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CHAPTER 6 - BODY COMPOSITION Objectives 1. What is body composition? 2. How does body composition affect a person’s health? 3. What are the health risks and costs associated with overweight and obesity? 4. What is the significance of body fat distribution? 5. What is Body Mass Index (BMI) and why is it important? Terminology Body Composition: The measurement of the body’s proportion of fat mass to fat free mass. Fat Mass: The amount of fat tissue in the body often expressed as a percentage of total body mass. Fat Free Mass (FFM): not fat tissue in the body such as bones, muscles, ligaments, and blood. Essential Fat: the amount of fat needed for vital body functions. Non-essential fat: the amount of fat that exceeds the necessary fat needed for vital body functions. This fat is considered energy storage. Overweight: the accumulation of non-essential body fat to the point that it adversely affects health. Obesity: is characterized by excessive accumulation of body fat Chapter 6 - Body Composition | 126 and can be defined as a more serious degree of being overweight. Adipose Tissue: another term for fat. More specifically it is loose connective tissue composed of adipocytes. Subcutaneous fat: fat tissue stored below the skin’s surface. Visceral Fat: fat tissue stored around central organs. Android shape: a body shape used to help characterize body fat distribution in which fat is stored in the abdominal region. The android shape is also called the “apple” shape. Gynoid shape: a body shape used to help characterize body fat distribution in which fat is stored in the hips, buttocks, and thighs. It is also called the pear shape. Body Mass Index (BMI): an index based on concept that weight and height should be proportionate. It is calculated by dividing weight by the height squared (weight/height2). Hydrodensitometry: This method attempts to measure the density of the body by using water displacement. Dual Energy X-ray Absorbtiometry (DEXA): A method of measuring body composition that uses low energy x-rays that also measure bone density. Air Displacement Plethysmography: A method of measuring body composition that measures the density of the body by using air displacement. Bio-electrical impedance analysis (BIA): A method of measuring body composition by emitting a small electrical current through the body and using the amount of resistance encountered by this current to predict body fat content. Skinfold Analysis: A method of measuring body composition by measuring the diameter of pinched skin at various sites on the body. 127 | Chapter 6 - Body Composition Body Weight versus Body Composition According to surveys, the top reason American females exercise is for weight control. For males, the top reason is to improve muscle tone while weight control ranks as the fourth most important reason.1 Levels of attractiveness based on weight and visible musculature are significant points of emphasis in American culture. As such, individuals with well-toned muscles and low body weight are marketed as superior within the context of attractiveness, financial success, and multiple other traits. Unfortunately, this emphasis, as seen in mainstream media, can result in unrealistic ideals and potentially harmful behaviors, such as eating disorders. Unlike the mainstream outlets, which focus on the association between fat levels and physical attractiveness, this chapter focuses on the health-related consequences related to good and bad body composition. Body composition is defined as the body’s relative amount of fat-free mass (FFM) and fat mass (FM) and is generally expressed as a percentage of total body weight. FFM includes bones, muscles, ligaments, body fluids and other organs, while FM is limited to fat tissue. The Importance of Measuring Body Composition Rather Than Just Tracking Body Weight Tracking weight can be helpful, but body composition measurements help separate a person’s actual weight from the weight that could be unhealthy. For example, an individual who weighs 200 pounds and has 8% Body Weight versus Body Composition | 128 body fat, such as an athlete, only carries around 16 pounds of FM. However, a 200-pound person who has a sedentary lifestyle and a body composition of 20%, carries 40 pounds of FM. Weight alone, in this case, does not distinguish between FFM and FM and would suggest both individuals have similar health. As body fat percentage increases, the potential for various diseases also increases significantly. 129 | Body Weight versus Body Composition Diseases Associated with Excessive Body Fat According to the National Institute of Health (NIH), a wide array of diseases can be linked to excessive body fat.2 Some of them are: Type II Diabetes Mellitus Hypertension Cancer Cerebrovascular Disease (Stroke) Cardiovascular Disease Metabolic Syndrome Lung Disorders Sleep Apnea Asthma Musculoskeletal Diseases Osteoarthritis Gout Gallbladder Disease Pancreatitis Non-Alcohol Fatty Liver Disease Dementia Psychological Problems and Quality of Life Kidney Disease Pregnancy Problems How Much Fat is Needed? Fat is a necessary component of daily nutrition. It is needed for healthy cellular function, energy, cushioning for vital organs, insulation, and for food flavor. Diseases Associated with Excessive Body Fat | 130 Fat storage in the body consists of two types of fat: essential and nonessential fat. Essential fat is the minimal amount of fat necessary for normal physiological function. For males and females, essential fat values are typically considered to be 3% and 12%, respectively. Fat above the minimal amount is referred to as nonessential fat. It is generally accepted that an overall range of 10-22 percent for men and 20-32 percent for women is considered satisfactory for good health. A body composition within the recommended range suggests a person has less risk of developing obesity-related diseases, such as diabetes, high blood pressure, and even some cancers. A woman’s essential fat range is naturally greater than a man’s because of fat deposits in breasts, uterus and sex-specific sites. In both males and females, non-essential fat reserves can be healthy, especially in providing substantial amounts of energy. Excessive body fat is categorized by the terms overweight and obesity. These terms do not implicate social status or physical attractiveness, but rather indicate health risks. Overweight is defined as the accumulation of non-essential body fat to the point that it adversely affects health. According to the American College of Sports Medicine (ACSM), the threshold for being characterized as overweight is having a body composition of FM greater than 32% and 19% for females and males, aged 20-39, respectively. 3 Obesity is characterized by excessive accumulation of body fat and can be defined as a more serious degree of being overweight. Classifications of obesity begin at body composition of FM greater than 39% and 25% in females and males ages 20-39, respectively. 4 131 | Diseases Associated with Excessive Body Fat Other Health Risks Diseases are not the only concern with an unhealthy body fat percentage. Several others are listed below. Performance of physical activity An important component of a healthy lifestyle and weight management is regular physical activity and exercise. To the contrary, those who live a sedentary lifestyle will find it more difficult to maintain a healthy body weight or develop adequate musculature, endurance, and flexibility. Unfortunately, additional body weight makes it more difficult to be active because it requires more energy and places a higher demand on weak muscles and the cardiovascular system. The result is a self-perpetuating cycle of inactivity leading to more body weight, which leads to more inactivity. Emotional wellness Studies indicate obesity is associated with a 25% increase in anxiety and mood disorders, regardless of age or gender. Other studies suggest increases in BMI significantly increase the incidence of personality disorders and anxiety and mood disorders. Additional studies have been able to associate a higher incidence of psychological disorders and suicidal tendencies in obese females compared with obese males.5 Diseases Associated with Excessive Body Fat | 132 Pre-mature death The association between obesity and diseases, such as cancer, CVD, and diabetes, suggests that people with more body fat generally have shorter lifespans. The Center for Disease Control (CDC) estimates up to 365,000 deaths each year can be linked with obesity, representing nearly 15% of all deaths. Other studies have tied the Years of Life Lost to body mass index measurements, estimating anywhere from 2 to 20 years can be lost, depending on ethnicity, age at time of obese classification, and gender. 6 Economic impact The physical harm caused by obesity and overweight is mirrored by its economic impact on the health care system. The CDC has estimated the medical costs to be about $147 billion in 2008, which includes preventative, diagnostic, and treatments. Overweight and obesity also contribute to loss of productivity at work through absenteeism and presenteeism, defined as being less productive while working. The annual nationwide productive costs fall within the range of from $3.38 to $6.38 billion.7 133 | Diseases Associated with Excessive Body Fat Body Fat Distribution Body composition measurements can help determine health risks and assist in creating an exercise and nutrition plan to maintain a healthy weight. However, the presence of unwanted body fat is not the only concern associated with an unhealthy weight. Where the fat is stored, or fat distribution, also affects overall health risks. Non-essential fat is primarily stored in adipose tissue, or fat cells, located on the surface of the body and surrounding the body’s organs. Surface fat, located just below the skin, is called subcutaneous fat. Fat that lies deeper in the body surrounding the body’s organs is called visceral fat. Unlike subcutaneous fat, visceral fat is more often associated with abdominal fat. Researchers have found that excessive belly fat decreases insulin sensitivity, making it easier to develop type II diabetes. It may also negatively impact blood lipid metabolism, contributing to more cases of cardiovascular disease and stroke in patients with excessive belly fat.8 Body fat distribution can easily be determined by simply looking in the mirror. The outline of the body, or body shape, would indicate the location of where body fat is stored. Abdominal fat storage patterns are generally compared to the shape of an apple, called the android shape. This shape is more commonly found in males and post-menopausal females. In terms of disease risk, this implies males and post-menopausal females are at greater risk of developing health issues associated with excessive visceral fat. Individuals who experience chronic stress tend to store fat in the abdominal region. A pear-shaped body fat distribution pattern, or gynoid shape, is more commonly found in pre-menopausal females. Gynoid shape is characterized by fat storage in the lower body such as the hips and Body Fat Distribution | 134 buttocks. This shape may be connected to females’ child-bearing abilities as enzymes associated with fat-storage and mobilization are activated during certain times of pregnancy and post-partum. Besides looking in the mirror to determine body shape, people can use an inexpensive tape measure to measure the diameter of their hips and waist. Many leading organizations and experts currently believe a waist circumference of 40 or greater for males and 35 or greater for females significantly increases risk of disease.9 In addition to measuring waist circumference, measuring the waist and the hips and using a waist-to-hip ratio (waist circumference divided by the hip circumference) is equally effective at predicting body fat-related health outcomes. According to the National Heart, Lung, and Blood Institute, a ratio of greater than 0.82 for females and 0.94 for males is associated with a higher risk of developing heart disease, diabetes, and hypertension. 10 135 | Body Fat Distribution Body Mass Index In addition to body composition and waist/hip circumferences, measuring body mass has also been used as an effective method to assess health risks. Body mass index (BMI) is a measurement of height (m 2 ) and weight (kg) suggesting that a person’s body’s weight should be proportional to his or her height. For example, based on the BMI scale, a female with a height of 5’6” should not weigh more than 155 lbs. If her weight exceeded 155 lbs., she would be categorized as “overweight.” BMI = Weight (kg) / Height (m 2 ) Among several criticisms, the BMI method has been faulted for not distinguishing between FM and FFM, since only the overall weight is taken into account. For athletes, who may be more massive as a result of larger muscles, this criticism holds true. For example, a professional football player who weighs 215 pounds and stands at 6’3” would have the exact same BMI as a relatively sedentary arm-chair quarterback who also weighs 215 pounds with the same height. This discrepancy also exists when applying BMI to the senior population. As age increases, muscle mass declines. Seniors who have experienced years of muscle mass decline but increased body fat may maintain a constant weight despite having a very different body composition. Other criticisms of using BMI as a health risk assessment tool include its failure to take age or gender into account. As discussed previously, females naturally have more body fat yet are classified in the same context as males. Because this measurement is so widely used by physicians, patients continue to express concerns about the validity of BMI as an indication of fatness. Regardless of the criticisms, BMI as used for the general population, has been shown to be a reasonable predictor of health outcomes. At Body Mass Index | 136 its core, it is not intended to be an estimate of body composition, i.e., measure Fat Mass and Fat-Free Mass. Instead, it is intended to be used as an estimate of healthy/unhealthy levels of body fat. When used as a means of tracking weight changes over time it can be a valuable tool in predicting health and for recommending lifestyle modifications.11 Waist-to-Hip Ratio An alternative measurement which some studies have found to be more accurate than BMI is waist-to-hip ratio. Unlike your body mass index (BMI), which calculates the ratio of your weight to your height, waist-to-hip ratio takes into account the differences in body structure. So the very fit football lineman who might have a BMI rating of obese, may have a much healthier WHR rating. WHR measures the ratio of your waist circumference to your hip circumference. It determines how much fat is stored on your waist, hips, and buttocks. 137 | Body Mass Index How to Measure Body Composition Multiple methods exist to estimate body composition. Remember, body composition is the ratio of Fat Mass and Fat-Free Mass used to help determine health risks. Of the other methods already mentioned (waist, waist-to-hip ratio, and BMI), none provide estimates of body composition but do provide measurements of other weight-related health markers, such as abdominal fat. Experts have designed several methods to estimate body composition. While they are not flawless, they do provide a fairly accurate representation of body composition. The most common are: Hydrostatic Weighing (Underwater Weighing) At one time, hydrostatic weighing (also and maybe more accurately called hydrodensitometry) was considered the criterion for measuring body composition. Many other methods are founded on this model, in one form or another. This method attempts to measure the density of the body by applying Archimedes’ principle: density = mass/volume. The mass and volume components are measured by using dry weight and then weight while being submerged in a water tank. Since fat is less dense than muscle tissue, a person with more body fat will weigh less in the water than a similar person with more lean mass. Using the measurements, the density can be determined and converted into body fat percentage. With a small margin of error (around 1-2%) this method is very accurate. Unfortunately, the expense and practicality of building and maintaining a water tank How to Measure Body Composition | 138 limits access for most. Also, for those with a fear of water, this would obviously not be the preferred method. Dual Energy X-Ray Absorptiometry (DEXA) Replacing underwater weighing as the new “gold standard,” is DEXA. While underwater weighing accurately compartmentalizes FM and FFM, DEXA adds a third compartment by using low-radiation Xrays to distinguish bone mineral. This addition slightly increases the accuracy of DEXA by eliminating some of the guess work associated with individual differences, such as total body water and bone mineral density.Originally, DEXA scanners were designed to determine and help diagnose bone density diseases. As a result, they can be found in many physicians’ offices. However, a full body scan, which takes only a few minutes, is all that is needed to also determine body fat percentage.Major disadvantages to this method are its high cost and the need for a well-trained professional to operate the equipment and analyze the results. Air Displacement (Plethysmography) A good alternative to more expensive methods, air displacement determines body density using the same principle as underwater weighing, by measuring mass and volume. Clearly, the main difference is that mass and volume are being determined by air displacement rather than water displacement. Using a commercial device (the Bod Pod is most commonly referenced), a person sits in a chamber that varies the air pressure allowing for body volume to be assessed. Air displacement provides a viable alternative for those with a fear of water.Like many other methods, the expense, availability, and training of personnel Air Displacement requires 139 | How to Measure Body Composition limit accessibility. Additionally, its accuracy is slightly less than underwater weighing. Bio-electrical Impedance Analysis (BIA) BIA takes a slightly different approach to measuring FFM. The premise behind BIA is that FFM will be proportional to the electrical conductivity of the body. Fat-tissue contains little water, making it a poor conductor of electricity; whereas, lean tissue contains mostly water and electrolytes, making it an excellent conductor. BIA devices emit a low-level electrical current through the body and measure the amount of resistance the current encounters. Based on the level of impedance, a pre-programed equation is used to estimate body fat percentage.The most accurate BIA devices use electrodes on the feet and hands to administer the point-to-point electrical current. The margin of error for these devices falls in the range of 3–5%. Portable or handheld BIA devices that only measure lower or upper body conductivity have a higher margin of error (4–8%).Because BIA devices primarily measure hydration, circumstances that may influence hydration status at the time of measurement must be taken into account. Recent exercise, bladder content, hydration habits, and meal timing can cause wide measurement variations and influence accuracy. However, this method is generally inexpensive, often portable, and requires limited training to use, making it a very practical option. Skinfold Analysis Skinfold analysis is a widely used method of assessing body composition because of its simplicity, portability, and affordability. It is also fairly accurate when administered properly. Margins of How to Measure Body Composition | 140 error are about 4–7%, depending on the quality of the skinfold calipers and skill of the administrator/technician. The assumption of skinfold measurement is that the amount of subcutaneous fat is proportionate to overall body fat. As such, a technician pinches the skin at various sites and uses calipers to measure and record the diameter of the skin folds. These numbers can then be plugged into an equation to generate an estimate of body fat percentage. The proportionality of subcutaneous fat and overall body fat depends on age, gender, ethnicity, and activity rates. As such, technicians should use the skinfold technique specific to the equation that accounts for those variables to improve accuracy. 141 | How to Measure Body Composition Weighing in on the U.S. Despite the well-known health concerns implicated in overweight and obesity and the availability of multiple methods for assessment and tools to improve body composition, current trends in the United States and around the world are moving in the wrong direction. The unprecedented number of obese Americans has led experts to label it an epidemic, much like they would a disease in a developing country. According to the CDC, the number of American adults (>20 years) that fall into the overweight classification based on BMI are 70.7%. Of those, 37.9% fall within the obese classification. In 1962, the overweight and obesity rates for adults in the U.S. were 32% and 13%, respectively. In other words, overweight trends have more than doubled and obesity rates have almost tripled over the past 50+ years.12 Of more concern are the increasing number of obese children ages 6-11 and adolescents ages 12-19, amounting to 17.4% and 20.6%, respectively. 13 While those numbers have stabilized over the past decade, this has led to a dramatic increase in insulin resistance, a form of diabetes formerly known as adult onset diabetes. With such a diverse population in the U.S. and with an understanding of how BMI is calculated, it is only natural to question the high number of overweight and obese citizens based on BMI alone. However, it is generally believed this is an accurate portrayal of weight status. In a study attempting to compare BMI measurements to actual body fat percentage, it was determined that the total number of obese citizens may be underestimated, and its current prevalence may be worse than is currently being reported. Weighing in on the U.S. | 142 What Can Be Done? With the available tools to identify health risks associated with body fat, anyone concerned about their health should gather as much data about body composition and body fat distribution as possible. Compiling multiple measurements and analyzing them provides a better idea of a person’s current health status and will help determine the next course of action. For example, BMI alone can be beneficial. But when combined with waist circumference, a greater understanding of risk can be achieved. Likewise, when combining BMI and waist circumference with body fat percentage, an ideal conclusion of health status can be made. In the lab accompanying this chapter, you will be guided through the process of assessing your BMI, waist circumference, waist-tohip ratio, and body fat percentage. The next course of action is to set goals and formulate a plan to get to a healthy range of weight and body fat percentage. Where weight loss is needed, the plan should include a balance of calorie restriction and physical activity/exercise. This might also include tracking your current eating and activity habits. More specific information on weight management strategies will be discussed in a later chapter. 143 | Weighing in on the U.S. Low Body Composition Because more people experience excess body fat, the focus up to this point has been on health concerns related to overweight and obesity. However, fat is an essential component to a healthy body, and in rare cases, individuals have insufficient fat reserves, which can also be a health concern. The range of essential body fat for males is 3-5% and 8-12% for females. Attempting to, or intentionally staying in those ranges, through excessive exercise or calorie restriction is not recommended. Unfortunately, low body fat is often associated with individuals struggling with eating disorders, the majority of whom are females. The main concern of low body fat relates to the number and quality of calories being consumed. Foods not only provide energy but also provide the necessary nutrients to facilitate vital body functions. For example, low amounts of iron from a poor diet can result in anemia. Potassium deficiencies can cause hypokalemia leading to cardiovascular irregularities. If adequate calcium is not being obtained from foods, bone deficiencies will result. Clearly, having low body fat, depending on the cause, can be equally as detrimental to health as having too much. The health concerns most often linked to low body fat are: Reproductive disorders Infrequent or missing menstrual cycles Respiratory disorders Immune System disorders Circulatory disorders Premature death In some cases, despite attempts to gain weight, individuals are unable to gain the pounds needed to maintain a healthy weight. In Low Body Composition | 144 these cases, as in the case of excess fat, a holistic approach should be taken to determine if the low levels of body fat are adversely affecting health. These individuals should monitor their eating habits to assure they are getting adequate nutrition for their daily activity needs. Additionally, other lifestyle habits should be monitored or avoided, such as smoking, which may suppress hunger. Additional reading on low body fat and its impact can be found on the Livestrong.com website, on this page: At what body fat percent do you start losing your period?. 145 | Low Body Composition Test Your Knowledge 1. The key to healthy body composition is to: a. Emphasize short-term weight loss b. Focus on lifestyle changes c. Emphasize diet only d. Set unrealistic goals 2. The people who tend to gain weight in the hip area have a higher incidence of coronary heart disease than those people who gain weight in the abdominal area. a. True b. False 3. The “Bod Pod” estimates percent body fat by using: a. Low energy x rays b. Water displacement c. Air displacement d. Electrical current 4. Essential body fat is best described as: a. Fat essential to look good b. Fat essential for body functioning c. Fat used as energy storage d. Fat used to cushion organs Test Your Knowledge | 146 5. Which of the following methods for measuring body composition would be considered most accurate? a. DEXA b. Skin folds c. BIA d. Plethysmography Answers: 1.B, 2.B, 3.C, 4.B, 5.A 147 | Test Your Knowledge CHAPTER 7 - NUTRITION Objectives 1. Summarize the basics of nutrition 2. Define macronutrients and micronutrients 3. Categorize and describe the body’s sources of energy 4. Analyze intake of nutrition and make appropriate changes Terminology Nutrition: The science of food and how the body uses it in health and disease Essential nutrients: Substances the body must get from foods because it cannot manufacture at all, or fast enough to meet needs. Macronutrient: An essential nutrient required in relatively large amounts. Micronutrient: An essential nutrient required in minute amounts. Kilocalorie: A measure of energy content in food; 1 kilocalorie represents the amount of energy needed to raise 1 liter of water 1°C Carbohydrates: The word carbohydrate literally means “hydrated carbon,” or carbon with water. Can be either simple or complex. Fats: Lipids consist of fatty acids, triglycerides, phospholipids, and sterols (cholesterol). Can be either Saturated or Unsaturated. Chapter 7 - Nutrition | 148 Proteins: Protein is another major macronutrient that, like carbohydrates, consists of small repeating units. But instead of sugars, proteins are made up of amino acids. Can be either complete or incomplete. Soluble Fiber: Fiber that is found to lower cholesterol levels. Insoluble Fiber: Fiber that binds to water and allows for soft fecal matter Vitamins: Organic substances found in food that can either be fat or water soluble. Minerals: Inorganic substances found in food or spices. 149 | Chapter 7 - Nutrition The Basics Nutrition can be defined as the science of the action of food, beverages, and their components in biological systems. A nutrient is a compound that provides a needed function in the body. Nutrients can be further classified based on the amount needed in the body. Macronutrients are the nutrients the body needs in larger amounts. Micronutrients are also important nutrients, but ones the body needs in smaller amounts. Macronutrients Micronutrients Carbohydrate Vitamins Protein Minerals Lipids Water Macronutrients Carbohydrates The word carbohydrate literally means “hydrated carbon,” or carbon with water. Thus, it is no surprise that carbohydrates are made up of carbon, hydrogen, and oxygen. Sucrose (table sugar) is an example of a commonly consumed carbohydrate. Some dietary examples of carbohydrates are whole-wheat bread, oatmeal, rice, sugary snacks/drinks, and pasta. The Basics | 150 Proteins Like carbohydrates, proteins are comprised of carbon, hydrogen, and oxygen, but they also contain nitrogen. Several dietary sources of proteins include nuts, beans/legumes, skim milk, egg whites, and meat. Lipids Lipids consist of fatty acids, triglycerides, phospholipids, and sterols (cholesterol). Lipids are also composed of carbon, hydrogen, and oxygen. Some dietary sources of lipids include, oils, butter, and egg yolks. Water Water is made up of hydrogen and oxygen and is the only macronutrient that provides no energy. Micronutrients Vitamins These compounds are essential for normal physiologic processes in the body. Minerals Minerals are the elements (think periodic table) that are essential for normal physiologic processes in the body. 151 | The Basics Carbohydrates Carbohydrates have become, surprisingly, quite controversial. However, it is important to understand that carbohydrates are a diverse group of compounds that have a multitude of effects on bodily functions. Thus, trying to make blanket statements about carbohydrates is not a good idea. Carbohydrates provide energy for the body as well as fiber for digestive health and blood sugar regulation. Many natural carbohydrates such as fruits, vegetables and whole grains provide essential vitamins and minerals. Carbohydrates can be broken into 2 categories: Simple carbohydrates: found naturally in fruits and milk and are added to candy and sweetened beverages. Simple carbohydrates provide quick energy. Complex carbohydrates: found in grains and legumes provide sustained energy. High-Fructose Corn Syrup Food manufacturers are always searching for cheaper ways to produce their products. One extremely popular method for reducing costs is the use of high-fructose corn syrup as an alternative to sucrose. High-fructose corn syrup is approximately 50% glucose and 50% fructose, which is the same as sucrose. Nevertheless, because increased consumption of high-fructose corn syrup has coincided with increased obesity in the United States, a lot of controversy surrounds its use. The New York Times article linked below discusses the growing Carbohydrates | 152 popularity of sugar compared to high fructose corn syrup: “Sugar is Back on Food Labels, This Time as a Selling Point” Fiber The simplest definition of fiber is indigestible matter. Indigestible means that it survives digestion in the small intestine and reaches the large intestine. There are the three major fiber classifications: 1. Dietary fiber This type of fiber contains both nondigestible carbohydrates and lignin and is always intrinsic and intact in plants. 2. Functional fiber This type of fiber contains nondigestible carbohydrates only and can be isolated, extracted, or synthesized. Functional fiber can be from plants or animals and produces beneficial physiological effects in humans. 3. Total Fiber Fiber that contains both dietary fiber and functional fiber. 153 | Carbohydrates Proteins Protein is another major macronutrient that, like carbohydrates, consists of small repeating units. But instead of sugars, proteins are made up of amino acids. Proteins can be classified as either complete or incomplete. Complete proteins provide adequate amounts of all nine essential amino acids. Animal proteins, such as meat, fish, milk, and eggs, are good examples of complete proteins. Incomplete proteins do not contain adequate amounts of one or more of the essential amino acids. For example, if a protein does not provide enough of the essential amino acid leucine it would be considered incomplete. Leucine would be referred to as the limiting amino acid because there is not enough of it for the protein to be complete. Most plant foods are incomplete proteins, with a few exceptions, such as soy. The table below shows the limiting amino acids in some plant foods. Self Magazine’s Nutrition Data website is a useful resource for determining protein quality and identifying complementary proteins. To use the site, go to www.nutritiondata.com, type the name of the food you want information on in the search bar and hit Enter. When you have selected your food from the list of possibilities, you will be given information about this food. Included in this information is the Protein Quality section. This will give you an amino acid score and a figure that illustrates which amino acid(s) is limiting. If your food is an incomplete protein, you can click “Find foods with a complementary profile.” This will take you to a list of dietary choices that will provide complementary proteins for your food. Proteins | 154 Fats (Lipids) Fats (lipids) are the most concentrated source of energy at 9 calories per gram. Fats provide long term stored energy, insulation, cushion and help the body absorb fat-soluble vitamins. Depending on the fatty acid structure a lipid may be monounsaturated, polyunsaturated, or saturated. Linoleic acid (omega 6) and alpha-linoleic acid (omega 3) are examples of polyunsaturated fats and are essential components of a healthy diet. These healthy fats have an interactive roll in cell metabolism as well as overall vascular health which reduces risk of certain types of heart disease. Trans-Fats When unsaturated fats go through a process of hydrogenation some fatty acids are changed to trans-fats. This hydrogenation process makes liquid fats (such as oils) solid at room temperature and resistant to spoilage. Many food manufacturers used hydrogenated oils in processed foods to give these foods a longer shelf-life. However, trans-fats have a negative impact on health by raising levels of bad cholesterol (LDL) and lowering good cholesterol (HDL). Trans-fats are associated with increased risk of heart disease, stroke and type-2 diabetes. Cholesterol Cholesterol is a fat-like (lipid-like) substance that your body uses as a building block to produce hormones, vitamin D, and digestive 155 | Fats (Lipids) juices that help you break down fats in your diet. HDL (high-density lipoprotein, or “good” cholesterol) and LDL (low-density lipoprotein, or “bad” cholesterol) are two types of lipoproteins that carry cholesterol to and from the body’s cells in the blood.The body needs some cholesterol to function, but when levels get too high, fatty deposits can accumulate in blood vessels, which causes them to narrow. This narrowing of the blood passageways by these lipids can lead to heart attacks, coronary artery disease, strokes, or other vascular diseases. Fats (Lipids) | 156 Vitamins Vitamins are organic compounds found in foods and are a necessary part of the biochemical reactions in the body. They are involved in a number of processes, including mineral and bone metabolism, and cell and tissue growth, and they act as cofactors for energy metabolism. You get most of your vitamins through your diet, although some can be formed from the precursors absorbed during digestion. For example, the body synthesizes vitamin A from the β-carotene in orange vegetables like carrots and sweet potatoes. Vitamins are either fat-soluble or water-soluble. Fat-soluble vitamins A, D, E, and K, are absorbed through the intestinal tract with lipids. Vitamin D is also synthesized in the skin through exposure to sunlight. Because they are carried in lipids, fat-soluble vitamins can accumulate in the lipids stored in the body. If excess vitamins are retained in the lipid stores in the body, hypervitaminosis can result. Water-soluble vitamins, including the eight B vitamins and vitamin C, are absorbed with water in the gastrointestinal tract. These vitamins move easily through bodily fluids, which are water based, so they are not stored in the body. Excess water-soluble vitamins are excreted in the urine. Therefore, hypervitaminosis of water-soluble vitamins rarely occurs, except with an excess of vitamin supplements. 157 | Vitamins Minerals Minerals in food are inorganic compounds that work with other nutrients to ensure the body functions properly. Minerals cannot be made in the body; they come from the diet. The amount of minerals in the body is small—only 4 percent of the total body mass—and most of that consists of the minerals that the body requires in moderate quantities: potassium, sodium, calcium, phosphorus, magnesium, and chloride. The most common minerals in the body are calcium and phosphorous, both of which are stored in the skeleton and necessary for the hardening of bones. Most minerals are ionized, and their ionic forms are used in physiological processes throughout the body. Sodium and chloride ions are electrolytes in the blood and extracellular tissues, and iron ions are critical to the formation of hemoglobin. There are additional trace minerals that are still important to the body’s functions, but their required quantities are much lower. Like vitamins, minerals can be consumed in toxic quantities (although it is rare). A healthy diet includes most of the minerals your body requires, so supplements and processed foods can add potentially toxic levels of minerals. The Major Minerals table provides a summary of minerals and their function in the body. Minerals | 158 Calories (Food Energy) Food energy is measured in kilocalories (kcals), commonly referred to as calories. Although technically incorrect, this terminology is so familiar that it will be used throughout this course. A kilocalorie is the amount of energy needed to raise 1 kilogram of water 1 degree Celsius. The number of kilocalories per gram for each nutrient is shown below: Nutrient Energy (kcal/g) Carbohydrate 4 Protein 4 Lipids 9 Water 0 Vitamins 0 Minerals 0 As the table above illustrates, only carbohydrates, protein, and lipids provide energy. However, there is another dietary energy source that is not a nutrient—alcohol. To emphasize, alcohol is not a nutrient, but it does provide 7 kilocalories of energy per gram. Knowing the number of calories in each nutrient allows a person to calculate/estimate the amount of calories contained in any food consumed. My Plate On average, a person needs 1500 to 2000 calories per day to sustain 159 | Calories (Food Energy) (or carry out) daily activities. The total number of calories needed by one person is dependent on their body mass, age, height, gender, activity level, and the amount of exercise per day. If exercise is regular part of one’s day, more calories are required. As a rule, people underestimate the number of calories ingested and overestimate the amount they burn through exercise. This can lead to ingestion of too many calories per day. The accumulation of an extra 3500 calories adds one pound of weight. If an excess of 200 calories per day is ingested, one extra pound of body weight will be gained every 18 days. At that rate, an extra 20 pounds can be gained over the course of a year. Of course, this increase in calories could be offset by increased exercise. Running or jogging one mile burns almost 100 calories. The type of food ingested also affects the body’s metabolic rate. Processing of carbohydrates requires less energy than processing of proteins. In fact, the breakdown of carbohydrates requires the least amount of energy, whereas the processing of proteins demands the most energy. In general, the amount of calories ingested and the amount of calories burned determines the overall weight. To lose weight, the number of calories burned per day must exceed the number ingested. Calories are in almost everything you ingest, so when considering calorie intake, beverages must also be considered. To help provide guidelines regarding the types and quantities of food that should be eaten every day, the USDA has updated their food guidelines from MyPyramid to MyPlate. They have put the recommended elements of a healthy meal into the context of a place setting of food. MyPlate categorizes food into the standard six food groups: fruits, vegetables, grains, protein foods, dairy, and oils. The accompanying website gives clear recommendations regarding quantity and type of each food that you should consume each day, as well as identifying which foods belong in each category. The accompanying graphic (Figure) gives a clear visual with general recommendations for a healthy and balanced meal. The guidelines Calories (Food Energy) | 160 recommend to “Make half your plate fruits and vegetables.” The other half is grains and protein, with a slightly higher quantity of grains than protein. Dairy products are represented by a drink, but the quantity can be applied to other dairy products as well. MyPlate The U.S. Department of Agriculture developed food guidelines called MyPlate to help demonstrate how to maintain a healthy lifestyle. Myplate.gov Summary Video: Healthy Eating 101 161 | Calories (Food Energy) Test Your Knowledge 1. The type of fiber that is known for lowering cholesterol levels: a. Insoluble b. Soluble c. Dietary d. No fiber is known for this 2. What type of protein is typically found from animals? a. Insoluble b. Soluble c. Incomplete d. Complete 3. MyPlate tells you to make half your plate have: a. Red meat b. Fruits and Veggies c. Carbohydrates, specifally simple ones d. Water 4. Macronutrients are: a. Vitamins and Minerals b. Water c. Vitamins, Minerals and Protein Test Your Knowledge | 162 d. Carbohydrates, Fats and Proteins 5. The calories that are found in one gram of fat is: a. 3 b. 4 c. 6 d. 9 Answers: 1.B, 2.D, 3.C, 4.D, 5.D 163 | Test Your Knowledge CHAPTER 8 - WEIGHT MANAGEMENT Objectives 1. Discuss how to manage weight through diet 2. Provide steps for starting a weight loss plan 3. Reinforce the importance of physical activity in weight management 4. Explain how to keep the weight off Terminology Binge Eating Disorder: Eating large amounts (typically an entire day’s worth) of calories in one sitting. Often done at night and alone. Anorexia Nervosa: A disorder where someone constricts caloric intake leading to extreme leanness. Bulimia Nervosa: Typically associated with large amounts of food, paired with a purge. This is what makes up the BingePurge cycle. Chapter 8 - Weight Management | 164 Weight Management Through Diet The majority of Americans are unhappy with their current weight. Almost everyone would like to lose at least 5 pounds. A growing percentage of Americans are carrying enough excess weight to put them at risk for many diseases and even death. Few people, however, know enough about their own bodies to successfully manage their weight. Anyone planning to start a weight loss program should begin by carefully considering the following factors: How many calories are being consumed daily? Myplate or HappyForks How many calories are being expended? BMR calculator How much fluids are being consumed? How well are electrolytes being managed? Achieving one’s ideal weight can be a challenge. But like most endeavors in life, knowledge is power. The more people know about their diet, the better equipped they will be to manage their weight. Most people focus on the number of calories consumed. However, it is also important for them to know how many macronutrients are in the foods they eat. The most effective way to do this is performing a 10-day nutritional intake analysis. These analyses are best done on consecutive days to account for the habitual ebb and flow of one’s daily food intake. Remaining healthy during any weight loss program is paramount. Fad diets that promise quick results do not consider the effects of rapid weight loss on the body. Restricting weight loss to 1 to 2 pounds a week is a far healthier approach. Slow weight loss also prevents the body from burning lean muscle since the body can only burn a certain amount of fat in a week. Dieters who experience 165 | Weight Management Through Diet steady declines in weight are more likely to keep the weight off. The term “diet” is often synonymous with strict routines that require drastic changes in one’s eating habits. In reality, the term “diet” simply describes the intake of food. To lose weight, dieters need a clear understanding of how weight loss occurs. One pound of fat loss is going to require a reduction in caloric intake of 3,500 calories. When viewed in terms of daily food intake, to lose a pound a week, a dieter needs to reduce their daily food intake by 500 calories a day: 3,500 calories/7 days= 500 calories per day. To successfully lose 2 pounds per week, that reduction would have to be doubled to 1,000 calories per day. Attempting to lose 2 pounds or more per week would require a calorie reduction too drastic to be maintained and too restrictive to be healthy. Thus the recommendation of combining diet and exercise is the most effective method for experiencing weight loss. Subtracting 500 calories of food intake and exerting 500 calories in exercise will provide that same 1000 calorie reduction, but in a manner that is far easier to maintain, and certainly more enjoyable. No matter what your weight loss goal is, even a modest weight loss, such as 5 to 10 percent of your total body weight, is likely to produce health benefits, such as improvements in blood pressure, blood cholesterol, and blood sugars.1 Getting Started with Weight Loss On its website, the CDC explains the importance of including physical activity as part of any weight loss program. You can find information about the benefits of physical activity, recommended levels of physical activity, and the number of calories burned during common activities in this step-by-step guide to healthy weight loss. That same information is reprinted below for your convenience: Weight Management Through Diet | 166 Step 1: Make a commitment. Making the decision to lose weight, change your lifestyle, and become healthier is a big step to take. Start simply by making a commitment to yourself. Many people find it helpful to sign a written contract committing to the process. This contract may include things like the amount of weight you want to lose, the date you would like to lose the weight by, the dietary changes you will make to establish healthy eating habits, and a plan for getting regular physical activity. Writing down the reasons why you want to lose weight can also help. It might be because you have a family history of heart disease, or because you want to see your kids get married, or simply because you want to feel better in your clothes. Post these reasons where they serve as a daily reminder of why you want to make this change. Step 2: Take stock of where you are. Consider talking to your health care provider. He or she can evaluate your height, weight, and explore other weight-related risk factors you may have. Ask for a follow-up appointment to monitor changes in your weight or any related health conditions. Keep a “food diary” for a few days, in which you write down everything you eat. By doing this, you become more aware of what you are eating and when you are eating. This awareness can help you avoid mindless eating. Next, examine your current lifestyle. Identify things that might pose challenges to your weight loss efforts. For example, does your work or travel schedule make it difficult to get enough physical activity? Do you find yourself eating sugary foods because that is what you buy for your kids? Do your coworkers frequently bring high-calorie 167 | Weight Management Through Diet items, such as doughnuts, to the workplace to share with everyone? Think through things you can do to help overcome these challenges. Finally, think about aspects of your lifestyle that can help you lose weight. For example, is there an area near your workplace where you and some coworkers can take a walk at lunchtime? Is there a place in your community, such as a YMCA, with exercise facilities for you and child care for your kids? Step 3: Set realistic goals. Set some short-term goals and reward your efforts along the way. If your long-term goal is to lose 40 pounds and to control your high blood pressure, some short-term eating and physical activity goals might be to start eating breakfast, taking a 15-minute walk in the evenings, or having a salad or vegetable with supper. Focus on two or three goals at a time. Great, effective goals are: Specific Realistic Forgiving (less than perfect) For example, “Exercise more” is not a specific goal. But if you say, “I will walk 15 minutes, 3 days a week for the first week,” you are setting a specific and realistic goal for the first week. Remember, small changes every day can lead to big results in the long run. Also, remember that realistic goals are achievable goals. By achieving your short-term goals day by day, you will feel good about your progress and be motivated to continue. Setting unrealistic goals, such as losing 20 pounds in 2 weeks, can leave you feeling defeated and frustrated. Being realistic also means expecting occasional setbacks. Setbacks happen when you get away from your plan for whatever Weight Management Through Diet | 168 reason—maybe the holidays, longer work hours, or another life change. When setbacks happen, get back on track as quickly as possible. Also, take some time to think about what you would do differently if a similar situation happens, to prevent setbacks. Keep in mind everyone is different—what works for someone else might not be right for you. Just because your neighbor lost weight by taking up running, doesn’t mean running is the best option for you. Try a variety of activities: walking, swimming, tennis, or group exercise classes, to see what you enjoy most and can fit into your life. These activities will be easier to stick with over the long term. Step 4: Identify resources for information and support. Find family members or friends who will support your weight loss efforts. Making lifestyle changes can feel easier when you have others you can talk to and rely on for support. You might have coworkers or neighbors with similar goals, and together you can share healthful recipes and plan group exercise. Joining a weight loss group or visiting a health care professional, such as a registered dietitian, can help. Step 5: Continually “check in” with yourself to monitor your progress. Revisit the goals you set for yourself in Step 3 and evaluate your progress regularly. If you set a goal to walk each morning but are having trouble fitting it in before work, see if you can shift your work hours or if you can get your walk in at lunchtime or after work. Evaluate which parts of your plan are working well and which ones need tweaking. Then rewrite your goals and plan accordingly. If you are consistently achieving a particular goal, add a new goal to help you continue on your pathway to success. 169 | Weight Management Through Diet Reward yourself for your successes! Recognize when you are meeting your goals and be proud of your progress. Use non-food rewards, such as a new workout top or bottom or a new pair of running shoes, a sports outing with friends, or a relaxing bath. Rewards help keep you motivated on the path to better health.2 Weight Management Through Diet | 170 The Importance of Physical Activity in Maintaining a Healthy Weight Why is physical activity important? Regular physical activity is important for good health, and it is especially important if you are trying to lose weight or to maintain a healthy weight. When losing weight, more physical activity increases the number of calories your body uses for energy or “burns off.” The burning of calories through physical activity, combined with reducing the number of calories you eat, creates a “calorie deficit” that results in weight loss. Most weight loss occurs because of decreased caloric intake. However, evidence shows the only way to maintain weight loss is to be engaged in regular physical activity. Most importantly, physical activity reduces risks of cardiovascular disease and diabetes beyond that produced by weight reduction alone. Physical activity also helps to: Maintain weight. Reduce high blood pressure. Reduce risk for type 2 diabetes, heart attack, stroke, and several forms of cancer. Reduce arthritis pain and associated disability. Reduce risk for osteoporosis and falls. 171 | The Importance of Physical Activity in Maintaining a Healthy Reduce symptoms of depression and anxiety. How much physical activity do I need? When it comes to weight management, people vary greatly in how much physical activity they need. Here are some guidelines to follow: To maintain your weight. Work your way up to 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorousintensity aerobic activity, or an equivalent mix of the two each week. Strong scientific evidence shows that physical activity can help you maintain your weight over time. However, the exact amount of physical activity needed to do this is not clear since it varies greatly from person to person. It is possible that you may need to do more than the equivalent of 150 minutes of moderate-intensity activity a week to maintain your weight. To lose weight and keep it off. You will need a high amount of physical activity unless you also adjust your diet and reduce the amount of calories you are eating and drinking. Getting to and staying at a healthy weight requires both regular physical activity and a healthy eating plan. What do moderate- and vigorous-intensity mean? Moderate: While performing the physical activity, if your breathing and heart rate is noticeably faster but you can still carry on a conversation, it is probably moderately intense. Examples include: Walking briskly (a 15-minute mile). Light yard work (raking/bagging leaves or using a lawn The Importance of Physical Activity in Maintaining a Healthy Weight | 172 mower). Light snow shoveling. Actively playing with children. Biking at a casual pace. Vigorous: If your heart rate is increased substantially, and you are breathing too hard and fast to have a conversation, it is probably vigorously intense. Examples include: Jogging/running. Swimming laps. Rollerblading/inline skating at a brisk pace. Cross-country skiing. Most competitive sports (football, basketball, or soccer). Jumping rope. This table provides a list of common physical activities and the average calories expended during those activities. Moderate Physical Activity Approximate Calories/30 Min. for a 154 lb. Person1 Approximate Calories/ Hr. for a 154 lb. Person1 Hiking 185 370 Light gardening/ yard work 165 330 Dancing 165 330 Golf (walking and carrying clubs) 165 330 Bicycling ( < 10 mph) 145 290 Walking (3.5 mph) 140 280 Weight lifting (general light workout) 110 220 Stretching 90 180 Vigorous Physical Activity Approximate Calories/30 Min. for a 154 lb. Person1 Approximate Calories/ Hr. for a 154 lb. Person1 173 | The Importance of Physical Activity in Maintaining a Healthy Weight Running/jogging (5 mph) 295 590 Bicycling (>10 mph) 295 590 Swimming (slow freestyle laps) 255 510 Aerobics 240 480 Walking (4.5 mph) 230 460 Heavy yard work (chopping wood) 220 440 Weightlifting (vigorous effort) 220 440 Basketball (vigorous) 220 440 1. Calories burned per hour will be higher for persons who weigh more than 154 lbs. (70 kg) and lower for persons who weigh less. Source: Adapted from Dietary Guidelines for Americans 2005, page 16, Table 4. The Importance of Physical Activity in Maintaining a Healthy Weight | 174 Keeping the Weight Off On its website the CDC admonishes that permanent weight loss is a result of making changes to eating habits that become a longterm part of a healthier lifestyle. You may access that section on their website in the references at the end of this chapter. It is also reprinted below for your convenience. Reflect, Replace, Reinforce: A process for improving your eating habits Create a list of your eating habits. Keeping a food diary for a few days, in which you write down everything you eat and the time of day you ate it, will help you uncover your habits. For example, you might discover that you always seek a sweet snack to get you through the mid-afternoon energy slump. Use this diary to help. It’s good to note how you were feeling when you decided to eat, especially if you were eating when not hungry. Were you tired? Stressed out? Highlight the habits on your list that may be leading you to overeat. Common eating habits that can lead to weight gain are: Eating too fast Always cleaning your plate Eating when not hungry Eating while standing up (may lead to eating mindlessly or too quickly) Always eating dessert Skipping meals (or maybe just 175 | Keeping the Weight Off breakfast) Look at the unhealthy eating habits you have highlighted. Be sure you have identified all the triggers that cause you to engage in those habits. Identify a few you would like to work on improving first. Don’t forget to pat yourself on the back for the things you are doing right. Maybe you almost always eat fruit for dessert, or you drink low-fat or fat-free milk. These are good habits! Recognizing your successes will help encourage you to make more changes. Create a list of “cues.” Review your food diary to become more aware of when and where you are “triggered” to eat for reasons other than hunger. Note how you are typically feeling at those times. Often an environmental “cue,” or a particular emotional state, is what encourages eating for non-hunger reasons. Common triggers for eating when not hungry are: Opening up the cabinet and seeing your favorite snack food. Sitting at home watching television. Before or after a stressful meeting or situation at work. Coming home after work and having no idea what’s for dinner. Having someone offer you a dish they made “just for you!” Walking past a candy dish on the counter. Sitting in the break room beside the vending machine. Seeing a plate of doughnuts at the morning staff meeting. Swinging through your favorite drive-through every morning. Feeling bored or tired and thinking food might offer a pickme-up. Circle the “cues” on your list that you face on a daily or weekly basis. Going home for the Thanksgiving holiday may be a trigger for you to Keeping the Weight Off | 176 overeat, and eventually, you want to have a plan for as many eating cues as you can. But for now, focus on the ones you face more often. Ask yourself these questions for each “cue” you have circled: Is there anything I can do to avoid the cue or situation? This option works best for cues that don’t involve others. For example, could you choose a different route to work to avoid stopping at a fast food restaurant on the way? Is there another place in the break room where you can sit so you are not next to the vending machine? For things I cannot avoid, can I do something differently that would be healthier? Obviously, you cannot avoid all situations that trigger your unhealthy eating habits, like staff meetings at work. In these situations, evaluate your options. Could you suggest or bring healthier snacks or beverages? Could you offer to take notes to distract your attention? Could you sit farther away from the food so it won’t be as easy to grab something? Could you plan ahead and eat a healthy snack before the meeting? Replace unhealthy habits with new, healthy ones. For example, in reflecting upon your eating habits, you may realize that you eat too fast when you eat alone. So, make a commitment to share a lunch each week with a colleague, or have a neighbor over for dinner one night a week. Other strategies might include putting your fork down between bites or minimizing other distractions (i.e., watching the news during dinner) that might keep you from paying attention to how quickly—and how much—you are eating. Here are more ideas to help you replace unhealthy habits: Eat more slowly. If you eat too quickly, you may “clean your 177 | Keeping the Weight Off plate” instead of paying attention to whether your hunger is satisfied. Eat only when you are truly hungry instead of when you are tired, anxious, or feeling an emotion besides hunger. If you find yourself eating when you are experiencing an emotion besides hunger, such as boredom or anxiety, try to find a non-eating activity to do instead. You may find a quick walk or phone call with a friend helps you feel better. Plan meals ahead of time to ensure that you eat a healthy wellbalanced meal. Reinforce your new, healthy habits and be patient with yourself. Habits take time to develop. It doesn’t happen overnight. When you do find yourself engaging in an unhealthy habit, stop as quickly as possible and ask yourself: Why do I do this? When did I start doing this? What changes do I need to make? Be careful not to berate yourself or think that one mistake “blows” a whole day’s worth of healthy habits. You can do it! It just takes one day at a time!4 Keeping the Weight Off | 178 Health Risks of Being Underweight The 2003–2006 National Health and Nutrition Examination Survey (NHANES) estimated that 1.8 percent of adults and 3.3 percent of children and adolescents in the United States are underweight. Centers for Disease Control and Prevention. “NCHS Health E-Stat. Prevalence of Underweight among Children and Adolescents: United States, 2003–2006.” Accessed October 8, 2011. http://www.cdc.gov/nchs/data/hestat/underweight/ underweight_children.htm. Being underweight is linked to nutritional deficiencies, especially iron-deficiency anemia, and to other problems such as delayed wound healing, hormonal abnormalities, increased susceptibility to infection, and increased risk of some chronic diseases such as osteoporosis. In children, being underweight can stunt growth. The most common underlying cause of being underweight in America is inadequate nutrition. Other causes are wasting diseases, such as cancer, multiple sclerosis, tuberculosis, and eating disorders. People with wasting diseases are encouraged to seek nutritional counseling, as a healthy diet greatly affects survival and improves responses to disease treatments. Eating disorders that result in underweight affect about eight million Americans (seven million women and one million men). Anorexia Nervosa Anorexia nervosa, more often referred to as “anorexia,” is a psychiatric illness in which a person obsesses about their weight 179 | Health Risks of Being Underweight and about food that they eat. Anorexia results in extreme nutrient inadequacy and eventually to organ malfunction. The National Institute of Mental Health (NIMH) reports that 0.9 percent of females and 0.3 percent of males will develop anorexia according to The National Institute of Mental Health. Eating Disorders. But it is an extreme example of how an unbalanced diet can affect health. Anorexia frequently manifests during adolescence and it has the highest rate of mortality of all mental illnesses. People with anorexia consume, on average, fewer than 1,000 kilocalories per day and exercise excessively. They are in a tremendous caloric imbalance. Moreover, some may participate in binge eating, self-induced vomiting, and purging with laxatives or enemas. The very first time a person starves him- or herself may trigger the onset of anorexia. The exact causes of anorexia are not completely known, but many things contribute to its development including economic status, as it is most prevalent in high-income families. It is a genetic disease and is often passed from one generation to the next. Pregnancy complications and abnormalities in the brain, endocrine system, and immune system may all contribute to the development of this illness. The primary signs of anorexia are fear of being overweight, extreme dieting, an unusual perception of body image, and depression. The secondary signs and symptoms of anorexia are all related to the caloric and nutrient deficiencies of the unbalanced diet and include excessive weight loss, a multitude of skin abnormalities, diarrhea, cavities and tooth loss, osteoporosis, and liver, kidney, and heart failure. There is no physical test that can be used to diagnose anorexia and distinguish it from other mental illnesses. Therefore, a correct diagnosis involves eliminating other mental illnesses, hormonal imbalances, and nervous system abnormalities. Eliminating these other possibilities involves numerous blood tests, urine tests, and x-rays. Coexisting organ malfunction is also examined. Treatment of any mental illness involves not only the individual, but also family, friends, and a psychiatric counselor. Health Risks of Being Underweight | 180 Treating anorexia also involves a dietitian, who helps to provide dietary solutions that often have to be adjusted over time. The goals of treatment for anorexia are to restore a healthy body weight and significantly reduce the behaviors associated with causing the eating disorder. Relapse to an unbalanced diet is high. Bulimia Bulimia, like anorexia, is a psychiatric illness that can have severe health consequences. The NIMH reports that 0.5 percent of females and 0.1 percent of males will have bulimia at some point in their lifetime. Bulimia is characterized by episodes of eating large amounts of food followed by purging, which is accomplished by vomiting and with the use of laxatives and diuretics. Unlike people with anorexia, those with bulimia often have a normal weight, making the disorder more difficult to detect and diagnose. The disorder is characterized by signs similar to anorexia such as fear of being overweight, extreme dieting, and bouts of excessive exercise. Secondary signs and symptoms include gastric reflux, severe erosion of tooth enamel, dehydration, electrolyte imbalances, lacerations in the mouth from vomiting, and peptic ulcers. Repeated damage to the esophagus puts people with bulimia at an increased risk for esophageal cancer. The disorder is also highly genetic, linked to depression and anxiety disorders, and most commonly occurs in adolescent girls and young women. Treatment often involves antidepressant medications and, like anorexia, has better results when both the family and the individual with the disorder participate in nutritional and psychiatric counseling. 181 | Health Risks of Being Underweight Binge-Eating Disorder Similar to those who experience anorexia and bulimia, people who have a binge-eating disorder have lost control over their eating. Binge-eating disorder is not currently diagnosed as a distinct psychiatric illness, although there is a proposal from the American Psychiatric Association to categorize it more specifically. People with binge-eating disorder will periodically overeat to the extreme, but their loss of control over eating is not followed by fasting, purging, or compulsive exercise. As a result, people with this disorder are often overweight or obese, and their chronic disease risks are those linked to having an abnormally high body weight such as hypertension, cardiovascular disease, and Type 2 diabetes. Additionally, they often experience guilt, shame, and depression. Binge-eating disorder is commonly associated with depression and anxiety disorders. According to the NIMH, binge-eating disorder is more prevalent than anorexia and bulimia, and affects 3.5 percent of females and 2.0 percent of males at some point during their lifetime. Treatment often involves antidepressant medication as well as nutritional and psychiatric counseling. Health Risks of Being Underweight | 182 Test Your Knowledge 1. To lose one pound of fat, how many calories must be burned? a. 1500 b. 2000 c. 3000 d. 3500 2. This is the type of eating disorder where someone eats too less calories for a long period. a. Binge-Eating Disorder b. Anorexia c. Bulimia d. Muscle Dysmorphic Disorder 3. The Eating disorder that happens at night, often alone: a. Binge-Eating Disorder b. Anorexia c. Bulimia d. Muscle Dysmorphic Disorder 4. The eating disorder that has a binge-purge cycle.: a. Binge-Eating Disorder b. Anorexia c. Bulimia 183 | Test Your Knowledge d. Muscle Dysmorphic Disorder 5. The % of Americans currently Overweight: a. 33 b. 45 c. 66 d. 90 Answers: 1.D, 2.B, 3.A, 4.C, 5.C Test Your Knowledge | 184 CHAPTER 9 - STRESS Objectives 1. Define stress 2. Describe the effects of stress on wellbeing 3. Identify effective strategies for managing stress 4. Assess your own levels of stress Terminology Stress – the body’s physical, mental, and emotional response to a particular stimulus Stressor – Something that causes stress Eustress – Good Stress Distress – Bad stress Adrenalin – a hormone secreted by the adrenal glands, especially in conditions of stress, increasing rates of blood circulation and breathing 185 | Chapter 9 - Stress What Is Stress and How Does It Affect Wellness? In today’s fast-paced society, most people complain about being stressed. However, when they use the term stress, they rarely know it’s true meaning. The word carries many negative connotations and is associated with an unpleasant or traumatic event. As such, people mistakenly believe that stress is simply the nervousness and tension experienced prior to, during, or after a negative event. In fact, the effects of stress are physiological, emotional, and psychological. Additionally, not all levels of stress are detrimental. The stress athletes experience right before a big game or college students feel right before an exam can enhance focus and increase their ability to concentrate. Stress is either good or bad depending on how long it persists and how it is perceived by the individual. This chapter will provide a deeper understanding of what stress is and provide effective strategies for managing stress. Stress is defined as the body’s physical, mental, and emotional response to a particular stimulus, called a stressor. This adaption/ coping-response helps the body prepare for challenging situations. It is the level of a person’s response to a stressor that determines whether the experience is positive or negative. As a hardworking college student, you may feel as if you know the meaning of stress all too well. You may dream of a future where the demands on your time are diminished, so you can escape the high levels of stress you are feeling now. Unfortunately, regardless of their situation, everyone experiences stress on a regular basis. The good news is, not all stress is bad! Small levels of stress can enhance cognitive brain function. Stress may provide the motivation and concentration you need to write an essay, practice a speech, or What Is Stress and How Does It Affect Wellness? | 186 prepare for a job interview. For most people, these types of stressors are manageable and not harmful. Stressors that have the potential for harm include the sudden loss of a loved one, the unexpected ending of a romantic relationship, or the unfair demands of an unreasonable boss. Defining Stress Stress, then, is more than simply the tension and apprehension generated by problems, obstacles, or traumatic events. Stress is the body’s automatic response (physical, mental, andemotional) to any stressor. It is a natural and unavoidable part of life, and it can be empowering and motivating, or harmful and potentially dangerous. For more information on stress click on the links below: What is Stress? What is stress and what causes it? Effects of Stress on Wellness As stated previously, not all stress is bad. In fact, the stress associated with riding a roller coaster, watching a scary movie, or scaling a cliff can enhance these experiences. Regardless of whether the stress experienced is negative or positive, the effects on the body are identical. When a person senses that a situation demands action, the body responds by releasing chemicals into the blood. The hypothalamus signals the adrenal glands to release a surge of hormones that include adrenaline and cortisol. The physiological effects of those chemicals—enhanced focus, quicker reaction time, and increased 187 | What Is Stress and How Does It Affect Wellness? heart rate, energy, and strength—are quite beneficial when faced with a potentially dangerous situation that is temporary. Unfortunately, most of the stressors people face—work, school, finances, relationships—are a part of everyday life, and thus, inescapable. Experiencing ongoing, unavoidable stress can result in some very unpleasant and harmful effects, both mental and physical. Chronic stress can cause upset stomach, headaches, sleep problems, and heart disease. It can also cause depression, anxiety, and even memory loss. To watch a video that describes the effects of stress in detail, click on the link below: How Stress Affects Your Body and Mind What Is Stress and How Does It Affect Wellness? | 188 What Are the Strategies for Managing Stress? Although stress in everyday life is unavoidable, there are ways to cope with it that will minimize or eliminate its harmful effects. The Anxiety and Depression Association of America (ADAA) provides a list of effective strategies for coping with stress. That document is linked here: Tips: Coping Strategies. For your convenience, it is also reprinted below with the ADAA’s permission. When you are feeling anxious or stressed, these strategies will help you cope: Take a time-out. Practice yoga, listen to music, meditate, get a massage, or learn relaxation techniques. Stepping back from the problem helps clear your head. Eat well-balanced meals. Do not skip any meals. Do keep healthful, energy-boosting snacks on hand. Limit alcohol and caffeine, which can aggravate anxiety and trigger panic attacks. Get enough sleep. When stressed, your body needs additional sleep and rest. Exercise daily to help you feel good and maintain your health. Take deep breaths. Inhale and exhale slowly. Count to 10 slowly. Repeat, and count to 20 if necessary. Do your best. Instead of aiming for perfection, which isn’t possible, be proud of however close you get. Accept that you cannot control everything. Put your stress in perspective: Is it really as bad as you think? Welcome humor. A good laugh goes a long way. Maintain a positive attitude. Make an effort to replace negative thoughts with positive ones. 189 | What Are the Strategies for Managing Stress? Get involved. Volunteer or find another way to be active in your community, which creates a support network and gives you a break from everyday stress. Learn what triggers your anxiety. Is it work, family, school, or something else you can identify? Write in a journal when you’re feeling stressed or anxious and look for a pattern. Talk to someone. Tell friends and family you’re feeling overwhelmed, and let them know how they can help you. Talk to a physician or therapist for professional help. Get help online. Online programs guided by professional coaches to help you turn healthy anxiety management into a habit. ◦ Listen to podcastson a wide range of topics ◦ Watch recorded webinarson topics ranging from how to worry less, coping with panic attacks, treatments for children, and helping suicidal families,and many more. Fitness Tips: Stay Healthy, Manage Stress To receive the greatest benefits from exercising, try to include at least 2½ hours of moderate-intensity physical activity (e.g., brisk walking) each week, 1¼ hours of a vigorous-intensity activity (such as jogging or swimming laps), or a combination of the two. 5 X 30: Jog, walk, bike, or dance three to five times a week for 30 minutes. Set small daily goals and aim for daily consistency rather than perfect workouts. It is better to walk every day for 15–20 minutes than to wait until the weekend for a three-hour fitness marathon. Lots of scientific data suggests that frequency is most important. Find forms of exercise that are fun or enjoyable. Extroverted people often like classes and group activities. People who are What Are the Strategies for Managing Stress? | 190 more introverted often prefer solo pursuits. Distract yourself with an iPod or other portable media player to download audiobooks, podcasts, or music. Many people find it is more fun to exercise while listening to material they enjoy. Recruit an “exercise buddy.” It is often easier to stick to your exercise routine when you have to stay committed to a friend, partner, or colleague. Be patient when you start a new exercise program. Most sedentary people require about four to eight weeks to feel coordinated and sufficiently in shape so that exercise feels easier. Additional strategies for coping with stress are linked below: Stress Management 10 Tips to Manage Stress 191 | What Are the Strategies for Managing Stress? Assess Your Stress Level Are you more or less stressed than your peers? The website linked below contains a stress test. On the website, scroll down to the “Quiz: Are You Stressed?” How Stressed Are You? Below is a link to the Lab for this chapter on stress. This may or may not be assigned for extra credit. Your instructor will inform you if it is. Online Stress Test Assess Your Stress Level | 192 Test Your Knowledge 1. The stage of stress where the stressor can cause death or health problems a. Alarm b. Resistance c. Exhaustion d. Relapse 2. Which of the following does not occur when the body first encounters stress a. Heart rate increase b. Breathing increase c. Increased sweating d. Faster digestion 3. What hormone is most likely to be released when stress is encountered a. Testosterone b. Adrenaline c. Estrogen d. Leptin 4. The immune system becomes stronger when a stress is first encounters a. True 193 | Test Your Knowledge b. False 5. Stress can cause all of the following except a. Headaches b. Insomnia c. Muscle cramps d. Upset stomach 6. Stress can lead to some mental concerns a. True b. False Answers: 1.C, 2.D, 3.B, 4.A, 5.C, 6.A Test Your Knowledge | 194 CHAPTER 10 - CARDIOVASCULAR DISEASE AND STROKE Objectives 1. Define cardiovascular disease 2. Identify types of cardiovascular disease 3. Identify risk factors for cardiovascular disease 4. Assess personal risk of cardiovascular disease Terminology Heart Disease: The disease of the heart that can be deemed deadly to about 425,000 people per year. Atherosclerosis: The narrowing and hardening of the arteries. Angina Pectoris: Crushing chest pains. Arrhythmia: A lack of “normal” heart rhythm. Myocardial Infarction: Heart Attack Cerebrovascular accident: Also known as CVA, is a term used for strokes Ischemic Stroke: A stroke happening in the vessels on the way to the brain, most likely from a blockage Hemorrhagic stroke: A stroke that happens when vessels in the brain rupture causing heavy bleeding within the brain. HDL Cholesterol: High-Density Lipoprotein, also known as the good type of cholesterol. 195 | Chapter 10 - Cardiovascular Disease and Stroke LDL Cholesterol: Low-Density Lipoprotein also known as the good type of cholesterol. Chapter 10 - Cardiovascular Disease and Stroke | 196 Heart Disease What is Heart Disease? Heart disease is the leading killer of Americans. Fortunately, the toll is much less — there are about 425,000 deaths each year from heart disease. In addition, the death rate from stroke, the third most common cause of death, has declined by about 75 percent since the early 1960s (NIH, 2017). While its root causes were unknown at that time, today, researchers can trace the problem to changes in the American lifestyle after World War II. Postwar prosperity led to more sedentary lifestyles and fattier diets. And cigarettes, which were introduced to soldiers during the war, became broadly popular. Researchers believe that the epidemic can be reversed if people eat healthier diets, exercise more, and stop smoking. (GPB, 2017) https://gpb.pbslearningmedia.org/resource/ envh10.health.heartdisease/heart-disease-americas-leadingcause-of-death/#.WQaEiVK-LR0 Things that lead to Cardiovascular Disease These 4 things can be linked to cardiovascular disease that you cannot change: 1. Age – As a person ages there is higher risk for CVD. There is a strong correlation with CVD and age. Although, with males, the risk seems to be when they are younger and females seem to be at higher risk post-menopausal. 2. Sex – Males are higher risk for CVD, especially at younger ages. 197 | Heart Disease Women can be at high risk in later parts of their lives. To help with some of this risk women can look at this http://www.nhlbi.nih.gov/educational/hearttruth 3. Race – African Americans have the highest risk factor for CVD 4. Family History/ Race – This can be one of the strongest predictors of CVD, but also has the smallest correlation to CVD overall. These 4 things can be linked to cardiovascular disease that you can change: 1. Tobacco – The strongest predictor of CVD is the use tobacco. The use of tobacco accounts for 30% of CVD risk. There is a significant reduction in risk for those who don’t use tobacco. 2. Obesity – Those that have a BMI greater than 30 have a higher than normal risk than those that do not have a BMI greater than 30. “The “obesity epidemic” experienced by the United States over the past several decades threaten to reverse important progress against heart disease. The NIH has undertaken several efforts to prevent or reduce obesity in children and young adults, including a set of randomized trials to identify effective approaches in individuals and a large project to evaluate community approaches to reduce obesity in children (NIH, 2017)” 3. Diet – CVD can be correlated to high intake of saturated fat and cholesterol. Risk of dietary cholesterol intake can be correlated to atherosclerosis. 4. Diabetes – Specifically Type 2 diabetes is looked at as already have had a heart attack. This is looked at as seriously as any of the other factors that you can control. Heart Disease | 198 Different types of CVD Coronary heart disease—often simply called heart disease—is the main form of heart disease. It is a disorder of the blood vessels of the heart that can lead to heart attack. A heart attack happens when an artery becomes blocked, preventing oxygen and nutrients from getting to the heart. Heart disease is one of several cardiovascular diseases, which are diseases of the heart and blood vessel system. Other cardiovascular diseases include stroke, high blood pressure, angina (chest pain), and rheumatic heart disease. (NIH, 2017) Heart Attack A Myocardial Infarction is otherwise known as a heart attack. This MI can be seen with the symptoms of Angina Pectoris: crushing chest pains, profound shortness of breath, left arm pain, radiating jaw pain or middle back pain. These signs and symptoms of heart attack are very serious and should be recognized as soon as possible and should be taken care of ASAP. What to do if you suspect someone having a heart attack. (Mayo Clinic) Call 911 or your local medical emergency number. Don’t ignore or attempt to tough out the symptoms of a heart attack for more than five minutes. If you don’t have access to emergency medical services, have a neighbor or a friend drive you to the nearest hospital. Drive yourself only as a last resort, and realize that it places you and others at risk when you drive under these circumstances. 199 | Different types of CVD Chew and swallow an aspirin. If advised to do so by 911, unless you are allergic to aspirin or have been told by your doctor never to take aspirin. Seek emergency help first, such as calling 911. Take nitroglycerin, if prescribed. If you think you’re having a heart attack and your doctor has previously prescribed nitroglycerin for you, take it as directed. Do not take anyone else’s nitroglycerin, because that could put you in more danger. Begin CPR if the person is unconscious. If you’re with a person who might be having a heart attack and he or she is unconscious, tell the 911 dispatcher or another emergency medical specialist. You may be advised to begin cardiopulmonary resuscitation (CPR). If you haven’t received CPR training, doctors recommend skipping mouth-to-mouth rescue breathing and performing only chest compressions (about 100 per minute). The dispatcher can instruct you in the proper procedures until help arrives. If an automated external defibrillator (AED) is available and the person is unconscious, begin CPR while the device is retrieved and set up. Attach the device and follow instructions that will be provided by the AED after it has evaluated the person’s condition. What is your Number? Lipoprotein Profile What: A blood test that measures total cholesterol, LDL “bad” cholesterol, HDL “good” cholesterol, and triglycerides (another form of fat in the blood). The test is given after a 9- to 12-hour fast. Why: To find out if you have any of the following: high blood Different types of CVD | 200 cholesterol (high total and LDL cholesterol), low HDL cholesterol, or high triglyceride levels. All affect your risk for heart disease. When: All healthy adults should have a lipoprotein profile done at least once every 5 years. Depending on the results, your doctor may want to repeat the test more frequently. Blood Pressure What: A simple, painless test using an inflatable arm cuff. Why: To find out if you have high blood pressure (also called hypertension) or prehypertension. Both are risk factors for heart disease. When: At least every 2 years, or more often if you have high blood pressure or prehypertension. Fasting Plasma Glucose What: The preferred test for diagnosing diabetes. After you have fasted overnight, you will be given a blood test the following morning. Why: To find out if you have diabetes or are likely to develop the disease. Fasting plasma glucose levels of 126 mg/dL or higher in two tests on different days mean that you have diabetes. Levels between 100 and 125 mg/dL mean that you have an increased risk of developing diabetes and may have prediabetes. Diabetes is an important risk factor for heart disease and other medical disorders. When: At least every 3 years, beginning at age 45. If you have risk factors for diabetes, you should be tested at a younger age and more often. 201 | Different types of CVD Stroke A cerebrovascularaccident or stroke is a blockage that occurs on the way to the brain. This ischemic stroke that is a blockage that occurs on the way to the brain is different than a hemorrhagic stroke which is a rupture in the arteries of the brain, it accounts for only 20% of all strokes. Using the Cincinnati Stroke Scale to identify early warning signs for stroke F = Face: Is one side of the face drooping down? A = Arm: Can the person raise both arms, or is one arm weak? S = Speech: Is speech slurred or confusing? T = Time: Time is critical!! Call 9-1-1 immediately!

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