provides general guidelines for assessing the potential severity of
heat stress. Individual reactions to heat will vary. It should be remembered that heat
illness can occur at lower temperatures than indicated on the chart. In addition, studies
indicate that susceptibility to heat illness tends to increase with age.
How To Use The 1. Across the top of the chart, locate the ENVIRONMENTAL
Heat Index Chart: TEMPERATURE i.e., the air temperature.
2. Down the left side of the chart, locate the RELATIVE
HUMIDTY.
3. Follow across and down to find the APPARENT
TEMPERATURE. Apparent Temperature is the combined
index of heat and humidity. It is an index of the body’s
sensation of heat caused by the temperature and humidity (the
reverse of the "wind chill factor").
Note: Exposure to full sunshine can increase Heat Index values by up to 15oF
APPARENT HEAT STRESS RISK WITH PHYSICAL ACTVITY AND/OR

TEMPERATURE PROLONGED EXPOSURE
90 o - 105 o Heat cramps or heat exhaustion possible
105 o - 130 o Heat cramps or heat exhaustion likely. Heatstroke possible
130 o and up Heatstroke highly likely
Note: This Heat Index chart is designed to provide general guidelines for
assessing the potential severity of heat stress. Individual reactions to heat will
vary. It should be remembered that heat illness can occur at lower temperatures
than indicated on the chart. In addition, studies indicate that susceptibility to
heat disorders tends to increase with age.
Permission to reprint granted by Gatorade Sports Science Institute.
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HEAT INDEX
ENVIRONMENTAL TEMPERATURE (oF)
70o 75o 80o 85o 90 o 95o 100o 105o 110o 115 o 120 o
Relative Apparent Temperature*
Humidity
0% 64 o 69 o 73 o 78 o 83 o 87 o 91 o 95 o 99 o 103 o 107 o
10% 65 o 70 o 75 o 80 o 85 o 90 o 95 o 100 o 105 o 111 o 116 o
20% 66 o 72 o 77 o 82 o 87 o 93 o 99 o 105 o 112 o 120 o 130 o
30% 67 o 73 o 78 o 84 o 90 o 96 o 104 o 113 o 123 o 135 o 148 o
40% 68 o 74 o 79 o 86 o 93 o 101 o 110 o 123 o 137 o 151 o
50% 69 o 75 o 81 o 88 o 96 o 107 o 120 o 135 o 150 o
60% 70 o 76 o 82 o 90 o 100 o 114 o 132 o 149 o
70% 70 o 77 o 85 o 93 o 106 o 124 o 144 o
80% 71 o 78 o 86 o 97 o 113 o 136 o
90% 71 o 79 o 88 o 102 o 122 o
100% 72 o 80 o 91 o 108 o
*Combined index of heat and humidity… what it "feels like" to the body. Source:
National Oceanic and Atmospheric Administration
6. Carbohydrate Guides for Exercise
Carbohydrate (CHO) Requirement During Prolonged Exercise and Competition
Two Hours Immediately During Exercise Or After

Before Before Competition Or Competition Competition Or
Competition Competition Or Exercise Up To Lasting >60 Prolonged
Sustained 60 Minutes1 Minutes Endurance
Activity Activity
Suggested Meal or snack, 30-60 gm If glycogen

Intake low fat, low fiber, CHO/hour. depleted (>2000
high CHO (200- Some kcal exercise),
300 gm) performance eat 1.5 gm
improvements at CHO/kg in first
as little as 20-25 30 minutes and
gm/hour. again every 2-4
Maximal rate of hours until
utilization = 60- replete.
75 grams/hour:
no additional
performance
benefits from
more.
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Consume familiar, well-tolerated foods during competition. Practice fueling strategies
during training. Generally, there is little performance enhancement from carbohydrate
loading for events less than one hour unless they are high intensity efforts.
7. Nutrient Composition of Common Sports Supplements
Energy Bars
Product Size Kcal* Protein Carb Fat Fiber Na %RDA # Nutrients Cost
Added
(gm) (gm) (gm) (gm) (gm) (mg) per 200
kcal**
365 Verve 68 210 8 44 1.5 4 140 6-25% 4 .85
Whole Foods
365 Everyday 50 200 18 18 4.5 2 109 50% 17 .89
Whole Foods
Power Bar 65 230 10 45 2.5 3 90 20-100% 17 1.21
Power Bar 65 240 7 45 4.5 4 80 15-100% 17 1.32

Harvest
Power Bar 78 290 24 38 5 3 105 20-100% 17 2.39
Protein Plus
Balance Bar 50 190 14 22 6 0 200 10-100% 24 1.36
Clif Bar 66 230 10 42 3.5 6 140 15-100% 23 1.30
Luna Bar 48 180 10 26 4 2 50 35-100% 23 1.10
Zone Bar 50 200 14 22 7 1 150 15-200% 20 1.69
Genisoy Bar 61.5 220 28 32 3.5 1 120 25% 19 1.17
Gatorade Bar 65 260 8 46 5 2 160 2-30% 11 .84
Hi Pro Balance 75 300 22 33 10 1 330 8-150% 23 .66
Energy Gels
Gu 31 100 0 25 0 0 20 ** 2.00
Power Gel 35 100 0 25 0 0 ** 1.51
Clif Shot 32 110 0 28 0 0 50 ** 2.00
Fluid Replacement Beverages

Gatorade 240 50 0 14 0 0 110 0 0 1.39
Powerade 240 70 0 19 0 0 55 10% 3 1.20
Propel 240 10 0 3 0 0 35 10-25% 6 6.60
*Macronutrients vary slightly within the same product line depending on flavors of the bar. **Gels may
contain caffeine.
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8. Exercise chart with body weights and kcal expenditure
per minute of activity1
Body weight (lb) 120 140 180 220

Sitting 1.5 1.8 2.3 2.8
Basketball, recreational 6.0 7.0 9.0 11.0
Bicycling (6 mph) 3.2 3.8 4.9 6.0
Bicycling (12 mph) 6.9 8.1 10.4 12.8
Bicycling (20 mph) 12.8 14.9 19.2 23.5
Dancing, moderate 3.8 4.5 5.7 7.0

(waltz)
Dancing vigorous 7.3 8.5 10.9 13.3
(aerobic)
Golf
(2-some, carry clubs) 4.4 5.1 6.6 8.0
Golf (power-cart) 2.3 2.7 3.5 4.3
Roller skating (9 mph) 5.1 5.9 7.6 9.4
Running
(mph) (min/mile)
5.0 12:00 7.3 8.5 10.9 13.4
6.0 8:35 10.2 11.9 15.4 18.8

9.0 6:40 12.9 15.1 19.5 23.9
Skiing, cross-country 7.8 9.2 11.9 14.5

(4 mph)
Skiing, downhill 7.8 9.2 11.9 14.5
Swimming (25 yds/min) 4.8 5.6 7.2 8.8
Swimming (50 yds/min) 8.5 9.9 12.8 15.6
Tennis, singles 6.0 7.0 9.0 11.1
Walking (20 min/mile) 3.3 3.8 4.9 6.0
Walking (15 min/mile) 5.1 5.9 7.6 9.4
Walking (12 min/mile) 6.5 7.7 9.8 12.0
Weight training 6.2 7.3 9.4 11.5

1. Source: Berning, JR, Steen, SN (1991) Sports Nutrition for the 90s: the Health Professionals
Handbook. Maryland: ASPEN: 256-263.
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9. Recommended Dietary Allowances and Dietary Reference Intakes
Since 1940, the Food and Nutrition Board of the National Academy of Sciences (NAS)
has developed and periodically published recommended dietary allowances (RDAs).
RDAs have been used as the scientific basis for federal nutrition and food policy in the
U.S. When first developed, RDAs were intended as allowances that would meet the
nutritional needs of most healthy people; they were designed for planning diets to
prevent nutrient deficiencies in groups. They have come to be used for many other
purposes, such as food labeling and food selection guides for healthy diets.
As scientific knowledge about diet and health has increased, technology has improved
to allow measurement of small changes in individual adaptation to consumption of
various levels of nutrients. Chronic diseases or conditions that had been difficult to
ascribe to inadequate or excess consumption of a specific nutrient have been found to
be closely linked to diet or nutrient intake. To include these possible relationships in the
definition of "adequacy" used to establish dietary allowances, the NAS Food and
Nutrition Board (FNB) has expanded its framework for determining dietary allowances.
Thus, Dietary Reference Intakes (DRIs) were established. The DRIs are a set of
reference values: Recommended Dietary Allowances (RDA), Adequate Intakes (AI),
and Tolerable Upper Intake Levels, (UL) that have replaced the 1989 Recommended
Dietary Allowances (RDAs). The AIs and ULs were established based on the
examination of data regarding increased consumption of nutrients in concentrated form,
either singly or in combination with others outside of the context of food, and because of
the use of fortification or enrichment of foods, the extent to which excess nutrient
intakes increase the risk of adverse or toxic effects. The following table gives the DRIs
for nutrients based on age and gender; adverse effects of excessive intakes are also
provided. Unless one is consuming large proportions of fortified foods, it is usually not
possible to reach toxic levels of nutrients from food alone; however, supplements may
need to be monitored to ensure that the UL is not exceeded.
Nutrient Life Stage RDA/AI ULa Adverse

Group effects of
excessive
intake
(mg/day) (mg/day) Kidney stones,
Calcium M 19-30 y 1000 2500 hypercalcemia,
M 31-50 y 1000 2500 milk alkali
M 50-70 y 1200 2500 syndrome, renal
M >70 y 1200 2500 insufficiency
F 19-30 y 1000 2500
F 31-50 y 1000 2500
F 50-70 y 1200 2500
F >70 y 1200 2500
Pregnant 19-30 y 1000 2500
Pregnant 31-50 y 1000 2500
Lactation 19-30 y 1000 2500
Lactation 31-50 y 1000 2500
Chromium (mcg/day) Chronic renal
M 19-30 y 35 ND failure
M 31-50 y 35 ND
- 13 -
M 50-70 y 30 ND
M>70 y 30 ND
F 19-30 y 25 ND
F 31-50 y 25 ND
F 50-70 y 20 ND
F >70 y 20 ND
Pregnant 19-30 y 30 ND
Lactation 19-30 y 45 ND
Copper (mcg/day) (mcg/day) Gastrointestinal
M 19-30 y 900 10,000 distress, liver
M 31-50 y 900 10,000 damage
M 50-70 y 900 10,000
M >70 y 900 10,000
F 19-30 y 900 10,000
F 31-50 y 900 10,000
F 50-70 y 900 10,000
F >70 y 900 10,000
Pregnant 19-30 y 1000 10,000
Pregnant 31-50 y 1000 10,000
Lactation 19-30 y 1300 10,000
Lactation 31-50 y 1300 10,000
Fluoride (mg/day) (mg/day) Tooth enamel
M 19-30 y 4 10 and skeletal
M 31-50 y 4 10 fluorosis
M 50-70 y 4 10
M >70 y 4 10
F 19-30 y 3 10
F 31-50 y 3 10
F 50-70 y 3 10
F >70 y 3 10
Pregnant 19-30 y 3 10
Lactation 19-30 y 3 10
Biotin (mcg/day) (mcg/day)
M 19-30 y 30 ND ND
M 31-50 y 30 ND
M 50-70 y 30 ND
M >70 y 30 ND
F 19-30 y 30 ND
F 31-50 y 30 ND
F 50-70 y 30 ND
F >70 y 30 ND
Choline (mg/day) (mg/day) Fishy body odor,
M 19-30 y 550 3500 sweating,
M 31-50 y 550 3500 salivation,
M 50-70 y 550 3500 hypotension,
M >70 y 550 3500 hepatotoxicity
F 19-30 y 425 3500
F 31-50 y 425 3500
F 50-70 y 425 3500
F >70 y 425 3500
Pregnant 19-30 y 450 3500
- 14 -
Pregnant 31-50 y 450 3500
Lactation 19-30 y 550 3500
Lactation 31-50 y 550 3500
Folate M 19-30 y (mcg/day) (mcg/day) Masks

M 31-50 y 400 1000 neurological
M 50-70 y 400 1000 complications in
M >70 y 400 1000 people with B12
F 19-30 y 400 1000 deficiency.
F 31-50 y 400 1000 No adverse
F 50-70 y 400 1000 affects have
F >70 y 400 1000 been reported
Pregnant 19-30 y 400 1000 with folate from
Pregnant 31-50 y 600 1000 food or
Lactation 19-30 y 600 1000 supplements.
Lactation 31-50 y 500 1000 The UL for folate
500 1000 applies to
synthetic forms
obtained from
supplements
and/or fortified
foods.
Niacin (mg/day) (mg/day) No evidence of
M 19-30 y 16 35 adverse effects
M 31-50 y 16 35 from niacin in
M 50-70 y 16 35 foods.
M >70 y 16 35 Adverse effects
F 19-30 y 14 35 from
F 31-50 y 14 35 supplements
F 50-70 y 14 35 include GI
F >70 y 14 35 distress and
Pregnant 19-30 y 18 35 flushing.
Pregnant 31-50 y 18 35 UL applies to
Lactation 19-30 y 17 35 niacin from
Lactation 31-50 y 17 35 supplements
and/or fortified
foods.
Panthothenic (mg/day) (mg/day) ND
Acid M 19-30 y 5 ND
M 31-50 y 5 ND
M50-70 y 5 ND
M >70 y 5 ND
F 19-30 y 5 ND
F 31-50 y 5 ND
F 50-70 y 5 ND
F >70 y 5 ND
Riboflavin (mg/day) (mg/day) ND
M 19-30 y 1.3 ND
M 31-50 y 1.3 ND
M 50-70 y 1.3 ND
M >70 y 1.3 ND
F 19-30 y 1.1 ND
F 31-50 y 1.1 ND
- 15 -
F 50-70 y 1.1 ND
F >70 y 1.1 ND
Pregnant 19-30 y 1.4 ND
Lactation 19-30 y 1.6 ND
Iodine (mcg/day) (mcg/day) Elevated thyroid
M 19-30 y 150 1100 stimulating
M 31-50 y 150 1100 hormone (TSH)
M 50-70 y 150 1100 concentration
M >70 y 150 1100
F 19-30 y 150 1100
F 31-50 y 150 1100
F 50-70 y 150 1100
F >70 y 150 1100
Pregnant 19-30 y 220 1100
Pregnant 31-50 y 220 1100
Lactation 19-30 y 290 1100
Lactation 31-50 y 290 1100
Iron (mg/day) (mg/day) Gastrointestinal

M 19-30 y 8 45 distress
M 31-50 y 8 45
M 50-70 y 8 45
M >70 y 8 45
F 19-30 y 18 45
F 31-50 y 18 45
F 50-70 y 8 45
F >70 y 8 45
Magnesium (mg/day) (mg/day) No known
M 19-30 y 400 350 adverse effects
M 31-50 y 420 350 from Mg in
M 50-70 y 420 350 foods.
M >70 y 420 350 Supplemental
F 19-30 y 310 350 Mg may cause
F 31-50 y 320 350 diarrhea.
F 50-70 y 320 350 The UL for Mg
F >70 y 320 350 represents intake
Pregnant 19-30 y 350 350 from
Pregnant 31-50 y 360 350 supplements and
Lactation 19-30 y 310 350 does not include
Lactation 31-50 y 320 350 water and food
intake.
Manganese (mg/day) (mg/day) Elevated blood
M 19-30 y 2.3 11 concentration
M 31-50 y 2.3 11 and neurotoxicity
M 50-70 y 2.3 11
M >70 y 2.3 11
F 19-30 y 1.8 11
F 31-50 y 1.8 11
F 50-70 y 1.8 11
F >70 y 1.8 11
Pregnant 19-30 y 2.0 11
Pregnant 31-50 y 2.0 11
Lactation 19-30 y 2.6 11
- 16 -
Molybdenum (mcg/day) (mcg/day) Reproductive
M 19-30 y 45 2000 effects as
M 31-50 y 45 2000 observed in
M 50-70 y 45 2000 animal studies
M >70 y 45 2000
F 19-30 y 45 2000
F 31-50 y 45 2000
F 50-70 y 45 2000
F >70 y 45 2000
Pregnant 19-30 y 50 2000
Pregnant 31-50 y 50 2000
Phosphorus (mg/day) (mg/day) Metastatic
M 19-30 y 700 4000 calcification,
M 31-50 y 700 4000 skeletal porosity,
M 50-70 y 700 4000 interference with
M >70 y 700 3000 calcium
F 19-30 y 700 4000 absorption
F 31-50 y 700 4000
F 50-70 y 700 4000
F >70 y 700 3000
Pregnant 19-30 y 700 3500
Pregnant 31-50 y 700 3500
Lactation 19-30 y 700 4000
Lactation 31-50 y 700 4000
Selenium (mcg/day) (mcg/day) Hair and nail
M 19-30 y 55 400 brittleness and
M 31-50 y 55 400 loss
M 50-70 y 55 400
M >70 y 55 400
F 19-30 y 55 400
F 31-50 y 55 400
F 50-70 y 55 400
F >70 y 55 400
Pregnant 19-30 y 60 400
Pregnant 31-50 y 60 400
Zinc (mg/day) (mg/day) Reduced copper

M 19-30 y 11 40 status
M 31-50 y 11 40
M 50-70 y 11 40
M >70 y 11 40
F 19-30 y 8 40
F 31-50 y 8 40
F 50-70 y 8 40
F >70 y 8 40
Vitamin A (mcg/day) (mcg/day) Teratological

M 19-30 y 900 3000 effects, liver
M 31-50 y 900 3000 toxicity
M 50-70 y 900 3000 Note: from
M >70 y 900 3000 preformed
- 17 -
F 19-30 y 700 3000 vitamin A only
F 31-50 y 700 3000
F 50-70 y 700 3000
F >70 y 700 3000
Pregnant 19-30 y 770 3000
Pregnant 31-50 y 770 3000
Lactation 19-30 y 1300 3000
Lactation 31-50 y 1300 3000
Vitamin B6 M 19-30 y (mg/day) (mg/day) No known

M 31-50 y 1.3 100 adverse effects
M 50-70 y 1.3 100 from B6 in food.
M >70 y 1.7 100 Sensory
F 19-30 y 1.7 100 neuropathy has
F 31-50 y 1.3 100 occurred from
F 50-70 y 1.3 100 high intakes of
F >70 y 1.5 100 supplemental
Pregnant 19-30 y 1.5 100 forms.
Pregnant 31-50 y 1.9 100
2.0 100
Vitamin B12 (mcg/day) (mcg/day) ND
M 19-30 y 2.4 ND
M 31-50 y 2.4 ND
M 50-70 y 2.4 ND
M >70 y 2.4 ND
F 19-30 y 2.4 ND
F 31-50 y 2.4 ND
F 50-70 y 2.4 ND
F >70 y 2.4 ND
Vitamin C (mg/day) (mg/day) GI disturbances,
M 19-30 y 90 2000 kidney stones,
M 31-50 y 90 2000 excess iron
M 50-70 y 90 2000 absorption
M >70 y 90 2000
F 19-30 y 75 2000
F 31-50 y 75 2000
F 50-70 y 75 2000
F >70 y 75 2000
Pregnant 19-30 y 85 2000
Pregnant 31-50 y 85 2000
Lactation 19-30 y 120 2000
Lactation 31-50 y 120 2000
Vitamin D (mcg/day) (mcg/day) Elevated plasma
M 19-30 y 5 50 25(OH) D
M 31-50 y 5 50 concentration
M 50-70 y 10 50 causing
M >70 y 15 50 hypercalcemia
F 19-30 y 5 50
F 31-50 y 5 50
F 50-70 y 10 50
F >70 y 15 50
- 18 -
Vitamin E (mg/day) (mg/day) No adverse
M 19-30 y 15 1000 effects known
M 31-50 y 15 1000 from vitamin E in
M 50-70 y 15 1000 foods.
M >70 y 15 1000 Adverse effects
F 19-30 y 15 1000 from vitamin E
F 31-50 y 15 1000 containing
F 50-70 y 15 1000 supplements
F >70 y 15 1000 may include
Pregnant 19-30 y 15 1000 hemorrhagic
Pregnant 31-50 y 15 1000 toxicity.
Lactation 19-30 y 19 1000 The UL for
Lactation 31-50 y 19 1000 vitamin E applies
to any form of
tocopherol
obtained from
supplements
and/or fortified
foods.
Vitamin K (mcg/day) (mcg/day) ND
M 19-30 y 120 ND
M 31-50 y 120 ND
M 50-70 y 120 ND
M >70 y 120 ND
F 19-30 y 90 ND
F 31-50 y 90 ND
F 50-70 y 90 ND
F >70 y 90 ND
ND
Thiamin (mg/day) (mg/day) ND
M 19-30 y 1.2 ND
M 31-50 y 1.2 ND
M 50-70 y 1.2 ND
M >70 y 1.2 ND
F 19-30 y 1.1 ND
F 31-50 y 1.1 ND
F 50-70 y 1.1 ND
F >70 y 1.1 ND
NOTE: The table is adapted from DRI reports. RDAs are in bold type while Adequate
Intakes (AI) are in ordinary type. RDAs and AIs may be used as goals for individual
intakes. RDAs are set to meet the needs of 97-98% of people in a group.
a
UL = The maximum amount that can be consumed safely. Includes intake from food,
water and supplements. When insufficient data exists to define an UL (ND), extra
caution may be warranted in consuming more than RDAs.
- 19 -
Sources: DRIs for Ca, P, Mg, Vitamin D, and Fluoride(1997); DRIs for Thiamin, Riboflavin, Niacin, B6,
Folate, B12, Pantothenic acid, Biotin and Choline(1998); DRIs for Vitamin C, Vitamin E, Selenium, and
Carotenoids(2000); DRIs for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine,
Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc(2001). These reports may be accessed
via www.nap.edu.
- 20 -
10. Calculating Energy Requirements
Estimated Kilocalorie Requirements for Adults (kcal/kg)1
Activity Level Men Women
Light 30 30
Moderate 40 37
Heavy 50 44
1. National Research Council. Recommended Dietary Allowances, 10th ed. Washington, DC: National
Academy Press; 1989.
• Energy requirements are influenced by age, heredity, sex, body composition,

body size, ambient temperature, and the type, duration, intensity and frequency
of exercise.
• It is necessary to consume an excess of 3,500 kcal to gain one pound of body

fat. Conversely, reducing cumulative dietary intake by 3,500 kcal over a period
of time will produce a one-pound fat loss.
11. Calculating Protein Requirements1

Group (Adults) Protein Needs grams /kg
RDA 0.8
Vegetarians Increase by 10%
Endurance athletes 1.2 - 1.4
Strength athletes 1.6 - 1.7
Elderly 1.252
1. ACSM, ADA and Dietitians of Canada Position Stand: Nutrition and Athletic Performance (2000).
Nutrition and Athletic Performance Medicine & Science in Sports & Exercise 32(12)2130-2145.
2. Campbell, WW, Crim, MC, Dallal, DE, Young, VR. (1994) Increased protein requirements in the
elderly: new data and retrospective reassessments. AJCN 60:167-175.
- 21 -
12. NCEP Lipid Management Guidelines: National Heart, Lung, and
Blood Institute: Adult Treatment Panel III (ATP III)
STEP 1: Determine lipoprotein levels - obtain complete lipoprotein profile after 9-

to 12-hour fast.
ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL)
LDL Cholesterol - Primary Target of Therapy*
<100 Optimal
100-129 Near Optimal/Above Optimal
130-159 Borderline High
160-189 High
>190 Very high
Total Cholesterol
<200 Desirable
200-239 Borderline High
>240 High
HDL Cholesterol
<40 Low
>60 High
STEP 2: Identify presence of clinical atherosclerotic disease that confers high

risk for coronary heart disease (CHD) events (CHD risk equivalent):
• Clinical CHD
• Symptomatic carotid artery disease
• Peripheral arterial disease
• Abdominal aortic aneurysm
Note: in ATP III, diabetes is regarded as a CHD risk equivalent.
STEP 3: Determine presence of major risk factors (other than LDL):

Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals
• Cigarette smoking
• Hypertension (BP 140/90 mm Hg or on antihypertensive medication)
• Low HDL cholesterol (<40 mg/dl)*
• Family history of premature CHD (CHD in male first degree relative <55 years;
CHD in female first degree relative <65 years)
• Age (men 45 years; women 55 years)
- 22 -
• HDL cholesterol >60 mg/dL counts as a "negative" risk factor; its presence
removes one risk factor from the total count.
STEP 4: If 2+ risk factors (other than LDL) are present without CHD or CHD risk
equivalent, assess 10-year (short-term) CHD risk
Risk Assessment
NHLBI’s Risk Assessment Tool for Estimating 10-year Risk of Developing Hard
CHD (Myocardial Infarction and Coronary Death) can be found at:
http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof
Or use Risk Finder Chart:
Note: Almost all people with 0-1 major risk factors have a 10 year risk of <10%: Thus,
10 year risk assessment in people with 0-1 risk factors is not necessary.
Three levels of 10-year risk:

• >20% -- CHD risk equivalent
• 10-20%
• <10%
STEP 5: Determine risk category:

• Establish LDL goal of therapy
- 23 -
• Determine need for therapeutic lifestyle changes (TLC)
• Determine level for drug consideration
LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)
and Drug Therapy in Different Risk Categories
LDL Level at Which to Initiate LDL Level at Which

LDL
Risk Category Therapeutic Lifestyle Changes to Consider Drug
Goal
(TLC) Therapy
CHD or CHD Risk <100 130 mg/dL (100-129
Equivalents (10-year risk mg/d 100 mg/dL
mg/dL: drug optional)*
>20%) L
10-year risk 10-20%: 130
<130 mg/dL
2+ Risk Factors (10-year
mg/d 130 mg/dL
risk 20%)
L 10-year risk <10%: 160
mg/dL
<160 190 mg/dL
0-1 Risk Factor** mg/d 160 mg/dL (160-189 mg/dL: LDL-
L lowering drug optional)
*Some authorities recommend use of LDL-lowering drugs in this category if an LDL

cholesterol <100 mg/dL cannot be achieved by therapeutic lifestyle changes. Others
prefer use of drugs that primarily modify triglycerides and HDL, e.g., nicotinic acid or
fibrate. Clinical judgment also may call for deferring drug therapy in this subcategory.
**Almost all people with 0-1 risk factor have a 10-year risk <10%, thus 10-year risk
assessment in people with 0-1 risk factor is not necessary.
Very High Risk
For people at very high risk, a group that is considered a “sub-set” of the high-risk
category, the update offers a new therapeutic lifestyle change option of treating LDL to
less than 70 mg/dL. For very high-risk patients whose LDL levels are already below 100
mg/dL, there is also an option to use drug therapy to reach the less than 70 mg/dL goal.
The NCEP defines very high-risk patients as those who have cardiovascular disease
together with either multiple risk factors (especially diabetes), or severe and poorly
controlled risk factors (e.g., continued smoking), or metabolic syndrome. Patients
hospitalized for acute coronary syndromes such as heart attack are also at very high
risk.
STEP 6: Initiate therapeutic lifestyle changes (TLC) if LDL is above goal.

TLC Features
• TLC Diet (see diet below)
• Weight management
• Increased physical activity
STEP 7: Consider adding drug therapy if LDL exceeds levels shown in Step 5
table:
• Consider drug simultaneously with TLC for CHD and CHD equivalents
• Consider adding drug to TLC after 3 months for other risk categories.
http://www.nhlbi.nih.gov/guidelines/cholesterol/
- 24 -
Drugs that Affect Lipid Metabolism
Lipid/
Agents and Daily Side
Drug Class Lipoprotein Contraindications
Doses Effects
Effects
Lovastatin (20-80 mg), Absolute:
HMG CoA Pravastatin (20-40 mg), Active or chronic liver
LDL-C 18-55% Myopathy
Reductase Simvastatin (20-80 mg), disease
HDL-C 5-15% Increased liver
Inhibitors Fluvastatin (20-80 mg), Relative:
TG 7-30% enzymes
(statins) Atorvastatin (10-80 mg), Concomitant use of
Cerivastatin (0.4-0.8 mg) these drugs*
Absolute:
GI distress
LDL-C 15-30% dysbeta-
Cholestyramine (4-16 g) Constipation
Bile Acid HDL-C 3-5% lipoproteinemia
Colestipol (5-20 g) Decreased
Sequestrants TG No change or TG >400 mg/dL
Colesevelam (2.6-3.8 g) absorption of
increase Relative:
other drugs
TG >200 mg/dL
Flushing
Immediate release Absolute:
Hyperglycemi
(crystalline) nicotinic acid Chronic liver disease
a
(1.5-3 gm), extended LDL-C 5-25% Severe gout
Hyperuricemia
Nicotinic Acid release nicotinic acid HDL-C 15-35% Relative:
(or gout)
(Niaspan ®) (1-2 g), TG 20-50% Diabetes
Upper GI
sustained release Hyperuricemia
distress
nicotinic acid (1-2 g) Peptic ulcer disease
Hepatotoxicity
LDL-C 5-20%
(may be increased Absolute:
Gemfibrozil (600 mg BID) Dyspepsia
in patients with Severe renal disease
Fibric Acids Fenofibrate (200 mg) Gallstones
high TG) Severe hepatic
Clofibrate (1000 mg BID) Myopathy
HDL-C 10-20% disease
TG 20-50%
*Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome
P-450 inhibitors (fibrates and niacin should be used with appropriate caution).
- 25 -
Dietary Guidelines
American Heart Association 1

Dietary Strategies to Reduce the Risk of Coronary Heart Disease
o Eat a variety of fruits and vegetables. Choose 5 or more servings per day.
o Eat a variety of grain products, including whole grains. Choose 6 or more servings per day.
o Include fat-free and low-fat milk products, fish, legumes (beans), skinless poultry and lean meats.
o Choose fats and oils with 2 grams or less saturated fat per tablespoon, such as liquid and tub margarines,
canola oil and olive oil.
o Balance the number of calories you eat with the number you use each day. (To find that number, multiply
the number of pounds you weigh now by 15 calories. This represents the average number of calories used
in one day if you're moderately active. If you get very little exercise, multiply your weight by 13 instead of
15. Less-active people burn fewer calories.)
o Maintain a level of physical activity that keeps you fit and matches the number of calories you eat. Walk or
do other activities for at least 30 minutes on most days. To lose weight, do enough activity to use up more
calories than you eat every day.
o Limit your intake of foods high in calories or low in nutrition, including foods like soft drinks and candy that
have a lot of sugars.
o Limit foods high in saturated fat, trans fat and/or cholesterol, such as full-fat milk products, fatty meats,
tropical oils, partially hydrogenated vegetable oils and egg yolks. Instead choose foods low in saturated fat,
trans fat and cholesterol from the first four points above.
o Eat less than 6 grams of salt (sodium chloride) per day (2,400 milligrams of sodium).
o Have no more than one alcoholic drink per day if you're a woman and no more than two if you're a man.
"One drink" means it has no more than 1/2 ounce of pure alcohol. Examples of one drink are 12 oz. of beer,
4 oz. of wine, 1 1/2 oz. of 80-proof spirits or 1 oz. of 100-proof spirits.
1. American Heart Association, April 2006 www.americanheart.org
NHLBI Total Lifestyle Change Diet to Reduce CAD Risk

Nutrient Recommendation Comment
Saturated Fat Less than 7% of total kcal Trans fatty acid intake should be
minimized as they raise LDL
Polyunsaturated Fat Up to 10 % of total kcal
Monounsaturated Fat Up to 20% of total kcal
Total fat 25-35% of total kcal Using 2g/day plant
stanols/sterols reduces LDL
Carbohydrate 50-60% of total kcal Choose complex carbohydrates
such as grains, whole grains,
fruits and vegetables
Fiber 20-30 g/day Increased viscous (soluble) fiber
to 10-25 g/day reduces LDL
Protein Approximately 15% of total
kcal
Cholesterol Less than 200 mg/day
Total kcal Balance activity and energy Remain moderately active
intake to achieve and maintain
a desirable weight
- 26 -
13. Prevention and Treatment of HTN Guidelines (NHLBI)
The JNC VII Guide To Prevention, Detection, Evaluation and Treatment of High Blood Pressure
- 27 -
http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf
HU
- 28 -
Dietary Approaches to Stop Hypertension (DASH) diet
DASH is an eating plan low in saturated fat, total fat and cholesterol, and high in fruits,
vegetables and low fat dairy foods. The plan is rich in calcium, magnesium, potassium
as well as protein and fiber. The diet reduced systolic pressure by an average of 6 mm
Hg and diastolic by 3 mm Hg in normotensive individuals; in those with hypertension,
the systolic dropped an average of 11 mm Hg and the diastolic about 6 mm Hg.
Selecting the lower-end of the number of servings, the diet provides about 1900
kilocalories and 70 grams protein, while the higher-end of the number of servings offer
2550 kilocalories and 105 grams protein. Number of servings may need to be reduced
for individuals if weight loss is desired.
Food Daily Serving Sizes Examples and Notes

Group Servings
Grains & 7-8 1 slice bread (1oz) Whole wheat bread, English muffin,
grain 1/2 muffin pita bread, bagel, cereals, grits,
products 1 cup dry cereal oatmeal, crackers, unsalted pretzels
1/2 cup rice, pasta or cereal and popcorn
5 crackers
1/4 bagel or pita
Vegetables 4-5 1 cup raw leafy vegetable Tomato, potato, carrot, green pea,
1/2 cup cooked vegetable squash, broccoli, turnip green, collard,
6 oz. vegetable juice kale, spinach, artichoke, green bean,
lima, sweet potato
Fruits 4-5 6 oz. fruit juice Banana, date, grape, orange, orange
1 medium fruit juice, grapefruit, mango, melon,
1/4 cup dried fruit peach, pineapple, prune, raisin,
1/2 cup fresh or canned fruit strawberry, tangerine
Low fat or fat 2-3 8 oz milk Fat free, skim or low fat 1% milk, fat
free dairy 1 c yogurt free or low fat frozen yogurt, low fat
foods 2.5 oz cheese and fat free cheese
1/2 cup cottage cheese
Meats, 2 or less 3 oz cooked meat, poultry or fish Select only lean; trim away visible fat;
poultry & fish broil, roast or boil; remove skin from
poultry
Nuts, seeds 4-5 per week 1/3 cup or 1.5 oz nuts Almond, mixed nuts, peanut, walnut,
& dry beans 2 Tbsp. or 1/2 oz seeds sunflower seed, kidney bean, lentil,
1/2 cup cooked beans peas
Fats & oils 2-3 1 tsp. soft margarine Soft margarine, low fat mayonnaise,
1 Tbsp. low fat mayonnaise light salad dressing, vegetable oil
2 Tbsp. light salad dressing (such as olive, corn, canola,
1 tsp. vegetable oil safflower)
Sweets, fat- 5 per week 1 Tbsp sugar, jelly Jelly beans, sugar, sherbet, gelatin,
free 8 oz. cola hard candy
1 Tbsp syrup
Source: U.S. Department of Health and Human Services; NIH Publication No. 99-4082. Originally
printed 1998 http://dash.bwh.harvard.edu
- 29 -
Sample DASH Diet Menus
The following two menus follow the lower and higher recommendations for serving sizes in the
DASH diet.
Lower End of DASH Higher End of DASH

Recommendations Recommendations
Breakfast Breakfast
2 cups Cheerios 2 slices toast
1 Tbsp sugar 1 Tbsp jelly
12 oz. orange juice 1 cup cantaloupe
8 oz. skim milk 1/2 cup cottage cheese
Coffee or tea Coffee or tea
Lunch Lunch
2 slices wheat bread, 1.5 oz. Swiss Baked potato
cheese, tomato 1/2 cup broccoli, steamed
2 cups tossed salad with 1/2 cup 1 oz. grated cheese
garbanzo beans 2 Tbsp. sour cream
2 Tbsp. light dressing 1 slice wheat bread
1 peach 30 grapes
Diet soda Diet lemonade
Dinner Dinner
1.5 cups spaghetti 6 oz. baked salmon
3 oz lean ground beef 1.5 cups rice, steamed with herbs
1/2 cup spaghetti sauce 1 cup tossed salad
1/2 cup steamed squash 2 teas. olive oil
1 teas. butter 1 teas. vinegar
Iced tea with sweetener 10 saltines
1 apple
8 oz. skim milk
Snack Snack
1/2 cup pineapple cubes 1/3 cup mixed nuts
- 30 -
14. Prevention and Treatment of Obesity Guidelines
Classification of Overweight and Obesity by BMI, Waist Circumference and

Associated Disease Risk
Disease Risk Relative to Normal
Weight and Waist Circumference
BMI (kg/m2) Obesity Men < 102 cm Men > 102 cm
Class (< 40 in.); (>40 in.);
Women < 88 Women > 88
cm (<35 in.) cm (>35 in.)
Underweight < 18.5
Normal 18.5-24.9
Overweight 25-29.9 Increases High
Obesity l 30.0-34.9 I High Very High
Obesity ll 35.0-39.9 II Very High Very High
Obesity lll >40.0 III Extremely High Extremely High
Health Risk and Waist Circumference

Men >102 cm >40 inches
Women >88 cm >35 inches
How And Where To Measure Waist Circumferance
- 31 -
Determination of Absolute Risk Status Based on Overweight and Obesity
Parameters
Determining the patient's absolute risk status requires consideration of the degree of
overweight, as well as the presence of existing diseases or risk factors. To do so
requires taking into account the patient's history, physical examination, and laboratory
results. Of greatest urgency is the need to detect existing CVD or end-organ damage
that trigger the need for intense risk factor modification as well as disease management.
Since the major risks of obesity are indirect (obesity elicits or aggravates hypertension,
dyslipidemias, and diabetes which cause cardiovascular complications), the
management of obesity should be implemented in the context of reducing these other
risk factors.
Identification of Patients at Very High Absolute Risk

The following disease conditions or target organ damage in hypertensive patients
denotes the presence of very high absolute risk that triggers the need for intense risk
factor modification as well as disease management. For example, the presence of very
high absolute risk indicates the need for aggressive cholesterol-lowering therapy.
a. Established coronary heart disease (CHD)
• History of myocardial infarction
• History of angina pectoris (stable or unstable)
• History of coronary artery surgery
• History of coronary artery procedures (angioplasty)
b. Presence of other atherosclerotic diseases
• Peripheral arterial disease
• Abdominal aortic aneurysm
• Symptomatic carotid artery disease
c. Type 2 diabetes
d. Sleep apnea
- 32 -
Treatment Algorithm
- 33 -
Selecting The Treatment for Obesity
BMI
Treatment 25-26.9 27-29.9 30-34.9 35-39.9 >40.0
Diet, physical With
With
activity, and behavior Indicated Indicated Indicated
comorbidities comorbidities
therapy
With
Pharmacotherapy Not Indicated Indicated Indicated Indicated
comorbidities
Surgery Not Indicated Not Indicated With comorbidities
Exercise recommendations for Obesity

Initially, moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days per week,
should be encouraged. Extremely obese persons may need to start with simple
exercises that can be intensified gradually in order to avoid injury. Although it will not
lead to a substantially greater weight loss than diet alone over 6 months, it is most
helpful in the prevention of weight regain. Exercise is beneficial for reducing risks for
cardiovascular disease and type 2 diabetes, beyond that produced by weight reduction
alone. Starting a physical activity regimen should include skilled supervision and
guidance as well as motivational techniques, in order to reduce injury potential and
enhance compliance.
The need for performing exercise testing for cardiopulmonary disease is based on a
patient's age, symptoms, and concomitant risk factors. For most obese patients,
physical activity should be initiated slowly, and the intensity should be increased
gradually. Initial activities may be increasing small tasks of daily living such as taking
the stairs or walking or swimming at a slow pace. With time, depending on progress, the
amount of weight lost, and functional capacity, the patient may engage in more
strenuous activities. Some of these include fitness walking, cycling, rowing, cross-
country skiing, aerobic dancing, and jumping rope. The same amounts of activity can be
obtained in longer sessions of moderately intense activities (such as brisk walking) as in
shorter sessions of more strenuous activities (such as running).
Caloric expenditure will vary depending on the individual's body weight and the intensity
of the activity. Reducing sedentary time, i. e., time spent watching television or playing
video games, is another approach to increasing activity. Patients should be encouraged
to build physical activities into each day. Examples include leaving public transportation
one stop before the usual one, parking farther than usual from work or shopping, and
walking up stairs instead of taking elevators or escalators. New forms of physical activity
should be suggested (e. g., gardening, walking a dog daily, or new athletic activities).
Identifying a safe area to perform the activity (e. g., community parks, gyms, pools, and
health clubs); or, a designated area in one's home can facilitate engaging in physical
activity. Encourage patients to plan and schedule physical activity 1 week in advance,
budget the time necessary to do it, and document their physical activity by keeping a
diary and recording the duration and intensity of exercise.
http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm
- 34 -
Haskell, et al. have suggested the use of 4kcal/kg of body weight of exercise daily (1).
The Surgeon General recommends a minimum of 2 kcal/kg daily (2). See section 8 of
this handbook for ideas on amount of exercise necessary for a given individual.
1. Haskell, WL, Montoye, HJ, Orenstein, D (1985) Physical activity and exercise to achieve health-
related physical fitness components. Public Health Rep 100:202-212.
2. DHHS: Physical activity and Health: A Report of the Surgeon General. Atlanta:US DHHS, CDC,
National Center for Chronic Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, 1996.
- 35 -
A Quick Primer For Health Professionals: Four Types Of Popular Weight Loss Diets
By Valerie Berkowitz, MS RD CDE
CJ Segal-Isaacson, EdD RD
Elena Tateo, MS RD
VERY LOW FAT MODERATELY LOW VERY LOW LOW/CONTROLLED

FAT CARBOHYDRATE CARBOHYDRATE
"Eat More, Weigh Less" Therapeutic Lifestyle "Dr. Atkins New Diet “The South Beach Diet”
by Dean Ornish, M.D. Changes (TLC) Diet by the Revolution" by Robert C. by Arthur Agatson, M.D.
American Heart Atkins, M.D.
Association
GOALS To prevent/reverse heart To reduce the risk and rate of To achieve weight loss, To achieve a healthy body weight
disease by lowering heart disease through weight maintenance, good and improve lipid and glucose
profile to prevent or reverse heart
cholesterol and blood adequate individualized health, increased energy, and disease and metabolic syndrome
pressure with diet and calories promoting weight prevent medical conditions associated with obesity.
lifestyle changes. reduction and encouraging such as heart disease,
increased physical activity. diabetes, and other diseases
Recommended for weight associated with metabolic
loss because of the premise Focus is placed on decreasing resistance.
that a low fat diet results in saturated fat and lowering
weight loss. LDL cholesterol. Controlling carbohydrate
intake and correcting
Eating a vegetarian diet that If diet alone is ineffective hormonal imbalances, such as
is high in fiber and another therapeutic option is excessive insulin levels will
carbohydrate and very low in used: help achieve goals.
fat will help achieve goals. plant stanols/sterols (2 g/day)
and soluble fiber (10-
25g/day).
NUTRIENT No caloric restriction Calories based on individual No caloric restriction, Does not require fixed percentage
COMPOSITION needs, caloric distribution: nutrient composition changes of protein, carbohydrate or fat.
Focus is placed on controlling
Carbohydrate: 70-80% with each phase of the refined carbohydrate intake but
Carbohydrate: 50-60% (~20- program: allows some whole grains, fruit and
Fat: 10 % (~15-25g) 30g fiber) vegetables (Phase 1 only allows
Protein: 15% Phase I, Induction low-glycemic vegetables.) Promotes
Total Fat: 25-35% Carbohydrate: 5-8% carb unsaturated fats, including omega-
3’s and monounsaturates (ie. olive
Saturated fat <7% (~20g) oil) in place of saturated and trans
- 36 -
Polyunsaturated fat Protein: 30-35% fat.
10% Fat: 60-65%
Monounsaturated fat Phase 1
20% Phase II, On-Going Weight
All carbohydrates restricted except
Cholesterol <200mg Loss Carbohydrate: 9- 12% for low-glycemic vegetables.
Sodium ≤ 2400mg (25- >45g) or Allows “normal” portions of
(60-90g with vigorous lean/medium fat protein and good
activity) fats. Sample meal plans indicate
Protein: 30-35% typical serving sizes.
Fat: 53-55%
Phase 2
Phase III, Pre-Maintenance The concept of glycemic index (GI)
Range of CHO is introduced and lower-GI
(individualized, slightly more carbohydrates, such as apples, high-
carbs than phase II, slightly fiber cereals, multigrain breads, and
less than phase IV) between reduced-fat milk, are gradually
reintroduced into the diet. Higher-
12.5 and 24%, 30-35% GI carbohydrates, such as refined-
protein (allow 3 months to grain breads and potatoes, are
lose the last few pounds) proscribed.
Carbohydrate: 12.5-24%
(individualized, slightly more Phase 3
than Phase II, slightly less
than Phase IV) Maintenance phase when one has
reached their ideal weight and no
Protein: 30-35%
foods are specifically prohibited.
Fat: 41-57%
*Allow 3 months to loose the
last 10 pounds
Phase IV, Maintenance

Carbohydrate: 13-25% (25-
>90g) or (>90g with vigorous
activity)
Protein: 30-35%
Fat: 40-45%
- 37 -
VERY LOW FAT MODERATELY LOW FAT VERY LOW CARBOHYDRATE LOW/CONTROLLED
CARBOHYDRATE
"Eat More, Weigh Less" Therapeutic Lifestyle Changes "Dr. Atkins New Diet Revolution" “The South Beach Diet”
by Dr. Dean Ornish (TLC) Diet by the American by Dr. Robert C. Atkins by Arthur Agatson, M.D.
Heart Association
FOODS Allowable foods: Allowable foods: Allowable foods: Phase 1
CONSUMED Beans/legumes, fruits, grains, All foods based on calories and Phase I, Induction First 14 days exclude bread, rice,
vegetables, non-fat dairy products portion size Liberal combinations of natural, not potatoes, pasta, baked goods, fruit,
Meat (lean cuts only), poultry, fish, hydrogenated, fats (oils, butter, candy, cake, cookies, ice cream,
Eliminate: peas/beans, tofu, eggs (< 2 heavy cream and mayonnaise) and sugar, and alcohol. Foods allowed:
All meats (including chicken/fish), yolks/week, unlimited egg whites) protein (fish, chicken, shellfish, lean/medium fat proteins including
all dairy except non-fat choices, all eggs, red meat) seafood, eggs, meat, poultry, tofu,
oils, olives, nuts/seeds, and avocado Milk/yogurt/ cheese (non-fat or low pork, veal, some unsaturated fats
fat) Measured portions of dark green such as olive or canola oil and nuts,
Avoid simple sugars, fats, and leafy and non-starchy salad low-glycemic vegetables such as
alcohol Fats/oils/nuts/salad dressing vegetables, olives, avocado, lemon greens, asparagus, broccoli, cabbage
(includes food preparation) juice cucumbers, etc., unsweetened fat-
Include fish oil supplements free or low-fat dairy, and if desired,
Fruit Eliminate: fruit, bread, pasta, grains, sugar-free “sweets” (limit “sweets”
starchy vegetables, milk, yogurt or to 75 calories per day).
Vegetables dairy
Phase 2
Grains, pasta, rice, cooked cereal, Add fruits excluding canned fruit,
potatoes, bread juice, pineapple, raisins and
watermelon. Add (sparingly) whole
Sweets/snacks grain bread, rice and pasta, sweet
potatoes, popcorn. May have red or
white wine and fat-free, sugar-free
pudding.
Phase 3
The most liberal stage of the diet.
There are no food lists and the
author suggests enjoying food
without over-indulging. If any
weight gain during this time, switch
back to Phase 1 for a week or two to
lose any weight you may have
gained.
- 38 -
VERY LOW FAT MODERATELY LOW FAT VERY LOW LOW/CONTROLLED
CARBOHYDRATE CARBOHYDRATE
by Dr. Dean Ornish Changes (TLC) Diet by the Revolution" by Dr. Robert by Arthur Agatson, M.D.
American Heart Association C. Atkins
FOODS Phase II, Ongoing Weight
CONSUMED Loss
Carbohydrate-containing low-
glycemic response foods
should be added carefully in
the following order: Non-
starchy salad vegetables, fresh
cheeses, seeds/nuts, berries
and other low-glycemic index
fruits, wine and other low-
carb spirits
Add 5 grams a day of

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

back like this as long as
satisfactory weight loss
continues.
- 39 -
FOODS Phase III, Near Goal Weight
CONSUMED Legumes, fruits higher in
glycemic index, starchy
vegetables and whole grains
The goal is to lose about one

pound per week. To do this,
add 10 grams of carbohydrate
per day for one week (add
another 10g carbohydrate per
day, if weight loss is >
1pound; decrease
carbohydrate if weight loss is
< than 1 pound).
If goal weight achieved,

maintain this level of
carbohydrate for one month
(add 10 grams of carbohydrate
per day to determine effect on
weight), if weight gain occurs
eliminate the 10 grams, if
weight is maintained this is
the critical carbohydrate level
for maintaining weight.
Phase IV, Maintenance

All foods selected above as
part of a varied nutrition
regimen
- 40 -
by Dr. Dean Ornish Changes (TLC) Diet by the Revolution" by Arthur Agatson, M.D.
American Heart Association by Dr. Robert C. Atkins
SAMPLE MENU Breakfast Breakfast Breakfast Phase 1
Fruit salad with nonfat cottage Egg white vegetable omelet, low-fat Whole egg mushroom, tomato and Breakfast
cheese topped with granola cheese, 1/2 bagel with jam cheese omelet with sliced avocado, 6 oz. Vegetable juice cocktail, 2
nitrite-free Canadian bacon vegetable quiche cups (recipe),
Lunch Lunch decaf coffee or tea.
Fresh vegetable salad topped with Minestrone soup, grilled turkey Lunch
tofu, raisins and mandarin orange sandwich with lettuce and tomato, Spinach and mixed leaf salad with Midmorning snack:
slices and a baked potato topped fruit cup fresh veggies topped with parmesan 1 part-skim mozzarella cheese stick
with nonfat yogurt cheese and sliced beef round and oil
Dinner Dinner and vinegar dressing Lunch:
Rice and beans with steamed Tossed salad, low-fat salad dressing, Sliced grilled chicken breast on
vegetables pasta with chicken and broccoli Dinner romaine, 2 Tbsp Balsamic
Salmon, kale topped with garlic, Vinaigrette (recipe) or low-sugar
lemon and sesame seeds prepared dressing
Sugar-free flavored gelatin dessert
Snack Snack Snack
Melon wedge fruit Chicken salad Mid-afternoon snack:
Celery stuffed with 1 wedge of light
cheese
Dinner:
Grilled Salmon with Rosemary
(recipe), steamed asparagus, tossed
salad, oil & vinegar to taste.
Dessert:
Vanilla Ricotta Crème (recipe)
- 41 -
CLAIMS "Eat more weigh less", eat an Consuming the appropriate Switch the body from carbohydrate
extremely low-fat vegetarian diet, percentages of nutrients within an to fat burning (lipolytic pathway) to
reduce stress, and exercise to individualized amount of calories correct metabolic abnormalities
reverse/prevent heart disease (i.e. will help to reduce cardiac risks and associated with excess carbohydrate
arterial clogging, angina) weight intake and insulin sensitivity
This will promote weight loss, This will promote good health, help
increase energy and eliminate the improve energy levels and help
need for medication. prevent medical conditions affected
by insulin resistance (obesity,
diabetes, heart disease, syndrome X,
PCOS, cancer and mood
swings/energy level)
- 42 -
SUPPORTING Ornish D, Scherwitz LW, Billings Lichtenstein AH, Ausman LM, Atkins RC. Dr. Atkins' New Diet A search of Pub Med using
EVIDENCE JH, et al. Intensive lifestyle changes Jalbert SM, et al. Efficacy of a Revolution. NY;NY: Avon Books; keywords “South Beach Diet” did
FOR CLAIMS for reversal of coronary heart Therapeutic Lifestyle Change/Step 2 2002.13 not return any citations specific to
disease. JAMA. 1998;280(23):2001- diet in moderately this diet. No references cited in
7.1 hypercholesterolemic middle-aged Sondike SB, Copperman, NM, book.
PMID: 9863857 and elderly female and male Jacobson MS. Low carbohydrate
subjects. J Lipid Res. dieting increases weight loss but not
Ornish D, Brown SE, Scherwitz 2002;43(2):264-73. 7 cardiovascular risk in obese
LW, et al. Lifestyle changes and PMID: 11861668 adolescents: a randomized
heart disease. Lancet, controlled trial. J AdolHealth.
1990;336(8707):129-33. 2 Executive Summary of The Third 2000;26:91. 14
PMID: 1975906 Report of The National Cholesterol
Education Program (NCEP) Expert Sharman MJ, Kraemer WJ, Love
Ornish, D. Avoiding Panel on Detection, Evaluation, And DM. et al. A ketogenic diet
revascularization with lifestyle Treatment of High Blood favorably affects serum biomarkers
changes: the multicenter lifestyle Cholesterol In Adults (Adult for cardiovascular disease in
demonstration project. Am J Treatment Panel III). JAMA. normal-weight men. J Nutr.
Cardiol. 1998; 82(10B): 72T-76T.3 2001;285(19):2486-97.8 2002;132(7):1879-85.15
PMID: 960380 PMID: 11368702 PMID: 12097663
Katan MB. High-oil compared with Westman EC, Yancy, WS, Edman
low-fat, high-carbohydrate diets in JS, et al. Effect of 6-month
the prevention of ischemic heart adherence to a very low
disease. Am J Clin Nutr. 1997; 66(4 carbohydrate diet program. Am J
Suppl):974S-979S. Med. 2002; 113(1):30-6. 16
PMID: 9322576 PMID: 12106620
Katan MB, Grundy SM, Willett

WC. Should a low-fat, high-
carbohydrate diet be recommended
for everyone? Beyond low-fat diets.
N Engl J Med. 1997;337(8):563-6.9
PMID: 9262504
- 43 -
by Dr. Dean Ornish Changes (TLC) Diet by the Revolution" by Arthur Agatson, M.D.
American Heart Association by Dr. Robert C. Atkins
REFUTING Kasim-Karakas SE, Almario Brown RC, Cox CM. Effects Westman EC. A review of None could be found.
EVIDENCE RU, Mueller WM, Peerson J. of high fat versus high very low carbohydrate diets
FOR Changes in plasma carbohydrate diets on plasma for weight loss. J Clin Obes
CLAIMS lipoproteins during low-fat, lipids and lipoproteins in Med. 1999;6(7):36-40. 17
high-carbohydrate diets: endurance athletes. Med Sci
effects of energy intake. Am J Sports Exerc.
Clin Nutr. 2000; 71(6):1439- 1998;30(12):1677-83.10
47.4 PMID: 9861599
PMID: 10837283
Krauss RM, Dreon DM. Low-
Taubes G. Nutrition. The soft density-lipoprotein subclasses
science of dietary fat. Science. and response to a low-fat diet
2001; 291(5513):2536-45.5 in healthy men. Am J Clin
PMID: 11286266 Nutr. 1995;62:478S-487S.11
PMID: 7625363
Dreon DM, Fernstrom HA,
Williams PT, et al. A very- Abbasi F, McLaughlin T,
low-fat diet is not associated Lamendola C, et al. High
with improved lipoprotein carbohydrate diets,
profiles in men with a triglyceride-rich lipoproteins,
predominance of large, low- and coronary heart disease
density lipoproteins. Am J risk. Am J Cardiol.
Clin Nutr. 1999;69: 411-18.6 2000;85(1):45-8.12
PMID: 10075324 PMID: 11078235
- 44 -
POTENTIAL Increased triglycerides, Decreased HDL without Short term Phase 3 (the maintenance
ADVERSE decrease in HDL, conditions change in TG or total Bad breath, muscle cramps, phase) of the diet is not well
EVENTS associated with a decrease in cholesterol/HDL-C ratio constipation, increased uric defined. The book indicates
fat-soluble, B vitamin stores acid levels and occasionally that no foods are restricted
and essential fatty acids elevated LDL during this phase. The overall
message may not be clear to
Long term the consumer in terms of how
Unknown, currently being much food they should eat to
studied prevent subsequent weight
gain.
CLINICAL Weight loss, reverse/prevent If portions are used Weight loss, decreased total Weight loss, may improve
BENEFITS heart disease, stress reduction appropriately, weight loss and cholesterol and triglycerides, lipid profile and glycemic
reduced risk of heart disease increased HDL and control during Phase I and II.
based on personal profile improvements in glycemic
control
- 45 -
Weight Loss Drugs
Indications for weight loss drugs approved by the FDA for long-term usage
• Patients with a BMI >30 and without concomitant obesity-related risk factors or
diseases.
• Patients with a BMI >27 with concomitant obesity-related risk factors or diseases.
Drug therapy for weight management has begun to change from short-term to long-term
use.
• Because of the tendency to regain weight after weight loss, the use of long-term
medication to aid in the treatment of obesity may be indicated for carefully selected
patients.
• If a patient has not lost the recommended 1 pound per week after at least 6 months
on a weight loss regimen that includes an LCD, increased physical activity, and
behavior therapy, then careful consideration may be given to pharmacotherapy.
• Reported concerns about unacceptable side effects, such as regurgitant valvular
lesions of the heart, led to the withdrawal of dexfenfluramine and fenfluramine from
the market in September 1997.
• In November 1997, the FDA approved Sibutramine and in April 1999 Orlistat, for
long-term use in obesity.
• These drugs are modestly effective in their ability to produce weight loss. Net weight
loss attributable to drugs has generally been reported to range from 2 to 10
kilograms.
• Initial responders tend to continue to respond, whereas initial nonresponders are
less likely to respond, even with an increase in dosage. If a patient does not lose 2
kilograms (4.4 lbs) in the first 4 weeks after initiating therapy, the likelihood of long-
term response is very low. This information may be used in deciding to discontinue
treatment.
Two classes of weight loss drugs

1. Anorexiants
2. Appetite suppressants.
Three classes of anorexiant drugs which affect neurotransmitters are:

1. Those that affect catecholamines, such as dopamine and norepinephrine;
2. Those that affect serotonin;
3. Those that affect more than one neurotransmitter.
- 46 -
Two commonly used current weight loss medications are:
Drug Dosage Mechanism Side Effects Comments

Sibutramine 5, 10, 15 mg Inhibits Increase in heart People with high blood
(Meridia) 10 mg p.o. the reuptake of rate and BP. pressure,
q.d. to start, norepinephrine, CHD, congestive heart
may be dopamine failure,
increased to and serotonin arrhythmias, or history of
15 mg or stroke
decreased to should not take
5 mg. sibutramine.
Orlistat 120 mg p.o. Inhibits Decreases A multivitamin
(Xenical) t.i.d. before pancreatic lipase; absorption of fat- supplement is
meals. decreases fat soluble vitamins. recommended when
absorption by Soft stools and taking this drug.
30% anal leakage.
Follow-Up Visit Schedule and assessment of side-effects

• Two to four weeks after initial visit
• Monthly for three months
• Every three months for the first year after initiating the medication.
• After the first year, the doctor will advise the patient on appropriate return visits.
Weight Loss Surgery

Candidates for weight loss surgery
• Patients with severe and resistant obesity
• Patients in whom efforts at other therapy have failed
• Patients in whom complications of obesity are present
• Patients at high risk for obesity-related morbidity and mortality
• Well informed and motivated patients with BMI>40
• Patients with BMI>35 who have comorbid conditions (cardiovascular, sleep apnea,
uncontrolled type 2 DM, weight-induced physical problems that interfere with
activities of daily living).
• Patients with acceptable operative risks
- 47 -
Surgical Interventions geared toward reducing food consumption:
Restrictive Operations: Limit food intake and do not interfere with the normal digestive
process.
• Adjustable Gastric Banding (AGB): A band of silicone is placed around the
stomach near its upper end, creating a small pouch and narrow passage into the
rest of the stomach.
• Vertical Banded Gastroplasty (VBG): Uses both a band and staples to create a
small stomach pouch. VBG is not often used today.
Advantages: Easier to perform and generally safer than malabsorptive
operations. AGB is routinely performed via laparoscopy.
Disadvantages: Lose less weight than from malabsorptive/combined operations.
Risks: Vomiting is the most common risk when patient eats too much food or the
narrow passage into the larger party of the stomach becomes blocked. Another
risk is slippage or wearing away of the band and some patients experience
infections and bleeding but this is much less common than other risks. Death
may occur from complications in less than 1 percent of all cases.
Combined Restrictive/Malabsorptive Operations: Malabsorptive operations

(intestinal bypasses) alone are no longer recommended because they result in
severe nutritional deficiencies. However, combined operations may be more
effective in improving the health problems associated with severe obesity.
• Roux-en-Y gastric bypass (RGB): The most common and successful
combined procedure in the US. The Surgeon creates a small stomach pouch
to restrict food intake. Next, a Y-shaped section of the small intestine is
attached to the pouch to allow food to bypass the lower stomach, the
duodenum, and the first portion of the jejunum.
• Biliopancreatic diversion (BPD): In this more complicated operation, the

lower portion of the stomach is removed. The small pouch that remains is
connected directly to the final segment of the small intestine, completely
bypassing the duodenum and jejunum. This poses a greater risk for nutritional
deficiencies.
Advantages: Most patients lose weight quickly with combined procedures
and continue to do so for up to 24 months after procedure. Weight
maintenance is more likely than in restrictive surgery alone. RGB is often
performed laparoscopically, which is less common with the BPD procedure.
Disadvantages: Combined procedures are more difficult to perform than
restrictive procedures. They are also more likely to result in long-term
nutritional deficiencies because the food bypasses the duodenum and
jejunum where many nutrients are absorbed. Most common deficiencies:
Vitamin B12, iron, calcium, and Vitamins A, D, E and K. RGB and BPD may
also cause “dumping syndrome” when food moves too quickly through the
body without being absorbed and may cause diarrhea, nausea, pain, bloating,
weakness, sweating, faintness.
- 48 -
Risks: In addition to risks associated with restrictive procedures such as
infections, combined procedures are more likely to lead to complications.
Combined operations carry a greater risk than restrictive operations for
abdominal hernias (up to 28 percent), which require a follow-up operation to
correct. The risk of hernia, however, is lower (about 3 percent) when
laparoscopic techniques are used. Risk of death for RGB patients is less than
1 percent of cases; BPD with duodenal switch has an increased risk of 2.5 to
5% of cases.
Summary Notes On Weight Loss Surgery

• Combined procedures may help patient lose 60 to 80 percent of excess weight.
• Compared to other interventions, surgery produces the longest period of sustained
weight loss.
• Decreases mortality for each year of follow-up when compared to non-surgical
approach. (2)
• Significant and prompt improvement in DM, sleep apnea, hypertension, GERD,
osteoarthritis, and urinary incontinence.
• Premenopausal women should avoid pregnancy until weight has stabilized.
• Women wishing to conceive after weight has stabilized post bariatric surgery should
be evaluated for micronutrient deficiencies and have them corrected prior to
conception.
• Good bariatric treatment should include medical, behavioral and nutritional
components.
1. Source: National Institute of Diabetes and Digestive & Kidney Diseases

http://win.niddk.nih.gov/publications/gastric.htm
2. McDonald, K.G., Long, S.D., Swanson, M.S. et al (1997) The gastric bypass operation reduces
the progression of mortality of NIDDM. Jo Gastrointestinal Surgery 1: 213-220.
Assessing Patients’ Motivation to Make Nutrition and Lifestyle Changes

Patients vary in their readiness (stages of change) for making lifestyle changes that lead
to weight loss. Before recommending a weight loss program, the following factors be
evaluated:
• Reasons and motivation for weight loss: What is the extent of the patient's
seriousness and readiness to undergo a sustained period of weight loss at this time?
What is the patient's current attitude about making a life-long commitment to
behavior change?
• Previous history of successful and unsuccessful weight loss attempts: What
factors were responsible for previous failures and successes at weight loss or
maintenance of normal body weight?
• Family, friends, and work-site support: What is the social framework in which the
patient will attempt to lose weight, and who are the possible helpers and antagonists
to such an attempt?
- 49 -
• The patient's understanding of overweight and obesity and how it contributes
to obesity-associated diseases: Does the patient have an appreciation of the
dangers of obesity, and are these dangers of significant concern to the patient?
• Attitude toward physical activity: Is the patient motivated to enter a program of
increased physical activity to assist in weight reduction?
• Time availability: Is the patient willing to commit the time required to interact with
health professionals in long-term weight loss therapy?
• Barriers: What are the obstacles that will interfere with the patient's ability to
implement the suggestions for change?
• Financial considerations: Is the patient willing to pay for obesity therapy? This may
include having to pay for travel to the medical facility, time lost from work, and
paying for professional counseling that is not covered by insurance.
- 50 -
Assessing Patient Motivation for Diet and Lifestyle Change
Stages of Change Characteristics Techniques for Practitioner

Pre-contemplation Unaware of need for or Empower patient – decision is hers.
possibility of change in health Encourage self-exploration, not action.
behavior.
Contemplation Aware of health issue and now Empower patient – decision is hers.
thinking about it. Encourage analysis of pros and cons
of health behavior.
Preparation Getting ready to make change Identify and assist in problem solving
in health behavior (setting (e.g. obstacles). Help patient identify
start/quit date, etc.). social support. Encourage initial small
steps.
Action Changing health behavior. Reinforce decision to act. Focus on
restructuring cues and social support.
Bolster self-efficacy for dealing with
obstacles.
Maintenance Keeping new health behavior. Plan for follow-up support. Reinforce
internal rewards and health benefits.
Discuss coping with relapse.
Relapse Falling back to old health Evaluate trigger for relapse. Reassess
behavior. motivation and barriers. Plan stronger
coping strategies.
Prochaska JO, DiClemente CC, Norcross JC.(1992) In search of how people change. Applications to
addictive behaviors. Am Psychol 47(9):1102-14
- 51 -
15. Criteria for the Diagnosis of Diabetes Mellitus and Impaired
Glucose Tolerance
Criteria for the Diagnosis of Diabetes and Impaired Glucose Tolerance1
Diabetes Mellitus (one of the following criteria):

• A casual plasma glucose concentration of >200 mg/dL(11.1 mmol/L) plus symptoms
of diabetes mellitus(polyuria, polydipsia, unintentional weight loss).
• A fasting plasma glucose (FPG) level of >126 mg/dL (7 mmol/L) on two separate
occasions. Fasting is defined as no caloric intake for > 8 hours.
• A 2-hour plasma glucose level of >200 mg/dL (11.1 mmol/L) during an oral glucose
tolerance test (OGTT) employing 75 grams of glucose.
Impaired Glucose Tolerance:
• 2-hour post-prandial glucose > 140 mg/dL (7.8 mmol/L) but <200 mg/dL (11.1 mmol/L)
on OGTT.
Impaired Fasting Glucose:
• Fasting plasma glucose > 100 mg/dL but < 126 mg/dL (6.1 to 7.0 mmol/L).
1. Report of the expert committee on the diagnosis and classification of DM(1997). Diabetes Care 20:
1183-1197.
ADA Treatment Guidelines for Glycemic Control in Type 2 Diabetes

Lab Value (whole blood) Normal Goal Action Suggested
Preprandial glucose < 90 mg/dL 80-120 mg/dL < 80 or > 140 mg/dL
Bedtime glucose < 120 md/dL 100-140 mg/dL < 100 mg/dL or > 160 mg/dL
HgbA1C < 6%* < 7% > 8%
* depending on lab norms.
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Medical Nutrition Algorithm IFG/Type 2 Diabetes Prevention & Therapy
http://www.dshs.state.tx.us/diabetes/PDF/algorithms/NUTRITIO.PDF
- 53 -
Pharmacological Algorithm for Type 2 Diabetes
http://www.dshs.state.tx.us/idcu/health/dpn/issues/DPN58N18.PDF
H
- 54 -
Lipids Algorithm IFG and Type 2 Diabetes
- 55 -
http://www.dshs.state.tx.us/diabetes/PDF/algorithms/LIPID.PDF
- 56 -
Medications for People with Type 2 Diabetes
Oral Antidiabetic Agents1

Generic Name Brand Daily Dose Duration Mechanism of Action Comments
Name (mg) of Action
(hours)
First-Generation Sulfonylureas
Tolbutamide Orinase 500-3000 6-12 Increases insulin secretion. Contraindicated when known
sensitivity to the drug, in
Chlorpropamide Diabinese 100-500 60
pregnancy.
Tolazamide Tolinase 100-1000 12-24
Second-Generation Sulfonylureas
Glipizide Glucotrol 2.5-20.0 12-24 Increases insulin secretion. Contraindicated when known
sensitivity to the drug,
Glucotrol XL 5-20 24
pregnancy.
Glyburide Diabeta 1.25-20.0 16-24
Micronase 0.75-12.0 12-24
Glynase
Pres Tab
Glimepiride Amaryl 1-4 24
Meglitinides
Repaglinide Prandin 1-16 ~1 Taken before meals to Metabolized by the liver; not
increase insulin secretion and contraindicated in renal
decrease post-prandial BS. insufficiency.
Biguanides
Metformin Glucophage 1500-2550 ~5.5* Primarily reduces hepatic Increases HDL cholesterol:
glucose production; also decreases triglyceride, total
increases muscle glucose cholesterol and LDL Avoid
uptake. use when sCr > 1.5 mg/dl,
liver failure, CHF; near
surgery or contrast studies.
Alpha-Glucosidase Inhibitors
Acarbose Precose 25-150 8* Inhibits carbohydrate Contraindicated in patients
absorption from the gut. with major GI disorders,
Miglitol Glyset 25-300 8* severe hepatic or renal
disease.
Thiazolidinediones
Rosiglitazone Avandia 4-8 12 Enhances sensitivity to insulin Monitor LFTs every 2 months
in peripheral tissues. for first year.
Pioglitazone Actos 15-45 24
*Plasma half-life
1. Adapted from: Umpierrez, G.E., Kitabchi, A.E. (2001) Managing Type 2 diabetes: Evolving srategies for
treatment. Obstetrics and Gynecology Clinics 28(2):401-419.
- 57 -
Comparative Profiles of Various Types of Regular Human Insulin
Onset Effective Maximal
Type of Insulin Peak (hr)
(hr) Duration (hr) Duration (hr)
<15
Lispro 1 3 4
min
0.5 to
Regular 2 to 3 3 to 6 6
1
NPH 2 to 4 4 to 10 10 to 16 18
Lente 3 to 4 4 to 12 12 to 18 20
Varies with
Ultralente 6 to 10 18 to 20 24 to 30
dose
Insulin glargine 1 to 2 Flat 24 (under review)
- 58 -
Nutritional and Exercise Recommendations for People with Type 2 Diabetes
1. The Essential Elements For Evaluating DM Nutrition-Related Outcomes

• Monitor glucose and HgbA1C.
• Monitor lipids.
• Monitor BP.
• Monitor renal status.
2. Goals of Medical Nutrition Therapy (MNT)

• Maintain blood glucose levels as near normal as possible using
medications, a balanced food intake, and physical activity.
• Achieve optimal serum lipids.
• Provide adequate calories to achieve a reasonable weight. Current focus is
more on glycemic control and less on weight loss.
• Prevent and treat long term complications of DM.
• Improve general health through good nutrition.
3. Nutrition Therapy and Type 2 Diabetes

• Pharmacologic weight loss agents may be of benefit for people with
BMI>27. Gastric reduction may be considered if BMI>35.
• Spacing meals and carbohydrate intake appropriately throughout the day
helps improve glycemic control.
• Include 10-20% of kcal as protein, from vegetable, grain and animal
sources. Severe protein restriction to 0.8 gm/kg may help delay the
progression of renal disease if overt nephropathy is present. Further
restriction to 0.6 gm/kg is suggested once GFR begins to fall.
- 59 -
Item Diabetes Diet Guidelines 1
Weight If excess body weight is present, restrict daily caloric intake by 500-1000 calories per day <
Management usual intake. In selected patients, drug therapy to achieve weight loss as an adjunct to lifestyle
change may be appropriate. In patients with severe/morbid obesity, surgical options, such as
gastric bypass and gastroplasty, may be appropriate. It is important to counsel patients on the
risks of surgery, including mortality, depression, hypoglycemia, nutritional deficiencies,
osteoporosis, and weight regain over the long term.
Protein ~10% of daily kcal
0.8 gm/kg body weight if overt nephropathy present
0.6 gm/kg if GFR is declining
Carbohydrate 45-65% of daily kcal. Total amount of CHO may be individualized based on nutrition
assessment, treatment goals, lipid profile.
Spacing CHO throughout day improves glycemic control.
Both the amount and type of CHO in food influence blood glucose level. Increased triglyceride
and VLDL may merit reduction CHO and increased monounsaturated kcal. Restricting total
carbohydrate to <130 g/day is not recommended in the management of DM.
Fiber Promotes bowel health and regularity.
20-35 gm total of soluble and insoluble recommended daily.
Alcohol May produce hypoglycemia in people treated with oral agents or insulin, especially if consumed
without food.
Limit to 1 drink daily for women, 2 for men.
Reduction or abstention if pancreatitis, neuropathy, dyslipidemia, especially
hypertriglyceridemia, or history of alcoholism.
Nutritive No evidence that foods sweetened with corn syrup, fruit concentrates, honey, molasses, and
Sweeteners maltose promote better DM control than sucrose.
Kcal from maltitol, mannitol, xylitol, and sorbitol should be counted in total kcal: These may
have a laxative effect.
Fat 25-35% of daily kcals. <7% kcal as saturated fat, < 10% kcal as polyunsaturates, 10-15% kcal
as monounsaturates, <300 mg cholesterol.
If LDL elevated- < 200 mg cholesterol.
Sodium General recommendations < 2300 mg daily.
Multivitamins Not recommended unless diet is of poor nutritional quality

1. Standards of Medical Care in Diabetes. 2006. American Diabetes Association
http://care.diabetesjournals.org/cgi/content/full/29/suppl_1/s4#T6
- 60 -
Types and Limitations of Various Artificial Sweeteners
Chemical Product Sweetness Uses Limitations Types of foods Year
Name Name Relative to Developed
Sugar
Saccharin Sweet N Low 200 to 700 Can be used in Avoid if pregnant All types Discovered in
times both hot & cold Causes cancer in 1870s
sweeter foods lab rats – not
than sugar (manufacturer sure about risks
recommends to humans.
substituting it for Bitter aftertaste.
only half the
sugar in recipes)
Aspartame NutraSweet; 160 to 220 Substitute 6 Do not use if Desserts, soft Discovered in
Equal; times (1gram) packets have PKU drinks, candy & 1965,
NatraTaste sweeter for each ¼ cup of Loses sweetness gum, teas, approved by
than sugar sugar when heated – breath mints, FDA in 1974
not good for vitamins & cold
baking preparations.
NatraTaste is
Kosher
Acesulfame Sweet One; 200 times Can use for Texture of baked Hot & cold Discovered in
potassium Sunette; sweeter baking & goods not same drinks, baked 1967,
(acesulfame- AlternaSweet than sugar cooking: does as with sugar. goods, etc. approved by
K) not break down Bitter aftertaste. Sweet One is FDA in 1988
when heated. Kosher
Use with sugar
when baking –
substitute 6
(1gram) packets
for each ¼ cup of
sugar.
Sodium and Cyclamate Banned for food Toothpaste, Discovered in
Calcium use in US in mouthwash, 1937. Lost
Cyclohexylsyl- 1970. Still used desserts, candy, FDA
famate in over 55 other etc. When approval in
countries. Heat previously used 1970.
stable. in foods, it was
blended together
with other
artificial
sweeteners b/c it
added bulk to
finished product.
- 61 -
Glycemic Index
The glycemic index (GI) is a ranking of carbohydrates on a scale from 0 to 100
according to the extent to which they raise blood sugar levels after eating. Foods with a
high GI are those that are rapidly digested and absorbed compared to a standard food
load (typically glucose or white bread.) Low-GI foods, by virtue of their slow digestion
and absorption, produce more gradual rises in blood sugar and insulin levels, and some
studies suggest that low-GI diets may improve both glucose and lipid levels in people
with diabetes (type 1 and type 2). (1) Other clinical trials have not confirmed this effect,
however. (2)
Although the glycemic index can be a useful tool for educating diabetic patients about
their diets, the concept has not been universally endorsed; in part because the GI of an
isolated food changes depending on a variety of factors. First, meals contain other
constituents such as protein and fat that affect the digestion and absorption rate of the
food. The total caloric content (or serving size) of the food, where it is grown, how it is
processed, and the style of preparation (cooking method and time) all affect the rate of
glycemia as well. Using carrots as an example, note the GI variability of this food based
on different conditions:
• Although boiled carrots have a low/moderate to high GI, the actual effect on
blood sugar is small because portion sizes are typically much smaller than that
used to test GI.
• Raw carrots have a very low GI of 16.
• Australian boiled carrots are reported to have a low GI (32 to 49), while Canadian
boiled carrots have a high GI (92). (3)
Glycemic Index and Diabetes

When working with a diabetic patient whose blood sugar or hemoglobin A1C is not well-
controlled, it is most important to look at the total amount of carbohydrates in the diet as
well as how this carbohydrate is distributed throughout the day. Secondarily, it may be
useful to encourage the patient to substitute higher-glycemic foods with lower-glycemic
ones.
The patient may benefit from a referral to a Registered Dietitian (RD) or Certified
Diabetes Educator (CDE) who can implement a plan and evaluate their progress. Some
steps the RD or CDE might take could include (4):
1. Monitor pre and post blood glucose concentration 1-2 hour after eating to assess
the effects of carbohydrate and total food intake on glycemic control (Note:
Normal glucose concentration is < 140 mg/dL at two hours but goals need to be
individualized based on the risk of hypoglycemia).
2. Determine if the amount of carbohydrate eaten is contributing to any post meal
elevation (keeping the amount of carbohydrate consistent will make assessing
the effects on postprandial glucose easier).
3. Examine the portion size, especially potential errors, in estimating how many
grams of carbohydrate may be in foods with variable portion sizes (e.g., pasta,
bagels, muffins) and
- 62 -
4. Examine components of carbohydrate such as fiber in legumes that may affect
the postprandial response and the glycemic load of food intake.
Glycemic Index of Select Foods*~
Low GI (55 or less) ** Medium GI (56-69) * * High GI (70 or more) * *

BREADS BREADS BREADS
100% stone ground whole wheat Whole wheat White bread
Heavy mixed grain Rye Kaiser roll
Pumpernickel Pita Bagel, white
CEREAL CEREAL CEREAL
All Bran™ Grapenuts™ Bran flakes
Bran Buds with Psyllium™ Shredded Wheat™ Corn flakes
Oatmeal Quick oats Rice Krispies™
Oat Bran™ Cheerios™
GRAINS GRAINS GRAINS
Parboiled or converted rice Basmati rice Short-grain rice
Barley Couscous
Bulgar Sweet corn
Pasta/noodles
STARCHY VEG, FRUIT, STARCHY VEG, FRUIT, STARCHY VEG, FRUIT,
LEGUMES LEGUMES LEGUMES
Sweet potato Potato, new/white Potato, baking (Russet)
Yam Cantaloupe French fries
Lentils Kiwi Watermelon
Chickpeas Black bean soup
Kidney beans Green pea soup
Split peas Apricot, raw (Italy)
Soy beans Peach, raw (Italy)
Baked beans Cantaloupe
Apple, raw OTHER OTHER
Grapes (Canada) Popcorn Pretzels
Banana Stoned Wheat Thins™ Rice cakes
Pineapple, raw (Philippines) Ryvita™ (rye crisps) Soda crackers
Orange, raw, Sunkist Scones
Gatorade (sports drink)
*Adapted from Canadian Diabetes Website www.diabetes.ca and Foster-Powell K, Holt, S, and Brand-
Miller, J Am J Clin Nutr 2002;76:5-56
~Lower-starch vegetables and raw berries are not included in the list due the their negligible effect on
glycemia.
**Expressed as a percentage of the value for glucose.
1. University of Sydney, Australia http://www.glycemicindex.com/aboutGI.htm
- 63 -
2. Sheard NF, Clark NG, Brand-Miller JC, Franz, MJ, Pi-Sunyer FX, Mayer-Davis e, Kulkarni K, Geil P:
Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement
of the American Diabetes Association. Diabetes Care 27:2266-2271. 2004
3. Foster-Powell K, Holt S and Brand-Miller J: International table of glycemic index and glycemic load
values: 2002 Am J Clin Nutr 2002; 76:5-56
4. Wylie-Rosett, J. Albert Einstein College of Medicine. Article pending review, Journal of American
Dietetic Association, 2007.
- 64 -
Exercise Recommendations for Type 2 Diabetes
• Favorable changes in glucose tolerance and insulin sensitivity subside 72 hours
after exercise. Therefore, exercise should be performed regularly.
• Individuals should strive to perform at least 1000 kcal weekly.
• People with Type 2 DM generally have a lower level of fitness than age and
activity-matched controls and should aim for an exercise level of 10-12 RPE (very
light to somewhat hard).
• Autonomic neuropathy may affect heart rate; therefore, RPE may be easier for
monitoring exercise use than heart rate.
• Low intensity exercise may enhance metabolic control but may not necessarily
produce CV training effects. It may increase likelihood of adherence and less
opportunity for musculoskeletal injury.
• Short-term, high-intensity exercise may increase blood sugar in obese, insulin
resistant people with Type 2 DM. Hyperglycemia may persist up to 1 hour after
activity.
• There is an inverse relationship between fitness level and mortality across all
levels of glycemic control (1). Intra-abdominal obesity may be decreased by
resistance training (2).
• Hypoglycemic reactions associated with exercise are rare, occurring mainly in
clients treated with insulin or sulfonlyurea oral medication, during prolonged or
intense physical exertion. Avoid exercise during the time of peak insulin activity.
Discourage insulin administration in a site that will be intensely exercised.
• For fluid and carbohydrate recommendations for prolonged exercise, see sections
5 and 6.
• Self blood glucose monitoring is helpful before and after activity.
Exercise Guidelines For Diabetes

Cardiovascular Exercise: 1000 Resistance Exercise: 8-10 exercises
kcal/week involving the major muscle groups
Frequency >3 nonconsecutive days per week and up >2 days weekly
to 5 days
Intensity Low to moderate 1 set of 10-15 repetitions to near
40-70% VO2max, fatigue.
10-12 RPE*.
If nephropathy present, avoid activity
which produces BP >180-200 mm Hg;
later stages low intensity 50% VO2max
Duration 10-15 minutes initially.
>30 minute goal.
30-60 minutes for weight loss.
Mode Walking
Non-weight bearing if peripheral
neuropathy: swim, aquatic activity,
stationary cycle.
- 65 -
*RPE=Rating of Perceived Exertion
1. Kohl, H.W., Gordon, N.F., Villegas, J.A., et al (1992) Cardiorespiratory fitness, glycemic status, and
mortality risk in men. Diabetes Care 15:185-192
2. Treuth, M.S., Hunter, G.R., Keekes-Szabo, R.L., et al (1995) Reduction in intra-abdominal adipose
tissue after strength training in older women. J Appl Physiol 78:1425-1431.
Client Evaluation before Beginning an Exercise Program (ADA 1 , ACSM 2 )

Appraisal of glucose control (HgbA1C)
Analysis of joint limitations
Evaluation of medications and potential for hypoglycemia with activity
Type and severity of complications (nephropathy, retinopathy, peripheral neuropathy)
Exercise ECG to establish safe target heart rates in clients with known or suspected CAD,
>30 years of age with Type 1 DM, Type 1 > 15 years, or Type 2 > 35 years old..
1. ADA American Diabetes Association. The Health Professional's Guide to Diabetes and
Exercise.(1995) Ruderman, N., and Devlin, J., eds. Alexandria, VA: ADA, Inc.
2. ACSM Position Stand: Exercise and Type 2 DM(2000) Medicine & Science in Sports & Exercise
32(7):1345-1360.
- 66 -
16. Nutrition Assessment And Guidelines for Older Individuals
- 67 -
NHLBI Guidelines for Weight Reduction after Age 65
Considerations in Prescribing Weight Reduction after 65 years of Age
• Potential ability to increase functional status.
• Ability to reduce the risk of future CV events.
• Patient motivation.
• Cardiovascular (CV) risk factors are especially increased in older persons who are
overweight.
• Obesity is a major predictor of functional limitations and mobility impairments in this
group.
Factors in safe weight reduction

• Include skilled nutrition counseling to minimize the adverse effects on bone health
and overall nutritional status.
• Include expert instruction in moderate weight-bearing and resistance activity.
• Aim to preserve lean body mass and reduce fat mass.
Exercise for Older Adults

• By the year 2030, there will be >70 million people in the U.S. > 65 years; people >
85 years will be the fastest growing segment of the population.
• While increasing physical activity may not always improve markers of training,
improved health and functionality may occur. Improvements in glucose metabolism
may occur even before weight or body composition changes.
• VO2MAX decreases 5-15% per decade after age 25. Maintaining high levels of
exercise training can diminish declines in VO2MAX.
• Older adults demonstrate similar physiologic responses (increase 10-30% VO2MAX)
with prolonged endurance exercise training.
• Older adults demonstrate similar or superior strength gains with resistance training
compared to younger people. Two to three fold increases in strength may be
demonstrated in 3-4 months.
• Symptomatic and asymptomatic CV disease increases in prevalence with age;
absolute and relative contraindications to exercise testing and exercise training
should be noted (ACSM, 1995).
• Sport-specific exercise testing may be necessary, e.g., a weightlifting stress test
prior to initiating a resistance activity program.(Evans, 1995)
• Muscle mass declines with age: urinary creatinine, an indirect measure of muscle
mass, decreases 50% between ages 20 to 90.
• Reduction in muscle strength is typical with age. Strength decreases approximately
15% per decade in the 6th and 7th decade and 30% per decade thereafter. Most of
the strength loss is due to loss of mass.
- 68 -
• Adequate protein intake is necessary for successful resistance training. Protein
requirements for the elderly are 1.25 gm/kg. (Campbell, 1994) This is an amount of
protein consumption that is typically not consumed by the majority of elderly people.
• Muscle strength is directly related to gait speed and walking ability.
• Postural stability, implying little or no risk of the individual losing balance while
standing or falling during a dynamic activity, decreases with age.
• Aging causes physical changes of the collagen fibers, increasing the fibers diameter
and decreasing extendibility. Flexibility begins to decline in the third decade of life.
Benefits of Endurance Exercise and Strength Training in Healthy Older Adults

• Lower fasting and glucose-induced insulin levels; improved insulin sensitivity and
glucose tolerance.
• Decreases in blood pressure with light to moderate intensity endurance exercise
training.
• Improvements in lipid profiles: increased HDL and HDL2, decreased triglyceride and
Tchol: HDL ratio.
• Decreases in body fat 1-4% even without weight loss.
• Marked decreases in intraabdominal fat.
• Improvements in CV function and improvements in some CV risk factors with
moderate to intense training.
• Increased activity level and muscle mass will increase metabolic rate, which
normally declines with age. Meeting the increased need for kilocalories will increase
the total nutrient load and enhance the likelihood of meeting RDIs.
• Strength training helps maintain bone density, aerobic capacity, enhances insulin
sensitivity and nitrogen retention. Functional independence and strength are
increased. Improvements in dynamic balance may decrease fall risk and
osteoporotic fractures.
• Light-intensity exercise training and strength training help improve postural stability.
• Physical activity increases sense of self-efficacy and control. Normally, males
experience a greater sense of self-efficacy. However, with exercise training in
women, the gender bias disappears.
• Exercise in the frail and very old provides physiological, metabolic, psychological
and functional adaptations to physical activity, which contributes to quality of life.
Goals in this population are to minimize biological changes of aging, reverse disuse
syndromes, control chronic disease, maximize psychological well-being, and
increase mobility and function.
• “Sedentariness” appears a far more dangerous condition than physical activity in the
very old.”(ACSM, 1998) Most aerobic training programs in this population are
conducted at 60% of maximal predicted heart rate.
- 69 -
Major Absolute Contraindications to Exercise Testing
• Recent ECG changes or MI
• Unstable angina
• Uncontrolled arrythmias
• Third degree heart block
• Acute congestive heart failure
Major Relative Contraindications for Exercise Testing

• Elevated blood pressure
• Cardiomyopathies
• Valvular heart disease
• Complex ventricular ectopy
• Uncontrolled metabolic diseases
1. ACSM. Guidelines for Exercise Testing and Prescription, (1995) 5th ed. Baltimore: Williams and
Wilkins: 1-373
2. ACSM Position Stand: Exercise and Physical Activity for Older Adults. Medicine & Science in Sports
& Exercise 30(6): 992-1008.
3. North, T.C., McCullagh, P., Tran, Z.V. (1990) Effect of exercise on depression. Exercise Sport
Science Review 18:379-415.
4. Evans, W. (1995) Exercise and Aging, in eds. Ruderman, N. and Devlin, J.T., The Health
Professional’s Guide to Diabetes and Exercise. Virginia: American Diabetes Association: 223-232.
5. Campbell, WW, Crim, MC, Dallal, DE, Young, VR. (1994) Increased protein requirements in the
elderly: new data and retrospective reassessments. AJCN 60:167-175.
.
Recommendations for Training for Older Americans
• Cardiovascular: See ACSM recommendations (section 4). Programs of less
intensity or those combining briefer periods throughout the day may elicit health, but
not necessarily CV training benefits.
• Strength Training: See ACSM recommendations (section 4). Results occur at a
weight 60-100% of one Repetition Max (RM) defined as the maximal amount that can
be lifted with one contraction. Weights should be increased every 2-3 weeks until
goal is achieved.
• Postural Stability: Broad based exercise program that includes balance training,
resistive exercise, walking and weight transfer to reduce risk of falling. Frequency
and intensity remain to be determined.
• Flexibility: Include exercises that have been shown to increase range of motion:
walking,
• Aerobic Dance, And Stretching: Due to age-related declines in flexibility,
stretching pre and post-activity is increasingly important in order to decrease the
likelihood of orthopedic injury.
- 70 -
Recommendations For The Very Old And Frail
• Cardiovascular: Should follow strength and balance training. At least 3 days
weekly, at least 20 minutes, 40-60% heart rate reserve, or 11-13 rating of perceived
exertion on the Borg scale.
• Strength Training: Progressive resistance training of the major muscle groups of the
upper and lower extremities and the trunk: at least 2 but ideally 3 days per week, 2-3
sets on each training day. Include some standing postures with free weights.
• Postural Stability: Broad based exercise program that includes balance training,
resistive exercise, walking and weight transfer, to reduce risk of falling. Frequency
and intensity remain to be determined.
• Flexibility: Should include exercises that have been shown to increase range of
motion: walking, aerobic dance, and stretching.
Borg Perceived Exertion Scale

Rating of Perceived Exertion (RPE) Description
6
7 Very, very light
8
9 Very light
10
11 Fairly light
12
13 Somewhat hard
14
15 Hard
16
17 Very hard
18
19 Very, very hard
20
Borg, G.A. (1982) Med Sci Sports Exercise 14:377-387.
- 71 -
17. ACS Recommendations for Nutrition and Physical Activity for
Cancer Prevention
Eat a variety of healthful foods, with an emphasis on plant sources.

• Eat five or more servings of a variety of vegetables and fruits each day.
• Choose whole grains in preference to processed (refined) grains and sugars.
• Limit consumption of red meats, especially those high in fat and processed.
• Choose foods that maintain a healthful weight.
Adopt a physically active lifestyle.

• Adults: engage in at least moderate activity for 30 minutes or more on 5 or more
days of the week; 45 minutes or more of moderate to vigorous activity on 5 or
more days per week may further enhance reductions in the risk of breast and
colon cancer.
• Children and adolescents: engage in at least 60 minutes per day of moderate-to-
vigorous physical activity at least 5 days per week.
Maintain a healthful weight throughout life.

• Balance caloric intake with physical activity.
• Lose weight if currently overweight or obese.
If you drink alcoholic beverages, limit consumption.

http://www.cancer.org/docroot/PED/content/PED_3_2X_Recommendations.asp?sitearea=PED
18. Osteoporosis Prevention and Treatment Guidelines
Goals for Management of Bone Health

Group Goal Recommended
Daily Calcium
Intake
Females <30 Maximize mineral density in bone 1000 mg
Females 30-- Maintain bone mineral stores 1000 mg
menopause
Pregnancy Maintain bone mineral stores. Provide for 1000 mg
fetus.
Lactation Maintain bone mineral stores. Provide for 1000 mg
milk production.
Females post- Reduce mineral losses 1200 mg
menopause on
HRT
- 72 -
Females post- Reduce mineral losses 1500 mg
menopause, no
HRT
Males < 65 years Maximize and maintain mineral density in 1000 mg
bone
Males 65+ years Maximize and maintain mineral density in 1500 mg
bone
Dietary Reference Intake Values for Vitamin D1

Life Stage Group2 Criterion AI (ug/day)3,4,5
19-30 years Serum 25 (OH)D 5
>70 years Serum 25 (OH)D 15
Pregnancy and Lactation Serum 25 (OH)D 5
1. Food and Nutrition Board Institute of Medicine. Dietary Reference Intake. Washington: National
Academy Press, 1999.
2. All groups are male and female except pregnancy and lactation.
3. As cholecalciferol. 1ug cholecalciferol = 40 IU vitamin D
4. AI = Adequate Intake. The experimentally determined estimate of nutrient intake by a defined group
of healthy people. AI is used if the scientific evidence is not available to derive an Estimated Average
Requirement (EAR). Some seemingly healthy people may require higher vitamin D intakes to
minimize risk of low serum25(OH)D levels and some individuals may be at lower risk on low dietary
intakes of vitamin D.
5. In the absence of exposure to sunlight.
Defining Osteoporosis
• Definition (WHO)- osteoporosis is present when the T-score is at least minus 2.5
SDs below the mean for young, adult, white women.
• T-score- the number of SDs above or below the average bone mineral density
(BMD) value for young, healthy, white women.
• Z-score- number of SDs above or below the average BMD for age and gender-
matched controls.
• Measures at the hip provide the best assessment for risk of hip fracture while
measures at the spine predict spinal fracture risk.
- 73 -
Goals for Patient Evaluation
1. Establish the diagnosis of osteoporosis on the basis of bone mass assessment.
2. Determine the fracture risk.
3. Decide on the need for instituting therapy.
• Adequate calcium intake is generally obtained through inclusion of dairy products
in the diet. See section 24 for a list of calcium rich foods.
• Vitamin D is obtained through fortified fluid milk (not yogurt or cottage cheese)
and through conversion in the skin in the presence of sunlight. Vitamin D is also
known as the "sunshine vitamin" because the body manufactures the vitamin
after being exposed to sunshine. Ten to 15 minutes of sunshine 3 times weekly is
adequate to produce the body’s requirement of vitamin D.
• When lactose intolerance limits calcium intake, consider lactose-reduced,
prepared milk, e.g., LactaidR. Clients may prepare lactose-reduced milk using
Lactaid drops purchased in the pharmacy section of most supermarkets. Lactase
tablets (LactaidR) are available for concurrent consumption with high-lactose
foodstuffs: however, these may not be as effective as fully reduced products for
severely intolerant individuals.
• Calcium supplements are often reported to produce constipation. This may be
alleviated by increased fiber and water intake.
• Maintain a healthy body weight and muscle mass.
• Exercise helps to build strong bones and slow bone loss. Resistance exercise
increases protective tissue mass around the skeleton and strengthens the spinal
area. Muscle strength and bone mineral density are directly related. Weight
bearing exercise, e.g., running, walking, stair climbing, and impact sports,
strengthens bones in the legs, hips, and lower spine. Furthermore, exercise,
which increases balance, e.g., Tai Chi, yoga, helps to prevent falls.
• Female athletes may be at risk if kilocalorie and dairy product intake is low, and
amenorrhea is present.
• Smoking exacerbates bone loss, perhaps through alterations in estrogen
production or intestinal absorption.
• Discourage alcohol intake in excess of 2 alcoholic beverages daily.
• Consider hormone replacement therapy (HRT). HRT is the most effective way to
reduce osteoporosis risk during and after menopause. Physical activity can not
be recommended as a substitute for HRT at the time of menopause (1)
• Walking programs may not prevent bone loss in postmenopausal women. The
addition of higher intensity activity combined with muscle-building activity is more
effective. (1)
• Evaluate risk for osteoporosis if glucocorticoid therapy daily is used for greater
than 2 months, e.g., prednisone >5mg q.d.
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Pharmacologic Therapy
1. Biphosphonates: Prospective Randomized Clinical Trials (PRCTs) and meta-
analyses have shown that cyclic etidronate, alendronate and risedronate increase
BMD at the spine and hip while consistently reducing the risk of vertebral fractures.
Alendronate and risedronate reduce the risk on nonvertebral fractures in women with
osteoporosis and adults with glucocorticoid-induced osteoporosis.
2. Selective Estrogen Receptor Modulators (SERMs): maximize beneficial effects of
estrogen on bone and minimize/antagonize deleterious effects on the breast and
endometrium. Raloxifene, a SERM approved by the FDA for the treatment and
prevention of osteoporosis, has been shown to reduce the risks of vertebral fracture
by 36% in large clinical trials. Tamoxifen, used in the treatment and prevention of
breast cancer, can maintain bone mass in postmenopausal women. However,
effects on fracture are unclear (2).
1. American College of Sports Medicine (1995) ACSM Position Stand on Osteoporosis and
Exercise. Medicine & Science in Sports & Exercise 27(4):I-vii.
2. National Institutes of Health Consensus Development Conference Statement. Osteoporosis
Prevention, Diagnosis and Therapy. March 27-29, 2000.
19. Diet and Dental Health 1,2

Effects of Nutrition on Dental Health3
Nutrition has a systemic effect on the development, regeneration and repair of both hard
and soft tissues. These effects include:
• Topical and local effects on the maintenance of oral tissues.
• Tooth enamel is influenced by systemic nutrition prior to eruption and topically by
the diet after tooth eruption.
Sucrose and Dental Caries

• Increased sugar consumption results in increased caries incidence.
• Incidence of caries is increased when retentive/adherent sugar is consumed
between meals, e.g., candies, raisins and cooked starches such as cookies,
crackers, and potato chips.
• Amount of sugar in the diet is not as important as the frequency and form of
consumption.
• Caries evolution shows wide interpersonal variation.
• Cessation of caries-promoting agents will decrease activity although, new lesions
may continue to develop.
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Factors in Dental Health
Saliva:
• Contains calcium and phosphate to remineralize early dental lesions.
• A critical pH<5.7 is necessary for this process.
• Also contains immune factors that such as lysozyme, lactoferrin and secretory IgA.
• Constant flow of saliva removes cariogenic material from the mouth.
• Diseases (Sjogren's or cancer of the neck with radiation therapy) or drugs
(antihistamines, antidepressants, diuretics, ma huang, ephedra) that reduce saliva
production can increase caries risk. Increased water intake may help counter the
effect.
• Frequent use of sugar-free gum increases saliva production and increases the pH of
dental plaque to > normal.
Oral Hygiene
Although brushing and flossing remove foodstuffs and bacteria from the mouth, the
greatest benefit is the application of fluoride to the tooth surface.
Fluoride:
• Strengthens enamel by being incorporated into the enamel especially during
remineralization episodes to form fluoroapatite.
• Present in many water supplies, toothpaste, mouth rinse and many foods.
• High-concentration topical applications are available at the dental office.
• Availability of fluoride may be the main reason for declines in caries rates in the
U.S.
• Optimum fluoride exposure will not fully protect teeth from poor dietary practices
although, it may reduce the effects.
• Intake during both pre and post-eruptive development of teeth is cariostatic.
Sports Drinks:
• Prolonged use of sports drinks is associated with dental erosion in athletes.
Intermittent use of drinks and use of sugar free gum may reduce tooth erosion
and caries risk.
To Reduce Caries:
• Monitor food choices and the frequency of eating.
• Follow a sugary snack with an anticariogenic one such as sugar-free gum or a
cariostatic food such as milk to raise plaque pH.4
1. Mobley, C. (1998)Diet and Dental Health. Topics in Nutrition 7. Pennsylvania: Hershey Foods
Corporation.
2. Mobley, C., Saunders, M. (1997) Oral health screening guidelines for nondental health care
providers. J Am Diet Assoc 97(suppl 2):S123-S126.
- 76 -
3. Gustafsson, B.E., Quensel, C.E., Lanke, S.L., et al (1954) The Vipeholm dental caries study
Acta Odont Scand 11:232-364.
4. Higham, S.M., Edgar, W.M. (1989) Effects of parafilm and cheese chewing on human dental
plaque pH and metabolism. Caries Res 23:42-48.
- 77 -
20. The New Food Pyramid
The USDA has recently revised the food pyramid that has been used for decades by
health care professionals, nutritionists, teachers, and interventionists to yield a more
interactive and individually-suited version based on the 2005 Dietary Guidelines for
Americans and the Dietary Reference Intakes from the National Academy of Sciences.
The new pyramid goes far beyond the old pyramid by stressing activity, moderation,
personalization, proportionality, variety and gradual improvement.
The symbolism of the new pyramid emphasizes many key concepts. For example, the
figure climbing up the stairs represents individual motivation and the step-by-step
process to achieve greater health. From left to right, the
colors in order represent: grains, vegetables, fruits, oils,
milk, and meat and beans. Each colored section is
roughly proportional to the amount that each of these food
groups should be present in a healthy person’s diet. The
wide base of each colored section stands for foods with
little or no solid fats or added sugars, and the narrow top
area stands for foods containing more added sugars and
solid fats, emphasizing that everything is acceptable in
moderation in conjunction with physical activity.
The USDA has created a highly interactive website that provides an important resource
both for the general public and for professionals. By entering values for age, sex, and
activity level, individuals can obtain a
personalized dietary recommendation based on Dietary recommendation for 30
the values represented in the pyramid (see Table year old female with average
1), as well as useful tips on: how to incorporate activity level (2000 kcal diet)
each of the food groups into a daily diet, what ►Grains 6 ounces
foods belong to each group and which are the ►Vegetables 2.5 cups
most nutrient dense, how to maintain variety, and ►Fruits 2 cups
how to read food labels accurately to be able to ►Milk 3 cups
make informed decisions. In addition, the ►Meat & Beans 5.5 ounces
website gives professionals a ready-made
education framework that includes teaching tools, such as posters and daily food
tracking charts, and more in-depth information to help guide individuals to achieve and
maintain a healthy weight.
For more information, visit the website at: http://www.mypyramid.gov.
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21. U.S. Dietary Guidelines for Americans 2005 1
Adequate Nutrients Within Calorie Needs
Key Recommendations:
• Consume a variety of nutrient-dense foods and beverages within and among the
basic food groups while choosing foods that limit the intake of saturated and
trans fats, cholesterol, added sugars, salt, and alcohol.
• Meet recommended intakes within energy needs by adopting a balanced eating
pattern, such as the USDA Food Guide or the DASH Eating Plan.
Weight Management
• To maintain body weight in a healthy range, balance calories from foods and
beverages with calories expended.
• To prevent gradual weight gain over time, make small decreases in food and
beverage calories and increase physical activity.
Physical Activity
• Engage in regular physical activity and reduce sedentary activities to promote
health, psychological well-being, and a healthy body weight.
o To reduce the risk of chronic disease in adulthood: Engage in at least 30
minutes of moderate-intensity physical activity, above usual activity, at
work or home on most days of the week.
o For most people, greater health benefits can be obtained by engaging in
physical activity of more vigorous intensity or longer duration.
o To help manage body weight and prevent gradual, unhealthy body weight
gain in adulthood: Engage in approximately 60 minutes of moderate- to
vigorous-intensity activity on most days of the week while not exceeding
caloric intake requirements.
o To sustain weight loss in adulthood: Participate in at least 60 to 90
minutes of daily moderate-intensity physical activity while not exceeding
caloric intake requirements. Some people may need to consult with a
healthcare provider before participating in this level of activity.
• Achieve physical fitness by including cardiovascular conditioning, stretching
exercises for flexibility, and resistance exercises or calisthenics for muscle
strength and endurance.
Food Groups To Encourage

• Consume a sufficient amount of fruits and vegetables while staying within energy
needs. Two cups of fruit and 21/2 cups of vegetables per day are recommended
for a reference 2,000-calorie intake, with higher or lower amounts depending on
the calorie level.
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• Choose a variety of fruits and vegetables each day. In particular, select from all
five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and
other vegetables) several times a week.
• Consume 3 or more ounce-equivalents of whole-grain products per day, with the
rest of the recommended grains coming from enriched or whole-grain products.
In general, at least half the grains should come from whole grains.
• Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products.
Fats
• Consume less than 10 percent of calories from saturated fatty acids and less
than 300 mg/day of cholesterol, and keep trans fatty acid consumption as low as
possible.
• Keep total fat intake between 20 to 35 percent of calories, with most fats coming
from sources of polyunsaturated and monounsaturated fatty acids, such as fish,
nuts, and vegetable oils.
• When selecting and preparing meat, poultry, dry beans, and milk or milk
products, make choices that are lean, low-fat, or fat-free.
• Limit intake of fats and oils high in saturated and/or trans fatty acids, and choose
products low in such fats and oils.
Carbohydrates
• Choose fiber-rich fruits, vegetables, and whole grains often.
• Choose and prepare foods and beverages with little added sugars or caloric
sweeteners, such as amounts suggested by the USDA Food Guide and the
DASH Eating Plan.
• Reduce the incidence of dental caries by practicing good oral hygiene and
consuming sugar- and starch-containing foods and beverages less frequently.
Sodium And Potassium

• Consume less than 2,300 mg (approximately 1 tsp of salt) of sodium per day.
• Choose and prepare foods with little salt. At the same time, consume potassium-
rich foods, such as fruits and vegetables.
Alcoholic Beverages
• Those who choose to drink alcoholic beverages should do so sensibly and in
moderation—defined as the consumption of up to one drink per day for women
and up to two drinks per day for men.
• Alcoholic beverages should not be consumed by some individuals, including
those who cannot restrict their alcohol intake, women of childbearing age who
may become pregnant, pregnant and lactating women, children and adolescents,
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individuals taking medications that can interact with alcohol, and those with
specific medical conditions.
• Alcoholic beverages should be avoided by individuals engaging in activities that
require attention, skill, or coordination, such as driving or operating machinery.
Food Safety
• To avoid microbial foodborne illness:
o Clean hands, food contact surfaces, and fruits and vegetables. Meat and
poultry should not be washed or rinsed.
o Separate raw, cooked, and ready-to-eat foods while shopping, preparing,
or storing foods.
o Cook foods to a safe temperature to kill microorganisms.
o Chill (refrigerate) perishable food promptly and defrost foods properly.
o Avoid raw (unpasteurized) milk or any products made from unpasteurized
milk, raw or partially cooked eggs or foods containing raw eggs, raw or
undercooked meat and poultry, unpasteurized juices, and raw sprouts.
1. Executive Summary Issued by HHS-USDA

http://www.health.gov/dietaryguidelines/dga2005/document/html/executivesummary.htm
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22. Referral to a Dietitian
INDICATORS for REFERRAL to the REGISTERED DIETITIAN (R.D.)
for MEDICAL NUTRITION THERAPY
Disease or Indicators Medical Nutrition Therapy Nutrition Services Needed Number Total R.D.
Condition R.D. Visits Hours Needed to
Desired Impact Outcome
Total cholesterol > 200 Reduced fat, trans fatty acid, saturated fat Diet instruction, restaurant dining 2-3 2.5-3.0
Hyperlipidemia mg/dl, and cholesterol. Increased omega 3 and strategies, menu planning and
HDL < 40 mg/dl, monounsaturated fat. recipe modification >3 if Varies greatly
LDL > 130 mg/dl (or >100 if May reduce ETOH and CHO if weight loss with client.
>2 risk factors or known triglyceride high. needed Ongoing services
CVD) promote the
Triglyceride >150 mg/dl most favorable
outcomes.
Type 2 New diagnosis, new/changed Individual diet plan based on patient BG Diet instruction that includes Initial Initial
Diabetes medication regimen, frequent patterns, weight, activity, DM CHO control, restaurant dining 3-5 3-5
Mellitus hypoglycemic events, medications, lipid status and organ strategies, label reading, menu
HgbA1C > 7%, fasting BG function. Encourage consistent exercise. planning, recipe modification and Follow-up Follow-up
almost always >150 mg/dl, behavior change goals; drug- at least 1-2 1-2 hours
starting SBGM, greater than 2 nutrient advice, coordinating per year
years since MNT counseling, eating, exercise, and SBGM.
Hypertension >140/ 90 mm Hg for Low sodium diet (<2,400 mg) or DASH Diet instruction, restaurant dining 2 1-2
uncomplicated hypertension; diet. Encourage consistent exercise. strategies, menu planning and
lower goal for those with recipe modification, drug-nutrient >3 if Varies greatly
target organ damage or advice, behavioral modification. weight loss with client.
clinical CV disease; Decrease or eliminate ETOH. needed Ongoing services
<130/ 85 mm Hg for patients promote the
with diabetes most favorable
outcomes.
Obesity BMI > 25 Calorie controlled. Encourage consistent Diet instruction, restaurant dining >3 Varies greatly
or Waist > 35" female; > 40" exercise. strategies, menu planning and with client.
Overweight male recipe modification; drug-nutrient Ongoing services
advice, behavioral modification. promote the
most favorable
outcomes.
Osteoporosis Z-score below the average Nutritionally dense diet with adequate Diet instruction, menu planning 1 1-1.5
BMD for age and gender- calcium and vitamin D. Promote healthy and recipe modification; drug-
matched controls. body weight and muscle mass. Encourage nutrient advice, supplement
consistent weight bearing exercise. evaluation.
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23. Herbal Supplements
There has been a significant increase in the use of dietary supplements including
nutraceuticals over the past two decades. Nutraceuticals include all herbal medications,
medicinal foods, and vitamins. Most patients do not reveal their use of herbs to their
health care providers and often consider herbs to be non-harmful supplements.
Because of the potential for toxicity or drug-nutrient interactions, physicians should
include herbal supplements in the medical history and should document the patient's
use of these drugs. Patients who are scheduled for surgical procedures need to be
screened for the use of supplements in order to avoid anesthesia reactions or other
complications.
The more commonly used herbal supplements are listed in the following table along
with the intended use, possible side effects, and contraindications.
Supplement Intended Use/Dose Side Effects And Possible

Name Complications
Bilberry Treatment of diarrhea; improves circulation and No know toxicity or adverse
reduced platelet aggregation; vision - increased reactions.
regeneration of rhodopsin/240-480 mg TID.
Chamomile Digestive aid in inflammatory bowel disease; used Avoid taking if allergic to
topically for inflammatory skin conditions such as ragweed, asters and
eczema, insect bites, and poison ivy; mouthwash chrysanthemums.
for canker sores/taken as tea; topical cream of 3-
10% concentration.
Cranberry Treatment of urinary tract infections/300-400 mg Consume with ample fluids; not
extract BID. to be used as substitute for
antibiotic.
Echinacea Prevention and treatment of colds and flu - immune Allergies to flowers of the daisy
stimulating, improves migration of white blood cells family; autoimmune disorders;
to attack microorganisms in the bloodstream; used progressive systemic disorders
orally for vaginal yeast infections/900 mg per day such as MS and TB.
for 10-14 days
Evening Treatment of eczema, diabetic neuropathy, PMS No reported side effects.
Primrose Oil and cyclical breast pain/3-6 grams per day.
Feverfew Prevention of migraines; may also help Avoid with use of other
inflammatory diseases such as arthritis/ 250 mg migraine drugs; avoid in
parthenolide per day. pregnancy & lactation; avoid if
allergic to daisies.
Garlic Reduces cholesterol biosynthesis in liver; has mild Drug interaction with
blood pressure lowering effect; fights bacteria like anticoagulants.
an antibiotic - stimulates body's natural defenses;
antioxidant/600-900 mg per day BID/TID.
Ginkgo Potent antioxidant; improves circulation and Side effects include GI
Biloba reduces platelet aggregation; used for treatment of disturbances and headaches.
cerebrovascular insufficiency, intermittent
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claudication, diabetic peripheral neuropathy/120-
240 mg divided BID/TID.
Ginseng Enhance mental performance; boost energy levels; Avoid with high blood pressure;
(Panax stimulate the immune system/100 mg BID for 2-3 avoid use with caffeine; avoid
ginseng) weeks followed by 1-2 week rest period. during pregnancy & lactation;
may cause menstrual
abnormalities and breast
tenderness; may cause GI
upset.
Kava Kava Used as an antianxiety and "tension reducing" Side effects: yellowing of the
agent/ 200-300 mg QD. skin; allergic rash; drug-drug
interactions with barbiturates
and antidepressants.
Milk Thistle Treatment for liver disease, viral hepatitis, and May cause transient laxative
alcoholic liver disease/ 70-80% silymarin given 160 effect .
mg TID for 8 weeks
Saw Palmetto Treatment of benign prostatic hyperplasia/ 320 mg Mild gastrointestinal
of lipophilic extract per day. disturbances. Not to be used
as a treatment for prostate
cancer.
St. John's Treatment for mild depression; inhibits monoamine Increases sensitivity to sunlight;
Wort oxidase (MAO)/extract which provides 1 mg not to be used with prescription
hypericin per day. antidepressants; tyramine
restriction may be needed;
physicians' approval needed to
use during pregnancy &
lactation; drug interactions with
anticoagulants, oral
contraceptives, anti-seizure
meds, drugs to treat HIV or
prevent transplant rejection.
Valerian Treatment of insomnia/300-500 mg before bedtime; Very objectionable smell.
treatment of mild anxiety/150 mg AM and 300-500
mg PM.
Vitex Treatment of PMS, hot flashes, and menorrhagia. Not to be used during
pregnancy or with hormonal
replacement therapy.
Sources:
1.Clinical Nutrition Elective Lecture "Use of Herbal Supplements", Roberta Anding, M.S., R.D., CDE,
Department of Pediatrics and Adolescent Sports Medicine, Baylor College of Medicine;
2. Herbalgram.org, Altmed.od.nih.gov, Amfoundation.org/herbmed.htm
- 84 -
24. Food Sources of Common Nutrients
Nutrient Food Sources
Calcium Milk & milk products, sardines, clams, oysters, kale, turnip greens, mustard
green, tofu
Phosphorous Cheese, egg yolk, milk, meat, fish, poultry, whole grain cereals, legumes,
nuts
Magnesium Whole grain cereals, tofu, nuts, meat, milk, green vegetables, legumes,
chocolate
Sodium Table salt, seafood, animal foods, milk, eggs (in most foods except fruit)
Chloride Table salt, seafood, milk, meat, eggs
Potassium Fruit, milk, meat, cereals, vegetables, legumes
Sulfur Meat, fish, poultry, eggs, milk, cheese, legumes, nuts
Iron Liver, meat, egg yolk, legumes, whole or enriched grains, dark green
vegetables, dark molasses, shrimp, oysters
Zinc Oysters, shellfish, herring, liver, legumes, milk, wheat bran
Copper Liver, shellfish, whole grains, cherries, legumes, kidney, poultry, oysters,
chocolate, nuts
Molybdenum Legumes, cereal grains, dark green leafy vegetables, organs
Iodine Iodized table salt, seafood
Manganese Beet greens, blueberries, whole grains, nuts, legumes, fruit, tea
Fluoride Drinking water (1 ppm), tea, coffee, rice, soybeans, spinach, gelatin, onions,
lettuce
Cobalt Liver, kidney, oysters, clams, poultry, milk
Selenium Grains, onions, meats, milk, vegetables (depending on selenium content of
soil in which they were grown)
Chromium Corn oil, clams, whole grain cereals, meats, some drinking water
Vitamin A Liver, kidney, milk fat, fortified margarine, egg yolk, yellow and dark green
leafy vegetables, apricots, cantaloupe, peaches
Vitamin D Vit D milk, irradiated foods, some in milk fat, liver, egg yolk, salmon, tuna,
fish, sardines
Vitamin E Wheat germ, vegetable oils, green leafy vegetables, milk, fat, egg yolk, nuts
Vitamin K Liver, soybean oil, other vegetable oils, green leafy vegetables, wheat bran
Vitamin B1 Pork, liver, organ meats, legumes, whole grain and enriched cereals and
(Thiamin) breads, wheat germ, potatoes
Vitamin B2 Milk, dairy foods, organ meats, green leafy vegetables, enriched cereals and
(Riboflavin) breads, eggs
Niacin Fish, liver, meat, poultry, many grains, egg, peanuts, milk, legumes, enriched
- 85 -
grains and breads
Vitamin B6 Pork, glandular meats, cereal bran and germ, milk, egg yolk, oatmeal, and
(Pyridoxine) legumes
Folate Green leafy vegetables, organ meats (leafy), lean beef, wheat, eggs, fish, dry
beans, lentils, cowpeas, asparagus, broccoli, collards, yeast
Vitamin B12 Liver, kidney, milk and dairy foods, meat, eggs (vegans will need
(Cobalamin) supplements)
Pantothenate Present in all plant and animal foods. Eggs, kidney, liver, salmon and yeast
are best sources.
Biotin Liver, mushrooms, peanuts, yeast, milk, meat, egg yolk, most vegetables,
banana, grapefruit, tomato, watermelon and strawberries
Vitamin C Citrus fruit, tomato, melon, peppers, greens, raw cabbage, guava,
(Ascorbate) strawberries, pineapple, potato
Resources: 1998 Texas Dietetic Association (TDA) Manual for Medical Nutrition Therapy.
- 86 -
Food Sources of Calcium
Food Amount Calcium (mg)
Buttermilk 1 cup 285
Chocolate milk 1 cup 284
Evaporated skim milk 1 cup 368
Whole milk 1 cup 291
Skim or 1% milk 1 cup 300
Low fat, 2% milk 1 cup 297
Milk (dry nonfat) 2 Tbsp. 104
American cheese 1 oz 174
Bleu cheese 1 oz 150
Cheddar cheese 1 oz 204
Cheese food 1 oz 174
(American)
Cheese food (Swiss) 1 oz 205
Colby cheese 1 oz 194
Cottage cheese (2% low 1 cup 155
fat)
Monterrey cheese 1 oz 212
Mozzarella cheese 1 oz 207
Muenster cheese 1 oz 203
Ricotta (part skim) ½ cup 334
Swiss cheese 1 oz 272
Milkshake (vanilla) 10 oz 415
Ice cream 1 cup 176
Ice milk (soft serve) 1 cup 274
Yogurt (fruit, low fat) 1 cup 345
Yogurt (plain) 1 cup 240
Pudding (chocolate) ½ cup 133
Custard (baked) ½ cup 148
Oysters 7-9 oz 113
Salmon (with bones) 3 ½ oz 185
Sardines (with bones) 3 oz 382
Tofu (regular) 4 oz 130
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Pizza (cheese) ¼ of a 14-inch pie 332
Chili con carne with 1 cup 82
beans
Macaroni & cheese 1 cup 181
Mushroom soup made 1 cup 191
with milk
Tomato soup made 1 cup 168
with milk
Bokchoy (cooked) 1 cup 252
Broccoli (fresh, 1 cup 72
cooked)
Collards (cooked) 1 cup 220
Mustard greens (fresh, 1 cup 104
cooked)
Turnip greens (fresh, 1 cup 267
cooked)
Spinach (frozen, 1 cup 276
cooked)
Lima beans (cooked) 1 cup 55
Navy beans (cooked) 1 cup 95
Black-eyed peas 1 cup 43
(cooked)
Great northern beans 1 cup 90
(cooked)
Kidney beans (cooked) 1 cup 74
Almonds ½ cup 184
Sesame seeds ½ cup 83
Sunflower seeds ½ cup 87
Molasses, blackstrap 1 Tbsp. 137
Reference: 1998 TDA Manual for Medical Nutrition Therapy
- 88 -
Foods Sources of Iron
Food Amount Iron*
Beef (cooked regular 4 oz 2.1 mg
hamburger)
Steak 3 oz 2.6 mg
Ham (light cured) 3 oz 0.7 mg
Lamb chop 3 oz 1.7 mg
Fish sandwich with 1 1.8 mg
cheese
Pork (cooked, 3 oz 1.3 mg
shoulder)
Scallops 6 2.0 mg
Shrimp (fried) 3 oz 1.4 mg
Veal cutlet 3 oz 0.8 mg
Black beans (dry, ½ cup 2.45 mg
cooked)
Pork & beans (dry, ½ cup 2.5 mg
cooked)
Chick peas (dry, ½ cup 2.45 mg
cooked)
Chili con carne with 1 cup 4.3 mg
beans
Pizza (cheese) 1 slice 1.6 mg
Chicken breast 3 oz 0.9 mg
(cooked)
Tuna (in oil) 3 oz 1.6 mg
Tuna (in water) 3 oz 0.6 mg
Turkey (no skin, light & 3 oz 1.4 mg
dark meat)
Cashew nuts 1 oz 1.7 mg
Egg 2 medium 1.4 mg
Peanuts 1 oz 0.5 mg
Peanut butter 1 Tbsp. 0.3 mg
Mixed nuts (dry 1oz 1.0 mg
roasted)
Apple juice 1 cup 1.9 mg
- 89 -
Prune juice 1 cup 3.0 mg
Tomato juice 1 cup 1.4 mg
Beets (cooked) ½ cup 1.5 mg
Spinach (raw, chopped) 1 cup 1.5 mg
Spinach (cooked) 1 cup 6.4 mg
Turnip (cooked) 1 cup 0.3 mg
Greens 1 cup 1.3 mg
Peas (frozen, cooked) 1 cup 2.5 mg
Raisins 1 oz or 1½ Tbsp. 0.3 mg
Apricots (dried) ½ cup 3.0 mg
Strawberries (whole) 1 cup 0.6 mg
Molasses (blackstrap) 2 Tbsp. 10.1 mg
Instant oatmeal 1 packet 6.7 mg
Cream of wheat 1 cup 10.7 mg
(fortified)
Raisin Bran ¾ cup or 1 oz 3.5 mg
Bread (enriched) 1 slice 0.9 mg
Noodles (enriched, 1 cup 2.6 mg
cooked)
Corn chips 1 oz 0.5 mg
Tortilla 1 2.2 mg
*Consuming foods high in Vitamin C at the same time will assist in absorption of iron.
Reference: http://www.rochester.edu/student-srvcs/UHS/iron.htm (and this web site
referenced “Nutritive Value of Food. U.S. Department of Agriculture Bulletin #72 Washington,
D.C.”)
Food Sources of Fiber

Food Serving Size Fiber (grams)
High Fiber Cereals (5g ⅓ to ½ cup 5.0 – 13.0
or more fiber per
serving)
Lentils (cooked) ½ cup 7.8
Lima beans (cooked) ½ cup 6.6
Black beans (cooked) ½ cup 6.5
Kidney beans (cooked) ½ cup 5.7
Pistachios (dry roasted) ⅓ cup 4.7
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Peanuts (dry roasted) ⅓ cup 4.6
Green peas (frozen, ½ cup 4.4
cooked)
Barley (cooked) ½ cup 4.3
Raspberries (raw) ½ cup 4.2
Bran muffin 1 = 2 oz 4.0
Acorn squash (baked) ½ cup 3.4
Wheat bran 2 Tbsp. 3.2
Orange 1 medium 3.1
Apple (with skin) 1 medium 3.0
Pear (with skin) 1 medium 3.0
Broccoli (cooked) ½ cup 2.8
Spinach (cooked) ½ cup 2.7
Carrots (cooked) ½ cup 2.6
Banana 1 small 2.2
Dried fruit (mixed) 1 oz 2.2
Blueberries ½ cup 2.0
Oatmeal (cooked) ½ cup 2.0
Whole wheat bread 1 slice 2.0
Green beans (cooked) ½ cup 1.9
Brown rice ½ cup 1.8
Prunes (dried) 3 prunes 1.8
Figs (dried) 1 fig 1.7
Pumpernickel bread 1 slice 1.6
Raisins (seedless) ¼ cup 1.5
Oat bran bagel ½ large bagel 1.4
Reference: Nutrition in Clinical Care, (1999) Vol 2(3), 187-188.
- 91 -
The National Cancer Institute recommends 20 to 35 grams of fiber daily. Here is a
quick method for assessing daily total dietary fiber intakes. Serving size can be
determined from US Department of Agriculture data or food label. Add the sum of each
of the following:
Servings of fruit (not juice) x 1.5 grams = ____g.

Servings of vegetables x 1.5 grams = ____g.
Servings of refined grains x 1.0 gram = ___ g.
Servings of whole grains x 2.5 grams = ___ g.
Additional foods = ___ g.
Total = ____g.
Reference: 1998 TDA Manual for Medical Nutrition Therapy
- 92 -
Food Sources of Omega 3 Fatty Acid
Food Item Portion Size Grams of Omega-3
(ALA + EPA + DHA)*
Canola oil 1 Tablespoon 1.4
Flaxseed oil 1 Tablespoon 6.7
Flaxseeds 1 Tablespoon 2.63
Walnut oil 1 Tablespoon 1.3
Walnuts ¼ cup 3.4
Wheat germ oil 1 Tablespoon 0.86
Soybeans, cooked ¼ cup 1.05
Catfish 3.5 oz, raw 0.6
Cod 3.5 oz, raw 0.2
Haddock 3.5 oz, raw 0.2
Herring 3.5 oz 1.7
Sardines 3.5 oz 1.5
Salmon 3.5 oz 1.9
Scallops, sea 3.5 oz, raw 0.2
Shrimp, gulf 3.5 oz, raw 0.3
Swordfish 3.5 oz, raw 0.9
Tuna, albacore 3.5 oz, raw 2.1
Tuna, yellowfin 3.5 oz, raw 0.6
Omega-3 enriched eggs** 1 egg 0.4
*Alpha-linoleic acid (ALA) is the parent compound of the omega-3 fatty acid family. ALA is the
precursor to the long-chain fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA) and is an essential fatty acid for humans because it cannot be synthesized from dietary
precursors. The recommended daily allowance by the American Dietetic Association is 1.5-3.0
grams omega-3 fatty acids per day. Flaxseed is the richest source of ALA. ALA is also found
in the oils of canola, wheat germ, soybeans, and walnuts. Fish contain only small amounts of
ALA, although salmon, sardines, and herring are rich in EPA and DHA. Leafy greens contain
small amounts of ALA but their overall contribution to the diet is minimal.
**The increased ALA content of omega-3 fatty acids is achieved by feeding hens rations
containing flaxseed.
Mediterranean countries, e.g., Crete, have a high amount of omega-3 fatty acid in the
diet. This is thought to be a factor in reduced cardiovascular disease and cancer.
Whereas the ratio of omega-6: omega-3 fatty acid in the diet of Crete is 4:1, the
American diet is 16:1.
Sources:
1. A.P. Simopoulos and J. Robinson (1999) The Omega Diet, HarperCollins Publishers.
2. Flaxseed Council of Canada.
3. www.seafoodhandbook.com
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The Albert Einstein

Nutrition and Preventive

BMI = (703) x Weight (lbs)

Classification of Overweight and Obesity by BMI 1

2. Body Fat Percent Norms

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

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

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

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

Adult WAVE Assessment

*Certain pts may require assessment for underweight

1. Adult and Pediatric WAVE Information at http://www.aecom.yu.edu/nutrition/instrume.htm

2) To reduce the risk of chronic disease in adulthood: Engage in at least 30 minutes of

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

6) Achieve physical fitness by including cardiovascular conditioning, stretching

Key Recommendations for Specific Population Groups1

• Pregnant women: In the absence of medical or obstetric complications, incorporate 30

• Older adults: Participate in regular physical activity to reduce functional declines

1. US Department of Health and Human Services, US Department of Agriculture,

5. Fluid Guidelines for Exercise

1. Adequate hydration is essential to prevent dehydration and injury during exercise

Fluid Requirement During Prolonged Exercise and Competition1

Fluid Requirement 400-600 ml 500 ml 150-350 ml 150-350 ml

1. American College of Sports Medicine, American Dietetic Association and Dietitians

2. Commercial sports beverages contain 55-110 mg Na/Liter.

APPARENT HEAT STRESS RISK WITH PHYSICAL ACTVITY AND/OR

90 o - 105 o Heat cramps or heat exhaustion possible

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

130 o and up Heatstroke highly likely

Permission to reprint granted by Gatorade Sports Science Institute.

6. Carbohydrate Guides for Exercise

Carbohydrate (CHO) Requirement During Prolonged Exercise and Competition

Two Hours Immediately During Exercise Or After

Suggested Meal or snack, 30-60 gm If glycogen

7. Nutrient Composition of Common Sports Supplements

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

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

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

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

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

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

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

Power Gel 35 100 0 25 0 0 ** 1.51

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

Fluid Replacement Beverages

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

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

Body weight (lb) 120 140 180 220

Basketball, recreational 6.0 7.0 9.0 11.0

Bicycling (6 mph) 3.2 3.8 4.9 6.0

Bicycling (12 mph) 6.9 8.1 10.4 12.8

Bicycling (20 mph) 12.8 14.9 19.2 23.5

Dancing, moderate 3.8 4.5 5.7 7.0

Roller skating (9 mph) 5.1 5.9 7.6 9.4

6.0 8:35 10.2 11.9 15.4 18.8

Skiing, cross-country 7.8 9.2 11.9 14.5

Swimming (25 yds/min) 4.8 5.6 7.2 8.8

Swimming (50 yds/min) 8.5 9.9 12.8 15.6

Tennis, singles 6.0 7.0 9.0 11.1

Walking (20 min/mile) 3.3 3.8 4.9 6.0

Walking (15 min/mile) 5.1 5.9 7.6 9.4

Walking (12 min/mile) 6.5 7.7 9.8 12.0

Weight training 6.2 7.3 9.4 11.5