guidelines for dietary...

CHAPTER 12

Guidelines for Dietary Planning

Sylvia Escott-Stump, MA, RD, LDNRobert Earl, DrPH, RD

337

KEY TERMSadequate intake (AI) the recommended daily intake level based on observed or experimentally determined approxi-mations of nutrient intake by a group (or groups) of healthy people; used when a recommended dietary allowance can-not be determineddaily reference values (DRVs) a set of food labeling refer-ence values for which no nutrient recommendation previ-ously existed; established for fat, saturated fatty acids, cho-lesterol, total carbohydrate, protein, dietary fi ber, sodium, and potassiumdaily value (DV) reference term on food labels to aid con-sumers in selecting a healthy diet; consists of two sets of references—the reference daily intakes (RDIs) and daily reference values (DRVs)—expressed as percentagesDietary Guidelines for Americans (DGA) dietary recommen-dations that promote health and reduce risk of chronic dis-ease for people ages 2 years and olderdietary reference intake (DRI) an overall term designed to encompass the four specifi c types of nutrient recommenda-tions (adequate intake [AI], estimated average requirement [EAR], recommended dietary allowance [RDA], and toler-able upper intake level [UL]); used for nutrient recommen-dations for the United States and Canadaestimated average requirement (EAR) nutrient intake value that is estimated to meet the requirements of half the healthy individuals in a groupestimated safe and adequate daily dietary intake (ESADDI) recommended intake ranges of nutrients for which not enough information is available to establish a recommended dietary allowance

health claim any claim on a food package label or other la-bel (such as an advertisement) of a food, including fi sh and game meat, that characterizes the relationship of any nutri-ent or other substance in the food to a disease or health-related conditionHealthy Eating Index (HEI) summary measure of overall diet quality; designed to assess and monitor the dietary sta-tus of AmericansMyPyramid Food Guidance System translates the Dietary Guidelines for Americans and nutrient recommendations into a visual form of the types and amounts of food to eat each day; new system incorporates physical activity into daily patternsnutrition facts label nutrient content information on food products designed to help consumers (4 years of age and older) select foods to incorporate into a healthy diet using the MyPyramid Food Guidance System and Dietary Guide-lines for Americansrecommended dietary allowance (RDA) the amount of a nutrient needed to meet the requirements of almost all (97% to 98%) of the healthy populationreference daily intakes (RDIs) set of dietary references for vi ta mins and minerals on food labels based on the 1968 recommended dietary allowances; replaces the U.S. recom-mended daily allowances that were previously used with nutrition labeling on food productstolerable upper intake level (UL) the highest daily intake amount of a nutrient that is likely to pose no risk of ad-verse health effects for almost all individuals in the gen-eral population

Sections of this chapter were written by Susan T. Borra, RD, and Paul R. Thomas, EdD, RD, for previous editions of this text.

338 PART 2 | Nutrition in the Life Cycle

An appropriate diet is adequate and balanced and considers the individual’s characteristics such as age and stage of de-velopment, taste preferences, and food habits. It also refl ects the availability of foods, socioeconomic conditions, storage and preparation facilities, and cooking skills. An adequate and balanced diet meets all the nutritional needs of an indi-vidual for maintenance, repair, living processes, growth, and development. It includes energy and all nutrients in proper amounts and in proportion to each other. The presence or absence of one essential nutrient may affect the availability, absorption, metabolism, or dietary need for others. The recognition of nutrient interrelationships provides further support for the principle of maintaining variety in foods to provide the most complete diet.

With increasing knowledge of diet and disease links that lead to premature disability and mortality among Ameri-cans, an appropriate diet is now considered one that helps reduce the risk of developing chronic degenerative diseases and conditions. In this era of vastly expanding scientifi c knowledge and information about food components, the way the public thinks about food intake for health promo-tion and disease prevention is changing rapidly. In addition to traditional nutrient requirements, the public often hears references to functional foods, which are foods or food com-ponents that provide more benefi ts than basic nutritional benefi ts. Dietitians and other health professionals are es-sential translators of food, nutrition, and health information into dietary choices and patterns for groups and individuals. See Conceptual Framework on the inside back cover.

According to the Food and Nutrition Board, choosing various foods to meet dietary recommendations should pro-vide adequate amounts of the nutrients that do not have well-defi ned recommended levels. A varied diet also ensures that a person is consuming suffi cient amounts of food con-stituents that, although not defi ned as nutrients, have bio-logic effects and may infl uence health and susceptibility to disease. Examples include dietary fi ber and carotenoids, as well as lesser known phytochemicals (substances found in plant products) such as isothiocyanates in broccoli or other cruciferous vegetables and lycopene in tomato products (see Tables 9-1 and 9-2). Diets rich in phytochemicals may help reduce the risk of developing certain types of cancer, but their exact mechanisms are not totally understood.

DETERMINING NUTRIENT NEEDSWorldwide GuidelinesNumerous standards serve as guides for planning and evalu-ating diets and food supplies for individuals and population groups. Many countries have issued guidelines appropriate for the circumstances and needs of their populations. The Food and Agriculture Organization (FAO) and the World Health Organization (WHO) of the United Nations have established international standards in many areas of food quality and safety, as well as dietary and nutrient recommen-dations. In the United States the Food and Nutrition Board (FNB) of the Institute of Medicine (IOM) has led the devel-

opment of nutrient recommendations since the 1940s. Since the mid-1990s, nutrient recommendations developed by the FNB have been used by the United States and Canada. The U.S. Department of Agriculture (USDA) and Department Health and Human Services (DHHS) have a shared respon-sibility for issuing dietary recommendations, collecting and analyzing food composition data, and formulating regula-tions for nutrition information on food products. In Canada, Health Canada is the agency responsible for Canadian di-etary recommendations and food labeling regulations.

Dietary Reference Intakes American standards for nutrient requirements have been the recommended dietary allowances (RDAs) established by the FNB of the IOM. They were fi rst published in 1941 and most recently revised between 1997 and 2002. Each revision incor-porates the most recent research fi ndings. In 1993 the FNB developed a framework for the development of nutrient rec-ommendations, called dietary reference intakes (DRI). DRIs encompass four types of nutrient recommendations for healthy individuals: adequate intake (AI), estimated average intake (EAR), RDA, and tolerable upper intake level (UL).

DRI reports for nutrients are now complete. Nutrition and health professionals should also use the most updated food composition databases and tables and inquire whether data used in computerized nutrient analysis programs have been revised to include the most up-to-date information.

ComponentsThe DRI model expands the previous RDA, which focused only on levels of nutrients for healthy populations to pre-vent defi ciency diseases. To respond to scientifi c advances in diet and health throughout the life cycle, the DRI model now includes four reference points.

The adequate intake (AI) is a nutrient recommendation based on observed or experimentally determined approxi-mation of nutrient intake by a group (or groups) of healthy people when suffi cient scientifi c evidence is not available to calculate an RDA or an EAR. The estimated average requirement (EAR) is the average requirement of a nutrient for healthy individuals; a functional or clinical assessment has been conducted, and measures of adequacy have been made at a specifi ed level of dietary intake. An EAR is the amount of a nutrient with which approximately one half of individuals would have their needs met and one half would not. The EAR should be used for assessing the nutrient adequacy of populations, not individuals.

The recommended dietary allowance (RDA) pres ents the amount of a nutrient needed to meet the requirements of al-most all (97% to 98%) of the healthy population of individuals for whom it was developed. An RDA for a nutrient should serve as a goal for intake for individuals, not as a benchmark of adequacy of diets of populations. Finally the tolerable upper intake level (UL) has been established for many nutrients to reduce the risk of adverse or toxic effects from increased con-sumption of nutrients in concentrated forms—either alone or combined with others (not in food)—or from enrichment and fortifi cation. A UL is the highest level of daily nutrient intake

CHAPTER 12 | Guidelines for Dietary Planning 339

that is unlikely to have any adverse health effects on almost all individuals in the general population. The DRIs for the mac-ronutrients, vi ta mins and minerals, including the Uls are pres-ented on the inside front cover and opening page of this text. The acceptable macronutrient distribution ranges based on energy intake are shown in Table 12-1.

Target PopulationEach of the nutrient recommendation categories in the DRI system is used for specifi c purposes among individuals or populations. The EAR is used for evaluating the nutrient intake of populations. The new RDA can be used for indi-viduals. Nutrient intakes between the RDA and the UL may further defi ne intakes that may promote health or prevent disease in the individual.

Age- and Sex-GroupsBecause nutrient needs are highly individualized depending on age, sexual development, and the reproductive status of females, the DRI framework has 10 age-groupings, includ-ing age-group categories for children, men and women 51 to 70 years of age, and those over 70 years of age. It sepa-rates three age-group categories each for pregnancy and lactation—less than 18 years, 19 to 30 years, and 31 to 50 years of age.

Reference Men and WomenThe requirement for many nutrients is based on body weight. The RDAs are listed according to reference men and women of designated height and weight. These values for age-sex groups of individuals older than 19 years of age are based on actual medians obtained for the American population by the third National Health and Nutrition Ex-amination Survey (NHANES) III, 1988 to 1994. Although this does not necessarily imply that these weight-for-height

values are ideal, at least they make it possible to defi ne rec-ommended allowances appropriate for the largest number of people. The reference heights and weights for children and adults in the U.S. are shown in Table 12-2.

Estimated Safe and Adequate Daily Dietary IntakesNumerous nutrients are known to be essential for life and health, but data for some are insuffi cient to establish a recommended intake. Intakes for these nutrients are esti-mated safe and adequate daily dietary intakes (ESADDI). Most intakes are shown as ranges to indicate that not only are specifi c recommendations not known, but also at least the upper and lower limits of safety should be observed.

NUTRITIONAL STATUS OF AMERICANS

Food and Nutrient Intake DataTwenty-two federal agencies collect information about the dietary and nutritional status of Americans and the relation-ship between diet and health. This effort is coordinated by the USDA and DHHS through the National Nutrition Monitoring and Related Research Program (NNMRRP) (FASEB, 1995). The NHANES and the Continuing Survey of Food Intakes by Individuals (CSFII) are the cornerstone surveys of the NNMRRP (see Chapter 11).

Overall the nutritional quality of the American diet shows that the population is slowly changing eating pat-terns and adopting more healthy diets, although gaps exist between consumption and government recommendations among population subgroups. Intake of total fat, saturated fatty acids, and cholesterol has decreased among some

AMDR (Percentage of Energy as kcal/day)

AMDR Sample Diet Adult, 2000-kcal/day Diet

Nutrient 1-3 Years 4-18 Years �19 Years % Reference* g/Day

Protein† 5-20 10-30 10-30 10 50Carbohydrate 45-65 45-65 45-65 60 300Fat 30-40 25-35 25-35 30 67�-Linolenic acid (*n-3)‡ 0.6-1.2 0.6-1.2 0.6-1.2 0.8 1.8Linoleic acid (n-6) 5-10 5-10 5-10 7 16Added sugars§ �25% of total calories 500 125

Acceptable Macronutrient Distribution Ranges

TABLE 12-1

Modifi ed from Food and Nutrition Board, Institute of Medicine: Dietary reference intakes for energy, carbohydrate, fi ber, fat, fatty acids, cholesterol, protein, and amino acids, Washington, DC, 2002, National Academies Press.

*Suggested maximum.

†Higher number in protein AMDR is set to complement AMDRs for carbohydrate and fat, not because it is a recommended upper limit in the range of calories from protein.

‡Up to 10% of the AMDR for a-linoenic acid can be consumed as EPA, DHA, or both (0.06%-0.12% of calories).

§Reference percentages chosen based on average dietary reference intake (DRI) for protein for adult men and women, then calculated back to percentage of calories. Carbohydrate and fat percentages chosen based on difference from protein and balanced with other federal dietary recommendations.


From Dietary Reference Intakes: Applications in dietary planning, Washington DC, 2003, The National Academies Press, http://www.iom.edu/CMS/3788/4003/4733.aspx.

*Taken from male and female median BMI and height-for-age data from the Third National Health and Nutrition Examination Survey (NHANES III), 1988-1994; used in earlier DRI reports.

†Taken from new data on male and female median BMI and height-for-age data from the Centers for Disease Control and Prevention/National Center for Health Statistics Growth Charts.

‡Calculated from CDC/NCIIS Growth Charts, median BMI and median height for ages 4 through 19 years.

Sex Age

Previous Median Body Mass Index* (BMI)

(kg/m2)

New Median BMI†

(kg/m2)

New Median Reference Height†

cm (in)

New Reference Weight‡ kg (lb)

Male, female 2-6 mo — — 62 (24) 6 (13) 7-12 mo — — 71 (28) 9 (20) 1-3 yr — — 86 (34) 12 (27) 4-8 yr 15.8 15.3 115 (15) 20 (11)

Male 9-13 yr 18.5 17.2 144 (57) 36 (79) 14-18 yr 21.3 20.5 174 (68) 61 (134) 19-30 yr 24.4 22.5 177 (70) 70 (154)

Female 9-13 yr 18.3 17.4 144 (57) 37 (81) 14-18 yr 21.3 20.4 163 (64) 54 (119) 19-30 yr 22.8 21.5 163 (61) 57 (126)

Reference Heights and Weights for Children and Adults in the United States

TABLE 12-2

portions of the population. The average consumption of servings of fruits and vegetables has risen to four per day, approaching the recommendation of fi ve servings per day. However, many Americans experience food insecurity, or hunger from not getting enough to eat (see Chapter 11).

Nutrition-related health measurements indicate that overweight and obesity are increasing from lack of physi-cal activity. The number of people with acceptable serum cholesterol levels is increasing, although some individuals still have high levels, a major risk factor for coronary heart disease. Hypertension remains a major public health prob-lem in middle-age and older adults; among non-Hispanic blacks it increases the risk of stroke and coronary heart disease. Osteoporosis develops more often among non-Hispanic whites than non-Hispanic blacks or Mexican Americans.

Healthy Eating IndexThe Center for Nutrition Policy and Promotion of the USDA releases the Healthy Eating Index (HEI) to measure how well people’s diets conform to recommended healthy eating patterns. The index provides a picture of foods people are eating, the amount of variety in their diets, and compli-ance with specifi c recommendations in the Dietary Guide-lines for Americans (DGA). The HEI is designed to assess and monitor the dietary status of Americans by using data from the CSFII and evaluating 10 components, each repres-enting different aspects of a healthy diet. The dietary com-ponents used in the evaluation include grains, vegetables, fruits, milk, meat, total fat, saturated fat, cholesterol sodium, and variety. Data from the HEI over time show that Ameri-

cans are reducing total fat and saturated fat in their diets and eating a wider variety of foods but still need to eat more fruit, drink more milk or calcium and vi ta min D concentrated beverages, and reduce their sodium intake. Women gener-ally have scores higher than men, and children ages 2 to 3 have the highest HEI scores. The overall healthy eating in-dex (HEI) score ranges from 0 to 100. In 1989 the overall HEI score was 61.5, in 1996 it was 63.8, and it remained the same in 2000. Of the U.S. population, 10% had a good diet with a rating of 80 or higher, 74% had diets that needed improvement, and 16% had poor diets with scores less than 51 (Basiotis et al., 2002). The Healthy Eating Index 2005 can be used to assess the diet of an individual also (Table 12-3).

Nutrition Monitoring ReportAt the request of the DHHS and USDA, the Expert Panel on Nutrition Monitoring was established by the Life Sci-ences Research Offi ce of the Federation of American Soci-eties for Experimental Biology (FASEB) to review the di-etary and nutritional status of the American population. The report of the committee summarized the results of data from NHANES II, Hispanic HANES, and the Nationwide Food Consumption Survey (NFCS) and CSFII surveys. In general, the committee concluded that the food supply in the United States is abundant, although some people may not receive enough nutrients for various reasons. Nutrient intakes are most likely to be low in persons living below the poverty level. Intakes of nutrients reported to be low in the general population are even lower in the poverty group. Key food components that are identifi ed as current or potential public health issues are listed in Table 12-4.


From U.S. Department of Agriculture, Center for Nutrition Policy and Promotion: Healthy eating index 2005, available at www.cnpp.usda.gov, accessed April 16, 2007.

*Intakes between the minimum and maximum levels are scored proportionately, except for saturated fat and sodium (see �).

†Legumes counted as vegetables only after meat and beans standard is met.

‡Includes all milk products, such as fl uid milk, yogurt, and cheese.

§Includes nonhydrogenated vegetable oils and oils in fi sh, nuts, and seeds.

�Saturated fat and sodium get a score of 8 for the intake levels that refl ect the 2005 Dietary Guidelines: �10% of calories from saturated fat and 1.1 g of sodium per 1000 kcal, respectively.

ComponentMaximum

Points Standard for Maximum ScoreStandard for Minimum Score of Zero

Total fruit (includes 100% juice) 5 �0.8 cup equiv per 1000 kcal No fruitWhole fruit (not juice) 5 �0.4 cup equiv per 1000 kcal No whole fruitTotal vegetables 5 �1.1 cup equiv per 1000 kcal No vegetablesDark green and orange vegetables and

legumes†5 �0.4 cup equiv per 1000 kcal No dark green or orange

vegetables or legumesTotal grains 5 �3.0 oz equiv per 1000 kcal No grainsWhole grains 5 �1.5 oz equiv per 1000 kcal No whole grainsMilk‡ 10 �1.3 cup equiv per 1000 kcal No milkMeat and beans 10 �2.5 oz equiv per 1000 kcal No meat or beansOils§ 10 �12 g per 1000 kcal No oilSaturated fat 10 �7% of energy� �15% of energySodium 10 �0.7 g per 1000 kcal� �2 g per 1000 kcalCalories from solid fat, alcohol and added

sugar (SoFAAS)20 �20% of energy �50% of energy

Healthy Eating Index 2005 Components and Standards for Scoring*

TABLE 12-3

Food Component Relevance to Public Health

Energy Median reported energy intakes in the 1988 to 1991 CSFII were below recommended levels, yet many adolescents and adults are overweight. The high prevalence of overweight indicates that an energy imbalance exists among Americans because of physical inactivity and underreporting of energy intake or food consumption in national surveys.

Total fat, saturated fat, and cholesterol

Intakes of fat, saturated fatty acids, and cholesterol among all age-groups older than 2 years of age were higher than recommended levels (�30% of calories for total fat and 8% to 10% of calories for saturated fatty acids). Cholesterol intakes were generally within the recommended range of 300 mg/dl or less.

Alcohol Intake of alcohol is a public health concern because it displaces food sources of nutrients and has potential health consequences.

Iron and calcium Low intakes of iron and calcium continue to be a public health concern, particularly among infants and females of childbearing age. Prevalence of iron defi ciency anemia was higher among these groups than among other age- and sex-groups. Low calcium intake is a particular concern among adolescent girls and adult women in most racial and ethnic groups.

Sodium Sodium intake continues to exceed government recommendations of 2400 mg/day in most age- and sex-groups.

Other nutrients at potential risk

Some population or age-groups may consume insuffi cient amounts of total carbohydrate and carbohydrate constituents such as dietary fi ber; protein; vi ta min A; antioxidant vi ta mins (vi ta mins C and E) carotenoids; folate, vi ta mins B6 and B12; magnesium, potassium, zinc, copper, selenium, phosphorus, and fl uoride. Intakes of polyunsaturated and monounsaturated fatty acids, trans-fatty acids, and fat substitutes may be unbalanced.

Food Components and Public Health Concerns

TABLE 12-4


General’s Reports on Nutrition and Health and the National Academy of Sciences (NAS) have provided similar qualitative or quantitative dietary recommendations. In Canada, dietary recommendations are prepared by Health Canada (see Clinical Insight: Nutrition Recommendations for Canadians).

Guidelines directed toward prevention of a particular disease, such as those from the National Cancer Institute, the American Diabetes Association, The American Heart Association, and the National Heart, Lung, and Blood Insti-tute’s cholesterol education guidelines, contain recommen-dations unique to particular conditions. The American Di-etetic Association (ADA) (2002) published a position statement stating that all foods can fi t into a healthful diet when the total diet, or overall pattern of food eaten, is con-sumed in moderation with appropriate portion sizes and combined with regular physical activity. The various guide-lines, summarized in Box 12-1 can be used by health coun-selors throughout most of the developed world.

Implementing the GuidelinesThe task of planning nutritious meals centers on including the essential nutrients in suffi cient amounts as outlined in the newest DRIs, in addition to appropriate amounts of energy, protein, carbohydrate (including fi ber and sugars), fat (especially saturated and trans-fats), cholesterol, and salt. Suggestions are included to help people meet the specifi cs of the recommendations. When specifi c numeric recom-mendations differ, they are pres ented as ranges.

The MyPyramid Food Guidance System, shown in Figure 12-1, offers a method for determining appropriate patterns for daily food choices based on servings from the fi ve major food groups. The MyPyramid system replaces the Food

The revision to Canada’s Food Guide to Healthy Eating was released in 2007 and developed age- and gender-

specifi c food intake patterns. These age- and gender-specifi c suggestions include 4 to 7 servings of vegetables and fruits, 3 to 7 servings of grain products, 2 to 3 servings of milk or milk alternatives, and 1 to 3 servings of meat or meat alternatives. Unlike MyPyramid in the United States, Canada’s Eating Well with Canada’s Food Guide contains four food groupings presented in a rainbow shape (Health Canada, 2007) (see Figure 12-2). Tips include:• Consume no more than 400-450 mg of caffeine per day.• Eat at least one dark green and one orange vegetable each

day.• Make at least half of grain products comsumed each day

whole grain.• Compare the Nutrition Facts table on food labels to

choose products that contain less fat, saturated fat, trans fat, sugar, and sodium.

Nutrition Recommendations for Canadians

CLINICAL INSIGHT

• Drink skim, 1% or 2% milk, or fortifi ed soy beverages each day. Check the food label to see if the soy beverage is fortifi ed with calcium and vitamin D.

• Include a small amount (30-45 ml [2-3 Tbsp]) of unsaturated fat each day to get the fat needed.

• Limit the intake of soft drinks, sports drinks, energy drinks, fruit drinks, punches, sweetened hot and cold beverages, and alcohol.

• Eat at least two Food Guide Servings of fi sh each week.• Build 30-60 minutes of moderate physical activity into

daily life for adults and at least 90 minutes a day for children and youth.

Data from Health Canada: Eating well with Canada’s food guide, ©Her Majesty the Queen in Right of Canada, represented by the Minister of Healthy Canada, 2007, available at www.hc-sc.gc.ca/fn-an/food-guide-aliment, accessed February 8, 2007.

NATIONAL GUIDELINES FOR DIET PLANNING

Within the past 30 years, attention has been focused increas-ingly on the relationship of nutrition to chronic diseases and conditions. Although this interest derives somewhat from the rapid increase in number of older adults and their longevity, it is also prompted by the desire to prevent premature deaths from diseases such as coronary heart disease, diabetes mellitus, and cancer. Approximately two thirds of deaths in the United States are caused by chronic disease.

Current Dietary Guidance in the United States and Canada Eating can be one of life’s greatest pleasures. People eat for enjoyment and to obtain energy and nutrients. Although many genetic, environmental, behavioral, and cultural fac-tors affect health, diet is equally important for promoting health and preventing disease.

In 1969, then President Nixon convened the White House Conference on Nutrition and Health (White House, 1970). Increased attention was being given to pre-vention of hunger and disease. The development of di-etary guidelines in the United States began with the 1977 report of the U.S. Senate Select Committee on Nutrition and Human Needs called Dietary Goals for the United States (U.S. Senate Select Committee on Nutrition and Human Needs, 1977).

In addition to these dietary guidelines, several other impor-tant government or expert reports have addressed dietary recommendations for healthy Americans. Previous Surgeon


Anatomy of MyPyramidOne size doesn’t fit allUSDA’s new MyPyramid symbolizes a personalized approach to healthy eating and physical activity.The symbol has been designed to be simple. It has been developed to remind consumers to makehealthy food choices and to be active every day. The different parts of the symbol are described below.

U.S. Department of AgricultureCenter for Nutrition Policy

and PromotionApril 2005 CNPP-16

GRAINSEat 6 oz. every day

VEGETABLESEat 21/2 cups

every day

FRUITSEat 2 cupsevery day

MILKGet 3 cups every

day;for kids aged2 to 8, it’s 2

MEAT &BEANS

Eat51/2 oz.everyday

OIL

S

ActivityActivity is represented by the steps and the person climbing them, as a reminder of the importance of daily physical activity.

ModerationModeration is represented by the narrowing of each food group from bottom to top. The wider base stands for foods with little or no solid fats or added sugars. These should be selected more often. The narrower top area stands for foods containing more added sugars and solid fats. The more active you are, the more of these foods can fit into your diet.

PersonalizationPersonalization is shown by the person on the steps, the slogan, and the URL. Find the kinds and amounts of food to eat each day at MyPyramid.gov.

Gradual ImprovementGradual improvement is encouraged by the slogan. It suggests that individuals can benefit from taking small steps to improve their diet and lifestyle each day

VarietyVariety is symbolized by the 6 color bands representing the 5 food groups of the Pyramid and oils. This illustrates that foods from all groups are needed each day for good health.

ProportionalityProportionality is shown by the different widths of the food group bands. The widths suggest how much food a person should choose from each group. The widths are just a general guide, not exact proportions. Check the Web site for how much is right for you.

For a 2,000-calorie diet, you need the amounts below from each food group. To find the amounts that are right for you, go to MyPyramid.gov.

FIGURE 12-1 MyPyramid Food Guidance System adds physical activity for public awareness. (U.S. Department of Agriculture and U.S. Department of Health and Human Services, available at http://www.mypyramid.gov/, accessed August 2, 2006).

• Adjust energy intake and exercise level to achieve and maintain appropriate body weight.

• Eat a wide variety of foods to ensure nutrient adequacy.• Increase total carbohydrate intake; increase complex

carbohydrate intake.• Eat less total fat and less saturated fat.• Eat more fi ber-rich foods.• Eat more fruits and vegetables.• Eat fewer high cholesterol foods.• Eat fewer high-sodium foods.• Reduce intake of concentrated sugars.

Universal Prescription for Health and Nutritional Fitness

BOX 12-1

• Drink alcohol in moderation or not at all.• Meet the recommended dietary allowance (RDA) for

calcium, a recommendation especially important for adolescents and women.

• Meet the RDA for iron, a recommendation especially for children, adolescents, and women of childbearing age.

• Limit protein to no more than twice the RDA.• If using a daily multivi ta min, choose dietary supplements

that do not exceed the dietary reference intake.• Drink fl uoridated water.


Guide Pyramid, which was highly visible but not clearly understood by the public.

For comparison, Eating Well with Canada’s Food Guide is shown in Figure 12-2. To help people select an eating pat-tern that achieves specifi c health promotion or disease pre-vention objectives, nutritionists should assist individuals in making food choices (e.g., to reduce fat, to increase fi ber).

Dietary recommendations have evolved during the past 30 years. Although numerous federal agencies are in-volved in the issuance of dietary guidance, USDA and DHHS lead the effort. Following the Senate’s Dietary Goals report, the Dietary Guidelines for Americans (DGA) was fi rst published in 1980. The guidelines were revised in 1985 (second edition), 1990 (third edition), 1995 (fourth edition), 2000 (fi fth edition) and the most recent guide-lines were released in 2005. With the passage of the Nutrition Monitoring Act in 1990, the dietary guidelines are now required to be reviewed every 5 years.

The DGA are designed to motivate consumers to change their eating and activity patterns by providing them with positive, simple messages. Using consumer research, the DGA develop messages that expand the infl uence of the dietary guidelines to encourage consumers to adopt them and ulti-mately change their behaviors. The messages reach out to consumers’ motivations, individual needs, and life goals and can be used in education, counseling, and communications initiatives. Box 12-2 lists the nine focus areas, Box 9-1 in Chapter 9 gives a summary of them, and the website provides full details and background information (see Useful Websites).

FOOD LABELING

To help consumers make choices between similar types of food products that can be incorporated into a healthy diet, the Food and Drug Administration (FDA) established a vol-untary system of providing selected nutrient information on food labels. The regulatory framework for nutrition informa-tion on food labels was revised and updated by the USDA

(which regulates meat and poultry products and eggs) and the FDA (which regulates all other foods) with enactment of the Nutrition Labeling and Education Act (NLEA) in 1990. The labels became mandatory in 1994.

Mandatory Nutrition LabelingAs a result of the NLEA, nutrition labels must appear on most foods except products that provide few nutrients (such as cof-fee and spices), restaurant foods, and ready-to-eat foods pre-pared on site, such as supermarket bakery and deli items (FDA, 1993). Providing nutrition information on many raw foods is voluntary. However, the FDA and USDA have called for a voluntary point-of-purchase program in which nutrition information is available in most supermarkets. Nutrition in-formation is provided through brochures or point-of-purchase posters for the 20 most popular fruits, vegetables, and fresh fi sh and the 45 major cuts of fresh meat and poultry.

Nutrition information for foods purchased in restau-rants is widely available at the point of purchase or from Internet sites or toll-free numbers. Ready-to-eat unpack-aged foods in delicatessens or supermarkets may provide nutrition information voluntarily. However, if nutrition claims are made, nutrition labeling is required at the point of purchase.

If a food makes the claim of being organic, it also must meet certain criteria and labeling requirements. In 2002 the government regulations were established for organic food labeling (see Focus On: Is it Really Organic and Is it Health-ier? in Chapter 11).

Standardized Serving SizesServing sizes of products are set by the government based on reference amounts commonly consumed. For example, a serving of milk is 8 oz, and a serving of salad dressing is 2 tbsp. Standardized serving sizes make it easier for consum-ers to compare the nutrient contents of similar products.

Nutrition Facts LabelThe nutrition facts label on a food product provides informa-tion on its per-serving calories and calories from fat. The la-bel then lists the amount (in grams) of total fat, saturated fat, cholesterol, sodium, total carbohydrate, dietary fi ber, sugar, and protein. For most of these nutrients the label also shows the percentage of the daily value (DV) supplied by a serving. A product’s content of vi ta mins A and C, calcium, and iron is listed in terms of DV percentage only. DVs show how a prod-uct fi ts into an overall diet by comparing its nutrient content with recommended intakes of those nutrients.

It is important to remember that DVs are not recom-mended intakes for individuals; no one nutrient standard applies to everyone. They are simply reference points to provide some perspective on daily nutrient needs. DVs are based on a 2000-kcal diet; however, the bottom of the nutri-tion label also provides the DVs for a 2500-kcal diet. For example, individuals who consume diets supplying more or fewer calories can still use the DVs as a rough guide to en-sure that they are getting adequate amounts of vi ta min C but not too much saturated fat.

The 2005 Dietary Guidelines for Americans: Nine Focus Areas

• Adequate nutrients within calorie needs • Weight management • Physical activity • Food groups to encourage • Fats • Carbohydrates • Sodium and potassium • Alcoholic beverages• Food safetyAvailable at http://www.healthierus.gov/dietaryguidelines/, accessed August 2, 2006.

BOX 12-2


1/2 1/21/2

1/2

1/23/41/2

1/2 1/21/2

1/2 3/4 3/41/2

1/43/43/4

1/21/2

FIGURE 12-2 Eating Well with Canada’s Food Guide. (Reprinted with permission from Health Canada. Data from Health Canada: Eating well with Canada’s food guide, ©Her Majesty the Queen in Right of Canada, represented by the Minister of Healthy Canada, 2007, available at www.hc-sc.gc.ca/fn-an/food-guide-aliment, accessed February 8, 2007. Continued


1/2

FIGURE 12-2, cont’d Eating Well with Canada’s Food Guide.


Nutrient Amount

Vitamin A 5000 IUVitamin C 60 mgThiamin 1.5 mgRobofl avin 1.7 mgNiacin 20 mgCalcium 1 gIron 18 mgVitamin D 400 IUVitamin E 30 IUVitamin B6 2 mgFolic acid 0.4Vitamin B12 6 mcgPhosphorus 1 gIodine 150 mcgMagnesium 400 mgZinc 15 mgCopper 2 mgBiotin 0.3 mgPantothenic acid 10 mgSelenium 70 mcg

Reference Daily Intakes

TABLE 12-5

From Center for Food Safety & Applied Nutrition: A food labeling guide, College Park, Md, 1994, U.S. Department of Agriculture, revised 1999.

Food Component DRV Calculation

Fat 65 g 30% of kcalSaturated fat 20 g 10% of kcalsCholesterol 300 mg Same regardless of kcalCarbohydrates (total) 300 g 60% of caloriesFiber 25 g 11.5 g per 1000 kcalProtein 50 g 10% of kcalSodium 2400 mg Same regardless of kcalPotassium 3500 mg Same regardless of kcal

Daily Reference Values (DRVs)

TABLE 12-6

note: The DRVs were established for adults and children over 4 years old. The values for energy yielding nutrients below are based on 2,000 calories per day.

From Center for Food Safety & Applied Nutrition: A food labeling guide, College Park, Md, 1994, U.S. Department of Agriculture, revised 1999.

Serving Size 1 cup (228 g)Servings Per Container 2

Sample label forMacaroni and Cheese

Calories 250Checkcalories

Limit thesenutrients

Quick guideto % Daily Value

• 5% or less is low• 20% or more is high

Get enoughof thesenutrients

Footnote

Total Fat 12 g Saturated Fat 3 g

Trans Fat 3 g

Cholesterol 30 mg

Sodium 470 mg

Total Carbohydrate 31 g

Dietary Fiber 0 g

Sugars 5 g

Protein 5 g

Vitamin A

Vitamin C

* Percent Daily Values are based on a 2000-calorie diet. Your Daily Values may be higher or lower, depending on your calorie needs:

Total Fat Sat FatCholesterolSodiumTotal Carbohydrate Dietary Fiber

Less thanLess thanLess thanLess than

65 g20 g300 mg2400 mg300 g25 g

80 g25 g300 mg2400 mg375 g30 g

Calories: 2000 2500

Calcium

Iron

4%2%

20%4%

18%15%

10%

20%

10%

0%

Amount Per Serving

% Daily Value*

Calories from Fat 110

Start here1

2

36

4

5

FIGURE 12-3 Nutrition facts label information. (Source: U.S. Food and Drug Administration, available at http://www.cfsan.fda.gov/∼dms/foodlab.html#twoparts, accessed August 2, 2006.)

The DVs exist for nutrients for which RDAs already exist (in which case they are known as reference daily intakes [RDIs]) (Table 12-5) and for which no RDAs exist (in which case they are known as daily reference values [DRVs] [Table 12-6]). However, food labels use only the term “daily value.” RDIs provide a large margin of safety; in general, the RDI for a nutrient is greater than the RDA for a specifi c age-group. The term RDI replaces the term U.S. RDAs used on previous food labels.

The previously mentioned nutrients must be listed on the food label. Nutrients that a manufacturer or processor may voluntarily disclose include those for which a DV has been established such as monounsaturated and saturated fat, potassium, vi ta mins such as thiamin and ribofl avin, and minerals such as iodine and magnesium. As new DRIs are developed in various categories, labeling laws are up-dated. Figure 12-3 shows a sample nutrition facts label.

Nutrient Content ClaimsNutrient content terms such as reduced sodium, fat free, low calorie, and healthy must now meet government defi ni-tions that apply to all foods (Box 12-3). For example, lean refers to a serving of meat, poultry, seafood, or game meat with less than 10 g of fat, less than 4 g of saturated fat, and less than 95 mg of cholesterol per serving or per 100 g. Ex-tra lean meat or poultry contains less than 5 g of fat, less than 2 g of saturated fat, and the same cholesterol content as lean, per serving, or per 100 g of product.

Health ClaimsA health claim is allowed only on appropriate food products that meet specifi ed standards. The government requires that health claims be worded in ways that are not misleading (e.g., the claim cannot imply that the food product itself helps pre-vent disease). Health claims cannot appear on foods that sup-ply more than 20% of the DV for fat, saturated fat, choles-terol, and sodium. The following is an example of a health


Free: This term means that a product contains no amount of, or only trivial or “physiologically inconsequential” amounts of, one or more of these components: fat, saturated fat, cholesterol, sodium, sugar, and calories. For example, “calorie-free” means fewer than 5 calories per serving, and “sugar-free” and “fat-free” both mean less than 0.5 g per serving. Synonyms for “free” include “without,” “no” and “zero.” A synonym for fat-free milk is “skim.”

Low: This term can be used on foods that can be eaten frequently without exceeding dietary guidelines for one or more of these components: fat, saturated fat, cholesterol, sodium, and calories.

• Low fat: 3 g or less per serving • Low saturated fat: 1 g or less per serving • Low sodium: 140 mg or less per serving • Very low sodium: 35 mg or less per serving • Low cholesterol: 20 mg or less and 2 g or less of

saturated fat per serving • Low calorie: 40 calories or less per serving

Synonyms for low include “little,” “few,” “low source of,” and “contains a small amount of.”

• Lean and extra lean: These terms can be used to describe the fat content of meat, poultry, seafood, and game meats.

Lean: less than 10 g fat, 4.5 g or less saturated fat, and less than 95 mg cholesterol per serving and per 100 g.

Extra lean: less than 5 g fat, less than 2 g saturated fat, and less than 95 mg cholesterol per serving and per 100 g.

High: This term can be used if the food contains 20% or more of the daily value for a particular nutrient in a serving.

Good source: This term means that one serving of a food contains 10% to 19% of the daily value for a particular nutrient.

Nutrient Content Claims

BOX 12-3

Reduced: This term means that a nutritionally altered product contains at least 25% less of a nutrient or of calories than the regular, or reference, product. However, a reduced claim can’t be made on a product if its reference food already meets the requirement for a “low” claim.

Less: This term means that a food, whether altered or not, contains 25% less of a nutrient or of calories than the reference food. For example, pretzels that have 25% less fat than potato chips could carry a “less” claim. “Fewer” is an acceptable synonym.

Light: This descriptor can mean two things:

• First, that a nutritionally altered product contains one-third fewer calories or half the fat of the reference food. If the food derives 50% or more of its calories from fat, the reduction must be 50% of the fat.

• Second, that the sodium content of a low-calorie, low-fat food has been reduced by 50%. In addition, “light in sodium” may be used on food in which the sodium content has been reduced by at least 50%.

• The term “light” still can be used to describe such properties as texture and color, as long as the label explains the intent (e.g., “light brown sugar” and “light and fl uffy.”

More: This term means that a serving of food, whether altered or not, contains a nutrient that is at least 10% of the daily value more than the reference food. The 10% of daily value also applies to “fortifi ed,” “enriched” and “added” “extra and plus” claims, but in these cases the food must be altered.

Data from Food and Drug Administration, available at http://www.fda.gov/opacom/backgrounders/foodlabel/newlabel.html#nutri, accessed August 2, 2006.

• Calcium and a reduced risk of osteoporosis • Dietary fat and an increased risk of cancer • Dietary saturated fat and cholesterol and an increased risk

of coronary heart disease • Fiber-containing grain products, fruits, and vegetables and

a reduced risk of cancer • Fruits, vegetables, and grain products that contain fi ber

and a reduced risk of coronary heart disease • Sodium and an increased risk of hypertension • Potassium and a decreased risk of hypertension • Fruits and vegetables and a reduced risk of cancer

Health Claims for Diet-Disease Relationships

BOX 12-4

• Folic acid during pregnancy and a reduced risk of neural tube defects

• Sugar alcohols and a reduced risk of dental caries • Soluble fi ber from certain foods, such as whole oats and

psyllium seed husk, and heart disease• Stanol and sterol esters (in vegetable oil spreads and salad

dressings) and a reduced risk of coronary heart disease Data from Food and Drug Administration, available at http://www.fda.gov/opacom/backgrounders/foodlabel/newlabel.html#nutri, accessed August 2, 2006.


claim for dietary fi ber and cancer: “Low-fat diets rich in fi ber-containing grain products, fruits, and vegetables may reduce the risk of some types of cancer, a disease associated with many factors.” Box 12-4 lists health claims that manufactur-ers can use to describe food-disease relationships.

CULTURAL ASPECTS OF DIETARY PLANNING

To plan diets for individuals or groups that are appropriate from a health and nutrition perspective, it is important that nutritionists and health professionals develop cultural awareness (cultural competency) and use resources that are targeted to the specifi c client or group. Numerous popula-

tion subgroups in the United States and throughout the world have specifi c cultural, ethnic, or religious beliefs and practices to consider. These groups have their own set of dietary practices or beliefs, which are important when con-sidering dietary planning.

The Mediterranean DietCultural, ethnic, or religious rules can have an effect on ac-cess to food, food choices, preparation, and storage methods. For example, the Mediterranean Diet Pyramid has been de-veloped to repres ent the eating pattern of the Mediterranean culture and to demonstrate a reasonable diet for reducing chronic disease (Figure 12-4) (see Focus On: The Mediterra-nean Diet: Is It Good for All of Us?). Cultural aspects of dietary planning may also include vegetarianism, ethnic heritage practices, and religious customs or rules.

FIGURE 12-4 The Traditional Healthy Mediterranean Diet Pyramid. (Courtesy Oldways Preservation and Exchange Trust. Adapted from: http://www.oldwayspt.org/, accessed March 13, 2007.)


CULTURAL DIETARY PATTERNS

Table 12-7 lists common cultural dietary patterns. The fol-lowing questions may help nutritionists accommodate food habits while meeting dietary recommendations:

• Which individual foods are the major components of the food or mixed dish to be classifi ed?

• To which food groups in the MyPyramid system or the Mediterranean Diet Pyramid do the foods seem most related?

• What are the important nutrient sources and their contribution to overall nutrient adequacy?

• How is the food used, and in what quantity is the food typically consumed?

• Do any food handling, preparation, or storage considerations compromise food safety or limit food choices?

Common Dietary Patterns: Southeast Asian During the past few decades the number of Southeast Asian refugees has increased dramatically worldwide. In the United States immigrants from Southeast Asia have become the third largest ethnic group after blacks and Hispanics.

Among these immigrants are numerous groups, each with a distinct language, culture, and food habits. From Laos, Cambodia, and Vietnam come the native ethnic groups, as well as Muslims and ethnic Chinese. From Laos, Thailand, and Southern China come the nomadic hill people, the Hmong (Tripp, 1982). Urban and rural immigrants may have lifestyles that differ considerably even when the people come from the same country.

The traditional Hmong (Southeast Asian) diet is high in complex carbohydrates and low in refi ned carbohydrates, predominantly from rice that is eaten at every meal. The Southeast Asian Hmong diet includes large amounts of fruits, vegetables, and soy products (mostly tofu), and smaller amounts of meat, poultry, and fi sh. Common spices include lemon grass, coriander, chili peppers, green onion, basil, cilantro, ginger, and garlic. Lemon and lime juice often are used in place of salad dressings and salt; soy and fi sh sauces and monosodium glutamate (MSG) are common seasonings (American Dietetic Association [ADA] and American Dia-betes Association, 1999).

Although lactose intolerance has been reported to be a problem in many Southeast Asians, many adults are able to drink it in small amounts without any discomfort. If the im-migrants are refugees, they may be at nutritional risk be-cause of low access to food supplies and parasitic anemias. General malnutrition, hypertension, dental caries, and iron defi ciency anemia have been identifi ed as problems among incoming refugees.

Common Dietary Patterns: Chinese In Chinese culture food plays a vital role in preventing and treating diseases and addressing certain health conditions. The traditional Chinese diet is much richer in carbohy-drates (i.e., rice) and includes various meats, poultry, and seafood in small quantities. The Chinese diet obtains more than 80% of its calories from grains, legumes, and vegeta-bles; 20% from animal protein, fruits, and fats. Northern Chinese cuisine may include more noodles, dumplings, and steamed buns made from wheat fl our. Stir-frying, deep-fat frying, braising, roasting, smoking, and steaming are com-mon food preparation techniques. When foods are fried, peanut or corn oil is used rather than lard, which is more common in Southeast Asian cuisine.

Although pork is often a mainstay, soybeans are also commonly used in forms including sprouts, dried, or fer-mented as tofu. Dairy products are rarely consumed. Fruits are abundant. Vegetables are also frequent in the diet, though rarely eaten raw; they are generally stir-fried, steamed, or added to soups just before serving. The bever-age of choice is clear, hot green tea.

Although Chinese meals are eaten communally, each re-gion has its own set of foods, ingredients, and cooking methods. Northern cuisine is characterized by garlic, leeks, and scallions, with noodles rather than rice. In the Western region Hunan cuisine includes liberal use of chili peppers and hot pepper sauces. Hunan dishes are spicier and oilier than dishes in other regions. Southern Chinese cuisine, or Cantonese, includes primarily steamed and stir-fried dishes

The Mediterranean Diet has received attention because of its potential for protecting the body against cardiovascu-

lar disease and cancers. The diet is rich in fruits, vegetables, whole grains, and sources of monounsaturated and polyun-saturated fatty acids (such as omega-3 fatty acids).

A trial involving this diet was conducted as part of the Lyon Diet Heart Study; 605 patients with coronary heart disease who had already had a heart attack were randomly selected to follow either a Mediterranean-type diet or a con-trol diet (Hakim, 1998). Those following the Mediterranean pattern ate less delicatessen food, beef, pork, butter, and cream and more vegetable oils, vegetable oil margarine-type spreads, and olive oil. The control diet was similar to the Step 1 American Heart Association (AHA) Prudent Diet (30% energy from fat). Compared with the control diet, the Mediterranean diet provided more fi ber, vi ta min C, and omega-3 fatty acids both from fi sh and as �-linolenic acid from walnuts, seeds, and herbs and less cholesterol and satu-rated fatty acids. Participants were monitored for 4 years, and at the end there was a 50% to 75% reduction in risk for an-other heart attack. The risk ratios were also lower for cancers, and overall mortality rates. More use of these strategies in dietary planning may be benefi cial in U.S. populations when combined with adequate daily physical activity.

The Mediterranean Diet: Is It Good for All of Us?

FOCUS ON

Text continued on p. 358


TA

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k in

test

ines

), ba

con,

pig

feet

and

ea

rs; f

ried

mea

ts a

nd

poul

try,

org

an m

eats

(k

idne

y, li

ver,

tong

ue,

trip

e); fi

sh

(cat

fi sh,

cr

awfi s

h, s

alm

on,

shri

mp,

tuna

); fr

ogs,

ra

bbit,

squ

irre

l, an

d a

vari

ety

of le

gum

es

and

nuts

But

ter

and

lard

; hon

ey,

mol

asse

s,

and

suga

r


Mex

ican

Cor

n (t

ortil

las,

mas

a ha

rina

), w

heat

, and

ri

ce p

rodu

cts;

sw

eet b

read

Cac

tus

(nop

ales

), ca

laba

za

crio

lla, c

hili

pepp

ers,

co

rn, j

icam

a, o

nion

s, p

eas,

pl

anta

ins,

squ

ashe

s (e

.g.,

chay

ote,

pum

pkin

), to

mat

illos

, tom

atoe

s,

yam

s, a

nd y

ucca

roo

t (c

assa

va o

r m

anio

c)

Avo

cado

s, b

anan

as, c

actu

s fr

uit,

cara

mbo

la,

casi

mir

oa, c

heri

moy

a,

coco

nut,

gran

adill

a,

guan

aban

a, g

uava

, le

mon

s, li

mes

, mam

ey,

man

goes

, mel

on,

oran

ges,

pap

aya,

pi

neap

ple,

str

awbe

rrie

s,

suga

r ca

ne, a

nd z

apot

e

Che

ese,

fl an

, so

ur c

ream

, an

d m

ilk

Bee

f, go

at, p

ork,

ch

icke

n, tu

rkey

; fi r

m-fl

esh

ed fi

sh,

shri

mp,

and

a v

arie

ty

of le

gum

es

Bac

on fa

t, la

rd

(man

teca

), sa

lt po

rt,

dair

y cr

eam

; su

gar,

and

pano

cha

(raw

bro

wn

cane

sug

ar)

Cen

tral

A

mer

ican

Cor

n (t

amal

es,

tort

illas

), ri

ce, a

nd

whe

at p

rodu

cts

Asp

arag

us, b

eets

, cab

bage

, ca

laba

za, c

hayo

te, c

hili

pepp

ers,

cor

n, c

ucum

bers

, eg

gpla

nt, h

eart

s of

pal

m,

leek

s, lo

roco

fl ow

ers,

on

ions

, pac

aya

buds

, pl

anta

ins,

pum

pkin

, sp

inac

h, s

wee

t pep

pers

, to

mat

illos

, wat

ercr

ess,

ya

ms,

yuc

ca, a

nd y

ucca

fl o

wer

App

les,

avo

cado

s,

bana

nas,

bre

adfr

uit,

cher

imoy

a, c

ocon

ut,

grap

es, g

uava

, mam

eys,

m

ango

es, n

ance

s,

oran

ges,

pap

aya,

pa

ssio

n fr

uit,

pejib

aye,

pi

neap

ples

, pru

nes,

ra

isin

s, ta

mar

ind,

ta

nger

ines

, and

zap

ote

Che

ese,

cre

am

and

milk

Bee

f, ig

uana

, liz

ards

, po

rk, a

nd v

enis

on;

chic

ken

duck

, tur

key

and

a va

riet

y of

fi sh

, sh

ellfi

sh, a

nd le

gum

es

But

ter,

lard

, ve

geta

ble

oils

, and

sh

orte

ning

; ho

ney,

su

gar,

suga

r sy

rup

Car

ibbe

an

Isla

nds

Cas

sava

bre

ad;

corn

mea

l (s

urru

litos

); oa

tmea

l; ri

ce, a

nd

whe

at p

rodu

cts

Arr

acac

ha, a

rrow

root

, bl

ack-

eyed

pea

s, c

abba

ge,

cala

baza

, cal

lalo

o, c

assa

va,

chili

es, c

orn,

cuc

umbe

rs,

eggp

lant

, mal

anga

s, o

kra,

on

ions

, pal

m h

eart

s,

pepp

ers,

rad

ishe

s,

spin

ach,

squ

ashe

s, s

wee

t po

tato

es, t

aro,

and

yam

s

Ace

rola

che

rrie

s, a

kee,

av

ocad

oes,

ban

anas

, br

eadf

ruit,

cai

mito

, ch

erim

oya,

citr

on,

coco

nuts

, coc

oplu

m,

goos

eber

ries

, gr

anad

illa,

gra

pefr

uit,

guav

a, g

uana

bana

, ja

ckfr

uit,

kum

quat

s,

lem

ons,

lim

es, m

amey

, m

ango

es, o

rang

es,

papa

yas,

pin

eapp

les

plan

tain

s,

pom

egra

nate

s, r

aisi

ns,

sapo

dilla

, sug

ar c

ane,

an

d ta

mar

ind

Che

ese

and

milk

Bee

f, go

at, p

ork,

ch

icke

n, tu

rkey

, and

a

vari

ety

of fi

sh,

shel

lfi sh

, and

legu

mes

But

ter,

coco

nut o

il,

lard

, and

ol

ive

oil;

suga

r ca

ne

prod

ucts

Con

tinue

d


Cul

ture

Bre

ad, C

erea

l, R

ice,

an

d Pas

ta G

roup

Vege

tabl

e G

roup

Frui

t G

roup

Milk

, Yog

urt,

C

hees

e G

roup

Mea

t, P

oult

ry, F

ish,

D

ry B

eans

, Egg

s,

and

Nut

s G

roup

sFa

ts, O

ils,

and

Sw

eets

Cub

an a

nd

Pue

rto

Ric

an

Ric

e; s

tarc

hy g

reen

ba

nana

s, u

sual

ly

frie

d (p

lant

ain)

Bee

ts, b

read

frui

t, ch

ayot

e,

chili

pep

pers

, egg

plan

t, on

ion,

tube

rs (y

ucca

), w

hite

yam

s (b

onia

to)

Coc

onut

s, g

uava

, man

go,

oran

ges

(sw

eet a

nd

sour

), pr

une

and

man

go p

aste

Flan

, har

d ch

eese

(que

so

de m

ano)

Chi

cken

, fi s

h, (a

ll ki

nds

and

prep

arat

ions

, in

clud

ing

smok

ed,

salte

d, c

anne

d, a

nd

fres

h), s

hellfi

sh,

le

gum

es (a

ll ki

nds,

es

peci

ally

bla

ck

bean

s), p

ork

(fri

ed),

saus

age

(cho

rizo

), ca

lf br

ain,

bee

f ton

gue

Oliv

e an

d pe

anut

oil,

la

rd,

coco

nut

Sout

h A

mer

ican

Am

aran

th (c

orn,

ri

ce, q

uino

a) a

nd

whe

at p

rodu

cts

Ahi

pa, a

rrac

acha

, cal

abaz

a,

cass

ava,

gre

en p

eppe

rs,

hear

ts o

f pal

m, k

ale,

okr

a,

oca,

oni

ons,

ros

ella

, sq

uash

, sw

eet p

otat

oes,

ya

con,

and

yam

s

Avo

cado

es, a

biu,

ace

rola

, ap

ples

, ban

ana,

cai

mito

, ca

sim

iroa

, che

rim

oya,

fe

ijoa,

gua

va, g

rape

s,

jack

frui

t, ja

bito

caba

, le

mon

s, li

mes

, lul

o,

mam

mea

, man

go,

mel

on, o

lives

, ora

nges

, pa

lm fr

uits

, pap

aya,

pa

ssio

n fr

uit,

peac

hes,

pi

neap

ple,

pita

nga,

qu

ince

, sap

ote,

and

st

raw

berr

ies

Che

ese

and

milk

Bee

f, fr

og, g

oat,

guin

ea

pig,

llam

a, m

utto

n,

pork

, and

rab

bit;

chic

ken,

duc

k, tu

rkey

an

d a

vari

ety

of fi

sh,

shel

lfi sh

, and

nut

s

Pal

m o

il, o

live

oil,

and

butt

er;

suga

r ca

ne,

brow

n su

gar,

and

hone

y

Chi

nese

Ric

e an

d re

late

d pr

oduc

ts (fl

our

, ca

kes,

and

no

odle

s); n

oodl

es

mad

e fr

om b

arle

y,

corn

, and

mill

et;

whe

at a

nd r

elat

ed

prod

ucts

(bre

ads,

no

odle

s, s

pagh

etti,

st

uffe

d no

odle

s [w

on to

n] a

nd

fi lle

d bu

ns [b

ow])

Bam

boo

shoo

ts, c

abba

ge

(nap

pa),

cele

ry, C

hine

se

turn

ips

(lo b

ok),

drie

d da

ylil

ies,

dry

fung

us

(Bla

ck J

uda’s

ear

); le

afy

gree

n ve

geta

bles

in

clud

ing

kale

, cre

ss,

mus

tard

gre

ens

(gai

ch

oy),

char

d (b

ok c

hoy)

, am

aran

th g

reen

s (y

in

choy

), w

olfb

erry

leav

es

(gou

gay

), an

d C

hine

se

bean

s

App

les,

ban

anas

, cus

tard

ap

ples

, coc

onut

s, d

ates

, lo

ngan

, fi g

s, g

rape

s,

kum

quat

s, li

me,

litc

hi,

man

go, m

uskm

elon

, or

ange

s, p

apay

a,

pass

ion

frui

t, pe

ache

s,

pers

imm

ons,

pi

neap

ples

, plu

ms,

po

meg

rana

tes,

po

mel

os, t

ange

rine

s,

and

wat

erm

elon

Milk

(cow

s,

buff

alo,

and

so

ymilk

)

Bee

f, la

mb,

and

por

k;

chic

ken,

duc

k, q

uail,

sq

uab,

a la

rge

vari

ety

of fi

sh a

nd s

hellfi

sh,

in

add

ition

to

legu

mes

and

nut

s

Lar

d; p

eanu

t, so

y, s

esam

e an

d ri

ce o

il;

hone

y, r

ice

or b

arle

y m

alt,

palm

su

gar,

sorg

hum

su

gar,

and

dehy

drat

ed

cane

juic

e

TA

BL

E 1

2-7

Cul

tura

l Die

tary

Pat

tern

s—co

nt’d


broc

coli

(gai

lan)

; eg

gpla

nt, l

otus

tube

rs,

okra

, sno

w p

eas,

stir

-fri

ed

vege

tabl

es (c

how

yuk

), ta

ro r

oots

, whi

te r

adis

h (d

aiko

n), a

nd y

ams

Japa

nese

Ric

e an

d ri

ce

prod

ucts

, ric

e fl o

ur

(moc

hiko

), no

odle

s (c

omen

/sob

a),

buck

whe

at a

nd

mill

et

Art

icho

ke, a

spar

agus

, ba

mbo

o sh

oots

(t

aken

oko)

, bur

dock

(g

obo)

, cab

bage

(nap

pa),

eggp

lant

, hor

sera

dish

(w

asab

i), m

izun

a,

mus

hroo

ms

(shi

itake

, m

atsu

take

, nam

eko)

, Ja

pane

se p

arsl

ey (s

eri),

lo

tus

root

(ren

kon)

, pi

ckle

d ca

bbag

e (k

imch

ee),

pick

led

vege

tabl

es, s

eaw

eed

(lave

r, no

ri, w

akam

e, k

ombu

), sn

ow p

eas,

spi

nach

, sw

eet

pota

to, v

eget

able

sou

p (m

izut

aki),

wat

ercr

ess,

w

hite

rad

ish

(dai

kon)

Pea

rlik

e ap

ple

(nas

i),

apri

cots

, ban

anas

, ch

erri

es, fi

gs,

gra

pefr

uit

(yuz

u), k

umqu

ats,

le

mon

s, li

mes

, pe

rsim

mon

s, p

lum

s,

pine

appl

es, s

traw

berr

y,

and

tang

erin

e (m

ikan

)

Milk

, but

ter,

and

ice

crea

mB

eef,

deer

, lam

b, p

ort,

rabb

it, v

eal;

fi sh

and

shel

lfi sh

, inc

ludi

ng

drie

d fi s

h w

ith b

ones

, ra

w fi

sh (s

ashi

mi),

and

fi s

h ca

ke (k

amab

oko)

; a

vari

ety

of p

oultr

y (c

hick

en, d

uck,

goo

se,

turk

ey) a

nd le

gum

es

(bla

ck b

eans

, red

be

ans,

soy

bean

s—as

to

fu, f

erm

ente

d so

ybea

n an

d sp

rout

s)

Lar

d; s

oy,

sesa

me,

ra

pese

ed

and

rice

oil;

ho

ney

and

suga

r

Kor

ean

Bar

ley,

buc

kwhe

at,

mill

et, r

ice

and

whe

at p

rodu

cts

Bam

boo

shoo

ts, b

ean

spro

uts,

be

ets,

cab

bage

, chi

ves,

ch

rysa

nthe

mum

leav

es,

cucu

mbe

r, eg

gpla

nt, f

ern,

gr

een

onio

n, g

reen

pep

per,

leek

s, lo

tus

root

, m

ushr

oom

s, o

nion

, per

illa,

se

awee

d, s

pina

ch, s

wee

t po

tato

, tur

nips

, wat

er

ches

tnut

, wat

ercr

ess,

and

w

hite

rad

ish

App

les,

Asi

an p

ears

, ch

erri

es, d

ates

, gra

pes,

m

elon

s, o

rang

es, p

ears

, pe

rsim

mon

s, p

lum

s, a

nd

tang

erin

es

Ver

y lit

tle, i

f any

, co

nsum

ptio

nB

eef,

oxta

il, p

ork,

ch

icke

n, p

heas

ant,

and

a va

riet

y of

fi sh

, sh

ellfi

sh, l

egum

es, a

nd

nuts

Sesa

me

oil

and

vege

tabl

e oi

l; ho

ney

and

suga

r

Con

tinue

d


Cul

ture

Bre

ad, C

erea

l, R

ice,

an

d Pas

ta G

roup

Vege

tabl

e G

roup

Frui

t G

roup

Milk

, Yog

urt,

C

hees

e G

roup

Mea

t, P

oult

ry, F

ish,

D

ry B

eans

, Egg

s,

and

Nut

s G

roup

sFa

ts, O

ils,

and

Sw

eets

Filip

ino

Noo

dles

, ric

e, r

ice

fl our

(moc

hiko

), st

uffe

d no

odle

s (w

on to

n), w

hite

br

ead

(pan

de

sal)

Am

aran

th, b

ambo

o sh

oots

, be

ets,

bur

dock

roo

t, ca

ssav

a, C

hine

se c

eler

y,

dark

gre

en le

afy

vege

tabl

es (m

alun

ggay

an

d sa

lvyo

t), e

ggpl

ant,

garl

ic, g

reen

pep

pers

, he

arts

of p

alm

, hya

cint

h be

an, k

amis

, lee

k,

mus

hroo

ms,

okr

a, o

nion

, sw

eet p

otat

oes

(cam

otes

), tu

rnip

s, a

nd r

oot c

rop

(gab

i)

App

les,

avo

cado

es,

bana

na, b

itter

mel

on

(am

pala

ya),

brea

dfru

it,

coco

nut,

guav

as,

jack

frui

t, lim

es,

man

goes

, pap

aya,

pod

fr

uit (

tam

arin

d),

pom

elos

, ram

buta

n,

rhub

arb,

sta

r fr

uit,

tam

arin

d, ta

ngel

o (n

aran

ghita

), an

d w

ater

mel

on

Whi

te c

hees

e,

evap

orat

ed

cow

or

goat

m

ilk, a

nd s

oy

milk

Bee

f, ca

raba

o, g

oat,

pork

, mon

key,

org

an

mea

ts, a

nd r

abbi

t; fi s

h, d

ried

fi sh

(dili

s),

egg

roll

(lum

pia)

, fi s

h sa

uce

(ala

man

g an

d ba

goon

g); l

egum

es

such

as

mun

g be

ans,

be

an s

prou

ts,

chic

kpea

s; a

nd

soyb

ean

curd

(tof

u)

Coc

onut

oil,

la

rd, a

nd

vege

tabl

e oi

l; br

own

and

whi

te

suga

r, co

conu

t, an

d ho

ney

Pac

ifi c

Isla

nder

sR

ice

and

whe

at

prod

ucts

Arr

owro

ot, b

itter

mel

on,

burd

ock

root

, cab

bage

, ca

rrot

, cas

sava

, dai

kon,

eg

gpla

nt, f

erm

s, g

reen

pe

pper

, hor

sera

dish

, jut

e,

kohl

rabi

, lee

ks lo

tus

root

, m

usta

rd g

reen

s, g

reen

on

ions

, sea

wee

d, s

pina

ch,

squa

shes

, sw

eet p

otat

o,

taro

, wat

er c

hest

nuts

, and

ya

ms

Ace

rola

che

rrie

s, a

pple

s,

apri

cot,

avoc

ado,

ba

nana

, bre

adfr

uit,

coco

nut,

guav

a,

jack

frui

t, ku

mqu

at,

litch

is, l

oqua

t, m

ango

, m

elon

s, p

apay

a, p

assi

on

frui

t, pe

ach,

pea

r, pi

neap

ple,

plu

m,

prun

e, s

traw

berr

ies,

an

d ta

mar

ind

Ver

y lit

tle, i

f an

y,

cons

umpt

ion

Bee

f, po

rk, c

hick

en,

duck

, squ

ab, t

urke

y;

a va

riet

y of

fi sh

, sh

ellfi

sh, a

nd le

gum

es

But

ter,

coco

nut

oil,

lard

, se

sam

e oi

l, an

d ve

geta

ble

oil;

suga

r

Sout

h A

sian

Ric

e, w

heat

, bu

ckw

heat

, cor

n,

mill

et, a

nd

sorg

hum

pro

duct

s

Aga

thi fl

ow

ers,

am

aran

th,

artic

hoke

s, b

ambo

o sh

oots

, bee

ts, b

itter

m

elon

, Bru

ssel

s sp

rout

s,

cabb

age,

col

lard

gre

ens,

cu

cum

bers

, dru

mst

ick

plan

t, eg

gpla

nt, l

otus

ro

ot, m

anio

c, m

ushr

oom

s,

okra

, pan

danu

s, p

lant

ain

fl ow

ers,

sag

o pa

lm,

spin

ach,

squ

ash,

turn

ips,

ya

ms,

wat

er c

hest

nuts

, w

ater

con

vulu

s, a

nd w

ater

lil

ies

App

les,

apr

icot

s,

avoc

adoe

s, b

anan

as,

coco

nut,

date

s, fi

gs,

grap

es, g

uava

, jac

kfru

it,

limes

, litc

his,

loqu

ats,

m

ango

es, m

elon

, no

ngus

, ora

nges

, pa

paya

, pea

ches

, pea

rs,

pers

imm

ons,

pin

eapp

le,

plum

s, p

omeg

rana

te,

pom

elos

, sta

r fr

uit,

suga

r ca

ne, t

ange

rine

s,

and

wat

erm

elon

Milk

(e

vapo

rate

d an

d fe

rmen

ted

prod

ucts

), ch

eese

, and

m

ilk-b

ased

de

sser

ts

Bee

f, go

at, m

utto

n,

pork

, chi

cken

, duc

k,

and

a va

riet

y of

fi sh

, se

afoo

d, le

gum

es, a

nd

nuts

Coc

onut

oil,

gh

ee,

mus

tard

oi

l, pe

anut

oi

l, se

sam

e se

ed o

il,

and

sunfl

ow

er

oil;

suga

r ca

ne,

jagg

ery,

an

d m

olas

ses

TA

BL

E 1

2-7

Cul

tura

l Die

tary

Pat

tern

s—co

nt’d


Jew

ish

(bot

h cu

ltura

l and

re

ligio

us

cust

oms)

Bag

el, b

uckw

heat

gr

oats

(kas

ha),

dum

plin

gs m

ade

with

mat

zoh

mea

l (m

atzo

h ba

lls o

r kn

aide

lach

), eg

g br

ead

(cha

llah)

, no

odle

or

pota

to

pudd

ing

(kug

el),

crep

e fi l

led

with

fa

rmer

che

ese

and/

or fr

uit (

blin

tz),

unle

aven

ed b

read

or

larg

e cr

acke

r m

ade

with

whe

at

fl our

and

wat

er

(mat

zoh)

Pot

ato

panc

akes

(lat

kes)

; ve

geta

ble

stew

mad

e w

ith

swee

t pot

atoe

s, c

arro

ts,

prun

es, a

nd s

omet

imes

br

iske

t (tz

imm

es);

beet

so

up (b

orsc

ht)

A m

ixtu

re o

f fi s

h fo

rmed

into

bal

ls a

nd

poac

hed

(gefi

lte

fi sh)

; sm

oked

sal

mon

(lox

)

Chi

cken

fat


with a lot of fi sh and shellfi sh. As Chinese adopt traditional American foods, their diet begins to include more sweets such as cookies, chocolate, soft drinks, and snacks.

Common Dietary Patterns: Hispanic CulturesHispanics are the most rapidly growing ethnic group in the United States, and Mexican-Americans are the largest sub-group of Hispanics. Hispanic cuisine is based on the con-cept of foods having “hot” and “cold” properties and on beliefs about the contribution of food to health and well-being (ADA and ADA 1998). “Cold” foods include most vegetables, tropical fruits, dairy products, and inexpensive cuts of meat. “Hot” foods include chili peppers, garlic, on-ions, most grains, expensive cuts of meat, oils, and alcohol. For example, pregnancy is considered a “hot” condition; thus “hot” foods upset the stomach. Therefore some His-panics may not eat chili peppers while pregnant for cultural reasons rather than because of safety issues for the mother or developing fetus. Depending on the part of the world, the main dishes of Hispanic diets may include meat (pork, veal, sausage), poultry, or fi sh. Rice and tortillas are mainstays of the diet, as are fruits and vegetables. Milk and cheese are consumed when available. Fried foods are often eaten and may need to be limited for medical reasons. Chili peppers are commonly used and are a rich source of vi ta min C. Chili peppers can range from mild to very hot and from small to very large.

Common Dietary Patterns: Native AmericansNative Americans (American Indians and Alaska Natives) often live on federal Indian reservations and in small rural communities. In this culture food has great religious and social signifi cance for celebrations and ceremonies. Food is more of a social or religious obligation than simple nourish-ment. Common foods may be prepared and used in differ-ent ways in various regions and tribal organizations. Fry bread (fried dough) is a central part of American Indian cuisine and is eaten with foods such as stews, soups, and bean dishes. Fried foods are generally prepared with lard.

Corn is the carbohydrate staple of the American Indian diet, in addition to protein-rich dried beans. Fruits and vegetables were traditionally gathered from the wild but are also cultivated on small farms. Lamb (mutton), goat, game, and poultry are more common than pork or beef. Diabetes is a big problem in natives consuming the mod-ern American diet (see Focus On: Diabetes Does Discrimi-nate, in Chapter 30).

Common Dietary Patterns: Alaska NativesThe Alaska Native diet consists of a mixture of traditional foods and American prepared and processed foods. The diet is high in protein and fat since it is based on meat, fi sh, sea mammals, and game as staple foods. Seaweed, willow leaves, and sour dock are some of the few edible plants consumed. Since obesity and diabetes mellitus are common, it is important to merge cultural sensitivity with diet and health issues.

Dietary Patterns of Specifi c Religious GroupsAnother major consideration is religious beliefs that affect dietary patterns (Table 12-8).

Jewish Food Customs, Dietary Laws, and HolidaysThe Jewish dietary laws are biblical ordinances that include rules regarding food, chiefl y about the selection, slaughter, and preparation of meat. Animals allowed to be eaten (clean) are quadrupeds that have cloven hooves and chew cud, spe-cifi cally cattle, sheep, goats, and deer. Permissible fowl are chicken, turkey, goose, pheasant, and duck. All animals and fowl must be inspected for disease and killed by a ritual slaughterer according to specifi c rules. Only the forequarter of the quadruped may be used, except when the hip sinew of the thigh vein can be removed, in which case the hindquar-ter is also allowed.

Blood is forbidden as food because blood is synonymous with life. The traditional process of koshering meat and poultry removes all blood before cooking. Koshering in-volves soaking meat in water, salting it thoroughly, allowing it to drain, and then washing it three times to remove the salt. Foods that have been prepared in this way can carry a kosher designation.

Meat and milk cannot be combined in the same meal. Milk or milk-related foods can be eaten immediately before a meal but not with a meal. After eating meat, a person must wait 6 hours before consuming milk products. Because of the rules related to separating meat and milk products, those in traditional orthodox Jewish homes must keep two com-pletely separate sets of dishes, silver, and cooking equip-ment—one for meat meals and one for dairy meals. Only fi sh with fi ns and scales can be eaten; thus no shellfi sh or eel is permissible. Fish can be eaten with dairy or meats. Eggs can also be combined with meat or milk. However, an egg yolk containing a drop of blood cannot be eaten because the blood is considered a chick embryo, or a sign of a new life.

Fruits, vegetables, cereal products, and all of the other foods that generally comprise a diet can be consumed with no restrictions. Bakery products and prepared food mixtures must be produced under acceptable kosher standards.

The most important of the Jewish holy days is the Sab-bath, or day of rest, which is observed from sundown on Friday until sundown on Saturdays. The Friday night meal is the most special of the week and usually includes fi sh and chicken. No food is allowed to be cooked or heated on Saturday; thus all food eaten on the Sabbath is cooked on Friday and either kept warm in the oven or eaten cold. Festival holidays include Rosh Hashanah (the New Year) in September; Succoth, the fall harvest holi-day; Chanukah (the Feast of Lights) in midwinter; and Purim, a joyous holiday in spring. Each holiday has cer-tain associated food delicacies. Yom Kippur, the Day of Atonement, occurs 10 days after Rosh Hashanah and is a day of fasting from all food and drink from sundown on the eve of the holiday to sundown on the holiday. Preg-nant females and those who are ill do not fast.


Passover, a spring commemorative festival lasting 8 days, includes special dietary requirements. During the Passover holiday leavened bread or cake is prohibited. Matzo, (i.e., unleavened bread) is eaten, and all cake and baked products are made of fl our from ground-up matzo or potato starch and leavened only with beaten egg whites. No salt is allowed in traditional Passover matzo. Varia-tions of fried matzo or matzo-meal pancakes are prepared with generous amounts of fat.

Muslim Food Customs, Dietary Laws, and HolidaysIslam promotes the concept of “eating to live.” Muslims are advised to stop eating while they are still hungry and always to share food. Although many foods are allowed, certain codes must be observed, and some dietary restric-tions exist. The fl esh of animals slaughtered in a humane way as outlined by Islamic law is considered halal (accord-ing to Islamic law). All meat to be consumed as food must be slaughtered with a ritual letting of blood while speak-ing the name of God. The slaughter can be done by any-one—no special person is designated for this function. Muslims eat kosher meat products because they know that they have been slaughtered properly. If an animal is slaughtered improperly, the meat becomes haram, or for-bidden. Pork and pork products such as gelatin are pro-

hibited, as are alcoholic beverages and alcohol products (e.g., vanilla extract or other alcohol-based food or fl avor-ing extracts).

Although all foods not specifi cally prohibited are allowed to be eaten, certain foods are recommended such as milk, dates, meat, seafood, sweets, honey, and olive oil. Prayers are offered before any food is eaten. Muslims fast every year during the month of Ramadan, which occurs during the ninth month of the Islamic lunar calendar. Muslims fast completely from dawn to sunset and eat only twice a day—before dawn and after sunset. The end of Ramadan is marked by the Feast of Breaking the Fast (Eid-ul-Fitr). Muslims are also encouraged to fast 3 days of every month. Menstruating, pregnant, or lactating females are not re-quired to fast but must make up the fasting days at some other time.

VegetarianismVegetarian diets are increasing in popularity. Those who choose them may be motivated by philosophic, religious, or ecologic concerns or a desire to have a healthier life-style. Considerable evidence attests to the health benefi ts of a vegetarian diet. Studies of Seventh-Day Adventists indicate that the diet results in lower rates of type 2 dia-betes, breast and colon cancer, and cardiovascular and gallbladder disease.

Buddhist Hindu Jewish Moslem

Christian Roman

Catholic

Christian Eastern

OrthodoxChristian Mormon

Christian Seventh Day

Adventist

Beef A X APork A A X X XMeats, all A A R R R R AEggs/dairy O O R R OFish A R R R AShellfi sh A R X O XAlcohol A X X XCoffee/tea A X XMeat and dairy

at same mealX

Leavened foods RRitual

slaughter of meats

� �

Moderation � � �

Fasting* � � � � � � �

Religious Dietary Practices

TABLE 12-8

Modifi ed from Kittler PG, Sucher KP: Food and culture, ed 4, Belmont, Ca, 2004, Thomson and Wadsworth; and Escott-Stump S: Nutrition and diagnosis-related care, Baltimore, Md, 2008, Lippincott Williams & Wilkins.

*Fasting varies from partial (abstention from certain foods or meals) to complete (no food or drink).

X, Prohibited or strongly discouraged; A, avoided by the most devout; R, some restrictions regarding types of foods or when a food may be eaten; O, permitted, but may be avoided at some observances; +, practiced.


Of the millions of Americans who profess to be vegetar-ians, many eliminate “red” meats but eat fi sh, poultry, and dairy products. A lacto-vegetarian does not eat meat, fi sh, poultry, or eggs but does consume milk, cheese, and other dairy products. A lacto-ovo-vegetarian also consumes eggs. A true vegetarian, or vegan, does not eat any food of animal origin. The vegan diet is the only vegetarian diet that has any real risk of obtaining inadequate nutrition, but this risk can be avoided by careful planning.

Vegetarian diets tend to be lower in iron than omnivorous diets, although the nonheme iron in fruits, vegetables, and unrefi ned cereals is usually accompanied either in the food or in the meal by large amounts of ascorbic acid that aids in iron assimilation. Vegetarians do not have a greater risk of iron defi ciency than those who are not vegetarians (ADA, 1997). Vegetarians who consume no dairy products may have low calcium intakes, and vi ta min D intakes may be inadequate among those in northern latitudes where there is less expo-sure to sunshine (see Focus On: Sunshine, Vitamin D, and Fortifi cation in Chapter 3). The calcium in some vegetables is inactivated by the presence of oxalates. Although phytates in unrefi ned cereals also can inactivate calcium, this is not a problem for Western vegetarians, whose diets tend to be based more on fruits and vegetables than on the unrefi ned cereals of Middle Eastern cultures. Long-term vegans may develop megaloblastic anemia because of a defi ciency of vi ta-min B12, found only in foods of animal origin. The high levels of folate in vegan diets may mask the neurologic damage of a vi ta min B12 defi ciency. Vegans should have a reliable source of vi ta min B12 such as fortifi ed breakfast cereals, soy bever-ages, or a supplement.

Although most vegetarians meet or exceed the require-ments for protein, their diets tend to be lower in protein than those of omnivores. This lower intake may help vege-tarians retain more calcium from their diets. Furthermore,

lower protein intake usually results in lower dietary fat be-cause many high-protein animal products are also rich in fat (ADA, 1997).

Well-planned vegetarian diets are safe for infants, chil-dren, and adolescents and can meet all of their nutritional requirements for growth. They are also adequate for preg-nant and lactating females. The key is that the diets be well planned. Vegetarians should pay special attention to ensure that they get adequate calcium, iron, zinc, and vi ta mins B12 and D. Calculated combinations of complementary protein sources is not necessary, especially if protein sources are reasonably varied.

• The latest science behind nutrient needs and requirement along with educational level, lifestyle patterns and socioeconomic status go into development of dietary guidelines, food guides, nutrition labeling and other educational material to provide information and direction on food and activity choices for individuals and groups.

• The cultural, ethnic and religious backgrounds of individuals and groups are highly infl uential in food choices and meal planning, and must be considered when translating eating guidelines into the lifestyle choices.

• With a knowledge of dietary planning, nutrient needs, and food and nutrient information, as well as developed skills in counseling, dietetic counselors and health professionals are essential translators of food, nutrition, and health information into food choices and patterns for groups or individuals.

FOCAL POINTS

Marty is a 45-year-old Jewish man who emigrated from Israel to the United States 3 years ago. He follows a

strict kosher diet. In addition, he does not drink milk but does consume other dairy products. He has a body mass index (BMI) of 32 and a family history of heart disease. He has come to you for advice on increasing his calcium intake.

CLINICAL SCENARIO 1

*Nutrition Diagnosis: Knowledge defi cit related to calcium as evidenced by request for nutrient and dietary information

1. What type of dietary guidance would you offer Marty?2. What type of dietary plan following strict kosher

protocols would meet his daily dietary needs and promote weight loss?

3. What suggestions would you offer him about dietary choices for a healthy heart?

4. Which special steps should Marty take to meet calcium requirements without using supplements?

5. How can food labeling information be used to help Marty meet his weight loss and nutrient goals and incorporate his religious dietary concerns?


Nan is a 20-year-old college student who has decided to become a vegetarian for nonreligious reasons. She does

not eat red meat, chicken, fi sh, or dairy products. She is 5 ft, 2 in and weighs 95 lb. Her health is stable, but she does have low serum levels of iron, zinc, and vi ta min B12. Her blood pressure is 90/75 mm Hg. She has been referred to the nutri-tion clinic for counseling about changing some of her dietary habits.

CLINICAL SCENARIO 2

USEFUL WEBSITES

American Dietetic Association www.eatright.org

Center for Nutrition Policy and Promotion, USDAwww.usda.gov/cnpp/

Centers for Disease Control, NHANES Surveywww.cdc.gov/nchs/nhanes.htm

Dietary Guidelines for Americanswww.health.gov/DietaryGuidelines

Eat Smart, Play Hardhttp://www.fns.usda.gov/eatsmartplayhardkids/

Ethnic and Cultural Food Guideswww.nal.usda.gov/fnic/etext/000023.html#xtocid2381818

Food and Drug Administration, Center for Food Safety and Applied Nutritionwww.cfsan.fda.gov

Food and Nutrition Information Center, National Agricultural Library, USDAwww.nal.usda.gov/fnic/

Health Canadahttp://www.hc-sc.gc.ca/fn-an/index_e.html

Healthy Eating Indexhttp://www.cnpp.usda.gov/

Institute of Medicine, National Academy of Scienceshttp://www.iom.edu/

International Food Information Councilhttp://ifi c.org

MyPyramid Food Guidance Systemhttp://www.mypyramid.gov/

National Center for Health Statisticswww.cdc.gov/nchs/nhanes.htm

Nutrition.gov (U.S. government nutrition site)www.nutrition.gov

U.S. Department of Agriculturewww.usda.gov

ReferencesAmerican Dietetic Association: Position of the American Dietetic

Association: vegetarian diets, J Am Diet Assoc 97:1317, 1997.American Dietetic Association: Position of the American Dietetic

Association: total diet approach to communicating food and nutrition information, J Am Diet Assoc 102:100, 2002.

American Dietetic Association and American Diabetes Association: Mexican American food practices, customs, and holidays, Ethnic and Regional Food Practices Series, Chicago, 1998b, American Dietetic Association.

American Dietetic Association and the American Diabetes Association: Hmong American food practices, customs, and holidays, Ethnic and Regional Food Practices Series, Chicago, 1999, American Dietetic Association.

*Nutrition Diagnosis: Inadequate intake of iron, zinc, and vi ta min B12 related to omission of animal foods as evidenced by low serum levels

1. What type of dietary guidance would you offer Nan?2. Nan is at risk for developing defi ciencies of which

nutrients?3. Plan a 3-day menu for Nan that excludes the foods she

does not eat but provides adequate amounts of the key nutrients she needs.

4. What other dietary health-related advice would you give Nan?


Federation of American Societies for Experimental Biology, Life Sciences Research Offi ce: Third report on nutrition monitoring in the United States, Prepared for the Interagency Board for Nutrition Monitoring and Related Research, Washington, DC, 1995, U.S. Government Printing Offi ce.

Food and Drug Administration: Focus on food labeling, Special Issue of FDA Consumer Magazine, Department of Health and Human Services Pub No (FDA) 93-2262, Washington, DC, May 1993, U.S. Government Printing Offi ce.

Hakim I: Mediterranean diets and cancer prevention, Arch Intern Med 158(11):1169, 1998.

Health Canada: Eating well with Canada’s food guide, ©Her Majesty the Queen in Right of Canada, represented by the Minister of Healthy Canada, 2007, available at www.hc-sc.gc.ca/fn-an/food-guide-aliment, accessed February 8, 2007.

Tripp RR: World refugee survey, 1982, New York, 1982, U.S. Committee for Refugees.

U.S. Department of Agriculture, Center for Nutrition Policy and Promotion: Healthy eating index 2005, available at www.cnpp.usda.gov, accessed April 16, 2007.

U.S. Senate Select Committee on Nutrition and Human Needs: Dietary goals for the United States, ed 2, Washington, DC, U.S. Senate, 95th Congress, fi rst session, December 1977.

White House: White House conference on food, nutrition, and health, Final report, Washington, DC, 1970, U.S. Government Printing Offi ce.

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