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Understanding Nutrition 13th Edition


Whitney Solutions Manual

Full download at link:

Solution Manual: https://testbankpack.com/

Test Bank: https://testbankpack.com/

Chapter 5 – The Lipids: Triglycerides, Phospholipids, and Sterols


Learning Objectives
After completing Chapter 5, the student will be able to:
5.1 Recognize the chemistry of fatty acids and triglycerides and differences between saturated and unsaturated
fats.
a. Describe the structure of a fatty acid and the effects of chain length and saturation on the properties of
the fat.
b. Describe the triglyceride.
c. List and describe the three types of fatty acids found in foods.
d. Explain the structure of the omega-3 and -6 fatty acids.
5.2 Describe the chemistry, food sources, and roles of phospholipids and sterols.
5.3 Summarize fat digestion, absorption, and transport.
a. Trace the digestion of lipids including identification of enzymes needed and the role of bile.
b. Describe the absorption of lipids into the intestine and the formation of the chylomicron.
c. Describe the role of the liver in the production of lipoproteins.
d. Explain the health implications of LDL and HDL and the factors that raise or lower levels of these
lipoproteins.
5.4 Outline the major roles of fats in the body, including a discussion of essential fatty acids and the omega
fatty acids.
a. Identify the uses of triglyceride in the body.
b. Identify the essential fatty acids and their role in the formation of eicosanoids.
5.5 Explain the relationships among saturated fat, trans fat, and cholesterol and chronic diseases, noting
recommendations.
5.6 Explain the relationships between monounsaturated and polyunsaturated fats and health, noting
recommendations.
5.7 Identify which fats support health and which impair it.
a. Name practical suggestions for food selections to replace saturated and trans fats with
monounsaturated and polyunsaturated fats.

Assignments and Other Instructional Materials


The following ready-to-use assignments are available in this chapter of the instructor’s manual:

© 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
76
• New! Case Study 5-1: Heart-Healthy Sandwich Choices
• Case Study 5-2: Heart-Healthy Diet Changes
• Worksheet 5-1: Trans Fat1
• Worksheet 5-2: Do You Know Your Fats?
• Worksheet 5-3: Check Your Lipid Choices2
• New! Worksheet 5-4: Chapter 5 Crossword Puzzle3
• Worksheet 5-5: Dietary Fat Recommendations (Internet Exercise)
• New! Critical thinking questions with answers
Other instructional materials in this chapter of the instructor’s manual include:
• Answer key for How To (pp. 152, 155, 156) activities and study card questions
• Classroom activities, featuring New! meal comparison activity (5-3)
• Worksheet answer keys (as appropriate)
• New! Handout 5-1: Chemical Structures of Acetic Acid and a Bile Acid
• Handout 5-2: How to Modify a Recipe—Lasagna4
• New! Handout 5-3: Butter and Margarine Labels Compared
• Handout 5-4: Cholesterol in Selected Foods
• New! Handout 5-5: Omega-3 Fatty Acid Content of Commonly Eaten Fish
• New! Handout 5-6: Potential Relationships among Dietary Saturated Fatty Acids, LDL Cholesterol, and Heart
Disease Risk
Visit the book’s instructor companion website to download:
• Handout 5-7: How to Use the Exchange System to Estimate Fat

Lecture Presentation Outline5


Key to instructor resource annotations (shown to the right of or below outline topics):
TRA = Transparency acetates: 13e = 13th edition, 12e = 12th edition, 11e = 11th edition, 10e = 10th edition
Website = Available for download from book companion website: HN = student handout
IM = Included in this instructor’s manual: CS = case study, WS = worksheet, CA = classroom activity

Introductory/whole chapter resources: Test Bank; IM WS 5-2, 5-4, CA 5-4

I. The Chemist’s View of Fatty Acids and Triglycerides


A. Fatty Acids – Explain fatty acids, including: IM HN 5-1
1. The Length of the Carbon Chain
a. Long-chain fatty acids.
b. Medium- and short-chain fatty acids
2. The Number of Double Bonds – Define and explain the following:
a. Saturated fatty acids 10e TRA 40
b. Unsaturated fatty acids
1. Monounsaturated fatty acids (MUFA) 10e TRA 41
2. Polyunsaturated fatty acids (PUFA) 10e TRA 42
a. Linoleic acid.
b. Linolenic acid
3. The Location of Double Bonds – The omega number (Figure 5-1) 10e TRA 43
a. Omega-3 fatty acid

1 Worksheets 5-1, 5-2, and 5-5 contributed by Daryle Wane.


2 Worksheet 5-3 and Handouts 5-1, 5-3, 5-4, 5-5, 5-6, and 5-7 contributed by Sharon Rady Rolfes
3 Contributed by Carrie King.
4 Source: Culinary Hearts Kitchen Course, Tallahassee, Florida, as taught by Sandra Woodruff, M.S., R.D., with

permission.
5 Contributed by Melissa Langone.

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77
b. Omega-6 fatty acid.
c. Omega-9 fatty acid .
B. Triglycerides – Lipids with three fatty acids attached to a glycerol (Figure 5-2 and 5-3) 10e TRA 44, 45
C. Characteristics of Solid Fats and Oils 12e TRA 10; 13e TRA 10
1. Firmness – Explain how the degree of unsaturation impacts firmness (Figure 5-4)
a. Saturated fats
b. Polyunsaturated fats.
c. Short versus long fatty acid chains (Figure 5-5)
2. Stability – Explain how the degree of unsaturation impacts stability
a. Saturated fat
b. Monounsaturated fat
c. Polyunsaturated fat
d. Protection from rancidity
3. Hydrogenation (Figure 5-6) 10e TRA 47
a. Protects against oxidation
b. Alters texture
4. Trans-Fatty Acids (Figure 5-7) 10e TRA 48; IM WS 5-1
a. Act like saturated fats in the body
b. Heart disease connection is being researched
c. Conjugated linoleic acid
II. The Chemist’s View of Phospholipids and Sterols
A. Phospholipids
1. Phospholipids in Foods 10e TRA 49
a. Define and explain phospholipids.
b Discuss food sources
2. Roles of Phospholipids
a. Explain the roles of phospholipids in transport and emulsification
b. Lecithin (Figure 5-8)
B. Sterols – A well-known sterol is cholesterol
1. Sterols in Foods – Discuss the food sources of the sterols 10e TRA 50; IM HN 5-4
2. Roles of Sterols – Explain the roles and metabolism of sterols, including: IM HN 5-1
a. Bile acids, sex hormones, adrenal hormones, and vitamin D
b. Cell membranes
c. Discuss liver production
d. Explain how sterols are involved in atherosclerosis
III. Digestion, Absorption, and Transport of Lipids
A. Lipid Digestion – Explain the process of lipid digestion in the following anatomical areas (Figure 5-11):
1. In the Mouth
2. In the Stomach
3. In the Small Intestine 10e TRA 51, 52
a. Cholecystokinin (CCK) (Figure 5-12)
b. Pancreatic and intestinal enzymes
c. Phospholipids are hydrolyzed (Figure 5-13)
d. Sterols are mostly absorbed as is
4. Bile’s Routes
a. Explain enterohepatic circulation (Figure 5-14)
b. Soluble fibers trap some bile
B. Lipid Absorption (Figure 5-15) 10e TRA 53
1. Glycerol and short- and medium-chain fatty acids
2. Monoglycerides and long-chain fatty acids
C. Lipid Transport – Transport is made possible by a group of vehicles known as lipoproteins
10e TRA 54, 55, 56; 12e TRA 11

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1. Chylomicrons (Figure 5-16)
a. Largest of the lipoproteins
b. Least dense
c. Get smaller as triglyceride portion is removed by the cells
2. VLDL (Very-Low-Density Lipoproteins)
a. Composed primarily of triglycerides
b. Made by the liver
c. Transport lipids to the tissues
d. Get smaller and more dense as triglyceride portion is removed
3. LDL (Low-Density Lipoproteins)
a. Composed primarily of cholesterol
b. Transport lipids to the tissues
4. HDL (High-Density Lipoproteins) (Figure 5-17)
a. Transport cholesterol from the cells to the liver
b. Have anti-inflammatory properties
5. Health Implications
a. High LDL is known as “bad” cholesterol
b. High HDL is known as “good” cholesterol
c. Factors that lower LDL and raise HDL
1. Weight control
2. Replace saturated fat with monounsaturated fat and polyunsaturated fat in the diet
3. Soluble fibers
4. Phytochemicals
5. Moderate alcohol consumption
6. Physical activity
d. Genes influence lipoprotein activity
IV. Lipids in the Body – Explain the roles of lipids in the body, including:
A. Roles of Triglycerides 10e TRA 57
1. A source of energy for the cells
2. Provide more energy than carbohydrates or proteins
3. Can be stored to an unlimited capacity in adipose tissue (Figure 5-18)
4. Adipose tissue secretes hormones (adipokines)
B. Essential Fatty Acids – Cannot be made by the body (Figure 5-19)
1. Linoleic Acid and the Omega-6 Family
a. Can make arachidonic acid, which is a conditionally essential fatty acid
b. Supplied by vegetable oils and meats
2. Linolenic Acid and the Omega-3 Family
a. Must be supplied by food
b. Can make EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid)
3. Eicosanoids
a. Made from arachidonic acid and EPA
b. Like hormones but have different effects on different cells
c. Include prostaglandins, thromboxanes, and leukotrienes
4. Omega-6 to Omega-3 Ratio – Experts disagree on the ideal ratio
5. Fatty Acid Deficiencies
a. Are rare in the U.S. and Canada
b. Occur in infants and children with fat-free or low-fat diets
C. A Preview of Lipid Metabolism
1. Storing Fat as Fat
a. Lipoprotein lipase (LPL) hydrolyzes triglycerides
b. Components reassembled into triglycerides for storage within adipocytes
2. Using Fat for Energy
a. Hormone-sensitive lipase dismantles triglycerides within adipocytes for release into the blood
b. Describe what occurs during fasting
c. Ketone bodies can be made from fat fragments

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79
V. Health Effects and Recommended Intakes of Saturated Fats, Trans Fats, and Cholesterol
A. Health Effects of Saturated Fats, Trans Fats, and Cholesterol
1. Blood lipid profile
a. Reveals concentrations of lipids in the blood
b. Desirable levels
1. Total cholesterol  200 mg/dL
2. LDL cholesterol  100 mg/dL
3. HDL cholesterol  60 mg/dL
4. Triglycerides  150 mg/dL
2. Heart Disease
a. Elevated blood cholesterol
b. Cholesterol accumulates in the arteries, restricts blood flow, and raises blood pressure
c. Saturated fat in the diet raises blood cholesterol
3. Cancer
a. Dietary fat has an association with risks for some types of cancer
b. May promote the growth of cancer
c. Some types of cancer have a stronger relationship to fat intake
4. Obesity – High fat intake combined with inactivity can lead to weight gain
B. Recommended Intakes of Saturated Fats, Trans Fats, and Cholesterol
1. The DRI and the 2010 Dietary Guidelines recommend fat at 20%-35% of energy intake (400-700
kcalories of a 2,000-kcalorie diet)
2. Also recommend 10% or less of energy intake from saturated fat, as little trans fat as possible, and 300
mg or less of cholesterol per day
3. Too little fat can be detrimental to health
VI. Health Effects and Recommended Intakes of Monounsaturated and Polyunsaturated Fats
A. Health Effects of Monounsaturated and Polyunsaturated Fats
1. Heart Disease IM CS 5-1, 5-2
a. Benefits from monounsaturated fats and polyunsaturated fats
1. Replacing saturated fat and trans fat with monounsaturated fat and polyunsaturated fat is the
most effective dietary strategy in preventing heart disease (example: Table 5-3)
2. Describe food sources of monounsaturated fat
3. Describe food sources of polyunsaturated fat
4. Describe food sources of omega-3 fats
b. Benefits from omega-3 fats – Beneficial effects in reducing risk of heart disease and stroke,
supporting the immune system, and defending against inflammation
2. Cancer – Omega-3 fats may be protective against certain types of cancer
3. Omega-3 Supplements – Discuss the potential benefits and risks
B. Recommended Intakes of Monounsaturated and Polyunsaturated Fats
1. AI have been established for linoleic and linolenic acids
2. AMDR: 5-10% kcal from linoleic acid, 0.6-1.2% kcal from linolenic acid
C. From Guidelines to Groceries IM WS 5-3, 5-5, HN 5-2, 5-3, 5-5, CA 5-1, 5-2, 5-3; Website HN 5-7
1. Protein Foods – Very lean and lean meats and meat alternates should be chosen
2. Milk and Milk Products – Choose fat-free and low-fat milks and milk products
3. Vegetables, Fruits, and Grains – Choose a wide variety of vegetables, fruits, and whole grains
4. Solid Fats and Oils – Avoid invisible fat from high-fat cheese and baked and fried foods
5. Read Food Labels – Choose wisely from many available food products
6. Fat Replacers
VII. Highlight: High-Fat Foods—Friend or Foe? IM HN 5-6
A. Guidelines for Fat Intake
1. It is recommended that individuals replace “bad” fats with “good” fats
2. Specific guidelines for reducing saturated fat, trans fat, and cholesterol
3. Specific guidelines for increasing monounsaturated and polyunsaturated fat

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80
B. High-Fat Foods and Heart Health 11e TRA 14
1. Cook with Olive Oil
a. Many health benefits
b. Still provides 9 kcal/gram
2. Nibble on Nuts
a. Many health benefits
b. Still a high-kcalorie food
3. Feast on Fish
a. Rich in long-chain omega-3 polyunsaturated fatty acids
b. Mercury caution for pregnant and lactating women and young children
C. High-Fat Foods and Heart Disease
1. Limit Fatty Meats, Whole-Milk Products, and Tropical Oils
a. Read food labels to determine those lowest in saturated fat
b. Choose leaner and lower-fat animal foods
2. Limit Hydrogenated Foods
a. Contain trans fats
b. Watch convenience foods
D. The Mediterranean Diet 13e TRA 11
1. Links with good health but may not be the only factor
2. Discuss foods included in this diet
E. Conclusion
1. Saturated fat and trans fat are poor for heart health
2. Unsaturated fat in moderation is good for heart health
3. Food is a mixture of good and bad fat
4. Manufacturers are complying with consumer requests
5. Try Mediterranean eating habits

Case Studies6
Case 5-1: Heart-Healthy Sandwich Choices
Tom H. is a 35-year-old single man who works in a warehouse and takes his lunch to work every day. He is 69
inches tall and weighs 190 pounds. A recent blood test revealed that Tom’s total and LDL cholesterol levels are
abnormally high. He has been instructed to reduce his intake of saturated fat and to eat more unsaturated fats. He is
now at the grocery store looking for sandwich foods to pack in his lunches this week. He notes the following
information on the Nutrition Facts labels:
Canned salmon without bones or skin: 2 oz, Calories 60, total fat 0.5 grams, saturated fat 0 grams, trans fat 0
grams, cholesterol 20 milligrams, protein 13 grams.
Cheddar cheese: 1 oz, Calories 110, total fat 9 grams, saturated fat 5 grams, trans fat 0 grams, cholesterol 30
milligrams, protein 7 grams.
Lite Havarti cheese: 1 oz, Calories 80, total fat 4 grams, saturated fat 3 grams, trans fat 0 grams, cholesterol 15
milligrams, protein 8 grams.
Pepperoni: 10 slices, Calories 130, total fat 11 grams, saturated fat 4.5 grams, trans fat 0 grams, cholesterol 30
milligrams, protein 7 gram.
Peanut butter: 2 T, Calories 200, total fat 15 grams, saturated fat 3 grams, trans fat 0 grams, cholesterol 0
milligrams, protein 9 grams.
Egg: 1 whole, Calories 80, total fat 5 grams, saturated fat 1.5 grams, trans fat 0 grams, cholesterol 200 milligrams,
protein 7 grams.
Sliced deli roast beef: 2 oz, Calories 80, total fat 2 grams, saturated fat 0.5 grams, trans fat 0 grams, cholesterol 25
milligrams, protein 13 grams.

6 Contributed by Barbara Quinn.

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1. What should Tom notice about the cholesterol content of these foods?
2. Even though eggs are a significant source of cholesterol, what other information on the nutrition label should
Tom consider if he decides to buy eggs?
3. Which of the foods being considered by Tom most likely contains more unsaturated fats than saturated fats?
How can Tom derive this information from the information on the label?
4. What should Tom notice about the relationship between total fat content and kcalories in these foods?
5. What two foods listed here are major sources of saturated fat? What strategies might Tom use if he wants to
include them in his diet?
6. Using some or all of these foods plus other ideas from the “How to” feature in this chapter (p. 152), plan one
week (5 days) of sandwich ideas for Tom that are in line with his diet goals.

Answer Key
1. Cholesterol is only found in animal-based foods; there is no cholesterol in plant-based foods. Eggs are high in
cholesterol.
2. Eggs are low in saturated fat and a good source of protein; they should be eaten in moderation.
3. Salmon, peanut butter. Unsaturated fats can be estimated by subtracting saturated and trans fats from total fat
content. For example, salmon contains 0.5 g total fat, 0 g saturated fat, and 0 g trans fat. Tom can assume the
0.5 gram (500 milligrams) represents polyunsaturated and/or monounsaturated fats. Omega-3 fatty acids (such
as those found in salmon) are polyunsaturated fats.
4. A food that is higher in total fat is usually higher in kcalories as well.
5. Pepperoni and cheese. Answers will vary, but may include eating these foods less often and in smaller amounts,
or having them accompany low-fat foods in a meal.
6. Answers will vary and may include ideas for combining these options with vegetables, low-fat breads, and
lower-fat mayonnaise or other spreads.

Case Study 5-2: Heart-Healthy Diet Changes


Dave is a 46-year-old attorney with a family history of heart disease (his father had a heart attack at the age of 56)
whose recent blood tests reveal high blood LDL cholesterol and triglyceride levels. His doctor has advised him to
eat less fat in his diet. Dave is a self-confessed “foodie” and he enjoys wine and cheese at several social functions
each week. He cooks with “real” butter at home and uses half milk and half cream in his coffee. Although fairly
inactive, Dave keeps his weight stable at 170 pounds. He is 5 feet 10 inches tall.

1. What factors may be contributing to Dave’s elevated cholesterol and triglyceride levels?
2. From the history given, identify the main sources of saturated fat in Dave’s diet. What are some reasonable
changes he could make to lower his intake of saturated fat from these foods?
3. Assume Dave eats about 2000 kcalories a day and that his doctor has advised him to limit his fat intake to 35
percent of his daily kcalories. Refer to the “How to” feature (p. 155) of this chapter to calculate his personal
Daily Value for fat.
4. According to the 2010 Dietary Guidelines for Americans, what is the maximum percentage of kcalories from
saturated fat that Dave should consume each day? Remembering that 1 gram of fat contains 9 kcalories,
calculate the maximum grams of saturated fat that Dave should eat each day based on his daily intake of 2000
kcalories.
5. Using information from Highlight 5, what additional advice would you offer Dave to improve his heart health?
6. Plan a one-day menu for Dave with higher amounts of healthful fatty acids and lower amounts of harmful fatty
acids.

Answer Key
1. Genetics (family history), excess alcohol consumption, diet high in saturated fat, inactivity.
2. Whole milk, cream, butter, and cheese. Replace saturated fats with unsaturated fat (refer to Table 5-3); i.e., use
olive oil in cooking in place of butter, replace cheese with nuts and fruit, use low-fat milk in coffee. Eat foods
high in saturated fat in smaller portions or less often.
3. 2000 kcal/day  0.35 = 700 kcalories ÷ 9 kcalories per gram = 78 grams of fat per day.

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4. Less than 10% of kcalories from saturated fat. 2000 kcal  0.10 = 200 kcal / 9 kcal per gram = 22 grams of
saturated fat per day.
5. Answers will vary and include: increase intake of fish, nuts, and olive oil in place of high-fat meats and dairy
foods; moderate alcohol intake; increase physical activity; and emphasize Mediterranean diet guidelines.
6. Answers will vary. Refer to Table H5-1 for examples of foods to include and avoid/limit in the meal plan.

Suggested Classroom Activities


Remember that, while they’re familiar to you, to a new student words such as glycerol, triglyceride, and lipoprotein
are a jumble of unfamiliar new terms. It takes time to assimilate this new information. It helps to define the terms
repeatedly as you lecture. To sustain motivation, interject information relevant to students and their personal lives.
Relate lipids to heart disease, cancer, obesity, and other subjects.

Classroom Activity 5-1: Compare Energy Values of Food Prepared by Different Techniques
Key concept: Effect of food preparation method on fat content Class size: Any
Instructions: Instruct students to calculate and compare the kcalories in a baked, broiled, or steamed food versus the
same food after frying. Use the table of nutrient composition of foods and fast foods in the appropriate appendix of
the textbook.

Classroom Activity 5-2: How to Modify a Recipe7


Key concept: Strategies for cutting fat in recipe Class size: Any
Materials needed: A copy of Handout 5-1 for each student
Instructions: Recipes can be modified to retain flavor and texture while the fat content is reduced during food
preparation. Provide students with a copy of Handout 5-1 (How to Modify a Recipe—Lasagna). Discuss the items
substituted for fat. Instruct students to bring in their own traditional recipes and practice modifying them according
to these suggestions. You can even designate a day for students to bring in food items they prepared from a modified
recipe.

Classroom Activity 5-3: Fat in a Fast Lunch (Meal Comparison)8


Key concept: Applying fat recommendations to food choices Class size: Any
Instructions: Present the three quick lunch meal plans below to students and use the discussion questions to prompt
them to evaluate the plans.
Lunch #1 – Taco Bell Lunch #2 – Subway Lunch #3 – Prepared at home
Gordita Supreme® – beef, 1 item Subway Club, with American Bread, whole-wheat, 2 slices
Nachos Bell Grande, 1 item cheese, 12-inch, no sauce, Peanut butter, chunky, 2 Tbsp
Mountain Dew, 30 ounces vegetables Jam, 1 Tbsp
Bottled water Yogurt, low-fat, 1 cup
Grapes, 1 cup
Baby carrots, 1 cup

Discussion questions:
1. What are the recommended maximum intakes for an adult for fat, saturated fat, cholesterol and sodium? How
do these three lunch options fit within the recommendations?
2. Which lunch meal plan most represents the recommendations in the DASH diet plan? Why?
3. Which lunch is the highest in unsaturated fats?
4. How could you increase the omega-3 fatty acids in one of the lunches?
5. How could you improve the lunches from the fast food restaurants?
Answer key:
1. Daily Values: 65 g fat (based on 30% of 2000-kcal diet), 20 g saturated fat (based on 10% of 2000-kcal diet),
300 mg cholesterol; DRI: 1500 mg sodium. Compare and contrast the three lunch meal plans.

7 Activity provided by: Sandra Woodruff, M.S., R.D.


8
Contributed by Carrie King

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83
2. Lunch #3. This meal plan contains yogurt, fruit, vegetables, and whole grains and is lowest in sodium.
3. Lunch #3 due to the peanut butter.
4. Order a tuna sandwich at Subway or make one at home.
5. Answers will vary. Possible answers include: skip the cheese on the Subway sandwich to save 400 mg sodium;
order two crunchy tacos at Taco Bell (340 kcalories, 10 grams total fat, 7 grams saturated fat, 50 mg
cholesterol, 580 mg sodium) and drink water.
Nutrient composition of meals for instructor reference:
Lunch #1 Menu Item Cal Fat SF CH Na
Gordita Supreme® – beef, 1 item 300 14 5 30 550
Nachos Bell Grande, 1 item 770 42 7 30 1020
Mountain Dew, 30 ounces 410 0 0 0 115
Totals 1480 56 12 60 1685

Lunch #2 Menu Item Cal Fat SF CH Na


Subway Club, with American cheese, 12-inch, no sauce, 700 16 7 100 2120
vegetables
Bottled water 0 0 0 0 0
Totals 700 16 7 100 2120

Lunch #3 Menu Item Cal Fat SF CH Na


Bread, whole-wheat, 2 slices 138 2 0.4 0 265
Peanut butter, chunky, 2 Tbsp 188 7.7 2.4 0 156
Jam, 1 Tbsp 56 0 0 0 6
Yogurt, low-fat, 1 cup 154 4 2.5 15 172
Grapes, 1 cup 67 0.4 0.1 0 2
Baby carrots, 1 cup 30 0.1 0 0 66
Totals 633 14.2 5.4 15 667

Key: Cal = kcalories, Fat = total fat (grams), SF = saturated fat (grams), CH = cholesterol (milligrams), Na = sodium
(milligrams)

Classroom Activity 5-4: Discussion of Changing Guidelines for Fat Intake


Object: Exploring beliefs about fat Class size: Any
Instructions: Before students read this chapter, ask them to write on a sheet of paper their beliefs about fat intake
recommendations. Instruct them to be as specific as possible. Give them 5-10 minutes to complete this exercise.
Then ask each student to share what they believe and compile a list. You can tell them that this chapter explores the
basis for intake recommendations and can talk about the challenge of presenting nutrition information to the public.

How To “Try It” Activities Answer Key


How to Make Heart-Healthy Choices—by Food Group9
Type of milk (1 cup) Whole Reduced-fat Low-fat Nonfat
Total kcal 149 122 102 83
Fat (g) 7.98 4.83 2.37 0.20
% kcal from fat 48% 36% 21% 2%

How to Calculate a Personal Daily Value from Fat


58 g fat per day

How to Understand “% Daily Value” and “% kCalories from Fat”

9Based on values from the USDA Nutrient Data Library


(http://www.nal.usda.gov/fnic/foodcomp/search/index.html).

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%DV for fat = 6%; % kcal from fat = 31%

Study Card 5 Answer Key


1. Three classes of lipids are triglycerides, phospholipids, and sterols. In the body, fats (triglycerides) function to
provide energy, insulate the body, protect against physical shock, serve as part of cell membranes, and
participate in cell signaling. In foods, fats serve as a vehicle for fat-soluble vitamins and many compounds that
give foods their flavor, texture, and palatability.
2. All fatty acids have the same basic structure—a chain of carbon and hydrogen atoms with an acid group
(COOH) at one end and a methyl group (CH3) at the other end. Fatty acids differ from one another in the length
of their carbon chains and in the number and location of their double bonds.
3. Chemists identify polyunsaturated fatty acids by the position of the double bond closest to the methyl (CH 3) end
of the carbon chain, which is described by an omega number. Polyunsaturated fatty acids with the closest
double bond three carbons away and six carbons away from the methyl end are omega-3 and omega-6 fatty
acids, respectively. Regular consumption of omega-3 fatty acids helps to prevent blood clots, protect against
irregular heartbeats, improve blood lipids, and lower blood pressure, especially in people with hypertension or
atherosclerosis. In addition, omega–3 fatty acids support a healthy immune system and suppress inflammation.
The omega-3 fatty acids of fatty fish may protect against some cancers as well, perhaps by suppressing
inflammation. Omega-6 fatty acids protect heart health by lowering LDL cholesterol and improving insulin
resistance.
4. A triglyceride consists of a glycerol (a 3-C alcohol) molecule bonded to 3 fatty acids.
5. The hydrogenation process modifies unsaturated fats by adding H atoms to them, eliminating some or all of the
double bonds between C atoms and producing a more saturated fat. Most often, a fat is partially hydrogenated,
and some of the double bonds that remain after processing change their configuration from cis to trans. A trans
fatty acid is one in which the Hs next to the double bonds are on opposite sides of the C chain, rather than on
the same side as in the cis form. In the body, trans-fatty behave more like saturated fats, increasing blood
cholesterol and the risk of heart disease.
6. c 7. c 8. d 9. c
10. Lipoproteins are clusters of lipids associated with proteins that serve as transport vehicles for lipids in the
lymph and blood. They allow fat-soluble compounds to travel within watery body fluids. The lipoproteins differ
in size, composition, density, origin, and function. They rank this way from largest/least dense to smallest/most
dense: chylomicrons, VLDL, LDL, and HDL. The greater the ratio of lipid content to protein content, the lower
the density of the lipoprotein. Chylomicrons and VLDL are particularly rich in triglycerides, and LDL has a
higher proportion of cholesterol. Chylomicrons are produced in intestinal cells, whereas VLDL and HDL are
produced in the liver, and LDL develop from VLDL within the blood as the latter’s triglycerides are removed
by cells and the cholesterol concentration of the particle increases. All except HDL function to deliver lipids to
body cells; HDL functions to return cholesterol from other body cells to the liver.
11. d 12. b 13. a 14. d
15. Because foods made with solid fats provide abundant energy, but few if any essential nutrients, they contribute
to weight gain and make it difficult to meet nutrient needs. Solid fats also provide abundant saturated fat, trans
fat, and cholesterol. Even without overweight or obesity, high intakes of solid fats increase the risk of some
chronic diseases. Elevated LDL cholesterol is a major risk factor for cardiovascular disease (CVD). Saturated
fats are most often implicated in raising LDL cholesterol. In general, the more saturated fat in the diet, the more
LDL cholesterol in the blood. Trans-fats alter blood cholesterol the same way some saturated fats do: they raise
LDL cholesterol and, at high intakes, lower HDL cholesterol. Replacing saturated fats with unsaturated fats
reduces LDL cholesterol and lowers the risk of heart disease.
16. The DRI and Dietary Guidelines suggest a diet that provides 20-35% of the daily energy intake from fat, less
than 10% of daily energy intake from saturated fat, as little trans fat as possible, and less than 300 milligrams
cholesterol. To reduce total dietary fat, eliminate fat as a seasoning and in cooking; remove the fat from high-fat
foods; replace high-fat foods with low-fat alternatives; and emphasize whole grains, fruits, and vegetables. To
reduce saturated fat intake, replace saturated with unsaturated fats: e.g., sauté foods in olive oil instead of butter,

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garnish salads with sunflower seeds instead of bacon, snack on mixed nuts instead of potato chips, use avocado
instead of cheese on a sandwich, and eat salmon instead of steak. To reduce cholesterol intake, replace animal-
derived with plant-derived foods.
17. c
18. Foods high in saturated fats include: whole milk, cream, butter, cheese, and ice cream; fatty cuts of beef and
pork; and coconut, palm, and palm kernel oils (the tropical oils and products containing them such as candies,
pastries, pies, doughnuts, and cookies). Foods high in unsaturated fats include: olive oil, canola oil, peanut oil,
safflower oil, and avocados (monounsaturated); and vegetable oils (sesame, soy, corn, sunflower), nuts, and
seeds (polyunsatured).
19. The Daily Value for fat for a 2000-kcal diet is 65 g—equivalent to 30% of kcal from fat.
20. b

Critical Thinking Questions10


1. Discuss how the structural/chemical properties of a fat affect its physical characteristics and stability.
2. Much attention has been placed on the negative association between trans fat intake and health/well-being.
Many states have gone so far as to literally ban trans fat from foods served in restaurants. Food labels are now
required to list the amount of trans fat on the label, but the majority of foods are now marketed as being free of
trans fat. Considering this, respond to the following questions: (1) Do you think that banning trans fat would
eliminate health damage from fat intake? (2) Can we assume that a food described on the label as trans fat free
contains no trans fat? (3) Does trans fat occur naturally in the diet independent of food processing?
3. Cholesterol has been linked to heart disease such that consumers recognize and try to limit their daily intake.
Can an individual live without ingesting cholesterol?
4. Explain how the concept of conditionally essential nutrients can be applied to lipid consumption.
5. Many consumers focus their selection process on choosing foods that are fat free and/or low in fat. Why has this
dietary choice not made much of a difference for most individuals, as indicated by present weight gaining trends
in the United States and other parts of the world?
6. What methods can the individual consumer use to adhere to the recommendations of less than 10% of
kilocalories from saturated fat and less than 300 milligrams of cholesterol per day on a long-term basis?

Answer Key
1. The structural design of lipids plays a key role in the presentation of physical characteristics and stability. Even
though fatty acids all have the same basic framework—long carbon chains inclusive of hydrogen with a methyl
group at one end and an acid at the other end—the arrangement and positioning of their atoms provides the
basis for differentiation. The length of the C chain and number/positioning of double bonds (if present) affect a
fat’s physical characteristics and stability. A point of unsaturation identifies the presence of a double bond.
Carbon within molecules requires four points of connection (single bonds) with other atoms. Carbons with four
single bonds (two of them with hydrogens) are described as saturated. If in a fatty acid there is a double bond
present, there are still four points of connection per carbon (one double bond, which counts as two, plus two
single bonds) but now the fat is considered to be unsaturated. The presence of two or more double bonds defines
a polyunsaturated fatty acid. The specific location of the first double bond also influences the physical
characteristics of the fatty acid. These different chemical arrangements lead to differences in physical
characteristics such that saturated fats are typically solid at room temperature whereas unsaturated fats are
typically liquid at room temperature. Additionally, stability is affected by the saturation characteristics of fats.
Saturated fats are more stable as compared to unsaturated fats due to the lack of double bonds, which are
vulnerable to oxidation. The effects of oxidation (e.g., rancidity) are greater with unsaturated fats.
2. An interesting dilemma is posed by the banning of trans fat in many parts of the United States. On one side is
the idea that this protects consumers from a food component identified as a significant risk factor for the

10 Contributed by Daryle Wane.

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86
development of chronic diseases such as heart disease and diabetes. On the other side of the discussion is the
idea that no one food component should be viewed as being exclusively bad since fats are needed both as
essential and non-essential nutrients. The key concern here is the amount of consumption of a specific fat
product such as trans fat in the American diet. What the average consumer fails to understand is that trans fat
occurs naturally in certain animal foods. Thus, it probably is impossible to eradicate all trans fat from an
omnivorous diet. It is not just trans fat consumption but also the quantities of saturated fats in the American diet
that have led to health concerns.
With regard to food labeling, according to federal law a food may be described on the package as being free of
certain nutrients, including trans fat, when up to 0.5 gram of the substance is present. Processing methods
(hydrogenation) of food products commonly results in the presence of trans fat in foods. It is therefore difficult
to restrict all foods that are hydrogenated from one’s daily diet without eliminating fast and processed foods.
Lastly, the independent intake of multiple food products throughout the day that are labeled as trans fat free but
actually contain small amounts, when combined, will provide a significant trans fat intake.
Although considerable attention is focused on the adverse effects of manufactured trans fat in the diet, a small
amount of trans fat is found naturally in animal food sources. Clinical research notes that this type of “natural”
trans fat likely does not have the same adverse effects as the manufactured version
(http://natamcancer.org/handouts/Gov-AHA_PDF_prev_earlydetection/TransFatFactSheet.pdf).
3. Cholesterol is a sterol substance that is manufactured in the body (endogenous) as well as outside of the body
(exogenous). Cholesterol is used to produce several key hormones and chemical substances in the body such as
vitamin D, bile acids, and sex and adrenal hormones. Cholesterol synthesis occurs in the liver, but cholesterol is
a constituent of all cells in the body. Thus, it would be naïve at best to think that one could live without
cholesterol. However, you can live without ingesting cholesterol, because when you do not take it in from
dietary sources, it is manufactured in the body. Additionally, as a result of genetic design, certain individuals
may have altered cholesterol synthesis patterns, leading to increased levels regardless of dietary intake.
Cholesterol has both beneficial actions in regard to the body as with the formation of key hormones and
negative actions based on accumulation of plaque in the endothelial capillary linings.
4. Conditionally essential nutrients are non-essential nutrients that become required nutrients as a result of specific
circumstances that exist in the body. This can occur as a result of growth, stress, and/or other medical
conditions wherein dietary intake of certain nutrients becomes critical to sustain growth and chemical balance.
In the case of lipid consumption, linoleic acid (an omega-6 fatty acid) is an essential nutrient that can be used in
the body to form other chemical compounds such as arachidonic acid and derivatives of omega-6 fatty acids.
Deficiencies in linoleic acid could lead to a situation in which arachidonic acid as well as omega-6 fatty acid
derivatives become conditionally essential to the body. These substances then will help make up for the lack of
their precursor, linoleic acid, in the body so that its functionality can be maintained.
5. Even though consumers are more aware of food option choices such as fat free or low in fat, the marketed
product often contains other “hidden” components that influence weight gaining trends. For example, most
processed food items have additional preservatives that besides adding to texture and stability can influence the
type and amount of provided nutrients. Foods that are low in fat and/or fat free often have increased caloric
values. It is important to compare product food labels (fat free and/or low fat versus the traditional food) to see
if one is really getting more or less of nutrients and calories. There is often a trade-off in these food
comparisons whereby fat is exchanged for carbohydrates, resulting in a no-win situation for the consumer. Less
fat and more calories lead to potential weight gain.
6. In order to minimize intake of saturated fats, one should restrict/limit the intake of animal foods containing solid
fats. Staying away from processed food selections will help to decrease intake of saturated and trans fats.
Including whole, fresh plant foods on a daily basis will be beneficial. It is important to consider not only dietary
planning and menu selection but also how exercise and activity can affect nutrient metabolism. Planning meals
in advance may help to balance individual dietary selections. An individual’s food consumption can vary day to
day, so if a person places attention on several days, she/he is more likely to make better overall food choices.
Reading of food labels along with awareness of food consumption both inside and outside of the home will lead
to better outcomes. It is the totality of the diet that affects an individual’s health and well-being over the long
term.

IM Worksheet Answer Key

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87

Worksheet 5-1: Trans Fat


1. To help consumers identify which foods contain trans fats, so that they can limit their intake of this type of fat
through their food choices.
2. The term trans refers to a type of double bond within a fatty acid in which the hydrogen atoms adjacent to the
double bond are on opposite sides of the carbon chain.
3. During the hydrogenation process, which is used to solidify liquid vegetable oils and make them more resistant
to oxidation, hydrogen molecules are added to unsaturated fatty acids. This usually results in partially
hydrogenated fats. At the same time, this process changes some of the double bonds that still remain from the
cis configuration (more common in nature) to the trans configuration, creating trans fats.
4. Trans-fatty acids behave more like saturated fats than unsaturated fats within the body. They raise LDL
cholesterol and lower HDL cholesterol (at high intakes), and seem to increase inflammation and insulin
resistance. Dietary trans-fatty acids are associated with heart disease risk.
5. Answers will vary.

Worksheet 5-2: Do You Know Your Fats?


All 10 statements are false.

Worksheet 5-3: Check Your Lipid Choices – Answers will vary.

Worksheet 5-4: Chapter 5 Crossword Puzzle


1. cholesterol 4. essential 7. triglyceride 10. phospholipids
2. hydrogenation 5. lipoproteins 8. emulsification 11. saturated
3. polyunsaturated 6. olive oil 9. LDL 12. trans fats

Worksheet 5-5: Dietary Fat Recommendations (Internet Exercise)


1. b 4. a 6. a. Sunflower oil, b. Corn oil, c. Partially-
2. b 5. c hydrogenated oils
3. b

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88

Worksheet 5-1: Trans Fat

Nutrition Facts
Wheat Squares Corn Flakes Not Mixed Grain
Sweetened Sweetened Flakes Sweetened
Serving Size 1 Box (35g) (19g) (27g)
Servings Per Container 1 1 1
Amount Per Serving
Calories 120 70 100
Calories from Fat 0 0 0
%Daily Value* % Daily Value* % Daily Value*
Total Fat 0g 0% 0g 0% 0g 0%
Saturated Fat 0g 0% 0g 0% 0g 0%
Trans Fat 0g 0g 0g
Cholesterol 0mg 0% 0mg 0% 0mg 0%
Sodium 0mg 0% 200mg 8% 120mg 5%
Potassium 125mg 4% 25mg 1% 30mg 1%
Total Carbohydrate 29g 10% 17g 6% 24g 8%
Dietary Fiber 3g 12% 1g 4% 1g 4%
Sugars 8g 6g 13g
Protein 4g 1g 1g
* Percent Daily Values are based on a 2,000 Vitamin A 0% 10% 10%
calorie diet. Your daily values may be higher or
lower depending on your calorie needs:
Vitamin C 0% 15% 90%
Calories: 2,000 2,500 Calcium 0% 0% 0%
Total Fat Less than 65g 80g Iron 10% 6% 20%
Sat Fat Less than 20g 25g
Cholesterol Less than 300mg 300mg
Thiamin 30% 15% 20%
Sodium Less than 2,400mg 2,400mg Riboflavin 30% 15% 20%
Potassium 3,500mg 3,500mg Niacin 30% 15% 20%
Total Carbohydrate 300g 375g
Vitamin B6 30% 15% 20%
Dietary Fiber 25g 30g

Source for label information: U.S. Food and Drug Administration

Trans Fat Label Implications

1. Why was trans fat added to the Nutrition Facts label?

2. What does the term “trans fat” mean with respect to structural composition?

3. What does the term “trans fat” mean with respect to food processing?

4. What does the term “trans fat” mean with respect to one’s daily diet?

5. Do you think that hydrogenation of unsaturated fats will be replaced by some other processing mechanism
leading to other potential health problems?

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Worksheet 5-2: Do You Know Your Fats?

Please indicate whether each of the following statements is true or false by circling the appropriate word.
Then tally the total number of true and false statements.

Fat statement:

True False 1. All margarine products have the same fat content.

True False 2. Hydrogenated food products are healthier than those that are not
hydrogenated.

True False 3. If you see “fat free” on the food product label, then the food is guaranteed to
have no fat.

True False 4. You can live without fats in your diet.

True False 5. A saturated fat is better for you than a polyunsaturated fat.

True False 6. In order to be healthy, you should have no cholesterol in your body.

True False 7. Eicosanoids do not provide any health benefits.

True False 8. All fatty acids can be synthesized in the body.

True False 9. There are no clinical deficiencies seen from too little fat in one’s diet.

True False 10. As long as your LDL cholesterol is within normal range, you need not worry.

Totals: _____ _____

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90

Worksheet 5-3: Check Your Lipid Choices

Fats give foods their flavor, texture, and palatability. Unfortunately, these same characteristics
entice people to eat too much from time to time. Do you know how to select low-fat foods that
will help you meet dietary fat recommendations? Look at these examples of foods and consider
how often you select the item that is lower in fat.

Which of these pairs are you most likely to select:

Peanuts or pretzels?

Hot dog or turkey sandwich?

Whole milk or nonfat milk?

Fried chicken or baked chicken?

Tuna packed in oil or tuna packed in water?

Spaghetti with alfredo sauce or with marinara sauce?

Croissants or bagels?

Sausage pizza or mushroom pizza?

The second item in each pair is lower in fat and making such fat-free or lower-fat food choices
regularly can help you meet dietary fat recommendations. In addition, eating plenty of whole-
grain products, fresh vegetables, legumes, and fruits daily will help to keep your fat intake under
control.

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91

Worksheet 5-4: Chapter 5 Crossword Puzzle


1

5 6

10 11

12

Across: Down:
3. For good health, dietary saturated and trans fats 1. Fat found in foods and manufactured by the body
should be partly replaced with monounsaturated that is both essential and potentially harmful
and _____ fats. 2. Food processing technique that adds hydrogen to
5. Transport digested fat through the bloodstream unsaturated bonds
8. The process by which bile acids mix dietary fats 4. Omega-3 and omega-6 are referred to as _____
with digestive fluids in the small intestine fatty acids because they are needed but cannot be
9. Type of cholesterol in a lipid profile that is made by the human body.
positively correlated with someone’s risk for a 6. Type of cooking oil recommended to promote
heart attack heart health
10. Components in cell membranes that facilitate 7. Contains one glycerol molecule and three fatty
passage of fat-soluble nutrients acids
12. Type of fats that should be consumed in the lowest 11. Fatty acids that have only single bonds between all
amount possible carbons are referred to as _____.

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Worksheet 5-5: Dietary Fat Recommendations (Internet Exercise)


Go to the following website to answers questions 1 and 2:
http://www.cdc.gov/nutrition/everyone/basics/fat/index.html. Do not close the window until you have
answered all of the questions.

1. The highest total fat limit is for the adult population.


a. True
b. False

2. Nonfat milk is recommended for children under the age of 2 in order to prevent excessive fat deposits
later on in life.
a. True
b. False

Now, scroll down the page to the links under More Information on Fats. Use the web pages on the
different types of dietary fats to answer questions 3-6.

3. Trans fats can increase high-density lipoproteins and are therefore considered to pose significant
cardiac problems.
a. True
b. False

4. Trans fat is listed on the Nutrition Facts panel on food labels as of 2006.
a. True
b. False

5. Which of the following recommendations is accurate with regard to the intake of saturated fats?
a. Consuming 15% of energy from saturated fats presents minimal cardiac risk
b. Omega-3 and omega-6 fatty acids are considered to be excellent sources of saturated fats
c. Increased consumption of saturated fats can lead to increased incidence of cardiac events
d. The majority of fats in your diet should include high percentages of saturated fatty acids

6. Match the food example with the type of fat.


a. Monounsaturated
b. Omega-6 polyunsaturated
c. Trans fat

_____ Corn oil


_____ Sunflower oil
_____ Partially-hydrogenated oils

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93

Handout 5-1: Chemical Structures of Acetic Acid and a Bile Acid

Acetic Acid – Acetic acid is a two-carbon organic acid.

A Bile Acid – This is one of several bile acids the liver makes from cholesterol. It is then bound to an
amino acid to improve its ability to form spherical complexes of emulsified fat (micelles). Most bile acids
occur as bile salts, usually in association with sodium, but sometimes with potassium or calcium.

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94

Handout 5-2: How to Modify a Recipe—Lasagna

Original Modified
1
/3 c olive oil (to sauté vegetables) [omit oil]
1 ½ c diced onions 1 ½ c onion, 1 green pepper, ½ lb mushrooms
2 cloves garlic 2 cloves garlic
1 ½ lb ground chuck ¾ lb ground round
2 t salt [omit salt]
2 lb tomato sauce use no-added-salt type tomato sauce
28 oz canned tomatoes use no-added-salt type canned tomatoes
6 oz canned tomato paste use no-added-salt type tomato paste
1 tbsp oregano 2 t oregano, 2 t basil, ¼ c fresh parsley
2 tsp onion salt [omit salt]
1 lb lasagna noodles 1 lb whole wheat lasagna noodles
2 tbsp olive oil (to cook noodles) [omit oil]
16 oz ricotta 16 oz low-fat cottage cheese, pureed
8 oz mozzarella 8 oz part skim mozzarella
10 oz parmesan 4 oz parmesan
oil to grease pan spray to grease pan

Yield 16 servings (2 9” x 12” pans)

Analysis Original Modified


Energy (kcal) 513 281
Protein (g) 35 21
Fat (g) 29 (6 t) 7 (1.4 t)
Sodium (mg) 1121 380
Cholesterol (mg) 73 32
% of calories from fat 51 24

Source: Culinary Hearts Kitchen Course, Tallahassee, Florida, as taught by Sandra Woodruff, M.S., R.D., with
permission.

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95

Handout 5-3: Butter and Margarine Labels Compared


Food labels list the kcalories from fat; the quantities and Daily Values for fat, saturated fat, and cholesterol; and the
quantities for trans fat. Information on polyunsaturated and monounsaturated fats is optional. Products that contain
0.5 g or less of trans fat and 0.5 g or less of saturated fat may claim “no trans fat.” Similarly, products that contain 2
mg or less of cholesterol and 2 g or less of saturated fat may claim to be “cholesterol-free.”
If the list of ingredients includes hydrogenated oils, you know the food contains trans fat. Chapter 2 explained that
foods list their ingredients in descending order of predominance by weight. As you can see from this example, the
closer “partially hydrogenated oils” is to the beginning of the ingredients list, the more trans fats the product
contains. Notice that most of the fat in butter is saturated, whereas most of the fat in margarine is unsaturated;
partially hydrogenated margarines tend to have more trans fat than hydrogenated liquid margarines.

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96

Handout 5-4: Cholesterol in Selected Foods

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97

Handout 5-5: Omega-3 Fatty Acid Content of Commonly Eaten Fish


>500 mg per 3.5-oz serving 150-500 mg per 3.5-oz serving <150 mg per 3.5-oz serving
Bronzini Black bass Cod (Pacific)
Herring (Atlantic and Pacific) Catfish (wild and farmed) Corvina
Mackerel Escolar Grouper
Oyster (Pacific) Clam Lobster
Salmon (chinook, coho, Copper Cod (Atlantic) Mahi-mahi
River, farmed, pink, sockeye,
Crab (Alaskan king) Monkfish
wild Atlantic)
Croakers Red snapper
Trout (wild and farmed)
Tilapia (farmed) Skate
Sardines
Flounder Triggerfish
Toothfish
Haddock Tuna
Hake Wahoo
Halibut
Oyster (eastern and farmed)
Perch
Scallop
Shrimp (mixed varieties)
Sole
Swordfish

Sources: K. L. Weaver and coauthors, The content of favorable and unfavorable polyunsaturated fatty
acids found in commonly eaten fish, Journal of the American Dietetic Association 108 (2008): 1178–
1185; P. M. Kris-Etherton, W. S. Harris, and L. J. Appel, Fish consumption, fish oil, omega-3 fatty acids,
and cardiovascular disease, Circulation 106 (2002): 2747–2757.

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98

Handout 5-6: Potential Relationships among Dietary Saturated Fatty Acids,


LDL Cholesterol, and Heart Disease Risk

a
Percentage of change in total dietary energy from saturated fatty acids.
b
Percentage of change in blood LDL cholesterol.
c
Percentage of change in an individual’s risk of heart disease; the percentage of change in risk may
increase when blood lipid changes are sustained over time.

SOURCE: Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III),
NIH publication no. 02-5215 (Bethesda, Md.: National Heart, Lung, and Blood Institute, 2002), pp. V-8
and II-4.

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