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Florida Dietetic Association
Manual of Medical
Nutrition Therapy
2011 Edition
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Editor:
Catherine Christie, PhD, RD, LD/N, FADA
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Assistant Editors:
Nancy Correa-Matos, PhD, RD
Judy Perkin, DrPH, RD
Judith C. Rodriguez, PhD, RD, LD/N, FADA
Claudia Sealey-Potts, PhD, RD
Jackie Shank, MS, LD/N, RD
Delores Truesdell, PhD, RD
Lauri Wright, PhD, RD
Kate N. Chang, UNF Nutrition Student
All rights reserved. No part of this manual, other than those specifically designed for
patient education, may be reproduced, stored in a retrieval system, or transmitted, in
Manual of Medical Nutrition Therapy 2011 Edition
iiiiPreface
The Manual of Medical Nutrition Therapy was written to serve as a nutrition care
guide for dietetics professionals and other health care professionals. Each section of the
Manual was researched, written, and reviewed by Registered Dietitians, Dietetic
Technicians Registered or nutrition/dietetic students in accredited programs. However,
the field of nutrition and its application to individual needs is constantly changing with
continuous research. Therefore, this Manual should always be used with consultation from
a Registered Dietitian.
The specific purpose of the Manual of Medical Nutrition Therapy is to provide
general practice information in the course of normal dietetics practice and to alert
practitioners to general areas of concern for which you may seek additional medical,
technical, or professional assistance. Many sections of the FDA Manual of Medical
Nutrition Therapy contain Practitioner Points for the Registered Dietitian (RD) and Dietetic
Technician Registered (DTR) and when appropriate Nutrition Education for the public.
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To be effective, medical nutrition therapy must be individualized for each person.

This requires a collaborative effort between the patient or client and the dietitian. Handing
out diet sheets to those with nutrition-related medical problems completely overlooks the
unique qualities of that person and limits the rate of adherence. The development and
maintenance of new eating behaviors requires commitment, time, and support from
qualified professionals.
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The Practitioner Points of each diet contain a brief description of rationale, use,
related physiology, nutrients modified, nutritional adequacy and references. The Nutrition
Education contains an introduction, purpose, nutrients modified, dietary guidelines, food
lists, sample menus or handouts, and approximate nutritional analysis. All diets analyzed
for this manual contain adequacy statements based on the 1989 Recommended Dietary
Allowances and Dietary Reference Intakes (DRIs) for adult males and females.
No warranty, explicit or implied, as to the appropriateness of application of the
contents of this manual to specific individuals is made by the Florida Dietetic Association,
the authors and reviewers, nor by their employers.
Acknowledgements
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Special thanks to the Florida Dietetic Association members who served

on the Board of Directors during the time of the 2011 manual revision for their
vision and support of this manual.
FDA Board Members
Holly Adams RD, LD/N
Stephanie Norris RD, LD/N
Heather Fisher RD, LD/N
Mandy Layman RD, LD/N
Molly Gladding RD, LD/N
Michelle Pugsley RD, LD/N
Joey Quinlan RD, LD/N
FDA Executive Director
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Christine Stapell MS, RD, LD/N,
Authors and Reviewers
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The following pages list the Authors and Reviewers who donated their
valuable time and expertise to write or review sections of the Manual of
Medical Nutrition Therapy. Without their exceptional work and dedication to
the Dietetics and Nutrition profession, this Manual would not be possible.
Manual of Medical Nutrition Therapy Authors

Michelle Albers, PhD, RD, LD/N
Linda Ammon, MS, RD, LD/N, CDE
Linda Attkisson, MS, RD, LD/N
Sharon M. Bartfield, MS, RD, LD/N
Mindy Benedict, RD, LD/N
Donnie Berger, MS
Lucille Beseler, MS, RD, LD/N, CSP
Linda B. Bobroff, PhD, RD, LD/N
Bernice Boivin, RD, LD/N
Ellen K. Bowser, MS, RD, LD/N, CSP
Ann Braun, RD
Susan Burke, MS, RD, LD/N, CDE
Mary Lu Carpenter, MS, RD, LD/N
Catherine Christie, PhD, RD, LD/N
Cathy Clark-Reyes, RD, LD/N
Dana Cohen, RD, LD/N
Suzanne Cole, MS, RD, LD/N
Peggy Cooper, MS, RD, LD/N
Nancy Correa-Matos, PhD, RD
Avernelle Cromer, RD
Ruth M. DeBusk, PhD, RD
Donna DeCunzo-Taddeo, RD, LD/N
Carolyn S. DeVries, RD, LD/N
Jamie Diamond, MS, RD, LD/N, CNSD
Marianne Duda, MS, RD, LD/N, CNSD
Evelyn B. Enrione, PhD, RD, LD/N
John R. Ferrante, MS, RD, LD/N
Joan Marn Franklin, MS, RD, LD/N
Patricia J. Funk, MS, RD, LD/N, CNSD
Maureen Gardner, MA, RD, LD/N
Molly Gladding, RD, LD/N
Dawn Goodholm, RD, LD/N
Leslene Gordon, PhD, RD, LD/N
Denise M. Hall, MS, RD, LD/N
Sarah Hall, RD, LD/N, CNSD
Lenore S. Hodges, PhD, RD, LD/N
Stephanie Holmes, MS, RD, LD/N, CNSD
Geanne Hudson, RD, LD/N
Rita Jackson, PhD, RD, LD/N
Delores C.S. James, PhD, RD, LD/N
Elaine Jansak, MS, RD, LD/N, CDE
Donna T. Jones, MSH, RD, LD/N
Gail P. A. Kauwell, PhD, RD, LD/N
Brenda Keen, RD, LD/N
Karen Kratina, PhD, MPE, RD, LD/N
Beverly J. Kraus, RD, LD/N
Susan Latham, MS, RD, LD/N
Grace Lau, RD, LD/N, CDE
Jennifer Lefton, RD, LD/N, CNSD
Kristen Leonburg, RD, LD/N
Sherry Mahoney, RD, LD/N, CDE
Connie Malik, RD, LD/N, CDE
Christina S. McClernan, MS, RD, LD/N, CNSD
Carol Mellen, MS, RD, LD/N
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Susan Moyers, PhD, MPH, LD/N

Misty Murray, MS, RD, LD/N
Annette Owen, DTR
Nadine Pazder, MS, RD, LD/N, CDE
Judy E. Perkin, DrPH, RD, LD, CHES
Erin Petrey, MS
Elsa Pinto-Lopez, MS, RD
Stephanie Quirantes, MS, RD, CNSD
Glenna Raidt, RD, LD/N, CDE
Sheah Rarback, MS, RD
Mirta Rios, RD, LD/N
Tania Rivera, MS, RD, LD/N
Judith C. Rodriguez, PhD, RD
Michelle Romano, RD, LD/N, CNSD
Michelle Schmitz, MS, RD, LD/N
Claudia Sealey-Potts, PhD, RD
Mindy Seltzer, RD, LD/N
Jackie Shank, MS, RD
Nancy Spaulding-Albright, MMS, RD, LD/N, CNSD
Barbara Sperrazza, MS, RD, LD/N, CDE
Nancy T. Smith, MS, RD, CDE
Deanna Stanz, MS, RD
Rheba Summerlin, MSH, RD
Vilia B. Tarrosa, MS, RD, LD/N
Susan J. Tassinari, MS, RD, LD/N
Cathy Trcalek, RD, LD/N
Joanna Uptagraft, RD, LDN
Catherine Wallace, MSH, RD, LD/N
Julia A. Watkins, PhD, MPH
Sally E. Weerts, PhD, RD
Vilma Willard, MS, RD, CSR, LD/N
Lauren Willis, RD, LD/N
Merrie M. Wilner, RD, LD/N
Debra Wilson-Case, DTR
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Manual of Medical Nutrition Therapy Reviewers

Lori Alexander, MSHS, RD, LD/N, CCRC
Melissa A. Baron, MS, RD, LD/N
Luce Bernard, MS, RD, LD/N, CDE
Amy E. Bowersock, PhD, FACSM
Gayle Brazzi Smith, MS, RD, LD/N
June Carder, MS, RD, LD/N
Mary Lu Carpenter, MS, RD, LD/N
Joy Chambers, MA, RD, LD/N
Catherine Christie, PhD, RD, LD/N
Michelle Ciccazzo, PhD, RD, LD/N
Laura Cook, PhD, RD, LD/N
Judith Cooper, MS, MBA, RD, LD/N
Sondra Cornett, MS, RD, LD/N
Helen L. Curtis, RD, LD/N, CDE
Sheila G. Dean, MS, RD, LD/N, CDE
Jamie Diamond, MS, RD, LD/N, CNSD
Evelyn B. Enrione, PhD, RD, LD/N
Jennifer Eshelman, MS, RD, LD/N, CSNC
Kristen M. Farnham, MSH, RD, LD/N
Jorge R. Franceschi, MSH, RD, LD/N
Mary C. Friesz, PhD, RD, LD/N, CDE
Donna Greenwood, PhD, RD, LD/N
Sarah Hall, RD, LD/N, CNSD
Pat Hare, RD, CPS
Cristen Harris, MS, RD, LD/N
Rebecca Helquist, RD, LD/N, CDE
Jennifer Hillan, MSH, RD, LD/N
Starr Horn, MS, RD, LD/N
Heather Huffman, MS, RD, LD/N
Alice Jaglowski, MSH
Kristi Jesionek-Brewton, RD, LD/N, CNSD
Elaine M. Jansak, MA, MS, RD, DCE, LD/N
Carol Francis Jubert, MS, RD
Stephanie Kahn, MS, RD, LD/N
Kristen Kenny-Keller, RD
Myerly Kertis, MS, RD, LD/N
Samantha Knight, MS, RD, LD/N
Cynthia Kupper, RD, CD
Grace Lee, MS, RD, LD/N
Jennifer Lefton, RD, LD/N, CNSD
Emily Marcus, RD, CDN
Victoria Martinez, RD, LD/N
Janet S. McKee, MS, RD, LD/N
Janis Mena, MPH, RD, LD/N
Christine Miller, MS, RD, LD/N, CDE
Susan Mitchell, PhD, RD, LD/N
Jen Moccia, MS, RD, LD/N
Kathy Nelson, RD, LD/N
Pamela Ofstein, MS, RD, LD/N
Peggy ONeil, MS, RD
Stephanie Perry, MSH, RD, LD/N
Theresa Perry, RD, LD/N
Denise Pickett-Bernard, PhD, RD, LD/N
Tania Rivera, MS, RD, LD/N
Judy Rodriguez, PhD, RD, LD/N
Ellen Rovinsky, MS, RD
Pam Schmidt, MS, RD, LD/N, CDE
Evelyn P. Schumacher, MS, RD, LD/N, CDE
Cecelia Sheridan, RD, LDN, CSP
Eunshil Shim, MS, RD, LD/N
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Andrea Skowronek, RD
Nancy Spyker, RD, LD/N
Isabel Suarez-Blandino, RD, LD/N
Vicki Sullivan, PhD, RD, LD/N
Leslie Taylor, Graduate Student
Aurea Thompson, MSH, RD, LD/N
R. Elaine Turner, PhD, RD
Lois J. Waltz, RD, LD/N
Julia Watkins, PhD, MPH
Sally E. Weerts, PhD, RD
Regan Zayas, MBA, RD, LD/N
Kim Zeller, MSH, RD
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Table of Contents
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A. The Nutrition Care Process
Nutrition Assessment
A1.1
Nutrition Education and Counseling
A2.1
Nutrition for Culturally Diverse Populations
A3.1
Calorimetry Equations Current Recommendations
A4.1
Nutrition Care Process
A5.1
B. Medical Nutrition Therapy for Overweight and Obesity

Adult Obesity Prevention
B1.1
Adult Nutrition for Weight Loss
B2.1
Childhood Obesity Prevention
B3.1
Treating the Overweight Child

Children and Physical Activity
Health at Every Size (HAES)
B5.1
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Physical Fitness and Athletic Performance
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Vegetarian Nutrition
Bariatric Surgery
Metabolic Syndrome
Nutrition Resources Online

Food Labeling
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B4.1
B6.1
C1.1
C2.1
C3.1
C4.1
C5.1
C6.1
Dietary Reference Intake (DRI)
C7.1
Complementary and Alternative Medicine
C8.1
Functional Foods
C9.1
Nutritional Care for Dental Health
C10.1
Up to Date: Folate, Food Folate, Folic Acid and Folacin
C11.1
Up to Date: Iron in Health Promotion and Disease Prevention
C12.1
Up to Date: Caffeine and Health
C13.1
D. Life Cycle Medical Nutrition Therapy

Nutrition Guidelines and Recommended Eating Patterns Under Revision
D1.1
Nutrition and Wellness: Balance of Body, Mind & Spirit
D2.1
Nutrition in Pregnancy
D3.1
Nutrition in Lactation
D4.1
Table of Contents
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Geriatric Nutrition
D5.1
Liberal Geriatric Diet
D6.1
No Concentrated Sweets Diet
D7.1
No Added Salt Diet
D8.1
Long Term Care Nutrition
D9.1
Nutrition Education for High Calorie/High Protein Diet
D10.1
Nutrition for Osteoporosis
D11.1
Nutrition for Anemia
D12.1
Nutrition for Wound Healing
D13.1
E. Pediatric Medical Nutrition Therapy

Infant Nutrition 0-12 Months
Nutrition for Children 1-10 yrs
Adolescent Nutrition
Nutrition for Children with Diarrhea
Preterm and Low Birth Weight Nutrition
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Pediatric Enteral Nutrition Support
Pediatric Parenteral Nutrition Support

Cystic Fibrosis Nutrition
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E1.1
E2.1
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E3.1
E4.1
E5.1
E6.1
E7.1
E8.1
Pediatric/Adolescent Inflammatory Bowel Disease Nutrition
E9.1
Pediatric Insulin Dependant Diabetes Mellitus Nutrition
E10.1
Pediatric HIV/AIDS Nutrition
E11.1
Inborn Errors of Metabolism- Phenylketonuria
E12.1
Inborn Errors of Metabolism- Galactosemia
E13.1
Inborn Errors of Metabolism- Maple Syrup Urine Disease
E14.1
Ketogenic Diet
E15.1
Growth Charts for Children
E16.1
F. Medical Nutrition Therapy for Textural Changes

Clear Liquid Diet
F1.1
Full Liquid Diet
F2.1
Pureed Diet
F3.1
Mechanical Soft Diet
F4.1
Soft Diet
F5.1
Dysphagia Diet
F6.1
Tonsellectomy Diet
F7.1
Table of Contents
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G. Medical Nutrition Therapy for Eating Disorders, Substance Abuse and Brain/Central Nervous
System Disorders
Nutrition for Eating Disorders
G1.1
Nutrition for Substance Abuse Treatment
G2.1
Nutrition for Neurological and Mental Disorders
G3.1
Primary Headaches (Migraine, Tension-Type, and Cluster Headaches)
G4.1
Nutrition for Depression
G5.1
Nutrition for AD/HD
G6.1
Nutrition for Autism
G7.1
H. Medical Nutrition Therapy for Cardiovascular Disease

Coronary Heart Disease and Hyperlipidemia
Congestive Heart Failure
H2.1
Sodium Controlled Diets

Heart Transplant
I. Medical Nutrition Therapy for Hypertension
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Nutrition for Hypertension

DASH Diet
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H1.1
J. Medical Nutrition Therapy for Diabetes

Nutrition for Diabetes
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H3.1
H4.1
I1.1
I2.1
J1.1
Diabetes Self-Management Training
J2.1
Nutrition for Hypoglycemia Secondary to Diabetes
J3.1
Nutrition for Functional Reactive Hypoglycemia
J4.1
Nutrition for Gestational Diabetes
J5.1
Nutrition for Diabetes Related Amputations
J6.1
K. Medical Nutrition Therapy for GI Disorders

Nutrition for Esophageal Reflux (GERD)
K1.1
High Fiber Diet
K2.1
Low Residue Diet
K3.1
Bland Diet
K4.1
Nutrition for Post-Gastrectomy
K5.1
Short Bowel Syndrome
K6.1
Table of Contents
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L. Medical Nutrition Therapy for Liver and Biliary Disorders

Protein Restricted Diet
L1.1
Fat Restricted Diet
L2.1
Nutrition for Liver Disease Updated Section!
L3.1
Nutrition for Cirrhosis
L4.1
M. Medical Nutrition Therapy for Kidney Disorders

Nutrition for Chronic Kidney Disease Stages 1-4
M1.1
Nutrition for Chronic Kidney Disease Stage 5
M2.1
N. Medical Nutrition Therapy for Hypermetabolic Conditions

Nutrition for Adult Burns
N1.1
Nutrition for Cancer

Nutrition for Solid Organ Transplantation
N3.1
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Nutrition for Chronic Obstructive Pulmonary Disease

Nutrition for HIV/AIDS
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O. Enteral and Parenteral Nutrition Support

Enteral Nutrition Support
Parenteral Nutrition Support
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N2.1
N4.1
N5.1
O1.1
O2.1
P. Medical Nutrition Therapy for Food Allergies/Intolerances/Restrictions

Nutrition for Food Allergies
P1.1
Egg Free Diet
P2.1
Gluten Free Diet
P3.1
Lactose Restricted Diet
P4.1
Milk Free Diet
P5.1
Wheat, Egg & Milk Free Diet
P6.1
Purine Controlled Diet
P7.1
Tyramine Restricted Diet
P8.1
Latex Sensitivity/Allergy Diet
P9.1
Oxalate Restricted Diet
P10.1
Q. Medical Nutrition Therapy for Medical Tests

Nutrition for Glucose Tolerance Test
Q1.1
Nutrition for Vanillylmandelic Acid (VMA) Test
Q2.1
Nutrition for 100 Gram Fat Fecal Fat Test
Q3.1
Nutrition for Serotonin (5-HIAA) Test
Q4.1
Table of Contents
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R. Spanish Nutrition Education Materials

Adult Weight Loss
R1.1
Adult Obesity
R2.1
Overweight Child
R3.1
CHD/Hyperlipidemia
R4.1
Sodium Controlled Diets
R5.1
Type 1 and Type 2 Diabetes
R6.1
Diabetes Self Management Training
R7.1
Gestational Diabetes
R8.1
Hypoglycemia Secondary to Diabetes Mellitus
R9.1
Functional Reactive Hypoglycemia

GERD
R11.1
Bland Diet
High Fiber Diet
Low Residue Diet
Dental Health
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R13.1
R14.1
R15.1
S1.1
Written by: Patricia J. Funk, MS, RD, LD/N,
CNSD, Shands at AGH, Gainesville, Florida
Reviewed by: Eunshil Shim, MS,RD,LD/N,
Consulting Dietitian, Gainesville, Florida
PRACTITIONER POINTS
RATIONALE
The purpose of a nutritional
assessment is to evaluate a patient's
nutritional adequacy to identify nutritionrelated problems, existing nutritional deficits
and degree of nutritional risk for developing
nutritional deficits. A nutritional assessment
is a comprehensive evaluation of a patients
nutritional status, which establishes baseline
data to evaluate the effectiveness of medical
nutritional therapies and to develop a nutritional care plan. A comprehensive nutritional
assessment utilizes both objective data and
subjective data from the patient and/or significant other to determine past and present
nutritional state of health. The recommendations made are dependent on the skill and
experience of the clinician in interpreting
available information and the significance
and limitations of the data.
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Elements of a comprehensive nutritional assessment include: a thorough

history (nutritional, medical, surgical, and social), psychological, medical record review,
physical examination, patient and/or caregiver interview, anthropometric measurements, laboratory data and assessment of
nutrient requirements (1).
NUTRITION HISTORY
The value of accurate dietary data is
well known. The act of obtaining accurate information is a challenging part of a complete
nutritional assessment. It is difficult to obtain
dietary data without influencing food intake.
Individuals may or may not be able to recall
foods eaten, others may agree to record
foods eaten. Few people can accurately
judge or report the size of portions eaten. In
A1.1
addition to usual or actual food intake,
information is obtained regarding physical
activity, ethnic, religious, and cultural
influences, economics, appetite, allergies
and food intolerances, home life, dental
health, gastrointestinal health, medications,
chronic diseases, weight changes and
nutrition problems as perceived by the
patient. See Information obtained from a nutrition history and patient/caregiver interview
in this section.
Methods for obtaining nutritional history
(2, 3)
The nutrition history is obtained by
interviewing the patient/caregiver/family. It
is important to establish rapport and convey
empathy and acceptance in order to
establish a relationship with the patient.
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Pace the interview to complete it within

an appropriate amount of time. It is helpful
to avoid complicated technical and medical
terminology. Techniques of communication
are encouraged such as acceptance, recognition, restating or paraphrasing. Avoid judging comments.
1. Twenty-four (24) hour recall provides
information on food intake of the
previous 24 hours.
2. Food frequency questionnaires or
checklists of foods with patient/client, or
caregiver indicating the frequency with
which foods are eaten.
3. Food records or diaries provide three to
five day records of actual food consumption.
4. Direct observation of patient's intake.
Information obtained from a nutrition
history and patient/caregiver interview (4)
Economics
income frequency and steadiness of
employment
amount of money budgeted for food
each week or month and individual's
perception of its adequacy for meeting
food needs
eligibility for food stamps, cost and
amount of stamps received
Physical Activity
occupation type, hours per week, shift,
estimated energy expenditure
exercise type, amount, frequency, seasonal changes
Sleep hours per day, continuous, or interrupted
handicaps
Ethnic, Religious, or Cultural Background
influence on eating habits
educational level
Home Life and Meal Patterns
number in household who eat meals
together
person who does the shopping
person who does the cooking
food storage and cooking facilities
type of housing, e.g. home, apartment,
adult congregate living facility
ability to shop and prepare food, or
dependence on others for this activity
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Appetite
good, poor, changes in amount and types
of foods eaten, including textures
factors that affect appetite including
changes in taste and smell
Allergies, Food Intolerances, Food
Avoidances
foods avoided and reasons
length of time of avoidance
description of problem caused by eating
avoided foods
Dental and Oral Health
condition of teeth, dentures, and/or gums
problems with eating and/or drinking due
to sore mouth/tongue, thrush
foods that cannot be eaten
A1.2
problems with swallowing, salivation,
chewing, jaw pain, food sticking in mouth
or throat
Gastrointestinal Health
problems with heartburn, bloating, gas,
diarrhea, vomiting, constipation, distention
frequency and severity of problems
home remedies
antacid, laxative, or other drug use
Chronic Disease
treatment
length of time of treatment
dietary modification physician prescription,
date of modification, education received,
comprehension and compliance with
nutrition prescription
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Medication
vitamin and/or mineral supplements
frequency, type, amount
herbal products type, frequency, amount,
reason for taking, or expected outcome
medications type, amount, frequency,
length of time taking medication, taken
with or without food.
Recent Weight Changes
loss or gain how many pounds, over what
length of time
intentional or non-intentional
Nutritional problems as perceived by the
patient
CLINICAL EVALUATION
Physical Examination
Thorough physical assessment is a key
component of the patients nutritional health
history. Observations in the general physical
exam are usually indicative of long-term nutrition depletion (13, 21).
Ideally, the physical exam should include assessment of muscle mass and
subcutaneous fat stores, inspection and palpation for edema and ascites (indicators of
diminished visceral protein levels and hepatic
dysfunction), inspection and evaluation for
signs and symptoms of vitamin and mineral
deficits (13, 21, 26).
Various clinical findings are associated
with specific nutrient deficiencies (5-8). Physical signs are usually non-specific and nonapparent until the patient is severely malnourished. Specific nutrient deficiencies
should be confirmed by appropriate laboratory data before therapy is instituted.
Nutritional Physical Examination
The exam proceeds from head to toe to
assess patients nutritional health. Equipment for assessment includes stethoscope,
reflex hammer, tape measure, calipers, thermometer, tongue blade, and penlight.
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Nutrition-focused-physical examination
concentrates on 4 techniques: (21, 34)
1.
2.
3.
4.
Inspection
Palpation
Percussion
Auscultation
Inspection: Good lighting is essential. Focus

on observation of color, texture, size and
shape.
Palpation: Exam by touching body structures,
pulsations and vibrations. Light palpation:
gently press in to a depth of 1 cm. Deep
palpation: press in to a depth of
approximately 4 cm. Light palpation is
adequate for nutrition examination.
Percussion: Produce sounds to locate organ
borders and assess organ shape and
position. Direct percussion: Tap fingertips or
hand directly against the body structure.
Indirect percussion: Use the nondominant
hand as the stationary hand. The middle
finger or pleximeter is hyperextended and the
A1.3
distal portion is placed firmly against the
clients skin. The middle finger of the
dominant hand strikes the pleximeter with
the fingertip, not the finger pad. It should hit
at a right angle to the stationary finger. The
finger strikes twice and is withdrawn immediately to avoid interfering with vibrations.
Different sounds are produced by different
tissues (21).
Auscultation: Uses the stethoscope to listen
to sounds produced by organs and viscera
including lungs, heart, blood vessels,
stomach and intestines. Auscultation is used
last in physical assessment except in the
abdomen. Since bowel sounds may be
disrupted by palpation, auscultation is used
second in the abdomen after inspection.
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Signs and symptoms that often indicate

nutritional deficiencies are described in
references 13 and 21. Details on physical
assessment skills can be viewed in The
American Dietetic Associations video:
Nutrition-Focused Physical Assessment Skills
for Dietitians (34).
ANTHROPOMETRY
Frame size
Determination of frame size is
important in interpreting weight and weight
for height tables. In many instances weight
tables are published only for "medium"
framed individuals. Of several methods
available, one of the easiest is to have
patients gauge their frame size by wrapping
the nondominant wrist with the thumb and
index finger of the dominant hand at the level
of the radius and ulnar styloid process. If the
fingertip and thumb meet, the frame is
medium; if the fingertip and thumb over lap,
the frame is small; if the fingertip and thumb
do not meet, the frame is large (9).
Frame size can also be determined by
measuring the smallest part of the right wrist
circumference, distal to the styloid process of
the ulna three times and then averaging the
measurements and recording the mean (10,
pg.10).
Frame size (r) = height in centimeters (cm)
wrist circumference (cm)
Classification of frame size:
small frame medium frame
men
<9.9
9.9 - 10.9
women
9.6 - 10.4
<9.6
large frame
>10.9
>10.4
A third method for determining frame

size is based on a measurement of elbow
width. Have the patient extend the arm and
bend the forearm upward at a 90-degree
angle. Keeping fingers straight, turn the
inside of the wrist toward the body. Place the
thumb and index finger of the other hand on
the two prominent bones on either side of the
elbow. Measure the space between the
thumb and index finger against a ruler or tape
measure. Compare it with the Table 1 below
that lists elbow measurements for medium framed men and women.
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Table 1. ELBOW BREADTH MEASUREMENTS

FOR A MEDIUM FRAME (11)
Men
Height
5'2" - 5'3"
5'5" - 5'7"
5'8" - 5'11"
6'0" - 6'3"
6'4" +
Women
Height
4'10" - 4'11"
5'0" - 5'3"
5'4" - 5'7"
5'8" - 5'11"
6'0" +
Elbow Breadth
2 1/2" - 2 7/8"
2 5/8" - 2 7/8"
2 3/4" - 3"
2 3/4" - 3 1/8"
2 7/8" - 3 1/4"
Elbow Breadth
2 1/4" - 2 1/2"
2 1/4" - 2 1/2"
2 3/8" - 2 5/8"
2 3/8" - 2 5/8"
2 1/2" - 2 3/4"
Measurements lower than those listed

indicate a small frame. Higher measurements
A1.4
indicate a larger frame.
Height
Measurement of height forms the basis
for calculation of ideal body weight (IBW),
caloric need, and adequacy of caloric intake.
Unfortunately, it is often missing from the
medical record. When documenting height,
the person should be barefoot, or wearing
only socks or stockings. The feet should be
together with the heels against the wall or
measuring board. The person should be
standing erect, neither slumped nor
stretching, looking straight ahead. The top of
the ear and outer corner of the eye should be
in a line parallel to the floor, called the
Frankfort plane. A horizontal bar, a
rectangular block of wood, or the top of the
statiometer then should be lowered to rest
flat on the top of the head. The height should
be read to the nearest 1/4 inch or 0.5
centimeters (4).
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Height can be estimated in bed-ridden

patients using knee-length prediction
equations. Using a broad blade caliper, with
the patient lying supine, and the knee bent at
a 90-degree angle. One blade of the caliper is
placed over the anterior surface of the left
thigh, above the condyles of the femur and
just proximal to the patella. The caliper shaft
is held parallel to the shaft of the tibia.
Pressure is applied, and two readings should
agree within +/- 0.5 cm. Height is then
calculated from the following two equations
(11):
Men: Height (cm) =
64.19 - (0.4 x age) + (2.02 x knee height)
Women: Height (cm) =
84.88 - (0.24 x age) + (1.83 x knee height)
Weight
Measurement of weight is a key
assessment parameter. It is often missing
from the medical record. Avoid relying on
A1.5
patients self-reports of weight or height.

Weights can easily be measured
inaccurately, or complicated by the patient's
medical condition, such as edema, ascites, or
tumors, or treatments, such as casts, traction
or life-support equipment. Accuracy in
measurement is essential as it is often the
foundation of important clinical decisions.
Use a beam balance scale, rather than
a spring scale, whenever possible.
Periodically calibrate the scale for accuracy,
especially if it is moved from place to place.
Use known weights for calibration. Weigh the
individual in light clothing without shoes and
heavy objects in their pockets, such as keys.
Record weight to the nearest 1/2 pound or
0.2 kilogram for adults. Use bed scales or
wheelchair scales for patients unable to
stand unassisted (4). The type of scale used
should be noted along with the weight,
especially with bed and wheelchair scales.
Fluctuations in weight may be due to
improper weighing techniques, such as:
weighing bedding or leaning on the bed when
weighing the patient, weighing orthopedic
appliances such as braces, or switching from
one scale to another without checking
calibration. When amputees are weighed it
should be noted whether or not they are
wearing any prosthetic devices during the
weighing.
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Estimation of Desirable Body Weight Using

the Hamwi Formula (2)
For women:
Allow 100 pounds for the first five feet of
their height.
Multiply each inch over five feet by 5 and
add it to 100.
For a small frame subtract 10%
For a large frame add 10%
For men:
Allow 106 pounds for the first five feet of
their height
Multiply each inch over five feet by 6 and
add it to 106
For a small frame subtract 10%
For a large frame add 10%
For example: a medium frame woman who is

5'6" tall: 100 + (5 x 6 = 30) = 130 pounds
A large frame man who is 5'6":
106 + (6 x 6 = 36) + 10% = 156 pounds
Estimation of Ideal Body Weight Adjusted
for Obesity
For obese patients, it is assumed that
fat has less metabolically active lean body
tissue than fat-free lean body tissue. It has
been reported that men have obese tissue
composed of 62% fat and 36% to 38% lean
body mass. Womens obese tissue is reported
to have up to 70% fat and 22% to 32% lean
body mass. Based on this information, an
adjusted ideal body weight (AIBW) equation
may be used.
Men: AIBW =
[(actual weight - IBW) x 0.38] + IBW
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Women: AIBW =
[(actual weight - IBW) x 0.32] + IBW
Many practitioners choose to use a

weight estimate called adjusted body weight
(Adj BW/ABW)
AdjBW= 0.25(actualBW-IdealBW) + IBW
The ABW equation assumes that obese
people possess an average of about 25%
metabolically active lean body tissue in their
weight in excess of their IBW.
Limitations of ABW:
It does not take into consideration the
wide variability in body composition among
obese people.
Estimation of Desirable Body Weight for
Amputees
Determine ideal body weight using
Hamwi formula or AIBW. Use the last known
height prior to amputation. Subtract the
percent listed below from ideal or adjusted
body weight for body part amputated to
determine desirable body weight (12).
Method #1 (based on cadaveric studies)
Hand
subtract 1%
Forearm with hand subtract 3%
Entire arm
subtract 6.5%
Foot
subtract 1.8%
Lower leg with foot subtract 5.9%
Entire leg
subtract 18.5%
Above the knee
subtract 13%
Below the knee
subtract 6%
Method #2 (gross estimation)
Foot amputation
subtract 5 lbs
Below knee
subtract 10 lbs
Above knee
subtract 15 lbs
Entire leg
subtract 20 lbs
Estimation of Desirable Body Weight for
Paraplegics and Quadriplegics
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A person with injury to the spinal cord is

at risk for obesity due to immobilization and
decreased energy expenditure. Maintenance
of an ideal body weight slightly below the
average for a healthy adult is recommended
to facilitate transfers and enhance self-care
activities (13).
Paraplegics:
For both men and women, subtract 5 10% from the desirable weight figured using
the Hamwi Formula.
Quadriplegics:
For both men and women, subtract 10 15% from the desirable weight figured using
the Hamwi Formula.
Interpretation of Weight Percent Usual
Body Weight
Usual Body Weight (UBW) is used most
A1.6
commonly to determine nutritional status
based on weight. Both a weight loss and a
weight gain need to be compared to the usual
or pre-illness weight, as well as comparing
the current weight to a reference standard.
Usual body weight is a more useful parameter
than healthy or ideal body weight when
evaluating the status of an ill patient. The
percentage of recent weight change with
respect to the UBW correlates best with acute
morbidity and mortality. The disadvantage is
that it is dependent on patient or caregiver
memory. A past medical record may be
available to give weight history.
Percent usual body weight (% UBW) =
(actual weight)__ X 100
(usual body weight)
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Clinical significance of %UBW (2):

85-90%
mild malnutrition
75-84%
moderate malnutrition
<74%
severe malnutrition
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Percent Ideal (Healthy) Body Weight
Due to inaccuracies associated with

some patient's ability to recall their previous
weight, it may be advisable to use the ideal
weight based on an average weight for height
obtained from a standard formula, such as
the Hamwi Formula.
Percent ideal body weight (% IBW) =

(actual weight)_ X 100
(ideal body weight)
Clinical significance (%IBW) (2):
morbidly obese
> 200%
obese
> 150%
overweight
> 120%
80 - 90%
mild malnutrition
70 - 79%
moderate malnutrition
<69%
severe malnutrition
Percent Weight Loss
Changes in the patient's percent of
usual weight are considered to be a more
accurate indicator of recent or chronic
nutritional deprivation than weight expressed
as a percent of ideal body weight. Current
body weight needs to be dry weight or nonedematous weight.
% weight loss = UBW-current weight
UBW
X 100
Clinical Significance (1):

Time
Significant
Severe weight
weight loss (%) loss (%)
1 week
1-2 %
> 2%
1 month
5%
>5%
3 months
7.5%
> 7.5%
6 months
10%
> 10%
Body Composition
As with other anthropometric measurements, care must be taken in the measurement technique and in the interpretation of
results. Single measurements are not particularly useful and should not be used in conjunction with other indices. Changes need to
be followed periodically over time to provide
meaningful data and assessments.
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Skinfold Measurements
Skinfold measurements using calipers

are a non-invasive measure of subcutaneous
fat for an indirect estimate of fat stores.
Estimate of fat stores provides an index of
the body's energy reserves. Skinfold
measurements are non-invasive, but
technique is critical for accuracy and affected
by intraobserver variability (measurements
taken by different people). Intraobserver error
(all measurements taken by one person) can
be reduced by extensive training and
practice. Intraobserver error depends on what
site is being measured and what procedure is
followed to take the measurements.
Triceps Skinfold (TSF)
A1.7
TSF is most commonly used in clinical
settings to estimate energy reserves because
it is an easily accessible and indirect
measure of subcutaneous fat. Measurements
of Mid-Arm Circumference (MAC), Mid-Arm
Muscle Circumference (MAMC) and Arm
Muscle Area (AMA) are indirect methods of
measuring somatic protein (skeletal muscle
mass). Nutritional risk based on these
measurements utilizes reference data which
are not available for elderly people or ethnic
minorities. Assessment of short-term changes
in body composition especially for ICU
patients or acutely stressed patients is not
reliable (13, 17, 21).
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Mid-Arm Circumference (MAC), Arm Muscle

Circumference (AMC), and Arm Muscle
Area (AMA)
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These are indirect methods of

measuring somatic protein (skeletal protein
mass). AMC is derived from TSF and MAC and
provides a quick and easy approximation of
skeletal muscle mass and degree of
depletion (11). They are estimated from the
following equations:
AMC (cm) = MAC (cm) - 0.314 TSF (mm)
AMA (cm2) = [MAC (cm) - 3.14 TSF (cm)] 2

4 (pi)
(Tables for percentile ranking of TSF, MAC, AMC,
AMA are listed in reference 14)
There is decreased accuracy of using

these measurements in the clinical setting
due to fluid shifts, changes in hydration
status, and fluid resuscitation. Standards for
these measurements were developed from
non-hospitalized populations and may
correlate poorly with hospitalized patients
nutritional status.
The above measurements are most
appropriate for assessing change over time in
individual patients (13, 17, 21). For healthy
persons, measure at the same time of day
A1.8
over time. Commonly used sites are as

follows:
Men: Chest, Abdomen, Thigh
Women: Triceps, Suprailium, Thigh
and thumb. Palpation of biceps and triceps

skinfolds between the finger and thumb is
also useful in assessing protein status in the
ill (13, 21).
For percent fat estimate for the above

sites, see Sports Nutrition: A Guide for the
Professional Working with Active People,
Tables 11.8 and 11.9 on pages 209, 210
(18).
Body Mass Index (BMI) (11, 13, 15, 17, 21)
Limitations of Skinfold Measurements
Both healthy and diseased persons have

short-term hydration-related body tissue
variations. People with CHF, liver and
kidney disease show pronounced fluid
shifts.
Equations used to predict fat mass (or
percentage body fat) and fat-free mass
are from skinfold measurements in
healthy populations and are not valid for
diseased populations.
Technique is critical to accuracy and
affected by observer error.
Differences in calipers and their
calibration can contribute to errors.
Some calipers consistently exert more
jaw force resulting in greater
compression and smaller values than
other calipers. Calipers should be
calibrated and re-calibrated routinely to
reduce errors.
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Assessment of Muscle Mass and

Subcutaneous Fat Stores in Critical Care
Patients
This is best done by inspection of muscle groups. Temporalis muscles, deltoids, suprascapular and infrascapular muscles, bellies of biceps, triceps and interossei of hands
should be observed and palpated. Long
muscle tendons that are prominent to
palpation are indicative of profound protein
depletion or 30% loss of total body protein
stores. This can be observed by appearance
and by palpating skinfolds between the finger
More frequently being used as the

method of determining obesity due to its
higher correlation with body fat rather than
body weight.
Body Mass Index = Weight (kg)
Height (m)2
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Body Mass Index = pounds x 705

(inches)2
Clinical Significance:
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Men
Acceptable weight
20.7 - 27.8
Intervention indicated > 26.4
Obesity
> 27.8
Severe Obesity
> 31.1
Morbid Obesity
> 45.4
Women
19.1 - 27.3
> 25.8
> 27.3
> 32.3
> 44.8
A nomogram may be used to determine

body mass index (11, 13, 21). Survival in a
person with a BMI below 14 is very unusual
(13).
ASSESSMENT OF CALORIE AND FLUID
NEEDS
Determination of caloric requirements
Definitions
Basal Energy Expenditure (BEE) is
represented by the Mifflin St. Jeor Equation
and used to predict basal metabolic rate:
BEE = BMR
Basal Metabolic Rate (BMR) is a
subject's energy expenditure measured in the
postabsorptive state (no food consumed
during the previous 12 hours) after resting
quietly for 30 minutes in a thermally neutral
environment (room temperature is perceived
as neither hot nor cold.)
Resting Metabolic Rate (RMR) also
known as Resting Energy Expenditure (REE),
is the term used for metabolic rate or energy
expenditure in the awake, resting,
postabsorptive (2 hours post meal) subject. It
is often measured by indirect calorimetry and
is approximately 10% higher than the BEE or
BMR (9).
Harris-Benedict Equation (15)
To calculate the BEE and subsequent
caloric requirement for men and women
follow the equation listed below, either using
the metric system or pounds and inches.
For men: BEE = 66.5 + 13.7(wt in kg) + 5.0 (ht in cm) 6.8 (age in years)
For women: BEE = 665 + 9.6 (wt in kg) + 1.8 (ht in cm)
- 4.7(age in years)
For men: BEE = 66 + 6.3 (wt in lbs) + 12.9 (ht in
inches) - 6.8 (age in years)
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For women: BEE = 655 + 4.3(wt in lbs) + 4.7(ht in

inches) - 4.7 (age in years)
To determine caloric requirements

using the BEE, multiply BEE by the
appropriate activity factor and injury factor.
Weight used may be adjusted ideal body
weight due to obesity as well.
Activity Factors
Injury Factors
Confined to Bed
1.2
Surgery
Minor
Major
1.0-1.2
1.1-1.3
Out of Bed
1.3
Skeletal or
Blunt Trauma
1.1-1.6
Normal ADLs
1.5
Head Trauma
1.6-1.8
Infection
Mild
Moderate
Severe
1.0-1.2
1.2-1.4
1.4-1.8
Burns (% body
surface area)
<20% BSA
1.2-1.5
20-40% BSA 1.5-1.8
>40% BSA
1.8-2.0
A1.9
Mifflin St. Jeor Equation (16)
To calculate the BEE and subsequent
caloric requirement for men and women
follow the equation listed below, either using
the metric system or pounds and inches.
Males: 9.99 X weight (kg) + 6.25 X height (cm) 4.92 X
age + 5.
Females: 9.99 X weight (kg) + 6.25 X height (cm)
4.92 X age 161.
For individuals who need to gain weight:

add 500 calories to their daily
requirement
For individuals who need to lose weight:
subtract 500 calories from their daily
requirement.
For additional calorie needs to provide
adequate calories with a fever, add 7% of
the BEE for every 1-degree over normal
using the Fahrenheit scale, or add 13% of
the BEE for every 1 degree over normal
using the Centigrade scale.
Calorie requirements = BEE (activity
factor + injury factor) + (calories for
desired loss or gain) + fever factor (16)
For paraplegics or quadriplegics,
calculate the BEE and use either 1.2 or
1.3 for activity factor, and injury factor as
appropriate.
For amputees, figure desirable body
weight as above, and either calculate BEE
with current height, if appropriate; or
multiplying desirable body weight using
the Hamwi formula described below.
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Hamwi Formula
To determine calorie need in nonmetabolically stressed individuals, this
formula is easy to use. Figure the individual's
weight from the height (see section B3b)
(17). Determine basal calories by multiplying
desirable body weight (DBW) in pounds by
10. Add activity calories based on level of
activity:
For sedentary activity multiply DBW by 3
For moderate activity multiply DBW by 5
A1.10
For strenuous activity multiply DBW by 10
Add additional calories as described

above for weight gain, or subtract for weight
loss.
For a small framed woman who is 5'8"
and sedentary and her current weight is 110
lbs.
5 feet = 100 lbs
8 inches = +40 lbs
140 lbs
14 for small frame
126
(x 10)
x 10 for basal calories

1260
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Kilocalorie per kilogram method
Used in non-metabolically stressed

persons, often when current weight is not
known. Convert ideal body weight based on
individual's height to kilograms. Multiply kilograms by factor representing weight status
and level of activity:
Light
refer
to
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IV
Estimation of protein needs can be

determined in several ways:
1000 for gain of 2 lbs per wk

2638 calories daily
Activity Sedentary
factor:
Over20
weight
Normal
25
weight
Under
30
weight
Strenuous: Walking uphill, activities involving

intermittent but frequent spurts of energy
(18).
DETERMINATION OF PROTEIN
REQUIREMENTS
(3 x 126) + 378 for sedentary activity

1638
Moderate: Frequent movements involving

arms and legs, walking briskly
For pediatric/adolescents
Pediatric Section of this manual.
(- 10%)
(+ 1000)
Light: Mostly seated or standing, with arm

movements
Moderate Strenuous
25
30
35
30
35
40
35
40
45-50
Activity levels should be determined

according to the type of activity that
comprises the major portion of the
individual's hours:
Sedentary: Confined to chair or bed rest.
Convalescing from debilitating disease.
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Predictive factors based on Recommended

Dietary Allowances per kilogram of body
weight
The requirements for healthy adults
(other than pregnant or lactating) are 0.8
grams of protein per kilogram per day (19).
This requirement
changes with specific
disease states and states of metabolic stress.
In general, patients who are starved but not
stressed require protein intakes of 1.0 gram
of protein per kilogram per day, while patients
who are highly stressed require a range of
1.5 - 2.0 grams of protein per kilogram per
day. Suggested guidelines are available to
assist the clinician in determining protein
requirements in specific disease states (13,
20, 21, 22).
Non-protein kilocalories to nitrogen ratio
Protein requirements can also be
determined by figuring appropriate nonprotein kilocalorie to nitrogen ratio. Generally,
for the non-stressed patient, the non-protein
calorie to nitrogen ratio should be 150:1. This
figure changes with specific diseases.
Stressed patients require a non-protein
calorie to nitrogen ratio of 80-100:1 (Note: 1
gram of nitrogen = 6.25 grams of protein)
(21).
Nitrogen balance studies
Protein requirements should be
routinely monitored via nitrogen balance
studies in stressed patients because
prediction of requirements is difficult in
septic, trauma, post-surgical or critically ill
patients. Note that nitrogen loss after injury
and infection is less than expected in the
elderly and in already depleted individuals
(23). Appropriate candidates for nitrogen
balance studies are catheterized patients on
reasonably well-defined nutrition support
regimens where energy intake and urinary
output is well controlled. Careful monitoring
of nitrogen intake is necessary for patients
receiving transitional or supplemental
feedings (13, 20, 21).
Determination of Fluid Requirements
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Multiple methods can be employed to

determine baseline daily fluid requirements
(20). Patients should have normal renal and
cardiac function to apply these predictive
factors. Use reference weight standards or
desirable body weight for obese patients and
actual body weight for others. RDA for water
in the normal, unstressed adult is 1 ml per
calorie of daily diet (18).
Adult requirements by age:
Method #1 (23, 32)

young active 16-30 years old: 40 ml/kg
average adult 25-55 years old: 35 ml/kg
older patients 56-65 years old: 30-35 ml/kg
elderly > 65 years old: 30 ml/kg
Method #2 (22, 32)
young adults vigorous with large muscle
mass: 40 ml/kg
adults 18-55 years old: 35 ml/kg
older adults >55 years old, with no cardiac or
renal disease: 30-35 ml/kg
Requirements based on body weight (22, 32)
A1.11
1000 ml for the first 10 kg of body weight

50 ml for the next 10 kg
for persons < 50 years: add 20 ml for each
additional kg
for persons > 50 years: add 15 ml for each
additional kg
Factors that
include fever, third
surgery or trauma,
suctioning, fistula
diarrhea, vomiting,
respirator (22).
increase fluid needs

space losses following
nasogastric tube for
and wound drains,
hyperventilation, and
Factors that decrease fluid needs

include cardiac or renal disease, and
dilutional hyponatremia (13, 20, 21).
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MEDICAL RECORDS REVIEW
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Medical History
The purpose is to provide detailed

information about past and present medical
problems. Some areas that affect nutritional
status are:
1. acute and chronic illnesses with
nutritional implications
2. hypermetabolic conditions
3. diagnostic procedures, therapies, or
treatments that increase nutrient needs
or induce malabsorption
4. surgical resections or diseases of the GI
tract, liver, gallbladder, or pancreas
5. alcohol or drug addiction
6. medications affecting appetite, digestion,
utilization, or excretion of nutrients
Medications
A thorough review of all medications an
individual is taking is necessary to determine
whether a drug-nutrient interaction could
impact their nutritional or medical status.
JCAHO continues to insist the RDs assume
responsibility for counseling on drug-nutrient
interaction. Use of over-the-counter
medications, e.g. laxative, analgesics, self-
prescribed vitamins, herbal products, or
experimental medications, should also be
identified.
Biochemical Assessment
While laboratory tests are used to
provide worthwhile information for evaluating
and managing nutritional status, they are
often influenced by non-nutritional factors.
Lab results can be altered by medications, hydration status, or other changes in metabolic
processes during illness or stress. Interpretation must include these confounding
factors (26). Values should be interpreted using the laboratory standards because assay
methods may vary among labs.
The major biochemical parameters for
assessing nutritional status can be divided
into those that measure lean body mass and
those that measure transport proteins that
are synthesized by the liver.
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Standard measurements of protein

status include serum levels of albumin,
transferrin, and prealbumin (transthyretin).
Because of their different half-lives, these
transport proteins can be used to assess an
individual's long-term (albumin with a half life
of 20 days), intermediate (transferrin with a
half-life of 8 days), and short-term
(prealbumin with a half life of 2 days) protein
status. Most readily available in lab reports is
albumin, with transferrin and prealbumin usually a costly, and frequently unseen test. Both
transferrin and prealbumin are most helpful
when fine-tuning a protein prescription for a
nutritionally depleted patient (1).
Hydration status is a common factor

that can falsely elevate or depress laboratory
parameters due to serum concentration or
third space losses (loss into interstitial
spaces). Estimated serum osmolality has
been suggested as a reliable measure of
body hydration status (20, 23, 26, 27).
Significant lab values should be interpreted
with caution if either dehydration or fluid
A1.12
overload is detected. Serum osmolality can
be estimated from serum sodium, blood urea
nitrogen, and glucose. All three are usually
available in even the most limited serum
chemistries.
mOsm/L = 2(Na + K) + BUN + Glu
2.8
18
Adult normal range is 280 - 295 mOsm/kg
Values may be increased with
dehydration, fever, insensible water losses,
burns, artificial ventilation, hyperglycemia,
glucosuria, high protein diets, IV sodium,
Addison's disease, and excessive losses as in
persistent vomiting or diarrhea.
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Values may be decreased in diabetes

insipidus, cerebral injuries with decreased
ADH, compulsive water drinking, aldosteronism, IV D5W, and fluid overload (20).
Other biochemical and urinary indications of hydration status include BUN/
creatinine ratio, urine specific gravity, serum
sodium, and hematocrit. Table 2 lists these
tests with values for dehydration, normal and
overhydration.
Hematologic Assessment (2, 3, 28)
Hematologic indices are used to
differentiate nutritional anemias from other
anemias. Nutritional anemias such as irondeficiency anemia and megaloblastic anemia
of B12 and folic acid deficiency are corrected
by replacement of the specific nutrient. In
non-nutritional anemias, such as the anemia
of chronic disease (seen in inflammatory
bowel disease and cancer), the mechanism
for the deficit may not be clear. Even though
routine laboratory studies may suggest iron
deficiency anemia, iron therapy may be
ineffective and even harmful.
Iron deficiency is the most common
single nutrient deficiency in the United States
and the most common cause of anemia.
Anemia refers to a hemoglobin level below
expected reference ranges and results from
infection, chronic disease, and deficiencies of
folate and vitamin B12. Medical management
for iron deficiency anemia includes
investigation of underlying causes including
inadequate nutrient intake, impaired utilization
or absorption, altered hematopoietic activity, or
blood loss.
Just as no single test is indicative of
malnutrition, no single laboratory test is
diagnostic of impaired iron status and several
different tests are used to assess iron status.
They may include hemoglobin, serum iron,
serum plasma ferritin, percent transferrin
saturation, red blood cell counts, red blood cell
protoporphyrin, or mean corpuscular volume
depending on the model requested. Additional
non-specific studies of inflammatory response
such as RBC sed-rate (red blood count
sedimentation rate or ESR), zeta-sedimentation
rate (SR), and C-reactive protein (CRP), allow for
discrimination between iron deficiency anemia
and the anemia caused by infection,
inflammation, and chronic disease. Red blood
cell indices typically include information on the
following:
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MCV (mean corpuscular volume): volume of

the red blood cell; increased values result in
macrocytosis (MCV > 100)
A1.13
of anemias.
Table 2. Assessment of Hydration Status (19)
Test
Dehydration
Norms
Overhydration
Est. serum
Osmolality
>300
280-295
mOsm/kg
<280
Urine
Specific
gravity
>1.035
1.035
1.003
g/ml
<1.003
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BUN:
creatinine
ratio
>25:1
Serum Na
Hct
10:1
<10:1
>148
135-145
mEq/l
<135
>52%
men
44-52%
men
<44%
>47
women
39-47%
women
<39%
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D
MCH (mean corpuscular hemoglobin): the

amount of hemoglobin in the red blood cells;
cells with low values are described as
hypochromic (MCH < 27)
MCHC (mean corpuscular hemoglobin
concentration): average concentration of
hemoglobin in the average red blood cell;
hypochromic at <320 gm of hemoglobin per
liter.
Typically cells in iron deficiency anemia
are hypochromic and microcytic while those in
B12 and folic acid deficiency show evidence of
macrocytosis. See Table 3 for summary of types
A1.14
TABLE 3- SUMMARY OF TYPE OF ANEMIAS
Hb Hct
MCV
Serum
Iron
TIBC
Transferrin
Saturation
Ferritin
RBC
Retic
Normal
or
Normal
or
Normal
or
Normal
or
Normal
or
Normal
, or
Normal
, or
Normal
Normal
Vitamin E
Normal
Normal
Chronic
Disease
Normal
Normal
Chronic
Infection
or
Normal
or
or Normal Normal
Iron
Deficiency
Vitamin B12
Folic Acid
T
S
E
Normal
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Written by: Judy E. Perkin, DrPH, RD, CHES,
Professor, Department of Public Health,
University of North Florida, Jacksonville and
Susan R. Mella, MS, RD, LD/N, Instructor,
Department of Biology and Health and
Wellness, Miami Dade College, North
Campus, Miami
Reviewed by: Michelle Ciccazzo, PhD, RD,
Associate Dean, College of Health and Urban
Affairs, Florida Atlantic University, Miami and
Judy Rodriguez, PhD, RD, LD/N, Professor,
Department of Public Health, University of
North Florida, Jacksonville
PRACTITIONER POINTS
RATIONALE AND USE
It has been stated that the health
promotion challenge confronting dietitians is
to connect peoples nutrition knowledge
with action and change.(1, pg.1,2). A large
body of dietetics and health education
literature notes that nutrition education and
nutrition counseling are health promoting
methods used by dietitians to increase
knowledge, alter attitudes, build skills, and to
ultimately help develop and maintain
appropriate health-related behaviors (1-15).
The literature recognizes that both nutrition
education and counseling need to have as a
foundation evidence-based information from
the sciences of food, dietetics, nutrition, and
health care (1-2, 4-18). Equally important is
that consideration needs to be given to client
or patient expectations, as well as
characteristics such as culture, age, gender,
educational and literacy levels, occupation,
religion, language, and lifestyle (5-15, 1926).
T
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Nutrition education may be accomplished at the individual, group, and community levels (7,10,22) or may involve
coordinated efforts targeting county, state,
national, or international populations (2, 10,
15, 27-30). Vehicles frequently used to deliver nutrition education include the following: classes, brochures, newsletters, self-
A2.1
study modules, written articles, posters, visual models, games, theatrical performances,
puppet shows, audiocassette tapes, grocery
store tours, food or cooking demonstrations,
food tasting events, magazines, newspapers,
television, videotapes, digital recordings, CDROMs, computer software, and the Internet
(7, 31-33). Examples of nutrition education
activities, as cited by Holli, Calabrese, and
OSullivan Maillet (7, pg.258), might include
the following: lectures, directed discussion,
debate, individual or group problem solving,
case studies, role playing and simulation,
demonstrations, and completion of projects.
Nutrition education may also be delivered
through messages on food product packaging, in product advertising, in food product
brochures, or via other promotional items designed to influence food or beverage consumption (11, 34). Frequently other creative
means are used to convey nutrition education messages (10). As an example, the
United States Department of Agriculture has
recently initiated use of a Food Safety
Mobile which is an automotive van designed
to deliver food safety messages by touring
across the country (35).
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Vaandrager and Koelen (36) have

advocated and described a collaborative,
community-based nutrition education approach which simultaneously involves a wide
spectrum of institutions (schools, retail food
outlets, restaurants, health organizations,
and consumers). Dietitians may want to consider this model or other collaborative models of nutrition education program design
that can effectively and efficiently
accomplish nutrition education objectives (2,
14, 37).
Nutrition counseling, as typically
described in the literature, involves the
establishment of a relationship of trust and
respect which addresses a clients nutritional
concerns through a goal-directed interchange between the client, or group, and the
dietitian (4-8, 38). Nutrition counseling is
generally accomplished in a dietitians pri-

vate practice office and/or in an institutional
setting such as a hospital or clinic (5-7). It
most frequently involves a one-to-one
interaction between dietitian and patient/
client, but can also occur in small groups (57, 22). Curry and Jaffe (5) emphasize the
problem-solving aspects of nutrition
counseling in Chapter 3 of their text and the
importance of culturally competent
counseling in Chapter 7. Holli, Calabrese, and
OSullivan Maillet (7) devote Chapter 8 of
their text to a discussion on the relationship
between nutrition counseling and cultural/life
cycle issues. Readers are directed to these
references for a thorough discussion of above
-stated topics.
THEORETICAL BASES OF NUTRTION
EDUCATION AND COUNSELING
Many practitioners and researchers
acknowledge that behavioral change theories
may help dietitians develop effective nutrition
education and counseling strategies. It has
been said that such theories may help dietitians understand how and why individuals
establish and alter dietary behaviors (5-8, 1012, 14). There are instances where more
than one theoretical framework may be used
in counseling and/or education (8, 9, 39) and
it has been advocated that dietitians may be
more effective as nutrition educators if this is
the case (7, 40). Laquatra and Danish (26,
pg. 1318) perceptively state that No model,
strategy, or technique works effectively with
everyone. Table 1 summarizes some of the
more common behavioral change theories
and models used in nutrition education and
counseling, provides example literature
citations, and gives examples of how the
theories or models may be used by the
dietitian (5-12, 14, 40).
T
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NUTRITION EDUCATION IN DIETETIC

PRACTICE
Contento et al. (14) reviewed over 200
studies of nutrition education programs and
focused on factors that contributed to their
A2.2
effectiveness. The report defined the following as contributing to nutrition education

program success 1) use of a behavioral
theory or theories; 2) use of techniques to
motivate program participants; 3)
incorporation of strategies to increase social
support and participant empowerment; 4)
use of environmental strategies to make
appropriate foods and beverages more
accessible; and /or 5) involvement of multiple
organizational partners in the delivery of
nutrition education messages.
The American Dietetic Association has
provided guidance for dietitians regarding
nutrition education for the public in a Position
Paper which advocates the use of a total
diet approach nutrition education message
(11). This guidance encourages the dietitian
to focus on messages related to moderation,
appropriate portion size, balance and
adequacy of the total diet over time, the
importance of obtaining nutrients from foods,
and physical activity (11, pg.100). In another
Position Paper, the American Dietetic
Association encourages dietitians to
collaborate with others and take leading roles
in disease prevention and health promotion
efforts which encompass the provision of
nutrition education, especially consumer
education (60).
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Texts and articles emphasize that the

process of nutrition education involves the
dietitian in multiple roles as an instructor, a
facilitator, a mentor, and a role model (2, 7).
Steps in the instruction process include the
following: 1) assessment of learning needs;
2) development of learning objectives; 3)
selection of educational content based on
audience needs and desires, as well as the
knowledge, skills, and motivations needed to
achieve objectives; 4) design and creation of
an appropriate learning environment; 5)
development or selection of appropriate
learning materials; 6) planning and
implementation of learning activities; and 7)
evaluation of the individual or group
educational experience (7).
A2.3
TABLE 1. BEHAVIORAL THEORIES AND MODELS USED IN NUTRITION EDUCATION AND

COUNSELING
Behavioral
Theory or Model
Name
Behavioral
Modification or
Behavioral SelfManagement
Description
This popular and

widely referenced
approach seeks to
condition behavior,
a term which denotes
linking a desired
dietary behavior to an
environmental
observation (5, 6, 7).
Those describing how
to use this approach
note that emphasis is
given to creating
behavioral change
through awareness of
cues or environmental
factors that trigger or
initiate dietary
behavior (5-8). Major
strategies described in
the literature to
implement this
approach are: selfmonitoring to identify
and modify behavioral
triggers (cues),
establishment of
nutrition behavior
goals, use of rewards
for appropriate eating
behaviors, seeing or
hearing about how
others handle a
situation, and
cognitive restructuring
to control
inappropriate thinking
about food (5-7, 41,
42).
Example Citations of
Nutrition Articles Using
Theory/ Models
Poston WSc 2nd, Foreyt

JP. Successful
management of the
obese patient. Am Fam
Physician. 2000; 61:
3615-3622.
Mossavar-Rahmani Y,
Henry H, Rodabough,
Bragg et al. Additional
self-monitoring tools in
the dietary modification
component of the
womens health
initiative. J Am Diet
Assoc. 2004; 104: 7686.
T
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Examples of How Theory/

Model May Be Used by
Dietitians
Nutrition EducationThe dietitian may facilitate a

group nutrition education
session on a dietary topic to
encourage client dialog about
factors that facilitate or cue
desirable and undesirable
dietary behaviors (6, 7).
E
IV
Nutrition Counseling- In order

to create an awareness of
environmental cues, several
texts suggest that the dietitian
ask a patient or client to keep
a log of consumption behavior
and also record related
environmental factors that
influence intake behaviors (5,
6, 7). Bauer and Sokolik (6,
pg.266) provide an Eating
Journal Behavior form that
may be used for this purpose.
Holli, Calabrese, and
OSullivan Maillet (7, pgs. 117
-119) provide an extensive
listing of behavior change
strategies that can be used in
nutrition counseling and also
on page 124 provide an
example for keeping a
behavioral management food
record.
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A2.4

COUNSELING
Behavioral
Theory or Model
Name
Consumer
Information
Processing
Theory
Description
Nutrition Articles
Using Theory/ Models

Dietitians
This theory, described

by Rudd and Glanz (43)
and Rosal (8), highlights
the need to present
dietary information
when persons are
receptive to receiving
the message, and also
stresses the importance
of nutrition information
being presented in a
manner that the client
or audience can
understand.
Rosal MC, Ebberling

CB, Ockene JK, Ockene
IS, Hebert JR.
Facilitating dietary
change: the patientcentered counseling
model. J Am Diet
Assoc. 2001; 101: 332
- 338, 341.
Nutrition EducationA dietitian may initiate a

nutrition education program
when he/she becomes
aware of community interest
in, and receptiveness to,
learning about a nutrition
topic. The resultant nutrition
education program
messages could be pretested to ensure that the
messages are interpreted
correctly by the intended
recipients of the nutrition
education (8, 43).
T
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Nutrition CounselingThe dietitian could ask

questions to ascertain client
readiness to receive a
nutrition message and could
also use communication
techniques and informal
tests of understanding to
ensure that information
shared with the client was
interpreted properly (8, 43).
A2.5

COUNSELING
Behavioral
Theory or Model
Name
Diffusion of
Innovations
Description
Nutrition Articles
This model postulates

that a new food
behavior could be
adopted in five stage
which have been
outlined as: 1)
knowledge of the new
behavior; 2)
development of a
positive attitude toward
the new behavior; 3) a
decision to adopt the
behavior; 4) adoption of
new behavior; and 5)
reinforcement of the
decision to adopt the
new behavior (7, 10,
44). This model speaks
not only to individual
dietary change but has
been used to classify
members of a group in
terms of diffusion
behavior stages labeled
in a continuum from
early to late adopters of
a dietary change
behavior (10).
1) Sigman-Grant M.
Can you have your low
fat cake and eat it too?
The role of fat-modified
products. J Am Diet
Assoc. 1997; 97 (7
Supple): S 76-81.

Dietitians
Nutrition Education- The

dietitian could use the
Diffusion of Innovations
approach to ascertain the
nutrition message most
appropriate for and attractive
to the target population or
population subgroups. A
2) Pollard C, Lewis J,
nutrition education message,
Miller M. Start right-eat for example, may be designed
right scheme:
to develop a positive attitude
implementing food and about a food by showing the
nutrition policy in child food consumed by an
care centers. Health
attractive person with a
Educ Behav. 2001: 28- healthy appearance (7).
320-330.
Nutrition Counseling- The
dietitian in counseling can
use this model to establish
counseling goals that are
appropriate to the clients
innovation stage. An example
might be to help the client
devise a goal and strategies
related to maintaining a new
behavior, such as increased
vegetable consumption (7,
10).
T
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A2.6

COUNSELING
Behavioral
Theory or Model
Name
Description
Nutrition Articles

Dietitians
Social Cognitive
(Social Learning)
Theory and the
Concept of SelfEfficacy
This theory, frequently

referenced in works
describing nutrition
education and
counseling efforts,
focuses on interactions
between humans and
their environment and
stresses the concept of
self-efficacy, acquisition
of knowledge and skills,
and learning through
doing the behavior
ones self or observing
the action or behavior
of others
(5-8, 10, 14, 50).
1) Hindin TJ, Contento

IR, Gussow JD. A media
literacy nutrition
education curriculum
for Head Start parents
about the effects of
television advertising
on their childrens food
requests. J Am Diet
Assoc. 2004; 104: 192198.
Nutrition EducationEmploying the notion of

learning through
observation, the dietitian
could design a nutrition
education program using
target population peers to
design, deliver, and role
model the relevant nutrition
education messages
(5-8, 10, 12, 14).
2) Resnicow K, Wallace
DC, Jackson A,
Digirolamo A, Odom E,
Wang T et al. Dietary
change through African
American churches:
baseline results and
program description of
the Eat for Life Trial. J
Cancer Educ. 2000
Fall; 15: 153-163.
Nutrition CounselingBauer and Sokolik (6, pg.6)

point out that nutrition
counseling methods such as
reinforcement, behavioral
contracting and tracking
aid in the development or
strengthening of client selfefficacy. Numerous other
texts on counseling (5-8, 10)
also suggest strategies for
dietitians that are based on
the social cognitive theory.
T
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A2.7

COUNSELING
Behavioral
Theory or Model
Name
Description
Theory of
Reasoned Action
and Planned
Behavior
This theory has been

used in nutrition
education studies to
link dietary and other
health behavior to the
concept of behavioral
intent that is believed to
be determined by 1)
attitude, 2) subjective
norms, and 3) the
perception of how
difficult behavioral
performance will be.
Subjective norms, in the
literature discussing the
Theory of Reasoned
Action and Planned
Behavior, have been
defined as reflections of
social pressure
related to engaging or
not engaging in a
dietary behavior
(10, 51-53).
Nutrition Articles
1) Kim K, Reicks M,
Sjoberg S. Applying the
theory of planned
behavior to predict
dairy product
consumption by older
adults. J Nutr Educ
Behav. 2003: 35: 294301.

Dietitians
Nutrition EducationThe dietitian could use this

theory to do the following:
1) design nutrition education
programs that would
develop positive social
norms about a nutrition
topic; and 2) highlight
behavioral strategies to
change diet that would be
2) Robinson R, Smith C. perceived as realistic and
Psychosocial and
achievable by members of
demographic variables the educational target group
associated with
(10, 51-53).
consumer intention to
purchase sustainably
Nutrition Counselingproduced foods as
In counseling, the dietitian
defined by the Midwest could reinforce clientFood Alliance. J Nutr
perceived norms supporting
Educ Behav. 2002; 34: desirable nutrition behavior
316-325.
change. The dietitian could
also work with the client to
3) Chase K, Reicks M, develop skills, attitudes, and
Jones JM. Applying the social circumstances that
theory of planned
would support the relative
behavior to promoting ease of desired dietary
whole-grain foods by
behavioral change
dietitians. J Am Diet
(10, 51-53).
Assoc. 2003; 103:
1639-1642.
T
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A2.8

COUNSELING
Behavioral Theory
or Model Name
Description
Transtheoretical or This model has been

Stages of Change widely adapted for use by
Model
dietitians and postulates
that behavioral change
occurs in stages related to
thought and action ranging
from precontemplation
(stage 1) where there is no
thought about a change in
behavior to maintenance
(final stage 5) where
behavior is displayed for
six months or more. Most
texts place the following
stages between the first
and fifth stages of the
model
contemplation (stage 2),
preparation (stage 3),
action (stage 4) (5-8,
10). At least one text (7)
also adds a stage of
termination after the
maintenance stage. This
model envisions
individuals moving through
changes or stages in a non
-linear manner, with return
to an earlier stage
possible
(5- 8, 10, 54-56).
Nutrition Articles Using
Theory/ Models

Dietitians
Nutrition EducationAs discussed in the literature,

dietitians have used this theory
to formulate nutrition education
content and strategies to match
the behavior state or stages of
the population or populations
desiring of or in need of dietary
behavior change (56-59). For
example, for an audience in the
2) Bass M, Turner L, Hunt pre-contemplation stage, the
S. Counseling female
nutrition education message
athletes: application of
could be aimed at sparking
the stages of change
awareness of a topic (10, 54model to avoid disordered 59). Alternatively if the
eating, amenorrhea, and audience is in the preparation
osteoporosis. Psychol
stage, the nutrition education
Rep. 2001; 88 ( 3 Pt 2):
program content might include
1153-1160.
and focus on specific tips to
enable the start of change (10,
3) Finckenor M, Byrd54-59).
Bredbenner C. Nutrition
intervention group
program based on stage- Nutrition CounselingBauer and Sokolik (6, pg.60)
oriented change
provide a visual approach to
processes of the
assessment of nutrition-related
Transtheoretical Model
stage of change and also
promotes long-term
reduction in fat intake. J outline three categories of
counseling strategies based on
Am Diet Assoc. 2000;
client stage ( 6, pg.70).
100: 335-342.
Kristal, Glanz, Curry, and
4) Greene GW, Rossi SR, Patterson (59) also provide very
Rossi JS, Velicer WF, Fava specific guidance with regard to
JL, Prochaska JO. Dietary using the transtheoretical
applications of the stages model to counsel patients.
of change model. J Am
Curry and Jaffe (5, pg.132) link
Diet Assoc. 1999; 99:
problem-solving aspects of
673-678.
counseling to the five
behavioral stages described in
5) Nitzke S, Auld G, Mc
Nulty J, Bock M, Bruhn C, the Transtheoretical model.
1) Steptoe A, PerkinsPorras L, Mc Kay C, Rink
E, Hilton S, Cappuccio FP.
Behavioral counseling to
increase consumption of
fruits and vegetables in
low income adults: a
randomized trial. Brit J
Med. 2003; 326:855.
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Gabel K et al. Stages of

change for reducing fat
and increasing fiber
among dietitians and
adults with diet-related
chronic disease. J Am Diet
Assoc. 1999: 99: 728731.

Holli, Calabrese, and OSullivan Maillet
(7, pg.212) discuss extensively how cognitive,
social, and behavioral theories have been
modified to deal with the issue of learning in
the context of nutrition education. These authors note that the cognitive approach
emphasizes asking questions, using repetition, establishing goals, and bringing new information into the persons memory. They
characterize social learning theory as stressing the importance of positive role modeling,
as well as observation and practice. And
finally, these authors state that behavioral
theories, as applied to the learning environment, focus on giving positive reinforcement
for acquisition of new knowledge and skills.
In addition to behavioral change
theories, nutrition education efforts may draw
on age-related theories specific to education
and learning (7). Important in this regard for
dietitians is the distinction made between
pedagogy (that deals with children as
learners) and andragogy (that deals with
adult learners) (7, 10).
T
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Pedagogy, based on characteristics and

needs of children, may emphasize acquisition
of knowledge and development of healthy
eating habits (10). Strategies of pedagogy
often focus on making learning fun and
hands on activities, as well as the use of
rewards and incentives (7, 10). Descriptions
of many excellent nutrition education
programs for children can regularly be found
in nutrition education and dietetics journals.
Examples are: The Food Friends: Making
New Foods Fun for Kids (61), a program
designed to teach children nutrition through
drawing and coloring (62), using a nutrition
calendar to promote childrens consumption
of fruits and vegetables (63), and
incorporation of garden activities to positively
influence childrens views of vegetables (6465).
In many hospital, clinic, and community

settings, dietitians may be dealing with adult
learners (6, 7, 10). The principles of
A2.9
andragogy , articulated by Knowles (66) and

summarized by nutrition education and
counseling texts, emphasize that
adult
learners have unique characteristics that
include: focusing on learning self-defined as
relevant and important, engaging in
learning more of their own free will, and
bringing life experiences and the need to
solve problems into the learning environment
(6, 7, 10). Examples of nutrition education
programs targeted to adults include: a
curriculum designed to teach dietary control
principles to persons with Type 2 diabetes
mellitus (67), development of brochures to
teach weight management principles (68),
use of cooking classes to promote low fat
dining (69), implementation of a workshop to
teach food money management and
government dietary advice (70), development
of manuals and uses of classes to aid in
development of positive body images (71),
and use of the Internet and newsletters to
deliver nutrition education messages to the
elderly (72-73).
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Learning needs related to nutrition may

be assessed through testing, surveys,
interviewing, focus groups, observation, or
through inference via an analysis of
nutritional problems (3, 7). As learning needs
are assessed, the dietitian can also ask
questions to ascertain receptiveness and
ability to change dietary behaviors (6, 7, 8).
Differences in learning style have also
been noted as being important in nutrition
education (6, 7). The dietitian, as an
educator, needs to be aware of the ways that
individuals learn most readily. For example,
some learners may be more visual, some
more auditory and others may learn most
effectively through techniques that
emphasize practice or hands on activity (7).
Once learning styles have been
assessed, specific learning objectives for the
nutrition education effort should be written in
order to clarify the intended learner outcome
or outcomes of the nutrition education

program or session (7, 10). Objectives can be
written using verbs describing anticipated
knowledge or skill gains, and should be
measurable so that learner evaluation can
assess the extent to which the objectives
were attained (7, 10, 74). Learning objectives
can be placed in categories called domains
which address major outcomes of nutrition
education such as knowledge (the cognitive
domain), skills (the psychomotor domain), or
beliefs and/or values (the affective domain)
(7, 74). Shown in Table 2 are example learner
objectives and learner evaluation strategies
for each domain (7).
It may be helpful, or in some cases
mandatory, to develop specific lesson plans
for a nutrition education session or program
(7, 10). Components of a nutrition education
lesson plan may include a description or listing of the following: 1) the name or title of the
nutrition lesson; 2) audience characteristics
and expected numbers of participants; 3)
learning objectives; 4) time or duration of lesson; 5) a learner assessment method related
to determination of existing knowledge level,
skill level, or attitudes; 6) main points to be
covered in the lesson; 7) learning activities
and/ or discussion points; 8) educational
materials to be used ( including handouts); 9)
equipment needed; 10) supplies needed and
11) post-lesson evaluation methods related
to the learning of the individual or of the
group (7, 10). Readers are referred to Holli,
Calabrese, and OSullivan Maillet (7, pgs.282
and 283) for examples of nutrition education
lesson plans.
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The environment in which nutrition

education takes place is important and may
influence educational outcomes as well (7,
10). Design and creation of a learning
environment should address the physical,
psychological, social, and cultural aspects (7,
10). Nutrition education sessions should be
located in venues or facilities that are easy
for the target group to locate and reach (10).
A physical environment conducive to learning
is one that allows hearing, seeing, and
A2.10
appropriate interaction (7). The room should

be a comfortable temperature with
appropriate types and numbers of seats (7,
10). If needed, the room should contain the
appropriate technological equipment in
working order and additional teaching
materials, including handouts, that could be
used if needed (7). In some instances, the
physical environment may be under less
control and therefore be potentially more
variable. For example, learners participating
via a computer or video connection at a
distant site may have multiple distractions
not amenable to instructor control (7). In
terms of an ideal psychological and social
environment for nutrition education, it has
been noted that the environment should be
respectful, interactive, and perceived as
accessible, understanding, and equitable (7,
10).
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The literature describes the process of

social marketing as employing concepts
related to marketing of commercial products
and services, and applying these to health
and nutrition with the goals of changing
attitudes and behaviors (10-12, 76, 77).
Social marketing is used in nutrition
education to develop nutrition education
programs that reflect the priorities and
culture of the defined audience (10, 12). The
programs content, format, strategies and
materials can be developed and assessed by
obtaining input from those who are to be the
recipients of the education (10, 12).
Examples of nutritional education programs
using the social marketing approach are
Project LEAN (Low Fat Eating for America
Now) (12, 78), the U.S. Department of
Agriculture Team Nutrition Initiative (79), and
the 5-A-Day campaign (11, 12). Social
marketing has also been used to develop
nutrition education messages for specific
cultural groups at the local level (80).
Additional information on the use of social
marketing to promote health can be found on
the American Public Health Association
website (81). The Boyle text (10, pg.557) also
provides an extensive list of resources on

Written by: Leslene Gordon, PhD, RD, LD/N,
Community Health Director, Hillsborough
County Health Department
Reviewed by: Victoria Martinez, RD, LD/N,
Public Health Nutrition Consultant, Lois J. Waltz,
RD, LD/N, Senior Public Health Nutritionist,
Cindy Hardy, RN, Assistant Community Health
Nursing Director and Barbara Roberts, MS, RD,
LD/N, Nutrition Consultant
PRACTITIONER POINTS
INTRODUCTION AND BACKGROUND
The term diverse refers to differences.
The many ways that Americans differ from
each other cannot be addressed within the
scope of this section. The focus then is on
cultural and religious diversity relevant to
the practice of dietetics.
Over recent years, demographic data,
including the United States Census reports,
have indicated a continuing increase in the
number of minority and ethnic populations.
It has been noted; however, that though
these increases are significant, they may
underestimate the actual numbers. Data
may not accurately categorize or count
those of mixed ethnicity or ancestry or
whites from other ethnic groups.
Additionally, the categories used can be
confusing to respondents. For example,
some citizens who have been historically
referred to as black but born outside of the
United States may not select African
American as the category to define
themselves.
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Further, the census does not record many

who reside in the U.S. but are not citizens
(1). Regardless of the actual numbers and
percentages, America continues to be one
of the most racially and ethnically diverse
populations in the world. This is a fact that
cannot be ignored by health professionals,
including those in the dietetics or nutrition
profession. There is significant evidence
that minority groups in America have
A3.1
disproportionately higher morbidity and

mortality rates for many chronic diseases
(2). Efforts to reduce these disparities have
become a major public health focus.
Ethnicity, and more broadly culture, has a
significant impact on disease development,
disease prevention, and treatment. The
nutritional status of an individual and the
steps that need to be taken to bring about
diet-related behavior change are greatly
impacted by culture.
A variety of definitions exist for the term
culture. Culture is a social identity and can
be broadly described as the learned
patterns of beliefs, attitudes, values,
customs and habits that are accepted by an
individual or a population. Culture is
dynamic and always changing. Religious
food habits are also a consideration for
many groups and an important part of their
identity (3). The diet related requirements
and regulations associated with Jewish,
Muslim, and Seventh Day Adventist
religions, to name just a few, can
sometimes be very specific and cannot be
ignored.
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Varied ethnic groups have their own

culturally derived foods and food habits.
These habits are not always the same even
within similar ethnic groups and change as
individuals and groups become assimilated
and acculturated. Some ethnic foods and
food habits may even become integrated
into the food ways of the mainstream
population. For example, tofu lasagna is an
American dish obviously born of Italian and
Chinese influences. The previously
mentioned factors help to complicate
matters and increase the need for a
culturally competent approach when
providing nutrition-related services.
APPLICATION
The culturally competent approach involves
having knowledge of the ethnic groups one
routinely works with, recognizing personal

biases, understanding the cultural
differences, and being able to communicate
effectively across cultural lines (4). Utilizing
effective listening, facilitating feedback,
encouraging client involvement, facilitating
behavior change and shared goal setting
are aspects of nutrition counseling that
should be employed especially when
counseling in a multicultural setting.
Gaining detailed information on the client or
patient from another culture is essential to
facilitate appropriate counseling and
increase the potential for diet-related
behavior change. Information can be gained
from a variety of books and electronic
sources but the nutrition professional
should not exclude information gained from
interviewing the client and others in the
ethnic group. Visiting food markets or ethnic
grocery stores and restaurants are also
good ways to become more informed. As
information is gained, it is important to
avoid stereotyping as we apply or use the
information. Individuals identified within a
specific group may not share all the same
values, beliefs, attitudes or behaviors of
their cultural group. Asking questions
becomes even more important so that
patients are seen and treated as
individuals, rather than as total
representation of a selected group.
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The following approach may be taken to

provide medical nutrition therapy or
preventive nutrition services to a culturally
diverse audience.
A. Understanding Your Own Worldview
The information needed to achieve success
in a multicultural setting actually begins
with the nutrition professional. Our
attitudes, values, opinions and how they
impact our behavior, decisions and how we
see life are based on our culture and would
be considered our worldview. For example,
we may have a worldview that is in line with
germ theory, i.e. microorganisms cause
disease. This may be very different from the
A3.2
worldview of others who believe that

diseases are often caused by spiritual or
supernatural forces or an imbalance in
nature. Another example would be a
provider who believes that the patient has
the ability or power to change his or her
health status and is faced with an individual
who feels that the progress of his disease is
not his to control or beyond his power to
control. It is therefore necessary that the
provider understand the potential for
cultural bias and how it may affect the
interaction with the patient, client, or group.
Understanding one's own cultural
perspective and recognizing that while
different they are not inferior or superior will
assist the practitioner in communicating
effectively. It further reduces the potential
for imposing one's worldview on others.
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Actions:
1. Consider your own cultural values and
biases.
2. Accept cultural differences without being
judgmental or discarding your own values.
3. Consider potential inherent biases in
measurement and assessment tools. Are
they
appropriate for measuring or evaluating
the population with whom you are working?
4. Be flexible and open to adapting your
counseling approach or procedure to where
practical, meet the needs of the patient,
client, or group (5).
B. Gaining General Background Information
It is necessary to gain information from the
client that may not directly relate to the
disease or specific nutrition concerns. The
information may be more demographic in
nature, but is relevant for assessment and
intervention.
Actions:
Determine specifically what the cultural
background is, as identified by the
individual. The broad term Hispanic, for
example, includes individuals of varied

races and ethnicities.
Gain health statistic data for the target
group. What are disease incidence rates
and what health conditions are most
prevalent in that group?
Determine if the individual is a recent
immigrant. If not, are traditional cultural
values maintained?
Determine the level of education and level
of fluency or language skills.
Religious affiliation, if relevant, including
level of orthodoxy or specific sect or group,
needs to be determined.
When relevant, specifics related to religious
dietary guidelines, holy days, holidays and
periods of fasting also need to be
recognized.
Are there barriers or limitations that may
affect dietary intake? These need to be
explored. For example, socioeconomic or
financial limitations, availability of
traditional foods, and knowledge of foods
available in U.S. supermarkets.
Determine family structure and the role of
family members as it relates to responding
to provider recommendations or making
health-related decisions.
Are there beliefs or values associated with
hierarchy, power and respect based on age,
sex, and place in the family or titles? These
factors must also be given some
consideration.
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C. Communication
To a great degree our success as dietetic

professionals depends on how effectively
we are able to communicate. It is our
professional responsibility to take steps that
will facilitate good communication with the
client, our patient. Ineffective
communication results in confusion,
noncompliance, poor outcomes and
dissatisfied or angry clients. To change
deeply rooted food habits or behaviors, we
must develop rapport with the client,
establish a trusting relationship, show
respect and empathy, deliver a clear
message, and gain the client's involvement
A3.3
and cooperation. Customs related to eye

contact, personal space, gestures, touching,
and the format used to verbally present
information varies greatly among cultures.
Gaining basic knowledge of the cultural
values, beliefs and practices for the specific
population you are working with is essential
for good cross-cultural communication. The
following actions, though limited, will assist
in communicating across culture lines.
Actions:
Establish rapport with the client. A
courteous, respectful verbal greeting is
appropriate in almost all cultures. Initial
formality is often acceptable until you have
gained information on how the patient
prefers to be addressed.
Arrange for a trained interpreter if needed.
Speak directly to the client even when using
an interpreter.
Avoid body language or touching that may
be misunderstood.
Speak clearly and choose a speech rate and
style that promotes understanding and
demonstrates respect.
Avoid slang, technical jargon, and complex
sentences.
Ask questions, listen carefully, and do not
assume anything. As much as practical, use
open-ended questions phrased in several
ways when necessary to obtain information.
Do not hesitate to explain to clients why the
information is necessary.
Encourage patients to ask questions and
make it clear that you are comfortable with
their questions.
Determine the patient's or client's reading
level or ability before using written
materials.
As
you
consider
presenting
recommendations, build on cultural
practices, reinforcing those that are positive
and promoting change only in those that are
harmful.
Though the practitioner is often seen as the
expert, it is important to base the format of
your presentation on your knowledge of the
individual and cultural group. For example,
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choosing a participative or authoritative
style, or being very direct versus being less
explicit should depend on your knowledge of
the individual.
Evaluate the client's understanding and
acceptance of your discussions and
recommendations.
D. Health Beliefs
The beliefs the client or patient may have
related to health in general or their specific
condition are culture-bound. The individual's
perceptions, beliefs and explanations for
what causes or cures disease or maintains
good health may be very different from
those of the provider. We have, as
providers, been trained in the context of the
biomedical paradigm. For the most part,
nature, fate, divine intervention or other
similar factors are not essential
considerations when providing treatment.
We assume that our scientific perception of
disease conditions and the steps that need
to be taken to prevent them or cure them
are congruent with those of the patient's.
This may not be the case. The dietitian must
gain specific information on the health
beliefs and values of the individual or group.
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Actions:
Helpful information to have includes
What does the individual call the sickness
or illness, what does he or she think caused
it, and what are its effects?
Does the client believe the condition can be
cured?
What does the client believe the cure for the
condition involves?
Does treatment include culturally traditional
treatment, folk or home remedies, or the
involvement of a cultural or folk healer?
Are alternative therapies being utilized?
Does the client have certain specific beliefs
related to food and health? Are specific
foods required to achieve and maintain
health (6)? Are specific foods selected or
avoided based on the type of illness or life
condition, such as pregnancy?
A3.4
Are there spiritual or supernatural

dimensions associated with health, illness,
or diet?
How is health defined?
Are there differing views related to the body,
body image, and size and how do these
reflect health or illness? Is being very lean,
for example, a sign of illness?
E. Food Ways, Beliefs and Practices
Food and what is considered edible or
inedible largely depends on culture. Corn,
which is enjoyed by most Americans, for
example may be considered fit only for farm
animals by the French. Eating and what is
eaten is often associated with religious
beliefs, ethnic behaviors and is reflective of
cultural heritage and identity. Culture-based
food habits are often the last things to
change even in individuals who adopt new
cultural norms. Core foods (staples regularly
included in the diet in unmodified from),
such as rice, are often the last things to be
eliminated from the diet. However,
assumptions cannot be made about an
individual's consumption based only on
general information related to their ethnic
or cultural group. For example, many African
Americans do not regularly consume a more
southern cuisine, "Soul Foods", as is
sometimes assumed. Individuals may hold
to traditional dietary practices or may adopt
mainstream food habits in varying degrees.
The following should be included in
assessment and planning when working
with different cultural groups.
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Actions:
Information that may need to be gained
includesAre there specific religious guidelines or
restrictions related to intake?
Are traditional foods available, are they
consumed, how often? Are there traditional
core foods that are consumed or required
for meals?
Are there unusual foods that are consumed

that have not been included in the
standardized tool for assessing intake?
Are foods given any beneficial or
detrimental value related to specific health
conditions?
Are there foods that are routinely restricted
from the diet because of taboos or other
cultural restrictions?
Who traditionally controls food purchase
and preparation? What are the traditional
food preparation methods used?
What non-traditional foods are eaten and
how often?
What is the typical meal pattern or how
many meals are eaten per day?
What is considered healthy eating? Does it
relate to specific food groups and/or the
amount of food or serving size eaten?
What beliefs and symbolisms are
associated with food and eating? Is eating a
social event with associated rituals? Does
offering abundant foods indicate hospitality,
generosity, and wealth?
What food related celebrations, holidays
and holy days are relevant?
Is the individual open to making changes in
traditional foods that may be detrimental to
the individual? Are there appropriate foods
within the traditional diet that may be used
to substitute for foods that need to be
avoided?
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We do not live in a cultural vacuum. For

most individuals, culture and ethnic identity
are a source of pride. The associated norms
provide stability and direction in our lives.
All of us are affected by beliefs, attitudes
and values that shape our perceptions that
are related to health in general and food,
specifically. These perceptions are learned
over time and are not easily changed.
Specific efforts must be made by the
nutrition professional to facilitate behavior
change in a culturally diverse environment.
Positive national health outcomes cannot
be achieved without these efforts. Further,
the Code of Ethics for the Profession of
Dietetics challenges dietetic practitioners
A3.5
under one of its principles to "provide

professional services in a manner that is
sensitive to cultural differences and does
not discriminate against others on the basis
of race, ethnicity, creed, religion, disability,
sex, age, sexual orientation, or national
origin"(7).
REFERENCES
1. Kittler PG, Sucher KP. Food and Culture
in America. A Nutrition Handbook, 2nd
Edition. Belmont, CA: Wadsworth
Publishing Co: 1998.
2. U.S. Department of Health and Services.
Health People Washington DC: U.S.
Printing 2000.
3. Bronner, Y. Cultural Sensitivity and
Nutrition Counseling. Top. Clin. Nutr.
1994;9(2): 13-19.
4. Curry KR, Jaffe, A. Nutrition Counseling
and Communication Skills. Philadelphia,
Pennsylvania: W.B. Saunders Co: 1998.
5. Ponterotto JG, Casas JM, Suzuki LA,
Alexander CM Handbook of Multicultural
Counseling. Thousand Oaks, California;
SAGE Publications Inc:1995.
6. American Dietetic Association Dietitians
of Canada. Manual of Clinical Dietetic.
6th Edition, 2000.
7. The American Dietetic Association.
http://www.eatright.org/ Accessed
January 15, 2009.
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Adult Obesity Prevention and Treatment

Written by: Susan Moyers, PhD, MPH, LD/N,
Department of Exercise Science and Sports
Studies, University of Tampa, Tampa
Reviewed by: Amy E. Bowersock, PhD,
FACSM
PRACTITIONER POINTS
Obesity Synopsis
Nearly two-thirds of adults in the
United States have crossed the BMI
thresholds and are now classified as either
overweight (BMI=25.0-29.9), or obese (BMI
=30) (1). Rates of obesity have doubled
since 1980, and the World Health
Organization now labels obesity a global
epidemic (2). In Florida, since 1986 when
monitoring began, obesity among adults has
has almost tripled increasing from 9.8
percent to 26.5 percent in year 2009 (3). In
2009, 36.9 percent of Florida adults were
overweight, or approximately 7,341,036
individuals living in our state.
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Much of what we know about rates of

overweight and obesity comes from the
Behavioral Risk Factor Surveillance System
(BRFSS). The BRFSS is an ongoing, statebased random-digit dialing survey organized
and produced by the US Centers for Disease
Control and Prevention.
Overall, in the United States, obesity

has been estimated to account for up to nine
percent of national health expenditures, up
to $147 billion in 2006. Health care
spending is 42 percent higher for obese
individuals compared with individuals of normal weight(4); and, most notably, medication
costs are 77 higher among the obese (5).
We now know that obesity is a
predictor of many adverse health conditions.
Indeed, a growing number of factors suggest
that obesity is a gateway - that is, a gate that
once passed through, dramatically increases
the likelihood of impaired quality of life and
chronic disease. Some analysts have
B1.1
projected that obesity has about the same

association with chronic health conditions as
does twenty years of aging, and greatly
exceeds the associations of smoking or
problem drinking (5). Life-table analysis has
estimated that 5.8 to 7 years of life may be
lost due to obesity among non-smokers, and
approximately 13 years of life may be lost
among obese smokers (6). If we can
decrease or prevent obesity, we can
ameliorate many of these conditions, which
would substantially impact quality of life as
well as health care costs.
Being obese carries an increased risk
of illness from hypertension, lipid disorders,
type 2 diabetes, coronary heart disease,
stroke, gallbladder disease, osteoarthritis,
sleep apnea, and respiratory problems.
Several forms of cancer are highly correlated
with body fatness, including cancers of the
colon, endometrium, prostate, kidney, and
breast. A recent study from the American
Cancer Society concluded that 14 percent of
all cancer deaths among men, and 20
percent among women are attributable to
overweight and obesity (7). Recent evidence
also associates obesity with rising rates of
non-alcoholic liver disease, and death from
cirrhosis among non-drinkers (8). In addition
to health consequences and costs, there are
other economic repercussions from obesity,
as higher BMI predicts increased job
absenteeism and work-hours foregone (9).
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A trend of particular concern is the rise

in morbid obesity (class 3 obesity, BMI > 40),
which has grown faster than obesity itself.
Data from the Behavioral Risk Factor
Surveillance System survey indicate that in
the year 2009, 2.2 percent of adult Americans were classified as morbidly obese. The
rates were highest among African-American
women (6 percent) (10). From 2001 to
2005, the percentage of adults with a BMI
>40 rose from 8.9 percent to 52.0 percent,
and those with a BMI >50 rose from 12.5
percent to 75 percent.(11). These extreme
BMI levels are associated with the most

severe health complications.
A once-accepted belief is that obesity
represents a self-induced state of overnutrition due to lack of willpower or weakness.
This paradigm is now replaced by the understanding that obesity is very complex and
involves social, cultural, genetic, biological,
environmental and developmental factors.
Scientists are especially interested in
identifying and understanding molecular
components that contribute to obesity, as
well as genetic determinants. Studies so far
have shown that, in humans, obesity is
seldom caused by a single gene, but is due
more to the interaction of a genetic proclivity
to obesity coupled with many other factors. A
great deal of study is focused on various
molecules believed to help regulate body
weight, adiposity, and energy expenditures.
Recent discoveries of leptin, ghrelin, and
several dozen other components of weight
and appetite regulation help clarify our knowledge of obesity. But despite the fascinating
results of studies, it remains that we are still
somewhat in the dark and there is no scientific consensus about the neurochemical and
endocrine pathways leading to obesity.
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While scientific opinion varies about

causes and contributors to obesity, almost
always the equation energy inputs vs.
energy outputs forms the basis for
understanding the trends. The dietary trends
are clear when we compare changes in eating
patterns over the past 30 to 40 years. Major
shifts are seen, including an increase in total
daily kcal intake, larger portion sizes; large
increases in consumption of snacks, soft
drinks and pizza (12, 13, 14). To cite one
example, Nielson and Popkin (15) report that
between 1977 and 1998, average portions
for hamburgers and salty snacks increased
by about 100 kcal, French fries by 68 kcal,
and soft drinks by 49 kcal.
Some experts suggest that the rise in
overweight and obesity can be traced, at
least in part, to the increase in habitual sodadrinking and snacking, and the widespread
B1.2
use of high fructose corn syrup as a

sweetener by the snack and beverage
industries (16). Fructose does not promote insulin secretion and is preferentially metabolized to lipid in the liver, thus contributing to
weight gain. USDA disappearance data
indicate that per capita intake of fructose
from combined sources was 62.4 pounds per
year, or approximately 77 grams (306 kcal)
per day in 1997. Almost three-quarters of this
fructose intake came from soft drinks (12).
Other experts note Americans are eating
much more high-fat cheese in snacks and
elsewhere, cheese is now the most widelymentioned protein food in chain restaurants,
with menu selections that top meats with
cheese, add cheese to breading, and serve
foods with cheese sauces adding to the
calories that already exist in the basic recipes
for these items.
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There is good news amidst the

disturbing trends, mounting body of data
shows that even modest weight loss can yield
substantial health benefits. A 5-10 percent
reduction in initial weight is associated with
significant improvements in systolic and
diastolic blood pressure, cholesterol and
plasma lipids, blood glucose, and can
improve risk factor clustering for vascular
diseases (17, 18), particularly in obese
individuals with type 2 diabetes (19). In
addition, recent intervention studies have
shown that a weight reduction of 5-10
percent is effective in preventing or at least
delaying the appearance of type 2 diabetes
and hypertension in high-risk individuals (20,
21).
However, the practical problem
remains, how do we translate results from
these studies into the daily practice of
dietetics?
Combined Approaches - Diet, Physical
Activity, Counseling
We know that a consistent course of
counseling and contact is important to weight

loss success. In its December 2003
recommendations to practitioners, the US
Preventive Services Task Force specified that
the most effective strategies for weight loss
are combination approaches using nutrition,
diet and exercise counseling, and behavioral
modification. In their review of evidence, the
Task Force stated that there is fair to good
evidence that high-intensity counseling,
defined as a minimum of 3 monthly one-onone visits, combined with behavioral interventions, produces sustained weight loss of typically 3 to 5 kg for 1 year in obese adults (22).
Two major intervention trials, as well as
several smaller trials, have demonstrated
that diet and exercise programs, coupled with
individualized nutrition counseling, provide
effective long-term weight management. A
randomized, prospective study in Finland (23)
employed a physician, study nurse,
nutritionist, and exercise physiologist. A total
of 522 middle-aged, overweight patients were
followed for three years. Goals included 5
percent weight reduction, moderate-intensity
physical activity of 30 min/day, dietary fat of
30 percent or less of total daily energy intake,
saturated fat of 10 percent or less of daily
intake, and fiber intake of 15 g/1,000 kcal or
more. Intervention group subjects received 7
individualized face-to-face, 30-minute
sessions with the study nutritionist in year 1,
and 4 sessions per year thereafter. All
subjects regularly measured and recorded
weight and physical activity. Control group
subjects were given the same general goals
and information in a single group session
with no individualized counseling. Physical
activity and weight loss maintenance was
significantly higher after three years for the
counseling group (3.5 kg compared with 0.9
kg).
In the United States Diabetes
Prevention Program (DPP), 24 out of 1,000
individuals participated in a lifestyle
intervention that included diet and physical
activity goals facilitated by case managers or
"lifestyle coaches." Participants were targeted
to lose 7 percent of baseline body weight and
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B1.3
engage in 150 minutes per week of physical

activity, such as brisk walking. Hallmarks of
the intervention included frequent contact
throughout the trial, a "toolbox" tailored to the
individual participant, and a network that
provided training, feedback, and clinical
support for the lifestyle coaches. Participants
followed a 16-session core curriculum, then
were seen face-to-face at least once every 2
months and contacted by phone at least once
between visits. Those in the lifestyle
intervention group lost an average of 7 kg
after 6 months; some of the weight was
regained, and net weight loss averaged about
4 kg at 4 years of follow-up.
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There are many approaches to weight

loss counseling that have been published,
including the approach employed in the DPP
(24). A growing number of practitioners favor
a technique known as motivational
interviewing, which centers on the use of
open-ended questions, reflective listening,
and patient-generated answers and solutions.
Some practitioners also follow a model called
the "stages of change," or transtheoretical
model, that strives to identify motivation and
readiness to change behaviors. A list of
references for motivational interviewing and
other counseling strategies is found in the
Nutrition Education and Counseling section of
this manual.
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Meanwhile, some practical tips for

clinical practice are adapted from the work of
psychologist Gary Foster, Director of the
Weight and Eating Disorders Program at the
University of Pennsylvania (25).
1. Set realistic expectations.
2. Be clear about what treatments can and
cannot do.
3. Have patient specifically identify goals.
For example, ask the person, "Eat less of
what?"
4. Have patient express when behaviors will
occur.
5. Have patient express how behaviors will
occur.

6. Do not ask why.
7. Have patient identify their most difficult
times for compliance.
8. Have patient maintain a record of
behavior (activity log, food diary).
9. Follow up on progress.
10. Congratulate successes without chastising failures.
From a practical standpoint, it is important to recognize that most interventions
result in a substantial, but not dramatic, loss
of weight, 5-10 percent of body weight. The
only treatment shown consistently to result in
sustained losses greater than 40 to 50
pounds is bariatric surgery (22, 26). It is also
important for patients to note that whatever
diet and lifestyle changes are made to lose
weight, there must be a strategy to maintain
the loss after the initial period if the weight
loss is to be sustained.
The following information may be
helpful for dietetics professionals when
considering a weight loss program for their
patients.
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Advertising Claims
About one in every three adult

Americans reports having tried one or more
weight loss plans, and most of the individuals
are not using the recommended combination
of reducing food intake and increasing
physical activity (27). Many turn to products
and services that are advertised to help drop
unwanted pounds. The US market for diet
and weight loss products was estimated to be
58.6 billion dollars in 2007 (28).
In September 2002, the Federal Trade
Commission (FTC) issued an advisory on
weight-loss advertising, concluding that,
despite vigorous law enforcement and
consumer education efforts, fraudulent and
misleading weight-loss advertising is
widespread. Over half of advertising for
weight loss products and services contained
false or unsupported claims in the FTC
B1.4
analysis. In December 2003, the FTC

announced an educational campaign for the
media that identifies seven common weightloss claims that are cautionary flags about a
product or service. These claims include:
Causes weight loss of two pounds or

more a week for a month or more without
dieting or exercise.
Causes substantial weight loss, no matter
what or how much the consumer eats.
Causes permanent weight loss (even
when the consumer stops using the
product).
Blocks the absorption of fat or calories to
enable consumers to lose substantial
weight.
Safely enables consumers to lose more
than three pounds per week for more
than four weeks.
Causes substantial weight loss for all
users.
Causes substantial weight loss by
wearing it on the body or rubbing it into
the skin.
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All of the above claims are scientifically

infeasible at the current time and advertising
that uses one or more of these claims is
subject to action by the FTC.
Internal Revenue Service and
Reimbursement Considerations
The US Internal Revenue Service has
determined that certain expenses associated
with weight loss are deductible medical
expenses under some conditions (29).
Patients cannot include the cost of a weightloss program if the purpose of the weight loss
is improvement of appearance or general
health. However, patients can deduct these
expenses if weight loss is a treatment for a
specific disease diagnosed by a physician
(such as obesity, hypertension, or heart
disease). The new ICD-9-CM codes for obesity
include:
obesity unspecified - 278.00
morbid obesity -278.01

dysmetabolic syndrome - 277.7
Codes for primary and/or associated

disease manifestations include athersclerosis
(414.01), diabetes (250.00), and others.
Deductible items include fees for membership in a weight reduction group, and attendance at periodic meetings. Memberships
in a gym, health club, or spa are not deductible, nor is the cost of diet food or beverages,
unless all three of the following requirements
are met:
The food does not satisfy normal

nutritional needs.
The food alleviates or treats an illness.
The need for the food is substantiated by
a physician.
The deductible amount for these foods
is limited to the amount by which the cost of
the special food exceeds the cost of a normal
diet.
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Before any diet and physical activity

program can be personalized and implemented, a nutrition assessment is needed,
along with an understanding of the
individual's readiness to change and motivation. It is important to determine factors
associated with weight gain, such as past history of exercise, pregnancy, and health
conditions, which may influence weight loss,
and sedentary and non-sedentary work
patterns. It is important to understand the
patient's dieting history, the types of diets
attempted and their relative success, along
with usual body weight, desired, highest,
lowest, and preferred body weights.
Properly measure height (using a wallmounted height board or stadiometer); measure weight using a calibrated balance-beam
scale, calculate BMI, waist circumference;
and body composition (% body fat). Assess
B1.5
energy balance using food records or diet

recalls, and assess resting energy
expenditures using standard equations, such
as Mifflin St. Jeor:
Males: 9.99 X weight (kg) + 6.25 X height
(cm) 4.92 X age + 5.
Females: 9.99 X weight (kg) + 6.25 X height
(cm) 4.92 X age 161.
There are also newer portable office
devices for measuring resting energy
expenditure (RMR). Two such devices are
BodyGem and MedGem (HealtheTech, Inc,
Golden, Colorado). The hand-held units use
indirect calorimetry by inhaled and exhaled
air with a fixed respiratory quotient of 0.85,
and a modified Weir equation to derive kcal
expended. (RMR= 6.931xVO2); VO2 = oxygen
uptake (ml/min)).
R
D
E
IV
Weight Loss Strategies
Recommendations should promote

weight loss of 0.5 to 1 lb/wk through diet and
exercise. For example, to attain a deficit of
500 kcal daily, recommend a diet with 250
fewer kcal combined with 250 additional kcal
in physical activity. (See the physical activity
table provided in the exercise section of this
section for specific energy expenditure in
activity). If a person is not able to adhere to
an exercise program, then achieve the kcal
deficit through diet alone, while encouraging
a more gradual introduction to exercise.
Remember that the most effective
approaches involve both diet and physical
activity, along with consistent counseling
(22).
Portion Control
Portion control is essential for weight
loss and for long term success in weight
maintenance (30). The US Department of
Agriculture (USDA) is responsible for defining
standard serving sizes for dietary guidance

and the Food and Drug Administration (FDA)
is responsible for defining standard serving
sizes for food labels. Standard serving sizes
are important in nutrition counseling, since
many products available in the marketplace
are sometimes as much as 2 to 8 times the
recommended standard serving sizes. This
inconsistency between the recommended
standard serving sizes and the marketplace
serving sizes is an opportunity for nutritionists
to educate the relationship between portion
sizes and energy intake for weight loss or
weight maintenance (I, II).
Pharmacotherapy for Weight Loss
In the State of Florida, the use of
pharmaceutical agents for weight loss is
subject to the Administrative Code (F.A.C.
Rule 64B8-9.012, Standards for the
Prescription of Obesity Drugs). The code
addresses prescription medications, as well
as OTC diet aids, herbs and other dietary
supplements. To justify the use of any weight
loss enhancer the patient must have either:
1) a BMI > 30 or above; 2) a BMI > 27 with at
least one co-morbidity factor (such as type 2
diabetes, lipid abnormalities, or sleep apnea);
or 3) a measurable body fat content equal to
or greater than 25 percent of body weight for
males, or 30 percent of body weight for
females.
T
S
E
Each practitioner who prescribes,

orders, or provides a weight loss enhancer
must assure that affected patients undergo
an in-person re-evaluation within 2 to 4
weeks of receiving the regimen, and
additional evaluation at least every three
months while continuing the regimen. The
consumer protection aspects of the code
specify, among other things, that practitioners may not promise specific results, may
not claim rapid, dramatic, or safe weight loss,
and may not suggest that diets or exercise
are not required.
Prescription Medications
B1.6
A number of prescription medications

are available to help promote weight loss that
is substantial, but not dramatic. Most studies
report a loss of about 5 percent to 10 percent
of initial body weight in patients undergoing
therapy with these agents. Medications that
have been approved by the US Food and Drug
Administration (FDA) for the induction and
maintenance of weight loss in adults include:
Sibutramine (Meridia)
Orlistat (Xenical)
Anorectics (appetite suppressants)
Phentermine and phentermine resin
(Medeva, Fastin, Ionamin(r))
Diethylpropion (Tenuate, Tenuate
Despan)
Mazindol (Mazanor, Sanorex)
Phendimetrazine Tartrate (Prelu-2,
Bontril)
Phenmetrazine (Preludin)
Orlistat has also received FDA approval
for use in adolescent populations (ages 12
through 16). Among the above-referenced
agents, sibutramine and orlistat are the most
commonly prescribed. The others are
indicated for short term use (a few weeks to
<3 months).
R
D
E
IV
Case reports and clinical trial data have

demonstrated that several other medications
may have anti-obesity properties, as weight
loss was an unexpected spin-off during
treatments for other health conditions. Some
practitioners prescribe these agents in "off
label" indications for obesity. The medications
include:
Topiramate (Topamax)
Metformin (Glucophage)
Bupropion (Wellbutrin)
Acarbose (Precose)
Miglotol (Glyset)
Zonisamide (Zonegran)
It should be noted that several barriers
limit the use of any weight loss medication,
including findings that most health insurance
providers do not cover their cost. Patients
must pay out-of-pocket for charges that
typically exceed $100 per month.

Sibutramine
Sibutramine acts on the central nervous
system to increase satiety, reduce hunger,
and lessen the drop in metabolic rate that
often occurs with weight loss (31). It is a
combined serotonin-norepinephrine reuptake
inhibitor, with features that resemble actions
of antidepressants and stimulants. Sibutramine does not seem to inhibit individuals
from starting to eat a meal, but rather
stimulates the feeling of fullness to promote
earlier termination of a meal and inhibit
between-meal snacking. Research suggests
that persons taking sibutramine eat less,
approximately 300 to 350 fewer kilocalories
per day compared to control subjects (31).
Weight reductions of 5 percent to 10 percent
have been observed with use of sibutramine
(32). In patients with type 2 diabetes, the
weight losses have been accompanied by
improved glycemic control and blood lipid
profiles (33).
T
S
E
Sibutramine dosages range from 5 mg

to 15 mg/day. Typically, a patient begins at
10 mg, and the dose is adjusted according to
results and patient tolerance. The FDA has
indicated a use of sibutramine for up to one
year. Since its pharmacological action
involves stimulation of the sympathetic
nervous system, patients taking sibutramine
may experience cardiovascular side effects.
In a study of individuals with type 2 diabetes,
sibutramine was associated with a heart rate
increase of >10 beats per minute in 42
percent of subjects (33). Among individuals
with uncomplicated obesity, sibutramine
produced a dose-dependent increase in heart
rate averaging 3-7 beats per minute (34).
Sibutramine is therefore not recommended
for patients with a history of coronary artery
disease, arrhythmias, congestive heart
failure, or stroke.
Sibutramine can also produce dosedependent increases in blood pressure,

especially during initial treatment, and is not
recommended for persons with uncontrolled
B1.7
hypertension. However, many patients who

lose 5 percent or more of initial body weight
experience an overall reduction in blood
pressure, which correlates with the amount of
lost weight, so the clinical relevance of a
short term slight increase in blood pressure is
unclear (33, 34). Data from studies indicate
the average increase in systolic blood
pressure with sibutramine at the 15 mg daily
dose is 1 mmHg, although substantial
number of patients experience increases of
5mmHg (33).
Sibutramine is also not recommended
in combination with certain antidepressant
agents, such as monoamine oxidase inhibitors or selective serotonin reuptake
inhibitors. Augmentation of adverse reactions
associated with sibutramine (tachycardia,
increased blood pressure) may occur with
concurrent use of other central acting agents
such as pseudoephedrine or ephedra.(35)
Sibutramine was removed from the US
market in 2010.
R
D
Orlistat
E
IV
Orlistat is an agent that inhibits gastric

lipase, causing lower gut enzyme activity to
reduce by approximately one-third the
amount of dietary fat that is absorbed. Typical
dosing of orlistat is 120 mg three times per
day. Depending on the fat content of an
individual's diet, this lowered absorption can
represent 150-200 kcal/day. The effects of
orlistat on diet are often self-limiting because
meals containing more than 20 g of fat tend
to generate side effects in the lower intestine.
This includes oily stools, flatus with
discharge, and fecal urgency; thus creating a
feedback mechanism that tends to decrease
the amount of fat patients consume.
Additionally, the reduction in lipid
absorption with orlistat is associated with a
reduction in the absorption of fat-soluble
vitamins. Supplements of these vitamins are
typically indicated, with care to separate the
dosing of orlistat and the supplement by >2
hours. In adults, the effects of orlistat on

serum concentrations of vitamins A, E, and D
have been minimal (36). Among adolescent
patients, absorption of retinol is not
significantly altered, but absorption of tocopherol is impaired, and plasma vitamin D
is significantly reduced, despite multivitamin
supplementation (37).
Most, but not all studies have shown
significant weight loss with orlistat (38). In
randomized trials of patients with diabetes,
participants who received orlistat plus diet
restriction lost 4 to 5 percent of their baseline
weight within 1 year, compared with 1 to 2
percent for those assigned to placebo plus
diet (39, 40, 41). Even in the absence of
weight loss, orlistat treatment resulted in
improved cholesterol profile and better
glycemic control (38).
Most clinical trials of weight loss
medications report results for one year or
less. However, in a four-year double-blind,
prospective European study among 3,305
patients, weight loss was significantly greater
in the orlistat group than in the placebo group
(5.8 vs. 3.0 kg) (42). One quarter of the
orlistat patients who stayed with the
medication kept off 10 percent of their initial
body weight after four years, compared to 16
percent of placebo patients. Both groups
were assigned to a dietary restriction of 700
to 800 fewer kcal per day than their baseline
diets.
T
S
E
Anorectics
Medications of this type act principally
on the satiety center of the hypothalamic and
limbic regions of the brain. The anorexic
effect is temporary, seldom lasting more than
a few weeks. The development of tolerance
and "wearing-off" of effects form the main
drawbacks of these medications. The
appetite suppressants have been associated
with abuse, particularly in connection with
long-term therapy, as they are pharmacologically related to amphetamines. When tolerance to these agents develops, the
B1.8
recommended dosage should not be

exceeded in an attempt to increase the
effect, but instead the drug should be
discontinued (43).
In addition, medications of this type are
stimulants that may produce nervousness, insomnia, elevated heart rate, anxiety, and
related effects. Common symptoms include
palpitations, tachycardia, arrhythmias, hypertension, nervousness, restlessness, dizziness, insomnia, tremors and headaches.
Patients also report dry mouth, unpleasant
taste, nausea, vomiting, diarrhea and
constipation (44). The effects of these agents
typically last approximately 4-6 hours, but
mazindol lasts between 8 and 15 hours.
E
IV
All of these drugs, except for mazindol,

are derivatives of -phenylethylamine, which
forms the backbone for the neurotransmitters
dopamine, norepinephrine, and epinephrine
all of which are synthesized from the amino
acid tyrosine. Mazindol is a tricyclic drug
similar in structure to some of the older
antidepressants such as imipramine. The
agents are indicated only for monotherapy
and should not be combined with selective
serotonin-reuptake inhibitor antidepressants
(e.g. fluoxetine, fluvoxamine, paroxetine,
sertraline) or monoamine oxidase (MAO)
inhibitors.
R
D
The following medications: phentermine, diethylpropion, benzphetamine, and

phendimetrazine are thought to stimulate the
release of norepinephrine, but they may also
stimulate dopamine release, particularly
phentermine. Phentermine appears to both
suppress appetite and increase energy expenditure. Mazindol blocks reuptake of
norepinephrine, and is thought also to stimulate thermogenesis and possibly delay gastric
emptying (44).
For mazindol, the dose is 1 to 3 mg per
day. The usual adult dosage of phentermine
hydrochloride is 8 mg 3 times daily, given 30
minutes before meals. Alternatively, 15 or 30
mg of phentermine as the resin complex, or

15-37.5 mg of phentermine hydrochloride,
may be given as a single daily dose in the
morning. Phentermine has not been studied
as a monotherapy for longer than 36 weeks
or approved for administration longer than a
few weeks (45).
The usual adult dosage of diethylpropion hydrochloride is 25 mg 3 times daily
1 hour before meals, an additional 25 mg
may be given in mid-evening. The extendedrelease tablet containing 75 mg of the drug
may be given once daily, in midmorning.
The dosages of benzphetamine vary
from 25 to 150 mg per day. For phendimetrazine tartrate the dosage range is 17.5
to 35 mg and for phenmetrazine it is 25 to
50 mg.
Metformin
Metformin (Glucophage) is a commonly
prescribed medication for Type 2 diabetes. It
is an "insulin sensitizer," that enhances
glucose uptake without promoting insulin
secretion. Metformin is not approved by the
FDA as a weight loss agent, but has been
used in "off label" indications for obesity.
T
S
E
In several studies, diabetic patients

assigned to metformin therapy experienced
modest weight loss (46). For example, the US
Diabetes Prevention Program was a large
randomized clinical trial with participants in
one arm of the trial receiving metformin
therapy (20). These subjects lost around 2 kg
after 6 months; weight loss was about 1 kg at
the end of 4 years of follow-up. This type of
observation led researchers to investigate
whether metformin might enhance weight
loss in non-diabetic individuals. Thus far,
studies to address this question suggest that
weight loss may indeed occur (47, 48).
However, most of the subjects in research to
date had features of insulin resistance
syndrome, so it is unclear whether weight
loss is due to an improvement in glucose
tolerance or an effect of the drug.
B1.9
Acarbose & Miglitol

Like metformin, acarbose and miglitol
are medications designed to improve
glycemic control in diabetes. Neither agent
has FDA approval for weight loss. However, a
side effect of weight loss has been reported
in diabetic persons taking these agents for
glycemic control, and some practitioners may
include these agents in a weight loss plan
(49).
The two drugs are inhibitors of the glucosidase enzyme in the small intestine.
The resulting effect is a dose-dependent
reduction in the digestion and absorption of
carbohydrates. It is suggested that weight
loss associated with these drugs occurs due
to lower net kcal intake resulting from
lowered absorption of nutrients. However,
there is some evidence that these agents
promote satiety by modulating production of
glucagon-like peptide 1 (GLP-1), a gut
hormone that contributes to the feeling of
fullness (50). So far, research has been
limited in connection with using these
medications for weight loss in non-diabetic
individuals. Two studies report that weight
loss was not significantly different between
those taking acarbose and placebo patients
(51, 52).
R
D
E
IV
It should be noted that acarbose and

miglitol promote the passage of undigested
carbohydrates to the large intestine, where
they are acted upon by intestinal flora and
can produce bloating, abdominal discomfort
and flatulence. These are the most widely
reported side effects in both drugs, although
fewer side effects are reported with miglitol
than acarbose.
Topiramate
Topiramate was developed and FDAapproved as an anti-seizure medication. Topiramate has not been approved as a weightloss agent. Shortly after its introduction as an
anti-convulsant, case reports began to

emerge indicating that patients taking topiramate experienced substantial weight loss
(53). Subsequently, several small trials have
been published showing successful weight
loss and reduced frequency of pathologic
eating patterns in persons with eating
disorders, such as binge eating disorder and
nocturnal eating syndrome (54, 55, 56).
Dosages have been titrated from 96 to 218
mg daily. In one study of uncomplicated
obesity, after six-months of treatment at
varying and sliding doses, topiramate was
associated with an average loss of about 6
percent of baseline body weight (57).
Subjects also participated in a lifestyle
program consisting of a 600 kcal/day deficit
diet, nutrition and exercise education, and
behavioral therapy. However, a high rate of
side effects was noted in the trial, including
paresthesia and dizziness, as well as
difficulty with memory, concentration, and
attention.
T
S
E
The mechanism of weight loss

associated with topiramate is not known,
however, animal studies indicate that
topiramate affects the regulation of energy
balance as well as influences metabolic
variables such as glucose and leptin (58).
Zonisamide
Zonisamide, like topiramate, is an anticonvulsant medication that has also been

associated with weight loss in limited study. It
has not been approved as an anti-obesity
treatment. It is reported that zonisamide
might help to regulate appetite by effects on
serotonin and dopamine. But thus far, there
is scant clinical evidence for zonisamide and
obesity. A single-blind study of 60 obese
patients at the Duke University Medical
Center reported an average weight loss of 14
pounds after 16-weeks of zonisamide
therapy, which was combined with dietary
restriction of 500 fewer than usual kcal per
day (59). In comparison, patients in a placebo
group lost an average of about 2 pounds.
B1.10
Bupropion
Bupropion (Wellbutrin) is a drug
approved for the treatment of depression and
smoking cessation. On the basis of the
clinical observations that a large percentage
of patients taking bupropion lost weight,
several research trials have been conducted
to determine its efficacy in facilitating weight
loss, with promising results (60, 61). Jain and
colleagues (62) report a randomized, doubleblind, placebo-controlled study among 394
adults who were obese but also diagnosed
with depressive symptoms. All subjects were
asked to follow a diet for 26 weeks with 500
fewer than usual kcal daily; half of patients
were assigned to sustained-release
bupropion at 300 mg/day. The group
receiving bupropion lost an average of 4.6
percent of base weight, compared to 1.7
percent of base weight loss for the control
group.
R
D
E
IV
Bupropion used in connection with

weight loss does not appear to depend on the
presence of underlying depression. In another
study involving 192 obese subjects who did
not report depressive symptoms, those
patients who completed 48 weeks of
bupropion therapy maintained losses of initial
body weight of 10 percent at 24 weeks, and
about 8 percent at 48 weeks (63).
The precise mechanism of action of
bupropion is unclear, but it is thought to
inhibit uptake of norepinephrine and
dopamine, and may help regulate food intake
(64). As a treatment for depression, the
recommended maximum daily dosage is 400
mg as extended-release tablets or 450 mg as
conventional tablets (45). Common adverse
effects of the drug include agitation, dry
mouth, insomnia, headache/migraine,
nausea/vomiting, constipation, and tremor
(45). Bupropion also carries a seizure risk of
four in 1,000 people at the maximum dose
(64). It is not recommended for patients with
a history of bulimia, anorexia or seizures
because the seizure risk may be even higher

Written by: Donna DeCunzo-Taddeo, RD, LD/
N, Weight Management Specialist,
Lighthouse Point, FL
Reviewed by: Mary C. Friesz, PhD, RD, LD/N,
CDE
PRACTITIONER POINTS
ETIOLOGY
Obesity is a complex, multifactorial,
chronic disease. The factors likely to
predispose some individuals to obesity
include genetic, metabolic, and hormonal
influences. Other factors, such as:
behavioral, environmental, physiological,
social, and cultural factors may also result in
energy imbalance and promote excessive fat
deposition. Bodyweight depends upon the
balance between calories consumed and
calories expended. This balance depends
largely on genetic make-up, level of physical
activity, body composition and resting energy
expenditure. If more calories are consumed
than expended, the excess calories are
stored as fat in the form of adipocytes (fat
cells).
T
S
E
The relative contribution of each of

these factors has been studied extensively,
and although genetics plays an important
role in the regulation of body weight. The
World Health Organization Consultation on
Obesity concluded that behavioral and
environmental factors (sedentary lifestyles
combined with excess energy intake) are the
primary variables responsible for the
dramatic increase in obesity during the past
two decades.
American society has evolved into an
environment that facilitates weight gain.
Studies show that approximately only 20
percent of Americans achieve the minimum
public health goal, established by the
Centers for Disease Control (CDC), of 30
minutes of moderate intensity physical
activity on most days of the week. The US is
also a leading innovator of passive
B2.1
entertainment. The average American adult

spends half of his or her leisure time
watching television. Combine this with jobs
that involve very little physical activity, video
games, movies, computing, gambling, etc.,
and it becomes apparent why daily caloric
expenditure has declined precipitously since
the 1950's and 60's.
Dietary patterns contribute substantially to the development of obesity. Despite
an increased focus on nutrition, a heightened awareness of the energy and fat
content of foods, and the availability of
various reduced-fat, fat-free, and sugar-free
foods and beverages, obesity continues to increase. Todays society facilitates excessive
consumption in the following ways:
its abundance of inexpensive, energydense foods.
the multitude of eating establishments
that reflect the increased prevalence of
dining out, particularly at fast food
restaurants, which serve super-sized
portions.
the ubiquitousness of food in places
ranging from gasoline stations to vending
machines, as well as in discount and
department stores.
R
D
E
IV
In addition, behavioral changes

common during holidays contribute to
seasonal weight gain during the winter
months, which although less than 0.5 kg (1.1
pounds) on average, is greater among
individuals who are overweight or obese and
it is responsible for at least half of annual
weight gain (1).
RATIONALE
Overweight and obesity have reached
epidemic proportions in the United States
and worldwide with more than 64 percent of
the US adult population being classified as
either overweight or obese (2, 3). The
rationale for treating obesity lies in its
adverse medical conditions. These
conditions substantially increase the risk of
Manual of Medical Nutrition Therapy Manual 2011 Edition

morbidity from hypertension, dyslipidemia,
type 2 diabetes, coronary artery disease,
stroke, gallbladder disease, osteoarthritis,
sleep apnea and respiratory problems and
cancers of the endometrium, breast, prostate
and colon (4-15).
The prevalence of overweight and
obesity has steadily increased over the years
among genders of all ages, from all racial and
ethnic groups and all educational levels (16).
From 1960 to 2000, the prevalence of
overweight (BMI > 25 to < 30) increased from
31.5 to 33.6 percent in U.S. adults aged 20
to 74 (17). The prevalence of obesity (BMI >
30) during this same time period more than
doubled, from 13.3 to 30.9 percent, with
most of this rise occurring in the past 20
years (18). From 1988 to 2000, the
prevalence of extreme obesity (BMI > 40)
increased from 2.9 to 4.7 percent, up from
0.8 percent in 1960 (18,19).
T
S
E
The prevalence of overweight and

obesity is also increasing for children and
adolescents in the United States.
Approximately 15.3 percent of children (ages
611) and 15.5 percent of adolescents (ages
1219) were overweight in 2000. An
additional 15 percent of children and 14.9
percent of adolescents were at risk for
overweight (BMI for age between the 85th
and 95th percentile) (20).
The economic costs of overweight and

obesity are estimated to be $99.2 billion
according to The National Institute of
Diabetes & Digestive & Kidney Diseases.
Americans spend $33 billion annually on
weight-loss products and services (described
as all efforts at weight loss or weight
maintenance including low-calorie foods,
nutritional supplements, over-the-counter
appetite suppressants, artificially sweetened
products such as diet sodas, and
memberships to commercial weight-loss
centers) (21).
Obesity is a complex chronic disease
B2.2
requiring a lifelong effort for successful

treatment. Treatment of an overweight or
obese individual involves two steps,
assessment and management. Assessment
determines the degree of overweight or
obesity and overall health status;
management involves weight loss and
maintenance of the reduced body weight and
control over risk factors.
ASSESSMENT
Assessment of an individual should
include the evaluation of body mass index
(BMI), waist circumference, and overall
medical risk.
E
IV
1. Body Mass Index (BMI): To determine an

individuals BMI, use the following formula or
refer to Table 1, Body Mass Index Table:
R
D
BMI= weight (in pounds) x 703

height (in inches) 2
Classifications for BMI (adopted by the Expert

Panel on Identification, Evaluation, and Treatment of Overweight and Obesity in Adults):
Classification
Underweight
Normal Weight
Overweight
Obesity (class1)
Obesity (class 2)
Extreme Obesity
BMI___________
<18.5
18.5-24.9
25-29.9
30-34.9
35-39.9
>40
*Please note: BMI may overestimate the degree

of fatness in muscular individuals. It may also
underestimate ones degree of fatness in
osteoporotic individuals. Also, the adult BMI
charts are not accurate for estimating BMI in
children and in adolescents.
2. Waist Circumference: Excess abdominal

fat is an important independent risk factor for
disease. Waist circumference is particularly
useful in those who are categorized as
normal or overweight. Males with a waist
circumference >40 inches and females with a
Adult Nutrition for Weight
B2.3
Table 1 Body Mass Index Table

BMI
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Body Weight (pounds)
Height
(inches)
59
94
99
104
109
114
119
124
128
133
138
143
148
153
158
163
168
173
60
97
102
107
112
118
123
128
133
138
143
148
153
158
163
168
174
179
61
100
106
111
116
122
127
132
137
143
148
153
158
164
169
174
180
185
62
104
109
115
120
126
131
136
142
147
153
158
164
169
175
180
186
191
63
107
113
118
124
130
135
141
146
152
158
163
169
175
180
186
191
197
64
110
116
122
128
134
140
145
151
180
186
192
197
204
65
114
120
126
132
138
144
150
156
186
192
198
204
210
66
118
124
130
136
142
148
155
161
192
198
204
210
216
67
121
127
134
140
146
153
159
166
68
125
131
138
144
151
158
164
69
128
135
142
149
155
162
70
132
139
146
153
160
71
136
143
150
157
72
140
147
154
73
144
151
74
148
75
76
R
D
E
IV
157
163
169
174
162
168
174
180
167
173
179
186
172
178
185
191
198
204
211
217
223
171
177
184
190
197
203
210
216
223
230
169
176
182
189
196
203
209
216
223
230
236
167
174
181
188
195
202
209
216
222
229
236
243
165
172
179
186
193
200
208
215
222
229
236
243
250
162
169
177
184
191
199
206
213
221
228
235
242
250
258
159
166
174
182
189
197
204
212
219
227
235
242
250
257
265
155
163
171
179
186
194
202
210
218
225
233
241
249
256
264
272
152
160
168
176
184
192
200
208
216
224
232
240
248
256
264
272
279
156
164
172
180
189
197
205
213
221
230
238
246
254
263
271
279
287
T
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BMI
36
37
38
Height
(inches)
39
40
41
42
43
44
45
46
B2.4
47
48
49
50
51
52
53
54
Body Weight (pounds)
58
172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258
59
178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267
60
184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276
61
190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285
62
196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295
63
203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304
64
209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314
65
216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324
66
223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334
67
230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344
68
236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354
69
243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365
70
250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376
71
257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386
72
265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397
73
272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408
74
280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420
75
287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431
76
295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443
T
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waist circumference >35 inches are at higher
risk for diabetes, dyslipidemia, hypertension
and cardiovascular disease. Individuals with
at risk waist circumferences should be
considered one risk category above that
defined by their BMI.
3. Risk factors or Comorbidities: Overall risk
factors must take into account the potential
presence of other risk factors.
Conditions denoting high absolute risk
include: established coronary heart disease,
other atherosclerotic diseases, type 2
diabetes and sleep apnea.
Three or more of the following risk
factors indicate high absolute risk:
hypertension, cigarette smoking, high lowdensity lipoprotein (LDL) cholesterol, low highdensity lipoprotein (HDL) cholesterol,
impaired fasting glucose, family history of
early cardiovascular disease and age (male>
45 and female> 55).
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The following conditions increase risk,

but are not life threatening: Osteoarthritis,
gallstones, stress incontinence and
gynecological abnormalities such as
amenorrhea and menorrhagia.
The individuals readiness to make

necessary lifestyle changes should also be
considered before beginning a weight loss
treatment. Evaluation of readiness should
include:
Reasons and motivation for weight loss
Previous attempts at weight loss
Support expected from family/friends
Understanding of risks and benefits
Attitudes toward physical activity
Time availability
Financial limitations linked to the
individuals adoption of change
CLASSIFICATION OF OVERWEIGHT AND
OBESITY
The primary classification of overweight
B2.5
and obesity is based on the assessment of

BMI, waist circumference and associated
disease risk. It should be noted that the
relationship between BMI and disease risk
varies among individuals and among different
populations. Table 2 lists disease risk relative
to normal weight and waist circumference.
TREATMENT/MANAGEMENT
The goals of therapy for those with a
BMI>30,those with a BMI between 25 to
29.9, or a high risk waist circumference and
two or more risk factors are to reduce body
weight and to maintain a lower body weight
long term. An initial weight loss of 10 percent
of body weight over 6 months is a
recommended target. One to two pounds of
weight loss per week is desirable. After the
first 6 months of weight loss therapy, the goal
should be changed to weight maintenance for
a period of time before further weight loss is
recommended.
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Preventing further weight gain is an

appropriate goal for individuals with a BMI of
25 to 29.9 who are not otherwise at high risk.
NUTRITION THERAPY
Nutrition therapy includes instructing
patients in the modification of their diets to
achieve a decrease in caloric intake. A diet
that is planned to create a deficit of 500 to
1000 kcal/day is integral in achieving a 1 to
2 pound weight loss per week. The
composition of the diet should also be
modified to minimize other risk factors.
Very Low Calorie Diets (VLCD) are those
diets consisting of less than 800 kcal/day.
VLCDs should not be used routinely for weight
loss and require special medical monitoring
and nutrient supplementation. Low calorie
diets (LCD) contain between 1000-1200
kcal/day for females and between 12001600 kcal/day for males or females who
weigh more than 165 pounds, or by those
B2.6
Table 2 Disease Risk* Relative to Normal Weight and Waist Circumference

BMI
(kg/m2)
Obesity
Class
Men 102 cm
(40 in) or less
Women 88 cm
(35 in) or less
Men > 102 cm

(40 in)
Women > 88 cm
(35 in)
Underweight
< 18.5
Normal
18.5 - 24.9
Overweight
25.0 - 29.9
Increased
High
Obesity
30.0 - 34.9
High
Very High
35.0 - 39.9
II
Very High
40.0 +
III
Extreme Obesity
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Extremely High
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Very High
Extremely High
*Disease risk for type 2 diabetes, hypertension, and CVD.

+Increased waist circumference can be a marker for increased risk, even in persons of normal weight.
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Adapted from Preventing and Managing the Global Epidemic of Obesity. Report of the World Health
Organization Consultation of Obesity. WHO, Geneva, June 1997.
Calories
Total Fat
Table 3 Step 1 Diet
Approximate reduction of 500-1000 kcal/day from usual intake

< 30% total calories
Saturated fat
8-10 total calories
Polyunsaturated fat
up to 10% total calories
Monounsaturated fat
up to 15% total calories
Cholesterol
<300 mg/day
Carbohydrates
>55% total calories
Protein
~15% total calories
Sodium Chloride
No more than 100 mmol/day (approximately 2.4g of sodium or 6 g sodium chloride)
Calcium
1000-1500 mg/day
Fiber
20-30g/day

who exercise regularly. The recommended
LCD is known as the Step 1 Diet and also
contains the nutrient composition that will
decrease other risk factors, such as high
blood cholesterol and hypertension. The
composition of the Step 1 Diet is listed in
Table 3.
Educational efforts should focus on:
The energy values of different foods
Food composition: fats, carbohydrates,
fiber, sodium and protein
Evaluation of nutrition labels to determine
caloric content and food composition
New habits of purchasing lower calorie
foods
Food preparation techniques
Portion control and avoiding overconsumption of high calorie foods
Adequate water/fluid intake
Limiting alcohol consumption
PHYSICAL ACTIVITY
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An increase in physical activity should

be an integral part of weight loss therapy and
maintenance. Moderate levels of physical
activity for 30 to 45 minutes, 3 to 5 days per
week should be encouraged as a starting
point.
Although it will not lead to a

substantially greater weight loss than diet
alone over 6 months, sustained physical
activity is most helpful in the prevention of
weight regain (22-24). In addition to helping
to control weight, physical activity decreases
the risk of dying from coronary heart disease
and reduces the risk of developing diabetes,
hypertension, or colon cancer. (25)
For most obese patients, physical
activity should be initiated slowly and the
intensity should be increased gradually. A
regimen of daily walking or water exercise is
suggested, particularly for those who are
obese.
BEHAVIOR
B2.7
Behavior therapy provides methods for

overcoming barriers to compliance with diet
therapy and/or increased physical activity. It
also assesses the individuals readiness to
begin a weight loss program. Proven behavior
modification techniques are used to assist
the individual in weight loss. It is important in
any weight loss program to set reasonable
and achievable short- and long-term goals. To
assist in modifying ones behaviors, any or a
combination of the following may be
implemented: self-monitoring; rewards, and/
or stimulus control.
PHARMACOTHERAPY
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Weight loss drugs approved by the FDA

for long-term use may be useful as an adjunct
to diet and physical activity for patients with a
BMI> 30 and without concomitant obesityrelated risk factors or diseases, or for those
with a BMI> 27 with concomitant obesityrelated risk factors or diseases. Drugs should
only be used as part of a comprehensive
program that includes diet, behavior
modification therapy and physical activity.
Physicians must monitor weight, blood
pressure, pulse and evaluate side effects
while individuals take such medications.
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WEIGHT LOSS SURGERY

Weight loss surgery is an option for
weight reduction for those who are clinically
severely obese (BMI>40 or BMI>35 with
comorbid conditions) and only for those in
which other methods have failed. An
integrated program that provides guidance on
diet, physical activity and psychosocial
concerns before and after surgery is
necessary.
WEIGHT LOSS PLATEAU
A weight loss plateau is common to
individuals following any weight loss program
lasting more than 6 months. Although the
cause is unclear, combinations of biological
and behavioral factors are responsible. It is at

this point that weight maintenance should be
implemented for a period of time before
weight loss efforts are reinstated.
WEIGHT MAINTENANCE
Some individuals will not be able to
accomplish a significant amount of weight
loss. The goal for these patients should be
guidance in preventing further weight gain
and for reducing risk factors, when present.
Key findings from the National Weight Control
Registry (NWCR), an ongoing study of individuals who have been successful at longterm weight maintenance include:
consumption of a low calorie, low fat diet;
high levels of physical activity; and remaining
vigilant about ones weight. Similar findings
concur that weight loss maintenance improves by maximizing contact with
individuals, encouraging moderate to high
levels of exercise, providing structured
approaches to modifying dietary intake,
increasing social support and problem solving
techniques and increasing initial weight-loss
success.
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Key Recommendations
(From the Expert Panel on the
Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults)
Weight loss to lower elevated blood

pressure in overweight and obese
persons with high blood pressure.
Weight loss to lower elevated levels of
total cholesterol, LDL-cholesterol, and
triglycerides, and to raise low levels of
HDL-cholesterol in overweight and obese
persons with dyslipidemia.
Weight loss to lower elevated blood
glucose levels in overweight and obese
persons with type 2 diabetes.
Use the BMI to assess overweight and
obesity. Body weight alone can be used to
follow weight loss, and to determine the
effectiveness of therapy.
The BMI to classify overweight and
obesity and to estimate relative risk of
disease compared to normal weight.

The waist circumference should be used
to assess abdominal fat content.
The initial goal of weight loss therapy
should be to reduce body weight by about
10 percent from baseline. With success,
and if warranted, further weight loss may
be attempted.
Weight loss should be about 1 to 2
pounds per week for a period of 6
months, with the subsequent strategy
based on the amount of weight lost.
Low calorie diets (LCD) such as the Step
1 Diet are indicated for weight loss in
overweight and obese persons. Reducing
fat as part of an LCD is a practical way to
reduce calories.
Reducing dietary fat alone without
reducing calories is not sufficient for
weight loss. However, reducing dietary
fat, along with reducing dietary
carbohydrates, can help reduce calories.
A diet that is individually planned to help
create a deficit of 500 to 1,000 kcal/day
should be an integral part of any program
aimed at achieving a weight loss of 1 to 2
pounds per week.
Physical activity should be part of a
comprehensive weight loss therapy and
weight control program because it: 1)
modestly contributes to weight loss in
overweight and obese adults, 2) may
decrease abdominal fat, 3) increases
cardiorespiratory fitness, and 4) may help
with maintenance of weight loss.
Physical activity should be an integral
part of weight loss therapy and weight
maintenance. Initially, moderate levels of
physical activity for 30 to 45 minutes, 3
to 5 days a week, should be encouraged.
All adults should set a long-term goal to
accumulate at least 30 minutes or more
of moderate-intensity physical activity on
most and preferably all days of the week.
The combination of a reduced calorie diet
and increased physical activity is
recommended since it produces weight
loss that may also result in decreases in
abdominal fat and increases in
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B2.8
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cardiorespiratory fitness.
Behavior therapy is a useful adjunct when
incorporated into treatment for weight
loss and weight maintenance.
Weight loss and weight maintenance
therapy should employ the combination
of LCDs, increased physical activity, and
behavior therapy.
After successful weight loss, the
likelihood of weight loss maintenance is
enhanced by a program consisting of
dietary therapy, physical activity, and
behavior modification therapy which
should continue indefinitely. Drug therapy
may also be used. However, drug safety
and efficacy beyond 1 year of total
treatment have not been established.
A weight maintenance program should be
a priority after the initial 6 months.
REFERENCES
T
S
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1. Yanovski JA, Yanovski SZ, Sovik KN, et al.

A prospective study of holiday weight
gain. N Engl J Med. 2000;342:861-867.
2. World Health Organization, (1998)
Obesity: Preventing and managing the
global epidemic, Report of WHO
Consultation on Obesity, Geneva, 3-5
June, 1997, WHO, 1998.
3. National Center for Health Statistics
(1999) (2000) Prevalence of overweight
and obesity among adults.
4. Dyer AR, Elliot P. The INTERSALT study;
relations of body mass index to blood
pressure. INTERSALT Co-operative
Research Group. J Hum Hypertens.
N1989;3:299-308.
5. Tchernof A, Lamarche B, PrudHomme D,
et al. The dense LDL phenotype:
association with plasma lipoprotein
levels, visceral obesity, and
hyperinsulinemia in men. Diabetes Care.
1996;19(6):629-637.
6. Lew EA, Garfinkel L. Variations in
mortality by weight among 750,000 men
and women. J Chronic Dis.1979;32:563576.
B2.9
7. Larsson B, Bjorntorp P, Tibblin G. The

health consequences of moderate
obesity. Int J Obes. 1981;5:97-116.
8. Ford ES, Williamson DF, Liu S. Weight
change and diabetes incidence: findings
from a national cohort of U.S. adults. Am J
Epidemiol. 1997;146:214-222.
9. Lipton RB, Liao Y, Cao G, Cooper RS,
McGee D. Determinants of incident noninsulin-dependent diabetes mellitus
among blacks and whites in a national
sample. The NHANES I Epidemiologic
Follow-up Study. Am J Epidemiol.
1993;138:826-839.
10. Hubert HB, Feinleib M, McNamara PM,
Castelli WP. Obesity as an independent
risk factor for cardiovascular disease: a
26-year follow-up of participants in the
Framingham Heart Study. Circulation.
1983;67:968-977.
11. Rexrode KM, Hennekens CH, Willett WC,
et al. A prospective study of body mass
index, weight change, and risk of stroke
in women. JAMA. 1997;277:1539-1545.
12. Stampfer MJ, Maclure KM, Colditz GA,
Manson JE, Willett WC. Risk of
symptomatic gallstones in women with
severe obesity. Am J Clin Nutr.
1992;55:652-658.
13. Hochberg MC, Lethbridge-Cejku M, Scott
WW Jr, Reichle R, Plato CC, Tobin JD. The
association of body weight, body fatness
and body fat distribution with
osteoarthritis of the knee: data from the
Baltimore Longitudinal Study of Aging. J
Rheumatol. 1995;22:488-493.
14. Young T, Palta M, Dempsey J, Skatrud J,
Weber S, Badr S. The occurrence of sleepdisordered breathing among middle-aged
adults. N Engl J Med.1993;328:12301235.
15. Chute CG, Willett WC, Colditz GA, et al. A
prospective study of body mass, height,
and smoking on the risk of colorectal
cancer in women. Cancer Causes Control.
1991;2:117-124.
16. Mokdad AH, Ford ES, Bowman BA, Dietz
WH, Vinicor F, Bales VS, Marks JS.
Prevalence of obesity, diabetes, and
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obesity-related health risk factors, 2001.
JAMA. 2003;289(1):76-79.
17. Pastor PN, Makuc DM, Reuben C, Xia H.
Chartbook on Trends in the Health of
Americans. Health, United States, 2002.
Hyattsville, MD: National Center for
Health Statistics. 2002.
18. Flegal KM, Carroll MD, Ogden CL, Johnson
CL. Prevalence and trends in obesity
among US adults, 1999-2000. JAMA.
2002;288:1723-1727.
19. Flegal KM, Carroll MD, Kuczmarski RJ,
Johnson CL. Overweight and obesity in
the United States: Prevalence and trends,
19601994. International Journal of
Obesity. 1998;22:3947.
20. Ogden CL, Flegal KM, Carroll MD, Johnson
CL. Prevalence and trends in overweight
among US children and adolescents,
1999-2000. JAMA. 2002;288:17281732.
21. Colditz GA. Economic costs of obesity. Am
J Clin Nutr. 1992;55:503-507s.
22. Katzel LI, Bleecker ER, Colman EG, Rogus
EM, Sorkin JD, Goldberg AP. Effects of
weight loss vs aerobic exercise training
on risk factors for coronary disease in
healthy, obese, middle-aged and older
men. A random-ized controlled trial.
JAMA. 1995;274:1915-1921.
23. Pate RR, Pratt M, Blair SN, et al. Physical
activity and public health. A
recommendation from the Centers for
Disease Control and Prevention and the
American College of Sports Medicine.
JAMA. 1995;273:402-407.
24. NIH Consensus Conference. Physical
activity and cardiovascular health. JAMA.
1996;276:241-246.
25. U.S. Department of Health and Humans
Services. Physical Activity and Health: A
Report of the Surgeon General. Centers
for Disease Control and Prevention.
1996.
T
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B2.10
RESOURCES
American Dietetic Association
216 West Jackson Boulevard
Chicago, IL 60606-6995
(312) 899-0040
1-800-877-1600 fax
http://www.eatright.org
National Institute of Diabetes and
Digestive and Kidney Diseases
National Institutes of Health
Building 31, Room 9A52
31 Center Drive
Bethesda, MD 20892-1818
(301) 496-5877
(301) 402-2125 fax
http://www.niddk.nih.go/index.htm
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The Weight-Control
Information Network
National Institute of Diabetes and
Digestive and Kidney Diseases
1 Win Way
(301) 570-2177
(301) 570-2186 fax
1-800-WIN-8098
National Diabetes Information
Clearinghouse (NIDDK)
1 Information Way
(301) 654-3327
(301) 907-8906 fax
American Society for
Bariatric Surgery (ASBS)
140 Northwest 75th Drive,
Suite C
Gainesville, FL 32607
(352) 331-4900
(352) 331-4975 fax
http://www.asbs.org/

American College of Sports Medicine
P.O. Box 1441
Indianapolis, IN 46206-1440
(317) 637-9200
(317) 634-7817 fax
http://www.acsm.org
American Diabetes Association
1660 Duke Street
Alexandria, VA 22314
1-800-DIABETES
http://www.diabetes.org
American Society of Bariatric
Physicians (ASBP)
5600 South Quebec Street,
Suite 109A
Englewood, CO 80111
(303) 770-2526, ext. 17
(membership information only)
(303) 779-4833
(303) 7794834 fax
http://www.asbp.org
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American Obesity Association

1250 24th Street, NW, Suite 300
Washington, DC 20037
202-776-7711
202-776-7712 fax
http://www.obesity.org
B2.11
American Heart Association

7272 Greenville Avenue
Dallas, TX 75231-4596
(214) 706-1220
(214) 706-1341 fax
1-800-AHA-USA1
(1-800-242-8721)
http://www.americanheart.org
National Institute of Neurological
Disorders and Stroke
P.O. Box 1350
Silver Spring, MD 20911
(800) 352-9424
http://www.ninds.nih.gov
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American Cancer Society

Atlanta, GA
1-800-ACS-2345
http://www.cancer.org
Office of Cancer Communications

National Cancer Institute
Building 31, Room 10A-24
31 Center Drive, MSC 2580
1-800-4-CANCER
(1-800-422-6237)
http://www.nci.nih.gov
B2.12
Nutrition Education Adult

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

Understanding portion sizes and calorie levels of food groups are important skills for weight
loss and weight maintenance. Within each food group, foods can be exchanged for each other. You
can use this list to give yourself more choices.
FOOD EXCHANGE LIST
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Vegetables contain 25 calories and 5 grams of carbohydrate. One serving equals:

1/2 cup
Cooked vegetables (carrots, broccoli, zucchini, cabbage, etc.)
1 cup
Raw vegetables or salad greens
1/2 cup
Vegetable juice
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If youre hungry, eat more fresh or steamed vegetables
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Fat-Free and Very Low fat Milk contain 90 calories per serving. One serving equals:
1 cup
3/4 cup
1 cup
Milk, fat-free or 1% fat
Yogurt, plain non fat or low fat
Yogurt, artificially sweetened
Very Lean Protein choices have 35 calories and 1 gram of fat per serving. One serving equals:
1 ounce
1 ounce
Turkey breast or chicken breast, skin removed
Fish fillet (flounder, sole, scrod, cod, etc.)
1 ounce
Canned tuna in water
1 ounce
Shellfish (clams, lobster, scallop, shrimp)
3/4 cup
Cottage cheese, non fat or low fat
2 each
Egg whites
1/4 cup
Egg substitute
1 ounce
Fat-free cheese
1/2 cup
Beans- cooked (black beans, kidney, chick peas or lentils): count as 1

starch/bread and 1 very lean protein

Website: www.eatrightflorida.org
For a referral to a nutrition professional in your area, visit: www.eatright.org .
2011 FDA. Reproduction of this medical nutrition therapy tool is permitted for educational purposes only.
It does not substitute for meeting with a Registered Dietitian to develop a personalized plan that is right for you.
B2.13

Weight Loss
Fruits contain 15 grams of carbohydrate and 60 calories. One serving equals:
1 small
Apple, banana, orange, nectarine
1 medium
Fresh peach
Kiwi
1/2
Grapefruit
1/2
Mango
1 cup
Fresh berries (strawberries, raspberries or blueberries)
1 cup
Fresh melon cubes
1/8
Honeydew melon
4 ounces
Unsweetened Juice
4 teaspoons
Jelly or Jam
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Lean Protein choices have 55 calories and 2-3 grams of fat per serving. One serving equals:
1 ounce
1 ounce
1 ounce
1 ounce
1 ounce
1 ounce
1 ounce
1 ounce
T
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Chicken- dark meat, skin removed

Turkey- dark meat, skin removed
Salmon, Swordfish, herring
Lean beef (flank steak, London broil, tenderloin, roast beef)*
Veal, roast or lean chop*

Lamb, roast or lean chop*
Pork, tenderloin or fresh ham*
Low fat cheese (3 grams or less of fat per ounce)
1 ounce
Low fat luncheon meats (with 3 grams or less of fat per ounce)
1/4 cup
4.5% cottage cheese
2 medium
Sardines
* Limit to 1-2 times per week

B2.14

Weight Loss
Medium Fat Proteins have 75 calories and 5 grams of fat per serving. One serving equals:
1 ounce
Beef (any prime cut), corned beef, ground beef **
1 ounce
Pork chop
1 each
Whole egg (medium) **
1 ounce
Mozzarella cheese
1/4 cup
Ricotta cheese
4 ounces
Tofu (note this is a Heart Healthy choice)

** choose these very infrequently
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Starches contain 15 grams of carbohydrate and 80 calories per serving. One serving equals:
1 slice
Bread (white, pumpernickel, whole wheat, rye)
2 slice
Reduced calorie or "lite" Bread
1/4 (1 Ounce)
Bagel (varies)
1/2
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English muffin
1/2
Hamburger bun
3/4 cup
1/3 cup
1/3 cup
1/3 cup
1/2 cup
1/2 cup
Cold cereal
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Rice, brown or white- cooked
Barley or couscous- cooked
Legumes (dried beans, peas or lentils)- cooked

Pasta- cooked
Bulgur- cooked
1/2 cup
Corn, sweet potato or green peas
3 ounce
Baked sweet or white potato
3/4 ounce
Pretzels
3 cups
Popcorn, hot air popped or microwave (80% light)

B2.15

Weight Loss
Fats contain 45 calories and 5 grams of fat per serving. One serving equals:
1 teaspoon
Oil (vegetable, corn, canola, olive, etc.)
1 teaspoon
Butter
1 teaspoon
Stick margarine
1 teaspoon
Mayonnaise
1 Tablespoon
Reduced fat margarine or mayonnaise
1 Tablespoon
Salad dressing
1 Tablespoon
Cream cheese
2 Tablespoons
Lite cream cheese
1/8
Avocado
8 large
Black olives
10 large
Stuffed green olives
1 slice
Bacon
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Source: Based on American Dietetic Association Exchange List
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B2.16

Weight Loss
Tips for a Healthier You!
Use
vegetables and whole grains as the focus of your meals.
Keep
healthy snacks visible and within reach such as fresh fruit, vegetables,
whole grain cereal, unsalted nuts, and low fat yogurt; you will be more likely
to snack on them!
Add
nuts and fruit to your salads, oatmeal, or cereal.
Use
fruit as dessert; fruit and yogurt make a great parfait!
If
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lunch is on the run, choose healthier options/restaurants and bring your

own sides (fruit, vegetables, trail mix).
Check
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out your local grocery store for healthy convenience items that require
little or no preparation.
Most
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convenient stores and gas stations sell fresh fruit, low fat milk, and
yogurt.
Choose
Bake,
healthy oils such as olive and vegetable.
broil, and grill instead of frying; steam veggies to preserve nutrients.
READ
FOOD LABELS and ingredients; limit food items with hydrogenated and
partially hydrogenated oils.
Increase
your whole grain consumption; choose items that have whole grains
listed as the first ingredient.
your portion sizes; use your measuring cups for a few weeks until you
can eye the amounts.
Watch
Handout created by: Catherine Wallace, MSH, RD, Baptist Medical Center
B2.17

Weight Loss
Instead of:
Try:
1/2 cup oil
1/2 cup unsweetened applesauce
1 cup heavy cream
1 cup evaporated fat free milk
1 cup shortening/lard
3/4 cup oil or soft (tub) margarine
1 egg
1 egg white + 2 tsp vegetable oil or egg

substitute
1 cup all-purpose flour
1/2 cup all-purpose flour and 1/2 cup

whole wheat flour
Oil for sauting
Salt
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American processed cheese
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Wine, sherry, vinegar, low-sodium broth,

tomato juice, lemon juice, skim milk,
water
Garlic, onions, herbs, spices, lemon,
pepper, Mrs. Dash
Try a variety of cheeses, some are lower

in fat: part skim mozzarella; provolone;
Swiss; Cabot reduced fat cheddar, soy
cheese (veggie cheese); watch portion
sizes
Canned vegetables and beans
Look for No Added Salt on the label or

rinse before heating to decrease the
amount of sodium. Remember fresh
and frozen are best!
Meat, Poultry
Look for the cuts loin or round when

selecting beef or pork; a round cut of
beef has less fat then dark chicken meat
Handout created by: Catherine Wallace, MSH, RD, Baptist Medical Center

Exercise? Yes You Can!

Did You Know?
Chewing gum at about 100 chews per minute uses

about 11 calories each hour. This was reported by the
Mayo Clinic in a publication no less prestigious than the
New England Journal of Medicine. If a person chewed
sugar-free gum during all waking hours and did not
change eating habits or other activities, there could be a
loss of more than 10 pounds of body fat per year - just
from the calories burned in chewing sugar-free gum! Of
course, sugared chewing gums don't have the same
effect because of the calories in the sugar.
The Energy Expended in Chewing Gum.
New England Journal of Medicine, December 30, 1999
T
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Moving Experiences
Physical activity is a powerful weapon

to help ensure a long and healthy life. The
studies tell us that people who exercise do
improve their health and live longer. How
much exercise we need to achieve this is
not yet clear. So far, the statistics tell us
that regular exercise, using 1,000 calories
a week, reduces risk of death from any
cause by 20 to 30 percent and exercising
more than that may offer additional risk
reduction. It does not have to be organized
sport activity being physically active onthe-job, with household tasks, or recreations all of these activities count.
We also know that not exercising can
increase our risks for many diseases,
including heart disease and the three
most common cancers colon, breast
and prostate. And we know that exercising even just a little can provide a protective effect, perhaps by helping us to keep
our body weight in a healthy range.
Exercise pumps more blood through

the veins. This increases the size of arteries, prevents fat from clogging them,
and helps prevent blood clots. Regular
exercise also increases the HDL (good)
cholesterol and helps lower total cholesterol, and lower blood pressure.
The lungs also benefit from exercise
as they become better conditioned so that
activities such as climbing stairs will not
make us out of breath. Muscles that are
not used become small and inelastic, but
aerobic exercise or anaerobic strength
training will help tone the body by increasing muscle size, strength and flexibility while burning fat.
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Coping With Lifes Stresses
Exercise is also a great stress-buster,

so we can feel more relaxed at the end of
a day. Stress from major life events or
just the hassles of daily living can affect
anyone. Chronic stress, when we get no
relief, leads to exhaustion or burnout, a
state that can cause physical changes.
The sinking feeling in the pit of the
stomach, the cold, clammy hands, the
tightness of the neck -- these are often
triggered by two stress hormones -- called
adrenalin and cortisol. Exercise helps to
burn up these stress hormones, so people
feel more physically at ease after an exercise session.
You Are Never Too Old
Physical activity over the course of a

lifetime seems to confer the greatest
benefit, but even people who begin exercise in their later years derive a benefit. A
study of 7,500 women over age
65 from Baltimore, Minneapolis, Pittsburgh and Portland, Oregon reported that

those who began to increase physical
activity 10 to 12 years earlier (to about
one mile a day of walking) experienced
lower death from all causes, including 40
percent fewer deaths from cardiovascular
disease and cancer, compared to inactive
women. This study and others also show
that beneficial activity is not limited to
vigorous exercise. Even moderate activity,
such as walking one mile per day, can
result in gains for health.
Fitting-In Fitness
Let's face it. Not everyone will spend

an hour or two each day at the gym.
Many of us just don't want to
sweat. More often, it
just seems that there
are not enough hours
in the day to make
room for fitness.
Mental as well as
physical fatigue
couple with time
demands and even
with the best of
intentions, exercise
just falls off the daily
schedule too often
for many of us.
It's important to
remember that we
don't have to spend
hours at the gym to benefit
from exercise. Just about any form of
physical activity provides health benefit
and helps us to relax.
Burning as few as 150 additional
calories a day by means of exercise reduces risks of high blood pressure, coronary artery disease, diabetes, and cancer.
We can burn 150 calories in a surprising
variety of activities, some of which we
might not consider to be "real" exercise.
For instance, one-half hour of brisk
walking, or bicycling does the job.
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What Is Aerobic Exercise?
The term aerobic means "using oxygen." During aerobic exercise we use
oxygen to burn a mixture of fat and
carbohydrates for energy. It takes a while
for the bodys metabolic engine to rev up
to aerobic mode. That is why aerobic exercise burns the most calories if done for 30
minutes, at least three times a week.
What Is Anaerobic Exercise?
The term anaerobic means "without

oxygen." During anaerobic exercise we
use mostly our bodys stored
carbohydrates for fuel. We use the
anaerobic mode during
short bouts of activity, like lifting a
heavy box or free-weight
for example, or running
from home plate to first or
second base on a baseball
diamond. Strength training to build muscles and
improve physique is
typically an anaerobic
exercise.
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Which Is Better?
Both types of exercise provide benefit.

Studies tell us that we
get the greatest benefit
if we perform both
aerobic and anaerobic
workouts. Generally
speaking, many experts
now believe that, of the
two, aerobic exercise
provides more overall boost to health.
Aerobic exercise strengthens the
heart and lungs, and has a favorable
effect on cholesterol and blood pressure,
among other things. Anaerobic strength
training improves muscle tone and body
composition, resulting in a greater
amount of lean body mass and lower body
fat, and may provide similar benefits for
the heart, and blood pressure.
It is also been shown that strenuous

activity
alters several hormones that play
Target Heart Rate is what the pulse
a role in health and disease. Physical
rate should be to exercise safely and
activity lowers blood insulin, glucose,
receive the maximum cardiovascular
triglycerides, and raises HDL cholesterol
benefits. Your age and how well condiall of which may help decrease disease
tioned you are determine your target
risk.
heart rate.
Exercise also seems to favorably
The simplest way to calculate your
own target heart rate is to subtract your
affect sex hormones such as testosterone
age from 220. This number is the maxiand estrogen. Both these hormones promum times your heart can beat in one
mote cancer growth. Men with prostate
minute. If you are just beginning, your
cancer have higher levels of testosterone
target heart rate should be
than healthy men, and
between 60% to 75% of your
women with breast
maximum heart rate but
cancer have more exposure to estrogen than
after six months you can
Age is not the
healthy women. Male
safely go up to 85%.
issue. Even
endurance athletes,
The easiest way to
people who
such as triathletes, have
check your heart rate is to
begin exercise
less testosterone than
place the tips of your middle
in
their
50s
and
non-athletes, and
and index fingers in the
60s and later in
groove of your throat just to
women who engage in
intensive physical
the side of the Adam's apple.
life derive a
activity have less
Count the heart beats for six
benefit from
estrogen than nonseconds and multiply the
exercise.
athletes. So, some of the
number of beats by 10. If
benefits of exercise may
you are not within target
come from effects on sex
range, adjust the workout.
hormones.
After cooling down, check your pulse
Fitness and Healthy Aging
rate again. It should be less than 100
Besides offering protection from major
beats per minute before you stop moving.
diseases such as heart disease and canIf it takes more than 5 minutes to recover,
cer, exercise can help us to be more vital
lower your workout intensity.
later in life.
As we age, the body has a tendency to
Keeping Off the Unwanted Weight
change composition, losing muscle mass
We don't really know why exercise
and skeleton, and gaining fat. Medically,
reduces disease risk. Exercise produces a
the condition is known as sarcopenia.
positive effect on weight, which may
Our body strength tends to go down, as
explain some of the benefits, because
does our activity level. Experts used to
obese people have higher risk for chronic
think that sarcopenia was inevitable in old
diseases, compared to non-obese people.
age, but it is not inevitable. Keeping active
Keeping weight in the healthy range
helps fend off the loss of energy, strength,
is important. And exercise is one way to
and muscle. Even among the so-called
help keep off those pounds. We see time
frail
elderly people 90 or so years of
and time again among people who diet
age strength training that involves
to lose weight, those who exercise tend to
resistance training can improve movement
keep off the pounds more than dieters
and muscle function.
who do not exercise, regardless of the type
of diet they have followed.
What Is a Target Heart Rate?
T
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What Is the Right Exercise for Me?
It is important to select some activity

that you can enjoy and stick with at least
three times a week for 30 minutes on
each day that you exercise.
Make sure you are dressed in clothing that is comfortable and loose fitting. If
the activity takes you outdoors, wear
light-weight clothes that allow body heat
to escape. On cold days, dress in layers
so you can remove one layer if exercise
gets you uncomfortably hot. If it is really
cold, wear a hat and gloves.
Cool-Down
Cooling down allows your heart rate,

breathing and blood pressure to return to
normal. It also prevents blood from pooling in your working muscles, returns it to
your heart and brain, and prepares your
body for stretching. To cool down, decrease your activity to a slower pace for
about five minutes. Then S T R E T C H,
holding each stretch 20 to 30 seconds.
Stretching after a workout improves
flexibility, lessens muscle soreness and
helps you relax.
Warm-Up
An exercise regime
should always include
five minutes of warm-up
-- a slow-pace version of
your activity -- a slow
walk for example. This
gradually increases
heart rate and blood
flow to prepare the heart
and muscles for exercise. Follow this with a
little stretching for another five minutes. This
helps to prevent injuries, since warm, stretched muscles are
less prone to injury than cold, tight ones.
Stretch your major muscle groups,
the muscles you plan to use during exercise. Stretch in a relaxed, controlled way.
Extend the muscle only as far as comfortable. If it hurts, you are doing too much.
Hold each stretch for 10 seconds. Do NOT
bounce. Do NOT hold your breath.
Breathe normally.
Work-Out
T
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After the warm up, start with 5 to 10

minutes of exercise, slowly increasing
until you reach target heart rate.
Gradually over a period of weeks or
months increase exercise time to 40 or 45
minutes at target heart rate. This
maximizes aerobic benefits. Dont try to
overdo it, especially at first.
R
D
Stretch your major

muscle groups, the ones
you used during exercise. Stretch and
breathe in the same
relaxed manner that you
used before the workout.
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Time of Day
The time we exercise is also important.

Avoid strenuous activity
if it is hot and humid
and also wait at least
two hours after eating.
Digesting food increases blood flow to the
stomach and intestines, but exercise
sends the blood to working muscles. This
causes food to stay in the GI tract longer,
which produces bloating, indigestion, and
other discomfort.
All About Muscles and Fat
Sedentary people who do little or no

regular exercise can lose up to 30% of
their muscle mass due to inactivity during
adulthood, averaging several pounds of
lost muscle per decade. Losing muscle
mass means the metabolism slows down,
because muscle needs a lot of calories to
maintain itself. Slower metabolism results
in the body burning fewer calories, and
that can cause weight gain.
Muscle is an active tissue. Each
pound of muscle requires about 30 to 50
calories per day for maintenance. What

does this mean in practical terms? Add
just one pound of muscle and burn 210 to
350 extra calories per week.
In contrast, each pound of fat only
burns 3 calories per day. So, it is easy to
see that, for two people who have the
same weight, the person whose body has
more muscle will use more calories by far
than the person whose body has more fat.
Strength & Resistance Training

Strength and resistance training, or
working out with weights, is a great way
to improve muscle mass and tone, plus
improve balance and
coordination and
helps smooth out the
body curves.
Before you begin
a program to work out
with weights, it is a
good idea to consult
with an expert -someone who can
show you proper body
alignment, form and
technique. This will
help maximize results,
and minimize risk of
injury and strain that can occur when we
dont use proper form.
Here are some things to remember
about strength training:
T
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E
Work the biggest muscles first

(chest, back, legs), then the
smaller muscles (shoulders,
biceps, triceps)
Balance the weights on right and
left sides, front and back.
Try to do 10 to 15 repetitions with
each exercise. A repetition (or rep)
is the number of times you lift the
weight.
Lift a weight that is just heavy
enough to tire your muscles after
10 to 15 reps (where you cannot lift
the weight again due to fatigue.

Start with a low weight of perhaps
one to five pounds on muscles of the
upper body, and ten pounds on
muscles of the lower body.
Target doing the workout 2 to 3 times
per week, resting your muscles for 48
hours between workouts to give the
muscles time to repair and rebuild.
Shoot for gradually increasing the
amount of weight you lift. When you
can do 10 to 15 reps at one weight
with ease, it is time to increase the
weight by three to five pounds on the
upper body, and up to ten pounds on
the lower body.
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Stop exercising
a muscle when
you feel you
may be losing
control of the
muscle, or if
the muscle is
too fatigued or
strained to
keep the the
correct form.
Dont add more
stress to muscles
that are already tired.
Take it slow when you perform the
reps. Many exercise experts advise to
count to 2 as you lift the weight,
and count to 4 as you lower it.
Exhale when you lift a weight. Never
hold your breath while lifting a
weight.
Rest 30 to 90 seconds between each
exercise.
Count on having some muscle
soreness, especially in the beginning
days of your program. This is normal.
The soreness eventually goes away as
you continue to workout. Remember
that a little soreness is fine, but
P A I N is not good. Stop if you feel
pain.
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When To See The Doctor First
If you are over age 35 or have a history of medical problems, it is important

to see your doctor before beginning an
exercise program.
Most doctors will perform a medical
evaluation to assess your health and
fitness. They will check blood pressure,
cholesterol, and weight, and identify any
problems that could affect your circulation, muscles or bones. Depending on
your health background, a doctor may
recommend an EKG (electrocardiogram to
monitor the heart rate and function), or a
treadmill test.
A fitness evaluation may also be
recommended to determine your current
fitness level and to set fitness goals. The
evaluation may involve a muscle strength
test, including push-ups and sit-ups; a
flexibility test to check your range to
stretch the various muscle groups; a back
assessment to determine strength and
flexibility to help avoid spinal injury; and
an assessment of body fat to determine
your fat to lean body mass ratio.
After examining the test results, your
doctor will be able to help you design an
exercise routine that will set you on your
way to better fitness.
T
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Small Moves
Here are some little exercise activities that, done regularly, can add up:
Leave the car behind and walk
to the store for that short trip to
buy a quart of milk or lotto
ticket.
In public buildings, and in
apartment complexes, take the
stairs rather than elevators.
Spend time window shopping
by walking around shopping
streets.
If you play golf, carry your own
club bag around the course.
E
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At the movies, at church or

temple, or at the mall, park far
away from the entrance, and
walk to the entrance.
R
D
Take the kids or grandkids out

to the park for a game of frisbee.
Make the dogs daily outing an
excuse for your getting some
exercise as well. Take a long
walk with the pooch.
Stand rather than sit when
you talk on the phone, entertain
friends, or engage in any type of
conversation. Standing uses up
40 percent more calories than
sitting.
Go dancing with your spouse or
with friends modern dancing,
ballroom dancing, ethnic
dancing, square dancing any
kind of dancing will do -- even
taking a ballet or tap dancing
class at the local YMCA or
school.
Activities and Calories Spent
You can use this table* to determine how many calories you may burn in a given
activity. Just find the column that that corresponds to your weight, and then move
down the column to see the activity. Multiply the number of calories per minute by the
number of minutes spent in the activity to find out how many calories are being used.
Activity
Cycling
Cycling
Cycling
Cycling
Stretches
Stretches
Dancing
Dancing
Dancing
Dancing
Fishing
Home
Home
Home
Home
Home
Home
Inactivity
Inactivity
Lawn
Lawn
Lawn
Music
Music
Work
Work
Work
Work
Work
Running
Running
Running
Running
Running
Sports
Sports
Sports
Sports
Sports
Sports
Sports
Intensity
Slow, for pleasure

10-11.9 mph, leisure, slow
12-13.9 mph, moderate
14-15.9 mph, vigorous
Stretching, hatha yoga
Water calisthenics
General
Aerobic, low impact
Aerobic, general
Aerobic, high impact
Fishing from boat
Sitting, knitting, sewing
Carpet or floor sweeping
Cleaning house
Washing the car
Painting, outside house
Carpentry, sawing hardwood
Watch TV, Listen to music
Sleeping
Mowing , riding mower
Mowing walk, power mower
Shoveling snow, by hand
Piano or organ
Drums
Sitting-light office work
Standing, light
Construction
Masonry
Carrying heavy loads
Running, 5 mph
Running, 5.2 mph
Running, 6 mph
Running, 7 mph
Running up stairs
Basketball, baskets
Basketball, game
Boxing, punching bag
Frisbee, ultimate
Golf, using power cart
Golf, pulling clubs
Handball
110lbs
130lbs
3.50
5.25
7.00
8.75
3.50
5.25
3.94
4.38
5.25
6.13
2.19
1.31
2.19
3.06
3.94
4.38
6.56
0.88
0.79
2.19
3.94
5.25
2.19
3.50
1.31
2.19
4.81
6.13
7.00
7.00
7.88
8.75
10.06
13.13
3.94
7.00
5.25
3.06
3.06
4.38
10.50
4.14
6.20
8.27
10.34
4.14
6.20
4.65
5.17
6.20
7.24
2.59
1.55
2.59
3.62
4.65
5.17
7.76
1.03
0.93
2.59
4.65
6.20
2.59
4.14
1.55
2.59
5.69
7.24
8.27
8.27
9.31
10.34
11.89
15.51
4.65
8.27
6.20
3.62
3.62
5.17
12.41
T
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Calories per Minute

150lbs 170 lbs 190lbs 210lbs
4.77
7.16
9.55
11.93
4.77
7.16
5.37
5.97
7.16
8.35
2.98
1.79
2.98
4.18
5.37
5.97
8.95
1.19
1.07
2.98
5.37
7.16
2.98
4.77
1.79
2.98
6.56
8.35
9.55
9.55
10.74
11.93
13.72
17.90
5.37
9.55
7.16
4.18
4.18
5.97
14.32
5.09
7.64
10.18
12.73
5.09
7.64
5.73
6.36
7.64
8.91
3.18
1.91
3.18
4.45
5.73
6.36
9.55
1.27
1.15
3.18
5.73
7.64
3.18
5.09
1.91
3.18
7.00
8.91
10.18
10.18
11.45
12.73
14.64
19.09
5.73
10.18
7.64
4.45
4.45
6.36
15.27
6.05
9.07
12.09
15.11
6.05
9.07
6.80
7.56
9.07
10.58
3.78
2.27
3.78
5.29
6.80
7.56
11.34
1.51
1.36
3.78
6.80
9.07
3.78
6.05
2.27
3.78
8.31
10.58
12.09
12.09
13.60
15.11
17.38
22.67
6.80
12.09
9.07
5.29
5.29
7.56
18.14
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D
6.68
10.02
13.36
16.70
6.68
10.02
7.52
8.35
10.02
11.69
4.18
2.51
4.18
5.85
7.52
8.35
12.53
1.67
1.50
4.18
7.52
10.02
4.18
6.68
2.51
4.18
9.19
11.69
13.36
13.36
15.03
16.70
19.21
25.06
7.52
13.36
10.02
5.85
5.85
8.35
20.05
E
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Activity
Intensity
110lbs
Sports
Sports
Sports
Sports
Sports
Sports
Sports
Sports
Sports
Sports
Sports
Walking
Walking
Walking
Walking
Walking
Walking
Walking
Walking
Walking
Walking
Water
Water
Water
Water
Winter
Winter
Winter
Winter
Hockey, ice or field

Horseback riding
Judo, karate, kick boxing
Racquetball, competitive
Rock climbing
Rope jumping, slow
Softball or baseball
Table tennis
Tai chi
Tennis, doubles
Tennis, singles
Downstairs
Hiking, cross country
Pushing stroller
Race walking
Up stairs
Walking, very slow
2.5 mph, level
3.0 mph, level, moderate
3.5 to 4.0 mph, level, brisk
4.5 mph, level, very brisk
Snorkeling
Surfing, body or board
Swimming, leisurely
Swimming laps, freestyle
Skiing, downhill, light
Skiing, downhill, racing
Snow shoeing
Snowmobiling
7.00
3.50
8.75
8.75
9.63
7.00
4.38
3.50
3.50
5.25
7.00
2.63
5.25
2.19
5.69
7.00
1.75
2.63
3.06
3.50
3.94
4.38
2.63
5.25
8.75
4.38
7.00
7.00
3.06
T
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130lbs
Calories per Minute

150lbs 170 lbs 190lbs 210lbs
8.27
4.14
10.34
10.34
11.37
8.27
5.17
4.14
4.14
6.20
8.27
3.10
6.20
2.59
6.72
8.27
2.07
3.10
3.62
4.14
4.65
5.17
3.10
6.20
10.34
5.17
8.27
8.27
3.62
9.55
10.18
4.77
5.09
11.93 12.73
11.93 12.73
13.12 14.00
9.55
10.18
5.97
6.36
4.77
5.09
4.77
5.09
7.16
7.64
9.55
10.18
3.58
3.82
7.16
7.64
2.98
3.18
7.76
8.27
9.55
10.18
2.39
2.55
3.58
3.82
4.18
4.45
4.77
5.09
5.37
5.73
5.97
6.36
3.58
3.82
7.16
7.64
11.93 12.73
5.97
6.36
9.55
10.18
9.55
10.18
4.18
4.45
R
D
12.09
6.05
15.11
15.11
16.62
12.09
7.56
6.05
6.05
9.07
12.09
4.53
9.07
3.78
9.82
12.09
3.02
4.53
5.29
6.05
6.80
7.56
4.53
9.07
15.11
7.56
12.09
12.09
5.29
13.36
6.68
16.70
16.70
18.37
13.36
8.35
6.68
6.68
10.02
13.36
5.01
10.02
4.18
10.86
13.36
3.34
5.01
5.85
6.68
7.52
8.35
5.01
10.02
16.70
8.35
13.36
13.36
5.85
E
IV
Data compiled from Ainsworth, et al. Compendium of Physical Activities: Classification of

Energy Cost of Human Physical Activities. Medicine and Science in Sports and Activities,
1993;25:71-80
Susan Moyers, PhD, MPH, LD/N

Nutrition for Childhood Obesity Prevention

Written by: Erin Petrey, MSH Dietetic Intern,
University of North Florida, Jacksonville
Reviewed by: Catherine Christie, PhD, RD,
LD/N, FADA. Chair, Department of Nutrition
& Dietetics, University of North Florida,
Jacksonville
PRACTITIONER POINTS
RATIONALE
The prevalence of childhood obesity
has increased greatly during the past three
decades (1). The prevalence of obesity
among children aged 6 to 11 years
increased from 6.5 percent in 1980 to 19.6
percent in 2008. The prevalence of obesity
among adolescents aged 12 to 19 years
increased from 5.0 percent to 18.1 percent
(2). Results from the 2007-2008 National
Health and Nutrition Examination Survey
(NHANES), using measured heights and
weights, indicate that an estimated 17
percent of children and adolescents ages 219 years are obese (2). Obesity may lead to
psychological, social, physical, and medical
problems for a child (3). BMI percentile on
the sex-specific BMI for age growth charts
which follow this section (CDC 2000) are
currently the best readily available measure
for determination of pediatric overweight and
prediction of risk for adult obesity.
T
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(4). The latter study also found that if

overweight begins before 8 years of age,
obesity in adulthood is likely to be more
severe.
Obese children and adolescents are at risk
for health problems during their youth and as
adults. Some negative health outcomes that
may be more obvious to children and their
parents are asthma, sleep apnea, skin
infection, and complaints of joint pain (4,6).
There are also more serious health risks
associated with obesity that may be less
obvious to the child or parent, such as high
blood pressure (hypertension), high
cholesterol, and Type 2 diabetes (4,6).
These conditions can have serious long-term
health effects and may require ongoing
medical treatment and management. The
bottom line is obesity can cause immediate
health problems as well as a number of very
serious chronic health conditions.
In addition, research indicates that obese
children have lower self esteem and self
confidence than their thinner peers (6). Low
self esteem and self confidence have been
linked to poor academic performance, fewer
friends, and depression (6). For all of these
reasons it is important to try and prevent
childhood obesity and identify overweight
and obese children quickly so they can begin
treatment and attain and maintain a healthy
weight.
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Underweight: BMI below the 5th percentile

Normal weight: BMI at the 5th and less than
the 85th percentile
Overweight: BMI at the 85th and below the
95th percentile
Obese: BMI at or above the 95th percentile
(need for in-depth medical assessment)
Obese children and adolescents are more
likely to become obese as adults (5). One
study found that approximately 80 percent of
children who were overweight at ages 1015
years were obese adults at age 25 years.
Another study found that 25 percent of
obese adults were overweight as children
B3.1
B3.2
Some examples of the problems associated

with obesity are (6):
Glucose intolerance and

insulin resistance
Type 2 Diabetes
Cholelithiasis (gallstones)
High blood pressure
Low self esteem

Negative body image
Depression
High cholesterol
Stigma
Teasing and bullying
Negative stereotyping
Discrimination
Social marginalization
Hepatic steatosis (fatty liver

disease (FLD)
Sleep apnea
Asthma
Skin conditions
Menstrual abnormalities
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Impaired balance
Orthopedic problems
Adapted from the National Alliance for

Nutrition and Activity Obesity Fact Sheet
Preventative measures are most

important, especially if there is a genetic
propensity toward obesity.
At times,
despite prudent measures, genetic and
environmental influences prevail and a
child becomes obese (7, 8). It is generally
agreed that the longer and the more obese
a child is, the more likely it is that the
condition will continue to adulthood
leading, in many cases, to depression and
chronic disease (3, 9, 10). In childhood
specifically, body weights should not be the
goal and weight loss may not always be
appropriate.
Instead, healthy lifestyles
including exercise and proper eating habits
should be encouraged, as well as improving
our childrens self esteem. If a child falls
into one or more categories outlined below,
consider further assessment, counseling,
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and medical nutrition therapy:

If > 95% for weight- for- length for kids
less than age 2
If > 95% BMI for age/sex for kids greater
than age 2
If child increases a percentile (or more)
above his/her established weight for age
pattern
If weight exceeds height by more than two
percentiles
These guidelines are for healthy children
over 2 years of age through puberty.
RELATED PHYSIOLOGY
Childhood obesity can result from the
influences and interactions of a number of
factors, including genetic, behavioral, and
environmental factors (11).

Genetic Factors
Studies suggest that specific genetic
characteristics may increase an individuals
predisposition to excess body weight (12,
13). However, this genetic susceptibility
may need to exist within a combination of
contributing behavioral and environmental
factors in order to have a significant effect
on weight.
Twin and adoption studies show that
genetics play a role in obesity (1). Twins
who were adopted by different families
were found to be closer in weight to their
biological parents than to their adoptive
parents (7). Prenatal factors such as
maternal obesity, excess pregnancy weight
gain, and diabetes, may also predispose a
child to obesity (14, 15). Mothers with
diabetes, either gestational or insulin
dependent diabetes prior to pregnancy,
have a higher percentage of babies of
elevated birth weight and children with a
greater risk of overweight and obesity. The
cause of this obesity risk from maternal
factors is still unknown, yet many
hypothesize a link to increased insulin
secretion, excess glucose, and/or
increased fat transfer.
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light approach or by eliminating one

or two high-calorie foods and excessive
fruit juice from the diet may be
beneficial (19). Educating children on
the use of MyPyramid to establish a
proper plan for eating and calorie
counting should not be approached.
Obese children generally have higher
total resting metabolic rates (RMR)
when compared to non-obese peers,
but the rate relative to body size may be
low and when adjusted for body
composition is not different.
Researchers have determined that
RMR is determined more by fat free
mass than any other factor with age
(RMR decreases with increasing age),
and gender (males have higher RMRs
than females) also playing a smaller but
significant role (20).
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Behavioral Factors
It is not possible to identify one

specific behavior as the cause of childhood
obesity, but certain behaviors can
contribute to an energy imbalance,
therefore leading to obesity.
Energy Intake: Dietary fat intake,

portion control and increased energy
expenditure are among the important
components of weight control (16).
Eating meals away from home, frequent
snacking on energy-dense foods, and
consuming beverages with added sugar
are often attributed to the consumption
of excess calories in children and teens
(17). Excluding inappropriate snacks
and overeating by utilizing the stop
B3.3
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Physical Activity: Physical activity, an

integral part of weight loss for children
and teens, may also have beneficial
effects on blood pressure and bone
strength (21). Families must establish
a family routine (including parents and
siblings) to include physical activity to
help metabolize fat, expend excess
calories as well as to increase fat free
mass (18). Children are encouraged to
have at least 60 minutes of moderate
intensity activity each day (1). At least
30 minutes of that should be from
physical activity at school (1). Team
sports, dance and martial arts are
examples of aerobic activities that may
benefit an obese child.
Physically
active children are more likely to remain
physically
active throughout
adolescence and possibly adulthood
(22).
Sedentary Behavior: Parents should be

encouraged to get their children involved
in activities where they will play and not
sit the bench and ones that are for
recreation not just competition. Limiting

television, video games and other
sedentary after-school activities is
imperative. Several studies have found a
positive association between time spent
watching television and prevalence of
obesity in children (23, 24).
The
American Academy of Pediatrics
recommends no more than 2 hours of
sedentary behavior each day. In regard
to screen time (time spent watching
television or playing video games),
children aged 0-2, should have zero
hours of screen time per day (1).
Children aged 2-18 should not exceed 12 hours of screen time per day (1).
Listed in Table 1 are recommended weight
goals for children according to age and BMI
percentile.
Age 2-7years BMI 85-94%
BMI > 95%
If no complications, weight
maintenance
If medical complications,
weight loss
T
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Age >7 years BMI 85-94%
Weight maintenance
BMI > 95%
If no complications, weight
maintenance
If medical complications,
weight loss
Weight loss
Table 1- Recommendations for Weight Goals (18):
Environmental Factors
A childs behavior related to food

intake and physical activity can be
influenced within the home, child care,
school, and community (17). Within the
home, parental obesity (of undetermined
cause) has been shown to play the biggest
role in the development of childhood obesity
in children 5 years of age, making genetics a
probable cause (25). Until the reasons for
obesity are identified and addressed, and
obese parents successfully improve their
eating and activity habits, permanent weight
loss attempts may fail.
The majority of childrens time is spent in
child care or at school. This can be a setting

in which healthy eating and physical activity
habits are established.
A childs community can play a big
role in influencing physical activity and
access to affordable and healthy food. A lack
of sidewalks, safe bike paths, and parks can
discourage children from walking or biking to
school as well as from participating in
outdoor physical activities (17).
Nutrients Modified
Nutrition guidelines for children
include all foods but recommend limited use
of high calorie, high fat and refined
carbohydrate foods. Fats should be limited to
20-30 percent of calories with < 10 percent
coming from saturated fat and < 300 mg of
cholesterol per day (26). Fat should not be
restricted in children younger than 2 years of
age.
MyPyramid should be utilized to
promote a healthy mixture of carbohydrate,
fat, and protein to maintain adequate growth
without inappropriate weight gain.
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Nutritional Adequacy
Diets should be evaluated using the
Recommended Dietary Allowances (RDA) and
the Dietary Reference Intakes (DRI) (27, 28).
RDAs can be used to assess the adequate
intake of nutrients that prevents a deficiency.
To assure intake of nutrients in levels that
may reduce the risk of diet-related diseases,
the DRIs are used.
When a variety of foods are consumed, this
diet is adequate for all nutrients specified by
the Dietary Reference Intakes (DRIs) for
children over the age of two.
MNT for Childhood Overweight and Obesity
(30)
The following are suggested pediatric
weight management protocols adapted from
the American Academy of Pediatrics:
1st RD Visit
B3.4
Medical and nutrition evaluation (blood

pressure, height, weight, BMI, growth
chart, review labs). See ADA Pediatric
Weight Management Evidence-Based
Nutrition Practice Guidelines.
Review PCP comments and goals as
available
Nutrition assessment (including
readiness to change assessment ) See
ADA Pediatric Weight Management
Evidence-Based Nutrition Practice
Guidelines.
Determine nutrition diagnosis
Prioritize needs and goals based on child
and family interests and issues (refer to
Nutrition Topic List)
Begin intervention/counseling/education
(for example: food pyramid food choices,
review portion sizes or other nutrition
topic from list) See ADA Pediatric Weight
Management Nutrition Intervention
Algorithm.
Recommend food and activity records
and/or self-monitoring activity to support
goals
Document
Discuss/share plan with PCP
T
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RD Visits 2-4
Review medical record/chart notes and
Pediatric Weight Management Ongoing
Care Coordination and Information Sharing
form from PCP as available; acknowledge
PCP feedback on goals/revised goals &
medical status, review reports from other
consultants, as applicable
Review labs from PCP, as applicable.
Medical and nutrition re-evaluation.
Recheck weight, etc. See ADA Pediatric
Weight Management Evidence-Based
Nutrition Practice Guidelines.
Update/modify nutrition diagnosis, as
needed
Review goals from prior session
Reinforce progress
Counseling on nutrition topic for the
session (Items identified from Nutrition
Topic List)
Establish new goals (or maintenance goal
B3.5
(s) at last visit). See ADA Pediatric Weight

Management Nutrition Intervention
Algorithm.
Recommend food and activity records and/
or self-monitoring activity to support goals
Document
Discuss/share plan with PCP
Nutrition Diagnoses
In regard to childhood overweight and
obesity, some possible PES statements and
nutrition diagnoses might be:
Excessive energy intake related to lack of

knowledge as evidenced by 3 sugary drinks/
day and BMI of 34.
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Excessive energy intake related to lack of

access to healthy food choices (fast food) as
evidenced by diet history and BMI of 35.
R
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Obesity related to lack of physical activity

and poor food choices as evidenced by diet
history and charting above 95th percentile on
growth chart.
REFERENCES
1. Barlow, et al.
Expert committee
recommendations regarding the
prevention, assessment, and treatment
of child and adolescent overweight and
obesity: Summary report. Pediatrics.
2007;120;S164-S192.
2. Han JC, Lawlor DA, Kimm SYS.
Childhood obesity. The Lancet.
2010;375: 1737-48.
3. Childhood Overweight and Obesity.
Center for Disease Control and
Prevention Web site. Accessed April
10, 2010.
Available at: http://
w w w . c d c .go v / o b e s i t y / c h i l d h o o d /
index.html.
4. Hill JO, Trowbridge FL. Childhood the
United States, 19861990." Arch
Pediatr Adolesc Med 1996;150(4):356
62.

Written by: Nadine Pazder, MS, RD, LD/N,
CDE, Outpatient Dietitian, Morton Plant
Hospital, Clearwater
Reviewed by: Pat Hare, RD, CPS, All
Childrens Hospital, St. Petersburg
PRACTITIONER POINTS
RATIONALE
T
S
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BMI 85-94% indicates risk of overweight

BMI > 95% indicates overweight and
need for in depth medical assessment
Preventative measures are most

important, especially if there is a genetic
propensity toward obesity. At times, despite
prudent measures, genetic and
environmental influences prevail and a child
becomes obese (3, 4, 5). It is generally
agreed that the longer and the more obese a
child is, the more likely it is that the condition
will continue to adulthood leading, in many
cases, to depression and chronic disease (2,
6, 7). In childhood specifically, body weights
should not be the goal and weight loss may
not always be appropriate. Instead, healthy
lifestyles including exercise and proper
eating habits should be encouraged, as well
as improving our childrens self esteem. If a
child falls into one or more categories
outlined below, consider further assessment,
counseling, and medical nutrition therapy:
less than age 2

If > 95% BMI for age/sex for kids greater
than age 2
If child increases a percentile (or more)
above his/her established weight for age
pattern
If weight exceeds height by more than
two percentiles
USE
Overweight and obesity are increasing

in prevalence among all age groups but
especially fast in children and adolescents
(1). Research indicates that up to 25 percent
of the nations youth can be considered
overweight or obese (1). Obesity may lead to
psychological, social, physical, and medical
problems for a child (2). BMI percentile on
the sex-specific BMI for age growth charts
which follow this section (CDC 2000) are
currently the best readily available measure
for determination of pediatric overweight and
prediction of risk for adult obesity.
B4.1
If > 95% for weight- for- length for kids
These guidelines are for healthy

children over 2 years of age through puberty.
RELATED PHYSIOLOGY
E
IV
Twin and adoption studies show that

genetics play a role in obesity. Twins who
were adopted by different families were
found to be closer in weight to their
biological parents than to their adoptive
parents (4). Prenatal factors: maternal
obesity, excess pregnancy weight gain, and
diabetes, may also predispose a child to
obesity (8, 9). Mothers with diabetes, either
gestational or insulin dependent diabetes
prior to pregnancy, have a higher percentage
of babies of elevated birth weight and
children with a greater risk of overweight and
obesity. The cause of this obesity risk from
maternal factors is still unknown, yet many
hypothesize a link to increased insulin
secretion, excess glucose, and/or increased
fat transfer.
R
D
Dietary fat intake, portion control and

increased energy expenditure are among the
important components of weight control
(10). Excluding inappropriate snacks and
overeating by utilizing the stop light
approach or by eliminating one or two highcalorie foods and excessive fruit juice (no
more than 12 oz per day) from the diet may
be beneficial (12). Educating children on the
use of MyPyramid to establish a proper plan
for eating and calorie counting should not be
approached.
Obese children generally have higher

total resting metabolic rates (RMR) when
compared to non-obese peers, but the rate
relative to body size may be low and when
adjusted for body composition is not
different. Researchers have determined that
RMR is determined more by fat free mass
than any other factor with age (RMR
decreases with increasing age), and gender
(males have higher RMRs than females) also
playing a smaller but significant role (13).
B4.2
However, parental obesity (of undetermined

cause) has been shown to play the biggest
role in the development of childhood obesity
in children 5 years of age, making genetics a
probable cause (14). Until the reasons for
obesity are identified and addressed, and
obese parents successfully improve their
eating and activity habits, permanent weight
loss attempts may fail.
NUTRIENTS MODIFIED
Exercise is an integral part of weight

loss. Families must establish a family routine
(including parents and siblings) to include
physical activity to help metabolize fat,
expend excess calories as well as to increase
fat free mass (11). At least 30 minutes of
activity should be a goal for all families. Team
sports, dance and martial arts are examples
of aerobic activities that may benefit an
obese child. Parents should be encouraged to
get their children involved in activities where
they will play and not sit the bench and ones
that are for recreation not just competition.
Limiting television, video games and other
sedentary after-school activities is imperative.
Listed in Table 1 are recommended weight
goals for children according to age and BMI
percentile.
T
S
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Table 1- Recommendations for Weight Goals (11):

Age
BMI 85-94%
2-7years
BMI > 95%
Age
BMI 85-94%
>7 years
BMI > 95%
Weight maintenance
If no complications,
weight maintenance
If medical
complications, weight
loss
If no complications,
weight maintenance
If medical
complications,
weight loss
Weight loss
A variety of factors: appetite, cultural

preferences and patterns, and psychological
needs drive and influence eating behavior.
This meal pattern includes all foods but

recommends limited use of high calorie, high
fat and refined carbohydrate foods. Fats
should be limited to 20-30 percent of calories
with <10 percent coming from saturated fat
and < 300mg of cholesterol per day (15). Fat
should not be restricted in children younger
than 2. MyPyramid should be utilized to
promote a healthy mixture of carbohydrate,
fat, and protein to maintain adequate growth
without inappropriate weight gain.
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NUTRITIONAL ADEQUACY
Diets should be evaluated using the

Recommended Dietary Allowances (RDA) and
the Dietary Reference Intakes (DRI) (16, 17).
RDAs can be used to assess the adequate
intake of nutrients that prevents a deficiency.
To assure intake of nutrients in levels that
may reduce the risk of diet-related diseases,
the DRIs are used.
When a variety of foods are consumed,
this diet is adequate for all nutrients specified
by the Dietary Reference Intakes (DRIs) for
children over the age of two.
REFERENCES
1.
2.
Troiano RP, Flegal KW. Overweight

children: description, epidemiology and
demographics. Pediatrics.
1998;101:497-504.
Hill JO, Trowbridge FL. Childhood obesity:
future directions and research priorities.

Pediatrics. 1998;101:570-574.
Garn SM, Sullivan TV, Hawthorne VM.
Fatness and obesity of parents of obese
individuals. Am J Clin Nutr.
1989;50:1308-1313.
4. Stunkard AJ, Sorennsen IA, Hanis C,
Teasdale TW, Chakraborty R, Schull WJ,
Schulsinger F. An adoption study of
human obesity. NEJM. 1986;314:193198.
5. Bouchard C, Tremblay A, Despres J,
Nadeau A, Lupien P, Therault G,
Dussault J, Moorjani S, Pinault S,
Fournier G. The response to long term
overfeeding in identical twins. NEJM.
1990;322:1477-1488.
6. Casey VA, Dwyer JT, Coleman KA,
Valedian I. Body mass index from
childhood to middle age: a 50 year
follow up. Am J Clin Nutr. 1992;56:1418.
7. Guo S, Roche A, Cameron Chumlea W,
Gardner J, Siervogel R. The predictive
value of childhood body mass index
values for overweight at age 35 years.
Am J Clin Nutr. 1994;59:815-816.
8. Whitaker RC, Dietz WH. Role of the
prenatal environment in the
development of obesity. J Pediatr.
1998;132:768-776.
9. Plagemann A, Harder T, Kohlkoff R,
Rhode W, Dorner G. Overweight and
obesity in infants of mothers with long
term insulin-dependant diabetes or
gestational diabetes. International
Journal of Obesity. 1997;21:451-456.
10. Williams Cl, Bollella M, Boccia L, Spark
A. Nutrition and the life cycle. Dietary fat
and childrens health. Nutrition
Today.1998;33:144-155.
11. Barlow SE, Dietz WH. Obesity evaluation
and treatment: expert committee
recommendations. Pediatrics. 102;e2948. (Electronic pages).
12. Dennison BA, Rockwell HL, Baker SL.
Excess fruit juice consumption by
preschool-aged children with short
stature and obesity. Pediatrics.
1997;99:15-22.
3.
T
S
E
B4.3
13. Molnar D, Schultz Y. The effect of

obesity, age, puberty and gender on
resting metabolic rate in children and
adolescents. Eur J Pediatr.
1997;156:376-381.
14. OCallaghan MJ, Williams GM, Anderson
MJ, Bor W, Najman JM. Prediction of
obesity in children at 5 years: a cohort
study. J Paediatr Child Health. 1997;33:
311-316.
15. American Academy of Pediatrics,
Committee on Nutrition, Statement on
Cholesterol Pediatrics. 90: 469, 1992.
16. National Research Council.
Recommended Dietary Allowance, 10th
Edition. National Academy Press.1989.
17. Dietary Reference Intakes. Food and
Nutrition Information Center web site.
2003. Available at: http://
www.nal.usda.gov/fnic/
etext/000105.html. Accessed October
2003.
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Written by: Delores C.S. James, PhD, RD,
LD/N, Associate Professor, Department of
Health Science Education, University of
Florida
Reviewed by: Jennifer Hutchison, RD, LD/N,
CSCS, Sports Dietitian, Private Practice
PRACTITIONER POINTS
RATIONALE
Physical fitness is as important to
health as proper nutrition. Physical fitness is
beneficial to everyone, regardless of the
initial level of fitness. The goal of a physical
fitness program is to reduce body fat and
increase lean muscle mass (1, 2). For
optimal health and prevention of weight gain,
approximately 2000 kcal/week should be
expended in physical activity (2-5). These
guidelines are designed to provide adequate
calories and nutrients for adequate
performance.
T
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RELATED PHYSIOLOGY
The components of a physical fitness

program are cardiovascular endurance, flexibility, muscular strength, muscular endurance, and body composition (4-7).
Cardiovascular Endurance refers to the

body's ability to use oxygen for muscular
work. A continuous supply of oxygen is
needed to burn carbohydrates and fats for
energy in aerobic activities. Cardiovascular
endurance improves with regular aerobic activities such as jogging, aerobic dancing,
walking, and cycling. Aerobic activities
involve continuous rhythmic activities of
large muscle groups for at least 20 minutes.
Short-term, high-intensity activities such as
diving, high jumping, and discus throwing
use anaerobic fuel sources. Activities such
as tennis, volleyball, basketball, and soccer
generally requires both aerobic and anaerobic fuel sources (4-7).
force that is exerted by a muscle or muscle

group in a single contraction. Muscular
strength is developed by progressive resistance by weight training with free weights
(dumbbells and barbells), exercise machines,
strength training equipment, Nautilus machines, and other resistance equipment.
Calisthenic exercises, such as sit-ups and
push-ups, can strengthen muscles but are
not as effective as weight training because
overloading of the muscles is difficult to
achieve; they are best suited for developing
muscular endurance (4-7).
Muscular Endurance refers to repeated
muscular force. It involves repetitions
against resistance that are less than maximal. Muscular endurance exercises include
calisthenics (push-ups, sit-ups), and
repeated lifting of weights (4-7).
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Flexibility refers to the ability of a joint to go

through a range of motion. Flexibility exercises include yoga and stretching activities.
Flexibility exercises should be part of the
warm-up and cool-down routines (4-7).
Body Composition refers to the proportion of
lean body weight to fat tissues. Lean body
weight is composed of muscles, bones, and
organs. Health risks for some chronic
diseases such as obesity, heart disease,
some cancers, diabetes, and hypertension
increase as proportion of body fat increases.
Body weight is influenced by genetics, age,
gender, body type, physical activity, and
individual variation. The average American
has 16 to 24 percent body fat (8).
Acceptable figures for the general population
are 15-18 percent for males and 20 to 25
percent for females. Males having more than
25 percent body fat and females having
more than 30 percent body fat are
considered obese and are at high risk for
certain chronic diseases (3). Percent body fat
for athletes usually ranges from 5 to 12
percent in males and 10 to 20 percent in
females, depending on the sport (8).
Muscular Strength refers to the maximal
C1.1

Body mass index (BMI) is an indicator of
body composition. Desirable BMI ranges are
21.9 to 22.4 for men and 21.3 to 22.1 for
women. BMI has limited usefulness for elite
and professional athletes as many of these
athletes have a higher portion of lean body
mass compared to fat mass. The National
Center for Health Statistics defines
overweight as BMI over 27. However, the
Dietary Guidelines for Americans, the
National Heart Lung and Blood Institute, and
the World Health Organization define
overweight as BMI over 25 (9). Individuals
with a BMI between 25 and 26.9 should be
encouraged to become physically active and
to avoid further weight gain (9).
Table 1. Calculating BMI

BMI =
Weight (kilograms)
Height (meters)2
T
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OR
BMI =
703 x Weight (pounds)

Height (in inches)2
For example, the BMI for a person 5'7" (170

centimeters) weighing 153 pounds (69.5
kilograms) is 24.
BMI =
703x 153
= 23.9
(1.7 meters) 2
or
BMI =
69.5 kg
= 24.0
(67 inches) 2
BENEFITS OF PHYSICAL ACTIVITY
lung function
Lowered LDL-cholesterol and increased
HDL-cholesterol
Decreased blood pressure and slower
resting pulse rates
Increased basal metabolic rate (BMR)
Increased lean muscle mass and
decrease in body fat
Increased bone density
Improved glucose tolerance
Increased self-esteem and a sense of well
-being
NUTRIENT REQUIREMENTS
Proper nutrition is essential for recreational, amateur, and professional athletes. To
date, no specific diet has been formulated for
athletes, but there are general guidelines and
recommendations for those engaged in
regular strenuous exercise.
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Energy
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IV
Energy needs will vary depending on

the individual, gender, age, the particular
event or sport, and the intensity, frequency
and the duration of the event or sport (3, 4,
12, 13). Energy needs can be determined by
an exercise physiologist who can administer
an oxygen consumption test at the competing
heart rate (13). A person's true caloric
requirement results from a combination of
basal energy expenditure (BEE), daily activity
needs, and energy expended during exercise
(8). If there is no access to physiological
testing, energy needs can be calculated by
hand. Mahan and Arlin (14) provide a quick
method for estimating daily energy
requirement:
Regular physical activity has several

health benefits. Most of these benefits can
be gained by performing moderate-intensity
activities. However, physical activity must be
performed regularly to maintain these effects
(1-6):
Reduced risk of coronary heart disease
Improved circulation, heart capacity, and
C1.2

Table 2. Estimating Energy Needs
1. Estimate desirable weight in kg
2. Determine basal needs:
male = 1 kcal/kg/hr x 24 hr
female = 0.95/kcal/kg/hr x 24 hr
3. Subtract 0.1 kcal/kg/hr of sleep
4. Add activity increment
30% sedentary
50% for moderately active
75% for active
100% strenuous work
5. Add the thermic effect of food (10% of
BEE plus activity increment)
For example, the energy needs for a

sedentary female who is 5' 10, weighs 150
pounds, and sleeps 8 hours/day:
1. 150 2.2 = 68.18 kg
2. 68.18 x 0.95 x 24 (BMR factor for
females) = 1554.5
3. 1554.5 - (68.18 x .1 x 8 = 54.54) =
1499.96
4. (1499.96 x .30%) + (1499.96 x .10) =
449.98 + 149 = 598.98
5. 1499.96 + 598.98 = 2098.94
6. Energy needs are approximately 2100
kcals per day
T
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The energy needs of athletes may be

calculated as follows (13).
Adult athlete:
ideal body weight (lbs) x 15 + (training
expenditure (kcal/min/lb x minutes x weight
in lb) = total daily energy needs (kcal)
Growing athlete:
ideal body weight (lbs) x 30 + training
expenditure (kcal/min/lb X minutes x weight
in lb) = total daily energy needs (kcal)
For example, the energy needs of a 150 lb

(68 kg) athlete who does cross-country
running for 90 minutes, expends 0.08 kcal/
min/lb body weight would be: total daily
energy needs is approximately 3330 calories:

150 x 15 + (0.08 x 90 x 150) =
2250+ 1080 = 3330 kcalories
Carbohydrate
Carbohydrates are an indispensable
fuel for essentially all types of athletic
performance. Glycogen depletion during
exercise leads to reduced performance and
decreased endurance (3, 8, 13). To provide
adequate substrate for glycogen synthesis
and to meet other nutritional needs, 60 to 65
percent of total energy should come from
carbohydrates. Ultraendurance and
ultradistance athletes (those who participate
in triathlons, and other events lasting 6 to
24+ hours) may require a diet of as high as
70 percent carbohydrates (3,13). 500 to 800
grams of carbohydrates (2,000 to 3,200 kcal)
per day may be needed to maintain maximal
glycogen stores in athletes (16, 17).
R
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Protein
E
IV
The Recommended Dietary Allowance

(RDA) for protein (0.8 gm/kg body weight)
may be inadequate for many athletes, such
as endurance athletes, body builders, and
football players. Endurance athletes should
consume 1.2 to 1.4 g/kg body weight,
whereas strength and power athletes may
need protein as high as 1.6 to 1.7 g/kg body
weight (18). Calculating protein needs on a
per kilogram body weight basis may be more
appropriate than calculating needs as a
percentage of total protein, as the latter may
result in excessive protein intake for athletes
with extremely high caloric intakes (3).
Fat
Fat is an important part of an athletes
diet as it provides energy, fat soluble
vitamins, and essential fatty acids. Fat should
not exceed 30 percent of total calories.
Saturated fat and trans fatty acids should be
limited, while emphasis on monounsaturated
C1.3
Written by: Catherine A. Wallace, MSH, RD,
LD/N, Baptist Medical Center, Jacksonville
LD/N, FADA, Nutrition Programs Director,
University of North Florida, Jacksonville
PRACTITIONER POINTS
RATIONALE
Vegetarianism is defined as the
practice and philosophy of eating a plant
based diet including grains, nuts, seeds, legumes, vegetables, and fruit (1, 2). However,
vegetarian diets vary according to ethical,
economic, environmental, humanitarian or
religious concerns. Most exclude meat, fowl,
and fish and some exclude eggs and dairy
products. There are different variations of
the vegetarian diet, but the three main types
are: vegan (strict vegetarian); lactovegetarian, which includes milk in the diet;
and lacto-ovo-vegetarian, which includes
milk and eggs. Another variation of the vegetarian diet, though not considered true
vegetarianism, is called pesco-vegetarian.
This variation of the vegetarian diet includes
fish and is sometimes referred to as macrobiotic. Refer to Table 1 for a listing of the
different classifications of the vegetarian
diet.
USE
T
S
E
The vegetarian diet is composed predominantly of plant foods and may or may
not include eggs and dairy products. The
2003 Position Statement of the American
Dietetic Association and Dietitians of Canada
states that an appropriately planned vegetarian diet is healthful, nutritionally adequate,
and provides health benefits in the prevention and treatment of certain diseases (3).
RELATED PHYSIOLOGY
Research has shown that vegetarians
are at a lower risk for many diseases and
conditions, including obesity, cardiovascular
C2.1
disease, hypertension, type 2 diabetes,
cancer, and diverticular disease and are at a
lower risk of mortality from chronic diseases
(2-12).
NUTRIENTS MODIFIED
Vegetarian diets can be healthful and
nutritionally adequate if properly planned
and a variety of foods are consumed.
Vegetarian diets tend to be higher in fiber,
vitamins A and C, and phytochemicals and
lower in calories, cholesterol, saturated fat,
and sodium than non-vegetarian diets (2, 11,
12). Groups at risk for inadequate caloric
and nutrient intake include: infants, children,
adolescents, and pregnant and lactating
women (3, 11, 12). However, with proper
planning a vegetarian diet can meet nutrient
needs throughout the life cycle (3).
R
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Nutrient deficiencies are possible if

adequate energy intake and a variety of
foods are not consumed (2-4). In planning a
vegetarian diet, one should choose a variety
of foods in accordance with the Dietary
Guidelines for Americans, and a modified
MyPyramid. In 2000, Oldways Preservation
and Exchange Trust developed The
Traditional Healthy Vegetarian Diet Pyramid
and the Traditional Healthy Vegetarian Diet
Pyramid for Children as seen in Figures 1
and 2 (13). This pyramid is a useful tool to
help professionals and their clients design
vegetarian meals appropriately. Another tool
that can be utilized for planning an
appropriate vegetarian diet is the New Food
Guide for North American Vegetarians which
was developed by dietitians and published in
the June 2003, Journal of The American
Dietetic Association (14).
Individuals following a vegetarian diet
need to plan meals accordingly to ensure
adequate intake of iron, zinc, vitamin D,
vitamin B12, omega-3 fatty acids, and overall
energy. Vegans should have a reliable source
C2.2
Table 1. VEGETARIAN DIET CLASSIFICATIONS

Diet
Classification
Foods
Included
Foods
Excluded
Nutritional
Concerns
Vegan
Grains, legumes,
vegetables, seavegetables, fruits,
seeds, nuts,
nutritional yeast,
vegetable oils, may
include soy
products and/or
meat analogs
Eggs, meat, fowl,

fish, shellfish, all
dairy products,
honey, products
containing animal
byproducts
Low calorie, protein,

riboflavin, vitamin B12,
iron, zinc, calcium,
vitamin D, omega-3 fatty
acids
LactoVegetarian
Grains, legumes,
seeds, nuts,
nutritional yeast,
vegetable oils, dairy
products, may
include soy
products and/or
meat analogs
Eggs, meat, fowl,

fish, shellfish
Iron, zinc, omega-3 fatty

acids
Grains, legumes,
seeds, nuts,
nutritional yeast,
vegetable oils, dairy
products, eggs, may
include soy
products and/or
meat analogs
Meat, fowl, fish,

shellfish
Zinc
Grains, legumes,
seeds, nuts, fish,
vegetable oils,
nutritional yeast
Meat, fowl, eggs,

dairy
Zinc, calcium, vitamin

B12, vitamin D
Lacto-OvoVegetarian
PescoVegetarian
(Macrobiotic)
T
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IV
Bariatric Surgery
Written by: Cathy Clark-Reyes, RD, LD/N,
Nutrition Concepts, Inc., Miami
Reviewed by: Emily Marcus, RD, CDN,
Bariatric Nutrition Coordinator, Center for
Weight Management, North Shore-Long
Island Jewish Health System
PRACTITIONER POINTS
RATIONALE
Obesity has reached epidemic
proportions in this country. It is a progressive
disease of multi-factorial origin. According to
the findings of NHANES survey (1999-2008),
33.8 percent of all American adults are now
obese and 68 percent are overweight. And,
nearly 12.4 percent of children age 2 to 5
and 17 percent of children age 6 to 11 were
overweight and 17.6 percent of adolescents
were overweight in the NHANES survey
(2003-2006). The prevalence of overweight
and obese adults from 1960-2 to 2005-6
has increased from 13.4 to 35.1 percent in
U.S. adults age 20 to 75 (1).
T
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Surgical weight loss is reserved for

morbidly obese patients who have been
unsuccessful at less invasive, supervised
attempts at weight loss. To be a candidate
for the surgery, one must have one or more
of the following criteria set forth by the 1991
National Institute of Health Consensus
Statement: One must be morbidly obese,
defined as anyone who is >100 lbs. over
Ideal Body Weight (IBW), Body Mass Index
(BMI) >40 kg/m2, or BMI >35 kg/m2 with comorbidities. Children and adolescents have
not been sufficiently studied to allow a
recommendation for surgery for them even in
the face of obesity associated with BMI
>40kg/m2 .
The National Institute of Health

Consensus Report in 1991 concluded,
Surgery is the only effective therapy for long
-term weight loss of individuals with morbid
obesity. The Consensus further provided the
C3.1
following recommendations for the treatment
of morbid obesity: 1) the individual being
considered for surgery be motivated to lose
weight and have attempted and failed at
medically-supervised dietary and behavioral
weight loss programs in the past, 2) either
gastric restrictive or gastric bypass are
acceptable weight loss surgical procedures
for the treatment of morbid obesity, 3) the
surgery should be performed only by a
surgeon skilled in Bariatric surgery, 4) the
surgical program should have a
multidisciplinary team, and 5) the program
should provide the surgical patient life-long
medical surveillance.
E
IV
There are several types of Bariatric

surgery. Some are purely restrictive such as
the Vertical Banded Gastroplasty (VBG) and
Laparoscopic Adjustable Gastric Banding
(LAGB); other procedures are primarily
malabsorptive such as the Biliopancreatic
Diversion/Switch (BPD); and the most well
known procedure is a combination of
restrictive and malabsorptive the Roux-N-Y
Gastric Bypass (RYGBP), which can be
standard, long-limb, or distal. Both
malabsorptive procedures are of greater
nutritional concern due to the fact that the
lower portion of the stomach and the
duodenum are bypassed. Other types
include: Silastic Ring Gastroplasty, Sleeve
Gastrectomy, and BPD with Duodenal Switch.
R
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The dietary concerns following these

procedures are control of food consistency
and volume, provision of adequate protein,
and maintenance of nutrient density.
Minimizing symptoms of dumping syndrome,
and the prevention of anemia and other
vitamin/mineral deficiencies are important
dietary factors with this surgery. Each
procedure has its own form of treatment and
diet therapy. Ultimately, the success of this
procedure hinges on lifestyle change and the
patients comprehension of their role in creating an optimal outcome. Nutrition education should ideally be provided within the
context of a comprehensive, interdisciplinary
Bariatric Surgery
C3.2
These dietary guidelines are for

patients who will or have undergone VBG,
LAGB, RYGBP or BPD for the treatment of
clinically severe morbid obesity.
loss tool as RYGBP because patients can still

tolerate sweets and high calorie liquids, while
patients with RYGBP experience dumping
syndrome with those same foods (4). Studies
show that patients typically will lose 50
percent of excess body weight. This surgery is
not without potential risk, primarily staple line
breakdown, which can lead to weight regain
over time.
RELATED PHYSIOLOGY
Laparoscopic Adjustable Gastric Band
behavioral weight management program.
USE
Purely Restrictive Procedures

Vertical Banded Gastroplasty
VBG creates a small pouch (capacity
of about 50 ml) by placing vertical rows of
staples in the upper end of the stomach. The
lower end of the vertical pouch created by the
staple rows becomes the outlet of the new
stomach and is encircled by a fine solid
silicone ring which effectively prevents the
1.0 cm opening from ever enlarging.
T
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Ethicon Endo-Surgery, Inc. 2004

Food empties from the small food
pouch into the stomach. Digestion and
absorption are normal from that point (2, 3).
The VBG has less risk of complications than
the RYGBP because there is no
malabsorption. Therefore the risk of vitamin
deficiencies and anemia is almost unheard
of. However, VBG is not as effective a weight
LAGB restricts the size of the stomach

by placing an adjustable silicone gastric band
around the upper stomach, creating a small
pouch. The new stomach pouch holds only a
small amount of food, restricting the amount
of food that can be eaten and making the
individual feel full sooner and for a longer
period of time. A hollow expandable band is
connected to a saline reservoir by a thin tube
that sits below the skin on the abdominal
wall. The band can then be tightened by
injecting additional saline or loosened by
removing saline.
R
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IV
If an individual fails to lose enough

weight, additional saline can be added by
syringe and needle to the access port site,
located beneath the skin on the left side of
the body. If an individual becomes ill and
needs additional nutrition, loses too much
weight, or becomes pregnant, saline can be
removed from the ring, making the opening
between the stomach pouch and the
remainder of the stomach larger and allowing
for increased food intake. The digestive
process then continues normally without any
malabsorption therefore decreasing the risk
of vitamin deficiencies or anemia. This
surgery is less invasive and reversible but
does not promise the same results as RYGBP.
The potential problems associated with this
surgery are band slippage and band erosion.
As with VBG, there is a learning curve
associated with this surgery and more
emphasis needs to be placed on behavior
modification and the development of good
nutrition practices (4).
Bariatric Surgery
C3.3
E
IV
Biliopancreatic Diversion (BPD)

The stomach pouch created with this
surgery is much smaller than with other
procedures. The goal is to restrict the amount
of food consumed and alter the normal
digestive process, but to a much greater
degree. The anatomy of the small intestine is
changed to divert the bile and pancreatic
juices so they meet the ingested food closer
to the middle or the end of the small
intestine. BPD removes approximately 3/4 of
the stomach to produce both restriction of
food intake and reduction of acid output.
Leaving enough upper stomach is important
to maintain proper nutrition. The small
intestine is then divided with one end
attached to the stomach pouch to create
what is called an "alimentary limb." All the
food moves through this segment though not
much is absorbed. The bile and pancreatic
juices move through the "biliopancreatic
limb," which is connected to the side of the
intestine close to the end. This supplies
digestive juice in the section of the intestine
now called the "common limb." The surgeon
is able to vary the length of the common limb
to regulate the amount of absorption of
protein, fat and fat-soluble vitamins.
T
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Biliopancreatic Diversion with "Duodenal

Switch" (BPD/DS)
This procedure is a variation of BPD in
which a larger pouch is created. The pylorus
between the stomach and small intestine is
left unchanged. The duodenum is divided so
that pancreatic and bile drainage is
bypassed. After division of the duodenum,
one end is anastomosed to the distal end of
the ileum creating the common limb. The
other part is anastomosed to the distal ileum
proximal to the ileocecal valve creating a
proximal enteric limb. The individual who has
the BPD/DS can eat more and weight loss is
attributed to malabsorption.
Bariatric Surgery
C3.4
permitting the digestion of the food (2, 3).

Roux-N-Y Gastric Bypass Surgery
According to the American Society for
Bariatric Surgery and the National Institutes
of Health, Roux-en-Y gastric bypass (RYGBP)
is the current gold standard procedure for
weight loss surgery. It is one of the most
frequently performed weight loss procedures
in the United States. The Roux-N-Y procedure
divides the stomach with horizontal rows of
staples to create a small food pouch
(measured capacity of <50 ml at the upper
end of the stomach). A new opening of about
1.0 cm diameter is made in the small portion
of the stomach. The proximal small intestine
is then divided close to its commencement
and the lower divided end brought up and
joined to the new stomach opening creating a
gastroenterostomy. The upper divided end is
connected into the jejunum 40-100 cm below
the gastroenterostomy.
T
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Food entering the new small stomach

causes a sensation of fullness, and then
slowly empties into the intestine through the
new small outlet. This re-routing causes
food to bypass the lower part of the stomach.
Digestive juices from the lower stomach and
duodenum flow to mix with food through the
new jejunal hook-up lower down, thus
E
IV
Roux-N-Y Gastric Bypass
R
D
With the arrangement of the new hookup between the stomach pouch and intestine,
gastric contents enter the jejunum directly
after leaving the stomach pouch. When
concentrated sweets are ingested the result
is hypertonicity of the jejunal contents, which
in turn, produces a rapid influx of fluids drawn
from the plasma and extracellular fluid. This
causes intestinal distention, a drop in
circulating blood volume with a subsequent
decrease in cardiac output and a release of
vasoactive peptides. This produces symptoms
known as Dumping Syndrome. This
syndrome is characterized by gastrointestinal
symptoms of epigastric fullness, nausea,
abdominal cramping, diarrhea and vasomotor
symptoms of flushing, sweating, weakness,
tachycardia and postural hypotension (2, 5).
These symptoms are considered an
advantage not a disadvantage of the RYGBP
because they discourage the patient from
eating high calorie, low nutrient sweet foods.
There is a learning curve associated with this
surgery and more emphasis needs to be
placed on behavior modification and the
development of good nutrition practices.
Metabolic Syndrome
Written by: Elaine M. Jansak, MS, RD, LD/N,
CDE, Consultant Dietitian
Reviewed by: Sarah Hall, RD, LD/N, CNSD,
Clinical Nutrition Manager at Shands at AGH
PRACTITIONER POINTS
RATIONALE
The Metabolic Syndrome criteria was
recently defined by the Third Report of the
National Cholesterol Education Program
Expert Panel on Detection, Evaluation, and
Treatment of Blood Cholesterol in Adults
(Adult Treatment Panel III or ATP III) (1).
Prevalence of Metabolic Syndrome is
quite high. The Centers for Disease Control
(CDC) estimate that 40 - 50 percent of
Americans over the age of 50 have
Metabolic Syndrome (2).
Prevalence increases with age, but the
syndrome in adults is documented as young
as 20 years old (24 percent of Americans
over the age of 20. Potentially 47 million
Americans have Metabolic Syndrome (2).
T
S
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Metabolic Syndrome needs to be

diagnosed and treated in order to decrease
mortality related to chronic disease. Despite
the knowledge that there are some genetic
factors in insulin resistance, treatment of
Metabolic Syndrome should not be deferred.
Triglyceride-rich lipoprotein cholesterol is especially athrogenic (called non-HDL cholesterol), and ideally should be treated prior to
Metabolic Syndrome risk factors (1).
C4.1
the success of these lifestyle changes and
the addition of a few specific recommendations.
ICD-9-CM code 277.7 is the classification code given for treatment of "Metabolic
Syndrome X" (4). Medical Nutrition Therapy
(MNT) goals for Metabolic Syndrome depend
on the presenting criteria. Specifically, they
are to achieve euglycemia, weight loss and a
healthy body weight, optimal lipid levels, and
normal blood pressure through diet, exercise
and healthy lifestyle changes.
USE
E
IV
Metabolic Syndrome is diagnosed

when three out of five qualifying criteria are
present (see Table 1) (1). Prevention and
treatment of Metabolic Syndrome significantly decreases the onset of obesity-related
illnesses, Type 2 Diabetes Mellitus (Type 2
diabetes) and Cardiovascular diseases (1).
R
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Major causes for Metabolic Syndrome

include poor nutrition, excess weight, and
lack of exercise. Dietary alterations and other
lifestyle changes reduce the incidence of this
syndrome and corresponding disease states.
METABOLIC SYNDROME
In studies around the world, intensive

individual counseling on weight reduction,
food intake, and physical activity has been
found to decrease the incidence of further
metabolic disease by 58 percent (3).
Metabolic Syndrome is so named

because of the complexity of the contributing
criteria. General features include abdominal
and intra-abdominal fat leading to large
waist circumference and sometimes obesity,
hyperlipidemia, blood pressure (BP) of at
least 130/80 mm Hg, and insulin resistance
measured as impaired fasting glucose or
impaired glucose tolerance (see Figure 1).
Often an inflammatory state is also present,
which can accelerate artery degeneration
and the onset of cardiovascular diseases (1).
Weight reduction and physical activity

will be the main therapeutic goals for
persons with Metabolic Syndrome. Other risk
factors will most commonly decrease with
More specific than overall obesity,

Metabolic Syndrome is related to the central
distribution of fat, including abdominal and
intra-abdominal fat, especially if insulin resis-
Metabolic Syndrome
C4.2
tance is a factor. The general features of this

syndrome have been reviewed extensively.
Names used include "Syndrome X",
"Dysmetabolic Syndrome", MetSyn, or
"Dysmetabolic Syndrome X" (4-7).
Persons with Metabolic Syndrome are
identified as candidates for intensified
Therapeutic Lifestyle Changes (TLC) (1).
Exercise and good stress management
techniques are required for TLC, but an
overall review of food choices, including a
medical nutrition therapy assessment of food
and behaviors is the foundation of treatment.
Untreated, Metabolic Syndrome progresses to hypertension, cardiovascular
disease, Type 2 diabetes, and the chronic
complications leading from these illnesses.
For additional information on these diseases,
see the appropriate sections of this manual.
Table 1Risk Factors / Criteria Metabolic
Syndrome
T
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1. Abdominal circumference:
>than 35 inches (88 cm) for women
>than 40 inches (102 cm) for men
2. Glucose (serum) of at least:

110 mg/dL
(fasting or oral glucose tolerance)
3. Triglycerides (serum) of at least
150 mg/dL
4. High Density Lipoprotein

Cholesterol:
<50 mg/dL for women
<40 mg/dL for men
(HDL)
5. Blood pressure (BP) of at least

130/85 mm Hg.
A combination of three or more risk factors
must be present for diagnosis and treatment
(1). Although any risk factor alone may
increase the risk of chronic illness.
RELATED PHYSIOLOGY
Metabolic Syndrome develops with
metabolic slowing of the body (for instance
from increased calories and decreased exercise) or metabolic disorder for other reasons
(smoking, alcohol, hormonal). Overall, less
glucose is used for fuel, free fatty acids are
created and glucose is stored as triglycerides.
A decrease of high density lipoproteins
(HDLs) occurs as lipids shift from glucose metabolism to lipogenesis. Increased fat storage
expands fat cells, which in turn, increases
body fat. The increase of body fat heightens
blood pressure and insulin resistance. Insulin
resistance creates a greater storage of fats
by triglycerides, increasing circulating free
fatty acids and vascular pressure. Although
complex, this is essentially the metabolic
criteria for the syndrome. Although excess
body fat and physical inactivity promote the
development of insulin resistance, some
individuals are at higher genetic risk (1).
R
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IV
Other metabolic changes also occur.

Coagulation factors and cytokines change the
vasculature and release inflammatory
markers. These also relate to a higher risk of
hypertension, stroke, and cardiovascular
disease (8). However, even without apparent
cardiovascular disease, treatment of
Metabolic Syndrome will decrease the risk of
diabetes.
Weight gain and increased hunger (a
sign of insulin resistance) is one of the
precursors that may be observed by the
individual at risk for obesity, pre-diabetes,
and Metabolic Syndrome. Complaints of
increased weight, hunger and abdominal girth
should be taken seriously and the individual
should be screened for additional risk factors.
If biochemical laboratory data determine
three out of five risk factors or criteria is met,
treatment regimens for Metabolic Syndrome
will be initiated. In absence of Metabolic
Syndrome, individuals should still be
encouraged to make TLC changes towards
optimal health.
Nutrition Resources Online

Written by: Susan Burke MS, RD, LD/N, CDE
VP Nutrition Services, eDiets.com
Reviewed by: Pamela Ofstein, MS, RD, LD/N,
Manager of Nutrition Product Development,
eDiets.com
C5.1
the data they are reading.
Guidelines for Evaluating Health
Information on the Internet
Web sites that end in .edu (defines an

educational institution) or .gov (defines
government agencies) are credible Web
sites, containing current and accurate
information.
Web sites ending in .org (defines

organizations, often nonprofit) also can
be a good source of information.
Commercial websites ending in .com

(defines commercial sites) can be a good
source of information.
PRACTITIONER POINTS
Guide to Online Resources for Nutrition
Professional
According to the National Center for
Health Statistics, 51% of adults aged 18-64
had used the Internet to look up health
information between January June 2009.
The Internet provides valuable
information for users seeking health
information, and can be a tool for educators
to easily access the most current standards
of care and professional policies. Sifting
through the large number of websites to
access credible information can be daunting.
There are no uniform guidelines for online
quality assessment of Web-based health
information for consumers. However, online
resources are available to help guide you to
reliable and reputable Websites.
T
S
E
Finding information on the Web is easy,

finding credible and reliable information is
not always guaranteed. The Health on the
Net Foundation and The American Dietetic
Association www.eatright.org are just two of
many nonprofit organizations that publish
guidelines for use in evaluating the quality of
health information provided on the Internet.
Look for websites that subscribe to The
Health on the Net Foundation http://
www.hon.ch/Global. These companies
promise to adhere to a Code of Conduct to
help standardize the reliability of medical
and health information available on the
World-Wide Web. The HON code defines a
set of rules to: hold Web site developers to
basic ethical standards in the presentation
of information, and help make sure readers
always know the source and the purpose of
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Websites requiring personal information

should have a privacy policy posted. Is information about the security of the site
clearly stated? This is especially important if the site asks you to fill in forms
with personal health information such as
your age, medical condition, or
medications for which you would like
information.
There should be a clear statement that

personal health information you share
with the site is not made available to
other organizations or companies.
Authors and contributors should post

their credentials, and affiliations. Qualified nutrition experts include Registered
Dietitians (RD) or Medical or Osteopathic
Physicians (MD or DO) and affiliations
with nationally known health
organizations such as the American
Dietetic Association (ADA), the American
Medical Association (AMA), or the
American Heart Association (AHA).
Information should be factual, with

references cited. Scientific studies
should have publication, year, page and
author included.
Food Labeling
C6.1
Written by: Molly Gladding, RD, LD/N, West

Palm Beach
Reviewed by: Judith Cooper, MS, MBA, RD,
LD/N. Senior Nutritionist, Palm Beach County
Health Department
nutrients or carried nutrition claims. Other

than adding sodium as a mandatory listing
and potassium as a voluntary listing, the
nutrition label remained the same for almost
20 years.
PRACTITIONER POINTS
Efforts to overhaul the program came

from consumers, regulators, professional
groups and Congress. As consumers became
more interested in nutrition, the efforts
increased. The industry argued, Nutrition
doesnt sell food. Price, taste and
convenience sell food. During the 1980s it
was clear that Nutrition does sell food and
health claims were becoming widespread.
RATIONALE
The Food and Drug Administration is
responsible for the implementation and
enforcement of the Nutrition Labeling and
Education Act of 1990. The regulations,
implemented in 1994, were intended to
insure that:
Most foods contain nutrition information
labeling
Labels will provide guidance on how a
food fits into a daily diet
Information will be presented on
nutrients of health concern to todays
consumers
Government definitions are established
for terms used to describe a foods
nutrient content
Health claims that relate to nutrient
content will be supported by scientific
evidence
Serving sizes are more consistent across
product lines, are expressed in
household and metric measures and
better reflect the amounts that people
eat
Provide a declaration of total percentage
of juice in juice drinks
Food labeling is mandatory for most
processed foods and is voluntary for raw
produce and fish
T
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E
History
The 1990 law represented the first
extensive change to the food labeling laws
since the voluntary nutrition labeling laws
enacted in 1974. The original act only
addressed products that contained added
E
IV
In the late 1980s the Surgeon General

released two reports (1998 Surgeon
Generals Report on Nutrition and Health;
1989 National Research Councils Diet and
Health: Implications for Reducing Chronic
Disease Risk) that lent strong support to the
development of a new labeling system.
These reports put forth evidence of a direct
relationship between diet and chronic
disease. This evidence combined with
questionable health claims led to the first
serious effort to revamp the food label.
R
D
In 1990 the Nutrition Labeling and

Education Act (NLEA) became law. The law
makes the United States the first country in
the world to have mandatory food labeling
and to allow labels to carry health claims.
Exemptions
Under NLEA, foods exempt from the
law include:
Foods available for immediate
consumption (hospital cafeterias, airline
food, and vendors such as vending
machines, sidewalk vendors, and all
cookie counters)
Food prepared primarily on site and readyto-eat food that is not for immediate
consumption (bakery, deli, candy store,
Dietary Reference Intakes

Written by: Sally E. Weerts, PhD, RD,
Jacksonville
Reviewed by: Helen L. Curtis, RD, LD/N,
CDE, Nutrition Consultant and Independent
Contractor, Interlachen
PRACTITIONER POINTS
OVERVIEW
The Dietary Reference Intakes (DRIs)
represent four separate tables, each of
which is designed to estimate quantities of
nutrients needed in the average daily diet by
normal, healthy populations living in the U.S.
and Canada. The most well known of the four
tables is the Recommended Dietary Allowances (RDAs), joined by the Estimated Average Requirement (EAR), Adequate Intakes
(AIs), and the Tolerable Upper Intake Levels
(ULs) (1-3).
The DRIs have three general purposes.
First, they provide sets of values used by
professionals to plan policy and assess daily
diets of individuals and populations. Values
are for males and females from infancy to
>70 years of age and for conditions of
pregnancy and lactation. Second, the DRIs
are used to set standards for diet planning
tools like the U.S. food labels and MyPyramid
(4). Third, these help to interpret data
gathered from population studies and clinical
research to learn about nutritional
inadequacies and excesses that may be of
interest or concern (5).
T
S
E
GOALS
The DRI committee, made up of
experts from the U.S. and Canada,
established four goals toward setting the
appropriate nutrient intake levels (6, 7).
These are:
Goal #1: Set adequate recommended

intake values as an RDA and/or AI.
Goal #2: Facilitate nutrition research
C7.1
and policy using EARs.
Goal #3: Establish upper-limit safety

guidelines as ULs.
Goal #4: Prevent chronic diseases by

linking newer research about nutrient
and non-nutrient levels that prevent
disease and promote health.
THE RDAs, EAR, AIs, and ULs

The RDAs are the levels of essential
nutrients that are judged to be adequate to
meet the known nutrient needs of practically
all healthy persons (1). These are calculated
from scientific data to meet the needs of
nearly all healthy people as they are adjusted
upward to allow for individual differences
and bioavailability of nutrients.
R
D
E
IV
The EAR is the level of a nutrient that is

estimated to meet the nutrient requirement
of one-half of the healthy individuals in each
grouping. The RDA can be set only for those
nutrients with an EAR. When there is
insufficient scientific evidence to calculate
an EAR, an AI is set, rather than an RDA, and
used as a goal.
The AIs are set through observations or
scientific estimates at levels needed to
maintain health and/or growth. For example,
the AIs in early infancy are based on the daily
mean nutrient intake supplied by human
breast milk.
The ULs, on the other hand, are the
highest level of nutrients on a daily basis
that pose no risk of adverse health effects.
These values are not recommendations but
are used to provide guidance for fortification
and other uses beyond the RDAs.
UPDATE
Sets of DRIs are a work in progress. In
September 2002, new DRIs were released
for energy, including Estimated Energy
Manual of Florida Medical Nutrition Therapy 2011 Edition

Requirements for four different activity levels;
and for the Acceptable Macronutrient
Distribution Ranges of 45 to 65% for
carbohydrate, 10 to 35% for protein, and 20
to 35% for fat. These join DRIs for the
antioxidants (carotenoids, selenium, and
vitamins A and E), bones (calcium,
phosphorus, magnesium, vitamin D, and
fluoride); for the B vitamins, choline, vitamins
A, and K, and the trace elements. New RDAs
for carbohydrate and protein have also been
established as have new AIs for total water
and the electrolytes sodium, potassium and
chloride (on an equi-molar basis to sodium);
fiber and essential fatty acids. Last, new ULs
have been established for sodium and
chloride. Current DRIs by nutrient are shown
on the following tables. (8)
REFERENCES
1. National Research Council, Food and
Nutrition Board. Recommended Dietary
Allowances, 10th Edition. Washington,
D.C. National Academy Press, 1989.
2. Institute of Medicine. Food and Nutrition
Board. Dietary Reference Intakes for
Calcium, Phosphorus, Magnesium,
Vitamin D, and Fluoride. Washington, D.C.
National Academy Press, 1997.
3. Institute of Medicine. Food and Nutrition
Board. Dietary Reference Intakes for
Thiamin, Riboflavin, Niacin, Vitamin B-6,
Folate, Vitamin B-12, Pantothenic Acid,
Biotin, and Choline. Washington, D.C.
National Academy Press, 1998.
4. U.S. Department of Agriculture. The Food
Guide Pyramid revised 2000. http://
www.mypyramid.gov/pyramid/index.html.
Accessed January 19, 2011..
5. Smolin, L.A. and Grosvenor. M.B. Nutrition:
Science and Applications, 4th Edition.
John Wiley & Sons, Inc, 2003.
6. Standing Committee on the Scientific
Evaluation of Dietary Reference Intakes,
Food and Nutrition Board, Institute of
Medicine, Dietary Reference Intakes:
Applications in Dietary Assessment
T
S
E
C7.2
Washington, D.C.: National Academy
Press, 2000.
7. Sizer, F. and Whitney, E.
Nutrition
Concepts and Controversies, 9th Edition.
Thomson Wadsworth, 2003.
8. Food and Nutrition Information Center.
Dietary Reference Intakes. http://
fnic.nal.usda.gov/nal_display/index.php?
info_center=4&tax_level=3&tax_subject=
256&topic_id=1342&level3_id=5140&le
vel4_id=0&level5_id=0&placement_defa
ult=0. Accessed: January 19, 2011.
R
D
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IV
C7.3
DIETARY REFERENCE INTAKES: MACRONUTRIENTS

Nutrient
Cabohydrate
Total digestible
Total Fiber
Function
RDA based on its

role as the primary
energy source for
the brain: AMDR
based on its role
as a source of
kilocalories to
maintain body
weight
Infant
0-6 mo
7-12 mo
Children
1-3 y
4-8 y
Males
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Females
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Pregnancy
< 18 y
19-30 y
31-50 y
Lactation
< 18 y
19-30 y
31-50 y
Infant
0-6 mo
7-12 mo
Children
1-3 y
4-8 y
Males
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Females
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Pregnancy
< 18 y
19-30 y
31-50 y
Lactation
< 18 y
19-30 y
31-50 y
RDA/AI *
(g/d)
AMDRa
Selected Food Sources
Adverse Effects of
Excessive Consumption
60*
95*
NDb
ND
130
130
45-65
45-65
130
130
130
130
130
130
45-65
45-65
45-65
45-65
45-65
45-65
Starch and sugar are the

major types of
carbohydrates. Grains and
vegetables (corn, pasta,
rice, potatoes, breads) are
sources of starch. Natural
sugars are found in fruits
and juices. Sources of
added sugars are soft
drinks, candy, fruit drinks,
and desserts.
130
130
130
130
130
130
45-65
45-65
45-65
45-65
45-65
45-65
While no defined intake

level at which potential
adverse effects of total
digestible carbohydrate
was identified, the upper
end of the adequate
macronutrient distribution
range (AMDR) was based
on decreasing risk of
chronic disease and
providing adequate intake
of other nutrients. It is
suggested that the
maximal intake of added
sugars be limited to
providing no more than
25% of energy.
175
175
175
45-65
45-65
45-65
210
210
210
T
S
E
Improves laxation,
reduces risk of
CHD, assists in
maintaining
normal blood
glucose levels.
Life Stage Group
ND
ND
19*
25*
31*
38*
38*
38*
30*
30*
R
D
45-65
45-65
45-65
E
IV
Includes dietary fiber

naturally present in grains
(such as found in oats,
wheat, or unmilled rice)
and functional fiber
synthesized or isolated
from plants or animals and
shown to be of benefit to
health.
26*
26*
25*
25*
21*
21*
28*
28*
28*
29*
29*
29*
Dietary fiber can have

variable compositions and
therefore it is difficult to
link a specific source of
fiber with a particular
adverse effect, especially
when phytates is also
present in the natural fiber
source. It is concluded that
as part of an overall
healthy diet, a high intake
of dietary fiber will not
produce deleterious effects
in healthy individuals.
While occasional adverse
GI symptoms are observed
when consuming isolated
or synthetic fibers, serious
chronic adverse effects
have not been observed.
Due to bulky the nature of
fibers, excess consumption
is likely to be self-limiting.
Therefore, a UL was not set
for individual functional
fibers.
Note: The table is adapted from the DRI reports, see www.nap.edu. It represents Recommended Dietary Allowances (RDAs) in bold type, Adequate Intakes
(AIs) in ordinary type followed by an asterisk (*). RDAs and AIs can both be used as goals for individual intake. RDAs are set to meet the needs of almost all
(97-98%) individuals in a group. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover the
needs of all individuals in the group, but lack of data prevent being able to specify with confidence the percentage of individuals covered by this intake.
A Acceptable Macronutrient Distribution Range (AMDR)A is the range of intake for a particular energy source that is associated with reduced risk of chronic
disease while providing intakes of essential nutrients. If an individual consumes excess of the AMDR, there is potential of increasing risk of chronic disease
and/or insufficient intakes of essential nutrients.
BND= Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source
of intake should be from food only to prevent high levels of intake.
SOURCES: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005). This report may be
accessed via www.nap.edu
C7.4

Nutrient
Total Fat
Function
Energy source and

when found in
foods, is a source
of n-6 and n-3
polyunsaturated
fatty acids. Its
presence in the
diet increases
absorption of fat
soluble vitamins
and precursors
such as vitamin A
and pro-vitamin A
carotenoids.
n-6
polyunsaturated
fatty acids
(linoleic acid)
Infant
0-6 mo
7-12 mo
Children
1-3 y
4-8 y
Males
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Females
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Pregnancy
< 18 y
19-30 y
31-50 y
Lactation
< 18 y
19-30 y
31-50 y
Infant
0-6 mo
7-12 mo
Children
1-3 y
4-8 y
Males
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Females
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Pregnancy
< 18 y
19-30 y
31-50 y
Lactation
< 18 y
19-30 y
31-50 y
RDA/AI *
(g/d)
AMDRa
Adverse Effects of
30-40
25-35
Butter, margarine,
vegetable oils, whole milk,
visible fat on meat and
poultry products, invisible
fat in fish, shellfish, some
plant products such as
seeds and nuts, and bakery
products.

adverse effects of total fat
end of AMDR is based on
decreasing risk of chronic
disease and providing
adequate intake of other
nutrients. The lower end of
the AMDR is based on
concerns related to the
increase in plasma
triacyglycerol
concentrations and
decreased HDL cholesterol
concentrations seen with
very low fat (and thus high
carbohydrate) diets.
31*
30*
25-35
25-35
20-35
20-35
20-35
20-35
25-35
25-35
20-35
20-35
20-35
20-35
20-35
20-35
20-35
R
D
20-35
20-35
20-35
T
S
E
Essential
component of
structural
membrane lipids,
involved in cell
signaling and
precursor of
eicosanoids.
Required for
normal skin
function.
Life Stage Group
4.4*
4.6*
7*
10*
12*
16*
17*
17*
14*
14*
NDb
ND
5-10
5-10
E
IV
Nuts, seeds, and vegetable

oils such as soybean,
safflower, and corn oil.
5-10
5-10
5-10
5-10
5-10
5-10
10*
11*
12*
12*
11*
11*
5-10
5-10
5-10
5-10
5-10
5-10
13*
13*
13*
5-10
5-10
5-10
13*
13*
13*
5-10
5-10
5-10

adverse effects of n-6
polyunsaturated fatty acids
end of the AMDR is based
on the lack of evidence
that demonstrates longterm safety and human in
vitro studies which show
increased free-radical
formation and lipid
peroxidation is thought to
be a component in the
development of
atherosclerotic plaques.
C7.5

Nutrient
n-3
Polyunsaturated
fatty acids
(-linolenic acid)
Saturated and
trans fatty acids,
and cholesterol
Function
Involved with
neurological
development and
growth. Precursor
of eicosanoids.
Infant
0-6 mo
7-12 mo
Children
1-3 y
4-8 y
Males
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Females
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Pregnancy
< 18 y
19-30 y
31-50 y
Lactation
< 18 y
19-30 y
31-50 y
Infant
0-6 mo
7-12 mo
Children
1-3 y
4-8 y
Males
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Females
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Pregnancy
< 18 y
19-30 y
31-50 y
Lactation
< 18 y
19-30 y
31-50 y
RDA/AI *
(g/d)
AMDRa
Adverse Effects of
0.5*
0.5*
NDb
ND
0.7*
0.9*
0.6-1.2
0.6-1.2
Vegetable oils such as

soybean, canola, and flax
seed oil, fish oils, fatty fish,
with smaller amounts in
meats and eggs.
1.2*
1.6*
1.6*
1.6*
1.6*
1.6*
0.6-1.2
0.6-1.2
0.6-1.2
0.6-1.2
0.6-1.2
0.6-1.2
1.0*
1.1*
1.1*
1.1*
1.1*
1.1*
0.6-1.2
0.6-1.2
0.6-1.2
0.6-1.2
0.6-1.2
0.6-1.2
1.4*
1.4*
1.4*
0.6-1.2
0.6-1.2
0.6-1.2

adverse effects of n-3
polyunsaturated fatty acids
end of AMDR is based on
maintaining appropriate
balance with n-6 fatty acids
and on the lack of evidence
that demonstrates longterm safety, along with
human in vitro studies
which show increased freeradical formation and lipid
peroxidation with higher
amounts of
polyunsaturated fatty
acids. Lipid peroxidation is
thought to be a component
in the development of
atherosclerotic plaques.
1.3*
1.3*
1.3*
T
S
E
No required role
for these nutrients
other than as
energy sources
was identified; the
body can
synthesize its
needs for
saturated fatty
acids and
cholesterol from
other sources.
Life Stage Group
ND
ND
R
D
0.6-1.2
0.6-1.2
0.6-1.2
E
IV
Saturated fatty acids are

present in animal fats
(meat fats and butter fat)
and coconut and palm
kernel oils. Sources of
cholesterol include liver,
eggs, and foods that
contain eggs such as
cheesecake and custard
pies. Sources of trans fatty
acids include stick
margarines and foods
containing hydrogenated or
partially-hydrogenated
vegetable shortenings.
There is an incremental
increase in plasma total
and low-density lipoprotein
cholesterol concentrations
with increased intake of
saturated or trans fatty
acids or with cholesterol at
even very low levels in the
diet. Therefore, the intakes
of each should be
minimized while
consuming a nutritionally
adequate diet.
C7.6

Nutrient
Protein and
amino acids
Function
Life Stage Group
Serves as the major

structural component
of all cells in the body
and functions as
enzymes in
membranes,
transport carriers,
and as some
hormones. During
digestion and
absorption dietary
proteins are broken
down to amino acids
which becomes the
building blocks of
these structural and
functional
compounds. Nine of
the amino acids are
must be provided in
the diet; these are
indispensable amino
acids. The body
canmakethe other
amino acids needed
to synthesize specific
structures from other
amino acids.
Infant
0-6 mo
7-12 mo
Children
1-3 y
4-8 y
Males
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Females
9-13 y
14-18 y
19-30 y
31-50 y
50-70 y
> 70 y
Pregnancy
< 18 y
19-30 y
31-50 y
Lactation
< 18 y
19-30 y
31-50 y
RDA/AI *
(g/d)a
AMDRb
Adverse Effects of
9.1*
11.0
NDc
ND
13
19
5-20
10-30
34
52
56
56
56
56
10-30
10-30
10-35
10-35
10-35
10-35

adverse effects of protein
end of AMDR based on
complementing the AMDR
for carbohydrate and fat for
the various age groups.
The lower end of the AMDR
is set at approximately the
RDA.
34
46
46
46
46
46
10-30
10-30
10-35
10-35
10-35
10-35
Proteins from animal

sources such as meat,
poultry, fish, eggs, milk,
cheese, and yogurt provide
all nine indispensable
amino acids in adequate
amounts and for this
reason are considered
complete proteins.
Proteins from plants,
legumes, grains, nuts,
seeds, and vegetables tend
to be deficient in one or
more of the indispensable
amino acids area are called
incomplete proteins.
Vegan diets are adequate
in total protein content can
be complete by
combining sources of
incomplete proteins which
lack different indispensable
amino acids.
T
S
E
71
71
71
71
71
71
R
D
10-35
10-35
10-35
10-35
10-35
10-35
E
IV
A Based on 1.5g/kg/day for infants, 1.1g/kg/day for 1-3 y, 0.95 g/kg/day for 4-13 y, 0.85 g/kg/day for 14-18, 0.8 g/kg/day for adults, and 1.1 g/kg/day for
pregnant (using pregnancy weight) and lactating women.
B Acceptable Macronutrient Distribution Range (AMDR)A is the range of intake for a particular energy source that is associated with reduced risk of chronic
NDc= Not determinable due to lack of data of adverse effects in this age group and concern with regard to lack of ability to handle excess amounts. Source
C7.7

Nutrient
Function
Indispensable
amino acids:
Histidine
Isoleucine
Lysine
Leucine
Methionine &
Cysteine
The building blocks of all

proteins in the body and some
hormones. These nine amino
acids must be provided in the
diet and thus are termed
indispensable amino acids.
The body can make the other
amino acids needed to synthesize specific structures
from other amino acids and
carbohydrate precursors.
Phenylalanine
& Tyrosine
Threonine
IOM/FNB 2002
Scoring Patterna
Mg/g
protein
Adverse effects of excessive consumption
Histidine
18
Isoleucine
25
Lysine
55
Leucine
51
Methionine &
Cysteine
25
Phenylalanine &
Tyrosine
47
Since there is no evidence that amino acids found in usual

or even high intakes of protein from food present any risk,
attention was focused on intakes of the L-form of these and
other amino acids found in dietary protein and amino acid
supplements. Even from well-studied amino acids, adequate dose-response data from human or animal studies
on which to base an UL were not available. While no defined intake level at which potential adverse effects of
protein was identified for any amino acid, this does not
mean that there is no potential for adverse effects resulting
from high intakes of amino acids from dietary supplements.
Since data on the adverse effects of high levels of amino
acid intakes from dietary supplements is limited, caution
may be warranted.
Threonine
27
Tryptophan
Valine
32
Tryptophan
Valine
T
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Note: The table is adapted from the DRI reports, see www.nap.edu.
R
D
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IV
A Based on the amino acid requirements derived for Preschool Children (1-3 y): (EAR for amino acid EAR for protein); for 1-3 y group where EAR for protein=
0.88 g/kg/day.
Nutrition Guidelines and Recommended Eating Patterns

Written by: Linda Benjamin Bobroff, PhD,
RD, LD/N, Professor, Department of Family,
Youth and Community Sciences, Institute of
Food and Agricultural Sciences, University of
Florida.
Reviewed by: Jennifer Hillan, MSH, RD, LD/
N, Clinical Dietitian, Pediatric Pulmonary
Center, University of Florida Health Science
Center, and R. Elaine Turner, PhD, RD,
Associate Professor, Food Science and
Human Nutrition Department, Institute of
Food and Agricultural Sciences, University of
Florida.
future developments in response to the new

food guidance system, MyPyramid. Our
discussion of the Dietary Guidelines for
Americans includes a brief history of Dietary
Guidelines and a discussion of the current
(sixth) edition. Finally, we include
suggestions for how dietitians can help
consumers use food guides to select foods
for a healthful diet, and provide links to
reliable on-line nutrition education
resources.
PRACTITIONER POINTS
The federal government has been

involved in advising Americans about their
diets since the late 1800s (1). Dietary
recommendations for the healthy American
population take the form of food guides,
which are based on dietary standards such
as the Dietary Reference Intakes (DRIs) and
recommendations for healthful diets such as
the Dietary Guidelines for Americans,
generally referred to simply as the Dietary
Guidelines (2-3).
INTRODUCTION
This chapter focuses on dietary recommendations for persons who have no special
dietary needs related to a medical condition
or illness. Currently, the primary foundations
of nutrition education for government
agencies and dietetics professionals who
work with healthy consumers are the Dietary
Guidelines for Americans 2005 and the new
food guidance system developed and
recently released by the U.S. Department of
Agriculture (USDA), which is called
MyPyramid.
T
S
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In this chapter we begin with a brief

history of food guides, leading to a
discussion about the current food guidance
system, MyPyramid. This latest food guide
was included in table format in the Dietary
Guidelines for Americans 2005, and formally
introduced to the public with the now familiar
graphic on April 19, 2005. We include
information about MyPyramid for Kids, a
graphic that is targeted to children six to
eleven years old. We also review several of
the food pyramids that have been developed
over the past few years by various
individuals, groups, and organizations. Since
several of these food pyramids were
developed to reflect different approaches to
a healthful diet in response to USDA's Food
Guide Pyramid, it will be of interest to follow
BRIEF HISTORY OF FOOD GUIDES
R
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IV
In each food guide developed by the

USDA since 1916, foods have been grouped
according to their nutrient content, with
foods having similar amounts of critical
nutrients appearing in the same food group.
Food guides suggest the amount of food
from various food groups that will provide a
healthful diet for people without special
dietary needs. Over the past century, our
definition of what constitutes a healthful diet
evolved as scientific advances provided
more information about human nutrient
requirements and relationships between diet
and health. USDA food guides changed
significantly during this time to reflect these
changes in knowledge as well as changes in
nutrition and health concerns of the healthy
population (1, 4).
Early food guides were designed to
help the population meet basic nutrient
needs such as calories, protein, and fat. The
emphasis was on getting enough to eat, and
D1.1

in times of want such as the Depression in
the 1930s and during World War II, USDAs
food economists included strategies for using
scarce resources efficiently (1, 4). To this day,
USDA provides food plans at various cost
levels, including the Thrifty Food Plan to
meet the needs of limited resource families
(5). When the first edition of the
Recommended Dietary Allowances (RDAs)
was published in 1941, the National
Research Council committee included a food
guide, developed in cooperation with USDA,
which showed how to meet the new RDAs
and prevent nutrient deficiencies (1, 4).
One of the most enduring of USDAs
food guides was The Basic Four, introduced
in 1956. This food guide provided a
foundation diet, and it was the basis of
nutrition education for more than 20 years
(1). As the relationship between diet and the
risk of the major chronic diseases began to
emerge in the 1970s, USDA added a fifth
food group, fats, sweets, and alcohol, to
emphasize that certain foods were to be
consumed only in moderation (1).
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After publication of the first edition of

the Dietary Guidelines for Americans, a new
food guide called A Pattern for Daily Food
Choices was introduced in 1986 (6). This
food guide was intended to help people
select a total diet that was consistent with the
Dietary Guidelines (7-8). A Pattern for Daily
Food Choices introduced an eating plan that
was moderate in nutrients of concern, fats,
sodium, and sugars, and that could reduce
the risk of obesity, cardiovascular disease,
and some forms of cancer. The new food
guide was designed to promote overall health
of Americans two years of age and older, and
to be usable by consumers with varying
eating styles and lifestyles (7). The food guide
emphasizes foods of plant origin, including
grain products (especially whole grains),
fruits, and vegetables, by recommending the
largest number of servings from these three
food groups. Fewer servings of dairy products
and protein-rich foods are included, while
fats, sweets, and alcoholic beverages are to

be consumed only in moderation (8). A
Pattern for Daily Food Choices appeared in
USDA publications beginning in the mid
1980s, but was not widely recognized until
the Food Guide Pyramid was released in
1992 (9, 10).
THE FOOD GUIDE PYRAMID
The Pattern for Daily Food Choices food
guide was represented graphically as the
Food Guide Pyramid, which was released in
1992, and used until USDA introduced its
new food guidance system in 2005 (9-10).
The Food Guide Pyramid was designed to
help people select foods to obtain the
nutrients they need while controlling their
intake of fat, saturated fat, cholesterol,
sugars, and sodium, in accordance with the
Dietary Guidelines. The number of servings
recommended within each food group was
given as a range, to reflect different calorie
needs among persons based on age, gender,
size, and activity levels. The intent was for
people to select the number of servings from
each food group that would allow them to
meet their calorie needs.
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Many consumers did not understand

this recommendation and were confused by
the range of servings given for each food
group, and even by the concept of serving.
USDA addressed this confusion with
publications such as How Much Are You
Eating? which examined servings, "a
standard amount used to help give advice
about how much to eat, or to identify how
many calories and nutrients are in a food
versus portions, "the amount of food you
choose to eat. There is no standard portion
size and no single right or wrong portion
size." (11). Nutrition educators spent much
time and effort helping consumers sort out
servings and portions, and it became clear
that servings needed to be omitted from the
food guidance system, and that is exactly
what USDA did in MyPyramid.
D1.2

MYPYRAMID
The new food guide has three key

messages:
Since the Food Guide Pyramid was

developed, the Dietary Guidelines have been
evaluated and updated twice, and new
nutritional standards (DRIs) have been
established. USDA spent several years
working on revisions to its food guidance
system to ensure that it continues to be
based on current and sound science and that
it is relevant to todays consumers. To that
end, the revision of the food guidance system
was coordinated with development of the
Dietary Guidelines for Americans 2005 (12).
On April 19, 2005, USDA unveiled
MyPyramid, not only a new symbol, but also a
more personalized and interactive food
guidance system that is designed to help
people make healthier food and physical
activity choices for healthy lifestyles that are
consistent with the Dietary Guidelines (1213). As with the Dietary Guidelines, the
recommendations of MyPyramid are
designed to be used together, and as a whole
they would result in the following changes
from a "typical" diet:
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Increased intake of vitamins, minerals,

dietary fiber, and other essential
nutrients, especially those that are often
low in "typical" diets.
Lowered intake of saturated fats, trans
fats, and cholesterol and increased
intake of fruits, vegetables, and whole
grains to decrease risk for some chronic
diseases.
Calorie intake balanced with energy
needs to prevent weight gain and/or
promote a healthy weight.
USDA provides extensive background
information for nutrition and health
professionals in the "For Professionals" link
on the website MyPyramid.gov. The following
is a brief overview of the MyPyramid food
guidance system, which can be
supplemented with materials from the
website.
1. Make smart choices within and among

the food groups.
2. Keep a balance between food intake and
physical activity.
3. Get the most nutrients from your calories.
Although the first key message is not
new, there is a stronger focus on variety
within the food groups in MyPyramid,
compared with the Food Guide Pyramid. The
emphasis on physical activity is clear from
the change in the graphic, with the steps and
the person walking up the steps
demonstrating the importance of physical
fitness as well as calorie balance for weight
control. The third key message focuses on
nutrient density, getting the most nutrients
from calories eaten (13). This is particularly
important with our aging population, since
calorie needs decrease with age, while the
need for most nutrients either stays the same
or increases. To avoid weight gain with age,
baby boomers and older persons need to eat
a nutrient dense diet and include up to 60
minutes of moderate to vigorous physical
activity most days of the week (3, 13).
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The six colored bands of MyPyramid

represent the need for variety in food choices.
In order from left to right, the bands
represent the Grains, Vegetables, Fruits, (Oils,
not a major food group), Milk, and Meat and
Beans food groups. By selecting
recommended amounts of foods from each
food group based on calorie needs,
consumers will get a wide variety of nutrients,
phytochemicals, and an appropriate calorie
intake to attain or maintain a healthy body
weight (13).
MyPyramid looks as though the Food
Guide Pyramid was pushed over, and that is
essentially what USDA did to create the new
graphic. You can see this transformation
demonstrated in a short animated feature on
the website. The vertical bands of the food
D1.3

groups that get narrower from the bottom to
the top symbolize that in each food group
there are foods that should be chosen more
often than others, based on nutrient content.
The healthier choices are those with little or
no solid fats or added sugars, and they
should form the base of our diets. Foods from
various food groups that contain solid fat
and/or added sugars can be eaten, but less
often to enjoy a diet that promotes good
health. We visualize these foods at the tip of
the appropriate food group bands. Persons
who are more active can fit more foods from
the upper part of the pyramid into their diets.
This concept of moderation can be applied to
sodium content of foods, with high sodium
foods visualized toward the top of the food
bands. This may be a hard concept for
consumers to grasp, and a challenging one
for nutrition educators to teach.
The different widths of the food group
bands represents proportionality, or the
relative amounts of food recommended from
each food group. The widest bands are those
representing the Grains, Milk, and Vegetable
groups, with Fruit a close fourth. Consuming
recommended intakes from these food
groups will provide a variety of nutrients and
dietary fiber and help reduce risk of chronic
diseases and conditions, including
hypertension, osteoporosis, and coronary
heart disease (13).
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The Educational Framework provided

on the MyPyramid.gov website section
designated "For Professionals," organizes key
concepts of the food guide into twelve topic
areas, with each describing what actions
should be taken for a healthy diet, how these
actions can be implemented by consumers,
and why each action is important for health.
These are not meant to be consumer
messages, but rather background information
that health professionals can use to develop
targeted messages and educational materials
for clients and consumers.
MyPyramid emphasizes that "one size
does not fit all." According to USDA,

MyPyramid "symbolizes a personalized
approach to healthy eating and physical
activity." This personalized approach is
demonstrated by three components of the
MyPyramid graphic, the person climbing the
stairs, the slogan "Steps to a Healthier You,"
and the website address MyPyramid.gov,
where consumers can obtain a personalized
food guide representing their calorie needs.
Since people have different calorie needs,
USDA developed a food guidance system that
includes 12 different calorie levels, from
1,000 to 3,200 calories/day. Consumers can
estimate their calorie needs by entering their
age, gender, and activity level into MyPyramid
Plan at the MyPyramid.gov website. They then
obtain a food guide customized to their
calorie level that indicates how much to eat
from each of the food groups.
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As mentioned above, this food guidance

system does not mention servings; rather, the
recommendations are given in total amount
of food to eat for the day from each food
group, in household measures such as cups
and ounces (13). Calorie values generated in
MyPyramid Plan are based on persons of
average height at a healthy weight, so
consumers may need assistance adjusting
their food intake to be more realistic for
them. Also, they can adjust their food intake if
they would like to lose or gain weight. Food
guides at the 12 different calorie levels may
be downloaded from the MyPyramid.gov
website.
The slogan, Steps to a Healthier You,
encourages consumers to make gradual
changes to improve their diets and lifestyles.
The slogan emphasizes that taking small
steps can lead to significant changes in
lifestyle and health. This is a very positive
message to present to clients and
consumers, as they dont have to feel
overwhelmed and under pressure to change
overnight.
When using the MyPyramid symbol,
D1.4

dietitians should be aware that USDA has
provided standards that should be carefully
followed in order to provide consistent
messages and appearance of the symbol,
and to avoid consumer confusion. The
MyPyramid Graphic Standards relate to size,
color, maintaining integrity of the food bands
widths and colors, and avoiding product,
program or other types of promotions
associated with MyPyramid.
MYPYRAMID FOR KIDS
MyPyramid for Kids also was released
in 2005. It presents simplified nutrition
messages that are geared toward the food
preferences and nutrient needs of children
aged six to eleven. The basic format of
MyPyramid for Kids is the same as for
MyPyramid, with vertical bands representing
the five food groups, plus oils, and the stairs
symbolizing physical activity. Rather than the
slogan "Steps to a Healthier You," MyPyramid
for Kids has "Eat Right. Exercise. Have Fun."
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A variety of kid-friendly foods are

pictured on the graphic, and diverse children
are pictured in active play, emphasizing the
importance of daily physical activity for young
children. Two messages are included, "Find
your balance between food and fun" and
"Fats and sugars, know your limits." These are
positive messages that communicate that
physical activity is fun, and that fats and
sugars are not off limits, but that intake
should be limited for good health.
The back of the mini poster, which is

downloadable from the MyPyramid website,
includes fourteen "Tips for Families," divided
into two categories: Eat Right and Exercise.
VARIATIONS ON THE FOOD GUIDE PYRAMID
Although USDA's Food Guide Pyramid
was adaptable for use with a variety of target
groups, a number of variations to the Pyramid
have been developed since it was introduced.
Pyramids for young children, older adults,
vegetarians, and various ethnic groups have

been developed by individuals, agencies, and
organizations, although most of these lack
the type of extensive research and
development process that was used to
prepare USDA's Food Guide Pyramid, and
subsequently, MyPyramid. In addition, a
Mediterranean food guide has received quite
a bit of media attention. This section provides
brief descriptions of some of the pyramids
that are readily available for use in educating
consumers about healthy approaches to their
daily diet. (Note: USDA's Food Guide Pyramid
for Young Children (14) has been replaced by
MyPyramid for Kids and will not be addressed
in this review.) As stated in the Introduction, it
will be of interest to see if any of these
"alternative" food pyramids are adapted in
response to the release of MyPyramid by
USDA.
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Older Adults. Researchers at the Tufts

University Center on Nutrition and Aging
developed a prototype of a pyramid for
persons over age seventy, which they
published in the Journal of Nutrition in 1999,
to stimulate discussion and further research
in this area (15). The need for a pyramid
targeted to older adults was clear when
nutrition educators began using the Modified
Food Guide Pyramid for People Over Seventy
Years of Age, or modified versions, in their
work with older adults (16). Special features
of this pyramid include, a.) slimmer size to
represent lower calorie needs, b.) addition of
water at the base of the pyramid due to
concerns about hydration status, c.) symbols
representing fiber in several food groups to
encourage consumption of high fiber foods,
and d.) notation that calcium, vitamin D and
vitamin B12 supplements may be needed.
A pyramid adapted at the University of
Florida in 2000, for a statewide Extension
program, Elder Nutrition and Food Safety
(ENAFS), which is targeted to older persons
participating at congregate nutrition sites,
includes many of the adaptations described
by the researchers at Tufts University, along
D1.5

with several key differences. The ENAFS Daily
Food Guide Pyramid for Elders features fluids
rather than water at the base of the pyramid,
omits the word "supplements" from the
graphic, and uses words (e.g. two or more)
rather than symbols (e.g. >) to describe the
number of servings for each food group. In
addition, the graphic includes canned and
frozen foods to emphasize food choices, such
as canned fruit, often used by older persons.
An updated Tufts pyramid, currently available
for use with consumers, features many of the
same changes from their original prototype
as appear in the ENAFS pyramid. University of
Florida IFAS Extension faculty are currently
evaluating whether or not to adapt the ENAFS
pyramid to be consistent with MyPyramid,
while still addressing the unique nutritional
needs of older persons.
Vegetarians. USDA's Food Guide Pyramid
had some flexibility to help vegetarians plan
healthful diets. However, special nutrient
concerns for vegetarians may not have been
satisfactorily addressed since the Pyramid
was designed for those consuming an
omnivorous diet. Over the years, various
vegetarian pyramids were developed to meet
the special needs of vegetarians.
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A Vegetarian Food Pyramid developed

with input from individuals who participated
in the Third International Congress on
Vegetarian Nutrition was published in the
Journal of Nutrition (17). The conceptual
framework for this pyramid was described
previously (18). Important principles included:
variety and abundance of plant foods;
emphasis on unrefined and minimally
processed foods; optional use of dairy
products and/or eggs; wide range of fat
intake; generous fluid intake; and other
lifestyle factors such as regular exercise and
daily exposure to sunlight (for vitamin D) and
fresh air (18). This vegetarian pyramid was
designed to meet the needs of both lactovegetarians and vegans, and addresses
nutrient concerns such as lower digestibility
of protein in plant-based diets, limited
availability of vitamin B12, vitamin D and

calcium, and lower bioavailability of zinc and
iron.
A second vegetarian pyramid was
published as part of a companion paper to
the joint position paper on vegetarian diets
published by the American Dietetic
Association and Dietitians of Canada in 2003
(19-20). The Food Guide for Vegetarians
actually is presented in two formats in the
paper, a rainbow and a pyramid (19). Canada
currently represents its food guide as a
rainbow. The food guide was designed to
assist persons following various types of
vegetarian diets in selecting diets that meet
Dietary Reference Intakes (DRI) for protein,
iron, zinc, calcium, vitamin D, riboflavin,
vitamin B12, vitamin A, omega-3 fatty acids,
and iodine (20). Food groups include: grains,
vegetables, fruits, legumes, nuts and other
protein-rich foods, fats, and calcium-rich
foods. The calcium-rich foods group includes
foods from each of the other food groups.
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Mediterranean Diet. Considerable media

attention has been focused on the potential
health benefits of the diet typically consumed
by people in the Mediterranean basin,
particularly in the olive growing areas of the
region. Epidemiological studies first reported
in the 1960s have been interpreted to
support consumption of a relatively high-fat
diet to reduce heart disease risk, as long as
the primary source of fat in the diet is olive
oil, which is rich in monounsaturated fatty
acids (MUFA) (21,22). The Mediterranean
Diet has been associated with overall
mortality in several cohort studies, indicating
that this style of eating style may increase
longevity (23,24). Data from a 44-month case
-control study supported the protective
effects of the Mediterranean diet against
death from coronary heart disease and
cancer, as well as total mortality (24).
Supporters of the Mediterranean Diet
Pyramid proposed that the Food Guide
Pyramid be changed to reflect the
D1.6

Mediterranean eating pattern. Even though
dietary fat is primarily in the form of olive oil
in the Mediterranean diet, concerns have
been raised about the high fat level of the
Greek diet in some regions, in light of
increasing incidence of obesity and
associated health problems in the Greek
population (25). This trend also is a major
concern in the U.S., with overweight and
obesity reaching "epidemic" proportions in
recent years.
The traditional Mediterranean diet is
largely plant-based, with high intake of
vegetables, legumes, fruits, nuts, cereals,
and olive oil, a moderately high intake of fish,
depending on location, low-to-moderate
intake of dairy products, primarily in the form
of yogurt and cheese, and low intake of
meats and poultry. Wine is regularly, but
moderately consumed, mostly with meals.
The level of fat in the diet varies among
countries and regions within countries in the
Mediterranean basin (22).
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Ethnic Groups. Numerous food guides have

been developed to address the eating
patterns of various ethnic groups. None has
been as widely tested and validated as
USDA's Food Guide Pyramid, but they provide
tools that may be useful for working with
specific audiences. USDA provides links to a
number of these pyramids on their website
(see Resources section).
Some of the pyramid variations, such as

the Soul Food Pyramid, adhere closely to the
food group design of the Food Guide Pyramid,
and appeal to a particular group by including
familiar foods and having an appealing
design. Others, such as the Asian Diet
Pyramid, address significant differences in
food preferences through the use of different
number and placement of food groups within
the pyramid structure. For example, since
many Asian Americans do not consume dairy
products, one level of the pyramid, labeled
"Optional Daily" is identified as "Fish &
Shellfish or Dairy," and Meat is at the very tip
of the pyramid, labeled as "Monthly". The

Asian Diet Pyramid also includes symbols
outside of the pyramid to represent physical
activity, along with alcoholic beverages.
The USDA's Center for Nutrition Policy
and Promotion website includes links to the
Asian Diet Pyramid, Bilingual Food Guide
Pyramids in over 30 different languages, and
the Native American Food Guide. The Native
American Food Guide uses the same food
groups as USDA's Food Guide Pyramid, but
includes "Low or Non-fat" in the descriptor for
the dairy products group to emphasize the
importance of these choices for this
population. The base of the pyramid indicates
two sections: Bread, Cereal Group and Rice,
Pasta Group, each of which suggests 6-11
servings; unless this is not meant to
represent two separate food groups (and
there is no line to separate the two sections),
it is an unusual recommendation for a people
at such high risk for obesity, diabetes and
heart disease (26).
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Faculty at the University of Connecticut

Family Nutrition Program and experts at the
Hispanic Health Council developed the Puerto
Rican Food Guide Pyramid (Figure 11). They
based the Pyramid on quantitative and focus
group research. It includes pictures of
traditional foods in the familiar five food
groups. Another pyramid targeted to the
Puerto Rican population is the Food Pyramid
for Puerto Rico, developed by a subcommittee of the Nutrition Committee of
Puerto Rico and released in 1994, just two
years after the Food Guide Pyramid was
published (27). Both of these pyramids
targeted to Puerto Ricans are very similar to
USDA's Food Guide Pyramid. The pyramid
developed in Puerto Rico includes water as
part of the food guide due to concerns about
hydration in a tropical climate and viandas
(e.g., plaintains, white and sweet potatoes,
yucca, celery root, and malanga) as part of
the pyramid's grain food base (27).
DIETARY GUIDELINES FOR AMERICANS
D1.7

The Dietary Guidelines for Americans
are recommendations about how to eat to
stay healthy based on current knowledge
about diet-disease relationships. The Dietary
Guidelines are targeted to Americans over
age two years since the dietary needs of
infants and toddlers are different from those
of older children and adults. The Dietary
Guidelines are the cornerstone of Federal
nutrition policy, influencing programs such as
USDA's Food Stamp Program, Special
Supplemental Nutrition Program for Women,
Infants and Children (WIC), and the School
Lunch Program (3,7).
In 1980, USDA and the U.S.
Department of Health, Education, and
Welfare (currently the Department of Health
and Human Services, USDHHS) published the
first edition of the Dietary Guidelines, called
Nutrition and Your Health: Dietary Guidelines
for Americans (6). The seven guidelines
recommended a diet that included a variety
of foods to provide essential nutrients and
adequate starch and fiber, that maintained
"ideal" body weight, and that was moderate in
fat, saturated fat, cholesterol, sugars,
sodium, and alcohol.
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Every five years, the Dietary Guidelines

are reviewed by a committee of nongovernment nutrition and health experts and
are re-issued by the USDA and USDHHS (see
box, Dietary Guidelines, A Brief History). The
Dietary Guidelines Advisory Committee for the
2005 edition conducted an extensive search
of the research literature, reviewed existing
reports and analyses conducted especially for
the Committee, and obtained input from
invited experts as well as from the public. The
current (sixth) edition of the Dietary
Guidelines was issued in February 2005, and
is a 70-page document targeted to
policymakers, nutrition educators, dietitians,
and healthcare providers, rather than to the
general public as in previous editions (3). A
separate consumer-oriented brochure,
Dietary Guidelines, A Brief History

The Dietary Guidelines were first published in
1980 (6), and the first revision, in 1985 (28),
included only minor changes in wording. After this second edition of the Guidelines was released, two major reports were
published, the Surgeon General's Report on
Nutrition and Health (29) and the National
Academy of Science's Diet and Health: Implications for Reducing Chronic Disease Risk
(30). These publications summarized current
knowledge in diet-disease relationships, and
were used by the Dietary Guidelines Advisory
Committee as scientific resources for the
third edition, published in 1990 (31). That
edition took a more positive approach, using
wording such as "choose ..." rather than
"avoid too much ..." It focused more on the
total diet, and included more specific, practical advice for each Guideline. This trend was
continued in the fourth edition, which was
published in 1995 (32). There was an increased emphasis on physical activity, and
instructions on using the Food Guide Pyramid
and the Nutrition Facts label to plan a healthful diet. Vegetarian diets were discussed for
the first time in the fourth edition. The fifth
edition took a new approach by dividing the
Guidelines into three components Aim, Build
and Choose and described ten guidelines.
For the first time, food safety was included as
a guideline, and the Variety guideline was
changed to "Let the Pyramid guide your food
choices," to emphasize food choices based
on this familiar educational tool (33). The
current edition encourages most Americans
"to eat fewer calories, be more active, and
make wiser food choices" (3). This edition is
described more fully in this chapter.
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Finding Your Way to a Healthier You, provides

tips for implementing the key
recommendations of the Dietary Guidelines
(see Resources for Education and
Counseling).
D1.8

The Dietary Guidelines for Americans
2005 is organized into nine inter-related
focus areas, each with key recommendations
for the general public and key
recommendations for specific population
groups. The intent is for the
recommendations to be implemented as a
whole to plan a healthful diet.
health:
"Consume a variety of nutrient-dense foods
and beverages within and among the basic
food groups while choosing foods that limit
the intake of saturated and trans fats,
cholesterol, added sugars, salt, and alcohol."
The nine chapters of the Dietary

Guidelines for Americans 2005 publication
are:
"Reduce the incidence of dental caries by

practicing good oral hygiene and consuming
sugar-and starch-containing foods and
beverages less frequently."
1.
2.
3.
4.
5.
6.
7.
8.
9.
Although the intake of most essential

nutrients is adequate in the U.S., the Dietary
Guidelines identified several nutrients as
potential concerns. These include vitamin E,
calcium, magnesium, potassium, and fiber for
children and adults, and vitamins A and C
among adults. The report also addresses
special micronutrient concerns for population
subgroups, as follows.
Adequate Nutrients within Calorie Needs

Weight Management
Physical Activity
Food Groups to Encourage
Fats
Carbohydrates
Sodium and Potassium
Alcoholic Beverages
Food Safety
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The 2005 Dietary Guidelines reflect

current concerns about overweight and
obesity, as well as attention to critical
nutrients that may be of concern through the
lifecycle. Calorie intake and/or energy
balance are addressed in six of the nine
chapters. The focus is on calorie intake rather
than the proportion of calories consumed
from protein, carbohydrate, or fat. It is
suggested that the healthiest way to
decrease energy consumption is to reduce
intake of added sugars, solid fats, and
alcohol in the diet since they provide "empty"
calories. Even small changes in energy
balance can make a difference in body weight
over time, for both children and adults. As in
the previous edition, physical activity is
included as a key message.
In a departure from previous editions of

the Dietary Guidelines, the current edition
addresses sugar intake as part of the
Carbohydrates chapter, rather than including
a key message targeted specifically to sugar
intake. Consumption of sugars is addressed
in the context of calorie control and dental
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Women of childbearing age who may

become pregnant: Eat foods high in heme
iron and/or consume iron-rich plant foods
or iron-fortified foods with an enhancer of
iron absorption, such as vitamin C-rich
foods.
Women of childbearing age who may
become pregnant and those in the first
trimester of pregnancy: Consume
adequate synthetic folic acid daily (from
fortified foods or supplements) in addition
to food forms of folate from a varied diet.
People over age 50: Consume vitamin
B12 in its crystalline form (i.e. fortified
foods or supplements).
Older adults, people with dark skin, and
people exposed to insufficient ultraviolet
band radiation (i.e., sunlight): Consume
extra vitamin D from vitamin D-fortified
foods and/or supplements.
The 2005 Dietary Guidelines indicate
that the greatest health benefits will be
obtained by following all of the
recommendations, although health benefits
can be reaped from following only some of
D1.9

them. To help consumers make food
selections for a healthful diet, the Dietary
Guidelines includes two eating patterns that
"exemplify" the guidelines. One is the DASH
eating plan, which was developed for the
Dietary Approaches to Stop Hypertension
(DASH) study, and the second is the new
USDA Food Guide, which was developed by
USDA specifically to help Americans
implement the Dietary Guidelines 2005. The
USDA Food Guide is rich in fruits, vegetables,
whole grains, and nonfat or low-fat milk
products; provides nutrients in amounts that
meet nutrient needs and reduce risk of
chronic disease; and is low in saturated fat,
cholesterol, and added sugars. The eating
pattern also can be low in trans fat, although
this is not included in USDA's model, and
sodium, with appropriate food choices, such
as limiting intake of foods containing partially
hydrogenated fat and selecting low or
reduced sodium products, respectively.
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The family and larger community

environments can play critical roles in
influencing lifestyle choices, such as whether
or not an individual consumes excess
calories, eats a healthful diet, and is
physically active, all of which contribute to
positive health outcomes. This is a critical
issue as we deal with increasing incidences
of obesity and type 2 diabetes among adults
and young people in our country. Dietitians
can help to influence community
environments that currently promote
overeating, consumption of foods of low
nutrient density (and often high calorie
density), and physical inactivity, through
involvement in community coalitions, schools,
and other local venues.
Dietary Guidelines and Young Children. The

Dietary Guidelines have always been
designed for adults and children over two
years of age and should not be applied to the
diets of children under two years of age.
Infants and toddlers require a more energydense diet containing adequate calories, fat,
and cholesterol to support growth and
D1.10
development. It is generally recommended

that beginning at the age of two years,
children be gradually introduced to a lower fat
diet, although this recommendation is not
without controversy among health
professionals (34). Dietitians can help
parents and caregivers understand young
childrens special nutrient needs, including
the need for a calorie-dense diet to avoid
inadequate food and nutrient intake in these
young people.
HELPING CONSUMERS USE FOOD GUIDES
Food guides were designed to help
people select foods for a healthful diet.
Grouping foods based on nutrient content is
helpful to people faced with tens of
thousands of choices at the supermarket and
in restaurants. However, consumers need
assistance in understanding and using food
guides in their daily lives. MyPyramid is no
exception, and dietitians can help consumers
interpret the messages, identify an
appropriate calorie level for their weight
management goals, and use the eating plan
to meet their calorie and nutrient needs
within the context of their ethnic background,
cultural preferences, and budgets.
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Variations in Nutrient Content. Although

specific foods within each food group contain
similar amounts of key nutrients, there are
large variations in the levels of some
micronutrients, such as beta-carotene and
folate in fruits and vegetables, and zinc in
meat and meat alternates. Dietitians can
help consumers make healthful choices
within the food groups to improve nutrient
density of the diet in general, and also to help
individuals make choices appropriate to their
eating styles and/or special nutrient needs.
MyPyramid provides more specific
advice regarding consumption of specific
foods within the food groups to enhance
variety and nutrient density. For example,
within the Vegetables Group, MyPyramid
includes weekly recommendations for five

subgroups, based on their nutrient content:
Dark Green Vegetables, Orange Vegetables,
Dry Beans and Peas, Starchy Vegetables, and
Other Vegetables. Specific food choices are
included in the "Inside The Pyramid" sections
of MyPyramid.gov. Dietitians are encouraged
to use the tools provided on the website in
working with clients to build a healthy diet.
Lifestyle. It has now been many years since
the "typical" American family, with dad in the
work force, mom at home, and children in
school has actually been typical. Women's
labor force participation rose from 46 percent
to almost 59 percent between 1975 and
1996. Among women with children under the
age of six, labor force participation changed
from 38.8 to 62.3 percent during this same
period (35) and in 2004, was 61.8 percent, a
slight decrease (36). In 2004, 70.4 percent
of women with children under the age of 18
were in the labor force (36). These women
have less time available than stay-at-home
mothers to prepare dinners "from scratch"
and to teach their children how to cook.
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Single mothers, who are likely to work

full-time, often have little time to prepare
family meals. Seventy-two percent of single
mothers were in the labor force in 2004 (36).
Many young people, including young parents,
have few if any food preparation skills, and
depend on pre-prepared foods including
frozen entrees, restaurant or supermarket
take out, and fast food. School age children
have limited access to food preparation skill
building through the school system. In many
homes the family dinner occurs on a weekly
basis if at all. Older people, especially
women, often live alone and may have
difficulty shopping, preparing, and/or eating
meals. All of these situations can have
negative impacts on the diets of people of all
ages in this country, and point to the need for
nutrition education to help people select and/
or prepare healthful foods that fit their
lifestyles.
Food Costs. For many people food costs are
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a significant factor in their food choices. In

2003, 11.2 percent of households in the U.S.
(12.6 million) were food insecure, meaning
that at some time during the year they did not
have access to enough food for all household
members due to a lack of resources (37).
Persons living in food insecure households
are more likely to experience hunger, poor
nutritional status, and health problems.
Dietitians can assist low-income
individuals in selecting healthful diets within
a limited budget by teaching them to
comparison shop, plan healthful low-cost
meals, and store and use leftovers. These
skills can help persons with limited resources
make their food dollar and/or food stamps
last all month and decrease food insecurity.
Dietitians who work with limited resource
families can also help them obtain
assistance, such as Food Stamps or WIC, to
reduce reliance on emergency food
programs.
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Cooperative Extension supports two

nutrition education programs targeted to
persons with limited resources, the Expanded
Food and Nutrition Education Program
(EFNEP) and the Food Stamp Nutrition
Education Program, called the Family
Nutrition Program (FNP) in many states,
including Florida. Dietitians in Florida can
contact their local county Extension office to
see which program might be available in their
counties. There may be opportunities to share
resources, refer clients to free nutrition
education classes, and collaborate to
address community nutrition and health
issues.
SOURCES FOR EDUCATION AND
COUNSELING
Note: All of the Federal government
publications may be reproduced for
educational purposes. For the latest updates
of USDA publications related to MyPyramid,
MyPyramid for Kids, and the Dietary
Guidelines, check the Center for Nutrition

Policy and Promotion website: http://
www.usda.gov/cnpp. Resources are being
developed in both English and Spanish.
Accessed January 15, 2009.
Dietary Guidelines for Americans, 6th Edition.
The booklet may be purchased from the
Federal Consumer Information Center, tollfree at (888) 878-3256. Download a PDF file
at: http://www.cnpp.usda.gov/Publications/
DietaryGuidelines/2005/2005DGPolicyDocu
ment.pdf. Accessed January 15, 2009.
Finding Your Way to a Healthier You.
Consumer brochure based on the Dietary
Guidelines for Americans 2005. Download a
PDF file at: http://www.health.gov/
dietaryguidelines/dga2005/document/pdf/
brochure.pdf. Accessed January 15, 2009.
MyPyramid. Download a PDF file of the
graphic and other resources, find information
for professionals, and use the interactive
features at: http://mypyramid.gov.
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MyPyramid food guides at 12 calorie levels

(1000 to 3200). Downloaded PDF files at:
http://mypyramid.gov/professionals/
results_downld.html. Accessed January 15,
2009.
MyPyramid Graphic Standards, Guidelines for

using the MyPyramid graphic. Source: http://
mypyramid.gov/downloads/resource/
MyPyramidGraphicStandards.pdf. Accessed
January 15, 2009.
MyPyramid for Kids. Download a PDF file of
the graphic and tips for healthy eating and
physical
activity
at
http://
www.mypyramid.gov/kids/index.html.
An interactive game for children (ages six to
eleven) is accessible through the website.
Modified Food Guide Pyramid for People Over
Seventy Years of Age. Available at: http://
n u tr i ti o n . t u f ts . ed u / 1 19 79 72 03 13 85/
Nutrition-Page-nl2w_1198058402614.html.
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ENAFS Daily Food Guide Pyramid for Elders.
Order ENAFS educational CDs from the
"Education" section of the IFAS bookstore:
http://www.ifasbooks.ufl.edu/merchant2/.
Accessed January 15, 2009.(The pyramid is
included in Module 1 in black and white and
in full color.) This pyramid is being reviewed
as we go to press.
Asian Food Pyramid: Available at http://
www.oldwayspt.org/asian_pyramid.html.
Mediterranean Diet Pyramid. Available at
http://www.oldwayspt.org/
med_pyramid.html. Accessed January 15,
2009.
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Native American Food Pyramid. Download the

image at: http://www.nal.usda.gov/fnic/Fpyr/
NAmFGP.html. Accessed January 15, 2009.
Puerto Rican Food Guide Pyramid. Download
the image at: http:/www.hispanichealth.com/
pyramid.htm. To order print copies, contact:
the University of Connecticut Family Nutrition
Program at (860) 486-3635, fax (860) 4863674, or email:lphillip@canr1.cag.uconn.edu.
FIGURES
My Pyramid Graphics, developed by the U.S.
Department of Agriculture, 2008. Source:
http://www.mypyramid.gov/global_nav/
media_resources.html. Accessed on January
15, 2009.
Modified Food Guide Pyramid for People Over
Seventy Years of Age, developed at the Tufts
University Center on Nutrition and Aging.
Source:
http://nutrition.tufts.edu/pdf/pyramid.pdf.
Vegetarian Food Pyramid, developed at
Arizona State University East, Mesa AZ.
Source: http://www.oldwayspt.org/

vegetarian_pyramid.html. Accessed January
15, 2009.
Vegetarian Food Guide, developed by the
American Dietetic Association and Dietitians
of Canada. Source: Can J Diet Pract Res.
2003;64(2):82-86.
The Traditional Healthy Mediterranean Diet
Pyramid, developed by Oldways Preservation
and Exchange Trust, 2000. Source:
http://www.oldwayspt.org/
med_pyramid.html. Accessed January 15,
2009.
Asian Diet Pyramid, developed by researchers
at Cornell and Harvard Universities, with
other experts. Source:
http://www.news.cornell.edu/
Chronicle/96/1.18.96/AsianDiet.html.
Native American Food Pyramid, California
Adolescent Nutrition and Fitness Program,
Source: http://www.nal.usda.gov/fnic/Fpyr/
NAmFGP.html. Accessed January 15, 2009.
REFERENCES
T
S
E
1. Welsh S, Davis C, Shaw A. A brief history

of food guides in the United States. Nutr
Today. 1992;27 6-11.
2. Standing Committee on the Scientific
Evaluation of Dietary Reference Intakes.
Dietary Reference Intakes for Calcium,
Phosphorus, Magnesium, Vitamin D, and
Fluoride. 1999. Food and Nutrition Board,
Institute of Medicine. Washington, DC.
National Academy Press.
3. U.S. Department of Agriculture and U.S.
Department of Health and Human
Services. Nutrition and Your Health:
Dietary Guidelines for Americans, Fifth
Edition. 2005. Available at: http://
w w w . c n p p . u s d a . g o v /
DGAs2005Guidelines.htm. Accessed
January 15, 2009.
4. Davis CA, Britten P, Myers EF. Past,
D1.13
present, and future of the Food Guide

Pyramid. J Am Diet Assoc. 2001;101:881
-885.
5. Economic Research Service. USDA.
Appendix C. USDAs Thrifty Food Plan. In:
Household Food Security in the United
States. FANRR-35. Washington DC: USDA,
2002.
Available
at:
http://
www.ers.usda.gov/publications/fanrr35/
fanrr35appc.pdf . Accessed January 15,
2009.
Department of Health and Human
Services. Nutrition and Your Health:
Dietary Guidelines for Americans. 1980.
USDA Home and Garden Bulletin No.
232.
7. Cronin FJ, Shaw AM, Krebs-Smith SM,
Marsland PM, Light L. Developing a food
guidance system to implement the
Dietary Guidelines. J Nutr Ed.
1987;19:281-302.
8. Welsh S, Davis C, and Shaw A.
Development of the Food Guide Pyramid.
Nutr Today. 1992;27:12-23.
9. Dixon LB, Cronin FJ, Krebs-Smith SM. Let
the Pyramid guide your food choices:
capturing the total diet concept. J Nutr.
2001;131:461S-472S.
10. U.S. Department of Agriculture, Human
Nutrition Information Service. The Food
Guide Pyramid, 1992. USDA Home and
Garden Bulletin No. 252.
11. Center for Nutrition Policy and Promotion,
U.S. Department of Agriculture. How
Much Are You Eating? 2002. USDA Home
and Garden Bulletin No. 267-1. Available
at:
http://www.cnpp.usda.gov/
P u b l i c a t i o n s /
DietaryGuidelines/2000/2000DGBrochur
eHowMuch.pdf. Accessed January 15,
2009
12. U.S. Department of Agriculture press
release April 15, 2005. Johanns Reveals
USDA's Steps to a Healthier You.
Available at: http://mypyramid.gov/
global_nav/media_press_release.html.
Accessed on January 15, 2009.
13. U.S. Department of Agriculture.
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MyPyramid. 2005. Available at: http://
mypyramid.gov. Accessed January 15,
2009.
14. Davis CA, Escobar A, Marcoe KL, Tarone C,
Shaw A, Saltos E, Powell R. Food Guide
Pyramid for Young Children 2 to 6 Years
Old: Technical Report on Background and
Development. U.S. Department of
Agriculture, Center for Nutrition Policy and
Promotion. 1999. CNPP-10.
15. Russell RM, Rasmussen H, Lichtenstein AH.
Modified Food Guide Pyramid for people
over seventy years of age. J Nutr. 1999;129
(3):751-753.
16. Martin, L.A., & Bobroff, L.B. Florida
partnership funds nutrition education for
Florida's elders. Gerontological Nutritionists
Newsletter, Spring 2000.
17. Venti CA and Johnston CS. Modified food
guide pyramid for lactovegetarians and
vegans. J Nutr. 2002;132:1050-1054.
18. Haddad EH, SabatJ J, Whitten CG. Vegetarian
food guide pyramid: a conceptual framework.
Am J Clin Nutr. 1999;70:615S-619S.
19. Messina V, Melina V, Mangels AR. A new food
guide for North American vegetarians. Can J
Diet Pract Res. 2003;64(2):82-86.
20. American Dietetic Association; Dietitians of
Canada. Position of the American Dietetic
Association and Dietitians of Canada:
Vegetarian Diets. J Am Diet Assoc 2003;103
(6):748-65.
21. Keys A. Coronary heart disease in seven
countries. Circulation. 1970; 41-42 (Suppl
1):1-211.
22. Kok FJ, Kromhout D. Atherosclerosis Epidemiological studies on the health effects
of a Mediterranean diet. Eur J Nutr. 2004;
(Suppl 1):43:1/2-1/5.
23. Knoops KTB, de Groot LCPGM, Kromhout D,
Perrin A-E, Moreiras-Varela O., Menotti A., van
Staveren WA. Mediterranean diet, lifestyle
factors, and 10-year mortality in elderly
European men and women. The HALE Project.
JAMA. 2004;292:1433-1439.
24. Trichopoulou A, Costacou T, Barnia C,
Trichopoulos D. Adherence to a
Mediterranean diet and survival in a Greek
population. N Engl J Med. 2003;348:25992608.
25. Ferro-Luzzi A, James WPT, Kafatos A. The high
-fat Greek diet: a recipe for all? Eur J Clin Nutr.
T
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E
D1.14
2002;56:796-809.
26. National Heart, Lung, and Blood Institute,
National Institutes of Health. Building Healthy
Hearts for American Indians and Alaska
Natives: A Background Report. 1998.
Available at: http://www.nhlbi.nih.gov/health/
prof/heart/other/na_bkgd.pdf Accessed on
January 15, 2009.
27. MacPherson-Sanchez A. A food guide pyramid
for Puerto Rico. Nutr Today. 1998;33:198209.
Department of Health and Human Services.
for Americans, 2nd Edition. 1985. USDA
Home and Garden Bulletin No. 232.
29. U.S. Department of Health and Human
Services. The Surgeon General's Report on
Nutrition and Health. 1988. DHHS (PHS)
Publication No. 88-50210.
30. Committee on Diet and Health, Food and
Nutrition Board, National Research Council.
Diet and Health. Implications for Reducing
Chronic Disease Risk. 1989. Washington, DC,
National Academy Press.
for Americans, 3rd ed. 1990. USDA Home and
for Americans, 4th ed. 1995. USDA Home and
33. Harper, AE. Dietary guidelines in perspective. J
Nutr. 1996; 126:1042S-1048S.
34. Bureau of Labor Statistics. U.S. Department of
Labor. Employment characteristics of families
in 2007. News Release, July 9, 2003.
Available at: http://stats.bls.gov/
news.release/pdf/famee.pdf. Accessed
January 15,2009.
Labor. Employment characteristics of families
in 2004. News Release, June 9, 2005.
Available at: http://stats.bls.gov/
news.release/pdf/famee.pdf. Accessed on
10/25/05.
36. Nord M, Andrews M, Carlson S. Household
Food security in the United States, 2003.
Food Assistance and Nutrition Research
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MyPyramid. 2005. Available at: http://
mypyramid.gov. Accessed January 15, 2009.
14. Davis CA, Escobar A, Marcoe KL, Tarone C,
Shaw A, Saltos E, Powell R. Food Guide Pyramid
for Young Children 2 to 6 Years Old: Technical
Report on Background and Development. U.S.
Department of Agriculture, Center for Nutrition
Policy and Promotion. 1999. CNPP-10.
15. Russell RM, Rasmussen H, Lichtenstein AH.
Modified Food Guide Pyramid for people over
seventy years of age. J Nutr. 1999;129(3):751753.
16. Martin, L.A., & Bobroff, L.B. Florida partnership
funds nutrition education for Florida's elders.
Gerontological Nutritionists Newsletter, Spring
2000.
17. Venti CA and Johnston CS. Modified food guide
pyramid for lactovegetarians and vegans. J Nutr.
2002;132:1050-1054.
18. Haddad EH, SabatJ J, Whitten CG. Vegetarian
food guide pyramid: a conceptual framework. Am
J Clin Nutr. 1999;70:615S-619S.
19. Messina V, Melina V, Mangels AR. A new food
guide for North American vegetarians. Can J Diet
Pract Res. 2003;64(2):82-86.
20. American Dietetic Association; Dietitians of
Canada. Position of the American Dietetic
Association and Dietitians of Canada: Vegetarian
Diets. J Am Diet Assoc 2003;103(6):748-65.
21. Keys A. Coronary heart disease in seven
countries. Circulation. 1970; 41-42 (Suppl 1):1211.
22. Kok FJ, Kromhout D. Atherosclerosis Epidemiological studies on the health effects of a
Mediterranean diet. Eur J Nutr. 2004;(Suppl
1):43:1/2-1/5.
23. Knoops KTB, de Groot LCPGM, Kromhout D,
Perrin A-E, Moreiras-Varela O., Menotti A., van
Staveren WA. Mediterranean diet, lifestyle
factors, and 10-year mortality in elderly European
men and women. The HALE Project. JAMA.
2004;292:1433-1439.
24. Trichopoulou A, Costacou T, Barnia C,
Trichopoulos D. Adherence to a Mediterranean
diet and survival in a Greek population. N Engl J
Med. 2003;348:2599-2608.
25. Ferro-Luzzi A, James WPT, Kafatos A. The high-fat
Greek diet: a recipe for all? Eur J Clin Nutr.
2002;56:796-809.
26. National Heart, Lung, and Blood Institute,
National Institutes of Health. Building Healthy
T
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Hearts for American Indians and Alaska Natives:

A Background Report. 1998. Available at: http://
www.nhlbi.nih.gov/health/prof/heart/other/
na_bkgd.pdf Accessed on January 15, 2009.
27. MacPherson-Sanchez A. A food guide pyramid for
Puerto Rico. Nutr Today. 1998;33:198-209.
Nutrition and Your Health: Dietary Guidelines for
Americans, 2nd Edition. 1985. USDA Home and
29. U.S. Department of Health and Human Services.
The Surgeon General's Report on Nutrition and
Health. 1988. DHHS (PHS) Publication No. 8850210.
30. Committee on Diet and Health, Food and
Nutrition Board, National Research Council. Diet
and Health. Implications for Reducing Chronic
Disease Risk. 1989. Washington, DC, National
Academy Press.
Americans, 3rd ed. 1990. USDA Home and
Americans, 4th ed. 1995. USDA Home and
33. Harper, AE. Dietary guidelines in perspective. J
Nutr. 1996; 126:1042S-1048S.
Labor. Employment characteristics of families in
2007. News Release, July 9, 2003. Available at:
http://stats.bls.gov/news.release/pdf/famee.pdf.
Accessed January 15,2009.
Labor. Employment characteristics of families in
2004. News Release, June 9, 2005. Available at:
http://stats.bls.gov/news.release/pdf/famee.pdf.
Accessed on 10/25/05.
36. Nord M, Andrews M, Carlson S. Household Food
security in the United States, 2003. Food
Assistance and Nutrition Research Report No.
(FANRR42), October 2004. Available at: http://
w w w . e r s . u s d a . g o v / p u b l i c a t i o n s /f a n r r 4 2 /
fanrr42.pdf. Accessed on January 15, 2009..
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The Florida Medical Nutrition Therapy Manual 2009 Edition
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FCS8559-Eng.
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Facts About the ENAFS Daily Food Guide Pyramid for Elders
The ENAFS Daily Food Guide Pyramid for Elders was adapted from the Modified Food Guide
Pyramid for People over Seventy Years of Age developed at the U.S. Department of Agriculture
(USDA) Human Nutrition Research Center on Aging at Tufts University. The Tufts pyramid is an
adaptation of The Food Guide Pyramid that was developed by USDA for the general population.
Compare the ENAFS Pyramid with USDAs Food Pyramid for the general population:
The ENAFS pyramid is slimmer: As we age, most of us need fewer calories from food. When eating
less food, it becomes especially important to choose nutrient-rich foods.
Fluids make up the base of the ENAFS pyramid: There is an increased concern about adequate
fluid intake in elders. Fluid needs may not be higher in elders, but dehydration and constipation are
common problems. These problems can be reduced by drinking appropriate fluids.
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The number of servings is different: A minimum numberinstead of a rangeof servings from each
food group is recommended. The number of recommended servings from the Milk, Yogurt, and
Cheese group is higher because elders have increased calcium and vitamin D needs.
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A need for fiber is indicated: It is important for elders to get enough fiber, in order to stay regular
and avoid constipation. Food groups in which you can select high fiber foods have the
symbol.
Diverse food choices are included: Ethnic food examples are included in the ENAFS pyramid, to
allow for diverse food preferences and customs. The Meat, Poultry, Fish, Dry Beans, Eggs, Nuts and
Tofu group is divided into two parts, to point out plant sources of protein.
Vitamin and mineral needs may be higher: Elders may need more calcium, vitamin D, and vitamin
B12, as indicated by the flag at the top of the ENAFS pyramid. Ask your physician or a registered
dietitian if a supplement is appropriate for you. It is best to get advice regarding supplement usage
from health professionals who are NOT selling these products.
TUFTS
FOOD Guide Pyramid for Older Adults
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Vegetarian Food Guides
Developed by the American Dietetic Association and Dietitians of Canada.
Source: Can J Diet Pract Res. 2003;64(2): 82-86.
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Native American Food Pyramid

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

Written by: Deanna Stanz, MS, RD
Pediatric Clinical Dietitian, Arnold Palmer
Women & Childrens Hospital, Orlando
Reviewed by: Dona Greenwood, PhD, RD,
LD/N, Director of Nutritional Care,
Tallahassee Memorial Regional Medical
Center
PRACTITIONER POINTS
RATIONALE
The diet for infants is designed to
provide adequate nutrients for optimal
growth and development. The primary
method of evaluating the nutritional status of
infants is growth.
USE
These guidelines are appropriate for
healthy term infants from birth to twelve
months of age.
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RELATED PHYSIOLOGY
The newborns birth weight is

determined by various factors such as length
of gestation, mothers pre-pregnancy weight,
as well as weight gain during pregnancy. The
average full-term birth weight in this country
is approximately 3500 grams (1). Weight
loss averaging 6% after birth is expected in
all full-term healthy infants due to fluid
losses and some catabolism of tissue. Most
infants regain this weight within the first two
weeks of life. Thereafter, infants gain weight
at a rapid but decelerating rate (1). See
Table 1. By four months of age, most infants
will double their birth weight. Likewise,
height increases at a rapid but decelerating
rate. Average length at birth is approximately
50-53cm. Infants usually increase their
length 50% by one year of age (1).
Infant feeding tends to occur in three

overlapping periods. It should be noted that
the rate at which an infant progresses
through these stages will vary depending on
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the infants rate of maturation of the nervous

system, intestinal tract, and kidneys. The
nursing period occurs when human milk or
an appropriate formula is the sole source of
nutrition. During the transitional period, age
appropriate foods are introduced in addition
to human milk or formula. The modified adult
period occurs when the infant is receiving
the primary source of nutrition from table
foods (2). Specifics on infant feeding as well
as infant development and feeding skills will
be addressed in subsequent paragraphs.
Table 2 states the Recommended Dietary
Allowance (RDA) for calories, protein and
fluids.
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Table 1. Average Expected Weight Gain for

Infants (1)
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Age (months)
Average
Weight Gain
(gm/day)
Expectation
0 - 4 months
20-25 gm/
day
Double birth
weight by 4-5
months
5 - 12
15 gm/day
Triple birth
weight by 12
months
Table 2. Dietary Recommendations for Infants

Calories/
kg BW
Protein
gm/kg
BW
Fluids
ml/kg
BW
0-6
months
108
2.2
140-160
6-12
months
98
1.6
125-155
Age
Breast milk and/or iron-fortified commercial formula provide the nutrients

needed by the healthy term infant (see Table
3). The Committee on Nutrition of the American Academy of Pediatrics recommends ironfortified formula for all formula-fed infants

(4). Iron stores in the newborn infant
preclude the need for other iron sources
during the first early months of life. Between
4-6 months of age iron stores begin to
deplete, erythropoiesis begins and there is a
rapid rise in total body hemoglobin (2). This
increases the need for dietary iron. Ironfortified cereals are the first semi-solid foods
to be incorporated into the infants diet
(1,5,6). Infant cereals are fortified with,
ferrous sulfate, reduced iron, and ferrous
fumarate, well absorbed forms of iron (6).
Between 3-4 months of age, the infant
is developmentally able to take solids from a
spoon and has lost the tongue thrust
reaction present from birth (1) (see Table 4).
Physical readiness for solids is further
demonstrated by ability to swallow non-liquid
foods, sitting independently and maintaining
balance (5). Breast milk or formula should be
added to thin cereal to the desired
consistency. The consistency should gradually
become thicker as the infant is able to
master swallowing and spoon feeding (1).
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The use of whole cows milk during

infancy is discouraged and has been
associated with iron-deficiency anemia,
possibly due to gastrointestinal blood loss (4,
5, 7). The composition of whole cows milk
(high in calcium, phosphorus, protein; low in
vitamin C) may affect the bioavailability of
iron from other dietary sources such as infant
cereal (7). The American Academy of
Pediatrics, Committee on Nutrition does not
recommend the use of whole cows milk or
low-iron commercial formulas during the first
year of life (3, 7).
Overdilution of infant formula reduces

the caloric and nutrient content of feedings.
Functionally immature kidneys in newborns
make them vulnerable to water imbalances
(1). If fed water instead of formula, or
provided with large quantities of water
between feedings, water intoxication with
resultant hyponatremia, irritability, or coma
may occur (1, 8). The fluids provided by
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breast milk or formula are sufficient to meet

an infants needs. Healthy infants usually
require little or no supplemental water,
except in hot weather and when solid foods
are introduced. The introduction of solids
increases renal load (4). In places where the
weather is very hot, a 4oz-bottle of water may
be appropriate for infants over 6 months.
At approximately 6-7 months, fruits and
vegetables may be added to the diet. The
exact order is not important, but only one new
food should be added at a time. Wait for 5-7
days and observe the infant for signs of
allergies or intolerance, such as diarrhea,
vomiting, or rash, before adding another new
food.
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Foods should be as simple as possible,

with minimal added sugar, sodium, or other
ingredients. The use of fruit or junior desserts
should be discouraged because of the high
content of simple carbohydrates (up to 30%
of calories as sucrose) and calories, with few
other nutrients (1, 5). Fruit juices may be
used when the infant is able to drink from a
cup (1, 4).
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When the infant is comfortable with the

texture of strained foods at 9-10 months,
simple mashed, soft and well-cooked table
foods can be added. Yogurt, mashed
potatoes, plain vegetables, grits, oatmeal and
other similar foods provide the infant with a
variety of textures (1).
In preparation for the transition from
breast milk or iron-fortified commercial
formulas to whole cows milk, additional iron
sources such as meat are added to the diet
at 9-10 months of age. Strained meats can
be purchased, or lean, well-cooked meat can
be finely chopped and mixed with other
foods. Meat dinners or combination dinners
are not recommended because they provide
less than half as much protein as pure meat
(1). Plain meats provide 220-250% more
protein and up to 200% more iron than meat
dinners.

Follow-up formulas for infants over six
months of age can provide additional iron for
those receiving inadequate amounts in their
solid feedings. These formulas are
nutritionally adequate, but are not necessary
for infants receiving appropriate amounts of
iron and vitamins in their diet (2).
Foods that are common allergens are
not added to the diet until close to or after
one year of age (5). These foods include eggs,
shellfish, citrus fruit, corn products and nuts.
Foods that are easily aspirated or that may
cause choking, like raisins, small candies
(M&Ms, etc.), nuts, hot dogs, peanut butter,
grapes, popcorn, and whole kernel corn, are
not appropriate for infants (1, 5). Honey has
been found to contain spores of Clostridium
botulinum, which can be fatal when consumed by infants with immature gastrointestinal and immune systems (1, 9). At one time,
honey was used to treat constipation, but it is
no longer recommended for infants.
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Training with a cup during the second

half of the first year is important. It will
facilitate weaning from the bottle and should
be accomplished as close to one year as
possible in order to prevent the development
of nursing bottle caries or baby bottle tooth
decay (1, 5). The leading cause of baby bottle
tooth decay is provision of concentrated
mono and disaccharides (milk/juices) in the
bottle, especially at bedtime (5).
E1.3
chooses not to breastfeed or stops before the

infants first birthday, an iron-fortified commercial formula is the best feeding alternative (5, 7). The Committee on Nutrition of the
American Academy of Pediatrics has issued a
policy statement on standard commercial
formulas. The composition of breast milk
from a healthy mother is used as the
standard for commercial formulas. The goal is
to approximate the minimum nutrient content
of breast milk; the maximum amount is
intended for infants with special needs (e.g.
low birth weight infants) (1).
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NUTRIENTS MODIFIED
This diet does not involve nutrient
modification. Rather, food varieties and
textures advance based on developmental
skills of the infant.
Breast milk is the recommended source
of nutrition for the first six months of life (5).
The American Academy of Pediatrics and the
American Dietetic Association have published
papers supporting breastfeeding. If a woman
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Table 3 COMMONLY USED INFANT FORMULAS AND INDICATIONS FOR USE
Formula *
Description
Indication
Similac{*}, Enfamil[*],
Good Start(*)
Modified skim cows milk:

For healthy, term infants; to be
reduced protein and mineral
used as an alternative when
content with blended fats added. breastfeeding is not possible (5)
Taurine is added
Isomil{*}, ProSobee[*],
Alsoy(*)
Soy isolate protein fortified with

methionine, corn syrup or
sucrose, soy, coconut, or oleo,
and vitamins and minerals
Lactofree[*]
Milk-based, lactose-free,
iron-fortified
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Nutramigen[*]
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Casein hydrolysate, soy

and corn oil
For infants recovering from

diarrhea, with galactosemia or
bovine protein intolerance (5)
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For infants, with lactose

intolerance, lactase deficiency,
chronic diarrhea, galactosemia
and that are allergic to soy
products
For infants, with intact protein
intolerance, galactosemia,
recovery from mild/moderate
diarrhea, food allergies
Pregestmil[*]
Casein hydrolysate and mediumchain triglycerides (MCT)
For infants with severe

malabsorption disorders (cystic
fibrosis, intractable diarrhea,
severe protein-energy
malnutrition, steatorrhea, short
gut syndrome)
Alimentum{*}
Casein hydrolysate, free amino

acids, MCT, safflower
and soy oils
For infants with protein

sensitivity or allergy, protein
maldigestion, fat malabsorption
* Registered Trademark
[*]Mead Johnson Nutritionals Pediatric Products Handbook
{*}Ross Laboratories Product Handbook
(*)Nestle Professional Handbook
E1.5
Table 4. INFANT DEVELOPMENT AND FEEDING SKILLS (10)

Development Skills
Mouth, Hand and Body Patterns
Babys Age
Baby is able to....
Birth through 5 months
Sucking/swallowing reflex
Tongue thrust reflex
Poor lip closure
Poor control of head, neck, trunk
Swallow liquids but pushes most

solid foods from the mouth
4 through 6 months
Draws in lower lip as spoon is removed

from mouth
Up and down movement
Transfers food from front to back of
tongue to swallow
Sits with support
Good head control
Uses whole hand to grasp objects
Take spoonful of pureed or strained

food and swallow it without choking
Control position of food in mouth
5 through 9 months
Up and down munching movement

Positions food between jaws for chewing
Begins to sit alone without support
Begins to use thumb and index finger to
pick up objects
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Eat mashed foods

Eat from spoon easily
8 through 11 months
Complete side-to-side tongue movement

Begins to curve lips around rim of cup
Sits alone easily
Eat ground or finely chopped food

Feed self with hands
Drink from a cup
10 through 11 months
Rotary chewing (grinding)

Begins to put spoon in mouth
Begins to hold cup
Eat chopped food and small pieces

of soft, cooked table food

REFERENCES
1. Pipes PL, Trahms CM. Nutrition in Infancy
and Childhood, 6th Edition. St. Louis, MO:
Mosby Year Book, Inc. 1997.
2. Kleinman RE. American Academy of
Pediatrics, Committee on Nutrition.
Pediatric Nutrition Handbook, 6th Edition.
2008.
3. Grummer-Strawn LM, Scanlon KS, Fein SB.
Infant feeding and feeding transition during
the first year of life.
Pediatrics
2008;122:S36-S42.
4. h t t p : / / b r i g h t f u t u r e s . a a p . o r g / p d f s /
G u i d e l i n e s _ P D F / 6 Promoting_Healthy_Nutrition.pdf
5. Samour PQ, Helm KK, Lang CE. Handbook
of Pediatric Nutrition. 3rd Edition. Sudbury,
MA: Jones and Bartlett; 2005.
6. American Academy of Pediatrics, Work Group
on Breastfeeding. Breastfeeding and the use
of human milk. Pediatrics 2005;115:496506.
Committee on Nutrition. The use of whole
cows milk in infancy. Pediatrics.
1992;89:1105.
8. Keating JP, Schears GJ, Dodge PR. Oral
water intoxication in infants: an American
epidemic. AJDC. 1991;45:985-990.
9. Aaron SS, Midura TF, Damus K, Thompson
B, Wood RM, Chin J. Honey and other
environmental risk factors for infant
botulism. J Ped. 1979;94:331-336.
10. Feeding Infants: A Guide for Use in the
Child Care Food Program. USDA-Food and
Nutrition Service, FNS-258.
11. Department of Dietetics, Childrens
Hospital. Infant Formulas and Selected
Nutritional Supplements. Columbus, OH:
Childrens Hospital Print Shop; 1993.
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Feeding Infants and Toddler Study.

2004;104:S22-S30.
3. US Department of Agriculture, Agricultural
Research Service. Food and Nutrient by
Region, 1994-1996. Table set 14. 1999.
4. Ryan C, Dwyer J, Ziegler P, Yang E, Moore
L, Song WO. What should infants eat and
what do infants really eat? Nutrition Today.
2002;37:50-56.
5. Greer FR, Sicherer SH, Burks W. Effects of
early nutritional interventions on the
development of atopic disease in infants
and children; the role of maternal dietary
restriction, breastfeeding, timing of
introduction of complementary foods and
hydrolyzed formulas. Pediatrics 2008;121
(1);183-191.
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Suggested References on Breastfeeding for

the Health Care Provider
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1. Position of the American Dietetic

Association: Promoting and Supporting
Breastfeeding. Journal of the American
Dietetic Association 2009;109:19261942.
Breastfeeding and the Use of Human
Milk . Pediatrics. 2005;115(2):496-506.
3. Worthington-Roberts, B., & Williams, S.R.
Nutrition in Pregnancy and Lactation. 6th
Edition. Missouri, Mosby-Yearbook. 1997.
4. The Womanly Art of Breastfeeding Illinois:
La Leche League International, 2005.
5. Neifert, M.
Dr. Moms Guide to
Breastfeeding. New York: Penguin, 1998.
6. Mohrbacher, N., & Stock, J., The
Breastfeeding Answer Book. Illinois: La
Leche League International, 2003.
ADDITIONAL REFERENCES
1. Devaney B, Zielger P, Pac S, Karwe V, Barr
S. Nutrient Intakes of Infant and Toddlers.
JADA. 2004;104:S14-S21.
2. Fox MK, Pac S, Devaney B, Jankowski L.
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Nutrition Education for

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

INTRODUCTION
Feeding practices and skills vary from infant to infant. However, some guidelines and recommendations have been established to facilitate this process and ensure that your infant will
receive the maximum benefits of good nutrition. Your pediatrician and registered dietitian (RD)
will answer questions about your infants nutrition and will help you establish feeding goals.
PURPOSE
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This diet is designed to provide adequate calories and nutrients to support healthy growth
and to prevent nutrition-related deficiencies during the first six months of life. From 6 to 12
months the diet is designed to increase food variety and provide about 35-50% of calories from
sources other than breast milk or iron-fortified commercial formula.
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NUTRIENTS MODIFIED
This diet does not involve nutrient modification. Rather, food varieties and textures advance based on development skills of the infant.
DIETARY GUIDELINES
In the first year, your baby will experience rapid growth and development. Adequate nutrition is needed to support healthy growth. This section will present information that will help you
provide adequate nutrition for your baby. These guidelines are intended for full-term, healthy babies. Although adequate feeding practices have been identified you must remember that your
baby is very unique. His/her growth, development, and needs may differ from those of other babies.
1. The American Academy of Pediatrics recommends infants receive human milk exclusively for
the first 6 months of life. Thereafter, breastfeeding should be continued, with the addition of
solid foods, at least through the infants first year. Human milk provides nutritional, immunological and psychosocial benefits to your baby. If you want to know more about breastfeeding, read the lactation section of this manual, Why should I nurse my baby? and other questions mothers ask about breastfeeding, by Pamela K. Wiggins, IBCLC, or ask your registered
For a referral to a nutrition professional in your area, visit: www.eatright.org
E1.8

reading materials about breastfeeding.
Benefits of Breastfeeding
Provides your baby with the nutrients needed for optimal growth
Provides immunological protection, especially in the first weeks of life when babys immune
system is immature and more susceptible
Decreases incidence of respiratory and gastrointestinal infections
Makes you feel closer to your baby
Provides health benefits for mothers that breastfeed
2. If you cannot or do not want to breastfeed, the acceptable alternative is iron-fortified
commercial formula. Iron-fortified commercial formula is nutritionally similar (not equal) to
breast milk and has been shown to prevent iron-deficiency anemia.
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3. For the first four months of life, your infants diet should be only breast milk and/or iron-fortified
commercial formula.
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4. When bottle feeding, hold the baby in a semi-upright position. Do not prop the bottle and do not
feed him/her when they are lying down because this increases the risk of choking. In addition,
the formula can flow into the middle ear increasing the chance of ear infection. Enjoy holding
your baby close to you.
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5. Breastfeed or bottle feed on demand; do not put your infant on a rigid feeding schedule.
6. Healthy infants may spit up a small amount of formula at each feeding. This does not affect
growth. Make sure the baby is not drinking too much at a time, that the nipple hole is not too
big, that the baby is not sucking air and that the feeding time is not too noisy. If the baby is
bringing up large amounts of formula, if he seems sick or is not growing well, contact your
pediatrician.
7. Start feeding iron-fortified baby cereal at approximately 4-6 months of age. Start with rice
cereal because it is less allergenic. Mix 1-2 tablespoons of dry cereal with breast milk or ironfortified commercial formula and thin the consistency to desired texture. Feed with an infant
spoon. Do not try to feed cereal from the infants bottle. This can result in overfeeding and
excessive weight gain. Introduce other single-grain fortified infant cereals to add variety.
Introduce only one new food at a time for 3-4 days before trying another. Look for signs of
allergies or intolerance, such as diarrhea or rash.
8. Vegetables and fruits can be introduced at 6 months of age. Begin with small amounts of plain,
strained vegetables or fruits, adding one new food item at a time. Gradually increase the
texture to mashed. When preparing strained vegetables at home, use fresh, high-quality
vegetables rather than canned vegetables that may be high in salt. Do not add salt, butter or
E1.9

margarine, sugar or honey.
9. When your baby is comfortable with strained foods (the age depends on babys individual
development), try simple mashed or well-cooked, soft table foods. Yogurt, mashed potatoes,
plain vegetables, grits or oatmeal can be used. Foods should be as simple as possible, with no
added sugar, salt, butter, margarine or honey.
10. In the beginning, your baby may refuse new flavors and textures. Try another food and
reintroduce the refused food later.
11. As your baby gets closer to one year of age, there is a need to provide iron-rich foods to replace
breast milk or iron-fortified formula. Start feeding meats at around 9-10 months of age. Use
strained meats first and gradually increase texture. Use lean cuts of well-cooked and finely
chopped meat.
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12. Foods that may cause allergies (eggs, shellfish, citrus fruits and chocolate) should not be fed
until close to or after 1 year of age.
13. Do not give infants raisins, nuts, peanut butter, hot dogs, grapes, popcorn, or whole kernel
corn because they may cause choking.
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FORMULA PREPARATION:
Aseptic Method:
Wash bottles, nipples, and caps in hot soapy water. Rinse well.
Place bottles, nipples, and caps and any other utensil to be used in a large pan. Add
approximately 5 inches of water and boil for 5-10 minutes. Remove from the pan and place on
clean cloth or paper towel.
Boil the water to be used for mixing the formula for 2 minutes. Cool.
Mix formula with the boiled and cooled water following the instructions on the label of the can.
Add 1 ounce of water to 1 ounce concentrated liquid formula. Add 2 ounces of water to 1
scoop of powdered formula.
Fill bottles with prepared formula and store in refrigerator for up to 48 hours.
Terminal Method: The American Academy of Pediatrics recommends this method if you use well
water or nonchlorinated water.
Wash bottles, nipples, and caps in hot soapy water. Rinse well.
Mix formula with water following the instructions on the label of the can. Add 1 ounce of water
to 1 ounce concentrated liquid formula. Add 2 ounces of water to 1 scoop of powdered formula.
Prepare enough bottles for 24 hours.
E1.10

Put nipples in bottles, upside down, with disc seals covering the top. Screw top loosely.
Put bottles in a rack or on towel in a big pot. Add 2-3 inches water and cover. Boil for 25
minutes.
Let bottles cool and refrigerate for up to 48 hours.
FOOD SAFETY AND THE INFANT
Do not buy baby food in damaged packages.

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

Clear Liquid Diet

Written by: Nancy Correa-Matos, PhD, RD,
Assistant Professor, Department of Nutrition
& Dietetics, University of North Florida
LD/N, FADA, Chair, Department of Nutrition
& Dietetics, University of North Florida
PRACTITIONER POINTS
RATIONALE
popsicles, red gelatin and other red clear

liquids should not be included. Several
commercially available products can be
added to increase kilocalories, protein, and
other nutrients. Additional modifications
such as omission of gas-forming carbonated
beverages and fruit juices may be necessary
following gastrointestinal surgery for some
patients.
The Clear Liquid Diet offers the

simplest form of food with regard to
digestion and absorption.
USE
This diet is used prior to some
diagnostic tests, pre- and post-operatively,
and when other liquids and solid foods are
not tolerated. It may be indicated as a short
term diet during acute inflammatory
conditions of the gastrointestinal tract or in
the acute stages of illness. The Clear Liquid
Diet helps prevent dehydration and relieve
thirst.
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RELATED PHYSIOLOGY
This diet provides fluids which do not

stimulate digestive processes. Clear liquids
are provided which leave no residue.
NUTRIENTS MODIFIED
The Clear Liquid Diet provides foods

that are liquid at room temperature. These
foods contain electrolytes and small
amounts of calories, mainly in the form of
carbohydrates. Milk and juices with pulp
must be avoided. Addition of strained fruit
juices such as grape, apple and cranberry
add to the nutritive value of this diet. While
many diagnostic tests require the patient to
be NPO past midnight, occasionally a clear
liquid diet may be ordered on the morning of
a procedure such as an endoscopy. Because
the presence of red liquids in the gut or
colon can be mistaken for blood, red juices,
This diet is inadequate in all nutrients

and kilocalories specified by the 1989
Recommended Dietary Allowances and the
2001 Dietary Reference Intakes (DRIs) for
adult males and females. It is also
inadequate in fluid for most patients and
fluid and electrolytes may be replaced
intravenously until the diet is advanced. It
should be used only for brief periods of time,
generally no more than 3 days. Beyond 3
days, appropriate oral supplementation is
suggested to meet nutrient needs (1).
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Noncaloric (sugar-free) liquid diets are

not appropriate for individuals with diabetes.
Individuals on clear liquid diets should
receive approximately 130-200 grams of
carbohydrate throughout the day, divided in
equal amounts at meals and snack times
(2). Advancing from clear liquids to full
liquids to solid foods should be done as soon
as a patient can tolerate the progression (2).
Emerging research is focusing in the
use of low residue soft diets instead of clear
liquids as early as during the first PO day
following laparotomy (3), or even before a
colonoscopy
procedure (4). Until more
research is done, clear liquid diets are still in
use in the clinical setting.
Clear Liquid Diet

REFERENCES
1. Mahan, LK & S Escott-Stump. Krauses
Food, Nutrition and Diet Therapy, 12th
Edition Philadelphia, PA: W.B. Saunders
Co.; 2008.
2. American Diabetes Association, Bantle
JP, Wylie-Rosett J, Albright AL, Apovian
CM, Clark NG, Franz MJ, Hoogwerf BJ,
Lichtenstein AH, Mayer-Davis E,
Mooradian AD, Wheeler ML. Nutrition
recommendations and interventions for
diabetes: a position statement of the
American Diabetes Association. Diabetes
Care 2008 Jan;31 Suppl 1:S61-78.
3. Park DI, Park SH, Lee SK, Baek YH, Han
DS, Eun CS, Kim WH, Byeon JS, Yang
SK.Efficacy of prepackaged, low residual
test meals with 4L polyethylene glycol
versus a clear liquid diet with 4L
polyethylene glycol bowel preparation: a
randomized trial. J Gastroenterol
Hepatol. 2009 Jun; 24(6):988-91.
4. Toulson Davisson Correia MI, Costa
Fonseca P, Machado Cruz GA.
Perioperative nutritional management of
patients undergoing laparotomy. Nutr
Hosp. 2009 Jul-Aug;24(4):479-84.
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Weight Loss
(Spanish Version)
EDUCACIN NUTRICIONAL PARA LA REDUCCIN DE PESO EN ADULTOS
Escrito por: Donna DeCunzo-Taddeo, RD,LD, Especialista en mantenimiento de peso, Lighthouse
Point, FL
Revisado by: Mary C. Friesz, PhD, RD, CDE, LD/N
Versin en Espaol escrito por: Daniel Santibanez, MPH, LD/N, Universidad del Norte de la Florida,
Jacksonville, Florida
EDUCACIN NUTRICIONAL PARA LA REDUCCION DE PESO EN ADULTOS
Entender las porciones y el contenido de caloras en los grupos de alimentos son
habilidades importantes para la perdida y el mantenimiento del peso. Usted puede intercambiar
las comidas dentro de cada uno de los grupos de alimentos. Use la lista de sustitutos para una
mayor variedad en la seleccin de alimentos.
LISTA DE SUSTITUTOS
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Verduras contienen 25 caloras y 5 gramos de carbohidratos. Una porcin equivale a:
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1/2 taza
Verduras cocidos (zanahoria, brcol, calabacn, col, etctera)
1 taza
Verduras crudas lechuga
1/2 taza
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Jugo de verduras
Si tiene hambre, coma ms verduras frescas o al vapor
Leche Desnatada muy Baja en Grasa contiene 90 calaras por racin. Una racin equivale:
1 taza
Leche, desnatada o al 1%
3/4 taza
1 taza
Yogur, natural sin grasa bajo en grasa
Yogur con edulcorante artificial
Protenas muy magras tienen 35 caloras y 1 gramo de grasa por racin. Una racin equivale:
1 onza
Pechuga de pavo pollo sin piel
1 onza
Filete de pescado (platija, lenguado, abadejo, bacalao, etctera)
1 onza
Atn enlatado en agua
1 onza
Mariscos (almeja, langosta, camarones)
3/4 taza
Requesn, sin grasa bajo en grasa
2 cantidades
Claras de huevos
1/4 taza
Sustituto de huevo
1 onza
Queso sin grasa
1/2 taza
Frijoles cocidos: cuntalos como un almidn/pan y una protena magra

Asociacin Diettica de Florida
Pgina de Internet: www.eatrightflorida.org
Para referidos a la nutricionista en su rea, favor de visitar la pgina: www.eatright.org
2011 FDA. La reproduccin de este documento es permitido slo para propsitos educativos.
Este documento no sustituye la visita con su dietista para desarrollar un plan adaptado a su condicin.
Manual of Medical Nutrition Therapy 2011 Edition Spanish Version
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Weight Loss
(Spanish Version)
Frutas contienen 15 gramos de carbohidratos y 60 caloras. Una porcin equivale a:
1 pequeo
Manzana, bananos, naranja, nectarines
1 mediano
Melocotn fresca
Kiwi
1/2
Toronja
1/2
Mango
1 taza
Moras frescas (fresas, frambuesas o arndanos)
1 taza
Cubitos de meln frescos
1/8
Meln dulce
4 onzas
Jugo natural
4 cuchaditas
Jalea mermelada
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Protenas Magras tienen 55 caloras y 2-3 gramos de grasa por racin. Una racin equivale:
1 onza
1 onza
1 onza
1 onza
1 onza
1 onza
1 onza
1 onza
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Pollo parte oscura, sin piel
Pavo parte oscura, sin piel
Salmn, espada, arenque
Res magra (falda, asado a la Londinense, lomo, rosbif)*
Ternera, asada chuleta magra*

Cordero, asada chuleta magra*
Cerdo, lomo jamn fresco*
Queso bajos en grasa (3 gramos menos de grasa por onza)
1 onza
Embutidos bajos en grasa (con 3 gramos menos de grasa por onza)
1/4 taza
Requesn
2 mediano
Sardinas
* Limite a 1-2 veces por semana

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Weight Loss
(Spanish Version)
Protenas de Grasa Moderada contienen 75 caloras y 5 gramos de grasa por porcin. Una porcin
equivale a:
1 onza
Res (cualquier corte de primera calidad), cecina de vaca, res molida**
1 onza
Chuleta de cerdo
1 cantidad
Huevo entero (mediano) **
1 onza
Queso mozzarella
1/4 taza
Requesn
4 onzas
Tofu /Queso de soya (Note que esta es una seleccin saludable para
el corazn)
E
IV
** Seleccione estos alimentos menos frecuentemente
R
D
Almidones contienen 15 gramos de carbohidratos y 80 caloras por porcin. Una racin equivale a:
1 rebanada
Pan (blanco, integral de centeno, integral, centeno)
2 rebanadas
Pan de caloras reducida liviano
1/4 (1 onza)
1/2
1/2
T
S
E
Rosquillas (varias)
Tortita (Inglesa)
3/4 taza
1/3 taza
1/3 taza
1/3 taza
Panecillo
Cereal
Arroz, integral blanco, cocido
Cebada cuscus - cocido

Legumbres (frijoles secos, guisantes lentejas)- cocidos
1/2 taza
Pasta- cocida
1/2 taza
Trigo cocido
1/2 taza
Maz, batata guisante verde
3 onza
Papa batata horneada
3/4 onza
Pretzels
3 taza
Palomitas de maz, cocidos en aire caliente o en microonda (80% bajo

en caloras)

R1.4S

Weight Loss
(Spanish Version)
Grasas contienen 45 caloras y 5 gramos de grasa por porcin. Una porcin equivale a:
1 cucharadita
Aceite (vegetal, maz, canola, oliva, etctera)
1 cucharadita
Mantequilla
1 cucharadita
Margarina en barra
1 cucharadita
Mayonesa
1 cucharada
Mayonesa margarina baja en grasa
1 cucharada
Aderezo
1 cucharada
Queso crema
2 cucharadas
Queso crema baja en grasa
1/8
Aguacate
8 grande
Aceitunas negras
10 grandes
Aceitunas verdes rellenas
1 rebanada
Tocineta
T
S
E
R
D
E
IV
Referencia: Basado en la lista de sustitutos provisto por la Asociacin Diettica Americana

R1.5S

Weight Loss
(Spanish Version)
Consejos para Estar Ms Saludable!

Use
verduras y granos integrales como el foco principal de sus comidas.
Mantenga
meriendas saludables visibles y a la mano tales como frutas

frescas, verduras, cereales integrales, nueces sin sal, y yogur bajo en grasa;
Ser ms fcil consumirlos!
Aada
Use
nueces y frutas por encima de sus ensaladas, avena, cereal.
E
IV
fruta como postre; las frutas y el yogur hacen un postre magnifico!
Si
come almuerzo sobre la marcha, seleccione restaurantes con opciones

saludables y traiga sus propios acompaantes (frutas, verduras, cctel de
frutas secos).
Busque
T
S
E
R
D
en su mercado local comidas saludables fciles de preparar que

requieran poca ninguna preparacin.
La
mayoras de las tiendas de conveniencia y gasolineras venden frutas

frescas, leche baja de grasa, y yogur.
Seleccione
Cocine
aceites saludables tales como de oliva y vegetal.
al horno, en la estufa, a la parrilla en vez de frer; cocine verduras al

vapor para conservar los nutrientes.
LEA
LA ETIQUETA DE LOS ALIMENTOS y los ingredientes; limite las comidas

con grasas hidrogenadas y aceites parcialmente hidrogenados.
Aumente
el consumo de granos integrales; seleccione productos que incluyen

tienen los granos integrales enlistado como el primer ingrediente.
Controle
el tamao de las porciones. Use sus tazas de medir por varias

semanas hasta que puede fijar las cantidades por usted mismo.

R1.6S

Weight Loss
(Spanish Version)
En Vez de:
Sustituya por
1/2 taza aceite
1/2 taza pur de manzana sin edulcorante
1 taza crema de leche
1 taza leche evaporada sin grasa
1 taza manteca vegetal/manteca
3/4 taza aceite margarina para untar (tarrina)
1 huevo
1 clara de huevo + 2 cucharadita de aceite

vegetal sustituto de huevo
1 taza harina de todo uso
1/2 taza harina de todo uso y 1/2 taza harina

integral
Aceite para frer
Sal
T
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E
Queso americano procesado
R
D
E
IV
Vino, jerez, vinagre, caldo bajo en sodio, jugo de

tomate, jugo de lima/limn, leche sin grasa,
agua
Ajo, cebollas, hierbas, especias, lima, pimienta,
Mrs. Dash
Pruebe una variedad de quesos, algunos son
ms bajo en grasa: mozzarella hecho con leche
sin grasa; provolone; queso suizo; cheddar
marca Cabot bajo en grasa, queso soya (queso
vegetariano); controle sus porciones
Verduras y frijoles enlatadas
Busque en las etiquetas por la frase Sin Sal

Aadido o escurra ante de cocinar para
disminuir la cantidad de sodio. Recuerde que
las frescas y congeladas con las mejores!
Carne, Aves
Busque por los cortes lomo redondo para

seleccionar res cerdo; un corte redondo de res
tiene menos grasa de la carne oscura de pollo
Escrito por: Catherine Cashman, MSH, RD, LD/N, Universidad del Norte de la Florida 2004
R2.1S
Nutrition Education for Adult

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

CONSEJOS:
Tome 8 tazas de agua cada da (1 taza
= 8 oz.).
Evite comida tales como bizcochos,
pasteles, papitas fritas, y refrescos.
Consuma porciones pequeas.
Seleccione alimentos nutritivos tales
como granos integrales
Leche, Yogur, Queso
T
S
E
_____# de Porciones
Grupo de
Verduras
_____# de
Porciones
E
IV
Grasas, Aceites, Dulces

Queso
Crema, Mayonesa, Mantequilla,
Aderezo
1 taza de leche
desnatada de
1% grasa
1 taza de yogur
bajo de grasa
1 oz. queso bajo
en grasa
taza cocido crudo

1 taza hojas crudas
taza jugo
_____# de Porciones
R
D
2 a 3 oz. Al da
(1 oz = 1 oz.
carne magra, 1
huevo, 1 cda.
Mantequilla de
man
1/4 taza frijoles
cocidos)
Carne, Mantequilla de
man, Huevos, Frijoles
Secos
_____# de Porciones
1 taza fresca, enlatada en sirope liviana,

jugo
3/4 taza 100% jugo
Grupo de
Frutas
_____# de
Porciones
Pan, cereal, arroz, pasta, galletas, panqueques, molletes

1 rebanada de pan integral
1/2 taza de cereales integrales
1/3 taza de arroz integral
1/2 taza de pasta integral
4 galletas de granos integrales
_____# de Porciones
Escrito por: Heather Huffman, MS, RD, LD/N

R2.2S

Obesity
(Spanish Version)
LISTA DE COMPRAS SALUDABLE

Bebidas:
Frutas:
Te sin edulcorante
Consejo: Seleccione fresca.
Refresco de dieta
Si es enlatada, escoge fruta en
100% jugo de fruta
sirope liviana o en su propio jugo.
Pan integral
Manzanas
100% jugo de verdura
Tortillas integrales
Naranjas
Agua embotellada
Arroz integral
Bananos
Pasta integral
Melocotones
Otros Productos Enlatados/en
Fresas
Jarros:
Arndanos
Mantequilla de man baja
Peras
en grasa
Uvas
Salsa de tomate
Sanda
Frijoles
Cereal:
Meln
Pur de manzanas
Consejo: Seleccione cereales con
Pia
Atn en agua
>5g de fibra por racin
Toronja
Concentrado de tomate
Cereal integral
Pan/Granos:
Consejo: Seleccione productos
100% integrales
Avena
Trigo molido
T
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E
Productos Lcteos:
Consejo: Seleccione productos
bajos en grasa sin grasa.
Leche desnatada baja
en grasa
Yogur bajo en grasa
Queso bajo en grasa
Helado bajo en grasa
R
D
Verduras:
Consejo: Seleccione fresca. Si es
enlatado, escoge bajo en sodio y
enjuage antes de cocinar.
Judas verdes
Brcol
Espinaca
Tomates
Lechuga
Pepinos
Champin/zetas
Apio
Zanahoria
Col
Maz
Papas
Calabacn
Calabaza amarilla
Pimientos
Coliflor
E
IV
Condimentos:
Salsa de tomate
Mostaza
Salsa pico de gallo
Mayonesa sin grasa
Sirope liviano
Aderezo bajo en grasa
Carne:
Consejo: Seleccione trozos de
carnes magras.
Quite la grasa visible antes de
cocinar.
Pechuga de pollo
Pechuga de pavo
Pescado
Consejos de Compras:
Use una lista de compras le ayudar a planificar comidas saludables. Nunca vaya al mercado con hambre.
Trate de planear sus comidas dndole nfasis a las verduras, frutas, y granos integrales, en vez de carne.
Trate de llenar su carrito de compras con frutas y verduras frescas. PLANIFIQUE! Sepa lo que quiere
comprar antes de ir y compre solamente lo que esta en su lista de compras.
Escrito por: Dr. Susan Moyers
R2.3S

Obesity
(Spanish Version)
Seleccione comidas que son preparadas de esta manera:

Ahumado
a la Parrilla
Horneado
Asado
Hervido
R
D
E
IV
Incluye una ensalada pequea con aderezo bajo en grasa

para aumentar la ingestin de verduras.
T
S
E
Comparta su Comida!
Divida la comida en mitad. Mitad de las caloras. Mitad de la grasa.
Pregunte por una caja cuando pida su comida y guarde mitad de la comida para el prximo da.
PREGUNTA:
Pregntele al mesero como la comida va a ser preparada.
Pregunte por alternativas bajas en grasa sin grasa.
Pida que pongan los condimentos al lado del plato.
EVITE:
Comidas fritas.
Salsas de crema.
Los refrescos! (Son altos en azcar.)
Los postres altos en caloras.
Escrito por: Dra. Susan Moyers
R15.1S

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

INTRODUCCIN
E
IV
Durante todas las etapas de la vida, la salud dental/oral esta influenciada por el estado de salud
en general. Es importante promover la prctica saludable de la higiene oral desde la infancia y
durante toda la vida. Esto ayudara a prevenir las caries dentales y las enfermedades periodontales.
Usted debe establecer una rutina simple, efectiva y llevadera para promover la salud dental y oral.
PROPSITO
T
S
E
R
D
El propsito de la promocin de una buena salud dental es para mantener la salud y prevenir
caries dentales, enfermedades periodontales y dolores asociados a enfermedades orales. Ms
aun, la salud puede afectar y a la vez, ser afectada por enfermedades en las cuales la dieta y la
intervencin nutricional es importante, como lo son la diabetes y las enfermedades
cardiovasculares.
La gingivitis o inflamacin de las encas (gingiva), es la etapa primaria de la enfermedad de

las encas. La enfermedad periodontal es una infeccin bacteriana que destruye la enca y los
tejidos que rodean y que proveen soporte a los dientes, causando la perdida de los mismos, pero
existen cosas que tu puedes hacer como parte de tu rutina diaria que ayudan a promover la salud
dental, prevenir la gingivitis y la enfermedad periodontal.
Las enfermedades periodontales ocurren debido a:
Higiene oral diaria inadecuada
Falta de limpieza dental profesional
Dietas inadecuadas no-balanceadas
Dentaduras u otros equipos dentales que no se ajustan adecuadamente
Dientes rellenos rotos cados
Dientes apiados mal acomodados
Factores sistmicos (desbalances nutricionales, diabetes, SIDA y cncer)
Medicamentos, especialmente si causa resequedad en la boca
R15.2S

(Spanish Version)
Dental Health
Estas recomendaciones le ayudaran a tener una buena salud dental y oral
Considere
Pregntese
Por qu?
La cantidad y tipo de
carbohidratos
Tendr un contenido
alto de azcar,
especialmente de
azcar aadida?
Las azcares, especialmente la sacarosa (sucrosa),

otras azcares aadidas y otros carbohidratos
fermentables, pueden convertirse en cidos en la boca.
Este acido puede destruir el esmalte de los dientes y
causar caries dentales.
La combinacin de
los alimentos
Esta usted tomando

refrescos con su
comida o esta tomado
solo el refresco?
Cuando las azucares se consumen solas, se convierten

ms rpidamente en cidos. Muchos alimentos ofrecen
alguna proteccin reduciendo la produccin de cidos.
Mientras ms usted mastique los alimentos, ms saliva
va a producir, y esto ayuda a remover las comidas de
los dientes.
T
S
E
La frecuencia de las
comidas
R
D
E
IV
Esta usted comiendo

picando
frecuentemente
durante el da?
Mientras ms veces haya comida en la boca, ms

oportunidad existe para que se produzcan cidos.
Se adhiere se pega
la comida a los
dientes?
Mientras ms se adhiera se pegue la comida en los

dientes, mayor es la oportunidad para que se produzcan
cidos.
Tiempo en que la
comida esta en la
boca
Esta usted comiendo

rpidamente,
permite que la comida
este en su boca por
mucho tiempo?
Mientras ms tiempo este la comida en la boca, mayor

es el tiempo en que el acido esta expuesto a los
dientes.
Tipo de comidas
Es esta una comida

saludable o es un
alimento alto en
caloras vacas?
Los alimentos saludables como las frutas y las verduras,

contienen una combinacin de nutrientes tales como
vitaminas, fibra y agua, los cuales estimulan la
masticacin y la produccin de saliva y estos ayudan a
mantener las encas y los dientes saludables.
Adherencia y
consistencia

R15.3S

(Spanish Version)
Dental Health
GUAS ALIMENTARIAS
Existe evidencia que el consumo frecuente de azucares y otros carbohidratos fermentables
esta asociado con el desarrollo de caries dentales y enfermedades periodontales. Existen guas
generales para las personas de todas las edades y etapas de la vida, y tambin, para diferentes
enfermedades y condiciones de salud.
El consumir una dieta saludable, moderada en azucares simples, como lo recomiendan Las
Guas Dietarias para los Americanos, publicada por el Departamento de Agricultura de los Estados
Unidos y el Departamento de Salud y Servicios Humanos, ayuda a promover la salud total y adems
la salud dental y oral.
EMBARAZO
E
IV
Los cambios hormonales que ocurren en esta etapa, pueden aumentar los riesgos padecer de
caries dentales, gingivitis, o enfermedades periodontales.
R
D
Utilice una pasta de dientes suave que contenga fluoruro si usted padece de nauseas en la
maana
Utilice el hilo dental, cepille y enjuague su boca con agua para remover el exceso de
partculas en la boca al consumir meriendas frecuentes, para nauseas en las maanas
Enjuague su boca frecuentemente con agua si esta vomitando
Hgase una limpieza dental profesional durante el segundo trimestre
Mastique goma de mascar con xylitol
Evite exponerse a rayos X
T
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E
INFANCIA Y NIEZ
Esta es una etapa muy importante para establecer comportamientos saludables para el cuidado de
su salud dental y oral y que estos duren para toda la vida.
Lacte a su beb
Evite poner a dormir a su beb con la botella en la boca
Evite compartir utensilios de comer, vasos y chupetes
Evite las bebidas dulces y carbonatadas
Limpie los dientes del beb con una toalla limpia despus de tomar la leche
Limpie los dientes del beb con un cepillo de dientes especial una vez los dientes hayan
salido
Enjuague su boca despus de comer
R15.4S

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

Estimule las visitas regulares al profesional de la salud dental para limpiezas y revisiones
rutinarias
ADULTEZ
Esta etapa es muy importante para mantener la salud oral, para prevenir problemas dentales en
los aos futuros, y para mantener la salud de los dientes permanentes, ya que dientes
desgastados, rallados, con aberturas prtesis dentales poco ajustadas, pueden contribuir al
deterioro de la salud dental al mantener atrapados depsitos de comidas en los dientes.
Cepille sus dientes por lo menos dos veces al da por dos minutos en cada cepillado
Use el hilo dental diariamente
Use pasta de dientes con fluoruro y enjuagador bucal con agente antimicrobiales
Consuma una dieta balanceada y limite el numero de meriendas entre las comidas
R15.5S

(Spanish Version)
Dental Health
Seleccione meriendas nutritivas como las manzanas, zanahorias, quesos, nueces, yogur
sin azcar aadida.
Limite las comidas azucaradas como las sodas, caramelos y galletas
Cepille los dientes despus de la comidas, y si no se puede cepillar, entonces enjuague su
boca con agua
Visite a su dentista con regularidad para limpiezas profesionales y revisiones dentales
GUAS GENERALES SI USA DENTADURAS
Use limpiadores especiales para dentaduras diariamente

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

(Spanish Version)
Dental Health
http://www.aapd.org/foundation/education.asp
2. American Dental Association. Manage Your Oral Health.
http://www.ada.org/public/media/videos/minute/index.asp
3. American Dietetic Association. Oral Health and Nutrition
http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/advocacy_1743_ENU_HTML.htm
4. American Dietetic Association. The impact of fluoride on health
http://www.eatright.org/cps/de/xchg/ada/hs.xsl/home_3795_ENU_HTML.htm
T
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Index
S1.1
A
Activity factor, A1.9-A1.10, C1.3
Acute kidney failure, M2.1
ADHD, G6.1
Adolescent nutrition , E3.1
Adequacy in, E3.4
Athletes, E3.4
Dietary guidelines, E3.6
Eating disorders, E3.4
Food choices, E3.1
Obesity, E3.3, B3.1
Pregnancy, E3.3
Sample menu for, E3.10
Adult nutrition assessment, A1.1
Amputations, A1.6
Anemias, A1.12
Anthropometric data, A1.3
Activity Factor, A1.9, A1.10
Biochemical data, A1.11
BMI, A1.8, B2.3
Calorie needs, A1.9
Clinical evaluation, A1.2
Diet history and intake data, A1.1
Elbow breadth, A1,4
Energy needs, A1.8
Fluid requirements, A1.11
Frame size, A1.4
Height, A1.4
Hamwi formula, A1.5, A1.9
Harris-Benedict, A1.9
Hematological, A1.12
Injury factors, A1.9
Immunological, A1.17
Lab values, A1.11
Malnutrition, A1.17
Medical history, A1.11
Midarm muscle circumference, A1.7
Nitrogen balance, A1.10
Paraplegic, A1.6
Percent IBW, A1.6
Percent weight loss, A1.6
Protein needs, A1.10
Quadriplegic, A1.6
Skinfold thickness, A1.7
Weight, A1.4
Adult nutrition for weight loss, B2.1
Assessment, B2.2
BMI Tables, B2.3
T
S
E
Exchange lists, B2.12

Nutrition education materials, B2.12
Nutrition therapy, B2.5
Physical activity, B2.7
Step 1 diet, B2.6
Weight maintenance, B2.8
AIDS, N5.1
Alcohol and drug abuse, G3.1
Nutrition education materials, G3.4
Allergies to food, P1.1
Alternative medicine, C8.1
Clinical centers, C8.16
Commonly used herbs, C8.14
Commonly used supplements, C8.13
Commonly used therapies, C8.12
Definitions, C8.1
Dietary supplements, C8.2
Resources, C8.5
Supplement labels, C8.3
Alzheimers disease, D5.4, D9.2
Amino acids, C2.7
Amputees, ideal body weight, A1.5
Anemia, A1.12, D12.1
Anorexia nervosa, G1.1
Description of, G1.2
Diagnostic criteria, G1.2
Nutrition therapy for, G1.6, G1.9,
G1.12
Signs and symptoms, G1.5
Anthropometric measurements, A1.3
Asian diet pyramid, D1.5, D1.22
Athletic performance, C1.1
Autism, G7.1
R
D
E
IV
B
Bariatric surgery, C3.1
Anemia, C3.6
Nutrition education materials, C3.10
BEE (Basal Energy Expenditure), A1.9
B vitamins, D2.12
Behavior modification and weight, B2.7
Biliopancreatic diversion (BPD), C3.3
Biochemical assessment, A1.11
Bland Diet, K4.1
Nutrition education materials, K4.3
Blenderized liquid diets, see pureed diet
Blood pressure, see hypertension
Index
S1.2
Body fat, A1.7

Body mass index (BMI), A1.8, B2.3
Bread, low protein, L1.8
Breast feeding, D4.1
Advantages of, D4.6
Guidelines for, D4.3
Resources, D4.6
Bulimia nervosa, G1.1
Description of, G1.2
Nutrition therapy for, G1.6, G1.9, G1.12
Burns, adult, N1.1
Calorie requirements, N1.2
Curreri formula, N1.2
Ireton-Jones formula, N1.2
Parenteral nutrition, N1.3
Monitoring nutrition, N1.4
C
Caffeine, C13.1
T
S
E
Calcium, D11.4, B2.12

In chronic kidney disease stages 1-4,
M1.2
In chronic kidney disease stage 5, M2.5
In osteoporosis, D11.3
In vegetarian diet, C2.3
Calorimetry, A 4.1
Calories, A1.9
Burns, N1.2
Cancer, N2.2
COPD, N4.1
Elderly, D5.3
HIV/AIDS, N5.7
Lactation, D4.2
Pregnancy, D3.2
Weight loss, B2.5
Cancer, N2.1
Cachexia, N2.1
Calorie needs, N2.2
Chemotherapy, N2.3
Dietary guidelines, N2.8
Low bacteria diet, N2.5
Neutropenic diet, N2.3
Nutrition education materials, N2.8
Prevention, N2.2
Radiotherapy, N2.3
Resources, N2.15
Taste alterations, N2.9
Carbohydrates, J1.4
Celiac disease, P3.1
Children 1-10 years, E2.1
Dental health, E2.2
Feeding skill development, E2.1
Food choices, E2.8
Nutrition education materials, E2.4
Childrens weight control, B3.1
Adequacy, B3.2
BMI Tables, B3.4
Educations materials, B3.6
Guidelines for meal planning, B3.6
Recommended weight goals, B3.2
Chemical dependency treatment, G3.1
Vitamin-mineral deficiencies associated
with substance abuse, G3.2
Cholesterol, H1.3
Congestive heart failure, H2.1
Nutrient drug considerations, H2.2
Coronary heart disease and hyperlipidemia,
H1.1
ATP III lipid classifications, H1.2
CHD risk factors, H1.1
Therapeutic Lifestyle Changes (TLC diet)
H1.3
Nutrition education materials, H1.8
Chronic obstructive pulmonary disease, N4.1
Chronic peptic ulcer disease diet, K4.1
Chronic kidney disease stage 5, M2.1
Body weight calculations, M2.10
Diabetic modifications, M2.6
Enteral supplements, M2.15
Hemodialysis, M2.1
Hyperlipidemia management, M2.6
Intradialytic parenteral nutrition (IDPN),
M2.2
Meal planning, M2.25
Modification in, M2.25
National Renal Diet food choices,
M2.12
Nutrient needs calculations, M2.10
Nutrition recommendations, M2.3
Nutrition supplements, M2.15-2.16
Peritoneal dialysis, M2.2
Resources, M2.18
Standard body weights, M2.11
R
D
E
IV
Index
S1.3
Chronic kidney disease stages 1-4, M1.1

Daily nutrient and fluid
recommendations, M1.3
Dietary guidelines, M1.6
Food lists for, M1.7
Meal patterns, M1.7
Modifications in, M1.6
Nutrient recommendations, M1.1
Purpose of, M1.1
Sample menu for, M1.9, M1.10
Stages of chronic kidney disease, M1.1
Chronic kidney failure, see chronic kidney
disease stage 5
Cirrhosis, L3.1, L1.1
Nutrition therapy, L1.4
Clear liquid diet, F1.1
Recommended foods in, F1.2
Sample menu for, F1.2
Complementary and alternative medicine,
C8.1
Clinical centers, C8.16
Commonly used herbs, C8.14
Commonly used supplements, C8.13
Commonly used therapies, C8.12
Definitions, C8.1
Dietary supplements, C8.2
Resources, C8.5
Supplement labels, C8.3
Complementary proteins, C2.7
Congestive heart failure, H2.1
Drug / nutrient considerations, H2.2
Nutrients modified, H2.1
Use of, E1.1
Continuous administration of tube feedings,
O1.2
Creatinine height index, A1.16
Crohns disease, pediatrics, E9.1
Crohns disease, adults, K3.1
Cultural Diversity, A3.1
Curreri formula, N1.2
Cystic fibrosis, E8.1
Life cycle, E8.3
Nutritional assessment and monitoring,
E8.2
Nutrition education materials, E8. 7
Sample menu, E8.8
Special circumstances, E8.4
T
S
E
D
Danish dessert, recipe for, L1.7
DASH diet, I1.5, I2.1
Nutrition education materials, I2.3
Decubitus Ulcers, D9.10, D13.1
Dental health, C10.1
Depression, G5.1
Diarrhea in children, E4.1
Commonly used rehydration solutions,
E4.3
Oral rehydration solutions, E4.1
Diabetes mellitus, J1.1
Alternate sweeteners, J1.4, J2.3
Amputations, J6.1
Carbohydrate counting, J1.7
Children and adolescents, J1.8
Classification, J1.5
Diagnostic criteria, J1.6
Definition and description, J1.2
Enteral nutrition, J1.10
Exchange lists, B2.12, J1.22
Exercise and stress, J1.8
Gastropathy, J1.9
Gastroparesis, J1.9
Goals of MNT, J1.1
Insulins and actions, J1.15
Meal planning, J1.17, J1.22
Oral hypoglycemic agents, J1.12
Prediabetes, J1.7
Nutrition education materials, J1.20
Nutrition intervention, J1.7
Sick days, J1.31, J2.3
Snack bars, J1.21
Diabetes self-management, J2.1
Alcohol management, J2.3
Alternate sweeteners, J1.4, J2.3
Exercise, J2.3
Hypoglycemia, J2.4
Meal planning, J2.4
Sick days, J1.31, J2.3
Dietary fiber, K2.1
Dietary, recommended allowances (RDA),
C7.1
Dietary Reference Intakes (DRI), C7.1
Diverse populations, A3.1
Diverticulitis, K3.1
Dopamine and tyramine restricted diet, P8.1
R
D
E
IV
Index
S1.4
Drugs
Over-the-counter, sodium content, H3.1
Dumping syndrome, K5.1
Dysphagia diet, F6.1
Dysphagia Outcome and Severity Scale,
F6.1
Liquids, F6.14
National Dysphagia Diet, F6.1
Nutrition education materials, F6.11
Recommended foods, F6.13
E
Eating disorders, G1.1
Approaches to health enhancement,
G1.13
Food guide, G1.19
Exercise, G1.7
Nutrition assessment, G1.9
Nutrition education materials, G
Nutrition therapy, G1.6, G1.9
Pharmacotherapy, G1.8
Special considerations, G1.14
Treatment overview, G1.6
Eating disorders not otherwise specified
(EDNOS), G1.3
Education and counseling, A2.1
Behavioral theories, A2.3
Learning objectives, A2.12
Egg free diet, P2.1
Elimination diet, P1.2
End stage renal failure, see Chronic Kidney
Disease stage 5
Enteral nutrition support, O1.1
Access, O1.1
Contraindications, O1.1
Formula selection, O1.1
Gastrointestinal complications, O1.4
Indications, O1.1
Mechanical complications, O1.4
Metabolic complications, O1.5
Monitoring guidelines, O1.2
Route of administration, O1.2
Esophageal reflux diet, K1.1
Esophagitis, K1.1
T
S
E
Ethnic food guides, D1.4, D1.21-1.24

Exogenous hypoglycemia, J4.1
F
Fasting hypoglycemia, J4.1
Fat restricted diet, L2.1
Fat soluble vitamins, D2.12
Fever factor, A1.9
Fiber, high, K2.1
Fiber content, H1.10, K2.3
Fitness, C1.1
Fluid replacement drinks, C1.4
Food allergies, P1.1
Classification system, P1.1
Diagnosis, P1.2
Elimination diet, P1.2
Immune reactions, P1.1
Food guide pyramids, D1.14-1.24
Food labeling, C6.1
Folate, folic acid and folacin, C11.1
Frame size, formula for determining, A1.4
Full liquid diet, F2.1
Sample menu, F2.4
Functional foods, C9.1
R
D
E
IV
G
Galactosemia, E13.1
Gall bladder disease, L2.1
Gastric bypass, see Bariatric surgery
Anemia, C3.6
Vertical banded gastroplasty, C3.2
Gastroparesis, J1.9
Geriatric nutrition, D5.1
Fluid requirements, D5.4
Malnutrition and weight loss, D5.4
Nutrient requirements, D5.3
Pressure sore development, D5.5
Side effects of medication, D5.2
Swallowing problems, D5.3
Index
S1.5
GERD, K1.1
Gestational diabetes, J5.1
Insulin requirements, J5.2
GI Disorders, Section K
Bland diet, K4.1
GERD, K1.1
High Fiber, K2.1
Low residue diet, K3.1
Post-gastrectomy, K5.1
Glucose self-monitoring, J2.2
Chart for self-monitoring, J1.28
Glucose tolerance test, Q1.1
Gluten Gliaden free diet, P3.1
Nutrition education materials, P3.3
Growth charts infants and children, E16.1
H
Hamwi formula, A1.5, A1.9
Harris-Benedict formula, A1.9
Headaches, G4.1
Health at every size, B5.1
Heart transplant, H4.1
Helicobacter pylori infection, K4.1
Hemigastrectomy, K5.1
Hemodialysis, M2.1
Hepatitis, L3.1, L1.1
Hepatic encephalopathy, L1.1
Hiatal hernia, K1.1
High biologic value protein, M1.1
High calorie high protein diet, D10.1
HIV / AIDS, N5.1
Classification system, N5.2
Drug / nutrient interaction, N5.5
Enteral / parenteral nutrition, N5.7
Medications, N5.3
Nutrient goals, N5.7
Unproven therapies, N5.7
Hyperlipidemias, H1.1
Hypertension, I1.1
Classification of blood pressure, I1.2
Nutrition therapy, I1.2
DASH diet, I1.5
T
S
E
Hypoglycemia, functional reactive, J4.1

Hypoglycemia secondary to diabetes, J3.1
Treatment, J3.5
I
Inborn errors of metabolism, E12.1-E14.1
Galactosemia, E13.1
Maple syrup urine disease, E14.1
Phenylketonuria, E12.1
Infant nutrition (0-12 months), E1.1
Infant development and feeding skills,
E1.5
Infant expected weight gain, E1.1
Infant food safety, E1.10
Infant formula preparation, E1.9
Infant nutrition, E1.1
Infant nutrition education materials,
E1.7
Inflammatory bowel disease, adult,K3.1, P3.1
Inflammatory bowel disease, pediatric/
adolescent, E9.1
Ulcerative colitis, E9.1
Crohns disease, E9.1
Nutrients of concerns, E9.2
Nutrition support, E9.3
Nutrition education materials, E9. 5
Injury factor, A1.9
Insulin, J1.15
Iron in health promotion and disease
prevention, C12.1
R
D
E
IV
J
Jejunostomy tube, E6.3, O1.1
K
Ketogenic diet, E15.1
Treatment centers in Florida, E15.2
Kwashiorkor, A1.17
Index
S1.6
Label at a glance, C6.8

Laboratory values, A1.11
Lactation, D4.1
Recommended nutrient intakes, D4.2
Nutrition education materials, D4.3
Lactose restricted diet, P4.1
Laproscopic adjustable gastric band, C3.2
Latex sensitivity / allergy, P9.1
Liberal geriatric diet, D.6.1
Nutrition interventions, D6.2
Liver disorders, L1.1 L4.1
Cirrhosis, L4.1
Hepatitis, L3.1
Long term care nutrition, D9.1
Decubitus ulcer stages and nutrition
needs, D9.10
Low bacteria diet, NG.5
Low density lipoproteins (LDL), H1.1
Low residue diet, K3.1
T
S
E
Maple syrup urine disease, E14.1

Malabsorption syndromes, L2.1
Marasmus, A1.17
MCT oil, L2.1
Mechanical soft diet, F4.1
Sample menu, F4.4
Medical foods (PKU), E12. 4
Mediterranean Diet, D1.4, D1.21
Metabolic syndrome, C4.1
Diagnostic criteria, C4.2
Mifflin-St Jeor, A5.1
Milk-free diet, P5.1
Minerals, D2.12, C7.1
Monoamine oxidase inhibitors (MAOI) drugs,
diet for, P8.1
National Cholesterol Education Program

Guidelines, H1.1
Neurological and mental disorders, G3.1
Neutropenic diet, G2.5
Nitrogen balance studies, A1.15
No added salt diet, D8.1
No Concentrated sweets diet, D7.1
Nutrition assessment, A1.1
Nutrition care process, A5.1
Nutrition guidelines and recommended food
patterns, D1.1
Dietary Guidelines for Americans, D1.5
Food guides, D1.1
Food guide pyramid, D1.2, D1.14
Food guide pyramids, D1.14-1.24
Resources for education and
counseling, D1.10
R
D
O
E
IV
Obesity Treatment in Adults, B1.1

Nutrition assessment, B1.5
Pharmacotherapy, B1.6
Physical activity, B1.13
Maintenance, B1.14
Patient education materials, B1.22
Obesity in Children, B3.1
Omega-3 fatty acids, C2.4, H1.4
Online nutrition resources, C5.1
Oral hydration solutions, E4.3
Oral hydration therapy, E4.1
Organ transplant, N3.1
Osteoporosis, D11.1
Calcium content of common foods,
D11.4
Classification, D11.1
Prevention, D11.2
Treatment, D11.5
Index
S1.7
Pancreatic enzyme replacement therapy,

E8.3
Pancreatitis, N3.2, L2.1
Paraplegic assessment, A1.6
Parenteral nutrition support, O2.1
Access, O2.1
Amino acid solutions, O2.2
Contraindications, O2.1
Complications, O2.6, O2.8
Electrolyte requirements, O2.4
Indications, O2.1
Macronutrients, O2.1
Micronutrients, O2.5
Mineral requirements, O2.3
Monitoring guidelines, O2.5
Transitioning, O2.7
Vitamin requirements, O2.3
Writing solution orders, O2.9
Parkinsons disease, D10.1
Pediatric enteral nutrition, E6.1
Complications, E6.4
Initiation of feeding, E6.1
Routes of intubation, E6.2
Special concerns, E6.5
Tolerance, E6.3
Pediatric HIV / AIDS, E11.1
Classification, E11.2
Clinical manifestations, E11.3
Definition of, E11.2
Infection-immunity-nutrition-interaction,
E11.3
Nutrition assessment, E11.4
Nutrition management, E11.5
Transmission, E11.1
Pediatric insulin-dependent diabetes mellitus
(IDDM), E10.1
Hypoglycemia, E10. 2
Meal planning guidelines, E10.2
Pediatric nutrition, See E1.1E15.1
Pediatric parenteral nutrition, E7.1
Access routes, E7. 2
Complications and monitoring, E7.7
Initiation, E7.1
Nutrient recommendations, E7.3
Peptic ulcer disease, K4.1
Peritoneal dialysis, M2.2
Pharmacological ergogenic aids, C1.6
Phenylketonuria, E12.1
T
S
E
Medical foods, E12.4

Recommended daily intakes, E12.4
Sample menu, E12.8
Physical Activity, Adults, B1.13, B2.7
Physical Activity Children, B4.1
Physical activity pyramid for children, B4.3
Physical fitness and athletic performance,
C1.1
Fluid requirements, C1.4
Glycogen loading, C1.5
Nutrient needs, C1.3
Ergogenic aids, C1.6
Plant stanols and sterols, H1.5
Post-gastrectomy diet, K5.1
Pregnancy, D3.1
Preconception nutrients, D3.2
Prenatal nutrients, D3.4
Required nutrients, D3.2
Weight status, D3.3
Pressure sore development, D9.10, D13.1
Preterm and low birth weight infants, E5.1
Commercial formulas, E5.5
Discharge summaries, E5.9
Human milk fortifiers, E5.6
Nutrient needs, E5.1
Nutrition support, E5.5
Poor growth, E5.9
Specialized formulasE5.7
Pro Mod, M2.16
Propofol, O2.2
Protein/calorie malnutrition, A1.17
Protein content of food groups, M2.12, B2.12
Protein restricted diet, L1.1
Protein controlled dietary supplement
suppliers, L1.3
Protein controlled meal pattern, L1.9
Pureed diet, F3.1
Sample menu, F3.6
Purine controlled diet, P7.1
Pyloroplasty, K5.1
R
D
E
IV
Q
Quadriplegic assessment, A1.6
Index
S1.8
Reactive hypoglycemia, J4.1

Recipes
Danish dessert, L1.8
High carbohydrate beverage, L1.8
Low protein bread, L1.8
Recommended dietary allowances, C7.1
Roux-N-Y, C3.4
S
Saturated fats, H1.3
Semi-thick liquids, F6.14
Serving sizes, D1.9
Short bowel syndrome, K6.1
Sodium controlled diet, H3.1
3000-4000 mg Sodium diet, H3.6
Label terms, H3.2
Sodium free seasonings, H3.5
Sources of sodium, H3.2
Soft diet, F5.1
Sample menu, F5.6
Spanish nutrition education materials, R1.1R15.1
Standard body weight, M2.11
Step 1 diet, B2.6
Substance abuse nutrition, G3.1
Nutrition education materials, G3.4
Sweeteners, J1.4, J2.3
T
S
E
Test diets, Q1.1-Q4.1

Glucose tolerance, Q1.1
100 gram fecal fat, Q3.1
Serotonin (5-HIAA) , Q4.1
VMA, Q2.1
Textural changes, F1.1-F6.1
Thick liquids, F6.14
Thin liquids, F6.14
Total gastrectomy, K5.1
Trans fatty acids, C6.2, H1.3
Tyramine and dopamine restricted diet, P8.1
Ulcerative colitis, K3.1

Pediatric ulcerative colitis, E9.1
Usual body weight, A1.6
V
Vagotomy, K5.1
Vanillylmandelic acid (VMA) test diet, Q2.1
Vegetarian diet, C2.1
Classification, C2.2
Complementary proteins, C2.7
Daily food guide, C2.7, D1.19, D1.20
Key nutrients, C2.3
Recommended patterns for vegan,
C2.11
Infants/children, C2.1
Very low calorie diets, B2.5
Vitamins, D2.12
Fat soluble. D2.12
Water soluble, D2.12
R
D
W
E
IV
Weight control diet, B2.6

Weight loss, adult, B2.1
Assessment, B2.2
BMI Tables, B2.3
Nutrition therapy, B2.5
Step 1 diet, B2.6
Weight maintenance, B2.8
Wellness, D2.1
Health continuum, D2.2
Wellness contract, D2.10
Wheat, egg and milk allergy diet, P6.1
Wheat flour equivalents, P6.3
Whipples procedure, K5.1
Wound Healing, D13.1
Z
Zinc, D2.12, D9.10

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Florida Dietetic Association

Manual of Medical Nutrition Therapy 2011 Edition

To be effective, medical nutrition therapy must be individualized for each person.

Manual of Medical Nutrition Therapy 2011 Edition

Special thanks to the Florida Dietetic Association members who served

Christine Stapell MS, RD, LD/N,

Authors and Reviewers

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy Authors

Susan Moyers, PhD, MPH, LD/N

Manual of Medical Nutrition Therapy 2011 Edition

Manual of Medical Nutrition Therapy Reviewers

Manual of Medical Nutrition Therapy 2011 Edition

Nutrition Education and Counseling

Nutrition for Culturally Diverse Populations

Calorimetry Equations Current Recommendations

Nutrition Care Process

B. Medical Nutrition Therapy for Overweight and Obesity

Adult Nutrition for Weight Loss

Childhood Obesity Prevention

Treating the Overweight Child

C. Medical Nutrition Therapy for Contemporary Nutrition Issues

Nutrition Resources Online

Dietary Reference Intake (DRI)

Complementary and Alternative Medicine

Nutritional Care for Dental Health

Up to Date: Folate, Food Folate, Folic Acid and Folacin

Up to Date: Iron in Health Promotion and Disease Prevention

Up to Date: Caffeine and Health

D. Life Cycle Medical Nutrition Therapy

Nutrition and Wellness: Balance of Body, Mind & Spirit

Manual of Medical Nutrition Therapy 2011 Edition

Liberal Geriatric Diet

No Concentrated Sweets Diet

No Added Salt Diet

Long Term Care Nutrition

Nutrition Education for High Calorie/High Protein Diet

Nutrition for Osteoporosis

Nutrition for Anemia

Nutrition for Wound Healing

E. Pediatric Medical Nutrition Therapy

Pediatric Enteral Nutrition Support

Pediatric Parenteral Nutrition Support

Pediatric/Adolescent Inflammatory Bowel Disease Nutrition

Pediatric Insulin Dependant Diabetes Mellitus Nutrition

Pediatric HIV/AIDS Nutrition

Inborn Errors of Metabolism- Phenylketonuria

Inborn Errors of Metabolism- Galactosemia

Inborn Errors of Metabolism- Maple Syrup Urine Disease

Growth Charts for Children

F. Medical Nutrition Therapy for Textural Changes

Full Liquid Diet

Mechanical Soft Diet

Nutrition for Substance Abuse Treatment

Nutrition for Neurological and Mental Disorders

Primary Headaches (Migraine, Tension-Type, and Cluster Headaches)

Nutrition for Depression

Nutrition for AD/HD

Nutrition for Autism

H. Medical Nutrition Therapy for Cardiovascular Disease

Sodium Controlled Diets

Nutrition for Hypertension