The Dental Hygienist’s Guide to Nutritional Care
5TH EDITION
Cynthia A. Stegeman, RDH, EdD, RDN, LD, CDE Ohio Delegate to the Academy of Nutrition and Dietetics National Board Dental Hygiene Examination Test Construction Committee Commission on Dental Competency Assessments Consultant Professor and Chairperson, Dental Hygiene Program University of Cincinnati, Blue Ash Cincinnati, Ohio
Judi Ratliff Davis, MS, RDN Former Quality Assurance Nutrition Consultant Women, Infants and Children (WIC) Program Texas Department of State Health Services Austin, Texas
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Table of Contents
Cover image
Title Page
Reference Tables
Copyright
Dedication
Preface
New to This Edition
Organization
About Evolve
Note From the Authors
Acknowledgments
About the Authors Part I Orientation to Basic Nutrition
1 Overview of Healthy Eating Habits
Basic Nutrition
Physiologic Functions of Nutrients
Basic Concepts of Nutrition
Government Nutrition Concerns
5
Nutrient Recommendations: Dietary Reference Intakes
Food Guidance System for Americans
Support Healthy Eating Patterns for All
MyPlate System
Other Food Guides
Nutrition Labeling
Student Readiness
References
2 Concepts in Biochemistry
What is Biochemistry?
Fundamentals of Biochemistry
Principle Biomolecules in Nutrition
Summary of Metabolism
Student Readiness
References
3 The Alimentary Canal
Physiology of the Gastrointestinal Tract
Oral Cavity
Esophagus
Gastric Digestion
Small Intestine
Large Intestine
Student Readiness
References
4 Carbohydrate
6
Classification
Physiologic Roles
Requirements
Sources
Hyperstates and Hypostates
Nonnutritive Sweeteners/Sugar Substitutes
Student Readiness
References
5 Protein
Amino Acids
Classification
Physiologic Roles
Requirements
Sources
Underconsumption and Health-Related Problems
Overconsumption and Health-Related Problems
Student Readiness
References
6 Lipids
Classification
Chemical Structure
Characteristics of Fatty Acids
Compound Lipids
Cholesterol
Physiologic Roles
7
Dietary Fats and Dental Health
Dietary Requirements
Sources
Overconsumption and Health-Related Problems
Underconsumption and Health-Related Problems
Fat Replacers
Student Readiness
References
7 Use of the Energy Nutrients
Metabolism
Role of the Liver
Role of the Kidneys
Carbohydrate Metabolism
Protein Metabolism
Lipid Metabolism
Alcohol Metabolism
Metabolic Interrelationships
Metabolic Energy
Basal Metabolic Rate
Total Energy Requirements
Energy Balance
Inadequate Energy Intake
Student Readiness
References
8 Vitamins Required for Calcified Structures
8
Overview of Vitamins
Vitamin A (Retinol, Carotene)
Vitamin D (Calciferol)
Vitamin E (Tocopherol)
Vitamin K (Quinone)
Vitamin C (Ascorbic Acid)
Student Readiness
References
9 Minerals Essential for Calcified Structures
Bone Mineralization and Growth
Formation of Teeth
Introduction to Minerals
Calcium
Phosphorus
Magnesium
Fluoride
Student Readiness
References
10 Nutrients Present in Calcified Structures
Copper
Selenium
Chromium
Manganese
Molybdenum
Ultratrace Elements
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Student Readiness
References
11 Vitamins Required for Oral Soft Tissues and Salivary Glands
Physiology of Soft Tissues
Thiamin (Vitamin B1)
Riboflavin (Vitamin B2)
Niacin (Vitamin B3)
Pantothenic Acid (Vitamin B5)
Vitamin B6 (Pyridoxine)
Folate/Folic Acid (Vitamin B9)
Vitamin B12 (Cobalamin)
Biotin (Vitamin B7)
Other Vitamins
Student Readiness
References
12 Fluids and Minerals Required for Oral Soft Tissues and Salivary Glands
Fluids
References
Electrolytes
Sodium
Chloride
Potassium
Iron
Zinc
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Iodine
Student Readiness
References
Part II Application of Nutrition Principles
13 Nutritional Requirements Affecting Oral Health in Women
Healthy Pregnancy
Lactation
Oral Contraceptive Agents
Menopause
Student Readiness
References
14 Nutritional Requirements During Growth and Development and Eating Habits Affecting Oral Health
Infants
Children Older Than 2 Years of Age: Dietary Guidelines 2015–2020 and Healthy People 2020
Utilizing the ChooseMyPlate Website
Toddler and Preschool Children
Attention-Deficit/Hyperactivity Disorder
Children With Special Needs
School-Age Children (7–12 Years Old)
Adolescents
Student Readiness
References
15 Nutritional Requirements for Older Adults and Eating Habits Affecting Oral Health
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General Health Status
Physiologic Factors Influencing Nutritional Needs and Status
Socioeconomic and Psychological Factors
Nutrient Requirements
Eating Patterns
Dietary Guidelines and MyPlate for Older Adults
Student Readiness
References
16 Food Factors Affecting Health
Health Care Disparities
Food Patterns
Working With Patients With Different Food Patterns
Food Budgets
Maintaining Optimal Nutrition During Food Preparation
Food Fads and Misinformation
Referrals for Nutritional Resources
Role of Dental Hygienists
Student Readiness
References
17 Effects of Systemic Disease on Nutritional Status and Oral Health
Effects of Chronic Disease on Intake
Anemias
Other Hematologic Disorders
Gastrointestinal Problems
Cardiovascular Conditions
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Skeletal System
Metabolic Problems
Neuromuscular Problems
Neoplasia
Acquired Immunodeficiency Syndrome (AIDS)
Mental Health Problems
Student Readiness
References
Part III Nutritional Aspects of Oral Health
18 Nutritional Aspects of Dental Caries
Major Factors in the Dental Caries Process
Other Factors Influencing Cariogenicity
Dental Hygiene Care Plan
Student Readiness
References
19 Nutritional Aspects of Gingivitis and Periodontal Disease
Physical Effects of Food on Periodontal Health
Nutritional Considerations for Periodontal Patients
Gingivitis
Chronic Periodontitis
Necrotizing Periodontal Diseases
Student Readiness
References
20 Nutritional Aspects of Alterations in the Oral Cavity
13
Orthodontics
Xerostomia
Root Caries and Dentin Hypersensitivity
Dentition Status
Oral and Maxillofacial Surgery
Loss of Alveolar Bone
Glossitis
Temporomandibular Disorder
Student Readiness
References
21 Nutritional Assessment and Education for Dental Patients
Evaluation of the Patient
Assessment of Nutritional Status
Identification of Nutritional Status
Formation of Nutrition Treatment Plan
Facilitative Communication Skills
Student Readiness
References
Glossary
Answers to Nutritional Quotient Questions
Index
IBC
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Reference Tables
Criteria and Dietary Reference Intake Values: For Energy by Active Individuals by Life Stage Groupa
Life Stage Group
Criterion ACTIVE PAL EERb (kcal/d) Male Female
0 through 6 mo
Energy expenditure plus energy deposition 570 520 (3 mo)
7 through 12 mo
Energy expenditure plus energy deposition 743 676 (9 mo)
1 through 2 y
Energy expenditure plus energy deposition 1,046 992 (24 mo)
3 through 8 y
Energy expenditure plus energy deposition 1,742 1,642 (6 y)
9 through 13 y
Energy expenditure plus energy deposition 2,279 2,071 (11 y)
14 through 18 y
Energy expenditure plus energy deposition 3,152 2,368 (16 y)
>18 y Energy expenditure 3,067c 2,403c (19 y) Pregnancy 14 through 18 y
Adolescent female EER plus change in Total Energy Expenditure (TEE) plus pregnancy energy deposition
1st trimester
2,368 (16 y)
2nd trimester
2,708 (16 y)
3rd trimester
2,820 (16 y)
19 through 50 y
Adult female EER plus change in TEE plus pregnancy energy deposition
1st trimester
2,403c (19 y)
2nd trimester
2,743c (19 y)
3rd trimester
2,855c (19 y)
Lactation 14 through 18 y
Adolescent female EER plus milk energy output minus w eight loss
1st 6 mo 2,698 (16 y) 2nd 6 mo 2,768 (16 y) 19 through 50 y
Adult female EER plus milk energy output minus w eight loss
1st 6 mo 2,733c (19 y) 2nd 6 mo 2,803c (19 y)
aFor healthy active Americans and Canadians. Based on the cited age, an active physical activity level, and the reference heights and weights cited in Table 1.1. Individualized EERs can be determined by using the equations in Chapter 5. bPAL = Physical Activity Level, EER = Estimated Energy Requirement. The intake that meets the average energy expenditure of individuals at the reference height, weight, and
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age (see Table 1.1). cSubtract 10 kcal/d for males and 7 kcal/d for females for each year of age above 19 years.
Reproduced with permission from Energy Calculations for Active Individuals by Life Stage Group. In Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate, National Academy of Sciences. Washington, DC: National Academies Press, 2005.
Dietary Reference Intakes (DRIs): Dietary Allowances and Adequate Intakes, Total Water, and Macronutrients (Food and Nutrition Board, National Academy of Medicine)
Life Stage Group
Total Water (L/d)
PROTEIN CARBOHYDRATE FIBER FAT n-6 POLYUNSATURATED FATTY ACIDS (α- linoleic acid)
n POLYUNSATURATED FATTY ACIDS (α- linoleic acid)
RDA/AI g/daya
AMDRb RDA/AI g/day AMDR
b RDA/AI g/day AMDR
b RDA/AI g/day AMDR
b RDA/AI g/day AMDR
b
Infants 0–6 mo
0.7* 9.1 NDc 60 ND ND ND 31 4.4* ND
7–12 mo
0.8* 11.0 ND 95 ND ND ND 30 4.6* ND
Children 1–3 y 1.3* 13 5–20 130 45–65 19* ND ND 30–40 7* 5–10 4–8 y 1.7* 19 10–30 130 45–65 25* ND ND 25–35 10* 5–10 Males 9–13 y 2.4* 34 10–30 130 45–65 31* ND ND 25–35 12* 5–10 14–18 y
3.3* 52 10–30 130 45–65 38* ND ND 25–35 16* 5–10
19–30 y
3.7* 56 10–35 130 45–65 38* ND ND 20–35 17* 5–10
31–50 y
3.7* 56 10–35 130 45–65 38* ND ND 20–35 17* 5–10
51–70 y
3.7* 56 10–35 130 45–65 30* ND ND 20–35 14* 5–10
>70 y 3.7* 56 10–35 130 45–65 30* ND ND 20–35 14* 5–10 Females 9–13 y 2.1* 34 10–30 130 45–65 26* ND ND 25–35 10* 5–10 14–18 y
2.3* 46 10–30 130 45–65 26* ND ND 25–35 11* 5–10
19–30 y
3.7* 46 10–35 130 45–65 25* ND ND 20–35 12* 5–10
31–50 y
3.7* 46 10–35 130 45–65 25* ND ND 20–35 12* 5–10
51–70 y
3.7* 46 10–35 130 45–65 21* ND ND 20–35 11* 5–10
>70 y 3.7* 46 10–35 130 45–65 21* ND ND 20–35 11* 5–10 Pregnant ≤18 y 3.0* 71 10–35 175 45–65 28* ND ND 20–35 13* 5–10 19–30 y
3.0* 71 10–35 175 45–65 28* ND ND 20–35 13* 5–10
31–50 y
3.0* 71 10–35 175 45–65 28* ND ND 20–35 13* 5–10
Lactating ≤18 y 3.8* 71 10–35 210 45–65 29* ND ND 20–35 13* 5–10
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19–30 y
3.8* 71 10–35 210 45–65 29* ND ND 20–35 13* 5–10
31–50 y
3.8* 71 10–35 210 45–65 29* ND ND 20–35 13* 5–10
aBased on 1.5 g/kg/day for infants, 1.1 g/kg/day for 1–3 y; 0.95 g/kg/day for 4–13 y, 0.85 g/kg/day for 14–18 y, 0.8 g/kg/day for adults, and 1.1 g/kg/day for pregnant (using prepregnancy weight) and lactating women. bAcceptable Macronutrient Distribution Range (AMDR) 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 has consumed in excess of the AMDR, there is a potential of increasing the risk of chronic diseases and insufficient intakes of essential nutrients. cND 5 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. dApproximately 10% of the total can come from longer-chain, n-3 fatty acids.
Dietary cholesterol, trans fatty acids, saturated fatty acids: As low as possible while consuming a nutritionally adequate diet.
Added sugars: Limit to no more than 25% of total energy.e
Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: The National Academies Press, 2002.
Note: This table represents Recommended Dietary Allowances (RDAs) in bold type and *Adequate Intakes (AIs) in ordinary type. RDAs and AIs may 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 prevents being able to specify with confidence the percentage of individuals covered by this intake.
Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Vitamins (Food and Nutrition Board, National Academy of Medicine)
Life Stage Group
Vitamin A (µg/d)a
Vitamin C (mg/d)
Vitamin D (µg/d)b,c
Vitamin E (mg/d)d
Vitamin K (µg/d)
Thiamin (mg/d)
Riboflavin (mg/d)
Niacin (mg/d)e
Vitamin B6 (mg/d)
Folate (µg/d)f
Vitamin B12 (µg/d)
Pantothenic Acid (mg/d)
Infants 0–6 mo
400* 40* 13 4* 2.0* 0.2* 0.3* 2* 0.1* 65* 0.4* 1.7*
7–12 mo
500* 50* 15 5* 2.5* 0.3* 0.4* 4* 0.3* 80* 0.5* 1.8*
Children 1–3 y 300 15 15 6 30* 0.5 0.5 6 0.5 150 0.9 2* 4–8 y 400 25 15 7 55* 0.6 0.6 8 0.6 200 1.2 3* Males 9–13 y 600 45 15 11 60* 0.9 0.9 12 1.0 300 1.8 4* 14–18 900 75 15 15 75* 1.2 1.3 16 1.3 400 2.4 5*
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y 19–30 y
900 90 15 15 120* 1.2 1.3 16 1.3 400 2.4 5*
31–50 y
900 90 15 15 120* 1.2 1.3 16 1.3 400 2.4 5*
51–70 y
900 90 15 15 120* 1.2 1.3 16 1.7 400 2.4h 5*
>70 y 900 90 20 15 120* 1.2 1.3 16 1.7 400 2.4h 5* Females 9–13 y 600 45 15 11 60* 0.9 0.9 12 1.0 300 1.8 4* 14–18 y
700 65 15 15 75* 1.0 1.0 14 1.2 400i 2.4 5*
19–30 y
700 75 15 15 90* 1.1 1.1 14 1.3 400i 2.4 5*
31–50 y
700 75 15 15 90* 1.1 1.1 14 1.3 400i 2.4 5*
51–70 y
700 75 15 15 90* 1.1 1.1 14 1.5 400 2.4h 5*
>70 y 700 75 20 15 90* 1.1 1.1 14 1.5 400 2.4h 5* Pregnancy 14–18 y
750 80 15 15 75* 1.4 1.4 18 1.9 600j 2.6 6*
19–30 y
770 85 15 15 90* 1.4 1.4 18 1.9 600j 2.6 6*
31–50 y
770 85 15 15 90* 1.4 1.4 18 1.9 600j 2.6 6*
Lactation 14–18 y
1,200 115 15 19 75* 1.4 1.6 17 2.0 500 2.8 7*
19–30 y
1,300 120 15 19 90* 1.4 1.6 17 2.0 500 2.8 7*
31–50 y
1,300 120 15 19 90* 1.4 1.6 17 2.0 500 2.8 7*
aAs retinol activity equivalents (RAEs). 1 RAE = 1 µg retinol, 12 µg β-carotene, 24 µg β- carotene, or 24 µg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is twofold greater than retinol equivalents (RE), whereas the RAE for preformed vitamin A is the same as RE. bAs cholecalciferol. 1 µg cholecalciferol = 40 IU vitamin D. cUnder the assumption of minimal sunlight. dAs α-tocopherol. α-Tocopherol includes RRR-α-tocopherol, the only form of α-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α-tocopherol (RRR-, RSR-, RRS-, and RSS-α-tocopherol) that occur in fortified foods and supplements. It does not include the 2S-stereoisomeric forms of α-tocopherol (SRR-, SSR-, SRS-, and SSS-α- tocopherol), also found in fortified foods and supplements. eAs niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan; 0–6 months = preformed niacin (not NE). fAs dietary folate equivalents (DFE). 1 DFE = 1 µg food folate = 0.6 µg of folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach. gAlthough AIs have been set for choline, there are few data to assess whether a dietary supply of choline is needed at all stages of the life cycle, and it may be that the choline requirement can be met by endogenous synthesis at some of these stages.
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hBecause 10% to 30% of older people may malabsorb food-bound B12, it is advisable for those older than 50 years to meet their RDA mainly by consuming foods fortified with B12 or a supplement containing B12. iIn view of evidence linking folate intake with neural tube defects in the fetus, it is recommended that all women capable of becoming pregnant consume 400 µg from supplements or fortified foods in addition to intake of food folate from a varied diet. jIt is assumed that women will continue consuming 400 µg from supplements or fortified food until their pregnancy is confirmed and they enter prenatal care, which ordinarily occurs after the end of the periconceptional period—the critical time for formation of the neural tube. NOTE: This table (taken from the DRI reports; see www.nap.edu) presents Recommended Dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*). An RDA is the average daily dietary intake level; sufficient to meet the nutrient requirements of nearly all (97%–98%) healthy individuals in a group. It is calculated from an Estimated Average Requirement (EAR). If sufficient scientific evidence is not available to establish an EAR for calculating an RDA, an AI is usually developed. For healthy breastfed infants, an AI is the mean intake. The AI for other life-stage and gender groups is believed to cover the needs of all healthy individuals in the groups, but lack of data or uncertainty in the data prevent being able to specify with confidence the percentage of individuals covered by this intake.
SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu.
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Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Elements (Food and Nutrition Board, National Academy of Medicine)
Life-Stage Group
Calcium (mg/d)
Chromium (µg/d)
Copper (µg/d)
Fluoride (mg/d)
Iodine (µg/d)
Iron (mg/d)
Magnesium (mg/d)
Infants 0–6 mo 200* 0.2* 200* 0.01* 110* 0.27* 30* 7–12 mo 260* 5.5* 220* 0.5* 130* 11 75* Children 1–3 y 700* 11* 340 0.7* 90 7 80 4–8 y 1000* 15* 440 1* 90 10 130 Males 9–13 y 1,300* 25* 700 2* 120 8 240 14–18 y 1,300* 35* 890 3* 150 11 410 19–30 y 1,000* 35* 900 4* 150 8 400 31–50 y 1,000* 35* 900 4* 150 8 420 51–70 y 1,200* 30* 900 4* 150 8 420 >70 y 1,200* 30* 900 4* 150 8 420 Females 9–13 y 1,300* 21* 700 2* 120 8 240 14–18 y 1,300* 24* 890 3* 150 15 360 19–30 y 1,000* 25* 900 3* 150 18 310 31–50 y 1,000* 25* 900 3* 150 18 320 51–70 y 1,200* 20* 900 3* 150 8 320 >70 y 1,200* 20* 900 3* 150 8 320 Pregnancy ≤18 y 1,300* 29* 1,000 3* 220 27 400 19–30 y 1,000* 30* 1,000 3* 220 27 350 31–50 y 1,000* 30* 1,000 3* 220 27 360 Lactation ≤18 y 1,300* 11* 1,300 3* 290 10 360 19–30 y 1,000* 15* 1,300 3* 290 9 310 31–50 y 1,000* 45* 1,300 3* 290 9 320
Copyright 2001 by the National Academy of Sciences. All rights reserved.
SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu.
Dietary Reference Intakes (DRIs): Estimated Average Requirements (Food and Nutrition Board, National Academy of Medicine)
Life Stage- Group
Calcium (mg/d)
CHO (g/kg/d)
Protein (g/d)
Vitamin A (µg/d)a
Vitamin C (mg/d)
Vitamin D (µg/d)
Vitamin E (mg/d)b
Thiamin (mg/d)
Riboflavin (mg/d)
Niacin (mg/d)c
Vitamin B6 (mg/d)
Infants 0–6
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mo 7–12 mo
1.0
Children 1–3 y 500 100 0.87 210 13 10 5 0.4 0.4 5 0.4 4–8 y 800 100 0.76 275 22 10 6 0.5 0.5 6 0.5 Males 9–13 y 1,100 100 0.76 445 39 10 9 0.7 0.8 9 0.8 14–18 y
1,100 100 0.73 630 63 10 12 1.0 1.1 12 1.1
19–30 y
800 100 0.66 625 75 10 12 1.0 1.1 12 1.1
31–50 y
800 100 0.66 625 75 10 12 1.0 1.1 12 1.1
51–70 y
800 100 0.66 625 75 10 12 1.0 1.1 12 1.4
>70 y 1,000 100 0.66 625 75 10 12 1.0 1.1 12 1.4 Females 9–13 y 1,100 100 0.76 420 39 10 9 0.7 0.8 9 0.8 14–18 y
1,100 100 0.71 485 56 10 12 0.9 0.9 11 1.0
19–30 y
800 100 0.66 500 60 10 12 0.9 0.9 11 1.1
31–50 y
800 100 0.66 500 60 10 12 0.9 0.9 11 1.1
51–70 y
1,000 100 0.66 500 60 10 12 0.9 0.9 11 1.3
>70 y 1,000 100 0.66 500 60 10 12 0.9 0.9 11 1.3 Pregnancy 14–18 y
1,000 135 0.88 530 66 10 12 1.2 1.2 14 1.6
19–30 y
800 135 0.88 550 70 10 12 1.2 1.2 14 1.6
31–50 y
800 135 0.88 550 70 10 12 1.2 1.2 14 1.6
Lactation 14–18 y
1,000 160 1.05 885 96 10 16 1.2 1.3 13 1.7
19–30 y
800 160 1.05 900 100 10 16 1.2 1.3 13 1.7
31–50 y
800 160 1.05 900 100 10 16 1.2 1.3 13 1.7
aAs retinol activity equivalents (RAEs). 1 RAE = 1 µg retinol, 12 µg β-carotene, 24 µg α- carotene, or 24 µg β-cryptoxanthin. The RAE for dietary provitamin A carotenoids is two- fold greater than retinol equivalents (RE), whereas the RAE for preformed vitamin A is the same as RE. bAs α-tocopherol. α-Tocopherol includes RRR-α-tocopherol, the only form of α-tocopherol that occurs naturally in foods, and the 2R-stereoisomeric forms of α-tocopherol (RRR-, RSR-, RRS-, and RSS-α-tocopherol) that occur in fortified foods and supplements. It does not include the 2S-stereoisomeric forms of α-tocopherol (SRR-, SSR-, SRS-, and SSS-α- tocopherol), also found in fortified foods and supplements. cAs niacin equivalents (NE). 1 mg of niacin = 60 mg of tryptophan. dAs dietary folate equivalents (DFE). 1 DFE = 1 µg food folate = 0.6 µg of folic acid from fortified food or as a supplement consumed with food = 0.5 µg of a supplement taken on an empty stomach.
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Note: An Estimated Average Requirement (EAR) is the average daily nutrient intake level estimated to meet the requirements of the healthv individuals in a group. EARs have not been established for vitamin K, pantothenic acid, biotin, choline, chromium, fluoride, manganese, or other nutrients not yet evaluated via the DRI process.
SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu.
Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Vitamins (Food and Nutrition Board, National Academy of Medicine)
Life- Stage Group
Vitamin A (µg/d)a
Vitamin C (mg/d)
Vitamin D (µg/d)
Vitamin E (mg/d)b,c
Vitamin K
Thiamin Riboflavin Niacin (mg/d)c
Vitamin B6 (mg/d)
Folate (µg/d)c
Vitamin B12
Infants 0–6 mo
600 NDe 25 ND ND ND ND ND ND ND ND
7–12 mo
600 ND 38 ND ND ND ND ND ND ND ND
Children 1–3 y 600 400 63 200 ND ND ND 10 30 300 ND 4–8 y 900 650 75 300 ND ND ND 15 40 400 ND Males 9–13 y 1,700 1,200 100 600 ND ND ND 20 60 600 ND 14–18 y
2,800 1,800 100 800 ND ND ND 30 80 800 ND
19–30 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
31–50 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
51–70 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
>70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND Females 9–13 y 1,700 1,200 100 600 ND ND ND 20 60 600 ND 14–18 y
2,800 1,800 100 800 ND ND ND 30 80 800 ND
19–30 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
31–50 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
51–70 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
>70 y 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND Pregnancy 14–18 y
2,800 1,800 100 800 ND ND ND 30 80 800 ND
19–30 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
31–50 3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
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y Lactation 14–18 y
2,800 1,800 100 800 ND ND ND 30 80 800 ND
19–30 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
31–50 y
3,000 2,000 100 1,000 ND ND ND 35 100 1,000 ND
aAs preformed vitamin A only. bAs α–tocopherol; applies to any form of supplemental α–tocopherol. cThe ULs for vitamin E, niacin, and folate apply to synthetic forms obtained from supplements, fortified foods, or a combination of the two. dβ-Carotene supplements are advised only to serve as a provitamin A source for individuals at risk of vitamin A deficiency. eND = 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.
Note: A Tolerable Upper Intake Level (UL) is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total intake from food, water, and supplements. Due to a lack of suitable data, ULs could not be established for vitamin K, thiamin, riboflavin, vitamin B12, pantothenic acid, biotin, and carotenoids. In the absence of a UL, extra caution may be warranted in consuming levels above recommended intakes. Members of the general population should be advised not to routinely exceed the UL. The UL is not meant to apply to individuals who are treated with the nutrient under medical supervision or to individuals with predisposing conditions that modify their sensitivity to the nutrient.
SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu.
Dietary Reference Intakes (DRIs): Tolerable Upper Intake Levels, Elements (Food and Nutrition Board, National Academy of Medicine)
Life- Stage Group
Arsenica Boron (mg/d)
Calcium (mg/d) Chromium
Copper (µg/d)
Fluoride (mg/d)
Iodine (µg/d)
Iron (mg/d)
Magnesium (mg/d)b
Manganese (mg/d)
Molybdenum (µg/d)
Infants 0–6 mo
NDe ND 1,000 ND ND 0.7 ND 40 ND ND ND
7–12 mo
ND ND 1,500 ND ND 0.9 ND 40 ND ND ND
Children
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1–3 y ND 3 2,500 ND 1,000 1.3 200 40 65 2 300 4–8 y ND 6 2,500 ND 3,000 2.2 300 40 110 3 600 Males 9–13 y ND 11 3,000 ND 5,000 10 600 40 350 6 1,100 14–18 y
ND 17 3,000 ND 8,000 10 900 45 350 9 1,700
19–30 y
ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000
31–50 y
ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000
51–70 y
ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000
>70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 Females 9–13 y ND 11 3,000 ND 5,000 10 600 40 350 6 1,100 14–18 y
ND 17 3,000 ND 8,000 10 900 45 350 9 1,700
19–30 y
ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000
31–50 y
ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000
51–70 y
ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000
>70 y ND 20 2,000 ND 10,000 10 1,100 45 350 11 2,000 Pregnancy 14–18 y
ND 17 3,000 ND 8,000 10 900 45 350 9 1,700
19–30 y
ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000
31–50 y
ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000
Lactation 14–18 y
ND 17 3,000 ND 8,000 10 900 45 350 9 1,700
19–30 y
ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000
31–50 y
ND 20 2,500 ND 10,000 10 1,100 45 350 11 2,000
aAlthough the UL was not determined for arsenic, there is no justification for adding arsenic to food or supplements. bThe ULs for magnesium represent intake from a pharmacologic agent only and do not include intake from food and water. cAlthough silicon has not been shown to cause adverse effects in humans, there is no justification for adding silicon to supplements. dAlthough vanadium in food has not been shown to cause adverse effects in humans, there is no justification for adding vanadium to food and vanadium supplements should be used with caution. The UL is based on adverse effects in laboratory animals; this data could be used to set a UL for adults but not children and adolescents. eND = 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.
Note: A Tolerable Upper Intake Level (UL) is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total intake from food, water, and
25
supplements. Due to a lack of suitable data, ULs could not be established for vitamin K, thiamin, riboflavin, vitamin B12, pantothenic acid, biotin, and carotenoids. In the absence of a UL, extra caution may be warranted in consuming levels above recommended intakes. Members of the general population should be advised not to routinely exceed the UL. The UL is not meant to apply to individuals who are treated with the nutrient under medical supervision or to individuals with predisposing conditions that modify their sensitivity to the nutrient.
SOURCES: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000); Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2001); Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate (2005); and Dietary Reference Intakes for Calcium and Vitamin D (2011). These reports may be accessed via www.nap.edu.
Body Mass Index Table
NORMAL OVERWEIGHT OBESE EXTREME OBESITY BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Height (inches)
Body Weight (pounds)
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328
SOURCE: Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: National Heart, Lung, and Blood Institute, 1998.
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http://www.nap.edu
Copyright
3251 Riverport Lane St. Louis, Missouri 63043
THE DENTAL HYGIENIST’S GUIDE TO NUTRITIONAL CARE, FIFTH EDITION ISBN: 978-0-323-497275
Copyright © 2019 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
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Names: Stegeman, Cynthia A., author. | Davis, Judi Ratliff, author. Title: The dental hygienist’s guide to nutritional care / Cynthia A. Stegeman, RDH, EdD, RDN, LD, CDE, Ohio Delegate to the Academy of Nutrition and Dietetics, Associate Professor, Dental Hygiene Program, University of Cincinnati, Cincinnati, Ohio, Judi Ratliff Davis, MS, RDN, Former Quality Assurance Nutrition Consultant, Women, Infants and Children (WIC) Program, Texas Department of State Health Services, Austin, Texas. Description: Fifth edition. | St. Louis, Missouri : Elsevier, Inc., [2019] | Includes bibliographical references and index. Identifiers: LCCN 2017059590| ISBN 9780323497275 (pbk. : alk. paper) | ISBN 9780323569460 (ebook) Subjects: LCSH: Nutrition and dental health. | Dental hygienists. Classification: LCC RK60.7 .S74 2019 | DDC 617.6/01–dc23 LC record available at https://lccn.loc.gov/2017059590
Content Strategist: Kristin R. Wilhelm Senior Content Development Manager: Ellen M. Wurm-Cutter Senior Content Development Specialist: Rebecca M. Leenhouts Publishing Services Manager: Deepthi Unni Project Manager: Radhika Sivalingam Designer: Brian Salisbury
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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https://lccn.loc.gov/2017059590
Dedication
This fifth edition is dedicated to all of the dental hygiene students, faculty, and practitioners throughout the world
who read and apply information from this text. Your curiosity and desire to gain evidence-based and applicable information
regarding the role of nutrition in oral health continues to guide the content.
Cyndee and Judi
and
To my husband, son, family, and dental hygiene and dietetic colleagues for their encouragement, support, visions, and
humor.
Cyndee
and
To my friends and family, especially my five granddaughters: Riley, Avery, Ellie, Maggie, and Callie, and my newest
addition, at last, a grandson, Falcon.
Judi
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Preface
The fifth edition of this nutrition textbook for dental professionals!!! Why is nutrition information always changing? Concisely, nutrition is a relatively new science. It has long been recognized that certain food factors are important to health: in the early 1800s, all English ships carried lime juice, with a portion given to each sailor daily. However, isolation and discovery of the exact elements in foods and the role they play in maintaining health and preventing disease is more complicated. The B vitamins were only discovered as late as the twentieth century. Scientists continue to research the nutrient content of foods, the specific physiologic uses of vitamins and minerals, and the quantity resulting in beneficial or harmful effects. Advances in technology continue to guide us in the functions and interactions of nutrients. After discovering vitamins and determining which minerals and elements are essential to health, even more food components have been discovered, such as antioxidants and polyphenols, leading to shifting directions and policies. Expect further changes as research delves into the effects of the microbiome and nutrigenomics in maintaining optimal health and preventing chronic diseases. The science of nutrition is further complicated by such factors as personal food habits and nutrient interactions. You will realize in studying this subject that nutrition is a dynamic field relevant to both you and your patients.
The study of nutrition is a rewarding topic for dental hygiene students and practitioners, not only as it relates to patient education but also for how it can affect the dental hygienist’s own health. The Dental Hygienist’s Guide to Nutritional Care is designed to show both dental hygiene students and practicing dental professionals how to apply sound nutrition principles when assessing, diagnosing, planning, implementing, and evaluating the total care of patients, as well as to help them contribute to the nutritional well-being of patients. The Academy of Nutrition and Dietetics, American Dental Hygienists’ Association, and American Dental Association each recognize nutrition as an integral component of oral health. The dental professional should be able to assess the oral cavity in relation to the patient’s nutrition, dietary habits, and overall health status. A holistic approach to dietary management of a disease by all members of the health care team is especially appropriate to coordinate managed health care.
Since the subject of nutrition is a hot topic in today’s world, the
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consumer is challenged to comprehend and apply the overwhelming amount of nutritional information that can be confusing and conflicting. As the health source that patients may see most often, dental professionals should be able to knowledgeably and authoritatively discuss nutritional practices with their patients or provide appropriate referrals as needed.
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New to This Edition This expertly revised edition provides the most recent developments in the field and new and improved resources for instructors, including: • The latest federal nutrition standards, including the 2020 Dietary
Guidelines for Americans and MyPlate • Updated art program, featuring modern illustrations, more clinical
photos, and food-source photos within micronutrient chapters • Content on interdisciplinary practice and the Food Safety
Modernization Act (FSMA), plus expanded coverage of older adults, vitamin D, and nutrigenomics
• Information on the role of biochemistry in dental hygiene and nutrition • TEACH Lesson Plans, PowerPoints, Answer Keys, and Student
Handouts provided for the instructor • An expanded and improved Test Bank with cognitive leveling based on
Bloom’s Taxonomy and mapping to the National Board Dental Hygiene Examination (NBDHE) blueprint
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Organization Part I, Orientation to Basic Nutrition, deals with basic principles of nutrition. A basic understanding of fundamental nutrition facts enables the dental hygienist to make wise judgments about eating habits, educate patients about needed dietary changes, and evaluate the flood of new information available. Nutrient deficiencies and excesses are addressed in sections entitled Hyper-States and Hypo-States, terms that are more congruent with real-life occurrences. Chapters addressing vitamins and minerals are arranged to cover the specific nutrients involved in oral calcified structures or oral soft tissues. The chapter entitled Concepts in Biochemistry introduces a basic understanding of biochemistry, the foundation for understanding and applying principles of nutrition. This chapter serves as a valuable resource throughout the textbook.
Part II, Considerations of Clinical Nutrition, addresses problems specifically involved in the application of basic nutrition principles through the lifespan within ethnic groups and socioeconomically deprived individuals. Because of the ever-changing, diverse population in the United States, food pyramids or food guides from eight different cultural groups are provided within the chapters or on the back cover. This helps dental hygienists recognize that food choices different from their own eating patterns may be nutritionally healthy. By approaching any necessary modifications with sensitivity and respect, patients are more likely to make suggested changes. Alterations in nutritional requirements and eating patterns affected by various stages of life— specifically for females, infants and children, and older adults—are discussed.
Part III, Nutritional Aspects of Oral Health, looks at factors involved in oral problems and the nutritional treatment of these problems. In these chapters, Dental Considerations and Nutritional Directions boxes provide specific information to consider during an assessment and educational dialogue by the dental professional, including (1) physical status and dietary habits; (2) interventions, or factors that need to be considered when caring for the patient; and (3) evaluations concerning the patient’s ability or motivation to make changes based on what has been learned during the appointment. A nutritional assessment is a basic procedure in dental management for the nutritional well-being of all patients. This involves performing a medical and dental assessment, evaluating dietary intake/history, and educating patients about healthful changes in food choices. Many conditions or their outcome are improved
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by encouraging patients to eat a wide variety of foods and beverages in appropriate portion sizes or to make minor changes in food choices to improve their health.
A variety of features throughout the text help to enhance the learning experience: • Student Learning Outcomes: A list of outcomes accompanies each
chapter to provide a guide to the important information to acquire from the chapter.
• Key Terms: Definitions of unfamiliar terms for each chapter in bold and blue letters within the text; also compiled in the Glossary for easy reference.
• Test Your NQ (nutrition quotient): True-false pretests to stimulate interest in the reading assignment; answers conveniently located in the back of the book.
• Dental Considerations: Practical information affecting the patient’s care or nutritional status.
• Nutritional Directions: Information to teach the patient to improve oral health and overall health status; stimulating discussions with the patient using the educational information for improvement of oral health, food choices, and/or overall health status.
• Health Applications: Current “hot topics” in nutrition, including the ways to obtain an adequate balance of nutrients by a vegetarian; understanding the difficulty in diagnosing persons with gluten sensitivity or intolerance, and adhering to a gluten-free diet; causes and treatment of obesity; and appropriate use of vitamin and mineral supplements.
• Case Application: Potential patient situations describing a clinical situation and providing the five-step care plan to help “pull it all together.”
• Student Readiness: Questions at the end of each chapter for students to determine their comprehension of the subject.
• Case Studies: Practical case studies for students to test their ability to make sound judgments when faced with real-life patient scenarios.
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About Evolve The Evolve website offers a variety of additional learning tools that greatly enhance the text for both students and instructors.
For the Student Evolve Student Resources offers the following: • Practice Quizzes. Each chapter contains approximately 400 National
Board Dental Hygiene Examination-style questions with instant- feedback answers, rationales, and page number references for remediation.
• Illustrated Case Studies. Written scenarios with accompanying photographs, and follow-up questions present situations observed frequently. These case studies serve as an excellent review source for the National Board Dental Hygiene Examination.
• Nutritrac Nutrition Analysis Version 5.0: An online tool allows users to analyze specifics of food intake and energy expenditure, manage weight loss and gain goals, and analyze nutrition and weight status.
• Food Pyramids and Guides from Around the World. Food pyramids and guides from a variety of countries are provided, including Mexico, Puerto Rico, the Philippines, Korea, China, Canada, Great Britain, Germany, Australia, Portugal, and Sweden. Also included are the Native American Food Pyramid, Mediterranean Diet Pyramid, DASH Eating Plan, Healthy Vegetarian Eating Patterns, My Vegan Plate, and MyPlate for Older Adults (©Tufts University).
• Food Diary and Food Analysis Forms. Printable versions of forms needed to complete the Personal Assessment Project as well as printable versions for Carbohydrate Intake Analysis and Menu Planning Record.
• MNA Mini Nutritional Assessment. A validated nutrition screening tool that can be used to asses for malnutrition in patients 65 years and older.
For the Instructor Evolve Instructor Resources offers the following: • Testbank. An extensive test bank makes the creation of quizzes and
exams easier. • TEACH Instructor Resources.
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• Lesson Plans organize chapter content into 50-minute class times and map to educational standards and chapter learning objectives.
• PowerPoints provide lecture presentations with talking points for discussion, all mapped to chapter learning objectives.
• Student Handouts are PDFs of the lecture presentations for easy posting and sharing with students.
• Image Collection. An image collection with the illustrations from the textbook is provided for ease of incorporating a photo or drawing into a lecture or quiz.
• Personal Assessment Project. A classroom learning activity is provided for students to objectively assess their own personal dietary patterns, practice the process of recording and analyzing food intake for its nutritive and cariogenic value, and use nutritional and dental knowledge to contribute to better general and oral health for self and patients.
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Note From the Authors With a better understanding of the importance of food choices, the members of a multidisciplinary health care team can complement each other’s work and provide optimal care for the patient. Even though specific amounts of nutrients are mentioned, the intent of this text is not for prescriptive use. Instead, its purpose is to provide dental hygiene students and practicing dental professionals with a relative idea of the amounts of various nutrients needed so that viable food sources can be recommended.
Dr. Cynthia Stegeman
Judi Ratliff Davis
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Acknowledgments
Because of the diversity of subjects presented in a general nutrition textbook, a compilation of the work of many people, whether direct or indirect, is necessary to present current and evidence-based information that is relevant to dental professionals. Whether the aid was in the area of a research study or verbal or written communications, each person’s help and support is truly appreciated.
Our sincere thanks to Barbara Altshuler, Assistant Professor Emeritus, Caruth School of Dental Hygiene, Baylor College of Dentistry, who “birthed” this nutrition textbook for dental hygienists and took this baby to W. B. Saunders to develop a resource for dental hygienists to assess the nutritional status of their patients. While your “early retirement” is a true loss to the dental hygiene profession, we hope you are enjoying your family time. It takes a team of experts to complete a textbook. We would like to acknowledge the hard work of Dr. Scott Tremain, Associate Professor in the Department of Chemistry at the University of Cincinnati Blue Ash, for creating a practical and usable chapter in biochemistry. Condensing complex information into one chapter is quite a feat. Another valuable contributor to the textbook is Dr. Amy Sullivan, RDH, at the University of Mississippi Medical Center. She worked diligently to improve Chapters 18 to 21. In addition to her knowledge in dental issues, her excellent photos provide an important supplement to the text. We also thank her dental hygiene students for their participation in the photos to demonstrate various education concepts. Special thanks to the dental hygiene faculty, staff, and students at the University of Cincinnati Blue Ash for their encouragement, expertise, and provision of research. Their consistent support and praise make the monumental task of updating a nutrition textbook easier and rewarding.
A special thanks to the librarians at the Texas Department of State Health Services, Carolyn Medina and David McLellan, who were superb at locating scientific references for “dramatic findings” publicized by the press. In addition to those listed, there are countless other friends and relatives to whom we wish to express our gratitude for their encouragement and support. Objective critiques from reviewers are invaluable to a good publication. We appreciate the insight, perspective, words of encouragement, and valuable ideas of the following reviewers:
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Wanda Cloet, RDH, MS, Central Community College, Hastings, Nebraska; Nanette Feil-Megill, BSc, DDS, RRDH, CAE, Canadian National Institute of Health, Ottawa, Ontario, Canada; Deborah L. Johnson, RDH-EPP, MS, Eastern Washington University, Spokane, Washington; Jodi Olmsted, RDH, PhD, School of Health Care Professions, University of Wisconsin, Stevens Point, Wisconsin; Nancy Shearer, RDH, BS, MEd, Cape Cod Community College, West Barnstable, Massachusetts; Julie Stage-Rosenberg, RDH, MPH, Truckee Meadows Community College, Reno, Nevada.
In addition, we appreciate the editing “eagle eye” of Professor Luke Burroughs, RDH, MPH, an assistant professor in the dental hygiene program at the University of Cincinnati Blue Ash.
We also wish to thank the many staff members at Elsevier who worked so tirelessly in the various phases of planning and producing this book. We are especially grateful to Kristin Wilhelm, Director, Private Sector Education Content, and Becky Leenhouts, Senior Content Development Specialist, for their helpful ideas and for seeing us through this project.
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About the Authors
Cynthia A. Stegeman, RDH, EdD, RDN, LD, CDE, FAND is the Chairperson and Professor in the Dental Hygiene Program at the University of Cincinnati Blue Ash. She has taught Nutrition and Health Education for over 30 years. Dr. Stegeman has been a dental hygienist for over 35 years and a long-time member of the American Dental Hygienists’ Association and the Academy of Nutrition and Dietetics. She is currently the Ohio delegate to the Academy of Nutrition and Dietetics, a member of the National Board Dental Hygiene Examination test construction committee, a consultant in the evaluation process of licensure of candidates for the dental hygiene profession for the Commission on Dental Competency Assessments, and a Certified Diabetes Educator. In addition, she speaks to numerous community and professional groups nationally and internationally, and has published over 80 articles on nutrition, dentistry, and diabetes. Dr. Stegeman received an Associate of Applied Science in Dental Hygiene from the University of Cincinnati, Bachelor of Science in Public Health Dentistry from Indiana University Purdue University at Indianapolis, Master of Education in Nutrition from the University of Cincinnati, dietetic internship from The Christ Hospital in Cincinnati, and Doctorate of Education in Instructional Design and Technology from the University of Cincinnati.
Judi Ratliff Davis, MS, RDN has been working in the field of nutrition and dietetics for 50 years. She worked for the Texas Department of State Health Services as a Quality Assurance Nutrition Consultant for the Women, Infants and Children (WIC) program for over 10 years. Despite retirement in Austin, Texas, she continues to be very active, serving as a volunteer in community service and church organizations locally—Lake Travis Crisis Ministries (local food bank), Healthcare Volunteer Associates Clinic, Lake Travis Mobile Meals, and Austin Disaster Relief Network–helping to ensure unmet nutritional needs of the less fortunate, both physically and economically. She also enjoys volunteering for the Texas Performing Arts at the University of Texas. An active member of the Academy of Nutrition and Dietetics for 50 years, she has held numerous offices and served on many committees in the Fort Worth Dietetic Association and the Austin Dietetic Association. She has had a variety of experiences in the field of nutrition, including teaching, clinical
45
dietitian, and consultant. She taught various nutrition courses to dental hygiene, nursing, and child development students as well as food service courses at Tarrant County College in Fort Worth, Texas. Her roles as a clinical dietitian and Certified Nutrition Support Specialist include Home-Based Community Support (HCS), Tarrant County Mental Health Mental Retardation; Rehabilitation Hospital of North Texas, Arlington, Texas; Fort Worth State School, Fort Worth, Texas; Rex Hospital, Raleigh, North Carolina; and Baptist Memorial Hospital, San Antonio, Texas. As a nutrition consultant, she worked in long-term care facilities and mental health facilities in western Virginia, San Antonio, and the Dallas–Fort Worth area, and for the Greenhouse, a health spa in Arlington, Texas. She also coauthored the nursing textbook Applied Nutrition and Diet Therapy for Nurses and has written several chapters for nursing references and textbooks. She received her Bachelor of Science degree in Foods and Nutrition from the University of Texas, Austin; Master of Science degree in Nutrition from Texas Woman’s University, Denton; and completed a dietetic internship at Indiana University Medical Center, Indianapolis.
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PA R T I Orientation to Basic Nutrition
OU TLI N E
1 Overview of Healthy Eating Habits 2 Concepts in Biochemistry 3 The Alimentary Canal Digestion and Absorption 4 Carbohydrate The Efficient Fuel 5 Protein The Cellular Foundation 6 Lipids The Condensed Energy 7 Use of the Energy Nutrients Metabolism and Balance 8 Vitamins Required for Calcified Structures 9 Minerals Essential for Calcified Structures 10 Nutrients Present in Calcified Structures 11 Vitamins Required for Oral Soft Tissues and Salivary Glands 12 Fluids and Minerals Required for Oral Soft Tissues and Salivary Glands
47
Overview of Healthy Eating Habits
STU D EN T LEAR N IN G OU TC OMES
Upon completion of this chapter, the student will be able to achieve the following student learning outcomes:
1. Discuss why dental hygenists, registered dietitians, and nutritionists need to be competent in assessing and providing basic nutritional education to patients.
2. List and describe the general physiologic functions of the six nutrient classifications of foods. Also, describe factors that influence patients’ food habits.
3. Discuss government concerns with nutrition, as well as the purpose and objectives of Healthy People 2020.
4. Discuss Dietary Reference Intakes (DRIs). 5. Describe the purpose of the 2015-2020 Dietary Guidelines for Americans,
and determine the number of food equivalents needed from each food group and subgroup based on the Healthy U.S.-Style Eating Pattern for various calorie levels.
6. Describe healthy eating patterns, and discuss the importance of vegetables, fruits, dairy, protein foods, and oils.
7. Discuss nutrients to limit, as well as other dietary components such as alcohol and caffeine.
8. Describe how physical activity and physical fitness are important factors for an individual’s overall health, and how healthful choices should be supported by all systems.
9. Assess the dietary intake of a patient using the MyPlate system. Also, discuss other food guides and how they compare to the MyPlate system.
10. Master how to read a nutritional label.
KEY TER MS Acceptable macronutrient distribution ranges (AMDRs) Adequate Intake (AI)
49
Bariatric surgery Body mass index (BMI) Calorie (cal) c-eq Daily Value (DV) Dietary Reference Intakes (DRIs) Energy Enrichment Estimated Average Requirement (EAR) Estimated Energy Requirement (EER) Fortification Ghrelin Health claim Healthy U.S.-Style Eating Pattern (U.S.-Pattern) Hydrogenation Hypertension Kilocalorie (kcal) Low nutrient density Macronutrients Micronutrients Nutrient content claims Nutrient-dense Nutrients Nutrition Nutrition and Dietetic Technician, Registered (DTR) Nutrition Facts label Nutritionist Obesity Overweight oz-eq Physical activity Physical fitness
50
Phytochemicals Precursor Qualified health claims Recommended Dietary Allowances (RDAs) Registered dietitian (RD)/registered dietitian nutritionist (RDN) Satiety Tolerable Upper Intake Level (UL) Trans fatty acids Unqualified health claims Whole grains
Te s t You r N Q
1. T/F Milk is a perfect food for everyone.
2. T/F According to the Dietary Guidelines for Americans, consumption of all sugars should be reduced.
3. T/F Water is the most important nutrient.
4. T/F Dietary Reference Intakes (DRIs) are required daily intakes essential for all patients to be healthy.
5. T/F Good nutrition is possible regardless of a patient’s cultural habits.
6. T/F Based on MyPlate, two to four servings daily are needed from the fruit and vegetable group.
7. T/F The Dietary Guidelines for Americans were written for healthy people to help reduce their risk of developing chronic diseases.
8. T/F Sugar is the leading cause of chronic health problems.
9. T/F The goal of the MyPlate Food Guidance System is to convey the importance of variety, moderation, and proportion.
10. T/F The only nutrients that provide energy are carbohydrates, fats,
51
and vitamins.
The dental hygiene profession continues to grow and rapidly move into the forefront of health care. To function as valuable members of today’s health care team, the dental hygienist must be knowledgeable in various aspects of health care. Because of the lifelong, synergistic, bidirectional relationship between oral health and nutritional status, dental hygienists and registered dietitians and nutritionists need to be competent in assessing and providing basic education to patients and provide referrals to each other to effect comprehensive patient care.
All registered dietitians and some nutritionists are considered experts in the field of food and nutrition, but their training prepares them for slightly different specialties. A nutritionist may have a 4-year degree in foods and nutrition and usually works in a public health setting assisting people in the community, such as pregnant women or older individuals, with diet-related health issues. In many states, a nutritionist is legally defined and is licensed or certified. Nutritionists work in local or state health departments and in the extension service of a land-grant university. A registered dietitian (RD) or registered dietitian nutritionist (RDN) has completed a minimum of a bachelor’s degree in foods and nutrition with training in normal and clinical nutrition, food science, food service management, research, and medical nutrition therapy. The credential RDN is granted by the Commission on Dietetic Registration for the Academy of Nutrition and Dietetics for those who have passed a national registration examination and who maintain updated knowledge of the field through continuing education. RDNs working in hospitals, long-term care facilities, health care providers’ offices, and pharmaceutical companies may be more involved with medical nutrition therapy or specialized diets. RDNs may also work in settings dealing principally with basic nutrition, such as in schools, community and research settings, wellness and fitness centers, public health and community programs, educational institutions, and health and wellness preventive programs. The addition of the term nutritionist helps identify the type of work performed. Actually, all registered dietitians are nutritionists, but not all nutritionists are registered dietitians.
A Nutrition and Dietetic Technician, Registered (NDTR) has completed a 2-year degree program in a dietetic technician program or has a 4-year degree from an approved program (approved by the Accreditation Council for Education in Nutrition and Dietetics). An NDTR, like the RDN, must pass a national registration examination and receive continuing education. The DTR normally works under the
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supervision of an RDN in such practice areas as hospitals, clinics, and nursing homes, but they may also work independently to provide general nutrition education to healthy populations.
Dental professionals typically see patients on a more regular basis than other health care professionals; this allows observation of many physical signs, particularly oral signs, of a nutrient deficiency or medical condition that affects nutritional status before it is diagnosed. Recognition of abnormal conditions and early referral to an appropriate health care professional can lead to positive health outcomes for patients. Assessment of dietary information obtained from a patient can also uncover habits detrimental to oral health readily addressed in the dental office. Additionally, compromised oral health may affect food choices. For example, patients with missing dentition or ill-fitting dentures may avoid foods that are hard to chew and reduce the quality and variety of their diets.
Finally, dental hygienists can follow up on goals established by patients to evaluate their understanding and compliance. Overall, the dental hygienist is committed to prevention of oral disease as well as the promotion of health and wellness. All health care professionals must work together to enhance patient care. This textbook provides the dental professional with the nutrition information that can realistically be applied to and practiced with patients in the dental setting.
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Basic Nutrition Nutrition is the process by which living things use food to obtain nutrients for energy, growth and development, and maintenance. Energy is the ability or power to do work. Nutrients are biochemical substances that can be supplied only in adequate amounts from an outside source, normally from food. One aspect of nutrition is the integration of physiologic and biochemical reactions within the body: (a) digesting food to make nutrients available, (b) absorbing and delivering nutrients to the cells where they are used, and (c) eliminating waste products.
Nutrition is a relatively new science and still an evolving discipline. People want science to be definitive; they become confused and concerned when scientific research challenges what they assume to be factual. In nutrition, something that is considered to be true today may be disrupted by future research refuting established beliefs. In many cases, the media exacerbate this situation by reporting new research and recommendations as soon as they are released. These findings may not necessarily be reproduced in further research. Often, it is difficult to separate a medical certainty from what is merely solid scientific conjecture. The pace of research has quickened; this text is based on current, well-established, and evidence-based nutrition advice. Everyone in the health care field must continue to stay abreast of ongoing research to knowledgeably respond to questions from patients.
Americans are interested in food and health issues and are concerned about their diet, their physical activity, and substances in foods they eat, but most Americans find it easier to do their own taxes than to choose an adequate balanced diet. This may be related to the fact that nutrition information is ever changing.
Psychological and social factors that enter into frequent decisions concerning food choices are also important aspects of nutrition. Freedom of choice and variety in consumption are important components of an individual’s personal and social life. Tastes, budget, environment, and cultural attitudes influence food choices. Systemic and environmental effects of nutrients, which are determined by these food choices, affect dental health.
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Physiologic Functions of Nutrients Physiologically, foods eaten are used for energy, tissue building, maintenance and replacement, and obtaining or producing numerous regulatory substances. Nutrients obtained from foods are the following: (1) water, (2) proteins, (3) carbohydrates, (4) fats, (5) minerals, and (6) vitamins. Other naturally occurring substances in various foods, such as phytochemicals (plant chemicals) also promote health.
Of these nutrients, only proteins, carbohydrates, and fats provide energy. Alcohol also provides calories but limited or no nutrients. The potential energy value of foods within the body is expressed in terms of the kilocalorie, more frequently referred to as the calorie. A kilocalorie (kcal) is a measure of heat equivalent to 1000 calories.
Nutrients work together and interact in complex metabolic reactions. Proteins, carbohydrates, and fats provide energy the body needs for metabolic processes. However, the body cannot use energy from these caloric-containing components of food without adequate amounts of vitamins and minerals. Vitamins and minerals, along with protein and water, are essential for the body to build and maintain body tissues and to regulate essential body processes.
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Basic Concepts of Nutrition Foods differ in the amount of nutrients they furnish. Any individual food can be compatible with good nutrition but should be evaluated in the context of the patient’s physiologic needs, the food’s nutrient content, and other food choices. The premise of nutritional care is that, in any cultural or environmental circumstance or for any personal taste or preference, good nutrition is possible. The total diet or overall pattern of food intake is the most important focus of healthful eating.
Increasing the variety of healthful foods consumed reduces the probability of developing isolated nutrient deficiencies, nutrient excesses, and toxicities resulting from nonnutritive components or contaminants in any particular food. A dietary change to eliminate or increase intake of one specific food component or nutrient usually alters the intake of other nutrients. For instance, because red meats are an excellent source of iron and zinc, decreasing cholesterol intake by limiting these meats can reduce dietary iron and zinc intake.
Essential nutrients are needed throughout life on a regular basis; only the amounts of nutrients require change. The patient’s consumption of foods and beverages, stage of growth and development, sex, body size, weight, physical activity, and state of health influence nutrient requirements.
Some nutrients can be converted by the body to meet physiologic needs. Nonessential nutrients can be used by the body but either are not required or can be synthesized from dietary precursors. Precursors are substances from which an active substance is formed. An example is carotene, found in fruits and vegetables, which the liver can convert into an active form of vitamin A.
Water is the most important nutrient. After water, nutrients of highest priority are those providing energy, which must be obtained from foods or supplied from physiologic stores. The human body has adaptive mechanisms that allow toleration of modest ranges in nutrient intakes. For instance, the metabolic rate usually decreases as a result of decreased caloric intake.
D e n t a l C on s id e ra t ion s
• Because nutrients work interdependently, a lack or excess of one can interfere with or prevent use of another. Asking the patient to record
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food and beverage intake for the past 24 to 72 hours allows assessment of nutrient intake.
• Evaluation of the patient’s intake of food and beverages can help determine whether intake is adequate or excessive.
• Abnormalities in the oral cavity can affect systemic health and nutrition. Additionally, nutritional conditions or their treatments can affect the oral cavity or the feasibility of delivering dental care.
N u t rit ion a l D ire c t ion s
• No single food contains all the essential nutrients in amounts needed for optimal health.
• Nutritional intake can either improve or adversely affect health.
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Government Nutrition Concerns Before 1977, nutritional efforts focused on ensuring that the food supply provided adequate nutrients to prevent deficiency diseases. The U.S. government recognized health and nutritional problems related to food choices in 1977 with the United States Dietary Goals, which addressed excessive consumption of some nutrients. In 1988, the Surgeon General issued a report confirming that 5 of the 10 leading causes of death (cardiovascular disease [CVD], certain types of cancer, stroke, diabetes mellitus, and atherosclerosis) were associated with dietary intake. These reports provided comprehensive science-based objectives to improve the health of the U.S. population and to establish national objectives for promoting health and preventing disease.
Healthy People Nutrition Objectives Healthy People 2000: National Health Promotion and Disease Prevention Objectives, initially introduced in 1990 by the U.S. Department of Health and Human Services (USDHHS), established objectives and goals to measure progress in specific areas. The objectives for Healthy People focus on (a) increasing the quality and years of healthy life, (b) eliminating health disparities among racial and ethnic groups, (c) creating social and physical environments that promote good health for everyone, and (d) promoting quality of life and healthful development and behaviors of all age groups. Based on progress toward these objectives by 2010, many of the 10-year national objectives were continued if they had not been met and/or goals were adjusted, and new goals were set for 2020. New topics continue to be added as needed.
Healthy People 2020 (Healthy People) identifies emerging public health priorities and aligns them with health promotion strategies driven by the best evidence available. Healthy People 2020 is organized into 42 topic areas with about 600 measurable objectives to be accomplished by 2020. It targets 22 objectives related to nutrition, physical activity, and weight, and 17 objectives related to oral health.1
A midcourse progress report on these objectives indicates that there was little or no detectable change for the prevalence of obesity among adults or children and adolescents or in mean daily intake of vegetables, but goals were met for adults meeting physical activity and muscle- strengthening objectives. The number of children, adolescents, and adults who had an annual dental visit declined. Two oral health objectives showing significant improvement are to increase the
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percentage of the U.S. population served by community water systems that are optimally fluoridated and the proportion of children who have received dental sealants.2 Little to no progress has been accomplished in the area of reducing health disparities for minority and low-income groups. Many other objectives showed small improvements.
Other relevant objectives are referenced throughout this text. The Healthy People website (https://www.healthypeople.gov/) is updated frequently, providing consumers and health care providers the opportunity to monitor progress.
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Nutrient Recommendations: Dietary Reference Intakes Recommendations for the amounts of required nutrients have undergone significant changes over the years, and the revised sets of nutrient-based reference values are collectively called the Dietary Reference Intakes (DRIs; see pp. iii–vi). In 1993, the Food and Nutrition Board of the Institute of Medicine (IOM, now the National Academy of Medicine) undertook this major project, which was completed in 2004. The DRIs, published by the National Academy of Medicine, are established by an expert group of scientists and RDNs from the United States and Canada. These groups of experts base their recommendations on the most current scientific knowledge from different types of studies involving nutrients for healthy populations.
Previous Recommended Dietary Allowances (RDAs) focused on amounts of nutrients necessary to prevent deficiency diseases. The current DRIs also attempt to (a) estimate amounts of required nutrients to improve long-term health and well-being by reducing risk of chronic diseases affected by nutrition, for example, heart disease, diabetes, osteoporosis, and cancer; and (b) establish maximum safe levels of tolerance. The four categories of nutrient-based reference values are relevant for various stages of life. The DRIs were intended for planning and assessing diets of healthy Americans and Canadians. The DRIs are inappropriate for malnourished individuals or patients whose requirements are affected by a disease state. Because of emerging evidence involving potential roles of nutrients or other food substances in ameliorating chronic diseases, the National Academies appointed a committee to make recommendations for establishing DRIs for specific nutrients that could ameliorate the risk of chronic diseases. In 2017, Guiding Principles for Developing Dietary Reference Intakes Based on Chronic Disease ad hoc committee established guiding principles to support future DRI committees in making decisions about recommending chronic disease DRIs.
Estimated Average Requirement The Estimated Average Requirement (EAR) is the amount of a nutrient that is estimated to meet the needs of half of the healthy individuals in a specific age and gender group. This set of values is useful in assessing nutrient adequacy or planning intakes of population groups, not individuals.
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Recommended Dietary Allowance The new RDA is generally higher than the EAR and provides a sufficient amount of a nutrient to meet the requirements of nearly all healthy individuals (97%–98%). These recommendations provide a generous margin of safety and are intended as a goal for achieving adequate intakes. No health benefits are established for consuming intakes greater than the RDA.
Adequate Intakes If sufficient scientific evidence was unavailable to determine an EAR or RDA, an Adequate Intake (AI) was established based on scientific judgments. An AI, which is derived from mean nutrient intakes by groups of healthy people, is the average amount of a nutrient that seems to maintain a defined nutritional state. An AI is expected to exceed average requirements of virtually all members of a life stage/gender group but is more tentative than an RDA. AI values were established for various life stages for several nutrients, including fluoride, because of uncertainties about the scientific data to determine EAR and RDA values that would reduce the risk of chronic disease.
Tolerable Upper Intake Level A Tolerable Upper Intake Level (UL) is the maximum daily level of nutrient intake that probably would not cause adverse health effects or toxic effects for most individuals in the general population. The potential risk of adverse effects increases as intake exceeds the UL. The term Tolerable Intake was selected to avoid implying that these higher levels would result in beneficial effects. These values are especially helpful because of increased consumption of nutrients in the form of dietary supplements or from enrichment and fortification. This recommendation pertains to habitual daily use and is based on combined intake of food, water, dietary supplements, and fortified foods, with a few exceptions: the UL for magnesium applies only to intake from nonfood sources; ULs for vitamin E, niacin, and folate apply only to fortified foods or supplement sources; and UL for vitamin A applies only to intake of preformed retinol, regardless of the source.
Acceptable Macronutrient Distribution Ranges Acceptable Macronutrient Distribution Ranges (AMDRs) were
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established for the macronutrients, fat, carbohydrate, protein, and two polyunsaturated fatty acids, to ensure sufficient intakes of essential nutrients (carbohydrate, protein and fat), while potentially reducing risk of chronic disease. Macronutrients are energy-providing nutrients needed in larger amounts than micronutrients, for example, vitamins and minerals. The AMDR is a range of intakes for food components that provide calories; these are expressed as a percentage of total energy intake because the intake of each depends on intake of the others or of total energy requirement of the individual. Increasing or decreasing one energy source while consuming a set amount of calories affects intake of the other sources of energy. For instance, if an individual who routinely consumes 2000 cal reduces fat intake, either protein or carbohydrate intake would need to increase to provide 2000 cal. Consuming amounts outside of the ranges increases risk of insufficient intake of essential nutrients. Recommended ranges for carbohydrates, fats, and proteins allow more flexibility in eating patterns for healthy individuals and as well as accomodating individual preferences.
Estimated Energy Requirement The Estimated Energy Requirement (EER) is defined as dietary energy intake that is predicted to maintain energy balance in healthy, normal- weight individuals of a defined age, gender, weight, height, and physical activity level consistent with good health. The EER is similar to the EAR, and no RDA was established because consuming more calories than are needed would result in weight gain. Because energy requirement depends on activity level, four different activity levels are provided.
Summary of Dietary Reference Intakes Because nutrient requirements are influenced by age and sexual development, the DRIs are listed for 16 groups, separating gender groups after 10 years of age. Separate levels are established for three categories of pregnant and lactating women. Also, two age groups for the older American population are available.
These guidelines apply to average daily intakes. Meeting the recommendations for every nutrient on a daily basis is very difficult and unnecessary. These nutrient goals are intended to be met by consuming a variety of foods whenever possible.
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D e n t a l C on s id e ra t ion s
• Use of DRIs as an assessment guide is for healthy patients only.
• An individual’s exact requirement for a specific nutrient is not known for certain.
• The ULs may be used to warn patients that excessive intake of nutrients from nutritional supplements could lead to adverse effects if taken on a regular basis.
• Generally, specific foods or food groups, rather than nutrients, should be discussed with patients.
• If an individual’s food consumption is below the RDA for a nutrient over several days, more food choices containing that particular nutrient should be encouraged.
N u t rit ion a l D ire c t ion s
• The DRIs are general guidelines for good health rather than specific requirements.
• Choosing a wide variety of foods will probably result in meeting established nutrient requirements.
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Food Guidance System for Americans Identification of nutrients and knowledge of their physiologic functions are significant developments. However, consumers eat and think in terms of food, not nutrients. Nutrient requirements and information must be interpreted into the “food” language that consumers understand. In 2015, the USDHHS and the U.S. Department of Agriculture (USDA) released the Dietary Guidelines for Americans 2015– 2020 (Dietary Guidelines), the eighth edition of the guidelines. These Dietary Guidelines are based on scientific knowledge to meet nutrient requirements, promote health, support active lives through physical activity, and reduce risks of chronic disease. The Dietary Guidelines are the foundation for MyPlate (www.ChooseMyPlate.gov), released in 2011 to help consumers become healthier by making wise food choices.
Another helpful tool is the food label that helps consumers determine what kind and how much food to eat. Nutrition labeling, required for most packaged foods, provides information on certain nutrients. The Nutrition Facts label enumerates nutrient content of food for the serving size specified and discloses the number of servings in the package. Knowing how to interpret labels enables consumers to accurately apply Dietary Guideline messages that correspond to the nutrients and other information on the label.
2015–2020 Dietary Guidelines for Americans The objective of the five key guidelines is to help consumers make healthful choices from each of the food groups that, with an awareness of caloric intake, will result in an overall healthful eating pattern (Fig. 1.1). An eating pattern represents all the foods and beverages consumed over time or a customary way of eating. Ideally, it meets nutritional needs without exceeding limitations with regard to saturated fats, added sugars, sodium, and total calories. The long-range goal of the Dietary Guidelines is to prevent, or at least decrease, the rate of chronic disease and mortality. Interestingly, a recent study attributed dietary factors as a substantial cause of mortality from heart disease, stroke, and type 2 diabetes. Intakes of high sodium, low nuts/seeds, highly processed meats, low seafood omega-3 fats, low fruits, and high sugar-sweetened beverages were related to diet-related deaths.3 All these nutrients/foods are addressed in the Dietary Guidelines.
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FIGURE 1.1 2015–2020 Dietary Guidelines for Americans. (From the U.S. Department of Agriculture and U.S. Department of Health and Human
Services: 2015-2020 Dietary Guidelines for Americans. 8th ed. Washington, DC; U.S. Government Printing Office: December 2015. https://health.gov/dietaryguidelines/2015/.)
The Dietary Guidelines reference the Healthy U.S.-Style Eating Pattern (U.S.-Pattern) that indicates the number of food equivalents from each food group and subgroups for 12 caloric levels to be consumed each week for an adequate healthful diet (Table 1.1). Foods providing similar kinds of nutrients are grouped together and, as a rule, foods in one group cannot replace those in another (Table 1.2). This U.S.-Pattern can be adapted easily using various types and proportions of foods that Americans typically consume; however, to provide all the essential nutrients, foods need to be nutrient dense and in appropriate amounts to prevent exceeding calorie limits and other limiting dietary components.
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Nutrient-dense foods provide substantial amounts of vitamins and minerals but relatively few calories. When many low nutrient-density foods or beverages (containing high fat, sugar, or alcohol) are chosen, obtaining adequate amounts of essential nutrients without gaining weight is unachievable. The consumption of excessive calories from fats, added sugars, and refined grains reduces intake of nutrient-dense foods and beverages without exceeding caloric requirements.
TABLE 1.1 Healthy U.S.-Style Eating Pattern: Recommended Amounts of Food From Each Food Group at 12 Calorie Levels
Calorie Level of Patterna 1000 1200 1800 2000 2400 3000 Food Group Daily Amountb of Food From Each Group (vegetable and protein foods
subgroup amounts are per w eek) Vegetables 1 c-eq
c-eq c-eq
c-eq
3 c-eq 4 c-eq
Dark-green vegetables (c-eq/w k) 1 2
Red and orange vegetables (c-eq/w k) 3 6
Legumes (beans and peas; c-eq/w k) 2 3
Starchy vegetables (c-eq/w k) 2 5 5 6 8
Other vegetables (c-eq/w k) 4 4 5 7
Fruits 1 c-eq 1 c-eq c-eq
2 c-eq 2 c-eq c-eq
Grains 3 oz-eq 4 oz-eq 6 oz-eq 6 oz-eq 8 oz-eq 10 oz-eq W hole grainsc (oz-eq/day) 2 3 3 4 5
Refined grains (oz-eq/day) 2 3 3 4 5
Dairy 2 c-eq c-eq
3 c-eq 3 c-eq 3 c-eq 3 c-eq
Protein Foods 2 oz-eq 3 oz-eq 5 oz-eq oz-eq
oz-eq
7 oz-eq
Seafood (oz-eq/w k) 3 4 8 8 10 10 Meats, poultry, eggs (oz-eq/w k) 10 14 23 26 31 33 Nuts, seeds, soy products (oz-eq/w k) 2 2 4 5 5 6 Oils 15 g 17g 24 g 27 g 31 g 44 g Limit on calories for other uses, calories (% of calories)d
150 (15%) 100 (8%) 170 (9%) 270 (14%) 350 (15%) 470 (16%)
aFood intake patterns at 1000, 1200, and 1400 calories are designed to meet the nutritional needs of 2- to 8-year-old children. Patterns from 1600 to 3200 calories are designed to meet the nutritional needs of children 9 years and older and adults. If a child 4 to 8 years of age needs more calories and, therefore, is following a pattern at 1600 calories or more, that child’s recommended amount from the dairy group should be 2.5 cups per day. Children 9 years and older and adults should not use the 1000-, 1200-, or 1400-calorie patterns. bFood group amounts shown in cup-equivalents (c-eq) or ounce-equivalents (oz-eq), as appropriate for each group, based on caloric and nutrient content. cAmounts of whole grains in the Patterns for children are less than the minimum of 3 oz-eq in all Patterns recommended for adults.
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dAll foods are assumed to be in nutrient-dense forms; lean or low-fat; and prepared without added fats, sugars, refined starches, or salt. If all food choices to meet food group recommendations are in nutrient-dense forms, a small number of calories remain within the overall calorie limit of the Pattern (i.e., limit on calories for other uses). The number of these calories depends on the overall calorie limit in the Pattern and the amounts of food from each food group required to meet nutritional goals. Calories from protein, carbohydrates, and total fats should be within the Acceptable Macronutrient Distribution Ranges (AMDRs). From U.S. Department of Health and Human Services, U.S. Department of Agriculture: 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: 2015 (Dec), USDHHS/USDA. https://health.gov/dietaryguidelines/2015/guidelines/appendix-3/.
TABLE 1.2 Principal Nutrient Contributions of Each Food Group
Nutrients Vegetable Fruit Meat Milk Grain Protein X X X Vitamin A X X Vitamin D Xa Vitamin E X Vitamin C X X Thiamin X Xb Riboflavin X Xb Niacin X Xb Vitamin B6 X X Folate/folic acid X X Xb Vitamin B12 Xc Xc Calcium X Phosphorus X X X Magnesium X X Xd Iron X Xb Zinc X X X Fiber X X Xd
aIf fortified bIf enriched cOnly animal products dWhole grains
Portion control is very important to stay within the desired caloric level. Portion size is different than serving size. The amounts from each food group and subgroup change as needed among the different caloric levels to meet nutrient and Dietary Guidelines standards and comply with calories and overconsumed dietary components. Fig. 1.2 is a simple tool from the USDHHS that provides relationships consumers can relate to for estimating portion sizes. Within the U.S.-Pattern, serving or portion
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sizes are depicted as c-eq or oz-eq. Vegetables, fruits, and dairy food groups are represented with c-eq, which is the amount of a food or beverage considered equal to 1 cup or one portion. A serving size of many popular foods or beverages differs due to (1) concentration (e.g., raisins or tomato paste), (2) fresh produce that does not compress into a cup (e.g., salad greens), or (3) foods that are measured in a different form (e.g., meat and cheese). A serving portion of food from the grain or protein groups is equivalent to one ounce (oz-eq). If a food is concentrated or contains minimal amounts of water (e.g., nuts, peanut butter, jerky, cooked beans, rice or pasta), its portion size may be less than a measured ounce (by weight). If it contains a large amount of water (e.g., tofu, cooked beans, cooked rice or pasta), it may be more than a measured ounce (weight).
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FIGURE 1.2 Serving size card. This tool can be used when estimating appropriate serving sizes when choosing/serving foods.
(From U.S. Department of Health and Human Services, National Heart, Lung and Blood Institute, Obesity Education Initiative. Serving sizes and portions: and servings: what’s
the difference? Portion distortion. https://www.nhlbi.nih.gov/health/educational/wecan/downloads/servingcard7.pdf.)
The U.S.-Patterns meet the RDA for almost all nutrients. Vitamins D and E and potassium are marginal in the U.S.-Patterns for many or all age–sex groups. Intake below the RDA or AI for these nutrients is not considered to be of public health concern.
Other meal patterns endorsed in the 2015–2020 Dietary Guidelines include the Dietary Approaches to Stop Hypertension (DASH) diet (see Chapter 12), Mediterranean-Style Eating Pattern (see Evolve website), and Healthy Vegetarian Eating Pattern (see Chapter 5 and Evolve website).
Key Recommendations for Healthy Eating Patterns A healthful eating pattern includes vegetables, fruits, dairy, protein foods, and oils, as summarized in the Key Recommendations (Box 1.1).
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https://www.nhlbi.nih.gov/health/educational/wecan/downloads/servingcard7.pdf
Box 1.1
2 0 1 5 – 2 0 2 0 Di e tary Gui de l i ne s f or A me ri c ans E x e c u t ive S u mma ry: K e y R e c omme n d a t ion s Consume a healthful eating pattern that accounts for all foods and beverages within an appropriate calorie level.
A Healthy Eating Pattern Includes:*
• A variety of vegetables from all of the subgroups–dark green, red and orange, legumes (beans and peas), starchy, and other
• Fruits, especially whole fruits
• Grains, at least half of which are whole grains
• Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages
• A variety of protein foods, including seafood; lean meats and poultry; eggs; legumes (beans and peas); and nuts, seeds, and soy products
• Oils
A Healthy Eating Pattern Limits:
• Saturated fats and trans fats, added sugars, and sodium Key recommendations that are quantitative are provided for several
components of the diet that should be limited. These components are of particular public health concern in the United States, and the specified limits can help individuals achieve healthy eating patterns within calorie limits:
• Consume less than 10% of calories per day from added sugarsa
• Consume less than 10% of calories per day from saturated fatsb
• Consume less than 2300 milligrams (mg) per day of sodiumc
• If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and up to two drinks per day for men—
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and only by adults of legal drinking age.d
*Definitions for each food group and subgroups are provided in subsequent sections of this chapter. aThe recommendation to limit intake of calories from added sugars is a target based on evidence that demonstrates the need to limit added sugars to meet food group and nutrient needs within calorie limits. bThe recommendation to limit intake of calories from saturated fats is a target based on evidence that replacing saturated fats with unsaturated fats is associated with reduced risk of cardiovascular disease. cThe recommendation to limit intake of sodium is the UL for individuals ages 14 years and older set by the National Academy of Medicine (formerly the Institute of Medicine). dThe amount of alcohol and calories in beverages varies and should be accounted for within the limits of healthy eating patterns. There are many circumstances in which individuals should not drink, such as during pregnancy.
From U.S. Department of Health and Human S ervices, U.S. Department of Agriculture, 2015–2020 Dieta ry Guidelines for America ns, 8th ed. Washington, DC: US DHHS/USDA, 2015. https://health.gov/dietaryguidelines/2015/guidelines/executive-summary/#key-recs.
Calorie Balance Individuals should consume a healthy eating pattern that includes all foods and beverages within an appropriate caloric level to achieve and/or maintain a healthy body weight. The basic element for healthful eating patterns is managing caloric balance, an average equilibrium between calories consumed (food and beverages) and calories expended (metabolic processes and physical activity). For a person to maintain a set weight, energy consumed from foods and beverages must equal calories expended in normal physiologic functions and physical activity. The average intake for Americans age 20 years and over in 2011 to 2012 was 2191 cal per day (1837 cal/day for women and 2567 cal/day for men).4 Because weight loss is a challenge requiring changes in many behaviors and patterns, avoiding excess pounds is ideal. Even small decreases in caloric intake can help prevent weight gain. A reduction in daily intake of 100 calories to prevent gradual weight gain is much easier than reducing daily intake by 500 calories to lose weight. In general, the best choice for weight loss involves a change in lifestyle, both in diet and physical activity. By frequently monitoring body weight, consumers can determine whether their eating patterns are providing an appropriate amount of
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calories and thereby adjust food intake and/or activity level. All Americans are encouraged to achieve and/or maintain a healthy body weight: • Children and adolescents are encouraged to maintain calorie balance to
support normal growth and development without promoting excess weight gain.
• Women are encouraged to achieve and maintain a healthy weight, and women who are pregnant are encouraged to gain weight within gestational weight gain guidelines (see Chapter 13).
• Adults who are overweight or obese should change both eating habits and physical activity to prevent additional weight gain and/or promote weight loss.
• Older adults (65 years and older) who are overweight or obese are encouraged to prevent additional weight gain. Intentional weight loss is beneficial for patients who have chronic conditions such as CVD or diabetes.
Body weight can be evaluated in relation to a person’s height using body mass index (BMI) to determine health risks that increase at higher levels of overweight (BMI 25.0–29.9) and obesity (BMI >30.0). BMI is a preferred method of defining healthy weight because it correlates more closely with actual body fat than height and weight tables. BMI can be determined by using the table on page ix and Table 1.3 to classify body weight category (underweight, normal weight, overweight, or obese). A BMI of less than 25 is generally considered a healthy weight; chronic disease risk increases in most people who have a BMI above 25. BMI reflects overall fat distribution and can be calculated quickly and inexpensively. BMI is not appropriate for pregnant and nursing women, infants and children younger than age 2 years (see special table on the Evolve website for children 2 to 20 years old), or some athletes with a large percentage of muscle.
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TABLE 1.3 Body Mass Index and Corresponding Body Weight Categories for Children and Adults
Body Weight Category
Children and Adolescents (Ages 2–19 y; BMI-for-Age Percentile Range)
Adults (BMI)
Underw eight < 5th percentile < 18.5 kg/m2 Normal w eight 5th percentile to < 85th percentile 18.5–24.9
kg/m2 Overw eight 85th to < 95th percentile 25.0–29.9
kg/m2 Obese ≥ 95th percentile ≥ 30.0 kg/m2
From U.S. Department of Health and Human Services, U.S. Department of Agriculture: 2015–2020 Dietary Guidelines for Americans. 8th ed. 2015 (Dec), USDHHS/USDA. https://health.gov/dietaryguidelines/2015/guidelines/.
BMI reveals little about overall body composition. It is a starting point in assessing an individual’s health status and risks that is noninvasive, inexpensive, and quick. Limitations of relying solely on a person’s BMI include the following: (1) women tend to have more body fat; (2) BMI can underestimate body fat in an elderly person who has lost lean body mass; (3) ethnic background can impact bone mineral density; and (4) BMI overestimates body fat in individuals who have very high levels of lean body mass. Athletes usually have high BMIs because of their increased muscle mass, not excess fat. On the other hand, a frail or inactive person with a normal-range BMI may have excess body fat and not appear out of shape. Additional muscle tissue aids body functions, but excessive fat interferes with normal metabolism. A healthy weight depends on the amount and location of body fat and other health indicators, such as blood pressure, glucose, and cholesterol and triglyceride levels.
Major ethnic differences exist regarding BMI. For example, Asian Americans or persons from India are at risk of health problems at a lower BMI (18.5–23.9 is a better range) than whites; African Americans can have higher BMIs (28.0) than other populations without developing health problems. Older adults can tolerate slightly more body fat and tend to have a better survival rate with a BMI in the upper range of normal.5
All foods and some beverages contain varying amounts of calories based on their nutrient content. Macronutrients include carbohydrates and protein that contribute 4 cal/g; fats, 9 cal/g; and alcohol, which, although not a nutrient, contributes 7 cal/g when consumed. Most foods and beverages contain combinations of macronutrients in varying amounts. There is little evidence that any individual macronutrient has a
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https://health.gov/dietaryguidelines/2015/guidelines/
unique impact on body weight. Caloric intake is the key factor to controlling body weight, not by manipulating the proportions of fat, carbohydrates, and protein but by balancing overall calories with energy expenditure.
A patient’s caloric requirements are based on size (height and weight), age, sex, and level of physical activity. Many Americans consume more calories than they need and spend large portions of their days engaged in sedentary behaviors that expend minimal calories. Consequently, many children and adults routinely consume more calories than they expend.
For weight maintenance, caloric requirements typically range from 1600 to 2400 calories daily for adult women and 2000 to 3000 calories for adult men, with variances depending on physical activity. The metabolic rate decreases with age, thus lowering caloric requirements for older adults.
Vegetables Vegetables are primary sources of the required nutrients dietary fiber, vitamin A (carotenoids), vitamin C, folic acid, and potassium (Table 1.4). Most vegetables are naturally low in fat and are cholesterol free. Because of their high water and fiber content, most vegetables are relatively low in calories. Dark-green vegetables provide calcium, iron, magnesium, and riboflavin. Beans are unusual because they are in both the vegetable and protein groups. Beans contain protein, fiber, calcium, folic acid, and potassium. Choosing dark-green, red, and orange vegetables; legumes (beans and peas); starchy vegetables; and other vegetables several times a week is encouraged to provide the many nutrients contributed by different vegetables.
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Table 1.4 Contributions of Selected Fruits and Vegetables
Fruit/Vegetable Vitamin Aa,b Vitamin Cc,d Fibere,f Acorn squash # # # Apple w ith skin # Avocado # † Banana # # Bell pepper † Bok choy † † Broccoli, cooked † † # Brussels sprouts † # Cabbage † # Cantaloupe † † Carrot † # # Cauliflow er † Collard greens † † Grapefruit # † Iceberg lettuce # Kale † † # Kiw i † # Kohlrabi † # Mango † † Orange † Papaya † † Pear # Prune, dried † Romaine lettuce † Spinach † # Straw berry † Sw eet potato † † # Sw iss chard † † Tomato # †
a# = Good source: 500–950 IU/100 g b† = Excellent source: ≥ 950 IU/100 g c# = Good source: 6–11.4 mg/100 g d† = Excellent source: ≥ 11.4 mg/100 g e# = Good source: 2.5–4.75 g/100 g f† = Excellent source: ≥ 4.75 g/100 g Data from U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. USDA National Nutrient Database for Standard Reference, Release 28. Version current: September 2015, slightly revised May 2016. Accessed August 8, 2017. https://www.ars.usda.gov/ba/bhnrc/ndl
Despite an abundance of nutritious foods available in the United States, many individuals do not choose the variety of nutrient-dense foods that provide all their nutrient requirements and enable them to remain within their calorie needs.
Vegetable choices include all fresh, frozen, canned, and dried options,
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cooked or raw, in addition to vegetable juices. Nutrient-dense vegetables are limited in the amount of salt, butter, or creamy sauces added. The U.S.-Pattern for a 2000-calorie diet includes c-eq of vegetables daily. For each vegetable subgroup, weekly amounts are recommended to ensure variety and meet nutrient needs.
Fruits All fruits or 100% fruit juices count as part of the fruit group. Fruits are naturally low in fat, sodium, and calories, and do not contain cholesterol. They are also important sources of potassium, dietary fiber, vitamin C, and folate (see Table 1.4). Fresh, frozen, canned, or dried fruits are recommended for their fiber content, but fruit juice should be minimized because it does not contain fiber and excess amounts can contribute extra calories.
Because of their high water content, fruits are more filling than juices, with fewer calories. Fruit juice can be part of a healthful diet, but only the proportion that is 100% fruit juice counts because these products usually contain added sugars. The percentage of juice in a beverage is indicated on the package label. Fruit juices containing added sugars are classified as sugar-sweetened beverages. The recommendation for children 6 months to 6 years old limits 100% fruit juice to 4 to 6 fluid ounces per day (infants under 6 months old should not be given any juice).
At least half of the recommended amount of fruit should be from whole fruits (fresh, canned, frozen, or dried). Fruits that contain a small amount of added sugar can be chosen as long as daily calories from added sugars does not exceed 10% and total caloric intake remains within limits. With canned fruits, those containing the least amount of added sugar should be selected. The recommended amount of fruits in the U.S- Pattern for 2000 cal is 2 c-eq daily (see Table 1.1 for amounts for different caloric levels).
Grains Grains are principally carbohydrates or starchy foods and are essential for a healthful diet. The U.S.-Patterns include whole grains and refined grains, but products made with refined grains, especially those high in saturated fats, added sugars, and/or sodium, such as cookies, cakes, and some snack foods are limited. All whole-grain, refined and enriched, or fortified-grain products are included in these two groups, for example, barley, buckwheat, bulgur, corn, millet, rice, rye, oats, sorghum, wheat,
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and wild rice. At the 2000-cal level, the U.S.-Pattern indicates a total of 6 oz-eq per
day. Most Americans are consuming more than the recommended amount of refined grains, but the Dietary Guidelines Advisory Committee estimates that 95% of Americans do not reach guideline amounts for whole grains.6
Whole grains are grains and grain products made from the entire grain seed, usually called the kernel, which consists of bran, germ, and endosperm. If the kernel has been cracked, crushed, or flaked, it must retain all components of the original grain kernel (bran, germ, and endosperm) to be called whole grain. Whole wheat, oatmeal, brown rice, whole rye, and quinoa are all whole grains. When selecting whole grains, the first or second ingredient listed on the ingredient panel should contain the words whole grain. One oz-eq of whole grains has 16 g of whole grains; a food that contains 8 g/oz-eq or more whole grains is at least half whole grains. Product labels usually indicate the grams of whole grain to help consumers identify food choices having a substantial amount of whole grains.
The difficulty in identifying whole grains is a major barrier. Labels such as “100% wheat,” “stone-ground,” and “multigrain” do not guarantee that the food contains whole grain. Multiple conflicting definitions exist for identifying whole-grain products, causing confusion for consumers. Color is a poor indicator of whole grains because molasses or caramel food coloring may be added. As a result of the Dietary Guidelines, food manufacturers have introduced more processed foods with higher whole-grain content.
Most whole grains are a good source of dietary fiber and are needed to meet the daily fiber recommendation. Whole grains differ from a nutritional perspective, with significant variations in levels and effects of the fiber. Whole-grain products contribute more fiber, magnesium, phosphorus, and zinc than do enriched products (Table 1.5). When whole grains are refined, vitamins, minerals, and dietary fiber are lost in the process.
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TABLE 1.5 Comparison of Nutrient Values of Selected Whole-Grain and Enriched Breads (1 slice)
Nutrients Enriched White Whole Wheat Multigrain Whole Grain Rye Protein (g) 3.0 3.98 3.47 4.0 2.72 Total dietary fiber (g) 0.6 1.9 1.9 3.0 1.9 Thiamin (mg) 0.20 0.126 0.73 0.740 0.139 Riboflavin (mg) 0.13 0.053 0.034 0.340 0.107 Niacin (mg) 1.89 1.420 1.051 1.20 1.218 Vitamin B6 (mg) 0.01 0.069 0.068 0.080 0.024 Total folate (mcg) 72 13 20 Unk 48 Iron (mg) 1.10 0.79 0.65 0.72 0.91 Zinc (mg) 0.21 0.57 0.44 0.60 0.36 Sodium (mg) 120 146 99 150 193 Calcium (mg) 4.0 52.0 27.0 20.0 23.0 Phosphorus (mg) 24.0 68.0 59.0 80.0 40.0 Magnesium (mg) 6.0 24.0 20.0 32.0 13.0
U.S. Department of Agriculture, Agricultural Research Service. 2016. USDA Food and Nutrient Database for Dietary Studies 2011–2012. Release 28. https://ndb.nal.usda.gov/ndb/. Accessed March 20, 2017.
Most refined grains are enriched with some of the nutrients lost in the process, but dietary fiber and some vitamins and minerals are not routinely added back in the enrichment process. Enrichment is the process by which iron, thiamin, riboflavin, folic acid, and niacin removed during processing are restored to approximate their original levels. This process is controlled by the U.S. Food and Drug Administration (FDA), which establishes the quantity of nutrients permitted.
Fortification is the process by which nutrients not present in the natural product are added or increased in the original product. Most processed breakfast cereals are fortified to achieve nutrient levels higher than those naturally occurring in the grain. Whole grains are a poor source of folic acid; thus, rather than relying exclusively on whole grains, some cereal products fortified with folic acid should be selected. Products that are enriched with folic acid are especially important for women who are pregnant or capable of becoming pregnant. Serious birth defects may occur during early pregnancy if adequate amounts of folic acid are not consumed. Despite the fact that enriched grains have a positive role in providing some vitamins and minerals, excessive amounts can result in excess calories being consumed. The recommended amount of refined grains is less than 3 oz-eq servings daily; at least one-half of an individual’s grain choices should be whole grains.
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